Intemational Joumal of Clinical Dentistry Volume 6, Number 3
ISSN: 1939-5833 © Nova Science Publishers, Inc.
APEXOGENESIS OF BILATERAL GROSSLY DECAYED IMMATURE MOLARS- A CASE REPORT
Suryakanth M. Pai, V. Revathy* and Raj F atenta Abid Department of Pedodontics and Preventive dentistry. College of Dental Sciences, Davangere Department of Pedodontics and Preventive dentistry, Karpaga Vinayaga Institute of Dental Sciences, Chennai Pedodontics, Private Practitioner, Yavatmal, India
ABSTRACT It is common to encounter incompletely fonned permanent molars that require some form of endodontic treatment due to carious destruction. The goal of treatment in such cases should be to preserve the pulp vitality and to ensure complete root development. Apexogenesis is one such conservative endodontic procedure which involves complete removal of coronal pulp followed by suitable medicament placement that preserves the vitality of the radicular pulp and causes healing of the wounded pulp tissues. This case report describes the complete root development of grossly decayed immature mandibular molars. Clinical Signífícance: Conservative endodontic treatments should be given preference in pédiatrie patients over radical treatment procedures. The case report shows success of such procedures with proper case selection.
INTRODUCTION The completion of root development and closure of the root apices take place up to 3 years after the tooth emption in a permanent tooth. Any irreversible injury from either infection or trauma during this period can pose a clinical challenge. The dentinal walls are thin and the apex lacks the constriction. It is not uncommon to fmd such immature teeth that require endodontic intervention in clinical practice. Nevertheless the main goal of treatment in dental diseases is to preserve the vitality of the pulp [1]. Pulpotomy comprises of amputation of coronal pulp and placement of protective agent over the remaining viable radicular pulp in order to preserve its vitality and function [2]. This Address for correspondence: Dr. Revathy Viswanathan, Department of Pedodontics, K.V. Institute of Dental Sciences, Chennai, TAMIL NADU, INDIA, PH - +00919380011233, E-MAIL- govisrev@rediffmail.com
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procedure implies removing infected and inflamed coronal pulp tissue at the level of the entrance of the root canals and has been used in exposed carious or traumatised teeth with incomplete root formation. Here, the role of the medicament is to preserve the vitality of the pulp in the root canals and nature takes care of the root development. The result of pulpotomy is apexogenesis. Apexogenesis as a therapeutic procedure is expected to enable the preservation of the function of Hertwigs Epithelial root sheath which enables the root elongation until it reaches optimal crown-root ratio, to preserve the vitality of tooth pulp whose odontoblasts are necessary to build the optimal thickness of the root walls, to provide the closure of the apical foramen until apical maturation. Hence the whole process depends on the vitality of the radicular pulp [3]. The success rate of this procedure has been reported to be 94-95%in fractured incisors and 93-94% in cariously exposed young permanent molars [4]. It is known that direct pulp capping is a more conservative procedure but when it is performed on a tooth with inflamed pulp, the probability of repair and long term success is low [5]. The purpose of this article is to report a case of apexogenesis in a patient with bilateral grossly decayed permanent first molars.
CASE REPORT A 9 year old girl reported to the department of pĂŠdiatrie dentistry with chief complaint of spontaneous pain in lower left and right first molar. The pain was intermittent and woke her up at night. On clinical examination, extensive carious lesion with gross destruction of the lower fn-st molars was seen. Radiograph revealed that the lesion was involving the pulp and the roots were immature with open apices (Figures la, lb). A diagnosis of irreversible pulpitis was made. However it was planned to preserve the vital radicular pulp in order to allow continued root development. Hence pulpotomy (Apexogenesis) was decided as the treatment plan for this patient. After administration of local anesthesia, the teeth were isolated with rubber dam. The carious lesion was removed carefully using a high speed handpiece with water spray. After complete removal of carious dentin, a large exposure of pulp was observed. The pulp tissues were removed from the pulp chamber and the surface was gently irrigated with isotonic saline until bleeding stopped. After hemostasis, sterile cotton pellets were used to dry the pulp chamber and the floor was capped with calcium hydroxide/saline paste, sealing the root canal entrances. IRM (Dentsply International Inc, Milford, DE) was placed as a base material over the calcium hydroxide and then a glass ionomer material was used as the coronal restoration. The patient was followed once in every 3 months. The periapical radiographs taken 14 months after pulpotomy showed apical closure in both the teeth. Endodontic treatment was then done in both the teeth. Post obturation radiographs showed completely formed apices that allowed for containment of obturation materials within the confines of root canal system (Figures 2a, 2b). In the next appointment, post space was prepared in the distal canals of both the teeth and pre fabricated posts were placed.The pulp chamber was then restored with Glass ionomer Cement and the teeth were further restored with stainless steel crowns (Figure 3).
Apexogenesis of Bilateral Grossly Decayed Immature Molars- A Case Report
Figures la, lh. Pre-operative IOPA of decayed molars.
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Figures 2a, 2b. Radiographs showing ohturation after apexogenesis.
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Figure 3. Stainless steel crowns.
DISCUSSION The advantages of vital pulp therapy include preservation of tooth vitality, continued root development and apical closure in immature teeth. The traditional material of choice for pulpotomy (apexogenesis) is calcium hydroxide. Tbis material has been shown by a number of authors to be the most predictable with regard to long term clinical success [6-9]. When pure calcium hydroxide is placed in direct contact with the pulp, caustic effects are produced due to the alkaline pH of about 12.5. Necrotic area caused by calcium bydroxide stimulates the mesenchymal cells to tum into fibroblasts first and later into odontoblasts that would form tbe matrix [10]. Although calcium hydroxide is a time tested material and its long term success has been proved in immature permanent teeth, certain inherent disadvantages of this material do exist. Apart from the root development, parts of the vital radicular pulp may become calcified making future endodontic treatment difficult [11]. The fibroblasts in the immediate contact of calcium hydroxide sbow changes in DNA, protein syntbesis and alkaline phospbatase activity [3]. As an altemative to calcium hydroxide, many other newer materials have emerged. MTA with its excellent sealing ability and tissue compatibility has shown favourable results in apexogenesis [12-15]. The other materials include Calcium Enriched mixture complex or new endodontic cement [16-19]. Although initial results of these materials are encouraging, long term successful results can only warrant the future use of these materials. Controversy exists as to whether farther root canal treatment is required after apexogenesis. It is known that these teetb continue to calcify even after root completion. Many instances of intra canal calcification have been reported in such teeth [11, 14]. In addition to this, incidence of intemal rĂŠsorption and pulpal necrosis exist in teeth treated in tbis manner. As it is not possible to determine the pulp vitality or health of the remaining pulp
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tissue, it has been suggested to perform endodontic treatment once the root development appears to be completed. The key to success in apexogenesis is a long term impervious seal from the oral environment. Hence a bacteria tight coronal restoration is necessary to prevent oral micro organisms from reaching the pulp cavity. In the present case. Glass ionomer restoration was done and the patient was recalled frequently to ensure an intact coronal seal. This paved the way for a successftil apexogenesis. Despite the availability of newer materials, calcium hydroxide is still a promising material for apexogenesis. Nevertheless frequent clinical follow up to ensure a tight coronal seal and radiographie follow up to rule out intra canal calcification and rĂŠsorption are needed for a successful biological apexogenesis.
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