Management of a Severely Malpositioned Replanted Avulsed Tooth: A Case Report

Dental trauma, such as luxation and/or avulsion injury, frequently presents in adolescents.^1-5 Management of these cases requires a scientific basis from which to formulate a treatment plan as well as communication and coordination between general dentists and specialists.

The American Association of Endodontics has published endodontic treatment protocols for avulsion and luxation injuries.⁶ However, some cases may fall outside the recommended guidelines. In these cases, literature concerning the timing of endodontic treatment, how treatment should be performed, and prognosis is lacking.

This case report describes an adolescent with a history of avulsion of one tooth and extrusive luxation of another. The replanted avulsed tooth was repositioned incorrectly. The report details the experimental endodontic treatment, which resulted in successful reattachment of the avulsed tooth at 1-year post-trauma, but subsequently failed between 1 and 2 years post-trauma.

Ten days prior to initial presentation to the author, a 13-year-old Caucasian male was hit in the face by a baseball. The trauma resulted in the extrusive luxation of tooth No. 8 and avulsion of tooth No. 9. The avulsed tooth was located and stored in milk while the patient was transported to a local emergency room. The extraoral dry time for tooth No. 9 was estimated at 10 minutes, while the time to replantation of the avulsed tooth was unknown. At the emergency room, tooth No. 9 was replanted and splinted with Coe-Pak Periodontal Dressing. The emergency room physician advised follow-up with the patient’s general dentist within 24 hours.

The next day, the patient presented to his general dentist. The general dentist placed an orthodontic wire splint. The patient returned to the general dentist’s office for splint removal shortly before presenting to the author.

At presentation (Figure 1 through Figure 4), the patient was symptomatic with a dull ache. Teeth Nos. 8 and 9 were repositioned incorrectly, with tooth No. 9 being severely malpositioned. Upon examination, the patient was afebrile and alert and oriented times three. He stated that he did not lose consciousness at the time of the trauma. The patient’s vital signs were determined and considered normal. The patient had no history of significant medical disease, denied all medications, and had no known drug or food allergies. His review of systems was noncontributory for systemic disease. The patient’s head-and-neck examination exhibited no signs of facial fracture. A small laceration of his upper lip in association with tooth No. 9 was healing well. Teeth Nos. 8 and 9 were malpositioned, with tooth No. 9 being severely extruded. The remainder of his head-and-neck examination was unremarkable.

Teeth Nos. 8 and 9 were tender to percussion and palpation. Teeth Nos. 8 and 9 were nonresponsive to cold testing (Frigi-dent™, Ellman International, www.ellman.com). Teeth Nos. 8 and 10 were +1 mobile, while tooth No. 9 was +3 mobile. The gingival tissue around tooth No. 9 was erythematous. Periodontal probing depths were 3 mm to 4 mm generalized for all teeth except tooth No. 9, whose probing depths were 6 mm to 8 mm. Upon radiographic examination, teeth Nos. 8, 9, and 10 had widened periodontal ligament spaces. No other pathology was noted. The remainder of the examination was unremarkable.

The teeth were diagnosed as follows: tooth No. 8—pulpal necrosis with a symptomatic apical periodontitis, with an extrusive luxation injury with mild malposition; tooth No. 9—pulpal necrosis with a symptomatic apical periodontitis, with history of avulsion and replantation with severe malposition; tooth No. 10—normal pulp with a symptomatic apical periodontitis with a subluxation injury.

The prognoses for the teeth were as follows: No. 8—questionable; No. 9—unfavorable; No. 10—favorable. A telephone consultation with a board-certified oral maxillofacial surgeon was conducted to corroborate an unfavorable prognosis for tooth No. 9. Discussion consisted of extraction and placement of an implant versus attempted endodontic therapy. Due to the patient’s age, it was concluded that retention of the tooth would be the best-case scenario and allow for an implant later in the patient’s life.

The patient and his parent were given these options for teeth Nos. 8, 9, and 10: no treatment; waiting for further symptoms; extraction; or re-extracting and replanting tooth No. 9 in proper position, splinting the maxillary anterior teeth for 7 to 10 days, then performing root canal treatments on teeth Nos. 8 and 9 and following the progress of tooth No. 10. The risks and benefits of these treatments were explained, including the possibility of root resorption and loss of teeth. The patient and his parent elected to re-extract tooth No. 9 and replant it with physiologic splinting for 7 to 10 days and then complete root canal treatment of teeth Nos. 8 and 9. Tooth No. 10 would be followed clinically and radiographically. Informed consent was acknowledged and signed.

Local anesthetic with epinephrine was administered via buccal infiltration and an incisive canal nerve block. Tooth No. 9 was extracted with a universal #150 extraction forceps (Hu-Friedy, www.hu-friedy.com) whose handles were secured with a rubber band. The beaks of the forceps were placed at the cementoenamel junction. After extraction, the tooth was held by the forceps in Save-A-Tooth^® solution (Phoenix-Lazerus, Inc, www.saveatooth.com). The socket was copiously irrigated with sterile physiologic saline (Baxter Health Corporation, www.baxter.com) to dislodge any coagulum. The socket was inspected and no cortical fractures were noted.

The tooth was replanted. A physiologic splint was placed using monofilament nylon (Cabela’s Proline^® Original Line 15 Lb. Test, Cabela’s, www.cabelas.com) spot-bonded to the teeth with ClearFil™ Bond (Kuraray America Dental, www.kuraraydental.com) and Dyract^® compomer (DENTSLPY Caulk, www.caulk.com) (Figure 5 and Figure 6).⁷ The patient was prescribed doxycycline 100 mg every 12 hours for 1 week, with a loading dose of 200 mg. The patient was instructed to take ibuprofen 400 mg to 600 mg every 4 to 6 hours for the next several days regardless of pain. Chlorhexidine mouth rinse was prescribed by the emergency room physician and was still being used by the patient twice a day. The continued use of chlorhexidine twice daily was recommended for 1 week. The patient was scheduled for root canal treatments on teeth Nos. 8 and 9 in 7 to 10 days.

The patient, who was then asymptomatic, presented 10 days later (20 days post-trauma). Upon examination, teeth Nos. 8 and 9 were tender to percussion and palpation, while tooth No. 10 was not tender. Teeth Nos. 8 and 9 were nonresponsive to thermal testing, while tooth No. 10 was responsive. Tooth No. 8 was +1 mobile, while tooth No. 9 remained +3 mobile. Radiographically, tooth No. 8 had an intact lamina dura except for the apical portion, which was due to persistent extrusion. Tooth No. 9 exhibited a widened periodontal ligament space (Figure 7). Local anesthetic with epinephrine was administered via buccal infiltration and an incisive canal block. Teeth Nos. 8 and 9 were isolated individually with a rubber dam for endodontic treatment. The rubber dam and the individual tooth were disinfected with 70% isopropyl alcohol. The rubber dam was sealed with OraSeal^® (Ultradent Products, Inc., www.ultradent.com). Nonsurgical treatment was performed under magnification with a Zeiss Opmi^® pico surgical operating microscope (Carl Zeiss Meditec, www.zeiss.com). Nonsurgical treatment of each tooth consisted of a standard endodontic access, biomechanical instrumentation with stainless steel hand files, Gates-Glidden burs 3-6, as well as Protaper and Profile Series 29 nickel titanium rotary instruments (all from DENTSPLY).

Upon access, both teeth were determined to have pulpal necrosis without signs of intracanal fracture. The teeth were alternatively irrigated with copious amounts of 6% sodium hypochlorite (NaOCl) (Clorox^® Bleach, The Clorox Company, www.thecloroxcompany.com) and 17% ethylenediaminetetraacetic acid (EDTA) (Vista Dental, www.vista-dental.com). Canal length estimation was determined with a Root ZX^® apex locator (Morita, www.morita.com). Final length was verified radiographically with a trial gutta percha point. The teeth were soaked and irrigated with MTAD per manufacturer’s recommendation (DENTSPLY). Canals were then dehydrated with 70% isopropyl alcohol (American Dental Supply,www.americandentalinc.com ). Obturation was completed (Figure 8) with gutta percha (DENTSPLY), and Pulp Canal Sealer EWT (SybronEndo, www.sybronendo.com), using a continuous wave technique with thermoplasticized backfill using System B (SybronEndo) and Calamus (DENTSPLY) units, respectively. The access openings were etched with 37% phosphoric acid (Benco Dental, www.benco.com), primed and bonded (ClearFil Bond), and restored with Geristore (DenMat, www.denmat.com). The accesses were polished and the occlusion adjusted.

After endodontic treatment, the splint was removed. At this time, a new splint was placed. The new splint altered the attachment on tooth No. 9. The new splint placed the attachment slightly incisal to the previous position to allow for slight apical pressure. The patient was advised to continue nonsteroidal medication as needed and to follow up in 1 week.

Eight days later, the patient presented and was asymptomatic. Tooth No. 8 had normal mobility, while the mobility of tooth No. 9 decreased to +2. Only tooth No. 9 was mildly tender to percussion, and all teeth were non-tender to palpation. Tooth No. 10 was nonresponsive to thermal testing. With decreasing mobility, it was recommended to leave the splint in place for 1 more week. Possible pulpal necrosis with normal periapical tissues was tentatively diagnosed for tooth No. 10 and would be re-evaluated at the patient’s next appointment. Re-evaluation was recommended for 1 week.

The patient presented 10 days later, now 38 days post-trauma (Figure 9 and Figure 10). Upon examination, teeth Nos. 8, 9, and 10 were non-tender to percussion and palpation. Tooth No. 9 was slightly mobile. Tooth No. 10 was nonresponsive to cold or electrical testing. Percussion sounding was not indicative of ankylosis. Radiographically, possible periapical pathology was noted on tooth No. 10. The patient was advised that tooth No. 10 might require root canal treatment. Since a false negative response was possible, root canal treatment on tooth No. 10 was postponed until the next re-evaluation unless symptoms developed. The splint was removed, and the patient was advised to return for re-evaluation in 3 weeks.

The patient presented 9 weeks later (73 days post-trauma) (Figure 11 and Figure 12). The patient was asymptomatic. All maxillary teeth were non-tender to percussion and palpation. Percussion sounding on teeth Nos. 8 and 9 was not indicative of ankylosis. Mobility for all teeth was normal. Tooth No. 10 was nonresponsive to both cold and electric testing. Periodontal probing depths were all less than 3 mm. Radiographically, teeth Nos. 8 and 9 displayed a widened periodontal ligament space, and No. 10 was determined to have periapical pathology. Slight apical external root resorption was noted on the mesial aspects of teeth Nos. 8 and 9. Tooth No. 10 was diagnosed with pulpal necrosis and an asymptomatic apical periodontitis. The patient and his parent were advised of the diagnosis for tooth No. 10 and given options for treatment, as well as the risks, benefits, and prognosis for each option. Informed consent was acknowledged and signed.

Nonsurgical root canal treatment on tooth No. 10 was performed as described previously. Voids were noted in the coronal restoration, which did not compromise the seal of the canal space. The patient was scheduled for follow-up in 3 weeks.

The patient presented for re-evaluation 11 weeks (21 weeks post-trauma) (Figure 13 through Figure 15) and 11 months later (1 year, 16 weeks post-trauma) (Figure 16 and Figure 17). At both appointments, the patient was asymptomatic. All teeth were non-tender to percussion and palpation. Percussion soundings were not indicative of ankylosis. Periodontal probing depths were less than 3 mm. Mobility was within normal limits. Radiographic examination showed apical healing. The external root resorption noted on the mesial aspects of teeth Nos. 8 and 9 appeared arrested. One-year follow up was recommended.

The patient presented 1 year later (2 years, 15 weeks post-trauma) (Figure 18 through Figure 20). Three months after his last follow-up appointment, orthodontic treatment had been started without any consultation. All teeth were non-tender to percussion and palpation. Percussion sounding was metallic on tooth No. 9, indicating ankylosis. Periodontal probing depths were within normal limits. Mobility was normal for all teeth except No. 9, which was immobile. Radiographic examination showed apical healing on teeth Nos. 8 and 10. Tooth No. 9 displayed a horizontal root fracture and moderate-to-severe external root resorption apically. The patient and his parent were advised of the findings.

The case presented detailed the management of extrusive luxation and avulsion injuries. Since multiple practitioners typically contribute in trauma cases, communication between medical and dental professionals is fundamental, but is often difficult. In this case, procedural errors were made.⁶ The endodontic community must educate physicians and dentists about appropriate trauma management.

While guidelines are consensus treatment regimens, individual cases may require modifications. In this case, the avulsed tooth was repositioned and splinted incorrectly. An endodontist should aid in directing a rational treatment plan.

Replantation with physiologic splinting produced unexpected success.⁸ Minimized dry time and appropriate transport media^9-11 have been correlated with successful outcomes. To some degree, the coagulum in the alveolar socket might have preserved the periodontal ligament and cementum. Removal of the coagulum possibly reduced the resorptive potential upon secondary replantation.

External root resorption, a significant complication of trauma, is due to injury or necrosis of the dental pulp, periodontal ligament, cementum and cementocytes,¹² or injury to the intermediate cementum.¹³ Treatment of resorption is primarily based upon alkalization of the root canal. Medication of the canal does not address the main causal factors of resorption. The removal of necrotic pulp and disinfection of the tooth, including the use of MTAD or an antibiotic cocktail, has the potential to eliminate any pulpal nidus.

Pharmaceuticals can decrease inflammatory root resorption^14-18 and slow orthodontic tooth movement.^14,16,19 Taken together, anti-inflammatory medications could decrease trauma-induced inflammatory root resorption.²⁰

Endodontic treatment of both the luxated and avulsed teeth was completed in one visit without medication with calcium hydroxide. The current recommendations do not indicate if luxation injuries require medication with calcium hydroxide. Calcium hydroxide treatment might have prevented the apical resorption, which was noted on tooth No. 8. The amount of resorption on tooth No. 8 was minimal and did not compromise its treatment, including orthodontic movement.

The rationale for treatment of the avulsed tooth in a single-visit technique was based on extraoral dry time. Using dry time as a guide, teeth that are replanted in severe malposition have exposed root surfaces, which would not be completely immersed in saliva, resulting in increased dry time. It was therefore estimated that the extraoral dry time for tooth No. 9 would have to be greater than 60 minutes. In addition, medicating an avulsed tooth with an extraoral dry time of 25 minutes has been shown to have no statistical difference regarding resorption compared to obturation with gutta percha and sealer.²¹

The resorption of tooth No. 9 might be related to orthodontic movement of the tooth.^22,23 While endodontic treatment of teeth does not increase and may actually decrease the chances of root resorption from orthodontic forces,²⁴ the timing of when it is safe for orthodontic movement of previously traumatized endodontically treated teeth remains unclear. Andreasen recommended waiting 3 months for mild injury (concussion and subluxation) and 1 year for severe injury (lateral, extrusive, or intrusive luxation and avulsion).²⁵ In this case report, orthodontics was initiated 1 year and 7 months following trauma and endodontic treatment. Currently, there are no standard guidelines for clinical and radiographic follow-up of previously traumatized teeth undergoing orthodontic tooth movement.

The current plan for tooth No. 9 is to maintain the tooth long enough to allow for an implant to be placed. If the resorption continues, the current obturation will be replaced with either white MTA or calcium hydroxide. Re-obturation with white MTA^26,27 or calcium hydroxide²⁸ could slow or arrest external root resorption long enough for subsequent placement of a dental implant.

The case described the attempted retention of an avulsed tooth that was replanted incorrectly. Not all trauma cases predispose themselves to rigid trauma recommendations. Knowledge, experience, and communication between practitioners are paramount to successful treatment outcomes.

The author would like to thank James B. Julian, DDS, for contributing his knowledge and expertise during telephone consultation for this case.

Philip L. Michaelson, MS, DMD
Diplomate
American Board of Endodontics

Private Practice
Chagrin Falls, Ohio