|Year : 2013 | Volume
| Issue : 3 | Page : 205-208
Intentional extraction and replantation: The last resort
VT Abdurahiman1, Sanju John Jolly2, M Abdul Khader3
1 Department of Prosthodontics, Al Ameen Dental College, Bijapur, Karnataka, India
2 Department of Prosthodontics, Indira Gandhi Institute of Dental Sciences, Kothamangalam, Kerala, India
3 Department of Prosthodontics, Malabar Dental College, Edappal, Kerala, India
|Date of Web Publication||11-Sep-2013|
V T Abdurahiman
Thushara, PO Vakkad, Via Paravanna, Malappuram - 676 502, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The importance of the first molar in the development of occlusion is well-known. The difficulties when first molar is not there during the eruption of the second molar and the premolar don't have to be explained much. The construction of a space maintainer in the area of missing first molar is difficult when seven and five are not erupted. The article highlights a case where a grossly decayed first molar with repeated endodontic failures was treated by intentional extraction and replantation as a last resort. A follow-up along with indications and considerations are documented.
Keywords: Arch stability, atraumatic extraction, conservation, occlusion, preventive orthodontics, replantation, space maintainer
|How to cite this article:|
Abdurahiman V T, Jolly SJ, Khader M A. Intentional extraction and replantation: The last resort. J Indian Soc Pedod Prev Dent 2013;31:205-8
|How to cite this URL:|
Abdurahiman V T, Jolly SJ, Khader M A. Intentional extraction and replantation: The last resort. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2020 Jul 12];31:205-8. Available from: http://www.jisppd.com/text.asp?2013/31/3/205/117969
| Introduction|| |
Conservation is always given importance in dentistry. Most of the time, in clinical practice, the above said is difficult to maintain as most of the dentist don't have the time or patients are busy or the importance are not understood as well. Conservation not only imply the maintenance of tooth structure or bone on which treatment is performed, but also to preserve surrounding tissues to enhance the future development. A good example for this is the preservation of decayed teeth/tooth for the uneventful eruption of adjacent teeth/tooth into its position. The latter can then be extracted or maintained depending upon the prognosis of the treatment carried out. First molar is considered to be the most important determinant of occlusion. It also helps in maintaining the arch stability and normal alignment. ,
Intentional extraction and replantation are a treatment to be considered when other modes of treatment fail. A case is presented here where a first molar was atraumatically extracted and replanted back after endodontic treatment and socket curettage after which a drastic cure in the condition occurred.
| Case Report|| |
A 10-year-old boy reported with the chief complaint of chronic swelling in the right lower half of the face. He gave a history of multiple endodontic therapies performed elsewhere for his lower tooth. Intra oral examination revealed grossly decayed 46 (lower right first molar) [Figure 1] with open pulp chamber, intact pulpal floor, multiple sinus tract opening in relation to 46 (both buccal and lingual), loss of attachment with slight horizontal mobility and no vertical mobility. The 47 (lower right second molar) was unerupted and 85 (right lower primary second molar) was intact. Radiographic examination of 46 showed [Figure 2] an open apex with no canal fillings, large periapical radiolucency and widening of periodontal space with no alveolar bone loss. It also revealed erupting 47 and 45. Patient was not willing to undergo root canal treatment anymore because of his past experiences and want to get it extracted. The patient's mother was informed about the consequences of early loss of the first molar and alternative options were discussed with her.
Option 1: To extract the tooth and give a removable space maintainer and to correct the occlusion through preventive orthodontics.
Option 2: To extract and replant the tooth immediately after carrying out external endodontic treatment as a last resort.
In the second option, nearly 50% success rate was given and was informed about the chances of the procedure to be switched to the first option, if the fracture of the tooth occurs during the extraction. The patient's mother accepted the condition and an informed consent were obtained from her. The patient was put on amoxicillin 250 mg and clavulanic acid 125 mg and metronidazole 200 mg three times daily for 5 days and was called on the 4 th day.
Patient was asked to rinse his mouth with Chlorhexidine gluconate solution (0.12%) and a local anesthesia was administered. A luxator was used to luxate the tooth (46) within its socket, which was followed by an atraumatic elevation using a molar forceps. The tooth was washed using saline. An inspection of the tooth revealed infected tissue fully covering the root surface [Figure 3]. The tooth was cleaned of the pathological tissue by scrapping using a B.P blade. An intermittent wetting with saline was performed during the scraping procedure. Excess scraping on the tooth was prevented due to chances of loss of viable periodontal tissues. The temporary filling was removed and the canals were prepared. During the preparation, the canals were irrigated using sterile saline and chlorhexidine (2%). Gutta-percha points and root canal cement were used for obturation. The excess material, which came through the apex was cut using scissors. A total of 0.5 mm of apical area was grounded off and a preparation for retrograde filling was performed. Silver amalgam was used for retrograde filling [Figure 4]. The tooth was then preserved in sterile saline.
|Figure 3: 46 atraumatically extracted (note infected tissue covering the root surface)|
Click here to view
The socket was curetted for pathologic tissues. Aggressive curettage was avoided as the socket was too deep and as a precaution to any complication that may encounter during or after the procedure. After curettage, irrigation was performed with saline followed by betadine solution (2%). The socket was then left for fresh bleeding. The tooth was then replanted to the freshly bleeding socket [Figure 5] and the occlusion was checked for. The tooth was then splinted to 85 [Figure 6]. The patient was called at the end of 24 h, 1 week, 1 month, 3 months, 6 months, and 1 year. The clinical examination at 1 month revealed uneventful healing, no sinus tracts, no mobility and no tenderness on percussion. Radiographic examination at the end of 6 months showed a decrease in periapical radiolucency. Clinical examination after a year revealed no signs and symptoms and successfully erupting 47 [Figure 7]. Radiograph taken at 1 year revealed no radiolucency and root resorption [Figure 8].
|Figure 7: Clinical view of 46 after 1 year (Note the uneventful eruption of 47)|
Click here to view
| Discussion|| |
Intentional replantation consists of extracting the tooth, finding and correcting the defect and replanting the tooth in its socket.  Similar types of cases have been reported earlier but a detailed review on the same is scarce. ,, Some authors suggest that intentional replantation must be considered as a routine treatment modality than a last resort, ,, Bender and Louis  reported 31 cases of intentional replantation with an overall success rate of 80.6% and with six recorded failures. Survival times varied from 1 day to 22 years. Messakob  have reported a successful three unit bridge on a replanted root for the first time. Benenati  did a 15.5-year follow-up clinical examination, which revealed the patient to be asymptomatic and functional. A recall film showed no evidence of root resorption. Rouhani et al.  reported a 95% success rate on reimplanted cases with an average retention of 3-5 years.
Preservation of natural dentition is the primary goal of any conservative treatment modality. Intentional replantation is an accepted endodontic treatment procedure in which a tooth is extracted and treated outside the oral cavity and then inserted into its socket to correct an obvious radiographic or clinical endodontic failure. Although not the primary therapy of choice, intentional replantation is an alternative to certain situations that a dentist should consider. ,, Clinicians should know well about its indications/contraindications, surgical procedure and complications following treatment. Numerous factors such as the amount of bone, the time the tooth is out of the socket, the preservation media,  aseptic conditions followed, radiographic findings etc come into considerations when such type of treatments are executed. External inflammatory resorption and ankylosis caused by the periodontal ligament damage are the most common failure associated with this mode of treatment. 
Considerations for Extraction and Replantation
- When there is difficulty in endodontic retreatment or inaccessibility to perform apical surgery especially in lower second and first molars, single-rooted teeth, etc. ,
- When the mental foramen are superimposed over the apex of the premolars. 
- When the molar apex is in proximity to the mandibular canal. 
- When patients object to periradicular surgery. ,
- When failures occur after apical surgery. 
- When surgery would create a periodontal pocket as a result of the extensive bone removal. 
- When teeth to be salvaged is of prime importance to the existence and development of stomatognathic system. 
- As a last resort when all other treatment modalities fail.
- If 75% of bone support persists and minimal tooth mobility persists. 
- No vertical mobility.
- When teeth can be extracted atraumatically.
| Conclusion|| |
The fact whether the tooth functions in the future depends upon various factors and is beyond the scope of this article. The patient has been informed to undergo check-up every 6 months along with a radiographic evaluation. Regular checkups should be performed until the patient attains the age of 18, where if required can go for a crown or related treatments. Such replantations can preserve and maintain the affected tooth until the entire arch is developed. Further studies and reviews are required to support these modalities of treatment as it's mandatory to develop good occlusion.
| Acknowledgment|| |
The author would like to thank Mr. Jameel Zargar, PhD. Student, Department of Physiology, Al Ameen Dental College, Bijapur.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]