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TREATMENT CONSIDERATIONS IN TRAUMATIZED IMMATURE PERMANENT

TEETH: A CASE SERIES

Article · March 2013

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 Int J Dent Case Reports 2013; 3(1): 39-43
© IJDCR 2013. All rights reserved
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TREATMENT CONS IDERATIONS IN TRAUMATIZED IMMATURE PERMANENT TEETH:

A CAS E S ERIES
Girish M. S.1 , Ramdas Balakrishna2 , Prakash Chandra 3 , Latha Anandakrishna 4 , Dhananjaya Gaviappa5 , Shylaja K C6

1
Senior lecturer, Depart ment of Pedodontics and Preventive Dentistry, M S Ramaiah Dental Co llege & Hospital,
Bangalore
2
Vice Principal & Professor, Depart ment of Oral and Maxillofacial Surgery, The Oxfo rd Dental Co llege and
Hospital, 10th Mile Stone, Hosur Road, Bo mmanahalli, Bangalore

3
Professor& Head, Depart ment of Pedodontics and Preventive Dentistry, M S Ramaiah Dental Co llege & Hospital,
Bangalore
4
Professor, Depart ment of Pedodontics and Preventive Dentistry, M S Ramaiah Dental College & Hospital,
Bangalore
5
Professor, Department of Pedodontics and Preventive Dentistry, M S Ramaiah Dental College & Hospital,
Bangalore
6
Consultant Dental Surgeon, Little pearls Specialty Dental Care, Yelahanka, Bangalore
Address for Correspondence
Dr. Girish M S. M D S
Senior lecturer
Depart ment of Pedodontics and Preventive Dentistry
M S Ramaiah Dental Co llege & Hospital
M S R I T Post,
Bangalore – 560054
Ph : +91 9845499588
E-mail –drgirish@gmail.co m

ABSTRACT
Trau matic injuries to dental tissues have been reported commonly among children. Such injuries occurred during the
developing stages of a tooth poses a risk of tooth turning non -vital, and further cessation of root development or
maturogenesis. Endodontic treatment of such cases would be a co mpro mised one in many aspects. Hence, it
necessitates the preservation of vitality and pro motes physiological maturation of tooth. Direct pulp capping,
pulpotomy and apexogenesis using various materials have been practiced since years. This case series is an attempt
to highlight the importance of preserving the vitality of t rau matised immature teeth, and a case of apexification
using absorbable collagen as internal matrix barrier for p lacement of Mineral Trio xide Aggregate.
Keywords: Apexogenesis; Apexification; Internal matrix; Apical Barrier
Girish, Balakrishna, Chandra, Anandakrishna, Gav iappa, Shylaja Trau matized Immature Permanent Teeth

INTRODUCTION
Injuries to young permanent teeth are exceedingly series of three cases, where traumat ized immature
common in young children and adolescents following teeth showed the capacity for further root
trauma to the Orofacial region [1]. Trau matic injuries development with direct pulp capping, and
sustained before closure of the apex often results in apexification using absorbable collagen as internal
immature pulpless teeth [2] due to the damage caused matrix for placement of MTA.
to the hertwigs epithelial root sheath leading to
cessation of root development. Root canal
rehabilitation is a significant challenge in a tooth with
open apex because of; the size o f the canal, the thin
and fragile dentinal walls and large open apex.
Absence of natural constriction at root apex in such
cases ends up with loss of control over the obturating
material [3]. Situation like this warrants the
preservation and maintenance of the pulp v itality
whenever possible and promotion of continued dentin
formation under favourable conditions[4]. Several
valuable reports document that under conditions
where at least some pulp tissues appear vital, a pulp
Figure 1: Fo llo w up rad iographs in relation to 21 (a)
capping procedure permits continued dentine Pre-operative rad iograph, (b) radiograph at 3rd month
formation, described as either continued root follow up, (c) Radiograph at 6th month follow up, (d)
follow up at 9th month, (e) 12th month follow up
development (Maturogenesis) or apical closure radiograph showing complete apexogenesis of 21.
(Apexogenesis)[5]. In situations where the
developing tooth loses its vitality, due to cessation of CAS E 1:-

root development there would be a comp ro mised A seven and half year old boy with subluxat ion injury

apical closure. Apexificat ion using calciu m reported with a complaint of sensitivity and pain on

hydroxide is used as a treat ment option in these chewing. No history of spontaneous pain was

cases. Creation of apical barrier in such cases is a reported by the boy. Clinical examination revealed a

difficult task and it is a long term treat ment complicated crown fracture with pulpal exposure in

procedure. To overcome this, single step apical relation to 21. The tooth responded positively on

barrier placement with Mineral Trio xide Aggregate percussion and was symptomless on palpation.

(MTA) has been suggested [6]. However, p lacement Radiographic examination showed open immature

of MTA or any other material in an open apex has a apex in relation to fractured tooth (Figure 1a). A

disadvantage of the material being pushed beyond the conservative approach with regard to treat ment

apex o r into a periapical lesion. In order to prevent modalities was drawn up. Under local anesthesia and

this, apexificat ion with modified internal matrix rubber dam isolation, the fractured tooth was rinsed

concept proposed by Bargholz[7] has wide with a copious amount of normal saline. Followed by

acceptability. The aim of the paper is to present a removal of all the weakened enamel which was prone
40
Int J Dent Case Reports March 2013, Vo l.3, No. 1
Girish, Balakrishna, Chandra, Anandakrishna, Gav iappa, Shylaja Trau matized Immature Permanent Teeth

to fracture. The fractured surface was blot dried to
remove moisture. A layer of Dycal(Dentsply, Caulk)
was placed on exposed pulp followed by a layer of
Light cured Glass Ionomer (GC Corp, To kyo). The
patient’s recall appointments were scheduled at every
three months. At the end, of the follow up period the
tooth was asymptomat ic without any clin ical and
radiological signs of failure. Closure of the root apex
and formation of radio opaque calcified bridge
beneath calciu m hydroxide could be noticed radio
graphically (Figure 1b).
Corp, Tokyo). Pat ient was followed up for twelve
months,radiographs were taken at 3rd , 6th and 12th
month. During the follow up, the patient was utterly
free of signs and symptoms of failure. At the end of
the twelfth month, there was a considerable amount
of closure (Figure 2d). Later on the tooth was
restored with light cured composite resin.

Figure 2 : Follow up radiographs in relat ion to 42,

(a) Pre-operative Rad iograph, (b) Rad iograph at 3rd
month,(c) Rad iograph at 6th month, (d) Radiagraph
at 12th month showing complete apexogenesis.

CAS E 2:-
An eight year old boy without any considerable
general health problems reported to the Depart ment
of Pediatric Dentistry about a fall he had an hour
back. Intraoral examination revealed that a
complicated horizontal mid cro wn fracture in relat ion
to his 42 with exposure of the pulp. The tooth was
not mobile or sensitive to percussion. There was no
Fig 3 : Follow up radiographs in relation to 11 & 21, (a)
soft tissue injury both intra and extra orally. The
Pre-operative radiograph, (b) radiograph at 18 th month
radiograph revealed open apex without any root follow up showing complete apexogenesis of 11 & 21
turned non-vital, (c) Placement of absorbable collagen as
fracture (Figure 2a). Considering the size of exposure
internal matrix barrier for 21, (d) placement of M TA using
it was decided to perform direct pulp capping under ProRoot MTA Gun, (e) Radiograph showing placement of
MTA at the apex of 21, (f) radiograph after 12 months of
local anesthesia and rubber dam isolation. The tooth
post obturation, with gutta-percha showing uneventful
was rinsed with normal saline and blot dried. Direct healing of periapical lesion in relation to 21.
pulp capping was done using MTA (Pro root,
Dentsply Tulsa Dental, OK USA), fo llo wed by CAS E 3:

placement of Light cured Glass Ionomer cement(GC

41
Int J Dent Case Reports March 2013, Vo l.3, No. 1
Girish, Balakrishna, Chandra, Anandakrishna, Gav iappa, Shylaja
An eight and half year old girl reported with history
of trauma during play hours in school. Her med ical
history was non-contributory. The clin ical
examination was done 24hrs after the trau ma. Intra
oral examination revealed horizontal co mplicated
fracture of 11. Tooth number 21 had an oblique non
complicated crown fracture. Both the teeth were firm,
and there was no tenderness to percussion.
Radiographic examinat ion revealed open apices in
relation to both the teeth, and fracture line involving
pulp in relat ion to 11 (Figure 3a). A conservative
treatment plan was prepared where, d irect pulp
capping with MTA was planned for 11, and the 21
was kept under observation. After ad min istration of
local anesthesia rubber dam isolation was achieved.
The tooth was irrigated with normal saline and blot
dried. MTA was placed on the exposure site fo llo wed
by restoration with light cured glass ionomer
cement(GC Co rp, Tokyo). The patient was asked to
report for further follow ups at an interval of every
three months. However, the patient failed to keep up
her appointments and reported after 18 months. On
reporting, rad iographic examination showed
complete apexogenesis (Fig 3b) with respect to 11.
The 21, which was under observation, had turned non
vital with an open apex (Figure 3b). Apexification -
to use absorbable collagen as an internal matrix
barrier was planned for the 21. The access opening
was under rubber dam isolation. Working length was
determined radio g raphically, and Bio mechanical
preparation was done with copious irrigation of
5.25% sodium hypochlorite followed by normal
saline. The canal was dried with paper point fo llo wed
by placement of intra canal dressing with calciu m
hydroxide paste. Patient was recalled at weekly
intervals for two weeks, and calciu m hydro xide
dressing was changed. After two weeks access cavity
42
Int J Dent Case Reports
Trau matized Immature Permanent Teeth
was reopened and intra canal dressing was flushed
out with saline irrigation. Canal was dried with paper
points. Following the dryness of canal, a sterile
absorbable collagen graft material (Fig 3c) was
pushed to periapical region till it was just at the apex
of the tooth. This acted as a barrier at the periap ical
region. MTA was placed in the apical 3-4mm of
apical portion of root using ProRoot MTA gun (Fig
3d). A wet cotton pellet was placed inside the root
canal with access cavity filled with Cavit G (Fig 3e).
After 24hrs root canal was reopened. Proper ap ical
barrier formation was confirmed with the butt end of
Guttapercha points. The canal was obturated with
guttapercha and post obturation follow up was done
for 12 months. The rad iographic examination showed
uneventful healing of the periapical lesion (Figure
3f).
DISCUSS ION
Among the traumatic in juries to dental tissues,
trauma to anterior teeth is extremely co mmon
affecting around 63.9% of children in the age group
of 7-12 yrs [8]. During this period, the majority of
anterior teeth will be immature [1]. Absence of apical
constriction in the root makes the obturation a tough
task. In addition to it, thin and divergent walls,
associated periapical lesion, long fo llo w up period
and frequent changing of intra canal dressing as in
apexification, the patient’s compliance might end up
with a co mpro mised treat ment in an immature tooth.
Keeping in v iew the above said drawbacks, of
apexification procedure, its always better maintain
the vitality o f injured tooth if the conditions are
favourable. Various materials like stem cells, Bone
morphogenic proteins, Hydro xy appetite crystals,
Dentinal chips for Direct Pulp Capping procedures
have been proposed and found to be successful in
March 2013, Vo l.3, No. 1
 Girish, Balakrishna, Chandra, Anandakrishna, Gav iappa, Shylaja
clin ical applicat ion[9]. However, these materials
might have limited applicat ion in day to day practice
owing to their technical limitations and economic
considerations. Calciu m hydro xide and mineral
trio xide aggregate have been widely used in direct
pulp capping procedures and apexogenesis with
proven success rates. The present series of case
reports showed that apexogenesis can still be
achieved using calciu m hydro xide and MTA as direct
pulp capping agents. In spite of variable degree of
trauma in the cases reported, Hertwig ep ithelial root
sheath and dental papilla remained viable, and
continued root formation could be achieved in all the
three cases. The tooth in Case 3, wh ich was
considered for observation, during its recall
appointment on clin ical and radiographic
examination had turned nonvital; it alarms the need
for regular clinical and radiographic observation.
Pulp sensitivity tests should be carried out at regular
intervals. Even though, Revascularisation
procedures could have been considered in this case,
due to time constraints with the patient, it was
decided to carry out apexification procedure using
MTA and absorbable collagen as internal matrix
barrier. Special care is necessary during the clinical
and radiographic evaluation during follow up of
traumatized immature teeth. The unpredictability in
success rates, stated in the literatures is clearly
indicative of the importance of case selection in
deciding whether pulp capping procedure
Apexification is the correct decision for a case. The
enormous repair potential of dental papilla of an
immature tooth, accompanied by proper pulpal
Int J Dent Case Reports
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Trau matized Immature Permanent Teeth
diagnosis will undoubtedly help in developing a
suitable treatment plan in preserving the vitality of
traumatized tooth.
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