Intentional replantation of periodontally compromised hopeless tooth.

Aesthetic considerations have influenced the management of dental maladies in varying degrees for many years. Even single tooth mal-alignment makes the patient to approach a dentist. Intentional replantation is a procedure in which an intentional tooth extraction is performed followed by reinsertion of the extracted tooth. Many authors agree that it should be reserved as the last resort to save a tooth after other procedures have failed or would likely to fail. The main reason of failure in replanted teeth is root resorption, specifically ankylosis or replacement resorption. Although the success rate is not always high, intentional replantation may be a treatment alternative that deserves consideration to maintain the natural dentition and avoid extraction of the tooth. Here is case report of a patient desiring alignment of malpositioned periodontally involved anterior single tooth due to various causes treated by intentional replantation.

INTRODUCTION

There are many and functional difficulties in the management of anterior teeth manifesting excessive periodontal destruction. Extraction is only treatment option of such many periodontally involved hopeless teeth. Although intentional replantation is usually contraindicated in teeth with moderate-to-severe periodontal involvement, there are studies presenting successful results with periodontally involved teeth. Intentional replantation involves the purposeful removal of a tooth and its reinsertation into the socket after proper endodontic management and repair.[1] Intentional replantation is a treatment option when more conventional forms of treatment either fail or are impossible. Itis thought that reimplantation may be considered as one of the viable mode of treatment in certain situations to preserve the natural dentition. Intentional replantation is contraindicated in the presence of periodontal disease, in which there is marked tooth mobility, furcation involvement or gingival inflammation. A replantation will have a lower success rate if the tooth is already compromised periodontally and missing the interseptal bone.[2] Although most of the authors revealed periodontal involvement as a contraindication for replantation, there are some studies with successful results with periodontally involved teeth. Two cases are presented here wherein, functional and conservative management of asymptomatic, slightly mobile, malpositioned and pathologically migrated upper central incisor are reported.

CASE REPORTS

Case 1

An 18 year female patient reported to the Department of Periodontics and Oral Implantology with the chief complaint of increasing gap in between upper front teeth since 8 months giving an appearance in the zone. Patient gave a history of trauma 2 years back in the same region. On clinical examination, patient had pathologically migrated 11. Grade II mobility in relation to 11. On probing, pocket depth of 7 mm on the mesial aspect of 11 and 5 mm on the distal and palatal aspect [Figure 1]. Radiographic examination revealed moderate to severe bone loss in relation to 11 (mesially) [Figure 2].

Figure 1

Pre-operative probing depth

Figure 2

Pre-operative

Treatment plan

Patient being a young female demanded to retain her natural tooth and denied for extraction of the tooth for esthetic reason. Considering the clinical situation, intentional replantation of 11 was planned after explaining the pros and cons of treatment to the patient. Phase I therapy was completedand intentional root canal treatment was carried out i.r.t 11. Replantation procedure was scheduled four weeks after the completion of the root canal treatment.

Surgical procedure

Atraumatic extraction was done i.r.t 11 after achieving adequate local [Figure 3]. Extracted tooth was carefully root planed for removal of necrotic cementum and granulation tissue. Extruded tooth was put back in new position after drilling apical bone with proper sized drill [Figures 4 and 5] and splinted with wire and composite for 3 months [Figure 6]. Post-operative instructions were given to patient to maintain proper oral hygiene. Recall check-up was done every month. Open flap debridement with bone graft and membrane was carried out 3 months after of the replantation procedure [Figure 7]. Patient recalled after 7 days for suture removal and every month thereafter, for 3 months. Patient is still under continual follow-up without any untoward effect 3 months follow-up after regenerative therapy clinical photograph [Figure 8] and radiographic photograph [Figure 9].

Figure 3

Extracted tooth

Figure 4

Reimplantation site prepared

Figure 5

Tooth reinserted in the extraction socket

Figure 6

Splinting done and tooth immobilized

Figure 7

Immediate post-operative intraoral periapical

Figure 8

3 months follow-up clinical picture

Figure 9

3 months follow-up radiographic picture

Case 2

Systemically healthy 24-year-old male patient came to Department of Periodontics, with the complaint of unaesthetic appearance of upper central teeth because of forwardly placed maxillary left central incisor since 6 months. Patient gave history of extraction of supernumerary tooth, which was placed palatal to 11 and 21, 3 months back. 21 had gradually come to the present position over 6 months [Figure 10]. Patient was also complaining about functional problems of the upper central teeth because of loss of biting ability due to forwardly placed and mobile tooth. During the clinical examination, approximately 6 mm of periodontal pocket were observed with 21. Radiographic examination was revealed moderate alveolar bone resorption reaching to the middle third of the tooth [Figure 11]. Mobility of the tooth was Grade II.

Figure 10

Pre-operative photograph

Figure 11

Pre-operative intraoral periapical

Patient demanded not to loose any teeth because of psychological reasons during the treatment plan phase. Considering patient's demands and the clinical situation, the treatment plan of upper anterior teeth (21) decided as Phase I periodontal therapy and intentional replantation and relocation of maxillary left central incisor followed by periodontal splint. Oral hygiene motivation, scaling and root were as the initial periodontal therapy. At the 4th week after the initial therapy, a considerable improvement in oral hygiene and gingival health and slight reduction in periodontal pocket depths were observed during the clinical examination. Endodontic treatment was performed prior to intentional replantation in three visits.

Replantation procedure

After giving local, gingival attachments of central teeth were removed by periotome and sulcular incisions. Left upper central tooth was gently and atraumatically extracted [Figure 12]. Granulation tissues in the extraction sockets were removed by gentle curettage and the sockets were rinsed with sterile saline [Figure 13]. All irritants and necrotic cementum were removed from the root surfaces with periodontal curettes carefully. Extruded tooth was put into position by preparing the reimplantation site [Figure 14], at the apical end of the socket to accommodate the tooth in the new position. Tooth was then placed into the socket in an adequate position contacting their roots directly to the alveolar bone [Figure 15]. The replanted tooth was then splinted with composite splint [Figure 16].

Figure 12

Extracted tooth

Figure 13

Extraction socket site

Figure 14

Reimplantation site prepared

Figure 15

Tooth reinserted in the extraction socket

Figure 16

Splinting done and tooth immobilized

Patient was advised not to eat stiff foods using maxillary anterior teeth at least for 3 months. Patient was prescribed amoxicillin 1 g. Bid for 5 days along with an analgesic and also recommended to use interdental brush at the replantation site, in addition to the routine oral hygiene attempts. Chlorhexidine mouthwash 0.2% was prescribed twice daily for 14 days. Regenerative therapy was carried out 3 months later. Patient was placed in a maintenance recall program every month for the first 3 months and every 3 months thereafter [Figure 17] 6 months post-operative showing bone fill [Figure 18] following regenerative therapy. The necessary oral prophylaxis was done, oral hygiene instructions were reinforced and splint integrity was checked along with clinical parameters at every recall visit.

Figure 17

3 months follow-up after splinting

Figure 18

Intraoral periapical of 6 months follow-up after regenerative therapy

Patient is under continued supportive periodontal therapy and has not shown any untoward effects of root resorption or mobility other than slight papillary recession at 14 months follow-up as per clinical and radiographic evaluation [Figures 19 and 20].

Figure 19

14 month post-operative follow-up

Figure 20

Intraoral periapical of 14 months follow-up

DISCUSSION

Intentional replantation is considered as the last resort treatment alternative for periodontally involved teeth. Some studies with successful results are also documented. Baykara and Eratalay 1995 reported successful results of intentional replantation of periodontally involved teeth for a period of 8 years.[3] Demiralp et al. 2003 replanted periodontally hopeless teeth and obtained positive results at 6 months.[4] Yaprak et al. 2010 successful intentional replantation and 4-year follow-up of two upper adjacent central teeth, which were extremely mobile due to advanced periodontal disease.[5] Similar treatment plan advocated in the present cases and successfully followed 3 months and are under continual follow-up. Patients are satisfied both aesthetically and functionally at the end of all procedures. As another alternative of this treatment, central incisor could be extracted and a fixed prosthetic restoration including laterals and opposite central could be done. However, this prosthetic approach would be concluded with some outcomes and little expensive treatment option for patient. Studies report that 40% of the alveolar height and 60% alveolar width may be lost in the first 6 months following extraction. Thus, pontics of central would be taller than usual and dark sites at the embrasure areas would be more extensive within the prosthesis. Prevention of post-extraction alveolar crest height and width loss was facilitated by intentional replantation application.[6] Some reports suggest that time interval between extraction and replantation procedures must not exceed 15 min.[7] In these case reports all the replantation procedures were completed in approximately 30 min. Rationale for periodontal treatment is debridement of irritants from the tooth and root surface. Periodontal pocket formation related to the alveolar bone resorption to the middle/apical third of the root enables the deposition of bacterial plaque and dental calculus, which in turn leads to periodontal destruction, pocket formation and bone loss.[8] In extreme conditions, it leads to mobility and extraction remains the mainstay of the treatment plan. According to the results of the study by Demiralp et al. (2003), the success of the intentional replantation treatment is directly related to correct selection of cases, based on clinical and radiographic evaluations.

CONCLUSION

Intentional replantation is considered as the last resort treatment alternative to delay extraction of periodontally compromised teeth. Intentional replantation can be used to treat periodontally involved cases with the benefits of performing debridement of root surface extraorally and cautiously without excessive tissue removal and also provides access for conditioning or treatment of root surfaces for better regeneration outcomes tooth survival rate. In these case reports, short term successful management of periodontally involved upper central tooth with intentional replantation is presented. Patients satisfied both and functionally after intentional replantation procedure. Both patients are kept under long-term follow-up.