Extraction and Replantation

Extraction and Replantation

To retain a tooth that Is considered nontreatable by conventional i nonsurgical) and/or surgical endodontic procedures.
Conventional treatment problems that often require surgical inter­vention include the following:
• Inadequate interocclusal space in which to gain access to the canals (eg, microstomia, trismus)
• Canals that are impossible to instrument
• Canals that resist disinfecting regimens
• Repeated exacerbations
• Continued and uncontrollable pain during and/or after treat-
• Asymptomatic lesions that continue to expand in size after
Problems that often preclude surgical treatment include the following
• Access to the problem is difficult (eg, perforation or resorption of interproximal root surfaces or lingual aspects of mandibular teeth)
• The bone is high, thick, and/or dense (eg, the external oblique ridge buccal to mandibular second and third molars)
• The risk to strategic anatomical structures (eg, palatal or mandibular vessels or proximity to adjacent roots) is unjustifi­able
• A severe periodontal problem exists and/or the removal of bone to gain access would leave the patient with an unbeatable peri­odontal problem.
• Previous apicoectomies have failed.
• The patient's medical condition prohibits a
ong surgical approach.
#15C Scalpel blade (Bard-Parker)
#12D Scalpel blade (Bard-Parker)
#5 Scalpel handle (Hu-Friedy)
E#301, E#302. E#303 Elevators (Hu-Friedy)
FX#13, FX#17, FX#33, FX#73, FMD#4, F#10S Forceps (Hu-Friedy)
#1. #2 Round burs (Brassier)
#701, #558 Fissure burs (Brassier)
Retrofill instruments (EIE Analytic Technology)
Suture setup
Sutures (Tevdek)
#18 Iris scissors (Hu-Friedy)
Mathieu-Kocher Perma-Sharp needle holder
1. The canals are cleansed, shaped, and filled with gutta-percha as well as possible. Some initial lift can be expected postsurgically, so it is advisable to take the tooth completely out of occlusion prior to extraction.
2. The gingival attachment is incised with a
scalpel (Fig 1-1 a)
3. A firm, carefully directed, continuous force is applied to an appropriately placed elevator. Elevation should continue until the tooth reaches a Class III mobility. Proper elevation IS critical and the most important factor in a suc­cessful replantation (Fig1-1 b)
4. Appropriately sized forceps are carefully posi­tioned on the neck of the crown, and the tooth is slowly raised from its socket with a gentle rotating force via the path of least resistance. Effort should be made to avoid crushing the tooth and the periodontal membrane.
5. If the tooth resists extraction, the elevation process is repeated.
6. Once the tooth has been lifted from its socket, the root(s) is examined for perforations, cracks, or other defects. The tooth should be held in the forceps throughout the balance of the reimplantation procedure. This protects the root-attached periodontal membrane from being injured during manipulation and helps reorient the operator to the path of reinsertion (Fig 11 c)
This is particularly advantageous when the crown of the tooth is mutilated or absent.
6. Once the tooth has been lifted from its socket, the root(s) is examined for perforations, cracks, or other defects. The tooth should be held in the forceps throughout the balance of the reimplantation procedure. This protects the root-attached periodontal membrane from being injured during manipulation and helps reorient the operator to the path of reinsertion (Fig 3). This is particularly advantageous when the crown of the tooth is mutilated or absent.
7. A radiograph is taken to inspect the surgical site for residual root, bone, or restorative mate­rial. Moistened gauze packing is placed over the alveolus, and the patient is instructed to maintain a gentle but constant biting force.
8. Wet gauze is carefully and gently wrapped around the forceps and the tooth, exposing only the apex and/or root defect to the opera­tor's line of sight.
9. Two to four millimeters of the apex is resected, and a Class I cavity is prepared in the center of the root(s) and/or the defect with a #1 or #2 round bur . All cutting procedures should be accompanied by a con­tinuous but indirect flow of room-temperature water or saline.
10. An appropriate root end filling material is placed and compacted in the preparation (Fig 1-1 d- Fig 1-1 c)
11. All excess filling material is curetted and/or gently washed away. The gauze is removed carefully, and the forceps tip and tooth are dipped into a cup of warm saline. The peri­odontal membrane is bathed clean with a gen­tle agitation.
12. The base of the socket can be curetted of any pathologic tissue, but the walls must be avoided to preserve any injured but still healthy periodontal membrane.

Fig 1-1 a                                                         Fig 1-1 b


Fig 1-1 c                                                             Fig 1-1 d

Fig 1-1 c

Figs 1-1a to 1-1 g The gingival attachment is incised and the tooth is ele­vated to a Class III mobility la and bl. The forceps are used to free the tooth from its socket lei. The defect is inspected, and a Class I cavity is prepared in the resected root wall in the case of the incisor (dl, or in the apex in the case of the molar lei. Once repaired, the tooth is gently guided into its alveolus, and a resin or suture splint is used to secure the tooth into position Ifl. The radiograph was taken at 38 years postsurgery Igl.

13. The tooth is carried to the socket and. with a gentle but firm force, is reinserted and guided into its original position. The insertion process should be slow enough to allow the trapped blood to escape from the alveolus. The reduction n root length allows any residual fluids to pool without creating a latent hydraulic pressure that would not only lift the tooth from its bed, but could become a source for postsurgical pain.
14. Once the tooth is properly seated, it is checked for alignment and occlusion. Because some initial ift occurs postsurgically (regardless of preventive attempts), the tooth must be kept clear of occlu­sion.
15. For interim stabilization, a series of sutures criss­crossing over the occlusal surfaces (MB-DL, ML-DB) keep the tooth in position and allow for lift. This is a particularly advantageous technique when there are no adjacent teeth. When adjacent teeth are present, a more rigid tooth-to-tooth bonded resin splint can be fabricated. When the procedure is accompanied by a gingivectomy. a periodontal zinc oxide splint can be placed. At no time is any splint left in place more than 10 days
Figs 1-1 f).
16. A postoperative radiograph is taken to verify the replanted position.
17. Appropriate antibiotics and analgesics are pre­scribed, if they are deemed necessary . The patient is scheduled for evaluation and suture or splint removal in 7 days. Postoperative care is discussed, and the patient s released with a printed set of instructions .
18. On the day of the patient's return visit, the splint may be removed, the occlusion checked, and the mobility evaluated.

Fig 1-1 f

19. A series of postoperative clinical and radiographic evaluation appointments should follow at 6 weeks. 3 months. 6 months, 1 year, 2 years, and 5 years (Fig 1-1 g).

Fig 1-1 g

1. Impossibility of tooth extraction without extreme compression pressure to the peri­odontium and bone. The success of an extract/replant procedure is directly proportional to the ease of extraction. In cases where the root anatomy or the thickness and density of the plates of bone impede the tooth's removal, a flap is laid and some of the buccal crestal bone is removed, in lieu of fracturing the root or severely injuring the periodontal membrane, it is sometimes better to hemisect or radisect the tooth and replant the roots separately (Figs1-2a to 1-2c).
2. The crown fractures during extraction. All patients entering an extract/replant procedure must be informed that crown or root fracture is always a risk and, depending on the circum­stances, the treatment plan may change or be aborted during the procedure. Most often the tooth to be extracted has little or no crown or what does exist is so undermined that the squeez­ing forces of the forceps crush what remains. Again, a flap must be reflected and sufficient cres­tal bone removed to gain additional forceps access. Unfortunately, studies show a higher rate of resorption can be expected the further apical the forceps are placed.
3. Root fracture of multirooted teeth. The problem clearly depends on the strategic location of the tooth in question and its need for the success of the restorative treatment plan, if the roots are sal­vageable, they may be sectioned from each other and the replant procedure continued for one or both.

Fig 1-2a                                                                         Fig 1-2b

4. Root defects. Prior to treatment, the patient should be informed that treating the defect by con­ventional surgical procedures depends on the degree of predictability of the repair. If access to the problem is compromised during the procedure, the conventional approach may be aborted and extract/replant procedures initiated (Figs 1-3a to 1-3e). If the prognosis for extract!on/replantation is poor, the procedure is terminated and the tooth is not replanted.

clip_image020 clip_image022
Fig 1-2C                                                                Fig 1-3a

Fig 1-3b                                                                     Fig 1-3c

Fig 1-3d                                                                       Fig 1-3e

Figs 1-3a to 1-3e When gaining access will sacrifice bone or root length la and bl, and the principles of surgery will be so compromised that the success of the procedure is in danger, extracting, repairing, and replanting proce­dures may be a better approach (c and dl. The radiograph was taken 1 8 years postsurgery lel.

5. External resorption. The potential for fracture during removal and further resorption following replantation should be thoroughly explained to the patient and agreed on prior to treatment.
6. Pain. Patients may experience pain for the first 7 to 10 days posttreatment and should be advised of and prepared for this possibility. Preoperatively. they should be administered an anti-inflammatory drug (400 to 800 mg of ibuprofen), which is continued during their post­operative recovery at the appropriate dosage . The pain following an extract/replant procedure is apt to be a sequela of the extraction trauma and its occurrence does not indicate imminent failure.
7. Risk. When a patient's medical condition does not warrant risk or his or her emotional disposi­tion will not tolerate the procedure, it should not be offered.
Furthermore, although the success of extrac­tion/replantation has been reported to be as high as 86%, it is by no means a guaranteed procedure. The patient must recognize and accept the conditions of treatment and seek other opinions or alternative treatment if unde­cided .
8. Uncooperative patients. A patient who is either uncooperative or unwilling to understand the procedure or its benefits is not a candidate for replantation. The risk of a breakdown in communication, and a lack of patient coopera­tion invites the threat of liability and does not warrant performing the procedure and assuming the responsibility.

1 comment:

Web Designers Pitampura said...

Hey keep posting such good and meaningful articles.


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