Permanent Trauma: Avulsion

Question 1

At what age is avulsion of permanent teeth most common and why?

Answer 1

In the young dentition when root development is incomplete and the periodontium is very resilient.

Question 2

What does replantation success depend on?

Answer 2

Extraalveolar period and extraalveolar handling.

Question 3

What are the requirements for optimal healing following avulsion?

Answer 3

• Tooth out of socket for minimal time possible
• Tooth stored in a physiologic medium (milk, saliva, saline or tissue culture media)
• Tooth reimplanted within 15 minutes for best chances, or 60 minutes maximum if in a storage medium

Tooth stored outside of the socket for longer than 60 minutes: all PDL cells likely to be non-viable. Poor prognosis.

Question 4

How long does it take for the gingivae, PDL and pulp to heal following avulsion?

Answer 4

• Gingival attachment: 1 week
• PDL revascularised: 2 weeks
• Pulp revascularised: 30-40 days (in a young person)

Question 5

What are suitable media for an avulsed tooth?

Answer 5

• Milk
• Saliva
• HBSS
• Saline

Water is better than letting the tooth dry out but not medium of choice.

Question 6

When should you not replant a tooth?

Answer 6

• Gross untreated caries that may indicate commitment to the necessary follow up won’t exist
• A pateint who cannot tolerate treatment under local anaesthetic
• Marked anterior crowding
• Prolonged dry storage of the avulsed tooth

Question 7

How long should you splint an avulsed tooth for?

Answer 7

2 weeks

Question 8

What 2 features should be considered when a patient presents within an avulsed tooth?

Answer 8

• Tetanus status (refer to GP to check vaccines are up to date)
• Antibiotics: recommended to prevent infection-related reactions and decrease occurence of inflammatory root resorption

Question 9

What follow up intervals should be followed?

Answer 9

• 2 weeks, 4 weeks, 3 months, 6 months, 1 year and then on an annual basis
• Monitor clinically and radiographically
• More frequent follow up for open apex teeth where spontaneous pulp space revascularisation is possible

Question 10

When observing teeth with open apices what signs and or symptoms indicate the need for endodontic intervention?

Answer 10

• Radiographic evidence of inflammatory resorption
• Absence of continued root formation

Question 11

Which permanent avulsed teeth with closed apices require endodontic treatment?

Answer 11

All of them.

Question 12

Describe endodontic treatment of mature teeth (closed apices) following avulsion.

Answer 12

Pulp extirpation started no later than 2 weeks after re-implantation.
The pulp will not revascularise.

Question 13

Describe endodontic treatment of immature teeth (open apices) following avulsion.

Answer 13

• May revascularise but needs close monitoring as resorption and pulp necrosis are common
• Should be reviewed more frequently due to the risk of infection related resoption and rapid loss of tooth and supporting bone when not detected

Question 14

What patient instructions should be given following an avulsion?

Answer 14

• Avoid contact sports
• Soft diet for 2 weeks
• Brush teeth with soft toothbrush
• Chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks