An avulsed tooth is a tooth that has been totally displaced from its socket. Children and adolescents sustaining this type of injury commonly present to the emergency department (ED). If the tooth is part of the permanent (secondary) dentition, the physician may be able to salvage it. It is emphasized that avulsion of a permanent tooth is a true dental emergency. An early study found that when avulsed teeth were reimplanted within 30 minutes, there was a 90% success rate; when they remained out for several hours, less than 5% exhibited long-term “survival” (1). More recent studies report an even shorter extraoral time period is required to achieve a good prognosis (2,3,4,5,6).

Maxillary central incisors are avulsed most frequently, followed by maxillary lateral incisors (7). Children with prognathism (buck teeth) are particularly prone to incur such injuries (8). Mandibular incisors and canines are avulsed less often, and posterior teeth only rarely (7).

The emergency physician must distinguish an avulsed deciduous (primary) tooth from a permanent one because their management differs greatly. Deciduous incisors are smaller and have less pronounced serrations along the edges. In addition, a deciduous maxillary central incisor is approximately the same size as its lateral counterpart, whereas a permanent maxillary central incisor is noticeably larger than the corresponding lateral incisor (see Table 64.1). Another clue is that deciduous incisors are most often exfoliated between 6 and 9 years of age. Mandibular central incisors are shed first (6 to 7 years of age), followed by maxillary central and mandibular lateral incisors (7 to 8 years of age), and maxillary lateral incisors (8 to 9 years of age) (see Table 64.2) (9).

Avulsions of permanent teeth occur most often in 7- to 10-year-old boys (8,10). Bicycle and skateboard accidents and sports injuries are the typical causes (11,12). Several factors predispose to exarticulations at this age. Between 7 and 10 years of age, the roots of the permanent teeth are immaturely formed, the periodontal ligaments are loosely structured and weakly connect the roots to the alveolar bone, and the alveolar bone is relatively soft (11,13). In contrast, older individuals with mature roots, strong periodontal ligaments, and hard alveolar bone are more likely to sustain a dental fracture rather than an avulsion.

The key to successful reimplantation is maintaining the viability of the periodontal ligament fibers. These surround the root and secure it to the adjacent alveolar bone. Following a traumatic avulsion, some fibers remain attached to the root whereas others remain on the surrounding alveolus. To avoid traumatizing the periodontal ligament fibers, one should only handle the tooth by its crown. In addition, the fibers are quite sensitive and do not tolerate drying or prolonged lack of nutrition. Therefore, if for some reason the tooth cannot be reimplanted immediately, it must be stored in a suitable liquid medium. Although a commercially prepared medium such as ViaSpan (which is used for transplant organ storage) or Hank’s balanced salt solution is best, this type of solution is rarely available, even in the ED (14,15,16). Cool milk, which is readily available in the home, is a good next choice, followed by intraoral saliva and physiologic saline solution (8,10,11,17,18). Storing the tooth in water is least preferable but is better than letting it dry (16,19).

The sole indication for reimplantation is avulsion of a permanent tooth that is not severely fractured. In general, a tooth with a root fracture or a vertical fracture more than half its length should not be reimplanted.