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By Jeff Ward, HIIS(oiaga). (;radDipClinDcnl. UDSC ( ~ e l h ) formcrly
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poslgraduate sludcnl. School ol'
Ikntal Wicnce, Tha llniversily of Melhourne, 71 1 Elizabeth Slrcret, Melbourne, Wloria 3000.

Address for correspondence: lavel 6. 766 Elizabclh Slrect. Melbournc, VIC 3000.

Intentional Replantation Of A Lower

Premolar
Abstract
Intentional replantation is the purposeful extraction
of a tooth to perform extraoral endodontic
treatment, curettage of apical soft tissue when
present and the replacement of the tooth in its
socket. This paper demonstrates the use of
intentional replantation as a technique to successfully
treat a case where conventional endodontic
retreatment and apical surgery were considered
unfeasible.

Introduction
Intentional replantation is performed mainly as an alternative to
extraction when conventional endodontic treatment or retredtment
is not successful and periapical surgery is not possible or is high-risk
due to the close presence of delicate anatomical structures ( I )
Bender and Rossman (2). suggest intentional replantationreduce
the adverse outcomes that other forms of endodontic surgery
experience in selected cases Intentional replantation has been
recommended as the first choice of surgical treatment for (2).
Situations where intentional replantation is indicated. including
surgical indications with close proximity to vital anatomical
structures such as the maxillary sinus. inferior alveolar nerve
canal and the mental foramen.
teeth with limited surgical access such as lower second or third
molars;
patients who object to periradicular surgery; and
mesial or distal perforations where surgical access would be
difficult.
Limitations of this treatment include. possible inability to carefully
and successfully extract the tooth in question. the considerable risk
of unrestorable fracture during the removal of the tooth. and the
high propensitytoward external root resorption. caused by damage
to the periodontal ligament and cementum during the extraction
and extra-alveolarperiod
A characteristic feature of intentional replantation failures is
external inflammatory or replacement root resorption Because of
these limitations. intentional replantation is often considered a last
resort to retain an endodontically-diseasedtooth (I. 3, 4)

hgure I Pre-operotivephotogroph of the gold crow1 on tooth 34

Figure 2 Pre-operative radiograph of tooth 34

Case Report
A 68-year-old female patient was referred to the Endodontic
Department of the Royal Dental Hospital of Melbourne for
consultation and treatment concerning tooth 34. The Patlent's
dental history indicated that tooth 34 had been endodontically
AUSTRALIAN F NDODONTICJOURNALVOLUME 3 0 Nc, 3 DtCLMBtR 2004

Figure 3. Proximo1 rodiograph of tooth 34 followrng extraction rhowry

root canal filling nnd post at buccol aspect
9u

Figure 4: Radiograph showing endcdontic hand file in uninstrumented

Iinguol canal.
figure 8: Post-operotiveradiograph showing tooth 34 replanted.

figure 5: Photograph showmng preparation of the retrograde preparations

using a small slow-speed bur.

Figure 6: Photograph showmng Super-EBA retrograde restoration.

Figure 7: Radiograph showrng Super-EBAretrograde restoration.

I00

Figure 9: Three-monthrecall.

treated. with a cast post and core and gold crown placed approximately I 5 years previously. Since early 2000. the patient had been
experiencing a dull ache from the region of tooth 34 that had
been slowly worsening.
On presentation. the patient reported a constant dull, throbbing
ache from tooth 34 and an inability to bite on the tooth without
pain. The patient's oral hygiene was good with all restorations
appearing intact and no cartes noted. Clinically, a generally wellmaintained and heavily restored dentition was present with tooth
34 tender to percussion. palpation and selective biting. A reasonably
well-fitting gold crown with subgingival margins was present on
tooth 34 (Fig. I). No abnormal periodontal probing depths were
detected with teeth 33 and 35 reacting positively to carbon dioxide
sensibility testing.
Radiographic examination disclosed that tooth 34 contained a
root-filling extending to approximately I .5 mm from the radiographic apex with a post and pin-retained crown (Fig. 2). A
radiolucency was present around the root apex of tooth 34. Close
examination revealed a thin radiolucent line alongside the one root
canal filling in the root of tooth 34. The mental foramen appeared
very close to the apex of tooth 34.
A diagnosis of chronic apical periodontitis with acute exacerbation was made for tooth 34. Likely aetiologies included probable
second, missed canal, or a wide figure eight-shaped root with a
fin that required cleaning. Alternatives included a cracked root.
resistant infection or extraradicular infection.
Treatment options were evaluated and discussed and a decision
was made to extract tooth 34, examine for cracks or a missed canal,
treat extra-orally if possible and then to replant in the extraction
socket. The risk of losing the tooth during the procedure or later as
a result of periodontal damage was explained to the patient.
AUSTMLIAN ENDODONTIC JOURNALVOLUME 30 No. 3 DECEMBER 2004

Figure 10: Slx-month recoll

fitting. A second missed canal was found lingual to the treated canal.
Two millimetres of the root apices was shaved back with a highspeed diamond bur. The missed lingual canal was instrumented
from the apex with endodontic handfiles and sterile saline (fig. 4).
Retrograde cavty preparations were made with slow speed burs in
both the buccal and lingual canals as well as the isthmus joining them
(Fig. 5). Super-EBA cement retrograde restorations were placed
and polished (figs 6 and 7). The blood clot was carefully rinsed out
of the extraction socket and the tooth then carefully replanted. The
tooth appeared to be well retained in the socket and the suckdown
splint was not used. Extra-oraltime was approximately I 5 minutes.
A final radiograph was taken to check the position of the tooth (Fig.
8). The patient was instructedto use a chlorhexidine mouthrinse.
Ten days later the patient returned for review. The tooth had
grade-two mobility and was tender to percussion but otherwise
asymptomatic. At three- and six-month recalls the patient presented with no symptoms and grade-one mobility. Radiographs
showed some angular bony remodelling with little change in the
radiographic appearance of the periapical radiolucency (Figs 9 and
10). At 12-month recall, tooth 34 was asymptomatic with radiographic evidence of healing (Fig. I I ). At the 18-monthrecall, tooth
34 was fully functional, asymptomatic and a radiograph showed
good resolution of the initial periapical radiolucency (Fig. 12).

Discussion

figure I I ; helve-month recoll.

figure 12: Gghteen-monthrecoll.

The recommended option of endodontic retreatment was dismissed by the patient due to cost. Periapical surgery was considered
but decided against due to the risk of damage to the mental nerve.
which was in close proximity of the apex of the 34.
Following the decision to perform intentional replantation for
tooth 34, a clear plastic suckdown was constructed to act as a
splint, if required, once the tooth was replanted The procedure
was carried out with several assistants to minimise the extrd-oral
time. Following anaesthesia, the tooth was carefully extracted with
forceps and kept moist by constant bathing in sterile saline. The
tooth was held by the crown only during the entire procedure.
Once extracted, the tooth was radiographed from a proximal
angulation and examined through the operatingmicroscope (Fig. 3).
No cracks were evident and the restoration margins appeared wellAUSTRALIAN LFJOODONTIC JOURNALVOLUME 30 No 3 DECtMBtR 200.1

Intentional replantation is performed mainly as an alternative to

extraction when both retreatment and apical surgery are considered unfeasible (5). Because of the risk of damage from the
extraction procedure and the extra-oral time. intentional replantation is generally only considered in those cases where conservative
or surgical procedures are contra-indicated.Intentional replantation
was indicated in this case due to the close proximity of the mental
foramen to the root apex, which was considered would imply risk
of damage during apical surgery.
Complications of this procedure tend to be relatedto the degree
of damage to the periodontal ligament and cementum during the
extraction and extra-alveolar period. Progressive replacement root
resorption has been reported as the major concern (3). In this case.
the tooth was carefully and easily extracted without fracture and
with minimal trauma to the periodontium. The extra-alveolartime
was kept to a minimum. the tooth was only touched by the crown
and sterile saline was used to keep the root moist during the
procedure. The extra-alveolar time for this case was approximately
I 5 minutes. Ideally, this time would have been less although
Kingsbury and Wiesenbaugh (6) concluded that teeth that were out
of the socket for less than 30 minutes had a high success rate.
Dryden and Arens (3) suggested that intentionally-replanted
teeth should be splinted in every case for 7- I 4 days. Andreasen
(7, 8) recommended minimal splinting due to the finding that
the early restoration of normal masticatory function with the
accompanying jiggling forces improves periodontal healing. In this
case, tooth 34 was well retained in the socket without splinting and.
although a splint had been constructed, it wasn't used. At all review
appointments, tooth 34 was stable in its position and after 18
months showed normal physiologic mobility.
A review of the literature shows a remarkably high success rate
for intentional replantation(IR). Koenig et 01. (9). in a study of I94
teeth, showed a success rate of 82% after 5 I months. Deeb el 01.
( 10). in a study of I65 IR teeth, reported a 74% success rate after
a fwe-year follow-up. Bender and Rossman (2). in a study of only
3 I teeth, showed a success rate of 8 I % after 22 years. One major
difficulty in interpretingthis data is that the success rate of intentional
101

replantationcases is often determined as the retention of the tooth

in question whether pathosis is present or not (5) This makes it
difficult to compare success rates with conventional treatment
modalities and doesn't help much with future treatment planning
With the case presented in this report. at the 18-monthreview.
tooth 34 was asymptomatic. in full function and the patient was
very happy The presenting symptoms had disappeared and tooth
34 was not tender to percussion or palpation The periodontium
around tooth 34 appeared normal with 3 mm probing depths
Mobility was normal. with no evidence of replacement root
resorption. Radiographic healing of the periapical pathosis was
encouraging as it indicated successful treatment of the infected root
canal system In this case, the aetiology of the presenting periapical
pathosis was likely to be the missed. presumably infected. lingual
canal Wth treatment of this canal. radiographic healing occurred
Loss of some crestal bone height around tooth 34 indicated
some damage to the periodontium from the extraction and/or
extra-alveolar time but this was apparent at the six-month review
and has not worsened since. Susceptibility to vertical root fracture
is present as tooth 34 now has a short root. minimal bony support
and a large post with little remaining root strength
Overall though, considering the only viable alternative the patient
was interested in was extraction. the result at the 18-month review
is excellent and the patient was very happy

Refcrences
I . Grossman LI. Intentional replantation: a clinical evaluation.
J Am Dent Assoc 1982; l04:633- 39.
2. Bender IB. Rossman LE. Replantationof endodonticallytreated
teeth. Oral Med Oral Surg Oral Pathol 1993; 76:623 30.
3. Dryden JA. Arens DE. Intentional replantation: a viable
alternative for selected cases. Dent Clin North Am 1992:

38~325.53.
4. Messkoub M. Intentional replantation: a successful alternative
for hopeless teeth. Oral Surg Oral Med Oral Pathol I99 I :
7 I :743-7.
5. Orstavik D. Pitt Ford TR. Essential Endodontology. Oxford:
Blackwell Scientific Publications: 1998.
6. Kingsbury B. Wiesenbaugh J. Intentional replantation of
mandibular premolars and molars. J Am Dent Assoc I97 I ;
83: 1053-7.
7. Andreasen JO.The effect of splinting upon periodontal healing
after replantation of permanent incisors in monkeys. Acta
Odontol Scand 1975; 33:3 13-23,
8. Andreasen JO. Periodontal healing after replantation of
traumatically avulsed human teeth. Assessment by mobility
testing and radiography. Acta Odontol Scand 1975;

33 1325-35.
9. Koenig KH. Nguyen NT, Barkhordar RA. Intentional
replantation: a report of 192 cases. Gen Dent 1988;
36:327-32.
10. Deeb E. Prieto PF! McKenna RC. Reimplantation of luxated
teeth in humans. J South Calif Dent Assoc 1965; 33: I94 206.

2005 ASE Undergraduate Essay Competition

lopic

Conditions And Notes

Case assessment and treatment planning: What governs your

decision to treat. refer or replace a tooth that potentially requires
endodontic treatment?

I. Essays must not exceed 3000 words, with a maximum of 50

references Essays should be typewritten and double spaced on
one side only of A4 sized paper
2. Essays must conform to the "Guidelines for Contnbutors" in
the Australian Endodontic Journal as published in each issue
of the Journal
3 Submitted entries from each dental school will initially be
assessed by the lecturer($)-in-chargeof Endodontology at that
School The lecturer will choose the best two essays from each
school that will then be forwarded to the Federal office of the
ASE Inc for judging Entries must reach the Secretaryflreasurer.
AS Inc by Friday 26 August 2005
4 Two copies of the entries from each state must be submitted
and no names or identifying marks should appear on the essay
Written hard copies of the entries should be accompanied by
a computer disk The candidate's name, home address and
university name should appear on a separate page loosely
attached to the essay
5 Essays will be coded for anonymity and sent to two judges
appointed by the ASE Inc Federal Executive. The decisions of
the judges shall be final
6 All essays must be submitted by one individual only, joint
submissions will not be considered

Eligibility
Students in the last two years of undergraduate dental courses
in an Australian. New Zealand or Fijian university.

Prizes
First Prize: $lo00 plus an inscribed commemorative plaque
The winning essay will also be published in the Australian Endodontic Journal,at the discretion of the Editor

Second Prize: $500

Each finalist will also receive one year's free subscription to the
Australian Endodontic Journal.

Closing Date
Essays must be submitted to the Lecturer-in-chargeof Endodontology at each dental school by 29 JULY 2005.

I02

AUSTWLIAN LNDODONTIC jOURNAL VOLUME 30 No. 3 DECEMBLR 2004