Uncommon crown-root fracture treated with adhesive tooth fragment reattachment: 7 years of follow-up

Crown-root fractures account for 5% of all fractures in permanent teeth and can involve enamel, dentin, and cementum. Depending on whether there is pulpal involvement, these problems may be classified as complicated (which are more common) or noncomplicated. The treatment depends on the level of the fracture line, root length and/or morphology, and esthetic needs. Several treatment strategies are available for esthetic and functional rehabilitation in crown-root fractures. Adhesive tooth fragment reattachment is the most conservative restorative option when the tooth fragment is available and the biological width has no or minimal violation. This article reports a case of an uncomplicated crown-root fracture in the permanent maxillary right central incisor of a young patient who received treatment with adhesive tooth fragment reattachment, preserving the anatomic characteristics of the fractured tooth after periodontal intervention. The fracture line of the fragment had an unusual shape, starting on the palatal side and extending to the buccal side subgingivally. After 7 years, the attached coronal fragment remained in position with good esthetics, as well as clinical and radiographic signs of pulpal vitality, periodontal health, and root integrity, thus indicating success.

Delayed tooth replantation following root canal filling with calcium hydroxide and MTA: Histomorphometric study in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Tooth fracture risk analysis based on a new finite element dental structure models using micro-CT data

The finite element (FE) analysis is an effective method to study the strength and predict the fracture risk of endodontically-treated teeth. This paper presents a rapid method developed to generate a comprehensive tooth FE model using data retrieved from micro-computed tomography (μCT). With this method, the inhomogeneity of material properties of teeth was included into the model without dividing the tooth model into different regions. The material properties of the tooth were assumed to be related to the mineral density. The fracture risk at different tooth portions was assessed for root canal treatments. The micro-CT images of a tooth were processed by a Matlab software programme and the CT numbers were retrieved. The tooth contours were obtained with thresholding segmentation using Amira. The inner and outer surfaces of the tooth were imported into Solidworks and a three-dimensional (3D) tooth model was constructed. An assembly of the tooth model with the periodontal ligament (PDL) layer and surrounding bone was imported into ABAQUS. The material properties of the tooth were calculated from the retrieved CT numbers via ABAQUS user's subroutines. Three root canal geometries (original and two enlargements) were investigated. The proposed method in this study can generate detailed 3D finite element models of a tooth with different root canal enlargements and filling materials, and would be very useful for the assessment of the fracture risk at different tooth portions after root canal treatments.

Revascularization and tissue regeneration of an empty root canal space is enhanced by a direct blood supply and stem cells

Background Regenerative endodontics is an innovative treatment concept aiming to regenerate pulp, dentin and root structures. In the diseased or necrotic tooth, the limitation in vascular supply renders successful tissue regeneration/generation in a whole tooth challenging. The aim of this study is to evaluate the ability of vascularized tissue to develop within a pulpless tooth using tissue engineering techniques. Materials and methods A pulpless tooth chamber, filled with collagen I gel containing isolated rat dental pulp cells (DPC) and angiogenic growth factors, was placed into a hole created in the femoral cortex or into its own tooth socket, respectively. The gross, histological and biochemical characteristics of the de novo tissue were evaluated at 4 and 8weeks post-transplantation. Results Tooth revascularization and tissue generation was observed only in the femur group, confirming the important role of vascular supply in tissue regeneration. The addition of cells and growth factors significantly promoted connective tissue production in the tooth chamber. Conclusion Successful revascularization and tissue regeneration in this model demonstrate the importance of a direct vascular supply and the advantages of a stem cell approach. © 2012 John Wiley & Sons A/S.

Root caries patterns and risk factors of middle-aged and elderly people in China

The objectives of this study were to describe root caries patterns of Chinese adults and to analyze the effect of selected demographic and socioeconomic factors on these patterns. A total sample of 1080 residents aged 35-44-years-old and 1080 residents aged 65-74-years-old from three urban and three rural survey sites in Hubei Province participated in both an oral health interview and a clinical oral health examination. Root surface caries prevalence rates were 13.1% in the middle-aged group and 43.9% in the elderly group. The mean number of teeth affected by caries in the middle-aged group was reported at 0.21 and 1.0 in the elderly group. Mean Root Caries Index (RCI) scores of the middle-aged were reported at 6.29 and elderly subjects were reported at 11.95. Elderly people living in rural areas reported a higher RCI score (13.24) than those living in urban areas (10.70). A significantly higher frequency of root surface caries was observed in elderly participants (P < 0.001, OR = 3.80) and ethnic minorities (P < 0.001, OR = 1.93). In addition, smokers, nontea drinkers, and those with an annual household income of 10,000 yuan or less tended to have higher caries prevalence. RCI figures for the different tooth types ranged from 1% to 16%, indicating a wide variation in attack rates. In conclusion, our study suggests that root surface caries occurrence is high among the Chinese adult population, especially older adults. With an increasing number of retained teeth in both middle-aged and elderly people, root caries is a growing disease in the People's Republic of China which deserves more attention in future research.

Characterisation of the efficacy of endodontic medications using a three-dimensional fluorescent tooth model: An ex vivo study

The purpose of this study was to establish a three-dimensional fluorescent tooth model to investigate bacterial viability against intra-canal medicaments across the thickness and surface of root dentine. Dental microbial biofilms (Enterococcus faecalis and Streptococcus mutans) were established on the external root surface and bacterial kill was monitored over time against intra-canal medicament (Ca(OH)2 ) using fluorescent microscopy in conjunction with BacLight SYTO9 and propidium iodide stains. An Olympus digital camera fitted to SZX16 fluorescent microscope captured images of bacterial cells in biofilms on the external root surface. Viability of biofilm was measured by calculating the total pixel area of green (viable bacteria) and red (non-viable bacteria) for each image using ImageJ® software. All data generated were assessed for normality and then analysed using a Mann-Whitney t-test. The viability of S. mutans biofilm following Ca(OH)2 treatment showed a significant decline compared with the untreated group (P = 0.0418). No significant difference was seen for E. faecalis biofilm between the Ca(OH)2 and untreated groups indicating Ca(OH)2 medicament is ineffective against E. faecalis biofilm. This novel three-dimensional fluorescent biofilm model provides a new clinically relevant tool for testing of medicaments against dental biofilms.

Subepithelial connective tissue graft for root coverage in smokers and non-smokers: A clinical and histologic controlled study in humans

Background: The aim of this study was to evaluate root coverage of gingival recessions and to compare graft vascularization in smokers and non-smokers. Methods: Thirty subjects, 15 smokers and 15 non-smokers, were selected. Each subject had one Miller Class I or II recession in a non-molar tooth. Clinical measurements of probing depth (PD), relative clinical attachment level (CAL), gingival recession (GR), and width of keratinized tissue (KT) were determined at baseline and 3 and 6 months after surgery. The recessions were treated surgically with a coronally positioned flap associated with a subepithelial connective tissue graft. A small portion of this graft was prepared for immunohistochemistry. Blood vessels were identified and counted by expression of factor VIII-related antigen-stained endothelial cells. Results: Intragroup analysis showed that after 6 months there a was gain in CAL, a decrease in GR, and an increase in KT for both groups (P<0.05), whereas changes in PD were not statistically significant. Smokers had less root coverage than non-smokers (58.02% +/- 19.75% versus 83.35% +/- 18.53%; P<0.05). Furthermore, the smokers had more GR (1.48 +/- 0.79 mm versus 0.52 +/- 0.60 mm) than the nonsmokers (P<0.05). Histomorphometry of the donor tissue revealed a blood vessel density of 49.01 +/- 11.91 vessels/200x field for non-smokers and 36.53 +/- 10.23 vessels/200x field for smokers (P<0.05). Conclusion: Root coverage with subepithelial connective tissue graft was negatively affected by smoking, which limited and jeopardized treatment results.

Arrest of root formation in a permanent maxillary central incisor subsequent to trauma and pulp necrosis to the primary predecessor

This paper reports a case in which a previous traumatic injury at the age of 2 and pulp necrosis to a primary incisor resulted in a rare injury to the permanent successor tooth. The radiographic examination at the age of 9 showed the arrest of root formation of the permanent maxillary right central incisor, which did not erupt. Tooth 11 was extracted and a functional removable space maintainer was prepared. At the age of 17, the patient received an anterior fixed prosthesis for re-establishment of the esthetics, phonetics and deglutition.

Ex vivo evaluation of the accuracy of two electronic apex locators during root canal length determination in primary teeth

Aim To evaluate ex vivo the accuracy of two electronic apex locators during root canal length determination in primary incisor and molar teeth with different stages of physiological root resorption. Methodology One calibrated examiner determined the root canal length in 17 primary incisors and 16 primary molars (total of 57 root canals) with different stages of root resorption based on the actual canal length and using two electronic apex locators. Root canal length was measured both visually, with the placement of a K-file 1 mm short of the apical foramen or the apical resorption bevel, and electronically using two electronic apex locators (Root ZX II - J. Morita Corp. and Mini Apex Locator - SybronEndo) according to the manufacturers` instructions. Data were analysed statistically using the intraclass correlation (ICC) test. Results Comparison of the actual root canal length and the electronic root canal length measurements revealed high correlation (ICC = 0.99), regardless of the tooth type (single-rooted and multi-rooted teeth) or the presence/absence of physiological root resorption. Conclusions Root ZX II and Mini Apex Locator proved useful and accurate for apex foramen location during root canal length measurement in primary incisors and molars.

In vitro analysis of human tooth pulp chamber temperature after low-intensity laser therapy at different power outputs

In vitro studies have provided conflicting evidence of temperature changes in the tooth pulp chamber after low-level laser irradiation of the tooth surface. The present study was an in vitro evaluation of temperature increases in the human tooth pulp chamber after diode laser irradiation (GaAlAs, lambda = 808 nm) using different power densities. Twelve human teeth (three incisors, three canines, three premolars and three molars) were sectioned in the cervical third of the root and enlarged for the introduction of a thermocouple into the pulp chamber. The teeth were irradiated with 417 mW, 207 mW and 78 mW power outputs for 30 s on the vestibular surface approximately 2 mm from the cervical line of the crown. The highest average increase in temperature (5.6A degrees C) was observed in incisors irradiated with 417 mW. None of the teeth (incisors, canines, premolars or molars) irradiated with 207 mW showed temperature increases higher than 5.5A degrees C that could potentially be harmful to pulp tissue. Teeth irradiated with 78 mW showed lower temperature increases. The study showed that diode laser irradiation with a wavelength of 808 nm at 417 mW power output increased the pulp chamber temperature of certain groups of teeth, especially incisors and premolars, to critical threshold values for the dental pulp (5.5A degrees C). Thus, this study serves as a warning to clinicians that ""more"" is not necessarily ""better"".

Short-term vs long-term calcium hydroxide therapy after immediate tooth replantation: a histomorphometric study in monkey's teeth

Endodontic treatment is an important step of tooth replantation protocols, but the ideal moment for definitive obturation of replanted teeth has not yet been established. In this study, a histomorphometric analysis was undertaken to evaluate the repair process on immediate replantation of monkeys teeth after calcium hydroxide (CH) therapy for 1 and 6 months followed by root canal filling with a CH-based sealer (Sealapex (R)). The maxillary and mandibular lateral incisors of five female Cebus apella monkeys were extracted, kept in sterile saline for 15 min, replanted and splinted with stainless steel orthodontic wire and composite resin for 10 days. In Group I (control), definitive root canal filling was performed before tooth extraction. In Groups II and III, CH therapy started after removal of splint, and definitive root canal filling was performed 1 and 6 months later, respectively. The animals were euthanized 9 months after replantation, and specimens were processed for histomorphometric analysis. In all groups, epithelial attachment occurred at the cementoenamel junction or very close to this region; the areas of resorption on root surface had small extension and depth and were repaired by newly formed cementum; and the periodontal ligament was organized. Statistical analysis of the scores obtained for the histomorphometric parameters did not show any statistically significant difference (P = 0.1221) among the groups. The results suggests that when endodontic treatment is initiated 10 days after immediate replantation and an antibiotic regimen is associated, definitive root canal filling can be performed after a short-term CH therapy.

Periodontal tissue response to coverage of root cavities restored with resin materials: A histomorphometric study in dogs

Background: the purpose of this study was to histomorphometrically evaluate the response of periodontal tissues covering Class V resin restorations in dogs.Methods: After raising a mucoperiosteal flap, bony defects measuring 5 x 5 mm were created on the buccal aspect of the canines of five dogs followed by cavity preparations on the root surface measuring 3 x 3 x 1 mm. Before repositioning the flap to cover the bone defect, the cavities were restored with composite resin (CR) or resin-modified glass ionomer cement (RMGIC) or were left unrestored as control (C). The dogs were euthanized 90 days after surgery. Specimens comprising the tooth and periodontal tissues were removed, processed routinely, cut into longitudinal serial sections in the bucco-lingual direction, and stained with hematoxylin and eosin (H&E) or Masson's trichrome. The most central sections were selected for histomorphometric analysis.Results: Histomorphometric analysis revealed apical migration of epithelial tissue onto the restorative materials (RMGIC and CR). The C group presented significantly longer connective tissue attachment (P < 0.05) than the RMGIC and CR groups and significantly higher bone regeneration (P < 0.05) compared to the RMGIC group. Histologically, the cervical third (CT) of all groups had the most marked chronic inflammatory infiltrate.Conclusions: Within the limits of this study, it can be concluded that the restorative materials used exhibit biocompatibility; however, both materials interfered with the development of new bone and the connective tissue attachment process.

Influence of enamel matrix derivative (Emdogain((R))) and sodium fluoride on the healing process in delayed tooth replantation: histologic and histometric analysis in rats

Although it has already been shown that enamel matrix derivative (Emdogain((R))) promotes periodontal regeneration in the treatment of intrabony periodontal defects, there is little information concerning its regenerative capacity in cases of delayed tooth replantation. To evaluate the alterations in the periodontal healing of replanted teeth after use of Emdogain((R)), the central incisors of 24 Wistar rats (Rattus norvegicus albinus) were extracted and left on the bench for 6 h. Thereafter, the dental papilla and the enamel organ of each tooth were sectioned for pulp removal by a retrograde way and the canal was irrigated with 1% sodium hypochlorite. The teeth were assigned to two groups:in group I, root surface was treated with 1% sodium hypochlorite for 10 min (changing the solution every 5 min), rinsed with saline for 10 min and immersed in 2% acidulated-phosphate sodium fluoride for 10 min; in group II, root surfaces were treated in the same way as described above, except for the application of Emdogain((R)) instead of sodium fluoride. The teeth were filled with calcium hydroxide (in group II right before Emdogain((R)) was applied) and replanted. All animals received antibiotic therapy. The rats were killed by anesthetic overdose 10 and 60 days after replantation. The pieces containing the replanted teeth were removed, fixated, decalcified and paraffin-embedded. Semi-serial 6-mu m-thick sections were obtained and stained with hematoxylin and eosin for histologic and histometric analyses. The use of 2% acidulated-phosphate sodium fluoride provided more areas of replacement resorption. The use of Emdogain((R)) resulted in more areas of ankylosis and was therefore not able to avoid dentoalveolar ankylosis. It may be concluded that neither 2% acidulated-phosphate sodium fluoride nor Emdogain((R)) were able to prevent root resorption in delayed tooth replantation in rats.

Treatment of root perforation by intentional reimplantation: a case report

Intentional reimplantation is defined as a procedure in which an intentional tooth extraction is performed followed by reinsertion of the extracted tooth into its own alveolus. Int his paper, intentional reimplantation is described and discussed as a treatment approach to root canal instrument separation in conjunction with root perforation. An 8-year follow-up case report is presented. The reimplanted tooth is now a fixed bridge abutment. Although successful in this case, the intentional reimplantation procedure should be considered a treatment of last resort, that is, when another treatment option is not viable for the treatment of root perforation/instrument retrieval.

Use of vitamin C in delayed tooth replantation

O objetivo deste trabalho foi avaliar microscopicamente, em reimplantes tardios de dentes de rato, os efeitos do tratamento da superfície radicular com diferentes soluções. Foram utilizados 30 ratos Rattus norvegicus albinos da linhagem Wistar que tiveram seus incisivos centrais extraídos e deixados sobre a bancada por 6 h. As polpas foram extirpadas e os canais irrigados com solução de hipoclorito de sódio a 1%. Após o preparo endodôntico, a superfície radicular de cada dente foi tratada com solução de hipoclorito de sódio a 1% por 10 min (trocada a cada 5 min) seguida de soro fisiológico por 10 min, e os dentes foram divididos em três grupos com 10 espécimes em cada um. Nos Grupos I, II e III, respectivamente, a superfície radicular foi tratada com fluoreto de sódio fosfato acidulado a 2%, vitamina C e vitamina C efervescente (2 g, Redoxon®). Após obturação com pasta de hidróxido de cálcio os dentes foram reimplantados e os animais foram sacrificados aos 10 e 60 dias. O Grupo I apresentou maiores áreas de reabsorção por substituição e anquilose. Comparando as formas de vitamina C utilizadas, a efervescente (Grupo III) foi a que apresentou resultados mais favoráveis com mais áreas de anquilose e reabsorção por substituição que áreas de reabsorção inflamatória.