Dental avulsion is the complete displacement of a tooth from its socket. Trauma from sports or accidents can cause avulsion. Clinically, there is bleeding from the empty socket. Radiographically, the socket appears empty with possible bone fractures. Treatment depends on extra-oral dry time - immediate replantation is best if dry time is short, whereas long dry time requires special management. Storage in media like saline or Hanks balanced salt solution best maintains viability of periodontal ligament cells. Complications may include inflammatory or replacement resorption, ankylosis or tooth submergence.

1. DENTAL
AVULSION
Dr.MOHAMMED SHALIK
Al-Azhar Dental College

6. DENTAL AVULSION is the complete
displacement of a tooth from its socket in alveolar
bone. It is also called as “EXARTICULATION” and
most often involves maxillary teeth.

7. CAUSE
S
• Trauma to the face and mouth from sports or other
accidents can cause teeth to fracture, loosen or even
knocked completely out of its socket (avulsion)..

8. CLINICAL FEATURE
Bleeding socket with missing teeth.

9. RADIOGRAPHIC FEATURES
Empty socket.
Associated bone fractures.
If the wound is recent then lamina dura is visible otherwise it
is obliterated.

10. TREATMENT
Reimplantation depends on extra oral time.
If apical foramen is not closed – endodontic therapy is
delayed till first signs of apical closure are seen.
If apical foramen is closed – endodontic therapy is done
after 1-2 weeks depending on type of reimplantation.

11. MANAGEMENT
• A. Management at site of injury.
• B. Management in the dental office.

12. MANAGEMENT AT SITE OF
INJURY.
• Replant immediately. If possible. Rinse with water before
replanting if the tooth is contaminated. When immediate
replantation is not possible, place tooth in the best
available transport medium available.

13. The following conditions should be considered before
replanting a permanent tooth.
The Alveolar socket should be reasonably intact.
The extra-alveolar period.
Short extra-alveolar storage : If the tooth since the time of
injury has been placed in a suitable medium and the extra-
alveolar time elapsed is short.

15. Long extra-alveolar storage : This is done in cases
where the extra oral dry period of tooth is long.

17. • i) Replantation of tooth.
• If tooth has been in any physiological storage media,
replant immediately..
• If extra oral dry time is less then 20 min, replant
immediately if the root apex is closed, subsequently
root canal therapy may be required. If the root apex is
open replant the tooth and monitor the tooth for pulpal
pathosis.
MANAGEMENT IN THE
DENTAL OFFICE

20. • If extra oral dry time is greater than 20 min rinse with
saline and replant only if the root apex is closed
because replanting the tooth with open apex increases
the risk of ankylosis.

24. MANAGEMENT OF THE
ROOT SURFACE
•Keep the tooth moist at all times
•Do not touch the root surface{hold tooth by the crown}
•Do not scrape or brush the root surface or remove the tip of
the root.
•If the root appears clean, replant as it is after rinsing with
saline.

25. • If the root surface is contaminated, rinse with Hank’s
balanced salt solution (HBSS) or saline (use tap water if
above are not available)

28. MANAGEMENT OF THE
SOCKET
•Do not curette the socket. If a clot is present, use light
irrigation with saline.
•Do not make a surgical flap unless bony fragments
prevent replantation.
•If the alveolar bone is collapsed and prevents
replantation carefully insert a blunt instrument into the
socket to reposition the bone to its original position. After
replantation manually compress facial and lingual bony
plates .

29. STORAGE MEDIA FOR AVULSED
TEETH
As dry storage is detrimental to the preservation of the
PDL, the Avulsed tooth must be prevented from drying by
the usage of storage media of correct osmolarity and pH.
EFFECT OF STORAGE MEDIA ON PERIODONTAL
HEALING

30. It should not produce any antigen antibody reactions
It should reduce the risk of post-implantation root
resorption or ankylosis.
It should have a good shelf life
IDEAL REQUIREMENTS
 It should have antimicrobial characterstics
 It should be able to maintain the viability or the periodontal
fibres.
 It should favour proliferative capacity of the cells.
 It should have the same osmolarity as that of body fluids.

31. TYPES OF STORAGE MEDIA
1.Saline Solution
2.Tap water
3.Saliva
4.Milk
5.Hank’s Balenced salt solution
6.Viaspan
7.Gatarade
8.Propolis
9.Contact lens solution
10.Emdogain
11.Egg white
12.Eagle’s medium
13.L-Dopa
14.Coconut water

32. Saline solution provides Osmolarity of
280mOsm/Kg despite being compatible to the
cells of the PDL.
1.Saline Solution
2.Tap water
 It is an unexcepted storage media for avulsed
tooth.
 It causes increased cell damage due to very
low osmolarity.
 Thus tap water is not suitable as stoage
media for retaining the viability of PDL cells

33.  It is used as storage medium for a short period of time.
 Its osmolarity is much lower than the pysiologic storage
saline (60-70 mOsm/Kg)
 It boots the harming effect of bacterial contamination.
3.Saliva
4.Milk
 It is important that it is used in the first 20
minutes after avulsion.
 Favourable results occur due to the
presence of aminoacids, carbohydrates and
vitamins.
 Pasteurisation of milk is responsible for
diminishing the number of bacteria

34.  Standard soliution.
 This solution is Non-toxic, Biocompatible with PDL cells, pH
balenced at 7.2, and osmolarity of 320 mOsm/kg
 It does not require refrigerator.
 It can be kept on the shelf for 2 years.
• Recently, an avulsed tooth preserving system called –
‘SAVE A TOOTH’ containing Hank’s balanced salt
solution(HBSS), a pH preserving fluid and trauma
reducing suspension apparatus is available.
• It may be used in serious accidents that relegate
replantation to secondary importance and hence
replanted when crisis is over.
5.Hank’s Balenced salt solution (HBSS)

36.  Cold Transport organ storage medium
 Osmolarity is 320 mOsm/L, with a pH of 7.4 which is
ideal for cell growth
 Non-carbonated sports drink
 pH of 3 and Osmolarity ranges from 280 mOsm/L to 360
mOsm/L
• It is a sticky resin that seeps from the buds or bark of trees,
chiefly confers.
• It has antiseptic, antibiotic, antibacterial, antifungal,
antiviral, antioxidant, anticarcinogenic properties.
6.Viaspan
7.Gatarade
8.Propolis

37. • They conatain buffered, isotonic saline solutions with
addition of preservatives that may preserve the viability
of PDL cells
• Emdogain diminishes the percentage of fibroblasts of the
PDL with the capability of forming colonies and that lowers
the capability of fibroblast to repopulate the dental radicular
surface after dental avulsion
• Teeth stored in egg white for 6-10 hours had a better
incidence of repair than those stored in milk for the same
amount of time
9.Contact lens solution
10.Emdogain
11.Egg white

38. • It conatins L-glutamine,penicillin, streptomycin, nystatin
and calf serum.
• It has high viability, mitogenic and clonogenic capacity
upto 8 hours of stoage at 4 degree C
• Levo dopa is a drug with possibe mitogenic effects.
• It stimulates pituitary to release GH which promotes
healing process.
• It also has local effects in the growth of PDL cells.
• Replenishes the fluids, electrolytes and sugar lost from
the body during heavy physical work
12.Eagle’s medium
13.L-Dopa
14.Coconut water

39. SPLINTING
 Splint should remain in place for 7-10 days However if
tooth demonstrates excessive mobility splint should be
maintained until mobility reduces

41. • Oral/systemic antibiotics
• Referral to physician for tetanus prophylaxis within
48 hours.
• Chlorhexidine rinses
• Analgesics
ADJUNCTIVE DRUG THERAPY

42. Potential complications of replantation are;
• 1) Inflammatory resorption
• 2) Replacement resorption
• 3) Ankylosis
• 4) Tooth submergence
COMPLICATIONS

43. CONCLUSION
An Avulsed permanent tooth is one of the few real
emergency situations in dentistry. Dentist sholuld always be
prepared to give appropriate advice to the public about first
aid managemnt of avulsed tooth.

44. REFERENCE
• Textbook of Pediatric Dentistry by Nikhil
Marwah
• Textbook of Pediatric Dentistry by Shobha
Tandon