7 Yr Recall on Intentional Replantation

It just so happens that in the last couple weeks I got the chance to do some long term recalls on a couple of intentional replantation cases.  I don't do a lot of these cases, but am surprised how many people are unfamiliar with this treatment option or have never seen one before.  Sometimes it makes me wonder if we should consider this treatment option more often when we have failure with traditional approaches.

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This most recent case is a periodontist who came to our practice.  I originally did the root canal in 2005.  It had an odd lateral lucency - which might be suggestive of a root fracture.  We completed root canal without finding a fracture. 

Unfortunately, at the 2 year re-evaluation, the lateral lesion did not resolve. Since I'm working on a periodontist friend of mine, why not try a retreat again?  We tried it and again found no root fracture, or obvious reason for the failure to heal.

Four years later at another re-evaluation, the bone loss on the lateral is even worse. We are still puzzled at why this has not resolved, but not convinced there is a root fracture, so we decided to try intentional replantation.   So, here are some of the best photos I have to document the process.

The tooth is gently extracted. Here it is immediately after extraction.

The root is kept moist and quickly examined for fractures.  None found, so we did retro preparation using and ultrasonic instrument.

An MTA retrofit is placed.

The tooth is replanted into the socket within 10 minutes of extraction.  Firm pressure is placed for an extended period of time. No splinting

A seven year recall finds tooth #31 asymptomatic and fully functional.  While the mesial bone looks irregular, there is no periodontal pocket.  If you look at the initial photo of the extracted tooth, you can see the periodontal ligament, but there appears to be an area where the ligament had been lost.  There was not visible fracture on that area of the root at that time.  My assumption is that the pdl may not have ever reformed in that area - causing the current radiographic appearance. 

It is interesting how a perfectly good root canal and retreatment failed to give the desired results, but a last ditch effort with replantation has been successful up to this point.

Root Amputation to Remove a Fractured Root and Retain A Tooth

Root amputation may allow a patient to save a tooth and the investment that has been made in the restorative work on a tooth.  The cost of root amputation is small in comparison to the cost of tooth replacement with an implant or bridge.  There may be certain situations where root amputation is the ideal treatment for your patient.

The following case was treated at Superstition Springs Endodontics.

Retreatment of #3 was previously attempted.

Surgical access to #3 discovered a fractured MB.  Options were discussed and MB root amputation was chosen and performed.  All remaining occlusal forces are directed over the remaining roots (P and DB).

1.5 Yr recall finds the patient asymptomatic and fully functional.  Bony support around the aputated root looks good.

9.5 Year Recall of Apicoectomy

Last post, talked about how apicoectomies can be used to save teeth and the periodontium - tissues whose form and function are never truly replaced by dental implants. As a follow up to that post, here's a 9.5 year recall on an apicoectomy.

 This patient has crowns on #6-#11.  Tooth #6 is causing a localized ache, affected by pressure and chewing. #6 is sensitive to percussion with normal probings. DX:  Prior RCT with Symptomatic Apical Periodontitis (SAP). The margins are suspicious, but apical surgery was chosen to address the infection without disturbing the existing crown.

Apicoectomy completed, no root fractures seen with microscope. MTA retrofill.

9.5 year recall.  Tooth is fully functional, asymptomatic with radiographic healing.  Apicoectomy has preserved the tooth and the periodontium for an extended period of time.

Apicoectomies Save Teeth

Endodontic surgery has an established record of success.  Modern materials and equipment (microsurgery) make it even more successful.

In a recent updated meta-analysis of the literature regarding endodontic surgery (Tsesis et. al.), a successful outcome of endodontic surgery was seen in 89% of patients at 1 year.  It also pointed out that modern materials and equipment (MTA and microscopes) are associated with better outcomes.

The following case shows the benefit of endodontic surgery, use of CBCT in surgical planning, and the surgical correction of endodontic overfill.

This root canal was done by her general dentist 3 months earlier.  As you can see it is overfilled, post placed, crown prepped and ready for new crown, but patient continues to have symptoms with the tooth.

CBCT taken to evaluate the root morphology. It is clear that this is a single root/canal.  (The canal has an oblong shape)  It was chosen to treat this tooth with apical surgery to preserve the restorative work that has been completed and assure that the overextened gutta percha is removed.

Apicoectomy completed with MTA retrofill.

9 month recall show complete healing of the periapical lesion, tooth is fully functional and asymptomatic.  This procedure saves the patient significant time and money over extraction and implant placement.

SOURCES:

Outcomes of Surgical Endodontic Treatment Performed by a Modern Technique: An Updated Meta-analysis of the Literature
Igor Tsesis, Eyal Rosen, Silvio Taschieri, Yoel Telishevsky Strauss, Valentina Ceresoli, Massimo Del Fabbro

Journal of endodontics 1 March 2013 (volume 39 issue 3 Pages 332-339 DOI: 10.1016/j.joen.2012.11.044) 

Root Canal Surgery to Repair Post Perforation

#6 Post perforation on a long span (7 unit) bridge. Pt is insistant that she does not want to lose this tooth or bridge at this time.  Lateral radiolucent lesion is present adjacent to the perforation.

CBCT taken to evaluate the position and extent of perforation, bone loss and possible surgical intervention. Given the treatment options, the patient wishes to try and maintain the tooth with surgical repair of post perforation. Pt understands that post repair will not improve coronal margins, but does not wish to replace bridge at this time.

Surgical flap reflected, post perforation located, 2-3mm post resected, lateral root preparation created.

Geristore used to repair root.

Lateral root restoration contoured to adjacent root.

Post Op radiograph showing perforation repair.

6 month recall showing initial healing. Pt is asymptomatic and fully functional.

At 18 month recall, bone has healed completely, tooth #6 is asymptomatic and fully functional.  Tooth #4 is now testing necrotic w/ asymptomatic apical periodontitis. RCT has been recommended.

 This case demonstrates how a skilled endodontist's surgical abilities can save what would seem like non-restorable, iatrogenic damage.

Re-Apicoectomy.

Occasionally, we see cases that have had previous treatment, retreatment, and apicoectomy, often times many decades ago, and now require intervention.  The prognosis on these cases is often guarded at best, and it is great that we have dental implants as an option.  If a tooth has a fractured root or is in poor restorative or periodontal condition, I generally recommend a dental implant.

However, there are some select cases, and select patients, where there are some alternatives.  I have a few such cases where I have elected to retreat a case with previous apicoectomy, and have had success without redoing the apicoectomy.  This is usually necessary where the entire canal system or chamber is contaminated, or there are missed canals that can be addressed.  In fact, a missed canals, or a leaking restoration are the most common reasons for apicoectomy failure.  I will save those cases for a future post, and instead show a couple cases where it was decided to "re-apico" the tooth.

This first patient suffered a traumatic sports injury 30 years ago to her anterior teeth.  The original root canal treatment was done at that time.  The teeth had apicoectomies within a few years.  The crowns on the teeth were recently redone, and a sinus tract was noticed soon after.  As an aside, the appearance of apical pathology on a previously treated tooth only following a new restoration is a common trend.  The most likely explanation is a lack of proper isolation during restorative care and a lack of seal in an old root canal treatment.  

There was heavy amalgam tatooing of the buccal mucosa, but the patient was happy with the esthetics of her new crowns after many years of having crowns she considered ugly.  I discussed treatment options at length, and ultimately referred her to a periodontist for implant consult and to learn about the alternative treatment.  After discussing the option of implants with her periodontist, she came back to me to take a chance on redoing the apicoectomy.  The sinus tract was only associated with #9, but upon access, a granuloma perforating the B plate of #8 was noted, and a decision was made to treat both teeth.

Preop #9

Preop #8

Intraoperative, note the extreme bevels already present.
A submarginal scalloped rectangular flap was selected due to an abundance of attached gingiva.  (pic is flipped)

Post op.  MTA retrofil.

1 month recall, no sinus tract.

The 6 month recall will be coming up soon.  

Case Two is similar and more recent.  This was an extremely challenging case.

This patient presented with two sinus tracts, each tracing to #9 and #10.  The crowns on 8-9 and 10 were all recently redone within the past three months.  The post on #9 is out the end, and crown to root ratio is poor.  I recommended ideally extracting #9.  A case could be made to retreat #10, and that would be my usual preference.  The patient understandably was averse to extracting #9, and so an alternate plan of apicoectomy of both #9 and #10 was suggested.  Tooth #9 was already splinted to #8, so mobility is unlikely.  I likened the desired final result to a cantilever bridge, with a little bit of support.  I cautioned the patient that the prognosis was guarded at best, and the patient again wished to proceed with treatment.  

Preop radiograph.

Dual sinus tract tracing.

Upon access, a complete lack of buccal cortical plate on #9 was noted, and is obviously not ideal.  (pic is flipped)
  A papilla-base preservation flap was selected due to a lack of attached gingiva for a  submarginal.
Hemostasis was a major challenge with this patient.

I was able to resect some of the post, retroprep the GP on the palatal aspect of it, and pack it with MTA.
(flipped pic)  I also apologize, the color balance is off on some of these last few photos.

The MTA retrofil on #10. (flipped pic)

Closure with interrupted sutures. (flipped pic)

Post op radiograph.

I was very pleased with the final result of this case.  Only time will tell if we can have sustained success.  I'll be recalling this case is the coming months.

These two cases turned out as well as I could have expected, but I always appreciate any feedback. I always have more to learn about endodontic surgery, since my preferred approach is retreatment for an overwhelming majority of cases, and I don't have some of the experience in surgery that some other clinicians have.  If you would have selected a different flap design, let me know! I'm open to suggestions.

Both cases posted here could certainly have been treatment planned as dental implants.  However, both patients were in the unique situation of very recently having invested in new crowns.  With careful patient selection and expectation management, I believe we can offer patients these types of treatments to preserve their natural teeth, even if for only for a few more years.  

For more unique cases and content, check out our facebook page, www.facebook.com/alpharettaendo.

Success with endodontic surgery (apicoectomy)

This patient was kicked in the face by a horse in 1998. Teeth were displaced (luxated). She repositioned them herself. RCT's on #24 and #25 were done in 2008 by her general dentist. In
Jan 2011 she is having pain, percussion sensitivity, normal probings, adjacent teeth WNL. These teeth are diagnosed as: Prior RCT's w/ Symptomatic Apical Periodontitis.

Axial and sagittal views in CBCT verify that these are single canals incisors. It also shows us the extent of the bone loss prior to our surgical access.

Due to the large size of the canals and over extension of the previous RCT, it was recommended to treat these teeth surgically with an apicoectomy.

Apicoectomy completed with MTA retrofill.

At 6 month recall the teeth are fully functional and asymptomatic. Radiographs show impressive healing of the apical bone. Endodontic surgery can preserve the natural tooth, which then helps to preserve the periodontium.


UPDATE: 1 year recall. Pt asymptomatic, fully functional.

CASE #2

The following case is a similar, double apicoectomy. The CBCT confirmed that there were no missed canals. The large posts and good crown margins were the reasons we chose surgery over non-surgical retreatment.

Endodontic surgery saves natural teeth.

Saving the Natural Tooth with Intentional Replantation

Intentional replantation is the intentional removal (extraction) and replantation of a tooth. This technique can be useful for teeth that cannot be treated with traditional endodontic surgery. This strategy can be particularly helpful in lower second molars where proximity to the mandibular nerve and thickness of the buccal bone make endodontic surgery difficult.


This patient presented for treatment of tooth #18. It had previous endodontic treatment 15 years earlier. The patient presented with some intraoral swelling and intermittent pain that was worsened with pressure and biting. Class II mobility and deep buccal probing were found along with the obvious periapical radiolucency and apical resorption. The tooth was diagnosed as: Prior RCT with chronic apical abscess. The large access cavity weakening the mesial tooth surface was noted and discussed as well as the possibility of a root fracture.

Treatment options discussed included:
1. Retreatment and look for fracture
2. Apicoectomy and look for fracture
3. Intentional replantation and look for fracture
4. Extraction

Due to the conical root structure, closeness to the mandibular canal, and probable root fracture, we decided to perform and intentional replantation.
Tooth was removed atraumatically and no root fractures were found.

Immediate root resection, retropreparation and retrofill with MTA was performed.
Patient was given PenVK 500mg for 5 days.
Patient was informed of the guarded prognosis following this procedure. Long term follow up will be required to determine the success.

6 year recall of the patient finds the tooth completely functional and asymptomatic. While there are many who would not have considered saving this tooth, the intentional reimplantation procedure has saved this patient thousands of dollars and allowed him to retain his natural tooth.