Akademik Veri Yönetim Sistemi
20.Uluslararası türk pedodont, derneği kongres,, Antalya, Türkiye, 6 - 09 Ekim 2022, ss.289-291, (Tam Metin Bildiri)
Regenerative Endodontic Treatment Of Young Permanent Teeth
With Complicated Crown Fracture Due To Dental Trauma
Nilay Öztürk1, Aybike Baş2, Periş Çelikel3, Fatih Şengül4
1Atatürk University Faculty of Dentistry, Department of Pedodontics, 25240, Erzurum, Turkey, nilayztrk93@gmail.com, 0000-0003-0311-6597
2Atatürk University Faculty of Dentistry, Department of Pedodontics, 25240, Erzurum, Turkey, aybkbass@gmail.com, 0000-0002-5287-1727
3Atatürk University Faculty of Dentistry, Department of Pedodontics, 25240, Erzurum, Turkey, celikelperis@gmail.com, 0000-0002-1807-4281
4Atatürk University Faculty of Dentistry, Department of Pedodontics, 25240, Erzurum, Turkey, fatihs@gmail.com, 0000-0001-6087-148X
Abstract
Introduction
Traumatic dental injuries can cause pulpal and periodontal damage to the teeth. The application of root canal treatment in young permanent teeth with dental trauma can cause various difficulties. Conventional treatment of permanent teeth with incomplete root development with infected pulp includes calcium hydroxide (Ca(OH)2) apexification and apical plugging with mineral trioxide aggregate (MTA) or a similar material. In recent years, there are regenerative endodontic treatment methods based on biological basis developed for the treatment of such teeth. In this case report, it is aimed to describe the application of regenerative endodontic treatment with Biodentineâ in a pediatric patient with necrotic pulp who had a complicated crown fracture due to dental trauma.
Case Report
A 10-year-old boy patient with a history of dental trauma applied to our clinic 9 months after the trauma and had an intraoral examination. A complicated crown fracture was detected in tooth number 11. Regenerative endodontic treatment with Biodentineâ was applied to the tooth with immature root and necrotic pulp. As a result of the 1-year radiographic follow-up of the patient, it was observed that the apex was significantly closed and there were no clinical symptoms.
Conclusion
Apexification with Ca(OH)2 or the apical plug method with a biocompatible material has several disadvantages. Regenerative endodontic treatment, which is a current protocol, has the potential to maintain root development. Therefore, it can be considered as an alternative treatment approach.
Introduction
Traumatic dental injuries can cause pulpal and periapical problems in teeth.
Most of these injuries can be seen in the immature teeth of children between the ages of 7-10. Crown fractures including enamel, dentin and pulp can be encountered in dental injuries. If the vitality of immature rooted teeth is lost as a result of dental traumatic injury, the endodontic treatment that will be applied to the tooth may become complicated (1). Mechanical cleaning and shaping of root canals makes endodontic treatment difficult due to the weak and fragile structures of immature rooted necrotic teeth (2, 3). Until today, various methods such as long-term calcium hydroxide (Ca(OH)2) apexification or single session apexification with a biocompatible material have been used in the endodontic treatment of immature rooted teeth (1). In spite of the upper hand of inducing apex closure in the apexification performed with (Ca(OH)2), various disadvantages such as the need for multiple appointments, the risk of contamination between sessions and the increase in root fragility are observed in this method. In the apexification treatment made with biocompatible material, the fragility of these teeth increases due to the undesirable root-crown ratio and thin root dentin, since root development is not maintained. In addition to endodontic treatments such as apexification and artificial apical barrier creation of immature rooted teeth, there are also regenerative endodontic treatment options that have gained popularity in recent years (3). It can be seen as an advantage that regenerative endodontic treatment allows root maturation by providing vital tissue formation compared to apexification (1). In this case report, regenerative endodontic treatment of a traumatized immature rooted maxillary central tooth is presented.
Case Report
A 10-year-old boy with a history of dental trauma applied to our Pedodontics Department at Atatürk University Faculty of Dentistry ,9 months after the trauma. It was learned that the patient did not have any systemic disease in the anamnesis taken from him. As a result of the clinical examination of the patient, a complicated crown fracture was detected in tooth number 11. On the radiographic examination, it was found that the apex of tooth number 11 was open, and no other periapical lesion was found (Figure 1). As a result of clinical and radiographic examinations, after the application of regenerative endodontic treatment for the tooth with necrotic pulp and immature root, it was decided to perform restoration with composite. Following the isolation process with a rubber cover after local anesthesia, the access cavity of the tooth was prepared with a high-speed sterile diamond bur under cool running water. Necrotic pulp tissue was removed without any instrumentation in the root canal. Root canal irrigation was done passively with 20 ml of 2.5% sodium hypochlorite (NaOCl) and physiological saline, respectively. After irrigation procedures, root canals were dried with paper cones. After drying, calcium hydroxide (Ca(OH)2) paste was applied to the root canal. After the teflon tape was placed in the canal opening, the access cavity was temporarily covered with glass ionomer cement (EQUIA Forte Fil,GC) and the patient was given an appointment 3 weeks later. After the isolation provided in the second visit, the temporary restoration was removed under local anesthesia (Safecaine), which does not contain epinephrine, and it was reached as far as the canal opening. The root canal was gently irrigated with 20 ml of 17% Ethylenediaminetetraacetic acid (EDTA). After the root canal was dried with the help of paper cones, the number 15 K-file was adjusted to be 2 mm longer than the root canal length measured with the apex locater in the first session, and the canal was flooded. The bleeding was expected to fill with blood up to the enamel-cementum boundary (Figure 2). After this process, the stabilized clot formed was carefully covered with Biodentineâ without applying pressure (Figure 3). A thin layer of resin modified glass ionomer cement (Ionoseal, VOCO GmbH) was placed on the Biodentineâ and activated by light. Finally, a direct composite (3M ESPE Filtek Ultimate, USA) restoration was performed. After the necessary occlusal adjustment was made, the restoration was polished with fine diamond bur, polishing discs and tires (Sof-Lex; 3M ESPE) and the treatment was completed (Figure 4). As a result of the 1-year radiographic follow-up of the patient, it was observed that the root tip was significantly closed and there were no clinical symptoms (Figure 5).
Figure 1: Preoperative periapical Figure 2: Expected bleeding up to the
radiograph of teeth enamel-cementum
Figure 3: Covering the stabilized clot Figure 4: Postoperative intraoral photograph
with Biodentineâ
Figure 5: 1-year follow-up periapical radiograph
Discussion
The presence of a healthy pulp tissue is important for success in vital pulp treatment (4). If a complicated crown fracture due to trauma is not treated, it can usually cause pulp necrosis. (5). Apexification is the traditional common method used in the treatment of teeth with necrotic pulp and immature roots. In the apexification method performed with calcium hydroxide, many disadvantages such as long treatment period, increased root fragility, coronal microleakage can be encountered.(6). Due to all these disadvantages, one-session apexification method with Mineral Trioxide Aggregate (MTA) has emerged as an alternative to calcium hydroxide apexification in recent years. However, MTA has negative aspects such as being very expensive, inability to maintain root development, and the presence of short weakened roots (7). For such reasons, regenerative endodontic treatment has been considered as an alternative approach. When the canal of the tooth with necrotic pulp is disinfected, revascularization can be performed under the presence of a suitable cell scaffold (8). In this revascularization, the blood clot, which acts as a skeleton in the apical part, with growth and differentiation factors also play an important role (9). Petrino et al.(10) recommended the use of a local anesthetic that does not contain epinephrine, as in this case. Calcium hydroxide is offered as an alternative to triple antibiotic paste for the revascularization procedure (11). In this case, calcium hydroxide was used as a medicament in the root canals, and the tooth was observed as asymptomatic 3 weeks after the application. This shows that the antibacterial protocol can provide effective disinfection in root canals. In this case report, it was possible to follow up the tooth that healed with its natural process after regenerative endodontic treatment. It was seen that the root length of the tooth as well as the root wall thickness increased, and the apical part of the tooth was closed. However, it is not known whether the tooth will develop root canal obliteration or apical periodontitis in its prognosis. Even if undesirable situations will occur, it will be important to keep the tooth in the mouth for a long time. For this reason, the primary treatment approach should be conservative methods, and other methods should be applied if failure is observed.
Conclusion
Apexification with Ca(OH)2 or the apical plug method with a biocompatible material has several disadvantages. The regenerative endodontic treatment method, which is a up-to-date protocol, has an upper hand as it has the potential to maintain vitality and root development. In this case report, successful results were obtained in immature rooted teeth with the regenerative endodontic treatment method. However, more clinical studies with long-term follow-up are needed for this treatment to be used routinely.
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