ABSTRACT by controlling the time factor, maintaining aseptic conditions


Intentional replantation has
been long considered to be the only recourse for saving a tooth when other
options like traditional root canal therapy and surgery are inconceivable.
Intentional replantation is a procedure in which a tooth is intentionally extracted
and then reinserted into its own socket for various treatment modalities.  In this case report, we discuss a case of
intentional re-implantation as a treatment option for failed root canal
treatment with broken instrument in the apical 1/3rd of a mesiobuccal canal of
right mandibular first molar, perforation in the furcation area and external to
distal root, underobturation, improper deroofing of pulp chamber and external
root resorption in both the roots and large periapical and furcation area  pathology 
of the same tooth . The critical factor required for the success of
intentional replantation i.e. preserving the viability of periodontal ligament
cells was given due attention by controlling the time factor, maintaining
aseptic conditions and minimal manipulation of the root surface. The case is still on recall, showing  asymptomatic tooth and IOPA radiograph
revealed a healing periapical area.

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Intentional replantation(IR) has been defined
by Grossman as “the purposeful removal of the tooth and its almost immediate
replacement with the objective of obturating the canals apically while the
tooth is out of its socket1.”.He also stated that it is the act of
deliberately removing a tooth and following examination, diagnosis, endodontic manipulation,
and repair—returning the tooth to its original socket to correct an apparent
clinical or radiographic endodontic failure2. Many authors agree
that it should be reserved as the last resort to save a tooth after other
procedures have failed or would likely to fail3. Messkoub reported
success rate in retaining replanted teeth vary between 52-95%4. The
main reason of failure in replanted teeth is root resorption, specifically
ankylosis or replacement resorption2,4. This is directly related to
the amount of time the tooth is out of the mouth during the procedure.

IR is usually recommended in teeth with failed
previous nonsurgical endodontics, persistent chronic pain, refractory
periapical pathology, vertical fractures, endodontic-periodontic lesions,
certain anatomic malformations such as radicular groove and nonfeasibility of
apicoectomy due to varied reasons like limited accessibility, anatomic
restrictions (e.g. buccal plate thickness, proximity to anatomical structures
such as the mandibular nerve or inoperable sites such as lingual surfaces of
mandibular molars)  or refusal of the
patients to undergo surgery or financial factors preclude conventional implant
placement. Buccal plate thickness may preclude surgical endodontic treatment in
mandibular molars and the palatal root of maxillary molars . Although post
removal is frequently possible in the hands of a skilled clinician,
occasionally posts or separated instrument removal may pose risks greater than
the potential benefits as compared with other options including extraction .If
executed correctly it is a one-stage treatment that would maintain the natural
tooth esthetics(5-8).

Contraindications include teeth with
preexistent moderate to severe periodontal disease, multirooted teeth with
diverging, long, curved roots that make extraction and reimplantation
impossible9,10. Though the process has been performed for years and
was used extensively to manage odontalgia with a success rate of upto 95%, it
is usually considered as the last resort treatment4,11. The
important aspects to be kept in mind to provide the best long term prognosis
are that firstly the extraction of the tooth should be atraumatic and the tooth
should be out of the mouth for the shortest period possible. These factors if
not taken care would increase the likelihood of replacement resorption which
majorly decreases the survival rate of replanted teeth.

Mineral trioxide aggregate
(MTA) has satisfactory properties, for solving many endodontic problems,
including: biocompatibility, favourable sealing ability, mechanical strength
and a capacity to promote periradicular tissue healing. Originally developed as
a surgical root-end filling material, MTA has been used successfully in several
clinical applications such as pulp capping, pulpotomy, perforation repair
treatment of traumatized teeth with immature apices and for treatment of root

The paper illustrates a
clinical case to exemplify the potential of intentional replantation as a
viable treatment option in the select case.


A 27 year old
male reported with a chief complaint of moderate pain in the lower right back
tooth region of jaw since one week. The dental history revealed that patient
was apparently alright 1 month back when he
experienced pain with a tooth in the lower right back
region of jaw for which root canal treatment had been done in 46 one year
ago.When patient reported to us 46 had an amalgam restoration, with a
discharging sinus in the buccal vestibular mucosa and was sensitive to apical
palpation and percussion .The patient had a noncontributory medical history;
radiograph taken showed that endodontic treatment had been attempted in the
mandibular right first molar tooth with a radiopaque structure at the apex of
the apical 1/3rd of the mesiobuccal root of 46 suggestive of an endodontic
instrument separation, radiolucency in the furcation area, at the apex of
mesial and distal roots suggesting large periapical and furcation area  pathology 
of the same tooth along with underobturation, improper deroofing of pulp
chamber and root resorption in both the roots(Fig. 1). There was radiographic
evidence of chronic apical periodontitis . The periodontal probing depths did
not exceed 3 mm.  The first resort was
retrieval of the separated instrument. All efforts for the retrieval of
instrument fell futile due to the excessive wedging of the instrument through
the apical foramina. Undue pressure in retrieving the instrument was avoided
due to the danger of apical fracture.An invasive apical surgery was not a
suitable option since instrument retrieval through a small bony window seemed
difficult. Large periapical lesion as depicted by the radiograph also pointed
towards the difficult removal of the granulomatous tissue via surgery. Moreover
other disadvantages like large volume bone removal required to access the apex
of 46 and proximity of the surgical site to the mandibular canal pointed
towards the inappropriateness of the case for a surgery.In view of all these
limitations intentional replantation was indicated as the alternative choice. The
patient was presented with the treatment options of extraction and a dental
implant or extraction with fixed and removable partial dentures as replacement. Endodontic retreatment and implant therapy were
declined by the patient. After understanding risks and benefits of all
treatment options, the patient made an informed decision to have the tooth
removed. Upon the patient’s decision to have the tooth extracted, the treatment
option of intentional replantation with associated risks and benefits was
offered. The patient accepted this treatment modality. The patient was conveyed
about the details of the procedure and a written informed consent was obtained.

The patient was prepared for carrying
out intentional replantation in 46. The mouth was rinsed with 0.12%
chlorhexidine gluconate and  profound
inferior alveolar nerve block, lingual and buccal nerve block was used to
achieve anesthesia with 2% lidocaine containing 1:100,000 epinephrine. 46 was
extracted as atraumatically as possible using forceps technique.  

The extracted tooth was placed in
cold normal saline solution. Thereafter using a sterile gauze sponge, the tooth
was held by the crown, Root canal treatment was completed extra orally, and the
broken instrument was carefully taken out with slight cutting of dentin which
was repaired with retrograde MTA  and ,
perforations in furcation area and in the cervical third of distal area were
repaired using MTA, granulation tissue is gently removed with curette (Fig.2 ).The
roots were treated with tetracycline for 2-3 minutes to enhance periodontal
ligament  regeneration. The tooth and
alveolus were then irrigated with sterile saline, the socket was gently
curetted to remove the apical granulation tissue and to prevent damage to parts
of remaining PDL attached to the socket wall (Fig.3a ). and the tooth was
replanted into its socket(Fig.3b ).The procedure took 28 minutes. The buccal
and lingual plates of bone were manually compressed and the patient was asked
to bite on a wood stick for a few minutes to stabilize the tooth.The tooth was
secured with functional splint  from 45 to 47 using multiflex co axial wire
for one month., given in
the form of orthodontic wire and flowable composite(Fig4). The occlusion was adjusted,
final radiograph was taken to verify the position of re-implanted tooth
in the socket(Fig 5) and
post-operative instructions given: chlorhexidine gluconate 0.12% rinse three
times per day after meals for 7 days, Cap Amoxicillin 500mg and Clavulinic acid
125 mg bd for 5 days, ibuprofen 600 mg every 4 to 6 h for 48 h and soft diet
for 2 week. The patient was recalled in 1 week for evaluation of the surgical
site. The splint was removed after 4 weeks of re-implantation .The postoperative period was uneventful with no pain and
discomfort. Root surface and the replanted tooth appeared intact and the
replanted tooth was asymptomatic. Clinically, the patient has been asymptomatic
with no mobility since the splint was removed. Patient had no pain or discomfort during
postoperative period. After 1 months the patient was asymptomatic, tenderness on  percussion was negative and IOPA revealed
healing and there was no signs of resorption. There was no pathological condition, good gingival
health and no periodontal pocket. A periodontal examination showed normal
sulcular depth and normal gingival.The
patient is kept on routine follow-ups every 6 months for further evaluation.

Fig.1-IOPA showing 46 a radiopaque structure(separated
instrument) at the apex of apical one third of mesial root, improper
deroofing of pulp chamber, underobturation in both root canals, and
periapical and furcation radiolucency showing pathology.


Fig.2- Extracted tooth with retreatment along with perforation
repair, apicectomy, instrument retrieval and apical, furcation area



Fig.3a- Granulation tissue carefully removed (gentle
curettage) with minimal damage to the walls of the socket and irrigated
with sterile normal saline. 


Fig.4- Postoperative showing replanted and splinted
tooth and final postoperative picture.




Fig.5- Postoperative IOPA radiograph to assure the
correct position of the tooth within the socket.


Fig3b. Postoperative picture of  insertion of the tooth within the socket.





Fig.6- One month recall radiograph showing healing
periapical and furcation area.



DISCUSSION-Intentional replantation has some advantages
over apical surgery, which includes being easier, less invasive, time
consuming, less costly procedure. In addition,diagnosis of the defect and its
correction is better performed extraorally. 
The greatest disadvantage of intentional replantation, which leads most
dentists to consider this technique as the last resort to save a tooth, is
occurrence of replacement resorption or ankylosis9,10.

replacement resorption is influenced by the extraalveolar time while the
inflammatory resorption is caused by infection after an improper RCT. Also,
ankylosis may be due to the removal of pericementum the splinting and a long
extra-alveolar period.49 It should be stated that resorptive process may occur
even after 10 years.95 Prevalence for resorption without visible contamination
after 2 years is 57%13. The success or failure of the IR depends on
vitality of PDL cells.These cells can be kept vital while the tooth is out of
the socket but kept moist, for at least 15to 20 minutes. Resultantly,
moistening the PDL with solutions such as saline solution, seems to prolong the
vitality of PDL cells.

In 1968, at the 4th International conference
on endodontics, Grossman and Chacker 
hypothesized a 3 years survival rate as suitable criteria for IR
success. They believed that if resorption is going to occur, it would be seen 1
to 2 years following the IR. However, the histologic studies showed
that more than 4 years is needed for assessment of success or failure of IR14.
Overall, intentionally replanted teeth should be named successful if
generalized resorption has not been occurred, if no rarefaction is present and
if the tooth has normally functioned and had no symptom for at least 5 years.
In another view, successful IR should satisfy clinical and radiographic
criteria. The clinical criteria include normal function, normal mobility and
healthy periodontium15. Also, the PA radiograph should reveal no
apical radiolucency or resorption. Splinting should be done only if required.
Semirigid splint should be given to allow for physiologic mobility of the tooth
and for no longer than a week period which again decreases the chances of
replacement resorption16.

CONCLUSION- Although until this day intentional
replantation is considered the procedure of the last resort , dentist may still
be unfamiliar with this technique. However, when the procedure is carefully
performed with proper case selection, success can be expected with an
acceptable survival rate. IR should be considered as an alternative treatment
in the selected cases and should be part of the therapeutic armamentarium.With
proper case selection intentional replantation can provide successful long term
results and should be more often used as a viable treatment option to extend
the life of a natural tooth for as long as possible in select cases. Although
this method has a satisfactory success rate, long-term followup is necessary to
evaluate reliability of this technique.

Through thorough knowledge of the prognosis,
the surgical procedure, the risk and benefits may assist patients and dentists
in effective decision making.`


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