Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study

Abstract A material of 885 luxated, non-vital incisors was evaluated radiographically with respect to healing of periodontal tissues including inflammatory root resorption and occurrence of ankylosis and cervical root fractures. The results were assessed after completion of calcium hydroxide treatment and 4 years after filling of the root canal with gutta-percha. After treatment with calcium hydroxide, periapical healing occurred in 95% of the teeth. Four years after filling with gutta-percha, periapical healing was present in 91% of the teeth. In the remaining teeth, recurrent or persistent periapical radiolucency was more frequent in overfilled than adequately filled teeth (P = 0.0001). There was no difference between immature and mature teeth. Inflammatory root resorption healed in 192 of 197 teeth (97%); in 5 teeth it developed into ankylosis. Ankylosis occurred in 13 teeth, all of which were intruded into the alveolar bone at the time of injury. The frequency of cervical root fractures was markedly higher in immature than mature teeth (P>0.0001). Among immature teeth, the frequency of fractures was dependent on the stage of root development [x²= 31,6) and ranged from 77% in teeth with the least to 28% in teeth with the most developed roots. The frequency of fractures was also related to the defects after healing of inflammatory root resorption in the cervical area of the root, significant at P< 0.0001.     

The effect of extra-alveolar root filling with calcium hydroxide on periodontal healing after replantation of permanent incisors in monkeys

The effect of calcium hydroxide, used as an extra-alveolar root filling material, on periodontal healing was examined in green vervet monkeys (Cercopithecus aethiopa). Incisors were extracted and a root canal filling of calcium hydroxide paste was processed. Control teeth were replanted after either pulp extirpation or root filling with gutta-percha. In the experimental groups, the extra-alveolar period was either 18 or 120 minutes. The animals were killed eight weeks after replantation, and the replanted teeth were examined histologically. The histologic parameters recorded for each tooth were surface resorption, inflammatory resorption, replacement resorption (ankylosis), periapical inflammatory changes, and downgrowth of pocket epithelium. Teeth with canals filled with calcium hydroxide that had an extra-alveolar time period of 18 minutes, showed noticeably more replacement resorption than either the teeth with canals filled with gutta-percha or those with extirpated pulps. Calcium hydroxide paste may diffuse through the apical foramen, thus injuring the periodontal ligament in the apical region. Consequently, the use of calcium hydroxide does not seem justified in the initial treatment of avulsed teeth, but it can be used after some weeks when periodontal ligament healing has progressed.     

Literature survey of apexification in connection with three cases

Endodontic treatment of three non-vital immature teeth is discussed. According Moorrees et al. root formation was in the stage two, six and four respectively. After access to the root canal, removing necrotic pulp and effective chemo-mechanical cleansing, Ca(OH)2 paste was used as a temporary filling material in each case. In two cases after closing the apical opening, permanent obturation was performed with half heated gutta-percha and lateral condensation to obtain a good seal. In one case permanent filling of the canal occurred with gutta-percha and AH26 as a sealer. In the first case two years, in the second case five years after obturation of the root canal with gutta-percha, periapical healing was evident in the control radiograph. In the third case using gutta-percha with AH26 as a sealer after two years new periapical lesion has developed. On the bases of literature data and our experiences in the case of non-vital immature teeth. Ca(OH)2 paste is the best temporary filling material to induce apexification process, and the half heated gutta-percha obturation is the most suitable permanent root filling material.     

Influence of root development on periodontal and pulpal healing after replantation of incisors in monkeys

The influence of root development on periodontal and pulpal healing after replantation was examined in 30 green vervet monkeys (cercopithecus aethiops) in which a total of 50 teeth were replanted. Maxillary central incisors with different stages of root development (immature, young mature and mature root formation) were replanted with untreated pulps or after root canal treatment with gutta percha and Kerr® sealer. The extra-alveolar period in all groups was 18 min. The animals were sacrificed 8 weeks after replantation and the teeth examined histologically. The following histologic parameters were registered for each tooth: surface resorption, inflammatory resorption, replacement resorption (ankylosis), downgrowth of pocket epithelium, periapical inflammatory changes and extent of vital pulp. Histologic analysis showed that the extent of vital pulp was significantly related to the stage of root development, being almost complete in teeth with immature roots and almost totally lacking in young mature and mature teeth. Surface resorption was found with the same frequency in the different root development groups while inflammatory resorption was slightly more frequent in young mature teeth than in mature teeth, a finding possibly related to a protective action of a thick cementum layer in the mature teeth. Replacement resorption was found with almost the same frequency in the different root development groups in non-endodontically treated teeth. As ankylosis is the most important factor determining the prognosis of replanted and autotrans-planted teeth, the present findings indicate that replantation and auto-transplantation of mature teeth could be of clinical use.     

Effects of intracanal medicaments on inflammatory resorption or occurrence of ankylosis in mature traumatized teeth: a review

Abstract A review of the literature of the effect of intracanal medicaments on inflammatory resorption or occurrence of ankylosis in mature traumatized teeth is presented. The results of the studies show that calcium hydroxide and Ledermix paste eliminate inflammatory resorption. Other medicaments such as gutta-percha with sealer, antibiotics, and calcitonin reduce or almost eliminate this complication. Ankylosis or replacement resorption develops in the root surfaces of teeth with mature roots irrespective of medicaments used. However, the percentage of relative surface area of the root which develops ankylosis is significantly higher in mature teeth treated with calcium hydroxide than in teeth treated with permanent root filling. Ledermix paste targets the resorbing cells without damaging neighbouring tissue. Recommendations for the use of calcium hydroxide and Ledermix paste as intracanal dressings in traumatized mature teeth are made.     

Periapical tissue reaction to root fillings with Sealapex

The histological response of periapical tissues to root canal fillings with Sealapex, pure calcium hydroxide and gutta-percha points was studied in dogs' teeth. After pulpal extirpation the root canals were enlarged, irrigated and dried. Teeth in the first group were filled with gutta-percha points alone, those in the second group were filled with pure calcium hydroxide and gutta-percha, and those in the third group were filled with Sealapex and gutta-percha. The animals were killed after 7, 30 and 90 days and histological sections of each specimen were prepared. It was concluded that hard tissue formation was more pronounced after root filling with Sealapex than with calcium hydroxide or gutta-percha points.     

Treatment of periapical lesions on dog''s teeth using periapically extruded Spad

Summary. The method of treating endodontically infected teeth with periapical involvement, by pushing Spad paste beyond the apex, was evaluated both radiographically and histologically 3 months aftr treatment. Sixteen root canals in a dog were used, on which periapical lesions had been experimentally instrumented and filled with Spad paste and gutta-percha points, after the root canal filling paste had been extruded periapically. The radiographic investigation did not show any evidence of periapical tissur repair or significant absorption of the extruded paste. The most profound histological finding was necrosis of the alvolar bone. Inflammation or extensive necrosos of the apical periodontal ligament, resorption of the teeth and ankylosis were also observed. The rusults of this experiment do not support the use of this method of treatment with Spad.     

Effect of immediate calcium hydroxide treatment and permanent root-filling on periodontal healing in contaminated replanted teeth

The effect of immediate permanent root-filling and immediate intracanal calcium hydroxide treatment on experimentally contaminated and necrotized periodontal membranes (PDM) in avulsed and subsequently replanted monkey teeth was studied. Almost the entire root surface in the non-endodontically treated control teeth were covered with inflammatory resorption. A significant shift towards ankylosis not associated with root resorption (greater than 80% of the total root surface area) was noted following calcium hydroxide treatment. About two thirds of the root surfaces from the teeth with permanent root fillings showed surface resorptions or ankylosis preceded by root resorption. The root surface area which would have been covered by inflammatory resorption, unless endodontic treatment had been implemented, were instead predominantly covered by either surface resorption (permanent root filling) or ankylosis (calcium hydroxide treatment). Ankylosis compared with surface resorption may in the long term lead to progressive loss of root substance due to replacement resorption. It was concluded that calcium hydroxide may be an excellent initial intracanal treatment in teeth with healthy PDM, but care should be taken not to risk unnecessary development of ankylosis by prolonged treatment of teeth with compromised PDM.     

Mineral trioxide aggregate as an alternative treatment for intruded permanent teeth with root resorption and incomplete apex formation

Abstract – A case of extensive crown fracture associated with intrusion of the permanent maxillary central incisors in an 8‐year‐old boy is reported. The treatment of both injured teeth included attempts of apexification and arrest of root resorption with calcium hydroxide. After 8 months of the trauma, there was no calcified barrier formation in the apex. Mineral trioxide aggregate (MTA) was then used as a filling material. At 15‐month follow up, the teeth were asymptomatic and correctly sealed, the external inflammatory root resorption had stopped, and the radiolucent image had disappeared, which meant the initial healing of the periapical lesion. MTA may be considered as an alternative option for the treatment of traumatized and immature permanent teeth.     

Effect of immediate calcium hydroxide treatment and permanent root-filling on periodontal healing in contaminated replanted teeth

Abstract – The effect of immediate permanent root-filling and immediate intracanal calcium hydroxide treatment on experimentally contaminated and necrotized periodontal membranes (PDM) in avulsed and subsequently replanted monkey teeth was studied. Almost the entire root surface in the non-endodontically treated control teeth were covered with inflammatory resorp-tion, A significant shift towards ankylosis not associated with root resorption (> 80% of the total root surface area) was noted following calcium hydroxide treatment. About two thirds of the root surfaces from the teeth with permanent root fillings showed surface resorptions or ankylosis preceded by root resorption. The root surface area which would have been covered by inffammatory resorption, unless endodontic treatment had been implemented, were instead predominantly covered by either surface resorption (permanent root filling) or ankylosis (calcium hydroxide treatment), Ankylosis compared with surface resorption may in the long term lead to progressive loss of root substance due to replacement resorption. It was concluded that calcium hydroxide may be an excellent initial intracanal treatment in teeth with healthy PDM, but care should be taken not to risk unnecessary development of ankylosis by prolonged treatment of teeth with compromised PDM.     

Results after replantation of avulsed permanent teeth. I. Endodontic considerations

Abstract – Following avulsion and replantation, teeth are at risk for infection and infection related resorption (IRR). Severe discolorations of tooth crowns and cervical root fractures are common. This study presents data on endodontic related complications of avulsed teeth replanted following an extraoral endodontic treatment. Periodontal aspects will be discussed in the second part of the present publication. Twenty‐eight permanent teeth in 24 patients aged seven to 17 years were replanted after avulsion. All teeth could be evaluated. In all teeth extraoral endodontic treatment by retrograde insertion of ceramic or titanium posts was performed. Mean observation period was 31.2 months (median: 24.1 months). Nine teeth healed with a functional peridontal ligament (PDL) (functional healing, FH), 19 teeth exhibited replacement resorption (RR), which was succeeded by IRR in three teeth after observation periods of more than 14 months. Diagnosis was set to tunneling resorption (one case) and to cervical resorption preceded by complete RR (two cases). No early IRR was observed. All six teeth rescued in physiologic conditions (cell culture medium of tooth rescue box) exhibited FH. Discolorations of tooth crowns or other complications (cervical root fractures, fractures of posts) were not observed. No differences in the healing results of immature and mature teeth were observed which is in contrast to previous studies. This finding is explained with the different endodontic treatment protocols. Extraoral endodontic treatment by retrograde insertion of posts prevents early IRR and minimizes the overall incidence of IRR. The method does not negatively influence periodontal healing. As there are further advantages (no discoloration, no root fractures, patient not involved, less radiographs, less time consumption, less costs) the method is recommended in isolated teeth before replantation. Especially immature teeth profit from the prevention of complications.     

The use of white Portland cement as an apical plug in a tooth with a necrotic pulp and wide-open apex: a case report

AIM: To present a case in which substantial periapical healing occurred with the use of white Portland cement (WPC) to create an apical plug in the root of an immature tooth. SUMMARY: Radiographic examination indicated an immature tooth (35) with a wide-open apex and a periapical radiolucency. The canal was mechanically cleaned using intracanal instruments and 5% NaOCl irrigation. Small pieces of resorbable collagen sponge were packed beyond the root apex with the aim of creating a periapical barrier for the compaction of filling material. WPC powder was then mixed with sterile water and delivered to the apical portion of the canal (approximately 3 mm). The patient was asked to return 1 week later for the continuation of treatment but he did return as planned. Seven months after the intervention the patient returned and another radiograph was exposed to reveal complete radiographic healing of the periapical region. The remainder of the canal was filled with thermoplastic gutta-percha. Clinical follow-up 1 year later revealed adequate clinical function, absence of clinical symptoms and no signs of periapical rarefaction. KEY LEARNING POINT: The positive clinical resolution of this case is encouraging for the use of WPC as an apical plug in immature teeth with necrotic pulps and wide-open apices.     

Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms

AIM: The purpose of the present study is to evaluate the healing of periapical lesions of teeth with positive and negative canal cultures at the time of obturation, and to evaluate the periapical healing of teeth treated in one visit (without) or in two visits with an interappointment dressing of calcium hydroxide. METHODOLOGY: Thirty-nine patients received root-canal treatment. In the first visit, teeth were instrumented, and 18 of these teeth were filled (after microbiological sampling) with calcium hydroxide in sterile saline. The other 21 teeth were obturated with gutta-percha and AH-26 sealer after microbiological sampling. Four weeks later, the teeth with calcium hydroxide were accessed again and after microbiological sampling they were obturated with gutta-percha and AH-26 sealer. Healing of periapical radiolucency was recorded over a period up to 4.5 years. RESULTS: In both the treatment groups, the size of the periapical lesions reduced significantly during the follow-up period. Complete radiographic healing was observed in 81% of the cases in the one-visit group, and in 71% of the cases in the two-visit group. The probability of success increased continuously over time for both treatment groups. Seven out of eight cases (87.5%) that showed a positive root-canal culture at the time of obturation healed. The number of colony forming units (CFU) in six out of eight positive canals was <10(2) CFU mL(-1). CONCLUSIONS: Within the limitations of this study, no significant differences in healing of periapical radiolucency was observed between teeth that were treated in one visit (without) and two visits with inclusion of calcium hydroxide for 4 weeks. The presence of a positive bacterial culture (CFU<10(2)) at the time of filling did not influence the outcome of treatment.     

Clinical performance of 3 endodontic sealers.

OBJECTIVE: Calcium hydroxide is used in endodontics as an interappointment dressing. Its inclusion in salicylate resin or zinc oxide-eugenol-based sealers for filling root canals also may lead to a better treatment outcome. The purpose of the present study was to compare the clinical/radiographic treatment outcome of 3 sealers, 2 of which contain calcium hydroxide. STUDY DESIGN: Two hundred and four teeth underwent a standardized endodontic treatment regimen and were assigned to 1 of 3 groups at the time of root filling: group PS, teeth filled with gutta-percha and Procosol sealer; group CR, teeth filled with gutta-percha and CRCS sealer; and group SA, teeth filled with gutta-percha and Sealapex sealer. The results of the treatment were assessed yearly for up to 4 years by clinical and radiologic (periapical index scores) controls. The ridit statistic (r) was used to compare PAI scores among the groups. RESULTS: The overall treatment results were comparable with, but slightly poorer than, results previously obtained from patients seen at the Dental School at the University of Oslo. During the first year after filling, the mean ridit value decreased from .51 +/- .039 to .31 +/- .042 (Deltar = .20) in the SA group. Corresponding values went from .43 +/- .030 to .38 +/- .035 (Deltar = .05) in the PS group and from 37 +/- .045 to .34 +/- .050 (Deltar = .03) in the CR group. At the 2-year examination, teeth in group SA had slightly better periapical conditions (r =.22 +/-.045) than did teeth in group PA (r = .30 +/- .037) or in group CR (r = .30 +/- 052). The difference was statistically significant at P = .01. By years 3 and 4, no significant difference among the groups was detected. CONCLUSIONS: The overall influence of the sealer on treatment outcome was small. Root fillings with salicylate resin containing Ca(OH)2 may support more rapid healing of apical periodontitis or operative trauma, but the results after 3 and 4 years were as good for zinc oxide-eugenol-based sealers with or without Ca(OH)2.     

Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in dogs

Mandibular incisors were extracted and allowed to dry in air for 45 min. They were then root-planed extensively, leaving a cervical collar and the apical region uninstrumented, to prevent direct contact between root surface and alveolar bone after replantation while, at the same time, enabling precise and stable reseating of the tooth. Control teeth were replanted either without further treatment or after treatment with citric acid for 3 min. Experimental teeth were treated before replantation with 1% SnF2 for 5 min, 1% tetracycline HCl for 5 min, or 1% SnF2 followed by 1% tetracycline. Histometric analysis of healing in the root-planed areas showed minimal amounts of inflammatory resorption and ankylosis after 21 days in experimental teeth as compared with the control teeth. A persisting inflammatory reaction in the periodontal ligament without root resorption was, however, frequently seen. The observations confirm that the frequency of adverse healing reactions after delayed replantation of teeth from which nonvital soft tissue remnants have been removed can be reduced by demineralizing the root surface and preventing mechanical trauma to the root surface in the postoperative period. Root surface treatment with SnF2 followed by tetracycline resulted in complete absence of inflammatory resorption and ankylosis in this short-term experiment.     

Effect of different root canal sealers on periapical repair of teeth with chronic periradicular periodontitis

Teeth with induced chronic periradicular periodontitis in dogs were root canal treated. After the biomechanical preparation, using K files and 5.25% sodium hypochlorite as the irrigant solution, all root canals were dressed with an antibacterial dressing based on calcium hydroxide, which was left in place for 7 days. After this time, the root canals were obturated with lateral condensation of cold gutta-percha with either a calcium hydroxide root canal filling material (Sealapex) or a zinc oxide-eugenol sealer (Fill Canal). After 270 days, histopathological analysis showed better apical and periapical repair in the teeth obturated with Sealapex ( P < 0.05).     

Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling – 1-year follow-up

Aim  To compare healing after root-end resection with a root-end filling of mineral trioxide aggregate (MTA) or smoothing of the orthograde gutta-percha (GP) root filling.
Methodology  Forty-four patients (consisting of 52 teeth with periapical infection), average age of 54.6 years (range 30–77) participated in a randomized clinical trial (RCT) comparing the MTA and GP treatment methods. Radiographs produced 1-week and 12 months post-operatively were compared after blinding for treatment method, and healing was assessed as complete, incomplete, uncertain, or unsatisfactory.
Results  Six teeth were not available for the 12-month follow-up: three teeth (GP) had been re-operated because of pain and two teeth (one GP, one MTA) had been extracted because of root fracture (these five teeth were classified as failures). One patient (GP) was not available for recall. In the GP group, seven teeth (28%) showed complete healing, six teeth (24%) incomplete healing, six teeth (24%) uncertain healing and two teeth (8%) unsatisfactory healing after 1 year. In the MTA group, 22 teeth (85%) showed complete healing, three teeth (12%) incomplete healing, and none were scored as uncertain or unsatisfactory healing after 1 year. The difference in healing between the GP and the MTA groups was significant ( P  <   0.001).
Conclusions  The results from this RCT emphasize the importance of placing a root-end filling after root-end resection. Teeth treated with MTA had significantly better healing (96%) than teeth treated by smoothing of the orthograde GP root filling only (52%).     

Effect of irrigating solution and calcium hydroxide root canal dressing on the repair of apical and periapical tissues of teeth with periapical lesion

The objective of this study was to evaluate the apical and periapical repair after endodontic treatment of teeth with pulp necrosis and a chronic periapical lesion in dogs. Seventy-two root canals from four mongrel dogs were submitted to biomechanical preparation, using 5.25% sodium hypochlorite or 2% chlorhexidine digluconate as the irrigating solution. The root canals were subsequently either filled immediately with Sealapex, using active lateral gutta-percha condensation, or a calcium hydroxide root canal dressing was applied for 15 days before filling with Sealapex. After 210 days, the animals were killed by anesthetic overdose, and the obtained histological sections were stained with hematoxylin and eosin for optical microscopic analysis of apical and periapical repair. There was better histological repair in the groups with the root canal dressing (p < 0.05) than the groups with immediate obturation. Comparing the immediate obturation groups, irrigation with chlorhexidine solution resulted in better repair than sodium hypochlorite.     

Periodontal and pulpal healing of monkey incisors preserved in tissue culture before replantation.

The effect of delayed replantation and tissue culture as a prevention against root resorption was examined in green Vervet monkeys (Cercopithecus aethiops). Extracted incisors were kept in tissue culture medium (Eagle's medium) for 5--14 days before replantation. The extra-alveolar dry period before tissue culture ranged from to 0 to 60 min. Incisors not subjected to tissue culture served as controls. The animals were sacrificed 8 weeks after replantation. The following histologic parameters were registered for each tooth: surface resorption, inflammatory resorption, replacement resorption (ankylosis), downgrowth of pocket epithelium, and periapical inflammatory changes. The evaluation of the pulp included the extent, recorded in mm, of pulp survival. Histometric evaluation showed that teeth immediately placed in tissue culture medium for 5--14 days showed improved periodontal healing, exhibiting significantly less inflammatory resorption than control teeth immediately replanted. Also the extent of pulp survival was significantly increased in teeth replanted after tissue culture. Teeth bench-dried for 60 min and thereafter placed in tissue culture medium also showed a significant reduction in the amount of inflammatory resorption and increased amount of pulp survival compared with control teeth replanted after the 60-min dry extra-alveolar period. Replacement resorption (ankylosis) was found in all teeth in both groups.     

Treatment of replacement resorption with Emdogain® − a prospective clinical study

The present clinical study investigated the outcome of intentional replantation using Emdogain for periodontal healing following trauma‐related ankylosis. Sixteen ankylosed teeth affected by replacement resorption were treated as follows: After tooth extraction, the root canal was obturated with a retrograde titanium post. Emdogain was applied to the root surface and into the extraction socket with subsequent replantation of the tooth. Evaluation parameters included horizontal and vertical Periotest scores, percussion sound and periapical radiographs. All findings were compared to those of the adjacent teeth. The mean follow‐up period was 15 months (range 4–24 months). Eleven teeth showed no signs of recurrence of ankylosis: they were in full function and exhibited no pathological clinical findings. Four severely traumatized teeth demonstrated a recurrence of ankylosis after a mean period of 6 months, one tooth was lost in a second accident after 7 months. The estimated probability of 1 year without recurrence of ankylosis was P = 0.66 (95% confidence interval [0.40; 0.94]). The mean survival time was 10.2 months (SD 1.1). The results indicate that treatment of replacement resorption following light to moderate trauma with replantation and Emdogain appears to prevent or delay recurrence of ankylosis in many cases.