The document discusses traumatic dental injuries including avulsion or complete displacement of a tooth from its socket. It defines avulsion and describes the associated injuries, causes, and long term consequences. It provides details on avulsed permanent teeth including common occurrence in maxillary central incisors, higher frequency in boys than girls, and common age of 7-9 years when permanent incisors are erupting. The document discusses management of avulsed teeth including storage media to maintain viability of periodontal ligament cells, immediate replantation when possible, and follow up care and potential complications.

1. The traumatic dental injuries
Luxation Injuries
AVULSION
(EXARTICULATION)
Dr. Hadil Abdallah Altilbani
BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine

2. Definition:
It is defined as complete displacement of the tooth out
of socket.
❑The common cause is a directed force sufficient to overcome the bond
between the affected tooth and the periodontal ligament within the
alveolar socket .
❑Losing a tooth can be physically and emotionally demanding, as a result
vacant place is not esthetically agreeable and is difficult to fill and
replace.
❑Long-term consequences include shifting of adjacent teeth resulting in
misalignment and periodontal disease.
Avulsed Permanent Teeth

4. • 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)
Avulsed Permanent Teeth
❖Incidence- 0.5% to 16% of treatment
Injuries
❖Main Etiologic factors:- Fights and A Knocked out tooth
- Sports injuries
- Automobile accidents

5. Associated injuries
1. Fracture of alveolar socket wall
2. Injuries to the lips and gingiva
Avulsed Permanent Teeth

7. Avulsed Tooth
• What tissue should be our primary
concern?
❑Pulp?
❑Socket?
❑PDL?
What to Do When a Patient Comes with
Avulsed Tooth?
When a patient comes with the avulsed tooth, the main aim of the
Reimplantation
Is to preserve the maximal number of
Periodontal Ligament Cells
which have capability to regenerate and repair the injured root
surface

8. Avulsed Tooth
• Ultimate goal
– PDL healing without root resorption
• Most critical factor
– Maintaining an intact and viable PDL on the root surface
Biologic Consequences
❖ Pulp Responses
There are several sequelae to avulsion injury of tooth. The
predominant and most consistent sequelae seen in such cases are as
follows:
1) Pulp healing.
2) Pulpal necrosis.
This usually occurs due to disruption of blood supply to the tooth.
Pulp testing and frequent
1) Pulp canal obliteration.

9. ❖Periodontal Ligament Responses
1. Surface Resorption
2. Replacement Resorption (Ankylosis)
3. Inflammatory Resorption
Andreasen JO, Hjorting-Hansen E.
Replantation of teeth II. Histological study of 22 replanted anterior teeth in humans.
Acta Odontol Scand 1966;24:287-306.
Biologic Consequences

10. • External Surface resorption
– • Is a self-limiting resorption that is
transient.
– • Small, superficial resorption
cavities in the cementum and the
outermost layers of the dentin
without an inflammatory reaction
in the PDL.
– • Caused by: traumatic injuries or
orthodontic treatment..
– • When trauma/pressure
discontinued – spontaneous healing
occur – - typical feature of REPAIR
RELATED RESORPTION without
associated breakdown of the lamina
dura.
– • This process is thought to be
exceedingly common but grossly
under- reported as it is sub-clinical.

11. • External Inflammatory
resorption
– • Is often seen radiographically as
an extensive peri-radicular
radiolucency associated with an
extensive inflammatory response
to endodontic pathosis.
– • Causes: Necrotic pulp.
– • Bacteria primarily located in pulp
& dentinal tubules trigger
osteoclastic activity resulting in
both tooth and bone resorption..
– • Resorption can affect all parts of
root.
– • Diagnosed 2-4 weeks after injury.
• Resorption rapidly progress –
total root resorption within few
months. • Most common after
avulsion and luxation injuries

12. Etiology

16. Periodontal Ligament Responses
▪ Replacement Resorption(Ankylosis)
➢ Direct union of bone and root
➢ Resorption of root
➢ Replacement with bone
➢ Direct result of loss of vital PDL

22. Inflammatory resorption
Replacement
resorption
(Ankylosis)
Surface resorption

23. Viable periodontal ligament (PL) cells
are required for the healing of avulsed
teeth after replantation.
Summary
The amount of damaged PDL is an
important factor in determining which
type of root resorption will occur.

24. Tratment considerations
1. Extraoral time
2. Extraoral environment
3. Root surface manipulation
4. Management of the socket
5. Stabilization
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)

25. Extraoral Time
• Shorter time = Better prognosis*
< 30 min → 10% resorption
> 90 min → 90% resorption
*Depending on storage medium
Teeth that are protected in Physiologically ideal media can be Re -implanted within
15min to one hour after accident with good prognosis.

26. Immediate Replantation

27. Temporary splinting of an avulsed
tooth with aluminium foil

29. Storage
Media For
Avulsed
Tooth
❑Hank’s Balanced Solution (Save-A-Tooth)
This pH-preserving fluid is best used with a trauma reducing suspension apparatus. The HBSS is biocompatible with
the tooth periodontal ligament cells and can keep these cells viable for 24 hours because of its ideal pH and
osmolality. Researches have shown that this fluid can rejuvenate degenerated ligament cells and maintain a success
rate of over 90 percent if an avulsed tooth is soaked in it for 30 minutes prior to replantation.

31. 2. Milk
Milk has shown to maintain vitality of periodontal
ligament cells for 3 hours. Milk is relatively bacteria-free
with pH and osmolality compatible with vital cells.
periodontal healing Almost as good as immediate
replantation

32. 4. Saliva
Saliva keeps the tooth moist. It has advantage that it is a
biological fluid. It provides 2 hrs of storage time for an avulsed
tooth. However, it is not ideal because of incompatible
osmolality, pH, and presence of bacteria.

33. ❑Saline
Saline is isotonic and sterile and thus can be
used as tooth carrier solution.
❑Water: This is the least desirable
transport medium because water is
hypotonic it results in hypotonic rapid cell
lysis.

34. Management Options for an
Avulsed Tooth

35. 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.
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)

36. ✓ 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.
✓ Administer local anesthesia. Remove the coagulum from the socket with a
stream of saline.
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 .
Management of the socket

37. Root Surface Manipulation
• Extraoral dry time determines
handling

39. Tooth maintained in storage solution with extra-oral time
<60 min

40. Precautions to be Taken While Handling the Avulsed Tooth
• Do not
Touch a viable ROOT with hands, forceps, gauze or anything, or try to SCRUB or clean it to avoid injury to the periodontal ligament
which on further, is difficult to revascularize the re-implanted tooth.
• Do not
Overlook fractures of Teeth And Alveolar Ridges. . Take radiographs of the area of injury to look for evidence of alveolar fracture.
• Do not
Replace PRIMARY teeth, because loss of these teeth early does not hinder development of succedaneous teeth.
Reimplanted primary teeth heal by ANKYLOSIS.
• Soft tissue lacerations should be tightly sutured, particularly cervically.
1. 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 Avoid caustic
chemicals, but do not curette the bone or remaining periodontal ligament
3. Replant the tooth gently with finger pressure.
4. Suture gingival lacerations, if present.
Management Options for an Avulsed Tooth

41. Using the forceps, partially insert the tooth into the socket. Gentle finger pressure can be used
for complete seating of the tooth, or the patient can bite on a piece of gauze to accomplish the
seating.

42. Tooth is dry
or extra-oral time is >1hr

43. Tooth is dry
or extra-oral time is >1hr
1. Remove any necrotic periodontal ligament by soaking the tooth in saline and
gently debriding the root surface with saline-soaked gauze.
2. The tooth should also be soaked in 2% sodium fluoride for 20 min. To slow down
osseous replacement .t is essential that the tooth be rehydrated 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.

45. Stabilization

46. Patient Instructions
➢ Soft food for 1 week
➢ Brush with soft bristle
➢ Rinse with chlorhexidine o.1% to prevent plaque accumulation
Additional Considerations
Follow-Up Care
➢ Clinical and radiographic control
after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
➢ Inflammatory resorption, replacement resorption ankylosis and tooth submergence are potential
complications when avulsed tooth are replanted

47. Pharmacologic treatment
✓ Systemic antibiotic during the first week after re plantation. To prevents
the development of root resorption.
✓ Refer the patient to a physician within 48 hours for a tetanus booster if the
avulsed tooth contacted soil or if the status of the tetanus coverage is
uncertain.
For systematic administration :
✓ Tetracycline is the 1st choice in appropriate dose the first week after
replantation
✓ The risk of permeant teeth pigmentation must be considered in young
patients ( it is not recommended in patients under 12.
✓ A penicillin phenoxymethylpenicillin ( pen V) or amoxicillin the first week
after replantation can be given as an alternative to tetracycline.

48. Antibiotic
Topical antibiotic:
( Minocycline or doxycycline 1mg/ 20 ml
of saline for 5 min soak )
appear experimentally to have +ve effect
on pulpal space revascularization and
periodontal healing in immature teeth .