Treatment of replacement resorption with Emdogain--a prospective clinical study

Tooth intentional replantation from 1964 to 2023: A bibliometric analysis

BACKGROUND/AIM

There is no thorough overview of intentional tooth replantation techniques. We performed a bibliometric analysis of the development of intentional tooth replantation.

MATERIALS AND METHODS

A comprehensive search of the Web of Science and SCOPUS databases was conducted in February 2023. Original articles and reviews of human studies with "intentional replantation" or synonyms in the titles, abstracts, or keywords were included. A descriptive analysis of bibliographic data, co-occurrence analysis, and coupling of publications was performed. Multivariate analysis was used to explore the bibliometric parameters associated with the citation counts.

RESULTS

The study included 171 papers, which were co-authored by 500 individuals affiliated with 217 institutions from 28 countries/regions. The USA contributed the greatest number of publications, followed by China, and Japan. The USA had 694 citations, followed by Japan (210), and Turkey (210). The Journal of Endodontics and Dental Traumatology contributed the most citations. Five directions for future research were identified based on the coupling relationships of publications, including "managing vertical root fractures with adhesive resin using the intentional replantation technique," "intentional replantation for periodontally hopeless or endodontically compromised teeth," "intentional replantation for treating abnormalities of morphological development," "outcomes and prognosis factors of intentional replantation," and "treating root replacement resorption by intentional replantation." Multivariate analysis showed that the publication year, Journal Citation Reports ranking of journals, study design, and disease type were predictors of citation counts.

CONCLUSIONS

This bibliometric analysis provides a comprehensive description of the intentional replantation technique. The USA published the greatest volume of papers and generated the most citations. The Journal of Endodontics and Dental Traumatology are considered the most influential. The Journal Citation Reports journal ranking (Q1, Q2), study design (case reports, cohort studies), and disease type (crown root fractures) were associated with the citation counts.

Management of ankylosed teeth using the decoronation technique: integrative literature review and case report

INTRODUCTION

The decoronation technique has been described in literature since 1984 and, based on the available results, it can lead to considerable benefits for the repair and rehabilitation of ankylosed teeth. Based on these reports, one could expect that this procedure would be well known by the dental community. However, this fact does not seem to be true, and this procedure is not widely used.

METHODS

The objective of this paper is to present appropriate literature that discusses decoronation and evaluate the perspectives of the procedure, both in relation to the technique and the long-term benefits for the patient. An integrative literature review at PubMed, ScieELO, and Lilacs databases was performed using the keywords "decoronation", "ridge preservation decoronation", "decoronation ankylosis". In addition, a case report will be presented to demonstrate the technique in a systematic and detailed manner.

RESULTS

Considering the inclusion criteria, 27 articles that present consistency regarding decoronation were selected.

CONCLUSION

There is scarce availability of scientific works related to the topic, to corroborate and discuss the technique. The present paper reinforces the benefits of this procedure, and revisit decoronation, attempting to provide a possible treatment for ankylosed teeth in growing patients.

Intentional replantation - a clinical review of cases undertaken at a major UK dental school

Introduction Intentional replantation (IR) may offer a solution for persistent periapical lesions associated with endodontically treated teeth in select cases. This case series demonstrates the use of IR as an alternative treatment approach to both orthograde and surgical endodontic retreatment. The indications, contraindications, benefits and risks of IR are discussed, and the clinical procedure is outlined.Setting Restorative Department, University Dental Hospital of Manchester, UK.Case reports Of the 13 cases presented, the follow-up period before discharge ranged from 3-28 months. Only one tooth which presented intra-operative challenges required extraction three months after IR due to post-operative mobility.Conclusion In select cases, IR may provide a simple, less invasive and cost-effective alternative to both endodontic retreatment and extraction alone following appropriate training.

Enamel matrix derivative (Emdogain) in treatment of replanted teeth - a systematic review

OBJECTIVE

The main purpose of the present systematic review was to evaluate the efficacy of enamel matrix derivative Emdogain in healing of replanted teeth in humans.

MATERIALS AND METHODS

This review conducted in adherence to PRISMA standards and was registered in PROSPERO with registration number CRD42017062736. We graded the methodological quality of the studies by means of Cochrane's tool of risk of bias in non-randomized studies - of interventions (ROBINS-I).

RESULTS

In total, 65 studies were identified for screening, and five studies were eligible. The uneventful healing of replanted teeth was varied from 20% to 75%. Two controlled trials found Emdogain treatment significantly reduced resorption of replanted teeth and improved the healing of periodontal ligament compared with controls. Two studies showed high recurrent resorption in Emdogain treated teeth.

CONCLUSIONS

To conclude, the number of publications that met all inclusion criteria were limited and did not allow for drawing evidence for Emdogain being effective in supporting healing of replanted teeth.

Periodontal wound healing following reciprocal autologous root transplantation in class III furcation defects

Purpose

Furcation involvement in the molars is difficult to treat, and has been recognized as a risk factor for tooth loss. Although periodontal regenerative therapies, including guided tissue regeneration and various types of bone grafts, have been applied to furcation defects, the effects of these treatments are limited, especially in large class III furcation defects. The purpose of this pilot study was to investigate the effect of reciprocal autologous root transplantation on periodontal wound healing and regeneration in class III furcation defects in dogs.

Methods

Furcation defects (7 mm wide and 6 mm high) were surgically created after root separation of the unilateral third and fourth premolars in 4 dogs. Eight furcation defects were randomized to receive either reciprocal autologous root transplantation (test) or no further treatment (control). In the test group, the mesial and distal roots were transplanted into the distal and mesial extraction sockets, respectively. The animals were sacrificed 10 weeks after surgery for histologic evaluation.

Results

The healing pattern in the control group was characterized by extensive collapse of the flap and limited periodontal regeneration. New bone formation in the test group (3.56±0.57 mm) was significantly greater than in the control group (0.62±0.21 mm). Dense collagen fibers inserting into the residual cementum on the transplanted root surfaces were observed in the test group. Slight ankylosis was observed in 2 of the 4 specimens in the test group on the mesiodistal sides where the root-planed surfaces faced the existing bone. Root resorption (RR) was detected in both the control and test groups.

Conclusions

Within the limits of this study, it can be concluded that reciprocal autologous root transplantation was effective for bone regeneration in class III furcation defects in dogs. However, further studies are required to standardize the approach in order to prevent unwanted RR prior to clinical application.

A retrospective analysis of factors influencing the success of autotransplanted posterior teeth

Background

Survival and success rates of tooth transplantations even after long follow-up periods have been shown to be very high. Nevertheless, it is important to analyse factors potentially influencing these rates. The aim of this study was to assess the influence on success of potential factors.

Methods

The research was based on a retrospective analysis of clinical and radiological data from a sample of 59 subjects (75 transplanted teeth). The follow-up period varied from 0.44 to 12.28 years (mean 3.95 years). Success rates were calculated and depicted with Kaplan-Meier plots. Log-rank tests were used to analyse the effect of root development stage, apex width, the use of enamel matrix proteins or the surgeon on success of transplantations.

Results

Results for success of premolar transplantations were comparable with already published data, while molars performed worse than shown in other studies. The surgeon performing the transplantation (p = 0.001) and tooth type (p ≤ 0.001) were significantly associated with transplantation success. Use of enamel matrix proteins (p = 0.10), root development stage (p = 0.13), the recipient area (p = 0.48) and apex width (p = 0.59) were not significantly associated with success.

Conclusions

Molar transplantations were not as successful as premolar transplantations; however, success rates varied greatly depending on the surgeon’s experience. The use of enamel matrix proteins as well as root development stage, the recipient area and apex width did not show significant associations with success of tooth transplantations.

Enamel matrix derivative for replanted teeth in animal models: a systematic review and meta-analysis

OBJECTIVES

To investigate the effect of enamel matrix derivative (EMD) on periodontal healing of replanted teeth in animal models.

MATERIALS AND METHODS

The authors searched MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Knowledge and Scopus for articles published up to Oct 2012. Animal studies in which EMD was applied in transplanted or replanted teeth with adequate controls and histological data were considered. Normal periodontal healing or root resorption determined by histology after EMD was applied in replanted teeth with adequate controls was used as outcome measures. The following search strategy was used: ('Emdogain' OR 'enamel matrix proteins' OR 'enamel matrix derivative') AND ('avulsion' OR 'transplantion' OR 'autotransplantation' OR 'replantation').

RESULTS

Six animal studies were included in the final review. There was great heterogeneity in study design among included studies. Two studies with similar study designs were identified and analyzed by a meta-analysis. The pooled estimates showed a significantly higher normal healing and surface resorption and significantly less inflammatory and replacement resorption in EMD-treated groups compared with non-EMD-treated groups.

CONCLUSIONS

With the limitations of this systematic review, the use of EMD led to greater normal periodontal healing and surface root resorption and less inflammatory and replacement root resorption in the presence of periodontal ligaments. However, no definite conclusion could be drawn with regard to the effect of EMD on periodontal healing and root resorption when no periodontal ligaments exist.

Histometric study of resorption on replanted teeth with enamel matrix-derived protein

BACKGROUND

Enamel matrix-derived proteins (Emdogain) stimulate the proliferation of periodontal ligament cells, contributing to their regeneration.

AIM

This study was to perform histometric assessment of root surface resorption in replanted teeth with the use of Emdogain®.

MATERIALS AND METHODS

Male Wistar rats (Rattus norvegicus), weighing 180 to 200 gm, were anesthetized, subjected to extraction of the upper right incisor tooth, which was then replanted into the alveoli with the following treatment: (a) control group--tooth with root canal filled with calcium hydroxide paste and (b) treated group--tooth with root canal filled with enamel matrix-derived protein. The animals were sacrificed 25 days after tooth replantation. The maxilla was processed to obtain thin sections (6 µ) and stained with hematoxylin and eosin. The resorption volume percentage of each dental element was calculated from the cementoenamel junction to the apex.

RESULTS

Quantification of resorption revealed that Emdogaintreated teeth showed a lower percentage of resorption (31.58%) compared to controls (80.48%) (statistically significant values--t-test p-value=0.0431).

CONCLUSION

It was concluded that Emdogain used as root canal filling has properties capable of showing a lower percentage of resorption in replanted teeth.

Intentional replantation: a procedure as a last resort

AIM

To address the indications, contraindications, surgical procedure, complications following treatment, factors influencing the results and success rate of intentional replantation procedure.

BACKGROUND

Intentional replantation is extraction of a tooth to do extraoral root canal therapy, curettage of apical lesion when present, and its replacement in its socket. It has been proposed as an alternative to routine extraction; however, it should be considered a last resort because the root may be fractured during extraction.

RESULTS

The success rate of intentional replantation is far below than routine endodontic treatment or apical surgery. Difficultness of tooth extraction, the possibility of fracture during extraction and the risk of external resorption are some limitations of this treatment. The most common causes of failure in intentionally replanted teeth are external inflammatory resorption or replacement resorption and ankylosis caused by periodontal ligament damage.

CONCLUSION

The success rate up to 95% with an average retention of 3 to 5 years, has been reported.

CLINICAL SIGNIFICANCE

In some cases, endodontic retreatment or apical surgery is impossible or impractical. In these situations, intentional replantation may be considered as a last resort for preserving the tooth, so all clinicians should know about its indications/contraindications, surgical procedure and complications following treatment.

Efficacy of the enamel matrix derivative to induce cementogenesis in vital and endodontically treated teeth with osseous dehiscence defects

This experiment assessed the efficacy of the enamel matrix derivative (EMD) to regenerate cementum in vital and endodontically treated teeth with osseous dehiscence defects. Five adult female beagle dogs were used. Thirty maxillary teeth (bilateral maxillary canines and second and fourth premolars) were randomly divided into two experimental groups (groups A and B, containing 12 teeth each) and one control group (group C). Endodontic treatment was only performed on teeth in group A compared with teeth in groups B and C. Buccal osseous dehiscence defects were surgically created in teeth from all groups. Teeth in the experimental group were treated with the EMD, whereas the controls were not. After 5 months, the animals were sacrificed and block sections of the teeth in experimental and control groups were processed for histological analysis. Newly regenerated cementum was observed in all teeth in groups A and B. No cementum regeneration was observed in group C. There was a significant difference in cementum generation between the experimental and control groups (P < 0.001). EMD therapy induces cementogenesis in vital and endodontically treated teeth with osseous dehiscence defects.

Enamel matrix derivative (Emdogain(R)) for periodontal tissue regeneration in intrabony defects

BACKGROUND

Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. Amelogenins are involved in the formation of enamel and periodontal attachment formation during tooth development.

OBJECTIVES

To test whether EMD is effective, and to compare EMD versus GTR, and various BG procedures for the treatment of intrabony defects.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: February 2009.

SELECTION CRITERIA

RCTs on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events. The following time-points were to be evaluated: 1, 5 and 10 years.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). It was decided not to investigate heterogeneity, but a sensitivity analysis for the risk of bias of the trials was performed.

MAIN RESULTS

Thirteen trials were included out of 35 potentially eligible trials. No included trial presented data after 5 years of follow up, therefore all data refer to the 1-year time point. A meta-analysis including nine trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.1 mm, 95% CI 0.61 to 1.55) and PPD reduction (0.9 mm, 95% CI 0.44 to 1.31) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had < 2 mm PAL gain in the control group, with RR 0.53 (95% CI 0.34 to 0.82). Approximately nine patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 25%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating only trials at a low risk of bias in a sensitivity analysis (four trials), the effect size for PAL was 0.62 mm (95% CI 0.28 to 0.96), which was less than 1.1 mm for the overall result. Comparing EMD with GTR (five trials), GTR showed statistically significant more postoperative complications (three trials, RR 0.12, 95% CI 0.02 to 0.85) and more REC (0.4 mm 95% CI 0.15 to 0.66). The only trial comparing EMD with a bioactive ceramic filler found statistically significant more REC (-1.60 mm, 95% CI -2.74 to -0.46) at the EMG treated sites.

AUTHORS' CONCLUSIONS

One year after its application, EMD significantly improved PAL levels (1.1 mm) and PPD reduction (0.9 mm) when compared to a placebo or control, however, the high degree of heterogeneity observed among trials suggests that results have to be interpreted with great caution. In addition, a sensitivity analysis indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications in the GTR group, there was no evidence of clinically important differences between GTR and EMD. Bone substitutes may be associated with less REC than EMD.

Stimulation of cytokines in osteoblasts cultured on enamel matrix derivative

OBJECTIVE

The purpose of this study was to evaluate the influence of enamel matrix derivative (EMD) on the release of transforming growth factor beta 1 (TGF-beta1), interleukin-6 (IL-6), insulin-like growth factor I (IGF-I), bone morphogenetic protein 2 (BMP-2), and osteoprotegerin (OPG) in human and mouse osteoblasts.

STUDY DESIGN

Human MG-63 and mouse MC3T3-E1 cells were seeded onto 6-well culture plates at an initial density of 5,000/cm(2) and grown in Dulbecco's eagle medium (DMEM) with 10% fetal bovine serum for 24 h. Then cells were cultured either with 100 microg/mL EMD added to DMEM or with DMEM only. After 2, 5, and 9 days' incubation the culture medium was collected and analyzed by enzyme-linked immunosorbent analysis. Data were analyzed using Student t test.

RESULTS

The EMD treatment significantly increased the production of IL-6 and TGF-beta1 (P < .05) at all time points. The release of OPG was also increased in mouse osteoblasts (P < .05). IGF-I and BMP-2 were not detected in both control and EMD-treated groups.

CONCLUSION

This study suggests that the stimulatory effects of EMD on tissue regeneration are mediated by the up-regulation of local mediators released by osteoblasts.

Evaluating Emdogain and healing of replanted teeth using an intra-individual experimental-control study design

The purpose of the present investigation was to use an intra-individual experimental-control study design to explore if application of Emdogain prior to re-plantation after a dry extra-alveolar period of 60 min would promote a favorable healing of the periodontal ligament cells. Ten patients, for whom already decisions had been taken to extract two maxillary premolars because of crowding, participated in the study. The teeth were extracted and endodontic treatment was performed extra orally. The experimental tooth and its alveolar socket were covered with Emdogain prior to replantation. The contra lateral tooth served as a control and was replanted without any prior treatment. The teeth were stabilized with a retainer for 3-7 days and the patients were followed up every third week. After 13 weeks, the teeth were finally extracted and prepared for histological examination. Radiographs were taken before the study period, at day 29 and prior to the final extraction. The results were in favor of Emdogain, but the overall difference between the Emdogain-treated tooth and its control was rather small, and it seemed questionable if the registered differences could be of any obvious practical clinical importance. Histologically, all the teeth showed some degree of pathology after such a long dry extra-oral time and the outcome seemed to be more correlated to the individual than to the treatment. Given more favorable conditions regarding storage medium and/or extra-oral time, Emdogain might still be of value for an uncomplicated healing after replantation.

Treatment of root surface in delayed tooth replantation: a review of literature

The time elapsed between a trauma and tooth replantation usually ranges from 1 to 4 h. The chances of root surface damage are higher when tooth replantation is not performed immediately or if the avulsed tooth is not stored in an adequate medium. This invariably leads to necrosis of pulp tissue, periodontal ligament cells and cementum, thus increasing the possibility of root resorption, which is the main cause of loss of replanted teeth. This paper presents a comprehensive review of literature on root surface treatments performed in cases of delayed tooth replantation with necrotic cemental periodontal ligament. Journal articles retrieved from PubMed/MedLine, Bireme and Scielo databases were reviewed. It was observed that, when there are no periodontal ligament remnants and contamination is under control, replacement resorption and ankylosis are the best results and that, although these events will end up leading to tooth loss, this will happen slowly with no loss of the alveolar ridge height, which is important for future prosthesis planning.

Development of ankylosis in permanent incisors following delayed replantation and severe intrusion

Ankylosis is a predictable outcome for replanted incisors and for most severely intruded incisors. There is no treatment to arrest or reverse this periodontal ligament complication. Ankylosis of the incisors of preadolescents alters local alveolar growth and eventually produces tooth loss subsequent to resorption. Currently, clinical methods used to diagnose ankylosis in the early postinjury period include subjective assessments of percussion sound and mobility and quantitative devices such as the Periotest. This paper describes the progression of ankylosis in two preadolescent patients that sustained severe trauma to their maxillary central incisors. A number of clinical assessments for diagnosis of ankylosis were compared for their usefulness, reliability and suitability.

Interrelation between endodontic status, pathologic cemental granules and periodontal ligament adhering to the root of extracted teeth

OBJECTIVES

To evaluate if the endodontic status has influence on the adherence of periodontal ligament (PDL) to extracted teeth and if the presence of "pathologic granules" is correlated to the endodontic status and/or the amount of adhering PDL.

STUDY DESIGN

Extracted teeth with different endodontic status and exhibiting no marginal periodontitis were histologically examined.

RESULTS

Observation of pathologic granules was related to a nonvital endodontium and to acute peroperative inflammation. Pathologic granules and denudation of the extracted roots were significantly related. Acute peroperative inflammation and low extraction forces were related to denudation of the roots. Such relation was not found for endodontic status, tooth type, root-form, and age of patients.

CONCLUSION

The existence of pathologic granules in unexposed cementum is strictly related to teeth with a nonvital endodontium. There is no effect of the endodontic status on the adherence of PDL when an acute inflammation is absent.

Treatment of replacement resorption by intentional replantation, resection of the ankylosed sites, and Emdogain�? results of a 6-year survey

The present clinical study investigated the outcome of intentional replantation using resection of the ankylosed sites of the root, extraoral endodontic treatment using titanium posts and Emdogain for periodontal healing following trauma-related ankylosis. During an evaluation period of 6 years, 16 ankylosed teeth affected by replacement resorption were treated as described. Evaluation parameters before treatment and during the follow-up period included Periotest scores, percussion sound and periapical radiographs. All findings were compared to those of the adjacent teeth. In a second accident, one tooth was lost after 7 months and was excluded as a dropout. Ankylosis did not recur in seven replanted teeth, which were observed for an average of 52.3 months (range: 24-68 months). Ankylosis recurred in eight teeth after an average period of 12 months (range: 4-26 months). An infraocclusion, normal or only slightly reduced Periotest scores and normal percussion sound were preoperatively found in six of seven successfully replanted teeth, which corresponded to a relatively small area of ankylosis. The majority of the teeth showing recurrent ankylosis preoperatively presented with normal position, negative Periotest scores and a high percussion sound which corresponded to an extended area of ankylosis. Statistically significant relationship between preoperative findings and the treatment outcome (P = 0.031) have become apparent. The results indicate that the treatment of minor areas of ankylosis by intentional replantation, resection of the ankylosed sites and Emdogain appeared to prevent or delay the recurrence of ankylosis in 7 of 15 teeth.

Inflammatory external root resorption following surgical treatment for intra-bony defects: a report of two cases involving EmdogainR and a review of the literature

BACKGROUND

Enamel matrix-derived proteins have been shown to regenerate periodontal tissues lost as a result of disease in humans. Emdogain, a commercial preparation of porcine enamel matrix derivative (EMD), has been shown to induce new cementum, periodontal ligament and bone formation in human periodontal defects. Although a number of studies have reported successful outcomes, local adverse effects have so far not been reported in the literature. This case report describes two examples of external inflammatory resorption following surgical root surface debridement and the use of Emdogain.

TREATMENT

The treatment in both cases involved raising a full-thickness flap following completion of non-surgical therapy. The granulation tissue from the defect was removed and the root surfaces debrided. Emdogain was applied following the manufacturers' instructions and involved conditioning the root surfaces with Pref-Gel and applying the Emdogain to the defect. The flaps were sutured and the site reviewed regularly. Radiographs were taken before the treatment was undertaken and also at 6 months to assess the healing of the defect.

RESULTS

External inflammatory root resorption was observed on the treated teeth 6-24 months after therapy.

CONCLUSION

External inflammatory root resorption may be an unusual adverse event following Emdogain treatment.

Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects

BACKGROUND

Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. Amelogenins are involved in the formation of enamel and periodontal attachment formation during tooth development.

OBJECTIVES

To test whether EMD is effective, and to compare EMD versus GTR, and various BG procedures for the treatment of intrabony defects.

SEARCH STRATEGY

We searched the Cochrane OHG Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of RCTs identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: May 2005.

SELECTION CRITERIA

RCTs on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events. The following time-points were to be evaluated: 1, 5 and 10 years.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). It was decided not to investigate heterogeneity, but a sensitivity analysis for the risk of bias of the trials was performed.

MAIN RESULTS

Ten trials were included out of 29 potentially eligible trials. No included trial presented data after 5 years of follow up, therefore all data refer to the 1-year time point. A meta-analysis including eight trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.2 mm, 95% CI 0.7 to 1.7) and PPD reduction (0.8 mm, 95% CI 0.5 to 1.0) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had < 2 mm PAL gain in the control group, with RR 0.48 (95% CI 0.29 to 0.80). Approximately six patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 35%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating the only two trials at a low risk of bias in a sensitivity analysis, the effect size for PAL was 0.6 mm, which was less than 1.2 mm for the overall result. Comparing EMD with GTR (five trials), GTR showed a statistically significant increase of REC (0.4 mm) and significantly more postoperative complications. No trials were found comparing EMD with BG.

AUTHORS' CONCLUSIONS

One year after its application, EMD significantly improved PAL levels (1.2 mm) and PPD reduction (0.8 mm) when compared to a placebo or control, however, the high degree of heterogeneity observed among trials suggests that results have to be interpreted with great caution. In addition a sensitivity analyses indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications in the GTR group, there was no evidence of clinically important differences between GTR and EMD.

RhBMP-7 improves survival and eruption in a growing tooth avulsion trauma model

Long-term loss of avulsed and replanted teeth is a frequent clinical problem. Bone morphogenetic protein-7 (BMP 7) induces cementogenesis in periodontitis-associated periodontal ligament (PDL) defects. This study's aim was to assess the utility of rhBMP 7 in a tooth avulsion trauma model in growing individuals. Immature primary incisors of 12 minipigs were extracted. PDL and cementum were removed either partially (group 1: 4 mm2 [n=28 teeth]; group 2: 16 mm2 [n=26 teeth]) or totally (group 3 [n=26 teeth]). 500 microg rhBMP 7/g collagen matrix was applied to the teeth from one side while the corresponding teeth on the contralateral side served as controls (split mouth model). After an experimental period of 4 months, microradiography, fluorescence and light microscopy of nondecalcified sections were performed. All teeth of group 1 survived and all teeth of group 3 were lost, whether rhBMP-7 was applied or not. In group 2, nine out of ten teeth survived when rhBMP-7 was applied and four out of ten teeth were lost when rhBMP-7 was not applied. In the presence of rhBMP-7, eruption of teeth in group 2 was significantly improved (difference [median]: 5 mm, P<0.05, n=6). Even though there was a tendency towards increased deposition rates of cementum under rhBMP-7, this difference was not significant (Wilcoxon: P>0.05, ANOVA: P=0.002; n=6/group). In conclusion, rhBMP-7 improved survival rates and eruption of replanted teeth in growing individuals. No adverse effects were seen. Based on the present results, future clinical trials appear to be warranted.

Replantation of 45 avulsed permanent teeth: a 1-year follow-up study

Thirty-four patients with 45 avulsed and replanted permanent teeth were followed for 1 year. All teeth were soaked in tetracycline before replantation. In addition, enamel matrix derivative was used in teeth with dry storage times exceeding 30 min. Splinting was carried out with a non-rigid titanium splint and was limited to 7-10 days. Within that period, root canal treatment was begun in all teeth with a closed apex, whereas teeth with an open apex and ideal post-traumatic storage were not instrumented. All patients were given tetracycline systematically for 10 days. The survival rate of replanted avulsed permanent teeth was 95.6% at the 1-year follow-up. In 82.2%, root canal treatment was performed. Pulp survival was never observed, but three teeth had pulp canal obliteration. Normal periodontal healing was observed in 57.7% of teeth; 42.3% of teeth showed external root resorption (28.9% replacement resorption, 6.7% infection-related resorption, 6.7% surface resorption). The occurrence of replacement resorption correlated with the period of extraoral dry storage. Compared with other clinical studies on avulsed and replanted teeth, the present study reports a higher percentage of periodontal healing. The favorable treatment outcome may be associated with a strict protocol to enforce endodontic treatment, the use of topical and systemic tetracycline, and the relatively high number of ideally stored teeth following avulsion. In contrast, the present study has a follow-up period limited to 1 year.

Use of Enamel Matrix Protein Derivative Before Dental Reimplantation: A Histometric Analysis

The use of enamel matrix protein in the treatment of periodontal defects has shown a favorable action on the proliferation of periodontal ligament cells, as well as on collagen formation and mineralization. The goal was to evaluate, histologically and histometrically, periodontal tissue regeneration after dental reimplantation using enamel matrix protein derivative (Emdogain, Biora AB, Malmö, Sweden). Male rats (Albinus, Wistar), weighing between 180 and 200 g, were divided in 3 groups. Animals in group I (control) had the upper right incisors extracted, the root canal was sealed with calcium hydroxide, and teeth were reimplanted in their alveoli. Group II underwent the same procedure, but the remaining periodontal ligament was removed from the root surfaces by root planing before reimplantation. In group III,following removal of the periodontal ligament, Emdogain was applied to the root surfaces. Animals were sacrificed 7, 20, and 60 days after reimplantation, and the alveoli were fixed, processed, and stained with hematoxylin and eosin. Formation of periodontal ligament, resorption areas, and ankylosis were analyzed. The results showed that group I (control) was better than groups II and III, with statistically significant differences on days 7 and 20 after reimplantation for formation of periodontal ligament. It may be concluded that with the methodology used, Emdogain was unable to stimulate tissue repair in reimplanted teeth.

Enamel matrix derivative inhibits TNF-α–induced apoptosis in osteoblastic MC3T3-E1 cells

OBJECTIVE

The purpose of this study was to examine the effect of enamel matrix derivative (EMD) on TNF-alpha-induced apoptosis in osteoblastic MC3T3-E1 cells.

STUDY DESIGN

MC3T3-E1 cells were cultured at an initial density of 5000/cm 2 in Dulbecco's modified eagle medium (DMEM) with 10% fetal bovine serum (FBS) and allowed to adhere for 24 hours. Medium was then changed into DMEM with 0.5% FBS. After 16 hours, cells were treated with EMD (100 microg/mL) alone, tumor necrosis factor alpha (TNF-alpha) (20 ng/mL) alone, transforming growth factor beta 1 (TGF-beta1) (10 ng/mL) alone, TNF-alpha plus TGF-beta1, or TNF-alpha plus EMD. Cells cultured with DMEM and 0.5% FBS served as control. Following 24-hour incubation, apoptosis was assessed by terminal deoxynucleotidyl transferase nick-end labeling (TUNEL) assay, and quantified by cell death enzyme-linked immunosorbent assay (ELISA).

RESULTS

Both TUNEL assay and cell death ELISA show that TNF-alpha induces apoptosis in MC3T3-E1 cells. TNF-alpha increases cell death by approximately 2-fold, which is attenuated by both EMD and TGF-beta1.

CONCLUSION

Like TGF-beta1, EMD protects osteoblasts from inflammation-induced apoptosis.

Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy

The status of the periodontal ligament (PDL) and of the pulp are decisive for the healing of avulsed and replanted teeth. A tooth rescue box was developed and distributed to offer optimal storage conditions for avulsed teeth. The therapy comprised extraoral endodontic treatment and applications of medicaments to enhance periodontal healing. In this long-term clinical study the healing results following avulsion and replantation were investigated. Twenty-eight permanent teeth in 24 patients were evaluated. The extraoral storage media and periods varied considerably. Soon after avulsion six teeth were stored in a cell culture medium (tooth rescue box Dentosafe) for 1-53 h; the PDL was defined as not compromised. Sixteen teeth were stored in a non-physiologic situation temporarily, the PDL was considered as compromised. Six teeth were stored in non-physiologic conditions for longer periods; the condition of the PDL was defined as hopeless. On 14 teeth antiresorptive-regenerative therapy (ART) with the local application of glucocorticoids and enamel matrix derivative and the systemic administration of doxycyclin was used. In all teeth extraoral endodontic treatment by retrograde insertion of posts was performed. The mean observation period was 31.2 months (+/-24.1; 5.1-100.2; median: 23.8). All six teeth rescued physiologically healed with a functional PDL (functional healing, FH) irrespective of the storage period. Of eight teeth with a compromised PDL on which ART was used, three teeth healed with a functional PDL. All other teeth showed replacement resorption, in three teeth additionally infection-related resorption was recorded. The predominant influence on the healing results was the immediate physiologic rescue of avulsed teeth (chi-square, P = 0.0001). The use of ART seemed to support FH (chi-square, P = 0.0547) in teeth with a compromised PDL. No other factors (maturity of roots, crown fractures, gender, age, antibiotics) were related to healing. In a linear regression analysis physiologic storage (P = 0.0013) and ART (P = 0.0421) were related to FH. For a good prognosis avulsed teeth should be stored immediately in a cell-compatible medium. Therefore the tooth rescue box should be distributed at places with higher risks of accidents, in families with children and in emergency facilities. The use of ART might have potential for enhancing the prognosis of teeth with a PDL that is compromised but not in a hopeless condition. Extraoral endodontic treatment reduces infection-related complications; this item was discussed in the first part of the publication.

Results after replantation of avulsed permanent teeth. III. Tooth loss and survival analysis

Avulsed permanent teeth were replanted following immediate extraoral endodontic treatment by insertion of posts from a retrograde direction. Some teeth were rescued in a physiologic environment (tissue culture medium contained in a tooth rescue box), and in some cases antiresorptive-regenerative therapy (ART) was used. The aim of the study was to identify variables that influence the incidence of tooth loss and the survival of avulsed and replanted permanent incisors. Twenty-eight permanent teeth in 24 patients aged 7-17 years were investigated. In all teeth extraoral endodontic treatment by retrograde insertion of posts was performed. All nine teeth with functional healing (FH) were in situ. Of the 19 teeth with non-FH, seven were removed to allow transplantations. Two teeth were removed due to severe infrapositions. One tooth was lost following a new trauma. No tooth was lost due to acute infections. In descriptive statistics the incidence of tooth loss was significantly related to healing (P = 0.0098, Fisher's exact test), to treatment planning, i.e. consecutive replantation of premolars and primary canines (P = 0.0001, Fisher's exact test) and to immediate physiologic rescue (P = 0.0394). ART was related to tooth loss when tested in teeth with a compromised periodontal ligament (P = 0.0389). No influence could be found for the parameters maturity, age and all other factors. In a regression analysis treatment planning was the only factor left which had a significant influence (P = 0.0002). The estimated mean survival time (Kaplan-Meier analysis) for all teeth was 57.3 months. The survival was significantly reduced (P = 0.0002, log rank test) when consecutive transplantations were intended and performed. No influence could be found for maturity, age and all other factors. The different findings to previous studies can be explained by the prevention of complications related to conventional endodontic treatment approaches. Statistics have to be carefully interpreted due to case preselection which is determined by the treatment guidelines and actual treatment options of the individual treating dentist.

EmdogainR does not prevent progressive root resorption after replantation of avulsed teeth: a clinical study

Emdogain has been shown in clinical and experimental studies to promote regeneration of all periodontal tissues: cementum with anchoring fibres, a functional, periodontal ligament and alveolar bone in connection with treatment of marginal periodontitis. The intention of this study was to analyse whether this regenerative capacity upon the periodontal ligament also worked in a trauma situation where a significant number of PDL cells have been eliminated because of unphysiologic storage or actual damage during avulsion or replantation. Furthermore if ankylosis sites already established because of earlier replantation after avulsion could be surgical removed and application of Emdogain could revert the ankylosis stage to a normal PDL situation. The first treatment situation was tested in seven patients with a total of 16 avulsed teeth with varying time of extra oral storage. The teeth were extra-orally endodontically treated and the root and socket covered with Emdogain before replantation. All teeth demonstrated subsequent ankylosis, primarily diagnosed by a percussion test. The second treatment situation where an ankylosis was already established constituted of seven patients with a total of 11 teeth because of previous replantation after avulsion. These teeth were all extracted, the ankylosis sites removed and the root and socket treated with Emdogain. After 6 months all teeth showed recurrence of ankylosis. It is concluded that Emdogain was not able to prevent or cure ankylosis.

Post-traumatic use of dental implants to rehabilitate anterior maxillary teeth

The treatment sequel of post-traumatic teeth for the use of dental implants in the anterior maxillary region to rehabilitate anterior maxillary missing teeth was evaluated. Files of 53 healthy patients reporting anterior dental trauma were reviewed. All patients had an anterior maxillary dental implant because of tooth loss after trauma. At initial examination, 18 patients (34%) had root canal treatment and an inflammatory lesion, 15 (28.3%) had a missing tooth on admission, 12 (22.6%) had a prior operation (i.e. root-end surgery or crown lengthening), 4 (7.5%) presented an ankylotic root, and 4 (7.5%) had a root remnant not suitable for rehabilitation, with no inflammatory periapical lesion. Treatment sequences and complications were recorded. Augmentation procedure (i.e. onlay bone graft or guided bone regeneration) was performed in 43 patients (81.1%), and 2 patients (3.8%) had orthodontic extrusion prior to tooth extraction and implantation. Implants were placed immediately in 25 patients (47.2%) and 4 (7.5%) had immediate loading at the time of implantation. Complications and postoperative incidents (fistula, inflammation, swelling hematoma, etc.) were observed in 24 patients (45.3%). There was no difference in complication and postoperative incident rates with regards to the implantation technique. Complications were found at the prosthetic phase in seven patients (13.2%; six fistula and one implant failure). When patients were divided into two groups, with and without an inflammatory lesion, a significantly lower complication and postoperative incident rate were found in the non-inflammatory group (P = 0.057). This study reaffirmed the necessity for scrupulous diagnosis of teeth and alveolar bone after a traumatic injury. Treatment is multidisciplinary, requiring surgical, orthodontic, endodontic, operative, and prosthetic compliance. A specially designed treatment plan for each patient is necessary. General rules do not apply.

Treatment Options of Untreatable Traumatized Anterior Maxillary Teeth for Future Use of Dental Implantation

The anterior maxilla is the most traumatized region during childhood. Posttraumatic complications occasionally lead to tooth loss as well as the need for future implants. Unfortunately, it is contraindicated to place dental implants during childhood. A waiting period of approximately 8 to 10 years before completion of growth is required. For this patient to become a candidate for future dental implants, it is necessary to ensure the continuous growth and to preserve the dimensions of the alveolar process until growth has ceased from time of injury until joint maturation. To achieve these goals, it is essential to coordinate the treatment sequence at the time of trauma. After loss of a traumatized anterior permanent maxillary incisor in young adults, treatment options are limited: orthodontic closure of the gap and reshaping the adjacent teeth, or tooth extraction and maintaining the gap with a temporary restoration. Orthdontic space closure has limited indications and requires prosthetic restoration of at least 2 teeth. Extraction and temporary restoration will usually lead to bone augmentation before implantation. Other possible treatment options include orthodontic extrusion of the root remnant (in cases of untreatable root fracture or complicated crown-root fracture) and a temporary crown to serve the patient until the completion of growth and development, autogenous tooth transplantation, intentional extraction and immediate tooth replantation, distraction osteogenesis, and decoronation. Because general rules do not apply, individual treatment plans are necessary.

Extraoral endodontic treatment by retrograde insertion of posts: a long-term study on replanted and transplanted teeth

OBJECTIVE

The aim of the study was to investigate the healing results of teeth replanted or transplanted in different indications and treated by extraoral root canal therapy.

STUDY DESIGN

Extraoral root canal treatment was performed from a retrograde direction with posts made of ceramics or titanium. Preoperatively, the pulp status was classified as definitely infected (n = 47) or not infected/symptomless (n = 78), and the condition of the periodontal ligament (PDL) was classified as damaged (n = 50) or not damaged (n = 75) according to trauma type and extraoral storage. The healing after replantation or transplantation was diagnosed as functional, ankylosis, or infection depending on clinical and radiographic findings.

RESULTS

In total, 125 teeth in 99 patients were replanted or transplanted. Mean observation period was 44.4 months. Teeth with a less damaged PDL in no case exhibited ankylosis/replacement resorption after a mean observation period of 53 months. Teeth without preoperative infection of the pulp in no case showed infection-related complications after a mean observation period of 30 months. Teeth classified as definitely infected before treatment had a high frequency of continuous periradicular bone and root resorption.

CONCLUSIONS

The extraoral insertion of posts appeared to inflict no additional damage to the PDL that was clinically relevant. Infection-related complications were prevented. Teeth that were classified as definitely infected at the time of treatment had a low rate of healing and should undergo conventional root canal disinfection before this surgical procedure is applied.