Endodontic Topics 2006, 14, 28–34 Copyright r Blackwell Munksgaard

All rights reserved ENDODONTIC TOPICS 2008

1601-1538

Tooth avulsion in children: to

replant or not
JENS OVE ANDREASEN, BARBRO MALMGREN & LEIF K. BAKLAND

Replanting avulsed teeth with a doubtful long-term prognosis due to unfavorable extra-alveolar conditions has
recently been questioned by Kenny and Barrett (1). Many factors, however, still favor replanting such teeth. First of
all, reliability of failure predictors has not yet been tested in prospective studies. Secondly, preservation of even
resorbing replanted teeth may offer significant long-term advantages in preparation for definitive treatment. Also,
for psychological reasons, replantation can significantly reduce the anxiety and despair of both the injured child and
the parents. Furthermore, decoronation of a resorbing anterior tooth will allow it to serve as a matrix for alveolar
bone formation and preserve an otherwise resorbing alveolar process, thereby leaving an environment of bone and
soft tissue that is optimal for both single implant insertion or fixed prosthesis. Finally, replantation and subsequent
decoronation, if indicated, appears to be cost-effective in comparison with non-replantation combined with
subsequent repeated prosthetic tooth replacements owing to vertical alveolar growth of adjacent ridge areas, with
eventual definitive implant placement or a fixed prosthesis.

Because of the frequent occurrence of progressive

Introduction
resorption affecting avulsed and replanted teeth, and
Replantation of avulsed teeth has been an established the problems in achieving successful long-term treat-
and recommended treatment procedure for more than ment results, abstaining from replantating avulsed
a century, and a series of clinical investigations has
shown that long-term survival can be expected in many
cases. In the largest published study so far, comprising
400 avulsed and replanted teeth, a median long-term
survival of 16.5 years was reported (2). This is a survival
time period that comes close to that of fixed crown and
bridge reconstruction. Although encouraging, it must
be recognized that progressive root resorption invol-
ving replanted avulsed teeth represents a severe
treatment problem and is the direct cause of extraction
of many such teeth (3).
These progressive resorption phenomena relate to
infection-related resorption (because of bacteria in the
root canal and dentinal tubules) and bony replacement
(ankylosis-related resorption), which gradually substi-
tutes the root with bone. Whereas infection-related
resorption can be treated using proper endodontic Fig. 1. Relationship between periodontal ligament
techniques, there is presently no effective curative (PDL) healing and length of extra-alveolar dry storage.
procedure for ankylosis-related resorption. From Andreasen et al (6).

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 Tooth avulsion in children

Fig. 3. Avulsed central incisor in an 8-year-old boy.

Fig. 2. A. A 9-year-old boy avulsed the central incisor in Extra-oral time was 45 min; the tooth had been kept in
an accident. He kept the tooth for 15 min in his hand, milk and was replanted by the family dentist. A.
then under his tongue for 45 min until it was replanted. Preoperative radiograph taken 48 h later when patient
Radiograph shows empty tooth socket before was referred for endodontic treatment. B. Root canal
replantation. B. Radiograph of replanted right central treatment was done 2 weeks later in one visit using
incisor. C. Radiograph of the replanted tooth 3 weeks mineral trioxide aggregate. C. Five-year follow-up. D.
later and before endodontic treatment. D. Follow-up Seven-year follow-up. Note the intact periodontal
radiograph taken 6 years later. Courtesy of Dr. Barbro ligament and lack of resorption. Courtesy of Dr. George
Malmgren. Bogen.

(3) (Fig. 1). In contrast, teeth with closed apices have a

teeth has been suggested for children in whom the significantly lower chance of healing.
extra-alveolar dry time exceeds 5 min because of The reason cited for non-replantation of teeth with
the expected progressive resorption, either type of 45 min of dry time is primarily related to the time-
which can lead to tooth loss in a relatively short time consuming process of performing endodontic treat-
span (4, 5). Thus it has been suggested that all teeth ment after replantation and the consequent total cost of
with a drying time of 45 min are very poor healing treatment when a later replacement for the resorbing
candidates (1). tooth becomes necessary. This view is not supported
There is, however, good evidence to support by the current treatment Guidelines of the Interna-
replanting avulsed teeth with 45 min of dry time. tional Association of Dental Traumatology (IADT) (7)
For replanted teeth in children with incomplete root and the Guidelines of the American Association of
formation, the critical drying period is 20 min, and even Endodontists (8). The IADT recommends that teeth,
with 20–60 min dry times, 15% of the teeth have a including children’s teeth, should be replanted. The
chance of optimal periodontal ligament (PDL) healing reasons for doing so can be stated as follows:

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Andreasen et al.

Fig. 4. A. Plaster model demonstrating the reduction in the width and height of the alveolar process after extraction of a
right central incisor. B. Section A is through the extraction site and section B is through the site of the adjacent tooth. C.
The graphic illustration depicts the loss of alveolar support, which is reduced by 15.7% after 3 months and 18–25% after
12 months. Courtesy of Dr. Olle Malmgren.

Chance of healing movements. Also, the growth of the jaws is intense and
varies in direction at that age. Therefore, treatment
There is in some cases a chance of both pulpal and
with space maintainers is complicated in the mixed and
periodontal healing even after extended extra-oral
young permanent dentitions because of skeletal growth
periods if proper extra-alveolar storage has been used.
and eruption of teeth.
Even in cases of subsequent pulp necrosis, endodontic
Patients with an overjet exceeding 6 mm and with
treatment can succeed in arresting infection-related
insufficient lip closure are at the highest risk (10, 11).
resorption (Figs 2 and 3). The strongest predictor for
An eventual malocclusion must be evaluated and special
healing appears to be the time of dry storage; however,
consideration to possible autotransplantation is of great
some cases still show PDL healing even after prolonged
importance.
extra-oral dry storage. It should be noted that the
A co-ordinated treatment plan with input from
reliability of healing predictors, such as storage time
specialists in various dental disciplines should be
and storage medium, has not yet been determined (9),
initiated (e.g. endodontics, prosthodontics, orthodon-
implying that active treatment (replantation) deserves
tics, pediatric dentistry, and oral and maxillofacial
the benefit of the doubt.
surgery) to achieve the most comprehensive evaluation.
This can only be accomplished when enough time is
Problem of selecting alternative treatment available and not at the time of the emergency
procedures at the time of the emergency treatment.

The dentist treating the injured child in an emergency

service is in most cases not likely to be the family dentist
Alveolar bone preservation concerns
and will not be involved in the definitive treatment
decision. Most avulsions occur in children between If an avulsed anterior tooth is not replanted,
8 and 12 years of age. During that time frame, the a significant loss of vertical and horizontal alveolar
erupted teeth change their positions and the whole bone will take place through bone resorption. After just
alveolar process is developing. In particular, the a few months, it will result in collapse of the labial aspect
eruption of canines can cause severe undesirable tooth of the alveolar process and subsequently also lead to

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 Tooth avulsion in children

a significant reduction in the height of the alveolar

process (12, 13) (Fig. 4). Both dimensions can be
restored with various bone augmentation procedures,
but these are unpredictable and time-consuming
procedures (14). It is important to recognize that
eventually both esthetically successful conventional
bridges and single standing implants rely on an intact
bony alveolar process and normal oral mucosa. The
recognition of this important requirement plays an
essential role in the decision of whether to replant or
not.
In 1984 a procedure known today as decoronation
was introduced and this has completely changed the
replantation philosophy. Replanted teeth in children
undergoing resorption as a result of traumatic injury
can now be used to preserve the height and width of the
alveolar process (15) (Fig. 5). The mode of action
behind this favorable phenomenon is possibly related
to formation of an active periosteum over the resorbing
root, thus allowing the resorbing root to serve as a
matrix for bone formation. The result is alveolar
Fig. 5. Difference in alveolar process anatomy after growth taking place in harmony with the adjacent
extraction (A) and after decoronation (B).
erupting teeth (16).
A. Photograph of the maxillary anterior ridge of an
18-year-old boy. The right maxillary central incisor The success of decoronation has recently been
was extracted at age 12. Note reduced ridge contour. demonstrated in 77 replanted, ankylosed teeth (17).
B. Photograph of the maxillary anterior ridge of a 19- In 30 patients, normal alveolar bone was noted
year-old girl. The right maxillary central incisor had been radiographically after 18 months. In 47 patients, root
replanted following avulsion, and decoronation was done
at the age of 14. Note full ridge contour. From Malmgren remnants were still present. In patients who have had
& Malmgren (15). decoronation before or during pubertal periods of
growth, no further infraposition of the alveolar
segment occurred during the observation period

Fig. 6. Decoronation of an ankylosed maxillary central incisor in infraposition. A. Radiograph of the tooth shows
extensive ankylosis-related resorption. B. Radiograph taken after the decoronation; the crown of the tooth is bonded to
the adjacent teeth. C. Six-month follow-up radiograph. Note bone growth coronal to the root fragments. D. Twelve-
month follow-up radiograph shows excellent ridge formation and almost complete replacement of the root with alveolar
bone. From Malmgren & Malmgren (15).

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Andreasen et al.

Fig. 7. A. Infraposition in a 14-year-old boy of a replanted maxillary central incisor undergoing ankylosis-related
resorption. (A1) The maxillary right central incisor is ankylosed and is in a noticeable infra-occlusal position. (A2) The
radiograph shows the extent of root resorption. (A3) A mucoperiosteal flap is raised. (A4) The crown is removed with a
diamond bur under continuous flow of saline, following which the temporary root filling is removed. B. Suturing and
temporization. (B1) The mucoperiosteal flap is pulled over the alveolus and sutured tightly. (B2) Radiograph shows
remaining root structure left in the alveolus. (B3 and B4) The removed crown is fitted as a temporary pontic by bonding it
to the adjacent teeth. C. Definitive treatment with implant. (C1 and C2) Ten years after decoronation, an implant is placed
in the site of the ankylosed tooth. (C3 and C4) An esthetically pleasing crown is placed on the implant. The importance of
having an adequate ridge for implant placement is illustrated in this case. From Malmgren & Malmgren (15).

(Fig. 6). The bone level, however, increased in the Psychological reasons
vertical direction, and when the patients reached
adulthood the alveolar ridges had maintained their For obvious reasons, trauma situations involving an
labial/palatal dimensions. An alveolar process thus anterior tooth avulsion are a major psychological
maintained is naturally optimal for successful insertion challenge for both the injured child and the parents
of an implant (17) (Fig. 7). (18). Replantation of the avulsed tooth, even if the

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 Tooth avulsion in children

Table 1. Estimated cost of trauma treatmentn

Implant and crown $4000
No replantation1orthodontic closure
Total $8700
Orthodontic treatment $6000 Five-year assessment of total cost of managing a 12-
year-old patient with an avulsed maxillary central
Reconstruction of moved and adjacent $4500
incisor.
teeth (porcelain laminates) n
US dollars, 2007.
Total $10 500

No replantation1resin-bonded bridge1bone
augmentation1implant
long-term prognosis is not ideal, represents a remedy
Resin-bonded bridge $2500 for this tragic situation, albeit for a limited time.
Ridge augmentation $2500
This consideration alone merits replantation being
carried out.
Implant and crown $4000

Total $9000
Cost–benefit considerations
No replantation1resin-bonded bridge1vertical distraction
1implant With the advent of decoronation, the cost–benefit ratio
of replanting avulsed teeth with a compromised out-
Resin-bonded bridge $2500
come has dramatically changed. Decoronation of
Vertical distraction osteogenesis $4000 resorbing replanted teeth may prevent the need for
future vertical and horizontal alveolar bone reconstruc-
Implant and crown $4000
tion, thus reducing the cost and complexity of future
Total $10 500 treatment (14). Table 1 shows a comparison of the
cost–benefit of replantation and non-replantation in
Replantation and splinting1decoronation1resin-bonded
bridge avulsion situations in children.

Replantation and splinting $700

Removal of splint $100 Analysis of cost–benefit

Root canal treatment $800 The cost–benefit analysis of replantation/decoronation
Yearly control $150
was accomplished in the following manner: eight
records from the Trauma Center at the Eastman
Decoronation $450 Institute in Stockholm, representing replantation
Resin-bonded bridge $2500 followed by decoronation later, were analyzed for the
time spent on various treatment procedures related to
Total $4700
the treatment of adolescents. These figures were
Replantation1resin-bonded bridge1decoronation1 analyzed by a group consisting of pediatric dentists,
implant endodontists, prosthodontists, and implant dentists
Replantation and splinting $700
from Loma Linda University Implant Dentistry Center.
In treatment situations in which no replantation
Removal of splint $100
treatment is performed, vertical and horizontal bone
loss will occur. This situation requires a combined
Root canal treatment $800 horizontal and vertical bone augmentation that can
Yearly control  3 $150 only be done surgically by either bone autotransplanta-
tion or vertical distraction osteogenesis before implant
Decoronation $450
insertion (14). Table 1 shows various treatment
Resin-bonded bridge $2500 scenarios related to the cost at one dental center in
the United States (Loma Linda). It appears that the

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Andreasen et al.

total cost for each treatment approach is very similar. 6. Andreasen JO, Bakland LK, Flores MT. Traumatic
But one would likely prefer replantation/decoronation Dental Injuries, 2nd edn. Oxford, UK: Blackwell
Munksgaard, 2003: 51.
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7. Flores MT, Andersson L, Andreasen JO, Bakland LK,
replantation with its problems. An additional advantage Malmgren B, Barnett F, Bourguignon C, DiAngelis A,
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Chicago, Ill., 2004. Available from www.aae.org.
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Conclusion for healing complications in the permanent dentition
after dental trauma. Endondontic Topics 2007, in press.
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replantation is to be preferred because resorbing Swed Dent J 1993: 17: 183–190.
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following extractions. J Prosth Dent 1960: 10: 25–32.
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13. Schropp L, Wenzel A, Kontopoulus L et al. Bone healing
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bridge will be in the treatment plan. Consequently extraction: a clinical and radiographic 12-month pro-
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