Avulsion/replantation case




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From: mohammed elseed
To: ROOTS
Sent: Thursday, August 31, 2006 11:33 AM
Subject: [roots] Advice on avulsion/replantation case

I am PG2 Endo resident at NSU (The class behind Sashi)

I have learned a lot from this great forum since I joined a few months ago, but this is the first time I am actually posting
a case and I really would like to receive everyone's input on how they think it could best be managed.

13 y/o patient was referred by GP for Endo consult on tooth # 9 last week Patient had a traumatic injury 1 year ago (July 2005)
# 9 was avulsed. Patient stated she was rushed to the ER and the tooth was replanted within 45 minutes. When I asked if she was
sure it was less than 1 hour she said yes. She also said that immediately after its avulsion the tooth was cleaned and kept in
milk until it was replanted in the ER and splinted to adjacent teeth with composite retained arch wire. Unfortunately the patient
did not have the splint removed until I saw her last week for the endo consult (That is a 13 months duration) Patient was
asymptomatic and only came to see me because of her GP referral.

On clinical exam:

# 9 was not discolored, not in infra-ocllussion and had a normal percussion sound. Pulp testing inconclusive.
Radiographic exam:
#9 showed clearly replacement resorption on the distal/apical portions of the root while normal PDL could be seen on the mesial
aspect of the root. (see RG)

Upon consultation with the faculty it was decided to go ahead extirpate the pulp and place in USP CaOH intracanal medicament.
As I accesed the tooth there was prominent bleeding from the pulp chamber(see photo) and definite pulp horns.
I assume that this was coming from the granulation tissue around the resorptive defect, since the chance of that tooth still
being vital is 0%. (May be I should have done a biopsy)

Following pulp extirpation and arresting the bleeding, I packed in CaOH + Cotton & IRM. I also removed the splint.

My question is what would be the recommended course of action:

Would you go with long-term CaOH and how often would you change it?
OR
Would you remove the CaOH and pack MTA into the defect (with or without a barrier)?

I explained to the patient and her mother that the prognosis is rather poor and there is no treatment for replacement
resorption once it started and we would do our best to retain the tooth as long as possible before the root is totally
resorbed.  My question to you Rooters is: What would be the best course of action to keep that tooth in the mouth for the
longest possible duration?

Any advice would be appreciated - Mohammed Elseed, PG2 Endo NSU

Mohammed,

Obviously this patient is too young for an implant.  A flipper will cause damage to the adjacent teeth and gingiva.  A fixed bridge
will damage #8 & 10.  If you can preserve #9 you will also preserve the ridge and keep the patient's options open for a later date.
A case like this, which is essentially hopeless, is an opportunity to think out of the box and try something that is based on sound
biology but outside the normal treatment options.  I think the lesion is too large to expect treatment with Ca(OH)2 to be effective.

If you are willing to think out of the box and can get your instructors approval you may be able to save the tooth.  You may be
able to stop the resorption and still have a tooth that is worth saving but it will require surgery.  Martin Trope has said that the
way to stop resorption in these cases is to surgically expose the site and grind out the resorption until you get down to good dentin
without any resorptive lacunae.  With a lesion this large that means you would have to grind away distal half of the apical 2/3 of
the root.  I would recommend keeping as much of the mesial half as possible to preserve a favorable crown:root ratio.  After you have
eliminated the resorptive defect, treat the remaining surface with EDTA or citric acid to remove the smear layer and allow rapid growth
of the cementum over the exposed collagen fibers of the treated dentin**.  This may allow reformation of the PDL if it works.  An intact
PDL is necessary to prevent further resorption.  The canal is filled at midroot with MTA.  I have a couple of cases of split roots
that were handled this way that I have attached for you to review and discuss with your instructors.  It may be too far out of the box
for them to consider.  If it doesn't work then the tooth will have to be extracted anyway so why not give this option a chance?
Let me know if you have any questions.  Both of these cases were submitted in my case portfolio to the ABE.

Randy Hedrick
Diplomate ABE

** Craig KR, Harrison JW. Radicular and periradicular wound healing following demineralization of resected root ends.
J Endod. 1991;17:197.



Randy, this is some serious out of the box thinking. Very, very nice. - Ahmad

Interesting.  I am not totally convinced that we are dealing with osseous replacement here.  But canal disinfection is a must regardless.
Routinely, I would use Ca(OH)2 here and evaluate for repair.

As long as we are outside the box....

Box 1: I would perhaps consider disinfecting the canal with TriMix and evaluating bone healing.  If healing occurs, MTA can be used
as a barrier, or try revascularization.

Box 2: Emdogain, although not predictable, has been used for extraction/replantation of ankylosed teeth Filipi.... Fred

Dent Traumatol. 2001 Jun;17(3):134-8.   Links
Treatment of replacement resorption with Emdogain--preliminary results after 10 months
Filippi A,
Pohl Y,
von Arx T.
Department of Oral Surgery, School of Dental Medicine, University of Berne, Switzerland. andreas.filippi@zmk.unibe.ch

Ankylosis of traumatized teeth in children and adolescents may inhibit further development and growth of the corresponding jawbone.
Therefore, ankylosed teeth should be removed. As an alternative treatment option to autotransplantation of a premolar, intentional
replantation using Emdogain may be considered, provided the ankylosis is detected at an early stage or has only affected a small area
of the root. Eleven ankylosed teeth presenting with replacement resorption were treated as follows: after tooth extraction, the root canal
was treated extraorally and obturated by retrograde insertion of a titanium post. Emdogain was applied to the root surface and into the
extraction socket with subsequent replantation of the tooth. During a mean follow-up period of 6.3 months, no signs of recurrence of
ankylosis were noted. The horizontally and vertically measured Periotest scores were identical to those obtained on the adjacent teeth.
These results suggest that intentional replantation using Emdogain may prevent or delay ankylosis of these replanted teeth.

Fred

Fred, I agree that it doesn't look like replacement resorption/ankylosis.  I think the correct terminology is external invasive resorption
(which doesn't have an ankylosis concern) or possibly inflammatory resorption.  IMHO, the CH currently in the canal will disinfect the
coronal half of the tooth but I suspect that it will have little effect on the apical half of the tooth because there is so much vascularity
in the resorptive lesion, the circulatory effects will carry away any hydroxyl ions or calcium ions that are released from the CH.  Especially
in a lesion this large.  Challenging case indeed - Randy


What's up mohammed?

Good to see you posting.

I had a similiar case 6 years ago.  16 year old kid had 24 and 25 avulsed.  they stayed out of his mouth dry for 24 hours.
dentist put them back and splinted them but never addressed the endodontic problem.  he saw me a few months later.  the teeth exhibited
class II mobility and there was of course resorption present all about the roots.

I relayed to his mother that the prognosis was poor.  she wanted to give treatment a try anyway.  i opened the teeth, cleaned and shaped
them and placed calcium hydroxide.  i used flax's theory and changed the calcium hydroxide every three months until it remained in the
canal (radiographically) at the next appointment.  this tooth 21 months.  at that time i filled the entire canal with MTA and a day later
placed composite.  treatment was completed in 2002.  I did his recall just last week and although they are not things of beauty
radiographically, i'm happy to report that they are still in the mouth, non-mobile and functioning.

Unfortunately the preoperative film are hard film.  i used this case as one of my board cases.  i'll send them down to nova for you to take
a look at if you want.

Here's the mid treatment pics

1.  with calcium hydroxide in place -  2001
2.  obturation post op - january 2002
3.  recall radiograph - 8/24/06

I won't draw any conclusions except that they're still there - Dr Barden





Flax was taught properly  ;-))) - Fred