Restorative Dentistry

Enhanced CPD DO C

Fahad Umer Momina Anis Motiwala Shizrah Jamal

Intentional Replantation:
An Underused Modality?
Abstract: Intentional replantation is a method to salvage teeth, especially in cases where orthograde re-treatment or apical surgery cannot
be performed because of anatomical constraints and limited access. Techniques of intentional replantation have evolved to enhance
clinical outcomes. The purpose of this case series, together with a narrative literature review, is to emphasize its importance, indications,
contraindications, associated risks, success, and consideration as a treatment option as an alternative to extraction.
CPD/Clinical Relevance: This article discusses the advantages, disadvantages, indications, contraindications and techniques for
intentional replantation.
Dent Update 2022; 49: 757–763

Orthograde root canal treatment is the
preferred option to treat pulpal or peri-apical
pathology.1 However, if the symptoms fail
to resolve despite optimum non-surgical
root canal treatment and subsequent non-
surgical re-treatment, then apical surgery,
which is the next indicated option, has to be
carried out to salvage teeth. Despite the high
success rates of apical surgery, its execution
may be challenging in some teeth, especially
in the molar region, because of anatomical
constraints.1 Therefore, intentional
replantation may be an alternative treatment
option for some of these cases.2,3
Intentional replantation is defined as
extracting the tooth, resecting the root
ends, followed by sealing with appropriate
root-end filling material and replacement
of the tooth back into its socket.4 This
technique was first practiced by Ambrose
Fahad Umer, BDS, FCPS, Assistant Professor, Operative Dentistry, Aga Khan University
Hospital, Karachi, Pakistan. Momina Anis Motiwala, BDS, Postgraduate Resident,
Operative Dentistry, Aga Khan University Hospital, Karachi, Pakistan. Shizrah Jamal, BDS,
Instructor, Operative Dentistry, Aga Khan University Hosptial, Karachi, Pakistan.
email: momina_anis@live.com
Pare in the 16th century, and Pierre Fauchard
during the 18th century, to salvage a
tooth that was extracted accidentally.5,6
Since then, intentionally carrying out this
technique has been reported in various
case studies.7,8 With time, the technique of
intentional replantation has been modified
to enhance its clinical outcomes.7,8 It is
a one-stage treatment to preserve the
patient’s aesthetics, as well as to maintain
the alveolar bone.9
In order to retain the natural tooth,
intentional replantation should be
considered as a reliable option. However,
because of the lack of relevant cases in the
literature, intentional replantation is often
considered a procedure of last resort. In
the present series, we discuss three cases,
together with a literature review related to
the technique.
Cases
Three cases were referred to Aga Khan
University Hospital dental clinics in 2019
with a common complaint of unresolved
severe pain (Table 1). The patients were aged
between 30 and 40 years and had received
previous root canal treatment initiated at
another dental practice. Detailed clinical and
radiographic examination revealed that the
related molar teeth were tender to palpation
and percussion, and an associated peri-
apical radiolucency was present. The teeth
were stable periodontally and opposed
by a natural tooth, hence the decision was
more inclined towards retaining the tooth.
Peri-apical surgery was not advised to the
patients because of anatomical constraints
and/or inadequate surgical access, which
would make the provision of this treatment
challenging. Two treatment options were
offered to the patients: extraction or
intentional replantation. Consent was taken
after a detailed discussion with the patients
over the pros and cons of intentional
replantation, along with its associated risks,
as specified in Table 2. The first step was
to complete the orthograde endodontic
treatment under local anesthesia (2%

October 2022 DentalUpdate 757

Restorative Dentistry

Case Gender Age Tooth (FDI) and lesion Size of Follow-up Root-end filling Perio- Occlusal
(years) type lesion period material probing reduction
(mm)
1 Male 30 UR7 3x3 1, 2, 4 weeks Endosequence BC Within No
(Figures 1 4 mm broken then 3, 6, Putty normal
and 2) instrument in apical 11 months limits
third of mesial canal
2 Male 34 UL7 4x3 1, 2, 4 weeks Pro Root MTA Within Yes
(Figures 3 Pulp chamber then 6 months normal
and 4) perforation and limits
untreated distal canal
3 Male 37 LL7 3x5 1, 2, 4 weeks Endosequence BC Within No
(Figure 5) Non-resolution of then 3, 6, Putty normal
clinical symptoms 12 months limits
on non-surgical
endodontics
Table 1. Summary of cases.

a b c d e

Figure 1. Pre-operative peri-apical radiograph LR7. (a) Intra-oral view. (b) Post-operative peri-apical radiograph. (c) Follow-up radiograph after 2 months.
(d) Follow-up radiograph after 6 months (LR8 extracted). (e) Follow-up radiograph after 1 year.

a c e

b d

lidocaine with 1:100,000 epinephrine) and

rubber dam isolation to ensure adequate
cleaning, shaping, and obturation if possible,
followed by intentional replantation.
In the first case, the patient was
symptomatic and an instrument was broken
in the mesio-lingual canal. This fractured
instrument could not be bypassed, therefore
the cleaning and shaping was incomplete
and the tooth was deemed to have guarded
Figure 2. (a) Granulation tissue attached with the apical portion. (b) Root-end resection. (c) Staining
prognosis. In the second case, the distal
with 2% methylene blue dye. (d–e) Placement of MTA.
canal was sclerosed and could not be

758 DentalUpdate October 2022


a d
b or EndoSequence BC putty (Brasseler
e
c into the socket, splinting was not needed.
instrumented and the patient remained
symptomatic, whereas in third case, the root
canal treatment was optimum, but associated
with a chronic apical abscess, hence the
decision to not attempt non-surgical
endodontic re-treatment before attempting
intentional replantation in all three cases.
Protocol for
intentional replantation
Under adequate anesthesia, atraumatic
extraction was performed using dental
October 2022 DentalUpdate 759
Figure 3. Pre-operative view tooth UL7. (a) Intra-
oral view. (b) CBCT slice view. (c) Peri-apical
radiograph. (d) Post-operative radiograph after
replantation. (e) Post-operative radiograph after
1 month.
molar forceps. The technique is tricky and
requires time and patience to avoid any
tooth fractures. The tooth was held from
the crown using the same forceps without
touching the root. The granuloma, where
attached to the root ends, was removed.
The apical third of the root was resected
using a high-speed handpiece and tapered
fissure bur (ISO 198/018, Mani Inc, Japan)
extra-orally under copious saline irrigation
using a 10-ml dental irrigation syringe,
and root-end preparation 3-mm deep was
Restorative Dentistry
completed using a round bur (ISO 001-
010, Mani Inc) in a high-speed handpiece
using the same irrigation. The tooth was
stained using 2% methylene blue dye and
inspected under magnification (×20–26)
for the presence of any crack, isthmus
or deformity on the root, and treated
by further preparing the apical end and
eliminating the defect. The root-end
preparation was then filled with a filling
material. ProRoot MTA (Dentsply, USA)
USA, Savannah, GA, USA) was used. The
socket was irrigated with saline using a
10-ml dental syringe to remove any clot,
but without curettage, and the tooth was
replaced in the socket with light pressure.
The position of the tooth was confirmed
by taking a post-operative radiograph.
During the entire procedure, the tooth was
handled by the crown using extraction
forceps, keeping the extra-oral time
within a maximum of 15 minutes. Since
the tooth was stable when placed back
Post-operative analgesics and a soft diet
was prescribed for the next 3 days. Follow-
up at 1, 2 and 4 weeks was carried out.
The patients were recalled after 6 and
12 months. The patients were advised and
sent to restorative dentists to receive a full
coverage restoration for the tooth.
One patient (Case 2) reported to our
clinic after 6 months with the treated
tooth fractured mesio-distally. A full
coverage restoration on this tooth had
not been completed and the tooth had to
be extracted.
Discussion and
literature review
The intentional replantation procedure
provides an alternative treatment to retain
teeth with failed root canal treatment.10
It is indicated specifically where surgical
endodontics would be difficult, or
impossible, owing to limited access or
visibility, or anatomical constraints, such
as close proximity of a nerve or sinus.
The indications and contraindications for
intentional replantation are outlined in
Table 3.
The successful outcome of this
treatment depends primarily upon
the maintenance of aseptic conditions
and limited extra-oral time, survival of
periodontal ligament cells on the root
surface, and gentle atraumatic extraction
with minimal manipulation of the socket.11
Handling and extra-oral time are two critical
Restorative Dentistry
a c
b d
Figure 4. Apicectomy. (a) Atraumatic extraction of tooth UL7. (b) Root end resection. (c) Staining with
2% methylene blue dye. (d, e) Placement of MTA.
a curettage of the tooth or the socket.
Figure 5. Case 3. (a) Post-operative peri-apical radiograph after 1 week. (b) Follow-up radiograph at
3 months.
factors to ensure maximum viability of PDL
cells. Extraction of the tooth is considered
to be the most technique-sensitive step.11
However, the extraction technique does
760 DentalUpdate October 2022
e
vary in the literature. Multiple studies have
reported the use of dental elevators to
luxate the tooth before forceps application,
whereas others stated that dental elevators
should not be used at all.11 In this series,
each tooth was extracted gently with the
help of forceps, avoiding dental elevators,
making sure that the beak did not contact
the root surface, to prevent periodontal
ligament (PDL) damage.12 The teeth were
held by the forceps while the root-end
preparation was performed under saline
rinse to avoid dehydration of the PDL cells.
Any granulation tissue attached to
the tooth should be removed carefully
to avoid damage to the PDL cells. The
literature advises minimal manipulation of
the tooth and the socket during extraction
or debridement.13 In Case 1, a granuloma
was attached to the apical portion of the
tooth. It was removed delicately, without
Some authors advise against the use of
curettage at all, whereas others favour the
involvement of the apical portion onlyalone,
without touching the wall of the socket8,14
This is to avoid damage to the remaining
PDL socket cells.13 There are different
recommendations for extra-oral times.
Kratchman et al reported that because of
the time-dependent viability of PDL cells,
the extra-oral time should not exceed 15
minutes.15 Thus, we tried to follow the same
protocol by limiting the extra-oral time. It
has been reported that the success rate was
90% when avulsed teeth were replanted
within 30 minutes.16
There are five studies reported in the
literature from 2016 onwards in which a
total of 505 teeth underwent intentional
replantation. They used Pro-root MTA
(Dentsply/Tulsa Dental, Tulsa, OK, USA),
IRM (Dentsply, York, PA, USA), Super
EBA (Harry J Bosworth Co, Skokie, IL,

Advantages
Maintaining viable periodontal ligament
Allows orthodontic movement
Alveolar growth continuation
Alveolar bone preservation
Other options are always open if the replantation fails
Maintenance of periodontal proprioception
Surgical and post-op maintenance is generally less
complicated for replanted teeth32
Table 2. The advantages and disadvantages of intentional replantation.
Indications
 Broken Instrument10
 Blocked or calcified canal10
 Perforation repair34
 Inaccessbile area34
 Thick buccal bone in posterior region35
 Anatomical structures lie in close
proximity to root apex, ie inferior
alveolar nerve, mental nerve,
sinus floor35
 Straight and fused roots10
 Persistent peri-radicular infection
Contraindications
 Periodontally compromised
tooth, mobile36
 Destroyed or missing labial
buccal plate36
 Vertical root fracture36
 Compromised tooth structure or
insufficient crown height36
 Curved or divergent roots10
 Patients at risk of developing MRONJ34
 Diagnosed haematological disorder34
 Traumatic occlusion
 Inadequate coronal seal
Table 3. Indications and contraindications for
intentional replantation.
USA), Endosequence BC Putty (Brasseler,
Savannah, GA, USA) or Biodentine as a
root-end filling material. A summary of the
follow-up period, extraction techniques
used, extra-oral time, probing depth
and survival rates are shown in Table 4
for comparison.
Our cases followed the modern
concepts of microsurgery, which has been
favoured lately because of its use of an
operating microscope, use of methylene
blue dye to identify cracks, use of micro-
instruments and highly biocompatible
root-end filling materials, such as bio-
silicate cements. The only occasion in which
we differed in the use of microsurgery
protocols was the use of a high-speed
October 2022 DentalUpdate 761
Disadvantages
External root resorption
Replacement resorption
Treatment failure
Fracture of tooth
Periodontal involvement33
hand piece for apical preparation. This
protocol of using carbide burs has
been recommended,12 while Cho et al17
recommended the use of ultrasonic
instruments, particularly in thin roots, to
improve efficiency and reduce the extra-
oral time.18
Root-end resection was up to 3 mm,
with a cavity depth of 3 mm and 0-degree
bevel angle as a part of contemporary
practice. As described in the literature, the
advent of microsurgery has increased the
success rate up to 90%.19–22
Several properties are required when
choosing a root-end filling material. These
include: sealing ability, antibacterial
activity, and more importantly, induction
of tissue regeneration. Although the ideal
material has yet to be found, MTA has
been accepted as one of the most suitable
materials used for surgical endodontic
procedures.23 MTA was used as the root-
end filling material in one of our cases
because of its reportedly long-lasting
sealing ability and minimal leakage
compared to other root-end filling
materials.24 However, MTA is a technique-
sensitive material that requires proper
handling and manipulation. It is necessary
that the consistency of the mixed material
is appropriate, and care must be taken
to avoid washing out while replacing
the tooth into the socket. In Case 1, MTA
wash-out was a major problem likely to
have a result of inadequate consistency,
and hence was replaced by Bioceramic
Putty (BC Putty). Bioceramic has a
higher resistance to washout, superior
mechanical properties and no shrinkage
on setting.25 Pre-mixed bioceramics like
BC Sealer (BC Sealer), EndoSequence
and BC Putty are hydrophilic and
insoluble. Their advantage is their ease
of handling because of the availability
of pre-mixed forms in syringes, which
eliminates inconsistencies arising from
hand mixing.25,26
Restorative Dentistry
There is variation in the studies
regarding whether to splint the tooth.12
Some studies recommended splinting only
when gross instability of the tooth was
present.27,28 Whereas, others incorporated
a splint for each case.2,4 In our cases, we
confirmed the accurate repositioning
with radiographs, and because the teeth
were stable, splinting was not necessary.
Furthermore, patients were instructed
to avoid chewing on the tooth during
the healing period to avoid excessive
masticatory forces that might affect the
healing process.27
Endodontically treated teeth are
primarily weakened by tooth preparation,
which may ultimately result in fracture
if not restored with a full-coverage
restoration.29 A cuspal coverage restoration
is recommended to reduce the chances
of tooth fracture, especially in posterior
teeth.30 This problem was highlighted in
Case 2 in which the patient reported with
a tooth fracture after 6 months because
a full coverage restoration had not been
carried out.
Intentional replantation is an underused
modality. In the era of implants, this
technique is less popular, but is still a
successful option. It is assumed that
implants yield a predictable and long-term
restorative plan. However, the literature
suggests that implant survival is no longer
than the survival and longevity of a
periodontally or endodontically involved
tooth, and hence, surpasses the average
implant life.31 Despite the literature on
intentional replantation being sparse,
we strongly recommend this modality to
preserve the natural dentition, keeping
in mind the feasibility, accessibility,
periodontal factors, patient motivation and
strategic importance of the tooth.
Conclusion
The intentional replantation technique
was used to preserve the natural dentition,
thereby following the main goal of
conservative treatment. It is a relatively
straightforward single-visit treatment
procedure. The outcome depends on case
selection, tooth and patient management,
along with timely follow-up.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
Restorative Dentistry

Probing
Number Retrograde Follow-up Extraction
Reference Study type Arch EA time depth Outcome
of cases material period technique

49 mandible Pro-root MTA, 12.5 Less than 93% survival

Cho et al17 Cohort 159 0.5–12 years Forceps
110 maxilla IRM, Super EBA minutes 6mm at 12 years

≤15 min 83.4%

#15 blade 31 Less than
26 survival at
Retrospective 36 mandible with mallet 6mm
Jang et al37 41 Pro root MTA Up to 11 years 11 teeth 4 years and
study 5 maxilla followed
with >15 73.0% at
by forceps more than 6
min 11 years

Endosequence
Grzanich 2 mandible Not Less than
Case series 3 BC Putty or Pro 24–28 months Healed
et al38 1 maxilla mentioned 3mm
Root MTA

<30min
178 82.8%
Retrospective 137 mandible Super EBA or Extraction 197 less than
Wu et al33 289 0.5–10 years survival at
study 78 maxilla Pro root MTA forceps 5mm
>30min 4 years
18 more
37
than 5mm

12 cases
Cunliffee 11 mandible MTA or Extraction Not Not healed;
Case series 13 3–28 months
et al13 2 maxilla Biodentine forceps mentioned mentioned one failure
(extracted)

Table 4. Summary of cases from the literature.

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Since 1996
01274 88 55 44 www.trycare.co.uk
2124.

October 2022 DentalUpdate 763