The Avulsed or Luxated tooth is both a dental and an emotional problem. It is usually the result of trauma to an anterior tooth of a child or young adult. the shock and pain of the injury and the loss of a tooth needed for eating, speaking and smiling, often lead to emotional upheaval in patient and parent.
The longer the luxated tooth is out of the socket, the less likely it will remain in a healthy, functional state after replantation.
The extraoral time for an avulsed tooth optimally should not exceed 30 min, the patient must be taken to the dentist immediately.
Can be divided into,
a. Management at the site of injury.
b. Management in the dental office.
a. Management at the site of injury:
- Wash the tooth in running water without brushing or cleaning it, and examine it to be certain that the tooth is intact.
- Have the patient rinse mouth. Replace tooth in its socket using gentle, steady finger pressure.
- If the patient is cooperative and able, have the patient gently close the teeth together to force the teeth together to force the tooth back into its original position.
- If immediate replantation is not possible, place the tooth in the best transport medium available.
Transport Media –
- Hank’s Balanced Salt Solution (H.B.B.S)
- Saliva (buccal vestibule)
- If none of these is readily available, use water.
b. Management in the dental office:
i. Replantation of Tooth –
- If extraoral dry time is more than 2 hours, replant immediately.
- If it exceeds 2 hours, soak the tooth in a topical Fluoride solution for 5-20 minutes, rinse in saline and relant.
- If tooth has been in any of the physiologic transport medium, then it is safe to replant immediately.
ii. Management of the Root surface -
- Keep the tooh moist at all times.
- Do not handle the root at all. (hold the tooth by its crown portion)
- Do not scrape or brush the root surface, or attempt to remove the root tip.
- If the root appears clean, replant as it is after rinsing with saline.
- If its contaminated, rinse with H.B.B.S or saline (use tap water if none of these are available).
- In case of persistent debris, gently use cotton pellet or a wet sponge to remove the remaining debris.
iii. Management of the socket -
- Gently aspirate without entering the socket, if a clot is present, use light irrigation with saline.
- Do not curette the socket.
- Do not vent the socket.
- Do not make a surgical flap unless bony fragments prevent replantation.
- If the alveolar bone is collapsed, and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position. Aafter replantation, manually compress facial and lingual bony plates.
iv. Management of Soft tissue -
- Tightly suture any soft tissue lacerations.
- Use acid etch resin alone or with soft arch wire, or useorthodontic brackets with passive arch wire.
- Splint should remain in place for 7-10 days; however if tooth demonstartes excessive mobility, splint should be replaced until mobility is within acceptable limits.
- Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).
- No biting on splinted teeth. The teeth should be kept out of occlusion.
- Soft diet
- Good oral hygiene.
Adjunctive Drug therapy
- Systemic Antibiotics
- Referral to physician for tetanus consultation within 48 hours.
- Chlorhexidine rinses.
i. Tooth with open apex (divergent roots) and less than 2 hours extraoral dry time:
- Replant in an attempt to revitalize the pulp.
- Recall patient every 3-4 weeks for evidence of pathosis.
- If pathosis is noted thoroughly clean and fill the canal with Calcium Hydroxide (apexification).
ii. Tooth with open apex, and more than 2 hours extraoral dry time:
- Thoroughly dry the canal and fill it with Calcium hydroxide.
- Recall the patient every 6-8 weeks.
iii. Tooth with partially to completely closed apex and less than 2 hours extraoral dry time:
- Pulp extirpation in 7-14 days.
- Medicate the canal with Calcium hydroxide.
- Obturate canal with Gutta Percha points and a sealant after 7-14 days of calcium hydroxide.
iv. Tooth with partially or completely closed apex, and greater than 2 hours of extraoral time:
- Perform root anal therapy intraorally or extraorally.
- If treated extraorally, avoid chemical or mechanical damage to root surface.
- Avulsed permanent teeth requires follow up evaluations for a minimum of 2-3 years to determine the outcome of therapy.
COMPLICATIONS OF TOOTH REPLANTATION
- Inflammatory resorption
- Replacement resorption
- Tooth Submergence
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- Dental Caries – Another reason to kick your sugar habit
- Chlorhexidine – A Gold Standard in Chemical Plaque Control.
- Gum Overgrowth – Gingival Enlargement – Size Does Matter
- Infection of the Gums – Pericoronitis
- Brushing and Flossing Teeth – No Rocket Science!