POINT/COUNTERPOINT

Avulsed maxillary central incisors: The case for

W
hen contemplating replantation and auto- from the clinician's ability to control important vari-
transplantation, the main focus for ortho- ables during autotransplantation vs no control of
dontists is likely to be the advantages of most circumstances after a traumatic avulsion. A sur-
autotransplantation, which has become an attractive geon has control of important variables such as extra-
treatment for replacing missing maxillary incisors. alveolar dry time and physiologic wetting solutions
The focus of this article will be on a comparison be- during autotransplantation, whereas a clinician com-
tween teeth replanted as autotransplants and those monly has no control over what happens to a tooth
replanted after traumatic avulsion. immediately after it is avulsed.
Dentists tend to think that most replanted avulsed In ideal clinical management, primarily 2 tissues, the
teeth have a poor long-term prognosis and create periodontal ligament and the pulp, are injured during
problematic restorative situations. These concerns are autotransplantation. In contrast, the periodontal liga-
focused on the potential for ment, pulp, cementum, alveo-
a replanted tooth to become lar bone, and gingiva might all
ankylosed. Replantation of With replantation, long-term be damaged in the trauma
an avulsed tooth, however, treatment decisions need not involving an avulsed or a dis-
does not necessarily guaran- be made while managing an placed tooth. The more struc-
tee that the tooth will become
emergency....Replanting an avulsed tures that are injured, the
ankylosed and give rise to more complicated and unpre-
a deficient alveolar ridge, nor tooth will allow interdisciplinary dictable the survival and re-
does it preclude autotrans- consultations and a definitive turn to function of these
plantation as a subsequent treatment plan. tissues becomes. From an end-
consideration. odontic perspective, however,
When considering replan- most pulpal problems can be
tation vs autotransplantation of an avulsed tooth, resolved with endodontic treatment in either autotrans-
the difference in published success rates appears to fa- plantation or replantation of an avulsed tooth.
vor autotransplantation. Although success rates are
important, they are not the sole consideration in the POTENTIAL FOR ANKYLOSIS
management of a missing anterior tooth. Reported The main concern in the treatment of a growing
success rates for autotransplanted teeth range from child is the potential for ankylosis of a replanted
21% to 100%.1 For autotransplanted premolars to tooth. Ankylosis is fusion of the alveolar bone and
the anterior region of the mouth, the success rate the root surface. It produces 2 clinical conse-
claims are 79% to 93%.2,3 The success rates for re- quences—replacement resorption and arrested ridge
planted teeth after traumatic avulsion are 9% to development. Replacement resorption is the progres-
50%.4 However, Andreasen and Andreasen4 and others sive resorption of the root of the tooth and its re-
have claimed success rates between 71% and 82% placement by bone. If it occurs, this characteristic
when avulsed teeth are replanted under more favor- can be used to a clinical advantage. Arrested develop-
able conditions.5,6 The disparate success rates arise ment of the alveolar ridge associated with an anky-
losed tooth can result in a progressive vertical ridge
Affiliate professor, Graduate Endodontics Program, Department of Endodon- defect as a child grows. Adequate augmentation of
tics, School of Dentistry, University of Washington, Seattle, Washington.
Reprint requests to: David R. Steiner, 4050 S 19th St, Ste 102, Tacoma,
these large defects remains a difficult clinical chal-
WA 98405; e-mail, [email protected]. lenge. These extensive ridge deformities have raised
Am J Orthod Dentofacial Orthop 2012;142:8-17 so many concerns that one consideration is that teeth
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
with an extra-alveolar time greater than 5 minutes
doi:10.1016/j.ajodo.2012.04.009 should not be replanted.7,8 But that approach comes
8
10 Point

Fig. Replantation of an avulsed central incisor followed by implant replacement. A, The maxillary right
central incisor was avulsed and replanted at age 10. At age 13, the incisal edge was lengthened with
composite. Ankylosis of the right central incisor caused a gingival margin discrepancy with the left cen-
tral incisor. B, At age 15, the incisal length of the ankylosed and submerged right central incisor was
increased with composite to help facilitate orthodontic treatment. After orthodontic treatment, the right
central incisor was extracted, and a bone graft was placed in the alveolar ridge. C, At age 19, the patient
had completed her facial growth, and an implant and a crown were placed in the grafted alveolar ridge
to replace the missing right central incisor (courtesy of Drs Ron Kuritani, Daniel Cook, David Crouch,
David Mathews, and Beth O'Connor).

with its own set of problems. These include long-term ligament, correlation of such data with prevention of
temporization for a growing child, progressive ridge ankylosis is not yet available.
resorption in the avulsion site that requires additional
separate grafting procedures, and the need for addi- ADVANTAGES OF REPLANTATION
tional orthodontic treatment. Replantation of an avulsed tooth is a basic starting
Although there has been extensive research related point even when the ideal conditions to prevent anky-
to replantation of avulsed teeth, ankylosis remains losis cannot be met. With replantation, long-term
the predominant clinical problem. Inquiries into the treatment decisions need not be made while manag-
factors that affect replantation success have been ing an emergency. To construct a complex treatment
published since the mid-1800s.9 Over time, research plan at the time of the tooth avulsion is an unreason-
suggests that the most important variable in preventing able expectation. Replanting an avulsed tooth will
ankylosis and replacement resorption is a viable peri- allow interdisciplinary consultations and a definitive
odontal ligament on the root of the tooth at the replan- treatment plan to ensue in a deliberate fashion. In
tation.10 Periodontal ligament viability is primarily addition, a replanted tooth can serve as an interim re-
associated with how long a tooth is out of the socket placement. It can also act as a scaffold to prevent
and the effect of the physiologic storage medium dur- rapid loss of alveolar bone during remodeling of the
ing the extraoral time. Immediate replantation (less socket. An alternative to replantation is to place
than 5 minutes) is best for the preservation of a viable a socket graft to preserve the alveolar ridge. This
periodontal ligament.10,11 In fact, viability of the peri- seems like a simple solution. Nevertheless, most acci-
odontal ligament remains high with an extra-alveolar dents occur between the ages of 8 and 12 years. A
dry time up to 15 minutes.4-6 socket graft must preserve the alveolar ridge until
Limiting the time the periodontal ligament is dry the child has stopped growing, often for a period of
while a tooth is out of the socket might also decrease 5 to 10 years. In a series of patients followed for 3
the incidence of ankylosis. Hank's balanced salt solu- to 7 years after traumatic tooth loss in the anterior
tion (SAVE-A-TOOTH; Phoenix-Lazerus, Inc, Potts- maxilla, socket grafting failed in 82.4% of the sites
town, Pa) is the preferred medium to preserve to provide sufficient bone to support the placement
periodontal ligament viability.12 As a practical matter, of a dental implant without an additional bone
however, cold milk and saliva are more likely to be im- graft.14
mediately at hand. Cold milk can keep the periodontal If a replanted tooth becomes ankylosed, it does not
ligament cells viable for about 6 hours, and saliva for preclude subsequent autotransplantation. Ankylosis
30 minutes.12,13 Although laboratory research has es- can be clinically diagnosed as early as 2 months after
tablished time parameters for the efficacy of storage replantation; most cases are found within 6 months
media in maintaining the viability of the periodontal to 1 year.4,10 If a tooth does become ankylosed and

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
12 Point

the child is a candidate for autotransplantation, the to a decoronated root. The base of the trapezoid is
tooth can still be removed without missing the optimal the root undergoing replacement resorption. In in-
time for transplantation success. stances of considerable vertical midfacial growth, the
Finally and most importantly, when a decision is distance increases from the retained root to the coronal
made to replant a tooth, it is crucial that the primary portion of the ridge. This distance can result in the level
dentist, specialists, and parents all assume responsibil- of the resorbing root being positioned too apically for it
ity for monitoring the child's dentition for signs of to add bone at the ideal level adjacent to the labial as-
replacement resorption. Together, each will have pect of the implant head. Even so, the resorbing root
a role in ensuring that any upcoming decision regard- would increase the volume of labial bone in the apical
ing autotransplantation or decoronation is made and region of the implant. But, as the height of the devel-
performed at the appropriate time (Fig). oping ridge continues to increase, the coronal aspect
of the ridge might become too narrow to support an
DECORONATION implant without a graft. In short, proper timing of de-
Decoronation of an ankylosed tooth is 1 solution coronation can increase the likelihood of an adequate
that has been proposed to prevent or mitigate a large implant site or a ridge width that would allow for a sin-
ridge defect in a growing child. First described in gle surgery that combines grafting and implant place-
1984, decoronation involves removal of the crown ment. But, in instances of prolonged vertical midfacial
and endodontic filling material from the root of an an- growth, even with the additional bone volume from de-
kylosed tooth, allowing the tissue to heal over the coronation, the coronal ridge might still require sepa-
retained root.15 Results have shown that new bone rate additional grafting in spite of seemingly proper
can develop coronally to the root remnant. In addition, timing and appropriate technical management of the
the retained root maintains the labial contours of the decoronation.
ridge directly over the root as the root is resorbed and
replaced by bone. Yet, in some case reports, the clinical TIMING THE APPROPRIATE TREATMENT
outcomes of decoronation appear to be inconsistent or How does a clinician judge the possible extent of
unsatisfactory. These reports have raised the question a ridge defect and know when to intervene? By begin-
of the efficacy of the decoronation procedure. In ning with median growth data for the start of adoles-
some case reports, decoronation was carried out too cent rapid growth and refining that information by
late to take advantage of adolescent growth.16-18 If de- observation and key questions, both the time to decor-
coronation were performed late in the growth spurt, 2 onate and the extent of the defect can be estimated.19
factors would combine to produce a deficient ridge in A simple observation by the parents is to record the
the decoronation site. skeletal height of the child every 3 months beginning
First, most of the vertical growth of the alveolar 6 months to 1 year before the median age for rapid
ridge and the eruption of the adjacent teeth are growth. A distinct change in height indicates that rapid
missed. Second, the presence of the crown of the an- growth has begun. In practice, after determining that
kylosed tooth prevents vertical and horizontal bone a child is in the initial stages of a growth spurt, an an-
growth coronally to the labial aspect of the retained kylosed tooth should be decoronated when it is 2 to 2.5
crown. Thus, decoronating this late in adolescent mm in infraocclusion.16 The tooth will have served as
growth is little better than an extraction and does an interim temporary and space maintainer up to that
not eliminate the need for additional separate grafting point, and decoronating it at this level of infraocclusion
procedures. can capture most of the adolescent rapid growth. After
Is it possible to alter the decoronation procedure to the completion of growth, ridge height might be imper-
achieve an optimal outcome? The mixed results after fect but adequate, since implants are generally placed
decoronation can be explained, in part, by when the about 3 mm apically to an ideal gingival margin.
procedure is performed and the extended facial growth Even if decoronation does not always obtain an ideal
after ankylosis. Decoronating an ankylosed tooth at or ridge, any mitigation of a defect would seem welcome.
near the start of adolescent rapid growth should facil- Not replanting a tooth after avulsion produces a defi-
itate associated alveolar bone growth as the adjacent cient ridge; socket grafting as an alternative to replan-
teeth erupt. This timing should lead to the greatest de- tation is not a long-term solution; and, relative to those
position of alveolar bone coronally to the retained root. choices, decoronation of an ankylosed replanted tooth
Clinical observations suggest that the labio-palatal can moderate a ridge defect enough that the extent and
width of the ridge has a trapezoidal shape coronally number of grafts are reduced.

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
14 Point

Up to this point, the discussion has been limited to make a nonsurgical approach technically undesirable.
children and adolescents. In adults, the clinical man- External resorption near the cementoenamel junction
agement and prognosis differs somewhat for a re- will require surgical repair of the defect with a restora-
planted avulsed tooth.4,20,21 Immediate replantation tion in the esthetic zone. In addition to these possible
has the best prognosis in both groups. An alveolar ridge complications, premolars autotransplanted to the
defect does not develop in an adult, even if the tooth maxillary anterior region are often positioned apically
becomes ankylosed since facial growth has ceased. Fur- to the incisal level of adjacent teeth. If the tooth
thermore, Andreasen and Andreasen4 found that 70% ankyloses at that level, it would be in infraposition.
of ankylosed teeth with mature roots survive for 10 There would be a ready-made alveolar ridge defect,
years. In contrast, 50% of ankylosed teeth with imma- and decoronation or grafting of the site would be
ture roots survive 10 years because the rate of resorp- necessary.
tion is much more rapid in children.4
CONCLUSIONS
LIMITATIONS OF AUTOTRANSPLANTATION
Based on the previous discussion, the following
Replantation of an avulsed tooth comes with conclusions can be made.
predictable issues that have workable solutions. It is
a reasonable clinical practice to replant an avulsed an- 1. It is a reasonable clinical practice to replant an
terior tooth. Autotransplantation also has a place in avulsed anterior tooth.
replacing missing incisors. But, as with all treatment 2. Socket grafting in children is not an effective alter-
choices, it has limitations. Optimal results occur within native to replantation of an avulsed tooth.
a relatively narrow age range. Specifically, treatment 3. The timing for decoronation of an ankylosed tooth
outcomes are best when the root of the donor tooth is critical to its outcome.
is two thirds to three quarters formed. That limits the 4. Optimal results for autotransplantation are
best candidates for treatment to children 9 to 12 years achieved within a narrow age range.
of age.3 When the root length does not fall within this
range, healing of the periodontal ligament can decrease I thank Dr. Gerald W. Harrington, Professor Emeri-
by up to 34% when the foramen of a donor tooth is not tus, Department of Endodontics, School of Dentistry,
wide open.2 Also, complications in obtaining an opti- University of Washington, for his expert help in prepar-
mal root length can increase by up to 25% when the ing this paper.
donor tooth's root is less than half formed.1 In patients
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