The replacement of a tooth that has been removed from the alveolar socket, either intentionally or by accident, is called

replantation. Replantation of avulsed teeth can be divided into two categories: those that are replanted within a short time (or preserved in a storage medium) and those that are replanted after a delay during which the periodontal membrane attached to the root has dried. In this chapter, consideration is also given to wound healing that involves both pulp and periodontal ligament tissue. Intentional replantation and transplantation of teeth have had a long and troublesome history. Despite experimental investigations initiated by Hunter as early as 1771. the time was not ripe for a break-through in this area, primarily because of a lack of knowledge about the etiology of root resorption and control of infection. However, extensive research particularly in the past two decades into the etiology and pathogenesis of root resorption , wound healing processes in the pulp and periodontium, and how these relate to infection, has made replantation and intentional replantation ot teeth predictable. These operations can thus be added to the dental armamentarium, while at the same time challenging the various dental specialties to broaden their horizons for new treatment potentials. In orthodontics, autotransplantation of teeth can add a new dimension to treatment planning. Instead of considering limited tooth movements w i t h i n one segment of the dental arch, a freedom of movement has been achieved in many situations where teeth can be placed exactly where the need dictates, whether it be in remote regions of the same jaw or in the opposing dental arch. Furthermore, banking for later use of premolars which must be extracted is now possible, for example where doubt exists about the prognosis of traumatized or endodontically treated anterior teeth. The orthodontic profession is thus challenged to outline indications for these new treatment possibilities. In periodontics, replantation of avulsed teeth has been an unreliable procedure. Recent advances in the knowledge of wound healing which takes place after

replantation of teeth has improved the predictability of these procedures and significantly increased their success rate. In addition, the unfortunate situation often faced that traumatized anterior teeth cannot be saved can now often be remedied by autotransplantation of premolars and later recontouring with a composite technique, a treatment which in some cases is to be preferred over fixed or removable prosthetic appliances. In endodontics, intentional replantation has been the last chance lor teeth which could not be treated adequately by conventional or surgical endodontic procedures. Another treatment approach, namely autotransplantation of premolars and third molars as replacements for unsalvageable teeth with endodontic complications, is now another feasible alternative. In prosthodontics. teeth can now in selected cases be placed exactly where the need dictates. In this context, the auto or allotransplantation must be carefully evaluated in light of various implant techniques. The latter procedure, however, is usually not indicated in young individuals due to the interference with growth of the alveolar process. In oral surgery traditional techniques for the removal of impacted teeth have aimed at not traumatizing the alveolus in order to promote socket healing. These techniques have for obvious reasons given no consideration to the preservation of a vital pulp, periodontal ligament, or dental follicle and as such must be altered radically when teeth are to be transplanted. A great challenge now in oral surgery is. therefore, the development of techniques which allow maximum cell survival in and around the potential transplant. The prerequisite for successful replantation and autotransplantation of teeth is a thorough know ledge of responses of the pulp and periodontium to injury and the healing capacities of both of these tissues. In a sense, autotransplantation of teeth can be considered as an intentional, controlled dental trauma. The knowledge

accumulated over the years in dental traumatology can in most situations be applied directly to autotransplantation of teeth. Thus, denial traumatology and dental transplantation are in fact two sides of the same coin, one being forced upon an individual, causing more or less damage, the other being an intentional trauma used to repair the earlier damage or remedy a difficult treatment problem. Especially the latter situation requires a thorough cost benefit analysis to ensure that the advantages of this type of therapv outweigh the potential complications.

Examination & diagnosis In avulsion, the periodontal membrane is separated; half is attached to root & the other half is to alveolus. Vitality of the periodontal membrane attached to the root is important for the success of replanted tooth. When exposed to air, periodontal ligament dries & become necrotic. After 30 minutes of dryness, the chance of recovery significantly reduces. Endodontic treatment should be delayed in an immature tooth because the pulp may revascularize after replantation. So, careful postoperative observation is necessary. In the case of delayed replantation, there is a definite difference in results depending on the patient's age. In children, delayed replantation is

usually not successful long term, making it important to discuss options thoroughly with the child's parents.

Treatment Plan Replantation should be attempted whenever possible. However, the healing mechanisms of immediate replantation and delayed replantation are different. In immediate replantation, the replantation is given priority over endodontic treatment. In delayed replantation, endodontic treatment is performed outside the oral cavity with a calcium hydroxide preparation before the tooth is replanted. In delayed replantation, the periodontal membrane is considered necrotic. Treatment Procedures Immediate replantation Immediate replantation is performed when the periodontal membrane of an avulsed tooth is considered vital. Replantation within 45 minutes of avulsion is considered immediate replantation. If the tooth is preserved in milk or in a preservative solution and is replanted within 24 hours, that is also considered immediate replantation.
1. Preservation of the avulsed tooth: When a patient calls to report an avulsion, give

clear instructions about what to do with the tooth. It may be preserved in milk, in the mouth, or in a commercial preservative solution. During the office visit, preserve the avulsed tooth in a physiologic saline solution .
2. Examination and diagnosis: Inspect the tooth and mouth, obtain the history, and

perform a radiographic examination to determine the condition of the surrounding alveolus .

3. Cleansing of the avulsed tooth: If it is difficult to remove contaminants from the

periodontal membrane, use an ultrasonic cleaner with physiologic saline solution for 3 minutes. Be sure to wrap the tooth with gauze. For a severely contaminated

tooth, use the ultrasonic scaler for debridement of the root surface while irrigating with physiologic saline solution, removing only the contaminant (within 30 seconds) .
4. Cleansing of the alveolus: Irrigate blood clots from the alveolar socket. 5. Replantation and splinting: Place the avulsed tooth gently into the socket and

splint it. If the adaptation between the replanted tooth and gingiva is poor, suture the gingiva to achieve close adaptation of the gingiva and cervical region. Use an orthodontic twisted wire (3M Unitek) and conventional adhesive resin for splinting . Avoid splinting too tightly; persistent pressure to the replanted tooth may affect the outcome.
6. Endodontic treatment: In a mature tooth, endodontic treatment begins before splint

removal (1 to 2 weeks after replantation). Use a calcium hydroxide preparation (Vitapex, Neo) for the initial filling and monitor the periodontal healing . In an immature tooth, wait until pulp necrosis can be confirmed, because pulp tissue may revascularize. If inflammatory root resorption is noted, begin endodontic treatment immediately.
7. Splint removal and follow-up: Remove the splint after 2 to 3 weeks . Examine

carefully for any root resorption and pulp necrosis .

8. Final root canal filling: Following the initial treatment of an avulsed tooth with

necrotic pulp, use sealer and gutta-percha points for final root canal filling after confirming apical closure .
9. Bleaching and restorative treatment: Bleach the tooth if necessary. Discoloration

is common in nonvital teeth. Use composite resin to fill the lingual access. Continue to monitor the tooth.

Delayed replantation

Delayed replantation is the replanting of an avulsed tooth with a necrotic periodontal ligament. Even in delayed replantation, the tooth should be replanted at the initial visit if possible . The more advanced the healing of the alveolus, the more difficult replantation and desired healing becomes .
1.

Cleansing of the avulsed tooth: Use ultrasonic cleansing with physiologic

saline solution. If it is difficult to remove the contaminant, use an ultrasonic scaler. However, do not remove periodontal ligament fibers from the root surface . Removing collagen fibers from the root surface by root planing may cause pocket formation and gingival recession after replantation. It may also reduce the longevity of the replanted tooth .
2.

Extraoral endodontic treatment: In delayed replantation, perform endodontic

treatment before replanting the tooth. Perform conventional enlargement and cleansing of the root canal and fill with a calcium hydroxide preparation . Calcium hydroxide aids asepsis of the root canal.
3.

Curettage and cleansing of the alveolar socket: Perform curettage and Replantation and splinting: Replant and splint the tooth . Complete endodontic treatment: In a mature tooth, replace the calcium

irrigation to remove blood clots and granulation tissue from the socket.
4.

5. Removal of splint: Remove the splint after about 4 weeks.

6.

hydroxide preparation with sealer and gutta-percha. In an immature root, leave the calcium hydroxide preparation or fill the canal with calcium hydroxide again, if necessary.
7.

Prognosis: The goal of delayed replantation is ankylosis; therefore, it is

important to understand the rate at which root resorption occurs .. The speed of root resorption due to ankylosis differs prepuberty and postpuberty. In prepuberty patients (during growth and development), the root will be resorbed in approximately 2 years . In postpuberty patients (after growth and development), root resorption may take more than 10 years . If ankylosis occurs in pubescent patients (when growth and development gradually cease), unesthetic conditions and poor function will result.

This is called infraocclusion . In such cases, the coronal part of the replanted tooth should be removed to the level of the cervical line.
8.

Treatment of resorbed replanted tooth: When a replanted tooth is lost due to

root resorption, choose a treatment such as autotransplantation of another tooth if one is available, an implant, or movement of teeth orthodontically to recover esthetics and function. The choice of treatment requires careful patient evaluation. Intentional replantation It is really a surgical rather than an emergency endodontic procedure. However, because the sequelae, splinting, and other procedures are often similar to those employed during a replantation that follows traumatic injury, intentional replantation will now be described. Intentional replantation implies that a tooth requiring endodontic treatment is purposely removed from its alveolar housing, Therefore the indications for intentional replantation would include situations described as follows: 1.
2.

When routine endodontic treatment of teeth is unpractical or impossible, as in When an obstruction of a canal is present, such as a broken instrument or a

patients who are unable to keep their mouths open for the necessary length of time calcification, or a periapical radiolucency is present, yet routine surgery is impractical, as in a lower molar with the mandibular canal in proximity
3.

When perforating internal or external resorption is present, yet surgery is When a foreign body, such as molten metal, is in the periodontal ligament or When previous treatment has failed but nonsurgical retreatment or surgery is

impractical 4.
5.

periapical tissue but surgery is impractical impractical some type of canal or apical preparation and/or filling is performed, and the tooth is returned to its original socket. Reattachment after replantation

a. Before replantation. There is periodontal membrane both in the alveolus and on the avulsed

b. Immediately after replantation. Reattachment of periodontal fibers occurs between the fibers of the periodontal membrane attached to the root surface and those from the gingival connective tissue and alveolar .socket.

c. After healing

Wound Healing in Replantation Healing of the periodontal membrane (reattachment and new attachment) Healing of the periodontal membrane after replantation is by reattachment. The ideal reattachment is the reorganization of connective tissue from the periodontal membrane attached to the root surface and gingival connective tissue or periodontal membrane tissue of the alveolus in a relatively short period of time (about 2 weeks). Usually, coronal to the alveolar bone margin, reattachment of the gingival connective tissue and periodontal membrane of the root occurs in 2 to 7 days. In the alveolus,

reattachment occurs in 2 weeks". If there is no healthy periodontal membrane on the replanted tooth, normal reattachment cannot occur. In replantation of a tooth with a partially missing vital periodontal membrane, the healing of the membrane requires new attachment."65-,The new attachment develops from regeneration of periodontal membrane tissue with deposition of cementum.Therefore, most of the periodontal healing after replantation depends on reattachment and healing of partially missing periodontal membrane by new attachment. Extensive periodontal membrane damage or necrosis of a replanted tooth, however, results in root resorption.

a Experimental removal of periodontal tissue with a fenestration from the oral vestibule and removal of alveolar bone, periodontal membrane, and cementum to prepare a small cavity in the dentin.b During healing. Cells proliferate from the surrounding periodontal membrane and invade the cavity in the dentin. c After healing. The periodontal membrane tissue regenerates while depositing cementum in the cavity. The bone tissue regenerates from the periphery. There is new attachment between the periodontal membrane and the bone tissue. Pulpal treatment and root development In an immature tooth, pulpal healing and root growth can be expected after replantation. Pulp tissue becomes ischemic after tooth avulsion. However, in case of a wide apex (more than 1 mm), it is possible for blood vessels to proliferate into the pulp cavity after replantation.'"71 Blood vessels and pulp cells near the apex (inside

Hertwig's epithelial sheath) proliferate coronally .This proliferation proceeds at about 0.5 mm a day,7 and the pulp cavity will be filled with vital tissue a few months after replantation. However, this regenerated pulp tissue rarely functions as before, and pulp canal obliteration occurs due to rapid deposition of hard tissue (osteodentin). The pulp may respond positively to the electric pulp test immediately after obliteration, but its future is uncertain. Also, in cases where Hertwig's epithelial sheath . at the apex is vital, root growth can be expected after replantation .However, it is impossible to predict how much root there will be compared to normal development.
Pulp healing

a. Avulsion of an immature tooth. The pulp changes ischemically.

b. During healing. After replantation, blood capillaries proliferate and invade the pulp cavity from the apex, growing coronally.

c. After healing. Proliferated pulp tissue in the pulp cavity calcifies rapidly, and the pulp cavity is obliterated.

Phantom root and inner periodontal ligament When there is trauma to the apical region of a developing root and Hertwig's epithelial root sheath is separated from the apex, a phantom root or inner PDL may develop ."~ ' Hertwig's epithelial root sheath cells, which originally formed the enamel epithelium, differentiate and reorganize to regenerate new tooth germs; therefore,a phantom root develops Tooth which was strategically extracted for orthodontic treatment, and two pieces of phantom roots. There is coronal formation on one phantom root thought to be enamel. During extraction, the area of inner PDL and the osseous tissue in the pulp cavity were removed Another outcome following replantation of immature teeth is the invasion of periodontal membrane tissue and osseous tissue into the pulp cavity , producing an inner PDL. The periodontal membrane tissue invades the pulp space apically and migrates coronally while depositing cementum. Osseous tissue also grows into the pulp space coronally

Classification and mechanism of root resorption If there is partial or complete necrosis of the periodontal membrane of a replanted tooth, root resorption occurs after replantation. Root resorption may be surface resorption, replacement resorption, or inflammatory resorption". Currently, it is thought that osteoclasts participate in the resorption of hard tissue such as root or bone and its mechanism continues to be elucidated" .Osteoclasts have two primary roles, physiologic remodeling of bone and defense of the body.Following are explanations

of the mechanism of each type of root resorption' ''J and treatment

Surface resorption. Surface resorption is limited to cementum, and repair occurs during the repair process of reattachment . It is a generic term of a transient root resorption. Provided the stimulus for resorption (bacteria) is removed, the surface resorption will be repaired. If the bacterial stimulation is not removed, surface resorption will proceed to either replacement resorption or inflammatory resorption.

Replacement resorption. In this condition, which is also called ankylosis, bone and root are fused. This phenomenon can be seen both histologically and radiographically. The mechanism of replacement resorption of a tooth is remodeling with osseous tissue. In other words, it is caused by the coupling phenomenon where root resorption by osteoclasts lying in osseous tissue and bone deposition by osteoblasts occur simultaneously." Therefore, the speed of replacement resorption correlates to the remodeling speed of bone (fast in young people and slow in adults). Approximately 50% of bone remodeling occurs in 1 year in children (prepuberty), while approximately 2% occurs in adults (postpuberty).Age greatly affects the success rate of delayed replantation. Cases of ankylosis in children show that roots are resorbed within a few years , a process that can take more than 10 years in adults .Long-term esthetics and function, therefore, can be maintained in delayed replanted teeth in adults. If ankylosis occurs after delayed replantation in pubescent patients (boys, 12 to 15 years; girls, 11 to 14 years), esthetics and function may be affected by infraocclusion . Vertical growth of alveolar bone depends mainly on tooth eruption.'4 With ankylosis, the tooth will not erupt and the alveolar bone will not grow. The degree of infraocclusion is affected by the patient's age; the younger the age, the

greater the degree of infraocclusion . In such cases, it is possible to recover normal alveolar height by reducing the ankylosed tooth crown to the level of the bone margin Inflammatory resorption. In a tooth with pulp necrosis, when cementum is resorbed by osteoclasts in an area of missing or necrotic periodontal membrane, dentinal tubules are exposed.95'"' Necrotic material and bacteria from the pulp cavity reach the root surface through the exposed dentinal tubules, and an inflammatory response occurs. Root resorption is advanced by osteoclasts which emerge as the inflammatory process spreads.Histologically, granulation tissue is present in the root resorption area, and, radiographically, radiolucencies are observed. The speed of inflammatory resorption is affected by the degree of infection; how ever, it is relatively fast regardless of age. Resorption continues until the cause of infection is removed, which can be accomplished by root canal treatment.Following root canal treatment, new attachment can be expected if periodon tal membrane cells invade the resorption areas.The same condition as in surface resorption will result, and root resorption will be contained.However, in cases of large resorption areas where osseous tissue reaches the root surface, inflammatory resorption may shift to replacement resorption. In such cases, the entire root may be resorbed.

Surface resorption

replacement resorption

inflammatory resorption

Preservation of periodontal membrane Methods for the preservation of the periodontal membrane in avulsed teeth Studies show positive results using storage media for preserving periodontal membrane cells outside the oral cavity.'" Periodontal membrane on the root surface can survive when it is left in a dry condition for up to 18 minutes, more than half die in 30 minutes, and most die in 120 minutes Most periodontal membrane cells live for 120 minutes in physiologic saline solution; however, they will die before 120 minutes in water. Hank's Balanced Salt Solution (HBSS). Best information at this time seems to indicate that HBSS is a very favorable transport medium for the avulsed tooth. A retrospective study reported by Krasner and Person (Krasner is the originator for the use of this product in endodontics) indicated that the solution was highly successful when used in 85.3% of replantation cases. HBSS contains sodium chloride, glucose, potassium chloride, sodium bicarbonate, sodium phosphate, calcium chloride, magnesium chloride, and magnesium sulfate. It has been used in the past as a tissue culture support for mammalian tissues and has demonstrated the ability to preserve and reconstitute the cells of the periodontal ligament. Krasner has developed an avulsed tooth storage system, named the Emergency Tooth Preserving System* (ETPS), which contains HBSS. a net for holding the tooth atraumatically, and a container for bringing the submerged tooth to the dentist. This system is available to schools, gymnasiums, park district fieldhouses, and other sites where tooth trauma may occur. Unquestionably. HBSS and the transporting system are valuable in treating avulsion cases. Still, I have some reservations concerning its use. Present information strongly indicates that the best chance for success is by immediate replantation at the site of trauma. The transporting system should be used only when such a procedure is not possible.

In the suggestions for use of the ETPS. soaking of the tooth in HBSS before reinsertion is suggested in certain cases. I believe that this is acceptable if the tooth has been allowed to dry out. but if the tooth has been handled properly and is moist, it is better to keep the extraoral time to a minimum and replant as soon as possible without soaking. Saliva. In a sense, the patient's own saliva is the best transport medium for an avulsed tooth. Favorable reports on using it have been published, and the logic for its use and its availability are obvious. After trauma to the face and jaws, youngsters generally drool saliva and blood constantly. Often a child comes to the dental office after any trauma to the mouth with a dish or hand towel around his or her neck to absorb this constant flow. There is no problem collecting several inches of saliva, tinged with blood, in a cup or small juice glass and then dropping the tooth into this very biologic liquid. Also, it has been suggested that when the tooth cannot be replanted at the site of injury and acceptable transport media are not present, it be placed in the patient's mouth or under the tongue. This method has received favorable reports. In such cases the transport medium being used successfully is saliva. For such a method for transporting to be considered, the patient must be an older child or adult. If the child is young, is unreliable, or has a severe gag reflex, there is too great a chance for swallowing the tooth on the trip to the dentists office. Milk. Andreasen favors milk over saliva as a transport medium. Many accidents that cause an avulsion occur related to athletics: on a baseball field, football field, playground, or gym. Except for when an accident happens in the home, milk is not readily available, whereas saliva is always present. Also, milk may contain many antigens that could act negatively from an immunologic standpoint on the reattachment process. Water. If no other acceptable transport medium is present, water is the liquid of last resort, but water is not the best liquid for transport.

Prognosis for intentional replantation. The outlook for an intentionally replanted tooth is superior to that for a traumatically avulsed replanted tooth. The time during which the tooth is out of the mouth, which is certainly critical, is greatly reduced and the replant is kept moist during the needed manipulation. Venting is provided by the trimming of the root end or curettage of the periapical area. No curettage of the periodontal ligament attached to the tooth is performed. Therefore all the criteria for successful replantation are adhered to. which is not always the case after trauma. Conclusion However,replantation should be considered as a last attempt to keep the alveolar bone,not as a primary endodontic treatment. The success of replantation depends on the time span of tooth remained outside the socket,the storage media used & management of the tooth and the socket done by the dentist.further endodontic or periapical treatment should be planned accordingly to

References 1.Endodontic therapy by Franklin S Weine 2.Endodontics by Ingle,4th edition