Evaluation of the effect of extraoral apicoectomy and retrograde filling for the sealing of the root canal system of mature auto-transplantation teeth

doi:10.21203/rs.3.rs-1987061/v1

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Evaluation of the effect of extraoral apicoectomy and retrograde filling for the sealing of the root canal system of mature auto-transplantation teeth

https://doi.org/10.21203/rs.3.rs-1987061/v1

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Objective: This study aimed to investigate the effectiveness and feasibility of the use of extra-oral apicoectomy combined with retrograde filling for the sealing of root canal system without root canal therapy in the process of autotransplantation of tooth（ATT） .

Materials and methods: Patients receiving autologous tooth transplantation in the Department of Oral Surgery, Hospital of Stomatology, Wuhan University from 2019 to 2020 were screened. A total 22 patients were included. All the roots of the donor tooth were fractured during tooth extraction, and root canal therapy was not performed temporarily after repairing the broken end and retrograde filling with iRoot BP plus. The periodontal status of the donor teeth 1–2 years after operation was studied, and CBCT was used to assess the presence of ankylosis, internal or external resorption of tooth, periodontitis, periapical periodontitis and omission of canal closure.

Results: 22 transplanted teeth of 22 cases were all capable of chewing, and 4 of them had adverse clinical or radiographic findings. Results show a retention rate of 100% and success rate of 81.8%. These figures are consistent with the success and retention rates of the traditional autotransplantation. 63.6% of patients were able to chew hard objects with the planted teeth, and 45.4% of the cases had food impaction.the chewing efficiency of the patient's transplanted teeth side accounted for an average of 82.0% on the healthy side.

Conclusion: The extra-oral apicoectomy combined with retrograde filling of the transplanted teeth yielded good results．

Clinical Revelance: In some special cases such as when the complex root canal system of the donor teeth cannot guarantee perfect root canal therapy, extra-oral apicoectomy and retrograde filling to seal the root canal system may be an alternative for patients with autogenous tooth transplantation.

Tooth auto-transplantation

apicoectomy

retrograde filling

chewing efficiency

ATT is a surgical procedure in which one’s own tooth is transplanted from one place to another [1]. It is commonly used to move the non-chewing third molar to the missing first or second molar extraction sockets or surgically prepared alveolar fossae. As a biocompatible rehabilitation method, ATT can repair dentition defects and maintain alveolar bone mass to maximise the use of natural teeth[1]. With the further development of oral instruments and related technologies in clinical research, the success rate of auto-transplantation has remarkably improved. The economical and practical ATT has been widely praised by dentists and patients[2].

Traditionally, root canal therapy is recommended for mature donor tooth within 2 weeks after surgery [3], and crown restoration is suggested in the later stage, which increase the time and economic cost of ATT. The complexity and diversity of wisdom tooth root canal system causes great challenges to the root canal therapy. Incomplete root canal treatment may result in the failure of ATT[3].

In clinical work, surgeons found that some patients with tooth transplantation who underwent apical resection and retrograde filling instead of conventional root canal therapy can also achieve good clinical prognosis. Relevant case reports have been published [4].

In the present study, patients with extra-oral apicoectomy and retrograde filling without root canal therapy were followed up for more than 1 year to observe the status and remediation effect of auto-transplanted teeth. Subsequently, it aimed to provide new ideas and reference for ATT.

Patient selection

A total of 22 patients with ATT were included from July 2019 to June 2020 in the Department of Oral Surgery of the Hospital of Stomatology Wuhan University. These cases involved patients with root/apical fracture caused by the extraction of donor tooth or with great difficulty in pre-operative CBCT evaluation of root canal therapy. All patients underwent extra-oral apicoectomy and retrograde filling with iRoot BP plus (Innovative Bioceramix, Inc.; British Columbia Canada V3N 0E9)during ATT surgery without conventional root canal therapy[5]. The cases were recorded 1–2 years after ATT, and the patient’s compliance was good. Informed consent had been signed. Patients who, for subjective or objective reasons, were unable or unwilling to cooperate with the observational study were excluded.

Surgical procedure

Alveolar nerve block anesthesia with 2% lidocaine and infiltration anesthesia with 4% attecaine and epinephrine (1:100,000) were administered. The donor teeth were extracted immediately after extracting the offending teeth, and the donor teeth should be stored in normal saline at 4°C immediately after extraction to ensure the vitality of the PDL. The donor teeth were wrapped with saline gauze, and the crown was held lightly. Sterile bur was used to remove or trim the root apex and rinse it with normal saline. The ultrasonic working tip was inverted and prepared to a depth of 3 mm, and iRoot BP plus retrograde filling was performed. Then, the alveolar fossa was prepared, and the enamelo-cemenal junction was placed at 2–3 mm below the gingival margin. Finally, the donor teeth were fixed with elastic ligating wires and flow resin, and the occlusion was raised with glass ions as appropriate. The patient was required to take food on the healthy side for at least four weeks, and the fixation device was removed at a follow-up visit after 4 weeks. The same materials and equipment were used for each patient.

Data collection

(1) Telephone follow-up

All patients were followed up by telephone after surgery to inquire about the survival of the auto-transplanted teeth, and arranged clinical and imaging examinations were arranged.

(2) Clinical examination and imaging evaluation

Follow-up patients were evaluated by a clinician who was not involved in the surgery procedure for clinical and radiological findings. Clinical assessment included percussion response, degree of periodontal loosening, gingival index and periodontal depth. It also includes missing tooth position and TMD condition, Ohi-s index, bruxism and occlusal relationship.

Radiographic evaluation includes is the presence of periodontal membrane space, lamina dura, transmission image and root canal omission.

(3) Questionnaire survey

The questionnaire mainly investigated whether the ATT could be used normally, the presence of any discomfort symptoms, and the satisfaction of patients with the current situation of the transplanted teeth. Scores were made to count the help of the ATT to chewing and the degree of reaching the expectation.

(4) Chewing efficiency test

A chewing efficiency test was designed to compare the difference of chewing efficiency between the ATT side and the healthy side by using the method of absorbance[6].

In this experiment, we selected 13 patients without bilateral dentition defects 1 year after receiving tooth transplantation and agreed to join the chewing efficiency test experiment.

Peanuts were selected as the chewing test. The subjects first gargled with pure water once. The weighed peanuts (1.00 ± 0.10 g) were placed into the mouth, and the patients were told to chew on the transplantation side at normal speed for 10 times. After chewing, the chewing material was transferred to a wide mouth bottle and fully mixed, 50 ml of suspension was centrifuged, and the absorbance value was measured at 590 nm using an absorbphobometer. The data were measured thrice in parallel, and the mean value was obtained. The same operation was carried out on the healthy side.[7]

After chewing for several times, the higher the chewing efficiency is, the smaller the food particles are, and the more soluble substances are produced. Subsequently, the concentration of the solution and the absorbance value increased.

GraphPad Prism 9 software was used for statistical analysis. The distribution (normal or non-normal) of the two groups of data was tested, and statistical difference in the data was determined using paired t test. P < 0.05 indicated statistically significant difference.

First, during the telephone follow-up, the patient was identified as surviving with the ATT in place and no pain or discomfort, but success cannot be determined. Failure was considered for the patient with autotransplanted tooth extracted. Failure was considered if degree II ~ III loosening or extensive root bone absorption appeared in the re-examination, and, which was difficult to repair and should be extracted, or had been extracted. Follow-up with one or more adverse clinical or radiographic findings was judged to be surviving rather than successful. The criteria for assessing transplant success are as follows: 1. No pain, tooth looseness 0-I degree, no signs of inflammation, no pain to percussion, no fistula, no gingival swelling; 2. Imaging examination showed the absence of signs of periapical, intra-, para-, or peri-radicular radiolucency, the periodontal space was intact, lamina dura was formed, and the height of surrounding alveolar ridge was not lower than that before the surgery.

Basic Information of patients

In total, 15 males and 7 females were included. Only one autotransplantation surgery was performed for each patient. The mean age was 28.68 years. The oldest patient was 51 years old, and the youngest patient was 12 years old. The clinical features are shown in Table 1. Among the donor teeth, 20 cases involved third molars, 1 case was impacted lateral incisor with cyst, and one was central incisor with periapical granuloma and calcification. Eighteen patients were transplanted immediately after tooth extraction, and four cases were transplanted within 4 weeks after tooth extraction. All donor teeth were fully developed permanent teeth with closed apical foramen. In total, 21 cases had to undergo partial apical resection or trimming and retrograde filling caused by root severed during extraction. Only one case chose apicoectomy and retrograde filling, because routine root canal treatment cannot dredge the calcification of the root canal. Routine root canal therapy was not performed in all patients.

Table 1

Basic Information of all patient
Patient			Perioperative		Follow up
Transplant,n	Gender	Age at surgery, y	Donor site	Recipient site	Follow up,m	Root canal therpy, y/n	Maximum depth of periodontal examination,mm	teeth mobility
1	m	51	18	47	15	n	3	0
2	f	27	48	17	15	y	3	0
3	m	24	38	37	15	n	7	0
4	f	20	38	36	16	n	3	0
5	f	26	21	21	16	n	3	0
6	f	25	38	36	18	n	3	0
7	f	38	38	36	14	n	3	0
8	f	27	38	37	13	y	3	I°
9	f	28	28	46	13	n	2	0
10	f	31	48	47	15	n	3	0
11	m	24	28	27	18	n	3	0
12	m	29	48	46	19	y	3	0
13	m	34	48	47	21	n	3	0
14	f	28	48	36	14	n	2	0
15	m	48	48	46	14	n	7	0
16	f	39	38	36	14	n	3	0
17	f	26	28	36	14	y	3	0
18	f	26	48	47	13	n	3	0
19	f	23	48	46	21	n	2	0
20	f	26	38	36	20	n	3	0
21	m	12	22	22	26	n	3	0
22	f	32	28	27	26	n	2	0

Table 1 (continued)
Patient	follow up
Transplant,n	gingival index(max)	Percussion	TMD, y/n	OHI-S	bruxism,y/n	occluding relation, R/L	Periradicular radiolucency,y/n	Periodontal space,y/n
1	0	—	n	6	y	I/I	n	y
2	2	±	n	6	n	I/I	y	y
3	2	±	n	4	n	III/III	n	y
4	0	—	n	1	n	I/I	n	y
5	0	—	n	3	n	I/I	n	y
6	2	±	n	6	n	I/II	n	y
7	0	—	n	3	n	I/I	n	y
8	2	—	n	6	n	I/III	y	y
9	0	—	y	1	n	II/II	n	y
10	0	—	n	3	n	I/I	n	y
11	0	—	n	3	n	I/I	n	y
12	0	—	n	6	n	I/I	y	y
13	0	—	n	13	n	II/II	n	y
14	2	—	n	7	n	I/I	n	y
15	2	—	n	10	n	I/II	n	y
16	2	—	n	1	n	III/I	n	y
17	2	±	n	3	y	I/I	y	y
18	0	—	n	6	n	I/I	n	y
19	0	—	n	6	n	I/I	n	y
20	1	—	n	5	n	I/I	n	y
21	1	—	n	3	n	I/I	n	y
22	1	—	n	4	n	I/I	n	y
(Follow-up data is available only for patients attending the examination.Timeframes are given in (m = months) and (y = years). Application of TMD, RCT, bruxism ,Periradicular radiolucency or Periodontal spaceare listed as (y = yes, n = no).. Application of transplant is(n = number)and gender framework is given in (m = male f = female).

Following-up data:

The mean follow-up time of 22 patients was 14.7 months, the survival rate of donor teeth was 100%, and the success rate was 81.8%. A complete clinical examination of a case is shown in Fig. 1. Among all the 22 cases that were followed up, 18 cases did not receive any follow-up treatment, and four cases eventually underwent root canal treatment, but no one underwent crown restoration. No dental fracture or obvious cleft was found, and no crown discoloration was observed in all cases. Four of the 22 patients experienced adverse clinical or radiological manifestations of the autotransplanted teeth (Fig. 2). The CBCT results of three cases showed varying degrees of bone density loss in the apical region of the graft, widening of the periodontal membrane space, and images of incomplete root canal closure. The CBCT results of the other patient showed no incomplete root canal closure, but external absorption occurred at 1/3 to 2/3 of the root distance and apical and communicated with the pulp cavity. Some images also show periodontal space widening and decrease in surrounding bone density.

Results of the satisfaction questionnaire:

All the 22 patients that were handed out with questionnaires participated in the survey, with a recovery rate of 100%.

The questionnaire results are as follows (Fig. 3):

What are the symptoms after tooth transplantation? A total of 45.5% of the patients exhibited symptoms of food impaction after tooth transplantation, 36.4% of the patient showed no abnormal symptoms of the ATT, and 18.1% of the patients reported other symptoms such as paresthesia during occlusal.

Whether the patients would actively avoid using ATT: 72.7% of the patients said no; 27.3% patients said yes.

Whether the ATT can chew normally and without chewing discomfort: 90.1% of patients said yes; 9.9% of patients said no.

Whether ATT can be used to chew hard objects (e.g., nuts and peanuts): 63.6% of patients chose yes; 27.2% patients chose no; 9.1% of patients did not fill in this option.

Whether the chewing efficiency was improved compared with that before surgery: 81.8% of the patients felt significant improvement; 18.2% of the patients felt that the improvement of masticatory efficiency was average.

Whether the surgical effect reached their expectations: 72.7% of the patients said that they had completely or to a great extent reached their expectations; 27.3% of the patients said that the treatment met their expectations.

Whether the patients were satisfied after tooth transplantation: 90.9% patients were satisfied or very satisfied; 9.1% of patients felt average.

Result of chewing efficiency test

The absorbance values of each group are shown in Table 2. Results show that the chewing efficiency of the patient's transplantation side accounted for an average of 82.0% on the healthy side.

Table 2

Spectrophotometric value and ratio of transplanted side to healthy side
Number	1	2	3	4	5	6	7	8	9	10	11	12	13
Transplanted Side(a)	0.216	0.413	0.288	0.499	0.416	0.434	0.231	0.502	0.458	0.554	0.581	0.332	0.594
Healthy Side(b)	0.339	0.394	0.490	0.616	0.631	0.450	0.244	0.597	0.581	0.727	0.648	0.534	0.541
a/b (%)	63.7	104.8	58.8	81.0	65.9	96.4	94.7	84.1	78.8	76.2	89.7	62.2	109.8
(Row a/b was designed to explore the percentage of masticatory efficiency of the transplanted side that could be restored to that of the healthy side)

The data of the two groups were normally distributed, and paired t-test indicates significant differences between the two groups (p < 0.05, Fig. 3)

Comparison of the success rate of donor tooth with fused root, single root and multi-root.

In total, 22 cases were divided into three groups according to the root condition of the donor tooth, namely, single root with single root canal (2 cases), multiple roots (11 cases) and fused roots (9 cases). The success rate of each group was calculated, among which the success rate of single root with single root canal was 100%, that of multi-root group was 90.9%, and that of the fusion root group was 66.7%.

This study aimed to investigate the feasibility of apical resection combined with retrograde filling and sealing of the root canal system without root canal therapy and to study the survival rate, success rate and related clinical manifestations. The retention rate of 22 transplanted teeth included in this study was 100%, and the success rate was 81.8%, which was basically consistent with the traditional operation. However, the study has some shortcomings such as small sample size and insufficient follow-up time. More clinical cases and longer follow-up time are needed to verify the treatment plan. To the best of our knowledge, this is the first study in which an external apical excision combined with retrograde filling was performed without endodontic treatment.

The results of a retrospective analysis of external apical resection for revascularisation of ATT showed that the 35 patients with a mean age of 13 years (range: 8–28 years) had a survival rate of 91.4% after a mean follow-up of 3.4 years, and 62.5% had no potential adverse findings, with a higher failure rate (72.7%) in the molar group than in the premolar group (17.6%) and the canine group (25%). ([8]) In Skoglund's animal studies, the removal of the apical root through the external mouth did not increase the chance of revascularisation[9]. Our study mainly focused on the tooth transplantation in the molar region. The donor teeth had multiple fused roots or irregular root canal morphology, and the diameter of apical hole required for the revascularisation of mature ATT after apical resection was hard to obtain; the teeth with apical diameters of 0.5–1.0 mm attained the highest clinical success rate[10]). The results of the present study show that 5 of the 7 mature molars showed post-operative symptoms or failure without revascularisation after apicectomy.[8]

Interestingly, based on the comparison of the merged roots of ATT (9 cases), single root with single root canal of ATT (2 cases) and multiple root of ATT success rate (11 cases), found in the ATT of adverse clinical and imaging findings : 3 cases were the ATT with fused roots group, only 1 case came from the ATT multiple roots group. this finding might be related to the low identification or high variation of the root canal of the fused root, suggesting that methylene blue staining combined with preoperative CBCT may be used to effectively distinguish the root canal orifice after root resection and thus achieve complete apical closure.

Perfect root canal therapy is a sufficient and necessary condition for the successful transplantation of mature permanent teeth. For donor teeth with fully developed roots, root canal therapy is usually started within 1–2 weeks after the operation to prevent the inflammatory absorption of root caused by pulp necrosis and effectively protect the periodontal membrane. [3] The main donor teeth for ATTs are wisdom teeth, whose root canal system may exhibit several anatomic variations[11]. General dentists may find it difficult to complete the filling ,which may restrict the promotion of ATT technology. Intraoperative apical resection and iRoot BP Plus backfilling were performed, which are simple to operate and could well seal the root canal orifice.

IRoot is a bioactive ceramic material based on calcium silicate. Its main components are calcium silicate, calcium carbonate, zirconia and tantalum oxide. iRoot BP Plus is paste, and it is non-toxic to pulp and periodontal tissue, has good biocompatibility, induces osteogenesis, promotes the regeneration of periodontal tissue, and has good sealing, antibacterial property, and adhesion ability[12]. In comparison with MTA, it can be used in the anterior teeth without changing the color of teeth, and it is not necessary to deploy when using, which can shorten the time of donor teeth in vitro.

Approximately 10% of the third molars with multiple roots have auxiliary root canals that communicate with periodontal tissue, which may be detrimental to our surgical method[13]. However, no adverse results caused by such reasons have been found in our cases in clinical and imaging examinations, thus requiring regular postoperative follow-up.

In one patient, external absorption occurred in the ATT and was communicated with the pulp cavity, which occurred near the root section. Moreover, periodontal membrane cells were considered to be damaged during root resection. The protection of periodontal membrane cells is one of the keys to the success of transplantation. During transplantation, the new 3D printed guide plate can reduce the number of trial implantation and the risk of iatrogenic injury. In addition, aseptic operation during the operation, gentle extraction method, control of a short time outside the mouth, and no pressure implanted in the compression area, are also important methods to protect periodontal membrane cells.

Necrotic pulp may cause endodontic absorption after root resection and retrograde filling, which is not present in our case so far. The American Society of Endodontics defines absorption as a physiological or pathological process that results in the loss of dentin, cementum, or bone tissue.Pathological absorption in tooth points to normal pulp tissue granulation denaturation, cause pulp cavity inside tooth body hard tissue absorption, and gradually to the pathological changes of the dentin layer around the progress.[17] Considering that the energy source required by cell activity cannot be separated from the supply of surrounding tissues, as long as no accessory root canal is connected with periodontal tissue, the occurrence of infection can be avoided in theory.

Among the 22 ATTs of 22 patients, 18 crowns remained intact, 4 had received root canal treatment caused by apical inflammation but no crown repair was carried out, and no tooth fracture or obvious hidden crack was found in all patients. Dehydration and root canal treatment do not change the physical and mechanical properties of dentine. The increased incidence of tooth fracture after root canal treatment is caused by the loss of dental structural integrity related to pathways preparation. Restorations that improve structural integrity will improve the outcome of root canal treatment. The integrity of dental crowns can improve its mechanical properties and greatly reduce its treatment cost.[18]

Tooth pulp necrosis results in crown discoloration, and the main cause of crown discoloration is tooth trauma and bacterial infection caused by pulpitis.[19] For molars and premolars, the teeth are not in the aesthetic zone, and even though crown discoloration has limited effect on the patient. The front teeth are in the aesthetic area. If the discoloration of the crown obviously affects the patient’s life, the patient may consider veneer repair or bleaching to meet their needs.

According to the chewing efficiency test and questionnaire survey, most of the patients think that their ATTs can chew normally (90%) and can chew hard objects (e.g., nuts and peanuts: 63.6%), and they will not actively avoid the use of ATTs (72.7%). Moreover, the chewing efficiency has been remarkably improved (81.8%), and it has recovered to 82.0% of the healthy side. Although 45.5% of the patients experienced symptoms of food impaction during chewing, the majority of patients were satisfied or very satisfied with the ATTs (90.9%). For the symptoms of food impaction, the conservative approach is to teach the patient to use dental floss to solve the problem, and dental treatment methods include full crown repair or orthodontic adjustment. However, after the restoration of mandibular arch with implant-supported prosthesis, both bite force and chewing efficiency of all subjects increased and were comparable to that of matched completely dentate subjects after 3 months[20]. This finding might have been obtained, because the crown shape of the ATT does not match the original molar of the donor tooth position, and the contact area between the ATT and its counterpart tooth is reduced, thus remarkably decreasing the chewing efficiency[21].

The extra-oral apicoectomy combined with retrograde filling of the transplanted teeth yielded good results༎However, the study has some shortcomings such as small sample size and insufficient follow-up time. In some special cases such as the complex root canal system of the donor teeth that cannot guarantee perfect root canal therapy, operating extra-oral apicoectomy and retrograde filling to seal the root canal system may be an alternative for patients with ATT.

Authors’ contribution

Haoyan Zhong conceived the project and performed the surgeries

Fenglin Liao collected the data.

Fenglin Liao and Hui Wang analyzed the data and wrote the manuscript.

Biao Zhang and Jihong Zhao approved the final version of the manuscript.

Ethics Approval and Informed Consent

1) The study complied with the Declaration of Helsinki (2013)and was approved by the Ethics Committee of the School &Hospital of Stomatology, Wuhan University.

2) For all studies involving human subjects, consent and signed informed consent has been obtained from the subjects (or parents or legal guardians of children under 16 years of age).

3) Any form of biomedical, clinical and biometric personal identifying data included in the manuscript has been obtained from the subject with a signed informed consent form.

Funding

No funding was obtained for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

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No competing interests reported.

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Evaluation of the effect of extraoral apicoectomy and retrograde filling for the sealing of the root canal system of mature auto-transplantation teeth

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Abstract

Figures

Introduction

Material And Method

Patient selection

Surgical procedure

Data collection

(1) Telephone follow-up

(2) Clinical examination and imaging evaluation

(3) Questionnaire survey

(4) Chewing efficiency test

Criteria

Results

Basic Information of patients

Following-up data:

Results of the satisfaction questionnaire:

Result of chewing efficiency test

Discussion

Conclusion

Declarations

References

Additional Declarations

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