|Year : 2016 | Volume
| Issue : 1 | Page : 29-32
The undesirable outcomes of late-referral traumatized immature permanent teeth and root-end-closure with mineral trioxide aggregate apical plug technique
Department of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey
|Date of Web Publication||10-Aug-2016|
Department of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dental traumatic injuries mostly occur in children and affect the anterior dental region. The immediate management of the injuries prevents the loss of dental and alveolar structures. The lack of natural apical constriction in immature permanent teeth due to the pulp necrosis is problematic to treat. Frequently, the apical plug technique is used to attain apical closure that provides the obturation of the root canals without extrusion of the obturation material. In this case report, the endodontic treatment was achieved using apical plug technique with mineral trioxide aggregate (MTA) while prosthetic crown retained with fiber-reinforced post was used to restore the traumatized crown fracture of maxillary incisors. This case report suggests that MTA is influential apical barrier and successively induce periapical healing.
Clinical Relevance to Interdisciplinary Dentistry
- This article is the case report of a young 17-year-old boy with immature permanent teeth and crown fracture
- The treatment of necrotic traumatized permanent teeth using mineral trioxide aggregate apical plug technique on a short-time scale is successful to achieve apical seal and healing of apical periodontitis while motivating the patient to attend the treatment
- The crown fracture requires the use of fiber post that is suitable material for immature permanent root canals.
Keywords: Apical plug, crown fracture, fiber post, immature permanent teeth, mineral trioxide aggregate
|How to cite this article:|
Aksel H. The undesirable outcomes of late-referral traumatized immature permanent teeth and root-end-closure with mineral trioxide aggregate apical plug technique. J Interdiscip Dentistry 2016;6:29-32
|How to cite this URL:|
Aksel H. The undesirable outcomes of late-referral traumatized immature permanent teeth and root-end-closure with mineral trioxide aggregate apical plug technique. J Interdiscip Dentistry [serial online] 2016 [cited 2021 Jun 21];6:29-32. Available from: https://www.jidonline.com/text.asp?2016/6/1/29/188164
| Introduction|| |
Traumatic injuries can affect dental and periradicular structure. Dental trauma generally occurs in children  and special needed/physically challenged individuals.  Several risk factors for dental trauma have been studied, but few are well established in the literature. 
Dento-alveolar injuries are considered as an emergency situation that proper diagnosis and treatment should be done as early as possible to achieve favorable results. Delaying of the dental evaluation and treatments leads to irreversible loss of tooth and alveolar structures. Furthermore, educational background of the patients seems to affect the level of awareness of the importance of immediate management of traumatized teeth.  Most of the children are not taken to a dentist for evaluation due to the fact that parents neglect dental care and the treatment that requires long-term follow-up. In fact, the mother's level of education was found as an important factor for the dental evaluation of an injury. Therefore, special attention should be given to children whose mothers have completed fewer years of education. 
Dental trauma mostly takes place in the anterior dental region.  Since upper incisors are more protracted than the other teeth. Missing, fractured or esthetically poor anterior teeth, and restorations may affect the nutrition, psychology, and personality development. Thus, the maintenance of the tooth is particularly important in these young patients.
Traumatized teeth that are treated according to the dental traumatic guideline have lower complication rates.  In this case report, we described the management and treatment of traumatized late-referral case of immature permanent incisors with crown fracture and emphasized the significance of early treatment and education to prevent further complications.
| Case report|| |
A 17-year-old boy, with noncontributory medical history, was referred for the treatment of pain in the upper incisors from rural area to the endodontic department. He had experienced a traumatic injury due to fall accident at the age of 8. In addition, avulsion of tooth #21 had been occurred in the accident. He failed to obtain any dental treatment until the teeth begun to pain severely.
Clinical examination revealed that the crowns of #11 and #22 were fractured previously in the accident with variable degrees, Ellis Class III, and IV, respectively [Figure 1]a. Periapical radiograph of the teeth showed incomplete root development with wide-open apices that were associated with periapical lesions in both teeth [Figure 2]a.
|Figure 1: (a) Intraoral film of the patient before treatment. (b) Intraoral film of the patient at 18 months recall visit|
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|Figure 2: (a) Preoperative radiograph of traumatized immature tooth #11 and tooth #22. (b) Radiograph after placement of mineral trioxide aggregate as an apical plug. (c) The backfill of the teeth with AH plus and thermoplasticized Gutta-percha (Obtura II, Fenton, MO, USA). (d) Eighteen months follow-up radiograph with complete resolution of periradicular lesions|
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Following the detailed explanation concerning the treatment and prognosis to the patient and his parents and approval of the treatment plan, the root canal treatment was initiated. Following rubber dam isolation, the access cavity was prepared, and the necrotic tissue remnants were gently removed using #80 K-type file (SybronEndo, Orange, CA, USA) at a working length 1 mm short of the radiographic apex. Slight drainage of pus was observed in the tooth #22 during debridement and copious gentle irrigation with 2.5% of sodium hypochlorite (NaOCl, ACE, Procter and Gamble, Istanbul, Turkey) was performed with a 30-G side-vented needle (Maxi-i-probe, Dentsply, Rinn, Elgin, IL) to minimize the possibility of extrusion of irrigants into the periapical space. The K-file was used only for debridement without enlargement of the root canals. A final irrigation was made with sterile saline. After drying with paper points, the calcium hydroxide dressing (SurePaste, SureDent Co. Ltd., Seongnam, Korea) was applied. The calcium hydroxide dressing was removed a week later by gentle instrumentation and 2.5% of NaOCl and 17% of ethylenediaminetetraacetic acid (Vista Dental Products, Racine, WI, USA) irrigation. Following irrigation and drying of the root canals, a small portion of the mineral trioxide aggregate (MTA; White Pro-Root MTA; Dentsply Maillefer, Ballaigues, Switzerland) was placed 1 mm below the working length using ProRoot MTA delivery gun (Dentsply). The incremental placement of the MTA plug was verified with a periapical radiograph [Figure 2]b. A moistened cotton pellet was placed on pulp chamber to provide setting reaction and the access cavity was closed with a glass-ionomer cement (Fuji IX GP, GC, Tokyo, Japan).
One week later, the setting of the MTA was confirmed with a hand plugger. The remainder of the root canals was filled with AH Plus (Dentsply/Maillefer, Ballaigues, Switzerland) and thermoplasticized Gutta-percha (Obtura II, Fenton, MO, USA) [Figure 2]c. The patient was guided for the prosthetic restoration of the teeth. Fiber reinforced post (Dentolic Fiberstift, Itena, France) was applied to the post space and the core was builded up with a resin composite (Filtek Z350; 3M ESPE, USA) providing slight reangulation of the tooth crown. In the laboratory, zirconium oxide framework (Amann Girbach AG, Austria) was generated from computer-aided design and computer-aided manufacturing and the full ceramic crown (CZR, Noritake, Japan) was fabricated. The restoration was cemented with light-cured adhesive resin cement (Clearfil Esthetic Cement, Kuraray, Japan). The crown of #23 was converted to the shape of #22 using a composite resin (Spectrum TPH, Dentsply, Germany). Eighteen months follow-up, radiograph showed healing of the periapical radiolucency [Figure 2]d. The patient satisfied with the esthetic and function of the prosthetic restoration [Figure 1]b.
| Discussion|| |
Dental trauma can cause pulp necrosis, and so root development of immature permanent teeth can be prevented. Immature roots become weak, short, and more susceptible to fracture. Therefore, it is difficult to perform chemomechanical debridement and create an effective apical seal using conventional endodontic treatment methods. Recently, introduced regenerative endodontic treatment in immature necrotic teeth, also called revascularization is a valuable treatment that allows the continuation of root development which is predictable by the evidence of progressive thickening of the dentinal walls, development of root length, and apical closure. However, revascularization procedures are not recommended for the patients who are younger than 7 years or older than 16 years.  Instead, the multivisit apexogenesis with calcium hydroxide and single-visit apical plug technique are suggested for the treatment. An apical plug technique requires fewer appointments to complete the treatment, has more predictable apical barrier formation, shortens the treatment period, and improves patient compliance.  Several studies have confirmed successful clinical outcomes including healing of existing periapical lesions in majority of immature teeth that were treated with an MTA apical plug. , In the present case, 5 mm MTA apical plug was used as suggested to completely prevent bacterial leakage. 
Chemo-mechanical preparation alone is not effective for the complete elimination of microorganisms and necrotic pulp tissue since the thin, fragile root canal walls prevent effective preparation. It was reported that MTA which is used as an apical plug material following a week initial dressing with calcium hydroxide in immature permanent incisors, results in successful removal of the root canal debris. 
Restoring of the immature tooth with crown fracture is highly complex and requires multidisciplinary treatments. Surely, the amount and quality of the remaining tooth structure is the major determinant to evaluate the restorability of the tooth. Considering the enhancing effect on the fracture resistance of immature teeth treated with MTA,  the fiber-reinforced post was used to retain the coronal prosthetic restoration in the present case. The flexural strength of fiber posts closely resembles that of dentin that provides increased fracture resistance to fragile immature roots while decreasing the incidence of catastrophic fracture. ,
The patient had delayed to seek dental treatment following his injury. The reason for this delay may be that his parents did not be aware of the dental evaluation and give low priority to dental treatment, the lack of any pain or symptoms for a long time, and the patient was too young to express his dental complaints to his parents effectively. In addition, it may be attributed to the unavailability of the dentists in rural areas. The possible solution for the problem, especially in rural areas might include the arrangement of the educational program to increase the teacher's low level of knowledge about the dental trauma and treatment.
This case can guide the clinician to deal with the treatment of necrotic traumatized permanent teeth using MTA apical plug technique. Allowing the treatment to be completed on a short-time scale and restoring the tooth at an early stage, this approach encourages and motivates the patient to attend the treatment. The immediate management of dental traumatic injuries can impede the loss of the natural tooth and delay the treatments with synthetic implant material.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hasan AA, Qudeimat MA, Andersson L. Prevalence of traumatic dental injuries in preschool children in Kuwait - A screening study. Dent Traumatol 2010;26:346-50.
Miamoto CB, Ramos-Jorge ML, Ferreira MC, Oliveira MD, Vieira-Andrade RG, Marques LS. Dental trauma in individuals with severe cerebral palsy: Prevalence and associated factors. Braz Oral Res 2011;25:319-23.
Glendor U. Aetiology and risk factors related to traumatic dental injuries - A review of the literature. Dent Traumatol 2009;25:19-31.
Vergotine RJ, Koerber A. The relationship of dental visits to parental knowledge of management of dental trauma. Pediatr Dent 2010;32:329-32.
Schuch HS, Goettems ML, Correa MB, Torriani DD, Demarco FF. Prevalence and treatment demand after traumatic dental injury in South Brazilian schoolchildren. Dent Traumatol 2013;29:297-302.
Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2-9.
Bücher K, Neumann C, Thiering E, Hickel R, Kühnisch J; International Association of Dental Traumatology. Complications and survival rates of teeth after dental trauma over a 5-year period. Clin Oral Investig 2013;17:1311-8.
Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth. Dent Traumatol 2012;28:33-41.
Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: Results from a case series. Int Endod J 2007;40:478-84.
Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod 2008;34:812-7.
Felippe WT, Felippe MC, Rocha MJ. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J 2006;39:2-9.
Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod 2005;31:117-9.
Moore A, Howley MF, O'Connell AC. Treatment of open apex teeth using two types of white mineral trioxide aggregate after initial dressing with calcium hydroxide in children. Dent Traumatol 2011;27:166-73.
Tanalp J, Dikbas I, Malkondu O, Ersev H, Güngör T, Bayirli G. Comparison of the fracture resistance of simulated immature permanent teeth using various canal filling materials and fiber posts. Dent Traumatol 2012;28:457-64.
Soares CJ, Soares PV, de Freitas Santos-Filho PC, Castro CG, Magalhaes D, Versluis A. The influence of cavity design and glass fiber posts on biomechanical behavior of endodontically treated premolars. J Endod 2008;34:1015-9.
Schmoldt SJ, Kirkpatrick TC, Rutledge RE, Yaccino JM. Reinforcement of simulated immature roots restored with composite resin, mineral trioxide aggregate, Gutta-percha, or a fiber post after thermocycling. J Endod 2011;37:1390-3.
[Figure 1], [Figure 2]