- Email: [email protected]
Surgical extrusion: A dental technique
DENTAL TECHNIQUE
Surgical extrusion: A dental technique Daniele Angerame, MD, DDS,a Matteo De Biasi, DDS, MS, PhD,b Blerina Kalaj, DDS,c and Michele Maglione, MD, DDSd When a substantial amount of ABSTRACT tooth tissue is lost because of This article describes a technique for surgically extruding severely compromised roots needing extensive dental caries, fracprosthetic rehabilitation. Unlike previously described approaches, the technique does not tures, or other causes, prerequire advanced clinical skills or equipment, may reduce the risk of tooth or bone fracture liminary adjunctive treatments during the luxation maneuvers, and does not seem to interfere with the alveolar socket healing are often needed to restore the process. (J Prosthet Dent 2020;-:---) tooth, especially if the biologic preservation for placing an implant without augmentawidth is violated. The reestablishment of the biologic tive surgical procedures has particular relevance for pawidth is required to reach and maintain healthy soft tients with limited financial resources who might be able tissues after restorative or prosthetic rehabilitation.1 For to afford an implant-supported prosthesis in the future. this purpose, surgical crown lengthening is often carried Because surgical extrusion aims to obtain adequate out before restoration, but this intervention can alter the luxation of the root avoiding residual dental structure morphology of the soft and hard tissues of the involved fragmentation and marginal bone fracture, some auand neighboring teeth, with possible unwanted esthetic thors9,10,13 have investigated the effectiveness of an and phonetic outcomes.1,2 Alternatively, the application atraumatic extraction technique using a specific device, of orthodontic traction can also extrude the tooth; namely the Benex root extraction system (Helmut Zepf nonetheless, this approach is not without limitations, Medizintechnik GmbH). Although harmless for the including patient acceptance, increased costs, prolonged alveolar bone and effective in delivering an extrusive treatment duration, and risk of relapse.3,4 force to extract the tooth, this system requires the Surgical extrusion, also known as intra-alveolar removal of sound root dentin as the root is drilled and a transplantation, for straight single-rooted teeth with screwdriver placed into the remaining root. The present substantial loss of structure and compromised biologic technique proposes a modified simplified surgical extruwidth was originally described as an instant alternative to sion that does not entail the use of advanced instruments orthodontic extrusion5 and has become less invasive and and preserves the root dentin. more predictable over the years.6-10 The technique, which has different options, is a 1-step procedure with demonstrated effectiveness.7 Moreover, the technique TECHNIQUE may be applied to roots usually deemed not restorable, allowing for bone preservation or implant site develop1. Deliver local anesthesia with the most appropriate ment and is similar to orthodontic extrusion as a means technique depending on the site to be operated on of improving the bone and gingival characteristics of the (Fig. 1A). implant recipient site.11,12 Ensuring sufficient bone
a
Associate Professor, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. Research fellow, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. c Graduate student, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. d Associate Professor, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. b
THE JOURNAL OF PROSTHETIC DENTISTRY
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Figure 1. Operative phases of simplified surgical extrusion. A, Preoperative occlusal view. B, Intrasulcular incision. C, Preparation of 3-mm to 4-mm deep groove between root to be extruded and alveolar bone with tapered-point diamond rotary instrument after flap elevation. D, Occlusal view of prepared groove. E, Splinting of extruded tooth to adjacent teeth 4 to 5 mm above bone crest level. F, Sutured flap.
2. Perform an intrasulcular incision (Fig. 1B) with a No. 15C scalpel blade (Kai) on both the buccal and lingual side from the mesial to the distal tooth adjacent to the root to be extruded. 3. Make vertical releasing incisions up to the mucogingival junction to improve visibility and access. As an alternative, extend the horizontal marginal incision. 4. Elevate the buccal and lingual full-thickness flaps. 5. To allow a firm grip of the forceps on the root, prepare a circumferential 3-mm to 4-mm deep groove between the root to be extruded and the surrounding bone by using a tapered-point diamond rotary instrument (863 4505; Intensiv SA) under water irrigation (Fig. 1C, 1D). 6. Once the root has been delicately luxated with rotational movements of the forceps, extrude the root and position it at least 4 to 5 mm coronally to the marginal bone crest to respect the biologic width and offer adequate ferrule for the definitive restoration. 7. Stabilize the root with a wire-composite resin splint (AP+ Flow; Sweden & Martina) to the adjacent teeth on the buccal, lingual, and, possibly, occlusal aspects in relation to the extent of the extrusion and reposition in a more convenient site (Fig. 1E). 8. Suture the flap with interdental sutures and then suture the vertical releasing incisions (Fig. 1F). The treatment and outcome of 2 patients can be seen in Figures 2, 3. Both patients were followed up uneventfully for 2 years after the definitive restoration.
THE JOURNAL OF PROSTHETIC DENTISTRY
DISCUSSION Surgical extrusion is a straightforward, reliable, and timesaving treatment option for the management of crown-root fractures.7 Once the extruded root has been stabilized, the tooth can be restored. Some devices specifically designed for the vertical extraction of straight roots offer several advantages over traditional extraction techniques, minimizing trauma to the surrounding periodontium.13 Additionally, the described technique represents an accessible alternative to more complex interventions. Only routinely used instruments are required for the procedure, and the modified surgical extrusion technique can be successfully accomplished by most clinicians. The full-thickness flaps improve the visibility, simplify the groove preparation around the root, and produce limited discomfort because ideally the vertical releasing incisions should not extend beyond the mucogingival junction. Alternatively, the surgeon may prefer to extend the horizontal marginal incision to avoid the vertical releasing incisions when the surrounding conditions such as the presence of restorations on the buccal surface of the neighboring teeth and the thickness and shape of the attached gingiva allow for this approach. However, a major disadvantage of this surgical extrusion technique is receiving 2 surgical flaps. The groove preparation seems to damage the bone only minimally because the marginal crest is preserved. The marginal bone remodels over the first 3 to 4 weeks and then stabilizes, with the lamina dura reappearing on
Angerame et al
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2020
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Figure 2. Treatment of severely compromised maxillary premolar with simplified surgical extrusion and zirconia complete crown. A, B, Preoperative condition. C, D, Immediate postoperative aspect; note multiple splint with composite resin and metal wire. E, F, Stabilized root; note ferrule. G, H, Interim crown in place. I, J, Definitive restoration with monolithic zirconia crown. K, L, Two-year clinical and radiographic appearance of treated tooth. G, H, Interim crown in place. I, J, Definitive restoration with monolithic zirconia crown. K, L, Two-year clinical and radiographic appearance of treated tooth.
the periapical radiographs within a few months. Furthermore, the canal anatomy is left untouched by the surgical procedures, and this is likely to contribute
Angerame et al
positively to the resistance of the restored root. The ferrule in the extruded roots may be sufficient to avoid the need for an endodontic post.
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Figure 3. Treatment of severely compromised mandibular premolar with simplified surgical extrusion and metal-ceramic inlay fixed partial denture. A, B, Preoperative condition. C, D, Immediate postoperative aspect; note multiple splint with composite resin and metal wire. E, F, Stabilized root, note suboptimal healing of mesial bone crest.
When surgically extruding roots to be restored, the most frequent complications, root resorption, and ankylosis are less frequent than after intentional tooth replantation after traumatic avulsion or autotransplantation because the root is always kept inside the
THE JOURNAL OF PROSTHETIC DENTISTRY
socket,9 with minimum damage to the periodontal cells.14 Disadvantages of the modified surgical extrusion include the need to prepare a conservative groove, as the clinician should be careful to avoid damage to the dental
Angerame et al
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2020
5
Figure 3. (continued). G, H, Definitive restoration with metal-ceramic inlay fixed partial denture; note progression of healing process. I, J, Two-year clinical and radiographic appearance of treated tooth.
and bony tissues. Minimal damage to the external coronal root surface has no relevant consequences because of the subsequent preparation for the definitive restoration. Moreover, similarly to what happens after other surgical and orthodontic extrusion techniques, the emergence profile and the interproximal spaces of the prosthetic restoration should be properly managed in roots with a pronounced taper, because their diameter at the cervical level can be considerably reduced after extrusion. SUMMARY The modified surgical extrusion is a viable option in the restoration of severely compromised single-rooted teeth or the management of nonrestorable roots in preparation for implant site development. Preparing a groove between the root and the alveolar bone may facilitate the luxation phase without compromising or retarding hard and soft tissue healing, even in the case of considerable changes in the original root position. The advantages include limited postoperative symptoms, low risk of
Angerame et al
complications, reduced chair-side time in comparison with other procedures, good esthetics, and ready acceptance from the patient. REFERENCES 1. Marzadori M, Stefanini M, Sangiorgi M, Mounssif I, Monaco C, Zucchelli G. Crown lengthening and restorative procedures in the esthetic zone. Periodontol 2000 2018;77:84-92. 2. Nobre CM, De Barros Pascoal AL, Albuquerque Souza E, Machion Shaddox L, Dos Santos Calderon P, De Aquino Martins AR, et al. A systematic review and meta-analysis on the effects of crown lengthening on adjacent and non-adjacent sites. Clin Oral Investig 2017;21:7-16. 3. Smidt A, Gleitman J, Dekel MS. Forced eruption of a solitary nonrestorable tooth using mini-implants as anchorage: rationale and technique. Int J Prosthodont 2009;22:441-6. 4. Darby LJ, Garvey TM, O’Connell AC. Orthodontic extrusion in the transitional dentition: a simple technique. Pediatr Dent 2009;31:520-2. 5. Tegsjo U, Valerius-Olsson H, Olgart K. Intra-alveolar transplantation of teeth with cervical root fractures. Swed Dent J 1978;2:73-82. 6. Pham HT, Nguyen PA, Pham TAV. Periodontal status of anterior teeth following clinical crown lengthening by minimally traumatic controlled surgical extrusion. Dent Traumatol 2018;34:455-63. 7. Das B, Muthu MS. Surgical extrusion as a treatment option for crown-root fracture in permanent anterior teeth: a systematic review. Dent Traumatol 2013;29:423-31.
THE JOURNAL OF PROSTHETIC DENTISTRY
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8. Becciani R, Faganello D, Fradeani M. Surgical extrusion: a simplified esthetic method of treating non-restorable teeth. Rationale and case report. Int J Esthet Dent 2018;13:240-73. 9. Kelly RD, Addison O, Tomson PL, Krastl G, Dietrich T. Atraumatic surgical extrusion to improve tooth restorability: a clinical report. J Prosthet Dent 2016;115:649-53. 10. Krug R, Connert T, Soliman S, Syfrig B, Dietrich T, Krastl G. Surgical extrusion with an atraumatic extraction system: a clinical study. J Prosthet Dent 2018;120:879-85. 11. Korayem M, Flores-Mir C, Nassar U, Olfert K. Implant site development by orthodontic extrusion. a systematic review. Angle Orthod 2008;78: 752-60. 12. Magkavali-Trikka P, Kirmanidou Y, Michalakis K, Gracis S, Kalpidis C, Pissiotis A, et al. Efficacy of two site-development procedures for implants in the maxillary esthetic region: a systematic review. Int J Oral Maxillofac Implants 2015;30:73-94. 13. Muska E, Walter C, Knight A, Taneja P, Bulsara Y, Hahn M, et al. Atraumatic vertical tooth extraction: a proof of principle clinical study of a
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
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novel system. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116: e303-10. 14. Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53.
Corresponding author: Dr Daniele Angerame University Clinical Department of Medical, Surgical, and Health Sciences Piazza Ospedale 1 Trieste I-34125 ITALY Email: [email protected] Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry. https://doi.org/10.1016/j.prosdent.2019.12.002
Angerame et al
Surgical extrusion: A dental technique Daniele Angerame, MD, DDS,a Matteo De Biasi, DDS, MS, PhD,b Blerina Kalaj, DDS,c and Michele Maglione, MD, DDSd When a substantial amount of ABSTRACT tooth tissue is lost because of This article describes a technique for surgically extruding severely compromised roots needing extensive dental caries, fracprosthetic rehabilitation. Unlike previously described approaches, the technique does not tures, or other causes, prerequire advanced clinical skills or equipment, may reduce the risk of tooth or bone fracture liminary adjunctive treatments during the luxation maneuvers, and does not seem to interfere with the alveolar socket healing are often needed to restore the process. (J Prosthet Dent 2020;-:---) tooth, especially if the biologic preservation for placing an implant without augmentawidth is violated. The reestablishment of the biologic tive surgical procedures has particular relevance for pawidth is required to reach and maintain healthy soft tients with limited financial resources who might be able tissues after restorative or prosthetic rehabilitation.1 For to afford an implant-supported prosthesis in the future. this purpose, surgical crown lengthening is often carried Because surgical extrusion aims to obtain adequate out before restoration, but this intervention can alter the luxation of the root avoiding residual dental structure morphology of the soft and hard tissues of the involved fragmentation and marginal bone fracture, some auand neighboring teeth, with possible unwanted esthetic thors9,10,13 have investigated the effectiveness of an and phonetic outcomes.1,2 Alternatively, the application atraumatic extraction technique using a specific device, of orthodontic traction can also extrude the tooth; namely the Benex root extraction system (Helmut Zepf nonetheless, this approach is not without limitations, Medizintechnik GmbH). Although harmless for the including patient acceptance, increased costs, prolonged alveolar bone and effective in delivering an extrusive treatment duration, and risk of relapse.3,4 force to extract the tooth, this system requires the Surgical extrusion, also known as intra-alveolar removal of sound root dentin as the root is drilled and a transplantation, for straight single-rooted teeth with screwdriver placed into the remaining root. The present substantial loss of structure and compromised biologic technique proposes a modified simplified surgical extruwidth was originally described as an instant alternative to sion that does not entail the use of advanced instruments orthodontic extrusion5 and has become less invasive and and preserves the root dentin. more predictable over the years.6-10 The technique, which has different options, is a 1-step procedure with demonstrated effectiveness.7 Moreover, the technique TECHNIQUE may be applied to roots usually deemed not restorable, allowing for bone preservation or implant site develop1. Deliver local anesthesia with the most appropriate ment and is similar to orthodontic extrusion as a means technique depending on the site to be operated on of improving the bone and gingival characteristics of the (Fig. 1A). implant recipient site.11,12 Ensuring sufficient bone
a
Associate Professor, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. Research fellow, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. c Graduate student, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. d Associate Professor, University Clinical Department of Medical, Surgical, and Health Sciences, University of Trieste, Trieste, Italy. b
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Figure 1. Operative phases of simplified surgical extrusion. A, Preoperative occlusal view. B, Intrasulcular incision. C, Preparation of 3-mm to 4-mm deep groove between root to be extruded and alveolar bone with tapered-point diamond rotary instrument after flap elevation. D, Occlusal view of prepared groove. E, Splinting of extruded tooth to adjacent teeth 4 to 5 mm above bone crest level. F, Sutured flap.
2. Perform an intrasulcular incision (Fig. 1B) with a No. 15C scalpel blade (Kai) on both the buccal and lingual side from the mesial to the distal tooth adjacent to the root to be extruded. 3. Make vertical releasing incisions up to the mucogingival junction to improve visibility and access. As an alternative, extend the horizontal marginal incision. 4. Elevate the buccal and lingual full-thickness flaps. 5. To allow a firm grip of the forceps on the root, prepare a circumferential 3-mm to 4-mm deep groove between the root to be extruded and the surrounding bone by using a tapered-point diamond rotary instrument (863 4505; Intensiv SA) under water irrigation (Fig. 1C, 1D). 6. Once the root has been delicately luxated with rotational movements of the forceps, extrude the root and position it at least 4 to 5 mm coronally to the marginal bone crest to respect the biologic width and offer adequate ferrule for the definitive restoration. 7. Stabilize the root with a wire-composite resin splint (AP+ Flow; Sweden & Martina) to the adjacent teeth on the buccal, lingual, and, possibly, occlusal aspects in relation to the extent of the extrusion and reposition in a more convenient site (Fig. 1E). 8. Suture the flap with interdental sutures and then suture the vertical releasing incisions (Fig. 1F). The treatment and outcome of 2 patients can be seen in Figures 2, 3. Both patients were followed up uneventfully for 2 years after the definitive restoration.
THE JOURNAL OF PROSTHETIC DENTISTRY
DISCUSSION Surgical extrusion is a straightforward, reliable, and timesaving treatment option for the management of crown-root fractures.7 Once the extruded root has been stabilized, the tooth can be restored. Some devices specifically designed for the vertical extraction of straight roots offer several advantages over traditional extraction techniques, minimizing trauma to the surrounding periodontium.13 Additionally, the described technique represents an accessible alternative to more complex interventions. Only routinely used instruments are required for the procedure, and the modified surgical extrusion technique can be successfully accomplished by most clinicians. The full-thickness flaps improve the visibility, simplify the groove preparation around the root, and produce limited discomfort because ideally the vertical releasing incisions should not extend beyond the mucogingival junction. Alternatively, the surgeon may prefer to extend the horizontal marginal incision to avoid the vertical releasing incisions when the surrounding conditions such as the presence of restorations on the buccal surface of the neighboring teeth and the thickness and shape of the attached gingiva allow for this approach. However, a major disadvantage of this surgical extrusion technique is receiving 2 surgical flaps. The groove preparation seems to damage the bone only minimally because the marginal crest is preserved. The marginal bone remodels over the first 3 to 4 weeks and then stabilizes, with the lamina dura reappearing on
Angerame et al
-
2020
3
Figure 2. Treatment of severely compromised maxillary premolar with simplified surgical extrusion and zirconia complete crown. A, B, Preoperative condition. C, D, Immediate postoperative aspect; note multiple splint with composite resin and metal wire. E, F, Stabilized root; note ferrule. G, H, Interim crown in place. I, J, Definitive restoration with monolithic zirconia crown. K, L, Two-year clinical and radiographic appearance of treated tooth. G, H, Interim crown in place. I, J, Definitive restoration with monolithic zirconia crown. K, L, Two-year clinical and radiographic appearance of treated tooth.
the periapical radiographs within a few months. Furthermore, the canal anatomy is left untouched by the surgical procedures, and this is likely to contribute
Angerame et al
positively to the resistance of the restored root. The ferrule in the extruded roots may be sufficient to avoid the need for an endodontic post.
THE JOURNAL OF PROSTHETIC DENTISTRY
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Volume
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Figure 3. Treatment of severely compromised mandibular premolar with simplified surgical extrusion and metal-ceramic inlay fixed partial denture. A, B, Preoperative condition. C, D, Immediate postoperative aspect; note multiple splint with composite resin and metal wire. E, F, Stabilized root, note suboptimal healing of mesial bone crest.
When surgically extruding roots to be restored, the most frequent complications, root resorption, and ankylosis are less frequent than after intentional tooth replantation after traumatic avulsion or autotransplantation because the root is always kept inside the
THE JOURNAL OF PROSTHETIC DENTISTRY
socket,9 with minimum damage to the periodontal cells.14 Disadvantages of the modified surgical extrusion include the need to prepare a conservative groove, as the clinician should be careful to avoid damage to the dental
Angerame et al
-
2020
5
Figure 3. (continued). G, H, Definitive restoration with metal-ceramic inlay fixed partial denture; note progression of healing process. I, J, Two-year clinical and radiographic appearance of treated tooth.
and bony tissues. Minimal damage to the external coronal root surface has no relevant consequences because of the subsequent preparation for the definitive restoration. Moreover, similarly to what happens after other surgical and orthodontic extrusion techniques, the emergence profile and the interproximal spaces of the prosthetic restoration should be properly managed in roots with a pronounced taper, because their diameter at the cervical level can be considerably reduced after extrusion. SUMMARY The modified surgical extrusion is a viable option in the restoration of severely compromised single-rooted teeth or the management of nonrestorable roots in preparation for implant site development. Preparing a groove between the root and the alveolar bone may facilitate the luxation phase without compromising or retarding hard and soft tissue healing, even in the case of considerable changes in the original root position. The advantages include limited postoperative symptoms, low risk of
Angerame et al
complications, reduced chair-side time in comparison with other procedures, good esthetics, and ready acceptance from the patient. REFERENCES 1. Marzadori M, Stefanini M, Sangiorgi M, Mounssif I, Monaco C, Zucchelli G. Crown lengthening and restorative procedures in the esthetic zone. Periodontol 2000 2018;77:84-92. 2. Nobre CM, De Barros Pascoal AL, Albuquerque Souza E, Machion Shaddox L, Dos Santos Calderon P, De Aquino Martins AR, et al. A systematic review and meta-analysis on the effects of crown lengthening on adjacent and non-adjacent sites. Clin Oral Investig 2017;21:7-16. 3. Smidt A, Gleitman J, Dekel MS. Forced eruption of a solitary nonrestorable tooth using mini-implants as anchorage: rationale and technique. Int J Prosthodont 2009;22:441-6. 4. Darby LJ, Garvey TM, O’Connell AC. Orthodontic extrusion in the transitional dentition: a simple technique. Pediatr Dent 2009;31:520-2. 5. Tegsjo U, Valerius-Olsson H, Olgart K. Intra-alveolar transplantation of teeth with cervical root fractures. Swed Dent J 1978;2:73-82. 6. Pham HT, Nguyen PA, Pham TAV. Periodontal status of anterior teeth following clinical crown lengthening by minimally traumatic controlled surgical extrusion. Dent Traumatol 2018;34:455-63. 7. Das B, Muthu MS. Surgical extrusion as a treatment option for crown-root fracture in permanent anterior teeth: a systematic review. Dent Traumatol 2013;29:423-31.
THE JOURNAL OF PROSTHETIC DENTISTRY
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8. Becciani R, Faganello D, Fradeani M. Surgical extrusion: a simplified esthetic method of treating non-restorable teeth. Rationale and case report. Int J Esthet Dent 2018;13:240-73. 9. Kelly RD, Addison O, Tomson PL, Krastl G, Dietrich T. Atraumatic surgical extrusion to improve tooth restorability: a clinical report. J Prosthet Dent 2016;115:649-53. 10. Krug R, Connert T, Soliman S, Syfrig B, Dietrich T, Krastl G. Surgical extrusion with an atraumatic extraction system: a clinical study. J Prosthet Dent 2018;120:879-85. 11. Korayem M, Flores-Mir C, Nassar U, Olfert K. Implant site development by orthodontic extrusion. a systematic review. Angle Orthod 2008;78: 752-60. 12. Magkavali-Trikka P, Kirmanidou Y, Michalakis K, Gracis S, Kalpidis C, Pissiotis A, et al. Efficacy of two site-development procedures for implants in the maxillary esthetic region: a systematic review. Int J Oral Maxillofac Implants 2015;30:73-94. 13. Muska E, Walter C, Knight A, Taneja P, Bulsara Y, Hahn M, et al. Atraumatic vertical tooth extraction: a proof of principle clinical study of a
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume
-
Issue
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novel system. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116: e303-10. 14. Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg 1981;10:43-53.
Corresponding author: Dr Daniele Angerame University Clinical Department of Medical, Surgical, and Health Sciences Piazza Ospedale 1 Trieste I-34125 ITALY Email: [email protected] Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry. https://doi.org/10.1016/j.prosdent.2019.12.002
Angerame et al