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Tooth avulsion refers to total displacement of the tooth out of its alveolar socket. This chapter discusses the causes of avulsion for both primary and permanent dentition in addition to the prevalence of avulsion comparing it between before and during COVID-19 era. Successful outcomes depend on procedure conduction with immediate replantation of the avulsed tooth and good handling of the tooth keeping the tooth in suitable available storage media till a professional service is obtainable. Management of this type of dental trauma necessitates awareness and collaboration between the lay personal at the site of injury in addition to the important role of different dental professional. After replantation of the avulsed tooth, it should be kept immobile with preservation of the functional (physiological) mobility by application of suitable splint. There are adjunctive therapies including antibiotics, analgesics, mouth washes, and tetanus vaccines. Endodontic therapy should be initiated within 7–10 days from the time of avulsion, where the outcomes generally might be favorable or unfavorable. Newly emergent teledentistry played important role in the treatment of tooth avulsion, especially during COVID-19 period.
Oral and Maxillofacial Surgery and Diagnostic Science, College of Dentistry, Qassim University, Qassim, Saudi Arabia
Randa Fath Elrahman Ibrahim
College of Dentistry, Qassim University, Qassim, Saudi Arabia
Hanan Alharbi
Department of Conservative Sciences, Division of Endodontics, College of Dentistry, Qassim University, Qassim, Saudi Arabia
*Address all correspondence to: manltahir@yahoo.com
1. Introduction
Tooth avulsion is a very serious traumatic dental injury (TDI) as tooth loss may remarkably compromise the patient in both functional and psychological aspects [1, 2].
Among all dental traumas, avulsion of the permanent tooth accounts for up to 16% of all dental injuries and constitutes the most serious one. It is considered as one of the few emergency situations in dentistry [3]. By definition, tooth avulsion refers to the total displacement of the tooth out of its alveolar socket (Figure 1) [4]. Presence of the tooth outside the socket leads to deterioration of the pulp and periodontal ligaments (PDLs) due to the lack of blood and nerve supply to their cells in addition to the unfavorable external environment such as dryness and possible contamination [5]. This may end up with periodontal attachment damage, pulp necrosis, and eventually tooth loss [6]. The maxillary central incisors are the most frequently involved teeth; boys and the age group of 7–11 years old are more susceptible to this type of trauma [7].
Figure 1.
Tooth avulsion refers to the total displacement of the tooth out of its alveolar socket.
1.1 Epidemiology of avulsed teeth before and during COVID-19 pandemic
The prevalence and incidence of reported traumatic dental injuries (TDIs) have significantly been affected during COVID-19 pandemic. In a retrospective analysis conducted at King’s College Hospital Dental Institute in London, UK, there was around 46% reduction in presented cases with TDIs during the COVID-19 compared to the year before for the same period of time [8]. With respect to avulsion injuries, the study revealed a remarkable decline in cases by around 93%. It also showed an increase in the mean delay in presentation following TDIs from 2.4 days the year before to 5.3 days during COVID-19 [8]. The reasons behind these changes were mostly related to the lockdown and forcible closure of dental practices during the pandemic. Although the urgent dental cares services in hospitals were mostly available worldwide, patients were hesitant to reach out to such centers due to the perceived fear of acquiring viral infections. Other studies also showed the same steep reduction in reported TDIs and traumatic injuries generally during COVID-19 [8, 9, 10].
According to previous studies, demographic data of reported cases has not differed between COVID-19 and years before except having less admitted cases in group age older than 70-year-old [8].
1.2 Causes
The etiology of tooth avulsion varies according to the type of dentition. Avulsion in primary dentition is typically a result of hard objects hitting the teeth, whereas avulsion in permanent dentition is generally a result of falls, fights, sport injuries, automobile or bicycle accidents, and domestic abuse. In permanent and primary dentition, avulsion generally occurs in the maxilla, and the most affected teeth are the maxillary central incisors (Figure 2). Increased overjet and incompetent lips were identified as potential etiological factors in such avulsion cases [11, 12, 13]. In rare cases, iatrogenic teeth avulsion during other procedures might happen and were reported in the literature [14, 15, 16, 17].
Figure 2.
Maxillary central incisors are the most frequently involved teeth in avulsions.
Several factors should be considered [18], when treating a patient with an avulsed permenant tooth (Figure 3):
Patient’s age
Medical status
Root development
Development of the dentition and of the face
Extra-oral time
Storage medium
Damage associated with the avulsed tooth
Figure 3.
Factors should be considered in the treatment of tooth avulsion.
2.1 Emergency treatment/management (at the site/and at the clinic)
Multidisciplinary approach in avulsion injuries is essential and considered a cornerstone during the management process. Though the management of avulsions is highly dependent on the early actions taken following the trauma and the time spent till reaching out healthcare services, this is furthermore affected during COVID-19 pandemic due to international lockdowns and restricted accessibility to hospitals. Such times clearly signify the importance of public awareness of first-aid measures in TDIs, especially avulsion.
International guidelines have been proposed to address TDIs and avulsions injuries. According to the International Association of Dental Traumatology (IADT) guidelines [19, 20, 21] and the European Society of Endodontology position statement [22], certain systematic approach has to be adopted to treat teeth avulsions. Obviously, tooth avulsion leads to necrosis of disrupted pulp which requires endodontic treatment.
We will be talking about the management for teeth avulsion and treatment choices during COVID-19. Best approach to treat an avulsed permanent tooth is immediate replantation. Whether the case is admitted to emergency clinic or people at trauma site are instructed on phone, the following steps are to be considered:
Take self-precautions while treating others at the emergency cite including wearing masks and personal protective equipment (PPE) if possible, to avoid viral infections. However, gold standard treatment always should be provided, even if dental aerosol-generating procedures (AGPs) are likely to be involved [23].
Calm the patient down.
Always aim for immediate replantation. If replantation cannot be done at the trauma site by surrounding peoples/parents/others, the tooth has to be stored as soon as possible in a storage media; milk, Hanks’ Balanced Salt Solution (HBSS), saliva, saline, or water. This is to avoid root surface dehydration. Then tooth can be replanted immediately at the emergency clinic.
Before replantation, tooth could be rinsed under running milk or saline to clean any dirt. It must be hold by the crown without touching root. Replanting primary teeth is contraindicated.
After tooth replantation, patient is asked to bite on gauze.
History: Review patient history in case of any other injury (potentially more serious) is involved, simultaneously. If any vomiting, headache, unconsciousness, or drowsiness are reported, this should be further investigated at the hospital, and also, if there is a previous injury to the teeth or the alveolar bone or if the occlusion has further changed.
How, when, and where the trauma/accident happened are all questions that should be answered. This will further help in evaluating the trauma for legal and insurance purposes. Any suspected abuse should be reported to local authority.
Anesthesia: administering local anesthesia is always recommended, preferably without vasoconstrictor [20].
Recent guidelines have detailed the plan on replanting tooth according to two main factors:
Extra-oral dry time: being less or more than 60 min.
Root maturation: closed or open apex.
For extra-oral dry time, it is used to assess periodontal ligament (PDL) cells’ viability. The soonest the tooth is replanted, within 15 min, the most likely PDL cells are viable. When the extra-oral dry time exceeds 60 min, it is more likely that PDL cells are nonviable. In all situations, it is recommended to replant the tooth acknowledging that prognosis is best when replantation is within 15 min and poorest when it is after 60 min [20]. Ankylosis-related (replacement) root resorption is an expected outcome in cases of late tooth replantation [18, 20, 24].
2.2 Factors might influence the success of replantation
These factors are the patient’s general health, the maturity of the root, the time the tooth is out of its socket, storage medium [11, 25, 26, 27], extra-alveolar permanence period, means of preservation, contamination, manipulation, and conditions of the avulsed tooth [28], and also relevant factors such as type of splint used and time of permanence (Figures 4 and 5).
.
Figure 4.
Factors might influence the success of tooth replantation.
Figure 5.
Potential complications following tooth replantation.
2.3 Storage media
Successful healing after replantation may occur only if the damage to the PDL cells was minimal. Immediate replantation of the avulsed tooth into the socket at the site of the trauma has been suggested to prevent further damage to the PDL cells left on the root surface from desiccation. As this is not always attainable since the lay person at the trauma site may lack the skill and the willingness to try this procedure. In such situations, it is recommended to put the avulsed tooth temporarily in a storage medium capable of preserving PDL cells viability. Thus, the extra-alveolar dry time and the type of storage medium are the most critical factors. Prolonging the duration of dry storage causes necrosis of the PDL cells after 30–60 min and decreases greatly the chances of healing after replantation [29].
2.3.1 Characteristics of the ideal storage medium [29]
No or minimal microbial contamination.
Readily available or accessible.
Physiologically compatible pH and osmolality to maintaining PDL cell viability.
The pH of the environment should be around 6.6–7.8 to maintain cell growth.
Optimal osmolality is 230–400 mOsmol/kg.21 as it affects water absorption of the cells.
2.3.2 Types of storage media
In their quest for an ideal storage media, a wide variety of materials have been tested by a lot of researchers for their role as potential storage media. The recent guidelines of IADT recommend in descending order of preference, milk, HBSS (Hanks’ Balanced Salt Solution), saliva, or saline as suitable and convenient storage mediums. Water is considered a poor medium but is better than dry storage. Other materials, some with promising results, include ViaSpan, propolis, and egg white [20, 30].
2.3.2.1 Milk
Many authorities recognized milk as the most recommended storage medium for avulsed teeth. The ease of obtaining it at accident sites makes it a practical choice. The physiological properties of milk are significantly better than other solutions, and pH (6.5–7.2) and osmolality (270 mOsm/kg) are compatible with PDL cells. Milk contains a combination of nutritional substances such as amino acids, carbohydrates, and vitamins capable of maintaining PDL cell viability. In addition, the presence of epithelial growth factor stimulates the proliferation and regeneration of epithelial cell rests of Malassez and activates the alveolar bone resorption. Hence, the bone tissue may be isolated from the tooth and decreases the chances of ankylosis [30, 31]. However, it should be noted that few reports argued that replanted teeth stored in milk were subject to ankylosis [32, 33, 34].
2.3.2.2 HBSS (Hanks’ Balanced Salt Solution)
The HBSS is a sterile, isotonic, and physiologically balanced standard saline solution which is used in biomedical research to support the growth of many cell types. It is a nontoxic solution, biocompatible with PDL cells; its pH (7.2) and osmolality (320 mOsm/kg) are balanced and considered almost ideal. It is composed of glucose, sodium, calcium, potassium, and magnesium ions.
HBSS is highly recommended for its ability to provide long-term preservation of PDL cells viability and proliferation capacity. Its ingredients may further help to reconstitute the depleted cellular components of the PDL. HBSS is commercially available as “Save-A-Tooth.” However, it is not found at most of the accident sites; this makes it an impractical storage medium [20, 29, 31, 32, 34].
2.3.2.3 Saliva
The only advantage of saliva as a storage media is its ease of availability immediately on almost all accident sites. However, it presents a possible source of bacterial contamination for PDL cells. Its osmolality (60–70 mOsm/kg) is considerably lower than the physiological osmolality; thus, cells stored in saliva show swelling and membrane damage. Saliva is better than tap water or dry storage, but it can be used only for very short storage time [29, 30, 31].
2.3.2.4 Saline
Normal saline, a 0.90% NaCl solution, has a physiological osmolality of 280 mOsm/kg which is compatible with the PDL cells. However, it is deficient in the essential nutrients, such as glucose, magnesium, and calcium which are needed to the normal metabolic functions of the cells of the PDL. Moreover, the hypotonic properties of saline induce rapid cellular lysis. Therefore, saline is not a good storage media unless for short periods only [29, 31].
2.3.2.5 Viaspan
Viaspan is a cell culture media widely used for storing and transporting organs to be transplanted. It has 320 mOsm/kg osmolality and 7.4 pH which favors cell growth and viability of the PDL cells. It is nearly an ideal material for storage of avulsed teeth for long periods. However, its high cost, short vitality expiration, and the limited access to it especially at the accident sites make it difficult to find and use this storage medium [31, 35].
2.3.2.6 Egg white
Egg white is considered a good storage media because of its high protein content, vitamins, and water. It is easily accessible and lacks microbial contamination with a pH of 8.6–9.3 and osmolality of 258 mOsmol/kg. Thus, it favors PDL cells viability and healing and presents a suitable choice for extended storage time [29, 31].
2.3.2.7 Tap water
Tap water has an approximate osmolality of 30 mOsm/kg and a pH of 7.4–7.79. It is not considered a suitable storage medium for avulsed teeth. It has bacterial contamination; its hypotonicity and nonphysiologically pH and osmolality favor the PDL cell lysis. Cells stored in water did not maintain their viability. However, it is better than dry storage and should be used only when there are no other alternatives (Table 1 and Figure 6) [29, 31].
Storage media
Osmolality (mOsmo/kg)
pH
Efficacy
Accessibility
Milk
270
6.5–7.2
✓
✓
HBSS
270–290
7.2–7.3
✓
Saliva
60–70
6.3
✓
Saline
280
7
✓
Viaspan
320
7.4
✓
Egg white
258
8.6–9.3
✓
✓
Tap water
30
7.4 7.79
✓
Table 1.
Characteristics of storage media.
Figure 6.
Milk as storage media.
2.4 Splinting
After replantation, the treatment of choice is splinting [2]. By definition, splinting is an assembly to protect, stabilize, and immobilize loosened, fractured, replanted, and traumatized teeth [3]. Also splinting is defined by American Association of Endodontists as “a rigid or flexible device or compound used to support, protect, or immobilize teeth that have been loosened, replanted, fractured, or subjected to certain endodontic procedures” [36].
To allow immobilization of the teeth during the initial period, it is mandatory using the so-called splint which is essential for the repair of periodontal ligament [37]. The use of semirigid splint is more indicated than the rigid one, considering that the long period of splinting is not recommended due to its expected complications namely substitutive resorption or ankylosis [38, 39]. One of the adverse healing outcomes of splinting is that forceful placement of the splint may cause additional trauma to the already affected pulp of the avulsed tooth [40].
2.4.1 Types of splints
Many different splinting techniques have been described [41]:
In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.
Cap splints and orthodontic bands were associated with a greater frequency of pulp necrosis and pulp canal obliteration when compared with acid etch resin splints and no splinting [44].
These splinting techniques were used prior to the development of a passively
applied acid etch resin technique and are no longer recommended [20]
Stabilize the tooth for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016″ or 0.4 mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. Second option is nylon fishing line (0.13–0.25 mm) which can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children with mixed dentition, since the status of the other teeth may result in instability or loss of such splint.
2.4.2 Management of the soft tissues and surrounding alveolar bone
Tooth-supporting tissue injuries and lip injuries may be associated with avulsion [45].
Soft tissue tearing of the socket gingiva associated with avulsed tooth should be noted [46].
There are three benefits may be gained from the tight stitching of such tearing [47]:
Stop of the bleeding.
Avoid the penetration of microorganism into periodontium.
Allow the primary healing of the wound.
In addition to the soft tissue, the socket itself needs to be manipulated before replantation of the root, if the alveolar bone has collapsed, attempts should be made to reconstruct its wall [48].
2.5 In clinic treatment
2.5.1 Root canal treatment in avulsed teeth
2.5.1.1 Closed apex
It is mandatory to initiate root canal treatment within 2 weeks of tooth replantation [20, 22]. Root canal treatment should start with intracanal medication; calcium hydroxide or antibiotic-corticosteroid paste dressing for 2 weeks up to 1 month or 6 weeks [49, 50] is followed by root canal filling.
2.5.1.2 Open apex
No root canal treatment is performed at first, but a close follow-up is needed to detect any clinical or radiographic signs of pulp necrosis. The aim is to re-establish blood supply of open apices and maintain root development which could happen spontaneously after replantation.
Radiographic and clinical examination is indicted after 2 weeks, 4 weeks, 6–8 weeks, 3 months, 6 months, 1 year, and yearly thereafter for at least 5 years. If there is any sign of external infection-related root resorption, endodontics intervention is advised whether it is apexification, root canal treatment, or regenerative endodontic procedures (REPs) [20, 22, 48].
2.5.2 Regenerative/revitalization procedures and avulsions
REPs have been proposed based on translational studies. In 2016, American Association of Endodontists and European Society of Endodontology have proposed clinical considerations and position statement; respectively, discussing REPs [51]. In avulsion injuries, REPs are only indicated in cases of immature root with open apex and signs of pulp necrosis. The clinical protocol is the same that have been proposed previously in the mentioned guidelines. A recent report implemented this approach to treat avulsed tooth and showed successful outcome with a 30-month follow-up [52]. The key is using biocompatible materials that would recruit stem cells to build hard tissue barriers and allow physiological growth of roots. Biocompatible materials could be MTA or tricalcium silicate cements, e.g. bioceramicsm that revealed successful outcomes in several reports [53].
Antibiotics given at the time of replantation to prevent the infection may occur due to tooth contamination or may be present in the storage media. Also, it can be prescribed prior to endodontic treatment. It is theoretically effective in preventing bacterial invasion of the necrotic pulp and; further, it may prevent the inflammatory resorption (Figure 7) [54].
Figure 7.
Adjunctive therapies in the treatment of avulsed tooth.
In all cases, appropriate dosage for the patient’s age and weight should be calculated.
Amoxicillin or penicillin remains the first choice due to their effectiveness on oral flora and low incidence of side effects. Alternative antibiotics should be considered for patients with an allergy to penicillin [55].
The effectiveness of tetracycline administered immediately after avulsion and replantation has been demonstrated in animal study [56, 57]. Specifically, doxycycline is an appropriate antibiotic to use because of its antimicrobial, anti-inflammatory, and anti-resorptive effects. But still doxycycline exerted no effect on the occurrence of complete pulp revascularization in replanted teeth [58]. Tetracycline or doxycycline is generally not recommended for patients under 12 years of age to avoid the risk of discoloration of permanent teeth [20, 56, 57].
3.1.1 Indications of antibiotics in patients with avulsed tooth
By searching the literature so far, there are some indications of antibiotic prescribed for the patient with avulsed tooth (Figure 8).
Replanted tooth with possibly contaminated root and/or storage media [20, 54] for medically compromised patient.
Prevention of sequalae of avulsion-related bacteremia in the susceptible patients [59].
Prevention of inflammatory resorption in cases with necrotic pulp (tetracycline with its antimicrobial and anti-resorptive effect) [58].
Figure 8.
Indication of antibiotics in patient with avulsed tooth.
3.2 Analgesic
Prescription of analgesic is case-dependent; accordingly, it should be assessed individually. The use of stronger pain killer is unlikely [20, 48].
3.3 Mouth wash
Chlorhexidine (CHX) is a commonly used antiseptic mouthwash and is available over the counter (OTC); the use of adjunctive short-term of CHX can enhance oral hygiene by managing dental plaque [60].
The recent recommendation is to use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks (during the entire period of splinting).
3.4 Tetanus vaccine
The possibility of environmental contamination of the injury can justify the administration of tetanus vaccine [19].
The patient should be sent to a physician for consultation regarding a tetanus booster within 48 h of the initial visit [20].
In cases of severe replacement resorption (RR) and ankylosis, decoronation can be considered as an alternative treatment with good clinical outcomes for children and adolescents to the age when an appropriate implant is possible. If carried out at the right time; it helps to preserve the bucco-palatal dimensions of the alveolar bone and at the same time allows for vertical bone growth. This enables for future implant insertion without the need for the costly and invasive procedure of alveolar ridge augmentation. However, this approach still needs solid studies to verify it [61, 62].
Timing of the decoronation is crucial and should be planned for each individual case with regard to the patient’s age, growth intensity, and growth pattern. In young patients, it is advantageous to retain an ankylosed tooth, if possible, to act as a space maintainer. However, it is very necessary to intervene before the effect of infraposition causes significant arrested alveolar bone growth that makes a final prosthetic solution difficult. When ankylosis is diagnosed before the age of 10 years, there is a high risk of severe infraposition, and the tooth should be carefully monitored every 6 months. There is also a risk of severe infraposition during the pubertal growth spurt which varies in time from one person to another and thus needs also careful monitoring [63].
Clinically, the procedure is simple. Under local anesthesia and a full-thickness flap, the crown of the ankylosed tooth is sectioned earlier the cementoenamel junction. The root is cleaned with a K-file and washed with saline, and the canal is allowed to fill with blood and then the flap is repositioned. Subsequently, esthetics is maintained using an adhesive bridge [62].
4.2 Autotransplantation
Autotransplantation of an immature maxillary premolar to replace an ankylosed tooth is considered a highly successful alternative technique and is particularly indicated when crowding requires extraction of a premolar. To achieve pulpal revascularization and successful periodontal healing of the donor tooth, the ideal root should develop to three-fourths of the complete root length. In such cases, the whole root of the ankylosed tooth must be extracted, and a premolar will be transplanted in its place. The transplant tooth with its sound periodontal ligament will induce new bone formation, have continued root development, and even maintain its vitality. An esthetic restoration and orthodontic treatment will follow the transplant [64, 65].
4.3 Partial prosthesis/dental implant
4.3.1 Prognosis and outcomes
The long-term prognosis of replanted avulsed teeth shows great variability; the observed outcomes are greatly heterogeneous ranging from healing without symptoms to inflammation and rapid tooth loss. Many studies had shown a relatively low survival rate of replanted avulsed teeth, compared to other types of traumata, ranging from 50% to 83.3% [66]. Under favorable conditions, replanted teeth may be retained for 5 or 10 years and even few of them for a lifetime. However, some may fail very soon after replantation.
4.3.2 Factors associated with unfavorable outcomes and low survival rate [65]:
Delayed replantation
Unphysiological storage
Teeth with open apices
After replantation of the tooth, the prognosis commonly remains uncertain. Replacement resorption and inflammatory resorption are probable adverse outcomes in comparison with the more favorable functional healing (FH): [66]
Functional healing
The damaged tissues including the cementum and dentin are being resorbed by multinuclear giant cells. In regions with minor damage, the ruptured periodontal fibers are being rebuilt (regeneration). In case of small resorption cavities, the denuded root surface is being recolonized by neighboring cementoblasts and these deposit the cementum in which the new periodontal fibers are anchored. This process represents healing with physiologic function (functional healing, FH) [66, 67].
Inflammatory (infection-related) root resorption
Root surfaces affected by the trauma are quickly colonized by multinuclear giant cells. If these cells are continuously stimulated by microbial products from an infected root canal, not adequately treated, infection-related resorption (IRR, formerly named inflammatory resorption) will result. Provided the tooth is still restorable, adequate endodontic treatment might stop the progression of IRR.
Replacement resorption is a special form of root resorption, and it follows serious luxation or avulsion injury. It is a common sequela of delayed replantation and/or dry storage. Due to excessive drying before replantation, the damaged periodontal ligament cells will start an inflammatory response over extended areas on the root surface. The resulting large resorption cavities may not be entirely covered by the cementoblasts in time. Regenerating alveolar bone will be attached directly onto the root surface. In time, through physiologic bone remodeling, the root cementum and dentin will be replaced by bone; a process termed replacement resorption (RR) or ankylosis-related root resorption [65, 66, 67].
If revascularization does not occur or appropriate endodontic therapy is not performed after tooth replantation, pulpal necrosis will occur. The combination of microbes in the root canal and the external surface of the root results in aggressive resorption and can lead to rapid tooth loss [20, 65].
In a growing patient and/or tooth with open apices, the ankylosed tooth shows severe and progressive infraocclusion. The alveolar bone will stop advancing in a coronal direction with the rest of the jaw leaving a big bone defect when the tooth is eventually lost causing major esthetic and functional challenges when it is time for the final replacement [48, 67].
Mature replanted teeth need clinical and radiographic monitoring at 2 weeks (with splint removal), 4 weeks, 3 months, 6 months, 1 year, and hence yearly for at least 5 years. For teeth with open apices where spontaneous pulp revascularization might occur, clinical and radiographic monitoring should be more frequent due to the high risk of infection-related (inflammatory) and/or ankylosis-related (replacement) root resorption. Therefore, replanted teeth with open apices should have clinical and radiographic monitoring at 2 weeks (with splint removal), 1 month, 2 months, 3 months, 6 months, 1 year, and hence yearly for at least 5 years [20].
Evaluation may include the following outcomes:
5.1 Favorable outcomes
The replanted tooth is
Asymptomatic, functional,
normal mobility,
no sensitivity to percussion,
normal percussion sound,
no radiolucencies and no radiographic evidence of root resorption. The lamina dura appears normal.
In addition, for teeth with open apices, radiographic evidence of continued root formation and tooth eruption.
Pulp canal obliteration is expected and can be recognized radiographically sometime during the first year after the trauma.
5.2 Unfavorable outcomes
Patient may or may not have symptoms.
Presence of swelling or sinus tract.
The tooth may have excessive mobility or no mobility (ankylosis) with high-pitched (metallic) percussion sound.
In case of open apex, if there is ankylosis, the tooth may gradually become infrapositioned.
Presence of radiolucencies.
Radiographic evidence of infection-related (inflammatory) resorption, ankylosis-related (replacement) resorption, or both.
Or absence of continued root formation (in case of open apex).
When ankylosis occurs in a growing patient, infraposition of the tooth is highly likely to create disturbances in alveolar and facial growth over the short, medium, and long term.
A relatively recent meta-analysis showed trauma of primary dentition to be as common as 22.7% [68] with variable prevalence of avulsion from 7 to 13% [69]. In general, avulsed primary teeth should not be replanted (according to the recommendations of the IADT) [19]. Nevertheless, there are case reports with varying degrees of success after replantation of primary teeth, whereas others reported negative results to the replanted primary tooth and its permanent successor. One systematic review concluded that here is a lack of high-quality studies to support this approach [69].
Such a severe injury to the primary tooth may have negative impact on the development and/or eruption of its permanent successor. Premature loss of avulsed primary teeth might sometimes lead to space loss, masticatory, speech, and esthetic problems; this may also cause negative impact on their behavior, pschological, and social well-being. Removable or fixed appliances present valid treatment options to minimize space loss and improve esthetics when necessary. Furthermore, movement of the tooth during avulsion and the proximity between the primary tooth and the germ of its developing successor may interfere with its further growth and maturation leading to the occurrence of enamel defects and tooth malformations. The risk of sequelae in the permanent successor after avulsion of primary teeth is higher when the injury occurs in young children (<2 years), when the trauma is of greater magnitude such as when more teeth are involved and lower jaw is affected [70, 71].
Sequelae to the permanent successor include (Figure 10) [70]:
7. The role of teledentistry in the treatment of avulsed teeth
Teledentistry can be used to monitor those traumatic injuries cases remotely. Teledentistry combines dentistry and telecommunications simultaneously with clinical information and images over remote distances for dental consultation and treatment planning [72].
In cases of traumatic injuries and avulsions specifically, initial emergency instructions could be delivered on phones till obtaining emergency healthcare services is possible. This helps in calming patients or patients’ guardians and maintains the first actions of replanting teeth or storing it in proper storage medium according to the recommendations. Teledentistry is also used at times of follow-up to report symptoms or other complications. It is mainly essential when specialty dentist is not available, yet their consultation, supervision, and valuable support could be used by the dental team in managing such cases [73]. A report showed that around 60% of patients contacted the telemedical center during the so-called “out of office hours” for dental trauma injuries. This percentage signifies the importance of having proper teledental channels addressing these incidents.
Tooth avulsion is the complete displacement of the tooth from its socket in the dental arch.
In this chapter, we tried to gather the scattered information about tooth avulsion. Despite the rich published literature, but still a lot of researches are needed to reach evidence-based conclusions.
Although the tooth avulsion is the topic of concern in general dentistry, we tried to write this perceived paper in the specialist’s manner to reflect more light on many related details.
Causes of tooth avulsion are divided into those for deciduous dentition and other for permanent dentition which are differ from each in their pattern and severity of the trauma [11, 12, 13, 14, 15, 16, 17].
Epidemiology has shown a reduction of cases during COVID-19 era. This was explained by patients’ perceived fear of acquiring viral infections and thus hesitancy to reach out to emergency centers [8, 9, 10].
Avulsion treatment outcomes are very dependent on the first-aid measure as well as the agility to seek dental treatment.
For the management, put it as two phases may let the whole picture organized and well determined by specific time (at the time of trauma) the first phase and the other which are at the clinic.
The storage media (milk, HBSS, saliva, or saline) are discussed in detail regarding the characteristic of each. Nevertheless, researches are still looking for an ideal medium; some materials such as propolis and egg white are very promising. However, the quality of evidence is considered low [74]; on the other hand, teeth splinting is discussed generally as well as specifically for the avulsed teeth (with and without alveolar bone fracture) [20].
The literature regarding the adjunctive therapies for the teeth avulsion showed the role of these therapies; in this chapter, we considered them concisely with stress upon the indications for each [19, 20, 48, 60].
Criteria of successful treatment is widely discussed which is depending on both clinical and radiographic features.
Alternative treatments for the avulsed tooth in cases of the failure of aforementioned treatment are decoronation, autotransplantation, partial prosthesis, and dental implant [61, 62, 63, 64, 65].
The key of optimum outcomes in avulsions cases rely on both radiographical and clinical follow-ups. This signifies the importance of teledentistry and its role in addressing such incidents [72].
The main adverse outcome of tooth replantation is replacement root resorption (ankylosis). It implies possible risks of infraocclusion, impairment of alveolar bone growth, and tooth loss. The risk increases dramatically with delayed replantation [20].
Tooth avulsion is one of few emergencies in dentistry; prevalence differs from area to area according to the cause and gender. Replantation, immediate or delayed is the treatment of choice for the avulsed permanent tooth still immediate and proper replantation is important for long term good prognosis. Many factors may determine the outcome and use of antibiotic; although it is questionable, it is indicated in certain conditions. Although there is no strong evidence for their effect on healing, storage media is one of the factors for the preservation of the vitality of the tooth. It is used according to its availability at the trauma site. There are two stages in the treatment: emergency treatment and definitive treatment; even so, there is no grantee for the success of the treatment. Any avulsed tooth may be followed by complications, either immediately or lately. Despite the recommendation for the manager of the avulsed teeth, still not all recommendation can be applied for every avulsed tooth. Accordingly, any tooth has got special related factors which would determine the treatment plan after studying them carefully.
As a result, immediate and proper replantation is important for long-term good prognosis.
1.Emerich K, Czerwinska M, Ordyniec-Kwasnica I. Immediate self-replantation of an avulsed permanent mandibular incisor—A case report. Dental Traumatology. 2010;26(5):443-446
2.Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental Traumatology. 2007;23(3):130-136
3.Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Wiley-Blackwell; 2019
4.Benmansour A. Treatment of complete traumatic avulsion of an incisor tooth in adults. Medecine et Sante Tropicales. 2013;23(2):128-131
5.Hicks RW, Green R, Van Wicklin SA. Dental avulsions: Review and recommendations. The Nurse Practitioner. 2016;41(6):58-62
6.Trope M. Avulsion and replantation. Refuat Hapeh Vehashinayim. 1993;19(2):6-15
7.I. P. Condutas endodônticas em dentes reimplantados. Espelho Clínico:São Caetano do Sul. 2001;4(24):8-9
8.Woolley J, Djemal S. Traumatic dental injuries during the COVID-19 pandemic. Primary Dental Journal. 2021;10(1):28-32
9.Hakeem FF, Alshahrani SM, Ghobain MA, Albabtain I, Aldibasi O, Alghnam S. The impact of COVID-19 lockdown on injuries in Saudi Arabia: Results from a level-I trauma center. Frontiers in Public Health. 2021;9:704294
10.Yang J, Yang G, Jin R, Song G, Yuan G. Changes in paediatric dental clinic after reopening during COVID-19 pandemic in Wuhan: A retrospective study. BMJ Open. 2022;12(1):e048430
11.Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen, Denmark: Mosby; 1994
12.Brin I, Ben-Bassat Y, Heling I, Brezniak N. Profile of an orthodontic patient at risk of dental trauma. Endodontics & Dental Traumatology. 2000;16(3):111-115
13.Kaba AD, Marechaux SC. A fourteen-year follow-up study of traumatic injuries to the permanent dentition. ASDC Journal of Dentistry for Children. 1989;56(6):417-425
14.Bak NB. Accidental tooth avulsion during tonsillectomy. Ugeskrift for Laeger. 2010;172(21):1611-1612
15.Tapashetti SA, Mahale P, Sattur A. Iatrogenic avulsion of a tooth−an endodontic mishap caused by rubber dam clamp−A case report. International Journal of Scientific Research. 2018;7(2):460-461
16.Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesthesia and Analgesia. 2009;108(5):1564-1573
17.Kaur A, Kumar V, Logani A. Accidental avulsion of a recently traumatised maxillary anterior tooth during rubber dam application. BMJ Case Report. 2021;14(8)
18.Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology. 2012;28(2):88-96
19.Day PF, Flores MT, O'Connell AC, Abbott PV, Tsilingaridis G, Fouad AF, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dental Traumatology. 2020;36(4):343-359
20.Fouad AF, Abbott PV, Tsilingaridis G, Cohenca N, Lauridsen E, Bourguignon C, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology. 2020;36(4):331-342
21.Levin L, Day PF, Hicks L, O’Connell A, Fouad AF, Bourguignon C, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: General introduction. Dental Traumatology. 2020;36(4):309-313
22.Krastl G, Weiger R, Filippi A, Van Waes H, Ebeleseder K, Ree M, et al. European Society of Endodontology position statement: Endodontic management of traumatized permanent teeth. International Endodontic Journal. 2021;54(9):1473-1481
23.Paediatric DTUaBSo, Dentistry. Permanent Dentition Acute Management of Traumatic Injuries and Follow-up Care during the COVID-19 Pandemic. 2020
24.Soares Ade J, Gomes BP, Zaia AA, Ferraz CC, de Souza-Filho FJ. Relationship between clinical-radiographic evaluation and outcome of teeth replantation. Dental Traumatology. 2008;24(2):183-188
25.Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. International Journal of Oral Surgery. 1981;10(1):43-53
26.Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Vastmanland, Sweden. Sweden Dental Journal. 1996;20(1–2):15-28
27.Cohenca SK, Eidlitz D, Nuni E, Moshonov J. New treatment protocols for avulsed teeth. Refuat Hapeh Vehashinayim. 2004;21:48-53
28.Bezerra SRSBR, Arruda IMS, Requejo LSL, Carneiro SCDAS. Reimplante dental: Estágio atual. Revista da Faculdade de Odontologia de Pernambuco. 1992;12(12):29-33
29.De Brier N, Borra V, Singletary EM, Zideman DA, De Buck E, et al. Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis. Dental Traumatology. 2020;36(5):453-476
30.Adnan S, Lone MM, Khan FR, Hussain SM, Nagi SE. Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review. Dental Traumatology. 2018;34(2):59-70
31.Is Khinda V, Kaur G, Kallar S, Khurana H. Clinical and practical implications of storage media used for tooth avulsion. International Journal of Clinical Pediatric Dental. 2017;10(2):158-165
32.Hasan MR, Takebe H, Shalehin N, Obara N, Saito T, Irie K. Effects of tooth storage media on periodontal ligament preservation. Dental Traumatology. 2017;33(5):383-392
33.de Paula Reis MV, Moura CC, Soares PB, Leoni GB, Souza-Neto MD, Barbosa DZ, et al. Histologic and micro-computed tomographic analyses of replanted teeth stored in different kind of media. Journal of Endodontia. 2014;40(5):665-669
34.Souza BDM, Garcia LFR, Bortoluzzi EA, Felippe WT, Felippe MCS. Effects of several storage media on viability and proliferation capacity of periodontal ligament cells. European Archives of Paediatric Dentistry. 2020;21(1):53-59
35.Poi WR, Sonoda CK, Martins CM, Melo ME, Pellizzer EP, de Mendonca MR, et al. Storage media for avulsed teeth: A literature review. Brazilian Dental Journal. 2013;24(5):437-445
36.Endodontists. AAo: An Annotated Glossary of Terms Used in Endodontics. 7th ed. Chicago: American Association of Endodontists; 2003
37.Veras SRA, Bem JSP, de Almeida ECB, Lins C. Dental splints: Types and time of immobilization post tooth avulsion. Journal of Istanbul University Faculty of Dentistry. 2017;51(3 Suppl 1):S69-S75
38.Lin S, Emodi O, Abu E-NI. Splinting of an injured tooth as part of emergency treatment. Dental Traumatology. 2008;24(3):370-372
39.Yoon H, Song M. Long-term retention of avulsed maxillary incisors with replacement root resorption: A 9-year follow-up. Case Report Dental. 2021;2021:8872859
40.Emshoff R, Moschen I, Strobl H. Adverse outcomes of dental trauma splinting as related to displacement injury and pulpal blood flow level. Dental Traumatology. 2008;24(1):32-37
41.Brown CL, Mackie IC. Splinting of traumatized teeth in children. Dental Update. 2003;30(2):78-82
42.Kahler B, Hu JY, Marriot-Smith CS, Heithersay GS. Splinting of teeth following trauma: A review and a new splinting recommendation. Australian Dental Journal. 2016;61(Suppl. 1):59-73
43.Hadziabdic N. The basics of splinting in dentoalveolar traumatology. In: Almasri M, Kummoona R, editors. Maxillofacial Surgery and Craniofacial Deformity: Practices and Updates. London: IntechOpen; 2020
44.Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dental Traumatology. 2008;24(1):2-10
45.Andreasen JOAaFM. Essentials of Traumatic Injuries to the Teeth: A Step-By-Step Treatment Guide. 2nd ed. Conpenhagen, Denmark: Munksgaard; 2001
46.Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dental Traumatology. 2002;18(1):1-11
47.Ram D, Cohenca N. Therapeutic protocols for avulsed permanent teeth: Review and clinical update. Pediatric Dentistry. 2004;26(3):251-255
48.Trope M. Avulsion of permanent teeth: Theory to practice. Dental Traumatology. 2011;27(4):281-294
49.Day PF, Gregg TA, Ashley P, Welbury RR, Cole BO, High AS, et al. Periodontal healing following avulsion and replantation of teeth: A multi-Centre randomized controlled trial to compare two root canal medicaments. Dental Traumatology. 2012;28(1):55-64
50.Bryson EC, Levin L, Banchs F, Abbott PV, Trope M. Effect of immediate intracanal placement of Ledermix paste(R) on healing of replanted dog teeth after extended dry times. Dental Traumatology. 2002;18(6):316-321
51.Galler KM, Krastl G, Simon S, Van Gorp G, Meschi N, Vahedi B, et al. European Society of Endodontology position statement: Revitalization procedures. International Endodontic Journal. 2016;49(8):717-723
52.Lu J, Liu H, Lu Z, Kahler B, Lin LM. Regenerative endodontic procedures for traumatized immature permanent teeth with severe external root resorption and root perforation. Journal of Endodontia. 2020;46(11):1610-1615
53.Hargreaves KM, Diogenes A, Teixeira FB. Treatment options: Biological basis of regenerative endodontic procedures. Journal of Endodontia. 2013;39(3 Suppl):S30-S43
54.Hammarström L, Blomlöf L, Feiglin B, Andersson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endodontics & Dental Traumatology. 1986;2(2):51-57
55.Sae-Lim V, Wang CY, Choi GW, Trope M. The effect of systemic tetracycline on resorption of dried replanted dogs' teeth. Endodontics & Dental Traumatology. 1998;14(3):127-132
56.Tsilingaridis G, Malmgren B, Skutberg C, Malmgren O. The effect of topical treatment with doxycycline compared to saline on 66 avulsed permanent teeth--a retrospective case-control study. Dental Traumatology. 2015;31(3):171-176
57.Meng M, Chen Y, Ren H, Zhang Q, Chen S, Zhou X, et al. Effect of tetracyclines on pulpal and periodontal healing after tooth replantation: A systematic review of human and animal studies. BMC Oral Health. 2021;21(1):289
58.Hamanaka EF, Poi WR, Brandini DA, Panzarini SR. Use of systemic antibiotic therapy after the replantation of avulsed permanent teeth: A literature review. Brazil Dental Science. 2017;20(1)
59.del Planells P, Barra Soto MJ, Santa Eulalia Troisfontaines E. Antibiotic prophylaxis in pediatric odontology. An update. Medicina Oral Patologia Oral Cirugia Bucal. 2006;11(4):E352
60.Brookes ZLS, Bescos R, Belfield LA, Ali K, Roberts A. Current uses of chlorhexidine for management of oral disease: A narrative review. Journal of Dentistry. 2020;103:103497
61.Cohenca N, Stabholz A. Decoronation—A conservative method to treat ankylosed teeth for preservation of alveolar ridge prior to permanent prosthetic reconstruction: Literature review and case presentation. Dental Traumatology. 2007;23(2):87-94
62.Sala M, Mendoza-Mendoza A, Yanez-Vico RM. Decoronation: An alternative treatment for replacement root resorption. Case Report Dental. 2017;2017:2826948
63.Malmgren B. Ridge preservation/decoronation. Journal of Endodontia. 2013;39(3 Suppl):S67-S72
64.Abella Sans F, Ribas March F, Zubizarreta-Macho A, Boschini L, Roig Cayon M, Duran-Sindreu TF. Guided autotransplant of a first premolar to replace a maxillary ankylosed incisor using a custom-designed osteotome. Journal of the American Dental Association. 2022;153(3):265-272
65.Petrovic B, Markovic D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dental Traumatology. 2010;26(1):52-59
66.Muller DD, Bissinger R, Reymus M, Bucher K, Hickel R, Kuhnisch J. Survival and complication analyses of avulsed and replanted permanent teeth. Scientific Reports. 2020;10(1):2841
67.Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dental Traumatology. 2005;21(2):93-101
68.Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis-one billion living people have had traumatic dental injuries. Dental Traumatology. 2018;34(2):71-86
69.Martins-Junior PA, Franco FA, de Barcelos RV, Marques LS, Ramos-Jorge ML. Replantation of avulsed primary teeth: A systematic review. International Journal of Paediatric Dentistry. 2014;24(2):77-83
70.Del Negro B, Lauridsen E, Mendes FM, Andreasen JO, Wanderley MT, Hermann NV. Impact of avulsion of the primary incisors on the occurrence of sequelae in the permanent teeth: A retrospective cohort study. Community Dentistry and Oral Epidemiology. 2021
71.Lenzi MM, da Silva Fidalgo TK, Luiz RR, Maia LC. Trauma in primary teeth and its effect on the development of permanent successors: A controlled study. Acta Odontologica Scandinavica. 2019;77(1):76-81
72.Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. Journal of International Society of Preventive and Community Dentist. 2011;1(2):37-44
73.Lienert N, Zitzmann NU, Filippi A, Weiger R, Krastl G. Teledental consultations related to trauma in a Swiss telemedical center: A retrospective survey. Dental Traumatology. 2010;26(3):223-227
74.Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: Avulsed (knocked out) and replanted. Cochrane Database of Systematic Reviews. 2019;2:CD006542
Written By
Manal Abdalla Eltahir, Randa Fath Elrahman Ibrahim and Hanan Alharbi
Submitted: 15 May 2022Reviewed: 14 June 2022Published: 22 July 2022
Open access peer-reviewed chapter
