Hindawi

Case Reports in Dentistry

Volume 2022, Article ID 2081684, 6 pages
https://doi.org/10.1155/2022/2081684

Case Report
Management of 3 Avulsed Permanent Teeth: Case Report of a 3-
Year Follow-up

Soukaina El Kharroubi , Sofia Drouri , Bouchra Doumari , Sara Dhoum ,

and Hafsa El Merini
Department of Conservative Dentistry and Endodontics, School of Dentistry, Hassan II University of Casablanca, Morocco

Correspondence should be addressed to Soukaina El Kharroubi; [email protected]

Received 18 May 2021; Revised 9 September 2021; Accepted 24 February 2022; Published 16 March 2022

Academic Editor: Tatiana Pereira-Cenci

Copyright © 2022 Soukaina El Kharroubi et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Dental avulsion is one of the most serious dental injuries. When the tooth is knocked out, the blood supply to the pulp is
interrupted and the periodontal ligament cells are exposed to injuries caused by the external environment. In recent years,
research findings have shown the possibility of complete healing under favorable conditions: replanting the tooth according to
the criteria required by the guideline such as the extra oral time which should be very short, the time of pulp removal after
replantation, and the appropriate storage medium. This set of criteria may lead to a slower progression of the phenomenon of
resorption with a better prognosis over time; however, there is a high risk of complications such as external root resorption
which lies in late replantation. The research results of many research-groups around the world have given us a better
understanding of healing and complications. Nowadays, even teeth that are replanted after a delay can be saved. The dentist
remains the key person in the case of dental trauma, namely, dental avulsion as his role is the management of the emergency
situations. The objective of this case study is to present a successful management of 3 avulsed permanent incisors, replanted
and remained with no complications for over a period of 3 years.

1. Introduction consequences of dental avulsion are countless; they differ from

patient to patient and may be related to the individuals’ quality
Tooth avulsion is a serious traumatic dental injury (total lux- of life, psychological, and social problems, as well as the costs
ation, extrusion, or avulsion). It is a dental trauma that cor- of treatment. [6]. In case of tooth avulsion, most periodontal
responds to the complete displacement of the tooth out of ligament cells left on the root surface are due to the tearing
the alveolar bone socket [1–3]. Avulsion of permanent teeth of the alveolar-dental ligament; these cells must be hydrated
varies from 0.5% to 16% of all traumatic injuries, as it is one to maintain the durability of the tooth while reducing the phe-
of the rare and serious dental injuries. The young population nomenon of resorption and allowing healing. However, when
is the most affected and the maxillary central incisors are the the extraoral time increases, leaving the periodontal ligament
teeth most often involved due to their exposed position in dry, inflammatory resorption occurs [4]. The incidence of an
the dental arch [4]. The risk of infection and root resorption external root resorption (inflammatory/replacement) remains
can occur at any time after avulsion and dental replantation, high even in a correct management of replantation of the
which may influence the treatment outcome and survival rate tooth. However, several criteria can lead to slow progression
including the prognosis of the teeth involved [5]. Besides, the and a better prognosis over time if they are well respected.
2 Case Reports in Dentistry

[6] After all, the natural history of inflammatory and replace-

ment resorption is important in order to detect the right prog-
nosis of the replanted tooth. [6]
The aim of this study/case report is to present a success-
ful replantation of 3 avulsed permanent maxillary incisors.
No sign of resorption and ankylosis were seen over a period
of 3 years.

2. Case Report
A 28-year-old female patient was referred to the Department
of Conservative Dentistry and Endodontics at the School of
Dentistry (Casablanca-Morocco) after an assault causing Figure 1: Intraoral view showing avulsion of teeth 11, 21, and 22.
three avulsions of maxillary incisors after one hour of
trauma. The patient was examined for extraoral signs of
injury, including swelling and asymmetry of the face. No
other oral injury was clinically detected. The patient
reported that she has a history of periodontitis already
treated and stabilized. The intraoral examination revealed
that the maxillary permanent central incisors and lateral left
incisor (tooth 11, 21, and 22) were avulsed with lacerations
of soft tissue of gingiva (Figure 1). The avulsed teeth had
been kept in whole milk, from the moment of trauma until
emergency visit 60 minutes later. The crowns of the avulsed
teeth were intact, and the roots had closed apexes (Figure 2).
Preoperative panoramic radiograph showed empty
sockets of 11, 21, and 22 (Figure 3) The alveolar bone losses
resulting from periodontal disease on these teeth and other Figure 2: Avulsed teeth conserved in milk for 60 minutes—intact
teeth are also observed in this radiograph. The roots and teeth.
sockets were cleaned gently with a saline rinse and the teeth
replanted manually compressed to its original position
under local anesthesia. Placement of teeth was confirmed resorption (inflammatory/replacement) can be high and var-
radiographically before a flexible splint was placed for 4 ies between 59% and 80% in patients with so-called correct
weeks (Figure 4). Systemic antibiotic therapy was prescribed replantation [6]. Several studies have investigated the effect
(penicillin 1 million units immediately, thereafter 2 million of dry storage that plays an important role in the viability
units daily for 6 days). A soft diet, good oral hygiene with of the periodontal ligament cells and may be responsible for
the use of a soft- bristled toothbrush, and a 0.12% chlorhex- the occurrence of inflammatory resorption. It has also been
idine mouth rinse were also prescribed for 2 weeks. shown that the periodontal ligament cells can survive a dry-
The patient was called after one-week postreplantation ing time of 10 to 15 minutes, but the possibility of their sur-
(Figure 5) for an intracanal placement of calcium hydroxide vival beyond this time where the drying time exceeds 60
which was renewed for after 3 months, and the canals were minutes may be very limited; as a result, the risk of early
obturated with Gutta-percha later (Figure 6). The splinting resorption increases [7]. Therefore, milk remains the correct
wire was removed after 4 weeks (Figure 7). Successive radio- balanced storage medium. It is the most relevant medium
graph testing (periapical and CBCT) was performed in the since it preserves the cells of the periodontal ligament for sev-
follow-up period to disclose root resorption (Figures 8, 9, eral hours and keeps them in a good condition until replan-
and 10) The radiographic tests showed no evidence of root tation. A balanced salt and saliva solution could also have
resorption. A periodontal bone loss has been detected with the same indications effects as milk [8]. As in this present
absence of the gingival inflammation or bleeding on probing case, the avulsed teeth were kept in milk for 60 minutes from
(absence of periodontal pocket); this represents a reliable the moment of trauma until emergency visit and remained
indicator of periodontal stability. intact. The factors associated with avulsion injury show that
an immature tooth develop more complications and have a
3. Discussion lower survival rate than a mature tooth [9]. In this present
clinical case, this factor is favorable, with three teeth closed
Dental avulsion mostly affects children and adolescents with apexes. Another study shows that the age of the patient can
a prevalence of 17.5%. It is mostly found among males than be a good factor to determine the progression of root resorp-
females [6]. tion in teeth with an extended extra oral time. [6] Rightly as
well, patients between 17 and 39 years old present higher
3.1. The Different Criteria Affecting the Management of the rates at the time of the avulsion trauma in comparison to
Replanted Avulsed Teeth. The incidence of the external root younger patients between 8 and 16 years old.
Case Reports in Dentistry 3

Figure 3: Preoperative panoramic radiograph showing empty sockets of 11, 21, and 22. No sign of fracture or contusion of the alveolar
sockets.

Figure 4: Immediate replanted and splinted teeth 11, 21, and 22. A
flexible splint stabilized teeth for 4 weeks.

Figure 6: Obturation canals after 3-months medication with

replanted calcium hydroxide treatment.

Figure 5: 1-week posttrauma. intraorally because it can minimize the extraoral time and
reduce many risk factors [12]. As in our case, the canals’
obturation with Gutta-percha and sealer was performed
A recent study also shows that the risk of developing intraorally. From a previously reported clinical study of
severe inflammatory resorption is related to the pulpectomy replanted teeth [13], the increase of the duration of the dry
time. The timing of pulp extirpation after replantation is time can lead to the increase of the risk of ankylosis which
very important and it must be done promptly to reduce is significantly higher with mature teeth that have closed
the risk of early complications [10]. Regarding our case, apex than with immature teeth [13] [14]. Moreover, it has
the pulpectomy was done after one-week postreplantation been shown that internal and external root resorption
and the intracanal calcium hydroxide was placed for 3 (inflammatory or replacement) have different incidences
months before the obturation canals. This aspect of the after dental avulsion and replantation [5]. As a result, it
treatment of replanted teeth/a replanted tooth has been the was found that the replacement root resorption is the most
most controversial and has undergone several changes over prominent, followed by the inflammatory external root
time. In the past clinical and experimental studies, endodon- resorption, then the surface root resorption, and finally, the
tic treatment (biomechanical preparation followed by obtu- internal root resorption which is the least common. Peri-
ration with Gutta-percha and sealer) used to be performed odontal disease has been considered a contraindication to
extraorally before the replantation. [11] Nowadays, guide- replantation. However, various studies have shown that peri-
lines recommend endodontic treatment to be performed odontitis is no more an absolute contraindication to dental
4 Case Reports in Dentistry

Figure 7: 4-week posttrauma.

Figure 9: CBCT images—3 years after replantation.

the time kept for the storage [3]. There are reports of
replanted teeth having favorable prognosis and could last
for over 30 years. Some of them remain in function for 5
Figure 8: 18-month follow-up of teeth. years or more, but most of them are lost due to root resorp-
tion or other complications like ankylosis. However, a good
management of the infection may lead to a tissue regenera-
replantation [15]. Teeth with one periodontal pocket >6 mm tion and give a good environment for its healing [17]. It
in patients under the age of 40 had a 2.5- and 2.6-fold lower has been reported that a favorable prognosis of a replanted
risk of failure, compared to the teeth with more pockets and teeth with an arrested external root resorption after a 2-
patients over the age of 40. These factors should be carefully year follow-up has shown that the use of milk as a storage
observed for teeth replantation [15]. Other studies have medium maintain the viability of periodontal ligament cells
shown that delayed replantation does not fully maintain [18]. As for our case, the 3 replanted teeth have not shown
the bone volume as the bone disappears with the tooth. In any sign of root resorption or ankylosis for 3 years. The min-
the anterior region of the maxilla, the buccal profile of the imum extraoral time and the appropriate storage medium
alveolar bone depends on teeth with a feasible periodontal after avulsion are directly associated with good prognosis
ligament [16]. In our case study, the conditions for the of a replanted tooth staying on the dental arch for a long-
replantation of the 3 teeth were favorable as the young time. This may happen because of a minimal infection,
patient had stable periodontitis that was successfully treated, maintenance of root cementum, and a periodontal ligament
and the maintenance phase of periodontal therapy per- cell on root surface remained alive. [19]
formed since that time. The absence of inflammation and Below are the different factors influencing the prognosis
bleeding on probing can be used as predictors of the peri- of the avulsed tooth [20]:
odontal stability.
(i) The type and the timing of the treatment
3.2. Prognosis. The prognosis of an avulsed replanted perma- (ii) Pulp removal (root canal treatment) after tooth
nent tooth depends on different criteria as the amount of replantation within 7-14 days showed a signifi-
damage to the root surface, the degree of the root develop- cantly higher survival rate
ment of the avulsed teeth, and the extra-alveolar dry period
and storage medium in which the tooth was kept prior to (iii) Contraindications to replantation: uncooperative
replantation. There are many factors that can affect the clin- patient, many severe caries, advanced and
ical success of a tooth replantation such as endodontic treat- untreated periodontal diseases, and serious general
ment, antibiotics prescription, age of the patient, type of the pathology (immunosuppression, severe cardiac
splinting used, and the time of the replantation, as well as conditions)
Case Reports in Dentistry 5

Figure 10: No pathology and resorption. 3-year radiograph examination.

(iv) Immature root (open apex) exhibits more compli- [3] D. D. Müller, R. Bissinger, M. Reymus, K. Bücher, R. Hickel,
cations and usually has worse prognosis compared and J. Kühnisch, “Survival and complication analyses of
to mature root (closed apex) with a lower survival avulsed and replanted permanent teeth,” Scientific Reports,
rate vol. 10, no. 1, p. 2841, 2020.
[4] M. Singh, N. Singh, R. K. Dhiman, and D. Kumar, “External
(v) Appropriate storage media increase the success rate replacement resorption in an avulsed reimplanted permanent
of replantation incisors,” Journal of the International Clinical Dental Research
Organization, vol. 5, no. 1, p. 27, 2014.
(vi) better treatment outcome lies in the immediate
replantation of the avulsed tooth [5] B. D. M. Souza, K. L. Dutra, M. M. Kuntze et al., “Incidence of
root resorption after the replantation of avulsed teeth: a meta-
(vii) The prognosis of replanted teeth is determined by analysis,” Journal of Endodontics, vol. 44, no. 8, pp. 1216–1227,
the patient’s compliance (postreplantation manage- 2018.
ment and follow-up appointments). [6] M. Mazur, R. Marasca, L. Ottolenghi et al., “Different resorp-
tive patterns of two avulsed and replanted upper central inci-
Therefore, it can be concluded that tooth avulsion sors based on scanning electron microscopy and
remains a severe dental injury with an unpredictable stereomicroscopic analysis: a case report,” Applied Sciences,
prognosis. vol. 10, no. 10, p. 3551, 2020.
[7] M. Trope, “Clinical management of the avulsed tooth: present
strategies and future directions,” Dental Traumatology, vol. 18,
4. Conclusion no. 1, pp. 1–11, 2002.
Although tooth avulsion is one of the most complicated [8] M. Donaldson and M. Kinirons, “Factors affecting the time of
types of teeth traumas. We were able to maintain a 3-year onset of resorption in avulsed and replanted incisor teeth in
follow-up of the 3 replanted teeth with no sign of root children,” Dental Traumatology, vol. 17, no. 5, pp. 201–205,
resorption or ankylosis. Our treatment can be considered a 2001.
successful one with a favorable prognosis. [9] B. Petrovic, D. Markovi’c, T. Peric, and D. Blagojevic, “Factors
A regular clinical and radiographic examination follow- related to treatment and outcomes of avulsed teeth,” Dental
up every year is fundamental. Traumatology, vol. 26, no. 1, pp. 52–59, 2010.
[10] A. M. Mavridou, E. Hauben, M. Wevers, E. Schepers,
L. Bergmans, and P. Lambrechts, “Understanding external cer-
Consent vical resorption patterns in endodontically treated teeth,”
International Endodontic Journal, vol. 50, no. 12, pp. 1116–
An informed and written consent from the patient for pub- 1133, 2017.
lication of the case report was obtained.
[11] J. O. Andreasen and E. Hjorting-Hansen, “Replantation of
teeth. I. Radiographic and clinical study of 110 human teeth
Conflicts of Interest replanted after accidental loss,” Acta Odontologica Scandina-
vica, vol. 24, no. 3, pp. 263–286, 1966.
The author(s) declare(s) that there is no conflict of interest [12] M. T. Flores, L. Andersson, J. O. Andreasen et al., “Guidelines
regarding the publication of this article. for the management of traumatic dental injuries. II. Avulsion
of permanent teeth,” Dental Traumatology, vol. 23, no. 3,
pp. 130–136, 2007.
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