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Intentional replantation
Intentional
replantation
Sandra Madison, D.D.S., M.S., Iowa City, Iowa COLLEGE
OF DENTISTRY,
UNIVERSITY
OF IOWA
Intentional replantation is an accepted endodontic procedure for treating teeth in cases in which intracanal and/or
surgical endodontic treatments are not recommended. Although not a frequently used
technique, intentional replantation is a treatment option that dentists should consider. An unusual case is described in which intentional replantation was required to maintain the tooth in the dentition. A 31 month follow-up evaluation revealed an asymptomatic, functional tooth with no radiographic signs of pathosis. (ORALSURG.ORAL MED.ORAL PATHOL.~~:~~~-709,1986)
I
ntentional replantation is an endodontic surgical technique involving the removal of a tooth, the performance of an apical surgical procedure, and the replantation of the tooth in its socket. This technique is used when conventional periapical surgery would be difficult or traumatic for the patient.’ The primary indication for intentional replantation is inadequate access to the surgical site. The possibility of performing successful periapical surgery may be compromised by the location of the tooth in the dental arch, the thickness of the surrounding bones, the proximity of anatomic structures, the location of the defect to be corrected, or the patient’s tolerance of the treatment.’ Given these indications, it is obvious that the teeth usually treated by intentional replantation are posterior teeth. As Gutmann* has asserted, intentional replantation should not be used to avoid posterior periapical surgery if that is the treatment of choice; however, in certain situations, intentional replantation should be considered as a treatment option. The following case report describes an unusual clinical situation in which intentional replantation was used. CASEREPORT
A 17-year-old white female patient with an uneventful medical history was evaluated at the dental college for treatment of amelogenesis imperfecta. Before restoration of the dentition, the patient was evaluated and treated in the orthodontic clinic for correction of a bilateral posterior crossbite. A rapid-expansion maxillary appliance was attached to the maxillary first premolars and first molars to separate and expand the palatal shelves and to move the maxillary posterior teeth into their proper transverse occlusal position. During treatment, the appliance separated at the molar
Fig. 1. Orthodontically
extruded maxillary left first pre-
molar.
solder joint, resulting in rapid orthodontic extrusion of the maxillary left first premolar (Figs. 1 and 2). The removal of the appliance was handled as an emergency, and the patient was seen in the orthodontic clinic 2 days later. On examination, the maxillary left first premolar was found to be extruded by 5 to 6 mm. The patient was unable to occlude. and was in extreme discomfort. At this time, the tooth could not be manually intruded into the socket because of the formation of a blood clot. Immediate treatment or extraction was necessary in order to facilitate placement and reactivation of the orthodontic appliance, thus preventing the collapse of the maxillary segments (the maxillary left first premolar would not be an abutment). With this time constraint, orthodontic intrusion was not a treatment option. After consultation among the orthodontist, the prosthodontist, the endodontist, and the oral surgeon, the decision was made to perform an intentional replantation in order to maintain the tooth. The tooth was extracted, the socket was curetted, and the tooth was replanted (Figs. 3,4, and 707
708
Madison
Oral Surg.
December,1986
Fig. 2. Periapical radiograph of maxillary left first premolar 3 days after extrusion.
Fig.
3. Extraction of maxillary left first premolar with
forceps.
Fig. 4. Apical curettage of socket following extraction of maxillary left first premolar.
5). An acid-etched composite retained monofilament splint was placed from the maxillary left canine to the first molar for stabilization and to maintain the tooth in the proper occlusal plane (Fig. 6).
Fig.
5. Maxillary left first premolar after replantation.
Fig. 6. Acid-etched, composite retained monofilament splint on buccal surfaces of maxillary left canine, premolars, and first molar.
Three weeks after intentional replantation, root canal therapy was initiated. The canals were chemomechanically prepared and obturated with calcium hydroxide, and the splint was removed. Periodontal examination revealed a 10 mm probeable defect on the lingual surface of the maxillary left first premolar. Class I mobility was noted. At the 6-week evaluation, the canals were cleaned and repacked with calcium hydroxide. The tooth exhibited physiologic mobility with a 4 mm periodontal pocket on the lingual surface. The calcium hydroxide was then changed at 3-month intervals. One year after intentional replantation, the root canal therapy was completed by obturating the canals with laterally condensedgutta-percha (Fig. 7). The apical area appeared normal radiographically, exhibiting an intact lamina dura. The tooth was restored with a cast post and core and a porcelain-fused-to-metal crown. When the patient was evaluated at the 18 month recall (3 I months after intentional replantation), the maxillary left first premolar was asymptomatic, in normal occlusal function, and without radiographic evidence of pathosis. Physiologic mobility was noted, with no probeable periodontal defects evident (Fig. 8).
Intentional replantation
Volume 62 Number 6
Fig. 7. Radiograph of maxillary left first premolar after obturation with laterally condensed gutta-percha and sealer (13 months after replantation).
DISCUSSION
The clinical case just described is unusual in regard to the circumstances surrounding the need for treatment. However, it demonstrates that intentional replantation is a viable treatment option when the more conventional forms of treatment are impossible. The prognosis for intentional replantation has been reported in both human and animal studies. The percentages of successful treatment range from 52% to 95%.4This is similar to the prognosis reported for periapical surgery.5v6 A serious complication following replantation is external root resorption. 3,’ Kingsbury and Wiesenbaugh4 reported that root resorption was not frequently observed in their study. Similarly, Grossman8 reported that only 8 of the 45 teeth intentionally replanted were lost becauseof root resorption. The factors that relate to the initiation of resorption and the overall prognosis of replantation include the amount of time that the tooth is out of the socket,9 damage to the periodontal ligamentlO and socket,” or canal treatment before replantation.‘* With atraumatic operating procedures, frequent evaluations, and the application of calcium hydroxide as an interim therapy (as is recommended for traumatic avulsions and replantations13), the problem of root resorption can be minimized. Most authorities will agree that the indications for intentional replantation occur infrequently. However, in an attempt to maintain the natural dentition, this is indeed a treatment alternative that deserves consideration. The author would like to thank Dr. John S. Casko, chairman, Department of Orthodontics, College of Den-
709
Fig. 8. Eighteen month recall radiograph following gutta-percha obturation (3 1 months after intentional replantation).
tistry, University of Iowa, and Ms. Nellie W. Kremenak, Dows Institute for Dental Research, for their help with this manuscript. REFERENCES
1. Cohen S, Burns RC. Pathways of the pulp. 3rd ed. St. Louis: The C.V. Mosby Co, 1984:640. 2. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomic considerations and clinical techniques. Int Endod J 1985;18:8-34. 3. Emmertsen E. Replantation of extracted molars. Preliminary report. ORAL SURG ORAL MED ORAL PATHOL 1956;9:115. 4. Kingsbury BC, Wiesenbaugh JM. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc 1971; 43:1053-7. 5. Altonen M, Matila K. Follow-up study of apicoectomized molars. Int J Oral Surg 1976;5:33-40. 6. Rud J, Andreasen JO, Moller-Jensen JE. A follow-up study of 1000 casestreated by endodontic surgery. Int J Oral Surg 1972;1:215-28. I. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. Acta Odontol Stand 1966;24:266. 8. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966;72:1111. 9. Loe H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys. Arch-Oral Biol 1961;3:176-84. 10. Andreasen JO. Kristerson L. The effect of limited drvina or removal of the.periodontal ligament upon periodontal healing after replantation of mature permanent incisors in monkeys. Acta Odontol Stand 1981;39:l-l 3. 11. Oswald RJ, Harrington GW, Van Hassel HJ. Replantation. 1. The role of the socket. J Endod 1980;6:479-84. 12. Andreasen JO, Kristerson L. The effect of extra-alveolar root filling with calcium hydroxide on the periodontal healing after replantation of permanent incisors in monkeys, J Endod 1981; 8:349-54. 13. Camp JH. Treatment of the avulsed tooth. J Am Dent Assoc
1983;107:706. Reprint requests to:
Dr. Sandra Madison Department of Endodontics School of Dentistry University of North Carolina Chapel Hill, N.C. 27514
replantation
Sandra Madison, D.D.S., M.S., Iowa City, Iowa COLLEGE
OF DENTISTRY,
UNIVERSITY
OF IOWA
Intentional replantation is an accepted endodontic procedure for treating teeth in cases in which intracanal and/or
surgical endodontic treatments are not recommended. Although not a frequently used
technique, intentional replantation is a treatment option that dentists should consider. An unusual case is described in which intentional replantation was required to maintain the tooth in the dentition. A 31 month follow-up evaluation revealed an asymptomatic, functional tooth with no radiographic signs of pathosis. (ORALSURG.ORAL MED.ORAL PATHOL.~~:~~~-709,1986)
I
ntentional replantation is an endodontic surgical technique involving the removal of a tooth, the performance of an apical surgical procedure, and the replantation of the tooth in its socket. This technique is used when conventional periapical surgery would be difficult or traumatic for the patient.’ The primary indication for intentional replantation is inadequate access to the surgical site. The possibility of performing successful periapical surgery may be compromised by the location of the tooth in the dental arch, the thickness of the surrounding bones, the proximity of anatomic structures, the location of the defect to be corrected, or the patient’s tolerance of the treatment.’ Given these indications, it is obvious that the teeth usually treated by intentional replantation are posterior teeth. As Gutmann* has asserted, intentional replantation should not be used to avoid posterior periapical surgery if that is the treatment of choice; however, in certain situations, intentional replantation should be considered as a treatment option. The following case report describes an unusual clinical situation in which intentional replantation was used. CASEREPORT
A 17-year-old white female patient with an uneventful medical history was evaluated at the dental college for treatment of amelogenesis imperfecta. Before restoration of the dentition, the patient was evaluated and treated in the orthodontic clinic for correction of a bilateral posterior crossbite. A rapid-expansion maxillary appliance was attached to the maxillary first premolars and first molars to separate and expand the palatal shelves and to move the maxillary posterior teeth into their proper transverse occlusal position. During treatment, the appliance separated at the molar
Fig. 1. Orthodontically
extruded maxillary left first pre-
molar.
solder joint, resulting in rapid orthodontic extrusion of the maxillary left first premolar (Figs. 1 and 2). The removal of the appliance was handled as an emergency, and the patient was seen in the orthodontic clinic 2 days later. On examination, the maxillary left first premolar was found to be extruded by 5 to 6 mm. The patient was unable to occlude. and was in extreme discomfort. At this time, the tooth could not be manually intruded into the socket because of the formation of a blood clot. Immediate treatment or extraction was necessary in order to facilitate placement and reactivation of the orthodontic appliance, thus preventing the collapse of the maxillary segments (the maxillary left first premolar would not be an abutment). With this time constraint, orthodontic intrusion was not a treatment option. After consultation among the orthodontist, the prosthodontist, the endodontist, and the oral surgeon, the decision was made to perform an intentional replantation in order to maintain the tooth. The tooth was extracted, the socket was curetted, and the tooth was replanted (Figs. 3,4, and 707
708
Madison
Oral Surg.
December,1986
Fig. 2. Periapical radiograph of maxillary left first premolar 3 days after extrusion.
Fig.
3. Extraction of maxillary left first premolar with
forceps.
Fig. 4. Apical curettage of socket following extraction of maxillary left first premolar.
5). An acid-etched composite retained monofilament splint was placed from the maxillary left canine to the first molar for stabilization and to maintain the tooth in the proper occlusal plane (Fig. 6).
Fig.
5. Maxillary left first premolar after replantation.
Fig. 6. Acid-etched, composite retained monofilament splint on buccal surfaces of maxillary left canine, premolars, and first molar.
Three weeks after intentional replantation, root canal therapy was initiated. The canals were chemomechanically prepared and obturated with calcium hydroxide, and the splint was removed. Periodontal examination revealed a 10 mm probeable defect on the lingual surface of the maxillary left first premolar. Class I mobility was noted. At the 6-week evaluation, the canals were cleaned and repacked with calcium hydroxide. The tooth exhibited physiologic mobility with a 4 mm periodontal pocket on the lingual surface. The calcium hydroxide was then changed at 3-month intervals. One year after intentional replantation, the root canal therapy was completed by obturating the canals with laterally condensedgutta-percha (Fig. 7). The apical area appeared normal radiographically, exhibiting an intact lamina dura. The tooth was restored with a cast post and core and a porcelain-fused-to-metal crown. When the patient was evaluated at the 18 month recall (3 I months after intentional replantation), the maxillary left first premolar was asymptomatic, in normal occlusal function, and without radiographic evidence of pathosis. Physiologic mobility was noted, with no probeable periodontal defects evident (Fig. 8).
Intentional replantation
Volume 62 Number 6
Fig. 7. Radiograph of maxillary left first premolar after obturation with laterally condensed gutta-percha and sealer (13 months after replantation).
DISCUSSION
The clinical case just described is unusual in regard to the circumstances surrounding the need for treatment. However, it demonstrates that intentional replantation is a viable treatment option when the more conventional forms of treatment are impossible. The prognosis for intentional replantation has been reported in both human and animal studies. The percentages of successful treatment range from 52% to 95%.4This is similar to the prognosis reported for periapical surgery.5v6 A serious complication following replantation is external root resorption. 3,’ Kingsbury and Wiesenbaugh4 reported that root resorption was not frequently observed in their study. Similarly, Grossman8 reported that only 8 of the 45 teeth intentionally replanted were lost becauseof root resorption. The factors that relate to the initiation of resorption and the overall prognosis of replantation include the amount of time that the tooth is out of the socket,9 damage to the periodontal ligamentlO and socket,” or canal treatment before replantation.‘* With atraumatic operating procedures, frequent evaluations, and the application of calcium hydroxide as an interim therapy (as is recommended for traumatic avulsions and replantations13), the problem of root resorption can be minimized. Most authorities will agree that the indications for intentional replantation occur infrequently. However, in an attempt to maintain the natural dentition, this is indeed a treatment alternative that deserves consideration. The author would like to thank Dr. John S. Casko, chairman, Department of Orthodontics, College of Den-
709
Fig. 8. Eighteen month recall radiograph following gutta-percha obturation (3 1 months after intentional replantation).
tistry, University of Iowa, and Ms. Nellie W. Kremenak, Dows Institute for Dental Research, for their help with this manuscript. REFERENCES
1. Cohen S, Burns RC. Pathways of the pulp. 3rd ed. St. Louis: The C.V. Mosby Co, 1984:640. 2. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomic considerations and clinical techniques. Int Endod J 1985;18:8-34. 3. Emmertsen E. Replantation of extracted molars. Preliminary report. ORAL SURG ORAL MED ORAL PATHOL 1956;9:115. 4. Kingsbury BC, Wiesenbaugh JM. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc 1971; 43:1053-7. 5. Altonen M, Matila K. Follow-up study of apicoectomized molars. Int J Oral Surg 1976;5:33-40. 6. Rud J, Andreasen JO, Moller-Jensen JE. A follow-up study of 1000 casestreated by endodontic surgery. Int J Oral Surg 1972;1:215-28. I. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. Acta Odontol Stand 1966;24:266. 8. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966;72:1111. 9. Loe H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys. Arch-Oral Biol 1961;3:176-84. 10. Andreasen JO. Kristerson L. The effect of limited drvina or removal of the.periodontal ligament upon periodontal healing after replantation of mature permanent incisors in monkeys. Acta Odontol Stand 1981;39:l-l 3. 11. Oswald RJ, Harrington GW, Van Hassel HJ. Replantation. 1. The role of the socket. J Endod 1980;6:479-84. 12. Andreasen JO, Kristerson L. The effect of extra-alveolar root filling with calcium hydroxide on the periodontal healing after replantation of permanent incisors in monkeys, J Endod 1981; 8:349-54. 13. Camp JH. Treatment of the avulsed tooth. J Am Dent Assoc
1983;107:706. Reprint requests to:
Dr. Sandra Madison Department of Endodontics School of Dentistry University of North Carolina Chapel Hill, N.C. 27514