MANAGEMENT

OF AVULSED
TOOTH
Presented By : Dr. Tanvir Ahammed
Intern Doctor, CIDCH
Contents
■ Introduction
■ Definition
■ Etiology
■ Clinical findings
■ Emergency management
■ Reimplantation
■ Storage media
■ Treatment outline
■ Instruction and follow-up
■ References
 Introduction
■ An avulsed tooth occurs when a tooth is completely dislodged
from its socket.
■ Avulsion of deciduous tooth doesn’t required replantation due to
permanent tooth will erupt in the place. Avulsion of permanent
teeth requires replantation to maintain the tooth in the arch.
■ Permanent teeth avulsion is seen in 5.3% of all the dental injuries
and the maxillary central incisors have the greatest possibility of
avulsion rather than all other tooth.
■ Avulsed teeth are real dental emergency which requires
immediate treatment.
Fig : Pictures showing avulsion of maxillary right central incisor.
Definition
Avulsion refers to the condition where tooth is completely
dislodged from its socket (extra-articulation) due to traumatic
injury. Avulsed teeth are dental emergencies and require
immediate treatment.
Etiology
■ Trauma to the face
■ Sports injury
■ Fall from height (collision)
■ RTA (road traffic accident)
■ Traumatic injury to upper jaw
(due to protruded maxillary incisor)
■ Tubewell handle injury to face
Pictorial Etiology of Tooth Avulsion
Clinical findings
■ Complete dislodgement of tooth from the socket.
■ Bleeding from the site of injury.
■ Laceration over the traumatized area.
■ Pain and discomfort over the avulsed tooth socket.
Emergency management
■ At first, clean the site of injury and check for other injuries.
■ If the tooth is not contaminated then hold the tooth within the socket by
pressing firm pressure by cotton pack or finger.
■ If the tooth is contaminated, then wash the tooth over the ruuning tap
water by holding the crown portion (not touching the root).
■ After cleaning the tooth, try to immediate reimplantation of avulsed
tooth. If not possible, then place the tooth into suitable storage media
(normal saline, ice water, milk, patient’s own saliva, etc.)
■ Consult with nearby dentist for further management as soon as
possible. (Best treatment can given if patient comes within 1 hour.)
Reimplantation
■ Reimplantation is the reinsertion of avulsed tooth into the socket.
■ Procedure : Gently push the tooth into the alveolar socket (pressing on
the crown) to seat the tooth but without compressing any tissues at the
root. Use digital pressure only.
■ Check bite : Have patient gently and slowly bite down to be sure
opposing teeth do not move the reimplanted tooth.
Storage media
■ Patient‘s own saliva
■ Hank’s Balanced Salt Solution (HBSS)
■ Normal Saline (0.9% NaCl solution)
■ Contact lens solution
■ Propolis
■ Coconut water
■ Milk and milk substitutes
■ Special culture media (Eagle‘s medium)
■ Organic storage media (ViaSpan)
Treatment outline
• Different Treatment Modalities in the
Management of an Avulsed Tooth :
1. Management of avulsed permanent tooth with closed
apex.
2. Management of avulsed permanent tooth with open apex.
3.Management of avulsed permanent tooth with closed or
open apex with extraoral dry time :

(A) Less than 30 minutes (B) 30-60 minutes (C) More than 60 minutes
■ TREATMENT GUIDELINES FOR AVULSED
PERMANENT TEETH WITH CLOSED APEX :
1. Leave the tooth in place.
2. Clean the area with water spray, saline, or chlorhexidine.
3. Suturing of gingival lacerations, if present.
4. Verify the normal position of the replanted tooth clinically and
radiographically.
5. Apply a flexible splint for up to 2 weeks.
6. Antibiotic and anti-tetanus therapy.
7. Patient instructions and follow-up.
8. Endodontic treatment is recommended 7-10 days after immediate
replantation and before the splint removal.
Figure : Pictures showing reimplantation of an avulsed
mature tooth (closed apex) --- (A) Clinical picture after
avulsion. (B) Radiographic evaluation. (C) Reimplantation
and splinting of avulsed tooth. (D) Radiographic picture of
the replanted tooth. (E) Clinical picture at the 3-year follow
up. (F) Radiographic assessment at 3-year follow up visit.
■ TREATMENT GUIDELINES FOR AVULSED
PERMANENT TOOTH WITH OPEN APEX :
1. Leave the tooth in place.
2. Clean the area with water spray, saline, or chlorhexidine.
3. Suture gingival lacerations, if present.
4. Verify normal position of the replanted tooth clinically and radiographically.
5. Flexible splint for up to 2 weeks.
6. Antibiotic and anti-tetanus therapy
7. Give patient instructions.
8. The goal for replanting still-developing (immature) teeth in children is to allow
for possible revascularization (apexogenisis) of the pulp space. If that does not
occur, root canal treatment may be recommended.
Figure : Pictures showing management of avulsed tooth with open apex (a)
Preoperative radiograph. (b) Radiograph after reimplantation and splinting.
(c) Radiograph after 1-year follow up. (d) Radiograph after 18-month follow
up. (e) Preoperative clinical picture. (f) Clinical picture after reimplantation
and splinting. (g) Clinical picture after 18-month follow up
• Management of avulsed permanent tooth with
closed or open apex with extraoral dry time less
than 30 minute (Golden time for replantation)
■ Extraoral Dry Time Less than 30 Minutes with Closed Apex :
1. Chance of PDL healing is excellent .
2. Treatment includes cleaning the tooth off debris and rinsing followed by
reimplantation and stabilization of avulsed tooth.
3. Follow-up evaluation is done at regular visits.

■ Extraoral Dry Time Less than 30 Minutes with Open Apex :

1. Revascularization of the pulp as well as continued root development is
possible.
2. Excellent result can be be seen after follow up visit.
• Management of avulsed permanent tooth with
closed or open apex with extraoral dry time within
30-60 minutes
• Chances of revascularization is extremely poor. Tooth with an open apex required
apexification procedure after replantation.
• Root canal treatment is initiated at the second visit at 7-10 days in a tooth with
closed apex.
• Treatment includes cleaning and replanting the tooth and accepting that the
complications may arise.
• Preserving the avulsed tooth in storage medium can reduce ankylosis as there is
increased chance of survival of cells.
• The tooth can be soaked in doxycycline (1mg of doxycycline mixed with 20 ml of
normal saline) for 5 minutes before replantation for improving the revascularization
significantly. Doxycycline or Minocycline is rhe choice of antibiotics to inhibit
bacteria also for removing the major obstacle.
• Management of avulsed permanent tooth with
closed or open apex with extraoral dry time more
than 60 minute

• Soaking is ineffective as all the cells might have died.

• Here the aim is to make the root resistant to resorption.
• The tooth may be soaked in citric acid for 5 minutes, then in 2% stannous fluoride
for 5 minutes and then in doxycycline for 5 minutes before reimplantation.
• Endodontic treatment can be performed extraorally by taking care to preserve the
remaining PDL.
• Following reimplantation : The tooth should be stabilized by acid etch composite
resin splint. Rigid splinting for longer periods should be avoided to prevent
ankylosis or resorption, 1-2 week should be sufficient.
 a

Figure : Management of avulsed permanent central incisors. (a) Clinical

picture of teeth lost due to avulsion, (b) Exfoliated teeth outside being
flooded with tooth saving media, (c) OPG showing missing central incisor,
(d) OPG showing replanted central incisors in position, (e) Clinical picture
of flexible wire splint after replantation.
Figure : (A, B) Pre-operative clinical and radiographical
images of avulsed socket (C) Avulsed teeth stored into storage
media. (D) Extra-oral root canal treatment initiated.
Instructions and Follow up
■ Patient’s instruction :
1. Avoid participation in contact sports.
2. Take soft diet for up to 2 weeks.
3. Brush the teeth with a soft toothbrush after each
meal.
4. Use a chlorhexidine (0.1%) mouth rinse twice a day
for 1 week.
■ Follow-up :

• In children and adolescent, ankylosis frequently

associated with infra position.

• Good communication is necessary for patient and the

guardians with follow-up visit.

• Careful follow up is required for successful outcome.

References

📕Principle and Practice of Pedodontics by Arathi Rao (3 rd

Edition)

📕Textbook of Pediatric Dentistry by Nikhil Marwah

(4th Edition)