Reinserting a tooth

[Antz002]

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I'd be really interested to know what sort of success to failure ratio there is for reinserting teeth which have been knocked out. I know its something which needs to be performed relatively quickly after occurring, but how is a tooth reinserted, and what methods are there to hold it in place once this has been done?

 

[aphistis]

I'd be really interested to know what sort of success to failure ratio there is for reinserting teeth which have been knocked out. I know its something which needs to be performed relatively quickly after occurring, but how is a tooth reinserted, and what methods are there to hold it in place once this has been done?

It decreases linearly with time, and it's dependent on preservation of the PDL fibers and immobilization of the tooth to allow for reattachment, but the success rate is high enough to merit trying if you have the opportunity.

Typically the tooth is held in place by attaching it to adjacent teeth with a wire splint for several days to several weeks, depending on the type of injury sustained.

 

[ItsGavinC]

Bill brought up the key points, and it's also important to note that prognosis can also be attributed to the age of the tooth (or the development of the apex).

 

[capisce?]

It decreases linearly with time, and it's dependent on preservation of the PDL fibers and immobilization of the tooth to allow for reattachment, but the success rate is high enough to merit trying if you have the opportunity.

Typically the tooth is held in place by attaching it to adjacent teeth with a wire splint for several days to several weeks, depending on the type of injury sustained.

Just to clarify...success is not linear with time. That would be saying a tooth out 1 hour is two times more successful than a tooth out 2 hours. Not true. I do understand what you meant Bill, ie the longer out of the mouth the worse the prognosis...which is accurate. For any chance of revascularization 5 mins is the threshold for reimplantation of an avulsed tooth. After that 5 min window success drops considerably, and not linearly. This per trauma guru Andreasen.

It depends on way too many factors to get into here....maturity as gavin mentioned, storage medium, time out of mouth, dry time/wet time, how tooth was handled, etc etc. In some cases (excessive dry time) the risk of reimplantation and ankylosis in a growing child is reason to leave it out and go from there.

 

[aphistis]

Just to clarify...success is not linear with time. That would be saying a tooth out 1 hour is two times more successful than a tooth out 2 hours. Not true. I do understand what you meant Bill, ie the longer out of the mouth the worse the prognosis...which is accurate. For any chance of revascularization 5 mins is the threshold for reimplantation of an avulsed tooth. After that 5 min window success drops considerably, and not linearly. This per trauma guru Andreasen.

It depends on way too many factors to get into here....maturity as gavin mentioned, storage medium, time out of mouth, dry time/wet time, how tooth was handled, etc etc. In some cases (excessive dry time) the risk of reimplantation and ankylosis in a growing child is reason to leave it out and go from there.

You're right, of course. I caught that after I made the post, but I got lazy and thought I could get away with it in this setting. Thanks for pointing out the correction.

 

[DrJeff]

Personally these days, with the success rates of implants being so high, if I'm dealing with an avulsion in a teen and older patient, titanium and porcelain are my 1st choice. In this population, by the time you bill for the re-implantation, the fixation, the endo and *if* the reimplantation is successful, the subsequent crown, you've got 1 expensive tooth that runs a decent risk of complications/failure for the rest of the patients life. Much lower longterm failure rate and a higher degree of predictability with the implant IMHO.

Sub teen population, basically I'll try and re-implant/fixate/endo but I'm basically telling the parents that if we're lucky, the tooth will last long enough to where the patient is old enough for an implant to be predictably placed esthetically. This sub teen population, which generally is pre-orthodontic treatment can present a decent challenge for the orthodontist, since in so many cases where a re-implantation takes place the tooth will ankylose, and then the orthodontist is potentially looking at a compromised final result if the location of that tooth isn't ideally where it should be.

 

[capisce?]

Personally these days, with the success rates of implants being so high, if I'm dealing with an avulsion in a teen and older patient, titanium and porcelain are my 1st choice. In this population, by the time you bill for the re-implantation, the fixation, the endo and *if* the reimplantation is successful, the subsequent crown, you've got 1 expensive tooth that runs a decent risk of complications/failure for the rest of the patients life. Much lower longterm failure rate and a higher degree of predictability with the implant IMHO.

Sub teen population, basically I'll try and re-implant/fixate/endo but I'm basically telling the parents that if we're lucky, the tooth will last long enough to where the patient is old enough for an implant to be predictably placed esthetically. This sub teen population, which generally is pre-orthodontic treatment can present a decent challenge for the orthodontist, since in so many cases where a re-implantation takes place the tooth will ankylose, and then the orthodontist is potentially looking at a compromised final result if the location of that tooth isn't ideally where it should be.

Hey Doc, what has your experience been with bone loss at the avulsion site and it's effects on your implants? I read a study regarding time of tooth loss and associated bone loss but can't recall what I read 😀

 

[DrJeff]

Hey Doc, what has your experience been with bone loss at the avulsion site and it's effects on your implants? I read a study regarding time of tooth loss and associated bone loss but can't recall what I read 😀

The few anteriors where I have had "successfull" re-implantation have all demonstrated some long term boneloss (1-3mm of horizontal bone loss) radiographically which occurred within the first 12 months post trauma/re- implantation but then (*knock on wood*) have stabilized - almost what you'd expect boneloss wise after doing some perio surgery

The few that I've had that have failed, just kept on loosing bone past the 12 month mark and had some vertical components to the boneloss pattern instead of just consistant horizontal boneloss. In these failures, the oral surgeon that places my implants did a complete debridement of the subsequent extraction site and then bonegrafted the site, keeping the graft site burried for atleast 6 months before inserting titanium. Not that I see them very often (My "average" over my career is about 1 per year), but looking retrospectively, from about the 6 month mark post re-implantation this is where I start to get very judicious about having the patient in every 6 weeks to probe the tooth to look for ANY beginning of a vertical defect. I find that by really staying ontop of these teeth and not being afraid to call a failure a failure at an early point, that you can generally maintain decent amounts of bone for the implant site👍 It's the one's where my brain was telling me that the tooth was failing at say the 8 to 9 month mark, but I just kept on watching the tooth for another 6 to 12 months before, that's where more grafting was needed to get the final esthetic result. Note, in just about all the cases where the vertical component of boneloss happened, the tooth was still stable early on, but I was able to go back and retrospectively watch that 1 wall defect accelerate over time😡😡