Received Date : 25-May-2016

Revised Date : 02-Aug-2016

Accepted Date : 22-Aug-2016
Article type : Case Report
Accepted Article
Management of coronal discolouration following a regenerative endodontic procedure in
a maxillary incisor

Dr Giselle D’Mello and Dr Luke Moloney

The Royal Children’s Hospital Melbourne, 50 Flemington Road, Parkville, VIC 3052

Correspondence to: Dr Giselle D’Mello,

Royal Children’s Hospital Melbourne, 50 Flemington Road, Parkville, VIC 3052
Giselle.D’Mello@rch.org.au
+61 3 93455344

Acknowledgements:
The authors would like to acknowledge the post-graduate students in paediatric
dentistry from the University of Melbourne and their supervising consultants Clinical
A/Prof James Lucas and Clinical A/Prof Kerrod Hallett for their contributions to the
management and clinical supervision of the presented case

Abstract and key words

Pulpal necrosis and infection in an immature anterior tooth subsequent to traumatic injury is
a challenging situation. Regenerative endodontics, resulting in continued development of
the tooth, provides a biological response to this clinical challenge. Regenerative endodontic
procedures require disinfection of the infected root canal and sealing of the pulp canal
space. Mineral trioxide aggregate (MTA) provides a good seal, is biocompatible, and allows
the formation of a hard tissue to occur within the root canal. MTA however, can lead to
significant staining of the crown of the tooth that is difficult to mask. This case report
describes the management of discolouration in an 11-year-old girl subsequent to a
regenerative endodontic procedure in an immature traumatised maxillary central incisor.

Key words: tooth discolouration, mineral trioxide aggregate, regenerative endodontics,

crown fractures

Introduction

Pulpal necrosis and infection in an immature anterior tooth subsequent to traumatic injury is
a challenging situation. Immature teeth have large pulp chambers, wide root canals, thin
dentine root walls, and wide dentinal tubules. Treatment options traditionally involved
This article has been accepted for publication and undergone full peer review but has
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which may lead to differences between this version and the Version of Record. Please
cite this article as doi: 10.1111/adj.12462
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 apexification of the tooth with long term calcium hydroxide to promote formation of an
apical barrier. This protocol involved numerous appointments and it was found that the
teeth after restoration were prone to root fractures (1). A single stage apexification
Accepted Article
technique, with the placement of an apical seal, preferably with mineral trioxide aggregate
(MTA), showed favourable results in vitro and in vivo (2-4). This technique still left a thin
walled root susceptible to fracture. Ideal management would be to eliminate the infection
and enable the tooth to continue root development with the formation of an apex and
lateral root dentine. This would require effective disinfection of the pulp canal space and
induction of cells to regenerate hard tissue. Iwaya et al in 2001 (5) described a case where
an immature premolar with apical periodontitis continued to develop after disinfection and
sealing off the empty root canal. Banchs and Trope in 2004 (6) proposed initiation of
bleeding into the canal space after disinfection in a premolar with apical periodontitis. They
extrapolated their technique and findings to theorise that avulsed and luxated teeth with
open apices could be encouraged to continue root development.

The area of endodontics that involves “biologically based procedures designed to

physiologically replace damaged tooth structures” in an immature permanent tooth with a
necrotic pulp has been termed regenerative endodontics (7, 8). The aim is to regenerate
functional pulpal tissue utilising a variety of regenerative endodontic procedures including
reestablishment of the vascular supply in the tooth; tissue engineering strategies of stem
cell therapy, scaffold implantation, and growth factor induction; and gene therapies (7, 8).
Since Banchs and Trope (2004) (6) described the procedure of using a blood clot scaffold,
numerous case reports and in vivo studies using animal models have described clinical
protocols and technical challenges (6, 9-13). The primary body of evidence for this
procedure has come from case reports that have shown thickening of the dentinal walls (5,
6, 9, 14, 15).

The success of regenerative endodontics is dependent on the ability to disinfect and prevent
re-infection of the pulp canal space by the placement of coronal seal that is effective while
being biocompatible and promoting the formation of hard tissue. MTA is clearly the material
of choice as laboratory and histological studies have conclusively demonstrated that it
reliably prevents bacterial penetration and forms a hard tissue barrier adjacent to vital
tissues with minimal inflammation. The primary drawback with the use of MTA for
regenerative procedures is the grey coronal discolouration that develops. To combat this,
white MTA (wMTA) (Pro-Root wMTA®)(Dentsply Tulsa Dental, USA) was developed. This
however, also led to grey discolouration of the coronal aspects of teeth (16-20). This
discolouration is extremely difficult to mask especially in young patients. Some have
suggested that in the esthetic zone, discolouration potential should be considered alongside
the biological characteristics of the material used (19). Belobrov and Parashos (2011)
demonstrated an excellent esthetic result after internally bleaching a maxillary incisor that
had discoloured after an MTA pulpotomy (17). This case report demonstrates the use of a
similar technique in the management of coronal discolouration in an immature tooth
following a regenerative endodontic procedure.

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 Case description and results

A 7-year-10-month-old girl presented to The Royal Children’s Hospital Melbourne with an

extra-oral swelling in August 2012. In June 2012, she had suffered a fall off her bicycle
Accepted Article
resulting in uncomplicated crown fractures of teeth 11 and 21. These fractures were
restored with composite resin by her general dental practitioner. In August 2012, she
developed a throbbing pain and presented to the emergency department at the Royal
Dental Hospital Melbourne, where the infected root canal of the 11 was accessed, debrided,
and dressed with odontopaste® (Australian Dental Manufacturing (ADM), Australia), a
calcium hydroxide based medicament with clindamycin hydrochloride 5% and triamcinolone
acetonide 1%. The following day an extra-oral swelling developed and rapidly increased in
size. On presentation to the Royal Children’s Hospital Melbourne, she had a firm extra-oral
swelling that involved the upper lip across the midline and extended up the right hand side
of the nose. It was found to be associated with an apical infection of tooth 11. Tooth 11 was
acutely tender to palpation and showed increased mobility. Tooth 12 also exhibited
increased mobility but was not tender to palpation. Teeth 21 and 22 were not tender to
percussion with mobility within the normal range. Figure 1 shows the radiograph taken at
initial presentation where the restorations on the mesioincisal edges of teeth 11 and 21 are
visible along with the access cavity in tooth 11. It also demonstrates the immature root
apices in all maxillary incisors. Tooth 11 was diagnosed with acute periapical periodontitis
with an associated facial cellulitis.

After 24 hours of IV amoxycillin tooth, 11 was re-accessed under nitrous oxide sedation and
rubber dam. Access was through the palatal aspect, the root canal space was irrigated with
copious amounts of sodium hypochlorite (1%), and dressed with odontopaste®.

On review one month later, tooth 11 was not tender to percussion and mobility was within
normal limits. Teeth 12, 21 and 22 were all positive to carbon dioxide cold testing, not
tender to percussion, and showed normal mobility. The restoration on the mesio-incisal
edge of tooth 21 had fractured and was replaced at this review appointment with composite
resin. At this stage, treatment options for tooth 11 were apexification with long-term
calcium hydroxide, single stage apexification with MTA, or a regenerative endodontic
procedure with induction of bleeding into the root canal space. The benefits and risks
associated with each were discussed and a regenerative endodontic procedure was planned
for tooth 11.

In October 2012, under nitrous oxide sedation, and local anaesthesia tooth 11 was re-
accessed, irrigated with sodium hypochlorite (1%), and the canal was gently filed with a size
#60 endodontic K file to at length of 20mm (Fig 2A). The canal was then irrigated with EDTA,
and dried with paper points. Under microscope guidance a size #45 endodontic K file was
bent slightly at the tip was placed beyond the radiographic end of the root at 20mm.
Bleeding was immediately induced and spontaneously ceased at half the visible canal length.
A surgicell® (Ethicon, USA) barrier and white mineral trioxide aggregate (Pro-Root wMTA)®
was placed in the coronal half to the cementoenamel junction. The coronal aspect above the
cementoenamel junction was sealed with Fuji VII (GC Corporation, Itabashi-Ku, Tokyo,
Japan) glass ionomer cement (GIC) and a composite resin restoration. A month later all the

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 maxillary anterior teeth were asymptomatic and radiographic examination showed a sealed
restoration and no anomalies in the root structure (Fig 2B).

The patient was reviewed 7, 15, 27, and 36 months later. At each review, all maxillary
Accepted Article
anterior teeth were asymptomatic and radiographic examination showed continued lateral
wall thickening in tooth 11 while the apex remained open. Tooth 21 has completed root
development with a narrowing of the root canal (Fig 3).

Discolouration was first clinically reported at the 7-month review as a grey discolouration
around the cervical margin. At 36-month review, in October 2015, the discolouration was a
significant concern for the patient and her parents especially as she was starting high school
in 2016 (Fig 4). It was determined that the discolouration was most likely secondary to the
presence of Pro-Root wMTA in the coronal aspect of the tooth. Treatment options for
management included masking the discolouration with a composite resin veneer or removal
of the Pro-Root wMTA. The ideal option would be partial removal of the Pro-Root wMTA
and internal bleaching with sodium perborate paste in a similar manner as described by
Belobrov and Parashos (2011), to maintain the positive biological result that has been
achieved since the revascularisation procedure (17).

In January 2016, with guidance of an operating microscope under rubber dam and local
anaesthetic, the pulp chamber of tooth 11 was re-accessed, the Pro-Root wMTA was
identified, and ultrasonic tips were used to remove 1mm of the Pro-Root wMTA. The access
cavity was then rinsed with sodium hypochlorite (1%) and acid etched (35% phosphoric acid)
(Ultradent, South Jordan, Utah). The base of the cavity was lined with GIC and a mixture of
sodium perborate and sterile water was placed in the coronal aspect of the access cavity and
sealed with Cavit W (3M Dental Products Division, St Paul, MN).

At review two weeks later, the tooth was asymptomatic and there was a considerable
improvement in the appearance of the tooth. Clinically the tooth had achieved a natural
tooth colour similar to the adjacent tooth. Radiographic assessment showed that a 3mm
layer of Pro-Root wMTA was still present in the root canal. Under rubber dam, the access
cavity was re-opened and the internal bleaching paste was rinsed away. The access cavity
was rinsed with sodium hypochlorite (1%), acid etched (35% phosphoric acid), and restored
with Fuji IX (GC Corporation, Itabashi-Ku, Tokyo, Japan) GIC and composite resin.

Discussion

Discolouration of the crown secondary to endodontic treatment of anterior teeth has been
an ongoing concern. Some of the commonly used products for endodontic treatment
contribute to some staining of the surrounding hard tissues (19). Staining of the tooth
cannot solely be attributed to endodontic products, as evidenced by traumatised teeth
where haemoglobin products penetrate the dentinal tubules (21). In anterior teeth where
endodontic procedures have been carried out, almost all products used (calcium hydroxide,
Ledermix® paste (Riemer, Griefswald, Germany), AH Plus® (Dentsply, Konstanz, Germany),
Pro-Root wMTA®) were found to contribute to discolouration (19). The case described above

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 confirms previous case reports of tooth discolouration secondary to the use of Pro-Root
wMTA®. The possibility of discolouration has restricted the use of MTA in the aesthetic zone.
The development of Pro-Root wMTA® was initially in response to a need for an endodontic
Accepted Article
material that would provide an excellent seal between the pulp chamber and the
surrounding tissues that was nontoxic, noncarcinogenic, biocompatible, insoluble,
dimensionally stable, and not cause staining of the hard tissues. Its antimicrobial properties
and the lack of an inflammatory reaction in adjacent vital tissues contribute to its
biocompatability (18, 22, 23).

The decision to remove Pro-Root wMTA from the coronal aspect of the root canal depends
primarily on the purpose of its use. To achieve predictable results, it is crucial that the
technique used is appropriate for the desired outcomes and the case. In some clinical
applications removal of the MTA would not be viable (16, 20). Belobrov and Parashos
(2011)(17) attempted removal with ultrasonic instruments to minimise tooth structure loss,
however this was unsuccessful and a high speed cutting handpiece was used to successfully
remove the MTA used as a pulp capping agent. In this case the Pro-Root wMTA was placed
to a greater depth in the root canal following a regenerative endodontic procedure.
Ultrasonic tips were used to partially remove the Pro-Root wMTA while maintaining tooth
structure. Ultrasonic units used in endodontics generate mechanical oscillations without
heat and combined with cutting tips offer improved control, access, and therefore,
predictability (24).

Young adolescents are particularly sensitive to appearances and the psychological impact of
an altered appearance can be significant. Several studies have reported that children
affected by alterations in appearance have decreased interactions, increased teasing,
negative self-perceptions, and negative social judgements by peers (25-27). There is very
limited research on the impact on the quality of life in children that have suffered traumatic
dental injuries to their permanent dentition. A series of studies from Brazil assessed the
impact of trauma to the dentoalveolar region in preschool children on the quality of life
using a parent proxy. They found that parents of preschool children who suffered
dentoalveolar injuries perceived their child to have a lower quality of life and a high impact
on the family (28, 29). In the challenging management of the non vital traumatised
permanent incisor, we have to ensure that we also manage the child and their concerns.
This treatment modality provided a self-aware young girl with an incisor that has been
biologically preserved as well as being aesthetically appealing.

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Accepted Article
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Accepted Article
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Figures legend

Figure 1Radiograph at presentation 23-08-12

Figure 2 Working length radiograph (17-10-12) and at review 1 month later (14-11-
12)

Figure 3 Radiographic examination at 7, 15, and 27 months after regenerative

endodontic procedure

Figure 4 Clinical photograph of the coronal discolouration and radiograph taken on

28-10-15

Figure 5 Clinical photograph and radiograph 2 weeks after removal of wMTA (6-2-
16)

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Accepted Article

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Accepted Article

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Accepted Article

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