5.6
Intentional Reimplantation
Rahul Bose and Bhavin Bhuva
Objectives
At the end of this case, the reader should appreciate when intentional reimplantation can be used as a valid treatment option and appreciate the procedural factors that will facilitate a favourable outcome.
Introduction
A 27‐year‐old male was referred by his general dental practitioner (GDP) for endodontic assessment and management of his upper right central incisor (UR1).
Chief Complaint
The patient complained of a severe, constant, dull throbbing ache localised to the UR1. A swelling subsequently developed in the region, which was managed with analgesics and antibiotics prescribed by the patient’s GDP.
Medical History
Unremarkable.
Dental History
There was a history of dento‐alveolar injury at the age of 12. The patient attended annually for dental check‐up appointments and hygienist maintenance.
Clinical Examination
Extraoral examination was unremarkable. The patient had an unrestored dentition and oral hygiene was good.
The UR1 was discoloured (Figure 5.6.1), tender to labial palpation and did not respond to electric or thermal sensibility testing. Both neighbouring teeth (UR2 and UL1) responded to sensibility testing. Periodontal probing depths were within normal limits and there was no associated mobility.
What did the radiographic examination reveal?
A periapical radiograph of the UR1 and UR2 (Figure 5.6.2) showed:
- Alveolar bone height within normal limits.
- UR1 had an intact crown with a subcrestal radiolucency on the mesial cervical aspect of the root; there was incomplete root development with an open apex and evidence of root blunting. A large periapical radiolucency extended from the mesial aspect of the UR1 to the mesial aspect of the UR3.
- UR2 had an intact crown with visible root canal, complete root development, and mature apex; there was an apical radiolucency extending from the mesial aspect of the UR1 to the mesial aspect of the UR3, encompassing the periapex of the UR2.
Cone beam computed tomography (CBCT) of the UR1 and UR2 (Figure 5.6.3) showed the following:
- The coronal view revealed that the UR1 had a subcrestal radiolucency on the mesial cervical margin of the root, with no pulpal communication, a visible root canal, open apex and large periapical radiolucency.
- The axial view demonstrated that the UR1 mesial radiolucency in the root did not extend into the root canal, and the buccal and palatal cortical plates were intact. There was partial loss of the outline of the incisive canal associated with the periapical radiolucency.
- The sagittal view showed that the UR1 had a wide‐open apex, external root resorption at the apex and a large periapical radiolucency with an intact palatal cortical plate.
Diagnosis and Treatment Planning
What was the diagnosis?
Diagnosis for the UR1 was symptomatic apical periodontitis associated with an infected necrotic pulp and external cervical resorption (ECR).
ECR develops in the cervical region of a tooth, as a result of damage to, and/or deficiency of, the subepithelial cementum. The aetiology is unknown, but some predisposing factors include trauma, parafunction, orthodontic treatment, periodontal treatment, dentoalveolar surgery, intracoronal bleaching, playing woodwind instruments, bisphosphonate therapy, varicella zoster virus infection and idiopathic causes. Early lesions can be asymptomatic and can sometimes appear clinically as a pink spot on the cervical margin. Early lesions are more often a chance radiographic finding. To assess the true extent of an ECR lesion, a CBCT scan is required. Lesions can then be classified using the Patel classification for ECR lesions (Table 5.6.1). The classification will help to formulate a treatment plan. This ECR lesion was classified as Patel 2Ap.
What were the treatment options?
- Orthograde root canal treatment followed by external repair and intentional reimplantation (IR).
- Surgical repair of ECR and orthograde root canal treatment.
- Root canal treatment and periodic review (no treatment of ECR).
- Extraction and replacement with single‐tooth implant, resin‐bonded bridge or removable partial denture.
- No treatment.
What are the possible consequences of not treating the tooth?
- Endodontic flare‐up.
- Progression of the ECR lesion with possible perforation into the root canal.
- Fracture (decoronation) of the tooth due to the weakening effect of progressive resorption.
Table 5.6.1 Patel classification of external cervical resorption.
| Height | Circumferential spread | Proximity to the root canal |
|---|---|---|
| 1: At cemento‐enamel junction level or coronal to the bone crest (supracrestal) 2: Extends into coronal third of the root and apical to the bone crest (subcrestal) 3: Extends into mid‐third of the root 4: Extends into apical third of the root |
A: |
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