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Replantation of a Mandibular Molar: Report of Case
C L IN IC A L
REPORTS
Replantation of a mandibular molar: report of case W illiam F. Stroner, DDS Daniel M. Laskin, DDS, MS
A young m an w as in d an g er of losing his m a n d ib u la r right first m olar. In an attem pt to save the tooth, two operators p erfo rm ed a replantation.
I ntentional replantation has been, and continues to be, a controversial subject. Weine,1 on the basis of his own experience, has disputed the re sults of Kingsbury and Weisenbaugh2; he pointed out that their study did not have adequate follow-up, and he suggested more conservative treat ment. Weine also refuted Leonard3and Deeb4 because in the cases they cite, treatment other than intentional re plantation was indicated. Grossman5 responded by stating that one of his greatest pleasures in 57 years of prac tice was to see a radiograph of an inten tionally replanted tooth that had been in service for 5, 10, or 15 years. According to Scott and Zelikow,6 there are two indications for inten tional replantation: accidental luxa tion and as a last resort for a strategic tooth that is not amenable to either conventional or surgical endodontic treatment. According to Weine,1inten tional replantation should be done only when no other method of therapy is possible. He suggests routine root canal therapy be performed even when the prognosis is unfavorable, with a suitable postoperative period to evalu ate healing. Periapical surgery of a fail ing case may still be advisable before resorting to intentional replantation. When extraction with intentional re plantation is indicated, Weine also r e c o m m e n d s tw o o p e ra to rs to minimize extraoral exposure of the tooth. He also recommends that a splint be prepared before surgery. Re plantation can also be unintentional, that is, replantation can occur when the tooth has been accidentally avulsed— as opposed to the replanta 730 ■ JADA, Vol. 103, November 1981
tion that occurs during the dental pro cedure. Three types of root resorption occur after replantation: surface resorption, which is normal and benign; replace ment resorption, the most common oc currence, which results in ankylosis and eventual loss of the tooth, though the latter may take a long time; and in flam m atory resorption, which is caused by a necrotic pulp and can be halted by an adequate apical seal. Be cause extraoral exposure time is such a crucial factor, the root canal treatment should be implemented after the re plantation, preferably w ithin two weeks if conditions allow, otherwise as soon as possible. In the Andreasen and HjortingHansen study,7,8 only 24% of the acci dentally avulsed replanted teeth were still functional five years after replan tation, thus indicating that intentional replantation cannot be considered a highly predictable procedure. How ever, there certainly are instances in which even such a short-lived result can be beneficial. Kemp and others,9in evaluating 71 replanted avulsed teeth, state that replantation is justified even though the procedure does not usually afford permanency.
Report of case A 19-year-old white man had an alveolar abscess, pain, and swelling in the vestibule of the right side of the mandible. The m an dibular right first molar was extremely mobile. The radiograph (Fig 1) showed a large radiolucent area surrounding the dis tal root and communicating w ith the furca. Root canal therapy had already been per formed. Because of the patient’s acute dis tress and the extreme mobility of the tooth, any thought of re-treating the root canals was discarded. Instead, the offending molar w ould be extracted and a fixed partial den ture w ould be constructed. However, as an afterthought, the patient was asked to con sider saving the tooth by replantation, even if only for a short time. Nothing w ould be lost because subsequent removal of the
Fig 1 ■ Large radiolucent area about apex of distal root, extending to furca. There is some ex ternal resorption of this root. Small radiolucent area is also present about apex of mesial root.
tooth w ould then produce the same final condition as removing it now. The patient chose the replantation procedure. A n alginate im pression was taken, a stone cast was poured, and a splint was constructed by soldering three bands of stainless steel together. A m andibular block was administered, followed by infiltration (w ith 2% lid o c a in e w ith e p in e p h rin e 1:100,000) of the long buccal and lingual nerves. Some difficulty was encountered w ith the extraction because of the d i vergence of the roots. Examination of the specimen disclosed no root fractures, the extension of the silver point beyond the mesiobuccal apex, and a distolingual fora men on the distal root, indicating high probability of an unfilled second canal. The external resorption of the distal root was not as prominent as it appeared to be in the radiograph. The extracted tooth was held in gauze soaked in isotonic saline solution during the endodontic procedure, and isotonic saline solution was continuously sprayed on the tooth during the preparation of the canals. Both the distobuccal and distolin gual foramens and apical portion of the ca n als were pre pare d a c c o rd in g to the method of Matsura10 and were filled with zinc-free amalgam that was condensed and burnished. W hile this was being done by one operator, the granulation tissue was curetted from the socket and the wound was thoroughly irrigated by the second operator. The overextended silver point was not reduced. Some difficulty was encountered while
C L IN IC A L
Fig 2 ■ Radiograph immediately following re
Fig 3 ■ Radiograph, taken eight months after
plantation. Matsura's technique using double
surgery, showing periapical bone regeneration.
lock creates large mass of amalgam, some of which lies next to periodontal ligament.
splinting period was longer than usual.
replacing the tooth in the alveolus because of the divergence of the roots. The distosuperior aspect of the alveolus was there fore reduced w ith a no. 8 round bur. W hen this was done, the tooth snapped into place and was stable. One 3-0 black silk suture was placed in the mesial and distal interproximal spaces to approximate the g ingi val papillae. The splint was then cemented w ith zincoxyphosphate cement (Fig 2). The tooth had not been out of the socket more than 12 minutes. Penicillin (250 mg, four times a day), given orally, was prescribed for five days. The patient was instructed not to chew on the involved side for two weeks and to m aintain good oral hygiene. The patient’s postoperative course was essentially normal, w ith a m in im um of pain and swelling. Sutures were removed after a week, at w hich time the gingival tissues appeared healthy and the tooth was still firmly splinted. No exudate could be ex pressed from the gingival sulcus. The pa tient was observed weekly for two weeks and then biweekly for a month. The patient then returned to college and was not seen u n til eight m onths later. A radiograph taken at that time showed evidence of bone regeneration (Fig 3). The patient was instructed to have the splint removed and to proceed w ith restora tion of the tooth. A radiograph taken by the private dentist 17 months later showed complete regeneration of the periapical bone. The patient was last seen on August 18, 1980, approximately four years after initial treatment. The tooth was firm and func-
REPORTS
tooth, intentional replantation was performed as a last resort. Matsura’s method of canal preparation, which results in a large area of amalgam on the root surface, was used. This method did not impair healing. Ac cording to Bjorvatn and Massler,11 ap plication of 1% SNF2 to the root sur faces for five minutes reduces root re sorption. This technique was not used in this case. Clinical and radiographic observation for almost four years sub stantiate this as a successful case.
Because patient attended college in another city, The authors thank Dr. Thomas Sperry, Univer sity of Illinois, department of orthodontics, for constructing the splint. Dr. Stroner is associate professor of endodontics and director of preclinical endodontics, de partment of endodontics, and Dr. Laskin is pro fessor and head, department of oral and maxillo facial surgery, University of Illinois College of Dentistry, 801 S Paulina St, PO Box 6998, Chicago, 111 60680. Address requests for reprints to Dr. Stroner.
Fig 4 ■ Radiograph nearly four years after re plantation shows clinically asymptomatic tooth with no radiographic radiolucent areas. Bone shows normal trabecular pattern. However, lack o f distinct periodontal ligam ent space and lam ina dura suggests ankylosis.
tional, and the gingival tissues were normal in appearance w ith no deep pocket forma tion. The radiograph (Fig 4) showed com plete bone regeneration, but the lack of periodontal space indicated that the tooth was most likely ankylosed.
Summary A patient with an alveolar abscess, swelling, pain, and an extremely mobile tooth had had previous root canal treatment. Extraction was rec ommended but, with informed con sent and the patient’s desire to keep his
1. Weine, F.S. The case against intentional re plantation. JADA 100(5):664-668, 1980. 2. Kingsbury, B.C., Jr., and Wiesenbaugh, J.M., Jr. Intentional replantation of mandibular premo lars and molars. JADA 83(5):1053-1057, 1971. 3. Leonard, I.J. Intentional replantation— a case report. CDS Rev 71(5):21-24, 1978. 4. Deeb, E. Replantation of teeth— a recom mended procedure. J South Calif State Dent Assoc 39:24-29, 1971. 5. Grossman, L.I. Intentional replantation, let ter. JADA 101(1):11-12, 1980. 6. Scott, J.N., and Zelikow, R. Replantation— a clinical philosophy. JADA 101(1):17-19, 1980. 7. Andreasen, J.O., and Hjorting-Hansen, E. Replantation of teeth. Radiographic and clinical study of 110 human teeth replanted after acciden tal loss. Acta Odontol Scand 24:263-286, 1966. 8. Andreasen, J.O., and Hjorting-Hansen, E. Replantation of teeth. Histological study of 22 re planted anterior teeth in humans. Acta Odontol Scand 24:287-306, 1966. 9. Kemp, W.B.; Grossman, L.I.; and Phillips, J. Evaluation of 71 replanted teeth. J Endod 3(l):30-35, 1977. 10. Matsura, S.J. A simplified root-end filling technic using silver amalgam. J Mich State Dent Assoc 44:40-41, 1962. 11. Bjorvatn, K., and Massler, M. Effect of fluo rides on root resorption in replanted rat molars. Acta Odontol Scand 29:17-29, 1971.
Stroner-Laskin : REPLANTATION OF MANDIBULAR MOLAR ■ 731
REPORTS
Replantation of a mandibular molar: report of case W illiam F. Stroner, DDS Daniel M. Laskin, DDS, MS
A young m an w as in d an g er of losing his m a n d ib u la r right first m olar. In an attem pt to save the tooth, two operators p erfo rm ed a replantation.
I ntentional replantation has been, and continues to be, a controversial subject. Weine,1 on the basis of his own experience, has disputed the re sults of Kingsbury and Weisenbaugh2; he pointed out that their study did not have adequate follow-up, and he suggested more conservative treat ment. Weine also refuted Leonard3and Deeb4 because in the cases they cite, treatment other than intentional re plantation was indicated. Grossman5 responded by stating that one of his greatest pleasures in 57 years of prac tice was to see a radiograph of an inten tionally replanted tooth that had been in service for 5, 10, or 15 years. According to Scott and Zelikow,6 there are two indications for inten tional replantation: accidental luxa tion and as a last resort for a strategic tooth that is not amenable to either conventional or surgical endodontic treatment. According to Weine,1inten tional replantation should be done only when no other method of therapy is possible. He suggests routine root canal therapy be performed even when the prognosis is unfavorable, with a suitable postoperative period to evalu ate healing. Periapical surgery of a fail ing case may still be advisable before resorting to intentional replantation. When extraction with intentional re plantation is indicated, Weine also r e c o m m e n d s tw o o p e ra to rs to minimize extraoral exposure of the tooth. He also recommends that a splint be prepared before surgery. Re plantation can also be unintentional, that is, replantation can occur when the tooth has been accidentally avulsed— as opposed to the replanta 730 ■ JADA, Vol. 103, November 1981
tion that occurs during the dental pro cedure. Three types of root resorption occur after replantation: surface resorption, which is normal and benign; replace ment resorption, the most common oc currence, which results in ankylosis and eventual loss of the tooth, though the latter may take a long time; and in flam m atory resorption, which is caused by a necrotic pulp and can be halted by an adequate apical seal. Be cause extraoral exposure time is such a crucial factor, the root canal treatment should be implemented after the re plantation, preferably w ithin two weeks if conditions allow, otherwise as soon as possible. In the Andreasen and HjortingHansen study,7,8 only 24% of the acci dentally avulsed replanted teeth were still functional five years after replan tation, thus indicating that intentional replantation cannot be considered a highly predictable procedure. How ever, there certainly are instances in which even such a short-lived result can be beneficial. Kemp and others,9in evaluating 71 replanted avulsed teeth, state that replantation is justified even though the procedure does not usually afford permanency.
Report of case A 19-year-old white man had an alveolar abscess, pain, and swelling in the vestibule of the right side of the mandible. The m an dibular right first molar was extremely mobile. The radiograph (Fig 1) showed a large radiolucent area surrounding the dis tal root and communicating w ith the furca. Root canal therapy had already been per formed. Because of the patient’s acute dis tress and the extreme mobility of the tooth, any thought of re-treating the root canals was discarded. Instead, the offending molar w ould be extracted and a fixed partial den ture w ould be constructed. However, as an afterthought, the patient was asked to con sider saving the tooth by replantation, even if only for a short time. Nothing w ould be lost because subsequent removal of the
Fig 1 ■ Large radiolucent area about apex of distal root, extending to furca. There is some ex ternal resorption of this root. Small radiolucent area is also present about apex of mesial root.
tooth w ould then produce the same final condition as removing it now. The patient chose the replantation procedure. A n alginate im pression was taken, a stone cast was poured, and a splint was constructed by soldering three bands of stainless steel together. A m andibular block was administered, followed by infiltration (w ith 2% lid o c a in e w ith e p in e p h rin e 1:100,000) of the long buccal and lingual nerves. Some difficulty was encountered w ith the extraction because of the d i vergence of the roots. Examination of the specimen disclosed no root fractures, the extension of the silver point beyond the mesiobuccal apex, and a distolingual fora men on the distal root, indicating high probability of an unfilled second canal. The external resorption of the distal root was not as prominent as it appeared to be in the radiograph. The extracted tooth was held in gauze soaked in isotonic saline solution during the endodontic procedure, and isotonic saline solution was continuously sprayed on the tooth during the preparation of the canals. Both the distobuccal and distolin gual foramens and apical portion of the ca n als were pre pare d a c c o rd in g to the method of Matsura10 and were filled with zinc-free amalgam that was condensed and burnished. W hile this was being done by one operator, the granulation tissue was curetted from the socket and the wound was thoroughly irrigated by the second operator. The overextended silver point was not reduced. Some difficulty was encountered while
C L IN IC A L
Fig 2 ■ Radiograph immediately following re
Fig 3 ■ Radiograph, taken eight months after
plantation. Matsura's technique using double
surgery, showing periapical bone regeneration.
lock creates large mass of amalgam, some of which lies next to periodontal ligament.
splinting period was longer than usual.
replacing the tooth in the alveolus because of the divergence of the roots. The distosuperior aspect of the alveolus was there fore reduced w ith a no. 8 round bur. W hen this was done, the tooth snapped into place and was stable. One 3-0 black silk suture was placed in the mesial and distal interproximal spaces to approximate the g ingi val papillae. The splint was then cemented w ith zincoxyphosphate cement (Fig 2). The tooth had not been out of the socket more than 12 minutes. Penicillin (250 mg, four times a day), given orally, was prescribed for five days. The patient was instructed not to chew on the involved side for two weeks and to m aintain good oral hygiene. The patient’s postoperative course was essentially normal, w ith a m in im um of pain and swelling. Sutures were removed after a week, at w hich time the gingival tissues appeared healthy and the tooth was still firmly splinted. No exudate could be ex pressed from the gingival sulcus. The pa tient was observed weekly for two weeks and then biweekly for a month. The patient then returned to college and was not seen u n til eight m onths later. A radiograph taken at that time showed evidence of bone regeneration (Fig 3). The patient was instructed to have the splint removed and to proceed w ith restora tion of the tooth. A radiograph taken by the private dentist 17 months later showed complete regeneration of the periapical bone. The patient was last seen on August 18, 1980, approximately four years after initial treatment. The tooth was firm and func-
REPORTS
tooth, intentional replantation was performed as a last resort. Matsura’s method of canal preparation, which results in a large area of amalgam on the root surface, was used. This method did not impair healing. Ac cording to Bjorvatn and Massler,11 ap plication of 1% SNF2 to the root sur faces for five minutes reduces root re sorption. This technique was not used in this case. Clinical and radiographic observation for almost four years sub stantiate this as a successful case.
Because patient attended college in another city, The authors thank Dr. Thomas Sperry, Univer sity of Illinois, department of orthodontics, for constructing the splint. Dr. Stroner is associate professor of endodontics and director of preclinical endodontics, de partment of endodontics, and Dr. Laskin is pro fessor and head, department of oral and maxillo facial surgery, University of Illinois College of Dentistry, 801 S Paulina St, PO Box 6998, Chicago, 111 60680. Address requests for reprints to Dr. Stroner.
Fig 4 ■ Radiograph nearly four years after re plantation shows clinically asymptomatic tooth with no radiographic radiolucent areas. Bone shows normal trabecular pattern. However, lack o f distinct periodontal ligam ent space and lam ina dura suggests ankylosis.
tional, and the gingival tissues were normal in appearance w ith no deep pocket forma tion. The radiograph (Fig 4) showed com plete bone regeneration, but the lack of periodontal space indicated that the tooth was most likely ankylosed.
Summary A patient with an alveolar abscess, swelling, pain, and an extremely mobile tooth had had previous root canal treatment. Extraction was rec ommended but, with informed con sent and the patient’s desire to keep his
1. Weine, F.S. The case against intentional re plantation. JADA 100(5):664-668, 1980. 2. Kingsbury, B.C., Jr., and Wiesenbaugh, J.M., Jr. Intentional replantation of mandibular premo lars and molars. JADA 83(5):1053-1057, 1971. 3. Leonard, I.J. Intentional replantation— a case report. CDS Rev 71(5):21-24, 1978. 4. Deeb, E. Replantation of teeth— a recom mended procedure. J South Calif State Dent Assoc 39:24-29, 1971. 5. Grossman, L.I. Intentional replantation, let ter. JADA 101(1):11-12, 1980. 6. Scott, J.N., and Zelikow, R. Replantation— a clinical philosophy. JADA 101(1):17-19, 1980. 7. Andreasen, J.O., and Hjorting-Hansen, E. Replantation of teeth. Radiographic and clinical study of 110 human teeth replanted after acciden tal loss. Acta Odontol Scand 24:263-286, 1966. 8. Andreasen, J.O., and Hjorting-Hansen, E. Replantation of teeth. Histological study of 22 re planted anterior teeth in humans. Acta Odontol Scand 24:287-306, 1966. 9. Kemp, W.B.; Grossman, L.I.; and Phillips, J. Evaluation of 71 replanted teeth. J Endod 3(l):30-35, 1977. 10. Matsura, S.J. A simplified root-end filling technic using silver amalgam. J Mich State Dent Assoc 44:40-41, 1962. 11. Bjorvatn, K., and Massler, M. Effect of fluo rides on root resorption in replanted rat molars. Acta Odontol Scand 29:17-29, 1971.
Stroner-Laskin : REPLANTATION OF MANDIBULAR MOLAR ■ 731