How to Reposition a Luxated (Displaced) Permanent Tooth
Dental traumas are all too common. Correct management is crucial to ensure the teeth have the best prognosis throughout their life. This is a How-To-Guide for repositioning luxated or displaced teeth. Please excuse the overly bright photos, it was a Sunday morning before Christmas and the parent kindly filmed it on their phone for us!
Step 1. Excellent Examination, Radiographs and Diagnosis
This post will not go into this topic, as we will cover it in later posts. However, a good examination, and therefore correct diagnosis, is mandatory to allow you to manage the trauma well. You will likely need to clean up the mouth/teeth to enable you to visualise everything well. If the patient is too sore to allow this, get some local in and then try again.
Pre Op Radiographs. #11 appears elongated as it is palatally luxated
#11 Palatally luxated after a metal drinkbottle to the tooth!
Ideally luxated teeth should be repositioned within 24hrs. The longer they are left, the harder it is to reposition. This is because the socket fills with blood and prevents you being able to ‘force’ the tooth back into place. On quite delayed injuries we have had to use orthodontic forces to reposition.
Step 2. Good LA
Excellent local anaesthetic is paramount to allow you to reposition the tooth/teeth well and without pain. There is nothing worse than starting to exert pressure and the patient feels pain! Ensure you anaesthetise the palatal tissues as well! On our courses, we cover how to give LA to children in a stress/pain free manner. We also discuss it in this post Local Anaesthetics and Children – Part 2, Where and How to Administer — Kids Dental Tips
Post LA, you will notice we have done palatal LA as well
Step 3. Clean More!
As you will be bonding a splint in place, you will need to ensure you have a clean surface to bond to. Clean the soft tissues and teeth with gauze. Do not try to reposition at this stage. Controlling bleeding can be a challenge, so hold off mucking around with the traumatised tooth/teeth too much at this stage.
Cleaned and getting ready to bond
Step 4. Bond the Splint
A separate post will examine which splinting materials are the best, however, in this case we used twisted ligature wire. This was as the trauma occurred 30 hrs prior so fishing line did not have the ‘strength’ to hold it in position. IADT recommends to bond to 1 tooth on either side of the traumatised tooth/teeth. Our advice, in cases where isolation and compliance is poor, would be to consider 2 teeth on either side for extra security/as a back up if one tooth debonds.
Bonding to the neighbouring teeth
Commence with bonding the supporting teeth to the splint, but do not bond the traumatised tooth/teeth yet. Anticipate the position of where the traumatised tooth/teeth will return prior to bonding. That is, if for example #11 is palatally luxated, when you have bonded the splint to the supporting teeth, there will be a gap between the displaced tooth and where the splint is. Then when you reposition the tooth, the splint will be right where it needs to be.
Step 5. Reposition
Once you have the supporting teeth splinted you are in the hot seat. Generally, luxated teeth will go palatally. Therefore, the root is commonly through the buccal plate and ‘locked in’. It can surprise you how much pressure you may need to reposition it, particularly more delayed ones. A tip is to use your thumb to push down on the apex as you pull the tooth forward. In this case we used a paddle pop stick with the patient biting on it to provide strength to reposition and ‘hold’ the tooth in place. Alternatively, you can use cotton rolls. Sometimes you may even need forceps to disengage it. Just don’t ‘disengage it’ so much you inspect the apex!
Repositioned and holding in place to bond the splint on
Please let the patient know you will be using a lot of pressure. This is why you had good LA! Reassure them it will not hurt, but they will feel the pressure.
Step 6. Bond the Tooth
Now it is in the correct position, you can bond it in to place in about 30seconds. Controlling bleeding as mentioned is always hard here, so you can get your assistant to hold cotton rolls at the gingival crevice. This highlights why you need to have everything in place prior to repositioning. Also, most kids (even really compliant ones) really don’t enjoy the repositioning feeling… As such, if you only have 30seconds left to do, it removes some heat out of the situation for you.
Step 7. Check
You need to ensure you are in the correct position. So at this stage take a radiograph to ensure the tooth is back into the correct position. If it is not, try again.
Back in the correct position. Some guide brusing of the gingiva is now apparent from when we repositioned the tooth.
Step 7. Review
You will review the patient, clinically and radiographically, as recommended by the IADT. Splint timeframes are also there, with luxated teeth generally 4 weeks.
12months Post Treatment. responding well to vitality testing and no pathology noted.
Conclusion
Correct management of traumatised teeth is a really important role as a dental practitioner. Incorrect management can have devastating consequences on that child or adult for the rest of their life. If you do find yourself a bit stuck, I am confident your local paediatric dentist, or endodontist, would be more than happy to offer advice or help you out.
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We hope this guide has been helpful for you!
Thanks
Sarah and Tim