avulsion

management of trauma to teeth leading to avulsion (Ellis class V fracture) in children

1. -A Project BY: Karishma Ashok Guided By: Dr Sumedh Khare M anagement of Ellis Class V Fractures

2. ELLIS & DAVEY'S CLASSIFICATION Class I : Simple fracture of crown invoving little or no dentin Class II: Extensive fracture of crown involving considerable dentin but not the dental pulp Class III: Extensive fracture of crown involving considerable dentin and exposing the dental pulp Class IV: Traumatised teeth that has become non-vital with or without loss of tooth structure

3. Class V: Teeth lost as a result of trauma Class VI: Fracture of root with or without loss of crown structure. Class VII: Displacement of a tooth without fracture of crown or root. Class VIII: Fracture of crown en masse and its replacement Class IX: Traumatic injury to primary teeth

4. ETIOLOGY 1. Fall 2. Accidents 3. Sports 4. Battered child syndrome 5. Assaults

5. PRE-DISPOSING FACTORS 1. Children with accident prone facial profile (a) Increased overjet with protrusion of upper incisors & insufficient lip closure (b) Angle’s Class II type 1 malocclusion (c) Angle’s Class I type 2 malocclusion 2. Children with cerebral palsy This is due to: (a) Abnormal muscle tone & function resulting in maxillary anterior protrusion Poor skeletal & muscle co-ordination 3. Dentinogenesis Imperfecta

6. AVULSION It is the term used to describe the complete displacement of tooth from its alveolus. It is called EXARTICULATION . Maxillary teeth most commonly affected . Age group:7-9 years (loosely structured pdl & low mineralisation ..hence minimal resistance to extrusion)

7. CLINICAL FEATURES Bleeding socket with missing tooth RADIOGRAPHIC FEATURES Empty socket Associated bone fractures If the wound is recent then lamina dura is visible, otherwise obliterated

8. TREATMENT MODALITIES Re-implantation Avulsed tooth with open apex – Endontic therapy is delayd till first signs of apical closure are seen Avulsed tooth with closed apex – Endodontic therapy is done after 1-2 weeks depending on the type of re-implantation

9. RE-IMPLANTATION The single most important factor in the success of re-implantation is the speed with which the tooth is re-implanted. Every effort should be made to re-implant the tooth within first 15-20 minutes. Case History should include exact information on : Time interval between injury or re-implantation 2. Condition under which the tooth has been stored The tooth to be stored in storage media like milk, saline, vestible of mouth, etc.

10. Avulsed tooth Tooth stored in vestibule Severly contused and fractured socket wall

11. PROCEDURE: 1. Reimplantation of a tooth with completed apex 2.Rinsing the tooth with saline 3. Reimplantation using slight finger pressure 4. splinting

12. PROCEDURE 1. Check the alveolar socket. It should be reasonably intact in order to provide a seat for the avulsed tooth. 2. The extra-alveolar period 3. Socket is gently rinsed with saline when it is clear of the clot & debris its walls are examined for presence, absence or collapse of socket wall 4. Palpitation of socket & surrounding apical areas is done to know if an alveolar frcture is present in addition to avulsion 5. Radiograph is taken

13. 6. Preparation of root A topical agent that is most widely used is alendronate. It is a IIIrd Generation bisphosphonate which exhibits oseoclastic inhibotry activity Two other Products – Alendronate & Emdogain may allow regeneration of periodontal ligament & inhibit or prevent replacement resorption which is a major cause of tooth avulsion 7. Preparation of Socket Emphasis is placed on removal of obstacles within socket to replacement of tooth into socket. The socket should be left unaltered to the greatest extent possible It should be lightly aspirated if a blood clot is present.

14. If the alveolar bone has collapsed, a blunt instrument should be inserted carefully into the socket in an attent to reposition. DO NOT currette the socket After re-implantation, manually compress the facial & lingual bony plates (i.e. If spread apart) 8. Splinting A splinting technique that allows the movement of tooth during healing and that is in place for minimal period results in a decreased incidence of ankylosis. Semigrid fixation for 7-10 days is recommended.

15. NOTE: Condition of the alveolus- after 3 weeks the socket area and gingiva are healed Socket is evacuated using excavator and surgical bur wash with saline Reimplant and splint Follow up

16. NOTE: Replanting a tooth with a non-vital pdl . Extra-oral dry storage over 24 hrs & severely contused Alveolus. Therefore delayed Reimplantation done. Root surface rinsed & cleaned free of dead pdl Pulp is extirpated and tooth Is treated with NaF solution

17. Management of Soft Tissue Soft tissue lacerations of the socket gingiva should be lightly sutured. Lip laceration is common with these injuries. Lip wound should be cleaned & sutured. Adjunctive Therapy A recent study reveals that systemic antibiotics given at the time of re-implantation & prior to endodontic treatment are effective in preventing bacterial invasion of necrotic pulp & therefore subsequent inflamatory response.

18. Home Care Since adequate brushing is difficul, mouth rinsing is advised. The patient should not bite on splinted teeth and should be advised soft diet. Second Visit / Follow-Up 7-10 days after first visit Emphasis is placed onpreseration & healing of attachment apparatus. Endodontic treatment ot be carried out, if necessary.

19. AUTOTRANSPLANTATION It is the process of transplanting tissue from one part of body to another in same individual. It is also termed as AUTOGRAFT. It has been successfully used in management of tooth loss following trauma.

20. Donor Tooth 3 rd Molar Lower 2 nd Premolar Lower 1 st Premolar Supernumerary teeth Lower Incisors Upper Premolar 1 st Molar Upper Central Incisor Upper Laterial Incisor Upper Incisor Upper Lateral Incisor Dependent on root shape PROCEDURE 1. Selection of donor tooth Recipient Site

21. 2. Analysis of Recipient Site Size & shape of recipient area Need for socket exploration or instrumentaion Stage of root development Optimal time for transplation is when root is 1/2 to ¾ formed. Revie w of Injured Tooth All teeth that are affected by trauma have to be reviewed regularly The review is carried out initially after 1 month, then 3 rd month & then every 6 month for at least 2 years after trauma Review should include sensitivity tests & radiographs

22. INDICATIONS Traumatized anterior teeth with long term prognosis Cases with Class I or II malocclusin with moderate to severe crowding involving extraction of premolar CONTRAINDICATIONS Re-implantation is contra-indicated in case of primary teeth. This is beacuse ankylosis may take place thus obstructing the eruption of permanent successors. In such cases, prosthetic implants may be done.

23. SPLINTING TECHNIQUE An effective splint should perform the following functions: Immobilize the loose tooth Hold repositioned teeth in alignment Protect the damaged tissue from occlusal forces

24. HEALING AND PATHOLOGY: The pathology of tooth re-implantation can be divided into: Pupal ractions Periodontal reactions Both pulp and periodontal ligament suffer extensive damage during an extra-oral period.

25. P ulpal reactions: Experiments have shown various distinct pulpo -dentinal response which can occur after immediatere -implantation. Regular tubular reparative dentin Irregular reparative dentin Osteodentin (Irregular reparative dentin with encapsulated bone cells) Irregular immature bone Regular lamellated bone Internal resorption Pulp necrosis

26. P eriodontal healing reactions: Histologic examination of re-implanted human teeth has shown four stages of healing: Healing with normal pdl Healing with surface resorption Healing with ankylosis (replacement resorption ) Healing with inflamatory response (infection related) Immediately after re-implantation, a coagulum is formed between the two parts of severed pdl . This line of seperation is usually situated in the middle of the pdl .

27. i . Healing with a normal pdl : Histologically , it is charecterised by complete regeneration of the pdl which usually takes about 4 weeks to complete including the nerve supply. Radiographically , therenis normal pdl space without signs of root resorption . Clinically, tooth is in normal position and ellicits a normal percussion tone. This type of healing will probably not take place in clinical conditions as trauma will result in injury to innermost layer of pdl leading to surface resorption .

28. Line of seperation After 3 days Proliferating connective tissue After 2 weeks new collagenous Fibres formed Normal state Restored(8 mnths )

29. ii. Healing with surface resorption : Histologically it is charecterised by localised areas on the root surface which show superficial resorption . Surface resorption is not progressive and self limiting. It shows repair with the formation of new cementum . Radiogrphically they may not be clearly disclosed due to their small size. Clinically, tooth is in normal position and normal percussion tone is ellicited .

30. iii. Healing with ankylosis (replacement resorption ): Histologically, ankylosis represents fusion of alveolar bone and the root surface and can be demonstrated in 2 weeks after re-implantation . Etiology may be related to absence of vital pdl cover over the root . Depending upon the extent of damage, replacement resorption can take place in two ways- Progressive (gradually resorbs the entire root; occurs if entire pdl is removed before re-implantation/excessive drying) Transient (once established ankylosis dissappers ; related to minor damage to the root. Ankylosis formed initially; later replaced by vital pdl )

31. iv. Healing with inflamatory response: Histologically characterised by bowl shaped resorption cavities in cementum . Inflamatory reaction consists of granulation tissue with numerous lymphocytes,plasma cells,PMNLs . Adjacent to these areas, root surface undergoes intense resorption with Howships lacunae nd osteoclasts . Radiographicaaly charecterised by bowl shaped radiolucencies along root surface as early as 2 weeks. Clinically I. Tooth is loose and extruded II. Sensitive to percussion III. Percussion note is dull.

32. Granulation tissue Area with active resorption surface resorption repaired with new cementum Necrotic pulp tissue

33. P rognosis : Tooth survival: 21-89% Pdl healing: 9-50% Pulp healing:4-27% COMPLICATIONS: If not treated, may lead to migration of adjacent teeth. Either re-implantation or space maintaince using orthodontic appliance is indicated.