Dental Traumatology 2003; 19: 233236 Printed in Denmark.

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Copyright # Blackwell Munksgaard 2003 DENTAL TRAUMATOLOGY ISSN 16004469

Case Report

Intentional replantation of a mandibular second molar with long-term follow-up: report of a case
Benenati FW. Intentional replantation of a mandibular second molar with long-term follow-up: report of a case. Dent Traumatol 2003;19: 233^236. # Blackwell Munksgaard, 2003. Abstract ^ A case is reported of a mandibular second molar that underwent non-surgical endodontic treatment and intentional replantation in an eort to relieve continued symptoms. A 15.5-year follow-up clinical examination revealed the patient to be asymptomatic, the tooth to be still functional, and a recall lm showed no evidence of root resorption. The indications for and limitations of intentional replantation as well as recommended literature on the subject are discussed. The intentional replantation of a tooth is a concept that has been known for over a thousand years, dating back to the eleventh century (1). It was later dened by Grossman as follows: `intentional replantation is a purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina' (2). He also stated that it is `the act of deliberately removing a tooth and ^ following examination, diagnosis, endodontic manipulation, and repair ^ returning the tooth to its original socket' (3). Many authors agree that it should be reserved as a last resort to save atooth after other procedures have failed or would likely fail (4^7). Messkoub (8) stated in his case report that the literature reports of the range of success in retaining replanted teeth in terms of time vary between 52 and 95%, when cases were followed from 1^22 years. He also mentioned in the same report that the average time of retention is 3^5 years.The main reason for the failure of retention of these teeth is root resorption, specically ankylosis or replacement resorption. This is directly related to the amount of time the tooth is out of the mouth during the procedure (2, 8, 9). Kratchman (10) has given a thoroughly listed and well-illustrated description of both indications andcontraindications for intentional replantation. Dryden & Arens (11) describedthehistological perspective of intentional replantation, and included indications, contraindications, technique, and an extensive review of the literature pertaining to this subject. The following is a case report which Fred W. Benenati
Department of Endodontics, College of Dentistry, University of Oklahoma, Oklahoma City, OK, USA Key words: dental; intentional replanatation Dr Fred W. Benenati, Department of Endodontics, College of Dentistry, University of Oklahoma, PO Box 26901, Oklahoma City, OK 73190, USA Fax: 1405 2713423 e-mail: fred-benenati@ouhsc.edu Accepted 2 October, 2002

describes the non-surgical endodontic treatment and intentional replantation of a mandibular molar and its nearly 16-year follow-up. Case report A 45-year-old White woman was referred for endodontic evaluation of the mandibular left rst and second molars on April 14, 1986. Her complaints were slight swelling facial to the rst molar and severe sensitivity to cold liquids in the area of the teeth. The patient's medical history included a stated allergy to codeine, a history of temporomandibular joint pain, gall bladder surgery, and a hysterectomy. She also reported seasonal hay fever and pollen allergies. Root canal therapy had been completed on the rst molar several years back, and a full metal crown was placed. The second molar had an occlusal amalgam restoration for a duration of several years. Upon clinical examination, both teeth were tender to percussion and the rst molar was tender to palpation facial to its mesial root. Slight swelling of the vestibule facial to the rst molar tooth was noted. The second molar responded with a sharp, lingering pain when an ice stick was applied to it.The rst molar did not respond to ice, nor did the adjacent second premolar. The second molar was found to have a mesial^distal hairline crack traversing the occlusal surface, which appeared to terminate above the gingival sulcus. Periodontal probing depths did not exceed 3 mm for both molars.

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Fig. 1. Preoperative film of mandibular left first and second molars. Note conical root form and fusion of roots of second molar. Thickened periodontal ligament spaces are noted at the apices of the second molar and the mesial apex of the first molar.

Fig. 2. Completed non-surgical endodontic treatment of the second molar and retreatment of the first molar.

Radiographic ndings (Fig.1) includedthickenedperiodontal ligament spaces at the apices of the second molar and at the mesial apex of the rst molar. The rst molar also displayed an inadequate existing root canalobturation.The patient was scheduledtobe seen the following day for treatment. The patient returned the next day, and a mandibular block local anesthetic was administered. Both molars were accessed in the usual manner using rubber dam isolation. A complete pulpectomy was performed on the second molar, and the existing obturations in the rst molar were removed. Complete canal lengths were gained in the rst molar in the disto-lingual and the mesio-lingual canal, and a previously missed disto-facial canal.The mesio-facial canal could not be completely negotiated. Cleaning and shaping with K-type les were accomplished in both teeth, the canals were dried, and the accesses closed with sterile cotton and a temporary lling cement. A prescription for penicillin tablets (500 mg) four times daily for 1week and Darvocet N-100, 12 tablets, one every 4^6 h as needed for pain was given. The patient was appointed for completion of treatment 1week later. On April 23, 1986, the patient returned with no further sensitivity to cold liquids and no vestibular swelling facial to the rst molar.The patient reported only mild soreness to pressure from the rst molar. A local anesthetic was given, rubber dam isolation achieved and both teeth were reaccessed. Instrumentation was completed in both the rst and second molars using sodium hypochlorite irrigation and Ktype les. Obturation was completed using warm gutta-percha vertical condensation and Kerr Pulp Canal Sealer (Romulus, Michigan). Abase ofpolycarboxylate was placed followed by amalgam to seal the occlusal accesses in both teeth. The patient was

advised that further treatment may be required for the rst molar due to inability to completely negotiate the mesio-facial canal. A periapical lm (Fig.2) was obtained, and the patient was instructed to have a full crown placed on the second molar and was placed on a 6-month recall. Over-the-counter analgesics were recommended to be taken if needed for postoperative soreness. The patient returned on May 28,1986, complaining of renewed swelling facial to the mandibular left rst molar. At this time, a permanent crown was in place on the replanted second molar.The patient was given a prescription for penicillin and scheduled for periapical surgery on the rst molar. This was completed onJune 4,1986, using a local anesthetic. Apical curettage was performed, and retroll amalgams were placed (Fig.3). The suture removal 1week later was uneventful. OnJune10,1986, the patient again called complaining of severe pain due to pressure from the second

Fig. 3. Surgical treatment of the first molar completed with amalgam retrofills at both apices.

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Intentional replantation of mandibular second molar: a case report molar. The occlusion on her crown was adjusted, and mild analgesics were recommended. She was instructed to call back if her pain continued. The patient called again onJuly 22,1986, complaining of slight swelling facial to the second molar. She was seen that day, and a clinical examination revealed slight swelling in the vestibule and extreme sensitivity to percussion. Periodontal probing was within normal limits (3 mm or less). The patient was advised that a periapical surgery was necessary. She declined to a surgery but did not want to lose the tooth. Because of the anatomical presence of fused roots onthat tooth, she was oered the alternative of intentional replantation, and appraised of its risks and limitations. She accepted this recommendation and was given a prescription forVibramycin 100 mg capsules, to be taken once every day for10 days, due to its anity for targeting bone infections. She was then scheduled for an intentional replantation procedure. The patient reported on August 12, 1986, and was asymptomatic. There was no swelling present at the time. A local anesthetic was given, and the tooth was removed with forceps without complication. Using a sterile gauze sponge, the tooth was held by hand on the crown and the fused apices were beveled using a high-speed handpiece. Retroll preparations were made with an inverted cone bur in a high-speed handpiece, and a spherical amalgam was condensed into the two preparations. The tooth was then irrigated with sterile saline and replanted into its socket (Fig.4). The total time out of the mouth was not more than 3 min. A soft periodontal packing was placed as a functional splint by wrapping it around both the rst and second molars on the facial and lingual surfaces. The occlusion was then adjusted on that tooth. Postoperative instructions as well as a prescription for Darvocet N-100 for pain were given. On August 20,1986, the patient returned and the packing was removed. The occlusion was readjusted. She was

Fig. 5. A15.5-year recall of both first and second molars. Second molar exhibits an intact root surface and periodontal ligament. The first molar exhibits normalperiradicular appearance as well.

comfortable at that time, reported only mild soreness, and was placed on a 6-month recall. Although the patient failed to report for her 6month recall, she returned nearly 16 years later on April 9, 2002 for a consultation involving another tooth. She was completely free of symptoms from the replanted mandibular second molar. Probing depths around it were no greater than 3 mm. Percussion was negative and elicited a normal sound. A periapical lm (Fig.5) showed no evidence of root resorption, and the root surface and periodontal ligament appeared intact. The rst molar also displayed a normal appearing periodontal ligament around both roots and was asymptomatic as well. Discussion As reportedby Kratchman (10), there are some advantages in performing an intentional replantation when periapical surgery is refused. The procedure is typically less time consuming and invasive than periapical surgery. He reported that indications included limited access, anatomical limitations, perforations in areas not accessible to surgery, patient management, failed apical surgery, and persistent chronic pain. With proper case selection, the procedure can be simple and straightforward. There is less chance of nerve bundle damage in the mandibular posterior region as well. This particular tooth had a fused, conical root shape, which lent some simplicity to extraction and manipulation during the surgical procedure. Kratchman also labeled this type of anatomical conguration as a `good/bad' candidate for intentional replantation: good because it involved fused roots, and bad because of its lack of a furcation, causing a possible diculty in stabilization. He listed contraindications to include pre-existent moderateto-serve periodontal disease, curved or ared roots, a non-restorable tooth, and missing interseptal bone.

Fig. 4. Second molar immediately after intentional replantation. Amalgam retrofills are in place.

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Benenati Fortunately, this tooth did not fall into any of these categories. The author acknowledges that there was a coincidence of the adjacent tooth requiring an extensive amount of endodontic treatment. It would have been inappropriate to exclude it from being part of the description of this case, because both teeth were initially treated at the same time. After having gone through one periapical surgery on the adjacent molar, the patient declined the option to perform another for the same tooth. Dryden & Arens (11) cited this as a viable indication for replantation, especially when all other options and risks had been considered and explained. The limited or dicult access to this tooth would have been another factor in performing periapical surgery, and as Kratchman (10) alludes to, a considerable amount of bone would be required to be removed to contact the apices. Patient compliance and the lack of periodontal disease (12) in this area were also important factors in the decision to perform the procedure. Certainly, the aforementioned risks of intentional replantation were considered. The impression that long-term success of these cases were generally poor, according to Weine (5), was also acknowledged and conveyed to the patient. Her desire to attempt to save the tooth was made with all these issues in mind, and fortunately to date, this treatment has resulted in her continued retention of the tooth. References
1. Weinberger B. Introduction to the history of dentistry,Vol.1. St. Louis: CV Mosby;1948. p. 105. 2. Grossman L. Endodontic practice, 11th edn. Philadelphia: Lea & Febiger;1988. p. 334^42. 3. Grossman L. Intentional replantation of teeth. J Am Dent Assoc 1982;104:633^9. 4. Grossman L, Ship I. Survival rate of replanted teeth. Oral Surg1970;29(6):899^906. 5. Weine F. The case against intentional replantation. J Am Dent Assoc 1980;100(5):664^8. 6. Deeb E, Prietto P, McKenna R. Reimplantation of luxated teeth in humans. J South Calif Dent Assoc 1965;33: 194^206. 7. Cohen S, Burns R. Pathways of the pulp, 4th edn. St. Louis: CV Mosby;1987. p. 607^8. 8. Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg1991;71(6):743^7. 9. Andreasen J, Hjorting H. Replantation of teeth. Part II. Histological study of 22 replanted anterior teeth in humans. Acta Odont Scand 1966;24:287^306. 10. Kratchman S. Intentional replantation. Dent Clinics North Am 1997;41(3):603^17. 11. Dryden J, Arens D. Intentional replantation. A viable alternative for selected teeth. Dent Clinics North Am 1994; 38(2):325^53. 12. Dumsha T, Gutmann J. Clinical guidelines for intentional replantation. Comp Cont Ed Dent 1985;6(8):606^8.

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