Dental Traumatology 2002: 18: 1–11 Copyright C Munksgaard 2002Printed in Denmark . All rights reserved

DENTAL TRAUMATOLOGYISSN 1600-4469

Editor’s noteAfter a year at the helm of Dental Traumatology I am more convinced than ever that a journal based exclusivelyon dental traumatology not only can survive but thrive as well. We seem to have turned a corner. After theunderstandable ‘wait and see’ attitude of some authors and readers, both submissions and subscribers increasedsharply in the second half of last year. An important and popular feature of last years issues were the guidelinesfor treatment of dental injuries of the International Association of Dental Traumatology (IADT). This year Iintend to replace the guidelines with review articles of invited authors. The aim of these reviews will be topresent current information on a subject of interest to practitioners and researchers in the field of dental trauma.I hope you find these articles as useful as you did the treatment guidelines!!!

CLINICAL MANAGEMENT OF THEAVULSED TOOTH: PRESENT STRATEGIESand FUTURE DIRECTIONSAbstract – The aim of this review article is to supplement the Martin Troperecently published International Association of Dental School of Dentistry, University of North Carolina,Traumatology (IADT) guidelines on treatment of the avulsed tooth. North Carolina, NC 27599, USA

A thorough discussion on the reasoning behind each guideline isKey words: avulsion; clinical managementpresented. In addition, the author’s views on alternate treatmentCorrespondence: Professor Martin Trope, J. B.strategies and future directions, along with recent research on theFriedland Professor and Chair, Department ofsubject of the avulsed tooth, are also presented.Endodontics, School of Dentistry, University ofNorth Carolina, North Carolina, NC 27599, USA

Favorable healing after an avulsion injury requiresquick emergency intervention followed by evaluationand possible treatment at decisive times during thehealing phase. The urgency of the emergency visitand the multidisciplinary nature of follow-up evalu-ations require both the lay public and practitionersfrom different dental disciplines to possess a knowl-edge of the treatment strategies involved. The aim ofthis review is to present the rationale for the presentguidelines and discuss possible future strategies for thetreatment of the avulsed tooth.

Consequences of tooth avulsion

When a tooth is avulsed, attachment damage andpulp necrosis occurs. The tooth is ‘separated’ fromthe socket, mainly due to the tearing of the peri-odontal ligament which leaves viable periodontal liga-ment cells on most of the root surface. In addition,due to the crushing of the tooth against the socket,small localized cemental damage also occurs.

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If the periodontal ligament left attached to the rootsurface does not dry out, the consequences of toothavulsion are usually minimal (1, 2). The hydratedperiodontal ligament cells will maintain their viability,allowing them to reattach on replantation withoutcausing any more than minimal destructive inflam-mation. In addition, since the crushing injury is con-tained within a very localized area, inflammationstimulated by the damaged tissues will be correspond-ingly limited, meaning that healing with new replace-ment cementum is likely to occur after the initial in-flammation has subsided (Fig. 1).

However, if excessive drying occurs before re-plantation, the damaged periodontal ligament cellswill elicit a severe inflammatory response over a dif-fuse area on the root surface. Unlike the situation de-scribed above, where the area to be repaired after theinitial inflammatory response is small, here a largearea of root surface is affected meaning that must berepaired by new tissue. The slower moving cemento-blasts cannot cover the entire root surface in time and

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Fig. 1. Cemental healing. A previous resorptive defect is filled withnew cementum (NC) and new periodontal ligament (NPdl).

it is likely that, in certain areas, bone will attach itselfdirectly onto the root surface. In time, through physi-ologic bone re-contouring, the entire root will be re-placed by bone; a process which has been termed oss-eous replacement or replacement resorption (3, 4)(Fig. 2).

Fig. 2. Osseous replacement. A. Histologicslide showing bone directly attached to theroot and areas of both bone and root un-dergoing active resorption. Both areas willlater be replaced with new bone; it is inthis way that the entire root will eventuallybe replaced by bone. B. Radiographic pic-ture. The root is being replaced by bone.The lamina dura is lost around the root asit becomes incorporated in the bone.

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Pulpal necrosis always occurs after an avulsion in-jury. While the necrotic pulp itself is of no conse-quence, the necrotic tissue is extremely susceptible tobacterial contamination. If revascularization does notoccur or effective endodontic therapy is not carriedout, the pulp space will inevitably become infected.The combination of bacteria in the root canal andcemental damage on the external surface of the rootresults in an external inflammatory resorption thatcan be very serious and lead to the rapid loss of thetooth (5) (Fig. 3).

Thus, the effects experienced after tooth avulsionhas occurred, appear directly related to the severityand surface area of the inflammation on the root sur-face, and the resultant damaged root surface thatmust be repaired. Treatment strategies should alwaysbe considered in the context of limiting the extentof the peri-radicular inflammation, thus tipping thebalance toward favorable (cemental) rather than un-favorable (osseous replacement or inflammatory re-sorption) healing.

Treatment Objectives

Treatment is directed at avoiding or minimizing theresultant inflammation which occurs as a direct resultof the two main consequences of the avulsed tooth,namely attachment damage and pulpal infection.

Attachment damage as a direct result of the avul-sion injury cannot be avoided. However, considerabledamage, primarily caused by drying, can additionallyoccur to the periodontal membrane in the time thatthe tooth is out of the mouth. Treatment is directed

Current and Future strategies for treating avulsed teeth

Fig. 3. External inflammatory root resorption due to pulpal infec-tion. A. Histologic slide showing multinucleated clastic cells re-sorbing the root. B. Radiographic appearance showing resorption(lucency) of the root and adjacent bone.

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towards minimizing this damage (and the resultantinflammation) so that the fewest possible compli-cations result. When severe additional damage cannotbe avoided and osseous replacement of the root isconsidered certain, steps are taken to slow the re-placement of the root by bone to maintain the toothin the mouth for as long as possible.

In the open apex tooth, all efforts are made to pro-mote revascularization of the pulp, thereby avoidingpulp space infection. When revascularization fails inthe open apex tooth or is not possible in the closedapex tooth, all treatment efforts are made to preventor eliminate toxins from the root canal space.

Clinical Management

Emergency Treatment at the Accident Site

Replant if possible or place in an appropriate storage medium.The damage that occured to the attachment appar-atus during the initial injury is unavoidable butusually minimal. However, all efforts are made tominimize necrosis of the remaining periodontal liga-ment while the tooth is out of the mouth. Pulpal se-quelae are not a concern initially and are dealt withat a later state of the treatment.

The single most important factor to ensure a favor-able outcome after replantation is the speed withwhich the tooth is replanted (6, 7). Of utmost import-ance is the prevention of drying, which causes loss ofnormal physiologic metabolism and morphology ofthe periodontal ligament cells (2, 7). Every effortshould be made to replant the tooth within the first15–20min (8). This usually requires emergency per-sonnel at the site of the injury with some knowledge oftreatment protocol. The dentist should communicateclearly with the person at the site of the accident.Ideally, information on how to deal with such a situ-ation should have already been given to the personwho is likely to be on-site in an environment wheresuch an accident is likely to occur, such as at schoolor on the playing field; for example, educational pres-entations for school nurses or athletics trainers.. How-ever, failing this, the information can be given overthe phone. The aim is to replant a clean tooth withan undamaged root surface as gently as possiblewhich means that the patient should be brought tothe office immediately. If doubt exists that the toothcan be replanted adequately, the tooth should bequickly stored in an appropriate medium until the pa-tient can get to the dental office for replantation. Sug-gested storage media in order of preference are; milk,saliva, either in the vestibule of the mouth or in acontainer into which the patient spits, physiologic sa-line or water (9). Water is the least desirable storagemedium because the hypotonic environment causesrapid cell lysis and increased inflammation on re-plantation (10).

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Cell culture media in specialized transport con-tainers, such as Hank’s Balanced Salt Solution(HBSS) or ViaSpanA, have shown superior ability inmaintaining the viability of the periodontal ligamentfibers for extended periods (11). However, they arepresently considered to be impractical as they are notgenerally available at the accident sites where injuryis likely to occur. If we consider that more than 60%of avulsion injuries occur close to the home or school(12), it should be beneficial to have these media avail-able in emergency kits at these two sites. In addition,it would not be unreasonable to have them in ambu-lances and places immediately accessible to otheremergency personnel who are involved in situationswhere the injuries of the patient mean that the teethmight otherwise be sacrificed due to a more serious,even life-threatening, situation.

Management in the Dental Office

Emergency VisitPrepare socket, prepare root, replant, functional splint, local andsystemic antibiotics. Recognizing that the dental injurymight be secondary to a more serious injury is essen-tial. If, on examination, a serious injury is suspected,immediate referral to the appropriate expert is thefirst priority. The focus of the emergency visit is theattachment apparatus. The aim is to replant the toothwith a minimum of irreversibly damaged cells, as thiswill cause inflammation, and the maximal number ofperiodontal ligament cells that have the potential toregenerate and repair the damaged root surface.

Diagnosis and Treatment Planning. If the tooth was re-planted at the site of injury, a complete history istaken to assess the likelihood of a favorable outcome.In addition, the position of the replanted tooth is as-sessed and adjusted if necessary. On rare occasions,the tooth may be ‘gently’ removed to prepare the rootto increase the chances of a favorable outcome(seebelow).

If the patient’s tooth is already out of the mouth,the storage medium should be evaluated and, ifnecessary, the tooth should be placed in a more ap-propriate medium. Hank’s Balanced Salt Solution ispresently considered the best medium for this purpose(Fig. 4). Milk or physiologic saline is also appropriatefor storage purposes.

The medical and accident history is taken and a clinicalexam carried out. The clinical examination should in-clude an examination of the socket to ascertain if itis intact and suitable for replantation. This is ac-complished by facial and palatal palpation. Thesocket is gently rinsed with saline (Fig. 5) and, whenclear of the clot and debris, its walls are examineddirectly for the presence, absence, or collapse of the

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Fig. 4. Avulsed tooth stored in Hank’s Balanced Salt Solution(HBSS) whilst a history and clinical exam is being carried out.

Fig. 5. Socket rinsed with sterile saline to allow for direct visualinspection manipulation and gentle replantation.

socket wall. Palpation of the socket and surroundingapical areas and pressure on the surrounding teethare used to ascertain if an alveolar fracture is pres-ent in addition to the avulsion. Movement of a seg-ment of bone as well as multiple teeth is suggestiveof an alveolar fracture. The socket and surroundingareas, including the soft tissues, should be radio-graphed. Three vertical angulations are required fordiagnosis of the presence of a horizontal root frac-ture in adjacent teeth (6). The remaining teeth inboth the upper and lower jaws should be examined

Current and Future strategies for treating avulsed teeth

for injuries, such as crown fractures, and any soft-tissue lacerations should be noted.

Preparation of the root

Preparation of the root is dependent on the maturityof the tooth (open vs. closed apex) and on the drytime of the tooth before it was placed in a storagemedium. A dry time of 60min is considered the pointwhere survival of root periodontal ligament cells isunlikely.

Extra – oral dry time , 60 min

Closed ApexThe root should be rinsed of debris with water orsaline and replanted in as gentle a fashion as possible.

If the tooth has a closed apex, revasculsarization isnot possible (13) but, because the tooth was dry forless than 60min (replanted or placed in appropriatemedium), the chance for periodontal healing exists.Most importantly, the chance of a severe inflamma-tory response at the time of replantation is lessened. Adry time of less than 15–20min is considered optimalwhere periodontal healing would be expected (1, 2,8).

A continuing challenge is the treatment of the tooththat has been dry for more than 20min (periodontalcell survival is assured) but less than 60min (peri-odontal survival unlikely). In these cases, logic sug-gests that the root surface consist of some cells withthe potential to regenerate and some that will act asinflammatory stimulators. Exciting new strategies arecurrently under investigation that may be extremelyvaluable in these cases. The use of EmdogainA (Bi-ora, Malmo, Sweden) has been found to be valuablein cases that were considered hopeless in the past (see

Fig. 6. Revasculariztion of an immaturetooth. A. The stage of root developmentsoon after replantation. B. One year later,it can be seen that the root has continuedto develop and thicken.

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below) and this medicament may prove extremelyvaluable in the 20–60 minute dry time period. Studiesare ongoing to evaluate its potential.

Open ApexSoak in doxycycline for 5min, gently rinse off debris, replant.In an open apex tooth, revascularization of the pulpas well as continued root development is possible (Fig.6). Cvek et al. (13) found in monkeys that soaking thetooth in doxycycline (1mg in approximately 20mL.of physiologic saline) for 5min before replantation sig-nificantly enhanced revascularization. This result wasconfirmed in dogs by Yanpiset et al. (14). While theseanimal studies do not provide us with a prediction ofthe rate of revascularization in humans, it is reason-able to expect that the same enhancement of re-vascularization that occurred in two animal specieswill occur in humans as well. As with the tooth withthe closed apex, the open-apex tooth is then gentlyrinsed and replanted.

Exra-oral dry time . 60 min

Closed ApexRemove the periodontal ligament by placing in acidfor 5min, soak in fluoride or cover the root with em-dogainA, replant.

When the root has been dry for 60min or more,the periodontal ligament cells are not expected to sur-vive (1, 2). In these cases, the root should be preparedto be as resistant to resorption as possible (attemptingto slow the osseous replacement process). These teethshould be soaked in acid for 5min to remove all re-maining periodontal ligament and thus remove thetissue that will initiate the inflammatory response onreplantation. The tooth should then be soaked in 2%stannous fluoride for 5min and replanted (15, 16).

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Aledronate was found to have similar resorption slow-ing effects as fluoride when used topically (17) butfurther studies need to be carried out to evaluatewhether its effectiveness is superior to fluoride andwhether this justifies its added cost. Recent studieshave found that EmdogainA (enamel matrix protein)may be extremely beneficial in teeth with extendedextra oral dry times, not only to make the root moreresistant to resorption but possibly to stimulate theformation of new periodontal ligament from thesocket (18, 19)(Fig. 7).

If the tooth has been dry for more than 60minand no consideration has been given to preserving theperiodontal ligament, the endodontics may be per-formed extraorally. In the case of a tooth with a

Fig. 7. EmdogainA placed A. on the root surface and B. into thesocket before the tooth is replanted.

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closed apex, no advantage exists to this additionalstep at the emergency visit. However, in a tooth withan open apex the endodontic treatment, if performedafter replantation, involves a long-term apexificationprocedure. In these cases, completing the root canaltreatment extraorally, where a seal in the blunderbussapex is easier to achieve, may be advantageous.When endodontic treatment is performed extraorally,it must be performed aseptically with the utmost careto achieve a root canal system that is free of bacteria.

Open apexReplant? If yes, treat as with closed apex tooth. Endodontictreatment may be performed out of the mouth. Since theseteeth are in young patients whose facial developmentis usually incomplete, many pediatric dentists con-sider the prognosis to be so poor and the potentialcomplications of an ankylosed tooth so severe thatthey recommend that these teeth are not replanted.In fact, not to replant these teeth is the present recom-mendation of the International Association of DentalTrauma (20). However, considerable debate exists asto whether it would be beneficial to replant the rooteven though it will inevitably be lost due to resorp-tion. If the patients are followed carefully and the rootsubmerged at the appropriate time (21, 22), the heightand, more importantly, the width of the alveolar bonewill be maintained, allowing for easier permanent res-toration at the appropriate time when the facial de-velopment of the child is complete. Studies are on-going to evaluate whether the present recommenda-tions should be changed.

Preparation of the socket

The socket should be left undisturbed before re-plantation (6). Emphasis is placed on the removal ofobstacles within the socket to facilitate the replace-ment of the tooth into the socket (23). It should belightly aspirated if a blood clot is present. If the al-veolar bone has collapsed, a factor which may pre-vent replantation or cause it to be traumatic, a bluntinstrument should be inserted carefully into the socketin an attempt to reposition the wall.

Splinting

A splinting technique that allows physiologic move-ment of the tooth during healing and that is in placefor a minimal time period results in a decreased inci-dence of ankylosis (6, 23–25). Semi-rigid (physiologic)fixation for 7–10days is recommended (6, 25). Thesplint should allow movement of the tooth, shouldhave no memory (so the tooth is not moved duringhealing), and should not impinge on the gingiva and/or prevent maintenance of oral hygiene in the area(Fig. 8). Many splints satisfy the requirements of an

Current and Future strategies for treating avulsed teeth

Fig. 8. Examples of splints. A. TTS splint. This splint allows spacefor adequate cleaning therefore minimizing infection due to plaqueand food debris. It is flexible in a horizontal and vertical direction.B. Resin splint that is too thick, making it impossible for the patientto keep it clean.

acceptable splint, with a new titanium trauma splintrecently been shown to be particularly effective andeasy to use (26). After the splint is in place, a radio-graph should be taken to verify the positioning of thetooth and as a preoperative reference for furthertreatment and follow-up. When the tooth is in thebest possible position, it is important to adjust the biteto ensure that it has not been splinted in a positionthat will cause traumatic occlusion. One week is suf-ficient to create periodontal support to maintain theavulsed tooth in position (6). Therefore, the splintshould be removed after 7–10days. The only excep-tion to this is when avulsion occurs in conjunctionwith alveolar fractures, in which case it is suggestedthat the tooth should be splinted for a suggestedperiod of 4–8 weeks (6).

Management of the soft tissues

Soft tissue lacerations of the socket gingiva shouldbe tightly sutured. Lacerations of the lip are fairlycommon with these types of injuries. The dentistshould approach lip lacerations with some cautionand it might be prudent to consult with a plastic

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surgeon at this stage. If these lacerations are su-tured, care must be taken to clean the wound thor-oughly beforehand as dirt, or even minute toothfragments, left in the wound affect healing and theesthetic result.

Adjunctive therapy

Systemic antibiotics given at the time of replantationand prior to endodontic treatment are effective inpreventing bacterial invasion of the necrotic pulp and,therefore, subsequent inflammatory resorption (27).Tetracycline has the additional benefit of decreasingroot resorption by affecting the motility of the osteo-clasts and reducing the effectiveness of collagenase(28). The administration of system antibiotics for pa-tients not susceptible to tetracycline staining is Doxy-cycline 2¿ per day for 7days at appropriate dose forpatient age and weight (28, 29) or Penicillin V 1000mg and 500mg 4¿ per day for 7days, beginning atthe emergency visit and continuing until the splint isremoved after 7–10days (27). The bacterial content ofthe sulcus should also be controlled during the healingphase. In addition to stressing the need for adequateoral hygiene to the patient, the use of chlorhexidinerinses for 7–10days may also be useful.

In a recent study by our group (as yet unpublished),great benefits were seen when the pulp contents wereremoved at the emergency visit and LedermixA wasplaced into the root canal. This product contains atetracycline corticosteroid combination that has beenshown to move through the dentinal tubules. Appar-ently the use of the medicament was able to shutdown the inflammatory response after replantation toallow for more favorable healing in comparison tothose teeth that did not possess the medicament. Weare confident that the immediate use of this medic-ament will become standard practice in the not toodistant future.

The need for analgesics should be assessed on anindividual case basis. The use of pain medicationstronger than a non-prescription, non-steroidal, anti-inflammatory drug is unusual. The patient should besent to a physician for consultation regarding a teta-nus booster within 48 h of the initial visit.

Second Visit

This visit should take place 7–10days after the emer-gency visit. At the emergency visit, emphasis wasplaced on the preservation and healing of the attach-ment apparatus. The focus of this visit is the preven-tion or elimination of potential irritants from the rootcanal space. These irritants, if present, provide thestimulus for the progression of the inflammatory re-sponse and bone and root resorption. Also, at thisvisit, the course of systemic antibiotics is completed,

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the chlorhexidine rinses can be stopped, and thesplint is removed.

Endodontic Treatment

Extra – oral time , 60 min

Closed ApexInitiate endodontic treatment at 7 to 10days. In caseswhere endodontic treatment is delayed or signs of re-sorption are present, treat with ‘long-term’ calciumhydroxide treatment before obturation.

No chance exists for the revascularization of theseteeth, and endodontic treatment should be initiatedat the second visit at 7–10days (6, 13). If therapy isinitiated at this optimum time, the pulp should benecrotic without infection or, at most, only minimalinfection (30–32). Therefore, endodontic therapywith an effective interappointment antibacterial agent(33) over a relatively short period of time (7–10days)is sufficient to ensure effective disinfection of the canal(34). If the dentist is confident of complete patientcooperation, long-term therapy with calcium hydrox-ide remains an excellent treatment method (5, 32).The advantage of its use is that it allows the dentistto have a temporary obturating material in place untilan intact periodontal ligament space is confirmed.Long-term calcium hydroxide treatment should al-ways be used when the injury occurred more than 2weeks before the start of endodontic treatment or ifradiographic evidence of resorption is present (32).

The root canal is thoroughly instrumented and irri-gated, then filled with a thick, powdery mix of cal-cium hydroxide and sterile saline (anesthetic solutionis also an acceptable vehicle). The calcium hydroxideis changed every 3months within a range of 6–24months. The canal is obturated when a radiographi-

Fig. 9. A. Active resorption can be seensoon after the tooth was replanted. B. Afterlong-term Ca (OH)2 treatment, the resorp-tive defects have healed, and an intact lam-ina dura can be traced around the root.The tooth is ready for obturation.

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cally intact periodontal membrane can be demon-strated around the root. Calcium hydroxide is an ef-fective antibacterial agent (33, 34), and favorably in-fluences the local environment at the resorption site,theoretically promoting healing (35). It also changesthe environment in the dentin to a more alkaline pH,which may slow the action of the resorptive cells andpromote hard tissue formation (35). However, thechanging of the calcium hydroxide should be kept toa minimum (not more than every 3months) becauseit has a necrotizing effect on the cells that areattempting to repopulate the damaged root surface(36).

While calcium hydroxide is considered the drug ofchoice in the prevention and treatment of inflamma-tory root resorption, it is not the only medicamentrecommended in these cases. Some attempts havebeen made to not only remove the stimulus for theresorbing cells but also to affect them directly. Theantibiotic-corticosteroid paste, Ledermix, is effectivein treating inflammatory root resorption by inhibitingthe spread of dentinoclasts (37, 38) without damagingthe periodontal ligament. Its ability to diffuse throughhuman tooth roots has been demonstrated (39), whilstits release and diffusion is further enhanced whenused in combination with calcium hydroxide paste(40). Calcitonin, a hormone that inhibits osteoclasticbone resorption, is also an effective medication in thetreatment of inflammatory root resorption (41).

Open ApexAvoid endodontic treatment and look for signs of revasculariza-tion. At first sign of an infected pulp initiate apexification pro-cedure. Teeth with open apices have the potential torevascularize and continue root development and ini-tial treatment is directed toward the re-establishmentof the blood supply (13, 14) (Fig. 3). The initiation of

Current and Future strategies for treating avulsed teeth

endodontic treatment is avoided if at all possible un-less definite signs of pulp necrosis, such as peri-radicu-lar inflammation, are present. The diagnosis of pulpvitality is extremely challenging in these cases. Aftertrauma, diagnosis of a necrotic pulp is particularlydesirable because, due to cemental damage accom-panying the traumatic injury, infection in these teethis potentially more harmful. External inflammatoryroot resorption can be extremely rapid in these youngteeth because the tubules are wide and allow the irri-tants to move freely to the external surface of the root(13, 14) (Fig. 9).

Patients are recalled every 3–4weeks for sensitivitytesting. Recent reports indicate that thermal tests withcarbon dioxide snow (ª78 æC) or difluordichlorme-thane (ª50 æC) placed at the incisal edge or pulphorn are the best methods for testing sensitivity, par-ticularly in young permanent teeth (42, 43, 46) (Fig.10). One of these two tests must be included in thesensitivity testing of these traumatized teeth. The laserDoppler flowmeter has been shown to be a superiortool in the diagnosis of revascularization of an imma-ture tooth after trauma (44). In a recent study in dogs,Yanpiset et al. (45) showed that the presence of re-vascularization can be detected as early as 4 weeksafter an avulsion by this method. Radiographic (api-cal breakdown and/or signs of lateral root resorption)and clinical (pain to percussion and palpation) signsof pathosis are carefully assessed. At the first sign ofpathosis, endodontic treatment should be initiatedand, after disinfection of the root canal space, anapexification procedure should be carried out.

Fig. 10. Modern cold testing methods, placed on the incisal edgeof the incisors.

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Extra-oral time . 60 min

Closed ApexAs with , 60 dry time. These teeth are treated endo-dontically in the same way as those teeth that had anextra-oral time of , 60min

Open Apex (if replanted)If endodontic treatment was not performed out of the mouth,initiate apexification procedure. In these teeth the chanceof revascularization is extremely poor (4, 32). There-fore, no attempt is made to revitalize these teeth. Anapexification procedure is initiated at the second visitif root canal treatment was not performed at theemergency visit. If endodontics was performed at theemergency visit, the second visit is a recall visit toassess initial healing only.

Temporary Restoration. Effectively sealing the coronal ac-cess is essential to prevent infection of the canal be-tween visits. Recommended temporary restorationsare reinforced zinc-oxide-eugenol cement, acid-etchcomposite resin, or glass-ionomer cement. The depthof the temporary restoration is critical to its seal-ability. A depth of at least 4mm is recommended sothat a cotton pellet cannot be placed; the temporaryrestoration is placed directly onto the calcium hydrox-ide in the access cavity. Calcium hydroxide shouldfirst be removed from the walls of the access cavitydue to the fact that it is soluble and will wash outwhen it comes into contact with saliva, leaving a de-fective temporary restoration.

After initiation of the root canal treatment, the splintis removed. If time does not permit complete removalof the splint at this visit, the resin tacks are smoothedso that the soft tissues are not irritated and the re-sidual resin is removed at a later appointment.

At this appointment, healing is usually sufficient toperform a detailed clinical examination on the teethsurrounding the avulsed tooth. The sensitivity tests,reaction to percussion and palpation, and periodontalprobing measurements should be carefully recordedfor reference at follow-up visits.

Obturation visit

At practioners convenience or, in cases of long-term calciumhydroxide therapy, when an intact lamina dura is traced. Ifthe endodontic treatment was initiated 7–10daysafter the avulsion and clinical and radiographic ex-aminations do not indicate pathosis, obturation of theroot canal at this visit is acceptable, although the useof long-term calcium hydroxide is a proven option foruse in these cases. On the other hand, if endodontictreatment was initiated more than 7–10days after theavulsion or active resorption is visible, the pulp space

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must first be disinfected before obturation. Tradition-ally, the re-establishment of a lamina dura (Fig. 9) isa radiographic sign that the canal bacteria have beencontrolled. When an intact lamina dura can betraced, obturation can take place.

The canal is re-instrumented and irrigated understrict asepsis. After completion of the instrumentation,the canal can be obturated by any acceptable tech-nique with special attention to an aseptic techniqueand the best possible seal of the obturating material.

Permanent Restoration

Much evidence exists that coronal leakage caused bydefective temporary and permanent restorations re-sults in a clinically relevant amount of bacterial con-tamination of the root canal after obturation. There-fore, the tooth should be permanently restored eitherat or soon after the time of obturation of the rootcanal. As with the temporary restoration, the depthof restoration is important for its seal and thereforethe deepest restoration possible should be made. Apost-obturation restoration should be avoided when-ever possible. Because most avulsions occur in the an-terior region of the mouth where esthetics is import-ant, composite resins with the addition of dentinbonding agents are usually recommended in thesecases. They have the additional advantage of intern-ally strengthening the tooth against fracture if anothertrauma should occur.

Follow-Up Care

Follow-up evaluations should take place at 3months,6months and yearly for at least 5years. If osseous re-placement is identified, timely revision of the long-term treatment plan is indicated. In the case of in-flammatory root resorption, a new attempt at dis-infection of the root canal space by standard re-treatment can reverse the process. Teeth adjacent toand surrounding the avulsed tooth or teeth may showpathologic changes long after the initial accident.Therefore, these teeth should be tested at recall andthe results compared to those collected soon after theaccident.

References

1. Andreasen JO. The effect of extra-alveolar period and storagemedia upon periodontal and pulpal healing after replantationof mature permanent incisors in monkeys. Int J Oral Surg1981;10:43–51.

2. Soder PO, Otteskog P, Andreasen JO, Modeer T. Effect ofdrying on viability of periodontal membrane. Scand J DentRes 1977;85:167–172.

3. Andreasen JO, Hjorting-Hansen E. Replantation of teeth, I:Radiographic and clinical study of 110 human teeth replantedafter accidental loss. Acta Odontol Scand 1966;24:263–269.

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4. Trope M. Root resorption of dental and traumatic origin.Classification based on etiology. J Pract Periodont AesthetDent 1998;10:515–522.

5. Tronstad L. Root resorptionetiology, terminology and clinicalmanifestations,. Endod Dent Traumatol 1988;4:241.

6. Andreasen JO, Andreasen FM. Textbook and Color Atlas ofTraumatic Injuries to the Teeth, 3rd edn. Copenhagen andSt. Louis, Munksgaard and CV Mosby, 1994.

7. Andreasen JO, Kristersson L. The effect of limited drying orremoval of the periodontal ligament: Periodontal healing afterreplantation of mature permanent incisors in monkeys. ActaOdontol Scand 1981;39:1.

8. Barrett EJ, Kenny DJ. Avulsed permanent teeth: a review ofthe literature and treatment guidelines. Endod DentTraumatol 1997;13:153–163.

9. Hiltz J, Trope M. Vitality of human lip fibroblasts in milk,Hanks Balanced Salt Solution and Viaspan storage media. En-dod Dent Traumatol 1991;7:69.

10. Blomlof L. Milk and saliva as possible storage media for trau-matically exarticulated teeth prior to replantation. Swed DentJ Suppl 1981;8:1.

11. Trope M, Friedman S. Periodontal healing of replanted dogteeth stored in Viaspan, milk and Hanks Balanced Salt Solu-tion. Endod Dent Traumatol 1992;8:183–188.

12. Hedegard B, Stalhone I. A study of traumatized permanentteeth in children aged 7–15 years. Part I. Swed Dent J1973;66:431–438.

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