How should extruded and intruded permanent teeth be managed emergently in children and adults, including assessment, repositioning, splinting duration, antibiotic therapy, tetanus prophylaxis, analgesia, and follow‑up?

Management of Tooth Extrusion and Intrusion

Extruded Permanent Teeth

For minor extrusion, immediately reposition the tooth with gentle digital pressure and refer for flexible splinting for 2 weeks if mobility persists; for excessive extrusion requiring dental forceps, refer immediately to a dentist. 1

Initial Assessment and Repositioning

• Minor extrusion: Apply gentle digital pressure to reposition the tooth back into the socket at the point of injury 1
• Excessive extrusion: Requires repositioning with dental forceps by a dentist—immediate referral is mandatory 1
• Verify that the repositioned tooth does not interfere with occlusion by having the patient say "cheese" or the letter "e" to visualize whether posterior teeth can fully interdigitate 1

Splinting Protocol

• Stabilize with a flexible splint for exactly 2 weeks after repositioning 1
• The dentist will determine need for pulp therapy based on root maturity 1

Follow-up Monitoring

• Monitor vigilantly for signs of pulpal necrosis: gingival swelling, increased mobility, parulis, or gray tooth discoloration 1, 2
• These complications may develop weeks to months after injury and require extraction evaluation 2

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Intruded Permanent Teeth

For mild intrusion with incomplete root formation, allow spontaneous re-eruption with close monitoring; for severe intrusion or complete root formation in patients over 17 years, perform surgical or orthodontic repositioning. 1, 3

Treatment Based on Root Development and Severity

Incomplete Root Formation (Immature Teeth)

• Expect spontaneous re-eruption for mild to moderate intrusion—this is the preferred approach 1, 3
• Bleeding from the gingival sulcus will be present 1
• If no visible re-eruption occurs after a few weeks, orthodontic or surgical repositioning becomes necessary 1
• Critical pitfall: Active repositioning (surgical or orthodontic) in teeth with incomplete root formation increases risk of pulp necrosis, root resorption, and marginal bone defects compared to allowing spontaneous eruption 3

Complete Root Formation

• Age 12-17 years: Spontaneous eruption can still occur but requires very careful monitoring 3
• Age >17 years: Spontaneous eruption is unlikely—either surgical or orthodontic repositioning should be attempted 3
• Orthodontic extrusion may slightly reduce (though not significantly) the risk of marginal bone complications compared to surgical repositioning, but requires more consultations (average 22 vs 17) 3

Severe Intrusion Cases

• The tooth may not be visible clinically—obtain intraoral radiography immediately to assess tooth position within the alveolus 1
• Risk of ankylosis (fusion to bone) exists, which may require extraction to prevent alveolar ridge warping, followed by artificial tooth placement 1
• Intrusions beyond 6 mm cannot regenerate functional periodontal ligament and are prone to root resorption and eventual extraction 4

Splinting for Intruded Teeth (If Repositioned)

• Type of splint (flexible, semirigid, or rigid) has no significant effect on healing outcomes 3
• Length of splinting (shorter or longer than 6 weeks) shows no significant difference in healing 3

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Adjunctive Management

Antibiotic Therapy

• Systemic antibiotics are NOT routinely indicated for extrusion or intrusion injuries 5, 3
• Antibiotics show no apparent effect on healing outcomes in intrusion cases 3
• Exception: Antibiotics ARE indicated for avulsed teeth after reimplantation (doxycycline for age >12 years, penicillin for age <12 years, clindamycin if penicillin-allergic) 1

Tetanus Prophylaxis

• Follow standard tetanus prophylaxis protocols based on immunization history and wound contamination (guideline evidence does not specifically address this, but standard wound care principles apply)

Analgesia

• Provide appropriate analgesia for pain control (specific recommendations not detailed in guidelines, but standard analgesics such as ibuprofen or acetaminophen are appropriate)

Post-Injury Instructions

• Soft diet only until healing occurs 5
• Restrict pacifier or thumb sucking in children 5
• Maintain good oral hygiene with gentle brushing 5

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Red Flags Requiring Immediate Dental Referral

• Multiple teeth moving together as a segment (indicates alveolar bone fracture) 2
• Tooth displacement interfering with occlusion (prevents permanent malocclusion) 2
• Severe extrusion or severe intrusion where tooth is not clinically visible 2
• Extensive gingival or facial swelling (potential abscess formation) 2
• Visible pulp exposure in associated crown fractures 2

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Common Pitfalls

• Never replant an avulsed primary tooth (risks damage to underlying permanent tooth germ), whereas permanent tooth avulsion requires immediate replantation 2, 5
• Do not rely on pain complaints alone in children—necrotic teeth may be painless, so caregivers must watch for visual signs including discoloration, swelling, and parulis 2
• Treatment delay beyond 24 hours has no effect on healing outcomes for intrusion, so focus on appropriate treatment method rather than speed 3
• Consider non-accidental injury in children younger than 5 years with severe tooth injury or inconsistent mechanism 2, 5