Management of Intruded Immature

Maxillary Central Incisor with Pulp

Necrosis and Severe External Resorption
by Regenerative Approach
{Giorgos N. Tzanetakis|Journal of Endodontics|February 2018

PRESENTED BY-
DR. RITIKA SATIJA
PG 2ND YR
 INTRODUCTION
 The traumatic injuries of immature permanent teeth
may have a harmful influence on physiological pulp
and root development.
loss of pulp vitality

 Such injuries may lead to - arrested or interrupted root development

Inflammatory or replacement resorption

 more severe the injury = more complicated trauma

consequences for affected teeth.
 Intrusive luxation (intrusion)
 most severe traumatic injuries of the permanent dentition

 Defined as the displacement of the tooth into the alveolar bone

along its axis, which is usually accompanied by fracture of its
socket.

 The vascular supply of the pulp is immediately interrupted,

 The supporting structures of the affected tooth are severely

injured.

 rare injury - prevalence varies between 0.3% and 1.9%.

 The incidence of pulp necrosis of injured teeth ranges
between 45% and 96%, whereas the incidence of root
resorption varies from 12% to 80%.
 In immature permanent teeth and in patients aged between 6
and 10 years, awaiting spontaneous re-eruption of the intruded
tooth appears to be the most appropriate treatment strategy.

 Orthodontic or surgical repositioning are the 2 alternative

treatment options mostly related to the patient’s age, the degree
of root development, and the degree of intrusion.

 These factors are also reported to be the most signifcant for the
management outcome
 However, once a pathologic condition has been established after
the intrusion injury, any clinical attempt should be made to save
the injured tooth.

 Intraoral swelling or the presence of a sinus tract associated

with periradicular lesion or inflammatory root resorption are
the main clinical and radiographic findings of such pathologic
condition.

 In the last 5 years, regenerative endodontic procedures (REPs)

have offered a more dynamic clinical approach for the
endodontic management of cases with uncertain prognosis.
 So far, no case of intruded immature tooth with pulp
necrosis and severe inflammatory root resorption that has
been managed by using an REP has been described in the
literature.

• Cantekin et al have described a case of immature necrotic

permanent incisor after a severe intrusion that was managed
by a revascularization procedure.

• However, the tooth did not present with severe inflammatory

resorption, was treated over multiple appointments, and
finally underwent conservative endodontic therapy because
of negative sensibility tests.
 Thus, the present case report describes the first clinical attempt
to manage and save an intruded immature maxillary central
incisor that presented with pulp necrosis and severe root
resorption by using a regenerative approach
Case Report:

 A 7-year-old male patient was referred to our clinic for the

management of a central incisor (tooth #9) after a traumatic
injury because of a fall that had occurred a day before.

 The boy did not complain of any pain to the injured tooth or the
surrounding soft tissues.

 The parents of the boy stated that the tooth had been inserted
into its pocket during the injury.
 C/E revealed an
-uncomplicated crown fracture(a small coronal part of the crown was
missing)
- a small amount of bleeding from the palatal soft tissues of the tooth.
- no mobility
-but slightly sensitive to percussion and palpation.
- did not respond to cold and electric pulp sensibility testing.

 R/E showed that the tooth was immature with open apex .

 Both clinical and radiographic examinations confirmed the intrusion,

which was calculated between 3 and 4 mm
 At that first visit, spontaneous re-eruption was expected as the
first clinical strategy choice because of the open apex and the
absence of pathologic signs and symptoms.

 The open dentinal tubules due to crown fracture were covered

with a thin layer of flow resin to avoid tubule contamination,
and the patient was scheduled for recall examination 3 weeks
later.

 The parents of the boy failed to attend the scheduled

appointment until intraoral swelling appeared at the buccal side
of the injured tooth 2 months after the first visit .
Clinical image of soft tissues with intraoral swelling
 C/E revealed
- presence of swelling, even though the tooth appeared to be
partially re-erupted.
- buccal area was sensitive to finger palpation
- tooth was tender to percussion.
- tooth mobility was characterized as grade I

- tooth did not respond to cold and electric pulp testing.

R/E showed
 presence of periradicular lesion associated with external root
resorption that was characterized as infection-related .
 Recall radiograph 2 months later.
A periradicular lesion is evident with initial signs of
root resorption
 The whole situation was described to the parents, and REP was
decided as the treatment of choice for this situation.

 Although the parents were informed about the clinical

situation, they preferred to postpone the therapy for 2 weeks to
think about it.

 Because of the tight schedule of the clinic, the first therapy

appointment was scheduled 3 weeks later.
 At that first appointment and before the beginning of the
treatment, informed consent was obtained.

 Local anesthesia with 4% articaine containing 1:200,000

epinephrine was initially administered.

 Despite the partial re-eruption of the tooth, appropriate rubber

dam isolation was a challenging procedure because of the
difficulty of clamp placement.
 After surgical removal of small amount of soft tissues palatally,
the tooth was appropriately isolated with rubber dam, and the
canal was accessed by using an Endo-access bur.

 The pulp was entirely disrupted, and a barbed broach was

carefully used to remove the necrotic remnants of the tissue
without touching root canal walls apically.

 Canal was gently irrigated with 10 mL 1% NaOCl, and the

working length was determined radiographically with #120 K-
file.
 No canal filing was performed, but ultrasonic activation of
NaOCl was carried out for 60 seconds (2x30seconds) for better
canal disinfection.

 Then the canal was again irrigated with another 10 mL 1%

NaOCl, dried with sterile paper points, and medicated with
calcium hydroxide. The access cavity was sealed with sterile
cotton pellet and Cavit G.
 The patient was recalled 2 weeks later.

 The tooth was asymptomatic, and the intraoral swelling was

completely resolved.

Clinical image of soft tissues at time of regenerative endodontic

therapy.
 Local anesthesia without a vasoconstrictor (mepivacaine 3%)
was administered.

 The tooth was isolated under a rubber dam

 The canal was again accessed and irrigated initially with 5 mL

1% NaOCl for the removal of the main bulk of calcium
hydroxide.
 Before dryness, an additional ultrasonic activation of NaOCl for 30
seconds took place for the complete removal of calcium hydroxide
from the root canal walls.

 Then a final rinse with 10 mL 17% EDTA followed, and tooth was
dried again with sterile paper points.

 Bleeding was induced with the use of #60 Hedstrom file to disturb
periapical tissues 2 mm beyond the root apex.

 After 2 minutes, a sufficient blood clot was created, and a small

amount of white mineral trioxide aggregate (MTA) (ProRootMTA)
was gently placed and condensed in the coronal third of the canal.
 The formation of an adequate blood clot is of utmost importance
for proper MTA placement, serving also as a protein scaffold inside
the root canal system.

 After 3days, MTA setting was confirmed, and the access cavity was
sealed permanently with glass ionomer cement and light-cured
composite resin.

 Then a final radiograph was taken to check the MTA placement.

 The patient was then recalled after 3, 12, 18 and 30 months

respectively.
Final radiograph of the case. Because of the treatment delay, the
radiographic appearance of the root resorption is worse in
relation to figure 3 weeks before.
 Periapical radiographs at 3 and 12 months showed
-initial signs of healing of the periradicular lesion,
- inhibition of the root resorption process, and
- progressive repair of the periodontal ligament .

 At the next recall appointments, periapical radiographs

revealed more evidence of progressive healing and remodeling
of lamina dura.
 However, at the final follow-up examinations, a gradual
development of a calcified bridge was apparent below the mass
of MTA.

 At the same time, calcified radiopaque deposits made their

appearance inside the root canal at the 18- and 30-month
appointments, without completion of root development at the
apical third .

 Clinically, the tooth remained normal and functional, and the

soft tissues maintained a physiological clinical appearance .
 Discussion
 REPs have offered a more dynamic and promising clinical
approach for the management of teeth with necrotic pulp and open
apex.

 In case of favorable outcome, these procedures

-allow the healing of the periapical area
-the progressive width of the root canal walls
-eventually the increase of the root length.

 Even if the complete apical closure or the thickening of root canal

walls is still questionable or uncertain, the REP may lead to
completely functional teeth that are free of clinical signs and
symptoms
 However, traumatized teeth remain a great challenge with respect
to their clinical management by using REPs.

 Traumatic injury of the periodontal ligament and supporting

structures may create an unfavorable microenvironment for an
appropriate healing outcome at the periradicular area.

 Root resorption in any of its forms (infection-related resorption,

replacement resorption) is the main pathologic process that makes
the prognosis uncertain or poor and may lead to tooth loss.
 Because of the rare occurrence of intrusive luxation, a small
amount of clinical evidence is available for the management and
treatment outcome of such traumatized teeth.

 A recent systematic review of the most important studies

concluded that in teeth with incomplete root development and
mild degree of intrusion, spontaneous re-eruption has the most
favorable outcome and is anticipated to be completed during
the first 4–8 months after injury.
 In the present case, the intruded tooth was left to re-erupt
because of the open apex and the mild degree of intrusion.

 After 2 months, the tooth had partially re-erupted; however,

intraoral swelling appeared as the first clinical finding of an
emerging pathologic process.

 According to the literature, a delayed diagnosis of pulp

necrosis is often made in mild intrusion injuries when re-
eruption is expected.

This occurs because of waiting for possible pulp space

revascularization in cases of teeth with immature apex.
 Thus, endodontic treatment is usually postponed until definite
signs of pulp necrosis have appeared.

 It is also reported that increased risk of pulp necrosis may be

associated with a concomitant crown fracture and exposed
dentin to oral environment.

In these cases, pulp necrosis has been correlated not only with the
extent of injury but also with bacterial invasion through dentinal
tubules toward the injured pulp
REP was the treatment of choice, which was performed in 2
disinfection steps because of the presence of severe external
inflammatory root resorption detected radiographically.
This was preferred to achieve more adequate chemical root canal
disinfection.

 Because of particularly thin root canal walls, no canal filing was

performed, and additional canal disinfection was carried out
through ultrasonic activation of NaOCl.

 At the second appointment, ultrasonic activation was

performed for the complete removal of calcium hydroxide from
the root canal walls.
 In the present case, the main challenge was the inhibition of the
external root resorption.

 The resorption process rapidly evolved because of the treatment

delay.

 It is well-known that the placement of Ca(OH)2 can significantly aid

toward the arrest of resorption through pH increase and subsequently
neutralization of the microenvironment of the exposed dentin
surfaces.

According to the guidelines of the European Society of Endodontology,

the American Association of Endodontists, and recent systematic
reviews, Ca(OH)2 can be used with similar outcome rate as an
alternative intracanal medicament instead of antibiotic paste.
 Through this process, the acidic environment of the resorbed
root surface is expected to be gradually neutralized, and the
osteoclastic activity can be prevented.

 If it is initially achieved, then the formation of a sufficient blood

clot on which MTA is to be placed may stimulate the ingrowth
of new tissue inside the root canal system and subsequently the
healing capacity of periapical tissues.
 The present case was followed to 30 months.

 During this time period, the healing process was normal, with
complete resolution of the disease and without any
postoperative complications.

 Nevertheless, healing is still in part unpredictable when REPs

are applied in severe cases of dental trauma.
 In this case, 2 unexpected outcomes were recorded during recall
examination period-
-The first was the incomplete root development,
- the second was the intracanal accumulation of calcified tissue observed
at the last 2 recall examinations.

 The fact that the injured tooth failed to complete root development
after 30 months may be a differentiating feature of the intrusion injury
when a regenerative approach is applied for the management of these
cases.

 However, such healing responses are presented in the literature and

may be considered as acceptable and non-reversible considering tooth
survival.
 In the literature, only 1 clinical report has presented endodontic
management of traumatized teeth with external root resorption
by using REPs.

 However, none of the 3 cases presented in this report was

associated with intrusion injury.

 This fact highlights not only the rarity of the described clinical
case but also the dynamics of the REPs regarding survival of
complex traumatized teeth cases.
 The present case also indicates clearly the severity of the
intrusion injury.

 Even if the degree of the intrusion is low, the injury should

never be underestimated because the risk of pulp necrosis and
root resorption remains extremely high.
CONCLUSION

 In conclusion, the present case also shows that severely

traumatized teeth with uncertain prognosis may have a great
chance to heal under the appropriate therapeutic conditions,
remaining functional and free of signs and symptoms.

 However, more case reports or clinical studies are needed with

large sample sizes to completely support this statement.
 Recall examination for at least 3 years is also necessary for the
clinical evaluation of tooth functionality and the radiographic
assessment of apical healing and root development.

 During the early follow-up period, the gradual remodeling of

the lamina dura and the supporting tissues around the root of
the injured tooth is the main radiographic finding of an initial
satisfactory outcome.