Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
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Review CHALLENGES IN PULPAL TREATMENT OF YOUNG PERMANENT TEETH – A REVIEW Anantharaj .A1,Praveen.P2, Karthik Venkataraghavan3, Prathibha Rani.S4, Sudhir.R5,Murali Krishnan.B6 1
Professor and Head, 2,3Professor, 4,5Lecturer, 6Post Graduate Student Department of Pediatric and preventive dentistry, D.A.P.M.R.V Dental College, Bangalore.
Abstract The golden rule in the practice of Endodontics is to debride and obturate the canals as efficiently and three dimensionally as possible in an amount of time and appointments that are reasonable to the patient. It is reasonable to assume that most Pedodontists have achieved the necessary skills to manage predictably and comfortably most of the endodontic cases in their practices. Unfortunately traumatic injuries to young permanent teeth are not uncommon and are said to affect 30%of children. These injuries often result in pulpal inflammation or necrosis and subsequent incomplete development of dentinal wall and root apices. The importance of careful case assessment and accurate pulpal diagnosis in the treatment of immature teeth with pulpal injury cannot be overemphasized. The diagnostic techniques for evaluating pulpal and periodontal healing subsequent to trauma are a major problem.
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Depending upon the vitality of the affected pulp, two approaches are possible, apexogenesis or apexification. As always, success is related to accurate diagnosis and a full understanding of the biological processes to be facilitated by the treatment. Key Words : Trauma, Diagnosis, Immature Apex, Apexification
Journal of Dental Sciences & Research 2:1: Pages 142-155
“Blunder
Introduction
buss�
canal
usually
The golden rule
required a surgical approach for
in the practice of Endodontics is to
the placement of an apical seal into
debride and obturate the canals as
the often fragile and flaring apex.
efficiently and three dimensionally
Treatment was complicated when
as possible in an amount of time
patient
and
conscious
appointments
that
reasonable to the patient.
are It is
reasonable to assume that most Pedodontists necessary
have skills
sedation
anaesthesia,
required
or
especially
general with
children.
the
Apexification
manage
hydroxide Ca (OH)
achieved to
management
with 2
calcium
has proved to
predictably and comfortably most
be a reliable and most welcome
of the endodontic cases in their
addition
practices
armamentarium Before
clinical 143
management
1966
the
of
the
to
the
described it in 1966.
Journal of Dental Sciences and Research
therapeutic
since
Frank
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
The
present
article is a
2. Extensive apical resorption Due
review of various materials and methods
which
practice
have
been
mentioning
in
to
orthodontics,
periapical pathosis or trauma.
the
advantages and disadvantages of
3.
Root end resection During periradicular surgery
the same.
4. Over-instrumentation
Causes of open apices
In
open
apex
cases
of
establishing
drainage though root canals and
I. Incomplete development The
1
typically
removing
gutta
percha
occurs when the pulp undergoes
during
necrosis as a result of caries or
constriction might sometimes be
trauma, before root growth and
inadequately removed.
development
are
complete
retreatment,
apical
(i.e.
denture Cvek’s Stages 1-4).
Pulpal
Some other causes of incomplete
developing roots
development are Dens in dente Dentin dysplasia (type II) An open apex can also occasionally form in a mature apex (Cvek’s stage 5) as a result of
an
points
injury
in
Unfortunately
teeth
with
traumatic
injuries to young permanent teeth are not uncommon and are said to affect 30% of children.
The
majority of these incidences occur before root formation is complete in the 8 to 12 year age range and
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Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
most commonly involve maxillary anterior teeth. These injuries often
-
and
incomplete
-
subsequent
development
usually sensitive to trauma but the
degree
fracture
during
before,
or
after
treatment.
The root sheath of Hertwig is
of
Which are susceptible to
of
dentinal wall and root apices.
because
Divergent
Thin dentinal walls
result in pulpal inflammation or necrosis
1
Short roots -
of
compromising
crown-root ratio
vascularity and cellularity in the apical region, root formation can
Thus
Fractures of crown.
continue even in the presence of
-
Compromising
pulpal inflammation and necrosis.
esthetics especially in
Because of the important role of
the anterior region
Hertwig’s epithelial root sheath in continued root development after
rehabilitation
be made to maintain its viability.
with open apices Large open apices
145
-
Convergent
-
Parallel
post
endodontic
pulpal injury, every effort should
Common problems associated
Necessitating
of
both
crown and root. Discoloration in long standing cases According to Morse et al there are at least 5 methods of treating a
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
1
tooth that has a necrotic pulp and
4. Apexification (Apical closure
an open apex. These methods are
induction) Inducing apical
1.
A customized cone (Blunt
end, rolled cone) Filling the root canal with the large (Blunt) end of a gutta percha cone or customized gutta percha
closure by
the formation of an apical stop (Calcium
hydroxide,
Ca(OH)2
generally
used)against
which
is a
permanent root canal filling can subsequently be inserted. 5. One visit apexification
cones with a sealer.
Placing 2. A short fill technique
a
biologically
acceptable substance in the apical portion of the root canal (Dentinal
Filling the root canal well short of the apex (before the walls have diverged) with gutta percha and sealer or zinc oxide eugenol (ZOE) alone. 3.
chips or Tricalcium phosphate have been used) thus forming an apical barrier. This is followed by filling the root canal with gutta percha and sealer.
Periapical surgery (with or
without a retro grade seal) Filling the root canal with
According to the studies done by Alfred
periapical
and
then
performing
surgery with or without
a reverse seal. 146
the
types
of
maturation can be as follows.
gutta percha and sealer as well as possible
Frank
Journal of Dental Sciences and Research
1. Continued
apical
development with a definite though minimal, recession
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
of the root canal i.e. the
A 5th type of canal closure has
apex develops normally.
been reported by Gerald M. Cathey
2. Continued
apical
development
without
any
2
(Cathey’s
treatment).
apexification Continued
apical
change in the root canal
development with calcific bridge
space (Dome apexification)
just coronal to apex
1
i.e. Apical maturation is
Review of apexogenesis
produced without the root
Although vital pulp capping and
canal changing its form.
pulpotomy procedures of curiously
3. Thin
calcific
formation
at
bridge, the
apex
exposed pulps in mature teeth remain controversial, it is
without apical development.
universally accepted that vital pulp
The
therapy is the treatment of choice
apex
keeps
blunderbuss closed
by
form a
but
thin
its it
walled
calcified bridge.
for vital immature teeth (incompletely developed apices). Certain authors
4. Lack of apical development
3
prefer that
maturogenesis become the
with a calcified bridge just
accepted term to use when dealing
coronal to the apex.
with the treatment of immature
The
apex keeps its blunderbuss
teeth with vital pulps.
form
Maturogenesis shows a concern not
and
the
bridge
of
calcified tissue is formed
only for a wide open apex
beneath it.
(apexogenesis) but also for roots having very thin and weak walls.
147
1
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
Apexogenesis involves removal of
3.
Promoting
root
1
end
the inflamed pulp and the
closure, thus creating a
placement of calcium hydroxide on
natural apical constriction
the remaining healthy pulp tissue.
for root canal filling.
Traditionally this has implied
Generating a dentinal bridge at the
removal of the coronal portion of
site of the pulpotomy. While the
the pulp
bridging is not essential for the
The
goals
of
apexogenesis,
stated by Webber 1.
148
are as follows.
Sustaining
a
viable
success of the procedure, it does suggest that the pulp has maintained its vitality.
thus
Review of apexification
allowing
continued
Apexification treatment is
development
of
supposed to create an environment
length
a
Hertwig’s
2.
2
as
sheath,
for
root more
to permit Hertwig’s epithelial root
favorable crown to root
sheath to continue its function of
ratio.
root development. The hardy
Maintaining pulpal vitality,
sheath is often able to recover its
thus
function in spite of inflammation,
allowing
the
remaining odontoblasts to
infection, and mechanical or
lay
chemical trauma
down
dentine,
producing a thicker root
However, other healing
and decreasing the chance
mechanisms may be involved, as
of root fracture.
apical closure has been reported to
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
1
occur even when Hertwig’s sheath
Cooke and Robotham5 hypothesize
had been removed surgically by
that the remnants of Hertwig’s
apical curettage during Ca (OH)2
epithelial root sheath, under
apexification treatment. Different
4
favorable conditions, may organize
methods
of
root components
apexification
1.
Removal
the apical mesodermal tissue into
of
infected
necrotic pulp tissue Moller et al have shown that
2. Use of antiseptic or antibiotic pastes. .
A number of investigators
infected necrotic pulp tissue
demonstrated apical closure using
induces strong inflammatory
an antiseptic paste as a temporary
reactions in the periapical tissues.
filling material following root canal
Therefore removal of the infected
debridement and Ball successfully
pulp tissue should create an
reproduced these results using an
environment conducive to apical
antibiotic paste.
closure without use of a
used a polyantibiotic paste to close
medication.
the
Some believe that instrumentation may in fact hamper root
Rule and Winter
apex, and in
described
some
continued
cases, root
development.
development and that preparation
3. Induction of a blood clot in
of these canals should be done
the peri radicular tissues.
cautiously, if at all. 149
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
1
Nygaard-Ostby hypothesized that
A study done by N. Shah7 in 2009
laceration of the periapical tissues
where 14 infected immature teeth
until
were
bleeding
produce
new
occurred vital
might
vascularized
treated
by
revascularization
pariapical
method.
The
tissue in the canal.
cases were followed up at regular
Ham
1972 also reported
intervals of 3 months; the range in
closure of the end of the root, by
follow-up was 0.5–3.5 years. There
‘induced
was
et
al
blood
clot’.
The
radiographic
resolution
periapical tissues were deliberately
periradicular
probed with a file until bleeding
length increase and thickening of
occurred
dentinal wall. None of the cases
Francisco Banchs and Martin Trope 6
in
a
case
report
described
wherein the canal was disinfected without
radiolucencies,
of root
presented with pain, reinfection, or radiographic
enlargement
of
preexisting apical pathology.
mechanical
instrumentation with the use of
4. Calcium hydroxide
copious irrigation followed by a
Calcium hydroxide was introduced
mixture of antibiotics (mixture of
by Hermann in the 1920’s for
Ciprofloxacin, metranidiazole and
endodontic treatment The
minocycline paste).
induction technique was first
A blood clot
was then produced to the level of
addressed in the United States in
the cementoenamel junction (CEJ),
1964 with separate presentations
followed
by Kaiser and Frank at the 21st
by
a
deep
coronal
restoration with MTA. 150
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
annual meeting of the American
months.
Association of Endodontists
reviewed 44 non vital immature
Mechanism of action of Ca(OH)2 to
incisors
induce formation of a solid apical
hydroxide apexification and found
barrier.
that the mean time to barrier
Some
of
the
postulated
mechanisms of the osteoconductive effects of Ca(OH)2 are as follows
8
Finucane
of
1
Kinirons
undergoing
calcium
formation was 34.2 weeks (range 13-67 weeks). Success rates
calcium
Published case reports and
concentration increase the activity
several long term studies have
of
stated a success rate of 74-96%
1.
Presence
of
high
calcium
dependent
pyrophosphatase. 2.
Direct effect on the apical and
periapical soft tissue
10
.
In a review of 10 studies, Sheehy an Roberts of
8
reported that the use
calcium hydroxide
for apical
barrier formation was successful in 3.
High pH, which may activate
alkaline phosphatase activity 4. Antibacterial activity
74-100% of cases irrespective of the proprietary brand used Mineral trioxide aggregate
Mean time for apical barrier formation
centered on the use of mineral
In a review of ten studies, Sheehy and Roberts
In recent times interest has
9
reported an average
length of time for apical barrier
trioxide
apexification. first
formation ranging from 5 to 20 151
aggregate
Journal of Dental Sciences and Research
This
introduced
(MTA)
for
material
was
in
1993
and
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
received
food
and
drug
necrotic pulp
and
open
1
apices.
administration (FDA) approval in
They concluded that MTA can be
1998.
considered a very effective option
A histomorphologocal study done
for
where the pulp was capped either
advantage of reduced treatment
with ProRoot (Dentsply) or MTA-
time, good sealing ability and high
Angelus
biocompatibility.
(Angelus)
and
restored
with zinc oxide eugenol cement.
and
processed
with
the
Calcium – β-glycerophosphate
After 30 and 60 days, teeth were extracted
apexification
calcium
–
β-
for
glycerophosphate is a source of
histological examination and the
calcium and inorganic phosphate
effects on the pulp were scored.
through
Overall, 94% and 88% of the
phosphates in blood and tissue
specimens
fluid,
capped
with
MTA-
Angelus and ProRoot, respectively, showed either total or partial hard tissue bridge formation and it was concluded that MTA or ProRoot can be used in caries free tooth for apex closure.11
al
where
it
is
alkaline
converted
to
hydroxyapatite. Meguni
Imai
13
demonstrates an
in
a
case
artificial
apical
barrier formation by using calcium – β – glycerophosphate paste in a
Mineral
open apex communicating with the
trioxide
maxillary sinus. The apical third of
aggregate was used for obturation
the root canal was medicated with
of maxillary central incisors with
ca – β glycerophosphate
152
in
and
by
non vital permanent tooth with an
A study done by Pinar Erdem et 12
hydrolysis
Journal of Dental Sciences and Research
powder
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
mixed with a .09% isotonic saline
Bone morphogenic proteins
solution. One week later, an apical barrier (about 1mm in thickness calculated
from
the
BMP’S are used to promote bone formation.
original
working length)
1
Stimulates proliferation of mesenchymal cells that
Collagen gel
subsequently differentiate into
In 1980 Nevins et al in a
osteogenic lineagesRutherford et al
subhuman primate study
15
demonstrated that cross linked
study that the addition of bone
collagen gel can be used to induce
morphogenic protein in a collagen
regeneration. In 1977 one clinical
carrier matrix when applied to
case was reported by Nevins et al
partially debried root canals
in which an immature partially vital
allowed for more tissue growth
maxillary lateral incisor was totally
than collagen matrix alone.
reported in a subhuman primate
pulpectomized and filled with a collagen gel. Alan Nevins, Paul Crespi
14
Conclusion
reviewed the use of Zyplast collagen gel as a hard tissue induction material in fractured and undeveloped teeth and reported favorable outcomes using collagencalcium phosphate gel
Every effort should be made to attain the genetically programmed closure of foramen that remains open because of early pulp death. This can be accomplished by apexification a method of
153
Journal of Dental Sciences and Research
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
Endo Dent. Traumatol
recharging the growth potential and restoring root growth and
1992:8:134-137.
foramen closure. The present
5. Cooke, Robotham. The closure
article gives a comprehensive
of open apices in non vital
review of the various materials and
immature incisor teeth - Letter to the Editor BDJ 1988:42-421.
methods used for apical closure. References
6.Francisco Branchs, M. Trope.
1.Henry Harbert. One step
Revascularization of immature
apexification without calcium
permanent teeth with apical
hydroxide. Joe 1996, vol. 22, No.
periodontitis : new treatment protocol. JOE 2004, Vol. 30 No. 4
12, 690-692
7. N. Shah, A. Logani, U. Bhaskar,
2. Raymond.T. Webber –
V. Aggarwa. Efficacy of
Apexogenesis versus apexification.
Revascularization to Induce
DCNA vol.28, No.4, October 1984.
Apexification/Apexogensis in Infected, Nonvital, Immature
3. Rebecca Weisleder, Claudia R
Teeth: A Pilot Clinical Study
Benitex. Maturogenosis – Is it a
Journal of Endodontics,
new concept ? JOE 2003;29:796-778.
2009,Volume 34, Issue 8, Pages 919-925.
4. Ohara PK, Trobinejad M. Apical
8. Mary Rafter, Apexification : a
closure of an immature root
review. Endodontic Dental
subsequent to apical curettage.
Traumatology 2005 : 21 (1) : 1
154
Journal of Dental Sciences and Research
1
Volume 2 Issue Pulpal treatment in young permanent teeth February 2011
1
9. .E.C. Sheehy, G.J. Roberts. Use
Volume 24, Number 5, October
of calcium hydroxide for apical
2008 , pp. e38-e41(1).
barrier formation and healing
13. Imai,
in non vital immature permanent teeth ; a review. BDJ:
10.Kleier dj, Barr ES. A study of
Endo.
apexified
Dent.
teeth.
Traumatol,
Evaluation
Application
Meguni
of
Ca-β-
barrier
formation.
JOE
1995. 14.Alan Neuins, Paul Crespi. A clinical study using the collagen gel zyplast in endodontic
1991:7:112-117. 11.
Hayashi,
glycerophophosphate for artificial apical
1997:183:241-246
endodontically
Yoshiniko
of
two
mineral
treatment. JOE Sep. 1998, Vol.
trioxide aggregate compounds as
24, No.9, 610-613.
pulp-capping
15. Shahrokh Shabahang, M.
agents
in
human
teeth, IEJ Jan 2009
Torobinejad. A comparative study
12. Pinar Erdem, Arzu; Sepet, Elif
of root end induction using
.Mineral
trioxide
obturation incisors
of
with
aggregate
maxillary necrotic
central
pulp
osteogenic protein-1, calcium
for
and
hydroxide, and mineral trioxide aggregate in dogs. JOE Vo.
open apices.Dental Traumatology,
25, No. 1 Jan. 1999
Correspondence Dr.Anantharaj .A, Professor and Head, Department of Pediatric and Preventive dentistry, D.A.P.M.R.V Dental College, Bangalore Email: dranantharaj@gmail.com 155
Journal of Dental Sciences and Research