Treatment of the Avulsed Permanent Tooth

Recommended Guidelines of the American Association of Endodontist

I. Management at Site of Injury

  1. Replant immediately, if possible. If contaminated, rinse with water before replanting.
  2. When immediate replantation is not possible, place tooth in the best transport medium available.

II. Transport Media

  1. Hank's Balanced Salt Solution (H.B.S.S.)
  2. Milk
  3. Saline
  4. Saliva (buccal Vestibule)
  5. If none of the above is readily available, use water.

III. Management in the Dental Office

  1. Replantation of Tooth
    1. If extraoral dry time is less than one hour with or without storage in a physiological media (such as Hank's Balanced Salt Solution, milk, or saline), replant immediately.
    2. If extraoral dry time is greater than one hour, soak in an accepted dental fluoride solution for 20 minutes, rinse with saline, and replant.
  2. Management of the Root Surface
    1. Keep the tooth moist at all times.
    2. Do not handle the root surface (hold tooth by the crown).
    3. Do not scrape or brush the root surface or remove the tip of the root.
    4. If the root appears clean, replant as is after rinsing with saline.
    5. If the root surface is contaminated, rinse with H.B.S.S. or saline (use tap water if above are not available). If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and/or gently brush off debris with a wet sponge.
  3. Management of the Socket
    1. Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline.
    2. Do not curette the socket.
    3. Do not vent socket.
    4. Do not make a surgical flap unless bony fragments prevent replantation.
    5. If the alveolar bone is collapsed and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position.
    6. After replantation, manually compress (if spread apart) facial and lingual bony plates.
  4. Management of Soft Tissues - tightly suture any soft tissue lacerations, particularly in the cervical region.
  5. Splinting (indicated in most cases)
    1. Use acid-etch/resin alone or with soft arch wire, or use orthodontic brackets with passive arch wire. Suture in place only if alternative splinting methods are unavailable. (circumferential wire splints are contraindicated.)
    2. Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits.
    3. Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).
    4. Home care during splinting period should encompass:
      1. No biting on splinted teeth
      2. Soft diet
      3. Maintenance of good oral hygiene

IV. Adjunctive Drug Therapy Considerations

  1. Systemic antibiotics
  2. Referral to physician for tetanus consultation within 48 hours
  3. Chlorhexidine rinses
  4. Analgesics

V. Endodontic Treatment

  1. Tooth with open apex (divergent apex) and less that one hour extraoral dry time:
    1. Replant in an attempt to revitalize the pulp.
    2. Recall patient every 3-4 weeks for evidence of pathosis.
    3. If pathosis is noted, thoroughly clean and fill the canal with calcium hydroxide (apexification procedure).
  2. Tooth with open apex (divergent apex) and greater that one hour extraoral dry time:
    1. Thoroughly clean and fill the canal with calcium hydroxide.
    2. Recall the patient in 6 - 8 weeks.
    3. Because of poor prognosis, consider alternative treatment options.
  3. Tooth with partially to completely closed apex and less than one hour extraoral dry time:
    1. Biomechanically clean the root canal system in 7-14 days.
    2. Medicate the canal with calcium hydroxide for as long as practical, usually 6-12 months.
    3. Then, obturate canal with gutta percha and sealer unless complications are apparent.
  4. Tooth with partially to completely closed apex and greater than 2 hours extraoral dry time:
    1. Perform root canal therapy either intraorally or extraorally.
    2. Prior to replantation, remove tissue tags from the root surface and soak the tooth in an accepted dental fluoride solution.

VI. Restoration of the Avulsed Tooth

  1. Recommended Temporary Restorations (placed prior to final obturation)
    1. Reinforced zinc oxide eugenol
    2. Acid etch/composite resin
  2. Recommended Permanent Restorations (placed immediately after final obturation)
    1. Dentin bonding agent
    2. Acid etch/composite resin

VII. Additional Considerations

  1. Avulsed primary teeth should not be replanted.
  2. Avulsed permanent teeth require follow-up evaluations for a minimum of 2-3 years to determine the outcome of therapy.
  3. Inflammatory resorption, replacement resorption, ankylosis and tooth submergence are potential complications when avulsed teeth are replanted.

The Guidelines are based on a review of the pertinent literature and clinical experience in managing cases. The literature is divided into four general categories: (1) clinical trials, (2) simulated injuries in animal models, (3) case reports and (4) opinion articles. The AAE recognizes that the most definitive information is gathered from properly designed clinical trials. Simulations from animal models are useful, but not totally conclusive when applied to human subjects.

Case reports and opinion articles have limited application. In studying a subject such as the accidentally avulsed permanent tooth, clinical trials are not always available and in many cases are impossible to perform. Therefore, these recommendations represent the state of the art and science at this moment but are subject to revision as additional research and knowledge become available.

Treatment of the Avulsed Permanent Tooth: Recommended Guidelines of the American Association of Endodontist are intended to aid the practitioner in the management and treatment of the accidentally avulsed tooth. Practitioners must always use their own best professional judgment. The American Association of Endodontists neither expressly nor implicitly warrants any positive results associated with the application of these guidelines. Although it is impossible to guarantee permanent retention of a tooth that has been avulsed, timely treatment of the tooth in the proper manner can maximize the chances for success.
© 1995 American Association of Endodontists, 211 East Chicago Avenue, Suite 1100, Chicago, IL 60611-2691 The Association grants a limited license to members of the Association to copy the Treatment of the Avulsed Permanent Tooth: Recommended Guidelines of the American Association of Endodontists for their own personal use and for no other purpose. The Treatment of the Avulsed Permanent Tooth: Recommended Guidelines of the American Association of Endodontists may not be reproduced for sale and may not be amended or altered in any manner. This license is not assignable.


The American Association of Endodontists


The Avulsed Permanent Tooth

Andreasen JO.   Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53.

Andreasen JO.  The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odontol Scand, 1975;33:313-23.

Andreasen JO.   Traumatic injuries of the teeth. 2nd ed. Philadelphia; WB Saunders, 1981.

Andreasen JO, Andreasen FM. Essentials of traumatic injuries to the teeth. Munksgaard, Copenhagen. 1190;120.

Andreasen JO, Borum MK, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to root growth. Endod Dent Traumatol 1995; 11:69.

Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Diagnosis of healing complications. Endod Dent Traumatol 1995; 11:51.

Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to pulp healing. Endod Dent Traumatol 1995; 11:59.

Andreasen JO, Borum MK, Jacobsen HL, & Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995; 11:76. Bjorvatn K, Selvig KA, Klinge B. Effect of tetracycline and SnF2 on root resorption in replanted incisors in dogs. J Dent Res, 1989,97:477-82.

Blomlof L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J, 1981;Suppl 8:1-26.

Blomlof L. Storage of human periodontal ligament cells in a combination of different media. J Dent Res 1981;60(11):1904-06.

Blomlof L, Lindskog S, Anderson L, Hedstrom K-G, Hammarstrom L. Storage of experimentally avulsed teeth in milk prior to replantation. J Dent Res 1983;62:912.

Blomlof L, Lindskog S, Hammarstrom L. Periodontal healing of exarticulated monkey teeth stored in milk or saliva. Scand J Dent Res 1981;89:251-9.

Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta percha. A retrospective clinical study. Endodon Dent Traumatol, 1992;8:45.

Cvek M. Tratement of non-vital permanent incisors with calcium hydroxide. II. Effect on external root resorption in luxated teeth compared with effect of root filling with gutta-percha. A follow-up. Odont Revy 1973;24:343-54.

Cvek M. Cleaton-Jones P. Austin J, Lownie J. Kling M and Fatti P. Pulp revascularization in reimplanted immature monkey incisors - predictability and the effect of antibiotic systematic prophylaxis. Endodon Dent Traumatol 1990;5:157-69.

Hammarstrom L, Blomlof L, Leiglin B, Anderson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endodon Dent Traumatol 1986;2:51-57.

Heimdahl A, Von Konow L. Lundquist G. Replantation of avulsed teeth after long extra-alveolar periods. Int J Oral Surg 1983;12:413-17.

Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hanks balanced salt solution and Viaspan storage media. Endodon Dent Traumatol 1991;7(2):69-72.

Kawashima Z. Pineda FR. Replanting avulsed primary teeth. J Am Dent Assoc 1992;123(10):90-1.

Kling M, Cvek M. Mejare I. et al. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endodon Dent Traumatol, 1986;2;83-9.

Kristerson L and Andreasen JO. The effect of splinting upon periodontal and pulpal healing after autotransplantation of mature and immature permanent incisors in monkeys. Int J Oral Surg, 1983;12;239.

Loe H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys. Arch Oral Biol 1961;3:176-84.

Mackie IC, Worthington HV. Investigation of children referred to a dental hospital with avulsed permanent incisor teeth. Endodon Dent Traumatol 1993;9;106-10.

Mackie IC, Worthington HV. An investigation of replantation of traumatically avulsed permanent incisor teeth. Br Dent J 1992;172(1):17-20.

Magura M. Elkafrawy A. Brown C. Newton C. Human saliva coronal microleakage in obturated canals: An in vitro study. J Endodon 1991;17:324-31.

Matsson L. Andreasen J. Cvek M. Granath LE. Ankylosis of experimentally reimplanted teeth related to extra-alveolar period and storage environment. Pediatr Dent, 1982;4:327-9.

Nordenvall KJ. Milk as storage medium for exarticulated teeth: report of case. J Dent Child 1992;59:150-5.

Oswald RJ. A postreplantation evaluation of air-dried and saliva-stored avulsed teeth. J Endodon 1980;6:546.

Ray H. Trope M, Buxt P. Switzer S. Influences of various factors on the radiographic periapical status of endodontically treated teeth. J Endodon 1993;19:187 (Abstract #7).

Skoglund A and Tronstad L. Pulpal changes in replanted and autotransplanted immature teeth of dogs. J Endodon 1981;7:309.

Sjogren M, Figdor D, Spangberg L. Sundqvist G. The antimicrobial effect of calcium hydroxide as a short term intracanal dressing. Int Endodon J, 1991;24:119-25.

Trope M and Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, Milk and Hanks Balanced Salt Solution. Endodon Dent Traumatol, 8:183-8.

Trope M, Moshonov J, Nissan R, Buxt P, & Yesilsoy C. Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth. Endod Dent Traumatol 1995; 11:124.

Trope M. Yesilsoy C, Korem L, Moshonov J, Friedman S. Effect of different endodontic treatment protocols on periodontal repair and root resorption of replanted dog teeth. J Endodon 1992;18(10):492-6.

Wilcox LR, Diaz-Arnold A. Coronal microleakage of permanent lingual access restorations in endodontically treated anterior teeth. Int Endodon J 1990;23(6):321.

Van Hassel HJ, Oswald RJ, Harrington GW. Replantation 2. The role of the periodontal ligament. J Endodon 1980;6:506.


This selected bibliography is intended only to be representative of some of the pertinent knowledge in the area involving the avulsed permanent tooth both from the historical as well as the research perspective. Citing the listed reference material is not meant to imply endorsement of any statement contained in the reference material, nor is it intended to be a complete bibliography of this subject area. Readers should consult other sources available to obtain a complete bibliography on this topic. These references should be updated periodically as new research information becomes available.


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