Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

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 3mm of the root.

Fig 5.12k Amount of surgical extrusion. More than 4 mm of the healthy tooth structure should be exposed above the crest of bone to preserve biologic width.

root that does not allow for simple extraction. Teeth with short roqt trunks are usually contraindicated. A minimum length of roots is necessary for proper function. Since intra-alveolar transplantation and intentional replantation are often considered the last choices of treatment to preserve teeth with deep decay or endodontic lesiops, treatment planning should include the possibility of orthodontic treatment or conventional endodontic treatment. 113

Sequence and Treatment Procedures

Fig 5-121 Suture and fixation. The extruded tooth needs to be stabilized and the soh tissue needs to be sutured around it. Fig 5-12m First, the mesial gingival flap is sutured with interrupted suture. The knot is made on either the 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 side from where the first knot was made (ie, if the first knot was made on the buccal side, the second knot should be 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 further by tying the extra length of suture across the coronal surface.

..

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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

Figs 5-12t and 5-12u Protection ofthe surgical 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 5 days and the suture is removed in 5 to 7 days.
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 tissue 3. Reflection of the gingival flap 4. Extraction by elevation 5. Apicoectomy and retrofilling 6. Replantation 7. Suture and fixation 8. Surgical dressing 9. Maintenance Caries control Complete caries control before surgery allows an estimate of the amount of available tooth structure remaining. 115

Sequence and Treatment Procedures

Figs 5-1 3a and 5-13b Preoperative view. Extensive externa I resorption is observed on the distal of the maxillary left lateral incisor in 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 involved coronal 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.

Sectioning of the gingival epithelium and incision of gingival

tissue After local anesthesia, the flap is reflected to reveal an area around the root. An intracrevicular 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 connective tissues and the periodontal ligament of the replanted tooth. 116
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I
Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

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Fig 5-139 Nter surgical extrusion. The tooth has beer splinted in its new position. Fig 5-13h Protection of the surgical site
with 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 of the gingival flap The gingival flap is reflected and 2 mm of bone around the root is exposed (see Fig 512f). Extraction by elevation The tooth is elevated after incision in the periodontal ligament around the root. The elevator is placed 45 to 70 degrees against the long axis of the tooth. Some damage to the periodontal ligament is inevitable, but in the case of extrusion, the periodontal ligament in this area is not important because that part of the root will be positioned supracrestally. 117

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I',

Sequence and Treatment Procedures

Fig 5-14a Preoperative view. Distal recurrent decay is evident in the left second molar. Fig 5-14b After sectioning of the fixed partial denture at the mesial 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 molar to be replanted in a more vertical (upright) position. Fig 5-14e After replantation, suturing, and fixation. The tooth was rotated 90 degrees to position the buccal side toward the mesial wall of the socket. Fig 5-14f After 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 year 6 months after the procedure. Fig 514j Two years 6 months after the procedure. Fig 5-14k Six years 9 months after the procedure. Fig 5-141 Ten years after the procedure.

118

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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

Apicoectomy and retrofilling One of the benefits associated with intentional replantation is that after extraction of the tooth, the presence of fracture lines and root resorption can be observed (see Fig 512h). Apicoectomy and retrofilling is done on teeth in which conventional root canal treatment has not been possible prior to the surgery, or when the apical configuration of the root made conventional endodontics impossible in that part of the root (see Figs 5-12h to 5-12j and 51 5g to 5-1 5i). During any procedure involving the root apex, the rest of the root should be protected with a saline-soaked gauze. Replantation In cases where the purpose is to surgically upright a tilted molar, the mesial side of the socket is recontoured after the extraction to allow for vertical alignment (see Fig 5-14). 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 shortest vertical length should be positioned so that it is situated near the lowest bone level to allow for the desired supracrestal tooth dimension (see Figs 5-11g and 5-13f). For instance, if a distally broken tooth

Clinical Hint: Bleaching of Root-Filled Teeth

Canal filling material

Bleaching material Cotton pellet Stopping Glass ionomer cement

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.

119

Sequence and Treatment Procedures

Fig 5-15a Preoperative panoramic view. Periapical lesion is observed in the area of mandibular left second molar. The patient, a

43-year-old female, is interested in

saving the tooth.

Fig 5-15b Three months after retreatment of the root canals. The periapical lesion has not diminished. Fig 5-15c Clinical view 3 months after retreatment showing continued presence of sinus tract.

Fig 5-15d Preoperative buccal view.

Note the occlusal relationship to the opposing teeth.

Fig 5-15e Extraction socket of the second molar.

Fig 5-15f Extracted second molar. Fig 5-15g Extracted second apical resection.
molar after

3-mm

120
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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

Fig 5-15h Preparation for apical filling.

II

Fig 5-15i Retrofilling with glass ionomer cement. _

Fig 5-15j After replantation. Suturing and fixation were performed simultaneously.
Fig 5-15k After 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 fixed partial denture. The periapical lesion is filling in with new bone.

121

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5

Sequence and Treatment Procedures

Fig 5-16 fotentional replantation of a mandibular premolar.

Fig 5-16a Preoperative view. Periapical lesion caused by fracture of a cusp of the mandibular right second premolar is observed in a 31-year-old female.

Fig 5-16b Two years 3 months after

root 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 5-16f Extraction 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 was placed because the canal was ade. quately filled. Fig 5-16h After intentional replantation.

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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

Fig 5-16i After intentional replantation. Fig 5-16j Four months after the procedure.

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

Fig 5-16m Two years 4 months after the procedure. Fig 5-16n Six years 3 months after the procedure. Other than slight root resorption on the 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.

123

Sequence and Treatment Procedures

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 head of the blade holder can be rotated 360 degrees. Blades (left to right): microblade, modified 15C, 15C, 12D.

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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

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 5-17f A Boley gauge The minirongeur is useful.

and probe. These tools are used for measurement of the donor teeth or recipient sites. Fig 5-17g Rongeurs.

125

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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. Fig 5-17k (top to bottom) Needle holders, tissue forceps, and scissors.

126 Ii... ;..

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Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

Fig 5-17m Surgical dressing. This is used for protection of the surgical site (COEPAK, GC America, Alsip, IL).

Fig 5-171 (above and right) Internal and external water dispenser of saline and reduced speed contra angle (5:1 ratio).

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.

127

Sequence and Treatment Procedures

Fig 5-18a Preoperative view of a transplanted second molar, which will be splinted to the adjacent first molar. Fig 5-18b Try-in of the wire. Fig 5-18c Etching of the enamel. Fig 5-18d Removal of etchant with water and drying. The high speed suction is placed on the occlusal
table and water is applied in a gingival to coronal direction so that contamination of the surgical area by etchant, water, and air is prevented. Fig 5-18e Application of composite resin. Fig 5-18f Placement of the wire. Fig 5-18g Application of additional composite resin on top of the wire. Fig 5-18h Contouring of the composite resin. Surface of the applied composite resin is smoothed with a wet cotton pellet. Fig 5-18i Occlusion check. Applied composite resin should not interfere with occlusion of the area. Minimal occlusal adjustment of the transplanted tooth is performed after completion of fixation.

is going to be surgically extracted, the tooth should be rotated so that the distal surface is lined up with the lingual side of the socket, and replanted in the extruded position and splinted (see Fig 5-13f). In cases of intentional replantation where the tooth is to be replaced in the original position, the tooth should be replanted gently without excessive force (see Figs 5-15 and 5-16). Suture and fixation Suturing of the flap and fixation (splinting) of the teeth often can be performed concurrently with the surgical extrusion because the shape of the extraction socket and the roots are similar and healing is faster than in conventional transplantation.
128

Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

The procedure is as follows (see Figs 5-121 to 5-12s). First, the mesial (or distal) part of the flap is sutured with an interrupted suture. The knot is placed on the lingual (or buccal) side. One part of the suture is left at about 30 mm (about 1 in). Next, the distal (or mesial) part of the flap is sutured. The knot is placed opposite of the first knot (either buccal or lingual). The suture is knotted after circling around the root twice. A slight coronal force is applied to the tooth by this procedure. An apically directed force is then applied by tying the suture across the coronal part of the tooth, thus stabilizing the tooth and preventing movement in either direction. This technique is very useful because the root can be retained vertically in any position. In cases of intentional replantation, simply tying a suture firmly over the incisal/occlusal surface will hold the tooth in position, and forcing the tooth apically is not a concern because it fits into a normal socket. If it is difficult to achieve stability of replanted teeth in cases of surgical up righting or extrusion, splints to the adjacent teeth with wire and resin may be necessary (see Figs 5-13f and 5-14e). Surgical dressing To enhance healing (reattachment), an aluminum sheet and surgical dressing are used to protect the surgical area by preventing infection and preserving the blood clot (see Figs 5-12t and 5-12u). Maintenance The surgical dressing is removed 3 to 5 days after surgery, and the suture is removed 5 to 7 days after surgery. At this point, initial reattachment at the cervical area is achieved and there is little chance that replanted teeth will drop out. Occlusal adjustment 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 teeth should be temporized for 1 to 2 months, before placing the definitive restoration (see Figs 5-11m and 5-11n). Composite resin restoration is indicated if enough tooth structure is available (see Fig 5-131). Because the crown-root ratio is less favorable for teeth that have been surgically repositioned (intra-alveolar transplantation) than it is for those that have undergone conventional transplantation or intentional replantation, occlusion must be adjusted carefully 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, occlusal adjustment 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 inten tional replantation has been applicable.

129

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Sequence and Treatment Procedures

Flgs5-19to 5-23 Clinica[ illustrations of intentional replantation (courtesy of Dr. Leif K 6akland).

Fig 5-19a Right mandibular canine before intentional replantation. Root canal treatment had been performed 1 year ealier, but symptoms continued. Fig 5-19b After extraction. Note the

second root. Both apical openings were

prepared and filled with amalgam

and the tooth was replanted.

Fig 5-19c Six-year follow-up. The tooth is asymptomatic and the periradicular bone appears normal.

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. The 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 subsequently placed on the tooth.

Fig 5-21a Left mandibular second molar before intentional replantation. Root canal treatment and core and crown placement were performed on the tooth 3 years earlier. Note the peri radicular lesion. The patient was symptomatic; there was a buccal sinus tract leading to the lesion. Fig 5-21 b Immediately after replantation. Root apices were resected; no retrofillings were placed. The crown was dislodged and was not recemented immediately.

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

was asymptomatic
mented.

and the crown was rece-

Fig 5-21d Two-year follow-up. Tooth remains asymptomatic and the peri radicular bone appears normal.

130

Sequence and Procedures of Intra-alveolar Transplantation and Intentional Replantation

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 was

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. The

The apical opening and the labial perforation were prepared and filled with mineral trioxide aggregate (ProRoot MTA, Dentsply Tulsa
patient continued to have symptoms, including slight labial swelling. Fig 5-23b Immediately after replantation. Dental, Tulsa, OK). Fig 5.23c One-year follow-up. The patient is asymptomatic, the tooth is stable, and there is no labial swelling.

131 .