Evaluating the Feasibility of Delayed Replantation: Report of 2 Cases

doi:10.21203/rs.3.rs-5242647/v1

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Case Report

Evaluating the Feasibility of Delayed Replantation: Report of 2 Cases

https://doi.org/10.21203/rs.3.rs-5242647/v1

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Introduction: Losing permanent teeth due to avulsion or extraction can affect patients psychologically and functionally. This condition can be managed through replantation, which involves implanting teeth into the socket. The success of avulsed tooth replantation is highly influenced by the choice of storage media, the duration of the tooth remains outside the socket, and the level of contamination. The key to successful replantation lies in the patient's condition, the donor tooth, and the recipient site.

Objective: To report the management of delayed replantation and its treatment outcomes in several cases.

Cases: The first case is an 11-year-old child who experienced avulsion of the left maxillary central incisor, which was replanted six days later. The second case is a 22-year-old woman who experienced avulsion of tooth 21 and underwent delayed replantation 15 hours later. Both avulsed teeth were treated with root canal treatment, with subsequent successful treatment outcomes afterward.

Conclusion: Delayed replantation treatment provided satisfactory results in all three cases. The replanted teeth showed no complaints, discoloration, or gingival swelling and were completely painless during each case's follow-up period. In Case 1, there was infra-positioning, ankylosis, and external resorption at the mesial alveolar crest of the tooth. Case 2 showed a well-functioning tooth, no periapical lesions, and satisfactory aesthetic results.

Avulsion

case report

delayed replantation

socket

Damage to the teeth and associated facial structures can be quite upsetting for the child and their parents, considering their important role in appearance and the resulting emotional effects. Prompt attention and management are crucial for all types of injuries, but tooth avulsion (ex-articulation) is a unique form of injury. The outcome in such cases is strongly influenced by the time between the tooth being knocked out and reattached [1, 2]. This type of injury is remarkable as it often affects the maxillary central incisors [3], significantly impacting a smile's overall appearance.

The success of reimplantation in clinical cases relies on various factors. These include the extent of periodontal damage, the condition of the alveolar socket, the time the tooth remains outside the socket, the maturity of the root, the method used to clean the contaminated root surface, the duration of splinting, and the administration of antibiotics [4–6].

Research has indicated that the effectiveness of periodontal ligament cells diminishes considerably after being stored outside the body for more than two hours. Based on a study conducted by Andreasen in 1975, it was observed that there is a notable decline in the number of viable cells following 60 minutes of dry storage. Furthermore, no viable cells were detected after 120 minutes [7]. According to Mathewson's study, the success rate of reimplantation can differ based on how long the tooth was outside of the mouth. For periods shorter than 30 minutes, the success rate is an impressive 90%. However, when the duration extends from 30 to 90 minutes, the success rate significantly decreases to 43%. When the period exceeds 90 minutes, the success rate drops to 7%. In such cases, inflammatory and replacement resorption is typically observed within one to two months, while root surface resorption becomes detectable after 12 months [8].

Despite being recommended, immediate transplantation of the avulsed tooth is not always feasible. This is often due to concomitant injuries the patient may have sustained during the accident and a lack of knowledge regarding properly managing such injuries at the accident site. This case report aimed to present two cases of delayed replantation of avulsed maxillary central incisors after an extended dry extra-alveolar period.

Case 1

An 11-year-old boy sought dental care at Gadjah Mada University Dental Hospital for a dislodged tooth resulting from falling while playing soccer (Fig. 1). Panoramic radiograph showed an intact avulsed tooth socket (Fig. 2). The tooth was found an hour after the incident, left to dry for six days, and wrapped in tissue due to the parents' limited knowledge. After root canal treatment, the tooth was replanted, and splinting was performed using an arch bar.

During the initial visit, the avulsed tooth was soaked in a saline solution, cleaned through brushing, underwent root canal extirpation, followed by root canal preparation using the step-back technique, and obturated with gutta-percha. Clinical examination of the socket revealed the absence of bone or tooth fragments, and panoramic radiographic examination (OPG) did not indicate the presence of such fragments.

Before replantation, the socket was rinsed with saline for cleaning, followed by infiltration anesthesia using 2% lidocaine HCl and curettage of the wound area. The dislodged tooth was repositioned in the socket with finger pressure, then splinting using an arch bar for one month on teeth 13–23 (Fig. 3). It is crucial to ensure that the occlusion does not experience premature contact to avoid pressure on the periodontal tissues of tooth 21.

On the second visit one month after replantation, the patient came to remove the arch bar splinting (Fig. 4) The replanted teeth were insensitive to percussion and palpation (no pain on tapping), and there was no gum swelling, luxation, or discoloration. Periapical radiography showed loss of the periodontal ligament at the apical region (Fig. 5)

Six months later, the patient returned for a follow-up; similar results were obtained as the second visit (Fig. 6a). The percussion examination produced a metallic sound with no complaints as well. The patient returned for observation after six years. Clinical examination results indicated that the tooth did not undergo discoloration but showed infra-position and ankylosis. This was evident from the percussion examination, which produced a different sound resembling a metallic tone. A periapical radiographic examination was conducted to assess the condition of the replanted tooth. Radiographic findings revealed no apical pathology in the periapical area but indicated the presence of ankylosis, characterized by the absence of the periodontal ligament. Additionally, an interpretation revealed external resorption on the mesial root near the cervical region of the tooth (Fig. 6b).

Case 2

A 22-year-old female patient presented to the Gadjah Mada University Dental Hospital emergency department around 9:00 AM due to a traffic accident. She reported dislodging one of her front teeth after her face collided with the motorcycle handlebars. The patient arrived without the dislodged tooth, and she was advised to search for it near the accident site. She returned to the emergency department around 2:00 AM the following day for additional treatment. The presence of any concurrent systemic disease was not specified by the patients. An intraoral examination revealed an avulsion of the maxillary left permanent central incisor tooth 21 (Fig. 7a). Additionally, the left central incisor (tooth 21) showed an enamel fracture, and a laceration of the chin area was identified. A vitality test indicated a positive response from the adjacent teeth.

Periapical and panoramic radiographs revealed no alveolar bone fracture. Examination of the avulsed tooth revealed that the crown had an enamel fracture and the root had a closed apex (Fig. 7b). At the initial visit, debris removal and brushing were conducted to eliminate contamination and necrotic periodontal tissue on the teeth. Subsequently, the teeth were stored in a saline storage medium. Anesthesia was administered to the labial mucosa of the gingiva from teeth 14 to 24 using lidocaine HCL compositum.

Tooth sockets were irrigated with saline until thoroughly cleaned. Following that, a curettage was performed to induce new bleeding. The avulsed tooth was then replanted into the socket of tooth 21 with digital pressure (using the fingers), ensuring proper repositioning. Teeth 14 to 24 underwent fixation using an arch bar, and a periapical radiograph was taken to assess the overall condition of the replanted socket (Fig. 8).

In addition, the patient was given guidance on maintaining a soft diet and instructions on mouth cleanliness throughout this period. Throughout the stabilization phase, the patient was told to clean her mouth with chlorhexidine. A preventive antibiotic treatment regimen was started, consisting of 625 mg/day of amoxicillin trihydrate and potassium clavulanate for a week. The patient was also recommended for a booster dose of anti-tetanus. The importance of routine clinical and radiological follow-ups was explained to the parents. After two weeks, the patient was reviewed, and there were no radiological or clinical pathology changes. Root canal treatment was conducted by an endodontist with a single visit and employing guta percha for obturation (Fig. 9).

During a follow-up session, the splinting wire was removed four weeks after the transplant. A resin composite was used to restore the fractured tooth crowns permanently. During the third-month follow-up, a percussion test on the avulsed tooth indicated a change in a percussion sound (metallic sound) due to ankylosis (Fig. 10).

Both clinical and radiographic evaluations over the three-month follow-up period showed the avulsed tooth to have favorable functional and aesthetic outcomes. Radiographic analysis demonstrated that there was no apical disease in the periapical area. Still, they showed ankylosis, meaning one-third of the tooth's distal root lacked the periodontal ligament (Fig. 11). The patient will be kept under close observation, and any required medical attention will be given as needed.

The guidelines for treating avulsed permanent teeth vary. Still, the consensus is that the ideal treatment for an avulsed tooth is immediate replantation [6, 9]. However, immediate replantation cannot always be done immediately. The treatment decision regarding avulsed teeth is related to the maturity of the root apex (open or closed) and the condition of the periodontal ligament (PDL) cells. The condition of the PDL cells depends on the storage medium and the time the tooth has been out of the mouth [1].

The extra-oral period significantly affects the outcome and directly correlates with the survival of PDL cells. Clinical studies have indicated that teeth replanted within 5 minutes after avulsion have the best prognosis [1]. After a dry time of 60 minutes or more, all PDL cells are nonviable. The storage and transport of media during the extra-oral time are also of vital significance [6, 9].

In patients with a prolonged extra-oral time, the tooth should be maintained in a suitable medium, such as HBSS, saline, milk, or saliva, until it is replanted by a dentist [10]. In the present cases, the teeth were kept in dry pieces of paper, and the extra-oral dry time was more than 60 minutes (6 days and 15 hours in Cases 1 and 2, respectively). The management of the two cases presented here was in accordance with the accepted replantation protocol described by the International Association of Dental Traumatology [6].

It is indicated that if the tooth has been dried for more than 60 min before replantation, the root canal treatment may be done extra-orally before replantation or later. Because there were no chances of obtaining pulp space revascularization and the periodontal ligament would be necrotic and not expected to heal, it was decided to treat the root canals extra-orally. According to traumatology guidelines and articles on delayed replantation cases, PDL cells will be necrotic following delayed replantation, resulting in a poor long-term prognosis [1, 3, 4, 6].

Most avulsion occurs before the patient’s facial growth is completed. Preventing resorption of the surrounding bone and maintaining the tooth in the space of the arch are critical until facial growth is completed [4]. Replantation can restore the patient’s esthetic appearance and occlusal function and prevent physiological trauma, which may be associated with a missing anterior tooth. If the avulsed incisors had not been replanted in the present cases, other treatment options might have included prosthetic replacement of the missing incisor, space closure with orthodontic treatment, or autotransplantation of another tooth to the empty space [11].

Replanted teeth must be monitored carefully, and clinical/radiographical findings should be recorded. Ankylosis is frequently associated with the infraposition of the replanted tooth in children and adolescents [4, 6]. The replanted teeth of both cases presented here showed signs of ankylosis. Although Case 2 did not show infraposition, slight infraposition was visible in Case 1 compared with the adjacent central incisor.

The replanted teeth must be fixed with resin-wire or fiber splint, and occlusal interferences must be removed. If the root is long with good initial stability, over-crown suture tying is sufficient, fixing the teeth for 2–3 weeks. Long-term, rigid fixation negatively affects periodontal ligament cell healing, whereas non-rigid 7-10-day fixation may promote healing and cell activity. However, some perform non-rigid fixation for two weeks to two months, depending on mobility decrease[12, 13].

In this case, a 3-week adjacent tooth fixation with a resin-wire splint was done. Endodontic treatment may be performed pre-op, intra-op, or post-op for the transplanted tooth. Some recommend pre-op to shorten extra-oral time and periodontal membrane trauma. For intra-op, the avulsed tooth should be saline-soaked to reduce periodontal ligament damage [14, 15]. Post-op treatment should be within 1–2 weeks, as inflammatory root resorption can occur if not initiated within two weeks.

Ultimately, the delayed replantation of teeth can lead to a remarkable outcome, with teeth finding a stable and functional position within the dental arch. This demonstrates the ability to maintain the surrounding bone for an extended period.

FUNDING

Partial financial support was received from the Indonesia Endowment Fund for Education Agency (Lembaga Pengelola Dana Pendidikan/LPDP).

COMPETING INTERESTS

The authors have no competing interests to declare relevant to this article's content.

AUTHOR CONTRIBUTIONS

Conceptualization of the study design was done by C. Y. H..; data curation and formal analysis was done by M. H. N.; M. H. N. prepared the original draft. All authors contributed to reviewing and editing the publication draft; visualization of the cases was contributed by M. H. N. All authors have read and agreed to the published version of the manuscript

ETHICS APPROVAL

This study is a Case Report. The Ethics Committee of the Faculty of Dentistry, Universitas Gadjah Mada and Gadjah Mada Dental Hospital, Prof. Soedomo, has confirmed that there is no obligation to obtain ethical approval in this type of study. The management of these cases were adhered to the standard of the emergency dental practice applied in our institution.

CONSENT

All patients have given written consent for these cases' examination and treatment. Written consent is made available by request to the corresponding author.

CONSENT TO PUBLISH

Informed consent was obtained from the patient (or the patient’s legal guardian) to publish this case report. The patient has been informed that no personal information, such as names, IDs, or addresses, will be included in the published material. Additionally, the patient has been made aware of the potential reach of this publication in both print and online formats and has agreed to the dissemination of the information.

CLINICAL TRIAL NUMBER

Not applicable

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No competing interests reported.

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Evaluating the Feasibility of Delayed Replantation: Report of 2 Cases

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Abstract

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INTRODUCTION

CASE REPORTS

Case 1

Case 2

DISCUSSION

CONCLUSION

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