Chapter 10

Permanent Dentition: Avulsion and Reimplantation

Aim

To provide a review of current practice for the treatment of avulsed permanent teeth.

Prognosis

After reading this chapter the reader should be aware of the appropriate treatment for avulsion injuries involving permanent teeth.

Aetiology

Most avulsion injuries in children occur as a result of falls during play, rather than organised sports. However, in late adolescence and in adults’ sporting injuries, road traffic accidents and violence are important causes. Upper central incisors are the most frequently avulsed teeth. The main complication of reimplantation of avulsed incisors is root resorption (inflammatory and/or replacement). This is related to necrosis of part or all of the periodontal ligament, damage to the cementum, and to necrosis of the pulp. Although the damage caused by the injury is beyond the control of the clinician, the provision of appropriate treatment both immediately and upon review improves the prognosis of reimplanted teeth. If a tooth is reimplanted in late childhood or early adolescence and allows both the adjacent permanent teeth to erupt into their normal positions, and the young person to be without a partial denture, then the reimplantation should be classified as a success. Define that aim as a ‘success’ to parents early in treatment. Do not give them expectations that the tooth will be retained for life. In the adult, the decision to reimplant, even if the tooth has a guarded prognosis, allows appropriate planning for its eventual prosthetic replacement.

Diagnosis

Successful healing after replantation can only occur if there is minimal damage to the pulp, periodontal ligament and cementum. This depends on appropriate ‘at the site of the accident’ management.

The first aid knowledge of parents, carers, friends and siblings gained through the media or local groups (e.g. sports centres, Scouts, Brownies, etc.) can be critical and invaluable in gaining long-term success. The local general dental practitioner has a very important role to play in educating the supervisors of these groups.

The following factors governing treatment are important:

• time of accident

• the extra-alveolar dry time (EADT)

• the type of extra-alveolar storage medium

• the total extra-alveolar time (EAT)

• possible bacterial contamination of root surfaces

• possible damage to root surfaces

• stage of root development

• soft-tissue damage

• cooperation of the patient.

The EADT is critical to survival of the periodontal ligament. The longer the EADT the more damage to the periodontal ligament and hence an increase in the amount of resorption that can be expected. It is now generally accepted that any dry time in excess of five minutes will lead to some permanent damage to the periodontal ligament.

The type of extra-alveolar storage medium should be iso-osmolar. Milk and saline (available more frequently now since the advent of contact lenses), the patient’s own saliva (by storing in the buccal sulcus), or indeed the parent’s buccal sulcus are all appropriate. Storage in the patient’s own buccal sulcus needs to take into account the age of the child and the danger of swallowing the tooth. However, as discussed shortly the best transport vehicle is the tooth’s own socket.

The total extra-alveolar time from avulsion to reimplantation is an important indicator of potential damage to periodontal ligament. There are documented reports of a teeth forming radiographically normal periodontal ligaments after being stored in milk for two hours prior to reimplantation.

Bacterial contamination of root surfaces significantly increases the risk of resorption after reimplantation.

Visual evaluation of apical development at the time of reimplantation is important in clarifying the aims of future treatment. Radiographs should be taken as soon as possible after the injury, taking into consideration the cooperation of the patient. They are necessary to assess damage to alveolar bone and adjacent teeth, and as a baseline for assessing future root development.

Treatment

Replantation after avulsion should nearly always be attempted, even though it may offer only a temporary solution given the frequent occurrence of external inflammatory resorption (EIR) and replacement resorption (RR). Even when resorption occurs, the tooth may be retained for years, acting as a natural space maintainer and preserving the height and width of the alveolus to facilitate later implant placement. If the socket has maintained its normal architecture after avulsion, then reimplantation is relatively easy (Fig 10-1). If the labial plate />

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