seminar on luxation tooth injuries including latest IADT guidelines.

1. LUXATION TOOTH INJURIES
BY-DR. PARAS ANGRISH

2. Injuries to periodontal tissues
Concussion
Subluxation
Intrusive luxation
Extrusive luxation
lateral luxation
Exarticulation

4. Prognosis of pulp after luxation injuries
Type of luxation injury Pulp death
concussion 4%
sub-luxation 12%
lateral luxation 77%
extrusive luxation 55 – 98%
intrusive luxation 100%
Barnett et al ‘02

5. Luxation injuries
 Largest group – 30 to 44%
 Includes
1. Concussion
2. Subluxation
3. Extrusive luxation
4. Lateral luxation
5. Intrusive luxation
6. Avulsion

6. CONCUSSION
Description An injury to the tooth-supporting structures
without increased mobility or displacement of
the tooth, but with pain to percussion.
Visual signs Not displaced.
Percussion test Tender to touch or tapping.
Mobility test No increased mobility.
Pulp sensibility test Usually a positive result.The test is important in
assessing future risk of healing complications.
A lack of response to the test indicates an
increased risk of later pulp necrosis.
Radiographic findings No radiographic abnormalities, the tooth is in-
situ in its socket.
Radiographs recommended As a routine: Occlusal, periapical exposure
and lateral view from mesial or distal aspect
of the tooth in question. This should be done in
order to exclude displacement.

8. Diagnosis

9. Concussion - Treatment Guidelines
Treatment objectives
•Usually there is no need for treatment.
Treatment
•Monitor pulpal condition for at least 1 year.
Patient instructions
•Soft food for 1 week.
Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene.
Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of
plaque and debris.
Follow-up
•Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

10. SUBLUXATION
 An injury to the tooth supporting structures
resulting in increased mobility, but without
displacement of the tooth. Bleeding from the
gingival sulcus confirms the diagnosis

12. ETIOLOGY

13. DIAGNOSTIC SIGNS
Description An injury to the tooth supporting structures resulting in increased
mobility, but without displacement of the tooth. Bleeding from the
gingival sulcus confirms the diagnosis
Visual signs Not displaced.
Percussion test Tender to touch or tapping.
Mobility test Increased mobility.
Pulp sensibility test Sensibility testing may be negative initially indicating transient pulpal
damage. Monitor pulpal response until a definitive pulpal diagnosis
can be made.
There will be a positive sensibility test result in about half the cases. The
test is important in assessing future risk of healing complications. A lack
of response at the initial test indicates an increased risk of later pulp
necrosis.
Radiographic findings Usually no radiographic abnormalities.
Radiographs recommended As a routine: Occlusal, periapical exposure and lateral view from the
mesial or distal aspect of the tooth.

14. TREATMENT OBJECTIVE
 Usually no need for treatment.
 TREATMENT
 A flexible splint to stabilize the tooth for patient comfort can be used for up to 2
weeks.
 PATIENT INSTRUCTIONS
 Soft food for 1 week.
 Good healing following an injury to the teeth and oral tissues depends, in part,
on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine
0.1 % is beneficial to prevent accumulation of plaque and debris.
 FOLLOW-UP
 Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

15. EXTRUSION
 Partial displacement of the tooth out of its socket. An injury to the tooth
characterized by partial or total separation of the periodontal ligament
resulting in loosening and displacement of the tooth. The alveolar socket
bone is intact in an extrusion injury as opposed to a lateral luxation injury. In
addition to axial displacement, the tooth will usually have an element of
protrusion or retrusion. In severe extrusion injuries the retrusion/protrusion
element can be very pronounced. In some cases it can be more
pronounced than the extrusive element.

16. ETIOLOGY

17. DIAGNOSTIC SIGNS
Definition Partial displacement of the tooth out of its alveolar socket.
An injury to the tooth characterized by partial or total separation of the
periodontal ligament resulting in loosening and displacement of the tooth.
The alveolar socket bone is intact in an extrusion injury as opposed to a
lateral luxation injury. Apart from axial displacement, the tooth will usually
have an element of protusion or retrusion. In severe extrusion injuries the
retrusion/protrusion element can be very pronounced. In some cases it can
be more pronounced than the extrusive element.
Visual signs Appears elongated.
Percussion test Tender.
Mobility test Excessively mobile.
Sensibility test Usually lack of response except for teeth with minor displacements. The test is
important in assessing risk of healing complications. A positive result to the
initial test indicates a reduced risk of later pulp necrosis.
In immature, not fully developed teeth, pulpal revascularization usually
occurs. In mature teeth pulp revascularization sometimes occurs.
Radiographic findings Increased periapical ligament space.
Radiographs recommended As a routine: Occlusal, periapical exposure and view from the mesial or distal
aspect of the tooth.

18. TREATMENT
 The exposed root surface of the displaced tooth is cleansed with saline before repositioning.
 Reposition the tooth by gently re-inserting it into the tooth socket with axial digital pressure (local anesthesia is usually not
necessary).
 Stabilize the tooth for 2 weeks using a flexible splint.
 Monitoring the pulpal condition is essential to diagnose associated root resorption.
Open apex: Revascularization can be confirmed radiographically by evidence of continued root formation and pulp canal
obliteration and usually a return to a positive pulp response to sensibility testing.
Closed apex: A continued lack of pulp response to sensibility testing should be taken as evidence of pulp necrosis together
with periapical rarefaction and sometimes crown discoloration.
 PATIENT INSTRUCTIONS
 Soft food for 1 week.
 Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft
brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris.
 FOLLOW-UP
 Clinical and radiographic control and splint removal after 2 weeks. Clinical and radiographic control at 4 weeks, 6-8 weeks, 6
months, and 1 year.

19. LATERAL LUXATION
 Displacement of the tooth other than axially. Displacement is
accompanied by comminution or fracture of either the labial or the
palatal/lingual alveolar bone.
Lateral luxation injuries, similar to extrusion injuries, are characterized by
partial or total separation of the periodontal ligament. However, lateral
luxations are complicated by fracture of either the labial or the
palatal/lingual alveolar bone and a compression zone in the cervical and
sometimes the apical area. If both sides of the alveolar socket have been
fractured, the injury should be classified as an alveolar fracture (alveolar
fractures rarely affect only a single tooth). In most cases of lateral luxation
the apex of the tooth has been forced into the bone by the displacement,
and the tooth is frequently non-mobile.

20. ETIOLOGY

21. DIAGNOSTIC SIGNS
Description Displacement of the tooth other than axially. Displacement is
accompanied by comminution or fracture of either the labial
or the palatal/lingual alveolar bone.
Lateral luxation injuries, similar to extrusion injuries, are
characterized by partial or total separation of the periodontal
ligament. However, lateral luxations are complicated by
fracture of either the labial or the palatal/lingual alveolar
bone and a compression zone in the cervical and sometimes
the apical area. If both sides of the alveolar socket have been
fractured, the injury should be classified as an alveolar fracture
(alveolar fractures rarely affect only a single tooth). In most
cases of lateral luxation the apex of the tooth has been
forced into the bone by the displacement, and the tooth is
frequently non-mobile.
Visual signs Displaced, usually in a palatal/lingual or labial direction.
Percussion test Usually gives a high metallic (ankylotic) sound.
Mobility test Usually immobile.
Sensibility test Sensibility tests will likely give a lack of response except for
teeth with minor displacements.
The test is important in assessing risk of healing complications.
A positive result at the initial examination indicates a reduced
risk of future pulp necrosis.

22. TREATMENT OBJECTIVE
 To reposition and splint a displaced tooth to facilitate pulp and periodontal ligament healing.
 TREATMENT
 Rinse the exposed part of the root surface with saline before repositioning.
 Apply a local anesthesia
 Reposition the tooth with forceps or with digital pressure to disengage it from its bony lock and gently
reposition it into its original location.
 Stabilize the tooth for 4 weeks using a flexible splint. 4 weeks is indicated due to the associated bone
fracture.
 Monitoring the pulpal condition is essential to diagnose root resorption. If the pulp becomes necrotic,
root canal treatment is indicated to prevent infection related root resorption.
In immature developing teeth, revascularization can be confirmed radiographically by evidence of
continued root formation, initiation of pulp canal obliteration and usually a return to a positive
response to sensibility testing.

23.  In fully formed teeth, a continued lack of response to sensibility testing (i.e. exceeding 3 months)
should be taken as evidence of pulp necrosis together with periapical radiolucency and sometimes
crown discoloration.
 Splint removal: after the fixation period (4 weeks) resin can be removed. If non-composite resin is used
it can be peeled off with a dental scaler. If composite is used i should be removed with a bur. The
tooth must be supported with digital pressure during this procedure.
 PATIENT INSTRUCTIONS
 Soft food for 1 week.
 Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene.
Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of
plaque and debris.
 FOLLOW-UP
 Clinical and radiographic control after 2 weeks. Clinical and radiographic control and splint removal
after 4 weeks. Clinical and radiographic control at 6-8 weeks, 6 months, 1 year and yearly for 5 years.

24. INTRUSION - INTRUSIVE LUXATION
 Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or
fracture of the alveolar socket.

25. ETIOLOGY

26. INTRUSION - DIAGNOSTIC SIGNS
Description Displacement of the tooth into the
alveolar bone. This injury is
accompanied by comminution or
fracture of the alveolar socket.
Visual signs The tooth is displaced axially into the
alveolar bone.
Percussion test Usually gives a high metallic
(ankylotic) sound.
Mobility test The tooth is immobile.
Sensibility test Sensibility test will likely give negative
response.
In immature, not fully developed
teeth, pulpal revascularization may
occur.
Radiographic findings The periodontal ligament space may
be absent from all or part of the root.
The cemento-enamel junction is
located more apically in the intruded
tooth than in adjacent non-injured
teeth, at times even apical to the
marginal bone level.
Radiographs recommended As a routine: Occlusal, periapical
exposure and lateral view from the
mesial or distal aspect of the tooth in
question. If the tooth is totally intruded
a lateral exposure is indicated to

27. TREATMENT
 Tooth intrusion is associated with a potential risk of tooth loss due to progressive root resorption (ankylosis or infection
related resorption). The following three methods are only partly evidence based.
 Spontaneous eruption
This is the treatment of choice for permanent teeth with incomplete root formation with minor or moderate intrusion. In
teeth with mature root development it is only recommended for teeth with minor intrusion.This treatment seems to lead to
fewer healing complications than orthodontic and surgical repositioning. If no movement within a few weeks, initiate
orthodontic or surgical repositioning before ankylosis can develop.
 Orthodontic repositioning
This treatment may be preferred for patients coming in for delayed treatment. This treatment method enables repair of
marginal bone in the socket along with the slow repositioning of the tooth.
 Surgical repositioning
This treatment technique is preferable in the acute phase. Intrusion with major dislocation of the tooth (more than 7 mm)
may be an indication for surgical repositioning.
 Common for all treatments
Endodontic treatment can prevent the necrotic pulp from initiating infection-related root resorption. This treatment should
be considered in all cases with completed root formation where the chance of pulp revascularization is unlikely.
Endodontic therapy should preferably be initiated within 3-4 weeks post-trauma. A temporary filling with calcium hydroxide
is recommended

28. Degree of
intrusion
Repositioning
Spontaneous Orthodontic Surgical
OPEN APEX
Up to 7 mm x
More than 7
mm
x x
CLOSED APEX
Up to 3 mm x
3-7 mm x x
More than 7
mm
x

29.  PATIENT INSTRUCTIONS
 Soft food for 1 week.
 Good healing following an injury to the teeth and oral tissues depends, in part, on good oral
hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent
accumulation of plaque and debris.
 FOLLOW-UP
 Control after 2 weeks. Splint removal and control after 4 weeks, 6-8 weeks, 6 months, 1 year and
yearly for 5 years

30. Sequalae to luxation injury
 Yellow discoloration
 Grey discoloration
 Resorption – 5 to 15%
 Incomplete root formation
 Primary teeth – pulp space obliteration by
calcification

31. Avulsed Permanent Teeth
 Incidence
 0.5% to 16% of
traumatic injuries
 Main etiologic
factors
 Fights
 Sports injuries
 Automobile
accidents

32. Avulsed Permanent Teeth
 Maxillary central incisor
 Most commonly avulsed
tooth
 Mandibular teeth
 Seldom affected
 Most frequently involves
a single tooth

33. Avulsed Permanent Teeth
 Most common age - 7 to
11
 Permanent incisors
erupting
 Loosely structured PDL

34. Avulsed Permanent Teeth
 Associated injuries
 Fracture of alveolar
socket wall

35. Avulsed Permanent Teeth
 Associated injuries
 Fracture of alveolar
socket wall
 Injuries to the lips
and gingiva

36. Management of the
Avulsed Tooth
 What tissue should
be our primary
concern?
 Pulp?

37. Management of the
Avulsed Tooth
 What tissue should
be our primary
concern?
 Pulp?
 Socket?

38. Management of the
Avulsed Tooth
 What tissue should
be our primary
concern?
 Pulp?
 Socket?
 PDL?

39. Management of the
Avulsed Tooth
 Ultimate goal
 PDL healing without
root resorption

40. Management of the
Avulsed Tooth
 Ultimate goal
 PDL healing without
root resorption
 Most critical factor
 Maintaining an
intact and viable
PDL on the root
surface

41. Periodontal Ligament
Responses
 Surface Resorption
 Replacement Resorption (Ankylosis)
 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.

42. Periodontal Ligament
Responses
 Surface resorption
 Superficial
resorption cavities
 Mainly in
cementum
 Complete repair of
PDL

43. 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

44. Periodontal Ligament
Responses
 Inflammatory
resorption
 Resorption of
cementum and
dentin
 Inflammatory reaction
in the periodontal
ligament

45. Etiology
 Inflammatory
resorption
 Surface resorption
of cementum
exposing dentinal
tubules

46. Etiology
 Inflammatory
resorption
 Surface resorption
of cementum
exposing dentinal
tubules
 Pulp necrosis

47. Etiology
 Inflammatory
resorption
 Surface resorption of
cementum exposing
dentinal tubules
 Pulp necrosis
 Toxic products from
the pulp provoke an
inflammatory
response in the PDL

48. Periodontal Ligament
Responses
 Surface resorption

49. Periodontal Ligament
Responses
 Surface resorption
 Replacement resorption (Ankylosis)

50. Periodontal Ligament
Responses
 Surface resorption
 Replacement resorption (Ankylosis)
 Inflammatory resorption

51. Treatment Considerations
 Extraoral time
 Extraoral environment
 Root surface manipulation
 Management of the socket
 Stabilization

52. Extraoral Time
 Shorter time = Better prognosis*
< 30 min  10% resorption
> 90 min  90% resorption
Andreasen JO, Hjorting-Hansen E.
Replantation of teeth I. Radiographic and clinical study
of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263-86.

53. Extraoral Time
 Shorter time = Better prognosis*
< 30 min  10% resorption
> 90 min  90% resorption
*depending on storage medium
Andreasen JO, Hjorting-Hansen E.
Replantation of teeth I. Radiographic and clinical study
of 110 human teeth replanted after accidental loss.
Acta Odontol Scand 1966;24:263-86.

54. Extraoral Environment
 Viability of PDL cells is
critical

55. Storage Media
 Tap Water
 Dry
 Saliva
 Saline
Andreasen JO.
Effect of extra-alveolar period and storage media
upon periodontal and pulpal healing after
replantation of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43-53.
Poor
results

56. Storage Media
 Tap Water
 Dry
 Saliva
 Saline
Andreasen JO.
Effect of extra-alveolar period and storage media
upon periodontal and pulpal healing after replantation
of mature permanent incisors in monkeys.
Int J Oral Surg 1981;10:43-53.
Good protection for 2
hrs
Poor results

57. Milk As A Storage Medium
 Physiologic
osmolality
 Markedly fewer
bacteria than
saliva
 Readily available

58. Storage Media - Milk vs. Saliva
 Storage for 2 hrs
 Periodontal healing almost as good as
immediate replantation
Blomlof L, et al.
Storage of experimentally avulsed teeth in milk
prior to replantation.
J Dent Res 1983;62:912-6.

59. Storage Media - Milk vs. Saliva
 Storage for 2 hrs
 Periodontal healing almost as good as
immediate replantation
 Storage for 6 hrs
 Saliva  extensive replacement resorption
 Milk  healing almost as good as immediate
replant
Blomlof L, et al.
Storage of experimentally avulsed teeth in milk
prior to replantation.
J Dent Res 1983;62:912-6.

60. Cell Culture Media
 Eagle’s Medium
 Hank’s Balanced Salt Solution

61. Hank’s Balanced Salt Solution
 Proper pH and osmolality
 Reconstitutes depleted cellular
metabolites
 Washes toxic breakdown products from
the root surface

62. Organ Transplant Storage Media
 Viaspan
 Dramatically prolongs the storage of human
organs
 Expensive
 Not readily available

63. Storage Media Comparison
 Viaspan
 Complete healing after 6 and 12 hrs
 Good for extended storage periods (72 and 96
hrs)
Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored in
Viaspan, milk and Hank’s balanced salt solution.
Endod Dent Traumatol 1992;8:183-8.

64. Storage Media Comparison
 Viaspan
 Complete healing after 6 and 12 hrs
 Good for extended storage periods (72 and 96
hrs)
 Hank’s balanced salt solution
 Healing results similar to Viaspan
Trope M, Friedman S.
Periodontal healing of replanted dog teeth stored in
Viaspan, milk and Hank’s balanced salt solution.
Endod Dent Traumatol 1992;8:183-8.

65. Recommended Storage Media
1. Socket
(immediate
replantation)
2. Cell culture
medium
3. Milk
4. Physiologic saline
5. Saliva

66. Root Surface Manipulation
 Attempt to retain PDL cell viability
 Do not curette root surface
 Avoid caustic chemicals
Van Hassel HJ, Oswald RJ, Harrington GW.
Replantation 2. The role of the periodontal
ligament.
J Endodon 1980;6:506-8.

67. Root Surface Manipulation
 Extraoral dry time determines handling

68. Root Surface Manipulation
 Extraoral dry time < 1 hr
 PDL healing is still possible
 Handling recommendations
 Keep root moist
 Do not handle root surface
 Gentle debridement

69. Root Surface Manipulation
 Extraoral dry time > 1 hr
 Loss of PDL cell viability
inevitable
 Treatment recommendations
 Remove tissue tags
 Soak in accepted dental fluoride solution for 20
min

70. Fluoride Treatment
 1.0-2.4% topical
fluoride solution
 Sodium fluoride
(Andreasen)
 Stannous fluoride
(Krasner)
 20 minute soak

71. Management of the Socket
 Remove contaminated coagulum
in socket
 Irrigate with sterile saline

72. Management of the Socket
 Examine socket  If fracture is evident
 Reposition fractured bone with a blunt
instrument

73. Management of the Socket
 Replant using light digital pressure

74. Stabilization
 Splint
 Definition  a rigid or flexible device used to support,
protect, or immobilize teeth, preventing further injury
 Types
• Acid etch composite
• Cross-suture

75. Acid Etch Composite Splints
 Interproximal composite

76. Acid Etch Composite Splints
 Composite with arch wire

77. Acid Etch Composite Splints
 Composite with monofilament nylon

78. Acid Etch Composite Splints
 Functional Splint
 20-30 lb
monofilament
nylon
 Bonded with
composite
 Allows physiologic
movement
Antrim DD, Ostrowski JS.
A functional splint for traumatized
teeth.
J Endodon 1982;8:328-31.

79. Cross-Suture Splint
 Indications
 No adjacent teeth
to splint to
 Unmanageable
traumatized
children

80. Cross-Suture Splint

81. Splinting Time
 Effect of splinting time
 7 days
 30 days
Nasjleti CE, Castelli WA,
Caffesse RG.
The effects of different splinting
times on replantation of teeth in
monkeys.
Oral Surg 1982;53:557-66.

82. Splinting Time
 Recommended time
 7 to 10 days
Nasjleti CE, Castelli WA,
Caffesse RG.
The effects of different splinting
times on replantation of teeth in
monkeys.
Oral Surg 1982;53:557-66.

83. Pulpal Prognosis
 Stage of root development
 Dry storage time
 Storage media
 Antibiotics

84. Stage of Root Development
 Mature roots (< 1.0 mm)
 Revascularization 0%
Kling M, et al. Endod Dent Traumatol 1986;2:83-9.
Andreasen JO, et al. Endod Dent Traumatol
1995;11:51-8.

85. Stage of Root Development
 Mature roots (< 1.0 mm)
 Revascularization 0%
 Immature roots (> 1.0 mm)
 Revascularization 18-34%
Kling M, et al. Endod Dent Traumatol 1986;2:83-9.
Andreasen JO, et al. Endod Dent Traumatol
1995;11:51-8.

86. Revascularization
 Loss of blood
supply to pulp

87. Revascularization – Day 4
 Coronal pulp
 Extensive ischemic
injury

88. Revascularization – Day 4
 Coronal pulp
 Extensive ischemic
injury
 Apical pulp
 Initial
revascularization

89. Revascularization – 4 Weeks
 Pulp status
 Revascularization
 Reinnervation
 New odontoblastic
layer

90. Revascularization
 Typical sequela
 Pulp canal
obliteration

91. Dry Storage Time
 As dry storage time increases
Pulp survival decreases
Andreasen JO, Borum MK, Jacobsen HL,
Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.

92. Storage Media
 Nonphysiologic
storage
 Minimal chance of pulp
revascularization
Andreasen JO, Borum MK, Jacobsen HL,
Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.

93. Storage Media
 Nonphysiologic storage
 Minimal chance of pulp
revascularization
 Physiologic storage
 HBSS, milk, saline, saliva
 Improved chance of pulp
revascularization
Andreasen JO, Borum MK, Jacobsen HL,
Andreasen FM.
Endod Dent Traumatol 1995;11;59-68.

94. Pulpal Prognosis - Antibiotics
 Systemic
antibiotics
 Pulp
revascularization is
not increased
Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling
M, Fatti P.
Endod Dent Traumatol 1990;6:157-69.

95. Pulpal Prognosis - Antibiotics
 Systemic antibiotics
 Pulp
revascularization is
not increased
 Topical antibiotics
 Beneficial effect
Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J,
Fatti P.
Endod Dent Traumatol 1990;6:170-6.

96. Pulpal Prognosis - Antibiotics
 Topical Doxycycline
 Decreased microorganisms
in pulpal lumen
 Increased pulp
revascularization
Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J,
Fatti P.
Endod Dent Traumatol 1990;6:170-6.

97. Pulpal Prognosis - Antibiotics
 Recommendation
 Topical Doxycycline
 1 mg in 20 ml physiologic
saline
 5 minute soak
Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J,
Fatti P.
Endod Dent Traumatol 1990;6:170-6.

98. Endodontic Rationale
 Mature root - 4 weeks
 Very limited
revascularization

99. Endodontic Rationale
 Mature root - 4 weeks
 Very limited
revascularization
 Ischemic coronal pulp
with great risk of infection
!!!

100. Endodontic Rationale – Mature
Root
 Pulpectomy  7-14 days

101. Endodontic Rationale – Mature
Root
 Calcium hydroxide placement

102. Endodontic Rationale –
Mature Root
 Calcium hydroxide
 Antibacterial
 Increases pH in dentin
 Favors mineralization over resorption
Tronstad L, Andreasen JO, et al.
pH changes in dental tissues after
root canal filling with calcium hydroxide.
J Endodon 1981;7:17-21.

103. Endodontic Rationale –
Mature Root
 Treatment recommendation
 Ca(OH)2 therapy for as long as
practical, usually 6-12 months
Treatment of the Avulsed Permanent
Tooth.
Recommended Guidelines of the
American Association of
Endodontists, 1995.

104. Specific Treatment Regimen

106. Specific Treatment Regimen
Root Development
 Closed apex
 Open apex
Extraoral Dry Time
 One hour or less
 More than one
hour
Treatment of the Avulsed Permanent
Tooth.
Recommended Guidelines of the
American Association of
Endodontists, 1995.

107. Treatment Flowchart
< 1 hr > 1 hr
Extraoral Dry Time
Apex Maturity
Closed Open Open or Closed
Pulpectomy
7-14 days
Observe
Option:
Extraoral
RCT
Pulpectomy
7-14 days

108. Emergency Treatment
 Replantation technique
 Local anesthetic, if
necessary
 Radiograph to verify
position
 Check occlusion
 Physiologic splint

109. Emergency Treatment
 Additional
Considerations
 Analgesics

110. Emergency Treatment
 Additional
Considerations
 Analgesics
 Chlorhexidine

111. Emergency Treatment
 Additional Considerations
 Analgesics
 Chlorhexidine
 Tetanus
 Refer to physician for tetanus prophylaxis prn
Rothstein RJ, Baker FJ.
Tetanus: Prevention and treatment.
J Am Med Assoc 1978;240:675-6.

112. Emergency Treatment
 Additional Considerations
 Analgesics
 Chlorhexidine
 Tetanus
 Antibiotics

113. Antibiotics
 Penicillin
 500 mg qid for 4-7 days
Andreasen JO.
Atlas of replantation and transplantation of
teeth.
Philadelphia: W.B. Saunders Co., 1992;57-
92.

114. Antibiotics
 Tetracycline vs. amoxicillin  in a
replacement resorption model
 Tetracycline had better anti-resorptive properties
Sae-Lim V, Wang CY, Choi GW, Trope M.
The effect of systemic tetracycline on resorption of
dried replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:127-32.

115. Antibiotics
 Tetracycline vs. amoxicillin  in an
inflammatory root resorption model
 Tetracycline had better anti-bacterial properties
Sae-Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:216-20.

116. Antibiotics
 Recommendation
 “Tetracycline could be considered as an alternative
to amoxicillin after avulsion injuries.”
Sae-Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs teeth.
Endod Dent Traumatol 1998;14:216-20.

117. Tetracycline Use In Young Children
 Tetracycline staining
 Not a problem since avulsed maxillary anteriors
have already erupted and are not susceptible
to staining
 At worst, posterior teeth might be stained
 Remote possibility with 7-10 day prescription
Sae-Lim V, Wang CY, Trope M.
Effect of systemic tetracycline and amoxicillin on
inflammatory root resorption of replanted dogs’ teeth.
Endod Dent Traumatol 1998;14:216-20.

118. Avulsion Sequelae
 Closed Apex
 Extraoral dry
time 1 hour or
less

119. Avulsion Sequelae
 Closed Apex
 Extraoral dry time
more than 1 hour

120. Avulsion Sequelae
 Open Apex
 Extraoral dry
time 1 hour or
less

121. Avulsion Sequelae
 Open Apex
 Extraoral dry time
more than 1 hour

122. Avulsion Management
 Be prepared -
Dental Trauma Kit
 Immerse tooth in a
physiologic storage
medium to “buy time”
 Determine extraoral dry
time
 Follow AAE AND IADT
Guidelines

123. REFERENCES
- Essentials of traumatic injuries to the teeth
J.O.Anderasen and F.M. Anderasen
-Treatment planning for traumatized teeth
- Mitsuhiro tsukiboshi
-cohen’s pathways of the pulp
tenth edition

124. - Ingle’s –Endodontics 6th edition
- Storage Media For Avulsed
Teeth: A Literature Review
Brazilian Dental Journal (2013) 24(5): 437-445
- Transport media for avulsed teeth:
A review Aust Endod J 2012; 38: 129–136

125. - A proposal for classification of tooth
fractures based on treatment need
Journal of Oral Science, Vol. 52, No. 4, 517-529,
2010
Assessment of pulp vitality: a review
International Journal of Paediatric Dentistry 2009;
19: 3–15
STUDY OF STORAGE MEDIA FOR AVULSED
TEETH Brazilian Journal of Dental Traumatology
(2009) 1(2): 69-76

126. Fracture resistance of tooth
fragment reattachment: effects of
different preparation techniques and
adhesive materials Dental
Traumatology 2010; 26: 9–15;