Avulsed immature maxillary incisor with prolonged dry storage
An 8-year-old boy is brought to the emergency clinic 4 hours after his maxillary right central incisor was avulsed during a fall at school. The tooth was picked up by a teacher, wrapped in tissue paper for 90 minutes, then placed in tap water for the journey. On arrival the tooth is out of the socket; the crown is intact, the root surface is contaminated with dirt, and the apex appears open on a periapical radiograph. The socket is filled with a blood clot and the adjacent central incisor is intruded and non-mobile. The boy is distressed, has no allergies, and his tetanus status is up to date. The parents ask whether the tooth can be put back and whether it will 'take'. The clinic has saline, saline-soaked gauze, and a flexible splint.
1. Should the tooth be replanted? Justify your decision using extraoral dry time, storage medium, and apex status.
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Replantation should be discussed as an option but with a guarded prognosis, not presented as a routine success. The tooth was dry for 90 minutes and then in tap water, which is hypo-osmotic and lethal to periodontal ligament cells. The open apex means revascularization is theoretically possible, but after more than 60 minutes of dry time the pulp and PDL are likely non-viable, so replacement resorption and ankylosis are expected. Replanting can still maintain alveolar bone and appearance during growth, but an ankylosed tooth may infra-occlude as the alveolus grows. The alternative is not to replant and manage the space prosthetically or orthodontically later. The decision should be shared with the parents, explaining that replantation is a temporary biological spacer with a poor long-term prognosis, and that the adjacent intruded tooth also needs assessment.
2. Describe the replantation procedure, splinting, and adjunctive measures you would use if the parents choose replantation.
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Hold the tooth by the crown, clean it gently with saline, and avoid scrubbing the root. Irrigate the socket with saline and remove the clot only if necessary. Replant with gentle pressure and check the position radiographically. Place a flexible splint for 2 weeks; a wire-and-composite or monofilament splint that allows physiological movement is appropriate. Prescribe amoxicillin (or doxycycline if the child is over 8 years and local protocol allows) and ensure tetanus status is current. Advise chlorhexidine rinse and soft diet. Because the apex is open but the dry time is prolonged, revascularization is unlikely; arrange endodontic review within 7–10 days and consider calcium hydroxide dressing or a bioceramic plug if infection or necrosis is evident. Do not instrument the canal aggressively if revascularization is being attempted, but the poor prognosis makes infection control the priority.
3. What follow-up and orthodontic plan would you arrange, including the intruded adjacent incisor?
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Review at 2 weeks for splint removal and healing, then at 4 weeks, 3 months, 6 months, and 1 year, with radiographs to monitor inflammatory and replacement resorption. Warn the parents that ankylosis may cause infraocclusion and that the tooth may eventually need decoronation or extraction. The intruded adjacent central incisor should be assessed radiographically for root development and position; an immature tooth may re-erupt spontaneously, while a mature intruded tooth may need orthodontic or surgical repositioning. Avoid applying orthodontic force to an ankylosed replanted tooth. Plan for space maintenance and defer any implant until growth is complete. Document the poor prognosis and ensure the child has a paediatric dental home for trauma follow-up.