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Clinical management of the avulsed tooth.

Treatment outside the dental office: Replant immediately after gentle washing if practical. If replantation is not practical, store the tooth in the best medium available. Storage media in order of preference are Hank's Balanced Salt Solution (HBSS), milk, saline, and saliva (buccal vestibule). Water is the least desirable storage medium. Treatment in the office: Emergency visit; Place tooth in HBSS while exam is conducted and history is taken. Prepare socket for gentle repositioning of the tooth. Prepare the root. Extraoral dry time < 20 minutes: Closed apex--replant immediately after gentle washing. Open apex--soak in 1 mg doxycycline in 20 mg saline for 5 minutes. Extraoral dry time 20 to 60 minutes: Soak in HBSS for 30 minutes and replant. Extraoral dry time > 60 minutes: soak in citric acid, 2% stannous fluoride, and doxycycline and replant. Endodontics can be done extraorally. Semirigid splint for 7 to 10 days. (If alveolar fracture is present, rigid splint for 4 to 8 weeks). Suture soft-tissue lacerations, particularly in the cervical area. Administer systemic antibiotics (penicillin V potassium if possible) Chlorhexidine rinses and stringent oral hygiene while the splint is in place (7 to 10 days). Analgesics as required. Second visit after 7 to 10 days: Endodontic treatment: Tooth with open apex and extraoral dry time of < 60 minutes: No endodontic treatment initially. Recall every 3 to 4 weeks to examine for evidence of pathosis. If pathosis is noted, disinfect the pulp space and start apexification procedure. Tooth with open apex and extraoral dry time > 60 minutes: If endodontics was not completed in the emergency visit, start endodontics and follow apexification procedure. Tooth with closed apex: Endodontics should be initiated after 7 to 10 days. Careful chemomechanical instrumentation under strict asepsis. Splint removed at end of visit. Obturation visit: If endodontics was initiated 7 to 10 days after the avulsion, obturation can take place after short-term calcium hydroxide treatment. If endodontics was initiated more than 14 days after the avulsion or inflammatory resorption, long-term calcium hydroxide for 6 to 24 months, obturated when an intact lamina dura is traced. Restorations: Temporary restorations: Should be 4 mm deep. Reinforced zinc-oxide-eugenol, acid-etch composite resin, glass-ionomer cement. Permanent restoration: Placed immediately after obturation. Acid-etch resin and dentin bonding agents. Follow-up care: Twice per year for 3 years and yearly for as long as possible. Late complications are common.

Dental Restoration, Permanent↗

Healing of human extraction sockets filled with Bio-Oss.

The aim of this study was to investigate the healing of human extraction sockets filled with Bio-Oss particles (Geistlich Pharma AG, Wolhusen, Switzerland). In 21 subjects, providing a total of 31 healing sites, at least one tooth was scheduled for extraction and the extraction sites for implant therapy. The dimensions of the alveolar ridge at the extraction sites were considered insufficient and required augmentation concomitant with tooth extraction. There were three treatment groups. In group A, the extraction sockets were covered with a Bio-Gide membrane (Geistlich Pharma AG) and in group B the extraction sockets were filled with Bio-Oss. The extraction sockets in group C were left to heal spontaneously. Biopsies from the extraction sites were collected at the time of implant installation. Samples from group A showed large amounts of lamellar bone and bone marrow and small proportions of woven bone. Sites grafted with Bio-Oss (group B) were comprised of connective tissue and small amounts of newly formed bone surrounding the graft particles. Only 40% of the circumference of the Bio-Oss particles was in contact with woven bone. Sites from group C were characterized by the presence of mineralized bone and bone marrow.

Adult↗

Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog.

OBJECTIVE: To study dimensional alterations of the alveolar ridge that occurred following implant placement in fresh extraction sockets. MATERIAL AND METHODS: Five beagle dogs were included in the study. In both quadrants of the mandible, incisions were made in the crevice region of the third and fourth pre-molars. Buccal and minute lingual full-thickness flaps were elevated. The mesial root of the four pre-molars root was filled and the teeth were hemi-sected. Following flap elevation in (3)P(3) and (4)P(4) regions, the distal roots were removed. In the right jaw quadrants, implants with a sand blasted and acid etched (SLA) surface were placed in the fresh extraction sockets, while in the left jaws the corresponding sockets were left for spontaneous healing. The mesial roots were retained as surgical control teeth. After 3 months, the animals were examined clinically, sacrificed and tissue blocks containing the implant sites, the adjacent tooth sites (mesial root) and the edentulous socket sites were dissected, prepared for ground sectioning and examined in the microscope. RESULTS: At implant sites, the level of bone-to-implant contact (BC) was located 2.6+/-0.4 mm (buccal aspect) and 0.2+/-0.5 mm (lingual aspect) apical of the SLA level. At the edentulous sites, the mean vertical distance (V) between the marginal termination of the buccal and lingual bone walls was 2.2+/-0.9 mm. At the surgically treated tooth sites, the mean amount of attachment loss was 0.5+/-0.5 mm (buccal) and 0.2+/-0.3 mm (lingual). CONCLUSIONS: Marked dimensional alterations had occurred in the edentulous ridge after 3 months of healing following the extraction of the distal root of mandibular pre-molars. The placement of an implant in the fresh extraction site obviously failed to prevent the re-modelling that occurred in the walls of the socket. The resulting height of the buccal and lingual walls at 3 months was similar at implants and edentulous sites and vertical bone loss was more pronounced at the buccal than at the lingual aspect of the ridge. It is suggested that the resorption of the socket walls that occurs following tooth removal must be considered in conjunction with implant placement in fresh extraction sockets.

Alveolar Process↗

[Socket healing after rat mandibular incisor extraction].

Prosthodontic treatment is difficult if the alveolar ridge is low or thin. To develop a method for alveolar ridge preservation after tooth extraction, we need an experimental model of a small animal, in which we can analyze the socket healing easily and quantitatively. The purpose of the present study was to establish such an experimental model. Ten weeks old male rats of Wistar strain were used. The edge of the right mandibular incisor was cut every three days three times and the incisor was extracted at three days after the final cut. The animals were sacrificed 0, 1, 2, 4, 8, 12 weeks after the extraction and the mandibles were dissected out. The length of the alveolar bone was measured on soft X-ray photographs and bone mineral content was measured with a dual energy X-ray absorptiometer (DEXA). Then, transverse sections of the alveolar bone were prepared. Periodic three-times cutting of the edge of the mandibular incisor made the extraction easy. Quantitative analyses of new bone formation in the socket and the resorption of the alveolar bone were possible with soft X-ray photography and DEXA. The histological findings corresponded well with the data from the soft X-ray photos and DEXA measurements. The present results demonstrated the possibility of simple and quantitative analyses of socket healing after the extraction of rat mandibular incisors. This experimental model would be useful for developing a method to prevent atrophy of the alveolar ridge after tooth extraction.

Animals↗

Effects of local injections of vasoactive drugs on eruption rate of incisor teeth in anaesthetized rats.

OBJECTIVES: Previous studies have suggested that the vasculature in the dental pulp and periodontal tissues plays an important role in producing the eruptive force in continuously erupting incisors. The aim of the present study was to investigate the effects of local injections of vasoactive drugs on regional blood flow within the socket in association with axial tooth movements to clarify the role of the local vascular system on tooth eruption. DESIGN: Twenty-two male Wistar rats, weighing 309+/-21 g (S.D.), were immobilized with halothane anaesthesia. We measured the regional blood flow within the socket using a laser Doppler flowmeter, and the axial movements of the mandibular incisor using a displacement detector. The local injections of the vasoactive drugs, adrenaline (0.001, 0.01, and 0.1 microg/kg body weight) and acetylcholine (0.05, 0.5, and 5 microg/kg), into the base of the incisor were performed by a microinjector at a rate of 1 microl/kg body weight. RESULTS: The injections of various doses of adrenaline decreased the mean regional blood flow and eruption rate dose-dependently, while those of acetylcholine increased the mean regional blood flow and eruption rate dose-dependently. The changes in the regional blood flow and eruption rate were transient. Significant correlations (p<0.001) were obtained between the maximum and minimum values in the regional blood flow and in the eruption rate following injections of various doses of adrenaline and acetylcholine. CONCLUSION: These results support the hypothesis that the eruptive force of the rat incisor is closely related to the vasculature within the socket.

Acetylcholine↗

Autogenous masticatory mucosal grafts in extraction socket seal procedures: a comparison between sockets grafted with demineralized freeze-dried bone and deproteinized bovine bone mineral.

Successful preservation of the edentulous ridge after extractions may eliminate or reduce the need for ridge augmentation procedures. It has been claimed that grafting fresh extraction sockets and sealing them with autogenous soft tissue grafts promote ridge preservation after tooth extraction. In this study, the survival of free autogenous connective tissue grafts sealing extraction sites was evaluated. In 24 healthy patients, 42 maxillary anterior teeth were extracted. After socket debridement, soft tissue margins of the socket orifice were carefully cut to remove epithelial debris, Sockets were filled with either demineralized freeze-dried bone allografts (DFDBA) or deproteinized natural bovine bone mineral xenograft (DBBMX) to the level of the alveolar bone crest. Circular connective tissue grafts, slightly larger in diameter than the soft tissue socket orifice, were obtained and placed on top of the filler graft material sealing the sockets. Grafts were stabilized and secured by sutures and inspected weekly for the first month. The grafts were classified into 3 groups according to clinical parameters: vital, partially vital and non-vital. After 1 week, 18 grafts were vital, 13 partially vital and 11 non-vital. When only 1 sample unit (1 site per patient) was compared between DFDBA and DBBMX grafted sockets, no significant difference in graft vitality was shown (P = 0.34 for vital; P = 0.67 for vital plus partially vital). After 1 month, all socket orifices were sealed with mucosa. Based on the present observations, it seems that connective tissue grafts sealing fresh extraction sites are mainly dependent on underlying tissue vascularization and that sealing grafted fresh extraction sockets filled with bone substitute allograft or xenograft materials may be beneficial but an unpredictable procedure.

Adolescent↗

Influence of environmental factors on tooth displacement.

An analysis of static occlusion including occlusal force and occlusal contact area in intercuspal position may be helpful but a dynamic analysis of occlusion should be regarded as more important for analyzing the stomatognathic system. Anthropological research has shown that the Japanese and the Mongolian populations share morphological and genetic similarities, although their dietary lives are not the same. The purpose of this study was to evaluate the relationship between environmental factors such as dietary life and stomatognathic function with a dynamic analysis of physiological tooth displacement. Ten clinically healthy subjects were recruited (mean age 24.8 +/- 1.0 years). The subjects were divided into two groups 1) Mongolian group: five Mongolians grown with a more or less natural texture diet and 2) Japanese group: five Japanese grown with a relatively soft diet. The displacement of the upper left first molar was measured during function using a three-dimensional tooth displacement transducer Type M-3. The tooth displacement in the Japanese group occurred mostly in an apicopalatal direction, but intruded basically parallel to the tooth axis in the Mongolian group. The stress-strain curve revealed that elastic socket deformation and viscous elements were more pronounced in the Japanese group. It was concluded that environmental factors such as dietary life could influence tooth displacement during function.

Adult↗

Delayed immediate implants: alveolar bone changes during the healing period.

Delaying the placement of immediate fixtures by 6-8 weeks after extraction of the natural dentition allows for the elimination of associated infective processes, the achievement of maximum osteoblastic activity that theoretically could help the osseointegration process and complete wound covering that simplifies the placement of grafts or membranes. This study examines the healing associated with 21 fixtures in 14 patients. The fixtures were placed into sockets 6-8 weeks after tooth extraction without the use of barrier membranes or bone substitutes. Measurements were taken immediately prior to fixture placement and 3-6 months later at the abutment placement. Alveolar bone height, the remaining socket depth and diameter and the depth to which a 3.75 mm fixture could be inserted into the socket were measured. After fixture placement the vertical and horizontal measurements from the cover screw to the surrounding alveolar bone and the distance from the cover screw to the CEJ of the adjacent tooth were recorded. All fixtures were integrated at exposure with 1 failure during the follow-up period. The distance from the cover screw to the buccal plate decreased by a mean of 2.17 mm. There was an increase in the mean vertical bone height at all 4 surfaces. When horizontal defects were present, the mean vertical distance decreased from 2.5 +/- 0.37 mm to 0.36 +/- 0.64 mm. When horizontal defects were absent, the mean vertical distance decreased from 3.86 +/- 0.58 mm to 0.48 +/- 0.25 mm. There was also a marked decrease in the horizontal distance between the bone margin and the surface of the fixture from 1.6 +/- 1.73 mm to 0.02 +/- 0.02 mm. These results indicate a strong tendency for the defects to fill-in the horizontal plane and for bone growth to occur in the vertical plane to the height of the cover screw. In conclusion the delayed immediate placement of fixtures has a good short-term prognosis with bone regeneration occurring around the defect without the use of barrier membranes or bone substitutes.

Adolescent↗

Heat transfer to the periodontal ligament during root obturation procedures using an in vitro model.

It appears to be important to avoid thermal injury to the periodontal ligament when using heated guttapercha techniques such as "System B." An in vitro model was developed, consisting of an extracted human tooth rooted in an artificial periodontal ligament (PDL) and alveolar socket, which allowed us to measure the temperature transferred to the root surface. The teeth were instrumented and subsequently embedded in alginate to simulate the PDL. Medium gutta-percha points were fit, sealer was applied, and a fine Buchanan plugger was used for condensation. Temperature measurements were taken simultaneously at the apex and 5 mm from the apex during obturation with two fine gauge thermocouples connected to a digital thermometer. The average temperature increase was approximately 1 degree C at the apex and approximately 2 degrees C at the 5 mm mark. The resulting temperature increases appear to be lower than previously reported by other investigators (Hardie, 1986, 1987; Barkhordar et al., 1990; Weller et al., 1991; Lee et al., 1998), who did not allow for the heat disseminating effect of the PDL.

Alginates↗

A histometric study in rats of the effect of the calcium antagonist amlodipine on bone healing after tooth extraction.

The purpose was to investigate whether amlodipine, a second-generation calcium antagonist used for the treatment of hypertension and angina, interferes with healing of rat alveolar bone. A progressive increase in volume density of new bone filling the socket was quantified by a histometric differential point-counting method 7-42 days after tooth extraction. The results showed a 20-30% decrease in bone volume fraction in the alveolus of amlodipine-treated animals from 7 days on, in addition to a higher (7-35%) volume fraction of connective tissue and a tendency toward an increase in the volume fraction of persisting coagulum. If confirmed in humans, the knowledge of a deleterious effect of Ca-channel blockers in hindering alveolar bone healing would be important in planning oral operations involving bone tissue, including those for device implantation.

Amlodipine↗

Selecting treatment options and sequencing treatment in the replacement of 2 maxillary central incisors with implants: a case report.

This article describes treatment provided to replace 2 maxillary central incisors with implant-supported restorations. The site of a missing maxillary central incisor was treated utilizing a bone expansion technique to augment the labial hard and soft-tissue profiles at the time of implant placement. The adjacent central incisor tooth, although destined to be extracted, was retained to serve as an abutment for a fixed provisional restoration until the first implant was deemed to have successfully integrated. At the appointment to uncover this implant, the fractured tooth was extracted and an implant was immediately placed into the socket. The first implant was then used to support the provisional restoration during the healing phase of the second implant. The techniques utilized resulted in optimum soft-tissue contours, allowed the patient to have a comfortable and esthetic provisional restoration, and minimized the number of surgical procedures.

Adult↗

Immediate tooth extraction, placement of a Tapered Screw-Vent implant, and provisionalization in the esthetic zone: a case report.

PURPOSE: This clinical report describes an immediate tooth extraction, followed by placement and provisional restoration of a dental implant in the prepared socket of a right maxillary central incisor. MATERIALS AND METHODS: The tooth was extracted with minimal hard and soft tissue trauma and without flap reflection. A flapless, transmucosal surgical approach was used to prepare the socket and insert a tapered implant. The implant was immediately restored with a provisional abutment and crown without occlusal contacts. An impression was made 22 days after implant insertion, and a definitive, all-ceramic restoration was placed 3 days later. RESULTS: During the period of provisional progressive loading, no significant soft tissue contraction was observed related to noninvasive operating techniques and the immediate insertion of the provisional restoration. The patient exhibited no clinical or radiologic complications through 8 months of clinical monitoring after loading. CONCLUSION: The Tapered Screw-Vent implant and all-ceramic restoration provided the patient with immediate esthetics, function, and comfort without any complications during the postloading follow-up period.

Adult↗

A 5-year prospective study of single-tooth replacements supported by the Astra Tech implant: a pilot study.

BACKGROUND: Implant-supported single-tooth replacements are an increasingly used method to replace teeth, especially in young patients. Therefore, long-term validation of different treatment modalities with different implant systems is of great importance. PURPOSE: The aim of the present study was to make a biologic, technical, and aesthetic evaluation of single-tooth replacement supported by the Astra Tech implant (Astra Tech AB, Mölndal, Sweden) during a 5-year period. MATERIALS AND METHODS: Twenty patients were divided into two consecutively treated groups. In group A the implants were placed "early" in the extraction sockets, and standard single-tooth abutments were used. In group B the implants were placed "delayed," and preparable abutments were used. Clinical examinations including registration of plaque, bleeding, crown lengths, soft tissue marginal level, papilla height, complications, and radiography were performed yearly. At the 3-year control examination the patient and a dentist evaluated aesthetic appearance with a visual analog scale. RESULTS: An implant survival rate of 100% and a crown survival rate of 95% over a period of 5 years were found. The mean loss of marginal bone adjacent to implants and neighboring teeth was less than 0.5 mm during the 5-year period, and there was no significant difference after crown placement between the treatment modality for group A and that for B. There were fewer clinical complications and repairs in group B than in group A. Soft tissue dimensions were more natural around implant crowns in group B as compared to group A, but this was not reflected in the patients' satisfaction with aesthetic appearance. On the other hand the dentist judged the restorations in group B higher concerning aesthetics than in group A. CONCLUSION: Implant-supported single-tooth replacement with the Astra Tech system is a reliable treatment resulting in a good 5-year prognosis and only few complications.

Adolescent↗

Intentional replantation of a maxillary molar. A 4-year follow-up.

A 4-year follow-up of a case treated by intentional replantation has been presented. A maxillary molar with a metal core was diagnosed as having acute apical periodontitis, endodontic treatment was determined to be impractical, and the tooth was extracted. Three roots canals which could not be detected roentgenologically were discovered and, after apicoectomy and reversed amalgam filling, the tooth was replanted in its socket. The follow-up reveals periapical repair with no signs of root resorption or ankylosis.

Adult↗

Socket seal surgery combined with immediate implant placement: a novel approach for single-tooth replacement.

Guided bone regeneration procedures around immediately placed implants may result in well-osseointegrated fixtures, but because of complexed flap manipulation, the functional, phonetic, and esthetic result may be unsatisfactory, especially when performed in the maxillary anterior region of the mouth. For better results a modified ridge preservation technique, called "socket seal surgery," which combines bone and soft tissue grafting and is performed prior to implant placement has been suggested. A novel approach is presented in which socket seal surgery is performed simultaneously with implant placement to achieve optimal replacement of an extracted maxillary anterior tooth.

Adolescent↗

Use of HTR synthetic bone as an augmentation material in conjunction with immediate implant placement: a case report.

Immediate placement of dental implants (DI) in fresh extraction sockets is associated with remaining voids around the DI and often a partial dehiscence or thin facial alveolar plate. Bioplant HTR synthetic bone (HTR) was used as a ridge preservation/augmentation material in conjunction with this method of DI placement. A 61-year-old white woman requiring extraction of tooth 12 opted for immediate DI placement. HTR was used to fill the remaining socket void and enhance the facial ridge width, and primary closure was attempted with sutures. DI uncovering was performed at about 6 months. Measurements were taken to the nearest 0.5 mm of the internal socket width and total site width at DI placement and uncovering. The internal socket width was essentially maintained (6.8 vs 6.6 mm), and the total ridge width showed a change from 8.7 to 9.1 mm. The results of this case suggest that HTR is a useful adjunct in the placement of immediate DIs for the preservation of ridge width.

Alveolar Ridge Augmentation↗