11.avulsion ppt.pptx trauma of anterior teeth

trauma

1. 2 MANAGEMENT OF AVULSION Guided by Dr. D. Praveen Associate Professor Presented by G. Sahithya (II MDS)

2. CONTENTS Definition Causes Replantation Factors Affecting The Success Of Replanted Tooth Types Of Storage Media Clinical Findings Radiographic Findings Treatment Guidelines For Avulsed Permanent Teeth Patient Instructions Prognosis Types Of Healing After Replantation Conclusion References

3. Previous Questions 1. Management of avulsed tooth-2017 (7marks) 2. Management of avulsed tooth -2011 (7 marks)

4. AVULSION Dental avulsion refers to the complete displacement of a tooth from its alveolar socket that causes pulp necrosis and destruction of periodontal tissues. It accounts for up to 16% of dental injuries and mostly occurs in children. Alotaibi S, Haftel A, Wagner ND. Avulsed Tooth.

5. The most common causes of dentoalveolar trauma include falls, especially in children, cycling, full-contact sports, traffic accidents, and assault. Dental trauma most frequently occurs at home, school, and sports centers. Anatomic features that increase the likelihood of dentoalveolar trauma include protuberant upper teeth, Etiology Overjet (Over 3 Mm), Anterior Open Bite, Malocclusion (Class II), Incompetent Lips, And Mouth Breathing

6. When an external impact occurs on a tooth, the periodontal fibers can tear, allowing partial or total displacement of the tooth from the socket. The ensuing damage can lead to neuro-vascular disruption, as well as pulp necrosis. maxillary central incisors maxillary lateral incisors. Pathophysiology Alotaibi S, Haftel A, Wagner ND. Avulsed Tooth.

7. Pulp necrosis can be treated without difficulty, but damage to the periodontal ligament (PDL) is challenging and causes replacement resorption and tooth loss Periodontal ligament fibers can desiccate rapidly in the open air. Even in a replanted tooth, the damaged periodontal ligament fibers can lead to bony resorption of the root. Root resorption will lead to crown fracture and loss of the tooth

8. A history of trauma to the tooth will reveal tooth avulsion, and the mechanism of injury can point to other injuries.  History should include -the length of time - the storage medium History and Physical

9. Physical examination foreign material, and tooth fragments evaluating the surrounding structures for other injuries such as lacerations, gingival contusions, and bone fractures If a tooth suspected of avulsion is not found, aspiration, gastro-intestinal placement, or intrusion should be ruled out.

10. Factors Affecting The Success Of Replanted Tooth Extra alveolar time Storage / transporting media Stage of root formation Condition of the pulp and root canal space Stabilization

11. Extra-alveolar conditions may be modified by storing the tooth in a physiological storage medium. A storage medium may be defined as a physiological solution that closely replicates the oral environment to help preserve the viability of PDL cells following avulsion.

12. Extra alveolar time

13. The tooth has been kept in a physiologic storage medium or stored in non-physiologic conditions, with the extra-oral dry time less than 60 minutes Physiologic storage media include tissue culture media and cell transport media. Examples of osmolality-balanced media are milk and Hanks’ Balanced Salt Solution (HBSS). visible contamination,--rinse the root surface--- stream of saline Check the avulsed tooth for surface debris. Remove any debris by gently agitating it in the storage medium/ stream of saline Put or leave the tooth in a storage medium while taking a history, examining the patient clinically and radiographically, and preparing the patient for the replantation.

14. Administer local anesthesia, preferably without a vasoconstrictor Irrigate the socket with sterile saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition the fractured fragment into its original position with a suitable instrument. Removal of the coagulum with a saline stream may allow better repositioning of the tooth. Replant the tooth slowly with slight digital pressure. Excessive force should not be used to replant the tooth back into its original position.

15. Verify the correct position of the replanted tooth both clinically and radiographically. Stabilize the tooth for 2 weeks using a passive, flexible wire of a diameter up to 0.4 mm. Suture gingival lacerations, if present. Initiate root canal treatment within 2 weeks after replantation

16. Extra-oral dry time longer than 60 minutes Delayed replantation has a poor long-term prognosis. The periodontal ligament becomes necrotic and is not expected to regenerate. The expected outcome is ankylosis-related (replacement) root resorption.

17. The goal of replantation in these cases is to restore, at least temporarily, esthetics and function while maintaining alveolar bone contour, width, and height. Therefore, the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes. The rate of ankylosis and resorption varies considerably and can be unpredictable

18. According to current guidelines, the management of avulsion can be categorized into four stages based on extraoral time and storage conditions.  Stage 1  represents onsite replantation in less than 5 min, the ideal treatment condition. Most PDL cells are vital.   In stage 2,  the tooth is stored in a wet condition for less than an hour, and there are still PDL cells, but the vitality might be reduced.  In Stages 3 and 4 , extra-oral time is more than an hour regardless of wet or dry storage, and PDL cells are most likely nonvital. In these stages, the prognosis is unfavorable due to the development of replacement resorption. Aksel H, Zhu X, Gauthier P, Zhang W, Azim AA, Huang GT. A new direction in managing avulsed teeth: stem cell-based de novo PDL regeneration. Stem cell research & therapy. 2022 Jan 28;13(1):34.

19. Successful tooth replantation with a favorable long-term prognosis particularly depends on the maintenance of PDL cell viability. The ideal storage medium should preserve cell vitality, should promote clonogenic capacity readily available or easily accessible at the site.

20. TYPES OF STORAGE MEDIA There are many solutions that have been proposed and/or tested as storage media for avulsed teeth. Hank’s balanced salt solution (HBSS) Eagle’s medium (EM) Milk Gatorade Custodiol Propolis Contact lens solution Tap water Egg white Saliva Normal saline Coconut water

21. Hank’s balanced salt solution (HBSS) -AAE recommended Essentially a pH-balanced salt solution It contains all of the essential metabolites and glucose necessary for the maintenance of cells. Composition : sodium chloride, D-glucose, potassium chloride, sodium bicarbonate, potassium phosphate, calcium chloride and magnesium sulphate anhydrous. Venugopal M. Recent Advances in Transport Medium for Avulsed Tooth: A Review. Amrita Journal of Medicine. 2022 Apr 1;18(2):37-44.

22. It can preserve cells and tissues for 24hrs and both the pH and the osmolality are ideal . The vitality, clonogenic and mitogenic capacity of PDL cells using this medium are excellent HBSS is the only medium that can replenish metabolites in depleted PDL cells .

23. Eagle’s medium contains glutamine, penicillin, streptomycin, nystatin. Preservation of PDL fibroblasts of the avulsed tooth for a longer period of time before reimplantation was satisfactory with Eagle’s medium. It acts by the proliferation of the PDL cells. viability of PDL was preserved when stored in Eagle’s medium for almost 48 h. EAGLE’S MEDIUM .

24. MILK Milk as a storage medium is the most practical transport medium. Contains amino acids and vitamins. Inactivates enzymes harmful to the PDL cells. Ph of 6.5 to 7.2 and osmolality of 270 mO smol / kg. It can potentially maintain PDL cell viability for up to 2 h . Venugopal M. Recent Advances in Transport Medium for Avulsed Tooth: A Review. Amrita Journal of Medicine. 2022 Apr 1;18(2):37-44.

25. Milk with a lower fat content more useful at maintaining cell viability than milk with higher fat content The drawbacks are: M ilk needs to be fresh and kept refrigerated I t does not replace depleted cell metabolites I t does not facilitate cell mitosis However, milk has a compatible osmolality with PDL cells and is readily available to the public in most situations.

26. It prevents cell death, but does not restore the cell’s normal morphology and ability to differentiate and undergo mitosis. At a cellular level, milk is ranked equal to HBSS as a storage medium although it loses its effectiveness after 2 hr. Milk is superior to saliva with regard to the number of viable cells. The osmolality of milk appears to be the most important factor .

27. GATORADE O riginally formulated as a drink for sports people to replenish electrolytes. Sigalas et al. showed that Gatorade was better than tap water, and that Gatorade may be viable for the short-term storage of avulsed teeth. Sigalas E, Regan JD, Kramer PR, Witherspoon DE, Opperman LA. Survival of human periodontal ligament cells in media proposed for transport of avulsed teeth. Dental traumatology. 2004 Feb;20(1):21-8.

28. ViaSpan Viaspan is clear to light-yellow, anti-pyrogenic solution. It has Ph of 7.4 and osmolality of 320 mOsmol /kg. It is very effective storage medium. Used for organ-transplantation. Maintains the viability of PDL cells and superior than HBBS. Drawbacks: should be refrigerated High cost Not readliy available in public.

29. CUSTODIOL It is the registered trademark of Dr. Franz. This is a histidine-tryptophan ketoglutarate solution It is used as a preservation solution for organ transplantation. Alacam et al reported that it is comparable to HBSS for cell preservation. However, it is not available to the public and therefore of little value as a storage medium for avulsed teeth. Alaçam T, Görgül G, Ömürlü H, Can M. Lactate dehydrogenase activity in periodontal ligament cells stored in different transport media. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 1996 Sep 1;82(3):321-3.

30. PROPOLIS Propolis is a multifunctional material. It has several biological activities including anti-inflammatory antibacterial anti-oxidant anti-fungal tissue regenerative actions. Mori GG, Nunes DC, Castilho LR, de Moraes IG, Poi WR. Propolis as storage media for avulsed teeth: microscopic and morphometric analysis in rats. Dent Traumatol 2010; 26: 80–5.

31. Tooth Rescue Box (DENTOSAFE) It contains a culture medium containing salts, amino acids, glucose and vitamins. It maintains the vitality of PDL cells for up to 48h at room temperature in vitro. They are essentially saline solutions with antimicrobial properties and therefore can be considered for storage media. Preservatives present in these solutions can be harmful to PDL cells and, hence, not recommended. Contact Lenses Solutions

32. TAP WATER It is hypotonic, not compatible with PDL cells and causes rapid cell lysis. Although some studies have suggested that it may be accepted as a storage medium for very brief periods when there are no alternatives. Least desirable storage medium available. I ts use will lead to ankylosis and replacement resorption.

33. Egg white has a pH of 8.6–9.3 and its osmolality is 258 mOsmol /kg. Egg white was more suitable than water . Sousa et al. showed that teeth stored in milk and egg white had comparable results with respect to collagen fibers organization and the number of viable cells. Due to high pH, loss of cell viability was seen over time and loss of cell viability may also be attributed to the presence of several egg proteins acting as foreign bodies. EGG WHITE

34. SALIVA I mmediate interim storage medium A vulsed teeth should not be stored for longer than 30 min in saliva. A precipitous decrease in functional capacity occurs within 60min Saliva contains potentially harmful substances, such as enzymes, bacteria and their by-products . In an animal study, Andreasen showed that saline and saliva were suitable storage medium for protection against root resorption for short extra-alveolar periods.

35. Normal Saline Isotonic saline has been used successfully as a storage medium by researchers. It has a comparable osmolality to that of PDL cells. Cvek et al. found that a tooth stored in normal saline for 30 min showed less resorption than a tooth stored dry for between 15 and 40 min. In contrast other study reported little difference in the development of ankylosis between teeth stored in normal saline and teeth kept dry.

36. Coconut Water Natural drink available biologically and hermetically inside the hard shell of coconut. Moreira- neto et al. Compared different storage medias; the coconut water group demonstrated significantly more viable PDL cells than hank’s balanced salt solution (HBSS) and milk, which is usually considered ideal. There are a few studies that showed that the tooth maintained in coconut water caused inflammatory resorption. Therefore, further studies are recommended before its commercial use as a storage media for the avulsed tooth

37. CONCLUSION The best storage media for the avulsed tooth when comparing their efficacy as per literature include Eagle’s culture medium = ViaSpan = Custodiol = HBSS > Milk ≥ Propolis ≥ Green tea ≥ Egg > coconut water. Venugopal M. Recent Advances in Transport Medium for Avulsed Tooth: A Review. Amrita Journal of Medicine. 2022 Apr 1;18(2):37-44.

38. The literature till date suggests, when comparing the practicality, cost-effectiveness, and ease of availability to the general public, that milk seems to be the most ideal transport medium for the avulsed tooth. The patient’s own serum seems to be an ideal storage media for tooth autotransplant procedures. However, it is important to consider the circumstances of the accident, the location while suggesting an appropriate transport medium for the avulsed tooth especially in case of emergencies. Venugopal M. Recent Advances in Transport Medium for Avulsed Tooth: A Review. Amrita Journal of Medicine. 2022 Apr 1;18(2):37-44.

39. Conclusion Although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, the following media have also demonstrated efficacy at preserving the cell viability: Hank's balanced salt solution, propolis, oral rehydration salts, rice water De Brier N,. Storage of an avulsed tooth prior to replantation: a systematic review and meta‐analysis. Dental Traumatology. 2020 Oct;36(5):453-76.

40. 3.Stage of root formation

41. 1. American Academy of Pediatric Dentistry. Acute traumatic injuries: Assessment and documentation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:668-9

42. 1. American Academy of Pediatric Dentistry. Acute traumatic injuries: Assessment and documentation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:668-9

43. . 2. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2020;36:331-342. Available at: “https://doi.org/10.1111/edt.12573”.

44. 4.Condition of pulp and root canal space

45. Clinical Findings Maxillary central incisors are frequently involved. Missing tooth in the traumatized area. Symptom of pain in that area. Other type of injuries may be associated – fracture of alveolar socket, soft tissue lacerations( lips, gingiva)

46. Several projections and angles radiographs are recommended Socket is empty without tooth Rules out any alveolar bone fracture Alveolar socket fracture Intact lamina dura Radiographic Findings

47. Anti-resorption Therapy It involves soaking the avulsed tooth in a storage solution containing antibiotics. Anti-resorption therapy is believed to prevent inflammation caused by necrotic cells and microbial contamination  Different regimes have been suggested; one includes a storage solution with 800 µg doxycycline and 640 µg dexamethasone for 20 minutes. In the meantime, the alveolus should be lightly irrigated with 0.9% physiologic saline solution and aspirated gently if a blood clot is obstructing it.

48. Tooth Replantation The tooth should be aligned anatomically and replanted, applying firm pressure to the socket. Most teeth can be successfully replanted if the extraoral dry time is less than 30 minutes; after this period, the survival probability of the tooth diminishes - the periodontal ligament cells are irreversibly damaged after 30 to 60 minutes

49. 5. Stabilization

50. Once the tooth has been replanted, it should be immobilized with a semi-rigid splint (e.g., titanium trauma splint).  The International Association of Dental Traumatology (IADT) guidelines indicate flexible splinting for all dental injuries. The splinting time is two weeks for avulsed teeth and four weeks if the avulsed tooth exceeds 60 minutes of dry time. Post-replantation Procedures Splinting

51. They believe that this stabilization helps the periodontal ligament to have better repair conditions, however those devices should be the least traumatic as possible Several types of splints are available, depending on the mobility degree, they are classified as: flexible, semi-rigid and rigid. Post-replantation Procedures Splinting Veras SR, Bem JS, Dealmeida EC, Dos Santos CC, Lins A. Dental splints: types and time of immobilization post tooth avulsion. European Oral Research. 2017 Sep 1;51(3).

52. The authors ideally recommend the use of semi-rigid splint in cases of dental avulsions when no bone fracture is detected. Non-rigid immobilization is the ideal device due to its passive, atraumatic and flexible features, which allows a certain functional movement, and thus a functional arrangement of the periodontal ligament fibers, reducing the risk of external resorption and ankyloses Even though Pereira et al. used the rigid contention in their clinical case, this contention produces a higher degree of external bone growth along the periodontal space with consequent ankylosis or substitutive resorption Veras SR, Bem JS, Dealmeida EC, Dos Santos CC, Lins A. Dental splints: types and time of immobilization post tooth avulsion. European Oral Research. 2017 Sep 1;51(3).

53. The splint must be removed after two weeks, where the tooth will be clinically and radiographically examined. After removing the splint, the tooth’s mobility is checked, and a pulp vitality test should be performed, preferably electric testing. If the tooth is non-vital-- root canal treatment is indicated Follow Up Appointment

54. If the pulp is vital, an x-ray should be taken using an individualized holder. During the consecutive follow-up appointments (after one, three, and six months), a new x-ray will be taken to check for resorption. After this point, if there is no visible resorption, the patient is recalled every year for follow-up. In case of resorption, a root canal treatment is indicated.

55. When the dry time is more than 60 minutes, the remaining PDL should be removed as it will become a stimulus for continued inflammation that accelerates infection-related resorption and ankylosis. The remaining PDL can be removed by gentle scaling and root planning, soft pumice prophylaxis, gauze, or soaking the tooth in 3% citric acid for 3 minutes. Fluoride treatment must follow this procedure as it slows down ankylosis and reduces the risk of resorption. 

56. Severe damage to the neurovascular bundle and the periodontal ligament can lead to replacement root resorption or inflammatory resorption. These complications can be anticipated and possibly prevented with disinfectants at the time of reimplantation and systemic antibiotics. Resorption complications may need a root canal.

57.  If the extraoral dry time is over 90 minutes, soaking the tooth in agents such as fluoride may decrease resorption rates. Immature teeth where the root has not yet wholly formed have a greater chance of revascularization after soaking in doxycycline.  Primary teeth should not undergo replantation as this can damage the underlying permanent tooth germ.

58. Differential Diagnosis Differential diagnosis of tooth avulsion includes complete tooth intrusion into the alveolar bone, subluxation, or lateral luxation. A 'missing tooth' needs to have intrusion, swallowing, or aspiration ruled out. These conditions can be distinguished by history and physical as well as by imaging modalities.

59. E xamining the long-term prognosis of avulsed teeth, concluded that the replantation of avulsed teeth is a highly successful procedure. However, the long and short-term prognosis is strongly affected by the dry time Prognosis

60. The major complications secondary to replantation of avulsed teeth include Complications Infections, Tooth discolorations, Sinus tract , Inflammatory root resorption, ankylosis of the root to the alveolus, Apical periodontitis, Pulp canal obliteration (PCO), and Pulp necrosis (ultimately leading to tooth loss). Resorption and ankylosis are associated more with the use of rigid splints as opposed to semi-rigid ones.

61. Tooth avulsion is associated with a high risk of loss of vitality, especially if the apex has completely developed. This may eventuate in pulp necrosis and inflammatory resorption of the root. If this goes unrecognized, periapical periodontitis may develop and can complicate the healing process and prognosis. Ankylosis

62. Pulp canal obliteration is apparent weeks to months after replantation and is heralded by radiographic density in the pulp chamber and canal.  Although it is thought to be a concomitant of healthy revascularization of the injured neurovascular bundles, approximately 15-25% of teeth with pulp canal obliteration develop pulp necrosis.

63. Inflammatory Healing : This initial phase begins immediately after replantation. The body responds to the trauma with inflammation, which helps to remove debris and bacteria. This phase typically lasts for a few days. Repair Healing : During this phase, the periodontal ligament (PDL) begins to regenerate. The healing process can involve the formation of new connective tissue and the re-establishment of blood supply. This stage can last several weeks to months. Regenerative Healing : In this phase, the PDL and alveolar bone start to regenerate fully. This can take several months and may involve the production of new bone and ligament tissues, restoring the tooth's function and stability. Types of Healing After Replantation of Avulsed Tooth

64. Bone Healing : If the tooth was replanted after being avulsed, the surrounding alveolar bone may also need to heal, particularly if there was any damage. Bone remodeling will occur over time as the body adapts to the new load and stress. Pulp Healing : The vitality of the tooth pulp is crucial. If the pulp remains healthy, it can heal; however, if there is necrosis or infection, further treatment may be necessary, such as root canal therapy. Long-Term Monitoring : Regular check-ups are essential to assess the status of the tooth and surrounding tissues over time. This helps identify any complications early, such as root resorption or periodontal issues

65. CASE-REPORT A 14-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry on March 14, 2017 with a chief complaint of dislodged upper front tooth due to trauma 72 h back Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6‐year follow‐up. Clinical Case Reports. 2024 Feb;12(2).

66. Treatment of the avulsed tooth before replantation: Avulsed tooth. Removing the PDL cells. Performing extraoral RCT. (D, E) After completion of extraoral RCT. (F) Placing the tooth in a solution of 2% sodium fluoride. Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6‐year follow‐up. Clinical Case Reports. 2024 Feb;12(2).

67. Replantation of the avulsed tooth was planned. Informed assent. The avulsed tooth was then cleaned and the remaining periodontal ligament (PDL) fibers were removed with Gracy curette followed by soft pumice prophylaxis As the extraoral dry time was more than 60 minutes, extraoral root canal treatment (RCT) of the avulsed tooth was planned.

68. The avulsed tooth was then kept in a solution of 2% sodium fluoride ( NaF ) ( Fluocal Gel, Septodont Healthcare Pvt. Ltd, India) for 20 min Under local anesthesia, the socket was curetted and cleaned with 5% normal saline. Replantation of the avulsed tooth was done and its proper position was verified using an intraoral periapical radiograph (IOPAR). The replanted tooth was then splinted from canine-canine using a 0.4-mm diameter stainless wire and composite resin Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6‐year follow‐up. Clinical Case Reports. 2024 Feb;12(2).

69. Antibiotics (Amoxicillin 500 mg eight hourly for 7 days) and analgesics (Paracetamol 500 mg as per need) were prescribed. The patient was advised to consume soft diet for 2 weeks and maintain good oral hygiene. The patient was then referred to the medical practitioner for the evaluation of the need for an anti-tetanus booster. The splint was kept for 4 weeks. On the regular follow-up visits till 5 years, the replanted tooth was asymptomatic without any mobility, swelling, or sinus tract formation clinically.

70. CONCLUSIONS Traumatic dental injuries are inevitable but what follows after such incidents are very much under the control of dental professionals once the patient is received. The present case report emphasizes the fact that replantation should be attempted in any case of avulsion, be it immediate or delayed. Despite the occurrence of replacement resorption, the tooth can stay healthy and functional in the arch for a longer duration. Never stop hoping, never stop trying! Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6‐year follow‐up. Clinical Case Reports. 2024 Feb;12(2).

71. Chief complaints Case 1: A 14-year-old boy was referred to the Department of General Dentistry and Emergency of the Fourth Military Medical University with complaints of pain and that his left upper central incisor fell out 18 h prior. Case 2: A 17-year-old boy visited the Department of General Dentistry and Emergency of the Fourth Military Medical University with complaints that his left upper lateral incisor had completely fallen out 2 h prior. Yang Y, Liu YL Rescuing “hopeless” avulsed teeth using autologous platelet-rich fibrin following delayed reimplantation: Two case reports. World Journal of Clinical Cases. 2023 Jan 1;11(3):635.

72. PRF is a second-generation platelet concentrate prepared from the patient’s own blood without the use of an anticoagulant through a single-step centrifugation process. In addition, PRF is available in a membrane or injectable form depending on the centrifugation process and consistency of the final product. The main scaffold component of PRF is fibrin, which develops a three-dimensional mesh crossover structure with a large interfibre space that contains numerous red blood cells, white blood cells and clusters of platelets . Platelet-rich fibrin (PRF)

73. The fibrin network of PRF protects platelets from immediate activation, eventually prolonging the duration of growth factors in PRF and promoting wound healing effects. Thus, PRF has the potential to enhance tissue regeneration, accelerate wound healing and induce stem cell differentiation through the consistent release of multiple growth factors. One study demonstrated that autologous PRF could effectively promote the periodontal healing of avulsed teeth after delayed replantation in dogs and thus control the occurrence and development of initial root resorption Yang Y, Liu YL Rescuing “hopeless” avulsed teeth using autologous platelet-rich fibrin following delayed reimplantation: Two case reports. World Journal of Clinical Cases. 2023 Jan 1;11(3):635.

74. A: The tube was immediately centrifuged at 400 × g for 10 min; B: The fibrin clot contained platelet-rich fibrin and was located in the middle of the tube; C: The clot was easily separated from the red corpuscles at the bottom; D: The platelet-rich fibrin membrane was cut into approximately 1 mm granules, and the red and white ends were mixed evenly The preparation process of the platelet-rich fibrin.

75. CONCLUSION Enriched with growth factors and leukocytes, PRF potentially reduces pathological resorption and promotes periodontal wound healing and periodontal ligament regeneration following delayed reimplantation of avulsed teeth. Although the viability of PRF must be demonstrated in more cases, the application of PRF may offer new therapeutic opportunities for traditionally hopeless avulsed teeth. Yang Y, Liu YL Rescuing “hopeless” avulsed teeth using autologous platelet-rich fibrin following delayed reimplantation: Two case reports. World Journal of Clinical Cases. 2023 Jan 1;11(3):635.

76. Tooth avulsion is different from all other dental injuries due to the extracorporeal situation with varying duration and degree of contamination of the teeth. The principle of treatment in tooth avulsion is to prevent further damage (collapse of the socket due to bone resorption) and to pave the way for subsequent treatment. However, one out of five teeth replanted after avulsion will heal and serve the patient for many years. For that reason replantation should as a rule be tried, not least for psychological reasons and for gaining time in decision making for definitive treatment Conclusion

77. Tooth SOS

78. References Andreasen jo, andreasen fm. Textbook and color atlas of traumatic injuries of the teeth. 3 rd ed. Marwah N. Text Book of Pediatric Dentisty . 2nd ed. Lucknow: Jaypee; 2009. Wilson Roberto Poi, Celso Koogi Sonoda. Storage Media For Av u l s e d Te e t h : A L i t e r a t u r e Review. Brazilian Dental Journal (2013) 24(5): 437-445 Trope M, Friedman S.Periodontal healing of replanted dog teeth stored in Viaspan , milk and Hank’s balanced salt solution.Endod Dent Traumatol 1992;8:183-8

79. Andreasen, J. O., Andreasen, F. M. & Andersson, L. eds. Textbook And Color Atlas Of Traumatic Injuries To The Teeth (Wiley Blackwell, Hoboken, NJ, 2019). Rai A, Koirala B, Dali M, Shrestha S. Delayed replantation of avulsed permanent maxillary central incisor: Case report with 6‐year follow‐up. Clinical Case Reports. 2024 Feb;12(2). . Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2020;36:331-342. Available at: “https://doi.org/10.1111/edt.12573”. American Academy of Pediatric Dentistry. Acute traumatic injuries: Assessment and documentation. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:668-9

80.  The injury damages the PDL and results in the migration of the surrounding PDL and bone cells. If more than 20% of PDL is damaged, the damaged area is mostly repopulated by fast-moving bone precursor cells rather than slower-moving PDL cells, causing ankylosis and replacement root resorption. Osteoblasts (OBs) express RANKL as a protein, and osteoclasts carry the respective RANK receptor. Activation of immune cells by injury leads to the release of cytokines, that induces osteoblasts to secrete RANKL. The binding of RANKL to RANK activates osteoclasts, and osteoclasts start to resorb root 

81. Aksel H, Zhu X, Gauthier P, Zhang W, Azim AA, Huang GT. A new direction in managing avulsed teeth: stem cell-based de novo PDL regeneration. Stem cell research & therapy. 2022 Jan 28;13(1):34.