Luxation tooth injuries

seminar on luxation tooth injuries including latest IADT guidelines.

1. LUXATION TOOTH INJURIES BY-Dr. paras angrish

2. Injuries to periodontal tissues Concussion Subluxation Intrusive luxation Extrusive luxation lateral luxation Exarticulation

3. Prognosis of pulp after luxation injuries Type of luxation injury Pulp death concussion 4% sub-luxation 12% lateral luxation 77% extrusive luxation 55 – 98% intrusive luxation 100% Barnett et al ‘02

4. Luxation injuries Largest group – 30 to 44% Includes 1. Concussion 2. Subluxation 3. Extrusive luxation 4. Lateral luxation 5. Intrusive luxation 6. Avulsion

5. CONCUSSION Description An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion. Visual signs Not displaced. Percussion test Tender to touch or tapping. Mobility test No increased mobility. Pulp sensibility test Usually a positive result. The test is important in assessing future risk of healing complications. A lack of response to the test indicates an increased risk of later pulp necrosis. Radiographic findings No radiographic abnormalities, the tooth is in-situ in its socket. Radiographs recommended As a routine: Occlusal, periapical exposure and lateral view from mesial or distal aspect of the tooth in question. This should be done in order to exclude displacement.

6. D iagnosis

7. Concussion - Treatment Guidelines Treatment objectives Usually there is no need for treatment. Treatment Monitor pulpal condition for at least 1 year. Patient instructions Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. Follow-up Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

8. SUBLUXATION An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus confirms the diagnosis

9. ETIOLOGY

10. Diagnostic signs Description An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus confirms the diagnosis Visual signs Not displaced. Percussion test Tender to touch or tapping. Mobility test Increased mobility. Pulp sensibility test Sensibility testing may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made.  There will be a positive sensibility test result in about half the cases. The test is important in assessing future risk of healing complications. A lack of response at the initial test indicates an increased risk of later pulp necrosis. Radiographic findings Usually no radiographic abnormalities. Radiographs recommended As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth.

11. Treatment objective Usually no need for treatment. Treatment A flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks. Patient instructions Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. Follow-up Clinical and radiographic control at 4 weeks, 6-8 weeks and 1 year.

12. Extrusion Partial displacement of the tooth out of its socket. An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone is intact in an extrusion injury as opposed to a lateral luxation injury. In addition to axial displacement, the tooth will usually have an element of protrusion or retrusion . In severe extrusion injuries the retrusion /protrusion element can be very pronounced. In some cases it can be more pronounced than the extrusive element.

13. ETIOLOGY

14. Diagnostic signs Definition Partial displacement of the tooth out of its alveolar socket.  An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone is intact in an extrusion injury as opposed to a lateral luxation injury. Apart from axial displacement, the tooth will usually have an element of protusion or retrusion. In severe extrusion injuries the retrusion/protrusion element can be very pronounced. In some cases it can be more pronounced than the extrusive element. Visual signs Appears elongated. Percussion test Tender. Mobility test Excessively mobile. Sensibility test Usually lack of response except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive result to the initial test indicates a reduced risk of later pulp necrosis. In immature, not fully developed teeth, pulpal revascularization usually occurs. In mature teeth pulp revascularization sometimes occurs. Radiographic findings Increased periapical ligament space. Radiographs recommended As a routine: Occlusal, periapical exposure and view from the mesial or distal aspect of the tooth.

15. Treatment The exposed root surface of the displaced tooth is cleansed with saline before repositioning. Reposition the tooth by gently re-inserting it into the tooth socket with axial digital pressure (local anesthesia is usually not necessary). Stabilize the tooth for 2 weeks using a flexible splint. Monitoring the pulpal condition is essential to diagnose associated root resorption. Open apex: Revascularization can be confirmed radiographically by evidence of continued root formation and pulp canal obliteration and usually a return to a positive pulp response to sensibility testing.  Closed apex: A continued lack of pulp response to sensibility testing should be taken as evidence of pulp necrosis together with periapical rarefaction and sometimes crown discoloration. Patient instructions Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. Follow-up Clinical and radiographic control and splint removal after 2 weeks. Clinical and radiographic control at 4 weeks, 6-8 weeks, 6 months, and 1 year.

16. Lateral luxation Displacement of the tooth  other than axially . Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone. Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by fracture of either the labial or the palatal/lingual alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently non-mobile.

17. ETIOLOGY

18.  Diagnostic signs Description Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone. Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by fracture of either the labial or the palatal/lingual alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently non-mobile. Visual signs Displaced, usually in a palatal/lingual or labial direction. Percussion test Usually gives a high metallic (ankylotic) sound. Mobility test Usually immobile. Sensibility test Sensibility tests will likely give a lack of response except for teeth with minor displacements. The test is important in assessing risk of healing complications. A positive result at the initial examination indicates a reduced risk of future pulp necrosis. Radiographic findings Widened periapical ligament space best seen on occlusal or eccentric exposures. Radiographs recommended As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth in question

19. Treatment objective To reposition and splint a displaced tooth to facilitate pulp and periodontal ligament healing. Treatment Rinse the exposed part of the root surface with saline before repositioning. Apply a local anesthesia Reposition the tooth with forceps or with digital pressure to disengage it from its bony lock and gently reposition it into its original location. Stabilize the tooth for 4 weeks using a flexible splint. 4 weeks is indicated due to the associated bone fracture. Monitoring the pulpal condition is essential to diagnose root resorption. If the pulp becomes necrotic, root canal treatment is indicated to prevent infection related root resorption. In immature developing teeth, revascularization can be confirmed radiographically by evidence of continued root formation, initiation of pulp canal obliteration and usually a return to a positive response to sensibility testing.

20. In fully formed teeth, a continued lack of response to sensibility testing (i.e. exceeding 3 months) should be taken as evidence of pulp necrosis together with periapical radiolucency and sometimes crown discoloration. Splint removal: after the fixation period (4 weeks) resin can be removed. If non-composite resin is used it can be peeled off with a dental scaler . If composite is used i should be removed with a bur. The tooth must be supported with digital pressure during this procedure. Patient instructions Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. Follow-up Clinical and radiographic control after 2 weeks. Clinical and radiographic control and splint removal after 4 weeks. Clinical and radiographic control at 6-8 weeks, 6 months, 1 year and yearly for 5 years.

21. Intrusion - Intrusive luxation Displacement of the tooth  into  the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.

22. ETIOLOGY

23. Intrusion - Diagnostic signs Description Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket. Visual signs The tooth is displaced axially into the alveolar bone. Percussion test Usually gives a high metallic (ankylotic) sound. Mobility test The tooth is immobile. Sensibility test Sensibility test will likely give negative response. In immature, not fully developed teeth, pulpal revascularization may occur. Radiographic findings The periodontal ligament space may be absent from all or part of the root. The cemento-enamel junction is located more apically in the intruded tooth than in adjacent non-injured teeth, at times even apical to the marginal bone level. Radiographs recommended As a routine: Occlusal, periapical exposure and lateral view from the mesial or distal aspect of the tooth in question. If the tooth is totally intruded a lateral exposure is indicated to make sure the tooth has not penetrated the nasal cavity

24. TREATMENT Tooth intrusion is associated with a potential risk of tooth loss due to progressive root resorption ( ankylosis or infection related resorption). The following three methods are only partly evidence based. Spontaneous eruption This is the treatment of choice for permanent teeth with incomplete root formation with minor or moderate intrusion. In teeth with mature root development it is only recommended for teeth with minor intrusion.This treatment seems to lead to fewer healing complications than orthodontic and surgical repositioning. If no movement within a few weeks, initiate orthodontic or surgical repositioning before ankylosis can develop. Orthodontic repositioning This treatment may be preferred for patients coming in for delayed treatment. This treatment method enables repair of marginal bone in the socket along with the slow repositioning of the tooth. Surgical repositioning   This treatment technique is preferable in the acute phase. Intrusion with major dislocation of the tooth (more than 7 mm) may be an indication for surgical repositioning. Common for all treatments Endodontic treatment can prevent the necrotic pulp from initiating infection-related root resorption. This treatment should be considered in all cases with completed root formation where the chance of pulp revascularization is unlikely. Endodontic therapy should preferably be initiated within 3-4 weeks post-trauma. A temporary filling with calcium hydroxide is recommended

25. Degree of intrusion Repositioning Spontaneous Orthodontic Surgical OPEN APEX Up to 7 mm x More than 7 mm x x CLOSED APEX Up to 3 mm x 3-7 mm x x More than 7 mm   x

26. Patient instructions Soft food for 1 week. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing with chlorhexidine 0.1 % is beneficial to prevent accumulation of plaque and debris. follow-up Control after 2 weeks. Splint removal and control after 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years

27. Sequalae to luxation injury Yellow discoloration Grey discoloration Resorption – 5 to 15% Incomplete root formation Primary teeth – pulp space obliteration by calcification

28. Avulsed Permanent Teeth Incidence 0.5% to 16% of traumatic injuries Main etiologic factors Fights Sports injuries Automobile accidents

29. Avulsed Permanent Teeth Maxillary central incisor Most commonly avulsed tooth Mandibular teeth Seldom affected Most frequently involves a single tooth

30. Avulsed Permanent Teeth Most common age - 7 to 11 Permanent incisors erupting Loosely structured PDL

31. Avulsed Permanent Teeth Associated injuries Fracture of alveolar socket wall

32. Avulsed Permanent Teeth Associated injuries Fracture of alveolar socket wall Injuries to the lips and gingiva

33. Management of the Avulsed Tooth What tissue should be our primary concern? Pulp?

34. Management of the Avulsed Tooth What tissue should be our primary concern? Pulp? Socket?

35. Management of the Avulsed Tooth What tissue should be our primary concern? Pulp? Socket? PDL?

36. Management of the Avulsed Tooth Ultimate goal PDL healing without root resorption

37. Management of the Avulsed Tooth Ultimate goal PDL healing without root resorption Most critical factor Maintaining an intact and viable PDL on the root surface

38. Periodontal Ligament Responses Surface Resorption Replacement Resorption ( Ankylosis ) Inflammatory Resorption Andreasen JO, Hjorting -Hansen E. Replantation of teeth II. Histological study of 22 replanted anterior teeth in humans. Acta Odontol Scand 1966;24:287-306.

39. Periodontal Ligament Responses Surface resorption Superficial resorption cavities Mainly in cementum Complete repair of PDL

40. Periodontal Ligament Responses Replacement resorption ( Ankylosis ) Direct union of bone and root Resorption of root - Replacement with bone Direct result of loss of vital PDL

41. Periodontal Ligament Responses Inflammatory resorption Resorption of cementum and dentin Inflammatory reaction in the periodontal ligament

42. Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules

43. Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules Pulp necrosis

44. Etiology Inflammatory resorption Surface resorption of cementum exposing dentinal tubules Pulp necrosis Toxic products from the pulp provoke an inflammatory response in the PDL

45. Periodontal Ligament Responses Surface resorption

46. Periodontal Ligament Responses Surface resorption Replacement resorption (Ankylosis)

47. Periodontal Ligament Responses Surface resorption Replacement resorption (Ankylosis) Inflammatory resorption

48. Treatment Considerations Extraoral time Extraoral environment Root surface manipulation Management of the socket Stabilization

49. Extraoral Time Shorter time = Better prognosis * < 30 min  10% resorption > 90 min  90% resorption Andreasen JO, Hjorting -Hansen E. Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263-86.

50. Extraoral Time Shorter time = Better prognosis * < 30 min  10% resorption > 90 min  90% resorption * depending on storage medium Andreasen JO, Hjorting -Hansen E. Replantation of teeth I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263-86.

51. Extraoral Environment Viability of PDL cells is critical

52. Storage Media Tap Water Dry Saliva Saline Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53. Poor results

53. Storage Media Tap Water Dry Saliva Saline Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53. Good protection for 2 hrs Poor results

54. Milk As A Storage Medium Physiologic osmolality Markedly fewer bacteria than saliva Readily available

55. Storage Media - Milk vs. Saliva Storage for 2 hrs Periodontal healing almost as good as immediate replantation Blomlof L, et al. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6.

56. Storage Media - Milk vs. Saliva Storage for 2 hrs Periodontal healing almost as good as immediate replantation Storage for 6 hrs Saliva  extensive replacement resorption Milk  healing almost as good as immediate replant Blomlof L, et al. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912-6.

57. Cell Culture Media Eagle’s Medium Hank’s Balanced Salt Solution

58. Hank’s Balanced Salt Solution Proper pH and osmolality Reconstitutes depleted cellular metabolites Washes toxic breakdown products from the root surface

59. Organ Transplant Storage Media Viaspan Dramatically prolongs the storage of human organs Expensive Not readily available

60. Storage Media Comparison Viaspan Complete healing after 6 and 12 hrs Good for extended storage periods (72 and 96 hrs ) 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.

61. Storage Media Comparison Viaspan Complete healing after 6 and 12 hrs Good for extended storage periods (72 and 96 hrs ) Hank’s balanced salt solution Healing results similar to Viaspan 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.

62. Recommended Storage Media 1. Socket (immediate replantation) 2. Cell culture medium 3. Milk 4. Physiologic saline 5. Saliva

63. Root Surface Manipulation Attempt to retain PDL cell viability Do not curette root surface Avoid caustic chemicals Van Hassel HJ, Oswald RJ, Harrington GW. Replantation 2. The role of the periodontal ligament. J Endodon 1980;6:506-8.

64. Root Surface Manipulation Extraoral dry time determines handling

65. Root Surface Manipulation Extraoral dry time < 1 hr PDL healing is still possible Handling recommendations Keep root moist Do not handle root surface Gentle debridement

66. Root Surface Manipulation Extraoral dry time > 1 hr Loss of PDL cell viability inevitable Treatment recommendations Remove tissue tags Soak in accepted dental fluoride solution for 20 min

67. Fluoride Treatment 1.0-2.4% topical fluoride solution Sodium fluoride ( Andreasen ) Stannous fluoride (Krasner) 20 minute soak

68. Management of the Socket Remove contaminated coagulum in socket Irrigate with sterile saline

69. Management of the Socket Examine socket  If fracture is evident Reposition fractured bone with a blunt instrument

70. Management of the Socket Replant using light digital pressure

71. Stabilization Splint Definition  a rigid or flexible device used to support, protect, or immobilize teeth, preventing further injury Types Acid etch composite Cross-suture

72. Acid Etch Composite Splints Interproximal composite

73. Acid Etch Composite Splints Composite with arch wire

74. Acid Etch Composite Splints Composite with monofilament nylon

75. Acid Etch Composite Splints Functional Splint 20-30 lb monofilament nylon Bonded with composite Allows physiologic movement Antrim DD, Ostrowski JS. A functional splint for traumatized teeth. J Endodon 1982;8:328-31.

76. Cross-Suture Splint Indications No adjacent teeth to splint to Unmanageable traumatized children

77. Cross-Suture Splint

78. Splinting Time Effect of splinting time 7 days 30 days Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

79. Splinting Time Recommended time 7 to 10 days Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg 1982;53:557-66.

80. Pulpal Prognosis Stage of root development Dry storage time Storage media Antibiotics

81. Stage of Root Development Mature roots ( < 1.0 mm) Revascularization 0% Kling M, et al. Endod Dent Traumatol 1986;2:83-9. Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.

82. Stage of Root Development Mature roots ( < 1.0 mm) Revascularization 0% Immature roots (> 1.0 mm) Revascularization 18-34% Kling M, et al. Endod Dent Traumatol 1986;2:83-9. Andreasen JO, et al. Endod Dent Traumatol 1995;11:51-8.

83. Revascularization Loss of blood supply to pulp

84. Revascularization – Day 4 Coronal pulp Extensive ischemic injury

85. Revascularization – Day 4 Coronal pulp Extensive ischemic injury Apical pulp Initial revascularization

86. Revascularization – 4 Weeks Pulp status Revascularization Reinnervation New odontoblastic layer

87. Revascularization Typical sequela Pulp canal obliteration

88. Dry Storage Time As dry storage time increases Pulp survival decreases Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

89. Storage Media Nonphysiologic storage Minimal chance of pulp revascularization Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

90. Storage Media Nonphysiologic storage Minimal chance of pulp revascularization Physiologic storage HBSS, milk, saline, saliva Improved chance of pulp revascularization Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Endod Dent Traumatol 1995;11;59-68.

91. Pulpal Prognosis - Antibiotics Systemic antibiotics Pulp revascularization is not increased Cvek M, Cleaton-Jones P, Austin J, Lowni J, Kling M, Fatti P. Endod Dent Traumatol 1990;6:157-69.

92. Pulpal Prognosis - Antibiotics Systemic antibiotics Pulp revascularization is not increased Topical antibiotics Beneficial effect Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

93. Pulpal Prognosis - Antibiotics Topical Doxycycline Decreased microorganisms in pulpal lumen Increased pulp revascularization Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

94. Pulpal Prognosis - Antibiotics Recommendation Topical Doxycycline 1 mg in 20 ml physiologic saline 5 minute soak Cvek M, Cleaton-Jones P, Austin J, Kling M, Lowni J, Fatti P. Endod Dent Traumatol 1990;6:170-6.

95. Endodontic Rationale Mature root - 4 weeks Very limited revascularization

96. Endodontic Rationale Mature root - 4 weeks Very limited revascularization Ischemic coronal pulp with great risk of infection !!!

97. Endodontic Rationale – Mature Root Pulpectomy  7-14 days

98. Endodontic Rationale – Mature Root Calcium hydroxide placement

99. Endodontic Rationale – Mature Root Calcium hydroxide Antibacterial Increases pH in dentin Favors mineralization over resorption Tronstad L, Andreasen JO, et al. pH changes in dental tissues after root canal filling with calcium hydroxide. J Endodon 1981;7:17-21.

100. Endodontic Rationale – Mature Root Treatment recommendation Ca(OH) 2 therapy for as long as practical, usually 6-12 months Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Association of Endodontists, 1995.

101. Specific Treatment Regimen

102. Specific Treatment Regimen Root Development Closed apex Open apex Extraoral Dry Time One hour or less More than one hour Treatment of the Avulsed Permanent Tooth. Recommended Guidelines of the American Association of Endodontists, 1995.

103. Treatment Flowchart < 1 hr > 1 hr Extraoral Dry Time Apex Maturity Closed Open Open or Closed Pulpectomy7-14 days Observe Option : Extraoral RCT Pulpectomy 7-14 days

104. Emergency Treatment Replantation technique Local anesthetic, if necessary Radiograph to verify position Check occlusion Physiologic splint

105. Emergency Treatment Additional Considerations Analgesics

106. Emergency Treatment Additional Considerations Analgesics Chlorhexidine

107. Emergency Treatment Additional Considerations Analgesics Chlorhexidine Tetanus Refer to physician for tetanus prophylaxis prn Rothstein RJ, Baker FJ. Tetanus: Prevention and treatment. J Am Med Assoc 1978;240:675-6.

108. Emergency Treatment Additional Considerations Analgesics Chlorhexidine Tetanus Antibiotics

109. Antibiotics Penicillin 500 mg qid for 4-7 days Andreasen JO. Atlas of replantation and transplantation of teeth. Philadelphia: W.B. Saunders Co., 1992;57- 92.

110. Antibiotics Tetracycline vs. amoxicillin  in a replacement resorption model Tetracycline had better anti- resorptive properties Sae -Lim V, Wang CY, Choi GW, Trope M. The effect of systemic tetracycline on resorption of dried replanted dogs’ teeth. Endod Dent Traumatol 1998;14:127-32.

111. Antibiotics Tetracycline vs. amoxicillin  in an inflammatory root resorption model Tetracycline had better anti-bacterial properties Sae-Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs’ teeth. Endod Dent Traumatol 1998;14:216-20.

112. Antibiotics Recommendation “Tetracycline could be considered as an alternative to amoxicillin after avulsion injuries.” Sae -Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs teeth. Endod Dent Traumatol 1998;14:216-20.

113. Tetracycline Use In Young Children Tetracycline staining Not a problem since avulsed maxillary anteriors have already erupted and are not susceptible to staining At worst, posterior teeth might be stained Remote possibility with 7-10 day prescription Sae -Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs’ teeth. Endod Dent Traumatol 1998;14:216-20.

114. Avulsion Sequelae Closed Apex Extraoral dry time 1 hour or less

115. Avulsion Sequelae Closed Apex Extraoral dry time more than 1 hour

116. Avulsion Sequelae Open Apex Extraoral dry time 1 hour or less

117. Avulsion Sequelae Open Apex Extraoral dry time more than 1 hour

118. Avulsion Management Be prepared - Dental Trauma Kit Immerse tooth in a physiologic storage medium to “buy time” Determine extraoral dry time Follow AAE AND IADT Guidelines

119. REFERENCES - Essentials of traumatic injuries to the teeth J.O.Anderasen and F.M. Anderasen Treatment planning for traumatized teeth - Mitsuhiro tsukiboshi cohen’s pathways of the pulp tenth edition

120. - Ingle’s –Endodontics 6 th edition - Storage Media For Avulsed Teeth : A Literature Review Brazilian Dental Journal (2013) 24(5): 437-445 - Transport media for avulsed teeth: A review Aust Endod J 2012; 38: 129–136

121. - A proposal for classification of tooth fractures based on treatment need Journal of Oral Science, Vol. 52, No. 4, 517-529, 2010 Assessment of pulp vitality: a review International Journal of Paediatric Dentistry 2009; 19: 3–15 STUDY OF STORAGE MEDIA FOR AVULSED TEETH Brazilian Journal of Dental Traumatology (2009) 1(2): 69-76

122. Fracture resistance of tooth fragment reattachment: effects of different preparation techniques and adhesive materials Dental Traumatology 2010; 26: 9–15 ;

123. Thank U