Avulsion Treatment

Tooth replanted before arrival at dental care center:

Avulsed immature permanent teeth (open apex)

  • Clean the area with water spray, saline or chlorhexidine. Do not extract the tooth. Suture soft tissue lacerations if present. Verify proper positioning of the replanted tooth clinically and radiographically. Place a flexible splint for two weeks.

  • Prescribe systemic antibiotics: For children 12 years and younger, administer Penicillin V at the patient's age and weight appropriate dose. For children older than 12 years, when there is minimal risk of tetracycline staining, administer Doxycycline twice daily for seven days at the patient's age and weight appropriate dose.

  • Refer the patient to medical personnel for evaluation of need for tetanus toxoid vaccine.

  • In teeth with open apices, that have been replanted immediately or kept in appropriate storage, pulp revascularization is possible. Avoid root canal treatment unless there is clinical and radiographic evidence of pulp necrosis.

  • Patient instructions: Soft diet for two weeks. Brush teeth with a soft toothbrush after each meal. Use chlorhexidine 0.1% mouth rinse twice daily for one week.

  • Follow up: Splint removal after two weeks. Perform clinical and radiographic examinations at four weeks, eight weeks, six months, twelve months and annually thereafter for five years. If the tooth exhibits symptoms, i.e., excessive mobility, ankylosis, radiographic necrosis or resorption, endodontic or surgical treatment is indicated.

Avulsed mature permanent teeth (closed apex)

  • Clean the area with water spray, saline or chlorhexidine. Do not extract the tooth. Suture soft tissue lacerations if present. Verify proper positioning of replanted tooth clinically and radiographically. Place a flexible splint for two weeks.

  • Prescribe systemic antibiotics: For children 12 years and younger, administer Penicillin V at the patient's age and weight appropriate dose. For children older than 12 years, when there is minimal risk of tetracycline staining, administer Doxycycline twice daily for seven days at the patient's age and weight appropriate dose.

  • Refer the patient to medical personnel for evaluation of need for tetanus toxoid vaccine.

  • Initiate root canal treatment seven to ten days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament for one month until permanent filling of the root canal.

  • Patient instructions: Soft diet for two weeks. Avoid contact sports. Brush teeth with a soft toothbrush after each meal. Use chlorhexidine 0.1% mouth rinse twice daily for one week.

  • Follow up: Perform clinical and radiographic examination at two weeks when the splint is removed, then at four weeks, then at three months, six months, one year and annually thereafter. If the tooth exhibits symptoms, i.e., excessive mobility, ankylosis, radiographic necrosis or resorption, endodontic or surgical treatment is indicated.

Tooth has been kept in appropriate storage media or extraoral dry time is less than sixty minutes:

If immediate replantation is not possible, the avulsed tooth is transported to the dental care facility in an appropriate medium (in order of preference Viaspan, Hank's Balanced Salt Solution, cold milk, saliva - buccal vestibule, saline, water). Upon arrival to the facility, tooth replantation consists of the following procedures:

  • Assess the extra-alveolar period and storage medium: the risk of ankylosis increases significantly with an extraoral dry time of 15 minutes. In such a situation, if the apex is closed and alveolar growth is completed, replantation is recommended as the final result will be aesthetically acceptable. If the apex is open and considerable alveolar bone growth is still expected, the increased the risk of ankylosis may result in a compromised aesthetic result. In such a situation, replantation is questionable. However, parents can be very persistent in avulsion situations and demand the tooth be replanted. Should the dentist capitulate to such demands, the progress of the replantation procedure should be followed very closely.  At the first sign of ankylosis, extraction or decoronation of the tooth is recommended.

  • Clean the root surface and apical foramen with a stream of saline. Flush the socket clot with a stream of saline.

  • Replant the tooth slowly with gentle digital pressure. Do not force the tooth. If resistance is met examine the socket for bony fractures. Verify the correct position clinically and radiographically.

  • Splint the tooth with a flexible splint and leave in place for two weeks.

  • Prescribe systemic antibiotics: For children 12 years and younger, administer Penicillin V at the patient's age and weight appropriate dose. For children older than 12 years, when there is minimal risk of tetracycline staining, administer Doxycycline twice daily for seven days at the patient's age and weight appropriate dose.

  • Refer the patient to medical personnel for evaluation of need for tetanus toxoid vaccine.

  • In teeth with open apices, that have been replanted immediately or kept in appropriate storage, pulp revascularization is possible. Avoid root canal treatment unless there is clinical and radiographic evidence of pulp necrosis. In a tooth with a closed apex initiate endodontic treatment seven to ten days after replantation.

  • Patient instructions: Soft diet for two weeks. Avoid contact sports. Brush teeth with a soft toothbrush after each meal. Use chlorhexidine 0.1% mouth rinse twice daily for one week.

  • Follow up: Perform clinical and radiographic examinations at two weeks when the splint is removed, at four weeks, eight weeks, six months, one year and annually thereafter. If the tooth exhibits symptoms, i.e., excessive mobility, ankylosis, radiographic necrosis or resorption, endodontic or surgical treatment is indicated.

Extra-oral dry time is greater than sixty minutes:

Delayed replantation has a poor long-term prognosis. The periodontal ligament is expected to become necrotic and healing is not expected. The long-term outcome is expected to be ankylosis and resorption of the root. The goal in this situation is to maintain alveolar ridge contour. If ankylosis occurs and the infrapositon of the tooth crown is more than 1mm, decoronation is recommended to preserve the contour of the alveolar ridge.

  • Remove the necrotic PDL from the avulsed tooth with scalers and gauze.

  • Perform root canal treatment on the tooth through the open apex prior to replantation. Fill the tooth extraorally with gutta percha and sealer.

  • Soak the tooth in a 2% NaF solution for 20 minutes to make the root surface more resistant to osteoclastic activity and delay the ankylosis process.

  • Replant the tooth slowly with gentle digital pressure. Do not force the tooth. If resistance is met examine the socket for bony fractures. Verify the correct position clinically and radiographically.

  • Splint the tooth with a flexible splint and leave in place for four weeks.

  • Prescribe systemic antibiotics: For children 12 years and younger, administer Penicillin V at the patient's age and weight appropriate dose. For children older than 12 years, when there is minimal risk of tetracycline staining, administer Doxycycline twice daily for seven days at the patient's age and weight appropriate dose.

  • Refer the patient to medical personnel for evaluation of need for tetanus toxoid vaccine.

  • Patient instructions: Soft diet for two weeks. Brush teeth with a soft toothbrush after each meal. Use chlorhexidine 0.1% mouth rinse twice daily for one week.

  • Follow up: Perform clinical and radiographic examinations at four weeks, three months, six months, twelve months and annually thereafter. If tooth exhibits symptoms, i.e., excessive mobility, ankylosis, radiographic necrosis or resorption, endodontic or surgical treatment is indicated.

  • Emphasize to the patient and parent the prognosis for replantation is poor and they should have an open mind to the possibility of losing the tooth.