Trauma 3 - Avulsion

Question 1

What is avulsion?

Answer 1

Complete displacement of tooth from socket

Separation of PDL + exposure of root surface

Question 2

What are some critical factors for avulsion replantation?

Answer 2

1. Extra-alveolar dry time - EADT
2. Extra-alveolar time - EAT
3. Type of storage medium

Question 3

What is EADT?

Answer 3

Time that tooth is out of the mouth before it was placed in a storage medium
(should be less than 30 mins or the cells will become non-viable)

Question 4

EADT time frame (2)

Answer 4

Should be less than 30 mins or the cells will become non-viable

Increases chance of PDL healing + cementum

Question 5

What is EAT?

Answer 5

Time tooth was out of socket, including the time was in the storage medium

Question 6

EAT time frame

Answer 6

Should be less than 60 mins or the tooth will become non-viable even if stored in a medium

Question 7

What happens to a tooths prognosis if it exceeded EADT + EAT time frame?

Answer 7

Not much chance of PDL healing

Need for bony healing

Question 8

Protocol if a patient attends with the tooth already replanted (3)

Answer 8

> Don’t remove
Leave it and follow instructions regarding splinting
Radiograph to establish status of root development

Question 9

List some public advice for an avulsed tooth (4)

Answer 9

1. Hold by crown
2. Wash in cold running water
3. Replace in socket + child bites on tissue
   OR
   Store in milk/saliva/saline
4. GET TO DENTIST

Question 10

Periodontal healing outcome post avulsion if tooth placed back into socket

Answer 10

Regeneration

Question 11

Periodontal healing outcome if tooth wasn’t placed back into socket ASAP

Answer 11

PDL/Cemental healing

Question 12

What can uncontrolled healing after avulsion lead to the production of? (3)

Answer 12

1. Granulation tissue
2. Infection
3. Abscess

Question 13

Pulpal outcomes post avulsion for an open apex

Answer 13

Regeneration - as the pulp is really wide and has more nerves coming the area

Closed apex has 1 vessel 1 nerve coming in so once ripped its less likely to regenerate

Question 14

Why would you conduct a controlled necrosis?

Answer 14

When you know the tooth is going to become non-vital

You can take the live bit out before it dies or causes infection

This stops an uncontrolled infection that leads to a necrotic pulp

Question 15

Tx for EAT<60mins and stored in medium closed apex

Answer 15

Chance of cement/PDL healing

1. Replant tooth under LA
2. Flexible splint for 14 days
3. Consider antibiotics and check tetanus status
4. After replantation + splinting, carry out pulp extirpation ideally 0-10 days unless apex is open (immature root)
5. Following extirpation + disinfection, place an antibiotic steroid paste as intra-canal medicament (leave in for 2 weeks)
6. Remove splint after 14 days
   - At 2 weeks clean + replace intracranial medicament with NSCaOH
7. Obturation with GP should take place within 4-6wks
   - Teeth with an open apex may revascularise

Question 16

Tx for EAT <60mins open apex

Answer 16

Immature open apex

If decision made not to RCT it must be closely monitored clinically + radiographically for signs of continued growth vs loss of vitality

REVIEW INTERVAL
2wks (splint removal)
4 wks
2 mths
3 mths
6 mths 
Yearly

Question 17

Course of action if tooth found to be non-vital and immature?

Answer 17

Extirpate pulp + refer

Question 18

Review timeframe for EAT <60mins closed apex

Answer 18

3mths
6mths
12mths
yearly

Question 19

Tx for EAT> 60mins closed apex

Answer 19

Unlikely to get PDL healing
Aim for bony healing by ankylosis

1. Scrub root clean of dead PDL cells
2. Extra-oral endodontics can be carried out prior to replantation
3. Replant tooth under LA
4. Splint: 4 weeks flexible splint
5. Consider antibiotic prescription

If extra-oral ends not carried out extirpate at 7-10days and use NSCaOH as initial intra-canal medicament for 4wks prior to obturation with GP

Question 20

Tx for EAT > 60 mins + open apex

Answer 20

Unlikely to get PDL healing
V small chance pulp will revascularise
Do not RTx unless signs of loss of vitality on follow up

1. Replant tooth under LA
2. Flexible splint for 4 weeks
3. Consider antibiotics
4. Check tetanus status
5. Monitor closely for signs of necrosis vs continued root development

Question 21

Review interval for >60mins EAT + open apex

Answer 21

2 weeks
4 weeks (splint removal)
2months
3months
6months
yearly

Question 22

When should replanting be avoided?

Answer 22

Immunocompromised
Other serious injuries that are priority

Usually even as a temporary space maintainer replanting is advised to help guide position of the adjacent erupting tooth

Question 23

Course of action if pulpal necrosis detected in open apex teeth?

Answer 23

Pulp extirpation to avoid inflammatory resorption