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*Dorota Olczak-Kowalczyk1, Grażyna Marczuk-Kolada2, Lidia Postek-Stefańska3, Barbara Bartosiak-Drosio1, Renata Filipińska4, Dariusz Gozdowski5, Elżbieta Łuczaj-Cepowicz2, Paulina Modzelewska-Chiniewicz1, Małgorzata Daszkowska4, Anna Jurczak6, Joanna Szczepańska4
Avulsion of permanent teeth in children – a retrospective analysis of the causes, management strategy and treatment outcomes
Całkowite zwichnięcia zębów stałych u dzieci – analiza retrospektywna przyczyn, metod postępowania i wyników leczenia
1Department of Paediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
2Department of Paediatric Dentistry, Medical University of Białystok
Head of Department: Grażyna Marczuk-Kolada, MD, PhD
3Department of Developmental Age Dentistry, Medical University of Silesia in Katowice
Head of Department: Lidia Postek-Stefańska, MD, PhD
4Department of Paediatric Dentistry, Medical University of Łódź
Head of Department: Professor Joanna Szczepańska, MD, PhD
5Department of Experimental Design and Bioinformatics, Department of Agriculture and Biology, Warsaw University of Life Sciences
Head of Department: Professor Wiesław Mądry, PhD
6Department of Paediatric Dentistry, Institute of Dentistry, Jagiellonian University Medical College
Head of Department: Anna Jurczak, MD, PhD
Wstęp. Całkowite zwichnięcie zęba powoduje jednoczesne uszkodzenie wielu tkanek – dziąsła, więzadła przyzębnego, miazgi, kości wyrostka zębodołowego, cementu i zębiny korzenia. Właściwe postępowanie po urazie zęba, już w miejscu wypadku, istotnie wpływa na pomyślność rokowania.
Cel pracy. Celem pracy było określenie związku płci i wieku pacjentów z miejscem i przyczyną zwichnięcia całkowitego zęba, rodzaju powikłań po replantacji zębów i czynników wpływających na ich występowanie.
Materiał i metody. Przeprowadzono analizę retrospektywną całkowicie zwichniętych 102 zębów stałych u 67 pacjentów. W grupie pacjentów po wykonanej replantacji odnotowywano informacje na temat: wieku, płci, czasu i przyczyny urazu, liczby zębów dotkniętych urazem, stadium rozwoju korzenia (dojrzały/niedojrzały), żywotności zębów, stanu tkanek okołokorzeniowych, czasu przebywania zęba poza jamą, medium, w jakim był przechowywany ząb, czasu, jaki upłynął od momentu wybicia zęba do replantacji, rodzaju i czasu szynowania oraz procesu gojenia.
Wyniki. Najczęściej wybiciu ulegały przyśrodkowe zęby sieczne szczęki. Do urazu zwykle dochodziło na ulicy lub podwórku, a większość urazów związana była z aktywnością sportową. Nie replantowano 10% zębów. Czas, jaki upłynął od urazu do udzielenia pierwszej pomocy, wahał się od 2 minut do 4 dni. Zęby przechowywano najczęściej na sucho. Obserwowano niewłaściwy sposób lub zbyt długie unieruchamiania związane z nieterminowym zgłaszaniem się pacjentów. Najczęściej obserwowanym powikłaniem była ankyloza. Ryzyko powikłań zmniejszały: brak współistniejących uszkodzeń pourazowych, replantacja < 60 minut od urazu, przechowywanie zęba w ślinie, prawidłowy sposób unieruchamiania oraz antybiotykoterapia.
Wnioski. Nieudzielenie pomocy na miejscu wypadku, niewłaściwe przechowywanie zęba całkowicie zwichniętego, błędy postępowania lekarskiego i niezgłaszanie się pacjentów na wyznaczone wizyty będące przyczynami powikłań gojenia wskazują na konieczność powszechnej edukacji dotyczącej postępowania w przypadku całkowitego zwichnięcia zęba.
Introduction. Avulsion of the tooth results in a simultaneous damage of many tissues – gingiva, periodontal ligament, pulp, alveolar bone, cement and dentin of the root. Proper management after tooth injury, already at the site of the accident, has a significant impact on successful prognosis.
Aim. The aim of the study was to determine the relationship between patient gender/age and the place/cause of tooth avulsion, the type of complications after tooth replantation as well as factors influencing their occurrence.
Material and methods. A retrospective analysis of 102 avulsed permanent teeth was performed in 67 patients. The following data was recorded in the group of patients after replantation: age, gender, time and cause of the injury, number of affected teeth, the stage of root maturation (mature/immature), vitality of the affected teeth, condition of supporting tissues, extra-oral time of avulsed teeth, storage media, time elapsed between injury and replantation, type and duration of splinting, and the healing process.
Results. Maxillary central incisors were most frequently avulsed. Dental trauma usually occurred in the street or courtyard, and most of the injuries were associated with sports activities. A total of 10% of teeth were not replanted. The time elapsed between the injury and first-aid ranged from 2 minutes to 4 days. Most teeth were stored dry. Improper or prolonged splinting due to untimely reporting on dental visits was observed. Ankylosis was the most common complication. The risk of complications was reduced due to: the lack of concomitant traumatic lesions, replantation < 60 minutes post-injury, tooth storage in saliva, correct splinting and antibiotic therapy.
Conclusions. Lack of first-aid at the accident site, improper storage of the avulsed tooth, medical errors and patients’ missing scheduled visits, all of which cause healing complications, indicate the need for public education on the management in tooth avulsion.
A sudden tooth injury causing dental avulsion results in a simultaneous damage of many tissues – gingiva, periodontal ligament (PDL), pulp, alveolar bone, cement and dentin of the root. Children aged 7-9 years are at increased risk of injury-related dental avulsion due to immature periodontal fibres and reduced resistance of periodontal ligament (PDL) to extrusion.
Avulsion of permanent teeth is one of the most serious dental injuries. Proper management after tooth injury, already at the scene of the accident, has a significant influence on successful prognosis. Although replantation is a treatment of choice in most cases, it may be impossible immediately after the injury (1-3).
There are a number of factors affecting the periodontal healing process in replanted teeth. Complications most often occur due to the lack of properly performed first-aid at the site of accident, patient’s reporting to the dentist a few hours after the accident and the use of inappropriate storage medium to ensure periodontal cell viability. Furthermore, despite appropriate treatment, pathological resorption (replacement, inflammatory) often occurs in these teeth, leading to progressive tooth mobility and loss (1, 4). First-aid procedures depend on the circumstances of the injury (site, cause), the age and general condition of the child with avulsed tooth and, most of all, the knowledge and skills of accident witnesses.
The aim of the study was to determine the relationship between patient gender/age and the place/cause of tooth avulsion, the type of complications after tooth replantation as well as factors influencing their occurrence.
Material and methods
A retrospective analysis of medical records from 67 patients with avulsion of at least one permanent tooth, presenting at paediatric dentistry clinics of four medical universities between 2006 and 2015, was performed. Patients who did not report for a follow-up visit after receiving first medical aid were excluded from the study. Qualification criteria were as follows: replantation and at least 2 months of follow-up.
Data on gender and age at injury, the cause and place of injury, the type and the number of avulsed teeth, the time elapsed between the injury and replantation, tooth storage conditions, person performing replantation, the methods of medical management and complications was obtained from medical records.
The obtained results were analysed statistically using Chi-square test and Kendall’s tau correlation. Statistica 12 and SPSS 22 were used for statistical analysis; a p-value of 0.05 was accepted as statistically significant.
Dental avulsion of 102 teeth occurred in 67 patients (mean 1.48 ± 1.04). Replantation was not performed in 10 avulsed teeth in 6 patients, including 2 teeth lost in a traffic accident (first medical aid was provided in the department of surgery), 6 teeth that were not found and 2 teeth due to unknown reasons. Injuries occurred at the age between 5.2 and 17.9 years, with a mean age of 10.29 ± 3.28 years (41.3% of patients aged between 5.2 and 10 years). Tooth avulsion was statistically significantly more common in girls and at a younger age compared to boys (9.29 years vs. 11.77 years; p = 0.005).
For the remaining 61 patients (21 girls and 40 boys), a total of 92 teeth were replanted (between 1 and 7 teeth in one patient; mean 1.43 ± 1.04; 1 tooth in 73.8%). Avulsion was more common in maxillary (79) rather than mandibular teeth (13). These were mostly maxillary central incisors (60), followed by maxillary lateral incisors (15), mandibular central incisors (7) mandibular lateral incisors (5), maxillary canines (3), mandibular canines (1), and the first maxillary premolar (1) (fig. 1).
Fig. 1. Types of avulsed teeth
Place and cause of injury
The place of injury remains unknown in 5 patients, and the cause of injury is unclear in 8 patients. Injuries most often occurred in the street or courtyard, less frequently at home, school or swimming pool (tab. 1). Most injuries (n = 20) were related to sports activities (32.2%), including cycling, team sports (e.g. colliding with another player during a football match, teeth stuck in a volleyball net), swimming pool activities (e.g. hitting with the teeth against the pipe or the knee) or other (e.g. a fall from the trampoline). A total of 8.19% of patients lost their teeth as a result of a fight (peer conflicts), while 3.27% due to a traffic accident. In one case, the dentist removed the wrong tooth.
Tab. 1. Place and cause of dental injury
|hitting an object ||9/14.75|
|collision with another person||2/3.27|
The analysis of Kendall rank correlation showed a significant relationship between age and injuries occurring at school and cycling-related injuries as well as gender and falls from a bicycle. The incidence of school accidents increased with age (correlation coefficient 0.192, p < 0.05). Bicycle accidents were significantly more common in girls (correlation coefficient 0.199, p < 0.05) and younger children (-0.182, p < 0.05).
The time of first medical aid and the storage of avulsed teeth
Medical records of 2 patients (3.27%) lacked data on the time elapsed between injury and first aid in relation to 3 avulsed teeth (3.26%). For the remaining 59 patients, the time of replantation of 89 teeth ranged from 2 minutes to 4 days (mean 6.39 ± 13.92 hours). One tooth was replanted after 4 days; the remaining 88 teeth were replanted within 48 hrs, an average of 5.13 ± 7.19 hours. A total of 22 teeth (22.82%) were replanted within 60 minutes of injury, including 2 teeth replanted immediately after avulsion and 67 teeth replanted more than 60 minutes (tab. 2) after the injury. Uncompleted root development was reported in 21 teeth.
Tab. 2. Time elapsed between the injury and the replantation of teeth with formed/unformed apices
|The time from injury to replantation||Number of teeth||Total||The time from injury to replantation|
|open apex||closed apex||mean ± SD|
|after < 60 minutes of injury||7||15||22||43.90 ± 19.71 minutes|
|after > 60 minutes of injury||14||53||67||7.97 ± 13.37 hrs|
|no data ||0||3||3||–|
|total ||21||71||92||6.39 ± 13.92 hrs|
Most teeth were stored dry in a tissue as well as in saliva or water (tab. 3). Only 10 teeth (10.86%) were replanted at paediatric dentistry clinics. As many as 47 teeth (51.08%) were replanted by dental surgeons, 18 teeth (19.56%) were replanted by dentists in primary dental care clinics, and the remaining teeth (18.47%) were replanted by doctors of medicine, nurses or teachers.
Tab. 3. Avulsed tooth storage prior to replantation
|dry in a tissue||saliva||milk||0.9% NaCl||water||missing data|
|< 60 minutes||2||6||5||1||3||0||4|
|> 60 minutes||–||16||11||0||12||19||9|
A total of 32 teeth were immobilised using Tigerstedt splints (in 16 cases the splint had to be changed due to severe traumatic impact on periodontal tissues); 54 teeth were immobilised using a wire or a glass fibre fixed with composite material, 6 teeth were immobilised using orthodontic braces. Braced are still used.
The time of dental immobilisation ranged between 8 and 180 days (mean 31.29 ± 28.74 days; for replanted teeth < 60 minutes post-injury: 25.23 ± 13.02 days; > 60 minutes post-injury: 33.10 ± 31.77 days). Prolonged immobilization was due to missed dental visits.
A total of 51 patients with 77 replanted teeth received systemic antibiotic therapy (amoxycillin or amoxycillin with clavulanic acid or clindamycin or cephalosporin). Soft tissue wound management was needed in 21 pa-tients (laceration of gums, lip wounds). Apart from one tooth mistakenly extracted by a dentist, first visits of these patients to university clinics (after immediate replantations) took place 1 hour up to 4 months post-injury.
The follow-up period ranged between 3 months up to 4 years (mean 29.5 ± 32.0 months). Endodontic treatment using apexification was needed in 21 teeth with incomplete root development. This was due to pulp necrosis in 17 cases, internal resorption in 3 cases and pulp obliteration complicated with periapical abscess in one case. Endodontic treatment of teeth with open apices was initiated 28 days up to 12 months of replantation (including teeth replanted within 60 minutes of injury, treated within 30 days to 10 months).
Ankylosis was the most common healing complication (35.8%), and usually affected teeth with open root apices or replanted later than 60 minutes after the injury (tab. 4).
Tab. 4. The occurrence of complications depending on the time of replantation and the stage of root apex development
|Root apex||Replantation time||Obliteration||Internal resorption||Ankylosis||External resorption|
|open apex (21 = 100%)||< 60 min||1||0||3||1|
|> 60 min||0||3||7||6|
|total||1 (4.7%)||3 (14.3%)||10 (47.6%)||7 (33.3%)|
|closed apex (71 = 100%)||< 60 min||–||–||3||0|
|> 60 min||–||–||18||18|
|unknown replantation time||–||–||–||1|
|total||0||–||22 (30.9%)||19 (26.7%)|
|total (92 = 100%)||1||3||33 (35.8%)||26 (31.5%)|
The analysis of Kendall rank correlation allowed to identify factors contributing to the occurrence of certain complications during periodontal healing (tab. 5). Complications were statistically significantly less common if the avulsed tooth was stored in saliva. If the tooth was stored in water, both ankylosis and external resorption occurred. In the case of teeth with open root apices and concomitant enamel-dentin fracture, complications in the form of ankylosis/external resorption occurred. Replantation before 60 minutes post injury, the use of a wire and composite or glass fibre and composite for splinting were more beneficial for the process of healing in relation to ankylosis/external resorption. General antibiotic therapy mainly prevented ankylosis.
Tab. 5. Statistically significant correlations between the occurrence of periodontal healing complications and factors related to tooth storage and type, replantation type and the therapeutic method (Kendall correlation coefficient)
| ||Any type of complicated periodontal healing (ankylosis/external resorption)||Ankylosis||External resorption|
|Avulsed tooth storage|
|concomitant enamel-dentin fracture||0.167*||-0.039||0. 164*|
|concomitant enamel-dentin-pulp fracture||0.082||0.147*||-0.052|
|Post-injury replantation time|
|< 60 minutes after injury||-0.207*||-0.091||-0.212*|
|> 60 minutes after injury||0.207*||0.091||0.212*|
|Type of splint|
|wire + composite||-0.260*||-0.190*||-0.069|
|glass fibre + composite||-0.246*||-0.188*||-0.130|
|splinting type modification||0.300*||0.280*||-0.082|
|systemic antibiotic therapy||-0.103||-0.246*||-0.005|
*statistical significance p < 0.05
our research shows that falling, hitting an object and bicycle accidents were the most common causes of dental avulsion, which is consistent with literature reports. The correlation between bicycle accidents and female gender/age should be emphasised. Literature data on the relationship between dental avulsion and gender/age are divergent. In our study group, dental avulsion was more common in girls than in boys. As opposed to our findings, Karayilmaz et al. (5) reported higher incidence of tooth avulsions among boys. Most authors also emphasise that the incidence of tooth avulsions is higher in children aged 9-10 years (6, 7). However, most children in our study group were over 10 years old. Maxillary central incisors were the most frequently avulsed teeth, as also confirmed by other authors. The most commonly observed avulsion of one tooth and the mean number of avulsed teeth (1.48) are also consistent with the observations of other authors (6-8).
Dental injuries usually occurred in the street or courtyard and were mostly related to sports activities. Other authors report, on the other hand, that dental injuries usually occur during school hours and are thus witnessed by teachers, whose knowledge on the management in such cases is, unfortunately, scarce. Among the surveyed teachers, including physical education teachers, only 8% indicated the need for immediate replantation, 78% would not attempt performing replantation, and only half of them would refer the child to the dentist immediately after the injury (9). Our study also revealed insufficient knowledge on the management strategy in dental avulsion, as evidenced by a failure to perform replantation in all dental avulsion cases. According to literature, abandoned attempt of replantation is more common, ranging between 48.38% up to 70% (6, 10, 11). In a similar study conducted in 66 children aged between 6 and 16 years, from a total of 93 avulsed teeth only 33 (64.5%) teeth in 29 children were replanted (10, 11).
Replantation is often delayed and the teeth are stored improperly. Concerns are also raised in relation to late visits of patients to dental clinics, preventing treatment initiation immediately after the injury. Also, medical management, e.g. teeth splinting using traumatic Tigerstedt’s splints, is dubious as wires are known to cause compression of the periodontal ligament and to provide access for bacterial invasion (12).
Periodically published guides, e.g. issued by the International Association of Dental Traumatology (IADT) and the American Academy of Pediatric Dentistry (AAPD), related to the diagnostics and management in traumatic dental injuries, provide the best practical guidelines based on current dental literature and experts’ discussions. According to the IADT guidelines, immediate replantation already at the scene of the injury is the best treatment strategy, although it does not guarantee a long-term maintenance of the tooth in the oral cavity. If for some reasons reinsertion of the tooth in its socket within 5 minutes of injury is impossible, the tooth should be stored in a humid environment, which in the first place includes (in addition to original media) physiological saline solution, milk and patient’s saliva. There are also situations when replantation in contraindicated, e.g. coexisting carries in the avulsed tooth or periodontal disease in the affected area, seriously damaged alveolar bone, uncooperative patients, systemic conditions such as heart diseases, immunosuppression, acute mental disorders, uncontrolled diabetes (1, 2, 13). Our research also confirmed that the coexistence of other traumatic lesions affects tooth replantation prognosis. Generally, the management and prognosis in permanent tooth avulsion depend on the stage of root development (closed/open apex), the medium for tooth storage and the dry extraoral time. Maintenance of periodontal ligament (PDL) viability has a significant impact on the success of replantation. PDL cells are unable to survive when the total dry storage time is longer than 60 minutes, irrespective of whether the tooth was additionally stored in humid environment or not (1-4, 6, 13). It was found based on our material that only 22% of teeth were implanted within 60 minutes of the injury. The percentage is lower than in the group of children presented by Karayilmaz et al. (5), where 45.5% of teeth were replanted within 30 minutes of injury. In our research, teeth were replanted within 2 minutes to 4 days of injury (after a mean of 6.39 ± 13.92 hours). The longest time elapsed between injury and replantation, which was reported by other researchers, was 2 days (14).
Ankylosis was the most common complication, especially after delayed replantation (5, 8). The risk of ankylosis increases significantly for teeth stored dry for longer than 20 minutes. In children, replacement resorption leading to ankylosis is often associated with dental infraocclusion due to inhibited vertical growth of the alveolar process (1, 4, 15). It affected 1/3 of children in our study group. We have found that the complication in the form of ankylosis was more common in teeth with open root apices and teeth replanted later than 60 minutes post-injury. It was also noted that all types of complications occurred less frequently when the avulsed tooth was stored in saliva as opposed to water, when both ankylosis and external resorption were reported. Water is not an adequate medium and a tooth storage time longer than 20 minutes is unbeneficial for the PDL cells (13). Still, it is a better environment than a dry tissue, which was most commonly used in the described cases. Similar errors in avulsed tooth storage as well as correlations with complications occurring during the healing process were observed by other authors (8).
Current evidence supports that short-lasting (7-14 days), elastic splinting of replanted teeth, which ensures minor tooth mobility, promotes periodontal and pulpal healing. This period is, however, extended to 4 weeks for teeth stored dry outside their sockets for more than 60 minutes (1, 3, 4, 16, 17). In our study, the average time of splinting was 25 days for teeth replanted up to 60 minutes following injury, and 33 days for teeth replanted after 60 minutes. Long splinting time, i.e. an average of more than 3 weeks for teeth stored outside the oral cavity for less than 1 hour, is particularly surprising. Prolonged splinting may result from patients’ failure to report for their scheduled visits or significant tooth mobility persisting after splint removal. Compliance with follow-up visits and good cooperation with the patient are necessary to ensure a proper course of treatment or its adjustment in the event of complications (1, 3, 4).
Despite doubts about the efficacy of systemic antibiotics after avulsed tooth replantation, a 7-day antibiotic therapy is recommended, which may be justified by patient’s health status or coexisting injuries, including soft tissue injuries. In some countries, tetracyclines are usually used for this purpose. In Poland, the most common antibiotic used in such cases is amoxicillin (a semi-synthetic β-lactam antibiotic showing bactericidal effects, belonging to the group of aminopenicillins) or amoxycillin with clavulanic acid (which when combined with β-lactam antibiotics, protects them against destruction due to bacterial β-lactamases) or clindamycin (a semi-synthetic antibiotic from the group of lincosamides) or cephalosporin (from the group of semi-synthetic β-lactam antibiotics with a broad bactericidal spectrum). Topical antibiotics (minocycline or doxycycline at a dose of 1 mg per 20 mL of physiological saline for soaking a tooth for 5 minutes) can have beneficial effects on successful pulp revascularisation and periodontal healing in immature teeth (1-4, 13, 17).
insufficient knowledge on the management in dental avulsion results in a failure to replant the tooth immediately after injury, a delayed dental visit and thus late tooth replantation, usually dry tooth storage or the use of inappropriate medium for this purpose. Ankylosis, which leads to the inevitable loss of the tooth, is the most common complication in such cases. Other causes of complicated replantation include therapeutic errors, the use of wire splints in particular, and patients’ non-compliance with scheduled visits. Therefore, there is a need for education on first aid in dental avulsion, tooth storage in the case of abandoned replantation as well as the importance of further treatment for the healing process.
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