Review Article
Intentional Replantation Techniques:
A Critical Review
Bradley D. Becker, DDS
Abstract
Introduction: Techniques and armamentarium for
intentional replantation have varied throughout the
years with no universally accepted clinical treatment
guidelines. A wide range of success rates has been re-
ported, and accordingly, this treatment method has
often been regarded as a treatment of last resort. How-
ever, recent studies have shown more consistent suc-
cess rates as high as 88% to 95%. In light of these
new studies, intentional replantation may now be
considered a more commonly accepted treatment mo-
dality. The purpose of this review was to critically
examine reported techniques for intentional replanta-
tion. Methods: A search of the literature on intentional
replantation techniques was performed using electronic
databases including PubMed, Medline, and Scopus. A
total of 3183 articles were generated and screened for
relevance based on defined inclusion and exclusion
criteria. Subsequently, 27 studies were included for crit-
ical review of technique. Results: There has been an
evolution in technique for intentional replantation over
the decades. Conclusions: Numerous aspects of the
procedure exhibit variations, whereas other aspects
exhibit considerable consistency. Few studies reported
techniques consistent with modern endodontic surgical
principles. (J Endod 2018;44:14–21)
Key Words
Intentional, reimplant, replant, replantation, review,
techniques
From the Division of Endodontics, Department of Oral Rehabilitation, Medical University of South Carolina, Charleston, South Carolina.
Address requests for reprints to Dr Bradley D. Becker, Medical University of South Carolina, Department of Oral Rehabilitation, Division of Endodontics, 29 Bee Street,
Charleston, SC 29425. E-mail address: bbeckerdds@gmail.com
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.08.002
14 Becker
P ost-treatment endodon-
tic disease, defined as
the persistence or develop-
Significance
Intentional replantation is a clinical technique used
by endodontists routinely throughout the world to
ment of an inflammatory
treat disease of endodontic origin. This article pro-
periapical or periradicular
vides a critical review of the reported and sug-
lesion in a previously
gested techniques, highlighting differences and
root-filled tooth, is a signif-
consistencies.
icant issue for oral health
care providers, especially
for endodontic specialists. The prevalence, according to cross-sectional epidemiological
studies, ranges from 16% to 65%, depending on the study population (1). The primary
cause has been attributed to the presence of microorganisms in the root canal system and/
or the periapical tissue, although additional etiologies, including the presence of cysts,
cholesterol crystals, and foreign bodies, have also been implicated (2). Several treatment
options with varying levels of success have been suggested, including nonsurgical end-
odontic retreatment and apical surgery (3). Because of improved operational efficiency,
difficulty with surgical access, and the desire to avoid delicate anatomic structures, inten-
tional replantation has been proposed as an additional method to resolve post-treatment
endodontic disease in select cases.
Intentional replantation has been defined as the deliberate extraction of a tooth
and after evaluation of root surfaces, endodontic manipulation, and repair, placement
of the tooth back in into its original socket (4). It is one of the oldest known methods for
the treatment of disease of endodontic origin, dating as far back as the 11th century
when Albulcasis described a replantation (5). In addition, from the 16th to 18th cen-
turies, multiple accounts of replantation were reported, including incorporation of a
root resection and root-end filling before reinsertion of the tooth (6). The evolution
of the procedure in more recent times has involved modification of techniques sur-
rounding tooth extraction, root-end resection and preparation, handling of the tooth
during surgical manipulation, and materials used for root-end filling.
The procedure now involves multiple surgical steps that must be executed with
precision for the best outcome. First, the selected tooth is carefully extracted so as
not to induce fracture, thereby rendering the tooth nonrestorable, and also to minimize
damage to the periodontal ligament (PDL). Survival of PDL cells has been noted to be a
critical factor influencing successful healing (7). Several authors have recommended
avoiding the use of dental elevators and limiting the application of dental forceps to
the crown of the tooth as a means to minimize trauma to the PDL cells (8–11).
This step has been considered by some as the most technique-sensitive portion of
the procedure (11).
After extraction of the tooth, the roots are examined for fractures, additional canals
or portals of exit, isthmi, and any additional anatomic features requiring attention (12).
Root inspection is best accomplished with the aid of a dental operating microscope
JOE — Volume 44, Number 1, January 2018

Figure 1. Handling and inspection of the extracted tooth.
(DOM) to properly magnify and illuminate the areas being evaluated
(11) (Figure 1). Following root inspection, root resections are made
using a high-speed handpiece, ideally of at least 3 mm, which has
been shown to eliminate 98% of apical ramifications and 93% of lateral
canals (13) (Figure 2). In the event that granulomatous tissue remains
attached to the root ends on extraction, it is carefully curetted or is
removed when the root is resected.
The root canals are then prepared to receive a root-end filling us-
ing either a high-speed handpiece or ultrasonic instrumentation
(Figure 3). The ideal root-end preparation has been described as a
class I cavity, at least 3 mm in depth, with parallel walls and consistent
Figure 2. Root-end resection.
JOE — Volume 44, Number 1, January 2018
Review Article
with the natural anatomic outline of the root canal space (14). The best
method to accomplish these goals is thought to be with ultrasonic
instrumentation, rather than high-speed surgical burs (11). The use
of ultrasonic instrumentation for root-end preparations has been asso-
ciated with the creation of fractures in the unsupported root-end and
thus must be performed with caution to avoid excessive force (15). A
root-end filling material is then placed and condensed into the prepa-
ration (Figure 4). Historically, amalgam was the material of choice for
root-end filling; however, newer materials, such as Super ethoxy-
benzoic acid (SuperEBA), mineral trioxide aggregate (MTA), and cal-
cium silicate cements, have shown superior ability to seal the root canal
Intentional Replantation Techniques 15
Review Article
Figure 3. Root-end preparation.
system and demonstrate greater biocompatibility (16). In addition to
their superior sealing ability, calcium silicate root-end filling materials
have demonstrated bioactivity with precipitation of apatite crystals on
dentinal surfaces (17, 18). Considering these more desirable
properties, amalgam is no longer advocated for use as a root-end filling
material.
Once root-end fillings have been completed, the tooth is ready for
reimplantation into its original socket. Before tooth replacement, the
socket may be curetted to remove any remaining granulomatous tissue
or cystic remnants. This practice has been somewhat controversial.
Some authors have advocated curettage of the most apical portion of
Figure 4. Root-end filling.
16 Becker
the socket while avoiding contact with the socket walls (19, 20).
Others have recommended avoiding curettage of the socket all
together. Instead, surgical suction devices are used to remove only
the blood clot, with careful attention to avoid any contact with socket
walls (9, 11, 12). Regardless of the method, the primary goal is to
avoid removing and/or traumatizing remaining PDL cells attached to
the alveolus, which aid in the healing process.
Once the socket has been prepared to receive the tooth and is free
of any obstruction, the tooth is gently placed in the socket in an axial
direction using digital pressure. If resistance is met, some have reported
using the patient’s bite pressure to further seat the tooth into its socket
JOE — Volume 44, Number 1, January 2018

(21, 22). Once completely seated, compression of the socket walls
using further digital pressure has been recommended (4, 12, 23) to
gain a more intimate adaptation of the socket wall and tooth root. An
assessment of stability of the tooth is rendered and the decision of
whether to apply a splint is made. The practice of splinting is
somewhat controversial. Some authors advocate splinting replanted
teeth for 7 to 10 days to 3 to 4 weeks (4, 12). Others recommend no
splinting unless advanced mobility is present (19, 24). In addition,
occlusal reduction of the implanted tooth has been advocated by
some (8, 19) and avoided by others (21). This final step completes
the procedure and the patient is then seen for postoperative examina-
tion at various time intervals.
Additional sources of contention during intentional replantation
surround the proper handling of the tooth during endodontic manipula-
tion and the time limits for the tooth to be out of the mouth. Both handling
and extraoral time are critical to ensuring maximum vitality of PDL cells.
Kratchman in 1997 (11) suggested holding the extracted tooth in dental
forceps while performing the root-end procedures. He also recommen-
ded performing the root resections while periodically submersing the
tooth in a bath of Hank’s balanced salt solution (HBSS) to maximize
the PDL survivability. More recent studies by Choi et al (25) and Cho
et al (26) report holding the tooth in saline-soaked gauze during manip-
ulation. It is important that the gauze is completely saturated with saline
and not sterile water, as dry gauze or sterile water may desiccate root sur-
faces and compromise the vitality of PDL cells (27).
Recommendations for extraoral times have also varied. In 1966,
Grossman (4) reported the time out of the mouth should be ‘‘a matter
of minutes,’’ noting specifically that the PDL can be kept alive for 15 to
20 minutes. Kratchman (11) recommended a maximum extraoral time
of 10 to 15 minutes. In the 1994 report by Dryden and Arens (28) on
intentional replantations, J. Andreasen was noted to have reported 90%
success rates when avulsed teeth were replanted within 30 minutes.
Specific indications for intentional replantation include circum-
stances that may preclude traditional apical surgery, such as areas of
limited access and visibility, close proximity to delicate anatomic struc-
tures, or when a periodontal defect may result. Other indications
include the presence of conditions for which nonsurgical retreatment
is impracticable, such as obstruction of the root canal system, or perfo-
ration that is not accessible (28). Finally, intentional replantation also
has been indicated in situations of difficult patient management, persis-
tent chronic pain, accidental iatrogenic avulsion, involuntary orthodon-
tic extrusion, and previous failure of nonsurgical retreatment and apical
surgery (29).
Critical Review of Reported Techniques
The reported and suggested techniques for intentional replanta-
tion demonstrate significant heterogeneity. There is continuity with
some aspects of the procedure, such as avoiding contact of cementum
during tooth extraction and utilization of saline as a root hydration me-
dium during endodontic manipulation, whereas other aspects vary
significantly. Examples of variation include administration of preoper-
ative antibiotics, number of operators, curettage of the tooth socket,
root resection method, root-end preparation method, root-end filling
material, extraoral time, and application of a splint. These similarities
and differences are highlighted in Table 1(4, 7–12, 19–26, 28–39).
A detailed analysis of the reported or advocated techniques re-
vealed the following.
Preoperative Antibiotics
In preparation for the intentional replantation procedure, preop-
erative antibiotics were recommended by a minority of authors, with
JOE — Volume 44, Number 1, January 2018
Review Article
most advocating no antibiotics, or administration only ‘‘as needed’’
for prevention of subacute bacterial endocarditis or infection of artifi-
cial joint replacements. For those recommending antibiotics as a mea-
sure to improve procedural results, the timing and choice of antibiotics
varied. Nosonowitz (8) advised starting antibiotics a day before the
operation, whereas others, such as Jang et al (37), reported beginning
the medication on the day of the procedure. The choices of antibiotics
included penicillin, ampicillin, clindamycin, and tetracycline.
Preoperative Disinfection
Preoperative disinfection of the surgical site was nearly universally
recommended. This included a range of techniques, from local
debridement of plaque and calculus to disinfection with chemical
agents such as glyoxide and metaphen. Chlorhexidine, in concentra-
tions of 0.12% or 2% was the most commonly recommended means
for disinfection.
Number of Operators
Several authors, such as Grossman (4), Raghoebar and Vissink
(35), Tewari and Chawla (21), Fegan and Steiman (23), and Guy
and Goerig (20), recommended performing intentional replantations
using 2 operators, one to perform the tooth extraction and the other
to perform the endodontic surgical manipulation. The purported
benefit was an increased efficiency in operating time and allowance
for greater focus on the task at hand, thus reducing the time that the
tooth was out of the mouth. Most studies, however, reported a single
operator for all aspects of treatment, with similar reported extraoral
times as those using 2.
Tooth Extraction Method
The methods for tooth extraction also varied greatly among
studies. Grossman, Guy and Goerig (20), and Tewari and Chawla
(21) reported the use of dental elevators either to loosen soft tissue
or the tooth before forceps application. Most authors, though, were im-
plicit that no dental elevators be used, and that the application of the
dental forceps be limited to the tooth crown with no root contact. An
additional consensus was to perform the extraction in a controlled, pro-
longed manner with a slow rocking motion to prevent and mitigate po-
tential damage to the periodontal ligament cells. Interestingly, Jang et al
(37) reported placing a #15 surgical scalpel in the tooth sulcus, then
driving the blade into tissue using a mallet to separate the periodontal
fibers.
Socket Protection
Subsequent to tooth extraction, and during endodontic surgical
manipulation of the tooth, some earlier authors, such as Grossman
(4), Deeb (30), and Nosonowitz (8), advocated placing sterile gauze
over the tooth socket as a means of protection from debris and saliva.
Although this practice seemed to fall out of favor with time, Cho et al
(26) reported using gauze to cover and protect the socket as recently
as 2016 in a study on intentional replantations.
Tooth Handling Method
Once the tooth extraction was completed, most operators recom-
mended holding the tooth by the crown with a saline-soaked gauze as a
measure to provide continued hydration of the root surface and peri-
odontal ligament cells. Nearly the same number recommended holding
the tooth by the crown using the beaks of the forceps, limiting contact to
enamel. Niemczyk (9), Kratchman (11), and Peer (29) additionally
recommended applying a rubber band to the handles of forceps to
Intentional Replantation Techniques 17
Review Article
TABLE 1. Critical Review of Intentional Replantation Techniques
No. Preoperative Preoperative Extraction Socket Hydration
operators antibiotic disinfection method covering Socket curettage Handling method medium
Grossman 2 NR Yes, antiseptic Elevator to loosen soft Yes, gauze Yes, carefully curetted Handheld/gauze Saline,
1966 tissue, then extracted blood clot removed Ringers with
erythromycin

Emmertsen, 1 Yes, NR Forceps, ging. loosened, Yes, iodoform Yes, periapical area Forceps Saline
Andreasen penicillin gentle luxation gauze
1966
Deeb 1968 NR Yes Yes, metaphen NR Yes, gauze Yes, apical area if Hand, saline-soaked Saline
pathosis, gauze
saline irr. of alveolus
Kingsbury NR No, NR NR Yes, gauze Yes, any diseased tissue Held by Allis clamp Saline
et al 1971 only PRN removed by apical or Kern bone
curettage clamp
Deeb 1971 NR Yes, Yes, metaphen Elevators and forceps Yes, gauze Yes, apical area no socket Hand, saline-soaked Saline
Cleocin wall tooth cervically gauze
Nosonowitz NR Yes Yes, NR gently ext’d; no contact Yes, gauze Yes, carefully with Handheld, wrapped Saline,
1972 on cementum blood clot in sterile gauze, zephir
saline chloride
Tewari, 2 NR NR Fine elevators then Yes, gauze Yes, and clot removed Hand, wrapped Normal
Chawla forceps min in wet gauze saline
1974 rocking motion

Grossman 2 NR Yes, antiseptic No elevator, forceps, Yes, gauze Yes at base, no walls clot Hand, wrapped in Sterile
1982 rotated as little aspirated irrig. w/ saline soaked saline
as possible saline gauze with
tetracycline
Nosonowitz NR Yes Yes, Gly-Oxide Forceps wrapped in gauze Yes, gauze Yes, any pathosis removed NR Isotonic
1984 engage crown on with blood clot solution
enamel band or
crown prior to ext
Guy, Goerig 2 No, only NR Elevator to loosen then NR Yes, only apical portion Handheld; tooth Warm
1984 PRN forceps ext no root suction blood clot wrapped in saline
surface cont gauze
Dumsha, 2 No Yes, antiseptic Min. cont with tth struct NR No, wall must not be Hand, gauze Isotonic
Gutmann forceps wrapped curetted gently wrapped in saline
1985 in gauze flushed saline-soaked
of clot gauze
Koenig NR NR NR ‘‘Usual manner’’ avoid Yes, gauze No, clot aspirated Handheld, gauze Sterile
et al 1988 undo manipulation from socket soaked in saline saline
in socket
Keller 1990 NR NR NR Care taken not to NR NR Forceps or spec. Saline
damage the holder
desmodontium
Greiner, NR Yes, NR Avoid touching pdl NR Do not touch walls NR Sterile saline
Hawkins tetracycline fibers
1991
Fegan, 2 No Yes, antiseptic Soft tissue loosened with Yes, gauze No, irrigated with saline Forceps, tooth wrapped cont.
Steiman such as CHX periosteal elev. Avoid to remove clot in moist gauze for irrigation
1991 damage to cementum forceps do not touch with saline
cementum
Bender, NR Yes, Yes, 0.2% CHX Flat beak of forceps no NR Yes, curetted lightly NR NR
Rossman ampicillin or cemental contact irrigated with saline
1993 clindamycin gingiva loosened
with periosteal elev
Koerner 1993 NR NR NR Reflect cervical gingiva, NR Yes, at base of socket Hand, gauze soaked Sterile saline
elevator to luxate suction clot in HBSS or HBSS
tooth, forceps ext
Dryden, NR NR Yes, CHX 0.12% #15 sever perio fibers NR NR Forceps, roots saline
Arens elevators used, forceps wrapped in
1994 ext. no cemental contact, saline-soaked
wrap beaks with gauze? gauze
Kratchman NR No, only Yes, 0.12% CHX Beaks above cej; no NR No, can be gently Forceps with Intermittently
1997 PRN elevators rubber band aspirated rubber band submerged
on handles handle in HBSS

Raghoebar, 2 NR NR Forceps, atraumatically NR Apical curettage, Hand, saline-soaked saline

Vissink irrigated gauze
1999 w/saline
Niemczyk NR No Yes, 0.12% CHX no elevator minimal NR No; gentle evacuation forceps; cont.
2001 contact with root rubber band submerged
surface handle in HBSS
Peer 2004 NR Yes Yes, 0.12% CHX No elevator, min. NR Yes, very gently aspirate Forceps, rubber ‘‘Physiologic
pressure, beaks socket only in apical band around solution’’
not touch cementum end handle
Abid 2010 1 NR Yes, 0.12% CHX No elev., forceps cor. NR Only apical portion Hand, const. 0.9% saline
to CEJ. min. force saline to remove clot soaked with
saline squirting
Choi 2014 1 No, only Yes, 0.2% CHX No elevators, physics Yes, gauze Yes, not wall though clot Hand, saline-soaked Saline
PRN forceps final ext with removed with saline gauze
conv. forceps

Asgary 2014 1 NR Yes, 0.2% CHX Gently, by means of NR Blood clot aspirated NR Saline
suitable periotome
pdl/root untouched
Cho 2016 NR NR NR Forceps, as carefully Yes, gauze No, rinsed with saline Hand, saline-soaked Saline
as possible, no gauze
root damage

Jang 2016 NR Yes, Yes, 0.1% CHX 15 blade parallel to pdl NR NR HBSS or saline
amoxicillin and hit with mallet, then
forceps. No elevators

Avg, average; cej, cementoenamel junction; CHX, chlorhexidine; const, constant; cont, continual/continuous; DOM, dental operating microscope; ext, extraction; ext’d, extracted; GG, Gates Glidden; ging, gingiva;
HBSS, Hank’s balanced salt solution; IRM, intermediate restorative material; irr, irrigationl; m, minutes; mag, magnification; MTA, mineral trioxide aggregate; NR, none/not reported; pdl, periodontal ligament;
perio, periodontal; PRN, as needed; rec’d, recommended; rt, root; struct, structure; SuperEBA, Super ethoxy-benzoic acid; tth, tooth/teeth; US, ultrasonic; w/, with; ZOE, zinc-oxide eugenol; ?, unknown.
 Review Article
TABLE 1. Continued
Root resection Root prep Inspection Occlusal
method method method Retrofill material Seating of tooth Time out of mouth Splinting reduction Outcome
2–3 mm or as No retroprep if NR Amalgam Finger; compression ‘‘A matter of Yes; 3–4 wks Slight relief 80%; 45 tth
much as filled; 2–3 mm of socket minutes’’;
needed; 15–20 m. pdl can
Rongeurs be kept alive

Yes, length? NR NR Kloroperka, Finger pressure NR Yes, lead foil No 81%; 100 tth
Amalgam, Gutta-
percha
‘‘At times’’ Yes, 1/3 rt length, NR Amalgam Finger pressure NR Yes, acrylic 67%; 117 tth
3–4 mm of
apical foramen
NR NR NR NR Finger pressure # 30 m, ‘‘shortest Only as Yes, remove 97%; 149 tth
time possible’’ necessary from direct
4 wk occlusal contact
‘‘At times’’ NR NR Amalgam Finger pressure NR Yes, acrylic Yes 74%

Yes/length? 2–3 mm bur NR Gutta-percha Finger pressure 15 m? NR Yes 78%

Amalgam compression of
socket
Yes Yes NR Gutta-percha Finger pressure bite 31–50 m Yes, wire No 62.10%
pressure
compression of
socket
PRN/length ? PRN, #2 round NR Amalgam Finger pressure 1–6 m Yes, 2–4 wk, NR NR
Rongeurs and inverted compression of wire splint
cone socket with
perio pack
$5 mm or to NR NR NR Finger pressure # 30m, ‘‘as soon as NR Yes NR; 9 tth
obstruction compression of possible’’
socket

PRN, length? Only PRN, 3–4 mm #23 explorer Amalgam Finger pressure 2–3 m for tooth prep No, only PRN NR 100%; 1 tth
700 bur Compression of and repair 7–10 days
socket
Yes/length? PRN, length? Yes, NR Amalgam Finger pressure 10–30 m Yes, rec’d Yes NR
compression of 7–10 d
socket

Yes, 1–3 mm Yes, 4 mm #701 NR Amalgam, ZOE Finger pressure Avg 12 m, 22 m or less No Yes 82%; 177 tth
#70 fissure bur forceps compression
bur of socket
Yes? Yes? NR Aluminum oxide, NR 20 m or less Yes, 3–4 wk Yes 92%; 25tth
ceramic pins

Yes, beveled Yes NR Amalgam Finger pressure Limit the time out of No, only if Yes NR
the mouth loose

Yes/length ? PRN/length? Yes, how? NR Finger pressure ‘‘Kept to an absolute No, ‘ most often Yes NR
compression of minimum’’ will not be
socket needed’’;
5–7 d
Yes/length? Yes/length? NR Amalgam Finger pressure; bite ‘‘The shorter the No, only PRN Yes 81%; 31 tth
pressure better’’

Yes, 2–3 mm Yes, 2–3 mm deep NR Amalgam, acceptable Finger pressure Within 10–15 m max Yes, if mobile, Yes NR
bevel ends 1 mm diameter retroseal material, compression of 30 m 2 wk
Super EBA socket
Yes, 2–3 mm Yes, no less than Yes, mag. Super EBA, IRM or Finger pressure bite ?, within 30 m quotes Yes, every case, Yes NR
#170 3–5 mm #34 lenses glass ionomer pressure Andreasen 7–14 d
fissure bur inverted methylene
cone bur blue dye
Yes/length? Yes, 330 bur Microscope ZOE, Super EBA Finger pressure; bite 10–15m No PRN N/A
pressure
compression of
socket
Yes, 2–3 mm Yes, 3–5 mm, NR Amalgam Finger pressure 8 m  1 m avg. range Yes, 17 splinted Yes 86%; 29 tth
round bur 6–13 m wire or
suture
Yes/ 1–3mm Yes, 3–4mm bur Yes, DOM ZOE or Super EBA Finger pressure NR Yes, if NR 100%; 1 tth
carbide indicated
fissure 7–10 days
Yes/length? Yes, 3–4 mm NR Amalgam, ZOE, Finger pressure ‘‘As brief as possible’’ No, only if NR 89%; 9 tth
Gutta-percha compression of avg. 5 m, #10 m needed
socket 1–2 wk
Yes, 2–3 mm Yes, 2 mm, 1 or NR Amalgam Finger pressure 2–3 m Yes, 10 d, silk Yes 90%; 20 tth
round bur 2 round bur suture
diamond
Yes, 2–3 mm Yes, 3 mm 330 bur Yes, DOM MTA Finger pressure bite 11 m 25 s  5 m 32 s No, only PRN, NR 95.1; 287 tth
diamond pressure 10–14 d
bur compression of
socket
Yes, 2–3 mm Yes, 3 mm, #3 NR CEM cement NR #15 m No Yes 90%
diamond GG bur
bur
Yes, 3 mm Yes, 3-mm-thick Yes, DOM IRM, SuperEBA, MTA Finger pressure 12.5 m, 4–25 m range No, only NR 93%; 159 tth
diamond roots, diamond methylene unstable
bur bur thin blue dye teeth, semi
roots, US rigid
Yes, 2–3 mm Yes, 3 mm 330 bur Yes, DOM and or Endocem, MTA, Finger pressure Some <15 m some >15 No, only NR 83%; 41 tth
#170 bur methylene Super EBA m unstable
blue dye teeth, 2 wk
Review Article
maintain a constant, consistent pressure on the tooth surface during
manipulation.
Root Hydration Medium
The use of saline for a root hydration medium was near unani-
mous. In contrast, Kratchman (11) and Niemczyk (9) each recommen-
ded HBSS. In addition, Kratchman (11) reported that periodic
submersion of the tooth in a bath of HBSS during root resection was
the best approach to avoid root desiccation.
Root Resection Method
Root-end resection methods also varied. Although many authors
did not specifically report the length of root-end resection, nearly all
advocated or reported performing some degree of resection. An excep-
tion was a 1982 study by Grossman (10) in which it was reported that
root resections were performed ‘‘as needed.’’ Most reported resections
were completed with the use of a carbide or diamond bur in a high-
speed handpiece. Length of resection also varied, with most reporting
1 to 3 mm, although Nosonowitz (8) reported root resections of 5
mm or larger.
Root-End Preparation Method
Subsequent to root-end resection, most operators performed a
root-end preparation. However, Grossman (4) recommended no
root-end preparation for those teeth with root canals that were already
filled. Studies by Guy and Goerig (20), Dumsha and Gutman (12), and
Fegan and Steiman (23) recommended root-end preparations on an
‘‘as-needed’’ basis. The lengths and methods of the root-end prepara-
tions varied. Some reported 2 to 3 mm, others 3 to 4 mm, and Deeb
(30) reported one-third the root length. Nearly all were completed us-
ing a carbide bur. Cho et al (26) were the only authors that reported the
use of ultrasonic instrumentation for root-end preparation, and only in
cases of thin roots.
Root-End Filling Material
To fill the root-end preparations, most authors used amalgam;
however, more recent studies by Cho et al (26), Jang et al (37), and
Choi et al (25) incorporated the use of newer materials such as inter-
mediate restorative material, SuperEBA, MTA, and Endocem. Additional
reported materials included zinc-oxide eugenol cements, glass ion-
omer, and gutta-percha. Notably, Keller et al (32) reported using
aluminum-oxide ceramic pins to fill root-end preparations.
Socket Curettage
After endodontic manipulation, and before reinsertion of the tooth
into its socket, all authors performed some manipulation of the socket
in preparation for seating. This varied from simple aspiration or rinsing
of the blood clot using a suction device or saline, to curettage of the
socket using surgical instruments. When curettage of the socket was
performed or suggested, some authors were implicit that only the apical
portion of the socket be touched, thus avoiding contact with walls,
whereas others made no distinction.
Tooth Insertion
To seat the tooth in the socket, 2 methods were reported. Most au-
thors used simple placement using fingers, then digital compression of
the socket walls. A minority suggested or reported further seating of the
tooth using the patient’s biting pressure to drive the tooth into position.
20 Becker
Tooth Splinting
On reinsertion, splinting of the tooth was variable. Many studies
included splinting only when gross instability of the tooth was present.
Others, such as Dryden and Arens (28), incorporated a splint for each
case. The advocated duration of splint application also varied from 7 to
10 days or 3 to 4 weeks. Material for splint fabrication ranged from wire
to acrylic to sutures. Emmertsen and Andreasen (7) reported the use of
lead foil for splinting. Relief of the reimplanted tooth from occlusal con-
tact was near unanimous, although a few recommended no adjustment
or only ‘‘as needed.’’
Two additional procedural categories demonstrated differences in
reported or suggested technique.
Root Inspection Method
Inspection of the tooth root for anatomic variations, such as addi-
tional portals of exit or isthmi, or root fractures, before endodontic sur-
gical manipulation, was rarely reported. This is a crucial step in keeping
with modern endodontic surgical technique, contributing to success or
failure of the procedure. In 1997, Kratchman (11) advocated the use of
a DOM to aid in inspection of the roots before continuing with the inten-
tional replantation procedure. Studies by Niemczyk (9), Choi et al (25),
Cho et al (26), and Jang et al (37) were the only additional articles to
explicitly report the use of a DOM for inspection.
In addition, staining of the root surface using methylene blue was
also incorporated. In contrast, most studies either did not report
whether the root was inspected or an alternate technique was used.
Guy and Goerig (20) reported inspection using a #23 explorer, whereas
Dryden and Arens (28) reported the use of ‘‘magnification lenses’’ and
methylene blue dye.
Extraoral Time
Finally, the time in which the tooth was kept out of the mouth for
manipulation varied among studies. Most authors advocated mini-
mizing this time to preserve vitality of the PDL cells. The times ranged
from 2 to 3 minutes, as reported by Abid et al (38), up to 31 to 50 mi-
nutes in the report by Tewari and Chawla (21). Most kept the extraoral
time to less than 30 minutes. Jang et al (37) reported higher success
rates for those teeth in which the extraoral time was 15 minutes or
less compared with those kept out for more than 15 minutes.
Discussion
The selection of intentional replantation as a treatment modality
has been controversial. There are many reported indications, yet the
procedure has often been considered a last resort option to retain nat-
ural teeth (4). As highlighted, there are several different steps in the pro-
cedure, thus the opportunity for many variations of technique and
materials. This may explain the wide range in reported success rates,
which are often less favorable than other treatment methods. A recent
systematic review of the literature by Torabinejad et al (40) found an
overall 88% survival rate for intentionally replanted teeth, with more
contemporary studies demonstrating success rates as high as 95%.
Because of recently reported high survival rates, intentional replanta-
tion might now be considered among more commonly accepted treat-
ment options. It was noted in this same study, however, that only 2 of the
articles were published in the past 12 years and also demonstrated dif-
ferences in clinical technique, thereby limiting the understanding of
contemporary intentional replantation practice (40). Thus, there seems
to exist a wide variation in techniques and associated outcomes possibly
stemming from the lack of an accepted protocol, as well as a lack of
adherence to modern endodontic surgery principles.
JOE — Volume 44, Number 1, January 2018

An interesting finding in this review was the relatively few studies
that reported techniques that strictly adhered to modern endodontic
surgical principles.
Modern microsurgical techniques for traditional root-end surgery
have been described by Kim and Kratchman (13) and include the uti-
lization of a DOM, ultrasonic instrumentation, micro-instruments, and
highly biocompatible root-end filling materials. More specific recom-
mendations were made including a minimum of 3 mm root resection,
a 0 bevel angle, and a 3-mm root preparation depth. Staining of the
root-end surface with methylene blue to identify fractures, additional
portals of exit, and isthmi was also suggested (13). It was also noted
that traditional techniques for endodontic surgery resulted in success
rates of 40% to 90%, whereas contemporary techniques that adhered
to modern endodontic surgical principles resulted in 85.0% to
96.8% success (13).
Studies by Setzer et al (41, 42), evaluating success rates for apical
surgery, concluded that when modern microsurgical techniques for
root-end surgery were used, superior and more predictable success
rates were achieved compared with traditional techniques. Thus, these
conclusions might be similarly expected if modern endodontic surgical
techniques and materials are used for intentional replantation
surgeries.
Conclusions
As highlighted by Torabinejad et al in 2015 (40), no universally
accepted clinical protocol for intentional replantation has been estab-
lished. An assessment and understanding of advocated techniques
and the evidence to support them is an important first step in developing
such guidelines.
Demonstrated in this review are many inconsistencies and varia-
tions in techniques that have been advocated or reported over the
past several decades. As is evidenced by improved success rates for
traditional root-end surgery (42), incorporating modern endodontic
surgical techniques, including the use of the DOM, staining medium, ul-
trasonic instruments, and newer, more biocompatible root-end filling
materials, may also improve success or survival rates of intentionally
replanted teeth.
Acknowledgment
I thank Dr Tim Rohde, Dr Joseph Assad, and Dr Robert Bethea
for their mentorship and guidance throughout this study. I also
thank Dr Amy Martin, Ms Ayaba Logan, and Mr Bob Poyer for their
expertise and guidance in the search of literature.
The author denies any conflicts of interest related to this study.
References
1. Haapasalo M, Shen YA, Ricucci D. Reasons for persistent and emerging post-
treatment endodontic disease. Endod Topics 2008;18:31–50.
2. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can
fail. Int Endod J 2001;34:1–10.
3. Friedman S. Considerations and concepts of case selection in the management of post-
treatment endodontic disease (treatment failure). Endod Topics 2002;1:54–78.
4. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966;72:1111–8.
5. Weinberger BW. An Introduction to the History of Dentistry. St. Louis, MO: C.V.
Mosby Co.; 1948.
6. Grossman LI. A brief history of endodontics. J Endod 1982;8:S36–40.
7. Emmertsen E, Andreasen JO. Replantation of extracted molars a radiographic and
histological study. Acta Odontol Scand 1966;24:327–46.
8. Nosonowitz DM. On intentional replantation. N Y J Dent 1972;42:44–7. passim.
JOE — Volume 44, Number 1, January 2018
Review Article
9. Niemczyk SP. Re-inventing intentional replantation: a modification of the technique.
Pract Proced Aesthet Dent 2001;13:433–9. quiz 440.
10. Grossman LI. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc
1982;104:633–9.
11. Kratchman S. Intentional replantation. Dent Clin North Am 1997;41:603–17.
12. Dumsha TC, Gutmann JL. Clinical guidelines for intentional replantation. Compend
Contin Educ Dent 1985;6(604):606–8.
13. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
J Endod 2006;32:601–23.
14. Carr GB, Murgel CAF. The use of the operating microscope in endodontics. Dent Clin
North Am 2010;54:191–214.
15. Abedi HR, Van Mierlo BL, Wilder-Smith P, et al. Effects of ultrasonic root-end cavity
preparation on the root apex. Oral Surg Oral Med Oral Pathol 1995;80:207–13.
16. Torabinejad M, Ford TRP. Root end filling materials: a review. Dent Traumatol
1996;12:161–78.
17. Nair U, Ghattas S, Saber M, et al. A comparative evaluation of the sealing ability of 2
root-end filling materials: an in vitro leakage study using Enterococcus faecalis.
Oral Surg Oral Med Oral Pathol 2011;112:e74–7.
18. Shokouhinejad N, Nekoofar MH, Razmi H, et al. Bioactivity of EndoSequence Root
Repair Material and Bioaggregate. Int Endod J 2012;45:1127–34.
19. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premo-
lars and molars. J Am Dent Assoc 1971;83:1053–7.
20. Guy SC, Goerig AC. Intentional replantation: technique and rationale. Quintessence
Int 1984;15:595–603.
21. Tewari A, Chawla H. Intentional replantation of pulpal or periapically involved per-
manent posterior teeth. J Indian Dent Assoc 1974;46:385–9.
22. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth.
Oral Surg Oral Med Oral Pathol 1993;76:623–30.
23. Fegan S, Steiman HR. Intentional replantation. J Mich Dent Assoc 1991;73:22–4.
24. Koenig KH, Nguyen NT, Barkhordar RA. Intentional replantation: a report of 192
cases. Gen Dent 1988;36:327–31.
25. Choi YH, Bae JH, Kim YK, et al. Clinical outcome of intentional replantation with pre-
operative orthodontic extrusion: a retrospective study. Int Endod J 2014;47:
1168–76.
26. Cho SY, Lee Y, Shin SJ, et al. Retention and healing outcomes after intentional
replantation. J Endod 2016;42:909–15.
27. Krasner PR. Management of tooth avulsion in the school setting. J Sch Nurs 1992;8:
22–4. 26.
28. Dryden JA, Arens DE. Intentional replantation. A viable alternative for selected cases.
Dent Clin North Am 1994;38:325–53.
29. Peer M. Intentional replantation—a ‘last resort’ treatment or a conventional treat-
ment procedure? Nine case reports. Dent Traumatol 2004;20:48–55.
30. Deeb E. Replantation of teeth–a recommended procedure. J South Calif Dent Assoc
1971;39:24–9.
31. Nosonowitz DM, Stanley HR. Intentional replantation to prevent predictable end-
odontic failures. Oral Surg Oral Med Oral Pathol 1984;57:423–32.
32. Keller U. A new method of tooth replantation and autotransplantation: aluminum
oxide ceramic for extraoral retrograde root filling. Oral Surg Oral Med Oral Pathol
1990;70:341–4.
33. Greiner JH, Hawkins RD. Intentional replantation. Endod Rep 1991;6:11–3.
34. Koerner KR. Intentional replantation. CDS Rev 1993;86:24–7.
35. Raghoebar GM, Vissink A. Results of intentional replantation of molars. J Oral
Maxillofac Surg 1999;57:240–4.
36. Asgary S, Alim Marvasti L, Kolahdouzan A. Indications and case series of intentional
replantation of teeth. Iran Endod J 2014;9:71–8.
37. Jang Y, Lee S-J, Yoon T-C, et al. Survival rate of teeth with a c-shaped canal after inten-
tional replantation: a study of 41 cases for up to 11 years. J Endod 2016;42:1320–5.
38. Abid WK. Post-surgical outcomes and prognosis of intentionally replanted lower
posterior teeth. Al-Rafidain Dent J 2010;10:332–40.
39. Deeb E. Intentional replantation of endodontically treated teeth. In: Transactions of
the Fourth International Conference on Endodontics. Philadelphia: University of
Pennsylvania Press; 1968.
40. Torabinejad M, Dinsbach NA, Turman M, et al. Survival of intentionally replanted
teeth and implant-supported single crowns: a systematic review. J Endod 2015;
41:992–8.
41. Setzer FC, Kohli MR, Shah SB, et al. Outcome of endodontic surgery: a meta-analysis
of the literature—part 2: comparison of endodontic microsurgical techniques with
and without the use of higher magnification. J Endod 2012;38:1–10.
42. Setzer FC, Shah SB, Kohli MR, et al. Outcome of endodontic surgery: a meta-analysis
of the literature—part 1: comparison of traditional root-end surgery and endodon-
tic microsurgery. J Endod 2010;36:1757–65.
Intentional Replantation Techniques 21