Clinical Advances in Periodontics Vol. 2, No. 4, November 2012 : Page-241

CASE REPORT Treatment Alternative for Root Resorption of an Avulsed Tooth in a Growing Child: A Case Report With a 4-Year Follow-Up Lian Ping Mau,* † Iok-Chao Pang, ‡ Chuen-Chyi Tseng, ‡ Yea-Huey Melody Chen, x and David L. Cochran* Introduction: Dental treatment is difficult in young patients who present with a root-resorbed permanent tooth and are still growing. The purpose of this case report is to present a treatment option to delay implant placement until the child ’ s growth has slowed and the tissues are fully developed so that an esthetic implant restoration can be achieved. Case Presentation: A 9-year-old female patient presented to the clinic after a traffic accident. Avulsion of her maxillary right central incisor had occurred and the tooth was repositioned during that emergency visit. The tooth vitality was followed regularly. Significant root resorption of the tooth was observed 4years after the accident. The treatment strategy was to retain the tooth as long as possible until her growth was completed. Root canal therapy was done, and the canal was sealed with cal-cium hydroxide, mineral trioxide aggregate, and glass ionomer cement. Unfortunately, root resorption continued. When the pa-tient was 22 years old, the tooth was extracted, and a standard-sized implant was placed immediately with a bone graft, collagen membrane, and connective tissue graft augmentation. A temporary restoration was inserted 5 months after implantation. The definitive restoration was fabricated 3 months after the provisional. The dentists and patient were satisfied with the final outcome. Conclusion: Repositioning of an avulsed tooth and conservative endodontic treatment despite root resorption preserved the adjacent bone in a young female until her growth was complete, allowing for the placement of a standard-sized dental implant with a natural esthetic restoration. Clin Adv Periodontics 2012;2:241-247. KeyWords : Bone regeneration; connective tissue; dentalimplantation; immediate dentalimplant loading; root resorption; tooth avulsion. Background Many studies have shown that tooth avulsion is relatively infrequent, ranging from 0.5% to 3% of traumatic injuries in the permanent dentition. 1 The maxillary central incisors are the most frequently avulsed teeth in both permanent and primary dentitions. 1 Themost frequentlyinvolved age group is 7to11years,with males experiencing avulsion three times more than females. 2 Root resorption of an avulsed tooth is one of the major complications ofdental trauma. Endodon-tic therapy and replantation of the tooth into the socket have * Department of Periodontics, University ofTexas Health Science Center at San Antonio,San Antonio, TX. † ‡ x a relatively low long-term prognosis because of root re-sorption. 3 Clinically, it is difficultto deal with a root-resorbed permanent tooth when the patient is still growing. The purpose of this case report is to present a treatment option of delaying dental implant placement, allowing for res-toration of tissues and post-adolescent growth. Clinical Presentation A 9-year-old female presented to the dental clinic at Chi Mei Medical Center, Tainan City, Taiwan, after a traffic accident in August, 1994. Avulsion of her maxillary right central incisor was found and the tooth was repositioned during the initial emergency visit. The tooth was clini-cally and radiographically examined by a general dentist (C-CT) on a regular basis. 4 Department of Periodontics, Chi Mei Medical Center, Tainan City, Taiwan. Center Union Dental Clinic, Tainan City, Taiwan. Department of Endodontics, Chi Mei Medical Center. Case Management Significant root resorption was found 4 years after the ac-cident (Fig.1). Therefore, the patient was referred to an endodontist (Y-HMC)for additional treatment. Root canal Clinical Advances in Periodontics, Vol. 2, No. 4, November 2012 Submitted July 14, 2011; accepted forpublication November 17, 2011 doi: 10.1902/cap.2012.110069 241

Treatment Alternative For Root Resorption Of An Avulsed Tooth In A Growing Child: A Case Report With A 4-Year Follow-Up

Lian Ping Mau, Iok-Chao Pang, Chuen-Chyi Tseng, Yea-Huey Melody Chen, David L. Cochran

Introduction: Dental treatment is difficult in young patients who present with a root-resorbed permanent tooth and are still growing. The purpose of this case report is to present a treatment option to delay implant placement until the child’s growth has slowed and the tissues are fully developed so that an esthetic implant restoration can be achieved. <br /> <br /> Case Presentation: A 9-year-old female patient presented to the clinic after a traffic accident. Avulsion of her maxillary right central incisor had occurred and the tooth was repositioned during that emergency visit. The tooth vitality was followed regularly. Significant root resorption of the tooth was observed 4 years after the accident. The treatment strategy was to retain the tooth as long as possible until her growth was completed. Root canal therapy was done, and the canal was sealed with calcium hydroxide, mineral trioxide aggregate, and glass ionomer cement. Unfortunately, root resorption continued. When the patient was 22 years old, the tooth was extracted, and a standard-sized implant was placed immediately with a bone graft, collagen membrane, and connective tissue graft augmentation. A temporary restoration was inserted 5 months after implantation. The definitive restoration was fabricated 3months after the provisional. The dentists and patient were satisfied with the final outcome. <br /> <br /> Conclusion: Repositioning of an avulsed tooth and conservative endodontic treatment despite root resorption preserved the adjacent bone in a young female until her growth was complete, allowing for the placement of a standard-sized dental implant with a natural esthetic restoration. Clin Adv Periodontics 2012;2:241-247. <br /> <br /> KeyWords: Bone regeneration; connective tissue; dental implantation; immediate dental implant loading; root resorption; tooth avulsion.<br /> <br /> Background <br /> <br /> Many studies have shown that tooth avulsion is relatively infrequent, ranging from 0.5% to 3% of traumatic injuries in the permanent dentition.1 The maxillary central incisors are the most frequently avulsed teeth in both permanent and primary dentitions.1 Themost frequently involved age group is 7 to11 years, with males experiencing avulsion three times more than females.2 Root resorption of an avulsed tooth is one of the major complications of dental trauma. Endodontic therapy and replantation of the tooth into the socket have a relatively low long-term prognosis because of root resorption. 3 Clinically, it is difficult to deal with a root-resorbed permanent tooth when the patient is still growing. The purpose of this case report is to present a treatment option of delaying dental implant placement, allowing for restoration of tissues and post-adolescent growth. <br /> <br /> Clinical Presentation <br /> <br /> A 9-year-old female presented to the dental clinic at Chi Mei Medical Center, Tainan City, Taiwan, after a traffic accident in August, 1994. Avulsion of her maxillary right central incisor was found and the tooth was repositioned during the initial emergency visit. The tooth was clinically and radiographically examined by a general dentist (C-CT) on a regular basis.4 <br /> <br /> Case Management <br /> <br /> Significant root resorption was found 4 years after the accident (Fig. 1). Therefore, the patient was referred to an endodontist (Y-HMC) for additional treatment. Root canal therapy was performed, and calcium hydroxide (Ca(OH)2) was used as intracanal medication (Fig. 2). The treatment objective was to retain the tooth until her growth was complete. The root canal was sealed with Ca(OH)2, mineral trioxide aggregate (MTA),k and glass ionomer cement (GIC){ (Fig. 3). The right maxillary central incisor was restored with composite resin (Fig. 4). Unfortunately, root resorption continued. When the patient was 22 years old, the resorbed root was beginning to affect the gingiva (Fig. 5). After a thorough examination, treatment plan explanation, and oral informed consent, the tooth was removed, and a standard-sized dental implant (sand-blasted acid-etched 4.1 12 mm)# was placed immediately in the extraction socket. AV-shaped buccal dehiscence defect was filled with deproteinized bovine bone mineral** and covered with a collagen membrane.†† A connective tissue graft (CTG) harvested fromthe hard palate in the premolar region was sutured onto the buccal flap and positioned to increase the buccal gingival contour. Closure was achieved with 4-0 sutures‡‡ and 5-0 nylon suturesxx (Figs. 6 through 10) . <br /> <br /> Clinical Outcomes <br /> <br /> Wound healing was uneventful and the sutures were removed after 2 weeks. The implant was allowed to fully integrate for 5 months. At that time, a surgical blade (#15C) was used to remove soft tissue on the top of the implant to access the healing abutment. A preformed provisional abutment was then shaped and fitted through the gingival into the top of the implant. A provisional restoration was then cemented on the provisional abutment to encourage soft-tissue contouring (Fig. 11). The soft-tissue contour appeared stableafter 3 months (Fig. 12). Customized abutments and the definitive implant single crown were fabricated 3 months after the provisional restoration (Fig. 13).The clinical results of the implant restoration after 4 years of follow-up was acceptable to the restoring dentist (I-CP) and patient. Importantly, the hard and soft tissues around the implant remained stable (Fig. 14).<br /> <br /> Discussion <br /> <br /> Root resorption is one of the major complications of dental trauma. Endodontic therapy and chemical conditioning of the root surface after an extended extraoral period has the potential to delay the resorptive processes of a replanted tooth.4 However, extraction is the usual final result of root resorption. <br /> <br /> The treatment options when a tooth has root resorption in a partially edentulous area include: 1) implant, 2) fixed partial denture (FPD), 3) removable partial denture (RPD), or 4) do not replace the tooth. Longitudinal reports indicate that prosthesis failure is more common and occurs more frequently with RPDs than with FPDs.5 Avivi-Arber and Zarb6 noted that ‘‘fixed prostheses are associated with the sacrifice of sound tooth tissue and inherent risks of pulp injury.’’ The most frequently reported complications in FPD abutment teeth are caries (18%) and need for endodontic treatment (11%).7 A meta-analysis concerning implants in partial edentulism and single-tooth replacement indicated survival rates of 93.6% and 97.5% after 6 to 7 years, respectively.8 Lindquist and Karlsson9 indicated a mean success rate of traditional FPDs at 8, 14, and 20 years as being 97%, 83%, and 65%, respectively.9 Implants offer considerable promise for reducing the disadvantages associated with traditional prosthodontic techniques.6 As such, they provide ameans of support for dental prostheses without relying on the remaining teeth. Potential abutment teeth are not traumatized and endodontic intervention is unlikely. <br /> <br /> Implant therapy was not considered in this casewhen the root resorption was first detected, because the growth process was not complete. Cronin and Oesterle10 reported on a single-tooth implant prosthesis performed after the traumatic avulsed maxillary central incisor in an 11-year-old boy.10When the boy reached 16 years of age, an increased gingival incisal length of the implant prosthesis and irregularity of the gingival contour were noted. Remodeling associated with skeletal growth in the region of the implant placement site could cause the implant to either become unsupported by bone or submerged within it.10 Implants placed after age 15 years in girls and 18 years in boys have the most predictable prognosis.11 <br /> <br /> Ochoa and Nanda12 compared the maxillary and mandibular growth in lateral cephalometric radiographs of 15 females and 13 males. The SNA angle did not change significantlywith age, but the SNB angle increased significantly in the males. The ANB angle decreased continuously until age 14. The palatal plane descended significantly from the horizontal plane.The anteriorand posterior nasal spinesmoved at approximately the same rate. The mandible grew in length twice asmuch as themaxilla fromages 6 to 20 years. With growth, the facial profiles of the males became straighter as the chin became more prominent. The females had less incremental growth and duration of growth of the mandible, so that the profiles remainedmore convex. Overall, skeletal and chronologic ages did not differ significantly, except at ages 10 and 16 years in the females. <br /> <br /> Foley and Mamandras13 reported on the facial growth in females 14 to 20 years of age. Overall mandibular growth as measured from the condylion to the gnathion was approximately twice that of the overall maxillary growth as measured from the condylion to the A point. The mandibular growth rate was found to be twice as great from 14 to 16 years as from 16 to 20 years. Ligthelm-Bakker et al.14 reported a negative correlation between the average growth rate of the upper and lower anterior facial height in boys. Boys with a relatively large facial height exhibited a higher than average growth rate of the lower anterior facial height compared to the upper facial height. In girls, a similar trend was present. The individual average growth rate of the anterior upper and lower facial height maintains or accentuates the early established facial form. <br /> <br /> Replacement of an avulsed tooth into a socket in young adolescents can preserve the alveolar ridge and gingival contour.15 Implant placement as a treatment option is contraindicated because substantial growth will occur. After growth has predominantly occurred, however, dental implants can provide support and function for missing teeth attributable to root resorption with excellent esthetic results and without preparation of adjacent natural teeth.16 <br /> <br /> In this case report, a one-staged immediate implant was placed. The advantages of immediate implant placement (IIP) are three-fold: 1) treatment time is significantly reduced; 2) ridge contour can be preserved; and 3) it is possible to place the implant in a more ideal axial position, thus enhancing fabrication, esthetics, and biomechanics of the subsequent restoration.17 Peri-implant hard and soft tissue have been reported to remain stable after IIP when a tooth with a resorbed root is removed.18 The V-shaped buccal osseous defect found in this case has the minimal amount of gingival recession compared to U- and Uushaped type defects.19 Facial gingival recession of a thin periodontal biotype has also been shown to be more pronounced than that of a thick biotype.19 Because this patient also had thin tissues, a technique combining aCTGwith IIP was used to achieve a more stable peri-implant tissue.20 Furthermore, a review article concluded that there was no significant difference in the success and survival rates between immediate and early implant placement.21 Thus, the IPP technique was chosen in this case report. Implant restoration should not be performed, however, before completion of most of the growth process in the adolescent patient. This 4-year follow-up case report demonstrates that an implant restoration of a maxillary central incisor removed as a result of root resorption caused by earlier trauma can be successful.<br /> <br /> Summary <br /> <br /> Why is this case new information? <br /> <br /> ■ Treatment alternative for root resorption of an avulsed tooth in a growing child <br /> <br /> What are the keys to successful management of this case? <br /> <br /> ■ Keep the avulsed tooth in position to maintain the alveolar bone as long as possible while the patient was still growing <br /> <br /> ■ Timing for IIP <br /> <br /> ■ Contour augmentation with bovine bone mineral, collagen membrane, and CTG <br /> <br /> What are the primary limitations to success in this case? <br /> <br /> ■ Length of time before the avulsed tooth is replaced <br /> <br /> ■ Malposition of the implant <br /> <br /> ■ Not augmenting soft tissues<br /> <br /> Acknowledgment <br /> <br /> The authors report no conflicts of interest related to this case report.<br /> <br /> CORRESPONDENCE: Dr. Chuen-Chyi Tseng, Center Union Dental Clinic, 376 Gongyuan S. Rd., North District, Tainan City, Taiwan. E-mail: jimtseng@ms15.hinet.net.<br /> <br /> References<br /> <br /> 1. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO, Andreasen FM, Andresson L, eds. Textbook and Color Atlas of Traumatic Injuries of the Teeth, 4th ed. Copenhagen, Denmark: Blackwell Munksgaard; 2007:444.<br /> <br /> 2. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263-286.<br /> <br /> 3. Mentag PJ, Kosinski TF, Sowinski LL. Dental implant reconstruction after endodontic failure: Report of case. J Am Dent Assoc 1990;121: 241-244.<br /> <br /> 4. American Association of Endodontists. Endodontic Considerations in the Management of Traumatic Dental Injuries. Available at: http:// www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_ Colleagues_for_Excellence_Newsletter/spring06ecfe.pdf. Accessed September 6, 2011.<br /> <br /> 5. Priest GF. Failure rates of restorations for single-tooth replacement. Int J Prosthodont 1996;9:38-45.<br /> <br /> 6. Avivi-Arber L, Zarb GA. Clinical effectiveness of implant-supported single-tooth replacement: The Toronto Study. Int J Oral Maxillofac Implants 1996;11:311-321.<br /> <br /> 7. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41.<br /> <br /> 8. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis of implants in partial edentulism. Clin Oral Implants Res 1998;9:80-90.<br /> <br /> 9. Lindquist E, Karlsson S. Success rate and failures for fixed partial dentures after 20 years of service: Part I. Int J Prosthodont 1998;11: 133-138.<br /> <br /> 10. Cronin RJ Jr., Oesterle LJ. Implant use in growing patients. Treatment planning concerns. Dent Clin North Am 1998;42:1-34.<br /> <br /> 11. Cronin RJ Jr., Oesterle LJ, Ranly DM. Mandibular implants and the growing patient. Int J Oral Maxillofac Implants 1994;9:55-62.<br /> <br /> 12. Ochoa BK, Nanda RS. Comparison of maxillary and mandibular growth. Am J Orthod Dentofacial Orthop 2004;125:148-159.<br /> <br /> 13. Foley TF, Mamandras AH. Facial growth in females 14 to 20 years of age. Am J Orthod Dentofacial Orthop 1992;101:248-254.<br /> <br /> 14. Ligthelm-Bakker AS, Wattel E, Uljee IH, Prahl-Andersen B. Vertical growth of the anterior face: A new approach. Am J Orthod Dentofacial Orthop 1992;101:509-513.<br /> <br /> 15. Shulman LB, Schnitman PA. Bone maintenance: Implant versus transplant. Biomater Med Devices Artif Organs 1979;7:333-338.<br /> <br /> 16. Zand C. Dental implant in resorbed root. J Oral Implantol 1993;19: 152-156.<br /> <br /> 17. Novaes AB Jr., Novaes AB. Immediate implants placed into infected sites: A clinical report. Int J Oral Maxillofac Implants 1995;10:609-613. <br /> <br /> 18. Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single implants: A surgical and prosthodontic rationale. Pract Periodontics Aesthet Dent 2000;12:817-824, quiz 826.<br /> <br /> 19. Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. J Oral Maxillofac Surg 2007;65(7, Suppl. 1):13-19.<br /> <br /> 20. Kan JY, Rungcharassaeng K, Lozada JL. Bilaminar subepithelial connective tissue grafts for immediate implant placement and provisionalization in the esthetic zone. J Calif Dent Assoc 2005;33:865-871.<br /> <br /> 21. Chen ST, Wilson TG Jr., Hammerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19(Suppl.):12-25.<br /> <br /> * Department of Periodontics, University of Texas Health Science Center at San Antonio, San Antonio, TX.<br /> <br /> † Department of Periodontics, Chi Mei MedicalCenter, Tainan City, Taiwan.<br /> <br /> ‡ Center Union Dental Clinic, Tainan City, Taiwan.<br /> <br /> X Department of Endodontics, Chi Mei Medical Center.<br /> <br /> Submitted July 14, 2011; accepted for publication November 17, 2011<br /> <br /> doi: 10.1902/cap.2012.110069<br /> <br /> || DENTSPLY Friadent Ceramed, Lakewood, CO.<br /> { Fuji K, GC, Tokyo, Japan.<br /> # Standard Plus implant, Straumann, Basel, Switzerland.<br /> ** Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland.<br /> †† Peri-Aid, Collagen Matrix, Franklin Lakes, NJ.<br /> <br /> ‡‡ 4-0 CV-5, Gore-Tex, W. L. Gore & Associates, Newark, DE.<br /> xx Ethicon, Moore Medical, Farmington, CT.

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