Case 2

History of the main complaint:

JB had a bicycle accident while playing at home, during which he fell and knocked out his top front tooth. There was some bleeding and mild pain. JB's mom contacted her dental student friend, who advised her to store the tooth in milk until they could visit a dentist. However, she was unsure how long the tooth had been kept dry before being placed in the milk. They presented to me 10 hours after the accident, with tooth 21 immersed in milk. The tooth's apex was closed.

Prenatal history:

JB's mother was healthy during pregnancy. She took no medications apart from the standard supplements, and her diet was a regular one. No special diet was followed.

Natal history:

JB was born full-term. There were no reported neonatal jaundice, birth complications, or injuries, and no congenital abnormalities were reported.

Postnatal History:

JB was breastfed for 5 months, after which he transitioned to bottle feeding with formula until the age of 2 years. His mother described the feeding as on demand and does not recall wiping JB's mouth after feeding, though he did not sleep with the bottle at night. After weaning, JB began drinking from a cup, often consuming milk with added sugar and sugary juices. By 9 months of age, he started eating solid foods and was introduced to regular family meals with no special dietary adjustments.

Medical History:

JB has been diagnosed with asthma and used an inhaler from the age of 3 to 7. He is currently not taking any medications and has no known allergies.

Dental History and Oral Hygiene Practices:

JB's first dental visit occurred when he was 6 years old due to a toothache in tooth 85 and multiple carious lesions. However, he was uncooperative, and the dentist was unable to complete the examination. It was decided to proceed with GA to complete all necessary treatment. The treatment performed under GA included fissure sealants on teeth 16, 26, 36, and 46, extractions of teeth 55, 54, 53, 52, 63, 64, 65, and 85, and fillings (Vitremer) for teeth 74, 75, and 84. He does not have regular dental visits.

JB brushes his teeth twice a day using age-appropriate toothpaste, under the supervision of his grandmother. Prior to this, his mother and grandmother were responsible for brushing his teeth. However, he does not floss.

JB is a smart boy, but he was understandably very nervous, anxious, and in shock during the visit. He was crying and clinging to his mother.

His facial appearance was symmetrical and normal, with no palpable lymph nodes. The temporomandibular joint was functioning normally, and his muscles were relaxed with no abnormalities.

Morphological Examination of the Face:

JB exhibits a convex facial profile. Both the maxilla and mandible are slightly prognathic, with the maxilla more pronounced. The lips are competent.

Molar classification: Class II on both sides

The maxillary midline: coincides with the midsagittal plane; however, 4mm diastema.

The mandibular midline: missing incisor.

Overjet: 11: 3mm. 21: 5mm

Overbite: 11: 4mm 21: 4mm

No Crossbite

No open bite

Buccal canine bulges: palpable

No habit.

No abnormalities were found in the tongue, frenum, or mucosa. However, there is visible plaque.

16, 15, 14, 12, 11, 22, 24, 25, 26 Sound. 53, 63 exfoliated. 21 avulsed.

36, 34, 31, 32, 41, 44, 46 Sound. 33, 43 Partially erupted. 42 missing. 85 extracted. 75 occlusal filling.

The bone and soft tissue anatomy appear normal. Tooth 42 is congenitally missing, and tooth 21 has been avulsed. JB's estimated dental age is 9–10 years, corresponding to the Inter-transitional Stage. Leeway space is compromised in all four quadrants due to early extractions. An unfavourable eruption sequence is observed in the third and fourth quadrants, with teeth 34 and 44 erupting ahead of 33 and 43. 13 and 23 are in favourable positions; however, there is insufficient space due to the early loss of teeth 53 and 63. 

JB's attitude was rated as Definitely negative on the Frankl Behavior Rating Scale (Shao et al., 2016).

 A combination of techniques was employed to manage JB's behaviour, including voice control, the tell-show-do method, distraction, enhancing control, parental presence/absence, and positive reinforcement.

During the visit, JB was crying and clinging to his mother, making it difficult for him to listen. I requested that his mother hand him over to his grandmother and explained the behavioural management techniques we would use to ensure everyone was on the same page.

I used voice control to establish appropriate adult-child roles to gain JB's attention and encourage compliance. He agreed to sit in the chair but remained uncooperative and refused to open his mouth.

I informed him that if he did not cooperate, his mother would be asked to leave the surgery and would not be allowed to return until he demonstrated improved behaviour. After this, he agreed to cooperate.

Emergency treatment: Reimplantation of 21

Preventive Phase:

1/ Oral hygiene education.

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

3/ Diet analysis: A 3-day diary.

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

Orthodontics: Consultation regarding the loss of space.

First Visit

Topical anaesthesia (labial and palatal) was applied, followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine. One ampule was administered via infiltration using the STA system.

The socket was thoroughly irrigated with saline to clear any debris or blood clots. The avulsed tooth (21) was carefully cleaned in a sterile saline stream to remove dead cells from the root surface. The pulp extirpation was performed extra-orally before reimplantation, as the apex was closed and the tooth had been outside for more than 10 hours, indicating that revitalization of the pulp space was not possible. Additionally, this will avoid the need for a separate procedure, especially with the JB's limited cooperation.

Ledermix was placed in the root canal as an intracanal medicament. Ledermix increases the chance of periodontal healing following replantation and reduces the risk of root resorption. If Ledermix is used, it should be placed immediately or shortly after replantation for 2 weeks, followed by calcium hydroxide for 2 weeks before obturation (ESE, 2021).

The tooth was reimplanted and stabilized with a flexible splint using 0.4 stainless steel wire and composite.

• Delayed replantation generally has a poor long-term prognosis, as the periodontal ligament typically becomes necrotic and does not regenerate, leading to ankylosis. The primary aim of replantation in these cases is to temporarily restore esthetics and function while preserving the alveolar bone's contour, width, and height. Consequently, replanting a permanent tooth is often the best option, even if extra-oral dry time exceeds 60 minutes, as it keeps future treatment options available. Extraction can still be performed if necessary after a thorough interdisciplinary assessment at an appropriate stage (Fouad et al., 2020).

No additional antibiotics were prescribed as JB was already taking Azithromycin for tonsillitis.

JB and his mother were given the following post-treatment care instructions:

Avoid participating in contact sports, maintain a soft diet, brush with a soft toothbrush after each meal, and use chlorhexidine (0.12%) mouth rinse twice daily for two weeks.

A follow-up appointment was scheduled for two weeks.

JB's mother called to schedule an urgent appointment five days after the first visit. Despite her advice, BJ bit on a chicken bone, breaking the splint. Although the tooth was mobile, it remained stable.

An appointment was scheduled for the following day to repair the splint. 

• Treatment done:

Splint repair.

Diagnosis and treatment plan.

Oral Hygiene Instruction and Demonstration:

Active brushing and flossing using a disclosing agent. JB's mom was advised to assist him in brushing his teeth twice a day and flossing until he can do it properly. They should use a disclosing tablet to guide him, as he never learned how to brush properly.

Fissure sealant: 16, 26, 36&46. As JB is a high-risk child and good moisture control was achieved, the resin-based fissure sealant 3M™ Clinpro™ Sealant was selected for its fluoride-releasing, caries-preventive benefits (Simonsen, 2002).

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).

Positive reinforcement: JB was rewarded with a balloon.

Post-care instructions were reiterated to both JB and his mother, emphasizing the importance of following dietary restrictions and avoiding hard foods to protect the healing tooth.

A week later, JB broke the splint again. An appointment was scheduled to repair it. Upon examination, the 21 was still mobile (Grade II) but remained stable.

The splint was repaired once more, and post-care instructions were reiterated to both BJ and his mother.

JB did not show up for his scheduled splint removal appointment, and we lost contact with his mother. The missed appointment coincided with the last week before the holiday break.

BJ returned three months later, still with the splint in place. According to his mother, the splint had broken again during that period. Since the faculty was closed for the holidays, they sought treatment at a private clinic, where the splint was repaired.

The splint was removed, and upon examination, the 21 was stable with physiological mobility. However, percussion testing revealed a slightly metallic sound, raising the suspicion of ankylosis. Given this, we have decided to delay the operation.

A CBCT scan was scheduled to assess the ankylosis further before proceeding with the next steps in treatment.

The CBCT scan performed to assess ankylosis was inconclusive. "There appears to be some narrowing of the PDL in the middle third of the root. The apex measures 0.88mm x 0.56mm. The low resolution of the CBCT scan makes ankylosis definitive confirmation problematic. Advise follow-up periapical radiograph."

We decided to follow up with periapical radiographs and obturate the root canal with a resorbable material. This choice was made to avoid removing permanent obturation material if ankylosis is confirmed.

The plan is to proceed with decoronation of the ankylosed 21 upon the first signs of infra occlusion. The aim is to remove the crown while preserving the resorbing root as a matrix for new bone development.

Ankylosis can cause severe damage to supporting tissues and neurovascular structures, which negatively impacts the success of replantation (Souza et al., 2018). One of the most serious complications following the replantation of avulsed teeth is root resorption (RR), which may present as either internal or external resorption, with external resorption being more common (Souza et al., 2018). External RR can be further classified into surface RR, inflammatory RR, and replacement RR (ankylosis), with replacement RR being the most significant type, followed by inflammatory RR, surface RR, and internal RR (Souza et al., 2018).

Internal RR is relatively rare in permanent dentition, whereas replacement RR is frequently observed in replanted teeth (Souza et al., 2018). Surface RR occurs when resorption cavities are small; nearby cementoblasts recolonize the denuded root surface, depositing new cementum where newly formed periodontal fibres anchor (Pohl et al., 2005). Inflammatory RR, on the other hand, is primarily associated with persistent root canal infection or pulp necrosis (Souza et al., 2018). If root canal treatment is performed, surface resorption will occur regardless of cavity depth (Andreasen, 1981).

Management options for ankylosis include:

• Autogenous tooth transplantation using a premolar to replace the traumatized maxillary central incisor.

• Decoronation to preserve the alveolar bone.

• Intentional reimplantation after extraction.

• Distraction osteogenesis.

• Early extraction and replacement with a removable prosthetic appliance (Abbott, 2016).

Decoronation preserves alveolar width and restores vertical bone height in growing individuals (Malmgren et al., 2015). The biological rationale is that the decoronated root acts as a matrix for new bone formation as the root resorbs (Malmgren et al., 2015). During this process, vertical alveolar bone is rebuilt as adjacent teeth continue to erupt (Malmgren et al., 2015). A new periosteum forms over the decoronated root, enabling vertical alveolar growth (Malmgren et al., 2015). The interdental fibres severed by the decoronation procedure reorganize between adjacent teeth. As these teeth erupt, they mediate marginal bone apposition through the dental periosteal fibre complex (Malmgren et al., 2015). The erupting teeth are connected to the periosteum covering the alveolar socket and, indirectly, to the alveolar gingival fibres inserted in the alveolar crest and the lamina propria of the interdental papilla (Malmgren et al., 2015). These structures generate traction forces, leading to bone apposition on top of the alveolar crest. This explanation is based on known anatomical features, eruption processes, and clinical observations (18) (Malmgren et al., 2015, Malmgren et al., 2006).

Procedure done during the fifth visit:

Topical anaesthesia was applied, followed by local anaesthesia using 2% lidocaine with 1:100,000 epinephrine, administered via infiltration with the STA system.

The temporary filling was removed, and the canal was thoroughly irrigated with 5% sodium hypochlorite. Working length was determined using both radiographs and an electronic apex locator. A K-file was utilized with a circumferential filing motion to remove the Ledermix, followed by final irrigation with 17% EDTA to eliminate the smear layer.

The canal was then obturated using Vitapex. A layer of Vitrebond was applied, and the access cavity was sealed with composite material.

Vitapex, used as a root canal filling material for pulpectomy in primary teeth, has been shown to resorb both extra-radicularly and intra-radicularly without adverse effects, proving to be clinically and radiographically successful (Nurko et al., 2000). Given that the tooth is expected to undergo replacement root resorption, Vitapex was considered the most appropriate material choice. 

Follow-up appointments were scheduled every three months, and JB's mother was advised to contact us at the first sign of infra occlusion.

This was JB's three-month follow-up appointment. A priapical view for the 21 was taken

Treatment Provided:

• Reinforced oral hygiene instructions.

• Reapplied fissure sealants on teeth 16, 26, 36, and 46.

• Reshaped tooth 21, which was taller than tooth 11 and tilted distally. JB's mother had expressed concerns about the aesthetics.

After consultation with the prosthodontic department, it was advised that, given JB's ongoing growth and the uncertain prognosis of tooth 21, the most appropriate course of action for now was to reshape the tooth to address the aesthetic concerns.

• ANDREASEN, J. 1981. Relationship between surface and inflammatory resorption and changes in the pulp after replantation of permanent incisors in monkeys. Journal of Endodontics, 7, 294-301.

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

• MALMGREN, B., MALMGREN, O. & ANDREASEN, J. O. 2006. Alveolar bone development after decoronation of ankylosed teeth. Endodontic topics, 14, 35-40.

• MALMGREN, B., TSILINGARIDIS, G. & MALMGREN, O. 2015. Long‐term follow up of 103 ankylosed permanent incisors surgically treated with decoronation–a retrospective cohort study. Dental Traumatology, 31, 184-189.

• NURKO, C., RANLY, D., GARCÍA-GODOY, F. & LAKSHMYYA, K. 2000. Resorption of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth: a case report. Pediatric dentistry, 22, 517-520.

• POHL, Y., FILIPPI, A. & KIRSCHNER, H. 2005. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive‐regenerative therapy. Dental Traumatology, 21, 93-101.

• 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.

• SIMONSEN, R. J. 2002. Pit and fissure sealant: review of the literature. Pediatric dentistry, 24, 393-414.

• SOUZA, B. D. M., DUTRA, K. L., KUNTZE, M. M., BORTOLUZZI, E. A., FLORES-MIR, C., REYES-CARMONA, J., FELIPPE, W. T., PORPORATTI, A. L. & CANTO, G. D. L. 2018. Incidence of root resorption after the replantation of avulsed teeth: a meta-analysis. Journal of endodontics, 44, 1216-1227.