available at www.jstage.jst.go.jp/browse/islsm
CASE REPORT
LASER ASSISTED TOOTH REPLANTATION CASE REPORT Cheng Hsiang Lu 1, Hung Chieh Lu 1, Jyuhn H. KE 2 and Wan Hong Lan 3
1: Lu’s Dental Clinic, Taipei, Taiwan 2: Anhui Medical University, Hefei, China 3: National Taiwan University, Taipei, Taiwan
Background and aim: Although intentional replantation for extraoral treatment is a solution for complicated endodontic cases, it is accompanied with risk of root resorption which is most likely due to extraction trauma and infected remnants. Laser therapies have long been proved for bactericidal and biostimulation effects. In the present case, a pulpitis combined severe periodontal destruction molar was extracted with an Er:YAG laser for thorough degranulation and disinfection. Before the extraction and right after the treatment, low level laser therapy (LLLT) with 810nm diode was applied for biostimulation. Result: Patient reported no post operative pain after laser treatment. Clinical follow-up showed uneventful healing, and excellent bone regeneration. Conclusion: The Er:YAG laser coupled with low level laser therapy (810 nm diode) has shown to assist and improve intentional replantation in disinfection procedure, and it may preserve more vital cells and enhance bioregeneration for less operative pain and better healing. Key words: laser therapy, intentional replantation, complicated endodontic case, disinfection, LLLT, biostimulation
INTRODUCTION: Extraction and extraoral endodontic treatment followed by tooth replantation had been developed as an alternative treatment for complicated or failure endodontic therapy. Conventional endodontic therapy was reported with success rates from 61% to 93% for molars; 1) while surgical endodontic therapy with success rate from 71% to 90%. 2) However, in both conventional and surgical endodontic treatments, problems in obtaining operation access due to associated structures such as maxillary sinus, restricted mouth opening or combination of endodontic and periodontic problems, could contraindicate the conventional and surgical endodontic treatments. In these cases, extraction and extraoral treatment under direct vision can be the procedure of choice. Addressee for Correspondence: Hung Chieh Lu, DDS Lu’s Dental Clinic, 155 Cung Cheng Road Hsindien, Taipei, Taiwan Tel: +886-2-2911-9952 / FAX: +886-2-2911-9952 E-mail: [email protected] ©2011 JMLL, Tokyo, Japan
Although, this procedure can be an alternative way, the technique may come with risk of root resorption. 3) This is most likely due to the extraction trauma and infected remnants. 4) The disinfection procedure is often compromised because of the complicated structure of root canal and dentinal tubules. Introducing of laser therapies offer the power of transmission disinfection 5) and biostimulation, 6-8) which in turn accelerate tissue regeneration and avoid risk of root resorption. This is especially beneficial for vitality and regeneration ability of PDL cell on the root surface and in the extraction socket, in the same case, chemical disinfectant like sodium hypochloride may prohibit even from killing cells.
CASE REPORT: A fifty-year-old male patient came for his aching tooth number 46 with no known medical condition, nor Manuscript received: August 15th, 2011 Accepted for publication: October 28th, 2011 J-STAGE advance published: November 2nd, 2011
Laser Therapy 20.4: 273-277
273
CASE REPORT
available at www.jstage.jst.go.jp/browse/islsm
smoking habit. There were three fistulas in the buccal side. The tooth was painful upon biting and had grade II mobility. (Fig.1) Periapical radiographic examination showed alveolar bone destruction all around the roots (Fig.2). According to the patient, his lower right first molar was painful for a couple of days; however he was too busy to visit the dentist until the pain eventually went down. Treatment plan was discussed with patient and decided to treat pulp and periodontal tissue with laser at the
same time. That way, the bacteria was attempted to be removed completely and minimized the chance of recurrent. Before the procedure, Amoxicillin 500 mg was given, and local tissue was stimulate with diode laser 810 nm, 50 mW for 3 minutes. Then the tooth was extracted carefully avoid extraction trauma for better regeneration. In order to minimize the time, when the tooth is out of the body during that the PDL cells is out of blood supply and increase the chance of infection,
Fig.1: Pain upon biting on tooth #46, note the swelling gum and three fistulas
Fig.2: Periapical film showed radiolucency around all the root surface
Fig.3: Curettage and laser disinfection with Er:YAG laser 100 mJ 30 Hz
Fig.4: Degranulation and disinfection with Er:YAG laser 100 mJ 30 Hz
a
b
Fig.5a,b: Root canal shaping and disinfection with Er:YAG laser 100 mL 30 Hz 274
Lu, CH ET AL.
available at www.jstage.jst.go.jp/browse/islsm
Fig.6: Root canal obturation
CASE REPORT
Fig.7: The occlusion was relief and tooth was replanted carefully
Fig.8: Radiographic examination right after tooth replant
Fig.9a: before treatment
Fig.9b: 3 months after, note the healing of periapical lesion
Fig.10a: tooth preparation
Fig10b: crown delivery
LASER ASSISTED TOOTH REPLANTATION
275
CASE REPORT degranulation and disinfection of the extraction socket with laser were operated simultaneously with the operation of tooth. (Fig.3) Granulation tissue on the root surface was removed with Er:YAG laser 100 mJ 30 Hz and laser disinfection was applied after all the granulation tissue was cleaned out. (Fig.4) While the tooth under root canal enlargement and Er:YAG laser disinfection (Fig.5a,b), the extraction socket was covered with wet gauze to prevent further contamination by saliva. After canal obturation with gutta-percha or Vitapex, the tooth was then replanted into socket. (Fig.6, Fig.7 and Fig.8) Right after the replantation, low level diode 810 nm laser was applied again to the periodontal tissue for three minutes. Diode 810 nm laser; 150 mW for 6 minutes irradiation from the cheek was applied two times a week whenever patient came back for follow up. Patient reported no post operative pain after treatment. Clinical follow up showed uneventful healing, and excellent bone regeneration. Three months after tooth replantation, the tooth was firm and healthy, patient was appointed for tooth preparation and impression taking. (Fig.9a,b, Fig.10a,b) After crown installation the patient was able to eat and chew normally.
available at www.jstage.jst.go.jp/browse/islsm
tooth can be extracted without risk of fracture, teeth with divergent roots, extensive restoration, badly caries, or post in the root canal are not indicated for tooth replantation. The biological effects of low level laser therapy (LLLT) have been observed and proven by many researches. Enhancing microcirculatory and lymphatic systems and the healing process of the wound was shown effective results in the experiment of Lievens. 10, 11) In the present case, an 810 nm diode laser was applied, with wavelengths between 780 and 830 nm to reach a better tissue penetration and to improve bone repair. 12) Laser irradiation before operation helps activate microcirculatory systems which in turns bring more nutrition and immune cells; on the other hands, irradiation after operation helps accelerate wound healing and reduce post operative pain by preventing pulse action potential in nerves. 13) The tooth is usually firm in the socket after 2-3 weeks of application with low level laser therapy at 50 mW ~ 100 mW, 3 minutes every other day. It was also noticed that the younger age group (10-30 years old) was found more significantly with inflammatory root resorption and periapical inflammation than in the older age group, possibly because of wider root canals and dentinal tubules which may result in bacteria and toxins passing through. 14)
DISCUSSION: CONCLUSION: The success rate of tooth replant was found at 39% to 62%, 9) comparing with that of conventional endodontic treatment from 61% to 93%, and surgical endodontic treatment from 71% to 90%, the primary treatment of choice should always be conservative endodontics. Before the decision is made for intentional replantation, it is necessary to determine whether the tooth can be extracted atraumatically and whether a sufficient root canal obturation can be achieved. Adequate radiographic survey should be made in order to see if the
With the use of Er:YAG laser, degranulation and disinfection are able to be carried out at the same time, coupled with low level diode 810nm laser, the PDL cell on the root surface and periodontal tissue may receive the benefit of biostimulation and shorten the time of regeneration. Laser assisted tooth replantation offers a better surgical field control, decreases post operation pain, and reduces time of healing.
REFERENCE: 1: Selden HS. Pulpoperiapical disease: Diagnosis and healing. Oral Surg Oral Med Oral Pathol 1974; 37: 271-83. 2: Tolmeijer JA. Apicoectomy on molars. Ned Tijdschr Tandheelkd 1972; 79: 137-42. 3: Andreasen JO. Rud J. Modes of healing histologically after endodontic surgery in 70 cases. Int J Oral Surg 1972; 1: 148-60 4: Andreasen JO. Treatment of fractured and avulsed teeth. J Dent Child 1971; 38: 29-48
276
5: Moritz A, Schoop U, Jiru E, Goharkhay K, Wernisch J, Sperr W: Morphological Changes of E. coli and E, faecalis after Er:YAG and Nd:YAG Laser Irradiation through Different Layers of Dentin. Abstract. 2nd Congress of the European Society for Oral Laser Application, Florence 2003 6: Al-Watban FA, Zhang XY, Andres BL: Low-level laser therapy enhances wound healing in diabetic rats: a comparison of different lasers, Photomed Laser surg 25(2): 72-77, 2007
Lu, CH ET AL.
available at www.jstage.jst.go.jp/browse/islsm
7: Hopkins JT, McLoda TA, Seegmiller JG, Baxter GD: Low-level laser therapy facilitates superficial wound healing in humans: a triple-blind, shamcontrolled study, J Athlet Train 39(3):223-229,2004 8: Silveira PCL, Streck EL, Pinho RA: Evaluation of mitochondrial respiratory chain activity in wound healing by low-level laser therapy, J Photochem Photobiol B Biol 86(3): 279-282,2007 9: Grossman LI. Intentional replantation of teeth. In: Robinson PJ, Guernsey LH, eds. Clinical transplantation in dental specialities. St Louis, Mosby, 1980: 65-76 10: Lievens P. Influence of laser irradiation on the motricity of lymphatic system and on the wound healing process laser. Proceedings International Congress Laser. Med Sur., 1989, p. 171-4. Bologna: Gallelly-Monduzzi. 11: Lievens P. The effect of IR laser irradiation on the vasomotricity of the lymphatic system. Laser Med Scien., 1991,6:189-91. 12: Walsh LJ. The current status of low-level laser therapy in dentistry. Part 2. Hard tissue applications.
LASER ASSISTED TOOTH REPLANTATION
CASE REPORT AustDent J, St Leonards, v.42, n.5, p.302-6, Oct.1997 13: Mezawa S, Iwata K, Naito K. The possible analgesic effect of soft-laser irradiation on heat nociceptors in the cat tongue. Arch Oral Bio 1988; 33:693-4 14: Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological study. Acta Odontol Scand 1966; 24: 327-46 15: Hartwell G, Bellizzi R. Clinical investigation of in vivo endodontically treated mandibular and maxillary molars. J Endod 1982;8:555-57 16: Jens O.: Andreasen Atlas of replantation and transplantation of teeth; 1992 Mediglobe SA, Switzerland: 100-108 17: Nagaoka S, Miyazaki Y, Liu H J, Iwamoto Y, Kitano M, Kawagoe M: Bacterial invasion into dentinal tubules of human vital and nonvital teeth. J Endod 21(2): 70-73, 1995 18: A. Moritz: Oral laser application; 2006 Quintessenz Verlags-GmbH, Berlin: 241-309
277
CASE REPORT
LASER ASSISTED TOOTH REPLANTATION CASE REPORT Cheng Hsiang Lu 1, Hung Chieh Lu 1, Jyuhn H. KE 2 and Wan Hong Lan 3
1: Lu’s Dental Clinic, Taipei, Taiwan 2: Anhui Medical University, Hefei, China 3: National Taiwan University, Taipei, Taiwan
Background and aim: Although intentional replantation for extraoral treatment is a solution for complicated endodontic cases, it is accompanied with risk of root resorption which is most likely due to extraction trauma and infected remnants. Laser therapies have long been proved for bactericidal and biostimulation effects. In the present case, a pulpitis combined severe periodontal destruction molar was extracted with an Er:YAG laser for thorough degranulation and disinfection. Before the extraction and right after the treatment, low level laser therapy (LLLT) with 810nm diode was applied for biostimulation. Result: Patient reported no post operative pain after laser treatment. Clinical follow-up showed uneventful healing, and excellent bone regeneration. Conclusion: The Er:YAG laser coupled with low level laser therapy (810 nm diode) has shown to assist and improve intentional replantation in disinfection procedure, and it may preserve more vital cells and enhance bioregeneration for less operative pain and better healing. Key words: laser therapy, intentional replantation, complicated endodontic case, disinfection, LLLT, biostimulation
INTRODUCTION: Extraction and extraoral endodontic treatment followed by tooth replantation had been developed as an alternative treatment for complicated or failure endodontic therapy. Conventional endodontic therapy was reported with success rates from 61% to 93% for molars; 1) while surgical endodontic therapy with success rate from 71% to 90%. 2) However, in both conventional and surgical endodontic treatments, problems in obtaining operation access due to associated structures such as maxillary sinus, restricted mouth opening or combination of endodontic and periodontic problems, could contraindicate the conventional and surgical endodontic treatments. In these cases, extraction and extraoral treatment under direct vision can be the procedure of choice. Addressee for Correspondence: Hung Chieh Lu, DDS Lu’s Dental Clinic, 155 Cung Cheng Road Hsindien, Taipei, Taiwan Tel: +886-2-2911-9952 / FAX: +886-2-2911-9952 E-mail: [email protected] ©2011 JMLL, Tokyo, Japan
Although, this procedure can be an alternative way, the technique may come with risk of root resorption. 3) This is most likely due to the extraction trauma and infected remnants. 4) The disinfection procedure is often compromised because of the complicated structure of root canal and dentinal tubules. Introducing of laser therapies offer the power of transmission disinfection 5) and biostimulation, 6-8) which in turn accelerate tissue regeneration and avoid risk of root resorption. This is especially beneficial for vitality and regeneration ability of PDL cell on the root surface and in the extraction socket, in the same case, chemical disinfectant like sodium hypochloride may prohibit even from killing cells.
CASE REPORT: A fifty-year-old male patient came for his aching tooth number 46 with no known medical condition, nor Manuscript received: August 15th, 2011 Accepted for publication: October 28th, 2011 J-STAGE advance published: November 2nd, 2011
Laser Therapy 20.4: 273-277
273
CASE REPORT
available at www.jstage.jst.go.jp/browse/islsm
smoking habit. There were three fistulas in the buccal side. The tooth was painful upon biting and had grade II mobility. (Fig.1) Periapical radiographic examination showed alveolar bone destruction all around the roots (Fig.2). According to the patient, his lower right first molar was painful for a couple of days; however he was too busy to visit the dentist until the pain eventually went down. Treatment plan was discussed with patient and decided to treat pulp and periodontal tissue with laser at the
same time. That way, the bacteria was attempted to be removed completely and minimized the chance of recurrent. Before the procedure, Amoxicillin 500 mg was given, and local tissue was stimulate with diode laser 810 nm, 50 mW for 3 minutes. Then the tooth was extracted carefully avoid extraction trauma for better regeneration. In order to minimize the time, when the tooth is out of the body during that the PDL cells is out of blood supply and increase the chance of infection,
Fig.1: Pain upon biting on tooth #46, note the swelling gum and three fistulas
Fig.2: Periapical film showed radiolucency around all the root surface
Fig.3: Curettage and laser disinfection with Er:YAG laser 100 mJ 30 Hz
Fig.4: Degranulation and disinfection with Er:YAG laser 100 mJ 30 Hz
a
b
Fig.5a,b: Root canal shaping and disinfection with Er:YAG laser 100 mL 30 Hz 274
Lu, CH ET AL.
available at www.jstage.jst.go.jp/browse/islsm
Fig.6: Root canal obturation
CASE REPORT
Fig.7: The occlusion was relief and tooth was replanted carefully
Fig.8: Radiographic examination right after tooth replant
Fig.9a: before treatment
Fig.9b: 3 months after, note the healing of periapical lesion
Fig.10a: tooth preparation
Fig10b: crown delivery
LASER ASSISTED TOOTH REPLANTATION
275
CASE REPORT degranulation and disinfection of the extraction socket with laser were operated simultaneously with the operation of tooth. (Fig.3) Granulation tissue on the root surface was removed with Er:YAG laser 100 mJ 30 Hz and laser disinfection was applied after all the granulation tissue was cleaned out. (Fig.4) While the tooth under root canal enlargement and Er:YAG laser disinfection (Fig.5a,b), the extraction socket was covered with wet gauze to prevent further contamination by saliva. After canal obturation with gutta-percha or Vitapex, the tooth was then replanted into socket. (Fig.6, Fig.7 and Fig.8) Right after the replantation, low level diode 810 nm laser was applied again to the periodontal tissue for three minutes. Diode 810 nm laser; 150 mW for 6 minutes irradiation from the cheek was applied two times a week whenever patient came back for follow up. Patient reported no post operative pain after treatment. Clinical follow up showed uneventful healing, and excellent bone regeneration. Three months after tooth replantation, the tooth was firm and healthy, patient was appointed for tooth preparation and impression taking. (Fig.9a,b, Fig.10a,b) After crown installation the patient was able to eat and chew normally.
available at www.jstage.jst.go.jp/browse/islsm
tooth can be extracted without risk of fracture, teeth with divergent roots, extensive restoration, badly caries, or post in the root canal are not indicated for tooth replantation. The biological effects of low level laser therapy (LLLT) have been observed and proven by many researches. Enhancing microcirculatory and lymphatic systems and the healing process of the wound was shown effective results in the experiment of Lievens. 10, 11) In the present case, an 810 nm diode laser was applied, with wavelengths between 780 and 830 nm to reach a better tissue penetration and to improve bone repair. 12) Laser irradiation before operation helps activate microcirculatory systems which in turns bring more nutrition and immune cells; on the other hands, irradiation after operation helps accelerate wound healing and reduce post operative pain by preventing pulse action potential in nerves. 13) The tooth is usually firm in the socket after 2-3 weeks of application with low level laser therapy at 50 mW ~ 100 mW, 3 minutes every other day. It was also noticed that the younger age group (10-30 years old) was found more significantly with inflammatory root resorption and periapical inflammation than in the older age group, possibly because of wider root canals and dentinal tubules which may result in bacteria and toxins passing through. 14)
DISCUSSION: CONCLUSION: The success rate of tooth replant was found at 39% to 62%, 9) comparing with that of conventional endodontic treatment from 61% to 93%, and surgical endodontic treatment from 71% to 90%, the primary treatment of choice should always be conservative endodontics. Before the decision is made for intentional replantation, it is necessary to determine whether the tooth can be extracted atraumatically and whether a sufficient root canal obturation can be achieved. Adequate radiographic survey should be made in order to see if the
With the use of Er:YAG laser, degranulation and disinfection are able to be carried out at the same time, coupled with low level diode 810nm laser, the PDL cell on the root surface and periodontal tissue may receive the benefit of biostimulation and shorten the time of regeneration. Laser assisted tooth replantation offers a better surgical field control, decreases post operation pain, and reduces time of healing.
REFERENCE: 1: Selden HS. Pulpoperiapical disease: Diagnosis and healing. Oral Surg Oral Med Oral Pathol 1974; 37: 271-83. 2: Tolmeijer JA. Apicoectomy on molars. Ned Tijdschr Tandheelkd 1972; 79: 137-42. 3: Andreasen JO. Rud J. Modes of healing histologically after endodontic surgery in 70 cases. Int J Oral Surg 1972; 1: 148-60 4: Andreasen JO. Treatment of fractured and avulsed teeth. J Dent Child 1971; 38: 29-48
276
5: Moritz A, Schoop U, Jiru E, Goharkhay K, Wernisch J, Sperr W: Morphological Changes of E. coli and E, faecalis after Er:YAG and Nd:YAG Laser Irradiation through Different Layers of Dentin. Abstract. 2nd Congress of the European Society for Oral Laser Application, Florence 2003 6: Al-Watban FA, Zhang XY, Andres BL: Low-level laser therapy enhances wound healing in diabetic rats: a comparison of different lasers, Photomed Laser surg 25(2): 72-77, 2007
Lu, CH ET AL.
available at www.jstage.jst.go.jp/browse/islsm
7: Hopkins JT, McLoda TA, Seegmiller JG, Baxter GD: Low-level laser therapy facilitates superficial wound healing in humans: a triple-blind, shamcontrolled study, J Athlet Train 39(3):223-229,2004 8: Silveira PCL, Streck EL, Pinho RA: Evaluation of mitochondrial respiratory chain activity in wound healing by low-level laser therapy, J Photochem Photobiol B Biol 86(3): 279-282,2007 9: Grossman LI. Intentional replantation of teeth. In: Robinson PJ, Guernsey LH, eds. Clinical transplantation in dental specialities. St Louis, Mosby, 1980: 65-76 10: Lievens P. Influence of laser irradiation on the motricity of lymphatic system and on the wound healing process laser. Proceedings International Congress Laser. Med Sur., 1989, p. 171-4. Bologna: Gallelly-Monduzzi. 11: Lievens P. The effect of IR laser irradiation on the vasomotricity of the lymphatic system. Laser Med Scien., 1991,6:189-91. 12: Walsh LJ. The current status of low-level laser therapy in dentistry. Part 2. Hard tissue applications.
LASER ASSISTED TOOTH REPLANTATION
CASE REPORT AustDent J, St Leonards, v.42, n.5, p.302-6, Oct.1997 13: Mezawa S, Iwata K, Naito K. The possible analgesic effect of soft-laser irradiation on heat nociceptors in the cat tongue. Arch Oral Bio 1988; 33:693-4 14: Emmertsen E, Andreasen JO. Replantation of extracted molars. A radiographic and histological study. Acta Odontol Scand 1966; 24: 327-46 15: Hartwell G, Bellizzi R. Clinical investigation of in vivo endodontically treated mandibular and maxillary molars. J Endod 1982;8:555-57 16: Jens O.: Andreasen Atlas of replantation and transplantation of teeth; 1992 Mediglobe SA, Switzerland: 100-108 17: Nagaoka S, Miyazaki Y, Liu H J, Iwamoto Y, Kitano M, Kawagoe M: Bacterial invasion into dentinal tubules of human vital and nonvital teeth. J Endod 21(2): 70-73, 1995 18: A. Moritz: Oral laser application; 2006 Quintessenz Verlags-GmbH, Berlin: 241-309
277
