Trauma to the anterior teeth mainly affects children and&nbsp;adolescents. Tooth avulsion has become a common dental&nbsp;injury, that can occur at any age with maxillary anteriors being&nbsp;commonly affected. It affects the esthetics and psychological&nbsp;well being of both the child and the parent. Management&nbsp;of tooth avulsion in the permanent dentition often presents&nbsp;a challenge to the dental professional. Definitive treatment&nbsp;planning and consultation with specialists is seldom possible&nbsp;at the time of emergency treatment. Replantation of the&nbsp;avulsed tooth is an immediate procedure, which can restore&nbsp;the esthetics, function and create positive impact on patient if&nbsp;carried out under ideal conditions. This article describes the&nbsp;management of a patient with an avulsed maxillary permanent&nbsp;central incisor, that had been stored in unfavorable conditions&nbsp;for about 48 hours. Adequate space maintenance, esthetics&nbsp;and functional requirements of the patient were totally met till&nbsp;a long-term treatment is planned, when the patient finishes his&nbsp;pubertal growth.&nbsp

L Shanthraj, Srinivas

Manju, M

Sethi, Natasha

English

Atharva Scientific Publications (E-Jounals)

M Manju et al 
104
ABSTRACT
Trauma to the anterior teeth mainly affects children and 
adolescents. Tooth avulsion has become a common dental 
injury, that can occur at any age with maxillary anteriors being 
commonly affected. It affects the esthetics and psychological 
well being of both the child and the parent. Management 
of tooth avulsion in the permanent dentition often presents 
a challenge to the dental professional. Definitive treatment 
planning and consultation with specialists is seldom possible 
at the time of emergency treatment. Replantation of the 
avulsed tooth is an immediate procedure, which can restore 
the esthetics, function and create positive impact on patient if 
carried out under ideal conditions. This article describes the 
management of a patient with an avulsed maxillary permanent 
central incisor, that had been stored in unfavorable conditions 
for about 48 hours. Adequate space maintenance, esthetics 
and functional requirements of the patient were totally met till 
a long-term treatment is planned, when the patient finishes his 
pubertal growth.
Keywords: Avulsion, Delayed replantation, Maxillary central 
incisor. 
How to cite this article: Manju M, Shanthraj SL, Sethi N. 
Delayed Replantation of Avulsed Incisor with Prolonged Extra-
oral Dry Storage. J Orofac Res 2015;5(3):104-107.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Avulsion of teeth results from traumatic injuries in 
the orofacial region. The term avulsion implies total 
displacement of the tooth out of the socket. It accounts 
for 0.5 to 16% of traumatic injuries in the permanent 
dentition.1 Maxillary anterior teeth are usually the most 
affected. Avulsion of permanent teeth occurs most often 
in children 7 to 9 years old, when the alveolar bone is 
relatively resilient and provides only minimal resistance 
to extrusive forces.1 The most preferable treatment option 
is replantation of the avulsed tooth, which can restore 
occlusal function and esthetic appearance shortly after 
trauma. In replantation the main objective is to reestablish 
the vitality of periodontal fibers after the treatment. The 
prognosis of replantation depends on the maintenance 
of vitality of the periodontal ligament (PDL) cells on the 
root surface.2 Clinical reports have indicated that the 
prognosis is best for teeth replanted within 5 minutes 
of avulsion.3-6 Most often replantation is not done 
immediately, because of injury circumstances. Extended 
non-physiological storage of avulsed teeth before 
replantation results in necrosis of the PDL and consequent 
healing by replacement root resorption.6 Degeneration of 
the PDL depends on factors, such as extra-alveolar period, 
storage medium used and management of the root. The 
tooth replantation procedure can be either successful or 
it will contribute to the normal development of jaw in 
growing patients as time is gained to establish a definitive 
treatment plan, when growth is completed.7 So, clinicians 
should be in a better position to minimize the incidence 
of complication associated with replantation. This article 
describes the management of mature avulsed maxillary 
central incisor with an extra-alveolar dry storage of 48 
hours.
CLINICAL REPORT
A 14-year-old boy reported to the department of pedo-
dontics and preventive dentistry, with the chief complaint 
of avulsed upper anterior tooth and lip laceration 
following a road traffic accident. Extraorally, there 
was moderate swelling and ulcer with crust formation 
on the upper lip. Clinical examinations revealed an 
Ellis class V fracture of upper right central incisor and 
Ellis class III fracture of left central incisor (Fig. 1). 
The avulsed tooth was retrieved from the site of the 
accident and was kept dry in a plastic container for 
48 hours. Examination of avulsed tooth revealed, that 
the root had closed apex and the tooth crown had an 
enamel fracture (Fig. 2). The root surface was covered 
with dried remnants of periodontal tissue. The patient’s 
medical history was unremarkable. All the adjacent teeth 
Delayed Replantation of Avulsed Incisor with Prolonged 
Extraoral Dry Storage
1M Manju, 2Srinivas L Shanthraj, 3Natasha Sethi 
JOFR
CASE REPORT 
10.5005/jp-journals-10026-1191
1,2Senior Lecturer, 3Postgraduate Student
1,3Department of Pedodontics and Preventive Dentistry, Dr 
Syamala Reddy Dental College and Hospital, Bengaluru 
Karnataka, India 
2Department of Pedodontics and Preventive Dentistry, Coorg 
Institute of Dental Sciences, Virajpet, Karnataka, India 
Corresponding Author: M Manju, B 206 Prism Sovereign 
Apart ment, BEML layout,12th cross Kundanahalli, Bengaluru 
Karnataka, India, Phone: +919740363327, e-mail: 
drmanjunair@gmail.com
Delayed Replantation of Avulsed Incisor with Prolonged Extraoral Dry Storage
Journal of Orofacial Research, July-September 2015;5(3):104-107 105
JOFR
showed positive response to the vitality test except #21. 
Radiological examination, revealed empty socket with 
no other hard-tissue injury and a panoramic radiograph 
confirmed no maxillary or mandibular fractures. 
Clinical and radiographic examination, revealed no 
foreign objects in the soft-tissue. The available treatment 
alternatives were explained to the parent, and it was 
decided to replant the avulsed tooth as an intermediate 
treatment. The main objective was to retain the tooth 
in the mouth for as long a period as possible, because 
of the patient’s age, although the tooth was stored in 
extremely unfavorable conditions. The avulsed tooth 
was rinsed gently with normal saline and root planing 
was done to remove the necrotic PDL cells. The tooth was 
then placed in 1% sodiumhypochlorite solution to 
dissolve PDL remnants. The tooth was then soaked in 
2.4% acidulated sodium fluoride solution for 20 minutes 
prior to replantation. Since, there was prolonged extraoral 
time, root canal therapy was completed extraorally and 
filled with gutta-percha points and access cavity was 
filled with composite. Under local anesthesia, the socket 
was gently curetted to remove any coagulum and induced 
fresh bleeding, and irrigated with physiologic saline 
solution in order to achieve the proper placement of 
the tooth. The labial and the palatal cortical plates were 
pressed to provide proper approximation. An intraoral 
periapical radiograph was taken to check for the proper 
placement of the replanted incisor. Etching was done with 
37% phosphoric acid from maxillary canine to canine. All 
the teeth were then rinsed with the avulsed tooth still 
under pressure. Bonding agent was applied and light 
cured. A stainless steel ligature wire was used to splint 
the teeth along with composite (Figs 3 and 4). Root canal 
treatment of the tooth # 21 was completed. Antibiotic and 
anti-inflammatory drugs were advised for 7 days. The 
patient was referred to the hospital for an anti-tetanus 
booster. The patient was advised to avoid biting with 
the splinted teeth and was put on soft diet for 2 weeks. 
 Fig. 1: Preoperative intraoral photograph showing avulsion 
irt 11  and class III fracture irt 21
Fig. 2: Avulsed tooth
Fig. 3: Replanted 11 stabilized by splinting Fig. 4: Intraoral periapical radiograph taken after replantation of 
11 and wire composite splinting 
M Manju et al 
106
Oral hygiene instructions were given and chlorhexidine 
mouthwash was recommended. Postoperative recall was 
performed after 1 week of replantation. As the tooth 
was not completely firm in the socket even after 7 days, 
it was decided to continue the splinting for 7 more days. 
The splint was removed after 14 days. The patient did 
not show any signs and symptoms like mobility, any 
type of root resorption after replantation. Composite 
build-up was done on 11 and 21 (Fig. 5). The patient was 
seen after 1, 3, 6 months and 1 year after replantation. 
Follow-up radiograph after 24 months intraoral 
periapical radiograph (IOPA) revealed showed no signs 
of resorption or ankylosis (Fig. 6). The patient is still 
under review. During the follow-up period, the patient 
was asymptomatic. Even if replacement root resorption 
occurs later, the replanted incisor will be replaced later 
with a prosthesis when its root will be totally resorbed. 
Long-term treatment may also include prosthodontic 
replacement with an implant when the patient finishes 
his pubertal growth.
DISCUSSION
The prognosis of an avulsed tooth is proportional to the 
extraoral time, which is a direct correlation of the status 
of the PDL cells.4 The storage and transport media during 
extraoral time of vital significance. The commonest 
transport media are Hank’s balanced salt solution 
(HBSS), milk, saline, and saliva (Buccal vestibule). In the 
present case, the avulsed tooth had been in extremely 
unfavorable condition for 48 hours. It was anticipated for 
poor prognosis as the chance of pulpal and periodontal 
healing would be extremely low. Considering the patient’s 
age and benefits of esthetics and function, replantation 
was attempted. 
According to Donaldson and Kinirons8 extraoral 
dry time is the most crucial factor associated with 
the development of postreplantation root resorption. 
Andreason9 claimed that replacement resorption 
occurred if the extraoral dry time was more than 
60 minutes, and no cell remained vital beyond 120 
minutes of dry time on the root.9 As the extraoral dry 
time was more than 60 minutes, root canal treatment was 
performed outside the oral cavity. This seems to prevent 
inflammatory root resorption caused by pulpal infection. 
Root planing of the tooth was done to remove all 
necrotic PDL to limit the degree of surface inflammation 
on the root surface. Tooth was then immersed in sodium 
hypochlorite to dissolve connective tissue remnants. 
Pretreatment of a delayed replanted tooth, prior to its 
replanting, will render it more resistant to resorption.10 
Andreasen and Andreasen1 recommends that the tooth 
should be soaked with 2.4% acidulated sodium fluoride 
solution for 20 minuters, before replantation.1 The use of 
fluoride solutions in different forms and concentrations 
have been recommended to treat the root surfaces 
in case of delayed tooth replantation assuming that 
demineralized dentin surface would be more prone to 
fluoride incorporation and might become more resistant 
to resorption.11 Fluoride acts on the bone tissues, 
cementum and dentin, by converting hydroxyapatite 
into fluorapatite which is more resistant to resorption. 
Of late Iqbal and Bamaas12 showed that extracted 
dogs’ teeth air-dried for periods up to 60 minutes 
benefited from surface treatment with an enamel matrix 
derivative gel before replantation. Periodontal healing 
was greater for the treated teeth than for control teeth, 
and there was less replacement resorption. Chemical 
treatment of root surface with various agents have been 
tried, but more data is required to support the clinical 
effectiveness. 
Splinting technique should allow physiologic 
movement of teeth during healing. The chances of 
Fig. 5: Postoperative photograph after  
composite build-up of 11 and 21
Fig. 6: Intraoral radiograph at the end of 24 months
Delayed Replantation of Avulsed Incisor with Prolonged Extraoral Dry Storage
Journal of Orofacial Research, July-September 2015;5(3):104-107 107
JOFR
ankylosis is decreased, if the splint is kept for a minimal 
period. The wire-composite splint has been thereby used 
to stabilize avulsed tooth, because it allows good oral 
hygiene and are well tolerated by the patient. Ankylosis of 
the incisors in young patients can result in infraocclusion 
as the patients grow.13 Severe infraocclusion can cause 
esthetic problems.
Systemic antibiotics are often recommended after 
replantation, but their effectiveness in preventing root 
resorption is questionable.14
In this case, patient’s esthetic and functional demands 
were totally met by the treatment. Although, there has 
not been any evidence of root resoption and ankylosis 
within a short period, it does not assure a good long-term 
prognosis of the tooth. Long-term follow-up is required 
to understand the possible outcome of the treatment.
SUMMARY 
Replanting should be considered as an intermediate 
treatment option in children and adolescents in cases 
of avulsed permanent teeth with prolonged non-
physiological storage. There will be preservation of 
alveolar bone by successful replantation of an avulsed 
tooth. If the replanted tooth is a failure afterwards 
(replacement resorption and tooth loss), the improved 
alveolar development will provide better permanent 
treatment considerations in later life. There is a also a need 
to create awareness among general public and members 
of sports team regarding emergency management of an 
avulsed tooth.
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 1. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO, 
Andreasen FM, editors. Textbook and colour atlas of 
traumatic injuries to the teeth. Copenhagen: Munksgaard; 
1994. p. 383-425.
 2. Thomas T, Gopikrishna V, Kandaswamy D. Comparative 
evaluation of maintenance of cell viability of an experimental 
transport media ‘coconut water’ with Hank’s balanced salt 
solution and milk, for transportation of an avulsed tooth: An 
in vitro cell culture study. J Conserv Dent 2008 Jan;11:22-29.
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Delayed Replantation of Avulsed Incisor with Prolonged Extraoral Dry Storage

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Delayed Replantation of Avulsed Incisor with Prolonged Extraoral Dry Storage

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