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BACKGROUND INFORMATION 1
AB
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COMPLEX PULP THERAPY
Revascularization ofaNecrotic Immature
Permanent Tooth
Indications
• Immature permanent tooth with incomplete root
development and there are no other treatment
options
• Necrotic pulp
• No known allergy to the antibiotics used
Technique
First step
• Disinfect the root canals
• Local anesthesia, dental dam isolation
Make a conservative access opening, followed by a
•
radiograph length measurement with a gutta‐
percha point). The gutta‐percha should be inserted
3 mm short of the apical foramen to prevent
damage to vital apical tissues
• Do not instrument the root canal walls
• Gently and carefully rinse the canal with 1.5%
Sodium Hypochlorite (NaOCl) (20 ml/canal, five
minutes) and then rinse with 17% EDTA(20 ml/
canal, five minutes). The needle should be inserted
2–3 mm short of the apical foramen
• Dry the canal with sterile paper points
• Make bi‐antibiotic paste by mixing equal parts of
ciprofloxacin and metronidazole with sterile saline
(Wigler 2013)
• Insert the bi‐antibiotic paste into the canal
usingasterile syringe 2–3 mm short of the apical
foramen
• Seal with 3–4 mm of a temporary restorative material
Second step (two tofour four weeks later)
•
Ensure that the tooth is asymptomatic and without
clinical signs of pathology (e.g. sinus tract)
• Anesthesia with 3 % mepivacaine without
vasoconstrictor. Apply a rubber dam
• Rinse the canal gently with copious amounts of
saline and 20ml of 17% EDTA
• Dry the canal with sterile paper points
• Insert a sterile endodontic hand file or an
endodontic explorer 2 mm past the canal terminus
into the periapical tissues to induce bleeding to fill
the canal spaces (Figure3.9.3)
• Stop the bleeding at a level of 3–4 mm below the
level of the cementoenamel junction with a moist
cotton pellet (sterile saline); leave it for ~10 minutes
so that the blood will clot at that level
The use of resorbable matrices such as
•
CollaPlugTM, CollacoteTM, CollaTapeTM over the
blood clot could be considered
• Place mineral trioxide aggregate (MTA) or other
bioceramic material carefully over the blood clot,
apical to the cementoenamel junction in order to
prevent discoloration. Close access with glass
ionomer cement and or composite resin to ensure
an excellent coronal seal
• Take a periapical radiograph as a baseline record
(Figure3.9.4)
• Follow‐up visits to re‐evaluate
(American Association of Endodontists (2016);
Duggal2017)
M. Intraoperative andPostoperative Images
(Figures3.9.3–3.9.6)
N. Prognosis andDiscussion
• Despite obliteration of the root canal space the
prognosis is good, especially with a continuous
periodontal ligament space and good root
development (see Figure 3.9.6). However, the tooth
should be monitored closely and may require further
treatment in the future
• As anticipated, there was no response to sensitivity
tests at three months or two years five months due
to the presence of the composite and MTA
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Figure 3.9.3 Intraoperative photographs. (A) Blood filling the
root canal space; (B) blood clot formed 3–4 mm below the
cementoenamel junction.
Clinical Cases inPediatric Dentistry 129
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Figure 3.9.4 Immediate postoperative periapical radiograph.
White mineral trioxide aggregate was placed over the blood
clot in the canal. Access cavity was sealed with temporary
restorative material.
• Pulp necrosis following traumatic injuries is mainly
due to the type and severity of the injury as well as to
the stage of root development. Endodontic
intervention is indicated only when the pulp is
necrotic or when there are clinical and radiographic
signs of infection (Barnett 2002)
•
The best treatment option for necrotic immature
permanent teeth is regeneration of the pulp. This will
allow further root development including elongation of
the root and thickening of the canal walls by dentin
deposition (Banchs and Trope 2004; Murray 2007;
Altaii 2017; Duggal 2017)
O. Common Complications andAlternative
Treatment Plans
Common Complications
• Green‐gray discoloration of the crown is sometimes
evident after using triple antibiotic paste containing
minocycline (Kim 2010). Therefore, the use of
minocycline is not recommended
Figure 3.9.5 Three‐month postoperative periapical radiograph.
Note the complete healing of the periapical radiolucency,
slight elongation of the root, and thickening of the canal walls.
The temporary restorative material was replaced by a
composite resin restoration.
•
Bacterial drug tolerance is a potential risk and as a
result the disinfecting action will be impaired
A systemic allergic reaction to the antibiotics could
•
have serious health consequences. Therefore, it is
critical to obtain a thorough medical history including
any known food or drug allergies
• Long‐term failure is possible showing reappearance
ofsymptoms and radiographic periapical
radiolucency
Alternative Treatment Plans
• Non‐setting calcium hydroxide can also be used to
achieve root canal disinfection
• Autotransplantation of immature permanent premolar
to replace the tooth
• Extraction and space closure when there is severe
crowding in the maxillary anterior area
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COMPLEX PULP THERAPY
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Figure 3.9.6 Two years and five months postoperative periapical radiograph. Note the significant, but not uniform, obliteration of
the root canal space. Also note a continuous periodontal ligament space.
Self‐Study Questions
1. What are the indications for the revascularization
procedure?
2. What materials can be used to disinfect the canal
space in the revascularization procedure?
3. In this case what is the outcome of the
revascularization procedure?
4. When is endodontic intervention indicated after a
traumatic injury?
5. What are possible complications of the
revascularization procedure?
Answers are located at the end of the case
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Self‐Study Answers
1. Immature permanent tooth; tooth has incomplete
root development with no other treatment option;
necrotic infected pulp; no known allergy to the
antibiotics used
2. Irrigation with 1.5% NaOCl (20 ml/canal, five
minutes); placement of bi‐antibiotic paste:
ciprofloxacin (quinolone) and metronidazole;
Calcium Hydroxide Ca(OH)2 in the root canal for
three to four weeks
3.
Ingrowth of connective tissue and dentin,
cementum, or bone‐like tissue into the pulp canal
space is evident
4. When the pulp is necrotic or when there are
clinical and radiographic signs of infection
Bibliography
Altaii M. 2017. Histological assessment of regenerative endo-
dontic treatment in animal studies with different scaffolds: a
systematic review. Dent Traumatol 33:235–44.
American Association of Endodontists. 2015. Glossary of
Endodontic Terms, 9th edition. Chicago.
American Association of Endodontists. 2016. Clinical Considerations
for a Regenerative Procedure (on the AAE website).
Banchs F, Trope M. 2004. Revascularization of immature
permanent teeth with apical periodontitis: new treatment
protocol? J Endod 30:196–200.
Barnett F. 2002. The role of endodontics in the treatment of
luxated permanent teeth. Dent Traumatol 18:47–56.
Possibilities include:
5.
• Green‐gray discoloration of the crown is
sometimes evident after using triple antibiotic
paste containing minocycline
• Bacterial drug tolerance is a potential risk and,
as a result, the disinfecting action will be
impaired
• A systemic allergic reaction to the antibiotics
could have serious health consequences
• Long‐term failure is possible showing
reappearance of symptoms and radiographic
periapical radiolucency
•
Cervical root fracture as a result of the thin
canal walls in the cervical area
Duggal M. 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 18:139–51.
Kim JH. 2010. Tooth discoloration of immature permanent inci-
sor associated with triple antibiotic therapy: a case report.
JEndod 36:1086–91.
Murray PE. 2007. Regenerative endodontics: a review of cur-
rent status and a call for action. J Endod 33:377–90.
Wigler R. 2013. Revascularization: a treatment for permanent
teeth with necrotic pulp and incomplete root development.
J Endod 39:319–26.
132 Clinical Cases inPediatric Dentistry
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Orofacial Trauma
S. Thikkurissy and Jennifer Cully
Case 1: Intrusion Injury to Primary Dentition ......................................................................................................134
S. Thikkurissy and Dennis J. McTigue
Case 2: Root Fracture in the Primary Dentition ................................................................................................... 139
S. Thikkurissy and Dennis J. McTigue
Case 3: Complicated Crown Fracture, Permanent Tooth ........................................................................................................... 143
Dennis J. McTigue and S. Thikkurissy
Case 4: Dentoalveolar Luxation Injury to Permanent Dentition ...........................................................................149
S. Thikkurissy and Dennis J. McTigue
Case 5: Permanent Tooth Root Fracture and Extrusive Luxation ......................................................................... 155
Dennis J. McTigue and S. Thikkurissy
Case 6: Permanent Incisor Intrusion ................................................................................................................... 161
Dennis J. McTigue and S. Thikkurissy
Case 7: Permanent Tooth Avulsion ...................................................................................................................... 167
Dennis J. McTigue and S. Thikkurissy
Case 8: Soft Tissue Injury Management ..............................................................................................................173
S. Thikkurissy and Dennis J. McTigue
Appendix Flowcharts ........................................................................................................................................177
Clinical Cases in Pediatric Dentistry, Second Edition. Edited by Amr M. Moursi.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/moursi/pediatrics
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Case 1
Intrusion Injury toPrimary Dentition
FUNDAMENTAL POINT 1
Obtaining aTrauma History
• Confirm that tetanus immunizations are up to
date. If last tetanus booster was five or more
years prior and wound is contaminated with soil/
debris, another tetanus toxoid booster is indicated (American Academy of Pediatrics 2011)
• Rule out closed head injury and refer for medical
consult if patient is positive for any of the following
(Centers for Disease Control and Prevention 2017):
Figure 4.1.1 Facial photograph.
• The preschool years represent a peak in incidence
A. Presenting Patient
• Two‐year‐, seven‐month‐old male (Figure4.1.1)
• New patient presenting as an emergency
of dental trauma, with some reports citing
incidence as high as 35% (Hargreaves etal. 1999)
Amnesia
Nausea/vomiting
Headache
Lethargy/irritability/confusion
Loss of consciousness
B. Chief Complaint andHistory
ofPresentInjury
• Mother states, “My son was running and hit the
stairs in our house”
• Child was running in home, fell and hit cement stairs
three hours ago. Injury was witnessed by mother,
who said that child “spit up food” after injury. No loss
of consciousness
• Child was taken to local emergency room and cleared
of any closed head trauma
• Child is in no distress
C. Social History
• Patient is only child
• Mother is the primary caregiver and stays at home
• Low socioeconomic status
134 Clinical Cases inPediatric Dentistry
D. Medical History
• History of recurrent otitis media infections per mother
• No known drug or food allergies, no medications,
vaccinations are up to date
E. Medical Consult
• Completed at the emergency room
F. Dental History
• No dental home
• Fair oral hygiene; mother states she brushes his teeth
every day
• Age‐appropriate diet
• Uses toothpaste containing fluoride
• Optimally fluoridated water
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• No history of trauma before today
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• Child is acting age‐appropriately, resisting being
separated from mother
G. Extraoral Exam
• Soft tissue injuries: bruising noted on lip
• No other significant findings
H. Intraoral Exam
Soft Tissues
• No significant findings
Hard Tissues
• No significant findings
Occlusal Evaluation ofPrimary Dentition
• Mesial step molar and class I canines
Other
• Minimal plaque accumulation noted
• Caries‐free dentition
• Maxillary right primary lateral incisor: slight mobility,
brown discoloration noted middle third
• Maxillary right primary central incisor: slight mobility
• Maxillary left primary central incisor: intruded to
gingival margin (Figure4.1.2)
• Maxillary left primary lateral incisor: slight mobility,
brown discoloration noted middle third
OrOfacial Trauma
Figure 4.1.2 Intraoral photograph showing intrusion of
maxillary left primary central incisor.
Diagnostic Tools
I.
• Radiographs not possible due to very poor patient
cooperation
• Vitality tests deferred
J. Diagnosis andProblem List
Diagnosis
• Maxillary right primary lateral incisor, right primary central
incisor, and left primary lateral incisor: subluxation
• Maxillary left primary central incisor: intrusion
Problem List
• No dental home
• Complete intrusion maxillary left primary central incisor
FUNDAMENTAL POINT 2
Radiographic andClinical Exam forTrauma
• Rule out other injuries, e.g. root fractures, alveolar
fracture, etc.
• Vitality testing of questionable value on primary
teeth and recognition of pulpal necrosis is typically
based on clinical presentation (Pugliesi etal. 2004)
Lateral occlusal lm (Figure4.1.3) is taken by attaching
•
a large occlusal lm to a tongue depressor and having
the child bite on the depressor, which may also aid in
collumnation. An alternative, if the child is too young
to bite or is uncooperative, is to have parent sit on
chair, with both the parent and child shielded, and
have the parent hold the lm on the child’s cheek
• The clinical exam of this patient revealed intrinsic
brownish discoloration. There are several theorized
sources of tooth discoloration in children including
systemic illness and certain medications. While
some dental staining, such as those due to
tetracycline, are well documented, others such as
Figure 4.1.3 Example of technique for extraoral
lateral occlusal radiograph.
extrinsic amoxicillin‐ clavulanic acid staining are
less studied and subsequently less thoroughly
understood (Garcia‐López etal. 2001)
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K. Treatment
• No treatment is indicated at this time (see Flowchart
A: Intrusion Injuriesat the end of this chapter)
• Advise parent of potential damage to permanent
tooth bud, including potential hypocalcifications
• Discharge instructions:
Avoid incising on injured segment until instructed
otherwise
Watch for clinical signs such as presence of parulis
or fistula
• Follow‐up treatment:
Patient was seen for follow‐up at one and two
months with minimal re‐eruption noted
Four‐month follow‐up: per mother, patient is
asymptomatic; the maxillary left primary central
incisor has fully re‐erupted into position
(Figure4.1.4) (McTigue and Thikkurissy 2018)
• Facilitate a dental home
The overall prognosis for this tooth is based on
•
theobservation that it did re‐erupt. The four‐month
postoperative radiograph demonstrated no
periapical resorption or radiolucency (Figure4.1.5).
The full understanding of the impact of the trauma
is limited to the two‐dimensional radiograph,
andthe successful eruption of the permanent
incisor is a benchmark for the overall success
oftreatment
Figure 4.1.4 Intraoral photograph showing re‐eruption of
maxillary left primary central incisor.
Prognosis andDiscussion
L.
• Follow‐up recommendations:
One week, exam
Three to four weeks, exams and radiographs
Six to eight weeks, exam
Six months, exam and radiographs
One year, exam and radiographs
Figure 4.1.5 Radiograph showing no periapical resorption
orradiolucency associated with the maxillary left primary
centralincisor.
M. Complications andAlternative
TreatmentPlan
• If root apex is exposed through buccal plate, tooth
can be left for spontaneous repositioning. If root apex
is in the developing tooth bud, tooth should be
extracted
• If the tooth failed to re‐erupt after six months of
evaluation, an extraction would be the recommended
course of treatment because any partial ankylotic
changes could impede the path of eruption of the
permanent incisor
• Although rare, there can be a concomitant root
fracture on a primary incisor. If the coronal fractured
segment is very mobile and poses any type of
aspiration risk, then the recommendation is extraction
of the coronal segment while leaving the apical
segment alone
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FUNDAMENTAL POINT 3
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Trauma Complications
• Trauma to primary teeth can lead to developmental
or hypoplastic defects in permanent successors
(Figure4.1.6) (Sennhenn‐Kirchner and Jacobs
2006)
• The majority of intruded primary incisors are
displaced in a labial direction (Holan and Ram 1999)
• All teeth involved in injury must be re‐assessed for
potential pulpal injury, which may not surface
immediately
• The majority of intruded primary incisors (88% in
some reports) will re‐erupt within six months
(Holan and Ram 1999)
OrOfacial Trauma
Figure 4.1.6 Example of hypoplastic defects (arrows) of
the permanent successors following intrusion trauma
to the primary incisors.
When there is no impingement on the permanent
•
tooth bud a wait‐and‐watch approach may be most
prudent because most incisors will re‐erupt within
six months
Self‐Study Questions
1. What are the instances in which immediate
extraction of intruded primary incisors would
beindicated?
2. How long should one wait and watch intruded
primary incisors to re‐erupt?
3. If the intruded tooth is asymptomatic at one
week post injury, is the pulp healthy?
4. If a root fracture was present in the apical one‐
third of the root, is it recommended to extract
surgically the remaining root tip?
5. At follow‐up, you notice the tooth has taken on
a chalky, yellow appearance. What is the probable
pulpal status of this tooth?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 137
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Self‐Study Answers
1. If a radiograph, such as a lateral occlusal, indicates that the primary tooth is intimately associated
with the permanent tooth bud, extraction may be
indicated. Any potential aspiration risk to the child
is also an indication for extraction. Extraction of
the intruded incisor does not necessarily spare the
successor from possible damage
2. While reports note that the majority of intruded
primary incisors will re‐erupt within six months,
re‐eruption should be assessed monthly and teeth
should demonstrate significant re‐eruption (although
not necessarily complete) by two months. If there is
no evidence of re‐eruption, then a careful clinical and
radiographic examination must be completed to
re‐assess treatment options such as extraction
Bibliography
American Academy of Pediatrics, Committee on Infectious
Diseases. 2011. Additional recommendations for use of tetanus toxoid, reduced‐content diphtheria toxoid, and acellular
pertussis vaccine (Tdap). Pediatrics 128(4):809–12. http://
dx.doi.org/10.1542/peds.2011‐1752.
Centers for Disease Control and Prevention (CDC). 2017.
Traumatic Brain Injury and Concussion. https://www.cdc.
gov/traumaticbraininjury/symptoms.html
Garcia‐López M, Martinez‐Blanco M, Martinez‐Mir I, Palop V.
2001. Amoxycillin‐clavulanic acid‐related tooth discoloration
in children. Pediatrics 108(3):819.
Hargreaves JA, Cleaton‐Jones PE, Roberts GJ et al. 1999.
Trauma to primary teeth of South African pre‐school children. Endod Dent Traumatol 15(2):73–6.
3. Not necessarily. In the instance of any
traumaticinjuries, the pulp may provide false‐
positive responses clinically for up to three
weeks post-injury. Sequelae such as replacement
resorption may not be apparent until six weeks
post-injury
4. If the remaining root tip is intimately related
to the permanent tooth bud, then any treatment
mustbe approached with the understanding that
there is potential for damaging the permanent
tooth as well
Pulpal canal obliteration can cause a chalky,
5.
yellow appearance
Holan G, Ram D. 1999. Sequelae and prognosis of intruded
primary incisors: a retrospective study. Pediatr Dent 21(4):
242–7.
McTigue D, Thikkurissy S. 2018. Trauma. In: The Handbook of
Pediatric Dentistry, 5th edition. Nowak AJ, Casamassimo
PS (eds). Chicago: American Academy of Pediatric Dentistry.
Pugliesi DM, Cunha RF, Delberm AC, Sundefeld ML. 2004.
Influence on the type of dental trauma on the pulp vitality
and the time elapsed until treatment: a study in patients
aged 0–3 years. Dent Traumatol 20(3):139–42.
Sennhenn‐Kirchner S, Jacobs HG. 2006. Traumatic injuries to the
primary dentition and effects on permanent successors– a
clinical follow‐up study. Dent Traumatol 22(5):237–41.
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