doi:10.1111/iej.12268
Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study
Y. H. Choi1,2, J. H. Bae2, Y. K. Kim3, H. Y. Kim4,5, S. K. Kim6 & B. H. Cho7 1
Department of Conservative Dentistry, School of Dentistry, Seoul National University, Seoul; 2Department of Conservative Dentistry, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam; 3Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam; 4Department of Dental Laboratory Science and Engineering, College of Health Science, Graduate School & BK21+ Program in Public Health Science, Korea University, Seoul; 5Department of Public Health Science, Graduate School & BK21+ Program in Public Health Science, Korea University, Seoul; 6Department of Conservative Dentistry, School of Dentistry, Kyungpook National University, Daegu; and 7 Department of Conservative Dentistry, School of Dentistry, Seoul National University and Dental Research Institute, Seoul, Korea
Abstract Choi YH, Bae JH, Kim YK, Kim HY, Kim SK, Cho BH. Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study. International Endodontic Journal, 47, 1168–1176, 2014.
Aim To evaluate retrospectively the clinical outcomes of intentional replantation (IR) of teeth in terms of tooth survival and periradicular healing and to investigate their prognostic factors. Methodology Two hundred and eighty-seven teeth treated by IR were analysed retrospectively. Clinical outcomes between the cases with preoperative orthodontic extrusion for 2–3 week and those without extrusion were analysed. The outcomes of IR were determined by clinical and radiographic evaluation. Tooth survival and periradicular healing estimates were compared using Kaplan–Meier analysis. The contribution of a patient’s age and gender, tooth type and location, and preoperative orthodontic extrusion was investigated using the multivariate Cox proportional hazard model.
Results The mean follow-up period was 25.4 9.3 months. The overall success rate of IR was 89.5% based on periradicular healing. The overall survival rate was 95.1%. The survival rates were 91.2% for the teeth extracted without extrusion and 98.1% for those extracted with extrusion. Amongst the variables tested, only the extraction technique with preoperative orthodontic extrusion significantly affected the survival rate (P = 0.016). Other prognostic variables, such as age and gender, tooth type and location, did not affect the survival of intentionally replanted teeth. Conclusions Intentional replantation was a viable treatment option for teeth with previously failed nonsurgical root canal treatment, regardless of a patient’s age and gender, and tooth type and location. Preoperative orthodontic extrusion for 2–3 weeks reduced root resorption and tooth fracture and can be recommended to enhance the outcome of IR. Keywords: extraction technique, intentional replantation, orthodontic extrusion, success estimate, survival estimate. Received 19 March 2013; accepted 8 February 2014
Correspondence: Byeong-Hoon Cho, DDS, PhD, Department of Conservative Dentistry, Seoul National University, School of Dentistry and Dental Research Institute, 101 Daehag-ro, Jongro-gu, Seoul 110-749, Korea (Tel.: +82 2 2072 3514; Fax: +82 2 764 3514; e-mails: [email protected]; [email protected]).
1168
International Endodontic Journal, 47, 1168–1176, 2014
Introduction The intentional replantation (IR) procedure, which includes purposeful extraction, extra-oral periradicular surgery and repositioning, has been used in dentistry for more than 250 years (Guy & Goerig 1984, Bender
© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
Choi et al. Clinical outcome of IR with orthodontic extrusion
& Rossman 1993, Kratchman 1997). Despite the lack of long-term evidence, IR has been considered as a rapid, predictable and reliable means of retaining a natural tooth that would otherwise be lost to extraction (Andreasen & Hjorting-Hansen 1966, Kingsbury & Wiesenbaugh 1971, Guy & Goerig 1984, Koenig et al. 1988, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003, Rouhani et al. 2011). Most IR studies used clinical and radiographic evaluations to investigate the success rate of the procedure based on periradicular healing (Bender & Rossman 1993, Hayashi et al. 2002). According to periradicular healing, a clinical study of IR reported that 82% of 192 teeth survived for 6–51 months (Koenig et al. 1988). Another study reported a 3-year healing rate of 95% for 151 teeth (Kingsbury & Wiesenbaugh 1971). Bender & Rossman (1993) concluded in their 22-year study that IR reduced adverse outcomes and, therefore, it should not be regarded as a last resort, but as another treatment option, such as periradicular surgery. There are several prognostic factors for IR. To prevent ankylosis or pathologic root resorption in traumatically avulsed and intentionally replanted teeth, the importance of potential prognostic factors, such as preserving a sound periodontal ligament (PDL) around the extracted root surface, preventing mechanical damage and chemical contamination, and careful extra-oral procedures, has been extensively studied (Andreasen & Hjorting-Hansen 1966, Kingsbury & Wiesenbaugh 1971, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003, Andersson et al. 2012). A clinically successful IR technique should avoid any crushing or contact with the root surface or socket (Niemczyk 2001, Wolcott & Rossman 2003). Many authors have emphasized that careful extraction without fracturing the tooth is crucial for successful IR (Kingsbury & Wiesenbaugh 1971, Guy & Goerig 1984, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003). The IR techniques usually involve using extraction forceps with a slow and firm luxating force by holding the tooth above the cementoenamel junction (Niemczyk 2001, Wolcott & Rossman 2003). However, most teeth requiring IR have weakened tooth structure due to previous root canal treatment and extensive restorations, including post and cores. Therefore, grasping the crown would increase the possibility of breakage (Kany 2002). Because the most common indication for IR is for multirooted posterior teeth in which nonsurgical root canal treatment has failed and
© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
periradicular surgery is not feasible, the extraction method of posterior teeth is important. In addition to the extraction technique, other factors that may affect the results of IR are extraction time, extra-oral time, a patient’s age and gender, and the location and type of teeth (Hayashi et al. 2002). Recently, an improved atraumatic safe extraction (ASE) method for IR was suggested (Choi et al. 2010). It recommended preoperative orthodontic extrusion for 2–3 weeks before surgery to increase tooth mobility and volume of PDL, which would allow easier extraction and reduce root resorption and ankylosis. Preoperative orthodontic extrusion for 2–3 weeks was recommended in the IR of teeth that had a complicated root structure and high risk of fracture during extraction. The teeth that received repeated nonsurgical root canal treatments and had multiple relatively large and physically weak roots, or little coronal crown structure to grasp because of substantial decay or existing core restorations were indicated for the preoperative orthodontic extrusion before the extraction procedure (Choi et al. 2010). This study evaluated whether the IR technique using orthodontic extrusion could improve the clinical outcome of the IR. For this purpose, the survival estimates (based on periradicular healing and functional success) and their prognostic factors of the 287 intentionally replanted teeth that survived until follow-up periods were investigated retrospectively.
Materials and methods Patient selection This study was conducted following approval from the Institutional Review Board of Seoul National University-Bundang Hospital (IRB no. B-1109/136-104). This was a retrospective cohort study that included 287 teeth from 285 patients who received IR from 2008 to 2011 at the Department of Conservative Dentistry of the Seoul National University-Bundang Hospital (Seoul, Korea). The mean age of patients was 41.2 14.3 years, and the age range was 11– 77 years. There were 121 men and 164 women. Most of the patients had no notable medical history, and they all were in relatively good health. Some patients who had high blood pressure or took aspirin daily were asked to contact their physicians for medical consultation before surgery. Inclusion criteria were defined as those teeth (i) for which nonsurgical root canal retreatment failed to alleviate symptoms,
International Endodontic Journal, 47, 1168–1176, 2014
1169
Clinical outcome of IR with orthodontic extrusion Choi et al.
(ii) in which a fractured instrument could not be removed or bypassed, (iii) in which the calcified canal with persistent symptomatic apical periodontitis was not negotiated, (iv) for which periradicular surgery was not feasible because anatomical structures (e.g. the inferior alveolar nerve, maxillary sinus and dense cortical bone) limited accessibility and made it difficult to perform periradicular surgery, (v) for which excessive bone reduction was anticipated during periradicular surgery because of the size of the periapical lesion and (vi) for which previous periradicular surgery had failed. In addition to these criteria, only a single tooth was included that had at least one neighbouring sound tooth without pathologic mobility or dental implant. Teeth with healthy PDL, normal physiologic mobility and moderate periodontal pocket depths (i.e.
Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study
Y. H. Choi1,2, J. H. Bae2, Y. K. Kim3, H. Y. Kim4,5, S. K. Kim6 & B. H. Cho7 1
Department of Conservative Dentistry, School of Dentistry, Seoul National University, Seoul; 2Department of Conservative Dentistry, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam; 3Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam; 4Department of Dental Laboratory Science and Engineering, College of Health Science, Graduate School & BK21+ Program in Public Health Science, Korea University, Seoul; 5Department of Public Health Science, Graduate School & BK21+ Program in Public Health Science, Korea University, Seoul; 6Department of Conservative Dentistry, School of Dentistry, Kyungpook National University, Daegu; and 7 Department of Conservative Dentistry, School of Dentistry, Seoul National University and Dental Research Institute, Seoul, Korea
Abstract Choi YH, Bae JH, Kim YK, Kim HY, Kim SK, Cho BH. Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study. International Endodontic Journal, 47, 1168–1176, 2014.
Aim To evaluate retrospectively the clinical outcomes of intentional replantation (IR) of teeth in terms of tooth survival and periradicular healing and to investigate their prognostic factors. Methodology Two hundred and eighty-seven teeth treated by IR were analysed retrospectively. Clinical outcomes between the cases with preoperative orthodontic extrusion for 2–3 week and those without extrusion were analysed. The outcomes of IR were determined by clinical and radiographic evaluation. Tooth survival and periradicular healing estimates were compared using Kaplan–Meier analysis. The contribution of a patient’s age and gender, tooth type and location, and preoperative orthodontic extrusion was investigated using the multivariate Cox proportional hazard model.
Results The mean follow-up period was 25.4 9.3 months. The overall success rate of IR was 89.5% based on periradicular healing. The overall survival rate was 95.1%. The survival rates were 91.2% for the teeth extracted without extrusion and 98.1% for those extracted with extrusion. Amongst the variables tested, only the extraction technique with preoperative orthodontic extrusion significantly affected the survival rate (P = 0.016). Other prognostic variables, such as age and gender, tooth type and location, did not affect the survival of intentionally replanted teeth. Conclusions Intentional replantation was a viable treatment option for teeth with previously failed nonsurgical root canal treatment, regardless of a patient’s age and gender, and tooth type and location. Preoperative orthodontic extrusion for 2–3 weeks reduced root resorption and tooth fracture and can be recommended to enhance the outcome of IR. Keywords: extraction technique, intentional replantation, orthodontic extrusion, success estimate, survival estimate. Received 19 March 2013; accepted 8 February 2014
Correspondence: Byeong-Hoon Cho, DDS, PhD, Department of Conservative Dentistry, Seoul National University, School of Dentistry and Dental Research Institute, 101 Daehag-ro, Jongro-gu, Seoul 110-749, Korea (Tel.: +82 2 2072 3514; Fax: +82 2 764 3514; e-mails: [email protected]; [email protected]).
1168
International Endodontic Journal, 47, 1168–1176, 2014
Introduction The intentional replantation (IR) procedure, which includes purposeful extraction, extra-oral periradicular surgery and repositioning, has been used in dentistry for more than 250 years (Guy & Goerig 1984, Bender
© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
Choi et al. Clinical outcome of IR with orthodontic extrusion
& Rossman 1993, Kratchman 1997). Despite the lack of long-term evidence, IR has been considered as a rapid, predictable and reliable means of retaining a natural tooth that would otherwise be lost to extraction (Andreasen & Hjorting-Hansen 1966, Kingsbury & Wiesenbaugh 1971, Guy & Goerig 1984, Koenig et al. 1988, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003, Rouhani et al. 2011). Most IR studies used clinical and radiographic evaluations to investigate the success rate of the procedure based on periradicular healing (Bender & Rossman 1993, Hayashi et al. 2002). According to periradicular healing, a clinical study of IR reported that 82% of 192 teeth survived for 6–51 months (Koenig et al. 1988). Another study reported a 3-year healing rate of 95% for 151 teeth (Kingsbury & Wiesenbaugh 1971). Bender & Rossman (1993) concluded in their 22-year study that IR reduced adverse outcomes and, therefore, it should not be regarded as a last resort, but as another treatment option, such as periradicular surgery. There are several prognostic factors for IR. To prevent ankylosis or pathologic root resorption in traumatically avulsed and intentionally replanted teeth, the importance of potential prognostic factors, such as preserving a sound periodontal ligament (PDL) around the extracted root surface, preventing mechanical damage and chemical contamination, and careful extra-oral procedures, has been extensively studied (Andreasen & Hjorting-Hansen 1966, Kingsbury & Wiesenbaugh 1971, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003, Andersson et al. 2012). A clinically successful IR technique should avoid any crushing or contact with the root surface or socket (Niemczyk 2001, Wolcott & Rossman 2003). Many authors have emphasized that careful extraction without fracturing the tooth is crucial for successful IR (Kingsbury & Wiesenbaugh 1971, Guy & Goerig 1984, Bender & Rossman 1993, Niemczyk 2001, Wolcott & Rossman 2003). The IR techniques usually involve using extraction forceps with a slow and firm luxating force by holding the tooth above the cementoenamel junction (Niemczyk 2001, Wolcott & Rossman 2003). However, most teeth requiring IR have weakened tooth structure due to previous root canal treatment and extensive restorations, including post and cores. Therefore, grasping the crown would increase the possibility of breakage (Kany 2002). Because the most common indication for IR is for multirooted posterior teeth in which nonsurgical root canal treatment has failed and
© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
periradicular surgery is not feasible, the extraction method of posterior teeth is important. In addition to the extraction technique, other factors that may affect the results of IR are extraction time, extra-oral time, a patient’s age and gender, and the location and type of teeth (Hayashi et al. 2002). Recently, an improved atraumatic safe extraction (ASE) method for IR was suggested (Choi et al. 2010). It recommended preoperative orthodontic extrusion for 2–3 weeks before surgery to increase tooth mobility and volume of PDL, which would allow easier extraction and reduce root resorption and ankylosis. Preoperative orthodontic extrusion for 2–3 weeks was recommended in the IR of teeth that had a complicated root structure and high risk of fracture during extraction. The teeth that received repeated nonsurgical root canal treatments and had multiple relatively large and physically weak roots, or little coronal crown structure to grasp because of substantial decay or existing core restorations were indicated for the preoperative orthodontic extrusion before the extraction procedure (Choi et al. 2010). This study evaluated whether the IR technique using orthodontic extrusion could improve the clinical outcome of the IR. For this purpose, the survival estimates (based on periradicular healing and functional success) and their prognostic factors of the 287 intentionally replanted teeth that survived until follow-up periods were investigated retrospectively.
Materials and methods Patient selection This study was conducted following approval from the Institutional Review Board of Seoul National University-Bundang Hospital (IRB no. B-1109/136-104). This was a retrospective cohort study that included 287 teeth from 285 patients who received IR from 2008 to 2011 at the Department of Conservative Dentistry of the Seoul National University-Bundang Hospital (Seoul, Korea). The mean age of patients was 41.2 14.3 years, and the age range was 11– 77 years. There were 121 men and 164 women. Most of the patients had no notable medical history, and they all were in relatively good health. Some patients who had high blood pressure or took aspirin daily were asked to contact their physicians for medical consultation before surgery. Inclusion criteria were defined as those teeth (i) for which nonsurgical root canal retreatment failed to alleviate symptoms,
International Endodontic Journal, 47, 1168–1176, 2014
1169
Clinical outcome of IR with orthodontic extrusion Choi et al.
(ii) in which a fractured instrument could not be removed or bypassed, (iii) in which the calcified canal with persistent symptomatic apical periodontitis was not negotiated, (iv) for which periradicular surgery was not feasible because anatomical structures (e.g. the inferior alveolar nerve, maxillary sinus and dense cortical bone) limited accessibility and made it difficult to perform periradicular surgery, (v) for which excessive bone reduction was anticipated during periradicular surgery because of the size of the periapical lesion and (vi) for which previous periradicular surgery had failed. In addition to these criteria, only a single tooth was included that had at least one neighbouring sound tooth without pathologic mobility or dental implant. Teeth with healthy PDL, normal physiologic mobility and moderate periodontal pocket depths (i.e.
