AVULSION

DEFINITION: -Tooth avulsion (exarticulation) implies total displacement of the tooth

out of its socket.

Exarticulation of teeth following traumatic injuries is relatively infrequent, ranging from

0.5 to 16% of traumatic injuries in the permanent dentition.

ETIOLOGY

According to Martins et al (2005) the main etiologic factors in the permanent dentition

are fights and sports injuries. While falls against hard objects are a frequent cause in the

primary dentition

Unknown (17%)

Altercations (17%)

Contact sports (15.9%)

Motor vehicle collision (10.8%)

Motorcycle accident (10.4%)

Ice hockey (2.3%)

HISTORY Martins et al. (2005)

Patient's age: Anterior primary teeth are usually present until age 6-7 years.

Mechanism of injury: Rule out concomitant injuries.

Location of the tooth when recovered: This helps to assess contamination.

Time out of socket: If the tooth was absent for less than 20 minutes, prognosis is better. All periodontal ligament cells die if the tooth is out of the socket longer than 60 minutes.

Storage media: Determine if the tooth was stored dry or in solution.

Transport method: Determine how the tooth was carried. Holding it by the root is typically worse.

CLINICAL FINDINGS In both the primary and permanent dentitions, the maxillary central incisors are the most

frequently avulsed teeth, while the lower jaw is seldom affected. Avulsion of teeth occurs

most often in children from 7 to 9 years of age, when the permanent incisors are erupting

at this age, the loosely structured periodontal ligament surrounding erupting teeth

provides only minimal resistance to an extrusive force. Most frequently, avulsion seems

to involve a single tooth; but multiple avulsions are occasionally encountered. Other

types of injuries are often associated with avulsions; among these, fractures of the

alveolar socket wall and injuries to the lips are the most common.

RADIOGRAPHIC FINDINGS

Radiographs should be taken if the clinical examination arouses suspicion of bone

fracture. In the primary dentition, radiographs will often reveal that a suspected avulsion

is actually an intrusion, where the primary tooth is buried in the jaw.

Four films (maxillary anterior, 3 periapical from various angles) are recommended to

evaluate dental injury, displacement, or possible complete intrusion.

Because these specialized films are often not available in the emergency department, a

limited facial series and a Panorex may be used to evaluate foreign bodies, displacement,

and maxillary and mandibular fractures.A Panorex may be used to assess mandibular

fracture.

Consequences of tooth avulsion

When a tooth is avulsed, attachment damage and pulp necrosis occurs. The tooth is

'separated' from the socket, mainly due to the tearing of the periodontal ligament which

leaves viable periodontal ligament cells on most of the root surface. In addition, due to

the crushing of the tooth against the socket, small localized cemental damage also occurs.

If the periodontal ligament left attached to the root surface does not dry out, the

consequences of tooth avulsion are usually minimal. The hydrated periodontal ligament

cells will maintain their viability, allowing them to reattach on replantation without

causing any more than minimal destructive inflammation. In addition, since the crushing

injury is contained within a very localized area, inflammation stimulated by the damaged

tissues will be correspondingly limited, meaning that healing with new replacement

cementum is likely to occur after the initial inflammation has subsided. However, if

excessive drying occurs before replantation, the damaged periodontal ligament cells will

elicit a severe inflammatory response over a diffuse area on the root surface. Unlike the

situation described above, where the area to be repaired after the initial inflammatory

response is small, here a large area of root surface is affected meaning that must be

repaired by new tissue. The slower moving cementoblasts cannot cover the entire root

surface in time and it is likely that, in certain areas, bone will attach itself directly onto

the root surface. In time, through physiologic bone re-contouring, the entire root will be

replaced by bone; a process which has been termed osseous replacement or replacement

resorption.Pulpal necrosis always occurs after an avulsion injury. While the necrotic

pulp itself is of no consequence, the necrotic tissue is extremely susceptible to bacterial

contamination. If revascularization does not occur or effective endodontic therapy is not

carried out, the pulp space will inevitably become infected. The combination of bacteria

in the root canal and cemental damage on the external surface of the root results in an

external inflammatory resorption that can be very serious and lead to the rapid loss of

the tooth. Thus, the effects experienced after tooth avulsion has occurred, appear directly

related to the severity and surface area of the inflammation on the root surface, and the

resultant damaged root surface that must be repaired. Treatment strategies should always

be considered in the context of limiting the extent of the peri-radicular inflammation,

thus tipping the balance toward favorable (cemental) rather than unfavorable (osseous

replacement or inflammatory resorption) healing.

TREATMENT OBJECTIVES Treatment is directed at avoiding or minimizing the effects of the two main complications

of the avulsed tooth, namely attachment damage and pulpal infection.

Attachment damage as direct result of avulsion can occur to the periodontal membrane in

the time when the tooth is out of the mouth. Treatment is directed as minimizing this

damage so that the fewest possible complications result. When severe additional damage

has occurred and replacement resorption is considered certain, steps are taken to slow the

resorptive process to maintain the tooth in the mouth for as long as possible. In the open

apex tooth, all efforts are made to promote revitalization of the pulp. In the closed apex

tooth or in the open apex tooth in which revitalization is unsuccessful all treatment efforts

are made to eliminate potential toxin from the root canal space.

CLINICAL MANAGEMENT

(A) EMERGENCY TREATMENT AT THE ACCIDENT SITE

Replant if possible or place in an storage medium

The single most important factor in the success of replantation is the speed with which

the tooth is replanted (Andreasen and Ansdreasen, 1994). Of utmost importance is the

prevention of drying, which causes loss of normal physiologic metabolism and

morphology of the periodontal ligament cells. Every effort should be made to replant the

tooth within the first 15 to 20 minutes (Barrett and Kenny1997). This usually requires

emergency personnel with experience in this type of injury. The dentist should give

careful instructions to the person at the scene of the accident over the phone. A clean

tooth with an undamaged root should be replanted as atraumatically as possible. The

person should be instructed to hold the tooth by the crown, wash the root gently in

running water or saline, and place it back in the socket as atraumatically as possible. The

patient should be brought to the office immediately. If doubt exists that the tooth can be

replanted adequately, the tooth should quickly be stored in an appropriate medium until

the patient can get to the dental office for replantation. Various suggested storage media

include water, the vestibule of the mouth, physiologic saline, milk, and cell culture

media in specialized transport containers (Hiltz and Trope, 1991). Water is the least

desirable storage medium because the hypotonic environment causes rapid cell lysis. The

vestibule of the mouth keeps the tooth moist but is not ideal because of incompatible

osmolality and pH and the presence of bacteria. However, saliva allows storage for up to

2 hours. Milk is considered the best storage medium for uncomplicated avulsion because

it is usually readily available at or near an accident site, it has a ph and osmolality

compatible to vital cells, and it is relatively free of bacteria. Milk effectively maintains

the vitality of the periodontal ligament cells. Recently an avulsed tooth preserving system

that contains, Hanks balanced salt solution (HBBS) a pH-preserving fluid and trauma

reducing suspension apparatus, was made available and has many potential advantages

(Trope and Friedman, 1992). This system could be available at schools and contact sport

events, in ambulances and hospital emergency rooms, or even in the home. The system

makes the use of a variety of storage media, enhances the possibility of maintaining the

viability of the periodontal ligament cells for an extended time after avulsion. The teeth

avulsed in serious accidents that relegate replantation to secondary importance might be

stored in these devices and replanted after the crisis is over.

(B) MANAGEMENT IN THE DENTAL OFFICE

EMERGENCY VISIT.

Diagnosis and treatment planning

The tooth should immediately be placed in the appropriate storage medium while a

history of the accident is obtained and the clinical examination is conducted. Hank’s

balanced salt solution is presently considered the best medium for this purpose. It is

commercially available and has a shelf life of 2 years or more. Milk or physiologic saline

is also appropriate for storage purposes. The clinical examination should include an

examination of the socket to ascertain if it is intact and suitable for replantation. The

socket is gently rinsed with saline and, when clear of the clot and debris, its walls are

examined directly for the presence, absence, or collapse of the socket wall. Palpation of

the socket and surrounding apical areas and pressure on the surrounding teeth are used to

ascertain if an alveolar fracture is present in addition to the avulsion. Movement of a

segment of bone as well as multiple teeth is suggestive of an alveolar fracture. The socket

and surrounding areas including the soft tissues should be radiographed. Three vertical

angulations are required for diagnosis of the presence of a horizontal root fracture in

adjacent teeth. The remaining teeth in both the upper and lower jaws should be examined

for crown fractures. Any soft tissue lacerations should be noted. Sensitivity testing at the

emergency visit is of limited value and should be delayed until the next visit.

Prepare socket/; prepare root/; replant/; and functional/; splint/; local and systemic

antibiotics.

Recognizing that the dental injury might be secondary to a more serious injury is

essential. If on examination a serious injury is suspected, immediate referral to the

appropriate expert is the first priority. The focus of the emergency visit is the attachment

apparatus. The aim is to replant the tooth with the maximal number of periodontal

ligament cells that have the potential to regenerate and repair the damaged root surface.

Necrotic and irreversibly damaged cells should be removed before replantation, if

possible. If, maintaining the periodontal ligament in a viable state is not possible, steps

are taken to alter the root as to slow the inevitable resorption. The necrotic pulp is not of

immediate concern because toxins are usually not present initially in a great enough

concentration to elicit an inflammatory response. Endodontics is not initiated at the

emergency visit and is not performed extra orally if any hope exists of vital periodontal

fibers on the root surface.

A medical history is extremely important and cannot be overlooked. The possible

presence of a more serious trauma than the avulsion must be assessed, and obtaining a

full history of the accident is essential. Reconstruction of the accident gives the idea of

the extent of the injury to the attachment apparatus as well as the likelihood of damage to

other teeth. Information about where the tooth was recovered, dry time, storage media

and mode of transportation of the patient and tooth is essential for formation of the

correct treatment choices. Local anesthesia is usually recommended for conductance of a

thorough clinical examination, if the tooth was replanted at the accident site, its

positioning in the socket is assessed. If unacceptable, the tooth is gently removed and

replanted after the correct positioning has been rectified.

The following clinical steps minimize root resorption when the tooth is not replanted at

the accident site

A) It has been suggested that the root surface be treated with various substances, such as

sodium flouride, tetracycline, stannous flouride, citric acid , hypochloric acid, calcium

hydroxide, formalin, alcohol, diphosphonates, and indomethacin in order to inhibit root

resorption.

The incorporation of fluoride ions in the cementum layer has been found to yield a root

surface resistant to resorption. Thus, in experiments with monkeys, a significant

reduction in the amount of radiographically evident root resorption was seen in teeth

treated with a fluoride solution. It was suggested that mature teeth with prolonged dry

extra-alveolar periods (i.e. greater than 1 hour) be placed in a fluoride solution (2.4%)

sodium fluoride phosphate acidulated at pH (5.5) for 20 minutes prior to replantation.

There after the root surface is rinsed with saline and the tooth replanted and splinted for 6

weeks. The effect of this treatment seems to be a 50% reduction of the replacement

resorption.

B) Apical part of the root is replaced with a cast vitallium implant. However, the results

of these procedures have not been convincing. Attempt has been made to prolong the

lifetime of replanted teeth by a replacement of the root tip with a ceramic implant (dense

sintered aluminum oxide). Before replantation, the apical half of the root is resected, the

root canal enlarged with special burs, whereafter a corresponding ceramic implant is

cemented ingression of root resorption of replanted human teeth.

1. PREPARATION OF THE ROOT

Preparation of the root is dependent on the maturity of the tooth (open vs closed apex)

and on the dry time of the tooth before it was placed in a storage medium. A dry time of

60 min is considered the point where survival of root periodontal ligament cells is

unlikely.

a) Extra oral dry time less than 20 minutes (closed apex)

If the tooth has a closed apex, revitalization is not possible but if the tooth was dry for

less than 20 minutes the chance for periodontal healing is excellent. The root should be

rinsed of debris with water or saline and replanted in as gentle a fashion as possible

(Andreasen1981).

Extra oral dry time less than 20 minutes (Open Apex)

In an open apex tooth, revascularization of the pulp as well as continued root

development is possible. In one study revascularization was significantly enhanced by

soaking the tooth in 1 mg of doxycycline in 20 mg of physiologic saline for 5 minutes

before replantation. The doxycycline inhibits bacteria in the pulpal lumen thus removing

the major obstacle to revascularization (Cvek et al 1990). As with the tooth with the

closed apex, the open apex tooth is then rinsed with water or saline and gently replanted.

Extra oral time 20 to 60 minutes (closed and open apices)

For drying periods of 20 to 60 minutes most authors suggest rinsing the tooth gently and

replanting it as soon as possible, accepting that complications are inevitable. However,

some evidence reveals that soaking such teeth in a storage medium can reduce ankylosis.

Survival of the remaining cells in the periodontal ligament may be improved in this

fashion. Probably of greater significance is that necrotic cells and debris including

bacteria float off of the root during the soaking period, leaving fewer stimuli for

inflammation when the tooth is replanted. These teeth should not be replanted

immediately but should be placed in a solution of Hanks balanced salt solution for 30

minutes before replantation.

Closed Apex

The root should be rinsed of debris with water or saline and replanted in as gentle fashion

as possible (Cvek et al 1990).If the tooth has a closed apex, revasculsarization is not

possible. but, because the tooth was dry for less than 60 min (replanted or placed in an

appropriate medium), the chance for periodontal healing exists. Most importantly, the

chance of a severe inflammatory response at the time of replantation is lessened. A dry

time of less than 15-20 min is considered optimal where periodontal healing would be

expected.

A continuing challenge is the treatment of the tooth that has been dry for more than

20 min (periodontal cell survival is assured) but less than 60 min (periodontal survival

unlikely). In these cases, the root surface consists of some cells with the potential to

regenerate and some that will act as inflammatory stimulators. The use of Emdogain

(Biora, Malmo, Sweden) has been found to be valuable in these cases. This medicament

is proved extremely valuable in the 20–60 minute dry time period.

Open Apex

Tooth with an open apex revascularization of the pulp as well as continued root

development is possible hence should be soaked in doxycycline for 5 min, gently rinse

off debris, and replant. In an open apex tooth, Cvek et al (1990) found in monkeys that

soaking the tooth in doxycycline (1 mg in approximately 20 ml of physiologic saline) for

5 min before replantation significantly enhances revascularization.

Exra-oral dry time > 60 min

Closed Apex

If the tooth has been dry for more than 60 min and no consideration has been given to

preserving the periodontal ligament, the endodontics may be performed extraorally. In

the case of a tooth with a closed apex, no advantage exists to this additional step at the

emergency visit.

the periodontal ligament is removed by placing in acid for 5 min, then should be soaked

in fluoride or the root covered with Emdogain, and replant. When the root has been dry

for 60 min or more, the periodontal ligament cells are not expected to survive. In these

cases, the root should be prepared to be as resistant to resorption as possible (attempting

to slow the osseous replacement process). These teeth should be soaked in acid for 5 min

to remove all remaining periodontal ligament and thus remove the tissue that will initiate

the inflammatory response on replantation. The tooth should then be soaked in 2%

stannous fluoride for 5 min and replanted. Aledronate was found to have similar

resorption slowing effects as fluoride when used topically but further studies need to be

carried out to evaluate whether its effectiveness is superior to fluoride and whether this

justifies its added cost. studies have found that Emdogain (enamel matrix protein) may be

extremely beneficial in teeth with extended extra oral dry times, not only to make the root

more resistant to resorption but possibly to stimulate the formation of new periodontal

ligament from the socket.

Attempts have been made to overcome the problem of ankylosis by placing different

materials between the tooth and the socket, such as silicone grease and methyl

methacrylate, absorbable surgical sponge (Gelfoam,) venous tissue, fascia and cutaneous

connective tissue. The outcome of using various materials could not prevent the root

resorption.

Open apex

Replant? If yes, treat as with closed apex tooth. Endodontic treatment may be performed

out of the mouth. Since these teeth are in young patients whose facial development is

usually incomplete, many pediatric dentists consider the prognosis to be so poor and the

potential complications of an ankylosed tooth so severe that they recommend that these

teeth are not replanted. In fact, not to replant these teeth is the present recommendation of

the International Association of dental trauma (Flores et al, 2001). However, considerable

debate exists as to whether it would be beneficial to replant the root even though it will

inevitably be lost due to resorption. If the patients are followed carefully and the root

submerged at the appropriate time the height and, more importantly, the width of the

alveolar bone will be maintained, allowing for easier permanent restoration at the

appropriate time when the facial development of the child is complete. However, in a

tooth with an open apex the endodontic treatment, if performed after replantation,

involves a long-term apexification procedure. In these cases, completing the root canal

treatment extraorally, where a seal in the blunderbuss apex is easier to achieve, may be

advantageous. When endodontic treatment is performed extraorally, it must be performed

aseptically with the utmost care to achieve a root canal system that is free of bacteria.

11. PREPARATION OF THE SOCKET

The socket plays a negligible role in the onset of complications after an avulsion and

should be left undisturbed before replantation. Emphasis is placed on removal of

obstacles within the socket to replacement of the tooth into the socket. However, the

environment in the socket might change with time, contributing to the prognosis of the

replantation. These changes have yet to be defined and no procedures for preparation of

the socket can yet to suggested. The socket should be let unaltered to the greatest extent

possible. It should be lightly aspirated if a blood clot is present. If the alveolar bone has

collapsed and may prevent replantation or cause it be traumatic, a blunt instrument should

be inserted carefully into the socket in an attempt to reposition the wall.

111. SPLINTING

Splinting technique advised, that will allow movement of the tooth during healing and in

place for a minimal time period results in a decreased incidence of ankylosis.

Semi rigid (physiologic) fixation for 7 to 10 days is recommended. The splint should

allow movement of the tooth, should have no memory and should not impinge on the

gingival and / or prevent maintenance of oral hygiene in the area.

Studies have shown that rigid splinting of replanted mature and an autotrasplanted

immature tooth increases the extent of root resorption. (Anderson 1985, Morley et al

1978,Andersson et al 1985). Replanted teeth should, therefore, only be splinted for a

minimal period of time. One week is normally sufficient to ensure adequate periodontal

support, as gingival fibers are already healed by this time.

Many types of splints fulfill these requirements. The acid –etch resin and arch wire splint

is probably the most commonly used splint for traumatic injuries. A passive wire (size

0.015 to 0.030) is shaped to conform to the facial aspect of the avulsed tooth and one or

two teeth on either side. The middle third of the facial surface of the teeth is acid etched

and light cured composite resin is used to attach the wire to the teeth on either side of the

affected tooth. When the sire is satisfactorily in place the patient is asked to bite gently

into a bite block (softened pink wax is useful) and gently force the avulsed tooth as far

into the socket as possible. The avulsed tooth is then added to the splint with light cured

composite resin. After the splint is in place, a radiograph should be taken to verify the

positioning of the tooth and as a preoperative reference for further treatment and follow-

up. When the tooth is in the best possible position, adjusting the bite to ensure that it has

not been splinted in a position causing traumatic occlusion is important. One week is

sufficient to create periodontal support to maintain the avulsed tooth in position.

Therefore, the splint should be removed after 7 to 10 days. The only exception is with

avulsion in conjunction with alveolar fractures, for which 4 to 8 weeks is the suggested

time of splinting.

A. “Non-rigid” for reimplantation and displacements

0.017 x .025 SS with composite

0.018 round SS with composite

Monofilament nylon (20-30 lb test)

7 – 10 days

B.“Rigid” for root fractures

0.030 Stainless steel wire + Composite

2-3 months.

Long term rigid splinting of replanted teeth increases risk of replacement root resorption

(ankylosis)

Titanium Trauma Splint

1V. MANAGEMENT OF SOFT TISSUESSoft tissue lacerations of the socket gingival should be tightly sutured. Lacerations of the

lip are fairly common with these types of injures. The dentist should approach lip

lacerations with some caution and a plastic surgery consult might be prudent. It these

lacerations are sutured, care must be taken to clean the wound thoroughly before hand

sutured, because dirt or even minute tooth fragments left in the would affect healing and

the esthetic result.

V.ADJUNCTIVE THERAPY Systemic antibiotics given at the time of replantation and prior to endodontic treatment

are effective in preventing bacterial invasion of the necrotic pulp and therefore

subsequent inflammatory resorption. The administration of systemic antibiotics is

recommended beginning at the emergency visit and continuing until the splint is

removed. The bacterial content of the sulcus also should be controlled during the healing

phase. In addition to stressing the need for adequate oral hygiene, chlorhexidine rinses

should be used for 7 to 10 days as well as the systemic antibiotics. The chlorhexidine

rinses assist the patient in maintaining good oral hygiene in the initial stages when the

tooth is still painful because of the trauma and also when the splint is in place and makes

adequate brushing and flossing difficult. The need for analgesics should be assessed on

an individual case basis. The use of pain medication stronger than nonprescription,

nonsteroidal anti-inflammatory drugs is unusual. Contamination of the wound may have

consequences beyond the effects on the tooth or teeth. The patient should be sent to

physician for consultation regarding a tetanus booster within 48 hours of the initial

visit.

(C) Second Visit

This visit should take place 7 to 10 days after the emergency visit. At the emergency

visit, emphasis is placed on the preservation and healing of the attachment apparatus. The

focus of this visit is the prevention or elimination of potential irritants from the root canal

space. These toxins, if present provide the stimulus for the progression of the

inflammatory response and bone and root resorption. Also at this visit, the course of

systemic antibiotics is completed, the chlorhexidine rinses can be stopped and the splint

is removed.

ENDODONTIC TREATMENT

Experimental studies in monkeys have shown that extraoral roots filling procedures as

well as the root filling materials themselves apparently injure the periodontal ligament.

This could be a result of seepage through the apical foramen or mechanical preparation of

the root canal, resulting in increased ankylosis apically when compared to non-

endodontically treated teeth. (Andreasen1981, Andreasen and Kristeron1981). Thus,

endodontic treatment should be delayed for 1 week after replantation in order to prevent

development of ankylosis and inflammatory resorption, as well as to allow splicing of

periodontal ligament fibers, which limits seepage of potentially harmful root filling

materials into the traumatized periodontal ligament.

a). Extra – oral time < 60 min

For teeth with closed Apex

Initiate endodontic treatment at 7 to 10 days. In cases where endodontic treatment is

delayed or signs of resorption are present, treat with 'long-term' calcium hydroxide

treatment before obturation.

If therapy is initiated, the pulp should be necrotic without infection or, at most, only

minimal infection. Therefore, endodontic therapy with an effective interappointment

antibacterial agent over a relatively short period of time (7–10 days) is sufficient to

ensure effective disinfection of the canal. Long-term therapy with calcium hydroxide

remains an excellent treatment method. The advantage of its use is that temporary

obturating material is in place until an intact periodontal ligament space is confirmed.

Long-term calcium hydroxide treatment should always be used when the injury occurred

more than 2 weeks before the start of endodontic treatment or if radiographic evidence of

resorption is present.

The root canal is thoroughly instrumented and irrigated, then filled with a thick, powdery

mix of calcium hydroxide and sterile saline (anesthetic solution is also an acceptable

vehicle). The calcium hydroxide is changed every 3 months within a range of 6–

24 months. The canal is obturated, when a radiographically intact periodontal membrane

can be demonstrated around the root. Calcium hydroxide is an effective antibacterial

agent and favorably influences the local environment at the resorption site, theoretically

promoting healing (Tronstad 1988). It also changes the environment in the dentin to a

more alkaline pH, which may slow the action of the resorptive cells and promote hard

tissue formation (Tronstad 1981). However, the changing of the calcium hydroxide

should be kept to a minimum (not more than every 3 months) because it has a necrotizing

effect on the cells that are attempting to repopulate the damaged root surface

(Lengheheden1990)

The antibiotic-corticosteroid paste, Ledermix, is effective in treating inflammatory root

resorption by inhibiting the spread of dentinoclasts without damaging the periodontal

ligament (Pierce 1988). Its ability to diffuse through human tooth roots has been

demonstrated. whilst its release and diffusion is further enhanced when used in

combination with calcium hydroxide paste (Abbott1989) Calcitonin, a hormone that

inhibits osteoclastic bone resorption, is also an effective medication in the treatment of

inflammatory root resorption(Pierce 1988)

b) For teeth with open Apex

Teeth with open apices have the potential to revascularize and continue root development

and initial treatment is directed toward the re-establishment of the blood supply

(Skoglund1981) hence endodontic treatment should be avoided unless definite signs of

pulp necrosis, such as peri-radicular inflammation, are present. At first sign of an infected

pulp one should initiate apexification procedure. The diagnosis of pulp vitality is

extremely challenging in these cases. After trauma, diagnosis of a necrotic pulp is

particularly desirable because, due to cemental damage accompanying the traumatic

injury, infection in these teeth is potentially more harmful. External inflammatory root

resorption can be extremely rapid in these young teeth because the tubules are wide and

allow the irritants to move freely to the external surface of the root (Cvek et al 1990,

Yanpiset and Trope, 2001).

Patients are recalled every 3–4 weeks for sensitivity testing. Reports indicate that thermal

tests with carbon dioxide snow (− 78 °C) or difluordichlormethane (− 50 °C) placed at

the incisal edge or pulp horn are the best methods for testing sensitivity, particularly in

young permanent teeth (Fulling and andreasen1976). One of these two tests must be

included in the sensitivity testing of these traumatized teeth. The laser Doppler flowmeter

has been shown to be a superior tool in the diagnosis of revascularization of an immature

tooth after trauma (Mesaros and Trope1997). In a recent study in dogs, Yanpiset et al

(2001) showed that the presence of revascularization can be detected as early as 4 weeks

after an avulsion by this method.

c) Tooth with an (open apex) and extra oral dry time of more than 60 minutes.

In these teeth the chance of revasculariztion is extremely poor (Andreasen1981,

Trope1992). Therefore, no attempt is made to revitalize these teeth. An apexification

procedure is initiated at the second visit. Because time of replantation is not critical in

these cases endodontic treatment could have been completed extraorally before

replantation at the emergency visit. In these cases the second visit is a recall visit to

assess initial healing only.

d) Tooth with a closed apex and extra oral dry time of more than 60 minutes.

As no chance exists for revitalization of these teeth, and endodontic treatment should be

initiated at the second visit at 7 to 10 days (Andreasen (1981) Cvek et al. (1990). If

therapy is initiated at this optimum time the pulp should be ischemically necrosed

without infection or at most only minimal infection (Tronstad1981). Therefore,

endodontic therapy with an effective interappointment antibacterial agent over a

relatively short period is sufficient to ensure effective disinfection of the canal. This

protocol is the new recommended treatment of American Association of Endodontists Ad

Hoc Committee on Treatment of the Avulsed tooth(As in Trope1995) The root canal is

thoroughly instrumented and irrigated and then filled with a thick mix of calcium

hydroxide and sterile saline. The calcium hydroxide is changed every 3 months within a

range of 6 to 24 months. The canal is obturated when a radiographically intact

periodontal membrane is demonstrated around the root.

New protocol Pohl et al, (2005)

Before 1995 during the examination, extraoral endodontic treatment was prepared and

started when pulp necrosis was predictable according to the maturity of the root and/or

the circumstances during the extraoral phase. Thus replantation was completed within

30–45 min after arrival of the patient. Since 1995 the teeth were stored at least 30 min in

the tissue culture medium; replantation as soon as possible was no longer followed. Every

few minutes the teeth were shaken gently within the medium. Before 1998 systemic

antibiotics (mostly penicillin) were prescribed but not on a regular basis. Since 1998

doxycyclin for systemic use was always prescribed as part of antiresorptive-regenerative

therapy (ART).

EXTRAORAL ENDODONTIC TREATMENT

According to the method described by Kirschner et al (1996). and Kirschner (2002) the

avulsed teeth were endodontically treated by an extraoral retrograde insertion of posts

made of ceramics or titanium.

INTENSIVE RINSING

For rinsing exclusively sterile isotonic saline was used. The root surface of the avulsed

teeth was intensively rinsed throughout the preparation of the root canal by the automatic

cooling system. Up to 1998 the root surface was additionally rinsed immediately before

replantation. Since 1998 the root surface was rinsed as soon as possible after arrival of

the patient, during the preparation of the root canal and immediately before the

application of a glucocorticoid to the storage medium. The alveolus was rinsed also

immediately before replantation.

ANTIRESORPTIVE-REGENERATIVE THERAPY)

Since 1998 the topical and systemic application of different medicaments is used to

depress resorption activity and support regeneration in the PDL. After completion of the

extraoral endodontic treatment and intense rinsing of the root surface the teeth are stored

for about 20 min in the tissue culture medium of the tooth rescue box Dentosafe to

which 40 μg ml1 dexamethasone had been added. Every few minutes the teeth were

shaken gently within this medium. Immediately before replantation – after removal of

the coagulum from the alveolus by rinsing with sterile isotonic saline – an EMD

(Emdogain) is applied onto the root surface and into the alveolus. After completion of

the treatment doxycyclin is prescribed for systemic use according to the patients' weight

(2 mg/ kg1 body weight daily, maximum dose 100 mg/day)  for 5 days.

The condition of the PDL at the time of placement in the tooth rescue box was defined

as not compromised, when the teeth were stored dry for less than 15 min and/or stored in

a non-physiologic wet medium for less than 30 min. The PDL was classified as

compromised when the dry storage was between 15 and 60 min and/or the non-

physiologic wet storage was between 30 and 120 min. The condition of the PDL was

defined hopeless when the extraoral time exceeded 60 min of dry and/or 120 min of non-

physiologic wet storage.

TEMPORARY RESTORATION

Effectively sealing the coronal access is essential to prevent infection of the canal

between visits. Recommended temporary restorations are reinforced zinc-oxide-eugenol

cement. Acids etch composite resin, or glass ionomer cement. The depth of the temporary

restoration is critical to its sealability. The temporary restoration is placed directly onto

the calcium hydroxide in the access cavity. Calcium hydroxide should be removed from

the walls of the access cavity because it is soluble and will wash out when into contact

with saliva, leaving a defective temporary restoration.

After initiation of the root canal treatment, the splint is removed. If time does not permit

complete removal of the splint at this visit, the resin tacks are smoothed so as not to

irritate the soft tissues and the residual resin is removed at a later appointment.

At this appointment, healing is usually sufficient to perform a detailed clinical

examination on the teeth surrounding the avulsed tooth. The sensitivity tests, reaction to

percussion and palpation and periodontal probing measurement should be carefully

recorded for reference at follow-up visits.

OBTURATION VISIT

If the endodontic treatment was initiated 7 to 10 days after the avulsion and clinical and

radiographic examinations do not indicate pathosis, obturation of the root canal at this

visit is acceptable although the use of long-term calcium hydroxide is a proven option for

these cases. On the other hand, if endodontic treatment was initiated more than 7–10 days

after the avulsion or active resorption is visible, the pulp space must first be disinfected

before obturation. Traditionally, the re-establishment of a lamina dura is a radiographic

sign that the canal bacteria have been controlled. When an intact lamina dura can be

traced, obturation can take place.

The canal is reinstrumented and irrigated under strict asepsis. After completion of the

instrumentation the canal can be obturated by any acceptable technique with special

attention to an aseptic technique and the best possible seal of the obturating material.

PERMANENT RESTORATION

Coronal leakage caused by defective temporary and permanent restorations results in a

clinically relevant amount of bacterial contamination of the root canal after obturation.

There fore, the tooth should receive a permanent restoration at or soon after the time of

obturation of the root canal. As with the temporary restoration, the depth of restoration is

important for its seal and therefore the deepest restoration possible should be made. A

post should be avoided if possible. Because most avulsions occur in the anterior region of

the mouth where esthetics is important, composite resin with the addition of dentin

bonding agents are usually recommended in these cases. They have the additional

advantage of internally strengthening the tooth against fracture if another trauma should

occur.

FOLLOW –UP CARE

Follow up care should take place at every 6 months for 3 years and yearly for as long as

possible. Follow-up of avulsion cases after completion of the obturation of the canal is

extremely important. If replacement resorption is identified timely revision of the long-

term treatment plant is indicated. In the case of inflammatory root resorption a new

attempt at disinfection of the root canal space can reverse the process. Teeth adjacent to

and surrounding the avulsed tooth or teeth may show pathologic changes long after in

initial accident. Therefore these teeth should be tested at recall and the result compared

to those collected soon after the accident.

Follow – up procedures for traumatized permanent teeth

Time Closed apex Open

apex

1 week S

Initial endodontic treatment

S

2-3 weeks C C

3-4 weeks C C

6-8 weeks C C

6 months C C

1 year C C

5 years C C

S = Splint removal. C = Clinical and radiographic examination

Closed Apex

(1)Satisfactory outcome – Clinical : asymptomatic, normal mobility, normal sound on

percussion.

Radiographic : no perdiographic : no periradicular radiolucencies indicative of progressive

external inflammatory root resorption (>2X normal lamina dura) or loss of lamina dura

indicative of ankylosis and replacement resorption.

(2) Unsatisfactory outcome – Clinical : symptomatic and/or high pitch percussion sound.

Radiographic : [Periradicular radiolucencies in the root and bone or radiographic replacement

of the root with bone.

Open Apex

(1) Satisfactory outcome - Clinical : asymptomatic, normal mobility and eruption pattern,

normal sound on percussion. Positive sensitivity test.

Radiographic : As with closed apex. Continued root development, pulp lumen

obliferation extremely common.

(2) Unsatisfactory Outcome : Clinical : symptomatic and / or high pitched percussion sound.

Tooth in infra – occlusion.

Radiographic : As with closed apex. Root fails to develop, the pulpal lumen does not

change in size.

Biologic Considerations Following Replantation Pulpal Reactions

Extensive pulpal changes could be observed as early as 3 days after replantation. The

most severe damage was usually observed in the coronal part of the pulp. Signs of

healing were seen within 2 weeks after replantation.

Various pulpo-dentinal responses, which occur after immediate replantation, are

classified as

I. Regular tubular reparative dentin.

II. Irregular reparative dentin with diminished tubular structures.

III. Irregular reparative dentin with encapsulated cells (osteodentin).

IV. Irregular immature bone.

V. Regular lamellated bone or cementum.

VI. Internal resorption.

VII. Pulp necrosis. (Anderson et al, 1968)

Severe primary pulpal damage was more often found in teeth with completed root

formation than in those with an open apex, where the pulpal repair seemed also to be

more rapid.

Periodontal Healing Reactions

Immediately after replantation, a coagulum is found between the two parts of the severed

periodontal ligament. The line of separation is most often situated in the middle of the

periodontal ligament, although separation can occur at the insertion of Sharpey’s fibers

into cementum or alveolar bone. Proliferation of connective tissue cells soon occurs and,

after 3 to 4 days, the gap in the periodontal ligament is obliterated by young connective

tissue. After 1 week, the epithelium is reattached at the cemento-enamel junction. This is

of clinical importance because it may imply a reduced risk of gingival infection and / or

reduced risk of bacterial invasion of either the root canal or periodontal ligament via the

gingival pocket.

Sequelae of Attachment Damage and pulp Necrosis

Trauma to the attachment apparatus results in a localized inflammation in the periodontal

ligament. If the inflammatory response is not excessive and no other stimuli to

inflammation are present, healing occurs with the formation of a new periodontal

ligament and cemental layer. This process is called surface resorption.

If the trauma is extensive with a large area of damage involving more than 20% of the

root surface, an abnormal attachment can occur after healing. After the initial

inflammatory response to remove debris resulting from the injury, a root surface devoid

of cementum results. Cells in the vicinity of the denuded root, now compete to repopulate

it. Often cells that are the precursors of bone will move across from the socket wall and

populate the damaged root rather than will the slower moving periodontal ligament cells.

Bone comes into direct contact with the root without an intermediate attachment

apparatus .This phenomenon is termed dentoalveolar ankylosis. Bone resorbs and

reforms physiologically throughout life. The osteoclasts in contact with the root resorb

the dentin. In the reforming phase, osteoblasts lay down bone in the area that was

previously root, eventually replacing it. This progressive effect of ankylosis in the

avulsed tooth is termed replacement resorption. It is characterized histologically by

direct contact between bone and dentin without a separating periodontal ligament and

cemental layer Radiographically, the distinction between the root and surrounding bone is

lost and a moth eaten a appearance results. Clinically, lack of mobility of the tooth and a

metallic sound to percussion is pathognomonic of infraocclusion in the developing

dentition. Ultimately, the tooth is lost.

The cemental layer is also a physical barrier that separates the root canal system from the

surrounding periodontal attachment. Under normal circumstances, if the pulp space

becomes infected the cemental layer does not allow the toxins from the pulp to reach the

periodontal ligament.

After an avulsion, the cemental covering is damaged and its protective quality is lost. It

the pulp, which is necrotic because of the avulsion, becomes infected; the toxins can now

pass through the dentinal tubules and stimulate an inflammatory response in the

corresponding periodontal ligament. The result is resorption of the root and bone. This

process is termed inflammatory root resorption.

The periodontal infiltrate consists of granulation tissue with lymphocytes, plasma cells,

and polymorphonuclear leukocytes, Multinucleated giant cells resorb the denuded root

surface and this continues until the stimulus is removed. Radiographically, inflammatory

resorption is observed as progressive radiolucent areas of the root and adjacent bone.

These changes can occur as early as 2 to 3 weeks after the avulsion.

Prognosis Replantation of teeth has been considered a temporary measure as many teeth succumb to

root resorption. However, a number of cases have been reported where replanted teeth

have been in service for 20 to 40 years with a normal periodontium, as revealed clinically

(positive pulpal sensibility) and radiographically,

In long-term study, it was shown that tooth survival was significantly related to the stage

of root development at the time of injury, being more favourable with increasing

developmental maturity.

STORAGE PERIOD AND STORAGE MEDIA

Hammer (1955) first addressed the importance of PDL cell viability prior to

reimplantation and demonsrated that the length of survival of a reimplanted tooth is

directly correlated with the amount of viable periodontal membrane.

Iqbal and Bamaas, (2001) stated that, the cause of root resorption at the cellular and

molecular level is not exactly known. Intermediate cementum is thought to resist root

resorption and its loss as a result of the trauma is thought to predispose to dentinal

resorption. In replantation studies using monkey incisors it has been shown that

periodontal ligament will regenerate as long as the viability of the cells close to the

cementum is maintained. Therefore, a great deal of attention in the past has been focused

on biologic storage and protection of the PDL cells in these teeth. These studies have

shown that, although it is possible to modify the healing response in various ways, true

periodontal regeneration with the restoration of original structure and function of the

periodontal tissues still occurs only occasionally.

It has also been stated that primary acellular cementum is the tissue which provides for

the attachment of ligament fiber bundles to the root surface and therefore is essential if

regeneration is to occur. Another significant relationship, which could be demonstrated in

a large clinical study, is the strong dependence between storage period and media and

pulpal healing. This was possibly due to the detrimental effect of cellular dehydration

during dry storage on the apical portion of the pulp or by damage incurred by non-

physiologic storage (e.g. prolonged tap water storage, chloramine, chlorhexidine and

alcohol). With nonphysiologic storage, the chances of pulpal revascularization were

minimal. With storage in physiological media (e.g. saline, saliva or milk), there was only

a weak relationship between the duration of storage and chances of pulpal

revasuclarization. (Andreasen et al, (1993) Avulsed teeth have been stored either in the

oral cavity or in other media, such as physiologic saline or tap water, before replantation.

Here it can also be mentioned that successful cases have been reported after extra-

alveolar periods of several hours

Andreasen et al(1995) found that periodontal ligament (PDL) healing was not likely after

an extraoral dry time of 75 min. When saliva or saline was used as the storage media,

PDL healing decrease after only 20 min. The American Academy of Pediatric Dentistry

(AAPD)2002 and the American Association of Endodontics (AAE) guidelines

recommended immediate reimplantation of avulsed permanent teeth.

Recently, a tooth preservating system utilizing HBSS as a storage media is available

called save A tooth.

Harkacz et al and Oslon et al tested the efficasy of Gatorade as a transpore medium for

PDL cells.

Sigalas et al(2004) studied the six storage solutions. They are

1.Culture medium(90%Dulbeccos minimum essential medium(DMEM)

2. Milk (2% reduced fat milk, fortified with vitamin D and E):-The improved viability of

cells stored in milk is due to physiologic osmolality of milk, the cytoprotective effects of

other nutrient constituents, as well as the ph buffering system . 2% reduced fat milk is

used instead of whole milk, because milk with lower fat content is more appropriate in

maintaining cell viability than with higher fat content and suggested as storage medium

when stored in ice.

3. HBSS:- Hanks balanced Salt solution(HBSS) is a standard salt solution and contains

essential nutirents.

The American Association Of Endodontics(AAE)1995 suggested as the storage medium

of choice, because of its ability to preserve the viability of the majority of the PDL and

it is non toxic, with balanced ph (7.2) and has an osmolality of 270-320mOsm

appropriate for normal cell growth.

4.Contact lens solution 1:-Contains buffered , isotonic saline solution with the addition

of preservative

Contact lens solution 2

Contact lens solution 3

5.Tap water

6.Gatorade:-It is a oral rehydration fluid commonly found at sporting events and has a

ph of 3 and osmolality of 280-360mOsm1.-1 Concluded that storage of an avulsed tooth

on ice is more benefecial than storage at room temperature.HBSS is the optimal solution

for storing avulsed tooth, the use of contact lens solutions and Gatorade at room

temperature and water in any situation should be avoided. If ice is avilable, low-fat milk

is an appropriate alternative to HBSS for storage of avulsed topoth. Either single bottle

contact lens solutions or Gatorade on ice could serve as short term storage medium.

The Tooth rescue box (Dentosafe, Dentosafe GmbH, Iserlohn, Germany; EMT Tooth

Saver, SmartPractice.com, Phoenix, AZ, USA) contains tissue culture medium, different

salts, and also contains amino acids, vitamins, and glucosis. The medium is shown to

maintain vitality and proliferative capacity of PDL cells for up to 48 h at room

temperature. The unopened box has a shelf life of 3 years at room temperature (below

37°C).

Conditioned medium:- It is prepared by removing medium from cultured cells growing

in the logarithmic phase for 3 days. This is the period of active proliferation during which

the number of cells increase exponentially and there is reduction of glucose and

glutamine for cells. It contains growth factors and hormones secreted by cells and it is

obtained from the supernatant of cultured human gingival fibroblast cells at the

confluence time and stored at –200 C until use.

Emdogain:-It is a sterilized aqueous solution of propylene glycol alginate which

contains, proteins of the amelogenin family extracted from developing porcine embryonal

enamel.Enamel matrix derivative (EMD) (Emdogain, Biora, Malmo, Sweden) was

introduced to promote periodontal regeneration.

Barrett et al. (2005) The pivotal role played by enamel matrix proteins in the development

of embryonic acellular cementum has led to the development of a new biological tool to

promote periodontal wound healing. EMDOGAIN, has shown promising results in

regenerating damaged periodontal tissue in animal and human studies.

Iqbal and Bamaas (2001) found that EMD preferentially stimulated cells with the

potential to form cementum and periodontal ligament from the tooth and socket

environment. In animal experiments extracted teeth were stored dry for 30 min and, after

application of EMD, were replanted into their sockets or transplanted to the abdominal

wall. Compared with teeth planted without EMD ,histologic results exhibited less root

resorption, better healing of resorption cavities and promoted periodontal healing. In a

clinical study ankylosed teeth were therapeutically replanted after application of EMD

onto the root surface and into the alveolus. During a mean observation period of

15 months a reestablishment of the ankylosis was not observed in teeth that had been

ankylosed due to a less severe trauma.

After reimplantation of extracted ankylosed teeth with root surfaces treated with

Emdogain there were no signs of recurring ankylosis during a mean follow-up period of

6 months.

Mode of application:- EMDOGAIN is mixed at least 15 min prior to its application to

the teeth to be re-implanted. Two minutes prior to re-implantation the socket is washed

with 5 ml of normal saline. The tooth is held by the crown, washed in a 2-ml flow of

normal saline, and dabbed over a 2×2 damp gauze to remove excess saline from the root

surfaces. The teeth are then coated with EMDOGAIN gel, which is squeezed through a 1-

mm diameter blunt needle, and teeth are re-implanted into their socket.

Propolis

It is an an antibacterial and antiinflammatory resinous bee-hive product which has the

potential to preserve the viability of PDL cells of an avulsed tooth.

Martin and Pileggi (2004) concluded that,

propolis may be able to maiatain PDL cell viability better than HBSS,milk, or

saline

The collagenase and dipase assay appears to be viable method for evaluating PDL

cell viabilty.

Prosthodontic replacement

A permanent anterior tooth lost due to the direct effects of traumatic episode or because it

failed to respond to therapy requires a prosthodontic replacement. The replacement

should be esthetic, function in speech and mastication and prevent tipping of adjacent

teeth.

In the young patient, a removable temporary appliance is constructed and worn until all

permanent anterior teeth have erupted, alveolar bone changes have decreased and the

pulp chambers have receded to allow preparation for fixed replacements.

In constructing the temporary appliance, consideration must be given to those areas in

which teeth are soon to erupt, and provision must be made either for leaving the areas of

eruption outside the area of the denture of for easy removal of the part of the denture in

the area of tooth eruption. If teeth are permitted to erupt beneath a denture, rapid

decalcification may occur, especially if the teeth are not brushed frequently.

The removable appliance may be constructed of acrylic, or acrylic and metal. The choice

of material will depend upon the desired permanence, the intended function, and the

design of the appliance.

PRIMARY TEETH

An avulsed primary tooth must not be replanted, because of the potential damage that it

may cause to the developing tooth germ Harding and Camp (1995), Andreasen and

Andreasen (1994),Garcia-Godoy and Pulver (2000). Reports on reimplanatation of

avulsed primary teeth, states that most of them were extracted 2-24 months later due to

complication such as abscess, mobility, and advanced root resorption.

In some cases reimplantation has been carried out in accordance with the requests of the

parents, in order to avoid the esthetic disorder associated with the absence of an upper

incisor at an early age.and found that , if the tooth was kept dry during the extraoral time ,

ankylosis may be anticipated due to necrosis of periodontal fiber following late

reimplantation of the primary teeth.

Weiger and Heuchert (1999) observed that internal and external enamel hypopasia and

dilacerations and arrested root growth, were rare findings.

It is important to keep it in mind that the intensity of injury may cause disturbances in

the developing tooth germ as well as the mechanical impact of the injured tooth

(depending on the child’s age at the time of injury.

Andreasen and Andreasen (1994) observed that when permanent incisors erupted, they

are affected by hypoplasia and by white or yellow brown opacity of the enamel and led to

the basis for recommendation that primary teeth are not reimplanted.

According to Harding and Camp (1995) avulsion that occur more than 2 years before the

date of natural exfoliation will result in delay of up to 2 years in the eruption of the

permanent tooth. Esienberg successfully replanted avulsed deciduous incisors

immediately after extra-oral root canal treatment although the tooth was not splinted and

remained functional for 3 years until physiologic exfoliation.

Ravn (1968) reports four cases of avulsed primary teeth, which were replanted and

remained immobilized for 4-6 weeks but root canal treatment was not carried out and

found that two of the observed teeth showed increased mobility and advanced root

resorption within the first year of replantation a third tooth was shed prematurely and

the fourth functioned for 2 years and 3 months. Mueller et al (1978) succeeded in

preserving an avulsed primary tooth that had been replanted by the father 1 min following

trauma, tooth was splinted for 2 weeks but was not treated endodontically.

Filippi et al (1994) proposed resecting the root of avulsed primary incisors and

completely incrementing the root canal system from retrograde prior to replantation and

that resection of the root apex prevents damage to the underlying tooth germ during

replantation.

Replantation is not considered in case of

A danger of aspiration

A retention problem

Inflammatory resorption and abscess formation.

when primary teeth are extracted as the result of an injury, a prosthetic replacement for

missing primary incisors can be constructed for esthetics if the parents insist.

A “pedi partial” may also be indicated if the child displays speech difficulties as the

result of not having a sufficient anterior tongue stop.

If the child starts a finger or tongue habit; prosthetic or habit appliance may be indicated.

Early loss of primary incisors either from avulsion or extraction only rarely causes space

loss.

Any one or a combination of the primary dentition and stances warrants the placement of

an anterior space maintainer

1. loss of an anterior tooth in a very young child (4 years of younger)

(2) loss of an anterior tooth in-patient with a Baume type II (crowed) primary dentition,

(3) loss of multiple adjacent anterior teeth.

The space maintainer may be fixed, in which case the second primary molars are banded

and artificial teeth are attached to a lingual arch wire (0-10 inch) with acrylic resin or a

removable acrylic space maintainer may be constructed. Construction of porcelain fused

to gold anterior bridge to replace a missing primary incisor can also be considered. Both

porcelain and gold are will tolerated by the gingival tissues; however, the cost of this

essentially temporary appliance may make it prohibitive to many dental patients. The

authors prefer a removable acrylic space maintainer. An acrylic appliance restoring the

lost tooth has good appearance. Restores function, maintains the space, and is usually

accepted by the patient. The principal disadvantage of this type of maintainer is its

susceptibility to loss or breakage by the young patient.

PEDIATRIC DENTISTRY V 29 / NO 1 JAN / FEB 07

PEDIATRIC DENTISTRY V 29 / NO 1 JAN / FEB 07

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