Received: 8 December 2023

| Revised: 10 January 2024

| Accepted: 25 January 2024

DOI: 10.1002/ccr3.8487

CASE REPORT

Delayed replantation of avulsed permanent maxillary

central incisor: Case report with 6-­year follow-­up

Amita Rai1 | Bandana Koirala2 | Mamta Dali2 | Sneha Shrestha2

1
Department of Pediatric and
Preventive Dentistry, People's Dental Key Clinical Message
College and Hospital, Kathmandu, Replantation should be attempted in any case of avulsion, be it immediate or
Nepal
2
delayed. Retention of the replanted tooth helps in preservation of adjacent alveo-
Department of Pedodontics and
Preventive Dentistry, College of Dental
lar bone. Despite the occurrence of replacement resorption, the tooth can stay
Surgery, B.P. Koirala Institute of Health healthy and functional in the arch for a longer duration.
Sciences, Dharan, Nepal
KEYWORDS
Correspondence
avulsion, delayed replantation, external cervical resorption, replacement resorption
Amita Rai, Department of Pediatric and
Preventive Dentistry, People's Dental
College and Hospital, Nayabazar,
Kathmandu, Nepal.
Email: amitarai2013@gmail.com

1 | I N T RO DU CT ION the extra-­alveolar conditions can be modified by storing

the avulsed tooth in a physiological storage medium.1
Avulsion, or exarticulation, is the complete displacement Numerous literatures have been published about replan-
of a tooth from its alveolar socket as a result of trauma.1,2 tation of an avulsed tooth, but literature reporting replan-
Immediate replantation is the treatment of choice in case tation after more than 72 h of avulsion with follow-­up of
of avulsion.3,4 However, immediate replantation generally more than 5 years are scarce.6–8
is not possible due to the presence of other comorbidities The present case report showcases the delayed replan-
like extensive life-­threatening injuries, complex damage tation of a permanent maxillary central incisor after 72 h
to the recipient site like complex dentoalveolar fractures, of avulsion where the avulsed tooth was stored in a dry
patient's emotional condition at the moment of trauma, field before replantation. Clinically, the replanted tooth
lack of accessible health care facility, and lack of knowl- was asymptomatic till 5-­year follow-­up visit, but there was
edge and confidence about the immediate replantation in presence of pinkish discoloration and slight infraposition
the general population or even the dental professionals.2 on the 6-­year follow-­up visit. Radiographically, there was
The long-­term prognosis of a replanted tooth is question- replacement root resorption on the 4-­week follow-­up visit
able as the replanted tooth might require extraction at a which was progressing gradually. Apart from that, there
later stage due to the possible complications like surface was evidence of external cervical resorption (ECR) on the
resorption, replacement resorption, and inflammatory re- 5-­year follow-­up visit which progressed extensively on the
sorption. However, not replanting the avulsed tooth is an 6-­year follow-­up visit, due to which plan for extraction of
irreversible decision, so every attempt should be made to replanted tooth was made. Nevertheless, the replanted
replant it.3–5 Where immediate replantation is not feasible, tooth served as an interim prosthesis till 6 years.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

Clin Case Rep. 2024;12:e8487.  wileyonlinelibrary.com/journal/ccr3 | 1 of 7

https://doi.org/10.1002/ccr3.8487
2 of 7 |    RAI et al.

2 | C A S E -­RE PORT

A 14-­year-­old female patient reported to the Department

of Pedodontics and Preventive Dentistry on March 14,
2017 with a chief complaint of dislodged upper front tooth
due to trauma 72 h back. The injury had occurred as she
slipped while pumping water from a hand water pump.
There was no history of loss of consciousness and bleed-
ing or discharge from the ear and nose. The day after the
injury, she had visited the nearby primary health care
center (PHC), but no treatment was provided there. There
was no history of tetanus prophylaxis in the PHC. The pa-
tient had brought the dislodged tooth stored in dry field
(Figure 1A). On examination of the avulsed tooth, there
was fracture in the incisal surface involving enamel and
dentin, and the periodontal ligament tissues of the avulsed
tooth were desiccated.
On extraoral examination, there was an abrasion in the
chin and the patient had convex a facial profile. There was
no evidence of swelling of the face, deviation or deflection
of the jaw, decreased mouth opening, and step deformity.
Intraorally, there was an empty socket of 11 and the socket
was filled with blood clots (Figure 2A). The patient had
end on molar relationship and overjet of 4 mm. On radio-
graphic examination, the socket was intact without any
sign of alveolar fracture (Figure 3A). The adjacent teeth
were intact with normal mobility.
Replantation of the avulsed tooth was planned.
Informed assent and consent were obtained for the pro-
cedures from the patient and her father. The avulsed tooth
was then cleaned and the remaining periodontal liga-
ment (PDL) fibers were removed with Gracy curette no.
1/2 (Hu-­Friedy Mfg. Co. LLC, USA) (Figure 1B), followed
by soft pumice prophylaxis. As the extraoral dry time was
more than 60 minutes, extraoral root canal treatment
(RCT) of the avulsed tooth was planned. Access opening
of the avulsed tooth was done followed by working length F I G U R E 1 Treatment of the avulsed tooth before replantation:
determination and biomechanical preparation (BMP) (A) Avulsed tooth. (B) Removing the PDL cells. (C) Performing
using sizes 10–55 Kerr files (Mani Inc. japan). After clean- extraoral RCT. (D, E) After completion of extraoral RCT. (F)
ing, shaping, and drying of the avulsed tooth root canal, Placing the tooth in a solution of 2% sodium fluoride.
obturation with gutta-­percha points (Meta Biomed Co.
Ltd., Korea) using lateral condensation technique was
done (Figure 1C–E). The fractured incisal surface was
restored with composite resin (Tetric N-­ Ceram, Shade then splinted from canine-­canine using a 0.4-­mm diam-
A2, Ivoclar Vivadent, Liechtenstein). The avulsed tooth eter stainless wire and composite resin (Tetric N-­Ceram,
was then kept in a solution of 2% sodium fluoride (NaF) Shade A2, Ivoclar Vivadent, Liechtenstein) (Figures 2C
(Fluocal Gel, Septodont Healthcare Pvt. Ltd, India) for and 3B). Antibiotics (Amoxicillin 500 mg eight hourly for
20 min (Figure 1F). Under local anesthesia (Lignocaine 7 days) and analgesics (Paracetamol 500 mg as per need)
2%, LOX*2% Neon Laboratories Limited, India), the were prescribed. The patient was advised to consume soft
socket was curetted and cleaned with 5% normal saline. diet for 2 weeks and maintain good oral hygiene. The pa-
Replantation of the avulsed tooth was done (Figure 2B) tient was then referred to the medical practitioner for the
and its proper position was verified using an intraoral evaluation of the need for an anti-­tetanus booster. The
periapical radiograph (IOPAR). The replanted tooth was splint was kept for 4 weeks.
RAI et al.    | 3 of 7

On the regular follow-­up visits till 5 years, the re- visit, the tooth was intact in the arch with no pain and
planted tooth was asymptomatic without any mo- mobility, but there was evidence of pinkish discolor-
bility, swelling, or sinus tract formation clinically ation and infraposition of <1 mm clinically (Figure 2F),
(Figure 2D,E). Radiographically, there was evidence of and the radiograph showed an increase in the amount of
replacement root resorption on the 4-­week follow-­up both the external cervical and replacement root resorp-
visit which was gradually progressing (Figure 3C–F). tion (Figure 3H). The adjacent teeth were normal both
But on the 5-­year follow-­up visit, along with replace- clinically and radiographically during the follow-­up vis-
ment resorption, there was initiation of external cervi- its. The patient was then referred for the extraction of
cal resorption also (Figure 3G). On the 6-­year follow-­up the tooth followed by provision of definitive prosthesis.

F I G U R E 2 Intraoral frontal photographs before replantation and post-­replantation follow-­up visits: (A) Preoperative. (B) After
replantation of avulsed tooth. (C) After splinting. (D) Four-­week follow-­up. (E) 19-­month follow-­up. (F) 6-­year follow-­up.

F I G U R E 3 Intraoral periapical radiographs before replantation and post-­replantation follow-­up visits. (A) Preoperative. (B) After
replantation of avulsed tooth and splinting. (C) Four-­week follow-­up. (D) Six-­month follow-­up. (E) Twelve-­month follow-­up. (F) Nineteen-­
month follow-­up. (G) Five-­year follow-­up. (H) Six-­year follow-­up.
4 of 7 |    RAI et al.

Extraction of the replanted tooth along with intraosse- management of the avulsed tooth, so the avulsed tooth
ous gutta percha was done which was then followed by was kept in dry field for 72 h, which ultimately led to
placement of implant prosthesis by the team of perio- compromise in the post-­replantation outcome. Provision
dontist and prosthodontist. of adequate infrastructure in the local health care cen-
ters, and knowledge about the emergency management
among the dentists, other health care professionals, and
3 | DI S C USSION even general population should be prioritized during
policy making.
Traumatic dental injuries (TDI) are very frequent in every Replantation of the avulsed tooth helps to maintain al-
part of the world. According to a comprehensive review veolar bone volume and morphology which at a later date
done by Petti et al. in 2018,9 the worldwide prevalence provides more rehabilitation options like implants.19,20
of TDI was 15.2% in permanent dentition, 22.7% in pri- Apart from that, retention of the patient's tooth by replan-
mary dentition, and 18.1% among 12-­year-­old children. tation or interim prosthesis offers psychological benefit to
Avulsion of permanent teeth is seen in 0.5%–16% of all the patients that his/her tooth was put back rather than
TDI.3,10 Among the TDI that occurred in Nepalese chil- an artificial tooth.21 This was evident in the present case
dren, avulsion of the tooth was found to be 19.64%, and as well, the replanted tooth provided immense psychologi-
the prevalence of avulsion was higher in permanent teeth cal benefit to the patient who was a 14-­year-­old adolescent
as compared to primary teeth.11 Age-­wise, children in the concerned very much about her esthetics.
age group 6–10 years have shown the highest prevalence Replantation of an avulsed tooth within 5 min of avul-
of avulsion. The reason for this high prevalence in this sion usually ensures prompt return of the PDL cells to
age group could be attributed to their playful nature and their normalcy.20,22 In case of more than 15 min of dry
their active involvement in contact sports.2,11–13 Injuries storage time, the precursor, progenitor, or stem cells are
of teeth like fractures are more common among adults no longer able to differentiate into fibroblasts,1,2 and after
whereas luxation injuries are more common in children. 30 min of dry storage, virtually all of the PDL cells that are
The smaller crown root ratio and elasticity of alveolar remaining on the root surface are likely to have become
bone which favors absorption of energy are the reasons necrotic hence the poor long-­term prognosis.1–3,23
for more frequent luxation injuries in children.14 Gender-­ Studies have been done focusing on either cell-­based
wise, males have been shown to have a higher prevalence therapy or activation of endogenous repairing systems in-
of avulsion injuries.12 The reason might be that boys pre- duced by additional biological cues. In a study done on
fer outdoor activities and contact sports more when com- animal models, there was a reestablishment of the PDL
pared to girls.11 Maxillary central incisors are the most cells where the cultured PDL cells were applied in de-
commonly avulsed teeth,12 and the patients often report layed replantation cases. Apart from cultured PDL cells,
a history of increased proclination of the avulsed teeth15 PDL stem cells, bone marrow mesenchymal stem cells,
as seen in the present case. Avulsion injuries are some- adipose-­derived stem cells, and other induced pluripotent
times associated with fractures of the avulsed tooth and stem cells have shown favorable results in reestablishing
intraoral and extraoral soft and hard tissue injuries.12 In the formation of PDL cells.24 Different literatures have
the present case also there was associated soft tissue in- presented cases in which delayed replantation had been
jury in the chin. attempted,6–8,25–31 but most of them being <72 h of extra-
As avulsion is a dental emergency situation, prompt oral dry time, and the replanted teeth serving its function
management of the avulsed tooth ensures better progno- for years.6,7,25–34
sis. A study conducted by Mazur et al. in 202116 among Storage medium enhances the healing outcome of
Italian dentists showed that the proper management the replanted teeth. Different materials/solutions like
protocol of avulsed tooth was not well understood by Hank's Balanced Salt Solution (HBSS), Eagle's Medium,
the participants and the same findings were revealed milk, ViaSpan, Eurocollins, Minimum Essential
by a study done among the Nepalese dentists.17 A study Medium, Gatorade, Custodiol, Dubelco's storage me-
conducted by Pradhan et al. among the Nepalese school dium, propolis, tooth rescue box (Dentosafe), condi-
teachers also revealed that the participants lacked ade- tioned medium, contact lens solution, tap water, egg
quate knowledge about emergency management of den- white, saliva, normal saline, saliva extract, green tea, red
tal trauma.18 In the present case also, the patient reported mulberry, ricetral, and coconut water are used as stor-
to the hospital after 72 h of avulsion as she lived in re- age media.1,2 A study conducted by Hegde et al.35 has
mote area where health care facility and manpower for shown that GC tooth mousse plus which contains ca-
management of avulsion cases were not available. The sein phosphopeptides-­ amorphous calcium phosphate
patient did not have knowledge about the emergency (CPP-­ACP) can also be used as storage media to prevent
RAI et al.    | 5 of 7

desiccation of PDL cells for up to 60 min. In the pres- resorption that initiates at the cervical aspect of the tooth.
ent case, although the extraoral dry time was 72 h which The exact cause and pathogenesis of ECR remain poorly
indicates a poor long-­term prognosis, replantation was understood. ECR is found to be caused due to the over-­
attempted. Once the patient and the avulsed tooth were proliferation of PDL tissues and inflammation is believed
received in the hospital, every attempt was made to fol- to be a prerequisite for the initiation. External repair, in-
low the standard guidelines.4 ternal repair, palliative treatment, and extraction are the
Placement of replanted tooth in 2% NaF for 20 min treatment options for ECR. In the present case, as there
was recommended by the IADT 2012 guidelines. NaF was rapidly progressing ECA and progressing replacement
was suggested to inhibit root resorption in delayed re- resorption, the mutual decision was made along with the
plantation cases as NaF was believed to convert the hy- patient to keep the tooth in its usual state till it was asymp-
droxyapatite present in dentin into fluorapatite which tomatic and then to refer for extraction.39
is more resistant to resorption. However due to lack of In the present case, the occurrence of inflammatory
scientific evidence, the IADT 2020 guidelines no more resorption (external cervical resorption) might be due to
advocated for the pretreatment of avulsed tooth with the residual inflamed PDL cells or residual inflamed pulp
NaF.3,4 A study done by Roskamp et al., in which post-­ tissued in the root canals which might have initiated the
replantation outcome was compared among the re- resorption. Meticulous cleaning of the root surface and
planted teeth managed following IADT 2012 and IADT the root canals might have prevented the occurrence of
2020 guidelines, showed no statistically significant ECR. Apart from ECR, the occurrence of replacement root
difference.36 resorption in the present case might be due to the pro-
Regular clinical and radiographic evaluation of the longed extraoral dry time of the avulsed tooth. This can
replanted teeth is advised at 2 weeks, 4 weeks, 3 months, be considered the limitation of the present case report.
6 months, 1 year, and yearly thereafter for at least 5 years. Nevertheless, the authors tried to provide the best man-
The periodontal reactions to replantation mainly occur in agement which was possible for the patient in the pre-
four different manners; healing with normal PDL, healing sented scenario, and occurrence of resorption in different
with surface resorption, healing with replacement resorp- forms has been reported by many authors6,25,26,29–31,34,39 in
tion, and healing with inflammatory resorption.5 Healing replantation cases despite the best possible management.
with normal PDL and healing with surface resorption are Lastly, the goal of replanting the tooth in the present
considered as the favorable outcomes,37 whereas the pres- case was to serve as the interim prosthesis until the patient,
ence of swelling or sinus tract, excessive mobility, infrapo- who was just 14 years of age, would be ready for the defini-
sition of the replanted tooth, replacement root resorption, tive prosthesis. Provisional prosthesis like removal partial
external root resorption, internal root resorption, external denture (RPD) and Ribbond fiber bonded fixed prosthesis
cervical resorption, and peri-­radicular radiolucency are can also be considered as the possible prosthetic options
the unfavorable outcomes in case of replantation.3,19 A in young patients. The coronal fragment of the avulsed
meta-­analysis conducted by Souza et al. have found the in- tooth can also be used for the rehabilitation of edentulous
cidence of internal root resorption to be 1.2%, surface root space along with RPD or ribbond bonded fixed prosthe-
resorption to be 13.3%, inflammatory root resorption to be sis.21,40 Retention of the whole or decoronated replanted
23.2%, and replacement root resorption to be 51%, which tooth for some years can be considered a success as the
shows that resorption in any form is inevitable sequelae of alveolar bone can be preserved, which on a later date pro-
a replanted tooth.6,7,25,26,29,30,34 vides a greater number of options for definite prosthesis
In delayed replantation cases, root resorption is com- like implants.19 Considering all the adversities like pro-
mon.3,38 In the present case, the occurrence of replace- longed extraoral dry time of 72 h, the replanted tooth was
ment root resorption within a month of replantation clinically intact in the arch for 6 years despite progressing
might have been due to the prolonged extraoral dry time replacement and external cervical resorption, and at the
that resulted in the destruction of PDL cells.1,3,4,23 Usually, same time having back own tooth replanted boosted the
replacement resorption is associated with infraposition. In confidence in the patient who was a 14-­year-­old adoles-
the present case, there was no evidence of infraposition till cent concerned very much of her esthetics.
5-­year follow-­up but in the 6-­year follow-­up visit, slight in-
fraposition of the replanted tooth was noticed. Apart from
replacement resorption, external cervical resorption was 4 | CONC LUSIONS
noticed on the 5-­year follow-­up which progressed rapidly
within a year. Traumatic dental injuries are inevitable but what follows
External cervical resorption which is also known as after such incidents are very much under the control of
invasive cervical resorption, is a specific class of external dental professionals once the patient is received. The
6 of 7 |    RAI et al.

present case report emphasizes the fact that replantation 5. Soares AJ, Souza GA, Pereira AC, Vargas-­Neto J, Zaia AA,
should be attempted in any case of avulsion, be it imme- Silva EJNL. Frequency of root resorption following trauma
diate or delayed. Despite the occurrence of replacement to permanent teeth. J Oral Sci. 2015;57:1-7. doi:10.2334/
resorption, the tooth can stay healthy and functional in josnusd.57.000
6. Ize-­Iyamu IN, Saheeb B. Reimplantation of avulsed dry perma-
the arch for a longer duration. Never stop hoping, never
nent teeth after three days: a report of two cases. Niger J Clin
stop trying! Pract. 2013;16:119-122. doi:10.4103/1119-­3077.106784
7. Kirziog Z, Gungor OE, Erdog Y. 16-­year follow-­up of an avulsed
AUTHOR CONTRIBUTIONS maxillary central incisor after replantation following 10-­ h
Amita Rai: Examination of the patient; investigation; storage: an unusual case. Spec Care Dentist. 2017;37:199-203.
treatment planning; management of the patient; follow- doi:10.1111/scd.12225
­up; literature review and writing – original draft. Bandana 8. Kolli NK, Challa R, Karthik A, Nuvvula S. Delayed replantation
of avulsed tooth with 4½ days extraoral time with 18 months
Koirala: Treatment planning; investigation; supervision;
follow up. J NTR Univ Health Sci. 2017;6:136-139. doi:10.4103/2
writing – review and editing. Mamta Dali: Treatment
277-­8632.208006
planning; supervision; investigation; writing – review and 9. Petti S, Glendor U, Andersson L. World traumatic dental injury
editing. Sneha Shrestha: Treatment planning; supervi- prevalence and incidence, a meta-­analysis-­one billion living
sion; writing – review and editing. people have had traumatic dental injuries. Dent Traumatol.
2018;34:71-86. doi:10.1111/edt.12389
ACKNOWLEDGMENTS 10. Shubham S, Nepal M, Mishra R, Kandel L, Gautam N.
The authors would like to thank Dr. Nitesh Tewari for his Prevalence of traumatic dental injury in a tertiary care hos-
pital: a descriptive cross-­sectional study. J Nepal Med Assoc.
guidance during the manuscript preparation.
2021;59:31-34. doi:10.31729/jnma.5556
11. Shrestha D, Upadhyay S. Pattern of traumatic dental injuries
FUNDING INFORMATION and associated risk factors: a hospital-­based study. Orthod J
None. Nepal. 2018;8:40-45.
12. Mesquita GC, Soares PBF, Moura CCG, Roscoe MG, Paiva SM,
CONFLICT OF INTEREST STATEMENT Soares CJ. A 12-­year retrospective study of avulsion cases in a
The authors have nothing to disclose. public Brazilian dental trauma service. Braz Dent J. 2017;28:749-
756. doi:10.1590/0103-­6440201701610
13. Balgi P, Poojari M, Pol S, Shetty S, Katge F. Replantation of an
DATA AVAILABILITY STATEMENT
avulsed tooth: a case report. J Dent Health Oral Disord Ther.
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able from the corresponding author upon reasonable 14. Skaricic J, Vuletic M, Hrvatin S, Jelicic J, Cukovic-­Bagic I, Juric
request. H. Prevalence, type and etiology of dental and soft tissue in-
juries in children in Croatia. Acta Clin Croat. 2016;55:209-216.
CONSENT doi:10.20471/acc.2016.55.02.05
Written informed consent for sharing the photographs 15. Dharmani CKK, Pathak A, Sidhu HS. Prevalence of trau-
matic dental injuries to anterior teeth in 8-­ 12-­
year-­ old
and publication was taken from the patient.
schoolchildren of Patiala City, Punjab, India: an epidemiolog-
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ORCID jp-­journals-­10005-­1583
Amita Rai https://orcid.org/0000-0003-2195-6389 16. Mazur M, Jedlinski M, Janiszewska-­ Olszowska J, et al.
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