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Avulsion of permanent teeth is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsion. Replantation is the treatment of choice, but cannot always be carried out immediately. An appropriate emergency management and treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner.
Treatment guidelines for avulsed permanent teeth with closed apex | Clinical situation | Treatment |
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| (1a) The tooth has been replanted prior to the patient arriving at the dental office or clinic | Clean the area with water spray, saline, or chlorhexidine. Do not extract the tooth. Suture gingival lacerations if present. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. | | Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V), in an appropriate dose for age and weight, can be given as alternative to tetracycline. | | If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer to physician for evaluation and need for a tetanus booster. | | Initiate root canal treatment 7–10 days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. | | (1b) The tooth has been kept in special storage media (Hank's Balanced Salt Solution), milk, saline, or saliva. The extra- oral dry time is less than 60 min | If contaminated, clean the root surface and apical foramen with a stream of saline and place the tooth in saline. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. | | Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V), at appropriate dose for age and weight, can be given as alternative to tetracycline. | | If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer the patient to a physician for evaluation and need for a tetanus booster. | | Initiate root canal treatment 7–10 days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. | | (1c) Extra-oral dry time longer than 60 min | Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation is to promote alveolar bone growth to encapsulate the replanted tooth. The expected eventual outcome is ankylosis and resorption of the root. In children below the age of 15, if ankylosis occurs, and when the infraposition of the tooth crown is more than 1 mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge. | | The technique for delayed replantation is: | | Remove attached necrotic soft tissue with gauze. | | Root canal treatment can be done on the tooth prior to replantation, or it can be done 7–10 days later as for other replantations. | | Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. | | Immerse the tooth in a 2% sodium fluoride solution for 20 min | | Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. | | Stabilize the tooth for 4 weeks using a flexible splint. | | Administration of systemic antibiotics, see (1a). | | Refer to physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus coverage is uncertain. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. |
Treatment guidelines for avulsed permanent teeth with open apex | (2a) The tooth has already been replanted prior to the patient arriving in the dental office or clinic. | Clean the area with water spray, saline or chlorhexidine. Do not extract the tooth. Suture gingival lacerations if present. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. | | Administer systemic antibiotics. For children 12 years and younger: Penicillin V at an appropriate dose for patient age and weight. | | Refer the patient to a physician for evaluation of need for a tetanus booster if avulsed tooth has contacted soil or tetanus coverage is uncertain. | | The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment may be recommended – see Follow-up procedures for avulsed permanent teeth. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. | | (2b) The tooth has been kept in special storage media (Hank's Balanced Salt Solution), milk, saline, or saliva. The extra- oral dry time is less than 60 min | If contaminated, clean the root surface and apical foramen with a stream of saline. Remove the coagulum from the socket with a stream of saline and then replant the tooth. If available, cover the root surface with minocycline hydrochloride microspheres (ArestinTM, OraPharma Inc, Warminster, PA, USA) before replanting the tooth. | | Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations, especially in the cervical area. Verify normal position of the replanted tooth clinically and radiographically. Apply a flexible splint for up to 2 weeks. | | Administer systemic antibiotics. For children 12 years and younger: Penicillin V at appropriate dose for patient age and weight. | | Refer to physician for evaluation of need for a tetanus booster if avulsed tooth has contacted soil or tetanus coverage is uncertain. | | The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment may be recommended – see Follow-up procedures for avulsed permanent teeth. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. | | (2c) Extra-oral dry time longer than 60 min | Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation of immature teeth in children is to maintain alveolar ridge contour. The eventual outcome is expected to be ankylosis and resorption of the root. It is important to recognize that if delayed replantation is done in a child, future treatment planning must be done to take into account the occurrence of tooth ankylosis and the effect of ankylosis on the alveolar ridge development. If ankylosis occurs, and when the infraposition of the tooth crown is more than 1 mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge. | | The technique for delayed replantation is: | | Remove attached necrotic soft tissue with gauze. | | Root canal treatment can be done on the tooth prior to replantation through the open apex. | | Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. | | Immerse the tooth in a 2% sodium fluoride solution for 20 min | | Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. | | Stabilize the tooth for 4 weeks using a flexible splint. | | Administration of systemic antibiotics, see (2a). | | Refer the patient to a physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus coverage is uncertain. | | Patient instructions | | Soft diet for up to 2 weeks. | | Brush teeth with a soft toothbrush after each meal. | | Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. | | Follow-up | | See Follow-up procedures for avulsed permanent teeth. |
Follow-up procedures for avulsed permanent teethRoot canal treatmentIf root canal treatment is indicated (teeth with closed apex), the ideal time to begin treatment is 7–10 days postreplantation. Calcium hydroxide is recommended for intra-canal medication for up to 1 month followed by root canal filling with an acceptable material. An exception is a tooth that has been dry for more than 60 min before replantation – in such cases the root canal treatment may be done prior to replantation. In teeth with open apexes, that have been replanted immediately or kept in appropriate storage media, pulp revascularization is possible. Root canal treatment should be avoided unless there is clinical and radiographic evidence of pulp necrosis. Clinical controlReplanted teeth should be monitored by frequent controls during the first year (once a week during the months 1, 3, 6, and 12) and then yearly thereafter. Clinical and radiographic examination will provide information to determine outcome. Evaluation may include the findings described as follows. Favorable outcome| (1) | Closed apex. Asymptomatic, normal mobility, normal percussion sound. No radiographic evidence of resorption or periradicular osteitis; the lamina dura should appear normal. | | (2) | Open apex. Asymptomatic, normal mobility, normal percussion sound. Radiographic evidence of arrested or continued root formation and eruption. Pulp canal obliteration is the rule. |
Unfavorable outcome| (1) | Closed apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-related replacement resorption). | | (2) | Open apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. In the case of ankylosis, the crown of the tooth will appear to be in an infra-occlusal position. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-related replacement resorption). |
Splinting guidelines for avulsed teethReplanted permanent teeth should be splinted up to 2 weeks. Wire-composite splint has been widely used to stabilize avulsed teeth because it allows good oral hygiene and are well tolerated by the patients Source:Dental Traumatology ,Volume 23 Issue 3 Page 130-136, June 2007
Marie Therese Flores, Barbro Malmgren, Lars Andersson, Jens Ove Andreasen, Leif K. Bakland, Frederick Barnett, Cecilia Bourguignon, Anthony DiAngelis, Lamar Hicks, Asgeir Sigurdsson, Martin Trope, Mitsuhiro Tsukiboshi, Thomas von Arx
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