Submitted by Dr Iseult Bouarroudj.

QuizDec2014

A seven-year-old boy presents with an avulsed UL1. The EOT was 45 minutes (20 minutes dry and 25 minutes in milk). Initial management included replantation under LA and a flexible splint was placed for two weeks. Appropriate antibiotic therapy was prescribed and the patient’s tetanus status confirmed. UL1 was partially erupted on avulsion with incomplete root development. The patient was reviewed three weeks post implantation and while UL1 was asymptomatic, an obvious sinus tract was present labially. Non-vitality was confirmed by sensibility testing and periapical pathology on radiographs.

Questions

  1. What is the long-term prognosis of this tooth?
  2. What are the most likely outcomes in this case?

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Answers to Quiz

  1. The long-term prognosis of this tooth is poor owing to the non-vitality of such an immature tooth and the likely sequelae of an avulsion injury.
  2. The most likely outcomes in this case include pulpal necrosis, infection-related resorption, ankylosis and eventual tooth loss. Root canal treatment was initially avoided in this case as there was a possibility of pulpal regeneration due to the immature root development. Indications where it is appropriate to see if pulpal healing by regeneration will occur are:

 

  • the tooth is immature (prior to the development of a complete root length with half or more apical closure) and where pulpal extirpation will leave a weakened root at increased risk of a late stage coronal fracture; and,
  • there is a chance of cemental/PDL healing of the periodontal membrane (extra-oral time of less than 30 minutes’ dry time and less than 90 minutes’ total extra alveolar time when stored in an appropriate storage medium).

For immature teeth meeting this criteria, no endodontic treatment is undertaken and the tooth is carefully monitored to assess pulpal regeneration or pulpal necrosis. In this presented case, pulpal necrosis ensued rapidly and endodontic treatment was commenced.
Due to the likelihood of replacement root resorption and eventual tooth loss patients should be referred to a specialist inter-disciplinary team for long-term treatment planning. Even in situations where favourable healing occurs by cemental/PDL healing, this early appointment is important to ensure the child and parents are fully aware of the possible outcomes and treatment options.
It must be emphasised that while the prognosis of the tooth is poor, the priority should be to maintain the tooth as long as possible to maintain dental arch space, dental arch symmetry, and alveolar bone contour, and minimise the psychosocial impact of the injury to the child. Long-term treatment options following planned loss of this tooth include: implant placement; fixed partial denture; auto-transplantation; or, orthodontic space close with restorative camouflage.

For further resources see:
•     http://www.dentaltraumaguide.org – International Association of Dental Traumatology
•     http://www.bspd.co.uk/UK – National Guidelines in Paediatric Dentistry – Treatment of Avulsed Permanent Teeth in Children