How To Replace and Splint an Avulsed Tooth

• An avulsed, extruded, laterally luxated, or severely subluxed (ie, mobile, painful, and possibly bleeding) permanent tooth

Absolute contraindications

• Primary tooth involvement

• Intruded tooth (pushed deeper into socket)

• Significant alveolar fracture, socket damage, or fractured or grossly decayed permanent tooth

• Moderate/severe periodontal disease in the area of the injured tooth

Such patients should be referred to a dentist or oral surgeon for management. Avulsed primary teeth are not replaced because they typically become necrotic, then infected. They may also become ankylosed and thus not exfoliate, thereby interfering with the eruption of the permanent teeth.

Relative contraindications

• Prolonged time out of socket (> 2 hours)

• Congenital cardiac defects

• Immunosuppression

Long-term prognosis is poor but do not discard the tooth; place the tooth in HBSS and consult with a dentist or oral surgeon regarding advisability of attempting replacement. If specialist advice is unavailable and/or follow-up is uncertain, advise patient of very poor prognosis. If patient desires, attempt replacement as described below if time is reasonably close to 2 hours.

• Tooth may detach and be aspirated.

• Long-term complications include inflammatory root resorption or ankylosis of tooth (union of root to socket by bone, rather than by periodontal ligament attachment).

• Dental chair, straight chair with head support, or stretcher

• Light source for intraoral illumination

• Nonsterile gloves

• Mask and safety glasses, or a face shield

• Gauze pads

• Cotton-tipped applicators

• Dental mirror or tongue blade

• Suction

• Cold-curing flexible splint material (eg, periodontal dressing)

Equipment to do local anesthesia:

• Dental aspirating syringe (with narrow barrel and custom injectable anesthetic cartridges) or other narrow barrel syringe (eg, 3 mL) with locking hub

• 25- or 27-gauge needle: 2-cm long for supraperiosteal infiltration; 3-cm long for nerve blocks

• Prognosis for reimplantation depends on survival of cells of the periodontal ligament: Handle the tooth only by the crown, do only gentle rinsing, and do not hold, manipulate, or scrape the root (doing so may remove viable periodontal ligament fibers).

• Antibiotic prophylaxis for endocarditis should be given to certain high-risk patients who have had an avulsed tooth replaced.

• Patients unable to cooperate with procedure (typically children) may require sedation.

Traumatic tooth displacements are defined progressively as:

• Concussion—Nondisplaced, nonmobile tooth, but with inflammation of periodontal ligament resulting in sensitivity of tooth to touch or pressure

• Subluxation—Nondisplaced, but mobile (loose) tooth

• Luxation—Displaced but not avulsed tooth

• Avulsion—Tooth completely removed from socket (complete luxation)

A relatively intact tooth socket (alveolar bone) to support the tooth is needed for successful reimplantation

• Position the patient inclined and with the occiput supported.

• Turn the head and extend the neck such that the avulsion site is accessible.

• For the lower jaw, use a semi-recumbent sitting position, making the lower occlusal plane roughly parallel to the floor when the mouth is open.

• For the upper jaw, use a more supine position, making the upper occlusal plane roughly 60 to 90 degrees to the floor.

Initial assessment and preparation

• Wear nonsterile gloves and mask/safety glasses, or face shield.

• Handle the tooth only by the crown and do not disturb any of the root's tissues.

If the tooth has been out of the socket < 20 minutes, immediately reimplant it. Gently rinse the tooth with saline. To prepare a space for the root, remove the bulk of the clot from the socket using gentle irrigation and suction (small-tipped). Do not waste time trying to remove the entire clot.

Be sure the tooth is oriented correctly. Use the contralateral tooth as a guide for orientation if needed.

If the tooth has been out of the socket > 20 minutes but <

If anesthesia is needed

• For most lower teeth, do an inferior alveolar nerve block.

• For most upper teeth, do supraperiosteal infiltration.

• For the frequent anterior permanent tooth avulsions that occur in school-aged children without other significant trauma, local infiltration over the socket usually provides adequate anesthesia and is faster than a nerve block.

Reinsert an avulsed tooth

• Holding the tooth by the crown, gently insert it into its socket in correct anatomic orientation (use contralateral side as a guide if needed).

• Gently push the tooth into the socket (pressing on the crown) to seat the tooth but without compressing any tissues at the root. Use digital pressure only.

• Check bite: Have patient gently and slowly bite down to be sure opposing teeth do not move the reimplanted tooth. Readjust position of tooth if needed so that the patient can bring the teeth together normally.

• Splint the tooth (see below).

• If the tooth cannot be seated securely or oriented with certainty, send the patient directly to a dentist.

Stabilize a subluxed (mobile but not displaced) tooth

• Gently move the crown to reposition the tooth to its correct location, but do not compress any tissues at the root.

• Splint the tooth (see below).

Reduce a luxated tooth (displaced to the side, or partially extruded from the socket; intruded teeth should be managed by a dentist)

• Use digital pressure as needed to reposition the displaced tooth into its correct anatomic position. Use adjacent and opposing teeth as guides. Gentle forceps traction in a forward direction is sometimes needed for palatally displaced teeth. Significantly displaced teeth are best referred directly to a dentist or oral surgeon.

• Check bite: Have the patient gently and slowly bite down to be sure opposing teeth do not move the repositioned tooth.

• Splint the tooth (see below).

Splint the reduced tooth

• Prepare the flexible splint material as directed by the manufacturer, particularly the recommended ratio of base and catalyst and degree of mixing, and roll the resultant putty into a cylindrical (sausage) shape using your moistened, gloved fingers.

• Maintain the tooth in position within the socket.

• Make 2 small strips of paste. Lay one strip over the buccal surface and one over the lingual/palatal surface of the reimplanted tooth, extending the strips across 1 or 2 teeth on either side. Do not cover the occlusal surfaces of the teeth.

• Gently smooth the surface of the putty while working it into the spaces between the teeth.

• If both sides of the teeth cannot be covered, place the splint only on the buccal side.

• If the temporary splint is not effective, send the patient directly to a dentist for more advanced splinting options.

• After reimplantation, obtain dental x-rays to identify associated damage.

• Give tetanus prophylaxis if needed.

• The patient should not chew on the affected side, should ingest only liquids and soft foods, and should avoid hot and cold foods.

• Very gentle warm salt water rinses are done every 3 to 4 hours (while awake) until follow-up.

• For relief of swelling, apply ice packs (30 minutes on, 30 minutes off) to the side of the face for 24 hours, then switch to warm compresses

• Arrange follow-up with a dentist as soon as possible, same day if possible, for hygienic splint placement (eg, wire and bonded resin).

• Instruct the patient that reinserting and splinting an avulsed tooth does not guarantee its survival. Even if reimplantation is successful, the tooth will require root canal therapy (rarely, a quickly reimplanted immature tooth with an open apex will revascularize and not require root canal).

• Do reimplantation within 30 minutes if possible. Reimplantation done after > 2 hours has a very poor prognosis.

• A tooth contaminated by dirt is a risk factor for tetanus, so immunization history should be checked.

• Expeditious reimplantation and careful handling of the tooth are paramount.

• Patients and parents are understandably worried and anxious. Calm reassurance is important in order to obtain the cooperation needed to reduce time to reimplantation.