The second place entry for the 2013 Young Dentist Endodontic Award by Rupal Shah - Non surgical endodontic treatment of the maxillary right central incisor with incomplete root formation
This report discusses the successful management of an anxious 10-year old patient, who required root canal treatment of her immature upper right central incisor, following a previous history of trauma. She was initially referred to the paediatric department at Birmingham Dental Hospital by her general dental practitioner. Following assessment and diagnosis, she underwent root canal therapy of her upper right central incisor, which was deemed to be non-vital and had an open apex.
10 year old female, school pupil
The patient’s chief complaint was her ‘fractured front teeth’ which she did not like the appearance of.
History of Presenting Complaint:
History of presenting complaint revealed that she had suffered trauma in November 2011, when she had fallen in the school playground and knocked her front teeth on metal railings. Both upper central incisors had fractured, but there was no obvious displacement at the time of injury.
No loss of consciousness or head injuries had been noted, but there was a laceration to the upper lip. She initially attended Heartlands Hospital, from which she was referred to Birmingham Children’s Hospital for a chest x-ray, as the tooth fragments had not been accounted for. The chest x-ray reported no abnormalities.
The patient then saw her GDP one day after the injury, and had adhesive composite restorations placed on the UR1 and UL1. However, these were subsequently lost after 6 weeks, and were not replaced.
The patient suffers from asthma, for which she uses Ventolin and Becotide inhalers, as and when required. She has not had any previous hospitalisations due to her asthma.
There is no history of any other previous trauma. Co-operation appeared to be reduced as the patient had not had any previous extensive dental treatment, and was therefore quite nervous.
Extra – oral
Scarring was noted in the midline of the patient’s upper lip; she had sustained a laceration to this area at the time of injury.
Intra – oral
Oral hygiene was fair, but some gingival inflammation was present.
Teeth present were:
Unrestored enamel-dentine fractures were evident on the UR1 and UL1, with the UL1 fracture being fairly extensive. Caries was noted on the LLD.
Occlusal analysis revealed a class one incisor relationship with class two right molars, and class one left molars.
All maxillary incisors responded positively to ethyl chloride. The UR2, UL1 and UL2 responded positively to Electric Pulp Tester whilst the UR1 tested negative. None of the maxillary incisors were tender to percussion and no labial sinus or tenderness, discolouration or mobility was noted.
Long cone periapical radiographs UR21, UL12 (Fig 1.1) revealed open apices on all maxillary incisors, and PDL widening around the apex of the UR1. It also showed the unrestored enamel-dentine fractures on both maxillary central incisors.
Fig. 1.1 Preoperative periapical radiographs
Upper Standard Occlusal Radiograph
Fig. 1.2 Upper standard occlusal radiograph
This radiograph confirmed PDL widening around the UR1, with associated periapical pathology. It also shows the open apices of all four upper incisors, as well as the presence of maxillary canines.
Soft Tissue X-ray
The soft tissue radiograph of the upper lip revealed no abnormalities, and no evidence of any tooth fragments in the lip (Fig. 1.3).
Fig. 1.3 Soft tissue radiograph of upper lip
- Enamel-dentine crown fractures UR1 and UL1;
- Likely non-vital UR1; chronic apical periodontitis secondary to trauma;
- Caries LLD;
- Anxious patient
1. Test cavity UR1, and proceed to non-surgical root canal therapy with MTA apical plug if non-vital +/- RA sedation (Birmingham Dental Hospital)
The patient was quite nervous, so the use of RA sedation was discussed; a RA sedation information sheet was given to the patient
2. Extraction of the UR1 with or without prosthetic replacement (GDP).
- Immediate: cover exposed dentine UR1 and UL1 with GIC (Birmingham Dental Hospital)
- OHI, dietary analysis and advice, bitewing radiographs (GDP)
- Scale and polish, restore caries LLD, fissure seal first permanent molars (GDP)
- Test cavity UR1 and proceed to root canal treatment if non-vital +/- RA sedation. Dress with non-setting calcium hydroxide until stable. (Birmingham Dental Hospital)
- Adhesive composite restorations UR1 and UL1 +/- RA sedation (Birmingham Dental Hospital)
- Review (Birmingham Dental Hospital)
Appropriate verbal and written consent was obtained prior to commencing treatment. As a test cavity was carried out on the UR1, no local anaesthetic was required. Isolation was achieved with dry dam, wedgets and Oroseal caulking material. The tooth, as expected, was found to be non-vital, and extirpated and dressed with non-setting calcium hydroxide as an intracanal medicament. A temporary dressing of a cotton wool pledget and GIC was placed in the access cavity. This initial management was carried out under RA sedation.
At two subsequent visits, the GIC fillings on the UR1 and UL1 were removed and replaced with adhesive composite restorations, and the UR1 root canal was further prepared. The root canal length was determined radiographically (Fig. 1.4), and the working length was measured as 21mm.
Fig. 1.4 Diagnostic radiograph to determine working length; 21mm
Chemo-mechanical cleaning of the canal was carried out using K-flex handfiles, interdental brushes, and 2.5 per cent sodium hypochlorite irrigation. The final apical size of the canal was 80, due to the immature apex and lack of apical barrier. An apical stepback technique was used to prepare the wide canal. The canal was again dressed with non-setting calcium hydroxide, a cotton wool pledget and GIC in the access cavity. After this visit, the patient felt less anxious, and opted to have future treatment without RA sedation.
At the next visit, the patient mentioned the tooth had been symptomatic. Therefore, it was decided to re-access and re-irrigate with 2.5 per cent sodium hypochlorite solution. The tooth was again temporary dressed with calcium hydroxide, a cotton wool pledget and GIC.
At the following appointment, the patient was asymptomatic. The canal was re-irrigated with sodium hypochlorite and dried with paper points. A master cone periapical radiograph was taken (Fig. 1.5) to confirm the length, and a 4mm apical plug of mineral trioxide aggregate was placed using the Micro Apical Placement System (Fig. 1.6). The remaining canal space was obturated with thermoplasticised GP (Obtura) and sealer using warm vertical compaction. A Vitrebond lining was placed over the GP, and the access cavity was restored with composite resin to create an effective coronal seal (Fig. 1.7).
Fig. 1.5 Master cone periapical radiograph Fig. 1.6 4mm MTA apical plug
Fig. 1.7 Post-operative radiograph
The patient recently attended for a six month review, which reported no symptoms associated with the UR1. With regards to the UL1, there was a query whether there was some periodontal ligament widening, however the sensibility tests were inconclusive and the tooth was asymptomatic. It was therefore decided to continue to monitor the UL1 for now, and review the patient again in a further six months.
The patient’s traumatic incident had resulted in pulpal necrosis of the UR1 and consequently an incomplete formation of the root. Effective cleaning of the canal walls was achieved with large K-flex handfiles, inter-dental brushes and sodium hypochlorite irrigation. The MTA technique allowed for successful obturation of the maxillary central incisor with an open apex.
I successfully completed this treatment in an anxious 10 year old girl, who had not had any previous extensive dental treatment. I overcame this by using different behaviour management techniques including tell-show-do, and ensuring that all appointments were not of too long a duration. This meant compliance was not lost. In fact, the patient initially began treatment under RA sedation due to her anxiety, but at subsequent visits, decided she no longer wanted it, and appeared to cope well without it.
Finally, I decided to submit this case, because I feel that I obtained an excellent final outcome, both clinically and radiographically. The tooth was symptom free at the six-month review appointment at Birmingham Dental Hospital. The 4mm MTA apical plug was to the correct length, and radiographically, there were no voids in the thermoplastic GP. The access cavity was sealed with a vitrebond lining, followed by adhesive composite restoration, ensuring a good coronal seal.
The endodontic prognosis for this tooth is good; however the patient is fully aware of the long term consequences of trauma, and the subsequent need for regular dental monitoring and sensibility testing of the traumatised upper incisor teeth.
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