A Child with a Traumatized Immature Incisor
An 8-year-old boy is brought to the clinic 4 hours after falling from a bicycle. His upper right central incisor is extruded and mobile, with bleeding from the gingival sulcus; the upper left central incisor is intact and non-mobile. Both are permanent, immature teeth with open apices on the radiograph. The extruded tooth shows a widened periodontal ligament space but no root fracture and no alveolar fracture on the radiograph. He is cooperative, has no head injury or loss of consciousness, and no medical history of note. His mother asks whether the tooth will 'grow back into place' and whether it should simply be removed because it is a baby tooth.
1. Classify the injury, correct the mother's assumption, and state the priorities for the first appointment.
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Classification: extrusion (a luxation injury) of a permanent immature maxillary central incisor, with an open apex, seen within 4 hours - a favorable window for intervention.
Correcting the assumption: these are permanent teeth, not primary teeth; the open apices confirm immaturity and mean the tooth has real potential for revascularization and continued root development. Extraction would sacrifice that potential and commit the child to prosthetic replacement during growth. The tooth will not 'grow back' on its own - it must be repositioned.
Priorities at the first visit
- Rule out associated injuries (alveolar fracture, head injury) - already excluded clinically and radiographically.
- Reposition the tooth gently into its socket with light digital pressure, confirming position clinically and radiographically.
- Stabilize with a flexible splint for about 2 weeks; a rigid splint risks ankylosis and interferes with healing.
- Check occlusion and relieve any traumatic contact.
- Give aftercare instructions and arrange follow-up; consider tetanus status.
- Do not begin root canal treatment now: the priority is to preserve the pulp's chance of revascularization.
2. Outline the follow-up schedule and the specific clinical and radiographic signs you would monitor, and explain what you would do if pulp necrosis is later confirmed.
Read the worked answer
Follow-up schedule (typical): 2 weeks (splint removal and baseline), 4 weeks, 3 months, 6 months, 1 year, and then annually until maturity.
What to monitor
- Clinical: mobility, percussion response, color change, sinus tract, tenderness, and continued eruption/development compared with the contralateral tooth.
- Radiographic: root development, canal width, continued apical closure, periapical changes, and any signs of inflammatory resorption or ankylosis.
- Sensory testing is unreliable in immature teeth and should not be used alone to declare necrosis.
If pulp necrosis is confirmed (e.g., arrested root development, periapical radiolucency, sinus tract): for an immature tooth with an open apex, consider revascularization/regenerative endodontic procedures if suitable, or apexification with an appropriate material to induce a hard-tissue barrier before definitive obturation. The choice depends on remaining canal space, patient cooperation, and the presence of infection. Extraction remains the last resort and would require a space-maintaining or prosthetic plan coordinated with growth. Emphasize to the mother that timely follow-up is what protects the tooth, and document each review.