Clinical Management of Tooth Avulsion

Definition

Consequences of Avulsion (If Untreated)

• Infection
• Loss of space in the dental arch
• Ankylosis
• Root resorption
• Abnormal root development of adjacent/successor teeth
• Color changes

First Aid / Immediate Management at Scene

Step 1 - Handle the Tooth Correctly

• Pick up the avulsed tooth by the crown only - never touch the root
• Do not scrub or scrape the root surface
• If dirty, rinse gently with saline or milk - do NOT use water

Step 2 - Storage Media (if immediate reimplantation not possible)

Management Options Based on Extraoral Dry Time

Case 1: Tooth out of socket < 15 minutes (Closed apex)

• Place tooth in tooth-preservation solution (HBSS/milk)
• Wash out the socket gently with saline
• Administer local anesthesia (without vasoconstrictor)
• Reimplant the tooth firmly into the socket
• Splint for 7-10 days
• Start endodontic therapy within 7-10 days of reimplantation

Case 2: Tooth out of socket 15-60 minutes

• PDL cells are stressed but still partially viable
• Rinse root surface gently with saline
• Irrigate the socket to remove the clot
• Reimplant the tooth
• Splint for 7-10 days
• Initiate root canal treatment within 7-10 days

Case 3: Tooth out of socket > 60 minutes (PDL cells necrotic)

• PDL cells are non-viable after 60 minutes of dry extraoral time
• Root canal treatment can be performed extra-orally before reimplantation
• Chemical treatment of root: soak root in 2% stannous fluoride for 5 minutes to reduce risk of resorption, then reimplant
• Even in this scenario, reimplantation may be done to preserve alveolar bone contour - though long-term tooth survival is poor
• Splinting is done as usual

Clinical Steps of Reimplantation

1. Take a history and clinical/radiographic examination
2. Hold the tooth by the crown at all times
3. Wash the socket gently with sterile saline - remove blood clot if needed
4. Administer local anesthesia without vasoconstrictor
5. Insert the root into the socket with the concave surface facing the tongue/palate
6. Apply slight manual pressure to seat the tooth - firm pressure increases ankylosis risk
7. Ask the patient to bite on gauze to hold the position
8. Splint the tooth to adjacent teeth

Splinting

• Splint should be passive and flexible (not rigid)
• Duration: 7 days (unless excessive mobility persists)
• Types:
  • Composite resin and wire (orthodontic wire/nylon fishing line)
  • Acid-etch composite splint
  • Orthodontic bands (extracoronal)
• The splint should not interfere with occlusion
• Extends to 2-3 adjacent teeth on either side

Endodontic Treatment (Root Canal Therapy)

When to start:

• In teeth with closed apex: start RCT within 7-10 days of reimplantation
• In teeth with open apex (immature): monitor for spontaneous revascularization - if pulp necrosis is detected, initiate apexification

Protocol for closed apex:

1. Access cavity preparation
2. Biomechanical preparation
3. Place calcium hydroxide (Ca(OH)₂) as intracanal medicament for up to 4 weeks - acts as anti-resorptive agent
4. Obturate with gutta-percha after confirming no resorption

Why calcium hydroxide?

• Raises intracanal pH, inhibiting bacterial activity
• Reduces inflammatory/replacement root resorption

Post-Emergency Management

• Remove splint after 7 days (unless excessive mobility)
• Endodontic therapy should be started within 7-10 days
• Prescribe antibiotics: Doxycycline 100 mg BD for 7 days (adults); Penicillin for children
• Check tetanus immunization status
• Chlorhexidine mouthwash twice daily for 1 week
• Soft diet advised
• Follow-up at: 1 week, 1 month, 3 months, 6 months, and 1 year

Contraindications to Reimplantation

• Primary tooth avulsion - never reimplant (can cause ankylosis and interfere with permanent tooth eruption)
• Severe caries or periodontal disease
• Uncooperative patient
• Risk of aspiration
• Immunocompromised patient
• Severe cardiac conditions
• Unstable/critically ill patient

Complications After Reimplantation

Prognosis

• Best prognosis: tooth reimplanted within 5 minutes at the site of accident
• If extraoral dry time < 60 minutes and properly stored: good prognosis
• If extraoral dry time > 60 minutes: poor long-term prognosis (ankylosis/resorption likely)
• Success rate: 80-90% under ideal conditions (tooth stored properly, reimplanted at dental office within 60 minutes)

Summary Algorithm

Avulsed Tooth
    |
    ├── Primary tooth → Do NOT reimplant → Space maintainer
    |
    └── Permanent tooth
            |
            ├── < 15 min dry → Reimplant immediately → Splint 7-10 days → RCT within 7-10 days
            |
            ├── 15-60 min (moist storage) → Clean socket → Reimplant → Splint → RCT 7-10 days
            |
            └── > 60 min dry → Extra-oral RCT → Chemical root treatment → Reimplant → Splint → Follow-up

• Storage media order: HBSS > Milk > Saline > Saliva > Water (never use plain water)
• PDL cell viability: < 60 min dry time is critical threshold
• RCT timing for closed apex: 7-10 days post-reimplantation
• Splint duration: 7 days (flexible, passive)
• Calcium hydroxide is the intracanal medicament of choice post-reimplantation
• Primary teeth are NEVER reimplanted after avulsion