Extraction and Replantation of a Peri-Apically Infected Tooth
INTRODUCTION
The advent of dental implants has saved many patients from compromised
oral function. Nonetheless, the astute clinician should not abandon
treatments that have been successful in the past. Treatments previously
deemed appropriate may still be appropriate in appropriate conditions.
Some teeth may be deemed unsalvageable but with appropriate applications
these deplorable teeth may be given increased longevity. This is a
report of a successful extraction, apical resection, retrograde filling
and intentional replantation of a maxillary left second premolar (1).
CASE REPORT
A 44-year-old female presented by referral for extraction of the
maxillary left second premolar tooth (#13) with subsequent implant
placement. The medical history was unremarkable. After an oral exam,
radiographs and a discussion of options, the tooth was deemed
potentially salvageable with an in situ or out-of-socket retrograde
procedure. The patient opted for an extraction, out-of-socket
apicoectomy and retrograde apical restoration and replantation (Fig. 1).
After informed consent the tooth was locally anesthetized with 1.6cc of
articaine (Ketocaine). The patient was administered 2000mg amoxicillin
orally, and chlorhexidine oral rinse. Anticipating an immediate
replacement, extraction and amalgam instruments were set-up. The
epithelial attachment was separated, and the coronal periodontal
ligament (PDL) carefully separated using periotomes and elevators (Karl
Schumacher, Des Plaines, Ill.). The tooth was slightly and carefully
luxated and removed atraumatically with a #150 forceps. The apical
lesion was removed, and the apical bone debrided. The PDL was not
removed. 3mm of the tooth apex was removed to insure the removal of any
accessory canals (2). An apical preparation was performed and filled
with amalgam (Valiant). Out-of-socket time was 22 seconds. The tooth was
then replanted in its original position. The tooth was stable and
immobile due to the presence of intact rigid socket bone. No flap was
raised. The occlusal surface was reduced about 0.25mm to minimize off
axial loading during function. Nonetheless, bis-acryl facial and lingual
braces were placed to minimize facial or lingual movement under
function. A soft diet was recommended. Amoxicillin and chlorhexidine
were prescribed. The patient was monitored weekly. After 3 weeks the
tooth was not percussion tender. The braces were removed at 4 weeks, and
the tooth was found to be stable and immobile (Fig. 2). The soft diet
was maintained for an additional 2 weeks. After 8 weeks the tooth was
deemed healed well enough to return to normal function (Fig.3).
DISCUSSION
Removing an infected tooth and performing an in-hand apicoectomy and
retrograde filling is not new (1). Nonetheless, we need to be reminded
that such treatment is within the standard of care in dentistry. Such
treatment may be cost effective and desirable for many patients.
The primary parameter of this modality is the careful and atraumatic
removal of the tooth in question. Maintaining the osseous walls is
imperative. The bone is needed for the stability of the re-implanted
tooth and reattachment of the periodontal ligament (1). A facial osseous
dehiscence or fenestration may prevent adequate stability for healing.
In this case, amalgam was used to seal the apex of the tooth. However,
mineral trioxide aggregate (MTA) may be a better choice due to its
biocompatibility and calcific barrier formation (3). MTA enhances
differentiation and upregulation of osteogenic PDL cells (4). MTA can
take several hours for a hard set. Unset MTA may be disturbed during
reseating of the tooth in the socket and thus not seal completely, so
amalgam was chosen instead.
Out-of-bone time should be less than one hour or as little time out of
the socket as possible (1,5, 6). Nonetheless, there are reports of young
patients with avulsed teeth out of the bone for much more than 1 hour
(1,6). However, with this procedure, if the dental team is prepared,
in-hand apicoectomy and retrofilling can take place in less than 30
seconds. This short period minimizes the time where the PDL is away from
its blood supply. The blood supply is ruptured indeed from the
extraction but vessels, fibers and nerves may reconnect and repair if
the disruption is short lived (1,3,5). The socket periodontal ligament
provides a blood supply for healing. The periodontal blood vessels and
fibers need to reattach to the distal separated segments for appropriate
healing (1,5, 7). This has been thought to occur if the out-of-bone time
is less than 1 hour (1,3,5). Thus, treatment speed is important. The
less time the tooth is out of the socket and away from its blood supply,
then the risk for failure is lessened (1,5).
Stability in the socket is important for reconnection of the supporting,
nutrient and neural tissues (1,3,5). A bis-acryl brace was placed to
insure stability of the tooth. The bis-acryl stent is easily placed (8).
It engages the adjacent teeth inter-proximally and into undercuts for
mechanical retention. In the case herein, the braces were removed after
the tooth demonstrated no pain with percussion and no significant
mobility.
A soft diet is needed to minimize an accidental overload of the healing
tooth during mastication (1,9). Chlorhexidine oral rinse helps to
maintain hygiene. Patient-compliance is important for oral hygiene and
to minimize tooth movement.
Dental ankylosis is rare. It is calcified PDL and may occur in
traumatized or avulsed teeth that are replanted in the socket (10, 11).
This can be the result of the removal of a tooth and reseating the tooth
in the socket. Although an uncommon outcome, ankylosis is possible. The
patient should be informed of this possibility. Nonetheless, securing a
diagnosis of ankylosis may be difficult even with cone beam computerized
tomography (CBCT) (11).
CONCLUSIONS
Successful immediate replantation of compromised teeth may depend on
several factors: atraumatic removal, presence of 4 rigid bone walls for
stability and accompanying vascular supply, occlusal reduction for
protection from occlusal forces, antibiotic coverage, a protective brace
to minimize tooth micromovement and patient dietary compliance. These
parameters are not proven and need validation through research and
clinical trials.
INFORMED CONSENT
A signed informed consent was obtained from the patient.
CONFLICT OF INTEREST
The author confirms that he has no conflict of interest financial,
academic or political.
REFERENCES
- Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu
V, Gambarini G. European Society of Endodontology position statement:
Surgical extrusion, intentional replantation and tooth
autotransplantation: European Society of Endodontology developed by.
Int Endod J. 2021 May;54(5):655-659.
- Ahmed HM, Hashem AA. Accessory roots and root canals in human anterior
teeth: a review and clinical considerations. Int Endod J. 2016
Aug;49(8):724-736.
- Maru V, Dixit U, Patil RSB, Parekh R. Cytotoxicity and Bioactivity of
Mineral Trioxide Aggregate and Bioactive Endodontic Type Cements: A
Systematic Review. Int J Clin Pediatr Dent. 2021 Jan-Feb;14(1):30-39.
- Wang MC, Yeh LY, Shih WY, Li WC, Chang KW, Lin SC. Portland cement
induces human periodontal ligament cells to differentiate by
upregulating miR-146a. J Formos Med Assoc. 2018 Apr;117(4):308-315.
- Mehrabi F, Djemal S. International Association for Dental Traumatology
guideline updates. Br Dent J. 2021 May;230(10):671-675.
- Brunet-Llobet L, Lahor-Soler E, Miranda-Rius J. Replantation of an
avulsed tooth after one day of storage in adverse extraoral dry
conditions: Acceptable outcome after a 10-year follow-up. Quintessence
Int. 2018;49(1):25-31.
- Mittmann CW, Kostka E, Ballout H, Preus M, Preissner R, Karaman M,
Preissner S. Outcome of revascularization therapy in traumatized
immature incisors. BMC Oral Health. 2020 Jul 14;20(1):207-217.
- Flanagan D. The bis-acryl stent. J Oral Implantol. 2013
Feb;39(1):69-72.
- Flanagan D. Diet and Implant Complications. J Oral Implantol. 2016
Jun;42(3):305-310.
- LeBlanc AR, Reisz RR, Brink KS, Abdala F. Mineralized periodontia in
extinct relatives of mammals shed light on the evolutionary history of
mineral homeostasis in periodontal tissue maintenance. J Clin
Periodontol. 2016 Apr;43(4):323-332.
- Ducommun F, Bornstein MM, Bosshardt D, Katsaros C, Dula K. Diagnosis
of tooth ankylosis using panoramic views, cone beam computed
tomography, and histological data: a retrospective observational case
series study. Eur J Orthod. 2018 May 25;40(3):231-238.