Case Report/Clinical Techniques

Intentional Replantation: A Case Report

Michael R. Cotter, DDS,* and John Panzarino, DMD
Abstract
Nonsurgical retreatment and surgical endodontics are
not always viable solutions to endodontic disease. Access for retreatment may be limited by posts. Surgical
endodontics may be limited by anatomical features
including bone thickness and nerve and sinus proximity.
Anatomical limitations and complex restorations may
prevent implant placement. Intentional replantation is
considered by many as a procedure of last resort when
nonsurgical or surgical endodontics is contra-indicated.
The treatment described demonstrates intentional replantation as a procedure to be considered when endodontic procedures or a dental implant are not possible.
(J Endod 2006;32:579 582)

Key Words
Alternative to implant, apico, apicoectomy, buccal plate
thickness, chlorohexidine gluconate, chronic apical periodontitis, endo, intentional replantation, molar endodontics, retreat, retro-prep, retro-seal, super EBA.

From the *Private practice, Mamaroneck, NY, Attending,

Montefiore Medical Center, Bronx, New York; Private practice, New Brunswick, New Jersey.
Address requests for reprints to Dr. Michael R. Cotter,
Department of Dentistry, 3332 Rochambeau Ave., Montefiore
Medical Center, Bronx, NY 10467. E-mail address:
michael@endocotter.com.
0099-2399/$0 - see front matter
Copyright 2006 by the American Association of
Endodontists.
doi:10.1016/j.joen.2005.08.004

ntentional replantation is defined by Grossman as the removal of a tooth and its

almost immediate replacement, with the object of obturating the canals apically while
the tooth is out of the socket. (1) It is considered by many as a procedure of last resort.
The indications for intentional replantation include failed previous nonsurgical endodontics, an apicoectomy procedure is unfavorable because of anatomical factors (e.g.
buccal plate thickness, proximity to anatomical structures such as the mandibular nerve
or inoperable sites such as lingual surfaces of mandibular molars) or financial factors
preclude conventional implant placement. Buccal plate thickness may preclude surgical endodontic treatment in mandibular molars and the palatal root of maxillary molars
(2). Although post removal is frequently possible in the hands of a skilled clinician,
occasionally posts or separated instrument removal may pose risks greater than the
potential benefits as compared with other options including extraction (3).
Contraindications to intentional replantation include: a more favorable prognosis
with either conventional apical surgery or implant placement, active periodontal disease, a nonrestorable tooth, extraction requiring hemi-section or osseous recontouring, the tooth is part of a multiple-tooth prosthesis, or the roots are divergent. In these
cases involving individual teeth (nonsplinted) with divergent roots, a single tooth osteotomy may be considered (4). Advantages of intentional replantation include: potentially more cost-effective and less time consuming than the alternatives. Disadvantages
include a risk of root fracture or root resorption. Bender and Rossman reported a
success rate of 81% of 31 teeth followed for up to 22 yr (5). Kingsbury and Weisenbaugh
reported a success rate of 95% for 151 teeth followed for 3 yr (6). The majority of
frequently success and failure studies comparing the outcomes of surgical treatment
with that of nonsurgical treatment since 1970 are case series (7).

Case Report
A 47 yr old female presented to the Advanced Education Program in Endodontics
at New York University College of Dentistry for evaluation of tooth #31. Her chief
complaint was pain from her lower right back tooth when she bites down. Her
medical history was non contributory, no allergies or medications. Dental history included endodontic therapy on tooth #31 with a post, core and crown. Clinical examination revealed pain to percussion and palpation. No evidence of a stoma was noted.
Tooth #31 was restored with a metal ceramic crown with appropriate marginal and
occlusal integrity. Teeth 2, 30, and 32 were present and in proper contact with #31.
Periodontal examination revealed mobility, probing depths and gingival tone within
normal limits. Radiographic examination revealed a large periapical radiolucency associated with the apex of tooth #31 (Fig. 1). Crestal bone levels appeared to be within
normal limits.
The patient was presented with the treatment options of extraction and a dental
implant or extraction with no replacement. Endodontic retreatment and implant therapy were declined by the patient. Surgical endodontics was contra-indicated because of
proximity to the inferior alveolar canal. After understanding risks and benefits of all
treatment options, the patient made an informed decision to have the tooth removed.
Upon the patients decision to have the tooth extracted, the treatment option of intentional replantation with associated risks and benefits was offered. The patient accepted.

Procedure
One hour before the procedure, the patient rinsed with chlorhexidine gluconate
0.12% and was given 600 mg of ibuprofen. Two operators were present throughout the
procedure. The patient was prepared for surgery and profound inferior alveolar and
lingual nerve block anesthesia was achieved with 2% lidocaine containing 1:100,000

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Figure 1. Radiograph illustrating a large periapical radiolucency associated

with the apex of tooth #31.

epinephrine. A mucoperiosteal flap was elevated to gain access to the

tooth apical to the crown margin to prevent damage to the crown. The
tooth was extracted with minimal trauma through the use of forceps
(Fig. 2). Operator #1 carried the tooth in the forceps over Hanks
solution to a microscope (Proteg, Global Surgical Corp., St. Louis,
MO) immediately adjacent to the patient. Under 12X, the apex was
resected with the lesion attached (Fig. 3) and the roots were evaluated
for vertical fractures. Although recommended treatment of a vertical
root fracture includes dentin bonding resin (8 hayashi, 9 hayashi), no
fractures were detected. The lesion was sent for histo-pathological analysis. The apices of the two roots were retro prepared (Satelec P5 Ultrasonic Booster) removing 3 mm of gutta-percha and debris (Fig. 4).
Irrigation was performed with sterile saline and the two canals were
dried with paper points, while the entire root surface was kept moist
with saline. The canals were sealed with super EBA fast-set and burnished (Fig. 5). As the tooth was being treated, operator #2 lightly
curetted the apical portion of the socket without disturbing the socket
walls coronal to the apex. The tooth was replanted into the socket in less
than 5 min from extraction. Two interrupted 4-0 silk sutures were used
to stabilize the tooth. A postoperative radiograph was taken (Fig. 6) and
the following postoperative instructions were given: chlorhexidine glu-

Figure 2. Photograph of the extraction site of tooth #31.

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Cotter and Panzarino

Figure 3. Photograph illustrating the apical resection of tooth #31.

conate 0.12% on a cotton swab over the site three times per day after
meals for 7 days, ibuprofen 600 mg every 4 to 6 h for 48 h and soft diet
for 2 wk. The patient was recalled in 1 wk for suture removal and
evaluation of the surgical site. At 1 wk, the soft tissues appeared pink in
color with minimal inflammation and pain upon biting had diminished.
Microscopic examination revealed soft tissue composed of granulation tissue infiltrated by acute and chronic inflammatory cells (Fig.
7). The histo-pathological diagnosis was dental granuloma. The patient
was recalled in 1 month. Healing was uneventful and the patients symptoms had subsided. Tooth mobility was normal. The patient was recalled
again at 1 yr and clinical examination revealed no response to percussion or palpation, soft tissue probing depths and mobility were within
normal limits. Radiographic examination revealed complete osseous
healing of the peri-apical radiolucency (Fig. 8).

Discussion
Intentional replantation is indicated when the apex of the involved tooth is in close proximity to the inferior alveolar nerve,
mental nerve or the maxillary sinus. Suture splinting is used to
secure the reimplanted tooth because rigid splinting may harbor
bacteria, delay healing and promote replacement resorption by not

Figure 4. Photograph illustrating the apical retro-prep of the mesial and distal
canals of tooth #31.

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Figure 5. Photograph of tooth #31 illustrating the apical retro-seal with Super
EBA.

Figure 7. Histological slide revealing soft tissue composed of granulation tissue

infiltrated by acute and chronic inflammatory cells.

allowing physiological mobility (10). In the case reported, the occlusal surface was not reduced during or after the surgery in an
effort to promote healing.
To achieve minimal extra-oral time, the procedure was rehearsed
with extracted teeth in a simulated setting five times. Extra-oral time in
this treatment was less than 5 min. The success of intentional replantation is likely dependent upon a minimally traumatic extraction, short
extra-oral time with copious irrigation and meticulous instrumentation
as well as carefully controlled postoperative patient compliance. Successful completion, according to Kratchman, of extra-oral manipulation
should not exceed 10 min (10). Radiographic analysis, after retrofill
and before replantation is an option than can be utilized for further
apical evaluation. This radiograph enables the operator to ensure the
apical fill adequately extends from the gutta-percha to the apex. It must
be noted that additional extra-oral time could hinder the overall success
of the procedure. It was determined before treatment, not to take an
immediate postoperative radiograph before reimplantation because of
the additional extra-oral time required. Although the retro-fill material

does not extend completely to the gutta-percha, visual inspection demonstrated adequate marginal adaption at the apex and #31 healed uneventfully.
In 1995 Pitt Ford found that Super EBA and Cavit showed similar mild inflammatory response as an apical sealer when compared
to zinc-oxide and eugenol, Kalzinol and amalgam (11). In 1999,
Adamo found no significant differences between amalgam, composite, MTA, and super EBA as retrograde sealing materials (12). The
retrograde seal used in this treatment was Super EBA because it is
easily manipulated, has a fast setting time and well tolerated by
peri-apical tissues. Data that has been published subsequent to the
procedure described here suggest that MTA-Angelus shows better
marginal adaptation than Super-EBA and Vitremer (13).
With the high success rate of dental implants and endodontics,
intentional replantation is not frequently the treatment of choice.
However, in cases where a dental implant, nonsurgical retreatment
or surgical treatment is not possible, intentional replantation may be
a viable treatment option. (8, 9)

Figure 6. Radiograph of tooth #31 immediately after replantation.

Figure 8. One year postoperative radiograph revealing complete osseous healing of the peri-apical radiolucency.

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1. Grossman LI. Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc
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7. Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Levels of evidence for the
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8. Hayashi M, Kinomoto Y, Miura M, Sato I, Takeshige F, Ebisu S. Short-term evaluation

of intentional replantation of vertically fractured roots reconstructed with dentinbonded resin. J Endod 2002;28:120 4.
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10. Kratchman S. Intentional replantation. Dent Clin North Am 1997;41:60317.
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13. Xavier CB, Weismann R, de Oliveira MG, Demarco FF, Pozza DH. Root-end filling
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