REPLANTATION

MADE BY: DR. AVDESH SHARMA M.D.S. II ND yr STUDENT

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Definition
The replacement of a tooth that has been removed from the alveolar socket, either intentionally or by trauma is called reimplantation

Tooth replantation is the reinsertion and splinting of a tooth that has been avulsed (knocked or torn out) of its socket
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Indication
Indicated following traumatic avulsion by the preservation of cellular vitality in the periodontal ligament and under conditions of asepsis.

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Demographics
Acc to the NCHS, about 5 million teeth are accidentally avulsed in the US each year. Most teeth that are replanted are lost through trauma, usually falls and other types of accidents. The most common trauma resulting in tooth avulsion are sports accidents that result in falls or blows to the head. The mandatory use of mouthguards, which are plastic devices that protect the upper teeth, has prevented approximately 200,000 oral injuries each year in football alone. Without a mouthguard, a person is 60 times more likely to experience dental trauma if he or she participates in these sports.
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TYPES OF REPLANTATION
Immediate replantation Delayed replantation Intentional replantation

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 Immediate replantation If the tooth has been left dry for less than one hour or kept in milk for no more than 4 to 6 hours, the protocol for treatment is described as Immediate replantation Delayed Replantation. If the tooth has been left dry for more than one hour, the protocol for treatment is described as Delayed replantation The treatment for teeth with more than 1 hour of extraalveolar time includes efforts to slow the inevitable replacement resorption

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 Intentional replantation Intentional replantation is the planned extraction and reinsertion of a tooth into its socket to correct an apparent clinical or radiographic endodontic failure

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Guidelines for replantation at the accident site

Ideally, if an avulsed tooth can be replanted at the site of injury, the prognosis is better than waiting until the patient is transported to a treatment facility. The following advice can be given over the telephone to someone able to assist the victim: Rinse the tooth in cold running water. The purpose is to rinse off any obvious debris that may have collected on the root surfaces

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Do not scrub the tooth. The less the root surface is touched, the less damage to fibers and cells.

Suggest that the person applying these first-aid measures handle the tooth by holding on to the crown of the tooth and not the root

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Replace the tooth in the socket. Many individuals, even parents, may be squeamish about this step.

A relatively easy way out is for the first-aid person to place the tooth, root tip first, partly into the socket, then let the patient bite down gently on a piece of cloth such as a handkerchief to move the tooth back into its normal, or nearly normal, position.

Bring the patient to the dental office right away to complete the treatment of replantation

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Use of Transport medium

If the avulsed tooth cannot be reimplanted at the time and site of the accident, it becomes incumbent to transport the tooth in a manner that will be conducive to a successful attachment. To accomplish this, a suitable transport media must be selected. Various medium are:

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1. Hanks balanced salt solution (HBSS) Krasner is the originator for the use of this product Contains sodium chloride, glucose, potassium chloride, sodium bicarbonate, sodium phosphate, calcium chloride, magnesium chloride and magnesium sulphate Has ability to preserve and reconstitute the cells of the periodontal ligament Has shelf life of two years Part of an avulsed tooth storage system named Emergency Tooth Preserving System

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2. Via span Used to transport organs for transplantation Has been shown to decrease resorption and maintain fibroblast vitality 3. Saliva Storage in the vestibule of the mouth keeps the tooth moist but is not ideal because of incompatible osmolality, ph, and the presence of bacteria When the tooth cannot be reimplanted at the site of injury and acceptable transport media are not present tooth should be placed in the patients mouth or under the tongue
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4. Milk Considered the best storage medium Has a ph and osmolality compatible to vital cells and is relatively free of bacteria Maintains viability of cells for 3 hours

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5. Water If no other acceptable transport medium is present, water is the liquid of last resort to prevent the tooth from drying Water is the least desirable storage medium because the hypotonic environment causes rapid cell lysis and increased inflammation on replantation

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Management in the dental office

Emergency visit The focus of the emergency visit is the attachment apparatus. The aim is to replant the tooth with the maximum number of periodontal ligament cells that have the potential to regenerate and repair the damaged tooth surface. If the tooth was replanted at the accident site, its positioning in the socket is assessed and a radiograph is made. If the tooth is not replanted at the accident site, the following steps are accomplished:
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Diagnosis and treatment planning Preparation of the root Preparation of the socket Splinting Management of soft tissues Adjunctive therapy

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Diagnosis and treatment planning

Replantation in the office must be preceded by a careful evaluation of the traumatized alveolus and the avulsed tooth. Avulsed tooth stored in (HBSS) whilst a history and clinical exam is being carried out. Radiograph the alveolar segment involved and any other oral area that appears also to have been injured. Look for evidence, both clinically and radiographically, of alveolar fracture.

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 Inspect the alveolar socket for foreign bodies and debris, taking care not to scrape the bony walls.

Socket rinsed with sterile saline to allow for direct visual inspection manipulation and gentle replantation

The blood clot in the socket can be gently suctioned and the socket irrigated with saline.

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 Check the avulsed tooth for debris on the root; if such debris cannot be rinsed off with saline or water, gently pick it off with cotton pliers. While inspecting the tooth, it can be held by the crown with a pair of extraction forceps. This permits examination of the tooth without touching the root surface.

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 Preparation of the root

Preparation of the root is dependent on the maturity of the tooth (open vs. closed apex) and on the dry time of the tooth before it was placed in a storage medium

Extraoral dry time less than 20 minutes, closed apex

If tooth has a closed apex, revitalization is not possible If the tooth was dry for less than 20 minutes the chance for periodontal healing is excellent The root should be rinsed of debris with water or saline and replanted in as gentle fashion as possible
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Extraoral dry time less than 20 minutes , open apex

Such teeth have the potential for revascularization and therefore should be monitored after replantation to look for signs of revascularization

It has been recommended to soak the avulsed tooth in a solution of doxycycline prior to replantation.

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 Cvek et al found in monkeys that soaking the tooth in doxycycline (1mg in approximately 20mL. of physiologic saline) for 5min before replantation significantly enhanced revascularization. This result was confirmed in dogs by Yanpiset et al.

As with the tooth with the closed apex, the open apex tooth is then rinsed with water or saline and gently replanted

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Extraoral time 20 to 60 minutes, closed and open apices

For drying periods of 20 to 60 minutes most authors suggest rinsing the tooth gently and replanting it as soon as possible, accepting that complications are inevitable Previously mentioned was an attempt was made to soak the tooth is saline for approximately 30 minutes before replantation with limited success

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 The use of Emdogain has been found to be valuable in cases that were considered hopeless in the past and this medicament may prove extremely valuable in the 2060 minute dry time period

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Extraoral dry time greater than 60 min. open and closed apices
When the root has been dry for 60min or more, the periodontal ligament cells are not expected to survive . In these cases, the root should be prepared to be as resistant to resorption as possible. Therefore the treatment for teeth with more than 1 hour of extra-alveolar time includes efforts to slow the inevitable replacement resorption

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 Examine the avulsed tooth for debris. In contrast to avulsed teeth with less than 1 hour extra-alveolar time, those with more than 1 hour are not expected to retain the vitality of periodontal ligament cells and fibers. Therefore, it is best to remove pieces of soft tissue attached to the root surface. This needs to be accomplished without overtly scraping the root surface. Remove the periodontal ligament by placing in acid for 5 minutes.

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 Soak the tooth in a 2% Stannous fluoride acidulated at pH 5.5 for 20 minutes or more. The fluoride will slow the resorptive process. Prepare the tooth socket by gently curetting the blood clot out of the alveolar socket and then irrigate with saline. Rinse the tooth thoroughly in saline and then insert it into the socket and splint for 6 weeks.

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 An additional procedure that is showing promise in reducing resportion is to fill the tooth socket with Emdogain prior to replantation. Because replanted teeth with more than 1 hour of extra-alveolar time are expected to resorb and ankylose, it is probably reasonable to expect only a limited length of service from such teeth. However, if the resorption is relatively slow, several years of service may result, and this is probably reason enough for performing this relatively simple procedure.

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EmdogainA placed : A. on the root surface and B. into the socket before the tooth is replanted

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 In young patients, such ankylosis can result in a lack of alveolar ridge development, so when infraocclusion becomes apparent in a growing child, it may be advisable to remove the crown in a process termed decoronation to allow proper ridge development.

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Decoronation of an ankylosed maxillary central incisor in infraposition

A. Radiograph of the tooth shows extensive ankylosis-related resorption. B. Radiograph taken after the decoronation; the crown of the tooth is bonded to the adjacent teeth. C. Six-month follow-up radiograph. Note bone growth coronal to the root fragments. D. Twelve-month follow-up radiograph shows excellent ridge formation and almost complete replacement of the root with alveolar bone. From Malmgren & Malmgren your name

Difference in alveolar process anatomy after extraction and after decoronation

A. Photograph of the maxillary anterior ridge of an 18-year-old boy. The right maxillary central incisor was extracted at age 12. Note reduced ridge contour. B. Photograph of the maxillary anterior ridge of a 19-year-old girl. The right maxillary central incisor had been replanted following avulsion, and decoronation was done at the age of 14. Note full ridge contour. From Malmgren & Malmgren your name

 Preparation of the socket

The socket should be left undisturbed before replantation Emphasis is placed on the removal of obstacles within the socket to facilitate the replacement of the tooth into the socket It should be lightly aspirated if a blood clot is present. If the alveolar bone has collapsed, a factor which may prevent replantation or cause it to be traumatic, a blunt instrument should be inserted carefully into the socket in an attempt to reposition the wall.
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Splinting

Types of spl

A. Titanium splint B. Resin splint your name

A splinting technique that allows physiologic movement of the tooth during healing and that is in place for a minimal time period results in a decreased incidence of ankylosis

Semi-rigid (physiologic) fixation for 710 days is recommended The splint should allow movement of the tooth, should have no memory , and should not impinge on the gingiva and/ or prevent maintenance of oral hygiene in the area

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 Many splints satisfy the requirements of an acceptable splint, with a new titanium trauma splint recently been shown to be particularly effective and easy to use. After the splint is in place, a radiograph should be taken to verify the positioning of the tooth and as a preoperative reference for further treatment and followup. When the tooth is in the best possible position, it is important to adjust the bite to ensure that it has not been splinted in a position that will cause traumatic occlusion.

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 One week is sufficient to create periodontal support to maintain the avulsed tooth in position. Therefore, the splint should be removed after 710 days. The only exception to this is when avulsion occurs in conjunction with alveolar fractures, in which case it is suggested that the tooth should be splinted for a suggested period of 48 weeks

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 Management of soft tissues

Soft tissue lacerations of the socket gingiva should be tightly sutured. Lacerations of the lip are fairly common with these types of injuries. The dentist should approach lip lacerations with some caution and it might be prudent to consult with a plastic surgeon at this stage. If these lacerations are sutured, care must be taken to clean the wound thoroughly beforehand as dirt, or even minute tooth fragments, left in the wound affect healing and the esthetic result.
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 Adjunctive therapy
Systemic antibiotics given at the time of replantation and prior to endodontic treatment are effective in preventing bacterial invasion of the necrotic pulp and, therefore, subsequent inflammatory resorption Tetracycline has the additional benefit of decreasing root resorption by affecting the motility of the osteoclasts and reducing the effectiveness of collagenase

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ADJUNCTIVE THERAPY

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 The administration of system antibiotics for patients not susceptible to tetracycline staining is Doxycycline per day for 7 days at appropriate dose for patient age and weight or Penicillin V 1000 mg and 500mg per day for 7days, beginning at the emergency visit and continuing until the splint is removed after 710 days . The bacterial content of the sulcus should also be controlled during the healing phase. In addition to stressing the need for adequate oral hygiene to the patient, the use of chlorhexidine rinses for 710days may also be useful.

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 In a recent study , great benefits were seen when the pulp contents were removed at the emergency visit and Ledermix was placed into the root canal. Apparently the use of the medicament was able to shut down the inflammatory response after replantation to allow for more favorable healing in comparison to those teeth that did not possess the medicament. The need for analgesics should be assessed on an individual case basis. The use of pain medication stronger than a non-prescription, non-steroidal, antiinflammatory drug is unusual. The patient should be sent to a physician for consultation regarding a tetanus booster within 48 hrs of the initial visit.
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Second visit This visit should take place 710days after the emergency visit. At the emergency visit, emphasis was placed on the preservation and healing of the attachment apparatus. The focus of this visit is the prevention or elimination of potential irritants from the root canal space. These irritants, if present, provide the stimulus for the progression of the inflammatory response and bone and root resorption. Also, at this visit, the course of systemic antibiotics is completed, the chlorhexidine rinses can be stopped, and the splint is removed.
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Endodontic treatment Extra oral time < 60 min Closed Apex Initiate endodontic treatment at 7 to 10 days. In cases where endodontic treatment is delayed or signs of resorption are present, treat with long-term calcium hydroxide treatment before obturation. No chance exists for the revascularization of these teeth, and endodontic treatment should be initiated at the second visit at 710days

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 If therapy is initiated at this optimum time, the pulp should be necrotic without infection or, at most, only minimal infection Therefore, endodontic therapy with an effective inter appointment antibacterial agent over a relatively short period of time (710 days) is sufficient to ensure effective disinfection of the canal.

The advantage of its use is that it allows the dentist to have a temporary obturating material in place until an intact periodontal ligament space is confirmed

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 Long-term calcium hydroxide treatment should always be used when the injury occurred more than 2 weeks before the start of endodontic treatment or if radiographic evidence of resorption is present The root canal is thoroughly instrumented and irrigated, then filled with a thick, powdery mix of calcium hydroxide and sterile saline . The calcium hydroxide is changed every 3 months within a range of 624 months.

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 It also changes the environment in the dentin to a more alkaline pH, which may slow the action of the resorptive cells and promote hard tissue formation. However, the changing of the calcium hydroxide should be kept to a minimum (not more than every 3 months) because it has a necrotizing effect on the cells that are attempting to repopulate the damaged root surface . While calcium hydroxide is considered the drug of choice in the prevention and treatment of inflammatory root resorption, it is not the only medicament recommended in these cases. Some attempts have been made to not only remove the stimulus for the resorbing cells but also to affect them directly.

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 The antibiotic-corticosteroid paste, Ledermix, is effective in treating inflammatory root resorption by inhibiting the spread of dentinoclasts without damaging the periodontal ligament. Its ability to diffuse through human tooth roots has been demonstrated , whilst its release and diffusion is further enhanced when used in combination with calcium hydroxide paste

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 H. Chen showed that Ledermix, Triamcinolone and Demeclocycline had statistically more favourable healing and more remaining root structure than the group filled with GP and sealer. ( DT 2008)

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 Thong Y L compared the effect of calcium hydroxide ( pulpdent) and a corticosteroid antibiotic paste Ledermix on periodontal healing and root resorption following replantation. Treatment with the ledermix inhibited inflammatory resoroption and was slightly more effective than calcium hydroxide than calcium hydroxide in producing a periodontal healing response. (DT 2001)

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Open Apex Avoid endodontic treatment and look for signs of revascularization. At first sign of an infected pulp initiate apexification procedure.

Teeth with open apices have the potential to revascularize and continue root development and initial treatment is directed toward the re-establishment of the blood supply The initiation of endodontic treatment is avoided if at all possible unless definite signs of pulp necrosis, such as peri-radicular inflammation, are present.

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 The diagnosis of pulp vitality is extremely challenging in these cases. After trauma, diagnosis of a necrotic pulp is particularly desirable because, due to cemental damage accompanying the traumatic injury, infection in these teeth is potentially more harmful. External inflammatory root resorption can be extremely rapid in these young teeth because the tubules are wide and allow the irritants to move freely to the external surface of the root

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 Patients are recalled every 34 weeks for sensitivity testing. Recent reports indicate that thermal tests with carbon dioxide snow or difluordichlormethane placed at the incisal edge or pulp horn are the best methods for testing sensitivity, particularly in young permanent teeth .

Modern cold testing methods, placed on the incisal edge of the incisors.

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 The laser Doppler flowmeter has been shown to be a superior tool in the diagnosis of revascularization of an immature tooth after trauma. Radiographic and clinical signs of pathosis are carefully assessed. At the first sign of pathosis, endodontic treatment should be initiated and, after disinfection of the root canal space, an apexification procedure should be carried out.

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Revasculariztion of an immature tooth. A. The stage of root development soon after replantation. B. One year later, it can be seen that the root has continued to develop and thicken
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Extra-oral time > 60 min Closed Apex As with < 60 dry time. These teeth are treated endodontically in the same way as those teeth that had an extra-oral time of < 60min

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 Open Apex (if replanted) If endodontic treatment was not performed out of the mouth, initiate apexification procedure. In these teeth the chance of revascularization is extremely poor Therefore, no attempt is made to revitalize these teeth. An apexification procedure is initiated at the second visit if root canal treatment was not performed at the emergency visit. If endodontics was performed at the emergency visit, the second visit is a recall visit to assess initial healing only.
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Temporary restoration Effectively sealing the coronal access is essential to prevent infection of the canal between visits. Recommended temporary restorations are reinforced zinc-oxide-eugenol cement, acid-etch composite resin, or glass-ionomer cement. The depth of the temporary restoration is critical to its sealability A depth of at least 4mm is recommended so that a cotton pellet cannot be placed; the temporary restoration is placed directly onto the calcium hydroxide in the access cavity.

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 Calcium hydroxide should first be removed from the walls of the access cavity due to the fact that it is soluble and will wash out when it comes into contact with saliva, leaving a defective temporary restoration. After initiation of the root canal treatment, the splint is removed. At this appointment, healing is usually sufficient to perform a detailed clinical examination on the teeth surrounding the avulsed tooth. The sensitivity tests, reaction to percussion and palpation, and periodontal probing measurements should be carefully recorded for reference at follow-up visits.
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Obturation visit The endodontic treatment was initiated 710 days after the avulsion and clinical and radiographic examinations do not indicate pathosis, obturation of the root canal at this visit is acceptable, although the use of long-term calcium hydroxide is a proven option for use in these cases. On the other hand, if endodontic treatment was initiated more than 710 days after the avulsion or active resorption is visible, the pulp space first be disinfected before obturation.

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 Traditionally, the re-establishment of a lamina dura is a radiographic sign that the canal bacteria have been controlled. When an intact lamina dura can be traced, obturation can take place. The canal is re-instrumented and irrigated under strict asepsis. After completion of the instrumentation, the canal can be obturated by any acceptable technique with special attention to an aseptic technique and the best possible seal of the obturating material

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Permanent restoration Much evidence exists that coronal leakage caused by defective temporary and permanent restorations results in a clinically relevant amount of bacterial contamination of the root canal after obturation. Therefore, the tooth should be permanently restored either at or soon after the time of obturation of the root canal.

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 As with the temporary restoration, the depth of restoration is important for its seal and therefore the deepest restoration possible should be made. A post-obturation restoration should be avoided whenever possible. Because most avulsions occur in the anterior region of the mouth where esthetics is important, composite resins with the addition of dentin bonding agents are usually recommended in these cases. They have the additional advantage of internally strengthening the tooth against fracture if another trauma should occur.

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Follow- up care Follow-up evaluations should take place at 3months, 6 months and yearly for at least 5 years. If osseous replacement is identified, timely revision of the longterm treatment plan is indicated. In the case of inflammatory root resorption, a new attempt at disinfection of the root canal space by standard retreatment can reverse the process. Teeth adjacent to and surrounding the avulsed tooth or teeth may show pathologic changes long after the initial accident. Therefore, these teeth should be tested at recall and the results compared to those collected soon after the accident.
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Long term prognosis for replanted teeth Long term prognosis for replantation is still very poor. The clinician must be aware that these teeth sometimes do well for long periods, and then for no apparent reason, problems arises.

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Intentional Replantation

Intentional replantation is the planned extraction and reinsertion of a tooth into its socket to correct an apparent clinical or radiographic endodontic failure ( Ward 2004) This procedure differs from the reinsertion of a tooth after an accidental avulsion (Bender 1993)

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 Fauchard is often credited with a description of intentional replantation. He described four cases of Intentional replantation, all of which were successful. Flangan and Myers have shown that teeth that were extracted and replaced in their sockets within 30 minutes showed no deleterious effect, whereas any further delay had an adverse effect.

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 Emmertsen and Andreasen evaluated 100 intentionally replanted molar teeth, a few of which had been followed up for as long as 13 years. No evidence of resorption of the roots was noted in 67% of the replanted teeth. Nasjetli intentionally replanted teeth in monkeys within half an hour and splinted with an acid etch splint for either 7 or 30 days; those splinted for 7 days showed no evidence of resorption, whereas those splinted for 30 days had increased areas of root resorption.

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Indications Weines when routine endodontic treatment of teeth is impractical or impossible, as in patients who are unable to keep their mouths open for the necessary length time when an obstruction of a canal is present, such as a broken instrument or a calcification, or a periapical radiolucency is present, yet routine surgery is impractical, as in a lower molar with mandibular canal in proximity
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 when perforating internal or external resorption is present, yet surgery is impractical when a foreign body, such as molten metal, is in the periodontal ligament or periapical tissue but surgery is impractical when previous treatment has failed but nonsurgical retreatment or surgery is impractical

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Grossmans when an instrument has been broken in the root canal and projects through the apical foramen when mechanical obstruction of the root canal is present, such as form of a pulp stone, fractured instrument, or glass bead that cannot be removed when perforation a root cannot easily be contained when the root canal is calcified or partly calcified, making it impossible to enter with root canal instrument, and area of rare faction is present when a root canal has been grossly overfilled and the protruding filling is irritating the periapical tissues
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 when the root canal is sharply curved and cannot be negotiated when the root canal is bifurcated as it approaches the root apex and cannot be negotiated when a foreign body is lying free in the periapical tissue and is acting as an irritant, such as an excess piece of gutta-percha that has broken off from the main stem, or grossly overfilled canal, or root canal cement, or when an absorbent point has been pushed completely through the apical foramen when root canal treatment has already been done, a periapical lesion is present, and canal filling cannot be removed

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Contraindications Teeth with flared and moderately curved roots Presence of periodontal disease Intentional replantation should be considered when it is the only alternative to extraction.

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Steps in Intentional Replantation

The tooth should be extracted as atraumatically as possible and received in a sterile gauze sponge saturated with normal saline solution.

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 Most crucial step: keep the forceps off the cementum above the CEJ
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 It should be held in the moist sponge throughout treatment, and the roots and attached periodontal tissue should be frequently irrigated with saline.

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 If the canals are not blocked, standard access is made to the pulp chamber, and the canal or canals are prepared and filled; the coronal access sealed in hand as carefully as in site. A slight (1-to2-mm apicoectomy, prior to retrofilling, is done to reduce the hydrostatic pressure buildup during replacement

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Roots containing blocked canals are retrofilled in the usual manner. Preparations in teeth with perforation or resorptive defects are similarly done. Root canal filling in these cases should be completed before the repair of defects. Before replantation, the alveolus should be gently curetted and irrigated with saline to remove the clot and freshen the socket, being careful not to promote excessive bleeding or detach viable periodontal ligament attachment to the alveolar bone.
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The tooth is replanted and stabilized with a splint if necessary. Posterior teeth normally are well retained and do not need splinting. Anterior teeth may be splinted with a coronal acid-etch technique using a direct bonding plastic.

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Post Operative care NSAIDs are the preferred class of drugs for managing post operative pain Sutures are removed 2 to 4 days after surgery Antibiotic coverage should be considered for patients at risk of developing bacterial endocarditis Patients with questionable healing should be reevaluated

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 Post operative instructions

 Inform patient that tooth will be painful for few days  Chew only on the other side  Eat only soft diet for 3- 4 days 3 Keep oral cavity clean

 Causes for failure

Contamination during replantation Undetected root fracture Procedural errors
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Prognosis for Intentional replantation The outlook for intentionally replanted toth is superior to that for a traumatically avulsed replanted tooth The time during which the tooth is out of the mouth, which is certainly critical, is greatly reduced, and the replant is kept moist during the needed manipulation Venting is provided by the trimming of the root end or curettage of the periapical area No curettage of the periodontal ligament attached to the tooth is performed Therefore all criteria for successful replantation are adhered to, which is not always after the case of trauma
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Post treatment sequelae

After the completion of routine endodontic therapy, the patient should be seen at regular 6 month intervals, at which time radiographs are taken. One of the two undesirable conditions may occur to replanted teeth: Root Resorption Ankylosis

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Resorption is the most frequent sequela to luxation injuries; three different types of resorption have been identified: surface, inflammatory, replacement (ankylotic) resorption

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Surface resorption
Small superficial cavities in cementum and outermost dentin. This type is not visible on radiographs and is usually repaired by new cementum.

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 It may be transitory or progressive. The former leads to repair, the latter to further resorption. Surface resorption is usually detectable only histologically and probably represents part of the process that takes place both during recovery and as a prelude to more severe resorption.

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Inflammatory resorption
Radiographically seen as a bowl-shaped resorptive area of the root and associated with adjacent bony radiolucencies. It involves both tooth structure and adjacent bone. Radiographically, there is apparent tooth loss along with adjacent bony destruction.

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 This type of resorption is typical in the apical area involving any tooth with a necrotic pulp; replanted teeth that have not had root canal treatment often show these resorptive lesions laterally as well as apically. Root canal therapy can be expected to arrest inflammatory resorption that involves replanted teeth; the resorption can be prevented by judicious timing of the root canal therapy. Optimally, that is about 10 to 14 days post replantation

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Replacement resorption
Resorption of the root surface and its substitution by bone, resulting in ankylosis. This is a frequent sequela to replantation.

As tooth structure is resorbed, it is replaced with bone that fuses to the tooth structure, thereby producing ankylosis. Root canal therapy has no effect on replacement resorption .

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 Replacement resorption can be expected in replanted teeth in which the root surface elements have become necrotic, usually owing to the drying effect of too long extra-alveolar time. Teeth not replanted within 1 hour of avulsion can be expected to fall into this category

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Conclusion
Replantation is a promosing attempt to preserve avulsed teeth. The best reimplantation prognosis is directly related to the amount of time the tooth is maintained extra-orally during the procedure. Favourable healing after an avulsion injury requires quick emergency intervention. Treatment strategies should always be considered in the context of limiting the unfavourable healing.

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References
Pathways of pulp, Eighth edition, Stephen Cohen and Burns Pathways of pulp, Ninth edition, Stephen Cohen and Burns Atlas of replantation and transplantation of teeth, Jens O. Andreasen Ingle, Bakland, Fifth edition Endodontic therapy, Weine, sixth edition Endodontic Practice, eleventh edition, Grossman Clinical management of the avulsed tooth: Present strategies and future directions, Dental Traumatology 2002: 18: 111
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 Efficacy of laser Doppler flowmetry for the diagnosis of revascularization of reimplanted immature dog teeth, Dental Traumatology 2001; 17: 6370 Tooth avulsion in children: to replant or not, Endodontic Topics 2006, 14, 2834

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