4
2003 I.O~tgi*ad~~t~' Caw Htbp~~a*t Cmipetitioii: Joint \\ imw By Jeff Ward, HIIS (oiaga). (;radDipClinDcnl. UDSC (~elh), formcrly poslgraduate sludcnl. School ol' Ikntal Wicnce, Tha llniversily of Melhourne, 71 1 Elizabeth Slrcret, Melbourne, Wloria 3000. Address for correspondence: lavel 6. 766 Elizabclh Slrect. Melbournc, VIC 3000. Intentional Replantation Of A Lower Premolar Abstract Intentional replantation is the purposeful extraction of a tooth to perform extraoral endodontic treatment, curettage of apical soft tissue when present and the replacement of the tooth in its socket. This paper demonstrates the use of intentional replantation as a technique to successfully treat a case where conventional endodontic retreatment and apical surgery were considered unfeasible. Introduction Intentional replantation is performed mainly as an alternative to extractionwhen conventional endodontic treatment or retredtment is not successful and periapical surgery is not possible or is high-risk due to the close presence of delicate anatomical structures ( I ) Bender and Rossman (2). suggest intentional replantationreduce the adverse outcomes that other forms of endodontic surgery experience in selected cases Intentional replantation has been recommended as the first choice of surgical treatment for (2). hgure I Pre-operotivephotogroph of the gold crow1 on tooth 34 Situations where intentional replantation is indicated. including surgical indications with close proximity to vital anatomical structures such as the maxillary sinus. inferior alveolar nerve canal and the mental foramen. teeth with limited surgical access such as lower second or third molars; patients who object to periradicular surgery; and mesial or distal perforations where surgical access would be Figure 2 Pre-operativeradiograph of tooth 34 difficult. Limitations of this treatment include. possible inability to carefully and successfully extract the tooth in question. the considerable risk of unrestorable fracture during the removal of the tooth. and the high propensitytoward external root resorption. caused by damage to the periodontal ligament and cementum during the extraction and extra-alveolarperiod A characteristic feature of intentional replantation failures is external inflammatory or replacement root resorption Because of these limitations. intentional replantation is often considered a last resort to retain an endodontically-diseasedtooth (I. 3, 4) Case Report A 68-year-old female patient was referred to the Endodontic Department of the Royal Dental Hospital of Melbourne for consultation and treatment concerning tooth 34. The Patlent's dental history indicated that tooth 34 had been endodontically Figure 3. Proximo1 rodiograph of tooth 34 followrng extraction rhowry root canal filling nnd post at buccol aspect AUSTRALIAN F NDODONTIC JOURNAL VOLUME 30 Nc, 3 DtCLMBtR 2004 9u

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2003 I . O ~ t g i * a d ~ ~ t ~ ' C a w Htbp~~a*t Cmipetitioii: Joint \\ imw

By Jeff Ward, HIIS (oiaga). (;radDipClinDcnl. UDSC (~e lh) , formcrly poslgraduate sludcnl. School ol' Ikntal Wicnce, Tha llniversily of Melhourne, 71 1 Elizabeth Slrcret, Melbourne, Wloria 3000. Address for correspondence: lavel 6. 766 Elizabclh Slrect. Melbournc, VIC 3000.

Intentional Replantation Of A Lower Premolar Abstract

Intentional replantation is the purposeful extraction of a tooth to perform extraoral endodontic treatment, curettage of apical soft tissue when present and the replacement of the tooth in its socket. This paper demonstrates the use of intentional replantation as a technique to successfully treat a case where conventional endodontic retreatment and apical surgery were considered unfeasible.

Introduction Intentional replantation is performed mainly as an alternative to

extraction when conventional endodontic treatment or retredtment is not successful and periapical surgery is not possible or is high-risk due to the close presence of delicate anatomical structures ( I )

Bender and Rossman (2). suggest intentional replantation reduce the adverse outcomes that other forms of endodontic surgery experience in selected cases Intentional replantation has been recommended as the first choice of surgical treatment for (2) .

hgure I Pre-operotive photogroph of the gold crow1 on tooth 34

Situations where intentional replantation is indicated. including surgical indications with close proximity to vital anatomical structures such as the maxillary sinus. inferior alveolar nerve canal and the mental foramen. teeth with limited surgical access such as lower second or third molars; patients who object to periradicular surgery; and mesial or distal perforations where surgical access would be

Figure 2 Pre-operative radiograph of tooth 34 difficult. Limitations of this treatment include. possible inability to carefully

and successfully extract the tooth in question. the considerable risk of unrestorable fracture during the removal of the tooth. and the high propensity toward external root resorption. caused by damage to the periodontal ligament and cementum during the extraction and extra-alveolar period

A characteristic feature of intentional replantation failures is external inflammatory or replacement root resorption Because of these limitations. intentional replantation is often considered a last resort to retain an endodontically-diseased tooth (I. 3, 4)

Case Report A 68-year-old female patient was referred to the Endodontic

Department of the Royal Dental Hospital of Melbourne for consultation and treatment concerning tooth 34. The Patlent's dental history indicated that tooth 34 had been endodontically

Figure 3. Proximo1 rodiograph of tooth 34 followrng extraction rhowry root canal filling nnd post at buccol aspect

AUSTRALIAN F NDODONTIC JOURNAL VOLUME 3 0 Nc, 3 DtCLMBtR 2004 9u

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Figure 4: Radiograph showing endcdontic hand file in uninstrumented Iinguol canal.

figure 8: Post-operotive radiograph showing tooth 34 replanted.

figure 5: Photograph showmng preparation of the retrograde preparations using a small slow-speed bur.

Figure 9: Three-month recall.

Figure 6: Photograph showmng Super-EBA retrograde restoration.

Figure 7: Radiograph showrng Super-EBA retrograde restoration.

I00

treated. with a cast post and core and gold crown placed approxi- mately I 5 years previously. Since early 2000. the patient had been experiencing a dull ache from the region of tooth 34 that had been slowly worsening.

On presentation. the patient reported a constant dull, throbbing ache from tooth 34 and an inability to bite on the tooth without pain. The patient's oral hygiene was good with all restorations appearing intact and no cartes noted. Clinically, a generally well- maintained and heavily restored dentition was present with tooth 34 tender to percussion. palpation and selective biting. A reasonably well-fitting gold crown with subgingival margins was present on tooth 34 (Fig. I). No abnormal periodontal probing depths were detected with teeth 33 and 35 reacting positively to carbon dioxide sensibility testing.

Radiographic examination disclosed that tooth 34 contained a root-filling extending to approximately I .5 mm from the radio- graphic apex with a post and pin-retained crown (Fig. 2). A radiolucency was present around the root apex of tooth 34. Close examination revealed a thin radiolucent line alongside the one root canal filling in the root of tooth 34. The mental foramen appeared very close to the apex of tooth 34.

A diagnosis of chronic apical periodontitis with acute exacer- bation was made for tooth 34. Likely aetiologies included probable second, missed canal, or a wide figure eight-shaped root with a fin that required cleaning. Alternatives included a cracked root. resistant infection or extraradicular infection.

Treatment options were evaluated and discussed and a decision was made to extract tooth 34, examine for cracks or a missed canal, treat extra-orally if possible and then to replant in the extraction socket. The risk of losing the tooth during the procedure or later as a result of periodontal damage was explained to the patient.

AUSTMLIAN ENDODONTIC JOURNAL VOLUME 30 No. 3 DECEMBER 2004

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Figure 10: Slx-month recoll

figure I I ; helve-month recoll.

figure 12: Gghteen-month recoll.

The recommended option of endodontic retreatment was dis- missed by the patient due to cost. Periapical surgery was considered but decided against due to the risk of damage to the mental nerve. which was in close proximity of the apex of the 34.

Following the decision to perform intentional replantation for tooth 34, a clear plastic suckdown was constructed to act as a splint, if required, once the tooth was replanted The procedure was carried out with several assistants to minimise the extrd-oral time. Following anaesthesia, the tooth was carefully extracted with forceps and kept moist by constant bathing in sterile saline. The tooth was held by the crown only during the entire procedure. Once extracted, the tooth was radiographed from a proximal angulation and examined through the operating microscope (Fig. 3). No cracks were evident and the restoration margins appeared well-

fitting. A second missed canal was found lingual to the treated canal. Two millimetres of the root apices was shaved back with a high- speed diamond bur. The missed lingual canal was instrumented from the apex with endodontic handfiles and sterile saline (fig. 4). Retrograde cavty preparations were made with slow speed burs in both the buccal and lingual canals as well as the isthmus joining them (Fig. 5). Super-EBA cement retrograde restorations were placed and polished (figs 6 and 7). The blood clot was carefully rinsed out of the extraction socket and the tooth then carefully replanted. The tooth appeared to be well retained in the socket and the suckdown splint was not used. Extra-oral time was approximately I 5 minutes. A final radiograph was taken to check the position of the tooth (Fig. 8). The patient was instructed to use a chlorhexidine mouthrinse.

Ten days later the patient returned for review. The tooth had grade-two mobility and was tender to percussion but otherwise asymptomatic. At three- and six-month recalls the patient pre- sented with no symptoms and grade-one mobility. Radiographs showed some angular bony remodelling with little change in the radiographic appearance of the periapical radiolucency (Figs 9 and 10). At 12-month recall, tooth 34 was asymptomatic with radio- graphic evidence of healing (Fig. I I ). At the 18-month recall, tooth 34 was fully functional, asymptomatic and a radiograph showed good resolution of the initial periapical radiolucency (Fig. 12).

Discussion Intentional replantation is performed mainly as an alternative to

extraction when both retreatment and apical surgery are con- sidered unfeasible (5). Because of the risk of damage from the extraction procedure and the extra-oral time. intentional replant- ation is generally only considered in those cases where conservative or surgical procedures are contra-indicated. Intentional replantation was indicated in this case due to the close proximity of the mental foramen to the root apex, which was considered would imply risk of damage during apical surgery.

Complications of this procedure tend to be related to the degree of damage to the periodontal ligament and cementum during the extraction and extra-alveolar period. Progressive replacement root resorption has been reported as the major concern (3). In this case. the tooth was carefully and easily extracted without fracture and with minimal trauma to the periodontium. The extra-alveolar time was kept to a minimum. the tooth was only touched by the crown and sterile saline was used to keep the root moist during the procedure. The extra-alveolar time for this case was approximately I5 minutes. Ideally, this time would have been less although Kingsbury and Wiesenbaugh (6) concluded that teeth that were out of the socket for less than 30 minutes had a high success rate.

Dryden and Arens (3) suggested that intentionally-replanted teeth should be splinted in every case for 7- I 4 days. Andreasen (7, 8) recommended minimal splinting due to the finding that the early restoration of normal masticatory function with the accompanying jiggling forces improves periodontal healing. In this case, tooth 34 was well retained in the socket without splinting and. although a splint had been constructed, it wasn't used. At all review appointments, tooth 34 was stable in its position and after 18 months showed normal physiologic mobility.

A review of the literature shows a remarkably high success rate for intentional replantation (IR). Koenig et 01. (9). in a study of I94 teeth, showed a success rate of 82% after 5 I months. Deeb el 01. ( 10). in a study of I65 IR teeth, reported a 74% success rate after a fwe-year follow-up. Bender and Rossman (2). in a study of only 3 I teeth, showed a success rate of 8 I % after 22 years. One major difficulty in interpreting this data is that the success rate of intentional

AUSTRALIAN LFJOODONTIC JOURNAL VOLUME 30 No 3 DECtMBt R 200.1 101

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replantation cases is often determined as the retention of the tooth in question whether pathosis is present or not (5) This makes it difficult to compare success rates with conventional treatment modalities and doesn't help much with future treatment planning

With the case presented in this report. at the 18-month review. tooth 34 was asymptomatic. in full function and the patient was very happy The presenting symptoms had disappeared and tooth 34 was not tender to percussion or palpation The periodontium around tooth 34 appeared normal with 3 mm probing depths Mobility was normal. with no evidence of replacement root resorption. Radiographic healing of the periapical pathosis was encouraging as it indicated successful treatment of the infected root canal system In this case, the aetiology of the presenting periapical pathosis was likely to be the missed. presumably infected. lingual canal Wth treatment of this canal. radiographic healing occurred

Loss of some crestal bone height around tooth 34 indicated some damage to the periodontium from the extraction and/or extra-alveolar time but this was apparent at the six-month review and has not worsened since. Susceptibility to vertical root fracture is present as tooth 34 now has a short root. minimal bony support and a large post with little remaining root strength

Overall though, considering the only viable alternative the patient was interested in was extraction. the result at the 18-month review is excellent and the patient was very happy

Re fcrences I . Grossman LI. Intentional replantation: a clinical evaluation.

J Am Dent Assoc 1982; l04:633- 39. 2. Bender IB. Rossman LE. Replantation of endodontically treated

teeth. Oral Med Oral Surg Oral Pathol 1993; 76:623 30. 3. Dryden JA. Arens DE. Intentional replantation: a viable

alternative for selected cases. Dent Clin North Am 1992:

4. Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg Oral Med Oral Pathol I99 I : 7 I :743-7.

5. Orstavik D. Pitt Ford TR. Essential Endodontology. Oxford: Blackwell Scientific Publications: 1998.

6. Kingsbury B. Wiesenbaugh J. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc I97 I ;

7. Andreasen JO. The effect of splinting upon periodontal healing after replantation of permanent incisors in monkeys. Acta Odontol Scand 1975; 33:3 13-23,

8. Andreasen JO. Periodontal healing after replantation of traumatically avulsed human teeth. Assessment by mobility testing and radiography. Acta Odontol Scand 1975;

9. Koenig KH. Nguyen NT, Barkhordar RA. Intentional replantation: a report of 192 cases. Gen Dent 1988;

10. Deeb E. Prieto PF! McKenna RC. Reimplantation of luxated teeth in humans. J South Calif Dent Assoc 1965; 33: I94 206.

38~325.53.

83: 1053-7.

33 1325-35.

36:327-32.

2005 ASE Undergraduate Essay Competition lopic Conditions And Notes

Case assessment and treatment planning: What governs your decision to treat. refer or replace a tooth that potentially requires endodontic treatment?

Eligibility Students in the last two years of undergraduate dental courses

in an Australian. New Zealand or Fijian university.

Prizes First Prize: $lo00 plus an inscribed commemorative plaque The winning essay will also be published in the Australian Endo- dontic Journal, at the discretion of the Editor Second Prize: $500 Each finalist will also receive one year's free subscription to the Australian Endodontic Journal.

Closing Date Essays must be submitted to the Lecturer-in-charge of Endo-

dontology at each dental school by 29 JULY 2005.

I. Essays must not exceed 3000 words, with a maximum of 50 references Essays should be typewritten and double spaced on one side only of A4 sized paper

2. Essays must conform to the "Guidelines for Contnbutors" in the Australian Endodontic Journal as published in each issue of the Journal

3 Submitted entries from each dental school will initially be assessed by the lecturer($)-in-charge of Endodontology at that School The lecturer will choose the best two essays from each school that will then be forwarded to the Federal office of the ASE Inc for judging Entries must reach the Secretaryflreasurer. AS€ Inc by Friday 26 August 2005

4 Two copies of the entries from each state must be submitted and no names or identifying marks should appear on the essay Written hard copies of the entries should be accompanied by a computer disk The candidate's name, home address and university name should appear on a separate page loosely attached to the essay

5 Essays will be coded for anonymity and sent to two judges appointed by the ASE Inc Federal Executive. The decisions of the judges shall be final

6 All essays must be submitted by one individual only, joint submissions will not be considered

I02 AUSTWLIAN LNDODONTIC jOURNAL VOLUME 30 No. 3 DECEMBLR 2004