Tooth replantation

Overview

Accidents at home, school, or in a motor vehicle, as well as altercations and contact sports, all result in dental injuries. The most frequently injured teeth are the maxillary central incisors. The prognosis is better when teeth are replanted within 5 minutes of avulsion; however, such ideal therapy is not always achievable.

When a tooth is entirely dislodged from its socket, it is said to have avulsed. Avulsed teeth are dental emergencies that must be treated quickly. To save your tooth, consider reinserting it as soon as possible. Teeth that are treated within 30 minutes to an hour have the highest probability of success.

The 7-11-year age group has the highest incidence of dental trauma, with a male to female ratio of 2:1. Permanent teeth are more likely to be damaged than temporary teeth (60 percent vs. 40 percent, respectively). A study of 800 children aged 11 to 13 indicated that about half of them had dental trauma in permanent front teeth, with around 10% of respondents not recalling a history of trauma. A study of 1298 trauma patients treated in an emergency room found that 24 percent had dental injuries, with two-thirds having tooth avulsions.

The most prevalent cause of oral trauma is a fall, which is followed by bike accidents, full-contact sports, and assaults. At least 32% of athletes who participated in full-contact sports had had a dental injury.

Ice hockey, football, lacrosse, rugby, martial arts, and skating are the riskiest activities for tooth injuries. Mouth guards have reduced the frequency of oral injuries, although helmets have not. In younger children, dental trauma should always raise the possibility of abuse.

Every year, about 5 million people in the United States have their teeth avulsed. The majority of oral trauma occurs in children aged 7 to 11. Males are twice as likely as females to get dental injuries.

What is Tooth replantation?

Tooth replantation is a type of restorative dentistry in which a luxated or avulsed tooth is reinserted and fixed into its socket using a series of dental procedures. The goal of tooth replantation is to replace missing teeth while preserving the natural dental landscape.

While there are variations of the process, such as Allotransplantation, in which a tooth is transplanted from one individual to another of the same species. It is a mostly defunct practice due to advancements in dentistry and the hazards and issues involved, including the spread of infections such as syphilis, histocompatibility, and the procedure's poor success rate, which has led in its use being largely abandoned.

In dentistry, auto-transplantation, also known as purposeful replantation, is described as the surgical migration of a tooth from one position on a person to another region on the same individual. While replantation is uncommon, it is used in contemporary dentistry to prevent future issues and conserve the natural dentition in circumstances when root canal and surgical endodontic procedures are troublesome.

The reattachment of an avulsed or luxated permanent tooth into its original socket is most commonly referred to as tooth replantation in the modern context.

What Causes Tooth Avulsion?

The periodontal ligament (PDL) is the soft tissue that connects the cementum that covers the roots of the teeth to the alveolar bone that surrounds them.

When a tooth sustains an external force, the periodontal fibers might break, causing the tooth to be partially or completely displaced from its socket. The resulting injury can cause neuro-vascular disruption and pulp necrosis. The most usually impacted teeth are the maxillary central incisors, followed by the maxillary lateral incisors. Several teeth are frequently avulsed.

In the open air, periodontal ligament fibers can quickly dehydrate. Even in a replanted tooth, damaged periodontal ligament fibers can cause root bone resorption (Resorption occurs when your body rejects a tooth as a self-defense mechanism as a result of a severe injury). Root resorption will result in crown fracture (the functional part of the tooth that is visible above the gum) and tooth loss.

A substantial amount of force is required to knock a tooth out of your mouth. The following are the most prevalent causes of avulsed teeth:

• Falls.
• Bicycle accidents.
• Sports injuries.
• Traffic accidents.
• Assaults.

Sports injuries might result in tooth loss. The following sports injuries can result in tooth avulsion:

• Football.
• Hockey.
• Lacrosse.
• Martial arts.
• Rugby.
• Skating.

What to do following Tooth avulsion?

An avulsed tooth is one that has totally fallen out of your mouth. No portion of your tooth remains in your mouth once it has been avulsed. Avulsed tooth symptoms may include:

• A gap in your mouth where your tooth was.
• Mouth pain.

When you lose a tooth, you may experience bleeding. If this is the case, bite down on a clean handkerchief or tiny washcloth. Aspirin, which might increase bleeding, should be avoided. If you are in pain, consult with your doctor to determine which pain relievers are best for you. Get medical attention if you have suffered a head injury, especially if you are experiencing dizziness or nausea. They will be able to rule out any further injuries.

To preserve an avulsed tooth, prompt treatment is required. See your dentist as soon as possible for further avulsed tooth treatment. To find out how to seek emergency care, contact your dentist or the nearest dentist. At the scene of the accident, you should treat the avulsed tooth yourself. You can do the following steps:

1. Take your tooth by the crown (white chewing surface). Don't go near the root (the part that usually holds your tooth to the bone below your gumline).
2. To eliminate any dust, rinse your teeth with water or milk. Avoid using soap and avoid scrubbing or drying the teeth.
3. Gently insert your tooth, root first, back into the socket. Avoid contacting the root of your tooth by holding it by the crown.
4. Bite on a napkin, gauze, or handkerchief to secure your tooth.
5. See a dentist promptly.

Prioritizing replantation of avulsed and excessively mobile luxated teeth on the verge of avulsion is associated with the greatest long-term prognosis and restoration of the oral landscape. Replanting a tooth that has been out of the socket for more than 60 minutes is pointless because the periodontal ligament (PDL) cells are no longer viable.

Prior to the availability of commercially accessible reconstitution solutions (e.g., Hank balanced salt solution, 320 mOsm, pH 7.2), the best therapy available to the avulsed tooth was quick reimplantation. Without a preservation solution, the odds of successful replantation decrease by around one percentage point for every minute the tooth is removed from the oral cavity.

If replantation is not feasible, the tooth should be preserved in an acceptable transportation medium (normal saline 0.9 percent, milk, or saliva (inside patient's lip or cheek)) and brought to an appropriate health institution with the patient.

Even if the periodontal ligament survives avulsion in adult teeth (those older than ten years), the pulp will not. The necrotic pulp will be removed (root canal) at the 1-week follow-up consultation with the dentist to prevent a prolonged inflammatory reaction from interfering with the repair of the periodontal ligament.

The periodontal ligament, not the tooth, is the primary target of fast replantation. The survival of the periodontal ligament increases the likelihood that the tooth will function for a longer period of time, with less root resorption and lower ankylosis.

After three years, over half of the teeth with luxation injuries become necrotic. Correct and quick care of these situations can improve treatment success.

Replantation of avulsed anterior permanent teeth can postpone or eliminate the need for prosthesis or difficult and costly restorative operations. Several studies have demonstrated that teeth that have been replanted can function for 20 years or more. A few of examples have been described in which replanted teeth have been functioning with a normal periodontium for 20 to 40 years.

How Teeth replantation is done?

Replantation is the preferred therapy; however, it is not always practicable. To enhance tooth survival, proper management of an avulsed tooth during the first 30 minutes and an organized treatment plan is required. The therapy initially seeks to retain tooth life or keep a functioning tooth in its alveolar socket in order to reduce alveolar bone development retardation, which will be required to put a dental implant in the future.

Storage medium:

As previously stated, keeping the avulsed tooth in an isotonic solution such as milk, saline, or saliva inhibits cell death in the root's periodontal ligament. PDL cell loss, on the other hand, is unavoidable, and storing the tooth in a solution is merely a temporary yet effective technique of controlling the tooth until replantation.

Short-term preservation in an isotonic solution has been shown to offer the same or even better healing benefits than immediate replantation. Because of its easy availability, proper pH, normal osmolarity, and quantity of nutrients and growth agents, milk is the most commonly used and recommended storage solution. It is worth mentioning that drinking water, because to its low osmolality, might harm the PDL.

Anti-resorption medium:

It entails soaking the avulsed tooth in an antibiotic-laced storage solution. Anti-resorption treatment is thought to prevent necrotic cell and microbial-caused inflammation. Several regimens have been proposed, including a 20-minute storage solution containing 800 µg doxycycline and 640 µg dexamethasone. Meanwhile, if a blood clot is clogging the alveolus, it should be mildly irrigated with 0.9 percent physiologic saline solution and gently aspirated.

Technique:

• The doctor will leave the tooth in the media if it was kept in a cell culture medium or milk when it arrived. If the avulsed tooth is stored in saliva or no media, he will place it in a cell culture medium or normal saline as soon as possible. If the tooth has been dry for 20 to 60 minutes, it should be immersed for 30 minutes in cell culture media.
• If the periodontal cells have been dry for more than an hour, the aim will be to decrease root resorption. Before replantation, dentists frequently prescribe soaking the tooth for 5 minutes in each of three distinct solutions: citric acid, 2% stannous fluoride, and lastly doxycycline syrup or suspension. The tooth should never be just thrown; instead, consult a dental practitioner for advice.
• The dentist will then perform a quick medical history and a thorough assessment of the traumatized individual:

1. Where, how, and when did the trauma occur? Are there fractures?
2. Is there any neurologic damage? Unconsciousness? Amnesia? Headache? Nausea?
3. Are there any underlying medical conditions? Immunocompromise? Diabetes? Prostheses? Cardiac conditions for which antibiotic prophylaxis is recommended?

• If any of these are life-threatening or limb-threatening, they should be addressed first. If not, the dentist will mentally record other issues while quickly preparing to replace the tooth.
• If required, a local anesthetic will be applied to the socket region after the patient is stabilized. The practitioner should take standard precautions with blood and bodily fluids.
• Then the doctor will perform a brief clinical examination:

1. Are there any other intraoral lacerations or disturbances?
2. Is the bite disturbed by other displaced teeth?
3. Make mental notes of these findings while rapidly preparing to replant the tooth.

• The tooth will be removed from its soaking solution and, using finger pressure, replanted as near to its natural position as possible while holding the crown with gauze or tooth forceps. Care must be taken not to come into contact with the root. The patient can facilitate the replantation process by gently chewing on gauze; this move can also help support the tooth following replantation until more permanent stabilization can be established
• The alignment must be anatomic (the curved side faces the tongue). the dentist then checks for malocclusion in the patient. If the tooth has occlusion with another tooth, it may be preferable to transfer the tooth in preservation media to a dental specialist for final replantation.
• The dentist will then apply semirigid splinting and administer penicillin VK 1 g orally (for those not already given parenteral dose), then 500 mg orally four times a day for 4 to 6 days (clindamycin for those allergic to penicillin). Tetanus toxoid is also administered if the patient has not had a booster within 5 years.

What happens after Tooth replantation?

Splinting:

After replanting the tooth, it should be immobilized with a semi-rigid splint (e.g., titanium trauma splint). Splinting immobilizes the replanted tooth while allowing the injured periodontal ligament fibers to reconnect the alveolus to the cementum.

Flexible splinting is recommended by the International Association of Dental Traumatology (IADT) for all dental injuries. The splinting period for avulsed teeth is two weeks. They do not prescribe any particular splint for alveolar fractures; however, they do advocate immobilizing the alveolar segment for four weeks. 

Systemic Antibiotics:

In the event of intolerance, doxycycline or amoxicillin should be prescribed for five days. The regimen for children under 50 kg comprises an initial dosage of 100 mg doxycycline on the first day and 50 mg on the next four days.

How do I take care of myself after Tooth replantation?

You should do the following to help protect your tooth after reinsertion:

• Avoid eating foods that are either too cold or too hot.
• Brush your teeth carefully after each meal with a gentle toothbrush.
• For two weeks, eat only soft foods and drinks.
• For two weeks, rinse with an antimicrobial chlorhexidine mouthwash twice a day.
• Use nonsteroidal anti-inflammatory medicines (NSAIDs) as needed to relieve pain.

You'll also need to see your dentist on a regular basis to have your reattached tooth checked. You should avoid contact sports unless your physician approves.

Follow up Appointments:

After two weeks, the splint must be removed and the tooth clinically and radiographically checked. After removing the splint, the tooth's mobility is evaluated, and a pulp vitality test, ideally pulse oximetry or electric testing, is conducted.

Because there is no chance of revascularization if the tooth is non-vital, a root canal therapy is recommended. If the pulp is vital, an x-ray should be taken using a specially designed holder. A repeat x-ray will be obtained to check for resorption at the subsequent follow-up sessions (after one, three, and six months). If there is no obvious resorption at this time, the patient is called back every year for a check-up. A root canal therapy is recommended in cases of resorption.

When the dry period exceeds 60 minutes, the leftover PDL should be removed since it acts as a stimulant for ongoing inflammation, which increases infection-related resorption and ankylosis. Gentle scaling and root planning, soft pumice prophylaxis, gauze, or soaking the tooth in 3% citric acid for 3 minutes can all be used to remove any residual PDL. Fluoride therapy is required after this operation because it delays ankylosis and minimizes the risk of resorption.

Severe neurovascular bundle and periodontal ligament injury might result in replacement root resorption or inflammatory resorption. These problems can be predicted and perhaps avoided by using disinfectants and systemic antibiotics during replantation.

Immature teeth with a partially developed root had a better probability of revascularization after soaking in doxycycline. Replanting primary teeth is not recommended since it might harm the underlying permanent tooth germ.

What is the prognosis following Tooth replantation?

Prompt treatment of a tooth avulsion might save your original tooth. Good dental care and frequent exams might help to extend the life of your teeth.

Although your tooth may continue to serve you for many years, doctors cannot promise how long your reinserted tooth will survive. Many issues can arise during tooth replantation, including:

• Ankylosis. This happens when your tooth bonds to the bone and begins to sink into the gum tissue.
• Apical periodontitis. Is an inflammation of the gum tissue around your teeth.
• Inflammatory root resorption. Is a disruption of the root structure of your tooth. Your tooth may become loose as a result of this.
• Pulp canal obliteration (PCO). Includes hard tissue deposits around the root canal walls. PCO is often painless, however it might result in pulp necrosis.
• Pulp necrosis. When the pulp (the tissue in the core of your teeth) dies. Pulp necrosis may need tooth extraction or root canal treatment.

Resorption and ankylosis are more commonly connected with the usage of hard splints rather than semi-rigid ones. Ankylosis can be particularly troublesome in young children going through the facial maturation phase, as the surrounding tissues continue to expand and the tooth seems submerged.

When should I see my healthcare provider following Tooth replantation?

You should see your provider about a replanted tooth if you experience:

• Bleeding.
• Continued tooth pain.
• Swelling.
• Tooth discoloration.

Conclusion

The insertion and temporary fixing of a totally or partially avulsed (knocked out) tooth owing to severe damage is referred to as tooth replantation. There is no feasible technique to avoid tooth avulsion, which generally happens as a result of an accident. Wearing a mouth guard during athletic activities, on the other hand, typically helps lessen danger.

The upper front permanent teeth are the most commonly knocked out, but primary teeth can also be avulsed. Primary (baby) teeth are not normally replanted since they are naturally replaced by permanent teeth later in life.

The success of dental restoration is determined by how long the tooth is out of the socket. Replantation success rates are substantially greater if accomplished within one hour of the tooth being knocked out.

When a tooth is knocked out, the damaged teeth must be captured and kept moist. Handle the tooth by the crown only, not the root. To keep the teeth clean, soak it in milk or a saline (salt water) solution. The solution for contact lenses is great. Keep the tooth out of water. To keep the tooth in its original location, the ideal place to preserve it is within the cheeks inside the mouth.

Splinting should be worn for two to four weeks, during which time the patient should avoid biting on the splinted tooth and properly wash his or her unaffected teeth. It is critical to maintain your mouth as clean as possible. Gingivitis is especially dangerous on afflicted teeth since they cannot be cleaned or flossed properly.

Ankylosis, apical periodontitis, inflammatory root resorption, pulp canal obliteration, and pulp necrosis are all possible complications after tooth replantation.