Can An Avulsed Permanent Incisor Be Immediately Replanted?

This Urgent Care Scenario (USC) is presented by the JCDA Oasis Team in collaboration with Dr. Mike Casas from the Department of Pediatric Dentistry at the University of Toronto. It is also available through JCDA Oasis Mobile

The immediate replantation of an avulsed permanent incisor is to be performed on suitable avulsed incisors with extra-alveolar time of less than 5 minutes (to avoid reduced predictability of periodontal healing). Dentists who have the occasion of performing immediate replantation likely witnessed the traumatic injury or arrived at the scene immediately after the injury that produced the avulsion.

Presentation

• Missing incisor tooth after a facial trauma and the tooth is recovered.
• Pain severity is variable.

Investigation

• Assess the patient’s overall medical status 
• Immediate replantation should be considered under these conditions:

• The patient is medically fit to tolerate management of the avulsion;
• The root and alveolus appear intact; and
• The gingiva appears to be adequate for wound closure. 

Diagnosis

Traumatic total exarticulation of an incisor that occurred in the preceding 5 minutes.

Treatment

The intended outcome is a functional periodontal ligament. As the avulsed incisor is a functionally free graft, timely replantation and immobilization of the incisor in the alveolus is critical to periodontal ligament healing outcomes.

Immediate Replantation

1. Seek patient or parents’ consent to proceed with replantation, including the potential need for future root canal therapy.
2. Handle the avulsed incisor by the crown.
3. Rinse the root lightly with water to dislodge any debris.
4. Replant the incisor in the socket to a position that approximates its original alignment in the alveolus.
5. Have the patient occlude on folded facial tissue to stabilize the incisor.
6. Further assessments of the injury site should be completed in an appropriately equipped dental office. 

Following Immediate Replantation

1. Patient should be transported to a dental facility for definitive management of the injury.
2. Examine the traumatized hard and soft tissues and the avulsed tooth.
3. Perform a radiographic examination.
4. Extract the incisor and proceed with wound management, under these conditions:
5. the status of the hard and soft tissues contraindicate replantation; or patient/parents decline proceeding further.
6. Perform replantation:

• Using local anesthetics, suture the soft tissue lacerations and splint the incisor with a semi-rigid splint. The splint should be extended to include one uninjured tooth either side of the injury. The splint may be purpose-built, constructed from orthodontic archwire, monofilament nylon line, or similar and bonded in place with acid-etch resin.
• Verify the position with a radiograph to confirm appropriate placement.
• Check the occlusion to ensure that the excess forces are not being applied to the traumatized tooth.
• The use of chlorhexidine mouth rinse during splinting is elective. If significant mucosal injuries are present, consider using swabs to aid local application, or diluting the mouthwash with an equal volume of water. Systemic antibiotic therapy isnot routinely required.
• Reassess the patient in 7-14 days, at which time pulp extirpation should be considered for incisors with closed apices, and the splint should be removed unless injuries to other teeth warrant a longer splinting duration.
• When assessing to determine if the splint is ready to be removed, minor mobility of the traumatized tooth is acceptable. The splint should only remain if the tooth exhibits severe (M3) mobility.

Advice

Regardless of the stage of incisor maturation, it is not necessary to provide pulp treatment during the immediate management of the injury. It can be addressed at follow-up appointments.

Immature incisors with open apices: there is potential for revascularization of the dental pulp.

Mature incisors with constricted apices: the likely outcome is pulp necrosis. 

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

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