|Year : 2016 | Volume
| Issue : 1 | Page : 46-49
Endodontic treatment of the maxillary central incisor with sequelae of dental trauma
Luiz Fernando Machado Silveira, Josue Martos, Melissa Feres Damian, Karoline Von Ahn Pinto
Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas, Brazil
|Date of Web Publication||21-Jun-2016|
Department of Semiology and Clinics, Faculty of Dentistry, Gonçalves Chaves Street, 457, Pelotas, RS 96015-560
Source of Support: None, Conflict of Interest: None
Dental trauma in immature teeth with necrotic pulp and apical foramen with large thin and fragile walls becomes a challenge to treat conventional endodontic treatment. The objective of this report is to demonstrate a clinical case in which the apexification through calcium hydroxide-based dressing, succeeded in forming a calcified apical barrier. It concluded that a barrier with mineral trioxide aggregate superimposed with the endodontic obturation of gutta-percha advocated in the central incisor led to a successful endodontic procedure.
Keywords: Apexification; dental trauma; endodontics; pulp necrosis.
|How to cite this article:|
Silveira LF, Martos J, Damian MF, Pinto KV. Endodontic treatment of the maxillary central incisor with sequelae of dental trauma. Endodontology 2016;28:46-9
| Introduction|| |
Traumatic injuries in young permanent teeth affect approximately 30% of children.  With these injuries, depending on the intensity of the trauma, a necrosis may occur or initiate an inflammatory process leading to interruption of root formation.  Despite the similarity of etiology with conventional endodontic treatment, the objective in these situations is to provide complete root development. An option of endodontic treatment for immature nonvital teeth includes apexification with calcium hydroxide or single visit with mineral trioxide aggregate (MTA) plug and gutta-percha obturation. ,,,
Root canal treatment at this time is a significant challenge if not impossible because of the root canal dentin walls being thin and fragile and the apex wide and open. Obturation of wide canal systems requires precise fabrication of a customized gutta-percha cone, and there is danger of splitting of the root during lateral condensation.  Many time, root canals with flaring walls cannot be obturated and sealed by orthograde methods and might require apical surgery and retrograde sealing of the canal. 
In these cases, the treatment of choice has been apexification ,,,, which involves creating a suitable environment through the complete emptying of the root canal for removal of waste and bacteria followed by dressing changes and to stimulate the formation of a calcified barrier. Calcium hydroxide has been widely used to induce canal endodontic apexification, usually for a long period, and to induce the formation of an apical hard tissue barrier. ,,,,
The objective of this work is to demonstrate a case in which the apexification through a calcium hydroxide-based dressing succeeded in forming a calcified apical barrier.
| Case Report|| |
A 12-year-old female patient was referred to the dental clinic, reporting a dental trauma of the maxillary right central incisor. Dental history revealed that the trauma was the result of a fall. The patient reported no treatment until that moment and the crown fragment had been lost. During the clinical examination, an uncomplicated crown fracture of the maxillary right central incisor was observed  [Figure 1] and was associated with the absence of pain. Pulp sensibility was measured with the −50°C pulp test; teeth 12, 13, 21, and 22 exhibited positive responses, and tooth 11, too.
Radiographic examination showed an image of the tooth 11 with incomplete root formation, a large root canal, and apical third of the root canal walls diverging to the apical aspect and apical bone rarefaction involving the lateral incisor region [Figure 2]. Another important aspect was the radiographic pulp calcification of the upper left central incisor (21).
After the diagnosis of pulp necrosis associated with chronic inflammation of the maxillary right central incisor, the therapeutic approach was endodontic treatment for the purpose of apexification through the application of calcium hydroxide for exceeding 12 months. The treatment plan also included an esthetic restoration of the fractured tooth.
After performing the endodontic access, observation of the pulp chamber and copious irrigation of the pulp chamber and cervical third held cleaning of the root canal to the working length with a #50 K-file (Dentsply/Maillefer, Ballaigues, Switzerland). With verification of the presence of pulp vital tissue at the 4 mm apical region by intense hemorrhage, we chose to restrict the root canal cleaning. We carried out the chemomechanical preparation considering the working length with an alternate irrigation with sodium hypochlorite at 5% mixed with 17% ethylenediaminetetraacetic acid.  After endodontic preparation, irrigation was performed with saline solution and complete withdrawal of the root canal, followed by the application of calcium hydroxide paste (Calen PMCC, SS White, Rio de Janeiro, Brazil).
An intracanal medication primarily containing calcium hydroxide (Calen PMCC, SS White, Rio de Janeiro, Brazil) was applied, and the patient was scheduled to return after 30 days [Figure 3]. The second query prompted the renewal of medication, which was repeated every 6 months for apical closure (8-14 months total). The provisional restoration used between queries was composed of acid conditioning and an adhesive system to prevent contamination via the endodontic access cavity and the dissolution of the medicamentous paste.
|Figure 3: Cleaning the root canal and insertion of the calcium hydroxide paste|
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The radiographic follow-up at each change of calcium hydroxide was recorded and the evaluation of the case was considered excellent due to observation of a calcified barrier forming at the beginning of the apical third of the upper incisor. Clinical inspection of the calcified barrier of the region was performed by carefully probing with a #20 endodontic file. As the barriers may exhibit porosity, we used a barrier with MTA (Pro-Root MTA, Maillefer/Dentsply, Switzerland) superimposed with the endodontic obturation of gutta-percha and cement-based endodontic zinc oxide [Figure 4].
|Figure 4: Root canal filling with association of the mineral trioxide aggregate and gutta-percha|
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Clinical and radiographic examination control showed a satisfactory repair and absence of any clinical symptom, plus evidence of bone repair [Figure 5],[Figure 6] and [Figure 7].
| Discussion|| |
The goal of apexification is to obtain an apical barrier to prevent the passage of toxins and bacteria into periapical tissues from the root canal. ,,, In our patient, the goal was achieved because it was possible to observe the formation of the apical barrier in the root apex.
The main objective is the antibacterial control of the root canal permitted apical formation. Difficulty was discovered when we found vital tissue along the path, even in cases of pulp necrosis at the level of the crown.
On the one hand, this allows maintaining root formation with thicker walls and a resilient and somewhat longer allowing for better cellular root of the tooth implantation. On the other hand, the option of removing this vital tissue is difficult to implement because the open apex associated with granulomatous characteristics will promote an intense hemorrhagic that hamper the proper endodontic procedure, and often its removal will not be complete.
The advantages of forming a more structured root will not be achieved when we opt for removing the entire pulp tissue. In this case, we chose the first procedure even though we were aware that the vital tissue could form a calcified barrier in contact with calcium hydroxide, which actually occurred. Control of the vitality of the remaining pulp tissue in the apical region is not possible clinically, so a radiographic follow-up is necessary. If there is a need to access the apical region, which does not often occur, this can be accomplished by its breakup with special drills handled by an experienced professional.
Many materials have been proposed for apexification, such as calcium hydroxide and MTA. According to some studies, the presence of high calcium concentration increases antibacterial activity and promotes the mechanisms of calcium hydroxide. 
On the contrary, a study by Andreasen et al.  indicates that the fracture strength of calcium hydroxide-filled immature teeth will be halved in a year because of the root filling. The other problem associated with this medication is the length of the treatment (sometimes up to 18 months) can be too long for the patient to maintain motivation.
For these reasons, there is a new concept of performing apexification in a single session, that has been defined by the maintenance all that pulp tissue capable of healing. The rationale is to establish an apical stop that would enable the root canal to be filled immediately. There is an attempt at root-end closure where an artificial apical stop is created.  Advantages of this technique include a shorter treatment term, development of a good apical seal, and periradicularly the MTA that induces hard tissue deposition. 
Within this context, controlled clinical trials are necessary to determine whether it significantly enhances the prognosis.  The protocol used in this clinical report is based on evidence-based literature. It just includes the temporary restoration with composite sealing and adhesion after conditioning resin to prevent coronal leakage and allow resistance to the tooth due to the fact that apexification is a long-term treatment.
We concluded that the apexification through the use of the therapy that was performed in the central incisor with incomplete root formation and necrotic tissue led to a successful finalization.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]