Avulsion and Replantation

8/2/2019 Avulsion and Replantation

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AVULSION ANDRE-IMPLANTATION

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ETIOLOGY AND FREQUENCY Tooth avulsion

(ex-articulation) impliestotal displacement of thetooth out if its socket.

0.5% to 16% in permanentdentition

7 to13% in the primarydentition

Permanent dentition fightsand sports injuries

Primary dentition fallsagainst hard objects

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CLINICAL FINDINGS Maxillary central incisors are frequently avulsed

teeth , while lower jaw seldom affected

Occurs in 7 to 9 years of age , when permanentincisors are erupting-loosely structured

periodontal ligament surrounding erupting

teeth provides minimal resistance to an

extrusive force.

Avulsion involves single tooth mostly

Multiple avulsions occasionally encountered

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Radiographic findings Suspicion of bone fractures

In primary dentition ,radiographs will often

reveal that a suspected avulsion is actually anintrusion where the primary tooth is buried in

the jaw

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PATHOLOGY

Divided into pulpal and periodontal reactions

Healing reaction depend upon the extra

alveolar and extra alveolar handling

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PULPAL REACTIONSDistinct pulpo-dentinal responses

which can occur after immediatereplantation have been classified

i. Regular tubular reparativedentin

ii. Irregular reparative dentin withdiminished tubular structures

iii. Irregular reparative dentin withencapsulated cells

iv. Irregular immature bone

v. Regular lamellated bone orcementum

vi. Internal resorption

vii. Pulp necrosis

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Extensive pulpal

changes could be

obtained as early as 3

days after replantation .

Damage observed in

coronal part of the pulp.

Signs of healing wereseen within 2 weeks

after replantation.

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Damaged tissue

mesenchymal cells and

capillaries

In border zone between

vital and necrotic tissue ,

neutrophils and round

cells were present insome cases

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The healing process led to the formation ofnew cell layer along the dentinal wall in the

regions where the odontoblasts had beendestroyed.

New hard tissue formation along the dentinal

walls was noted after 17 days , but it most casesmatrix formation started somewhat later.

Gradually the cells along the pup walls beganto show similarities to odontoblasts withcytoplasmic processes within the newly formedmatrix.

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Severe pulpal damage wasmore often found in teeth

with completed rootformation than in those

with an open apex, wherethe pulpal repair seemedalso to be more rapid.

Mitoises were seen inbands of schwann cells 14days after replantation.

Regenerating nerve fiberswere observed after 1month.

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In microangoigraphic studies of the

revascularization process after replantationof

teeth in dogs ,it was demonstrated that in

growth of new vessels could be seen 4 days

after repalantation. After 10days vessels were

seen in the apical half of the pulp and after 30

days in the entire pulp.

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PERIODONTAL HEALING Coagulum is found between tow parts of severed

periodontal ligament

Line of separation is often situated in the middle of

the periodontal ligament Proliferation of connective tissue cells soon occurs

3 to 4 days

After 1 week the epithelium is reattached at thecemento enamel junction clinical importance , itmay imply a reduced risk gingival infection andreduced risk of bacterial invasion

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After 2 weeks , the split line in the periodontal

ligament is healed and collagen fibers are seen

extending from the cemental surface to the

alveolar bone . Resorption activity can now be

recognized

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Histological examination Healing with normal healing

Healing with surface resorption

Healing with ankylosis (replacementresorption)

Healing with inflammatory resorption

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Healing with a normal periodontal healing

Complete regeneration of the periodontal ligamentusually takes place 2-4 weeks .

Occur only if the inner most layers along the root

surface are vital.

Normal periodontal ligament space without signs

of root resorption

Clinically normal

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Healing with surface resorption Localized areas along the root surface which show

superfacial resorption lacunae repaired by new cementum surface resorption

Self limiting show s repair with new cementum

Most resorption lacunae are superfacial and confined to the

cementum.

Due to smaller size surface resorption are not disclosed

radiographically.

Clinically normal

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Healing with ankylosis Ankylosis represents a fusion of the alveolar bone and root

surface and can be demonstrated 2 weeks after replantation .

Etiology related to absence of a vital periodontal ligamentcover on the root surface.

Replacement resorption develops in two different directions extent of the damage to the periodontal ligament cover ofthe rootprogressive resorption which gradually resorbs theentire the root

Tansient replacement resorption in which a once establishedankylosis later disappears possibly related to areas of minordamage to the root surface .

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Progressive resorption is elicted when the entire

periodontal ligament is removed before

replantation or after replantation.

The ankylosed root becomes part of thenormal bone remodelling system and is

gradually replaced by bone . After some time ,

little of the tooth substance remains . At this

stage the resorptive processes are usuallyintensified , along the surface of the root canal ,

a phenomenon known as tunneling resorption

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Radiographicallydisappearance of the

normal periodontalspace and continuousreplacement of rootsubstance with bone.

Replacementresorption recognizedradiographically 2months after

replantation ; howeverin most cases 6 monthsfor 1 year elapses

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Clinically tooth is immobile and children

frequently infraposition

Percusion tone is high , differing clearly fromadjacent tooth.

In cases of TR - a small areas of periodontal

ligament space has disappeared.

Dis appearence always happens within the first

year, is followed by the return of normal

percussion.

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HEALING WITH INFLAMMATORY

RESORPTION

Histologically

-bowl shaped resorption cavities in cementum

and dentin associated with inflammatorychanges in the adjacent periodontal tissue.

- consists of granulation tissue with lymphocytes

, plasma cells , and PMN

Root surface under goes intense resorption with

numerous Howships lacunae and osteocalsts

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Pathogenesis Minor Injuries to the periodontal ligament and /or

cementum due to trauma or contamination with

bacterial induce small resorption cavities on the rootsurface , presumably in the same manner as in surfaceresorption.

If these resorption cavities expose dentinal tubulesand the root canal contains infected necrotic tissue ,toxins from these areas will penetrate along thedentinal tubules to the lateral periodontal tissues andprovoke an inflammatory response.

This in turn will intensify the resorption process whichadvances towards the root canal. The resorptionprocess can progressively very rapidly ie. Within a fewmonths the entire root can be resorbed.

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Inflammatory resorption is especially frequent

and aggressive after replantation in patients

from 6 to 10 years of age. The explanation for

this probably a combination of wide dentinal

tubules and /or a the protective cementum

cover. In older age groups , the resorption

process is allowed to progress and involvelarge areas of the root surface , replacement

resorption can take over inflammatory

resorption has been arrested by endodontictherapy.

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Radiographically , inflammatory resorption ischaracterized by radiolucent bowl shaped cavitationsalong the root surface with corresponding excavationsin the adjacent bone . the first radiographic sign

inflammatory resorption can be demonstrated as earlyas 2 weeks after replantation and usually firstrecognized at the cervical third of the root. As in thecase ankylosis , this resorption type is usually evident

within the first 2 years after replantation.

Clinically , the replanted tooth is losse and extruded.Moreover t tooth is sensitive to percussion andpercussion tone is dull.

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Treatment of the

Avulsed tooth

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Case history

-time interval between injury and replantation as well as the

conditions which the tooth has been stored.(eg , saline , saliva, milk, tap water, or dry )

Periodontal healing of replanted dog teeth stored in milk and

egg albumen(dental traumatolgy 2009

Commercial tissue culture medium(viaspan) could be used

for extra oral storage.

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Examination for surface contaminants

Examination of alveolus

Pre treatment radiograph

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Careful planning is of outmost important for

the success of replantation of avulsed teeth.

Following conditions should be considered

- should be advanced periodontal disease- socket should be reasonably intact

- extra alveolar period should be considered

ie. Extra alveolar period exceeding 1 hour areusually associated with marked root resorption .

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Replantation is decided upon following procedures


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Replantation is decided upon following procedures

Placed in saline

Root surface rinsed with saline to remove visiblecontaminants

Alveolus rinsed with saline to remove coagulum

No effort should be made to sterilize the root surface

Socket is then examined for any evidence of fracture Local anesthesia not necessary unless gingival

lacerations require suturing or the alveolar socket.

Tooth is replanted with minimal digital pressure

Rigid splinting increases the extent of root resorption(acta odontol scand 1975, 1981)

Replanted teeth should , therefore only splinted forone week to ensure adequate periodontal support , asgingival fibers are already healed by this time.

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Decreased extra alveolar period Cleaned if dirty by rinsing in tap water and placing

it into the socket

Animal experiments have shown that the storage inmilk or saliva has almost the same effect as storagein saline .

Long term storage in tap water has adverse effectin periodontal healing

Patient should be instructed to keep the tooth inplace with either finger pressure or by biting on ahandkercheif

Tetanus prophylaxis is important

Experiment al studies have shown that systemicantibiotics may lesson the resorption attack on theroot surface.

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Prolonged extra alveolar period Periodontal ligament can be assumed to be necrotic

root surface should be treated with various substances Sodium flouride(Shulman lb , Gedalia Jdent reaserch 1973)

Tetracycline (SelvingActa odontal scand 1990)

Stannous flouride

Citric acid (Klinge - Acta odontal scand 1984) Hypochloric acid (nordenram-scand j dent research -1973)

Calcium hydroxide(MinkJ Dent research -1968)

Formalin

Alcohol

Diphosphantes (butcher- j dent research -1955)

Indomethacin(walsh-asdc dent child- 1987)

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In case of closed apical foramen endodontic treatment should be performed prophylactically

,as pulp necrosis can be anticipated.

Recent experimental studies in monkeys have shown thatextra oral root fillings materials themselves apparently injurethe periodontal ligament. This could be result of seepagethrough the apical foramen or mechanical preparation of theroot canal , resulting in increased ankylosis apically whencompared to non endodontically treated teeth.(AndersonJOE 1981 )

Thus endodontic treatment should be delayed for 1 weekafter replantation in order to prevent development of

ankylosis and inflammatory resorption , as well as to allowsplicing of periodontal ligament fibers which limits seepage ofpotentially harmful root filling materials into the traumatizedperiodontal ligament.

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When apical foramen wide open ! If replantation has taken place within 3 hours

after injury it is justifiable to awaitrevascularization

radiographic controls should be made 2 and 3weeks after replantation- periapical ostetis seen

at this time If this occurs endodontic therapy is initiated

and calcium hydroxide introduced to eliminatethe periapical inflammation and arrest rootresorption .

After a week endodontic procedure isproceeded

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The incorporation of fluoride ions in the cementum layer has been

found to yeaild a root surface resistant to resorption. It has been

suggested that mature teeth with prolonged dry extra alveolar periods

(ie greater then 1 hour ) be placed in a fluoride (2.4% of sodiumflouride) at ph 5.5 solution for 20 minutes prior to replantation

Thereafter the root surface is rinsed with saline and the tooth replanted

and splinted for 6 weeks . the effect of this treatment seems to be 50%

reduction of the progression of root resorption of replanted human

teeth

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Oooooooooooooouch!Resorption of root ?

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Several attempts made

Slicone grease and methyl metha acraylate

(MinkJ dent res-1968)

Absorbable gel sponge(sherman-1968)

Venous tissue

Fascia and cutaneous connective tissue

Biocompatibility evaluation of alendronate paste in rat'ssubcutaneous tissue

Dental traumatolgy 2009

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Replacement of the apical part Cast vitallium implant(quintessence int 1972)

Ceramic implant , dense cintered aluminuim

oxide (kirschner dental implants and

materials system -1980)

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Pulpal healing and pulp necrosis revasucalrization of the pulp will occur in replanted teeth with

completed root formation , provided that replantation is carried outimmediately .

pulps of teeth with incomplete root formation can becomerevascularized if replantation is carried out within 3 hours .pulpalsensibility test are unrelaile immediately after replanatation.

Functional repair of pulpal nerve fibers in human teeth isestablished approximately 35 days after replantation . at this timeelectrical stimuli can elicit sensibility responses.

In the absence of a reaction to electrical stimulation , it should be

borne in mind that a decrease in the size of the coronal part of thepulp chamber or root canal on the radiograph is a more reliablesign of vital pulp tissue thermal or electrical pulp testing

The most significant predictors of pulpal healing appear to be thewidth and length and type of extra alveolar storage .

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The width and length of the root canal The relationship between tha diameter of the apical

foramen and the chance of pulpal revascularizationapparently is an expression of the size of the contact area atthe pulpo-periodontal interface, whereas the length of theroot canal probably reflects the time necessary torepopulate the ischemic pulp.

With a favorable ratio apical foramen and short root canalversus a narrow apical foramen and long root the odds foran intervening pulpal infection are reduced.

A limiting factor in pulpal revascularization afterreplantation appears to be an apical diameter of under1.mm . This size , however , is to a certain degree arbitrary,as pulp in teeth with constricted apical foramina are usuallyextripated prophylactically.

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Storage period and storage media Non Physiologic storage

Eg. Prolonged tap water storage ,chlorine

chlorhexidine

alcohol

Physiologic storage

eg. Saliva , saline or milk

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The best media tested during research indescending order were ViaSpan, EaglesMedium, and Hanks Balanced Salt Solution

HBSS).

Despite the fact that ViaSpan and Eagles

Medium provide the best storage environment,these media are not practical options. Thesemedia are not readily available to school nursesand are not packaged for individual uses.

Despite the time advantages, these media maybe cost prohibitive when compared to otheroptions available, for example, ViaSpan is $600a gallon.

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HBSS has unquestionably been the most testedsolution. Of the other suggested solutions (seechart 1), the options that provide acceptable

storage have limited availability and the optionsthat are readily available are either far inferiorto HBSS or are actually damaging to the PDLcells.

0.9% normal sterile saline has a compatibleosmolality with the PDL cells,but does notcontain any nutrients to help maintain cell

vitality. Therefore, sterile saline is only good asa short-term storage medium for avulsed teethand should not be used if the tooth cannot bereimplanted within 1 hour.

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Milk has a compatible osmolalty with the PDL cells of an avulsed tooth

and has been tested as effective to store teeth for no more than 2-3

hours. Milk does not contain the necessary nutrients to maintain the

PDL cells for any longer periods of time.

Additionally, there are issues related to the practicality of using milk

that severely impact its efficacy. Milk sounds, like an easy, inexpensive

method for storage, however, using milk is not as effective as other

media available and is logistically more difficult than other, moreeffective options.

For example, if a child avulses a tooth on a remote sports playing field

no milk will be readily available. Additionally, the milk needs to be

kept refrigerated during transport for the best prognosis. Therefore, aschool nurse should have a storage media that can be located at the

scene of any accident.

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There is another commercially available

product marketed for the storage of avulsed

teeth called EMT ToothSaver, which containsantibiotic-free protective medium.

EMT ToothSaver has not been tested forefficacy and does not have FDA approval nor

the ADA Seal of Acceptance. The

compatibility of EMT ToothSaver cannot beknown without research testing and therefore,

this media cannot be recommended.

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Like water, saliva is not compatible with the

PDL cells. In addition to the damage the saliva

can cause to the cells, saliva also contains

bacteria that can cause the PDL cells tobecome infected. Therefore, it is not

recommended to store teeth in neither a cup

with saliva nor in the mouth of the victim oranother person.

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There have been some recommendations touse tap water with a pinch of salt. Somebelieves this recommendation to be a

misunderstanding of what HBSS and sterilesaline are. HBSS is not a saltwater solution, buta scientifically designed researched fluid thatcontains all of the essential metabolites and

glucose necessary for maintenance of cells.Adding salt to water will create a solution that isdamaging to PDL cells.

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HBSS is the authors recommendation for the

optimal storage media for use in schools. HBSS,

found in Save-A-Tooth has been tested for efficacy

and is able to be kept in the school nurses officeas well as at sporting events without temperature

control methods. Hopefully, this article provides

information that will enable a school nurse to

select the best storage medium for avulsed teeth.This selection can significantly affect the ultimate

prognosis for avulsed replanted teeth.

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it appears that CW may be better alternative to HBSS ormilk in terms of maintaining PDL cell viability after

avulsion and storage.

(A quantitative analysis of coconut water: a newstorage media for avulsed teeth )..Velayutham Gopikrishna MDSa, , ,Toby Thomas MDSb and Deivanayagam Kandaswamy MDs

(oooo 2008))

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http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP1-4RP4KPR-11&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1041573907&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f2b86c620d28667b38e7b434d3eafa79http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP1-4RP4KPR-11&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1041573907&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f2b86c620d28667b38e7b434d3eafa79http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP1-4RP4KPR-11&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1041573907&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f2b86c620d28667b38e7b434d3eafa79http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP1-4RP4KPR-11&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1041573907&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f2b86c620d28667b38e7b434d3eafa79


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Comparison of coconut water, propolis, HBSS,and milk on PDL cell survival.

Gopikrishna V, Baweja PS, Venkateshbabu N,Thomas T, Kandaswamy D.

(joe 2008)

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Viability of human fibroblasts in coconut water

as a storage medium

(IEJ-2009)

Coconut water was worse than milk in

maintaining human fibroblast cell viability.

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Decision tree in avulsed tooth


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Decision tree in avulsed tooth

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Hanks balanced salt solution REAGENT COMPOSITION Potassium Phosphate 0.44 mM

Potassium Chloride 5.37 mM Sodium Phosphate,

Dibasic 0.34 mM

Sodium Chloride 136.89 mMD-Glucose 5.55 mM

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Periodontal healing and root resorption Periodontal healing isn usually around 20%

Clinical factors dry extra alveolar period

seems to be the most crucial .

In most clinical cases , avulsed teeth have been

stored either in the oral cavity or in othermedia, such as physiologic saline or tap water,

before replantation.

Recent experimental studies have indicated thatthe storage media more than the length of the

extra alveolar period determine prognosis.

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Stage of root development The layer of PDL on the root can vary in thickness

from a single cell layer to the full thickness of aperiodontal ligament.

Thus the more mature the root formation thethinner is PDL tissue layer. This could possibly

explain the influence of root formation upondevelopment of root resorption found in a recentclinical study.

Thus a thick periodontal ligament , which

supposedly can tolerate a certain dry periodbefore evaporation has killed the critical cell layersnext to the cementum , showed less dependenceupon dry storage

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Replacement resorption (ankylosis) Diagnosed clinically after 4- 8 weeks

Mechanical device perio test register s the mobility Severity of ankylosis initial damage of root surface ,

age of the patient and type of endodontic treatmentperformed.

young patient is that ankylosis can anchor the toothin its position and thus disturb normal growth of thealveolar process.

The result is a marked infraocclusion of the

replanted tooth with migration and malocclusion ofadjacent teeth

Treatment extraction or luxation with orthododnticextrusion

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Inflammatory resorption Can occur 3 months

after replantation

Related to presence of

an infected pulp

Arrest of resorptive

process cab be achieved

by appropriateendodontic therapy

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Resorption by erupting teeth A special resorption is encountered when a replanted

tooth comes into contact with an erupting tooth, aswhen a lateral incisor lies close to the path of anerupting canine.

Apparently the pressure , exerted by the follicle of theerupting tooth initiates or accelerates root resorption .

A method to minimize the risk of resorption from theerupting tooth could be early removal of the primarypredecessor in order to facilitate eruption , possibly ina direction away from the replanted tooth .

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Root development and disturbances in


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root growth

Root growth

Continued root development can occurespecially if the pulp has become totally

revascularized .However root development can continuedespite pulp necrosis. root development is

partially or completely arrested and the rootcanal becomes obliterated or bone and PDLcan invade the pulp chamber which in somecases can lead to an ankylosis

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Phantom roots

A rare complication to avulsion of immature permanentteeth is the formation of an abnormal root structure at the

site of tooth loss.

The explanation for this appears to be that pulp tissue andHertwigs epithelial root sheath remain in the alveolar

socket after avulsion.

These tissues resume their formative function after injury.

New dentin is formed by the odontobalsts and the hertwigsepithelial root sheath initiates root development.

A parallel to this is the tooth like structures occasionally

formed when natal or neonatal teeth are extracted and

dental papilla is left situ.rxdentistry.net

Complications due to early loss of teeth


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Malformation in the developing dentition

disturbance In the development ofpermanent successors

Space loss -.

a delay in eruption of the succeedingincisors of approximately 1 year is generally

found if the loss has occurred at an early stage

of development . unless the time of loss is close

to the normal time of shedding , premature

eruption of permanent successors is rare.

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Avulsion and Replantation