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4. Types Of Replantation
Replantation is defined as the replacing
of a tooth in its socket following
deliberate or traumatic avulsion – Harty
& Ogston
Replantation Of Avulsed tooth
Intentional Replantation
Auto-transplantation
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5. Replantation of Avulsed Tooth
Treatment Objectives
Clinical management
• Management at the site
• In-office management
• Preparation of root surface
• Endodontic treatment
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6. Following Avulsion…
Tearing of PDL leaves viable cells on root surface
Cemental tear
Hydrated PDL maintains viability of cells – combat
inflammation
Cementoblast Vs Osteoblast Mobility
With time osseous recontouring occurs
Pulpal necrosis always occurs
Combination of cemental damage & pulpal infection
– external inflammatory root resorption
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7. Treatment Objectives
Avoiding or minimizing resultant inflammation -
attachment damage & pulpal infection
In case of additional damage – steps to slow
resorptive process
In Open Apex – revascularization
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9. Management at site of Accident
Replant if possible or place in appropriate storage
media – minimize necrosis of PDL
Speed: replant within 15- 20 min
Dentist communication – instructions & preparation in
office
Storage media: Milk > Saliva > physiological saline or
water
HBSS or ViaSpan
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10. Transport Media
Hammer – first to address the importance of PDL cell
viability
Cvek et al – isotonic saline for 30 min, ↓ resorption
Blomlof et al – water & saliva very damaging to PDL cells
Lindskog et al – saliva & Milk
Following avulsion → deprived of blood supply →
depletion of stored metabolites → cell metabolism must
be restore by 60 min
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11. Transport media
• Saline • HBSS
• Milk • ViaSpan
• Patient’s vestibule • Fibroblast culture
• Water medium
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12. Milk
Most practical & compatible medium provided the
avulsed teeth placed in it within 15 – 20 min
Blomlof et al – Milk compatible only when cold & fresh
Only prevents cell death, no preservation of cell
morphology & it’s ability to undergo mitosis
Maintains osmotic pressure but does not reconstitute
depleted metabolites
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13. Hanks Balanced Salt Medium
Composition
Ingredients F.W. Most popular
KCl 74.56 medium - Krasner
KH2PO4 136.09 Osmolarity – 270-
NaCl 58.44 290 mOsm/l
Na2HPO4. 7H2O 137.99
Known to preserve
D-Glusose 180-16
cultured PDLF &
MgSO4. 7H2O 264.48
avulsed teeth for
CaCl2, 2H2O 147.02
extended periods
NaHCO 384.01
Phenol Red
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14. Save – A – Tooth
Removable basket
Suspension net
pH balanced
preserving fluid
(HBSS)
Lid sponge
Storage
ETPS / Dentosafe
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15. ViaSpan
ViaSpan is a clear to light yellow, sterile, non-
pyrogenic solution for hypothermic flushing and
storage of organs
Osmolarity of 320 mOsM/ L,
Sodium concentration of 29 mEq/L
Potassium concentration of 125 mEq/L
pH - 7.4 at room temperature
Penicillin G, Regular Insulin & Dexamethasone
Used for cold storage of liver, pancreas & kidney
before transplantation
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16. Hiltz & Trope – HBSS: 71.3% fibroblast for 24 hrs
ViaSpan: 76.7% vitality upto 24hrs; 37.6%
at 168hrs
Milk: 6 hrs viability
Matsson et al – EOT>15 min, must be soaked in HBSS
for 30 min
Courts et al – HBSS 50% > cells than milk; 10 -50 times
more cells than saline or water
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17. Growth Factors & storage medium:
Polypeptide growth factors (GF) are biological
mediators that regulate the
Proliferation
Differentiation
Cell motility
Matrix synthesis
Two best – plate derived growth factor PDGF
Insulin Growth factor IGF
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18. Growth Factors & storage medium:
Topical application – stimulates DNA, collagen & non-
collagenous protein synthesis, doubling connective
tissue healing in 1st week
Lynch et al – PDGF-B & IGF → PDL attachment by 5-
10 folds
Ashkenazi et al – { HBSS, ViaSpan, MEM & MEM-S }
+ GF → ↑ viability, mitogenicity & clonogenicity
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19. Propolis
Bee-hive product
Inherent antibacterial & anti-inflammatory properties
Obtained from South-eastern Brazil
Storage medium prepared by dissolving in 0.4%
ethanol
Promising results in maintaining PDL cells viability –
Martin & Pileggi
Only medium – antibacterial & anti-inflammatory
Further research required
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20. Management in Office
Emergency visit
Diagnosis & treatment planning
- transfer tooth to reconstituting media
Medical & accident h/o, clinical exam
Examination of socket
Facial and palatal palpation – collapse of socket wall
Radiographs – 3 vertical angulation
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21. Preparation of the Root
Extra-oral dry time < 60 min
Closed apex:
Root rinsed with saline or water
Continuing challenge: 20 min > EO Time < 60 min
In these cases, logic suggests that the root surface consists
of living cells
Open Apex:
Soak in doxycycline for 5 min, gently rinse debris and
replant - Revascularization
I mg in 20 ml physiologic saline – Cvek et al, Yanpiset et al
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22. Extra-oral dry time >60 min
Closed Apex:
Viability lost. Aim - root resistant to resorption
Remove PDL by placing in acid for 5 min, soak in 2 %
SnF for 5 min or apply Emdogain, Replant
Emdogain & Alendronate
Endodontics performed extra-orally
Open Apex:
Treat as with closed apex, endodontics preformed
outside
IADT – not to replant - replacement resorption/
Ankylosis
Maintains height & width of alveolar bone
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24. Fluorides
Fluoride uptake in hard tissues, more resistant to
resorption
Interferes with bacterial adhesion
Andreason - 20 min in 2.4% NaF, acidulated at 5.5
Bjorvant et al, Selvig et al – 1% SnF + 1% doxycycline
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25. Tetracycline
Anti-resorptive & anti-microbial properties
Systemic & Local
Inhibits collagenase activity which inhibits bone loss
Adsorb to dentin which has sustained release
Surface demineralization – binds matrix proteins & +
fibroblasts thus increasing fibronectin binding to dentin
Minocycline loaded in microspheres
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26. Alendronate
3rd generation bisphosphonates
Pathologic osteoclast mediated hard tissue resorption in
diseased states – osteoporosis, Paget’s disease & bone
malignancies
↑ affinity for CaPO4
interferes with receptors on osteoclasts, ↑es osteoclast
inhibiting osteoblasts, interferes with ruffled border of
ostoeclasts
Topical – direct / HBSS
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27. Enamel Matrix Derivative
Primary acellular cementum provides
attachment for sharpey’s fibers
Slavkin & Boyde – EMDs expressed by
HERS causes cementum formation
Hammerstrom et al – EMD causes
deposition of acellular extrinsic fiber
cementum
Emdogain – diff & proliferation of
cementoblasts that cover the root
surface before the contact of
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Osteoblasts to the root surface
28. Enamel Matrix Derivative
Iqbal et al – Emdogain in beagle dogs
viable PDL cells are not the only factor for desired
healing. Resorption seen at the 8th wk was seen to be
arrested by 12th wk.
Healing by regeneration not repair
Immunogenic potential extremely low
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30. Preparation of the socket
Left undisturbed
Removal of any obstacles
Blood clot – aspirated gently
Collapsed alveolar wall gently repositioned
with blunt instrument
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31. Splinting
Should allow physiologic movement to prevent ankylosis
Semi rigid fixation for 7 – 10 days, PDL healing
days
No difference in healing between splinted & non-splinted tooth
Radiograph
Occlusion
Periotest technique – tooth mobility & early replacement
resorption. PTV depends on the damping characteristic of PDL.
CI – 3-13; LI – 3-10
In conjunction with alveolar fractures – 4-8 weeks
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32. Splinting
Requirements of a splint:
Intra-oral application
Ease of placement & removal
Adequate fixation for whole stabilization
No additional trauma to splinted tooth
Allow physiological tooth mobility
No interference with occlusion
Ease of oral hygiene maintenance
No damage to gingival tissues
Allow endodontic treatment & periodontal testing
Esthetically acceptable
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33. Splinting
Methods of stabilization:
Orthodontic-wire splint
Wire composite splint
Resin splint
Porcelain veneers
Acrylic splints
Titanium trauma splint – von Arx & Filippi
Pure Ti – 0.2 mm thick
Molded easily
Available in 2 lengths – 52mm & 100mm
Rhomboidal mesh structure – flexible in all directions
Area of bonding is less
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34. Management of Soft Tissues
Lacerations to socket gingiva are sutured
Lip lacerations must be cleaned thoroughly
as dirt or minute tooth fragment may be
present that will impair wound healing
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35. Adjunctive Therapy
Systemic antibiotic- at replantation, prior to endodontic
therapy to prevent bacterial invasion of pulp
Tetracycline – decreases root resorption by affecting
osteoclast motility and collagenase activity
Doxycycline – 1 -0 -1 X 7 days
Chlorhexidine mouthwash, Adequate oral hygiene
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36. ENDODONTIC TREATMENT
Extra-oral time < 60 min
Closed apex (7-10 days)
No chance of revascularization, hence started
Minimal or no infection
Balanced force technique
Effective use of an intra-canal medicament
Calcium hydroxide
Ledermix Paste
Calcitonin – osteoclastic inhibition
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37. Calcium Hydroxide
Short term use for 7-10 days: Canal disinfection
Long term therapy:
6 – 24 months/ 3 months
Mandatory if RCT is initiated 2 weeks after the injury
Used as a temporary obturating material till normal
PDL is confirmed
Powder mixed with saline / anesthetic solution
Creates alkaline environment - ↓ resorbing activity & ↑
promoting hard tissue formation ( Alk Phosphatase)
Dressing not changed frequently – Necrotizing effect
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39. Ledermix Paste
Triamcinolone acetonide – 1%
- Diffuses through dentinal tubule
- Higher in coronal third
- Max by 14 wks
Dimethyl Chlortetracycline – 3.021%
- Affinity to bivalent & trivalent cations. Eg, Ca++
causes tooth discoluration, aggravated by exposure to
light
Immature teeth > mature teeth
Paste restricted to root dentin, 2-3 mm below CEJ
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40. Open Apex:
Look for revascularization, RCT avoided until signs of
pulp necrosis
Open Apex
Revascularization Apexification
•CO2 Snow, Difluoro •C/F - Loss of vitality, pain
dichloromethane, •R/F – apical break down,
LDF Lat. Root resoprtion
•4wks- Yanpiset et al
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42. Extra-oral time > 60 min
Closed Apex:
Endodontic treatment similar to EO time< 60 min
Open Apex:
If endodontic treatment not performed out of mouth,
initiate apexification.
If RCT performed in first visit, then 2nd visit is to assess
healing only
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43. Temporary Restoration:
Effective sealing of coronal access – prevent microbial
ingress
Reinforced ZnOE, acid etched-composite resin or GIC
Depth – 4mm
Temporary directly placed on the intra-canal
medicament
Intra-canal medicament must be removed from the walls
to prevent micro-leakage.
After initiation of root canal treatment, splint is removed
Thorough clinical examination of surround teeth are
made.
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44. Obturation Visit
If RCT initiated by 7- If long term CaOH
10 days of trauma and therapy, then obturate
Radiograph indicates when intact Lamina Dura
no pathosis - is traced
OBTURATE
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45. Permanent Restoration:
Coronal seal is as important as what lies beneath it
Restored at the time of obturation or soon after
obturation
Deepest restoration possible is made, preferably with
resin composites ( min – 4mm )
Follow-up & Care:
3 months, 6 months and yearly atleast for 5 years.
If osseous replacement or external infl root resorption is
identified – retreatment with long term Ca OH can
reverse the process.
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46. Management Recomendations
The International Association of Dental
Traumatology – 2001: M.T. Flores, J.O. Andreasen &
L.K. Balkland
Decision Analysis proposed by J.Y. Lee, W.F. Vann –
2000
Treatment Categories proposed by Krasner &
Rankow - 1995
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47. IADT guidelines, For closed apex
Diagnosis Tooth already Kept in spl SM; EODT> 60min
Cl Situation replanted EODT<60min
Treatment Clean area with If contaminated, clean Remove PDL &
water spray or root surf & apical area coagulum from
chlorhex. Do not with stream of saline. socket
extract tooth Remove coagulum Examine socket
Examine alveolar Immerse in 2.4%
socket NaF(pH 5.5- 5min)
Replant with digital Fill socket with
pressure Emdogain & replant
Suture Gingival lacerations,espl cervical area, IOPA for position
Apply fexible splint for 1 week
Rx Doxycycline 2 X per day – 7 days (Pt age & wt). Tetanus
booster. Initiate Endo treatment – 7-10 days. Place CaOH - ICM
Patient Soft diet for 2 wks, use soft brush after every meal
Instruction Chlorhexidine mouthwash – 2 times/day for 1 wk. Follow-up.
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48. IADT guidelines, For open apex
Diagnosis Tooth already Kept in spl SM; EODT> 60min
Cl Situation replanted EODT<60min
Treatment Clean area with If contaminated, clean root Replantation not
water spray or surf & apical area with indicated.
chlorhex. Do not stream of saline.
extract tooth Remove coagulum
Place in doxycycline
Examine alveolar socket
Replant with digital
pressure
Suture Gingival lacerations,espl cervical area, IOPA for position
Apply flexible splint for 1 week
Rx Penicillin V 1000/500mg; 4Xperday – 7 days. Doxycycline 2 X
per day – 7 days (Pt age & wt). Tetanus booster. Initiate Endo
treatment – 7-10 days.
Patient Soft diet www.indiandentalacademy.com every meal
for 2 wks, use soft brush after
Instruction Chlorhexidine mouthwash – 2 times/day for 1 wk. Follow-up.
49. Decision analysis by Lee & Vann
Avulsed Tooth
Immature Pulp (>2mm)
Cat.1: Cat.2: 15-6 hrs, Cat.3: 15- Cat.4:0-60min Cat.5: >60
Replant imme stored in 120min, wet but Extra-oral Dry min Extra-oral
at site physiologic med not phy.med storage Dry time
Change to Soak in citric
Soak in 1% HBSS if acid-3min;
Doxcy-5min available Remove PDL
with scaler
Replant; IOPA
Flexible splint
Place in NaF
Sys Antibiotics; tetanus
– 20min
Post-op instructions; Follow-up
Assess for apexogenesis or root
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canal therapy
50. Decision analysis by Lee & Vann
Avulsed Tooth
Mature Pulp Closed
Apex
Cat.2: Cat.3: >60
Cat.1: Replant min Extra-oral
imme/ Storage in 15-120min,wet
but not Dry time
phy.med – 15min-
6hrs phy mediun
Change to Soak in citric
HBSS if acid-3min;
available Remove PDL
with scaler
Replant; IOPA
Flexible splint
Place in NaF
Sys Antibiotics; tetanus
– 20min
Post-op instructions; Follow-up
With possible exception of Cat.1,
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All require RCT
51. Treatment Categories of Avulsed Tooth
Krasner & Rankow, 1995
Category 1 Mature Apex, < 15 min EO time
Category 2 Mature Apex, 15 min – 24hrs EO time, Reconstituting
Storage medium (RCM)
Category 3 Mature Apex, 15-160min EO time, Non-reconstituting
Storage medium (NRCM), but wet storage medium
Category 4 Mature apex, EO Dry time <120 min
Category 5 Mature apex, EO Dry time >120 min
Category 6 Immature Apex, EOT <15 min
Category 7 Immature Apex, EOT 15min-24hrs. RCM
Category 8 Immature Apex, EOT 15 to 160min in NRCM, but wet med
Category 9 Immature Apex, EO Dry time <120 min
Category 10 Immature apex, EO Dry time >120 min
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52. Sequlae to Replantation
1. Healing with normal Periodontal Ligament
2. Healing with Ankylosis
3. Replacement resorption
4. External Inflammatory Root Resorption
5. Healing of bone
6. Revascularization in immature apices
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53. Healing with Normal Periodontal Ligament
Following replantation, coagulum is present between the
two parts of PDL
Proliferation of young connective tissue takes place by 3-
4 days
Small areas of resorption – repaired by new cementum;
Surface resorption. This type is self-limiting
resorption
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54. Healing with Normal Periodontal Ligament
By 2 weeks – new collagen fibers develop
Repair occurs without restoration of proper anatomy
Surface resorption & repair occur in 90% of normal root
surfaces
Epithelial healing - long junctional attachment
Normal sound to percussion
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55. Events in Resorption
Role of cementoblasts & intermediate cementum
Cementoblasts & signaling molecules
IC – hypercalcific zone, permeability barrier – EIRR
Role Of Periodontal Ligament
Barrier between cementum & alveolar bone
Interaction between cells of bone & PDL-
establishment of territorial boundaries
Low molecular weight proteolytic activity inhibitor –
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Anti-invasion Factor: blood vessels, cartilage, teeth
Factor
56. Events in Resorption
Fibroblast motility – Fibronectin, PDGF, intracellular
actin microfilament, Gelosin
Role of inflammation
Osteoclast & odontoclasts recruitment
Acidic pH –
ruffled border proton pump, Acid
phosphatase, Carbionic anhydrase
Proteinase enzymes – collagenase, MMP, cysteine
proteinase
Prostaglandin – fusion of oestoeclast precursors
Substance P – CBFa gene of Osteoblast
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57. Events in Resorption
Role of bacteria
Produce acid & protease
Stimulation of osteolytic factors – endotoxins
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58. Healing with Ankylosis
Degree of damage to PDL & extent of
viable cells present
Rate of progression rapid in young
individuals
Large areas to be healed – cells forming
bone come in contact with the root
This bony union is termed Ankylosis,
with no intervening connective tissue*Ne
et al
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59. Healing with Ankylosis
Transient ( 20%) & Permanent
Ankylosis( > 4mm2 )
Radiographically – No PDL
space, evident by 4 -6 wks
Clinically, loss of mobility when
>10% ankylosed & high metallic
sound
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60. Healing with Ankylosis
Infra-position is a common finding if tooth was
replanted < 10yrs of age. Impairs the growth of alv
bone
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61. Healing with Replacement Resorption
Continuous process becomes a
part of normal remodeling cycle
Replacement Resorption or
Osseous Replacement – presence
of inflamed connective tissue*
Ne et al
Tunneling resorption
C/F – high pitched sound on
percussion
R/F – No PDL, moth eaten
appearance. Evident by 3-4
months www.indiandentalacademy.com
62. External Inflammatory Root Resorption
Directly related – Damage of PDL &
bacteria in root canal & dentinal
tubules
Bowl-shaped areas of resorption of
cementum & dentin associated with
inflammatory changes in the
periodontium
Granulation tissue + lymphocytes,
plasma cells & PMNs.
Pathogenesis – very rapid
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63. External Inflammatory Root Resorption
Risk of resorption increases dramatically after 5 min of
dryness & probability of resorption increasing by 29% for
every additional 10min of drying – Kinirons et al
Incidence increased in pulp extripation was delayed for
more than 20 days- Kinirons et al
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64. External Inflammatory Root Resorption
R/F – continuous resorption with adjacent radiolucency;
3 wks
Evident with first year of replantation – tooth is loose &
extruded, sensitive and dull to percussion
Both inflammatory & replacement resorption can be
diagnosed by 2-6 mos of replantation. If not detected by
2 yrs, chances very low.
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65. External Inflammatory Root Resorption
Andreasen & Hjorting-Hansen 110 replanted teeth
30 min – 90% no resorption for 2 yrs
>2 hrs - 95% showed root resorption
Andreasen et al – immediated < 18 min replacement &
inflammatory resorption
Andreasen & Boden – least resorption seen when teeth
replanted within 15 mints
Shulman et al – use of NaF to reduce root resorption
Lindskog et al – avulsed teeth with necrotic PDL had high
incidence of root resorption and ankylosis
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66. Treatment for EIRR
Filippi et al
For children & Adolescent
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67. Bone Healing
Genetically cells of PDL can diff – Osteoblast,
Cementoblast & fibroblasts
Bone induction is observed as rapid bone regeneration
takes place adjacent to the tooth.
Extent of healing – inflammation
3-4 weeks
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68. Revascularization
Endodontic treatment with open apices – 30% fracture
during/ after treatment
Pulp revascularisation- prevents pulp space infection,
continued root development, apex closure
Success – 18 - 41%
Key factor – presence/ absence of bacteria –Cvek el al
histology study in dogs – Ritter et al
Vital pulp with normal odontoblast layer
Vital connective tissue with reactive dentin layer
Vital mineralised connective tissue
Necrotic pulp www.indiandentalacademy.com
69. Revascularization
more than 1mm
blood vessels proliferate
into pulp cavity 0.5 mm a
day
pulp canal obliteration
occurs due to deposition
of hard tissue
(osteodentin)
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70. Phantom root and inner
periodontal ligament
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71. Prognosis…
Replanted teeth , temporary measure as many lead to
Root resorption
Study reports replanted teeth in service for 20- 40 yrs
ROOT RESORPTION
Majority of replanted teeth – root resorption: 80-90 %
Advances in storage medium & surfaces treatment has
increased the life of replanted teeth
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72. INTENTIONAL REPLANTATION
Abulcasis in 11th century
Grossman in 1966 “… Last resort”
Weine in 1980 “ I can think of no procedure
with a poorer prognosis….”
It is the purposeful removal of a tooth and its
almost replacement with the object of
obturating the canals apically while the tooth
is out of its socket – Grossman 1966
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73. Rationale of Treatment
Last resort to attempt to salvage the tooth provided the
following have been addressed
Even if routine root canal treatment is unfavorable, it
must be performed & followed for a suitable post-op
period for evaluation & healing
Etiological factors of failing endodontically treated tooth
must be recognized and all considerations of
retreatment applied
Periradicular surgery must be considered treatment of
choice before resorting to IR
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74. Indications
1. Difficult access
2. Anatomic limitation
3. Perforations in areas not
accessible by surgery
4. Failed apical surgery
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75. Indications
5. When apical surgery would create defects
6. Deciduous teeth needed as space maintainers
7. Maintain post extraction alveolar bone for a
denture
8. Persistent chronic pain
9. Patient Management
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76. Contraindications
1. Persistent moderate to severe periodontal disease
2. Curved and flared roots
3. Non-restorable tooth
4. Missing inter-septal bone
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77. Premedication & Block Anesthesia
Premedication- procedure complicated, time consuming,
with lot of osseous preparation
Amoxycillin 500mg – 1 day before
chlorhexidine mouth rinse – 1 day before
NSAID – 2hrs before surgery
Ansethesia – Max teeth– Local infil & PSA
- Mand teeth - inf alveolar, lingual & long
buccal NB. Gow-gates technique
intraosseous anesthesia - adjunct
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78. Atraumatic Extraction
Beaks of the forceps must always remain above CEJ to
avoid injury to PDL cells
Use of rubber band around the handle of the forceps
Slow rocking motion in bucco-lingual direction
Extraction could take 20-30 min
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79. Short Extra Oral Time
Extra oral time–10-15min
Tooth constantly bathed
in HBSS
Procedure performed 6 –
10 inches from the
solution basin
Retro prep – 330 bur /
C-shaped canal –
ultrasonics
Root-end filling placed &
polished with diamond
finishing www.indiandentalacademy.com
abrasive
80. Replantation
Avoid curettage of socket – risk of replacement
resorption
Granuloma / cyst comes along with the root
Socket contents aspirated with thin, tapered aspirator
Tooth placed back & buccal & lingual bones manually
compressed
Patient can bite on a wooden stick to stabilize the tooth
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81. Splinting
Usually not required, but if indicated:
Periodontal packing: 1 wk, trap lot of bacteria
Sutures: placed diagonally over the occlusal surface
Composite: placed inter-proximally on either side of the
replanted tooth. 7-10 days
‘A’ splint: allows physiological mobility, 1 wk
Post-operative care
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82. Success Rates
Author Year No.of Follow-up Success
teeth rate
Grossman 1966 45 2-11 yrs 80%
Kingsburg et al 1971 151 3 yrs 95%
Bender & Rossman 1993 31 1-22yrs 80.6%
Failure:
• Resorption
• Rarefaction due to infection
• Pain
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• Fracture
83. IR for Vertically Fractured Teeth
Fracture inaccessible by surgery
Adhesive resin > GIC
Rotational Replantation – why?
Prevents epithelial down growth along the fracture
line
Provides viable PDL against the curetted pocket wall
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84. IR for Periodontally involved Teeth
50% bone loss, deep periodontal pockets & advanced
mobility
Lu, Baykar et al – 32 mos, 8 yrs
Procedure
Root planing, removal of all necrotic cementum & PDL
Surface treatment with tetracycline HCl for 5 min
Eplithelial lining curetted
Splinted for 6 months
Ankylosis/ Resorption
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85. AUTOTRANSPLANTATION
Sequence: clinical & radiographic examination,
diagnosis, treatment planning, surgical procedure,
endodontic treatment, restorative treatment & follow-up
Steps
Pre-op antibiotics
Disinfection & anesthesia
Extraction of tooth at recipient site
Extraction of the donor tooth
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Preparation of recipient site
86. AUTOTRANSPLANTATION
Try-in & adjustments
Trimming & suturing of the flap at the donor site
Positioning & splinting
Occlusal adjustments
Radiographic evaluation
Surgical dressing
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