Avulsion

An avulsed tooth is completely displaced out of its socket; this trauma has also been referred to as an exarticulation. The length of extra-alveolar time determines both treatment procedures and prognosis. If the tooth has been left dry for less than 1 hour or kept in milk for no more than 4 to 6 hours, the protocol for treatment is described as “immediate” replantation; more than 1 hour of dry time is “delayed” replantation.

 

•Immediate Replantation

Replantation in the office must be preceded by a careful evaluation of the traumatized alveolus and the avulsed tooth.

1) Look for evidence, both clinically and radiographically, of alveolar fracture.

2) Inspect the alveolar socket for foreign bodies and debris, taking care not to scrape the bony walls.

3) The blood clot in the socket can be gently suctioned and the socket irrigated with saline.

4) Check the avulsed tooth for debris on the root; if such debris cannot be rinsed off with saline or water, gently pick it off with tweezers.

5) While inspecting the tooth, it can be held by the crown using gauze moistened in saline, which permits examination of the tooth without touching the root surface.

6) Gently insert the tooth into the socket.

7) The insertion should be slow and gentle so that pressure is minimized.

8) When the tooth is nearly in place, have the patient complete the process by biting on a piece of gauze.

9) Check occlusion. It is most important that it should not be in hyperocclusion. Such premature contact would delay or prevent recovery.

10) Need for splinting would depend on degree of mobility.

11) The physiologic splint should be left in place only long enough for the initial reattachment of periodontal ligament fibers; in most cases that can be expected to take place in 1 to 2 weeks, after which the splint should be removed.

12) Antibiotics should be administered for 5-7 days

13) Evaluate after 2 weeks and initiate endodontic therapy after 14 days. The exception to the rule of root canal therapy for avulsed teeth is when the tooth is still developing and has a wide open apical foramen. Such teeth have the potential for pulp revascularization.

•Delayed Replantation

The treatment for teeth with more than 1 hour of extra-alveolar time should include efforts to slow the inevitable replacement resorption.

1) Examine the avulsed tooth for debris. In contrast to avulsed teeth with less than 1-hour extra-alveolar time, those with more than 1 hour are not expected to retain the vitality of periodontal ligament cells and fibers.Therefore, it is best to remove pieces of soft tissue attached to the root surface.

2) Perform root canal therapy with the tooth in vitro. This can often be best accomplished by holding the tooth by the crown and proceeding with the endodontic treatment through an apical or coronal approach.

3) Apical approach involves resecting 2 – 3 mm of the root tip and completing extirpation, disinfection and obturtation procedures.

4) A coronal approach will involve greater destruction of tooth structure

5) Soak the tooth in a 2.4% fluoride solution acidulated at pH 5.5 for 20 minutes or more. The fluoride will slow the resorptive process.

6) The rest of the procedure mirrors the technique in immediate replantation.

7) Splint for 6 weeks.

• Protection of Root Surface

To reduce chance of replacement resorption you must ensure the following:

• Don’t allow the root to dry out since the periodontal ligament cells will necrose

• Storage media is important milk or tissue culture are the best media Saliva,Saline or Plastic Wrap are acceptable (avoid water)

• Replant/reposition immediately or as soon as possible.

• Physiologic splint to promote healing and prevent resorption due to disuse

To reduce chance of inflammatory resorption following two are required

a) Antibiotics are prescribed orally.

b) Endodontic treatment.