Tooth avulsion & replantation

• Replantation is the technique in which a tooth is reinserted into the alveolus after its loss or displacement by accidental means
• The prognosis of the replanted tooth depends on the time elapsed between the avulsion and the time tooth was placed back into the socket &  the way tooth was carried to the dentist.
• If avulsion has occurred at a clean place than tooth can be placed back into the socket by the patient himself or by someone near to him,and can than rush to dental clinic nearby.But if tooth has avulsed in a place that is dirty like that of a playground or something like that than ask the patient to come immediately to the clinic with tooth in a storage medium.
• Various storage medium available are-Hanks balanced salt solution,isotonic saline and bovine pasteurized skim milk are the best available storage medium.Saliva and tap water can also be used as storage media but its must to note that neither saliva nor tap water are better storage media than hanks balanced salt solution or milk,if tooth is to be stored for more than 30 min. before replantation.
• When patient arrives to your clinic than first look for alveolar bone fracture or severe soft tissue injury and than  irrigate the socket with betadine and saline.At the same time keep the avulsed tooth in a doxycycline solution for 5 minutes.every attempt should be made to preserve viable periodontal ligaments in the socket and the root surface of tooth.Tooth should be place back into the socket by using digital pressure.If the clot is present in the socket,it will be displaced as the tooth is repositioned.If the tooth doesn't slip back on digital pressure than it can be forced by using local anaesthesia or a X ray can be taken.After this do a semi rigid splinting using a thin wire and composite.Keep patient on antibiotics and antiinflammatory and analgesic drugs.Also prescribe patient with tetanus toxoid injection.Keep calling the patient at regular intervals.Chances of re-vascularisation are greater when the apex is not closed and tooth is immature.But if apex is closed than RCT becomes mandatory and it should be carried out after the 7 days of injury,with splints are still there.Calcium hydroxide should be used as obturating material.It can be latter replaced by gutta percha but at least for a year calcium hydroxide should be used and it should be renewed after 6 months with fresh calcium hydroxide. 
• Rigid splinting should not be advocated as it can lead to ankylosis.
• Emdogain can be used to before placing the tooth into the socket.It improves the prognosis.
• Calcium hydroxide reduce the chances of external root resorption and it can also be used for closing the open apex of root.(apexification)
• If the time elapsed between the avulsion & replantation of tooth is more than one hour than remove all the dead periodontal ligaments from the tooth root surface and socket by irrigation with sodium hypochlorite.Soak tooth in sodium hypochlorite for 15 minutes.After that do RCT of the tooth outside the socket and Place the tooth in 2% stannous flouride for at least 5 minutes and than obturate the canal with calcium hydoxide.Doxycycline should also be used.After that place the tooth back into the socket and do semi rigid splinting for minimal 14 days period.