Management of teeth with necrotic pulps and open apices

Fracture Resistance of Simulated Immature Teeth Filled with Three Types of Calcium Silicate Cement after Intracanal Medication with Ca(OH)2: An Ex Vivo Study

Objectives

The aim of this study was to evaluate the 1-day fracture resistance of simulated immature teeth with an apical plug with ProRoot MTA, MTA Angelus, and RetroMTA after calcium hydroxide intracanal medication.

Materials and Methods

Sixty extracted, single-rooted human mandibular premolars were randomly divided into six groups of 10 teeth each. Firstly, to standardize the 9 mm root length, the crowns were cut off at and 9 mm below the cementoenamel junction transversely. Simulations for immature apices were carried out by using No. 1-6 Peeso reamers to pass through the apex to obtain a diameter of 1.7 mm at the apical opening. One group served as a negative control without any treatment, while the other groups received 30 days of calcium hydroxide intracanal medication. Four groups were plugs with 4 mm of ProRoot MTA, MTA Angelus, RetroMTA, and gutta-percha, respectively. The last one was served as a positive control group without filling inside. After 1 day of incubation, specimens were vertically loaded in a universal testing machine at a crosshead speed of 1 mm/min until fracture occurred. The peak load to fracture (Newton) and fracture pattern were recorded. A one-way analysis of variance (ANOVA) followed by Tukey's HSD test was used for data analysis.

Results

The highest mean load to fracture was shown in the negative control group (543.33 ± 37.17 N), followed by ProRoot MTA (432.82 ± 68.06 N), MTA Angelus (396.92 ± 59.93 N), RetroMTA (389.08 ± 56.25 N), and gutta-percha (283.28 ± 43.40 N), and the lowest belonged to the positive control group (239.98 ± 27.19 N). The significant differences were found between both the control and experimental groups with an apical plug with calcium silicate cement (p  < 0.05). There were no significant differences among those three apical plugs (p  > 0.05).

Conclusion

Apical plugs with ProRoot MTA, MTA Angelus, and RetroMTA had an immediate strengthening effect on simulated immature teeth after calcium hydroxide intracanal medication had been used.

A Prospective Study of Long-Term Regenerative Endodontics Outcomes of Necrotic Immature Permanent Teeth: An 8-Year Follow-Up

For the management of necrotic immature teeth, regenerative endodontics offers the advantage of further root lengthening, thickening of dentin wall, and apical closure. This prospective study aimed to evaluate the long-term outcome of regenerative endodontics in immature necrotic permanent teeth. A total of 23 immature roots were medicated by triple antibiotic paste. After 21 days, bleeding was induced by over-instrumentation, and then mineral trioxide aggregate and coronal restoration were applied. Patients were scheduled for clinical and radiographic follow-up for 8 years. The radiographic changes of root dimensions were assessed using the ImageJ Plugin and statistically analyzed by Kruskal-Wallis test at a 95% confidence level. For qualitative evaluation, images were overlapped and analyzed using Photoshop software. All teeth were asymptomatic one month after the treatment. All teeth (n = 18) with preoperative periapical radiolucency showed complete resolution within 6-9 months. Recall rate at two, three, and eight years was 69.6%, 56.5%, and 34.8%, respectively. Continuous root development with a significant increase in root length and thickening of dentin wall accompanied by a significant decrease in apical canal diameter was seen at the end of the observation period (p < 0.001). In conclusion, the long-term outcome of regenerative endodontics revealed successful clinical and radiographic results with appropriate case selection.

Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The aim of this systematic review was to evaluate the existing randomized controlled trials (RCTs) on the safety and efficacy of vital pulp therapy (VPT) and to analyze the outcomes of VPT performed with a variety of pulp-capping materials and techniques.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and gray literature were searched (January 2000-March 2021). Study selection and data extraction were performed in duplicate. Eligible RCTs were critically appraised for risk of bias and quality of evidence and were meta-analyzed to estimate the treatment effects.

RESULTS

Fourteen studies were included. The pooled success rate of VPT using contemporary capping materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials (CSMs) was 93.2% (95% confidence interval [CI], 91.6%-94.9%). Multiple subgroup analyses by different etiologies, procedure types, developmental stages of teeth, and preoperative diagnoses were performed. Analyses presented low certainty of evidence. No significant difference was noted between MTA and CSM at 12 months or a longer follow-up (risk ratio = 0.99; 95% CI, 0.95-1.03) with low certainty of evidence. Laser-assisted VPT failed to show significantly better outcomes than conventional VPT (risk ratio = 1.19; 95% CI, 0.99-1.49) with very low certainty of evidence.

CONCLUSIONS

When MTA or CSM was used as a capping material, VPT was 93% successful. The techniques, etiologies, developmental stages of teeth, and preoperative diagnosis had no significant influence on treatment outcomes. No major adverse effects (except discoloration associated with the use of MTA) were identified. The overall quality of evidence was low.

Management of an Unsuccessful Regenerative Endodontic Procedure after Tooth Fracture: A Case Report

Dental trauma is a very frequent occurrence in children and adolescents, which creates a great impact on the esthetics, functions, and phonetics. Traumatic dental injuries can range from simple enamel fractures to permanent tooth loss. This case report presents an eight-year-old patient with an uncomplicated crown fracture of tooth 21, and 30 days after trauma, it was diagnosed as necrotic pulp. The first treatment choice was a regenerative endodontic procedure (REP), however, the failure led to apexification with Mineral Trioxide Aggregate (MTA). The chosen rehabilitation was a composite veneer. Concerning the available literature and fracture enamel dentin, the treatment approach proposed for the case provided good functional and esthetic outcomes.

Use of mineral trioxide aggregate for retreatment of a tooth with large periapical lesion, wide-open apices and vertical root fracture

Chronic periapical lesions in necrotic teeth with open apex are difficult to manage. The situation becomes more complex if the tooth has a fracture line. This case report describes the management of a traumatised tooth that had already undergone unsuccessful endodontic treatment with a large periapical lesion and open apex along with a fracture line in the root. An attempt was made to save the tooth by using mineral trioxide aggregate (MTA) cement for orthograde filling, retrograde filling and also for sealing of the fracture line. Moreover, the bone defect was filled with autogenous bone harvested from the external oblique ridge. MTA, a bioactive tricalcium silicate cement, has been used in treating complex endodontic cases as it shows promising potential by inducing the biological mechanisms necessary for repair of involved teeth. A 1-year follow-up showed progressive healing as evident by radiographs and lack of any clinical signs and symptoms.

Management of incompletely developed teeth requiring root canal treatment

Endodontic management of the permanent immature tooth continues to be a challenge for both clinicians and researchers. Clinical concerns are primarily related to achieving adequate levels of disinfection as 'aggressive' instrumentation is contraindicated and hence there exists a much greater reliance on endodontic irrigants and medicaments. The open apex has also presented obturation difficulties, notably in controlling length. Long-term apexification procedures with calcium hydroxide have proven to be successful in retaining many of these immature infected teeth but due to their thin dentinal walls and perceived problems associated with long-term placement of calcium hydroxide, they have been found to be prone to cervical fracture and subsequent tooth loss. In recent years there has developed an increasing interest in the possibility of 'regenerating' pulp tissue in an infected immature tooth. It is apparent that although the philosophy and hope of 'regeneration' is commendable, recent histologic studies appear to suggest that the calcified material deposited on the canal wall is bone/cementum rather than dentine, hence the absence of pulp tissue with or without an odontoblast layer.

A standardized novel method to measure radiographic root changes after endodontic therapy in immature teeth

INTRODUCTION

Outcome studies of endodontic treatment of necrotic immature permanent teeth rely on radiographic measures as surrogates of whether the treatment achieved regeneration/revascularization/revitalization. An increase in radiographic root length and/or width is thought to result in a better long-term prognosis for the tooth. In this study, a method to measure radiographic outcomes of endodontic therapies on immature teeth was developed and validated.

METHODS

A standardized protocol was developed for measuring the entire area of the root of immature teeth. The radiographic root area (RRA) measurement accounts for the entire surface area of the root as observed on a periapical radiograph. Reviewers were given instructions on how to measure RRA, and they completed measurements on a set of standardized radiographs.

RESULTS

The intraclass correlation between the 4 reviewers was 0.9945, suggesting a high concordance among reviewers. There was no effect of the reviewer on the measured RRA values. High concordance was also observed when 1 rater repeated the measurements, with an intraclass correlation value of 0.9995. There was no significant difference in RRA values measured at the 2 sessions by the same rater. Furthermore, significant differences in RRA were detectable between clinical cases that showed obvious continued root development and cases that did not demonstrate discernible root development.

CONCLUSIONS

These results suggest that RRA is a valid measure to assess radiographic outcomes in endodontically treated immature teeth, and RRA should be useful in future clinical studies of regenerative endodontic outcomes.