Resident’s Name: Jessica Wilson

Article title: Orthodontic management of traumatic avulsion of permanent incisors in a child with sickle cell anemia: a case report.

Author(s): Oluwatosin et al.

Journal: Cases Journal

Year. Volume (number). Page #’s: 2009. 2:8123.

Major topic: Managing patients with sickle cell anemia

Overview of method of research: Case Report

Purpose: To present a case of trauma resulting in avulsion of the anterior teeth in a sickle-cell anemia (SCA) patient and the subsequent orthodontic and restorative treatment.

Background:
Acute dental infections are a well known trigger of sickle cell crises and should be prevented and adequately treated quickly.
People with sickle cell anemia are more prone to developing osteomyelitis due to hypovascularity of the bone marrow secondary to thrombosis.
The use of local anesthesia with vasoconstrictor is not contraindicated in sickle-cell patients.

Case Report:
An 8 yo male of Sub-Saharan Africa ethnicity presents one day after an accident at school. Both central maxillary incisors were avulsed causing minimal bleeding, but only #9 was found and placed in milk. The patient’s medical history was significant for previously diagnosed for SCA. Estimated hemoglobin percent was 4.5g/dl and several sickled RBCs were present in the peripheral blood smear.
The socket was gently irrigated for foreign bodies and replantation of #9 was attempted. The incisor was splinted; a stat dose of antibiotics for sub acute bacteria endocarditis (SBE) and tetanus prophylaxis were given. The patient was given a 5 day course of amoxicillin, acetaminophen for the pain and a chlorhexidine rinse. Three days later, the patient returned and the parents reported moderate bleeding. 10 days post-op, radiographic exam was performed and soft diet was advised.
Unfortunately, two weeks after splinting, the patient was involved in a domestic accident at home traumatizing the central incisor. This resulted in third degree mobility of the tooth and the tooth was finally extracted as the replantation was deemed to have failed. Denture fabrication was recommended, but the patient was lost to follow up until 4 years later.
When the patient presented 4 years post trauma, intraoral exam revealed a total loss of space for the maxillary central incisors, supraerupted mandibular incisors with mild crowding and an exaggerated curve of spee. The buccal segments were fairly well aligned. The patient displayed bilateral class I molar and canine relationship, but class II div I incisor relationship. His overbite was 5mm and minimal overjet. Extraoral exam revealed mild maxillary protrusion associated with increased medullary activity and a high lip line with 2mm gingival display.
Orthodontic treatment included the extraction of a lower lateral incisor to alleviate crowding and level and alignment of the remaining mandibular teeth. Space for the maxillary central incisors was progressively regained with open coil springs over a 12 month period. A passive coil was then placed for an additional 6 months to retain the space (20mm) and at 18 months the patient was debonded and a Hawley retainer with stock teeth was fit. Parents and the patient were satisfied with esthetics. The patient never presented with and vaso-occlusive crisis.

Discussion:
Replantation of the central incisor deemed as a failure for several possible reasons including the prolonged extra oral time and re-dramatization. According to this article, milk has shown to maintain the vitality of the PDL for up to 3 hours.
Orthodontic treatment of people with SCA although there is a high probability that it may result in a poor outcome due to vaso-occlusive crises. This prevents local blood flow and therefore oxygen depletion, acidosis, necrosis and severe pain. The treating practitioner should know about the disease, possible complications and proper treatment. Adequate levels of oxygenation and body temperature were maintained and minimal forces were applied. Emotional stress was minimized by scheduling appointments in the morning and during the chronic phase of the disease. If the patient was in pain at all, he was referred to his physician and reappointed accordingly.
Patients with SCA have a decereased ability to remove bacteria from the bloodstream and often an enlarged heart. Antibiotic premedication was given however, there is no evidence-based guideline for doing so.

Conclusion:
A multidisciplinary approach should be taken.
Biocompatable forces should be used to correct malocclusion and bone changes should be carefully monitored. Any intense forces should be carefully planned.

Assessment of Article: I am not a huge fan of this article. It was poorly written and the only photo incorporated was post-ortho treatment. I wish they reviewed more about SCA.