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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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Volume 2 Issue Pulpal treatment in young permanent teeth February 2011

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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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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

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Volume 2 Issue Pulpal treatment in young permanent teeth February 2011

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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

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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

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Volume 2 Issue Pulpal treatment in young permanent teeth February 2011

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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

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Volume 2 Issue Pulpal treatment in young permanent teeth February 2011

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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

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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

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Volume 2 Issue Pulpal treatment in young permanent teeth February 2011

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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


CHALLENGES IN PULPAL TREATMENT OF YOUNG PERMANENT TEETH– A REVIEW