Tooth avulsion, or the complete displacement of a tooth from its socket, is a serious dental injury that can lead to complications if not treated properly. The patient, a 13-year-old girl, had her two front teeth avulsed after a bicycle accident. Her teeth were replanted but later became mobile and were extracted. Dental implants were placed but required soft tissue grafting due to insufficient bone and tissue. Pink porcelain crowns were ultimately used to improve esthetics. Dental hygienists play an important role in educating patients on proper oral hygiene to promote the long-term success of replanted or implanted teeth.

1. tooth aulsion
Retrieved from: http://www.dentistryiq.com/articles/2013/05/dental…This document is
not the complete case study. In order to adhere to the curriculum of biology 106 some items
have been removedand figures have been renumbered. The entire document can be viewed
on the web site from which the case study was obtained.Dental Trauma:A hygiene
student’s case studyBy Lauren Wilgenbusch, Minnesota State University, MankatoMay 7,
2013Tooth avulsion is among the most common and serious dental injuries. According to
the American Academy of Pediatric Dentistry, it is defined as “the complete
displacement of a tooth out of its socket.― It is responsible for up to 16% of all dental
injuries in the permanent dentition. Healing of an avulsed tooth often presents a challenge
and depends on the vitality of the cell layers along the root surface. Immediate replantation
at the accident site is the most critical determinant for the survival of avulsed teeth. Delay in
replantation will perpetually result in root resorption and loss of the tooth (Kenny,
2006).Complications after replantation of avulsed teeth are common and have conveyed
incidence rates ranging from 57% to 80% (Nesiama & Sinn, 2010). Complications may arise
during the next several years of regular dental exams, including ankylosis, excessive
mobility of the tooth, and resorption. Other complications that can emerge consist of
discoloration, infection in the pulp, and reinclusion of the tooth as a result of root
replacement resorption and ankylosis (Emerich & Wyszowski, 2010). Most replanted teeth
will be lost in five to seven years even if root canal therapy has been done after replantation
(Nesiama & Sinn, 2010).The patient, a 13-year-old female, was seen for emergency
treatment in July 2005. The child was catapulted over the handlebars of a bicycle, resulting
in the avulsion of the right and left permanent maxillary central incisors. The avulsed teeth
were left dry in the palm of her hand for 10 minutes until she reached the hospital where
the teeth were placed in milk. Other oral injuries included a laceration on the right side of
the philtrum, which was sutured. Examination of the avulsed teeth revealed that the crowns
were intact but the mesial incisal edges of both were fractured. Treatment options were
explained to the parents and replantation of the avulsed teeth was chosen. She was referred
to a local dentist to have the teeth replanted. The roots of the teeth were planed to remove
any debris and were then reinserted into the alveolar socket and secured with a splint for
six weeks. During the next year the patient had root canals done, followed by metal posts
and PFM crowns placed on the avulsed teeth.Due to the patient’s age at the time of
trauma, the crowns were replaced five years later with lava crowns, which are porcelain
crowns with a zirconia framework inside.One year after the crowns were replaced, the teeth

2. became mobile. The patient went in for an appointment and radiographs confirmed
external root resorption had occured around the reimplanted teeth (refer to figure 1).Figure
1The root resorption in this case was most likely due to PDL damage. Treatment options
were explained and the decision was made to extract the teeth and place dental implants.
She was referred to a Mankato, Minnesota oral surgeon for the implants.Implants in the
anterior region signify a particular challenge for oral surgeons. The ideal outcome is normal,
natural-looking teeth, but that is not always a possibility. Many considerations need to be
made in order for the implants to look as natural as possible, such as the need for bone and
tissue grafting (Block, 2001).When extracting a tooth with intentions of replacing it with an
implant, the decision needs to be made whether to do an immediate implant placement or
delayed placement. In this case, infection was not present, so implants were able to be
placed immediately.In the case of the patient, bone grafting was needed and was performed
at the same time as extraction and implant placement. Most anterior maxillary tooth sites
have insufficient bone and soft tissue, requiring both bone and soft tissue augmentation
(Block, 2001).The patient was healing well until a week after the surgery, when a suture
became unfastened, mobilizing the tissue and exposing the facial and mesial root surfaces of
number seven.The patient was then referred to a periodontist with optimistic expectations
of a successful tissue graft. She was seen for a consult and a treatment plan was developed.
The patient had a mucogingival defect at the facial and mesial surfaces of number seven;
each presented three millimeters of recession. The papillary tissue between numbers seven
and eight was absent, which presented a particular challenge for the periodontist since lost
papillary tissue previously could not be regenerated. The patient returned for surgery two
weeks later. Local anesthesia was used on the patient. A connective tissue bed was made on
the recipient site. To receive a decent color match, the donor tissue was taken from the
attached gingiva on the buccal side of teeth numbers two and three; the papilla was
included in the donor tissue. It was then transplanted onto the connective tissue bed and
sutured into position with the donor papilla replacing the missing papilla between teeth
numbers seven and eight. A periodontal dressing was placed over the donor site to aid in
healing and the patient was dismissed. The patient returned for a post-op appointment two
weeks after the procedure and a good response was shown with a wide band of keratinized
soft tissue support, partial facial root coverage, and regeneration of a mesial papilla.After
healing of the epithelial graft, the patient returned to her general dentist to have the
abutments and crowns placed. The healing abutments were removed, impressions were
taken and shades were matched and sent to the lab (refer to figure 2).Figure 2The patient
returned two weeks later for the crown fitting. The doctors were successful in regenerating
some of the tissue on tooth number seven but were not efficacious in restoring the tissue
apical to the implants. The crown placement resulted in lengthy-looking crowns, which did
not meet the patient’s esthetic demands, so different treatment options were considered
(refer to figure 3).Figure 3It was agreed to use pink porcelain crowns. The use of gingiva-
colored ceramics in addition with a fixed prosthesis has been recommended for treatment
of gingival recession (Capa, 2007). It can be challenging to achieve natural gingiva color so a
gingival shade guide was sent to the office and used to match the tissue. An intraoral
photograph was taken to assist the technician in providing the proper gingival

3. color.Radiographs were taken to confirm adequate crown placement and photographs were
taken of the final results (refer to figures 5 &6).Figure 5Figure 4ConclusionDental hygienists
play a key role in maintaining the replacement of avulsed teeth. They are faced with the
challenge of treating patients who have avulsed teeth and educating them with proper oral
hygiene instruction so they last for years to come, whether they are reimplanted or replaced
with dental implants. Patients that have successfully undergone dental implant surgery
should receive treatment modifications during dental care. All patients with dental implants
should be treated with plastic instruments in the affected area because stainless steel or
titanium instruments may scratch the surface of the implant promoting the growth of
plaque biofilm; the use of ultrasonic machines should also be avoided (Todescan, Lavigne &
Kelekis-Cholakis, 2012).Individual treatment modifications may also have to be considered
depending on the past periodontal health of the patient. Several studies have shown that
prior periodontal infections are a significant source of periodontal pathogens and may
proliferate to the dental implant. Other factors that put patients at greater risk include the
presence of diabetes mellitus, poor plaque control, and cigarette smokers. Patients with any
of these qualities should be closely monitored on a regular basis in hopes of extending the
life of their dental implants (Todescan et al, 2012).A thorough understanding of the clinical
signs on peri-implant diseases is critical to the prognosis of the implant. There are many
clinical examinations that can be used to discover the health status of a dental implant. This
includes a soft tissue assessment, plaque index, clinical probing depths, bleeding on
probing, suppuration, stability of soft tissue margins, mobility, and bone levels (Todescan et
al, 2012).The soft tissue assessment entails checking for clinical signs of gingival
inflammation, including edema, redness, and variations of delineation and uniformity. A
plaque index measuring system should also be utilized during the clinical examination.
Studies have shown that implants sprayed with titanium plasma that possess a rough
surface have higher plaque retention rates than smooth surface implants. On the other
hand, other studies have shown no correlation between the surface texture of an implant
and plaque retention. However, caution is advised when monitoring rough surfaced
implants because of the possibility of greater amounts of plaque accumulation (Todescan et
al, 2012).Probing is an essential and dependable diagnostic guideline in the longitudinal
monitoring of peri-implant tissues. A plastic probe should be utilized at recall appointments
to measure the midaspect of the mesiobuccal, buccal, distobuccal, mesiolingual, lingual, and
distolingual surfaces of the abutment. At the initial appointment after the placement of the
implant, baseline probing depths should be determined. Probing depths for traditionally
placed implants with supraosseous platforms generally range from two to four millimeters.
Intraosseous implants or implants placed at bone level may display slightly greater probing
depths. Increase in clinical probing depths along with bleeding upon probing and
suppuration are generally associated with loss of attachment and should be regarded as a
peri-implant disease. The clinical assessment should also include monitoring the soft tissue
margins in relation to the fixed dental implant. Apically migrating gingival tissue may
expose the implant surface to bacteria, increasing biofilm accumulation. Any recession
around the implant should be noted and monitored (Todescan et al, 2012).Mobility should
be routinely evaluated by means of manual examination or automated testing devices such

4. as the Periotestdental measuring instrument or the Ostell instrument. The cause of any
signs of mobility should always be determined if possible. Mobility may be due to failure of
the prosthetic or osseointegration. If the implant device moves as a whole unit, failure has
occurred and the device should be removed (Todescan et al, 2012).If clinical signs imply
peri-implantitis is present, radiographs should be taken to confirm the diagnosis. At each
recall appointment, an effort should be made to calibrate radiographic techniques so that
the relationship between bone and implant can be well defined. It is also important to
establish baseline bone levels after implant placement for comparison reasons (Todescan et
al, 2012).There are three diagnoses that can be made in regards to the health of dental
implants. Healthy is when no clinical signs of inflammation are present. Implant mucositis is
characterized as a localized inflammatory lesion within the soft tissue, and may be
recognized by redness and bleeding upon probing. Peri-implantitis is identified by a
localized inflammatory lesion which also includes attachment loss around an
osseointegrateddental implant. It is often correlated with increased probing depths,
suppuration, bleeding on probing, and loss of supporting bone (Todescan et al, 2012).Daily
plaque removal is the most critical factor in maintaining dental implants. Therefore, it is
imperative the patient have a thorough understanding of their responsibility in preserving
their implants along with proper at-home care techniques. An individualized oral hygiene
regimen should be provided for the patient according to the condition of the soft tissues and
extent of plaque accumulation and should be reviewed at every recall appointment. Home
care devices that have been shown to aid in the maintenance of dental implants include soft
toothbrushes, interdental brushes without metal wiring, end-tufted brushes, gauze, many
types of floss, stannous fluoride gel, and chlorhexidine rinse (Todescan et al, 2012).In
conclusion, traumatic dental injuries such as avulsion can be accompanied by many
complications and can also be time consuming and costly. In addition, they may affect many
aspects of life such as function, appearance, and self-esteem. But with new technology and
experts in their field, missing teeth and tissue can be esthetically replaced and maintained
and the patient’s quality of life and self-esteem can be returned.References1. Block, M.,
(2001). Anterior aesthetic implant restorations: Surgical techniques for optimal
results.Color Atlas of Dental Implant Surgery (pp. 109-158). Philadelphia, PA: The
CurticCenter.2. Capa, N. (2007). An alternative treatment approach to gingival recession:
Gingiva-colored partial porcelain veneers: A clinical report.The Journal of Prosthetic
Dentistry, 98(2), 82-84. doi: 10.1016/S0022-3913(07)60040-7.3. Emerich, K. & Wyszowski,
J. (2010). Clinical practice: Dental trauma.European Journal of Pediatrics, 169(9), 1045-
1050. doi:10.1007/s00431-009-1130-x4. Kenny, D. (2006). Whether to replant avulsed
permanent teeth.Dental Abstracts, 51(1), 9-10. Doi:10.1016/j.bbr.2011.03.0315. Nesiama, J.
& Sinn, D., (2010). Tooth avulsion.Clinical Pediatric Emergency Medicine, 11(2), 108-111.
Retrieved fromhttp://www.sciencedirect.com6. Sclar, A., (2003). Subepithelial connective
tissue graft technique for dental implants.Soft Tissue and Esthetic Considerations in Implant
Therapy. (pp.141-162). Carol Stream, IL: Quintessence Publishing Co, Inc.7. Todescan, S.,
Lavigne, S., & Kelekis-Cholakis, A. (2012). Guidance for the maintenance care of dental
implants: clinical review. Journal of the Canadian Dental Association ,78(107), 1-8.
Retrieved from http://www.jcda.ca/article/c107

5. Name:______________________________________________Grade_________/20Instructions: Read
the case study. Type the number of each question and the answer to each question. Do not
retype the question. Submit the assignment to Canvas and/or Submit a hard copy to your
lab instructor by the due date. YOUR INSTRUCTOR WILL DETERMINE WHETHER THE
ASSIGNMENT IS TO BE SUBMITTED ON CANVAS OR SUBMISSION OF A HARD COPY.
References must be included. APA format is expected . Review the course policy re:
Academic Honesty, the policy applies to this case study.1. Define a tooth avulsion.2. Define
ankylosis of a tooth.3. Define resorption of a tooth.4. Label the diagram of the
tooth.A.B.C.D.E.ABCDE