Dentoalveolar trauma are injuries caused by an external impact on the dentition and its surrounding apparatus; they can have multiple outcomes ranging from contusion of the tooth to total dislocation of the tooth from the alveolar bone, termed tooth avulsion. A significant amount of force is usually necessary for avulsion of teeth, and other injuries to the surrounding structures should be suspected.
Traffic accidents, violence, full contact sports, and falls, especially in younger patients with poor balance are the most common causes of an avulsed tooth. The maxillary central incisors are the most commonly affected teeth, and often more than one tooth is avulsed. In a systematic review published in 2015, the most common places for dental trauma to occur was found to be in a home setting, followed by school and street settings.
In a study conducted on 1298 trauma patients that received treatment in the emergency room, 24% included dental injuries. Of which, 16% avulsed teeth most commonly in school-aged patients.  Bemelmans reported that at least 32% of athletes involved in full contact sports had experienced some form of injury to their dentition. The highest prevalence of dental trauma was reported in children, mainly due to their weak balance and poor coordination when they start walking. In general, dental trauma showed more gender predilection with male patients having a higher prevalence than females.
The periodontal ligament (PDL) is the soft tissue connecting the cementum that covers the roots of the teeth to the surrounding alveolar bone. When an external impact occurs on a tooth, the fibers of the periodontal ligament can tear causing total displacement of the tooth from the socket.
Maintaining the viability of the periodontal fibers remaining the root of the tooth after avulsion is integral for the long-term prognosis. Immediate replantation will allow the PDL to reform the connections within the socket. The current general consensus is that time lapsed since the avulsion is the most critical factor for the prognosis and immediate replantation and of the avulsed tooth yields the best results, with the prognosis worsening as time increases.
A history of trauma to the tooth will reveal tooth avulsion, and the mechanism of injury can point to other injuries. History should include the length of time since tooth avulsion, the storage medium in which the tooth has been placed, and if the tooth is a primary or permanent tooth. By 14 years of age, a patient's primary teeth should be replaced by permanent teeth. Physical examination involves the assessment of the tooth socket for foreign material, tooth fragments, and lacerations as these can prevent tooth replantation. Evaluation of the surrounding structures for other injuries such as lacerations, fractures, and ecchymoses is also necessary. If a tooth is avulsed and not found, aspiration of the tooth or an intruded tooth should be a consideration.
Imaging modalities including extra and intraoral radiographs and CT scans can aid in evaluation for alveolar and surrounding fractures, assessment to verify that the tooth is not intruded when not found intraorally, but it can delay tooth replantation.
Most often tooth avulsions occur outside of treatment facilities. Avulsed teeth should be handled by the crown to prevent damage to the root surface and PDL fibers. Studies have shown that if the tooth is not going replanted within in five minutes, it should be placed in a storage media such as a balanced salt solution and milk. These can increase the time of viability of avulsed teeth, while media such as water can damage the PDL due to its low osmolality. If no storage media is available, a tooth may be placed back in the mouth for saliva to act as the storage media. Before replantation, the socket and tooth may be lightly irrigated with normal saline to clean the structures, and the socket may be aspirated gently if a blood clot is obstructing it. The tooth should be aligned anatomically, and firm pressure applied into the socket to replant the tooth. Most teeth can be successfully replanted if the extraoral dry time is less than 60 minutes; after this period the survival of the tooth is unlikely. Storage media can increase the viability time of the PDL allowing for more than 60 minutes. If extraoral dry time is more than 60 minutes, soaking the tooth in agents such as fluoride may decrease resorption rates. Immature teeth where the root has not yet wholly formed have a greater chance of revascularization with soaking in doxycycline, increasing the success rate in these teeth. Dental consultation is recommended in these cases.
Bonding resins and sutures may be needed and a fixable splint two weeks is indicated for securing the tooth in place once replanted. Primary teeth should not undergo replantation as this can damage the underlying permanent tooth germ.
In cases where the dry time was more than 60 minutes, and there was no use of any storage media, removal of the remaining PDL should undertaken as it will become a stimulus for continued inflammation that accelerates infection-related resorption and ankylosis. The remaining PDL can be removed by multiple methods that include; gentle scaling and root planning, soft pumice prophylaxis, gauze, or soaking the tooth in 3% citric acid for 3 minutes. The fluoride treatment must follow this process as it slows down the process of ankylosis and reduces the risk of resorption.
Differential diagnosis of tooth avulsion includes complete intrusion of the tooth into the alveolar bone. These two conditions can be easily distinguished by the history obtained from the patient/parent and by imaging modalities.
In a study published by Karayilmaz et al., they examined the long-term prognosis of avulsed teeth and concluded that the reimplantation of avulsed teeth is a highly successful procedure. The long and short term prognosis is strongly affected by the dry time.
The major complications faced with reimplantation of avulsed teeth include; first, ankylosis in which there is PDL loss, and the tooth fuses to the alveolar bone. This condition can be problematic if the patient is growing as the surrounding structures will continue to develop, and the tooth will look submerged. Second, loss of vitality, as the severing of blood vessels occurs when the tooth is avulsed, so there is a high risk of loss of vitality especially if the apex has completely developed. If this goes unrecognized, a periapical abscess may develop and can complicate the healing process and prognoses.
Patient and parental education and the early seeking of medical care can improve the prognosis and success of treatment, as this can reduce the dry time. Using the appropriate protective mouthguards can reduce the incidence of potential injury in high-risk practices such as contact sports.
Tetanus immunization should be updated if necessary after tooth avulsion. Dental follow-up is recommended for further treatment after replantation. Brushing teeth after every meal and using chlorhexidine 0.12% rinse twice daily can decrease infection rates. Often antibiotics are prescribed to prevent infection. Patients should be placed on a soft to chew diet for at least two weeks following tooth avulsion. The success of replantation of the tooth is difficult to predict, and the patient\family should be warned that dental root resorption and tooth loss is possible.
The need for early reimplantation and the appropriate storage medium is an important factor that is less recognized by the patients, parents and medical professionals. It is necessary for primary care providers, nurse practitioners, and the general dentist to educate the public regarding the prognosis and success of reimplantation, how early treatment is important and the preferred storage medium is a balanced salt solution or milk.
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