International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth

Board takeaway

Replant an avulsed permanent tooth promptly when feasible; never replant a primary tooth.

• Initial assessment: root maturity, actual extraoral dry time, storage conditions, associated injury, and the child's medical status.
• Closed apex: begin root canal treatment within two weeks.
• Open apex: closely monitor possible revascularization; treat definite necrosis and infection promptly.
• Prolonged dry time: periodontal-ligament damage is expected, but delayed replantation can temporarily preserve appearance, function, and alveolar contour.
• Counseling: explain that temporary benefit alongside ankylosis, resorption, and later tooth-loss risk.

Compare the endodontic and review pathways

Root maturity changes endodontic timing and surveillance. Both pathways require immediate care, dry-time/storage assessment, appropriate stabilization, antibiotics/tetanus assessment, and home instructions. Open-apex inflammatory resorption can progress rapidly; closer review may be needed.

First aid at the accident

1. Calm the patient; identify a permanent tooth. Handle only the crown, avoiding the root.
2. If dirty, gently rinse with milk, saline, or the patient's saliva; replant immediately. Have the patient bite on gauze or a clean cloth to retain position.
3. If replantation is impossible or unsafe, such as with unconsciousness, immediately immerse the tooth.
   • The guideline's practical preference order: milk → HBSS → saliva collected in a container → saline.
   • Water is poor but preferable to air drying.
4. Bring patient and tooth for immediate dental care. Root dehydration begins within minutes.

Prepare before an injury

Teach parents, teachers, and the public beforehand; the IADT Save a Tooth poster and ToothSOS app support emergency education.

History and PDL prognosis

• Record dry intervals separately from time in storage; determine open versus closed apex and evaluate clinically/radiographically.
• Likely viable: immediate replantation or approximately 15 minutes after injury.
• Possibly viable, compromised: stored in a suitable medium with total extraoral dry time < 60 minutes.
• Likely nonviable: total dry time >60 minutes, regardless of subsequent storage. Most PDL cells are already nonviable after about 30 minutes dry; 60 minutes is not a safe waiting window.
• Assess individual reasons against replantation: severe caries/periodontal disease, inability to cooperate, severe cognitive impairment requiring sedation, immunosuppression, or severe cardiac disease. These require individualized judgment.

Emergency clinic: replantation pathways

• Already replanted: clean the injured area, verify position clinically and radiographically, and leave a correctly positioned tooth in place.
  • Correct malposition gently; wrong-socket placement or rotation may be repositioned up to 48 hours after injury.
• Not replanted, dry time < 60 minutes: gently remove gross debris by agitation in storage medium or brief saline/physiologic-medium rinsing. Keep the tooth immersed during history, examination, and preparation.
• Provide local anesthesia; irrigate the socket with sterile saline.
• Inspect and reposition a fractured socket wall; remove obstructing coagulum when needed.
• Replant slowly with light digital pressure, avoiding force; verify position clinically/radiographically.
• Delayed case >60 minutes: use the same gentle replantation principles.
  • For a closed-apex tooth, loose contamination may also be removed with saline-soaked gauze.
  • Do not promise PDL regeneration: ankylosis and replacement resorption are expected.
• All pathways require stabilization, suturing of gingival lacerations when present, systemic antibiotic consideration per the guideline, tetanus review, home instructions, and follow-up.
• Counsel delayed cases about unpredictable resorption rate, eventual tooth loss, and possible decoronation/autotransplantation if ankylosis causes infraposition during growth.

Splint and pain control

• Default: passive flexible splint for 2 weeks, allowing slight mobility. Wire diameter up to 0.4 mm (0.016 inch); nylon line 0.13–0.25 mm is an alternative.
• Avoid nylon stabilization when too few permanent teeth are available. Short immature roots may need longer stabilization.
• Associated alveolar/jaw fracture: a more rigid splint for about 4 weeks.
• Place labially, preserving occlusion and palatal/lingual endodontic access. Keep resin away from marginal gingiva and interproximal spaces for cleaning.
• At removal, check position and occlusion. Add one week only if opposing teeth could cause further trauma or the tooth cannot maintain its position; mobility alone does not mandate extension.
• Local anesthesia is recommended in the clinical setting.
• Protocols prefer no vasoconstrictor, but the anesthetic discussion acknowledges little evidence supporting its omission.
• A regional block may suit severe injury within clinician expertise.

Antibiotics and tetanus

• Systemic antibiotics are recommended after replantation for contamination and infection-related resorption risk, although their benefit is explicitly uncertain. Medical status/associated injuries may also justify coverage.

• Amoxicillin or penicillin are first choices; consider alternatives for penicillin allergy. Calculate dose for age/weight; this source does not give a specific regimen.

• Doxycycline: AAPD's 2026 antibiotic best practice lists it as an alternative to penicillin for avulsion and reports that short-term use (< 21 days) has not been associated with tooth discoloration in children under 8.

  • Choose the agent according to allergy, age, weight, and medical status.
  • This safety finding is not an avulsion dosing or duration regimen.

• Older age caution versus current guidance: IADT's 2020 guideline generally advised against tetracycline/doxycycline below age 12.

  • Do not turn that older caution into an absolute current ban on doxycycline under 12; the 2026 AAPD guidance includes a pediatric alternative and newer safety evidence.

• Topical antibiotic soaking: animal promise has not translated into demonstrated human revascularization benefit. No particular agent, duration, or application method is recommended.

• Check tetanus history; refer to a physician to determine booster need rather than assuming immunization is complete.

Endodontics: closed versus open apex

• Closed apex: initiate root canal treatment within 2 weeks after replantation, including delayed cases.
• Use dental dam isolation; anchor to an uninjured neighboring tooth when appropriate to avoid further trauma.
• Calcium hydroxide: intracanal medication for up to 1 month, then root filling.
• If choosing corticosteroid or corticosteroid/antibiotic intracanal medication: place immediately or soon after replantation and retain for at least 6 weeks. Avoid coronal placement and counsel about discoloration.
• Open apex: allow potential spontaneous pulp-space revascularization and continued root maturation.
  • Do not initiate endodontics without definite clinical/radiographic evidence of necrosis and infection; the source retains this approach even in its delayed-replantation pathway.
• Once necrosis/infection is identified, promptly institute root canal treatment, apexification, or revitalization/revascularization. Balance healing potential against rapidly destructive inflammatory resorption in children.
• If future decoronation is anticipated, consider intracanal material choice and duration.

Home care and recall

• Avoid contact sports; soft diet for up to 2 weeks, as tolerated.
• Soft toothbrush after each meal; 0.12% chlorhexidine rinse twice daily for 2 weeks, only if the child can rinse and spit safely.
• Reinforce compliance and give parents the prognosis and recall plan.
• Clinical and radiographic review:
  • Closed apex/general schedule: 2 weeks (splint removal), 4 weeks, 3 months, 6 months, 1 year, then annually for at least 5 years.
  • Open apex: 2 weeks, 1, 2, 3, 6 months, 1 year, then annually for at least 5 years; closer observation detects rapid infection-related tooth/bone loss.

Recognize healing and complications

• Favorable: comfortable functional tooth, normal mobility/percussion, no percussion tenderness. Closed apex: normal lamina dura, no radiolucency or resorption.
• Open apex: continued root development and eruption; canal obliteration during the first year can represent healing.
• Unfavorable: swelling/sinus tract, excessive mobility or immobility, radiolucencies, resorption; immature teeth may stop developing. Symptoms may be absent.
• Inflammatory resorption: root and/or surrounding bone resorption.
• Replacement resorption/ankylosis: absent PDL space, root replaced by bone, metallic percussion. Both resorption patterns can coexist.
• Ankylosis during growth risks infraposition and disturbed alveolar/facial development.

Long-term planning and evidence gaps

• Coordinate pediatric, endodontic, orthodontic, and restorative expertise early—ideally before infraposition. Discuss costs, time, prognosis, and family priorities.
• Options include decoronation, autotransplantation, resin-retained bridge, removable partial denture, or orthodontic closure with/without composite reshaping. Keep options available until maturity; implants may be considered after growth.
• Decoronation threshold: ankylosed tooth with esthetically unacceptable infraocclusion that simple restoration cannot correct; no fixed millimeter threshold is supplied.
• Track core outcomes: periodontal/pulp-space healing, pain, discoloration, tooth loss, quality of life, perceived appearance, trauma anxiety, visit burden, and avulsion-specific infraocclusion.
• Research gaps include revascularization protocols, splint choice/duration, anesthetic vasoconstrictors, antibiotics, intracanal corticosteroids, alveolar development after replantation/decoronation, periodontal regeneration/healing, and home care.
• Proposed approaches are not automatically established recommendations.

Common board traps

Answer aloud

An immature incisor arrives in milk after 20 minutes dry. What drives your plan?

Replant promptly when appropriate and preserve the immature tooth’s potential for pulp revascularization.

• Record actual dry time and time in each storage medium; time out of the mouth is not necessarily time dry.

• Immediate care: Replant gently, verify position, and use a passive flexible splint for 2 weeks unless associated bone injury changes the plan.

• Adjuncts: Include guideline-recommended antibiotics (benefit uncertain), tetanus assessment, and homecare.

• Pulp plan: Preserve revascularization potential and treat definite necrosis and infection promptly.

Does one hour in water mean an avulsed permanent tooth had one hour of dry time?

No. Record actual cumulative dry time separately from time in each storage medium.

• Water is a poor storage medium, but storage in water is not air drying.
• Root maturity, storage conditions, associated injury, and medical status also change the plan.
• Do not use the 60-minute dry-time category as a safe waiting period.

When should root canal treatment begin after replanting a closed-apex permanent tooth?

Begin within two weeks after replantation, including delayed-replantation cases.

• Use dental dam isolation; an uninjured neighboring tooth can support the retainer to avoid further trauma.
• This timetable belongs to the closed-apex pathway, not every replanted immature tooth.

What triggers endodontic treatment after replanting an open-apex permanent tooth?

Definite clinical or radiographic evidence of pulp necrosis and infection triggers prompt treatment.

• Until then, preserve possible pulp-space revascularization and continued root development.
• The IADT pathway retains this approach even after prolonged dry time.
• Review closely: infection-related resorption can progress rapidly in immature teeth, without waiting for pain.

How does an associated alveolar or jaw fracture change splinting after permanent-tooth avulsion?

Use a more rigid splint for about four weeks for the associated fracture.

• Without this indication, the default is a passive flexible splint for two weeks.
• Short immature roots may require longer stabilization; reassess the individual injury.
• Mobility at routine removal alone does not require extension. An extra week may be appropriate if opposing teeth cause further trauma or the tooth cannot maintain position.

A mature incisor was dry for 90 minutes. Why replant?

After 90 minutes dry, the periodontal ligament has a poor prognosis and ankylosis with replacement resorption is expected.

• Benefit: Replantation can still temporarily restore appearance and function and preserve alveolar contour while long-term options are planned.
• Treatment: Explain that prognosis, replant as appropriate, use a flexible splint for two weeks absent an associated fracture indication, and initiate endodontic treatment within two weeks for the mature tooth.
• Follow-up: Long-term interdisciplinary follow-up is essential.

What do a metallic percussion sound and increasing infraocclusion suggest in a painless replanted permanent tooth, and how should you manage it?

A metallic percussion sound and increasing infraocclusion suggest ankylosis and replacement resorption even when the tooth is painless.

• Assessment: Confirm the findings clinically and radiographically and assess the child's growth with the interdisciplinary team.
• Option: Decoronation may be considered when infraocclusion compromises appearance and a simple restoration cannot correct it; the plan must account for continuing growth.

How do routine avulsion follow-up schedules differ by apex?

Use clinical and radiographic review for both; the open-apex pathway requires additional early surveillance.

• Routine splint removal is at two weeks; associated alveolar/jaw fracture changes stabilization to about four weeks with a more rigid splint.
• Monitor root development, infection-related resorption, ankylosis/replacement resorption, and growth-related infra-position. Infection-related resorption can progress rapidly in immature teeth; do not wait for pain.

What home care follows permanent-tooth replantation?

Protect healing, maintain hygiene, and keep the planned reviews.

• Avoid contact sports and maintain a soft diet for up to two weeks according to tolerance.
• Soft toothbrush after each meal; 0.12% chlorhexidine rinse twice daily for two weeks only if the child can rinse and spit safely.
• Reinforce antibiotic and tetanus instructions and explain complications/prognosis.