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Intentional replantation - a clinical review of cases undertaken at a major UK

dental school

Article in British dental journal official journal of the British Dental Association: BDJ online · August 2020
DOI: 10.1038/s41415-020-1988-6

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 VERIFIABLE CPD PAPER
CLINICAL Restorative dentistry

Intentional replantation – a clinical review of cases

undertaken at a major UK dental school
Joanne Cunliffe,*1 Khawer Ayub,2 James Darcey3 and Emma Foster-Thomas4

Key points
Intentional replantation (IR) may Case selection for IR is key. The materials and techniques IR could potentially be performed
offer a solution for symptomatic associated with IR have evolved by all dentists following
persistent periapical lesions. considerably since its inception. appropriate training.

Abstract
Introduction Intentional replantation (IR) may offer a solution for persistent periapical lesions associated with
endodontically treated teeth in select cases. This case series demonstrates the use of IR as an alternative treatment
approach to both orthograde and surgical endodontic retreatment. The indications, contraindications, benefits and
risks of IR are discussed, and the clinical procedure is outlined.
Setting Restorative Department, University Dental Hospital of Manchester, UK.
Case reports Of the 13 cases presented, the follow-up period before discharge ranged from 3–28 months. Only one
tooth which presented intra-operative challenges required extraction three months after IR due to post-operative
mobility.
Conclusion In select cases, IR may provide a simple, less invasive and cost-effective alternative to both endodontic
retreatment and extraction alone following appropriate training.

Introduction
Despite high success rates of up to 85% for
primary root canal treatment, failure may
still occur and new pathosis develop.1 Nair
proposed six potential reasons for persistence
of periapical lesions (Box 1).2
Without histopathological analysis, it is
often not possible to determine the aetiology
of endodontic failure from the clinical findings
alone. Nevertheless, according to current
quality guidelines for endodontic treatment,
further treatment is recommended for
endodontically treated teeth with periapical
lesions that have not resolved four years after
treatment or have persistent symptoms.3 It
1
Senior Lecturer/Honorary Consultant, University of
Manchester, UK; 2Speciality Registrar in Restorative
Dentistry, King’s College Hospital and William Harvey
Hospital, UK; 3Consultant and Honorary Lecturer in
Restorative Dentistry, University Dental Hospital of
Manchester, UK; 4Academic Clinical Fellow in Restorative
Dentistry, University of Manchester, UK.
*Correspondence to: Joanne Cunliffe
Email address: joanne.cunliffe@manchester.ac.uk
Refereed Paper.
Accepted 24 April 2020
https://doi.org/10.1038/s41415-020-1988-6
is generally accepted that orthograde non-
surgical retreatment is the first-line approach
for treatment in cases of failure4 and high
success rates of up to 80.1% have been quoted.1
It is important that an operator can
distinguish between fundamentally different
clinical scenarios. The first one is where the
initial root canal treatment (RCT) is of such
poor quality that the microbial biofilm will
be similar to that of a non-instrumented
case. This is unlikely to pose challenges to the
operator and has a higher success rate. The
second scenario is where the RCT has been
undertaken to a high standard and there is a
possibility that anatomy has been missed or
more virulent species of pathogens exist. These
cases can be more challenging and require a
more intensive approach to instrumentation
and decontamination. Finally, cases with
iatrogenic and/or anatomical challenges can
prevent adequate access to the canal system and
thus prevent successful treatment.5 The success
rates in the latter two scenarios may be lower
due to difficulty in completely removing the
obturation material, resistance of remaining
bacteria or pre-existing procedural errors,
such as irreparable perforation, transportation,
ledging, fractured instrument or calcification.6
Clinicians must attempt to foresee these
challenging cases, and an informed consent
process must include a pragmatic prediction
of success and clearly cover the ever-present
risk of further iatrogenic damage during
retreatment. Furthermore, there are cases
where orthograde retreatment is not a viable
treatment option, including cases with complex
apical anatomy, a complex coronal restoration
for which removal may jeopardise restorability,
and in instances where patients do not wish
to invest the cost and time associated with
complex treatment.7 In these situations where
orthograde retreatment is not possible, surgical
endodontic treatment might be necessary.8
Significant advances in endodontic surgery
have been made in the last two decades,
including the use of the operating microscope,
micro-surgical armamentarium and new
bioactive materials that have resulted in higher
success rates compared to traditional surgery.9
There are, however, inherent challenges to
apical surgery, including accessibility due
to position, thickness of buccal cortical
bone, shallow vestibular depth, proximity
to anatomical structures and post-operative

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discomfort.7 Consequently, there are scenarios
in which a patient may want to retain a tooth,
but orthograde retreatment and apical surgery
are contraindicated. Intentional replantation
(IR) may offer a solution for symptomatic
persistent periapical lesions in these cases.10
Intentional replantation
Definition and history
IR involves the purposeful extraction of a
tooth, root end resection and preparation
instrumentation and apical sealing, followed
by replantation to its original socket.11,12 IR is
a one-appointment treatment that aims to save
teeth for which orthograde retreatment and
periapical surgery are contraindicated.13,14 The
concept of IR was first described in the eleventh
century by Albucasis, an Arabic physician.10
In the seventeenth century, Fauchard and
Woofendale advocated IR for incorrectly
extracted teeth.14 In 1755, Hunter linked the
success of this technique to the preservation
of vital periodontal ligament (PDL).15 This has
been validated in multiple studies since.16,17,18
Indications
Prior to undertaking IR, it is essential that
a clinician has both the knowledge, skills
and equipment to undertake this procedure.
Furthermore, it is essential that the clinician
has thoroughly explained the benefits and
potential limitations of the procedure, most
importantly the risk that replantation may not
be possible. Several clinical indications for this
technique have been proposed:
1. Persistent symptomatic apical periodontitis
in situations where orthograde retreatment
is complicated (calcified canal/separated
instrument/complex restoration) or has
failed14,19,20
2. Surgical treatment has either failed or
is contraindicated due to anatomic or
accessibility limitations;21 for example,
in mandibular second molars, which
would likely require excessive buccal
bone removal, risking periodontal pocket
formation.22 Furthermore, maxillary sinus
proximity to maxillary molars can present
accessibility challenges
3. Correction of overextended root filling
material with persistent disease where
periapical surgery is not possible19
4. Management of resorption defects that
cannot be accessed conventionally 23
5. Management of root fractures in mature
and immature teeth24,25,26
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Restorative dentistry CLINICAL
Box 1 Predisposing factors that lead to persistence of periapical lesions
following primary root canal treatment
1. Microbial intra-radicular infection which might result from inadequate disinfection or coronal leakage
2. Microbial extra-radicular infection, including actinomycosis and Propionibacterium, that cannot be
accessed or disinfected by conventional means
3. Non-microbial extra-radicular irritation (cholesterol crystals)
4. Exogenous extra-radicular foreign body reaction (eg granuloma, overextended root canal filling and
extruded sealer)
5. A true cystic lesion
6. Surgical scar tissue.
(adapted from Nair)2
Table 1 Benefits and risks of IR compared to conventional apical surgery
Benefits of IR Risks associated with IR
Reduced morbidity21 Tooth fracture preventing replantation
Less invasive External inflammatory resorption
An approach that could potentially be performed by
External replacement resorption
all dentists following appropriate training
Potential to be more cost-effective (ie equipment Collection of an appropriate sample for
requirements) histopathology (when required) may be more difficult
6. Management of teeth with developmental
anomalies that are particularly challenging
to treat via conventional RCT, such as
germinated and fused teeth, the presence
of radicular grooves and C- or O-shaped
canals27,28
7. Long-term alveolar bone preservation is
required; for example, in cases where dental
implants may be considered as part of the
oral rehabilitation29,30
Fig. 1 Extracted tooth held by the crown with
8. Management of root perforations on the saline-soaked gauze
lingual or proximal aspect of a tooth, which
would require excessive removal of bone to
expose the perforation site.23,31 to the need to extract a tooth in IR, this
technique should not routinely be considered
Contraindications for patients with medical conditions known
This technically complex treatment should to pose risks during dento-alveolar surgery,
only be undertaken if the patient’s primary including but not limited to individuals who are
disease is stable and they can maintain good immunocompromised, have had radiotherapy
oral hygiene.32 Tooth factors which would to this region, are at risk of MRONJ or have
contraindicate IR include vertical root fracture, diagnosed haematological disorders. 23,34
presence of periodontal disease with marked In these circumstances, one must carefully
mobility, insufficient clinical crown height consider the alternative treatment options and,
to allow stable application of forceps and where possible, avoid an extraction.
complex root anatomy.33 It must be possible
to atraumatically extract the tooth. Thus, IR Prognostic factors
is contraindicated if the tooth has divergent, Several critical parameters for success have
flared and/or curved roots, or advanced been identified, including case selection,
external replacement resorption, due to the aseptic operating conditions, atraumatic
increased risk of fracture during extraction.11,19 extraction, extra-alveolar time, preservation
The risk of tooth fracture is greatly reduced if of PDL cells via avoidance of chemical and
the roots are fused and/or straight and when mechanical trauma, initial tooth stability while
there is extensive periapical bone loss.19 Due maintaining the physiological movement of
231
 CLINICAL Restorative dentistry
Fig. 2 a) Resection of the root. b, c) Use of ultrasonic tips for retrograde preparation
15 minutes in dry conditions compromises the
viability of the PDL cells, increasing the risk
of replacement resorption and ankylosis.40
Thus, it is essential to ensure the extraction
is conducted slowly and atraumatically
using forceps above the cementoenamel
junction (CEJ), the extracted tooth is kept
moist and the extra-alveolar time is kept to a
minimum.41,42 It has been shown that the risk
of replacement resorption is age-related and
progresses faster in younger indidviduals.14
Tooth type and location and a patient’s age
and gender have not been shown to affect the
Fig. 3 A silk suture placed immediately
survival of intentionally replanted teeth.35
following tooth replantation
The choice of the extra-alveolar preparation
method may result in varying treatment
replanted tooth, thorough instrumentation success. It has been proposed that root surface
and a hermetic apical seal.21,35,36,37 preparation with tetracycline hydrochloride
Success of a replanted tooth is dependent on may improve the prognosis by both reducing
its careful surgical management, specifically osteoclastic bone resorption and reducing the
the preservation of an intact PDL. A critical inflammatory response.43 However, the role
factor cited in the literature is extra-alveolar of root conditioning in periodontal healing
time.37,38 Andresen et al.39 reported that the requires further investigation. The use of
ability of the PDL to regenerate reduces when enamel matrix-derived proteins may also
the extra-alveolar time is greater than five improve periodontal and cemental survival and
minutes. An extra-alveolar time of more than healing.18,44 In addition, the modern bioactive,
Fig. 4 Case 1. a) A 33-year-old male was referred due to access difficulties for 41. b) A further
attempt to access the canal was undertaken which resulted in instrument separation in the
middle third of the root canal. c) Instrument retrieval attempts lead to a perforation on the
distal aspect of the root. d) The decision was taken to attempt IR on the 41. IR was completed
uneventfully. The perforation was repaired extraorally and the separated instrument was left
in situ. A periapical radiograph taken six months following IR shows a reduction in the size of
the apical radiolucency associated with this tooth
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biocompatible root end filling material, such
as mineral trioxide aggregate (MTA) and
Biodentine, may enhance periapical healing.19
Pre-operative orthodontic extrusion has
been demonstrated to improve success of IR.
A retrospective study by Choi et al.35 assessed
survival rates of IR in 287 teeth following two
to three weeks of orthodontic extrusion. This
study found that pre-operative orthodontic
extrusion increased the survival rate by
reducing root resorption and tooth fracture.
The benefits and risks of IR compared to
conventional apical surgery are summarised
in Table 1.
Clinical procedure
1. Consent and local anaesthetic
2. Extraction: the tooth must be gripped firmly
using forceps holding the crown above the
CEJ. An alternative approach for single-
rooted teeth (not used for the below cases)
is to utilise the Benex extraction system,
which can prevent the need to handle the
root surface during apical preparation
through the ability to hold the root via
the screw head.45 To avoid damage to the
cementum, elevators should be avoided.46
Rotational forces should be performed
to extract premolar teeth and a figure-of-
eight movement with mild buccolingual
movement should be performed for molar
teeth.35 Allowing for short pauses during
this process may be beneficial for PDL
expansion and consequently facilitate the
extraction. This step can often take 15
minutes or longer
3. Gentle manipulation of the tooth: the
tooth should be gently held by the crown
with physiologic saline-soaked gauze
(Fig. 1), while the patient bites down gently
on gauze to prevent saliva contamination
of the socket.14 It is essential to avoid any
unnecessary contact with the root surface.
Start recording the extra-alveolar time
4. Socket preparation: there is conflicting
evidence regarding socket preparation.
Some authors state that any periapical
granulomatous tissue should be gently
removed with a curette without damaging
the socket walls,17,47,48 while others advocate
extensive curettage of the socket in an
attempt to reduce subsequent inflammatory
response.49 However, the authors would not
recommend any socket preparation, in order
to prevent breakdown of the forming blood
clot and to avoid damage to any remaining
PDL cells or anatomical structures
 Restorative dentistry CLINICAL

5. Tooth preparation: the root surface should

be inspected under magnification for
evidence of cracks or perforations.21,50
A high-speed fissure bur is then used to
remove 2–3 mm of the root tip (Fig. 2a). A
rose-head (0.8 mm diameter) or ultrasonic
diamond-coated endodontic tips should
then be used to retro-prepare 3–5 mm
into the canal (Figures 2b and 2c). The
cavity should then be obturated with well-
condensed bioactive materials such as MTA
or Biodentine51 Fig. 5 Case 2. a) A portion of the crown fractured during extraction, but the tooth was
6. Replantation: the tooth should be gently deemed restorable and the remaining portion was implanted into the socket. b) A periapical
radiograph taken three months post-operatively shows good bony infill
repositioned into the socket using digital
pressure.51 The patient is then instructed
to gently bite on either gauze or a tongue
blade to prevent extrusion. 35 Occlusal
adjustment of the replanted tooth should
not be required.52 Occlusal adjustment is
only advocated if there is clear guidance
on this tooth or a non-working side
interference that may expose the tooth to
higher functional forces11,22,52,53
7. Splinting: the practice of splinting in IR Fig. 6 Case 3. a) A 52-year-old female was referred with persistent symptoms associated with
is somewhat controversial; some authors the 46. The referring GDP had completed primary endodontic treatment on this tooth. A pre-
advocate flexible splinting for a maximum operative radiograph showed overextension of the root filling in both the mesial and distal
of 14 days.51 The authors recommend roots. b) IR was undertaken; however, intra-operatively, the mesial root fractured, so only the
placement of a silk suture crossing the distal root was reimplanted. c) At the three-month review appointment, the 46 root was noted
to be mobile and was consequently extracted
occlusal surface of the tooth (Fig. 3), which
is to be removed at the review appointment
8. Confirmation of tooth position
radiographically 52
9. Post-operative instructions: routine
exodontia post-operative instructions to be
given. Emphasis should be made on a soft
diet and maintenance of excellent plaque
control with tooth brushing and use of an
antiseptic mouth rinse.

Case reports
The following cases of IR were all completed at
the University Dental Hospital of Manchester.

Case 1
A 33-year-old male was referred due to
access difficulties for 41 (Fig. 4a). A further
attempt to access the canal was undertaken,
which resulted in instrument separation
in the middle third of the root canal
(Fig. 4b). Instrument retrieval attempts lead
to a perforation on the distal aspect of the root
Fig. 7 Case 4. a) Clinical and radiographic examination revealed apical pathology associated
(Fig. 4c). The decision was taken to attempt
with the 44 and 46. b) Primary RCT on 46 was completed but presenting symptoms did not
IR on the 41. IR was completed uneventfully.
improve. c) After a discussion with the patient, it was agreed to complete IR on the 44. d) Post-
The perforation was repaired extraorally and operative radiographs show healing of the apical areas associated with both the 44 and 46
the separated instrument was left in situ. over a 12-month period
A periapical radiograph taken six months

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 CLINICAL Restorative dentistry

Case 3
A 52-year-old female was referred with
persistent symptoms associated with the 46.
The referring general dental practitioner (GDP)
had completed primary endodontic treatment
on this tooth. A pre-operative radiograph
showed overextension of the root filling in
both the mesial and distal roots (Fig. 6a). IR
Fig. 8 Case 5. a) A 42-year-old female was referred with asymptomatic apical periodontitis was undertaken; however, intra-operatively,
associated with the 36. Despite apparent acceptable endodontic retreatment, the apical lesion the mesial root fractured and so only the
persisted. b, c) Following a discussion of the treatment options, the patient opted for IR. The distal root was reimplanted (Fig. 6b). At the
procedure was completed uneventfully and post-operative radiographs show a reduction in three-month review appointment, the 46 root
the apical radiolucency was noted to be mobile and was consequently
extracted (Fig. 6c). This case demonstrates how
intra-operative complications can compromise
the long-term outcomes in IR.

Case 4
A 57-year-old female was referred with pain
localised to the lower right quadrant. Clinical
and radiographic examination revealed apical
pathology associated with the 44 and 46 (Fig.
7a). Primary RCT on 46 was completed but
presenting symptoms did not improve (Fig.
7b). After a discussion with the patient, it
was agreed to complete IR on the 44 (Fig. 7c).
The treatment was uneventful with an extra-
alveolar time of four minutes. At the review,
symptoms had resolved and post-operative
radiographs show healing of the apical areas
Fig 9 Case 6. a) A 64-year-old male was referred following trauma to his 21 as a teenager.
b) Post-operatively, the tooth was splinted with a flexible wire and composite splint to the
associated with both the 44 and 46 over a
adjacent teeth. c) Follow-up over a four-month period showed an improvement to the initial 12-month period (Fig. 7d).
situation and a halt to the resorptive process
Case 5
A 42-year-old female was referred with
asymptomatic apical periodontitis associated
with the 36. Despite apparent acceptable
endodontic retreatment, the apical lesion
persisted (Fig. 8a). Following a discussion of
the treatment options, the patient opted for IR.
The procedure was completed uneventfully and
post-operative radiographs show a reduction
in the apical radiolucency (Figures 8b and 8c).
Fig 10 Case 7. a) A 76-year-old female was referred after her GDP had difficulty accessing the 37
during primary endodontic treatment. The decision was then taken to perform IR, which was
completed uneventfully. Post-operative radiographs taken b) immediately following IR and c)
Case 6
after 12 months show an acceptable outcome with reduction in the size of the apical radiolucency A 64-year-old male was referred following
trauma to his 21 as a teenager (Fig. 9a). A
CBCT showed external root resorption on
following IR shows a reduction in the size of was made to locate this canal. Due to the the palatal aspect in the mid-third of the
the apical radiolucency associated with this proximity to the mental foramen, the patient root. The tooth was atraumatically extracted,
tooth (Fig. 4d). opted to attempt IR of the 34. A portion of allowing access to the defect which was
the crown fractured during extraction, but repaired with Biodentine. Post-operatively,
Case 2 the tooth was deemed restorable and the the tooth was splinted with a flexible wire and
A 45-year-old female was referred with remaining portion was implanted into the composite splint to the adjacent teeth (Fig. 9b).
persistent apical periodontitis for 34. A CBCT socket (Fig. 5a). A periapical radiograph Follow-up over a four-month period showed
demonstrated that there was an untreated taken three months post-operatively shows an improvement to the initial situation and a
lingual canal. An unsuccessful attempt good bony infill (Fig. 5b). halt to the resorptive process (Fig. 9c).

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 Restorative dentistry CLINICAL

Case 7
A 76-year-old female was referred after her
GDP had difficulty accessing the 37 during
primary endodontic treatment (Fig. 10a).
Clinical and radiographic examination
revealed a heavily broken-down tooth
with an apical radiolucency centred on
the root apices. An attempt was made to
access and negotiate the canals, which
proved unsuccessful. The decision was then
taken to perform IR, which was completed
uneventfully. Post-operative radiographs
taken immediately following IR (Fig. 10b)
and after 12 months (Fig. 10c) show an
acceptable outcome with reduction in the
size of the apical radiolucency. However,
some horizontal and intra-furcal bone loss
occurred during this period.
Case 8
A 53-year-old male was referred for the treatment
of a 37, which had a pulpal floor perforation.
Radiographic examination showed an apical
radiolucency at 36 and 37 apices (Fig. 11a). IR
was completed on the 37 and the perforation was
repaired (Fig. 11b). At this stage, with agreement
from the patient, no treatment was completed
for the 36. The periapical radiograph taken three
months post-operatively demonstrates apical
healing of the 37 (Fig. 11c).
Case 9
A 50-year-old male was referred following the
unsuccessful primary endodontic treatment
of 11 and for management of the internal
resorption of 21 (Fig. 12a). Radiographs
Fig. 11 Case 8. a) Radiographic examination showed an apical radiolucency at 36 and 37
apices. b) IR was completed on the 37 and the perforation was repaired. c) At this stage,
with agreement from the patient, no treatment was completed for the 36. The periapical
radiograph taken three months post-operatively demonstrates apical healing on 37
and a CBCT showed a poorly obturated 11 Case 11
and extensive internal root resorption of 21. A 45-year-old female patient was referred for
Endodontic retreatment was completed on treatment of a 37, for which the primary RCT
the 11 (Fig. 12b) and IR alongside a repair of was unsuccessful and the root canal filling was
the resorptive defect was undertaken on the overextended in the distal root. Due to anatomical
21 (Fig. 12c). A periapical radiograph taken location, an apicectomy was not possible. This
15 months post-operatively shows a large patient has been followed up for 28 months
improvement in the apical areas of both teeth following IR. Post-operative radiographs show
(Fig. 12d). healing of the apical areas (Figures 14a and 14b).
The pre-operative film radiograph was returned
Case 10 to the GDP following treatment.
A 64-year-old female was referred by her
GDP for treatment of a 37 due to presence of Case 12
a separated instrument in the mesio-buccal A 45-year-old male was referred with an
canal (Fig. 13a). IR was decided to be the endo-perio lesion of the 45. Conventional
best treatment choice in this instance due to endodontic and periodontal treatment were
the position of the fragment. The procedure completed; however, symptoms did not
was completed uneventfully and the mesio- improve. IR was completed in an attempt
buccal root was prepared and obturated to the to allow resolution of the perio-endo lesion
fragment (Fig. 13b). At the six-month review, (Fig. 15a). Clinical and radiographic follow-up
the patient was symptom-free and apical over nine months showed a reduction in the
healing of 37 was evident radiographically extent and severity of the lesion associated with
(Fig. 13c). 45 (Fig. 15b).

Fig. 12 Case 9. a) A 50-year-old male was referred following the unsuccessful primary endodontic treatment of 11 and for management of the
internal resorption of 21. Radiographs and a CBCT showed a poorly obturated 11 and extensive internal root resorption of 21. b) Endodontic
retreatment was completed on the 11. c) IR alongside a repair of the resorptive defect was undertaken on the 21. d) A periapical radiograph
taken 15 months post-operatively shows a large improvement in the apical areas of both teeth

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 CLINICAL Restorative dentistry

Case 13
A 39-year-old female was referred due
to symptomatic apical periodontitis of
36. Radiographically, it was thought that
improvements on the primary RCT of 36
could be made (Fig. 16a). However, ledging
complicated orthograde retreatment;
Fig. 13 Case 10. a) A 64-year-old female was referred by her GDP for treatment of a 37 due therefore, IR was completed (Fig. 16b). A
to presence of a separated instrument in the mesio-buccal canal. b) IR was decided to be the periapical radiograph taken three months
best treatment choice in this instance due to the position of the fragment. The procedure post-operatively shows bony infill in the apical
was completed uneventfully and the mesio-buccal root was prepared and obturated to the area of the 36 and horizontal bone loss mesially
fragment. c) At the six-month review, the patient was symptom-free and apical healing of 37 and distally (Fig. 16c).
was evident radiographically

Discussion

Short-term successful management of

compromised teeth is presented in these 13
cases. Table 2 outlines the cases discussed in
this case series. Although one tooth required
extraction shortly following IR, this tooth
was compromised intra-operatively due to
a root fracturing during extraction. Without
the option of IR, many of these teeth would
Fig. 14 Case 11: A 45-year-old female patient was referred for treatment of a 37, for which the have required extraction to relieve symptoms.
primary RCT was unsuccessful and the root canal filling was overextended in the distal root. Overall, the 12 patients who have retained their
Due to anatomical location, an apicectomy was not possible. This patient has been followed up teeth following IR are satisfied and no patients
for 28 months following IR. a, b) Post-operative radiographs show healing of the apical areas
have been re-referred. The key limitation with
the above cases is the lack of longer-term
follow-up, since the longest follow-up period
before discharge was 28 months. This would
have allowed determination of the incidence
of post-operative complications, particularly
root resorption which is an important adverse
outcome of IR discussed in the literature.10
As this was not part of a research project and
the cases were undertaken in a secondary care
setting, long-term follow-up is not undertaken
and patients are discharged to their GDPs for
Fig. 15 Case 12. a) A 45-year-old male was referred with an endo-perio lesion of the 45. clinical and radiographic review.
Conventional endodontic and periodontal treatment were completed; however, symptoms The materials and techniques associated
did not improve. IR was completed in an attempt to allow resolution of the perio-endo lesion. with IR have evolved considerably since its
b) Clinical and radiographic follow-up over nine months showed a reduction in the extent and inception, especially since the introduction
severity of the lesion associated with 45 of bioceramic materials. However, there is a
paucity of level 1 evidence investigating IR
success and no universally accepted clinical
protocol for IR.51 A recent systematic review
found an overall mean survival of 88% for
IR teeth. 10 Most available evidence is not
interventional and is in the form of case
studies and case series. Due to heterogeneity
in case selection, technique and outcome
measures, it is challenging to conduct a
Fig. 16 Case 13. a) A 39-year-old female was referred due to symptomatic apical periodontitis comparison. Furthermore, the definition
of 36. Radiographically, it was thought that improvements on the primary RCT of 36 could be of success varies across the literature,
made. b) However, ledging complicated orthograde retreatment; therefore, IR was completed.
with varying lengths of tooth retention
c) A periapical radiograph taken three months post-operatively shows bony infill in the apical
constituting success, specifically three, five
area of the 36 and horizontal bone loss mesially and distally
or ten years.10,52

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7. Friedman S. Considerations and concepts of case

Table 2 Summary of the cases included in this case series selection in the management of post-treatment
endodontic disease (treatment failure). Endod Topics
Follow-up time 2002; 1: 54–78.
Age Gender Tooth Symptoms Diagnosis
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