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Clinical SHOWCASE Unintentional Replantation: a Technique to Avoid

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Clinical SHOWCASE Unintentional Replantation: a Technique to Avoid Clinical SHOWCASE Unintentional Replantation: A Technique to Avoid Robert S. Roda, DDS, MS any times in a dentist’s career, he the greatest contour of the alveolar or she will make a decision that swelling was over the upper left cuspid. Mhas unintended consequences. In Both teeth had been prepared as bridge the case reported here, some quick abutments, but the temporary bridge was thinking was required to resolve the out- not present. There was an open come of an unexpected series of events. endodontic access in the premolar with Because clinical learning is best achieved no pulp exposure and a small composite by retrospective analysis, a list of lessons resin restoration in the cuspid. Both the to be learned from this case is also pro- cuspid and the second premolar were vided, in the hope that it helps readers to tender to percussion. The cuspid was also avoid this particular situation. very tender to bite (determined with a Tooth Slooth instrument, Professional Case Report Results Inc, Laguna Niguel, Calif.) and to A 63-year-old woman presented with buccal alveolar palpation. The premolar severe pain and extraoral facial swelling in The articles for this was not tender to bite or palpation. The the upper left quadrant, which had begun month’s “Clinical cuspid did not respond to cold tests, the day before the visit and was wors- Showcase” section were whereas the premolar was hyperrespon- ening. Her medical history was noncon- written by speakers sive but with nonlingering pain consistent at the 2006 CDA Annual tributory except for mitral valve prolapse with reversible pulpitis. Intraoral radiog- Convention, which will (with regurgitation); she was receiving raphy (Fig. 1) showed the presence of a be held August 24–26 in antibiotic prophylaxis for subacute bacte- periapical radiolucency around the root St.John’s, Newfoundland. rial endocarditis. Her general dentist had end of the cuspid. There was thickening of Dr.Roda’s full-day session attempted endodontic therapy that day on at the convention, titled the upper left second premolar, but could the periodontal ligament space all around “Endodontic diagnosis and not find the canals because of pulp calcifi- the root of the premolar consistent with therapy update,” will cation and difficulty achieving complete occlusal trauma. There was also distal ver- be presented on anesthesia; the patient had therefore been tical bone loss associated with a 5 mm Friday, August 25. referred for specialist treatment. probing depth on this tooth. It was deter- Clinical examination revealed exten- mined that the pain originated from the sive extraoral and intraoral swelling cuspid, and the final diagnosis for that extending from the upper left lateral tooth was pulp necrosis with acute apical incisor to the upper left second premolar; (phoenix) abscess. The patient selected Figure 1: A periapical radiolucency is Figure 2: Final obturation of the cuspid. visible at the root end of the cuspid. JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 • 133 –––– Clinical Showcase –––– Figure 3: Radiography 1 year after Figure 4: Morell crown remover. Figure 5: The premolar was inadvertently initial treatment shows thickening of the peri- removed with the bridge. (Reprinted from odontal ligament space on the premolar and Cohen and Hargreaves,3 with permission complete healing of the cuspid. from Elsevier.) Figure 6: Hank’s balanced salt solution Figure 7: Mineral trioxide aggregate used to Figure 8: Placement of mineral trioxide was used to bathe the premolar. fill retropreparation. aggregate in the retropreparation. nonsurgical root canal therapy (NSRCT) from the space on the premolar with associated condensing list of options provided. osteitis. The apical lesion around the cuspid had The premolar access was filled with interme- completely healed, but the post space in the cuspid diate restorative material (Caulk Dentsply, York, was empty. Clinical testing confirmed pulp necrosis Penn.), and the patient was warned to watch for with subacute periradicular periodontitis in the symptoms of pulpitis that could necessitate root premolar. After discussion of the options, the canal therapy in the future. An access preparation patient chose NSRCT. The general dentist was made in the cuspid tooth produced copious puru- informed of the situation. He asked if there was any lent exudate. A cotton pellet was placed in the access way to remove the bridge intact to allow its reuse; he preparation to allow the tooth to remain open for was informed that it was unlikely but could be drainage, since the exudate did not stop despite attempted. The patient agreed, despite the risk of thorough debridement. Two days later, the cuspid exarticulation of the premolar. A careful attempt to was cleaned, shaped and closed. The treatment was remove the bridge with a Morell crown remover finished uneventfully 2 weeks later, and the patient (Henry Schein, Port Washington, N.Y.) (Fig. 4) was referred back to her general dentist for post and resulted in inadvertent removal of the premolar core fabrication and placement of a fixed partial with the prosthesis attached (Fig. 5). denture (Fig. 2). The tooth was immediately replaced in the The patient returned 1 year later with an inter- socket to allow time to procure the armamentaria mittent spontaneous ache in the upper left quad- needed for replantation. The tooth was gently rant which had started 10 days before. She had exarticulated again and bathed in Hank’s balanced sensitivity to bite on the new bridge but no sensi- salt solution (EMT Toothsaver, SmartPractice, tivity to temperature. The bridge retainer on the Phoenix, Ariz.) (Fig. 6). A 0.5-mm section of the cuspid was loose, whereas that on the premolar root end was resected, and the canal was instru- adhered well. Periapical radiography (Fig. 3) mented from the apical dimension using rotary showed thickening of the periodontal ligament ProFiles (Dentsply Endodontics, Tulsa, Okla.), with 134 JCDA • www.cda-adc.ca/jcda • March 2006, Vol. 72, No. 2 • –––– Clinical Showcase –––– Figure 9: The cuspid retainer was Figure 10: Radiograph taken immediately Figure 11: Complete healing 30 months after reseated simultaneously with final after cementation shows the preformed post the premolar was replanted. replantation of the attached premolar. in the cuspid and the final obturation of the premolar. the salt solution as the irrigant. The canal was obtu- be reversible. In this situation, there is a high likelihood that pulpal rated with gutta-percha and an epoxy resin sealer pathosis will develop. (ThermaSeal Plus, Dentsply Endodontics). A small If there is a post space in a tooth, fill it with a post, with gutta- retropreparation was made using a high-speed percha and sealer, or with some other restorative material. In the case handpiece cooled with sterile water; the retro- reported here, the presence of a post and core might have prevented preparation was filled with mineral trioxide the cuspid retainer from being dislodged.2 aggregate (ProRoot MTA, Dentsply Endodontics) Do not attempt to remove a bridge intact unless both (Figs. 7 and 8). After disinfection of the cuspid abutments are sound and firmly attached to the periodontium. Even post space, a #4 Parapost (Coltene/Whaledent, under ideal circumstances, this procedure frequently results in damage Cuyahoga Falls, Ohio) was cemented with glass to the prosthesis or teeth, and it is often impossible to remove the ionomer cement (Fuji-Cem, GC America, Alsip, prosthesis in any case.3 Despite the great success of intentional Ill.). The cuspid retainer was filled with Durelon replantation in endodontics,4 unintentional replantation cannot be (3M ESPE, St. Paul, Minn.) and reseated simultane- recommended, because of its uncontrolled nature. ously with final replantation of the attached pre- Never perform any treatment simply because a patient molar (Figs. 9 and 10). Total time out of the socket or another practitioner requests it. If you have any reservations about was 35 minutes; the tooth was continuously bathed a course of action, find an acceptable alternative. Otherwise, your in the salt solution during that period. The patient practice may become more “exciting” than you would like. C had minimal soreness over the next few days, which resolved completely. Re-evaluation at 30 months THE AUTHOR (Fig. 11) showed complete healing around both asymptomatic abutments, and the prosthesis was Dr. Roda is an adjunct assistant professor in the clinically intact. department of endodontics, Baylor College of Dentistry, Dallas, Texas. Correspondence to: Dr.Robert S. Roda, 7054 E. Cochise, Lessons Learned Ste B-115, Scottsdale, AZ 85253. Email: [email protected]. This case illustrates some pitfalls in clinical decision-making that The author has no declared financial interests in any company need to be avoided. The following guidelines represent lessons learned manufacturing the types of products mentioned in this article. from this case. Do not attempt to perform endodontic therapy on a tooth (in this References case, the second premolar at the time of the initial swelling) unless you 1. Berman LH, Hartwell GR. Diagnosis. In: Cohen S, Hargreaves KM, editors. Pathways of the pulp. 9th ed. St. Louis: Mosby Elsevier; 2006. are certain of the diagnosis.1 If you cannot accurately determine the p. 2–39. cause of a patient’s problem, you must refer the patient to someone 2. Wagnild G, Mueller K. Restoration of endodontically treated teeth. In: Cohen S, Hargreaves KM, editors. Pathways of the pulp. 9th ed. St. who can. At the very least, you should not perform any treatment if Louis: Mosby Elsevier; 2006; p. 786–821. there is any uncertainty about the diagnosis. 3. Roda RS, Gettleman BH. Non-surgical retreatment. In: Cohen S, If an endodontic access has been attempted on a tooth, especially Hargreaves KM, editors. Pathways of the pulp. 9th ed. St. Louis: Mosby Elsevier; 2006.
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