Avulsed teeth

Hello, welcome back. So last week in this series on trauma is where we’re looking at avulsion of the teeth. OK, so this is a worst case scenario. Ah, what do we do? And this is the one where it’s so important, that initial management, because it will actually make all the difference with prognosis for these teeth. So when we think about principles for avulsion, it’s, again, thinking about optimising the chances for the cells of the periodontal ligament, PDL, to remain alive. So once they come out of that socket, they are really not very happy, and they want to get back into the socket as soon as possible.

And the longer the tooth is out of the socket, the more likely that the cells of the PDL are going to die. And if you can keep those cells alive, you can reduce the chances of getting inflammatory resorption. And that can be quite rapid and really eat through root, so you really want to try and stop that. And if you can’t reimplant the tooth– so if it’s been lost, or they went to A&E and they forgot about the tooth because other things were happening and it’s two days later that they remember and there’s no chance to reimplant, then you really want to think about space maintenance. You don’t want that space to close.

You want to put something there, and again, I always think, if it was me, I definitely wouldn’t want to walk around with a gap in front of my mouth. So definitely need to think about that. So when it comes to key factors, it’s really– in back of your mind, I want you to have that clock from 24, if you’re familiar with the TV series 24 where they had the ticking clock going away in the background. The moment that tooth comes out, that’s what we’ve got to be thinking of because it literally is a countdown to how quickly can we get this tooth back in to save those PDL cells.

So things that are going to affect our outcome is maturity of the root apex. A closed apex is going to have less chance to revascularization than one that’s wide open. So that’s going to have an effect, but what’s really key are the extra-oral time, the time that that tooth is out of the socket, and then what has it been stored in? Because if that tooth has been stored dry, those PDL cells, after about six to eight minutes, are probably going to die, but if it has been stored in a medium– and most people know that milk is a fantastic medium to store it in– then it’s got a bit more of a chance.

But remember, in your mind, imagine that ticking clock. It’s counting down, and you want to get it reimplanted as soon as possible. So if you get a phone call from the school or a parent saying, [GASPS] my child’s tooth came out, check if it’s a permanent tooth and then try and encourage them to put it straight back in because that’s going to give it the best prognosis. So when we think about treatment of how we manage an avulsed permanent tooth, we tend to think about it as a less than 60 minutes or over 60 minutes. Now, it’s difficult. Sometimes, parents don’t really know.

It’s all a bit chaotic when the trauma happened, but it’s just to give you a bit of an idea. Now, it’s not to say, oh, it’s 61 minutes. I mustn’t do this. Or it’s 59 minutes. I can do that. You have to bring all the factors in, but it’s just to give you a rough guide of about an hour. So if you’ve got an open apex and the tooth was not reimplanted at the site of the trauma, what you want to do is– you’ll probably find that there’s a clot starting to form in the socket, so you may have to gently irrigate that. And then you want to get the tooth back in.

You may have to just gently irrigate the tooth, as well, if it’s got a bit dirty, but you really want to get it back into the socket as soon as possible. Now, if it’s really soon after the trauma and the child’s a little bit like, oh, I’m not quite sure what happened here– I’m a bit dazed from the trauma– you may be able to just put it back in straight away without them realising. But it may be that you’re going to have to– because you’re going to have to press up a little bit, you’re going to have to give some local.

And it’s much better to give local and know you’ve repositioned it fully than to just try and put it in half way and leave it there because you really want to get it back into the socket. Then you’re going to verify its position, and normally, they say, check it radiographically first. But it’s a little bit difficult to do when you haven’t splinted the tooth because it’s just hanging in the socket, so I tend to splint it first for a couple of weeks. Then I take a radiograph to check it. Whether they need antibiotics or tetanus, you’re going to check medical history for that, and then you would review again in a week. So that’s for an open apex.

Now, the reason why we don’t rush in and do endodontic treatment for an open apex is there is a chance it could revitalise, but if it’s a closed apex, it’s not going to. So you know that you’re going to get them back after a week to 10 days, and you’re going to start endodontic treatment because you want to make sure you don’t have an inflamed necrotic pulp that’s going to speed up that resorption process. So that if it’s less than an hour, and that’s how you do. So here’s the thing. This is one where the patient literally fell outside the stairs of the Eastman Hospital, came straight up to see us, and we just put it straight back in.

And that’s really what you want to do. Get that tooth back in the socket as soon as possible. What happens if that tooth has been out of the socket for over an hour now? OK, again, depends what it has been stored in, but if it’s been kept dry in a little tissue and in that time, you know the PDL cells are dead. OK, so now it’s about damage limitation, really. So again, you’re going to rinse the tooth. You’re definitely going to need to irrigate the socket if there’s a clot there.

You’re going to need local to be able to reimplant that tooth because that socket, now, is going to be a little bit harder to negotiate to put the tooth back in. Again, you’re going to verify the position, splint for two weeks, think about antibiotics and tetanus, but you know that the PDL cells are pretty dead now. They’ve been out of the mouth for an hour. They’re not very happy, so you are going to need to start endodontic treatment. And you may consider doing that even before you put the tooth back in, if it has literally been out of the mouth for about four or five hours.

Well, you know you’re going to do endodontic, so you may as well start it and then put the tooth back in or put the tooth back in and do it after. It depends on the situation, but once it’s been out of the mouth for more than an hour, we know the PDL cells are pretty likely to be dead. So what about splinting? Well, I’m very much of the view that splinting should be easy to place, easy to remove. You want to keep things simple. So wire and composite splint, you don’t need anything fancy. If you’ve got titanium-type splints or anything, brackets and arch wire, and you’ve got them all available and you’re happy to use them, great.

But if not, actually, just a bit of composite and some wire, even a paper clip if you need to, something that’s just going to help to stabilise those teeth, is fine. Always do it on the labial surface, OK? It’s so tricky to put on if it’s on the palatal or lingual surface, and it’s really tricky to remove. And actually, it can occlude with patients– it can stop them occluding properly, so keep it on the labial surface. It’s only going to be on for a few weeks, so the patient can put up that just because that’s the optimal place to get some healing.

Usually, you would just do it on one side of each traumatised tooth, so you’re keeping it nice and simple. And what you want to do is make sure that your splint is in the middle of the crown of the tooth. You don’t want it right near the incisal edge so that when they’re biting, it’s causing issues. And you certainly don’t want it near the gingival tissues because that’s going to compromise oral hygiene, and that’s going to mean you won’t get gingival healing, which is what you want to get, that nice seal around there again. So keep it on the middle of the tooth, as you can see on the picture here.

But what happens– like I say, the other scenario you need to think about, what happens if we can’t put that tooth back in? It’s been lost. It went up the Hoover, or no one can find it, and so on. And I think what you really want to do is maintain that space, whether it’s a partial denture, initially, whether it’s a raisin retained bridge and so on, but what you don’t want is to have teeth on either side drift into the space.

Because that can be really difficult to manage later on if you want to try and restore the ascetics because you don’t have enough space, and it can actually be very difficult to move everything along orthodontically, particularly when you get centre line shifts. So it’s really important that you put something there, and like I say, I think most patients would want something. They wouldn’t want a gap at the front, so it’s really important if you can’t maintain any tooth that’s been lost to trauma that you do keep that space with an immediate replacement. So in summary, when we talk about avulsion, it’s all about limiting resorption so you want to make sure that, where possible, reimplant the tooth straight away.

Remember the ticking clock. Remember, you want to get that tooth back into the socket as soon as possible to give it the best chance of healing itself. And if you can’t and the tooth is lost for whatever reason, always maintain that space. Thank you.