REPLANTATION IN DENTISTRY          INDIAN DENTAL ACADEMY      Leader in Continuing Dental Education         www.indiandent...
Contents   Introduction   Definition & Types of replantation   Replantation of Avulsed tooth   Management recommendati...
Introduction         www.indiandentalacademy.com
Types Of ReplantationReplantation is defined as the replacing  of a tooth in its socket following  deliberate or traumatic...
Replantation of Avulsed Tooth   Treatment Objectives   Clinical management    •   Management at the site    •   In-offic...
Following Avulsion…   Tearing of PDL leaves viable cells on root surface   Cemental tear   Hydrated PDL maintains viabi...
Treatment Objectives   Avoiding or minimizing resultant inflammation -    attachment damage & pulpal infection   In case...
Factors influencing outcome…         www.indiandentalacademy.com
Management at site of Accident   Replant if possible or place in appropriate storage    media – minimize necrosis of PDL...
Transport Media   Hammer – first to address the importance of PDL cell    viability   Cvek et al – isotonic saline for 3...
Transport media• Saline                          • HBSS• Milk                            • ViaSpan• Patient’s vestibule   ...
Milk   Most practical & compatible medium provided the    avulsed teeth placed in it within 15 – 20 min   Blomlof et al ...
Hanks Balanced Salt MediumCompositionIngredients             F.W.           Most popularKCl                     74.56    ...
Save – A – Tooth                        Removable basket                        Suspension net                        p...
ViaSpan   ViaSpan is a clear to light yellow, sterile, non-    pyrogenic solution for hypothermic flushing and    storage...
   Hiltz & Trope – HBSS: 71.3% fibroblast for 24 hrs                  ViaSpan: 76.7% vitality upto 24hrs; 37.6%          ...
Growth Factors & storage medium:   Polypeptide   growth factors (GF) are biological   mediators that regulate the        ...
Growth Factors & storage medium:   Topical application –   stimulates DNA, collagen & non-    collagenous protein synthes...
Propolis   Bee-hive product   Inherent antibacterial & anti-inflammatory properties   Obtained from South-eastern Brazi...
Management in Office   Emergency visit       Diagnosis & treatment planning         - transfer tooth to reconstituting m...
Preparation of the RootExtra-oral dry time < 60 minClosed apex:   Root rinsed with saline or water   Continuing challeng...
Extra-oral dry time >60 minClosed Apex:   Viability lost. Aim - root resistant to resorption   Remove PDL by placing in ...
Root Surface Treatment Acid treatment Fluorides Tetracycline Alendronate Enamel Matrix     Derivative Ozone         ...
Fluorides   Fluoride uptake in hard tissues, more resistant to    resorption   Interferes with bacterial adhesion   And...
Tetracycline   Anti-resorptive & anti-microbial properties   Systemic & Local   Inhibits collagenase activity which inh...
Alendronate   3rd generation bisphosphonates   Pathologic osteoclast mediated hard tissue resorption in    diseased stat...
Enamel Matrix Derivative   Primary acellular cementum provides    attachment for sharpey’s fibers   Slavkin & Boyde – EM...
Enamel Matrix Derivative   Iqbal et al – Emdogain in beagle dogs         viable PDL cells are not the only factor for des...
Others…   Ozone     Disinfection    +   cellular metabolism, ↑ intracellular ATP,      ↑ cytokines – TGF-β1   Acid tre...
Preparation of the socket   Left undisturbed   Removal of any obstacles   Blood clot – aspirated gently   Collapsed al...
Splinting   Should allow physiologic movement to prevent ankylosis   Semi rigid fixation for 7 – 10 days, PDL healing   ...
SplintingRequirements of a splint:   Intra-oral application   Ease of placement & removal   Adequate fixation for whole...
SplintingMethods of stabilization: Orthodontic-wire splint Wire composite splint Resin splint Porcelain veneers Acryl...
Management of Soft Tissues   Lacerations to socket gingiva are sutured   Lip lacerations must be cleaned thoroughly    a...
Adjunctive Therapy   Systemic antibiotic- at replantation, prior to endodontic    therapy to prevent bacterial invasion o...
ENDODONTIC TREATMENTExtra-oral time < 60 minClosed apex (7-10 days)   No chance of revascularization, hence started   Mi...
Calcium Hydroxide   Short term use for 7-10 days: Canal disinfection   Long term therapy:    6   – 24 months/ 3 months ...
Calcium Hydroxide Therapy      www.indiandentalacademy.com
Ledermix Paste   Triamcinolone acetonide – 1%    - Diffuses through dentinal tubule    - Higher in coronal third    - Max...
Open Apex:   Look for revascularization, RCT avoided until signs of    pulp necrosis                         Open Apex   ...
Resorption Following Replantation          www.indiandentalacademy.com
Extra-oral time > 60 minClosed Apex:   Endodontic treatment similar to EO time< 60 minOpen Apex:   If endodontic treatme...
Temporary Restoration:   Effective sealing of coronal access – prevent microbial    ingress   Reinforced ZnOE, acid etch...
Obturation Visit If RCT initiated by 7-           If long term CaOH10 days of trauma and           therapy, then obturate ...
Permanent Restoration:   Coronal seal is as important as what lies beneath it   Restored at the time of obturation or so...
Management Recomendations   The International Association of Dental    Traumatology – 2001: M.T. Flores, J.O. Andreasen &...
IADT guidelines, For closed apex  Diagnosis      Tooth already         Kept in spl SM;           EODT> 60min Cl Situation ...
IADT guidelines, For open apex  Diagnosis      Tooth already           Kept in spl SM;           EODT> 60min Cl Situation ...
Decision analysis by Lee & Vann                                Avulsed Tooth                             Immature Pulp (>2...
Decision analysis by Lee & Vann                               Avulsed Tooth                              Mature Pulp Close...
Treatment Categories of Avulsed ToothKrasner & Rankow, 1995 Category 1    Mature Apex, < 15 min EO time Category 2    Matu...
Sequlae to Replantation1.   Healing with normal Periodontal Ligament2.   Healing with Ankylosis3.   Replacement resorption...
Healing with Normal Periodontal Ligament   Following replantation, coagulum is present between the    two parts of PDL  ...
Healing with Normal Periodontal Ligament   By 2 weeks – new collagen fibers develop   Repair occurs without restoration ...
Events in Resorption   Role of cementoblasts & intermediate cementum     Cementoblasts     & signaling molecules     IC...
Events in Resorption     Fibroblast motility – Fibronectin, PDGF, intracellular      actin microfilament, Gelosin   Role...
Events in Resorption   Role of bacteria     Produce  acid & protease     Stimulation of osteolytic factors – endotoxins...
Healing with Ankylosis   Degree of damage to PDL & extent of    viable cells present   Rate of progression rapid in youn...
Healing with Ankylosis   Transient ( 20%) & Permanent    Ankylosis( > 4mm2 )   Radiographically – No PDL    space, evide...
Healing with Ankylosis   Infra-position is a common finding if tooth was    replanted < 10yrs of age. Impairs the growth ...
Healing with Replacement Resorption   Continuous process becomes a    part of normal remodeling cycle   Replacement Reso...
External Inflammatory Root Resorption   Directly related – Damage of PDL &    bacteria in root canal & dentinal    tubule...
External Inflammatory Root Resorption   Risk of resorption increases dramatically after 5 min of    dryness & probability...
External Inflammatory Root Resorption   R/F – continuous resorption with adjacent radiolucency;    3 wks   Evident with ...
External Inflammatory Root Resorption   Andreasen & Hjorting-Hansen 110 replanted teeth              30 min – 90% no reso...
Treatment for EIRR                                  Filippi et alFor children & Adolescent                  www.indiandent...
Bone Healing   Genetically cells of PDL can diff – Osteoblast,    Cementoblast & fibroblasts   Bone induction is observe...
Revascularization   Endodontic treatment with open apices – 30% fracture    during/ after treatment   Pulp revascularisa...
Revascularization   more than 1mm   blood vessels proliferate    into pulp cavity 0.5 mm a    day   pulp canal oblitera...
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 s...
INTENTIONAL REPLANTATION   Abulcasis in 11th century   Grossman in 1966 “… Last resort”   Weine in 1980 “ I can think o...
Rationale of TreatmentLast resort to attempt to salvage the tooth provided the    following have been addressed   Even if...
Indications1.   Difficult access2.   Anatomic limitation3.   Perforations in areas not     accessible by surgery4.   Faile...
Indications5.   When apical surgery would create defects6.   Deciduous teeth needed as space maintainers7.   Maintain post...
Contraindications1.   Persistent moderate to severe periodontal disease2.   Curved and flared roots3.   Non-restorable too...
Premedication & Block Anesthesia   Premedication- procedure complicated, time consuming,    with lot of osseous preparati...
Atraumatic Extraction   Beaks of the forceps must always remain above CEJ to    avoid injury to PDL cells   Use of rubbe...
Short Extra Oral Time   Extra oral time–10-15min   Tooth constantly bathed    in HBSS   Procedure performed 6 –    10 i...
Replantation   Avoid curettage of socket – risk of replacement    resorption   Granuloma / cyst comes along with the roo...
SplintingUsually not required, but if indicated:   Periodontal packing: 1 wk, trap lot of bacteria   Sutures: placed dia...
Success Rates      Author          Year      No.of   Follow-up   Success                                teeth             ...
IR for Vertically Fractured Teeth   Fracture inaccessible by surgery   Adhesive resin > GIC   Rotational Replantation –...
IR for Periodontally involved Teeth   50% bone loss, deep periodontal pockets & advanced    mobility   Lu, Baykar et al ...
AUTOTRANSPLANTATION   Sequence: clinical & radiographic examination,    diagnosis, treatment planning, surgical procedure...
AUTOTRANSPLANTATION   Try-in & adjustments   Trimming & suturing of the flap at the donor site   Positioning & splintin...
AUTOTRANSPLANTATION www.indiandentalacademy.com
AUTOTRANSPLANTATION   Survival rate – 74 – 100%   Younger patients, higher success rates   Tsukiboshi – 250 transplants...
God &Replantation     www.indiandentalacademy.com
References   Pathways of pulp – 8th edn Cohen   Surgical endodontics – Gutmann, 3rd edn   Traumatic Injuries – OJ Andre...
References   Autotransplantation of teeth; Requirements for predictable success.    Dent traumatol 2002, 18: 157-180   P...
References   Replantation with intentional rotation of a complete vertical fracture    root using adhesive resin cement. ...
References   In vitro viability, mitogenecity & clonogenic capacities of PDL    fibroblasts after storage in 4 media supp...
Thank You       www.indiandentalacademy.com
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Replantation in dentistry / /certified fixed orthodontic courses by Indian dental academy

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Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.


Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients

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  • Indian Dental Academy Now offers comprehensive online Orthodontics course Course includes: 1.whiteboard lecture presentations 2.access and support @ 350 USD only. For Demo please visit :www.idalectures.com/preview/ For more details visit: www.idalectures.com Please contact us for any clarifications: idalectures@gmail.com indiandentalacademy@gmail.com Thanks &amp; Regards Indian Dental Academy
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Replantation in dentistry / /certified fixed orthodontic courses by Indian dental academy

  1. 1. REPLANTATION IN DENTISTRY INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 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. 3. Introduction www.indiandentalacademy.com
  4. 4. Types Of ReplantationReplantation 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. 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. 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. 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. 8. Factors influencing outcome… www.indiandentalacademy.com
  9. 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. 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. 11. Transport media• Saline • HBSS• Milk • ViaSpan• Patient’s vestibule • Fibroblast culture• Water medium www.indiandentalacademy.com
  12. 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. 13. Hanks Balanced Salt MediumCompositionIngredients F.W.  Most popularKCl 74.56 medium - KrasnerKH2PO4 136.09  Osmolarity – 270-NaCl 58.44 290 mOsm/lNa2HPO4. 7H2O 137.99  Known to preserveD-Glusose 180-16 cultured PDLF &MgSO4. 7H2O 264.48 avulsed teeth forCaCl2, 2H2O 147.02 extended periodsNaHCO 384.01Phenol Red www.indiandentalacademy.com
  14. 14. Save – A – Tooth  Removable basket  Suspension net  pH balanced preserving fluid (HBSS)  Lid sponge  Storage  ETPS / Dentosafe www.indiandentalacademy.com
  15. 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. 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. 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. 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. 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. 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. 21. Preparation of the RootExtra-oral dry time < 60 minClosed 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 cellsOpen 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. 22. Extra-oral dry time >60 minClosed 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-orallyOpen 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. 23. Root Surface Treatment Acid treatment Fluorides Tetracycline Alendronate Enamel Matrix Derivative Ozone www.indiandentalacademy.com
  24. 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. 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. 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. 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. 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. 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. 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. 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. 32. SplintingRequirements 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. 33. SplintingMethods 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. 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. 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. 36. ENDODONTIC TREATMENTExtra-oral time < 60 minClosed 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. 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. 38. Calcium Hydroxide Therapy www.indiandentalacademy.com
  39. 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. 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. 41. Resorption Following Replantation www.indiandentalacademy.com
  42. 42. Extra-oral time > 60 minClosed Apex: Endodontic treatment similar to EO time< 60 minOpen 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. 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. 44. Obturation Visit If RCT initiated by 7- If long term CaOH10 days of trauma and therapy, then obturate Radiograph indicates when intact Lamina Dura no pathosis - is traced OBTURATE www.indiandentalacademy.com
  45. 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. 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. 47. IADT guidelines, For closed apex Diagnosis Tooth already Kept in spl SM; EODT> 60min Cl Situation replanted EODT<60minTreatment 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 - ICMPatient Soft diet for 2 wks, use soft brush after every mealInstruction Chlorhexidine mouthwash – 2 times/day for 1 wk. Follow-up. www.indiandentalacademy.com
  48. 48. IADT guidelines, For open apex Diagnosis Tooth already Kept in spl SM; EODT> 60min Cl Situation replanted EODT<60minTreatment 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 afterInstruction Chlorhexidine mouthwash – 2 times/day for 1 wk. Follow-up.
  49. 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: >60Replant 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. 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. 51. Treatment Categories of Avulsed ToothKrasner & 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. 52. Sequlae to Replantation1. Healing with normal Periodontal Ligament2. Healing with Ankylosis3. Replacement resorption4. External Inflammatory Root Resorption5. Healing of bone6. Revascularization in immature apices www.indiandentalacademy.com
  53. 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. 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. 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. 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. 57. Events in Resorption Role of bacteria  Produce acid & protease  Stimulation of osteolytic factors – endotoxins www.indiandentalacademy.com
  58. 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. 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. 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. 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. 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. 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. 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. 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. 66. Treatment for EIRR Filippi et alFor children & Adolescent www.indiandentalacademy.com
  67. 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. 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. 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. 70. Phantom root and inner periodontal ligament www.indiandentalacademy.com
  71. 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. 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. 73. Rationale of TreatmentLast 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. 74. Indications1. Difficult access2. Anatomic limitation3. Perforations in areas not accessible by surgery4. Failed apical surgery www.indiandentalacademy.com
  75. 75. Indications5. When apical surgery would create defects6. Deciduous teeth needed as space maintainers7. Maintain post extraction alveolar bone for a denture8. Persistent chronic pain9. Patient Management www.indiandentalacademy.com
  76. 76. Contraindications1. Persistent moderate to severe periodontal disease2. Curved and flared roots3. Non-restorable tooth4. Missing inter-septal bone www.indiandentalacademy.com
  77. 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. 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. 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. 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. 81. SplintingUsually 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. 82. Success Rates Author Year No.of Follow-up Success teeth rateGrossman 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. 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. 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. 85. AUTOTRANSPLANTATION Sequence: clinical & radiographic examination, diagnosis, treatment planning, surgical procedure, endodontic treatment, restorative treatment & follow-upSteps Pre-op antibiotics Disinfection & anesthesia Extraction of tooth at recipient site Extraction of the donor tooth www.indiandentalacademy.com Preparation of recipient site
  86. 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
  87. 87. AUTOTRANSPLANTATION www.indiandentalacademy.com
  88. 88. AUTOTRANSPLANTATION Survival rate – 74 – 100% Younger patients, higher success rates Tsukiboshi – 250 transplants  Survival rate – 90 %  Success rate – 82 % www.indiandentalacademy.com
  89. 89. God &Replantation www.indiandentalacademy.com
  90. 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. 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. 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. 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. 94. Thank You www.indiandentalacademy.com

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