Resorpsjoner og

reaksjoner

Dag Ørstavik

UiO, IKO, Avd. endo 2013 http://www.uio-endo.no

Vevsreaksjoner som involverer ben og

dentin • Apikal periodontitt

– Akutte faser, abscess

– Kroniske aspekter

– Fistel

• Intern resorpsjon

• Ekstern resorpsjon

• Cervical resorpsjon

– Idiopatisk

– Multiple

• Andre osteolytiske prosesser:

cyster, tumorer

• Nivåer

– Klinikk

– Røntgen

– Histologi

– Biologiske

mekanismer

• Dentinresorpsjon

– Mest aktuell

Classification

• Local mechanical repair resorption (undetected)

• Transient root resorption

• Pressure resorption

• Infection-induced root resorption

– Internal resorption

– External inflammatory root resorption

• Cervical root resorption (incl Multiple cervical

resorptions)

• Replacement resorption (ankylosis)

Modified from Tronstad 2003

The resorptive process

• Denudation:

– Cementum

– Predentin

• Remodelling:

– Deposition

– Resorption

• Infectious/pathological

– Internal inflammatory

– External inflammatory

• Physiological/protective

– Pressure induced

– Surface repair

– Replacement/ankylosis

Menezes R, Garlet TP, Letra A, Bramante CM, Campanelli AP, Figueira Rde C, Sogayar MC, Granjeiro JM, Garlet

GP. Differential patterns of receptor activator of nuclear factor kappa B ligand/osteoprotegerin expression in human

periapical granulomas: possible association with progressive or stable nature of the lesions.

J Endod. 2008 Aug;34(8):932-8

Hvordan oppstår odonto/osteo-

klaster? • Osteoclasts formation requires the presence of RANK

ligand (receptor activator of nuclear factor κβ) and M-CSF (Macrophage colony-stimulating factor). These membrane bound proteins are produced by neighbouring stromal cells and osteoblasts; thus requiring direct contact between these cells and osteoclast precursors.

• M-CSF acts through its receptor on the osteoclast [precursor], c-fms (colony stimulating factor 1 receptor), a transmembrane tyrosine kinase-receptor, leading to secondary messenger activation of tyrosine kinase Src. Both of these molecules are necessary for osteoclastogenesis and are widely involved in the differentiation of monocyte/macrophage derived cells.

http://en.wikipedia.org/wiki/Osteoclast; 2007-06-21

Hvordan oppstår odonto/osteo-

klaster? • Osteoclasts formation requires the presence of RANK ligand (receptor activator of

nuclear factor κβ) and M-CSF (Macrophage colony-stimulating factor). These membrane bound proteins are produced by neighbouring stromal cells and osteoblasts; thus requiring direct contact between these cells and osteoclast precursors.

• M-CSF acts through its receptor on the osteoclast, c-fms (colony stimulating factor 1 receptor), a transmembrane tyrosine kinase-receptor, leading to secondary messenger activation of tyrosine kinase Src. Both of these molecules are necessary for osteoclastogenesis and are widely involved in the differentiation of monocyte/macrophage derived cells.

• RANKL is a member of the tumour necrosis family (TNF), and is essential in osteoclastogenesis. RANKL knockout mice exhibit a phenotype of osteopetrosis and defects of tooth eruption, along with an absence or deficiency of osteoclasts. RANKL activates NF-κβ (nuclear factor-κβ) and NFATc1 (nuclear factor of activated t cells, cytoplasmic, calcineurin-dependent 1) through RANK. NF-κβ activation is stimulated almost immediately after RANKL-RANK interaction occurs, and is not upregulated. NFATc1 stimulation, however, begins ~24-48 hours after binding occurs and its expression has been shown to be RANKL dependent.

• Osteoclast differentiation is inhibited by osteoprotegerin (OPG), which binds to RANKL thereby preventing interaction with RANK.

http://en.wikipedia.org/wiki/Osteoclast; 2007-06-21

http://atvb.ahajournals.org/content/vol22/issue4/images/large/6FF2.jpeg

Figure 2. Mode of action and biological effects of RANKL, RANK, and OPG on

bone metabolism and the immune system. (1) RANKL is expressed by

osteoblastic lineage cells (cell-bound RANKL) and activated T lymphocytes

(soluble RANKL). A truncated ectodomain form of RANKL is derived from the

cell-bound form after cleavage by the enzyme TACE. (2) All three RANKL

variants stimulate their specific receptor, RANK, which is located on

osteoclastic and dendritic cells and thus modulate various biological functions.

(3) OPG is secreted by osteoblastic lineage and other cells and acts as a

soluble receptor antagonist which neutralizes RANKL (black), and thus,

prevents RANKL-RANK interaction.4 OPG also blocks the pro-apoptotic

cytokine TRAIL (white).

Schoppet M, Preissner KT,

Hofbauer LC. RANK ligand and

osteoprotegerin: paracrine

regulators of bone metabolism

and vascular function. Arterioscler

Thromb Vasc Biol. 2002 Apr

1;22(4):549-53. Review.

http://en.wikipedia.org/wiki/Osteoclast; 2007-06-21

www.drstoute.com/procedures/path1.htm

ameloblastoma

www.cda-adc.ca/.../graphics/russell_figures.htm

cuspid resorption

http://www.unige.ch/cyberdocuments/theses2002/MeiriS

D/images/image051.jpg

ankylose

Mavragani et al., 2000

Karies?

Nordahl,

Mjør,

Haapasalo,

Ørstavik

Where are the microbes?

AP

P

PDL

Etter Haapasalo 2004

Infected dentin? Side connections? No cells available to start digesting

Microtrauma?

----

Ankylosis

Surface repair

resorption

Inflammatory

root

resorption

Elisabeth Samuelsen

Behandling av intern resorpsjon

Elisabeth Samuelsen

Fuss et al. 2003

Heithersay 2004

Heithersay 2004

Histologic appearance

of an incisor tooth with

invasive resorption. An

intact layer of dentine

and predentine on the

pulpal aspect (*)

separates the pulp from

the resorbing tissue.

The resorption cavity is

filled with a mass of

fibrovascular tissue

with active

mononucleated and

multi nucleated classic

cells lining resportion

lacunae (arrows).

(Hematoxylin-eosin

stain; original

magnification x 40.).

(Courtesy of Dr John

McNamara.)

Heithersay 2004

Fig 9

Heithersay 2004

Heithersay 2004

Heithersay 2004

Histologic appearance of an extensive invasive cervical resorption with

radicular extensions. Masses of ectopic calcific tissue are evident both

within the fibrovascular tissue occupying the resorption cavity and on

resorbed dentin surfaces. In addition communicating channels can be

seen connecting with the periodontal ligament (large arrows). Other

channels can be seen within the inferior aspect of the radicular dentine

(small arrows). (Hematoxylin-eosin stain; original magnification x30.)

Fig 12

Heithersay 2004

A low

powered

photograph

shows the

walling off of

the pulp

space by

dentin

separating it

from the

surrounding

extensive

resorptive

process

Heithersay 2004

Mass of fibrovascular tissue infiltrated with inflammatory cells, located within

a large resorptive cavity that has a wide connection with the periodontal

tissue (large arrow). The dentin has been extensively replaced by bone-like

tissue. A small section of intact pulp can be seen on the superior aspect of

the section (small arrow). Hematoxylin-eosin stain; original magnification

x30.)

Heithersay 2004

Heithersay 2004

Heithersay 2004

Treatment

• non-surgical treatment involves topical

application of a 90% aqueous solution of

trichloracetic acid to the resorptive tissue,

curettage, endodontic treatment where

necessary, and restoration with glass-

ionomer cement. Adjunctive orthodontic

extrusion may be employed in some

advanced lesions.

Heithersay 2004

Fig 18a Heithersay 2004

Invasive Cervical Resorption

• Class 1 – Denotes a small invasive resorptive lesion near the cervical area with shallow penetration into dentine.

• Class 2 – Denotes a well-defined invasive resorptive lesion that has penetrated close to the coronal pulp chamber but shows little or no extension into the radicular dentine.

• Class 3 – Denotes a deeper invasion of dentine by resorbing tissue, not only involving the coronal dentine but also extending into the coronal third of the root.

• Class 4 – Denotes a large invasive resorptive process that has extended beyond the coronal third of the root.

Heithersay 2004

Heithersay 2004

Heithersay 2004

Endo memento

• ”Hvor er bakteriene?”

– Pulpa eksponert eller ikke

• ”Hvor lenge har de vært der?”

– Komplisert kronefraktur (infraksjoner)

– Utslåtte tenner: ikke bare periodontiet

• ”Hva er skaden på periodontiet?”

– Infeksiøs resorpsjon

– Cervikal resorpsjon – en senskade?

1998-03-03

14 år gammel

pike

Fraktur midtrot;

lingualt

dislokert;

12 (!) asensibel;

11,21(!),22,23

pos

1998-03-03

Fraktur midtrot;

lingualt dislokert;

12 (!) asensibel;

13,11,21(!),22,23 pos

remplassert;

fiksert labialt;

Rett etter

fjernelse av

fiksering;

13 til 23 nå

pos senstest

1998-03-16

Dental Trauma Guide

For root fractures where the coronal fragment have been avulsed

out of the socket please use the treatment guidelines for avulsion

otherwise proceed as described below.

Rinse exposed root surface with saline before repositioning.If

displaced, reposition the coronal segment of the tooth as soon as

possible.

Check that correct position has been reached radiographically.

Stabilize the tooth with a flexible splint for 4 weeks. If the root

fracture is near the cervical area of the tooth stabilization is

benificial for a longer period of time (up to 4 months).

Monitor healing for at least 1 year to determine pulpal status. If

pulp necrosis develops, then root canal treatment of the coronal

tooth segment to the fracture line is indicated.

2009-09-16 1999-02-22

Kontroll 11 mndr;

alle pos sens

2012-09-06

Kontroll 14 år;

alle pos sens test;

ingen subj sympt.

2009-09-16 2012-09-06 ”Stå stille, ikke bare gjør noe”

Day 0

Respons på subluksasjon

1 month

Day 0

Transient AP Respons på subluksasjon

Boyd 1995

1 month

4 months

10 months

27 months EPT høy terskel; CO2 kulde

positiv; EPT tilbake etter 4 mndr

The patient (female, 35 yrs) was in a bicycle accident

30.08.2009 and treated at the University Hospital. Teeth 33 to

41 and tooth 21 were extracted, and the maxilla was luxated

because of fracture. The patient was referred to the

Department of Prosthodontics for evaluation and treatment,

and then referred to the Department of Endodontics (Thomas

Myrhaug).

2009-09-16

+18 dager: 2009-09-16

2009-09-16

2009-09-30

2009-09-30

2009-09-30

2009-10-20

2009-09-30

2009-10-20

2009-09-30

T0 T+14d T+34d

Tann 0916 0930 1020

12 41

11 80 70 48

22 80 80 80

23 39

34 45

43 28

10 % falske svar på EPT

2009-10-27

2009-10-27

2010

2011-10-19

Endodonti, kirurgi og protetikk etter traume 2009-2012

La tilheling skje

uforstyrret,

men behandle

infeksjonen før

den ”setter seg”

Problematisering:

obliterasjon 11

Endodonti, kirurgi og protetikk etter traume 2009-2012

Prognostiske vurderinger Langtidseffekter av

behandlingsbeslutninger

Estetikk

The patient (female, 54 yrs) has had orthodontic treatment twice. The first time was when she

was 11-12 years and the second time 12 years ago (at 42). She complained to her dentist almost

a year after the first symptoms, now with signs of an acute periodontal infection. Radiographs

revealed an extensive resorptive process that had developed in her lower right canine.

C Herbjørnsen 2007

Kroniske traumer/senfølger: Cervikal resorpsjon

Endodonti (nesten) alltid nødvendig

ved cervikale resorpsjoner

Ferdigbehandlet -> 1-års-kontroll, ingen data siden.

60% i funksjon etter 1,5 til 7 års observasjon,

færre i denne kategorien

Uformell endo-konsult oktober 2012, OPG juni 2012

Senfølger: transplantasjon/kjeveortopedi? Her er agenesi startpunkt for behandling; det kan også være traumer

Feb 2008 Pike, 17 år. Agenesi 15,14,12,22,24,25

Kontinuerlig kjeveortopedi 4 år

2004: Autotranspl 45 til 13 og 34 til 22

OPG Juni 2012

Ktr 2 år 2012. Passe fornøyd med estetikken. Anbefales gingivektomi

og laminat på ”22”. -> spes-klinikk

Jun 2012: Totalobliterasjon av ”22”; endodonti-konsultasjon

Jun 2012: CBCT viser åpenbar benpatologi med overveiende sannsynlig pulpalt utspring; en apikal periodontitt med lateral lokalisasjon. Tverrsnittet viser totalobliterasjon av ”22”. Endodonti vanskelig eller umulig? Snittbilder: B Mork-Knutsen, IKO, UiO

21 år, kvinne

Fall fra sykkel

2004 07 22:

13 slått ut

[12 ikke til stede]

11, 21 slått ut

1 time etter fallet:

13, 11 remplassert,

21 tapt

2004 09 15: til endo-

dontisk behandling;

2 fistler

Harald Prestegaard, UiO

21 år, kvinne

Fall fra sykkel

2004 07 22:

13 slått ut

[12 ikke til stede]

11, 21 slått ut

1 time etter fallet:

13, 11 remplassert,

21 tapt

2004 09 15: til endo-

dontisk behandling;

2 fistler: 2 måneder

uten oppfølging

Harald Prestegaard, UiO

2004 09 15: Vanlig behandling med Ca(OH)2 etter irrigasjon NaOCl og CHX

Harald Prestegaard, UiO

2004 11 03: Fistler lukket, tilheling apikalt, men 13M? Infeksiøs resorpsjon?

Harald Prestegaard, UiO

2005 01 12: Fistler lukket, tilheling apikalt,

men 13M verre (infeksiøs rotresorpsjon), og stadig øm: ekstraheres

Harald Prestegaard, UiO

2006 03 21: Implantater 13 og 21, asymptomatisk med full tilheling 11.

Rotfylt før permanent restaurering

Harald Prestegaard, UiO

Rotfylt tann vs implantat

Rotfylt tann

• Pro:

– Etter full tilheling, topp

prognose

– Bevarer alveolarprosess;

enkel vei til god estetikk

– Kan etterfølges av ny

behandling

• Con:

– Traumetenner mindre

studert

– Uforutsigbare senskader

Implantat

• Pro:

– Etter full tilheling, topp

prognose

– Kjente og begrensede

komplikasjoner

• Con:

– Lang behandlingstid

– Vanskeligere estetikk

– irreversibelt

Endodonti vs implantat

0

20

40

60

80

100

Prosent

Endo Impl

Success Survival Repair Failure

Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR. Retrospective cross sectional comparison of initial nonsurgical

endodontic treatment and single-tooth implants. J Endod. 2006 Sep;32(9):822-7. NSRCT outcomes were affected by

periradicular periodontitis (p = 0.001), post placement (p = 0.013), and overfilling (p = 0.003).

Synkope og fall mars 2004

Start endo sept 2004

Birte Nikolaisen: Nov 2004

September 6th endodontic treatment of 11 and 21 was started. Both coronal and apical parts were instrumented and

dressed with Ultracal®. Teeth were reopened and inter-appointment dressing changed four times in the period from

September 6th to November 2nd due to pain and/or persistent bleeding from the canal.

Desember 2004, after MTA and

composite placement.

Ingen blødning, asymptomatisk,

kirurgi utsatt, ble ikke aktuelt

Birte Nikolaisen

Eksamensspørsmål

List opp vilkårene for

tannresorpsjon

• Dentin må eksponeres:

– Cementum eller predentin må være brutt

• Det må være bløtvev med blodtilførsel mot

dentin

– Fra pulpa

– Fra periodontiet

List opp årsaker til tannresorpsjon

• Fysiologisk/beskyttende

– Trykkindusert

– Overflatereparasjoner

– Vevsintegrasjon: Ankylose

• Infeksiøst/patologisk

– Intern resorpsjon

– Ekstern inflammatorisk

Hva er ”blunting” av røtter? Når

skjer det?

• Røttene (spesielt overkjevens

front) er forkortet og avrundet

• Forekommer etter aggressiv

kjeveortopedisk behandling

Klassifisér kliniske former av

rotresorpsjon

• Lokale resorpsjoner reparerer mikroskader i cement (ikke synlige klinisk el røntgenologisk)

• Forbigående rotresorpsjon (etter mindre traume)

• Trykkindusert rotresorpsjon (ortodonti, tannfrembrudd, tumorer)

• Infeksjonsindusert rotresorpsjon – Intern rotresorpsjon

– Ekstern inflammatorisk rotresorpsjon

• Erstatningsresorpsjon (ankylose)

• Cervikale resorpsjoner – Isolerte

– Multiple

Hva er typisk for intern

rotresorpsjon?

• Klinisk

– Gjerne asymptomatisk

– Uten tegn,

– Men kan være brutt

gjennom og gi

symptomer på

periodontitt eller

(sjelden) frakturere

• Røntgenologisk

– Jevn, nær sirkulær

– Sentrert ut fra pulpa

• Histologisk

– Nekrose koronalt, vitalt

apikalt (en stund)

Hva er typisk for ekstern

inflammatorisk rotresorpsjon?

• Klinisk

– Gjerne asymptomatisk

– Kan forløpe svært

hurtig

– Følger gjerne et

traume (intrusjon,

eksartikulasjon)

• Røntgenologisk

– Eksentriske opptak vil

vise at

periodontalspalten er

involvert

• Histologisk

– Nekrotisk infisert pulpa

– Ingen spesielle

kjennetegn i bløtvevet

Hva er typisk for cervikal

rotresorpsjon?

• Klinisk

– Gjerne asymptomatisk

– Pink spot kan

forekomme

– Kan simulere karies I

tannhalsen

• Røntgenologisk

– ”Møllspist” dentin;

ekstensjoner også

aksialt i tannen

– Kan omslutte pulpa;

omrisset av den kan

gjenkjennes

• Histologisk

– Invasjon av osteoid vev

i resorpsjonsområdet

Beskriv de 4 klassene for cervikal

rotresorpsjon

• 1 – Lokalisert i samlet kavitet uten utløpere

• 2 – Starter utbredelse sidelengs og apikalt

• 3 – Begynner å omslutte pulpa, tydelige spor i apikal

retning

• 4 – Omslutter pulpa, utløpere apikalt på begge sider av

rotkanalen

Crit Rev Oral Biol Med. 2004;15(2):64-81.

NEW MOLECULES IN THE TUMOR

NECROSIS FACTOR LIGAND AND

RECEPTOR SUPERFAMILIES WITH

IMPORTANCE FOR PHYSIOLOGICAL AND

PATHOLOGICAL BONE RESORPTION.

Lerner UH.

A mononuclear phagocyte

colony-stimulating factor

(M-CSF) synthesized by

mesenchymal cells

PU.1 regulates

cytokine-dependent

proliferation and

differentiation of

granulocyte/macrophage

progenitors

Receptor activator of nuclear

factor- B ligand (RANKL) is a

critical cytokine for osteoclast

differentiation and activation and

an essential regulator of

osteoblast-osteoclast cross-talks

(4). RANKL activates its receptor

RANK, which is located on

osteoclastic lineage cells, and this

interaction is prevented by

osteoprotegerin (OPG), which acts

as an endogenous receptor

antagonist and blocks the effects of

RANKL (4). While RANKL

enhances bone resorption and

bone loss and promotes

osteoporosis, OPG has opposite

effects (5).