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A case of replantation of deciduous upper central incisors under different extra-alveolar conditions
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
Available online at www.sciencedirect.com
Pediatric Dental Journal journal homepage: www.elsevier.com/locate/pdj
Case Report
A case of replantation of deciduous upper central incisors under different extra-alveolar conditions Nobutaka Isogawa a,b,*, Kaori Ito c, Masakazu Ikeda c,d, Masaaki Ishikawa b a
National Center for Child Health and Development, Pedodontics and Orthodontics, Tokyo, Japan Faculty of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan c Kameda Clinic Dental Center, Chiba, Japan d Department of Comprehensive Dentistry, Kanagawa Dental College, Kanagawa, Japan b
article info
abstract
Article history:
Purpose: The extra-alveolar condition of an avulsed tooth is important for its successful
Received 13 March 2015
replantation. Here we report a case of deciduous incisors replantation under different
Received in revised form
extra-alveolar conditions.
19 July 2015
Case report: Traumatically avulsed upper deciduous central incisors of a 3-year-old girl were
Accepted 11 August 2015
replanted. Two hours before replantation, the left incisor was in a moist condition, while
Available online xxx
the right one was dry. After 3 years, we found that the deciduous incisors were correctly replaced by their successors.
Keywords:
Conclusion: The difference in extra-alveolar conditions between both avulsed deciduous
Ankyloses
central incisors did not produce significant differences between them after replantation.
Avulsed deciduous tooth
Copyright © 2015 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
Extra-alveolar condition Oral injury
1.
Introduction
Avulsion is one of the most severe injuries to the tooth and its periodontal tissue. Based on the guidelines of the International Association of Dental Traumatology, it is not recommended to replant an avulsed deciduous tooth [1]. However, a recent review by Kato [2] stated that an avulsed deciduous tooth should be replanted if there are good extra-alveolar conditions [2]. In addition, some practitioners have reported replantation of avulsed deciduous teeth, with good results
[3e6]. Among the extra-alveolar conditions of an avulsed tooth, the presence of moisture around the tooth before replantation seems to be critical [3e12]. Here we present a case of replantation of avulsed upper deciduous central incisors within 2 h, under different moist conditions.
2.
Case report
A female patient aged 3 years and 4 months came to our clinic with a complaint of avulsed deciduous upper central incisors.
* Corresponding author. Division of Pedodontics/Orthodontics, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan. E-mail address: [email protected] (N. Isogawa). http://dx.doi.org/10.1016/j.pdj.2015.08.001 0917-2394/Copyright © 2015 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
2
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
Fig. 1 e Labial view before replantation. Both central incisors were avulsed and blood clots filled the sockets. (A) Labial view. (B) Radiograph.
Approximately 1 h before, she fell down and hit her upper central incisors against a wooden sash of a window, losing them. Right after the accident, her grandmother found and wrapped the left incisor in food wrapping plastic film, but she did not find the right incisor. The patient did not show neurological symptoms or extraoral injuries, and no other oral injuries were detected by either visual inspection or in radiographs. The alveolar sockets of both central incisors were filled with blood clots (Fig. 1). The examination of the left incisor revealed that although the incisal enamel edge was chipped, the other part of the tooth was intact, and the root surface was covered with moist remnants of periodontal tissue. This incisor was dipped in a saline solution containing heparin (10 U/mL) and ampicillin (100 mg/mL). We explained the benefits and risks of the available treatment options to the child's mother and grandmother, and they selected the replantation option. Her grandmother went back home in search of the right incisor, and brought it to the clinic 1 h later. The right incisor, which had been under a dry condition for about 2 h, was also rinsed in the same saline solution. We replanted both incisors without using endodontic treatments, and fixed them using twisted 0.4-mm orthodontic ligature wire and Super-Bond resin (Sun Medical, Suwa, Japan) from the right to the left lateral incisors. Another radiograph was taken to confirm proper positioning of the replanted incisors (Fig. 2). Postoperative drugs (i.e., amoxicillin, acetaminophen, and povidone iodine solution) were prescribed. The patient was cooperative throughout the treatment. At the 2-week follow up, the marginal gingiva of the central incisors was a little red, and a grayebrown discoloration in the right incisor was observed (Fig. 3). One month after replantation, the dental resin at the right canine and lateral incisor
was detached and rebonded. Two months later, the fixation was removed. The periodontal space of the right central incisor appeared unclear in the radiograph (Fig. 4). Four months later, the right incisor was inclined towards the labial side compared to the left incisor, and the periodontal space of the left incisor also became unclear (Fig. 5). Ankylosis of both incisors was suspected after performing percussion tests and radiographs. Six months later, the discoloration of the right incisor disappeared, and resorption at the lower one-third of the internal root of the left incisor was observed (Fig. 6). Fourteen months later, apical and internal root resorption of the left incisor progressed, and the percussion test revealed no signs of ankylosis (Fig. 7). Twenty months later, the percussion test showed the same results for the right incisor. Apical root resorption progressed, and Grade l tooth mobility was observed in both incisors (Fig. 8). Two years and 3 months later, the replanted teeth were still in almost their original positions, with no pain or inflammation, and their successors seemed to develop normally both in their root formation and eruptive movements. Three years later, both deciduous incisors exfoliated, and their successors erupted in normal positions. However, both permanent incisors showed white spots in the medial incisal edge of the labial side (Fig. 9). This study was approved by the institutional review board of national center for child health and development.
3.
Discussion
The main reasons for replantation of avulsed deciduous teeth not being recommended are the risk of damage to the
Fig. 2 e Labial view after replantation. Both incisors were replanted to their correct positions and fixed using wire and resin. (A) Labial view. (B) Radiograph. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
3
Fig. 3 e Incisor images 2 weeks after replantation. Discoloration of the right central incisor was observed, and incisors presented almost normal anatomical appearance. (A) Palatal view. (B) Radiograph.
Fig. 4 e Incisor images 2 months after replantation. The periodontal space of the right incisor became unclear.
Fig. 5 e Incisor images 4 months after replantation. The periodontal space of both central incisors was unclear.
calcification, and delayed or maldirected eruption of their successors [1,13,14]. However, Holan [15] insisted that there is no evidence to support this theory, even if such risk exists. In addition, some case reports have shown good results after replantation of avulsed deciduous teeth [3e6]. In the case of replantation of avulsed deciduous teeth, Miyashin [16] noted the following necessary conditions: (1) replantation takes place within 3 h after injury; (2) the root surface of the avulsed tooth is in a moist condition during the extra-alveolar period; (3) there is enough alveolar bone remaining for the avulsed tooth to be replanted to the original position; (4) there are enough adjacent teeth to fix the avulsed tooth; and (5) the caretaker understands the risks and benefits of replantation or other treatment options, and can decide a treatment plan by themselves. In our case, the left central incisor fulfilled all the requirements, but the right incisor did not meet requirement 2. From 4 months after replantation, ankylosis of both teeth was suspected from both radiographs and percussion tests, suggesting a failure in revitalization of the periodontal ligaments. The suspected causes of ankylosis in this case seemed to be related to the extra-alveolar conditions of the avulsed teeth, storage medium, and the long fixation period. The earlier start of ankylosis and more labial inclination observed in the right incisor compared to the left might be due to differences in extra-alveolar conditions between them. In many clinics, a saline solution is an accessible medium in which to store avulsed teeth. However, saline solutions are an adequate storage medium only for short periods of time,
Fig. 6 e Incisor images 6 months after replantation. The discoloration of the right incisor disappeared, and internal root resorption of the left incisor was observed. (A) Labial view. (B) Radiograph. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
4
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
Fig. 7 e Incisor images 14 months after replantation. Internal apical root resorption progressed in the left incisor.
Fig. 8 e Incisor images 20 months after replantation. Apical root resorption progressed in both incisors.
because they do not contain essential ions and glucose that are necessary to maintain the viability of periodontal ligament cells [12,17,18]. In addition, ankylosis can be induced by prolonged dry extraoral conditions of avulsed teeth [8,9,18e20]. Our study showed that immersing the avulsed tooth in a saline solution for 1 h seemed to be a negative factor for the viability of periodontal ligament tissue, even though it is better than a dry condition. The fixation period is also important to keep the vitality of periodontal ligament cells, and long-term fixation may cause ankylosis and replacement resorption of the root [8,17,19,20]. In recent treatment guidelines [1,14] the recommended fixation period is up to 2 weeks for avulsed permanent teeth; however, in our case fixation time was 2 months. We did not perform any endodontic treatment to the incisors before replantation because we expected some
revascularization of their pulp, and we applied heparin to the saline solution to prevent coagulation. The exact time of devitalization of the pulp was unknown; however, both replanted teeth kept normal color and mobility until they were replaced by their successors, with no sign of pulp inflammation except for a temporary discoloration in the right incisor. This temporary discoloration might suggest that the dry condition is more severe than saline to maintain the viability of pulp tissue. Although early endodontic treatment is recommended when there is internal root resorption after replanting avulsed permanent teeth [3,21,22], in our case, since the position of root resorption was not cervical but in the lower one-third, we took a wait-and-see approach [23]. Three years after replantation, the permanent central incisors erupted in normal positions, although they presented white spots on the labial side of the mesial incisal edge. Traumatic injuries to deciduous teeth commonly result in the presence of white spots in their permanent successors, and white spots are frequently observed in avulsions [24,25]. Miyashin et al. [26] reported the presence of white spots in 73% of permanent successors after avulsion of deciduous teeth without replantation. For 3 years after replantation, no inflammation was observed in inspections or longitudinal radiographs. Therefore, this suggests that the white spots were not caused by the replantation, but by the initial trauma. In this case, the avulsed teeth had an uneventful course after replantation, and the only consequence was the presence of white spots in the permanent successors. Even though careful observation is necessary, replantation of avulsed deciduous teeth seems to be worth trying.
4.
Conclusion
Contrary to the guidelines of the International Association of Dental Traumatology, in recent years replantation of avulsed deciduous teeth in good extra-alveolar conditions has been suggested. This report showed the progress of replantation of avulsed deciduous upper central incisors under different conditions during the extra-alveolar period. The revitalization of both pulp and periodontal ligament tissue was unknown; however, both deciduous incisors kept almost their original positions with no negative clinical symptoms until they were replaced by their successors, and only white spots were observed in the normally erupted successors. The difference in extra-alveolar conditions between both avulsed deciduous central incisors did not produce significant differences between them after replantation.
Conflict of interest The authors declare no conflicts of interest.
references Fig. 9 e Incisor images 3 years after replantation. Both permanent central incisors erupted in their normal positions, and showed white spots on the lingual side of the medial incisal edge.
[1] Malmgren B, Andreasen JO, Flores MT, et al. International Association of dental traumatology guidelines for the
Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
[2]
[3]
[4]
[5]
[6] [7]
[8]
[9]
[10]
[11]
[12] [13] [14]
[15]
management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2012;28:174e82. Kato M. On the traumatic dental injuries of primary and immature permanent teethdThe treatments with guidelines for the management of traumatic dental injuries. Jpn J Ped Dent 2011;49:215e30 [in Japanese]. Kinoshita S, Mitomi T, Taguchi Y, et al. Prognosis of replanted primary incisors after injuries. Endod Dent Traumatol 2000;16:175e83. Shirase T, Kuroda A, Kawakami T, et al. Case of operation of a replantation of a deciduous toot. Jpn J Ped Dent 2004;42:561e8 [in Japanese]. Kubo S, Kadoya M, Takeuchi T, et al. Replantation of an avulsed primary central incisor. J Hard Tissue Biol 2005;14:154e6. de Carvalho Rocha MJ, Cardoso M. Reimplantation of primary tooth-case report. Dent Traumatol 2008;24:e4e10. Casterline AC. Replantation of avulsed central incisor with advanced periodontal disease: a case report. Endod Dent Traumatol 1999;15:135e7. Kinirons MJ, Gregg TA, Welbury RR, et al. Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption. Br Dent J 2000;189:263e6. Cho SY, Cheng AC. Replantation of an avulsed incisor after prolonged dry storage: a case report. J Can Dent Assoc 2002;68:297e300. Sigalas E, Regan JD, Kramer PR, et al. Survival of human periodontal ligament cells in media proposed for transport of avulsed teeth. Dent Traumatol 2004;20:21e8. Petrovic B, Markovic D, Peric T, et al. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26:52e9. Poi WR, Sonoda CK, Martins CM, et al. Storage media for avulsed teeth: a literature review. Braz Dent J 2013;24:437e45. Cameron AC, Widmer RP. Handbook of Pediatric Dentistry. 3rd ed. London: Mosby Elsevier; 2008. p. 115. American Academy of Pediatric Dentistry Reference Manual 2012e2013. Guideline on management of acute dental trauma. Pediatr Dent 2012;34:230e8. Holan G. Replantation of avulsed primary incisors: a critical review of a controversial treatment. Dent Traumatol 2013;29:178e84.
5
[16] Miyashin M. Long-term prognosis of replanted primary teeth after traumatic avulsion. Additional volume of the Quintessence Year Book. 2012. p. 193e9 [in Japanese]. [17] Andreasen JO, Borum MK, Jacobsen HL, et al. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76e89. [18] Barett EJ, Kenny DJ. Avulsed permanent teeth: a review of the literature and treatment guidelines. Endod Dent Traumatol 1997;13:153e63. [19] Cvek M, Granath LE, Hollender L. Treatment of non-vital permanent incisors with calcium hydroxide. 3. Variation of occurrence of ankylosis of reimplanted teeth with duration of extra-alveolar period and storage environment. Odontol Revy 1974;25:43e56. [20] Khalilak Z, Shikholislami M, Mohajeri L. Delayed tooth replantation after traumatic avulsion: a case report. Iran Endod J 2008;3:86e9. [21] Stewart CJ, Elledge RO, Kinirons MJ, et al. Factors affecting the timing of pulp extirpation in a sample of 66 replanted avulsed teeth in children and adolescents. Dent Traumatol 2008;24:625e7. [22] Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part I: timing of pulp extirpation. Dent Traumatol 2009;25:32e42. [23] de Aguiar Santos BO, de Mendonc¸a DS, de Sousa DL, et al. Root resorption after dental traumas: classification and clinical, radiographic and histologic aspects. RSBO 2011;8:439e45. [24] Mueller BH, Whitsett BD. Management of an avulsed deciduous incisor. Report of a case. Oral Surg Oral Med Oral Pathol 1978;46:442e6. [25] Ishikawa M, Satoh K, Miyashin M. A clinical study of traumatic injuries to deciduous teeth. (3). The influence on their permanent successors. Jpn J Ped Dent 1990;28:397e406 [in Japanese]. [26] Miyashin M, Nakayama M, Ishikawa M, et al. A clinical study of traumatic injuries to primary teeth. (4). The long-term consequences of trauma. Jpn J Ped Dent 2001;39:1078e87 [in Japanese].
Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
Available online at www.sciencedirect.com
Pediatric Dental Journal journal homepage: www.elsevier.com/locate/pdj
Case Report
A case of replantation of deciduous upper central incisors under different extra-alveolar conditions Nobutaka Isogawa a,b,*, Kaori Ito c, Masakazu Ikeda c,d, Masaaki Ishikawa b a
National Center for Child Health and Development, Pedodontics and Orthodontics, Tokyo, Japan Faculty of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan c Kameda Clinic Dental Center, Chiba, Japan d Department of Comprehensive Dentistry, Kanagawa Dental College, Kanagawa, Japan b
article info
abstract
Article history:
Purpose: The extra-alveolar condition of an avulsed tooth is important for its successful
Received 13 March 2015
replantation. Here we report a case of deciduous incisors replantation under different
Received in revised form
extra-alveolar conditions.
19 July 2015
Case report: Traumatically avulsed upper deciduous central incisors of a 3-year-old girl were
Accepted 11 August 2015
replanted. Two hours before replantation, the left incisor was in a moist condition, while
Available online xxx
the right one was dry. After 3 years, we found that the deciduous incisors were correctly replaced by their successors.
Keywords:
Conclusion: The difference in extra-alveolar conditions between both avulsed deciduous
Ankyloses
central incisors did not produce significant differences between them after replantation.
Avulsed deciduous tooth
Copyright © 2015 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
Extra-alveolar condition Oral injury
1.
Introduction
Avulsion is one of the most severe injuries to the tooth and its periodontal tissue. Based on the guidelines of the International Association of Dental Traumatology, it is not recommended to replant an avulsed deciduous tooth [1]. However, a recent review by Kato [2] stated that an avulsed deciduous tooth should be replanted if there are good extra-alveolar conditions [2]. In addition, some practitioners have reported replantation of avulsed deciduous teeth, with good results
[3e6]. Among the extra-alveolar conditions of an avulsed tooth, the presence of moisture around the tooth before replantation seems to be critical [3e12]. Here we present a case of replantation of avulsed upper deciduous central incisors within 2 h, under different moist conditions.
2.
Case report
A female patient aged 3 years and 4 months came to our clinic with a complaint of avulsed deciduous upper central incisors.
* Corresponding author. Division of Pedodontics/Orthodontics, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan. E-mail address: [email protected] (N. Isogawa). http://dx.doi.org/10.1016/j.pdj.2015.08.001 0917-2394/Copyright © 2015 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
2
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
Fig. 1 e Labial view before replantation. Both central incisors were avulsed and blood clots filled the sockets. (A) Labial view. (B) Radiograph.
Approximately 1 h before, she fell down and hit her upper central incisors against a wooden sash of a window, losing them. Right after the accident, her grandmother found and wrapped the left incisor in food wrapping plastic film, but she did not find the right incisor. The patient did not show neurological symptoms or extraoral injuries, and no other oral injuries were detected by either visual inspection or in radiographs. The alveolar sockets of both central incisors were filled with blood clots (Fig. 1). The examination of the left incisor revealed that although the incisal enamel edge was chipped, the other part of the tooth was intact, and the root surface was covered with moist remnants of periodontal tissue. This incisor was dipped in a saline solution containing heparin (10 U/mL) and ampicillin (100 mg/mL). We explained the benefits and risks of the available treatment options to the child's mother and grandmother, and they selected the replantation option. Her grandmother went back home in search of the right incisor, and brought it to the clinic 1 h later. The right incisor, which had been under a dry condition for about 2 h, was also rinsed in the same saline solution. We replanted both incisors without using endodontic treatments, and fixed them using twisted 0.4-mm orthodontic ligature wire and Super-Bond resin (Sun Medical, Suwa, Japan) from the right to the left lateral incisors. Another radiograph was taken to confirm proper positioning of the replanted incisors (Fig. 2). Postoperative drugs (i.e., amoxicillin, acetaminophen, and povidone iodine solution) were prescribed. The patient was cooperative throughout the treatment. At the 2-week follow up, the marginal gingiva of the central incisors was a little red, and a grayebrown discoloration in the right incisor was observed (Fig. 3). One month after replantation, the dental resin at the right canine and lateral incisor
was detached and rebonded. Two months later, the fixation was removed. The periodontal space of the right central incisor appeared unclear in the radiograph (Fig. 4). Four months later, the right incisor was inclined towards the labial side compared to the left incisor, and the periodontal space of the left incisor also became unclear (Fig. 5). Ankylosis of both incisors was suspected after performing percussion tests and radiographs. Six months later, the discoloration of the right incisor disappeared, and resorption at the lower one-third of the internal root of the left incisor was observed (Fig. 6). Fourteen months later, apical and internal root resorption of the left incisor progressed, and the percussion test revealed no signs of ankylosis (Fig. 7). Twenty months later, the percussion test showed the same results for the right incisor. Apical root resorption progressed, and Grade l tooth mobility was observed in both incisors (Fig. 8). Two years and 3 months later, the replanted teeth were still in almost their original positions, with no pain or inflammation, and their successors seemed to develop normally both in their root formation and eruptive movements. Three years later, both deciduous incisors exfoliated, and their successors erupted in normal positions. However, both permanent incisors showed white spots in the medial incisal edge of the labial side (Fig. 9). This study was approved by the institutional review board of national center for child health and development.
3.
Discussion
The main reasons for replantation of avulsed deciduous teeth not being recommended are the risk of damage to the
Fig. 2 e Labial view after replantation. Both incisors were replanted to their correct positions and fixed using wire and resin. (A) Labial view. (B) Radiograph. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
3
Fig. 3 e Incisor images 2 weeks after replantation. Discoloration of the right central incisor was observed, and incisors presented almost normal anatomical appearance. (A) Palatal view. (B) Radiograph.
Fig. 4 e Incisor images 2 months after replantation. The periodontal space of the right incisor became unclear.
Fig. 5 e Incisor images 4 months after replantation. The periodontal space of both central incisors was unclear.
calcification, and delayed or maldirected eruption of their successors [1,13,14]. However, Holan [15] insisted that there is no evidence to support this theory, even if such risk exists. In addition, some case reports have shown good results after replantation of avulsed deciduous teeth [3e6]. In the case of replantation of avulsed deciduous teeth, Miyashin [16] noted the following necessary conditions: (1) replantation takes place within 3 h after injury; (2) the root surface of the avulsed tooth is in a moist condition during the extra-alveolar period; (3) there is enough alveolar bone remaining for the avulsed tooth to be replanted to the original position; (4) there are enough adjacent teeth to fix the avulsed tooth; and (5) the caretaker understands the risks and benefits of replantation or other treatment options, and can decide a treatment plan by themselves. In our case, the left central incisor fulfilled all the requirements, but the right incisor did not meet requirement 2. From 4 months after replantation, ankylosis of both teeth was suspected from both radiographs and percussion tests, suggesting a failure in revitalization of the periodontal ligaments. The suspected causes of ankylosis in this case seemed to be related to the extra-alveolar conditions of the avulsed teeth, storage medium, and the long fixation period. The earlier start of ankylosis and more labial inclination observed in the right incisor compared to the left might be due to differences in extra-alveolar conditions between them. In many clinics, a saline solution is an accessible medium in which to store avulsed teeth. However, saline solutions are an adequate storage medium only for short periods of time,
Fig. 6 e Incisor images 6 months after replantation. The discoloration of the right incisor disappeared, and internal root resorption of the left incisor was observed. (A) Labial view. (B) Radiograph. Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001
4
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 5 ) 1 e5
Fig. 7 e Incisor images 14 months after replantation. Internal apical root resorption progressed in the left incisor.
Fig. 8 e Incisor images 20 months after replantation. Apical root resorption progressed in both incisors.
because they do not contain essential ions and glucose that are necessary to maintain the viability of periodontal ligament cells [12,17,18]. In addition, ankylosis can be induced by prolonged dry extraoral conditions of avulsed teeth [8,9,18e20]. Our study showed that immersing the avulsed tooth in a saline solution for 1 h seemed to be a negative factor for the viability of periodontal ligament tissue, even though it is better than a dry condition. The fixation period is also important to keep the vitality of periodontal ligament cells, and long-term fixation may cause ankylosis and replacement resorption of the root [8,17,19,20]. In recent treatment guidelines [1,14] the recommended fixation period is up to 2 weeks for avulsed permanent teeth; however, in our case fixation time was 2 months. We did not perform any endodontic treatment to the incisors before replantation because we expected some
revascularization of their pulp, and we applied heparin to the saline solution to prevent coagulation. The exact time of devitalization of the pulp was unknown; however, both replanted teeth kept normal color and mobility until they were replaced by their successors, with no sign of pulp inflammation except for a temporary discoloration in the right incisor. This temporary discoloration might suggest that the dry condition is more severe than saline to maintain the viability of pulp tissue. Although early endodontic treatment is recommended when there is internal root resorption after replanting avulsed permanent teeth [3,21,22], in our case, since the position of root resorption was not cervical but in the lower one-third, we took a wait-and-see approach [23]. Three years after replantation, the permanent central incisors erupted in normal positions, although they presented white spots on the labial side of the mesial incisal edge. Traumatic injuries to deciduous teeth commonly result in the presence of white spots in their permanent successors, and white spots are frequently observed in avulsions [24,25]. Miyashin et al. [26] reported the presence of white spots in 73% of permanent successors after avulsion of deciduous teeth without replantation. For 3 years after replantation, no inflammation was observed in inspections or longitudinal radiographs. Therefore, this suggests that the white spots were not caused by the replantation, but by the initial trauma. In this case, the avulsed teeth had an uneventful course after replantation, and the only consequence was the presence of white spots in the permanent successors. Even though careful observation is necessary, replantation of avulsed deciduous teeth seems to be worth trying.
4.
Conclusion
Contrary to the guidelines of the International Association of Dental Traumatology, in recent years replantation of avulsed deciduous teeth in good extra-alveolar conditions has been suggested. This report showed the progress of replantation of avulsed deciduous upper central incisors under different conditions during the extra-alveolar period. The revitalization of both pulp and periodontal ligament tissue was unknown; however, both deciduous incisors kept almost their original positions with no negative clinical symptoms until they were replaced by their successors, and only white spots were observed in the normally erupted successors. The difference in extra-alveolar conditions between both avulsed deciduous central incisors did not produce significant differences between them after replantation.
Conflict of interest The authors declare no conflicts of interest.
references Fig. 9 e Incisor images 3 years after replantation. Both permanent central incisors erupted in their normal positions, and showed white spots on the lingual side of the medial incisal edge.
[1] Malmgren B, Andreasen JO, Flores MT, et al. International Association of dental traumatology guidelines for the
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Please cite this article in press as: Isogawa N, et al., A case of replantation of deciduous upper central incisors under different extraalveolar conditions, Pediatric Dental Journal (2015), http://dx.doi.org/10.1016/j.pdj.2015.08.001