Intentional replantation – a predictable treatment procedure for teeth with persistent endodontic disease
Featured Products Promotional FeaturesPosted by: Dental Design 19th January 2023
In 1982, Grossman defined intentional replantation (IR) as being ‘a purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina’. He also stated that it is ‘the act of deliberately removing a tooth and, following examination, diagnosis, endodontic manipulation and repair – returning the tooth to its original socket to correct an apparent clinical or radiographic endodontic failure’.[i]
IR should only be used as a last resort therapy after all other endodontic procedures (primary and secondary root canal treatment) have failed and where apical surgery is not feasible due to poor access, or the proximity of the apical area to nerves or other anatomical structures. Contraindications of this treatment include cases where extraction could result in fracturing the roots or the coronal part of the tooth.
Research has reported a success rate for the procedure of 83% in cases where no orthodontic extrusion was performed prior to IR. This figure jumps up to 94% in cases where both procedures were performed.[ii]
Benefits of intentional replantation:
- Less invasive than apical surgery
- Procedure of relatively low difficulty with a high success rate
- Inexpensive, quick procedure in comparison with apical surgery
Case One – Intentional replantation of a lower left second molar associated with a large periapical cyst-like lesion
A 44-year-old male with no contributing medical history was referred for an endodontic evaluation of teeth from the mandibular left quadrant. The patient’s chief complaint was a throbbing discomfort located in the lower left molars. Upon examination, both first and second lower left molars appeared to be tender to percussion. No sinus tracts or pockets were noted at this stage.
A preoperatory radiograph was taken. (Fig.1) This revealed that the LL6 presented with what appeared to be a well-adapted full coverage crown, substandard root canal fillings, apical resorption of the distal root and associated periapical radiolucencies. In the case of the LL7, a complex configuration of the root canal system – C shaped anatomy – was noted, as well a large associated periapical radiolucency. Coronally, LL7 presented with a large coronal restoration with radiographic signs of secondary decay. The pulpal diagnosis was that of a previously root treated tooth for LL6 and of pulp necrosis for LL7, while both teeth shared the same periapical diagnosis: symptomatic apical periodontitis.
A discussion of treatment going forward was initiated with the patient. All options, with both advantages and disadvantages, were discussed.
The agreed treatment plan included the restorability assessment of LL7 and if restorable, root canal therapy for both LL6 and LL7. In the eventuality that one or both treatments would fail, apical surgery (LL6) or intentional replantation (LL7) were suggested.
All procedures – endodontic, restorative and surgical – were performed exclusively with the aid of a dental operating microscope. The root canal treatments and the immediate adhesive coronal restorations were performed in two separate sessions and they were uneventful. Arrangements to review the case after one year were made. (Fig. 2)
Eight months after the completion of root canal therapy, the patient returned due to a recent episode of flare up associated with the lower left molars. Upon clinical inspection, a buccal sinus tract and a pocket of 10mm associated with LL7 were noted. (Fig. 3)
CBCT scan analysis showed a previously root treated LL6 and LL7 with root fillings within standards. Also, a large periapical cyst-like lesion, situated in close proximity to the mandibular canal, associated with LL7 and encompassing the distal root of LL6 was noted. (Fig. 4)
Treatment options included apicoectomy (very difficult, poor prognosis on account of a very challenging access and extent of the bone defect), intentional replantation of LL7 or, extraction and replacement with a single implant supported crown. The risks and benefits were explained to the patient. In the end, patient opted for intentional replantation of LL7.
Treatment procedure
Antisepsis was carried out using 0.2% chlorhexidine gluconate; then, the inferior alveolar nerve block was performed using a cartridge of lidocaine (2% lidocaine with 1/80000) as well as buccal and lingual infiltration anaesthesia. The LL7 was then extracted as atraumatically as possible. During the extraoral period the periodontal tissue was kept hydrated with the help of a moist gauze. Subsequently, 3mm of the root apex were resected, and the root end cavity was prepared and filled with Mineral Trioxide Aggregate (MTA). Due to the patient having a limited mouth opening and also the size of the bone defect, a complete removal of the granulation tissue was not possible. Blood clots were removed by normal saline rinsing. Immediately after, the tooth was repositioned into its bone socket and a flexible buccal splint was placed. The postoperative radiograph showed a correct repositioning of LL7 and a retrofilling within radiographic standards. (Fig. 5)
The splint was removed one week later. Three months after, the buccal sinus tract appeared to be healed and the periodontal probing was within normal limits. (Fig. 6)
One-year review
The tooth was asymptomatic to all clinical tests, with periodontal probing and mobility within the normal limits. Radiographic examination showed signs of bone regeneration in the periapical area associated with LL6 and LL7. This was further confirmed by means of CBCT scan analysis. At this point, the outcome of the procedure was deemed as favourable and a full coverage crown on the LL7 was advised. (Fig. 7)
Conclusions
As an endodontic procedure for teeth with persistent endodontic disease where periradicular surgery is not feasible, IR is a reliable, low complexity manoeuvre that is usually associated with a predictable outcome, given good case selection.
Images
For further information please call EndoCare on 020 7224 0999
Or visit www.endocare.co.uk
Author Bio:
Corneliu is a Registered Endodontic Specialist at EndoCare. He is focused on providing patient comfort and wellbeing, alongside high-quality treatment. He is actively engaged in academic teaching and holds a lecturer position at International University of Catalonia and very much enjoys the study sessions of the Langham Study Group.
[i] Grossman LI. Intentional replantation of teeth: A clinical evaluation. J Am Dent Assoc 1982;104:633-39.
[ii] Choi., Y et al. Clinical Outcome of Intentional Replantation with Preoperative Orthodontic Extrusion: A Retrospective Study. Int Endod J. 2014 Dec;47(12):1168-76
