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k

Fig 5-129 The empty socket.

Figs 5-12h and 5-12i Evaluation of the root,

apicoectomy, and retrofilling.

Figs 5-12j An LEO is usually caused by

problems originating in the most apical 3mmof the root.

Fig 5.12k Amount of surgical extrusion. More

han 4 mm of the healthy tooth structure

should be exposed above the crest of bone to

preserve biologic width.

Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

root that does not allow for simple extraction. Teeth with short roqt trunks a

usually contraindicated. A minimum length of roots is necessary for prop

function. Since intra-alveolar transplantation and intentional replantation aoften considered the last choices of treatment to preserve teeth with deep dec

or endodontic lesiops, treatment planning should include the possibility

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Fig 5-121 Suture and fixation. The extruded toothneeds to be stabilized and the soh tissue needs to

be sutured around it.

5. Sequence and Treatment Procedures

Fig 5-12m First, the mesial gingival flap is sutured

with interrupted suture. The knot is made on either

he buccal or the lingual side. One end of the suture

is cut so that it extends about 30 mm.

Figs 5-12n and 5-120 Interrupted suture of the

distal side. The knot is made on the opposite siderom where the first knot was made (ie, if the first

knot was made on the buccal side, the second knot

shouldbe made on the lingual side).

Figs 5-12p and 5-12q The longer end of the

suture is wrapped around the tooth twice, then

another knot is made.

Figs 5-12r and 5-12s The tooth is stabilized

in its new position and prevented from extruding

urther by tying the extra length of suture across

he coronal surface.

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Figs 5-12t and 5-12u Protection ofthe sur-gical site and prevention of infection with

aluminum sheet and surgical dressing.

Fig 5-12v Six days after the procedure.The surgical dressing is removed in 3 to 5days and the suture is removed in 5 to 7days.

Fig 5-12w Four months after the proce

dure. Restorative treatment is started after

healing is complete.

Surgical procedure

Before surgery, caries control and acute periodontal treatment must be accom

plished. Once these steps have been taken, the general procedure of intra

alveolar transplantation and intentional replantation is as follows:

1. Local anesthesia

2. Sectioning of the gingival epithelium and incision of gingival tissue3. Reflection of the gingival flap 4.Extraction by elevation5. Apicoectomy and retrofilling6. Replantation7. Suture and fixation8. Surgical dressing9. Maintenance

Caries control

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5 . Sequence and Treatment Procedures

e

Figs 5-1 3a and 5-13b Preoperative view.

Extensive externa I resorption is observed on

he distal of the maxillary left lateral incisorin

a 1 O-year-old male.

Fig 5-13c Preoperative palatal view.

Fig 5-13d Extracted lateral incisor for surgical

extrusion.

Fig 5-13e The lateral incisor. The involvedcoronal portion was cut off extraorally. Before

extraction, the root canal was cleaned and filled

with calcium hydroxide.

Fig 5-13f The lateral incisor in place. Distal

aspect of the tooth is placed labial (rotated 90

degrees) and fixed, exposing enough tooth

structure above the crest of bone.

Sectioningof the gingival epithelium and incision ofgingivaltissueAfter local anesthesia, the flap is reflected to reveal an area around the root. Anintracrevicular incision is made around the adjacent teeth and a reverse bevel

incision is made around the extruded tooth (see Figs 5-12c to 5-12e). The

intracrevicular incision will minimize attachment loss in the healthy adjacent

teeth; the reverse bevel incision will remove the inner epithelium of the extrud- _ed

tooth while preserving as much keratinized gingiva as possible. The removal of the

inner epithelium will enhance healing (reattachment) between the gingival

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.


__

Fig 5-139 Nter surgical extrusion. Thetooth has beer splinted in its new position.

Fig 5-13h Protection of the surgical siteith surgical dressing.

Fig 5-13i One month after the procedure.

Fig 5-13j Four months after the procedure.

Apical closure is apparent.

Fig 5-13k Root canal obturation with sealer and

gutta percha.

Fig 5-131 Five months after the procedure.

Tooth is restored with composite resin.

Reflection ofthe gingival flapThe gingival flap is reflected and 2 mm of bone around the root is exposed (see Fig 5-12f).

Extractionby elevationThe tooth is elevated after incision in the periodontal ligament around the root. Theelevator is placed 45 to 70 degrees against the long axis of the tooth. Some damage tothe periodontal ligament is inevitable, but in the case of extrusion, the periodontal

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I',


c

Fig 5-14a Preoperative view. Distal recurrent decay is evident in the left second molar. Fig 5-14b Aftersectioning of the fixed partial denture at themesial abutment and removal of the caries from the second molar. It is ready for extraction and replantation in a more upright position. Fig 5-14c The

extracted molar. The shape of the molar is ideal for this procedure. Fig 5-14d The extraction socket. The socket was modified to allow the molarto be replanted in a more vertical (upright) position. Fig 5-14e After replantation, suturing, and fixation. The tooth was rotated 90 degrees toposition the buccal side toward the mesial wall of the socket. Fig 5-14fAfter the procedure. Fig 5-14g One month after the procedure. Fig 5-14h

Three months after the procedure. The teeth are prepared for a new fixed partial denture. Fig 5-14i One year6 months after the procedure. Fig 5-14j Two years 6 months after theprocedure. Fig 5-14k Six years 9 months after the procedure. Fig 5-141 Ten years after the procedure.

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_i_

picoectomy and retrofillingOne of the benefits associated with intentional replantation is that after extraction ofthe tooth, the presence of fracture lines and root resorption can be observed (see Fig 5-

12h). Apicoectomy and retrofilling is done on teeth in which conventional root canaltreatment has not been possible prior to the surgery, or when the apical configurationof the root made conventional endodontics impossible in that part of the root (see Figs5-12h to 5-12j and 51 5g to 5-1 5i). During any procedure involving the root apex, therest of the root should be protected with a saline-soaked gauze.

ReplantationIn cases where the purpose is to surgically upright a tilted molar, the mesial side ofthe socket is recontoured after the extraction to allow for vertical alignment (see Fig5-14). The tooth is then replanted so that at least 4 mm of intact tooth structure is

above the alveolar crest (see Fig 5-12k). The side of the tooth with the shortestvertical length should be positioned so that it is situated near the lowest bone level toallow for the desired supracrestal tooth dimension (see Figs 5-11g and 5-13f). Forinstance, if a distally broken tooth

Clinical Hint: Bleaching of Root-Filled Teeth

Canal fillingmaterial

Bleaching material

Cotton pellet

Stopping

Glass ionomercement

b

a As a bleaching agent, mix equal amounts of sodium perborate and 3% hydrogen peroxide solution. b Partially remove the root filling

material from the cervical aspect of the tooth and place 10% soda of hypochlorous acid in the cavity for 30 seconds. Immediately cleanse the

area, then place the bleaching agent in the labial aspect, as shown in the diagram. Seal with glassionomer cement. The bleaching material

should remain in place for 2 to 3 weeks; if the result is not satisfactory, the procedure can be repeated. This method allows even bleaching

across a crown.

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Fig 5-15a Preoperative panoramic v

Periapical lesion is observed in the are

mandibular left second molar. The patie

43-year-old female, is interestedsaving the tooth.

Fig 5-15b Three months after retreatme

the root canals. The periapical lesion ha

diminished.

Fig 5-15c Clinical view 3 months

retreatment showing continued presenc

sinus tract.

Fig 5-15d Preoperative buccal vNote the occlusal relationship to the opp

teeth.

Fig 5-15e Extraction socket of the se

molar.

Fig 5-15fExtracted second molar.

Fig 5-15g Extracted second molar after 3

apical resection.

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Fig 5-15h Preparation for apical filling.

Fig 5-15i Retrofilling with glass ionomercement. _

Fig 5-15j After replantation. Suturing and

fixation were performed simultaneously.

Fig 5-15kAfter intentional replantation.

Figs 5-151 and 5-15m Four months after the

procedure.

Figs 5-15n and 5-150 Six months after the

procedure. Restorative treatment with a new

ixedpartial denture. The periapical lesion isfilling in with new bone.

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Fig 5-16 fotentional replantation of a mandibular premolar.

Fig 5-16a Preoperative view. Periapical

lesion caused by fracture of a cusp ofthe mandibular right second premolar isobserved in a 31-year-old female.

Fig 5-16b Two years 3 months afterroot canal therapy. The periapical lesion

still exists.

Fig 5-16c Four years 6 months later. Despite

retreatment the lesion persisted.

Fig 5-16d Four years 6 months later. A

buccal sinus tract is present.

Figs 5-16e and 5-16fExtraction of the second

premolar for intentional replantation.

_

Fig 5-16g Three millimeters of the apex of the

root was cut off extraorally. No retrofill. ing

as placed because the canal was ade. quately

filled.

Fig 5-16h After intentional replantation.

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Fig 5-16i After intentional replantation.

Fig 5-16j Four months after the procedure.

Figs 5-16k and 5-161 One year 4 monthsafter replantation.

Fig 5-16m Two years 4 months after the

procedure.

Fig 5-16n Six years 3 months after the pro-

cedure. Other than slight root resorption on

he mesial side, no complication is observed.

Figs 5-160 and 5-16p Buccal and lingual

view 6 years 3 months after the procedure.

Probing depth and mobility are within normal

limits.


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Fig 5-17a A set of surgical instruments for transplantation. Fig 5-17b A set of burs for

preparation of the recipient site. Fig 5-17c Blade holder for microsurgery and blades. The headof the blade holder can be rotated 360 degrees. Blades (left to right): microblade, modified 15C,15C, 12D.

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,_

.

Fig 5-17d Diamond-coated forceps. Diamonds are coated on the inner surface of the forceps so that the extracted teeth are held securely.

Fig 5-17e (top to bottom) A mallet for socket-lifting procedure, an osteotome, and a periosteal elevator.

Fig 5-17fA Boley gauge and probe. These tools are used for measurement of the donor teeth or recipient sites. Fig 5-17g Rongeurs.The minirongeur is useful.

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n5 . Sequence and Treatment Procedures

Fig 5-17 (continued)

Fig 5-17h Periosteal elevator. Fig 5-17i Chisels. These are used for elevation of cortical bone plate.

Fig 5-17j Forceps. Diamond-coated forceps (top) and serrated forceps (bottom) are useful for holding the donor tooth or gingival flap. F

(top to bottom) Needle holders, tissue forceps, and scissors.

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Fig 5-171 (above and right) Internal and external water dispenserof

saline and reduced speed contra angle (5:1 ratio).

Fig 5-17m Surgical dressing. This is used fo protection of the surgical site (COEPAK, G

America, Alsip, IL).

Fig 5-17n Wires. These are used for fixation of the donor teeth (twisted wire 1 X 3, 3M Unitek, Monrovia, CA). Fig 5-170 Self-curing composite resin. This

is used for fixation of the donor teeth. Composite resin for core buildup is easier to remove because of its color. Fig 5.17p Composite resin

syringe. This is used to dispense composite resin during fixation of the donor teeth.

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The procedure is as follows (see Figs 5-121 to 5-12s). First, the mesial (or distalpart of the flap is sutured with an interrupted suture. The knot is placed on the lingua(or buccal) side. One part of the suture is left at about 30 mm (about 1 in). Next, thedistal (or mesial) part of the flap is sutured. The knot is placed opposite of the firstknot (either buccal or lingual). The suture is knotted after circling around the roo

twice. A slight coronal force is applied to the tooth by this procedure. An apicallydirected force is then applied by tying the suture across the coronal part of the tooththus stabilizing the tooth and preventing movement in either direction. This techniqueis very useful because the root can be retained vertically in any position. In cases ointentional replantation, simply tying a suture firmly over the incisal/occlusal surfacewill hold the tooth in position, and forcing the tooth apically is not a concern becauseit fits into a normal socket. If it is difficult to achieve stability of replanted teeth incases of surgical up righting or extrusion, splints to the adjacent teeth with wire andresin may be necessary (see Figs 5-13f and 5-14e).

Surgical dressingTo enhance healing (reattachment), an aluminum sheet and surgical dressing are used

to protect the surgical area by preventing infection and preserving the blood clot (seeFigs 5-12t and 5-12u).

MaintenanceThe surgical dressing is removed 3 to 5 days after surgery, and the suture is removed5 to 7 days after surgery. At this point, initial reattachment at the cervical area isachieved and there is little chance that replanted teeth will drop out. Occlusaladjustment may be necessary to minimize occlusal force for the first 2 months.

Restorative treatment

Restorative treatment of the replanted or intra-alveolar transplanted tooth can

be started 2 to 3 months after surgery. After placement of post and core, the teethshould be temporized for 1 to 2 months, before placing the definitive restoration (seeFigs 5-11m and 5-11n). Composite resin restoration is indicated if enough toothstructure is available (see Fig 5-131).

Because the crown-root ratio is less favorable for teeth that have been surgicallyrepositioned (intra-alveolar transplantation) than it is for those that have undergoneconventional transplantation or intentional replantation, occlusion must be adjustedcarefully to minimize occlusal force, especially lateral force.

Maintenance

Patients need to be on a maintenance program to prevent caries and periodontal

disease. If transplanted (or replanted) teeth demonstrate excessive mobility, occlusaladjustment should be performed to promote periodontal healing.

Clinical illustrations of intentional replantation

Figures 5-19 to 5-23 illustrate a variety of clinical situations in which intentional replantation has been applicable.


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5 . Sequence and Treatment ProceduresFlgs5-19to 5-23 Clinica[ illustrations ofintentional replantation (courtesy of Dr. Leif K

6akland).

,"_

Fig 5-20a Right mandibular second molar before intentional replantation. Root canal treatment and post, core, and crown placement were

performed on the tooth 6 years earlier; symptoms had recently developed. Note periradiuclar lesion. Fig 5-20b After intentional replantation. Th

apical opening was prepared and filled with reinforced zinc oxide eugenol cement. The crown was dislodged during extraction. Fig 5-20c Oneyear follow-up. The patient is asymptomatic. Note evidence of periradicular bone regeneration. A new crown was subsequentlyplaced on the tooth.

Fig 5-19a Right mandibular canine beforeintentional replantation. Root canal treatmen

had been performed 1 year ealier, bu

symptoms continued.

Fig 5-19b After extraction. Note thesecond root. Both apical openings were prepared and filled with amalgamand the tooth was replanted.

Fig 5-19c Six-year follow-up. The tooth is

asymptomatic and the periradicularbone

appears normal.

Fig 5-21a Left mandibular second molabefore intentional replantation. Root canareatment and core and crown placemen

were performed on the tooth 3 years earlie

Note the peri radicular lesion. The patien

was symptomatic; there was a buccal sinu

ract leading to the lesion.

Fig 5-21 b Immediately after replantation

Root apices were resected; no retrofillingwere placed. The crown was dislodged an

was not recemented immediately.

Fig 5-21c Six-month follow-up. The toot

was asymptomatic and the crown was rece

mented.

Fig 5-21d Two-year follow-up. Tooth remain

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Fig 5.22a Right maxillary second molar before intentional replantation. The tooth required root canal therapy; the root canal system was

extremely complex and the dentist was unable to clean and prepare the canal system adequately. The canals were filled as well as possible and the tooth w

scheduled for replantation. Fig 5-22b Immediately after replantation. The apical canal opening was filled with

amalgam. Fig 5.22c Seven-year follow-up. The tooth is asymptomatic and the periradicular tissues are normal.

Fig 5-23a Right maxillary central incisor before intentional replantation. The tooth had undergone a long series of procedures over a peri

od of several years. The most recent was apical surgery, which included an attempt at repairing a labial root perforation that happened during postpreparation. Th

patient continued to have symptoms, including slight labial swelling. Fig 5-23b Immediately after replantation. The apical opening and the labia

perforation were prepared and filled with mineral trioxide aggregate (ProRoot MTA, Dentsply Tulsa

Dental, Tulsa, OK). Fig 5.23c One-year follow-up. The patient is asymptomatic, the tooth is stable, and there is no labial swelling.

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