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Loyola University ChicagoLoyola eCommons
Master's Theses Theses and Dissertations
1978
The Effect of a Calcium Hydroxide Paste onResorption of Replanted Teeth in DogsDale Marshall AndersonLoyola University Chicago
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This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.Copyright © 1978 Dale Marshall Anderson
Recommended CitationAnderson, Dale Marshall, "The Effect of a Calcium Hydroxide Paste on Resorption of Replanted Teeth in Dogs" (1978). Master'sTheses. Paper 2978.http://ecommons.luc.edu/luc_theses/2978
THE EFFECT OF A CALCIUM HYDROXIDE PASTE ON
RESORPTION OF REPLANTED TEETII IN DOGS
by
Dale M. Anderson, B.S., D.D.S.
A Thesis Submitted to the Faculty of the Graduate School of
Loyola University of Chicago in Partial Fulfillment
of the Requirements for the Degree of
Master of Science
April
1978
_ ___..- ;[:1BRAl::,'("i -
OOYOl ~ ' n\11'· ,n:: "" '. '
DEDICATION
To my parents, Marshall and Virginia Anderson,
whose love and guidance have meant so much to me, to
my wife, Kathy, for her love and understanding, and to
her parents, David and Lotta Borgardt, for their love
and constant support.
ii
ACKNOWLEDGMENTS
To Dr. Bruce Felder and Dr. John Gillan, whose
hard work and moral support allowed this research to
be completed.
To Dr. Norman Wood, whose abilities, knowledge,
and integrity hopefully have rubbed off on me during the
years I have known him.
To Dr. John Madonia, teacher, administrator, and
friend to all his students.
To Dr. Marshall Smulson, whose guidance and friend
ship has gone far beyond the field of endodontics.
To Dr. Franklin Weine for his friendship, excellence
in teaching and personal counsel.
iii
VITA
The author, Dale Marshall Anderson, is the son
of Nels Marshall and Virginia Ruth Anderson. He was
born in Chicago, Illinois, on May 18, 1949.
He received his elementary education at West
Northfield School in Northbrook, Illinois, and his
secondary education at Glenbrook North High School,
where he was a member of the National Honor Society,
and graduated in June of 1966. In September of the
same year he entered Wheaton College, Wheaton, Illinois,
where he received a Bachelor of Science degree in June
of 1970 with a major in Biology.
In September of 1970 he entered the Loyola
University School of Dentistry (Chicago College of
Dental Surgery,) where he graduated in June of 1974
with the degree of Doctor of Dental Surgery. Honors
included Omicron Kappa Upsilon national dental honor
society, and the American Academy of Oral Medicine
award.
After receiving his D.D.S. degree, he was in
private dental practice in Palatine, Illinois from
August, 1974 to August, 1976. He held the position of
part-time Clinical Instructor in the Department of Oral
Diagnosis at Loyola University School of Dentistry from
December, 1975 until August, 1976, when he began the
iv
graduate program at the same institution, pursuing the
degree of Master of Science in Oral Biology and a
specialty certificate in the Department of Endodontics.
v
DEDICATION . . .
ACKNOWLEDGEMENTS •
TABLE OF CONTENTS
I I I I I I I I I I I I I I I
. . . . . • • • • . . . . . . . VITA •• . . . . . . • • . . . • • 0 • . . . . . . TABLE OF CONTENTS I I I I I I I I I I I I I I I I
LIST OF TABLES • . . . . . . . . . . . . . . LIST OF FIGURES
Chapter
. . . . . . . . . . . . . . . . .
I. INTRODUCTION . . . • • . • • . • • • • .
II. REVIEW OF THE LITERATURE • • • . . • . .
III. MATERIALS AND METHODS . . . . . . . . . IV.
v. RESULTS . . . DISCUSSION • •
SUMMARY AND CONCLUSIONS
• • • . . . . . . . . • • • • • • . . . . . . . . . . . . . . . . . . . .
REFERENCES • • I I I I 0 • • • • • . . . . • •
FIGURES 0 I 0 I 0 0 0 0 I 0 I I 0 I I I I I I 1 I
vi
Page
ii
iii
iv
vi
vii
viii
1
3
47
54
71
80
82
97
LIST OF TABLES
Table Page
1 0 Results, Dog Number One 0 0 0 0 0 0 0 0 0 62
2o Results, Dog Number Two 0 0 0 0 0 0 0 0 0 0 0 63
3o Results, Dog Number Three 0 0 0 0 0 0 0 0 0 0 64
4o Results, Dog Number Four 0 0 0 0 0 0 0 0 0 0 65
5o Results, Dog Number Five 0 0 0 0 0 0 0 0 0 0 66
6o Results, Dog Number Six 0 0 0 0 0 0 0 0 0 0 0 67
7o Summarized Histologic Scores 0 0 0 0 0 0 0 0 68
8o Statistical Analysis 0 0 0 0 0 0 0 0 0 0 0 0 69
9o Comparison of Contralateral Gutta-Percha and Ca(OH)2 Filled Teeth 0 0 0 0 0 0 0 0 0 0 70
vii
LIST OF FIGURES
Figure Page
1. 99
2. 99
3. 101
4. 101
5. 103
6. 103
7. 105
8. 105
9. 107
10. 107
11. 109
12. 109
13. • 111
14. 111
15. 113
16. 113
17. 115
18. 115
1 9. "117
viii
CHAPTER I
INTRODUCTION
Proper treatment of traumatic injuries has always
been a particular problem in dentistry as well as
medicine, because of the need for quick, decisive,
and correct treatment. Emergency treatment, often
rendered in the middle of an already hectic day, may
have long lasting negative effects on the unfortunate
patient presenting to his dentist with his teeth in
his hand after an accident, especially if the treatment
rendered is inadequate or incorrect. Although replant-
ation of avulsed teeth has been practiced for centuries,
only in the last twenty years has proper research on
the effect of the many contradictory methods of treat-
ment begun to change tooth replantation from a pessi-
mistic temporary measure to a more predictable procedure.
Although adults may suffer tooth avulsion, often
as the result of automobile accidents or physical
altercations, children may suffer severe psychological
trauma in addition to the physical injury. Children
most frequently lose teeth due to sports accidents or
overexuberant roughhousing. Because anatomical consider-
ations usually prevent the construction of fixed bridge
work in children and young teenagers,these youngsters 1
2
are forced to wear bulky and often unaesthetic removable
acrylic appliances for years. Therefore, it is fortunate
that the replantation procedure is being refined by
isolating the pertinent variables and determining
which methods lead to increased success. Healthy re
tention of these teeth through the formative years,
when the emotional impact of the loss of anterior teeth
may mean severe impairment of the psychosocial develop
ment of a child, may soon become a predictable procedure.
Root resorption is a likely sequela of tooth
replantation, and is probably the most common reason
for failure in these cares (1). Endodontic therapy using
gutta-perrna and sealer as a filling technique is
commonly performed on replanted teeth, but several recent
studies have reported either prevention or arrest of
external resorption by using calcium hydroxide as an
intermediate root canal filling material. The purpose
of this study is to determine histologically and
radiographically, using dogs as an experimental model,
whether teeth replanted with a calcium hydroxide paste
in the root canals show any difference in incidence or
severity of external resorption from teeth conventionally
filled with gutta-percha and sealer.
CHAPTER II
REVIEW OF THE LITERATURE
Replantation of teeth has been defined as "the
return of a tooth avulsed by acute trauma, into its
alveolus." (2) Grossman (3) defined intentional
replantation as "the intentional removal of a tooth
and its reinsertion into its socket after endodontic
manipulation or obturation of the canals or both,"
and transplantation as "the removal of a tooth from
one socket and insertion into another socket of the
same or a different person." The literature pertaining
to these three different modes of reinsertion of teeth
into empty sockets shows much overlapping of research
methods, applicable results, and healing processes,
so although there are many important differences
between replantation of avulsed teeth, intentional
replantation, and transplantation, any review of the
literature in the first area would be incomplete without
including selected articles from the other two areas.
Albucasis made the first reference in the liter
ature to replantation in 1050, so it has been attempted
for hundreds of years. The first research on the subject
was reported in 1775 by Hunter (4), who reached the con
clusion that a vital periodontal ligament was a pre
requisite for successful replantation. In order to
3
prolong the life of recently extracted teeth, he planted
them in the comb of a rooster, until such time as he
would have occasion to use them. Barbikow reported
that in Elizabethan times, it was fashionable for
socialites to have the extracted teeth of paupers
transplanted into their mouths. An increase in the
incidence of tuberculosis and syphilis and other infec
tious diseases, however, brought this practice to an
end. (5)
Even against resistance from those who supported
the focal infection theory and advocated extraction of
all "pulpless" teeth, preliminary research into tooth
replantation began to appear in the literature in the
third decade of this century. Wilkinson (6), in 1926,
extracted two monkey lateral incisors and replanted them
five days later. Postoperative examination after 53 days
showed root resorption. Skillen and Lundquist (7), in
1929, found more promising results. They replanted
teeth in dogs and found normal reattachment through
formation of cementum. B5decker and Lefkowitz (8), in
1935, however, extracted anterior teeth in six dogs,
placed retrograde amalgam fillings, while keeping teeth
moist with sterile saline, and replanted the teeth within
thirty minutes. Microscopic examination revealed areas
of resorption which they equated with "areas of infec
tion," so they concluded that "this procedure would
4
probably not come into vogue again because of the real
dangers of focal infection in human teeth." The impact
of this study may be one of the reasons why very little
research was done on replantation until the 1950's, when
the focal infection theory rapidly lost acceptance,
at least pertaining to teeth with proper endodontic
therapy.
Intentional extraction and replantation of teeth
was described by Grossman (3), 1966, as being performed
when problems encountered in conventional endodontic
therapy preclude successful therapy. Such problems as
broken instruments lodged in the canal, root perforati~n,
excessive canal curvature, or blockage of the canal were
depicted. It is used as an alternative to extraction
5
and prosthetic replacement. When teeth were kept moist
with a saline antibiotic solution during extraoral
treatment, he reported that 36 out of 45 replantations
done intentionally were successful, with no root resorp
tion, at an average of 5.6 years recall time. Emmertsen,
et al (9) the same year reported on 100 molars with
inaccessable canals and periapical pathosis that were
extracted, kept moist with saline, and treated from the
apical end and filled with either amalgam or gutta-percha,
and replanted after curettage of the periapical area.
The teeth were splinted for eight days and radio
graphed for up to thirteen years. Only 34% showed
periapical healing and absence of root resorption at
one year, but they reported that teeth with periapical
radiolucencies at time of replantation showed signifi
cantly less root resorption than those without. Also,
patients less than 30 years of age had inflammatory
root resorption and periapical inflammation more fre
quently than older age groups. Kaplan and Ward (10)
in 1971 suggested that repositioning of malposed or
rotated teeth, and replantation after extraction of
6
the wrong tooth, were two additional indications for
intentional replantation, and listed as contraindications
systemic healing problems, loss of crestal bone, root
fractures, destruction of labial plate of bone, and
hypercementosis. Simon and Kimura (11) in 1974 extracted
teeth, treated the roots endodontically, and replanted
them in their sockets, the crowns being cut off below the
level of the crestal bone, in an attempt to maintain the
height and width of alveolar bone for the support of
prosthetic appliances. Eighteen month postoperative
clinical and radiographic findings indicated that although
no bone formed coronal to the roots, and many of the roots
were resorbing, clinically some cases appeared to be
maintaining bone to different degrees. Simon, et al, (12)
the next year, in a histologic study of the same or
similar teeth, showed normal periodontal ligament,
resorption, ankylosis, and repaired tooth structure,
without predictability as to location or severity. They
also described an eosinophilic cuticle-like band found
between the epithelium covering replanted dentin surfaces
artd the resorbed dentin. Even though the success rates
reported for most of the intentional replantation studies
are not particularly high, a report by Kirsten (13) of
an intentional replant done in 1938, successful for 25
years, makes it seem a reasonable alternative to extrac
tion and replacement in selected cases.
Transplantation of teeth from one socket to another
is classified by Natiella, et·al (14) as being either
autogenous (in the same individual), homogenous (within
7
the same species), or heterogenous (one species to another).
The same authors give the overall rate of success for
antogenous transplants as greater than fifty per cent.
Schulman, et al (15) studied autogenous transplants
(maxillary left central incisor to right central's
socket) and allogeneic (the same as homogenous) trans
plants, and found that while the autogenous grafts
rapidly reattached by normal periodontal ligament, the
allografts became firm as a result of ankylosis, wi_th
exagerated periapical inflammation, progressive vertical
bone loss, and extensive inflammatory and replacement
root resorption. Grewe and Felts (16) found, by study-
ing tritiated thymidine incorporation, that mouse teeth
replanted into their sockets exhibited further growth
and maturation. Teeth transplanted from one animal
to another, however, were all non-viable, and showed no
growth or maturation, many becoming exfoliated. Various
techniques have been used in an attempt to improve
transplantation successa Weinreb, et al (17) found
that if a portion of the accompanying alveolar bone in
autogenous transplants was implanted along with the
grafted tooth with the periodontal ligament intact,
root resorption would not occur. Contrary to these
findings, however, Luke and Boyne (18) have shown that
the transplantation of teeth with the surrounding perio
dontal ligament and bone resulted in an extensive root
resorptive process. Costich, et al (19) replanted and
transplanted 120 hamster molars, finding that freezing
teeth at -70° C and storing them at -8° C for one to 66
days before replantation or transplantation led to an
overall 60% rate of successful retention for up to 89
days. Storage of teeth in culture medium at 37° C for
one to two days led to 77% success.
Transplantation of teeth from one animal to another
is complicated by immune reactions to foreign tissue.
Boyne (zo) reported that the rejection phenomenon after
tooth transplantation, although not of the same magnitude
as that elicited by other types of tissues, may be
evidenced by a chronic inflammatory infiltration of cells
8
surrounding the transplant and extending into the pulpal
tissue. Failure of the pulp to function as a dentin
forming agent and to assist in the completion of the
structure of the tooth root, with fibrous encapsulation
and root resorption with replacement by osseous tissue
are also seen. The results of a study by Robinson and
Rowlands (21) in 1972 also show that teeth used in
transplantation are antigenic. Prior sensitization of
the recipient by skin grafting resulted in more frequent
loss of the tooth allografts and more intense lympho
cytic infiltration around the graft beds. In a later
study (22), 1974, the same authors evaluated tooth allo
grafts in Syrian hamsters, and found that while isolated
allogenic mineralized tooth surface, with the periodontal
ligament enzymatically removed, was not immunogenic
9
(did not serve as a primary response to secondary skin
grafts), isolated periodontal ligament was shown to evoke
an accelerated rejection of skin grafts, proving its
antigenicity. How the rejection phenomenon and the
inflammatory reaction usually associated with transplanted
teeth relate to the inflammatory resorption, ankylosis,
and too frequent failure of replanted avulsed teeth, is
a matter that deserves much more study. As LeCavalier
(23) stated, "many authors believe that the body treats
replanted teeth as a foreign protein and thus eventually
rejects them."
Several studies have been done.in the last twenty
years to determine the longevity of replanted avulsed
teeth, although many failed to isolate the individual
factors affecting success.
In 1959, Lenstrup and Skeiller (24) followed the
progress for several years of forty-six patients who
had traumatically avulsed teeth replanted using various
methods, and concluded that "the long-term prospects of
preserving a replanted tooth are unfavorable, since
root resorption results in most cases." Garber (25),
in 1965, stated that replanted teeth had an average
retention of five years, as reported by most clinicians.
Ingle (26) feels that the average life span of such
teeth is between five and ten years. Grossman (27),
in 1970, complained that papers on replantation claiming
success after only six to twelve months are not valid,
and followed 54 cases from various sources for up to
10
three yearsa Two thirds of the teeth remained in function
for two or more years. Kemp, et al (28), in a continuation
of Grossman's study including 71 cases, found that the
longer the teeth were replanted, the more likely that
root resorption would occur, while the teeth replanted
for the longest period had the fewest periapical rare
factions. They concluded that replantation of avulsed
teeth is justified despite the fact that it is not usually
a permanent procedure. "Success" of a replanted tooth is
a relative term, and the success rates reported depend
greatly on the criteria on which the judgement is based.
Messing (29) used as his definition of success "fixation
of the tooth in its socket without residual inflammation,
.•. either by ankylosis or by regeneration and reattach-
11
ment of the periodontal ligamenc the latter mode obviously
preferred." Emmertsen, et al (9) regarded as successful
any implant that was firm in normal function and had
normal gingival attachments and no root radiolucencies.
Talim and Antia (30) followed up fourteen intentional
replants for one year and concluded that nine were
successful using the following criteria: The teeth must • perform masticatory function without discomfort, gingival
color, contour, texture, and sulcus depth must be normal,
and theremust be no radiographic evidence of resorption
of tooth or bone. Knight, et al (31) pointed out the
great difference between clinical and histologic criteria
for success, with the results of his work replanting
teeth in dogs. Seven of sixteen teeth were clinically
successful, showing stability, function, and absence of
inflammation in soft tissue. None of the sixteen teeth,
however, met their histologic criteria of success, ~hich
was defined as the absence of root resorption, abscess,
and cyst formation, reattachment of the epithelium at
the proper level, reformation of the periodontal ligament
12
without ankylosis, and reestablishment of the vitality
of the tooth. In practice, one certainly must be satisfied
with meeting clinical success criteria, but it should be
noted that it is not usually a normal histologic result.
The histologic mechanism of healing of the perio-
dontium surrounding replanted teeth has been studied
" extensively. Andreasen and Hjorting-Hansen (32) found that
the first six weeks are the most critical to the survival
of the implant, since this is the period of major pro
gress in the healing of the periodontal membrane. Woehrle
(33) found that although there may be a "primary reattach-
ment" or a true healing of the severed periodontal tissue,
an extended or adverse extraoral course led to a "secondary
reattachment." This involved replacement of degenerating
periodontal tissues attached to the replanted tooth by
new ligament fibers provided by viable alveolar fragments.
The alveolar fragments also provided cellular elements
for the secretion of a new cementum matrix. Then, entrap-
ment of the regenerating fibers in the newly deposited
calcifying cementum provides a functional periodontium.
This secondary reattachment, according to Woehrle, is
dependent on the status of the supporting alveolar tissues,
the replant being passive, a substrate for cementum
deposition dictated by the extraoral history and the
periodontal tissues. Johansen, (34) after replanting
13
teeth immediately, found that true reattachment was an
unpredktable occurrence, and postulated that reattachment
took place in the vascular area of the periodontal mem-
brane without new formation of bone and cementum as a
prerequisite~ This healing by first intention was the
initial phase of reattachment of the extracted tooth,
and it took place without new formation of the entire
fiber apparatus across the periodontal membrane. By the
eleventh day the fibers and the bone along the original
alveolar wall were replaced by new fibers embedded in a
layer of new bone. Caffesse, et al (35) replanted teeth
in monkeys twenty minutes after extraction, and found
that a highly cellular periodontal membrane developed,
and although fibers reattached to reparative bone and
cementum, they seldom regained functional orientation.
Cervical~and apical root resorption was a universal
complication, but arrested areas of resorption often
showed repair by deposition of cementum. Massler (36),
in a clinical assessment of healing following tooth
replantation, stated that epithelial cuff reattachment
occurred at one week, periodontal ligament reattachment
in two to four weeks, and root resorption was evident
radiographically by six weeks. Nasjleti, et al (37)
agreed that a new junctional epithelium was established
(in monkeys) at seven days, while at the same time
.. connective tissue proliferation was at its peak, ?'\
starting mainly from the supro-crestal connective tissue
and the bone marrow spaces. The interface in the
periodontal ligament was undetectable histologically
by seven days. Large numbers of epithelial rests were
seen in the periodontal ligaments of the replanted teeth.
Loe and Waerhaug (38) hypothesized that the epithelial
rests of Malassez play a role in the maintenance of the
periodontal space in teeth replanted with a "vital"
periodontal membrane. Kaplan and Ward (10) stressed
the importance of the organizing blood clot in the repair
of the periodontal ligament when kept vital, the repair
being complete in one month. Hamner, et al (39) studying
replanted teeth in baboons, described a massive infil
tration of lymphocytes and plasma cells in the healing It
periodontal membrane. Rockert and Ohman (40) found that
within one month after replantation, demineralized areas
were seen in cementum and dentin using microradiography.
These seemed to be areas of degenerative change and they
thought that the demineralization was caused by lack of
"membrane covering cementumc"
The location of the epithelial attachment was
unpredictable after replantation, according to Groper
and Bernick (41), but Deeb (42) feels that elimination
14
of periodontal disease by curettage of crevicular epithel
ium and careful repositioning of gingival tissues is
important in replantation procedures in order to improve
a predictable reattachment.
Root resorption is such a common occurrence after
replantation that many authors have considered it normal
and unavoidableo Caffesse, et al (35) after following up
replanted teeth in monkeys for three to four years, con
cluded that cervical and apical root resorption is a
universal complication after tooth reimplantation, and
that arrested areas of resorption will show repair by
deposition of cementum. Andreasen and HjBrting-Hansen
(43), however, described thDee separate and distinct types
of root resorption. The first and most desirable was
minor"surface resorption" that occurs in what they de
scribed as normal healing, which is quickly repaired by
cementum deposition. The second was "replacement resorp
tion," or progressive ankylosis with tooth structure
replaced by bone. ·The third type was referred to as
"inflammatory resorption," and was the most destructive
15
type, tooth structure rapidly becoming replaced by granu
lation-type tissue. Within each type, Andreasen (44) later
distinguished between active, arrested, or repaired areas
of resorption when studied microscopically. He believed
that since it was observed that resorption, when present,
always started within one year after replantation, only
teeth with an observation period greater than one year would
be regarded as successful. (43)
16
Surface resorption was described in a histologic
study of replanted human teeth by Andreasen and Hjorting
Hansen (32) as showing small superficial resorption cavities
in the cementum and outermost layers of the dentin. No
inflammatory reaction in the periodontal membrane was
seen, and most cavities showed repair with cementoid.
Barbikow, et gl (45) working with monkeys, described surface
resorption as becoming evident within two weeks after
replantation. Andreasen (46) postulated that these super
ficial resorption lacunae may represent localized areas of
traumatic damage to the periodontal ligament or cementum,
and that it was self limiting, usually with spontaneous
repair. Normally, only the most severe of these are seen
radiographically, and clinically a normal percussion sound
is heard.
In a histometric study of periodontal healing in
rats by Andreasen, (47) an experimental injury with a bur
through the vestibular bone, periodontal ligament, and
superficial root surface of a mandibular molar was seen
to heal in three phases. Bone repair with formation of
an ankylosis occurred initially, followed by repair
of the periodontal ligament including removal of the
established ankylosis, with repair of the cementum
occurring last. In another study by the same author (48)
assessing periodontal healing after replantation of avulsed
17
human teeth, he described two distinct types of ankylosis.
The first he called a "transient replacement resorption,"
with radiographic signs of ankylosis and clinical lower-
ing of tooth mobility, both disappearing within several
weeks. This may be the same type of healing that he
described after the injury to the rats. The second type
of ankylosis, however, was a "permanent replacement re
sorption," with lowered mobility values occurring by five
weeks, radiographic signs of resorption without radiolucency
of tooth replaced by bone not evident until eight weeks.
Andreasen and HjBrting-Hansen (32) described this histolo
gically as showing cementum and bone being replaced by, and
in direct contact with, lamellar bone, with osteoblastic
activity often evident. Andreasen (46) hypothesized that
a blood clot in the periodontal ligament organized into
granulation tissue, and was replaced rapidly by bony
trabeculae uniting.the alveolar socket with the tooth.
Root resorption may or may not preceed ankylosis. The
tooth may be involved in the normal remodeling cycle of
the bone, gradually being replaced py bone. The same author
also stated that the replacement resorption was usually
first seen radiographically by three to four months
after replantation, usually starting in the apical one
third of the root. Often eruption was halted, and the
percussion sound was high-pitched. Barbikow (45) believed
that while replacement resorption was caused by devitalized
periodontal ligament tissue, inflammatory resorption was
caused by necrotic pulpal products.
Inflammatory resorption, as described by Andreasen
and HjBrting-Hansen (43), was often seen as early as
18
three to four weeks after replantation, and was radio
graphically characterized by loss of root substance with
adjacent radiolucency in the bone. Histologically, the
same authors (32) described bowl-shaped areas of resorp
tion of cementum and dentin, associated with inflammatory
changes of the adjacent periodontal tissue. The resorp
tive areas were characterized by Howship's lacunae
containing multinucleated cells, and in the inflamed
periodontal tissue were seen intense concentrations of
polymorphonuclear leukocytes, lymphocytes, and plasma
cells, with proliferation of capillaries. Andreasen (46)
believed that small resorptive cavities in the root
surface may expose or open dentinal tubules. This may
allow necrotic tissue, toxic autolyzed pulp components,
or bacteria from a necrotic pulp or an inadequate root
canal filling to penetrate into the periodontal tissues,
causing an inflammatory reaction. Andreasen and HjBrting
Hansen (32) carried this further, saying that inflammation
of the periodontal ligament from necrotic tissue in the
canal provoked a response which could result in complete
resorption of the root with no attempt at repair, as long
as the necrotic'pulp was present.
One of the multitude of variables affecting the
successful healing after tooth replantation is the
19
extent of damage to the teeth and supporting structures.
Andreasen (49) considered root fracture a contrain
dication to replantation. According to Humphrey (50), the
maxillary anterior teeth are the teeth most often avulsed,
and the alveolar bone in this area is often displaced,
or even fractured. Woehrle (33) believed that the viable
alveolar fragments were the source of the new ligament
fibers and cells for new cementum secretion, so it was not
surprising that Andreasen and HjBrting-Hansen (43) found
that of nineteen cases of replantation with accompanying
alveolar bone fracture, all showed extensive resorption
and a poor long-term prognosis. McCagie (51), however,
reported a case where three teeth were replanted after
being out of the mouth for five days, with loss of most of
the buccal plate. Two and one-half years later, very little
resorption was evident. Lu (52) recommended replanting
teeth even adjacent to jaw fractures after soaking them in
benzalkonium chloride. He thought that root canal therapy
was not.necessary as long as the teeth had a "normal
appearance clinically," but that healing of a replanted
tooth normally occurred by ankylosis.
The stage of root development at the time of avulsion
has been shown to affect the course of healing after
replantation. Kaqueler and Massler (53), in a study
using dogs, found that replantation of mature teeth was
uniformly less successful than that of immature teeth,
when endodontic therapy was not done. Although the
extraoral time period was more important to the immature
teeth with open apices, the temperature and storage
20
medium variables were more important than the extraoral
period to mature teeth. Lenstrup and Skeiller (24) found
in studying forty-six patients with replanted teeth that
the younger the tooth, the more pronounced and progressive
was the resorption. Andreasen (46) found that inflam
matory resorption was especially frequent in permanent
incisors with incomplete root formation, possibly because
of thin dentinal walls and wide dentinal tubules, through
which toxic pulpal products could more easily pass. The
pulps of the immature teeth, however, revascularized
more often than those of mature teeth. Massler (36)
said that mature teeth healed more slowly than immature
teeth after immediate replantation, but that the difference
between the two was small if replantation was delayed for
more than 24 hours. Andreasen and Hj8rting-Hansen (32)
found that a functional arrangement of the periodontal
fibers after replantation occurred in almost all of the
young teeth, except in those areas of the root surface
where active resorption and ankylosis were present.
In the mature teeth, the fibers were usually randomly
arranged or ran parallel to the root surface.
21
Probably the two most important factors affecting
the survival of replanted teeth are the amount of time
that an avulsed tooth is outside the socket and the
environment that it is kept in during that time. McElroy
(54) reported on a case where a thirteen year old boy
knocked out four maxillary anterior teeth, immediately
replanted them himself, and they functioned for 44 years
afterward. Kemp, et al (28) studying 71 avulsed teeth
replanted by many different clinicians, found that only
13.7% of the teeth were replanted within one hour after
avulsion, so usually time out of the socket is a major
factor. Andreasen and HjBrting-Hansen(43), after studying
110 replanted avulsed human teeth for from two months to
thirteen years, concluded that the degree of replacement
resorption was proportional to the extraoral time. Ninety
per cent of teeth replanted within 30 minutes showed no
resorption, while the vast majority of teeth replanted
90 minutes or more after loss showed extensive resorption.
A variable frequency of resorption was seen in those with
extraoral periods of from 31 to 90 minutes. Flanagan and
Myers (55) extracted and replanted hamster teeth after
variable time periods, with the teeth kept in sterile
saline, and found that teeth replanted immediately or
22
within 30 minutes showed a minimum of tissue inflammation,
while those kept out longer, especially up to six hours,
showed very poor results, osteomyelitis, pulp necrosis,
and root resorption occurring. Kaplan and Ward (10) felt
that the success rate was directly proportional to the
amount of viable periodontal ligament present. They con
cluded that an excessive extraoral period produced
irreversible degenerative changes in the periodontal
ligament prior to replantation. The presence of this
layer of necrotic tissue, which requires removal by
phagocytosis, retarded or prevented reattachment. There
are several studies, however, that minimized time and
environmental factors. Lenstrup and Skeiller (24) studied
46 patients who had had avulsed teeth replanted and found
no correlation between the extraoral period or method
of preservation, and the degree or rate of resorption.
They found that root resorption resulted in most cases.
Since this study was reported in 1959, it is possible that
replantation methods found preferable today were not used
in these patients. Anderson, et al (56) felt that the
periodontal tissues can become reattached even after
six hours out of the mouth. This was, however, not
attachment by a normal periodontal ligament. Groper and
Bernick (41) replanted teeth in dogs after extraoral
times from zero to twenty-four hours, with the teeth
kept in sterile gauze. They concluded that no evidence
appeared to show that dry storage alone for a period of
two hours or more had any effect on the presence of a
functional periodontal ligament, at least during the
period of their study. Repair of resorbed areas along
the entire root surface took place regardless of extra
oral time. The thirty day length of their study may
not have been long enough to make any broad generaliza
tions. Cvek (57) studied 38 human luxated and replanted
teeth for 22 to 78 months, and found that all teeth
stored dry for one hour or more became ankylotic. If
the dry interval was short, less than fifteen minutes,
23
the further course was good. If the dry interval was
moderate, ankylosis was less if the tooth was stored in
isotonic saline for about 30 minutes before replantation.
Barbikow (45) found that there was no difference in healing
after replanting monkey teeth immediately than after
storage for fifteen minutes in saline. Loe and Waerhaug
(38), after replanting 58 teeth in monkeys and dogs,
found that teeth replanted with a vital periodontal
ligament always formed a normal periodontal ligament
without ankylosis. Teeth allowed to dry for a short time
ankylosed, with minor areas of normal periodontal ligament
attachment, while teeth with periodontal ligaments dried
for longer times never formed normal periodontal ligaments.
24
Kristerson, gt al (58) maintained the viability of perio
dontal ligament cells of 21 teeth by the use of a transport
medium and tissue culture for four weeks. Four teeth
replanted after eleven weeks in this medium showed good
healing after five months. Nasjlete,· et 21 (59) found that
ten monkey teeth stored in a culture medium at 4° C for
seven days before replantation showed 100% success at one
year, while ten other teeth stored at -10° C for the same
time showed only 50% success. Jonck (60), however, stored
human teeth in isotonic saline at 4° C, and found active
resorption six weeks after replantation. Other teeth
which he stored in the patient's own blood (treated with
dextrose citrate to prevent coagulation) for three weeks
before replantation showed no signs of resorption after
two years.
The effects of various methods of direct manipulation
of the periodontal ligament on healing after replantation
has been discussed by many authors. Hammer, (61) in 1955,
believed that the life-span of a replanted tooth was
directly proportional to the area of the periodontal
ligament remaining attached to the tooth. Loe and Waerhaug
(38) found that teeth replanted in dogs and monkey~ after
removing the periodontal ligament by curettage never
regained their normal reattachment apparatus, but had the
periodontal space occupied by soft tissue, soon replaced
25
by bone, with ankylosis complete by 30 days. Bennett (62)
found that teeth replanted after scraping the periodontal
ligament formed a new periodontal membrane within two
or three months, but it was followed by complete bony
ankylosis and osseous rebuilding of the root. When the
ligament was not removed there was complete restitution
of a normal periodontal ligament within four to six weeks.
Hammer, et at (39) replanted teeth in baboons, discing
the distal root surface of the teeth, while leaving the
rest of the root surface alone. The mesial side main
tained a good periodontal union twelve months after re
plantation, with only focal microscopic resorption, while
the disced distal surface showed severe root resorption,
with a massive infiltration of lymphocytes and plasma
cells in the periodontal ligament. Sherman (63) replanted
incisors in dogs after performing root canal therapy.
More extensive root resorption and ankylosis were observed
on the teeth replanted after scraping the root surface
and wrapping with resorbable surgical sponge as a perio
dontal ligament substitute than those replanted with the
periodontal ligament unmanipulated. Ogus (64) described
a technique which involved casting and cementing a vitallium
thimble implant with a rough external surface over the
prepared root surface before replanting teeth, in an
effort to prevent root resorption. No actual clinical
cases were reported. Keller, et al (65) in an effort to
26
stimulate fibrotic attachment of replanted monkey teeth
to the socket, adapted venous segments over the roots of
teeth prior to replantation. Increased sulcus depth, root
resorption, and ankylosis were seen in the experimental
teeth compared to control teeth. Natkin (66), discussing
the value of scraping the periodontal ligament before
replantation, stressed the importance of whether or not
the ligament alone is removed, or whether the cementum is
also removed, exposing dentin. Morris (14), found that
after surgical detachment of periodontal tissues, healing
was normal against untouched or lightly curetted cementum,
but healing did not occur against the bare dentin of teeth
with non-vital pulps, including those with previous root
canal therapy. Baurer, et al (67) was able to remove the
periodontal ligament enzymatically from extracted teeth
in as little as fifteen minutes, without observable damage
to the cementum. Huard, et gl (68) using rhesus monkeys,
cultured periodontal ligament fibroblasts on enzymatically
debrided root surfaces, establishing a network of viable
fibers, and replanted one of these teeth in a monkey.
The tooth was reextracted seven months later, and a normal
looking periodontal ligament was seen with no visible
areas of resorption.
The advisability of apicoectomy before replantation
has been debated. Harris (69) advised cutting off the root
apex, cleaning out the root canal, and leaving the
lingual access open to avoid f-luid pressure in the
periapical area. If root end resorption occurred later,
he recommended treating it by surgical exposure and
"shaving" the root end down to "fresh" tooth structure.
Anderson, ~ al (56) thought that cutting off the root
end in older teeth promoted repair by secondary cementum
and reattachment of the periodontal ligament in this
area, and Massler (36) advocated "snipping off the root
tip" if the tooth resists replacement in its former
locus. Bennett (62) disagreed with these procedures.
He believed that since it has been suggested that resorp
tion begins where small pieces of cementum are torn from
the root during extraction, it would follow that apico
ectomy should not be performed.
27
Although there is almost complete agreement in the
literature that replanted teeth should be splinted, there
is little agreement as to the type and duration of splint
ing. A most unusual splint was one reported by Serrano
(70), where a horizontal hole was drilled through the
alveolar bone and root of the replanted tooth, through
which was driven a "retention rod" of calf's bone. Others
were more conventional. Pearson and Nicolazzo (71) de
scribed an arch bar wiring technique, while Barbikow (5)
recommended splinting by full arch coverage with an
appliance to open the bite from two to four m~llimeters.
Biven, et al (72) suggested processed acrylic buccal and
lingual splints, which~ wired together through the
interproximals. Jenner (73) recommended a ligature
wire splint covered with cold-cure acrylic, while
Rand (74) described an linusual technique of suturing
28
through the buccal and lingual periosteum, with the suture
running over the incisal edge between the mammelons.
Humphrey (50) splinted anterior teeth by soldering
together interproximally either stainless steel crowns
or orthodontic bands. McEvoy and Mink (75) advocated
acid etching the labial surfaces of the teeth, then apply
ing a 3 mm. strip of acrylic resin across the labial
surfaces and interproximals. Heiman, et ~ (76) described
a splint attaching an arch wire to the labial surfaces of
the teeth by means of an adhesive composite system. Hovland
and Gutmann (77) cemented direct-bonded, mesh-backed
orthodontic brackets to the teeth, and attached an arch
wire with elastic ligatures, and Berman and Buch (78)
covered similar direct-bonded brackets with a band of
acrylic.
Although Johansen (34) found when replanting guinea
pig teeth that splinting or not splinting showed no
difference in healing, splinting of avulsed human teeth
aft~r replantation has been almost universally accepted.
Barbikow (5) thought that 30 day immobilization was needed,
29
Pearson and Nicolazzo (71) recommended splinting for six
to eight weeks, Hargreaves and Craig (79) for eight to
twelve weeks, and Henning (80) advised "at least three
months." Andreasen (44) has published the only objective
research into this area, replanting teeth in 21 monkeys,
splinting for six weeks, two weeks, or no splint at all.
The monkeys were sacrificed at eight weeks, and although
teeth that were out for 120 minutes showed extensive
ankylosis irrespective of splinting method, teeth that
were out for eighteen minutes showed significantly less
frequency and extent of replacement resorption when not
splinted compared to the splinted teeth. Andreasen (81)
at the present time recommends splinting replanted teeth
for one week only.
Antibiotic coverage has been advised (71), and
in cases of severe tissue injury is probably warranted
but Massler (82) and Andreasen and HjBrting-Hansen (43)
have both shown experimentally that systemic antibiotic
administration did not significantly affect the rate
of healing of the periodontal tissues.
Disinfection of root surfaces before replantation
has been advised by some authors. Loe and Waerhaug (38)
washed roots in 1% phenyl mercuric acetate, Messing (29)
soaked teeth in chlorhexidine diacetate solution for
five minutes, and Lu (52) soaked them in benzalkonium
chloride. Massler (82), however, found that applying
caustic drugs such as phenol or silver nitrate in an
attempt to disinfect the tooth increased the rate and
extent of root resorption. Andreasen (49) concurred,
saying that attempts to sterilize the tooth surface may
damage or destroy vital periodontal tissue and cementum.
30
Other chemicaltreatments of avulsed teeth beside
germicides have been used in an attempt to improve
healing. Fluorides have been the most extensively tested.
Schulman, et al (83) soaked teeth from monkeys in sodium
fluoride solution before replantation and found mixed
results, with some apparent lessening of resorption of
the fluoride-treated teeth. Bjorvatn and Massler (84)
soaked rat teeth in 10% stannous fluoride solution for
five minutes before replantation, and found increased
resorption. Dilution to a 1% solution showed an improve
ment of root resorption over control teeth, although
not totally preventing it. Bjorvatn and Weiss (85)
found that a 2% solution of sodium fluoride clearly
decreased root resorption in replanted rat molars.
Colletti (86) described a "root incision technique,"
where grooves were cut in the root exposing the canals
which were then filled with amalgam, and these teeth
were soaked in a 1 O% stannous fluoride solution for two
minutes. He claimed a 94% success rate in human teeth,
although he accepted ankylosis as an acceptable result.
31
In.another study Schulman, et al (83) found that after
tooth immersion in fluoride and replantation, the fluoride
vas taken up significantly into the bone of the socket wall.
White (87), in 1975, related a case where teeth traumatic
ally avulsed were replanted after lying at the bottom
of a swimming pool for 24 hours. Healing was good, and
the author thought that since both were halogens, the
effect of chlorine may have been similar to that reported
by fluoride. Robinson and Shapiro (88) soaked hamster
molars in a diphosphonate solution before transplantation,
but found no difference in healing compared to control
teeth. Huebsch (89) treated root surfaces of dog teeth
with methyl-2-cyanoacrylate adhesive before replantation,
but the teeth were all exfoliated within fourteen to
sixty days. Nordenram, ~ al (90) superficially deminer
alized roots of monkey teeth in hydrochloric acid, re
planted teeth, and.found that the demineralizing treat
ment caused an accelerated resorption and ankylosis of
the teeth. Bjorvatn and Weiss (85) found that soaking
roots in tetracyclines before replantation produced a
marked increase in alveolar bone growth, so that roots
so treated became quickly ankylosed. Fong and Berger
(91), attempting to reduce the antigenicity of tooth
transplants, irradiated the teeth with high doses of x
radiation, but observation of the transplants showed that
the radiation destroyed the viable tissues of the
autograft,.so that poor healing and no further root
development resulted.
~~ny studies have been undertaken to determine the
effect of endodontic therapy on replanted teeth. Some
authors felt it preferable to replant without pulp
therapy. In 1929, Skillen and Lundquist (7) replanted
teeth in dogs, and found that "the (endodontically)
treated tooth suffered much more extensively through
resorption than the untreated, fusion of bone and
32
cementum also occurring in the former." The exact method
of endodontic treatment was not mentioned, nor was it
clear whether or not the extraoral times were equal.
Various studies have shown that sometimes pulp vitality
can be maintained to some extent. Costich, gt al (92)
immediately replanted 29 hamster molars immediately after
extraction. At three months, most had vital tissue in
the canals, some with osteodentin formation, .but almost
one half also showed ankylosis. Sorg (93) replanted
twenty hamster second molars with developed apices
within five minutes after extraction. Sixteen of twenty
teeth were retained until the 34 to 63 day sacrifice time.
Nine of these sixteen showed regenerated nerves within
the pulp, three of these pulps being histologically
normal, six pulps showing normal tissue with varying
amounts of osteoid material. Morrison (94) reported a case
33
where a central incisor with an undeveloped apex was
replanted within 30 minutes of traumatic avulsion. Three
weeks later the tooth responded to thermal and electric
vitality tests, and two years later a normal completely
developed root apex was seen on x-ray examination. Ten
years later the pulp chamber was completely filled
in radiographically, but the periapex and periodontal
ligament appeared normal. Henning (80) felt that it was
probable that the time taken in performing root filling
before replantation led to damage to the root surface
because of increased extraoral time, which may outweigh
the benefits of pulp removal. Rothchild, et al (95)
replanted teeth in dogs, and concluded that there appeared
to be little difference, if any, between endodontic and
non-endodontic replants with respect to ankylosis and
bone deposition (at 30 days.) This was not in agreement
with the earlier study by Knight, ~ al (31), also using
dogs. Knight found that although all teeth showed mild
to severe diffuse resorption, localized cervical resorp
tion was much worse in the untreated teeth. Ankylosis
occurred with equal frequency in treated and untreated
teeth, but general tissue response was better in t~e
treated teeth. They recommended that replanted teeth
have root canal therapy done as soon as possible. Barbikow
(45) replanted central incisors in monkeys with and with
out root canal therapy, with an average time extraoral of
34
fifteen minutes. They found no difference in healing for
up to eight weeks, other than the presence of periapical
abscesses in the non-treated teeth. Andreasen and HjBrting
Hansen (43) followed up 110 replanted human teeth. They
concluded that if a replanted tooth was not endodontically
treated and the pulp became necrotic, toxic products from
the pulp could destroy the periodontal membrane and
cementum via the dentinal tubules. This would cause poor
healing and inflammatory resorption, usually leading to
loss of these teeth in from two to ten months.
Often the stage of root development has been used as
a factor in deciding whether to replant and hope for pulp
revitalization, or to perform endodontic therapy. Anderson,
et al (56) found that the size of the opening of the apical
foramen was important to pulpal survival. Andreasen and
HjBrting-Hansen (43) reported that seven of thirteen
human teeth with open apices replanted without endodontic
therapy showed pulp survival, with gradual obliteration
of the pulp chamber. Six teeth showed pulp necrosis, five
of these with extensive rapid inflammatory resorption.
Andreasen (46) found that teeth with open apices may
revascularize if out of the socket for less than 30
minutes, with some chance of revascularization up to two
hours. Most of these teeth showed arrested root develop
ment and pulp canal obliteration with osteoid or bone.
35
Monsour (96) replanted anterior teeth with open apices
in eight dogs. Most teeth showed the entire pulp chamber
filled with granulation tissue leading to "osteo-dentin"
deposition by cells differentiated from the fibrous
replacement tissues. He felt that vital replantation
was superior to root canal therapy if done immediately II
and with open apices. Ohman (97 & 98) studied teeth that
were replanted immediately and reextracted at various
later times, finding that regenerating nerve fibers were
evident at one month. This was consistant with vital pulp
test responses that were seen two months after replantation
in 33 of 37 teeth tested. He said that a better indica-
tion of vitality was the reduction in the size of the pulp
chamber radiographically. Smith (99) reported a case
where a 26 year old man replanted his own tooth immediate-
ly after it was totally avulsed into his mouth. Although
the apex was fully developed, it remained in function for
25 years with calcific degeneration of the pulp, but no
root resorption or apical rarefaction was evident radio-
graphically. In spite of an isolated case like this,
Whiteacre and Edwards (100) said that pulp necrosis occurred
in over 80% of replanted teeth with closed apices, and
root canal therapy should be instituted as soon as this
occurs.
36
The length of time that an avulsed tooth is out of
the socket, and thus the degree of pulp tissue breakdown,
should be of prime importance in deciding whether or not
to institute immediate endodontic therapy. Heithersay
(101) normally recommended replanting the tooth
immediately, then commencing root canal therapy within
ten days, unless the tooth was out longer than two hours,
in which case endodontic therapy can be carried out first.
Deeb (42) said to perform endodontics prior to replanta
tion, unless the tooth was out less than one hour, in
which case endodontics should be delayed three to four
weeks to evaluate pulpal healing. Andreasen and HjBrting
Hansen (43) believed thatpulp removal and endodontic
therapy should be performed as soon as possible to prevent
inflammatory resorption from pulp breakdown products, but
not at the expense of increasing the extraoral time. The
same authors (32) in another study found that pulp necrosis
usually occurred between two and seven weeks after replanta
tion, if at all, so they recommended immediate replantation
with endodontic therapy done within two weeks afterward.
Many materials and methods have been recommended for
performing root canal therapy on avulsed teeth. Bennett
(62) believed that the material used for the root filling
does not appear to influence the reattachment, provided
there-is an adequate apical seal. Pulp extiration alone
is not advised, as Woehrle (33) found that this caused
abscess formation in replanted teeth, while complete
endodontic therapy showed minimum periapical pathosis.
Andreasen and HjBrting-Hansen (32) recommended gutta
percha and sealer as a root canal filling, while Deeb
37
(42) and Messing (29) advised performing an apicoectomy
and reverse filling with amalgam. Harndt and Hoefig (102)
described the use of a chromium-vanadium steel endodontic
implant to aid in the retention of a replanted avulsed
tooth. Marosky (103) recommended a vitallium post as a
filling material, as it could be easily removed if severe
resorption occurred necessitating extraction, with calcium
hydroxide as a sealer, as it is resorbable and may retard
resorption. Recently calcium hydroxide has itself been
shown to have an effect on root resorption. In 1973
McKinley (104) described a case where external root resorp
tion following avulsion and replantation of a central
incisor was arrested by placement of a calcium hydroxide
paste in the root canal. The tooth was later filled
with gutta-percha and sealer.
Calcium hydroxide has had a multitude of uses in
dentistry, beginning in 1930 when Hermann (105) introduced
it as calxyl for pulp capping, showing the ability of the
pulp to protect itself through formation of a dentin bridge.
38
Zander (106), in 1939, described pulp healing after treat
ment of pulp exposures with pure calcium hydroxide. Later,
in 1949, Glass and Zander (107) found that calcium hydrox
ide acts as a stimulus for the conversion of undifferent
iated mesenchymal cells of the pulp to form a new odonto
blastic layer after pulp injury. When calcium hydroxide
was used as a base, MjBr (108), in 1967, found that sound
dentin showed increased density through intratubular
secondary mineralization. Avery (109) found that calcium
hydroxide would induce reparative dentin underlying a
cavity much more readily than under an exposure. Heys ~ al
(110) showed that calcium hydroxide, when placed in cavities
of moderate depth, produced at three days a moderate pulpal
inflammatory response. By five weeks a decrease in inflam
mation and the formation of repairative dentin was seen,
with sclerosis of dentinal tubules. Macchetti and Toledo
(Ill) used tetracycline to study secondary mineralization
of healthy dentin under calcium hydroxide bases, and found
increased mineralization in the dentin below the base,
and at the dentinopulpal boundry. The time during which
calcium hydroxide acted on the dentin was relatively short,
reaching its maximum on the second day after treatment,
with the effects disappearing completely by the fifth
day. Eidelman, et al (112) placed calcium hydroxide over
the deepest one millimete~ of remaining carious dentin
(indirect pulp cap) after deep excavations. They found
a significant increase in phosphorous content when the
remaining dentin was checked after two to twelve weeks,
indicating that a remineralization of the carious dentin
occurred. Spedding, ~ al (113) found that 60% of pulp
caps in monkeys were successful when calcium hydroxide
was used, while formocresol showed 70% success and was
39
judged superior as a pulp capping agent .. Kozlov and
Massler (114), however, found that pulp caps in rat molars
with calcium hydroxide produced a good repairative reaction,
with a small zone of inflammation, well encapsulated.
Under this a wide bridge of repairative dentin was formed
centrally and laterally to bridge the site of amputation,
with normal, relatively uninflamed, pulp beneath.
Krakow, gt gl {115) and Moodnik (116) recommended
vital calcium hydroxide pulpotomy for immature teeth with
damaged pulps, in order to allow for continued apical
development. While Moodnik advised that root canal
therapy be performed after apical closure, Krakow said
that it was not necessary unless calcification of the canal
was seen on recall examination. Via (117) studied 800
cases of calcium hydroxide pulpotomies, and found only
31.1% success, most failures because of internal re---
sorption. SchrBder and Granath (118) stressed the
importance of the calcium hydroxide being in intimate
40
contact with vital pulp tissue, because otherwise an
eosinophilic calcium-hydroxide-fixed extra-pulpal blood
clot was formed betweeh the two. This could give rise
to chronic granulation tissue and internal dentin resorp
tion. SchrBder (119), and SchrBder and Granath (120)
found, after experimental pulpotomy, a layer of necrosis
immediately beneath the calcium hydroxide which irritated
the underlying pulp to respond with hard tissue formation.
They believed that the high pH of the calcium hydroxide
was responsible for the tissue changes.
In 1961, Nygaard-Ostby (121) described apical closure
by hard tissue deposition of teeth with open immature
apices and necrotic pulps. He accomplished this by
placing a short root canal filling after purposely lacer
ating the periapical tissues to produce a blood clot,
which organized into cementum-like tissue. Kaiser (122)
in 1964 introduced the idea of treating these teeth with
a paste made by mixing calcium hydroxide with camphorated
parachlorophenol, which produced a bridging over the apex
allowing proper obliteration of the canal and eliminating
the need for surgery. Frank (123) in 1966 expanded on
Kaiser 9 s treatment, outlining a step-by-step proced~re
for calcium hydroxide and camphorated parachlorophenol
treatment of open-apex permanent teeth with necrotic pulps.
Michanowicz and Michanowicz (124) in 1967 recommended
placing a layer of calcium hydroxide at the end of a
canal with an open apex, and condensing gutta-percha and
sealer into the canal. Frank (125) in 1967 explained
that calcium hydroxide was used for the apexification
technique because it was simple and inexpensive, but
that it was the removal of infection, not the calcium
41
hydroxide, that allowed Hertwig's sheath to resume its
function of apical closure. Steiner, ~ al (126) thought
that introduction of the calcium hydroxide paste after II
stimulating apical bleeding (Nygaard-Ostby) may be the
most favorable condition for stimulating closure of the
apex. Van Hassell and Natkin (127) in 1970 reported
calcium hydroxide-induced root end closure of immature
molar teeth with necrotic pulps. In 1971 Dylewski (128)
studied calcium hydroxide apexification of immature monkey
incisors, and found that instead of a continuation of
normal root development, the calcium hydroxide induced a
repair process in the connective tissue of the apical
area. That same year Steiner and Van Hassell (129) found
that the calcific root end closure that formed when calcium
hydroxide was used satisfied the usual criteria for identi
fication as cementum. Torneck and Smith (130) and Torneck,
gt al (131, 132, 133) studied the effects of various
procedures on the apical development of immature monkey
teeth. Some degree of root growth and foraminal closure
were seen after pulpectomy with and without coronal seal,
and with and without canal disinfection and medication.
The use of a calcium hydroxide treatment paste, however,
increased the predictability and amount of hard tissue
formation over any of the other treatments.
Other authors have questioned the value and effect
of the calcium hydroxide in apexification. Ham, et al
(134) found that periapical healing and calcified tissue
42
formation could occur in monkeys with either short gutta-
percha or calcium hydroxide paste fillings. Roberts and
Brilliant (135) in 1975 found that tricalcium phosphate
was as effective as calcium hydroxide in inducing apical
closure in human immature pulpless teeth. They concluded
that it was not the highly alkaline pH of calcium hydrox
ide (11.8) that induced closure, because the pH of the
tricalcium phosphate was only 8.6. In 1977 England and
Best (136) extripated the pulps in 40 permanent premolars
with immature apices in seve~ young dogs, leaving half
of the teeth open to the oral environment and sealing the
other half with a temporary cement. Without the use of
any drugs in the canals, by seven to eleven weeks 85.5%
of the open teeth and 50% of those that were closed -
showed complete apical closure. It was concluded that
drugs such as calcium hydroxide were not necessary to stim-
ulate apical closure in dogs.
Calcium hydroxide pastes also have been evaluated
as a root canal filling material in teeth with mature
apices. Matsumiya and Kitamura (137) found that filling
the root canals with a paste made of calcium hydroxide
43
and sterile water had the effect of accelerating the
natural healing functions in the periapical tissues of
dogs. They felt that this was due in part to an anti
microbial effect of the calcium hydroxide in the apical
tissues. Holland (138) and Martin and Crabb (139) reported
that calcium hydroxide was an excellent root canal filling
material, showing periapical healing by hard tissue for
mation, throughaprocess similar to the pulp healing when
the same material is used there. Stromberg (140), however,
showed no statistically significantdifferences in healing
between teeth filled with calcium hydroxide, dibasic
calcium phosphate (pH7) and gutta- percha with chloro
form-resin. Weinstein and Goldman (141) found that no
apical bridging was observed after mature monkey teeth were
debrided and filled with calcium hydroxide paste. They
concluded that the metabolism of teeth with mature apices
was quite different from teeth with immature apices.
Calcium hydroxide has been shown by Frank and Weine
(142) to effect the periodontal healing of a perforative
defect of internal resorption when placed in the debrided
canal. A later permanent root canal filling may then be
placed against a matrix of normal periodontal tissues.
44
Frank (143) further applied this technique to aid in the
repair of mechanical performations as the result of a
misdirected bur. Stewart (144) also demonstrated the
healing of internal or external root resorptive defects
after placement of a calcium hydroxide paste into the
canal. He suggested that metacresylacetate was less
irritating and gave more rapid healing with calcium
hydroxide than did the camphorated parachlorophenol used
by the previous two authors quoted. Sinai (145) in 1977
suggested that the induction of calcification external to
the tooth by calcium hydroxide is basically the same
process whether resorptive perforations or open apices
are the sites of calcific repair.
Andreasen (46) in 1971 suggested that endodontic
therapy may arrest inflammatory resorption in replanted
teeth by eliminating toxic degenerating pulpal products.
He recommended calcium hydroxide as the root canal filling
material in immature teetho Nine out of ten cases treated
with calcium hydroxide showed new periodontal ligament
formation and arrest of resorption. In five cases the
apical foramen sealed withhardtissue or completed root
formation. The same author (49) recommended convenrional
root canal therapy with gutta-percha and sealer for
mature replanted teeth showing inflammatory root resorp- .
tion. In some cases he thought that it would lead to an
arrest of the resorptive process. Cvek (146, 147)
found that treatment of replanted avulsed human incisors
showing external root resorption with calcium hydroxide
or gutta-percha and sealer showed the same results. 98%
of the for~and 94% of the latter showed arrest of pre
existing external root resorption after treatment. He
felt that the high frequency of success in both groups
suggested that the removal of necrotic pulp tissue was
45
the decisive factor in the healingof external root resorp
tion of the inflammatory or non-ankylosing type. In 1976
Burke (148) described a clinical case where external in
flammatory root resorption was arrested in a replanted
tooth after filling of the canal with a calcium hydroxide
paste, with the development of a radiographically normal
periodontal ligament. A thorough histologic study has
not been reported investigating the value of the placement
of calcium hydroxide paste into the root canal at the time
of replantation, or the subsequent effect on root resorp
tion.
Vital stains or dyes have been used in various
studies as markers to study the apposition and resorption
of bone, cementum, and dentiTh Hoyte (149) described the use
of alizarin red for this purpose, and Frost (150) the use
of tetracycline, which can be seen under fluorescent
microscopic examination. Goland and Grand (151) found
that Procion dyes, when given intravenously, permanently
46
marked incremental lines and zones of growth in teeth and
bone. The markers persisted during processing and decal
cification of the specimins. Prescott, et al (152) found
that Procion Brilliant Red H-8BS was the most efficient
marker of the Procion dyes, and could be seen under both
ultraviolet light and light microscopy, even in decalcified
paraffin sections cut at 7~ • This same dye was used by
Sherman (63) in 1968 to study resorption of teeth after
replantation, and by Ham, ~ al (134) in 1972 to s~udy
apexification. Binnie and Mitchell (153) used both tetra
cycline and Procion H-8BS to study induced calcification in
rat connective tissues, and Reames, et al (154) used the
Procion dye to label new bone overlying submerged retained
roots.
CHAPTER III
MATERIALS AND METHODS
Six healthy young adult beagle dogs, of inter
minate age, randomly selected, three male and three
female, each weighing between 9.9 and twelve kilograms
were used in this study. The animals were individually
caged and maintained on a diet of standard laboratory·
meal and water ad libitum. All were radiographed
preoperatively to ensure normal anterior tooth anatomy
with complete apical development, and were examined
to determine that periodontal disease was either not
present or was limited to marginal gingivitis. All
radiographs in this study were taken using standard
bisecting angle radiographic technique, with a portable
hand held x-ray generator giving 60 K.V.P. at 20 mili
amperes at 0.4 second exposure time. Kodak (a) peri
apical ultra-speed film, size two, was held by a spring
type mouth-prop, with the x-ray source-to-film distance
kept close to twenty centimeters. Radiographs were
developed in a portable light-tight developing box in
Insta-neg (b) rapid developing solution for twenty seconds,
a Eastman Kodak Company, Rochester, New York.
b Microcopy, Culver City, California.
47
fixed in Insta-fix (b) concentrated fixer for forty
seconds, and washed in running water for five minutes.
Each suitable animal was premedicated with an
intramuscular injection of 1 cc. of Innovar (c) per
10 kilograms of body weight, the active ingredients
being fentanyl citrate 0.4 mg./ml. and droperidol
20 mg./ml., to sedate the animals and make them more
48
manageable, and also with a subcutane(j)US injection of
1.5 cc. of Atrosed (d) per 10 ~ilograms body weight,
active ingredient atropine sulfate 0.5 mg./ml., to limit
salivary flow. When the desired sedative effect was
reached, a foreleg was shaved, swabbed with alcohol,
the large anterior vein located, and an intravenous
injection of sodium pentabarbital (e) 65 mg./ml., an
intermediate acting barbiturate, was given to effect
(approximately 4 cc./10kg.,) as determined by the loss
of pedal reflex and the passage through the stage of
excitement into one of slow, steady resperation. When
the proper level of anesthesia was reached, the left
and right maxillary second incisors were extracted, . using sterile elevators and forceps, as atraumatically
and aseptically as possible, and held in sterile,
c Pitman-Moore, Inc. Washington Crossing, New Jersey.
d Burns-Biotec Laboratories Division, Chromalloy Pharmaceutical, Inc., Oakland, California.
e W.A. Butler Company, Columbus, Ohio.
dry, gauze during endodontic therapy, to allow the
periodontal ligament to dry, and serve as a controlled
stimulus for root resorption in experimental and control
teeth equally. In both left and right incisors lingual
access cavities were prepared to the pulp with a sterile
bur, and a number fifteen K-type endodontic file was
inserted until the tip could be seen through the apex,
sometimes easily accomplished, and sometimes requiring
some degree of force due to the multiple small foramina
common to dog root apices. The length of the files
were adjusted, and the canals were filed, using frequent
irrigation with 5.25% sodium hypochlorite solution, to
approximately a number forty file, one millimeter short
of the apex, and subsequently step-flared (1) several
sizes larger. Care was taken that the canal irrigant
49
not touch the external root surface. One of the incisors,
alternating left and right side on every other dog, was
immediately filled with laterally condensed gutta-percha
(f) and Procosol (g) non-staining root canal sealer,
while the contralateral tooth was filled with calcium
hydroxide powder and barium sulfate powder (for radio
opacity) in a proportion of 6al, mixed to a thick paste
with camphorated monoparachlorophenol, and vertically
condensed to the apex with hand pluggers. The access
f Premier Dental Products Co., Philadelphia, Pennsylvania g Proco-sol Chemical Co., Inc., W. Conshohocken, PA
cavities were sealed with amalgam, and each tooth was
slowly but firmly replanted into its socket after being
held in dry sterile gauze for exactly sixty minutes
extraoral time. The periodontal ligament tissues on
the root surfaces were disturbed minimally during
treatment (other than allowing them to dry out,) and
50
the sockets were not curetted, but were flushed with
sterile saline, so as to loosen the blood clot but not
to remove periodontal ligament tissue on the socket wall.
Then the mandibular second incisors were extracted,
treated identically to the maxillary teeth, but filed
to one instrument size smaller apically due to the
smaller size of the canals, and each tooth was replanted
also in sixty minutes after its extraction. The labial
enamel of the six incisors in each arch was etched with
a phosphoric acid solution for one minute, great care
being taken not to let the etching solution touch the
gingival tissues, washed with a gauze pad soaked with
water, and air dried. Each replanted tooth, and the
tooth on either side of it, were notched on the labial
surface with a bur, wrapped with orthodontic ligature
wire in a tightly twisted figure-eight fashion, and the
labial surfaces of the teeth and wire were covered with
an orthodontic adhesive resin (h) for stabilization.
h Ortho International Services, Inc., Wilmington, Delaware
Postoperative radiographs were taken, and the animal
was placed back in its cage and given its normal diet
and water ~ libitum. Each animal appeared normal and
healthy by the first postoperative day.
Thirty days after the replantation procedure each
dog again was sedated with the same intramuscular dosage
of Innovar, and anesthetized lightly with intravenous
sodium pentobarbital. The splints were removed with a
scaler if still present, and the teeth were checked for
mobility and periodontal condition, specifically pocket
51
depth and gingival inflammation. Radiographs were taken,
and each dog received an intraperitoneal injection of the
vital dye Procion Red H-8B (i), 200 mg./kg. body weight,
in sterile saline to make 10 cc. of solution.
Sixty days postoperative each dog was sedated,
anesthetized, radiographed, and the teeth examined for
mobility and periodontal condition.
At ninety days postoperative time, each dog was
sedated with Innovar, anesthetized with pentobarbital,
radiographed, and examined for tooth mobility and perio
dontal condition. It was then sacrificed by giving an
intravenous injection of 10 cc. of Bueuthenasia-D (j),
i Polysciences, Inc., Warrington, Pennsylvania.
j Burns-Biotec Laboratories Divsion, Chromalloy Pharmaceutical, Inc., Oakland, California.
a highly toxic parenteral solution of sodium pento-
barbital 195 mg./ml., and phenytoin sodium 25 mg./ml.,
specifically designed for rapid and painless euthenasia
of animals. Cessation of vital signs occurred usually
within ten seconds after injection of the drug. The
52
soft tissue surrounding the anterior maxilla and mandible
was quickly and carefully dissected free, and the an-
terior teeth with the surrounding bone was cut free
with an electric bone saw, and immediately placed in
10% neutral buffered formalin for fixation. The labial
and lingual plates of cortical bone were thinned and
opened in areas adjacent to the teeth to be studied to
allow for better fixation, and the formalin solutions
were changed every 24 hours for the first few days. The
specimins remained in the formalin for at least two weeks.
Subsequent to fixation, the jaws-were decalcified
for four to five weeks in a solution made up of equal
parts of solutions of 50% formic acid and 20% sodium
citrate, until radiolucent radiographically and of a
rubbery consistancy, when they were cut with a razor
blade into blocks of bone containing the individual
replanted teeth. A tooth which was not replanted was
included from each animal as a control. The individual
blocks were decalfified for several days to allow better
penetration. ~h individual tooth-bone block was then
cut into three segments, apical, middle, and cervical,
53
which were dehydrated in increasing concentrations of
alcohol and embedded in paraffin. Seven micron sections
were cut from the apical end of each segment, seven slides
with from ten to sixteen sections per slide from each
tooth segment. Of these seven slides, the first, fourth,
and seventh slides were stained with hematoxylin and eosin,
while the other four slides were left unstained and mounted
for examination by fluorescent microscopy or for possible
future special staining.
The radiographs of each pair of teeth were mounted
in plastic mounts, in the sequence of preoperative,
immediate postoperative, thirty day, sixty day, and ninety
day, so that the radiographic progression of healing and/or
pathosis could easily be determined.
CHAPTER IV
RESULTS
The operative procedures and postoperative course
of healing were accomplished quite smoothly. The only
problem encountered during the experimental replantation
was the difficulty of extraction of the mandibular inci
sors of the dog. Because of the combination of very resil
iant periodontal ligaments and thin roots of these teeth,
roots were fractured in dogs one and five, in spite of
extremely careful extraction technique. This necessi-
tated surgical extraction of the apical segments, and
resulted in four less teeth being used in the study than
originally planned, giving a total of twenty teeth extracted
and successfully replanted. The dogs seemed to suffer no
ill effects from the procedure after the first day, and
all animals appeared healthy throughout the study, with
no serious weight loss seen. The splints were well tol
erated and functioned well, most lasting until the 30 day
evaluation when they were removed. All replantated teeth
remained in the socketthroughout the study, with the ex
ception of three teeth in dog number four, which were
exfoliated due to severe inflammatory root resorption, two
before 30 days and one between 30 and 60 days.
The vital dye which was injected intraperitnneally at
30 days seemed to cause no ill effects on the health of
the animals, but one particular side effect was noted.
54
55
The sclera of the eye, the gingiva and lips, and the ab
dominal skin were all stained a bright red color, which
persisted throughout the study. Apparently collagen was
stained by the dye as well as bone.
After sacrifice and histologic preparation of the
specimens, a systematic microscopic examination was made
of the histologic sections, which had been assigned a
coded numbering system. This allowed evaluation of histo
logic criteria without knowledge of or bias towards the
filling material used. It was difficult to visually dif
ferentiate between filling materials microscopically, be
cause much of it was lost during processing and both the
calcium hydroxide and gutta-percha appeared as an amorphous,
granular mass when present. Thirty microscopic cross
sections were examined from each tooth segment (apical,
middle, and cervical thirds.) Each section was examined
and graded in each of five categories: normal periodontal
ligament, surface resorption with a regenerated periodon
tal ligament, replacement resorption (ankylosis), slight
inflammatory resorption, and severe inflammatory resorp
tion. Each of the 30 sections from each tooth segment
was given a numerical sco~e from zero to four in each of
the five previously described categories. This score was
determined by mentally dividing each section into four quad
rants, then noting how many quadrants in which the process
56
described in each category was seen. Thus for a given
segment of a tooth a score of between zero and 120 was
given in each histologic category. Twenty teeth studied,
divided into three segments each, with five histologic
categories, resulted in 300 histologic scores. The
results of this examination were charted for each dog
in tables one through six. The radiographs were examined
without knowledge of the corresponding histologic results,
and were also included in these tables, along with the
clinical periodontal observations.
The histologic categories were based on Andreasen's
(43) three types of external root resorption, with the
added classifications of normal (unresorbed) cementum. It
was found during examination of the sections that inflamma
tory resorption was seen in two extremes. One was called
slight inflammatory resorption, and showed shallow punched
out areas through the cementum, extending into the dentin
not more than one quarter of its thickness. The periodontal
ligament in these areas showed mild inflammatory cell in
filtration, with occasional osteoclasts present along the
dentinal walls of the resorbed defects. Repair of resorp
tion by cementum was sometimes seen adjacent to th~se areas.
The second type was called severe inflammatory resorption,
and was seen as large areas of granulomatous tissue extend
ing from the periodontal ligament deep into the dentin,
57
often encompassing one-quarter to one-half of the tooth in
cross section, and extending into the root canal space. At
the interface with the dentin, under high-power examina
tion, was seen scooped-out areas of resorption, most
filled with a multinucleated osteoclastic cell (figure 12, 13.)
The granulomatous tissue was composed of a loose connective
tissue framework with many capillaries, densely infiltrated
with many polymorphonuclear leukocytes and lymphocytes,
with occasional plasma cells, macrophages, and giant cells.
These two types of inflammatory resorption were probably
differing degrees of the same pathologic process, or ar
rested and active forms. Nevertheless, they appeared in
separate and distinct areas, with little gradation in
between. For the purposes of comparing the two filling
materials, the presence of each type of inflammatory res
orption was computed separately. Inflammatory resorption
was seen radiographically as radiolucent areas within the
tooth or bone (figure 14, 17.)
The maxillary left incisor of dog number two, filled
with calcium hydroxide, was cut in two by severe inflammatory
resorption, with loss of the cervical two thirds of the
tooth. Histologic sections through the cervical area showed
a massive infiltration of plasma cells, indicating a severe
inflammatory response (figure 18,19.) It is possible that this
might suggest the presence of an autoimmune response.
58
The third histologic category was replacement resorp
tion, or ankylosis. Histologically, this was seen as areas
of resorbed dentin fused intimately with alveolar bone
(figure 3, 8.) This was seen sometimes as isolated tra
beculae of bone occasionally in contact with dentin, or
as large areas of contact, sometimes involving almost the
entire periphery of the root. Osteoblasts were often seen
lined up along the periphery of the dentin and bone, in
dicating active bone formation, even at the 90 day sacri
fice time. Radiographic findings in ankylosis included
disappearance of the normal periodontal ligament space,
and continuous replacement of resorbed root surface with
bone (figure 9. )
The most prevalent histologic category seen in this
study was surface resorption repaired by cementum. Small
resorptive lacunae were seen along the dentin and cementum
surface, repaired by cellular secondary cementum (figure 5.)
A normal periodontal ligament was present. This type of
resorption was also seen in areas of the roots of unoper
ated control teeth, and is evidently an area of spontaneous
repair of small areas of damaged cementum.
The fifth histologic category was the presence of
normal periodontal ligament and unresorbed cementum (figure
3.) There were relatively few areas showing this lack of
root resorption, although it was more prevalent in cervical
areas than in apical or middle. Both repaired surface
resorption and normal ligament and cementum were seen
radiographically as having a normal periodontal space
around the replanted tooth.
It must be stressed that never was an entire root
59
or root-third seen histologically as fitting into one
category of healing or resorption. Usually even one his
tologic cross-section showed two or three categories (figure
3.) For example, repaired surface resorption was often
interspersed with areas of ankylosis, and even severe
inflammatory resorption was seen in the same cross-section
with normal cementum and periodontal ligament. From this
it is obvious that accurate radiographic interpretation of
the root resorptive processes is impossible, unless a large
area is grossly affected.
The three teeth in dog number four, which were exfol
iated because of extensive inflammatory root resorption,
were histologically scored as showing total inflammatory
root resorption, given 120 points at each level, even
through by the 90 day sacrifice time the sockets were in an
advanced state of healing. The inflammatory resorption was
clearly evident in the 30 day radiographs, with large radio
lucent areas surrounding the roots, leading to exfoliation.
By 90 days radiographic evidence of bony healing of the
sockets could be seen.
60
The Procion vital dye was not seen to fluoresce as
was expected when unstained sections, or th~estained with
hematoxylin and eosin, were examined with the fluore
scent microscope. Unresorbed cementum on unreplanted
control teeth and on a very few sections of replanted
teeth demonstrated a darker-staining red band in the
hematoxylin and eosin stained sections. Without the con
firmation of the fluorecence, it was not determined
whether this was a layer of secondary cementum laid down
and stained by the vital dye, or merely a zone of darker
staining by the hematoxylin and eosin.
Table 7 shows a summary of the histologic scores for
all twenty teeth, grouped according to the five histologic
criteria studied, the three segrrents of the teeth studied,
and the two different canal filling materials used. Since
the purpose of this study was to determine whether a dif
ference in root resorption would be seen between teeth
filled with gutta-percha and sealer or calcium hydroxide,
the histologic results were subjected to statistical ana
lysis. Within each of the five resorption catagories
studied, and for each third of the root surface studied, a
two-sample t-test was applied, comparing the scores of
the ten teeth filled with each material. The formulas used,
the limits at 5% and 1% probability, and the t-test results
61
can be seen in Table 8. The results showed no statistically
significant difference in histologic scores between the two
filling materials, at either the 5% or 1% level of proba
bility, at any level of the root examined. Since no
differences were seen within any of the groups as divided
according to root third, statistical analysis of the total
tooth scores was thought to be unnecessary and was not done.
In Table 9, the teeth were grouped in the same cate
gories, but the histologic results were evaluated to spe
cifically comparethe paired contralateral teeth, one
filled with each material. This may also be a valid
analysis, because variations in healing and tissue response
between animals are eliminated. For each category including
ten pairs of teeth, the number of teeth filled with each
filling material showing the higher score of the pair in
each category of evaluation is listed. The number of
times the two teeth showed equal scores in a given cate
gory is also shown. Careful examination of this table
may give additional information beyond the point totals and
statistical analysis in tables seven and eight.
TABLE 1 Normal Surface ~eplacement Slight Severe
Dog Ill Periodonta Resorption, Resorption Inflammat. Inflammat. Ligament & Regenerate( (Ankylosis) Resorption Resorption Cementum P. D. L.
Histologic Scores, 30 sections each 1/3, scored 0-120 Maxillary Apical 8 84 82 5 0 Incisor Gutta- Middle 4 56 117 7 0 Percha
Cervical43 49 55 34 0
Maxillary Ap. 0 53 76 17 11 Incisor Ca(OH) 2 Mid. 12 106 81 20 0
Cerv. 34 63 14 38 30
Mandibular Incisor Gutta- Tooth fractured during extraction Percha
Mandibular Incisor Ca(OH) 2 Tooth not extracted
Radiograph. Appearance
-
Good, mild Ankylosis
II
II
Good, mild Ankylosis
II
II
~linical Periodonta !Appearance
Tooth firm, gingiva
uninflamed
Tooth firm, gingiva
uninflamed
0'1 N
TABLE 2 Normal Surface ~eplacement Slight Severe Radiograph. Clinical
Dog 112 Periodontal Resorption, Resorption Inflammat. Inflammat. Appearance ,Periodonta Ligament & Regenerated (Ankylosis) Resorption Resorption Appearance Cementum P, D. L,
Histologic Scores, 30 sections each 1/3, scored 0-120 IMild Tooth Maxillary Apical 0 68 75 55 0 ~nkylosis slightly Incisor mobile, Gutta- Middle 6 49 113 58 0 II gingiva Percha slightly
Cervical 2 44 29 47 10 Inflammat. inflammed resorption
Maxillary Ap. 0 49 68 32 59 Inflammat. Crown lost, Incisor resorption periodonta, Ca(OH) 2
tissues Mid. 0 0 0 0 120 II inflammed
Severe inf. resorption,
Cerv. 0 0 0 0 120 crown lost
Ap. 0 96 0 30 0 Good Tooth Mandibular firm, Incisor Mild gingiva Gutta- Mid, 15 105 0 21 0 ankylosis uninflamed Percha
Cerv. 0 66 0 37 86 Inflammat. resoq~_tion
Mandibular Ap. 0 65 10 25 30 Very good Tooth 'Incisor firm, Ca(OH) 2 Mid. 27 82 30 33 0 Very good gingiva
uninflamed
Cerv. 0 120 0 20 0 Very good
TABLE 3 Normal Surface ~eplacement Slight Severe Radiograph. Clinical Periodontal Re~orption, ~esorption Inflammat. Inflammat. lA ppearance Periodmtal
Dog lf3 Ligament & Regenerated (Ankylosis) Resorption Resorption Appearance Cementum P. D. L.
Histologic Scores, 30 sections each 1/3, scored 0-120 !Fairly Maxillary ~pical 0 0 0 0 120 severe Tooth Incisor !ankylosis firm, Gutta- Middle 0 0 120 0 0 ~evere gingiva Percha
ankylosis uninflamec
~ervical 38 31 45 25 0 Good
~p. 0 26 99 40 0 Fairly Tooth ~evere Maxillary ~nkylosis
firm, Incisor gingiva Ca(OH) 2 Mid. 24 35 57 52 0 Mild uninflamed
~nkylosis
~erv. 30 20 38 21 9 ~ood
~p. 0 57 0 45 17 Severe Tooth linflammat. Mandibular Ire sorption slightly
Incisor mobile, Gutta- Mid. 23 53 49 38 0 ~ood gingiva Percha inflamed
Cerv. 45 90 0 63 0 ~ood
~p. 0 42 58 44 0 ~~ld Tooth Mandibular linflammat. firm, Incisor Ice sorption gingiva Ca(OH) 2 Mid. 30 49 88 37 0 Good uninflamed
~erv. 64 52 10 50 0 Good
Dog /}4
Maxillary Incisor Gutta-Percha
Maxillary Incisor Ca(OH) 2
Mandibular Incisor Gutta-Percha
Mandibular Incisor Ca(OH) 2
TABLE 4 Normal :>urface IKeplacenent !~light !Severe PeriodontalResorption, Resorption Inflammat. Inflammat. ~igament & Regenerated (Ankylosis Resorption Resorption Cementum P. D. L.
Histolo~ic Scores 30 SP('f"i(ms Ml('h 1/3 scoren 0-120 Apical I I I I 120
Severe inflammatory resorption, Middle tooth exfoliated by 30 days. 120
Cervical 120 Ap.
I 120
Severe inflammatory resorption, Mid. tooth exfoliated between.30 and 120 60 days.
Cerv. 120
Ap. 120 Severe inflammatory resorption, tooth exfoliated before 30 days.
Mid. 120
Cerv. 120 Ap. 0 55 70 26 0
Mid. 10 63 73 21 0
Cerv. 38 71 33 30 0
Rad~ograph. Clin~cal Appearance Periodamal
Appearance
Healing Gingiva socket healed by 90 days by 90 day~
Healing Gingiva socket healed by 90 days by 90 dayE
Healing Gingiva socket healed by 90 days by 90 dayE
Good Tooth firm, gingiva
Good uninflamed
Good 0\ VI
TABLE 5 ~ormal Surface ~eplacement Slight Severe ~adiograph. Clinical
Dog :f}5 Periodontal Resorption, ~esorption Inflammat. Inflammat. ~ppearance Periodonta !Ligament & Regenerated Ankylosis) Resorption Resorption 1\ppearance Cementum P, D, L,
Histologic Scores, 30 sections each 1/3, scored 0-120 Mild Maxillary A. pi cal 21 48 53 19 0 ankylosis Tooth Incisor Mild firm, Gutta- !Middle 25 83 88 20 0 ankylosis gingiva Percha uninflamec
Cervical 0 15 61 33 85 Seybre tgs i!i'J~!Sfl lAp. 1 45 80 40 0 ~oderate Tooth
Maxillary infl. or firm, replac, res. Incisor Severe
gingiva Ca(OH) 2 ~id. 1 71 84 41 0 inflammat. uninflamec
resorption
Cerv. 29 50 46 33 27 Good
Mandibular Incisor Tooth fractured during extraction Gutta-Percha
Mandibular Incisor Tooth not extracted Ca(OH) 2
TABLE 6 Normal Surface l<.eplacement Sl~ght Severe Radiograph. f.-linical
Dog i!6 Periodontal Resorption, Resorption Inflarnrnat. Inflammat. Appearance Periodonta Ligament & Regenerated {Ankylosis) Resorption Resorption ~ppearance Cementum P. D. L.
Histologic Scores, 30 sections each l/3, scored 0-120 Mild Maxillary Apical 2 57 120 0 0 ankylosis Tooth Incisor firm, Gutta- Middle 0 45 120 10 0 Severe gingiva Percha ankylosis uninflamec
Severe Cervical 7 33 66 35 0 ankylosis
Ap. 0 43 120 58 0 Severe Tooth Maxillary ankylosis mobile, Incisor Very sae:re gingiva Ca(OH) 2 Mid. 12 70 120 63 0 inflammat. uninflamec
resorption
Cerv. 24 32 0 34 45 " Ap. 0 68 120 73 0 Mild infl. Crown
Mandibular resorption lost, Incisor gingiva Gutta- Mid. 0 65 101 80 16 Severe infl inflamed Percha resorption
Cerv. 0 0 0 0 120 Crown lost
Ap. 0 82 88 42 0 Good Tooth
Mandibular ! firm,
Incisor gingiva Ca(OH) 2
Mid. 37 81 88 38 0 Good uninflamec
Cerv. 33 91 0 68 0 Good
TABLE 7 Summarized Histologic Scores
Normal Surface Replacement Periodontal Resorption, Resorption Ligament & Regenerated (Ankylosis) Cementum P. D. L.
Gutta-percha
Apical 1/3 25 478 450
Ca(OH) 2 1 460 669
Gutta-percha
Middle 1/3 73 456 708
Ca(OH) 2 153 557 621
Gutta-percha 135 328 256
Cervical 1/3
Ca(OH) 2 252 499 141
Gutta-percha 233 1262 1414
Totals
Ca(OH) 2 406 1516 1431
Slight Inflammatory Resorption
227
324
234
305
274
294
735
923
Severe Inflammatory Resorption
377
220
356
240
541
351
1274
811 "' 00
TABLE 8 Statistical Analysis
Two-sample t-test applied to histologic results of Table 7, comparing the two filling materials tested.
where s ~ = ___ < x ..... 1:;........-_. _x..;:;.1_)_2
_+ __ <_x..:2.__-_-_x:::.2 _) 2_
(N1 - 1) + (N2 - 1)
Both N1 and N2 are constant at 10, therefore degrees of freedom is 18.
Apical
Middle
Cervical
At~= .05, limits are +2.10
At«= .01, limits are +2.88
Normal Surface Replacement Periodontal Resorption, Resorption Ligament & Regenerated (Ankylosis) Cementum P. D. L. II t II value comp ~ring gutta-per pha vs. Ca(OH) 2
1.16 0.135 -1.09
0.151 -0.634 0.413
-1.30 -1.10 1.07
Slight Severe Inflammatory Inflammatory Resorption Resorption
-0. 97 6 0.715
-0.657 0.480
-0.212 0.815 0\ \o
APICAL 1/3
MIDDLE 1/3
CERVICAL 1/3
TOTAL
TABLE 9
Comparison of Contralateral Gutta-Percha and Ca(OH) 2 filled Teeth
Normal .surface Replacement Periodontal Resorption & Resorption Ligament & Regenerated (Ankylosis) Cementum P. D. L. NUMBER OF TEETH SHOWING THE HIGHER HISTOLOGIC
G-P Higher 3 6 3
CH Higher 0 3 5
Equal 7 1 2
G-P Higher 2 4 5
CH Higher 7 5 3
Equal 1 1 2
G-P Higher 3 4 5
CH Higher 5 5 2
Equal 2 1 3
G-P Higher 8 G-P 14 G-P 13
CH Higher 12 CH 13 CH 10
Equal 10 Equal 3 Equal 7
Slight Severe Inflammatory Inflammatory Resorption Resorption
SCORE IN EACH CATAGORY
4 3
6 3
1 4
3 2
6 2
1 6
5 4
3 4
2 2
G-P 12 G-P 9
CH 14 CH 9
Equal 4 Equal 12
CHAPTER V
DISCUSSION
The results of this study indicate that it was im
possible to demonstrate a difference in any type of root
resorption at any level of the root when calcium hydroxide
was used as an immediate root canal filling material, when
compared with gutta-percha and sealer. No extensive con
clusions, however, should be made from the data presented
here. Due to the low sample size (twenty teeth) and be
cause only one set of experimental replantation conditions
were used, further work in this area would seem to be war
ranted. The effects of a different extraoral time and
environment are unknown as to their interaction with the
role of the canal filling material. The time of placement
of the calcium hydroxide canal dressing also may be very
important. The studies that showed promising results with
calcium hydroxide in the.arrest of root resorption all had
the paste being placed into the canals at sometime after
replantation, after resorption had begun, and after some
periodontal ligament heal~ng had taken place. Andreasen
(81) has suggested that calcium hydroxide placed into the
root canal at the time of replantation may act as a. necro
tizing agent to an unregenerated periodontal ligament,
preventing initial healing. Therfore, he suggested canal
debridment one week after replantation, with delay of calcium
71
72
hydroxide placement for two more weeks after that, to
allow for primary healing of the periodontal ligament.
This may act as a natural barrier to prevent a gross
flooding of the socket with the caustic, highly alkaline
calcium hydroxide. Nevertheless, in this study the calcium
hydroxide treated teeth showed no worse resorption than
the gutta-percha and sealer treated teeth. Gutta-percha
has been shown by many studies, including Feldman and
Nyberg (155) 1 to be very well tolerated by the tissues,
while Procosol sealer has been shown by Kapsimalis and
Evans (156) to have excellent sealing ability, and by
Rappaport (157) to evoke a very mild inflammatory response
in rat connective tissue. Therefore, this combination
should serve as a good control with which to compare the
effects of the calcium hydroxide. Further study into the
precise effect of calcium hydroxide, in the root canal,
on the periodontal tissues after replantation G warranted.
The material has such proven effects on pulpal and periapical
tissues when used as a capping or apexification agent that
it would be surprising if it had no effect when used in
replanted teeth. Other experiment conditions other than
those in the present study should be evaluated.
Calcium hydroxide has been shown to definitely alter
dentin, which may transmit changes through the tubules to
the cementum surface and periodontal ligament. Linden (158)
73
demonstrated, with an in vitro study, the presence of
molecular level pathways of communication between the pulp
chamber and the root surface. Calcium hydroxide is a small
molecule, so it may be able to penetrate these tubules.
It is not clear which part of the calcium hydroxide
molecule exerts the active effect on pulp, dentin, and
periapical tissues. Sciaki and Pisanti (159) and Pisanti
and Siaki (160) demonstrated, by the use of labeled calcium
ions, that the calcium used in the formation of the dentin
bridge over a healing pulp cap is not contributed by the
calcium hydroxide, but comes from the circulating serum
calcium. Raisz (161), studying the osteoclastic resorption
of fetal rat bone in tissue culture, stimulated by parathor
mone, found that raising the calcium ion concentration
from five to'twelve mg./100ml. had no effect on the rate
of active bone resorption. An increased calcium ion
content, however, did cause a decrease in mineral loss,
through a decrease in dissolution of bone mineral. In a
similar study, Raisz and Niemann (162) found that while a
calcium ion increase did not affect active bone resorption,
an increased phosphate concentration significantly decreased
parathormone-induced osteoclastic resorption of bone in
tissue culture. Possibly a high-phosphate root canal filling
should be studied as a root canal filling material for
treatment of root resorption after replantation. Whether
74
the fact that changes in ion concentration have been found
to alter bone resorption, may be extended to include ex
ternal root resorption is unknown. Orban (163) stated,
however, that osteoclasts are the active cells in both
bone resorption and resorption of the roots of teeth, so
research findings on bone resorption, although a separate
process, may be at least partially applicable to root
resorption.
The extreme alkalinity of calcium hydroxide, usually
reported to be around pH 12, has been suggested as being
responsible for its actions on tissue. Laws (164) found
that the pH of calcium hydroxide from a treated pulpotomy
was 7.4, the decrease attributed to dilution by the sur
rounding tissue fluids, whose pH may have been at the same
time raised somewhat. This pH effect has been suggested
by SchrBder and Granath (120) as being the cause of the
dentin bridging under a pulp cap by irritation of remaining
pulp tissue. Raisz (161) found in his tissue culture study
that parathormone could stimulate osteoclastic bone resorp
tion from pH 6·.78 to 7.45. Raising the pH to 7.6 with
bicarbonate inhibited the bone resorption significantly.
This is near the pH of the spent calcium hydroxide after
equilibration with tissue fluid reported by Laws. Although
it has not been proven directly, it would seem to follow
that perhaps calcium hydroxide, when placed in the root
75
canal, may, by penetration through the dentinal tubules or
apical foramena, have a direct effect on osteoclastic
resorption after replantation.
Menkin (165) created a severe inflammatory response
in the pleural cavity of dogs by injecting irritants. He
discovered that as the inflammation progressed, the exudate
became more acidic. When the pH increased, however, the
outlook was more favorable and the animal tended to improve.
It is possible that calcium hydroxide may change the en
vironment of the periodontal ligament from one of inflam
mation and resorption to a more alkaline pH which is more
conducive to healing and calcification of resorbed areas.
Even though calcium hydroxide has been shown by Spangberg
(166, 167) to be highly toxic to HeLa cells and human skin
fibroblasts in tissue culture, it has also been demonstrated
that it can induce calcification in connective tissue of
rats by both Mitchell and Shankwalker (168) and Binnie and
Mitchell (153). This calcification was described as being
an "osteoid" material, which is morphologically very similar
to secondary cementum, the method by which root resorption
is healed.
Binnie and Rowe (169) found that calcium hydroxide
materials seemed to be particularly useful in an infected
environment, when used as a root canal filling material.
Cvek (170), in studying apexification of teeth with
76
pulp necrosis and periapical pathosis, " assumed that
calcium hydroxide per §Q may act as a long-acting anti
bacterial agent." Fisher (171) found that viable micro
organisms were not recoverable from previously infected
carious dentine in vital permanent teeth exposed to a
lining paste of pure calcium hydroxide and water, while
simple isolation did not kill the organisms. Matsumiya
and Kitamura (137) filled experimentally infected root
canals in dogs with a calcium hydroxide paste. They found
that bacteria living in the periapical tissues were clearly
observed to diminish and disappear as healing progressed.
They concluded that "calcium hydroxide has an antibacterial
effect in the dental tissue." Since Andreasen (46) attri
butes inflammatory root resorption after replantation
largely to infected necrotic tissue within the root canal
escaping through dentinal tubules, especially in young
teeth, perhaps the antibacterial effects of calcium hydroxide
would be beneficial to the periodontal healing of this type
of resorption. To what extent this is true has not yet
been proven.
All of these theories on the possible modes of action
of calcium hydroxide on replanted teeth·must remain theories
until proven. They are not consistent with the findings
of the present study. Within its very limited confines,
therrresults showed no discernable differences in several
types of root resorption between calcium hydroxide-filled
teeth, and teeth filled with gutta-percha and sealer,
which are control materials well accepted as being
relatively innocuous in their effect on tissue.
Splinting for 30 days may have had an effect on
the results of this study, possibly causing higher inci
dence of ankylosis than if they had been removed at
77
one week as recommended by Andreasen (44). Whatever
effect that this had, however, would have been shared
equally by teeth filled by both methods. It was effective
in preventing exfoliation of teeth through eating and
chewing, before the regenerating periodontal ligament
had enough strength of its own.
As in any animal study, great care must be taken
when extrapolating results to humans. Although Nygaard
Ostby (121) and Matsumiya and Kitamura (137) found similar
healing in humans and dogs, Gad (172) found that periodontal
disease progressed five times as fast in dogs than in
humans. Whether or not there is a similar difference in
healing after replantation is unknown, as no controlled
studies have been done in this area.
Systemic .conditions and individual healing variations
may have great effect on the healing and subsequent re
sorption of replanted teeth. All replanted teeth in five
dogs in this study remained in the socket, with varying
degrees of resorption, by the termination of the study.
Dog number four, however, had three teeth exfoliate
_78
because of gross inflammatory resorption, even though all
six animals were treated identically throughout the study.
Why this dog reacted so differently to the treatment is
unknown, but the fact that there was such a variation
between animals leads to the conclusion that systemic
healing differences may account for some of the clinical
unpredictability of replantation.
Most clinical replantation studies are largely
evaluated radiographically, unless the teeth are extracted
because of failure of treatment. In general, in this study,
the correlation between radiographic and histologic results
was good only when an advanced state of pathosis was
present, such as severe inflammatory root resorption. More
moderate resorption was often difficult to diagnose properly
by the use of the radiograph. Often the loss of the
integrity of the lamina dura and lack of sharpness of
detail of the root surface was evident radiographically.
Microscopic examination, however, revealed anything from
repaired surface resorption to moderate ankyosis or mild
inflammatory r~sorption, or a combination of histologic
entities. Care should be taken in evaluating replanted
teeth radiographically, especially when testing various
methods of treatment.
It is not known why the Procion vital dye was not
seen in the histologic sections. Procion red H-8BS has
79
been reported in the literature to stain bone and cemen
tum that was being laid down while the dye was present in
the circulation. When an attempt was made to purchase
this dye from the manufacturer, their representative stated
that Procion H-8B reactive red 31 had replaced, and was
identical to1 Procion red H-8BS, so the former is what
was used in this study. They may have been in error,
however, because the dye was not seen in unstained sections,
and no fluorescence was seen. The dye may have stained
collagen but not calcified tissues, it may have been
removed from bone and cementum during fixation and de
calcification, or it may show no fluorescence even if
present. Its importance to the study was not critical,
however, and its use was intended merely as a tool to see
whether resorption occurred before or after the 30 day
time that it was injected, by the presence or absence of
a fluorescent ring of cementumo
SUMMARY AND CONCLUSIONS
Twenty maxillary and mandibular incisors in six
beagle dogs were extracted and replanted after drying
in sterile gauze for one hour. During that hour, the
root canals were debrided, prepared, and filled, half
with gutta-percha and sealer, and half with a pa~te ·made
of calcium hydroxide and camphorated parachlorophenol.
The animals were radiographed and observed for ninety
days, at which time they were sacrificed. Histologic
sections were examined and graded in five categories
ranging from normal cementum to severe inflammatory re
sorption. The histologic results were statistically
evaluated to determine whether or not there was a difference
in root resorption when the teeth were filled with calcium
hydroxide paste or gutta-percha and sealer. The experi
ment showed the following:
a) All the replanted teeth showed extensive resorp
tion when examined histologically, ranging from
surface resorption repaired by cementum depo
sition to severe anklosis or inflammatory
resorption.
b) The reaction at the surface of an individual
tooth was not uniform. Usually one type of
resorption was seen in close relationship to
another, in almost any combination. This was
80
81
true within the same histologic cross-section,
and also between different levels of the root
from apex to cervix.
c) This study was unable to demonstrate, at any
level of the root, any statistically significant
differences in any type of resorption between
teeth filled with calcium hydroxide or gutta-
percha and sealer.
d) Radiographic examination proved inadequate in ,
critically evaluating the results of replantation.
Only large areas of resorption were correctly
interpreted radiographically, when compared
with histologic sections.
e) No broad conclusions as to the value of calcium
hydroxide in treating or preventing root resorp-
tion in replanted teeth should be made from these
results alone. Due to the limited number of
teeth and the single set of replantation condi-
tions, thisstudy should be regarded as a pilot
study. Further work is necessary using varied
extraoral times and environments, as well as
with delayed placement of the calcium hydroxide
paste for several weeks after replantation.
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104. McKinley, B.: Treatment of external root resorption following avulsion and reimplantation of a maxillary central incisor, Alaska Med. J, 15 (3): 73, May, 1973.
105. Hermann, B.W.: Dentinobliteration der Wurzelkanaele nach der Behandlling mit Kalzium, Zahnarzt Rundsch 39: 888, 1930.
106. Zander, H.A.: Reaction of the pulp to calcium hydroxide, J. Dent, Res. 18: 373, Aug. 1939.
107. Glass, R.L., and Zander, H.A.: Pulp healing, J. Dent. Res. 28: 97 , 1 94 9.
108. Mjor, I.A.: Histologic studies of human coronol dentin following the insertion of various materials in experimentally prepared cavities, Arch. Oral Biol. 12 (4): 441, 1967.
109. Avery, J.K.: Response of the pulp and dentin to contactly filling materials, J. Dent. Res. 54, spec. no. 8, PB 188, June 1975.
110. Heys, D.R., Heys, R.J., Cox C.F., and Avery J .K.: Histopathologic evaluation of the effects of 4 calcium hydroxide liners on monkey pulps, J. Oral Pathol. 5 (3): 129, 1976.
111. Macchetti, D.O., Toledo, O.A.: Secondary mineralization of rat molar healthy dentin by means of calcium hydroxide: A fluorescence study, J. Dent. Child. 38 (4): 247, 1971.
112. Eidelman, E., Finn, S.B., Koulourides, T.: Remineralization of carious dentin treated calcium hydroxide, J. Dent. Child. 32 (4): 218, 1965.
113. Spedding, R.H., Mitchell, D.F., and McDonald R.E.: Formocresol and calcium hydroxide therapy, J. Dent. Res. 44 (5): 1023, 1965.
114. Kozlov, M., and Massler, M,: Histologic effects of various drugs on amputated pulps of rat molars, Oral Surg. 13 (4): 455, 1960.
91
115. Krakow, A.A., Berk, H., and Gron, P.: Therapeutic induction of root formation in the exposed incompletely formed tooth with vital pulp, Oral Surg, 43 (5): 755, 1977.
116. Moodnik, R.: Clinical correlations of the development of the root apex and surrounding structures, Oral Surg. 16 (5): 600, 1963.
117. Via, W.: Evaluation of deciduous molars treated by pulpotomy and Ca(OH) 2 JADA 50 (1): 34, 1955.
118. Schr8der, u., and Granath, L.G.: On internal dentin resorption in deciduous molars treated by pulpotomy and capped with calcium hydroxide, Odontol. Revy. 22 ( 2) : 1 7 9 ' 1 971 •
119. Schr8der, U.: Evaluation of healing following experimental pulpotomy of intact human teeth and capping with calcium hydroxide, Odontol. Revy. 23 (3): 329, 1972.
120. Schr8der, U., and Granath, L.: Early rxn of intact human teeth to Ca(00)2 follaving experimental pulpotomy and its significance to the development of hard tissue barrier, Odontol. Revy, 22 (2): 379, 1971.
121. Nygaard-Ostby, B.: The role of the blood clot in endodontic therapy, Act. Odontol. Scand. 19: 323-353, 1961.
122. Kaiser, H.J.: Management of wide open canals with calcium hydroxide, Read before the American Assoc. of Endodontists,Washington, DC, April 17, 1964.
123. Frank, A.L.: Therapy for the divergent pulpless tooth by continued apical formation, JADA 72:87, Jan. 1966.
124. Michanowicz, J.P., and Michanowicz, A.E: A conservative approach and procedure to fill an incompletely formed root using calcium hydroxide as an adjunct, J. Dent. Child. 32: 42, 1967.
125. Frank, A.L.: Treatment of the wide open apex, Dent. Clin. N. Am, p. 688, No~, 1967.
92
126. Steiner, J.C., Dow, P.R., and Cathey, G.M.: Inducing root end closure of non-vital permanent teeth, J. Dent. Child 35: 47, 1968.
127. Van Hassel, H.J., and Natkin,E.: Induction of root end closure, J. Dent. Child. 37: 57, 1970.
128. Dylewski, T.: Apical closure of non-vital teeth, Oral Surg, 32: 82, 1971.
129. Steiner, J.C., and Van Hassel, H.J.: Experimental root apexification in primates, Oral Surg. 31: 409, 1971.
130. Torneck, C.D., and Smith, J.: Biological effects of endodontic procedure on developing incisor teeth, Oral Surg. 30: 258-266, 1970.
131. Torneck, C.D., Smith, J., and Grindall: Biological effect of endodontic procedures m developing incisor teeth, part II. Effect of pulp injury and contamination Oral Surg, 35: 378, 1973.
132. Torneck, C.D., Smith, J., and Grindall, P.: Biological effects of endodontic procedures on developing incisor teeth, part III, effect of debridment and disinfection procedures in the treatment of experimentally induced pulp and periapical desease, Oral Surg. 35: 532, 1973.
133. Torneck, C.D., Smith,~' and Grindall, P.: Biologic effects of endodontic procedures on developing incisor teeth, part IV, effect of debridment procedures and Ca(OH)2 - CMCP paste in the treatment of experimentally induced pulp and perapical desease, Oral Surg. 35: 541, 1973 0
134. Ham, J., Patterson, S., and Mitchell, D.: Induced apical closure of immature pulpless teeth in monkeys, Oral Surg. 33: 438, 1972.
135. Roberts, S.C., and Brilliant, J.D.: Tricalcium phosphate as an adjunct to apical closure in pulpless permanent teeth, compared to Ca(OH)2, J. Endod. 1 (8): 263' 197 50
93
136. England, M.C., and Best, E.: Noninduced apical closure in immature roots of dog's teeth, J, Endod. 3 (11): 411, 1977.
137, Matsumiya, S,, and Kitamura, M,: Histo-pathological and histo-bacteriological studies of the relation between the condition of sterilization of the interior of the root canal and the healing process of periapical tissues in experimentally infected root canal treatment, Bull. Tokyo Dent, Coll. 1: 1 p.l, 1960.
138, Holland, R., DeMello, W., Nery, M,J., Bernabe, F.E., and DeSouza, V.: Reaction of human periapical tissue to pulp extirpation and immediate root canal fillingwithcalciumhydroxide, J, Endod, 3 (2): 63, 1977'
139. Martin, D.M., and Crabb, B.S.: Calcium hydroxide in root canal therapy. A review, Br. Dent, J, 142 (9): 277, 1977 0
140. Stromberg, T.: Wound healing after total pulpectomy in dogs. A comparative study between root fillings with calcium hydroxide, dibasic calcium phosphate, and gutta-percha, Odontol. Revy. 20 (2): 147, 1969.
141. Weinstein, T., and Goldman, M.: Apical hard-tissue deposition in adult teeth of monkeys with use of calcium hydroxide, Oral Surg. 43 (4): 627, 1977.
142. Frank, A.L., and Weine, F.S.: Non-surgical therapy for the perforative defect of internal resorption, J, Am. Dent. Assoc. 87: 863, 1973.
143. Frank, A.L,: Resorption, perforations, and fractures, Dent. Clin. North Am. 18 (2): 465, 1974.
144. Stewart, G,G,: Ca (OH)2 induced root healing, J. Am, Dent. Assoc. 90: 793, 1975,
145. Sinai, I.H.: Endodontic perforations: their prognosis and treatment, J. Am. Dent. Assoc. 95 (1): 90, 1977.
146. Cvek, M.: Clinical procedures promoting apical closure and arrest of external root resorption in nonvital p~rmanent incisors, Trans. Int. Conf. Ended. 5: 30, 1973.
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147, Cvek, M.: Treatment of non-vital permanent incisors with Ca(OH)2, II, effect on external root resorption in luxated teeth compared with effect of root filling with gutta-percha - a follow up, Odontol. Revy. 24: 343 1 1973 o
148. Burke, J,H.: Reversal of external root resorption, J. Endod. 2 (3): 87, 1976.
149. Hoyte, D.: Alizarin red in the study of the apposition and resorption of bone, Am. J. Phys. Anthrop. 2 9 I 15 7 1 1 968 o
150. Frost, H.: Tetracycline bone labeling in anatomy, Am. J. Phys. Anthrop. 29: 183, 1968.
151. Goland, P., and Grand N.: Chloro-S-Triazines as markers and fixatives for the study of growth in teeth and bones, Am. J. Phys. Anthrop. 29: 201, 1968.
152. Prescott, G., Mitchell, D., and Fahrny, H.: Procion dyes as matrix markers in growing bone and teeth, Am. J. Phys. Anthrop. 29: 219, 1968.
153. Binnie, W.H., and Mitchell, D.F.: Induced calcification in the subd<:~rmal tissues of the rat, J. Dent. Res. 52: 1087, 1973.
154. Reames, R.L., Nickel, J.S., Patterson, S.S., Boone, M., and El-Kafrawy, A.H.: Clinical, radiographic, and histologic study of endodontically treated retained roots to preserve alveolar bone, J. Endod. 1 (11): 367, 1975.
155. Feldman, G., and Nyborg, H.: Tissue reaction to root filling materials, Odontol. Revy. 13: 1, 1962.
156. Kapsimalis, P., and Evans, R.: Sealing properties of endodontic filling materials using radioactive polar and nonpolar isotopes, Oral Surg. 22: 386, 1966.
157. Rappaport, H.M.: Toxicity of endodontic filling materials, Oral Surg. 18: 785, 1964. ·
158. Linden, L.: Microscopic observation of fluid flow through cementum and dentin. An in vitro study on human teeth, Odontol. Revy. 19: 367, 1968.
159. Sciaky, I., and Pisanti, S,: Localization of calcium placed over amputated pulps in dog's teeth, J. Dent. Res. 39: 1128,1960.
95
160. Pisanti, S. , and Sciaky, I.: Origin of calcium in the repair wall after pulp exposure in the dog, J. Dent, Res, 43: 641, 1964.
161. Raisz, L.: Bone resorption in tissue culture:Factors influencing the response to parathyroid hormone, J, Clin. Invest. 44 (1), 103, 1965.
162. Raisz, L.G., and Niemann, I.: Effect of phosphate, calcium, and magnesium on bone resorption and hormonal responses in tissue culture, Endocrinology 85: 446 ' 1 96 9.
163. Sicher, H., ed.: Orban's Oral Histology and EmbryolQgy, c.v. Mosby Co., 1966.
164. Laws, A.J.: Calcium hydroxide as a possible root filling material, N.Z. Dent. J. 58: 274, 1962.
165. Menkin, V.: Biochemical Mechanisms in Inflammation 2nd ed., p. 67 Springfield, IL, Thomas, 1956.
166. Spangberg, L.: Biologic effects of root canal filling materials, II, effect in vitro of water soluble components of root canal filling material on He La cells, Odontol. Revy. 20: 133, 1969.
167. Spangberg, L.: Biological effects of root canal filling materials, ~· Toxic effect in vitro of root filling materials on He La cells and human skin fibroblasts, Odontol. Revy. 29 (4): 427, 1969.
168. Mitchell, D.F., and Shankwalker, G.: Osteogenic potential of calcium hydroxide and other materials in soft tissue and bone wounds, Ja Dent. Res. 37: 1157' 1958.
169. Binnie, W.H., and Rowe, A.H.R.: A histologic study of the periapical tissues of incompletely formed pulpless teeth filled with calcium hydroxide, J. Dent. Res. 52: 1110, 1973.
170. Cvek, M.: Treatment of non-vital permanent incisors with Ca(OH)2, I. Follow-up of periapical repair and apical closure of immature roots, Odont. Revy. 23, 27, 1972.
96
171. Fisher, F.J.: The effect of a calcium hydroxidewater paste on micro-organisms in carious dentine, Br. Dent. J, 133 (1): 19, 1972.
172. Gad, T.J.: Periodontal disease in dogs, J. Periodont. Res. 3: 268-272, 1968.
FIGURES
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98
Figure 1: Dog #4, maxillary pre-operative radiograph.
Figure 2: Dog 114, maxillary immediate post-operative radiograph. Tooth on left of photograph filled with Ca(OH)?, contralateral tooth filled with gutta-percha and sealer.
99
1
2
Figure 3:
Figure 4:
100
Dog #3, mandibular incisor, Ca(OH) 2 filling. Unreplanted control tooth (CT), replanted tooth showing normal cementum (NC), severe ankylosis at right (A). (Hematoxylin and eosin stain, original magnification X40),
Surface resorption, repaired with cementum. Schematic drawing from Andreasen (49),
101
4
Figure 5:
Figure 6:
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Dog #2, mandibular incisor, Ca(OH) 2 filling. Normal periodontal ligament and repairing surface resorption. (Hematoxylin and eosin stain, original magnification XlOO).
Dog #2, mandibular 90 day radiograph. Tooth at left, filled with Ca(OH) 7 , showing surface resorption, repaired by cementum. Tooth at right, filled with gutta-percha and sealer, showing cervical severe inflammatory resorption.
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6
Figure 7:
Figure 8:
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Progressive replacement resorption (ankylosis). Schematic drawing from Andreasen (49).
Dog #3, maxillary incisor, gutta-percha and sealer filling. Ankylosis. Dentin(D), bone (B), osteoblast (OB), osteoclast (OC). (Hematoxylin and eosin stain, original magnification XlOO).
105
Figure 9:
Figure 10:
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Dog #3, maxillary 60 day radiograph. Tooth at left, filled with gutta-percha and sealer, showing ankylosis with spotty inflammatory resorption. Tooth at right, filled with Ca(OH) 2 , showing severe ankylosis.
Severe progressive inflammatory resorption. Schematic drawing from Andreasen (49).
107
9
Figure 11:
Figure 12:
108
Dog #4, mandibular incisor, Ca(OH) 2 filling. Slight inflammatory resorption (SIR) next to normal cementum (NC). (Hematoxylin and eosin stain, original magnification X40).
Dog #1, maxillary incisor, Ca(OH) 2 filling. Cervical severe inflammatory resorption. Granulomatous tissue (GT), active osteoclastic resorption of dentin (OR). (Hematoxylin and eosin stain, original magnification X40).
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11
Figure 13:
Figure 14:
110
Same histologic section as Figure 12. Higher power view of osteoclasts ~C), or dentinoclasts, in resorptive lacunae in dentin. (Hematoxylin and eosin stain, origional magnification X100).
Dog #4, maxillary 30 day radiograph. Tooth at left, filled with Ca(OH) , showing extreme inflammatory root and bo~e resorption. Tooth at right already lost, residual socket showing diffuse radiolucency with loss of lamina dura.
11 1
14
Figure 15:
Figure 16:
112
Dog 114, maxillary incisor, Ca(OH) 2 filling. Tooth exfoliated because of inflammatory resorption. Osteoblasts forming bone around residual filling material. ~Hematoxylin and eosin stain, original magnification X40).
Same histologic section as Figure 15. Higher n0wer view of osteoblasts (OB) formir~ h0~~ around mass of connective tissue containing islands of calcified tissue (CT) and granular Ca(OH) 2 particles (CH). (Hematoxylin and eosin stain, original magnification X100).
113
Figure 17:
Figure 18:
114
Dog #2, maxillary 60 day radiograph. Tooth at left, filled with Ca(OH) 2 , showing severe cervical inflammatory root resorption. Tooth at right, filled with gutta-percha and sealer, showing mild ankylosis.
Dog #2, maxillary incisor, Ca(OH) 2 filling. Crown lost because of cervical inflammatory resorption. Epithelium (E) with dense infiltration of inflammatory cells (IC) in connective tissue. (Hematoxvlin and eosin stain, origi~al magnification X40).
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17
116
Figure 19: Same histologic section as Figure 18. Higher power view of inflammatory cell infiltration, showing predominance of plasma cells (arrows). (Hematoxylin and eosin stain, origional magnification X400).
117
APPROVAL SHEET
The thesis submitted by Dale M, Anderson, B.S., D. D. S,, has been read and approved by the following committee:
Dr. John V, Madonia, Director Associate Dean, Professor of Microbiology, Loyola University School of Dentistry
Dr. Marshall H. Smulson Professor and Chairman, Department of Endodontics, Loyola University School of Dentistry
Dr. Norman K, Wood Professor and Chairman, Department of Oral Diagnosis, Loyola University School of Dentistry
The final copies have been examined by the director of the thesis and the signature which ap:p:p.rs below verifies the fact that any necessary changes have been incorporated and that the thesis is now given final approval by the Committee with reference to content and form.
The thesis is therefore accepted in partial fulfillment of the requirements for the degree of Master of Science in Oral Biology.