Case Report/Clinical Techniques
Saving Natural Teeth: Intentional
Replantation—Protocol and Case Series
Derek Grzanich, DDS, MsD, Gabriella Rizzo, DDS, and Renato Menezes Silva, DDS, MS, PhD
Abstract
Introduction: Intentional replantation is a reliable and
predictable treatment for cases in which nonsurgical
endodontic retreatment failed or is impractical and end-
odontic surgery is hampered because of anatomic limita-
tions. Methods and Results: This article presents a
protocol for intentional replantation illustrated with
some interesting cases. The cases presented here are
from patients (average age, 61 years) with no contrib-
uting medical history. The cases are molars with previ-
ous failed endodontic treatment/retreatment and
diagnosed with apical periodontitis. Treatment proced-
ures included atraumatic extractions with minimal ma-
nipulations of the periodontal ligament, followed by
root-end resection, root-end preparation with ultrasonic
tips, root-end fill with bioceramic cement, and rapid
tooth replacement into the socket. Granulomatous tis-
sue was gently curetted when applicable. All procedures
were performed under the microscope. Conclusions:
Intentional replantation with careful case selection
may be considered as a last option for preserving hope-
less teeth. Atraumatic extraction by using state-of-the-
art equipment, instruments, and materials, minimal
extra-alveolar time, and maintaining an aseptic tech-
nique are key factors for success. (J Endod
2017;43:2119–2124)
Key Words
Apical surgery, endodontic treatment, intentional
replantation
From the Department of Endodontics, University of Texas Health Science Center at Houston, School of Dentistry at Houston, Houston, Texas.
Address requests for reprints to Dr Renato Menezes Silva, Department of Endodontics, University of Texas School of Dentistry at Houston, 7500 Cambridge Street,
Suite 6411, Houston, TX 77054. E-mail address: Renato.M.Silva@uth.tmc.edu
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.08.009
JOE — Volume 43, Number 12, December 2017
I ntentional replantation
of a tooth involves removing
the tooth and reinserting it
Significance
This article presents a protocol for intentional
replantation for cases in which conventional end-
into the socket after end-
odontic retreatment failed or is impractical and
odontic manipulation, obtu-
endodontic surgery is hampered because of
ration of the canal/root-end
anatomic limitations.
filling, or both (1).
Although nonsurgical
endodontic therapy has been shown to have an excellent survival rate (2), this initial pro-
cedure can occasionally fail to address the entire source of infection, resulting in persis-
tence of periapical symptoms. Another treatment option is endodontic surgery. The
objective of apical surgery is to surgically maintain a tooth that primarily has an endodontic
lesion that cannot be resolved by nonsurgical endodontic (re)treatment (3). It has been
reported in the literature that high success rates of 94% can be obtained by using modern
apical microsurgery (4). However, apical surgery may be considered an unfavorable pro-
cedure when anatomic factors may interfere with surgery outcome (eg, buccal plate thick-
ness, proximity to anatomic structures such as the mandibular nerve, or inoperable sites
such as lingual surfaces of mandibular molars) (1, 5).
Intentional replantation is indicated when a previous endodontic treatment failed
and because an orthograde endodontic retreatment or apical surgery is impractical (5).
Another important factor to take into consideration is when financial factors preclude
conventional implant placement (6, 7), and intentional replantation may be considered
a unique chance for preserving a natural tooth.
The main advantage of intentional replantation technique is that tooth surfaces,
including inaccessible areas, can be visualized and instrumented completely without
damaging adjacent periodontal tissues, contributing to reestablishment of healthy peri-
radicular tissues. The contraindications to intentional replantation are periodontal
involvement with extensive mobility of the tooth, destroyed or missing labial or buccal
plate, or septal bone at the bifurcation (1,5–7).
Intentional replantation is not a frequently used treatment technique in private of-
fices because of the wide variance in reported success rates (1, 7, 8) and the absence of
an established protocol (9, 10). However, a recent systematic review and meta-analysis
revealed a weighted mean survival of 88% (95% confidence interval, 81%–94%) for
intentional replanted teeth (9).
The purpose of this article is to share a protocol used for intentional replantation
in our institution as well as cases where clinical and radiographic exams showed char-
acteristics of a good outcome.
Methods
The cases presented here are from patients (average age, 61 years) with no
contributing medical history who were referred to the Department of Endodontics at
School of Dentistry, University of Texas Health Science Center at Houston (UTSD).
Intentional Replantation Cases 2119
Case Report/Clinical Techniques
All cases were performed by endodontic residents under faculty super-
vision. The cases were molars with previous failed endodontic treat-
ment/retreatment and diagnosed with apical periodontitis. After
proper medical and dental history review, clinical exam comprised in-
spection of the entire mouth (teeth, tongue, gingiva, and mucosa), ther-
mal tests, percussion, palpation, and probing depths. Radiographic
exam consisted of conventional radiographs and cone-bean computed
tomography (CBCT).
After diagnosis, treatment plan, and all consents were signed,
treatment procedures included atraumatic extractions as possible
(minimal damage to the surrounding tissues and bone by using deep
gripping forceps) under local anesthesia, minimal manipulations of
the periodontal ligament, followed by root-end resection, root-end
preparation with ultrasonic tips, root-end fill with bioceramic cement,
and rapid tooth replacement into the socket. All procedures were per-
formed under the microscope. Granulomatous tissue, when present,
was gently curetted and socket irrigated with sterile saline solution.
All tissues were submitted to microscopic analysis. Occlusion adjust-
ments were performed when necessary. All cases were followed up clin-
ically and radiographically for at least 24 months (Fig. 1). All cases were
functional and asymptomatic. Figure 2 describes the protocol adopted
for all cases described here.
Case Reports
Case 1
A 64-year-old woman presented to the endodontic clinic (UTSD)
for evaluation of tooth #31 (Fig. 3). Her chief complaint was ‘‘discom-
fort and a strange tissue formation in the lower right area.’’ Her medical
history was unremarkable. Dental history included previous endodontic
treatment in tooth #31 completed 3 years prior. Clinical examination
revealed a sinus tract in the buccal area of tooth #31, no pain on palpa-
tion, but slight discomfort to percussion. Radiographic examination re-
vealed a previously treated root canal, bone loss pattern in mesial and
distal areas, radiolucency compatible with apical periodontitis, and a
separated instrument in the mesial root. Pulp diagnosis was determined
to be previously endodontically treated and periapical diagnosis as
chronic apical abscess.
The patient was presented with different treatment options
including endodontic retreatment, apical surgery, and intentional

Figure 1. Protocol used for all cases described in this article. After atraumatic extraction procedure, the tooth is immediately placed in Hank’s balanced salt
solution (A and B); root and remaining periodontal ligament should not be touched. Root inspection and dye staining of the tooth (C); tooth held (crown
only) with a wet gauze (Hank’s balance salt solution). All granulomatous/inflammatory tissue should be removed from the roots and submitted to microscopic
analysis (D); root-end resection (E); root-end preparation performed with ultrasonic tips and constant irrigation with saline solution (F and G). All procedures
were performed under dental operating microscope visualization (H). Root-end filling material is disposed and condensed into prepared tooth (I–K); tooth is
replanted into the socket (L).

2120 Grzanich et al. JOE — Volume 43, Number 12, December 2017

Figure 2. Intentional replantation protocol.
replantation or tooth extraction. After risk and benefits were discussed,
the patient decided to have the intentional extraction and replantation.
During the extraction the crown fractured, and caries was noted. The
patient was informed she would need a new crown. The tissue collected
from the apical area was sent for histopathologic analysis, which further
revealed the diagnosis of periapical granuloma.
After 7 days, the patient reported no symptoms, and clinical eval-
uation revealed mobility class II. A provisional crown was cemented. A
second follow-up was performed 6 months after the initial procedure; at
this visit the patient was asymptomatic. The tooth was not tender to per-
cussion and palpation tests. Physiologic mobility was noted, and peri-
odontal probing was less than 3 mm. Bone loss pattern was
unchanged from the preoperative state. At 14 months, clinical and
radiographic evaluation showed normal healing. A definitive crown
was cemented at the graduate prosthodontics clinic. At 28-month
follow-up, the patient remained asymptomatic, and the tooth retained
normal function. Radiographic examination revealed complete osseous
healing with no signs of root resorption or ankylosis.
Case 2
A 35-year-old man presented to our clinic with pain and intraoral
swelling; he was referred to UTSD for evaluation of tooth #14 (Fig. 4).
Patient reported a history of amelogenesis imperfecta. Dental history
also included previous endodontic treatment in tooth #14 performed
1 year prior. Clinical examination revealed pain to both palpation and
percussion. Radiographic examination revealed a previously treated
root canal and radiolucency suggestive of apical periodontitis. Patient re-
JOE — Volume 43, Number 12, December 2017
Case Report/Clinical Techniques
ported that he was taking Aleve (naproxen) 2 pills (440 mg) every
4 hours for pain; however, it was not helping. Patient also reported
high fever and malaise. Temperature was checked (101 F).
Radiographic and CBCT images suggested an atypical anatomy.
Pulp diagnosis was determined as previously endodontically treated
and periapical diagnosis as acute apical abscess. Treatment options
were discussed with patient (endodontic retreatment, apical surgery,
tooth extraction, or intentional extraction and replantation). After
risk and benefits were discussed, the patient opted for intentional
replantation mainly because of financial concerns. At this visit, incision
and drainage were performed, and patient was prescribed with a treat-
ment course with amoxicillin (1 tablet every 6 hours for 7 days). Patient
was scheduled for intentional replantation the week after.
The same treatment protocol described above was used for this
case. An interesting finding noted was an apical isthmus connecting
the distobuccal canal to the palatal canal.
At 7 days, the first follow-up appointment was performed, and he re-
ported no symptoms. At 3 months, the patient remained asymptomatic, no
intraoral or extraoral swelling was present, and gingival tissues appeared
healthy. At 6-month follow-up, tooth #14 was not tender to percussion or
palpation and presented physiologic mobility. A porcelain fused metal
crown was cemented on that tooth at the predoctoral clinic. A 2-year
follow-up evaluation was consistent with clinical and radiographic healing.
Case 3
An 86-year-old woman was referred to our clinic for evaluation
of tooth #18 (Fig. 5). She had a medical history of cancer, stroke,
Intentional Replantation Cases 2121
Case Report/Clinical Techniques

Figure 3. Case 1: preoperative radiograph of tooth #31. Star shows an image suggestive of a separated instrument in the mesiobuccal canal (A and B); CBCT image
showing large (approximately 3 mm in diameter) apical radiolucency in close proximity to inferior alveolar nerve (C, arrow); preoperative photograph showing
sinus tract (arrow) in buccal area of tooth #31 (D); 14-month postoperative periapical radiograph (E), 28-month follow-up periapical radiograph (F) and CBCT
(G) images; postoperative photograph (7 days after replantation procedure) showing normal healing and no signs of inflammation (H).
and hepatitis B. Dental history included previous endodontic treat- I. Radiographic examination showed a previously treated root canal
ment of tooth #18 completed 13 years prior. Clinical examination and J-shaped radiolucency in the middle and apical portions of the
revealed a 6-mm mesiolingual periodontal pocket and mobility class mesial root, which was suggestive of root fracture. Tooth #18 was

Figure 4. Case 2: preoperative radiograph (before endodontic treatment) of tooth #14 (A); photograph (B), periapical radiograph (C), and CBCT images (D and
E) before replantation procedure; root-end resection followed by root-end preparation (F and G); postoperative radiograph (H); 1-month follow-up radiograph
(I); 6-month follow-up radiograph (J), 15-month follow-up radiograph (K); 2-year follow-up radiograph (L).

2122 Grzanich et al. JOE — Volume 43, Number 12, December 2017
 Case Report/Clinical Techniques

Figure 5. Case 3: preoperative radiograph of tooth #18 (A); CBCT images showing mesial, furcation, and apical radiolucency (B–D); arrow shows apical radio-
lucency in close proximity with inferior alveolar nerve (D); root-end resection followed by root-end preparation and root-end filling material condensed into the
prepared tooth (E–G); bone grafting (Bio-Oss; large particles, 1.0–2.0 mm cancellous granules 2 g) performed at mesial root socket before replantation (H);
postoperative radiograph (I); 4-month follow-up radiograph (J); 26-month follow-up buccal and lingual clinical photo showing no signs of inflammation (K and L),
as well as periapical radiograph showing signs of periradicular bone healing (M).

diagnosed as previous endodontically treated with asymptomatic
apical periodontitis.
Intentional replantation was offered as a treatment option on the
basis of the possibility of a fracture, considering the patient’s desire to
keep the tooth. Risk and benefits were discussed, and the patient decided
to have the procedure. A vertical root fracture was observed in the mesial
root extending to the cervical region. Mesial root-end resection and root-
end preparation were performed. Bone graft (Bio-Oss; Geistlich, Prince-
ton, NJ) was placed in the mesial root region. After the procedure, the
tissue collected from the apical area was sent for histopathologic analysis,
which revealed a diagnosis of periapical granuloma.
When the patient presented at 7 days for her first follow-up appoint-
ment, the tooth was tender to palpation. The soft tissue around the tooth
appeared unremarkable. Occlusion adjustment was performed. At 1
month she was asymptomatic, and radiographic examination showed
new bone formation. Four months later, the tooth was no longer tender
to percussion or palpation, and radiographic evaluation showed establish-
ment of normal periodontal ligament space. At 2-year follow-up, patient
was asymptomatic, and there was no sign of root resorption or ankylosis.
Discussion
Intentional replantation is ideal when the operator desires superb
access and visualization of root apex and furcation (11, 12) or where the
operator wishes to address both periapical and periradicular infection
(13). In this respect, it provides benefits of retreatment and periradic-
ular surgery (14). The patient’s desire to keep their natural teeth should
also be taken into consideration. Case #3 well describes this situation,
where an 86-year-old woman with a diagnosis of root fracture and indi-
cation of tooth extraction appealed to try to save her tooth.
The modern intentional replantation procedure by using state-of-
the-art equipment, instruments, and materials has come a long way and
has been shown to have a very good success rate (15). The success is
likely dependent on a minimally traumatic extraction (minimal damage
to the surrounding tissues and bone), understanding of the apical anat-
omy, short extraoral time with adequate vision and illumination (micro-
scope), copious irrigation, and meticulous instrumentation as well as
carefully controlled postoperative patient instruction adherence
(1,5,7,16–18). The biocompatibility of the filling material will also
affect the healing process (16, 18). Case selection also plays a
crucial aspect in the outcome of the procedure. It has been reported
in the literature that root-fractured molars (17) and periodontally
involved (14) or traumatized teeth with evidence of ankylosis and/or
replacement resorption (19) are likely to have lower prognosis
compared with endodontically failed teeth (13).
We strongly recommend using small or limited-volume CBCT im-
aging techniques for diagnosis and treatment plan. In regard to

JOE — Volume 43, Number 12, December 2017 Intentional Replantation Cases 2123
Case Report/Clinical Techniques
splinting, we agree with previous studies showing that splinting is not
mandatory and should be performed only if necessary, such as in short
roots or lack of interseptal bone (12, 16).
Intentional replantation procedure is a relatively fast and simple
procedure that gives the patient only minimal postoperative discom-
fort (8), reduces clinical work time, and has fewer possible compli-
cations and less cost as compared with nonsurgical endodontic
retreatment or dental implants (9). Intentional replantation has
been used for cases that are more complicated, such as vertically frac-
tured roots reconstructed with dentin-bonded resin, demonstrating to
be a useful treatment to preserve fractured roots with long-term effi-
cacy (14, 20).
All cases presented in this article have not shown root resorption
or ankyloses; they presented clinical and radiographic normal healing
throughout the follow-up evaluations, remaining asymptomatic to date.
This procedure produces predictable outcomes in the healing of lesions
of endodontic origin and can be a valuable tool in our arsenal of treat-
ment modalities.
Conclusion
The course of the patients in this case series suggests with clinical
and radiographic evidence that intentional replantation is a procedure
that, when properly performed, can provide good long-term results for
teeth that otherwise would be regarded as hopeless.
Acknowledgments
The authors thank the study participants.
The authors deny any conflicts of interest related to this study.
References
1. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966;72:1111–8.
2124 Grzanich et al.
2. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population
in the USA: an epidemiological study. J Endod 2004;12:846–50.
3. Von Arx T. Failed root canals: the case for apicoectomy (periradicular surgery).
J Oral Maxillofac Surg 2005;63:832–7.
4. Setzer FC, Shah SB, Kohli MR, et al. Outcome of endodontic surgery: a meta-analysis
of the literature—part 1: comparison of traditional root-end surgery and endodon-
tic microsurgery. J Endod 2010;36:1757–65.
5. Sherman P Jr. Intentional replantation of teeth in dogs and monkeys. J Dent Res
1968;47:1066–71.
6. Cotter M, Panzarino J. Intentional replantation: a case report. J Endod 2006;32:
579–82.
7. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth.
Oral Surg Oral Med Oral Pathol 1993;76:623–30.
8. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premo-
lars and molars. J Am Dent Assoc 1971;83:1053–7.
9. Torabinejad M, Dinsbach N, Turman M, et al. Survival of intentionally replanted
teeth and implant-supported single crowns: a systematic review. J Endod 2015;
41:992–8.
10. Natiella JR, Armitage JE, Greene GW. The replantation and transplantation of teeth.
Oral Surg Oral Med Oral Pathol 1970;29:397–419.
11. Solomon C. Intentional replantation: report of case. J Endod 1981;7:316–9.
12. Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional replantation: a procedure
as a last resort. J Contemp Dent Pract 2011;12:486–92.
13. Wolcott J, Rossman LE. Intentional replantation of endodontically treated teeth: an
update. Compend Contin Educ Dent 2003;24:68–72.
14. Kawai K, Masaka N. Vertical root fracture treated by bonding fragments and rota-
tional replantation. Dent Traumatol 2002;18:42–5.
15. Asgary S, Marvasti L, Kolahdouzan A. Indications and case series of intentional
replantation of teeth. Iran Endod J 2014;9:71–8.
16. Peer M. Intentional replantation: a ‘last resort’ treatment or a conventional treat-
ment procedure? nine case reports. Dent Traumatol 2004;20:48–55.
17. Nimczyk SP. Re-inventing intentional replantation: a modification of the technique.
Pract Proced Aesthet Dent 2001;13:433–9.
18. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
J Endod 2006;32:601–23.
19. Nasjleti CE, Caffesse RG, Castelli WA. Replantation of mature teeth without endodon-
tics in monkeys. J Dent Res 1978;57:650–8.
20. Hayashi M, Kinomoto Y, Takeshige F, Ebisu S. Prognosis of intentional replantation of verti-
cally fractured roots reconstructed with dentin-bonded resin. J Endod 2004;30:145–8.
JOE — Volume 43, Number 12, December 2017