Management of Avulsed Permanent Incisors: A Comprehensive Update

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Management of Avulsed Permanent Incisors: A Comprehensive Update
Author(s): Judy McIntyre, DMD, MS, et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2007. Vol 29, no 1.
Major topic: Treatment of avulsed permanent teeth
Overview of method of research: Systematic comprehensive review of guidelines

Findings:
Avulsions occur most often in children 8-12 years old. This in part is due to the PDL being loosely structured, and the teeth having incomplete roots. Avulsions range from 1-16% of all dental trauma. The goal of this paper was to update the 2001 flow charts, incorporating current concepts, literature, and new philosophies.
When a tooth is avulsed, there is going to be attachment damage (duh). Damage to the PDL can be done during the injury, and while the tooth is out of the socket. Care should be taken to minimize as much damage to the PDL as possible, as this will lead to fewer complications in the future.

Pulpal Infection
When a tooth is avulsed the blood supply to the tooth is severed. While pulpal necrosis is almost certain9depending on the developmental stage of the tooth, amount of extra oral time, etc.), revascularization is possible. An avulsed tooth with an open apex (>1m), this is especially true. A closed apex (<1m) has little chance of revasc. Due to this, tx of a closed apex is aimed at prevention/elimination of bacterial toxins from the pulpal chamber.

First Steps in Tx
The best prognosis for an avulsed tooth is to a traumatically and immediately re-implant the tooth, after a gentle rinse under sterile saline, if available. For closed apexes, RCT will still be necessary, while open apexes may revasc. Resorption is a very common complication, occurring in more then 68% if cases.

Emergency Visits
How to handle the situation all comes down to how long has the tooth been out of the socket, and if the apex is open or closed. The best situation is a tooth that has an open apex that has been out for <20 min, with the worst case being a closed apex out for >60 min.
When presented with the tooth of <20 min avulsed, any debris should be carefully cleaned off with ideally sterile saline. Handle the tooth by the crown only, don’t scrape off the debris as PDL cells may be damaged. Make sure there is a screen over the drain so it the tooth doesn’t go for a swim, and no effort should be made to sterilize the tooth.
For >60 min extra oral, in hand RCT should be done in hand if possible. Soaking the tooth in HBSS or alendronate (bone strengthening medication) can aid in cemental healing. Alendronate has shown to be more effective than HBSS.

Socket Tx
Ideally the socket is still intact. Clean any debris, and if a clot has formed, remove it. If the socket has collapsed it should be reshaped with bunt instrument.

Splinting
7-10 days of passive splinting with a flexible wire or fishing line held in place by flowable composite to allow for physiological movement and cleansability.

Success of Reimplanted Teeth
Success of a reimplanted tooth is not just about if the tooth lasts a lifetime. Another type of success includes the retention of the tooth until craniofacial growth and development are complete. If the tooth can simply preserve the socket until its time for an implant, it’s a win.

New Tx’s
Applying topical antibiotics (minocycline or doxycycline) for 5 minutes can help increase the success rates (revasc) of avulsed teeth with an open apex. This is not true for closed apexes.

Preserving the PDL
The sooner we can reimplant the tooth, the better. The magic window seems to be 20 min or less. With many teeth not being reimplanted, transport is an issue. HBSS is a great medium as is save-a-tooth, and milk. Milk will preserve PDL cells for up to 8 hours. Do NOT soak the tooth in tap water as this cause cell lysis.

Condemned PDL’s
While revasc. Is great, RCT can provide a great long-term outcome. However without a PDL, resorption is inevitable. The American Association of Endodontics does not recommend reimplanting a tooth if it has been extra oral for >60 min due to the risk of ankylosis. As pediatric dentists, it’s our job to consider the growth and development of the child. Therefore is we can slow down the resorption and ankylosis, we can set up the patient for success later in life.
In this process, the PDL should be removed by either light scaling or soaking in citric acid for 3 minutes, followed by a soak in a fluoride solution for 5-20 min. This can significantly reduce the rate of resorption during the first 5 years. This additional time can get the child to the point of complete growth and development. Also, soaking of a tooth in tetracycline can increase revasc, and can decrease the incidence of resorption and ankylosis.
Recent studies with Emdogain, an enamel matrix derivative of pig origin, has been used to coat the entire root surface of the tooth prior to reimplantation. This enhances PDL cell proliferation and protein production and may act as a matrix to rebuild the PDL. More research is needed on this.
Almost half of reimplanted avulsed teeth become ankylosed, which can be a desirable outcome in the still growing child. Extraction an avulsed tooth can cause loss of attachment, loss of the cortical plate, and bony deformation. A possible treatment to combat these negative outcomes is decoronation. A flap is raised, the clinical crown and root are removed with a bur below the CEJ. The root filling material is removed and the intracanal space is allowed to fill with blood, creating a new ‘socket’. From here a tooth can be bonded to adjacent teeth, or a ‘flipper’ can be made. This procedure can preserve the buccolingual volume as well as the vertical height of the alveolus.

Adjunctive Systemic Antibiotics
This may prevent infection and necrosis of the pulp. Tetracycline has been shown to be antiresorptive, antiosteoclastic, anti-infammatory, antibacterial, and can prevent resorption. However it can stain teeth permanently, and should not be given to still growing children. For growing children either Pen VK or doxycycline can be used for 7-10 days.
Key points/Summary: Nothing has really changed from the flow charts. Follow them.

Assessment of Article: Good review of current protocol and new treatments.