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Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 222-225

Intentional replantation of endodontically treated second premolar with chronic apical abscess

1 Dental Department, King Abdulaziz Medical City, Ministry of National Guard Hospital, Jeddah, KSA
2 Dental Department, King Abdulaziz University, University Dental Hospital, Jeddah, KSA

Date of Web Publication16-Aug-2019

Correspondence Address:
Dr. Shihanah Ali Faydhi
General Dentist, King Abdulaziz University, University Dental Hospital, P. O. Box: 80209, Jeddah 21589
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_117_18

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A case of 51-year-old female reported with pain of failed root canal treatment of the mandibular right second premolar. Periapical lesion, mobility, and deep periodontal pocket were detected during examination. Intentional replantation was discussed with the patient. The tooth was atraumatically extracted followed by root end resection and retrograde cavity preparation and filling with MTA. Curettage in conjunction with irrigation of the alveolus was considered to eliminate the inflammatory tissue. The tooth was replanted back into its socket and splinted to the adjacent tooth. The total extraoral treatment time was ≤15 min. One- and three-month follow-up revealed no clinical symptoms and progressive periapical healing. After 2 years and 7 months, complete periapical healing was evident. The success rate of intentional replantation is very promising when the procedural techniques are applied properly.

Keywords: Conservative treatment, intentional replantation, retrograde preparation, root end resection

How to cite this article:
Abduljabbar F, Faydhi SA. Intentional replantation of endodontically treated second premolar with chronic apical abscess. Saudi Endod J 2019;9:222-5

How to cite this URL:
Abduljabbar F, Faydhi SA. Intentional replantation of endodontically treated second premolar with chronic apical abscess. Saudi Endod J [serial online] 2019 [cited 2020 Apr 1];9:222-5. Available from: http://www.saudiendodj.com/text.asp?2019/9/3/222/264641

  Introduction Top

Intentional replantation has been proposed as an alternative to routine extraction; it is a conservative treatment modality that aims to preserve the natural tooth. Grossman,[1] described the technique of intentional replantation as the deliberate extraction of a tooth with minimal manipulations of the periodontal ligament, followed by extra-oral root canal treatment and placement of the tooth back into its original socket.[1],[2],[3]

Failure of root canal treatment leads to posttreatment disease. Persistence or development of peri-radicular disease eventually jeopardizes the success of the treatment. According to Lin,[4] the persistence of bacterial infection after root canal treatment and/or presence of preoperative peri-apical rarefaction are the major causes of root canal treatment failure. Secondary etiologic factors include the presence of a cystic lesion, an over- or under-extension of the root canal filling, and improper coronal seal (leakage).[5] Some complications during instrumentation or procedural errors might lead to perforations, ledges, or missed canals. Postendodontic treatment disease develops when the endodontic treatment falls short of the standard clinical principles.[6]

There are several indications for intentional replantation. First, it is an alternative treatment option when the conventional endodontic retreatment is not feasible. It is the last treatment option for cases that present with canal obstruction due to a cemented post, complicated perforation, or separated instrument.[7] Second, intentional replantation is indicated when the surgical approach to the apices is impossible, especially if the tooth is symptomatic. Surgical complications are most likely when there is proximity to a major anatomical structure such as the mental nerve, or in cases where extensive bone removal is required and injury to the surrounding anatomical structures is expected; for example, odontogenic maxillary sinusitis is associated with an infected tooth.[8] Limited mouth opening or truisms may decrease the essential visibility that a clinician needs to perform the surgery; furthermore, peri-radicular surgery confers a greater likelihood of trauma to the temporomandibular joint and patient discomfort. Intentional replantation might decrease the risk of all of these complications, and in some cases, could be the only suitable treatment option to save the tooth.[9]

On the contrary, in some cases, intentional replantation is contraindicated if atraumatic extraction cannot be performed. The clinical crown of the tooth should be of a sufficient length to provide the necessary space for a stable forceps grip. The morphologic variations of the posterior teeth should be examined properly. Severely curved or flared roots in multirooted teeth are difficult to extract. Intentional replantation is contraindicated for a periodontally compromised tooth. The presence of a deep pocket, furcation involvement, or marked mobility can lead to treatment failure. Although there is some controversy, Cho et al.[10] suggested that periodontal involvement should not be considered as an absolute contraindication, as the number of teeth involved and the patient's age are important factors in the success rate of intentional replantation. If the patient rejects the treatment or cannot attend the clinic for further follow-up, the case should be referred for regular tooth extraction.

  Case Report Top

A 51-year-old female reported of moderate pain at mandibular right second premolar (#45) and wanted to replace missing mandibular right first molar (#46). Clinical examination revealed a failed root canal attempt in tooth #45 with cemented post and final crown. The root canal treatment was done 5 years ago. The tooth was tender to percussion with grade 2 mobility and deep periodontal pocket (4 mm). Radiographic examination showed poor root canal filling and peri-apical radiolucency [Figure 1]a.
Figure 1: (a) Preoperative radiograph showed apical radiolucency of tooth #45. (b) Atraumatic simple extraction using lower premolar forceps. (c) Root end resection. (d) Retrograde preparation and filing. (e) Replantation into the socket. (f) Splinting of the tooth. (g) Postoperative radiograph. (h) Follow-up after 3 months. (i) Follow-up after 2 years and 7 months showing complete healing

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Conventional root canal retreatment was not possible because the canal was obstructed with the cemented post and crown, and it was difficult to negotiate the root canal. The patient's desire to save tooth #45 and to replace the adjacent missing tooth #46 with an implant required treating the peri-apical infection and facilitating sufficient bone healing to create a pre-formed healthy environment for implant placement. Hence, intentional replantation was planned. The patient agreed on the treatment after a brief discussion about all of the details, benefits, drawbacks, and the alternative treatment options. On the day of surgery, the patient was given a pre-operative anti-inflammatory drug (Brufen, tablet 600 mg, Saudi Arabia). Inferior alveolar nerve block and buccal infiltration anaesthesia was given. Delicate luxation and atraumatic extraction was performed using lower premolar forceps, the root was inspected, and no intraoperative complications occurred [Figure 1]b. During the extra-oral time, the tooth was covered with a sterile gauze, slightly saturated with a sterile saline solution, and held by hand on the crown to maintain the vitality of the PDL cells of the root. The total extra-oral treatment time was ≤15 min. Root end resection and retrograde cavity was prepared using a high-speed hand piece and was filled with ProRoot™ MTA (Dentsuply Maillefer, Ballaigues, Switzerland) [Figure 1]c and [Figure 1]d extra-orally. Curettage in conjunction with irrigation of the alveolus cavity was done to remove the inflammatory tissue. The tooth was replanted back into its socket [Figure 1]e and splinted to the adjacent tooth #44 [Figure 1]f using an orthodontics wire and composite. A postoperative radiograph was taken [Figure 1]g. Postoperative instructions were briefly described to the patient: have a soft diet and follow the oral hygiene instructions. Corsodyl 0.2%, antiseptic mouthwash (alcohol free) was prescribed (Omega Pharma Manufacturing GmbH and Co. KG, Herrenberg, Germany).

After 2 weeks, the splint was removed. The oral hygiene condition was good and the gingiva was healing. At the 1-month follow-up, the clinical symptoms had subsided completely with no evidence of radiographic changes. Three months later, the tooth was asymptomatic and peri-apical bone formation was noted radiographically with a noticeable decrease in the size of the peri-apical rarefaction [Figure 1]h. The mobility of the tooth decreased to grade 1 as well as the periodontal pocket (3 mm pocket). After 2 years and 7 months follow up, complete healing and bone formation was evident [Figure 1]i.

  Discussion Top

The intentional replantation procedure provides an alternative treatment pathway by which we can avoid the complications and prolonged treatment time of the nonsurgical retreatment. With good case selection, intentional replantation is easier than nonsurgical endodontic retreatment, making it an available option for a skilled general practitioner.[11] The concept of this conservative treatment aims to save the natural tooth, and subsequently, to avoid the sequelae of missing teeth. This procedure provides a final chance for a natural tooth to heal, and it preserves the tooth's functional and aesthetic properties.

The successful outcome of this treatment depends primarily upon the maintenance of aseptic conditions and limited extra-oral time, survival of periodontal ligament cells on the root surface, and gentle atraumatic extraction with minimal manipulation of the socket. The patient should avoid chewing on the tooth during the healing period to avoid any excessive mastication forces that might affect the healing process.[7] Splinting of the tooth for 2 weeks as indicated can enhance healing and support the tooth when mobility is present.[12] An oral hygiene checkup should be considered to prevent plaque accumulation. Certainly, patient cooperation and willingness for routine checkup appointments should be discussed before the treatment. Although the success rate of this treatment is high, it is crucial to follow the procedural instructions.

The ideal root-end filling material fulfills specific properties. It should have a good sealing ability, biocompatibility, antibacterial activity, and cementogenesis. Although the ideal material has yet to be found, MTA has been accepted as one of the most suitable materials used in apicoectomy procedures.[13] MTA showed a long-lasting sealing ability, minimal leakage, compared to other root-end filling materials.[14] However, MTA is a technique-sensitive material that requires proper handling and manipulation. Studies have shown that the healing process following peri-radicular surgery is initiated by mesenchymal cells that differentiate into mature cells such as osteoblasts, fibroblasts, or cementoblasts, which in turn induce osseous regeneration and apical healing.[13]

Intentional replantation was recommended based on the diagnostic findings, the patient's refusal for the surgical peri-apical treatment, and the patient's desire to save the tooth. Certainly, the risks of intentional replantation were conveyed to the patient. Gentle atraumatic extraction was done successfully. According to Hammarström et al.,[15] when the teeth of an experimental group were treated with a completely dry extra-oral time of 15 min, initial ankylosis did not happen; therefore, a fair prognosis was expected. By considering intentional replantation as the treatment of choice, we could avoid the complications, expense, and longer treatment time associated with nonsurgical endodontic retreatment. In this case, the patient was satisfied with the successful treatment outcome and the infection-free, complete healing of the periapical area, which allows for placement of a dental implant to replace the adjacent missing tooth #46. Fortunately, at the time of writing, the treated tooth #45 is still retained and is functioning normally.[16]

The procedure of intentional replantation involves critical surgical steps that must be handled with precision to achieve a favourable outcome. Case selection and the anatomical structure of the tooth should be examined carefully to prevent tooth fracture. It is ideal to have single, straight-rooted teeth as central incisors and premolars. Extraction should be performed using the appropriate forceps. The use of surgical elevators is contraindicated. The tips of the forceps should not exceed the cemento-enamel junction to avoid any unnecessary trauma to the periodontal ligament. Maintenance of the periodontal ligament lining the socket is important for the healing process. Some studies considered the vitality of PDL is crucial the healing and prevention of ankylosis and root resorption complications.[17]

Studies recommend minimal manipulation of the walls of the socket during extraction or debridement. Some authors reject the use of curettage. Others advocate for curettage of the most apical portion without touching the walls.[18],[19] Several case reports suggests that intentional replantation is a reliable procedure and the retention rate of the teeth after replantation is high even after more than 10 years follow up.[20] Intentional replantation is a conservative treatment that should be considered before tooth extraction in order to maintain the natural dentition.[7]

  Conclusion Top

The intentional replantation procedure was chosen to preserve the natural dentition, thereby upholding the main goal of any conservative treatment. It is an easy and fast treatment option than nonsurgical retreatment or surgical apicoectomy. The outcome result depends on how the case was managed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966;72:1111-8.  Back to cited text no. 1
Cotter MR, Panzarino J. Intentional replantation: A case report. J Endod 2006;32:579-82.  Back to cited text no. 2
Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional replantation: A procedure as a last resort. J Contemp Dent Pract 2011;12:486-92.  Back to cited text no. 3
Lin LM, Skribner JE, Gaengler P. Factors associated with endodontic treatment failures. J Endod 1992;18:625-7.  Back to cited text no. 4
Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent 2016;10:144-7.  Back to cited text no. 5
[PUBMED]  [Full text]  
Pecora CN, Baskaradoss JK, Al-Sharif A, Al-Rejaie M, Mokhlis H, Al-Fouzan K, et al. Histological evaluation of the root apices of failed endodontic cases. Saudi Endod J 2015;5:120-4.  Back to cited text no. 6
  [Full text]  
Peer M. Intentional replantation – A 'last resort' treatment or a conventional treatment procedure? Nine case reports. Dent Traumatol 2004;20:48-55.  Back to cited text no. 7
Peñarrocha M, García B, Martí E, Palop M, von Arx T. Intentional replantation for the management of maxillary sinusitis. Int Endod J 2007;40:891-9.  Back to cited text no. 8
Kumar V, Logani A, Shah N. Intentional replantation: A viable alternative for management of palatogingival groove. Saudi Endod J 2013;3:90-4.  Back to cited text no. 9
  [Full text]  
Cho SY, Lee SJ, Kim E. Clinical outcomes after intentional replantation of periodontally involved teeth. J Endod 2017;43:550-5.  Back to cited text no. 10
Asgary S, Alim Marvasti L, Kolahdouzan A. Indications and case series of intentional replantation of teeth. Iran Endod J 2014;9:71-8.  Back to cited text no. 11
Becker BD. Intentional replantation techniques: A critical review. J Endod 2018;44:14-21.  Back to cited text no. 12
Bodrumlu E. Biocompatibility of retrograde root filling materials: A review. Aust Endod J 2008;34:30-5.  Back to cited text no. 13
Wu MK, Kontakiotis EG, Wesselink PR. Long-term seal provided by some root-end filling materials. J Endod 1998;24:557-60.  Back to cited text no. 14
Hammarström L, Blomlöf L, Lindskog S. Dynamics of dentoalveolar ankylosis and associated root resorption. Endod Dent Traumatol 1989;5:163-75.  Back to cited text no. 15
Gurpreet S, Bahuguna N, Mahajan P. Intentional reimplantation – Two case reports. Endod 2011;23:59-65.  Back to cited text no. 16
Loe H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys. Arch Oral Biol 1961;3:176-84.  Back to cited text no. 17
Kingsbury BC Jr., Wiesenbaugh JM Jr. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc 1971;83:1053-7.  Back to cited text no. 18
Guy SC, Goerig AC. Intentional replantation: Technique and rationale. Quintessence Int 1984;15:595-603.  Back to cited text no. 19
Cho SY, Lee Y, Shin SJ, Kim E, Jung IY, Friedman S, et al. Retention and healing outcomes after intentional replantation. J Endod 2016;42:909-15.  Back to cited text no. 20


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