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Abstract – The aim of this study was to find out the causes that lead to dental avulsion in children, to analyze the effectiveness of our treatment and the response of the adults when such incidents occur and finally to determine the occurrence of posttraumatic complications some time after the injury, especially the resorption of the affected teeth root. We analyzed the documentations of a sample of patients containing 57 children who had a total of 90 avulsed teeth and were treated in Dentistry Department of Medical Faculty in Pilsen, Czech Republic, in the years between 1995 and 2005. We discovered that most frequently the children experience dental avulsion in the age between 8 and 11 years old, the most affected teeth are the upper central incisors and the most frequent causes are sports and games which are very common in these ages, in various environments, like schools, sport fields and home. The majority of the children were transferred to the Dentistry Department either quite long after the avulsion incident and without the avulsed teeth, or with the avulsed teeth which were carried in an inappropriate transport medium, indicating that there is insufficient knowledge of adult people, especially the ones who are in daily contact with children, on how to provide first aid in cases of dental avulsion.
Traumatic injuries are very common in young ages, especially in children between 8 and 11 years old (1–5). This study was concentrated on dental avulsion, a situation which is defined as the traumatic expulsion of the tooth from its alveolar socket, during which the neighboring tissues are affected also, and more specifically the periodontal ligaments, the nerves and vessels in the apical area of the root, the gingiva, the alveolar bone and the cement of the root surface (1, 4, 5). It involves mainly teeth with unfinished root development and it belongs among the most serious dental traumas (2) which often results in the loss of the injured tooth. The outcome of the treatment of dental avulsion, as well as the occurrence of future posttraumatic complications depends not only on the time interval between the incident and the dental treatment which ideally should be up to 20–30 min, but also on the transport medium that the avulsed tooth was stored until the visit to the dentist (2–4, 6–9).
The aim of this study was: (i) to find the causes and mechanisms leading to avulsion of permanent teeth, (ii) to determine the frequency of replantation of the avulsed teeth, (iii) to specify the storage medium and the extraoral time and (iv) to analyze any healing events, focusing on the type of the root resorption of the replanted teeth. Moreover, this study was performed in order to evaluate if the response of the adults who were present in such incidents was acute and effective.
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- Materials and methods
Avulsion of teeth occurs more frequently in the ages between 7 and 11 years old (9). In this study 56% of the patients belonged to that age category. Concerning the sex which is most frequently affected, our results confirm the data in the literature (8, 10) since 67% of our patients were boys and only 33% were girls, so the ratio boys/girls was equal to 2:1.
The most frequent causes of dental avulsion are falls from bicycles, falls during walking and running, sports, playing and traffic accidents. In the literature the most frequent causes for dental injuries are quite similar (10, 11).
In this study, like in all studies in the literature (4, 12, 13) the most frequent affected teeth are the upper central incisors and in most of the cases dental avulsion is accompanied with other injuries, like injuries of the neighboring soft tissues, alveolar bone, etc.
The most critical factor for a successful replantation is the transport medium in which the avulsed tooth is stored until the transport of the child to the dentist and the extraoral time interval (1–4, 6, 14, 15). Extraoral period is the time duration between the traumatic avulsion of the tooth until its replantation and it should ideally be up to 20–30 min (1–5). In this study, only one tooth was replanted 30 min after the injury and in one case the child replanted the tooth itself at the place of the accident. Concerning the transport media, it has been proved that the ideal one is the Hanks Balanced Solution in which the avulsed teeth could be stored even up to 24 h and the vitality of the periodontal ligaments will be saved (8, 10). Apart from that, saline solution or milk can be used with relatively good results. Another way is to save the tooth in the oral vestibulum. Water should be the last choice to store the tooth and only if we can not find the prementioned solutions (10).
After replantation, it is advised by many authors (1–6) to apply semi-rigid splinting of the tooth for 7–10 days. In Dentistry Department in Pilsen the replanted teeth were splinted for 2 weeks in most of the cases. The prolongation of the splinting use may lead to ankylosis of the replanted tooth. It is always on the benefit of the patient to prescribe antibiotics and analgetics, mouth rinses with 0.12% chlorhexidine digluconate solution and finally advise the patient to have good oral hygiene and use soft diet.
For teeth with completed root development, after 2 weeks we performed endodontic therapy, in order to decrease the risk of future appearance of inflammatory resorption of the root (8, 16–18). In cases of avulsed teeth with uncompleted root development we should wait before proceeding to endodontic treatment, because if the tooth is replanted until 1 h after its expulsion from the socket, we could expect pulp revascularization, which in the future X-ray controls will be verified by continuation of root development of the replanted tooth. Endodontic treatment should be performed only when clinical and X-ray controls of the tooth with incomplete root development indicate a necrotic pulp (1–5).
The type of healing of the replanted tooth depends on the reaction of the periodontium and the pulp after replantation (19–22). Superficial resorption is considered to be the favorable type of healing and is due to mechanical injury of the periodontal ligaments and the superficial layer of the cement of the root during avulsion injury. Replacement resorption or ankylosis appears in teeth that their periodontal ligaments have dried, have been destructed or removed from the surface of the root (4, 5, 14, 23). Usually this type of resorption can be seen during radiographic controls, 2 months after replantation. Apart from that, sometimes it may lead to infraocclusion which can be diagnosed clinically. This unpleasant situation can be treated by decoronation, a technique that comprises the separation of the clinical crown from the root with a diamond bur, after the elevation of a mucoperiosteal flap and the removal of the root filling (15, 24). This technique has the advantage that the root is gradually resorbed and replaced by alveolar bone and in this case the bone is preserved and can be used in the future for implant. In advance, the separated clinical crown could be bonded to the adjacent teeth, providing the patient a satisfactory aesthetic result. This technique was used in three patients (12%). Inflammatory resorption is the most serious type of root resorption, having the worst prognosis. It is characterized by resorption of the cement and dentin of the root together with inflammatory changes of the periodontium. This type of resorption is always associated with necrosis and infection of the pulp from where bacteria enter the periodontal space through the dentinal tubules. Inflammatory resorption can appear 3 weeks after replantation, and can progress so fast, the might lead to loss of the affected tooth within 8–12 weeks (4). We met with such a situation in three patients (12%). We suppose that the appearance of inflammatory resorption is always related to endodontic treatment on time and filling of root canal with calcium hydroxide, and this is the reason that the occurrence of this serious complication was relatively low in this study group of patients. Other serious complications are considered to be the resorption of the alveolar septum (found in one case, 4%) and the obliteration of the root canal (found in two cases, 8%).