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Rapid action can save a tooth which has been knocked out

If a permanent tooth has been knocked out (Avulsed) then prompt action can greatly increase the chances of the tooth surviving. This is especially important considering it is often the front teeth which are lost through trauma.

Teeth are retained in place by the periodontal ligament and keeping this ligament alive is critical to a favourable long term outcome. It is important that whoever triages telephone calls from patients, or emergency information patient access, gives clear information about how to look after a tooth which has been avulsed. Our practice offers this advice on our website about the emergency management of a knocked out tooth. No attempt should be made to re-implant a primary tooth as this can damage the underlying permanent successor.

Patient presenting after UR1 had been avulsed and UL1 luxated. The teeth had been re-implanted and splinted in A&E

When at the dental surgery, the permanent tooth should be re-implanted if possible. The length of time the tooth has been out of the mouth will determine what treatment protocol is followed. The Dental Trauma Guide outlines clearly what the treatment protocol is.

I have seen a few patients recently who have been unfortunate to have avulsed a central incisor tooth. Normally, these cases attend after the tooth has been re-implanted and I see different techniques being used for this. The patient in the photograph had fallen and avulsed the upper right central incisor tooth and luxated the upper left central incisor tooth. These teeth had been re-implanted and re-positioned to a high standard in A&E. Tooth fragments remaining in the lip had also been investigated and ruled out.

If a patient attends with a tooth which has been avulsed, this pathway may be helpful with clinical decision making. When the tooth has been re-implanted, a flexible splint needs to be used. This helps reduce the risk of ankylosis of the tooth. To place a flexible splint, orthodontic brackets and passive wire can be bonded to the avulsed and adjacent teeth. Alternatively, stainless steel wire bonded to the adjacent teeth with composite can be used. Studies have used stainless steel wires as flexible splints with varying diameters from 0.5mm- 0.015mm. Monofilament nylon fishing line has also been used as a flexible splint (line rated 20-30 pounds). I measured the diameter of a paperclip and it is 0.9mm which would be the diameter required for a rigid splint so this would be an inappropriate wire thickness to splint teeth after luxation/ avulsion. I have 0.3mm stainless steel wire stored away in case of emergency.

After the tooth has been re-implanted it should be splinted for 2 weeks if the tooth was outside the mouth for less than an hour or stored correctly. If the tooth has an extra-oral dry time of more than an hour, then there is less likelihood of the ligament remaining any vitality to the splint needs to be in place for longer (4 weeks recommended). The goal for delayed re-implantation cases is to try and retain the tooth for as long as possible - ankylosis and resorption of the tooth are likely.

Root canal treatment of avulsed upper right central and luxated upper left central incisor teeth

Trauma which causes an avulsion can also cause damage to the adjacent teeth, so the vitality of these needs to be tested. Endodontic treatment is inevitable for the avulsed tooth and this should be performed 7-10 days after re-implantation. In trauma cases, I like to do treatment over two sessions with calcium hydroxide sealed in the pulp space as an inter-visit dressing. My rationale for this is the calcium hydroxide can reduce inflammatory mediators which hopefully reduces the risk of resorption or ankylosis in the future.

Composite bonding to restore fractured incisal edges after splint removal

Restoring aesthetics can be challenging initially, especially when the splint is in place. Regular follow-up with radiographs is important as resorption or ankylosis is likely, especially if the ligament around the tooth has degraded prior to re-implantation.

Reviewing healing radiographically is recommended at 4 week, 3 month, 6 month, then annual intervals.

In this case, the upper right central incisor was avulsed and upper left lateral incisor luxated. The UR1 was out of the mouth around 50 minutes and not stored correctly. It was re-implanted by A&E really well with an orthodontic wire and brackets. When I saw the patient a week after the teeth had been re-implanted, I checked the pulp vitality of the central incisor teeth but also the opposing teeth and adjacent teeth. UR1 and UL1 were necrotic and disinfected and filled with calcium hydroxide and the splint removed 2 weeks after placement. When I reviewed the teeth, the UR1 (which had been avulsed) was well retained and there was physiological movement suggesting there was no ankylosis (yet!). The teeth were obturated with GP and AH+ sealer and a composite restoration placed palatally to seal the access cavity. Once the splint was removed, the fractured incisal edges were restored with composite.

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