Replantation of Avulsed Tooth: A Case Report and Review

Abstract

An avulsed tooth refers to a tooth that has been completely dislodged from its socket in the jaw, usually as a result of trauma or an accident. This is considered a dental emergency, and immediate action can significantly improve the chances of saving the tooth. Replantation plays a critical role in managing an avulsed tooth and aims to restore its function, esthetics, and maintain the integrity of the dental arch. Successful replantation depends on quick action, appropriate handling of the tooth, and proper postreplantation care. A male patient aged 7 years presented with a traumatic dental injury sustained to the anterior maxillary region due to an accidental fall. Avulsed tooth 21 was discovered during clinical examination; it was replanted in accordance with the International Association of Dental Traumatology's (IADT) recommendations and secured in position with splinting. Conventional root canal therapy was initiated 2 weeks postreplantation. The root canal treatment was completed 4 weeks postreplantation followed by removal of the splint. Follow-up done at regular intervals showed lack of adverse clinical signs/symptoms and lack of resorption on radiographic interpretation.

How to cite this article

Lall AB, Singhal M, Chandra L, et al. Replantation of Avulsed Tooth: A Case Report and Review. Int J Clin Pediatr Dent 2025;18(9):1153–1160.

Introduction

A significant impact to the teeth and surrounding tissues can lead to dentoalveolar trauma, potentially resulting in complex outcomes such as the avulsion of a tooth from its socket. Dental injuries are most frequently observed in children between the ages of 7 and 11.¹

The complete disengagement of a tooth from its alveolus is referred to as an avulsion. It is also known as exarticulation, and it frequently involves the maxillary teeth. Sports injuries, height falls, and automobile accidents that directly stress the teeth and periodontal ligaments are the most common causes of tooth avulsion.²

An avulsed tooth's root surface becomes extremely vulnerable to contamination from debris, soil, microorganisms, etc., if the extraoral dry period lasts more than 60 minutes. This contaminated root surface could lead to infection or difficulties during replantation. The prognosis of avulsed teeth following replantation is influenced by several factors, including the duration between the avulsion and replantation, the type of storage medium utilized, the stage of root development, the timing of root canal treatment (whether conducted prior to or after replantation), the interval at which root canal treatment is performed (immediately or after 1 week), and the surface treatment of the tooth prior to replantation.³

The major objective of avulsion treatment is to save the tooth or keep it functioning in order to prevent ankylosis, root resorption, and to allow the alveolar ridge to grow normally. Replanting the avulsed tooth as soon as possible after an avulsion injury is the best course of action. The positive prognosis in the treatment of an avulsion injury is influenced by timely intervention, considerable therapy plans, and appropriate emergency management. Previously, extraoral root canal therapy was recommended prior to replantation. However, to minimize the extraoral time, the current guidelines recommend root canal therapy be performed intraorally. Along with observation of the tooth every month to assess the vitality, mobility, ankylosis, and resorption.²

This study emphasizes the careful protocols followed in the successful replantation of an avulsed maxillary central incisor, despite a prolonged extraoral period of 90 minutes. The procedure was in accordance with the treatment guidelines outlined by the International Association of Dental Traumatology (IADT) and includes a detailed review analysis of available treatment options and pertinent findings.

Clinical Case

A 7-year-old male patient presented to the emergency department with an alleged history of fall, resulting in trauma to the anterior maxillary region. The patient preserved the avulsed tooth in a handkerchief and reported to the emergency unit approximately one and a half hours after the incident of trauma. The patient had no significant medical history and remained alert and responsive throughout the examination process.

The extraoral examination revealed swelling over the upper lip with no soft tissue injury. On intraoral examination, the left maxillary central incisor 21 was missing with a bleeding alveolar socket of 21 and no associated injuries to the gingiva. On palpation of the maxillary anterior segment, the dentoalveolar fracture was ruled out. The avulsed tooth had an intact crown and root with an open apex. The case was diagnosed as an Ellis Class V fracture of 21.

The patient was informed, and consent was taken, informing him about the potential complications associated with the replantation of an avulsed tooth that had experienced an extraoral duration of approximately 90 minutes, including inflammatory resorption, replacement resorption/ankylosis, and tooth discoloration.

The root surface was carefully rinsed with normal saline to remove any adhered debris. The avulsed tooth was subsequently immersed in gentamicin for 20 minutes. Throughout the procedure, the tooth was handled exclusively by the crown to avoid contact with the root surface. The tooth was then repositioned and replanted using a figure-of-eight wiring splint (Flowchart 1 and Fig. 1).

Flowchart 1:

Flowchart depicting treatment

Figs 1A to F:

(A) Maxillary occlusal view showing alveolar socket of avulsed 21, (B) Labial surface of avulsed tooth, (C) Open apex of avulsed 21, (D) Maxillary occlusal view showing replanted 21 using figure of eight splinting method, (E) Front view showing replanted 21, (F) IOPA of 11, 21 after splinting

The patient was recalled on the next day to be reviewed on an outpatient basis, on examination the tooth was found to have grade I mobility. The stability of the replanted tooth was then reinforced by a composite based splint using 26-gauge orthodontic wire secured with light-cure flowable composite resin. At the middle third level of the crown, the labial surfaces of the maxillary anterior teeth were spot etched for 20 seconds using 37% phosphoric acid, followed by rinsing and air drying. After that, the bonding agent was applied to the prepared surfaces and polymerized using light-curing for 20 seconds. Flowable composite material was placed on all six maxillary anterior teeth, and the orthodontic wire was secured in position by sequentially curing each tooth for 20 seconds (Fig. 2).

Figs 2A to C:

(A) Etching prior to composite splint application, (B) Composite splint application, (C) IOPA of 11, 21 after composite splint application

The patient was prescribed oral analgesics and antibiotics for 5 days. Postoperative instructions were provided to adhere to a soft diet for two weeks, use a soft-bristled toothbrush, and perform oral hygiene maintenance with a 0.12% chlorhexidine mouth rinse. The patient was strictly advised to avoid biting from maxillary anterior teeth. The patient was scheduled for a follow-up after 2 weeks, during which conventional root canal therapy was initiated on the replanted tooth in the Department of Pediatric Dentistry.

After 2 weeks the splints were removed and tooth was assessed, no mobility or discrepancy in occlusion was observed. The replanted tooth's clinical examination during the 1-month follow-up appointment revealed normal physiologic mobility and normal probing sulcular depth. Radiographic evaluation demonstrated a normal periapical region with no evidence of periapical radiolucency. The lamina dura appeared intact, the periodontal ligament (PDL) space around tooth 21 was uniform, and no indications suggestive of resorption were observed.

The root canal treatment (RCT) of tooth 21 was performed. A collagen plug was placed to achieve an apical seal of the tooth, corresponding to the extent of root formation. Following biomechanical preparation (BMP), obturation was completed using biodentine and gutta-percha (Fig. 3).

Figs 3A and B:

(A) Occlusion after splint removal, (B) IOPA of 11, 21 after splint removal

A follow-up after 3 months (Fig. 4) and subsequently after 6 months was conducted (Fig. 5). Currently, the patient is being regularly reviewed for regular follow-ups.

Fig. 4:

IOPA showing 11, 21, 22 at 3 months

Fig. 5:

IOPA showing 11, 21, 22, 23 at 6 months

Discussion

Usually following trauma, an avulsed tooth falls to the ground. A tooth that has been out of its socket for more than 60 minutes is susceptible to contamination from dirt, grime, microbes, and human interaction thus making surface treatment, cleaning, and disinfection crucial. The goal of surface therapy is to eliminate nonviable PDL fibers, as they may serve as an infection source and cause inflammatory resorption. Additionally, the nonviable periodontal tissue may stimulate the socket's undifferentiated mesenchymal cells to differentiate into osteoblasts, which would result in replacement resorption, or ankylosis. Therefore, an avulsed tooth surface therapy is crucial to the success of delayed replantation.³

The patient's overall health, the root's maturity, storage media, and extraoral duration are the variables that impact the effectiveness of replantation; the latter two are the most important (Table 1). Milk is the most widely used and advised storage medium for maintaining an avulsed tooth because it is readily available, has a pH that is adequate, and contains the right growth factors, nutrients, and osmolarity. Additionally, epithelial growth factor (EGF), which is found in milk, also encourages the growth and regeneration of Malassez's epithelial cell rest.²

Table 1:

Factors determining the outcome of replanted avulsed tooth

Factors responsible for tooth replantation	Success	Failure
Extraoral dry time	<60 minutes	>60 minutes
Storage media	Physiological storage media	Water/no storage media
Handling of tooth	Minimal manipulation of root surface	Scraping or vigorous cleaning of root
Socket condition	Intact alveolar socket with minimal trauma	Severe trauma to alveolar bone
Timing of treatment	Immediate	Delayed
Anti-inflammatory and antibiotic medications	Reduce risk of infection thus increasing success rate	Lack of antibiotic coverage increases the risk of infection
Endodontic treatment	Within 7–10 days after trauma	>2 weeks after trauma
Age of tooth	Teeth with closed apex	Teeth with open apex
Patient age	<30 years	>30 years
General state of health	No systemic conditions	Systemic conditions such as diabetes, blood dyscrasias, etc.
Patient compliance	Maintenance of oral hygiene	Incompliance to follow postoperative instructions

It is best to either immediately transplant an avulsed tooth or to keep it in a physiological medium, such as saline, for a little amount of time before doing so. Avulsed teeth can also be kept longer in saline solution, milk, saliva, ViaSpan, Eagle's medium, Hank's balanced salt solution (HBSS), propolis, and other media before being replanted.⁴

The effectiveness of replanting an avulsed tooth depends on the reattachment of periodontal tissue and pulpal healing, both of which are favored by splinting. The tooth should be kept in its natural position without causing more trauma, orthodontic forces, or gingival irritation; aspiration and ingestion should be prevented; and the splint should permit proper dental hygiene. According to IADT standards (2020), a splint should be semirigid to permit the tooth's natural movement. Prolonged splinting should be avoided to avoid replacement resorption, which would cause the replanted avulsed tooth to ankylose.⁵

In the present case series, clinical and radiographic outcomes of immature permanent teeth with subject to trauma were treated with the help of a collagen plug and biodentine. Biodentine exhibits excellent marginal integrity due to its capacity to form hydroxyapatite crystals, which enhances the seal at the interface between the material and dentin.⁶ Thus in the current case report biodentine was used as it is highly effective in root canal treatment for teeth with an immature apex due to its bioactive properties, promoting apical closure by stimulating odontoblastic activity and forming a calcified barrier (Gandolfi et al., 2014).⁷ Its superior sealing ability prevents bacterial leakage, ensuring long-term success. Additionally, its biocompatibility supports tissue healing and reduces inflammatory reactions (Zanini et al., 2012).⁸ Biodentine's mechanical strength and durability make it suitable for clinical use in such cases. Factors such as inter-radicular radiolucency, periodontal ligament widening, or procedural errors affect the radio visibility of biodentine thus making it difficult to locate in the radiograph.

A significant challenge in cases involving a wide-open apex is the requirement to confine the material strictly to the apical region. To address this issue, an apical barrier was established using a collagen sponge. Excessive extrusion of material may lead to the persistence of inflammation. This ongoing inflammatory process can hinder or even prevent tissue repair.⁹

This review contains 20 studies investigating the relationship between extraoral dry time, splinting methods, and surface treatments in the cases of tooth avulsion (Table 2^10–28).

Table 2:

Association between extraoral dry time, surface treatment, and splinting method with the outcomes gained in 20 studies

Author (Year)	Extraoral dry time	No. of cases	Surface treatment/Storage media	Splinting method	Outcome	Follow-up period
Kinoshita et al.10	30 minutes–3.5 hours	10	Stored in tap water, milk/saline, saline, milk, and oral cavity.	Composite splint	Replanted tooth in case 8 was extracted because of severe inflammatory root resorption. Avulsed incisor in case 9 was replanted 2 hours after injury, replacement root resorption advanced to dentin was detected 3 years and 7 months after replantation.	1 year 6 months–5 years 10 months
Walter et al.11	6 minutes	1	Stored in saline for 1 hour.	Composite based splint	No complication till 3 years.	3 years
Werder et al.12	60 minutes	1	Kept in normal saline for 1 hour.	Composite based splint	No complications till 2.8 years.	2.8 years
Sonoda et al.13	None (Tooth was placed in the socket)	1	Debridement with normal saline.	Composite splint	No complications till 3 years.	3 years
Verma14	N/A	1	Debridement with normal saline.	Composite splint	No complications till 3 months.	3 months
Anand et al.15	24 hours	1	Scaling and root planning. Conditioning of the root was done with 10% phosphoric acid. Immersed in APF gel for 20 minutes followed by metronidazole solution again for 20 minutes.	Composite based splint	After 12 weeks, the tooth developed mild infraocclusion (of about 1 mm) and progressive ankylosis but it remained functional and was esthetically acceptable.	6 months
Harris et al.16	36 hours	1	Storage in 2.5% NaOCl for 20 minutes. Conditioning with citric acid for 5 minutes. Prior to replantation, the root surface was immersed in 2% acidulated phosphate fluoride gel for 5 minutes.	Composite based splint	No complication till 24 months.	24 months
Savas et al.17	7 hours–27 hours	2	Debridement using normal saline. Performed retrograde RCT.	Composite splint	After 12 weeks clinical initial replacement resorption and ankylosis was seen.	1 year
Müller et al.18	2 hours	49	Kept in Hanks' balanced solution for 20 minutes. Debridement using normal saline.	Composite based splint	63.2% teeth had no complications till 3.2 years, remaining teeth underwent resorption.	3.2 years
Agrawal et al.19	30 hours	1	Debridement with saline irrigation. Placed in a 2.4% acidulated sodium fluoride solution.	Composite based splint	No complication till 12 months.	12 months
Rahbar and Hassani-Dehkharghani20	30 hours	1	Soaked in the hydrofluoric acid gel (Ultradent®) for 5 minutes then in doxycycline solution (doxycycline dissolved in water in a ratio of one to one) for 5 minutes.	Resin Splint	No complication till 12 months.	12 months
Daga et al.21	72 hours	1	Debridement with saline. Kept in 2% sodium fluoride solution followed by placement in doxycycline antibiotic solution.	Composite based splint	No complication till 12 months.	12 months
Coste et al.22	10 minutes–7 days	767	Kept in Hanks' balanced salt solution. Socket copiously irrigated with saline.	Composite based splint	Survival rate for mature teeth was 50% after 5.5 years.	7 months–5.5 years
Parthasarathy et al.23	60 minutes	3	PDL fibers scraped using 11 no. BP blade. Kept in normal saline for 10 minutes. Performed retrograde RCT. APF for 15 minutes to treat the root surface. PRF placement on the root surface and socket.	Composite splint	After 2 weeks loss of labial cortical plate was observed following which periodontal regenerative procedures were performed. After surgery no complications till 1 year.	1 year
Widyastuti et al.24	15 hours	1	Kept in saline for 15 minutes. Retrograde RCT. Apicoectomy. Scaling and root planning.	Arch bar fixation	No complications till 3 months.	3 months
Kharroubi et al.25	10–20 minutes	26	Kept in whole milk for 1 hour. Debridement using normal saline.	Resin splint	No complication till 3 months.	3 months
Gul et al.26	6 minutes–60 minutes	145	Kept in Hanks' balanced solution for 10 minutes.	Composite based splint	Follow-up period ranged from 7 months to 23 years, teeth which had greater extraoral dry time showed high risk of ankylosis.	7 months–23 years
Kolcakoglu et al.27	8 hours	1	Stored in water. Performed retrograde MTA filling.	Composite splint	On postoperative day 50, replacement resorption started in the left maxillary incisor tooth. An ankylotic sound was heard on percussion. On the 105th postoperative day, the external replacement resorption area had expanded and apical resection was performed. The resected area was filled with Platelet rich plasma (PRP).	4 months
Rai et al.28	72 hours	1	PDL stripping followed by soft pumice prophylaxis. Performed retrograde RCT. Socket curettage followed by saline irrigation.	Composite splint	Evidence of replacement root resorption on the 4-week follow-up visit, which gradually progressed to external cervical resorption and later, there was evidence of pinkish discoloration and infraposition of <1mm clinically.	6 years
Saputra et al.4	30 minutes	1	Kept in normal saline for 30 minutes.	Composite based splint	No complications till 1 month.	1 month

Current IADT Guidelines for Avulsed Permanent Teeth with Open Apex and Extraoral Dry Time of More Than 60 Minutes²⁹

Preoperatively

Examine the avulsed tooth and gently shake it in the storage media to get debris off its surface. The surface can also be rinsed with normal saline. While taking the patient's history, perform a clinical and radiographic examination. To prepare the tooth for replantation, place or leave the tooth in a storage medium.

Intraoperatively

Give local anesthesia, ideally without the use of a vasoconstrictor. Use sterile saline to irrigate the socket. Check the socket of the alveolus. Use the appropriate tool to realign the fractured segment if the socket wall is fractured. Slowly replace the tooth while applying a little digital pressure. Make sure the transplanted tooth is positioned correctly using both clinical and radiographic methods. For 2 weeks, use a passive, flexible wire up to 0.016” (0.4 mm) in diameter to stabilize the tooth. Keep the bonding chemicals and composite away from the proximal regions and gingival tissues. As an alternative, a flexible splint can be made with nylon fishing line (0.13–0.25 mm) and bonded to the teeth using composite. A more firm splint is recommended in cases with concomitant alveolar or jawbone fractures, and it should be left in situ for approximately 4 weeks. If there are any gingival lacerations, suture them. When replanting immature teeth in young adults and children, the objective is revascularization of the pulp area, which can result in more root development and maturation. It is important to balance the likelihood of revascularization with the danger of external infection-related (inflammatory) root resorption.

Postoperatively

In young adults and children, this resorption happens quite quickly. As soon as pulp necrosis and infection are detected, apexification, pulp revascularization, or root canal therapy should be started if spontaneous revascularization does not take place. Give antibiotics systemically, verify the tetanus status, and give advice for recovery after surgery and follow-up on regular intervals.

The longest extraoral dry time was observed in the study by Coste et al.²² associated with a 50% survival rate in a follow-up period of 5.5 years whereas the shortest extraoral dry time was observed in the study by Walter et al.¹¹ associated with good outcome in terms of survival rate of replanted tooth. Sonoda et al.¹³ performed a case where there was no extraoral dry time as the tooth was placed by the patient in the alveolar socket, most satisfactory outcomes were obtained with no complications till complete follow-up period of 3 months. The most common surface treatments included the use of normal saline, Hanks' balanced solution and acidulated phosphate fluoride (APF) gel application. Parthasarathy et al.,²³ performed scraping of PDL fibers of the avulsed tooth which was found to be associated with loss of labial cortical plate. No significant association between splinting method and outcome was found, while the most preferred splinting method was application of composite splint. There was a study by Widyastuti et al.,²⁴ in which arch bar fixation was used for splinting which obtained satisfactory results. A strong significance was found between the outcomes and follow-up period, the shortest follow-up period was found in a study by Saputra et al.,⁴ where no complications were observed till complete follow-up period of 1 month. The longest follow-up period was found in the study by Gul et al.,²⁶ where follow-up period ranged from 7 months to 23 years, teeth which had greater extraoral dry time showed high risk of ankylosis. Similar findings were observed in the studies of Kinoshita et al.,¹⁰ Müller et al.,¹⁸ Coste et al.,²² where the follow-up period was 1 year 6 months–5 years 10 months, 3.2 years, 7 months–5.5 years, respectively.

Owing to a lack of research, some elements of tooth replantation have not been evaluated like revascularization of the pulp space in a tooth that has been reimplanted, ideal splint kinds and duration in relation to pulp and periodontal healing, the impact of using a local anesthetic that contains vasoconstrictors on healing, the impact of systemic and topical antibiotics on root resorption and healing, intracanal corticosteroids' impact on root resorption and healing, and the alveolar crest's long-term growth or establishment after decoronation and replantation, restoring normal function is impacted by periodontal regeneration, after tooth replantation, periodontal healing occurs.

Future trends in replantation of avulsed teeth are driven by advancements in regenerative medicine, materials science, and digital health technologies. Use of stem cells from dental pulp or other sources may be used to regenerate PDL tissues that promote reattachment of the tooth. Laser use for reducing microbial load and promoting tissue healing during replantation is one of the latest advances. These innovations aim to enhance the long-term success of replantation, minimize complications, and make emergency care more effective and accessible.

Conclusion

The replantation of an avulsed tooth is a crucial procedure that requires timely and appropriate management to ensure optimal outcomes. Success largely depends on factors such as the time elapsed since the avulsion, the condition of the periodontal ligament, and the storage medium used for the tooth before replantation. Immediate replantation or the use of a suitable storage medium can significantly improve the prognosis. Long-term success also hinges on proper follow-up care, including monitoring for potential complications such as root resorption or ankylosis. By adhering to best practices and employing multidisciplinary collaboration when needed, dental professionals can maximize the chances of restoring both function and esthetics in patients with avulsed teeth.

Orcid

Nidhi Gupta https://orcid.org/0000-0002-1086-1336