SIMPLE REPLANTATION PROTOCOL TO AVOID ANKYLOSIS IN TEETH INTENDED FOR ORTHODONTIC TREATMENT : A REVIEW

1. YuliNugraeni David BuntoroKamadjaja HaryonoUtomo SIMPLE REPLANTATION PROTOCOL TO AVOID ANKYLOSIS IN TEETH INTENDED FOR ORTHODONTIC TREATMENT : A REVIEW

2. 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 Introduction

3. 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

4. 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

5. 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

6. 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 ↗ Treatment of Avulsion

7. 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 Antiresorptive-regenarative therapy (ART)

8. 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

9. 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 + Accelarateankylosis (RR) in matture teeth Endodontic treatment of Avulsed teeth

10. 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

11. Ladermix : healing ↗ resorption ↘ Ca (OH)2 + ChKM : healing process of PDL ↗ if application delayed ± 7 days after replatation Intracanal medicament

12. 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 DISCUSSION:

13. 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 → standarttx protocol at emergencies visit

14. EMD is the promising result replantation↗↗ • The alternatives medicament : doxycycline, minicycline, alendronate, atauLadermix • 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)

15. direct extirpation without endotx • 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

16. 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

17. 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

18. The main principle to prevent ankylosis: reducing the inflamation of the PDL. Inflamation leads to altered function of PDL →mineralized tissue forming cells → ankylosis