Delayed Replantation of an Avulsed Immature Central Incisor With 45 Minutes of Dry Storage
A 9-year-old boy is brought to the clinic at 17:40. He fell from his bicycle at 15:00 and his upper right central incisor (11) was avulsed. A teacher picked the tooth up by the crown and wrapped it in a paper tissue; 45 minutes later the mother placed it in a small carton of milk, where it stayed until arrival. Total extraoral time is therefore about two hours forty minutes, of which roughly 45 minutes was dry. The child is alert, has had no loss of consciousness or vomiting, and takes no medication. His tetanus record cannot be found; the last documented booster was at 4 years old.
Examination: the socket of 11 is intact and the radiograph shows no alveolar fracture, no root fragments and a wide open apex. The avulsed tooth has a clean root surface with no fracture, but the periodontal ligament looks dry and is missing over about one third of the root. The adjacent 21 has an enamel–dentine crown fracture, responds to cold, and is not mobile or tender to percussion. The other teeth and soft tissues are unremarkable, apart from early caries in 55 and 65.
1. Would you replant the tooth? Justify your decision and describe exactly what you would do to the tooth and socket before replantation.
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Yes, replant - after an honest discussion with the parents.
- The socket is intact, there is no alveolar fracture and no other injury. Replantation preserves alveolar bone and gingival architecture, which matters greatly in a 9-year-old who cannot have an implant until growth is complete. Even with a poor periodontal prognosis, replantation is generally recommended in a child because the alternative - space loss, ridge resorption and complex later reconstruction - is worse.
- Forty-five minutes of dry storage within about two hours forty minutes extraorally means the periodontal ligament is largely non-viable. Expect inflammatory resorption or ankylosis rather than a normal periodontal ligament, with survival often measured in a few years. The parents must hear this before treatment starts, and it must be documented.
- Technique: handle the tooth by the crown only. Do not curette the socket. Irrigate gently with saline. Remove gross debris from the root with saline-soaked gauze rather than scraping. Some delayed-replantation protocols recommend a brief soak in a doxycycline solution to reduce resorption; this is optional and must not delay replantation. Replant with gentle digital pressure, then confirm position clinically and radiographically.
- The wide open apex offers a theoretical chance of revascularisation, but with this dry time it is unlikely.
- Do not replant if the socket is fractured or the tooth is so contaminated it cannot be cleaned; neither applies here.
2. Describe your splinting, prescribing and tetanus plan, and how you would manage the crown fracture on 21.
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Splint. A flexible splint (wire and composite, or nylon) from 11 to the adjacent teeth, placed slightly supragingivally so the gingiva is not traumatised, with no occlusal interference. Two weeks is the recommended duration for avulsion. Check the occlusion in centric and excursive movements and adjust the splint rather than the tooth.
Antibiotics. Systemic antibiotics are recommended after replantation. Phenoxymethylpenicillin or amoxicillin for seven days is appropriate, after checking allergy. Tetracycline is an evidence-based alternative and may reduce resorption, but in a 9-year-old the risk of intrinsic staining has to be weighed; a single short course carries a small risk, and amoxicillin is a defensible first choice.
Tetanus. The record is incomplete, so refer him the same day to his physician or the emergency department for assessment and a booster if indicated. Do not let this delay replantation.
Analgesia and plaque control. Paracetamol or ibuprofen by weight; chlorhexidine 0.12% twice daily for two weeks, applied with a cotton bud rather than by vigorous rinsing in a young child, to reduce plaque-related resorption.
21 crown fracture. The pulp is not exposed and the tooth responds to cold, so seal the dentine with glass-ionomer or composite and check vitality at follow-up. Warn the parents that a temporary loss of response can occur after trauma, and that if the tooth later becomes non-vital it will need endodontic treatment.
Instructions. Soft diet for two weeks, no biting on the splinted teeth, no contact sports, and how to clean around the splint with a soft brush.
3. What prognosis would you give the family, what follow-up schedule would you arrange, and what findings would prompt endodontic or surgical intervention?
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Prognosis discussion. Be honest but not hopeless. 'The tooth was out of the mouth for nearly three hours and was dry for part of that, so the fibres that hold it in have been damaged. We will put it back because that gives the best chance of keeping the bone and gum in the right place for his future, but we expect problems: the root may be eaten away, or fuse to the bone, over the next months or years. There is a small chance it heals normally. We will monitor and decide together as things change.'
Follow-up - clinical examination and periapical radiograph:
- 2 weeks: remove the splint, check soft tissue healing and mobility.
- 4 weeks, 3 months, 6 months and 12 months, then yearly until root formation is complete and growth has ceased.
- Watch for a sinus tract, percussion tenderness, mobility, inflammatory resorption (usually within the first 12 months, often at 3 to 6 months) and replacement resorption or ankylosis (which may appear later and progress slowly).
Intervention
- Signs of infection or inflammatory resorption: endodontic treatment. With an open apex, consider revascularisation or apexification rather than immediate conventional obturation; in delayed replantation with a necrotic pulp, root canal treatment is often needed anyway, with calcium hydroxide or a bioceramic between visits.
- Ankylosis: do not rush to extract in a growing child. Decoronation - removing the crown and leaving the root to be replaced by bone - preserves ridge volume for later implant placement. Extraction is reserved for persistent infection or severe infra-occlusion with ridge collapse.
- Also monitor the 21 for vitality and the developing occlusion; a 9-year-old with an avulsed upper central incisor is at risk of space loss and may need orthodontic review later.
Give the family written instructions and an emergency contact, and send a copy of the letter to their physician and the school.