Dental Traumatology 2014; doi: 10.1111/edt.12141

Effect of fibroblast growth factor and enamel matrix derivative treatment on root resorption after delayed replantation Elif Bahar Tuna1,2, Kiyoshi Arai1, Merva Soluk Tekkesin3, Figen Seymen2, Koray Gencay2, Noboru Kuboyama4, Takahide Maeda1 1 Department of Pediatric Dentistry, Nihon University School of Dentistry at Matsudo, Chiba, Japan; 2Department of Pedodontics, Istanbul University Faculty of Dentistry, Istanbul, Turkey; 3Department of Tumor Pathology, Institute of Oncology, Istanbul University, Istanbul, Turkey; 4Department of Pharmacology, Nihon University School of Dentistry at Matsudo, Chiba, Japan

Key words: Dog; Enamel Matrix Derivative; Fibroblast Growth Factor-basic; Tooth Replantation; Periodontal Ligament Correspondence to: Elif Bahar Tuna, Istanbul University Faculty of Dentistry, Department of Pedodontics, 34093 Capa, Istanbul, Turkey Tel.: +90 212 414 2020/30283 Fax: +90 212 5310515 e-mail: [email protected] Accepted 27 August, 2014

Abstract – Background: Periodontal ligament (PDL) healing and long term prognosis of replanted avulsed teeth should rely on several factors including length of extra-oral dry time and type of the storage medium. The status of periodontal ligament is critical for the healing of replanted teeth. Different substances have been used for root surface treatment to promote formation of PDL and increase the survival of avulsed teeth submitted to replantation. Aim: The purpose of this study was to assess the effect of recombinant basic fibroblast growth factor 2 (bFGF) and enamel matrix derivative (EMD) on root resorption after delayed replantation. Design: 18 freshly extracted single-rooted incisor and premolar teeth were extracted from the beagle dogs and immersed in whole bovine milk for 45 and 60 min (n = 3 each). Following storage period, sockets washed and teeth were treated with bFGF and EMD and replanted into the sockets. After 8 weeks, dogs were sacrificed, specimens processed to 4-lm thick serial sections for histopathologic examination and morphometric assessments. Thus, the proportions of the roots that exhibited signs of surface resorption, inflammatory resorption, and replacement resorption, that is, ankylosis and normal PDL were noted. Results: The percentage of root resorption was in the following order: EMD>milk>bFGF for 45 min and milk>EMD>bFGF for 60 min. For all groups, teeth stored 60 min showed significantly higher incidence of PDL resorption than those stored for 45 min (P < 0.01). The highest incidence of replacement resorption was observed in teeth treated with EMD for 60 min. After 8 weeks, the least resorption was found in bFGF-treated group (P < 0.01). Conclusions: The findings of this study suggest that use of bFGF favored the formation of new periodontal ligament; prevent ankylosis and resorption process following delayed replantation of teeth while EMD shows replacement resorption, which may turn to ankylosis.

A consequence of injury and dental avulsion refers to the complete displacement of a tooth from its alveolar socket, which can affect the pulp and periodontal ligament (PDL) tissues, dental hard tissues, alveolar bone, and gingiva (1, 2). The reported incidence of dental avulsion ranges from 1 to 16% of all traumatic injuries to permanent dentition (1). In cases of avulsion, mechanical trauma to the PDL, dehydration, and PDL cell viability particularly can complicate the prognosis (3). The viability of PDL cells depends on the duration of the tooth’s extra-alveolar period, its storage medium, and the preservation of the root—all of which are critical for tooth replantation (4, 5). The most important factor, however, is the duration of extra-oral dry time, which directly affects the viability of PDL cells remaining on the root surface (6). Nevertheless, clinical research showed that most avulsed teeth are replanted © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

only after a prolonged extra-alveolar period and dry or inadequate wet storage (7). Wound healing normally results from the competition of PDL fibroblasts and osteoblasts of the socket wall. If the damage is minor and not sustained by infection, healing will occur in adjacent, non-injured PDL cells. However, if severe PDL damage occurred at the time of injury (8) or there is prolonged extra-alveolar desiccation of PDL cells, then ankylosis and replacement resorption ensue (9). Although the mechanism of ankylosis remains unclear, clinical and experimental studies showed that the most important factor in its prevention is PDL viability (10, 11). The presence of necrotic PDL remnants on the root surface may trigger an inflammatory root resorption process, which is the major cause of replanted tooth loss (6, 10). After the replantation of a tooth with a damaged root surface, the first reaction is 1

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inflammation. Dead and dying PDL cells, along with other debris on the root surface, can initiate this inflammatory response that involves osteoclast-mediated root resorption in proportion to the initial damage (8). Thus, if the initial inflammatory response can be minimized or prevented altogether, then both the size of the damaged root can be minimized and favorable healing promoted (12). The dry storage of avulsed teeth can cause the death of PDL cells attached to the root. In this context, the activity of cells derived from PDL plays a crucial role (13). PDL contains several cell populations, including those of fibroblasts, cementoblasts, osteoblastic and osteoclastic cells, and mesenchymal cells. As such, the complex process of PDL regeneration requires PDL cell proliferation, differentiation, and colonization in the wound area. It was therefore suggested that further research aimed to improve periodontal tissue healing after replantation should concentrate on preserving vital PDL by manipulating PDL cell proliferation and differentiation (14). Several protocols have been used to maintain PDL viability; some involve milk (2, 4, 11), propolis (1), antiresorptive substances such as alendronate (15), and tooth enamel protein (9, 16–18). In cases of extensive extra-alveolar dry storage, using fluoride treatment can double the tooth’s survival time (19). Recent research proposed preventing ankylosis by applying to the root surface a medium that favors the regeneration of injured parts of the PDL (20). Meanwhile, other studies showed that using fibroblast growth factors offer a promising alternative to prevent or control the development of external root resorption, especially replacement resorption (3, 21). Basic fibroblast growth factor 2 (bFGF or FGF-2) is a single-chain polypeptide associated predominantly with mesodermally derived cells (22) that induces angiogenesis, chemotaxis, and the proliferation of undifferentiated ectodermal cells in PDL tissue (23, 24). bFGF exhibits angiogenic activity in and a mitogenic disposition toward mesenchymal cells within the PDL as well as was reported to effectively regenerate periodontal tissue, new cementum with Sharpey’s fibers, new functionally oriented PDL fibers, and new alveolar bone in animal models (25). Diverse evidence clearly indicates that the local application of recombinant bFGF stimulates bone formation at the applied site (23). Moreover, Kitamura et al. (26) suggested that topically applying bFGF can regenerate human periodontal tissue destroyed by periodontitis (26). Recently, the use of enamel matrix derivatives (EMDs) in periodontal regeneration was shown to support the role played by cementum in periodontal wound healing (16, 17). EMDs contain amelogenin as a major component, as well as other enamel matrix proteins such as enamelins, tuftelin, amelin, and ameloblastin (27). Emdogainâ, a commercially available porcine EMD, has been used to form periodontal tissue, as it stimulates the regeneration of periodontal tissue—including the acellular cementum, PDLs, and alveolar bone—by mimicking tooth development (9, 28). Furthermore, when an EMD applied

to the root surface, an enhanced formation of cementum—either cellular or acellular—with large numbers of inserting collagen fibers occurred (29). EMDs were also shown to inhibit epithelial cell growth, which can interfere with the regenerative process (20). As replanted teeth usually have missing or destroyed areas of PDL, using EMDs might optimize PDL healing treatments and prevent ankylosis-related root resorption. This study therefore aimed to evaluate by histopathologic examination and morphometric assessment the effects of bFGF and EMD on root resorption in dogs’ teeth during delayed replantation. Materials and methods Experimental use of dogs

Six beagle dogs 6 years of age (average body weight 10.9  2.3 kg) were purchased from Japan SLC (Shizuoka, Japan). At all times, the dogs were allowed access to food and water ad libitum. Before their use in this study, they were kept for 1 month in an environment with a 12 h light/dark cycle (light from 8:00 to 20:00) and a climate of 23  1°C with a humidity of 60  10%. All dogs were kept and used in accordance with the guidelines of the Care and Use of Laboratory Animals of Nihon University School of Dentistry in Matsudo, Japan (05-0003). The study protocol was approved by the review board of Nihon University’s School of Dentistry’s ethics committee. Surgical intervention

During surgical procedures, all dogs were injected intravenously with 25 mg kg 1 of sodium pentobarbital (Somnopentylâ, Kyoritsu Seiyaku, Tokyo, Japan). Non-carious, closed apex, and periodontally sound maxillary incisor and mandibular first premolar teeth were atraumatically extracted to simulate dental avulsion. Extracted teeth were immersed in bovine milk at room temperature for either 45 or 60 min. Following storage, sockets were washed and teeth treated with either 200 lg of bFGF (human recombinant bFGF, Wako, Osaka, Japan) diluted with 5 ml sterile purified water or 0.1 ml of EMD gel (Emdogainâ, Straumann, Basel, Switzerland) dispensed from a blunt needle syringe onto the root surface. Animal study groups

After extraction, teeth were divided into six groups with three teeth each. Each group was treated with a different combination of extra-alveolar period and treatment. In Group 1, teeth were immersed in whole bovine milk for 45 min, while those in Group 2 were also stored in whole bovine milk, but for 60 min. In Group 3, teeth were stored in whole bovine milk for 45 min and received the bFGF application, while those in Group 4 experienced the same procedure, but for a duration of 60 min. In Group 5, teeth were stored in whole bovine milk for 45 min and received the EMD © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Effect of bFGF and EMD treatment on root resorption

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17 s. An isotropic resolution of 130 9 130 9 130 lm voxel size was selected, which displayed the microstructure of the dog mandible. The three-dimensional bone architecture was reconstructed and calculated using a morphometric program (TRI/3DBON, Ratoc System Engineering, Tokyo, Japan). A threshold value of 100 was used, as per previous studies (31, 32).

application, while those in Group 6 experienced the same procedure, but for a duration of 60 min. Following tooth immersion in milk, sockets were washed via saline irrigation, and teeth were gently replanted in their original sockets and splinted functionally for 15 days. The dogs received a commercial solid diet (DS-A, Oriental Yeast Co., Ltd, Tokyo, Japan) and were maintained on soft diet mixed with the same portion of water (50% water) for the splinting period. Immediately after replantation and continuing for 10 days, each dog received an intramuscular injection of 20 mg kg 1 of sodium ampicillin (Viccillinâ, Meiji, Tokyo, Japan).

Morphometric analysis

The intersections of the horizontal lines and peripheral contour of the root surface were analyzed and classified as either normal or absorptive. Areas of inflammatory root resorption, replacement resorption, and surface resorption, as well as total area of resorbed root dentin and cementum, were analyzed. The total area of root dentin and area of resorbed root dentin were measured in mm2 and converted to percentages for statistical analysis. The Image-Pro Plus 3.0 (Media Cybernetics, Inc., Rockville, MD, USA) morphometric program was used to calculate the peripheral contour of the root surface (Fig. 4).

Histological analysis (specimen processing)

The dogs were sacrified with an injection of ketamine hydrochloride (Ketalarâ Daiichi Sankyo, Tokyo, Japan) 8 weeks after surgery. After each dog’s upper and lower jaws were removed, the tissue blocks— including the teeth, bone, and soft tissue—were fixed with 10% phosphate-buffered formalin for 20 days, decalcified in K-CXâ (Falma Co., Ltd., Tokyo, Japan) for 2 weeks, and then trimmed, dehydrated, and embedded in paraffin. Serial sections (4 lm) were obtained in a mesial—distal plane for histopathologic and morphometric analyses. Sections were stained with hematoxylin and eosin, photographed with an Image Command 7098 version 1.60 camera (Olympus Optical Co. Ltd, Tokyo, Japan), for histometric measurements. Characteristics of the PDL, alveolar bone, cementum, and dentin were observed, as well as the occurrence of resorption, alongside Andreasen’s criteria (30). The following characteristics were specifically noted: normal PDL, surface resorption, inflammatory resorption, and replacement resorption or ankylosis.

Statistical analysis

The percentage of each histological classification for each root and treatment group was calculated using the Statistical Package for the Social Sciences version 15.0 (SPSS Inc., Chicago, IL, USA). All results were expressed as mean  SD. Data were analyzed using two-way ANOVA, one-way ANOVA, and Tukey’s tests. Student’s t-tests adopting a significance level of 5% (P < 0.05) were also used for parameters between groups. Results

Micro-CT examination

Histopathologic features

Quantitative imageological analysis of bone tissue was performed with in vivo micro-computed tomography (CT) system (Rigaku-mCTâ, Tokyo, Japan). Dog maxillae and mandibles were scanned with micro CT with an X-ray source of 90 kV/50 lA. During imaging, the dogs received general anesthesia and were restrained on a fixed base to prevent body movement from affecting the images. Each dog was set on the object stage and imaged in a 360° rotation with an exposure time of

Teeth in Group 1—which were immersed in whole bovine milk for 45 min—presented intact root surfaces, thin to moderate cementum, and well-organized PDL and alveolar bones. Well-structured parallel collagen fibers reattached to the cementum and alveolar bones. No signs of resorption or abnormalities were observed on most of the total root surface (Fig. 1a). Remarkably, the teeth in Group 2—which were immersed in whole bovine milk for 60 min—exhibited

(a)

(b)

Fig. 1. (a and b) Teeth in Groups 1 and 2 were immersed in milk for 45 and 60 min, respectively. Group 1 showed good periodontal ligament (PDL)-to-bone transition, in which PDL exhibited parallel fibers in the periodontal space. Group 2 showed small resorption areas, and bone formation was observed in close contact to the root (hematoxylin and eosin, original magnification 1009 and 1009). SR, surface resorption; PDL, periodontal ligament; D, dentin; B, bone. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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Tuna et al. Lastly, the teeth in Group 6—which were immersed in whole bovine milk for 60 min and received the EMD application—distinct replacement resorption was observed in the middle and apical thirds, as was discrete bone formation in close contact to the roots near the apexes, which characterizes ankylosis. In this group, revascularization was remarkable, and in a few samples, slight surface resorption occurred (Fig. 3b).

slight surface resorption on the root surfaces. The PDL was better organized in areas where the cementum was preserved than in those where it was absent. In these latter areas, collagen fibers were poorly structured and revascularization more distinct. In some specimens, small portions of alveolar bone tissue appeared alongside cementum, which characterizes dental ankylosis (Fig. 1b). In the teeth in Group 3—which were immersed in whole bovine milk for 45 min and received the bFGF application—histological evidence of root resorption was not observed around the root surfaces. Newly formed, PDL-like connective tissue with signs of normality occupied the space between the root surfaces. Alveolar bones were observed in a major portion of the root surfaces (Fig. 2a). In the teeth of Group 4—which were immersed in whole bovine milk for 60 min and received the bFGF application—good PDL-to-bone transition was apparent, and newly formed connective tissue between the root surfaces and alveolar bones was observed in a major portion of the root surfaces. Some specimens in this group also presented thin cementum (Fig. 2b). In the teeth in Group 5—which were immersed in whole bovine milk for 45 min and received the EMD application—replacement resorption was remarkable. Extensive areas of ankylosis covering the cervical and middle thirds were observed, and in some samples, PDL was nearly well-organized between the scattered, thin cementum and new bone formation (Fig. 3a).

(a)

Micro CT findings

To follow the progress of resorption, images were obtained using a micro CT device at 0, 1, 2, 4, 6, and 8 weeks after surgery. Image reconstruction was performed on a personal computer using a specially designed I-Viewâ (J. Morita, Kyoto, Japan). Micro CT findings for the specimens appear in Figs 1–3. In Groups 3–6, external resorption was not observed, although external resorption appeared 8 weeks after surgery in Group 4. Morphometric analysis

Table 1 presents means (%) and SDs of the area of resorbed root dentin according to total resorption. Microphotography revealed areas of inflammatory resorption at the root surface of replanted teeth after 8 weeks. Total resorption areas showed statistically significant differences between teeth immersed for 45 min and those immersed for 60 min (P < 0.01) (Fig. 5).

(b)

Fig. 2. (a and b) Teeth in Groups 3 and 4 were immersed in milk for 45 and 60 min, respectively, and received a basic fibroblast growth factor 2 application. These groups showed good periodontal ligament-to-bone transition and newly formed connective tissue between the root surface and alveolar bone on most of the total surface. An arrow (blue) shows new cement formation on the root surface, while another arrow (black) shows inflammatory resorption (hematoxylin and eosin, original magnification 1009 and 1009).

(a)

(b)

Fig. 3. (a and b) Teeth in Groups 5 and 6 were immersed in milk for 45 and 60 min, respectively, as well as received an enamel matrix derivative application. Group 5 showed extensive areas of ankylosis covering the cervical and middle thirds, as well as signs of replacement resorption. (b) shows signs of ankylosis and replacement resorption. Arrows show newly formed bone on the root surface. The coronal portions of both (a) and (b) exhibit signs of ankylosis and replacement resorption (hematoxylin and eosin, original magnification 1009 and 1009). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Effect of bFGF and EMD treatment on root resorption Table 1. Mean values of percentages of total root resorption in the histomorphometric analyses conducted over a period of 8 weeks Milk MeanSD

Time

FGF Mean  SD

45 min 4.98  0.43 Resorption area (% total) Inflammatory 3.27  0.87 resorption Replacement 1.72  0.62 resorption 60 min 16.59  0.89 Resorption area (% total) Inflammatory 9.45  1.74 resorption Replacement 7.14  1.99 resorption One-way

ANOVA

P

EMD Mean  SD

2.41  0.85 5.81  0.59 0.001** 1.45  0.52 3.63  0.57 0.001** 0.95  0.47 2.17  0.67 0.004** 4.67  0.42 7.89  0.39 0.001** 2.59  0.64 3.96  0.67 0.001** 2.07  0.58 3.92  0,57 0.001**

test **P < 0.01.

Among teeth immersed in milk for 45 min, Groups 1 and 5 showed greater inflammatory resorption than Group 3 (P = 0.001, P = 0.001, P < 0.01, respectively), while Group 5 showed significantly higher replacement resorption than Group 3 (P = 0.003 and P < 0.01, respectively). Among teeth immersed in milk for 60 min, Group 2 showed significantly different inflammatory resorption than Groups 4 and 6 (P = 0.001 and P < 0.01, and P < 0.01, respectively). Replacement resorption in Group 6 was significantly higher than in Group 4 (P = 0.032 and P < 0.05, respectively). Between the times intervals, all groups showed increased resorption (P < 0.01) except Group 5 and 6 for inflammatory resorption (P > 0.05) (Table 2). Discussion

In cases of dental avulsion, the primary goal is to preserve the vitality of PDL cells attached to the root Table 2. Distribution of the mean values of resorptions in the histomorphometric analyses conducted over a period of 8 weeks Time Treatment Milk Resorption area (%) Inflammatory resorption Replacement resorption FGF Resorption area (%) Inflammatory resorption Replacement resorption EMD Resorption area (%) Inflammatory resorption Replacement resorption

45 min Mean  SD

60 min Mean  SD

P

4.98  0.43 3.27  0.87 1.72  0.62

16.59  0.89 9.45  1.74 7.14  1.99

0.001** 0.001** 0.001**

2.41  0.85 1.45  0.52 0.95  0.47

4.67  0.42 2.59  0.64 2.07  0.58

0.001** 0.003** 0.002**

5.81  0.59 3.63  0.57 2.17  0.67

7.89  0.39 3.96  0.67 3.92  0.57

0.001** 0.342 0.001**

Student’s t-test **P < 0.01. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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surface until an appropriate treatment can be performed to facilitate a favorable reattachment of the PDL. Maintaining PDL vitality is crucial for a good prognosis, as the presence of necrotic PDL remnants can cause the development of root resorption, which can lead to replanted tooth loss (33). Areas of the root surface without vital PDL cells will be subject to attack by osteoclasts, which will entirely prevent PDL regeneration. By contrast, precluding the initial inflammatory response can increase the likelihood of PDL cell proliferation and differentiation, as well as maintain the cementum (34). There is a great deal of evidence of the effect of topically applied recombinant bFGF. For one, it was shown to stimulate local cementum formation and to be effective in healing avulsion (27). Furthermore, other researchers reported that local bFGF application stimulated undifferentiated cells in residual periodontal tissue in the early phase of wound healing, as well as promoted local inflammatory reactions and subsequently affected the regeneration of periodontal tissue treated with bFGF (35, 36). Sae–Lim et al. (21) reported that the topical application of bFGF also stimulates multipotent mesenchymal cells within the PDL, thereby inducing differentiation into—and the subsequent regeneration of—the desired periodontal tissue. As a molecular biological element, bFGF also both promotes fibroblast proliferation and enhances periodontal tissue regeneration. Seshima et al. (3) recently confirmed this conclusion, as well as additionally suggested that bFGF favored the formation of regenerative periodontal tissue in tooth replantation. In the present study, the topical application of bFGF healed the periodontal tissue in delayed replantation without inducing ankylosis, root surface resorption, or epithelial downgrowth. The successful replantation of avulsed teeth depends upon the limitation—if not prevention—of inflammatory and replacement root resorption (10). In the present study, the most promising results in all experimental groups occurred in those in which the root surfaces were treated with bFGF (Groups 3 and 4). The histopathological differences observed in this study between the storage durations and treatments indicate that the use of bFGF favored the formation of regenerative periodontal tissue in tooth replantation. New cementum formation on the root surface increased, the incidence of ankylosis decreased, and—most importantly— the root was protected from replacement resorption in all specimens of groups treated with bFGF. In these groups, reduced replacement resorption indicates the efficacy of bFGF in the enhancement of periodontal regeneration and PDL reconstruction in avulsed teeth. In association with bFGF’s ability to stimulate residual PDL cells, this finding may explain the new cementum formation in the tooth and socket environments of Groups 3 and 4. EMD was also applied to the root surface of avulsed teeth prior to their replantation. Gestrelius et al. (37) investigated the influence of EMD on the properties of PDL cells, including migration, adhesiveness, proliferation, biosynthetic activity, and nodule formation. They

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Fig. 4. Microscope and Image-Pro Plus were used on the root surface to measure resorption and root surface. Means (%) and SD of the area of resorbed root dentin according to total resorption are shown.

Fig. 5. Means (%) and SDs of the total occurrence of total root resorption.

found that, although this substance increased the proliferation of PDL cells, protein synthesis, and the formation of nodules, it had no significant effect on the migration and adhesiveness of the cells. In another clinical study, Filippi et al. (38) applied EMD to the root surface and extraction site, after which the teeth were replanted. During a follow-up period of 10 months, no signs of ankylosis were observed. The authors thus concluded that intentional replantation using EMD may delay, if not prevent, ankylosis associated with tooth replantation. Although lacking all known growth factors, EMD was reported to stimulate and increase the production of alkaline phosphatase and transforming growth factors in PDL cells (39). In turn, transforming growth factors were shown to play a role in wound healing by inducing fibroblast chemotaxis, increasing the production of collagen and fibronectin, and inhibiting collagen degradation (40). An animal study reported a lower incidence of replacement resorption in dog teeth when EMD was applied to the root surface prior to replantation, compared with teeth not pretreated before replantation (17). However, some reports concluded that EMD cannot cure and can probably not prevent ankylosis, as well as that it cannot significantly reduce replacement resorption in teeth that undergo delayed replantation (9, 16, 41). In the present study, the highest average root resorption occurred following the delayed replantation of

avulsed teeth in Group 6 (7.89  0.39) in both radiographic and histomorphometric analyses. Replacement resorption associated with the delayed replantation of avulsed teeth is a progressive condition that results in the gradual replacement of the normal root structure by bone (42). In the present study, treatment with EMD gel did not seem to influence the periodontal healing of replanted roots, as shown in teeth treated with EMD. The occurrence of replacement resorption was similar to that of teeth in Groups 5 and 6, in which the roots were replanted with the remaining PDL and at high risk of replacement resorption. It was also demonstrated that teeth treated with EMD did not interfere with the healing process. Teeth treated with EMD thus exhibited signs of replacement resorption and the percent area/root exposed to ankylosis. In the present study, teeth treated with bFGF showed newly formed connective tissue between the root surface and alveolar bone, which indicates a good PDL-to-bone transition that can, in turn, prevent resorption on the root surface. However, signs of replacement resorption and ankylosis were noted in the cervical and middle thirds of teeth in Groups 5 and 6, which indicates that newly formed bone did not promote the survival of the replanted teeth. This study demonstrated the efficacy of bFGF on periodontal regeneration in beagles, although further studies are needed to confirm the effectiveness of bFGF therapy in humans. The histopathological differences observed in this study suggest that using bFGF promotes the regeneration of periodontal tissue during tooth replantation. Results also suggest that applying EMD to the root surface has limited inductive effects upon the remaining PDL cells, although such could change given changes to the local environment of the root surface. Future developments in tissue engineering might facilitate improved periodontal regeneration, as well as provide new perspectives on the treatment of delayed replanted teeth. Acknowledgement

This work has been supported by research grant given to Elif Bahar Tuna by the Scientific and Technological Research Council of Turkey (TUBITAK, BIDEB 2219). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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Effect of fibroblast growth factor and enamel matrix derivative treatment on root resorption after delayed replantation.

Periodontal ligament (PDL) healing and long term prognosis of replanted avulsed teeth should rely on several factors including length of extra-oral dr...
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