Case report: a combined avulsion and root fracture/avulsion trauma with ten years review.
When a child presents with more than one type of trauma to anterior permanent teeth there is sometimes a dilemma as to the appropriate treatment for all the teeth involved. Replantation of avulsed permanent teeth in general dental practice has been reported [Sharma and Duggal, 1994] and therapeutic protocols for avulsed teeth have been reviewed [Ram and Cohenca, 2004]. In a study by Welbury et al.  treated root-fractured permanent incisors were assessed with respect to pulp vitality, root tissue union, and tooth survival. Root fractured permanent teeth have been treated using removable splints designed to stabilize mobile anterior teeth and eliminate occlusal trauma due to malocclusion [Qin et al., 2002].
The most common approach for root fractures is to use rigid splinting for 12 weeks, but its benefits are questionable. The splinting method appears to be related to healing of root fractures [Andreasen et al., 2004 ], with a preference to pulp healing and fusion of fragments with a certain flexibility of the splint and possibly also to non-traumatogenic splint application. Splinting for up to 4 weeks has been suggested so as to influence the healing pattern.
When one tooth is avulsed the question is whether to try and replant the tooth into its socket, depending on the duration of extra-alveolar time. In addition, whether a storage medium has been used or not is pertinent. It has become common practice that if the extra-alveolar period is over 20 minutes, with dry storage and root formation is complete, then the prognosis of avulsed teeth is not as good; giving a poor prognosis as pulpal necrosis can develop.
Thus, what should be the approach if a child presents with both an avulsed tooth and a root fracture, perhaps involving different teeth? Just such an occurrence occurred and this case report details the successful approach.
The patient (aged 14 yrs at the time of injury) attended Leeds Dental Institute (LDI) for emergency treatment following an assault by two boys on his way to school. The trauma occurred at 08.15h (March 1998) and the patient's parent was advised by telephone to attempt reimplantation of the teeth (11 and 21), which was not possible and it was therefore advised to place these teeth in milk and attend LDI urgently. The patient attended at 09.45h with the teeth stored in milk. The priority was to replant the avulsed teeth as soon as possible as the extra-alveolar time was already 90 minutes. Whilst the teeth were being replanted a history and examination was performed with the completion of a trauma form. The patient, who had no relevant medical history, was in the permanent dentition, caries-free and had good oral hygiene.
Treatment. The immediate treatment was reimplantation and splinting of the avulsed 21 and the root fracture avulsion of 11 (Figures 1a-d and 2a-d). Prior to reimplantation the exact lengths of the avulsed 21 and the root fractured 11 were measured for future reference during root canal therapy (RCT). Local analgesia was used and irrigation of the sockets was carried out to remove the coagulated blood clots so that full repositioning would be possible. The teeth were then splinted using a semi-rigid/physiological splint with 0.5mm orthodontic wire and acid etch composite. Periapical radiographs were taken after replantation which showed very good repositioning (Figure 2d).
Penicillin V tablets 250mg qds for 5 days and 0.2% Chlorhexidine gluconate (CHX) mouthwash were prescribed. The patient's anti-tetanus status was checked. The interesting feature of this case was that there was a combined avulsion and root fracture avulsion. The dilemma was whether the splinting should have been rigid or flexible and should the duration of splinting have been for 10 days (avulsion) or for 3 months (root fracture)? The 21 was released from the splint at 8 days and the splint totally removed at 4 weeks. Root canal treatment was completed for both teeth after use of non-setting calcium hydroxide. Gutta percha was used for root canal obturation with the 11 being root filled to the fracture line.
Follow-up. Close follow-up showed no problems for the next three years but granulation tissue formation between the two fractured fragments of the maxillary right central incisor was evident (Figure 3). In May 2001 the patient attended for review and periapical radiographs of 11 and 12 were taken. A dark radiolucency was observed around the gutta percha root filling of 11 that indicated internal resorption had commenced (Figure 4a-b). However, this was found to be due to ingrowth of granulation tissue which was removed and the 11 was re-root filled with gutta percha using the Obtura II system. The patient was last reviewed in March 2008 (10 years post-trauma) and clinically there was no aesthetic change in the crown shades of 11and 21 (Figure 5) and there were no clinical signs of mobility, tenderness to percussion, pain or ankylosis. Periapical radiographs confirmed the absence of periapical pathology or ankylosis and there have been no further complications since (Figure 6).
Traumatic injuries to permanent teeth include coronal and root fractures, subluxations, luxations, and avulsions. The main risk following avulsions and root fractures are: pulpal or periodontal (PDL) necrosis, root ankylosis and resorption [Andreasen et al., 1995a and 1995b].
Root Fracture and Avulsion injuries. There are different schools of thoughts on management of root fractures. The most commonly used management technique for root fractures is rigid splinting for 12 weeks but its benefits are questionable. The treatment of root-fractured permanent incisors has been assessed with respect to pulp vitality, root tissue union, and tooth survival [Welbury et al., 2002]. The effects of clinical and radiographic parameters and rigid splinting on the outcome were also examined. The findings were that the hard root tissue union was significantly affected by pulp necrosis and luxation of the coronal fragment. Survival was poorest for root fractures within the gingival third of the root. Splinting with rigid fixation had no significant effect on pulp vitality and type of root tissue union.
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Storage Temperature and Medium. The temperature (above 0[degrees]C) of the storage medium is of importance only for dry storage and in such a situation only for shorter extra-alveolar periods, i.e. up to 60-min storage as extensive destruction of the PDL always takes place for longer periods. The commonly used storage mediums are milk, isotonic solution or saliva [Schwartz et al., 2002]. The most popular one is milk as it is inexpensive and readily available. The other mediums such as isotonic solutions have a shelf life and therefore need restocking periodically. However, saliva is a very good storage medium but there is the risk of inhalation of a tooth or tooth fragment if held in the buccal sulcus. Furthermore, wet storage (saliva and/or saline) for more than 5 min decreased the chance of pulpal revascularization; whereas dry extra alveolar storage decreased the chance of revascularization [Andreasen et al., 1981]. Based on these findings, immediate replantation after brief cleansing in saline is recommended.
Extra-alveolar Period. The extra-alveolar time until replanting the avulsed tooth is the major prognostic factor. Inflammatory root resorption is especially common after dry storage and is related to the extra-alveolar period [Andreasen et al., 1995a, b]. After 30 min dry storage, this type of resorption was very prominent. Teeth stored in tap water, saline or saliva, had a similar frequency of inflammatory resorption, which increased with increased extra-alveolar periods. Replacement resorption had a strong relationship to dry storage and was to be expected after 60 min.
Should a tooth be re-implanted or not? It is a very difficult decision whether to re-implant or discard the tooth after avulsion. However, the benefits of reimplantation are greater than choosing to discard the exarticulated tooth/teeth. Firstly, the patient/parents do not have to go through the psychological trauma of losing an anterior tooth. If the extra-alveolar period is less than 20 minutes with wet storage then the chances of periodontal healing are significantly higher and when apical root formation is incomplete pulpal revascularization is possible. With the above two factors we can improve the prognosis of an avulsion. In contrast, if the extra-alveolar period is over 20 minutes with dry storage and root formation is complete, the prognosis of avulsed teeth is not as good. Poor prognosis can develop due to pulpal necrosis, PDL death can lead to internal resorption, ankylosis, replacement resorption and eventually to the loss of the tooth. However, one of the positive outcomes is that alveolar growth continues and the patient is more prepared psychologically for losing the avulsed tooth after a number of years.
Splinting Technique. Adhesive techniques are usually employed for splinting of traumatized teeth [von Arx, 2005]. Root fractured permanent teeth have been treated with removable splints [Qin et al., 2002], designed to stabilize mobile anterior teeth and eliminate occlusal trauma due to malocclusion. Most root fractures displayed transient external resorption around the fracture lines. However, surface resorption appeared to be self-limiting and not to threaten the retention of the tooth. In contrast, inflammatory resorption was mainly observed in teeth with pulp necrosis, but in all cases this was arrested with endodontic treatment. The removable splints used appeared to positively affect healing after traumatic injuries.
The splinting method appears to be related to healing of root fractures [Andreasen et al., 2004], with a preference to pulp healing and fusion of fragments with a certain flexibility of the splint and possibly also non-traumatogenic splint application. Splinting for up to 4 weeks was shown to influence the healing pattern.
Cvek et al.  reinforced the doubts of the efficacy of long-term splinting. The types of splint used for root fracture healing should allow physiological tooth movement. Rigid splints enhance PDL damage and ankylosis. In contrast, repositioning appeared to enhance the likelihood of both pulp healing and hard tissue repair.
Duration of splinting. Splinting for more than 4 weeks was not found to influence the healing pattern. Minimal treatment delay (a few days) appears not to result in inferior healing [Andreasen et al, 2004]. Although all dental traumatologists agree that for avulsions short term (8-10 days) flexible splinting is advisable there is controversy for root fractures. Originally, Andreasen et al.  advised rigid long term splinting (3 months) for root fractures and most clinicians have taken this as the definitive treatment for such cases. However, it is now believed that root fracture avulsion cases should be treated as avulsion cases and not as root fracture cases. Recent research proposes the ideal time of splinting for root fracture avulsion cases to be about 4-6 weeks [Welbury et al., 2002].
For this patient's case it was a matter of trying what was believed to be the best approach based on the literature at that time. For the first three years there were no complications at all and after such a time we would have expected the teeth to have a good prognosis. However, internal resorption of 11 around the gutta-percha was then evident due to ingress of granulation tissue. Perhaps obturation of the root canal was not ideal and this subsequently led to ingress of the granulation tissue. The original radiograph, following reimplantation, showed very good repositioning. There was subsequent movement of the fragments and healing by fibrosis and granulation then took place. For the patient it took a number of years for the granulation tissue to ingress into the canal of 11 and for root resorption to commence. It is to be hoped that the resorptive process has arrested. We now have very good canal obturation using the Obtura II system. However, we still plan to monitor both teeth very carefully for a number of years. The major benefits from the patient's perspective are that he still has his own teeth (11 and 21) with no colour change, pain or mobility, good function and occlusion. The patient's smile has survived 10 years. He has been monitored through his developmental years into adulthood.
Non setting calcium hydroxide versus tetracyclines and steroid preparations (ledermix). The materials used for intracanal medicaments are non-setting calcium hydroxide and steroid/ tetracycline (Ledermix) based preparations. The Ledermix paste-treated roots showed statistically significantly more healing and less resorption than the roots treated with calcium hydroxide [Bryson et al., 2002]. Root filling with Ledermix paste also resulted in significantly less loss in root mass due to resorption compared to those roots filled with calcium hydroxide. Immediate intracanal placement of Ledermix paste at the emergency visit after an avulsion injury appears to decrease resorption and increase favorable healing. The longterm use of calcium hydroxide is more effective than shortterm treatment for established inflammatory root resorption [Trope et al, 1995]. In addition, long term use of aqueous calcium hydroxide paste placed in the pulp chamber increased dentinal pH [Perez et al., 2001].
Complications of Periodontal and Pulpal Healing. The status of the periodontal ligament (PDL) and of the pulp is decisive for the healing of avulsed and replanted teeth. The most commonly seen problem is ankylosis. It demonstrates a lack of physiologic mobility and later shows radiographic evidence of replacement resorption. The width of the apical foramen and the length of the root canal were measured on radiographs taken at the time of injury [Andreasen et al., 2004]. A multivariate statistical analysis revealed that pulpal revascularization was more frequent in teeth with shorter distances from the apical foramen to the pulp horns. However, another study [Schwartz et al., 2002] revealed, pulpal healing was limited to the entrance of the pulp canal, and no significance was shown between pulpal healing and the storage medium, time or temperature.
As this patient was an adolescent at the time of trauma, infraocclusion relative to adjacent teeth would have become apparent during jaw growth. Despite considerable knowledge about the pathogenesis of ankylosis gathered from animal studies and observation of human replanted teeth, there is no known treatment to arrest this condition [Campbell et al., 2005]. The only possible management to prevent it is physiological splinting which was carried out in this case. Current advice on the management for avulsion and root fractures in the permanent dentition are shown in Tables 1 and 2.
Protocols for treatment of avulsions and root fractures. Reviewing the literature it is apparent that the approach to dealing with these aspects of trauma need constantly bringing up to date as research reveals new insights for test practice. Tables 1 and 2 give schematic layouts as suggested approaches for the management of these traumatic instances.
A case of a child with both a tooth avulsion and concomitant root fracture is described. It was successfully treated by initial semi-rigid splinting for 10 days the avulsion and release of that tooth from the splint, with continued splinting for 4 weeks for the root fracture.
Andreasen JO. . Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995a;11:59-68.
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995b;11:76-89.
Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004; 20:203-11.
Boyd DH, Kinirons MJ, Gregg TA.A prospective study of factors affecting survival of replanted permanent incisors in children. Int J Paediatr Dent 2000;10:200-5.
Bryson EC, Levin L, Banchs F, Abbott PV, Trope M. Effect of immediate intracanal placement of Ledermix Paste[R] on healing of replanted dog teeth after extended dry times. Dent Traumatol 2002;18:316-21.
Campbell KM, Casas MJ, Kenny DJ. Ankylosis of traumatized permanent incisors: pathogenesis and current approaches to diagnosis and management. J Can Dent Assoc 2005;71:763-8.
Cvek M, Andreasen JO, Borum MK. Healing of 208 intra-alveolar root fractures in patients aged 7-17 years. Dent Traumatol 2001;17:53-62.
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Schwartz O, Andreasen FM, Andreasen JO. Effects of temperature, storage time and media on periodontal and pulpal healing after replantation of incisors in monkeys. Dent Traumatol. 2002;18:190-5.
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Trope M, Moshonov J, Nissan R, Buxt P, Yesilsoy C. Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth. Endod Dent Traumatol 1995;11:124-8.
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S. B. Misra, K. J. Toumba. Dept. Paediatric and Preventive Dentistry, Division of Child Dental Health, Leeds Dental Institute, Leeds, Great Britain.
Postal address: Dr. S.B. Misra., Orthodontic Department, Manchester Dental Hospital, Minshul Street, Manchester, England
Table 1. Schematic layout for dealing with an avulsion of a permanent tooth. Avulsion Advice to the patient on the phone: * Try re-implantation after rinsing under saline. DO NOT touch or scrub clean the root surface (PDL will be damaged). * If unable to re-implant store the tooth in isotonic solution i.e. milk (to maintain PDL vitality). * Attend at GDP promptly with the isotonically stored tooth (isotonically stored PDL can be revived if extra alveolar period is <45 mins). Patient in Dental Chair: * Check PMH and establish the cause of injury. * GENTLY clean the socket and root surface of avulsed tooth with sterile saline. Check for no alveolar fractures before re-implantation. * Handling by the crown only, re-implant the tooth into its socket. * USE PHYSIOLOGICAL SPLINTING for 7-10 days (Flexible wire 0.5-0.7mm to avoid ankylosis) with adjacent teeth on both sides of avulsion. * Prescribe antibiotics and a 0.2% chlorhexidine mouth wash and oral hygiene instructions. * Check tetanus status. patient should be reviewed in 7-10 days; take periapical radiograph and then: * If root development is incomplete with an open apex keep under review for signs of revascularization. If pulpal necrosis is present then commence the following: * When root development is complete and the apex closed commence extirpation and for the first 2 weeks RC dressing material should be Ledermix paste[R] and then non-setting calcium hydroxide (NCH) dressing with bonded restoration in access cavity and then follow with endodontic therapy. Long term Complications of avulsion: * Loss of vitality of pulp will result in: Discolouration, internal root resorption and eventually loss of tooth unless treated properly. * Loss of vitality of PDL will result in: Ankylosis, replacement root resorption, infra-occlusion and loss of tooth. Table 2. Schematic layout for dealing with a root fracture/ avulsion of a permanent tooth. Root Fracture/Avulsion Advice to the patient on the phone: Same as for avulsion patient in Dental Chair: * Check PMH and establish the cause of injury. * Unless the coronal fragment has exarticulated, take a periapical radiograph to establish level of the root fracture. * Reposition the tooth that has # and proceed with splinting. Semi-rigid splinting (Flexible wire 0.5- 0.7mm) with adjacent teeth on both sides of avulsion and the splint remains for 4-6 weeks. Prescribe antibiotics and chlorhexidine and check tetanus status. Patient Reviewed in 7-10 days take periapical radiograph and then: * Commence extirpation of # coronal fragment and for the first 2 weeks RC dressing material should be Ledrmix paste and then NCH dressing with a bonded restoration in access cavity and then endodontic therapy. * In root fracture cases there are two objectives, firstly to achieve the union of two fragments (without granulation tissue interposing in between them) and secondly leave the apical root fragment in situ in the alveolus as it helps to maintain the bone height and remains vital.
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|Author:||Misra, S.B.; Toumba, K.J.|
|Publication:||European Archives of Paediatric Dentistry|
|Article Type:||Case study|
|Date:||Sep 1, 2008|
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