An avulsed permanent tooth is manually reinserted into its socket as soon as possible after the avulsion. A temporary splint will immobilize the reimplanted tooth, promoting restoration of the periodontal ligament.
Avulsed teeth that are quickly replaced (< 30 minutes) have a good prognosis and are often retained, although most ultimately require a root canal. The longer the tooth has been out of the socket, the worse the prognosis, so replacement by emergency or primary care practitioners is often warranted. However, after about 2 hours, replacement is usually not done by nonspecialists unless in consultation with a dentist, and is usually not considered worth trying after about 3 hours.
Patients should be instructed not to wash or scrub their avulsed tooth and to bring it in a container of milk or (for reliable patients) under their tongue. Health professionals should keep a supply of a buffered liquid such as Hanks' Balanced Salt Solution (HBSS) as a temporary storage/transport medium.
Indications for Replacing and Splinting an Avulsed Tooth
- An avulsed, extruded, laterally luxated, or severely subluxed (ie, mobile, painful, and possibly bleeding) permanent tooth
Contraindications to Replacing and Splinting an Avulsed Tooth
- Primary tooth involvement
- Intruded tooth (pushed deeper into socket)
- Significant alveolar fracture, socket damage, or fractured or grossly decayed permanent tooth
- Moderate/severe periodontal disease in the area of the injured tooth
Such patients should be referred to a dentist or oral surgeon for management. Avulsed primary teeth are not replaced because they typically become necrotic, then infected. They may also become ankylosed and thus not exfoliate, thereby interfering with the eruption of the permanent teeth.
- Prolonged time out of socket (> 2 hours)
Long-term prognosis is poor but do not discard the tooth; place the tooth in HBSS and consult with a dentist or oral surgeon regarding advisability of attempting replacement. If specialist advice is unavailable and/or follow-up is uncertain, advise patient of very poor prognosis. If patient desires, attempt replacement as described below if time is reasonably close to 2 hours.
Complications of Replacing and Splinting an Avulsed Tooth
- Tooth may detach and be aspirated.
- Long-term complications include inflammatory root resorption or ankylosis of tooth (union of root to socket by bone, rather than by periodontal ligament attachment).
Equipment for Replacing and Splinting an Avulsed Tooth
- Dental chair, straight chair with head support, or stretcher
- Light source for intraoral illumination
- Nonsterile gloves
- Mask and safety glasses, or a face shield
- Gauze pads
- Cotton-tipped applicators
- Dental mirror or tongue blade
- Hanks' balanced salt solution (preferred), or, if unavailable, milk
- Cold-curing flexible splint material (eg, periodontal dressing)
Equipment to do local anesthesia:
- Topical anesthetic ointment* (eg, lidocaine 5%, benzocaine 20%)
- Injectable local anesthetic such as lidocaine 2% with or without epinephrine† 1:100,000, or for longer duration anesthesia, bupivacaine 0.5% with or without epinephrine† 1:200,000
- Dental aspirating syringe (with narrow barrel and custom injectable anesthetic cartridges) or other narrow barrel syringe (eg, 3 mL) with locking hub
- 25- or 27-gauge needle: 2-cm long for supraperiosteal infiltration; 3-cm long for nerve blocks
* CAUTION: All topical anesthetic preparations are absorbed from mucosal surfaces and toxicity may result when dose limits are exceeded. Ointments are easier to control than less-concentrated topical liquids and gels. Excess benzocaine rarely may cause methemoglobinemia.
† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg; lidocaine with epinephrine, 7 mg/kg; bupivacaine, 1.5 mg/kg: Note a 1% solution (of any substance) represents 10 mg/mL (1 gm/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.
- Prognosis for reimplantation depends on survival of cells of the periodontal ligament: Handle the tooth only by the crown, do only gentle rinsing, and do not hold, manipulate, or scrape the root (doing so may remove viable periodontal ligament fibers).
- Antibiotic prophylaxis for endocarditis should be given to certain high-risk patients who have had an avulsed tooth replaced.
- Patients unable to cooperate with procedure (typically children) may require sedation.
Relevant Anatomy for Replacing and Splinting an Avulsed Tooth
Traumatic tooth displacements are defined progressively as:
- Concussion—Nondisplaced, nonmobile tooth, but with inflammation of periodontal ligament resulting in sensitivity of tooth to touch or pressure
- Subluxation—Nondisplaced, but mobile (loose) tooth
- Luxation—Displaced but not avulsed tooth
- Avulsion—Tooth completely removed from socket (complete luxation)
A relatively intact tooth socket (alveolar bone) to support the tooth is needed for successful reimplantation
Positioning for Replacing and Splinting an Avulsed Tooth
- Position the patient inclined and with the occiput supported.
- Turn the head and extend the neck such that the avulsion site is accessible.
- For the lower jaw, use a semi-recumbent sitting position, making the lower occlusal plane roughly parallel to the floor when the mouth is open.
- For the upper jaw, use a more supine position, making the upper occlusal plane roughly 60 to 90 degrees to the floor.
Step-by-Step Description of Procedure
Initial assessment and preparation
- Wear nonsterile gloves and mask/safety glasses, or face shield.
- Handle the tooth only by the crown and do not disturb any of the root's tissues.
If the tooth has been out of the socket < 20 minutes, immediately reimplant it. Gently rinse the tooth with saline. To prepare a space for the root, remove the bulk of the clot from the socket using gentle irrigation and suction (small-tipped). Do not waste time trying to remove the entire clot.
Be sure the tooth is oriented correctly. Use the contralateral tooth as a guide for orientation if needed.
If the tooth has been out of the socket > 20 minutes but < 2 hours, soak the tooth in Hanks' balanced salt solution (HBSS; the preferred treatment) for 30 minutes to re-vitalize the cells of the periodontal fibers, then reimplant the tooth. If HBSS is not available, milk can be used, but is less desirable. Saline is an even less desirable alternative. Remove the clot as described above.
If anesthesia is needed
- For most lower teeth, do an inferior alveolar nerve block.
- For most upper teeth, do supraperiosteal infiltration.
- For the frequent anterior tooth avulsions that occur in school-aged children without other significant trauma, local infiltration over the socket usually provides adequate anesthesia and is faster than a nerve block.
Reinsert an avulsed tooth
- Holding the tooth by the crown, gently insert it into its socket in correct anatomic orientation (use contralateral side as a guide if needed).
- Gently push the tooth into the socket (pressing on the crown) to seat the tooth but without compressing any tissues at the root.
- Check bite: Have patient gently and slowly bite down to be sure opposing teeth do not move the reimplanted tooth. Readjust position of tooth if needed so that the patient can bring the teeth together normally.
- Splint the tooth (see below).
- If the tooth cannot be seated securely or oriented with certainty, send the patient directly to a dentist.
Stabilize a subluxed (mobile but not displaced) tooth
- Gently move the crown to reposition the tooth to its correct location, but do not compress any tissues at the root.
- Splint the tooth (see below).
Reduce a luxated tooth (displaced to the side, or partially extruded from the socket; intruded teeth should be managed by a dentist)
- Use digital pressure as needed to reposition the displaced tooth into its correct anatomic position. Use adjacent and opposing teeth as guides. Gentle forceps traction in a forward direction is sometimes needed for palatally displaced teeth. Significantly displaced teeth are best referred directly to a dentist or oral surgeon.
- Check bite: Have the patient gently and slowly bite down to be sure opposing teeth do not move the repositioned tooth.
- Splint the tooth (see below).
Splint the reduced tooth
- Prepare the flexible splint material as directed (eg, for Coe-PakTM periodontal paste, thoroughly blend a 1:1 ratio of base and catalyst and roll into a cylindrical [sausage] shape using your moistened, gloved fingers).
- Maintain the tooth in position within the socket.
- Make 2 small strips of paste. Lay one strip over the buccal surface and one over the lingual/palatal surface of the reimplanted tooth, extending the strips across 1 or 2 teeth on either side. Do not cover the occlusal surfaces of the teeth.
- Gently smooth the surface of the paste while working it into the spaces between the teeth.
- If both sides of the teeth cannot be covered, place the splint only on the buccal side.
- If the temporary splint is not effective, send the patient directly to a dentist for more advanced splinting options.
- After reimplantation, obtain dental x-rays to identify associated damage.
Aftercare for a Replaced and Splinted Avulsed Tooth
- Give tetanus prophylaxis if needed.
- Antibiotics are usually appropriate (eg, amoxicillin 500 mg 3 times a day for 7 days).
- The patient should not chew on the affected side, should eat only liquids and soft foods, and avoid hot and cold foods.
- Very gentle warm salt water rinses are done every 3 to 4 hours until follow-up. Gentle brushing is done down away from the gum line.
- Ice chips and NSAIDs (nonsteroidal anti-inflammatory drugs, eg, ibuprofen 400 mg every 6 hours) are given for pain; narcotic analgesics (eg, acetaminophen with codeine, hydrocodone, or oxycodone) may be used if needed for a severe injury.
- For relief of swelling, apply ice packs (30 minutes on, 30 minutes off) to the side of the face for 24 hours, then switch to warm compresses
- Arrange follow-up with a dentist as soon as possible, same day if possible, for hygienic splint placement (eg, wire and bonded resin).
- Instruct the patient that reinserting and splinting an avulsed tooth does not guarantee its survival. Even if reimplantation is successful, the tooth will require root canal therapy (rarely, a quickly reimplanted immature tooth with an open apex will revascularize and not require root canal).
Warnings and Common Errors
- Do reimplantation within 30 minutes if possible. Reimplantation done after > 2 hours has a very poor prognosis.
- A tooth contaminated by dirt is a risk factor for tetanus, so immunization history should be checked.
Tricks and Tips
- Expeditious reimplantation and careful handling of the tooth are paramount.
- Patients and parents are understandably worried and anxious. Calm reassurance is important in order to obtain the cooperation needed to reduce time to reimplantation.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|ibuprofen||ADVIL, MOTRIN IB|
|codeine||No US brand name|