Reimplantation of primary avulsed teeth. Why not discuss it?

Libyan International Medical University Preventive and Community D. Caroline Mohamed D. Caroline Piske de A. Mohamed

A question: Is dental trauma common in primary dentition?

D. Caroline Mohamed

Yes it is...
Indeed, it is more common than in permanent dentition because the motor coordination is still developing.

D. Caroline Mohamed

Dental Trauma prevalence in primary dentition

Author Year Sample Age/ Prevalence

Mestrinho et all.

1998

1853

1-5 years 30%

Zembruski et al.

2002

1545

0-6 years

35.5%

Zarzar et al.

2008

519

1-3 years

41.6%

D. Caroline Mohamed

Dental trauma
Risk Factors Caries lesions Overjet > 3 mm Class II Type I Inexistence of labial protection Obesity Epileptic disorders Dentinogenesis imperfecta Etiologicy Factors Falls Traffic accidents Sports accidents Violence ( Battled child)
(Kramer, Feldens, 2005, Simes et al, 2004)

D. Caroline Mohamed

Risk for Trauma

Boys > girls ( almost 2 X more) Upper central incisive (57,58%)

Commonest lesions:

subluxation lateral luxation Intrusion avulsion

( 21,45% - 50% ) ( 16,66%) ( 6% ) ( 4% to 17,18%)

Simes et al, 2004. (1310 patients with 2234 traumatized teeth) (ANDREASEN & ANDREASEN, 1994) Molina , J. Et al. Dental Trauma 24: 503-509, 2008

D. Caroline Mohamed

 Why does avulsion happen more in children than in adults?

D. Caroline Mohamed

 The chance of avulsion occurring in primary dentition is greater, a fact attributed to the greater resilience of bone at this age, whereas in permanent dentition there is a greater prevalence of fractures.

Borum MK & Andreasen JO. 1998. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol,14(1): 3144 Mohamed D. Caroline 8

 Primary teeth trauma brings great injury risk for the permanent teeth germ.

D. Caroline Mohamed

Determinants factors for the presence of lesions on pre erupted permanent teeth after deciduous trauma Age of patient at the time of trauma ( The younger the worse) The Nolla s Stage of development of the permanent tooth germ ( around stage 6) Type of trauma (degree and direction of the malposition of the primary teeth)
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Severity of injury
Energy of impact. Resilience of impacting object. Shape of impacting object. Angle of direction of impacting force.

 Link between Age of the patient /The Nolla s Stage of development of the permanent tooth germ

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Classification of teeth injury

Concussion ( no bleeding/ no displacement)

Subluxation

Lateral luxation

Extrusive luxation

Intrusion
D. Caroline Mohamed

Avulsion
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Traumatic injuries to the primary dentition affects the tooth itself:

Coronal discoloration Pulpal necrosis Pulpal canal obliteration Root resorption Abcess or cellulitis formation

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Possible alterations related to dental trauma on deciduous teeth ( trauma infection)

Root fracture

Cystic lesion

External radicular reabsortion and periapical lesion

Calcification

Internal reabsortion

D. Caroline Mohamed

Trauma-FOUSP- Brazil

a) Position of traumatic force b) Buccal intrusio of the primary tooth damages the enamel and enamel organ during formation c) Malformation of the crown and hypoplasia of the enamel are due to vertical force on C early in development d) And e) Bending and deformity of the crown tooth germ it is bent between B and E f) Bending and deformity of the root tooh germ bent on F g) Lack of root development damage to Hertwigs epithelial root sheath ( entire germ pushed apically)

Speculative effects of trauma to the primary teeth on permanent teeth buds.

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Possible effects on permanent teeth after trauma/ reimplantation of avulsed deciduous teeth

Enamel Hypoplasia Cystic lesion

Teeth discoloration Root bendingdilaceration

http://www.ortodontiaspo.com.br/SPO-V.40-n.3/V.40-n.3%20(6).pdf D. Caroline Mohamed 18

Traumatic injuries to the primary dentition effecting succedaneous permanent dentition:

White or yellow-brown discoloration of enamel White or yellow-brown discoloration of enamel with circular enamel hypoplasia Crown dilacerations Odontoma-like malformation Root duplication Vestibular root angulation Lateral root angulation or dilacerations Partial or complete arrest of root formation Sequestration of permanent tooth germs Disturbance in eruption

The Journal of Contemporary Dental Practice, November-December 2011;12(6):511-5Rakesh K Agarwal et al15 1. Carvalho JC, Vinker F, Declerck D. Malocclusion, dental injuries and dental anomalies in the primary dentition of Belgian children. Int J Paediatr Dent 1998;8:137-41. Lenzi AR, Medeiros PJ. Severe sequelae of acute dental trauma in the primary dentition--a case report. Dent Traumatol 2006;22:334-6. Jcomo D, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dent Traumatol 2009;doi: 10.1111/j.1600-9657.2009.00764.x.. von Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 1993;38:1-10.. Tzoglu S, Yolcu U, Tozoglu U. Developmental disturbance of maxillary lateral incisor after trauma. Dent Traumatol 2007;23:85-6.. Andreasen J, Andreasen, FM. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen: Munksgaard; 1991. von Gool AV. Injury to the permanent tooth germ after trauma to the deciduous predecessor. Oral Surg Oral Med Oral Pathol 1973;35:2-12. Jafarzadeh H, Abbott PV. Dilaceration: review of an endodontic challenge. J Endod 2007;33:1025-30.. Flores MT, Malmgren B, Andersson L. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent T Christophersen P, Freund M, Harild L. Avulsion of primary teeth and sequelae on the permanent successors. Dent Traumatol 2005;21:320-3. Zilberman Y, Fuks CD, Bassat YB, Brin I, Lustmann JL. Effect of trauma to primary incisors on root development of their permanent sucessors. Pediatr Dent 1986;8:289-93. Assuno L, Ferelle A, Iwakura M, Cunha R. Effects on permanent teeth after luxation injuries to the primary predecessors: a study in children assisted at an emergency service. Dent Traumatol 2009;25:165-70.. Tewari N, Pandey RK. Root hypoplasia: an unusual sequela to primary tooth trauma. Dent Traumatol 2010;26:115-7.. Sakai VT, Moretti AB, Oliveira TM. Replantation of an avulsed maxillary primary central incisor and management of df dilaceration as a sequel on the permanent successor. DentTraumatol 2008;24:569-73.

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The common treatment for lateral luxation in primary teeth is repositioning, splinting and maybe RCT

D. Caroline Mohamed

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The common treatment after deciduous intrusion is wait - follow up maybe RCT or extraction in cases of germ proximity or involvment

Fig. 2 Initial oral color photo (a) and radiograph (b) (1y2m, female) An oral color photo at 3 months after the injury (c) A radiograph at 6 months D. Caroline Mohamed after the injury (d)

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And in cases of deciduous avulsion? Most of the parents dont look for treatment... Who looks for...will have ...

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 Maybe sutures, antibiotic therapy, sometimes space mantainers...

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 Remember... Avulsion in primary dentition is more frequent than in permanent dentition.

(Andreassen, 1997, Marzola et al., 2006)

If you work with children you will have a good chance to care of child with avulsed teeth.

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 There are many articles about injuries to germs of permanent teeth after avulsion of deciduous teeth with and without treatment. These problems, may occur regardless of the treatment of the traumatized primary teeth.

Torriani, Dione Dias; Baldisseira, Elaine de Fatima Zanchin and Goettems, Marilia Leo. Managment of root dilaceration in a central incisor after avulsion of primary tooth: a case report witha 6 year follow up. Rev. Odonto cinc. (online). 2011, vol.26, n.4, pp. 355-358. D. Caroline Mohamed 25

If you don't reimplant after avulsion to avoid damage to the successor, you may not reposition any dislocated tooth, since damage can happen in any type of dislocation. (Dr. Yango Pohl)

D. Caroline Mohamed

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WHAT ?

D. Caroline Mohamed

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 I will explain.....

D. Caroline Mohamed

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Observe the proximity between the deciduous teeth and the permanent germs

D. Caroline Mohamed HTTP://WWW.ORTODONTIACONTEMPORANEA.COM/2011_09_01_ARCHIVE.HTML

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Imagem: Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. Oxford: Blackwell Munksgaard 2001p D. Caroline Mohamed 30

Trauma on deciduous

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Movement of the crown of the tooth to palatine and the tip of the root buccally

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Production of a coagulum that may stifens by the time...

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Repositioning the tooth.....may pressure the coagulum to the permanent tooth germ

D. Caroline Mohamed

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If you don't reimplant after avulsion to avoid damage from the coagulum to the successor, you may not reposition any dislocated tooth, since this would add much more damage. But we still take our chances and repositionate lateral luxations and mild dislocations

D. Caroline Mohamed

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And about the avulsed tooth?

D. Caroline Mohamed

36

What do the guides indicates about reimplantation of deciduous teeth?

The American Academy of pediatric Dentistry contra indicate the reimplant of avulsed primary teeth to prevent necrosis of the pulp, infection, inflamation and injury for the permanent germ.

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 The British Society of Pediatric Dentistry indicates that The deciduous teeth should not be reimplanted because the high possibility of danger that can happen on the time of the implantation by the pressure that the coagulum can exert on the folicullum, can lead to alterations on the development of the germ of the permanent tooth.

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But, if I.....
....... could prevent the necrose of the pulp and the possible injury to the permanent germ? ....... wash out ( irrigate) the coagulum? ...... and if I cut off the tip ( apicectomy) of the deciduous root....?

Could I be safe???
(Filippi A, Pohl Y, Kirschner H., 2007)
D. Caroline Mohamed 39

Before replantation you could (and should) remove the coagulum that has filled the alveolus, by irrigation.. and be free from the damage related to the coagulum
(Filippi A, Pohl Y, Kirschner H., 2007)

D. Caroline Mohamed

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We can reimplant deciduous - but we need special indications and a method that promises to not harm the permanent germ.

D. Caroline Mohamed

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 Key factors for the recommendation of primary avulsed traumatized tooth reimplantation. UFSC-Brazil:
(a) the strategic value of the primary tooth, that is, the time the tooth will be present in the dental arch before the natural physiologic exfoliation; (b) the period of time the tooth was kept out of the alveolus (maximum 30 min); (c) the storage means of the avulsed tooth (wet); (d) the contamination level of the location where the tooth fell; (e) the presence of contiguous teeth to splint; and (f) the presence of nutritious or nonnutritious habits in the childs routine, which may affect the stability of the reimplanted tooth.

When these factors are associated, the reimplantation is recommended. Similar to that proposed for permanent teeth, the sooner the better the outcome.
D. Caroline Mohamed 42

Prognosis
The prognosis of a reimplanted tooth depends on the indications for reimplantation :
Childs good general health condition/ dentist skills leading with child / Parents permission Childs age/ The stage of deciduous root formation ( < 4 years)/ no root surface manipulation Alveolus integrity/ management of the socket Extra oral time ( < 30 min) Extra oral environment - Hanks Balanced Salt Solution (HBSS) solution (70%
of PDL cells can remain viable for as long as 4 days - proper osmolality, ph and nutritional metabolites and glucose) / cold milk / physiologic saline

Treatment and stabilization - RCT / splint/ Consider tetanus prophylaxis and antibiotic coverage.

Fried I, Erickson P. Anterior tooth trauma in the primary dentition: incidence, classification, treatment methods, and sequelae: a review of the literature. J Dent Child 1995;62:25661. 2. Matsson L, Andreasen JO, Cvek M, et al. Ankylosis of experimentally reimplanted teeth related to extra-alveolar period and storage environment. Pediatr Dent. 1982;4:327-9. 6. Andreasen J.O, Reinholdt I, Dybdahl R, et al. Periodontal and pulpal healing of monkey incisors preserved in tissue culture before replantation. Int J Oral Surg. 1978;7:104-112. Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in ViaSpan, milk and Hanks Balanced Salt Solution. Endod Dent Traumatol. 1992;8:183-8. 4. Cvek M, Cleaton-Jones P, Austin J, et al. Effect of topical application of doxycycline on pulp revascularization and periodontal healing in reimplanted monkey incisors. Endod Dent Traumatol. 1990;6:170-6.

43

Mohamed

 1) You should avoid possible causes for damage at the successor such as: mechanical trauma during the replantation by root tip or coagulum, and infection - deriving from an infection of the necrotic pulp tissues.

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 A) Remove the root tip before replantation If the root tip is resected before replantation for about 3 mm, then there is a safe distance of at least 3mm to the permanent germ... No chance at all for damaging it.

(Filippi A, Pohl Y, Kirschner H., 2007)

D. Caroline Mohamed 45

 B) Immediate (before replantation) endodontic treatment from a retrograde direction and obturation of the canal with a resorbable sealer. ( Calcium hydroxide + zinc oxide + propylene glycol). C) Splint of the teeth

The immediate RCT prevents any microorganisms from entering the canal, thus there is minor risk of an infection coming from the root canal.
(Filippi A, Pohl Y, Kirschner H., 2007)
D. Caroline Mohamed 46

 And what about ankylosis? Deciduous teeth avulsed /kept dry for more than 30 min should not be reimplanted!
( incidence 1.3 9.9% all etiologies, Miller et al., 1983) No data about prevalence of ankylosis after reimplant of avulsed deciduous teeth few cases literature )

Trope M. Clinical maagment of the avulsed tooth: Present strategie and future directions. Dental Traumatology 2002; 18(1) : 1-11)

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Possible contraindications to replantation:

Near time for normal eruption Compliance Compromising integrity of the avulsed tooth or supporting tissues. Lack of alveolar integrity. Compromised medical condition :Immunocompromised health, severe congenital cardiac
anomalies, severe uncontrolled seizure disorder, severe mental disability, severe uncontrolled diabetes, and
D. Caroline Mohamed 48

And about the literature on deciduous reimplantation?

D. Caroline Mohamed

49

 Yes, many researchers and faculties around the world are indicating reimplantation of avulsed deciduous as part of their protocol of pedodontic trauma treatment in special cases.

(Fried I, Erickson P. Anterior tooth trauma in the primary dentition: incidence, classification, treatment methods, and sequelae: a review of the literature. J Dent Child 1995;62:25661.)

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 The literature demonstrated that an avulsed primary tooth incisor can be preserved without causing damage to the developing permanent successor.

Filippi A, Pohl Y, Kirschner H. Replantation of avulsed primary anterior teeth: treatment and limitations. J Dent Child 1997;64:272 5. Gatewood JC, Thornton JB. Successful replantation and splinting of a maxillary segment fracture in the primary dentition. Pediatr Dent 1995;17:1246. Hill CJ. Oral trauma to the pre-school child. Dent Clin North Am 1984;28:17786. Joho JO, Marechaux SC. Trauma in the primary dentition: a clinical presentation. ASDC J Dent Child 1980;47:16774..Kawashima Z, Pineda LF. Replanting avulsed primary teeth. JADA 1992;123:902. Mueller BH, Whitsett BD. Management of na avulsed deciduous incisor. Oral Med Oral Pathol 1978;46:4426. D. Caroline Mohamed 51

Case reports of replanted primary incisors

Replantation of Avulsed Primary Incisors: A RiskBenefit Assessment . Erica L. Zamon, B.Sc. David J. Kenny, B.Sc., DDS, PhD.
Author(s) Kinoshita and others4 Tooth replanted each patient 71 81 82 52 81 72 71 72 Tsukiboshi8 81 Weiger and Heuchert16 61 24 Yes Yes 30 71 46 Yes No 15 Exfoliated.Permanent incisor had enamel defect Extraction due to abscess. Permanent incisor had discolouration 36 2 42 17 Yes Yes Yes Yes Yes No No No 120 N/A 30 60 in Follow-up months 27 60 Splinted Yes Yes Root canal treatment No No Extra-alveolar (min.) 30 60 time Outcomes Primary tooth still present Exfoliated. Permanent incisor had enamel defect Exfoliated, normal Extraction due to abscess Extraction due to root resorption Extractions due to gingival abscesses

Filippi and others18 61 Zerman and others9 61 Kawashima and Pineda10 81 Pefaur17 Mueller and Whitsett11 Crabb and Crabb20 Ravn21 62 61

51

Yes

Yes

N/A

N/A N/A

51

N/A

N/A

N/A

N/A

71

N/A

No

No

60

Exfoliated

60 N/A

No Yes

Yes No

60 1

Exfoliated Exfoliated. Permanent incisor had Turners hypoplasia Exfoliated Mobility and advanced resorption Mobility and advanced resorption Premature exfoliation Extraction due to ankylosis Exfoliated Exfoliated

51 N/A N/A N/A N/A

60 8 10 12 27 36 48

No Yes Yes Yes Yes No No

No No No No No Yes No

<1 N/A N/A N/A N/A N/A <1

Eisenberg19 Sakellariou22

62 51

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 But...

Why mantain a tooth that will be any way in the future exfoliated?

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Benefits from reimplantation of avulsed deciduous teeth

Mantainence of a complete dentition Decrease the parents fear and guilt from their child tooth loss. Better social acceptance and auto estim. Prevention of functional problems in the mastication and phonetics.( in cases of multiple teeth loss) Space mantainence for child of less than 3 years that my have difficult to use removable space mantainers
Zamon EL, Kenny DJ. Replantation of avulsed primary incisors: a risk benefit assessment. J Can Dent Assoc.2001; 67(7):386.Prevention . Gable TO, Kummer AW, Lee L, Creaghead NA, Moore LJ. Premature loss of the maxillary primary incisors: effect on speech production. ASDC J Dent Child 1995; 62(3):173-9.The etiology of orthodontic problems. In: Proffit WR, Fields HR, editors. Contemporary orthodontics. 2nd ed. Toronto: Mosby-Year Book Inc; 1993. p. 128-9.

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 If the primary incisors are lost before the child has mastered speech, his speech development may be affected temporarily until the permanent incisors come in affecting their social life. Oral diseases present not only biological sequelae, but also emotional and psychosocial consequences.

Cortes MI, Marcenes W & Sheiham A. 2002. Impact of traumatic injuries to the permanent teeth on the oral health-related quality of life in 12-14-year-old children. Community Dent Oral Epidemiol, 30(3): 1938. Fakhruddin KS, Lawrence HP, Kenny DJ & Locker D. 2008. Impact of treated and untreated dental injuries on the quality of life of Ontario school children. Dent Traumatol, 24(3): 30913. Ramos-Jorge ML, Bosco VL, Peres MA & Nunes AC. 2007. The impact of treatment of dental trauma on the quality of life of adolescents a case-control study in southern Brazil. Dent Traumatol, 23(2): 1149. D. Caroline Mohamed 55

Some cases:

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D. Caroline Mohamed

57 for Mitsuhiro Tsukiboshi, Treatment Planning Traumatized Teeth, Quintessence books.

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 Case report
A patient, 2 years and 6 months of age, suffered the avulsion of tooth 61. The girl was assisted in less than 30 min and, during this time, the tooth was stored in milk.

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Fig. 8. Physiological root resorption of the right and left upper incisor.

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Fig. 9. Right and left permanent upper incisor without alteration.

Maria Jose de Carvalho Rocha, Mariane Cardoso. Dental Traumatology 2008; Reimplantation of primary tooth case report 24: e4e10; doi: 10.1111/j.1600-9657.2008.00557.x

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Prevention of trauma gives the best success rate

The prevention of dental trauma is our responsability as health professionals

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CONCLUSION
Tooth avulsion must be managed properly and the dentist must be prepared to decide the best approach to minimize the biological and psychosocial consequences in the patient. In primary dentition, clinical and radiographic control of patients with a history of avulsion should be performed until the eruption of a permanent successor.

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Thank you!!

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References:
Borum MK & Andreasen JO. 1998. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol,14(1): 3144Brazillian Congress of Dental Traumatollogy 2 nd CBTD- So Paulo, May 2009. Tsukiboshi Mitsuhiro. Treatment Planning for Traumatized Teeth. Atlases. WU 17 tBB25g 20DOa RK490. t7513 2000. Quintessence Publishing Co, Inc. Japan. SIMES, F.G.; LEONARDI, D. P.; BARATTO FILHO, F. et al. Fatores etiolgicos relacionados ao traumatismo alvolo-dentrio de pacientes atendidos no pronto socorro odontolgico do Hospital Universitrio Cajuru. Revista Sul-Brasileira de Odontologia. v. 1, n. 1, p. 50-55, 2004. ANDREASEN, J.O., ANDREASEN, F.M. Textbook and color atlas of traumatic injuries to the teeth. 3.ed. Copenhagen: Munksgaard, 1994. Cap.3: Classification, Etiology and Epidemiology, p.151-180. Nolla CM. The development of the permanent teeth. J Dent Child. 1960;27:254-66. [ Links ]

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Carlos EstrelaI; Jos Valladares NetoII; Mike Reis BuenoIII; Orlando Aguirre GuedesIV; Olavo Cesar Lyra PortoIV; Jesus Djalma PcoraV.Linear measurements of human permanent dental development stages using Cone-Beam Computed Tomography: a preliminary study. Dental Press Journal of Orthodontics Online version ISSN 2176-9451. Dental Press J. Orthod. vol.15 no.5 Maring Sept./Oct. 2010 The Journal of Contemporary Dental Practice, November-December 2011;12(6):511-5Rakesh K Agarwal et al15 1. Carvalho JC, Vinker F, Declerck D. Malocclusion, dental injuries and dental anomalies in the primary dentition of Belgian children. Int J Paediatr Dent 1998;8:137-41. Lenzi AR, Medeiros PJ. Severe sequelae of acute dental trauma in the primary dentition--a case report. Dent Traumatol 2006;22:334-6. Jcomo D, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dent Traumatol 2009;doi: 10.1111/j.1600-9657.2009.00764.x.. von Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 1993;38:1-10.. Tzoglu S, Yolcu U, Tozoglu U. Developmental disturbance of maxillary lateral incisor after trauma. Dent Traumatol 2007;23:85-6.. Andreasen J, Andreasen, FM. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen: Munksgaard; 1991. von Gool AV. Injury to the permanent tooth germ after trauma to the deciduous predecessor. Oral Surg Oral Med Oral Pathol 1973;35:2-12. Jafarzadeh H, Abbott PV. Dilaceration: review of an endodontic challenge. J Endod 2007;33:1025-30.. Flores MT, Malmgren B, Andersson L. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent T Christophersen P, Freund M, Harild L. Avulsion of primary teeth and sequelae on the permanent successors. Dent Traumatol 2005;21:320-3. Zilberman Y, Fuks CD, Bassat YB, Brin I, Lustmann JL. Effect of trauma to primary incisors on root development of their permanent sucessors. Pediatr Dent 1986;8:28993. Assuno L, Ferelle A, Iwakura M, Cunha R. Effects on permanent teeth after luxation injuries to the primary predecessors: a study in children assisted at an emergency service. Dent Traumatol 2009;25:16570.. Tewari N, Pandey RK. Root hypoplasia: an unusual sequela to primary tooth trauma. Dent Traumatol 2010;26:115-7.. Sakai VT, Moretti AB, Oliveira TM. Replantation of an avulsed maxillary primary central incisor and management of df dilaceration as a sequel on the permanent successor. DentTraumatol 2008;24:569-73. Torriani, Dione Dias; Baldisseira, Elaine de Fatima Zanchin and Goettems, Marilia Leo. Managment of root dilaceration in a central incisor after avulsion of primary tooth: a case report witha 6 year follow up. Rev. Odonto cinc. (online). 2011, vol.26, n.4, pp. 355-358.

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Filippi A, Pohl Y, Kirschner H. Replantation of avulsed primary anterior teeth: treatment and limitations. J Dent Child 1997;64:2725. Gatewood JC, Thornton JB. Successful replantation and splinting of a maxillary segment fracture in the primary dentition. Pediatr Dent 1995;17:1246. Hill CJ. Oral trauma to the pre-school child. Dent Clin North Am 1984;28:17786. Joho JO, Marechaux SC. Trauma in the primary dentition: a clinical presentation.
ASDC J Dent Child 1980;47:16774..Kawashima Z, Pineda LF. Replanting avulsed primary teeth. JADA 1992;123:902. Mueller BH, Whitsett BD. Management of na avulsed deciduous incisor. Oral Med Oral Pathol 1978;46:442 6. 2. Matsson L, Andreasen JO, Cvek M, et al. Ankylosis of experimentally reimplanted teeth related to extra-alveolar period and storage environment. Pediatr Dent. 1982;4:327-9. Andreasen J.O, Reinholdt I, Dybdahl R, et al. Periodontal and pulpal healing of monkey incisors preserved in tissue culture before replantation. Int J Oral Surg. 1978;7:104-112.. Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in ViaSpan, milk and Hanks Balanced Salt Solution. Endod Dent Traumatol. 1992;8:183-8.

D. Caroline Mohamed

67