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Trick of the Trade: Dental Avulsion and Subluxation

2016-11-11T18:51:18+00:00

ToothAvulsion
It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground.  She’s crying because of the event but is otherwise unscathed.  At this point it’s time to take care of the avulsion.  What to do? (see PV Card on ED Treatment of Dental Trauma)

 
Close up repair 4


Trick of the Trade

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

  1. Lightly rinse tooth with saline solution.
  2. Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
  3. Gently reimplant tooth into a satisfactory anatomic position.
  4. Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, “mesial” means right edge and “distal” means left edge in dental speak.
  5. Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
  6. Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
  7. Hold the splint under pressure for about 1 minute.
  8. Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible. 

Warnings

  • Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
  • Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.
Close up repair 3
 
Close up repair 2
 
 
Reference

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

 

 

Hans Rosenberg, MD

ALiEM Contributor
Assistant Professor, Emergency Medicine
Ottawa Hospital
  • Anonymous

    Dermabond is safe to use on teeth? During follow up, how is the dermabond/nasal bridge removed?

  • Hello,
    1) Although Dermabond is not specifically FDA approved for oral use 2-octyl cyanoacrylate and it’s derivatives have been used in numerous oral applications in the Dental and ENT world with not concerns re: safety. Other cyanoacrylate formulations do have FDA approval for oral use.
    2) The dermabond will either be easily scaled off by the dentist or given time (likely less than a week) it will come off on it’s own.
    Hope that answers your questions.

  • Anonymous

    What’s the evidence for rinsing the tooth and socket with saline, and then patting dry the socket? My understanding is this maneuver would destroy and integrity of the peridontal ligament and leave the tooth ankylosed?
    How long do you have until you shouldn’t implant an avulsed tooth?

  • Hello, good questions:
    1) I do not know the “evidence” per say as I don’t think there are any double blinded placebo controlled trials of rinsing versus not rinsing or patting versus not. However, most common references in the ED (eg. latest Tintinalli Chapter 240) or dental world do suggest to rinse the tooth to get rid of debris, rinse the socket to get rid of excess clot and gently pat the tooth/socket to remove clot/necrotic tissue/further debris as needed. You of course have to be very careful with the apex to preserve as much of the periodontal ligament as possible. As long as you do not rub the periodontal ligament there should be minimal chance of causing damage. Additionally, the patting of the tooth in the above technique really occurs after reimplanting, when the apex is back in the socket.
    2) Dry tooth you are looking at ~60 minutes, with Hank’s Balanced Saline Solution you will have something in the area of “hours”, milk will also work very well, and finally saline. Of all those DRY time will be the worst for the tooth.