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<< Back to 2005 Case List

February 2005Replantation Miracle

Fig. 1 - Sept 2004

An 11 year old boy presented in my office in September of 2004 having sustained an injury while on a trampoline. "Lucas" was a family friend and his mother was concerned that these teeth would eventually be lost. The mandibular right central and lateral incisors had been completely avulsed and replanted approximately an hour later by his General Dentist. No special solutions were used to store the teeth, which were kept in water. The teeth were replaced and splinted with a flexible mesh wire and composite. ( Fig.1) I did not see the patient until 5 weeks after the original injury. Much to my dismay. No attempt had been made by the previous dentist to extirpate the dead pulp or place CaOH in the canals.

The central incisor showed some distal apical resorption and apical radiolucency. The lateral incisor was in much worse condition. There was drainage from the mesial gingival crevice and deep pocketing. I prepared Lucas' mother for the likely possibility that this lateral incisor would be lost. I told her I would do my best to save it but I wasn't sure of the long term prognosis. Actually, I was very pessimistic about its chances when he presented.

Fig. 2 - Sept. 2004


This young patient never had any dental procedures performed on him before so I tried to do as little as possible during the first visit in order to gain his confidence. Rather than immediately place anesthesia, I chose to briefly isolate the lower teeth with cotton rolls. The mesh wire was quickly debonded from the teeth and I made a quick access, carefully extirpating the pulps with broaches that had ligatures attached to them ( to prevent the possibility of swallowing the broaches. I HATE working without dam!) ) The canals were then rinsed with NaOCL 5.25% and Chlorhexidine 2% and then CaOH (Pulpdent) paste was spun into the canals with a Lentulo spiral. ( Fig.2 ) You must have an alert assistant to help you with diligent suction when working under such trying circumstances.

Fig. 3 - Oct. 2004


During the next appointment (about 3 weeks later), anesthesia was administered via mandibular block. This allowed me to firmly clamp the patient's right deciduous "E" and get good rubber dam isolation of the teeth to be treated. Trial working lengths were taken with size #40 files to assess the relative size of the canals. ( Fig.3 ) After establishing some approximate working lengths, the canals were again cleaned with a combination of hand (S) files and ultrasonics. The initial CaOH medication was removed and the canals were dressed with CaOH again, trying to get it as close to the apex as possible without gross overfill.( Fig.4)

Fig. 4 - Oct. 2004

Another change of intracanal dressing was made in December of 2004, prior to the holidays. (Fig.5) I was impressed with the bone fill on the mesial aspect of the lateral. Furthermore, the drainage and pocketing were gone. Maybe this wasn't such a lost cause after all !? Was there hope for these teeth?

Fig. 5 - Dec. 2005

The patient was seen again in early February of 2005 and the change was remarkable. Bone fill was virtually complete. The crestal bone had reestablished itself. Mobility was approaching normal and the patient was asymptomatic. I was elated and so was his mother ! (Fig.6)

Fig. 6

The canals were irrigated again and I attempted to remove all CaOH remnants with ultrasonics. A custom chloroform dip impression technique was used to assist with maximum adaptation of the gutta percha cone to the canal walls and to try to avoid extruding the gutta percha into the periapex of the resorbed root tips. The accesses were bonded with flowable composite and he was almost as good as new. The clinical results were very satisfying and my buddy "Lucas" looks like he'll keep these teeth - as long as he stays away from trampolines! (Fig.7)

Fig. 7 - Final Fill Feb. 2005


Conclusion

Children's dental traumas are not only traumatic to the child patient, the parents are also understandably worried. These avulsed mandibular teeth presented with severe resorption and what initially appeared to be terminal loss of the supporting periodontium.

In order to minimize possible resorption at the onset, the necrotic pulps should be immediately extirpated once the teeth have been avulsed, as the chances for re-valcularization of a tooth with this level of apical development is virtually nil. The canals should be immediately medicated with CaOH. This can easily be done extraorally at the time of replantation or intraorally soon after. In this case, we were fortunate that the supporting bone responded to the removal of the canal based irritants and that healing occurred with spectacular results. Special efforts should be made to ensure that no orthodontic forces are placed on them, as this may trigger additional resorption and loss of the teeth.