This document summarizes avulsion, which is the complete displacement of a tooth from its socket due to trauma. It discusses the classification, epidemiology, occurrence, diagnosis, treatment, healing and pathology, storage media, and references for avulsion. Key points include: - Avulsion most commonly occurs in maxillary central incisors of children aged 7-9 years. - Immediate replantation within 60 minutes of avulsion and use of storage media like Hank's Balanced Salt Solution that maintain viability of periodontal ligament cells is ideal for successful healing. - Treatment involves cleaning and splinting the replanted tooth with follow-up including antibiotics and endodontic therapy if needed. Complications include

1. AVULSION
-BY
ANKITA KHANDELWAL
2ND YEAR POST GRADUATE
DEPARTMENT OF PEDODONTICS

2. TRAUMA

3. WHAT IS AVULSION????
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4. CLASSIFICATION:
ELLIS AND DAVIES (1960)
- Class 5: Tooth loss due to trauma
PULVER’S Classification
• Class V
– Division II: Partial Avulsion
– Division III: Complete avulsion
WHO Classification
Exarticulation (Complete Avulsion) N 873. 68

5. ETIOLOGY:

6. EPIDEMIOLOGY:
Boys: 31-40%
Girls: 16-30%
Boys: 12-33%
Girls: 4-19%
2-4 years &
9-10 years
2-3 years
Acc to Andreasen: Prevalence of dental injuries varies from
4-14%

7. OCCURRENCE:
Permanent dentition:- 0.5-16%
Primary dentition:- 7-13%
Max Central Incisors is most affected
Often in children from 7 to 9 years when permanent incisors
are erupting.- (loose pdl structures)
Mostly involves single tooth

8. DIAGNOSIS:
WHEN
BITE
DISTURBANCE

9. CLINICAL EXAMINATION?
• Recording of extraoral wounds and palpation
of the facial skeleton
• Recording of injuries to oral mucosa or
gingiva
• Examination of the tooth crown for presence
and extent of fractures
• Palpation of the alveolar process

10. TREATMENT
AT THE SITE OF ACCIDENT

12. TREATMENT
AT THE CLINIC

13. TREATMENT
Case history
Time lapse
Storage media
and time
Examination of
avulsed tooth,
alveolus and
other injury
Prognosis

14. IDEAL REQUIREMENTS
REPLANTATION
No periodontal
disease
Socket should
be intact
Extra -alveolar
period
Stage of root
development

15. EXTRA-ALVEOLAR PERIOD
PDL
cells
Most likely viable
(tooth replanted
immediately)
May be viable but
compromised
(dry time <60
min)
Non viable
(dry time
>60min)

16. CLOSED APEX OPEN APEX
REPLANTATION
PRETREATMENT
WITH TETRACYCLINE
REPLANTATION PROCEDURE

17. CLOSED APEX
• Leave the tooth in place
• Clean the area
• Suture gingival lacerations
• Verify the normal position of
replanted tooth
• Apply flexible splint
TOOTH HAS BEEN REPLANTED BEFORE THE
PATIENTS ARRIVAL AT THE CLINIC

18. SPLINTING
Rigid or flexible device that maintains in position a
displaced or movable part
1. Rest
2. Redistribution of
forces
3. Preservation of arch
integrity
4. Restoration of
functional stability
5. Psychological well-
being

19. SPLINTING PROCEDURE
ACID ETCHING APPLICATION OF BONDING AGENT
WIRE PLACED ON COMPOSITECURING

20. • Administer systemic antibiotics
• Check tetanus protection
• Give patient instructions
• Initiate RCT 7-10 days after replantation and
before splint removal
• Follow up
1. Avoid participation in contact
sports
2. Soft diet for upto 2weeks.
Thereafter normal function
as soon as possible
3. Brush teeth with soft
toothbrush after each meal
4. Use a CHX (0.1%) mouth
rinse twice a day for 1 week

21. If root canal therapy was initiated, complete within 1 month.
OR
If patient does not present until >2 weeks after trauma and/or
if radiographic resorption is present:
• Pulpectomy/debridement as soon as possible.
• Long-term calcium hydroxide therapy/slurry and change
every 3 months.
• Complete root canal therapy when periodontal
ligament/lamina dura is observed/healthy.
Follow-up: 1 week, 1 month, 3 months, 6 months, 12
months, and annually for 5 years.

22. Tooth kept in storage media and
<60min
CLEANING
TOOTH IMMERSED
IN SALINE ADMINISTER LA
IRRIGATE SOCKET
WITH SALINE
REPLANTATION WITH
SLIGHT DIGITAL PRESSURE
1. Suture gingival lacerations
2. Verify the normal position of
replanted tooth
3. Apply flexible splint
4. Administer systemic
antibiotics
5. Check tetanus protection
6. Give patient instructions
7. Initiate RCT 7-10 days after
replantation and before splint
removal
8. Follow up

23. DRY TIME >60 MINS
POOR PROGNOSIS
GOAL -
AESTHETICS
ANKYLOSIS

24. PROCEDURE
REMOVAL OF
CONTAMINATED
COAGULUM
1. Administer LA
2. Irrigate Socket with saline
3. Examination Of Alveolar Socket
4. Replantation Of Tooth
5. Suture Gingival Lacerations
6. Verify Normal Position Of The Tooth
7. Stabilize The Tooth For 4 Weeks
Using Flexible Splint
8. Administration Of Systemic
Antibiotics
9. Check Tetanus Protection
10.Give Patients Instruction
11.Follow Up
RCT
FLUORIDE
TREATMENT
2% NaF for 20 mins

25. OPEN APEX
1. Leave the tooth in place
2. Clean the area
3. Suture gingival lacerations
4. Verify the normal position of
replanted tooth
5. Apply flexible splint(2 weeks)
6. Administer systemic antibiotics
7. Check tetanus protection
8. Give patient instructions
9. Revascularization. If not then RCT
10. Follow up
TOOTH HAS BEEN REPLANTED BEFORE THE PATIENTS ARRIVAL AT THE
CLINIC

26. • Monitor every 4 weeks + pulp test + radiographs.
• Ideal outcome: revascularization and/or apexogenesis occurs
over the next 12 to 18 months.
• Alternative outcomes:
– Initiate apexification with mineral trioxide aggregate (MTA) or
calcium hydroxide or root canal therapy if clinical and/or
radiographic pathology presents.
– Consider decoronation procedure when clinical infraposition of the
tooth appears and/or clinical and radiographic findings of ankylosis
manifest.
• Follow-up: 1 week, 1 month, 3 months, 6 months, 12 months,
and annually for 5 years.

27. Tooth kept in storage media and
<60min
Clean the root surface and apical foramen with stream of saline
Topical application of antibiotics
Administer LA
Examine the alveolar socket
Remove the coagulum in the socket and replant the tooth slowly with slight
digital pressure

28. Suture gingival lacerations
Verify normal position of replanted tooth
Apply flexible splint (2wks)
Administer systemic antibiotics
Check tetanus protection
Give patient instructions
Follow up

29. DRY TIME >60 MINS
POOR PROGNOSIS
GOAL -
AESTHETICS
ANKYLOSIS

30. PROCEDURE
REMOVAL OF
CONTAMINATED
COAGULUM
1. Administer LA
2. Irrigate Socket with saline
3. Examination Of Alveolar Socket
4. Replantation Of Tooth
5. Suture Gingival Lacerations
6. Verify Normal Position Of The Tooth
7. Stabilize The Tooth For 4 Weeks
Using Flexible Splint
8. Administration Of Systemic
Antibiotics
9. Check Tetanus Protection
10.Give Patients Instruction
11.Follow Up
RCT
FLUORIDE
TREATMENT
2% NaF for 20 mins

31. HEALING AND PATHOLOGY
PULPAL
REACTION
PERIODONTAL
REACTION

32. PULPAL REACTIONS

33. PERIODONTAL HEALING
REACTIONS
Replantation
Coagulum
Proliferation of connective tissue
Epithelium reattached to CEJ
Splicing of gingival collagen fibres

34. Infrabony fibres uniting
1st superficial osteoclast attack seen along root surface
After 2 wks Split line in PDL healed
Resorption activity recognized along root surface

35. DIFFERENT HEALING MODALITIES
IN PDL
Healing
with normal
PDL
Healing
with surface
resorption
Healing
with
ankylosis
Healing with
inflammatory
resorption

36. HEALING WITH NORMAL PDL

37. HEALING WITH SURFACE
RESORPTION
•Not progressive
•Self limiting
•Repair with
new cementum
•Repair related resorption

38. HEALING WITH ANKYLOSIS
REPLACEMENT RESORPTION
PROGRESSIVE
REPLACEMENT
RESORPTION
TRANSIENT
REPLACEMENT
RESORPTION
TUNNELING
RESORPTION

39. HEALING WITH
INFLAMMATORY RESORPTION
INFECTION – RELATED RESORPTION

40. STORAGE MEDIA
Preserving
cellular PDL
Promotes
mitogenicity
Non toxic
Preserve
functional
capabilities
Osmolality:
290-330
mOsm/L
ph:
6.6-7.8

41. TYPES OF STORAGE MEDIA:

42. TAP WATER
•Shorter Period
Of Time
•No Alternative
•Hypotonic
•Rapid Lysis Of
Cells
Pileggi R, Dumsha TC, Nor JE. Assessment of post traumatic PDL cell viability by a novel
collagenase assay. Dent Traumatol 2002;18:186-189

43. SALINE SOLUTION
•Similar Osmolality
(280mOsm/Kg)
•No Growth Products
•Unable to maintain
metabolism of
Fibroblasts
•Storage Period:
•Upto 30 Mins With 80%
Cell Viability
Bazmi BA, Singh AK, Kar S, Mubtasum H. Storage media for avulsed tooth – a review. Ind J
Multidis Dent 2013;3(3):741-749.

44. SALIVA
•Shorter period of time
•Immediately avaliable
•Better than dry storage or
tap water
•osmolality (60-70 mOsm/kg)
•Damage to pdl cells
•Presence of microorganisms
Vineet IS Khinda, Gurpreet Kaur, Gurlal S Brar, Shiminder Kallar, Heena Khurana. Clinical and Practical Implications of
Storage Media used for Tooth Avulsion. International Journal of Clinical Pediatric Dentistry, April-June 2017;10(2):158-165

45. MILK
CONTENTS OF SIGNIFICANCE:
•Amino acids
•Carbohydrates
•Essential nutrients
Low fat milk preferrable
Better than saliva and tap water
Vineet IS Khinda, Gurpreet Kaur, Gurlal S Brar, Shiminder Kallar, Heena Khurana. Clinical and
Practical Implications of Storage Media used for Tooth Avulsion. International Journal of Clinical
Pediatric Dentistry, April-June 2017;10(2):158-165

46. GATORADE
CONTENTS OF
SIGNIFICANCE:
Electrolytes
•Sports beverage
•Harmful osmolality
•Destroys pdl cells
•Short term storage upto 20 mins
Malhotra N, Cyriac R, Acharya S. Clinical implications of storage media in dentistry: a review.
Endo (Lond Engl) 2010 Sept;4(3):179-188.

47. COCONUT WATER
CONTENTS OF SIGNIFICANCE:
Vitamins, Minerals, Amino Acids,
Carbohydrates, Enzymes, Antioxidants
Similalr osmolality to body fluids
Increases mitogenicity
Economical & easily available
STORAGE PERIOD LIMIT:
Upto 8 hrs with pdl cell viability
comparable to HBSS

48. CONTACT LENS SOLUTION
• Essentially saline
solution
• Osmolarity is
damaging to pdl
• Cannot be
preferred

49. HANK’S BALANCED SALT SOLUTION
CONTENTS OF SIGNIFICANCE:
• NaCl, glucose, KCl, NaHCO3,
NaPO4, CaCl, MgCl, MgSO4
• Recommended by AAE
• Preserves and reconstitutes PDl cells
• Not easily available
STORAGE PERIOD LIMIT:
• Extensive – upto 72 to 96 hrs with
maximum cell viability

50. PROPOLIS
CONTENTS OF SIGNIFICANCE:
Resin(55%)
Essential oils
Amino acids, minerals, ethanol, vit A, B complex, E and bioflavon
Better
preservation
of root
cementum
layer
STORAGE PERIOD
LIMIT:
Upto 45 mins with
90% viability

51. VIASPAN
Osmolality=320mOsm/kg
pH =7.4
•High Cost
•Short Vitality Expiration, And
•Difficulty In Its Availability

52. EAGLE’S MEDIUM
• Contents of significance:
Amino acids, vitamins, bicarbonates
• Pdl cells proliferated
• Not practical
• Storage period limit:
Upto 60 mins after transfering from
primary media with 90% viability

53. EMDOGAIN

54. EGG WHITE
Osmolality: 251 to
298 mOsm/kg.
Better than milk
STORAGE
PERIOD LIMIT:
Upto 6-10 hrs

55. REFERENCES
• Textbook And Color Atlas of Traumatic injuries of the Tooth.
Andearson, 4th edition
• Textbook Of Pediatric Dentistry, Shobha Tandon, 2nd Edition
• Textbook Of Pediatric Dentistry, Nikhil Marwah, 2nd Edition
• L. Leelavathi1, R. Karthick, S. Leena Sankari N. Aravindha
Babu. Avulsed Tooth – A Review. Biomedical & Pharmacology
Journal.2016;Vol. 9(2), 847-850.
• Dental trauma guidelines. IADT, 2012.
• Badruddin Ahmed Bazmi, Anil Kumar Singh, Sudipta Kar1,
Hajara Mubtasum. Storage Media for Avulsed Tooth – A Review.
Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 3,
May-July 2013

56. • Vineet IS Khinda, Gurpreet Kaur, Gurlal S Brar, Shiminder
Kallar, Heena Khurana. Clinical and Practical Implications of
Storage Media used for Tooth Avulsion. International Journal
of Clinical Pediatric Dentistry, April-June 2017;10(2):158-165.
• Lars Andersson ,Jens O. Andreasen, Peter Day, Geoffrey
Heithersay, Martin Trope, Anthony J. DiAngelis,David J. Kenny,
Asgeir Sigurdsson, Cecilia Bourguignon, Marie Therese Flores,
Morris Lamar Hicks, Antonio R. Lenzi, Barbro Malmgren, Alex
J. Moule, Mitsuhiro Tsukiboshi. Guidelines for the
Management of Traumatic Dental Injuries: 2. Avulsion of
Permanent Teeth, Dental Traumatology 2012;28:88-96

57. • Decision Trees For Management Of An Avulsed permanent
Tooth. American Academy Of Pediatric Dentistry. Reference
Manual; V37 / No 6;15 / 16