II. Definition
- Most severe of Tooth Luxation injuries
- Tooth is completely displaced from alveolar bone
III. Epidemiology
- Most commonly affects anterior teeth as they are more easily avulsed (single root, cone shaped)
IV. Contraindications: Reimplantation
- Primary alveolar ridge Fracture
- Tooth left dry and out of socket for >60 minutes (unlikely to implant successfully
- Immunocompromised patient (relative)
- Tooth integrity compromised (relative)
- Implantation socket integrity compromised (relative)
V. Management: General
- Avulsed Permanent Teeth (secondary teeth) are a Dental Emergency
- Nerve, artery and vein bundle is completely severed on complete Tooth Avulsion
- Reimplantation within 5 minutes: 85-97% healing rate
- Goal is reimplantation within 15-20 minutes
- Reimplantation after dry and out of socket >60 minutes: Tooth rarely heals
- May attempt tooth reimplantation if within 1.5 hours of tooth loss
- Better chance of successful reimplantation if tooth is clean and socket is bleeding
- Avulsed Primary Teeth should not be reimplanted
- Children lose Primary Teeth at ages 6-7 years old
- First primary tooth loss is anterior followed by posterior (often bottom and then top)
- Primary Teeth are small, flat, milky white with little to no root
- Contrast with Permanent Teeth that are larger
- Permanent Teeth start with ridged cutting edges (mamelons) that gradually wear down
- Most common Avulsed Teeth are the top front (Maxillary anterior, incisors)
- Compare to bottom teeth, as these are the first typically to be replaced by Permanent Teeth
- Dental referral if avulsed primary tooth without an obvious palpable secondary tooth beneath
- Routine referral due to the risk of crowding of Permanent Teeth
VI. Management: Technique for tooth reimplantation
- Avoid periodontal ligament (at root) injury (critical for successful reimplantation)
- Hold tooth gently by crown
- Do not touch, rub or clean root
- Do not wipe the tooth
- Do not dry the tooth (tooth preservation relies on moisture)
- Evaluate tooth
- Gently remove debris from tooth
- Rinse tooth with saline or Chlorhexidine, or cool Running tap water
- Observe for Tooth Fracture
- Evaluate for open apex (immature, incompletely developed tooth root with large hole)
- Soaking the tooth Doxycycline 1 mg/20 ml for 20 min may improve implantation success
- Gently remove debris from tooth
- Evaluate dental socket
- May require Regional Anesthesia
- Remove coagulated blood and debris with saline irrigation
- Dry base if bleeding
- Consider using Nasal Cannula at 10-15 L blown at tooth base to assist keeping surface dry
- Evaluate for alveolar bone Fracture
- May occur with Tooth Avulsion
- Reduce alveolar Fracture prior to tooth reimplantation
- Reimplant tooth as soon as possible
- Determine correct position and orientation in dental arch
- Insert tooth gently into socket with minimal pressure
- Gentle rocking may be needed to orient the tooth correctly in the socket
- Align the tooth with adjacent teeth
- Check the Occlusion or bite
- Patient may bite gently down on a wash cloth to secure in place
- Secure tooth with temporary splint to adjacent teeth
- See Dental Splint
- Additional measures if tooth avulsed and out of mouth for more than 1 hour
- Soak tooth in 2% Sodium Fluoride solution for 20 minutes prior to reimplantation attempt
VII. Management: Reimplantation not possible
- Transport tooth to dentist if reimplant not possible
- Tranport media
- Hank's Balanced Salt Solution (e.g. Save-A-Tooth)
- Considered best option by some dentists
- Pasteurized Milk packed in ice (not evaporated or condensed)
- Normal Saline
- Avoid harmful storage media
- Do not store in Saliva due to cell lysis, infection
- Do not store in patient's mouth (aside from dental socket) due to aspiration risk
- Do not store tooth in other person's mouth
- Do not store tooth in dry tissue or cloth
- Avoid tap water or Gatorade due to risk of Periodontal ligament degradation
- Hank's Balanced Salt Solution (e.g. Save-A-Tooth)
VIII. Management: Post-Reimplantation
- Dental evaluation as soon as possible
- Secure Splinting of tooth
- Root canal may be needed at 7-10 days after reimplantation (endodontist)
- Antibiotic prophylaxis with Penicillin VK (or Clindamycin) for 7 days
- Consider chlorhexadine 0.1% mouthwash twice daily for 7 days
- Tetanus Vaccine if not given in last 5 years
IX. References
- Hehn and Warrington (2016) Crit Dec Emerg Med 30(6):12-3
- Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
- Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
- (2006) Correspondence from Dr. Paul Krasner, DDS
- McTigue (2000) Pediatr Clin North Am 47(5):1067-84 [PubMed]