Intentional Reimplantation : A Seminar

•         Introduction

•         Definition

•         History

•         Indications

•         Contraindications

•         Procedure

•         Team work

•         Prognosis

•         Surgical complications

•         Healing followed by replantation

•         Recent advances

•         Conclusion

•         References

INTRODUCTION:

•      Intentional replantation involves the purposeful removal of a tooth and its reinsertation into the socket after proper endodontic manipulation and repair. Intentional replantation is a treatment option when more conventional forms of treatment either fail or are impossible. Generally it is thought that it may be considered as a viable mode of treatment in certain situations to preserve the natural dentition.

•      Intentional replantation is an artificial setting mimicking complete tooth avulsion. However, the circumstancing factors are near ideal. The level of tooth contamination and physical damage is likely to be far less than in the case of an accidental injury. Moreover, the single most important factor in the demise of an avulsed tooth,  Extraoral dry time, is not a factor because it is practically nonexistent.  During intentional replantation, the tooth is immediately submerged in tissue culture medium, with the tooth out-of-socket times being under 10 minutes.

DEFINITION:

•     Intentional replantation may be defined as the purposeful extraction of a tooth to repair a defect or cause of a treatment failure and then returning the tooth to its original socket.

Ingle.

•      Replantation is “The purposeful removal of a tooth and its almost immediate replacement
with the object of obturating the canals apically while the tooth is out of its socket”

Dr. Grossman (1982)

HISTORY:

•      At the eleventh century AD, Abulcasis described the first account of replantation and use of ligatures to splint the replanted tooth.

•      Pierre Fauchard, in 1712, reported an Intentional Replantation, fifteen minutes after extraction.

•      In 1768, Thomas Berdmore reported Intentional Replantation for mature and immature teeth.

•      In 1783, Woofendale reported Intentional Replantation of diseased teeth.

•      In 1778, John Hunter believed that boiling the extracted tooth prior to replantation may help to remove the tooth disease.

•      In 1890, Scheff addressed the PDL role in prognosis of replanted teeth.

•      In 1955, Hammer described the importance of leaving an intact PDL on intentionally replanted teeth. He believed that a healthy PDL is essential for reattachment and retention of replanted teeth. He stated 'an average 10 years life span could be expected when replantation was accomplished in a technically flawless manner.'

•      In 1961, Loe and Waerhaug  tried to replant teeth immediately to keep the PDL vital. Resultantly, ankylosis was not seen; however, all teeth showed resorption repaired with cementum. These results have been confirmed by Deeb in 1965 and Edwards in 1966.

INDICATIONS:

•      Weine has stated that intentional replantation is only indicated

•      When all other endodontic nonsurgical and surgical treatments have been performed and failed or were deemed impossible to perform.

•      When periradicular surgery will not allow visualization of the area on the root to be repaired or

•      There is danger of damaging adjacent vital structures such as the contents of the mandibular canal or mental foramen.

•      Specific indications may include but are not limited to the following situations:

•      Where nonsurgical and surgical endodontic procedures have been deemed impossible and the patient desires all possible efforts be made to retain the natural tooth:

•      Limited mandibular opening that prevents the performance of nonsurgical or periradicular surgical endodontic procedures;

•      Root canal obstructions;

•      Nonsurgical and surgical treatments have failed and symptoms and/or periradicular disease persists;

•      Resorptive or perforation root defects that exist on areas that are not accessible via the usual surgical approach without excessive loss of root length or alveolar bone; and

•      To allow thorough examination of all surfaces of the root in order to identify or rule out the presence of a root defect, such as a crack or root perforation.

CONTRAINDICATIONS:

•      Contraindications may include the following:

•      Teeth with long, curved roots that require a surgical extraction procedure for removal from the socket,

•      Advanced periodontal disease that has resulted in poor periodontal support and mobility of the tooth;

•      Mutirooted teeth with roots that diverge making extraction and replantation impossible;

•      Teeth with nonrestorable caries; and

•      Teeth that are amenable to additional nonsurgical and surgical endodontic procedures.

PROCEDURE:

•      Once the decision has been made and accepted by the patient to perform the intentional replantation procedure, any nonsurgical endodontic procedures should be completed to the best degree possible.

•      The pulp chamber and coronal access are then restored to help stabilize and reinforce the coronal tooth structure during the extraction procedure.

•      Intentional replantation is best accomplished as a team effort because each member of the team will be assigned, trained, and skilled to perform a specific function.

•      This team approach will minimize the extra-oral time for the tooth, facilitate the removal of any diseased tissue from the apical portion of the socket, and accelerate the repair of the root surface defect or the placement of a root-end filling.

•      Another method to minimize the time the tooth is out of the socket is to plan so that all necessary instruments and materials necessary to accomplish the entire procedure are out and readily available in the operating area.

•      Once adequate local anesthesia is obtained, the periodontal fibers in the gingival crevice area are detached with a scalpel blade of an appropriate size in order to loosen the gingival tissues attached to the tooth in this area.

•      A surgical elevator should either not be used or used only minimally to loosen the tooth in the socket. If the use of the elevator results in damage to the cementum or periodontal ligament on the root surface, it may compromise the success of the case.

•      If possible all the loosening of the tooth should be accomplished with the extraction forcep as the tooth is slowly and gently loosened. and removed from the socket.

•      It is crucial to remove the tooth and roots in one piece.

•      Following extraction, the crown of the tooth should be wrapped in gauze moistened with saline or Hanks Balanced Salt Solution and held with the beaks of the forceps.

•      It is also extremely important that the root surfaces be constantly bathed with one of these solutions during the entire extra-oral time.

•      The roots are then thoroughly examined with magnification and a fiber optic light to evaluate for the presence of root fractures or periradicular perforation or resorptive defects.

•      Sterile methylene blue dye may be applied to the root surfaces in order to enhance the visualization of root defects.

•      If no root fractures are found and the prognosis for replantation appears to be positive, any root defects noted should be repaired with an appropriate material. If root-end resection is indicated, it should be accomplished perpendicular to the long axis of the root with the same bur and in the same manner as if the tooth was still in the socket.

•      After root- end resection, the appropriate ultrasonic tip is used to create the small 3-mm-deep Class I rootend preparation.

•      An appropriate root-end filling material will then be placed. If a team approach is being used, one operator repairs the root defect while the second operator gently removes any diseased tissue from the extraction socket.

•      Once the repair/rootend filling material is placed, the extraction socket is irrigated with normal saline and gently suctioned to remove any blood clot that may have formed. The tooth is then carefully reinserted back into its socket.

•      Reinsertion of the tooth into the socket may be difficult at times so care must be taken to assure the tooth is returned to the socket in its proper orientation.

•      After the tooth has been inserted back into the socket, the patient is asked to bite so that the occlusion can be checked to assure the tooth is fully seated back into the socket.

•      In some cases, posterior teeth are well retained in their sockets and stabilization with a splint may not be required. If excessive mobility is present, splinting will be necessary.

•      In the case of a posterior tooth, stabilization may be achieved by placing a figure-8 suture over the occlusal surface of the tooth or by using a prefabricated acrylic splint. Stabilization may also be achieved by using a flexible wire or monofilament line bonded to adjacent teeth with an acid-etch composite resin system.

•      The patient should be re-evaluated 7 to 14 days following the intentional replantation to remove any stabilization that was placed and to evaluate tooth mobility. Other follow-up visits should be scheduled 1, 3, 6, and 12 months following the procedure.

TEAM WORK:

•      Intentional replantation is best accomplished as a team effort because each member of the team will be assigned, trained, and skilled to perform a specific function.

•      This team approach will minimize the extra-oral time for the tooth, facilitate the removal of any diseased tissue from the apical portion of the socket, and accelerate the repair of the root surface defect or the placement of a root-end filling.

•      Another method to minimize the time the tooth is out of the socket is to plan so that all necessary instruments and materials necessary to accomplish the entire procedure are out and readily available in the operating area.

PROGNOSIS:

Various factors to be kept in mind for better prognosis of replanted tooth are:

•         The tooth should be kept out of the socket for the shortest time possible.

•         The PDL should be kept in moist saline or in Hanks Balanced Salt Solution during entire time the tooth is out of the socket

•         The extraction should be accomplished as atraumatically as possible.

•         Part of the success of the procedure will also depend on the ability to extract the involved tooth without fracturing the root or roots.

•         The patient should always be advised that fracture of the tooth is possible during the extraction procedure, and if this occurs, the pieces of the tooth will be removed and discarded.

•         Kingsbury and Wiesenbaugh got

•         95% success rate with

•         151 mandibular premolar and molars

•         over a 3-year period.

•         Bender and Rossman got

•         80.6% success with

•         31 intentional reimplantation cases with

•         observation periods of up to 22 years.

•         Raghoebar and Vissink got

•         72% success in

•         29 cases

•         after 5-year observation period.

•         Intentional replantation is not a completely predictable procedure, but under favorable conditions, some fairly acceptable success have been reported.

SURGICAL COMPLICATIONS:

·         Although serious postoperative surgical complications are rare, the clinician should be prepared to respond to patient concerns and recognize when additional treatment may be necessary.

·         Mild to moderate postoperative pain, swelling, ecchymosis, or infection.

·         Extraoral ecchymosis occurs when blood seeps through the interstitial tissues;

o   This condition is self-limiting and does not affect the prognosis.

o   Moist heat applied to the area may be helpful,

o   Complete resolution of discoloration may take up to 2 weeks. Heat should not be applied to the face during the first 24 hours after surgery.

·         Sinus exposure during surgical root canal procedures on maxillary posterior teeth is not uncommon. Postoperative antibiotics and decongestants are often recommended

·         Patients should be advised that some postoperative oozing of blood is normal, but significant bleeding is uncommon and may require attention.

REVASCULARISATION:-

• Out of 72 immature teeth (width of apical foramen 1.1–5.0 mm) the pulp was revascularized in 13 (18%),
• While in 88 mature teeth (width of apical foramen 1.0 mm or less) no revascularization occurred.
• Among parameters tested statistically in immature teeth, a significantly increased frequency of revascularization (p < 0.05) was only found in teeth reimplanted within 45 minutes.
• All teeth in which revascularization did not occur exhibited a periapical radiolucency and/or external inflammatory root resorption.

HEALING FOLLOWED BY REPLANTATION:-

• The primary periodontal healing is usually uneventful.
• Ankylosis and Replacement resorption will occur if extensive areas of the root surface are denuded during extraction and replantation.
• However, if the technical aspects of the treatment are well controlled, reestablishment of a normal periodontal ligament can be expected to occur.

RECENT ADVANCES:-

• Surgical Operating Microscopes
• Ultrasonic Tips For Root End Preparation
• MTA
• Emdogain

CONCLUSION:-

• Once regarded as a last resort before extraction, today intentional replantation in selected cases is a viable and logical mode of treatment.
• With the development of new protocols for intentional replantation, the procedure has become more predictable and
• should always be considered as a part of possible treatment planning

REFERENCES:-

1.      Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional Replantation: A Procedure as a Last Resort. J Contemp Dent Pract 2011;12(6):486-492.

2.      Kingsbury B, Weisenbaugh J. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc 1971;83:1053.

3.      Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1993;76:623.

4.      Raghoebar GM, Vissink A. Results of intentional replantation of molars. J Oral. Maxillofac Surg 1999;57:240.

5.      Rajiv B, Sunandan M, Ramta B, Dilpreet K. Intentional Replantation: A Measure To Save The Natural Tooth.Journal Of Clinical And Diagnostic Research  2010 October, 5:3276-3278.

6.      Filho FB et al. Intentional Replantation: Case Report Of An Alternative Treatment For Endodontic Therapy Failure. RSBO V. 1, N. 1, 2004.

7.      Tang et al. Intentional replantation for iatrogenic perforation of the furcation: A case report. Quintessence Int 1996;27:69¡-696.

8.      Hsin Yc Et Al. Treatment of Cemental Tear Using Intentional Replantation. JES Vol 2 No. 1 August 2011.

9.      Peer M. Intentional Replantation: A Last Resort Treatment Or Conventional Treatment Procedure? Nine Case Reports. Dent Traumatol 2004;20; 48-55.

10.  Kling, M., Cvek, M. and Mejàre, I. (1986), Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Dental Traumatology, 2: 83–89.

11.  Cohen, S., Hargreaves, K. M. Pathways of the Pulp, 10^TH Ed, 2011, Missouri, Mosby, 720-776.

12.  Ingle JI, Bakland LK. Ingle’s Endodontics, 6th, 2008, London, BC Decker, 1233-1295.