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Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 822-825
Replantation of an avulsed tooth with an extended extra oral period

1 Department of Prosthodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra, India
3 Private practioner, India

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Date of Submission30-Mar-2011
Date of Decision28-Dec-2011
Date of Acceptance27-Jan-2012
Date of Web Publication3-May-2013


In this study, we have reported a case of the replantation of a maxillary incisor with an extended extraoral period following a traumatic avulsion. After storage in normal saline, the root surface of the avulsed tooth was conditioned with citric acid and treated with a triple antibiotic solution. The tooth socket was filled with Emdogain before replantation. A 12 month, 18 month and a 5 year follow-up clinical examination revealed the patient to be asymptomatic, and the tooth was functional. The recall radiograph showed no evidence of renewed periradicular breakdown and apical root resorption.

Keywords: Avulsion, extended extraoral time, replantation

How to cite this article:
Kubasad G, Ghivari S, Garg K. Replantation of an avulsed tooth with an extended extra oral period. Indian J Dent Res 2012;23:822-5

How to cite this URL:
Kubasad G, Ghivari S, Garg K. Replantation of an avulsed tooth with an extended extra oral period. Indian J Dent Res [serial online] 2012 [cited 2021 Aug 5];23:822-5. Available from:
Sudden impact involving the face or the head may result in the ex-articulation of the tooth and may force it to come out of the socket completely. [1] Avulsion of tooth comprises 1-16% of traumatic injuries to permanent dentition and most commonly involves single maxillary incisors. It is seen most frequently in young adults involved in various sports activities. [2] Replantation of tooth beyond 5 minutes has been defined as delayed replantation by Andersen. [3] Two important reasons have been cited for delayed replantation, namely, lack of knowledge of the people at the site of injury for the management of an avulsed tooth, and also as the soft tissue lacerations and bleeding mask the loss of teeth. [4] Factors influencing the periodontal ligament (PDL) vitality in an avulsed tooth are the extra-oral exposure period and the media of storage. Many clinical practices can help improve the long term results and the output of the replantation of an avulsed tooth. The avulsed tooth should be stored in an appropriate media. Further, the chances of functional healing can be increased by conditioning the surface of the tooth with topical antibiotics and acid conditioners such as citric acid, and also with the use of enamel matrix protein (Emdogain). [4],[5]

Emdogain is a porcine enamel matrix, predominantly consisting of amelogenins, and other growth factors which have been shown in vitro to promote PDL cell proliferation and collagen production, and also enhance mineralization. [6] Treatment of an avulsed tooth depends upon the apical maturity of the tooth. When a tooth with a mature apex is avulsed, pulpal necrosis should be anticipated and root canal therapy should be planned. [5] Chances of periodontal healing after replantation of the avulsed tooth are around 25%, and different studies have reported chances ranging from 11% to 50%. Replantation of avulsed teeth with an extended extra alveolar period was seen to be associated with complications such as frequent root resorption and ankylosis. [7],[8] The following study reports a rare case of periodontal healing of a replanted maxillary central incisor with an extra oral period of 21 hours, and its 5 years follow up observations.

   Case Report Top

A 18 year male patient reported to our department for the treatment of a dental traumatic avulsion after hours on 24 th March, 2005. The permanent right maxillary central incisor (11) had been avulsed as a result of a bicycle accident. The patient arrived to the dental clinic three hours after the accident and did not carry the avulsed tooth with him. Extra-oral examination of the patient revealed lacerations on the chin and nose without any fractures of the facial bones. An intra-oral examination revealed an Ellis Class IV crown fracture of 12 [Figure 1] with gingival laceration. No dento-alveolar fractures seen and 11 was avulsed due to trauma. Radiographic examination (parallax view), revealed no tooth remnants in the socket of the avulsed tooth [Figure 2], and also no dento-alveolar fractures were detected. Base line vitality testes were carried out on 12 and 21 to know the response of the pulp, and a delayed response was noted.
Figure 1: Preoperative intra oral view after 11 tooth avulsion in the patient in the study

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Figure 2: Diagnostic radiograph (parallax view) after tooth avulsion of the patient in the study

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The patient was instructed to store the avulsed tooth in normal saline and bring it to the dental office immediately. Patient was placed on penicillin (Amoxicillin 500 mg) for 1 week every 6 hourly and non-steroidal anti-inflammatory drugs (Diclofenac sodium + Paracetamol, twice a day). The tetanus toxoid injection was given intramuscularly. However, the patient did not bring the avulsed tooth on the same day. On the next day, on 25 th March 2005, in the morning hours, the patient brought an avulsed tooth to the dental clinic which was stored in saline, and had an extra oral dry time of 3 hours and wet storage time of 18 hours. A few periodontal fibers were found attached to the surface of the root. Before the replantation, the socket was rinsed with saline and a triple antibiotic solution (triple antibiotic powder mixed with saline). The root surface was then conditioned with citric acid for five minutes [Figure 3] and then soaked in a solution containing triple antibiotic powder [Ciprofloxicin (500 mg) + Metronidazole (300mg) + Doxycycline (100 mg)], and a saline solution for 5 minutes. The socket was filled with Emdogain (EMD, BioraAB, Sweden), and the tooth was replanted in the socket [Figure 4]. The avulsed tooth was splinted with a semi rigid composite splint and a passive orthodontic wire to allow the stimulation of the PDL. Patient was placed on a soft diet and instructed to use chlorhexidine mouthwash twice daily.
Figure 3: Surface treatment of the root surface of the avulsed tooth with citric acid revealing no tooth remnants in the socket the patient in the study

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Figure 4: Replanted avulsed 11 in the socket in the patient in the study

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The patient was followed up after one week, and the extra-oral swelling had resolved by then. The buccal vestibule and facial gingiva opposite the maxillary central incisors looked healthy. The periapical radiograph revealed no periapical osseous breakdown. On vitality testing, 12, and 21 showed a delayed response. Also, 21 appeared discolored. Endodontic treatment of the 11, 12 and 21 was initiated under rubber dam (split dam technique) in the same appointment. Endodontic access cavity was created on the replanted tooth under local anesthesia, lidocaine with adrenaline, infiltration anasthesia. The contents of the canal were debrided and a tentative working length was established. Hypochlorite irrigation was performed before, during and after the debridement procedure. The canal was than dried and packed with calcium hydroxide (RC Cal, Prime dental products, India) paste. The temporary restoration was placed in access cavity and patient was appointed for follow up in the 2 weeks.

Patient reported on 15 th April 2005 without any clinical symptoms such as pain or swelling. As the replanted tooth was still not completely firm in the alveolus, it was decided to continue the splinting for another week. Radiographic examination showed no evidence of resorption. Biomechanical preparation was done by a step-back technique with an apical preparation corresponding to the size of 50 K-files (Mani Inc., Japan), followed by obturation using lateral condensation technique and AH plus sealer. Access cavity was then sealed with Glass Ionomer Cement (FUGI II, Japan), and a Composite (3M, ESPE, USA) build up was done for 11, 12, 21 [Figure 5].
Figure 5: 11 Post obturation of the patient

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Patient was recalled on 22 nd April 2005 for a follow up appointment. The splint was removed and the radiographic examination revealed no root surface changes. On 25 th June 2005, the patient returned without symptoms such as pain or swelling, the tooth was firm without mobility, and there were no radiographic changes. However, the teeth 11, 12 and 21 were discolored, and this was of esthetic concern to the patient. Non vital bleaching of 11, 12 and 21 was planned; however, the patient insisted for immediate esthetic correction, and hence, ceramic crowns with Zirconia core were planned. Patient was recalled on 26 th September 2005, the teeth were prepared and the impression was taken using addition silicone impression material (Aquasil monophase, Dentsply, Caulk, USA). Ceramic crowns were replaced the resin provisional after a week [Figure 6].
Figure 6: Post-operative facial view after crown cementation of the patient

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Patient was recalled then at 12 months [Figure 7], 18 months and 5 year [Figure 8] follow-up appointments. All the three traumatized teeth were symptom free. There was no tenderness on percussionand the presence of any swelling or sinus tract formation was ruled out. The surrounding gingiva appeared completely healthy. Periapical radiograph revealed complete apical healing and regeneration of PDL for the replanted tooth.
Figure 7: Post-operative 1 year follow up of the patient

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Figure 8: Post-operative 5 year follow up of the patient

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   Discussion Top

Healing and long term retention of an avulsed tooth depend upon the stage of root development when the tooth is avulsed and the length of the extra alveolar storage period, that is, immediate or delayed replantation. [7],[9] The more the extra oral dry time, the lesser are the chances of healing. In this unique case report of a 18 year old patient with extended extra oral dry time for his avulsed 11 of about 21 hours, we have shown how the case was attempted at being managed. Normal Saline was used as storage media as it is easily available. [10],[11] The regimen adopted here was the same as suggested by Selvig, et al. to increase the chances of success of delayed replantation cases, with few modifications. The tooth was first soaked in citric acid for 5 minutes followed by triple antibiotic solution for 5 minutes. The root surface was demineralized by citric acid and Doxycycline (triple antibiotic solution) exposing the collagenous matrix of the hard tissues of the root surface. This matrix acts as substrate for the mesenchymal cells, and also inhibit and reduce the bacterial adhesion. [12]

Before replantation of the avulsed 11, the socket was filled with Emdogain (enamel matrix protein). Rationale to use Emdogain in cases with delayed replantation was based on its ability to promote periodontal regeneration and prevent root resorption and or ankylosis. [13] The avulsed tooth was held in the socket with a semi rigid splint using a passive orthodontic wire, thus allowing the stimulation of the PDL formation and reducing the chances of ankylosis. [6] The patient was given a 1 week course of systemic antibiotics after replantation following the pharmacological guidelines. Antibiotics are thought to minimize infection that may arise from necrotic pulp and reduce the incidence of inflammatory resorption. [14]

Calcium hydroxide intracanal medicament was placed for one week which was followed by instrumentation and obturation. [5] It was observed that teeth treated with calcium hydroxide alone exhibited more severe resorption, while the teeth treated with calcium hydroxide followed by obturation with gutta-percha and sealer, showed least resorption. [4] The goal of replanting the permanent incisor was to retain the tooth until any surface resorption was observed, and to prevent the space loss. The most common complications of delayed replantation are inflammatory resorption and tooth ankylosis. If the regimen of proper root surface treatment is followed, a good prognosis with less than 2% resorption can be achieved. [15] The patient was recalled to assess the status of PDL cells at 12 month, 18 month and 5 year follow up periods. At 5 years follow up, the avulsed tooth was asymptomatic with a normal percussion tone and reduced mobility. Further, the tooth showed no signs of ankylosis, and the absence of clinical and radiographic signs of infection with an intact lamina dura were suggestive of a favorable healing.

   References Top

1.Bakeland LK, Ingle IJ. Endodontic considerations in dental trauma. Endodontics. 5 th ed. Hamilton London: BC Decker Inc; 2002. p. 795-6.  Back to cited text no. 1
2.Goldbeck AP, Haney KL. Replantation of an avulsed permanent maxillary incisor with an immature apex: Report of a case. Dent Traumatol 2008;24:120-3.  Back to cited text no. 2
3.Trope M. Current concepts in replantation of avulsed teeth. Alpha Omegan 1997;90:56-63.  Back to cited text no. 3
4.Anderson JO, Borum MK, Jacobson HL, Anderson FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995;11:59-68.  Back to cited text no. 4
5.Anderson JO, Borum MK, Jacobson HL, Anderson FM. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 1995;11:51-8.  Back to cited text no. 5
6.Ashkenazi MZ. In vitro clonogenic capacity of periodontal ligament fibroblasts cultured with emdogain. Dent Traumatol 2006;22:25-9.  Back to cited text no. 6
7.Barret EJ, Kenny DJ. Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endod Dent Traumatol 1997;13:269-75.  Back to cited text no. 7
8.Anderson L, Bodin I, Sorenson S. Progression of root resorption following replantation of human teeth after extended extraoral storage. Dent Traumatol 1989;5:38-47.  Back to cited text no. 8
9.Souza B, Luckemeyer D, Felippe W, Simoes C, Felippe M. Effect of temperature and storage media on human periodontal ligament fibroblast viability. Dent Traumatol 2010;26:271-5.  Back to cited text no. 9
10.Koca H, Ak T, Sutekin E, Koca O, Acar S. Delayed replantation of an avulsed tooth after 5 hours of storage in saliva; case report. Dent Traumatol 2010;26:370-3.  Back to cited text no. 10
11.Chung H, Kim M, Yang W, Ko H. An intersting healing out come of a replanted tooth: A case report. Dent Traumatol 2011;27:77-80.  Back to cited text no. 11
12.Selvig KA, Bjorvatn K, Boogle GC, Wikesjo UM. Effect of stannous fluoride and tetracycline on repair after delayed tooth replantation in dogs. Scand J Dent Res 1992;100:200-3.  Back to cited text no. 12
13.Petrovic B, Markovic D, Peric T, Blagojevic M. Factors related to treatment outcomes of avulsed teeth. Dent Traumatol 2010;26:52-9.  Back to cited text no. 13
14.Flores MT, Anderson L, Anderson JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130-6.  Back to cited text no. 14
15.Trope M. Avulsion of permanent teeth: Theory to practice. Dent Traumatol 2011;27:281-94.  Back to cited text no. 15

Correspondence Address:
Sheetal Ghivari
Department of Conservative Dentistry and Endodontics, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.111271

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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