Download simple replantation protocol to avoid ankylosis in eatment

Yuli Nugraeni
David Buntoro Kamadjaja
Haryono Utomo
SIMPLE REPLANTATION PROTOCOL TO AVOID
ANKYLOSIS IN TEETH INTENDED FOR
ORTHODONTIC TREATMENT : A REVIEW
INTRODUCTION
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Dental trauma is one of the most serious oral health
problems in active children and adolescents.
It requires immediate initial emergency treatment
followed by integrated procedures.
Tooth avulsion accounts for 0,5-16% of traumatic
injures in the permanent dentition and for 7-21% of
injures in the primary dentition
Avulsion of permanent occur at age of 7-10
year
 Avulsions → severe pulpal and periodontal
injures
 Pulp necrosis and consecutive infections →
ankylosis (Replacement Resorption, RR) and
infection-related resorption (IRR)
 Tooth ankylosis leads to difficulties in
orthodontic treatment i.e. retracting the avulsed
protruded teeth
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Management for ankylosis → supported by
little evidence →do not offer and any proven
long term benefit
 Antiresorptive-regenerative therapy (ART) +local
application of glucocorticoids +enamel matrix
derivative (EMD, Emdogain) + systemic
administration of doxycycline combined with
semi-rigid fixation →successful results
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The objective of this review is to purpose a new
simple protocol of avulsed tooth management
which also minimize the risk of ankylosis.
AVULSION :
a complete displacement of tooth out of socket
→ severe PDL + fracture of alveolus
TREATMENT OF AVULSION
Immediate replantation (within 5 min)
 Required for regeneration of the PDL
 Prognosis :
 In the permanent teeth is dependent upon
formation of root development and extra oral
dry time → a risk for pulp necrosis, root
resorption, ankylosis, infraocclusion.
 The best prognosis: replanted immediately if >
5min: stored in medium to maintain vitality of
PDL). > 15 min → risk of ankylosis ↗
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ANTIRESORPTIVE-REGENARATIVE THERAPY (ART)
ART : to depress resorption activity and support
regeneration in the PDL
ART + EMD (® Emdogain) + Doxycycline : ↗prognosis
of avulsed teeth
Treatment strategies :
 avoiding inflammation
 increasing revascularization
 producing hard barriers in the teeth with open
apices
Extra oral dry time> 60 min:
EMD should applied onto the root surface and into the
alveolus
EMD contains protein (amelogenin) and thought to aid in
the migration, attachment, proliferative capacity and
biosynthetic activity of PDL cells.
EMD : ↗PDL cell proliferation and protein production→
regenerating PDL
ENDODONTIC TREATMENT OF AVULSED TEETH
Endo treatment → essential for the progress of healing
of the replanted tooth
Controversies : in closed apex tooth (<1mm) →EO/IO
The best result : endodontically treated → inserted to
socket + pulp extirpation directly → prevent IRR
The canal → debrided, dressed with
corticosteroid/antibiotic ( Ca(OH)2 ) → 1 to 3 months
Endodontic + gutta-percha or Ca(Oh)2 :delays
periodontal healing + Accelarate ankylosis (RR) in
matture teeth
In mature teeth → Endo tx should be
commenced 7-10 days following replantation
 In immature teeth ( the time is short and the
apex is open ) → revascularization → Endo tx
can be delayed
 If px compliance → Endo tx is assured →
Apexification, root filling with GP/MTA → can be
carried out later
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INTRACANAL MEDICAMENT
Ladermix : healing ↗ resorption ↘
 Ca (OH)2 + ChKM : healing process of PDL ↗ if
application delayed ± 7 days after replatation
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DISCUSSION:
Ankylosis and root resorption in tooth avulsion
treatment, caused:
 improper management directly
 dry time exceeding 60 min
 Persistent inflamation of the PDL
 Minimal or absence of occlusal force
After 60 min extra oral dry time : the survival
rate of The PDL cells →almost zero, and
osseous replacement is predicted
 Direct extirpation the pulps + application of
intraradicular medicament → beneficial
 Ladermix → proliferation of dentinoclast →
mixed with Ca(OH)2 ↗
 Corticosteroids in intracanal → standart tx
protocol at emergencies visit
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EMD is the promising result replantation ↗↗
 The alternatives medicament : doxycycline,
minicycline, alendronate, atau Ladermix
 The best factors may prevent replantation from
ankylosis and root resorption :
dry time < 60 min
decontamination of root surface
application of preserving PDL agent (EMD)
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direct
extirpation without endo tx
ART + intracanal medicament
Semi rigid splinting for 2-3 weeks
Endo tx
The successful result : significantly higher in open
apex teeth
Our new concept : to create open apex condition by
widening the apical → to remove the delta area
which contains accessory canals
This new concept  simple proccedure had several
benefits :
 Open apex  intracanal medicament to enter
periapical area  PDL inflamation ↘
 Remove the accessory canals  difficult for pulp
sterilization
 Facilitates drainage of inflamaotry mediators in
periapical area
The follow up : apexification procedures or final root
canal filling
The simple procedures : the use of medicament
that commonly available in dental office →
Ca(OH)2, CHKM, Endomethasone®,
minocycline gel for topical application in the
sulcular area. In case of absence of ideal wire
for splinting with brackets, attached to the
tooth with GIC or composites
The main principle to prevent ankylosis: reducing
the inflamation of the PDL.
Inflamation leads to altered function of PDL
→mineralized tissue forming cells → ankylosis