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Traumatic Injuries to the Teeth

  • Crown Fractures

  • Crown-Root Fractures

  • Root Fractures

  • Luxation Injuries

  • Avulsion

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Management of the Avulsed Tooth

  • Overview

  • Periodontal Ligament Responses

  • Treatment Considerations

  • Pulpal Prognosis / Endodontic Rationale

  • Treatment Regimen

Avulsed Permanent Teeth

  • Incidence: 0.5% to 16% of traumatic injuries

  • Main Etiologic Factors:

    • Fights

    • Sports injuries

    • Automobile accidents

Common Avulsed Teeth Characteristics

  • Most Common Tooth Avulsed: Maxillary central incisor

  • Mandibular Teeth: Seldom affected

  • Frequency: Usually involves a single tooth

Demographics for Avulsed Permanent Teeth

  • Most Common Age Range: 7 to 11 years

    • Context: Permanent incisors erupting

    • Characteristics: Loosely structured periodontal ligament (PDL)

Associated Injuries with Avulsed Teeth

  • Fracture of the alveolar socket wall

  • Injuries to the lips and gingiva

Management Considerations for Avulsed Tooth

  • Primary Tissue Concern:

    • Pulp?

    • Socket?

    • PDL?

  • Ultimate Goal:

    • Achieve PDL healing without root resorption

    • Critical Factor:

      • Maintaining an intact and viable PDL on the root surface

Periodontal Ligament Responses

  • Types of Resorption:

    • Surface Resorption

    • Replacement Resorption (Ankylosis)

    • Inflammatory Resorption

Treatment Considerations

  • Factors Affecting Management:

    • Extraoral time

    • Extraoral environment

    • Root surface manipulation

    • Management of the socket

    • Stabilization

Viability of PDL Cells

  • Critical to maintain viability during the management of avulsed teeth

Storage Media for Avulsed Teeth

  • Inappropriate Options:

    • Tap Water

    • Dry storage

  • Recommended Options:

    • Saliva, Saline, and Milk

      • Milk is preferred due to better physiologic osmolality and fewer bacteria

      • Ideal to use homogenized Vitamin D milk

Comparative Storage Media Efficacy

  • Storage for 2 Hours:

    • Milk: Periodontal healing almost as good as immediate replantation

    • Saliva: Extensive replacement resorption

  • Storage for 6 Hours:

    • Milk: Healing associated with immediate replantation

    • Saliva: Extensive replacement resorption

Hank's Balanced Salt Solution

  • Advantages:

    • Complete healing after 6 and 12 hours

    • Good for extended periods (72 and 96 hours)

  • pH and Osmolality:

    • Properly maintains root health

Recommended Storage Media Summary

  1. Immediate replantation in the socket

  2. Cell culture medium (0.9% Sodium Chloride Irrigation)

  3. Milk (VITAMIN A & D low-fat)

  4. Physiologic saline

  5. Saliva

Root Surface Manipulation Guidelines

  • PDL Cell Viability:

    • Preserve by avoiding curetting and caustic chemicals

  • Extraoral Dry Time:

    • < 1 hour: PDL healing is still possible

    • 1 hour: Loss of PDL viability

Socket Management Steps

  • Remove contaminated coagulum

  • Irrigate with sterile saline

  • Assess for fractional sockets and reposition as necessary

Stabilization Techniques

  • Multiple Types of Splints:

    • Acid etch composite

    • Flexible splints using fishing line, wire

    • Rigid composite splints

    • Cross-suture splints for cases with no adjacent teeth

Endodontic Rationale for Pulp Management

  • Focus on maintaining healthy pulp conditions:

    • Acknowledge the time of storage, maturity of the root, and any possible treatments needed post-replantation

Follow-up Considerations for Avulsed Teeth

  • Symptoms to monitor:

    • Pain and infection post-treatment

    • Pulp vitality assessments

  • Regular follow up:

    • Early monitoring of tooth stability and overall health

Emergency Treatment Recommendations

  • Understand emergency protocols for different scenarios based on extraoral dry times and maturity of tooth apex

  • Antibiotic Recommendations:

    • Doxycycline for individuals above 12 years

    • Amoxicillin for individuals under 12 years

Final Summary

  • Be prepared with a Dental Trauma Kit

  • Use physiologic storage media for the delayed treatment of avulsed teeth

  • Follow American Association of Endodontists (AAE) guidelines for all treatment protocols.