I understand that most authors do not indicate the reimplantation of deciduous teeth, but maybe they generalize the treatment with an NO answer for reimplantation. I think they could enhance the subject and I give the question of the possibility of reimplantation in cases where the condition of the tooth and the child are good, the child is under 4 years old, good behavior, the time that elapsed between the accident and the visit to the dentist is less than 30 minutes, the tooth was well conditioned, do not you think it worth a try? And about the procedure of cutting the apex of the root to minimize the possibility of trauma to the tooth germs of permanent teeth, what you think about this procedure?
I guess wht one do in this case is go for extraction in order to avoid any harm to the permanent tooth germ and for the placement of the artificial tooth but with the help of a robond... For esthetic reasons
There are two reasons for not replanting avulsed primary tooth:
1. to avoid any harm to underlying developing tooth germ.
2. replanted deciduous teeth may get ankylosed therefore could lead to impeded/no eruption of permanent successor by further forming fibrous tissue thus necessating more appointments.
alternate to this would be fabrication of a fixed partial denture which would maintain the aesthetics and the space also.
We always target the healthy permanent dentition. There is no need for replanting avulsed primary tooth. We must avoid any harm to underlying developing tooth germ.
We can maintain esthetic and function by several ways.
i think should consider it ... recently i read a study about the same topic:
effects of traumatic dental injuries to primary teeth on permenant teeth- a clinical follow-up study done in brazil
Dent Traumatol. 2011 Apr;27(2):117-21. doi: 10.1111/j.1600-9657.2010.00959.x. Epub 2010 Dec 28.
http://www.ncbi.nlm.nih.gov/pubmed/21199335
my colleague did reimplant once ,no untoward effect seen.
but she did endodontic treatment prior to it. i think in given case scenario, we should try, especially if the time extra orally is less. I do think apiecoectomy is good suggestion to prevent injury to successor. we do not have many article regarding reimplantation of decidous anteriors. most common answer-- i.e., not to reimplant may be due to generalised assumption.
Do it - but use a method that promises to not harm the permanent germ.
1. Some theoretical thoughts
a. The rate with observable damage/consequences at the permanent successor after avulsion of a primary incisor is already >50% - without replantation! The rate after intrusion is somewhat higher. You will never be able to inflict the same damage like an intruded incisor... Thus, there is not much chance for worsening the rate of damage of the permanent successor by replantation...
b. If you don't replant to avoid damage to the successor, you may not reposition any dislocated tooth, since this would add much more damage: While before replantation you could (and should) remove the coagulum that has filled the alveolus, you can't do that with the coagulum that has filled the gap between apex of primary tooth and permanent tooth germ that is left when the apex of the primary tooth is dislocated labially (which is the typical situation). By repositioning the dislocated root - and you have to consider that the coagulum stiffens with time - you press the coagulum against the permanent tooth germ. No problem with the avulsed tooth in this regard...
c. There is not any study which would show an increased damage after replantation. Thus the rejection is based purely on assumptions...
2. Practical HowTo
Possible causes for damage at the successor are mechanical trauma during the replantation (by root tip or coagulum), and infection (deriving from an infection of the necrotic pulp tissues).
a Removal of root tip before replantation
If the root tip is resected before replantation for about 3 mm, then there is a distance of at least 3mm to the permanent germ... No chance at all for damaging it.
b Immediate (before replantation) endodontic treatment from a retrograde direction
Prepare (from retrograde) the root canal, use normal extirpation needles, endo files and reamers, the dentine of the primary teeth is soft, no problem. Use a resorbable root filling material; we use Ca-hydroxide.
The immediate endo prevents any microorganisms from entering the canal, thus there is no risk of an infection in the root canal, no apical periodontitis, no infection related resorption.
3. Ankylosis
Andreasen (Textbook) reports on a few ankylosed primary teeth; there were obviously no severe complications deriving from ankylosis.
Up to now, we only replanted primary teeth which promised to heal in "normally". And this occurred in all these few cases. Thus we don't have any own experiences with avulsed, replanted and ankylosed primary teeth...
But with the promising report of Andreasen we are just updating our protocol...
Main advantage: Speech not disturbed. No necessity for a prosthesis...
To be considered: Age / Compliance
We are just preparing a paper with this topic. Will hopefully be back soon with some pictures, but we have to consider copyright issues/ the demand of no earlier publication.... Meanwhile you may want to have a look at our strategy and method we use for permanent teeth: the only difference is that in these cases we don't use a temporary root filling material, but a definite one (titanium posts)... Or you may want to follow some more avulsion topics...
Hi, Dr. Pammi
sorry, I misunderstood your comment , thought you were against extraoral root resection. Can't understand why I had this impression.
Do you have any own experiences?
To Dr Mohamed
Was this a clinical case? If yes, what did you do? Sorry, I'm quite late, I just stumpled about this case...
For better finding these dental trauma topics I added a topic Dental Traumatology; I just wrote it into that field when I added a question... There is a notification that it is under investigation. Does anyone know how this could be supported? Maybe all who have asked a question could add this topic to their question?
Would be great; at the moment you have to search at least pedo, ortho, endo, and oral and maxillofac surgery, perhaps psychology, epidemiology and whatelse can be related to dental trauma - awkward. I think we would need that topic - dental trauma has some very unique and unusual properties, it can't be subsided in some other topics...
Dr Pohl,
I had no difference in opinion in regards to extra oral resection of apex, for it justifies that there shall be no injury to permanent tooth germ,
Dear Dr. Pammi,
yes, I know now, you are absolutely right. For some reason I had a different impression initially, which was my fault. Most probably I was too fast with reading. So we have the identical conviction - that is great, thank you.
Do you have some cases? Or your colleague? Maybe we could combine our cases?
Best regards
Yango
just published...
G. Holan, an expert in the field, critically reviews the guidelines/recommendations on avulsed primary incisors.
http://onlinelibrary.wiley.com/doi/10.1111/edt.12038/abstract
Thank you all by this nice discussion, I had some cases where I reimplantated the decidous teeth of 3 to 4 years old child, after no more than 30 minutes after the trauma and they had no problem for exfoliation . I´m sure Dr Yango that it is more a question of generalization of treatment and maube the value of the primary dentition still is something to enhance between common people and even dentists.
I was just at the 9th Austrian Congress on Dental Trauma.
In a private discussion a colleague said he would not replant an avulsed primary tooth - unless it would be his son who had lost it... What an aesculapian attitude. I was upset...
Yes, Caroline.
However, there are these guidelines, based on nothing except assumptions. But they have a tremendous impact on the colleagues.
After I finished a lecture on tooth avulsion - within a curriculum "dentistry for children" - including the recommendation to replant primary incisors, the colleague who had invited me (and is a well known professor in paediatric dentistry) said to the visitors that I'm basically right with my scientific analysis, but the guidelines would tell to not replant a primary tooth, and they would have to consider legal problems if the permanent tooth would show any alterations.... How to discuss against such an "argument"?
Yes Dr. I understand you , Last tuesday I had a new case on the Benghazi Faculty where I am a teacher and I recommended a collegue to not extract an intruded anterior incisor of a 4 years old girl and he remembered me that the sylabus of the Faculty recommends the extration....
After all this discussion I ask again how mauch of evidence based dentistry we have in this issue of children dental trauma and What can we do to make this issue more scientifically reviewed
oh, yesss.
There is merely any evidence in dentistry. Even in endodontology, which has a somewhat longer tradition (in regard of being organized) and a huge number of members, compared to trauma, the decision on the irrigant that shall be used is based on in vitro studies. Despite NaOCl is toxic, it was not tested clinically for 70 years now, until recently. You may follow the discussions on irrigants here in rg... they are also a discussion on evidence...
And if there are studies, they are mostly not worth the paper they are written on... Even the most important colleagues have published real scientific catastrophes, which conclude just the opposite of what the data say. But try to convince people to abandon upon what they believe... For many colleagues science seems to be another word for religion. They don't even listen, they ignore you, if they don't have arguments and if they can't compete with you. It is a game of power, and that has nothing to do with facts or data or science...
Read the article of Holan; you can just feel the anger about the established and official standpoints which are not based on any scientific result but define the standard...
What is to do?
Sample your cases, present and publish. Discuss again and again, even if they laugh at you. Try to get them in a personal discussion, if they are in a group, they are too strong, it is simplier to not take you serious then.
It is a big job to convince people.
See here my report on a discussion on NaOCl
https://www.researchgate.net/post/What_do_you_think_about_the_lack_of_agreement_concerning_irrigation?cp=re65_x_p2&ch=reg&loginT=N06bYvE8xLKC3p2JppegK_WLlYkolMIsBGcCgWhbqdarMXfCcjb70w%2C%2C&pli=1#view=51a44faed11b8ba035000059
Embarassing.
Thank you a lot, I will try to get permission from the faculty for treating those cases in a less aggressive way. and maybe we can do something more for those children and for real science.
see my recent article: Holan G. Replantation of avulsed primary incisors: a critical review of a controversial treatment. Dent Traumatol. 2013 Jun;29(3):178-84.
Thank you for your answer , I am glad that I can reach your article, I was looking for it.
Yes, the article by Gideon Holan is really worth to be read. Independent thinking, open minded and critical discussion of guidelines and recommendations which have been repeated and repeated and repeated, passed from one generation of dentists to the next one, until believes are considered facts and assumptions are considered evidence. One of the most important publications in Dental Traumatology in recent years. Well done.
I totally agree with Dr. Pohl and Dr. Holan. When one reviews the evidence regarding secondary effects of dental avulsion of deciduous teeth on permanent teeth, one finds that the results are mixed with percentages ranging from 38% to almost 80% depending on the author that you read. As Dr. Pohl mentioned, the defect on the permanent teeth is going to appear even if you don´t replant. What most dentist seem to forget is that the age at which the trauma occurs has an important role. It is not the same to have the avulsion at two years of age (when the permanent incisors are at a very early stage of develompent) than at four years of age when the crown is almost complete, in this last case most likely there will be no defect on the permanent incisors.
On the other hand, when one reviews the guidelines from the International Association of Dental Traumatology, one will find that the references on which guidelines are based, are mostly case reports, epidemiological reports, opinions and textbook references, and the reason for that is that there is no evidence regarding this subject.
One final idea. I am almost sure that there are many pediatric dentists who have replanted primary incisors, or have cases in which these incisors have been replanted by their parents or guardians, and for sure the dentist has not extracted them after being replanted. What about if someone would collect these cases in order to get an important database from which conclusions based on a statistically significant sample can be drawn? . I for one have several of these cases that I could provide.
Dario Cardenas DDS, MSc. Professor Emeritus CES University, Colombia S:A
Your idea, Dr. Cardenas is interesting. The problem in collecting information from a large group of dentists is that each one provides a different treatment. Knowing this limitation we can still try to collect information and create a data base. The first step should be to compose a questionnaire that will include all necessary information about the injury, the treatment rendered and the consequences. The second step should be looking for the best way to distribute the questionnaire to as many dentists as possible providing a response system and a site in which the data will be kept. We should make a pilot analysis on a relatively small group of cases to make sure that our questionnaire is relevant. The last point is the statistical analysis of the data when we believe we have enough cases. I did not mention yet the need to finance such a study.
I call you, Dr. Dario Cardenas, Dr. Carolina Mohamed and Dr. Yango pohl to create a research group to investigate the outcome of reimplantation of primary teeth.
Ok, time to get active. After years with proposals for international studies under the roof of the IADT - without resonance - we just have to take our own responsibility.
So, Caroline, I will join the group.
Dr. Dario Cardenas, are you willing and capable to join the group? More colleagues who are interested?
I suggest that Dr. Gideon Holan should be in the group. Depending on the nature of this group, which we would have to define, I suggest Dr. Holan would be primus inter pares, or head, or president, respectively, as he has the experience and the knowledge from sampling these heterogeneous data, and I guess he has quite some more information from his study than he could use in the publication. And he has already done most of the work he requested, since he had to deal with incomplete data in his review, so he knows what is missing.
I therefore would like to ask you, Dr. Holan, would help the group with your experience, your skills, your data - and your presence and well-known name, which could be a door opener here and there.
Kind regards
Yango
Sorry for taking so long in answering, I was away on vacation, but now I am back. I am willing and ready to work in this endeavour. I also propose Dr. Holan to lead the group, as for me, I will start collecting cases from my office, and from several colleagues in Colombia. To start I will ask the colleagues for a short description of the cases, indicating age of the patient, time out of the mouth, preservation media, type and duration of splint, were antibiotics prescribed or not, type of endodontic treatment, damage to the permanent dentition.
I will be glad to receive any suggestions.
Dario Cardenas DDS, Msc
Professor Emeritus CES University
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