Avulsed permanent incisor replanted after 40 minutes in milk

§Chief complaint

Front tooth knocked out during a cycling accident

§Medical & dental history

• 01Healthy; tetanus immunisation current
• 0221 avulsed, stored in cold milk by a teacher, presented at 40 minutes

§Clinical examination

• 01Empty socket at 21 with a clot and intact alveolar walls
• 02Avulsed tooth intact with a closed apex; root surface not scraped
• 0322 and 11 subluxated, grade I mobile, no displacement
• 04Lip laceration 8 mm, no foreign bodies

§Figures

§Differential diagnosis

§Final diagnosis

Avulsion of 21 with a closed apex, extra-oral dry time under 15 minutes and 40 minutes in milk

Short dry time with physiological storage medium gives a realistic chance of periodontal ligament cell survival, so immediate replantation with a flexible splint and later root canal treatment offers the best prognosis.

§Investigations

• 01IOPA of 11, 21, 22 and occlusal view — exclude root and alveolar fracture, confirm socket integrity
• 02Confirm tetanus status
• 03Radiograph of the lip laceration if any fragment is unaccounted for

§Radiology

• 01IOPA — socket intact, no root fracture; closed apex on 21
• 02Post-splint radiograph confirms correct seating

§Treatment plan

• 01Gentle rinse with saline, replant immediately
• 02Flexible (passive) splint for 2 weeks
• 03Root canal treatment begun at 7-10 days with calcium hydroxide dressing
• 04Systemic antibiotics, chlorhexidine rinse, soft diet

§Surgical procedure

• 01Socket irrigated with saline, clot removed, tooth replanted with gentle digital pressure
• 02Composite and wire flexible splint 21 to 12 and 22
• 03Lip laceration sutured with 6-0 resorbable material

§Follow-up & outcome

• 01Day 10 — root canal treatment initiated, calcium hydroxide placed
• 02Week 2 — splint removed; tooth firm
• 033, 6 and 12 months — obturated, no external inflammatory resorption; annual review for 5 years

Outcome: Tooth retained and functional at 2 years with no radiographic resorption.

§Discussion

• 01Periodontal ligament cell viability is the single determinant of long-term outcome; dry time beyond 60 minutes makes ankylosis and replacement resorption likely.
• 02Milk, saline, saliva or a cell culture medium are acceptable storage media; water is the worst because it lyses cells.
• 03In closed-apex teeth, pulp revascularisation does not occur, so root canal treatment is planned from the outset.

§Clinical pearls / learning points

• 01Hold the tooth by the crown — never scrub the root.
• 02Flexible splint for 2 weeks; rigid splinting increases ankylosis risk.
• 03Never replant an avulsed primary tooth.

§Viva questions

§MCQs

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