AVULSED TOOTH TREATMENT OPTIONS

 THE OCCLUSAL GUIDE

The occlusal guide is a preformed polypropylene orthodontic positioner. For decades, orthodontists have used custom-made positioners to fine-tune orthodontic detail into their fixed orthodontic cases. Orthodontic labs manufacture custom-made positioners by cutting out every tooth from a plaster cast of a nearly completed orthodontic case. The cut-out plaster teeth are reassembled into perfect occlusion in ideal tip, torque, and angulation at Angle class I interdigitation. Then a polypropylene, football-style mouth guard is fabricated over the ideally reset plaster cast. 
Dr. Earl Bergersen, an orthodontist and developer of the occlusal guide, realized how extremely uniform the human dentition is. This is why preformed denture teeth can precisely restore ideal aesthetics to an edentulous patient and why aesthetic dentistry has adopted the “golden proportions” in cosmetic makeovers. Prefabricating the positioner by duplicating different sizes of denture teeth set to ideal class I occlusion eliminated the need for orthodontists to remove the last upper and lower wires, take an impression, replace the same wires, send the poured models to the lab for positioner fabrication, and have the patient return for debonding, debracketing, and appliance insertion. Orthodontists could now select the size needed and insert the best-fitting appliance immediately after fixed appliance removal. The patient needs to do heavy biting exercises for a prescribed length of time, say 2 hours per day for one week, prior to final retention.
Dr. Bergersen soon realized that his device with a motivated child could do far more than provide fine detail to a near-finished orthodontic case. He found that the occlusal guide was capable of correcting severe orthodontic malocclusions with sustained use in a motivated child. Huge overjet/overbite cases could be corrected 1 mm per month. Severely crooked teeth with absence of crowding could be straightened over several months of heavy biting exercises. The flexible but firm polypropylene rims can catch misaligned teeth and slowly force them into place. The occlusal guide became the most frequently used orthodontic appliance worldwide.

THE AVULSED TOOTH STABILIZING APPLIANCE
The problem with using an occlusal guide to stabilize avulsed teeth is that it is both an upper and lower bulky, football-style rubber mold. The patient has to eat and drink, necessitating early removal during the crucial 7- to 10-day period for avulsed teeth. Early removal could possibly remove the teeth with the appliance, because dried blood and contaminants cake to the very loose teeth, and the appliance slots grasp tooth curvatures, making removal risky.
However, if the mandibular half was eliminated from the appliance, leaving only the upper, then with some difficulty the patient could eat and drink for days, perhaps weeks, before removing the occlusal guide (see Figure). Longer-term wear may allow complete reattachment of the avulsed teeth. Intermittent biting exercises would place an apically directed force, maintaining the terminal root in the depth of socket position at an ideal tip, torque, and angulation. I estimate that 3 sizes of the appliance would fit 90% of patients: small, medium, and large. The size is determined by arch width and central incisor width.
Frequently, pediatric patients age 6 to 8, in their ugly duckling stage, have teeth ectopically positioned with flared centrals and huge diastemas. Because of the very flexible material used to fabricate the occlusal guide, these teeth can still be stabilized by the appliance even if the central incisors overlap into the lateral slots. Again, the occlusal guide was designed to straighten crooked teeth. Different size appliances may be inserted to determine the best fit, although this appliance will not fit all mouths.

The patient should be instructed to wear the appliance continuously for 7 to 10 days including eating, drinking, and sleeping, while intermittently biting hard into the appliance throughout the waking hours as much as possible. Sleep could be difficult, especially the first night, and as with any oral appliance, temporary excessive salivation is a frequent problem.
After 7 to 10 days, the child should be re-examined. Then the dentist should peel back the phlanges of the appliance labially and palatally, detaching any dried blood and contaminants. The teeth should be examined for stability and firmness. If after 7 to 10 days a firm reattachment is not evident, the teeth should be removed.
Besides being useful for tooth reimplantation in the ugly duckling stage, this device could be used for multiple avulsed teeth that are difficult to stabilize. For example, I had a patient who avulsed all 4 maxillary incisors when his teeth caught the net while dunking a basketball. The attempt to reimplant and stabilize them by an oral surgeon was unsuccessful. Stabilizing multiple teeth avulsions in a bloody operating field with composite and orthodontic wire can be very difficult. The patient now has 4 implants.
This device could also remedy other traumatic dental injuries, such as accident victims where the incisors are crushed palatally or are very loose but not fractured. These teeth could be repositioned to close to an ideal position and the appliance inserted for 7 to 10 days.