Transcript simple replantation protocol to avoid ankylosis in eatment

Yuli Nugraeni, Endodontist
David Buntoro Kamadjaja, Oral Surgeon
Haryono Utomo, Orthodontist
SIMPLE REPLANTATION PROTOCOL TO AVOID
ANKYLOSIS IN TEETH INTENDED FOR
ORTHODONTIC TREATMENT : A REVIEW
Evidence Based- Case: extra-oral endodontic +
direct root canal filling with guttap percha
Periapical lesion
Internal resorption
INTRODUCTION
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Dental trauma is one of the most serious oral health
problems in active children and adolescents.
It requires immediate initial emergency treatment
followed by integrated procedures. (American Association of
Endodontic 2006)
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Dentoalveolar injuries in the anterior region maxillary
 tooth avulsion or intrusion
Tooth avulsion : 0,5-16% of traumatic injures in the
permanent dentition and for 7-21% of injures in the
primary dentition (Lin, 2006)
Avulsion of permanent occur at age of 7-10
year
 Avulsions → severe pulpal and periodontal
injures
 Pulp necrosis and consecutive infections →
ankylosis (Replacement Resorption, RR) and
infection-related resorption (IRR) (Teikin dkk, 2008)
 Tooth ankylosis leads to difficulties in
orthodontic treatment i.e. retracting the avulsed
protruded teeth (Campbell dkk, 2005)
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Management for ankylosis → supported by
little evidence →do not offer any proven long
term benefit
 Antiresorptive-regenerative therapy (ART) +local
application of glucocorticoids +enamel matrix
derivative (EMD, Emdogain) + systemic
administration of doxycycline combined with
semi-rigid fixation →successful results
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(www.aapd.org/media/ Policies Guidelines/ G trauma.pdf)
The objective of this review is to propose a new simple
protocol of avulsed tooth management which also
minimize the risk of ankylosis.
AVULSION :

a complete displacement of tooth out of socket →
severe PDL + fracture of alveolus
In emergency situation A prompt decision should
be made to treat with replantation  negative
consequences : ankylosis + root resoption
(www.aapd.org/media/ Policies Guidelines/ G trauma.pdf, 2008)
TREATMENT OF AVULSION

Immediate replantation (within 5 min)
 Required for regeneration of the PDL
(Lin, 2006)
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Prognosis :
 In the permanent teeth is dependent upon
formation of root development and extra oral dry
time → a risk for pulp necrosis, root resorption,
ankylosis, infraocclusion
 The best prognosis: replanted immediately if >
5min: stored in medium to maintain vitality of
PDL). > 15 min → risk of ankylosis ↗( McIntyre, 2007;
Flores, 2007)
ART : to depress resorption activity and support
regeneration in the PDL
ART + EMD (® Emdogain) + Doxycycline : ↗prognosis of
avulsed teeth
Treatment strategies :
 avoiding inflammation
 increasing revascularization
 producing hard barriers in the teeth with open apices
(www.aapd.org/media/ Policies Guidelines/ G trauma.pdf)
Splinting  stabilizing the tooth with semi rigid for 1 week
w/o alveolar fracture; 2 to 3 weeks with alveolar fracture
(DiAngelis, 2006)
Occlusal force
 increase NO synthesis by iNOS  necessary for
repair of injured PDL fibers, angiogenesis and nerve
regeneration; NO  apoptosis osteoblast  + bone
formation  (Chen at al, 2005)
 increase fibroblast growth factor (bFGF/FGF-2)  key
factor of PDL healing ( Hu et al, 2008 )
EMDOGAIN®
Extra oral dry time> 60 min:
EMD should applied onto the root
surface and into the alveolus
EMD contains protein (amelogenin)
and thought to aid in the
migration, attachment,
proliferative capacity and
biosynthetic activity of PDL cells.
EMD : ↗PDL cell proliferation and
protein production→ regenerating
PDL (Flores, 2007)
ENDODONTIC TREATMENT OF AVULSED TEETH
Endo treatment → essential for the progress of healing
of the replanted tooth
Controversies : in closed apex tooth (<1mm) →EO/IO
The best result : w/o endodontically treated → inserted
to socket + pulp extirpation directly w/o filling i.e.with
gutta-percha→ prevent IRR. Splinting  endo tx
The canal → debrided, dressed with
corticosteroid/antibiotic ( Ca(OH)2 ) → 1 to 3 months
 obturated
!!! Endodontic + gutta-percha or Ca(Oh)2 : delays
periodontal healing + Accelerate ankylosis (RR) in
mature teeth (AAE, 2006; AAPD, 2008)
In mature teeth → Endo tx should be
commenced 7-10 days following replantation
 In immature teeth ( the time out of the mouth is
short and the apex is open ) → possible
revascularization → Endo tx can be delayed
 If px compliance → Endo tx is assured →
Apexification, root filling with GP/MTA → can be
carried out later ( Flores, 2007 )
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INTRACANAL MEDICAMENT
Ladermix : healing ↗ resorption ↘
 Ca (OH)2 + ChKM : healing process of PDL ↗ if
application delayed ± 7 days after replatation
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Pharmacological treatment
Tetanus prophylaxis and antibiotic should be
considered
 After completion of the ART  doxycycline max
100 mg/day for 5 days  antimicrobial and
anti resorptive 
(direct inhibitory effect on resorption activity of
osteoclast and collagenase) ( Pohl et al, 2005 )
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DISCUSSION:
Ankylosis and root resorption in tooth avulsion
treatment, caused by:
 Delayed / improper management
 Dry time exceeding 60 min
 Persistent inflammation of the PDL
 Minimal or absence of occlusal force
After 60 min extra oral dry time : the survival
rate of The PDL cells →almost zero, and
osseous replacement is predicted
 Direct extirpation the pulps + application of
intraradicular medicament → beneficial
 Ledermix → proliferation of dentinoclast →
mixed with Ca(OH)2 ↗
 Corticosteroids in intracanal → standart tx
protocol at emergencies visit
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APEXIFICATION
Figure 1a. Open apex filled with Ca(OH)2
Figure 1b. Apex closing process
(adapted from Tsukiboshi I. Treatment planning for traumatized teeth21)
EMD is the promising result replantation ↗↗
 The alternatives medicament : doxycycline,
minocycline, alendronate, atau Ledermix
 The best factors may prevent replantation from
ankylosis and root resorption :
dry time < 60 min
decontamination of root surface
application of preserving PDL agent (EMD)

direct
extirpation without endo tx
ART + intracanal medicament
Semi rigid splinting for 2-3 weeks
Endo tx
The successful result : significantly higher in open
apex teeth: WHY?
Our new concept : to create open apex condition by
widening the apical → to remove the delta area
which contains accessory canals
This new concept  simple protocol had several
benefits :
 Open apex  facilitate intracanal medicament to
enter periapical area  PDL inflammation ↘
 Remove the accessory canals  difficult for pulp
sterilization
 Facilitates drainage of inflammatory mediators in
periapical area
The follow up : apexification procedures or final root
canal filling
Apex opening direction
Delta area
The simple protocol: the use of medicament that
commonly available in dental office →
Ca(OH)2, CHKM, Endomethasone®,
minocycline gel for topical application in the
sulcular area. In case of absence of ideal wire
for splinting with brackets, attach twisted
ligature wires to the tooth with GIC or
composites
Conclusion :
The main principle to prevent ankylosis: reducing
the inflammation of the PDL.
Inflammation leads to altered function of PDL
→mineralized tissue forming cells → ankylosis
These simple management protocol which
facilitate the application of anti-inflammatory
medicament  considered a logical concept.
However, further laboratory and clinical
researches are required
THANK YOU