Indications for Intentional Replantation

Intentional replantation is the intentional removal of a tooth and replantion into the socket following endodontic manipulation.

Success with this treatment is dependent upon atraumatic extraction, minimal manipulation of the periodontal ligament, rapid replacement into the socket, and minimizing occlusal forces following replantation.

While endodontic apical surgery (apicoecotomy) is the most common type of endodontic surgery performed, intentional replantation is an option when apical surgery is not indicated due to anatomical considerations. These may include: proximity to the mental foramen or mandibular canal, thickness of Md buccal bone along oblique line angle, and proximity to Mx sinuses.

I have found intention replantation useful in the following clinical situations:

Cases where endodontic surgery is not an option due to difficult anatomy...

1. Md 2nd Molars - access through buccal bone difficult
2. Md 1st & 2nd Bicuspids - closeness to the mental foramen
3. Mx 2nd Molars - access difficult & sinus complications likely

Cases where conventional retreatment has been unsuccessful or not likely to be successful

1. Cases with ledging and/or separated instruments
2. Retreatment has been attempted without success

Other factors to consider...

The root anatomy has to allow an atraumatic extraction to occur. Conical shaped roots are most ideal.

Intentional replantation provides a treatment option when tooth replacement with an implant or bridge is not feasible.

These patients have already had endodontic therapy, and crowns placed. Costs associated with this additional treatment are minimal compared to cost of tooth replacement.

The following cases demonstrate intentional replantation.

CASE #1

RCT was completed and patient continued to have apical pain. Extrusion of sealer was assumed to be the cause of the apical periodontitis. Close proximity to the mental foramen makes apical surgery contraindicated.

Following atraumatic extraction, the gross overextension of gutta percha is obvious. Apical resection and burnishing of gutta percha completed within minutes.

Tooth replanted and treatment completed.

CASE #2

Initial RCT completed.

Sinus tract persists.


Non-surgical retx completed and symptoms persist. Discussion with patient of options:
1. Extraction
2. Replantation
Pt understood options and selected intentional replantation.

Atraumatic extraction, immediate resection.

Replantation completed.

3 month recall. Tooth asymptomatic and completely functional.

Sources:
Pathways of Pulp, 9th edition - online version. p767-768.

Is That a Root Fracture?

Large J-shaped lesions are often associated with vertical root fractures. This tooth was asymptomatic to percussion, non responsive to thermal testing and surprisingly normal to probing. Diagnosis: necrotic pulp and asymptomatic apical periodontitis. It was was determined to be an endodontic problem.

The large radiolucency extends up the distal root into the furcation. Microscopic examination during endodontic therapy revealed no root fracture. In this case, the assumption of a root fracture, based on radiographs alone, would have been incorrect.

Without proper diagnosis, this tooth might easily be labeled a fractured root and extracted. A new crown is indicated to prevent coronal leakage.

Root Canal Treatment Saves a Perforated Tooth

This root canal was started in July '09. After having difficulty finding the canals, the tooth was referred to our office.

Upon opening the tooth, we found a supraboney perforation on the ML surface.

Canals were located using a operating microscope and the root canal completed.

The ML perforation was repaired using Geristore. (Since this perforation was above the crestal bone, a restorative material that would not wash out must be used. MTA is not the best material in this type of perforation)

A six month recall finds the lesions almost completely healed and the tooth pain free and functional.

Calcium Hydroxide as Intercanal Medicament

Ca(OH)2 pastes are used in endodontics as a temporary canal filling material for multiple purposes including:
1. Stimulate continue root development
2. Control exudate/disinfect the canal system
3. Prevention of external root resorption following traumatic injuries
4. Create an apical barrier following over instrumentation

Occasionally, I will use calcium hydroxide as a intracanal medicament to look for signs of initial healing prior to obturation. On this particular retreatment case, the distal canal was long and wide. I was concerned there may have been some resorption or possible an apical crack that I could not visualize.

Pre-Operative Radiograph

Calcium Hydroxide paste was placed (and extruded) in the canals.

3 month recall shows remarkable resorption of the extruded Ca(OH)2 and healing of the apical lesion.

Tooth was re-obturated and another tooth has been saved!

Source:
Cohen & Burns. Pathways of Pulp 6th ed. p.406-407.

Herodontics? - Revisited

In Aug 2009, an American Academy of Implant Dentistry press release stated, "...times have changed and patients should forego prolonged dental heroics to save failing teeth and replace them with long-lasting dental implants". While it universally accepted that implants are a great way to replace missing teeth, a more controversial topic is when to replace a diseased tooth with an implant. In my opinion, those promoting dental implants have become increasingly more aggressive about replacing natural teeth.

As a specialist, I am occasionally called upon to perform "heroic" procedures. This may be following some iatrogenic damage or by a patient who wishes to retain a natural tooth at any cost. While I would much rather treat a normal, straightforward endodontic case, the use of microscopes, ultrasonics and MTA have allowed us to preserve teeth that many would consider "hopeless". I am often amazed at the success that we have with some of these "heroic" cases.

The following case was previously posted, but the patient returned for a 4 year recall last month. Unfortunately, the patient was returning for another root repair perforation following endodontic access on a different tooth. This case would be considered a "heroic" case by anyone's standard! In this particular case, this patient has been pleased with his decision to retain the tooth.

Original Post
This root canal was done just over four years ago. The patient presented with pain to percussion, and an 8 mm buccal probing was present. The RCT had been completed 2 years previously and recently became symptomatic.
DX: Prior RCT w/ Symptomatic Apical Periodontitis.
Treatment recommended: Non-surgical retreatment, perforation repair with possible need for endodontic surgery. Prognosis: guarded.

As you can see, the MB canal is very calcified. Calcification of this kind would make this case a very high level of difficulty. The MB canal was missed and the furcation was found, instrumented & obturated. Proper case selection can help prevent this type of complication. However, if this does occur, one would expect to find bleeding and the tactile sensation of the pdl/cortical bone is very different from the canal. Length determination films, working films or final films should also identify the perforation. I would recommend immediate referral to an endodontist for treatment of an iatrogenic event such as this.

Retreatment completed. MB canal located and treated. Furcal perforation repaired with MTA. Patient placed on recall to watch the area and see if endodontic surgery will be required.

Recall at 2 years & 3 months. Patient reports complete function and no symptoms. The 8mm periodontal probing has dissappeared. This tooth is considered "healing", and scheduled for a 1 year recall.

You can call it "herodontics", but that tooth is functional, apical bone looks good, periodontal pocket has disappeared. This will be a fun case to watch over time.

4 Year Recall

Asymptomatic & fully functional.

NOTE: I have never said this is pretty. Actually, its pretty ugly. However, retaining the natural tooth has preserved the crestal bone, provided normal function, and cost much less in time and money than any replacement option available.

Retreatment & MTA Save a Perforated Tooth

The following case was submitted by Dr. Rico D. Short of Smyrna, GA.

Original endodontic treatment was done 15 years ago. The crowns on 8 & 9 were replaced 2 years earlier at which time the dentist placed post for retention. During post preparation, the root was perforated. A large lesion has developed.


DX: Prior RCT w/ Chronic Apical Abscess w/ root perforation. Pt was informed the prognosis was questionable due to the perforation. Pt understood and consented for treatment including perforation repair.

Retreatment on #8 completed with MTA root repair.

8 month recall

22 month recall finds patient asymptomatic and functioning with no mobility and normal probing depths.

While many clinicians would have deemed this tooth "hopeless" and recommended extraction, MTA, microscopes and a expert clinician can save teeth that otherwise would be extracted.

Endodontic Retreatment & MTA Preserve the Tooth

Here's a tooth that had endodontic treatment over 10 years ago. While the clinician had difficulty finding all the canals, the tooth has been functional for quite some time. A large furcal defect raises suspicion of a root fracture or perforation.

DX: Prior RCT w/ Symptomatic Apical Periodontitis.

There are many who would consider this hopeless and recommend extraction.

Let us consider the cause of this treatment failure:

1. Missed Canals

2. Furcal Perforation or Root Fracture?

Can these issues be addressed to preserve the natural tooth?

In my consultation with the patient, I explain these issues and that endodontic re-treatment may be able to save the tooth (as long as the root is not fractured). I also explain the alternative option of extraction.

Finding missing canals is a simple solution.

A perforated root can be repaired with guarded prognosis.

A fractured root will require extraction.

I tell the patient the only way to know for sure is to open the tooth and investigate. Considering the nice crown on the tooth, the cost of attempting to save the tooth is minimal, compared to the cost of removing and replacing. In this case the patient elected re-treatment.

Pre-operative radiograph.

Upon access, 2 additional canals are located and instrumented. A furcal perforation is also identified. No root fractures are found.

Re-treatment is complete. Canals obturated with gutta percha and furcal perforation repaired with MTA. Glass ionomer base is placed over MTA.

7 month recall shows a tooth that is fully functional with remarkable healing of the furcal defect. Endodontic re-treatment has preserved the natural tooth.

Dens in Dente

Dens in Dente literally means "a tooth within a tooth". It is a developmental anomaly caused by an epithelial invagination during the development of the tooth. Enamel is laid down on the internal surface of the tooth. This is most frequently seen in maxillary lateral incisors.

A thin layer of enamel can be seen internally. An amalgam restoration was previously placed at some point to try and seal off the development groove into the dens in dente.

Access for endodontic treatment reveals the internal layer of enamel.

Endodontic treatment is completed.


This peg lateral incisor also shows the internal and external layers of enamel of a dens in dente. The large dens in dente has also affected the overall development of the tooth.
Submitted by: Dr. Rico D. Short of Smyrna, GA.

Apexification with Calcium Hydroxide & MTA Fill

This 15 year old patient has a history of trauma to #8. Trauma occurred at an age before apical closure occurred. Tooth was diagnosed with necrotic pulp and symptomatic apical periodontitis. Note the large periapical lesion.

Traditional apexification using Ca(OH)2 was used.

Tooth debrided to the apex, NaOCl irrigation.

Ca(OH)2 placed.

3 month check shows resorption of Ca(OH)2, but apex still open. Apical lesion almost completely healed.

Ca(OH)2 placed again.

10 month re-evaluation. Apical barrier present, so it was time to obturate. This is a great view of the apical barrier that has formed.

Tooth was obturated with MTA. If this tooth ever needs apical treatment, a simple resection will be done without retropreparation or retrofilling.

Removing a Broken Endodontic File

Anyone performing endodontics occasionally has a separated instrument. This case was referred for removal of a separated instrument.

The file is in the MB#2 canal. Since it is in the upper third of the canal, good visualization with a microscope and proper ultrasonic technique will make this file removal possible.

After finding the file, careful ultrasonic instrumention is used to remove dentin around the file - opening up the MB groove. This is done carefully without touching the file itself. We want to expose 2-3 mm of the file before we begin vibrating the file itself.

Too much contact with the file in this early stage can cause a coronal piece of the file to break off, making it more difficult.

Once the coronal coronal 2-3mm of the file has been accessed, the ultrasonic is placed on the most apical part of the file to begin vibrating it. This should loosen the file and vibrate it out. If the file breaks again, then repeat step one.

The file was removed and the MB#2 canal instrumented.

Removal of the separated instrument complete.

Use of an operating microscope is essential in effective removal of a separated instrument.