Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted

Experts consensus on management of tooth luxation and avulsion

Traumatic dental injuries (TDIs) of teeth occur frequently in children and adolescents. TDIs that impact the periodontal tissues and alveolar tissue can be classified into concussion, subluxation, extrusive luxation, intrusive luxation, lateral luxation, and avulsion. In these TDIs, management of injured soft tissue, mainly periodontal ligament, and dental pulp, is crucial in maintaining the function and longevity of the injured teeth. Factors that need to be considered for management in laxation injuries include the maturation stage of the traumatic teeth, mobility, direction of displacement, distance of displacement, and whether there are alveolar fractures. In avulsion, the maturation stage of the permanent tooth, the out-socket time, storage media/condition of the avulsed tooth, and management of the PDL should also be considered. Especially, in this review, we have subdivided the immature tooth into the adolescent tooth (Nolla stage 9) and the very young tooth (Nolla stage 8 and below). This consensus paper aimed to discuss the impacts of those factors on the trauma management and prognosis of TDI to provide a streamlined guide for clinicians from clinical evaluation, diagnostic process, management plan decision, follow-up, and orthodontic treatment for tooth luxation and avulsion injuries.

Two-year Follow-up of Avulsed Teeth Submittted to Laser Therapies: A Case Report

Background:

Replanted teeth can lead to critical biological conditions involving ankylosis and external root resorption. To prevent these occurrences, antimicrobial Photodynamic Therapy (aPDT) and Photobiomodulation Therapy (PBMT) can be used during the postoperative phase.

Case Report:

The present report described the clinical case of a patient, an adult male with the avulsion of teeth #11 and #21. Teeth were stored under dry conditions and replanted 18h after trauma. The pulp was removed before replantation and aPDT was performed using a low power laser (660 nm,100 mW, 9 J) in direct irradiation of the root canal. A passive flexible splint was fixed in place from tooth #13 to #23 for 4 weeks. The PBMT was applied three times a week, for the first 2 months, using the same laser device but with an infrared wavelength (808 nm, 100 mW, 3J). Clinical and radiographic examination supported the assessment of inflammatory/infectious resorption.

Conclusion:

The combination of laser therapy with endodontic procedures for treating traumatized teeth ensured successful clinical and radiographic outcomes at a 2-year follow-up examination.

Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted

BACKGROUND

Traumatic dental injuries are common. One of the most severe injuries is when a permanent tooth is knocked completely out of the mouth (avulsed). In most circumstances the tooth should be replanted as quickly as possible. There is uncertainty on which interventions will maximise the survival and repair of the replanted tooth. This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To compare the effects of a range of interventions for managing traumatised permanent front teeth with avulsion injuries.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 March 2018), Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 2) in the Cochrane Library (searched 8 March 2018), MEDLINE Ovid (1946 to 8 March 2018), and Embase Ovid (1980 to 8 March 2018). The US National Institutes of Health Ongoing Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We considered randomised and quasi-randomised controlled trials that included a minimum follow-up period of 12 months, for interventions for avulsed and replanted permanent front teeth.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias. Authors were contacted where further information about their study was required.

MAIN RESULTS

Four studies, involving a total of 183 participants and 257 teeth were identified. Each of the interventions aimed to reduce infection or alter the inflammatory response or both at the time of or shortly after the tooth or teeth were replanted. Each study assessed a different intervention and therefore it was not appropriate or possible to numerically synthesise the data. All evidence was rated as being of very low quality due to problems with risk of bias and imprecision of results. This means that we are very uncertain about all of the results presented in this review.One study at high risk of bias with 69 participants (138 teeth) compared a 20-minute soak with gentamycin sulphate for both groups prior to replantation with the experimental group receiving daily hyperbaric oxygen for 80 minutes for the first 10 days. There was some evidence of a benefit for the hyperbaric oxygen group in respect of periodontal healing, tooth survival, and pulpal healing.One study at unclear risk of bias with 22 participants (27 teeth) compared the use of two root canal medicaments, Ledermix and Ultracal. There was insufficient evidence of a difference for periodontal healing or tooth survival. This was the only study to formally report adverse events with none identified. Study authors reported that Ledermix caused a greater level of patient dissatisfaction with the colour of avulsed and replanted teeth.A third study at high risk of bias with 19 participants compared extra- or intra-oral endodontics for avulsed teeth which were stored dry for longer than 60 minutes before replantation. There was insufficient evidence of a difference in periodontal healing.The fourth study at high risk of bias with 73 participants compared a 10-minute soak in either thymosin alpha 1 or saline before replantation followed by daily gingival injections with these same medicaments for the first 7 days. There was some evidence of a benefit for thymosin alpha 1 with respect to periodontal healing and tooth survival.

AUTHORS' CONCLUSIONS

Based on the results of the included studies, there is insufficient evidence to support or refute the effectiveness of different interventions for avulsed and replanted permanent front teeth. The overall quality of existing evidence was very low, and therefore great caution should be exercised when generalising the results of the included trials. There is urgent need for further well-designed randomised controlled trials.

Efficacy of Hank's balanced salt solution compared to other solutions in the preservation of the periodontal ligament. A systematic review and meta-analysis

This systematic review and meta-analysis (MA) aimed to verify the capacity of different storage media to preserve viability of periodontal ligament cells in comparison to Hank’s Balanced Salt Solution. The searches, selection process, data extraction and Risk of Bias control were conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Five MA were conducted to compare the cell viability between milk versus Hank's balanced salt solution (HBSS) in a dichotomous (1) or continuous (2) data model; tap water versus HBSS (3); medicinal herbals versus HBSS (4); and saline solution versus HBSS (5). 693 potentially studies were identified, with 18 studies included in the qualitative and 8 studies included in the quantitative analysis. Most of the articles presented a low risk of bias. HBSS medium showed a superior ratio of cell viability compared to tap water (RR 0.26; 95% CI [0.21, 0.32]; p < 0.00001; I2 = 96%) and saline solution (RR 0.76; 95% CI [0.69, 0.84]; p < 0.0001; I2 = 99%). Herbal medicines showed a similar ratio of cell viability when compared to HBSS (RR 0.97; 95% CI [0.94, 1.00]; p = 0.08; I² = 50%). Mixed results were observed between milk and HBSS: a superior ratio of HBSS was observed in an overall evaluation (RR 0.26; 95% CI [0.21, 0.32]; p < 0.00001; I² = 96%), and a similar ratio was achieved when periodontal ligament (PDL) cells were removed prior to immersion in the solution (RR 0.94; 95% CI [0.87, 1.01]; p = 0.10; I2 = 0%) or rinsed in tap water or maintained in open air prior to immersion (RR 0.63; 95% CI [0.35, 1.12]; p = 0.11; I2 = not applicable). This systematic review and MA suggests that milk and herbal medicines could represent an alternative to HBSS. However, more studies are necessary to obtain a reliable conclusion.

Reimplantation of avulsed maxillary central incisors – case report of an 8-year follow-up

Dental trauma is very common, especially in children and adolescents. Tooth avulsion (exarticulation), which is a result of complete rupture of periodontal ligaments is one of the most severe dental injuries. The treatment of choice in avulsion of permanent teeth is reimplantation. Survival of reimplanted teeth depends greatly on the time and conditions in which teeth were stored outside the oral cavity. This report presents a case of 18-year old male with avulsion of central maxillary incisors. The teeth were reimplanted 14 hours after injury. During 8-year follow up no major complications occurred and the teeth still maintain their function, although signs of mild replacement resorption are visible on the follow-up radiographs.

Multidisciplinary treatment options of tooth avulsion considering different therapy concepts

BACKGROUND

Avulsion of permanent front teeth is a rare accident, mostly affecting children between seven and nine years of age. Replanted and splinted, these teeth often develop inflammation, severe resorption or ankylosis affecting alveolar bone development and have to be extracted sooner or later.

OBJECTIVES

The purpose of this study was to evaluate different therapy concepts to create a structured concept for the treatment of avulsions.

RESULTS

Based on existing therapy concepts, a concept for different initial conditions (dry time, age, growth, tooth, hard and soft tissues) was developed and is presented here.

CONCLUSION

A great deal of research has been performed during recent years and guidelines for the management of avulsions have been published. With the help of this literature it is possible to identify the best treatment procedure for each tooth.

CLINICAL RELEVANCE

The prognosis of avulsed teeth can be improved by considering evidence-based therapy concepts. Resorption, ankylosis and tooth loss could be minimized.

Interventions for treating traumatised permanent front teeth: luxated (dislodged) teeth

BACKGROUND

Dental trauma is common especially in children and young adults. One group of dento-alveolar injuries is classified as luxation. This group includes a subgroup of severe injuries where the tooth is displaced from its original position. These injuries are classified further by the direction in which the tooth has been displaced, namely: intrusion, extrusion and lateral luxation.

OBJECTIVES

To evaluate the effects of a range of interventions for treating displaced luxated permanent front teeth.

SEARCH METHODS

Search strategies were developed for MEDLINE via OVID and revised appropriately for the following databases: Cochrane Oral Health Group's Trials Register (to 20 August 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 8), MEDLINE via OVID (1966 to August 2012), EMBASE via Elsevier (1974 to August 2012), and LILACS via BIREME (1982 to August 2012). Dissertations, Theses and Abstracts were searched as were reference lists from articles. There were no language restrictions.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of treatment interventions for displaced luxated permanent front teeth. Included trials had to have a minimum follow-up period of 12 months.

DATA COLLECTION AND ANALYSIS

Two review authors independently and in duplicate assessed the eligibility of all reports identified in the searches. Authors were contacted for additional information where required.

MAIN RESULTS

No randomised or quasi-randomised controlled trials were found.

AUTHORS' CONCLUSIONS

We found no randomised or quasi-randomised trials of interventions to treat displaced luxated permanent front teeth. Current clinical guidelines are based on available information from case series studies and expert opinions. Randomised controlled trials in this area of dental trauma are required to robustly identify the benefits of different treatment strategies.

Periodontal healing following avulsion and replantation of teeth: a multi-centre randomized controlled trial to compare two root canal medicaments

BACKGROUND

 Non-setting calcium hydroxide (Ultracal XS(®) ) is recommended by the International Association of Dental Traumatology as the initial medicament following avulsion and replantation for mature teeth. There is experimental evidence to suggest Ledermix(®) , placed as an alternative inter-visit dressing may improve periodontal healing.

AIM

 This study investigated, using a multi-centre randomized controlled trial, the effect of two root canal medicaments, Ledermix(®) and Ultracal XS(®) , on periodontal healing of avulsed and replanted teeth.

MATERIAL AND METHODS

 Children were recruited if they fulfilled all inclusion criteria. Treatment followed a standardized protocol. Assessment of periodontal healing or ankylosis was made clinically and radiographically by an experienced, 'blinded', clinician at 12months.

RESULTS

 Over 200 patients were assessed for eligibility at five centres. Twenty-nine patients were eligible for inclusion. Final analysis involved 22 patients with 27 teeth. Ankylosis was detected in four of the 12 teeth in the Ledermix(®) group and nine of 15 in the Ultracal XS(®) group. No significant difference between medicaments was found in the proportion of teeth or patients showing periodontal healing.

DISCUSSION

 There was no significant difference in periodontal healing between the two medicaments at either a tooth or patient level. The numbers recruited fell short of an estimated power calculation. For patients meeting the inclusion criteria and completing the trial, periodontal healing was seen in 52% of teeth at the 12-month assessment between both groups. The only factor found to significantly influence the periodontal outcome was dry time.

The treatment of anterior dental trauma

BACKGROUND

Avulsed frontal teeth often cannot be saved because of improper or lack of initial treatment. The result is a need for multiple interventions over the patient's lifetime, which also carry a high financial cost.

METHODS

We explored the subject of lost anterior teeth in young patients with a PubMed search based on the term "prevalence of traumatic dental injuries" over the time period 2000-2010. In this article, we selectively review the publications retrieved by the search and give case examples to illustrate the proper initial treatment of children and adolescents (ages 6 to 17) with broken anterior teeth.

RESULTS

The search retrieved 138 articles. Here, we review retrospective clinical studies of dental trauma between the ages of 6 and 17: only 6 adequately designed studies of this type were found. The estimated prevalence of anterior dental trauma in this age group ranged from 6.4% to 37.9%. The recommended initial steps for the preservation of traumatized teeth are easy to take. Avulsed teeth can and should be replanted at once. If there is no time, or if the patient simultaneously has other, life-threatening injuries, the avulsed teeth can be stored in a special nutrient medium until they can be replanted. Commercially available tooth rescue boxes enable replantation to be performed up to 24 hours after the injury.

CONCLUSION

The authors of the selected studies agree that dental trauma is often improperly treated. Timely treatment of injured anterior teeth prevents much further damage and expensive treatment for the affected young patients.