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DT Israel

13 Dentaltribune israel editionEndo Tribune Dr Muhamad Abu-Hussein, Greece; Dr Sarafianou Aspasia, Greece; Dr Abdulgani Azzaldeen, Israel Intentional replantation has been practised for many years as a treatment modality for pulpless teeth. Although the success ratio for intentional replantation is far below that for routine or surgical endodontics,thisprocedureshould be considered an alternative to tooth extraction. A case of mandibular second molars treated with intentional replantation and retrograde fillings is reported in this article. At the eight-year recall visit, radiographs showed no evidence of pathological changes. Introduction Intentional replantation (IR) is the extraction of a tooth to perform extra-oral root-canal therapy, curettage of an apical lesion when present and its replacement in its socket.1,2 Grossman in 19823 defined it as follows: “A purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina.” He also stated that it is “the act of deliberately removing a tooth and following examination, diagnosis, endodontic manipulation, and repair, returning the tooth to its original socket to correct an apparent clinical or radiographic endodontic failure”.4 It is a one- stage treatment that will maintain the natural tooth aesthetics if successful.5 This method was first reported nearly a thousand years ago. In the eleventh century AD, Abulcasis gave the first account of replantation and use of ligatures to splint the replanted tooth.6 Fauchard, in 1712,7 reported an IR performed 15 minutes after extraction. In 1768, Berdmore reported IR of mature and immature teeth.8 In 1783, Woofendale reported IR of diseased teeth.9 In 1778, Hunter believed that boiling the extracted tooth prior to replantation might help to remove the tooth disease.10 In 1890, Scheff11 addressed the role of the periodontal ligament (PDL) in the prognosis of replanted teeth. In 1955, Hammer12 described the importance of leaving an intact PDL on intentionally replanted teeth. He believed that a healthy PDL is essential for reattachment and retention of replanted teeth. He stated “an average 10 years life span could be expected when replantation was accomplished in a technically flawless manner.” In 1961, Loe and Waerhaug13 tried to replant teeth immediately to keep the PDL vital. Consequently, ankylosiswasnotseen;however,all teeth showed resorption repaired with cementum. These results were confirmed by Deeb in 196514 and Edwards in 1966.15 In 1968, Sherman16 showed that normal PDL could be kept vital when all other endodontic non-surgical and surgical treatments have failed or are deemed impossible to perform; when the patient is not able to open his or her mouth fully, preventing the performance of nonsurgical or peri-radicular surgical endodontic procedures; in the case of root- canal obstructions; and when there are restorative or perforation root defects in areas that are not accessible via the usual surgical approach without excessive loss of root length or alveolar bone. Contra-indications may include long, curved roots; advanced periodontal diseases that have resulted in poor periodontal support and tooth mobility; multi-rooted teeth with diverging roots that make extraction and replantation impossible; and 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 possible, and the extraction of the tooth should be atraumatic to minimise damage to the cementum and the PDL.1,7,8 The PDL attached to the root surface be kept moist in saline, Hanks’ balanced salt solution, Viaspan or a doxycycline solution for the entire time the tooth is outside the socket. We have documented three clinical cases to exemplify the potential of IR as a viable treatment option in select endodontic cases. The purpose of this article is to report a case of successful IR as an alternative to extraction.13–15,17 Case report A 48-year-old woman was referred for evaluation and treatment of a painful mandibular left second molar. The patient described recent severe throbbing pain associated with the left second molar area, extending to the left ear, of three days’ duration. The patient stated that she had had a cavity in tooth 37 (Fig. 1) and her dentist had performed root-canal therapy a few months before her presentation. Upon examination, tenderness to percussion and palpation were noted and sulcus depths around tooth 37 did not exceed 3mm. Radiographic examination revealed an endodontic failure associated with a periradicular radiolucency (Fig. 2). The patient was anaesthetised, and tooth37wasextractedandreceived in a sterile gauze sponge saturated with saline solution. The wound was packed with sterile gauze and the patient asked to close her teeth together to immobilise the pack. Resection of both the mesial and distal roots was performed by bevelling the root tip with a #702 bur in a straight handpiece. Retro- preparation of the mesial root was accomplished using a #1/2 round bur in a contra-angle handpiece with copious irrigation. An MTA retrograde filling was placed in the root canals (Fig. 3). Once the extra-oral procedure had been completed the socket was irrigated gently with a normal saline solution to remove the clot and the tooth was replanted. No splint was needed. Six weeks later, the patient was asymptomatic and the replanted tooth was firm in its socket. At the time, the patient was advised to proceed with the final restoration on the replanted molar (Figs. 4–8). After one year (Fig. 9), three years (Fig. 10), four years (Fig. 11) and eight years (Fig. 12), the patient attended for evaluation and radiographs were taken of the tooth. The radiographs showed no evidence of resorption and the patient was asymptomatic. Discussion Intentional replantation is an accepted endodontic procedure in cases in which intra-canal and surgical endodontic treatments are not recommended. Although not frequently used, IR is a treatment option that dentists should consider under these conditions. If the standard protocols during IR are not followed, root resorption and ankylosis may be observed within one month and one to two months, respectively.17,18 Most resorptive processes are diagnosed within the first two to three years. However, although rare, new resorptive processes could occur even after five or ten years.17 As various investigators report varying success rates, it is difficult to predict the outcome for IR. Bender and Rossman19 evaluated 31 cases with an overall success rate of 80.6 % (six recorded failures). Replanted teeth survived from one day to 22 years. A second mandibular molar that failed after three weeks was replanted successfully a second time with no signs of failure after Eight-year follow-up of successful intentional replantation Fig. 1_Pulpal diagnosis: necrosis, narrow periodontal pocket 10 mm deep, Grade I+ mobility. Fig. 2_A radiograph after six months: same pocket depth, Grade II mobility, plenty of exudate. Fig. 3_Extracted, apex filled with MTA; no exudate and Grade I+ mobility at the two- month recall. Fig. 4_A radiograph after six weeks showing the healing periapical lesion. Fig. 5_A radiograph after six months showing no fractures; no widened PDL, Grade I mobility. Fig. 6_Intra-oral photograph showing the clinical situation. Fig. 7_Closed contacts between teeth. Fig. 8_Gingival recession present, periodontal pocket depths were 2–3 mm around the tooth. There was little bleeding on probing.