Written by Bart McFarland, DMD Monday, 31 October 2005 19:00
Preservation of natural dentition is the primary goal of any conservative treatment modality. Although not the primary therapy of choice, extraction and reimplantation of the same tooth are indicated in situations when the patient (and/or the existing clinical conditions) will not accept alternative solutions such as root canal treatment, apicoectomy, or implants.
The patient, a 30-year-old white male, presented with continuous pain in the right maxillary area. Testing revealed that there was no thermal response, but the patient had a positive response to percussion and pressure, specifically, pain when digital pressure was applied to the apical area of tooth No. 4. This pain had been noticeable for a period of 1 week and was getting progressively worse. The patient had been given a prescription for antibiotics and pain medications 2 days prior to coming into our office: penicillin VK 500 4 times per day and Lorcet Plus (Forest [hydrocodone APAP 7.5/650]) 4 times a day as needed.
|Figure 1. X-ray of tooth No. 4 shows signs of abscess at the distal apex (darker shaded area).|
As seen in a radiograph (Figure 1), tooth No. 4 had previously been treated with root canal therapy. A look at the periodontal ligament shows signs of abscess; it is evident the root canal had failed. At this point the patient was given 4 options: (1) redo the root canal and place a ceramic post in the canal to repair the crown, (2) send the patient to an oral surgeon for an apicoectomy, (3) extract the tooth and place an implant, and (4) do an intentional extraction and reimplantation. After all options were discussed with the patient, he decided to go with option 4: extraction and reimplantation.
Before an extraction and reimplantation procedure, the patient must be informed of the possible problems:
(1) breaking of the root itself, which would require an extraction and an implant or bridge;
(2) breaking of the crown, which would require a new crown; and
(3) damage to adjacent teeth while extracting the involved tooth.
Several conditions should be present before considering extraction, apicoectomy, and reimplantation.
(1) The conical shaped roots should be present.
(2) The involved tooth should have some mobility, which will facilitate a less traumatic extraction.
Once it is determined that the tooth fits the criteria, a consent must be reviewed with and agreed upon by the patient and placed in their chart.
CLINICAL PROCEDURE: PART 1
|Figure 2. Extracted tooth placed on sterile gauze. The lingual cusp broke off during extraction.||Figure 3. IRM (zinc oxide and eugenol) is placed on the apical end.|
The tooth must be anesthetized, ideally with a Safe-Mate safety needle (MedPro) and one carpule of Septocaine (Septodont). Approx-imately 5 to 10 minutes later, a little less than quarter of a carpule of Septocaine was given on the palliative side. Once the tooth was completely anesthetized, straight elevators were used to elevate the tooth from the distal and from the mesial. Ninety percent of the extraction should be accomplished with elevators. After the tooth was elevated out of the socket, it was placed on a sterile gauze pad and wetted with saline (Figure 2). The tooth should not be out of the socket more than 5 minutes, and the root should be touched as little as possible. For this case, I beveled the apical end of the tooth and placed interim restorative material (Figure 3).
|Figure 4. The cusp is cemented back onto the tooth.|
Next, the tooth was rinsed with saline or milk, and it was then ready for reimplantation. However, in this particular case, the lingual cusp of the tooth broke loose during the extraction and had to be repaired before reimplantation could begin. The repair was made by simply recementing the cusp onto the tooth (Figure 4).
AN INTERESTING AND NOTABLE DISCOVERY
Upon further inspection, it was evident that when this tooth had previously undergone root canal treatment, the lingual cusp was spared on the original prep. A closer look at the patient’s dental records revealed that this tooth had previously been restored with a CEREC (Sirona) onlay that was originally cemented in June 2003 with Panavia (Kuraray Dental). Until now, I had thought that the restoration broke off, when in actuality the CEREC restoration (milled from a VITA Mark II Bloc) and the Panavia bond holding it in place remained unscathed and solidly intact during the entire extraction procedure. It was the actual lingual cusp of the natural tooth that broke—not the CEREC onlay. This is “living proof” of the durability of both the CEREC restoration as well as the cement used to hold it in place.
CLINICAL PROCEDURE: PART 2
|Figure 5. Tooth is placed back into socket.||Figure 6. View of lingual splint fabricated with composite and temporarily cemented in place.|
After the tooth was repaired, it was reimplanted back to its apical position (Figure 5). The patient was allowed to bite, and the bite was checked to make sure the tooth was in occlusion as it was before. The bleeding was stopped with gauze, and a lingual splint made of composite was placed from teeth Nos. 3 to 5 and temporarily cemented in place to help keep the reimplanted tooth No. 4 securely in its socket while it healed (Figure 6). Because teeth Nos. 3 and 4 are posterior teeth and have been treated endodontically, both teeth were treatment planned for full-coverage CEREC crowns.
The patient was placed on Lorcet Plus (12 tabs, 1 tablet as needed, up to 4 per day) and continued to take antibiotics for a period of 5 days (1 tablet 4 times). He was called later that night and reported no pain, and returned to the office 5 days later for an examination and a prophy. The splint that bonded the tooth in place was re-evaluated and was doing well.
|Figure 7. Postoperative x-ray of tooth No. 4, approximately 6 weeks after reimplantation.|
The patient was seen again approximately 1 month after the extraction and apicoectomy had been performed. No mobility and no pain were noted, so the splint was removed. Photographs and a radiograph (Figure 7) were taken. The patient was placed on recall and will be re-evaluated every 6 months.
Extractions and reimplantations must all meet the following criteria to be successful:
(1) informed consent
(2) all roots need to be conically shaped
(3) teeth need to be somewhat mobile
(4) a good knowledge of oral surgery is needed with respect to extractions
Intentional dental reimplantation is a treatment alternative that should not be underrated, especially when conventional endodontic or surgical treatment is not applicable. This is an excellent treatment with a very predictable result. I have done approximately 30 re-implantations, and have lost only 1 tooth to date.
In order to be successful with extraction and reimplantation cases, the practitioner must have the right patient and the right rapport with that patient. The practitioner also must be able to assess the tooth and be comfortable with the fact that it can be extracted without breakage. Additionally, being able to recognize tooth morphologies that can lead to extraction problems is a must. This is a skill that is perfected through experience. Reimplantation is a predictable and acceptable method of treatment in my office when patients present with root canals that require retreatment due to failure or those that cannot be completed due to sclerosing of the canals.
Dr. McFarland received his doctor of dental medicine degree from the University of Kentucky. He maintains a private practice in Paris, Ky, with an associate. He has had the CEREC machine for 6 years, during which he has placed approximately 3,500 restorations, and he has been using the Waterlase combined with the CEREC machine to perform root canals. He also specializes in computerized dentistry. He can be reached at (859) 987-4775.
Disclosure: Dr. McFarland invented and patented the Safe Mate needle that is used in this article.
1. When you said "The repair was made by simply recementing the cusp onto the tooth (Figure 4).", what cement did you use and is it as strong as the original enamel strength?
2. Is the pulp still alive and intact? If not, won't the tooth eventually deteriorate?
3. How is the tooth held in place? Does the periodontal ligament reattach as before?
4. Do many other dentists perform this surgery?
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