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Muhammad AH, Watted N, Abdulgani A Eight-year follow-up of successful intentional replantation. Roots. 2013; 3:28-31
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Jang Y, Lee S-J, Yoon T-C Survival rate of teeth with a C-shaped canal after intentional replantation: a study of 41 cases for up to 11 years. J Endod. 2016; 42:1320-1325
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Intentional replantation is a method to salvage teeth, especially in cases where orthograde re-treatment or apical surgery cannot be performed because of anatomical constraints and limited access. Techniques of intentional replantation have evolved to enhance clinical outcomes. The purpose of this case series, together with a narrative literature review, is to emphasize its importance, indications, contraindications, associated risks, success, and consideration as a treatment option as an alternative to extraction.
CPD/Clinical Relevance: This article discusses the advantages, disadvantages, indications, contraindications and techniques for intential replantation.
Article
Orthograde root canal treatment is the preferred option to treat pulpal or peri-apical pathology.1 However, if the symptoms fail to resolve despite optimum non-surgical root canal treatment and subsequent non-surgical re-treatment, then apical surgery, which is the next indicated option, has to be carried out to salvage teeth. Despite the high success rates of apical surgery, its execution may be challenging in some teeth, especially in the molar region, because of anatomical constraints.1 Therefore, intentional replantation may be an alternative treatment option for some of these cases.2,3
Intentional replantation is defined as extracting the tooth, resecting the root ends, followed by sealing with appropriate root-end filling material and replacement of the tooth back into its socket.4 This technique was first practiced by Ambrose Pare in the 16th century, and Pierre Fauchard during the 18th century, to salvage a tooth that was extracted accidentally.5,6 Since then, intentionally carrying out this technique has been reported in various case studies.7,8 With time, the technique of intentional replantation has been modified to enhance its clinical outcomes.7,8 It is a one-stage treatment to preserve the patient's aesthetics, as well as to maintain the alveolar bone.9
In order to retain the natural tooth, intentional replantation should be considered as a reliable option. However, because of the lack of relevant cases in the literature, intentional replantation is often considered a procedure of last resort. In the present series, we discuss three cases, together with a literature review related to the technique.
Cases
Three cases were referred to Aga Khan University Hospital dental clinics in 2019 with a common complaint of unresolved severe pain (Table 1). The patients were aged between 30 and 40 years and had received previous root canal treatment initiated at another dental practice. Detailed clinical and radiographic examination revealed that the related molar teeth were tender to palpation and percussion, and an associated peri-apical radiolucency was present. The teeth were stable periodontally and opposed by a natural tooth, hence the decision was more inclined towards retaining the tooth. Peri-apical surgery was not advised to the patients because of anatomical constraints and/or inadequate surgical access, which would make the provision of this treatment challenging. Two treatment options were offered to the patients: extraction or intentional replantation. Consent was taken after a detailed discussion with the patients over the pros and cons of intentional replantation, along with its associated risks, as specified in Table 2. The first step was to complete the orthograde endodontic treatment under local anesthesia (2% lidocaine with 1:100,000 epinephrine) and rubber dam isolation to ensure adequate cleaning, shaping, and obturation if possible, followed by intentional replantation.
LL7Non-resolution of clinical symptoms on non-surgical endodontics
3x5
1, 2, 4 weeks then 3, 6, 12 months
Endosequence BC Putty
Within normal limits
No
Figure 1. Pre-operative peri-apical radiograph LR7. (a) Intra-oral view. (b) Post-operative peri-apical radiograph. (c) Follow-up radiograph after 2 months. (d) Follow-up radiograph after 6 months (LR8 extracted). (e) Follow-up radiograph after 1 year.Figure 2.
(a) Granulation tissue attached with the apical portion. (b) Root-end resection. (c) Staining with 2% methylene blue dye. (d–e) Placement of MTA.Figure 3. Pre-operative view tooth UL7. (a) Intra-oral view. (b) CBCT slice view. (c) Peri-apical radiograph. (d) Post-operative radiograph after replantation. (e) Post-operative radiograph after 1 month.Figure 4. Apicectomy. (a) Atraumatic extraction of tooth UL7. (b) Root end resection. (c) Staining with 2% methylene blue dye. (d, e) Placement of MTA.Figure 5. Case 3. (a) Post-operative peri-apical radiograph after 1 week. (b) Follow-up radiograph at 3 months.
Advantages
Disadvantages
Maintaining viable periodontal ligamentAllows orthodontic movementAlveolar growth continuationAlveolar bone preservationOther options are always open if the replantation failsMaintenance of periodontal proprioceptionSurgical and post-op maintenance is generally less complicated for replanted teeth32
External root resorptionReplacement resorptionTreatment failureFracture of toothPeriodontal involvement33
In the first case, the patient was symptomatic and an instrument was broken in the mesio-lingual canal. This fractured instrument could not be bypassed, therefore the cleaning and shaping was incomplete and the tooth was deemed to have guarded prognosis. In the second case, the distal canal was sclerosed and could not be instrumented and the patient remained symptomatic, whereas in third case, the root canal treatment was optimum, but associated with a chronic apical abscess, hence the decision to not attempt non-surgical endodontic re-treatment before attempting intentional replantation in all three cases.
Protocol for intentional replantation
Under adequate anesthesia, atraumatic extraction was performed using dental molar forceps. The technique is tricky and requires time and patience to avoid any tooth fractures. The tooth was held from the crown using the same forceps without touching the root. The granuloma, where attached to the root ends, was removed. The apical third of the root was resected using a high-speed handpiece and tapered fissure bur (ISO 198/018, Mani Inc, Japan) extra-orally under copious saline irrigation using a 10-ml dental irrigation syringe, and root-end preparation 3-mm deep was completed using a round bur (ISO 001-010, Mani Inc) in a high-speed handpiece using the same irrigation. The tooth was stained using 2% methylene blue dye and inspected under magnification (×20–26) for the presence of any crack, isthmus or deformity on the root, and treated by further preparing the apical end and eliminating the defect. The root-end preparation was then filled with a filling material. ProRoot MTA (Dentsply, USA) or EndoSequence BC putty (Brasseler USA, Savannah, GA, USA) was used. The socket was irrigated with saline using a 10-ml dental syringe to remove any clot, but without curettage, and the tooth was replaced in the socket with light pressure. The position of the tooth was confirmed by taking a post-operative radiograph. During the entire procedure, the tooth was handled by the crown using extraction forceps, keeping the extra-oral time within a maximum of 15 minutes. Since the tooth was stable when placed back into the socket, splinting was not needed. Post-operative analgesics and a soft diet was prescribed for the next 3 days. Follow-up at 1, 2 and 4 weeks was carried out. The patients were recalled after 6 and 12 months. The patients were advised and sent to restorative dentists to receive a full coverage restoration for the tooth.
One patient (Case 2) reported to our clinic after 6 months with the treated tooth fractured mesio-distally. A full coverage restoration on this tooth had not been completed and the tooth had to be extracted.
Discussion and literature review
The intentional replantation procedure provides an alternative treatment to retain teeth with failed root canal treatment.10 It is indicated specifically where surgical endodontics would be difficult, or impossible, owing to limited access or visibility, or anatomical constraints, such as close proximity of a nerve or sinus. The indications and contraindications for intentional replantation are outlined in Table 3.
The successful outcome of this treatment depends primarily upon the maintenance of aseptic conditions and limited extra-oral time, survival of periodontal ligament cells on the root surface, and gentle atraumatic extraction with minimal manipulation of the socket.11 Handling and extra-oral time are two critical factors to ensure maximum viability of PDL cells. Extraction of the tooth is considered to be the most technique-sensitive step.11 However, the extraction technique does vary in the literature. Multiple studies have reported the use of dental elevators to luxate the tooth before forceps application, whereas others stated that dental elevators should not be used at all.11 In this series, each tooth was extracted gently with the help of forceps, avoiding dental elevators, making sure that the beak did not contact the root surface, to prevent periodontal ligament (PDL) damage.12 The teeth were held by the forceps while the root-end preparation was performed under saline rinse to avoid dehydration of the PDL cells.
Any granulation tissue attached to the tooth should be removed carefully to avoid damage to the PDL cells. The literature advises minimal manipulation of the tooth and the socket during extraction or debridement.13 In Case 1, a granuloma was attached to the apical portion of the tooth. It was removed delicately, without curettage of the tooth or the socket. Some authors advise against the use of curettage at all, whereas others favour the involvement of the apical portion onlyalone, without touching the wall of the socket8,14 This is to avoid damage to the remaining PDL socket cells.13 There are different recommendations for extra-oral times. Kratchman et al reported that because of the time-dependent viability of PDL cells, the extra-oral time should not exceed 15 minutes.15 Thus, we tried to follow the same protocol by limiting the extra-oral time. It has been reported that the success rate was 90% when avulsed teeth were replanted within 30 minutes.16
There are five studies reported in the literature from 2016 onwards in which a total of 505 teeth underwent intentional replantation. They used Pro-root MTA (Dentsply/Tulsa Dental, Tulsa, OK, USA), IRM (Dentsply, York, PA, USA), Super EBA (Harry J Bosworth Co, Skokie, IL, USA), Endosequence BC Putty (Brasseler, Savannah, GA, USA) or Biodentine as a root-end filling material. A summary of the follow-up period, extraction techniques used, extra-oral time, probing depth and survival rates are shown in Table 4 for comparison.
Our cases followed the modern concepts of microsurgery, which has been favoured lately because of its use of an operating microscope, use of methylene blue dye to identify cracks, use of micro-instruments and highly biocompatible root-end filling materials, such as bio-silicate cements. The only occasion in which we differed in the use of microsurgery protocols was the use of a high-speed hand piece for apical preparation. This protocol of using carbide burs has been recommended,12 while Cho et al17 recommended the use of ultrasonic instruments, particularly in thin roots, to improve efficiency and reduce the extra-oral time.18
Root-end resection was up to 3 mm, with a cavity depth of 3 mm and 0-degree bevel angle as a part of contemporary practice. As described in the literature, the advent of microsurgery has increased the success rate up to 90%.19,20,21,22
Several properties are required when choosing a root-end filling material. These include: sealing ability, antibacterial activity, and more importantly, induction of tissue regeneration. Although the ideal material has yet to be found, MTA has been accepted as one of the most suitable materials used for surgical endodontic procedures.23 MTA was used as the root-end filling material in one of our cases because of its reportedly long-lasting sealing ability and minimal leakage compared to other root-end filling materials.24 However, MTA is a technique-sensitive material that requires proper handling and manipulation. It is necessary that the consistency of the mixed material is appropriate, and care must be taken to avoid washing out while replacing the tooth into the socket. In Case 1, MTA wash-out was a major problem likely to have a result of inadequate consistency, and hence was replaced by Bioceramic Putty (BC Putty). Bioceramic has a higher resistance to washout, superior mechanical properties and no shrinkage on setting.25 Pre-mixed bioceramics like BC Sealer (BC Sealer), EndoSequence and BC Putty are hydrophilic and insoluble. Their advantage is their ease of handling because of the availability of pre-mixed forms in syringes, which eliminates inconsistencies arising from hand mixing.25,26
There is variation in the studies regarding whether to splint the tooth.12 Some studies recommended splinting only when gross instability of the tooth was present.27,28 Whereas, others incorporated a splint for each case.2,4 In our cases, we confirmed the accurate repositioning with radiographs, and because the teeth were stable, splinting was not necessary. Furthermore, patients were instructed to avoid chewing on the tooth during the healing period to avoid excessive masticatory forces that might affect the healing process.27
Endodontically treated teeth are primarily weakened by tooth preparation, which may ultimately result in fracture if not restored with a full-coverage restoration.29 A cuspal coverage restoration is recommended to reduce the chances of tooth fracture, especially in posterior teeth.30 This problem was highlighted in Case 2 in which the patient reported with a tooth fracture after 6 months because a full coverage restoration had not been carried out.
Intentional replantation is an underused modality. In the era of implants, this technique is less popular, but is still a successful option. It is assumed that implants yield a predictable and long-term restorative plan. However, the literature suggests that implant survival is no longer than the survival and longevity of a periodontally or endodontically involved tooth, and hence, surpasses the average implant life.31 Despite the literature on intentional replantation being sparse, we strongly recommend this modality to preserve the natural dentition, keeping in mind the feasibility, accessibility, periodontal factors, patient motivation and strategic importance of the tooth.
Conclusion
The intentional replantation technique was used to preserve the natural dentition, thereby following the main goal of conservative treatment. It is a relatively straightforward single-visit treatment procedure. The outcome depends on case selection, tooth and patient management, along with timely follow-up.
