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The replacement of a tooth that has been removed from the alveolar socket,
either intentionally or by accident, is called replantation. Replantation of avulsed teeth
can be divided into two categories: those that are replanted within a short time (or
preserved in a storage medium) and those that are replanted after a delay during whichthe periodontal membrane attached to the root has dried. In this chapter, consideration
is also given to wound healing that involves both pulp and periodontal ligament tissue.
Intentional replantation and transplantation of teeth have had a long and
troublesome history. Despite experimental investigations initiated by Hunter as early
as 1771. the time was not ripe for a break-through in this area, primarily because of a
lack of knowledge about the etiology of root resorption and control of infection.
However, extensive research particularly in the past two decades into the etiology and
pathogenesis of root resorption , wound healing processes in the pulp and
periodontium, and how these relate to infection, has made replantation and intentional
replantation ot teeth predictable. These operations can thus be added to the dental
armamentarium, while at the same time challenging the various dental specialties to
broaden their horizons for new treatment potentials.
In orthodontics, autotransplantation of teeth can add a new dimension to
treatment planning. Instead of considering limited tooth movements w i th in one
segment of the dental arch, a freedom of movement has been achieved in many
situations where teeth can be placed exactly where the need dictates, whether it be in
remote regions of the same jaw or in the opposing dental arch. Furthermore, banking
for later use of premolars which must be extracted is now possible, for example where
doubt exists about the prognosis of traumatized or endodontically treated anterior
teeth. The orthodontic profession is thus challenged to outline indications for these
new treatment possibilities.
In periodontics, replantation of avulsed teeth has been an unreliable procedure.
Recent advances in the knowledge of wound healing which takes place after
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replantation of teeth has improved the predictability of these procedures and sig-
nificantly increased their success rate. In addition, the unfortunate situation often faced
that traumatized anterior teeth cannot be saved can now often be remedied by
autotransplantation of premolars and later recontouring with a composite technique, atreatment which in some cases is to be preferred over fixed or removable prosthetic
appliances.
In endodontics, i ntentional replantation has been the last chance lor teeth
which could not be treated adequately by conventional or surgical endodontic
procedures. Another treatment approach, namely autotransplantation of premolars and
third molars as replacements for unsalvageable teeth with endodontic complications,
is now another feasible alternative.
In prosthodontics. teeth can now in selected cases be placed exactly where the
need dictates. In this context, the auto or allotransplantation must be carefully
evaluated in light of various implant techniques. The latter procedure, however, is
usually not indicated in young individuals due to the interference with growth of the
alveolar process.
In oral surgery traditional techniques for the removal of impacted teeth have
aimed at not traumatizing the alveolus in order to promote socket healing. These
techniques have for obvious reasons given no consideration to the preservation of a
vital pulp, periodontal ligament, or dental follicle and as such must be altered radically
when teeth are to be transplanted. A great challenge now in oral surgery is. therefore,
the development of techniques which allow maximum cell survival in and around the
potential transplant.
The prerequisite for successful replantation and autotransplantation of teeth is a
thorough know ledge of responses of the pulp and periodontium to injury and the
healing ca pa ci ties of both of these tissues. In a sense, autotransplantation of teeth can
be considered as an intentional, controlled dental trauma. The knowledge
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accumulated over the years in dental traumatology can in most situations be applied
directly to autotransplantation of teeth. Thus, denial traumatology and dental
transplantation are in fact two sides of the same coin, one being forced upon an
individual, causing more or less damage, the other being an intentional trauma usedto repair the earlier damage or remedy a difficult treatment problem. Especially the
latter situation requires a thorough cost benefit analysis to ensure that the advantages
of this type of therapv outweigh the potential complications.
Examination & diagnosis
In avulsion, the periodontal membrane is separated; half is attached to root &
the other half is to alveolus. Vitality of the periodontal membrane attached to the root
is important for the success of replanted tooth. When exposed to air, periodontal
ligament dries & become necrotic. After 30 minutes of dryness, the chance of recoverysignificantly reduces. Endodontic treatment should be delayed in an immature tooth
because the pulp may revascularize after replantation. So, careful postoperative
observation is necessary. In the case of delayed replantation, there is a definite
difference in results depending on the patient's age. In children, delayed replantation is
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usually not successful long term, making it important to discuss options thoroughly
with the child's parents.
Treatment Plan
Replantation should be attempted whenever possible. However, the healing
mechanisms of immediate replantation and delayed replantation are different. In
immediate replantation, the replantation is given priority over endodontic treatment.
In delayed replantation, endodontic treatment is performed outside the oral cavity
with a calcium hydroxide preparation before the tooth is replanted. In delayed
replantation, the periodontal membrane is considered necrotic.
Treatment Procedures
Immediate replantation
Immediate replantation is performed when the periodontal membrane of an avulsed
tooth is considered vital. Replantation within 45 minutes of avulsion is considered
immediate replantation. If the tooth is preserved in milk or in a preservative solution
and is replanted within 24 hours, that is also considered immediate replantation.
1. Preservation of the avulsed tooth: When a patient calls to report an avulsion, give
clear instructions about what to do with the tooth. It may be preserved in milk, in
the mouth, or in a commercial preservative solution. During the office visit,
preserve the avulsed tooth in a physiologic saline solution .
2. Examination and diagnosis: Inspect the tooth and mouth, obtain the history, and
perform a radiographic examination to determine the condition of the surrounding
alveolus .
3. Cleansing of the avulsed tooth: If it is difficult to remove contaminants from the
periodontal membrane, use an ultrasonic cleaner with physiologic saline solution
for 3 minutes. Be sure to wrap the tooth with gauze. For a severely contaminated
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tooth, use the ultrasonic scaler for debridement of the root surface while irrigating
with physiologic saline solution, removing only the contaminant (within 30
seconds) .
4. Cleansing of the alveolus: Irrigate blood clots from the alveolar socket.5. Replantation and splinting: Place the avulsed tooth gently into the socket and
splint it. If the adaptation between the replanted tooth and gingiva is poor, suture
the gingiva to achieve close adaptation of the gingiva and cervical region. Use an
orthodontic twisted wire (3M Unitek) and conventional adhesive resin for
splinting . Avoid splinting too tightly; persistent pressure to the replanted tooth
may affect the outcome.
6. Endodontic treatment: In a mature tooth, endodontic treatment begins before splint
removal (1 to 2 weeks after replantation). Use a calcium hydroxide preparation
(Vitapex, Neo) for the initial filling and monitor the periodontal healing . In an
immature tooth, wait until pulp necrosis can be confirmed, because pulp tissue may
revascularize. If inflammatory root resorption is noted, begin endodontic treatment
immediately.
7. Splint removal and follow-up: Remove the splint after 2 to 3 weeks . Examine
carefully for any root resorption and pulp necrosis .
8. Final root canal filling: Following the initial treatment of an avulsed tooth with
necrotic pulp, use sealer and gutta-percha points for final root canal filling after
confirming apical closure .
9. Bleaching and restorative treatment: Bleach the tooth if necessary. Discoloration
is common in nonvital teeth. Use composite resin to fill the lingual access.
Continue to monitor the tooth.
Delayed replantation
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Delayed replantation is the replanting of an avulsed tooth with a necrotic peri-
odontal ligament. Even in delayed replantation, the tooth should be replanted at the
in it ia l visit if possible . The more advanced the healing of the alveolus, the more
difficult replantation and desired healing becomes .1. Cleansing of the avulsed tooth: Use ultrasonic cleansing with physiologic
saline solution. If it is difficult to remove the contaminant, use an ultrasonic scaler.
However, do not remove periodontal ligament fibers from the root surface . Removing
collagen fibers from the root surface by root planing may cause pocket formation and
gingival recession after replantation. It may also reduce the longevity of the replanted
tooth .
2. Extraoral endodontic treatment: In delayed replantation, perform endodontic
treatment before replanting the tooth. Perform conventional enlargement and
cleansing of the root canal and fill with a calcium hydroxide preparation . Calcium
hydroxide aids asepsis of the root canal.
3. Curettage and cleansing of the alveolar socket: Perform curettage and
irrigation to remove blood clots and granulation tissue from the socket.
4. Replantation and splinting: Replant and splint the tooth .
5.Removal of splint: Remove the splint after about 4 weeks.
6. Complete endodontic treatment: In a mature tooth, replace the calcium
hydroxide preparation with sealer and gutta-percha. In an immature root, leave the
calcium hydroxide preparation or fill the canal with calcium hydroxide again, if
necessary.
7. Prognosis: The goal of delayed replantation is ankylosis; therefore, it is
important to understand the rate at which root resorption occurs .. The speed of root
resorption due to ankylosis differs prepuberty and postpuberty. In prepuberty patients
(during growth and development), the root will be resorbed in approximately 2 years .
In postpuberty patients (after growth and development), root resorption may take
more than 10 years . If ankylosis occurs in pubescent patients (when growth and
development gradually cease), unesthetic conditions and poor function will result.
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This is called infraocclusion . In such cases, the coronal part of the replanted tooth
should be removed to the level of the cervical line.
8. Treatment of resorbed replanted tooth: When a replanted tooth is lost due to
root resorption, choose a treatment such as autotransplantation of another tooth if oneis available, an implant, or movement of teeth orthodontically to recover esthetics and
function. The choice of treatment requires careful patient evaluation.
Intentional replantation
It is really a surgical rather than an emergency endodontic procedure. However,
because the sequelae, splinting, and other procedures are often similar to those
employed during a replantation that follows traumatic injury, intentional replantation
will now be described.
Intentional replantation implies that a tooth requiring endodontic treatment is
purposely removed from its alveolar housing, Therefore the indications for intentional
replantation would include situations described as follows:
1. When routine endodontic treatment of teeth is unpractical or impossible, as in
patients who are unable to keep their mouths open for the necessary length of time
2. 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 the mandibular canal in proximity
3. When perforating internal or external resorption is present, yet surgery is
impractical
4. When a foreign body, such as molten metal, is in the periodontal ligament or
periapical tissue but surgery is impractical
5. When previous treatment has failed but nonsurgical retreatment or surgery is
impractical some type of canal or apical preparation and/or filling is performed, and
the tooth is returned to its original socket.
Reattachment after replantation
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.
Wound Healing in Replantation
Healing of the periodontal membrane (reattachment and new attachment)
Healing of the periodontal membrane after replantation is by reattachment. The ideal
reattachment is the reorganization of connective tissue from the periodontal
membrane attached to the root surface and gingival connective tissue or periodontal
membrane tissue of the alveolus in a relatively short period of time (about 2 weeks).
Usually, coronal to the alveolar bone margin, reattachment of the gingival connective
tissue and periodontal membrane of the root occurs in 2 to 7 days. In the alveolus,
a. Before replantation.There is periodontal
membrane both in the
alveolus and on the avulsed
b.Immediately afterreplantation. Reattachment
of periodontal fibers occurs
between the fibers of the
periodontal membrane
attached to the root surface
and those from the gingival
connective tissue and
alveolar socket.
c. After healing
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reattachment occurs in 2 weeks". If there is no healthy periodontal membrane on the
replanted tooth, normal reattachment cannot occur.
In replantation of a tooth with a partially missing vital periodontal membrane,
the healing of the membrane requires new attachment."65-,The new attachment devel-
ops from regeneration of periodontal membrane tissue with deposition of
cementum.Therefore, most of the periodontal healing after replantation depends on
reattachment and healing of partially missing periodontal membrane by new
attachment. Extensive periodontal membrane damage or necrosis of a replanted tooth,
however, results in root resorption.
a Experimental removal of periodontal tissue with a fenestration from the oralvestibule and removal of alveolar bone, periodontal membrane, and cementum toprepare a small cavity in the dentin.b During healing. Cells proliferate from thesurrounding periodontal membrane and invade the cavity in the dentin. c Afterhealing. The periodontal membrane tissue regenerates while depositing cementum inthe cavity. The bone tissue regenerates from the periphery. There is new attachmentbetween the periodontal membrane and the bone tissue.
Pulpal treatment and root development
In an immature tooth, pulpal healing and root growth can be expected after
replantation. Pulp tissue becomes ischemic after tooth avulsion. However, in case of a
wide apex (more than 1 mm), it is possible for blood vessels to proliferate into the
pulp cavity after replantation.'"71 Blood vessels and pulp cells near the apex (inside
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Hertwig's epithelial sheath) proliferate coronally .This proliferation proceeds at about
0.5 mm a day,7 and the pulp cavity will be filled with vital tissue a few months after
replantation. However, th is regenerated pulp tissue rarely functions as before, and
pulp canal obliteration occurs due to rapid deposition of hard tissue (osteodentin)
.
Thepulp may respond positively to the electric pulp test immediately after obliteration, but
its future is uncertain.
Also, in cases where Hertwig's epithelial sheath . at the apex is vital, root
growth can be expected after replantation .However, it is impossible to predict how
much root there will be compared to normal development.
Pulp healing
a. Avulsion of an
immature tooth. The pulp
changes ischemically.
b. During healing. After
replantation, blood
capillaries proliferate and
invade the pulp cavity from
the apex, growing
coronally.
c. After healing.
Proliferated pulp tissue
in the pulp cavity
calcifies rapidly, and
the pulp cavity is
obliterated.
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Phantom root and inner periodontal ligament
When there is trauma to the apical region of a developing root and Hertwig's epithelial
root sheath is separated from the apex, a phantom root or inner PDL may develop ."~ '
Hertwig's epithelial root sheath
cells, which originally formed the
enamel epithelium, differentiate
and reorganize to regenerate new
tooth germs; therefore,a phantom
root develops
Tooth which was strategically extracted for orthodontic treatment, and two pieces of
phantom roots. There is coronal formation on one phantom root thought to be enamel.
During extraction, the area of inner PDL and the osseous tissue in the pulp cavity
were removed
Another outcome following replantation of immature teeth is the invasion of
periodontal membrane tissue and osseous tissue into the pulp cavity , producing an
inner PDL. The periodontal membrane tissue invades the pulp space apically and
migrates coronally while depositing cementum. Osseous tissue also grows into the
pulp space coronally
Classification and mechanism of root resorption
If there is partial or complete necrosis of the periodontal membrane of a replanted
tooth, root resorption occurs after replantation. Root resorption may be surfaceresorption, replacement resorption, or inflammatory resorption". Currently, it is
thought that osteoclasts participate in the resorption of hard tissue such as root or bone
and its mechanism continues to be elucidated" .Osteoclasts have two primary roles,
physiologic remodeling of bone and defense of the body.Following are explanations
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of the mechanism of each type of root resorption' ''J and treatment
Surface resorption. Surface resorption is limited to cementum, and repair occurs
during the repair process of reattachment . It is a generic term of a transient root
resorption. Provided the stimulus for resorption (bacteria) is removed, the surface
resorption will be repaired. If the bacterial stimulation is not removed, surface
resorption will proceed to either replacement resorption or inflammatory resorption.
Replacement resorption. In this condition, which is also called ankylosis, bone and
root are fused. This phenomenon can be seen both histologically and radiographically.
The mechanism of replacement resorption of a tooth is remodeling with osseous tissue.
In other words, it is caused by the coupling phenomenon where root resorption by
osteoclasts lying in osseous tissue and bone deposition by osteoblasts occur
simultaneously." Therefore, the speed of replacement resorption correlates to the
remodeling speed of bone (fast in young people and slow in adults). Approximately
50% of bone remodeling occurs in 1 year in children (prepuberty), whileapproximately 2% occurs in adults (postpuberty).Age greatly affects the success rate
of delayed replantation. Cases of ankylosis in children show that roots are resorbed
within a few years , a process that can take more than 10 years in adults .Long-term
esthetics and function, therefore, can be maintained in delayed replanted teeth in
adults.
If ankylosis occurs after delayed replantation in pubescent patients (boys, 12 to
15 years; girls, 11 to 14 years), esthetics and function may be affected by
infraocclusion . Vertical growth of alveolar bone depends mainly on tooth eruption.'4
With ankylosis, the tooth will not erupt and the alveolar bone will not grow. The
degree of infraocclusion is affected by the patient's age; the younger the age, the
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greater the degree of infraocclusion . In such cases, it is possible to recover normal
alveolar height by reducing the ankylosed tooth crown to the level of the bone margin
Inflammatory resorption. In a tooth with pulp necrosis, when cementum is
resorbed by osteoclasts in an area of missing or necrotic periodontal membrane,
dentinal tubules are exposed.95'"' Necrotic material and bacteria from the pulp cavity
reach the root surface through the exposed dentinal tubules, and an inflammatory
response occurs. Root resorption is advanced by osteoclasts which emerge as the
inflammatory process spreads.Histologically, granulation tissue is present in the root
resorption area, and, radiographically, radiolucencies are observed.
The speed of inflammatory resorption is affected by the degree of infection; how
ever, it is relatively fast regardless of age. Resorption continues until the cause of
infection is removed, which can be accomplished by root canal treatment.Following
root canal treatment, new attachment can be expected if periodon
tal membrane cells invade the resorption areas.The same condition as in surface
resorption will result, and root resorption will be contained.However, in cases of
large resorption areas where osseous tissue reaches the root surface, inflammatory
resorption may shift to replacement resorption. In such cases, the entire root may
be resorbed.
Surface resorption replacement resorption inflammatory resorption
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Preservation of periodontal membrane
Methods for the preservation of the periodontal membrane in avulsed teeth Studies
show positive results using storage media for preserving periodontal membrane cells
outside the oral cavity.'" Periodontal membrane on the root surface can survive when
it is left in a dry condition for up to 18 minutes, more than half die in 30 minutes, and
most die in 120 minutes Most periodontal membrane cells live for 120 minutes in
physiologic saline solution; however, they will die before 120 minutes in water.
Hank's Balanced Salt Solution (HBSS). Best information at this time seems to
indicate that HBSS is a very favorable transport medium for the avulsed tooth. A
retrospective study reported by Krasner and Person (Krasner is the originator for the
use of this product in endodontics) indicated that the solution was highly successful
when used in 85.3% of replantation cases. HBSS contains sodium chloride, glucose,
potassium chloride, sodium bicarbonate, sodium phosphate, calcium chloride,
magnesium chloride, and magnesium sulfate. It has been used in the past as a tissue
culture support for mammalian tissues and has demonstrated the ability to preserve and
reconstitute the cells of the periodontal ligament.
Krasner has developed an avulsed tooth storage system, named the Emergency Tooth
Preserving System* (ETPS), which contains HBSS. a net for holding the tooth
atraumatically, and a container for bringing the submerged tooth to the dentist. This
system is available to schools, gymnasiums, park district fieldhouses, and other sites
where tooth trauma may occur.
Unquestionably. HBSS and the transporting system are valuable in treating avulsion
cases. Still, I have some reservations concerning its use. Present information strongly
indicates that the best chance for success is by immediate replantation at the site of
trauma. The transporting system should be used only when such a procedure is not
possible.
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In the suggestions for use of the ETPS. soaking of the tooth in HBSS before
reinsertion is suggested in certain cases. I believe that this is acceptable if the tooth has
been allowed to dry out. but if the tooth has been handled properly and is moist, it is
better to keep the extraoral time to a minimum and replant as soon as possible withoutsoaking.
Saliva.In a sense, the patient's own saliva is the best transport medium for an avulsed
tooth. Favorable reports on using it have been published, and the logic for its use and its
availability are obvious. After trauma to the face and jaws, youngsters generally drool
saliva and blood constantly. Often a child comes to the dental office after any trauma to
the mouth with a dish or hand towel around his or her neck to absorb this constant
flow. There is no problem collecting several inches of saliva, tinged with blood, in a
cup or small juice glass and then dropping the tooth into this very biologic liquid.
Also, it has been suggested that when the tooth cannot be replanted at the site of injury
and acceptable transport media are not present, it be placed in the patient's mouth or
under the tongue. This method has received favorable reports. In such cases the transport
medium being used successfully is saliva. For such a method for transporting to be con-
sidered, the patient must be an older child or adult. If the child is young, is unreliable,
or has a severe gag reflex, there is too great a chance for swallowing the tooth on the
trip to the dentists office.
Milk.Andreasen favors milk over saliva as a transport medium. Many accidents that
cause an avulsion occur related to athletics: on a baseball field, football field,
playground, or gym. Except for when an accident happens in the home, milk is not
readily available, whereas saliva is always present. Also, milk may contain many
antigens that could act negatively from an immunologic standpoint on the
reattachment process.
Water.If no other acceptable transport medium is present, water is the liquid of last
resort, but water is not the best liquid for transport.
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Prognosis for intentional replantation.
The outlook for an intentionally replanted tooth 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 the criteria for successful replantation are
adhered to. which is not always the case after trauma.
Conclusion
However,replantation should be considered as a last attempt to keep the
alveolar bone,not as a primary endodontic treatment. The success of replantation
depends on the time span of tooth remained outside the socket,the storage media
used & management of the tooth and the socket done by the dentist.further
endodontic or periapical treatment should be planned accordingly to
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References
1.Endodontic therapy by Franklin S Weine
2.Endodontics by Ingle,4th edition