Delayed replantation of avulsed mature teeth with calcium hydroxide treatment

Three avulsed teeth that were replanted and splinted after approximately a 200-min dry extraoral period in two patients are presented. In case 1 calcium hydroxide treatment was performed 1 month after replantation, because the patient did not come for endodontic treatment on the day after replantation as requested. In case 2, calcium hydroxide treatment was initiated on the day after replantation. Calcium hydroxide treatment was used to prevent or treat inflammatory root resorption. During the follow-up periods the teeth reported in these cases have remained in a stable, functional position and did not reveal clinical ankylosis or replacement resorption.     

Federal University of Santa Catarina endodontic treatment of traumatized primary teeth – part 2

Abstract –  This research sought to evaluate periapical repair in 28 traumatized deciduous teeth that had suffered endodontic intervention due to the presence of internal or external inflammatory resorption or replacement root resorption. After obtaining endodontic access, work length and biomechanical preparation, the root canals were filled with calcium hydroxide and propylene glycol under the form of a dense slurry, during 12 months. Replacement of the intracanal dressing was performed when monthly radiographic examinations showed its absence. After 12 months the teeth were obturated with zinc oxide and eugenol cement . Halting of the inflammatory and replacement root resorption (64.3%; n  = 28) occurred 9 months after the use of calcium hydroxide dressings, in a total of 18 successful cases. Fisher's test was applied to relate success with the type of trauma, work length time, child's age and pulpal condition. The test did not present statistical significance ( P  < 0.05). However, in the qualitative analysis, failure was observed in those cases (35.7%) where replacement resorption was already present at the moment of treatment (up to two-thirds) associated with severe trauma cases. The authors concluded that endodontic treatment must be initiated at an early stage, and must be coincident with the radiographic signs of resorption. Success of the treatment is directly related to the seriousness of the sequelae at the moment of the first examination or the endodontic treatment.     

Management of an avulsed tooth with severe root resorption

Delayed replantation of an avulsed tooth with an open apex resulted in failure of revascularization, necrosis of the pulp and extensive external root resorption. Removal of the necrotic pulp and repeated intra-canal dressings of calcium hydroxide over a three year period arrested the inflammatory resorptive process. The process was replaced by replacement resorption leading to ankylosis and infra-occlusion of the affected tooth. As the tooth was asymptomatic, it was retained in the arch to act as a space maintainer. To improve aesthetics, the crown was recontoured using a light-cured resin.     

Intentional replantation with 180° rotation of a crown–root fracture: a case report

Abstract  – Crown–root fractures are frequently difficult to treat and have a bad prognosis. To restore the biological space, intentional replantation can be chosen when osteotomy/osteoplasty and dental traction are not viable. Intentional replantation with tooth rotation consists of extraction, 180° rotation and replantation, thus restoring the biological space. After treatment of inflammatory resorption with calcium hydroxide, endodontic treatment was completed. The patient was followed up with clinical examination (mobility test, gingival sulcus depth) and radiographic analysis (to analyze root resorption: inflammatory and/or substitution, and the integrity of the alveolar cortex and the periodontal space) for 3 years and there were no signs of resorption.     

Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth

Abstract This study examined, histologically, the healing of intentionally produced inflammatory root resorption of replanted teeth in beagle dogs, treated with short- or long-term placement of calcium hydroxide. Thirty beagle dog incisors were randomly divided into four groups. In group 1 (negative control), uninfected incisors were extracted, the roots were longitudinally grooved and the teeth were replanted within 2 min. In group 2 the root canals were artificially infected followed by extraction, longitudinal grooving, and replantation as in group 1. Radiographs were taken biweekly and at the first signs of inflammatory root resorption or at 4 weeks, the root canals were fully instrumented and medicated with calcium hydroxide. In group 2, the root canals were permanently obturated with gutta-percha and sealer after 1 week of calcium hydroxide. The teeth in group 3 were treated as described in group 2 but after 1 wk the calcium hydroxide dressing was repacked for the duration of the study. In group 4 (positive control) the teeth were treated as described in groups 2 and 3 but no endodontic treatment was performed. Twrelve weeks after the initiation of the endodontic treatment, sacrifice and histological preparation were carried out. In group 1, complete cemental repair was seen in all teeth. In group 2, five often teeth showed complete cemental repair whereas in group 3 complete cemental repair was seen in nine of ten teeth. None of the teeth in group 4 showed cemental repair. It was concluded that long-term may be more effective than short-term calcium hydroxide treatment of established inflammatory root resorption.     

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.     

Replantation of teeth and antibiotic treatment

Abstract Administration of antibiotics is usually recommended when a traumatically avulsed tooth is replanted, in order to prevent bacterial contamination. In the present study, permanent lateral incisors of monkeys were extracted, allowed to dry for 1 h and then replanted. Some teeth had their pulp chambers opened labially and left open for 3 wk after replantation. The monkeys were treated with antibiotics (i.m.) either at the lime of replantation or 3 wk after replantation. In some monkeys, antibiotics were placed in the pulpal cavity. Comparisons were made of the effect of endodontic treatment on periodontal healing and root resorption. The monkeys were killed 8 wk after replantation. It was found that after systemic antibiotic treatment at the time of replantation there was no inflammatory root resorption. Also, endodontic treatment at the time of replantation prevented inflammatory root resorption. When systemic antibiotic treatment was instituted 3 wk after (he replantation, there was no reduction of the inflammatory root resorption as compared with teeth without antibiotic treatment. Application of antibiotics in the pulp 3 wk after replantation almost completely eliminated the inflammatory resorption. In all the treatment groups where administration of antibiotics or endodontic treatment had prevented, reduced or eliminated inflammatory root resorption, 30–45% of the root surface area was ankylotic 8 wk after replantation.     

Treatment and prognosis of avulsed teeth: A discussion and case report

A documented case that involves avulsion of an incisor is reported. Calcium hydroxide failed to prevent progressive irreversible root resorption. The importance of extraoral time, transport media, duration and type of splinting, as well as the rationale for the use of calcium hydroxide in the treatment of avulsed teeth are discussed. This case could serve as a reminder to practitioners, that patient compliance, timing and sequencing of endodontic therapy, and regular recalls is critical in the prevention or treatment of root resorption in avulsed teeth. It also emphasizes the frustration of many clinicians in treating avulsed immature teeth. The reporting of long-term documented cases should be encouraged so that replantation techniques may be evaluated.     

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.     

Severe external root resorption arrested by conventional endodontic treatment

A case is presented of inflammatory external root resorption detected on radiographic examination. Conventional endodontic treatment, including calcium hydroxide dressing for two weeks and obturation of the root canal system using the vertical compaction of warm gutta-percha technique was a simple and effective treatment modality for arresting the resorptive process and maintaining the integrity of the patient dentition.     

The role of endodontics in the treatment of luxated permanent teeth

Abstract  – Pulp necrosis is a common complication following traumatic dental injuries and is related to the type and severity of the injury, as well as to the stage of development of the injured tooth. Endodontic intervention is required when there are clinical and radiographic signs of pulpal infection and its sequelae. Arrested tooth development with periradicular pathosis, external inflammatory root resorption, sinus tract formation and pain on percussion are indicative of root-canal infection in the post-traumatized teeth, and require immediate endodontic treatment. The use of calcium hydroxide in the treatment of teeth with post-traumatic pulp necrosis and its sequelae has been shown to be extremely beneficial for the long-term retention of the injured teeth. Calcium hydroxide has been shown to arrest and repair external inflammatory root resorptive defects, eliminate the endodontopathic microorganisms from the root canal system and induce hard-tissue barrier formation at the apex of non-vital immature teeth. This paper reviews the endodontic treatment required by post-traumatic non-vital permanent teeth.     

Treatment of external inflammatory root resorption after autogenous tooth transplantation: case report

This paper describes a case of autogenous tooth transplantation. An external inflammatory root resorption developed in a 30-year-old female patient and was successfully treated with the placement of calcium hydroxide-based intracanal dressings. Autotransplantation of tooth 32 into the extraction socket of tooth 30 was carried out with no intraoperative complications and uneventful postoperative course. However, the patient did not appear on the 14th postoperative day to initiate endodontic therapy of the transplanted tooth. She did not return for 3 months, at which time the clinical and periapical radiographic examinations revealed the presence of external inflammatory root resorption. Endodontic treatment was initiated immediately. Root canals were prepared and filled with a calcium hydroxide-based intracanal dressing (Calen paste), changed every 21 days during a 6-month period, and were thereafter obturated with Sealapex calcium hydroxide-based sealer and gutta-percha points. After 2 years of follow-up, the transplanted tooth was symptom free with no exacerbated sensibility to percussion, normal mobility, occlusion, and masticatory function. Probing revealed no periodontal pockets or other pathological signs. Radiographic examination showed the periradicular area with normal appearance, completely healed resorption areas, and presence of an intact lamina dura.     

Intracanal dressing and root canal filling materials in tooth replantation: a literature review

Abstract – The prognosis of tooth replantation is usually related to the need of endodontic treatment, which has a direct relationship with the occurrence of root resorptions. Several studies have been undertaken in an attempt to prevent, delay, or treat these complications, which are the main causes of loss of replanted teeth. This literature review examines research evidence on intracanal dressings and root canal filling materials used in cases of tooth replantation. A comprehensive search was performed in the Medline/Pubmed, Bireme and Scielo full‐text electronic journal databases to retrieve English‐language articles referring to these topics that had been published between 1964 and 2010. Calcium hydroxide (CH) remains the usually recommended choice as an intracanal medicament in replanted teeth; however, there is evidence to support the initial use of a corticosteroid‐antibiotic combination such as Ledermix paste to control potential early resorption, prior to the introduction of CH where the beneficial effect in the treatment of progressive root resorption has been well proven. Regarding root filling materials, CH‐containing sealers are a good option because of their biological properties. Accurate diagnosis and adequate treatment plan may constitute very complex tasks, particularly in tooth avulsion because several variables are involved. In addition to the technical knowledge and clinical experience directed toward the quality of treatment, patient education may favorably influence the survival of replanted teeth.     

The use of calcium hydroxide and mineral trioxide aggregate on apexification of a replanted tooth: a case report

Abstract – Aim: To report the outcome of the endodontic treatment of a reimplanted central maxillary incisor with open apex after 8 years and 7 months of follow‐up. Summary: This case report presents the treatment of a right central maxillary incisor of an 8‐year old white male patient with history of traumatic avulsion and immediate replantation. The endodontic therapy consisted of periodical changes of calcium hydroxide dressing and a definitive root canal filling with mineral trioxide aggregate (MTA). The treatment was successful without pathologies up to 7 years of follow‐up. After the institution of orthodontic treatment a localized and late root resorption was noticed at the last radiographic examination (8 years and 7 months postoperative follow‐up). Moreover, the use of MTA promoted a mild crown grey discoloration.     

Periodontal response to two intracanal medicaments in replanted monkey incisors

Abstract – Intracanal medicaments are recommended for use in replanted teeth to inhibit inflammatory root resorption. This study compared the effect of calcium hydroxide (Pulpdent^®) and a corticosteroid-antibiotic paste (Ledermix^®) on periodontal healing and root resorption following replantation. Incisors of eight Macaca fascicularis monkeys were extracted, stored dry for 15 min and replanted. After 11 days, root canals in two adjacent maxillary incisors were treated with one medicament and contralateral incisors with the other medicament, or left as untreated controls. Animals were sacrificed 8 weeks later and the teeth prepared for histomorphometric evaluation of periodontal ligament inflammation and root resorption. Periodontal ligament inflammation and inflammatory root resorption were markedly inhibited by both calcium hydroxide and corticosteroid-antibiotic relative to untreated controls. Replacement resorption was lowest in the corticosteroid-antibiotic group, and significantly ( P <0.05) more normal periodontal ligament was present in this group (79.6%) than in calcium hydroxide and control groups (64.6% and 62.7%, respectively). Treatment with the corticosteroid-antibiotic inhibited inflammatory resorption and was slightly more effective than calcium hydroxide in producing a periodontal healing response.     

Progression of root resorption following replantation of human teeth after extended extraoral storage

Abstract Avulsed human permanent teeth subjected to a minimum of 1 h dry extraoral storage before replantation were followed radiographically for an average of 4.8 years. The depth of root resorption cavities was assessed using a radiographic index, and the rate of root resorption was defined as the index change over time. The frequency of inflammatory and replacement resorption was determined at each observation time. Replacement resorption increased in frequency with time in all patients. In teeth endodontically treated within 3 weeks of replantation, minimal inflammatory resorption was found regardless of the age of the patients. In teeth where endodontic treatment was performed more than 3 weeks after replantation, the frequency of inflammatory resorption was significantly higher in young patients but not in older patients, up to more than 3 years after replantation. The rate of root resorption was found to be related to age. In patients 8–16 years old at the time of avulsion the rate of root resorption was significantly higher compared with patients 17–39 years old. Age had a higher impact on the rate of root resorption compared with the delay in endodontic treatment after replantation. It was concluded that a tooth replanted with a necrotic periodontal membrane will become ankylosed and resorbed within 3–7 years in young patients, whereas a tooth replanted under similar conditions in older patients may remain in function for a considerably longer time.     

Progression of root resorption following replantation of human teeth after extended extraoral storage

Avulsed human permanent teeth subjected to a minimum of 1 h dry extraoral storage before replantation were followed radiographically for an average of 4.8 years. The depth of root resorption cavities was assessed using a radiographic index, and the rate of root resorption was defined as the index change over time. The frequency of inflammatory and replacement resorption was determined at each observation time. Replacement resorption increased in frequency with time in all patients. In teeth endodontically treated within 3 weeks of replantation, minimal inflammatory resorption was found regardless of the age of the patients. In teeth where endodontic treatment was performed more than 3 weeks after replantation, the frequency of inflammatory resorption was significantly higher in young patients but not in older patients, up to more than 3 years after replantation. The rate of root resorption was found to be related to age. In patients 8-16 years old at the time of avulsion the rate of root resorption was significantly higher compared with patients 17-39 years old. Age had a higher impact on the rate of root resorption compared with the delay in endodontic treatment after replantation. It was concluded that a tooth replanted with a necrotic periodontal membrane will become ankylosed and resorbed within 3-7 years in young patients, whereas a tooth replanted under similar conditions in older patients may remain in function for a considerably longer time.     

Periapical tissue reactions to calcium hydroxide and MTA after external root resorption as a sequela of delayed tooth replantation

Clinical experience has shown that most avulsed teeth are replanted after a long extra-alveolar time and dry or inadequate wet storage, causing necrosis of periodontal ligament cells. This condition invariably leads to development of external root resorption, leaving the filling material in contact with the periapical connective tissues. In this study, the periapical tissue reactions to calcium hydroxide (CH) and mineral trioxide aggregate (MTA) were evaluated after occurrence of external root resorption as an expected sequela of delayed tooth replantation. Twenty male Wistar rats (Rattus norvegicus, albinus) had their right upper incisor extracted and maintained in dry storage for 60 min. Then, the dental papilla, enamel organ, pulp tissue, and periodontal ligament were removed, and the teeth were immersed in a 2% acidulated phosphate sodium fluoride solution, pH 5.5, for 10 min. The teeth were randomly assigned into two groups (n = 10), in which the canals were filled with either a CH and saline paste (CH group) or MTA (MTA group). The sockets were irrigated with saline, and the teeth were replanted. After 80 days, it was possible to observe large areas of replacement root resorption and some areas of inflammatory root resorption in both groups. More severe inflammatory tissue reaction was observed in contact with calcium hydroxide compared with the mineral trioxide aggregate. New bone formation was more intense at the bottom of the socket in the MTA group. In conclusion, as far as periapical tissue compatibility is concerned, intracanal MTA can be considered as a viable option for root canal filling in delayed tooth replantation, in which external root resorption is an expected sequela.     

Effect of delayed calcium hydroxide treatment on periodontal healing in contaminated replanted teeth

Abstract – The effect of delayed intracanal calcium hydroxide treatment on experimentally induced extensive inflammatory root resorption in monkeys was studied. A significant shift from inflammatory resorption to ankylosis was noted following calcium hydroxide treatment. Furthermore, calcium hydroxide treatment appeared to change the pattern of ankylosis over time, although the total ankylotic area remained the same. Ankylosis preceded by root resorption (replacement resorption) increased, while ankylosis not associated with root resorption decreased. It was concluded that intracanal calcium hydroxide treatment of teeth with compromised PDM may cause unnecessary replacement resorption if left in the root canal for a long time or changed repeatedly.     

Effect of delayed calcium hydroxide treatment on periodontal healing in contaminated replanted teeth

The effect of delayed intracanal calcium hydroxide treatment on experimentally induced extensive inflammatory root resorption in monkeys was studied. A significant shift from inflammatory resorption to ankylosis was noted following calcium hydroxide treatment. Furthermore, calcium hydroxide treatment appeared to change the pattern of ankylosis over time, although the total ankylotic area remained the same. Ankylosis preceded by root resorption (replacement resorption) increased, while ankylosis not associated with root resorption decreased. It was concluded that intracanal calcium hydroxide treatment of teeth with compromised PDM may cause unnecessary replacement resorption if left in the root canal for a long time or changed repeatedly.