Pulp Revascularization in Immature Permanent Tooth With Apical Periodontitis Using MTA

7/25/2019 Pulp Revascularization in Immature Permanent Tooth With Apical Periodontitis Using MTA

1/6

Case ReportPulp Revascularization in Immature Permanent Tooth with

Apical Periodontitis Using Mineral Trioxide Aggregate

Katsura Saeki,1Yuko Fujita,1Yasuhiro Shiono,1 Yasuhiro Morimoto,2 and Kenshi Maki1

Department of Pediatric Dentistry, Kyushu Dental University, -- Manazuru, Kokurakita-ku, Kitakyushu -, Japan Department of Oral Diagnostic Science, Kyushu Dental University, Kitakyushu -, Japan

Correspondence should be addressed to Kenshi Maki; [email protected]

Received February ; Revised April ; Accepted April ; Published May

Academic Editor: Jukka H. Meurman

Copyright Katsura Saeki et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Mineral trioxide aggregate (MA) is a material that has been used worldwide in several clinical applications, such as apical barriersin teeth with immature apices, repair o root perorations, root-end lling, pulp capping, and pulpotomy. Te purpose o thiscase report was to describe successul revascularization treatment o an immature mandibular right second premolar with apicalperiodontitis in a -year-old emale patient. Afer preparing an access cavity without anesthesia, the tooth was isolated using arubber dam and accessed. Te canal was gently debrided using % sodium hypochlorite (NaOCl) and % hydrogen peroxideirrigant. And then MA was packed into the canal. X-ray photographic examination showed the dentin bridge months aferthe revascularization procedure. Tickening o the canal wall and complete apical closure were conrmed months afer the

treatment. In this case, MA showed clinical and radiographic success at revascularization treatment in immature permanenttooth. Te successul outcome o this case suggests that MA is reliable and effective or endodontic treatment in the pediatricdentistry.

1. Introduction

Immature permanent teeth with apical periodontitis or anabscess are generally treated by apexication []. However,revascularization procedures have recently been recom-mended to treat immature permanent teeth with necroticpulp tissue and/or apical periodontitis or an abscess.

Mineral trioxide aggregate (MA) is a material used

worldwide in a variety o clinical applications, such as anapical barrier or teeth with immature apices, repair o rootperorations, root-end lling, pulp capping, and pulpotomyprocedures []. In this paper successul revascularizationtreatment o an immature mandibular right second premolarwith apical periodontitis in a -year-old patient using MAwas described.

2. Case Report

In June , a -year-old Japanese girl was reerred to privateclinic by a general dentist or detailed examination o agingival abscess in the mandibular right second premolar.

Te medical history o the patient was unremarkable, andthere was no relevant amily history o medical or dentalabnormalities. An extraoral examination revealed swelling inthe buccal region and the patient complained o spontaneouspain. Furthermore, an intraoral examination revealed a gin-gival abscess in the region o the mandibular right secondpremolar (Figure (a)). Te percussion test was positive.

Radiographic ndings showed enlargement o the peri-

odontal ligament space, along with extensive radiolucencyin the periradicular region in the area o the mandibularright second premolar as compared with the mandibular lefsecond premolar (Figures(b)and(c)). Te pulp vitality testwas negative. Te clinical diagnosis was acute periradicularperiodontitis o the mandibular right second premolar withpulpal necrosis.

Te patient underwent oral surgery at Kyushu Den-tal University Hospital. Te reason or hospitalization wasbecause she was not able to eat orgingival swelling andspon-taneous pain. During hospitalization, she received an intra-

venous drip containing an antibiotic. She lef the hospital days later andwas reerred to our clinic. Postsurgery intraoral

Hindawi Publishing CorporationCase Reports in MedicineVolume 2014, Article ID 564908, 5 pageshttp://dx.doi.org/10.1155/2014/564908
http://dx.doi.org/10.1155/2014/564908http://dx.doi.org/10.1155/2014/564908


2/6

Case Reports in Medicine

(a) (b)

(c)

F : (a) Preoperative intraoral photograph showing a gingival abscess in the mandibular right second premolar. (b) Panoramic X-rayshowing extensive radiolucency in the periradicular region in the mandibular right second premolar compared with the mandibular lefsecond premolar. (c) X-ray showing an immature open apex and enlargement o the periodontal ligament space and extensive radiolucencyin the periradicular region in the mandibular right second premolar.

examination showed no abnormalities on the gingiva o themandibular right second premolar (Figure (a)). However,the talon cusp o the mandibular right second premolar wasractured (Figure (b)). Without using anesthetic, the toothwas isolated with a rubber dam and accessed. Upon enteringthe coronal aspect o the root canal, hemorrhaging into thepulp chamber was observed (Figure (c)). A le o K sizewas inserted into the canal. Te length o le is mm.And the patient reported discomort, indicating potentialsurvival o residual vital pulp tissue. Te hemorrhaging inthe coronal portion o the canal was gently irrigated; thenthe area was debrided using . mL o % sodium hypochlo-rite (NaOCl) and . mL o % hydrogen peroxide [, ].No instrumentation was perormed. Next, MA (Pro-RootMA, Dentsply Sankin, ochigi, Japan) was packed into the

canal using MAP system (Dentsply Sankin, ochigi, Japan)(Figure (d)) and the access cavity was closed with glass-ionomer cement (Fuji IX GP, GC, okyo, Japan). An X-rayobtained afer the procedure conrmed MA placement inthe canal (Figure (e)).

Six months later, an intraoral examination showed noabnormalities in the gingiva o the mandibular right sec-ond premolar (Figure (a)), while an X-ray photographicevaluation showed ormation o a dentin bridge in themandibular right second premolar (Figures(b)and (c)).en months later, an intraoral examination showed noabnormalities o the gingiva in the mandibular right secondpremolar (Figure (a)), and X-ray images revealed ormation

o a dentin bridge and thickening o the canal walls in themandibular right second premolar (Figures(b)and(c)).

We think it is important to ollow up this tooth, but shehad moved. It is too ar or her to reer to our clinic. So wecould not ollow up her.

3. Discussion

Apexogenesis is done is in immature teeth when part o thepulp tissue inside the root canal remains vital and apparentlyhealthy. Tis procedure allows continued physiological devel-opment and ormation o the root end.

In cases with an immature root with a large apicaloramen, pulp inection associated with an apical lesion does

not always indicate pulp necrosis, as seen in our patient,likely because the pulp at this stage is vital enough andhas extremely high healing ability. Tose procedures havebeen shown to result in increased thickening o the canalwalls by deposition o hard tissue and encourage continuedroot development in affected immature permanent teeth[]. Continued root development o revascularizationo immature permanent necrotic teeth depends on whetherHertwigs epithelial sheath survives in cases o apical peri-odontitis/abscess. Hertwigs epithelial sheath has importantrole in root development and shape and may be involved inregulation o the differentiation o periodontal ligament stemcells with the ormation o cementum.


3/6


(a) (b)

(c) (d) (e)

F : (a) Intraoral photograph showing no abnormalities o gingiva. (b) Te central cusp o the mandibular right second premolar had

been ractured. (c) Afer controlling hemorrhage, viable tissue was obser ved in the canal because insertion o a K-le evoked a sensation. (d)Placement o MA in the canal. (e) Postoperative X-ray photograph showing MA placement in canal.

(a) (b) (c)

F : (a) Intraoral photograph showing no abnormalities o gingiva. (b) Panoramic X-ray photograph showing the ormation o a dentinbridge in the mandibular right second premolar. (c) X-ray shows that radiolucency became less radiolucent in the periradicular region andthe ormation o a dentin bridge in the mandibular right second premolar.


4/6


(a) (b) (c)

F : (a) Intraoral photograph showing no abnormalities o gingiva. (b) Panoramic X-ray showing the ormation o a dentin bridge andthickening o the canal walls in the mandibular right second premolar. (c) Panoramic X-ray showing the ormation o a dentin bridge andthickening o the canal walls and establishment o the periodontal ligament space and lamina dura in the mandibular right second premolar.

MA is a cement material with excellent biocompatibilityand good sealing capacity that is able to produce hardtissues such as dentin and cementum []. It is used orapexication and sealing o communication between the rootandperiodontal tissue, such as in reverse root canal lling andperoration repair []. However, there are ew reports o itsuse or pulp revascularization using MA [, ]. Calciumhydroxide ormulations are typically used or apexogenesisand poor sealing capacity []. Furthermore, ormation o anecrotic layer immediately beneath the pulp can occur andthe procedure must be changed to a pulpectomy in somecases due to spreading inammation, as it does not providean adequate biodeense mechanism against even a limitedbacterial invasion []. Accordingly, we used MA in thiscase. Generally, the root o a tooth with pulp revascularizationis smaller than a mature tooth and is characterized bymore rapid calcication o the pulp than that seen afer aconventional apexogenesis procedure, as noted in the presentcase []. Chen et al. [] demonstrated ve types o responseo these immature teeth withinected necrotic pulp tissueandapical periodontitis/abscess to revascularization procedures:type , ormation o a hard tissue barrier in the canal betweenthe coronal cement plug and root apex using MA. Te

present case was consistent with type . In cases with animmature root with a large apical oramen, pulp inectionassociated with an apical lesion does not always indicate pulpnecrosis, as seen in our patient, likely because the pulp at thisstage is vital enough and has extremely high healing ability.It has been reported that pulp revascularization was inducedby removing inective material rom the root canal andapply-ing calcium hydroxide past MA [, ]. raditionally, inthe clinical protocol or revascularization treatment, severalkinds o antibacterial medicine were used. But, recently, itreported that a single-visit pulp revascularization protocolcan be a avorable treatment or partially necrotic immaturepermanent teeth using MA as a pulpal seal [].

Accordingly, or immature tooth with a pulp inectionand open apical oramen, treatment should start with pulprevascularization and then shif to apexication i incurable,while considering the inection to be reversible.

4. Conclusion

In the present case, clinical and radiographic evidenceshowed successul use o MA or revascularization treat-

ment o an immature permanent tooth. More studies arenecessary to understand the mechanisms o pulp revascular-ization comparing different protocols.

Conflict of Interests

No potential conict o interests was disclosed.

Acknowledgments

Tis study was supported in part by grants-in-aid or scien-tic research rom the Ministry o Education, Science, Sports,and Culture o Japan and rom Kitakyushu to Kenshi Maki.

References

[] M. Rafer, Apexication: a review, Dental Traumatology, vol., no. , pp. , .

[] S.-I. Iwaya, M. Ikawa, and M. Kubota, Revascularization o animmature permanent tooth with apical periodontitis and sinustract,Dental Traumatology, vol. , no. , pp. , .

[] F. Banchs and M. rope, Revascularization o immature per-manent teeth with apical periodontitis: new treatment proto-col?Journal of Endodontics, vol. , no. , pp. , .

[] P. Becerra, D.Ricucci,S. Loghin, J.L. Gibbs,and L. M. Lin,His-tologic study o a human immature permanent premolar with


5/6


chronic apical abscess afer revascularization/revitalization,Journal of Endodontics, vol. , no. , pp. , .

[] H. W. Roberts, J. M. oth, D. W. Berzins, and D. G. Charlton,Mineral trioxide aggregate material use in endodontic treat-ment: a review o the literature,Dental Materials, vol. , no. ,pp. , .

[] A. Rao, A. Rao, and R. Shenoy, Mineral trioxide aggregateareview,Journal of Clinical Pediatric Dentistry, vol. , no. , pp., .

[] S. Simon, F. Rilliard, A. Berdal, and P. Machtou, Te use omineral trioxide aggregate in one-visit apexication treatment:a prospective study, International Endodontic Journal, vol. ,no. , pp. , .

[] I. H. Barngkgei, E. S. Halboub, and R. S. lboni, Pulpotomyo symptomatic permanent teeth with carious exposure usingmineral trioxide aggregate,Iranian Endodontic Journal, vol. ,no. , pp. , .

[] A. Harandi, M. Forghani, and J. Ghoddusi, pulp therapy withthree different pulpotomy agents in immature molars: a casereport, Iranian Endodontic Journal, vol. , no. , pp. ,

.[] Y. Fujita and K. Maki, Single-visit revascularization treatment

o an immature permanent tooth with apical periodontitis: acase report,Pediatric Dental Journal, vol. , pp. , .

[] M. Y.-H. Chen, K.-L. Chen, C.-A. Chen, F. ayebaty, P. A.Rosenberg, and L. M. Lin, Responses o immature permanentteeth with inected necrotic pulp tissue and apical periodon-titis/abscess to revascularization procedures, InternationalEndodontic Journal, vol. , no. , pp. , .

[] S. I. Iwaya, M. Ikawa, and M. Kubota, Revascularization oan immature permanent tooth with periradicular abscess aferluxation,Dental Traumatology, vol. , no. , pp. , .

[] K. Neha, R. Kansal, P. Garg, R. Joshi, D. Garg, and H.-S. Grover,Management o immature teeth by dentin-pulp regeneration: a

recent approach,Medicina Oral, Patologia Oral y Cirugia Bucal,vol. , no. , pp. ee, .

[] R. K. Subay, B. Ilhan, and H. Ulukapi, Mineral trioxide aggre-gate as a pulpotomy agent in immature teeth: long-term casereport,European Journal of Dentistry, vol. , pp. , .

[] J. A. H. Lindeboom, J. W. F. H. Frenken, F. H. M. Kroon, andH. P. van den Akker, A comparative prospective randomizedclinical study o MA and IRM as root-end lling materials insingle-rooted teeth in endodontic surgery, Oral Surgery, OralMedicine, Oral Pathology, Oral Radiology, and Endodontics, vol., no. , pp. , .

[] S. Y. Shin, J. S. Albert, and R. E. Mortman, Onesteppulp revas-cularization treatment o an immature permanent tooth withchronic apical abscess: a case report,International EndodonticJournal, vol. , no. , pp. , .

[] D. M. Ferris and J. C. Baumgartner, Peroration repair com-paring two types o mineral trioxide aggregate, Journal ofEndodontics, vol. , no. , pp. , .

[] P. E. Murray, A. A. Haez, A. J.Smith, and C. F. Cox, Identica-tion o hierarchical actors to guide clinical decision making orsuccessul long-term pulp capping,Quintessence International,vol. , no. , pp. , .


6/6

Submit your manuscripts at

http://www.hindawi.com

Documents

Pulp Revascularization in Immature Permanent Tooth With Apical Periodontitis Using MTA