Pulp Revascularization in a primary Necrotic Central Incisor

Case description

An 8-year-old male patient presented to the pédiatrie dental clinic at Miami Children's Hospital, Miami, Fla., USA. The parent reported that the patient suffered dental trauma 7 months prior, fracturing his permanent maxillary right and left central incisors at the mesial-incisal angle. The pulp was not exposed at the time of injury. Six months after the injury, the patient went to a general dentist with a complaint of spontaneous pain and was prescribed amoxicillin every 8 hours for 2 weeks. One month later, the patient developed an acute apical abscess with swelling buccal to the permanent maxillary left central incisor and was again prescribed the same course of antibiotics. The patient had a regular dental home prior to the injury and had no significant medical history. Upon our examination (2 weeks after the second course of antibiotics), 

(Figure 1) Periapical radiograph sequence of revascularization and apexogenesis. 

(a) Permanent maxillary left central incisor prior to pulp regeneration therapy 

showing an open apex (immature root), restored mesial incisai angle, and periapical radiolucency at the apex of the permanent maxillary left central incisor.

(b) Mineral trioxide aggregate placement at the cervical level after the blood clot 

was formed

(c) Three-month follow-up showing the early stages of apexogenesis

and healing of the periapical radiolucency, and (d-e) Continued healing of the 

periapical area and apexogenesis at 6- and 11 -month follow-ups, respectively.

the permanent maxillary left central incisor still presented an acute apical abscess with buccal swelling. Radiographie examination revealed an open apex and periapical radiolucency (Figure la). The following day, the patient received an endodontic consultation, resulting in a decision to attempt pulp regenerative techniques. At the first treatment appointment, the tooth was nonresponsive to vitality testing with Endo Ice (Coltene Whaledent, Mahwah, N.J., USA) and Vitality Scanner (SybronEndo, Orange, Calif, USA). The patient reported to be sensitive to palpation and had no mobility or discomfort upon percussion. His probing depths were within normal limits on the permanent left maxillary central incisor. The permanent left lateral incisor responded within normal limits to the pulp vitality tests. After administration of local anesthesia with 1.8 ml 2% lidocaine and 1:100,000 epinephrine (Novocol, Cambridge, Ontario, Canada) and rubber dam isolation, the pulp chamber  was accessed from the palatal surface and confirmed necrotic. The canal was irrigated with 6% sodium hypochlorite (Clorox, Oakland, Calif, USA) and dried with sterile paper points (Dentsply, Tulsa, Okla., USA). No instrumentation of the canal was performed. A triple antibiotic medicament in a 1:1:1 ratio—comprised of metronidazole (Pleva Pharmaceutical, Zagreb, Croatia), ciprofloxaein (Teva Pharmaeeutieals, Sellersville, Pa., USA), and minoeycline (Global Pharmaceutical, Philadelphia, Pa., USA)— Figure 2.

(Figure 2) .  Periapical radiograph of the permatient maxillary left central incisot at 2 weeks after initial treatment with triple antibiotic paste, with guttapercha tracing the sinus tract

was used to ease manipulation, the thickening agent carboxymethylcellulose (Spectrum, New Brunswick, N.J., USA) was added and mixed into the triple antibiotic paste with a number 24 spatula (Hu-Friedy, Chicago, 111., USA). This mixture was placed into the root canal with a Centrix syringe and standard syringe tips (Centrix Dental, Shelton, Conn., USA), covered with a sterile cotton pellet, and temporarily restored with CavitG (ESPE, Seefeld, Germany). (ESPE, Seefeld, Germany). Fourteen days after treatment was initiated, the patient returned to the clinic having lost the temporary restoration. At this visit, the patient was re-examined and found to now have a draining sinus tract apical to the permanent maxillary left central incisor (Figure 2). After the local anesthetic was administered and isolation achieved with the rubber dam, the canal was again irrigated with 6% sodium hypochlorite, treated with the same TAP, and covered with a sterile cotton pellet. The access was closed and the tooth was temporarily restored with Gavit-G. The patient was asymptomatic at the 21-day follow-up after the second TAP treatment. After local anesthesia and isolation were obtained, the temporary restoration, eotton pellet, and TAP were removed. The eanal was then irrigated with 6% sodium hypoehlorite and dried with sterile paper points. A number 20 sterile K type endodontie file (Dentsply) was introdueed into the apical area to stimulate bleeding into the eanal spaee. The blood was allowed to reaeh the level of the eementoenamel junetion (CEJ), where a blood clot was formed (Figure lb). Mineral trioxide aggregate (MTA, Dentsply) was mixed with 2% lidocaine and 1:100,000 epinephrine and placed over the clot. A thin layer of cavity liner (Lime-Lite, Pulpdent, Watertown, Mass., USA) was placed over the MTA, cured, and etched, and the access opening was restored with TPH Composite (Dentsply Caulk, Milford, Del, USA). Three months after the regeneration procedure, the patient was still asymptomatic and the sinus traet had healed eompletely. Coverage over the aeeess was intaet and radiographie examination revealed the healing of the periapieal area and the appearanee of the apex elosing (Figure le). Six months after the regeneration proeedure, the patient was asymptomatie but the permanent maxillary left eentral ineisor presented with a slight grayish diseoloration (Figure 3). 

(Figure 3). Patient's anterior teeth at -11 month follow-up follow-up showing

a slight grayish discoloration in the permanent maxillary left central incisor.

The tooth had no mobility, no pain on pereussion or palpation, and no positive reaetion to the eold test. The lamina dura and periodontal ligament were within normal limits, and continued root development was noted (Figure Id). Eight months after the regeneration procedure, the tooth was restored with TPH composite. The patient was asymptomatic, and the grayish discoloration was still present. At the following recall exam, 11 months after treatment, root development appeared complete and dentinal wall thickening was noted, particularly in the root's apical third (Figure le).

Discussion

The resulting closure of the root apex and thickening of the root walls demonstrated successful revascularization and maturogenesis after applying triple antibiotic therapy and MTA' seal of a necrotic immature permanent ineisor. Vitality testing would not be viable sinee the eoronal plug does not allow aeeess to the dentinal tubules where new pulp tissue has been regenerated below the CEJ level. Other studies report similar findings on inconclusive pulp vitality tests after regeneration procedures." Discoloration of the newly vascularized incisor correlates with previous studies using tetracyclines in their antibiotic medicament. In out study, white MTA vs gray MTA was used to minimize the possibility of discoloration. Bonding techniques have been attempted to reduce the negative esthetic effect, but no treatment has yet proven effective for improving discoloration.Pediatrie dentists and endodontists alike agree that regenerative techniques will be viable treatment modalities in the future. Half of the endodontists in one study already used some type of regenerative therapy in their practice. Current technology, including laser Doppler flowmetry, allows us to

effectively evaluate whether revascularization has occurred and whether regenerative techniques need to be initiated.Revascularization has even been successfully attempted in primary teeth.'"'With an increasing breadth of clinical evidence and practitioner acceptance, regenerative techniques may become a standard technique in treating immature necrotic permanent teeth.

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Treatment of Maxillary Lateral Incisor Agenesis with Zirconia-Based All-Ceramic Resin-Bonded Fixed Partial Dentures

CASE REPORT

A 14-year-old female patient presented  to the University of Pennsylvania Faculty  Practice with congenitally missing maxillary lateral incisors. She was nearing  completion of a 5-year orthodontic  treatment phase that included palatal  expansion and she was seeking consultation for subsequent prosthetic  treatment of the edentulous lateral incisor areas. Her medical history was  unremarkable, and her dental history  included orthodontic treatment, routine  recall visits, minor operative dentistry,  and sealants on permanent molars. A  comprehensive examination was conducted, including radiographic (Fig 1)  and dental examinations, periodontal  probing, and temporomandibular evaluation. Preliminary study casts were  mounted in an articulator.

(Fig 1)

Diagnosis and treatment planning

Extraoral findings were normal, and intraoral and radiographic findings revealed no caries lesions. All soft tissues  

were normal and healthy. The anterior  

teeth had a shade of A3 (VITA Shade  

guide, Vident). Mild-to-moderate enamel hypoplasia was noted throughout the  

dentition. The maxillary canines had  

markedly pointed cusps, and mamelons were present on the mandibular lateral incisors. The patient was unhappy  

with both the shade of her teeth and the  

mandibular mamelons but did not want  

any changes to the characteristic hypoplastic markings, other tooth morphology, or position and angulations of her  

natural teeth. The edentulous alveolar  

ridges were mildly deficient in the orofacial dimension. Denture teeth were fixed  

to the orthodontic archwire to occupy  

the missing lateral incisor spaces. The  

patient had a Class I skeletal relationship with bilateral Class I molar relationships and canine guidance.  

All other findings were normal. The  

dentofacial diagnosis was good. Anterior spacing was adequate for restorative  

replacement. The periodontal diagnosis  

was type I according to American 

Academy of Periodontology criteria.  The biomechanical diagnosis showed  no compromised areas. The functional  diagnosis was normal, consistent with  the current degree of tooth eruption.  

The prognosis for this dentition and  

for patient compliance was good. All  

treatment options were discussed with  

the patient and her parents. Dental implants were not recommended at that  

time due to the patient’s incomplete  

growth. The treatment goals were as  

follows: (1) provide minimally invasive,  

prosthetic replacement of the missing  

lateral incisors; (2) meet the patient’s  

and parents’ esthetic expectations;  

and  (3) achieve stable occlusion.  

The definitive treatment plan included  

tooth bleaching and zirconia-based  

CRBFPDs, which would allow for implant placement at a later time.

Clinical treatment 

The patient returned 3 months later  

following the completion of orthodontic treatment. A Hawley-type retainer32 

with denture teeth for the edentulous  

spaces had already been fabricated.  

New diagnostic casts were made  

and mounted in an articulator for occlusal analysis, preparation planning,  

and framework design. Bleaching  

trays were fabricated on a second set  

of diagnostic casts. The patient followed an at-home bleaching protocol  

(Opalescence PF 10%, Ultradent) and  

was advised to bleach one arch at a  

time, nightly, for 1 week per arch. Shade  

B1 was selected at the postbleaching  

follow-up appointment. Figures 2 and  

3 show the preoperative situation with  

the retainer in place. Due to the occlusal scheme and canine guidance,  

the central incisors were selected as  

abutment teeth for the single retainers.  

Figures 4 and 5 show the preoperative  

intraoral situation without the retainer in  

place. During the preparation appointment, a 0.6-mm reduction of the lingual  

surfaces of the maxillary central incisors was carried out using a tapered  

chamfer diamond bur (no. 856-016,  

Brasseler). A slight interproximal elbow  

preparation was completed to counter  

dislodging forces and increase frame 

work connector strength. Finally, a small  

indentation was placed in the center  

of the lingual fossa preparation to facilitate exact three-dimensional seating  

of the framework (Fig 6).

                           ( figure 2)                                                                (figure 3)

                           ( figure 4)                                                                (figure 5)

 (figure 6)

Final impressions were made using a vinyl polysiloxane (VPS) putty in a full-arch stock  

impression tray and a light-body wash  

material syringed onto the prepared  

teeth (Aquasil Easy Mix putty, Aquasil  

Ultra LV). An opposing cast impression  

was also made with VPS putty, and interocclusal records were taken using  

Regisil 2X (Dentsply).  

Master casts and opposing casts  

were fabricated in the dental laboratory, mounted, and scanned. The frameworks were designed on the computer  

(Figs 7 and 8) and milled from zirconia  

ceramic. A small, extra wing was fabricated on each framework to facilitate  

correct placement during try-in (Fig 9).  

These wings would later be removed.  

The frameworks were designed to provide optimal support for the veneering  

porcelain (Fig 10). 

                           ( figure 7)                                                                (figure 8)

                           ( figure 9                                                                (figure 10)

A try-in visit was scheduled to verify  

the path of draw, fit, and margins of the  

frameworks. Three-dimensional seating of the wings was confirmed, assisted by the small indentations prepared  

in the lingual fossa areas. The final  

shade was selected. In the laboratory,  

master casts were slightly trimmed in 

the edentulous ridge areas to accommodate ovate pontics and optimize the  

soft tissue architecture and esthetics.  

External layers of feldspathic veneering porcelain were fired onto the frameworks, matching the characteristics of  

the adjacent natural teeth (eg, enamel  

hypoplasia and stains) (Fig 11). The  

definitive restorations can be seen in  

Fig 12. 

                           ( figure 11)                                                                (figure 12)

The definitive CRBFPDs were tried  

in to verify the fit, pontic relief, and esthetics. A small lateral incision (approximately 3 mm wide and 1.5 mm deep)  

was placed in the alveolar crest area  

of the maxillary lateral incisors with an  

electrosurgical unit to decrease tension  

of the soft tissue and allow for intimate  

seating of the ovate pontic. The intaglio surfaces of  the frameworks were  

then cleaned in an ultrasonic bath with  

alcohol. The bonding surfaces of the  

retainer wings were airborne-particle  

abraded with 30-μm aluminum oxide  

particles at a pressure of 1.5 bar for  

5 seconds at a distance of 1 cm. Care  

was taken to protect the feldspathic  

veneering porcelain during this procedure. Next, Clearfil Ceramic Primer  

(Kuraray) was applied in a thin layer

(Fig 13) and left to air dry. The adherent  

surfaces of the maxillary central incisors  

were cleaned with pumice and rinsed.  

The area was isolated and prepared for  

final cementation with Panavia 21 TC  

(Kuraray). For better control, the two  

FPDs were bonded independently, one  

after the other. The enamel bonding surfaces were acid etched with 40% phosphoric acid (K-Etchant gel, Kuraray) for  

30 seconds. After thorough rinsing and  

drying, self-etching ED Primer (Kuraray)  

was applied and lightly dried. Each  

restoration was placed in position, and  

excess cement was removed from the  

margins with microbrushes. Oxyguard II  

(Kuraray) was applied onto the marginal areas and sprayed off after complete  

polymerization of the composite resin  

luting agent.

 (figure 13)

Any excess cement still remaining  

was removed with an explorer and a  

sharp scaler. Occlusion was confirmed  

in maximum intercuspation, protrusion,  

and lateral excursions. Proper management of the occlusion of the pontic is crucial for the long-term success  

of cantilever prostheses. If eccentric  

contact remains on the pontic, the  

potential risks include loosening of  

the restoration, migration of the abutment, and fracture.33,34 

Therefore, all 

contacts in protrusive and excursive  

movements were removed from the  

cantilever. Any adjusted ceramic surfaces were polished (Dialite Polishing  

Kit, Brasseler). Mamelons on the mandibular lateral incisors were smoothed  

flat using polishing disks (Super Snap,  

Shofu). Alginate impressions were  

made from each arch, and an occlusal  

guard was fabricated for the patient 

to wear at night. All esthetic and functional parameters were verified during  

the subsequent follow-up visits, which  

were initially scheduled at 1 week,  

4 weeks, 8 weeks, and 6 months and  

then at 6-month intervals thereafter. 

CONCLUSIONS 

Zirconia-based cantilever resin-bonded  

fixed partial dentures provide a viable  

treatment option for missing lateral incisors in select cases. These restorations  

are cost effective and require few treatment steps. Specific design and clinical handling protocols must be followed  

to achieve long-term clinical success.  

Further clinical trials are necessary to  

confirm the already promising results  

of these restorations.

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One-stage Surgical Alveolar Augmentation (PAOO) For Rapid Orthodontic Movement

Introduction

An increasing number of adult patients have  been seeking orthodontic treatment, and a  short treatment time has been a recurring  request. As result a number of surgical  techniques have been developed because the  surgical injury of the cortical bone adjacent  to the area of desired tooth movement has  been reported to initiate biochemical changes leading to rapid tooth movement[1]. Wilcko et al. introduced surgical  orthodontic therapy which included the  innovative strategy of combining  corticotomy surgery with alveolar grafting  in a technique referred to as Accelerated  Osteogenic Orthodontics (AOO) and more  recently to as Periodontally Accelerated  Osteogenic Orthodontics (PAOO)[2-5].  Significant acceleration in orthodontic tooth  movement has been extensively reported  following a combination of selective  alveolar decortication and bone grafting  surgery, with the latter being responsible for  the increased scope of tooth movement and  the long-term improvement of the  periodontium. This conventional  corticotomy approach consists of raising  full-thickness flaps and using a bur to create  cortical incisions. Then an allograft is placed at the sites needing the bone  expansion necessary for proper orthodontic  tooth movement. This intentional injury to the cortical bone results in a modification of  the bone metabolism, leading to a transient  state of osteopenia, described as rapid  acceleratory phenomenon (RAP). RAP was  demonstrated at the alveolar bone level  following corticotomy and would be  responsible for rapid tooth movement.

Case Description

A 24-year-old male was referred to  orthodontic consultation for deep bite and  retro-positioned lower incisors which were  not allowing maintenance of oral hygiene in  the lingual aspect of the lower incisors and  attrition of the lower incisors. He strongly expressed the demand for a rapid  completion of her treatment, citing  professional and personal reasons. His  dental history included regular dental visits  and complete oral prophylaxsis. Extraoral and intraoral examination  The patient showed a symmetrical face and a  normal soft tissue profile with normal  vertical facial height (Figure1). The temporomandibular joints were within  normal limits. The lips were competent at rest with adequate vermillion display. Patient  presented with a class I molar and canine relationship. The incisors presented  with relationship similar to that of seen class  II division 2 relationship. The overjet was  0mm, and the overbite was ~100% of lower  incisor coverage.When smiling, he  exhibited 100% of maxillary incisal display.

 (Figure1)

The maxillary dental midline was  coincident with the facial midline and  maxillomandibular midlines were  concordant (Figure 2-4).

                      (Figure 2)                                 (Figure 3)                                       (Figure 4) 

The maxillary and mandibular arch forms  were U-shaped maxillary arch had 3mm of  crowding while mandibular arch presented  6 mm of crowding with few rotated teeth   (Figure 5).

 

(Figure 5)

The curve of Spee was 3 mm, and the  periodontium was healthy.   From a skeletal standpoint, he had a class I  pattern with normal lengths maxilla and  mandible, a hypodivergent mandible,  reduced lower anterior facial height and  retroclined upper and lower incisors.

Treatment Objectives

The goal of the treatment was to resolve the  crowding in both arches, open the bite, to  correct the incisor relations and maintain  class I dental relationship that would be  pleasing to the patient and decrease treatment duration. The patient was offered  the conventional orthodontic treatment as  well as an innovative treatment combining  comprehensive orthodontic care with  periodontal surgery (PAOO) to accelerate  tooth movement. In this procedure, a bone  graft was also planned in the area where  expansion was needed to expand the bony  envelop in the direction of tooth movement  and increase periodontal support to improve  long-term stability in areas where relapse  commonly occurs following orthodontic  expansion. Because the patient sought a  short treatment time, the orthodontic  treatment coupled with PAOO was chosen.

Surgical Technique

The fixed orthodontic appliance (Gemini 22  slot brackets, MBT prescription, 3M) was  placed with standard technique onto the  upper arch only, consisting of second  premolar to second premolar brackets and  bands with buccal tubes on 1st molars.  Alignment and leveling was initiated with  round NiTi wires. The surgery was  performed 2 week following placement of  the fixed orthodontic appliance. On the day of surgery, orthodontic archwire  was removed and patient was asked to  perform mouth-brushing. 2grams of  amoxicillin was taken by the patient 30  minutes prior to the surgery. On the dental  chair chlorhexidine mouthwash was  performed by the patient. After local  anesthesia, full thickness buccal flap was  raised from mesial of 15 to mesial of 25 with  crevicular incisons maintaining the  interdental papillae. Vertical release  incisions were performed inter-proximally  between 14-15 & 24-25 (Figure 6).

 (Figure 6)

Bony prominences on the canine roots were  leveled with help of straight diamond burrs.  Corticotomy was done on the exposed bone  surface with help of round diamond burrs  mounted on a reduction mircomotor handpiece under copious amount of irrigation  (Figure 7). Flaps were positioned and sutured with silk 

sutures (Figure 8).

 (Figure 7)

(Figure 8)

Orthodontic archwire was secured back into  the brackets. Patient was instructed to apply local cold  fomentation intermittently for first 12 hours  after the surgery.  He was also instructed to  only take cold diet for 24 hours. Amoxicillin  coverage was to continue for 3 more days.  Rigorous brushing in the area of surgery was  advised against for the 1st week. Check up  was scheduled for the next day.

Treatment Progress 

The patient reported using only two tablets  of the NSAID after surgery. No swelling,  bruising, or severe discomfort was  associated with this procedure. The patient  could resume oral physiotherapy 24 hours  after the surgery. The periodontal healing  was optimum with minimal to no scarring at  2 weeks.  During the first 6 to 10 weeks of orthodontic  treatment, the maxillary arch was fully  leveled and aligned using increasing size of  nickel titanium alloy wires (0.014, 0.016,  0.018, 0.016 x 0.022). Bite opening and arch  expansion was achieved with reverse curved  stainless steel wire and stoppard steel wire. In the following six weeks  adequate  maxillary arch expansion and bite opening  was achieved so as to allow the bonding of  the mandibular arch. 2 weeks following the  bonding of the mandibular arch corticotomy  surgery was planned and executed in a  manner similar to that of the maxillary arch.  The only differences was that the  mandibular archwire was not removed from  the bracket as there ease of excess to the  anterior alveolus (Figure9-12)

  (Figure 9)               (Figure 10)                 (Figure 11)                 (Figure 12)

During the course of treatment (figure 13),

 

(figure 13)

a sharp increase in tooth mobility was  observed, resulting from the transient  osteopenia induced by the surgery. Also  important to emphasize is that higher forces  are applied to the teeth as compared with  conventional orthodontic treatment to  maintain mechanical stimulation of the  alveolar bone and the osteopenic state,  allowing for rapid treatment.

Treatment Results

After 26 weeks of active treatment,  sequential de-bonding was performed. The  brackets on the premolars were removed to  allow them settle into occlusion. 4 weeks  later complete appliance was removed and a  fixed lingual retainer was inserted from  premolar to premolar on both arches. To  maintain the bite,   circumferential retainer  with anterior bite plane was given to the  patient to be worn 24 hours (figure 14-17).

 (figure 14)                                      (figure 15)                                           (figure 16)

(figure 17)

Conclusions

PAOO is an innovative, technique to achieve  rapid orthodontic tooth movement. This  novel technique also allows the possibility  for hard- and/or soft-tissue augmentation,  leading to an enhanced periodontium and an 

increased scope of tooth movement. PAOO  proves to be efficient from both the patients'  and clinicians' standpoints and offers the  advantages that should lead to greater  acceptance in the dental community.

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References: 

1. Bogoch E, Gschwend N, Rahn B, et al.  

Healing of cancellous bone osteotomy in 

rabbits-part I: regulation of bone volume 

and the regional acceleratory 

phenomenon in normal bone. J Orthop 

Res. 1993;11(2):285-291.

2. Wilcko, M.T., Wilko, W.M., Bissada, 

N.F., 2008. An evidence-based analysis 

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Orthod. 14: 305-316.

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J.E., Wilcko, M.T., 2003. Rapid 

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J.E., Ferguson, OJ., 2000. Accelerated 

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