Yuli Nugraeni, EndodontistDavid Buntoro Kamadjaja, Oral SurgeonHaryono Utomo, Orthodontist

Evidence Based- Case: extra-oral endodontic +direct root canal filling with guttap percha

Periapical lesion

Internal resorption

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)

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)

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 (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)

Immediate replantation (within 5 min)Required for regeneration of the PDL (Lin, 2006)

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)

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 )

Ladermix : healing ↗ resorption ↘ Ca (OH)2 + ChKM : healing process of

PDL ↗ if application delayed ± 7 days after replatation

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 )

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

APEXIFICATIONFigure 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 txART + intracanal medicamentSemi rigid splinting for 2-3 weeksEndo txThe 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 fillingApex 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.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