History of Endodontics aae/abe



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Partial Pulpotomy. NOTE – foundation study for CVEK PULPOTOMY FOR TRAUMA CASES !! (96% success)
Holland 2002 Dent Traum – Dog study – success of treatment of traumatic fractures is partly dependant on how quickly therapeutic treatment is rendered.
Fuks 1987 Endo Dent Traum – Partial pulpotomy is treatment of choice in crown-fractured teeth with pulp exposure (including closed apicies)
Sensibility tests: +

Mobility: normal, Percussion: - (if + evaluate for root fx or luxation)

Radiographs: Occlusal film (rule out root fx), 2 PAs: Mesial/Distal

Treatment for crown fractures

Crown/Root Fractures: Occlusal Film, 2-3 PAs; CBCT (root/alveolar fxs only)

Uncomplicated crown fracture

  • Baseline pulp test

  • Smooth edges or restore with composite

  • Place Dycal base on exposed dentin

  • F/U at 6-8wks, 1 yr

Complicated crown fracture

  • DPC (MTA) if small, <24 hours, and open apex

  • Cvek pulpotomy if larger, >24 hours, or closed apex

    • Remove 2mm of pulp with diamond and H2O spray, then DPC

  • Pulpectomy if necrotic or uncontrolled hemorrhage

  • F/U at 6-8 wks, 1 yr

Crown-root fracture

4 options after removing coronal fragment: F/U at 6-8 wks, 1 yr

  • Gingival reattachment

  • Crown lengthening

  • Ortho extrusion

  • Extraction

NOTE: Transient Loss of Sensibility testing – (up to 3 months), Need 1 add’l sign of necrosis – PARL, Vestibular swelling, dramatic color change

Horizontal root fractures:


  1. Mechanowitz – Healing of root fracture occurs from the PDL

  2. Jacobsen70-90% incidence of PCO, 25% Necrosis

  3. Andreasen 201210 yr survival root fractures: Apical 89%, Mid root: 78%, Cervical/Mid root: 67%; Cervical: 33%; CT healing only (8 yr survival): Apical, Mid root, Cervical/Mid root: 80%, Cervical: 25%


Healing mechanisms of root fractures:

  1. Andreasen/Hjorting-Hansen 1966:

  1. Hard tissue fusion

  2. PDL (C.T.) only

  3. PDL (C.T.) + bone

  4. Granulation tissue = Non-healing (necrosis of coronal segment)



Horizontal root fractures:

*Root fractures/Alveolar fractures – Occlusal/2 PAs/CBCT



Root fracture

  • Clinical/Radiographic examination (Occlusal/2 PAs/CBCT)

  • Reposition, confirm position with PAs

  • Flexible splint 4 weeks or 4 months (cervical root fracture)

  • F/U at 4 weeks, 6-8 weeks, 4 months*, 6 months, 1 yr, then annually

  • RCT of coronal segment if necrosis, apical matrix may be needed

  • SX removal of necrotic apical segment if necessary

  • Transient discoloration (grey) or False neg. pulp testing (up to 3 months)

NOTE: Alveolar fracture has same recall schedule as Root Fracture: 4 wks (remove splint), 6-8 wks, 4 mo, 6 mo, 1 year – 5 years

Andreasen 1967 JOS4 types of healing, mobility of coronal segment is important for healing

  1. Calcified (callous) – hard tissue fusion

  2. Connective tissue - PDL

  3. Bone/Connective tissue – Bone/PDL

  4. Granulation/inflammatory (non-union) – Necrosis of coronal segment

Horizontal root fractures
Degering; Bender JADA 1983 – Recommend 3 radiographs with different vertical angulations to view horizontal fracture (See also Brynolf)
Andreasen – semirigid splint 2-4 weeks for horizontal root fractures, 4 months in cervical root fractures due to increased stability
Jacobsen 1975 – Long term prognosis of anterior teeth with root fractures

  1. Location of the fracture influenced repair only slightly

  2. Longevity (prognosis) of teeth was not shortened even when necrosis occurs; Necrosis: 25%; PCO 70-90%

  3. Optimal treatment:

    1. reposition

    2. fixation – flexible/physiologic

    3. relief of occlusion


What is the prognosis for luxation injuries ?
Closed Apex


Injury

(Pulpal Necrosis)

Andreasen/Vesteergard-Pederson

1985

Dumsha

Concussion

3%

2%

Subluxation

6%




Extrusion

26% (~30%)

98%

Lateral luxation

58% (~60%)

77%

Intrusion

94% (~90%)

100%


Trope, Pathways of the Pulp: If sensibility testing indicates necrosis at the 2 wk f/u, CLOSED APEX ONLY (Luxation injuries – extrusive/lateral/intrusive), NSRCT should be performed due to high success of NSRCT in non-infected pulp versus risk of external inflammatory root resorption complication.

Luxation Injuries

IADT Guidelines 2012 – de Angelis/Andreasen, AAE Guidelines 2014



2 PAs (M/D), CBCT (same as avulsions)

Concussion

  • PDL injury only

  • Percussion pos., No mobility, No displacement

  • Vitality testing normal

  • No treatment needed – soft food 1 wk, CHX 0.12% 2 wks

  • Follow up: 2 wks, 4 wks, 6-8 wks, 6 months, 1 year

Subluxation

  • PDL injury only

  • Percussion pos., Inc. mobility, No displacement

  • Vitality testing may be initially negative (transient)

  • Bleeding from sulcus

  • Flexible splint for 2 weeks – patient comfort only

  • Follow up: 2 weeks, 4 weeks, 6-8 wks, 6 months, 1 year


*Transient pulpal necrosis: up to 3 months, monitor for clinical/radiographic signs of necrosis (At least 2 signs/symptoms needed for pulpal necrosis)

Luxation Injuries

IADT Guidelines 2012 – de Angelis/Andreasen, AAE Guidelines 2014



2 PAs (M/D), Occlusal, CBCT

Extrusive Luxation

  • Tooth appears long, Excessive mobility

  • Vitality testing are likely negative

  • Radiographically: Increased PDL space apically

  • Reposition w/ fingers, physiological splint for 2 weeks

  • NSRCT if no response to vitality testing at 2 week f/u (closed apex)

  • Follow up: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years

Lateral Luxation

  • Tooth is displaced in a palatal/lingual or labial direction, poss alv. fx (F)

  • No mobility, high percussion sound (ankylotic)

  • Vitality testing negative

  • Possible alveolar fracture – palpable, Increased PDL space apically

  • Reposition w/ forceps or fingers and physiologic splint for 4 weeks

  • Monitor pulpal response

  • NSRCT if no response to vitality test at 2 week f/u (closed apex)

  • Recall: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years

*If pulpal necrosis (open apex) – attempt pulpal revascularization or MTA apexification

Luxation Injuries

IADT Guidelines 2012 – de Angelis/Andreasen, AAE Guidelines 2014



Occlusal, 2 PAs (M/D), CBCT

Intrusion

  • Tooth is displaced axially into alveolar bone – appears short

  • Loss of PDL space apically

  • No mobility, high metallic percussion sound (ankylotic)

  • Vitality testing negative

  • CEJ apical to level of adjacent tooth, may be apical to level of marginal bone




  • Recall: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years

Open apex:

  •  7 mm: Allow spontaneous re-eruption, if no movement after 2-3 weeks, ortho reposition

  • > 7 mm: Ortho or surgical reposition

  • Monitor for pulp vitality

Closed apex:

  • < 3mm/<17 y.o.: Allow spontaneous re-eruption, after 2-3 weeks, reposition ortho or surgically

  • 3-7 mm: Ortho or surgical repostition

  • > 7 mm: Surgical reposition

  • NSRCT at 2 week f/u

  • Splint 4 weeks

Discuss luxation injuries

  1. Bergenholtz 197464% of the time, traumatized teeth with necrotic pulps have a mixed flora with anaerobes predominating. Aseptic necrosis was found in the other teeth.

  2. Bhaskar JADA 1973 – EPT, cold, heat testing are unreliable following trauma. Blood supply may still be functioning.

  3. Barnett 2002 Dent Trauma – RCT is necessary when there are clinical and radiographic signs of pulpal infection.

  4. Siskos 1996 Endod Dent Traum – Techniques to reposition intruded tooth include:

    1. Observation for spontaneous reeruption – minimal intrusion

    2. Surgical reposition – w/ early RCT to prevent anklyosis

    3. Orthodontic reposition – luxation of intruded tooth before applying ortho forces may prevent ankylosis.

  5. Feiglin 1996 EDT – Histology – concussion and subluxation caused minimal damage. Lateral extrusion, intrusion caused major damage. Histology often not related to clinical symptoms

Discuss storage media for avulsed teeth

  1. HBSS:

    1. Trope/Friedman - Provided 96h storage- no replacement resorption

    2. Ashkenazi - PDLF cells: HBSS=MILK > Viaspan

  2. Viaspan:

    1. Trope/Friedman; Pettiete/Trope - Comparable storage times to HBSS (96h) (T/F), >HBSS (P/T)

  3. Milk (low fat is better- Walker):

    1. Blomlof - pH and osmolality are compatible; better than Saliva -  Infl. Root Resorption; 3 hours milk = Immediate replantation

    2. Trope – Provided 6 hours of storage

  4. Saline: Andreasen 1981 – 0-120 mins – no replacment resorption

  5. Saliva: Andreasen 1981 – 0-120 mins – no replacement resorption

  6. Water: Blomlof 1981 - hypotonic – causes cell lysis; Andreasen 1981 -  Replacement resorption with tap water (0-120 mins)

Andreasen 1986 – Saline storage of a previously dry tooth has no positive effect on resorption or pulpal repair.

Discuss splinting of avulsed teeth

Physiologic (Flexible) Splint: up to 0.016” or 0.4 mm



  1. Antrim 1982 JOE – describes a technique using 30lb monofilament nylon line and acid etch resin to splint traumatically luxated or avulsed teeth. The non-rigid splint stabilizes traumatized teeth and allows for physiologic movement.




  1. Nasjleti/Casteli 1982 OOO – Replanted teeth splinted for 7 days – PDL repaired w/ no resorption/ankylosis. Extended splinting periods (30 days) induced further root resorption and ankylosis.




  1. Berude/Hicks 1988 JOE – Monkey study - No differences observed in healing in replanted teeth w/ physiologic splint, rigid splint, no splint.

Discuss Effect of Diet on Healing

  1. Andersson 1985 – Monkey study – Eval. Hard pellet vs. Soft diet post replantation (8 weeks) for replacement resorption. Significantly less replacement resorption in the hard pellet group – Normal Mastication

How would you manage an avulsed tooth clinically?

Management at site:

  1. Gently wash if dirty, replant

  2. If unable to replant, store in HBSS, milk, saline or saliva (no water!)

  3. Proceed to office


Andreasen 1981– Monkey study, relationship exists between extra-alveolar time, storage medium and root resorption. After 60 min of dry storage, Replacement resorption is very prominent. After 30 mins dry time, Inflammatory resorption is prominent. Saline, Saliva – no replacement resorption at 2 hrs. Water bad – hypotonic, cell lysis (Blomlof).
General Adjuncts to trauma treatment:

  1. tetanus booster – if tooth touches soil

  2. chlorhexidine rinses – 0.12%, 2 wks

  3. analgesics, antibiotics (Pen VK or Doxycycline)

  4. recall for 5 years

How would you manage an avulsed tooth clinically? Continued

Avulsion: OPEN APEX , Storage Media and/or < 1 hour extra-oral dry time



Rational: Promote Revascularization

  1. Rinse root surface/AF with Saline, Anesthesia, Irrigate socket

  2. Soak 5 mins in suspension 1mg Doxycycline in 20 mL Saline*

  3. Coat with Minocycline microspheres (Arrestin)** IADT 2012

  4. Replant, Verify position w/ PAs, Physiologic splint up to 14 days

  5. Administer antibiotics, check tetanus booster, patient instructions (soft diet, CHX)

  6. Recall, if necrotic, proceed with revascularization or MTA apexification

*Cvek/Cleaton Jones 1990 EDT – monkey study, Showed a decreased frequency of microorganisms in the pulpal lumen and less ankylosis or inflam resorption as a result of the soaking in Doxcycyline (1mg in 20 mL saline). No revascularization in closed apex teeth. Inc AF opening (> 1mm), Inc Revascularization (Kling)

**Ritter/Trope 2004 – dog study, Minocycline (Arrestin) promoted revascularization of immature avulsed teeth (dry 5 mins), 91% revas. (vital tissue)

How would you manage an avulsed tooth clinically? Continued

Avulsion: OPEN APEX, >1 hour extra-oral dry time

Poor prognosis for revascularization, PDL necrotic, Goal: replant for esthetics, function and maintain alveolar bone contourOutcome: Ankylosis/resorption


  1. Remove tissue tags with wet gauze

  2. Soak in 2% NaF for 20 mins

  3. Complete RCT extraorally or No RCT/Monitor (esp wide open apex)

  4. Anesthesia, Replant, Verify position w/PAs

  5. Physiologic splint 4 weeks, Antibiotics, Tetanus booster, Pt instructions (soft diet, CHX)

  6. Recall, Decoronation necessary when infraposition > 1mm

  7. Baseline: Weight/Height measurements to follow growth and need for decoronation

Kling/Cvek 1986 – immature teeth replanted >45 mins =  revascularization

Coccia 1980 – human study; 5 min 2% NaF soak (vs. saline) prior to replantation  replacement resorption (esp in longer dry times); Fl binds with HAP to create FAP (resistant to resorption). Delays replacement resorption (2x survival time)

How would you manage an avulsed tooth clinically? Continued

Avulsion: CLOSED APEX, Storage Media and/or < 1 hour extraoral dry time



  1. Rinse root surface/AF with Saline, Anesthesia, Irrigate socket, Replant

  2. Verify position w/ PAs, Physiologic splint up to 2 weeks, Antibiotics, Tetanus booster, Patient instructions (soft diet, CHX rinse)

  3. Initiate RCT 7-10 days (Rationale: prevent infection of canal that leads to external inflammatory resorption), Remove splint at 14 days

  4. Place CaOH2 for up to 1 month

  5. Obturate canal when CaOH2 is removed

Gregorio/Jeansonne 1994 – dog study; Immed. pulpectomy/CaOH2:  replacement resorption vs delayed 18 days; Delayed 4-18 days: NSD in resorption (surface, inflamm, replacement) – Supports waiting 7-10 days to initiate pulpectomy/CaOH2

Trope/Yesilsoy 1992 – No difference in inflammatory & replacement resorption between 1 week and 8 weeks CaOH2 when RCT initiated at day 14

Dumsha 1995 – No difference in inflammatory resorption between avulsed teeth obturated with gutta-percha or long term CaOH2 (5 months). Perform RCT at 14-28 days and obturate with gutta-percha.

How would you manage an avulsed tooth clinically? Continued

Avulsion: CLOSED APEX, > 1 hour extra-oral dry time



Rational: PDL is necrotic, prepare root to resist replacement resorption

  1. Remove tissue tags with wet gauze

  2. Soak in 2% NaF for 20 minutes

  3. Anesthesia, Irrigate socket, Replant, Verify position w/ PAs,

  4. Physiologic splint for 2 weeks, Antibiotics, Tetanus booster, Patient instructions (soft diet, CHX rinse)

  5. Initiate RCT 7-10 days (or before replantation)

  6. Place CaOH2 for up to 1 month

  7. Obturate canals when CaOH2 is removed


Kling/Cvek – Mature teeth (AF < 1mm) exhibited no revascularization

Coccia – 2% NaF delays replacement resorption, 2X survival time expected

Gregorio/Jeansonne Delay Pulp/CaOH2 for 7-10 days following replant to  replacement resorption (damages PDL/prevents healing) – Andreasen; Lindskog

Trope/Yesilsoy: 1 wk = 8 wk CaOH2 for inflamm/replacement resorption

What are some factors that affect healing of avulsed teeth?

  1. Andreasen 1966

    1. PDL showed 4 types of healing:

      1. Normal

      2. Replacement resorption (Dentoalveolar ankylosis)

      3. Surface (transient) resorption

      4. Inflammatory resorption

    2. 90 % of teeth replanted w/in 30 min = no resorption

    3. Majority of teeth replanted after 90 min = resorption




  1. Lindskog/Hammarstrom 1985 EDT –Avulsion, if PDL damage, removal of the PDL with NaOCl to reduce resorption. Destruction of >20% of the root surface is required for replacement resorption to occur




  1. Oswald/VanHassel 1980 – monkey study, all 90 minute dried teeth showed ankylosis and replacement resorption. All saliva-stored teeth retained normal mobility, healing PDL space and no resorption.

What are some factors that affect healing of avulsed teeth?
Andreasen/Borum 1995Factors related to Pulpal and PDL healing:

  1. Pulpal Healing (Revascularization)

    1. Pulp length:  pulp length,  revascularization

    2. Wet extra-oral period: <5 min,  revascularization

    3. Dry extra-oral period:  dry time,  revascularization

  2. PDL Healing: Stage of root development, Dry time =  Replace. Resorp.

  3. Diagnosis of Resorption:

    1. External inflammatory: < 6 months (radiograph)

    2. Replacement: 1-2 months (clinical), < 12 months (radiograph)


Soder 1977 – Effect of drying on the viability of PDLF cells, >60 mins dry time = no viable PDLF cells
Andreasen 1981 – Effect of extra-alveolar dry time: 30 mins – inflammatory resorption, 60 mins – replacement resorption. Wet after dry does NOT help.

Discuss Root Resorption in Avulsion Cases


  1. External Inflammatory Root Resorption (Andreasen, Trope)

    1. Surface/Transient

    2. Progressive

  2. Replacement Resorption/Ankylosis (Lindskog, Andreasen)

    1. Initial Inflammatory Root Resorption (may or may not)

    2. Replacement with Osseous tissue (Osteoblasts faster than cementoblasts) – Transient or Progressive

  • Lindskog/Hammarstrom 1985 EDT –Destruction >20% of root surface = progressive ankylosis/replacement resorption

  • Andersson 1989 - >60 min extraoral dry time, rate of replacement resorption was age related: Young patients – 3-7 yrs, Older patients – much slower

  • Andreasen 1995 – Diagnosis: External Inflammatory: <6 months (radiographically), Replacement: 1-2 months (clinically), <12 months (radiographically), Surface: <12 months

Discuss Root Resorption in Trauma Cases
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