Yuli Nugraeni David Buntoro Kamadjaja Haryono Utomo
Feb 25, 2016
Yuli NugraeniDavid Buntoro KamadjajaHaryono Utomo
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
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
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
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 ↗
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
Endo treatment → essential for the progress of healing of the replanted tooth
Controversies : in closed apex tooth (<1mm) →EO/IOThe best result : endodontically treated → inserted
to socket + pulp extirpation directly → prevent IRRThe 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
Ladermix : healing ↗ resorption ↘ Ca (OH)2 + ChKM : healing process of
PDL ↗ if application delayed ± 7 days after replatation
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
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)
direct extirpation without endo txART + intracanal medicamentSemi rigid splinting for 2-3 weeksEndo txThe successful result : significantly higher in open apex teethOur 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