Wednesday, September 25, 2013

Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome



Permanent Tooth Replantation Following Avulsion: Using a Decision Tree to Achieve the Best Outcome

By Judy D. McIntyre, DMD, MS; Jessica Y Lee, MPH, PhD; Martin Trope, DMD; William F. Vann Jr. DMD, PhD

Pediatric Dentistry V31/ No2 MAR/APR 2009

Resident Avani Khera

Purpose: Update of tooth replantation flowcharts published in 2001 and 2007 (via guidelines from the AAE and IADT) with current concepts, philosophies, literature based findings and consensus from the 2008 AAPD Dental Trauma Symposium

-The maxillary central is incisor is the most commonly avulsed tooth, between ages of 8-12 years.
-2 primary complications occurs 1) pulpal infection 2) PDL damage

Clinical Management: Minimize attachment damage and PDL inflammation
1.    IMMEDIATE REPLANTATION!
2.     Dry time less than 20 minutes is ideal
3.     If open apex, tooth may revascularize, closed apex need RCT.
4.     The alveolar socket can be rinsed with saline to remove contaminated clot.
5.     Replanted teeth should be splinted for 2 weeks with flexible wire and bonded into place with flowable resin.
6.     Avulsed teeth should be retained until after craniofacial growth and development are completed (18 years), after which other treatment options such as dental implant of bridge should be considered.
7.     Doxycycline or Penn VK 7 days/chlorohexidine RX should be given following replantation.
8.     If open apex tooth is not immediately replanted at accident site but is less than 60 minutes, we should soak in 1% doxycycline solution (not sure we have this)? If more than 60 minutes soak in NaF.
9.     If the tooth has been out of the mouth for more than 60 minutes (open or closed apex-the PDL is dead), the tooth should be scaled to remove the PDL (to prevent a stimulus for inflammation that will accelerate infected related resorption) and placed in NaF solution (NaF will delay, but not prevent ankylosis).


Newer Treatment Regimens:
-Soaking an open apex tooth in a topical antibiotic solution increases its change of revascularization (1 mg doxycycline+20mL sterile water). You can also use Arestin (minocycline).
-HBSS solution is the best solution to transport an avulsed tooth in, as it is pH and organ preserving medium. Milk is the second best alternative.  Gatorade and contact len solution on ice has shown to be ok. Tap water is the worst.

Long-term therapy of condemned PDL:
Ankylosis is an unfortunate outcome for about 48% of replanted teeth.
-When an adolescent’s maxillary growth is completed, the following is an excellent treatment option for an ankylosed tooth:
1. Decoronation (raise a flap, remove crown below level of CEJ, remove root filling material and allow intracanal space to fill with bood)
2. Suture the flap over the site of the newly created “socket”
3. Use the crown of the extracted tooth as a splinted pontic to adjacent teeth.
----this will buy time to preserve the volume, BL, and vertical height of the alveolar process for possible implant in the future.

Why prescribe oral antibiotics?
To prevent bacterial invasion of the necrotic pulp that may precipitate inflammatory resorption.
-If you give RX of tetracycline, make sure child is more than 12 years of age!

Thoughts:
This article is excellent as it provides long term clinical trials and evidenced based research to support its findings.  I’m not sure how common it is that we see children at Hasbro within 20 minutes, however, I think the ED does a good job about replanting teeth immediately.  Lastly, I thought the decoronation technique was very interesting and would love to see a clinical case completed at St. Jo’s trying out this technique.


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