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Necrosis of the revascularized pulp in an immature infected maxillary second premolar following apexogenesis - a case report

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  • Tishk International University

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Nowadays, the trend in treating the infected immature permanent tooth is with disinfection and revuscularization of the root canal instead of apexification. By revuscularing the root canal and utilizing, a biocompatible material will create a new pulp tissue that can provide vital cells, which are able to continue the root formation to the normal length, wall thickness and close the apex. The purpose of this case report is to present a patient case where in revascularization of the infected immature tooth pulp space had been performed which end with necrosis after complete root formation. Immature maxillary permanent second premolar with a single canal revascularızed in vivo by a blood clot from the periapical tissues into the canal space after disinfection. This case differ form other cases of revuscularization in that CMCP used as intracanal medicament in the first visit and the new pulp found non-vital after root completion.
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Introduction
Tooth viability can be maintained by the presence of vital pulp,
because it supply the tooth with nutrition and biologically works as
a sensor for pathogenic stimuli detection. The loss of vitality in an
immature tooth leads to a poor crown-root ratio, thin walls of the
root which is liable to fracture, and with an open apex. Every effort
needed to attain the closure of foramen that remains open because
of early pulp necrosis. This treatment could be by apexigenesis,
which is a method of recharging the growth and restoring root growth
and foramen closure,1 that is important for the long-term prognosis
and integrity of the periapical tissues. The common treatment of an
infected immature permanent tooth is by apexication using MTA
or calcium hydroxid, which its disadvantages are the thin root walls
and disproportion of crown-root length due to non- growth in the root
but only a barrier closing the apical area of the root against gutta-
percha condensation, and the root will be weak and predisposed to
fracture at any time. Nygaard-Ostby2 was the rst in revascularizating
the pulp space in necrotic, infected teeth, whose study was aimed
to determine the reaction of the periodontal tissue if the whole pulp
was removed from the canal and lled this empty canal with blood,
the author stated that tissue formations could take place if the empty
canal was lled only with blood from the periapical area, it has been
noticed an increase in length of the root but the process stopped
because of the shortage in materials and instruments. In most of
cases of the non-vital teeth are infected, and the disinfection is the
rst phase of revascularization to ensure periapical healing.3−5 Iwaya6
treated a necrotic, infected permanent tooth by revascularization
after disinfection of infected root-canal dentine by topical use of a
combination of ciprooxacin, metronidazole and minocycline that
used by Hoshino et al.7 and bacterial tight sealed of access cavity.
Iwaya6,8 used calcium hydroxide in the coronal part of the canal after
disinfection and revascularization; the result was the disappearance
of the radiolucency and the root increased in length and thickness
after 5 months and complete root formation after 30 months occurred.
Banchs & Trope9 accomplished the same treatment but the MTA used
instead of calcium hydroxide. Copious irrigation with 5.25% sodium
hypochlorite, the radiolucency disappeared after 2 months and at
the 24-months recall the root walls became thick and the growth of
the root was analogous to the contiguous and contra lateral teeth. A
case of non-vital infected immature mandibular second premolar was
reported in which root formation took place after a single-visit calcium
hydroxide apexication treatment. In this case, a barrier of hard tissue
was formed, with a separate, mesioapically root growing, seven
months after treatment. The auther concluded that changing of the
calcium hydroxide is not always needed to induce apical closure.10 An
appropriate cleaning, shaping, asepsis, and lling of the root canal are
the conditions must be available for the success of non-surgical root
canal treatment11An effective regenerative endodontic method using a
minor difference of the tri-antibiotic paste established by Hoshino and
colleagues, as amoxicillin was used instead of minocycline,12 which
results over an eighteen months period in healing of apical periodontitis
and the draining sinus, the root became mature with the closure of the
apex, and the tooth became responsive to pulp sensibility testing. Pulp
revascularization is a process to induce blood inside the root canal to
let vital cells inside the root from which specic cells can be formed.
Those cells will form the root to the normal length and thickness and
be more resistant to the forces of mastication than the tooth treated
with apexication.12,13 The potent evidence for successful regenerative
treatment is the following clinical outcomes; resolution of apical
periodontitis, continued radiographic root development.14 The aim of
this report is to present a case of infected immature permanent tooth
treated with pulp revuscularization. Over instrumentation was the rst
step then Camphor phenol (CMCP) was used as canal disinfectant
prior to the triple antibiotic followed by vital tissue formation in
the apical half of the root. The vital cells in contact with calcium
hydroxide, could form the root to the full length and thickness with
closed apex. After complete root formation, the tooth lost its vitality.
J Dent Health Oral Disord Ther. 2018;9(6):508511. 508
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Necrosis of the revascularized pulp in an immature
infected maxillary second premolar following
apexogenesis - a case report
Volume 9 Issue 6 - 2018
Bushra Rashid Noaman
Department of Pedodontics, Ishik University, Iraq
Correspondence: Bushra Rashid Noaman, Department of
Pedodontics, Ishik University, Iraq, Tel 09647510207481,
Email
Received: November 23, 2018 | Published: December 11,
2018
Abstract
Nowadays, the trend in treating the infected immature permanent tooth is with
disinfection and revuscularization of the root canal instead of apexification. By
revuscularing the root canal and utilizing, a biocompatible material will create a new
pulp tissue that can provide vital cells, which are able to continue the root formation
to the normal length, wall thickness and close the apex. The purpose of this case report
is to present a patient case where in revascularization of the infected immature tooth
pulp space had been performed which end with necrosis after complete root formatıon.
Iimmature maxillary permanent second premolar with a single canal revascularızed in
vivo by a blood clot from the periapical tissues into the canal space after disinfection.
This case differ form other cases of revuscularization in that CMCP used as intracanal
medicament in the first visit and the new pulp found non-vital after root completion.
Keywords: immature tooth, revascularization, calcium hydroxide, apexogenesis,
pulp necrosis
Journal of Dental Health Oral Disorders & erapy
Case Report Open Access
Necrosis of the revascularized pulp in an immature infected maxillary second premolar following
apexogenesis - a case report 509
Copyright:
©2018 Noaman
Citation: Noaman BR. Necrosis of the revascularized pulp in an immature infected maxillary second premolar following apexogenesis - a case report. J Dent
Health Oral Disord Ther. 2018;9(6):508511. DOI: 10.15406/jdhodt.2018.09.00438
Case report
A nine years old boy referred to the pediatric clinic with normal
medical history. The patient’s chief complaint was pain on chewing in
the upper left quadrant. Intraoral examination revealed the presence
of a maxillary left second premolar with disto-occlusal temporary
lling. The tooth was tender to percussion and redness in the
gingival tissue beside the tooth was evident. The tooth treated by a
dentist and the treatment was; access opening, instrumentation and
dressed with camphorated monochlorophenol (CMCP) wetted cotton
and temporary lling. The report of the dentist explained that over
instrumentation done and injury of the periapical area happened.
Periapical intraoral radiograph displayed that the tooth was immature
with large periapical radiolucency (Figure 1). The child‘s economic
status was poor and the MTA is expensive so the treatment performed
by using calcium hydroxide.6,15
Figure 1 Diagnostic radiograph. The second premolar has open apex with a
periapical radiolocency and disto-occlusal carious lesion extend to the pulp.
Treatment procedure
First visit: on removal of the temporary lling and CMCP cotton,
there was bleeding in this time from the canal. The working length
estimated which was 17mm (without anesthesia and there was no
pain). The pulp irrigated with 5.25% sodium hypochlorite then a triple
antibiotic used inside the canal which was consisted of ciprooxacin,
metronidazol and minocycline (100µ/ml for each one mixed with
distilled water as a paste before use). Care was taken in insertion of
the antibiotic without touching the pulp chamber in order to avoid
discoloration of the crown. Then the tooth dressed with a dry cotton
palette and a temporary lling and appointment given after four weeks
(Figure 1).
Second visit: All symptoms disappeared, the tooth re-entered, with
consideration given in maintaining good isolation. On insertion of a
paper point a resistant felt, and a pain felt by the patient nearly in the
middle of the canal to this length the calcium hydroxide with barrium
sulphate (Metapaste (Calcium Hydroxide w/ Barium Sulfate- Korea)
injected in the coronal half of the root. The tooth restored and the
x-ray showed decrease in the size of the radiolocency after the use of
the antibiotic paste in the canal for three weeks, and difference in the
apical shape ( signs of healing), and the calcium hydroxide lled the
coronal half of the canal in its rst day of use (Figure 2).
Follow up visits
After six months: a healthy gingiva around the tooth was detected.
The tooth examined the by percussion test, and by x-ray; there was
no tenderness, and x-ray revealed the decreasing size in the periapical
radiolocency, and slight root elongation (Figure 3). The patient given
an appointment after six months.
Figure 2 Radiograph after 28 days after the use of the triple antibiotic shows
decrease in size of the periapical radiolocency and difference in the apical
shape (signs of healing) from the rst radiograph, and showing the calcium
hydroxide to the half of the canal in its rst day of use inside the canal.
Figure 3 A radiograph 6 months after the use of calcium hydroxide showing
noticable decrease size in periapical radiolucency, and slight root elongation.
Six months later: tooth was with no signs and symptoms. X-ray
showed complete disappearance of the radiolocency, complete root
formation, closure of the apex and increase in root walls thickness
(Figure 4).
Figure 4 12 months after the use of the calcium hydroxide showing complete
disappearance of the radiolocency and complete closure of the apex; increase
in root length and thickness of the walls.
Necrosis of the revascularized pulp in an immature infected maxillary second premolar following
apexogenesis - a case report 510
Copyright:
©2018 Noaman
Citation: Noaman BR. Necrosis of the revascularized pulp in an immature infected maxillary second premolar following apexogenesis - a case report. J Dent
Health Oral Disord Ther. 2018;9(6):508511. DOI: 10.15406/jdhodt.2018.09.00438
Electric pulp testing was negative. The calcium hydroxide
removed, a new working length estimated which was 21mm. Sımple
Instrumentation of the canal with a le at length 21mm, calcied
tissue removed from the apical half of the canal. Rapid 2.5% sodium
hypochlorite irregation with agitation and good dryness of the canal
achieved, the canal lled with gutta percha by lateral condensation
technique (Figure 5).
Figure 5 A radiograph 14 months after he use of the calcium hydroxide,
showing the obturation with gutta percha on length 21mm.
Discussion
It is a chalenge to treat necrotic immature tooth due to trauma or
caries endodontically, because of the open apex against gutta percha
condensation and poor apical seal, thin root which can be fracture in
the future and for the disproportion in the crown-root ratio. İn young
patients the treatment of such a tooth should be with a long-term
prognosis and must aim to maintain the integrity of the periapical
tissues, those will put the dentist in a confront. In th is case report
early erupted maxillary second premolar before age of ten years gives
the probability of long standing infection of the pre-successor which
caused root resorption and early exfoliation, and bone resorption then
early eruption of the permanent successor. The early infection in
this permanent tooth may be related to long standing abscess can
affect the amelogenesis of the permanent tooth bud lead to hypoplasia
making the tooth liable for caries as soon as it erupts. Clinical case
reports have showed that the possibility of treating immature infected
permanent which are indicated for apexication may be treated by
apexogenesis,2,6,8 The process that happen in pulp revascularization of
the necrotic immature tooth is resumbling in action to reimplantation
of the an avulsed immature tooth; an open apex and a short root that
permits new tissue to grow agin inside the pulp space readily, in which
the canal is not infected therefore, it can work as a scaffold for growing
of new tissue. After avulsion of the immature permanent tooth, the
apical part of the pulp may remain vital then after re-implantation this
vital pulp will proliferate coronally replacing the necrotized portion
of the pulp. In this case there was an injury of the periapical tissue
during pulp extirpation by the rst dentist, the blood transferred inside
the root canal and acted as a scaffold for new vital cells to form,
which could reform the root as in many research studies.6,8,16 While
the protocol of pulp revuscularization17 didn’t state the use of CMCP,
which is used sometimes as root canal antiseptic18 and it is used in
this case prior to the start with the rst step of the protocol. The root
canal debridement is necessary to provide a suitable environment
for the regeneration to take place, therefore the root canal irrigated
by 5.25% sodium hypochlorite instead of instrumentation to avoid
further weakness of the root.19 The use of the tripple antibiotic7 would
decrease the number of microorganisms then healing of the periapical
infection could takeplace, and from the x-ray (Figure 2) appears that
the size of the lesion decreased and the root started increasing in length,
which indicates the sterilization of the canal is the rst treatment that
should be done. İn the presence of the blood which induced from
the periapical area by over instrumentation done by the rst dentist
and completion of the sterelization, tissue formed inside he canal
which contain the vital cells that started apexogenesis after utilizing
the calcium hydroxide in contact with this tissue. In the traditional
methods of pulp revascularization, the material used is the MTA but
in this case the calcium hydroxide used since it is biocompatable and
used in direct pulp capping and pulpotomy of immature permanent
teeth in contact with the pulp and the same material used by many
researchers,6,18 and its notable healing of periapical infection and hard
tissue barrier formation.6,8,20 The effect of calcium hydroxide inducing
periapical healing could be referred to both its antibacterial and
mineralizing effects, the high alkalinity (usually pH 12 to 13) of the
calcium hydroxide can distroy the microorganisms when put in direct
contact with them. After the distruction of the bacteria, their substrate
will be neutralized. When the calcium hydroxide put in contact with
vital connective tissue in the root canal had the same effect as when
it is used as a direct pulp capping material, therefore, success of root
canal therapy is increased. İn this case large peripical lesion healed
completely within a period of 12 months by the use of calcium
hydroxide as an intracanal medicament. Before the obturation of the
canal with gutta perch the canal irregated with rapid 2.5% NaOCl
to insure complete removal of the calcium hydroxide to minimize
softening of dentine and maintain unaltered canal shapes. Agitation
was used with the irregation to insure the maximum removal of
calcium hydroxide.21 The stage of root in the current case is stage 8
according to Mendoza et al.22 study in 2010 in which one third of the
root was formed before necrosis of the pulp. The periapical repair
was with round apex due to continued root formation until normal
appearance of the root obtained which is considered a cementoid type
closure according to Mendoza et al.21 In spite that the tooth became
necrotic but before its necrosis the crown tooth ratio corrected, the
walls become thicker and the apex closed so it was successful in
comparison with apexication technique.
Conclusion
This tratment approach could heal the periapical infection and
promoted root development. This case is differ in treatment from the
protocol of the revuscularization, that CMCP used in the rst visit.
This treatment approach could help in saving infected immature
tooth by physiologically reinforcing the root walls and increase
the root length. In this patient, the 12-months recall clinical and
radiographic examination was consistent with an immature tooth that
had successfully re-vascularized but ended with pulp necrosis. The
result of this case suggests the necessity of follow-up of those cases
to test the vitality.
Acknowledgments
This research supported by research centre of Ishik University,
Erbil, Iraq.
Conicts of interest
The author declares that there is no conicts of interest.
Necrosis of the revascularized pulp in an immature infected maxillary second premolar following
apexogenesis - a case report 511
Copyright:
©2018 Noaman
Citation: Noaman BR. Necrosis of the revascularized pulp in an immature infected maxillary second premolar following apexogenesis - a case report. J Dent
Health Oral Disord Ther. 2018;9(6):508511. DOI: 10.15406/jdhodt.2018.09.00438
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