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BACKGROUND INFORMATION 2
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COMPLEX PULP THERAPY
Apexication Risks andComplications
• Apexification has been successfully achieved
using Ca(OH)2. Nevertheless, this procedure has
several shortcomings. Ca(OH)2 apexification is
associated with a high frequency of cervical root
fractures (Cvek 1992; Andreason etal. 2006;
Rosenberg etal. 2007). The frequency of
fractures among immature teeth ranged from
77% in teeth with the least developed roots to
28% in teeth with the most developed roots. This
is probably attributed to its hygroscopic and
proteolytic properties which lead to desiccation
of the dentin
The formation of an apical barrier may take
•
between three and 24 months, and requires
cooperation of the treated child and his or her
parents. An alternative approach is a one visit
Self‐Study Questions
apexification which uses an artificial barrier placed
at the apical portion of the canal, and enables the
immediate obturation of the root canal with
gutta‐percha. However, it has been reported that
the MTA used for one visit apexification may have
the same weakening effect as Ca(OH)
(Duggal etal. 2017). Another disadvantage of the
MTA is crown discoloration. This may be overcome
by the use of Biodentine or EndoSequence (Huang
2009; Marconyak etal. 2016)
• Revascularization may be an alternative to
apexification. This technique enables not only apical
closure, but also elongation and thickening of the
dentinal walls (Huang 2009). Although the results
of this procedure are promising they are not
predictable and further studies are needed (Banchs
and Trope 2004; Chen etal. 2012; Galler2016)
on dentin
2
1. In this case is the stage of root development consistent with the child’s age?
2. What special care should be taken in performing
irrigation during RCT of an immature tooth?
3. What are the suggested methods to determine
working length in teeth with an open apex?
4. How can you verify that the Ca(OH)2 paste lled
the canal to its entire length?
5. What are the alternative treatment options to
apexication with Ca(OH)2?
Answers are located at the end of the case
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Self‐Study Answers
1. The central incisor typically erupts at seven years
of age and its root is completed three years later.
Considering the fact that the trauma occurred nine
months prior to the time she was referred to
treatment (around age nine), the stage of root
development is reasonable
2. Copious irrigation is performed carefully so as
tonot pass solutions beyond the apex and to
avoidthe risk of a cytotoxic effect on periapical
tissues
Bibliography
Andreasen JO, Munksgaard EC, Bakland LK. 2006.
Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or
MTA. Dent Traumatol 22:154–6.
Banchs F, Trope M. 2004 Revascularization of immature
permanent teeth with apical periodontitis: new treatment
protocol? J Endod 30:196–200.
Chen MY, Chen KL, Chen CA etal. 2012. Responses of imma-
ture permanent teeth with infected necrotic pulp tissue and
apical periodontitis/abscess to revascularization procedures.
Int Endod J 45(3):294–305.
Cvek M. 1992. Prognosis of luxated non‐vital maxillary incisors
treated with calcium hydroxide and filled with gutta percha.
A retrospective study. Endod Dent Traumatol 8:45–55.
Duggal M, Tong HJ, Al‐Ansary M etal. 2017. Interventions for
the endodontic management of non‐vital traumatised immature permanent anterior teeth in children and adolescents: a
systematic review of the evidence and guidelines of the
European Academy of Paediatric Dentistry. Eur Arch Paediatr
Dent 18(3):139–51.
Fava LR, Saunders WP. 1999. Calcium hydroxide pastes: clas-
sification and clinical indications. Int Endod J 32:257–82.
Galler KM. 2016. Clinical procedures for revitalization: current
knowledge and considerations. Int Endod J 49:926–36.
3. Using an apex locator in such cases is limited;
hence, the paper point method confirmed by a
radiograph is suggested
4. Ca(OH)2 packing must be verified by a radiograph;
all of the root canal should have the same opacity as
the dentin
5. One visit apexification using bioceramic materials
or MTA. Alternatively, revascularization/regeneration
may be considered
Harrison JW. 1984. Irrigation of the root canal system.
DentClin North Am 4:797–808.
Hasselgren G, Olsson B, Cvek M. 1988. Effects of calcium
hydroxide and sodium hypochlorite on the dissolution of
necrotic porcine muscle tissue. J Endod 14:125–7.
Huang GT. 2009. Apexification: the beginning of its end. Int
Endod J 42(10):855–66.
Marconyak LJ Jr, Kirkpatrick TC, Roberts HW et al. 2016.
A comparison of coronal tooth discoloration elicited
by various endodontic reparative materials. J Endod
42(3):470–3.
Naenni N, Thoma K, Zehnder M. 2004. Soft tissue dissolution
capacity of currently used and potential endodontic irrigants.
J Endod 30:785–7.
Rafter M. 2005. Apexification: a review. Dent Traumatol
21:1–8.
Rosenberg B, Murray PE, Namerow K. 2007. The effect of
calcium hydroxide root filling on dentin fracture strength.
Dent Traumatol 23:26–9.
Siqueira JF Jr, Lopes HP. 1999. Mechanisms of antimicrobial
activity of calcium hydroxide: a critical review. Int Endod J
32:361–9.
Tanomaru Filho M, Leonardo MR, Silva LAB et al. 2002.
Inflammatory response to different endodontic irrigating
solutions. Int Endod J 35:735–9.
120 Clinical Cases inPediatric Dentistry
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COMPLEX PULP THERAPY
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Case 8
Root End Closure withMineral Trioxide Aggregate
Social History
C.
• Single child
• Middle class family
D. Medical History
• No significant findings, no known drug or
foodallergies, no medications, vaccinations are
uptodate
Figure 3.8.1 Facial photograph.
A. Presenting Patient
• Nine‐year‐old male (Figure3.8.1)
B. Chief Complaint andHistory ofPresent
Injury
The patient was referred by his dentist for root canal
•
treatment (RCT) of the maxillary right permanent
central incisor. This tooth had a traumatic injury when
the patient was seven years of age
• History of treatment: at the emergency appointment
one week prior, the patient presented with a large
facial swelling diagnosed as an acute periradicular
abscess originating from the maxillary right
permanent central incisor. Upon accessing the root
canal, there was pus drainage. The dentist placed a
calcium hydroxide (Ca(OH)2) dressing in the canal,
sealed it with a temporary filling, and prescribed
amoxicillin 250 mg/5 cm3, three times per day,
foroneweek
E. Medical Consult
• Not applicable
F. Dental History
• Has a dental home
• Eats a regular balanced diet
• Fair oral hygiene habits, brushes his teeth twice a day
unsupervised
• Uses a fluoride‐containing toothpaste
• Lives in an optimally fluoridated area
• Dental trauma at age seven
• Cooperative
G. Extraoral Exam
•
No significant findings, the facial swelling had
resolved
H. Intraoral Exam
Soft Tissues
• No significant findings
Hard Tissues
• No significant findings
Occlusal Evaluation ofMixed Dentition
• Class I permanent molars and primary canines,
anterior crowding, overjet 5 mm, overbite 50%
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Dental Exam
• Minimal plaque
• Caries free
• First permanent molars with amalgam restorations
• The maxillary right permanent central incisor had a
temporary filling covering the lingual surface access
I. Diagnostic Tools
• Periapical radiograph of the maxillary right
permanent central incisor (Figure3.8.2) showed
temporary filling, wide root canal with thin walls,
immature tooth with open apex, round radiolucent
periapical area (Figure3.8.2, arrow) surrounded by a
radiopaque zone
• Clinical examination showed: temporary filling; 2 mm
pocket; physiologic mobility; no sensitivity to
percussion, electric pulp test (EPT) and cold test; slight
tenderness on palpation; no sinus tract; no swelling
J. Differential Diagnosis
• Remnants of the dental sac
• Periapical true cyst
• Non‐odontogenic lesion
K. Diagnosis andProblem List
Diagnosis
• Immature tooth with asymptomatic apical
periodontitis
Figure 3.8.2 Periapical radiograph of the maxillary right
permanent central incisor (arrow at radiolucent area).
Problem List
Difficult to establish correct working length in
•
immature teeth
• Risky to file a tooth with thin root canal walls
• Obturation of a tooth with wide open apex may result
in overfilling
• Cold test and EPT are unreliable in immature teeth
• Difficult to differentiate between the radiographic
appearance of a dental sac and chronic apical
periodontitis
BACKGROUND INFORMATION 1
Mineral Trioxide Aggregate
• Mineral trioxide aggregate (MTA) is a powder that
consists of hydrophilic particles which set in the
presence of moisture; it reacts with tissue fluids to
form a hard tissue apical barrier
• MTA is the first restorative material that
consistently allows overgrowth of cementum and
itmay facilitate the regeneration of the
periodontalligament (Torabinejad etal. 1997;
Schwartz etal. 1999)
• The use of MTA requires only one or two visits to
complete the apexification, depending on the type
of MTA used (Duggal etal. 2017)
122 Clinical Cases inPediatric Dentistry
• A drawback to the use of MTA is the potential to
cause coronal discoloration of the crown. However,
there are alternative materials that can be used for
an apical plug, especially when esthetics is a
concern. Bioceramic materials, such as Biodentine®
or EndoSequence™, stain the teeth to a lesser
extent than MTA and are also osteoconductive
(Cheng etal. 2010; Mozynska etal. 2017). In
addition, an apical matrix can be placed in order to
limit the extension of the apical plug beyond the
borders of the root canals (Yadav etal. 2015)
• Obturation of the root canal can be performed with
a vertical condensation of warm gutta‐percha in the
remainder of the canal
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L. Comprehensive Treatment Plan
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• Explain to the parents the difficulties in treating an
immature permanent tooth
• Establish an apical barrier with MTA, followed by RCT
and the final restoration
• Follow‐up care should include:
Immediate postoperative and home care instructions
after each appointment
Recall after one year, followed by yearly clinical and
radiographic examination for five years
Dental Treatment
• First appointment:
Local anesthesia, rubber dam, and removal of the
temporary filling
Working length established using a radiograph in
conjunction with the paper point method
Copious irrigation with 0.5% chlorhexidine, followed
by minimal mechanical instrumentation of the root
canal walls and additional irrigation with ultrasonic
activation
Because there was no apical stop, a Ca(OH)2 paste
was placed using a syringe with a small‐gauge
needle, followed by an intermediate restorative
material temporary filling
• Second appointment, two weeks later:
Copious irrigation with 0.5% chlorhexidine
Apical barrier created with MTA
Wet paper point and wet cotton pellet placed over
the MTA plug followed by a temporary filling
(Figure3.8.3)
COMPLEX PULP THERAPY
Figure 3.8.4 Radiograph showing obturation of the root canal.
Third appointment, one week later:
•
Setting of the MTA plug verified
Root canal space irrigated with 0.5% chlorhexidine
and dried
Canal was obturated with warm injectable gutta‐
percha (Figure3.8.4)
Coronal access sealed with temporary restoration
Patient referred back to dentist for final restoration
M. Clinical andRadiographic Follow‐Up
• The tooth is asymptomatic and functional 12 months
postoperatively (Figure3.8.5). The size of the periapical radiolucency diminished; full healing is expected
Figure 3.8.3 Radiograph showing closure of the apex with an
MTA plug.
Figure 3.8.5 Twelve‐month postoperative radiograph.
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FUNDAMENTAL POINT 1
Calcium Hydroxide vs. Mineral Trioxide
Aggregate
• In comparison to Ca(OH)2 apexification, apical
closure with MTA is more predictable along with
reduction in treatment time, number of
appointments, and radiographs. The tooth can
be restored with minimal delay, preventing the
risk of root fracture and reinfection. There is a
growing body of evidence to suggest the
recommendation of MTA, instead of Ca(OH)2,
for apexification in traumatized anterior teeth
(Duggal 2017)
N. Prognosis andDiscussion
• Due to their thin dentinal walls, these teeth are prone
to fracture. Therefore, a mouth guard is suggested to
decrease the risk of injury in risky situations (sports,
biking, etc.). Nonetheless, the parents and the patient
should bear in mind that this tooth may be lost in the
future
O.
Common Complications andAlternative
Treatment Plans
Common Complications
• After apexification, the immature root is short and the
crown : root ratio is not favorable. Post placement
(ifneeded) is difficult due to the size and irregular
shape of the root canal, and placement of a permanent
crown should be delayed due to the patient’s
continuous growth and maturing of the gingival tissues
Alternative Treatment Plans
• Apexification with Ca(OH)
2
• Revascularization may be considered as another
option, especially when the root canal walls are very
thin, and the tooth is in an earlier stage of
development. The procedure involves two steps, the
initial step is disinfection of the root canal using a triple
antibiotic paste. In the second step, bleeding is
induced from the apical tissues and allowed to fill the
root canal in order to serve as a scaffold for stem cells,
which will enable the continued maturation of the root
(Banchs and Trope 2004; Diogenes and Ruparel 2017).
Although results are promising for revascularization of
traumatized necrotic immature teeth, root maturation
may still be inconsistent (Saoudetal. 2014)
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Self‐Study Questions
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COMPLEX PULP THERAPY
1. What are the main problems in endodontic
treatment of immature teeth?
2. What are the problems in establishing working
length in immature teeth?
3. What are the reasons for preferring a single‐visit
root closure with MTA rather than apexication
with Ca(OH)2?
4. What are the alternative materials which can
beused for apexication, and what are their
advantages?
Answers are located at the end of the case
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Self‐Study Answers
1. Immature teeth have a wide‐open apex;
therefore, it is impossible to seal the root canal
without overfilling beyond the apex. Furthermore, if
filled with Ca(OH)2 these teeth are more prone to
fracture
2. The exact position of the biologic apex in teeth
with a blunderbuss apex is not apparent. It is
advisable to use a paper point to measure the exact
length of the root canal. Bleeding at the end of the
paper point or a wet paper point indicates
overextension
Bibliography
Banchs F, Trope M. 2004. Revascularization of immature perma-
nent teeth with apical periodontitis: new treatment protocol?
J Endod 30(4):196–200.
Cheng L, Ye F, Yang R etal. 2010.Osteoinduction of hydroxyapa-
tite/beta‐tricalcium phosphate bioceramics in mice with a
fractured fibula. Acta Biomater 6(4):1569–74.
Diogenes A, Ruparel NB. 2017. Regenerative endodontic proce-
dures: clinical outcomes. Dent Clin North Am 61(1):111–25.
Duggal M, Tong HJ, Al‐Ansary M etal. 2017. Interventions for
the endodontic management of non‐vital traumatised immature permanent anterior teeth in children and adolescents: a
systematic review of the evidence and guidelines of the
European Academy of Paediatric Dentistry. Eur Arch Paediatr
Dent 18(3):139–51.
Mozynska J, Metlerski M, Lipski M, Nowicka A. 2017. Tooth
discoloration induced by different calcium silicate‐based
3. (i) Ca(OH)2 apexification is more time consuming
than creating an apical barrier with MTA; (ii) Ca(OH)2
can make these teeth more prone to fracture,
whereas MTA strengthens the root; (iii) MTA creates
a better biologic seal; (iv) root end closure with MTA
is also more predictable
4. Biodentine, EndoSequence and other bioceramic
materials can also be used for apexification. They
stain the teeth to a lesser extent than MTA and are
also osteoconductive
cements: a systematic review of in vitro studies. J Endod
43(10):1593–601.
Saoud TM, Zaazou A, Nabil A etal. 2014. Clinical and radio-
graphic outcomes of traumatized immature permanent
necrotic teeth after revascularization/revitalization therapy.
JEndod 40(12):1946–52.
Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. 1999.
Mineral trioxide aggregate: a new material for endodontics.
JADA 130:967–75.
Torabinejad M, Pitt Ford TR, McKendry DJ etal. 1997. Histologic
assessment of mineral trioxide aggregate as a root‐end filling in monkeys. J Endod 23:225–8.
Yadav P, Pruthi PJ, Naval RR etal. 2015. Novel use of platelet‐
rich fibrin matrix and MTA as an apical barrier in the management of a failed revascularization case. Dent Traumatol
31(4):328–31.
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COMPLEX PULP THERAPY
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Case 9
Revascularization ofNecrotic Immature Permanent Tooth
withApical Periodontitis
A. Presenting Patient
• Seven‐year‐, five‐month‐old Caucasian male
Chief Complaint andHistory of
B.
PresentIllness
• Patient has no complaint of pain
• Was referred by his dentist as a result of periapical
radiolucency observed in maxillary right permanent
central incisor
C. Social History
• Second out of three children
• Middle socioeconomic class
D. Medical History
• Healthy
• No known food or drug allergies
E. Medical Consult
• Not applicable
F. Dental History
• Balanced and healthy diet, drinks mostly tap water
•
Has a dental home
• Brushes without supervision twice a day with
toothpaste containing fluoride
• Water fluoridation level between 0.1 and 0.2 ppm
• Due to moderate anxiety, previous dental treatment
was performed with nitrous oxide
• Trauma history:
Four months ago the patient slipped while playing
in his room, fell and fractured both maxillary
permanent central incisors crowns. The mesio‐
incisal crown fractures did not expose the pulp
One week ago the teeth were examined during a
regular dental check‐up. Periapical radiolucency was
observed in maxillary right permanent central
incisor and he was referred for care
Figure 3.9.1 Preoperative intraoral photograph. Note the open
bite and the mesio‐incisal crown fractures in both maxillary
permanent central incisors crowns.
See Chapter4: Orofacial Trauma for more information
on obtaining an appropriate trauma history
G. Extraoral Exam
• No special findings
H. Intraoral Exam (Figure3.9.1)
• Mixed dentition
• Anterior open bite
• Maxillary left permanent central incisor with mesio‐
incisal crown fracture but asymptomatic
• Maxillary right permanent central incisor:
Mesio‐incisal crown fracture
No crown discoloration
Normal mobility
I. Diagnostic Tools
• Periapical radiograph of maxillary anterior area
(Figure3.9.2)
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However, in cases of VRF the most common
symptoms are swelling, sinus tract, and a local
narrow periodontal pocket. Because these symptoms
were not found, the most probable diagnosis is
asymptomatic apical periodontitis
FUNDAMENTAL POINT 1
Denitions
• Asymptomatic apical periodontitis: inflammation
and destruction of apical periodontium that
isofpulpal origin, appears as an apical
radiolucentarea, and does not produce
clinicalsymptoms
• VRF: a fracture in the root whereby the fractured
segments are incompletely separated; it may
occur buccal‐lingually or mesial‐distally; it
maycause an isolated periodontal defect(s) or
sinus tract; it may or may not be radiographically
evident
(American Association of Endodontists, 2015)
Figure 3.9.2 Preoperative periapical radiograph of maxillary
anterior area. Note the short immature root with thin dentin
walls in the maxillary right permanent central incisor. Also
note the radiolucent area around the root apex as compared
with the maxillary left permanent central incisor.
• Maxillary right permanent central incisor with
negative response to cold test and sensitive to
percussion
J.
Differential Diagnosis forMaxillary Right
Permanent Central Incisor
• Asymptomatic apical periodontitis (pulp necrosis)
• Vertical root fracture (VRF) (pulp necrosis)
K. Diagnosis andProblem List
Diagnosis forMaxillary Right Permanent
Central Incisor
• Pulp necrosis
• Periapex‐asymptomatic apical periodontitis
• As the root is immature with very thin walls and the
tooth was injured, there is a possibility of VRF.
Problem List
• Difficult to disinfect the canal space in immature teeth
because of the potential for irrigation extrusion
• Risky to file a tooth with thin root canal walls
• Obturation of a tooth with wide open apex may result
in overfilling
• Cold test and electric pulp test are unreliable in immature
teeth
• Possibility of root fracture due to the thin dentin
walls
• Unfavorable crown : root ratio
• Potentially uncooperative behavior due to moderate
anxiety
L. Comprehensive Treatment Plan
• Explanation to the parents of difficulties in treating an
immature permanent tooth
• Behavioral management using nitrous oxide
• Revascularization procedure
• Restoration
• Follow‐up care includes:
Orthodontic consultation
Recall at 3, 6 and 12 months after the
revascularization and once a year thereafter
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