Trauma - Avulsion Flashcards
Classification of PDL injuries
Concussion, Subluxation, Lateral luxation, Extrusion, intrusion, Avulsion, DA #
Factors affecting avulsion prognsis
EADT, Storage medium, replanted
Advice for an avulsed tooth
Permanent - Hold by crown and clean with running water, replant gently
Storage medium - saliva, milk, blood
Immediate dental attendance
Factors that can alter management in avulsed tooth management
Permanent/ primary tooth, root development (open/closed apex), EADT - <60/>60MINS
AVULSION: CLOSED APEX - tooth replanted prior to dental attendance
- Tx
- Pt instructions
- Follow up
Treatment
Leave the tooth in place.
Clean the area with water spray, saline or chlorhexidine.
Administer local anethesia if necessary, preferably with no vasoconstrictor.
If the tooth were replanted in the wrong socket or rotated, reposition the tooth into the proper location up to 48 hours after the traumatic incident.
Suture gingival lacerations, if present.
Verify normal position of the replanted tooth both clinically and radiographically.
Apply a flexible splint for 2 weeks (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician for a tetanus booster.
Initiate root canal treatment within 2 weeks after replantation and before splint removal.
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-up
Root canal treatment within 2 weeks after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly after replantation and left for at least 2 weeks.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years.
AVULSION: CLOSED APEX <60min from injury
- Tx
- Pt instructions
- Follow up
The tooth has been kept in a physiologic storage medium or stored in non-physiologic conditions, the extra-oral time has been less than 60 minutes
Examples of physiologic or osmolality-balanced media are milk, saline, saliva or Hank’s Balanced Salt Solution
Treatment
Clean the root surface and apical foramen with a stream of saline, or gauze soaked in saline.
Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, preferably without vasoconstrictor.
Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks, keep away from the gingiva (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
Initiate root canal treatment within 2 weeks after replantation and before splint removal.
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-up
Root canal treatment within 2 weeks after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly after replantation and left for at least 2 weeks.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years.
AVULSION: CLOSED APEX>60mins
- Tx
- Pt instructions
- Follow up
Extraoral dry time exceeding 60 minutes or other reasons suggesting non-viable cells
Treatment
Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and cannot be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour. However, the expected possible outcome is ankylosis and resorption of the root and the tooth will be lost eventually.
Clean the root surface and apical foramen with a stream of saline, or gauze soaked in saline.
Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, preferably without vasoconstrictor.
Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks, keep away from the gingiva (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
Initiate root canal treatment within 2 weeks after replantation and before splint removal.
To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation has been suggested (2% sodium fluoride solution for 20 minutes).
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-up
Root canal treatment within 2 weeks after replantation. Place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly after replantation and left for at least 2 weeks.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years.
Delayed replantation has a poor long‐term prognosis. The periodontal ligament becomes necrotic and is not expected to regenerate. The expected outcome is ankylosis‐related (replacement) root resorption. The goal of replantation in these cases is to restore esthetics and function, at least temporarily, while maintaining alveolar bone contour, width, and height. Therefore, the decision to replant a tooth is almost always the correct decision even if the extra‐oral time is more than 60 minutes. Replantation will keep future treatment options open. The tooth can always be extracted later if needed, and at the appropriate point following a prompt inter‐disciplinary assessment. Parents should be informed that decoronation or other procedures such as autotransplantation might be necessary if the replanted tooth becomes ankylosed and infra‐positioned depending on the patient’s growth and the likelihood of tooth loss. The rate of ankylosis and resorption varies considerably and can be unpredictable.
AVULSION: OPEN APEX - reimplanted prior to attendance
- Tx
- Pt instructions
- Follow up
Treatment
Leave the tooth in place.
Apply local anesthesia, if necessary, preferably with no vasoconstrictor.
Clean the area with water spray, saline or chlorhexidine.
Suture gingival laceration, if present.
Verify normal position of the replanted tooth both clinically and radiographically.
Apply a flexible splint for 2 weeks (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, apexification, pulp revitalization/revascularization is recommended.
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-up
For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly for at least 5 years.
In immature teeth with open apices, there is a potential for spontaneous healing to occur in the form of new connective tissue with a vascular supply. This allows continued root development and maturation. Hence, endodontic treatment should not be initiated unless there are definite signs of pulp necrosis and infection of the root canal system at follow-up appointments.
AVULSION : OPEN APEX - <60mins
- Tx
- Pt instructions
- Follow up
Clean the root surface and apical foramen with a stream of saline.
Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, prefereably without vasoconstrictor.
Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Suture gingival lacerations, especially in the cervical area.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, apexification, pulp revitalization/revascularization is recommended.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the pulp space. The risk of infection-related root resorption should be weighed up against the chances of revascularization. Such resorption is very rapid in children. If revascularization does not occur, root canal treatment may be recommended.
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week
Follow-up
For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly.
AVULSION: OPEN APEX >60mins
- Tx
- Pt instructions
- Follow up
Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and cannot be expected to heal. The goal in delayed replantation is to restore the tooth to the dentition for esthetic, functional and psychological reasons and to maintain alveolar contour. The possible outcome will be ankylosis and resorption of the root.
Clean the root surface and apical foramen with a stream of saline.
Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
Administer local anesthesia, preferably without vasoconstrictor.
Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument.
Irrigate the socket with saline.
Replant the tooth slowly with slight digital pressure.
Suture gingival lacerations, especially in the cervical area.
Verify normal position of the replanted tooth clinically and radiographically.
Apply a flexible splint for up to 2 weeks (see more about Splinting in our Vocabulary).
Administer systemic antibiotics. Amoxycillin or penicillin is the first choice (for 7 days at the appropriate dose for the patient’s age and weight). Alternative antibiotics should be considered for patients with an allergy to penicillin.
If the avulsed tooth has been in contact with soil and if tetanus coverage is uncertain, contact a physician for a tetanus booster.
The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, apexification, pulp revitalization/revascularization is recommended.
To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to replantation is suggested (2% sodium fluoride solution for 20 minutes).
Patient instructions
Avoid participation in contact sports.
Soft food for up to 2 weeks.
Brush teeth with a soft toothbrush after each meal.
Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.
Follow-up
For immature teeth, root canal treatment should be avoided unless there is clinical or radiographic evidence of pulp necrosis.
Splint removal and clinical and radiographic control after 2 weeks.
Clinical and radiographic control after 4 weeks, 2 months, 3 months, 6 months, 1 year and then yearly.
Delayed replantation has a poor long‐term prognosis. The periodontal ligament becomes necrotic and is not expected to regenerate. The expected outcome is ankylosis‐related (replacement) root resorption. The goal of replantation in these cases is to restore esthetics and function, at least temporarily, while maintaining alveolar bone contour, width, and height. Therefore, the decision to replant a tooth is almost always the correct decision even if the extra‐oral time is more than 60 minutes. Replantation will keep future treatment options open. The tooth can always be extracted later if needed, and at the appropriate point following a prompt inter‐disciplinary assessment. Parents should be informed that decoronation or other procedures such as autotransplantation might be necessary if the replanted tooth becomes ankylosed and infra‐positioned depending on the patient’s growth and the likelihood of tooth loss. The rate of ankylosis and resorption varies considerably and can be unpredictable.
Healing outcomes: Periodontal and pulpal
Periodontal Outcomes • Regeneration • PDL/cemental healing • Bony Healing • Uncontrolled infection Pulpal Outcomes • Regeneration • Controlled necrosis (elective disinfection) • Uncontrolled infection
When NOT to implant a permanent tooth
If very immature apex and EAT> 90mins
(may still be best to replant)
• Child is immunocompromised
• The child has other serious injuries and
warrant preferential emergency treatment
and / or intensive care being dealt with.
Types of resorption
External surface
External Inflammatory
Internal Inflammatory
Replacement resorption/ankylosis
External surface and inflam resorption aetiology
External surface - excessive ortho force
External inflam - Damage to PDL - necrotic pulp tissue propagated via dentinal tubules. Progressive
Rg - indistinct root surface, intact RC tramlines
Treat - pulp extirpation, mechanical and chemical irrigation, NSCaOH - 4-6 weeks, obturate with GP
Internal inflammatory resorption aetiology
Non Vital pulp, progressive.
Rg - Indistinct RC tramlines, root surface intact
Treatment - Pulp extirpation, mechanical and chemical irrigation, NS CaOH for 4-6 wk then obturate with GP.
