CASE
REPORT/CASO
CLINICO
338
CONGRESSO
NAZIONALE
VINCITORE
PREMIO
GIORGIO
LAVAGNOLI
Complex
endodontic
and
conservative
treatment
of
a
traumatized
central
incisor
Recupero
endodontico-conservativo
complesso
di
un
incisivo
centrale
superiore
traumatizzato
Nicola
Scotti
*
,
Damiano
Pasqualini,
Elio
Berutti
DepartmentofSurgicalSciences,DentalSchoolLingotto,UniversityofTurin,Italy
Received7May2014;accepted13May2014
Availableonline19June2014
KEYWORDS Open-apex; MTA; Directrestoration; Dentaltrauma; Composite. Abstract
Objectives: Thefunctionalrecoveryofatoothwithopen-apexalreadyendodonticallytreatedis
possiblethankstothematerials,suchastheMTA,abletoproduceaneffectivesealoftheapex
which can induce a restitutio-ad-integrum.A direct composite resin restoration may then
provideacoronalsealimmediateandeffectiveintime,abletoensureacompletehealingof
theendodonticpathology.
Materialsandmethods: Thehereby-clinicalcasedescribesacombinedapproach(endodontic
andconservative)fortheaesthetic-functionalrecoveryofaseverelyfracturedupperincisorofa
childof11years.
Resultsandconclusions: Atthecontrolvisit,after12monthsfromthecompletionofthecoronal
restoration,acompletehealingofperiradicularbonetissue isobservedthroughRx.Clinical
examinationshowedgingivaltissuewithoutinflammationandtheprobingdepthisnotincreased,
despitethepresenceofacavitymarginplacedbelowthegingivalmargin.
ß2014Societa` ItalianadiEndodonzia.ProductionandhostingbyElsevierB.V.Allrightsreserved.
PeerreviewunderresponsibilityofSocieta` ItalianadiEndodonzia.
1121-4171/$—seefrontmatterß2014Societa` Italianadi Endodonzia.ProductionandhostingbyElsevierB.V.Allrights reserved.
http://dx.doi.org/10.1016/j.gien.2014.05.002
* Correspondingauthorat:DentalSchoolLingotto,Universita` degli StudidiTorino,ViaNizza230,10126Torino,Italy.
Tel.:+390116331568.
E-mail:nicola.scotti@unito.it(N.Scotti).
Availableonlineatwww.sciencedirect.com
ScienceDirect
Introduction
Previousepidemiologicalstudiesclaimthatoneinfour peo-plehaspast experience ofdental trauma, with anannual incidencethat,intheUnitedStates,rangingfrom1to3%of thepopulation.1
The dentaltrauma may presentdifferent clinical situa-tions,dependingonthedirectionandtheforcewithwhich theyoccur,whichsignificantlyaffectthediagnosis,treatment and,mostimportantly,theprognosisofteethinvolved.The mostcommondentaltraumasincludefracturesoftheenamel (67%ofcases),followedbyenamel-dentinfractures(25.3%). Indeed,wecanhavedifferentlevelsoffracture:involvingonly the clinical crown or, in the worst cases, with margins of fractureatthelevelofthegingivalsulcus,belowtheCEJor evenengagingtheroot.Insomeofthesecasesmayalsobe involvedtheendodonticportionofthetooth.Inanycase,itis fundamentalforapropertreatmentplantoidentifyproperly theextensionoftheenamel-dentinefractureandwhichdental and/orperiodontaltissuesareinvolved.
Thefractureextensionleads,infact,thetreatment. Cur-rently,whenlesionsaremostlylocalizedabovetheCEJ,and the fragment lost is recovered, stored correctly and still intact,itcanberepositionedthankstoadhesivetechniques. Whenthe portions of the clinical crown fractured are not retrieved,thetoothcanberehabilitatedbymeansofdirect orindirectadhesiverestorativetechniques.3Whenyouhave complicatedfracturesordislocationsthatleadtoirreversible damagetothepulptissue,endodontictherapyisnecessary.4
Allpatientsaffectedbydental traumashouldreceivea restorativetreatmentfast,simpleandthatgivesgood aes-theticandfunctionalresults.Incasesoflargelossesoftissue, therehabilitationoftheanteriorteethofthese patientsis used obtained through indirect restorations.5,6 However, thankstothedevelopmentofcompositematerialsand adhe-sivetechniques,currentlythedirectrestorationswith com-posite resins, if properly planned, can provide excellent aestheticsandfunctioninthefaceofalessinvasivetherapy.
Materials
and
methods
ThepatientP.S.,10-year-oldmale,hascometothe Depart-mentofOperativeDentistryandEndodonticsofThe Univer-sityof Turinbecause of an exacerbation of chronic apical periodontitisintherightuppercentralincisorwithprevious
dentaltrauma.Clinically,thetoothshowedanincongruous and fractured composite restoration, made as a result of complicated coronal fracture extended belowthe gingival margin, due to an injury occurred three months earlier (Fig. 1). The periapical radiography showed that 1.1 has an open-apex with previous and incongruous endodontic treatment,endodonticmaterialbeyondtheapexandalarge periradicularosteolyticlesion(Fig.2).
In order to resolvein the first instance theendodontic lesion an endodontic retreatment was performed. After havinganesthetizedthearea,thefieldisolationwasobtained bymeansofarubberdam.Oncetheaccesstotherootcanal wascreated,thematerialemployedfortheprevious endo-dontictreatment was removed.Then, to obtain cleansing anddisinfectionoftherootcanalwithouttheriskthatthe solutionscouldgoover-apex,alternatingwasheswere per-formedwith5%sodiumhypochloriteand10%EDTAwiththe aidofanegativepressuresystem(Endovac,....).Sincethe large diameter of the apex, a MTA apical-plug (ProRoot, Maillefer, Ballaigues, Switzerland) has been realized (Fig. 3). After a week, the proper hardening of the MTA was checked and the orthograde endodontic therapy was completedwiththeback-packwithHotShot(SybronEndo, California,USA)andthecoronalsealwithglass-ionomer(Fuji IX,GC,Tokyo,Japan).
After6weeks,themicro-surgicalendodontictherapywas performed in order to remove the endodontic material beyondtheapexandregularizetheshapeoftheapex.After havinganesthetizedtheareawithlocalanesthesia,usinga solution of adrenaline mepivacaine+sol. 1:100000, and maintained haemostasis with a solution of mepivacaine+ epinephrine 1:50000, a sulcular incision extended to 1.2
PAROLECHIAVE Apicebeante; MTA; Restaurodiretto; Traumadentale; Composito. Riassunto
Obiettivi: Il recupero funzionale di un elemento dentario con apice beante gia` trattato
endodonticamentee` oggipossibilegrazieamateriali,qualil’MTA,ingradodiprodurreunsigillo
apicale efficace in grado di portare aduna restitution-ad-integrum. Un restauro diretto in
compositopuo` successivamentefornireunsigillocoronaleefficaceneltempo,indispensabileper
ottenereunaguarigioneendodonticacompleta.
Materiali e metodi: Il caso clinico presentato mostra un approccio combinato (endodotico
e conservativo) per il recupero estetico-funzionale di un incisivo centrale superiore di un
bambinodi11anni.
Risultati econclusioni: Allavisitadicontrollo,dopo12 mesidalcompletamentodelrestauro
coronale, si puo` osservare dall’esame radiografico una completaguarigione dei tessutoosseo
periradicolare.All’esameclinicosi puo` apprezzareuntessutogengivalenon infiammatosenza
aumentodiprofondita` disondaggiononostanteunmarginedelrestaurocoronalepostosottogengiva.
ß2014Societa` ItalianadiEndodonzia.ProductionandhostingbyElsevierB.V.Tuttiidirittiriservati.
Figure1 Initialclinicalcondition:1.1showsaseverefracture
and2.1 wasmade.Distally to 1.2a releasingincisionwas performedandafull-thicknessflapwasraiseduptohighlight thegranulomatoustissueplacedapicallyto1.1.
Once the lesion and the endodontic material were removed, we debrided with care theresulting bony-cript. Atthispoint,thankstotheorthogradecanalobturationwith MTA,itwassufficienttoregularizetheshapeoftheapexwith tungstencarbidemulti-bladesbur(Fig. 4).Thesofttissues wererepositionedwiththeaidofasyntheticmonofilament suture(Tevdek6/0),whichwasremovedafter4days.
Theclinicalandradiographiccontrolcarriedoutafter3 monthsshowedaninitialboneremineralizationandhealed softtissues,thusjustifyingthecompletionoftherapywith directcompositerestoration.Inordertohighlightandexpose thecervicalfracturemargin,thusallowingaproperisolation of the operative field and get a peripheral seal on the enamel, a second full-thickness flap was necessary (Fig.5).Itwasthenisolatedwitharubberdam,the glass-ionomerwasremovedandtheenamelmarginswerefinished
withamediumgritdisc(Sof-LexXT,3MESPE,St.Paul,USA) inordertoremovethenotsupportedenamelprisms(Fig.6). Theadhesivesystem,a3-step etch-and-rinse(Optibond FL,Kerr,Bioggio,Switzerland),wasappliedasfollow: etch-ingwith36%phosphoricacid(Ultradent,SaltLakeCity,USA) for 40s on enamel and15seconds on dentin; rinsing with watersprayfor30sandair-drying;multi-layerapplicationof theprimer; multi-layer applicationof the bonding;curing withLEDlamp(Valo,Ultradent)for20s.Thedirect restora-tionwasperformedusinganincrementallayeringtechnique. The composite resin (Clearfil ES-2, Kuraray) was applied stratifying the masses starting from the buccal surface. For thisstep, the useof a silicone guide obtainedfrom a diagnostic waxwas fundamental as aguide eitherfor the reconstruction morphology either as a support, while the interproximalwallswererealizedthankstoacetatematrix.
Figure2 Initialperi-apicalX-ray.
Figure3 MTAapicalplug.
Figure4 Apexshapeattheendoftheendodonticsurgerywith
MTAapicalseal.
Figure5 Full-thicknessflaptoexposecervicalmarginsofthe
fracture.
Figure6 Afterrubberdampositioning,thefourthclasscavity
Afterwardsthedentinmasswasstratifiedonthecomposite buccalwalland,finally,atranslucentcompositeforapplied as final layer of the vestibular surface (Fig. 7). Once the restorationwasfinishedandpolished, therubberdam was removedandthesofttissueswererepositionedwitha syn-theticmonofilamentsuture.
Afteroneweek thesutureswereremovedandfinishing and polishingprocedures were completed with a fine-grit diamondbur(Komet,Lemgo,Germany),medium-graindisks (SofLexXT3MESPE),siliconepoints(PoGo,DentsplyDeTrey GmbH, Konstanz) and self-polishing brushes (Occlubrush, KerrDentalCorporation,Bioggio,Switzerland).
Results
TheX-raycontrolafter12months(Fig.8)showedan effec-tive coronal seal and complete bone healing. At clinical examination,thecompositerestorationshowedagood inte-gration,bothaesthetic andfunctional,with theremaining
tissues(Fig.9).Theperiodontaltissuesalsoappearhealthy, showingnoresidualscarstosurgicalprocedures,whichwere performedtoallowfunctionalrecoveryofthetooth.
Discussion
The dental trauma is an accidental event that brings the cliniciantoactpromptlywithhigh-leveltherapiesinorderto guaranteeadurablerehabilitation.Then,aboveallwhenthe patient is a child, the direct composite restorations are considered the ideal or rather the mandatory therapeutic choicefortherehabilitationofatraumatizedanteriortooth. Thistypeofrestorationistypicallyusedforaesthetic restora-tionsinsmallormediumcavities.
Themainadvantageofadirectcompositerestorationofa traumatizedanteriortoothistheminimallyinvasiveness:the cavity preparation is almost absentand it saves the most soundhardtissueaspossible,thusallowingre-intervention withoutagreatsacrificeofadditionaltissue.Thatiswhythe above technique is considered the gold standard for the rehabilitation ofan anteriortoothin ayoungpatient. The conceptofreversibilityledtoconsiderthedirectcomposite restorationasthefirstchoicerehabilitation.
Directtechniques,inaddition,couldbecompletedinone appointment,ensuringthepatientafastresultboth aesthe-ticallyandfunctionally.Moreover,incaseofendodontically treatedteeth, thepossibility to quicklyobtain ahermetic coronalsealcouldalsosignificantlyinfluencesthesuccessof theendodontictherapyitself.7
Inthepresentclinicalcase,theinitialendodontic condi-tionwasdefinitelytiedtoawrongchoiceintherootcanal treatment technique previously performed.In the case of largeapices,isamplydemonstratedthatthegutta-perchais notableto createahermeticapicalseal,8fundamentalto avoidtheonsetofperiapicaldisease.Intheseconditions,it was obviously necessary to perform a first orthograde approach,inordertoremovetheendodonticmaterialused previouslyanddisinfecttherootcanal,andsubsequentlya retrograde approach, in order to remove the over-apex endodonticmaterial andregularize theshape of theapex toensureaclinicalconditionmoreinclinedtohealing.
Conclusion
The 12-month follow-up visit showed that the combined orthograde-retrogradeendodonticapproachandsubsequent direct composite restoration created ideal conditions for
Figure8 After 12 month coronal seal is still effective and
periradicularboneappearhealed.
Figure9 Clinicalexamafter12month:thecomposite
restora-tionshowsgoodfunctionalandaestheticalintegration.
Figure 7 Direct composite restoration once finished and
obtaining acomplete healing of both hard tissue andsoft tissue.
Conflict
of
interest
Theauthorshavenoconflictofintereststodeclare.
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