External Root Resorption: Is Intentional Replantation a Viable Treatment Option: A Case Report

INTRODUCTION

External cervical resorption (ECR) originates on the external surface of the root, typically just below the epithelial attachment. It often progresses aggressively, leading to considerable tooth structure loss.

This case report aims to present a multidisciplinary approach to managing ECR in a patient. The key challenge lies in selecting the most appropriate treatment, balancing evidence-based guidelines with clinical expertise.¹

The prognosis of ECR treatment relies not only on the quality of endodontic intervention, when necessary, but also on the chosen technique.

In this case, the resorption's location and the patient's limited mouth opening made management difficult. Consequently, an extra-oral approach with intentional replantation was chosen as the treatment method.²

CASE REPORT

A 38 year old female patient came to the department of Conservative Dentistry and Endodontics with complaint of pain on chewing and mobility of tooth in lower right back tooth region. On clinical examination there was class 1 caries and grade 1 mobility wrt 45. On vitality testing with cold test gave no response indicating pulpal necrosis wrt 45. Radiographic examination showed external cervical resorption towards the mesial aspect of the root and large J shaped periapical radiolucency wrt 45 . Diagnosis made was pulpal necrosis and external cervical resorption with symptomatic apical periodontitis wrt 45. Treatment plan was non surgical root canal treatment followed by intentional reimplantation wrt 45.

First the root canal treatment was performed intraorally. After copious irrigation with NaOCl and EDTA, the obturation was done with gutta-percha and bio-ceramic sealer (EndoSequence BC Sealer, Brassler, USA). The tooth was then filled with resin composite.

The extraction was performed as atraumatically as possible. Extraoral treatment involved cleaning the resorption area using a fine diamond bur and root end resection was performed and filling the defect with GIC. The tooth was handled only with sterile gauze and gloves, and it was continuously kept moist with sterile saline. Replantation was completed within 15 minutes of extraction. The tooth was then splinted to the adjacent teeth and removed from occlusion.

DISCUSSION

Management of ECR is highly complex and dependent on several factors, such as the extent and location of the resorptive lesion, accessibility, and the presence or absence of symptoms. Since it often leads to significant structural damage before detection, early diagnosis is crucial for improving the prognosis.⁴ Treatment options aim to remove the resorptive tissue, repair the defect, and restore normal function. However, access to the resorptive area can be difficult, especially in cases where the lesion is located deep within the root or in patients with anatomical challenges such as limited mouth opening.³

Conventional treatments for ECR include endodontic therapy, surgical exposure, and restoration of the affected area. However, when these approaches are unfeasible, as in cases where deep lesions are inaccessible intraorally, more advanced techniques like intentional replantation may be considered.

The success of intentional replantation hinges on several key factors:

1. Atraumatic Extraction: It is critical to minimize damage to the periodontal ligament and surrounding structures during extraction. Maintaining the integrity of the periodontal ligament helps reduce the risk of root resorption and improves the chances of successful replantation.
2. Extraoral Management: During extraoral treatment, the resorptive lesion must be carefully debrided, often with a fine diamond bur, and the defect filled with a suitable material like a self-etch, self-adhesive composite. The handling of the tooth is crucial—sterile gauze, gloves, and constant moistening with saline are necessary to preserve tissue vitality.⁵
3. Time Considerations: Minimizing the extraoral time is essential. Studies suggest that keeping the tooth out of the socket for less than 15 minutes is ideal, as prolonged exposure increases the risk of resorption and ankylosis post-replantation.
4. Post-Replantation Care: After replantation, the tooth is typically splinted to adjacent teeth to provide stability during the healing process, and it is removed from occlusion to prevent excessive loading. Splinting ensures that the periodontal ligament has an optimal environment for healing, reducing the risk of further complications like root resorption.

Prognosis and Long-term Considerations

The long-term success of intentional replantation depends on several factors, including the stage of the resorptive lesion, the quality of endodontic and restorative procedures, and patient-specific variables like immune response and oral hygiene. Potential complications include root resorption, ankylosis, and eventual tooth loss. However, when executed with precision, intentional replantation can preserve the tooth for several years, delaying the need for more invasive procedures such as implants.⁶

Intentional replantation is often considered a last-resort treatment option for managing ECR, but it can offer excellent outcomes in cases where more conventional treatment options are insufficient or impractical. Advances in materials, imaging, and microsurgical techniques have improved the predictability and success rates of this technique, making it a viable option for managing complex endodontic cases.

CONCLUSION

ECR are always a challenge for the clinician. In some cases, the standard procedures are difficult to implement. Intentional replantation after treating the tooth extra orally could be an option, in case where is feasible, to improve the prognosis of a tooth that otherwise would be hopeless.

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