Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2014  |  Volume : 32  |  Issue : 2  |  Page : 172--175

Maturogenesis by revascularization in an infected immature permanent tooth


Vanka Amit1, Ankur Jain2, Ullal Anand Nayak3, Manohar Bhat4,  
1 Department of Pedodontics, Ibn Sina National Medical College, Jeddah, Kingdom of Saudi Arabia
2 Department of Pedodontics and Preventive Dentistry, People's Dental Academy, Bhopal, Madhya Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Rajasthan Dental College, Jaipur, Rajasthan, India
4 Department of Pedodontics and Preventive Dentistry, Jaipur Dental College, Jaipur, Rajasthan, India

Correspondence Address:
Vanka Amit
Department of Pedodontics, Ibn Sina National Medical College, Jeddah, Kingdom of Saudi Arabia

Abstract

Root canal treatment in teeth with incomplete root formation is a challenge. A case of maturogenesis in an immature infected tooth along with probable factors needed for success is discussed. Although clinical and radiographic evidence points to healing and root development, the long-term prognosis and the behavior of tissue occupying the canal space needs further investigation before the procedure can be adopted into routine clinical practice.



How to cite this article:
Amit V, Jain A, Nayak UA, Bhat M. Maturogenesis by revascularization in an infected immature permanent tooth.J Indian Soc Pedod Prev Dent 2014;32:172-175


How to cite this URL:
Amit V, Jain A, Nayak UA, Bhat M. Maturogenesis by revascularization in an infected immature permanent tooth. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Nov 22 ];32:172-175
Available from: http://www.jisppd.com/text.asp?2014/32/2/172/130992


Full Text

 Introduction



While a young permanent tooth with a wide apical foramen may sometimes recover from a traumatic injury by re-establishing blood flow, severe impact destroys the pulp vessels at the apical foramen and leads to pulp necrosis. [1] When teeth with incomplete root formation suffer pulp necrosis, the root development ceases and apical closure cannot be achieved. Root canal treatment at this time is a significant challenge; due to the size of the canal, the thin and fragile dentin walls and the large open apex. [2] Traditionally such cases have been treated with prolonged calcium hydroxide to induce the formation of hard tissue barrier. [3] Several studies have also researched mineral trioxide aggregate (MTA) and suggested that its placement as an apical plug is a predictable and reproducible clinical procedure. [2],[4]

As early as 1961, in a series of experimental investigations in dogs and human beings it was found that tissue formations could take place in the absence of pulp if the empty canal was filled with only blood from the periapical area. [5] It has also been shown that under certain conditions revascularization occurs in young teeth that have been traumatically avulsed, leaving a necrotic but uninfected pulp. [6] Presented here is a case of maturogenesis of the root inspite of presence of periapical infection.

 Case Report



The case we presented here is about a 10-year-old Indian girl who reported to the Department of Pedodontics and Preventive Dentistry with pain in the lower right back tooth region. The medical history was non-contributory. The mandibular first premolar (tooth no. 44) was found to be tender on percussion, with slightly increased mobility and pain on palpation in the associated gingiva. History of laceration of lip and subsequent "pain in the tooth for a few days after falling from bicycle 2 years back" was the only history elicited. The tooth did not respond to the electric pulp test. Radiographically, the premolar had diffuse periapical radiolucency, with widened periodontal ligament (PDL) space and incomplete root formation [Figure 1]a. The occlusal and proximal surfaces of the tooth were intact with no carious lesions diagnosed either clinically or radiographically. No signs of vertical fracture or presence of occlusal tubercle were found. With the diagnosis of a periapical abscess being made, endodontic treatment was initiated. In the first appointment emergency access opening was made without local anesthesia to establish drainage. The canal was explored to assess the presence of remnants of pulp tissue in the canal. Frank pus was encountered with no sensation even when instrumented slightly beyond working length. Access cavity was followed by gentle irrigation with 5.25% hypochlorite then 17% ethylenediaminetetraacetic acid (EDTA) followed by saline. The width of apex was wide enough to allow size 80 k file to freely pass into the periapical area. After drying canals with paper points, creamy mix of 1:1:1 ciprofloxacin (Ranbaxy laboratories) Metronidazole (Nicholas Piramal, India) and cefaclor (Ranbaxy laboratories) paste with sterile water was introduced into the canal using lentulospiral (Dentsply Maillefer) mounted on reduction gear handpiece until the level of cementoenamel junction (CEJ) followed by temporization by cavit.

At the next appointment 3 weeks later, anesthesia was achieved using 2% lignocaine without vasoconstrictor. The antibiotic paste was irrigated out using copious irrigation with saline. After drying with paper points, bleeding was induced into the canal using a sterile 20 size K-file that allowed for free passage into the periapical region without touching the walls of apical foramen. The bleeding was controlled using sterile cotton pellet just below the CEJ [Figure 2]a. Grey MTA (Angelus) was carefully placed above the blood clot up to the level of the CEJ [Figure 2]b. The access was sealed with a moist cotton pellet and cavit. At 2 days later, cavit was replaced with composite resin restoration (Z250 Filtek; 3M ESPE).

During the 18 months follow-up, the patient remained asymptomatic. The tooth responded negatively to the pulp tests at all the visits. Nevertheless, the radiographs demonstrated evidence of periradicular bone healing, partial regeneration of PDL space and root development when compared with pre-operative radiographs [Figure 1]b and c.{Figure 1}{Figure 2}

 Discussion



Treatment of immature pulpless teeth has always presented an enigma to the clinician. Surgical endodontic procedure to seal the wide-open blunderbuss apical opening has several disadvantages such as compromised crown root ratio in an immature tooth and failure to achieve cooperation, particularly in a child.

Prolonged contact with calcium hydroxide leads to a significant decrease in the intrinsic properties of exposed dentin, which when coupled with repeated use of root canal irrigants such as sodium hypochlorite, results in further weakening of the dentin and renders the tooth more prone to fractures. [7]

While MTA does overcome some of the problems associated with calcium hydroxide, including reinforcing the thin walls on the apical portion, it is incapable of increasing thickness of dentin. Continued physiological root development (a process also termed as maturogenesis) and not just closure of root apex (apexogenesis) [8] along with thickening of the root canal walls are the greatest advantages revascularization of pulp offers. In the presented case, root development was significant, but the thickening of root canals was lacking, a finding consistent with some of the responses observed in a previous case series. [9]

Disinfection of the canal has been described as the key factor to create an environment conducive to revascularization. [10] The use of irrigants such as chlorhexidine in higher concentration may affect the viability of the cells involved in the regenerative process and hence was not used in the presented case. The use of EDTA is thought to remove the smear layer and encourage habitation of root canal walls by viable cells. [11]

While some cases have used calcium hydroxide as intracanal medicaments, [12] several others have used a combination of ciprofloxacin, metronidazole and minocycline. [13],[14] With reports suggesting tooth discoloration is associated with the use of minocycline in the presented case it was replaced with cefaclor. Besides being effective, no discoloration of the tooth was observed. [15]

The presence of a suitable scaffold is one of the prerequisites of regenerative procedures. The blood clot induced during this procedure constitutes a fibrin pathway for migration of cells. [16] The process of inducing bleeding by manipulation of perapical tissues is associated with delivery of mesenchymal stem cells into the root canal systems, at higher levels than those in the systemic blood. [16] Thus, a niche for these stem cells appears to be present in the apical papilla region and the cells have been termed as stem cells from apical papilla. However, prolonged infection may eventually lead to a total necrosis of the pulp and apical papilla. [17] Maturogenesis would then be unlikely thus at least partially explaining some of the failures associated with the procedure. In vitro results show that MTA helps in proliferation and migration of human mesenchymal stem cells, enhancing the process of tissue growth in the canal. [18]

The size of the apical opening has been described as another deciding factor [19] with successful revascularization being associated with 1 mm or more mesiodistal width, as was demonstrated from the presented case. Lesser width can hamper the in growth of vital tissue leading to failure. It is also important to use local anesthetic without vasoconstrictor, while inducing bleeding, to promote the flow of blood into the canal. [20]

During the follow-up period, the tooth showed no response to the sensitivity cold and electric tests. The absence of a positive response could be because the tissue that invaginated into the canal space was probably not innervated [21] or may not be pulp tissue in the proper sense. The nature of tissue occupying the pulp space has been a matter of speculation. It has generally been described as a cell rich, well vascularized connective tissue and an extension from the periapical tissue. [22] The nature of hard tissue deposited has also been described to be intracanal cementum (IC), dentin-associated mineralized tissue and bony islands. The IC may also form a bridge at the apex, in the apical third or mid third of the canal. [23] Thus, it appears to be imperative that further research be directed towards factors that determine the lineage these mesenchymal stem cells get differentiated into. While it is desirable that these stem cells differentiate into odontoblasts and hence lay down dentin, in vivo reports have not provided precise information about a hard tissue with the classical pulp-odontoblast-dentin relationship. [24]

 Conclusion



Revascularization leading to maturogenesis is possible. While root development and hard tissue deposition takes place, the predictability of the procedure, the type of differentiation stem cells undergo and the eventual type of hard tissue laid down is still not clear. The long-term effects of this procedure require a thorough evaluation before it can be recommended as part of routine treatment modality in immature pulpless teeth.

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