immature teeth Flashcards
What are the treatment options for teeth with incompletely developed apices with a pulpal diagnosis of necrotic pulp? Define each option.
With incompletely developed apices with a necrotic pulp, the treatment options are apexification, apical barrier, or a regeneration procedure.
• Apexification is defined as “A method to induce a
calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulps” (AAE Glossary of Endodontic Terms 2016). Apexification is completed in multiple visits during which calcium hydroxide is placed in the root canal to induce an apical barrier and checked each visit for a calcific apical barrier. One disadvantage of apexification is that it takes an average of 12.9 months (Dominguez Reyes, Muñoz & Aznar 2005), with time ranging from 5 to 20 months (Sheehy & Roberts 1997). Moreover, in vitro studies have shown calcium hydroxide decreases the fracture strength of immature teeth with prolonged use (Andreasen, Farik & Munksgaard 2002).
• Apical barrier technique is defined as “placement of a matrix in the apical region to prevent extrusion of endodontic filling material; typically refers to teeth with open apices” (AAE Glossary of Endodontic Terms 2016). This technique is completed in one or two visits, depending on whether the clinician wants to check if the barrier material has fully set prior to restoring the tooth. Mineral trioxide aggregate (MTA) (Torabinejad, Watson & Pitt Ford 1993) is commonly used, but many other calcium silicate materials, such as Biodentine® (Septodont, Lancaster, PA, USA) and EndoSequence® Root Repair Material (Brassler, Savannah, GA, USA), have come on the market since MTA was developed.
• Pulpal regeneration technique is defined as “biologically‐based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as cells of the pulp‐dentin complex” (AAE Glossary of Endodontic Terms 2016). Basically, the pulp space is disinfected and pulpal‐like tissue is encouraged to form inside the root to continue root development (i.e., more dentin to thicken the root and increase its length).
What are the treatment options for teeth with incompletely developed apices with a pulpal diagnosis of normal pulp, reversible pulpitis, or irreversible pulpitis?
With incompletely developed apices with a pulpal diagnosis of normal pulp, reversible pulpitis, symptomatic irreversible pulpitis, or asymptomatic irreversible pulpitis, apexogenesis is the treatment of choice.
• Apexogenesis is defined as “[a] vital pulp therapy procedure performed to encourage continued physiological development and formation of the root end; frequently used to describe vital pulp therapy…” (AAE Glossary of EndodonticTerms 2016).The term includes direct pulp cap, indirect pulp cap, partial (Cvek) pulpotomy or pulpotomy. Direct pulp cap is where the exposed pulp is covered with MTA or any other calcium silicate material; historically calcium hydroxide was used. Indirect pulp cap means the pulp is never exposed clinically by leaving a layer of decay over the top of the pulp and covering with MTA or any other calcium silicate material, and the tooth is defini- tively restored, or the tooth is temporarily restored and re‐entered at a later date to completely remove the remaining decay. Pulpotomy is where the coronal pulp tissue is partially (Cvek) removed or the coronal pulpal tissue is removed (complete pulpotomy), the pulp stump(s) is (are) covered with MTA or any other calcium silicate material, and the tooth is restored.
Describe the clinical steps for a regeneration procedure.
The clinical steps for Regeneration (adopted from the AAE Clinical Considerations for a Regenerative Procedure) are as follows:
First Appointment
• Obtain informed consent.
• Use a rubber dam to isolate tooth after local
anesthesia administration.
• Access and irrigate with 20 ml per canal of 1.5%
sodium hypochlorite (NaOCl; Martin et al. 2014) taking precaution to prevent irrigation extrusion (i.e., side vented needle or EndoVac® [Kerr, Orange, CA, USA]).Then irrigate 1 mm from the end of the root with 20 ml per canal of saline or Ethylenediaminetetraacetic acid (EDTA) over the course of 5 minutes.
• Dry canal(s) with paper points.
• Use a syringe to place calcium hydroxide paste
(e.g., Ultracal XS® [Ultradent, South Jordan, UT, USA]) into the canal(s). Syringeable versions of calcium hydroxide are easier to remove at subse- quent appointments than calcium hydroxide powder mixed with water.
• Alternatively, use triple antibiotic paste in a mix of 1:1:1 ciprofloxacin: metronidazole: minocycline to a final concentration of 0.1–1.0 mg/ml instead of calcium hydroxide. The minocycline in triple antibi- otic paste has been shown to cause tooth discol- oration, but sealing the pulp chamber with bonding agent and keeping paste below the cementoenamel junction (CEJ) can help prevent this complication, as can using double antibiotic paste (omitting the minocycline from the triple antibiotic paste).
• Temporize coronal access with material of choice (e.g., CavitTM [3M,Two Harbors, MN, USA], Fuji Triage® [GC America Inc., Alsip, IL, USA] glass ionomer, etc.) at least 3–4 mm thick for proper seal.
Second Appointment (1–4 weeks later)
• Evaluate for the presence of infection, like swell- ing or sinus tract. If still present, consider using antimicrobial for longer or the use of a different antimicrobial (i.e., switch calcium hydroxide to triple antibiotic paste or vice versa).
• Use a rubber dam to isolate the tooth after local anesthesia administration with 3% mepivacaine (no epinephrine or other vasoconstrictor).
• Remove temporary restoration.
• Irrigate with about 20 ml per canal of 17% EDTA.
• Dry the canal(s) with paper points.
• Over‐instrument into the periapical tissues (pre-
curved endodontic file, endo explorer, etc.) to create bleeding into the canal space and allow blood to fill to level of CEJ. Some authors advo- cate using platelet‐rich plasma, platelet rich fibrin or autologous fibrin matrix alternatively for creating a blood clot in the canal system.
• Place a resorbable collagen matrix (CollaPlug® [Zimmer Dental, Carlsbad, CA, USA], HeliPLUG® [Integra Miltex Plainsboro, NJ, USA], etc.) over the formed blot clot, if needed.
• Place ProRoot® MTA (Dentsply Sirona, Johnson City,TN, USA) white.
• Alternatively, in place of MTA, any other calcium silicate cement (e.g., Biodentine® and EndoSequence® Root Repair Material) can be used to prevent staining of the tooth.
• GC Fuji II® (GC America Inc., Alsip, IL, USA) glass ionomer is placed in a 3–4 mm layer over the MTA or other material used.
• Follow‐up in 6 months, 1 year, and yearly thereafter.
Describe the clinical steps for an apexogenesis procedure.
The clinical steps for an apexogenesis procedure are as follows:
• Obtain informed consent.
• Use a rubber dam to isolate tooth after local
anesthesia administration.
• Remove all decay, if present, and if pulp is
exposed (Figure 24.13), obtain hemostasis with a 3–6% NaOCl‐saturated cotton pellet placed over the pulp exposure (Figure 24.14).
• Note: If an indirect pulp cap is desired, leave a layer of decay over the top of the pulp, but ensure all circumferential margins are caries free.Then place MTA or any other calcium silicate material over the top of the decay, and restore the tooth either temporarily or definitively (Maltz et al. 2002).
• If after 10 minutes pulpal hemostasis is not obtained (Figure 24.15), perform a partial pulpomtomy by carefully removing a few millimeters of pulpal tissue with a diamond bur in a high‐speed hand piece with copious water coolant. After another 5–10 minutes of using a 3–6% NaOCl‐saturated cotton pellet, observe the pulp for bleeding.You may have to perform a pulpotomy (Figure 24.16) to ultimately obtain hemostasis. Hemostasis must be obtained prior to covering pulp with MTA (Figure 24.17; Bogen and Chandler 2008).
• Alternatively, in place of MTA, any other calcium silicate cement (e.g., Biodentine® and EndoSequence® Root Repair Material; Figure 24.18) can be used to prevent staining of the tooth.
• Cover with a thin layer of glass ionomer (e.g., GC Fuji LiningTM LC; Figure 24.19).
• Optional (only if MTA is used, but not required): Instead of covering with a layer of glass ionomer, place a wet (water) cotton pellet over the MTA and temporize coronal access with material of choice (e.g., CavitTM, Fuji Triage® glass ionomer, etc.).Bring patient back after at least 4 hours to check if MTA is initially set.
• Definitively restore the tooth.
• Follow‐upin6months,1year,andyearlythereafter.
Describe the clinical steps for an apical barrier technique.
The clinical steps for the apical barrier technique are as follows:
• Obtain informed consent (see preoperative radio-
graph Figure 24.20).
• Use a rubber dam to isolate tooth after local anesthesia administration.
• Remove all decay, if present.
• Access and obtain working length (Figure 24.21).
Clean, shape, and disinfect the canal(s) with
NaOCl irrigation after obtaining working length. • Dry the canal(s) with paper points.
• Optional: Place calcium hydroxide paste (e.g.,
Ultracal XS®), temporize coronal access, and bring patient back within 1 month to prevent weakening the root from prolonged use of calcium hydroxide (Andreasen, Munksgaard, & Bakland 2006).
• Optional: Place a resorbable collagen matrix (CollaPlug, HeliPLUG, etc.) or calcium sulfate hemihydrate (e.g., Dentogen® [Orthogen, Springfield, NJ, USA]) into the periapical region until an apical stop is developed at working length.This prevents extrusion of material in the next step.
• Place 5 mm of MTA (Al‐Kahtani et al. 2005) or any other calcium silicate cements (e.g. Biodentine® and Endosequence® Root Repair Material) in the apical portion of root.This material should extend to working length (Figure 24.22).
• Optional (only if MTA is used, but not required): Place a wet (water) cotton pellet over the MTA and temporize coronal access with material of choice (e.g., CavitTM, Fuji Triage® glass ionomer, etc.). Bring patient back after at least 4 hours to check i• Place a layer of pulp canal sealer (e.g., AH Plus® [Dentsply Sirona]) and backfill with thermoplasticized gutta‐percha (Figure 24.23) and restore definitively (Figure 24.24) or bond fiber post(s) in canal space and restore access definitively (Ree 2015).
• Follow‐up in 6 months (Figure 24.25), 1 year (Figure 24.26), and yearly thereafter.f MTA is initially set.
