Tuesday, May 31, 2016

Emerging Therapies for the Management of Traumatized Immature Permanent Incisors

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Amir Yavari                                                                                   Date: 06/01/2016

Article Title:  
Emerging Therapies for the Management of Traumatized Immature Permanent Incisors
Author(s): Miller E.K., et all
Journal: Journal of Pediatric Dentistry
Date: 2012
Type of Article: Case Report  
Main Purpose: Report the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption.
Summary:
Early loss of immature permanent teeth due to pulpal necrosis secondary to trauma can have dire consequences for a child's growth and development.
The treatment alternatives include:
-       Surgical endodontics, traditional calcium hydroxide apexification
-       Mineral trioxide aggregate (MTA) apexification
These options pose potential complications, including: arrest of root development; weakened dentinal walls and increased potential for fracture.
Revascularization of the dentin-pulp complex is a new approach that involves disinfecting the root canal system followed by tissue repair and regeneration while allowing for continued root development and thickening of the lateral dentinal walls through deposition of new hard tissue.
The purpose of this report was to present the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption.
A healthy 9 year-old male presented to the ED Pediatric Dental Service with dental trauma. Cursory dental exam revealed multiple abrasions, swellings, and contusions and avulsion of the permanent maxillary right central incisor. The tooth had been placed in cold milk within 3 minutes of the trauma. The patient was anesthetized using 0.9 ml of 3% mepivicaine without epinephrine. Because topical antibiotic treatment reduces micro-abscesses in the pulpal lumen, reduces contamination of the root surface and pulp space, and helps facilitate a biological environment that aids revascularization, the tooth was placed in a 1% doxycycline/sterile saline solution for 5 minutes. The tooth was replanted with digital pressure and splinted using a titanium trauma splint. Prescriptions were given for a chlorhexidine rinse twice daily and doxycycline 150 mg for 7 days, because administration of systemic antibiotics has been shown to prevent or inhibit external root resorption.

Six months later, internal bleaching was performed to remove cervical discoloration from the triple antibiotic paste.
At 18 months, the tooth remained vital and had evidence of continued root development.

Assessment of Article:  Level of Evidence/Comments:

Wednesday, May 25, 2016

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.


Department of Pediatric Dentistry

Lutheran Medical Center

 

Resident’s Name: John Diune                                                            Date: 5/25/2016

Article Title: International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.
Author(s): Di Angelis, A.J., et al
Journal: Dental Traumatology
Date: 2012
Major Topic: Trauma
Type of Article: Literature review
Main Purpose: Establish updated guidelines for trauma
Key Points/Summary:
Traumatic dental injuries (TDIs) account for 5% of all injuries for which people seek treatment.
 
25% school children experience dental trauma
33% adults experience trauma to permanent dentition
 
Luxation most common TDI in primary dentition
Crown fracture more in permanent dentition
 
International Association of Dental Traumatology (IADT) 2012 updated guidelines for immediate or urgent care of TDIs.
-          Current dental literature using EMBASE, MEDLINE, and PUBMED from 1996-2011
-          Expert professional judgement from group of researchers and clinicians
 
Radiographic examination recommendations:
1.       90o horizontal angle centered on tooth
2.       Occlusal view
3.       PA with lateral angulations from mesial and distal aspects
-          CBCT not considered routine, but emerging imaging modality providing enhanced visualization
 
Splinting type and duration
-          Short-term, non-rigid splints recommended for luxated, avulsed, and root-fractured teeth
-          Type of splint and duration not significantly related to healing outcome
-          Considered best practice to
o   Maintain repositioned tooth in correct position
o   Provide patient comfort
o   Improve function
 
Antibiotic use
-          Limited evidence in management of luxated or root-fractured teeth
-          Patient dependent
 
Sensibility tests
-          At least 2 signs/symptoms needed for diagnosis of pulpal necrosis (at time of injury sensibility tests frequently negative)
-          Regular follow-up needed for diagnosis of pulpal necrosis
 
Immature vs mature permanent teeth
-          Preserving pulp vitality is crucial – every effort should be made
-          Crown-fracture (w/ or w/out pulp exposure) and luxation injury has greater frequency of pulp necrosis
 
Pulp canal obliteration (PCO)
-          PCO occurs more frequently when Open apex and suffered severe luxation injury
-          Ongoing vitality
-          Common after root fracture
 
Patient instructions
-          Patient compliance with follow-up and home care contributes to better healing
-          SEE GUIDELINES for TABLES and PICTURES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of Article:  Level of Evidence/Comments:
 
 
 
 
 
 
 
 
 
 

 

AAPD Clinical Guideline on Management of Acute Dental Trauma

AAPD Clinical Guideline on Management of Acute Dental Trauma
Journal:  AAPD Guidelines
Author: Council on clinical Affairs
Date:  2001, Revised: 2004, 2007, 2010, 2011
Major Topic: Management of Acute Dental Trauma
Main Purpose:
  • The greatest incidence of trauma to the primary teeth occurs at 2 to 3 years of age, when motor coordination is developing and the most common injuries to permanent teeth occur secondary to falls, followed by traffic accidents, violence, and sports.
  • History, circumstances of the injury, pattern of trauma, and behavior of the child and/or caregiver are important in distinguishing non-abusive injuries from abuse.
  • Practitioners have the responsibility to appropriately manage or refer children as dictated by the complexity of the injury: compromised airway, neurological deficits, hemorrhage, nausea/vomiting, or suspected loss of consciousness all require further evaluation by a physician.
  • Be sure to caution parents that the primary tooth’s displacement may result in any of several permanent tooth complications, including enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption patterns or sequence.
  • To stabilize a tooth following traumatic injury, a splint may be necessary.  Characteristics of the ideal splint include:  easily fabricated in the mouth without additional trauma; passive unless orthodontic forces are intended; allows physiologic mobility; nonirritating to soft tissues; does not interfere with occlusion; allows endodontic access and vitality testing; easily cleansed; easily removed.

Management Recommendations

Infraction: incomplete fracture/crack of the enamel without loss of tooth structure.
Diagnosis: Normal gross and radiographic appearance; craze lines apparent, especially with trans-illumination.

Crown fracture–uncomplicated :an enamel fracture or an enamel-dentin fracture that does not involve the pulp.
Treatment objectives: Maintain pulp vitality; restore esthetics and function. Injured lips, tongue, and gingiva should be examined for tooth fragments. Take radiographs when lacerations are present. Rough margins and edges of minor fractures can be smooth. For larger factures, lost tooth structure can be restored.

Crown fracture–complicated: an enamel-dentin fracture with pulp exposure. 
Treatment objectives: 1) Primary teeth: determined by life expectancy of the traumatized primary tooth and vitality of the pulpal tissue. 2) Permanent teeth: alternatives are direct pulp capping, partial pulpotomy, full pulpotomy, and pulpectomy.

Crown/root fracture: an enamel, dentin, and cementum fracture with or without pulp exposure.
Treatment objectives:  1) Primary teeth: When it cannot or should not be restored, the entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth.  2) Permanent teeth: Stabilize the coronal fragment. Definitive treatment alternatives are: remove the coronal fragment followed by a supragingival restoration or necessary gingivectomy, osteotomy, or extrusion (surgical or orthodontic) to prepare for restoration

Root fracture: a dentin and cementum fracture involving the pulp.
Treatment objectives: 1) Primary teeth: Extract or observe. It is not recommended to reposition and stabilize. 2) Permanent teeth: Reposition and stabilize the coronal fragment as soon as possible.
General prognosis: In permanent teeth, the location of the root fracture has not been shown to affect pulp survival after injury, so stabilization of teeth with fractures in the cervical third of the root should be attempted.

Concussion: injury to the tooth-supporting structures without mobility or displacement of the tooth.
Diagnosis: Clinical findings reveal a tooth tender to pressure and percussion without mobility, displacement, or sulcular bleeding. No radiographic findings.

Subluxation: injury to tooth-supporting structures that creates mobilitiy without tooth displacement.
Treatment objectives: 1) Primary teeth: follow for pathology.  2) Permanent teeth: Stabilize the tooth and relieve occlusal interferences. For comfort, a flexible splint can be used for no more than 2 weeks.

Lateral luxation: displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs. 
Treatment objectives: 1)  Primary teeth: allow passive or spontaneous repositioning if there is no occlusal interference. When there is occlusal interference, the tooth can be gently repositioned or slightly reduced if the interference is minor. When the injury is severe or the tooth is nearing exfoliation, extraction is the treatment of choice; 2)   Permanent teeth: Reposition with finger pressure; may need to be extrude to free itself from the apical lock in the cortical bone plate. Splinting an additional 2 to 4 weeks may be needed with breakdown of marginal bone.

Intrusion: apical displacement of tooth into the alveolar bone. PDL is compressed and fracture of the alveolar socket often occurs.
Diagnosis: Tooth appears to be shortened or missing. No mobility or tenderness. PDL space is not continuous.  Relationship to follicle of permanent successor: If the apex is displaced labially, the apical tip can be seen radiographically and the tooth appears shorter than its contralateral. If the apex is displaced palatally towards the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth appears elongated. An extraoral lateral radiograph may also be useful.








Treatment objectives
1) Primary teeth: allow for spontaneous re-eruption except when displaced into the developing successor; in that situation, extract;  2)  Permanent teeth: reposition passively or actively or surgically and then stabilize for up to 4 weeks. For immature teeth with more eruptive potential (root 1⁄2 to 2/3 formed), allow for spontaneous eruption. In mature teeth, reposition and start RCT within the first 3 weeks.
General prognosis: In primary teeth, 90% of intruded teeth will re-erupt spontaneously (either partially or completely) in 2 to 6 months.  Ankylosis may occur if the periodontal ligament was severely damaged. 

Extrusion: partial displacement of the tooth axially from the socket; partial avulsion.
Diagnosis: tooth appears elongated and is mobile. Radiographic findings: increased PDL space.
Treatment objectives:
1) Primary teeth: allow tooth to reposition spontaneously or reposition for minor extrusion (<3 mm) in an immature developing tooth. Indications for an extraction: severe extrusion or mobility, the tooth is nearing exfoliation, the child is unable to cope with the emergency situation, or the tooth is fully formed; 2) Permanent teeth: reposition with slow/steady apical pressure to displace clot at apex and splint for up to 2 weeks.

Avulsion: complete displacement of tooth out of socket. The periodontal ligament is severed and fracture of the alveolus may occur.
Treatment objectives:
1) Primary teeth: primary teeth should not be reimplanted because of the potential for subsequent   
damage to developing permanent tooth germs; 2)    Permanent teeth: replant ASAP and then stabilize for two weeks and consider tetanus and antibiotic   coverage except when replanting is contraindicated by: stage of dental development (risk for ankylosis where considerable alveolar growth has to take place), compromising medical condition, or compromised integrity of the avulsed tooth or supporting tissues.
General prognosis: Depends on root development and extraoral dry time.Best prognosis if replanted immediately. If not, it should be stored in a medium that will help maintain vitality of the PDL fibers. The best physiologic transportation media for avulsed teeth include (in order of preference): ViaspanTM, Hank’s Balanced Salt Solution, and cold milk.  Next best: saliva, physiologic saline, or water.  Water is detrimental - long-term storage (>20 min) in water has an adverse effect on PDL healing, but it is a better choice than dry storage. The risk of ankylosis increases with an extraoral dry time of 20 minutes.  An extraoral dry time of 60 minutes is considered the point where survival of the root periodontal cells is unlikely.
If >60 minutes dry storage, goal is to delay the ankylotic process as long as possible: the remaining PDL should be removed with gentle scaling and root planning, soft pumice prophylaxis, gauze, or soaking the tooth in 3% citric acid for 3 minutes; then a sodium fluoride treatment for 20 minutes. Rationale: this will delay ankylosis because fluoroapatite is more resistant to ankylosis than hydroxyapatite.

Orthodontic movement of traumatized teeth
Simple crown/root fractures without pulpal involvement, wait 3 months. Minor trauma to the tooth and periodontium (concussions, subluxations, and extrusions) also require a 3 month wait.  With moderate to severe trauma/damage to the periodontium, wait at least of 6 months. With root fractures, teeth cannot be moved for at least 1 year.  Because teeth that have sustained severe periodontal injury have been found to undergo pulp necrosis when orthodontic movement was initiated even after a rest period, light intermittent forces are recommended along with avoidance of prolonged tipping forces and contact with the buccal or lingual cortical plates. 
EndFragment


Guidelines for the Managemenet of Traumatic Injuries: 2. Avulsion of Permanent Teeth


Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:   John Kiang                                                                                                Date: 5/25/16
Article Title: Guidelines for the Managemenet of Traumatic Injuries: 2. Avulsion of Permanent Teeth
Author(s): Lars Andreasen et al.
Journal: Reference Manuel  
Date: Dental Traumatology 2012
Major Topic: Trauma Tx.

Main Purpose: The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of avulsed permanent teeth.
Key Points/Summary
Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis.
Avulsion is seen in 0.5%-3% of all dental injuries
Replantation is in most situations the tx of choice (not indicated in severe caries, perio disease, non-cooperative patient, severe medical conditions ie immunosuppression and severe cardiac conditions.
Less than 60 minutes and kept in solution (Hanks, milk etc – viable PDL cells):
Closed Apex
·      If tooth has been replanted prior to arrival:
·      Leave tooth in place
·      Clean area: water, saline, chlorhexidine
·      Suture lacerations
·      Verify tooth position clinically and Radiographically
·      Apply flexible splint for 2 weeks
·      Administer Abx
·      Check Tetanus coverage
·      Patient instructions
·      Initiate RCT in 7-10 days
·      Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Kept in physiological storage medium for less than 60 min. Closed Apex
·      Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline thereby removing contamination and dead cells from the root surface.
  • Administer local anesthesia
  • Irrigate the socket with saline.
  • Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
  • Replant the tooth slowly with slight digital pressure. Do not use force.
  • Suture gingival lacerations if present.
  • Verify normal position of the replanted tooth both, clinically and radiographically.
  • Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
  • Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at appropriate dose for age and weight, is an alternative to tetracycline.
  • If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
  • Initiate root canal treatment 7-10 days after replantation and before splint removal.
  • Soft food for up tp 2 weeks.
  • Brush teeth with a soft toothbrush after each meal.
  • Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.
  • Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
  • Splint removal and clinical and radiographic control after 2 weeks.
  • Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Greater than 60 minutes extra-oral dry time: Closed Apex

Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and can not be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour. However, the expected eventual outcome is ankylosis and resorption of the root and the tooth will be lost eventually.

  • Remove attached non-viable soft tissue carefully, with gauze.
  • Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
  • Administer local anesthesia
  • Irrigate the socket with saline.
  • Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
  • Replant the tooth slowly with slight digital pressure. Do not use force.
  • Suture gingival lacerations if present.
  • Verify normal position of the replanted tooth clinically and radiographically.
  • Stabilize the tooth for 4 weeks using a flexible splint.
  • Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
  • If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.
  • Avoide participation in contact sports.
  • Soft food for up to 2 weeks.
  • Brush teeth with a soft toothbrush after each meal.
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
  • Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immidiately or shortly following replantation and left for at least 2 weeks.
  • Splint removal and clinical and radiographic control after 4 weeks.
  • Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
Ankylosis is unavoidable after delayed replantation and must be taken into consideration. In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome. Decoronation may be necessary when infraposition (> 1 mm) is seen. For more detailed information of this procedure the reader is referred to textbooks.


Open apex:
Tooth replanted prior to the patients arrival at the dental office or clinic
  • Leave the tooth in place.
  • Clean the area with water spray, saline, or chlorhexidine.
  • Suture gingival laceration if present.
  • Verify normal position of the replanted tooth both clinically and radiographically.
  • Apply a flexible splint for up to 1-2 weeks.
  • Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
  • If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
  • The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment is recommended.
  • Avoide participation in contact sports.
  • Soft food for up to 2 weeks.
  • Brush teeth with a soft toothbrush after each meal.
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
  • For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
  • Splint removal and clinical and radiographic control after 2 weeks.
  • Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Open apex:
Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank's Balanced Salt Solution) and/or stored dry less than 60 minutes.

 

  • Clean the root surface and apical foramen with a stream of saline.
  • Topical application of antibiotics has been shown to enhance chances for revascularization of the pulp and can be considered if available (minocycline or doxycycline 1 mg per 20 ml saline for 5 minutes soak).
  • Administer local anesthesia.
  • Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
  • Irrigate the socket with saline.
  • Replant the tooth slowly with slight digital pressure.
  • Suture gingival lacerations, especially in the cervical area.
  • Verify normal position of the replanted tooth clinically and radiographically.
  • Apply a flexible splint for up to 2 weeks.
  • Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
  • If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space. The risk of infection-related root resorption should be weighed up agains the chances of revascularization. such resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.
  • Avoide participation in contact sports.
  • Soft food for up to 2 weeks.
  • Brush teeth with a soft toothbrush after each meal.
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
  • For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
  • Splint removal and clinical and radiographic control after 2 weeks.
  • Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Open apex:
Dry time longer than 60 min or other reasons suggesting non-viable cells.

 

Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in delayed replantation is to restore the tooth to the dentition for esthetic, functional , and psychological reasons and to maintain alveolar contour. The eventual outcome will be ankylosis and resorption of the root.

  • Remove attached non-viable soft tissue with gauze.
  • Root canal treatment can be carried out prior to replantation or later.
  • Administer local anesthesia.
  • Irrigate the socket with saline.
  • Examine the alveolar socket. if there is a fracture of the socket wall, reposition it with a suitable instrument.
  • Replant the tooth slowly with slight digital pressure.
  • Suture gingival lacerations if present.
  • Verify normal position of the replanted tooth clinically and radiographically.
  • Stabilize the tooth for 4 weeks using a flexible splint.
  • Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to tetracycline.
  • If the avulsed tooth has been in contact with soil or if tetanus coverage is uncertain, refer to physician for evaluation of the need for a tetanus booster.
To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.
  • Avoide participation in contact sports.
  • Soft food for up to 2 weeks.
  • Brush teeth with a soft toothbrush after each meal.
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
  • For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
  • Splint removal and clinical and radiographic control after 4 weeks.
  • Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
Ankylosis is unavoidable after delayed replantation and must be taken into consideration. In children and adolescents ankylosis is frequently associated with infraposition. Careful follow-up is required and good communication is necessary to ensure the patient and guardian of this likely outcome. Decoronation may be necessary when infraposition (> 1 mm) is seen. For more detailed information of this procedure the reader is referred to textbooks.