CASE REPORT/CLINICAL TECHNIQUES

Intentional Replantation with an Ralf Krug, DMD,

Sebastian Soliman, DMD, and

Atraumatic Extraction System Gabriel Krastl, DMD

in Teeth with Extensive Cervical

Resorption

ABSTRACT
SIGNIFICANCE
External cervical resorption (ECR) often renders a tooth nonrestorable, especially if it extends
deeply within the dental hard tissue. Intentional replantation is sometimes performed as the Intentional replantation with
last resort to save the tooth but may limit conventional forceps extraction because of the high axial atraumatic tooth
risk of periodontal ligament cell damage or crown fracture.This case report describes the extraction improves the
intentional replantation of an upper central incisor with extensive ECR using an axial, chances of saving otherwise
atraumatic extraction system to save the otherwise hopeless tooth. The patient was an hopeless teeth with extensive
asymptomatic 37-year-old man with no contributing medical history. The treatment protocol external cervical resorption and
included atraumatic extraction followed by granulation tissue removal, extraoral root canal substantial dental hard tissue
treatment, and adhesive restoration of the extensive resorption defect. During extraoral loss.
manipulation, the utmost care was taken to prevent root surface drying, contamination with
dental adhesive, or heat-induced periodontal ligament damage during curing. Two and a half
years after replantation, clinical and radiographic examinations revealed normal healing and no
symptoms but a slight reduction of bone level compared with the preoperative level and no
signs of root resorption or ankylosis. The successful outcome in this case supports the idea of
performing intentional replantation with an atraumatic extraction system to save teeth with
extensive cervical root resorption and a high risk of fracture during extraction. (J Endod
2019;-:1–6.)

KEY WORDS
Ankylosis; atraumatic extraction; external cervical resorption; intentional replantation;
periodontal healing

External cervical resorption (ECR) is a resorptive process that enters the dental hard tissue from a cervical
entry point and extends to the pulp chamber. It usually progresses in the coronal-apical direction,
encircling the root canal. Studies indicate that the presence of a protective layer known as the pericanalar
resorption-resistant sheet and high proportions of predentin and dentin may limit the extent of root From the Department of Conservative
resorption1,2. However, the removal of granulomatous tissue frequently results in pulp exposure followed Dentistry and Periodontology and Center
by the need for root canal treatment. The etiology of ECR is still not fully understood, but several potential of Dental Traumatology, University
Hospital of Wu€rzburg, Wu
€rzburg,
etiologic factors and predisposing factors have been described, including orthodontic treatment, dental
Germany
trauma, intracoronal bleaching, surgery in the cementoenamel junction (CEJ) area, periodontal therapy
Address requests for reprints to Dr Ralf
(eg, deep root scaling and planing), and idiopathic factors3–6. As explained in the European Society of
Krug, Department of Conservative
Endodontology position statement, the Heithersay classification of ECR is based on 2-dimensional Dentistry and Periodontology and Center
imaging, resulting in underestimation and/or inadequate appreciation of the true extent of the resorptive of Dental Traumatology, University
process7. Heithersay classifies ECR into 4 types wherein class 3 and 4 resorptions are the types with the Hospital of Wu€rzburg, Pleicherwall 2,
97070 Wu €rzburg, Germany.
most extensive dental hard tissue loss3. Patel’s new 3-dimensional classification, based on periapical
E-mail address: krug_r@ukw.de
radiographs and cone-beam computed tomographic imaging8, aims to facilitate decision making, 0099-2399/$ - see front matter
treatment planning, and prognosis9. It considers simultaneously the height of the lesion, its
Copyright © 2019 American Association
circumferential spread, and its proximity to the root canal8,9. In the present case, the lesion was graded as
of Endodontists.
size 2Bp because it extended into the subcrestal, coronal third of the root; had a circumferential spread https://doi.org/10.1016/
exceeding 90 ; and was likely to have pulpal involvement. j.joen.2019.07.012

JOE  Volume -, Number -, - 2019 Intentional Replantation in Teeth with ECR 1

FIGURE 1 – Radiography and diagnostic imaging: (A ) periapical radiography and (B ) transversal, (C ) axial, and (D ) animated 3-dimensional cone-beam computed tomographic
imaging focused on evaluating the extent of ECR in tooth 11. The clinical appearance of the (E ) labial and (F ) palatal aspect of the tooth with the anchor screw of the AES inserted in the
root canal.

The following approaches to ECR 3. The external approach is performed with required to restore a proper gingival
management have been reported in the adjunctive orthodontic extrusion of the root contour19.
literature: followed by prosthetic treatment/artificial Intentional replantation is the last option
crown placement17. to conserve hopeless teeth; it involves
1. The surgical approach: flap surgery is
4. Intentional replantation: appropriate extraoral restoration of the resorptive lesion
performed with or without surgical crown
techniques are used to extract the tooth as followed by tooth replacement. The most
lengthening as needed to improve
atraumatically as possible and to minimize beneficial aspect of the procedure is the
restorability, and the resorptive lesion is
the extra-alveolar time18. possibility to inspect the lesion and place a
restored with a regular filling or, if close to
regular filling under direct vision. This minimizes
bone level, with mineral trioxide aggregate
Understandably, the more preferred the risk of filling material extruding into the
(MTA)10–12. Removing a significant amount
approaches for more extensive ECR (eg, surrounding tissues. However, a possible
of bone jeopardizes the periodontal
class 3 and 4) are treatment options 3 and 4. drawback is that intentional replantation may
prognosis, especially in class 4 cases13.
Orthodontic extrusion after the external result in root resorption. The chances of
Moreover, excessive bone removal may
approach is aimed to transpose the lesion to periodontal healing after intentional
result in an unfavorable gingival architecture
a more coronal position to enable adequate replantation depend on 2 main factors: the
and poor esthetics in the anterior region14.
restorative treatment. Long treatment degree of mechanical damage to the PDL
2. The nonsurgical internal approach:
duration and high costs are the main during extraction and the duration of extra-
trichloroacetic acid is used to remove the
limitations of this procedure. Because of alveolar manipulation. Furthermore, teeth with
resorptive lesion, and hydraulic calcium
coronal movement of the gingiva and the extensive resorption have a high risk of fracture
silicate cement is used to obturate the
supporting bone, periodontal surgery is often during extraction. Thus, an atraumatic
canal15,16.

2 Krug et al. JOE  Volume -, Number -, - 2019

FIGURE 2 – Intentional replantation started with (A ) vertical extraction of the tooth using an AES and (B ) extraoral inspection of the resorptive cavity without touching the root surface.
(C ) A view of the alveolar socket filled with blood, (D ) extraoral root canal shaping, and (E ) filling. (F ) The extracted tooth was stored in a cell culture medium (Dentosafe) during (G )
radiographic assessment of the technical quality of the root canal filling.
extraction system (AES), which is anchored in
the root dentin and solely generates axial
forces, appears to address both issues.
The Benex Extraction System (Helmut
Zepf Medizintechnik GmbH, Seitingen-
Oberflacht, Germany) was designed to reduce
trauma to the alveolar socket during tooth
extraction in order to facilitate subsequent
tooth reimplantation of the tooth20,21. The first
clinical report describing the use of this system
for atraumatic surgical extrusion pointed out
that it is less invasive and supposedly
associated with fewer iatrogenic complications
than previous extrusion procedures22. A more
recent article describes in detail the clinical
procedure for surgical extrusion, which the
authors characterize as a recognized option for
the restoration of teeth with insufficient coronal
tooth structure21. Another study in animals
revealed that teeth extruded using a special
extrusion instrument that works similar to the
Benex system showed significantly less
extensive cementoblast loss than teeth
removed by conventional forceps extraction23.
This leads to the assumption that atraumatic
extraction may decrease cementum damage
and increase the likelihood of periodontal
healing compared with conventional extraction
methods.
JOE  Volume -, Number -, - 2019
Based on these favorable findings, we
predict that the use of atraumatic extraction will
improve the outcome of intentional
replantation in ECR teeth with substantial hard
tissue loss. Here, we present the first report of
intentional replantation with atraumatic
extraction to save a tooth with extensive ECR
using a specially designed AES.
CASE REPORT
A 37-year-old man was referred to us
(Department of Conservative Dentistry and
Periodontology and Center of Dental
Traumatology, University Hospital of
Wu€rzburg, Wu €rzburg, Germany) for evaluation
of the right maxillary central incisor. The
patient’s medical history was unremarkable.
Tooth 11 had no caries or fillings, and the
patient was completely asymptomatic.
Orthodontic treatment of the natural dentition
had been performed more than 20 years
previously. The referring dentist reported tissue
formation in the palatal CEJ area. A periapical
radiograph revealed a coronal radiolucency
consistent with extensive ECR (Fig. 1A). CBCT
imaging with a limited field of view displayed
extensive hard tissue loss (Fig. 1B–D).
Clinically, there was no pain on palpation or
percussion, and the gingival surfaces
appeared nonirritated. The pulp vitality test
was positive, and a resorption lacuna was
detected on the palatal aspect of the tooth on
probing.
The patient was advised of his treatment
options, including external approaches (ie, 1
and 3) intentional replantation (ie, 4), and tooth
extraction. After being informed of the risks
and benefits of each option, the patient chose
intentional extraction followed by replantation.
Intentional replantation was performed
by an experienced operator (G.K.) and 2
assistants (R.K. and K.R.) (Supplemental Video
S1 is available online at www.jendodon.com).
After local anesthesia, trepanation was
performed to access the root canal system.
The root canal was enlarged with Gates-
Glidden drills. A diamond bur was used to
prepare an access cavity for insertion of a self-
tapping anchor screw (diameter 5 1.8 mm)
into the coronal part of the root (Fig. 1E and F).
The AES (Benex) was assembled and placed
on the adjacent teeth. A sectional impression
tray with silicon impression material helped to
achieve proper placement. Next, a pull string
was attached to the anchor screw (Fig. 2A),
and the tooth was extruded by gradually
increasing the traction force by turning the
Intentional Replantation in Teeth with ECR 3
FIGURE 3 – (A ) Preparation of the resorptive lesion using a rotary diamond bur, (B ) selective enamel etching, (C ) priming and bonding of dental hard tissue, and (D ) luting. (E ) High-
translucency composite was placed in layer depths of up to 4 mm while constantly remoistening the root surface with Dentosafe medium. (F ) The appearance of the final restoration
before replantation.
knob at the end of the extractor clockwise. If
severe resistance was encountered, a
constant force was applied for 30–40 seconds
before further increasing traction. The tooth
was temporarily stored in a commercial tooth
storage product containing a special cell
culture medium (Dentosafe; Medice GmbH &
Co KG, Iserlohn, Germany) after successful
extraction and between extraoral steps. In
addition, the root surface was constantly
remoistened with the cell culture medium
during pulp tissue removal, resorptive lesion
cleaning, root canal shaping and filling, and the
placement of regular composite filling. The
tooth crown was secured extraorally using
forceps (Fig. 2B–G). The root canal was
shaped using rotary nickel-titanium files (Mtwo;
VDW GmbH, Munich, Germany) of up to ISO
60 in size. Obturation was achieved by a warm
vertical condensation technique with gutta-
percha and sealer (AH Plus, Dentsply Sirona
GmbH, Bensheim, Germany). The root-filled
tooth was even kept in the cell culture medium
during extraoral radiographic checks for
adequate root canal obturation. Margins and
cavities of the lesion were prepared using a
4 Krug et al.
diamond bur. Selective enamel etching and
priming and bonding of the dental hard tissue
were performed. The utmost care was taken
during each step of extraoral manipulation, in
particular, to avoid contamination of the
periodontal ligament with adhesive and to
prevent heat-induced damage during curing.
A high-translucency composite resin
(SDR, Dentsply Sirona GmbH) was placed in
layer depths of up to 4 mm (Fig. 3A–F). The
socket was left untouched during extraoral
manipulation. After an estimated extraoral
working time of 12 minutes, the blood clot in
the alveolar socket was removed, and the
tooth was gently replanted into its original
position. Finally, the tooth was splinted with
bonded composite resin to the adjacent teeth
for 2 weeks (Fig. 4A–C).
At the 2-week follow-up, the patient was
free of symptoms, and the replanted tooth had
class II mobility. At the second follow-up (6
months), the patient was completely symptom
free. The tooth showed normal mobility,
periodontal probing depths were less than 3
mm in general and 5 mm beside the palatal
restored section, and there was no metallic
percussion sound. At the 2.5-year follow-up,
clinical and radiographic examinations revealed
normal healing, no symptoms, minor reduction
of bone level compared with the preoperative
status, and no root resorption or ankylosis
(Fig. 4D–F). Mobility and periodontal probing
depth remained unchanged. Compared with
the adjacent teeth, percussion sounds were
normal, and there was no metallic percussion
sound indicative of ankylosis.
DISCUSSION
This case report describes the 2.5-year
outcome of intentional replantation to save a
maxillary central incisor with ECR using an
AES. The tooth showed periodontal healing in
the absence of ankylosis, as evidenced
clinically by normal percussion sounds and
radiographically by a uniform periodontal
space. The observation period appears to be
long enough to indicate a favorable long-term
prognosis. Although infection-related root
resorption is usually radiographically assessed
within the first weeks after tooth replantation24,
radiologic detection of replacement resorption
JOE  Volume -, Number -, - 2019
FIGURE 4 – (A ) Rapid reinsertion of the restored tooth into the socket with (B and D ) clinically nonirritated gingiva. (C ) A 2-week follow-up radiograph showing adequate tooth
position, with the tooth adhesively splinted to the adjacent teeth. At the 2.5-year follow-up, (D and E ) the tooth was clinically stable and (F ) showed no radiologic signs of root
resorption.
usually requires 1 year25. Clinical signs of
ankylosis (eg, the absence of tooth mobility
and a high metallic percussion sound) usually
precede the radiographic diagnosis and are
generally detected within 4–8 weeks after
replantation25. Most complications occur
within 1 year after replantation, but late healing
complications may develop later and cannot
be excluded26.
If treated in the early stages, ECR teeth
have a good prognosis, but severe cases are
considered high risk27. Various treatment
options (ie, 1–4) are used to manage lesions
with substantial dental hard tissue loss near
the CEJ area. Intentional replantation is 1 of the
last treatment options to conserve teeth
compromised by ECR, which is frequently
reported in association with endodontic
failure28. The mean survival of intentionally
replanted and root canal–treated teeth was
estimated to be as high as 88% and the mean
prevalence of root resorption 11%29. There is
a lack of evidence regarding the outcome of
intentionally replanted teeth with ECR.
One group recently reported successful
periodontal healing of an intentionally replanted
lower canine with ECR over an 18-month follow-
up period30. The resorptive lesion was extraorally
filled with glass ionomer cement, and root canal
treatment was intraorally performed after
replantation, providing the benefit of minimal
JOE  Volume -, Number -, - 2019
extra-alveolar time. Nevertheless, we decided to
follow a single-visit approach combining
extraoral endodontic treatment and adhesive
placement of a regular composite filling.
Tooth replantation within 15 minutes has
been identified as a predictor of complication-free
healing26. A detailed protocol for intentional
replantation in cases with previous failed
endodontic (re)treatment was recently
published31. In the present case, the total time
required for extraoral root canal shaping, cleaning,
and filling as well as for final adhesive luting of the
composite may have approached this critical 15-
minute limit. However, every effort was made to
ensure a high cementoblast survival rate.
Measures included a 3-person team approach
with 1 operator and 2 assistants, constant
remoistening of the root surface with cell culture
medium between each step of the extraoral
workflow (Fig. 3E), keeping the tooth completely
submerged in cell culture medium during extraoral
radiographic imaging (Fig. 2F), and rapid
replantation of the tooth into the socket (Fig. 4A).
The management of teeth with severe ECRs is
always challenging, even if cone-beam computed
tomographic imaging and dental microscopy are
used, as described in this case report15.
To minimize the risk of biological
complications after tooth extraction, we used
an AES to avoid the application of
compression force onto the periodontal tissue.
The authors of an animal study observed that
sites subjected to more compression during
conventional forceps extraction compared
with atraumatic extraction showed more
extensive cementoblast loss and concluded
that root resorption might be more likely to
develop in those locations23. So far, it seems
that teeth with circular root cross sections, like
the upper central incisor treated in the present
case, may have a low risk of resorption
because they undergo less compression
against the alveolar socket when manipulated
using rotational movements. However, the root
anatomy is rarely perfectly round, even if it may
look so macroscopically. Characteristically, a
distal curved root tip often exists. Thus,
cementoblast damage must be prevented
during the extraction of all tooth types.
A proof-of-principle clinical study
revealed that minimally invasive tooth
extraction can be achieved by using an AES.
Extraction failures because of insufficient
screw retention or alignment, root fracture, or
unfavorable root morphology lead to
complications in 11% of single-rooted teeth20.
A clinical study revealed that the technical
complication rate in teeth surgically extruded
with an AES was 9.7%32. This case report
shows a successful outcome of intentional
replantation with atraumatic tooth extraction
without complications such as root fracture or
Intentional Replantation in Teeth with ECR 5
retention loss. Adverse events during AES with extensive cervical root resorption The authors deny any conflicts of
usage could be avoided by operator’s and a high risk of fracture during interest related to this study.
experience, cautious handling, and timing. extraction.

ACKNOWLEDGMENTS SUPPLEMENTARY MATERIAL

CONCLUSION
The successful outcome in this case
supports the idea of performing intentional
replantation with an AES to save teeth
The authors thank Kerstin Rosenberger for her Supplementary material associated with this
brilliant assistance in our elaborate 3-person article can be found in the online version at
team approach performing intentional www.jendodon.com (https://doi.org/10.1016/
replantation. j.joen.2019.07.012).

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