Case 1

History of the chief complaint:

Last week, he tripped and hit his mouth against a post. There was continuous pain, and his front tooth moved inward. I gave him Panadol, which relieved the pain. We went to the dentist the next day, and the dentist prescribed antibiotics and referred us here. The 11 was not repositioned.

• Prenatal history:

LC's mother maintained good health throughout her pregnancy. Apart from the routine pregnancy regimen, which included multivitamins and iron supplements, she did not take any other medications. She followed a regular diet without any special dietary restrictions.

• Natal history:

LC was born full-term with no reported neonatal jaundice, birth complications, injuries, or congenital abnormalities.

• Postnatal history:

LC was breastfed for six months and did not use a bottle during that time. His mother did not wipe his mouth after feeding, and on occasions, he slept with a bottle. After weaning, his diet included milk with added sugar, sugary juices, and tea, consumed from a regular cup. He began eating solid foods at six months, following regular family meals.

• Medical history:

LC is a healthy child with no significant childhood illnesses and is up to date with all his vaccinations. He has no known allergies.

• Dental History and Oral Hygiene Practices:

Aside from his recent visit to the dentist, where only an examination was conducted before referring LC to us, this is his first comprehensive dental visit. LC has been brushing twice daily on his own with adult toothpaste since the age of six. He flosses but not regularly.

LC is an intelligent child who exhibits no signs of anxiety or nervousness. He performs well academically. Though shy and reserved, he prefers solitary activities and enjoys spending time indoors.

His facial appearance was symmetrical and normal, with no palpable lymphadenopathy. The temporomandibular joint was functioning properly, and his muscles were relaxed with no abnormalities detected.

• Morphological examination of the face:

LC exhibits a convex facial profile with a prognathic maxilla and retrognathic mandible. Lips are competent.

• Molar classification:

Right class I, Left class I.

• The maxillary midline vs midsagittal plane 1mm to the right.

• Mandibular midline vs midsagittal plane coincides at rest and occlusion.

• Overjet:  11: 3mm; 21: 5mm.

• Overbite: 3mm

• No Crossbite.

• No open bite.

• No habit.

No abnormalities were detected in the oral mucosa. A tongue tie is present; however, it does not affect his speech. There is visible plaque.

11: luxated palatally; 2mm gingival recession Class I (Miller's classification). Tender to percussion and did not respond to the cold test (ethyl chloride)

21: Tender to percussion, did not respond to the cold test (ethyl chloride).

• It's not clear on the radiograph whether the 11 and 21 apices are opened or closed.

• No anomalies or pathologies. The bone and soft tissue anatomy appeared normal, with all permanent. The estimated dental age is 12, corresponding to the second transitional stage. The sequence of eruption is unfavourable in the fourth quadrant with the 37 erupting ahead of the 34&35.

LC's attitude was rated as Definitely Positive on the Frankl Behavior Rating Scale (Shao et al., 2016). The behaviour management techniques planned included Tell-Show-Do, distraction, and positive reinforcement, aiming to ensure he continued to have a positive attitude toward dental care. Since there was no emergency, we began with simple procedures to gradually introduce LC to the dental setting and build his comfort level. 

• Preventive Phase:

1/Oral hygiene education.

2/Fluoride application: 4 times per year as LC is a high caries risk child.

3/Diet analysis: A 3-day diary.

4/Fissure sealant: 16, 26, 36, 46

• Orthodontics: Consultation regarding the palatally luxated 11.

• Follow-up Plan:

Regular follow-up appointments will include both clinical and radiographic examinations at 4 weeks, 8 weeks, 3 months, 6 months, 1 year post-trauma, and annually for the following 5 years (Bourguignon et al., 2020). This timeline is crucial to monitor potential complications after luxation injuries, including:

• Symptomatic pulp necrosis

• Apical periodontitis

• Ankylosis

• External inflammatory resorption

During follow-up visits, certain signs may indicate pulp necrosis, although many patients do not experience pain or swelling due to the ischemic nature of pulp necrosis following luxation injuries. Tenderness to percussion is only present in teeth with acute periapical inflammation. The presence of two out of the three key indicators (tooth discolouration, negative sensibility testing, increasing periapical radiolucency) warrants root canal treatment (ESE, 2021). Additional clinical signs may include the formation of a fistula or sinus tract, mucosal swelling, abscess formation, or persistent tooth mobility (ESE, 2021).

In the early weeks after dentoalveolar trauma, apical bone resorption or incomplete repositioning of the tooth can mimic apical periodontitis. For immature teeth, the cessation of root development signals pulp necrosis. Rapid external infection-related root resorption (EIR) is uncommon, except in cases of tooth intrusion, where it is more frequently observed (Krastl et al., 2021).

First Visit

1/ Diagnosis and treatment plan.

2/ Oral Hygiene Instruction and Demonstration:

Oral Hygiene Instruction and Demonstration:

Active brushing and flossing were demonstrated using a disclosing agent to highlight areas of plaque accumulation. LC's mother was advised to supervise his brushing until he masters the correct technique, as he has not been properly instructed on how to brush effectively.

3/ Fluoride application

Because of the controlled swallowing reflex at his age, and he could understand the instructions. Acidulated phosphate fluoride gel ([APF]; 1.23% F, 12,300 ppm F) 4 times per year as he is a high-risk child.

Professionally applied topical fluoride treatments are efficacious in reducing the prevalence of dental caries. APF has a low pH, enabling it to deliver fluoride faster into enamel (AAPD).

4/Diet analysis: A 3-day diary was given to the mother.

• The next appointment is scheduled for 4 weeks. LC's mother has been advised to regularly lift his upper lip to check for any signs of swelling or gumboil and to contact us immediately if any symptoms or swelling develop.

• LC missed his scheduled follow-up appointment at 4 weeks but returned 4 months later, reporting no pain or swelling. This lack of symptoms is consistent with the ischemic nature of pulp necrosis following luxation injuries (ESE, 2021). The radiograph, however, revealed apical radiolucency associated with teeth 11 and 21, along with signs of external resorption on the distal aspect of tooth 21's root and the apex of the 11. Both teeth were sensitive to percussion and unresponsive to the cold test (ethyl chloride).

• According to the European Society of Endodontology (ESE, 2021), the presence of two out of the three key indicators (tooth discolouration, negative sensibility testing, and increasing periapical radiolucency) justifies root canal treatment. In LC's case, the negative sensibility test and increasing periapical radiolucency were present, necessitating emergency root canal treatment for teeth 11 and 21.

Procedure:

Topical anaesthesia (labial and palatal) was applied, followed by local anaesthesia using 2% lidocaine with 1:100,000 epinephrine, administered via one ampule infiltration using the STA system. A rubber dam was placed for isolation.

Endodontic access cavities were prepared in teeth 11 and 21. The working length of the canals was determined using an electronic apex locator and confirmed with a periapical radiograph.

Canal debridement was carried out using light instrumentation with H-files, followed by thorough irrigation with 5% sodium hypochlorite to remove necrotic pulp tissue. Irrigation was applied using a side-vented needle to minimize the risk of extruding the irrigant into the periapical area.

Mechanical removal of root dentin was kept to a minimum, as the primary focus was on extensive irrigation with sodium hypochlorite for the removal of necrotic tissue and disinfection of the root canal system (ESE, 2021).

The canals were dried with paper points, and calcium hydroxide was placed as an intracanal medicament for two weeks (ESE, 2021).

The access cavities were then temporized with conventional GIC filling.

• A #55 gutta-percha cone was used to assess the apical status of teeth 11 and 21:

• Tooth 11: The #55 gutta-percha cone passed through the apex, indicating an open apex. Consequently, an apical plug was created using MTA, followed by thermoplastic backfill using the Gutta-Smart system (Dentsply Sirona) to fill the remaining canal.

• Tooth 21: The #55 gutta-percha cone exhibited tug-back, indicating a closed apex. Therefore, the canal was obturated using the warm vertical condensation technique.

• Local Anesthesia & Isolation:

Local anaesthesia was administered using one ampule of 2% lidocaine with 1:100,000 epinephrine via the STA system.

A rubber dam was placed for isolation.

1. • Canal Preparation:

The temporary filling was removed, and the canals were irrigated thoroughly with 5% sodium hypochlorite.

A K-file with a circumferential filing motion was used to remove the calcium hydroxide (CaOH2), followed by final irrigation with 17% EDTA to eliminate the smear layer.

1. Tooth 11 – Apical Plug and Backfill:

1. • MTA Placement: NuSmile NeoMTA2 was mixed according to the manufacturer’s instructions and applied to the canal using the MAP system.

   • After placing three layers of MTA, a periapical radiograph confirmed a 4 mm apical MTA plug.

   • Sealer Application: A thin layer of bioceramic sealer was applied to the canal walls.

   • Thermoplastic Backfill: Following MTA plug placement, a thermoplastic backfill technique was employed using the Gutta-Smart system. As recommended, no master cone was used to avoid the risk of over-extrusion, ensuring the integrity of the MTA plug (Shah et al., 2022). The melted gutta-percha was compacted to create a three-dimensional seal using Gutta-Smart.

2. Tooth 21 – Warm Vertical Obturation:

1. • Master Cone Selection: A #55 gutta-percha cone was selected as it provided the necessary tug-back at the apex.

   • Sealer Application: A thin layer of bioceramic sealer was applied to the canal walls.

   • Downpack Phase: The master cone was placed, and a heated plugger (Gutta-Smart) was used to soften and condense the coronal portion of the gutta-percha while preserving the apical seal.

   • Backfill Phase: After confirming the apical condensation with a periapical radiograph, the remaining canal space was backfilled with additional heated gutta-percha, which was incrementally packed until the canal was fully sealed.

   •    Final Restoration:

   • Both access cavities were sealed with composite resin restorations to ensure a durable coronal seal.

The next appointment was scheduled after 3 months as LC is a high caries-risk child.

•  BOURGUIGNON, C., COHENCA, N., LAURIDSEN, E., FLORES, M. T., O'CONNELL, A. C., DAY, P. F., TSILINGARIDIS, G., ABBOTT, P. V., FOUAD, A. F. & HICKS, L. 2020. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dental Traumatology, 36, 314-330.

• DENTISTRY, A. A. O. P. 2020. Pediatric restorative dentistry. The reference manual of pediatric dentistry, 2021, 371-83.

• ESE 2021. European Society of Endodontology position statement: endodontic management of traumatized permanent teeth. International Endodontic Journal, 54, 1473-1481.

• KRASTL, G., WEIGER, R., FILIPPI, A., VAN WAES, H., EBELESEDER, K., REE, M., CONNERT, T., WIDBILLER, M., TJÄDERHANE, L. & DUMMER, P. 2021. Endodontic management of traumatized permanent teeth: a comprehensive review. International Endodontic Journal, 54, 1221-1245.

• SHAO, A., KAHABUKA, F. & MBAWALLA, H. 2016. Children’s behaviour in the dental setting according to Frankl behaviour rating and their influencing factors. J Dent Sci, 1, 1-12.