As far back as 1967, Herb Schilder recognized that long-term endodontic success could approach 100%.1 For necrotic teeth, years of studies have demonstrated that success rates are usually lower.2 Cleaning and shaping a canal filled with bacteria would appear to pose a greater threat to success than simply having to remove inflamed tissue. So what should we do if a root canal fails, despite our best efforts? Retreatment, apical surgery, or extraction are usually the only treatment modalities discussed. And, each has risks and benefits along with its limitations. The following case report depicts another option, one that is often overlooked — intentional replantation.
Intentional replantation is a procedure which involves the “purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina.”3 From my own experience, I am often surprised that few dentists have either heard of this modality or believe that it can be a successful treatment option. While it is usually a treatment “of last resort,” success rates have been shown to approach 95%.4 In fact, it really only has one major drawback in my mind – that the tooth can completely fracture, rendering it useless to the patient. Unlike other treatment alternatives, case selection becomes critical when deciding whether this is truly a viable course of action. The following case exemplifies this point beautifully.
A 25-year-old Hispanic woman had been treated for root canal therapy several years ago by her former dentist, for tooth #29. Although she had terrible pain and swelling prior to the initial procedure by this dentist, she was pain free for almost three years. When that dentist retired, the new, younger partner began treating her. Having not had a complete radiographic exam in over five years, the new dentist decided that it was time to do so. He realized from the radiographs that the patient had a 5mm round radiolucency apical to tooth #29 (Fig. 1). This was not present at the time of the initial root canal procedure. Additionally, significant apical root resorption was evident. Unwilling to perform retreatment or apical surgery, the dentist sent the patient to me to determine if the tooth could be salvaged.
Complicating matters, several issues existed. Financially, the patient had very limited funds. She was young and about to get married. She was clear that she did not have the finances to pay for an implant at this time. In fact, she asked that we save the tooth for as long as possible, so that she could raise funds to perhaps have an implant in the future, if my treatment failed. But aside from finances, anatomical problems also existed. Although it was difficult to see on the PA, a radiolucency was visible several mm apical to the one associated with the tooth. Considering this was tooth #29, it was pretty clear to me what it likely was — the mental foramen. Although I suggested taking a panoramic radiograph to confirm, the patient was wary, having just had a full radiographic exam involving 20 peri-apical figures. We decided to use what information we already had.
Retreatment was a concern because the apex was so resorbed. Keeping a tight apical stop would be challenging; but it is imperative if the foramen is underneath. And what if the crown fractured during retreatment? Removing the post could require an access preparation greater than usual. Or perhaps the porcelain would chip off? Not ideal circumstances, to say the least.
So what about surgery? Success rates have been demonstrated to be greater than 93%.5 Unfortunately, we again run into several risks. What if the patient gets paresthesia from the procedure? In this particular area, this is a real possibility, no matter how remote. What if while excavating the likely lesion, it somehow communicates with the foramen? Having gone over these unlikely, but possible complications with the patient, I became acutely aware that this modality would have little interest to her.
So, perhaps I would send her back to her dentist for extraction of the tooth. He could maintain that space with some sort of an appliance. Or, perhaps just fabricate a three unit bridge for her. In the end, the patient and I chose none of these options. Instead, we attempted to intentionally replant her tooth.
Since the patient did not have any medical problems or allergies, I anesthetized her with one carpule carbocaine and one carpule xylocaine with epinephrine 1:100,000, via inferior alvealor and long buccal injections. One important step to remember before starting treatment was that I reduced the occlusion on the tooth. Performing this step later can sometimes prove to be problematic. Unlike a typical extraction where I luxate the tooth with an elevator, I simply used an Ashe forceps to extract the tooth, moving buccal to lingual, and eventually rotating the tooth out of its socket. Here is why this was so simple: the root was entirely conical in shape — a distinct advantage whenever performing this procedure.
Within 10-15 minutes, I was able to resect the apex and seal the foramen with a thick plug of gray MTA (Fig. 2). I replanted the tooth immediately back into its original socket and sutured it in place with a mattress suture. To further prevent it from moving, I simply placed flowable composite in each corner, further “locking it in” (Fig. 3). Double checking that the tooth was out of occlusion, I took a post-operative radiograph to ensure that the outcome was to my satisfaction (Fig. 4). The patient returned in two weeks to remove the suture and any remaining pieces of composite. Having spoken to her the day after the procedure, she experienced no swelling and no pain. However, she did ice her face for a day and a half to ensure that swelling and discomfort would be reduced.
At her six month checkup, bone healing was certainly visible but not complete (Fig. 5). Soon after, I lost contact with the patient. For some time I could not get her to return for another post-operative checkup. One day she called me on her own explaining that she was married and had a beautiful baby girl. She had not had any dental treatment for almost a year and a half. Now that she was ready to again check her teeth, she visited my office to take the necessary checkup radiograph. Apical healing was now visibly complete (Fig. 6 & 7). Full bone regeneration had occurred. Four years later, I was happy to see that she still had the tooth and was beginning orthodontic therapy to correct other dental issues that required attention. Mobility was very slight, although coronally, about 1mm of bone may have been lost. The mesial now probed 3mm. And, to say the least, the patient was extremely thrilled with the entire procedure and after-care. So then I decided to ask her the obvious: when are you going to get that implant?OH
Dr. Joseph Chikvashvili is currently Director of Endodontics at Newark Beth Israel Medical Center and practices endodontics full-time in West Orange, New Jersey, in private practice alongside Dr. Noah Chivian. He is also President of Essex County Dental Society. And recently, he was elected Secretary to the NJ Association of Endodontists. He also remains active in many other organizations. He has published several articles in various journals, including Dentistry Today, Parkell Today and Compendium.
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REFERENCES
1 Schilder H: Filling the root canals in three dimensions, Dent Clin North Am 723, 1967.
2 Imura N, Pinheiro E, Gomes B, Zaia A, Ferraz C, Souza-Filho F. The Outcome of Endodontic Treatment: A Retrospective Study of 2000 Cases Performed by a Specialist, J of Endod 2007; 33(11): 1278-1282.
3 Grossman L. Endodontic Practice, 11th edition. Philadelphia: Lea & Febiger; 1988. p. 334-42.
4 Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg 1991; 71(6): 743-7.
5 Kim E, Son
g J, Jung I, Lee S, and Kim S. Prospective Clinical Study Evaluating Endodontic Microsurgery Outcomes for Cases with Lesions of Endodontic Origin Compared with Cases with Lesions of Combined Periodontal-Endodontic Origin, J of Endod 2008; 34(5): 546-551.
