AVULSION

O. K. PREETHI
Ⅱyear MDS
 CONTENTS

1. INTRODUCTION

2. CLASSIFICATION OF AVULSED TEETH

3. TRANSPORT MEDIUM FOR AVULSED TOOTH

4. TREATMENT MODALITIES

5. FOLLOW – UP PROCEDURES FOR AVULSED PERMANENT TEETH

6. HEALING

7. CONCLUSION AND REFERENCES

 INTRODUCTION

DEFINITION :
Complete and total displacement of the tooth from its socket

INCIDENCE :
0.5-3% of traumatic injuries in permanent dentition
7-13% of traumatic injuries in primary dentition

ETIOLOGICAL FACTORS : Sports and fight injuries

Road traffic accidents

MOST FREQUENTLY AVULSED TEETH : Maxillary central incisors

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 CLASSIFICATION OF AVULSED TEETH

BASED ON THE RECOMMENDATIONS AND GUIDELINES GIVEN BY

THE INTERNATIONAL ASSOCIATION OF DENTAL TRAUMATOLOGY
(IADT) IN 2007

The tooth has already been replanted at the site of avulsion

The tooth has been kept in special storage media with the extraoral dry
time less than 60 minutes

Extraoral dry time longer than 60 minutes

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 TRANSPORT MEDIA
• If the patient/parent cannot replace the tooth in its socket, care in transporting
that tooth to the dentist becomes essential.
• Most readily available vehicle - patient’s mouth (the tooth is bathed in
saliva at body temperature)
• If this cannot be safely done (if the patient is too young), - place the tooth in an
appropriate medium for transport to the dentist
• Optimal extraoral time for an avulsed tooth should not exceed 20 minutes
• Sooner the replantation - better the prognosis

×
Wrapping the tooth in Dehydration -
a dry handkerchief or periodontal
paper tissue ligament

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 TRANSPORT MEDIA

• HBSS (Hank’s balanced salt solution)

• Viaspan
• Patient’s own saliva
• Vestibule of the mouth
• Container into which the patient spits
• Milk
• Propolis
• Coconut water
• Physiological saline
• Water

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 HANK'S BALANCED SALT SOLUTION (HBSS)

• HBSS is essentially a pH-balanced salt solution contains ingredients, such as glucose, sodium
chloride, potassium chloride, calcium chloride, magnesium chloride, sodium bi- carbonate
and sodium phosphate, which can sustain and reconstitute the depleted cellular components
of the PDL cells.
• It can preserve cells and tissues for 24 h and both the pH (7.4) and the osmolality (280
mOsmol Kg-1) are ideal.
• HBSS - the most effective medium for preserving viability, mitogenicity, and clonogenic
capacities of PDL cells for up to 24 h at 4°C when compared with other solutions.
Ashkenazi et al, 2001
 HANK'S BALANCED SALT SOLUTION (HBSS)

• 94% cell viability after storage of cultured human PDL cells for 24 h

Huang et al, 2011

• The Save-A-Tooth solution, which contains HBSS, showed inferior results than
the original product, which may be explained by the fact that HBSS is prepared
for immediate use, when it has a better performance.

• However, HBSS use is restricted to laboratory environments and is not readily

available at an accident site, which makes it impracticable as a storage medium
for avulsed tooth.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 VIASPAN

• Viaspan - a new storage medium presently used for organ

transplant storage,
• ViaSpan has osmolality of 320 mOsm/kg, which enables
excellent cellular growth. Its pH is 7.4 , which is ideal for the
cellular growth.
• It also contains adenosine, which is necessary for cell
division.
• Both HBSS and Viaspan proved to be superior to milk
• Viaspan is considered as a medium close to ideal, but it must
be refrigerated, it has a high cost and it is not readily available
to the general public, especially at the moment of the
accident, makes it difficult to use.
Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 SALIVA / BUCCAL VESTIBULE

• Unfavorable characteristics - non-physiological pH and osmolality (lower than

the physiologic i.e. 60-70 mosmol Kg-1), high microbial contamination and
hypotonicity.
• Storage for 2 to 3 hours causes swelling and membrane damage of PDL cells.
• However, it produces one-third less cell damage than dry storage or storage in
tap water. Saliva - short-term storage medium (less than 30 min) and its use
should be limited to cases where the extra-alveolar duration is less and other
superior storage media are not available.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 CULTURE MEDIUM

• Eagle's Minimal Essential Medium containing 4 mL of L-glutamine - 105

IU/L of penicillin; 100 μg/mL of streptomycin, 10 μg/mL of Nystatin, and
calf serum (10% v/v)—demonstrated that the cell culture medium (Eagle's
medium at 37°C) can preserve PDL fibroblasts for extended periods before
reimplantation.
• Teeth preserved in the culture for 5 to 7 days showed significantly reduced
levels of inflammatory resorption.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 CUSTODIOL

• Custodiol is a histidine-tryptophan ketoglutarate solution with high flow

properties and low potassium content.
• It is used as a preservation solution for organ transplantation.
• Its composition is similar to that of extracellular fluid. It has an osmolality of
310mOsmol Kg-1. Custodial is comparable to HBSS for cell preservation.
• However, it is not available to the public and therefore of little value as a
storage medium for avulsed teeth.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 MILK

• Milk - an isotonic liquid with an approximately

neutral pH (6.5 to 7.2) and physiological osmolality
(270 mOsmol Kg-1), has low or no bacterial content,
contains growth factors and essential nutrients for
cells, in addition to having a high availability mostly
everywhere and low cost.
• Used in the first 20 min after avulsion. Milk only
prevents cell death rather than restoring normal
morphology and ability to differentiate and mitosis.
• Milk is able to maintain the osmotic pressure for
periodontal ligament cells but it does not have the
ability to reconstitute depleted cell metabolites and
restore viability.
 MILK

• Fibroblasts stored in milk remain vital but their

morphology was distorted.
• Milk can potentially maintain PDL cell viability
for up to 2 hours.
• The vitality, clonogenic and mitogenic capacity of
PDL cells in milk are similar to the values for
HBSS.
• Cooler temperatures reduce cell swelling, increase
cell viability and improve PDL cells recovery
• The drawbacks are that milk needs to be fresh and
kept refrigerated, it does not replace depleted cell
metabolites, and it does not facilitate cell mitosis.
 PROPOLIS
• Propolis is a natural substance produced by honeybees with remarkable
antioxidant, anti-inflammatory, antimicrobial and tissue regenerative
actions.

• Martin and Pileggi (2004) - teeth stored in propolis demonstrated the

highest viability for PDL cells, when compared to milk, saline or
HBSS.

• It can inhibit the late stages of osteoclast maturation so it may be

useful as an intracanal medicament to reduce resorption of traumatized
teeth.

• Casaroto et al (2010) - good results for maintenance of cell viability,

but root resorptions were visible, which compromises its efficacy for
this purpose.
 PROPOLIS

• 10% propolis was more effective than a 20% solution.

• Propolis could be used for avulsed teeth and that a 6-h

period of storage was more appropriate than 60 min of
storage.

• Porpolis is a promising medium for the maintenance of

PDL cell viability.

• Major disadvantage - not readily available to the public

and therefore of little value as a storage medium for
avulsed teeth.
Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 GREEN TEA EXTRACT

• Green tea extract - remarkable anti-inflammatory, antioxidant, anticarcinogenic

effects.
• Osmolality and pH were not ideal.
• Higher the extract concentration the more efficient the medium.
• Further in vivo research is necessary before its use can be recommended.
Jung et al, 2011

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 EGG WHITE
• Teeth stored in egg white for 6-10 h had a better incidence of repair than those
stored in milk for the same amount of time.
• Egg white has a pH of 8.6–9.3 and its osmolality is between 251 and 298
mOsmol Kg-1.
• No significant difference between egg white and HBSS at storage times of 1,
2, 4, 8 and 12 h has been established.
• Some experiments show a small loss of efficacy overtime, possibly due to
egg‘s high pH and also because the PDL cells could target the several egg
proteins as strange bodies.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 COCONUT WATER

• Coconut water is biologically pure and sterile, with a rich presence of amino
acids, proteins, vitamins, and minerals.

• This natural isotonic fluid is available in its natural form directly from the
coconut or in long shelf life packages and plastic bottles, mainly in tropical
countries.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 Coconut water was
superior to HBSS, milk or
propolis in maintaining
the viability of PDL cells.
Gopikrishna et al, 2008
Inflammatory resorption was more frequent
when the tooth was maintained in coconut
water compared with milk.
Thomas et al, 2008
Pearson et al, 2003

15 to 120 min storage in Coconut water has an acidic pH of 4.1, which

coconut water is as is deleterious to cell metabolism.
efficient as storage in Moreira-Neto et al, 2009
HBBS.
Thomas et al, 2008 Milk presented a better performance than
coconut water in relation to the cell viability.
Souza et al, 2009
Therefore - difficult to consider coconut water as an adequate storage medium for avulsed teeth
because of the difficulty of neutralizing the coconut water to obtain a pH of 7.0 under clinical
condition.
 MORUSRUBRA (RED MULBERRY)
• This fruit contain greater amount of flavonoids, alkaloids and polysaccharides in
addition to antioxidant substances.

• Though studies had showed promising results as storage / transport media for
avulsed teeth, their lack of availability limit their indication and its biological
properties have not been established yet.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 GROWTH FACTORS
• The use of growth factors supplemented in storage media can function as potent biological
mediators for the promotion of PDL regeneration.

• After 24 h of storage in different storage media supplemented with growth factors, that there
was an increase in the mitogenicity of PDL fibroblasts by 20 to 37%.

• However, this supplementation did not increase the mitogenic capacity of PDL fibroblasts
stored at room temperature for 2 to 8 h.

• Thus, supplementation of growth factors in storage median improved the effectiveness of the
media only when the storage period was long (more than 24 hours).

• For short periods of storage (2 to 8 h), the use of media without growth factors is preferable.

• However addition of growth factors on storage media need to be manufactured and distributed
for clinical use.
 PATIENT’S OWN SERUM
The histologic picture after the tooth had been preserved in serum for about one
hour showed that the tissues still stained well, indicating that serum can maintain
the vitality of the periodontal membrane during the critical extra-alveolar period
during tooth transplant or replant procedure.
EURO-COLLINS
• Hypothermal medium developed for preserving organs to be transplanted.
• Ph of 7.4 and osmolality of 420 mOsmol Kg-1 – favourable for cell growth
• Teeth stored in the Euro-Collins solution, observed similar results to those
observed after immediate replantation, with good repair of supporting tissues,
repair and reorganization of vessels and PDL collagen fibers and neoformation
of cementum. Their lack of availability and high cost make their routine use
unviable.
Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 RICETRAL

• Commercial oral rehydration formulation, which contains essential nutrients

like glucose and vital salts in concentrations considered adequate for the cell
metabolism.
• Ability of Ricetral to retain PDL cell vitality is similar to HBSS and both these
solutions are better than milk.
• Further research is necessary before its use can be recommended to confirm its
efficacy.

Rajendran et al, 2011

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 PROBIOTIC SOLUTION

• Probiotic may be able to maintain PDL cell viability as HBSS, milk, or saline.

• However further studies are required to confirm its beneficial effect.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 NORMAL SALINE

• Physiological pH and osmolality of 280 mOsmol Kg-1 - compatible to the

cells of PDL, but lacks essential nutrients such as magnesium, calcium and
glucose; necessary to the normal metabolic needs of the cells of the PDL.

• Saline solution was harmful to the cells of PDL in avulsed teeth if it is used
for longer than two hours.

×
Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 TAP WATER

• Least desirable transport medium

• Bacterial contamination, hypotonicity and non-physiological pH of 7.4 to

7.79 and an osmolality of 30 mOsmol Kg-1, which causes rapid PDL cells
lysis.

×
Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 STORAGE MEDIA

Comparing Efficacy (in maintaining PDL cell viability):

Eagle's culture medium = Viaspan = Euro collins = Custodiol = HBSS > Milk ≥
Propolis ≥ Green tea ≥ Egg > coconut water ≥ Ricetral.

Comparing the practicalities of using these solutions, cost-effectiveness and

ease of availability to the general public :

Milk seems to be most ideal transport media for avulsed tooth.

Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa SK et al, 2014
 EMERGENCY TREATMENT AT THE SITE OF AVULSION INJURY

1. Wash the tooth in running water without brushing or cleaning it and examine it
to be certain that the tooth is intact

2. Avoid touching or scraping the root surface of the tooth

3. Have the patient to rinse his/her mouth

4. Replace the tooth in its socket using gentle, steady finger pressure

5. Take the patient to the dentist immediately

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 The tooth has already been replanted at the site of avulsion

Clean the area with

Do not extract Suture gingival
water spray, saline
the tooth lacerations
or chlorhexidine

Administer systemic
Verify normal of
antibiotics - Apply a flexible
the replanted
Doxycycline splint for a
tooth both
In young patients - period of 2
clinically and
phenoxymethyl weeks
radiographically
penicillin
GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION
 OPEN APEX CLOSED APEX

• Goal for replanting still -

• Root canal treatment is
developing (immature)
done after 7 – 10 days of
teeth in children is to allow
replantation and before
for possible
splint removal
revascularization of the
tooth pulp • Calcium hydroxide is
placed as an intracanal
• If that does not occur, root
medicament until filling of
canal treatment is
the root canal
recommended

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

The tooth has been kept in storage media with the extraoral dry time less than
60 minutes

CLOSED APEX
• If contaminated, clean the root surface and apical foramen with a
stream of saline and place the tooth in saline
• Remove the coagulum from the socket with a stream of saline
• Examine the alveolar socket
• If there is a fracture of the socket wall, reposition it with a suitable
instrument
• Replant the tooth slowly with slight digital pressure
• Continue with the treatment as in the case of the tooth that has already
been replanted at the site of avulsion

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

Alveolar socket Tooth rinsed – saline

Reimplantation
 OPEN APEX

• If contaminated, clean the root surface and apical foramen with a

stream of saline
• Remove the coagulum from the socket with a stream of saline and
then replant the tooth
• If available, cover the root surface with minocycline hydrochloride
microspheres before replanting the tooth
• After this, continue with the same treatment as in the case of the
tooth that has been replanted at the site of avulsion

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 Extraoral dry time longer than 60 minutes

CLOSED APEX

• Delayed replantation has a poor long-term prognosis

• Periodontal ligament will be necrotic and not expected to heal
• Goal - to promote alveolar bone growth to encapsulate the replanted
tooth
• Expected outcome – ankylosis and resorption of the root
• In children below 15 years, if ankylosis occurs and when the
infraposition of the tooth crown is more than 1mm, it is recommended
to perform decoronation to preserve the contour of the alveolar ridge

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 TECHNIQUE FOR DELAYED REPLANTATION

• Remove attached necrotic soft tissue with gauze

• Root canal treatment can be done on the tooth prior to replantation,
or it can be done 7-10 days later
• Remove the coagulum from the socket with a stream of saline
• Examine the alveolar socket. If there is a fracture of the socket wall,
reposition it with a suitable instrument
• Immerse the tooth in a 2% sodium fluoride solution for 20 minutes
• Replant the tooth slowly with slight digital pressure and suture
gingival lacerations

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 CLOSED APEX

• Verify normal position of the replanted tooth clinically and

radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Administration of systemic antibiotics.
 OPEN APEX

• Delayed replantation has a poor long-term prognosis

• The periodontal ligament will be necrotic and not expected to heal
• Goal – maintain alveolar ridge contour
• Eventual outcome
• – ankylosis
Remove attached necroticand
soft resorption
tissue with gauzeof the root
• If delayed replantation
• is done
Root canal treatment canin a child,
be done future
on the tooth priortreatment
to planning
replantation, or it can be done 7-10 days
must be done to take into account the occurrence of tooth ankylosis
and the effect of ankylosis on the alveolar ridge development.
• Treatment – similar to that of closed apex .

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 FOLLOW – UP PROCEDURES

ROOT CANAL TREATMENT

• In teeth with closed apex, ideal time to begin root canal treatment is 7
-10 days after replantation procedure. Calcium hydroxide - intracanal
medication for up to 1 month followed by root canal filling.
• In teeth with open apices, that have been replanted immediately or
kept in appropriate storage media, pulp revascularization is possible.
Root canal treatment is avoided unless there is clinical and
radiographic evidence of pulpal necrosis.
• Root canal treatment - done prior to replantation in a tooth that has
been dry for more than 60 minutes before replantation.

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 FOLLOW – UP

Replanted tooth – monitored by frequent controls during the first year

(once a week during the months 1, 3, 6 and 12) and then yearly
thereafter
Clinical and radiographic examinations will provide information to
determine the eventual clinical outcome

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 FAVOURABLE OUTCOME

OPEN APEX CLOSED APEX

Tooth is asymptomatic
with normal mobility and
normal percussion sound.
Radiographic evidence of
arrested or continued root
formation and eruption.
Tooth is asymptomatic
with normal mobility and
normal percussion sound.
No radiographic evidence
of resorption or
periradicular osteitis; the
lamina dura appears
normal.

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 UNFAVOURABLE OUTCOME

OPEN APEX CLOSED APEX

Tooth is symptomatic with
excessive mobility or no mobility
and high-pitched percussion
sound. In case of ankylosis, the
crown of the tooth will appear to
be in an infraocclusion position.
Radiographic evidence of
resorption (inflammatory,
infection-related or ankylosis-
related replacement resorption)
Tooth is symptomatic with
excessive mobility or no
mobility and high-pitched
percussion sound.
Radiographic evidence of
resorption (inflammatory,
infection-related or
ankylosis-related replacement
resorption)

GROSSMAN’S ENDODONTIC PRACTICE – 12th EDITION

 HEALING

SURFACE INFLAMMATORY
REPLACEMENT RESORPTION
RESORPTION RESORPTION

• Extensive damage – PDL, • Superficial

Cementum resorption • Radiolucent bowl-
• Healing from alveolus – union- cavities- shaped cavitations
tooth & bone cementum & along the root
• Root replaced- bone outer dentin. surface
• Mobility – absent • Repair • clinically- loose and
• Younger patients- infraocclusion process extruded

TEXTBOOK AND COLOR ATLAS OF TRAUMATIC INJURIES TO THE TEETH BY

J.O.ANDREASEN AND F.M.ANDREASEN – 3rd EDITION
 HEALING WITH SURFACE RESORPTION
HISTOLOGICALLY
Localized areas on root surface which show superficial resorption lacunae
repaired by new cementum.
Self-limiting and shows repair with new cementum.
RADIOGRAPHICALLY
Not – disclosed radiographically - small size.
Ideal angulation - small excavations of the root surface with an adjacent
periodontal ligament space of normal width.
CLINICALLY
Tooth is in a normal position and a normal percussion tone can be elicited
TEXTBOOK AND COLOR ATLAS OF TRAUMATIC INJURIES TO THE TEETH BY
J.O.ANDREASEN AND F.M.ANDREASEN – 3rd EDITION
 HEALING WITH REPLACEMENT RESORPTION
HISTOLOGICALLY

Fusion of the alveolar bone and the root surface.

Etiology – absence of vital periodontal ligament cover on the root surface

RADIOGRAPHICALLY

Disappearance of normal periodontal space and continuous replacement of root

substance with bone

CLINICALLY
Tooth is immobile. Children-infraocclusion.
Percussion tone is high
TEXTBOOK AND COLOR ATLAS OF TRAUMATIC INJURIES TO THE TEETH BY
J.O.ANDREASEN AND F.M.ANDREASEN – 3rd EDITION
 HEALING

REPLACEMENT INFLAMMATORY SURFACE

RESORPTION RESORPTION RESORPTION
 SPLINTING
• Semirigid fixation for one to two weeks is recommended.
• Splint should allow movement of the tooth, should have no memory and
should not impinge on the gingiva and/or prevent maintenance of oral
hygiene.
• Titanium trauma splint – effective and easy to use

COHEN’S PATHWAYS OF THE PULP

 CONCLUSION

• Trauma to teeth is a common occurrence that every dental surgeon must

be prepared to assess, evaluate and treat when necessary.

• Understanding the basic principles and therapeutic protocols can help to

provide the appropriate treatment and prevent complications.
 REFERENCES

1. Grossman’s endodontic practice

2. Cohen’s pathways of the pulp

3. Ingle’s textbook of endodontics

4. Textbook and color atlas of traumatic injuries to the teeth by J.O.Andreasen

and F.M.Andreasen

5. Extra-Alveolar Storage Media for teeth : A Literature review by Sangappa

SK et al, 2014;2(7):963–72
THANK YOU