intentional re plantation case report of an
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BARATTO FILHO, Flares; VANNI, José Roberto; LIMONGI, Orlando; FARINIUK, Luiz
Fernando; TRAVASSOS, Rosana; Santana ALBUQUERQUE, Diana
Intentional replantation: case report of an alternative treatment for endodontic therapy
failure
RSBO. Revista Sul-Brasileira de Odontologia, Vol. 1, Núm. 1, 2004, pp. 36-40
Universidade da Região de Joinville
Brasil
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Intent ional replant at ion : case repor t o f analternat ive t reatment f or endodont ic therapyfailure
Reim plante in tencional: relato de caso como um aalternativa para o tratamento dos insucessosendodônticos
Flares BARATTO FILHO*
J os é Rob er to VANNI**
Or lan do LIMONGI***
Luiz Fer n a n do FARINIUK****
Rosana TRAVASSOS*****
Diana Santana ALBUQUERQUE*****
Cor r espondence: Dr. Flares Baratto Filho
Avenue Professor Pedro Viriato Parigot de Sousa, 1100 – ap. 701-7Mossunguê – Curitiba – Paraná – Brazil
CEP 81200-10 0 – fax: +55 4 1 33 6203 5
E-m ail: fba ra tto@u ol.com.b r
* Facu lty of Dentistr y, Univers ity of Perna m bu co (FOP-UPE). Faculty of Dentist ry, Univers ity of J oinville (UNIVILLE), Faculty of Den tistr y,
University Cent er of Positivo (UNICENP), M.Sc.** Faculty of Dentis try, Univers ity of Perna m bu co (FOP-UPE). Facu lty of Dentist ry, University of Passo Fun do (UPF), M.Sc.*** Faculty of Dentistr y, University of Perna m bu co (FOP-UPE). Faculty of Dentis tr y, University of Canoa s (ULBRA), M.Sc.**** Pontifical Catholic University of Paraná (PUC-PR).***** Faculty of Dentistry, University of Pernambuco (FOP-UPE), Ph.D.
Recebido em 14/ 12 / 03. Aceito em 1 / 3/ 04.
Keywords : replantation; resorption;
uns uccessful endod ontic
treatment.
Abstract
The aim of this stu dy was to pr esent an a ltern ative treatm ent after the occurr ence
of endodontic therapy failure. The authors report a clinical case of a second
maxillary permanent molar, which was indicated for intentional replantation
as a n altern ative treatm ent. Extraction was per form ed followed by apicoectomy
of the thr ee roots and radicular d econtam ination with citric acid (pH= 1) for 1
m in; the roots were then r etro-obturated with am algam and the tooth r eplanted
in the a lveolus. The extra-buccal per iod lasted 1 5 m in. Clinico-rad iograph ical
follow-up examinations were done at 2, 3 and 5 years and no symptoms or
rad icular r esorption were found . There was b one neo-form ation a t the palatal
root that had presented a periapical lesion. Intentional replantation can be
indicated correctly as an alternative treatment for cases in which conservativeendodontic therapy or su rgical technique cannot be perform ed.
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RSBO v. 1, n. 1, 2004 – 37
Resumo
O objetivo deste estudo foi apresentar uma alternativa de
tratam ento para os casos de insu cessos na terapia endodôntica.Os autores demonstram um caso clí nico de um s egun do m olar
superior que foi indicado para o reimplante intencional. A
exodontia foi realizada e logo ap ós feita a apicectomia da s três
r a í zes, seguida pela descontamina ção radicular com uma
solução de ácido (pH = 1) por 1 minu to; as ra í zes foram
retroobturadas com amálgam a e o den te foi então reim plantado
em seu alvéolo. O tempo extrabucal foi de 15 minutos. Um
acompanham ento clí nico radiográfico foi realizado em 2, 3 e 5
anos, em que nenhum sintoma de reabsor ção radicular foi
evidenciado e u m a neoform ação óssea foi localizad a n a r egião
da lesão periap ical qu e existia na ra iz palatina . Conclui-se que
o re implan te in tenc iona l pode s e r ind icado como uma
alternativa de tr atamento para os casos em q ue o tratam ento
endodôntico convencional ou ciru rgias par aendod ônticas não
obtiveram sucesso.
Palavr as-chave: reimplante; reabsor çã o;
insucessos do tr atamen-to endodôntico.
Introduction
The intentional replantation technique is an
alternative for the clinician in these situations, and
can reach 85% survival in the first 5 years, with a
m ean s ur vival of 10 year s [7].
Intentional replantation can be defined as the
extra ction of a tooth followed b y extra-ora l endod ontic
therapy and the re-placement of the tooth in thealveoli. The main indication for replantation is when
there is no oth er alternative to maintain th e tooth in
the or al cavity [15] and accord ing to Weine [16 ] other
indications of this pr ocedu re ar e: 1) when th ere is a
perforation, or internal or external resorption and
surgery is not possible; 2) when routine endodontic
treatm ent is not poss ible such as in patients who are
incapable of m aintaining their m outh open for a long
period of tim e; 3) when th e root canal is sealed and
there is a fractured instrument, calcification, or
periapical radiolucency and routine surgery is not
pos sible; 4) when th ere is a foreign bod y, such as a
f i l l ing mater ia l , in the per iodonta l l igament orperiapical tissu e and sur gery is n ot poss ible; 5) when
pr evious tr eatment failed and sur gical or non-sur gical
retreatment is not possible.
Thus, a case of a second maxillary molar is
reported in which in tent ional replanta t ion was
indicated.
Case repor t
A 36-year-old male patient who had already had
end odon tic retr eatm ent of the root cana l of the second
left maxillary molar was seen. Clinically, this toothpresented spontaneous, continual and intense pain;
the periapical mucosa was mildly edematous at the
buccal region and the tooth was hypersensitive to
percussion. Examination of radiographs brought by
the pa t ient showed the presence of a f rac tured
instru m ent in the m esio-buccal root (which according
to the pa t i en t occur red dur ing the endodon t ic
pr ocedu re) an d over-filling of the pa latal root (which
occurred du ring the retreatmen t) (figur es 1 an d 2 ).
Figur e 1 – Fractured file in the m esio- buccal root
Figure 2 – Over- fill ing of t he palatal root and pre- imp lantradiograph
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38 – Intentional replantation: case report of an alternative treatment for endodontic therapy failureBaratto Filho et al.
Af t er d e t a i l ed a n a m n e s i s , i n t e n t i o n a l
r e p l a n t a t i o n w a s i n d i c a t e d d u e t o a n a t o m i c
difficulties (near the maxillary sinus) of this tooth
for an apicoectomy and the fractured instrum ent andover-filling. The patient was informed of the risks
and the benefits of this treatm ent and agreed to it.
T he pa t i en t rece ived an t ib io t i c s and an t i -
inflammatory medication (500 mg of amoxicillin,
every 8 h for 7 days and 50 mg sodium diclofenac,
every 8 h for 3 days) and was instructed to return
72 h later for the procedure. After this period the
patient returned with decreased symptomatology
and surgery was performed.
After sub -periosteal anesthesia, syndesm otomy
and careful extraction were performed to avoid
poss ible corona l and /or r adicular fractur e. The toothwas placed in a container with saline and the alveolus
was carefully cur etted an d irr igated with saline and
closed b y gauze emb edd ed in this s olution. Th e tooth
was man ipu la ted on ly touch ing the c rown and
apicoectomy [9] (3 r oots) and deconta m ination citric
acid (pH = 1 for 1 m in) were perform ed. The roots
were then retrofilled with amalgam and the tooth
was replanted and rad iograp hed (figur e 3).
Figure 3 – Post- implant radiograph
The alveolus was not r adiograp hed because the
patient did not agree to be exposed to u nnecessary
rad iation. The tooth was th en imm obilized by a sem i-
rigid splint, which remained in place for 2 weeks.
The tooth remained extra-buccally for only 15
min, which certainly influenced the case prognosis.
Clinico-radiographical follow-up
The firs t follow-up was two years a fter th e rem oval
of the splint (figure 4), followed by a 3-year (figure 5)
and 5-year (figur e 6) follow-up . Ther e was p eriap ical
healing with n o r adicular r esorption, bu t with a slight
increase in the pre-existent periodontal problem,
probably due to the change of restoration that didnot ha ve proximal adequ ate proximal contact.
Figur e 4 – Two- year f ollow- up
Figu re 5 – Three- year f ollow- up
Figu re 6 – Five- year follow- up
DiscussionIntentional rep lantation is a viable alternative in
the case of unsuccessful endodontic procedures,
however it mu st be accomp lished as quickly as possible.
Magini et al. [11] reported that radicular or
coronal fracture must be considered before this
procedure evaluating the tooth with clinical and
ra diograp hical examinations, obs erving the resistance
of the crown and root especially in terms of caries,
extensive restorations or the presence of post-core
system s. Therefore, this pr ocedure m ust be performed
with ad equate criteria and corr ect planning [10].
After extraction and before replantation thealveolus mus t be d elicately curetted and irrigated with
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RSBO v. 1, n. 1, 2004 – 39
saline to prevent excessive bleeding [14]. De Deus [5]
reported that this is fundam ental for th e pr evention of
ankylosis of the replanted element, also affirming that
the re - in teg ra t ion and re -cons t i tu t ion o f thepericementum is associated to the intensity of the
traum a and the act of replantation (the less the traum a
and the faster the operation, the higher th e success rate).
And reasen [1 , 2 , 3] reported tha t su bs t i tu t ion
r es or p t i on co u ld oc cu r a fte r tw o we ek s of
replanta t ion in two forms , according to the extent
of damage: t rans i t ional subs t i tu t ion resorpt ion
in wh ic h a n a lr ea d y es t a b li s h ed a n k ylo s is
d i s appea rs , and the pe rmanen t subs t i tu t ion in
wh ic h t h e r a d ic u la r s u r fa ce is gr a d u a lly
s u b s t i t u t e d . T h i s r e s o r p t i o n i s r e l a t e d t o t h e
ex tens ive d am age be tween the m os t in t im a telayers of the periodontal l igament of the root.
Grossman [7] reported successful healing in
intentional replantation in 32-62% of the cases. In
this study, he analyzed the time of surgery and the
failure of treatment, thus, calculating the survival
rate of the replanted tooth. After 5 years, an 85%
success rate can be expected with a 10-year mean
sur vival rate for th e replanted tooth. Our case report
pr esents a 5 -year follow-up .
Citric acid was used only to decontaminate the
remnant root surface; however, Register & Burdick
[12,1 3] repor ted tha t when corr ectly us ed, citric acidcauses superficial root demineralization capable of
ind ucing cem entogenesis an d r e-inser tion of collagen
fibers, an d th us ind ucing a m ore efficient and qu ick
peri-radicular healing.
Andreasen [1] cited two other s tudies [4, 6]
t h a t s h o w e d t h a t r e t r o g r a d e o b t u r a t i o n w i t h
amalgam is respons ible for m ore resorp t ion than
g u t t a - p e r c h a . H o w e v e r , i n o u r c a s e w e u s e d
amalgam due to the quickness in which the r e t ro-
obtura t ion could be perform ed.
In spite of the fact that Ingle & Taintor [8 ]
r e p o r t e d t h a t p o s t e r i o r t e e t h d o n o t n e e dimmobil iza t ion because they are normal ly wel l
retained, we used semi-rigid immobilization for 15
days for better comfort for the patient in the post-
operative period.
Andreasen [1] reported that in patients 10-30
years of age, inflammatory radicular resorption is
significantly more frequent than in older patients.
This is pr obably related to larger r oot canals and/
or dent ina l tubules tha t would eas i ly a l low the
passage of bac ter ia and the i r endotoxins to the
periodontium, however, the 36-year-old patient of
this report had no problem.
Conclusions
Although intentional replantation is consideredby many a s an audac ious p rocedure , i t c an be
indicated correctly as an alternative treatment for
cases in which conservative endodontic therapy or
sur gical techn ique cannot be p erform ed.
References
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2. And rea sen J O. Ana lysis of pa thogenesis an d
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3 . An d r e a s e n J O . P e r i o d o n t a l h e a l i n g a f t e r
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