Overview
Definition:
Avulsion is the complete displacement of a tooth from its socket
Reimplantation is the immediate or delayed repositioning of the avulsed tooth into its alveolar socket to promote healing and preserve its vitality.
Epidemiology:
Dental trauma is common in children, with avulsion accounting for 1-16% of all traumatic dental injuries in permanent teeth
Boys are more frequently affected than girls
Falls, sports-related injuries, and traffic accidents are primary causes.
Clinical Significance:
Prompt and correct management of avulsed permanent teeth is crucial for successful reimplantation, minimizing complications like ankylosis, root resorption, and pulp necrosis, thereby preserving tooth function and aesthetics for the long term
This is a critical emergency in pediatric dentistry.
Clinical Presentation
Symptoms:
Sudden, visible tooth loss from the mouth
Bleeding from the socket
Pain, particularly if the child is conscious and aware of the injury
Absence of the tooth on clinical examination.
Signs:
Empty alveolar socket with visible bleeding or clot
Potential signs of associated facial trauma like lacerations, contusions, or swelling
The avulsed tooth may be found at the accident scene.
Diagnostic Criteria:
Diagnosis is based on the clear history of complete tooth displacement from its socket and the absence of the tooth from the oral cavity during examination
Radiographic confirmation of the socket may be helpful if the tooth cannot be located.
Diagnostic Approach
History Taking:
Urgent assessment of the event: mechanism of injury, time since avulsion, and conditions under which the tooth was stored (e.g., dry, saliva, milk, saline)
Determine tetanus immunization status
Assess for other injuries.
Physical Examination:
Careful inspection of the oral cavity for the avulsed tooth
Examination of the alveolar socket for bleeding, foreign bodies, or comminution
Thorough extraoral and intraoral examination for associated injuries to soft tissues and other teeth.
Investigations:
Radiographs (intraoral periapical and occlusal) are essential to rule out root fractures, assess the socket integrity, and check for unerupted teeth or pathology
However, immediate imaging may delay treatment
reimplantation should proceed without delay if possible.
Differential Diagnosis:
Tooth luxation (partial displacement), tooth intrusion (tooth pushed into the socket), tooth avulsion is the complete loss
Other causes of tooth loss include caries and exfoliation, which are easily distinguishable by history.
Management
Initial Management:
Immediate action is paramount
Locate the avulsed tooth
Handle the tooth by its crown only, avoiding contact with the root surface
If the tooth is dirty, gently rinse it with saline or milk
do NOT scrub or use soap
Place the tooth in a suitable storage medium immediately.
Storage Medium:
Optimal: Hank's Balanced Salt Solution (HBSS)
Alternatives: Milk, physiological saline (0.9% NaCl), or the patient's saliva (if child is old enough not to swallow)
Avoid tap water or storing dry, as this severely compromises cell viability and prognosis.
Reimplantation Procedure:
Gently reposition the tooth into the socket, ensuring correct anatomical orientation
If the tooth is dirty and rinsed, gently irrigate the socket with saline
Stabilize the reimplanted tooth with a flexible splint (e.g., wire-composite splint) to prevent mobility
Avoid over-splinting or rigid splints.
Splinting:
Flexible splinting is crucial for 7-14 days to allow for periodontal ligament reattachment and healing
Check for occlusal interference and adjust if necessary to prevent traumatic forces on the replanted tooth
Remove splint after 7-14 days.
Post Reimplantation Care:
Prescribe systemic antibiotics (e.g., doxycycline, amoxicillin) for 7-10 days to prevent infection
Administer tetanus prophylaxis if indicated
Provide pain relief as needed
Advise a soft diet for 2 weeks
Instruct on meticulous oral hygiene with a soft toothbrush and antiseptic mouthwash (e.g., chlorhexidine).
Complications
Early Complications:
Infection of the socket or surrounding tissues
Inflammatory root resorption (irreversible)
Pulp necrosis if the periodontal ligament is severely damaged or not revascularized.
Late Complications:
Replacement resorption (ankylosis), where the tooth root is replaced by bone, leading to infraocclusion and eventual loss
Failure of revascularization leading to non-vital pulp requiring root canal treatment
Delayed complications of infection or inflammation.
Prevention Strategies:
Prompt and appropriate storage medium and rapid reimplantation
Gentle handling of the tooth and socket
Appropriate splinting
Systemic antibiotics
Good oral hygiene
Regular follow-up for early detection of complications.
Prognosis
Factors Affecting Prognosis:
Time out of socket (dry storage time is critical
<15 mins is favorable, >90 mins significantly reduces success)
Storage medium used
Extent of periodontal ligament damage
Age of the patient
Presence of infection
Proper management at each stage.
Outcomes:
With optimal management (short dry time, correct storage, immediate reimplantation, appropriate splinting, and follow-up), successful periodontal ligament healing and potential revascularization can occur, leading to good long-term prognosis
However, root canal treatment will likely be needed due to pulp necrosis.
Follow Up:
Regular follow-up appointments are essential: at 2 weeks (splint removal), 4-6 weeks (assess vitality and radiological signs of healing), 3 months, 6 months, 1 year, and then annually for up to 5 years
Monitor for signs of infection, inflammation, ankylosis, and resorption.
Key Points
Exam Focus:
The "golden hour" for dry avulsed tooth storage is crucial
Storage media and immediate reimplantation are key
Differentiate between inflammatory and replacement resorption
Management of periodontal ligament injury is paramount.
Clinical Pearls:
Always ask about the storage medium if the tooth is brought to you
Emphasize handling the tooth by the crown
Use flexible splints
Systemic antibiotics are vital
Educate parents about potential complications like pulp necrosis and resorption.
Common Mistakes:
Storing the tooth dry or in inappropriate media (e.g., tap water)
Scrubbing the root surface
Using rigid splints or over-splinting
Delaying reimplantation unnecessarily
Inadequate or no antibiotic prophylaxis
Neglecting long-term follow-up.