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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 4  »  Monitoring pulp vitality after transplantation of teeth with mature roots
Monitoring pulp vitality after transplantation of teeth with mature roots
Discussion - References.

Revascularization is a process in which ingrowth of highly vascularized connective tissue occurs into the pulp space; or in which blood vessels already present in the pulp of the transplanted tooth anastomose with blood vessels from the periodontium (Skoglund et al . 1978, Skoglund & Tronstad 1981). Relationships have been shown between the occurrence of pulp revascularization and the level of tooth development, the surgical procedure, the extra-alveolar time period, the type of tooth and the level of oral hygiene (Andreasen 1986, Andreasen et al . 1990). Teeth that still have open apices have a high chance of revascularization and the possibility for further root development (Andreasen & Pedersen 1985). In the presented case, hard tissue was deposited in the original pulpal cavity. This tissue could histologically turn out to be tissue resembling bone or cementum in combination with a necrotic pulp. However, as an alternative, the original pulp tissue could have survived the operation (Skoglund & Tronstad 1981), and the pulp space obliterated with dentine. This process can be accelerated by trauma, such as transplantation (Andreasen et al . 1987). Though not fully understood, the accelerated deposition of hard tissue in the pulp space is explained as an uncontrolled cellular response to a trauma through which the blood supply to the pulpal tissues has been diminished (Biesterfeld et al . 1979). One explanation for the obliteration of the pulp space in an apparently mature, transplanted tooth could be that the radiographic appearance of mature root apices was in fact false. Since only the mesiodistal width of the root canal can be judged radiographically apices may seem closed, when they are open bucco-palatally facilitating the occurrence of pulp revascularization (Duell 1973). Secondly, the atraumatily and sterile surgical procedure, during which the extra-alveolar time was reduced to a minimum, may have helped to limit the chance for infection of the transplant and the surrounding tissues (Andreasen et al . 1970, Altonen et al . 1978, Kahnberg 1987). Furthermore, if the apices were actually closed, pulp revascularization might have been the result of so-called ‘transient apical breakdown’ (Andreasen 1986).
Elective root canal treatment has been proposed for transplanted teeth with closed apices (Lownie et al . 1986). Justification for this treatment is the low proportion of pulps that actually revascularize, and the high incidence of inflammatory resorption of the root. It is also justified when the pulp space is obliterated, which would make root canal treatment difficult or impossible in the event of pulp necrosis. However, it has been shown that teeth with obliterated pulp space do not become necrotic more often than those without pulp obliterations (Robertson et al . 1996). Further, if such a pulp did eventually become necrotic, root canal treatment may still be possible since the root canal has to be accessible in order to become infected with bacteria (Cvek et al . 1982).
An alternative to elective root canal treatment immediately after transplantation of teeth, even for apparently closed apices, may be to strictly monitor the patient for signs of pulpal revascularization or periradicular disease. This regime involves inspection for discolouration, sensitivity tests, tenderness on percussion, signs of inflammation, periradicular pathology and root resorption. The appointments for these assessments should be scheduled 1 week, 3 weeks, 6 weeks, 3 months, 6 months and 1 year after transplantation (Andreasen et al . 1987). This schedule is also proposed for the follow-up of avulsed teeth, which are similarly at risk for developing pulpal pathology and consequent periradicular disease (Andreasen et al . 1990). If during one of these follow-up inspections pathological signs are present, root canal treatment should commence. It is important to note that the lack of reaction to sensitivity tests alone does not mean that pulpal necrosis has occurred (Andreasen 1989). Lack of reaction to sensitivity tests at a certain inspection can be followed by a reaction the next. The possibility also exists that sensitivity does not recur after a trauma, but vitality does, as can be deduced from radiographs on which the root develops as normal without any pathological signs.
The decision not to start root canal treatment in this case was a relatively easy one, since at presentation, 5 months had already passed following the transplantation. At that time, no signs of pathology were present and the transplanted tooth has functioned without any problems or signs for 26 months. This represents a good prognosis for retaining the tooth, since most cases of pulp necrosis develop within 2 years (Andreasen & Pedersen 1985).


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