11 year old boy presented with avulsion of anterior tooth

1. 11 yrs old boy
presented with trauma to face

2. A 11 year boy presented with loss of anterior tooth
PRESENTING COMPLAINT

3. HISTORY OF PRESENTING
COMPLAINT
11 year old boy presented with sudden blow to the face
during sports which led to complete loss of tooth from
tooth socket of upper jaw 1 hours ago

4. Medical and Dental History
.The patient had no relevant past medical history
and was fully alert as well as responsive during
the process of examination.
. Tooth was kept in milk after avulsion
. EAT ( extra alveolar time ) > 60 mins

5. Fully closed apex
No fracture of crown and root of tooth
Clinical Examination of
Avulsed Tooth Examination

6. Extra oral examination
Mild abrasion
Slight swollen upper and lower lip.

7. Intra-oral examination
Missing left maxillary lateral incisor
Normal marginal gingiva in the associated area

8. .Inspection and palpation of the anterior
maxillary segment, the dento-alveolar
fracture was ruled out.

9. Radiographic Features
• Radiographic evaluation revealed an empty
alveolar socket with an intact lamina dura
and no other injury or fracture of the
adjacent teeth and associated alveolar
structures.

10. Management

11. The patient and parents were informed about the
possible complications (inflammatory resorption of
root, replacement resorption/ankylosis, tooth
discolouration) involved with replanting an avulsed
tooth that had endured an extra-oral time of
approximately 60 minutes
Informed consent was taken.

12. PREPARATION OF AVULSED TOOTH AND
ALVEOLAR SOCKET
Local anesthetic was given to alveolar socket
Tooth root surface and socket was then gently
rinsed with normal saline in order to remove any
foreign body or clot

13. Root canal therapy was done extraorally as
EAT ( extra alveolar time )> 60 mins

15. Repositioning of tooth
Check occlusion
Splinting after radiographic verification
STEPS IN REPLANTATION OF
AVULSED TOOTH

16. • Oral analgesics and antibiotics were prescribed for
five days.
• Advised to maintain a soft diet for two weeks
• Oral hygiene instructions were given
• Follow up was advised after 2 weeks
POSTOPERATIVE
INSTRUCTIONS

18. Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, et al. International
Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in
the primary dentition. Dent Traumatol. 2012;28:174-82

20. AVULSION
• Total dislocation of the tooth from its socket,
known as tooth avulsion.1
• It is the most serious dental injury requiring
emergency treatment.
Ashraf F. Fouad, Paul V. Abbott, Georgios Tsilingaridis, Nestor Cohenca, Eva Lauridsen, Cecilia Bourguignon, Anne O'Connell, Marie Therese Flores, Peter
F. Day, Lamar Hicks, Jens Ove Andreasen, Zafer C. Cehreli, Stephen Harlamb, Bill Kahler, Adeleke Oginni, Marc Semper, Liran Levin.International
Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teethDental Traumatology.
2020;36:331–342.https://doi.org/10.1111/edt.12573

21. EPIDEMIOLOGY
• Over one billion people all over the world had
suffered a dental injury, which would rank
fifth on the list of the world's most common
injuries.1
• In Pakistan, the nationwide frequency of
dental injuries is 13.7%.2
• Males were significantly more affected than
females.2
1-Petti S, Glendor U, Andersson L. World traumatic dental injury frequency and incidence, a meta-analysis-One billion living people have had traumatic
dental injuries. Dent Traumatol 2018; 34(2): 71-86. https://doi.org/10.1111/edt.12389.
2-Sajid M, Noreen R, Jamil M, Javed M, Haider E, Ahmad M, et al. Frequency of dental traumatic injuries in young children in public school of Layyah. Pak
Oral Dental J 2019; 39(4): 337-40.

22. • Peak incidence of dental trauma occurs in
the 7-11-year age group.Permanent teeth
are injured more than decidous (60% vs.
40%, respectively).1
• The tooth most commonly affected are the
upper front teeth, especially the central
incisors.2
1-Shubham S, Nepal M, Mishra R, Kandel L, Gautam N. Frequency of traumatic dental injury in a tertiary care hospital: a descriptive
cross-sectional study. J Nepal Med Assoc 2021; 59(233): 31-34. https://doi.org/10.31729%2Fjnma.5556.
2-Vieira WA, Pecorari VGA, Figueiredo-de-Almeida R, Carvas Junior N, Vargas-Neto J, Santos ECA, et al. Frequency of dental
trauma in Brazilian children and adolescents: a systematic review and meta-analysis. Cad Saude Publica 2021; 37(12): e00015920.
https://doi.org/10.1590/0102-311x00015920.

23. ETIOLOGY AND PREVALENCE
Causes of Traumatic Dental Injury 2 %age
FALL 68.5
SPORTS
11.2
CLASS II DIV I WITH PROMINENT INCISORS
7.6
BITING ON HARD OBJECT
6.8
VIOLENCE 3.2
TRAFFIC 2.4
MISCELLANEOUS 0.4
QURAT-UL-AIN, ALI SHAHID, MUHAMMAD AFZAL, SHEHNOOR AZHAR, HAMNA KHAWAJA, MUHAMMAD SHAIRAZ SADIQ
Frequency of Traumatic Dental Injuries to Anterior Teeth Among 7 to 14
Year-Old School Children P J M H S Vol. 16, No. 07, July 2022 283 DOI: https://doi.org/10.53350/pjmhs22167283

24. Class II div I with prominent incisors

25. When an external impact occurs on a tooth, the
periodontal fibers can tear, allowing partial or
total displacement of the tooth from the socket.
PATHOPHYSIOLOGY

26. Periodontal Ligament (PDL)
• Normal width of the PDL ranges from 0.15 mm to 0.21 mm
• PDL is a physiological hammock that support tooth in
socket.
• The PDL consists of principal fibers, loose connective
tissue, blast and clast cells, oxytalan fibers and Rest of
Malassez cell.
• The primary principal fiber group consists of five different
fiber subgroups. These fiber subgroups include the
following:
1. alveolar crest
2. horizontal
3. oblique
4. apical
5. interradicular on multirooted teeth.

27. Function
1.Resists the impact of occlusal forces (shock absorption).
2. Provide soft tissue “casing’' to protect the vessels and
nerves from injury by mechanical forces.
3. Attaches the teeth to the bone.
4. Maintains the gingival tissues in their proper relationship
to the teeth.
5. Transmission of occlusal forces to the bone.

28. Three types of healing modalities have been
described depending on the severity of injury
sustained by the periodontal tissue in avulsed tooth
i.Functional healing
ii. Healing with inflammatory resorption.
iii. Healing with replacement resorption.
PERIODONTAL LIGAMENTS REACTION

29. Several factors influence the pulpal reaction
such as
. the width of the apical foramen
. closure of apical foramen
. the extra-alveolar period
. the storage medium.
PULPAL REACTION
.

30. CONTRAINDICATION OF REPLANTATION
• Severe caries or periodontal disease.
• Severe cognitive impairment requiring
sedation.
• Severe medical conditions such as
immunosuppression,seziure disorder.
• An uncooperative patient.

31.  Relavent History taking and radiologival evaluation
 Replantation of avulsed tooth
 Splinting of avulsed tooth
 Medication
 Follow up
Steps in management of avulsed
permanent anterior teeth

32.  Call the nearby Dentist if possible.
 Pick the tooth by its crown.
 Do not touch the root.
 Check to see if the root surface is clean.
 If dirt is present on the root, rinse gently
with fresh milk, saline or water.
 Do not scrub dirt off the root.
 Place the tooth into its socket if possible.
Emergency Management at Site
of Injury

33. The best storage medium is the tooth socket itself
Other transport media are
1. Saliva of patient - bucal sulcus
2.Physiological saline (0.9% sodium chloride).
3. Fresh milk
4.pH balanced cell preserving solutions such as
Hank’s Balanced Salt Solution.
Storage and Transportation
Medium

34. By dental surgeon
Pre-operative Assessment
i. Dental /medical history.
ii. Clinical evaluation of dental trauma and its site.
iii. Investigations.
The above procedures should be carried out quickly but
thoroughly so that precious time is not wasted.
Management at Dental
Clinic/Emergency
Department

35. Replantation protocol
i. Place the tooth in physiological saline
ii. Administer local anesthesia to alveolar socket.
iii. Gently irrigate socket with normal saline
iv. Avoid manipulating the socket aggresively .
v. If the root is contaminated, run physiological saline
over the tooth.
vi.Seat the tooth back gently into its socket using light
finger pressure.
vii.Check occlusion and do functional
splinting for 2 weeks

36. EXTRA ORAL
TIME
LESS THAN
60 MIN
OPEN
APEX
Replant tooth
RCT done only if pulp
necrosis occur
CLOSED
APEX
Rinse debris with water
replant gently
MORE THAN
60 MIN
OPEN
APEX
Replant tooth
RCT done after two
weeks
CLOSED
APEX
Replant tooth
RCT done extra orally

37. SPLINTING
• A mandatory step in management of avulsed tooth.
• The replanted tooth needs to be stabilized in position
by flexible splinting for 2 week.
• If alveolar bone is fractured, splint for 4 weeks .
• Take a periapical dental radiograph to ascertain
position of replanted tooth and as baseline
information.

38. Patient instructions
• Avoid participation in contact sports.
• Maintain a soft diet for up to 2 weeks, according to the
tolerance of the patient.
• Brush their teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.12%) mouth rinse twice a day for
2 weeks.
• Refer the patient to a physician for evaluation of the
need for a tetanus booster.

39. Medication
• Prescribe Oral antibiotics . Amoxicillin or penicillin remain the first
choices due to their effectiveness on oral flora and low incidence
of side effects.
• Alternative antibiotics should be considered for patients with an
allergy to penicillin.
• Oral analgesic can be given if required
• 0.12% chlorhexidine gluconate mouthwash twice daily for 2
week.

40. Pathologic Sequelae of Replantation
The possible complications following replantation of permanent
teeth can be
• Pulp canal obliteration.
• Inflammatory resorption.
• Pulp necrosis
• Internal resorption.
• The periodontal ligament becomes necrotic and is not
expected to regenerate.
• Ankylosis-related (replacement) root resorption.
• Infra-positioned
Malmgren B, Tsilingaridis G, Malmgren O. Long-term follow up of 103 ankylosed permanent incisors surgically treated with decoronation - a
retrospective cohort study. Dent Traumatol. 2015; 31: 184–9

41. AVULSION OF DECIDIOUS TEETH
• Replanting avulsed primary teeth is not advised by the
International Association for Dental Traumatology (IADT)
guidelines 2020.2
1.Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis-One billion living people have had traumatic
dental injuries. Dent Traumatol. 2018; 34: 71–86.
2.Day, Flores MT, O’Connell AC, Abbott PV, Tsilingaridis G, Fouad AF, et al. International Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 3 Injuries in the primary dentition. Dent Traumatol 2020;36:343–59.
• For children, aged 0-6 years, oral injuries account for 18%
of all physical injuries and the mouth is the second most
common area of the body to be injured.
• A recent meta-analysis on traumatic dental injuries (TDIs)
reveals a world prevalence of 22.7% affecting the primary
teeth.1

42. FOLLOW UP
• Clinical and radiographic follow-up should take place at 2
weeks, 4 weeks, 3 months, 6 months, 1 year and then
yearly thereafter for a period of 5 years

43. A 10-year-old boy was playing football when he collided
with another player and fell down, hitting his mouth against
the ground. Upon examination, it was observed that his
upper right central incisor (tooth #8) had been completely
knocked out. There was bleeding from the socket and the
tooth was found on the ground. The boy was brought to
the dentist immediately.
What is the first step in managing an avulsed tooth?
a) Cleaning the tooth with water
b) Placing the tooth back into the socket immediately
c) Rinsing the mouth with mouthwash
d) Discarding the avulsed tooth
MCQS

44. A 12-year-old boy patient presents to the dental clinic after
sustaining a fall while playing soccer. He reports
significant trauma to his mouth and is in noticeable
distress. Upon examination, you notice that his maxillary
central incisors (teeth #8 and #9) are completely
displaced from their sockets and are avulsed. There is
also minor bleeding from the sockets. The patient's
medical history is unremarkable, and he is otherwise
healthy.
After replanting the avulsed teeth, what additional
measures should be taken to stabilize them?
a) Use a rigid splint and secure it with composite resin.
b) Apply ice packs externally to reduce swelling.
c) Prescribe antibiotics to prevent infection.
d) Perform root canal treatment immediately.

45. A 14-year-old boy presents to the emergency department after
a sports-related injury during a soccer game. He was hit in the
face by a stray ball, resulting in the avulsion of two of his upper
front teeth. Upon examination, you notice that both teeth are
completely displaced from their sockets, with exposed roots and
minimal attached soft tissue. The patient is in mild distress and
is accompanied by his concerned parents.
Which of the following is the recommended method for handling
avulsed teeth during transportation to the dental clinic?
a) Holding the teeth by the crown and rinsing them under tap
water
b) Placing the teeth in a container filled with saline solution
c) Wrapping the teeth in a dry paper towel
d) Placing the teeth back into their sockets immediately

47. THANK YOU.