Int J Dent Case Reports 2014; 4(2): 62-71

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MANAGEMENT OF TRAUMATIC AVULS ED PERMAN ENT TEETH IN CHILDRENS : TECHNIQUE

REVIS ITED AND LITERATURE REVIEW

Namita Chauhan 1 , Deepak Passi2 , Jaya Bharti3 , Sangeeta Yadav4, Shiwani Garg 5
1
Department of Pedodontics and Preventive Dentistry, Govern ment Dental College and Hospital, A mritsar, India
2
Department of Oral and Maxillofacial Surgery, E.S.I.C Dental Co llege and Hospital, Roh ini , Delh i, India
3
Department of Oral and Maxillofacial Surgery, D.J Dental Co llege and Hospital, Modinagar, Ghaziabad , U.P.,
India
4
Depart ment of Conservative Dentistry and Endodontics , E.S.I.C Dental College and Hospital, Rohin i , Delhi,
India.
5
Depart ment of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research ,
Ferozpur , Punjab, India

Address for Correspondence

Dr. Deepak Passi
Depart ment of Oral and Maxillofacial Surgery
E.S.I.C Dental College and Hospital, Rohin i
Delh i, India

ABSTRACT
Avulsion of permanent teeth is one of the most serious dental injuries, and a pro mpt and correct emergency
management is very important for the prognosis. Tooth avulsion represents 0.5–16% of trau matic injuries.
Management of tooth avulsion in the permanent dentition often pres ents a challenge. Such in juries should be
recognized and treated expeditiously because several studies support a more likely favorable p rognosis with timely
and appropriate initial management.
The case report presents replantation of an avulsed right permanent maxillary central incisor in a 14 year old boy.
Tooth was stored in milk. After the patient reported to us, it was insed with saline to remove debris. The tooth was
replanted & splinted following 12 hour ext ra-oral time. One week later, it was treated endodontically & calciu m
hydroxide dressing was placed for 1 month; subsequently, the tooth was obturated with gutta -percha. This case
report describes treatment & a 1 year follow-up of the tooth. During one year of follow-up, no evidence of anky losis
or inflammatory resorption was observed & the tooth was stable & remained functional & esthetically acceptable.
Keywords: Avulsion; Replantation; Hank’s balanced salt solution (HBSS), Ankylosis; Replacement
Chauhan, Passi, Bhart i
INTRODUCTION
Tooth avulsion implies total displacement of the
tooth from its socket and represents 0.5–16% of
traumatic inju ries in the permanent dentition and 7–
13% in the primary dentition [1]. Avulsion is mainly
seen in child ren and young adults, at an age when the
alveolar bone is resilient and provides only minimal
resistance to extrusive forces.The most commonly
affected tooth is maxillary central incisors [2].
Prognosis of avulsed tooth depends on the measures
taken at the time of accident such as choice of
transport mediu m and time taken before performing
the treatment. Replantation of a tooth beyond 5 min
has been defined by Andreasen as delayed
replantation that affects tooth survival. Various
storage media can be used for avulsed tooth such as
Hank’s balanced salt solution (HBSS), milk, saliva,
Visapan, saline, etc. [3]
HBSS, a pH preserving flu id, is best used for
traumatized tooth. It is widely used in bio med ical
research to support the growth of many cells types
.This solution is non-toxic; it is bioco mpatible with
periodontal ligament cells, pH balanced at 7.2 and
has an osmolality of 320 mOs m/kg .[4,5,6]
The American Association of Endodontics indicates
milk as a solution for avulsed teeth, for keeping the
viability of the human cellular periodontal ligament.7 .
Milk is significantly better than others solutions for
its physiological properties, including pH and
osmolality compatib le to those of the cells fro m the
periodontal ligament; the easy way of obtaining it
and for being free of bacteria [7, 8]. But it is
important that it is used in the first 20 minutes after
avulsion [9]. The favorable results of milk probably
occur due to the presence of nutritional substances
such as aminoacids, carbohydrates and vitamins
[9,10,11,12,13]. The pasteurizat ion of milk is
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Int J Dent Case Reports
Tooth Avulsion
responsible for dimin ishing the number of bacteria
and bacteriostatic substances, also for the inactive
presence of enzymes, which could be potentially
harmful to the fibroblasts of the periodontal ligament
[9, 13]. Blo ml of et al. [14], Trope and Fried man [16]
recommend milk as an excellent storing solution for
6 hours, however, milk can not revive the
degenerated cells. An avulsed tooth which has
remained in a dry mediu m and later has been put into
milk before reimp lantation, will probably have as
undesirable prognosis as that which has been into a
dry med iu m and has undergone reimplantation
[14,15]. Rep lantation of avulsed teeth is
recommended in accordance with certain guidelines,
but can lead to several complications in 57–80% of
cases. The extent of long-term damage to the tooth
and the supporting tissues depends upon the
treatment of that tooth before replantation, the extra-
alveolar t ime, the storage mediu m and the patient’s
general health.
Figure 1: Ext ra-oral photograph of patient
Avulsions should be emphasized because of prompt
and proper initial care, long-term clinical and
radiographic follow-up. On the other hand, the
June 2014, Vo l.4, No. 2
Chauhan, Passi, Bhart i Tooth Avulsion

integrity of the periodontal ligament, advocated by
many researchers as being essential for the success of
replantation, cannot be controlled by the dental
professional, as it depends on the interaction of
factors [17, 18].
Evaluation of IOPA R X-ray at the first visit shows
No clear fracture line in the alveolar bone in the
maxillary right primary central incisor area [ Figure
3] . The ad jacent teeth showed neither the expansion
of the periodontal ligament space nor root fracture.

Case Report
A 14-year-old young boy [Figure1] reported for
emergency treatment at Department of Pedodontics
and Preventive Dentistry, Govern ment Dental
College and Hospital, A mritsar with a h istory of fall
at a playground. The time that had elapsed between
the fall and his referral was 12 hours and the tooth
had been stored in milk during this period. The
avulsed tooth had as closed apex with moist
periodontal tissue on its root surface and no
additional damages were found. The alveolar socket
of the avulsed tooth was filled with blood clot
without bleeding [Figure 2]. Neither tooth mobility
nor positional abnormalities were detected in other
Figure 3: Intra-oral Radiograph showing missing
teeth. Furthermore, no lacerated wound was present
right maxillary central incisor
in the g ingiva in the maxillary right central incisor
area.
Treatment pl anning
Since the patient was young, replantation of the
avulsed tooth was decided in the best interest of the
patient and to relieve him fro m psychological,
cosmetic and functional trau ma. To co mplete the
examination, periap ical radiographs were taken.
Radiographs showed a normal socket for tooth 11
and non-fractured root for tooth 21 were observed.
The parents were informed about the treatment
procedure and the expected prognosis. The avulsed
tooth preserved in milk [Figure 4] was washed with
Figure 2: Socket showing missing right maxillary physiological saline and follo wed by antibacterial
central incisor solution The avulsed tooth was soaked in 2% sodium
fluoride gel and local anesthesia was administered
with lidocaine 2% with 1:100000 epinephrine

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Int J Dent Case Reports June 2014, Vo l.4, No. 2
Chauhan, Passi, Bhart i Tooth Avulsion

of 3rd week [Figure 7 ], splint was removed and

radiograph was taken and endodontic treatment was
Prior to rep lantation under local anesthesia, the
completed. The patient was seen postoperatively at 1
socket was gently cleaned and light irrigation with
month, 3 months, 6 months and then followed-up
saline solution was done. The teeth were then placed
every six months. The patient was followed-up for
in the socket with light finger pressure and position.
one year [Figure 9]. The tooth remained functional
A radiograph was taken to check the proper
and was esthetically acceptable. The percussion tone
placement of the avulsed tooth [Figure 6] and after
and the tooth mobility were normal.
confirmat ion of proper placement; tooth splinting
Radiographically, no inflammatory or rep lacement
was done with the composite splint.
root resorption was detected and the adjacent anterior
teeth remained asymptomatic [Figure 8]

Figure 4: Tooth stored by the patient in milk

Figure 5: Sp linting of tooth

Any sharp edges were smoothened and adjacent

tissues were irrigated using betadine solution. Splint DISCUSS ION

was performed using the adjacent teeth as the Avulsion of tooth takes place when a tooth directly

anchorage unit [Figure 5], and using orthodontic sustains trauma which displaces the tooth from the

ligature wires and composite resin. The following socket. The maxillary central incisors are the

antibiotic and anti-inflammatory drugs were advised commonest avulsed teeth in both dentitions i.e.,

for 5 days, a comb ination of A mo xycillin and primary and permanent due to their pro minence in

Clo xacillin-500 mg TDS and A combination of the jaw. The prognosis of an avulsed tooth is

Ibuprofen and Paracetamol-TDS. Apart fro m this the proportional to its extraoral time, wh ich is a direct

patient was advised to avoid biting with the splinted correlation o f the status of the periodontal ligament

teeth. Soft diet and maintenance of good oral cells[19].

hygiene were advised . Treat ment of avulsion is often challenging and should

After co mplet ion of the procedure, patient was be managed as an emergency. The golden t ime for

recalled after 7 days for follow-up examination. replantation is 20-30 minutes; if it is not possible, the

Patient was asymptomatic after 7 days and after 2 tooth should be kept in an appropriate storage media

weeks, removal of splinting was planned. At the end for preserving the vitality of the periodontal ligament

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Int J Dent Case Reports June 2014, Vo l.4, No. 2
Chauhan, Passi, Bhart i
cells. The vitality of the periodontal ligament on the
surface of the root, increases the probability of
reinsertion of dental fibers with the alveolar ones,
when reimp lantation is immed iate; that is, when it is
done up to one hour after avuls ion [20].
Figure 6: Immediate radiograph
Besides the promptness of reimp lantation, the storing
med iu m in which the tooth is placed is also a
determining factor to extending the life of the tooth.
The most preferable storage medias are Viaspan and
HBSS (Han k’s Balanced Salt So lution (21)
.Unfortunately, these media are not accessible at the
site of trauma. M ilk has sufficient nutrients,
appropriate PH and osmolality with fewer bacteria.
Placing an avulsed tooth in milk at roo m temperature
can preserve the cell viability for up to 6 hours [21]
Teeth replanted fro m 6 hrs to 48 hrs after avulsion
and treated endodontically are shown to be clinically
functional for a nu mber of years. There are reports of
ankylosis and replacement resorption .It seems that
the absence of viable periodontal ligament cells is the
major et iological factor. During ankylosis, the tooth
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Int J Dent Case Reports
Tooth Avulsion
root merges with the remodeled normal bone and is
gradually rep laced with bone. The latter can be
recognized with in 4-8 weeks after replantation.
Clin ically, the tooth is immobile and might be infra-
occluded and have a metallic percussion sound.
Radiographically, the periodontal space disappears
[22,23]
Figure 7: Endodontic treatment init iated at 3rd week
Biologic basis for success of repl antation following
avulsion.
Every tooth is connected to its surrounding bone by
the periodontal ligament. The tooth receives its
nourishment through this ligament. When a tooth is
knocked-out, this ligament is stretched and splits in
half; half stays on the tooth root and half stays on the
socket wall. If these two halves can be kept alive, the
tooth can be replanted and the halves of the ligament
will reattach and the tooth will remain vital. The half
that stays on the socket wall, since it remains
connected to the bone blood supply, is naturally kept
alive. However, the ligament cells that remain on the
tooth root lose their blood and nutrition supply and
June 2014, Vo l.4, No. 2
Chauhan, Passi, Bhart i Tooth Avulsion

must be artificially maintained. They must be
protected from t wo potentially destructive processes:
cell crushing and loss of normal. All treat ment
between the time of the accident and the ultimate
replantation must be focused on preventing these two
possibilit ies [28]
Cvek[31] showed that removal of the dental
pulp following reimp lantation was necessary to
prevent resorption of the tooth root. In 1974,
Cvek showed that storage of avulsed out teeth in
saline could improve the success of replanted teeth.
In 1977, Lindskog et al.[32] showed that the key to
retention of the avulsed-out teeth was to maintain the
vitality of the periodontal ligament. In 1980, Blo mlof
[33] showed the storing the periodontal ligament cells
in a bioco mpatible mediu m could extend the extra
oral time to four hours or more.

Figure 8: Post-operative radiograph

The first reported cases of avulsed teeth being

replanted was by Pare’ in 1593. In 1706, Pierre
Fauchard also reported avulsed replanting teeth.
Figure 9: Fo llo w up after 1year
Wigoper in 1933 used a cast gold splint to hold
reimp lanted teeth in place. In 1959, Lenstrup and
He found that the best storage mediu m was a med ical
Skieller [29] declared that the success rate of
research fluid called Hank’s Balanced So lution. In
replanted avulsed out teeth should be considered a
this study, it was serendipitously discovered that milk
temporary procedure because the success rate of less
could also maintain cell viability for two hours. In
than 10% was so poor. In 1966 [30] in a retrospective
1981,. In 1983, Matsson et al.[34]showed that
study, Andresen theorized that 90% of avulsed teeth
soaking in Hank’s Balanced So lution fo r thirty
could be successfully retained if they were replanted
minutes prior to reimp lantation could revitalize
within the first 30 minutes of the accident.
extracted dog’s teeth that were d ry for 60 minutes. In
Andreasen showed that crushing of cells on the tooth
1989 [35] a systematic storage device was developed
root could cause death of the cells and lead to
to optimally store and preserve avulsed out teeth. In
resorption and reduction in prognosis. In 1974,
1992, Trope et al.[36] showed that extracted dog’s
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Int J Dent Case Reports June 2014, Vo l.4, No. 2
Chauhan, Passi, Bhart i Tooth Avulsion

teeth could be stored in Han k’s Balanced So lution for Future areas of research:
up to 96 hours and still maintain significant vitality. A number of pro mising treat ment procedures for
In this study, milk was only able to maintain v itality avulsed teeth have been discussed in literature, some
for two hours. of them do have experimental evidence but some are
still needs further research and documentation.
In the present case report, keeping the tooth for 12
1. Methods for removal of non-viab le PDL
hours showed a good prolonged prog nosis . If the
physiologic media (e.g. co ld milk o r contact lens 2. Conditioning the PDL with extra-oral
saline solution) are not availab le, soaking the tooth in storage in tissueculture media prior to
non-physiologic media such as saliva (placing the replantation.
tooth in buccal vestibule), normal saline and tap
3. Conditioning the PDL with enamel matrix
water is a superior option co mpared to keeping it in a
protein prior to replantation for teeth with
dry condition. Although they are detrimental to the
short extra-oral periods.
periodontal cells, saliva and saline can maintain the
cell viab ility for 2 hours and tap water can preserve 4. Topical treat ment of root surface with
them fo r 20 minutes [21]. fluoride for teeth with long extra-oral period.

Another tissue which may be damaged during 5. Revascularization of pulp spaceand method
avulsion is the pulpal tissue. In closed apex teeth with of pro moting this.
narrow apical fo ramen, prophylactic endodontic
treatment should be performed after rep lantation. But 6. Optimal splint types with regards to

in wide open apex teeth, as there is a chance for periodontal and pulpal healing.

revascularizat ion, accurate observation is

7. Effect of adrenaline content of L.A on
recommended. In these teeth, uninfected necrotic
healing.
pulp may act as scaffold for later regenerative
processes. Kling et al. reported that there is more 8. Reducing the inflammation with
chance of revascularization, if the tooth is replanted corticosteroids.
within 45 minutes [24]. Therefore, the open apex
9. Extra oral root filling o f teethwith less than
teeth should be controlled radiographically; in case of
60 minute drying period.
any signs of necrosis such as root resorption, root
canal therapy is the treatment of choice [25, 26,27]. 10. Use of titaniu m posts for root elongation and
In this case report, the avulsed tooth had a mature as alternative to conventional root canal
root, thus one week after the replantation, the pulp treatment.
was extirpated expired. In the present case, although
11. Long term develop ment of alveolar crest
the tooth was stored in milk for the whole ext ra-
following reimp lantation and decoronation.
alveolar duration, some parts of the periodontal
ligament t issues seemed to have become necrotic
because of the prolonged extra-alveolar period.

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Chauhan, Passi, Bhart i Tooth Avulsion

CONCLUS ION fro m exart iculated teeth stored in saline o r milk using
Since the key to the success lies in the status of fluorescein diacetate. Int Endod J, 27: 1–5.
periodontal ligament, ut most care was taken to
preserve the integrity of the periodontal ligament. 1
year follow up has shown successful outcome of the 8.Pearson RM, Liewehr FR, West L, Patton WR,
treatment. McPherson J & Runner RR. 2003. Hu man
periodontal ligament cell v iability in milk and milk
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