Traumatic extraction of upper central incisors

Summary Introduction Tooth and other oral tissue damage can occur at any time of life. Traumatic extraction is a complex traumatic injury characterized by complete dislodgement of the tooth from its alveolus. The diagnosis of traumatically injured teeth includes X-rays and a detailed clinical examination. Case report A twelve-year-old boy reported at the dental clinic of the Faculty of Medicine due to the injury in the anterior maxillary region. It was a sport injury. The time elapsed since the accident was 2 hours and 20 minutes. According to the clinical examination and X-rays the diagnosis was: The teeth 11 and 21 – Complete traumatic dental avulsion and fracture; 22-Hypodontia and chin contusion and laceration. The teeth were brought in physiological solution. After applying local anesthetic, soft tissue was cleaned, the teeth positioned back in their alveoli and an immobilizing splint of fiberglass fibers placed. The patient was administered antibiotics and recommended tetanus prophylaxis. Seven days after the injury, teeth were treated endodontically. After one month, the immobilizing splint was removed. The tooth 21 was definitely obturated and composite buildups were done on both teeth. Calcium hydroxide dressing was left in the canal of the tooth 11. One month and 3 weeks after the injury, a fistula appeared above the tooth 11, and the treatment was finally completed after seven months. Conclusion Traumatic tooth injuries, of any kind, require urgent treatment as time loss usually reduces chances for successful treatment. One year after the injury, the patient had no symptoms and the result was functional and aesthetically acceptable.


INTRODUCTION
Traumatic injuries of teeth and other oral tissues can occur at any time of life. They happen usually between 1-3 years in primary and 8-11 years in permanent dentition [1,2]. The most commonly affected teeth are upper central and lateral maxillary incisors that are more exposed to injuries due to anterior position [3]. Injuries of anterior teeth can lead to phonetic, functional, aesthetical problems as well as disorders in occlusion [1]. Preliminary studies suggest that boys are more prone to trauma [4][5][6][7][8].
Traumatic tooth extraction (Avulsio completa, Extrusio completa, Luxatio completa dentis, Exarticulatio completa) is a complete loss of a tooth from the alveolus and it is one of the most serious tooth injuries. Although clinically visible alveolus is easily detected, the diagnosis of traumatic tooth injuries is only established after the X-ray examination. Differential diagnostic considerations are tooth inntrusion (Intrusio dentis) and root fracture with the loss of crown (Fractura radicis dentis). The main cause of traumatic extraction in primary dentition is fall, while in permanent dentition it is direct (frontal) stroke of the tooth. The frequency of these injuries in primary dentition is 7%, while in permanent dentition it is lower and about 0.9% of all tooth injuries [9].
Traumatic tooth injuries of any kind require immediate treatment as any loss of time reduces the chances of successful treatment. In the case of tooth avulsion, the success of tooth replantation, posttraumatic period, as well as the possibility and the rate of complications, depends on numerous factors [10]. The most important are: the time between the injury and the time of tooth replantation, the way tooth is kept during this time period, the stage of development of the root, the condition of alveolar bone, the preliminary condition of the crown of the tooth, pulp and periodontal ligament, the existence of possible orthodontic irregularities as well as the replantation procedure itself [11]. Although long-term prognosis for retaining tooth in the jaw is not certain, due to the importance of preserving the height of alveolar ridge, function, phonetics and esthetics, it is always important to try replantation if there are adequate conditions for it.
The aim of this paper was to show the procedure, the treatment and complications after the tooth avulsion.

CASE REPORT
A 12-year-old boy visited nearest dental clinic in Visegrad due to a tooth injury in the upper jaw after falling during sport activity. Patient gave a history of the fall and he did not show any signs or symptoms of neurological damage. Due to the lack of material for the immobilization splint, the boy was sent to a dental clinic at the Faculty of Medicine in Foca. After obtaining accident history and performed clinical examination ( Figure 1) and X-ray (Figure 2), the following diagnosis was made: The teeth 11 and 21 -Complete traumatic dental avulsion; 22-Hypodontia; 11 -Traumatic tooth fracture class I; 21 -Traumatic tooth fracture class II as well as chin contusion and laceration.
The teeth were transported in a glass bottle with physiological solution (Figure 3). The available treatment options were explained to the parents. After 2 hours and 20 minutes, the replantation procedure was performed as per recommendation of The International Association of Dental Traumatology -IADT [12]. Local anesthesia was administered. In order to remove impurities and blood clots, injured region was cleaned with sterile gauze soaked with saline. Removal of soft deposits from adjacent teeth on which the splint was to be placed was performed. 37% orthophosphoric acid was applied for 30 seconds ( Figure  4). After rinsing and drying ( Figure 5), an adhesive was placed. During this time, the avulsed teeth were removed from the transport medium, carefully rinsed with saline and on the vestibular surface of the crown the same procedure of etching with the acid ( Figure 6) and adhesive was performed. The alveoli were rinsed with saline and avulsed teeth were slowly replanted using digital pressure only. An immobilizing splint was installed (Figure 7). The time elapsed from the moment of injuries to the completion of replantation was 2 hours and 45 minutes. Tetanus prophylaxis was recommended, tetracycline antibiotics prescribed for 5 days and analgesics as needed. Patient was advised to take soft diet and maintain good oral hygiene. The postop checkup was scheduled 7 days after.
At the first checkup, the replanted teeth were mostly firm and stable on mild palpation. After clinical and radiographical evaluation root canal was performed on both teeth 11 and 21 according to the standard procedure. After copious irrigation with physiological solution and drying the canal with paper points, the teeth were filled with calcium hydroxide (Calcipulpe®Septodont, Cedex, France) and patient was scheduled for the next checkup in 7 days. At the second checkup, 15 days after the injury, the re-   planted teeth were not completely firm to palpation, while on the mild vertical and horizontal percussion they were sensitive, especially the tooth 11. Taking into account the size of the injured area, hypodontia of the tooth 22, the time that elapsed from the moment of injury to teeth replantation, the immobilizing splint was kept in place for another two weeks. One month after the injury, calcium hydroxide dressing was removed, canals irrigated with 2% sodium hypochlorite solution and physiological solution. The X ray examination was done. Due to the satisfactory clinical and radiological findings the tooth 21 was finally obturated while calcium hydroxide was placed back in the canal of the tooth 11. In the same visit, the immobilization splint was removed. Then after, the teeth that were in the splint were treated with Fluorogal®Forte Gel, Galenika A.D.
Belgrade. The patient was scheduled for another visit in three days. After 1 month and 3 days, composite buildups were done on both teeth, 11 and 21. The tooth 21 was definitely obturated (Gutaperka points and pastes for definitive obturation) while on the tooth 11 root canal treatment continued until all symptoms of chronic infection were gone. After 1 month and 3 weeks, a fistula appeared above the root of the tooth 11. Calcium hydroxide was replenished every month, and seven months after the injury, the tooth 11 was definitely obturated. One year after the injury, the patient did not have any subjective sympthoms, and the result achieved was functionally and aesthetically acceptable ( Figure 8). However, X ray showed the initial signs of internal resorption of the tooth 21 ( Figure 9). The patient has been monitoring on regular checkups scheduled every six months patient for up to 5 years.

DISCUSSION
It has been recommended in some studies that every avulsed tooth should be replanted regardless of the time between the accident and replantation [9]. Considering    the age of the patient, the size of injured area, the way the teeth were kept in saline, and hypodontia of the tooth 22, replantation was also chosen in our case. The parents were presented with options and minimal chances for successful treatment of teeth replantation. Also they understood posttraumatic period and possible complications.
Extraalveolar time can be short (less than 20 min), medium (20-60 min) and long (more than 60 min). Although for our patient extraalveolar time was long (2 hours and 20 minutes after the injury), avulsed central incisors were replanted and the immobilization splint was placed. It is believed that periodontal ligament maintains its vitality within the first 20 minutes of the injury [12, 13, 14]. The teeth replanted within that time frame have the best prognosis and the greatest possibility for healing of periodontal ligaments [12]. However, the literature presents cases of tooth restoration even after 36 hours of injury [15]. Ideally, avulsed tooth is to be returned to the alveolus immediately after the injury occurs. If this is not done, it is necessary to put the tooth in the transport medium and, as soon as possible, refer patient to the dentist. The type of media in which the tooth is stored determines the long-term prognosis of the replanted tooth. Ideal medium should preserve most of functional capabilities of periodontal ligament cells [14]. The tooth must not be dried or transported in dry, which occurs when wrapping in wipes and gauze or similar things. This leads to dehydration of still preserved cells on the surface of root that start to die in dry medium. There are various media for storing avulsed teeth that are widely available (water, saliva, saline, milk, ...) as well as specialized media. Water can protect the tooth from dehydration but if it is used for more than 20 minutes it leads to rapid deterioration of periodontal ligament cells [16].
Saliva is easily accessible and favorable storage medium if used for less than one hour. Research has shown that saline as an environment for storing avulsed teeth can also be harmful to periodontal ligament cells if used for more than two hours because there are not enough essential nutrients such as magnesium, calcium and glucose, which are important for the metabolic needs of periodontal cells [17]. Modern research suggests that milk is an excellent storage medium for up to 6 hours because it does not have bacteria and has pH and osmolality compatible with those of the periodontal ligament cell and has nutrients such as amino acids, carbohydrates and vitamins [9, 18, 19]. There are several types of special media for transportation of avulsed teeth: Hank's Balanced Saline Solution (HBSS), DentoSafe and ViaSpan media for tissue and organ transplantation [3,19]. Today, DentoSafe (Dentosafe GmbH, Iserlohn, Germany) is considered to be the most appropriate media for preserving and transporting avulsed tooth [16], and therefore DentoSafe vials should be available in all places at risk of dental trauma such as schools, daycares, children's playgrounds and sport fields.
Endodontic treatment of injured teeth, in our patient, started after seven days. Some authors point out that, in order to prevent necrosis of the pulp of the avulsed tooth, it is necessary to start the root canal treatment for 7-10 days from avulsion [14], which is in accordance with our procedure. Any further delay greatly increases the risk of post-implantation necrosis and loss of teeth [16]. Postdental trauma complications can occur in pulp, periodontal ligament, and surrounding structures. The most common are pulp necrosis [20] and root resorption [10, 21]. One month and 3 weeks after the injury a fistula appeared above one replanted tooth (11) in our case. There was also palpation and percussion sensitivity on the same tooth. Some authors suggest that optimal length of having the immobilization splint, for regeneration of periodontal ligament is two weeks [12,16]. Due to the size of traumatic field and hypodontia of the tooth 22 our patient wore a splint longer than recommended time. In our case the patient had two avulsed teeth even though the most common is just one affected tooth [3].
Trauma has serious aesthetical, functional, psychological and economic consequences for patients and their parents [16,22]. Our patient and his parents were unaware that teeth can be replanted back to their place until dentist suggested such an intervention. Other studies conducted on this topic have also shown that parents' knowledge of tooth injuries and possible treatment is inadequate [22,23]. Everyone involved in childcare should be properly educated in prevention and treatment of all kinds of dental trauma. Replantation of avulsed tooth in children is not important only from functional point, but it also has great psychological, emotional and social significance both for the child and parents.

CONCLUSION
Early tooth loss has a negative impact on child's psychosocial development. It is therefore important to educate parents and all childcare personnel (educators, teaching staff, trainers) about injury prevention, urgent treatment, possibilities of replantation of avulsed teeth, as well as the procedure and possible way of transporting avulsed teeth. Transporting mediums for avulsed teeth should be available in all daycares, schools and sports clubs. In addition children involved in sport activities should be wearing sport guards.