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Complex endodontic and conservative treatment of a traumatized central incisor

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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

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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

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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

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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

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obtaining acomplete healing of both hard tissue andsoft tissue.

Conflict

of

interest

Theauthorshavenoconflictofintereststodeclare.

References

1. AnderssonL.Epidemiologyoftraumaticdentalinjuries.JEndod 2013;39(3Suppl.):S2—5.

3. DiangelisAJ,AndreasenJO,EbelesederKA,KennyDJ,TropeM, SigurdssonA,etal.InternationalAssociationofDental Trauma-tology,InternationalAssociationofDentalTraumatology guide-lines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012Feb;28(1):2—12.

4.Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiangelisAJ,etal.InternationalAssociationofDental Traumatol-ogy,InternationalAssociationofDentalTraumatologyguidelines forthemanagementoftraumaticdentalinjuries:2.Avulsionof permanentteeth.DentTraumatol2012Apr;28(2):88—96.

5.StojanacI,RamicB,PremovicM,DrobacM,PetrovicL.Crown reattachmentwithcomplicatedchisel-typefractureusing fiber-reinforcedpost.DentTraumatol2013;29(6):479—82.

6.VitalMC,CaprioglioC,MartignoneA,MarchesiU,BotticelliAR. Combined technique with polyethylene fibers and composite resinsinrestorationoftraumatizedanteriorteeth.Dent Trau-matol2004;20(3):172—7.

7.Sjo¨grenU,FigdorD,PerssonS,SundqvistG.Influenceofinfection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30(5):297—306.

8.Hachmeister DR,Schindler WG, Walker 3rd WA,Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endod 2002;28(5):386—90.

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