Journal of Dental Health and Oral Research

Open Access Research Article

The Influence of Terms of Pulp Extirpation during Tooth Auto

Transplantation on Resorption and Ankylosis in Adults
Kristina Badalyan1, Alena Zedgenidze1*
1
Department of Clinical and Experimental Implantology of National Medical Research Center of Dentistry and
other Facial Surgery, Saint Timura Frunze, 16, Moscow, Russia
*
Corresponding Author: Alena Zedgenidze, Department of Clinical and Experimental Implantology of
National Medical Research Center of Dentistry and other Facial Surgery, Saint Timura Frunze, 16, Moscow,
Russia; Email: [email protected]

Received Date: 02-09-2020; Accepted Date: 01-10-2020; Published Date: 09-10-2020

Copyright© 2020 by Badalyan K, et al. All rights reserved. This is an open access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.

Abstract
Objectives: According to the studies, the best time for endodontic treatment after accidental
replan-tation is no more than two weeks. Unlike cases of tooth trauma, in autotransplantation,
all the manipulations flow under relatively sterile conditions and the likelihood of pulp
infection is minimal. We decided to check out the resorption rate in case of different terms of
pulp extirpation and whether revascularization is possible with a favorable healing course.

Material and Methods: In this study we performed the autologous transplantation of closed-
apex third molars in 52 adult patients, divided in 3 groups. In the 1st group (8 cases) the pulp
extirpation was done before the surgery, in the 2nd group it was performed in 2 weeks after the
surgery (33 cases). In the 3rd group there was no treatment at all (11 cases).

Results: Results were evaluated after 3, 6, 12, 24 months by clinical and radio-graphic
examination. The survival rate and the pulp condition of the transplanted teeth was observed.
The dynamic periotestometry examination was performed in order to track the resorptive
processes. For statistical data processing we used the Mann-Whitney test.

Conclusions. No dependence of the development of inflammatory and replacement resorption

on the time of pulp extirpation was evaluated. During this observation period direct
confirmation of revascularization has not been obtained. Despite possible pulp necrosis inside
the transplanted tooth, the risk of inflammatory resorption is minimal in the absence of
Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 2

infection. Periotestometry data showed that process of replacement resorption stopped after 6
months in most cases.

Keywords

Autologous Transplantation; Resorption; Ankylosis; Pulp Extirpation; Revascularization;

Periotestometry

Introduction

In accidental replantation, the recommended time for endodontic treatment is no more than two
weeks [1]. It is explained by the pulp infection and the damage of the root surface which
initiates the inflammatory resorption process. On contrary, in auto transplantation the tooth
most likely remains uninfected, which requires a review of the timing and need of endodontic
treatment in general. Root inflammatory resorption is a progressive process of dentin
resorption that occurs in a transplanted or replanted tooth with a damaged periodontal ligament
and infected pulp [1-3].

Bacteria and their metabolic products migrate along the tubules to the root surface, causing an
inflammatory response in the surrounding tissues [4]. It occurs when the osteoclasts penetrate
the cement layer and comes into contact with the dentinal tubules, which are associated with
infected tissue of a necrotic pulp. However, if the resorption cavity does not penetrate into the
intermediate cement layer, a tooth with necrotic pulp will cause only surface resorption, and
the intermediate cement layer will inhibit the spread of toxic elements [5]. If the inflammatory
resorption occurs the main characteristic of its presence is granulation tissue, which contains a
large number of vessels in the resorptive lacunae, which makes this zone radiopaque, so we
can observe it on X-ray pictures within 1 and 2 months after transplantation [5-9]. In rare cases,
delayed inflammatory resorption can be also observed in the cervical part of the root in several
years after transplantation [10,11]. On the other hand, some studies reported a complete
absence of inflammatory resorption [12-15]. The absence of complications could be provided
by careful transplant manipulation and sterile pulp chamber. According to the literature,
endodontic treatment is extremely important for the success of tooth auto transplantation with
closed apex. However, the recommended pulp extirpation time re-mains controversial.
Recommendations on the terms of endodontic treatment vary in different sources from 7 to 14
days [16-18]. In some studies, endodontic treatment was delayed or was not performed at all,
especially in young patients with transient step of apical third development, when the root is
fully formed, but the apical foramen is still wide [19]. According to some authors such teeth
do not need pulp extirpation due to the chance of revascularisation [20,21].

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 3

Material and Methods

In this study, third molars were transplanted in adults aged 18 to 76 years. We used
recommended auto transplantation protocol: atraumatic extirpation, extra-oral time no more
than 15 minutes in wet environment, 3D model usage if needed, non-rigid splinting for 4 weeks
in average [2]. Firstly, the groups were divided by the root anatomy on the group with fully
closed apexes and the group with 1 mm in diameter apexes. Donors with wide apexes were
transplanted without any treatment - (group 1: 11 cases). The transplants had one root and,
radiologically, the apical distance between the walls of the root in apical third was at least 1
mm (Fig. 1). Thus, in the remaining cases the necessary endodontic treatment was performed
before surgery (group 2: 8 cases) and within 2 weeks after the transplantation (group 3: 33
cases). This division was due to the possibility of secure rubberdam placing because in most
of the cases donor tooth was not fully erupted. That is why the root canal management was
done after the surgery and the rubberdam clasp was positioned on a distal tooth to minimise
periodontal trauma (Fig. 2). Endodontic treatment included mechanical root canal enlargement
up to size 35/02 profile (Dentsply), irrigation with sodium hypochlorite solution 3% (Par-can
3%, Septodont) and EDTA 17% (MD cleanser Meta biomed), vertical gutta-percha filling with
sealer AH plus (Dentsply). During the treatment, control radiographs were performed. All
trans-planted teeth were introduced into occlusion during the first 6 months after
transplantation by prosthetics or direct resin restoration. Results were obtained after 3, 6, 12,
24 months. During the clinical examination we evaluated the colour of the crown, cold test,
percussion, the depth of periodontal attachment measured at 6 points. At the X-ray examination
the width of the periodontal ligament space and signs of inflammation were estimated by two
specialists. For teeth that have not under-gone endodontic treatment a cold test was applied.

For this study, we used the Periotest device, which consists of a shock and measuring device.
The tip transmits an electronically controlled mechanical impulse to the tooth; the control coil
provides a constant frequency of impulses of the striker with compensation for friction and
gravity. Periotest measurements can vary from –8 to +50. Values from –8 to +9 are considered
normal, from +10 to +19 correspond to first distinguishable sign of movement, from +20 to
+29 to mobility, de-termined visually when crown deviates within 1 mm of its normal position,
from +30 to +50 to easily noticeable mobility [22]. Using the periotestometry data we analysed
tooth mobility changes during 2 years (Fig. 3). Periotestometry was performed by two
specialists in a horizontal position of the patient. Mann-Whitney test was used for statistical
data processing.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 4

Figure 1: Example of wide apex donor tooth from 1st group.

Figure 2: Example of rubberdam placing to minimise the trauma of periodontal ligament of

transplant.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 5

Figure 3: Periotest data for all cases. Values under -4 (cu) are considered as ankylotic.

Results
In all cases of the absence of endodontic treatment (group 1) during clinical examination, signs
of inflammatory resorption were not detected. The teeth also had not changed the colour. The
depth of periodontal attachment was not more than 3 mm. The result of cold test in all cases
was negative. While analysing x-rays, signs of periapical inflammation were detected in 2
cases, endodontic treatment was done afterwards (Fig. 4-7). In 5 cases, the periodontal ligament
space was narrowed or could not be seen. The periotestometry values showed drastic changes
in first 6 months, however, subsequently, teeth were stable in 9 cases, during the 2 year period.
Final measurements after 2 years showed normal mobility [-4, 5, 5 cu Periotest] in all cases
(100%) (Fig. 8).

In group where endodontic treatment was carried out before the surgery (group 2), clinical
signs of inflammation also were not detected. In 2 cases there was a local damage of periodontal
attachment leading to recessions of 3 mm. Periotestometry data showed sharp decrease in
values in first 6 months in 3 cases. No tooth mobility was detected after 2 years, the values of
periotestometry were distributed as normal in 7 cases, ankylosis was detected in 1 case (Fig.
9). The X-rays showed narrowing of the periodontal gap in certain areas in 3 cases.

In the 3rd group root canal treatment was done in 2 weeks after the surgery and clinically
showed no signs of inflammation. In 4 cases a partial loss of periodontal attachment on the
distal surface was observed. The depth of the recessions was 5 mm (3 cases) and 7 mm (1 case).

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 6

In addition, this transplants had excessive mobility 3 months after surgery, but no mobility was
observed after two years (Fig. 10). In 17 cases areas of narrowing of the periodontal ligament
space were determined on the radiograph. Periotestometry values obtained 2 years after surgery
in 30 cases revealed normal mobility; 3 cases were determined ankylotic.

Statistical data processing was performed using the Mann-Whitney test for multivariate
analysis of unrelated groups. It was shown that at a significance level of 0.05 we cannot reject
the null hypothesis that the values of the periotest are distributed identically in teeth with pulp
extirpated and teeth without endodontic treatment (p-value = 0.43) (Fig. 11,12) [23,24].

Figure 4: Wide apex transplant 4 weeks after the surgery with confirmed apical periodontitis.

Figure 5: Endodontic treatment. Apical plug control.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 7

Figure 6: 3 months after transplantation.

Figure 7: 1 year after transplantation.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 8

Figure 8: Periotest data for teeth with leaved pulp.

Figure 9: Periotest data for teeth underwent pulp extirpation before the surgery.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 9

Figure 10: Periotest data for teeth underwent pulp extirpation in 2 weeks after the surgery.

Figure 11: Сase distribution according to the following parameters.

Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 10

Figure 12: Distribution of periotestometry values for pulp extirpated and not-extirpated teeth
2 years after autotransplantation.

Conclusion

According to the results of the study no dependence of the development of inflammatory and
re-placement resorption on terms of pulp extirpation was evaluated. The results obtained in the
1 group, where pulp extirpation was not performed, did not show the presence of an
inflammatory process in the periodontium. The absence of attachment loss in this group is
apparently caused by the full root coverage by the periodontal ligament and good condition of
recipient zone. Despite the negative cold tests and possible pulp necrosis inside the transplanted
tooth, the risk of inflammatory resorption is minimal in the absence of infection. During the
observation period of 2 years direct confirmation of revascularization has not been obtained,
however these patients will be examined further. Probably it makes sense to use pulse oximetry
test to determine blood flow in the pulp chamber. Periotestometry data showed that process of
replacement resorption stopped after 6 months in most cases.

In groups, where endodontic treatment was performed, the risks associated with infection of
the pulp chamber and the periodontal ligament injury during the treatment were minimized.
Even so, ankylosis occurred in 97% cases probably due to the trauma of root cement during
Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 11

auto transplantation. However, periotestometry values after six months remained stable, which
indicates a suspended resorption process. The recession’s occurred on distal surfaces most
likely caused by the lack cortical recipient bone volume, which led to the attachment formation
at the level of existing bone tissue.

We received satisfactory results of auto transplantation during this study. Stable result within
2 years after the operation makes it possible to use this operation on daily basis. The study
showed that in adult patients there is no need for immediate pulp extirpation under the condition
of wide apex. Perhaps, in auto transplantation there is a chance of blood supply restoration
when the absence of pulp infection provided. In this case, the indication for endodontic
treatment will be symptoms of apical periodontitis or the presence of inflammatory resorption.
Both of these conditions need to be regularly monitored.

According to the literature, the restoration of pulp sensitivity after an injury can occur within
several years. Moreover, blood supply can be restored much earlier, which was determined by
some researchers using pulse oximetry. Due to the use of molars for transplantation, this the
research method was not available due to the anatomical structure of the coronal part.
Nevertheless, this region is of great interest and requires further observations.

Acknowledgments
Great and special gratitude to I Khisambeev, statistical analysis expert.

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Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301
 12

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Badalyan K | Volume 1; Issue 2 (2020) | JDHOR-1(2)-012 | Research Article

Citation: Badalyan K, et al. The Influence of Terms of Pulp Extirpation during Tooth Auto
Transplantation on Resorption and Ankylosis in Adults. J Dental Health Oral Res. 2020;1(2):1-12.

DOI: http://dx.doi.org/10.46889/JDHOR.2020.1301