Intentional replantation of a mandibular molar: case report and 14-year follow-up

Henry Herrera, DDS, MSc, PhD,a Mário Roberto Leonardo, DDS, MSc, PhD,b Helen Herrera, DDS, MSc, PhD,a Lucas Miralda, DDS, MSc, PhD,a and Raquel Assed Bezerra da Silva, DDS, MSc,c El Salvador and São Paulo, Brazil
EVANGELIC UNIVERSITY OF EL SALVADOR AND UNIVERSITY OF SÃO PAULO

This case report describes the nonsurgical endodontic treatment and intentional replantation of a mandibular molar and its nearly 14-year follow-up. A 56-year-old woman sought treatment with complaint of discomfort and sensitivity in the mandibular left area. The radiographic examination showed that the mandibular left first molar was endodontically treated, with over-instrumentation of the distal root and unsatisfactory obturation on the mesial root. A large periapical lesion was observed surrounding the roots. In view of the patient’s limited interocclusal space and objection to undergo an apical surgery, intentional replantation was suggested as an alternative. The patient returned for clinical and radiographic follow-up at 15 days, 40 days, 6 months, 12 months, and once yearly thereafter. At the last visit, after 14 years, no painful symptomatology was reported, probing depth was no greater than 3 mm, the periradicular area had normal appearance and no evidence of root resorption or periapical lesion. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e85-e87)

Conventional endodontic treatment may fail eventually although it usually has high success rates.1-4 In case of failure, alternative treatments, such as intentional tooth replantation, may be considered. Intentional replantation (IR) is a concept that has been known for over a thousand years5 and consists of a technique in which a tooth is intentionally extracted and reinserted into its socket immediately after endodontic treatment and apical repair outside the oral cavity.6,7 IR is indicated for teeth with anatomic limitations, accessibility problems, or persistent chronic pain and for patients who have cooperation problems or refuse to undergo periapical surgery. Many authors8-11 agree that this technique should be reserved as a “last resort” after other procedures have failed or when endodontic periradicular surgery is not an option.12 Contraindications include teeth with curved or flared roots, preexistent moderate to severe periodontal disease, or vertical fractures.12 The success of this therapy relies primarily on the maintenance of aseptic conditions during the intervena

tion, which is attained with a series of measures including use of chlorhexidine mouthwash, disinfection of the operative field, immersion of the tooth in sterile saline, and irradiation of the alveolus by laser.13 Retention rate of intentionally replanted teeth is reported to range from 52% to 95%.6,14-16 Although IR is a relatively simple, inexpensive, and less time-consuming procedure, it may be associated to root resorption, specifically replacement resorption (ankylosis), which reduces the survival rate of the replanted teeth.12,16 However, this is directly related to the amount of time the tooth is out of the mouth during the procedure.5,16,17 This case report describes the nonsurgical endodontic treatment and intentional replantation of a mandibular molar and its nearly 14 years of follow-up. CASE REPORT
A 56-year-old woman sought treatment with complaint of discomfort and sensitivity in the mandibular left area. After her medical history was reviewed, a radiograph of the area was taken, which showed that the mandibular left first molar was endodontically treated, with over-instrumentation of the distal root and unsatisfactory obturation on the mesial root. A large periapical lesion was observed surrounding both roots (Fig. 1). Root canal therapy had been completed several years before and the tooth received a full metal crown. Upon clinical examination, periodontal probing depths did not exceed 3 mm but the tooth was tender to percussion and palpation. The patient had little interocclusal space because of limited mouth opening. In view of this limitation and the patient’s refusal to undergo a more invasive apical surgery, the intentional replantation technique was indicated as an

Professor of the Evangelic University of El Salvador, El Salvador. Chairman, Department of Pediatric Clinics, Preventive and Social Dentistry, Faculty of Dentistry of Ribeirão Preto, University of São Paulo, Brazil. c Doctor Postgraduate Student, Department of Pediatric Clinics, Preventive and Social Dentistry, Faculty of Dentistry of Ribeirão Preto, University of São Paulo, Brazil. Received for publication Feb 2, 2006; accepted for publication Feb 3, 2006. 1079-2104/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.02.008
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Fig. 1. Periapical radiograph showing the mandibular left first molar with unsatisfactory endodontic therapy. Note the over-instrumentation and the large apical periodontitis.

Fig. 2. Radiograph exposed immediately after extraction of the mandibular left first molar for endodontic treatment.

alternative. A written informed consent was obtained and the patient was scheduled for treatment. At the patient’s return, antisepsis was carried out with 0.12% chlorhexidine gluconate, a mandibular block local anesthetic was administered, and the tooth was carefully extracted with forceps with no intraoperative complications (Fig. 2). The tooth was held in a sterile gauze sponge and the apices were beveled with a bur. With the tooth out of socket, access preparation was done through the crown, the old root filling removed, and the root canals were biomechanically prepared and obturated. Root end cavities were prepared with an inverted cone bur and filled with spherical amalgam. The tooth was rinsed in sterile saline and replanted into its socket 30 minutes after extraction (Fig. 3). A soft periodontal packing was placed as a functional splint. The occlusion was adjusted and postoperative instructions were given. The patient returned for clinical and radiographic follow-up at 15 days (at which time the splint was removed), 40 days, 6 months, 12 months, and once yearly thereafter. The postoperative period was uneventful. Root surface and periodontal ligament appeared intact and the replanted tooth was asymptomatic. Five years after treatment, there were no areas of periradicular bone resorption and the periapical lesion was completely healed (Fig. 4). At the last follow-up, after 14 years, the patient reported no painful symptomatology, probing depth was no greater than 3 mm, and percussion was negative. Radiographically, the periradicular area had normal appearance and no evidence of root resorption or periapical lesion was observed (Fig. 5).

Fig. 3. Mandibular first left molar immediately after intentional replantation.

DISCUSSION Intentional replantation has some advantages over apical surgery, which include being an easier, less-invasive, less time-consuming, and less-costly procedure. In addition, root canal therapy is better performed extraorally.12,18 On the other hand, the greatest disadvantage of intentional replantation, which leads most dentists to consider this technique as a last resort to save a tooth, is that replacement resorption or ankylosis may occur. How-

ever, recent long-term studies4,6,12,18,19 have shown that the success rates for intentional replantation are similar to those for apical surgery. In the case reported in this article, after 14 years of follow-up there was no evidence of ankylosis, the replanted tooth displayed normal-appearing periodontal ligament around the roots, and the patient did not have any painful complaint. The indications for intentional replantation include failure of root canal treatments, anatomic limitations, perforations in areas inaccessible to surgery, persistent chronic pain, or patient management.12,20 In the case we described, the patient came to the clinic presenting an unsatisfactory endodontic treatment, chronic pain, and sensitivity to percussion and palpation. Intentional replantation was chosen as the treatment option on the basis of the clinical indication and the patient’s refusal to undergo a periapical surgery. The long-term follow-up confirmed the successful management of the case. Splinting is necessary after replantation to reduce mobility of the tooth and aid the initial periodontal healing. However, replanted teeth should be splinted

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dentition, in situations where other procedures would likely fail.
REFERENCES
1. Kirkevang LL, Orstavik D, Hörsted-Bindslev P, Wenzel A. Periapical status and quality of root fillings and coronal restorations in a Danish population. Int Endod J 2000;33:509-15. 2. Marques MD, Moreira B, Eriksen HM. Prevalence of apical periodontitis and results of endodontic treatment in an adult Portuguese population. Int Endod J 1998;31:161-5. 3. Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. Int Endod J 1996;29:150-5. 4. Shintani S, Tsuji M, Toyosawa S, Ooshima T. Intentional replantation of an immature permanent lower incisor because of a refratory periapical lesion: case report and 5-year follow-up. Int J Ped Dent 2004;14:218-22. 5. Weinberger B. Introduction to the history of dentistry. St. Louis: CV Mosby, 1948. p. 105. 6. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol 1993;76:623-30. 7. Grossman L. Endodontic practice. 11th ed. Philadelphia: Lea & Febiger, 1988. p. 334 – 42. 8. Cohen S, Burns R. Pathways of the pulp. 4th ed. St. Louis: CV Mosby, 1987. p. 607– 8. 9. Deeb E, Prietto P, McKensa R. Replantation of luxated teeth in humans. J South Calif Dent Assoc 1965;33:194-206. 10. Grossman L, Ship I. Survival rate of replanted teeth. Oral Surg 1970;29:899-906. 11. Weine F. The case against intentional replantation. J Am Dent Assoc 1980;100:664-8. 12. Peer M. Intentional replantation—a “last resort” treatment or a conventional treatment procedure? Nine case reports. Dent Traumatol 2004;20:48-55. 13. Nuzzolese E, Cirulli N, Lepore MM, D’Amore A. Intentional replantation: a case report. J Cont Dent Proct 2004;5:121-30. 14. Andreasen JO, Borum MK, Jacobsen HL, Adreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11: 76-83. 15. Madison S. Intentional replantation. Oral Surg Oral Med Oral Pathol. 1986;62:707-9. 16. Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg 1991;71:743-7. 17. Andreasen JO, Hjorting H. Replantation of teeth. Part II. Histological study of 22 replanted anterior teeth in humans. Acta Odont Scand 1966;24:287-306. 18. Kratchman S. Intentional replantation. Dent Clin North Am 1997;41:603-17. 19. Benenati FW. Intentional replantation of a mandibular second molar with long-term follow-up: report of a case. Dent Traumatol 2003;19:233-6. 20. Dumsha TC, Gutman JC. Clinical guidelines for intentional replantation. Compend Contin Educ Dent 1985;6:604-8. Reprint requests: Mário Roberto Leonardo, DDS, MSc, PhD Departamento de Clínica Infantil Odontologia Preventiva e Social Faculdade de Odontologia de Ribeirão Preto USP, Avenida do Café, S/N 14040-904 Ribeirão Preto, SP, Brasil raquel@forp.usp.br

Fig. 4. Five-year radiographic follow-up.

Fig. 5. Replanted tooth 14 years after intentional replantation. The tooth exhibits normal periradicular appearance, absence of root resorption, intact root surface, and normal periodontal ligament.

only for a short period (1 to 2 weeks).4,12 In this case, a semi-rigid splint was used because a certain amount of mobility should be allowed for periodontal healing. Splinting was removed 2 weeks after replantation. In conclusion, with proper case selection, intentional replantation can provide long-term results as good as those of apical surgery and should be more often considered as a viable treatment option to preserve the natural

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