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What are the current options for treatment of immature permanent teeth that have had trauma leading to pulp necrosis?

This question was submitted by a general dentist: What are the current options for treatment of immature permanent teeth that have had trauma leading to pulp necrosis? Drs. Aimee Castro, Jamie Ong, Anoushe Sekhavat and Rae Varughese

Drs. Aimee Castro, Jamie Ong, Anoushe Sekhavat, and Rae Varughese are second-year graduate students in Pediatric Dentistry at the University of Toronto 

A necrotic immature incisor can be distressing to both parents and children. Long term concerns for management of these teeth include unfavourable crown-root ratio, parallel root walls that prevent traditional treatment of the root canal space and fragile thin walls that may predispose to vertical root fracture. Three available treatment options variably address these long term concerns.

The traditional and most commonly used option for treatment of an immature necrotic incisor is apexification with calcium hydroxide paste [Ca(OH)2] that was first described by Frank in 1966. The Frank technique promotes the induction of an apical barrier in a necrotic tooth, thereby, allowing root canal therapy to be completed. Necrotic pulp tissue is removed from the canal that is then filled with Ca(OH)2. The Ca(OH)is replaced/replenishedevery three months until a calcified apical barrier is established. Obturation is commonly completed with gutta percha and the tooth is restored. Limitations of the Frank technique are that no predictable increase in root length results and multiple appointments are required to achieve apical closure. Equivocal evidence suggests that teeth treated with the Frank technique may be more susceptible to fracture due to long term exposure to Ca(OH)2.Two additional options exist that  require more advanced skills and are often performed by endodontists or practitioners with advanced training.. The second option uses an apical mineral trioxide aggregate (MTA) plug to shorten overall apexification treatment time. The tooth is first medicated with Ca(OH)2 until it is asymptomatic. Then an MTA plug is placed at the apex of the root. After the MTA is set, gutta percha or other root canal filling material can be used to obturate the root canal. As in the Frank technique, no additional root length can be expected to result but the treatment can be completed in fewer appointments due to the presence of an apical MTA plug that allows sealing of the pulp space.

The goal of the third option, pulp revascularization, is vastly different than the first two options. The goals of revascularization are to stimulate apical root growth as well as to restore the blood circulation to the pulp space. In an immature necrotic tooth with an open apex, the apical pulpal tissue may remain vital and can act as a scaffold on which new tissue can grow upon. There are 3 requirements for this procedure: a disinfected canal space, a matrix into which the tissue can grow and a tight coronal seal to prevent bacterial microleakage.  Commonly, a triple antibiotic paste consisting of ciprofloxacin, metronidazole, and minocycline is used to disinfect the canal space.  After the canal is disinfected, an endodontic file is used to provoke apical tissues to bleed into the canal space until it is filled with blood. The coronal access is then sealed with MTA and a restoration is placed.

Revascularization is a relatively new technique that purports to produce continued root growth and maintain vital soft tissue within the pulp space. However, the procedure is not without limitations. The triple antibiotic mix and MTA may cause significant crown discoloration. Also,recent animal investigations suggest that the tissues formed in response to revascularization therapy are not typical root dentin nor pulp connective tissue but rather cementum/bone as well as predominantly vascular soft tissue within the pulp space. The significance of these alterations to tooth structure are not known.

In summary, each treatment option has its own benefits and limitations that should be discussed with the parents and the child. The first option, apexification with Ca(OH)2, is the most well documented in the literature; however, the MTA plug and revascularization demonstrate promise as solutions for a necrotic pulp in a immature permanent incisor. 

References

  1. Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc. 1966;72(1):87-93.
  2. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004;30(4):196-200.
  3. Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J. 1996;29(2):125-30.
  4. Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YH, Chiang CP. Regenerative endodontic treatment for necrotic immature permanent teeth. J Endod. 2009 Feb;35(2):160-4. Epub 2008 Dec 12.

 

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2 Comments

  1. Name April 30, 2013

    This is very informative and with this up to date material it is helpful in explaning this to the parents.

    Reply
  2. VR September 4, 2013

    Fantastic response! Well laid out.

    Thanks!

    Reply

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