Trauma to the oral cavity is a common dental problem, where Early diagnosis. Appropriate initial treatment.

Optimal definite treatment.

Should be a goal in the management of traumatic injuries.

Sudden impact involving the face or head may result in trauma to the teeth and supporting structures.

I- frequent causes :
a-falling while running, traffic accidents, c-acts of violence, and sports.
Automobile accidents are often very destructive. One estimate suggests that 20 to 60% of all traffic accidents

bd-

II- Incidence of traumatic injury:

1) Age:

Deciduous most common (2-5 years). Permanent (8-12 years).

2) Sex:

Boys > girls 2:1.

3) Site:

80% upper central. Maxillary lateral incisors.

Numerous studies indicate that malocclusion predisposes to dental injuries.

Class I Traumatized -crown and Root are intact . a- Devitalized pulp . b- Devitalized pulp with incomplete root formation. c- Internal and External resorption. d- Calcification- Concussion. ClassII Coronal fracture - Pulp not exposed (Enamel fracture) ClassIII Coronal fracture pulp exposed (Dentin fracture) ClassIV Coronal fracture extending subgingivally . ClassV Root fracture with or without loss of crown structure. Division I : Horizontal fracture Division 2: Vertical and chisel fracture. Class VI Displacement of tooth with or without fracture Division I: Partial displacement

* Old Classification: Ellis Classification

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

WHO classification:
1) Enamel fracture: (A) Enamel infraction (cracks). (B) Complete
pulpal involvement (uncomplicated).

(chipping). 2) Crown fracture without

3) Crown fracture with pulpal involvement (complicated). 4) Root fracture. 5) Crown root fracture.

6) Tooth luxation: (A) Concussion (B) Subluxation. (C) Luxation.

7) Extrusion. 8) Intrusion. 9) Avulsion.

10) Alveolar bone injury.

Examination & Diagnosis

I. Case history. II. Clinical examination. III. Vitality test. IV.Radiograph.

1) Case history: 1) Case history:

(A) Chief complaint: in patients own words. (B) History of the injury:
The prognosis of injured teeth is logically often dependent, to a great extent on the time that has elapsed between the accident & when the emergency treatment is provided. Necessity of tetanus vaccination is influenced by the location of the accident.

1. When? did

the injury occur

2. Where? did

the injury occur

3. How

did the injury occur?

Hard blow coronal fracture. Padded blow root fracture. 4.Have you had similar injuries before?
Repeated injuries to teeth affect the pulp & their ability to recover from the trauma.

5. Have you noticed any other symptoms since the injury?

Signs & symptoms to be

watched: dizziness, vomiting & blurred vision. Affirmative response to any of the above indications needs

(C) Medical history:: Allergic reaction. Current medication. Tetanus immunization status.

2) Clinical examination: 2) Clinical examination: (A) Extra-oral examination:

Laceration of head & neck. Deviation contour. TMJ. from normal bony

(B) Intra-oral examination:

Soft tissue examination. Hard tissue examination.

Soft tissue examination

Laceration of lips & tongue must be radiographically examined for embedded foreign bodies.

Hard tissue examination

Check occlusion. Several alignement fracture of mandible or maxilla. Tooth discolouration. Crown fracture. Tooth displacement. teeth are out of

Palpation

PERCUSION.

 PROBING. MOBILITY.

3) Vitality test:
Thermal. Electrical. Cavity test.
They are in reality sensitivity tests for nerve functions & do not indicate the presence or absence of blood circulation within

A THERMAL TEST HEAT TEST 1 Warm gutta percha. 2 Warm Instrument. 3 Heated ball burnishes. 4 Frictional heat from rubber polishing disk.

 COLD

TEST

1 Co2 Snow. 2 Ethyl chloride. 3Ice in dental carpule. 4Endo Ice.

B Vitality Tests: ELECTRIC PULP TESTER (E.P.T):

A variety of devices are available for testing pulp vitality: 1 Battery operated device. 2Constricted in the dental unit.

Response to vitality tests:

1. Mild to moderate degree of
awareness of slight pain that subsides within 1-2 seconds after the stimulus has been removed (normal limits).

2. Strong momentary painful response

that subsides within 1-2 seconds after the stimulus has been removed (reversible pulpitis).

3. Moderate
response

to that

Necrotic painful strong pulp. Recent trauma. lingers for Excessive some

Controversy has for decades surrounded the validity of thermal & electrical tests on traumatized teeth. A negative response is not a reliable evidence of pulp death, because the teeth may be in a state of shock & may

1) Radiographic examination:
The cannot complete tooth teeth. Multiple radiographs at different angulations are & examination be of teeth considered without the a

traumatized

radiograph of the injured adjacent

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

1) Enamel fracture

Diagnosis:

Transillumination Chief complaint:

sharp

or

Scheduled follow up is needed. Very good prognosis.

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. . 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

2)Crown fracture without pulpal involvement (Uncomplicated fracture)

Diagnosis:
Determine the state of the pulp & periradicular tissue by usual examination procedure.

Treatment:
A) Primary goal of treatment is to protect the pulp by sealing dentinal tubules with Ca(OH)2.

B) Restoration with composite resin.

C) If the tooth fragment is available, attempt to reattach it.

Follow up is done periodically to determine the state of the pulp.

The prognosis & reaction of the pulp depends on: A) Proximity of the fracture to

the pulp. B) Surface of dentin exposed. C) Length of time between trauma & treatment.

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

3) Crown fracture with pulp involvement (Complicated fracture)

Choice of treatment & prognosis depends on:

A.Degree of root maturity. B.Size of the exposure.

C.Time elapsed between trauma & treatment.

mature apex (1) EXPOSURE WITHIN 24 HOURS: - Pulp still vital means:
1-The exposed pulp red in colour. 2-Bleed freely when picked with explorer.

TREATMENT:
1-Should involve pulpotomy or pulp capping. 2-Pulpotomy is best then pulp capping because: a-bacterial contamination occurred in traumatic exposure, it is likely removed in pulpotomy but it remain in pulp capping. b-It is difficult to restore a pulp capped tooth without distributing the capping, that is not true in pulpotomy. c-It is difficult to obtain retention in pulp capping, while easy in pulpotomy. d-The success of pulpotomy procedures compared favorably with the success of

A) Vital pulp therapy (apexogenesis):

a-Pulp capping: Involves application of dressing Ca(OH)2 to exposed pulp in attempt to preserve its vitality.

b-Cervical pulpotomy:
Removal of pulp tissue till cervical level & application of capping agent to promote healing.

c-Shallow pulpotomy
(Cvek pulpotomy)

Removal of pulp tissue to depth of about 2 mm & application of capping agent.

Follow up is needed. The feature for successful vital pulp therapy: 1. Pulp vitality is preserved. 1. No clinical signs or symptoms. 2. No radiographic evidence of peri-radicular pathologic changes. 4. Immature root continues its formation.

N.B.:

Apexogenesis treatment

is until

a the

temporary

root is completely formed, then conservative root canal treatment is done.

(2) EXPOSURE AFTER LONG PEROID: In this case the pulp should be devitalized in this the pulp should be completely removed pulpectomy

Immature apex
(Necrotic pulp) The conventional treatment of pulpless teeth was apical surgery.

Disadvantages of surgery:
Condensing pressure of amalgam may lead to root fracture. Retro-filling of apices of immature teeth, often means packing of amalgam into the preparation with paper-thin walls. (Frank 1966). Procedure involves young children and can

APEXIFICATION:
It is biologic phenomena of cementification which lead to apical closure. Believes that this process is natural but it must stimulatedly biologic activator (Calcium Hydroxide) + intracanal medicament

a- initial appointment 1-Rubber dam and access cavity opened . 2-Large blunted file (H-Type) remove necrotic canal content then irrigation. 3-Enlargement the canal until clear dentin. b-Material: 1-Calcium Hydroxide with Compherated Para Chloro Phenol mixed to a thick, dry putty-like consistency. 2-With long plugger insert the mixture gently to the space to apex and fill the canal completely. 3-Place a dry cotton pellet over the mixture, and then cover with ZOE

c- Subsequent appointment: Four to six months after first appointment and by radiographic examination . a-If there is no response (apex appear to be opened), the initial appointment repeated. These may be done from 6 months to 2 years.

b-If there is a response. There are four appearance that may be seen in the radiograph:

1-The root end formed and sealed, the canal shape not changed. 2-The root end formed and sealed but the canal fill in with blunderbuss apex. 3-The root end blunderbuss in shape and closed with thin calcified

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. . 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

4) Root fracture

Root fracture constitutes 3% or less of all traumatic dental injuries.

Root fracture could be:

1-

A)

Complete

(2

separate parts) B) Incomplete (crack in root without of the 2

separation parts). 2A) Single

line

of

Horizontal.
A- Cervical third B- Middle third C- Apical third

Vertical. Chisel (diagonal) fracture.

Diagnosis of root fracture

1.Mobility of the tooth. 2.Displacement
segment. of coronal

3.Pain on biting. 4.Radiograph:

Root fractures are not always horizontal, so root fracture is often missed by radiograph unless x-ray beam passes directly through the fracture line.

Root fractures are not always horizontal, so root fracture is often missed by radiograph Additional unless x-ray beam films must passes directly be takenthe through fracture line. (45, 90, 110) degree.

Emergency (initial) treatment for root fracture

1) Apical 1/3 with no mobility or displacement no treatment & healing will occur follow-up.

2) Mobility of the coronal segment.

Prognosis depends on: A.Amount of dislocation. B.Comunication between fracture site & gingival sulcus. C.Location & direction of fracture. D.The quality of the treatment.

* The healing of the fractured segments may take one of this form: 1- CALCIFIED HEALING : (CALLUS FORMATION):

If the fragments are in close position with little mobility of the part and tooth with root. It is possible to get a calcified callus formation at fracture site, both externally or the root surface and internally on the root canal. Mobility : within limits.

2- CONNECTIVE TISSUE HEALING: -If the fragments are separated or some mobility of the tooth, formation of fibrosis attachment similar to periodontal ligament , the fracture dentin surface may be lined by cementum. -The sharp edges of fractured was rounded by surface resorption. Mobility : little mobility. Vitality : reduce level of response

3- COMBINATION BONE AND CONNECTIVE TISSUE HEALING: -If the fragments are with further separation and possible mobility of broken part growth of new bone between fracture segments, the fracture surface will be lined by cementum with periodontal ligaments between tooth and new bone. Mobility : quite firm.

4-HEALING WITH NON UNION AND GRANULATION TISSUE FORMATION: 1-When there is severe dislocation of fractured fragment and possible contamination of the pulp with oral fluids. 2-The incisal portion of the pulp undergo necrosis and apical portion still vital. 3- The necrotic pulp stimulate inflammation and granulation tissue in the fracture line causing resorption of bone which may be extend to adjacent

Horizontal Fracture

TREATMENT PHILOSOPHY OF TEETH WITH FRACTURED ROOT.

1-CERVICAL THIRD FRACTURE:

B, below B, Root canal A, Root fracture at or Root canal therapy completed. therapy completed crestal bone.

C,Cementation of a

D, Occlusal view; horizontal wire is bent to cross midline of the tooth to be extruded.Wire

F,When satisfactory extrusion h been completed, the tooth is , Elastic is attached to activate extrusion. stabilized until periodontal and bony repair are complete

Periodontal and bony repair completed.

H, Permanent restoration.

A- Crown-root fracture of a right central incisor necessitating orthodontic extrusion owing to palatal extension of fracture. Note that the loose palatal segment (arrow)

B- Adequate remaining tooth length allows use of the technique.

C- One-visit root canal therapy performed after removal of loose palatal fragement.

D -Extrusion hook cemented in prepared post space.

E -Extrusion hook cemented in prepared

F- Horizontal wire attached to adjacent teeth at desired position by acid-etched composite.

G-Activation elastic placed over hook and wire

H- Two weeks later, the tooth has extruded the desired distance.

I- It is now stabilized for 8 weeks by use of ligature wire.

2- MIDDLE THIRD FRACTURE

I-in case of treated apical half.
first appointment: 1- Rubber dam + intracoronal cavity preparation + Pulpectomy. 2- Enlargement the canal till size 70 100 3- Close with cotton + Zinc Oxide and Eugenol. Second appointment: 1-Removal of Zinc Oxide and Eugenol. 2- Obturate the canal .

II-in case of Non-treated apical half.

1- Rubber dam + intra coronal cavity preparation + pulpectomy 2- Root canal enlargement till 70- 100 of cervical portion. 3- Apicectomy and remove apical half. 4- Select the chrome- cobalt pin (Endossias pin) smaller than last file.

3- APICAL THIRD FRACTURE:

1234Root canal treatment . Apicectomy. Retrograde amalgam. Closed the cavity.

**Vertical root fracture.

Extraction.

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

5) Crown - root fracture:

C/R fracture may be:
A- Complicated

(pulp involvement).
B- Uncomplicated

(without involvement).

pulp

Causes of C/R fracture A. Trauma. B. During obturation, due to

excessive force. C. During post placement. D.Large sized restoration.

Diagnosis of C/R fracture

1. Fragments may be loose & attached only to the periodontal ligament. 2. Pain when loose fragments are

manipulated. 3. The fragments are easy to remove & bleeding ligament from the periodontal fills the fracture

often

Treatment:
1) All loose fragments must be removed before the definite ttt can be started.

2)

If the fracture is incomplete & involves the crown the crown is made to prevent the fracture from proceeding to involve the root.

The

treatment

is

the

same

as

complicated or uncomplicated crown fracture. The seriousness of the complications depends on the apical extent of the attachment injury.

If the apical extent of the fracture is within 4 mm of the gingival crevice crown lengthening (gingivectomy & alveoplasty). If more than that & root is not too short extrusion.

New Classification W H O

No-873 World Health Organization of Oral Injurie 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involvement 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussio sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavit 802.20 Fracture or communication of alveolar process of mandible and Maxilla.

6- Tooth luxation The goal in treatment of luxation injuries is to promote the recovery of both the pulp & periodontal health, but realistically except in young, immature teeth, pulp recovery

is not likely to occur as

(a) Concussion:
-The blow

(Trauma) to the tooth may be sufficient to cause bleeding in periodontal ligament and pulpal edema. -The increased fluid in periodontal ligament pressure of mastication

DIAGNOSIS: E.P.T: Mobility: Percussion:

positive response Normal mobility. Tooth tender to percussion

TREATMENT : - adjusting the tooth slightly out of occlusion. FOLLOW UP : - E.P.T for vitality should be repeated at 1,3,6,12 month intervals. -If tooth initially respond positive

(B) Subluxation:
When a tooth, as a result of trauma, is sensitive to percussion and has increased mobility, it is classified as subluxated. Electric pulp test results may be either no response or positive; if they are the former, damage to the

DIAGNOSIS:
E.P.T: Negative or positive response Mobility: Increase mobility. Percussion: Tooth tender to percussion

TREATMENT :
1. Treatment initially may be none, except to allow tooth to rest. 2. Sometimes it is necessary to stabilize tooth for a short period of time (2-3 weeks) to promote periodontal ligament recovery. 3. Needs long term follow up.

FOLLOW UP :
- E.P.T for vitality should be repeated at 1,3,6,12 month intervals.

(C) Lateral luxation.

Traumatic injuries may result in displacement of a tooth labially, lingually, distally, or mesially Such displacement is called lateral luxation, and it is often very painful, particularly when the displacement results in the tooth being moved into a position of premature occlusion. An example of such lateral luxation is when a maxillary incisor is pushed palatally. The crown makes occlusal contact long before

DIAGNOSIS:
E.P.T: Negative or positive response Mobility: Increase mobility. Percussion: Tender to percussion Displacement: Horizontal displacement

Treatment:
A) Immediate repositioning of the teeth, then splinting for 2-6 weeks.

B) Definite treatment is root canal treatment & Ca(OH)2 is put in 1-2 weeks after the injury for a period of 6-12 months

New Classification W H O

No-873 World Health Organization of Oral Injuries. 873.60 Enamel fracture. 873.61 Crown fracture without pulp involvement. 873.62 Crown fracture with pulp involveme 873.63 Root Fracture. 873.64 Crown - Root fracture. 873.66 Tooth Luxation (dislocation, concussion, sublaxation). 873.67 Intrusion and Extrusion. 873.68 Complete Avulsion. 873.69 Other injuries (Soft tissue or oral cavity). 802.20 Fracture or communication of alveo

1-Extrusion

DIAGNOSIS: E.P.T.: response. Radiography: Exhibit marked increase periodontal ligaments apically. Clinical Examination : 1- There is difference in the incisal level with adjacent . 2- Mobility : It is slightly mobile. 3- Percussion : Sensitive to percussion. 4- There is some bleeding from socket (due to injury of periodontal ligaments).

I- Minor (Slight) Extrusion: (less than 5mm).

TREATMENT :

-slight grinding of insical edge to restore the incisal level

II- Major (Great) Extrusion : (more than 5mm).

1-Small semilunar incision is made an opening through alveolar cortical plate of the bone at level of root apex with No 6 round bur. 2- The blood is related and Tooth is pushed into normal position N.B. Sometimes when pushing the tooth it resist the push due to formation of blood clot in the socket. 3-Splinting the offending tooth for six

2) Intrusion.

Intrusion of teeth ranges from slight infrocclusion to total disappearance.

DIAGNOSIS:
1-Visual examination :There is
difference in incisal level with adjacent. that is not mobile

2-Mobility : It is firmly wedged in bone, 3-Percussion: give hard and harsh 4-Radiograph : May show loss of
periodontal space. sound in compared to normal tooth.

N.B. Sometimes central incisor is completely intruded and it may

TREATMENT:
A-Minor (Slight) Intrusion:
1- After period of time it may erupted to its normal position. 2- If not, by applying finger spring cemented to labial surfaces.

B- Major (Great) Intrusion:

-By retract the tooth by forceps.

ENDODONTIC TREATMENT: I-TOOTH WITH COMPLETE ROOT FORMATION: There are several factor may be helpful in deciding whether or not to enter the canal, the primary factor is to determine pulpal necrosis.
1-In Major displacement (over 5mm) or intrusive injuries , pulpal necrosis therefore root canal treatment is indicated, and applying Coat as temporary filling to prevent root rosorption. 2-While in Minor displacement (under 5mm),need no emergency root canal

II- TOOTH WITH INCOMPLETE ROOT FORMATION:

1-A displaced tooth with incomplete developed root has better prognosis for pulpal survival, Retention of vital pulp enhance normal development of root. 2-On the other hand, inflammation root resorption in immature tooth progress more rapidly. 3-When decision is made that pulp

3) Avulsion.

1-It is occurs when traumatic injury totally displace tooth from socket. 2-Permanent dentition 1-16% , Deciduous 7 - 13%. 3-Age: 7 - 11 years. 4-Sex: Male >3 females. 5-Tooth : central incisors. 6-Jaws : Maxilla > mandible. 7-The prognosis of replanted tooth still very poor. 8-The sooner the implantation is carried out after accident the more favorable

FACTORS AFFECTING THE SUCCESS OF REPLANTATION : 1- EXTRA - ORAL TIME. 1-The shorter the extra-oral time the better the prognosis. 2-90% of teeth replanted before 30 minutes give no root resorption. 3- While 95% of teeth replanted after 2 hours ,lead to root resorption. 4-The critical time for dry storage 30 minutes. 5-Replantation after 60 minute in dry

2-STORAGE MEDIA:
1-The storage media is critical if immediate replanation is impossible 2-The tooth should be stored in physiologic medium ,to prevent further injury to periodontal ligaments cells. 3-Under no circumstance the tooth allowed to dry because, dryness accelerate cellular necrosis. 4-The importance of storage media,to

5- The storage media include: a-Milk:is the best storage media superior than saliva because Physiologic osmolality, Composition, and availability. mitotic activity of periodontal cell maintained for 6 hours in Milk. b-Normal saline: is best storage media than saliva - but it is less available than milk. some investigators, storage of tooth in saline give much more resorption than milk. c-Saliva: is the last choice when other are not available. some investigators: storage of tooth in saliva for 2 - 3 hour cases swelling and

Storage media in ascending order of desirability A. Water. B. Saliva. C. Saline. D. Milk.

E. Hanks balanced salt solution (HBSS) (cell culture media) F. Via-span: Media used for

transplantation operation.

3-PRESERVATION OF THE PERIODONTAL LIGAMENTS AND RESORPTION : 1- Healing with normal periodontal ligaments is not achieved when it replanted with necrotic periodontal membrane , ankylosis develop as the necrotic tissue are replaced by bone formation. 2-If the periodontal ligaments replaced before replantation, extensive replacement resorption. 3- Following replantation a clot formed in periodontal ligaments healing begins

TREATMENT:
A- Tooth with Incomplete root formation 1-Revascularization may occur following replantation, pulp removal should be delayed until pulpal necrosis are evident. 2-If signs of pulpal necrosis occur immediate root canal treatment following replantation and splinting. 3- It is possible that root formed following revascularization. 4- In some cases, root formation ceases and obliteration of the canal by dentin or bone.

The immature tooth might necessary.

revascularize, so

replantation, splinting & long term follow up is

B- Tooth with Complete Root Formation:

-There are 2 theories about root canal treatment before or after replantation: First Theory : R C T before replantation. 1-The tooth should be endodontically treated (pulpectomy) before replantation because,if the tooth not treated the usual sequel are pulp necrosis of inflammation resorption.

N.B. :some investigators believed that its wrong because: a- Further damage to periodontal ligament from handling the tooth. b- Exposure to chemical during the procedures. c- Bacterial contamination. d- Prolonged extra- oral time.

Second Theory : R C T after replantation.

1-The tooth should be endodontically treated (pulpectomy) after replantation to prevent inflammation root resorption within 1-2 week following resorption. 2-This achieved through the splint placed during emergency treatment appointment, thus the tooth will not be firmly attached, extirpation due

Under favorable conditions, many replanted teeth are retained for 5-10 years & few for a lifetime, others however fail soon after replantation.

*REPLANTATION TECHNIQUE
1-Clean the socket to remove the clotted blood and any foreign materials by gentile curettage: A- within 30 minutes-2h irrigation with normal saline. B- More than 2h the tooth immersed for 20 minute at 2.4% phosphate solution fluoride (P.H.5.5) for prevent root resorption or ankylosis. 2-Make a small surgical vent (opening) to

Handling of tooth during extra-oral time: Avoid scrubbing the tooth & handle the tooth by holding the crown.

Examination of the socket.

4-The alveolar plate should be squeezed firmly against the tooth with digital pressure. 5-A radiograph should be exposed to verify the adequacy of resorption. 6-Any soft tissue lacerations are sutured to arrest seepage of hemorrhage prior to splinting. 7-The affecting tooth should be out of occlusion by grinding the opposite tooth.

Replantation of the tooth & splinting for 1-2 weeks.

8-ANTIBIOTICS : The systemic administration of antibiotic at the time of and during the first week following replantation has been shown to prevent invasion of the necrotic pulp. 9-TETANUS PROPHYLAXASIS: if the wound or avulsed teeth has been contaminated with soil, the patient must receive tetanus injection. 10-The Patient asked to avoid using the offending tooth for 2-3 weeks

FOLLOW UP: 1-Radiograph : Carefully for any pathosis. 2-Discoloration: Checked by oral examination for colour change. 3-E.P.T: Unreliable in teeth with incompletely formed root. 4-Mobility: Negative response. 5-Percussion :Negative response. 6-Repair: Functional repair of pulp nerve fiber are re-established within 35 days.

HEALING OF THE AVULSED TOOTH :

1-HEALING WITH A NORMAL PERIODONTAL LIGAMENT :

1-Complete repair of periodontal ligament occur with this type of healing, without significant inflammation change. 2-Small area of resorption representing localized areas of damage to periodontal ligament termed surface resorption, these usually involve cementum but

Healing with normal periodontal ligament.

2-HEALING WITH ANKYLOSIS OR REPLACEMENT RESORPTION: 1-Ankylosis occurs when areas of root resorption are repaired by deposition of bone, resulting in fusion of root surface and alveolar bone. 2-Etiology : related to observe of vital periodontal ligament or root surface, Progenitor cells (Undifferentiated Mesencymle Cell) with osteogenic potential from adjacent bone marrow migrate into damaged area and formed ankylosis. 3-In minor injuries to periodontal ligament

4-Observed histologically after 2 weeks and radiographically after 2 months. Absence of normal R.L of periapical space. 5-Radiographically show:

Surface resorption:
Small superficial cavities in cementum and outermost dentin.

(B) Resorption of cementum & dentin, until loss of the tooth.

3- INFLAMMATORY RESORPTION: 1-Granulation tissue in the periodontal ligament adjacent to large areas of root resorption. 2-Occur on root surface adjacent to areas of damage to periodontal ligaments or drying of periodontal ligament before replantation. 3-Etiology: A toxic products and bacteria penetrating from root canal through dentinal tubule into

4-If these teeth is not endodontically treatment immediately, it will be apically resorped resulting in loss of tooth. 5-They can be demonstrated 1 week after replantation and it will be progressive if it not endodontically treatment. 6-The inflammation resorption dependent in four condition :

a-Injury of periodontal ligaments. b- Exposure of dentinal tubule. c-Communication of exposed tubules with necrotic pulp or with leakage

7-The inflammation resorption a the mechanism of elimination infected calcified tissue from the body by action of osteoclasts, which is specialized macrophage activity participate in the healing process to repair traumatized tooth and bone. 8-These inflammation resorption is difficult to eliminate once it begins, if endodontically treatment delayed more than 3 weeks following replantation.

Inflammatory resorption:

Root canal therapy can be expected to arrest inflammatory resorption that involves replanted teeth.