Endo Tribune United Kingdom Edition

June 201416 Endo Tribune United Kingdom Edition Eight-year follow-up of successful intentional replantation Authors Dr Muhamad Abu-Hussein; Dr Sarafianou Aspasia; Dr Abdulgani Azzaldeen I ntentional replantation has been practised for many years as a treatment modality for pulp-less teeth. Although the success ratio for intentional replanta- tion is far below that for rou- tine or surgical endodontics, this procedure should be con- sidered an alternative to tooth extraction. A case of mandibu- lar 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 patho- logical changes. Introduction Intentional replantation (IR) is the extraction of a tooth to perform extra-oral root-canal therapy, curettage of an api- cal 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 imme- diately after sealing the apical foramina.” He also stated that it is “the act of deliberately removing a tooth and follow- ing examination, diagnosis, endodontic manipulation, and repair, returning the tooth to its original socket to correct an apparent clinical or radio- graphic endodontic failure”.4 It is a one-stage treatment that will maintain the natural tooth aesthetics if successful.5 This method was first re- ported nearly a thousand years ago. In the eleventh century AD, Abulcasis gave the first ac- count of replantation and use of ligatures to splint the replant- ed 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 re- move the tooth disease.10 In 1890, Scheff11 addressed the role of the periodontal liga- ment (PDL) in the prognosis of replanted teeth. In 1955, Ham- mer12 described the importance of leaving an intact PDL on in- tentionally 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 accom- plished in a technically flaw- less manner.” In 1961, Loe and Waerhaug13 tried to replant teeth immediately to keep the PDL vital. Consequently, ankylosis was not seen; how- ever, all teeth showed resorp- tion 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. Intentional replantation is specifically indicated: • 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 non- surgical or peri-radicular surgical endodontic proce- dures • In the case of root-canal obstructions • When there are restorative or perforation root defects in areas that are not acces- sible via the usual surgical approach without exces- sive loss of root length or alveolar bone Contra-indications may in- clude: • Long, curved roots • Advanced periodontal dis- eases that have resulted in poor periodontal support and tooth mobility • Multi-rooted teeth with diverging roots that make extraction and replanta- tion impossible • Teeth with non-restorable caries In order to provide the best long-term prognosis for a tooth that is to be replanted inten- tionally, the tooth must be kept out of the socket for the short- est period possible, and the ex- traction of the tooth should be atraumatic to minimise dam- age 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 doxy- cycline 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 treat- ment option in select endodon- tic 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 re- ferred for evaluation and treat- ment of a painful mandibular left second molar. The patient described recent severe throb- bing pain associated with the left second molar area, ex- tending to the left ear, of three days’ duration. The patient stated that she had had a cav- ity 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 examina- tion revealed an endodontic failure associated with a peri- radicular radiolucency (Fig. 2). The patient was anaesthe- tised, and tooth 37 was extract- ed and received in a sterile gauze sponge saturated with ‘Although the success ratio for inten- tional replantation is far below that for routine or surgical endodontics, this procedure should be considered an al- ternative to tooth extraction’ Fig. 1_Pulpal diagnosis: necrosis, narrow periodontal pocket 10mm 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 wid- ened PDL, Grade I mobility.

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