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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 46-49

Endodontic treatment of the maxillary central incisor with sequelae of dental trauma


Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas, Brazil

Date of Web Publication21-Jun-2016

Correspondence Address:
Josue Martos
Department of Semiology and Clinics, Faculty of Dentistry, Gonçalves Chaves Street, 457, Pelotas, RS 96015-560
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-7212.184340

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  Abstract 

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

How to cite this URL:
Silveira LF, Martos J, Damian MF, Pinto KV. Endodontic treatment of the maxillary central incisor with sequelae of dental trauma. Endodontology [serial online] 2016 [cited 2019 Jan 19];28:46-9. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/1/46/184340


  Introduction Top


Traumatic injuries in young permanent teeth affect approximately 30% of children. [1] 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. [2] 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. [3],[4],[5],[6]

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. [7] 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. [7]

In these cases, the treatment of choice has been apexification [4],[5],[8],[9],[10] 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. [4],[5],[8],[9],[10]

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 Top


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 [11] [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).
Figure 1: Clinical appearance of the fractured tooth

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Figure 2: Initial radiographic aspect

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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. [11] 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].
Figure 5: Final aspect of restored central incisor

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Figure 6: Follow-up aspect at 3 months of the restored tooth

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Figure 7: Radiograph evaluation at the 10 months

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  Discussion Top


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. [3],[4],[5],[6] 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. [12]

On the contrary, a study by Andreasen et al. [13] 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. [8] Advantages of this technique include a shorter treatment term, development of a good apical seal, and periradicularly the MTA that induces hard tissue deposition. [6]

Within this context, controlled clinical trials are necessary to determine whether it significantly enhances the prognosis. [14] 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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235-9.  Back to cited text no. 1
    
2.
Cohenca N, Simon JH, Mathur A, Malfaz JM. Clinical indications for digital imaging in dento-alveolar trauma. Part 2: Root resorption. Dent Traumatol 2007;23:105-13.  Back to cited text no. 2
    
3.
Girish CK, Ghivari SB. Apexification with apical plug of MTA. Report of cases. Arch Oral Sci Res 2011;1:104-7.  Back to cited text no. 3
    
4.
Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: Systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e36-42.  Back to cited text no. 4
    
5.
Gawthaman M, Vinodh S, Mathian VM, Vijayaraghavan R, Karunakaran R. Apexification with calcium hydroxide and mineral trioxide aggregate: Report of two cases. J Pharm Bioallied Sci 2013;5 Suppl 2:S131-4.  Back to cited text no. 5
    
6.
Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodontics Aesthet Dent 2000;12:315-20.  Back to cited text no. 6
    
7.
Shah N, Logani A, Bhaskar U, Aggarwal V. Efficacy of revascularization to induce apexification/apexogensis in infected, nonvital, immature teeth: A pilot clinical study. J Endod 2008;34:919-25.  Back to cited text no. 7
    
8.
Morse DR, O′Larnic J, Yesilsoy C. Apexification: Review of the literature. Quintessence Int 1990;21:589-98.  Back to cited text no. 8
    
9.
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 9
    
10.
Barbin EL, Sposito OS, Machado JW, Martos J, Damian MF. Apexification of the central incisor with incomplete root formation and pulp necrosis associated with apical periodontitis. Endodoncia 2013;31:146-51.  Back to cited text no. 10
    
11.
Silveira LF, Silveira CF, Martos J, Castro LA. Evaluation of the different irrigation regimens with sodium hypochlorite and EDTA in removing the smear layer during root canal preparation. J Microsc Ultrastruct 2013;1:51-6.  Back to cited text no. 11
    
12.
Siqueira JF Jr., Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9.  Back to cited text no. 12
    
13.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 13
    
14.
Hiremath H, Gada N, Kini Y, Kulkarni S, Yakub SS, Metgud S. Single-step apical barrier placement in immature teeth using mineral trioxide aggregate and management of periapical inflammatory lesion using platelet-rich plasma and hydroxyapatite. J Endod 2008;34:1020-4.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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