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REPLANTATION
 IN DENTISTRY


          INDIAN DENTAL ACADEMY
      Leader in Continuing Dental Education
         www.indiandentalacademy.com
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Contents
   Introduction
   Definition & Types of replantation
   Replantation of Avulsed tooth
   Management recommendations
   Squealae to replantation
   Intentional Replantation
   Auto-transplantation
   Conclusion

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Introduction




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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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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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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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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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Factors influencing outcome…



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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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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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Transport media



• Saline                          • HBSS
• Milk                            • ViaSpan
• Patient’s vestibule             • Fibroblast culture
• Water                                    medium




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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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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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Save – A – Tooth

                        Removable basket
                        Suspension net
                        pH balanced
                         preserving fluid
                         (HBSS)
                        Lid sponge
                        Storage
                        ETPS / Dentosafe


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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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   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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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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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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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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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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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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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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Root Surface Treatment
 Acid treatment
 Fluorides
 Tetracycline
 Alendronate
 Enamel Matrix

     Derivative
 Ozone

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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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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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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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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
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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Others…
   Ozone
     Disinfection

    +   cellular metabolism, ↑ intracellular ATP,
      ↑ cytokines – TGF-β1
   Acid treatment results in;
     Necrotic   cementum & PDL – inflammatory response
     Removes     smear layer – reparative cementogenesis
      with a layer of intermediate cementum – Craig &
      Harrison       www.indiandentalacademy.com
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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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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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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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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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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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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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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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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Calcium Hydroxide Therapy




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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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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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Resorption Following Replantation




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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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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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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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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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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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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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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.
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
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
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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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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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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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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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
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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Events in Resorption
   Role of bacteria
     Produce  acid & protease
     Stimulation of osteolytic factors – endotoxins




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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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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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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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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
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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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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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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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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Treatment for EIRR
                                  Filippi et al




For children & Adolescent
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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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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
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)



                  www.indiandentalacademy.com
Phantom root and inner
 periodontal ligament




    www.indiandentalacademy.com
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

                    www.indiandentalacademy.com
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

           www.indiandentalacademy.com
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
           www.indiandentalacademy.com
Indications
1.   Difficult access
2.   Anatomic limitation
3.   Perforations in areas not
     accessible by surgery
4.   Failed apical surgery




            www.indiandentalacademy.com
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




           www.indiandentalacademy.com
Contraindications
1.   Persistent moderate to severe periodontal disease
2.   Curved and flared roots
3.   Non-restorable tooth
4.   Missing inter-septal bone




           www.indiandentalacademy.com
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
            www.indiandentalacademy.com
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




            www.indiandentalacademy.com
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
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


             www.indiandentalacademy.com
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


             www.indiandentalacademy.com
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
              www.indiandentalacademy.com
     • Fracture
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


             www.indiandentalacademy.com
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
            www.indiandentalacademy.com
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
           www.indiandentalacademy.com
    Preparation of recipient site
AUTOTRANSPLANTATION
   Try-in & adjustments
   Trimming & suturing of the flap at the donor site
   Positioning & splinting
   Occlusal adjustments
   Radiographic evaluation
   Surgical dressing




             www.indiandentalacademy.com
AUTOTRANSPLANTATION




 www.indiandentalacademy.com
AUTOTRANSPLANTATION

   Survival rate – 74 – 100%
   Younger patients, higher success rates
   Tsukiboshi – 250 transplants
     Survival
             rate – 90 %
     Success rate – 82 %




           www.indiandentalacademy.com
God &
Replantation




     www.indiandentalacademy.com
References
   Pathways of pulp – 8th edn Cohen
   Surgical endodontics – Gutmann, 3rd edn
   Traumatic Injuries – OJ Andreason, 3rd edn
   Intentional Replantation. DCNA, 1997, 41;603-617
   Clinical management of the avulsed tooth: present strategies &
    Future directions. Dent traumatol 2002, 18: 1-11
   Therapeutic protocols for Avulsed Permanent teeth: Review &
    Clinical update. Pediatr Dent. 2004, 26: 251-255
   New philosophy for the treatment of Avulsed teeth. OOO, 1995; 79:
    616-623
   Guidelines for evaluation & management of traumatic dental injuries.
    Dent traumatol 2001, 17: 193-196
   Management of Avulsed permanent Incisors: A decision analysis
                    www.indiandentalacademy.com
    based on changing concepts. Pediatr Dent. 2000, 23: 357-360
References
   Autotransplantation of teeth; Requirements for predictable success.
    Dent traumatol 2002, 18: 157-180
   PCNA-expression of cementoblasts & fibroblasts on the root surface
    after extra-oral rinsing for decontamination. Dent traumatol 2002,
    18: 262-268
   Treatment of replacement resorption with Emdogain – a prospective
    study. Dent traumatol 2002, 18: 138 – 143
   Treatment of replacement resorption with Emdogain – preliminary
    results after 10 months. Dent traumatol 2002, 18:134-138
   Effect of enamel matrix derivative (Emdogain) upon periodontal
    healing after replantation of permanent incisors in Beagle dogs.
    Dent traumatol 2001. 17: 36-45
   Effect of topical Alendronate on root resorption of dried replanted
    dog teeth. Dent traumatol 2001. 17: 120-126
   Intentional replantation for periodontally involved hopeless teeth.
                         www.indiandentalacademy.com
    Dent traumatol 2003. 19: 45-51
References
   Replantation with intentional rotation of a complete vertical fracture
    root using adhesive resin cement. Dent traumatol 2003. 19: 115-117
   Vertical root fracture treated by bonding fragments & rotational
    replantation. Dent traumatol 2002, 18: 42-45.
   Short-term evaluation of Intentional Replantation of vertically
    fractured roots reconstructed with Dentin Bonded resin. JOE 2002,
    28:120-124
   Pulp revascularization of replanted immature dog teeth after
    treatment with minocycline & doxcycline assessed by LDF,
    radiography & histology. Dent traumatol 2004, 20: 75- 84.
   External inflammatory & Replacement resorption of luxated &
    avulsed replanted permanent incisors: a review & case report. Dent
    traumatol 2003, 19: 170-174
   Assessment of post traumatic PDL cell viability by a novel
    collagenase assay. Dent traumatol 2002, 18: 186-189
                       www.indiandentalacademy.com
    A quantitative analysis of Propolis: a promising new storage media
    following avulsion. Dent traumatol 2004, 20: 85-89
References
   In vitro viability, mitogenecity & clonogenic capacities of PDL
    fibroblasts after storage in 4 media supplemented with growth
    factors. Dent traumatol 2001, 17: 27-35
   Rate of infraposition of reimplanted ankylosed incisors related to
    age & growth in children. Dent traumatol 2002, 18: 28-36
   Splinting of traumatized teeth with a new device: Titanium trauma
    splint. Dent traumatol 2001, 17: 180-184
   Comparison of TTS with 3 commonly used splinting techniques.
    Dent traumatol 2001, 17: 266-274
   Effects of Ledermix paste on discolration of mature teeth. IEJ, 2000,
    33: 227-233
   Dental root resorption. OOO, 1999,88: 647-653
   Tooth resorption. Quintessence Int, 1999, 30: 9-25
   Intermediate Cementum. OOO 1995, 79: 24-33
                    www.indiandentalacademy.com
   Internet sources
Thank You




       www.indiandentalacademy.com

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Replantation in dentistry / /certified fixed orthodontic courses by Indian dental academy

  • 1. REPLANTATION IN DENTISTRY INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. Contents  Introduction  Definition & Types of replantation  Replantation of Avulsed tooth  Management recommendations  Squealae to replantation  Intentional Replantation  Auto-transplantation  Conclusion www.indiandentalacademy.com
  • 3. Introduction www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 5. Replantation of Avulsed Tooth  Treatment Objectives  Clinical management • Management at the site • In-office management • Preparation of root surface • Endodontic treatment www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 8. Factors influencing outcome… www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 11. Transport media • Saline • HBSS • Milk • ViaSpan • Patient’s vestibule • Fibroblast culture • Water medium www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 14. Save – A – Tooth  Removable basket  Suspension net  pH balanced preserving fluid (HBSS)  Lid sponge  Storage  ETPS / Dentosafe www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 23. Root Surface Treatment  Acid treatment  Fluorides  Tetracycline  Alendronate  Enamel Matrix Derivative  Ozone www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com 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 www.indiandentalacademy.com
  • 29. Others…  Ozone  Disinfection + cellular metabolism, ↑ intracellular ATP, ↑ cytokines – TGF-β1  Acid treatment results in;  Necrotic cementum & PDL – inflammatory response  Removes smear layer – reparative cementogenesis with a layer of intermediate cementum – Craig & Harrison www.indiandentalacademy.com
  • 30. Preparation of the socket  Left undisturbed  Removal of any obstacles  Blood clot – aspirated gently  Collapsed alveolar wall gently repositioned with blunt instrument www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 38. Calcium Hydroxide Therapy www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 41. Resorption Following Replantation www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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. www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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. www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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. www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com 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, www.indiandentalacademy.com 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 – www.indiandentalacademy.com 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 www.indiandentalacademy.com
  • 57. Events in Resorption  Role of bacteria  Produce acid & protease  Stimulation of osteolytic factors – endotoxins www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 60. Healing with Ankylosis  Infra-position is a common finding if tooth was replanted < 10yrs of age. Impairs the growth of alv bone www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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. www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 66. Treatment for EIRR Filippi et al For children & Adolescent www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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) www.indiandentalacademy.com
  • 70. Phantom root and inner periodontal ligament www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 74. Indications 1. Difficult access 2. Anatomic limitation 3. Perforations in areas not accessible by surgery 4. Failed apical surgery www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 76. Contraindications 1. Persistent moderate to severe periodontal disease 2. Curved and flared roots 3. Non-restorable tooth 4. Missing inter-septal bone www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com • 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 www.indiandentalacademy.com
  • 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 www.indiandentalacademy.com
  • 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  www.indiandentalacademy.com 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 www.indiandentalacademy.com
  • 88. AUTOTRANSPLANTATION  Survival rate – 74 – 100%  Younger patients, higher success rates  Tsukiboshi – 250 transplants  Survival rate – 90 %  Success rate – 82 % www.indiandentalacademy.com
  • 89. God & Replantation www.indiandentalacademy.com
  • 90. References  Pathways of pulp – 8th edn Cohen  Surgical endodontics – Gutmann, 3rd edn  Traumatic Injuries – OJ Andreason, 3rd edn  Intentional Replantation. DCNA, 1997, 41;603-617  Clinical management of the avulsed tooth: present strategies & Future directions. Dent traumatol 2002, 18: 1-11  Therapeutic protocols for Avulsed Permanent teeth: Review & Clinical update. Pediatr Dent. 2004, 26: 251-255  New philosophy for the treatment of Avulsed teeth. OOO, 1995; 79: 616-623  Guidelines for evaluation & management of traumatic dental injuries. Dent traumatol 2001, 17: 193-196  Management of Avulsed permanent Incisors: A decision analysis www.indiandentalacademy.com based on changing concepts. Pediatr Dent. 2000, 23: 357-360
  • 91. References  Autotransplantation of teeth; Requirements for predictable success. Dent traumatol 2002, 18: 157-180  PCNA-expression of cementoblasts & fibroblasts on the root surface after extra-oral rinsing for decontamination. Dent traumatol 2002, 18: 262-268  Treatment of replacement resorption with Emdogain – a prospective study. Dent traumatol 2002, 18: 138 – 143  Treatment of replacement resorption with Emdogain – preliminary results after 10 months. Dent traumatol 2002, 18:134-138  Effect of enamel matrix derivative (Emdogain) upon periodontal healing after replantation of permanent incisors in Beagle dogs. Dent traumatol 2001. 17: 36-45  Effect of topical Alendronate on root resorption of dried replanted dog teeth. Dent traumatol 2001. 17: 120-126  Intentional replantation for periodontally involved hopeless teeth. www.indiandentalacademy.com Dent traumatol 2003. 19: 45-51
  • 92. References  Replantation with intentional rotation of a complete vertical fracture root using adhesive resin cement. Dent traumatol 2003. 19: 115-117  Vertical root fracture treated by bonding fragments & rotational replantation. Dent traumatol 2002, 18: 42-45.  Short-term evaluation of Intentional Replantation of vertically fractured roots reconstructed with Dentin Bonded resin. JOE 2002, 28:120-124  Pulp revascularization of replanted immature dog teeth after treatment with minocycline & doxcycline assessed by LDF, radiography & histology. Dent traumatol 2004, 20: 75- 84.  External inflammatory & Replacement resorption of luxated & avulsed replanted permanent incisors: a review & case report. Dent traumatol 2003, 19: 170-174  Assessment of post traumatic PDL cell viability by a novel collagenase assay. Dent traumatol 2002, 18: 186-189  www.indiandentalacademy.com A quantitative analysis of Propolis: a promising new storage media following avulsion. Dent traumatol 2004, 20: 85-89
  • 93. References  In vitro viability, mitogenecity & clonogenic capacities of PDL fibroblasts after storage in 4 media supplemented with growth factors. Dent traumatol 2001, 17: 27-35  Rate of infraposition of reimplanted ankylosed incisors related to age & growth in children. Dent traumatol 2002, 18: 28-36  Splinting of traumatized teeth with a new device: Titanium trauma splint. Dent traumatol 2001, 17: 180-184  Comparison of TTS with 3 commonly used splinting techniques. Dent traumatol 2001, 17: 266-274  Effects of Ledermix paste on discolration of mature teeth. IEJ, 2000, 33: 227-233  Dental root resorption. OOO, 1999,88: 647-653  Tooth resorption. Quintessence Int, 1999, 30: 9-25  Intermediate Cementum. OOO 1995, 79: 24-33 www.indiandentalacademy.com  Internet sources
  • 94. Thank You www.indiandentalacademy.com