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ntentional Replantation: A Case Reportichael R. Cotter, DDS,* and John Panzarino, DMD†

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bstractonsurgical retreatment and surgical endodontics areot always viable solutions to endodontic disease. Ac-ess for retreatment may be limited by posts. Surgicalndodontics may be limited by anatomical featuresncluding bone thickness and nerve and sinus proximity.natomical limitations and complex restorations mayrevent implant placement. Intentional replantation isonsidered by many as a procedure of last resort whenonsurgical or surgical endodontics is contra-indicated.he treatment described demonstrates intentional re-lantation as a procedure to be considered when end-dontic procedures or a dental implant are not possible.J Endod 2006;32:579–582)

ey Wordslternative to implant, apico, apicoectomy, buccal plate

hickness, chlorohexidine gluconate, chronic apical pe-iodontitis, endo, intentional replantation, molar end-dontics, retreat, retro-prep, retro-seal, super EBA.

From the *Private practice, Mamaroneck, NY, Attending,ontefiore Medical Center, Bronx, New York; †Private prac-

ice, New Brunswick, New Jersey.Address requests for reprints to Dr. Michael R. Cotter,

epartment of Dentistry, 3332 Rochambeau Ave., Montefioreedical Center, Bronx, NY 10467. E-mail address:ichael@endocotter.com.

099-2399/$0 - see front matterCopyright © 2006 by the American Association of

ndodontists.oi:10.1016/j.joen.2005.08.004

l

OE — Volume 32, Number 6, June 2006

ntentional replantation is defined by Grossman as the “removal of a tooth and itsalmost immediate replacement, with the object of obturating the canals apically while

he tooth is out of the socket.” (1) It is considered by many as a procedure of last resort.he indications for intentional replantation include failed previous nonsurgical end-dontics, an apicoectomy procedure is unfavorable because of anatomical factors (e.g.uccal plate thickness, proximity to anatomical structures such as the mandibular nerver inoperable sites such as lingual surfaces of mandibular molars) or financial factorsreclude conventional implant placement. Buccal plate thickness may preclude surgi-al endodontic treatment in mandibular molars and the palatal root of maxillary molars2). Although post removal is frequently possible in the hands of a skilled clinician,ccasionally posts or separated instrument removal may pose risks greater than theotential benefits as compared with other options including extraction (3).

Contraindications to intentional replantation include: a more favorable prognosisith either conventional apical surgery or implant placement, active periodontal dis-ase, a nonrestorable tooth, extraction requiring hemi-section or osseous recontour-ng, the tooth is part of a multiple-tooth prosthesis, or the roots are divergent. In theseases involving individual teeth (nonsplinted) with divergent roots, a single tooth os-eotomy may be considered (4). Advantages of intentional replantation include: poten-ially more cost-effective and less time consuming than the alternatives. Disadvantagesnclude a risk of root fracture or root resorption. Bender and Rossman reported auccess rate of 81% of 31 teeth followed for up to 22 yr (5). Kingsbury and Weisenbaugheported a success rate of 95% for 151 teeth followed for 3 yr (6). The majority ofrequently success and failure studies comparing the outcomes of surgical treatmentith that of nonsurgical treatment since 1970 are case series (7).

Case ReportA 47 yr old female presented to the Advanced Education Program in Endodontics

t New York University College of Dentistry for evaluation of tooth #31. Her chiefomplaint was “pain from her lower right back tooth when she bites down.” Heredical history was non contributory, no allergies or medications. Dental history in-

luded endodontic therapy on tooth #31 with a post, core and crown. Clinical exami-ation revealed pain to percussion and palpation. No evidence of a stoma was noted.ooth #31 was restored with a metal ceramic crown with appropriate marginal andcclusal integrity. Teeth 2, 30, and 32 were present and in proper contact with #31.eriodontal examination revealed mobility, probing depths and gingival tone withinormal limits. Radiographic examination revealed a large periapical radiolucency as-ociated with the apex of tooth #31 (Fig. 1). Crestal bone levels appeared to be withinormal limits.

The patient was presented with the treatment options of extraction and a dentalmplant or extraction with no replacement. Endodontic retreatment and implant ther-py were declined by the patient. Surgical endodontics was contra-indicated because ofroximity to the inferior alveolar canal. After understanding risks and benefits of all

reatment options, the patient made an informed decision to have the tooth removed.pon the patient’s decision to have the tooth extracted, the treatment option of inten-

ional replantation with associated risks and benefits was offered. The patient accepted.

ProcedureOne hour before the procedure, the patient rinsed with chlorhexidine gluconate

.12% and was given 600 mg of ibuprofen. Two operators were present throughout therocedure. The patient was prepared for surgery and profound inferior alveolar and

ingual nerve block anesthesia was achieved with 2% lidocaine containing 1:100,000

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pinephrine. A mucoperiosteal flap was elevated to gain access to theooth apical to the crown margin to prevent damage to the crown. Theooth was extracted with minimal trauma through the use of forcepsFig. 2). Operator #1 carried the tooth in the forceps over Hank’solution to a microscope (Protegé, Global Surgical Corp., St. Louis,O) immediately adjacent to the patient. Under 12X, the apex was

esected with the lesion attached (Fig. 3) and the roots were evaluatedor vertical fractures. Although recommended treatment of a verticaloot fracture includes dentin bonding resin (8 hayashi, 9 hayashi), noractures were detected. The lesion was sent for histo-pathological anal-sis. The apices of the two roots were retro prepared (Satelec P5 Ultra-onic Booster) removing 3 mm of gutta-percha and debris (Fig. 4).rrigation was performed with sterile saline and the two canals wereried with paper points, while the entire root surface was kept moistith saline. The canals were sealed with super EBA fast-set and bur-ished (Fig. 5). As the tooth was being treated, operator #2 lightlyuretted the apical portion of the socket without disturbing the socketalls coronal to the apex. The tooth was replanted into the socket in less

han 5 min from extraction. Two interrupted 4-0 silk sutures were usedo stabilize the tooth. A postoperative radiograph was taken (Fig. 6) andhe following postoperative instructions were given: chlorhexidine glu-

igure 1. Radiograph illustrating a large periapical radiolucency associatedith the apex of tooth #31.

igure 2. Photograph of the extraction site of tooth #31. c

80 Cotter and Panzarino

onate 0.12% on a cotton swab over the site three times per day aftereals for 7 days, ibuprofen 600 mg every 4 to 6 h for 48 h and soft diet

or 2 wk. The patient was recalled in 1 wk for suture removal andvaluation of the surgical site. At 1 wk, the soft tissues appeared pink inolor with minimal inflammation and pain upon biting had diminished.

Microscopic examination revealed soft tissue composed of gran-lation tissue infiltrated by acute and chronic inflammatory cells (Fig.). The histo-pathological diagnosis was dental granuloma. The patientas recalled in 1 month. Healing was uneventful and the patient’s symp-

oms had subsided. Tooth mobility was normal. The patient was recalledgain at 1 yr and clinical examination revealed no response to percus-ion or palpation, soft tissue probing depths and mobility were withinormal limits. Radiographic examination revealed complete osseousealing of the peri-apical radiolucency (Fig. 8).

DiscussionIntentional replantation is indicated when the apex of the in-

olved tooth is in close proximity to the inferior alveolar nerve,ental nerve or the maxillary sinus. Suture splinting is used to

ecure the reimplanted tooth because rigid splinting may harboracteria, delay healing and promote replacement resorption by not

igure 3. Photograph illustrating the apical resection of tooth #31.

igure 4. Photograph illustrating the apical retro-prep of the mesial and distal

anals of tooth #31.

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llowing physiological mobility (10). In the case reported, the oc-lusal surface was not reduced during or after the surgery in anffort to promote healing.

To achieve minimal extra-oral time, the procedure was rehearsedith extracted teeth in a simulated setting five times. Extra-oral time in

his treatment was less than 5 min. The success of intentional replanta-ion is likely dependent upon a minimally traumatic extraction, shortxtra-oral time with copious irrigation and meticulous instrumentations well as carefully controlled postoperative patient compliance. Suc-essful completion, according to Kratchman, of extra-oral manipulationhould not exceed 10 min (10). Radiographic analysis, after retrofillnd before replantation is an option than can be utilized for furtherpical evaluation. This radiograph enables the operator to ensure thepical fill adequately extends from the gutta-percha to the apex. It muste noted that additional extra-oral time could hinder the overall successf the procedure. It was determined before treatment, not to take anmmediate postoperative radiograph before reimplantation because ofhe additional extra-oral time required. Although the retro-fill material

igure 5. Photograph of tooth #31 illustrating the apical retro-seal with SuperBA.

igure 6. Radiograph of tooth #31 immediately after replantation. i

OE — Volume 32, Number 6, June 2006

oes not extend completely to the gutta-percha, visual inspection dem-nstrated adequate marginal adaption at the apex and #31 healed un-ventfully.

In 1995 Pitt Ford found that Super EBA and Cavit showed sim-lar mild inflammatory response as an apical sealer when comparedo zinc-oxide and eugenol, Kalzinol and amalgam (11). In 1999,damo found no significant differences between amalgam, compos-

te, MTA, and super EBA as retrograde sealing materials (12). Theetrograde seal used in this treatment was Super EBA because it isasily manipulated, has a fast setting time and well tolerated byeri-apical tissues. Data that has been published subsequent to therocedure described here suggest that MTA-Angelus shows betterarginal adaptation than Super-EBA and Vitremer (13).

With the high success rate of dental implants and endodontics,ntentional replantation is not frequently the treatment of choice.owever, in cases where a dental implant, nonsurgical retreatmentr surgical treatment is not possible, intentional replantation may beviable treatment option. (8, 9)

igure 7. Histological slide revealing soft tissue composed of granulation tissuenfiltrated by acute and chronic inflammatory cells.

igure 8. One year postoperative radiograph revealing complete osseous heal-

ng of the peri-apical radiolucency.

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References1. Grossman LI. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc

1982;104:633–9.2. Jin GC, Kim KD, Roh BD, Lee CY, Lee SJ. Buccal bone plate thickness of the Asian

people. J Endod 2005;31:430 – 4.3. Ruddle CJ. Nonsurgical retreatment. J Endod 2004;30:827– 45.4. Kany FM. Single-tooth osteotomy for intention replantation. J Endod

2002;28:408 –10.5. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral

Surg Oral Med Oral Pathol 1993;76:623–30.6. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premo-

lars and molars. J Am Dent Assoc 1971;83:1053–7.7. Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Levels of evidence for the

outcome of endodontic surgery. J Endod 2005;31:19 –24.

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8. Hayashi M, Kinomoto Y, Miura M, Sato I, Takeshige F, Ebisu S. Short-term evaluationof intentional replantation of vertically fractured roots reconstructed with dentin-bonded resin. J Endod 2002;28:120 – 4.

9. Hayashi M, Kinomoto Y, Takeshige F, Ebisu S. Prognosis of intentional replantation ofvertically fractured roots reconstructed with dentin-bonded resin. J Endod2004;30:145– 8.

0. Kratchman S. Intentional replantation. Dent Clin North Am 1997;41:603–17.1. Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP. Effect of super-EBA as a root

end filling on healing after replantation. J Endod 1995;21:13–5.2. Adamo L. A comparison of MTA, Super-EBA, composite and amalgam as root-end

filling materials using a bacterial microleakage model. Int Endod J1999;32:197–203.

3. Xavier CB, Weismann R, de Oliveira MG, Demarco FF, Pozza DH. Root-end filling

materials: apical microleakage and marginal adaptation. J Endod 2005;31:539 – 42.

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