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Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 | 201

Delayed replantation of an avulsed maxillary premolar

with open apex: A 24 months follow-up case report
Ravi K. S., Pinky C.
, Shikhar Kumar
, Amit Vanka
Department of Preventive Dental Sciences, Division of Pedodontics and Preventive Dentistry, College of Dentistry, King Khalid
University, Abha, Kingdom of Saudi Arabia,
Division of Pedodontics and Preventive Dentistry, Faculty of Dentistry, Ibn Sina National
College of Medical Sciences, Jeddah, Kingdom of Saudi Arabia,
Pediatric Dentistry, Farooqia Dental College & Hospital, Mysore,
Pediatric and Preventive Dentistry, University College of Medical Science, New Delhi, India
that will cause tooth loss.
Andreason has reported
that if the tooth has been out of the mouth for more
than 2 h, there is 95% chance of external resorption.
Nevertheless, if managed appropriately, avulsed
teeth with viable PDL when reimplanted can remain
functional for some years. This article describes the rare
case of management of an immature avulsed premolar
with an extra-alveolar dry storage of more than 3 h.
Case Report
A healthy 11-year-old boy reported to the Department
of Pediatric Dentistry with a chief complaint of missing
upper right back tooth and lip laceration. History
revealed that patient has had bicycle accident about
3 h ago resulting in loss of upper right back tooth.
Intraoral examination revealed lip laceration along
with clinically missing maxillary right rst premolar
[Figure 1]. Following which parents were asked to
visit the site of accident to nd the avulsed tooth if
possible and meanwhile periapical radiographic
investigation carried out revealed no evidence of
any associated hard tissue injury. The tooth was
subsequently found at the site of accident with soil
contamination [Figure 2]. Examination of avulsed
tooth revealed intact crown and root with wide apical
Address for correspondence:
Dr. Pinky C,
Department of Pediatric Dentistry, Farooqia Dental College
& Hospital, Tilak Nagar, Mysore - 570 021, Karnataka, India.
Case Report
Avulsion of permanent teeth is most serious of
all dental injuries and accounts for 1-16% of all
traumatic injuries, of which maxillary incisors are
most commonly involved. However, in this report a
rare case of isolated avulsed immature premolar has
been described. The patient had reported more than
3 hours after the trauma with a tooth stored in dry
condition and soil contamination. The prognosis
depends on measures taken at the place of accident
or the time immediately after avulsion. Replantation
is the treatment of choice, but cannot always be
performed immediately. An appropriate emergency
management and treatment plan is important for
good prognosis. In this report stepwise management
of an avulsed immature maxillary premolar with
extended period of dry storage has been described
followed up for a period of 2 yrs.
KEYWORDS: Avulsion, delayed replantation,
immature premolar
Avulsion accounts for 0.5-16% of traumatic injuries in
the permanent dentition.
Avulsion of permanent
teeth can occur at any age, but is most common in young
permanent dentition due to roots being incompletely
formed and resilient periodontium and bone.
Prognosis depends on measures taken at the place of
accident or the time immediately after avulsion.
a tooth is avulsed, attachment damage, pulp necrosis,
and small localized cemental damage occurs. If the
periodontal ligament (PDL) left attached to the root
surface does not dry out, the negative consequences
of tooth avulsion are usually minimal. However, if
excessive drying occurs, following replantation these
PDL cells will elicit a severe inammatory response,
with physiologic bone re-contouring on the root surface
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Ravi, et al.: Immature maxillary premolar avulsion
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 | 202
tissue, and thoroughly debrided with physiologic
saline solution. The tooth was gently replanted with
digital pressure, occlusion was evaluated and wire
splinted with acid etch composite resin attached to
adjacent teeth for a period of 2 weeks [Figures 3 and
4]. Patient was administered 5 days course of 250
mg amoxicillin thrice daily to prevent infection and
advised to be on soft diet. Oral hygiene instructions
were given and chlorhexidine mouthwash (Hexidine
2%, ICPA Health Products LTD, India) recommended
twice a day for 2 week. Splint was removed after 2
weeks with no post-operative clinical or radiographic
complications and patient was followed-up regularly
at 6, 12, 18, and 24 months [Figures 5-8]. Tooth showed
no clinical symptoms such as mobility, periodontal
pocket or color change. Dull note on percussion was
yielded at 24 months follow-up visit and periapical
radiographic examination showed no sign of external
root resorption.
Best available treatment for avulsed teeth is immediate
replantation, but for a variety of reasons this can be
foramina and necrotic dried remnants of periodontal
tissue due to extensive extraoral dry storage of
over 3 h. Patient had bimaxillary protrusion and
was referred to the Department of Orthodontics
for possibility of extraction of other premolars
and orthodontic correction. Despite advisability of
orthodontic treatment and poor prognosis associated
with replantation of an avulsed tooth, parents
declined any kind of dental intervention and wanted
the tooth to restored back. Treatment plan was
established to carry out root surface treatment and
extraoral root canal treatment (RCT). The tooth root
was treated with triple antibiotic paste consisting
of ciprooxacin, metronidazole, and minocycline in
the ratio of 3:1:1 mixed with propylene glycol for a
period of 10 min. Conventional enlargement and
cleaning of root canal was performed. The canals
were dried with sterile paper points and obturated
with Gutta Percha (Dentsply Maillefer Swiss made,
Ballaigues) and the root ends were sealed with glass
ionomer cement (GC Fuji IX, Tokyo, Japan). Under
local anesthesia the socket was gently curetted to
remove any coagulum, granulation and pathologic
Figure 1: Pre-operative intraoral photograph showing an avulsed
right rst premolar
Figure 3: Post-operative intraoral photograph after replantation and
splinting with composite resin wire splint
Figure 2: Photograph of an avulsed premolar with soil contamination
Figure 4: Post-operative intraoral radiograph following splinting
Ravi, et al.: Immature maxillary premolar avulsion
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 | 203
difcult for nonprofessional person and teeth are
often covered with debris. Clinical evidence suggests
that macroscopic contamination on the root surface
results in signicant higher percentage of teeth healing
with ankylosis following avulsion and replantation.
An explanation for this is that any foreign material
and bacteria will increase the extent and duration of
inammatory response.
In the present report, the time elapsed from occurrence
of trauma up to emergency care was more than 3 h,
worsened by dry storage and soil contamination on
root surface. The anticipated healing of pulpal and
periodontal tissues was extremely low as per scientic
literature. However, despite unsatisfactory conditions
replantation was the treatment option due to parents
insistence and young age of the patient as the young
permanent tooth loss leads to severe arrest of alveolar
bone formation in a growing child. Alveolar ridge
would be narrow and difcult to restore in future with
either a bridge or implant. Most conservative approach
for managing the avulsed teeth is to reimplant them as
soon as possible.
The prerequisite for functional healing of an avulsed
tooth is absence of infection. Early infection related
complications derive from infected pulp space leading
to tooth loss. Hence, pre-replantation extraoral RCT was
performed in this case to prevent a common complication
of inammatory root resorption, that occurs more
rapidly in young patients as the dentinal tubules
are more patent and readily transmit inammatory
products from pulp to the root surface.
In this report, the root surface of premolar suffered
extensive damage from improper storage conditions.
Acc to Trope, when severe additional damage cannot
be avoided and osseous replacement of the root
is considered certain, steps are taken to slow the
replacement of root by bone to maintain the tooth
in mouth for as long as possible.
Root surface
treatment with various agents such as tetracycline,
dexamethasone, stannous uoride, sodium uoride,
and tetracycline have been suggested by various
In this case, root surface treatment was
carried out with triple antibiotic paste containing
ciprooxacin, metronidazole, and minocycline mixed
Figure 5: 6 months follow-up radiograph Figure 6: 12 months follow-up radiograph
Figure 7: 18 months follow-up radiograph Figure 8: 24 months follow-up radiograph demonstrating good bone
healing without any root resorption
Ravi, et al.: Immature maxillary premolar avulsion
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 | 204
with propylene glycol to decontaminate the surface
and exert prolonged bactericidal effect on PDL.

According to Makkes et al. uncontaminated devitalized
tissue cause low/no inammatory reaction, and
thereby accounting for good periodontal healing in
this case at 24 months follow-up.
Experimental studies in non-human primates have
demonstrated that rigid splinting, i.e., immobilization
or a prolonged splinting period may lead to extensive
PDL healing complications, such as dentoalveolar
ankylosis or external root resorption (replacement
Hence, splinting technique that allows
physiologic movement of the tooth during healing,
and that is in place for a minimal time period should
be used.
Wire-composite resin splint was used in
this case for a period of 2 weeks as it allows good oral
hygiene maintenance and well tolerated by patient.
An avulsed tooth will be exposed to bacterial
contamination both extraorally and intraorally and
reduction in bacterial inammatory stimulus by the
use of antibiotics may have some role in improving
periodontal and pulpal healing.
Patient in this report
was prescribed 5 days course of amoxycillin as the
bacteria found within the alveolar socket of avulsed
teeth have been found to be sensitive to penicillin
based antibiotics in an investigation carried out by
Parry et al.
During 2 years follow-up, patients esthetics and
occlusal function have been maintained. Clinically,
dull note on percussion was yielded at last follow-
up visit, but radiographically there was no evidence
of any resorption. The expected outcome in this case
was replacement resorption, but radiographic normal
appearance of root could be attributed to limitation of
intraoral radiography, i.e., unable to visualize the teeth
3-dimensionally. However, the patient is still under
follow-up to determine the ultimate fate of this tooth
replanted under unfavorable conditions.
Despite the fact that tooth had extended extra-alveolar
dry storage, root surface treatment with triple antibiotic
paste rendered the root surface more resistant to
resorption, indicating the possibility of its long survival
in oral cavity. This case report highlights the need for
in depth investigation of root surface treatment options
and the importance of replanting avulsed teeth even
when the conditions are not very favorable.
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How to cite this article: Ravi KS, Pinky C, Kumar S, Vanka A.
Delayed replantation of an avulsed maxillary premolar with open
apex: A 24 months follow-up case report. J Indian Soc Pedod Prev
Dent 2013;31:201-4.
Source of Support: Nil, Conflict of Interest: None declared.