Replantation of an Avulsed-Tooth by Using Trepanation: A Case Report
Didi Wahyudi1*, Leonardo Lubis2
¹Center of Excellence Biomedical and Healthcare Technology, Telkom University, Bandung, Indonesia.
²Biomedical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.
*Corresponding author
*Didi Wahyudi, Center of Excellence Biomedical and Healthcare Technology, Telkom University, Bandung,
Indonesia.
Email: didiwahyudi@outlook.com
DOI: 10.55920/JCRMHS.2024.08.001340
Figure 1: The image taken by the parents shortly after the accident occurred.
Replantation was carried out taking into account the young age of the patient who felt uncomfortable using dentures. The replanted tooth was expected to last as long as possible until the patient could accept using dentures. Due to the delay since the accident, replantation was performed immediately without referring the patient to get a periapical radiograph first as there was no radiography equipment available at the clinic.
The tooth crown and root were cleaned using ultrasonic scaling and root canal cleaning procedures were performed. The tooth was then washed with 0.2% Chlorhexidine and rinsed with 0.9% NaCl. After administering local anaesthesia, curettage in the socket area was performed accompanied by irrigation using 0.9% NaCl. The cleaned tooth was then placed back into the socket. Once in the correct position, the tooth was splinted to the upper left lateral incisor using composite. Considering the delayed replantation case, the tooth's root canal was left open following trepanation principles to prevent the risk of suppurative swelling that could occur in a non-vital tooth. Trepanation allowed for the drainage of gas and fluids that could potentially occur in that condition. Metronidazole was prescribed for a 5-day course. The patient and parents agreed that if swelling or pain symptoms occur later on, the tooth can be extracted again to make a denture. The patient was instructed to maintain oral hygiene, including brushing the palatal surface of the replanted tooth to prevent the trepanation canal from becoming blocked.
Six days after the replantation with trepanation was completed, the patient was asked to return for observation and to evaluate whether antibiotics needed to be prescribed again. He didn't complain of anything. There was no percussion sensitivity or pain experienced. The patient only received prophylactic scaling with an emphasis on promptly visiting if there are any complaints because no more antibiotics are being taken. If swelling and pain occur, the patient was reminded that the tooth can be extracted again as explained and agreed upon initially.
Two months after the replantation, the patient returned but to request the extraction of one loose primary tooth. There were still no complaints about the replanted tooth. The patient's confidence grew stronger to avoid having the tooth extracted again in the near future to be replaced with a dental prosthesis. Several photos were then taken for documentation (Fig. 2).
Figure 2: Front and back view of the replanted tooth with trepanation canal on the palatal aspect.
Due to school activities and extracurricular involvements, the patient returned for a dental check-up 14 months after the replantation procedure. The replanted tooth was separated from the upper left lateral incisor by removing the composite that was initially attached to both teeth. Ten months later, the patient returned again without any complaints, showing no percussion sensitivity or mobility in the replanted tooth (Fig. 3). This indicates that during 24 months post-replantation, the patient had never experienced any swelling, loose teeth, or pain, even while eating. Subsequently, the patient was advised to undergo a periapical radiography to confirm the absence of any abscess concerns from the delayed replantation procedure (Fig. 4), during which the tooth was left on the ground around soccer field without proper sterilization.
Figure 3: Front view of the tooth after 24 months of replantation.
Figure 4: Periapical radiography after 24 months of replantation
Knowing that there was no percussion sensitivity, mobility, gingival recession, and no periapical abscess seen on the radiograph, the patient still wanted to keep the tooth for as long as possible. Five days after the periapical radiograph was taken, the tooth crown was reshaped using composite (Fig. 5) to match the upper right central incisor because the tooth was desired by the patient to be retained even longer. The trepanation was still left as it was (Fig. 6) until a decision is made on the next steps through discussions with the patient and parents.
Figure 5: Front teeth appearance after crown reshaping with composite.
Figure 6: Palatal view of the tooth where the trepanation canal can still be found.
Scaling was performed again to reduce plaque accumulation found around the cervical area of the teeth to maintain periodontal tissue health. A common concern in replantation cases is root resorption. Oral cavity cleanliness must be properly maintained to reduce the risk of inflammation. Having the appropriate treatment plan for non-vital teeth that undergo replantation is another crucial aspect to consider in managing root resorption. The alveolar bone around the replanted tooth, which still appeared to embrace the root on radiography, is very likely one of the reasons why there was no mobility. Trepanation may have also assisted in preventing the formation of a periapical abscess, which commonly occurs in non-vital teeth, where the abscess would lead to alveolar bone resorption and eventually cause the tooth to become loose. During the patient's visit for scaling and reshaping the crown of the tooth, information was also obtained from the parents that the patient has had a habit of mouth breathing since childhood due to having allergies that frequently congest the nose.