Avulsion is complete displacement of the tooth from the socket. Avulsed primary teeth should not be replanted. In the primary dentition, the maxillary anterior region is at low risk for space loss unless the avulsion occurs prior to the eruption of the canines or the dentition is crowded. Fixed or removable appliances, while not always necessary, can be fabricated to satisfy parental concerns for esthetics or to return a loss of oral or phonetic function.
An avulsed permanent tooth should be replanted as soon as possible. Care should be taken to handle the crown rather than the root surface, though foreign material on the root may be rinsed briefly with cold water prior to reimplantation. The reimplanted tooth should be stabilized in its anatomically correct location by a flexible splint for 2 weeks.
If it is not possible to reimplant the tooth right away, it should be stored in a medium that will help maintain the vitality of the periodontal ligament fibers on the root’s surface. Transportation media for avulsed teeth include: Hank’s Balanced Salt Solution, cold milk, saliva (either by holding the tooth in the mouth between the molars and cheek, or by spitting into a cup and storing the tooth in the cup), or physiologic saline. Teeth should not be stored in water.
In permanent avulsed teeth, there is considerable risk for pulp necrosis, root resorption, and ankylosis following reimplantation. The risk of ankylosis increases significantly with increased extraoral dry time. An extraoral dry time of 60 minutes is considered the point where survival of the root periodontal cells is unlikely. However, reimplantation may still be considered for the chance to preserve alveolar bone following a later decoronation procedure. Tetanus prophylaxis and antibiotic coverage should be considered if the avulsed tooth was in contact with soil.
Close monitoring is required following reimplantation. If the avulsed tooth had a closed apex, pulpectomy/debridement should be performed within 7 to 10 days. When an avulsed immature tooth is reimplanted, it has a chance of remaining vital due to its open apex and exposed neurovascular bundle. If the tooth becomes necrotic, a revascularization procedure can be performed to stimulate continued root formation and apex closure.