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?
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.
- Lightly rinse tooth with saline solution.
- Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
- Gently reimplant tooth into a satisfactory anatomic position.
- 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.
- 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.
- 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.
- Hold the splint under pressure for about 1 minute.
- 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.
- 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.
- Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.
To follow up with the wildly popular Paucis Verbis card made by Dr. Hans Rosenberg (University of Ottawa), here is his card on Dental Infections. This card summarizes common dental infection complaints (like the periapical abscess seen to the right) that we see in the Emergency Department.
How cool is this — I have talented emergency physicians contributing Paucis Verbis card content! This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here’s his recent article in Annals of EM on reimplantation of avulsed teeth.1