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Intentional replantation: A successful alternative for hopeless teeth
Intentional replantation: A successful alternative for hopeless teeth Mahnaz Messkoub, DDS, MScD,” Houston, Texas An interesting case of intentional reimplantation, in which the distal root of a mandibular molar was reimplanted after hemisection, is reported for the first time. This root served as the distal abutment three-unit bridge. A 3-year follow-up revealed a successful outcome, with a clinically asymptomatic functional tooth with no radiographic signs of resorption or ankylosis. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:743-7)
A s Grossman’states,“intentionalreplantationis a purposefulremovalof a toothandits reinsertioninto the socketalmost immediatelyafter sealingthe apical foramina.”Accordingto mostauthors,intentional replantationis reservedasa last resortto savean otherwiselost tooth.lm5Such writers considerthat indicationsfor replantationarefew andshouldbelimited to the posteriorteeth,whereconventionalendodontic therapybecomesinfeasibleandsurgicalintervention is unadvisablebecauseof anatomic considerations and difficult access.Intentional replantationis contraindicatedin teethwith advancedperiodontaldiseaseand teeth with extensivecaries5-’ Grossman6 recommendsintentional replantation of deciduous teethasan alternativeto extractionandreplacement with a spacemaintainer. REVIEW
OF THE LITERATURE
A reviewof the literature revealsthat intentional replantationis not a newor experimentalprocedure. Fourchard*andWoofendalegin the seventeenth century wereamongthefirst clinicianswhoadvocatedthe replantationof teeth in casesof extraction of the wrongtooth or teeth in which the nervecouldnot be readily destroyed.Intentionalreplantationis alsorecordedin A History of Dental and Oral Science in America. 1o Histologicstudiesin humanbeingsandin animalsshowthat completereattachmentof the periodontal ligament occurs after replantation.5v l r-r3 The retentiontime of a reimplantedtooth is directly relatedto the amountof viableperiodontalligament presentat the time of reimplantation.5‘* ‘*-is It has beendemonstratedby all authorsthat themain cause
*In private 7/15/25180
practice.
for a and
of failure in intentionally replanted teeth is root resorptionand ankylosis (replacementresorption) causedby a damagedperiodontalligament.* According to Andersson,lgunlike replantedavulsedteeth, intentionallyreplantedteeth are not subjectto progressiveroot resorption.He alsofoundthat replacement resorption (ankylosis) is age related and progresses morerapidly in youngerthan in olderpersons. More than 2000 casesof replantationof human teethhavebeenreportedin the literatureby different investigatorst Although most of these casesconcernedreplantationof avulsedteethaftertrauma,the conceptis the same:a tooth is separatedfrom its attachmentapparatuseitherintentionallyor asa result of a trauma. The time the periodontal ligament remainsaway from its blood supply is critical, althoughAnderssonetal.,” in ananimal study,showed that periodontalligamentswill healafter replantation of the tooth evenafter 120minutesout of the mouth. However,accordingto mostauthors,20 to 30minutes is the maximum time that shouldelapsebetweenextraction and replantation:‘,12*r3140Root resorption can bepreventedor delayedby extirpationof the necrotic and infected pulp, followed by endodontic treatment.2324,43-4gThe clinical successof a replantedtooth can be determinedon the basisof its stability and function,andon the absenceof inflammation in the adjacentsoft tissue.The histologiccriteria includeabsenceof periapicallesion,root resorption, and reattachmentof the periodontalligament without ankylosis.1-3T 5,13*I9 The degreeof successin retentionof a replanted tooth in terms of time variedbetween52%and 95% *References l-3, 5, 7, 11, 13, 14, 16-18. TReferences 5-7, 12, 13, 15, 17, 18, 19, 20-42. 743
744
Messkoub
Fig. 1. Preoperative radiograph of lower left first molar before placement of crown (1985). Note severe calcification of pulp chamber and root canal space.
Fig. 2. Radiograph of lower left first molar with crown I !h years later ( 1986).
when these cases were followed from 1 to 22 years.* Although cases have been reported of long-term retention, 10 to 22 years, by different investigators, 20*25.28.j” the average time of retention is 3 to 5 years. After replantation, resorption occurs within a I- or 2-year period and would be evident on x-ray. 5. 12.13.I’)
tions. Clinicians should scrub and wear sterile gloves. The tooth and adjacent area must be scrubbed with an antiseptic.
TECHNIQUE
The following technique is recommended by most authors 2-5, 12. 13, 39.40 Pretreatment
Whenever possible, the root canal must be filled in advance, even though the filling cannot be extended to the apex because of obstruction of the canal. The crown must be filled with amalgam to prevent its fracture during extraction. A slight relief of occlusion is advisable to prevent postoperative trauma.45 When periodontal disease is present, it should be treated before implantation. If there is a chance of flare-up between the time of filling and implantation, antibiotic therapy is recommended. Because time is a critical factor in the prognosis for intentional replantation, this procedure should be carried out by two clinicians-one who is experienced in extraction, the other who is prepared to perform the endodontic treatment and to replace the tooth in the socket. The patient’s medical and dental histories, and x-ray film must be carefully reviewed. A consent form must be signed by the patient before the operation. This procedure must be done under aseptic condi-
*References 5, 7, 12,
14,
15,
21, 29, 31, 42.
Tooth
extraction
The surgical site is anesthetized, and the area around the tooth is covered by sterile gauze. The tooth is then extracted as atraumatically as possible, with an effort not to damage the buccal and lingual bony plate or the interradicular bony septum. To prevent the crushing of the periodontal membrane, the use of elevation and rotation during the extraction must be avoided. While the apical soft tissue is carefully curetted, care should be taken not to disturb the walls of the socket, so as to conserve any periodontal membrane that is still attached to the wall. The socket is then covered with two or three sterile gauze pads to prevent contamination. Tooth
preparation
As soon as the tooth is out of its socket, it must be covered by sterile gauze, saturated with sterile saline solution, and given to the clinician in charge of endodontic treatment. When the root canal has been filled in advance, the apical 2 to 3 mm is snipped off with rongeur forceps, level with the root canal filling. In cases where the canal cannot be filled because of blockage after the root tips were severed, cavities are prepared at the root tips and filled with amalgam or gutta-percha to seal the apical foramina. Tooth
replantation
The gauze pack is then removed from the socket, the blood clot is aspirated, and the tooth is replaced in its socket. The buccal and lingual plates of bone are then pressed together with the fingers and checked for occlusion.
Intentional
Volume 7 I Number 6
3. Radiograph immediately after hemisection and reimplantation.
Fig.
replantation
745
Fig. 4. Appearance at 4-month follow-up with three-unit bridge in place. Note healthy periodontal ligament.
Stabilization
The replanted tooth must be stabilized with a splint if necessary. Posterior teeth normally are well retained and do not require splinting. Anterior teeth, however, can be splinted with a direct bonding technique or an acrylic splint. Some authors found that splinting did not help the healing of periodontal ligaments after replantation; to the contrary, the frequency and extent of ankylosis (replacement resorption) was significantly higher in the cases of splinted teeth.46-48 Andersson et a1.49 state that masticatory stimulation probably prevents or reduces the development of ankylosis. Postoperative
instruction
To reduce the possibility of infection, an oral antibiotic is prescribed for 5 to 7 days and the patient is asked to rinse the mouth with salt water. Frequent brushing is essential. Pain and swelling are rare complaints; when they do occur, a pain medication is prescribed and the patient is advised to use an ice bag for swelling. The patient is seen at weekly intervals until the splint is removed. After 2 weeks the replanted tooth is relatively firm and the periodontal tissue is normal. The patient is then followed up in 6-month intervals and examined clinically and radiographitally. CASE REPORT
A 50-year-old man had symptoms of spontaneous pain exacerbated by thermal changes, primarily heat, on the lower left first molar. Medical history was not contributory. Review of the dental history revealed that the patient had been treated for moderate periodontal disease1% years ago and the involved tooth was pulp capped and crowned (Fig. 1). On clinical and radiographic examination, severecalcification of the pulp chamber and root canal spacewas noted and a diagnosis of acute pulpitis was made (Fig. 2). The
Fig. 5. Appearance at 18-month follow-up of tooth, showing no evidence of root resorption.
patient was informed of the difficulty of conventional root canal treatment becauseof severecalcification, and the following treatment options were presented to him: (1) periapical surgery, (2) intentional replantation, and (3) extraction with fabrication of a three-unit bridge. The patient did not accept the periapical surgery because of the involved risks. He consented to intentional replantation if conventional endodontic treatment was deemed impossible. An attempt was made to negotiate the canals but because of the severecalcification was unsuccessful. The patient’s symptoms persisted. An antibiotic (500 mg penicillin V potassium) and hydrocodone bitartrate (Vicodin) were prescribed, and an appointment was scheduled for intentional replantation. The procedure was followed as described earlier, with some exceptions, by two clinicians. The crown was removed before the extraction and the accessfilled with cold-cure composite. During extraction the mesial root broke, and it was then decided to hemisect the tooth and reimplant the distal root. The apex was sealed with amalgam, and the root was replanted (Fig. 3). No
746
Messkoub
ORhI
SURG
ORAl
MED
ORAL
PA.rHOl
June
Fig. 6. Appearance at 3-year follow-up shows no signsof ankylosis or resorption.
1991
teeth when conventional or surgical endodontic treatment is not recommended. In this article a brief review of the applicable literature, rationale for this treatment modality, and description of the technique of intentional replantation have been discussed. An interesting case is presented in which the distal root of a lower molar was reimplanted after hemisection. This reimplanted root served as the distal abutment of a three-unit bridge. A 3-year follow-up revealed a clinically asymptomatic and functional tooth with no sign of resorption or ankylosis. The possibility of long-term retention (10 to 12 years) indicates that intentional replantation is indeed a reliable and predictable treatment option and should be practiced more frequently. REFERENCES
splint was used, but the mesial socket was sutured. The patient was dismissed with written home care instructions. At the 1-week postoperative visit the suture was removed. The patient reported very little pain or discomfort. Mobility was + 1 at this time. At the 4-week postoperative visit no mobility was noted, gingival tissue appeared normal, and no symptoms were present. A three-unit porcelain bridge was fabricated and cemented 4 months later, with the distal root as the distal abutment (Fig. 4). An 18-month clinical and radiographic evaluation of the tooth showed no signs of apical or lateral root resorption or ankylosis (Fig. 5). The patient was asymptomatic, and gingiva was healthy. A 3-year clinical and radiographic follow-up showed no changes (Fig. 6). DISCUSSION
Intentional replantations have been practiced in dentistry for 250 years. This treatment is accepted almost universally among dentists for traumatically avulsed teeth, and there is no reason why it should not be used for other situations. Indications for intentional replantation occur infrequently; however, in an attempt to maintain natural dentition, this is indeed a treatment option when the more conventional forms of treatment either fail or are impossible. The success of intentional replantation is directly related to the viability of the periodontal ligament. Therefore the procedure should be done as atraumatically as possible, under sterile conditions, to preserve the vitality of the attachment apparatus. The time span during which the tooth is out of its socket also must be shortened by cooperation between the attending clinicians. This technique is simple, fast, and has a high success rate (52% to 95%), with an average retention time of 3 to 5 years. SUMMARY
Intentional replantation is an accepted and predictable endodontic procedure for treatment of the
1. Grossman 2. 3. 4. 5. 6. 7. 8. 9. 10. Il.
12.
13.
14. 15. 16. 17. 18.
19. 20. 21.
22.
L. Endodontic practice. 1 lth ed. Philadelphia: Lea & Febiger, 1988:334-42. Weine F. Endodontic therapy. 4th ed. St Louis: CV Mosby. 1989:210-3. lngle J. Endodontics. 3rd ed. Philadelphia: Lea & Febiger. 1985:664-6. Cohen B, Burns RC. Pathways of the pulp. 4th ed. St Louis: CV Mosby, 1987:607-g. Deeb E, Prietto P, McKenna R. Reimplantation of luxated teeth in humans. J South Calif Dent Assoc 1965;33:194-206. Grossman L. Intentional replantation of teeth. J Am Dent Assoc 1966:72:1 1 1 l-8. Healy A, Harry J. Replantation: a brief review and report of a case sequel. J Oral Surg 1953;6:775-9. Fauchard P; Lindsay L, trans. Surgeon dentist. London: Butterworth, 1946: 140. Woofendale R. Practical observation on the teeth. London: J Johnson, 1783: 137. Dexter JE. A history of dental and oral science in America. Philadelphia: Samuel S White, 1877:lOS. Blomllif L, Andersson L, Lindskog S. Periodontal healing of replanted monkey teeth prevented from drying. Acta Odont Stand 1983;41:1 17-23. Grossman L. Chacker F. Clinical evaluation and histologic study of intentionally replanted teeth. In: Transactions of the Fourth International Conference on Endodontics. Philadelphia: University of Pennsylvania, 1968: 127-44. Andreasen J, Hjorting HE. Replantation of teeth. Part II. Histological study of 22 replanted anterior teeth in humans. Acta Odont Stand 1966;24:287-306. Marshall J. Physiologic and traumatic apical resorption. J Am Dent Assoc 1935;22:1545-58. lngle J. Replantation following total luxation. Dent Digest 1953;59:386-90. Maxmen H. An aid in successful replantation and post resection canal filling technique. Alpha Omegan 1950;44: 1 17-26. Anderson W. Sharav Y, Massler M. Periodontal reattachment after tooth replantation. J Periodontol 1968;6:161-7. Lu DP. Intentional replantation of periodontically involved and endodontically mistreated tooth. ORAL SURG ORAL MED ORAL PATHOL 1986;6 1:508- 13. Andersson L. Dentoalveolar ankylosis and associated root resorption in replanted teeth. Swed Dent J Suppl 1988;56:1-75. Grossman L. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc 1982;104:633-9. Kingsbury BC, Weisenbaugh JM. Intentional replantation of mandibular molars and premolars. J Am Dent ASSOC 1971;83:1053-7. Knight M, Cans B, Calandra J. The effect of root canal therapy on replanted teeth of dogs. J Oral Surg 1964;18:227-9.
Intentional
Volume 7 1 Number 6 23. Nasjleti CE, Castelli WA, Caffesse RG. Replantation of mature teeth without endodontic treatment in monkeys. J Dent Res 1978;57:650-8. 24. Rothschild DL, Goodman A, Blakey K. A histologic study of replanted and transplanted endodontically and nonendodontitally treated teeth in dogs. J Oral Surg 1969;28:871-6. 25. Nosonowitz DM, Stanley HR. Intentional replantation to prevent predictable endodontic failures. ORAL SURC ORAL MED ORAL PATHOL 1984;57:423-32. 26. Dryden J. Ten-year follow-up of intentionally replanted mandibular second molar. J Endod 1986;12:265-7. .27. Abrams R. Tooth replantation: 11 years follow-up, Aust Dent J 1987;32:427-9. 28. Donnelly J. Intentional replantation: case update. J Endod 1989;15:84. 29. Karl K, Nguyen N, Barkhordar R. Intentional replantation: a report of 192 cases. J Gen Dent 1988;36:327-31. 30. Matusow R. Clinical observation regarding the treatment of traumatically avulsed mature “teeth.” Part I. ORAL SURG ORAL MED ORAL PATHOL 1985;60:94-9. 31. Bielas L. Evaluation of the results of tooth replantation [Abstract]. Dent Abstr 1960;5:147. 32. Hammer H. Replantation and implantation of teeth. Int Dent J 1955;5:439-57. 33. Emmersten E. Replantation of extracted molars. ORAL SURG ORAL MED ORAL PATHOL 1956:9:115-22. 34. Kemp W, Grossman L, Phillips J. Evaluation of 71 replanted teeth. J Endod 1977;3:30-5. 35. Natiella J, Armitage J, Greene G. The replantation and transplantation of teeth. ORAL SURC ORAL MED ORAL PATHOL 1970;29:397-419. 36. Guy S, Goerig A. Intentional replantation: technique and rationale. Quintessence Int 1984;15:595-603. 37. Madison S. Intentional replantation. ORAL SURC ORAL MED ORAL PATHOL 1986;62:707-9. 38. Din F. Intentional replantation to prevent loss of an abutment tooth. J Gen Dent 1987;35:39-41. 39. McCalla R. Intentional replantation: a “viable” alternative to extraction or retreatment. J Tenn Dent Assoc 1985;65:26-8.
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747
40. Andreasen J, Hjorting-Hansen L. Replantation of teeth. Part I. Radiographic and clinical study of 1 IO human teeth replanted after accidental loss. Acta Odont Stand 1966;24: 263-86. 41. Matusow R. Clinical observation regarding the treatment of traumatic avulsed mature “teeth.” Part II. ORAL SURG ORAL MED ORAL PATHOL 1985;60:428-35. 42. Deeb E. Intentional replantation of endodontically treated teeth. In: Transactions of the Fourth International Conference on Endodontics. Philadelphia: University of Pennsylvania, 1968:147-57. 43. Andreasen JO. Treatment of fractured and avulsed teeth. J Dent Child 1971;38:29-39. 44. Andreasen JO. The effect of pulp extirpation or root canal treatment on periodontal healing after replantation of permanent incisors in monkeys. J Endod 1982;8:245-52. 45. Andreasen JO. The effect of excessive occlusal trauma upon periodontal healing after replantation of mature permanent incisors in monkeys. Swed Dent J 1981;5:115-22. 46. Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odont Stand 1975;33:3 13-23. 47. Nasjleti JE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. J Oral Surg 1982;53:557-66. 48. Biven G, Ritchie G, Gerstein H. Acrylic splint for intentional replantation. ORAL SURG ORAL MED ORAL PATHOL 1970;30:537-9. 49. Andersson L, Lindskog S, Blomhof L, Hedstrom K, Hammarstrom L. Effect of masticatory stimulation on dentoalveolar ankylosis after experimental tooth replantation. Endod Dent Traumatol 1985;1:13-6.
Reprint
requests
to:
Mahnaz Messkoub, DDS, MScD 902 Frostwood, Suite 185 Houston, TX 77024
A s Grossman’states,“intentionalreplantationis a purposefulremovalof a toothandits reinsertioninto the socketalmost immediatelyafter sealingthe apical foramina.”Accordingto mostauthors,intentional replantationis reservedasa last resortto savean otherwiselost tooth.lm5Such writers considerthat indicationsfor replantationarefew andshouldbelimited to the posteriorteeth,whereconventionalendodontic therapybecomesinfeasibleandsurgicalintervention is unadvisablebecauseof anatomic considerations and difficult access.Intentional replantationis contraindicatedin teethwith advancedperiodontaldiseaseand teeth with extensivecaries5-’ Grossman6 recommendsintentional replantation of deciduous teethasan alternativeto extractionandreplacement with a spacemaintainer. REVIEW
OF THE LITERATURE
A reviewof the literature revealsthat intentional replantationis not a newor experimentalprocedure. Fourchard*andWoofendalegin the seventeenth century wereamongthefirst clinicianswhoadvocatedthe replantationof teeth in casesof extraction of the wrongtooth or teeth in which the nervecouldnot be readily destroyed.Intentionalreplantationis alsorecordedin A History of Dental and Oral Science in America. 1o Histologicstudiesin humanbeingsandin animalsshowthat completereattachmentof the periodontal ligament occurs after replantation.5v l r-r3 The retentiontime of a reimplantedtooth is directly relatedto the amountof viableperiodontalligament presentat the time of reimplantation.5‘* ‘*-is It has beendemonstratedby all authorsthat themain cause
*In private 7/15/25180
practice.
for a and
of failure in intentionally replanted teeth is root resorptionand ankylosis (replacementresorption) causedby a damagedperiodontalligament.* According to Andersson,lgunlike replantedavulsedteeth, intentionallyreplantedteeth are not subjectto progressiveroot resorption.He alsofoundthat replacement resorption (ankylosis) is age related and progresses morerapidly in youngerthan in olderpersons. More than 2000 casesof replantationof human teethhavebeenreportedin the literatureby different investigatorst Although most of these casesconcernedreplantationof avulsedteethaftertrauma,the conceptis the same:a tooth is separatedfrom its attachmentapparatuseitherintentionallyor asa result of a trauma. The time the periodontal ligament remainsaway from its blood supply is critical, althoughAnderssonetal.,” in ananimal study,showed that periodontalligamentswill healafter replantation of the tooth evenafter 120minutesout of the mouth. However,accordingto mostauthors,20 to 30minutes is the maximum time that shouldelapsebetweenextraction and replantation:‘,12*r3140Root resorption can bepreventedor delayedby extirpationof the necrotic and infected pulp, followed by endodontic treatment.2324,43-4gThe clinical successof a replantedtooth can be determinedon the basisof its stability and function,andon the absenceof inflammation in the adjacentsoft tissue.The histologiccriteria includeabsenceof periapicallesion,root resorption, and reattachmentof the periodontalligament without ankylosis.1-3T 5,13*I9 The degreeof successin retentionof a replanted tooth in terms of time variedbetween52%and 95% *References l-3, 5, 7, 11, 13, 14, 16-18. TReferences 5-7, 12, 13, 15, 17, 18, 19, 20-42. 743
744
Messkoub
Fig. 1. Preoperative radiograph of lower left first molar before placement of crown (1985). Note severe calcification of pulp chamber and root canal space.
Fig. 2. Radiograph of lower left first molar with crown I !h years later ( 1986).
when these cases were followed from 1 to 22 years.* Although cases have been reported of long-term retention, 10 to 22 years, by different investigators, 20*25.28.j” the average time of retention is 3 to 5 years. After replantation, resorption occurs within a I- or 2-year period and would be evident on x-ray. 5. 12.13.I’)
tions. Clinicians should scrub and wear sterile gloves. The tooth and adjacent area must be scrubbed with an antiseptic.
TECHNIQUE
The following technique is recommended by most authors 2-5, 12. 13, 39.40 Pretreatment
Whenever possible, the root canal must be filled in advance, even though the filling cannot be extended to the apex because of obstruction of the canal. The crown must be filled with amalgam to prevent its fracture during extraction. A slight relief of occlusion is advisable to prevent postoperative trauma.45 When periodontal disease is present, it should be treated before implantation. If there is a chance of flare-up between the time of filling and implantation, antibiotic therapy is recommended. Because time is a critical factor in the prognosis for intentional replantation, this procedure should be carried out by two clinicians-one who is experienced in extraction, the other who is prepared to perform the endodontic treatment and to replace the tooth in the socket. The patient’s medical and dental histories, and x-ray film must be carefully reviewed. A consent form must be signed by the patient before the operation. This procedure must be done under aseptic condi-
*References 5, 7, 12,
14,
15,
21, 29, 31, 42.
Tooth
extraction
The surgical site is anesthetized, and the area around the tooth is covered by sterile gauze. The tooth is then extracted as atraumatically as possible, with an effort not to damage the buccal and lingual bony plate or the interradicular bony septum. To prevent the crushing of the periodontal membrane, the use of elevation and rotation during the extraction must be avoided. While the apical soft tissue is carefully curetted, care should be taken not to disturb the walls of the socket, so as to conserve any periodontal membrane that is still attached to the wall. The socket is then covered with two or three sterile gauze pads to prevent contamination. Tooth
preparation
As soon as the tooth is out of its socket, it must be covered by sterile gauze, saturated with sterile saline solution, and given to the clinician in charge of endodontic treatment. When the root canal has been filled in advance, the apical 2 to 3 mm is snipped off with rongeur forceps, level with the root canal filling. In cases where the canal cannot be filled because of blockage after the root tips were severed, cavities are prepared at the root tips and filled with amalgam or gutta-percha to seal the apical foramina. Tooth
replantation
The gauze pack is then removed from the socket, the blood clot is aspirated, and the tooth is replaced in its socket. The buccal and lingual plates of bone are then pressed together with the fingers and checked for occlusion.
Intentional
Volume 7 I Number 6
3. Radiograph immediately after hemisection and reimplantation.
Fig.
replantation
745
Fig. 4. Appearance at 4-month follow-up with three-unit bridge in place. Note healthy periodontal ligament.
Stabilization
The replanted tooth must be stabilized with a splint if necessary. Posterior teeth normally are well retained and do not require splinting. Anterior teeth, however, can be splinted with a direct bonding technique or an acrylic splint. Some authors found that splinting did not help the healing of periodontal ligaments after replantation; to the contrary, the frequency and extent of ankylosis (replacement resorption) was significantly higher in the cases of splinted teeth.46-48 Andersson et a1.49 state that masticatory stimulation probably prevents or reduces the development of ankylosis. Postoperative
instruction
To reduce the possibility of infection, an oral antibiotic is prescribed for 5 to 7 days and the patient is asked to rinse the mouth with salt water. Frequent brushing is essential. Pain and swelling are rare complaints; when they do occur, a pain medication is prescribed and the patient is advised to use an ice bag for swelling. The patient is seen at weekly intervals until the splint is removed. After 2 weeks the replanted tooth is relatively firm and the periodontal tissue is normal. The patient is then followed up in 6-month intervals and examined clinically and radiographitally. CASE REPORT
A 50-year-old man had symptoms of spontaneous pain exacerbated by thermal changes, primarily heat, on the lower left first molar. Medical history was not contributory. Review of the dental history revealed that the patient had been treated for moderate periodontal disease1% years ago and the involved tooth was pulp capped and crowned (Fig. 1). On clinical and radiographic examination, severecalcification of the pulp chamber and root canal spacewas noted and a diagnosis of acute pulpitis was made (Fig. 2). The
Fig. 5. Appearance at 18-month follow-up of tooth, showing no evidence of root resorption.
patient was informed of the difficulty of conventional root canal treatment becauseof severecalcification, and the following treatment options were presented to him: (1) periapical surgery, (2) intentional replantation, and (3) extraction with fabrication of a three-unit bridge. The patient did not accept the periapical surgery because of the involved risks. He consented to intentional replantation if conventional endodontic treatment was deemed impossible. An attempt was made to negotiate the canals but because of the severecalcification was unsuccessful. The patient’s symptoms persisted. An antibiotic (500 mg penicillin V potassium) and hydrocodone bitartrate (Vicodin) were prescribed, and an appointment was scheduled for intentional replantation. The procedure was followed as described earlier, with some exceptions, by two clinicians. The crown was removed before the extraction and the accessfilled with cold-cure composite. During extraction the mesial root broke, and it was then decided to hemisect the tooth and reimplant the distal root. The apex was sealed with amalgam, and the root was replanted (Fig. 3). No
746
Messkoub
ORhI
SURG
ORAl
MED
ORAL
PA.rHOl
June
Fig. 6. Appearance at 3-year follow-up shows no signsof ankylosis or resorption.
1991
teeth when conventional or surgical endodontic treatment is not recommended. In this article a brief review of the applicable literature, rationale for this treatment modality, and description of the technique of intentional replantation have been discussed. An interesting case is presented in which the distal root of a lower molar was reimplanted after hemisection. This reimplanted root served as the distal abutment of a three-unit bridge. A 3-year follow-up revealed a clinically asymptomatic and functional tooth with no sign of resorption or ankylosis. The possibility of long-term retention (10 to 12 years) indicates that intentional replantation is indeed a reliable and predictable treatment option and should be practiced more frequently. REFERENCES
splint was used, but the mesial socket was sutured. The patient was dismissed with written home care instructions. At the 1-week postoperative visit the suture was removed. The patient reported very little pain or discomfort. Mobility was + 1 at this time. At the 4-week postoperative visit no mobility was noted, gingival tissue appeared normal, and no symptoms were present. A three-unit porcelain bridge was fabricated and cemented 4 months later, with the distal root as the distal abutment (Fig. 4). An 18-month clinical and radiographic evaluation of the tooth showed no signs of apical or lateral root resorption or ankylosis (Fig. 5). The patient was asymptomatic, and gingiva was healthy. A 3-year clinical and radiographic follow-up showed no changes (Fig. 6). DISCUSSION
Intentional replantations have been practiced in dentistry for 250 years. This treatment is accepted almost universally among dentists for traumatically avulsed teeth, and there is no reason why it should not be used for other situations. Indications for intentional replantation occur infrequently; however, in an attempt to maintain natural dentition, this is indeed a treatment option when the more conventional forms of treatment either fail or are impossible. The success of intentional replantation is directly related to the viability of the periodontal ligament. Therefore the procedure should be done as atraumatically as possible, under sterile conditions, to preserve the vitality of the attachment apparatus. The time span during which the tooth is out of its socket also must be shortened by cooperation between the attending clinicians. This technique is simple, fast, and has a high success rate (52% to 95%), with an average retention time of 3 to 5 years. SUMMARY
Intentional replantation is an accepted and predictable endodontic procedure for treatment of the
1. Grossman 2. 3. 4. 5. 6. 7. 8. 9. 10. Il.
12.
13.
14. 15. 16. 17. 18.
19. 20. 21.
22.
L. Endodontic practice. 1 lth ed. Philadelphia: Lea & Febiger, 1988:334-42. Weine F. Endodontic therapy. 4th ed. St Louis: CV Mosby. 1989:210-3. lngle J. Endodontics. 3rd ed. Philadelphia: Lea & Febiger. 1985:664-6. Cohen B, Burns RC. Pathways of the pulp. 4th ed. St Louis: CV Mosby, 1987:607-g. Deeb E, Prietto P, McKenna R. Reimplantation of luxated teeth in humans. J South Calif Dent Assoc 1965;33:194-206. Grossman L. Intentional replantation of teeth. J Am Dent Assoc 1966:72:1 1 1 l-8. Healy A, Harry J. Replantation: a brief review and report of a case sequel. J Oral Surg 1953;6:775-9. Fauchard P; Lindsay L, trans. Surgeon dentist. London: Butterworth, 1946: 140. Woofendale R. Practical observation on the teeth. London: J Johnson, 1783: 137. Dexter JE. A history of dental and oral science in America. Philadelphia: Samuel S White, 1877:lOS. Blomllif L, Andersson L, Lindskog S. Periodontal healing of replanted monkey teeth prevented from drying. Acta Odont Stand 1983;41:1 17-23. Grossman L. Chacker F. Clinical evaluation and histologic study of intentionally replanted teeth. In: Transactions of the Fourth International Conference on Endodontics. Philadelphia: University of Pennsylvania, 1968: 127-44. Andreasen J, Hjorting HE. Replantation of teeth. Part II. Histological study of 22 replanted anterior teeth in humans. Acta Odont Stand 1966;24:287-306. Marshall J. Physiologic and traumatic apical resorption. J Am Dent Assoc 1935;22:1545-58. lngle J. Replantation following total luxation. Dent Digest 1953;59:386-90. Maxmen H. An aid in successful replantation and post resection canal filling technique. Alpha Omegan 1950;44: 1 17-26. Anderson W. Sharav Y, Massler M. Periodontal reattachment after tooth replantation. J Periodontol 1968;6:161-7. Lu DP. Intentional replantation of periodontically involved and endodontically mistreated tooth. ORAL SURG ORAL MED ORAL PATHOL 1986;6 1:508- 13. Andersson L. Dentoalveolar ankylosis and associated root resorption in replanted teeth. Swed Dent J Suppl 1988;56:1-75. Grossman L. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc 1982;104:633-9. Kingsbury BC, Weisenbaugh JM. Intentional replantation of mandibular molars and premolars. J Am Dent ASSOC 1971;83:1053-7. Knight M, Cans B, Calandra J. The effect of root canal therapy on replanted teeth of dogs. J Oral Surg 1964;18:227-9.
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Volume 7 1 Number 6 23. Nasjleti CE, Castelli WA, Caffesse RG. Replantation of mature teeth without endodontic treatment in monkeys. J Dent Res 1978;57:650-8. 24. Rothschild DL, Goodman A, Blakey K. A histologic study of replanted and transplanted endodontically and nonendodontitally treated teeth in dogs. J Oral Surg 1969;28:871-6. 25. Nosonowitz DM, Stanley HR. Intentional replantation to prevent predictable endodontic failures. ORAL SURC ORAL MED ORAL PATHOL 1984;57:423-32. 26. Dryden J. Ten-year follow-up of intentionally replanted mandibular second molar. J Endod 1986;12:265-7. .27. Abrams R. Tooth replantation: 11 years follow-up, Aust Dent J 1987;32:427-9. 28. Donnelly J. Intentional replantation: case update. J Endod 1989;15:84. 29. Karl K, Nguyen N, Barkhordar R. Intentional replantation: a report of 192 cases. J Gen Dent 1988;36:327-31. 30. Matusow R. Clinical observation regarding the treatment of traumatically avulsed mature “teeth.” Part I. ORAL SURG ORAL MED ORAL PATHOL 1985;60:94-9. 31. Bielas L. Evaluation of the results of tooth replantation [Abstract]. Dent Abstr 1960;5:147. 32. Hammer H. Replantation and implantation of teeth. Int Dent J 1955;5:439-57. 33. Emmersten E. Replantation of extracted molars. ORAL SURG ORAL MED ORAL PATHOL 1956:9:115-22. 34. Kemp W, Grossman L, Phillips J. Evaluation of 71 replanted teeth. J Endod 1977;3:30-5. 35. Natiella J, Armitage J, Greene G. The replantation and transplantation of teeth. ORAL SURC ORAL MED ORAL PATHOL 1970;29:397-419. 36. Guy S, Goerig A. Intentional replantation: technique and rationale. Quintessence Int 1984;15:595-603. 37. Madison S. Intentional replantation. ORAL SURC ORAL MED ORAL PATHOL 1986;62:707-9. 38. Din F. Intentional replantation to prevent loss of an abutment tooth. J Gen Dent 1987;35:39-41. 39. McCalla R. Intentional replantation: a “viable” alternative to extraction or retreatment. J Tenn Dent Assoc 1985;65:26-8.
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40. Andreasen J, Hjorting-Hansen L. Replantation of teeth. Part I. Radiographic and clinical study of 1 IO human teeth replanted after accidental loss. Acta Odont Stand 1966;24: 263-86. 41. Matusow R. Clinical observation regarding the treatment of traumatic avulsed mature “teeth.” Part II. ORAL SURG ORAL MED ORAL PATHOL 1985;60:428-35. 42. Deeb E. Intentional replantation of endodontically treated teeth. In: Transactions of the Fourth International Conference on Endodontics. Philadelphia: University of Pennsylvania, 1968:147-57. 43. Andreasen JO. Treatment of fractured and avulsed teeth. J Dent Child 1971;38:29-39. 44. Andreasen JO. The effect of pulp extirpation or root canal treatment on periodontal healing after replantation of permanent incisors in monkeys. J Endod 1982;8:245-52. 45. Andreasen JO. The effect of excessive occlusal trauma upon periodontal healing after replantation of mature permanent incisors in monkeys. Swed Dent J 1981;5:115-22. 46. Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odont Stand 1975;33:3 13-23. 47. Nasjleti JE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. J Oral Surg 1982;53:557-66. 48. Biven G, Ritchie G, Gerstein H. Acrylic splint for intentional replantation. ORAL SURG ORAL MED ORAL PATHOL 1970;30:537-9. 49. Andersson L, Lindskog S, Blomhof L, Hedstrom K, Hammarstrom L. Effect of masticatory stimulation on dentoalveolar ankylosis after experimental tooth replantation. Endod Dent Traumatol 1985;1:13-6.
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