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Acta Odontologica Scandinavica Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/iode20
Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in dogs a
b
Knut A. Selvig , Kjell Bjorvatn & Noel Claffey a
c
School of Dentistry, University of Bergen, Bergen, Norway
b
School of Dentistry, Loma Linda University, Loma Linda, California, USA c
Dental School, Trinity College, Dublin, Ireland Published online: 23 May 2015.
To cite this article: Knut A. Selvig, Kjell Bjorvatn & Noel Claffey (1990) Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in dogs, Acta Odontologica Scandinavica, 48:2, 107-112 To link to this article: http://dx.doi.org/10.3109/00016359009005865
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in- dogs Knut A . Selvig, Kjell Bjorvatn and Noel Claffey School of Dentistry, University of Bergen, Bergen, Norway; School of Dentistry, Loma Linda University, Loma Linda, California, USA; and Dental School, Trinity College. Dublin. Ireland
Downloaded by [RMIT University] at 17:04 13 August 2015
Selvig KA, Bjorvatn K. Claffey N. Effect of stannous fluoride and tetracycline on rcpair after delayed replantation of root-planed teeth in dogs. Acta Ocontol Scand 1990:48: 107-1 12. Ode. ISSN 0001-6357. Mandibular incisors were extracted and allowed to dry in air for 45 min. 'They were then rootplaned extensively. leaving a cervical collar and the apical region uninstrumented, to prevent direct contact between root surface and alveolar bone after replantation while. at the same time, enabling precise and stable reseating of the tooth. Control teeth were replanted either without further treatment or after treatment with citric acid for 3 min. Experimental teeth were treated before replantation with 1%; SnF, for 5 min, 1%. tetracycline HCI for 5 min, or 1% SnFz followed by 1% tetracycline. Histometric analysis of healing in the root-planed areas showed minimal amounts of inflammatory resorption and ankylosis after 21 days in experimental teeth as compared with the control tceth. A persisting inflammatory reaction in the periodontal ligament without root resorption was, howevcr. frequently seen. The observations confirm that the frequency of adverse healing reactions aftcr delayed replantation ot' teeth from which nonvital soft tissue remnants have been removcd can he reduced by demineralizing the root surface and preventing mechanical trauma to the root surface in the postoperative period. Root surface treatment with SnF2followed by tetracycline resulted in complete absence of inflammatory resorption and ankylosis in this short-tcrm experiment. 0 Pathology; periodontal ligament; tooth reimplanlutiori Knu! A . Seloig, Department of Dental Reseurch, School I7 Arstadveien. N-5009 Bergen, Norwuy
When traumatically or experimentally avulsed teeth can be reseated immediately, uneventful repair of the periodontal ligament generally occurs (1-4). The prognosis becomes progressively poorer, however, with increasing extraoral time (3,5-10). Dry storage, infection, or trauma to the root surface during removal or reinsertion of the tooth may also adversely affect the long-term healing result (4, 11-13). In a clinical situation it may be necessary to replant a tooth that has been stored extraorally beyond the period compatible with preservation of cellular vitality and/or has been exposed to infection. In such cases removal of soft tissue remnants from the root surface may be contemplated (14,15). Several methods have been proposed for storage of the tooth and preparation of the root before replantation, to stimulate connective tissue reattachment and improve the prognosis of healing (10, 15-17).
(11Dentisrr~.Unioer.sity of
Bergen,
In a recent study we found that treating the root surface with SnF2followed by tetracycline may improve the healing result after replantation of teeth that have been stored dry for an extended time (18). In addition, we have shown that preventing direct contact between the root and the bony surface of the alveolus may reduce the tendency to ankylosis and provide a more favorable healing result (19), thus confirming the findings of Andreasen (1 1,12). In the present study we used the experimental model described by Klinge et al. (19) to study the effect of SnF2 and tetracycline on healing after replantation of teeth that had been bench-dried for 45 min and rootplaned.
Materials and methods Five young adult beagles were available for experimentation. The dogs were littermates.
108
K. A . S d o i g
(11
d.
,411 teeth in these dogs had completed root Table 1. Distribution o f cxperimental matcrial h y treatformation. Experimental procedures were ment procedure carried o u t on the first, second, and third mandibular incisors. The dogs were fed a standard laboratory diet of soft consistency throughout thi: study. 3 3 3 7 1 5 With the dogs under intravenous thiopenJ 2 3 5 I tal sodium. (Pentothalo Sodium) anesthesia, I 5 4 3 1 the experimeiitd teeth were extracted. To 3 3 3 2 5 3 2 4 3 \ minimize damage to the root surface, only 5 clcvators were used. Immediately after exFor description of expcrimcntal procedurcy in groups triiction the teeth were cleansed with a flow 1-5, see tcxt. of saline and left t o dry on the bench for 45 * LKI, = lower right third incisor. ctc. rnin. The middle part of the root was then root-planed extensively with diamonds and l-inishing burs, leaving the cervical and apiGroup 5: As Group 2, but immersed in cal root surface areas uninstrumented (Fig. 1% SnFz for 5 min followed by 1 % tctr:r1 j . 'The tceth were assigned to one of the fol- cycline for 5 min instead of citric acid. The teeth were carefully reseatcd in the lou.ing trcxitment groups: G r m { p I: Replanted without further treat- alveolus, using finger pressure. N o fixation was used. Distribution of the experimental mcnt . G ~ Y I2:I Irnnrersed (~ in a saturated solution teeth by treatment procedure is shown in of citric acid ( p H 1) for 3 min, rinsed briefly Table 1. A few teeth were lost postwith saline. and replanted. operatively, resulting in an uneven distri( i r o i q ) .?: .4s Group 2, but immersed in a bution among experimental groups. O n l y 1'': solution o f SnF2 ( p H 3.0) for 5 min two teeth were assigned t o each control instcad oi' citric acid. group, as the healing pattern after the con.f'iroiq? 4: As Group 2, but immersed in a trol procedures has been studied previously 1% solutioii of tetracycline HCI ( p H 2.6) for (19). Healing was allowed for 21 days. 'The main 5 min instead of citric acid. consideration in thc choice of obscrvation period was to enable complete connective tissue healing and possible establishment of a new fiber attachment, while, on the other hand, the extension of the instrumented part of the root surface would be still discernible and not affected unduly by any resorptive processes. In a previous study using the same experimental design, it was found that, at 21 days of healing, a particular healing pattern at one root surface level did n o t extend into the adjacent area (19). In addition. the short observation period obviated the need for endodontic treatment of the experimental teeth. When the dogs were killed. the mandibles were cut through in the region o f the cuspids, and the anterior segment was removed and placed in 10% neutral. buffered formalin 1 : ~ .1. Rocit-planed mandibular third and first dog incifor 14 days. After demineralization in 5.244 WI-S before replantation. By leaving a cervical collar and :he apica-region uninstrumented, precise and stahlc nitric acid, the tissue blocks were divided in n x a t i i i g (.IT thc tooth was obtained. the midline, and the right and left halvc:s
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~
~~~
SnF, and tetracycline in tooth replantation
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ACTA ODONTOL SCAND 48 (19YO)
embedded in paraffin. Horizontal sections were made at 7 pm through the first, second, and third incisor and stained with hematoxylin and eosin. Histometric analysis of the healing events was carried out for each tooth separately and was limited to the root-planed portion of each root. Evaluation of healing events at each site followed the scheme used previously (19), originally introduced by Andreasen (9,11,12) and Andreasen & Kristerson (20). At each measuring point the presence of surface resorption, inflammatory resorption, ankylosis, or inflammatory reaction in the absence of resorption was recorded. Absence of such sequelae was recorded as normal healing. For each tooth the proportion of the experimental root surface area showing the different healing results was calculated and expressed as a percentage. Statistical analysis included calculation of means and standard deviations. Because of the distinct difference between treatment groups and the small number of specimens within each group, further statistical analysis was not considered appropriate.
Results
109
inflammatory resorption and ankylosis were also present to a considerable extent in one of these teeth. Teeth treated with either SnF, or tetracycline (groups 3 and 4) showed great variation in healing response within each group, as evidenced by the large standard deviations within the different healing categories. In the SnF2 treatment group (group 3 ) three teeth showed uncomplicated healing with scattered surface resorption, whereas two teeth showed extensive inflammatory reaction in the periodontal ligament but relative absence of ankylosis and inflammatory resorption. Similarly, tetracycline treatment alone (group 4) resulted in normal healing in four teeth, whereas the remaining four teeth showed various amounts of infammatory resorption, ankylosis, and persisting inflammation in the absence of resorption or ankylosis. Roots that had been treated with SnF2 followed by tetracycline (group 5 ) were characterized by absence of both inflammatory resorption and ankylosis. Three of the five teeth in this group showed complete and uncomplicated repair, whereas two teeth showed areas of persisting inflammatory reaction in the periodontal ligament without resorption. The occurrence of surface resorption was also insignificant in this group.
The frequency of different healing results in accordance with treatment group is shown in Table 2. In teeth that had been root-planed only (group 1) periodontal healing was characterized by massive ankylosis and inflam- Discussion matory resorption. Teeth that had been treated with citric acid (group 2) showed This study utilized the experimental model a predominance of normal healing or the introduced by Klinge et al. (39), in which the presence of surface resorption. However, teeth were extensively root-planed before Table 2. Delayed replantation of root-planed teeth. Tissue reaction by treatment group in percentage of available sites (mean t standard deviation) Tissue reaction Treatment group
No. of teeth
Normal
Surface resorption
Inflammatory resorption
1
2 2 5 8 5
5*1 64 c 2 58 2 47 47i31 64 c 46
Xi6
15 t 16 326 22525 254
31 t 33 5+6
2 3 4 5
18 t 30
Ankylosis 57 5 25 18 i 2.5 224 6216
Intiammation. no resorption
37 t 47 5 + 14 31 c 47
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rcinsertion, leaving only a cervical collar and the apical region uninstrumented. Although this procedure is not immediately applicable t o a clinical situation, it enables precise and stable reseating o f the tooth and eliminates direct contact between the experimental portion o f the root surface and alveolar bone. This model is therefore suitable for studying the effects of mechanical and'chemical treatments on the healing after tooth replantat ion. undisturbed by any traumatic effects of tooth-to-bone contact. The working hypothesis in this study was that, i n those cases in which the root surface hiis t o be mechanically cleaned before tooth replantation because of prolonged dry >torage, infection, or severe damage, an improved healing result can be achieved by 1 ) demineralizing the root surface, to expose the collagenous matrix of the hard tissue; 2) reducing resorption and ankylosis by treating the root surface with a fluoride; and 3) adding an antibiotic with a high degree of substantivity to the local environment. The choice of fluoride and antibiotic, and their concentrations, was based on earlier observations (21, 22). In addition. morc recent studies of the substantivity and biologic effects of tetracyclines (23-32) and of the effect o f topical application of tetracycline in periodontal regeneration studies (33) had indicated that this may also be the preferable antibiotic substance in replantation studies. l'he combined root surface treatment with SnF, atid tetracycline produced a short-term healing result characterized by an absence of inflammatory resorption and ankylosis. This contrasted sharply with the healing result after mcchanical root surface cleansing only (group I ) . As in earlier studies, this procedure resulted in massive ankylosis. Only a minimal number o f teeth that were rootplaned conly were included in this study. as rt w a s thought that the predominant healing pattern after dry storage with and without root planing has been adequately established h y earlier studies ( 2 , 5 , 10, 12, 19, 34). !'he cf'f'ect of SnF, and tetracycline treatment in delayed replantation has recently been tcstecl by Bjorvatn et al. (18). The cxperinicntal design in that study differed. however. from that o f the present study.
Whereas Bjorvatn et al. (18) replanted teeth with remaining periodontal ligament remnants, the present study utilized teeth that were extensively root-planed before replantation. The rationale for root planing was to simulate elimination of necrotic and possibly infected tissue and t o enable the study of periodontal healing when root surface and alveolar bone are prevented from direct contact. In addition, this experimental design can be considered as simulating implantation of homologous or xenogeneic teeth. which may have t o be fashioned to size before insertion. The healing result differed in some respects between the two studies. In teeth with periodontal ligament remnants preserved (18), but not in root-planed teeth, tetracycline treatment eliminated the toxic effect of the SnF, treatment. This difference may, possibly, be related to differences in the amount of SnF, or tetracycline taken up by the root surface in the two experiments. It seems likely that the extensively root-planed surface may have adsorbed considerably higher amounts of the fluoride than the noninstrumented surface as a result of denudation of the hard tissue and exposure o f dentinal tubules. Both SnF, and tetracycline, in the concentrations used, are highly acidic and. Frcsumably, have a demineralizing effect on the instrumented root surface not unlike that o f citric acid ( 3 5 , 3 6 ) . Among these agents, only SnF2 appears to have an inhibitory effect on root resorption. The latter observation concurs with earlier findings (18. l9,71.22). In evaluating the results, however. it should be kept in mind that none o f the expcrimental agents have been tested over a wider range of concentrations and that the concentrations used therefore were somewhat arbitrary. Reducing the concentration of SnF, and tetracycline may, conceivably, reduce cytotoxic effects and favor more subtle effects on connective tissue metabolism It has recently been suggested th:!t, in delayed replantation, it would be of udvantage to remove periodontal ligament remnants but preserve the cementum, since necrotic soft tissue may stimulate intlammation and subsequent resorption, while the denuded root surface itself appcars resistant
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A C r A ODONTOL SCAND 48 (1990)
Sn F2 und /e/rucycliiie in loath replanlalion
111
6. Andreasen JO. Hjorting-Hansen E. Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted aftcr accidental loss. Acta Odontol Scand 1966;24:263-86. 7 . H u n t RVV. Regeneration of periodontal and transseptal fibers after autografts in rhesus monkeys: a qualitative approach. J Dent Rcs .. 1972;5i:1183-42. 8.Soder P O , Otteskoe. P, Andreasen JO. Modker T. Effect of drying o n viability of periodontal membrane. Scand J Dent Res 1977;85:164-8. 9. Andreasen JO. T h e effect of splinting upon healing after replantation of permanent incisors in monkeys. Acta Odontol Scand 1975;33:313-23. 10. Andreasen JO. Effect of extraalveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-54. 11. Andreasen JO. Analysis of topography of surfaceand inflammatory root resorption after replantation of mature permanent incisors in monkeys. Swed Dent J 1980;4: 135-44. 12 Andreasen JO. Analysis of pathogenesis and topography of replacement root resorption (ankylosis) after replantation of mature permanent incisors in monkeys. Swed Dent J 1980:4:231-40. 13. Andreasen JO. Relationship between cell damage in the periodontal ligameni after replantation and subsequent development of root resorption. A timerelated study in monkeys. Acta Odontol Scand 1981;39: 15-25, 14. Lindskog S, Pierce AM. Blomliif L, Harnmarstrom L. T h e role of the necrotic periodontal membrane in cementum resorption and ankylosis. Endod Dent Traumatol 1985:1:96-101. 15. Hammarstrom L, Lindskog S . Blomlof L. Utslagna och replanterade tander. E n sammanfattning av experimentella studier. Tandlakartidn 1985;77: Acknowledsemen/.-This study was supported in part 1400-12. by grants from A / S Norsk Dental Depots Fond and the 16. BlomlBf L, Lindskog S . Hammarstrijm Id. PeriMeltzer Foundation. The University of Hergen. odontal healing of exarticulated monkey teeth stored in milk or saliva. Scand J Dent Res 1981;89:251-9. 17. Blomlof L. Lindskog S, Andersson L. HedstrBm KG, Hammarstrom L. Storage of cxperimcntally avulscd teeth in milk prior to replantation. J Dent References Res 1983;62:Y 12-6. 18. Bjorvatn K. Selvig KA, Klinge B. The effect of I , Barbakow F H , Cleaton-Jones PE. Experimental tetracycline and SnFL on root resorption in replantation of root-canal-filled and untreated teeth replanted incisors in dogs. Scand J Dent Res 1989: in the vervet monkey. J Endodont 1977;3:89-93. 97x477-82. 2. Andreasen JO. Periodontal healing aftcr replantation and autotransplantation of incisors in 19. Klinge B, Nilveus R , Selvig KA. T h e effect of citric acid on repair after dclayed tooth replantation in monkeys. Int J Oral Surg 1981:10:5461. dogs. Acta Odontol Scand 1984:42:351-9. 3. Andreasen JO. Exarticulations. In: Andreascn JO. cd. Traumatic injuries of the teeth. 2nd ed. Copen- 20. Andreasen JO, Kristerson L. The effect of limited drying or removal ofthe periodontal ligament. Perihagen: Munksgaard, 1981:203-42. odontal healing after replantation of mature per4. Blomliif L, Andersson L, Lindskog S. Hedstrom manent incisors in monkeys. Acta Odontol Scand K-G, Hammarstrdin L. Periodontal healing of 1981;39:3-13. replanted monkey teeth prevented from drying. 21.Bjorvatn K, Massler M. Effect o f fluorides on root Acta Odontol Scand 1983:41:117-23. resorption in replanted rat molars. Acta Odontol 5. Loe H, Waerhaug J . Experimental replantation of Scand 1971:29: 17-29. tccth in dogs and monkeys. Arch Oral Biol 22. Bjorvatn K, Weiss MB. Effect of topical application 1961;3: 17684.
against resorption (14). In accordance with this viewpoint, the present study indicates that a root-planed surface as well may be rendered relatively resistant to resorption by suitable treatment. For both ethical and economic reasons, this and other studies have been carried out on a relatively small number of animals. The results, therefore, are in need of future confirmation. In some of the treatment groups variations in the healing pattern occurred, indicating that healing was influenced by variables not under experimental control. It can be argued, however, that those specimens showing the most favorable healing result are indicative of the biologic healing potential under the given experimental conditions. The experimental design used in this study enabled precise and stable reseating of the replanted teeth and thus enabled histometric analysis of periodontal healing unaffected by direct contact between root surface and alveolar bone. On the other hand, only short-term observations, after an observation period of 3 weeks, could be made. Within these limitations, however, this study confirms the promising effect of a combined treatment with SnF, and tetracycline in delayed replantation of root-planed teeth.
-
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d !liiorii.lc. cortisone and tetracycline on reimikiiitccl I;II mol:irs. Fasctt 1971 ;6:27-31. .?.i ikikcr I’J. Evans R T , Coburn KA. biali;ip:icity. Scand J Dent Kes 1985:93:192?ti.
C;olul-, 1 ,:\I, liamaniurthy ‘TF, McNamara TF. ct al. ‘I c.rr:iiylines inhibit tissue collagcnase activity. A i i c u riict:hanisni i n thc treatment o f periodontal L’ I I’criodont Kea 19XJ;19:651-5.
30. Golub LM. Wolff M. Lec HM. ct al. Further evidcncc that tetracyclines inhibit collagenase activity in human crevicular Huid and from other main.. malian sources. J Periodont Res l985:20: 12-23. 31. Tcrranova VP. Franzetti LC, IIic S. et al. A hiochemical approach to periodontal rcgcneration: tetracycline treatment of dentin promotes librohlast adhesion and growth. J Periodont Kes 1OXO:2l:33& 7. 32. Wikesjii UME, Baker PI. Christersson L A . et al. A biochcmical approach t o periodontal regeneration: tetracycline treatment conditions dentin surface\. J Periodont Res 1986;21:322-9. 33. Claffcy N , Bogle G . Bjorvatn K , Sclvig K A . Egelberg J . Topical application of tetracyclinr i n regenerative periodontal surgery in Iwaglcs. A c t : i Odontol Scand 1987;35:141-6. 34. Leite MC, Okamoto 1‘. The influcnce ol extrnoral timc upon healing after tooth replantation-a histological study in rat incisors. 1 Nihon Univ Sch Dent l984;26:31&30. 35. Garrett JS, Criggcr M , Egelberg J . Eliects ol citric acid o n diseased root surf 1978: 13: 155-53. i 6 . Tveit A B , Selvig KA. In vivo recalcification 01 dentin demineralized by citric acid. Sc;incl J I k n t Rcs 1981;89:38-42.
Acta Odontologica Scandinavica Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/iode20
Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in dogs a
b
Knut A. Selvig , Kjell Bjorvatn & Noel Claffey a
c
School of Dentistry, University of Bergen, Bergen, Norway
b
School of Dentistry, Loma Linda University, Loma Linda, California, USA c
Dental School, Trinity College, Dublin, Ireland Published online: 23 May 2015.
To cite this article: Knut A. Selvig, Kjell Bjorvatn & Noel Claffey (1990) Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in dogs, Acta Odontologica Scandinavica, 48:2, 107-112 To link to this article: http://dx.doi.org/10.3109/00016359009005865
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Effect of stannous fluoride and tetracycline on repair after delayed replantation of root-planed teeth in- dogs Knut A . Selvig, Kjell Bjorvatn and Noel Claffey School of Dentistry, University of Bergen, Bergen, Norway; School of Dentistry, Loma Linda University, Loma Linda, California, USA; and Dental School, Trinity College. Dublin. Ireland
Downloaded by [RMIT University] at 17:04 13 August 2015
Selvig KA, Bjorvatn K. Claffey N. Effect of stannous fluoride and tetracycline on rcpair after delayed replantation of root-planed teeth in dogs. Acta Ocontol Scand 1990:48: 107-1 12. Ode. ISSN 0001-6357. Mandibular incisors were extracted and allowed to dry in air for 45 min. 'They were then rootplaned extensively. leaving a cervical collar and the apical region uninstrumented, to prevent direct contact between root surface and alveolar bone after replantation while. at the same time, enabling precise and stable reseating of the tooth. Control teeth were replanted either without further treatment or after treatment with citric acid for 3 min. Experimental teeth were treated before replantation with 1%; SnF, for 5 min, 1%. tetracycline HCI for 5 min, or 1% SnFz followed by 1% tetracycline. Histometric analysis of healing in the root-planed areas showed minimal amounts of inflammatory resorption and ankylosis after 21 days in experimental teeth as compared with the control tceth. A persisting inflammatory reaction in the periodontal ligament without root resorption was, howevcr. frequently seen. The observations confirm that the frequency of adverse healing reactions aftcr delayed replantation ot' teeth from which nonvital soft tissue remnants have been removcd can he reduced by demineralizing the root surface and preventing mechanical trauma to the root surface in the postoperative period. Root surface treatment with SnF2followed by tetracycline resulted in complete absence of inflammatory resorption and ankylosis in this short-tcrm experiment. 0 Pathology; periodontal ligament; tooth reimplanlutiori Knu! A . Seloig, Department of Dental Reseurch, School I7 Arstadveien. N-5009 Bergen, Norwuy
When traumatically or experimentally avulsed teeth can be reseated immediately, uneventful repair of the periodontal ligament generally occurs (1-4). The prognosis becomes progressively poorer, however, with increasing extraoral time (3,5-10). Dry storage, infection, or trauma to the root surface during removal or reinsertion of the tooth may also adversely affect the long-term healing result (4, 11-13). In a clinical situation it may be necessary to replant a tooth that has been stored extraorally beyond the period compatible with preservation of cellular vitality and/or has been exposed to infection. In such cases removal of soft tissue remnants from the root surface may be contemplated (14,15). Several methods have been proposed for storage of the tooth and preparation of the root before replantation, to stimulate connective tissue reattachment and improve the prognosis of healing (10, 15-17).
(11Dentisrr~.Unioer.sity of
Bergen,
In a recent study we found that treating the root surface with SnF2followed by tetracycline may improve the healing result after replantation of teeth that have been stored dry for an extended time (18). In addition, we have shown that preventing direct contact between the root and the bony surface of the alveolus may reduce the tendency to ankylosis and provide a more favorable healing result (19), thus confirming the findings of Andreasen (1 1,12). In the present study we used the experimental model described by Klinge et al. (19) to study the effect of SnF2 and tetracycline on healing after replantation of teeth that had been bench-dried for 45 min and rootplaned.
Materials and methods Five young adult beagles were available for experimentation. The dogs were littermates.
108
K. A . S d o i g
(11
d.
,411 teeth in these dogs had completed root Table 1. Distribution o f cxperimental matcrial h y treatformation. Experimental procedures were ment procedure carried o u t on the first, second, and third mandibular incisors. The dogs were fed a standard laboratory diet of soft consistency throughout thi: study. 3 3 3 7 1 5 With the dogs under intravenous thiopenJ 2 3 5 I tal sodium. (Pentothalo Sodium) anesthesia, I 5 4 3 1 the experimeiitd teeth were extracted. To 3 3 3 2 5 3 2 4 3 \ minimize damage to the root surface, only 5 clcvators were used. Immediately after exFor description of expcrimcntal procedurcy in groups triiction the teeth were cleansed with a flow 1-5, see tcxt. of saline and left t o dry on the bench for 45 * LKI, = lower right third incisor. ctc. rnin. The middle part of the root was then root-planed extensively with diamonds and l-inishing burs, leaving the cervical and apiGroup 5: As Group 2, but immersed in cal root surface areas uninstrumented (Fig. 1% SnFz for 5 min followed by 1 % tctr:r1 j . 'The tceth were assigned to one of the fol- cycline for 5 min instead of citric acid. The teeth were carefully reseatcd in the lou.ing trcxitment groups: G r m { p I: Replanted without further treat- alveolus, using finger pressure. N o fixation was used. Distribution of the experimental mcnt . G ~ Y I2:I Irnnrersed (~ in a saturated solution teeth by treatment procedure is shown in of citric acid ( p H 1) for 3 min, rinsed briefly Table 1. A few teeth were lost postwith saline. and replanted. operatively, resulting in an uneven distri( i r o i q ) .?: .4s Group 2, but immersed in a bution among experimental groups. O n l y 1'': solution o f SnF2 ( p H 3.0) for 5 min two teeth were assigned t o each control instcad oi' citric acid. group, as the healing pattern after the con.f'iroiq? 4: As Group 2, but immersed in a trol procedures has been studied previously 1% solutioii of tetracycline HCI ( p H 2.6) for (19). Healing was allowed for 21 days. 'The main 5 min instead of citric acid. consideration in thc choice of obscrvation period was to enable complete connective tissue healing and possible establishment of a new fiber attachment, while, on the other hand, the extension of the instrumented part of the root surface would be still discernible and not affected unduly by any resorptive processes. In a previous study using the same experimental design, it was found that, at 21 days of healing, a particular healing pattern at one root surface level did n o t extend into the adjacent area (19). In addition. the short observation period obviated the need for endodontic treatment of the experimental teeth. When the dogs were killed. the mandibles were cut through in the region o f the cuspids, and the anterior segment was removed and placed in 10% neutral. buffered formalin 1 : ~ .1. Rocit-planed mandibular third and first dog incifor 14 days. After demineralization in 5.244 WI-S before replantation. By leaving a cervical collar and :he apica-region uninstrumented, precise and stahlc nitric acid, the tissue blocks were divided in n x a t i i i g (.IT thc tooth was obtained. the midline, and the right and left halvc:s
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SnF, and tetracycline in tooth replantation
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ACTA ODONTOL SCAND 48 (19YO)
embedded in paraffin. Horizontal sections were made at 7 pm through the first, second, and third incisor and stained with hematoxylin and eosin. Histometric analysis of the healing events was carried out for each tooth separately and was limited to the root-planed portion of each root. Evaluation of healing events at each site followed the scheme used previously (19), originally introduced by Andreasen (9,11,12) and Andreasen & Kristerson (20). At each measuring point the presence of surface resorption, inflammatory resorption, ankylosis, or inflammatory reaction in the absence of resorption was recorded. Absence of such sequelae was recorded as normal healing. For each tooth the proportion of the experimental root surface area showing the different healing results was calculated and expressed as a percentage. Statistical analysis included calculation of means and standard deviations. Because of the distinct difference between treatment groups and the small number of specimens within each group, further statistical analysis was not considered appropriate.
Results
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inflammatory resorption and ankylosis were also present to a considerable extent in one of these teeth. Teeth treated with either SnF, or tetracycline (groups 3 and 4) showed great variation in healing response within each group, as evidenced by the large standard deviations within the different healing categories. In the SnF2 treatment group (group 3 ) three teeth showed uncomplicated healing with scattered surface resorption, whereas two teeth showed extensive inflammatory reaction in the periodontal ligament but relative absence of ankylosis and inflammatory resorption. Similarly, tetracycline treatment alone (group 4) resulted in normal healing in four teeth, whereas the remaining four teeth showed various amounts of infammatory resorption, ankylosis, and persisting inflammation in the absence of resorption or ankylosis. Roots that had been treated with SnF2 followed by tetracycline (group 5 ) were characterized by absence of both inflammatory resorption and ankylosis. Three of the five teeth in this group showed complete and uncomplicated repair, whereas two teeth showed areas of persisting inflammatory reaction in the periodontal ligament without resorption. The occurrence of surface resorption was also insignificant in this group.
The frequency of different healing results in accordance with treatment group is shown in Table 2. In teeth that had been root-planed only (group 1) periodontal healing was characterized by massive ankylosis and inflam- Discussion matory resorption. Teeth that had been treated with citric acid (group 2) showed This study utilized the experimental model a predominance of normal healing or the introduced by Klinge et al. (39), in which the presence of surface resorption. However, teeth were extensively root-planed before Table 2. Delayed replantation of root-planed teeth. Tissue reaction by treatment group in percentage of available sites (mean t standard deviation) Tissue reaction Treatment group
No. of teeth
Normal
Surface resorption
Inflammatory resorption
1
2 2 5 8 5
5*1 64 c 2 58 2 47 47i31 64 c 46
Xi6
15 t 16 326 22525 254
31 t 33 5+6
2 3 4 5
18 t 30
Ankylosis 57 5 25 18 i 2.5 224 6216
Intiammation. no resorption
37 t 47 5 + 14 31 c 47
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rcinsertion, leaving only a cervical collar and the apical region uninstrumented. Although this procedure is not immediately applicable t o a clinical situation, it enables precise and stable reseating o f the tooth and eliminates direct contact between the experimental portion o f the root surface and alveolar bone. This model is therefore suitable for studying the effects of mechanical and'chemical treatments on the healing after tooth replantat ion. undisturbed by any traumatic effects of tooth-to-bone contact. The working hypothesis in this study was that, i n those cases in which the root surface hiis t o be mechanically cleaned before tooth replantation because of prolonged dry >torage, infection, or severe damage, an improved healing result can be achieved by 1 ) demineralizing the root surface, to expose the collagenous matrix of the hard tissue; 2) reducing resorption and ankylosis by treating the root surface with a fluoride; and 3) adding an antibiotic with a high degree of substantivity to the local environment. The choice of fluoride and antibiotic, and their concentrations, was based on earlier observations (21, 22). In addition. morc recent studies of the substantivity and biologic effects of tetracyclines (23-32) and of the effect o f topical application of tetracycline in periodontal regeneration studies (33) had indicated that this may also be the preferable antibiotic substance in replantation studies. l'he combined root surface treatment with SnF, atid tetracycline produced a short-term healing result characterized by an absence of inflammatory resorption and ankylosis. This contrasted sharply with the healing result after mcchanical root surface cleansing only (group I ) . As in earlier studies, this procedure resulted in massive ankylosis. Only a minimal number o f teeth that were rootplaned conly were included in this study. as rt w a s thought that the predominant healing pattern after dry storage with and without root planing has been adequately established h y earlier studies ( 2 , 5 , 10, 12, 19, 34). !'he cf'f'ect of SnF, and tetracycline treatment in delayed replantation has recently been tcstecl by Bjorvatn et al. (18). The cxperinicntal design in that study differed. however. from that o f the present study.
Whereas Bjorvatn et al. (18) replanted teeth with remaining periodontal ligament remnants, the present study utilized teeth that were extensively root-planed before replantation. The rationale for root planing was to simulate elimination of necrotic and possibly infected tissue and t o enable the study of periodontal healing when root surface and alveolar bone are prevented from direct contact. In addition, this experimental design can be considered as simulating implantation of homologous or xenogeneic teeth. which may have t o be fashioned to size before insertion. The healing result differed in some respects between the two studies. In teeth with periodontal ligament remnants preserved (18), but not in root-planed teeth, tetracycline treatment eliminated the toxic effect of the SnF, treatment. This difference may, possibly, be related to differences in the amount of SnF, or tetracycline taken up by the root surface in the two experiments. It seems likely that the extensively root-planed surface may have adsorbed considerably higher amounts of the fluoride than the noninstrumented surface as a result of denudation of the hard tissue and exposure o f dentinal tubules. Both SnF, and tetracycline, in the concentrations used, are highly acidic and. Frcsumably, have a demineralizing effect on the instrumented root surface not unlike that o f citric acid ( 3 5 , 3 6 ) . Among these agents, only SnF2 appears to have an inhibitory effect on root resorption. The latter observation concurs with earlier findings (18. l9,71.22). In evaluating the results, however. it should be kept in mind that none o f the expcrimental agents have been tested over a wider range of concentrations and that the concentrations used therefore were somewhat arbitrary. Reducing the concentration of SnF, and tetracycline may, conceivably, reduce cytotoxic effects and favor more subtle effects on connective tissue metabolism It has recently been suggested th:!t, in delayed replantation, it would be of udvantage to remove periodontal ligament remnants but preserve the cementum, since necrotic soft tissue may stimulate intlammation and subsequent resorption, while the denuded root surface itself appcars resistant
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A C r A ODONTOL SCAND 48 (1990)
Sn F2 und /e/rucycliiie in loath replanlalion
111
6. Andreasen JO. Hjorting-Hansen E. Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted aftcr accidental loss. Acta Odontol Scand 1966;24:263-86. 7 . H u n t RVV. Regeneration of periodontal and transseptal fibers after autografts in rhesus monkeys: a qualitative approach. J Dent Rcs .. 1972;5i:1183-42. 8.Soder P O , Otteskoe. P, Andreasen JO. Modker T. Effect of drying o n viability of periodontal membrane. Scand J Dent Res 1977;85:164-8. 9. Andreasen JO. T h e effect of splinting upon healing after replantation of permanent incisors in monkeys. Acta Odontol Scand 1975;33:313-23. 10. Andreasen JO. Effect of extraalveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-54. 11. Andreasen JO. Analysis of topography of surfaceand inflammatory root resorption after replantation of mature permanent incisors in monkeys. Swed Dent J 1980;4: 135-44. 12 Andreasen JO. Analysis of pathogenesis and topography of replacement root resorption (ankylosis) after replantation of mature permanent incisors in monkeys. Swed Dent J 1980:4:231-40. 13. Andreasen JO. Relationship between cell damage in the periodontal ligameni after replantation and subsequent development of root resorption. A timerelated study in monkeys. Acta Odontol Scand 1981;39: 15-25, 14. Lindskog S, Pierce AM. Blomliif L, Harnmarstrom L. T h e role of the necrotic periodontal membrane in cementum resorption and ankylosis. Endod Dent Traumatol 1985:1:96-101. 15. Hammarstrom L, Lindskog S . Blomlof L. Utslagna och replanterade tander. E n sammanfattning av experimentella studier. Tandlakartidn 1985;77: Acknowledsemen/.-This study was supported in part 1400-12. by grants from A / S Norsk Dental Depots Fond and the 16. BlomlBf L, Lindskog S . Hammarstrijm Id. PeriMeltzer Foundation. The University of Hergen. odontal healing of exarticulated monkey teeth stored in milk or saliva. Scand J Dent Res 1981;89:251-9. 17. Blomlof L. Lindskog S, Andersson L. HedstrBm KG, Hammarstrom L. Storage of cxperimcntally avulscd teeth in milk prior to replantation. J Dent References Res 1983;62:Y 12-6. 18. Bjorvatn K. Selvig KA, Klinge B. The effect of I , Barbakow F H , Cleaton-Jones PE. Experimental tetracycline and SnFL on root resorption in replantation of root-canal-filled and untreated teeth replanted incisors in dogs. Scand J Dent Res 1989: in the vervet monkey. J Endodont 1977;3:89-93. 97x477-82. 2. Andreasen JO. Periodontal healing aftcr replantation and autotransplantation of incisors in 19. Klinge B, Nilveus R , Selvig KA. T h e effect of citric acid on repair after dclayed tooth replantation in monkeys. Int J Oral Surg 1981:10:5461. dogs. Acta Odontol Scand 1984:42:351-9. 3. Andreasen JO. Exarticulations. In: Andreascn JO. cd. Traumatic injuries of the teeth. 2nd ed. Copen- 20. Andreasen JO, Kristerson L. The effect of limited drying or removal ofthe periodontal ligament. Perihagen: Munksgaard, 1981:203-42. odontal healing after replantation of mature per4. Blomliif L, Andersson L, Lindskog S. Hedstrom manent incisors in monkeys. Acta Odontol Scand K-G, Hammarstrdin L. Periodontal healing of 1981;39:3-13. replanted monkey teeth prevented from drying. 21.Bjorvatn K, Massler M. Effect o f fluorides on root Acta Odontol Scand 1983:41:117-23. resorption in replanted rat molars. Acta Odontol 5. Loe H, Waerhaug J . Experimental replantation of Scand 1971:29: 17-29. tccth in dogs and monkeys. Arch Oral Biol 22. Bjorvatn K, Weiss MB. Effect of topical application 1961;3: 17684.
against resorption (14). In accordance with this viewpoint, the present study indicates that a root-planed surface as well may be rendered relatively resistant to resorption by suitable treatment. For both ethical and economic reasons, this and other studies have been carried out on a relatively small number of animals. The results, therefore, are in need of future confirmation. In some of the treatment groups variations in the healing pattern occurred, indicating that healing was influenced by variables not under experimental control. It can be argued, however, that those specimens showing the most favorable healing result are indicative of the biologic healing potential under the given experimental conditions. The experimental design used in this study enabled precise and stable reseating of the replanted teeth and thus enabled histometric analysis of periodontal healing unaffected by direct contact between root surface and alveolar bone. On the other hand, only short-term observations, after an observation period of 3 weeks, could be made. Within these limitations, however, this study confirms the promising effect of a combined treatment with SnF, and tetracycline in delayed replantation of root-planed teeth.
-
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d !liiorii.lc. cortisone and tetracycline on reimikiiitccl I;II mol:irs. Fasctt 1971 ;6:27-31. .?.i ikikcr I’J. Evans R T , Coburn KA. biali;ip:icity. Scand J Dent Kes 1985:93:192?ti.
C;olul-, 1 ,:\I, liamaniurthy ‘TF, McNamara TF. ct al. ‘I c.rr:iiylines inhibit tissue collagcnase activity. A i i c u riict:hanisni i n thc treatment o f periodontal L’ I I’criodont Kea 19XJ;19:651-5.
30. Golub LM. Wolff M. Lec HM. ct al. Further evidcncc that tetracyclines inhibit collagenase activity in human crevicular Huid and from other main.. malian sources. J Periodont Res l985:20: 12-23. 31. Tcrranova VP. Franzetti LC, IIic S. et al. A hiochemical approach to periodontal rcgcneration: tetracycline treatment of dentin promotes librohlast adhesion and growth. J Periodont Kes 1OXO:2l:33& 7. 32. Wikesjii UME, Baker PI. Christersson L A . et al. A biochcmical approach t o periodontal regeneration: tetracycline treatment conditions dentin surface\. J Periodont Res 1986;21:322-9. 33. Claffcy N , Bogle G . Bjorvatn K , Sclvig K A . Egelberg J . Topical application of tetracyclinr i n regenerative periodontal surgery in Iwaglcs. A c t : i Odontol Scand 1987;35:141-6. 34. Leite MC, Okamoto 1‘. The influcnce ol extrnoral timc upon healing after tooth replantation-a histological study in rat incisors. 1 Nihon Univ Sch Dent l984;26:31&30. 35. Garrett JS, Criggcr M , Egelberg J . Eliects ol citric acid o n diseased root surf 1978: 13: 155-53. i 6 . Tveit A B , Selvig KA. In vivo recalcification 01 dentin demineralized by citric acid. Sc;incl J I k n t Rcs 1981;89:38-42.
