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Management strategies of the unsalvageable tooth.

UNLABELLED: A tooth is deemed unsalvageable when it can no longer be preserved for use of function or aesthetic purposes. If proper treatment planning is done, tooth extraction can be performed with adjunctive procedures, to provide a more predictable restorative outcome for the patient. This review paper summarizes the possible treatment strategies available for the management of a tooth with a poor prognosis, so as to manage the patient better before the restorative treatment phase commences. CLINICAL RELEVANCE: The management of an unsalvageable tooth using interdisciplinary approaches offers the clinician strategies for providing a more favourable restorative outcome.

Alveolar Bone Loss↗

Tooth resorption.

Tooth resorption is a common sequela following injuries to or irritation of the periodontal ligament and/or tooth pulp. The course of tooth resorption involves an elaborate interaction among inflammatory cells, resorbing cells, and hard tissue structures. The key cells involved in resorption are of the classic type, which include osteoblasts and odontoclasts. Types of tooth resorption include internal resorption and external resorption. There are two types of internal resorption: root canal (internal) replacement resorption and internal inflammatory resorption. External resorption can be classified into four categories by its clinical and histologic manifestations: external surface resorption, external inflammatory root resorption, replacement resorption, and ankylosis. External inflammatory root resorption can be further categorized into cervical resorption with or without a vital pulp (invasive cervical root resorption) and external apical root resorption. Other variations of resorption include combined internal and external resorption and transient apical breakdown.

Humans↗

A radiographic study of rostral tooth development in young Friesian cattle.

Twenty-nine British Friesian cattle fed the same diet, slaughtered at various weights and including bulls, steers (castrated males) and females (heifers) were examined. The stage of their rostral tooth development was recorded both visually and radiographically. Insufficient animals were present in each sex and slaughter weight treatment group to allow any comparison between them. When the data for each sex were compared, no statistically significant differences were seen between the mean ages at which bulls, steers and heifers attained each stage of dental development as determined from their radiographs. The results for all 29 cattle were then combined. This combined data showed a relationship between age and those stages of tooth formation which could be differentiated by examination of the X-ray films. As most phases of tooth formation occurred within well defined limits, it is suggested that radiographs of rostral tooth development might be used to estimate the age of cattle.

Age Factors↗

The avulsed tooth--the best implant.

Successful management of the avulsed tooth begins at the accident site. Correct first-aid care followed by proper management in the dental surgery will significantly improve the prognosis for the avulsed tooth. The major aim following avulsion is the prevention of further damage to the periodontal ligament and, if possible, the maintenance of pulp vascularity. Studies have indicated that variables such as the extra-oral period, the storage medium and the stage of root development of the avulsed tooth significantly influence the final outcome. Endodontic therapy and chemical conditioning of the root surface after an extended extra-oral period has the potential to delay the resorptive processes of a replanted tooth.

Dental Pulp↗

Pattern of permanent tooth loss in Nigerian children and their prosthetic replacement.

The pattern of permanent tooth loss and prosthetic replacement in 76 children were studied. Dental caries and its sequelae were the most frequent cause of tooth loss (64.47%) followed by trauma (21.05%). Molars accounted for 64.20% of tooth type lost due to dental caries and its sequelae while loss of incisors (19.75%) was due to trauma. It was observed that only incisors were replaced (81.25%) due to their conspicuous position in the mouth whereas a large number of molars were lost and none was replaced. The need to periodically assess children after tooth loss for prosthetic replacement was emphasised.

Adolescent↗

[Assessment of traumatic tooth injuries in the emergency room].

Many patients with facial injuries are first seen by doctors in the emergency room. Injuries affecting teeth and alveolar process are common in children; approximately half of all children have sustained such an injury before adulthood. Dentoalveolar trauma does not pose a significant morbid risk for the trauma patient. However, failure to recognise or obtain appropriate consultation can result in premature tooth or alveolar bone loss, resulting in problematic prosthetic rehabilitation. Emergency room doctors should know the initial treatment guidelines for traumatic dental injuries to provide optimal treatment before the patient can seen by a dentist. An avulsed tooth should be replanted immediately, or kept moist until it can be replanted. Prognosis is related to storage media and the length of the extra-alveolar period. Teeth replanted within 5 minutes have the best prognosis. If the primary consultation is by phone the patient, or the parent, should be informed to replant the avulsed tooth. If this is not feasible the tooth should be stored in milk, saliva (oral cavity) or physiologic saline until replanted. Primary teeth are not replanted.

Child↗

Anterior tooth trauma in the primary dentition: incidence, classification, treatment methods, and sequelae: a review of the literature.

A review of the literature is presented to discuss anterior tooth trauma in the primary dentition. Studies show that the incidence ranges from 4 percent to 30 percent and varies depending upon the sex and age of the child. Classification of the type of trauma is subdivided into trauma to the tooth and trauma to the periodontium. Treatment modalities depend upon various factors and range from nontreatment to splinting to extraction. Possible sequelae of primary tooth trauma may include tooth discoloration, loss of vitality, root resorption and/or abscess formation. Careful follow-up is recommended following any type of trauma, because the ultimate goal in treatment is to prevent damage to the permanent successor.

Aftercare↗

[Deciduous tooth intrusions and the odontogenesis of the permanent teeth. Developmental disorders of the permanent teeth following intrusion injuries to the deciduous teeth].

Traumata to primary teeth occur very often in small children. The highest prevalence of developmental disturbances of permanent teeth after trauma to their predecessors has been recorded after intrusive injuries of primary teeth. In the present survey 47% of the recalled children had such developmental disturbances. The majority of developmental disturbances consisted of enamel hypoplasia (59%) which included discoloration, defects or a combination of both. In some cases the clinical feature of enamel defects could be diagnosed radiographically before tooth eruption. However, the total number of all enamel discolorations was to be detected after complete tooth eruption only. The so-called pre-eruptive calciotraumatic lines on radiographs corresponded clinically to circular enamel defects or crown dilacerations. Generally, a high correlation was found between the degree of intrusion (of the primary tooth) and the frequency and severity of developmental disturbance (of the permanent tooth). No correlation was found, however, concerning the treatment of intruded primary teeth and the occurrence of developmental disturbances. Whether intruded primary teeth were removed immediately or left to spontaneous re-eruption did not affect the incidence and type of developmental disturbances.

Child↗

Tooth eruption molecules enhance MCP-1 gene expression in the dental follicle of the rat.

Tooth eruption is a localized developmental event that requires the presence of the dental follicle, a loose connective tissue sac that surrounds each tooth. Early postnatally in the first mandibular molar of the rat there is an influx into the follicle of mononuclear cells (monocytes) which, in turn, fuse to form osteoclasts that resorb the bone to form an eruption pathway. The chemoattractant that may attract the mononuclear cells to the follicle to initiate the cellular events of eruption is monocyte chemotactic protein-one (MCP-1). MCP-1 is secreted by the dental follicle cells and its gene is expressed maximally at an early postnatal age, correlating with the monocyte influx into the follicle. In this study, we show that other potential tooth eruption molecules--EGF, IL-1alpha, TGF-beta1 and CSF-1--all enhance the expression of the MCP-1 gene in the cultured dental follicle cells. In vivo, injections of IL-1alpha or EGF also enhance the gene expression of MCP-1 in the follicle with maximal enhancement occurring in the early postnatal days. Thus, there appears to be a redundant function of the different tooth eruption genes to ensure that the MCP-1 gene is expressed. In turn, expression of MCP-1 may be critical for recruiting the monocytes to the dental follicle to initiate the cellular events of tooth eruption.

Animals↗

PDGF-A and PDGFR-alpha regulate tooth formation via autocrine mechanism during mandibular morphogenesis in vitro.

Platelet-derived growth factor A (PDGF-A) binding to the PDGF receptor alpha (PDGFR-alpha) mediates signal transduction processes related to DNA synthesis, cell migrations, cytodifferentiation, and wound healing. Recent studies indicate that PDGFR-alpha functions during cranial neural crest cell migrations and first branchial arch morphogenesis (Stephenson et al. [1991] Proc. Natl. Acad. Sci. USA 88:6-10; Morrison-Graham et al. [1992] Development 115:133-142; Hu et al. [1995] Int. J. Dev. Biol. 39:939-945; Soriano [1997] Development 124:2691-2700). The present studies were designed to test the hypothesis that PDGF-A, interacts with its cognate receptor PDGFR-alpha via an autocrine mechanism that regulates the timing, rates, and size of embryonic mouse tooth morphogenesis. Both PDGF-A and PDGFR-alpha transcripts were coordinately expressed in mandibular prominences prior to and during tooth formation using reverse transcriptase-polymerase chain reaction (RT-PCR). During the dental lamina stage, ligand and receptor were present in both enamel organ epithelium and adjacent mesenchymal cells. During the bud stage, ligand and receptor were localized mainly to the enamel organ epithelium. Exogenous PDGF-A at 20 ng/ml enhanced tooth development to reach the cap stage with increased tooth size (P < 0.05) using embryonic day (E)10 mandibular explants cultured in serumless, chemically defined medium. A significant increase in DNA synthesis was observed within enamel organ epithelium at E10+4 when the mandibular explants were treated with PDGF-A at 20 ng/ml. These data suggest that PDGF-A and its cognate receptor (PDGFR-alpha) regulate the size and stage of tooth development via an autocrine mechanism during odontogenesis in vitro.

Animals↗

Nerve growth factor (NGF) supports tooth morphogenesis in mouse first branchial arch explants.

Posterior midbrain and anterior hindbrain neuroectoderm trans-differentiate into cranial neural crest cells (CNCC), emigrate from the neural folds, and become crest-derived ectomesenchyme within the mandibular and maxillary processes. To investigate the growth factor requirement specific for the initiation of tooth morphogenesis, we designed studies to test whether nerve growth factor (NGF) can support odontogenesis in a first branchial arch (FBA) explant culture system. FBA explants containing neural-fold tissues before CNCC emigration and the anlagen of the FBA were microdissected from embryonic day 8 (E8) mouse embryos, and cultured for 8 days in medium supplemented with 10% fetal calf serum only, or serum-containing medium further supplemented with either NGF or epidermal growth factor (EGF) at three different concentrations: 50, 100, or 200 ng/ml. Morphological, morphometric, and total protein analyses indicated that growth and development in all groups were comparable. Meckel's cartilage and tongue formation were also observed in all groups. However, odontogenesis was only detected in explants cultured in the presence of exogenous NGF. NGF-supplemented cultures were permissive for bud stage (50 ng/ml) as well as cap stage of tooth morphogenesis (100 and 200 ng/ml). Morphometric analyses of the volume of tooth organs showed a significant dose-dependent increase in tooth volume as the concentration of NGF increased. Whole-mount in situ hybridization and semiquantitative reverse transcription-polymerase chain reaction for Pax9, a molecular marker of dental mesenchyme, further supported and confirmed the morphological data of the specificity and dose dependency of NGF on odontogenesis. We conclude that (1) E8 FBA explants contain premigratory CNCC that are capable of emigration, proliferation, and differentiation in vitro; (2) serum-supplemented medium is permissive for CNCC differentiation into tongue myoblasts and chondrocytes in FBA explants; and (3) NGF controls CNCC cell fate specification and differentiation into tooth organs.

Animals↗

Relative cheek-tooth size in Australopithecus.

Until the discovery of Australopithecus afarensis, cheek-tooth megadontia was unequivocally one of the defining characteristics of the australopithecine grade in human evolution along with bipedalism and small brains. This species, however, has an average postcanine area of 757 mm2, which is more like Homo habilis (759 mm2) than A. africanus (856 mm2). But what is its relative cheek-tooth size in comparison to body size? One approach to this question is to compare postcanine tooth area to estimated body weight. By this method all Australopithecus species are megadont: they have cheek teeth 1.7 to 2.3 times larger than modern hominoids of similar body size. The series from A. afarensis to A. africanus to A. robustus to A. boisei shows strong positive allometry indicating increasing megadontia through time. The series from H. habilis to H. erectus to H. sapiens shows strong negative allometry which implies a sharp reduction in the relative size of the posterior teeth. Postcanine megadontia in Australopithecus species can also be demonstrated by comparing tooth size and body size in associated skeletons: A. afarensis (represented by A.L. 288-1) has a cheek-tooth size 2.8 times larger than expected from modern hominoids; A. africanus (Sts 7) and A. robustus (TM 1517) are over twice the expected size. The evolutionary transition from the megadont condition of Australopithecus to the trend of decreasing megadontia seen in the Homo lineage may have occurred between 3.0 and 2.5 m.y. from A. afarensis to H.habilis but other evidence indicates that it is more likely to have occurred between 2.5 to 2.0 m.y. from an A. africanus-like form to H. habilis.

Body Weight↗

Small tooth sizes in a nineteenth century South Carolina plantation slave series.

Sub-Saharan African (and derived) populations typically exhibit larger mean tooth crown diameters than whites in spite of considerable population variability. We report on a 19th century series of American black slaves from a single cemetery near Charleston, South Carolina, that possessed notably smaller crown sizes. Analysis identifies a characteristic set of differences compared to caucasians, including retention of large maxillary lateral incisors and disproportionately large premolars and molars. Regression of principal components scores (derived from the mesiodistal diameters) on the sum of all diameters (used here as a measure of overall tooth mass) confirms a basic ethnic difference between black and white odontometrics: significantly more of the tooth mass is apportioned to the cheek teeth (premolars, molars) in blacks than whites. The difference (expressed as residuals from linear regression on tooth mass) holds for the several groups assessed here despite considerable intergroup variability in tooth sizes. Potential explanations for the notably small diameters of this plantation series are speculative, but may involve kin-based divergences and/or reflect the natural intergroup differences extant in the African slave sources.

Adult↗

Tooth wear and temporomandibular joint change in Australian aboriginal populations.

The masticatory system consists of teeth, temporomandibular joints, and the supporting craniofacial skeleton. The form and function of each of these components of the system can be understood only within the overall context of the system. In a series of studies, the complex relationships between tooth wear and temporomandibular joint morphology and pathology were considered in samples consisting of a total of 58 male and 54 female crania from two Australian Aboriginal populations. The extent and buccolingual direction of tooth wear were assessed using established techniques. Both metric and nonmetric descriptions of temporomandibular joint morphology and pathology were developed. Significant differences in patterns of tooth wear and in the frequencies of various temporomandibular joint changes were evident between sexes and between populations. Furthermore, significant correlations between a number of tooth and joint variables were also evident. In addition, there was clear evidence of relationships between both tooth wear and temporomandibular joint changes and craniofacial morphology. The results of this study provide additional evidence of the complex relationships between the form and function of the masticatory system.

Adult↗

Bone and cartilage resorption in relation to tooth development in the anterior part of the mandible in cichlid fish: a light and TEM study.

This paper presents ultrastructural features of the contact region between particular tooth germs and Meckel's cartilage prior to, during, and after initial resorption of the perichondral bone and of the cartilage in the cichlids Hemichromis bimaculatus and Astatotilapia burtoni. Imminent resorption opposite such teeth is announced by the presence, in this region, of a particular cell type, considered to be a stage in the cytodifferentiation of osteoclasts. Slightly later, an osteoclast with typical ruffled border is seen to open a fenestra in the perichondral bone which surrounds Meckel's cartilage. Although the action of the osteoclast is directed primarily towards the bone, it may also affect, to a much lesser extent, the underlying uncalcified cartilage. Typically, fibroblast-like cells invade the resorption cavity along with the osteoclast; the tooth germ soon follows. Capillaries are seen to invade the cartilage only at a later stage when a large cavity has been established. It is proposed that the fibroblast-like cells may have a dual function: degradation of cartilage and deposition of new bone. Although these processes are normally limited to the area surrounding tooth germs at specific loci, tooth germs in other positions may sometimes be seen invade the cartilage. They do so either passively, because of the existence of such a cavity, or as a result of their own resorption-inducing activity. Whatever the mechanism, attachment bone is being deposited within the erosion cavity and on the surface of the exposed perichondral bone. The stimuli possibly eliciting resorption of Meckel's cartilage are discussed. It is hypothesized that pressure exerted by the growing tooth germ may stimulate the osteoblasts covering the bone surface and, in this way, provoke osteoclastic bone resorption.

Animals↗

Immunohistochemical localization of periostin in tooth and its surrounding tissues in mouse mandibles during development.

Previous reports have shown expression of immunoreactivity for periostin, originally identified as osteoblast-specific factor-2, in the periosteum and periodontal ligament. However, the developmental changes in its expression and the detailed immunolocalization have remained veiled. The present study was undertaken to examine the spatiotemporal expression of this protein in teeth and their associated tissues of mice during development at light and electron microscopic levels. In tooth germs at cap stage, periostin immunoreactivity was recognizable in the interface between inner enamel epithelium and preodontoblasts as well as in the mesenchymal tissues around cervical loop. Dental follicles around tooth germs at bell stage localized periostin immunopositivity in addition to the immunopositive areas observed in cap-staged tooth germs, although the functional significance of periostin has remained unclear in tooth development. Furthermore, periostin immunoreactivity was also found in the alveolar bone surface. In the incisors of both 7- and 21-day-old mice, immunoreaction for periostin was discernible in the lingual periodontal ligament and labial fibrous tissue adjacent to the papillary layer. After postnatal day 7, immunoreaction for periostin came to be restricted to the fibrous bundles in the periodontal ligament in accordance with the organization of the periodontal fibers, indicating its localization matched the morphogenesis of the periodontal ligament. Immunoelectron microscopic observation of the mature periodontal ligament verified the localization of periostin between the cytoplasmic processes of periodontal fibroblasts and cementoblasts and the adjacent collagen fibrils. Our findings suggest that periostin is involved at the sites of the cell-to-matrix interaction, serving as adhesive equipment for bearing mechanical forces, including occlusal force and tooth eruption.

Animals↗

Timing of odontogenic neural crest cell migration and tooth-forming capability in mice.

The mammalian tooth develops through sequential and reciprocal interactions between cranial neural crest (CNC)- derived ectomesenchymal cells and the stomadial epithelium. Classic tissue recombination studies demonstrated that premigratory CNC cells and CNC-derived ectomesenchymal cells possess odontogenic capacity and can respond to oral epithelial signals to form a tooth, suggesting that the CNC cells contributing to odontogenic tissue are not prespecified. Here we show that, in mice, CNC cells have populated the forming first branchial arch before the 9-somite stage and continue to migrate into the arch by the 13-somite stage. Grafts of the first arch from the 10-somite embryo or earlier yielded membranous bone and cysts but no teeth after subrenal culture. However, grafts of the first arch with its dorsally adjacent tissue containing migrating neural crest cells from the same age embryos gave rise to teeth. In contrast, teeth formed in first arch grafts that do not contain migrating neural crest cells from embryos with 12 or more somites. Interestingly, the acquisition of tooth forming capability in the first arch coincides with the onset of Fgf8 expression in the oral epithelium. These results suggest that there exists a population of odontogenic neural crest cells that migrates into the first arch between the 10- and 12-somite stages. These cells either possess odontogenic potential and are able to initiate tooth development, or can respond to odontogenic signals derived from the oral epithelium to support tooth formation.

Animals↗

Tooth patterning and enamel formation can be manipulated by misexpression of TNF receptor Edar.

Signaling by Edar, a tumor necrosis factor receptor, is required for the development of ectodermal organs. Mutations in Edar or other molecules of the same signaling pathway cause ectodermal dysplasias in humans and mice. In these diseases, teeth are missing or malformed, and the development of hairs and several glands is hypoplastic. During tooth and hair development, Edar expression becomes patterned to ectodermal placodes and signaling centers. This localization has been suggested to be required for organogenesis. We have expressed Edar throughout the ectoderm using the keratin 14 promoter and show that this misexpression disrupts tooth patterning and differentiation. Tooth shape and cusp number are differentially affected, depending on the amount of transgene expression. In addition, tooth enamel formation is defective in a dose-dependent manner. We speculate that the tooth patterning defects are caused by ectopic Edar activity outside the signaling centers.

Amelogenesis↗