Dental Tribune United Kindom Edition

July 30 - August 5, 201220 Endo Tribune United Kingdom Edition I ntentional replantation is defined as the purposeful extraction of a tooth in or- der to repair a defect or cause of treatment failure and there- after the return of the tooth to its original socket.1 Any tooth that can be atraumatically re- moved in one piece is a poten- tial candidate for intentional replantation. However, specific indica- tions include:1–3 • all other endodontic non- surgical and surgical treat- ments have failed or are deemed impossible to perform • limited mouth opening that prevents the performance of non-surgical or peri-radicular surgical endodontic proce- dures • root-canal obstructions • restorative or perforation root defects that exist in ar- eas that are not accessible via the usual surgical approach without excessive loss of root length or alveolar bone Contraindications may in- clude:1–2 • long, curved roots • advanced periodontal dis- eases that have resulted in poor periodontal support and tooth mobility • multi-rooted teeth with di- verging roots that make ex- traction and reimplantation impossible • 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 shortest period possi- ble, and the extraction of the tooth should be atraumatic to minimise damage to the ce- mentum and the periodontal ligament. The periodontal ligament attached to the root surface should be kept moist in sa- line, Hank’s Buffered Salt Solution (HBSS), Viaspan or Doxycycline solution for the entire time the tooth is outside the socket. We have documented three clinical cases to exemplify the potential of intentional replantation as a viable treat- ment option in select endo- dontic cases. Case I A 14-year-old male patient presented with a separated Lentulo spiral extending 4- 5mm beyond the apex of the mesiolingual root canal of tooth #46 (Figs. 1a–d). The tooth was badly broken and the instrument tightly screwed into the root canal. All efforts to remove the spiral were fu- tile, and we were concerned that it would fracture at the apex. Apical surgery was ruled out because accessibility to the mesiolingual root would have been limited. We decided to replant the tooth intention- ally and discussed this treat- ment option with the patient, who agreed to our proposal. Since the tooth was badly bro- ken, we planned to reinforce its core with a post in the dis- tal canal prior to extraction. Once we had obtained ad- equate anaesthesia, the tooth was extracted atraumatically with an extraction forceps. We did not use surgical elevators and took care that the beaks did not go beyond the cemen- to-enamel junction (CEJ), as this may have damaged the cementum and the periodon- tal ligament. Following extraction, we kept the tooth moist by immersing it in Vias- pan. With the beaks of the forceps, we held the tooth by its crown and cut the overextended Lentulo spi- ral. Thereafter, we per- formed a 3mm Class I root- end preparation with an ultrasonic tip, at the api- cal end of all three canals. A retrograde filling was done with mineral trioxide aggregate (MTA). The extrac- tion socket was then irrigated with normal saline and gen- tly suctioned to remove blood clots. The socket was filled with tricalcium phosphate in order for the tooth to be 2 - 3mm higher than before. This helped in planning a good post-endodontic restoration. The tooth was carefully reinserted into its socket and brought into occlusion with digital manipulation and pa- tient bite force. The tooth was stabilised it its socket with a sling suture. The patient was re-evaluated after seven days, and the sutures were re- moved. Case II A 22-year-old male patient presented with a history of trauma to his maxillary ante- rior region. Clinical examina- tion revealed an Ellis Class III fracture of tooth #12, with the fracture line extending to the root palatally. Once the mobile fragment had been ex- tracted, we realised that the fracture line extended 2 -3mm sub-crestally. In order to bring the apical end of the fracture line to a supra-crestal posi- tion, we considered two op- tions: orthodontic extrusion and intentional replantation. The patient did not accept orthodontics as an option ow- ing to the extended treatment time required. Once the tooth had been atraumatically extracted, it was kept moist in Viaspan. Intentional replantation: A viable treatment option for specific endodontic conditions Prof Naseem Shah, Dr Ajay Logani & Dr Abhinav Kumar Fig 1a Tooth #46 with a fractured Lentulo spiral pushed past the apical foramen in the mesiolingual canal. Fig 1bTooth replanted after removal of the fractured instrument (apicoectomy and retro- grade MTA obturation) Fig 1c Clinical photograph showing stabilisation of the replanted tooth with sling sutures. Fig 1d Six-month follow-up ‘In order to provide the best long-term prognosis for a tooth that is to be replant- ed intentionally, the tooth must be kept out of the socket for the shortest period possi- ble’ Fig 2a_Clinical photograph of tooth #12 showing the PGG