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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 231-235
Treatment of paraesthesia following root canal treatment by intentional tooth replantation: A review of the literature and a case report


1 The Maurice and Gabriela, Goldschleger School of Dental Medicine, Tel Aviv University, Israel
2 Department of Biomedical, Surgical and Dental Sciences, Universitŕ degli Studi di Milano - IRCCS Istituto Ortopedico Galeazzi, Dental Clinic, Milan, Italy

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Date of Submission16-Jan-2011
Date of Decision12-May-2012
Date of Acceptance09-Jun-2011
Date of Web Publication4-Jul-2014
 

   Abstract 

Background: Some endodontic procedures may cause damage to the inferior alveolar nerve, leading to paraesthesia. When such complication is due to extrusion of obturation material beyond the apex, it can be managed by intentional replantation (IR). IR consists of the removal of a tooth and its re-insertion into the socket after performing a proper root end manipulation. It is a relatively conservative procedure aimed at preserving the tooth and, with correct case selection, can provide a predictable outcome.
Aims: The aim of the present paper is to report a case of paraesthesia following endodontic treatment of second mandibular molar successfully treated by intentional replantation.
Results and Conclusion: In our opinion this treatment modality may be considered when the extrusion of root canal filling material causes irritation to the periapical tissues and endodontic retreatment is unfeasible.

Keywords: Intentional replantation, paraesthesia, root canal treatment

How to cite this article:
Tsesis I, Taschieri S, Rosen E, Corbella S, Fabbro MD. Treatment of paraesthesia following root canal treatment by intentional tooth replantation: A review of the literature and a case report. Indian J Dent Res 2014;25:231-5

How to cite this URL:
Tsesis I, Taschieri S, Rosen E, Corbella S, Fabbro MD. Treatment of paraesthesia following root canal treatment by intentional tooth replantation: A review of the literature and a case report. Indian J Dent Res [serial online] 2014 [cited 2020 Jan 21];25:231-5. Available from: http://www.ijdr.in/text.asp?2014/25/2/231/135931
In 1943, Seddon et al. [1] suggested a classification for neural injuries that was based on the severity of the tissue injury and the prognosis. Three levels of injury were suggested:

  1. Neuropraxia, characterized by local myelin damage, with axon continuity and no distal  Wallerian degeneration More Details. This form of injury is most commonly due to nerve compression. Recovery is complete and takes from a few hours to days [2]
  2. Axonotmesis is typical of crush injuries and is defined as loss of continuity of the axon, with preservation of the neural connective tissue sheath, which can support axonal regeneration. Distal Wallerian degeneration of the axons occurs. Axons regenerate at a rate of approximately 1 mm per day. Recovery is incomplete and may take several months.
  3. Neurotmesis is the most severe grade of peripheral nerve injury. There is nerve severance and anesthesia in the nerve distribution. There is no sensory recovery. [2],[3]


Paraesthesia is a classical sensory response resulting from neuropraxia [3] and is defined as 'a burning or prickling sensation or partial numbness caused by neural injury. Patients have described it variously as warmth, cold, burning, aching, prickling, tingling, pins and needles, numbness, and formication (itching in the absence of stimuli).' [4],[5]

Paresthesia in the distribution of the inferior alveolar nerve (IAN) could be idiopathic or it could result from trauma, tumors, connective tissue diseases, infectious diseases, and demineralizing diseases. [6] Various endodontic procedures may lead to IAN injury, a rare but serious treatment complication. [7],[8] IAN injury can result from periapical surgery, over-instrumentation, irritant root canal medicaments, and overfilling by root canal obturation materials. [9] Most cases have been reported in the lower second molars, but the complication may also occur in the first molars and premolars. [10] Three etiological mechanisms have been suggested: (1) mechanical trauma from over-instrumentation, (2) pressure caused by the presence of the endodontic point or sealant within the inferior alveolar canal, and (3) a neurotoxic effect of the endodontic medicaments or sealant materials. [10]

The pressure mechanism of injury is explained by the closed space of the osseous mandibular canal, which predisposes the enclosed nerve to compartment syndrome. Compression of the arterial blood supply of the nerve results in an acute phase with increased vascular permeability, edema, and ischemia, leading to decreased oxygen delivery to the nerve. Long periods of stretch and compressive forces can cause irreversible changes, with fibroblast invasion, scarring, and fiber degeneration. Recovery depends on the duration of the trauma and the severity of the lesion. Thus, decompression of the compartment may be indicated in order to prevent irreversible nerve damage. [3]

Chemical neurotoxicity results from extruded endodontic materials. [11-14] The filling materials most commonly associated with this complication are paraformaldehyde-containing pastes [e.g., Sargenti N2 paste (Hager and Werken, GmbH and Co. KG, Duisburg, Germany) and AH26 ® (Dentsply Maillefer Instruments, Ballaigues, Switzerland)]. Paraformaldehyde is a polymeric hydrate of formaldehyde that on contact with water releases formaldehyde gas, which may cause permanent damage to the nerve. [13],[14] AH26 ® is a synthetic resin that could cause neurotoxicity due to the formaldehyde formed from hexamethylenetetramine. [12],[14] Long-lasting nerve damage has also been reported with eugenol-containing cements (Zinc Oxide Eugenol (ZOE) and Portland Cements PCs). Eugenol is a phenol derivative that can penetrate the nerve and coagulate the proteins, causing chemical destruction of the axon. [3]

Both nonsurgical and surgical clinical modalities have been suggested for the treatment of endodontically-induced symptomatic IAN injuries. All suggested techniques are primarily based on case reports and small case-series studies. [2],[10] The common knowledge is that nerve damage increases with duration of the injury. [3] If radiographic evaluation reveals endodontic material within the confines of the inferior alveolar canal, careful monitoring of the patient during the postoperative period is crucial. If nerve injury-associated symptoms appear, aggressive treatment,including decompression, debridement, irrigation and cleaning of the nerve canal, may be indicated. [10]

Intentional replantation (IR) consists of the removal of a tooth and its re-insertion into the socket after endodontic manipulation or obturation of the canal, or both. [15] It is a relatively conservative procedure that, with correct case selection, results in a predictable outcome. [15],[16]

Grossman [15] reported 50 human teeth that were replanted, of which 45 were followed for more than 2 years. The teeth received pre-replantation endodontic therapy and coronal restoration whenever possible. The reported survival rate was 80% (36/45 replanted teeth survived). Bender and Rossman [16] reported an overall success rate of 80.6% for 31 teeth that were intentionally replantated. Weine, [17] however, criticized the IR modality, claiming that literature review reveals that viable treatment alternatives were often disregarded. He suggested that the possible indications of IR be minimized since the outcome is unpredictable. [17] However, his conclusions were based mainly on his personal experience.

The aim of the present paper is to report a case of paraesthesia following endodontic treatment of a second mandibular molar, which was successfully treated by IR.


   Case report Top


A 20-year-old female patient presented to the surgical department with the main complaint of lack of sensation in her right lower lip and chin that had appeared following endodontic treatment of the lower right second molar 1 month earlier.

Her medical history was noncontributory. Anamnesis revealed that the paraesthesia had started 10 days after the endodontic treatment and had progressed slowly until there was almost complete lack of sensation in the affected area. On clinical examination, there was no sensation on light touch and pin prick on the right lower lip and chin. A panoramic x-ray and CT scan examination [Figure 1] demonstrated radiopaque filling material extending into the mandibular canal space adjacent to a single-rooted root canal-treated lower right second molar.
Figure 1: Preoperative panoramic and CT scan showing radiopaque filling material extending into the mandibular canal space from the lower right second molar

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The decision to perform IR was made after the patient had been informed about the expected prognosis and treatment alternatives. Following local anesthesia by mandibular block, the tooth was carefully extracted, with the overextended gutta-percha filling protruding from the root apex [Figure 2]. Under surgical loupes (magnification 2.5×), the root was resected 3 mm from the apex, confirming that only one root canal was present. The root canal was prepared to the depth of 3 mm using a low-speed 0.5-mm round tungsten bur, dried with paper points and filled with Intermediate Restorative Material (IRM; LD Caulk, Milford, DE, USA). The tooth was re-inserted in its socket without splinting [Figure 3]. The whole procedure took less than 8 min. During the procedure the tooth was held in surgical forceps. Care was taken not to touch the root surface and expose the periodontal ligament. The patient was advised to take oral doxycycline 100 mg tablets, once daily, for 1 week and dexamethasone 2 mg, three times daily, for 3 days. She was also instructed to rinse with a 0.2% chlorhexidine solution twice a day for 7 days and to brush the involved tooth gently with a soft-bristle toothbrush.
Figure 2: The picture shows both the socket after dental extraction and the extracted tooth with a protruding gutta-percha point

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Figure 3: Radiographic and clinical view of the tooth immediately after replantation

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At follow-up 1 week after the treatment, the patient reported significant improvement in symptoms, with partial resolution of the paraesthesia. At follow-up 3 months after treatment, the tooth was asymptomatic without pathological mobility, and full recovery of sensation was observed. At the recall visits performed at 6 months, 1 year, and 4 years following the treatment, the tooth remained asymptomatic. Satisfactory bone regeneration was observed radiographically and the sensation in the previously affected areas was normal [Figure 4].
Figure 4: The 4-years follow-up periapical x-ray reveals good bone regeneration around the root apex

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   Discussion Top


In 1966, Grossman [15] suggested several possible indications and contraindications for performing IR. The suggested indications included cases of broken endodontic instruments; mechanical obstruction of the root canal; root perforation; calcified root canal; large periapical rarefaction or suspected cyst in a posterior tooth, when retrograde endodontic surgery is not feasible; cases of root resorption; and sharply curved canals. The contraindications included periodontal involvement, with extensive tooth mobility; labial or cortical plates that are destroyed or missing; and likelihood that extraction of the tooth would fracture the crown or roots. [15]

Bender and Rossman [16] suggested that IR should be considered as another useful treatment modality and not as a procedure of last resort. They recommended IR as the treatment of choice for lower second molars, single-rooted teeth, and lower first molars when apical surgery is not possible due to difficult access; when the mental foramen is superimposed over the apex of the premolars; when the molar apex is in close proximity to the mandibular canal; when patients refuse periradicular surgery; when failures occur after apical surgery; and when surgery would create a periodontal pocket as a result of extensive bone removal. They stated that apical surgery is to be preferred for first molars with curved or widespread roots because they are more prone to fracture during the extraction. [16]

It should be noted that modern day endodontics offers many opportunities to diagnose and treat cases that traditionally presented a tremendous clinical challenge. [18-22] Thus, IR should be considered only in rare cases when orthograde/retrograde modern retreatment is unfeasible.

In the present case, the patient was informed of the uncertain etiology of her paraesthesia (inflammation or nerve compression) and of the available alternative therapeutic procedures. We explained that her condition could be due to the presence of endodontic material (cement or gutta-percha) in the alveolar canal, the presence of bacterial flora beyond the apex, and/or inadequate orthograde therapy.

In this patient, the first possible therapy was tooth extraction and partial removal of the lesion, without isolating the alveolar nerve. However, with this treatment, in addition to the loss of the tooth there was the risk of persistence of the inflammatory stimulus due the permanence of the cement. The second option was tooth extraction and total enucleation of the lesion and of the foreign material. With this, all possible irritants could have been removed but there was a very high risk of nerve injury. The final option was tooth replantation without lesion enucleation, which would allow her to keep the tooth and, at the same time, remove all the inflammatory factors except for the endodontic cement. Tooth retreatment was not considered as a viable treatment option because of the risk of further dislodging the endodontic obturation material beyond the apex during root canal instrumentation. This, in fact, could have worsened the injury.

The patient chose to undergo tooth replantation and was aware that, in case of failure of treatment and persistence of the symptoms, all the possible irritants could be removed in a subsequent surgical procedure.

In our opinion, this treatment modality, first presented by Grossman [15] and still viable today, should be considered when root canal filling material is lying free in the tissues, acting as a foreign body irritating the periapical tissues, and retrograde endodontic treatment is unfeasible due to proximity of a major dental nerve on the root apex. [15],[16] Doxycycline 100 mg tablets and dexamethasone 2 mg were used as postsurgical medications because of the beneficial effects of such drugs in tooth replantation. [23-25]

The replanted tooth was not rigidly splinted because of the immediate initial stability and because we wanted to avoid any negative effects on the prognosis due to ankylosis and complications during root development, which are problems that have been described in the literature. [26-28]

Some endodontic sealers, when extruded beyond the apex, can cause severe toxic reactions in the tissues surrounding the tooth. [11-14] In the present case, the fact that the neurological symptoms and signs disappeared after the intervention suggest that the sealer did not have any influence in determining the paraesthesia. As agreed with the patient, no further surgical procedure was performed to remove the sealer in the inferior alveolar canal because of regression of the neurological symptoms.

In the literature, some cases of tooth replantation with a follow-up duration of 15 years or longer have been reported. [29],[30] A recent retrospective study [31] of 42 endodontically-treated teeth suggested that a median recall period of 2.8 years may be sufficient for establishing the prognosis in such cases. However, studies with a larger sample size would be needed to provide conclusive data about the correct follow-up evaluation time.

In conclusion, this case report suggests that tooth replantation can be a viable alternative for the management of paraesthesia following inadequate endodontic therapy.

 
   References Top

1.Seddon HJ, Medawar PB, Smith H. Rate of regeneration of peripheral nerves in man. J Physiol 1943;102:191-215.  Back to cited text no. 1
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3.Scolozzi P, Lombardi T, Jaques B. Successful inferior alveolar nerve decompression for dysesthesia following endodontic treatment: Report of 4 cases treated by mandibular sagittal osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:625-31.  Back to cited text no. 3
    
4.Lambrianidis T, Molyvdas J. Paresthesia of the inferior alveolar nerve caused by periodontal-endodontic pathosis. Oral Surg Oral Med Oral Pathol 1987;63:90-2.  Back to cited text no. 4
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Correspondence Address:
Massimo Del Fabbro
Department of Biomedical, Surgical and Dental Sciences, Universitŕ degli Studi di Milano - IRCCS Istituto Ortopedico Galeazzi, Dental Clinic, Milan, Italy

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.135931

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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