Extruded immature central incisor in a tearful nine-year-old
Jasmine, aged 9, is brought in 40 minutes after falling from a swing. Her upper right central incisor (11) has been driven forward: it is extruded by about 3 mm, grade II mobile and tender to percussion. The upper left central incisor (21) has a small enamel-dentine fracture on the mesio-incisal corner; it is not mobile and responds to cold testing. Radiographs show that 11 has an open apex with roughly two-thirds root development, and no root or alveolar fracture; 21 is intact at the root. There is no pulp exposure in either tooth. Jasmine is tearful and has not eaten since the accident. She has no medical history, no allergies and her tetanus cover is up to date. Her mother asks twice whether the front tooth will 'die' and whether the tooth should simply be taken out.
1. How would you manage the 11 at this visit, including splinting, and why?
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Sequence and behaviour first - a tearful, frightened 9-year-old cannot be treated safely. I would use simple tell-show-do, treat the 21 first because it needs no local anaesthetic and builds trust, and keep the mother present as a silent comforter.
Reposition - with local anaesthetic if needed, gently push the extruded 11 back into its normal position with gauze or finger pressure, then check the occlusion. The tooth must not be left in traumatic contact, because occlusal trauma drives resorption and ankylosis.
Splint - a flexible splint: 0.016-inch stainless steel wire or nylon line bonded with composite to 11 and the two adjacent teeth, or a comparable physiological splint. It must be flexible, not rigid: rigid splinting of a luxated immature tooth increases the risk of ankylosis. Duration is 2 weeks for extrusive luxation; 4 weeks would be for lateral luxation or an alveolar fracture.
Check - occlusion, soft tissues, no other mobile or displaced teeth, and no alveolar fracture on the radiograph.
Adjuncts - no routine antibiotics. Chlorhexidine 0.12% rinse twice daily for a week, soft diet for 2 weeks, weight-based paracetamol or ibuprofen, and no pen or thumb sucking and no contact sports. Tetanus cover is current. Reassure that a little mobility and tenderness is expected for several days.
2. How would you manage the pulp of the 11, and what follow-up would you arrange? When would you intervene endodontically?
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Aim - this is an immature tooth with an open apex and no pulp exposure. The objective is to preserve pulp vitality so the root can keep forming and the walls thicken.
Do not extirpate now. Sensibility testing immediately after trauma is unreliable: a negative response now does not mean necrosis, and a positive one does not guarantee survival. The correct action at this visit is repositioning and splinting only.
Follow-up - clinical and radiographic review at 4 weeks, 3 months, 6 months, 12 months, then annually until the apex closes. At each visit: colour, mobility, tenderness, sensibility, percussion, and a periapical radiograph looking at the apex, the root walls and the periodontal ligament space.
Triggers for intervention - grey discolouration, a developing periapical radiolucency, inflammatory root resorption, arrested root development, or a persistently negative sensibility result with symptoms. The options then are pulp extirpation with apexification (an MTA plug or calcium hydroxide), or revitalisation, which is attractive at 9 because it may permit continued root development and reduce the risk of a cervical root fracture. I would discuss both with the mother if that point is reached.
The 21 - seal the enamel-dentine fracture with glass ionomer or composite to prevent microleakage. If the mother kept the fragment in saline or milk it can be reattached. Monitor vitality at the same reviews.
3. What would you say to the mother and how would you address her anxiety and her question about extracting the tooth?
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What I would say - in plain language, without jargon and without false reassurance: the tooth has been pushed forward and has been put back and splinted; the root is not fully grown, which is actually helpful because a young tooth has a better capacity to heal; the supporting ligament has been bruised and needs about two weeks of rest.
Prognosis - I would give an honest range rather than a guarantee: most luxated immature teeth survive, but a proportion lose their nerve supply and need root canal treatment later, and some discolour. I would not use the word 'dead tooth' to a 9-year-old; I would say the tooth 'may need some treatment later'.
Why we do not extract - removing the tooth now would leave a gap at an age when the bone and later orthodontics matter, and it is not necessary today. Extraction would only be considered if the tooth became infected and unrestorable.
Engagement - invite questions, check understanding by asking her to repeat the plan back, give written information with the review dates, and give the practice contact number for trauma out of hours. Explain the soft diet, the chlorhexidine rinse and the sports advice. Explain that the splint comes off in two weeks.
Anxiety - acknowledge the mother's worry explicitly, avoid rushing, and let Jasmine hold a mirror. Document the discussion, including that the risks of necrosis and of later endodontic treatment were explained.