Avulsed immature central incisor: replantation and follow-up
A 9-year-old boy is brought to the emergency department 50 minutes after falling from his bicycle and knocking out his upper right central incisor (11). His mother found the tooth on the pavement, held it by the crown, rinsed it briefly with tap water, and placed it in a cup of milk about 20 minutes after the accident. The child is alert, has no head injury, vomiting, or loss of consciousness, and no other teeth are mobile or fractured. Intraorally, the socket is intact with a blood clot, the alveolar bone is not fractured, and the adjacent teeth respond normally to cold. The avulsed tooth has an intact crown and an open apex, and its root surface looks clean. His tetanus status is unknown and he has no known allergies. The mother asks whether the tooth can be saved and whether he needs a root canal today.
1. List the immediate steps you would take in the emergency department and justify the time-critical ones.
Read the worked answer
- Replant as soon as possible. The tooth has been out for about 50 minutes, with roughly 20 minutes dry and the rest in milk; this is still within the window in which replantation offers a realistic chance of survival. Immediate replantation takes priority over radiographs.
- Assess and prepare. Check for head injury (already absent), confirm the tooth is the permanent 11 and not a primary tooth, and inspect the socket for a fractured alveolar wall. Give local anaesthesia, irrigate the socket with saline and remove the clot gently.
- Handle and replant. Hold the tooth by the crown, rinse with saline - do not scrub, use disinfectant or touch the root - and replant with gentle digital pressure. Confirm position clinically and radiographically and check the occlusion.
- Stabilise and support. Flexible splint for 2 weeks, chlorhexidine mouth rinse, soft diet, analgesia, tetanus booster if not up to date, and systemic antibiotics according to the avulsion protocol.
- Refer or schedule follow-up. Review at 2 weeks, 4 weeks, 3, 6 and 12 months, then yearly.
2. What splint would you use, for how long, and why?
Read the worked answer
A flexible splint - for example a light wire or nylon line bonded with composite to the adjacent teeth - for 2 weeks.
Reasoning: a replanted tooth needs to heal the periodontal ligament, but it also needs physiological movement to discourage ankylosis and replacement resorption. Rigid splinting for longer periods increases the risk of ankylosis and is not recommended for a simple avulsion. The splint should be passive and should not hold the tooth in traumatic occlusion; adjust it if the child cannot close comfortably. If there were an associated alveolar fracture, the splinting period would be longer. Review the splint at each visit and remove it at 2 weeks if the tooth is stable.
3. The mother asks about root canal treatment and the long-term outcome. Explain your answer, including what you will monitor.
Read the worked answer
Because the apex is open, the tooth has a chance of revascularisation if the pulp survives, or if a necrotic pulp is treated with a revascularisation procedure. That is why I would not start root canal treatment on the day of replantation: instrumenting an immature root immediately would destroy the cells needed for further root development and weaken the root.
What I will monitor: colour, mobility, percussion response, signs of sinus tract or swelling, and radiographs for pulp canal obliteration, inflammatory root resorption, ankylosis and continued root development.
If the pulp becomes necrotic with apical periodontitis, the options are revascularisation or apexification, not a standard adult root canal. The mother should understand that pulp necrosis is common after avulsion even with ideal management, and that long-term follow-up is essential.