AVULSION AND

RE-IMPLANTATION
DR SHABEEL shabeelpn@gmail.com
ETIOLOGY AND FREQUENCY
 Tooth avulsion
 (ex-articulation) implies total
displacement of the tooth out if
its socket.

 0.5% to 16% in permanent

dentition
 7 to13% in the primary dentition
 Permanent dentition –fights and
sports injuries
 Primary dentition – falls against
hard objects

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CLINICAL FINDINGS

 Maxillary central incisors are frequently

avulsed teeth , while lower jaw seldom affected
 Occurs in 7 to 9 years of age , when permanent
incisors are erupting-loosely structured
periodontal ligament surrounding erupting
teeth provides minimal resistance to an
extrusive force.
 Avulsion involves single tooth mostly
 Multiple avulsions occasionally encountered
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Radiographic findings

 Suspicion of bone fractures

 In primary dentition ,radiographs will often
reveal that a suspected avulsion is actually an
intrusion where the primary tooth is buried in
the jaw

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PATHOLOGY

 Divided into pulpal and periodontal reactions

 Healing reaction depend upon the extra

alveolar and extra alveolar handling

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PULPAL REACTIONS
Distinct pulpo-dentinal responses
which can occur after immediate
replantation have been classified
i. Regular tubular reparative dentin
ii. Irregular reparative dentin with
diminished tubular structures
iii. Irregular reparative dentin with
encapsulated cells
iv. Irregular immature bone
v. Regular lamellated bone or
cementum
vi. Internal resorption
vii. Pulp necrosis

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 Extensive pulpal
changes could be
obtained as early as 3
days after replantation .
 Damage observed in
coronal part of the pulp.
 Signs of healing were
seen within 2 weeks
after replantation.

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 Damaged tissue –
mesenchymal cells and
capillaries
 In border zone between
vital and necrotic tissue
, neutrophils and round
cells were present in
some cases

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 The healing process led to the formation of new
cell layer along the dentinal wall in the regions
where the odontoblasts had been destroyed.

 New hard tissue formation along the dentinal

walls was noted after 17 days , but it most cases
matrix formation started somewhat later.

 Gradually the cells along the pup walls began

to show similarities to odontoblasts with
cytoplasmic processes within the newly formed
matrix.
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 Severe 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.

 Mitoises were seen in

bands of schwann cells 14
days after replantation.
 Regenerating nerve fibers
were observed after 1
month.
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In microangoigraphic studies of the
revascularization process after replantationof
teeth in dogs ,it was demonstrated that in
growth of new vessels could be seen 4 days
after repalantation. After 10days vessels were
seen in the apical half of the pulp and after 30
days in the entire pulp.

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PERIODONTAL HEALING

 Coagulum is found between tow parts of severed

periodontal ligament
 Line of separation is often situated in the middle of
the periodontal ligament
 Proliferation of connective tissue cells soon occurs
3 to 4 days
 After 1 week the epithelium is reattached at the
cemento enamel junction – clinical importance , it
may imply a reduced risk gingival infection and
reduced risk of bacterial invasion
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 After 2 weeks , the split line in the periodontal
ligament is healed and collagen fibers are seen
extending from the cemental surface to the
alveolar bone . Resorption activity can now be
recognized

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Histological examination

 Healing with normal healing

 Healing with surface resorption
 Healing with ankylosis (replacement
resorption)
 Healing with inflammatory resorption

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Healing with a normal periodontal healing

 Complete regeneration of the periodontal

ligament usually takes place 2-4 weeks .
 Occur only if the inner most layers along the root
surface are vital.
 Normal periodontal ligament space without signs
of root resorption
 Clinically normal

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Healing with surface resorption
 Localized areas along the root surface which show
superfacial resorption lacunae repaired by new cementum
– surface resorption
 Self limiting – show s repair with new cementum
 Most resorption lacunae are superfacial and confined to
the cementum.
 Due to smaller size surface resorption are not disclosed
radiographically.
 Clinically normal

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Healing with ankylosis
 Ankylosis represents a fusion of the alveolar bone and root surface
and can be demonstrated 2 weeks after replantation .

 Etiology related to absence of a vital periodontal ligament cover

on the root surface.

 Replacement resorption develops in two different directions –

extent of the damage to the periodontal ligament cover of the root
–progressive resorption which gradually resorbs the entire the root

 Tansient replacement resorption in which a once established

ankylosis later disappears – possibly related to areas of minor
damage to the root surface .

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 Progressive resorption is elicted when the entire
periodontal ligament is removed before
replantation or after replantation.

 The ankylosed root becomes part of the normal

bone remodelling system and is gradually
replaced by bone . After some time , little of the
tooth substance remains . At this stage the
resorptive processes are usually intensified ,
along the surface of the root canal , a
phenomenon known as tunneling resorption

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 Radiographically –
disappearance of the
normal periodontal space
and continuous
replacement of root
substance with bone.
 Replacement resorption–
recognized
radiographically 2
months after replantation
; however in most cases
6 months for 1 year
elapses
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 Clinically – tooth is immobile and children
frequently infraposition
 Percusion tone is high , differing clearly from
adjacent tooth.
 In cases of TR - a small areas of periodontal
ligament space has disappeared.
 Dis appearence always happens within the first
year, is followed by the return of normal
percussion.
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HEALING WITH INFLAMMATORY
RESORPTION
 Histologically
 -bowl –shaped resorption cavities in cementum
and dentin associated with inflammatory
changes in the adjacent periodontal tissue.
 - consists of granulation tissue with lymphocytes
, plasma cells , and PMN
 Root surface under goes intense resorption with
numerous Howships lacunae and osteocalsts

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Pathogenesis
 Minor Injuries to the periodontal ligament and /or cementum
due to trauma or contamination with bacterial induce small
resorption cavities on the root surface , presumably in the
same manner as in surface resorption.

 If these resorption cavities expose dentinal tubules and the

root canal contains infected necrotic tissue , toxins from these
areas will penetrate along the dentinal tubules to the lateral
periodontal tissues and provoke an inflammatory response.

 This in turn will intensify the resorption process which

advances towards the root canal. The resorption process can
progressively very rapidly ie. Within a few months the entire
root can be resorbed.

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 Inflammatory resorption is especially
frequent and aggressive after replantation in
patients from 6 to 10 years of age. The
explanation for this probably a combination
of wide dentinal tubules and /or a the
protective cementum cover. In older age
groups , the resorption process is allowed to
progress and involve large areas of the root
surface , replacement resorption can take
over inflammatory resorption has been
arrested by endodontic therapy.

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 Radiographically , inflammatory resorption is characterized
by radiolucent bowl shaped cavitations along the root
surface with corresponding excavations in the adjacent bone
. the first radiographic sign inflammatory resorption can be
demonstrated as early as 2 weeks after replantation and
usually first recognized at the cervical third of the root. As
in the case ankylosis , this resorption type is usually evident
within the first 2 years after replantation.

 Clinically , the replanted tooth is losse and extruded.

Moreover t tooth is sensitive to percussion and percussion
tone is dull.
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Treatment of the
Avulsed tooth

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 Case history
-time interval between injury and replantation as well as
the conditions which the tooth has been stored.
(eg , saline , saliva, milk, tap water, or dry )
Periodontal healing of replanted dog teeth stored in milk and
egg albumen(dental traumatolgy 2009

 Commercial tissue culture medium(viaspan) could be used

for extra oral storage.

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 Examination for surface contaminants
 Examination of alveolus
 Pre treatment radiograph

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 Careful planning is of outmost important for
the success of replantation of avulsed teeth.

 Following conditions should be considered

- should be advanced periodontal disease
- socket should be reasonably intact
- extra alveolar period should be considered
ie. Extra alveolar period exceeding 1 hour are
usually associated with marked root resorption
.

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Replantation is decided upon following
procedures
 Placed in saline
 Root surface rinsed with saline to remove visible contaminants
 Alveolus rinsed with saline to remove coagulum
 No effort should be made to sterilize the root surface
 Socket is then examined for any evidence of fracture
 Local anesthesia not necessary unless gingival lacerations
require suturing or the alveolar socket.
 Tooth is replanted with minimal digital pressure
 Rigid splinting increases the extent of root resorption (acta
odontol scand 1975, 1981)
 Replanted teeth should , therefore only splinted for one week
to ensure adequate periodontal support , as gingival fibers are
already healed by this time.

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Decreased extra alveolar period
 Cleaned if dirty by rinsing in tap water and placing it
into the socket
 Animal experiments have shown that the storage in milk
or saliva has almost the same effect as storage in saline .
 Long term storage in tap water has adverse effect in
periodontal healing
 Patient should be instructed to keep the tooth in place
with either finger pressure or by biting on a
handkercheif
 Tetanus prophylaxis is important
 Experiment al studies have shown that systemic
antibiotics may lesson the resorption attack on the root
surface.

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Prolonged extra alveolar period
 Periodontal ligament can be assumed to be necrotic
 root surface should be treated with various substances
 Sodium flouride(Shulman lb , Gedalia Jdent reaserch 1973)
 Tetracycline (Selving –Acta odontal scand 1990)
 Stannous flouride
 Citric acid (Klinge - Acta odontal scand 1984)
 Hypochloric acid (nordenram-scand j dent research -1973)
 Calcium hydroxide(Mink –J Dent research -1968)
 Formalin
 Alcohol
 Diphosphantes (butcher- j dent research -1955)
 Indomethacin(walsh-asdc dent child- 1987)

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In case of closed apical foramen
 endodontic treatment should be performed prophylactically ,as pulp
necrosis can be anticipated.

 Recent experimental studies in monkeys have shown that extra oral

root fillings materials themselves apparently injure the periodontal
ligament. This could be 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.(Anderson JOE 1981 )

 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.
  

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When apical foramen wide open !
 If replantation has taken place within 3 hours
after injury it is justifiable to await
revascularization
 radiographic controls should be made 2 and 3
weeks after replantation- periapical ostetis seen
at this time
 If this occurs endodontic therapy is initiated and
calcium hydroxide introduced to eliminate the
periapical inflammation and arrest root
resorption .
 After a week endodontic procedure is proceeded

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 The incorporation of fluoride ions in the cementum layer has been found
to yeaild a root surface resistant to resorption. It has been suggested that
mature teeth with prolonged dry extra alveolar periods (ie greater then 1
hour ) be placed in a fluoride (2.4% of sodium flouride) at ph 5.5 solution
for 20 minutes prior to replantation
 
 Thereafter the root surface is rinsed with saline and the tooth replanted
and splinted for 6 weeks . the effect of this treatment seems to be 50%
reduction of the progression of root resorption of replanted human teeth

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Oooooooooooooouch!
Resorption of root ?

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Several attempts made

 Slicone grease and methyl metha acraylate

(Mink –J dent res-1968)
 Absorbable gel sponge(sherman-1968)
 Venous tissue
 Fascia and cutaneous connective tissue
Biocompatibility evaluation of alendronate paste in rat's
subcutaneous tissue

Dental traumatolgy 2009

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Replacement of the apical part

 Cast vitallium implant(quintessence int 1972)

 Ceramic implant , dense cintered aluminuim
oxide (kirschner – dental implants and
materials system -1980)

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Tooth survival

 In long term study , it was shown tooth

survival was significantly related to the stage
of root development at the time of injury,
being more favourable with increasing
developmental maturity

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Pulpal healing and pulp necrosis
 revasucalrization of the pulp will occur in replanted teeth with completed
root formation , provided that replantation is carried out immediately .

 pulps of teeth with incomplete root formation can become revascularized

if replantation is carried out within 3 hours .pulpal sensibility test are
unrelaile immediately after replanatation.

 Functional repair of pulpal nerve fibers in human teeth is established

approximately 35 days after replantation . at this time electrical stimuli
can elicit sensibility responses.

 In the absence of a reaction to electrical stimulation , it should be borne

in mind that a decrease in the size of the coronal part of the pulp chamber
or root canal on the radiograph is a more reliable sign of vital pulp tissue
thermal or electrical pulp testing

 The most significant predictors of pulpal healing appear to be the width

and length and type of extra alveolar storage .
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The width and length of the root
canal
 The relationship between tha diameter of the apical foramen and the
chance of pulpal revascularization apparently is an expression of
the size of the contact area at the pulpo-periodontal interface,
whereas the length of the root canal probably reflects the time
necessary to repopulate the ischemic pulp.

 With a favorable ratio apical foramen and short root canal versus a
narrow apical foramen and long root the odds for an intervening
pulpal infection are reduced.

 A limiting factor in pulpal revascularization after replantation

appears to be an apical diameter of under 1.mm . This size ,
however , is to a certain degree arbitrary, as pulp in teeth with
constricted apical foramina are usually extripated prophylactically.

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Storage period and storage media
 Non Physiologic storage
Eg. Prolonged tap water storage ,
chlorine
chlorhexidine
alcohol

Physiologic storage
eg. Saliva , saline or milk

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 The best media tested during research in
descending order were ViaSpan, Eagle’s
Medium, and Hank’s Balanced Salt Solution
HBSS).

 Despite the fact that ViaSpan and Eagle’s

Medium provide the best storage environment,
these media are not practical options. These
media are not readily available to school nurses
and are not packaged for individual uses. Despite
the time advantages, these media may be cost
prohibitive when compared to other options
available, for example, ViaSpan is $600 a gallon.
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 HBSS has unquestionably been the most tested
solution. Of the other suggested solutions (see
chart 1), the options that provide acceptable
storage have limited availability and the options
that are readily available are either far inferior to
HBSS or are actually damaging to the PDL cells.
 0.9% normal sterile saline has a compatible
osmolality with the PDL cells,but does not
contain any nutrients to help maintain cell
vitality. Therefore, sterile saline is only good as
a short-term storage medium for avulsed teeth
and should not be used if the tooth cannot be
reimplanted within 1 hour.
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 Milk has a compatible osmolalty with the PDL cells of an avulsed
tooth and has been tested as effective to store teeth for no more than
2-3 hours. Milk does not contain the necessary nutrients to maintain
the PDL cells for any longer periods of time.

 Additionally, there are issues related to the practicality of using milk

that severely impact its efficacy. Milk sounds, like an easy,
inexpensive method for storage, however, using milk is not as
effective as other media available and is logistically more difficult
than other, more effective options.

 For example, if a child avulses a tooth on a remote sports playing

field no milk will be readily available. Additionally, the milk needs to
be kept refrigerated during transport for the best prognosis. Therefore,
a school nurse should have a storage media that can be located at the
scene of any accident.

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 There is another commercially available
product marketed for the storage of avulsed
teeth called EMT ToothSaver, which contains
antibiotic-free protective medium.

 EMT ToothSaver has not been tested for

efficacy and does not have FDA approval nor
the ADA Seal of Acceptance. The
compatibility of EMT ToothSaver cannot be
known without research testing and therefore,
this media cannot be recommended.

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 Like water, saliva is not compatible with the
PDL cells. In addition to the damage the saliva
can cause to the cells, saliva also contains
bacteria that can cause the PDL cells to
become infected. Therefore, it is not
recommended to store teeth in neither a cup
with saliva nor in the mouth of the victim or
another person.

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 There have been some recommendations to use
tap water with a pinch of salt. Some believes
this recommendation to be a misunderstanding
of what HBSS and sterile saline are. HBSS is
not a saltwater solution, but a scientifically
designed researched fluid that contains all of
the essential metabolites and glucose necessary
for maintenance of cells. Adding salt to water
will create a solution that is damaging to PDL
cells.
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 HBSS is the author’s recommendation for the
optimal storage media for use in schools. HBSS,
found in Save-A-Tooth has been tested for efficacy
and is able to be kept in the school nurse’s office as
well as at sporting events without temperature
control methods. Hopefully, this article provides
information that will enable a school nurse to select
the best storage medium for avulsed teeth. This
selection can significantly affect the ultimate
prognosis for avulsed replanted teeth.

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 it appears that CW may be better alternative to HBSS or
milk in terms of maintaining PDL cell viability after
avulsion and storage.
(A quantitative analysis of coconut water: a
new storage media for avulsed teeth )..Velayutham Gopikrishna
MDSa, , , Toby Thomas MDSb and Deivanayagam Kandaswamy MDs
 (oooo 2008))

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 Comparison of coconut water, propolis,
HBSS, and milk on PDL cell survival.
 Gopikrishna V, Baweja PS, Venkateshbabu
N, Thomas T, Kandaswamy D.
 (joe 2008)

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 Viability of human fibroblasts in coconut
water as a storage medium
(IEJ-2009)
Coconut water was worse than milk in
maintaining human fibroblast cell viability.

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Decision tree in avulsed tooth

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Hanks balanced salt solution

 REAGENT COMPOSITION
 Potassium Phosphate 0.44 mM
 Potassium Chloride 5.37 mM
 Sodium Phosphate,
 Dibasic 0.34 mM
 Sodium Chloride 136.89 mM
D-Glucose 5.55 mM

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Periodontal healing and root
resorption
 Periodontal healing isn usually around 20%
 Clinical factors – dry extra alveolar period
seems to be the most crucial .
 In most clinical cases , avulsed teeth have
been stored either in the oral cavity or in other
media, such as physiologic saline or tap water,
before replantation.
 Recent experimental studies have indicated
that the storage media more than the length of
the extra alveolar period determine prognosis.

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Stage of root development
 The layer of PDL on the root can vary in thickness
from a single cell layer to the full thickness of a
periodontal ligament.
 Thus the more mature the root formation the thinner
is PDL tissue layer. This could possibly explain the
influence of root formation upon development of
root resorption found in a recent clinical study.
 Thus a thick periodontal ligament , which
supposedly can tolerate a certain dry period before
evaporation has killed the critical cell layers next to
the cementum , showed less dependence upon dry
storage
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Replacement resorption (ankylosis)
 Diagnosed clinically after 4- 8 weeks
 Mechanical device perio test register s the mobility
 Severity of ankylosis – initial damage of root surface , age
of the patient and type of endodontic treatment performed.
 young patient is that ankylosis can anchor the tooth in its
position and thus disturb normal growth of the alveolar
process.
 The result is a marked infraocclusion of the replanted
tooth with migration and malocclusion of adjacent teeth
 Treatment – extraction or luxation with orthododntic
extrusion

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Inflammatory resorption

 Can occur 3 months

after replantation
 Related to presence of
an infected pulp
 Arrest of resorptive
process cab be achieved
by appropriate
endodontic therapy

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Resorption by erupting teeth

 A special resorption is encountered when a replanted tooth

comes into contact with an erupting tooth, as when a
lateral incisor lies close to the path of an erupting canine.
 
 Apparently the pressure , exerted by the follicle of the
erupting tooth initiates or accelerates root resorption .

 A method to minimize the risk of resorption from the

erupting tooth could be early removal of the primary
predecessor in order to facilitate eruption , possibly in a
direction away from the replanted tooth .
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Root development and disturbances
in root growth
 Root growth

 Continued root development can occur especially

if the pulp has become totally revascularized .
However root development can continue despite
pulp necrosis. root development is partially or
completely arrested and the root canal becomes
obliterated or bone and PDL can invade the pulp
chamber which in some cases can lead to an
ankylosis

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Phantom roots
 A rare complication to avulsion of immature permanent
teeth is the formation of an abnormal root structure at the
site of tooth loss.

 The explanation for this appears to be that pulp tissue and

Hertwigs epithelial root sheath remain in the alveolar
socket after avulsion.
 These tissues resume their formative function after injury.
New dentin is formed by the odontobalsts and the
hertwigs epithelial root sheath initiates root development.
 A parallel to this is the tooth like structures occasionally
formed when natal or neonatal teeth are extracted and
dental papilla is left situ.
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Complications due to early loss of
teeth
 Malformation in the developing dentition
disturbance In the development of
permanent successors
 Space loss -.
a delay in eruption of the succeeding
incisors of approximately 1 year is generally
found if the loss has occurred at an early stage
of development . unless the time of loss is
close to the normal time of shedding ,
premature eruption of permanent successors is
rare.
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 Thank you

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