management of trauma to teeth leading to avulsion (Ellis class V fracture) in children

1. -A Project BY:
Karishma Ashok
Guided By:
Dr Sumedh Khare

2. Class I: Simple fracture of crown invoving little or
no dentin
Class II: Extensive fracture of crown involving
considerable dentin but not the dental pulp
Class III: Extensive fracture of crown involving
considerable dentin and exposing the dental pulp
Class IV: Traumatised teeth that has become non-
vital with or without loss of tooth structure

3. Class V: Teeth lost as a result of trauma
Class VI: Fracture of root with or
without loss of crown structure.
Class VII: Displacement of a tooth
without fracture of crown or root.
Class VIII: Fracture of crown en
masse and its replacement
Class IX: Traumatic injury to
primary teeth

4. ETIOLOGY
 1. Fall
 2. Accidents
 3. Sports
 4. Battered child syndrome
 5. Assaults

5.  1. Children with accident prone facial profile
 (a) Increased overjet with protrusion of upper incisors &
insufficient lip closure
 (b) Angle’s Class II type 1 malocclusion
 (c) Angle’s Class I type 2 malocclusion
 2. Children with cerebral palsy
 This is due to:
 (a) Abnormal muscle tone & function resulting in
maxillary anterior protrusion
 Poor skeletal & muscle co-ordination
 3. Dentinogenesis Imperfecta

6.  It is the term used to describe the complete
displacement of tooth from its alveolus. It is called
EXARTICULATION .
 Maxillary teeth most commonly
affected.
 Age group:7-9 years
(loosely structured pdl &
low mineralisation..hence
minimal resistance to
extrusion)

8.  Bleeding socket with missing tooth
RADIOGRAPHIC FEATURES
 Empty socket
 Associated bone fractures
 If the wound is recent then lamina dura is visible,
otherwise obliterated

9.  Re-implantation
 Avulsed tooth with open apex – Endontic therapy is
delayd till first signs of apical closure are seen
 Avulsed tooth with closed apex – Endodontic therapy
is done after 1-2 weeks depending on the type of re-
implantation

10. The single most important factor in the success of re-
implantation is the speed with which the tooth is re-
implanted. Every effort should be made to re-implant the
tooth within first 15-20 minutes.
Case History should include exact information on :
1. Time interval between injury or re-implantation
2. Condition under which the tooth has been stored
The tooth to be stored in storage media like milk, saline,
vestible of mouth, etc.

11.  Avulsed tooth
 Tooth stored in
vestibule
 Severly contused
and fractured socket
wall

12. PROCEDURE:
 1. Reimplantation of a
tooth with completed
apex
 2.Rinsing the tooth
with saline
 3. Reimplantation
using slight
finger pressure
 4. splinting

13.  1. Check the alveolar socket. It should be reasonably
intact in order to provide a seat for the avulsed tooth.
 2. The extra-alveolar period
 3. Socket is gently rinsed with saline when it is clear of
the clot & debris its walls are examined for presence,
absence or collapse of socket wall
 4. Palpitation of socket & surrounding apical areas is
done to know if an alveolar frcture is present in
addition to avulsion
 5. Radiograph is taken

15. 6. Preparation of root
A topical agent that is most widely used is alendronate.
It is a IIIrd Generation bisphosphonate which exhibits
oseoclastic inhibotry activity
Two other Products – Alendronate & Emdogain may allow
regeneration of periodontal ligament & inhibit or prevent
replacement resorption which is a major cause of tooth
avulsion
7. Preparation of Socket
 Emphasis is placed on removal of obstacles within socket
to replacement of tooth into socket.
 The socket should be left unaltered to the greatest extent
possible
 It should be lightly aspirated if a blood clot is present.

16.  If the alveolar bone has collapsed, a blunt instrument
should be inserted carefully into the socket in an
attent to reposition.
 DO NOT currette the socket
 After re-implantation, manually compress the facial &
lingual bony plates (i.e. If spread apart)
8. Splinting
A splinting technique that allows the movement of tooth
during healing and that is in place for minimal period
results in a decreased incidence of ankylosis. Semigrid
fixation for 7-10 days is recommended.

17. NOTE:
 Condition of the alveolus-
after 3 weeks the socket area
and gingiva are healed
 Socket is evacuated using
excavator and surgical bur
 wash with saline
 Reimplant and splint
 Follow up

18. NOTE:
 Replanting a tooth with a
non-vital pdl.
 Extra-oral dry storage over
24 hrs & severely contused
 Alveolus.
 Therefore delayed
Reimplantation done.
 Root surface rinsed &
cleaned free of dead pdl
 Pulp is extirpated and tooth
Is treated with NaF solution

19.  Management of Soft Tissue
• Soft tissue lacerations of the socket gingiva should be
lightly sutured.
• Lip laceration is common with these injuries. Lip
wound should be cleaned & sutured.
 Adjunctive Therapy
A recent study reveals that systemic antibiotics given at
the time of re-implantation & prior to endodontic
treatment are effective in preventing bacterial invasion
of necrotic pulp & therefore subsequent inflamatory
response.

20.  Home Care
Since adequate brushing is difficul, mouth rinsing is
advised. The patient should not bite on splinted
teeth and should be advised soft diet.
 Second Visit / Follow-Up
7-10 days after first visit
Emphasis is placed onpreseration & healing of
attachment apparatus.
Endodontic treatment ot be carried out, if necessary.

23. It is the process of transplanting tissue from one part of
body to another in same individual. It is also termed
as AUTOGRAFT.
It has been successfully used in management of tooth
loss following trauma.

24. Donor Tooth
 3rd Molar
 Lower 2nd Premolar
 Lower 1st Premolar
 Supernumerary teeth
 Lower Incisors
 Upper Premolar
 1st Molar
 Upper Central Incisor
 Upper Laterial Incisor
 Upper Incisor
 Upper Lateral Incisor
 Dependent on root
shape
Recipient Site

25.  Size & shape of recipient area
 Need for socket exploration or instrumentaion
 Stage of root development
 Optimal time for transplation is when root is 1/2 to ¾
formed.
3. Revie w of Injured Tooth
 All teeth that are affected by trauma have to be reviewed
regularly
 The review is carried out initially after 1 month, then 3rd
month & then every 6 month for at least 2 years after
trauma
 Review should include sensitivity tests & radiographs

26. 1. Traumatized anterior teeth with long term prognosis
2. Cases with Class I or II malocclusin with moderate to
severe crowding involving extraction of premolar
CONTRAINDICATIONS
Re-implantation is contra-indicated in case of primary
teeth. This is beacuse ankylosis may take place thus
obstructing the eruption of permanent successors.
In such cases, prosthetic implants may be done.

27. An effective splint should perform the following
functions:
 Immobilize the loose tooth
 Hold repositioned teeth in alignment
 Protect the damaged tissue from occlusal forces

28. The pathology of tooth re-implantation can be divided
into:
I. Pupal ractions
II. Periodontal reactions
Both pulp and periodontal ligament suffer extensive
damage during an extra-oral period.

29. Experiments have shown various distinct pulpo-dentinal
response which can occur after immediatere-
implantation.
1. Regular tubular reparative dentin
2. Irregular reparative dentin
3. Osteodentin (Irregular reparative dentin with
encapsulated bone cells)
4. Irregular immature bone
5. Regular lamellated bone
6. Internal resorption
7. Pulp necrosis

31. Histologic examination of re-implanted human teeth
has shown four stages of healing:
1. Healing with normal pdl
2. Healing with surface resorption
3. Healing with ankylosis (replacement resorption)
4. Healing with inflamatory response (infection
related)
Immediately after re-implantation, a coagulum is
formed between the two parts of severed pdl.
This line of seperation is usually situated in the middle
of the pdl.

32. i. Healing with a normal pdl:
 Histologically, it is charecterised by complete
regeneration of the pdl which usually takes about 4
weeks to complete including the nerve supply.
 Radiographically, therenis normal pdl space without
signs of root resorption.
 Clinically, tooth is in normal position and ellicits a
normal percussion tone.
 This type of healing will probably not take place in
clinical conditions as trauma will result in injury to
innermost layer of pdl leading to surface resorption.

33. Line of seperation
After 3 days
Proliferating
connective tissue
After 2 weeks
new collagenous
Fibres formed
Normal state
Restored(8 mnths)

34. ii. Healing with surface resorption:
 Histologically it is charecterised by localised areas on
the root surface which show superficial resorption.
 Surface resorption is not progressive and self limiting.
 It shows repair with the formation of new cementum.
 Radiogrphically they may not be clearly disclosed due
to their small size.
 Clinically, tooth is in normal position and normal
percussion tone is ellicited.

35. iii. Healing with ankylosis (replacement resorption):
 Histologically, ankylosis represents fusion of alveolar
bone and the root surface and can be demonstrated in
2 weeks after re-implantation.
 Etiology may be related to absence of vital pdl cover
over the root.
 Depending upon the extent of damage, replacement
resorption can take place in two ways-
i. Progressive (gradually resorbs the entire root; occurs
if entire pdl is removed before re-
implantation/excessive drying)
ii. Transient (once established ankylosis dissappers;
related to minor damage to the root. Ankylosis
formed initially; later replaced by vital pdl)

37. iv. Healing with inflamatory response:
 Histologically characterised by bowl shaped resorption
cavities in cementum.
 Inflamatory reaction consists of granulation tissue
with numerous lymphocytes,plasma cells,PMNLs.
 Adjacent to these areas, root surface undergoes intense
resorption with Howships lacunae nd osteoclasts.
 Radiographicaaly charecterised by bowl shaped
radiolucencies along root surface as early as 2 weeks.
 Clinically
I. Tooth is loose and extruded
II. Sensitive to percussion
III. Percussion note is dull.

38. Granulation tissue
Area with active
resorption
surface
resorption
repaired with new
cementum
Necrotic pulp
tissue

39.  Tooth survival: 21-89%
 Pdl healing: 9-50%
 Pulp healing:4-27%
COMPLICATIONS:
If not treated, may lead to migration of adjacent teeth.
Either re-implantation or space maintaince using
orthodontic appliance is indicated.