AVULSION AND RE-IMPLANTATION

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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, Eagles Medium, and Hanks Balanced Salt Solution HBSS).
Despite the fact that ViaSpan and Eagles

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 authors 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 nurses 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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