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Dental Tribune Middle East & Africa Edition | 3/2016 15 PaEDIatrIC Avulsion in Paediatric Dentistry: Management of a Double Dental Emergency in a Child ByDrGhadaHussain&DrIyadHus- sein,UAE Introduction General dental practitioners and paediatric dentists face real dental emergencies that effect children, es- pecially dental trauma. Avulsion is considered, in terms of severity, the worst of all dento-alveolar injuries. This is when the tooth is completely displaced out of its socket and the socket is found empty or filled with a blood coagulum. We report a case that describes the management of an avulsed maxillary central incisor (21) in a fit and healthy 8-year-old boy, accompanied by a lower lip lac- eration. The management of 21 took placeupoveraperiodof12months. CaseReport An 8-year old child presented to the department of paediatric dentistry at the Hamdan Bin Mohammed Col- lege of Dental Medicine (HBMCDM) at the Mohammed Bin Rashid Uni- versity (MBRU) in Dubai Healthcare City. He allegedly fell off a climbing wall, and knocked out his upper left maxillaryincisor(tooth#21)andcut hislowerlip(Figures1and2).Thisoc- curred at 14:15 hours at school, and the school nurse called the patient’s mother at 14:20 hours. The patient’s mother asked the nurse to find the tooth and put it in milk. The tooth’s “dry time” was thus around 10 min- utes. The patient attended with both his mother and aunt, to our special- istclinicat14:55hours. The tooth was presented in a milk container (Figure 3) and the tooth’s “wet time” was 50 minutes. By the time, the tooth was replanted, the tooth’s total “dry and wet time” or Extra-Alveolar Time (EAT) was around60minutes. Upon history taking, the child had fallen on a gravelled playground, with no loss of consciousness (LOC), nausea, vomiting or disorientation. He was responsive, alert, and other- wise fit and well with no known al- lergies. There were no safeguarding concerns.Hisdentalhistoryrevealed that he was an irregular attendee, with no history of dental treatment under local anaesthesia (LA) but he had a history of avulsed primary toothwhenhewastwoyearsoldand had multiple primary teeth extrac- tions under general anaesthesia (GA) fouryearsago. Extraoralexamination • No TMJ, alveolar or facial bone frac- turesdetected. • Lower lip through- and-through ragged laceration of the lower lip (Figure1). •Class2skeletalprofile. IntraoralExamination •21:emptysocketwithcoagulum. • Laceration of the buccal gingiva near21. •IncisorrelationshipClass2Division 1 (OJ= 10mm). Mum informed us of her son having proclined incisors priortotheinjury. •Nomissingfragmentsofteeth. •Teethpresent(FDI): Radiographicexamination Periapical views of the upper maxil- lary incisors were obtained to rule out any root fractures (See Figures 4 a & b) revealed immature roots of teeth # 12, 11, 22, no root fractures and an inverted supernumerary apical to 11 and an empty socket of 21. There was no need for soft tissue radiographs as no tooth fragments were missing and the tooth was ac- countedfor. Diagnosticsummary •21avulsedwithimmatureroot. •Concussion12,11,22. • Through-and through lower lip lac- erationinvolvingthevermilion. • Inverted conical supernumerary/ mesiodens$. • Behaviour: Mildly anxious at ini- tial presentation, very cooperative throughthetreatmentvisit. Aimsandobjectivesoftreatment •Managementofacutetraumaticin- juryandreplanttheavulsed21 •Suturethelaceratedlip. • Monitor the vitality and periodon- talhealingof21. • Preserve 21 in the short and me- dium term aiming to maintain the bonelevelinthelongterm. • Inform patient and parents about the poor long-term prognosis of 21 and the available de- finitive future treat- mentoptions. Treatment Plan After the patient’s ini- tial assessment, we ad- ministered LA to his upper anterior sextant and lower lip. During this time, both the tooth and socket were gently irrigated with physiological saline. 21 was found to have an im- mature root and open apex. (Figures 5a&b). Within the hour, tooth 21 was gently replanted into the socket (Figure 6) and a flexible 0.5mm wire/compos- ite passive splint of teeth #12, 11, 21, 22wassecured(Figure7).Wesutured the lacerated lower lip in multiple layers (mucosa, deep and superfi- cial) using Vicryl® (Sizes 40 and 60 ) resorbable fine sutures (Figure 8 and 9). This took place after thorough de- bridement of the wound with physi- ological saline. Care was taken to as- sure alignment of the lip’s vermilion involvedinthelaceration. The patient was advised to maintain a soft diet, and analgesics (Paraceta- mol 500mg PRN) and antibiotics (Amoxicillin 250mg TDS for 5 days) were prescribed. Chlorexidine glu- conate 0.2% 10 mls BD mouth rinse was advised. After discussing the short and long- term consequences, a follow up appointment was ar- rangedinaweek,andthepatientwas discharged. We advised the patient Figure 1: Initial presentation. 21 was avulsed anditssocketappearedempty.Therewasalac- erationof thelowerlip Figure5(a&b).Avulsed21withopenapexwasirrigatedwithsalineassoonasthepatientarrived to theclinic.Notice the toothwasheldwithout touching theroot topreserve thePDL tissue Figure 2: Palatal view of 21 socket. Notice the coagulumfilledsocket Figure 3: Storage medium of 21 was milk. The “wet time”was50minutes Figure6:Tooth21wasreplantedgentlyintothe socket after giving LA. This took place 60 min- utesafter theinjury Figure 7. A passive composite and wire splint involved#12 to22.Thelipwasyet unsutured. Figures 4 (a & b). Empy socket of 21 due to its avulsion. Notice the immature apices of 12, 11 and 22. In addition there was a supernumerary tooth/mesiodens Figure 8. Suturing of the lower lip laceration in three layers using fine resorbable sutures (Vic- ryl®Sizes40 and60 ). Figure 9. Immediate post suturing. Notice the wound margins had been aligned so the ver- milionwascontinuous. Figure10(a&b):Theclinicalappearancefollowingasecondtraumaincident thathappenedwith- in twohoursof fitting thedentalsplint. to attend his general medical prac- titioner (GMP) to obtain a Tetanus booster injection straight after the appointment. A second trauma within two hours Withintwohoursofleavingourclin- ic, the patient suffered another trau- ma affecting the injured area. This happened at the GMP receptionist’s office. As the receptionist was ask- ing the patient’s mother where her son was, she pointed to him (he was standing behind her) and accidently hit her son in the mouth. There was no LOC, nausea, vomiting or disori- entation. This caused the GMP con- cern so she sent the patient back to us for a reassessment. To our sur- prise, the patient showed up in our clinic (at 18:20 hours) with renewed bleeding from his mouth (Figure 10 a&b). After obtaining a new history and carrying out an assessment, the wound was debrided. The splint and sutures were examined and were found to be intact. Although the splintwasslightlymobile(Grade1),it was securely bonded to the teeth. No newradiographs were indicated.The patient and family were reassured andthe above advice was re-iterated. They went back to the GMP for the ÿPage16 16 55 54 53 12 11 -- 22 63 64 65 26 46 85 83 42 41 31 32 73 75 36 Dental Tribune Middle East & Africa Edition | 3/201615 165554531211 -- 2263646526 46858342413132737536