New Ideas for Avulsed Tooth Reimplantation

It is every general dentist’s nightmare. At 4 o’clock after a busy day, a frantic mother calls telling your receptionist that her 6-year-old son has knocked out his front permanent teeth in a playground accident. When the bloody, crying child arrives at your office, the mother hands you a cup of milk with teeth Nos. 9 and 10 at the bottom. Upon clinical examination, you realize that not only has the child avulsed his central and lateral incisors, but the alveolar bone on both teeth has broken out both buccally and palatally. After numbing the now hysterical child, an attempt to reimplant the teeth seems useless because (1) tooth No. 8 is the only decent tooth to bond to and (2) replacing the teeth into broken sockets feels like placing teeth into Jell-O. Despite your best effort to compress periosteum and alveolar bone around the teeth to stabilize them, the likelihood of successful reimplantation is poor.
Such an occurrence is a long-term personal and family tragedy emotionally, aesthetically, and financially. The probable outcomes are apexification, endodontic treatment, eventual extraction, and a “flipper” partial, bridgework, or implant.
This article will discuss a new approach to stabilizing avulsed teeth that the author believes may have benefits not only for this application, but for other dental trauma situations as well.

THE “UGLY DUCKLING” STAGE
The ugly duckling stage is an awkward period in a child’s life when newly erupted maxillary incisors appear to be “snow shovels” in a small face. This is a particularly hazardous time for traumatic dental injuries because of the size and protruding nature of the front teeth, the softness of the alveolar bone, the lack of completed radicular formation, and the lack of ability to splint to adjacent teeth.
Frequently, avulsed teeth occur in young patients with predisposing orthodontic conditions such as thumb-sucking and/or class II malocclusion with excessively flared maxillary central incisors. These patients have maxillary incisors that hang over the lower lip, and when the child falls down, his or her teeth strike first without lip cushion to soften the blow.
I’ve known orthodontists who routinely extract a tooth with a history of avulsion. These teeth frequently ankylose and often fail long term. They feel it is better to correct the problem in the patient’s teens than to retreat the problem in the patient’s 30s or 40s.
When I saw the child described in the opening paragraph, the next day after trying to splint avulsed teeth Nos. 9 and 10 to teeth Nos. 8 and 11, I realized there was no hope. The orthodontic wire and composite were removed from the hanging teeth, and the patient was fitted with an occlusal guide. The appliance was inserted over the loose teeth.

THE OCCLUSAL GUIDE
The occlusal guide is a preformed polypropylene orthodontic positioner. For decades, orthodontists have used custom-made positioners to fine-tune orthodontic detail into their fixed orthodontic cases. Orthodontic labs manufacture custom-made positioners by cutting out every tooth from a plaster cast of a nearly completed orthodontic case. The cut-out plaster teeth are reassembled into perfect occlusion in ideal tip, torque, and angulation at Angle class I interdigitation. Then a polypropylene, football-style mouth guard is fabricated over the ideally reset plaster cast.
Dr. Earl Bergersen, an orthodontist and developer of the occlusal guide, realized how extremely uniform the human dentition is. This is why preformed denture teeth can precisely restore ideal aesthetics to an edentulous patient and why aesthetic dentistry has adopted the “golden proportions” in cosmetic makeovers. Prefabricating the positioner by duplicating different sizes of denture teeth set to ideal class I occlusion eliminated the need for orthodontists to remove the last upper and lower wires, take an impression, replace the same wires, send the poured models to the lab for positioner fabrication, and have the patient return for debonding, debracketing, and appliance insertion. Orthodontists could now select the size needed and insert the best-fitting appliance immediately after fixed appliance removal. The patient needs to do heavy biting exercises for a prescribed length of time, say 2 hours per day for one week, prior to final retention.
Dr. Bergersen soon realized that his device with a motivated child could do far more than provide fine detail to a near-finished orthodontic case. He found that the occlusal guide was capable of correcting severe orthodontic malocclusions with sustained use in a motivated child. Huge overjet/overbite cases could be corrected 1 mm per month. Severely crooked teeth with absence of crowding could be straightened over several months of heavy biting exercises. The flexible but firm polypropylene rims can catch misaligned teeth and slowly force them into place. The occlusal guide became the most frequently used orthodontic appliance worldwide.

THE AVULSED TOOTH STABILIZING APPLIANCE
The problem with using an occlusal guide to stabilize avulsed teeth is that it is both an upper and lower bulky, football-style rubber mold. The patient has to eat and drink, necessitating early removal during the crucial 7- to 10-day period for avulsed teeth. Early removal could possibly remove the teeth with the appliance, because dried blood and contaminants cake to the very loose teeth, and the appliance slots grasp tooth curvatures, making removal risky.
However, if the mandibular half was eliminated from the appliance, leaving only the upper, then with some difficulty the patient could eat and drink for days, perhaps weeks, before removing the occlusal guide (see Figure). Longer-term wear may allow complete reattachment of the avulsed teeth. Intermittent biting exercises would place an apically directed force, maintaining the terminal root in the depth of socket position at an ideal tip, torque, and angulation. I estimate that 3 sizes of the appliance would fit 90% of patients: small, medium, and large. The size is determined by arch width and central incisor width.
Frequently, pediatric patients age 6 to 8, in their ugly duckling stage, have teeth ectopically positioned with flared centrals and huge diastemas. Because of the very flexible material used to fabricate the occlusal guide, these teeth can still be stabilized by the appliance even if the central incisors overlap into the lateral slots. Again, the occlusal guide was designed to straighten crooked teeth. Different size appliances may be inserted to determine the best fit, although this appliance will not fit all mouths.

Figure. Eliminating the mandibular half from the occlusal guide appliance, leaving only the maxillary, will allow the patient with some difficulty to eat and drink for days, maybe weeks, before removal. Long-term continuous wear will allow complete reattachment.

The patient should be instructed to wear the appliance continuously for 7 to 10 days including eating, drinking, and sleeping, while intermittently biting hard into the appliance throughout the waking hours as much as possible. Sleep could be difficult, especially the first night, and as with any oral appliance, temporary excessive salivation is a frequent problem.
After 7 to 10 days, the child should be re-examined. Then the dentist should peel back the phlanges of the appliance labially and palatally, detaching any dried blood and contaminants. The teeth should be examined for stability and firmness. If after 7 to 10 days a firm reattachment is not evident, the teeth should be removed.
Besides being useful for tooth reimplantation in the ugly duckling stage, this device could be used for multiple avulsed teeth that are difficult to stabilize. For example, I had a patient who avulsed all 4 maxillary incisors when his teeth caught the net while dunking a basketball. The attempt to reimplant and stabilize them by an oral surgeon was unsuccessful. Stabilizing multiple teeth avulsions in a bloody operating field with composite and orthodontic wire can be very difficult. The patient now has 4 implants.
This device could also remedy other traumatic dental injuries, such as accident victims where the incisors are crushed palatally or are very loose but not fractured. These teeth could be repositioned to close to an ideal position and the appliance inserted for 7 to 10 days.
Perhaps this device could be useful for fractured teeth; broken teeth stabilized precisely may allow successful root canal treatment, especially with current perforation sealing techniques. I propose the hypothesis that sustained, apically directed pressure on the crown into the bony socket of a mid root fracture would more likely correctly align a fractured root than a dentist bonding a loose crown haphazardly to adjacent teeth with orthodontic wire.

DISCUSSION

Many gaps exist in current treatment for successful reimplantation of avulsed teeth, even if the accident victim arrives to a medical professional within the narrow window of time needed. For example, general dentists see these cases so infrequently that they are often ill-suited to treat a screaming, bloody, ugly duckling child with no adjacent teeth to which to bond. They often refer them to an oral surgeon across town.
In car accidents with multiple avulsed teeth, medical per-sonnel are rarely prepared to handle anything dental. Even large trauma centers with around-the-clock general surgery, orthopedic, and cardiovascular residency coverage often call in oral surgeons to handle tooth avulsions. What if every paramedic had 3 sizes of the avulsed tooth stabilizing splint on board his vehicle and was trained to reimplant and insert the appliance even as a temporary means to stabilize? What if every emergency room physician/resident or general dentist had these appliances on hand ready to use?
Perhaps unconscious accident victims could be stabilized by reimplanting the teeth, selecting and fitting the appropriate appliance, relining the splint with cold care liquid gel polypropelene, and reinserting the appliance over avulsed teeth until the material was hardened and secure.

CONCLUSION

How many avulsed teeth are lost by holes in the healthcare system? How many avulsed teeth are lost by poor stabilization of multiple avulsed teeth with little to which to bond? How will prolonged, intermittent, apically directed biting force affect reimplantation success in the short term and long term? Can nondental, first-arriving healthcare professionals be trained to reimplant avulsed teeth with a preformed polypropylene mold? Will mid root fractures have a greater chance of success if the broken fragments are compressed over each other for 7 to 10 days? Will this device help other dental injuries such as subluxation and tooth loosening?
The answers to these questions won’t be known for perhaps years. However, how many thousands of avulsed teeth are failing currently? Failure to reimplant an avulsed tooth correctly can doom a young child and the family to a long emotional, financial, and aesthetic tragedy. This article has discussed a new treatment ap-proach that the author feels has promise for stabilizing avulsed teeth and for certain other dental trauma situations as well. Additional clinical experience is needed to determine how successful this approach will be.


(Note: Currently, the Nebraska Medical Center Trauma Center is investigating this appliance.)


Dr. Brosnihan is a 1981 graduate of Creighton University Dental School. He is currently practicing in Oakland, Neb. He has previously been published in Dentistry Today, JADA, Dentistry (England), The Irish Dentist, and the Journal of Clinical Orthodontics. He can be reached at (402) 685-5677.