Monday, April 14, 2008

Intentional Replantation

Replantation of an avulsed tooth is a well known and accepted treatment following a traumatic dental injury. Preservation of vital cells in the periodontal ligament allow reattachment of the tooth in the alveolar socket. Rates of success at 5 years reported in the literature ranges between 70% - 91% (1).

The main factors limiting the success of this treatment are the amount of time the tooth is out of the mouth, disruption of the periodontal ligament and bacterial contamination.

Although not common or well known, intentional removal and replantation of a tooth is an effective mode of treatment for teeth that cannot be treated with traditional endodontic surgery. This strategy can be particularly helpful in lower second molars where proximity to the mandibular nerve and thickness of the buccal bone make endodontic surgery difficult.

Intentional replantation allows the clinician to control the variables that would limit the success of a replantation following traumatic avulsion. Atraumatic extraction, minimal time out of the mouth and aseptic technique, allow a clinician to perform apical procedures that otherwise could not be performed.

Again, while not commonplace, intentional replantation is a treatment option that can be considered in special cases. It may offer your patient a final opportunity to retain a natural tooth, when endodontic surgery is not an option.

This case was actually an UNintentional, intentional replantation. Let me explain. This patient presented to our office with a bridge from #27 to #29. Significant buccal decay was present. The general dentist and the patient wanted to try and maintain this bridge.

Her dentist placed an amalgam root surface filling under the buccal margin of the bridge. A distal periapical radiolucency developed. I was then asked to complete the RCT on the tooth. Since the anterior abutment was loose, we decided that to remove the bridge, complete the endodontic treatment, and retrofit a post and core back to the bridge. Hardly an ideal restorative solution, but a solution that worked for the patient in her particular circumstance.

While attempting to remove the bridge, the entire tooth came out. At this point, this became an intentional replantation case.

Within a matter of minutes, we did a retroprep and MTA retrofill.

The anterior abutment of the bridge was then permanently cemented on and the posterior abutment replanted into the socket.

This patient returned last week for a 3 month re-evaluation. The tooth was sensitive for a while, but she now reports no sensitivity or swelling and she can now chew nuts on that side!
If you look closely you can see that the distal lesion has healed. While this is a very short term result, the healing of the apical lesion, lack of symptoms would indicate initial success. We will continue to monitor this tooth over time. Look forward to updates!



TC said...

Thank you for writing this post on a most interesting and engaging topic. While I am in no way an endodontist or even a dentist, I am hoping to become one, and this blog as well as posts similar to this one inspire me even more to succeed at my goal. As a very athletic person and a college student, I have seen young people lose or chip teeth all too often. As many of my friends know I am interested in dentistry, in turn I am constantly barraged with questions about why teeth cannot simply be “shoved back in” when they fall out. After reading the article, I can explain that factors such as the amount of time the tooth is out of the mouth, damage to the periodontal ligament, and contamination by bacteria can all affect the ability of a dentist to reimplant a tooth. As a layman I was curious about what traditional endodontic surgeries and conditions must be avoided or present in order for a professional to support intentional reimplantation. The specific incident that you address covered this in addition to being very exciting to read. It showed me that dentists are truly required to think on their feet, and that when the unexpected happens one must act quickly and calmly. The idea of being quick on your feet makes me wonder how modern the idea of intentional reimplantation is. While it seems that the process could be very old-fashioned, even back to the times where doctors worked in unclean environments, it also seems very progressive and new. This then creates a new question, whether or not the method is a viable alternative to tooth replacement by implant or bridge. Obviously, as previously mentioned, there are certain criteria for the process to take place, but are these criteria easily met? And if so, are they less specific or more specific than choosing to get an implant? Moreover, are there other factors that can affect the situation such as income and age? I seem to find that the world of dentistry has numerous ways to accomplish the same task, and I am curious in this instance which is generally superior.

The Endo Blog said...

As I mentioned, this is not a commonplace treatment modality. I view it mostly as an outside alternative to endodontic surgery in an area where surgery is difficult or risky (nerve damage).
As with any treatment there are complications that can occur with this treatment. For example, external root resorption is always a possible complication following avulsion or intentional reimplantation.
There is some debate about the value of endodontic surgery. There are some who look at the old endodontic surgery studies and claim that it is not worth doing and would prefer to place an implant. However, endodontic mircosurgery today is very different than endodontic surgery of the past.

Anonymous said...

This case will have a good prognosis because of the lack of pre-existing infection.

My concern in cases like this is the untreated canal space. Are you worried about infection within that necrotic space at some time in the future if orthograde treatment is not done?

The Endo Blog said...

Another excellent point from periapex!
In a case like this, endodontic treatment will likely be needed.
Since the lesion has healed and it is asymptomatic, that should probably done anytime now.

Javier Pascual Irigoyen said...

Great case!! Just one question could be perform a coventional RCT after reimplantation instead of the retropreparation an MTA plug in order to minimize the time out of the socket. How many minutes can be the tooth out of the socket and then be reimplanted safely (with low risk of external root resorption). I also think that conventional RCT must be perform in the rest of the canal. Thanks again, Your blog is really interesting.

Anonymous said...

I am a patient whose endodontist has offered intentional reimplantation as treatment for an upper left molar. He has basically performed two root canals on that tooth without finding much, but the infection returns (last time after two months). I'm willing to take a chance on reimplantation, but shall I wait until the tooth hurts again or do the procedure now as a preventative?

The Endo Blog said...

Dear Anonymous,
In my opinion, if the infection has returned previously, I would go ahead with the treatment recommended by your endodontist.
I would assume that your tooth has conical shaped roots, which would make it easy to remove and reimplant. If the roots are not conical shaped, then I would personally prefer to treat the tooth with an apicoectomy.