this lecture is about how to deal with tooth avulsion from the onset of trauma until the complete management in a form of informative case presentation

1. Tooth avulsion

2. Difinition
2
Tooth avulsion (exarticulation, total luxation) implies total displacement of the
tooth out of its socket.

3. etiology
3

4. An 11-year-old schoolboy has avulsed a permanent
incisor tooth A child has slipped in the school
playground and knocked out a front tooth. The
accident happened less than 5 minutes ago, the
tooth has been found and it is wrapped in a tissue..
4
Chief compliant
.

5. 5
any loss of
consciousness ?.
Disorientation and impaired
response to simple questions may
indicate a brain injury that would
require immediate hospital
assessment.
NO

6. • Reimplantation of an avulsed tooth is
contraindicated in a child predisposed to infective
endocarditis.
• Any known clotting defect could result in
problematic bleeding from a tooth socket.
6
medical history
.
Our patient was
fit and well

7. 7
Are there any
other injuries?.
Limb extremity injuries are common in playground
accidents, and the mother should be asked to
establish whether there is any suspicion of limb
fracture or lacerations that require suturing. Dealing
with these might be a higher priority than the
avulsed tooth.
Just simple scratches on
the skin of hand and leg

8. Are there any other injuries?
8

9. Tetanus prophylaxis should always be considered in the
case of contaminated wounds. In a previously
immunized patient (i.e. longer than 10 years previous
to injury), a dose of 0.5 ml tetanus toxoid should be
given (booster injection). In unimmunized patients,
passive immunization should be provided.
9
tetanus
immunization?
.
yes

10. 10
What age is
the child? .
The age will determine whether the
tooth is primary or permanent and, if
permanent, the likely stage of root
development.
Our patient was 11
years old

11. Where do you store the tooth??
.

12. • The saline solution provides osmolality of 280 mOsm/kg
and despite being compatible to the cells of the
periodontal ligament, it lacks essential nutrients necessary
to the normal metabolic needsof the cells of the
periodontal ligament. saline solution was harmful to the
cells of the periodontal ligament in avulse teeth if it is
used for longer than two hours.
Salinesolution:

13. – It is an unacceptable storage media for
avulsed teeth.
–human PDL cells stored in tap water for 1
hour caused more PDL cell damage than the
other physiological and nonphysiological
storage media tested.
– They attributed the increased cell damage to
the cells lysis caused by the very low
osmolarity of tap water.
Tapwater:
13

14. Saliva:
– It can be used as a storing medium for a short period of time, Its osmolality is much
lower than the physiologic saline (60–70 mOsm/kg), thus it boosts the harming effects of
bacterial contamination.
– Its only advantage is it availability.
Saliva:
14

15. The American Association of Endodontics indicate milk as a solution for avulsed teeth, for
keeping the viability of the human cellular periodontal ligament.
– Milk is significantly better than other solutions for its physiological properties, including
pH and osmolality compatible to those of the cells from the periodontal ligament; but it is
important that it is used in the first 20 minutes after avulsion.
– The favorable results of milk probably occur due to the presence of nutritional
substances, such as amino acids, carbohydrates and vitamins.
– The pasteurization of milk is responsible for diminishing the number of bacteria and
bacteriostatic substances, also for the inactive presence of enzymes, which could be
potentially harmful to the fibroblasts of the periodontal ligament.
milk as an excellent storing solution for 6 hours, however, milk cannot revive the
degenerated cells.
Milk:
15

16. It is a standard saline solution that is widely used in biomedical research to
support the growth of many cells types.
This solution is nontoxic, it is biocompatible with periodontal ligament cells
It is composed of sodium chloride, Dglucose; potassium chloride; sodium
bicarbonate;sodium phosphate; potassium phosphate; calcium chloride,
magnesium chloride and magnesium sulfate.
It contains ingredients, such as glucose, calcium and magnesium ions which
can sustain the depleted cellular components of the periodontal ligament
cells.
It is commercially available as Save-ATooth which has an inner net to receive
the avulsed tooth and to minimize cell trauma during transport.
Hank’sbalancedsaltsolution:
16

17. The patient’s mother stored the
tooth in the saliva
.

18. 18
.
Radiographic
examination
Radiographic Features
• Empty socket or contain
sharp object
• Associated bone fractures.

19. 19
When ????.
Short extra-alveolar storage:
This is done if the tooth since
the time of injury has been placed in
a suitable medium and the extra-
alveolar time elapsed is short.
Long extra-alveolar storage:
This is done in cases where the
extraoral dry period of tooth is long
The trauma occurred 5
mintues ago and the
tooth stored in saliva

20. Short extra-alveolar storage:
20
Give local analgesia.
Replant the tooth.
Holding the crown either in fingers or forceps, rinse
the root surface with sterile saline then swiftly and
gently replace the tooth in the socket, applying
sufficient pressure in an apical direction to position
the tooth as near to its original position as can be
estimated. The child should then bite firmly on a
carefully positioned gauze roll to hold it in position.
The socket
Irrigate the socket with sterile isotonic saline
to remove blood clot

21. Splint the tooth
• The most practical type of splint is a short
length of stainless steel wire cemented on to
the labial surface of the replanted tooth and
adjacent incisors with blobs of acid-etch
retained composite
• it must be passive and flexible to avoid exerting
orthodontic forces.
• It is important to keep the splint well away
from the gingival margin to allow access for
oral hygiene because bacterial ingress into the
wounded periodontal ligament can
significantly compromise healing.
• The splint should be left inplace for 7–10 days.
Rigid splinting for longer periods increases the
chances of ankylosis.
Short extra-alveolar storage:
21

22. • Prescribe antibioticsand pain killer: A 7-day course of oral systemic antibiotics should be
prescribed to cover the immediate postimplantation period.
• Prescribe chlorhexidine mouthrinse (0.12%) twice daily during the splinting period to
help to keep the area clean and reduce the bacterial flora around the injured periodontal
ligament.
• Give dietary advice. A soft diet should be recommended during the splinting period,
avoiding foods that require incising.
instruction
22

23. Long extra-alveolar storage:
23

24. Immaturetooth
24

25. Immaturetooth
25
Pulpal healing in three replanted incisors after a long extra-alveolar period of 2 minutes dry and 88 minutes in
saline in an 8-year-old boy. 1995.

26. Immaturetooth
26

27. Immaturetooth
27

28. prognosis
28

29. Histologically, this type of healing is characterized by localized areas along the root surface,
which show superficial resorption lacunae repaired by new cementum. This surface
resorption presumably represents localized areas of damage to PDL or cementum, which is
healed by PDL, derived cells. Clinically, the tooth is in normal position and a normal
percussion tone can be heard.
HealingwithSurfaceResorption
29

30. HealingwithSurfaceResorption
30
Surface resorption of a replanted right central incisor. Note the superficial appearance on the root and
sparse involvement on the lamina dura. The resorption cavity is stationary during the entire observation
period.

31. • replacement resorption. Following ankylosis, the tooth becomes fused to bone and is
remodelled and progressively replaced by bone as part of the process of normal bone
turnover. No treatment
HealingwithAnkylosis(ReplacemenResorption)
31

32. Healing with Ankylosis
(Replacemen Resorption)
32

33. HealingwithInflammatoryResorption
33

34. HealingwithInflammatoryResorption
34

35. 35

36. references
36

37. 37