Portland Cement: An Overview as a Root Repair Material

Portland cement (PC) is used in challenging endodontic situations in which preserving the health and functionality of pulp tissue is of considerable importance. PC forms the main component of mineral trioxide aggregate (MTA) and demonstrates similar desirable properties as an orthograde or retrograde filling material. PC is able to protect pulp against bacterial infiltration, induce reparative dentinogenesis, and form dentin bridge during the pulp healing process. The biocompatibility, bioactivity, and physical properties of PC have been investigated in vitro and in animal models, as well as in some limited clinical trials. This paper reviews Portland cement’s structure and its characteristics and reaction in various environments and eventually accentuates the present concerns with this material. This bioactive endodontic cement has shown promising success rates compared to MTA; however, considerable modifications are required in order to improve its characteristics and expand its application scope as a root repair material. Hence, the extensive chemical modifications incorporated into PC composition to facilitate preparation and handling procedures are discussed. It is still important to further address the applicability, reliability, and cost-effectiveness of PC before transferring into day-to-day clinical practice.

The Functional Impact of Home-based Self-rehabilitation Following Arthroscopic Root Repair

Purpose: COVID-19 pandemic makes outdoors rehabilitation a potential hazard. Patient education to perform simple home-based exercises seems to be an interesting and sometimes a mandatory option. This study provides a comparison between the conventional and home-based virtual rehabilitation after surgical repair of medial meniscus root tears. Methods: All patients who underwent MPRT repair with a modified trans-tibial pull-out technique from March 2019 to March 2021 were evaluated. Those who underwent surgery after December 2019 were trained to perform self-rehabilitation. The rest had undergone outdoors specialized rehabilitation according to a unified protocol and these were used as a historical control group. All patients were followed up for a minimum of 2 year after surgery. Final Lysholm scores were utilized to compare functional outcomes. Results: Forty-three consecutive patients with medial meniscal root tears were studied. Thirty-nine (90.7%) were women and 4 (9.3%) were men. The mean age of participants was 53.2 ±8.1 years. The total Lysholm knee score, and all its items were significantly improved in both groups at a two-year follow-up (p<0.05), except the “Using cane or crutches” item (p=0.065). Nevertheless, the final Lysholm knee score improvement was higher in patients who performed outdoors specialized rehabilitation and in patients with shorter time-to-surgery.Conclusion: Regardless of age and gender, home-based rehabilitation after meniscal root repair with the modified trans-tibial pull-out technique improved the patients’ function at a two-year follow-up. Nonetheless, this effect was still significantly lower than that of the outdoors specialized rehabilitation. Future work is required to clarify basic protocols for home-based tele-rehabilitation programs and determine clinical, radiological and functional results.Level of evidence: Level IV, therapeutic, historically controlled study

Prevalence and prevention of orthodontically induced dental resorption

Since 1914, when Ottolengui first described it, dentists and patients have been tormented with root resorption, an unwanted but typical sequence of orthodontic mechanotherapeutics. It has been demonstrated that among other potentially hazardous chemicals, the orthodontic equipment employed has a considerable impact on root repair. The‏‏‎ root‏‏‎ repair‏‏‎ process‏‏‎ is‏‏‎ highly‏‏‎ linked‏‏‎ to‏‏‎ periodontal‏‏‎ ligament‏‏‎ necrosis‏‏‎ damage.‏‏‎ When‏‏‎ intense‏‏‎ orthodontic‏‏‎ pressures‏‏‎ are‏‏‎ applied‏‏‎ for‏‏‎ an‏‏‎ extended‏‏‎ length‏‏‎ of‏‏‎ time‏‏‎,‏‏‎ hyalinization‏‏‎ of‏‏‎ the‏‏‎ underlying‏‏‎ periodontal‏‏‎ ligament‏‏‎ can‏‏‎ occur‏‏‎ quickly.‏‏‎ Protective‏‏‎ leukocytes‏‏‎ from‏‏‎ periodontal‏‏‎ ligament‏‏‎ capillaries‏‏‎ mix‏‏‎ quickly‏‏‎ with‏‏‎ osteoclast‏‏‎ progenitors‏‏‎ to‏‏‎ create‏‏‎ cells‏‏‎ with‏‏‎ high-density‏‏‎ genes‏‏‎ capable‏‏‎ of‏‏‎ regenerating‏‏‎ mineral‏‏‎ tissue‏‏‎.‏‏‎ External‏‏‎ apical‏‏‎ root‏‏‎ repair‏‏‎ begins‏‏‎ when‏‏‎ a‏‏‎ protective‏‏‎ layer‏‏‎ of‏‏‎ cementoblasts‏‏‎ including‏‏‎ the‏‏‎ hyalinized‏‏‎ periodontal‏‏‎ ligament,‏‏‎ dies,‏‏‎ allowing‏‏‎ odontoclasts‏‏‎ to‏‏‎ rebuild‏‏‎ cement‏‏‎ and‏‏‎ teeth.‏‏‎ Initially,‏‏‎ a‏‏‎ cemented‏‏‎ protective‏‏‎ layer‏‏‎ is‏‏‎ lost,‏‏‎ exposing‏‏‎ a‏‏‎ green‏‏‎ cement‏‏‎ surface‏‏‎ to‏‏‎ odontoclastic‏‏‎ assaults‏‏‎.‏‏‎ On the other hand, the maxillary second premolar exhibited more excellent root rates in Asians than in Caucasians. The data were taken as evidence that specific races such as Asians were less likely than longer roots to be involved in root repair or were impacted by mutant morphology. In addition, radiographic examination of intermediate IOPAR therapy can detect at-risk teeth and suggest the necessity for appropriate rest to improve performance or anatomical structure. Treatment of afflicted individuals should be continued with caution and proper use of high-intensity light while avoiding movements linked with re-screening such as ingesting.

Loosening of Posteromedial Meniscal Root Repairs Affects Knee Mechanics: A Finite Element Study

Meniscal root repairs are susceptible to unrecoverable loosening that may displace the meniscus from the initial position reduced during surgery. Despite this, the effects of a loosened meniscal root repair on knee mechanics are unknown. We hypothesized that anatomic root repairs without loosening would restore knee mechanics to the intact condition better than loosened anatomic root repairs, but that loosened repairs would restore mechanics better than untreated meniscal root tears. Finite element knee models were used to evaluate changes in cartilage and meniscus mechanics due to repair loosening. The mechanical response from loosened anatomic root repairs was compared to anatomic repairs without loosening and untreated root tears. All conditions were evaluated at three flexion angles, 0°, 30°, and 60°, and a compressive force of 1,000 N to simulate return-to-activity loading. The two-simple-suture method was represented within the models to simulate posteromedial meniscal root repairs and repair loosening was derived from previous biomechanical experimental data. Loosening decreased hoop stresses throughout the meniscus, increased posterior extrusion, and shifted loading through the meniscus-cartilage region to the cartilage-cartilage region compared to the anatomic root repair without loosening. Despite differences between repairs and loosened repairs, the changes from loosened repairs more closely resembled the anatomic repair without loosening than the untreated root repair condition. Therefore, root repairs are susceptible to loosening that will prevent a successful initial repair from remaining in the intended position and will alter mechanics, although repairs that loosen appear better than leaving tears untreated.

Meniscal Root Repair

Background: Meniscal root tears typically result from a hyperflexion/squatting injury or are in conjunction with ligamentous knee injury. Once a complete tear occurs, the meniscus is unable to convert axial loads to transverse hoop stresses which result in increased tibiofemoral contact pressure and osteoarthritis. The goal of a meniscal root repair is to anatomically reattach the meniscal root to the tibia plateau. Complete and partial healing occurs in over 93% of cases with retear rates ranging from 0% to 7%. Indications: We present a case of a highly active 21-year-old male collegiate soccer play that sustained a medial meniscal root tear after slipping on ice. Technique: An anatomic medial meniscal root repair was performed using a transtibial guide and 2 loop sutures tied over a button. Results: Full anatomic footprint coverage was able to be achieved intraoperatively and gentle range of motion from 0 to 90° of flexion did not result in gap formation. Discussion/Conclusion: Successful outcomes with full anatomic footprint coverage of the medial meniscal root can be achieved with 2-loop suture button configuration.

Arthroscopic Medial Meniscus Root Repair With Transtibial Ripstop Technique

Background: Meniscal root tears are radial tears occurring at or within 1 cm of the meniscal root attachment. These injuries have been shown to be the biomechanical equivalent of a total meniscectomy and are thought to be responsible for a rapid progression of osteoarthritis if left untreated. Indications: Meniscal root repair is indicated if possible, with the exception of patients who have diffuse Outerbridge 3-4 osteoarthritis of the ipsilateral compartment, those who are poor surgical candidates due to age or medical comorbidity, or in whom nonsymptomatic tears are found incidentally. Technique Description: Standard 2-portal arthroscopy is performed. Once a medial root tear has been identified and concomitant pathology has been addressed, we typically begin the repair by trephinating the deep medial collateral ligament with an 18-gauge needle to enhance visualization and avoid iatrogenic cartilage injury. Arthroscopic shaver is used to debride the meniscal root as needed. A meniscal root guide is introduced into the joint and an incision is made on the anteromedial tibia for outside-in drilling of a transosseous tunnel. Drilling is performed with a 5-mm retroreaming device, and a 10-mm socket is created. Nonabsorbable suture is then passed through the meniscus using a self-capture device in an inverted mattress configuration, following by 2 cinch stitches. The sutures are then shuttled into the transosseous tunnel, and the meniscal root is reduced and tensioned in full extension, with the sutures being fixated into a suture anchor on the anteromedial tibia. Results: A recent large systematic review of 1086 patients undergoing treatment of meniscal root tear via either debridement or nonoperative management compared with meniscal repair found that conversion to total knee arthroplasty occurred in 11% to 54% of those managed via debridement or nonoperative care versus 0% to 1% for those with root repair. Discussion/Conclusion: Currently, meniscal root repair offers the greatest improvement and lowest risk of conversion to arthroplasty following meniscal root tear. The present technique offers a durable repair that we believe combines ease of execution with decreased risk of suture pull-out, by creating a ripstop-type construct. Long-term outcome studies are needed for this and other root repair techniques.