Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted

Rescuing “hopeless” avulsed teeth using autologous platelet-rich fibrin following delayed reimplantation: Two case reports

BACKGROUND

Tooth avulsion is one of the most severe types of dental trauma. Most avulsed teeth undergo long-term ankylosis and replacement resorption after delayed reimplantation and exhibit a poor prognosis. The aim of this work was to improve the success rate of avulsed teeth after delayed reimplantation using autologous platelet-rich fibrin (PRF).

CASE SUMMARY

Case 1 was a 14-year-old boy who fell and knocked out his left upper central incisor 18 h prior to his arrival at the department. The diagnoses were avulsion of tooth 21, lateral luxation of tooth 11 and alveolar fracture of teeth 11 and 21. In case 2, a 17-year-old boy fell 2 h prior to his presentation to the hospital, and his left upper lateral incisor was completely knocked out of the alveolar socket. The diagnoses included avulsion of tooth 22, complicated crown fracture of tooth 11 and complicated crown-root fracture of tooth 21. The avulsed teeth were reimplanted along with autologous PRF granules and splinted using a semiflexible titanium preshaped labial arch. The root canals of the avulsed teeth were filled with calcium hydroxide paste, and root canal filling was performed 4 wk after reimplantation. The reimplanted teeth showed no symptoms of inflammatory root resorption or ankylosis at the 3-, 6-, and 12-mo follow-up examinations after reimplantation with autologous PRF. In addition to the avulsed teeth, the other injured teeth were treated using corresponding conventional treatment methods.

CONCLUSION

These cases provide examples of the successful use of PRF to reduce pathological root resorption of the avulsed teeth, and the application of PRF may provide new healing opportunities for traditionally “hopeless” avulsed teeth.

Network Meta-Analysis of 10 Storage Mediums for Preserving Avulsed Teeth

Many storage mediums are available for the storage of avulsed teeth to preserve the viability of periodontal ligament (PDL) cells before replantation; however, it is unclear which medium is the optimal option. We performed this network meta-analysis to answer this question. A comprehensive search was conducted in PubMed, EMBASE, and the Cochrane library to capture eligible studies investigating the comparative efficacy of Hank's balanced salt solution (HBSS), aloe vera gel (AVG), oral rehydration solution (ORS), coconut water, egg white, green tea, propolis, saline, milk, and water. Statistical analysis was conducted using Review Manager v5.3 and ADDIS v1.16.8. In total, 20 RCTs involving 31 reports were included finally. Direct meta-analysis suggested that HBSS was superior to ORS, milk, saline, and water, ORS was superior to milk but inferior to coconut water and propolis, egg white was superior to milk but inferior to AVG and propolis, propolis was superior to AVG, milk, and saline, and coconut water and water was inferior to saline and milk, respectively. Network meta-analysis suggested that AVG was inferior to the other nine mediums, and propolis was superior to HBSS (SMD, −5260.24; 95% CrI, −10447.39 to −70.37) and milk (SMD, −5461.11; 95% CrI, −10574.99 to −328.51). Moreover, ranking probabilities indicated the highest probability for propolis, followed by saline, ORS, HBSS, milk, egg white, water, green tea, and AVG successively. Propolis may be the optimal media for storing avulsed teeth before replantation. However, given the availability of propolis and HBSS and the hypotonic properties of saline, ORS or milk should also be preferentially selected.

Severe Case of Delayed Replantation of Avulsed Permanent Central Incisor: A Case Report with Four-Year Follow-Up

Avulsion is one of the most serious dental traumatic injuries with a reserved prognosis. This case report describes multiple trauma lesions in permanent central incisors of an eight-year-old girl and a four-year follow-up. The right upper incisor suffered avulsion, remained 16 h extraorally, and was replanted after extraoral endodontic therapy. The left maxillary central incisor suffered a noncomplicated crown fracture with concomitant subluxation. The present case adds to the literature a rare occurrence of success in a severe case with poor prognosis. For this reason, the International Association for Dental Traumatology (IADT) guidelines should be followed and, even in extreme situations, replantation should always be considered.

Tooth Bioengineering and Regenerative Dentistry

Over the past 100 y, tremendous progress has been made in the fields of dental tissue engineering and regenerative dental medicine, collectively known as translational dentistry. Translational dentistry has benefited from the more mature field of tissue engineering and regenerative medicine (TERM), established on the belief that biocompatible scaffolds, cells, and growth factors could be used to create functional, living replacement tissues and organs. TERM, created and pioneered by an interdisciplinary group of clinicians, biomedical engineers, and basic research scientists, works to create bioengineered replacement tissues that provide at least enough function for patients to survive until donor organs are available and, at best, fully functional replacement organs. Ultimately, the goal of both TERM and regenerative dentistry is to bring new and more effective therapies to the clinic to treat those in need. Very recently, the National Institutes of Health/National Institute of Dental and Craniofacial Research invested $24 million over a 3-y period to create dental oral and craniofacial translational resource centers to facilitate the development of more effective therapies to treat edentulism and other dental-related diseases over the next decade. This exciting era in regenerative dentistry, particularly for whole-tooth tissue engineering, builds on many key successes over the past 100 y that have contributed toward our current knowledge and understanding of signaling pathways directing natural tooth and dental tissue development-the foundation for current strategies to engineer functional, living replacement dental tissues and whole teeth. Here we use a historical perspective to present key findings and pivotal advances made in the field of translational dentistry over the past 100 y. We will first describe how this process has evolved over the past 100 y and then hypothesize on what to expect over the next century.

Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted

BACKGROUND

Traumatic dental injuries are common. One of the most severe injuries is when a permanent tooth is knocked completely out of the mouth (avulsed). In most circumstances the tooth should be replanted as quickly as possible. There is uncertainty on which interventions will maximise the survival and repair of the replanted tooth. This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To compare the effects of a range of interventions for managing traumatised permanent front teeth with avulsion injuries.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 March 2018), Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 2) in the Cochrane Library (searched 8 March 2018), MEDLINE Ovid (1946 to 8 March 2018), and Embase Ovid (1980 to 8 March 2018). The US National Institutes of Health Ongoing Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We considered randomised and quasi-randomised controlled trials that included a minimum follow-up period of 12 months, for interventions for avulsed and replanted permanent front teeth.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias. Authors were contacted where further information about their study was required.

MAIN RESULTS

Four studies, involving a total of 183 participants and 257 teeth were identified. Each of the interventions aimed to reduce infection or alter the inflammatory response or both at the time of or shortly after the tooth or teeth were replanted. Each study assessed a different intervention and therefore it was not appropriate or possible to numerically synthesise the data. All evidence was rated as being of very low quality due to problems with risk of bias and imprecision of results. This means that we are very uncertain about all of the results presented in this review.One study at high risk of bias with 69 participants (138 teeth) compared a 20-minute soak with gentamycin sulphate for both groups prior to replantation with the experimental group receiving daily hyperbaric oxygen for 80 minutes for the first 10 days. There was some evidence of a benefit for the hyperbaric oxygen group in respect of periodontal healing, tooth survival, and pulpal healing.One study at unclear risk of bias with 22 participants (27 teeth) compared the use of two root canal medicaments, Ledermix and Ultracal. There was insufficient evidence of a difference for periodontal healing or tooth survival. This was the only study to formally report adverse events with none identified. Study authors reported that Ledermix caused a greater level of patient dissatisfaction with the colour of avulsed and replanted teeth.A third study at high risk of bias with 19 participants compared extra- or intra-oral endodontics for avulsed teeth which were stored dry for longer than 60 minutes before replantation. There was insufficient evidence of a difference in periodontal healing.The fourth study at high risk of bias with 73 participants compared a 10-minute soak in either thymosin alpha 1 or saline before replantation followed by daily gingival injections with these same medicaments for the first 7 days. There was some evidence of a benefit for thymosin alpha 1 with respect to periodontal healing and tooth survival.

AUTHORS' CONCLUSIONS

Based on the results of the included studies, there is insufficient evidence to support or refute the effectiveness of different interventions for avulsed and replanted permanent front teeth. The overall quality of existing evidence was very low, and therefore great caution should be exercised when generalising the results of the included trials. There is urgent need for further well-designed randomised controlled trials.