Avulsions If an immature permanent tooth has been out of the mouth for less than one hour and has an apical diameter greater than 1mm, pulpal revascularization is possible. The tooth should be replaced in its socket, stabilized and monitored closely for three to four weeks. During this time, watch for changes in tooth color, pain, swelling or loosening of the tooth. If any of these problems arise, an apexification procedure may be initiated followed by a permanent root canal filling. If an immature permanent tooth has been out of the mouth for more than one hour, the tooth may be replaced in the socket. The canal should be debrided and filled with calcium hydroxide. Stabilization will likely be needed, and the tooth should be re-evaluated in six to eight weeks. The prognosis of this tooth is generally poor, so you may wish to discuss other treatment options with the patient.

Avulsion Quick emergency intervention Urgent clinical treatment Multidisciplinary nature

Accident Site Replant if possible or place in appropriate storage medium to minimize necrosis of PDL cells Storage media in order of preference, Hank’s balanced salt solution, milk, saliva, saline or water. Water is better then dry but is hypotonic and rapid cell lysis, death and resulting inflammation. Single most important factor is speedy replantation, make effort to replant with in 20 minutes.

Dental Office Prepare the socket Prepare the root Replant Construct splint Administer local or systemic antibiotics

Preparation of the Root Extraoral dry time less then 60 minutes Closed apex: rinse root with saline and replant gently. Pulp will die but if replanted within 20 minutes a good chance of PDL healing exists. Over 60 minutes periodontal cell survival is unlikely. Open apex: gently rinse off debris with saline, soak in doxycycline for 5 minutes. This enhances pulpal revascularization. (1 mg in 20 ml of saline)

Preparation of the Root extraoral dry time exceeds 60 minutes Closed Apex: remove entire PDL by placing in acid, rinse with saline and soak in 2% stannous fluoride for five minutes, replant. Open Apex: Controversy regarding replanting. Is yes same as above but definitely do endodontics extraorally to facilitate the seal. Will be lost do to osseous replacement resorption but will maintain height and width of alveolar bone

Preparation of the Socket Leave undisturbed before replantation If an organized clot is blocking replantation gently rinse with saline and lightly aspirate If alveolar bone has collapsed use a blunt instrument to reposition the wall

Splinting Splint should allow some movement to stimulate PDL fibers to reattach. A rigid splint promotes ankylosis Physiologic splint removed in 2 weeks Make sure the repositioned tooth and splint are not in traumatic occlusion. Remember if the avulsed tooth occurs in conjunction with an alveolar fracture splint must remain for 4 to 8 weeks

Adjunctive Therapy Begin antibiotics from day of replantation until splint removal. For patients not susceptible to tetracycline staining use doxycycline (decreases resorption) or Pen VK Gentle oral hygiene and chlorhexidine rinses Pain relieve usually NSAI if needed

Endodontic Treatment Extraoral time less than 60 minutes with closed apex: Initiate endodontic after 2 weeks use long term CAOH before obturation to inhibit resorption Opened apex less than 60 minutes: Avoid endodontic treatment, look for signs of revascularization. Follow closely at first sign of infection initiate apexification procedures.

Endodontic Treatment Extraoral time more than 60 minutes with closed apex: Initiate endodontic therapy after 2 weeks, use long term CAOH treatment More than 60 minutes and an open apex: do the endodontics outside the mouth before replanting. If it was replanted without an obturation initiate apexification. Remember some would suggest not replanting because of certain replacement resorption