Intentional reimplantation - two case reports

Case Report Intentional reimplantation - two case reports GURPREET SINGH * NIKHIL BAHUGUNA ** PARDEEP MAHAJAN *** ABSTRACT Intentional reimplantation is a procedure in which an intentional tooth extraction is performed followed by reinsertion of the extracted tooth into its own alveolus. In this article, intentional reimplantation is described and discussed as a treatment approach for failed root canal treatment with broken instrument periapically in mandibular second molar and in a case of perforating internal resorption in maxillary central incisor. A 2 year follow up and 6 month follow up respectively revealed the patient to be asymptomatic, the tooth to be functional and a recall film showed no evidence of root resorption. The indications for and limitations of intentional replantation as well as recommended literature on the subject are discussed. INTRODUCTION Intentional reimplantation was defined by Grossman as the purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina 7. He also stated that it is the act of deliberately removing a tooth and following examination, diagnosis, endodontic manipulation and repair returning the tooth into its original socket 8. Many authors agree that it should be reserved as the last resort to save a tooth after other procedures have failed or would likely to fail 1. Messkoub 14 reported success rate in retaining replanted teeth vary between 52-95%. The main reason of failure in replanted teeth is root resorption, specifically ankylosis or replacement resorption. This is directly related to the amount of time the tooth is out of the mouth during the procedure 7, 14. Kratchman 12 has given a thoroughly listed and well illustrated description of both indications and contraindications for intentional reimplantation. Dryden and Arens 4 described the histological perspective of intentional reimplantation and included indications, contraindications, technique, and an extensive review of the literature pertaining to this subject. Mineral trioxide aggregate (MTA) has satisfactory properties, for solving many endodontic problems, including: biocompatibility, favourable sealing ability, mechanical strength and a capacity to promote periradicular tissue healing. Originally developed as a surgical root-end filling material, MTA has been used successfully in several clinical applications such as pulp capping, pulpotomy, perforation repair treatment of traumatized teeth with immature apices and for treatment of root resorptions 9. The present article describes two cases of intentional replantation -: 1) maxillary central incisor with perforating internal resorption and 2) mandibular second molar with fractured instrument periapically. * Senior Lecturer, ** Reader, *** Prof. and Head, Dept. of Conservative Dentistry & Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur. 59

CASE REPORTS CASE- 1 A 25 year old male reported to the Department of Conservative Dentistry and Endodontics at Genesis Institute of Dental Sciences and Research, Ferozepur with chief complaint of slight pain in the left maxillary anterior tooth since a week. The dental history revealed trauma to the front teeth as a result of road accident 7 years back. Crown fracture of 21 was diagnosed at that time. There had been no other injury to dental hard tissues. Pulp space therapy had been initiated after few days of the accident which was discontinued by the patient. When patient reported to us, 21 was fractured [Fig-1] and sensitive to apical palpation and percussion. There was actively draining sinus tract from the alveolar mucosa above 21. Radiographic examination showed oval shaped radiolucency at the junction of the middle and apical third of the root [Fig-1]. Supplemental radiographs were taken from different angles in order to make a definitive diagnosis and to examine the extent of the tooth destruction. It was discovered that there was external root perforation associated with internal resorption. A periapical radiolucency was also present with respect to 21. The resulting clinical situation had guarded prognosis. To overcome the problem, several treatment options were discussed. The patient was reluctant to go for periapical surgery. Finally, endodontic treatment followed by tooth reimplantation was selected as clinical procedure. The tooth was isolated with rubber dam and access to root canal obtained. The working length was established 0.5mm short of the radiographic GURPREET SINGH, NIKHIL BAHUGUNA, PARDEEP MAHAJAN apex and the root canal preparation was accomplished using 3% sodium hypochlorite and hand instrumentation. After completion of chemomechanical preparation, the canals were finally irrigated with 3% sodium hypochlorite solution, dried with sterile paper points and filled with calcium hydroxide (Metapex) [Fig-2] for a week. The calcium hydroxide paste was removed after a week and the root canal was obturated with gutta percha and sealer [Fig-3] by vertical and thermatic condensation via coronal access cavity. The tooth was then extracted as atraumatically as possible [Fig-4]. During the extraoral period the periodontal tissue was frequently irrigated with sterile saline solution. The alveolus was subjected to curettage, in order to remove inflammatory tissue. The alveolus was irrigated with sterile saline solution. Root end resection and removal of the resorptive defect [Fig-5] was performed extraorally followed by sealing by MTA (angeulus) [Fig-6]. This procedure took approximately 10 minutes. Thereafter tooth was replanted and secured with orthodontic wire and flowable composite [Fig-7]. The occlusion was adjusted in order to ensure that tooth to be free of interface. An intraoral periapical radiograph revealed proper repositioning of the tooth and proper root end filling [Fig-8]. Novamox LB 500 mg three times a day for 5 days; combiflam three times a day for 5 days and 0.12% chlorhexidine rinses three times for seven days were prescribed. The splint was removed after 3 weeks of reimplanatation. Patient had no pain or discomfort during postoperative period. After 6 months the patient was asymptomatic, percussion was negative and IOPA revealed healing and there was no signs 60

INTENTIONAL REIMPLANTATION - TWO CASE REPORTS of resorption [Fig-9]. There was no pathological condition, good gingival health and no periodontal pocket. 4. AFTER EXTRACTION 1. PREOPERATIVE PHOTOGRAPH AND IOPA 5. ROOT END PREPARATION 2. METAPEX GIVEN 6. RESTORATION WITH MTA 7. SPLINT IN PLACE 3. POSTOBTURATION IOPA 61

CASE- 2 8. IOPA AFTER SPLINTING 9. AFTER SIX MONTHS A 35 year old male reported to the department with chief complaint of persistent pain in right lower back tooth after 1 year of pulp space therapy of that tooth. 47 was endodontically treated 1 year back by a general dentist. After taking an IOPA, external apical resorption of the roots, overextending root canal filling material and broken instrument in periapical area was detected [Fig-1]. The patient was advised that a periapical surgery was necessary. He declined to the surgery but did not want to lose the tooth. Because of the anatomical limitations, the patient was offered the alternative of intentional reimplanatation, and appraised of its risks and limitations. He accepted this recommendation and was given prescription of amoxicillin 500mg for three times a day for three days. He was then scheduled for an intentional reimplanatation procedure. Local anesthesia was administered and the tooth was removed with forceps without complication [Fig-2]. Using a sterile gauze sponge, the tooth was held by hand on the crown and the roots were beveled using high speed handpiece [Fig-4]. Retrofil preparations were made with straight bur in a high speed handpiece [Fig-5] and MTA was condensed into the preparations [Fig- 6]. The alveolus was gently curreted and the pathology was removed [Fig-7] and the broken instrument was carefully taken out [Fig-3]. The tooth was then irrigated with sterile saline and replanted into its socket. The procedure took 12 minutes. A sling suture around the tooth was used as the splint for three weeks [Fig-8]. The occlusion was adjusted on that tooth. Postoperative instructions and prescription for injection voveron for pain were given. After three weeks the sutures were removed and the patient was asymptomatic. The patient was placed on 6 months recall for two years. After two years the patient was completely free of symptoms. Percussion was negative and elicited a normal sound. A periapical film showed no evidence of root resorption [Fig-9], and the root surface and periodontal ligament appeared intact. 62

INTENTIONAL REIMPLANTATION - TWO CASE REPORTS 1. PREOPERATIVE PHOTOGRAPH AND IOPA 5. PREPARED ROOT ENDS 2. AFTER EXTRACTION 6. RESTORATION WITH MTA 3. INSTRUMENT REMOVED 7. REMOVAL OF GRANULOMA 4. ROOT END PREPARATIONS 63

GURPREET SINGH, NIKHIL BAHUGUNA, PARDEEP MAHAJAN DISCUSSION 8. SPLINTING DONE 9. AFTER TWO YEARS As reported by Kratchman 12, there are some advantages in performing intentional reimplanatation when periapical surgery is refused. The procedure is typically less time consuming and invasive as compared to periapical surgery. He reported that indications included limited access, anatomical limitations, and perforations in areas not accessible to surgery, failed apical surgery and persistent chronic pain. With proper case selection, the procedure is simple and straightforward. There is less chance of damage of vital structures adjacent to the teeth. The central incisor in the first case and second molar in second case had straight conical shape roots which made the extraction and the manipulation during the procedure simple and less time consuming. In the present case reports, the teeth were outside the mouth approximately less than 15 minutes, manipulation was kept minimal, and the periodontal ligament was not removed as recommended by most authors. The best reimplantic prognosis is directly related to the amount of time the tooth is maintained extraorally during the procedure. From some reports, the potential for resorption in replanted teeth increases if they remain outside the mouth for more than 30 minutes 15. Kratchman 12 also listed contraindications of this procedure like preexistent moderate to severe periodontal disease, curved or flared roots, a non restorable tooth and missing interseptal bone. Fortunately, teeth in the both cases did not fall into any of these categories. Dryden and Arens 4 cited refusal of the patient for periapical surgery as a viable indication for the intentional replantation. The esthetic concern for the central incisor was another factor for performing intentional reimplanatation as the surgical procedure would lead to shrinkage of gingival margin. Also the considerable amount of bone would be removed to reach the apex of the tooth 12. Patient compliance and lack of periodontal disease 5 in this area were also important factors in the decision to perform the procedure. Certainly the risks of intentional reimplanatation were considered and acknowledged and conveyed to the patients. Their desire to save the tooth was made with all these issues in the mind, fortunately to date; this procedure resulted in the continued retention of teeth in both the cases. CONCLUSION Some authors consider Intentional Reimplantation to be a last resort; whereas others 64

INTENTIONAL REIMPLANTATION - TWO CASE REPORTS consider it as another treatment modality. This alternative treatment may be predictable and suggested for certain cases when routine treatment cannot be undertaken or has failed, where periapical surgery would either be impracticable or refused by the patient or unlikely to succeed. References: 1. Benenati FW. Intentional replantation of a mandibular second molar with long-term follow-up: report of a case. Dental Traumatology 2003; 19: 233-6. 2. Caliskan MK, Turkun M. Prognosis of permanent teeth with internal resorption: a clinical review. Endod Dent Traumatol 1997; 13: 75-81. 3. Caliskan M.K., Turkun M. Root canal treatment of a root fractured incisor tooth with internal resorption: a case report. International Endodontic Journal 1996; 29: 393-7. 4. Dryden J, Arens D. Intentional Replantation. A viable alternative for selected teeth. Dent Clinics North Am 1994; 38(2): 325-53. 5. Dumsha T, Gutmann J. Clinical guidelines for intentional replantation. Comp Cont Ed Dent 1985; 6(8): 606-8. 6. Gencoglu N., Yildrim T., Garip Y., Karagenc B., Yilmaz H. Effectiveness of different gutta-percha techniques when filling experimental internal resorptive cavities. International Endodontic Journal 2008; 41: 836-842. 7. Grossman L. Endodontic practice, 11 th edn. Philadelphia: Lea & Febiger; 1988. p. 334-42. 8. Grossman L. Intentional replantation of teeth. J Am Dent Assoc 1982; 104: 633-9. 9. Jacobovitz M., de Lima R.K.P. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. International Endodontic Journal 2008; 41: 905-12. 10. Keinan D., Heling I., Stabholtz A., Moshonov J. Rapidly progressive internal root resorption: a case report. Dental Traumatology 2008; 24: 546-9. 11. Kinirons MJ, Boyd DH, Gregg TA. Inflammatory and replacement resorption in reimplanted permanent incisor teeth: a study of the characteristics of 84 teeth. Endod Dent Traumatol 1999; 15: 269-272. 12. Kratchman S. Intentional Replantation. Dent Clinics North Am 1997; 41(3): 603-17. 13. Meire M., De Moor R. Mineral trioxide aggregate repair of perforating internal resorption in a mandibular molar. JOE 2008; 34: 220-223. 14. Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg 1991; 71(6): 743-7. 15. Pennarocha M., Garcia B., Marti E., Palop M., von Arx T. Intentional replantation for the management of maxillary sinusitis. International Endodontic Journal 2007; 40: 891-9. 16. Pohl Y., Fillipi A., Tekin U., Kirschner H. Periodontal healing after intentional auto-alloplastic reimplantation of injured immature upper front teeth. J Clin Periodontol 2000; 27: 198-204. 17. Poi WR, Sonoda CK, Salineiro SL, Martin SC. Treatment of root perforation by intentional reimplantation: a case report. Endod Dent Traumatol 1999; 15: 132-4. 65