Non-surgical endodontic treatment of the maxillary right central incisor with incomplete root formation

CASE REPORT/YOUNG DENTIST ENDODONTIC AWARD

Dr. Rupal Shah, second-place winner of the Young Dentist Endodontic Award of the UK, examines the successful management of an anxious 10-year-old patient

Introduction

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 pediatric 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.

Patient details

10-year-old female, school pupil

History

Presenting complaint

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 in Birmingham, England, 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 general practitioner 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.

Medical history

The patient suffers from asthma, for which she uses Ventolin^® and Becotide^™ inhalers, as and when required. She has not had any previous hospitalizations due to her asthma.

Dental history

There is no history of any other previous trauma. Cooperation appeared to be reduced, as the patient had not had any previous extensive dental treatment and was therefore quite nervous.

Examination

Extraoral

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.

Intraoral

Soft tissues

Oral hygiene was fair, but some gingival inflammation was present.

Hard tissues

Teeth present were: 

6EDC21 12CDE6 

6EDC21 12CDE6 

Unrestored enamel-dentin fractures were evident on the UR1 and UL1, with the UL1 fracture being fairly extensive. Caries was noted on the LLD.

Occlusion

Occlusal analysis revealed a class 1 incisor relationship with class 2 right molars and class 1 left molars.

Special investigations

All maxillary incisors responded positively to ethyl chloride. The UR2, UL1, and UL2 responded positively to an electric pulp tester while the UR1 tested negative. None of the maxillary incisors were tender to percussion, and no labial sinus or tenderness, discoloration, or mobility was noted.

Radiographic examination

Periapical radiographs

Long cone periapical radiographs UR21, UL12 (Figure 1.1) revealed open apices on all maxillary incisors, and PDL widening around the apex of the UR1. It also showed the unrestored enamel-dentin fractures on both maxillary central incisors.

Upper standard occlusal radiograph

This radiograph confirmed PDL widening around the UR1, with associated periapical pathology. It also shows the open apices of all 4 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 (Figure 1.3).

Diagnoses

1. Enamel-dentin crown fractures UR1 and UL1
2. Likely non-vital UR1; chronic apical periodontitis secondary to trauma
3. Caries LLD
4. Anxious patient

Treatment options

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).

Treatment plan

1. Immediate: cover exposed dentin UR1 and UL1 with glass ionomer cement (GIC) (Birmingham Dental Hospital)
2. OHI, dietary analysis and advice, bitewing radiographs (GDP)
3. Scale and polish, restore caries LLD, fissure seal 1st permanent molars (GDP)
4. 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)
5. Adhesive composite restorations UR1 and UL1 +/- RA sedation (Birmingham Dental Hospital)
6. Review (Birmingham Dental Hospital)

Treatment protocol

Appropriate verbal and written consent was obtained prior to commencing treatment. As a test cavity was carried out on the UR1, no local anesthetic was required. Isolation was achieved with dry dam, wedgets, and OraSeal^® (Ultradent) 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 (Figure 1.4), and the working length was measured as 21 mm.

Chemo-mechanical cleaning of the canal was carried out using K-flex handfiles, interdental brushes, and 2.5% 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% sodium hypochlorite solution. The tooth was again temporarily 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 (Figure 1.5) to confirm the length, and a 4 mm apical plug of mineral trioxide aggregate was placed using the Micro Apical Placement System (Figure 1.6). The remaining canal space was obturated with thermoplasticized GP (Obtura) and sealer using warm vertical compaction. A Vitrebond^™ (3M^™ ESPE^™) lining was placed over the GP, and the access cavity was restored with composite resin to create an effective coronal seal (Figure 1.7). 

Review 

The patient recently attended for a 6-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 6 months.

Discussion

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 behavior 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 6-month review appointment at Birmingham Dental Hospital. The 4 mm 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 traumatized upper incisor teeth.

References

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