CASE REPORT

Conservative Dentistry
and Endodontics

Delayed
Replantation of
Avulsed Permanent
Maxillary Right
Lateral Incisor:
A Case Report

Abstract
This case report presents a case of traumatic dental injury
leading to avulsion. Tooth avulsion is a dental emergency and
it needs to be addressed immediately. Replantation of the
avulsed tooth restores aesthetics and occlusal function. A 34
year old male presented with avulsed maxillary right lateral
incisor and badly fractured maxillary right central incisor due
to trauma 48hrs earlier. Treatment guidelines for avulsed
permanent teeth with prolonged extra oral time were carried
out and extra oral root canal treatment was done and the tooth
was gently repositioned and splinted. The adjacent fractured
central incisor was also endodontically treated and restored
with a custom made post. The patient was recalled after 3, 6,
Madhu Billa and 12 months for clinical and radiographic evaluation. During
P. G. Student the follow-up period both the teeth remained in a stable and
Correspondence Address functional position.
Dept of Conservative Dentistry and Endodontics
Sibar Institute of Dental Sciences || Key Words
Takkellapadu, Guntur, A. P. Avulsion, Cast Post, Replantation, Storage medium.

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 || Introduction (buccal vestibule), saline, coconut water are considered
Tooth avulsion is the complete displacement of a tooth as readily available storage media for an avulsed tooth.
from its socket1. Avulsion of the tooth comprises 1 to Water is not recommended because the hypotonic
16% of traumatic injuries in permanent dentition and > *  $†‰  # Š   :
7.2% in primary dentition. It most commonly involves et al measured the average number of vital human lip
maxillary incisors while the mandibular teeth are //   *    Z‹Œ    * 
less affected. The prevalence of avulsion in children three different storage media and concluded that after
increases between the ages of 7 and 9 years due to 12 hours, Viaspan was effective at keeping 72.9% of
incomplete root development and minimal resistance cells vital while HBSS and milk maintained the vitality
of the alveolar bone or periodontal ligament2. of 70.5% and 43.4% cells, respectively9.

The aetiology varies according to the type of dentition. The chances of functional healing can be increased
Avulsion in primary dentition is usually a result of hard by conditioning the surface of the tooth with topical
/[ *   !        *  antibiotics like minocycline and acid conditioners
sports injuries, automobile accidents in permanent such as citric acid, and also with the use of enamel
dentition. Increased overjet and incompetent lips were matrix protein (Emdogain)10. This case report presents
     *   >  the management of an avulsed maxillary right lateral
cases3. incisor tooth and badly fractured central incisor after
an extended dry extra oral period.
The primary goal in the management of an avulsed
tooth is to preserve and treat the supporting tooth
|| Case Report
tissues and to replant the avulsed teeth. The success of
replantation depends on the patient’s general health, A 35-year old male patient reported to the Department
the maturity of the root, extra oral time, and storage of Conservative Dentistry and Endodontics, SIBAR
medium4#  ' *   * Institute of Dental Sciences, with trauma to the upper
vitality in an avulsed tooth are the extra oral exposure front teeth due to a bike accident. Clinical examination
period and the medium of storage. Replantation of revealed avulsed permanent maxillary right lateral
 / >    /      incisor (tooth no #12) (Ellis class-V) and badly fractured
replantation by Andersen5. Longer the time lapse central incisor (tooth number #11) (Ellis class-VIII)
between the tooth avulsion and replantation greater is (Fig.1). Trauma had occurred 48 hours earlier. The
  =       ' patient had already consulted a general physician and
root resorption6. Lack of knowledge in the people at no neurological damage or medical complications
the site of injury for the management of an avulsed have been detected.
tooth, as also the soft tissue lacerations and bleeding The patient had collected the avulsed tooth #12
masking the loss of the teeth are two main reasons for (Fig.2A) and wrapped it in a piece of paper since
the delayed replantation7. the time of injury due to lack of knowledge about
The avulsed tooth should be located quickly and storage media. Periapical and panoramic radiographs
replanted at the site of the injury itself if possible revealed no alveolar bone wall fracture or other hard
before reaching to the dentist. If not the tooth has to tissue injuries. Examination of the avulsed tooth (#12)
be immediately placed in a suitable transport medium.
The prognosis for avulsions improves if the PDL cells
are preserved. Soder et al and Andreasen have shown
that when a tooth is avulsed from the socket, PDL
cells on the root surface will remain viable if they are
hydrated8.
Tissue transport medium, such as Viaspan (DuPont
Pharmaceuticals, Wilmington, DE) and Hank’s Balance
Salt Solution (HBSS) (Mediatech, Herndon, VA) are
Fig.1: Preoperative Photograph and Radiograph
exceptionally superior storage media while milk, saliva

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 Fig.2A: Avulsed tooth Fig.2B: Minocycline treatment

Fig.5: Composite Splinting

showed that the tooth was completely intact without

any cracks or fracture lines. Root surface was covered
with dried remnants of periodontal tissue and debris.
The adjacent central incisor was fractured 2 mm above
the cemento-enamel junction and the patient could
     *# :  !
informed about the treatment protocol and possible
risks and a consent form was duly signed.
Local anaesthesia was administered and the socket
of the tooth (#12) was gently rinsed with saline
and betadine solutions. The tooth was cleaned
Fig.3: Extraoral endodontic treatment carefully to remove necrotic and dried remnants
of periodontal tissue. The tooth was soaked for 5
minutes in minocycline solution (Fig.2B) prepared
/ +*    /  @ Z]]*
Sun Pharmaceuticals, India) with saline. Extra-oral
endodontic treatment for #12 was initiated (Fig.3)
and the root canal was obturated with AH Plus sealer
(Dentsply). Glass ionomer cement (Ketac Molar, 3M/
ESPE Dental Products, St. Paul, MN, USA) was used
to restore the access cavity. The tooth (#12) was
gently repositioned into the socket and the position
     ! >  /    
*  *#\# :  ! /  !
a 21 gauge orthodontic stainless steel wire and the
     <  : ’'!
IvoclarVivadent, Schaan). (Fig.5)
In the same visit, access opening was done for tooth
#11, working length was determined, cleaning and
* !  ! “   
irrigation with 2.5% NaOCl and 17% EDTA. Calcium
Fig.4: Replantation of avulsed tooth
hydroxide intra canal medicament was placed in the
canal as inter appointment dressing and sealed with
Cavit (3M). Oral hygiene instructions were explained

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 to the patient and the patient was advised to take soft
diet. Prophylactic antibiotic therapy with amoxicillin
trihydrate/potassium clavulanate (625mg b.i.d) and
  \]]* /## !  /  
week.
The patient was informed about the importance
of regular clinical and radiographic follow-ups. The
patient was reviewed after two weeks, and no clinical
or radiographic pathological changes were detected in
tooth #12. Simultaneously the treatment for the tooth
#11 has been carried out. The tooth was planned to be
restored with a custom made post and core. The tooth
was obturated using sectional obturation method in
Fig.6: Sectional Obturationirt #11 the apical 6 mm (Fig.6) and sealed with cavit (3M/ESPE
Dental Products, St. Paul, MN, USA).
The patient was reviewed again four weeks after
replantation, the splinting wire was removed, the tooth
(#12) strongly adhered to the socket and no mobility
was seen. Simultaneously post space preparation
was done in tooth #11 with peeso reamers, without
disturbing the adjacent replanted tooth and a wax
impression of the post space was recorded and sent
for casting.
The patient was recalled after four weeks again for cast
Fig.7: Cast Post Cementation done post cementation and follow-up of replanted tooth.
Necessary incisal adjustments were made and the post
was cemented with Type-I GIC (GC Fuji I) (Fig.7). The
!  !   >   
crown and elastomeric impressions were taken. One
week later the crowns were cemented (Fig.8) and the
patient was asked to report after 6 and 12 months
for clinical and radiographic evaluation. During the
12- month follow-up period, both teeth (#12 and
#11) remained in a stable, functional position (Fig.9).
Fig.8: Immediate postoperative photograph and radiograph The patient was kept under observation for further
evaluation.

|| Discussion
Avulsion is a dental emergency that needs to be
assessed rapidly and managed appropriately. The
determination of treatment plan is very important in
these cases. The protocol for the treatment of avulsed
permanent teeth varies according to the maturity of
Fig.9: 12 month follow-up radiograph and photograph showing
the apex and the extra oral time and the condition
no pathologic signs of the PDL cells. The storage and transport media are
   > * # U  !   *
extra-oral time, the tooth should be maintained in a

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 suitable medium, such as HBSS, saline, milk, or saliva for 5 minutes for better results. In the present study
until it is replanted. After a dry time of 60 minutes or the tooth was conditioned with minocycline solution
more, all PDL cells become nonviable. to reduce the microbial load. Minocycline also
   > '   
and replacement root resorption and facilitates the
The management of the case presented here was in
regeneration of periodontal tissues after replantation.
accordance with the replantation protocol described by
Ma KM et al in a study done on monkey teeth found
the International Association of Dental Traumatology11.
higher occurrence of complete healing (32.46%) in
In the present case, the tooth was kept in dry piece of
teeth treated with minocycline compared to delayed
paper and the extra oral dry time was more than 60
replantation group with no minocycline treatment
minutes (48 hours). If the tooth has been dry for more
(16.58%)15.
than 60 minutes before replantation, it is indicated
that the root canal treatment may be done extra-orally The patient had suffered from crown fracture of #11 as
prior to replantation because there were no chances well, along with avulsion of #12. It has been managed
 /*    >     by traditional custom made post. The traditional cast
periodontal ligament will be necrotic and not expected post provides a better geometric adaptation to the
to heal12. canals, requires minimum tooth structure removal and
adapts well to roots with minimal remaining coronal
Replantation can restore the patient’s aesthetic
tooth structure.
appearance and occlusal function and prevent
physiological trauma, which may be associated The patient has to be kept on regular clinical and
with a missing anterior. The best transportation radiographic observation for possible ankylosis,
media for avulsed teeth are Viaspan, HBSS, tissue      ' 
culture medium, cool milk, saliva (buccal vestibule), resorption. Follow-up appointments should be
and physiologic saline, in the order of preference. scheduled at 2 weeks, 4 weeks, 6 months, and 12
Milk is considered to be the best readily available months and annually for 5 years. This case report
transportation media because its osmolality and pH are describes the challenges faced by clinicians during
within the acceptable biological range. It can preserve management of multiple traumatic injuries (avulsion
the periodontal ligament cells up to six hours13. and fracture of crown en masse). Intervention should
/ /     /  *
Before initiating the replantation of avulsed teeth the
with the clinician’s skill and expectations of patients.
socket and the surrounding areas should be carefully
Therefore, the clinician should be able to identify
assessed for fractures and repositioning. Any debris
various problems involved and has to design the
on the avulsed tooth should be cleaned with sterile
treatment plan accordingly.
saline only. The PDL should be removed by soaking the
      #\”   '   
acidulated to a pH of 5.5. This procedure will remove || Conclusion
the damaged tissue that would otherwise initiate an The success of replanted avulsed tooth is directly
'   # :     + proportional to the time and storage medium used.
protein, Emdogain, is now recommended because Clinical studies have shown that teeth replaced within
recent studies demonstrate that it may make the root 20-30 minutes have the best prognosis. Despite of
more resistant to resorption and promote the growth extended dry extra oral time (48 hours) and no storage
of a new PDL from the socket14. The tooth can also media used, the avulsed tooth can be retained in a
be soaked in an antibiotic solution like minocycline stable and functional position in the dental arch.

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 Co-authors

Roopadevi Garlapati Tanuja Tiruveedula Lalitha Pulavarthi

MDS, Reader P. G. Student P. G. Student

|| References
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