Avulsion injuries are devastating for our patients. A model patient tepeing away for years and all of a sudden bang they go from 28 pearly whites to a gappy smile that can be both physically and mentally debilitating. These injuries are not difficult to treat per se their optimal management depends heavily on time and expertise to deliver what is required. In such situations the best ‘clinician’ is the patient. As soon as the tooth has left the mouth the sooner it is re-implanted the better. As the periodontal ligament fibres are shredded by the injury their ability to heal is heavily associated with ‘dry time’ and the cellular death this causes. Even if managed optimally the tooth has a guarded prognosis and this solitary incident may commit the patient to extensive dental treatment for the rest of their life. The following provides a summary on the management of teeth with closed apices.
SOON
If the tooth has been replanted soon after the injury the periodontal ligament cells are still viable and the prognosis is as best as can be expected. When the tooth presents to you the following steps can be taken.
- Radiograph the area to ensure there are no underlying issues and also to ensure the tooth has been replanted correctly.
- If the tooth reveals itself to require further repositioning apply local anaesthetic and utilise firm digital pressure. Retake radiograph if necessary. A good guide is the incisal level of the adjacent tooth as long as it hasn’t also been displaced.
- Once optimally positioned provide a flexible splint utilising composite and 018 orthodontic wire for two weeks. This should be applied to the teeth either side of the injury, if multiple teeth are involved the splint should be extended as needed.
- Provide the patient with 100mg of doxycycline twice a day for 7 days.
- Check patients tetanus status.
- Initiate root canal treatment within 7 days.
The purpose of the doxycycline is not only to prevent infection there are physiological benefits such as reducing the chance of resorption.
OPTIMAL STORAGE and LESS THAN 60 MINS since injury
If the tooth presents less than 60 minutes after the injury and has been stored in Hanks Balanced Salt Solution then there is a fighting chance !
- Clean the root with saline gently removing debris
- Anaesthetise the area
- Irrigate the socket
- Reposition any alveolar fractures within the socket
- Replant the tooth with firm digital pressure
- Check radiograph
- Once optimally positioned provide a flexible splint utilising composite and 018 orthodontic wire for two weeks. This should be applied to the teeth either side of the injury.
- Provide the patient with 100mg of doxycycline twice a day for 7 days
- Check patients tetanus status
- Initiate root canal treatment within 7 days.
POOR STORAGE and GREATER THAN 60 MINS since injury
Greater than 60 minutes in a fully grown patient means that a good outcome to treatment will be maintenance of alveolar contour by the replanted root and the chance of periodontal regeneration is poor. Ankylosis is very likely in these situations and sequalae of this should be explained to the patient prior to replanting the tooth.
The steps are largely the same as when the tooth is optimally stored with a couple of differences.
- The splint should be in place for about 4 weeks as opposed to two.
- There is an option of soaking the root in 2% sodium fluoride solution for 20 minutes in order to slow down replacement resorbtion but is not absolutely indicated.
The video below summarises the stages of management
