cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
125
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
126
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
127
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
128
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
129
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
130
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
131
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
132
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
133
REE 18(3) Riobamba sep. - dic. 2024
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
134
REE 18(3) Riobamba sep. - dic. 2024
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
Intentional replantation of a mandibular second molar with atypical internal apical morphology:
A case report
Reimplante intencional de un segundo molar mandibular con morfología apical interna atípica:
Informe de un caso
https://doi.org/10.37135/ee.04.21.10
Authors
Henry Paul Valverde Haro1,2,3 - https://orcid.org/0000-0003-2901-8928
Pablo Andres Parra Martinez1 - https://orcid.org/0000-0002-3896-3684
Adriana Denisse Erazo Conde3 - https://orcid.org/0009-0001-8194-9116
Affiliations
1National University of Chimborazo, Chimborazo, Riobamba, Ecuador
2University of Grande Rio (UNIGRANRIO), Rio de Janeiro, RJ, Brazil.
3ENDOsolutions Research Group , Chimborazo, Riobamba, Ecuador.
Author correspondence: Henry Paul Valverde Haro DDS. MSc. PhD Student in Clinical and
Experimental Dentistry, University of Grande Rio, Rua Professor José de Souza Herdy, 1160 Duke
of Caxias, RJ, Brazil 25071-202. Email: e-mail: endosolutionsec@gmail.com
Recibido: 8 de junio de 2024 Aprobado: 12 de septiembre de 2024
ABSTRACT
Periodontitis after endodontic treatment is mainly caused by a persistent bacterial infection at the
root canal level and in the periradicular tissues. However, there is a 5 % to 15 % prevalence where
bacteria can persist in adequate endodontic treatments that are generally caused by atypical internal
morphologies that prevent the access of instruments and antimicrobial irrigating agents to areas with
anatomical difficulty. This article describes a clinical case of a mandibular second molar with an
atypical apical internal morphology, which presented symptoms associated with canal filling in its
first intervention. The tooth was immediately reimplanted intentionally and fixed with an X-shaped
suture for two weeks. Appropriate intervention with intentional replantation resulted in the resolution
of symptoms and healing of periradicular tissue with clinical and radiographic follow-up for two
years.
Keywords: non-vital tooth, retreatment, endodontics, root canal preparation
RESUMEN
La periodontitis apical después del tratamiento endodóntico es causada principalmente por una
infección bacteriana persistente a nivel del conducto radicular y en los tejidos perirradiculares. Sin
embargo, existe una prevalencia del 5 % al 15 % en donde las bacterias pueden persistir en tratamientos
endodónticos adecuados que son generalmente causados por morfologías internas atípicas que impiden
el acceso de los instrumentos y agentes irrigantes antimicrobianos a las zonas con dificultad anatómica.
Este artículo describe un caso clínico de un segundo molar mandibular con una morfología interna
apical atípica, que presentó síntomas asociados a la obturación del conducto en su primera intervención.
El diente se reimplantó inmediatamente de manera intencional y se fijó con una sutura en forma de
X durante dos semanas. La intervención adecuada con el reimplante intencional dio como resultado
la resolución de los síntomas y la curación del tejido perirradicular con el seguimiento clínico y
radiográfico durante dos años.
Palabras clave: diente no vital, retratamiento, endodoncia, preparación del conducto radicular
INTRODUCTION
Apical periodontitis after endodontic treatment is mainly due to a persistent bacterial infection at the root
canal level and in the periradicular tissues.(1-3) These bacteria have been widely studied and identified by
cultures and advanced molecular methods.(4) Therefore, the persistence of this disease is due to the
accumulation of bacteria in pathogenic biofilms in specific spaces of the root canal and is associated
with inflammatory reactions, extreme pain, abscess formation, and odontogenic cellulitis.(5) However,
there is a prevalence of 5 % to 15 % of teeth in which bacteria can persist after adequate endodontic
treatments, which are generally due to atypical internal morphologies, such as apical branches, lateral
canals, isthmuses, and curvatures that prevent the access of instruments and antimicrobial irrigating
agents to these areas with anatomical difficulties.(6,7)
Endodontic instruments shape and clean the main canal, and it has been shown that due to root anatomy
and instrument characteristics, there are areas of the canal that are not contacted and fail to achieve
proper root canal obturation.(8) Microcomputer tomography studies have reported 10-50 % unprepared
surfaces in small root canals, so root canal cleaning and shaping is always a challenge for even the most
experienced clinician.(9)
Symptoms of such pathologies may be related to the lack of space in the canal system for the
inflammatory exudate to filter and relieve periapical intratissue pressure.(10) Intentional replantation is
an alternative surgical treatment that addresses complex anatomies by resecting the apical 3 mm, with
favorable prognoses reaching 95 % success if modern endodontic surgical principles are used.(11) Today,
translational dentistry is an essential vision for contemporary clinical practice, as it allows the transfer
of science to the clinic and thus preserves dental organs and surrounding tissues. The intentional
replantation presented in the clinical case meets the standards accepted by current literature, where a
fundamental step is appropriately managing the structures without compromising function and
aesthetics. Therefore, this article describes clinical apical periodontitis following primary root canal
treatment. An atypical internal morphology of apical branches was observed in the apical portion,
which caused symptoms when chewing.
CASE PRESENTATION
This clinical case has been written following the recommendations for endodontics (PRICE) 2020
case reports.(12) A 37-year-old female patient of Ecuadorian nationality with no significant medical or
dental history, either personal or family. She came to the consultation due to constant pain at the level
of tooth 37. The patient reported that she had undergone endodontic treatment approximately one
month ago, with symptoms associated with chewing. The initial radiograph showed that the endodontic
treatment was in good condition, and the apical portion had apical deltas sealed with obturating material.
The diagnosis was post-treatment apical periodontitis. Since the anatomical difficulties in the apical
part could lead to failure of non-surgical retreatment, the patient accepted the proposed treatment
plan. After signing the informed consent, the intentional reimplantation procedure was carried out.
An extraction was performed with an atraumatic surgical elevator kit, and the tooth was luxated until
avulsion was achieved. A Zekrya bur was used to trim the apical 3 mm of the tooth. The apical defiling
was performed with an ultrasonic diamond tip until 3 mm of retropreparation of the canal was achieved.
The periodontal ligament fibers were hydrated with irrigation through a saline syringe, and the
remains of gutta-percha were removed. The retro-prepared space was dried with sterile paper cones
and the bioceramic material (BioC Repair, Angelus, Londrina). The bioceramic material was then
packed, and the excess was removed with a small sterile applicator on the root surface, irrigating it
with saline to hydrate the periodontal ligament fibers and remove any remaining bioceramic material.
The tooth was immediately replanted intentionally and fixed with an X-shaped suture for two weeks.
A flowable resin was placed on the occlusal surface to improve suture retention.
A periapical radiograph was taken immediately after reimplantation, and the suture was removed
fifteen days after the procedure. At the monthly control of the intentional reimplantation, there was
no mobility. The patient was satisfied with the immediate results of the treatment and was advised of
the importance of post-endodontic rehabilitation and continued follow-up. Radiographic follow-up
controls showed bone repair in the area where the root resection was performed after six months, one
year, and two years. The patient remained asymptomatic.
Figure 1. – A. Intraoral photograph – B. Alveolus after atraumatic extraction – C. Retropreparation
with ultrasonic tip – D. Retrofilling with bioceramic material – E. Cleaning of excess retrofilling
material – F. Reimplantation and fixation with X-suture.
Figure 2. – A. Initial periapical radiograph – B. Immediate periapical radiograph after reimplantation
control – C. Periapical radiograph after one month after reimplantation control – D. Periapical
radiograph after six months after reimplantation control – E. Periapical radiograph after one year
after reimplantation control – F. Periapical radiograph after two years after reimplantation control.
DISCUSSION
Intentional reimplantation is not a novelty, and since the first case reports(13), it is considered the last
surgical option for preserving teeth with a poor endodontic prognosis.(14) It has been demonstrated to
be effective in solving problems of endodontic origin in areas of difficult surgical access, in the
presence of anatomical difficulties, in patients taking bisphosphonates, and in patients who do not
respond favorably to primary endodontic treatment. However, It is not a routine procedure, and the
periodontal ligament must be preserved so that the tooth's proprioceptive property is not lost.(16) The
reason for intentional reimplantation in this case was that the tooth did not respond to primary
endodontic treatment.
In all replantation procedures, an intentional replantation procedure should be performed, carried out
in the shortest possible time, and a moist environment to preserve the viability of the periodontal
ligament cells.(17)
Andreasen et al.(18) reported that periodontal healing is impaired when alveolar extra time exceeds 5
minutes. Lauridsen et al.(19) demonstrated a 59.4 % prevalence of external root resorption in cases
where alveolar extra time exceeds 20 minutes. Therefore, it is suggested that the extra-alveolar time
of the replanted tooth should not exceed 15 minutes, and that tooth preservation should be carried
out under external humidity conditions with a large amount of saline irrigation, which positively
affects the results of intentional replantation.(15,17)
This case report demonstrates the efficacy of this surgical endodontic technique by the results obtained
in the two years of follow-up, with the absence of clinical symptoms and the stability of the tissues
adjacent to the reimplanted tooth in the clinical and radiographic controls. These results agree with
the previously reported clinical cases in which a high success rate has been demonstrated, with
follow-up periods ranging from two to twenty years.(20-25)
The main limitations of this case report were not being able to perform a non-surgical retreatment
due to the apical anatomical difficulty presented by the molar and not being able to perform a surgi-
cal intervention due to the healthy vestibular cortex that the patient had, a limitation that was overco-
me by performing the intentional reimplantation.
This case report deals with a single-rooted posterior tooth. According to Plotino and colleagues(17),
no significant differences in the survival rates of intentional replantation between single-rooted and
multi-rooted teeth were found. Therefore, the number of roots of the replanted teeth does not significantly
impact the results of the intentional replantation process. However, attention should be paid to possible
anatomical alterations of the root of the treated tooth that may prevent the execution of the atraumatic
extraction process.(26) Another important point is the use of technology in intentional replantation
treatments, such as ultrasonic devices or the operating microscope, which positively influenced the
extra-alveolar stay time and improved the treatment results by reducing the duration of the intentional
replantation procedure, the invasiveness of the procedure, and the failure rates.(27)
In the root resection process, the apical 3 mm with a high-rotation drill of the Zekrya type was removed.
In previous studies, Grossman(28) used rongeur forceps to remove the apical third, while Emmertsen
and Andreasen(29) used carbide discs in their research on root resection. On the other hand, Bender
and Rossman(30) used diamond discs and stones for this procedure. Therefore, 3 mm resection is
recommended to remove 98 % of all apical branches and 93 % of lateral canals. Failure to remove
these canals altogether may lead to treatment failure in the future.(31,32)
Another critical stage of the intentional replantation procedure is retrograde sealing. The present case
report used a premixed bioceramic (BioC Repair, Londrina, Brazil), which is a reformulated material
with an easy-to-handle consistency that has hydrophilic characteristics that allow its use in operating
environments with blood contamination, resulting in an optimization of working time and more
significant long-term stability.(33) A Study has determined that this material also has genocompatibility
and is not cytotoxic in osteoblastic cells.(34) Abrao et al.(35) have used mineral trioxide aggregate
(MTA) cement for several years, chosen for being biocompatible, osteoinductive, and antimicrobial,
with excellent sealing power, dimensional stability, hardness, and slight expansion. However, MTA
has some negative characteristics, such as staining of dentin, difficulty in mixing due to its sandy
consistency, which can cause waste of the material, and poor dispersion, which causes high porosity.(36)
Regarding follow-up, in the present case, the bone remodeling process is continuously observed from
six months to two years of follow-up. This is a favorable point for the success and the periapical
health status of the tooth treated with intentional reimplantation. Javed et al.(37) mention that from
twelve months onwards, it is possible to identify the survival or healing of the lesions associated with
intentional reimplantation for a follow-up period of three to four years, during which the complete
neoformation of bone tissue in the apical region is observed.
CONCLUSIONS
This case report presents an unusual case of a mandibular second molar with an atypical apical internal
morphology that exhibited symptoms associated with canal obturation at its first intervention.
Following the appropriate intervention, which consisted of intentional replantation, the symptoms
resolved, and the periradicular tissue healed, as reflected by clinical and radiographic follow-up.
Acknowledgements
Thanks to the team at the ENDOsolutions endodontic clinic.
Funding
This case report has been self-funded.
Conflict of interest
The authors declare no conflict of interest.
Contribution
Conceptualization: HP Valverde, AD Erazo. Analysis of clinical data, execution of treatment, performed
radiographic examinations, and interpretation of imaging findings: HP Valverde. Formal analysis of
literature: HP Valverde, PA Parra, AD Erazo. Writing of the original draft: HP Valverde, PA Parra,
AD Erazo. Review and editing of writing: HP Valverde, AD Erazo.
REFERENCES
1. Siqueira JF, Rôças IN, Ricucci D, Hülsmann M. Causes and management of post-treatment
apical periodontitis. British Dental Journal. 2014 [accessed on 15 May 2024];216(6):305-312.
Available online: https://www.nature.com/articles/sj.bdj.2014.200.
2. Antunes HS, Rôças IN, Alves FRF, Siqueira JF, Jr. Total and Specific Bacterial Levels in the
Apical Root Canal System of Teeth with Post-treatment Apical Periodontitis. Journal of
Endodontics. 2015 [accessed on 15 May 2024];41(7):1037-1042. Available online:
https://www.jendodon.com/article/S0099-2399(15)00240-X/abstract.
3. Provenzano JC, Antunes HS, Alves FRF, Rôças IN, Alves WS, Silva MRS, et al. Host-Bacterial
Interactions in Post-treatment Apical Periodontitis: A Metaproteome Analysis. Journal of
Endodontics. 2016 [accessed on 16 May 2024];42(6):880-885. Available online:
https://www.jendodon.com/article/S0099-2399(16)30022-X/abstract.
4. Zandi H, Kristoffersen AK, Ørstavik D, Rôças IN, Siqueira JF, Jr., Enersen M. Microbial
Analysis of Endodontic Infections in Root-filled Teeth with Apical Periodontitis before and
after Irrigation Using Pyrosequencing. Journal of Endodontics. 2018 [accessed on 16 May
2024];44(3):372-378. Available online: https://www.jendodon.com/article/S0099-2399(17)
31264-5/abstract.
5. Shin JM, Luo T, Lee KH, Guerreiro D, Botero TM, McDonald NJ, et al. Deciphering Endodontic
Microbial Communities by Next-generation Sequencing. Journal of Endodontics. 2018
[accessed on 17 May 2024];44(7):1080-1087. Available online: https://www.jendodon.com/
article/S0099-2399(18)30241-3/abstract.
6. Siqueira JF, Jr., Antunes HS, Pérez AR, Alves FRF, Mdala I, Silva EJNL, et al. The Apical
Root Canal System of Teeth with Post-treatment Apical Periodontitis: Correlating Microbiologic,
Tomographic, and Histopathologic Findings. Journal of Endodontics. 2020 [accessed on 18
May 2024];46(9):1195-1203. Available online: https://www.jendodon.com/article/S0099-
2399(20)30383-6/abstract.
7. Hernández SR, Siqueira JF, Jr., Voigt DD, Soimu G, Brasil SC, Provenzano JC, et al.
Bacteriologic Conditions of the Apical Root Canal System of Teeth with and without
Posttreatment Apical Periodontitis: A Correlative Multianalytical Approach. Journal of
Endodontics. 2024 [accessed on 19 May 2024];50(2):154-163. Available online:
https://www.jendodon.com/article/S0099-2399(23)00723-9/abstract.
8. Kalantar Motamedi MR, Mortaheb A, Zare Jahromi M, Gilbert BE. Micro-CT Evaluation of
Four Root Canal Obturation Techniques. Scanning. 2021 [accessed on 20 May 2024]; 2021:
6632822:1-7. Available online: https://onlinelibrary.wiley.com/doi/10.1155/2021/6632822.
9. Siqueira Junior JF, Rocas IDN, Marceliano-Alves MF, Perez AR, Ricucci D. Unprepared
root canal surface areas: causes, clinical implications, and therapeutic strategies. Braz Oral
Res. 2018 [accessed on 20 May 2024];32(1):2-19. Available online: https://www.scielo.br/j/
bor/a/8p3bLKhhjcrzryGhQxQBBLc/?lang=en.
10. Villa-Machado PA, Restrepo-Patiño DM, Calvo-Trejos JP, Restrepo-Restrepo FA,
Tobón-Arroyave SI, Provenzano JC, et al. Cone-beam Computed Tomographic and
Micro-computed Tomographic Evaluations of the Root Apexes of Teeth with Post-treatment
Apical Periodontitis. Journal of Endodontics. 2020 [accessed on 20 May 2024];46(11):
1695-1701. Available online: https://www.jendodon.com/article/S0099-2399(20)30496-9/
abstract.
11. Becker BD. Intentional Replantation Techniques: A Critical Review. Journal of Endodontics.
2018 [accessed on 20 May 2024];44(1):14-21. Available online: https://www.jendodon.com/
article/S0099-2399(17)30944-5/fulltext.
12. Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020
guidelines for reporting case reports in Endodontics: a consensus-based development. Int
Endod J. 2020 [accessed on 20 May 2024];53(5):619-626. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13285.
13. Sheikhnezami M, Azarpazhooh A, Mokhber A, Shamsian K, Bagheri M, Jafarzadeh H. The
Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor:
A TurboReg Analysis of a Case. J Clin Pediatr Dent. 2022 [accessed on 20 May 2024];46(3):
183-187. Available online: https://www.jocpd.com/articles/10.17796/1053-4625-46.3.2.
14. Asgary S, Parhizkar A. Healing of a large endodontic lesion due to a procedural accident
using intentional replantation; a case report. J Dent Sci. 2023 [accessed on 20 May 2024];
18(3):1414-1416. Available online: https://www.sciencedirect.com/science/article/pii/
S1991790222003038?via%3Dihub.
15. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Present
status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.
Int Endod J. 2022 [accessed on 20 May 2024];55(3):827-842. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/iej.13723.
16. Marouane O, Turki A, Oualha L, Douki N. Tooth replantation: an update. Med Buccale Chir
Buccale. 2017 [accessed on 20 May 2024];23(2):103–110. Available online: https://www.jomos.
org/articles/mbcb/pdf/2017/02/mbcb150072.pdf
17. Pisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional
Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthcare
(Basel). 2022 [accessed on 20 May 2024];11(1):1-17. Available online: https://www.mdpi.com/
2227-9032/11/1/11.
18. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent
incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995
[accessed on 20 May 2024];11(2):76–89. Available online: https://doi.org/10.1111/j.1600-
9657.1995.tb00464.x.
19. Lauridsen E, Andreasen JO, Bouaziz O, Andersson L. Risk of ankylosis of 400 avulsed and
replanted human teeth in relation to length of dry storage: a re-evaluation of a long-term clinical
study. Dent Traumatol. 2020 [accessed on 20 May 2024];36(2):108–116 Available online:
https://doi.org/10.1111/edt.12520.
20. Huang JW, Gan YN, Xu H, Han S, Zhu H, Jia L, et al. Tooth intentional replantation from 1964
to 2023: A bibliometric analysis. Dent Traumatol. 2024 [accessed on 20 May 2024];40(1):
121-132. Available online: https://onlinelibrary.wiley.com/doi/10.1111/edt.12884.
21. Chaniotis A, Kouimtzis TH. Intentional replantation and Biodentine root reconstruction. A
case report with 10-year follow-up. Int Endod J. 2021 [accessed on 20 May 2024];54(6):
988-1000. Available online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13475.
22. Chiu YL, Chiang CP, Lee MS, Ho CJ. Intentional replantation - A case report with 20-year
follow-up. J Dent Sci. 2023 [accessed on 20 May 2024];18(1):453-455. Available online:
https://www.sciencedirect.com/science/article/pii/S1991790222002203?via%3Dihub.
23. Moura LF, Lima MD, Moura MS, Carvalho PV, Cravinhos JC, Carvalho CM. Treatment of a
crown-root fracture with intentional replantation - case report with 16-year follow-up. Int
Endod J. 2012 [accessed on 18 May 2024];45(10):955-960. Available online: https://onlinelibrary.
wiley.com/doi/10.1111/j.1365-2591.2012.02078.x.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 18
Número 3
135
REE 18(3) Riobamba sep. - dic. 2024
24. Niavarzi S, Noori F, Sheikhrezaei MS, Ghabraei S. Diagnosis and Treatment of an Incomplete
Crown-Root Fracture with Intentional Replantation: A Case Report. Front Dent. 2022 [accessed
on 20 May 2024];19(24):1-6. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC9675627/.
25. Okamoto M, Asahi Y, Duncan HF, Kuriki N, Takahashi Y, Hayashi M. Repair of an Extensive
External Cervical Resorption Lesion Using Intentional Replantation with Crown Rotation. Case
Rep Dent. 2023 [accessed on 18 May 2024]; 2023:2103999:1-10. Available online: https://onlinelibrary.
wiley.com/doi/10.1155/2023/2103999.
26. Wang Y, Hofmann M, Ruf S, Zhang J, Huang Q. Intentional replantation and dental autotrans
plantation of mandibular posterior teeth: Two case reports. Medicine (Baltimore). 2023 [ accessed
on 17 May 2024];102(46):1-6. Available online: https://journals.lww.com/md-journal/fulltext/
2023/11170/intentional_replantation_and_dental.1.aspx.
27. Plotino G, Abella Sans F, Duggal MS, Grande NM, Krastl G, Nagendrababu V, et al. Clinical
procedures and outcome of surgical extrusion, intentional replantation and tooth autotransplantation-
a narrative review. Int Endod J. 2020 [accessed on 19 May 2024];53(12):1636-1652. Available
online: https://onlinelibrary.wiley.com/doi/10.1111/iej.13396.
28. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc. 1966 [accessed on 19 May
2024];72(5):1111–1118. Available online: https://doi.org/10.14219/jada.archive.1966.0125.
29. Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological
study. Acta Odontol Scand. 1966 [accessed on 19 May 2024];24(3):327–46. Available online:
https://doi.org/10.3109/00016356609028225.
30. Bender IB, Rossman LE. Intentional replantation of end- odontically treated teeth. Oral Surg
Oral Med Oral Pathol. 1993 [accessed on 19 May 2024];76(5):623–30. Available online:
https://doi.org/10.1016/0030-4220(93)90073-D.
31. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with
root end resection and retro- grade filling. J Endod. 1994 [accessed on 19 May 2024];20(1):22–6.
Available online: https://www.jendodon.com/article/S0099-2399(06)80022-1/abstract.
32. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod.
2006 [accessed on 19 May 2024];32(7):601–23. Available online: https://doi.org/10.1016/j.joen.
2005.12.010.
33. Klein-Junior CA, Zimmer R, Dobler T, Oliveira V, Marinowic DR, Ozkomur A, et al. Cytotoxicity
assessment of Bio-C Repair Ion+: A new calcium silicate-based cement. J Dent Res Dent Clin
Dent Prospects. 2021[accessed on 18 May 2024];15(3):152-156. Available online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8538145/.
34. Ghilotti J, Sanz JL, Lopez-Garcia S, Guerrero-Girones J, Pecci-Lloret MP, Lozano A, et al.
Comparative Surface Morphology, Chemical Composition, and Cytocompatibility of Bio-C
Repair, Biodentine, and ProRoot MTA on hDPCs. Materials (Basel). 2020 [18 May 2024];13(9):
1-13. Available online: https://www.mdpi.com/1996-1944/13/9/2189.
35. Abrao SMS, Gregorio D, Azevedo MKC, Mori GG, Poli-Frederico RC, Maia LP. Cytotoxicity
and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA
Repair HP. Braz Dent J. 2023 [accessed on 20 May 2024];34(2):14-20. Available online:
https://www.scielo.br/j/bdj/a/hyfbVyBv8dMqpzNVdm53DBr/?lang=en.
36. Queiroz MB, Inada RNH, Jampani JLA, Guerreiro-Tanomaru JM, Sasso-Cerri E, Tanomaru-Filho
M, et al. Biocompatibility and bioactive potential of an experimental tricalcium silicate-based
cement in comparison with Bio-C repair and MTA Repair HP materials. Int Endod J. 2023
[accessed on 19 May 2024];56(2):259-277. Available online: https://onlinelibrary.wiley.com/
doi/10.1111/iej.13863.
37. Javed F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth
with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2022 [29 Jul
2024]; 00:1–14. Available online: https://doi. org/10.1111/aej.12707.
