- Avulsion of permanent teeth most commonly involves maxillary central incisors in children ages 7-9 years old when they are erupting. Boys experience avulsion more than girls. - If a tooth is avulsed, it should be replanted immediately if clean or cleaned and replanted. It is important to replant the tooth within 10 minutes for the best prognosis. - After replantation, the tooth should be splinted for 10-14 days and the patient should receive antibiotics and follow up dental treatment which may include root canals or monitoring depending on the maturity of the root.

1. Avulsion of Permanent tooth
Rasha Adel Ragab
Assistant Lecturer-Cairo University

2. • Occurrence: Most commonly
a maxillary central incisor
• Sex: Boys 3 times more frequent than Girls
• Age: commonly in children 7 to 9 years of age
when permanent incisors are erupting
Andreasen suggests that the loosely
structured periodontal ligament
surrounding the erupting teeth
favors complete avulsion.
(McDonald's and Avery, 2011)

4. First Aid Advice
• Parents,
• Caregivers and
• Teachers

7. Information can be given over the telephone

8. • Keep the child calm.
• Do not allow the child to eat or drink.
If sedation or anaesthesia is required for extensive
injuries, then the child may need to be fasted.

9. Locate the tooth and hold by the
crown only.
check the patient’s clothing

10. Replant the tooth immediately if clean.
If the tooth is dirty, it should be washed
preferably with milk if available, otherwise
saline or the patient’s saliva. As a last resort,
very briefly rinse under cold water
(10 seconds only)

11. Hold the tooth in place by biting gently on a
handkerchief or clean cloth, or use aluminium
foil or similar and seek urgent dental treatment.

12. If unable to replant the tooth, store it in isotonic
media to prevent dehydration and death of the
periodontal ligament cells. Use:
 Milk (the preferred solution)
 Saline.
 Neither Saliva.
water nor saliva is as good as milk or saline, if the
tooth must be stored for a long period (more than 30 minutes
 HBSS
before replantation).
Because water is hypotonic, its use leads to rapid cell lysis
A commercial product designed specifically for storing avulsed teeth is the
Emergency and Medical increased Treatment inflammation Toothsaver (EMT on Toothsaver;
replantation.
SmartPractice, Phoenix, Ariz). The system includes an appropriate
container for storage and transport of the tooth while immersed in a Ph
balanced cell culture fluid (similar to Hanks balanced salt solution). This
product has a 2-year shelf-(McDonald's life without and refrigeration.
Avery, 2011)

13. Seek urgent dental treatment

14. Time is essential! The long-term
prognosis of the tooth is severely reduced
after 10 min of being dry and out of the
mouth.
Do not waste time searching for an ideal
storage medium, replant the tooth!
Every effort should be directed toward
preserving a viable periodontal ligament.
(McDonald's and Avery, 2011)

15. Management in the dental surgery

17. It is usually still better to replant the tooth
(Cameron, 2013)
The replanted tooth serves as a space maintainer
and often guides adjacent teeth into their proper
position in the arch, a function that is important
during the transitional dentition period and has a
has psychological value.
(McDonald's and Avery, 2011)

19. Replantation
is the technique in which a tooth, usually one in
the anterior region, is reinserted into the
alveolus after its loss or displacement by
accidental means.
Treatment is directed at avoiding or
minimizing the resultant inflammation, which
occurs as a direct result of the two main
consequences of tooth avulsion: attachment
damage and pulpal infection.

20. The sooner a tooth can be replanted in its
socket after avulsion, the better the prognosis
will be for retention without root resorption.
Andreasen and Hjørting-Hansen reported a
follow-up study of 110 replanted teeth.
Of those replanted within 30 minutes, 90%
showed no discernible evidence of resorption 2
or more years later. However, 95% of the teeth
replanted more than 2 hours after the injury
showed root resorption.

21. The following are guidelines for replanting avulsed
permanent teeth.
Tooth replanted prior to arrival
Tooth maintained in storage solution
with extra-oral time <60 min
Tooth is dry or extra-oral time is
>30 min

22.  Tooth replanted prior to arrival
Debride the mouth but do not extract the tooth.

23.  Tooth maintained in storage solution
with extra-oral time <60 min
1. Gently debride the root surface under copious
saline, milk or tissue-culture media )Hanks
balanced salt solution) irrigation. When holding
teeth, always do so by only holding the crown
2. Give local anaesthesia and gently debride the
tooth socket with saline to remove any blood
clot, but do not curette the bone or
remaining periodontal ligament
3.Replant the tooth gently with finger pressure..

24. Tooth is dry
or extra-oral time is >30 min
1 Remove any necrotic periodontal ligament by soaking
the tooth in saline and gently debriding the root surface
with saline-soaked gauze.
2 The Damage tooth should to the also cementum be soaked must in 2% be avoided sodium fluoride
and
for 20 min. It is essential that the tooth be rehydrated
mechanical instrumentation should be avoided
prior to replantation.
3 Give local anaesthesia and gently debride the tooth
socket with saline to remove the blood clot; do not
curette the bone or remaining ligament.
4 Replant the tooth gently with finger pressure.

25. Management following replantation
1. Splint for …….. days
2. Reposition and suture any degloved gingival tissues and suture
all lacerations.
3. Prescribe a high-dose, broad-spectrum antibiotic and check
current immunization status.
4. Account for any lost teeth. A chest radiograph may be required.
5. Normal diet and strict oral hygiene including chlorhexidine
gluconate 0.2% mouthwash.

27. Splinting of Avulsed Teeth
Splints should be flexible to allow normal
physiological movement of the tooth;
Rigid stabilization seems to stimulate
replacement resorption of the root and is
This helps to reduce the development of
ankylosis and replacement resorption.
detrimental to proper healing of the
periodontal ligament.

28. Splint should meet the following
criteria:
• It should be easy to fabricate directly in the mouth
without lengthy laboratory procedures.
• It should be able to be placed passively without
causing forces on the teeth.
• It should not touch the gingival tissues, causing gingival
irritation.
• It should not interfere with normal occlusion.
• It should be easily cleaned and allow for proper oral
hygiene.
• It should allow an approach for endodontic therapy.
• It should be easily removed.
(McDonald's and Avery, 2011)

29. Types of Splints
(McDonald's and Avery, 2011)

30. Types of Splints
• Orthodontic brackets with a light archwire
(0.014˝).
1. Easier and quicker to place.
2. Allows the splint to be readily removed and replaced
so that the mobility of the teeth can be monitored.
3. Easier to maintain oral hygiene.
4. Less time to remove and less chance of damage to
the teeth following removal of composite resin
(often used to excess)

31. • Composite resin and nylon fibre (0.6 mm)
such as fishing line

32. • Titanium trauma splint.

34. Timing of splinting
• Splints should generally stay in place for 10–14
days if there are no complicating factors such
as alveolar or root fractures.
• Avulsed teeth that were kept dry more than
60 min. prior to replantation may require
splinting for up to 4 weeks.

35. Root canal treatment
Immature
root apex
Mature
root apex

36. Immature root apex
Should not have root canal treatment
immediately after the replantation;
instead they should be monitored to see
whether the pulp revascularizes.

37. Mature root apex
Root canal treatment should be commenced
immediately
to prevent external inflammatory root
resorption

39. Patient instructions
• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day
for 1 week.

40. (McDonald's and Avery, 2011)

41. Complications in Endodontic
Management of Avulsed Teeth
External
Inflammatory
Root Resorption
Ankylosis
External
Replacement
Root Resorption

43. Ankylosis

44. External Replacement Root
Resorption

45. THANK YOU