Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth

Risk of ankylosis of avulsed teeth immediately replanted or stored under favorable storage conditions before replantation: A long-term clinical study

BACKGROUND/AIM

There are few long-term clinical follow-up studies on human teeth replanted immediately or after storage in a suitable storage medium prior to replantation. This study aimed to assess the risk of ankylosis in avulsed human teeth replanted immediately or after storage in physiological media for a short time.

MATERIAL

Data from 116 patients with 145 replanted avulsed permanent teeth were selected from a comprehensive dental trauma database in Copenhagen University Hospital. The following teeth were selected: Group 1 comprised 36 teeth replanted immediately (dry time <6 min; wet time <6 min). Group 2 comprised 61 teeth replanted after physiologic storage media (saliva and saline) (dry time <6 min; wet time >5 min; wet time ranged from 7 to 170 min, and mean wet time was 59 min). Group 3 (control) included 48 teeth replanted after dry storage (dry time > 60 min).

METHOD

Clinical and radiographic registrations were carried out according to a standardized protocol; follow-up ranged from 7 months to 23 years. Ankylosis was diagnosed by percussion test and radiographs and related to the conditions prior to replantation and stage of root development.

RESULTS

The overall risk of ankylosis was 17.2% [95% CI: 4.61; 29.79] for immediately replanted teeth, 55.3% [95% CI: 42.54; 68.00] for teeth stored in physiologic media before replantation, and 85.7% [95% CI: 75.70; 95.73] for teeth stored dry more than 1 h. Mature teeth showed a significantly higher risk of ankylosis than immature teeth.

CONCLUSION

This clinical long-term study has verified earlier experimental studies showing that immediate reimplantation has the lowest risk of ankylosis. Physiologic storage media are good alternatives that also reduce the risk of ankylosis compared to dry storage, where ankylosis is more likely although not always seen. Mature teeth are significantly more likely to develop ankylosis.

The effect of fibroblast growth factor-2 on the outcomes of tooth replantation: A systematic review of animal studies

Background/Aim: The ideal treatment of tooth avulsion is replantation. However, replanting teeth may lead to root resorption. Fibroblast growth factor-2 (FGF-2) is a cytokine that plays an important role in wound repair and tissue regeneration. Recently, FGF-2 has been studied a potential regenerative agent to prevent root resorption and ankylosis. The aim of this review is to analyze and summarize the currently available literature focusing on using FGF-2 based regenerative modalities to improve the outcomes of tooth replantation. Materials and Methods: An electronic search was conducted via PubMed/Medline, Google Scholar and ISI Web of Knowledge, using the Medical Subject Headings (MeSH) terms "Basic fibroblast growth factor," "Fibroblast growth factor-2," "tooth replantation," and "replantation" for studies published between January 2001 and June 2021. Data was extracted and quality assessment was carried using the ARRIVE guidelines. Results: Nine animal studies were included in this review. In six studies, FGF-2 had a favorable effect on the tissue regeneration around roots of replanted teeth when compared to other treatment groups. However, quality assessment of the studies revealed many sources of bias and deficiencies in the studies. Conclusions: Within the limitations of this study, it may be concluded that FGF-2 may improve the outcomes of delayed replantation of avulsed teeth. However, more long-term animal studies, with improved experimental designs, and clinical trials are required to determine the clinical potential of the growth factor in improving the outcomes of delayed tooth replantation.

The Top 100 Most-Cited Articles on Permanent Teeth Avulsion: A Bibliometric Analysis

INTRODUCTION

Knowledge of bibliometric indices on the avulsion of permanent teeth can help researchers to identify gaps in the literature. The aim of this study was to analyze the bibliometric characteristics of the 100 most-cited articles on the avulsion of permanent teeth.

MATERIALS AND METHODS

Two researchers conducted an unfiltered search in the Core Collection section of the Web of Science (WoS-CC) database. The following data were extracted: position in the citation list, total number and density of citations, title, authors, institution, country, year of publication, journal, keywords, study design, tooth storage medium, and other topics of interest. Bibliometric networks were generated and analyzed using the VOSviewer software. Descriptive analysis and a Poisson regression analysis were performed (P < .05).

RESULTS

The number of citations per article varied between 31 and 407. The average was 70.05, and 13 articles received more than 100 citations. J.O. Andreasen (n = 13) and M. Trope (n = 15) were the authors who contributed most often to publications. The United States was the country with the highest number of articles (n = 31). Authors associated with the University of Copenhagen, Denmark (n = 9) and University of North Carolina, USA (n = 10) showed higher productivity. In vitro/animal model studies were the most frequent study designs (n = 50), and the most-discussed topic of interest was prognosis (n = 47). There was strong clustering among 13 research groups.

CONCLUSION

Observational studies, published by authors from Europe and about prognosis or treatment presented more citation ratio in WoS-CC. Clinical studies on permanent tooth avulsion are needed to increase the quality of scientific evidence and provide insights for health professionals and public policy makers.

Global status of knowledge of parents for emergency management of traumatic dental injuries: a systematic review and meta-analysis

RESEARCH PROTOCOL

The protocol was developed as per the recommendations of the Cochrane-handbook and PRISMA and was registered in PROSPERO.

LITERATURE SEARCH

Search was performed by using MeSH-Terms and keywords in PubMed, Scopus, Embase, Web of Sciences, Lilacs, and Cochrane databases and gray literature sources 15th July 2022. There were no limits regarding the year of publication and language. Hand-searching of included articles was also performed. Titles and abstracts and later full texts were screened as per strict inclusion and exclusion criteria.

DATA EXTRACTION

Self-designed pilot-tested form was used.

QUALITY APPRAISAL

Risk of bias was analyzed through Joanna-Brigg's-Institute's-critical appraisal checklist. The evidence analysis was done by using the GRADE approach.

DATA ANALYSIS

Qualitative synthesis was performed for describing the study characteristics, details of sampling, and results of various questionnaires. It was discussed by the expert group and presented using KAP heat map. Meta-analysis was done by using Random Effects Model.

RESULTS AND INTERPRETATION

The risk of bias was found to be low in seven and moderate in one study. It was observed that >50% of parents knew about the urgency to seek professional advice after TDI. Only <50% of parents were confident of their ability to identify the injured tooth, clean the soiled avulsed tooth, and perform the replantation. Appropriate responses regarding immediate action after tooth avulsion were given by 54.5% (95% CI: 50.2-58.8, p = 0.042) of parents. The knowledge of the parents regarding the emergency management of TDI was found to be inadequate. The majority of them were interested in obtaining information about dental trauma first aid.

Is Revascularization the Treatment of Choice for Traumatized Necrotic Immature Teeth? A Systematic Review and Meta-Analysis

Regenerative endodontic treatment (RET) has been considered a reliable procedure to treat immature necrotic teeth; however, the effect of dental trauma on the prognosis of RET is questionable. This systematic review aimed to evaluate the current level of evidence for revascularization techniques (the RET) in the management of traumatized necrotic immature permanent teeth with or without periapical radiolucent areas. Four electronic databases—PubMed, Web of Science, Scopus, and Embase—were searched until November 2022. Only randomized clinical trials, cohort studies, and case-control studies with a minimum of 10 cases and 12 months of follow-ups were included. The search identified 363 preliminary results. After discarding the duplicates and screening the titles, abstracts, and full texts, 13 articles were considered eligible. The results showed that RET techniques seemed to have high survival and success rates, 93.8% and 88.3%, respectively, in the treatment of traumatized necrotic immature permanent teeth. Root maturation with RET techniques seemed to be lower in traumatized teeth. Future studies are needed to evaluate root maturation in traumatized teeth using 3-dimensional radiographic evaluations. In addition, the lack of literature on the studies comparing RET and apexification (calcium hydroxide or an MTA) in the treatment of traumatized necrotic immature teeth highlights the necessity for high-level clinical studies comparing these treatment modalities.

Long Term Outcome of Avulsed Immature Mandibular Incisor with Progressive External Root Resorption: 9 Years Follow-Up

Background

Avulsion of permanent teeth is the most common in young permanent dentition. Replantation of immature teeth after avulsion represents a major challenge in terms of treatment management and long-term prognosis. This case report describes 9 years of follow-up for an avulsed and replanted immature mandibular lateral incisor with progressive external root resorption.

Methods

A 7-year-old patient following an accident in which his mandibular left central incisor was avulsed and replanted within one hour after being stored in a physiological storage medium. However, radiographic examination conducted six weeks after the dental injury revealed inflammatory root resorption of the replanted tooth #31. To address root resorption, endodontic treatment was performed involving the use of calcium hydroxide as an intracanal medication for a short period of time, followed by root canal obturation with mineral trioxide aggregate placed below the crestal bone margin.

Results

Three months later the root resorption had progressed. Consequently, a decision was made to perform periodontal surgery. While the long-term follow-up revealed that the inflammatory root resorption had damaged half of the root, the tooth remained functional and aesthetically favourable.

Conclusions

Despite the challenges associated with replantation of an immature tooth following avulsion, this case demonstrated favourable outcomes. The tooth maintained its functionality, exhibited favourable aesthetic, and the dimensions of the alveolar ridge were preserved, allowing for the physiological expansion of the dental arch.

Effect of systemic antibiotic therapy on pulp repair following extrusive luxation and avulsion in a murine model: A histomorphological study

BACKGROUND/AIM

The evidence for any benefit of systemic antibiotic therapy on pulp survival following extrusive luxation and avulsion is inconclusive. The aim of this study was to evaluate the effect of systemic antibiotic therapy with amoxycillin and tetracycline for 7 days on different aspects of dental pulp repair in a murine model.

MATERIAL AND METHODS

The right maxillary incisor of 180 4 to 8-week-old male Wistar rats underwent extrusive luxation or avulsion. The animals were then treated with saline solution (control), tetracycline, or amoxicillin administered intra-gastrically for 7 days, and euthanized at 7, 15, and 30 days post-operatively. The layer of odontoblast cells, reparative dentin deposition, Hertwig's epithelial root sheath, pulp necrosis, and periapical inflammatory infiltrate were histomorphologically analyzed and scored. Mann-Whitney, Kruskal-Wallis, and Dunn tests were used to compare mean scores for the different procedures, treatments, and times (p ≤ .05).

RESULTS

Significant differences were observed between luxated and avulsed teeth (p < .05). In luxated teeth, no differences were observed among treatments and times, except for more tertiary dentin deposition in the coronal third with the use of tetracycline compared with amoxicillin at 15 days (p < .05). In avulsed teeth, higher scores for the layer of odontoblast cells and lower scores for periapical inflammatory infiltrate at 7 days and pulp necrosis at 7 and 15 days were observed in the amoxicillin group compared to the saline and tetracycline groups (p < .05). At 30 days, however, no differences were observed among treatments.

CONCLUSIONS

The use of systemic antibiotic therapy with tetracycline or amoxicillin for 7 days did not contribute to pulp repair following extrusive luxation or avulsion in rats. However, the results warrant further research into the use of amoxicillin for a more extended period of time in cases of avulsion.

Biomaterial scaffolds for clinical procedures in endodontic regeneration

Regenerative endodontic procedures have been rapidly evolving over the past two decades and are employed extensively in clinical endodontics. These procedures have been perceived as valuable adjuvants to conventional strategies in the treatment of necrotic immature permanent teeth that were deemed to have poor prognosis. As a component biological triad of tissue engineering (i.e., stem cells, growth factors and scaffolds), biomaterial scaffolds have demonstrated clinical potential as an armamentarium in regenerative endodontic procedures and achieved remarkable advancements. The aim of the present review is to provide a broad overview of biomaterials employed for scaffolding in regenerative endodontics. The favorable properties and limitations of biomaterials organized in naturally derived, host-derived and synthetic material categories were discussed. Preclinical and clinical studies published over the past five years on the performance of biomaterial scaffolds, as well as current challenges and future perspectives for the application of biomaterials for scaffolding and clinical evaluation of biomaterial scaffolds in regenerative endodontic procedures were addressed in depth.

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Overview of biomaterials for scaffolding in regenerative endodontics are presented.

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Findings of preclinical and clinical studies on the performance of biomaterial scaffolds are summarized.

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Challenges and future prospects in biomaterial scaffolds are discussed.

Low-intensity pulsed ultrasound attenuates replacement root resorption of avulsed teeth stored in dry condition in dogs

This study aimed to investigate the effects of low-intensity pulsed ultrasound (LIPUS) on replacement root resorption after replantation of avulsed teeth stored in a dry condition in dogs. A total of 73 premolar roots from four male mongrel dogs were intentionally avulsed with forceps and divided into four groups—HN, HL, DN, and DL—according to storage conditions and whether or not they received LIPUS treatment. Thirty-eight roots were kept in Hanks’ Balanced Salt Solution for 30 min (HN and HL groups), whereas the remaining 35 roots were left to dry in the air for an hour (DN and DL groups) prior to replantation. Following replantation, the roots in the HL and DL groups (21 and 18 roots, respectively) received a 20-min daily LIPUS treatment for 2 weeks. The animals were euthanized 4 weeks after the operation. Micro-computed tomography images were acquired for each root and the amount of replacement root resorption was measured three-dimensionally. Histological assessments were also carried out. There was significantly less replacement root resorption for the roots in the DL group compared to the DN group (p < 0.01). Histological findings in the DN group demonstrated evident replacement root resorption, whereas the DL group revealed less severe resorption compared to the DN group. Within the limitations, these results suggest that LIPUS could attenuate the replacement resorption of avulsed teeth stored in a dry condition, thereby improving their prognosis.

Effect of tetracyclines on pulpal and periodontal healing after tooth replantation: a systematic review of human and animal studies

Background

Pulpal and periodontal healing are two main concerns of delayed replantation of avulsed teeth. The objective of this review was to evaluate the effectiveness of topical and systemic application of tetracyclines on pulpal and periodontal healing after tooth replantation.

Methods

A comprehensive electronic search was conducted in six databases. This systematic review was carried out according to Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

After exclusion of 246 irrelevant papers, 14 animal studies and one human study were included in this review. The human study showed that avulsed permanent teeth treated with doxycycline did not show a better clinical outcome for pulp and periodontal healing compared with treatment with normal saline. As for animal studies, significant more pulpal healing was observed in immature teeth treated with topical doxycycline in two researches, while another one study showed that there is no difference between teeth treated with normal saline and teeth treated with doxycycline. Systemic doxycycline exerted no significant effect on pulpal revascularization illustrated by one research. Only one out of four articles illustrated the positive effect of systemic tetracyclines on periodontal healing. One paper reported that intracanal application of demeclocycline promoted favorable periodontal healing. Two articles showed topical doxycycline contributed to favorable periodontal healing, while five studies showed no significant effect of topical tetracyclines on periodontal healing.

Conclusions

As a result of data heterogeneity and limitations of the studies, the effect of topical or systemic application of tetracyclines on pulpal and periodontal healing is inconclusive. More studies are required to get more clinically significant conclusions.

Ingrowth of Mineralized Tissue into the Root Canal of Immature Permanent Teeth after a Traumatic Injury: A Report of 3 Cases

The aim of this case series was to describe the endodontic management of 3 immature permanent teeth that sustained traumatic injuries and subsequently presented with complete ingrowth of mineralized tissue into the canal space. Ingrowth of bone/mineralized tissue into the canal has been considered a poor long-term outcome with an inherent risk of ankylosis. In cases 1 and 2, no endodontic treatment was undertaken, except for emergency management requiring splinting. The cases were followed for 36 and 23 months, respectively. No ankylosis was evident over the review period, and normal teeth eruption was apparent. In case 1, the tooth was treated orthodontically and was responsive to pulp sensibility testing. In both cases, there was an appearance of an internal periodontal ligament-like space on the inner root wall of the canal. In case 3, 2 years postinjury, pulp necrosis and apical periodontitis occurred, and the tooth was managed with regenerative endodontic treatment consistent with the European Society of Endodontology and the American Association of Endodontists guidelines/recommendations for a regenerative procedure. The case was followed for 8 years after regenerative endodontic treatment. No ankylosis was noted with normal eruption of the teeth. The tooth was responsive to pulp sensibility testing despite the ingrowth of mineralized tissue, which was confirmed clinically.

The effects of reducing the root length by apicoectomy on dental pulp revascularization following tooth replantation in mice

BACKGROUND/AIM

Root length is a critical factor for dental pulp regeneration following tooth replantation. The aim of this study was to analyze the effects of reducing the root length by apicoectomy on the pulp healing process using a model for tooth replantation.

MATERIAL AND METHODS

After extraction of the upper first molars (M1) of 3-week-old mice, the roots from the experimental group (EG) were shortened to half to two-thirds of their length before replantation, whereas in the control group (CG) the extracted teeth were immediately repositioned into their alveolar sockets. To determine the effects of root resection on the survival of inherent pulp cells, this study included tooth transplantation with root resection using wild-type (WT) and green fluorescent protein (GFP) transgenic mice. The M1 of GFP transgenic mice were transplanted into the alveolar socket of the M1 of WT mice. The roots of the right M1 were shortened (EG), whereas the left M1 remained untreated (CG).

RESULTS

Apoptotic cells in the EG significantly decreased in number compared with the CG at day 3. Cell proliferative activity in the EG was significantly higher than that in the CG in the root pulp during days 3-5, and nestin-positive odontoblast-like cells began to arrange themselves along the pulp-dentin border in the cusp area at day 5 in the EG but not in the CG. At week 2, tertiary dentin had formed throughout the pulp in the EG, whereas the combined tissue of dentin and bone occupied the pulp space in 60% of the CG. Root resection also positively affected the survival of inherent pulp cells to differentiate into odontoblast-like cells as demonstrated by transplantation using GFP transgenic mice.

CONCLUSIONS

Reducing the root length accelerated pulp regeneration following tooth replantation due to the better environment for revascularization.

Endodontic management of traumatized permanent teeth: a comprehensive review

The pulp plays a key role in the treatment of traumatic dental injuries (TDIs) and is strongly associated with the outcome, particularly in severe cases. A correct pulp diagnosis is essential as it forms the basis for developing the appropriate management strategy. However, many TDIs are complex, and their treatment requires a profound knowledge of the physiological and pathological responses of the affected tissues. This comprehensive review will look at the dentine-pulp complex and its interaction with the surrounding tissues following TDIs. The literature up to 2020 was reviewed based on several searches on PubMed and the Cochrane Library using relevant terms. In addition to the recently revised guidelines of the International Association of Dental Traumatology, this article aims to provide background information with a focus on endodontic aspects and to gather evidence on which a clinician can make decisions on the choice of the appropriate endodontic approach for traumatized permanent teeth.

The risks of ankylosis of 89 avulsed human teeth stored in saliva prior to replantation-A re-evaluation of a long-term clinical study

BACKGROUND/AIM

The survival of an avulsed tooth highly depends on the emergency management. The aim of this study was to evaluate the risk of ankylosis for avulsed human teeth stored in saliva preceded by various dry storage conditions prior to replantation.

MATERIAL AND METHODS

Data include 74 patients (54 male and 20 female) with 89 avulsed and replanted teeth (16 immature teeth, 73 mature teeth). Patient ages ranged from 6 to 36 years (median: 13.0 years). All teeth were stored in saliva before replantation. Treatment and follow-up were performed according to a standardized procedure. Follow-up periods ranged from 7 months to 20 years (mean 5.3 years). The risk of ankylosis over time was estimated by the Aalen-Johansen method in relation to the length of dry storage and the stage of root development. The effect of risk factors (root development and length of dry time) on the risk of ankylosis was analysed by Cox regression analysis.

RESULTS

For mature teeth, dry storage for 5 min or less before saliva storage resulted in a 47.4% (95% confidence interval (CI): 32.8-60.7) ankylosis rate. When dry storage was >5 min and <20 min, the risk of ankylosis was 76.8% (95% CI: 45.7-91.5). When dry storage exceeded 20 min prior to saliva storage, ankylosis increased to 89.3% (95% CI: 68.0-96.7). Ankylosis also increased with increasing saliva storage time. Specifically, one additional minute of wet time increased the ankylosis hazard rate (HR) by approximately 1% (CI = [0%, 2%], p = .052). Teeth with mature root development were significantly more frequently affected by ankylosis than teeth with immature root development (HR: 2.4 (95% CI: 1.0-5.5), p = .04).

CONCLUSION

Temporary storage in saliva should be encouraged if an avulsed permanent tooth cannot be immediately replanted or a suitable storage medium such as milk or saline is not immediately available at the place of the accident.

Effect of root surface treatment with denusomab after delayed tooth replantation

OBJECTIVES

To evaluate denosumab, a human monoclonal antibody that mimics the effects of osteoprotegerin in bone metabolism, as a topical treatment of root surface to be used prior to delayed tooth replantation.

MATERIALS AND METHODS

Thirty-six rats' right incisors were used. Teeth were extracted and divided into: delayed replantation without root surface treatment (control); delayed replantation with root surface treatment with denosumab 60 mg/mL and 30 mg/mL, respectively, for 10 min both experimentals groups. After that, the root canals were filled with calcium hydroxide and replanted. After 15 and 60 days, the animals were euthanized, and the samples were collected and processed for microscopic analysis. Histological sections were performed, and stained with HE to describe the dental characteristics, measure ankylosis, replacement resorption, and dental resorption by conventional microscopy. Also, was performed Brown & Brenn staining and immunohistochemistry for RANKL, OPG, and periostin.

RESULTS

Denosumab 60 mg/mL reducted ankylosis (p < 0.0001), replacement resorption (p < 0.0001), and tooth resorption, 60 days after replantation, compared to untreated replanted teeth (p < 0.005). Lower bacterial contamination in root surface in the denosumab treatment groups was found, regardless of the concentration used (p < 0.001). Also, denosumab treatment inhibited the expression of RANKL without modulating OPG. Periostin was observed in periodontal ligament of replanted tooth, although this labelling was absent in the ankylosis areas, in both experimental periods.

CONCLUSION

Treatment of the root surface with denosumab at 60 mg/mL of rat teeth before delayed replantation reduced dental root resorption compared with the untreated teeth after 60 days.

CLINICAL RELEVANCE

Survival of a replanted tooth has been a challenge in clinical practice. The use of a medication, such as denosumab, to limit dental root resorption represents an important therapeutical approach.

Outcome of revascularization therapy in traumatized immature incisors

Background

The aim of this retrospective analysis was to evaluate the clinical and radiological outcome of revascularization therapy in traumatized permanent incisors to determine whether this approach could be implemented into clinical routine.

Methods

A total of 16 traumatized incisors (either avulsion or severe luxation/intrusion) with open apices (> 1 mm) that underwent revascularization following a standardized protocol were analyzed with a mean follow-up of 22 months. Radiographs and clinical parameters (such as root length, pulp space, dentin wall width, apical foramen, alveolar bone loss, ankylosis/mobility, supra−/infraposition, discoloration, probing depth) were compared pre- and postoperatively and statistically analyzed.

Results

Over the follow-up period, 81.3% of the teeth survived revascularization and regained sensitivity, while 18.7% failed, as they had to be extracted due to serious root resorption. Regarding radiographic outcomes a significant difference could only be found in the decrease of apical foramina (p = 0.04). The other parameters showed no significant difference between pre- and postoperative measurements. More than half of the teeth (56.3%) developed root resorptions and 31.3% displayed signs of ankylosis and 92.9% developed discolorations during follow-up. However, 85.7% of the teeth maintained the bone level and outcomes of mobility showed a significant solidification.

Conclusions

Revascularization is a promising approach for the treatment of immature incisors to regain sensitivity and to enhance apical closure and at least to maintain alveolar bone in terms of a socket preservation. Further studies have to be performed to determine ideal conditions (type of trauma, age, width of apical foramen) for a revascularization.

Treatment after inadequate immediate replantation of accidentally extracted immature mandibular premolar during primary molar extraction

During extraction of the primary mandibular right second molar in an 11-year-old girl, the unerupted second premolar was accidentally extracted. Clinical and radiographic examination showed that the immediately replanted immature premolar was not oriented and positioned correctly. Four hours later, treatment consisted of manual extrusion of the permanent tooth bud, rotation, and gentle repositioning into its original position. Adequate replantation was confirmed by a post-operative radiograph. After 2 years and 4 months, clinical examination revealed normal, healthy appearance of the replanted tooth, no sensitivity to percussion, no tenderness to palpation, and a slight response to a cold pulp sensibility test. A radiograph showed completely developed root with closed apical foramen, slightly irregular root morphology and shorter root length, complete obliteration of the pulp, and no signs of periapical pathosis.

Effects of Er:YAG Laser on the Attachment of Human Periodontal Ligament Fibroblasts to Denuded Root Surfaces Simulating Delayed Replantation Cases: An In Vitro Study

Objective: To investigate the effects of Er:YAG laser on the attachment of human periodontal ligament fibroblasts (hPDLFs) to denuded root surfaces simulating delayed replantation cases. Background data: Dental avulsion is one of the most severe dental traumas, which is often treated with replantation. In delayed replantation scenarios, poor prognosis, including root resorption, usually occurs due to poor root surface conditioning and nonviable hPDLF attachment. Methods: Thirty-six root fragments (5 × 5 × 2 mm) were obtained from periodontium tissue-free premolar root surfaces. Specimens were randomly and equally assigned to the following: Group A, untreated control; Group B, 25 J/cm² and 10 Hz of Er:YAG laser irradiation; and Group C, 50 J/cm² and 10 Hz of Er:YAG laser irradiation. Some specimens in each group were then prepared for surface topography visualization under SEM, others were subjected to coculture with hPDLF suspension, and cell adhesion was further evaluated by SEM. Results: Group A presented homogenous smooth root surface, with fewer and round-shaped cells attached; Group B and C exhibited rather rough and irregular morphologies, and spindle-shaped fibroblasts were firmly attached by numerous lamellipodia and extensions. After a 3-day coculture, the number of fibroblasts attached in Group A was significantly lower compared with the other two laser-treated groups (p = 0.008 < 0.05). No significant alterations were observed between the two laser groups (p = 0.135 > 0.05). Conclusions: Er:YAG laser-treated root surfaces are compatible for the attachment of PDLFs, which suggests that Er:YAG laser irradiation may be used as a promising strategy for root surface conditioning in delayed replantation cases.

Effect of calcium hydroxide on inflammatory root resorption and ankylosis in replanted teeth compared with other intracanal materials: a review

Calcium hydroxide (CH) is the gold-standard intracanal dressing for teeth subjected to traumatic avulsion. A common complication after the replantation of avulsed teeth is root resorption (RR). The current review was conducted to compare the effect of CH with that of other intracanal medications and filling materials on inflammatory RR and replacement RR (ankylosis) in replanted teeth. The PubMed and Scopus databases were searched through June 2018 using specific keywords related to the title of the present article. The materials that were compared to CH were in 2 categories: 1) mineral trioxide aggregate (MTA) and endodontic sealers as permanent filling materials for single-visit treatment, and 2) Ledermix, bisphosphonates, acetazolamide, indomethacin, gallium nitrate, and enamel matrix-derived protein (Emdogain) as intracanal medicaments for multiple-visit management of avulsed teeth prior to the final obturation. MTA can be used as a single-visit root filling material; however, there are limited data on its efficacy due to a lack of clinical trials. Ledermix and acetazolamide were comparable to CH in reducing RR. Emdogain seems to be an interesting material, but the data supporting its use as an intracanal medication remain very limited. The conclusions drawn in this study were limited by the insufficiency of clinical trials.

Are critical size bone notch defects possible in the rabbit mandible?

Objectives

Small animal maxillofacial models, such as non-segmental critical size defects (CSDs) in the rabbit mandible, need to be standardized for use as preclinical models of bone regeneration to mimic clinical conditions such as maxillofacial trauma. The objective of this study is the establishment of a mechanically competent CSD model in the rabbit mandible to allow standardized evaluation of bone regeneration therapies.

Materials and Methods

Three sizes of bony defect were generated in the mandibular body of rabbit hemi-mandibles: 12 mm×5 mm, 12 mm×8 mm, and 15 mm×10 mm. The hemi-mandibles were tested to failure in 3-point flexure. The 12 mm×5 mm defect was then chosen for the defect size created in the mandibles of 26 rabbits with or without cautery of the defect margins and bone regeneration was assessed after 6 and 12 weeks. Regenerated bone density and volume were evaluated using radiography, micro-computed tomography, and histology.

Results

Flexural strength of the 12 mm×5 mm defect was similar to its contralateral; whereas the 12 mm×8 mm and 15 mm×10 mm groups carried significantly less load than their respective contralaterals (P<0.05). This demonstrated that the 12 mm×5 mm defect did not significantly compromise mandibular mechanical integrity. Significantly less (P<0.05) bone was regenerated at 6 weeks in cauterized defect margins compared to controls without cautery. After 12 weeks, the bone volume of the group with cautery increased to that of the control without cautery after 6 weeks.

Conclusion

An empty defect size of 12 mm×5 mm in the rabbit mandibular model maintains sufficient mechanical stability to not require additional stabilization. However, this defect size allows for bone regeneration across the defect. Cautery of the defect only delays regeneration by 6 weeks suggesting that the performance of bone graft materials in mandibular defects of this size should be considered with caution.

Knowledge, awareness, and attitude among the employees in emergency ambulance services towards traumatic dental injuries

Introduction:

Traumatic dental injuries are the most frequently encountered dental emergencies. Psychologically a missing tooth in the front tooth region can be a cause of social embarassment for the child and may elevate the anxiety level in the parents. The prognosis of any road traffic accident (RTA) mainly depends on the employees in emergency ambulance services to prompt correct emergency measures.

Aim of the Study:

The purpose of this study was to evaluate the knowledge and the awareness level of the employees in emergency ambulance services regarding the management of dental trauma in patients who have sustained RTAs.

Materials and Methods:

In total, 100 healthcare workers in 108 emergency ambulance services were randomly evaluated using a self-structured questionnaire in and around Kancheepuram district of Tamil Nadu.

Results:

The overall knowledge of the personnel in 108 emergency ambulance services regarding management of traumatic injuries to the teeth was not satisfactory. Approximately, 86% of employees reported that no dental first aid is given for the patient who has sustained RTA.

Conclusion:

Dental trauma awareness program and first aid training will help in rebuilding the awareness and knowledge regarding the importance of management in a dental emergency.

Parental self-perceived knowledge and attitudes toward emergency management of avulsed permanent teeth in Imphal: A cross-sectional study

Introduction:

Dental avulsion is one of the dental traumatic injuries commonly affecting children aged between 6 and 12 years. One of the major limitations in obtaining a successful outcome while treating dental avulsions is the lack of knowledge on its first aid management among parents. The present study aims to assess the knowledge and attitude of parents in Imphal toward the emergency management of avulsed permanent tooth using a self-reported questionnaire method.

Materials and Methods:

The present cross-sectional study was undertaken among 777 parents of 6–12-year-old children who were recruited through 2 private schools in Imphal. A questionnaire consisting of 14 closed-ended questions used to assess the parental knowledge and attitude on emergency management of avulsed permanent teeth was distributed to the respondents after obtaining official consent from the respective schools and informed consent from the respondents.

Statistical Analysis:

Chi-square test was used to assess the association between the results and the educational status, gender, and geographical location of the respondents.

Results:

The study revealed that only a fraction of the respondents, i.e., 11.8% gave a positive response on attempting “self-replantation” and higher fractions (76.1%) of the respondents reported to have received no previous information on the emergency management of dental avulsion.

Conclusion:

About 96.1% of the respondents showed interest on acquiring knowledge on the emergency management of dental avulsion. This warrants the urgent need on educating the parents on the first aid emergency management of avulsed tooth.

Dental Pulp Revascularization in a Replanted Avulsed Immature Maxillary Permanent Central Incisor

An 8-year-old girl sustained an accidental traumatic avulsion of her right maxillary permanent central incisor. She arrived with her mother at a hospital dental clinic with the right maxillary central incisor tooth wrappe in a wet paper towel over 1 hour after the injury. Replantation was accomplished without root surface alteration or root canal intervention. Clinical and radiographic follow-up examinations for over 1 year revealed continued root growth and apical development of the replanted avulsed immature maxillary central incisor with no signs or symptoms of pulpal or periapical pathosis. Excellent outcomes were achieved for periodontal ligament reattachment without removal of the periodontal membrane and pulp revascularization without endodontic intervention.

Regenerative Endodontic Procedures: Clinical Outcomes

Immature teeth are at risk for pulp necrosis, resulting in arrested root development and poor long-term prognosis. There is growing evidence that regenerative endodontic procedures promote desirable clinical outcomes. Despite significant advances in the field of regenerative endodontics and acceptable clinical outcomes, current evidence suggests that the tissues formed following currently used procedures do not completely recapitulate the former pulp-dentin complex. Further research is needed to identify prognostic factors and predictors of successful outcomes and to develop different treatment strategies to better predictably achieve all identified clinical outcomes, while favoring tissue formation that more closely resembles the pulp-dentin complex.

Evaluation of Knowledge of Physical Education Students on Dental Trauma

Introduction:

Sports’ practitioners are vulnerable to dental trauma; if this occurs, the emergency treatment should be fast and efficient. This may be performed by any person at the site of the accident, not only by dental professionals. Physical educators may face dental trauma and should be able to provide proper care. This study had the objective evaluated the knowledge of physical education graduates on dental trauma.

Materials and Methods:

A questionnaire containing questions on dental trauma was applied to 199 physical education students; after collection of the questionnaires, data were tabulated and processed on the software Epi Info 2000 (Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, USA). As a result, only 36.7% of participants would take the individual suffering trauma to the dental professional, 56.8% believe that the avulsed tooth should be replanted, and 42.2% would replant it. Only 7.5% would store the avulsed tooth in an ideal storage medium for transportation.

Conclusion:

It was concluded that there is a lack of knowledge on dental trauma among physical education graduates, evidencing the need of public policies to allow education on this issue.

Paradigm Shift from Stem Cells to Cell-Free Regenerative Endodontic Procedures: A Critical Review

Regenerative endodontic procedures of immature teeth with necrotic pulp have become a part of therapeutic endodontic spectrum and are considered as an alternative to calcium hydroxide or mineral trioxide aggregate apexification. In last decade, numerous case reports and series with usage of cell-free approaches known as revascularization, revitalization, or maturogenesis have been published. This cell-free approach prevails in clinical regenerative endodontics because of its relative ease of performance, lower financial demands, and absence of complications such as tumorigenesis of used stem cells. In this article, the integral steps of cell-free treatment approaches such as source of stem cells, possible endogenous scaffolds, sources of growth factors, and width of apical foramen in the context of sufficient disinfection of root canal system and outcome of treatment are discussed. Despite not being a fully established treatment protocol, the achieved outcomes are promising regardless of it having a reparative character than a regenerative one.

Management of incompletely developed teeth requiring root canal treatment

Endodontic management of the permanent immature tooth continues to be a challenge for both clinicians and researchers. Clinical concerns are primarily related to achieving adequate levels of disinfection as 'aggressive' instrumentation is contraindicated and hence there exists a much greater reliance on endodontic irrigants and medicaments. The open apex has also presented obturation difficulties, notably in controlling length. Long-term apexification procedures with calcium hydroxide have proven to be successful in retaining many of these immature infected teeth but due to their thin dentinal walls and perceived problems associated with long-term placement of calcium hydroxide, they have been found to be prone to cervical fracture and subsequent tooth loss. In recent years there has developed an increasing interest in the possibility of 'regenerating' pulp tissue in an infected immature tooth. It is apparent that although the philosophy and hope of 'regeneration' is commendable, recent histologic studies appear to suggest that the calcified material deposited on the canal wall is bone/cementum rather than dentine, hence the absence of pulp tissue with or without an odontoblast layer.

Knowledge, Awareness and Attitude towards Emergency Management of Dental Trauma among the Parents of Kolkata-An Institutional Study

INTRODUCTION

Traumatic dental injuries are one of the commonly encountered dental emergencies. Missing anterior tooth in children due to any injury can be a source of considerable physical and psychological discomfort for the child. The prognosis of some dental injuries depends to a great extent on parents' knowledge of correct and prompt emergency measures.

AIM

The purpose of this cross-sectional study was to assess the knowledge, attitude and awareness level of parents regarding the emergency management of dental trauma and to find out the relation of the responses to social variables.

MATERIALS AND METHODS

A total of 2000 parents were surveyed over a period of three months using a pretested close ended questionnaire prepared in English, Hindi as well as in the regional language which was divided into three parts: Part 1 contained questions on personal information, Part 2 on an imaginary case of trauma to assess their knowledge regarding trauma management and Part 3 related to their attitude towards dental trauma management education. The data was statistically analysed using descriptive and chi-square statistics.

RESULTS

The overall knowledge of parents regarding emergency management of trauma was not satisfactory. Although most of the people were in favour of taking professional consultation for emergency management of trauma but most of them were unaware of the steps that need to be taken on their part so as to minimize complications and improve prognosis.

CONCLUSION

Educational campaigns are the need of the day to increase the knowledge of parents regarding emergency management of dental trauma.

Storage media for avulsed teeth: a literature review

Dental avulsion is the most severe type of traumatic tooth injuries because it causes damage to several structures and results in the complete displacement of the tooth from its socket in the alveolar bone. The ideal situation is to replant an exarticulated tooth immediately after avulsion because the extraoral time is a determinant factor for treatment success and for a good prognosis. However, it is not always possible. The success of replantation depends on a number of factors that may contribute to accelerate or minimize the occurrence of root resorption or ankylosis, among which is the type and characteristics of the medium used for temporary storage during the time elapsed between avulsion and replantation. Maintaining the tooth in an adequate wet medium that can preserve, as longer as possible, the vitality of the periodontal ligament cells that remain on root surface is the key to success of replantation. Recent research has led to the development of storage media that produce conditions that closely resemble the original socket environment, with adequate osmolality (cell pressure), pH, nutritional metabolites and glucose, and thus create the best possible conditions for storage. Although these storage media can now be purchased in the form of retail products, the most common scenario is that such a product will not be readily available at the moment of the accident This paper reviews the literature on the different storage media that have been investigated for avulsed teeth based on full-length papers retrieved from PubMed/Medline, Lilacs, BBO and SciELO electronic databases using the key words 'storage medium', 'transportation medium', 'avulsion', 'tooth avulsion', 'replantation', 'tooth replantation', 'milk' and 'propolis'. After application of inclusion and exclusion criteria, 39 papers were selected and critically reviewed with respect to the characteristics, efficacy and ease of access of the storage medium. The review of the literature showed that a wide array of types of wet storage media have been evaluated in laboratory studies and clinical reports, including cell and tissue culture solutions like Hank's Balanced Salt Solution (HBSS); medical/hospital products developed specifically for organ storage purposes, such as Viaspan® and Euro-Collins®; culture media, like Minimum Essential Medium (MEM); saline; natural products like water, saliva, bovine milk and its variations, propolis, green tea, Morus rubra (red mulberry), egg white and coconut water; rehydrating solutions, like Gatorade® and Ricetral, and even contact lens solutions. Based on the literature, it could be stated that, so far, apart from Based on the literature, it could be stated that, so far, apart from solutions designed specifically for storage and culture purposes, regular pasteurized whole milk is the most frequently recommended and with the best prognosis among other solutions that are likely to be available at the scene of an accident, such as water, saline or saliva. Its advantages include its high availability, ready accessibility, physiologically compatible pH and osmolality (fluid pressure) with the root-surface adhered PDL cells, presence of nutrients and growth factors. However, there is not yet a single solution that fulfills all requirements to be considered as the ideal medium for temporary storage of avulsed teeth, and research on this field should carry on.

Delayed replantation of avulsed teeth: two case reports

This case report presents two cases of delayed replantation of avulsed maxillary central incisors after an extended dry extra-alveolar period. Eight-year-old boy and 10-year-old boy presented with avulsed maxillary central incisors due to trauma occurring 27 and 7 hours earlier, respectively. Treatment guidelines for avulsed mature/immature permanent teeth with prolonged extra-oral time were carried out for the teeth and the extra-oral endodontic treatment was completed. After having been repositioned, the teeth were stabilized for 4 weeks and prophylactic antibiotic was prescribed. Clinical and radiographic controls were done after 18 months for Case I and 12 months for Case II. During the follow-up periods the teeth reported in these cases have remained in a stable, functional position but revealed clinical initial replacement resorption and ankylosis.

Clinical and radiographic outcomes of traumatized immature permanent necrotic teeth after revascularization/revitalization therapy

INTRODUCTION

Revascularization treatment is rapidly becoming an accepted treatment alternative for the management of endodontic pathology in immature permanent teeth with necrotic dental pulps. However, the success and timing of clinical resolution of symptoms, and radiographic outcomes of interest, such as continued hard tissue deposition within the root, are largely unknown.

METHODS

In this prospective cohort study, 20 teeth were treated with a standardized revascularization treatment protocol and monitored for clinical and radiographic changes for 1 year. Standardized radiographs were collected at regular intervals, and radiographic changes were quantified.

RESULTS

All 20 treated teeth survived during the 12-month follow-up period, and all 20 also met the clinical criteria for success at 12 months. As a group, the treated teeth showed a statistically significant increase in radiographic root width and length and a decrease in apical diameter, although the changes in many cases were quite small (such that the clinical significance is unclear). The within-case percent change in apical diameter after 3 months was 16% and had increased to 79% by 12 months, with 55% (11/20) showing complete apical closure. The within-case percent change in root length averaged less than 1% at 3 months and increased to 5% at 12 months. The within-case percent change in root thickness averaged 3% at 3 months and 21% at 12 months.

CONCLUSIONS

Although clinical success was highly predictable with this procedure, clinically meaningful radiographic root thickening and lengthening are less predictable after 1-year of follow-up. Apical closure is the most consistent radiographic finding.

Replantation after traumatic avulsion

The aim of this report is to present the case of an accidentally avulsed maxillary central incisor kept in saline solution from the moment of trauma until its replantation 3 h later in a 13-year-old girl. The avulsed tooth was replanted back into the alveolar socket and splinted with composite resin. Calcium hydroxide intracanal dressing was used to prevent inflammatory root resorption. Radiographic and clinical examinations were performed during 27 months follow-up. During the 15 months follow-up period, the tooth remained in a stable functional position and did not reveal replacement resorption. But mild infraocclusion and root resorption were developed 21 months after replantation. The amount of damage to tooth and supporting structures, emergency treatment and follow-up period play a role in the prognosis of the avulsed tooth. It can be recommended to keep the avulsed tooth in saline solution at least when more appropriate storage media are not on handle immediately.

Reimplantation of avulsed dry permanent teeth after three days: a report of two cases

Two cases of reimplantation of avulsed teeth that occurred after 72 hours are reported. The two patients were male and female aged 13 and 24 years, respectively. The avulsed teeth were not placed in any storage medium for the duration they were out of the mouth and there was no periodontal ligament remaining on their root surfaces before the reimplantation. The teeth in these two patients are still firm without complications after 7 and 17 months. We suggest that the procedures adopted in treating these case should be used by clinicians in treating carefully selected cases that match the cases presented in this paper, which may present to them in their clinics.