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Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 171-174

Delayed replantation of avulsed permanent maxillary central incisor - with unfavorable outcome after 12 months

Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Anupam Saha
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_8_17

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Avulsion of permanent teeth constitutes a dental emergency and accounts for 1%–16% of all traumatic dental injuries. It occurs frequently among 7–14 years age group, whereas maxillary central incisors are the most commonly effected. Esthetics and occlusion function can be restored with replantation of an avulsed tooth. The purpose of this article is to describe a management of an 11-year-old male child with avulsed permanent maxillary central incisor which was replanted subsequently 48 h after root surface treatment with triple antibiotic paste. Follow-up visits showed signs of “replacement resorption.”

Keywords: Avulsion, delayed replantation, trauma, triple antibiotic paste

How to cite this article:
Saha A, Nirmala SS, Sahiti P, Tharay N. Delayed replantation of avulsed permanent maxillary central incisor - with unfavorable outcome after 12 months. SRM J Res Dent Sci 2017;8:171-4

How to cite this URL:
Saha A, Nirmala SS, Sahiti P, Tharay N. Delayed replantation of avulsed permanent maxillary central incisor - with unfavorable outcome after 12 months. SRM J Res Dent Sci [serial online] 2017 [cited 2022 May 25];8:171-4. Available from:

  Introduction Top

Avulsion is defined as the complete displacement of tooth out of the socket.[1] The periodontal ligament fibers are severed, and blood supply to pulp tissue is amputated resulting in necrosis of pulp.[2] It is relatively uncommon type of traumatic injury representing 1%–16% of the traumatic dental injuries and occurs frequently between 7 and 14 years of age. Avulsion of tooth is a special form of injury which requires immediate attention and management, and the prognosis is associated with the duration between the time the tooth is avulsed and when it is replanted.[3],[4] However, immediate replantation might not be possible because of lack of knowledge of management of such injuries at site of trauma.[5] Excessive drying of avulsed tooth results in necrosis of periodontal ligament cells, which elicits an inflammatory response, with physiologic bone recontouring on the root surface leading to tooth loss.[6] However, if management is done appropriately with proper root surface treatment, the replanted tooth may remain functional. This case report describes the replantation of avulsed permanent tooth with root surface treatment using triple antibiotic paste.

  Case Report Top

A healthy 11-year-old boy reported to the department of pediatric dentistry with a chief complaint of avulsed permanent maxillary right central incisor [Figure 1]. History revealed that trauma occurred while the patient was playing in the ground and no history of loss of consciousness or vomiting. The tooth was kept extraorally in dry condition, and the patient had reported to the dentist after 48 h. No signs of injury intraorally and extraorally except for the avulsed maxillary right central incisor. Examination of tooth socket revealed fracture of the buccal cortical plate in the region of trauma and tooth examination revealed closed root apex and fractured crown. A panoramic radiograph was taken to rule out any broken bony segment in the socket [Figure 2]. Treatment options were explained to the parent and replantation of the tooth was planned to retain the tooth in the oral cavity. The tooth and socket were cleaned with normal saline, and the root surface was debrided to remove necrotic periodontal tissue. As it is a delayed replantation, where the tooth was exposed to extraoral dry time for >48 h, endodontic treatment was planned extraorally [Figure 3]. After access opening, all the necrotic pulpal tissue was removed, and the canal was irrigated thoroughly with 5.25% sodium hypochlorite. Biomechanical preparation of the canal was done up to size 60 using K-files and obturated with Portland cement. Glass ionomer cement was used as an intermediate restorative material. Externally, the root apex was filled with calcium hydroxide and iodoform paste. The root surface was cleaned with soft pumice prophylaxis and treated with a triple antibiotic paste containing ciprofloxacin, metronidazole, and minocycline mixed with propylene glycol (Antibiotic [3 mix] – ratio 1:1:1). The socket was curetted thoroughly, and blood clot was removed. The tooth was placed in the socket under local anesthesia and the lacerated gingiva was sutured tightly. Splinting was done from canine to canine using multiflex wire without any occlusal interference. A periapical radiograph was taken to verify the position of replanted tooth in the socket. The patient was placed on systemic antibiotic coverage for 7 days and discharged with oral hygiene instructions. The patient was recalled after 1 week interval for removal of suture and after 3 weeks for removal of splint. The patient was reviewed 1, 3, 6, 9, and 12 months for periodic evaluation clinically [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f and radiographically [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d,[Figure 3]e,[Figure 3]f. There was neither clinical nor radiographic changes were evident on 1, 3, 6, and 9 months follow-up visits on 12 months follow-up visit there was evident of replacement resorption on the intraoral periapical radiograph. The follow-up pattern and clinical and radiographic evaluation were mentioned in [Table 1].
Figure 1: Preoperative frontal view showing missing tooth 11 (a), avulsed tooth 11 (b) and panoramic view showing avulsed tooth 11 (c)

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Figure 2: Clinical evaluation of reimplanted avulsed tooth 11 after 1 week (a), 1 month (b), 3 months (c), 6 months (d), 9 months (e), and 12 months (f)

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Figure 3: Radiographic evaluation of reimplanted avulsed tooth 11 after 1 week (a), 1 month (b), 3 months (c), 6 months (d), 9 months (e), and 12 months (f)

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Table 1: Clinical and radiographic evaluation of reimplanted avulsive central incisor in follow-up visits

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  Discussion Top

Tooth avulsion is a severe traumatic injury that results in complete displacement of tooth out socket along with damage to pulp and periodontal ligament.[7] Children aged 7–12 years face avulsion more, because of the intensity, type of trauma combined to the loose structure of the periodontal ligament of teeth.[8] Psychologically, there will be more impact on the patient and his or her parents due to avulsion. Hence, replantation is the best conservative approach available either to restore the aesthetics or to preserve the alveolar bone height.[9] Andreasen has reported that immediate replantation of tooth at the moment of avulsion has the greatest detriment of tooth survival chances and delayed replantation may lead to inflammatory resorption.[10]

Andreasen and Kristerson [4] recommended if a tooth has been exposed to extraoral dry time for >60 min, the periodontal ligament cells are not expected to survive [4] and in the present scenario, the avulsed tooth has been exposed to dry condition for >48 h, so the treatment planned was replantation after extraoral endodontic treatment and root treatment to delay the process of resorption.

For successful replantation of an avulsed tooth, the absence of infection is necessary, and early infection-related complications derive from infected pulp space, because of more patent dentinal tubules in young patients that readily transmits inflammatory products from pulp to root surface. Hence, extraoral root canal treatment was done before replantation.[11],[12] The necrotic pulp was extirpated thoroughly with proper biomechanical preparation and root canal was obturated with Portland cement 1 mm short of the apex. Externally, the apical foramen was filled retrograde with calcium hydroxide and iodoform paste. Calcium hydroxide changes the environment to a more alkaline pH, which may slow the action of the resorptive cells and promote hard tissue formation.[13],[14]

In the present scenario, tooth has been in extraoral dry time for >48 h; it was supposed that periodontal ligament cells were dead.[15] Hence, the root surface was cleaned with soft pumice prophylaxis to remove remaining nonviable periodontal ligament cells which might act as a source of infection and accelerate the resorption process. The root surface was treated with a triple antibiotic paste containing ciprofloxacin, metronidazole, and minocycline mixed with propylene glycol to decontaminate the root surface and exert prolonged bactericidal effect on the periodontal ligament.[16]

After replantation of the tooth into the socket, the lacerated gingiva was sutured tightly so as to promote better wound healing.[17] Semi-rigid fixation was done with multiflex wire extending from canine to canine, to allow physiologic movement of teeth during mastication.[3] Occlusion is checked to verify premature contacts while biting to avoid further injury to adjacent periodontal tissues and to prevent traumatic occlusion. Systemic antibiotics such as amoxicillin and doxycycline were administered for 1 week. Owing to the disadvantage of teeth staining with tetracycline patient was prescribed with doxycycline twice a day for 7 days. Chlorhexidine mouth rinse was prescribed for 7–10 days and patient was thoroughly instructed about the oral hygiene measures.

During 6- and 9-month follow-up, patient's esthetics and occlusal function have been maintained. An intraoral periapical radiograph showed replacement resorption between tooth and alveolar bone during 12-month follow-up. Intraoral percussion of the replanted tooth gave dull note referring to ankylosis between tooth and socket. Among the three types of healing modalities, described depending on the severity of injury sustained by the periodontal ligament, healing with replacement resorption has occurred, because of failure of regeneration of periodontal fibers with resultant bony fusion between teeth and socket.[18] However, the patient is still under follow-up to determine the ultimate fate of the replanted tooth under unfavorable conditions.

  Conclusion Top

Replantation of avulsed permanent teeth with prolonged extraoral time should be performed making the patient and his or her parents aware about the consequences and outcomes of such treatment, although the risk of progressive replacement resorption and subsequent tooth loss is high. Consequently, this case report provides insight about the application of triple antibiotic paste as root surface treatment before replantation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

American Academy of Pediatric Dentistry. Guidelines on management of acute dental trauma. Pediatr Dent 2011;34:12-3.  Back to cited text no. 1
Ram D, Cohenca N. Therapeutic protocols for avulsed permanent teeth: Review and clinical update. Pediatr Dent 2004;26:251-5.  Back to cited text no. 2
Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Copenhagen: Munksgaard; 1993. p. 216-56.  Back to cited text no. 3
Andreasen JO, Kristerson L. The effect of limited drying or removal of the periodontal ligament. Periodontal healing after replantation of mature permanent incisors in monkeys. Acta Odontol Scand 1981;39:1-3.  Back to cited text no. 4
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors 2. Factors related to pulpal healing. Endod Dent Traumatol 1995;11:59-68.  Back to cited text no. 5
Fidel SR, Santiago MR, Reis C, Pinho MA, Fide RA. Successful treatment of a multiple dental trauma: Case report of combined avulsion and intrusion. Braz J Dent Traumatol 2009;1:32-7.  Back to cited text no. 6
Pohl Y, Wahl G, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. III. Tooth loss and survival analysis. Dent Traumatol 2005;21:102-10.  Back to cited text no. 7
Goyal R, Tandon B, Singla K, Singh J, Singh N. Replantation of avulsed teeth: A case report. Ind J Compr Dent Care 2014;4:476-9.  Back to cited text no. 8
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dent Traumatol 2007;23:130-6.  Back to cited text no. 9
Andreasen JO. Traumatic dental injuries in children. Int J Paediatr Dent 2000;10:181.  Back to cited text no. 10
Finucane D, Kinirons MJ. External inflammatory and replacement resorption of luxated, and avulsed replanted permanent incisors: A review and case presentation. Dent Traumatol 2003;19:170-4.  Back to cited text no. 11
Fuss Z, Tsesis I, Lin S. Root resorption – Diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol 2003;19:175-82.  Back to cited text no. 12
Tronstad L, Andreasen JO, Hasselgren G, Kristerson L, Riis I. PH changes in dental tissues after root canal filling with calcium hydroxide. J Endod 1981;7:17-21.  Back to cited text no. 13
Teixeira FB, Levin LG, Trope M. Investigation of pH at different dentinal sites after placement of calcium hydroxide dressing by two methods. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:511-6.  Back to cited text no. 14
McIntyre JD, Lee JY, Trope M, Vann WF Jr. Permanent tooth replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 2009;31:137-44.  Back to cited text no. 15
Cruz EV, Kota K, Huque J, Iwaku M, Hoshino E. Penetration of propylene glycol into dentine. Int Endod J 2002;35:330-6.  Back to cited text no. 16
Trope M. Avulsion of permanent teeth: Theory to practice. Dent Traumatol 2011;27:281-94.  Back to cited text no. 17
Petrovic B, Marković D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26:52-9.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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