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Long Beach VA, Endodontic Section
Rahim Karmali DDS, Steven Merchant DDS, Stephen Davis DDS
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Author Date Subject Title Take Away
Etiology and
pathogenesis of Most frequent in adolescents. Boys to girls almost 3:1. Max ant almost 75% of traumatized teeth. 50% were less
traumatic dental than 10 yrs old. Don't forget to check other teeth, even in the opposing arch. Check for soft tissue injuries as well.
Andreasen 1970 Trauma injuries In the perm dentition, extrusions are most common, followed by simple crown fx and then avulsions.
Replantation of 8% had pulpal healing (34% w/ incomplete root formation). Primary factor in pulpal healing was the length of the root
400 avulsed (<17mm much better px). Most of those that healed had calc met. 24% had complete PDL healing (36% if healed
permanent resorption inc). Most sig factor was replantation time (73% healed if replanted w/in 5 min). Of those that did not
Andreasen 1995 Trauma incisors. heal: 61% replacement resorption, 30% Inflamm resorp, 5% surface resorp.
189 luxated perm teeth followed for an avg of 3.4 yrs. Necrosis was found in 52% of the time. It was related type of
luxation (sublux best, intrusion worst) and root development (open apex better than closed apex). Pulp obliteration
happened 22% of the time. Related to root development, type of luxation and crown fx. For obliteration to occur, the
pulp has to remain vital, so this was more common in open apex, sublux and/or no crown fx. Progressive external
Luxation of resorption occurred in 11%. Type of luxation, time to tx, and reduction were related. Reduction surprisingly caused
permanent teeth more resorption, thought to be the trauma to the PDL assoc w/ reduction. Loss of marginal ridge support was 10%.
Andreasen 1970 Trauma due to trauma Type of luxation, time to tx and alveolar fx were related. Rigid splinting was used for an avg of 6 wks.
84 single-rooted teeth w/ intact crowns. 64% showed growth. Most were mixed flora w/ a single strain dominating,
Microorganisms avg of 4 isolated strains. Predominance of anaerobes. Bacteroides, Corynebacterium, Peptostrep, and
from necrotic pulp Fusobacterium were common. Length of time btwn trauma and tx did not influence composition of microflora. PARL
of traumatized 71%, external resorption 28%. Specimens that were PARL- showed no growth of baceria, so if no sx, endo can be
Bergenholtz 1974 Trauma teeth postponed.
Long-term
prognosis of
traumatized 122 traumatized teeth were followed form 10-23 years (16 yr avg). 64% had complete pulpal obliteration, 21% of the
permanent severely traumatized necrosed and only 4% of the moderately traumatized necrosed. None of the 36% w/ partial
anterior teeth obliteration showed necrosis. The more severe the injury, the more likely it was to have complete obliteration and
showing calcifying necroses w/ PARL. Conclusions: extended observation periods are needed to predict outcome. Only teeth w/
processes in the complete obliteration are susceptible to necrosis. Also, it is possible to predict in which cases total pulpal obliteration
Kerekes 1977 Trauma pulp cavity will occur in. Even if 21% of the totally obliterated canals necrosed, routine endo is not prudent.
Pulpal prognosis
following extrusive After observing 52 teeth after extrusive luxation from 4wks to 1.5yrs, 98% showed necrosis. Higher percentage than
luxation injuries in reported w/ Andreasen and Eklund's separate studies, but this one had an older pt population (mean 20yrs) which
permanent teeth meant a grtr poss of complete apical closure. Also, the severity of these injuries are prob grtr than those in the other
with closed two studies. So, teeth with fully developed apices that are forcefully seperated from their blood supply are likely to
Dumsha 1982 Trauma apexes. necrose.
Prognosis of
luxated non-vital
maxillary incisors
treated with
CaOH and filled
with GP. A 60 incisors w/ complex crown fx was treated w/ shallow pulpotomy and CaOH. Exposures prior to tx were from 1 day
retrospective to 90 days. Pulpotomy was done w/ a diamond bur and exposed pulp was irrig w/ saline. Followed for 1-5 yrs. 96%
Cvek 1992 Trauma clinical study healed. Comments: Today we would irrig w/ NaOCl and place MTA as the pulp capping agent.
29 pts w/ alveolar fx involving 71 teeth. Mean observation time was 6.5 yrs. 75% showed necrosis. Related to how
Fractures of the quickly tooth was splinted, thereby limiting further trauma to microvasculature. 15% showed pulp obliteration. Time
alveolar process to tx was also sig related. Since vitality is necessary for pulp obliteration to occur, it happened to teeth that were
Andreasen 1970 Trauma of the jaw splinted w/in 60 minutes. Root resorption 11%. Loss of marginal bone support 13%
Prognosis of teeth 132 pts involving 185 teeth, observation period from 1-3 yrs. 59% of the teeth completely recovered. Inciidence and
involved in the degree of pulpal and perio complications was closely related to the location of the fx line (at the apex or down the
Kahnberg, line of mandibular PDL) and the amt of displacement of the fragments. How well the fx could be reduced and stabilized also played a
Ridell 1979 Trauma fractures role. 23% of the teeth that tested - at initial exam showed + sensibility at follow up, thus a long -term follow up is nec.
Pulpal and
radicular
response to Maxillary osteotomies were done on 4 monkeys. Killed 150 days post op. The pulp of a majority of teeth showed
maxillary pathological pulpal changes, even in the presence of collateral circulation. NSRCT will not save teeth involved in
osteotomy in external resorption caused by any cut, longitudinal or cross. Apices cut during the osteotomies caused necrosis in
Langeland 1982 Trauma monkeys every case.
A radioigraphic
evaluation of the
response of
previously
avulsed teeth and
partially avulsed
teeth to Ortho tx can be accomplished successfully in teeth that have been avulsed and reimplanted. They respond normally
orthodontic to movement forces. Apical resorption does occur more often in these teeth. How long do you stabilize the avulsed
Hines 1970 Trauma movement tooth prior to initiating movement forces????
23 EXT monkey teeth were place in milk, saliva and saline. Histochemically analyzed at 1,2,&3 hrs. Stained for two
enzymes to determine vitality of the PDL and pulp. At 1 hr, milk showed a slightly better staining. At 2 &3 hrs, milk
Blomlof, Vitality of PDL was sig better at maintaining vitality. There was a slow degeneration of the pulp suggesting a low content of autolytic
Lindskog, cells after storage enzymes in the pulp. Comments: Blomlof is the milk man!!! Milk can maintain PDL vitality for about 6hrs, HBSS is
Hammarstro of monkey teeth in about 24-48 hrs, Viaspan is about 48 hrs. Tap water sucks, but it is better than dry. Wrapping in plastic wrap is
m 1980 Trauma milk or saliva better than dry as well.
Various areas of PDL were dried or removed from the roots of monkey teeth and replanted. Histo study after 2,4,& 8
wks. In the drying experiment, ankylosis was established after 2 wks corresponding to the dried area of root. This
The effect of was removed by a resorptive process in a majority of the cases after 8 wks. When 1 or 4 mm squared of the PDL
limited drying or was removed, a transient ankylosis which resolved after 8 wks was also noted. The 9 & 16mm squared removal of
removal of the PDL resulted in a persistent ankylosis at 8wks. If the damaged PDL is next to vital PDL, ankylosis can be reversed
Andreasen 1981 Trauma PDL by a resorptive process, the extent of this process is estimated to be 1-1.5mm.
Teeth were EXT from monkeys. Extra-oral NSRCT. One group was kept moist and replanted in in 18 min. The
other was allowed to dry for 120 min. 1/2 the monkeys in each group had their labial plate removed. Sacrificed and
Interrelation eval'd after 8 wks. In the 18 min group, resorption was independent of the presence of the cortical plate. Bone level
between alveolar was sig more coronally placed than in the 120 min group. In the 120 min group, no sig diff in the freq of root
bone and PDL resorption, in most cases the labial plate was only partly reformed or not reformed at all. Conclusion: a sig
repair after relationship exists btwn PDL vitality (extra-oral dry time) and labial plate repair. Supports theory that cells in and
replantation of around the PDL are capable of bone induction. Also, removal of the bone socket did not prevent root resorption, so
mature permanent CT facing a damaged root surface can induce root resorption. Comments: This can be used to justify the surgical
incisors in principle of locating the root first, then moving to find the apex. If you can do this with reasonable skill, there will be
Andreasen 1981 Trauma monkeys limited effect on the PDL. It will not effect healing of the bone, nor will there be permanent replacement resorption.
The effect of pulp
extirpation or root
canal treatment Teeth were EXT from monkeys. Pulp extirpation was performed on all teeth and one half of the material was obt w/
on periodontal GP. Some were replanted after being kept moist for 18 min. The others were allowed to dry for 120 min. Sacrificed
healing after after 8 wks. Extra-oral filling lead to more ankylosis and surf resorption, but less inflamm resorption. In root filled
replantation of teeth, the resorption occurred close to the apical foramen, indicating that the filling procudure or the materials used
permanent (Kerr sealer) further damages the PDL. Extra-oral pulp extirpation did not change the extent of resorption.
incisors in Conclusion: The avulsed tooth should be replanted immediately, prior to extirpation or full NSRCT. This may inc the
Andreasen 1981 Trauma monkeys extent of inflamm root resorption, but CaOH tx later offers a predictable result.
EXT in monkeys and replanted them w/ or w/o completing extra-oral RCT. EXT atraumatically and PDL kept moist.
Reimplanted from 18 to 120 min. Followed for 2-8 weeks and studied histologically. Inflamm root resorption, in
Relationship contrast to surface resorption, was always linked to the presence of a luekocyte zone or necrotic pulp tissue. Teeth
between surface w/o bacteria in the necrotic pulp had fewer inflamm resorption cavities. Inflamm resorption was strongly linked to the
and inflammatory "corner" surfaces of the root. The theory of why this all happens is that damaged PDL is removed by a resorption
resoption and process, leading to the resorption of cementum and dentin and these "corners" are more likely to have damged PDL
changes in pulp from the EXT or trauma. Now either surface resorption or infalmm resorption can take place depending on the the
after replantation extent of exposed dentinal tubules and the status of the pulp. If the initial resorption is deep, and the pulp is infected,
of permanent then toxins will leak through the tubules and inflamm resorption will occur. If the cavity is shallow, even an infected
incisors in pulp may cause only surface resorption. Finally, when the pulp is vital, inflamed or not, or NSRCT has been
Andreasen 1981 Trauma monkeys performed, then surface resorption occurs regardless of the depth of the cavity.
Avulsed human
teeth replanted 21 human avulsed teeth were replanted w/in 15 minutes and followed for an average of five years. 15/21 ( approx
within 15 minutes- 75) showed no sign of resorption or shallow non-progressive resorption. 6 teeth showed signs of progressive
Andersson, long term clinical resorption, 5 of these did not have NSRCT w/in three weeks. Teeth replanted w/in 15 min have a favorable long-
Bodin 1990 Trauma follow up term prognosis.
Epithelial rests'
function in
replantation: is
splinting Teeth from mongrel dogs were EXT, Cavit retroseal placed, and replanted w/in 3 min. Followed from 24-48 days.
Wallace, necessary in Where there were Rests of Mallesez, resorption was absent. Splinting is not nec to prevent replacement resorption.
Vergona 1990 Trauma replantation Splinting too long will result in more replacement resorption.
29 aulsed teeth were replanted. In most cases, extra-oral NSRCT was completed before replantation and splinting.
Replantation: Followed for 8 yrs. The incidence of root resorption was higher in teeth that had been replanted after an hour. When
analysis of 29 resorption occurred, it was w/in a year. Some teeth that had long extra-oral times showed no signs of resorption...so
Gonda 1990 Trauma teeth you never know.
The effect of citric
acid treatment on 95 dog teeth were EXT, root planed, replanted and followed up to 56 days. Half of the teeth were soaked w/ citric
periodontal acid for 3 min prior to replantation. At 3 and 14 days, the citric acid group showed better healing. At 56 days though,
healing after the citric acid group had much more replacement resorption and inflamm resorption. Hypothesis that the citric acid
replantation of acts as a chemotactic agent for resorptive cells or that it makes the root surface more prone to resorption and
Zervas 1991 Trauma permanent teeth ankylosis. Do not treat teeth to be replanted w/ citric acid.
Periodontal 72 dog teeth were treated endodontically, extractracted and placed in Viaspan or milk for 6-36 hrs and Viaspan or
healing of HBSS for 36-96 hrs. Histologically examined after 2 mo. Milk had good results upto 6 hrs of storage. Viaspan
replanted dog proved ot be superior to milk and similar to HBSS. Interesting to note that from 24-48 hrs of storage, there was an
teeth stored in inc incidence of replacement and inflamm resorption. The incidence dropped to lower levels after 48 hrs of storage.
Viaspan, milk, and Hypothesized that from 24-48 hrs, there is a host inflamm rxn in the socket which dissapates after 48 hrs. If the PDL
Trope, Hank's balanced vitality can be maintained for this time period w/ Viaspan or HBSS, and replanted after 48 hrs, then good results can
Friedman 1992 Trauma salt solution be expected.
Intentional Report of 31 teeth treated w/ intentional replantation. Contraindications: perio dz, mobility, furcal involvement,
replantation of gingivitis, long curved roots, divergent roots. Ab given 1 hr prior to procedure and given for 4 days later. Root end
endodontically resected and amal retrofill placed. Splinting was not nec, tooth placed in socket and pt instructed to bite down. Perio
Bender 1993 Trauma treated teeth pack placed and removed after 3-4 wks. Overall success rate of 80% (78% in molars).
Intentional
Kratchman 1997 Trauma replantation Great review of the replantation procedure. Step-by-step.
400 replanted perm incisors were followed for up to 20 yrs (5 yr avg). Stored and rinsed in saline once pt arrived at
clinic. Tooth was replanted and splinted. RCT depended upon level of root formation and rdx evidence of infection.
Replantation of Moorees classification was described. 1-4 represent 1/4 to 4/4 root development. 5 is a half-open apex. 6 is a fully
400 avulsed developed apex. In root formation stages 2-5, pulpal revascularization occured in 34% of the cases. The trend was
permanent the less developed roots showed a grtr chance of revascularization (2=60%, 5=24%). Perio healing w/o any signs of
incisors. 1. resorption occurred in 24% of the cases, 36% adding in teeth w/ arrested resorption. The less mature roots did
Diagnosis of better. Replacement resorption was the most common form of non-healing, followed by inflamm resorption and surf
healing resorption. Tooth survival was much better for mature teeth b/c rate of resorption was slower and there was more
Andreasen 1995 Trauma complications tooth structure available to resorb. For a mature tooth, survival was about 70% @ 10 yrs.
Treatment of the
avulsed tooth.
Recommended
guidelines of the
AAE 1995 Trauma AAE
94 replanted teeth w/ incomplete root formation were studied. Pulp healing occurred 34% of the time. Pulp
Replantation of sensibility frequently occurred around 6 mo (range 4 mo to 2 yrs). Almost all of the pulps that healed underwent
400 avulsed calcific metamorphosis. Necrosis or inflamm resorption were usually evident rdx after 3 wks. A very stong
permanent correlation btwn pulp length and pulpal healing. Lengths of 17mm or less did better. Hypothesized that the grtr the
incisors. 2. distance to revascularize, the grtr the chance of infection. Extra-alveolar storage was also am important
Factors related to prognosticator. Wet storage was better than dry. Storage soln (saliva, other's saliva or saline) did not seem to
Andreasen 1995 Trauma pulp healing. matter. Replantation w/in 5 min was the best.
Replantation of
400 avulsed 30 replanted teeth w/ incomplete root formation were studied. Extent of root formation was related to pulpal
permanent revascularization or necrosis. 11/13 teeth w/ pulpal healing showed complete or partial root formation. 10/15
incisors. 3. necrosed teeth showed arrested root formation. There was a tendency towards more root formation if the extra-oral
Factors related to dry time was less than 45 min. Also describes the necessity of maintaining vitality of the HERS, without which, root
Andreasen 1995 Trauma root growth formation would cease.
Replantation of
400 avulsed 400 replanted perm incisors were followed. Complete PDL healing was found in only 24% of the cases. When
permanent resorption occurred, 60% of the time it was replacement resorption, 30% inflamm and 5% surf resorp. Replacement
incisors. 4. resorption was clinically evident w/in the first couple of months. Rdx dx was evident around 1 yr. Immediate
Factors relating to replantation was the single most important factor. When replanted immediately, healing occured in 85-97% of the
periodontal cases, depending upon root formation. PDL healed less freq in older groups, prob due to a thinner PDL which is
Andreasen 1995 Trauma ligament healing. easier to injure. Longer extra-oral times resulted in less healing.
Monkey teeth were endo tx to rule out inflamm root resorption. Extracted. Negative control group was immed
replanted. Positive control group was bench dried for an hour before replanting. All other groups were dried for an
The effect of hour and various methods, w/ and w/o removal of PDL, or Emdogain application was performed before replantation.
Emdogain on Block resections at 16 wks. Immed replantation had a 99% healing rate. 1 hr bench dry had a 17% healing rate.
periodontal Removing the PDL and replanting healed at 5%. Adding Emdogain after an hour of bench drying brought the healing
healing in rate to about 20%. Not much different than leaving the PDL on and just replanting. Removing the dried PDL before
replanted replantation is not a good idea. A good quote that is at the crux of replacement resorption: "The competitive wound
Sae-Lim 2004 Trauma monkeys' teeth healing of the damaged root surface would favor the endosteal osteoblasts over the PDL fibroblasts."
Effect of different
endodontic
treatment Dog teeth were used. Group 1: RCT, extracted, grooved and replanted. Group 2: Pulpectomy, infected w/ saliva,
protocols on temped w/o intracanal meds, extracted, grooved and replanted. 2 wks later, CaOH for a week then obt. Group 3:
periodontal repair Treated like group 2, but CaOH for 8 wks, no obt. Teeth studied histologically after 8 wks. 8/8 teeth in group 1
and root showed complete cemental repair. Group 2 and 3: 7/9 complete and 2/9 partial cemental repair. 1 tooth in the long-
resorption of term CaOH group showed ankylosis, theorized that it was the high pH of the CaOH that caused necrosis of the PDL
Trope, replanted dog cells. Discussion: The pH at the external root surface remains the same after CaOH b/c of the buffering effect of the
Friedman 1992 Trauma teeth dentin...so why ankylosis???
4 types of healing for fx teeth. 1. Healing w/ calcified tissue. 2. Interproximal CT. 3. Interproximal bone and CT. 4.
Interproximal granulation tissue (this is assoc w/ pulp necrosis). Necrosis occurs in coronal segment 44% of the
Treatment of time, apical segment almost always retains vitality. PDL heals in 3 ways after avulsion and replantation. 1. Healing
fractured and w/ normal PDL. 2. Healing with ankylosis. 3. Inflamm resorption. Length of extra-oral period is the primary clinical
Andreasen 1971 Trauma avulsed teeth factor assoc w/ healing.
Rapid neurologic
assessment and
initial
management for
the patient with
tramatic dental
Croll 1980 Trauma injuries