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Systematic Literature Review
Avulsion of permanent teeth with open apex: a
systematic review of the literature
Felipe G. Belladonna1
Ane Poly1
João M. S. Teixeira1
Viviane D. M. A. Nascimento1
Sandra R. Fidel1
Rivail A. S. Fidel1
Corresponding author:
Felipe G. Belladonna
Rua Otávio Carneiro, 64 – ap. 703
CEP 24230-191 – Icaraí – Niterói – Brasil
E-mail: felipebelladonna@hotmail.com
1 Department of Endodontics, University of R io de Janeiro State – Rio de Janeiro – RJ – Brazil.
Received for publication: August 9, 2011. Accepted for publication: January 9, 2012.
Abstract
Introduct ion: Considered the most serious of denta l i n�uries,Considered the most serious of dental in�uries,
avulsion is known as the tot al displacement of tooth out of its
socket. Treatment includes immediate replantation and its success
is directly related to several factors. Objective: This paper aimed
to review the literature in a systematic way on dental avulsion ofin a systematic way on dental avulsion of
permanent teeth with open apex, covering various topics such as:
reason for avulsion; storage media; time out of the socket; use of
antibiotics; splinting time; toot h vitality; presence of resorption
and/or obliteration of pulp canal; and following-up time. Material
and methods: PubMed/MedLine database and Dental Traumatology
�ourna l were searched, from May to June of 2011, and severa l
studies comprising the current and classic literature were listed
using the following terms: tooth avulsion, open apex, permanent
and case report. Results and conclusion: Twelve cases reports were
selected. Cases of dental trauma in open apex teeth may have a goodCases of dental trauma in open apex teeth may have a good
prognosis if the following steps are taken: the hydration of the tooth
and immediately replantation. It is important to search dental care,
even if everything seems solved, and the tooth following-up should
be performed periodically as informed by the dentist.
ISSN:
Printed version: 1806-7727
Electronic version: 1984-5685
RSBO. 2012 Jul-Sep;9(3):309-15
Keywords: tooth
avulsion; tooth
replantation; tooth
in�uries.
Belladonna et al.
Avulsion of permanent teeth with open apex: a systematic review of the literature
310 –
Introduction
During the last decades tooth trauma has been
considered an increasing problem of public health,
unlike dental caries which is in decreasing for
years [22, 28, 33]. The prevalence of traumatized
teeth reported by literature var ies from 10 to
51%. It is know n that toot h trauma may have
not only physica l but also economical, social and
psychological severe consequences [13].
Amo ng a l l toot h les ion s, av u lsi on is the
most serious one [16]. It is characterized by the
complete displacement of the toot h out of its
socket, severely affecting the pulp, periodontal
ligament and alveolar bone [8, 42]. The frequency
of av ulsion in permanent dentit ion is from 0.5
to 16% [19, 35]. The avulsion lesions i n chi ldren
occur more frequent ly from 7 to 9 years-old [31],
when the permanent incisors a re erupting, most
in boys than girls [41]. In most of the times, t he
lesion involves a si ngle tooth only, and maxillary
cent ra l incisor is t he most avulsed teeth [9].
Immediate replant ation is t he tre atment
of choice for the ca ses of toot h avulsion [19].
Howev er, be c aus e of seve ral factors as lack
of knowledge on what to do at the moment of
the accident, this rarely occurs [5, 30]. W hen
the tooth is not rep lanted at the moment of
its avulsion, t he patient shou ld be gu ided to
keep it in an appropriate medium and search
for a dentist [35]. According to Trope [39], this
storage aims to decrease the post-repla ntation
inf lammato r y re s ponse, avoid i ng the tooth
dry nes s a nd maintain i ng the viabilit y of the
periodonta l ligament cells.
The result of tooth avulsion treatment, as well
as the occurrence of post-traumatic complications
in t he future, does not only depend on the time
interva l betwe en the accident and the dent a l
treatment – which ideally should be performed
from 20 to 30 minutes –, but also on the medium
in which the avulsed tooth was kept until the
dentist appoi ntment [8, 40].
The aim of this study was to evaluate, through
a systematic literature review, the main cli nical
and radiographic characteristics of cases reports
on the avulsion of permanent tooth with open
apex, such as: reason for av ulsion; storage of the
tooth; time out of toot h socket; use of ant ibiotics;
time of splinting; toot h v italit y; pre sence of
resorption and/or root canal obliteration; and
following-up period.
Methodology
To perform this literature review, the studies
were searched either through PubMed/MedLine
databa se or directly in Dental Traumatology
�ou rna l. At the sa me ti me, a cross se a r c h
was carried out, considering t he bibliograph ic
references of the papers selected. On PubMed /
MedLi ne database, t he fol low i ng ter ms were
employed: avulsion AND open apex (23); avulsion
AND open apex AND permanent (14). Following,
considering the time interva l from June of 2006
and June of 2011, a new search was performed
with the fol lowi ng terms: av ulsion AND toot h
AND case report (180). Considering t he Dental
Traumatology �ournal, the papers on avulsion
(29), at the aforementioned time interval, were
searched among the total of 567 papers published
in that period.
The search was performed from May to June
of 2011 by all authors, which also evaluated the
results together. Firstly, the selection of the papers
was executed based on their abstracts; following,
the complete texts were analyzed. Inclusion criteria
comprised studies published from June of 2006
to June of 2011, on the clinical a nd radiographic
find ings of t he avulsion of perma nent toot h
with open apex. Exclusion criteria compr ised:
a) studies on animals or laboratorial studies; b)
studies on primary teeth; c) literature reviews; d)
intentional extractions, transplants and luxations.
Editoria ls, summaries, and studies inaccessible
through available databases or libraries were
also excluded.
Results
A f t e r the readi n g of t h e ab s t ract s, th e
eliminat ion of duplicate studies and evaluation
according to inclusion and exclusion criteria, the
first a nd second searches on PubMed/ MedLine
database resu lt ed in 7 a nd 14 case repor t s,
re s p e ct i vely; and 3 case reports i n Den t a l
Traumatology �ournal. After the complete reading
of t he papers selected, 12 case repor ts were
included (table I).
RSBO. 2012 Jul-Sep;9(3):309-15 – 311
Table I – Main case reports on the avulsion of permanent teeth with open apex
Author/
year
Reason for
avulsion
Time out of
the socket
Tooth
storage Antibiotics Time of
splinting Vitality Resorption Root canal
obliteration
Following-
up time
Karp et al.
[29]
Hit by a
golf ball 20 minutes Water and
milk Yes 12 days No Yes No 865 days
Baldissera
et al. [7]
Not
reported 4 hours Dry Yes Not
reported No Yes No 14 years
Davidovich
et al. [12]
Crash into
a chair 10 minutes Dry Yes 6 week No No Yes 2 years
Goldbeck
and Haney
[20]
Bicycle fall 2,5 hours Milk Yes 13 days No Yes No 14
months
Sahin et
al. [37]
Fall from
own height 45 minutes Milk Yes 6 weeks Yes No No 5 months
Arrow [6]
Crash into
a school
chair and
fall
10 minutes Mi lk Yes 3 weeks No No Yes 2.25
years
Jacobovitz
and Lima
[26]
In a
football
Immediately
after t he
accident
Tap water No 10 days No Yes Yes
8 years
and 7
months
Koca et al.
[30]
Not
reported 5 hours Saliva Yes 1 week No No No 2 years
Lux et al.
[31]
Accident in
a pool
Not
reported Not reported Not
reported 14 days No Yes No 2 yea rs
Simon et
al. [38] At school
Immediately
after t he
accident
Not reported Yes 3 weeks Yes No No 2 years
Wang et al.
[42]
Fall from
own height 50 minutes Water Yes 9 days No Yes No 1 yea r
Chung et
al. [9]
Crash into
a tree 3 hours Saliva Yes 2 weeks No No No 3.5 years
A research conducted in Brazil [22] concluded
that the avulsion was the most common type of
trauma, affecting 32.9% of the teeth; 29.4% of the
cases occurred in primary dentition and in 34%
in permanent dentitions.
Im mediate replant of a n av u lsed tooth is
the ideal emergency procedure of choice to be
performed at the accident site, as observed by
Rai et al. [36]. In that study, the authors reported
a cas e of a 15-yea r-old boy who sea rched for
treatment because of a purulent infection in the
area of a tooth replanted by him six years ago.
The endodont ic treatment was performed and
af ter 4 years of radiographic following-up, the
lesion disappeared and there were no signals of
resorption
The great concern is that most of population
does not have such knowledge and generally is
referred to medical emergency after the accident.
A research [1] conducted with doctors and dentists
concluded that 83.3% of the doctors do not have
any knowledge on how to proceed in cases of
traumatized teeth, while 93.3% of the dentists
showed the required knowledge.
Discussion
Among all face lesions, tooth trauma is the most
common one, from which tooth avulsion occurs
in 0.5 to 16% of these cases [1, 9]. A comparison
among the prevalence of trauma lesions in several
countries for primary and permanent dentition
showed that boys are affected at a double frequency
of that of girls [41], with peaks of incidence from
7 to 9 years, when the permanent central incisors
are erupting and the periodontal ligament shows
only a minimum resistance to the extrusive force
[15, 31, 40]. Tooth trauma was prevalent in primary
dentition (at 5 years-old) in 31 to 40% of boys and
in 16 to 30% of girls. In permanent dentition (at 12
years-old), the prevalence ranges from 12 to 33%
in boys and from 4 to 19% in girls [3].
Belladonna et al.
Avulsion of permanent teeth with open apex: a systematic review of the literature
312 –
Fru�eri and Costa Jr. [18] reported in a research
conducted in Brazil that the fall (20%) was the
most common cause of tooth trauma, followed by
accidents occurred during sports practice (10%),
physical aggression (9%), car accidents (6%) and
fights (4%). Other factors (2%), such as fainting
and work accidents were also cited. By analyzing
the main case reports searched by this systematic
literature review, it was observed that the most
frequent causes of avulsion were related to falls
and to accidents due to sports practice.
Toot h replant success direct ly depends on
the perio d of extra-a lveol ar time and on the
storage mediu m used to keep the tooth up to
replantat ion [2, 5].
Cvek et al. [11] demonstrated that 13% of the
teeth kept dry for 15 minutes, 40% kept dry from
20 to 40 minutes and 100% kept dry for more than
60 minutes showed signals of ankylosis. Therefore,
the prevention of the periodontal ligament drying
is of extreme importance. The extra-oral dry time
results in irreversible damage to the periodontal
ligament cells, which after replantation provokes a
inf lammatory response in a diffuse area of the root
surface, leading to ankylosis and consequently to
tooth loss. Excepting Baldissera et al. [7], Goldbeck
and Haney [20], Koca et al. [30], Chung et al. [9],
who replanted the tooth after a period longer than
60 minutes, and Lux et al. [31] who did not report
the time amount in which the tooth was kept out
of its socket, all other cases were replanted in less
than 60 minutes.
The best treatment choice for an avulsed tooth
is immediate replantation, so that the damages to
the periodontal ligament cells are decreased and
the ideal healing without resorption is achieved.
Notwithstanding, this rarely occurs, because of
factors such as the emotional stress of the people
involved and the lack of knowledge on first aid [30].
When immediate replantation is not performed, the
tooth should be kept in humid conditions. There are
solutions capable of preserving the viability of the
periodontal ligament cells for the time amount that
these cells are out of the tooth socket. The main
solutions are: water, which although protecting the
tooth from dehydration (because it is a hypotonic
medium) it provokes the fast lysis of the periodontal
ligament cells; saliva, which has small osmolarity,
contributing for the increasing of the harmful effects
of bacterial contamination and presents as the only
advantage the fact of being easily available; saline
solution, which shows compatible osmolarity with
the periodontal ligament cells, but lacks of nutrients
such as calcium, magnesium and glucose required
for a normal functioning of the metabolism of
these cells; milk, which the medium indicated for
the American Association of Endodontics as the
solution for avulsed teeth because it maintains
the viability of the periodontal ligament cells and
it is significantly better than the other solutions
because of its physiological properties, including
pH and osmolarit y compatible wit h that of the
periodontal ligament cells, although it is not capable
of revit aliz ing degenerate d cells; a nd Hank`s
balanced salt solution, which is considered t he
best storage medium for avulsed teeth because it
has ideal osmolarity and pH and it is very efficient
for the preservation and even regeneration of the
periodontal ligament cells [14, 21]. In the papers
researched by this literature review, most of the
case reports used milk as storage medium. For the
studies of Jacobovitz and Lima [26] and Simon et
al. [38], the tooth was replanted immediately after
the avulsion.
Teet h wit h i nco mplet e ape xes wh ich ar e
replanted in less than 60 minutes after the avulsion
may recover because of pulp revascularization.
However, this healing process did not occur in
several times because the apical tissue is highly
susceptible to bacterial contamination [17]. Cvek et
al. [10] reported that in teeth with open apexes, to
avoid the contamination of the root surface could
promote pulp revascularization. For this purpose,
Wang et al. [42] recommended to im merse the
avulsed tooth in doxycycline for 5 minutes prior
to the replantation. After the replantation, tetanus
prophylaxis and systemic antibiotics should also be
prescribed for the patient [2]. All studied included in
this literature review used systemic antibiotics after
replantation, except for the studies of Jacobovitz
and Lima [26] and Lux et al. [31].
Currently, semi-rigid splinting is used to help
the periodont al healing. The current protocols
recommend the splinting for teeth undergoing
luxation, avulsion or root fracture. Studies indicated
that the splinting type and time were not significant
variables when related to t he healing outcomes
[27, 34].
According to Hinckfuss and Messer [25], the
success probability of periodontal healing a fter
replantation is not affected by the splinting time.
The vitality of periodontal ligament cells strongly
affected by the extra-oral time amount and the
storage conditions may have a higher effect on
the splinting period. Basically, three tissues are
involved in the hea ling after tooth replantation:
the pulp, periodontal ligament and alveolar bone.
After trauma, the pulp may present three healing
RSBO. 2012 Jul-Sep;9(3):309-15 – 313
modalities: survival, obliteration or necrosis. This
latter has a fundamental role in the post-traumatic
development of external root resorption [8].
A study based on evidences of 236 permanent
teeth replanted after avulsion concluded that the
probability of well-successful periodontal healing
was improved by extirpating the pulp in a period
of 14 days after replantation because it decreases
the risk of developing inflammatory resorption [23].
Additionally, according to Andreasen and Andreasen
[3], a tooth referred to replantation must not show
advanced periodontal disease and the alveolar
socket must be reasonably intact; also, extraoral
periods exceeding 1 hour are generally associated
with root resorption. Corroborating this idea, all
case reports in which the tooth was replanted in
less than 1 hour did not show resorption signals,
except in the study of Karp et al. [29].
The tooth may be in function for 20 years or
more after its replantation [32]. Additionally, the
closer to the rizogenesis ending, the higher will
be its longevity [4]. In replanted teeth, frequently
ankylosis may develop in sites of inflammatory
resorption previously stopped.
Ac cording to t he Gu idelines on av u lsion
published by Flores et al. [17], the proper treatment
of different cases of avulsion is described below.
In cases of teeth with open apex, replanted before
searching for treatment, the site must be cleaned
by air �ets, saline or chlorhexidine; the extraction
of the tooth is not indicated. If the patient comes
to treatment with the tooth out of the socket, root
surface and apical foramen must be cleaned by
saline, as well as the socket for removing blood
clot; next, the socket should be examined which
must be repositioned in cases of fracture, and
finally, the tooth must be replanted by gentle digital
pressure. In these cases, semi-rigid splinting must
be maintained for up to 2 weeks. However, if the
tooth was kept in extraoral time longer than 60
minutes, the prognosis would not be favorable. The
goal of performing such replantation is to promote
alveolar bone growth to encapsulate the replanted
tooth. The expected result is an eventual ankylosis
and root resorption. The proper procedure is to
remove the necrotic tissue gently with the aid of
gauze. Root cana l treatment may be performed
either prior to replantation or 7 to 10 days after
it, although in cases of open apex endodont ic
treatment should be performed prior to replantation.
Following, it is necessary to immerse the tooth
in a 2% sodium f luoride solution for 20 minutes
and then performing its replantation. In this case,
the semi-rigid splinting should be kept for until 4
weeks. From that moment on, the treatment is the
same for all cases: to suture possible lacerations;
verify clinical a nd radiographically the norma l
position of the replanted tooth; apply a semi-rigid
splinting and administrate systemic antibiotics; if
the avulsed tooth was in contact with the ground,
tet anus vaccine must be prescribed; start the
endodontic treatment 7 to 10 days after replantation,
by employ ing ca lcium hydroxide as intracanal
medication for until one month followed by root
canal obturation. This must be executed prior to
the splinting removal. Nex t, the tooth must be
followed-up. In teeth with open apex, such treatment
should be avoided unless there should be clinical
and radiographic evidence of pulp necrosis. The
patient must follow a soft diet for until two weeks,
perform oral hygiene with soft-bristle toothbrush
after every meal and rinse with 0.1% chlorhexidine
solution twice a day for one week.
The repla nted teeth should be followed-up
frequently during the first year (once a week in the
1st month, then once a month at the 3rd , 6t h and
12th month) and, then, annually. The clinical and
radiographic examinations will provide information
to determine the result of the replantation procedure.
The result is considered positive when the tooth is
asymptomatic, with normal mobility and normal
sound to percussion, in addition to the radiographic
evidence of the continuation of root formation and
obliteration of root canal, which is considered a rule.
On the other hand, the result is considered negative
when the tooth is symptomatic with either excessive
or no mobility (ankylosis) and showing a metallic
sound to percussion. In ankylosis cases, tooth crown
seemed to be in infraocclusion. Additionally, the
radiographic evidence of resorption (inflammatory,
related to infect ion; or subst it ut ive, related to
ankylosis) is seen as a negative result [17].
Other critical question on tooth trauma outcomes
is the patient’s compliance to treatment. In many
cases, the patient must return to appointments many
times, either for only clinical and radiographically
examinations or for uncomfortable procedures. This
is the most common cause of treatment drop-out
by the patients [15].
Conclusion
The most frequent causes of tooth avulsion in
teeth with open apex are related to falls and accidents
in sports practice. The immediate replantation is
considered the best treatment choice. If this is not
possible, the tooth should be kept in an appropriate
medium and the patient should seek the dentist
Belladonna et al.
Avulsion of permanent teeth with open apex: a systematic review of the literature
314 –
urgently. On the other hand, the dentist must be
prepared and updated to follow a relevant protocol in
each case, guiding the patient on the importance of
the following-up appointments. The healing process
should be followed-up for a long period, therefore
enabling an early treatment at the first signs of
pulp necrosis and/or root resorption.
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