Review Article

Intentional Replantation Techniques:

A Critical Review
Bradley D. Becker, DDS

Abstract
Introduction: Techniques and armamentarium for
intentional replantation have varied throughout the
years with no universally accepted clinical treatment
P ost-treatment endodon-
tic disease, defined as
the persistence or develop-
Significance
Intentional replantation is a clinical technique used
by endodontists routinely throughout the world to
guidelines. A wide range of success rates has been re- ment of an inflammatory
treat disease of endodontic origin. This article pro-
ported, and accordingly, this treatment method has periapical or periradicular
vides a critical review of the reported and sug-
often been regarded as a treatment of last resort. How- lesion in a previously
gested techniques, highlighting differences and
ever, recent studies have shown more consistent suc- root-filled tooth, is a signif-
consistencies.
cess rates as high as 88% to 95%. In light of these icant issue for oral health
new studies, intentional replantation may now be care providers, especially
considered a more commonly accepted treatment mo- for endodontic specialists. The prevalence, according to cross-sectional epidemiological
dality. The purpose of this review was to critically studies, ranges from 16% to 65%, depending on the study population (1). The primary
examine reported techniques for intentional replanta- cause has been attributed to the presence of microorganisms in the root canal system and/
tion. Methods: A search of the literature on intentional or the periapical tissue, although additional etiologies, including the presence of cysts,
replantation techniques was performed using electronic cholesterol crystals, and foreign bodies, have also been implicated (2). Several treatment
databases including PubMed, Medline, and Scopus. A options with varying levels of success have been suggested, including nonsurgical end-
total of 3183 articles were generated and screened for odontic retreatment and apical surgery (3). Because of improved operational efficiency,
relevance based on defined inclusion and exclusion difficulty with surgical access, and the desire to avoid delicate anatomic structures, inten-
criteria. Subsequently, 27 studies were included for crit- tional replantation has been proposed as an additional method to resolve post-treatment
ical review of technique. Results: There has been an endodontic disease in select cases.
evolution in technique for intentional replantation over Intentional replantation has been defined as the deliberate extraction of a tooth
the decades. Conclusions: Numerous aspects of the and after evaluation of root surfaces, endodontic manipulation, and repair, placement
procedure exhibit variations, whereas other aspects of the tooth back in into its original socket (4). It is one of the oldest known methods for
exhibit considerable consistency. Few studies reported the treatment of disease of endodontic origin, dating as far back as the 11th century
techniques consistent with modern endodontic surgical when Albulcasis described a replantation (5). In addition, from the 16th to 18th cen-
principles. (J Endod 2018;44:14–21) turies, multiple accounts of replantation were reported, including incorporation of a
root resection and root-end filling before reinsertion of the tooth (6). The evolution
Key Words of the procedure in more recent times has involved modification of techniques sur-
Intentional, reimplant, replant, replantation, review, rounding tooth extraction, root-end resection and preparation, handling of the tooth
techniques during surgical manipulation, and materials used for root-end filling.
The procedure now involves multiple surgical steps that must be executed with
precision for the best outcome. First, the selected tooth is carefully extracted so as
not to induce fracture, thereby rendering the tooth nonrestorable, and also to minimize
damage to the periodontal ligament (PDL). Survival of PDL cells has been noted to be a
critical factor influencing successful healing (7). Several authors have recommended
avoiding the use of dental elevators and limiting the application of dental forceps to
the crown of the tooth as a means to minimize trauma to the PDL cells (8–11).
This step has been considered by some as the most technique-sensitive portion of
the procedure (11).
After extraction of the tooth, the roots are examined for fractures, additional canals
or portals of exit, isthmi, and any additional anatomic features requiring attention (12).
Root inspection is best accomplished with the aid of a dental operating microscope

From the Division of Endodontics, Department of Oral Rehabilitation, Medical University of South Carolina, Charleston, South Carolina.
Address requests for reprints to Dr Bradley D. Becker, Medical University of South Carolina, Department of Oral Rehabilitation, Division of Endodontics, 29 Bee Street,
Charleston, SC 29425. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.08.002

14 Becker JOE — Volume 44, Number 1, January 2018

 Review Article

Figure 1. Handling and inspection of the extracted tooth.

(DOM) to properly magnify and illuminate the areas being evaluated with the natural anatomic outline of the root canal space (14). The best
(11) (Figure 1). Following root inspection, root resections are made method to accomplish these goals is thought to be with ultrasonic
using a high-speed handpiece, ideally of at least 3 mm, which has instrumentation, rather than high-speed surgical burs (11). The use
been shown to eliminate 98% of apical ramifications and 93% of lateral of ultrasonic instrumentation for root-end preparations has been asso-
canals (13) (Figure 2). In the event that granulomatous tissue remains ciated with the creation of fractures in the unsupported root-end and
attached to the root ends on extraction, it is carefully curetted or is thus must be performed with caution to avoid excessive force (15). A
removed when the root is resected. root-end filling material is then placed and condensed into the prepa-
The root canals are then prepared to receive a root-end filling us- ration (Figure 4). Historically, amalgam was the material of choice for
ing either a high-speed handpiece or ultrasonic instrumentation root-end filling; however, newer materials, such as Super ethoxy-
(Figure 3). The ideal root-end preparation has been described as a benzoic acid (SuperEBA), mineral trioxide aggregate (MTA), and cal-
class I cavity, at least 3 mm in depth, with parallel walls and consistent cium silicate cements, have shown superior ability to seal the root canal

Figure 2. Root-end resection.

JOE — Volume 44, Number 1, January 2018 Intentional Replantation Techniques 15

Review Article

Figure 3. Root-end preparation.

system and demonstrate greater biocompatibility (16). In addition to the socket while avoiding contact with the socket walls (19, 20).
their superior sealing ability, calcium silicate root-end filling materials Others have recommended avoiding curettage of the socket all
have demonstrated bioactivity with precipitation of apatite crystals on together. Instead, surgical suction devices are used to remove only
dentinal surfaces (17, 18). Considering these more desirable the blood clot, with careful attention to avoid any contact with socket
properties, amalgam is no longer advocated for use as a root-end filling walls (9, 11, 12). Regardless of the method, the primary goal is to
material. avoid removing and/or traumatizing remaining PDL cells attached to
Once root-end fillings have been completed, the tooth is ready for the alveolus, which aid in the healing process.
reimplantation into its original socket. Before tooth replacement, the Once the socket has been prepared to receive the tooth and is free
socket may be curetted to remove any remaining granulomatous tissue of any obstruction, the tooth is gently placed in the socket in an axial
or cystic remnants. This practice has been somewhat controversial. direction using digital pressure. If resistance is met, some have reported
Some authors have advocated curettage of the most apical portion of using the patient’s bite pressure to further seat the tooth into its socket

Figure 4. Root-end filling.

16 Becker JOE — Volume 44, Number 1, January 2018

 Review Article
(21, 22). Once completely seated, compression of the socket walls most advocating no antibiotics, or administration only ‘‘as needed’’
using further digital pressure has been recommended (4, 12, 23) to for prevention of subacute bacterial endocarditis or infection of artifi-
gain a more intimate adaptation of the socket wall and tooth root. An cial joint replacements. For those recommending antibiotics as a mea-
assessment of stability of the tooth is rendered and the decision of sure to improve procedural results, the timing and choice of antibiotics
whether to apply a splint is made. The practice of splinting is varied. Nosonowitz (8) advised starting antibiotics a day before the
somewhat controversial. Some authors advocate splinting replanted operation, whereas others, such as Jang et al (37), reported beginning
teeth for 7 to 10 days to 3 to 4 weeks (4, 12). Others recommend no the medication on the day of the procedure. The choices of antibiotics
splinting unless advanced mobility is present (19, 24). In addition, included penicillin, ampicillin, clindamycin, and tetracycline.
occlusal reduction of the implanted tooth has been advocated by
some (8, 19) and avoided by others (21). This final step completes Preoperative Disinfection
the procedure and the patient is then seen for postoperative examina- Preoperative disinfection of the surgical site was nearly universally
tion at various time intervals. recommended. This included a range of techniques, from local
Additional sources of contention during intentional replantation debridement of plaque and calculus to disinfection with chemical
surround the proper handling of the tooth during endodontic manipula- agents such as glyoxide and metaphen. Chlorhexidine, in concentra-
tion and the time limits for the tooth to be out of the mouth. Both handling tions of 0.12% or 2% was the most commonly recommended means
and extraoral time are critical to ensuring maximum vitality of PDL cells. for disinfection.
Kratchman in 1997 (11) suggested holding the extracted tooth in dental
forceps while performing the root-end procedures. He also recommen-
ded performing the root resections while periodically submersing the Number of Operators
tooth in a bath of Hank’s balanced salt solution (HBSS) to maximize Several authors, such as Grossman (4), Raghoebar and Vissink
the PDL survivability. More recent studies by Choi et al (25) and Cho (35), Tewari and Chawla (21), Fegan and Steiman (23), and Guy
et al (26) report holding the tooth in saline-soaked gauze during manip- and Goerig (20), recommended performing intentional replantations
ulation. It is important that the gauze is completely saturated with saline using 2 operators, one to perform the tooth extraction and the other
and not sterile water, as dry gauze or sterile water may desiccate root sur- to perform the endodontic surgical manipulation. The purported
faces and compromise the vitality of PDL cells (27). benefit was an increased efficiency in operating time and allowance
Recommendations for extraoral times have also varied. In 1966, for greater focus on the task at hand, thus reducing the time that the
Grossman (4) reported the time out of the mouth should be ‘‘a matter tooth was out of the mouth. Most studies, however, reported a single
of minutes,’’ noting specifically that the PDL can be kept alive for 15 to operator for all aspects of treatment, with similar reported extraoral
20 minutes. Kratchman (11) recommended a maximum extraoral time times as those using 2.
of 10 to 15 minutes. In the 1994 report by Dryden and Arens (28) on
intentional replantations, J. Andreasen was noted to have reported 90% Tooth Extraction Method
success rates when avulsed teeth were replanted within 30 minutes. The methods for tooth extraction also varied greatly among
Specific indications for intentional replantation include circum- studies. Grossman, Guy and Goerig (20), and Tewari and Chawla
stances that may preclude traditional apical surgery, such as areas of (21) reported the use of dental elevators either to loosen soft tissue
limited access and visibility, close proximity to delicate anatomic struc- or the tooth before forceps application. Most authors, though, were im-
tures, or when a periodontal defect may result. Other indications plicit that no dental elevators be used, and that the application of the
include the presence of conditions for which nonsurgical retreatment dental forceps be limited to the tooth crown with no root contact. An
is impracticable, such as obstruction of the root canal system, or perfo- additional consensus was to perform the extraction in a controlled, pro-
ration that is not accessible (28). Finally, intentional replantation also longed manner with a slow rocking motion to prevent and mitigate po-
has been indicated in situations of difficult patient management, persis- tential damage to the periodontal ligament cells. Interestingly, Jang et al
tent chronic pain, accidental iatrogenic avulsion, involuntary orthodon- (37) reported placing a #15 surgical scalpel in the tooth sulcus, then
tic extrusion, and previous failure of nonsurgical retreatment and apical driving the blade into tissue using a mallet to separate the periodontal
surgery (29). fibers.

Critical Review of Reported Techniques Socket Protection

The reported and suggested techniques for intentional replanta- Subsequent to tooth extraction, and during endodontic surgical
tion demonstrate significant heterogeneity. There is continuity with manipulation of the tooth, some earlier authors, such as Grossman
some aspects of the procedure, such as avoiding contact of cementum (4), Deeb (30), and Nosonowitz (8), advocated placing sterile gauze
during tooth extraction and utilization of saline as a root hydration me- over the tooth socket as a means of protection from debris and saliva.
dium during endodontic manipulation, whereas other aspects vary Although this practice seemed to fall out of favor with time, Cho et al
significantly. Examples of variation include administration of preoper- (26) reported using gauze to cover and protect the socket as recently
ative antibiotics, number of operators, curettage of the tooth socket, as 2016 in a study on intentional replantations.
root resection method, root-end preparation method, root-end filling
material, extraoral time, and application of a splint. These similarities Tooth Handling Method
and differences are highlighted in Table 1(4, 7–12, 19–26, 28–39).
Once the tooth extraction was completed, most operators recom-
A detailed analysis of the reported or advocated techniques re-
mended holding the tooth by the crown with a saline-soaked gauze as a
vealed the following.
measure to provide continued hydration of the root surface and peri-
odontal ligament cells. Nearly the same number recommended holding
Preoperative Antibiotics the tooth by the crown using the beaks of the forceps, limiting contact to
In preparation for the intentional replantation procedure, preop- enamel. Niemczyk (9), Kratchman (11), and Peer (29) additionally
erative antibiotics were recommended by a minority of authors, with recommended applying a rubber band to the handles of forceps to

JOE — Volume 44, Number 1, January 2018 Intentional Replantation Techniques 17

Review Article
TABLE 1. Critical Review of Intentional Replantation Techniques
No. Preoperative Preoperative Extraction Socket Hydration
operators antibiotic disinfection method covering Socket curettage Handling method medium
Grossman 2 NR Yes, antiseptic Elevator to loosen soft Yes, gauze Yes, carefully curetted Handheld/gauze Saline,
1966 tissue, then extracted blood clot removed Ringers with
erythromycin

Emmertsen, 1 Yes, NR Forceps, ging. loosened, Yes, iodoform Yes, periapical area Forceps Saline
Andreasen penicillin gentle luxation gauze
1966
Deeb 1968 NR Yes Yes, metaphen NR Yes, gauze Yes, apical area if Hand, saline-soaked Saline
pathosis, gauze
saline irr. of alveolus
Kingsbury NR No, NR NR Yes, gauze Yes, any diseased tissue Held by Allis clamp Saline
et al 1971 only PRN removed by apical or Kern bone
curettage clamp
Deeb 1971 NR Yes, Yes, metaphen Elevators and forceps Yes, gauze Yes, apical area no socket Hand, saline-soaked Saline
Cleocin wall tooth cervically gauze
Nosonowitz NR Yes Yes, NR gently ext’d; no contact Yes, gauze Yes, carefully with Handheld, wrapped Saline,
1972 on cementum blood clot in sterile gauze, zephir
saline chloride
Tewari, 2 NR NR Fine elevators then Yes, gauze Yes, and clot removed Hand, wrapped Normal
Chawla forceps min in wet gauze saline
1974 rocking motion

Grossman 2 NR Yes, antiseptic No elevator, forceps, Yes, gauze Yes at base, no walls clot Hand, wrapped in Sterile
1982 rotated as little aspirated irrig. w/ saline soaked saline
as possible saline gauze with
tetracycline
Nosonowitz NR Yes Yes, Gly-Oxide Forceps wrapped in gauze Yes, gauze Yes, any pathosis removed NR Isotonic
1984 engage crown on with blood clot solution
enamel band or
crown prior to ext
Guy, Goerig 2 No, only NR Elevator to loosen then NR Yes, only apical portion Handheld; tooth Warm
1984 PRN forceps ext no root suction blood clot wrapped in saline
surface cont gauze
Dumsha, 2 No Yes, antiseptic Min. cont with tth struct NR No, wall must not be Hand, gauze Isotonic
Gutmann forceps wrapped curetted gently wrapped in saline
1985 in gauze flushed saline-soaked
of clot gauze
Koenig NR NR NR ‘‘Usual manner’’ avoid Yes, gauze No, clot aspirated Handheld, gauze Sterile
et al 1988 undo manipulation from socket soaked in saline saline
in socket
Keller 1990 NR NR NR Care taken not to NR NR Forceps or spec. Saline
damage the holder
desmodontium
Greiner, NR Yes, NR Avoid touching pdl NR Do not touch walls NR Sterile saline
Hawkins tetracycline fibers
1991
Fegan, 2 No Yes, antiseptic Soft tissue loosened with Yes, gauze No, irrigated with saline Forceps, tooth wrapped cont.
Steiman such as CHX periosteal elev. Avoid to remove clot in moist gauze for irrigation
1991 damage to cementum forceps do not touch with saline
cementum
Bender, NR Yes, Yes, 0.2% CHX Flat beak of forceps no NR Yes, curetted lightly NR NR
Rossman ampicillin or cemental contact irrigated with saline
1993 clindamycin gingiva loosened
with periosteal elev
Koerner 1993 NR NR NR Reflect cervical gingiva, NR Yes, at base of socket Hand, gauze soaked Sterile saline
elevator to luxate suction clot in HBSS or HBSS
tooth, forceps ext
Dryden, NR NR Yes, CHX 0.12% #15 sever perio fibers NR NR Forceps, roots saline
Arens elevators used, forceps wrapped in
1994 ext. no cemental contact, saline-soaked
wrap beaks with gauze? gauze
Kratchman NR No, only Yes, 0.12% CHX Beaks above cej; no NR No, can be gently Forceps with Intermittently
1997 PRN elevators rubber band aspirated rubber band submerged
on handles handle in HBSS

Raghoebar, 2 NR NR Forceps, atraumatically NR Apical curettage, Hand, saline-soaked saline

Vissink irrigated gauze
1999 w/saline
Niemczyk NR No Yes, 0.12% CHX no elevator minimal NR No; gentle evacuation forceps; cont.
2001 contact with root rubber band submerged
surface handle in HBSS
Peer 2004 NR Yes Yes, 0.12% CHX No elevator, min. NR Yes, very gently aspirate Forceps, rubber ‘‘Physiologic
pressure, beaks socket only in apical band around solution’’
not touch cementum end handle
Abid 2010 1 NR Yes, 0.12% CHX No elev., forceps cor. NR Only apical portion Hand, const. 0.9% saline
to CEJ. min. force saline to remove clot soaked with
saline squirting
Choi 2014 1 No, only Yes, 0.2% CHX No elevators, physics Yes, gauze Yes, not wall though clot Hand, saline-soaked Saline
PRN forceps final ext with removed with saline gauze
conv. forceps

Asgary 2014 1 NR Yes, 0.2% CHX Gently, by means of NR Blood clot aspirated NR Saline
suitable periotome
pdl/root untouched
Cho 2016 NR NR NR Forceps, as carefully Yes, gauze No, rinsed with saline Hand, saline-soaked Saline
as possible, no gauze
root damage

Jang 2016 NR Yes, Yes, 0.1% CHX 15 blade parallel to pdl NR NR HBSS or saline
amoxicillin and hit with mallet, then
forceps. No elevators

Avg, average; cej, cementoenamel junction; CHX, chlorhexidine; const, constant; cont, continual/continuous; DOM, dental operating microscope; ext, extraction; ext’d, extracted; GG, Gates Glidden; ging, gingiva;
HBSS, Hank’s balanced salt solution; IRM, intermediate restorative material; irr, irrigationl; m, minutes; mag, magnification; MTA, mineral trioxide aggregate; NR, none/not reported; pdl, periodontal ligament;
perio, periodontal; PRN, as needed; rec’d, recommended; rt, root; struct, structure; SuperEBA, Super ethoxy-benzoic acid; tth, tooth/teeth; US, ultrasonic; w/, with; ZOE, zinc-oxide eugenol; ?, unknown.
 Review Article
TABLE 1. Continued
Root resection Root prep Inspection Occlusal
method method method Retrofill material Seating of tooth Time out of mouth Splinting reduction Outcome
2–3 mm or as No retroprep if NR Amalgam Finger; compression ‘‘A matter of Yes; 3–4 wks Slight relief 80%; 45 tth
much as filled; 2–3 mm of socket minutes’’;
needed; 15–20 m. pdl can
Rongeurs be kept alive

Yes, length? NR NR Kloroperka, Finger pressure NR Yes, lead foil No 81%; 100 tth
Amalgam, Gutta-
percha
‘‘At times’’ Yes, 1/3 rt length, NR Amalgam Finger pressure NR Yes, acrylic 67%; 117 tth
3–4 mm of
apical foramen
NR NR NR NR Finger pressure # 30 m, ‘‘shortest Only as Yes, remove 97%; 149 tth
time possible’’ necessary from direct
4 wk occlusal contact
‘‘At times’’ NR NR Amalgam Finger pressure NR Yes, acrylic Yes 74%

Yes/length? 2–3 mm bur NR Gutta-percha Finger pressure 15 m? NR Yes 78%

Amalgam compression of
socket
Yes Yes NR Gutta-percha Finger pressure bite 31–50 m Yes, wire No 62.10%
pressure
compression of
socket
PRN/length ? PRN, #2 round NR Amalgam Finger pressure 1–6 m Yes, 2–4 wk, NR NR
Rongeurs and inverted compression of wire splint
cone socket with
perio pack
$5 mm or to NR NR NR Finger pressure # 30m, ‘‘as soon as NR Yes NR; 9 tth
obstruction compression of possible’’
socket

PRN, length? Only PRN, 3–4 mm #23 explorer Amalgam Finger pressure 2–3 m for tooth prep No, only PRN NR 100%; 1 tth
700 bur Compression of and repair 7–10 days
socket
Yes/length? PRN, length? Yes, NR Amalgam Finger pressure 10–30 m Yes, rec’d Yes NR
compression of 7–10 d
socket

Yes, 1–3 mm Yes, 4 mm #701 NR Amalgam, ZOE Finger pressure Avg 12 m, 22 m or less No Yes 82%; 177 tth
#70 fissure bur forceps compression
bur of socket
Yes? Yes? NR Aluminum oxide, NR 20 m or less Yes, 3–4 wk Yes 92%; 25tth
ceramic pins

Yes, beveled Yes NR Amalgam Finger pressure Limit the time out of No, only if Yes NR
the mouth loose

Yes/length ? PRN/length? Yes, how? NR Finger pressure ‘‘Kept to an absolute No, ‘ most often Yes NR
compression of minimum’’ will not be
socket needed’’;
5–7 d
Yes/length? Yes/length? NR Amalgam Finger pressure; bite ‘‘The shorter the No, only PRN Yes 81%; 31 tth
pressure better’’

Yes, 2–3 mm Yes, 2–3 mm deep NR Amalgam, acceptable Finger pressure Within 10–15 m max Yes, if mobile, Yes NR
bevel ends 1 mm diameter retroseal material, compression of 30 m 2 wk
Super EBA socket
Yes, 2–3 mm Yes, no less than Yes, mag. Super EBA, IRM or Finger pressure bite ?, within 30 m quotes Yes, every case, Yes NR
#170 3–5 mm #34 lenses glass ionomer pressure Andreasen 7–14 d
fissure bur inverted methylene
cone bur blue dye
Yes/length? Yes, 330 bur Microscope ZOE, Super EBA Finger pressure; bite 10–15m No PRN N/A
pressure
compression of
socket
Yes, 2–3 mm Yes, 3–5 mm, NR Amalgam Finger pressure 8 m  1 m avg. range Yes, 17 splinted Yes 86%; 29 tth
round bur 6–13 m wire or
suture
Yes/ 1–3mm Yes, 3–4mm bur Yes, DOM ZOE or Super EBA Finger pressure NR Yes, if NR 100%; 1 tth
carbide indicated
fissure 7–10 days
Yes/length? Yes, 3–4 mm NR Amalgam, ZOE, Finger pressure ‘‘As brief as possible’’ No, only if NR 89%; 9 tth
Gutta-percha compression of avg. 5 m, #10 m needed
socket 1–2 wk
Yes, 2–3 mm Yes, 2 mm, 1 or NR Amalgam Finger pressure 2–3 m Yes, 10 d, silk Yes 90%; 20 tth
round bur 2 round bur suture
diamond
Yes, 2–3 mm Yes, 3 mm 330 bur Yes, DOM MTA Finger pressure bite 11 m 25 s  5 m 32 s No, only PRN, NR 95.1; 287 tth
diamond pressure 10–14 d
bur compression of
socket
Yes, 2–3 mm Yes, 3 mm, #3 NR CEM cement NR #15 m No Yes 90%
diamond GG bur
bur
Yes, 3 mm Yes, 3-mm-thick Yes, DOM IRM, SuperEBA, MTA Finger pressure 12.5 m, 4–25 m range No, only NR 93%; 159 tth
diamond roots, diamond methylene unstable
bur bur thin blue dye teeth, semi
roots, US rigid
Yes, 2–3 mm Yes, 3 mm 330 bur Yes, DOM and or Endocem, MTA, Finger pressure Some <15 m some >15 No, only NR 83%; 41 tth
#170 bur methylene Super EBA m unstable
blue dye teeth, 2 wk
Review Article
maintain a constant, consistent pressure on the tooth surface during Tooth Splinting
manipulation. On reinsertion, splinting of the tooth was variable. Many studies
included splinting only when gross instability of the tooth was present.
Root Hydration Medium Others, such as Dryden and Arens (28), incorporated a splint for each
The use of saline for a root hydration medium was near unani- case. The advocated duration of splint application also varied from 7 to
mous. In contrast, Kratchman (11) and Niemczyk (9) each recommen- 10 days or 3 to 4 weeks. Material for splint fabrication ranged from wire
ded HBSS. In addition, Kratchman (11) reported that periodic to acrylic to sutures. Emmertsen and Andreasen (7) reported the use of
submersion of the tooth in a bath of HBSS during root resection was lead foil for splinting. Relief of the reimplanted tooth from occlusal con-
the best approach to avoid root desiccation. tact was near unanimous, although a few recommended no adjustment
or only ‘‘as needed.’’
Two additional procedural categories demonstrated differences in
Root Resection Method reported or suggested technique.
Root-end resection methods also varied. Although many authors
did not specifically report the length of root-end resection, nearly all Root Inspection Method
advocated or reported performing some degree of resection. An excep-
Inspection of the tooth root for anatomic variations, such as addi-
tion was a 1982 study by Grossman (10) in which it was reported that
tional portals of exit or isthmi, or root fractures, before endodontic sur-
root resections were performed ‘‘as needed.’’ Most reported resections
gical manipulation, was rarely reported. This is a crucial step in keeping
were completed with the use of a carbide or diamond bur in a high-
with modern endodontic surgical technique, contributing to success or
speed handpiece. Length of resection also varied, with most reporting
failure of the procedure. In 1997, Kratchman (11) advocated the use of
1 to 3 mm, although Nosonowitz (8) reported root resections of 5
a DOM to aid in inspection of the roots before continuing with the inten-
mm or larger.
tional replantation procedure. Studies by Niemczyk (9), Choi et al (25),
Cho et al (26), and Jang et al (37) were the only additional articles to
Root-End Preparation Method explicitly report the use of a DOM for inspection.
Subsequent to root-end resection, most operators performed a In addition, staining of the root surface using methylene blue was
root-end preparation. However, Grossman (4) recommended no also incorporated. In contrast, most studies either did not report
root-end preparation for those teeth with root canals that were already whether the root was inspected or an alternate technique was used.
filled. Studies by Guy and Goerig (20), Dumsha and Gutman (12), and Guy and Goerig (20) reported inspection using a #23 explorer, whereas
Fegan and Steiman (23) recommended root-end preparations on an Dryden and Arens (28) reported the use of ‘‘magnification lenses’’ and
‘‘as-needed’’ basis. The lengths and methods of the root-end prepara- methylene blue dye.
tions varied. Some reported 2 to 3 mm, others 3 to 4 mm, and Deeb
(30) reported one-third the root length. Nearly all were completed us- Extraoral Time
ing a carbide bur. Cho et al (26) were the only authors that reported the Finally, the time in which the tooth was kept out of the mouth for
use of ultrasonic instrumentation for root-end preparation, and only in manipulation varied among studies. Most authors advocated mini-
cases of thin roots. mizing this time to preserve vitality of the PDL cells. The times ranged
from 2 to 3 minutes, as reported by Abid et al (38), up to 31 to 50 mi-
Root-End Filling Material nutes in the report by Tewari and Chawla (21). Most kept the extraoral
To fill the root-end preparations, most authors used amalgam; time to less than 30 minutes. Jang et al (37) reported higher success
however, more recent studies by Cho et al (26), Jang et al (37), and rates for those teeth in which the extraoral time was 15 minutes or
Choi et al (25) incorporated the use of newer materials such as inter- less compared with those kept out for more than 15 minutes.
mediate restorative material, SuperEBA, MTA, and Endocem. Additional
reported materials included zinc-oxide eugenol cements, glass ion- Discussion
omer, and gutta-percha. Notably, Keller et al (32) reported using The selection of intentional replantation as a treatment modality
aluminum-oxide ceramic pins to fill root-end preparations. has been controversial. There are many reported indications, yet the
procedure has often been considered a last resort option to retain nat-
Socket Curettage ural teeth (4). As highlighted, there are several different steps in the pro-
After endodontic manipulation, and before reinsertion of the tooth cedure, thus the opportunity for many variations of technique and
into its socket, all authors performed some manipulation of the socket materials. This may explain the wide range in reported success rates,
in preparation for seating. This varied from simple aspiration or rinsing which are often less favorable than other treatment methods. A recent
of the blood clot using a suction device or saline, to curettage of the systematic review of the literature by Torabinejad et al (40) found an
socket using surgical instruments. When curettage of the socket was overall 88% survival rate for intentionally replanted teeth, with more
performed or suggested, some authors were implicit that only the apical contemporary studies demonstrating success rates as high as 95%.
portion of the socket be touched, thus avoiding contact with walls, Because of recently reported high survival rates, intentional replanta-
whereas others made no distinction. tion might now be considered among more commonly accepted treat-
ment options. It was noted in this same study, however, that only 2 of the
articles were published in the past 12 years and also demonstrated dif-
Tooth Insertion ferences in clinical technique, thereby limiting the understanding of
To seat the tooth in the socket, 2 methods were reported. Most au- contemporary intentional replantation practice (40). Thus, there seems
thors used simple placement using fingers, then digital compression of to exist a wide variation in techniques and associated outcomes possibly
the socket walls. A minority suggested or reported further seating of the stemming from the lack of an accepted protocol, as well as a lack of
tooth using the patient’s biting pressure to drive the tooth into position. adherence to modern endodontic surgery principles.

20 Becker JOE — Volume 44, Number 1, January 2018

 Review Article
An interesting finding in this review was the relatively few studies 9. Niemczyk SP. Re-inventing intentional replantation: a modification of the technique.
that reported techniques that strictly adhered to modern endodontic Pract Proced Aesthet Dent 2001;13:433–9. quiz 440.
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highly biocompatible root-end filling materials. More specific recom- 13. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
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a 0 bevel angle, and a 3-mm root preparation depth. Staining of the North Am 2010;54:191–214.
root-end surface with methylene blue to identify fractures, additional 15. Abedi HR, Van Mierlo BL, Wilder-Smith P, et al. Effects of ultrasonic root-end cavity
portals of exit, and isthmi was also suggested (13). It was also noted preparation on the root apex. Oral Surg Oral Med Oral Pathol 1995;80:207–13.
16. Torabinejad M, Ford TRP. Root end filling materials: a review. Dent Traumatol
that traditional techniques for endodontic surgery resulted in success 1996;12:161–78.
rates of 40% to 90%, whereas contemporary techniques that adhered 17. Nair U, Ghattas S, Saber M, et al. A comparative evaluation of the sealing ability of 2
to modern endodontic surgical principles resulted in 85.0% to root-end filling materials: an in vitro leakage study using Enterococcus faecalis.
96.8% success (13). Oral Surg Oral Med Oral Pathol 2011;112:e74–7.
Studies by Setzer et al (41, 42), evaluating success rates for apical 18. Shokouhinejad N, Nekoofar MH, Razmi H, et al. Bioactivity of EndoSequence Root
Repair Material and Bioaggregate. Int Endod J 2012;45:1127–34.
surgery, concluded that when modern microsurgical techniques for 19. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premo-
root-end surgery were used, superior and more predictable success lars and molars. J Am Dent Assoc 1971;83:1053–7.
rates were achieved compared with traditional techniques. Thus, these 20. Guy SC, Goerig AC. Intentional replantation: technique and rationale. Quintessence
conclusions might be similarly expected if modern endodontic surgical Int 1984;15:595–603.
21. Tewari A, Chawla H. Intentional replantation of pulpal or periapically involved per-
techniques and materials are used for intentional replantation manent posterior teeth. J Indian Dent Assoc 1974;46:385–9.
surgeries. 22. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth.
Oral Surg Oral Med Oral Pathol 1993;76:623–30.
Conclusions 23. Fegan S, Steiman HR. Intentional replantation. J Mich Dent Assoc 1991;73:22–4.
24. Koenig KH, Nguyen NT, Barkhordar RA. Intentional replantation: a report of 192
As highlighted by Torabinejad et al in 2015 (40), no universally cases. Gen Dent 1988;36:327–31.
accepted clinical protocol for intentional replantation has been estab- 25. Choi YH, Bae JH, Kim YK, et al. Clinical outcome of intentional replantation with pre-
lished. An assessment and understanding of advocated techniques operative orthodontic extrusion: a retrospective study. Int Endod J 2014;47:
and the evidence to support them is an important first step in developing 1168–76.
26. Cho SY, Lee Y, Shin SJ, et al. Retention and healing outcomes after intentional
such guidelines. replantation. J Endod 2016;42:909–15.
Demonstrated in this review are many inconsistencies and varia- 27. Krasner PR. Management of tooth avulsion in the school setting. J Sch Nurs 1992;8:
tions in techniques that have been advocated or reported over the 22–4. 26.
past several decades. As is evidenced by improved success rates for 28. Dryden JA, Arens DE. Intentional replantation. A viable alternative for selected cases.
Dent Clin North Am 1994;38:325–53.
traditional root-end surgery (42), incorporating modern endodontic 29. Peer M. Intentional replantation—a ‘last resort’ treatment or a conventional treat-
surgical techniques, including the use of the DOM, staining medium, ul- ment procedure? Nine case reports. Dent Traumatol 2004;20:48–55.
trasonic instruments, and newer, more biocompatible root-end filling 30. Deeb E. Replantation of teeth–a recommended procedure. J South Calif Dent Assoc
materials, may also improve success or survival rates of intentionally 1971;39:24–9.
replanted teeth. 31. Nosonowitz DM, Stanley HR. Intentional replantation to prevent predictable end-
odontic failures. Oral Surg Oral Med Oral Pathol 1984;57:423–32.
32. Keller U. A new method of tooth replantation and autotransplantation: aluminum
Acknowledgment oxide ceramic for extraoral retrograde root filling. Oral Surg Oral Med Oral Pathol
1990;70:341–4.
I thank Dr Tim Rohde, Dr Joseph Assad, and Dr Robert Bethea 33. Greiner JH, Hawkins RD. Intentional replantation. Endod Rep 1991;6:11–3.
for their mentorship and guidance throughout this study. I also 34. Koerner KR. Intentional replantation. CDS Rev 1993;86:24–7.
thank Dr Amy Martin, Ms Ayaba Logan, and Mr Bob Poyer for their 35. Raghoebar GM, Vissink A. Results of intentional replantation of molars. J Oral
expertise and guidance in the search of literature. Maxillofac Surg 1999;57:240–4.
36. Asgary S, Alim Marvasti L, Kolahdouzan A. Indications and case series of intentional
The author denies any conflicts of interest related to this study. replantation of teeth. Iran Endod J 2014;9:71–8.
37. Jang Y, Lee S-J, Yoon T-C, et al. Survival rate of teeth with a c-shaped canal after inten-
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