This case report presents a case of delayed replantation of avulsed maxillary central incisor. The patient had reported more than 36 hours after the trauma with a tooth stored in cold milk. Replantation of the avulsed tooth can restore esthetic appearance and occlusal function shortly after the injury. Replantation is the treatment of choice, but cannot always be performed immediately. Now after months, the tooth is functional, firm and free of symptoms with minimal signs of resorption. Even though the long-term prognosis is uncertain, this treatment technique has proven to be an advantage for the patient by maintaining the esthetics, by maintaining the height of alveolar bone and making the provision of an aesthetically acceptable permanent restoration at a later age if prognosis becomes poor.

Key words: Avulsion, delayed reimplantation,


Tooth avulsion is complete displacement of a tooth from its socket. Tooth/teeth avulsion has become common due to sharp rise in road traffic accident cases. It is followed by fall and sport related injuries, usually the maxillary anterior teeth are most affected. Increased overjet and incompetent lips were identified as potential etiological factors in such avulsion cases. Although avulsion usually involves a single tooth, tooth- supporting tissue injuries, lip injuries and multiple avulsions have also been documented. Avulsion not only leads to loss of function, but also will result in a negative impact on quality of life and social discomfort leading to lowered self-esteem, embarrassment upon smiling and difficulty in relating with others.

The ideal treatment for an avulsed permanent tooth is its immediate reimplantation into the socket. Although recommended, immediate transplantation of the avulsed tooth is not always possible due to the patient’s concomitant injuries at the time of accident and lack of knowledge in the management of such injuries at the site of the accident.

The success of reimplantation depends on the patient’s general health, the maturity of the root,

the time the tooth is out of its socket, and storage medium. The period of extra-oral time and the storage medium have the most critical effect on the status of the periodontal ligament cells. As the duration of extra-oral time increases, the root surface damage also increases which leads to necrosis of the pulp tissue, cemental and periodontal ligament tissue leading to external root resorption and eventually loss of reimplantedteeth.

In such cases, the replanted tooth fails with subsequent loss of the tooth. Surface resorption is generally diagnosed after 12 months andinflammatory resorption and replacement resorption are usually observed after 1 and 1-2 months, respectively. However, irrespective ofthe state of the tooth or time spent out of the mouth, the avulsed tooth that is reimplanted remains the best implant. However, when endodontic treatment is carried out on avulsed teeth, it improves thechances of retention and prevention of replacement resorption. The aim of this case report was to report the …. month-follow-up of avulsed right maxillary central permanent tooth which was replanted in the dental office after a period of 36 hours.

Case Report

A 22-year-old female patient presented in our clinic with a chief complaint of loss of her right maxillary central incisor. Patient gave a history of the fall, while she was running for to catch the steamboat. The patient reported that she and her friends were looking for the avulsed tooth in the site of accident but they couldn’t find her tooth. Patient claimed that she found her tooth after she came home and found her tooth after changing her sweater. And the patient placed her tooth in cold milk when she found her tooth. The patient had already been seen by the medical staff of the emergency unit of a local hospital who had detected no neurological damage or medical complications.

Any concomitant systematic disease is not defined by the patient. Extra orally there were bruises, swelling, irregularity and bleeding on the upper lip. The intraoral examination revealed that the maxillary right permanent central incisor was avulsed. An uncomplicated crown fracture, with dentin involvement of the upper left permanent central incisor was detected. In a vitality test, the adjacent teeth gave a positive response. Examination of the tooth socket did not reveal any fracture of the bony wall or tooth segment. Radiographic examination revealed no fracture of adjacent teeth or any foreign object in the soft tissue broken tooth, bony segment in the socket. Examination of the avulsed tooth revealed dentinal fracture. Roots were completely closed, and root surface was covered with dirt remnants of necrotic periodontal tissue. Avulsed tooth was gently and thoroughly washed in saline. The root surface planned to remove necrotic periodontal tissues and all the debris was removed gently. Since extra oral time exceeded 2 hours, root canal treatment was decided to complete extra orally.Enlargementand cleaning of root canal was performed. The canal was dried with sterile paper points and obturated with Gutta-Percha. Flowable glass ionomer cement was used to restore the access cavity. Local anesthesia was administered and socket was gently curetted to remove any coagulum, granulation or pathologic tissue and then the socket was irrigated with physiologic saline solution. The tooth was gently replanted with slight digital pressure into its socket. The position of the

replanted tooth was verified both clinically and radiographically. Stainless steel wire splinted with acid-etch composite resin and splinting was done from canine

to canine for a period of 2 weeks. The occlusion of the patient was checked to verify that there were no pre-mature contacts while biting to avoid further injury to the adjacent periodontal tissues.

The patient was kept on antibiotics (Amoxicillin/clavulanate) 1 gr twice daily to prevent infection and Ibuprofen 400 mg thrice daily for 5 days. The patient was referred to the medical practioner for an antitetanus booster. Patient was advised to be on soft diet, oral hygiene instructions were given and chlorhexidine mouthwash recommended twice a day for 2 weeks. The patient was rewieved after two weeks with no post-operative clinical or radiographic complications and the splint was removed. Patient was followed-up regularly at 3 and 6 months. Tooth showed no clinical symptoms such as mobility, periodontal pocket or color change. During the 6-month follow-up, clinical and radiographic examinations showed satisfactory functional and esthetic values.


A review of the literature shows that an extraoral time of lessthan 15minutes gives a greater success rate of retention of reimplanted teeth, but if the time lapse is between 15 to 60 minutes, some authors advise that the tooth must be stored in suitable storage medium and transported to the clinic.

Some of the storage media that have been frequently used include Hanks balanced salt solution, modified Eagles solution, Via Span, Euro‑Collins solution, Emergency Medical Tooth saver, saline, powdered or pasteurized milk, bovine milk, saliva, or chicken egg white. Prolonged extra-alveolar period and closed apex are the factors that cause deficiency in pulpal and periodontal healing, so it was assumed that the prognosis of the tooth would be negligible or poor.

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