Intentional replantation of a mandibular molar: case report and

14-year follow-up
Henry Herrera, DDS, MSc, PhD,a Mário Roberto Leonardo, DDS, MSc, PhD,b
Helen Herrera, DDS, MSc, PhD,a Lucas Miralda, DDS, MSc, PhD,a and
Raquel Assed Bezerra da Silva, DDS, MSc,c El Salvador and São Paulo, Brazil
EVANGELIC UNIVERSITY OF EL SALVADOR AND UNIVERSITY OF SÃO PAULO

This case report describes the nonsurgical endodontic treatment and intentional replantation of a mandibular
molar and its nearly 14-year follow-up. A 56-year-old woman sought treatment with complaint of discomfort and
sensitivity in the mandibular left area. The radiographic examination showed that the mandibular left first molar was
endodontically treated, with over-instrumentation of the distal root and unsatisfactory obturation on the mesial root. A
large periapical lesion was observed surrounding the roots. In view of the patient’s limited interocclusal space and
objection to undergo an apical surgery, intentional replantation was suggested as an alternative. The patient returned
for clinical and radiographic follow-up at 15 days, 40 days, 6 months, 12 months, and once yearly thereafter. At the
last visit, after 14 years, no painful symptomatology was reported, probing depth was no greater than 3 mm, the
periradicular area had normal appearance and no evidence of root resorption or periapical lesion. (Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2006;102:e85-e87)

Conventional endodontic treatment may fail eventually
although it usually has high success rates.1-4 In case of
failure, alternative treatments, such as intentional tooth
replantation, may be considered.
Intentional replantation (IR) is a concept that has been
known for over a thousand years5 and consists of a tech-
nique in which a tooth is intentionally extracted and re-
inserted into its socket immediately after endodontic treat-
ment and apical repair outside the oral cavity.6,7 IR is
indicated for teeth with anatomic limitations, accessibility
problems, or persistent chronic pain and for patients who
have cooperation problems or refuse to undergo periapical
surgery. Many authors8-11 agree that this technique should
be reserved as a “last resort” after other procedures have
failed or when endodontic periradicular surgery is not an
option.12 Contraindications include teeth with curved or
flared roots, preexistent moderate to severe periodontal
disease, or vertical fractures.12
The success of this therapy relies primarily on the
maintenance of aseptic conditions during the interven-
a
Professor of the Evangelic University of El Salvador, El Salvador.
b
Chairman, Department of Pediatric Clinics, Preventive and Social
Dentistry, Faculty of Dentistry of Ribeirão Preto, University of São
Paulo, Brazil.
c
Doctor Postgraduate Student, Department of Pediatric Clinics, Pre-
ventive and Social Dentistry, Faculty of Dentistry of Ribeirão Preto,
University of São Paulo, Brazil.
Received for publication Feb 2, 2006; accepted for publication Feb 3,
2006.
1079-2104/$ - see front matter
© 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2006.02.008
tion, which is attained with a series of measures includ-
ing use of chlorhexidine mouthwash, disinfection of the
operative field, immersion of the tooth in sterile saline,
and irradiation of the alveolus by laser.13 Retention rate
of intentionally replanted teeth is reported to range
from 52% to 95%.6,14-16
Although IR is a relatively simple, inexpensive, and
less time-consuming procedure, it may be associated to
root resorption, specifically replacement resorption (an-
kylosis), which reduces the survival rate of the re-
planted teeth.12,16 However, this is directly related to
the amount of time the tooth is out of the mouth during
the procedure.5,16,17
This case report describes the nonsurgical endodon-
tic treatment and intentional replantation of a mandib-
ular molar and its nearly 14 years of follow-up.
CASE REPORT
A 56-year-old woman sought treatment with complaint of
discomfort and sensitivity in the mandibular left area. After
her medical history was reviewed, a radiograph of the area
was taken, which showed that the mandibular left first molar
was endodontically treated, with over-instrumentation of the
distal root and unsatisfactory obturation on the mesial root. A
large periapical lesion was observed surrounding both roots
(Fig. 1). Root canal therapy had been completed several years
before and the tooth received a full metal crown. Upon
clinical examination, periodontal probing depths did not ex-
ceed 3 mm but the tooth was tender to percussion and pal-
pation. The patient had little interocclusal space because of
limited mouth opening. In view of this limitation and the
patient’s refusal to undergo a more invasive apical surgery,
the intentional replantation technique was indicated as an

e85
 OOOOE
e86 Herrera et al. October 2006

Fig. 1. Periapical radiograph showing the mandibular left Fig. 2. Radiograph exposed immediately after extraction of
first molar with unsatisfactory endodontic therapy. Note the the mandibular left first molar for endodontic treatment.
over-instrumentation and the large apical periodontitis.

alternative. A written informed consent was obtained and the

patient was scheduled for treatment.
At the patient’s return, antisepsis was carried out with
0.12% chlorhexidine gluconate, a mandibular block local
anesthetic was administered, and the tooth was carefully
extracted with forceps with no intraoperative complications
(Fig. 2). The tooth was held in a sterile gauze sponge and the
apices were beveled with a bur. With the tooth out of socket,
access preparation was done through the crown, the old root
filling removed, and the root canals were biomechanically
prepared and obturated. Root end cavities were prepared with
an inverted cone bur and filled with spherical amalgam. The
tooth was rinsed in sterile saline and replanted into its socket
30 minutes after extraction (Fig. 3). A soft periodontal pack- Fig. 3. Mandibular first left molar immediately after inten-
ing was placed as a functional splint. The occlusion was tional replantation.
adjusted and postoperative instructions were given.
The patient returned for clinical and radiographic fol-
low-up at 15 days (at which time the splint was removed), 40 ever, recent long-term studies4,6,12,18,19 have shown that
days, 6 months, 12 months, and once yearly thereafter. The the success rates for intentional replantation are similar to
postoperative period was uneventful. Root surface and peri- those for apical surgery. In the case reported in this article,
odontal ligament appeared intact and the replanted tooth was after 14 years of follow-up there was no evidence of
asymptomatic. Five years after treatment, there were no areas
ankylosis, the replanted tooth displayed normal-appearing
of periradicular bone resorption and the periapical lesion was
completely healed (Fig. 4).
periodontal ligament around the roots, and the patient did
At the last follow-up, after 14 years, the patient reported no not have any painful complaint.
painful symptomatology, probing depth was no greater than 3 The indications for intentional replantation include fail-
mm, and percussion was negative. Radiographically, the ure of root canal treatments, anatomic limitations, perfo-
periradicular area had normal appearance and no evidence of rations in areas inaccessible to surgery, persistent chronic
root resorption or periapical lesion was observed (Fig. 5). pain, or patient management.12,20 In the case we de-
scribed, the patient came to the clinic presenting an un-
DISCUSSION satisfactory endodontic treatment, chronic pain, and sen-
Intentional replantation has some advantages over api- sitivity to percussion and palpation. Intentional
cal surgery, which include being an easier, less-invasive, replantation was chosen as the treatment option on the
less time-consuming, and less-costly procedure. In addi- basis of the clinical indication and the patient’s refusal to
tion, root canal therapy is better performed ex- undergo a periapical surgery. The long-term follow-up
traorally.12,18 On the other hand, the greatest disadvantage confirmed the successful management of the case.
of intentional replantation, which leads most dentists to Splinting is necessary after replantation to reduce
consider this technique as a last resort to save a tooth, is mobility of the tooth and aid the initial periodontal
that replacement resorption or ankylosis may occur. How- healing. However, replanted teeth should be splinted
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Volume 102, Number 4
Fig. 4. Five-year radiographic follow-up.
Fig. 5. Replanted tooth 14 years after intentional replantation. The
tooth exhibits normal periradicular appearance, absence of root
resorption, intact root surface, and normal periodontal ligament.
only for a short period (1 to 2 weeks).4,12 In this case,
a semi-rigid splint was used because a certain amount
of mobility should be allowed for periodontal healing.
Splinting was removed 2 weeks after replantation.
In conclusion, with proper case selection, intentional
replantation can provide long-term results as good as
those of apical surgery and should be more often consid-
ered as a viable treatment option to preserve the natural
Herrera et al. e87
dentition, in situations where other procedures would
likely fail.
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Reprint requests:
Mário Roberto Leonardo, DDS, MSc, PhD
Departamento de Clínica Infantil
Odontologia Preventiva e Social
Faculdade de Odontologia de Ribeirão Preto
USP, Avenida do Café, S/N
14040-904 Ribeirão Preto, SP, Brasil
raquel@forp.usp.br