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?

The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.

Resident: Adam J. Bottrill
Date: 21AUG09
Region: Providence

Article title: The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.

Author(s): Holan, Gideon DMD et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 24:1 pp: 38-42
Year: 2002
Major topic: Diagnostic radiographs for intruded maxillary primary incisors.
Minor topic(s): None
Type of Article: Comparative diagnostic study.

Main Purpose: Assess the contribution of a lateral extraoral radiograph for diagnosing the relation between the root of intruded maxillary primary incisors and their permanent successors.
Overview of method of research: Quantitative, clinically diagnostic study.
Findings: N/A

Key points in the article discussion: Intrusive luxation has been found by some authors to be the most common type of injury to the primary incisor region. The proximity of the primary incisor to the labial surface of the permanent successor increases the risk of damage to the developing bud from trauma. It is therefore very important to determine the relation between the root of the intruded primary root and the permanent successor.

A. Methods
1. Study group: all children with intruded primary incisors who presented to XC clinic of the Dept of Ped Dent at the Hadassah School of Dental Medicine in Jerusalem, Israel.
a. 18 mo period.
b. 37 children with 55 intruded primary incisors.
c. age: 8 to 63 mo.
d. 56% were partially intruded and 44% completely disappeared in to tissue.
e. 29 pts (w/ 44 teeth) checked within 2 days
f. 60% w/ only 1 intruded tooth. Rest had 2 or more.
g. 93 total 3-step evaluations were available.
2. Teeth intruded more than 7 days are not included in the study.
3. Three steps for root relationship assessment.
a. Clinical exam: Inspection of tooth, and soft/hard tissue surrounding the intruded tooth.
b. PA evaluation: (and sometimes repeating step 1)
c. Lateral extraoral radiograph evaluation:
4. Clinical signs include:
a. hematoma presence
b. projection of labial bone plate
c. relative elongating or shortening of teeth.
d. “unable to assess”
5. Assessments are made independently
6. LATERAL RADIOGRAPH WAS CONSIDERED “CONTRIBUTORY” IF A FINAL DECISION COULD NOT BE MADE WITHOUT STEP 3, OR IF IT DIFFERED FROM THAT MADE FOLLOWING THE 1ST AND 2ND STEPS.
7. Ability to assess the tooth alignment following steps 2 and 3 was statistically analyzed using the McNemar test.

B. Results
1. Assessment was possible in 86% of step 1; 62% of step 2; 42% of step 3. All others were “unable to assess.”
2. In only 5 (5%) of evaluations was step #3 found “contributory.”
3. DIFFERENCE IN EVAUATORS ABILITY TO ASSESS POSITION AFTER STEP 3 VS AFTER STEP 2 WAS NOT STATISTICALLY SIGNIFICANT.
4. Separate evaluations made for:
a. Intrusion of single vs multiple teeth, central vs lateral, partially vs completely intruded, less than vs more than 20mo.,
b. no statistically significant differences in any of these parameters existed.
5. When useful, lateral radiographs were MORE useful when assessing single-tooth intrusions and central intrusions.
6. Also, lateral radiographs were more useful in pt’s under 20 mo.
a. this may be due to the overall difficulty in assessing the position as well as the low radiodensity of permanent succesors.
7. In the case of any evaluator disagreement, 5 of the 6 disagreements occurred in step 3.

Summary of conclusions: In the case of intrusion of maxillary primary incisors, the contribution of the lateral extraoral radiograph in determining the alignment of the root of intruded teeth is LOW.

A. Possible explanations:
1. Overlap, errors in aligning the cone correctly.
2. When evaluating the lateral radiograph alone, one can only clearly Dx when the root of the intruded tooth has been significantly displaced labially. OTHERWISE NO CONCLUSION CAN BE MADE.
3. Should still attempt to Dx based on PA radiograph and not clinical exam alone.
a. gap between intruded tooth and permanent successor.
b. shortened, more opaque image of intruded incisor
c. lack of rotation of the permanent successor

B. Finally:
1. Lateral extraoral radiographs should not be used routinely in cases of intrusion of primary incisors. Lateral radiographs should only be taken when it’s expected contribution can be confirmed by other methods.

Assessment of article: Applicable and well organized. This topic has the potential to be controversial as it seems we have all been instructed at some point in our education to use these lateral radiographs as a diagnostic tool.