Dental Tribune United Kindom Edition

July 30 - August 5, 201222 Endo Tribune United Kingdom Edition a surgical approach can be difficult, for example on the lingual root of a mandibular molar, or in cases in which a surgical approach would be very invasive, such as the removal of thick bone from the buccal aspect of a second mandibular molar. Intentional replantation has a better prognosis when the extra-oral time is kept as short as possible and trauma to the periodontal ligament and cementum is minimised.1 It is advisable to perform rou- tine endodontic treatment intra-orally before the tooth is extracted to minimise the extra-oral time. It is also sug- gested that a team of two den- tists work in tandem to prevent prolonged treatment time, thus improving the chances of success. The use of elevators should be avoided, and the beaks of the extraction for- ceps should not go beyond the CEJ. The cortical bone integ- rity should be maintained, and the tooth should be extracted as atraumatically as possible. The medium in which the tooth is kept moist plays an important role. Saline, HBSS, milk, Viaspan, to name a few, are widely used. Viaspan is used for organ transplanta- tion and preservation. Owing to its anti-oxidant activity, the solution keeps the periodontal ligament moist and reduces the likelihood of surface re- sorption.2 We generally use ultra- sonic tips to prepare the root- end and the debridement of the PGG. It conserves the tooth structure and produces significantly less smear layer compared with burs.3 Com- monly used root-end filling materials are amalgam, Inter- mediate Restorative Material (IRM), Super EBA, GIC, Dia- ket, composite and MTA. The sealing ability and marginal adaptation of MTA have been proven to be superior and not adversely affected by blood contamination. In addition, MTA promotes deposition of new cementum and stimu- lates osteoblastic adherence to the retro-filled surface. In two of our cases, trical- cium phosphate was placed in the apical few millime- tres of the socket. This was done in order to bring the defect supragingivally so that the integrity, aesthetics and prognosis of the case were improved. Tricalcium phos- phate is an osteo-conductive material that acts as scaffold for bone growth and is gradu- ally degraded and replaced by bone.10 A palato-gingival groove is a developmental anomaly that represents an infolding of enamel and Hertwig’s epithe- lial root sheath.11 PGG can vary in depth, length and complex- ity, causing varying degrees of periodontal defects. Mild grooves terminate at the CEJ, whereas moderate grooves continue apically along the root surface. A treatment op- tion for a PGG terminating close to CEJ is to expose the groove surgically and to seal it thereafter. As presented, the groove extended beyond the apex in Case III. Here, the defect was sealed extra-orally and the tooth replanted. GIC was used to seal the PGG, as it chemically adheres to the tooth structure and has a good sealing ability and antibacte- rial effect.12 After replantation, the tooth was splinted for ten days. The splint enabled physiologi- cal movement of the tooth to prevent ankylosis. Endodontic treatment was completed one week after replantation in or- der to prevent inflammatory resorption and ankylosis and to allow splicing of periodon- tal fibres, which limits the seepage of potentially harm- ful root-filling materials into the traumatised periodontal ligament.13 Final restoration of the tooth was delayed to avoid loading and to ensure that proper healing of periodontal ligament took place. In recent years, sever- al bio-modulators, such as enamel matrix protein14, hy- droxyapatite and plateletrich plasma,15 have been used in intentional replantation cases to improve the success rates. Guided tissue-regeneration techniques can also be em- ployed along with these sup- plements to further improve the likelihood of success. We conclude that inten- tional replantation is a viable treatment option in carefully selected cases in which all other treatment options have been exhausted. We would like to acknowl- edge the assistance of Dr Akanksha Gupta and Dr Nikhil Sinha._ • Editorial note: A complete list of references is available from the publisher. page 21DTß About the author Prof Naseem Shah is Head of the Department of Conservative Dentistry and Endodontics and Chief of the Cen- tre for Dental Education and Research at the All India Institute of Medical Sciences. She can be contacted at naseemys@ gmail.com. 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 obtu- rated canal. The sealed PGG is superim- posed on the root-canal obturation ‘The sealing ability and marginal adapta- tion of MTA have been proven to be superior and not adversely affected by blood contamination’ • This article was first published in the International version of Roots Issue 1 2012