Yuli NugraeniDavid Buntoro KamadjajaHaryono Utomo

Dental trauma is one of the most serious oral health problems in active children and adolescents.

It requires immediate initial emergency treatment followed by integrated procedures.

Tooth avulsion accounts for 0,5-16% of traumatic injures in the permanent dentition and for 7-21% of injures in the primary dentition

Avulsion of permanent occur at age of 7-10 year

Avulsions → severe pulpal and periodontal injures

Pulp necrosis and consecutive infections → ankylosis (Replacement Resorption, RR) and infection-related resorption (IRR)

Tooth ankylosis leads to difficulties in orthodontic treatment i.e. retracting the avulsed protruded teeth

Management for ankylosis → supported by little evidence →do not offer and any proven long term benefit

Antiresorptive-regenerative therapy (ART) +local application of glucocorticoids +enamel matrix derivative (EMD, Emdogain) + systemic administration of doxycycline combined with semi-rigid fixation →successful results

The objective of this review is to purpose a new simple protocol of avulsed tooth management which also minimize the risk of ankylosis.

AVULSION :a complete displacement of tooth out of socket → severe PDL + fracture of alveolus

Immediate replantation (within 5 min) Required for regeneration of the PDL

Prognosis : In the permanent teeth is dependent upon

formation of root development and extra oral dry time → a risk for pulp necrosis, root resorption, ankylosis, infraocclusion.

The best prognosis: replanted immediately if > 5min: stored in medium to maintain vitality of PDL). > 15 min → risk of ankylosis ↗

ART : to depress resorption activity and support regeneration in the PDL

ART + EMD (® Emdogain) + Doxycycline : ↗prognosis of avulsed teeth

Treatment strategies : avoiding inflammation increasing revascularization producing hard barriers in the teeth with

open apices

Extra oral dry time> 60 min: EMD should applied onto the root surface and into the alveolus

EMD contains protein (amelogenin) and thought to aid in the migration, attachment, proliferative capacity and biosynthetic activity of PDL cells.

EMD : ↗PDL cell proliferation and protein production→ regenerating PDL

Endo treatment → essential for the progress of healing of the replanted tooth

Controversies : in closed apex tooth (<1mm) →EO/IOThe best result : endodontically treated → inserted

to socket + pulp extirpation directly → prevent IRRThe canal → debrided, dressed with

corticosteroid/antibiotic ( Ca(OH)2 ) → 1 to 3 months

Endodontic + gutta-percha or Ca(Oh)2 :delays periodontal healing + Accelarate ankylosis (RR) in matture teeth

In mature teeth → Endo tx should be commenced 7-10 days following replantation

In immature teeth ( the time is short and the apex is open ) → revascularization → Endo tx can be delayed

If px compliance → Endo tx is assured → Apexification, root filling with GP/MTA → can be carried out later

Ladermix : healing ↗ resorption ↘ Ca (OH)2 + ChKM : healing process of

PDL ↗ if application delayed ± 7 days after replatation

Ankylosis and root resorption in tooth avulsion treatment, caused:

improper management directly dry time exceeding 60 min Persistent inflamation of the PDL Minimal or absence of occlusal force

After 60 min extra oral dry time : the survival rate of The PDL cells →almost zero, and osseous replacement is predicted

Direct extirpation the pulps + application of intraradicular medicament → beneficial

Ladermix → proliferation of dentinoclast → mixed with Ca(OH)2 ↗

Corticosteroids in intracanal → standart tx protocol at emergencies visit

EMD is the promising result replantation ↗↗

The alternatives medicament : doxycycline, minicycline, alendronate, atau Ladermix

The best factors may prevent replantation from ankylosis and root resorption :

dry time < 60 min decontamination of root surface application of preserving PDL agent (EMD)

direct extirpation without endo txART + intracanal medicamentSemi rigid splinting for 2-3 weeksEndo txThe successful result : significantly higher in open apex teethOur new concept : to create open apex condition by widening the apical → to remove the delta area which contains accessory canals

This new concept simple proccedure had several benefits :

Open apex intracanal medicament to enter periapical area PDL inflamation ↘

Remove the accessory canals difficult for pulp sterilization

Facilitates drainage of inflamaotry mediators in periapical area

The follow up : apexification procedures or final root canal filling

The simple procedures : the use of medicament that commonly available in dental office → Ca(OH)2, CHKM, Endomethasone®, minocycline gel for topical application in the sulcular area. In case of absence of ideal wire for splinting with brackets, attached to the tooth with GIC or composites

The main principle to prevent ankylosis: reducing the inflamation of the PDL.

Inflamation leads to altered function of PDL →mineralized tissue forming cells → ankylosis