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Avulsion:central incisors:central papilla From: Marga Ree To: ROOTS Sent: Friday, December 14, 2007 8:15 PM Subject: [roots] Avulsion This 11 year old boy got an accident in the swimming pool. Bot central incisors were avulsed, and placed in milk after 5-10 minutes, according to the staff. I saw him 1 hour after the trauma took place. What an emotional happaning for the kid and the mother. Both were crying out loudly, and there was blood all over the place. We did everything to calm them down. Technically spoken, it was not easy to keep a dry field when pcacing the splint with composite, but we were successful in getting it dry in the end. We took care not touching the roots, just rinsed them gently with Hanks Balanced Salt Solution. Blood clot was removed from the alveoli with the same solution. After splinting, we took a rad, to verify the correct position, and came to the conclusion that 11 was not correctly replanted. So I removed the composite, and readjusted the position, placed composite and took another rad. This time both teeth were in the correct position. We sutured the gums with 6-O, put him on AB and a mouth rinse of CHX. Two weeks later, we removed the splint and started rct in both teeth. Two weeks later we finished treatment. Incredible how it looked like after 2 weeks, you could hardly see any soft tissue damage anymore, except for the flat central papilla. Last clinical picture is a 3 months follow-up. We restored the incisal edges with composite. He is doing fine, and we gave him a fair prognosis, since the teeth were placed in milk after 5-10 minutes. This is one of the most rewarding treatments I ever did. - Marga
Dear Marga. Beautiful case as usual. I need to know how did you manage the pt. Did you sedate or procedure were done under L.A. - Raghu Thanks Raghu, Treatment was done under LA, no additional sedation. Marga what can i say? great job !!! marga. - Rafael Marte Fiallo Awesome documentation of a great case! - Maarten. Marga, you are a blessing to your patients! Clot removal with Hanks? Just rinsing with a syringe provided enough agitation to dislodge the clot? Suture removal and pulpectomy was done in the same time frame---two weeks? or sutures removed sooner than this? - KendelG Hi Kendel, Thanks for the compliment, but I am sure you would have done the same! I was doing my shopping for dinner when my husband called me that this patient was on his way to our practice. I left my shopping car for what it was, and drove immediately to the practice. The only thing that was important is to build up some sort of rapport with the boy in a very short time. As soon as we calmed him (and his mother) down, treatment was carried out without any problems. Yes, clot removal was done with rinsing. We removed the sutures 1 week after the accident and started rct with a CaOH dressing. We removed the splint 2 weeks after the trauma took place, and after 3 weeks, we finished treatment. - Marga Thank you for sharing this marvellous case with us. Did you use ledermix paste for the intracanal dressing ( a la Paul Abbot) to reduce the chance of resorption or solely cal.hyd. Milk was used here successfully; as a general question to everyone would this be the preferred liquid to use in a domestic/school situation if asked over the phone what to do? I have no other suggestions other than to advise against water! - Thanks again - Stephen Day. Stephen, thanks a lot for your kind words! No, I didn't use Ledermix, because I was afraid for possible discoloration of tooth structure. I used solely Ca(OH)2. I am curious to the experience of other colleagues regarding the use Ledermix for these type of cases. I think that milk is the preferred liquid, because it's readily available. In the Netherlands, almost every child drinks milk, so it's available in every household, school and canteen of a sport complex. - Marga Keep your eyes open for research on the use of egg albumin, which is also readily available in many settings. I recently read an unpublished dog study by A. Khademi that evaluated replantation outcomes after extended extraoral storage in a variety of media. Egg albumin significantly outperformed the other media including milk. I have not seen any other reports, and this one has not made it to publication yet apparently. I will post the abstract if I can find it. I am not ready to begin recommending patients use it, but it looked very promising. Robert Corr Resident, Loma Linda Univ. Is the patients own saliva an option here? Is is not the solution with which the tooth was in contact with prior to Avulsion..............I mean eversince it erupted into the oral cavity it is in contact with saliva? - Sachin Hi Sachin, Purely speculating here but I wold guess that saliva outside the mouth would perform fairly well. My understanding is that the tonicity of the storage media is critical. The osmotic pressure or tension ruptures the pdl cells that are trying to survive when the tooth is dry, or thrust into plain water, or other unsuitable solution. It is an interesting idea, because you may be able to get an hysterical child to spit into a cup, and likely it would also contain blood as well as saliva, and it would be readily available. Trying to get a child to hold an avulsed tooth in the mouth during this anxious time may be quite a trick. - KendelG There is an article in the current Dental Traumatology journal comparing milk, ice, contact lens fluid, Gatorade and Hanks balanced salt solution. Ice came out as best with less apoptosis.- Stephen Day Hi Marga .............one more to the list of amazing Marga cases. What is the chain like material you have used for the splint? - Sachin Thanks Sachin. The splint is called a titanium trauma splint, tts, by Medartis. These are very easy to manipulate and bond to enamel. See also attached paper, Patterson supplies them in the US.: https://www.pattersondental.com/app.aspx?cmd=get_item&id=200409 - Marga So I would conclude that findings here support the following conclusion: Placing a tooth in Hank's or Milk, then placing that container on ice, performs best of all groups tested. Am I correct in my reading of the m&m? - Thanks, KendelG
