1. AVULSION

2. AVULSION ( EXARTICULATION OR TOTAL LUXATION )
DEFINITION : The tooth is displaced totally out of it’s socket.

3. CLINICAL APPEARANCE
The socket is found empty or filled with coagulum.

4. EPIDEMIOLOGY Rare injuries(1.6% of dental injury)
Primary dentition > secondary dentition
Boys > girls
The teeth most commonly damaged are upper central incisor

5. ETIOLOGY Cause: accident contact sports fighting Predisposing factor :
Cl II malocclusion
Periodontal disease

6. HISTORY TAKING When did the injury take place ?
Where did the injury take place ?
How did the injury take place ?

7. HISTORY TAKING Has treatment been provided elsewhere ?
Has there been previous trauma ?
Has avulsed tooth been accounted for ?

8. HISTORY TAKING MEDICAL HISTORY DENTAL HISTORY SOCIAL HISTORY
FAMILY HISTORY

9. Neurological Assessment
- Obtain information : loss of consciousness, neck or head pain, and numbness
- Ask about the event…. amnesia?
- Other signs: nausea, vomiting, drowsiness, blurred vision

10. EXTRAORAL EXAMINATION
Facial wound
Fracture of mandible / maxilla
Occlusion
Mandibular movement

11. INTRAORAL EXAMINATION
Solf tissue
Foreign body
Alveolar bone fracture

12. RADIOGRAPHIC EXAMINATION
Are routinely to determine the socket
Check for supporting structure and adjacent tooth
Compare with the future radiographs

13. RADIOGRAPHIC EXAMINATION

14. TREATMENT OF AVULSED TOOTH
Success of treatment depend on
Extraoral time
Storage media
Stage of tooth development

15. EXTRAORAL TIME
After 60 minutes of dry storage media very few PL cells remain viable.
120 minutes - complete PL cells necrosis.

16. STORAGE MEDIA
Hank’s balance salt
solution (HBSS)
Milk
Saliva
Water

17. TREATMENT OF AVULSED TOOTH
Preparation of the avulsed tooth
Preparation of the socket
Replantation
Splinting
Follow up

18. PREPARATION OF THE AVULSED TOOTH
Saline to remove foreign bodies
Avoid scraping the root surface

19. PREPARATION OF THE SOCKET
The region should be anesthetized
Gently clean with NSS to remove clotted blood and foreign materials

20. PREPARATION OF THE SOCKET

21. REPLANTATION Press the tooth gently into the socket
Compress buccal and lingual plate of bone
Take radiograph immediately

22. REPLANTATION

23. SPLINTING Requirements of splint
Provide stabilization for the replanted tooth
Slight physiologic movement
Hygienically designed
Not leave the replanted tooth in traumatic occlusion

24. SPLINTING Wire composite splint Composite splint Removable flexible
acrylic splint
Orthodontics wire
Etc.

25. SPLINTING

26. SPLINTING
How long?
the fixation period should be sufficient to allow the reattachment of PDL. This will take from 1 – 3 weeks.

27. FOLLOW UP
A well designed follow up procedure is diagnose complication.
1 week.
2 weeks.
3 weeks. A radiographic examination is able to demonstrate periapical radiolucency

28. FOLLOW UP
6 weeks. A clinical and radiographic examination A clinical and radiographic examination is able to demonstrate most case of inflammatory resorption

29. FOLLOW UP 2 and 6 months. Optional for cases with questionable healing
1 year. A clinical and radiographic examination can ascertain the long – term prognosis

30. WOUND HEALING AFTER REPLANTATION
Surface resorption
Replacement resorption
Inflammatory root resorption

31. Surface resorption
Surface resorption is manifested as a excavations on the root surface without associated breakdown of the lamina dura.

32. Surface resorption

33. Replacement resorption
Replacement resorption (ankylosis) is initially seen as a disappearance of PDL space, later follow by a substitution with bone.

34. Replacement resorption
PDL injury -> inflammation -> osteoclastic activity -> fusion between bone and root surface

35. Inflammatory resorption
Inflammatory resorption is seen as bowl shaped cavities on the root surface with an associate radiolucency affecting the lamina dura.

36. Inflammatory resorption

37. Summary

38. The influence of storage conditions on the clonogenic capacity of periodontal cell : implication for tooth replantation
P.C. Lekic , D.J. Kenny & E.J. Barrett
International Endodontic Journal (1998)31,

39. INTRODUCTION
Viable periodontal ligament (PL) cells are required for the healing of avulsed teeth after replantation.

40. INTRODUCTION
The viability of PL cells in extra- alveolar conditions may be extended by incubating the avulsed tooth in a physiologic storage medium.

41. INTRODUCTION
Regeneration of PL following replantation is closely related to preservation of the viability PL cells that adhere to avulsed teeth

42. OBJECTIVES
To investigate the effects of combinations of storage media on the clonogenic capacity of human PL cells at two different extra alveolar period.

43. MATERIALS AND METHODS 20 human premolar teeth were extracted
Aged 11 – 14 years
4 storage media (saliva , milk , HBSS , MEM)
All teeth were assayed at 30 and 60 min

44. MATERIALS AND METHODS Twenty extracted human premolars Time 0 min
15 teeth
5 teeth
Saliva (23c)
MEM (+4c)
5 teeth
Per condition
Milk
Saliva
HBSS
MEM (+4c)
One-half of PL tissue explanted from premolar(cells released and analyzed for clonogenic capacity)

45. RESULTS

46. CONCLUSION
Immediate storage of a avulsed teeth in autologous saliva , a followed by transfer to chilled milk , preserves the presence of sufficient progenitor cells in the PL to warrant replantation and the possibility of PL healing at 60 min extra-alveolar duration.

47. Any
Questions?

48. Thanks for your attention

49. REFERENCES
Peter J. Robinson,Louis H. Grernsey: Clinical Transplantation in Dental Specialties.C.V.Mostby,Missouri,1980
G.J.Robert,P.Longhurst: Oral and Dental Trauma in Children and Adolestcents,Oxford university press Inc. New York, 1996
Mitsuhiro Tsukiboshi: Autotransplantation of Teeth,Quintessence,Tokyo,2001
J.O.Andreasen,F.M.Andreasen,L.K.Bakland, et al: Traumatic Dental Injury.Munksgaard.Copenhagen,1999
M.E.J.Curzon: Handbook of Dental Trauma,Wrigth,Jordan Hill,Oxford,1999

50. Special thanks
อ.ทพ.ชยารพ สุพรรณชาติ