I case report _ intentional replantation

Intentional replantation:
A viable treatment option for
specific endodontic conditions
Authors_ Prof Naseem Shah, Dr Ajay Logani & Dr Abhinav Kumar, India

_multi-rooted teeth with diverging roots that make

extraction and reimplantation impossible; and
_teeth with non-restorable caries.

In order to provide the best long-term prognosis

for a tooth that is to be replanted intentionally,
the tooth must be kept out of the socket for the
Fig. 1a Fig. 1b
shortest period possible, and the extraction of the
tooth should be atraumatic to minimise damage to
the cementum and the periodontal ligament. The
periodontal ligament attached to the root surface
should be kept moist in saline, Hank’s Buffered Salt
Solution (HBSS), Viaspan or Doxycycline solution for
the entire time the tooth is outside the socket.
Fig. 1c Fig. 1d
We have documented three clinical cases to
Fig. 1a_Tooth #46 with a fractured _Intentional replantation is defined as the pur- exemplify the potential of intentional replantation
Lentulo spiral pushed past the apical poseful extraction of a tooth in order to repair a as a viable treatment option in select endodontic
foramen in the mesiolingual canal. defect or cause of treatment failure and thereafter cases.
Fig. 1b_Tooth replanted after the return of the tooth to its original socket.1 Any
removal of the fractured instrument tooth that can be atraumatically removed in one _Case I
(apicoectomy and retrograde piece is a potential candidate for intentional replan-
MTA obturation). tation. However, specific indications include:1–3 A 14-year-old male patient presented with a
Fig. 1c_Clinical photograph showing separated Lentulo spiral extending 4 to 5mm beyond
stabilisation of the replanted tooth _all other endodontic non-surgical and surgical the apex of the mesiolingual root canal of tooth #46
with sling sutures. treatments have failed or are deemed impossible to (Figs. 1a–d). The tooth was badly broken and the
Fig. 1d_Six-month follow-up. perform; instrument tightly screwed into the root canal. All
_limited mouth opening that prevents the perform- efforts to remove the spiral were futile, and we were
ance of non-surgical or peri-radicular surgical concerned that it would fracture at the apex.
endodontic procedures;
_root-canal obstructions; and Apical surgery was ruled out because accessibil-
_restorative or perforation root defects that exist in ity to the mesiolingual root would have been limited.
areas that are not accessible via the usual surgical We decided to replant the tooth intentionally and
approach without excessive loss of root length or discussed this treatment option with the patient,
alveolar bone. who agreed to our proposal. Since the tooth was
badly broken, we planned to reinforce its core with a
Contraindications may include:1–2 post in the distal canal prior to extraction.

_long, curved roots; Once we had obtained adequate anaesthesia, the

_advanced periodontal diseases that have resulted tooth was extracted atraumatically with an extrac-
in poor periodontal support and tooth mobility; tion forceps. We did not use surgical elevators and

10 I roots 1_ 2012
 case report _ intentional replantation I

took care that the beaks did not go beyond the ce- history of trauma, and clinical examination revealed
mento-enamel junction (CEJ), as this may have dam- a deep palato-gingival groove (PGG) with respect to
aged the cementum and the periodontal ligament. tooth #12 (Figs. 2a–e). The intra-oral peri-apical
radiograph revealed a peri-apical radiolucency. We
Following extraction, we kept the tooth moist decided to extract the tooth, seal the groove and
by immersing it in Viaspan. With the beaks of the then replant the tooth. After adequate anaesthesia
forceps, we held the tooth by its crown and cut the had been obtained, the tooth was extracted with
overextended Lentulo spiral. Thereafter, we per- all the necessary precautions and immersed in Via-
formed a 3mm Class I root-end preparation with an span. With help of the forceps, it was then held by its
ultrasonic tip, at the apical end of all three canals. crown. The PGG was debrided with the tip of the
A retrograde filling was done with mineral trioxide ultrasonic scaler and sealed with glass-ionomer
aggregate (MTA). The extraction socket was then cement (GIC). The socket was then gently curetted
irrigated with normal saline and gently suctioned to and the tooth reinserted. Sutures were placed in the
remove blood clots. The socket was filled with trical- inter-dental area and endodontic treatment was
cium phosphate in order for the tooth to be 2 to 3mm completed one week later. The apical 4 to 5mm of the
higher than before. This helped in planning a good root were sealed with MTA, and the rest of the root
post-endodontic restoration. canal was back-filled with thermo-plasticised gutta-
percha. The patient was re-evaluated after seven
The tooth was carefully reinserted into its socket days.
and brought into occlusion with digital manipula-
tion and patient bite force. The tooth was stabilised _Discussion
it its socket with a sling suture. The patient was
re-evaluated after seven days, and the sutures were Intentional replantation in dentistry has been
removed. performed for more than ten centuries and was used
extensively to manage odontalgia.4 In 1561, Pare
_Case II recommended its use when a healthy instead of a
diseased tooth was mistakenly extracted!5 In 1712,
A 22-year-old male patient presented with a Pierre Fauchard6 replanted a tooth and reported it
history of trauma to his maxillary anterior region. to be stable on follow-up. Several steps in the re-
Clinical examination revealed an Ellis Class III frac- plantation were debated, for instance the need for
ture of tooth #12, with the fracture line extending to amputation of root apices, immediate or delayed
the root palatally. Once the mobile fragment had replantation, root-canal obturation before or after
been extracted, we realised that the fracture line replantation, removal or preservation of periodontal
extended 2 to 3mm sub-crestally. In order to bring ligament cells and the goal of ultimate healing—
the apical end of the fracture line to a supra-crestal bony ankylosis or ligament repair.
position, we considered two options: orthodontic
extrusion and intentional replantation. The patient It was in 1881 that Thompson7 presented the trea-
did not accept orthodontics as an option owing to tise on the replantation of teeth and emphasised the
the extended treatment time required. importance of peri-cemental tissues for treatment
success. Later, Fredel8 in 1887 and Scheff 9 in 1890
Once the tooth had been atraumatically ex- addressed the role of periodontal ligament cells with
tracted, it was kept moist in Viaspan. We inserted regard to external root resorption after replantation.
tricalcium phosphate in the apical 3 to 4mm of the As the replantation technique became increasingly
socket and reinserted the tooth with a 180° rotation refined, it was used as an easy alternative for failing
to bring the deep fracture line into a more accessible root-canal treatment and hence evoked sharp criti-
labial side. The tooth was then splinted with fibre- cism for the technique of replantation per se.
reinforced composite for a period of three weeks.
The root-canal treatment was completed at a later There are many reasons for an adverse outcome
date, and the facial surface was built up with com- of a replantation: the tooth can fracture during ex-
posite. We decided not to proceed with the crown traction and may be completely lost; peri-cemental
immediately after stabilisation to prevent loading of tissues can be damaged, reducing the likelihood of
the tooth. The patient was recalled periodically for reattachment; infection; external root resorption;
follow-up. and ankylosis. Therefore, it is extremely important
to understand that intentional replantation should
_Case III be the last choice, selected only when all the other
options of treatment—non-surgical and surgical—
A 23-year-old female patient presented with have been exhausted. Replantation can be a treat-
pain in her upper right anterior tooth. There was no ment of choice in cases in which a surgical approach

roots
1 _ 2012 I 11
 I case report _ intentional replantation

Fig. 2a_Clinical photograph of

tooth #12 showing the PGG.
Fig. 2b_Intra-oral peri-apical
radiograph showing the
peri-apical lesion.
Fig. 2c_Tooth extracted,
PGG prepared with ultrasonics.
Fig. 2d_PGG sealed with GIC.
Fig. 2e_Intra-oral X-ray showing
Fig. 2a Fig. 2b Fig. 2c Fig. 2d Fig. 2e
obturated canal. The sealed PGG
is superimposed on the
root-canal obturation. can be difficult, for example on the lingual root of a scaffold for bone growth and is gradually degraded
mandibular molar, or in cases in which a surgical ap- and replaced by bone.10
proach would be very invasive, such as the removal
of thick bone from the buccal aspect of a second A palato-gingival groove is a developmental
mandibular molar. anomaly that represents an infolding of enamel
and Hertwig’s epithelial root sheath.11 PGG can vary
Intentional replantation has a better prognosis in depth, length and complexity, causing varying
when the extra-oral time is kept as short as possible degrees of periodontal defects. Mild grooves termi-
and trauma to the periodontal ligament and cemen- nate at the CEJ, whereas moderate grooves continue
tum is minimised.1 It is advisable to perform routine apically along the root surface. A treatment option
endodontic treatment intra-orally before the tooth for a PGG terminating close to CEJ is to expose the
is extracted to minimise the extra-oral time. It is also groove surgically and to seal it thereafter. As pre-
suggested that a team of two dentists work in tan- sented, the groove extended beyond the apex in
dem to prevent prolonged treatment time, thus im- Case III. Here, the defect was sealed extra-orally and
proving the chances of success. The use of elevators the tooth replanted. GIC was used to seal the PGG,
should be avoided, and the beaks of the extraction as it chemically adheres to the tooth structure and
forceps should not go beyond the CEJ. The cortical has a good sealing ability and antibacterial effect.12
bone integrity should be maintained, and the tooth
should be extracted as atraumatically as possible. After replantation, the tooth was splinted for ten
days. The splint enabled physiological movement of
The medium in which the tooth is kept moist the tooth to prevent ankylosis. Endodontic treatment
plays an important role. Saline, HBSS, milk, Viaspan, was completed one week after replantation in order
to name a few, are widely used. Viaspan is used for to prevent inflammatory resorption and ankylosis
organ transplantation and preservation. Owing to its and to allow splicing of periodontal fibres, which
antioxidant activity, the solution keeps the perio- limits the seepage of potentially harmful root-fill-
dontal ligament moist and reduces the likelihood of ing materials into the traumatised periodontal liga-
surface resorption.2 ment.13 Final restoration of the tooth was delayed to
_contact roots avoid loading and to ensure that proper healing of
We generally use ultrasonic tips to prepare the periodontal ligament took place.
root-end and the debridement of the PGG. It con-
serves the tooth structure and produces signifi- In recent years, several bio-modulators, such as
cantly less smear layer compared with burs.3 Com- enamel matrix protein14, hydroxyapatite and platelet-
monly used root-end filling materials are amalgam, rich plasma,15 have been used in intentional replan-
Intermediate Restorative Material (IRM), Super EBA, tation cases to improve the success rates. Guided
GIC, Diaket, composite and MTA. The sealing ability tissue-regeneration techniques can also be employed
and marginal adaptation of MTA have been proven along with these supplements to further improve the
Prof Naseem Shah is to be superior and not adversely affected by blood likelihood of success.
Head of the Department of contamination. In addition, MTA promotes deposi-
Conservative Dentistry and tion of new cementum and stimulates osteoblastic We conclude that intentional replantation is a viable
Endodontics and Chief of adherence to the retro-filled surface. treatment option in carefully selected cases in which
the Centre for Dental Edu- all other treatment options have been exhausted.
cation and Research at the In two of our cases, tricalcium phosphate was
All India Institute of Medical placed in the apical few millimetres of the socket. We would like to acknowledge the assistance of
Sciences. She can be This was done in order to bring the defect supra- Dr Akanksha Gupta and Dr Nikhil Sinha._
contacted at gingivally so that the integrity, aesthetics and prog-
naseemys@[Link]. nosis of the case were improved. Tricalcium phos- Editorial note: A complete list of references is available
phate is an osteo-conductive material that acts as from the publisher.

12 I roots 1_ 2012
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