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CASE REPOR t
Publication
Apexification and coronal restoration after
traumatic tooth avulsion: a 10 year follow-up

Dr Oliver Pontius,
MSD
Diplomate, American Board
of Endodontics,
Höhestr. 15,
D-61348, Bad Homburg,
Germany
Key words
adhesive restoration, apexification, avulsion, dental trauma, immature root, MTA This case report looks at a case of traumatic avulsion and subsequent apexification of a maxillary permanent incisor of a 6-year-old boy and a 10-year follow-up is reported. Treatment included apex-ification of the tooth with incomplete root formation using mineral trioxide aggregate and restora-tion of the immature root with a zirconia post and a coronal composite restoration. At the 10-yearfollow-up the tooth was asymptomatic, functional and showed radiographically intact periapical tissues.
Introduction
further trauma of the periapical tissues due to overex-tended root canal fillings and may also lead to three- Dental injuries are very common in children and ado- dimensionally underfilled root canals prone to leak- lescents. According to Trope1 the maxillary central inci- age2. An apexification treatment procedure is sors are the most frequently avulsed teeth in both the indicated in such cases. Long-term apexification with permanent and primary dentition. When a tooth is calcium hydroxide dressings has been performed with avulsed, the attachment apparatus of the root (peri- reasonable success3. The aim of this treatment mode odontal ligament and the cemental layer) is damaged is to induce the formation of a hard tissue barrier at the and the blood vessels at the apex of the tooth are sev- apex so that a root canal filling material can be prop- ered, rendering the pulp necrotic2. Treatment is erly introduced without the risk of over-extension4.
directed at minimising damage and inflammation of The disadvantage of using calcium hydroxide for the periodontal membrane. In the tooth with incom- apexification is that it can take several months to plete root development, the primary treatment goal obtain a physiological hard tissue apical barrier. The must be to promote revascularisation of the pulp patient is required to present for treatment at multiple tissue. In non-vital immature teeth with open apices, times and, in addition, these teeth are susceptible to a number of difficulties for adequate endodontic ther- fracture during treatment2,4. It has been demonstrated apy are present. The lack of an apical stop may lead to that the long-term use of calcium hydroxide can Apexification and coronal restoration
Publication
had been performed. The patient saw his physician The clinical examination 2.5 weeks after the trauma (Fig 1) revealed that teeth 11 and 21 were partiallyerupted, slightly protruded and rotated. A sinus tractwas present about 4 mm below the buccal gingivalmargin of tooth 21 (Fig 2). Enamel craze lines in tooth11 were clearly visible using transillumination. All otherteeth were intact and free from caries. Periodontal tis-sues appeared healthy. The pocket depths of tooth 11 Fig 1 Intraoral view during clinical examination two and a
half weeks after the trauma . A sinus tract was present
were 2 mm on the buccal, palatal, distal and mesial about 4 mm below the buccal-gingival margin of tooth 21.
aspects. Sound periodontal probing was not performedfor tooth 21 as it had been replanted shortly. No mobil- weaken dentine and make teeth even more suscepti- ity of the adjacent teeth was present with exception of ble to fracture5. Mineral trioxide aggregate or MTA tooth 21, which showed grade 1 to 2 mobility. (Pro Root, Dentsply, Konstanz, Germany) has proved In the clinical tests tooth 21 was slightly tender to to be a potential root-end filling material. In vitro and palpation, percussion and biting pressure. Tooth 11 in vivo studies have demonstrated the good sealing showed a delayed response to cold, heat, and electric ability of this material, its excellent biocompatibility pulp testing (Vitality tester, Analytic, Orange, CA, USA: and low cytotoxicity, and also its effect on the induc- threshold reading 67/80). Tooth 21 did not respond to tion of odontoblast activity and on the formation of a any of the sensibility tests used. Periapical radiographic hard-tissue barrier6-10. Meanwhile, clinical studies have examination (Fig 3) showed the immature open apices confirmed the high regenerative potential of MTA, of teeth 11 and 21, an intact periodontal ligament of thus justifying its use for creating an apical barrier in tooth 11, as well as evidence of an inflammatory root resorption in the apical part of tooth 21. The aim of this report is to describe the treatment A diagnosis of pulp necrosis and asymptomatic of an avulsed immature permanent incisor submitted apical periodontitis was made for tooth 21. The fol- to apexification with MTA, and the subsequent coro- lowing treatment plan was presented to the parents: apexification followed by non-surgical root canal ther-apy of tooth 21. As an alternative approach the extrac-tion of tooth 21 followed by orthodontic treatment Case report
was discussed. The restorative treatment plan includeda bonded composite restoration and a custom-made A 6-year-old boy with no general health problems was mouthguard. The parents were informed about the referred to the author’s endodontic office on July 6th 1999 for treatment of tooth 21. About 2.5 weeks pre- On July 7th 1999 treatment was started. Local viously, the boy had suffered an injury while rollerblad- anaesthesia was administered (1.8 ml of 2% lidocaine ing. He had hit the ground and avulsed his maxillary HCL [36 mg] with 1:100,000 adrenaline [0.018 mg]).
left central incisor (June 19th 1999). His father had Rubber dam was fixed with dental floss, isolating teeth recovered the tooth from the ground, wrapped it in a 21 and 11. Using a surgical operating microscope an napkin and the boy had immediately seen the family’s access cavity was prepared. Ultrasonically activated irri- clinician. Following a clinical examination, it was con- gation was performed with 0.5% sodium hypochlorite.
firmed that there were no other injuries present and Cleaning and shaping were performed using Gates the socket and the tooth was rinsed with sterile saline, Glidden drills #2 to #5 and K-type hand files. Root canal and the tooth replanted. According to the patient’s length was determined with an electrical apex locator father, the extra-oral dry time was about 45 minutes.
(Root ZX, Morita, Tokyo, Japan) and the result was con- No antibiotic coverage and no splinting of the tooth firmed radiographically with a size 120 K-file (Fig 4). Apexification and coronal restoration
Publication
Fig 2 Preoperative radiograph, sinus
Fig 3 Preoperative radiograph, July 6th
Fig 4 Working length radiograph, July
An aqueous calcium hydroxide suspension was packed hydroxide dressing was carried out if necessary.
with Schilder hand pluggers (Dentsply) and the access Ibuprofen (200 mg) was prescribed every 6 hours (if cavity was sealed with glass-ionomer cement (Ketac Molar, Espe, Seefeld, Germany). After removal of the At the following visit (January 4th 2000) the tooth rubber dam, the occlusion was checked and the patient was asymptomatic and the sinus tract was closed.
was rescheduled for a 3 month radiographic check and After local anaesthesia and isolation using rubber dam replacement of the calcium hydroxide dressing if nec- (as previously described) the access to the root canal essary. Ibuprofen 200-mg was prescribed every 6 hours was reopened under the microscope. The calcium if post-operative pain meant an analgesic was required.
hydroxide dressing seemed washed out again and At the second visit (September 10th 1999), the ultrasonically activated irrigation with 0.5% sodium patient reported that the sinus tract initially had hypochlorite cleaning and shaping to working length resolved, but had reappeared the previous week. After using K-type hand files was repeated. There still was local anaesthesia with 1.8 ml of 2% lidocaine HCL (36 no evidence of a hard-tissue barrier. The final irrigation mg) with 1:100,000 adrenaline (0.018 mg), rubber consisted of a 17% EDTA rinse followed by sodium dam (clamp #9T, Hu Friedy, Leimen, Germany) was hypochlorite. The root canal was dried with sterile applied. Under the microscope the calcium hydroxide paper points. MTA was placed into the apical 5 mm of intracanal dressing seemed to have been washed out.
the canal under control with the surgical microscope Gentle irrigation with 0.5% sodium hypochlorite acti- (Fig 6) using a MTA carrier (Dovgan Carrier, Quality vated by ultrasonics was performed. Cleaning and Aspirators, Duncanville, TX, USA) and condensed with shaping to the working length was repeated, the fora- Schilder hand pluggers and ultrasonics. A moistened men was probed with a size 150 Kerr hand file. There cotton pellet (2% chlorhexidine) was placed over the was no evidence of an apical barrier. Calcium hydrox- material. The access cavity was closed with glass- ide was again packed with Schilder hand pluggers and ionomer cement. A prescription for 200 mg of ibupro- the access cavity sealed with glass-ionomer cement.
fen every 6 hours as needed for pain was given to the The calcium hydroxide dressing was checked radi- ographically (Fig 5). The patient was rescheduled for On January 21st 2000, rubber dam was applied, a 3 month check and replacement of the calcium the temporary filling was removed, and the hardness Apexification and coronal restoration
Publication
Fig 5 Contr
ol of the density and ex- o
oxide, September 10 c
Fig 6 Root canal filling with MTA
(January 4th 2000) was placed into the
apical 5 mm of the canal with Schilder
pluggers under control with the surgi-
cal microscope.
Fig 7 Conditioning of the enamel with phosphoric acid,
Fig 8 Adhesive fixation of the zirconia post with composite,
of the MTA was checked under the microscope with a MI, USA), the occlusion was checked and a post- sharp explorer. A zirconia post (Cerapost, ISO 110, operative radiograph was taken (Fig 10).
Komet, Lemgo, Germany) was adhesively fixed into Six months later (July 11th 2000), a recall check was the wide root canal to strengthen the fragile root. The done by the family clinician. The tooth was asympto- largest available post was inserted in an upside-down matic. The periapical radiograph showed an intact peri- direction due to the very wide diameter of the canal.
odontal ligament with some type of osseous-like tissue The enamel was etched by applying 34% phosphoric forming apically to the MTA (Fig 11). Periodontal tissues acid for 60 seconds (Fig 7), followed by irrigation with appeared healthy, pocket depths were 2mm on the sterile saline. A dentine-bonding agent (Clearfill, buccal and distal, and 1mm on the palatal and mesial Morita, Kuraray, Japan) was applied, and a size 3 zir- aspects and no increased tooth mobility was present. conia post (Fig 8) was adhesively fixed (Panavia TC, On June 27th 2002, the patient was scheduled for a Morita, Kuraray, Japan). The access cavity was sealed further recall appointment with his clinician. The tooth with a composite (Fig 9), (Herculite, Kerr, Romulus, was still asymptomatic. Radiographically, some osseous Apexification and coronal restoration
Publication
2000. ence
Fig 9 Access cavity sealed with composite, January 21st
2000.
Fig 11 Recall radiograph, July 11th
Fig 12 Recall radiograph, June 27th
Fig 13 Recall radiograph, June 27th
structure had formed apically to the MTA, which had The periodontal tissues showed local gingivitis around taken a root-like shape, to the extent that a lamina dura the labial aspect of tooth 21, pocket depths were 3mm appeared to have formed (Figs 12 and 13). The peri- on the mesial and distal, and 1mm on the palatal and odontal tissues appeared healthy, pocket depths were 2mm on the buccal aspect, no mobility was present. 2mm on the mesial and distal, and 1mm on the palatal A 10-year recall check was performed by the and buccal aspects, and no increased mobility was patient’s clinician on January 5th 2009. The tooth was present. In the meantime, the patient underwent ortho- asymptomatic. The periapical radiograph showed an intact periodontal ligament surrounding the root-like On April 24th 2006, the patient was scheduled for structure apically to the MTA (Fig 15). Periodontal tis- another recall appointment. The tooth was asympto- sues appeared healthy, pocket depths were within matic. Apically to the root-like structure exhibiting a normal limits and no increased tooth mobility was normal periodontal ligament, there was another radio- present. The clinical crown of the tooth appeared opaque area followed by a radiolucent zone (Fig 14).
Apexification and coronal restoration
Publication
Recall radiograph, April 24th o
Fig 15 Recall radiograph, January 5th
2009.
Fig 16 Intraoral view January 5th
2009.
Discussion
Recent studies showed that soaking the tooth in doxycycline17 or covering the root with minocycline18 Although the tooth was not replanted within the first significantly enhanced revascularisation in dogs. 20 minutes after avulsion, the root exhibited almost no The apical barrier technique using MTA seems external resorption, even 10 years after the trauma.
very promising in traumatic tooth injuries with open Perhaps even revascularisation as well as continued apices11,12. As MTA has been found to be able to root development would have been possible if the ensure a tight closure of an apical foramen and to most recent treatment protocols13-15 had been fol- promote cementum coverage directly upon the MTA lowed. Regenerative endodontics promotes a para- surface, a double seal of the root canal can be digm shift in treating endodontically involved imma- achieved6-9. Short-term placement of calcium ture permanent teeth. This ranges from performing hydroxide in the root canal with the purpose of dis- apexification procedures to conserving any dental infecting the root canal and dentinal tubules, dissolv- stem cells that might remain in the disinfected viable ing pulp remnants and also drying up the apical zone tissues so as to allow tissue regeneration and repair to before obturation of the root canal with MTA, achieve apexogenesis/maturogenesis16.
appears to be a good alternative to the long-term use Apexification and coronal restoration
Publication
Cvek M. Prognosis of luxated non-vital maxillary incisors n
of calcium hydroxide from a mechanical point of view treated with calcium hydroxide and filled with gutta-per- (fracture resistance)19. However, further prospective cha. A retrospective clinical study. Endod Dent Traumatol long-term outcome studies should be designed to compare this procedure with the traditional calcium Andreasen JO, Farik B, Munksgaard E.C. Long-term calci-um hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-137.
Reinforcement of the thin dentinal walls seems to Torabinejad M, Pitt Ford TR, Abedi HR, Kariyawasam SP,Tang HM. Tissue reaction to implanted root-end filling ma- be critical in these cases. According to Kerekes et al4, terials in the tibia and mandible of guinea pigs. J Endod approximately 30% of these teeth will fracture during Torabinejad, M, Pitt Ford TR, McKendry DJ, Abedi HR, or after endodontic treatment. Therefore, it is recom- Miller DA, Kariyawasam SP. Histologic assessment of min- mended that intracoronal adhesive restorations are eral trioxide aggregate as a root-end filling in monkeys. JEndod 1997;23:225-228.
placed to strengthen these teeth internally20. The use Nakata TT, Bae KS, Baumgartner JC. Perforation repair of a bonded all-ceramic high-toughness post made of comparing mineral trioxide aggregate and amalgam usingan anaerobic bacterial leakage model. J Endod 1998; zirconia may have helped to increase the fracture resist- ance of this fragile tooth and to improve the aesthetic 10. Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: outcome when compared with non-precious alloy a review of the literature. Dent Mater 2008;24:149-164.
posts (which may have lead to discoloration of the 11. Simon S, Rilliard F, Berdal A, Machtou P. The use of miner- tooth)21. However, the future may be in the restoration al trioxide aggregate in one-visit apexification treatment:aprospective study. Int Endod J 2007;40:186-197.
of these teeth with tooth-coloured bonded fibre posts 12. Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG.
exhibiting almost the same modulus of elasticity as Clinical outcomes of artificial root-end barriers with MineralTrioxide Aggregate in teeth with immature apices. J Endod dentine and being easier to remove in cases of 13. Trope M. Regenerative potential of dental pulp. J Endod Considering the alternative treatment options dis- 14. Jung IJ, Lee SJ, Hargreaves KM. Biologically based treat- cussed earlier, the patient and his parents highly appre- ment of immature permanent teeth with pulpal necrosis: acase series. J Endod 2008;34:876-887.
ciated the advantages of the endodontic approach, 15. Shabahang S, Torabinejad M, Boyne PP, Abedi HR, especially in the long-term, as this meant high patient McMillan P. A comparative study of root-end induction us-ing osteogenic protein-1, calcium hydroxide, and mineral comfort, an acceptable aesthetic outcome and rea- trioxide aggregate in dogs. J Endod 1999;25:1-5.
16. Huang GT. A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration.
J Dent 2008;36:379-386.
17. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti Acknowledgements
P. Effect of topical application of doxycycline on pulp revas-cularization and periodontal healing in reimplanted monkeyincisors. Endod Dent Traumatol 1990:64:170-176.
The author would like to thank Prof Hülsmann for his 18. Ritter AL, Ritter AV, Murrah, V, Sigurdsson A, Trope M. Pulp revascularization of replanted immature dog teeth after valuable help during the preparation of this manuscript.
treatment with minocycline and doxycycline assessed bylaser Doppler flowmetry, radiography, and histology. DentTraumatol 2004;20:75-84.
19. Andreasen JO, Munksgaard EC, Bakland, LK. Comparison References
of fracture resistance in root canals of immature sheep teethafter filling with calcium hydroxide or MTA. Dent Traumatol Trope M. Clinical management of the avulsed tooth. Dent 20. Katebzadeh N, Dalton BC, Trope M. Strengthening imma- Trope M, Chivian N, Sigurdsson A. The role of endodontics ture teeth during and after apexification. J Endod after dental traumatic injuries. In: Cohen S, Burns R (eds).
Pathways of the pulp ed 8., St. Louis: Mosby-Elsevier, 21. Strub JR, Pontius O, Koutayas S. Survival rate and fracture strength of incisors restored with different post and core Rafter M. Apexification: a review. Dent Traumatol 2005; systems after exposure in the artificial mouth. J Oral Rehabil Kerekes K, Heide K, Jacobsen I. Follow-up examination of 22. Ferrari M, Vichi A, Garcia-Godoy F. Retrospective study of endodontic treatment in traumatized juvenile incisors. J the clinical performance of fiber posts. Am J Dent 2000;13

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