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mineralized eollagenous matrices such as cementum, dentin and bone. Israel Speriing*, Dov Itzkowitz*, Aryeh. Y. Kaufman** and Itzhak Binderman. "Section of ...
A new treatment of heterotransplanted teeth to prevent progression of root resorption Sperling I, Itzkowitz D, Kaufman A, Binderman I. A new treatment of heterotransplanted teeth to prevent progression of root resorption. Endod Dent Traumatol 1986: 2: 117-120. Abstract - A new treatment is suggested to prevent root resorption of heterotransplanted teeth. After conservative root canal treatment, the root surface was treated with concentrated citric acid solution to demineralize the root surface. The demineralized collagenous matrix was then treated with n-aeetylcysteine to inhibit eollagenase activity and collagen degradation. Two cases are presented. The initial results supported the notion that anticollagenase drugs might be useful in preventing resorption of mineralized eollagenous matrices such as cementum, dentin and bone.

Israel Speriing*, Dov Itzkowitz*, Aryeh Y. Kaufman** and Itzhak Binderman "Section of Periodontoiogy, "Section of Endodontoiogy, Section of Oral Bioiogy, School of Dentai Medicine, Sackier Faculty of Medicine, Tei Aviv University and Hard Tissues taboratory, Tei Aviv Medical Center, Tel Aviv, Israei

Key words: heterotranspiantation, human teeth, root resorption. Israel Sperling, QM.Q, Section of Periodontoiogy, School of Dental Medicine, Tei Aviv tiniversity, Ramat Aviv, Tei Aviv, Israel. Accepted for pubiication January 10, 1986

In clinical and experimental replantation and transplantation of teeth, the main cause of loss of the tooth graft is root resorption (1,2). Andreasen & HjortingHansen (3) have reported that root resorption of replanted teeth oecurred in 95% of cases when the extra-alveolar period exceeded 2 hours. Experimental studies have shown that the viability of the periodontal ligament cells and the eementoblasts which cover the root surface of a replanted tooth are of vital importance for the prevention of root resorption (3). Several teehniques have been used in an attempt to retard root resorption, including immersion in sodium fluoride (4), repeated cycles of freezing and thawing, enzymatic removal of periodontal ligament (2, 5) and root surface demineralization by topical application of citric acid (6). We propose treating the root surface of teeth prior to replantation or transplantation in a two-step procedure: (i) limited demineralization of the root surface; and (ii) grafting of eollagenase inhibitors. This novel treatment is based on the following hypothesis (7, 8): the resorption of mineralized collagenous matrix is a complex process which involves the release of bone mineral, removal of glycoproteins and breakdowti of collagen. Usually, when replatiting or transplanting a tooth, the mineralized niatrix of the root surface is chemotactic to osteoclast-like cells, initiatitig demineralization of the surface area (9, 1 0). Normally, the surface of bone or cementum is lined by a continuous layer of cells which protect it from the overlying osteoclasts. Any factor(s), chemical or physical, which destroy the lining cells will

expose the mineralized surface, allowing attachment of osteoclasts. It has also been suggested that degradation of the demineralized matrix may occur either by the eollagenase already present in the collagen matrix of the root surface or by its secretion by neighboring eells (12). Probably these two processes represent the tuajor mechanisms by which root surfaces of replanted and transplanted teeth are resorbed. We therefore suggest preventing the accumulation of osteoclast-like cells on the root surface by producing a limited demineralized zone of the root surface. Secondly, we aimed to prevent the non-mineralized collagen matrix from being degraded. Therefore, we propose treating the surfaces with eollagenase inhibitors which irreversibly inactivate the eollagenase present on the root surface. In the present paper, we report the first results from a study with heterotransplanted human incisors. Material and methods Untreatable maxillary central incisors in 2 patients were extracted. Intact human teeth with a shape and size similar to the extraeted teeth were selected. The teeth were prepared for heterotranspiantation in the following way: the root surface was cleaned and tissue and cementum were thoroughly scraped away. The roots were given their final shape and size by means of grinditig with diamonds and polishing with paper discs and paste, and the teeth were disinfected in 70% alcohol for 1 h. Endodontic treat117

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ment was theti performed. The root canals were instrumented, enlarged and filled with gutta-percha and AH26 root canal sealer. The teeth were then rinsed with sterile saline solution and the roots were immersed in saturated eitric acid solution for 5 minutes (11). This was followed by a thorough rinsing of the roots with sterile saline and immersion in 5% N-acctyl cysteine solution for 5 min. All of the above procedures were carried out under aseptic conditions. The conditioned teeth were then immediatedly transj^lanted and s]:)linted to the tieighboring

Fig. I. Gase I. Radiograph of maxillary central incisor, 1 wk after heterotranspiantation. The primary periodontal healing was uneventful.

Fig. 3. Gase 1. l'hotograph ol niaxilhiry incisor region, 2 yr after heterotranspiantation ol right central incisor. 1 he esthetic results are excellent.

Fig. 2. Ga.se 1. Radiogra|)h of maxillary central iiuisor, 2 yr after heterotranspiantation. Ankylosis of (he root is evident, but resorption is minimal.

I'lg. 4. Gase 2. Radiograph of maxillary central incisor, 2 wk afler heterotranspiantation. A periodontal ligament-like space is visible.

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Heterotranspiantation of teeth teeth for 6 weeks. Routine post-operative instructions were given, including avoidance of loaditig of the transplanted teeth. Periodic examinations and radiographic follow-ups were performed every 6 wk up to 6 months, and then every year. Results The preliminary results were encouraging, in that the teeth adapted well to the tissues. The postoperative repair was uneventful, the teeth were firm and the esthetic results excellent (Figs. 1-6). The

attached gingiva was pink and firm and no probable pockets were observed. The sound to percussion resembled that of ankylosed teeth. In one of the teeth, ankylosis was confirmed radiographically (Fig. 2). In the other tooth, a periodontal ligamentlike radiolucent area was visible around the root (Fig. 5). Discussion Usually, in the process of root resorption, after removal of the mineral, the breakdown of the highly crosslinked cemental or dentinal collagen is much dependent on the local activity of a specific enzyme, eollagenase. A recent study from our laboratory indicates the presetice of eollagenase in human dentin tnatrix (12). The action of eollagenase may be controlled by inhibitors present in tissues (13, 14). In fact, it has been shown that human teeth contain a substance which is inhibitory to human gingiva! eollagenase (14). N-acetyl cysteine is a simple chemical agent commonly used in the therapy oi'keraloconjunctivitis sicca

Fig. 5. Gase 2. Radiograph of maxillary eentral incisor, 1 yr after heterotranspiantation. Some marginal bone lose is evident. A narrow periodontal ligamenl-like space is slill visible.

for its eollagenase inhibitory properties (11). Its ii'reversible inhibitory action on tissue eollagenase and its use in ophthalmology encouraged us to try this agent to prevent collagen degradation of heterotransplanted teeth. The first results were promising, and further controlled experiments will show if the method will gain clinical importance. In conclusion, a new method for inhibition of root resorption in heterotransplanted teeth is described. The method is based on the hypothesis that mineralized root matrix is ehemotactic to osteoclastic activity and thai collagen degradation can be prevented by anti-collagetiase drugs. References 1. Sinn.MAN 1,15. The transplantation aulogenieity of (ooth homografts. Oral Smg 1964; 17: 389-94. 2. RoiiiNsoN PJ, ROWLANDS DT. F.videncc of the alloinimtmogenic potential of donor ])eriodontal ligament. .'Im J Pathol 1974; 75.-..503 12. 3. ANDREASEN J O , HJORTING-HANSEN E . Replantation of teeth

I. Radiographic and clinical study of 110 human teeth replanted after aecidenlal loss, .icta Odont Scand 1966; 24: 263 86. 4. SHtiLMAN LB, KALIS P, GOI.DHAI!ER P. Fluoride inhibition of tooth replant root resorption in ecbus monkeys. J Oral Ther 1968; 4: 331 7. 5. BAfER RA, C^RENspAN R.'\, SHfi.MAN LB. Prelraiisplant in vitro: I".in7.ymolysis of periodontal ligament. J Dent Res 1970; 49: 635. 6. NYM.\N S, HOUSTON F, SARHED G , LINDHE J. KARRING T .

Healing following reiniplantation of teeth stibjected to root planing and citrie aiid trealment 7 Clin Period 1985; 12: 294 305. Fig. 6. Gase 2. Photograph of maxillary incisor region, 1 yr after heterotranspiantation of left central ineisor. T h e esthetic results a r e excellent.

7. BINDERMAN I, DAYAN D, MECHANIC G L . Mechanisms of

Ijone destruction. In: SADE J, ed. Colesteatoma and Mastoid Surgery. Amsterdam: Kngler l'ublication.s, 1982, pp. 383-6.

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Speriing et al. 8. MECHANIC GL, BINDERMAN I, HARELL A. A novel hypothesis

for bone resorption and remodelling. In; SILBERMAN M , SLAVKIN HG, eds. Current Advances in Skeletogenesis: Biomineralization, Mediators and Metabolic Bone Disease. Amsterdam: Ex-

cerpta Medica, 1982, pp. 322-5. 9. MiNKiN G, PosEK R, NEWBREY J. Mononuclear phagoeytes and bone resorption: Identification and preliminary characterization of a bone derived macrophage chemotaetic factor. Metabolic Bone Disease and Related Re.search 1981; 2: 363-9. 10. KAHN AJ, STEWART GG, TEITELBAUM SL. Gontact-mediated

bone resorption by human monoeytes in vitro. Science 1978; 199: 988-9.

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11. GosTA ND, SLATTER DH. Potency of n-acetyleysteine as a eollagenase inhibitor in pharmaceutical preparations effeets of temperature and storage. Amt Vet J 1983; 60: 195-6. 12. DAYAN D, BINDERMAN I, MECHANIC GL. A preliminary study

of activation of eollagenase in carious human dentine matrix. Arch Oral Biol 1983; 28: 185 7. 13. WERB Z. Pathways for the modtilation of maerophage eollagenase activity. Calcif Tissue 1978; (Abstr. Sj:)eeial Suppl.) 213-28. 14. GEICER SB, HARPER E. The inhibition of human gingival

eollagenase by an inhibitor extracted Irom human teeth. J Periodont Res 1981; 16: 8-12.