Tooth avulsion in the school setting

Tooth avulsions occur when a tooth is displaced from its socket. Tooth avulsions are common dental injuries that may occur before, during, or after school. Therefore, it is essential that school nurses be well prepared to intervene when such a dental emergency arises. It is also imperative that school nurses and school personnel are fully equipped to manage a tooth avulsion. Time is of the essence when attempting to save an avulsed tooth. The goal is to successfully reinsert the avulsed tooth and to preserve the periodontal ligament. The school nurse is responsible for implementing the appropriate actions needed to save the avulsed tooth.

Occlusal forces promote periodontal healing of transplanted teeth and prevent dentoalveolar ankylosis: an experimental study in rats

The process of healing periodontal ligaments (PDL) after transplantation has been widely examined, but the mechanism for preventing dentoalveolar ankylosis is still unclear. In this study, we focused on the role of mechanical stimuli in preventing ankylosis using an animal model of tooth transplantation assessed by histologic observation and evaluation of proliferating PDL cells. Five-week-old Sprague-Dawley male rats were divided into occluded and nonoccluded groups. The right maxillary first molars were replanted in both groups, and histologic observations were carried out after one or two weeks. The proliferative activity of PDL cells was also examined by assessing the distribution of 5-bromo-2'-deoxyuridine (BrdU). After two weeks in the nonoccluded group, ankylosis was clearly detected and PDL stricture was obvious, whereas no severe bone or root resorption was observed. On the other hand, the occluded group showed an enlarged and thickened PDL with extensive root resorption, but no ankylosis. Based on these findings, the replanted teeth were given a one-week healing period and then occlusion recovery was assessed, which resulted in decreased ankylosis and root resorption. The proliferative activity of PDL cells in the occluded group was generally higher than in the nonoccluded group. The activity of PDL cells in the recovery group was also higher than that of the nonoccluded group. These results suggest that occlusal stimuli promoted the regeneration of the PDL and prevented dentoalveolar ankylosis, whereas excessive initial force might cause severe root and bone resorption.

Use of Enamel Matrix Protein Derivative Before Dental Reimplantation: A Histometric Analysis

The use of enamel matrix protein in the treatment of periodontal defects has shown a favorable action on the proliferation of periodontal ligament cells, as well as on collagen formation and mineralization. The goal was to evaluate, histologically and histometrically, periodontal tissue regeneration after dental reimplantation using enamel matrix protein derivative (Emdogain, Biora AB, Malmö, Sweden). Male rats (Albinus, Wistar), weighing between 180 and 200 g, were divided in 3 groups. Animals in group I (control) had the upper right incisors extracted, the root canal was sealed with calcium hydroxide, and teeth were reimplanted in their alveoli. Group II underwent the same procedure, but the remaining periodontal ligament was removed from the root surfaces by root planing before reimplantation. In group III,following removal of the periodontal ligament, Emdogain was applied to the root surfaces. Animals were sacrificed 7, 20, and 60 days after reimplantation, and the alveoli were fixed, processed, and stained with hematoxylin and eosin. Formation of periodontal ligament, resorption areas, and ankylosis were analyzed. The results showed that group I (control) was better than groups II and III, with statistically significant differences on days 7 and 20 after reimplantation for formation of periodontal ligament. It may be concluded that with the methodology used, Emdogain was unable to stimulate tissue repair in reimplanted teeth.

[Analysis of the causes and emergency management of 154 traumatized permanent incisors in primary school children]

PURPOSE

This study was designed to investigate the related factors of permanent incisors trauma among primary school children, and evaluate the results of replantation of 56 avulsed teeth.

METHODS

Data were collected by 122 questionnaire from teachers or parents of the primary school children with dental trauma, with regard to the related trauma causes, altitudes and emergency management of dental avulsion. 56 avulsed teeth were replanted immediately after appropriate manipulation. The results of replantation were evaluated 1 year later.

RESULTS

Tumble (fall off) was the main cause for dental trauma. The maxillary central incisor was most vulnerable to injury, without differences between the right and the left side. Single tooth injury was predominant in all age groups. Children with an incisal overjet tended to have a greater chance of dental trauma. Crown fractures represented 89 (57.79%)of 154 traumatized teeth; root fractures represented 9 (5.84%); avulsed represented 56 (36.3%). Most teachers and parents had little knowledge of the correct procedures for replanting or transporting avulsed teeth. 53 of 56 replanted teeth (94.64%) were integrated successfully.

CONCLUSION

The parents and school educators should be advised about prevention of injuries and actions to be taken in case of an accident. The functional and esthetical outcome of replantation in avulsed teeth is excellent.

Splinting of traumatized teeth with focus on adhesive techniques

Splinting of traumatized teeth is an important step in the treatment of periodontally injured teeth and a precondition of healing of the periodontal tissues. Although it has been shown in animal experiments that replanted teeth without splinting showed analogous healing outcomes compared to splinted teeth, the placement of a splint in dental trauma situations is warranted for medico-legal reasons, for the comfort of the patient, and for the avoidance of additional trauma during periodontal healing. Ideally, the splinting of traumatized teeth should be an easy and fast procedure for the dentist. Trauma splints should be comfortable and easy to keep clean for the patient. The splint should allow some physiologic mobility to promote healing of the periodontal tissues. The widely used and recommended wire-composite splint, with material variations, meets the ideal requirements of current splinting concepts in dental traumatology. Times of using destructive tissue-coverage splints are definitely gone. They are too rigid, compromise periodontal and gingival healing, and are uncomfortable to the patient. The objective of this article is to present the current concepts in splinting of traumatized teeth. The given recommendations about splinting techniques and splinting periods are based on experimental and clinical studies.

The effect of basic fibroblast growth factor on delayed-replanted monkey teeth

BACKGROUND

Basic fibroblast growth factor (bFGF; FGF-2) has been reported to facilitate wound healing and periodontal regeneration in experimental alveolar bone defects. The purpose of this study was to evaluate histologically the effect of topically applied bFGF with or without fibrin glue on delayed-replanted monkey teeth prone to replacement resorption.

METHODS

Forty-five roots from five monkeys were endodontically treated aseptically and then extracted as atraumatically as possible. Ten negative control roots were replanted immediately, while 12 positive control roots were allowed to bench dry for 1 hour prior to replantation, both without further treatment. Roots in the two experimental groups were bench dried for 1 hour, rinsed with saline, and then replanted into sockets filled with bFGF with (11 roots) or without (12 roots) fibrin glue. After 12 weeks, histological sections were prepared and evaluated according to morphometric analysis as complete healing or unfavorable healing composed of inflammatory resorption and replacement resorption.

RESULTS

Kruskal-Wallis and Mann-Whitney U tests showed teeth in the negative control group to have significantly higher complete healing (98.88% +/- 2.30%) and significantly lower unfavorable healing (1.12% +/- 2.30%) than the positive control group and the experimental groups. bFGF/fibrin glue group showed higher occurrence of complete healing (39.06% +/- 41.62%) compared to the bFGF group (25.28% +/- 28.85%) and the positive control group (16.58% +/- 19.60%), although the differences were not significant. Comparing the complete and unfavorable healing, there was no significant difference in the bFGF/fibrin glue group (P = 0.47), but the differences were significant in the other groups (P < 0.05).

CONCLUSION

Topical application of bFGF with fibrin glue showed an insignificantly higher occurrence of complete healing in delayed-replanted monkey teeth.

Occlusal forces promote periodontal healing of transplanted teeth with enhanced nitric oxide synthesis

It has been reported that occlusal forces promote periodontal healing of transplanted teeth and prevent dentoalveolar ankylosis, although its mechanism is still unclear. Nitric oxide (NO) produced by NO synthase (NOS) is considered to be an important factor which is involved in wound healing, and it increases with mechanical stimuli. The objective of this study was to examine the relationship among occlusal stimuli, inducible NOS (iNOS) and PDL healing of transplanted teeth. Five-week-old Sprague-Dawley male rats were used for this study. The right maxillary first molars of rats were replanted and animals were divided into occluded and non-occluded groups. Histologic observations were carried out after one and two weeks. After two weeks, the non-occluded group had clearly detectable ankylosis and obvious PDL stricture. On the other hand, the occluded group showed an enlarged and thickened PDL without ankylosis. The number of iNOS positive cells in the occluded group, samples significantly increased in comparison to that of the non-occluded group. These results suggest that occlusal stimuli enhanced the production of NO in the PDL healing process of transplanted teeth and a favorable result could be obtained.

Treatment of avulsed teeth with Emdogain--a case report

The present case report describes the reimplantation of avulsed teeth with the treatment of Emdogain. Case was avulsed right maxillary permanent central and lateral incisor in a 9-year-old girl suffering from a traumatic injury. After pretreatment of avulsed teeth, Emdogain was applied to the root surface and into the extraction socket with subsequent replantation of the tooth. Evaluation parameters included horizontal and vertical percussion sound and periapical radiographs. At 1-2-6-12-month follow-up period, the clinical and radiographic appearance of the teeth showed resolution of mobility and no signs of replacement resorbption.

Treatment of a severe dental lateral luxation associated with extrusion in an 8-month-old baby: a conservative approach

This case report documents the trauma and follow-up care of lateral luxation associated with extrusion of the lower central incisors in an 8-month-old patient. The teeth were repositioned by digital pressure and stabilized using proximal sutures. Clinical and radiographic follow-up 40 months after the injury showed alterations in both incisors, but both remained functional and free of pathology.

EmdogainR does not prevent progressive root resorption after replantation of avulsed teeth: a clinical study

Emdogain has been shown in clinical and experimental studies to promote regeneration of all periodontal tissues: cementum with anchoring fibres, a functional, periodontal ligament and alveolar bone in connection with treatment of marginal periodontitis. The intention of this study was to analyse whether this regenerative capacity upon the periodontal ligament also worked in a trauma situation where a significant number of PDL cells have been eliminated because of unphysiologic storage or actual damage during avulsion or replantation. Furthermore if ankylosis sites already established because of earlier replantation after avulsion could be surgical removed and application of Emdogain could revert the ankylosis stage to a normal PDL situation. The first treatment situation was tested in seven patients with a total of 16 avulsed teeth with varying time of extra oral storage. The teeth were extra-orally endodontically treated and the root and socket covered with Emdogain before replantation. All teeth demonstrated subsequent ankylosis, primarily diagnosed by a percussion test. The second treatment situation where an ankylosis was already established constituted of seven patients with a total of 11 teeth because of previous replantation after avulsion. These teeth were all extracted, the ankylosis sites removed and the root and socket treated with Emdogain. After 6 months all teeth showed recurrence of ankylosis. It is concluded that Emdogain was not able to prevent or cure ankylosis.

[Injuries to permanent teeth. Part 2: Therapy of avulsion]

The present paper describes the current treatment philosophy of dislocated or avulsed permanent teeth at our school. Splinting and medication (root canal treatment, systemic antibiotics, etc.) are targeted to minimize the initial inflammatory reaction and to reduce post-traumatic complications such as pulp necrosis and/ or external root resorption.

Auto-transplantation of central incisor with root dilaceration. Technical note

A case of central incisor with root dilaceration and ensuing impactation was treated by means of auto-transplantation. The 7-year follow-up period shows a stable result.

Intentional Replantation Of A Lower Premolar

Intentional replantation is the purposeful extraction of a tooth to perform extraoral endodontic treatment, curettage of apical soft tissue when present and the replacement of the tooth in its socket. This paper demonstrates the use of intentional replantation as a technique to successfully treat a case where conventional endodontic retreatment and apical surgery were considered unfeasible.

Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics

This is the second part of a retrospective study of 400 root-fractured permanent incisors. In this article, the effect of various treatment procedures is analyzed. Treatment delay, i.e. treatment later than 24 h after injury, did not change the root fracture healing pattern, healing with hard tissue between fragments (HH1), interposition of bone and/or periodontal ligament (PDL) or pulp necrosis (NEC). When initial displacement did not exceed 1 mm, optimal repositioning appeared to significantly enhance both the likelihood of pulpal healing and hard tissue repair (HH1). Significant differences in healing were found among the different splinting techniques. The lowest frequency of healing was found with cap splints and the highest with fiberglass or Kevlar splints. The latter splinting procedure showed almost the same healing result as non-splinting. Comparison between non-splinting and splinting for non-displaced teeth was found to reveal no benefit from splinting. With respect to root fractures with displacement, too few cases were available for analysis. No beneficial effect of splinting periods greater than 4 weeks could be demonstrated. The administration of antibiotics had the paradoxical effect of promoting both HH1 and NEC. No explanation could be found. It was concluded that, optimal repositioning seems to favor healing. Furthermore, the chosen splinting method appears to be related to healing of root fractures, with a preference to pulp healing and healing fusion of fragments to a certain flexibility of the splint and possibly also non-traumatogenic splint application. Splinting for more than 4 weeks was not found to influence the healing pattern. A certain treatment delay (a few days) appears not to result in inferior healing. The role of antibiotics upon fracture healing is questionable.

New Regenerative Surgical Treatment of Cystic Diseases of the Jaw by Utilizing Grafting of Cancellous Iliac Bone and Replanting of Patient’s Teeth

The authors developed a new regenerative surgical technique for cystic diseases of the jaw. In this surgery, all teeth that are rooted in or located adjacent to the cyst are extracted for replanting, and attached soft tissues, including cystic wall as well as dental pulp, are completely removed. Gingiva is cut open at the alveolar crest and abraded subperiosteally, the jaw on the cystic lesion is widely exposed, and cortical bone on the frontal wall of the cystic lesion is dissected. After the entire cyst is exposed, it is completely removed with scrapers and bars. The defect is reconstructed by the following procedures: the extracted and treated teeth are replanted; cancellous iliac bone (bone marrow) is grafted around the teeth and in the defect; and after thorough washing and making numerous small holes, the frontal wall of the cortical bone is returned to the original position and fixed. Three to 4 months later when the jaw has regenerated and the replanted teeth have taken, a prosthesis is set on the replanted teeth and biting is started. This technique was applied to a 16-year-old male patient who had odontogenic keratocysts on the lower right teeth (numbers 6, 5, 4, 3, 2, and 1), the lower left teeth (numbers 1, 2, 3, and 4), and the upper right teeth (numbers 5, 4, 3, and 2). The patient regained normal biting capability, and the esthetic outcome was also satisfactory. This technique would be a useful treatment method for cystic diseases of the jaw.

The biomechanical properties of the healing periodontium of replanted rat mandibular incisors

One of the most important aspects in tooth replantation seems to be restoration of the tooth support function of the healing periodontal ligament (PDL). We examined the support function, as measured by the mechanical properties, of the healing PDL at 7, 14, and 21 days after replantation of the left mandibular incisor in rats. From each dissected left mandible, a transverse section(650 microm in thickness) of the incisor was cut through an axis near the labial alveolar crest. Each section was intrusively loaded at a rate of 5 mm min(-1), and the shear stress-strain curve for the PDL was analyzed. Mechanical measures of the healing PDL showed gradual improvement after replantation. By 21 days, the mechanical strength returned to 53% of the control value; the extensibility, to 85%; the stiffness, to 61%; and the toughness, to 52%. The healing PDL exhibited reattachment of fibers in the middle region of the PDL, and the birefringent collagen fibers appeared to have regained the functional orientation by 14 days. The ratios occupied by the birefringent collagen fibers in the tooth-related, middle, and bone-related areas of the healing PDL gradually improved and returned to 78, 51, and 48% of the respective control values by 21 days. These results suggest that the support function of the healing PDL is gradually restored and that the biomechanical restoration is closely related to the reorganization and reorientation of collagen fiber bundles in replanted rat incisors.

Management of a complex dentoalveolar trauma with multiple avulsions: a case report

Treatment of permanent tooth avulsions in an adolescent poses significant difficulties for the dental clinician. This case report gives details about the treatment of a complex dentoalveolar trauma involving multiple avulsions of primary molars, permanent incisors, permanent molars, and premolar toothbuds. Immediate treatment of the injury and short-term esthetic replacement of the dentition is described. A brief review of current research relative to the treatment of permanent tooth avulsions is provided.

Successful treatment of a radicular groove by intentional replantation and EmdogainR therapy

Radicular groove is an anatomical malformation often predisposing to a severe periodontal defect. Treatment of such an anomaly presents a clinical challenge to the operator. Presented is a case of successful treatment of a radicular groove associated with a maxillary lateral incisor in a 15-year-old girl. A combination of endodontic, intentional replantation and Emdogain therapy was used. At 1-year follow-up, the patient was comfortable and active healing was evident.

Treatment Options of Untreatable Traumatized Anterior Maxillary Teeth for Future Use of Dental Implantation

The anterior maxilla is the most traumatized region during childhood. Posttraumatic complications occasionally lead to tooth loss as well as the need for future implants. Unfortunately, it is contraindicated to place dental implants during childhood. A waiting period of approximately 8 to 10 years before completion of growth is required. For this patient to become a candidate for future dental implants, it is necessary to ensure the continuous growth and to preserve the dimensions of the alveolar process until growth has ceased from time of injury until joint maturation. To achieve these goals, it is essential to coordinate the treatment sequence at the time of trauma. After loss of a traumatized anterior permanent maxillary incisor in young adults, treatment options are limited: orthodontic closure of the gap and reshaping the adjacent teeth, or tooth extraction and maintaining the gap with a temporary restoration. Orthdontic space closure has limited indications and requires prosthetic restoration of at least 2 teeth. Extraction and temporary restoration will usually lead to bone augmentation before implantation. Other possible treatment options include orthodontic extrusion of the root remnant (in cases of untreatable root fracture or complicated crown-root fracture) and a temporary crown to serve the patient until the completion of growth and development, autogenous tooth transplantation, intentional extraction and immediate tooth replantation, distraction osteogenesis, and decoronation. Because general rules do not apply, individual treatment plans are necessary.

Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry, radiography, and histology

This study investigated the effect of topical antibiotic treatment on pulp revascularization in replanted teeth. Thirty-four immature teeth were selected from three young dogs. Baseline radiographs and laser Doppler flowmetry (LDF) readings were obtained. Specimens were randomly divided into four groups: Thirty-eight teeth were extracted, kept dry for 5 min, and either (Group 1) covered with minocycline mixture (G1, n = 11), (Group 2) soaked in doxycycline (G2, n = 11), or (Group 3) soaked in saline (G3-negative control, n = 6), and replanted. Teeth in Group 4 were not extracted (positive control, n = 6). Postoperative radiographs and LDF readings were obtained for 2 months after replantation. After sacrifice, the jaws were collected and processed for light microscopy. Pre- and postreplantation LDF readings and radiographs, and histologic findings were analyzed to assess revascularization. Pulp revascularization occurred in 91% (G1), 73% (G2), and 33% (G3) of the specimens. In conclusion, minocycline facilitates pulp revascularization in replanted immature teeth after replantation.

[Dentoalveolar traumatology]

The dentist will be confronted unexpectedly with a dentoalveolar trauma patient. This patient has to be seen immediately and has to be treated adequately. The risk of overlooking trauma-related signs when examining these patients, can be minimized by following a strict protocol. This article describes a protocol for examination and treatment of a patient with a dentoalveolar trauma. The prognosis after treatment of the trauma is discussed. Also some recommendations regarding aftercare and prevention are presented.

Intentional replantation of an immature permanent lower incisor because of a refractory peri-apical lesion: case report and 5-year follow-up

We performed an intentional replantation of an immature lower incisor that had a refractory peri-apical lesion. The incisor was extracted and the peri-apical lesion was removed by curettage. The root canal of the tooth was then rapidly irrigated, and filled with a calcium hydroxide and iodoform paste (Vitapex(R)), after which the tooth was fixed with an arch wire splint. Five years later, no clinical or radiographic abnormalities were found, and the root apex was obturated by an apical bridge formation. A team of two dentists is essential to prevent a prolonged operation time, thus eliminating any of the causes of ankylosis. Furthermore, calcium hydroxide and iodoform paste, along with an arch wire splint retained with composite resin, led to good healing of the periodontal tissue after the intentional replantation. Our results indicate that intentional replantation is a useful method for an immature tooth with refractory peri-apical problems.

Therapeutic protocols for avulsed permanent teeth: review and clinical update

Traumatic injuries to permanent teeth include coronal and root fractures, subluxations, luxations, and avulsions. The most common complications after avulsions are necrosis of the pulp and root resorption. Treatment is often complex, time consuming, and expensive and requires multidisciplinary approaches such as endodontic and periodontal treatments, surgery, orthodontic movements, as well as esthetic coronal restoration. This review describes new clinical modalities for the treatment of avulsed teeth and discusses the rationale for their use.

Endodontic treatment of reimplanted avulsed teeth

By using an appropriate storage system such as a Save-A-Tooth and having knowledge of appropriate treatment options, an avulsed tooth can be reimplanted with the greatest chance of success. Using the different categories of avulsed teeth discussed in this article as a guide, the clinician can determine the most applicable course of treatment. If endodontic treatment is based on the clinical condition of the pulp and PDL cells, the chance of success following reimplantation is improved.

Periodontal regeneration of transplanted rat molars after cryopreservation

The effects of cryopreservation on periodontal regeneration of transplanted rat molars were investigated histologically and histochemically in rats. Bilateral first and second maxillary molars of 4-week-old Wistar rats were gently extracted and transplanted into the abdominal subcutaneous connective tissue immediately or after cryopreservation in liquid nitrogen overnight. Donor teeth were slowly frozen by a rate-controlling freezer (program freezer) using 5% dimethylsulfoxide (DMSO) and 6% hydroxyethyl starch (HES) as cryoprotectants. One-four weeks after transplantation, they were carefully excised with the surrounding tissues. Regeneration of acellular cementum, periodontal ligament, and alveolar bone were observed 2 weeks after immediate transplantation. The pulp was repaired by the ingrowth of granulation tissue from the root apex followed by the formation of calcified tissue. The regenerated periodontal ligament was positive for alkaline phosphatase (ALP). Small or mononuclear tartrate resistant acid phosphatase (TRAP) positive cells were scattered on the newly formed alveolar bone and on the hard tissue in the pulp, but there was no external or internal progressive root resorption at 4 weeks. Cryopreserved teeth had acellular cementum with a rough surface at 1 week, but with the increase of cementoblasts and the appearance of periodontal ligament and alveolar bone, the surface became smooth at 3 weeks. Epithelial rests of Malassez (ERM) also revived. After regeneration of the periodontal tissues at 4 weeks, there was no evidence of root resorption. Although the process proceeded slowly, the cryopreserved teeth showed the periodontal regeneration substantially similar to that of the immediately transplanted teeth without progressive root resorption, indicating that they could be applicable for clinical use.

A quantitative analysis of Propolis: a promising new storage media following avulsion

Both length of extra-alveolar time and type of storage media are significant factors that can affect the long-term prognosis of replanted teeth. Numerous studies have examined various media in an attempt to determine the ideal material for storage of the avulsed tooth. The purpose of this study was to use a Collagenase-Dispase assay to investigate the potential of a new storage media, Propolis, in maintaining viable periodontal ligament (PDL) cells on simulated avulsed teeth. Seventy freshly extracted human teeth were divided into five experimental groups and two control groups. The positive and negative controls corresponded to 0-min and an 8-h dry time, respectively. The experimental teeth were stored dry for 30 min and then immersed in one of the five media (Hank's balanced salt solution (HBSS), milk, saline, Propolis 50%, and Propolis 100% for 45 min). The teeth were then treated with dispase grade II and collagenase for 30 min. The number of viable PDL cells were counted with a hemocytometer and analyzed. Statistical analysis demonstrated that both Propolis groups kept significantly more PDL cells viable compared to either milk, saline, or HBSS. Within the parameters of this study, it appears that Propolis may be a better alternative to HBSS, milk, or saline in terms of maintaining PDL cell viability after avulsion and storage.

Tooth replantation after traumatic avulsion: a 27-year follow up

This report presents a case of replantation of a traumatically avulsed central incisor in a 32-year-old woman. The tooth was replanted after a 30-min extra-alveolar period. Emergency unconventional immobilization was performed, using 2-0 chromic gut, and a restorative composite made Gunning-type splint. The tooth is still in place 27 years after replantation (1976 to date) without marked resorption.

[New treatment protocols for avulsed teeth]

Traumatized teeth present a clinical challenge with regard to their diagnosis, treatment plan and prognosis. The injuries to the permanent dentition include crown and root fractures, subluxations, luxations and tooth avulsion. Common complications are pulp necrosis, periapical pathosis and root resorption. This article will describe new clinical modalities for the treatment of avulsed teeth and discuss the rational for their use.

Prognosis of Intentional Replantation of Vertically Fractured Roots Reconstructed with Dentin-Bonded Resin

There is no particular treatment established to preserve vertically fractured teeth. We evaluated the long-term prognosis of the intentional replantation of 26 vertically fractured roots after reconstruction with 4-META/MMA-TBB dentin-bonded resin. Replanted teeth were evaluated according to clinical criteria and radiographic examinations for periods ranging from 4 to 76 months. Eighteen cases were functional and retained, with six fully successful; the others needed further observation. Eight cases failed to respond to treatment because of refracture, recurrence of gingival inflammation, or both. Longevity was calculated as 88.5% at 12 months after replantation, 69.2% at 36 months, and 59.3% at 60 months. All failures occurred in premolar and molar teeth. Longitudinal fractures extending more than 2/3 from the cervical portion toward the apex showed significantly shorter longevity compared with fractures within the 2/3 area (log-rank test, p = 0.02). Intentional replantation of vertically fractured roots reconstructed with dentin-bonded resin may be considered for incisors as an alternative to extraction, although the long-term success is not optimal.

Reimplantation, bone augmentation, and implantation procedures for impacted maxillary canines: A clinical report

Single tooth implant-supported restorations have become a common procedure for the restoration of missing teeth. This clinical report describes the treatment and long-term follow-up of 2 maxillary implant-supported crowns in the canine region placed after unsuccessful reimplantation and successful bone augmentation procedures. In spite of the complicated procedures presented, a good long-term clinical result was achieved.

Histologic analysis of pulpal revascularization of autotransplanted immature teeth after removal of the original pulp tissue

The survival rate of replanted and autotransplanted teeth is mainly affected by the reaction of the pulp. Pulpal necrosis can cause periapical inflammation and inflammatory root resorption. The purpose of this study is to learn more about the pulpal changes in autotransplanted immature teeth whose pulp tissue was removed before transplantation. The experimental material consisted of 16 single-rooted teeth with open apices, from a beagle dog (3 months of age). At day 0, 4 teeth were extracted, the pulpal tissues were removed, and the teeth were then transplanted to their contralateral side. The same procedure was carried out on days 9, 16, and 23, each time for 4 single-rooted teeth. Longitudinal paraffin sections were made for histologic investigation. The results showed that, after 7 days, 2 of the 4 teeth had an ingrowth of new tissue over one fourth of their length. After 14 days, all 4 teeth had ingrowth (> or =one fourth of the pulp chamber). At the 21-day observation, more than half of the pulp chambers of all teeth were filled, and, after 30 days, there was total ingrowth in 3 of the 4 teeth. This new tissue consisted of well-organized and well-vascularized connective tissue.

Assessing revascularization of avulsed permanent maxillary incisors by laser Doppler flowmetry

BACKGROUND

Laser Doppler flowmetry, or LDF, is a noninvasive method used to assess pulpal blood flow, or PBF. Dental avulsion is associated with loss of pulpal sensitivity. The authors conducted this study to assess whether LDF could be used to detect revascularization of replanted teeth.

METHODS

The authors used LDF to assess the PBF values of avulsed permanent maxillary incisors treated using replantation and splinting in 17 subjects. They took measurements at four sessions: on the day of splint removal and at 12 weeks, 24 weeks and 36 weeks after splint removal. Five vital control teeth and five nonvital control teeth were used to assess the background signal. At 36 weeks, the authors determined clinically and radiographically whether revascularization had occurred.

RESULTS

LDF readings correctly predicted the pulp status in 88.2 percent of the readings. Of the readings for vital teeth, 100 percent were correct, and of the readings for nonvital teeth, 80 percent were correct. Univariate analysis of variance demonstrated that in revascularized teeth, the PBF value increased significantly from splint removal to week 12 after splint removal and from week 24 to week 36 after splint removal. In the teeth that failed to revascularize, the PBF value dropped significantly from week 24 to week 36 after splint removal.

CONCLUSIONS

The results of this study suggest that LDF accurately diagnoses revascularization of avulsed maxillary incisors after replantation and splinting.

CLINICAL IMPLICATIONS

LDF may become useful in detecting revascularization much earlier than standard sensitivity tests.

A new approach using the surgical extrusion procedure as an alternative for the reestablishment of biologic width

A modification of the surgical extrusion technique to treat fractured teeth was realized as an alternative periodontal therapy to avoid ostectomy following orthodontic extrusion of teeth with their biologic widths compromised by different etiologic involvements. After delicate luxation and arrested avulsion, the teeth were coronally positioned to allow room for a new biologic width. Clinical and radiographic monitoring showed the ability of the periodontium to adapt function and esthetic recovery. The advantages and disadvantages of this therapeutic procedure for resolution of a periodontal involvement are presented.

Clinical outcomes for permanent incisor luxations in a pediatric population. II. Extrusions

A longitudinal outcome study was undertaken to identify variables that significantly influenced outcomes for extruded permanent maxillary incisors of children and adolescents. Clinical and radiographic data was available for 35 patients (18 males, 17 females) representing 55 incisors. Mean age at the time of injury was 10.6 years (range: 7.1-17.8 years). Mean time elapsed to follow up was 1320 days (range: 423-2887 days). Survival analysis was used to identify variables significantly related to the prognosis of these teeth. The loss of an incisor following extrusion was uncommon as only one tooth (1/55) required extraction. There was no statistically significant difference in survival between severely extruded teeth and avulsions that had been stored in physiological media (P > 0.10). Pulp necrosis (PN) was the most common complication following injury (43%) and it most often occurred during the first year. Although not statistically significant, a trend towards increased PN was found with more severely extruded teeth (P = 0.20, relative risk = 2.08). Pulp canal obliteration (PCO) was the second most common outcome (35%). The degree of extrusion was proven to be significantly associated with the development of PCO (P = 0.03, relative risk = 0.33). Root resorption was an uncommon outcome (3/55). This study represents the first outcome data on extrusions to permanent maxillary incisors in an exclusively pediatric population.

The effect of Emdogain gel on periodontal healing in replanted monkeys’ teeth

OBJECTIVE

We sought to histologically evaluate the effect of Emdogain gel on periodontal healing in monkeys' teeth undergoing delayed replantation. Study design Mature monkey teeth simulating avulsion were endodontically treated before extraction. Negative control teeth (group N = 10 roots) underwent immediate replantation, whereas the rest were bench-dried for 1 hour and treated in one of the following ways before replantation: the positive control teeth (group P = 12 roots) had no further treatment; group C teeth (4 roots) had the periodontal ligament removed; group D teeth (10 roots) were treated with Emdogain gel; group E teeth (6 roots) had the periodontal ligament removed before the application of Emdogain gel; and group F teeth (7 roots) had the periodontal ligament removed, the root surface conditioned, and Emdogain gel applied. Periodontal healing was evaluated after 16 weeks by undertaking histomorphometric analysis.

RESULTS

The Kruskal-Wallis and Mann-Whitney U tests revealed that group N teeth had a statistically higher occurrence of complete healing than did all other groups, whereas group P was not significantly different in any of the healing categories from D, E, and F, the groups in which Emdogain gel was used. Group C teeth had a significantly higher occurrence of replacement root resorption than did the teeth in groups P and F-but were not significantly different from teeth in groups D and E.

CONCLUSION

Emdogain gel did not appear to significantly reduce replacement resorption in monkeys' teeth that had undergone delayed replantation.

[Emergency signs in oro-facial traumatology in children and adolescents]

Based on an analysis of the literature concerning the children and adolescents with dental trauma to primary and permanent teeth, the treatment is multidisciplinary, requiring surgical, orthodontic, operative and prosthetic compliance. Periodic check-up is essential. These guidelines are intended as an aid to the dentist in the management and treatment of traumatized teeth and should be revised as soon as more evidence about the effect of treatment delay becomes available.

[Preservation of alveolar bone of un-restorable traumatized maxillary incisors for future]

Anterior maxillary implantation is a challenging treatment for both the surgeon and prosthodontist due to high esthetic demands in this area. However, it is the most traumatized and most exposed region to habits. Prompt and appropriate management can significantly improve prognosis of many dentoalveolar injuries, especially in young patients. Unfortunately, many traumatized teeth are overtreated or left untreated, which lead to a much more complicated treatment at the time of permanent restoration at adulthood. The facial cortical plate over the roots of the maxillary teeth is thin and porous. Periapical infections, as well as prolonged and stubborn surgical treatments (repeated root end surgeries) can cause resorption of the labial plate, migrate to a more palatal position, and may later require an augmentation procedure prior to implant placement. The treatment-options of traumatized, anterior maxillary, un-restorable fractured root and ankylosed infraocluded teeth, in relation to preservation of the adjacent alveolar bone for future use of dental implantation will be discussed. The recommended treatment of crown-root fracture of permanent incisor includes removal of the coronal fragment and supragingival restoration of the fractured root. In severe cases in which the fracture line positions deeply under the gingival margin, this treatment may be supplemented by gingivectomy and/or osteotomy, as well as surgical or orthodontic extrusion of the root. In young patients, use of these treatment options as temporary treatment to preserve the facial cortical plate is important. Preservation of alveolar dimension will enable implantation after the completion of growth and development. Dento-alveolar ankylosis accompanied by replacement resorption is a serious complication following severe injury to the periodontal membrane. This complication develops mainly following avulsion and intrusion but also following lateral luxation and root fracture. Replacement resorption develops after severe damage to the periodontal ligament cells that cover the root surface. As a result of this damage, the periodontal ligament is replaced by bone tissue, causing ankylosis between bone and tooth. Following ankylosis, resorption of cementum and root dentin occurs. These processes eventually result in replacement of the entire root by bone. In young children it could arrest the growth of the alveolar process and create an infra-occluded tooth, resulting in a severe bony defect that is difficult to correct. In addition, loss of the maxillary incisor leads to serious esthetic and restorative problems, particularly when the trauma occurs at a young age. Therefore, ankylosed teeth should be treated as soon as diagnosed. Alternative treatments include intentional extraction and immediate replantation of the ankylosed tooth to its socket after embedding the tooth and the socket in Emdogain. This treatment is indicated only when the ankylosis or the replacement resorption is diagnosed at an early stage or has affected only a small area of the root. When the resorption is diagnosed at a later stage, auto transplantation of first lower pre-molar to the anterior region or decoronation of the ankylosed tooth may be considered. Decoronation is a simple and safe surgical procedure for preservation of alveolar bone prior to implant placement. It should be considered as a treatment option for teeth affected by replacement resorption. The alternative treatment of surgical extraction of an ankylosed tooth often leads to considerable bone loss and reduced bone volume in the oro-facial dimension. This may later necessitate an augmentation procedure.

CONCLUSION

Scrupulous diagnosis of teeth and the alveolar bone after a traumatic injury is necessary. Treatment is multidisciplinary, requiring endodontic, surgical, orthodontic, operative and prosthetic compliance. An individual treatment plan for each patient is necessary. General rule do not apply. Periodic check-up is essential.

Root resorption in dental trauma: 45 cases followed for 5 years

We aimed to: (i) study the prevalence of root resorption after luxation or avulsion injuries on permanent teeth referred to our dental clinic over a 3-year period; (ii) study the relationship between type of injury and resultant type of resorption complication; and (iii) evaluate success of treatment protocols for various resorption complications. We observed 1943 patients with dental trauma, aged between 2 and 26 years, referred to the Accident and Emergency Department of the Dental Clinic, University of Brescia, from 1st September 1997 to 31st December 2001. Of these, 261 permanent teeth had sustained luxation (n = 188) or avulsion (n = 73) injuries. Permanent teeth luxation and avulsion injuries occurred most often in upper incisors (75%) of patients mostly aged 12-21 years, with males more commonly affected than females (68.3% vs. 31.7%). These cases were followed for 5 years, and complications and response to treatment were recorded. Root resorption was observed in 45 (17.24%) of these cases. Of the 45 cases with resorption, 9 were associated with luxation injury (20%) while 36 (80%) with avulsion. We distinguished 30 cases of inflammatory root resorption (18 transient and 12 progressive) and 15 cases of ankylosis and osseous replacement. When resorption was recognized, quick and effective treatment could still result in an excellent functional and aesthetic outcome for these teeth.

Intentional replantation of a mandibular second molar with long-term follow-up: report of a case

A case is reported of a mandibular second molar that underwent non-surgical endodontic treatment and intentional replantation in an effort to relieve continued symptoms. A 15.5-year follow-up clinical examination revealed the patient to be asymptomatic, the tooth to be still functional, and a recall film showed no evidence of root resorption. The indications for and limitations of intentional replantation as well as recommended literature on the subject are discussed.

[Replacement of a missing tooth with transplantation. Case report]

The replantation and transplantation are wide-spread therapies applied in case of tooth avulsion. It is also possible for such a tooth not to get back into the original socket, and it would be replaced to another tooth alveoli. In this presented case we transplanted a wisdom tooth to the place of the first lower molar immediately after extraction. The same time, by this case we discussed the therapeutical principles and possible prognosis too.

MTA apexification combined with conventional root canal retreatment

Apexification aims to induce apical closure of the open root apex with a hard-tissue barrier, against which a root filling can be compacted. Despite the popularity of the apexification procedure, calcium hydroxide therapy has some disadvantages that include variability of treatment time, unpredictability of apical closure, difficulties with patient follow-up and delayed treatment. Mineral trioxide aggregate (MTA) is a potential apical barrier material with good sealability and a high degree of biocompatibility. This paper demonstrates the placement of an apical barrier using MTA as an alternative to conventional long-term calcium hydroxide therapy.

Effect of minocycline on healing of replanted dog teeth after extended dry times

Minocycline is available as a locally administered tetracycline derivative antibiotic (Arestin, OraPharma, Inc., Warminster, PA, USA) which demonstrated antibacterial activity and anti-inflammatory action that may slow down resorptive processes after severe traumatic injuries to the dentition. A total of 48 premolar roots of six mongrel dogs were instrumented in an aseptic fashion with rotary nickel-titanium files and obturated with vertically condensed warm gutta percha. All accesses were sealed with glass ionomer, the roots extracted and then allowed to bench dry for 60 min. Group 1 consisted of 15 roots that were coated with minocycline and replanted and nine roots that were replanted without minocycline. Group 2 consisted of 24 roots, all of which were prepared with a uniform cemental defect down to sound dentin along the lateral aspect of the root, with a high-speed bur following the 60-min dry time. Half of the roots (12) were then coated with minocycline and replanted, and the other 12 roots were replanted without minocycline. After 4 months, the dogs were killed and the roots prepared for histological evaluation. About 5- microm thick cross-sections of the root and surrounding tissue taken every 90 microm were evaluated for healing. In addition, residual root mass was also measured in the roots of group 1 to determine the extent of root structure loss for each treatment method. The roots with and without minocycline treatment showed no significant differences between the remaining root mass or the percentage of favorably healed root surfaces. The use of minocycline is not currently recommended for prevention or attenuation of external root resorption following avulsion in a dog trauma model.

The effect of topical minocycline on replacement resorption of replanted monkeys' teeth

Tetracycline has been reported to possess antiresorptive properties in addition to antimicrobial actions. Systemic administration of tetracycline showed variable results in the control of replacement resorption after replantation with good results in half of the cases, and almost no healing in the rest. The purpose of this study was to evaluate histologically the effect of topically applied minocycline on replacement resorption of replanted monkeys' teeth. Thirty-two roots from seven monkeys were endodontically treated aseptically to prevent inflammatory resorption of pulpal origin, a common sequela after avulsion injury. Teeth were then extracted as atraumatically as possible. Teeth in the negative control group (10 roots) were replanted almost immediately, while teeth in the positive control group (12 roots) were allowed to bench-dry for 1 h prior to replantation, both without further treatment. Teeth in the experimental group (10 roots) were bench-dried for 1 h, rinsed with saline, and then immersed in 1 ml of 50 mg ml(-1) minocycline hydrochloride for 5 min before replantation. No splinting was used. After 12 weeks, the animals were sacrificed and histological sections were prepared and evaluated according to a morphometric analysis modified from that described by Andreasen (1987) as complete healing, inflammatory resorption, and replacement resorption. Kruskal-Wallis test showed significant differences among the three groups in all the three healing categories. Further analysis with Mann-Whitney U-test showed teeth in the negative control group to have significantly higher complete healing and significant lower unfavorable healing, comprising of replacement resorption and inflammatory root resorption than the positive control group and the minocycline group. Topical application of minocycline to the root surface appeared to result in slightly higher occurrence of complete healing (32.46%) compared to the delayed replantation group with no minocycline treatment (positive control) (16.58%), but the difference was not statistically significant (P = 0.09).