Endodontics of the traumatized immature incisor Flashcards
Definition -
An immature permanent incisor
defined as one where the apex can be
considered to be open.
Root growth
Divergent- Parallel- Convergent
Challenges of non vital immature tooth
Compromised crown root ratio
Thin root dentine walls
Lack of dentinal stop against which
root canal materials can be
condensed
Endodontics in non vital immature
tooth
APEXIFICATION
RCT of these teeth requires a root end
closure technique to form a barrier at apex
to enable a root filling to be condensed
without going through apex
◦ Calcium hydroxide therapy to induce barrier
◦ Artificial plug (MTA)
Different to APEXOGENESIS – when aim is
to maintain vitality and allow continued root
growth (vital pulpotomy)
Apexification
calcium hydroxide (calcific barrier)
Apexogenesis
Vital pulpotomy
Apexification
MTA
Diagnosis of Loss of Vitality
Signs + Symptoms
Pain, swelling, sinus, TTP, mobility, colour
change
Diagnosis of Loss of Vitality
Radiographic examination
Periapical radiolucency (PAP), arrest of
root development
Diagnosis of Loss of vitality
Sensibility tests
Negative
Diagnosis of Loss of vitality
Any doubt of loss of vitality ?
delay endo Rx
◦ Review 3 mths
◦ Better prognosis if no acute abscess
Acute Abscess- Emergency
treatment
Ideally
full extirpation of pulp and dress with
non-setting Calcium Hydroxide paste
Acute Abscess- Emergency
treatment
But if acutely tender
Prescription
Arrange appt 24 – 48 hrs
Sedative dressing – e.g. odontopaste
Acute Abscess- Emergency
treatment
Ideally… and if accutely tender…
- Apexification ie
◦ Calcium Hydroxide (past)
◦ MTA (current method) - Regenerative Endodontic Technique
Aims of CH Apexification
Creation of a calcific barrier across the
root apex
Allows obturation of canal
Method of CH Apexification
Repeated dressing of nonsetting
Calcium hydroxide at 3-6
monthly intervals
Once barrier achieved remainder of canal
obturated with thermoplastic GP
Average 9 months to form up to 3 years
Traditional
Apexification of
immature root
canal (see imaged labelled)
“Plug” of coarse
mineralised tissue at
apex
Empty root canal
Traditional
Apexification of
immature root
canal
See other images
Periodontal ligament
Dentine of root
Canal
“Plug” of coarse osteocementum
material
Traditional CH Apexification
(apical closure and success rates)
Can see a barrier
. 90% apical closure with Ca(OH)2
* 85% success @ 5yrs for adequate root
filling
Disadvantages of
Apexification
Multiple visits
Lengthy treatment - may take up to 30 mths for
barrier
Difficult technique
Position and quality of barrier unpredictable
Discolouration
brittleness (risk of cervical #)
Expensive in terms
1. Clinical time
2. Parent’s time off work
3. Missed school
Clinical technique- MTA Barrier
Consent
Isolation
Access cavity
Widen cervical constriction (Gates Glidden)
Extirpation of the pulp
Estimation of full working length (1mm short of
radiographic apex
Preparation of root canal, sterile water / 0.5%
Milton irrigation (must avoid extrusion through
apex)
Needle loose and 2-3mm short of working length
Dry the root canal
Interim Root canal dressing (CH) +RMGI
Canal morphology
Cervical constriction (remove this)
Access cavity
Triangular shaped access (apex towards gingival
margin
Larger than access cavity for mature tooth
Canal preparation
Straight line access
May be up to no 140 file
Ultrasonic activation or bristle brush
Canal preparation instruments
Plugger
Bristle brush
Fine tip for
placement of non
setting Calcium
CaOH brands
Hypocal, Calasept,
Ultracal
Clinical technique- MTA Barrier review onwards?
Review in 1-2weeks
Obturation when
no clinical signs of PAP
no radiographic signs of PAP or
evidence of healing PAP
clean dry canal
Clinical technique apexification
Fine tipped MTA carrier
Ideally using microscope
Plugger marker 2 mm short of WL
Careful condensation until 4mm
thickness
Clean canal walls and access (MTA
stains)
Confirm placement with radiograph
When set obturate (ProRoot
2nd visit reqd)
◦ Thermoplastic GP- diverging/parallel
◦ Fibrepost
MTA properties
Hydrophilic
5 min working time, sets <4hrs
pH 12.5
Non-resorbable
High biocompatibility
Compressive strength = reinforced ZOE
=EBA<amalgam
Low leakage <Amalgam + IRM
MTA Composition
(75% Portland cement)
Tricalcium silicate
Bismuth oxide
Dicalcium oxide
Tricalcium aluminate
Gypsum
◦ Silicate oxide
◦ Tetra calcium
aluminoferrite
Add Water
Colloid gel of
calcium oxide in
33% calcium
49% phosphate
6% silica
3% chloride
2% carbon
Delivery- using
ProRoot MTA or MTA-Angelus/ thermoplastic obturation
Pro-root MTA
75% Portland
Cement
20% Bismuth oxide
5% Calcium sulfate
MTA-Angelus
80% Portland
Cement
20% Bismuth oxide
Fast set
Radiographic follow up
Check radiograph immediately after RCT
Follow up visit
◦ Radiograph at 1 year
MTA Advantages
Small number of visits
Biocompatible
Low leakage
Radioopaque
Better success than CH technique
Disadvantages
Cost
Discolouration with poor handling
No reinforcement of canal
Contributes to brittleness
Restoration of immature root treated teeth
Where no bleaching GP removed to cemento
enamel junction
Direct composite crown build up
Avoid conventional posts +/- crown
can consider DT light post
Restoration of immature root treated teeth-
Why avoid conventional posts +/- crown
- Short root
- Leaves inadequate root filling
- Fragile canal walls
- High risk of root fracture
DT light post
Double taper
system
Fibre composite
post
Colour matched
posts and drills
Post colour
changes with water
eases removal
Reinforces weak
remaining tooth
structure
Failures?
2 photos?
Regenerative Endodontic
Technique
Aims to harness potential of stem cells
at apical papilla
Repopulation of root canal space by
stem cells from apical papilla
Cells similar to dental pulp progenitor
cells
Canal repopulated with vital tissue
Produces further hard tissue of root
Regenerative Endodontic
Technique
Advantages
◦ Thicker root
◦ ↓propensity for root fracture
◦ Success requires no additional treatment
◦ ↓risk of reinfection as ↓reaccess
Regenerative Endodontic
Technique
Disadvantages
◦ Lack of long term follow-up data
◦ Not determined stage and duration of
pathosis which leads to destruction of stem
cells
◦ Pulp canal obliteration may complicate future
endodontics
Technique 1
Visit 1
Consent
+/-LA estimate
Rubber dam isolation
Pulp extirpated with barbed broach
(Working length from preop rads)
Copious irrigation (1.5% sodium
hypochlorite) of canals with mild
disinfectant 2mm short of apex
5ml saline flush
Dry canal
and then …
Technique 1
Visit 1 cont.
Antibiotics sealed into canal (avoid pulp
chamber) mixed with sterile water
◦ Ciprofloxacin
◦ Metronidazole
Cotton pellet
GIC
Earlier protocols used TABdiscolouration
◦ Ciprofloxacin
◦ Metronidazole
◦ Minocycline
Technique 2
Visit 2 (2-4 weeks later)
If no signs/ symps of infection
Epinephrine free LA
Rubber Dam isolation
Irrigate with saline
Irrigate with 10ml 17% EDTA
Dry with paper points
Sharp instrument 2 mm beyond apex to
induce bleeding to fill canal
Induce clot
Clean coronal portion
Seal with Calcium silicate cement, GI,
Composite
Technique 3
Follow-up
Clinical and radiographic at 6 months
Clinical and radiographic at 12 months
RET Conclusions
Root development and thickening
highly unpredictable
Until tissue engineering can be
translated into practice RET should be
limited only to those cases where
prognosis of the immature tooth is
deemed to be poor with the use of the
traditional approach (CH/MTA)
