Management of avulsed Permanent Incisors: A decision analysis based on changing concepts

Resident: Adam J. Bottrill
Date: 17SEP10
Region: Providence
Article title: Management of avulsed Permanent Incisors: A decision analysis based on changing concepts
Author(s):Lee, Jessica DDS et al.
Journal: Pediatric Dentistry
Page #s: 357-360
Year: 23:3, 2001
Major topic: Avulsion injuries
Minor topic(s): NA
Type of Article: Analysis of avulsion injury management
Main Purpose: Provide a decision tree describing the management of avulsed incisors.

Key points in the article discussion:

I. General:

A. Reported incidence of avulsion 1-16% of all traumatic injuries. Maxillary central incisors most common

B. Age 8-12 most common permanent incisor avulsion.
1. loosely formed PDL provides minimal resistance to avulsion force.

C. Most common cause... fights and sports.

D. Treatment is aimed at minimizing the number of complications that occur
1. ankylosis, pulpal infection, PDL damage etc...

II. Management

A. THOROUGH HISTORY
1. Time Interval, conditions of avulsion, storage material

B. If decision is made to re-implant, RINSE with saline to remove visible debris... DO NOT SCRAPE DEBRIS OFF.

C. Teeth have been shown to survive from 20-40 yrs with normal periodontium. In other words... under the correct conditions, the tooth CAN be saved.

III. "New" Tx regimens

A. Topical AB's for enhanced revascularization

B. Hank's to preserve PDL

C. >1hr dry storage ... scrape off PDL, rinse and replant

D. Systemic AB's at time of reimplantation

Assessment of article: I like decision trees (...dork, I know). So this article is sans shenanigans in my book.

09/17/2010 Factors Affecting Outcomes of Traumatically Extruded Permanent Teeth in Children

Resident: J. Hencler
Date: 09/17/2010

Article title: Factors Affecting Outcomes of Traumatically Extruded Permanent Teeth in Children

Author(s): Humphreys et al.
Journal: Pediatric Dentistry-25: 5, 2003
Major topic: Extrusion injuries
Type of Article: Clinical observation

Main Purpose:
Determine the prevalence of residual extrusion, pulpal necrosis, and resorption for extruded permanent teeth and to establish the effect of presentation and treatment factors.

Overview of method of research:
72 traumatically extruded permanent incisors were observed. Clinical and radiographic outcomes were analyzed and related to presenting and tx factors. Pulp status was tested (EPT) at 2 wks, 6 wks, and subsequently at 3 mo intervals. Radiographs were taken up to 1 yr following the trauma to examine resorption prevalence.

Findings:
Delay in repositioning had a significant effect on residual incisor extrusion, indicating that teeth repositioned at a later stage after trauma were more likely to have been less than fully repositioned. The median delay prior to the repositioning procedure was 24h. Factors associated with the prevalence of pulp necrosis were the degree of apical closure and degree of initial extrusion. The presence of a closed apex significantly affected pulp necrosis followed by the degree of initial extrusion. A delay in repositioning the tooth did not have an effect on pulp necrosis. Inflammatory resorption may be affected by pulp necrosis.

Key points in the article discussion:
Extrusion is a form of luxation injury that results when the tooth is partially displaced from the socket in an axial direction. This type of injury results in rupture of PDL and damage to apical vessels. Clinically the tooth will appear elongated and is initially mobile. Bleeding is seen in the gingival sulcus and the percussion sound is dull. Radiographic exam will reveal increased PDL space.
Extruded teeth, when gently repositioned and splinted for a short duration, appear to have a good prognosis. Due to the nature of the injury, w/ damage and ischemic changes occurring the PDL and pulp, regular clinical and radiographic f/u are important b/c the incidence of pulp necrosis is high, especially in teeth with closed apices. If pulp necrosis occurs, ENDO should be initiated to reduce the risk of inflammatory resorption. A delay in tx can make manual repositioning very difficult and excessive force should be avoided as this will increase the risk of damage to supporting structures. If it is not possible to fully reposition, allow healing to occur if no occlusal interferences, then correct orthodontically. Overall, it appears that the prognosis for this type of injury is good, with the loss of pulp vitality being the most common complication.

Summary of conclusions:
Delay in repositioning extruded teeth increases the risk of residual extrusion. In extruded teeth, the main sequela is pulp necrosis, often detected w/in 8 wks. Apical closure and degree of extrusion increase the risk of pulp necrosis. In extruded teeth, there is a lower risk of inflammatory resorption. Extruded teeth should be repositioned promptly and monitored.

Assessment of article:
Very good article, straightforward and clinically significant.