Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal healing

Resident: Adam J. Bottrill
Date: 04SEP09
Region: Providence

Article title: Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal healing.
Author(s): Andreasen JO, et al.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 76-89
Year: 1995
Major topic: Permanent incisor replantation
Minor topic(s): Periodontal ligament healing
Type of Article: Causal comparison

Main Purpose: Analyze the analyze factors related to the avulsion injury, extra-alveolar storage or subsequent treatment which contributed to periodontal ligament healing.

Overview of method of research: Prospective case comparison
Findings: Not telling.

Key points in the article discussion:

A. Past Studies: There have been many studies on PDL healing after replantation of avulsed teeth. The results of these studies suggest that the frequency of adequate PDL healing centers somewhere around 25% (but varies from 11% to 50%). No study has established definite relationships to extra-alveolar conditions or treatment factors. Typically, this is due to limited “n”.
1. There have been very conflicting results with studies concerning the effectiveness of saline storage after avulsion. This study will therefore, NOT examine the resorption-reducing effects of saline storage.
2. Often, retrospective studies reveal inaccurate charting. A PROSPECTIVE study is needed.

B. Clinical Materials and Methods:
1. 400 avulsed and subsequently replanted permanent incisors.
2. Clinical and radiographic evaluations.of the replanted
3. 5 categories of healing:
a. normal healing
b. surface resorption
c. inflammatory resorption
d. ankylosis
e. combination of the others
4. Many teeth eliminated from statistical analysis and presented independently.
a. extreme non-physiologic storage methods
b. double fractures (one tooth eliminated)
c. 272 teeth remained
5. First, analyzed for “significant” factors, then regression analysis using these variables to determine the interrelationship between the variables and “final risk.”

C. Results
1. PDL healing found in 26% (96 teeth) of the 400 and 25% (69 teeth) of the 272.
2. Chronology
a. surface resorption: 18 (4.5%) of the 400. Usually Dx no later than 12 mo.
b. inflammatory resorption: 120 (30%) of the 400. Usually Dx within first 6 mo. Sometimes secondary to ankylosis.
c. replacement resorption (anjylosis): 243 (61%) of the 400. Usually Dx by clinical findings at around 1-2 mo. Radiographically, only 212 ankylosed teeth observed and almost always AFTER clinical finding.
d. studies of short duration may be biased in that they would not catch resorption occurring after the study is complete.
3. PDL healing factors:
a. sex: NSF
b. tooth loc: NSF
c. crown fracture: NSF
d. age: PDL healing SIG less frequent in older people (>16)
e. root dev: PDL SIG less frequent with more advanced root development. Possibly due to thinning of the PDL as the tooth develops.
f. immediate replantation: MOST SIG increase of PDL healing in those that are immediately replanted (73% healing). Actually may just be a reflection of the ABSENCE of damage due to different types of unsatisfactory storage methods. Also, the value of rinsing avulsed teeth prior to replantation is still “unsettled.”
g. dry extra-alveolar storage: increasing dry storage time diminishes likelihood of PDL healing. “General time limit of 75 minutes”. Appears to be due to necrosis of PDL cells. After 90 minutes, only 10% of root surface covered by vital cells.
h. wet extra-alveolar storage: (saline or saliva) only extra-alveolar wet storage periods exceeding 20 minutes were accompanied by decreased PDL healing.
i. dry/wet storage: comb of dry AND wet storage resulted in SIG lower healing rate among teeth stored >20minutes.
j. dry/wet storage interaction: in teeth with dry storage <9>6 weeks showed increased resorption tendancy.
o. antibiotics: NSF
p. erupting teeth: increased potential for resorption
q. gingival healing: NSF
4. Using multivariate analysis, only 4 factors were found to be significantly related to PDL healing:
a. IMMEDIATE REPLANTATION (3)
b. DRY STORAGE PERIOD (2)
c. WET STORAGE PERIOD (4)
d. STAGE OF ROOT DEVELOPMENT (1)
5. Actual variation of probability of PDL healing is…. GET THIS!... 3% to 97% depending on the combination of factors!

D. Discussion
1. The fact that only 25% of teeth showed PDL healing (which matches the rate in previous studies) reflects the fact that the MAJORITY of teeth are handled incorrectly. This is shenanigans (i.e…. a bad thing).
2. IMMEDIATE reimplantation leads to approx 85-97% healing.
3. “In cases where immediate reimplantation cannot be carried out, the present study indicates no preference for storage in the oral cavity or in saline.”

Assessment of article: This article doesn’t mention Hank’s and only mentions the use of milk once. I don’t know when these methods were discovered, but I’m guessing this article was written prior to their discovery?