Introduction ● Avulsion is the complete displacement of tooth from the socket ● Avulsion of permanent teeth is seen in .5-3% of all dental injuries. ● It is one of the most serious injuries, and the prognosis is very much dependent on: Action taken at the place of injury And promptly after the avulsion. Most of the cases, Replantation Treatment of choice But cannot always carried out Replantation NOT indicated; First aid for avulsed teeth ● Dentist should be prepared to give advices about first aid for avulsed teeth to public. ● Avulsed teeth is on of a REAL EMERGENCY situation in dentistry. ● Instruction may be given by phone to people at the emergency site. ● Make sure that the avulsed tooth is a permanent tooth. ● Keep the patient calm. ● Fined the tooth and pick it up from the crown Not the root. ● If the tooth is dirty, wash it briefly (MAX 10 s) under cold running water and reposition it. ● Try to encourage the patient to replant the tooth. ● Once the tooth is in place bite into a napkin to hold the tooth in position. ● If it is not possible (e.g. pt unconscious), place the tooth in a glass of storage media (e.g. Milk) and bring with the patient to emergency clinic. ● The tooth can be transported in the mouth, by keeping the tooth inside the lip or cheek if the patient is conscious. ● If the patient is very young, he/she may swallow the tooth, therefore it is advisable to ask the patient to spit in a container and place the tooth in it (AVOID WATER) Storage media (if available) is advisable (tissue cutler / transport medium, Hanks balanced storage media (HBSS or saline) Storage media Milk and milk substitutes Contents of significance ▸ Amino acids ▸ Carbohydrates ▸ Essential nutrients ● Long life milk is more advantageous ● Better than saliva and tap water ● pasteurized better ● Low fat milk preferable ● Storage period limit Milk products upto 4 hours Milk up to 8 hours ▸ Contents of significance ● vitamins, minerals, amino acids, carbohydrates, antioxidants, enzymes, phytonitrite ● Similar osmolality to body fluids ● Increases mitogenicity ● Economical & Easily available ● Full concentration is better ● Storage period limit-Upto 8 hours with pdl cell viability comparable to HBSS ▸ Contents of significance ● resin (55%) essential oils ● amino acids, minerals ethanol ● vitamins A, B complex, E and bioflavon ● Better preservation of root cementum layer ● Storage period limit Upto 45 mins with 90 % viability ▸ Contents of significance ● Ovalbumin, proteins,minerals ● Absence of contamination and easy access ● High ph and protein reaction to Pdl cells risk ● Proved to be better than milk in regeneration ● Storage period limit

1. AVULSION OF
TOOTH
UVA VIGNESH M
FINAL YEAR BDS
541811096

2. Introduction
● Avulsion is the complete
displacement of tooth from the
socket
● Avulsion of permanent teeth is seen
in .5-3% of all dental injuries.
● It is one of the most serious injuries,
and the prognosis is very much
dependent on: Action taken at the
place of injury And promptly after the
avulsion.

3. Most of the cases,
Replantation
Treatment of choice
But cannot always carried out

4. Replantation NOT indicated;
Severe caries Severe periodontal
disease
Non cooperative
patients
Severe medical
condition
(immunosuppressio
n and sever cardiac
conditions)

5. First aid for avulsed
teeth

6. ● Dentist should be prepared to
give advices about first aid for
avulsed teeth to public.
● Avulsed teeth is on of a REAL
EMERGENCY situation in
dentistry.
● Instruction may be given by
phone to people at the
emergency site.

7. Instructions
● Make sure that the avulsed tooth is a
permanent tooth.
● Keep the patient calm.
● Fined the tooth and pick it up from the crown
Not the root.
● If the tooth is dirty, wash it briefly (MAX 10 s)
under cold running water and reposition it.

8. ● Try to encourage the patient to replant
the tooth.
● Once the tooth is in place bite into a
napkin to hold the tooth in position.
● If it is not possible (e.g. pt unconscious),
place the tooth in a glass of storage
media (e.g. Milk) and bring with the
patient to emergency clinic.

9. ● The tooth can be transported in the mouth, by
keeping the tooth inside the lip or cheek if the
patient is conscious.
● If the patient is very young, he/she may swallow the
tooth, therefore it is advisable to ask the patient to
spit in a container and place the tooth in it (AVOID
WATER)

10. Storage media (if available)
is advisable (tissue cutler /
transport medium, Hanks
balanced storage media
(HBSS or saline)

11. Storage media

12. Natural
media
Milk and milk substitutes
Contents of significance
▸ Amino acids
▸ Carbohydrates
▸ Essential nutrients
● Long life milk is more advantageous
● Better than saliva and tap water
● pasteurized better
● Low fat milk preferable
● Storage period limit Milk products upto 4 hours
Milk up to 8 hours

13. Coconut
water
▸ Contents of significance
● vitamins, minerals, amino acids,
carbohydrates, antioxidants, enzymes,
phytonitrite
● Similar osmolality to body fluids
● Increases mitogenicity
● Economical & Easily available
● Full concentration is better
● Storage period limit-Upto 8 hours with pdl
cell viability comparable to HBSS

14. Propolis ▸ Contents of significance
● resin (55%) essential oils
● amino acids, minerals ethanol
● vitamins A, B complex, E and bioflavon
● Better preservation of root cementum layer
● Storage period limit Upto 45 mins with 90 %
viability

15. Egg white ▸ Contents of significance
● Ovalbumin, proteins,minerals
● Absence of contamination and easy
access
● High ph and protein reaction to Pdl cells
risk
● Proved to be better than milk in
regeneration
● Storage period limit -Upto 6-10 hours

16. Tap water ● Hypotonic and rapid lysis of cells
● Final choice when no alternative is
available Storage period limit
● Only for a very shorter period of time

17. Saliva ● immediate interim storage medium
● Buccal vestibule or in a container
● Potentially damaging enzymes and bact
Reduction in clonogenic capacity
● STORAGE PERIOD LIMIT
Only for very short extra alveolar periods
upto 30 mins

18. Artificial
storage
media
Hank's Balanced Salt Solution (HBSS):
▸ Contents of significance
● sodium chloride, glucose, potassium chloride,
sodium bicarbonate, sodium phosphate, calcium
chloride, and magnesium chloride and magnesium
sulphate
● Recommended by AAE
● Preserves and reconstitutes Pdl cells Storage
period limit
● Not easily available
● Extensive - upto 72 to 96 hours with maximum
viabilit

19. Contact lens
solution:
● essentially saline solutions
● Osmolarity is damaging to Pdl
● Cannot be prefered

20. Gatorade: ▸ Contents of significance
● electrolytes
● Sports beverage
● Better than tap water on ice
● Harmful osmolality
● Destroys pdl cells
● short term storage media upto 20 mins

21. normal saline ● Similar osmolality
● No growth products
● Unable to maintain metabolism of
fibroblasts
● Storage period limit
Upto 30 mins with 80% cell viability

22. Organic
storage
media
ViaSpan:
● Sodium and potassium
● alters cell viability
● optimal pressure for growth
● Long-term superiority over HBSS
● No significant changes in short term
storage

23. Special
culture
media
Eagle's medium (EM):
▸ Contents of significance
● amino acids, vitamins and bicarbonates
● Pdl cells proliferated
● Not practical
● Even transfer from saliva produced best
results
● Storage period limit-Upto 60 mins after
transferring from primary media with 90%
viability

24. Additives Emdogain
● Enamel matrix proteins
● diminishes the percentage of fibroblasts
of the periodontal ligament with capability
of forming colonies
● Deyals replacement resorption
● Alone is not sufficient

25. Ascorbic
acid
● increased the ALP activity
● required for the binding of PDL cells to
type I collagen
● Type 1 collagen is critical to pdl
differentiation

26. L-dopa
● dopaminergic systems
● Growth promoting hormone like
substance
● Synergistic effects with HBSS ▸
Increases mitogenicity
● Dopa Extract

27. Protocol for
management of avulsed
teeth with open apex

28. The tooth
has been
replanted
before the
patient's
arrival at the
clinic:
● Leave the tooth in place.
● Clean the area with water spray, saline, or
chlorhexidine.
● Soak the tooth in 1 mg of Doxycycline of physiologic
saline for 5 mins ( doxycycline inhibits bacteria in the
plup lumen thus removing major obstacle to
revascularization
● Suture gingival lacerations, if present.
● Verify normal position of the replanted tooth clinically
and radiographically.
● flexible splint for up to 2 weeks.

29. ● Antibiotic and anti tetanus therapy
● Give patient instructions.
● The goal for replanting still-developing (immature) teeth
in children is to allow for possible revascularization
(apexogenesis) of the pulp space. If that does not occur,
root canal treatment may be recommended

30. The tooth has
been kept in a
physiologic
storage medium
and/or stored
dry, the extra-oral
dry time has
been <60 min
● Clean the root surface and apical foramen with a
stream of saline.
● Soak the tooth in appropriate medium like saline or
HBBS solution for 30 mins.This reduces the
ankylosis.Survival of the remaining PDL cells get
improved
● LA
● Examine the alveolar socket. If fractured, reposition it
with a suitable instrument.

31. ● Remove the coagulum in the socket and replant the
tooth slowly with slight digital pressure.
● Suture gingival lacerations, especially in the cervical
area.
● Verify normal position of the replanted tooth clinically
and radiographically.
● Apply a flexible splint for up to 2 weeks

32. ● Antibiotic and anti tetanus therapy.
● Give patient instructions.
● The goal for replanting (immature)
teeth in children is to allow for
possible revascularization
(apexogenesis) of the pulp space. If
that does not occur, root canal
treatment may be recommended.

33. Dry time >60 min or other
reasons suggesting
non-viable
cells
● Remove attached non-viable soft tissue
carefully
● When the root is dried more than 1 hr
,soaking in the storage medium is not
effective as almost all periodontal cells would
have dried
● Administer local anesthesia. 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.

34. 5.In this condition,root should be prepared to resistant to
resorption
6.Soak the tooth in citric acid for 5 mins followed by 2%
stannous fluoride for 5 mins
7.Root canal treatment to the tooth can be carried out prior
to replantation or later.
8.After completing RCT seal the blunderbuss open apex
extraorally

35. 9. Replant the tooth slowly with slight digital pressure.
10. Suture gingival laceration.if needed
11.Verify normal position of the replanted tooth clinically
and radiographically.
12.Stabilize the tooth for 4 weeks using a flexible splint.
13.Antibiotic and anti tetanus therapy

36. 14. Give patient instructions.
15. To slow down osseous replacement of the tooth, treatment
of the root surface with fluoride prior to replantation (2%
sodium fluoride solution for 20 min)

37. Patient instructions
● Avoid participation in contact
sports.
● Soft diet for up to 2 weeks.
Thereafter normal function as soon
as possible.
● Brush teeth with a soft toothbrush
after each meal.
● Use a chlorhexidine (0.1%) mouth
rinse twice a day for 1 week.

38. In children and adolescent ankylosis is frequently
associated with infra position
Careful follow up is required
Good communication to insecure the patient and
the guardians with this possible outcome
Decoronation may be necessary later when
infraposition is seen(> 1mm)