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Number, type and severity of dental injuries per patient differ according to the patient’s age and the cause of accident. The trauma group resulting from pedestrian-, bicycle-, and car-related injuries is usually dominated by multiple dental injuries, injuries to the supporting bone and soft-tissue injuries. This report describes a case of a 16.2-year-old female who suffered traumatic injuries to her permanent maxillary incisors after a car accident. Concussion of tooth 12, extrusive luxation of tooth 11, avulsion of tooth 21 and subluxation with complicated crown fracture of tooth 22 were observed at the emergency visit 75 minutes after the trauma. Tooth 21 was dry stored for 15 minutes, then in milk for 60 minutes. The treatment plan according to IADT guidelines was performed with the satisfaction of the dentists and the patient. After 1 year follow-up a replacement root resorption of tooth 21 was diagnosed; it was then considered severe at the time of the 2 year control visit. Educational programs are essential to optimize the treatment outcome both at the accident site and also at the dental office.
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Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up
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Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up
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                                                                                                                               Case report



                   Multiple traumatic injury to maxillary incisors
                   in an adolescent female: treatment outcome
                   with two years follow-up




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                   Roberto Biagi, MD, DDS, MSc1                                   Educational programs are essential to optimize the
                   Filippo Cardarelli, DDS, MSc2                                  treatment outcome both at the accident site and al-




                                                                                    io
                   Ennio Storti, MD, DDS3                                         so at the dental office.
                   Alessandra Majorana, MD, DDS4
                   Giampietro Farronato, MD, DDS, MSc1                            Key words: permanent incisor, extrusive luxation,
                                                                                  avulsion, crown fracture, replantation, root resorption.




                                                                                 az
                   1 Fondazione IRCCS Cà Granda, Ospedale Maggiore
                     Policlinico, Department of Orthodontics and Paediatric       Introduction
                     Dentistry, School of Dentistry, University of Milan, Italy




                                                                              rn
                   2 Private practice of Orthodontics and Paediatric Den-         Number, type and severity of dental injuries per patient
                     tistry, Isernia, Italy                                       differ according to the patient’s age and the cause of
                   3 Department of Orthodontics, School of Dentistry,             accident (1). Traffic accidents may be focused as a




                                                                           te
                     “Vita - Salute San Raffaele” University, Milan, Italy        possible increasing cause of dental injuries and repre-
                   4 Department of Paediatric Dentistry, Dental School,           sented 10% of the etiologic factors in a sample of Nor-
                     University of Brescia, Italy                                 wegians aged 7-18 years (2) and 7.5% in Austrians
                                                                                  with a mean age of 17.8 years (SD error 0.287) (3).

                   Corresponding author:
                                                                        In        Car accidents particularly accounted for 5.6% of the
                                                                                  oral and dental injuries in Israeli population during
                   Roberto Biagi, MD, DDS, MSc                                    childhood and adolescence (4) and for 2% in a study
                   Fondazione IRCCS Cà Granda                                     conducted at the Boston Children’s Hospital Medical
                   Ospedale Maggiore Policlinico                                  Center and two private pedodontic officers in 1979 (5).
                                                          ni
                   Department of Orthodontics and Paediatric Dentistry,           The trauma group resulting from pedestrian-, bicycle-,
                   School of Dentistry, University of Milan                       and car-related injuries is usually dominated by multi-
                   Via della Commenda, 10                                         ple dental injuries, injuries to the supporting bone and
                   20122 Milano Italy                                             soft-tissue injuries (6).
                                            o

                   Phone: +39 02 50320240                                         The present case report describes the treatment out-
                   E-mail: roberto.biagi@unimi.it                                 come of traumatic maxillary incisors injuries of a 16.2-
                                        izi


                                                                                  year-old female due to a car accident, with a follow-up
                                                                                  of 2 years.
                   Summary
                          Ed




                   Number, type and severity of dental injuries per pa-           Case report
                   tient differ according to the patient’s age and the
                   cause of accident. The trauma group resulting from             A healthy 16.2 year-old female was referred to the den-
                   pedestrian-, bicycle-, and car-related injuries is             tal office after suffering trauma to her maxillary incisors,
                   usually dominated by multiple dental injuries, in-             following a car accident occurred 75 minutes before.
                   juries to the supporting bone and soft-tissue in-              Facial bone and TMJ examination revealed no patho-
               C




                   juries.                                                        logical signs and symptoms, while intraoral examination
                   This report describes a case of a 16.2-year-old fe-            showed concussion of tooth 12; extrusive luxation of
    CI




                   male who suffered traumatic injuries to her perma-             tooth 11; avulsion of tooth 21 and subluxation with
                   nent maxillary incisors after a car accident. Con-             complicated crown fracture of tooth 22 (Figs. 1 and 2).
                   cussion of tooth 12, extrusive luxation of tooth 11,           Tooth 21 was dry stored for 15 minutes, then in milk for
                   avulsion of tooth 21 and subluxation with compli-              60 minutes. Panoramic and periapical radiographs ex-
                   cated crown fracture of tooth 22 were observed at              cluded bone and root fractures (Fig. 3). Spontaneous
                   the emergency visit 75 minutes after the trauma.               pain was present in the region of maxillary incisors.
©




                   Tooth 21 was dry stored for 15 minutes, then in                With the parents’ and patient’s informed consent, a lo-
                   milk for 60 minutes. The treatment plan according              cal anesthetic was administered. The tooth 11 was
                   to IADT guidelines was performed with the satisfac-            gently pushed back into its socket; the root of tooth 21
                   tion of the dentists and the patient. After 1 year fol-        was rinsed with saline, such as its alveolus to remove
                   low-up a replacement root resorption of tooth 21               the contaminated coagulum, prior to its replantation in
                   was diagnosed; it was then considered severe at                its socket with a gentle pressure; the tooth 22 was
                   the time of the 2 year control visit.                          treated with pulp capping with calcium hydroxide and a

                   212                                                                              Annali di Stomatologia 2013; IV (2): 212-217
7-biagi_- 19/06/13 10:38 Pagina 213




                   Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up




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                   Figure 1. Intraoral view at the time of traumatic injury.




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                                                                                  Figure 3. Periapical radiograph at the time of traumatic in-
                                                                                  jury.
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                                                                                  Figure 4. Functional splinting with an orthodontic 0.016-
                                         izi


                                                                                  inch stainless steel wire and composite resin.
                   Figure 2. Tooth 21.

                                                                                  The patient was scheduled for follow-up and was moni-
                          Ed




                   dentin bonding agent to create a seal against bacterial        tored weekly in the first month after the trauma, then af-
                   invasion into dentinal tubules. The fractured crown frag-      ter 3 months, 6 months, 1 year and 2 years.
                   ment wasn’t available. The dentin and pulp protection          An initial phase of replacement root resorption of
                   was incorporated into the splint.                              tooth 21 was suspected at the 6 months radiographic
                   A functional splinting with an orthodontic 0.016-inch          control (Figs. 8 a, b) and became evident 6 months
                   stainless steel wire and composite resin was positioned        later (1 year follow-up) (Figs. 9 a, b). The last radi-
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                   from tooth 13 to tooth 23 (Fig. 4) for a period up to 2        ographic examination during the 2 years recall re-
                   weeks, as suggested by the guidelines of the Interna-          vealed a dramatic increase of replacement root re-
                   tional Association of Dental Traumatology (IADT).
    CI




                                                                                  sorption of tooth 21 (Fig. 10), so that its survival rate
                   Systemic antibiotic (amoxicillin 2 g for day for 7 days) and   became low. Clinically, a gingivitis particularly on the
                   analgesic medicament on demand were prescribed. The            maxillary arch due to poor oral hygiene was diag-
                   patient received instructions about an appropriate soft di-    nosed (Fig. 11).
                   et and about an adequate oral personal hygiene
                   (chlorhexidine 0.12% mouth rinse twice a day for 1 week
©




                   and a soft toothbrush to brush her teeth after each meal).     Discussion
                   After 3 weeks, and not after 2 weeks as planned, teeth
                   11, 21 and 22 where endodontically treated (Fig. 5) and        In case of multiple injuries the treatment can be compli-
                   the splint was removed.                                        cated and usually requests a multidisciplinary team ap-
                   Afterwards tooth 22 was restored with a glass-fiber en-        proach. The present clinical report refers about 5 con-
                   dodontic post build-up and an alumina ceramic crown            current types of dental trauma involving teeth mineral-
                   (Figs. 6 and 7).                                               ized tissues and their supporting tissues: concussion of

                   Annali di Stomatologia 2013; IV (2): 212-217                                                                           213
7-biagi_- 19/06/13 10:38 Pagina 214




                   R. Biagi et al.


                                                                                8A




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                   Figure 5. Periapical radiograph after endodontic treatment
                   when the splint was removed.
                                           o             ni
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                          Ed




                   Figure 6. Glass-fiber endodontic post build-up and prepa-
                   ration of tooth 22.
               C
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                                                                                Figures 8A and B. Periapical radiographs at 6 months con-
                                                                                trol visit.
©




                                                                                tooth 12, extrusive luxation of tooth 11, avulsion of
                                                                                tooth 21, subluxation and complicated crown fracture of
                                                                                tooth 22, according to Andreasen’s classification (7),
                                                                                which is the most frequently used (8) and the more
                                                                                comprehensive system which allows for minimal sub-
                   Figure 7. Restoration of tooth 22 with an alumina ceramic    jective interpretations (1).
                   crown.                                                       Extrusive luxation is an uncommon type of injury in per-

                   214                                                                           Annali di Stomatologia 2013; IV (2): 212-217
7-biagi_- 19/06/13 10:38 Pagina 215




                   Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up


                   9A




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                                                                                  Figure 10. Periapical radiograph at 2 years recall visit.


                   9B
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                                                                                  Figure 11. Intraoral view at 2 years recall visit.


                                                                                  ing. Up to 43% of prevalence of pulp necrosis was re-
                          Ed




                                                                                  ferred by Lee et al. (9) and Humphreys et al. (10), so an
                                                                                  endodontic treatment was considered for tooth 11.
                                                                                  Tooth 21 on the contrary was avulsed. Avulsion repre-
                                                                                  sents a dramatic situation in dental traumatology, par-
                                                                                  ticularly in subjects who have not yet reached the maxi-
                                                                                  mum peak growth rate. Although replantation is the
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                                                                                  usual procedure, it must be considered a temporary
                                                                                  measure because many teeth are lost due to root re-
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                                                                                  sorption. Prognosis depends mainly on length and type
                                                                                  of extra-alveolar storage, stage of root development
                                                                                  and contamination of the root surface (11). In this clini-
                   Figures 9A and B. Periapical radiographs at 1 year recall
                   visit.                                                         cal case, the development of the root was already com-
                                                                                  pleted, so that the revascularization of the pulp was ex-
                                                                                  tremely limited; the first 15 minutes it was kept dry and
©




                   manent dentition. The tooth, in this case report tooth         in the next 60 minutes in milk. In 1981, Andreasen JO
                   11, appears elongated with bleeding from periodontal           (12) observed 70.5 ± 17.3% of periodontal healing of
                   ligament and mobile. Pain is present during occlusion          mature permanent incisors of monkeys after 18 minutes
                   and an increased periodontal ligament space is diag-           of dry storage. Milk can be considered the best storage
                   nosed by means of a periapical radiograph. The stage           medium for avulsed teeth available at the time of trau-
                   of root formation and the severity of extrusive luxation       ma or shortly after. Blomlöf (13) referred that 71% of
                   are usually the major parameters influencing pulp heal-        periodontal ligament cells were viable after 3 hours in

                   Annali di Stomatologia 2013; IV (2): 212-217                                                                               215
7-biagi_- 19/06/13 10:38 Pagina 216




                   R. Biagi et al.


                   milk storage and 50% after 12 hours. Other re-                So educational programs are essential to optimize the
                   searchers such as Huang et al. (14) and Rozenfarb et          treatment outcome that depend both on a timely and
                   al. (15) confirmed the validity of milk as storage medium     adequate emergency treatment at the site of the acci-
                   for exarticulated teeth.                                      dent, and on a multidisciplinary therapeutic approach
                   Before prosthodontic rehabilitation, tooth 22 was emer-       by the dentists.




                                                                                                                                                 li
                   gency treated with calcium hydroxide for pulp capping
                   and a dentin bonding agent mainly to control pain and




                                                                                     na
                   sensitivity sealing dentinal tubules. A definitive restora-   Acknowledgements
                   tion with glass-fiber post build-up and alumina ceramic
                   crown was chosen to maximize the patient’s esthetic           The authors have appreciated the useful comments of
                   request.                                                      Dr. Silvia Faverzani Gibbs.




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                   Finally a wire-composite splint was placed from tooth
                   13 to tooth 23 according to IADT guidelines (16, 17).
                   Splint is justified by medico-legal aspects, periodontal      References




                                                                                az
                   ligament cells protection and patient comfort. Flexible
                   splint was preferred to rigid splint to preserve physio-       1. Bastone EB, Freer TJ, McNamara JR. Epidemiology of den-
                   logic teeth mobility and avoid further damage to peri-            tal trauma: a review of the literature. Aust Dent J 2000; 45:2-
                   odontal ligament as dentoalveolar ankylosis. Wire-com-            9.
                                                                                  2. Skaare AB, Jacobsen I. Etiological factors related to dental




                                                                             rn
                   posite splinting, in this case 0.016-inch stainless steel
                                                                                     injuries in Norvegians aged 7-18 years. Dent Traumatol 2003;
                   wire and composite resin, is a simple and fast tech-              19:304-308.
                   nique without laboratory procedures and it is useful           3. Gassner R, Bösch R, Tuli T, Emshoff R. Prevalence of den-
                   when an emergency treatment occurs with a compro-                 tal trauma in 6000 patients with facial injuries. Implications




                                                                          te
                   mised working field. Moreover it allows a good oral hy-           for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol
                   giene (11, 18).                                                   Endod 1999; 87:27-33.
                   The patient was scheduled for follow-up: recall visits         4. Levin L, Samorodnitzsky GR, Schwartz-Arad D, Geiger SB.
                   were planned weekly in the first month, then after 3 and          Dental and oral trauma during childhood and adolescence
                   6 months, yearly in the first 5 years.
                                                                       In            in Israel: occurrence, causes, and outcomes. Dent Traumatol
                                                                                     2007; 23:356-359.
                   Unfortunately the patient deserted the 2 weeks recall
                                                                                  5. Meadow D, Lindner G, Needleman H. Oral trauma in chil-
                   visit, so the splint was removed only after 3 weeks and           dren. Pediatr Dent 1984; 6:248-251.
                   the endodontic treatment of teeth 11, 21 and 22 was            6. Glendor U. Aetiology and risk factors related to traumatic den-
                   performed in the same occasion.
                                                          ni
                                                                                     tal injuries - a review of the literature. Dent Traumatol 2009;
                   Replacement root resorption of tooth 21 was suspected             25:19-31.
                   after 6 months, was confirmed after 1 year and appeared        7. Glendor U, Marcenes W, Andreasen JO. Classification, epi-
                   severe after 2 years recall. All the other teeth were in          demiology and etiology. In: Andreasen JO, Andreasen FM,
                                            o

                   good condition and a poor oral hygiene was observed.              Andersson L, eds. Textbook and Color Atlas of Traumatic
                   Although splinting time of 14 days or less is recom-              Injuries to the Teeth. 4th Ed. Oxford, UK. Blackwell Publishing
                                                                                     Ltd 2007; 217-254.
                                        izi


                   mended by IADT and 1 week may be adequate, its du-
                                                                                  8. Feliciano KMPC, de França Caldas Jr A. A systematic re-
                   ration doesn’t affect the likelihood of successful peri-
                                                                                     view of the diagnostic classifications of traumatic dental in-
                   odontal healing after replantation (19, 20). However a            juries. Dent Traumatol 2006; 22:71-76.
                   short period must be considered the best practice to-          9. Lee R, Barret EJ, Kenny DJ. Clinical outcomes for perma-
                          Ed




                   day. So in this case the replacement root resorption              nent incisor luxations in a pediatric population II. Extrusions
                   may be caused by an inadequate tooth storage: if the              Dent Traumatol 2003; 19:274-279.
                   tooth isn’t kept in milk immediately but only after a peri-   10. Humphreys K, Kinirons M, Welbury RR, Cole BOI, Bryan
                   od in dry storage, the prognosis would probably be the            RAE, Campbell O, Fung DE. Factors affecting outcomes of
                   same of any other dried and replanted tooth. Dead cells           traumatically extruded permanent teeth in children. Pediatr
                                                                                     Dent 2003; 25:475-478.
                   cannot be revitalized by milk (21).
               C




                                                                                 11. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO,
                   Finally, infraocclusion of tooth 21 wasn’t observed be-
                                                                                     Andreasen FM, Andersson L, eds. Textbook and Color At-
                   cause of physical maturity of the patient (22), for which         las of Traumatic Injuries to the Teeth. 4th Ed. Oxford, UK.
    CI




                   a future implant rehabilitation is planned.                       Blackwell Publishing Ltd; 2007:444-488.
                                                                                 12. Andreasen JO. Effect of extra-alveolar period and storage
                                                                                     media upon periodontal and pulpal healing after replantation
                   Conclusion                                                        of mature permanent incisors in monkeys. Int J Oral Surg
                                                                                     1981; 10:43-53.
                   Traumatic injuries to permanent maxillary incisors rep-       13. Blomlöf L. Storage of human periodontal ligament cells in a
©




                   resent a dramatic situation from an aesthetic point of            combination of different media. J Dent Res 1981; 60:1904-
                                                                                     1906.
                   view that involve the social and psychological behavior
                                                                                 14. Huang S, Remeikis NA, Daniel JC. Effect of long-term ex-
                   of the patient.                                                   posure of human periodontal ligament cells to milk and oth-
                   The dentist can offer an emotional support to the young           er solutions. J Endod 1996; 22:30-33.
                   patients and their parents, but when the accident caus-       15. Rozenfarb N, Kupietzky A, Shey Z. Milk and egg albumen
                   es multiple complex dental injuries the prognosis is of-          are superior to human saliva in preserving human skin fi-
                   ten unfavorable and the teeth survival is compromised.            broblast. Pediatr Dent 1997; 19:347-348.


                   216                                                                               Annali di Stomatologia 2013; IV (2): 212-217
7-biagi_- 19/06/13 10:38 Pagina 217




                   Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up


                   16. Flores MT el al. Guidelines for the management of traumatic           matol 2008; 24:2-10.
                       dental injuries. I Fractures and luxations of permanent teeth.    20. Hinckfuss SE, Messer LB. Splint duration and periodontal out-
                       Dent Traumatol 2007; 23:66-71.                                        comes for replanted avulsed teeth: a systematic review. Dent
                   17. Flores MT et al. Guidelines for the management of traumatic           Traumatol 2009; 25:150-157.
                       dental injuries. II Avulsion of permanent teeth. Dent Traumatol   21. Blomlöf L, Lindskog S, Andersson L, Hendström KG, Ham-




                                                                                                                                                       li
                       2007; 23:130-136.                                                     marström L. Storage of experimentally avulsed teeth in milk
                   18. von Arx T. Splinting of traumatized teeth with focus on ad-           prior to replantation. J Dent Res 1983; 62:912-916.




                                                                                            na
                       hesive techniques. J Calif Dent Assoc 2005; 33:409-414.           22. Malmgren B, Malmgren O. Rate of infraposition of reimplanted
                   19. Kahler B, Heithersay GS. An evidence-based appraisal of               ankylosed incisors related to age and growth in children and
                       splinting luxated, avulsed and root-fractured teeth. Dent Trau-       adolescents. Dent Traumatol 2002; 18:28-36.




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                   Annali di Stomatologia 2013; IV (2): 212-217                                                                                      217
