Avulsed permanent central incisor with a long dry time in a 9-year-old
A 9-year-old boy is brought to the surgery 80 minutes after falling from his bicycle. His upper left central incisor was avulsed and has been carried in a dry tissue. On examination the socket is intact, the tooth has a closed apex and no fracture, and there is an enamel-dentine fracture of the upper right central incisor which responds normally to sensibility testing. He is fit and well, fully immunised, takes no medication and has no other injuries. He is due to fly abroad on holiday in three days.
1. How do you manage the avulsed tooth and the socket now, and what are the critical variables?
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Recognise the determinant first: extraoral dry time. The prognosis of a replanted tooth is set almost entirely by the viability of the periodontal ligament. This tooth has been dry for around 80 minutes with a closed apex - that is well beyond the 60-minute threshold at which the ligament is expected to be non-viable. Be clear in your own mind: replantation here is not a treatment that will save the tooth in the long term.
What that means practically
- Replantation is still an option rather than a rule. The realistic outcomes are replacement resorption (ankylosis) and loss during the growth spurt, or inflammatory resorption. Some clinicians replant anyway to preserve alveolar bone and appearance and to allow planned decoronation later; others advise against replantation of a closed-apex tooth with this dry time. This is a genuine area of divergence, so present it as a choice with an informed discussion rather than pretending there is one right answer.
- If replanting: handle the tooth by the crown only, do not scrape or curette the root or use a scrub brush, do not remove the socket clot, and do not attempt root canal treatment before replanting. Replant with gentle digital pressure; no force.
- If not replanting: the socket is left to heal and the focus shifts to the traumatised 11, the alveolar ridge and the eventual replacement plan, which cannot be finalised until growth is complete.
Check and record: tetanus status (fully immunised, so no booster needed, but record it), and examine thoroughly for a root fragment in the lip or socket and for an associated alveolar fracture.
2. Assuming replantation is agreed, describe the splint, the adjunctive measures and the follow-up, justifying each.
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Splinting
- A flexible splint (wire and composite, or a light nylon/composite splint) placed on the two adjacent teeth, with the composite only on enamel, not extending onto the traumatised tooth's gingival third. The purpose is to hold position, not to immobilise rigidly: rigid splinting increases ankylosis, and ankylosis is precisely the risk here.
- Duration 2 weeks for a closed-apex tooth with an intact socket. Longer is not better.
- Check the occlusion in centric and lateral excursions before discharge; a splint that creates a traumatic occlusion does its own damage.
Adjuncts
- Systemic antibiotic - amoxicillin (or an appropriate alternative if allergic) for about a week, to reduce the risk of bacterial contamination of the necrotic pulp space and subsequent inflammatory resorption.
- Chlorhexidine 0.12% mouthwash twice daily for a week (or applied with a cotton bud in a young child) and extra-oral chlorhexidine on the gingivae around the splinted tooth.
- Soft diet, avoid biting on the tooth, meticulous plaque control - the splint is a plaque trap.
- Analgesia: paracetamol, with ibuprofen appropriate if there is no contraindication.
Follow-up and the endodontic decision Review at 2 weeks for splint removal, then at 4 weeks, 3 months, 6 months and 1 year, with radiographs and sensibility testing. For a closed apex, root canal treatment is generally planned early (commonly within 7-10 days) with a calcium hydroxide dressing, because the pulp is predictably necrotic and inflammatory resorption is the risk to pre-empt. Sensibility testing is unreliable in the first weeks and a negative response does not by itself mean the pulp is dead.
3. He is flying in three days. What do you tell the family, and what would you modify?
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What to tell them - in plain words
- The tooth has been out of the mouth for well over an hour in a dry tissue, and that is the single worst thing for its long-term survival. Replanting gives the best chance of appearance and bone, but the tooth is likely to fuse to the bone and may not last through his teenage growth. Say this now, not after the failure; families cope far better with an honest prediction than with a surprise.
- Even if the tooth fails, the socket and bone will be preserved, which keeps his options open for a definitive replacement once growth has finished. Avoid any suggestion of an implant at the age of 9: he has several centimetres of growth left and implants do not move with the alveolus.
- The fractured 11 needs a sealed composite restoration or a temporary seal in the short term - pulp protection first, appearance second.
The holiday
- Flying with a splint and recent dental trauma is not in itself dangerous, but the practical problems are real: pain, a loose splint and no access to review. If the flight is unavoidable, provide written instructions, a contact route, and a check before departure.
- Do not let the holiday dictate the clinical plan. Do not, for example, leave the tooth unsplinted or leave the 11 unsealed in order to fit around it, and do not cut follow-up short.
- If the flying date cannot be met, arrange review at 2 weeks with a dentist abroad explicitly in writing, and give the family the radiograph and a short summary to hand over.
- Give clear red flags: pain, swelling, mobility, a bad taste, or the tooth going pink or grey - the last two suggest resorption, and early recognition is the only thing that changes the outcome.