AVULSION

AVULSION ( EXARTICULATION OR TOTAL LUXATION ) DEFINITION : The tooth is displaced totally out of it’s socket.

CLINICAL APPEARANCE The socket is found empty or filled with coagulum.

EPIDEMIOLOGY Rare injuries(1.6% of dental injury) Primary dentition > secondary dentition Boys > girls The teeth most commonly damaged are upper central incisor

ETIOLOGY Cause: accident contact sports fighting Predisposing factor : Cl II malocclusion Periodontal disease

HISTORY TAKING When did the injury take place ? Where did the injury take place ? How did the injury take place ?

HISTORY TAKING Has treatment been provided elsewhere ? Has there been previous trauma ? Has avulsed tooth been accounted for ?

HISTORY TAKING MEDICAL HISTORY DENTAL HISTORY SOCIAL HISTORY FAMILY HISTORY

Neurological Assessment - Obtain information : loss of consciousness, neck or head pain, and numbness - Ask about the event…. amnesia? - Other signs: nausea, vomiting, drowsiness, blurred vision

EXTRAORAL EXAMINATION Facial wound Fracture of mandible / maxilla Occlusion Mandibular movement

INTRAORAL EXAMINATION Solf tissue Foreign body Alveolar bone fracture

RADIOGRAPHIC EXAMINATION Are routinely to determine the socket Check for supporting structure and adjacent tooth Compare with the future radiographs

RADIOGRAPHIC EXAMINATION

TREATMENT OF AVULSED TOOTH Success of treatment depend on Extraoral time Storage media Stage of tooth development

EXTRAORAL TIME After 60 minutes of dry storage media very few PL cells remain viable. 120 minutes - complete PL cells necrosis.

STORAGE MEDIA Hank’s balance salt solution (HBSS) Milk Saliva Water

TREATMENT OF AVULSED TOOTH Preparation of the avulsed tooth Preparation of the socket Replantation Splinting Follow up

PREPARATION OF THE AVULSED TOOTH Saline to remove foreign bodies Avoid scraping the root surface

PREPARATION OF THE SOCKET The region should be anesthetized Gently clean with NSS to remove clotted blood and foreign materials

PREPARATION OF THE SOCKET

REPLANTATION Press the tooth gently into the socket Compress buccal and lingual plate of bone Take radiograph immediately

REPLANTATION

SPLINTING Requirements of splint Provide stabilization for the replanted tooth Slight physiologic movement Hygienically designed Not leave the replanted tooth in traumatic occlusion

SPLINTING Wire composite splint Composite splint Removable flexible acrylic splint Orthodontics wire Etc.

SPLINTING

SPLINTING How long? the fixation period should be sufficient to allow the reattachment of PDL. This will take from 1 – 3 weeks.

FOLLOW UP A well designed follow up procedure is diagnose complication. 1 week. 2 weeks. 3 weeks. A radiographic examination is able to demonstrate periapical radiolucency

FOLLOW UP 6 weeks. A clinical and radiographic examination A clinical and radiographic examination is able to demonstrate most case of inflammatory resorption

FOLLOW UP 2 and 6 months. Optional for cases with questionable healing 1 year. A clinical and radiographic examination can ascertain the long – term prognosis

WOUND HEALING AFTER REPLANTATION Surface resorption Replacement resorption Inflammatory root resorption

Surface resorption Surface resorption is manifested as a excavations on the root surface without associated breakdown of the lamina dura.

Surface resorption

Replacement resorption Replacement resorption (ankylosis) is initially seen as a disappearance of PDL space, later follow by a substitution with bone.

Replacement resorption PDL injury -> inflammation -> osteoclastic activity -> fusion between bone and root surface

Inflammatory resorption Inflammatory resorption is seen as bowl shaped cavities on the root surface with an associate radiolucency affecting the lamina dura.

Inflammatory resorption

Summary

The influence of storage conditions on the clonogenic capacity of periodontal cell : implication for tooth replantation P.C. Lekic , D.J. Kenny & E.J. Barrett International Endodontic Journal (1998)31,137-140

INTRODUCTION Viable periodontal ligament (PL) cells are required for the healing of avulsed teeth after replantation.

INTRODUCTION The viability of PL cells in extra- alveolar conditions may be extended by incubating the avulsed tooth in a physiologic storage medium.

INTRODUCTION Regeneration of PL following replantation is closely related to preservation of the viability PL cells that adhere to avulsed teeth

OBJECTIVES To investigate the effects of combinations of storage media on the clonogenic capacity of human PL cells at two different extra alveolar period.

MATERIALS AND METHODS 20 human premolar teeth were extracted Aged 11 – 14 years 4 storage media (saliva , milk , HBSS , MEM) All teeth were assayed at 30 and 60 min

MATERIALS AND METHODS Twenty extracted human premolars Time 0 min 15 teeth 5 teeth Saliva (23c) MEM (+4c) 5 teeth Per condition Milk Saliva HBSS MEM (+4c) One-half of PL tissue explanted from premolar(cells released and analyzed for clonogenic capacity)

RESULTS

CONCLUSION Immediate storage of a avulsed teeth in autologous saliva , a followed by transfer to chilled milk , preserves the presence of sufficient progenitor cells in the PL to warrant replantation and the possibility of PL healing at 60 min extra-alveolar duration.

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REFERENCES Peter J. Robinson,Louis H. Grernsey: Clinical Transplantation in Dental Specialties.C.V.Mostby,Missouri,1980 G.J.Robert,P.Longhurst: Oral and Dental Trauma in Children and Adolestcents,Oxford university press Inc. New York, 1996 Mitsuhiro Tsukiboshi: Autotransplantation of Teeth,Quintessence,Tokyo,2001 J.O.Andreasen,F.M.Andreasen,L.K.Bakland, et al: Traumatic Dental Injury.Munksgaard.Copenhagen,1999 M.E.J.Curzon: Handbook of Dental Trauma,Wrigth,Jordan Hill,Oxford,1999

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