Lupine Publishers | Management of Internal Root Resorption with Bioceramic Material on Permanent Tooth-A Case Report

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Internal root resorption (IRR) is a category of pulp disease characterized by the loss of dentine as a result of the action of clastic cells stimulated by pulpal inflammation. The objective of this case report was to account for the diagnosis and management of an internal root resorption without perforation. The patient, a 26-year-old male, came to Guru Nanak Institute of Dental Sciences and Research, West Bengal, without having symptoms in the tooth. Endodontic treatment was performed using the following methods: irrigation of the root canal with 2.5% of sodium hypochlorite, then calcium hydroxide (CH) was applied as intracanal medicament for one month. Complete instrumentation was done with Hyflex One File (Coltene) and obturation with corresponding guta-percha and Roeko Guttaflow Bio seal sealer (Coltene). The patient was checked after one week and then after six months. He did not have any symptoms and IOPA radiograph did not show any further progression of the lesion.

Keywords:Internal Root Resorption; Calcium Hydroxide (CH); Sodium Hypochlorite; MTA

Introduction

The Glossary of the American Association of Endodontists defines internal root resorption (IRR) as a condition associated with a physiological or pathological process that results in the loss of dentin, cement and bone [1]. Most teeth with internal root resorption are symptom free and are first clinically recognized through routine radiographs. However, when resorption actively progresses, the tooth is only partially vital and may present typical symptoms of pulpitis. Bell (1830) first reported about IRR. Mummery (1920) called it “pink tooth of Mummery” due to the presence of pink discoloration on the crown [2]. This condition, although rare, is more frequent in the male population. The IRR is more common in the presence of a periapical lesion. Its prevalence was estimated between 0.01% and 1% depending on the inflammatory condition of the pulp [3]. The IRR could be caused by several stimuli: trauma, chronic inflammation of pulp/periodontal ligament, heat created by the friction of drills during the preparation of cavities, cracked tooth syndrome, tooth reimplantation and orthodontic treatment [4]. There have also been reported cases of internal reabsorption caused by Herpes Zoster virus [5]. The IRR is caused by inflammatory stimuli which produce an alteration of the odontoclast inhibitory mechanism resulting in an alteration of the pre-dentine layer. The vascular change in the pulp produces hyperemia increasing oxygen tension and causing an acidic pH level that attracts multinucleated cells, odontoclasts and dentin clasts. Dominance of inhibitory substances such as OPG (osteoprotegerin) as activators of RANKL (receptor activator of factor kappa B ligand) followed by swelling, results in the rupture of protective coatings allowing the invasion of odontoclasts and initiating resorptive patterns. Connective, post-resorptive activity tissue transforms into metaplastic granulation tissue [6]. Generally, IRR detection is done by X-rays, however, the use of cone beams computed tomography (CBCT) has been reported to be highly useful for diagnosis in endodontics, since it shows the lesion in detail and includes information about adjacent anatomy, which X-rays does not provide [7]. The periapical radiography is limited because it provides a twodimensional image [8], whereas diagnosis by CBCT shows images in all their dimensions through tomographic slices, without image overlay [9]. Also, diagnosis by CBCT may improve the accuracy and efficiency in the prognosis of the tooth [10]. Therapeutically, the biomaterial employed can influence the prognosis of the nonsurgical endodontic treatment done for extensive internal root resorption [11]. MTA is most commonly used in these cases because of its sealing ability, biocompatibility and potential induction of osteogenesis and cement genesis and it can be used in a humid environment [12]. Another study using an experimental immature tooth model, demonstrated that the MTA also increased the fracture resistance of bovine incisors when submitted to different reinforcement treatments Recently bioceramics are widely used in endodontics. Roeko Guttaflow Bio seal (COLTENE) is a bioceramic endodontic sealer which claims to avoid shrinkage upon setting as it has Zirconium oxide is used as the radiopacifier, and the material is claimed to be aluminum-free, non-soluble and does not shrink during setting. It gives advantage of flow of material as well as sealing ability which better bond with the corresponding gutta percha used for obturation [13]. The purpose of this case report is to describe the diagnosis and clinical management of an internal root resorption with bioceramic material.

Case Report

Male patient, 26 years old, treated at the post graduate department in Guru Nanak Institute of Dental Sciences and Research. The patient reported no pain at the time of appointment the chief complaint was discoloration of the front tooth which was traumatized 5 year back. Vitality tests using Endo-Ice (Coltene, Switzerland) were performed in [11]; the tooth gave negative response. The patient did not present tooth mobility and periodontal pockets. IOPA radiograph of the affected tooth#11 showed an oval enlargement (ballooning out) of the root canal space (Figure 1). The pulp chamber and canal cannot be followed throughout the lesion. Radiograph performed at different angulation to confirm the resorptive lacunae is a continuation of the distorted border of the root canal. Endodontic treatment was suggested; therefore, isolation protocol was performed to make the cavity opening later (Figure 2). Working length of the tooth was determined by IOPA radiograph using #15K file (Figure 3) and the result was confirmed with apex locator Canal Pro (COLTENE). After removing the pulp tissue properly chemical-mechanical instrumentation was performed with Hyflex One File (COLTENE) and irrigation was done with 1ml of 2.5% of sodium hypochlorite between each time instrumentation with 30-gauge side vented needle. This was followed by irrigation with normal saline to remove any remnants of hypochlorite, later canal was dried with absorbent points. Ca (OH)2 dressing was given for 1month and the medicament was changed weekly. After one month, temporary restoration was removed with [4] round diamond bur, canal was irrigated with 5 mL of 2.5% sodium hypochlorite (NaOCl) and 5 mL of 17% of ethylenediaminetetraacetic acid for removing the Ca (OH) dressing and then the canal was flushed with normal saline and dried.

Figure 1: .

Figure 2:

Figure 3:

Figure 4:

Figure 5: .

After removing the medication, obturation was done with Hyflex corresponding Gutta Percha and the remaining pulp chamber was obturated with Guttaflow Bio seal sealer (Figure 4). Access cavity restoration was done with light cure composite resin. The patient was recalled after 6 and 12 months (Figure 5, 6) for clinical and radiographic follow up. Clinical examination of tooth was functional without sensitivity to percussion or palpation [11].

Figure 6: .

Discussion

There is always a dilemma of whether to treat a tooth with a questionable prognosis endodontically or extract it and subsequently place an implant. Bell first reported a case on internal resorption in 1830. Since then there have been numerous reports in the literature [14]. Two types of internal root resorption are generally described: the internal root canal inflammatory resorption and the internal root canal replacement resorption. In the inflammatory resorption, the resorptive process of the intraradicular dentin progresses without adjunctive deposition of hard tissues adjacent to the resorptive sites. The phenomenon is associated with the presence of granulation tissues in the resorbed area and identifiable with routine radiographs as are radiolucent zone centered on the root canal. In the replacement resorption, the resorptive activity cause defects in the dentin adjacent to the root canal, with concomitant deposition of bone like tissue in some regions of the defect. It results in an irregular enlargement of the pulp space with partially or fully obliterated area of the pulp chamber. Internal resorption is the result of an inflamed pulp and the clastic precursor cells recruiting through the blood vessels. Treatment of internal resorption is quite predictable as it is easy to control the process of internal root resorption via severing the blood supply to the resorbing tissues with conventional root canal therapy. Intraoral X-ray of IRR is characterized by the radiographic appearance of an oval shape enlargement within the pulp chamber or the root canal. However, the early diagnosis of the IRR is difficult by examination of a conventional X-ray. If IRR is suspected, several shots under different angles of incidence are recommended. In the treatment of internal resorption, the use of calcium hydroxide also has two other important goals: to control bleeding, and to necrotize residual pulp tissue and to make the necrotic tissue more soluble to sodium hypochlorite. Because of the limited access by instruments to all areas of the resorption cavity, chemical means are needed to completely clean the canal. Studies on the effectiveness of sodium hypochlorite and calcium hydroxide to remove the resorptive and other tissues from the root canal indicate that they have an additive or even synergistic effect [15]. In cases where the resorption has not perforated, it is usually enough to use calcium hydroxide paste in the canal once from 1 to 2 weeks. This allows removal of the residual tissue at the next appointment by irrigation and instrumentation. In our treatment protocol, we choose Guttaflow Bio seal (COLTENE) sealer due to its versatile property of Bioceramic component & gutta-percha particles. Upon contact with fluids, this material provides natural repair constituents, such as silicates and calcium, which contribute to the activation of biochemical processes, providing additional support to the root canal regeneration. A novel material for root canal filling that combines gutta-percha in a powder form with a particle size of less than 30 μm and a sealer. The sealer has also showed least cytotoxicity as well as inflammatory reaction [15].

Conclusion

It is puzzling in diagnosing and treating a root resorption case, therefore a suitable management is perilous. Thorough investigations and discussion are required for the management especially when the prognosis of the tooth is poor upon consultation. Absence of periapical lesion and no signs and symptoms at the 12-months review provided a favorable outcome to once a tooth of hopeless prognosis.

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Lupine Publishers | Management of Mesiodens In Mixed Dentition- Molariform and Tuberculate: A Case Report

  Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Timely intervention is the key to any setback in the mixed dentition. Teeth which are supplemental to the normal dentition are supernumeraries, the most common being mesiodens, present in the premaxillary region. Certain pathological consequences may arise due to mesiodens like unaesthetic midline diastema, rotation, displacement, root resorption and cyst formation. The current case report presents the management of developing malocclusion in the anterior region due to the presence of mesiodentes- a molariform and a tuberculate. The molariform mesiodens was impeding the eruption of the maxillary right central incisor, thus the surgical removal of both mesiodentes was planned and executed. In addition to this soft tissue uncovering was done for the unerupted maxillary central incisor. On follow up, uneventful healing was observed successfully.

Keywords:Mesiodens; Mesiodentes; Mixed Dentition; Molariform; Tuberculate

Introduction

Supernumerary teeth, or hyperdontia, is a term that describes teeth that are surplus in number when compared to the normal complement of teeth [1]. The etiology of supernumerary teeth remains unclear and not yet completely understood [2]. Among the various proposed theories that have attempted to explain the causes behind the development of supernumerary teeth, current literature favors the ‘lamina hyperactivity theory’ that states hyperdontia results from independent, locally conditioned hyperactivity of the dental lamina [1]. The most commonly occurring supernumerary tooth is the ‘mesiodens’, a term that was initially coined by Balk in 1917. As the name suggests, the mesiodens is usually located mesial to the central incisors in the premaxillary region [3]. With a frequency of prevalence between 0.15-3% in the permanent dentition and 0.02-1.9% in the primary dentition, it may occur as single or multiple, unilateral or bilateral, may be erupted or impacted and frequently found in conjection with cleft lip and palate and syndromes like Cleidocranial dysostosis, Gardner’s syndrome, Ellis-Van Creveld syndrome, Ehlers- Danlos syndrome, Incontinentia Pigmenti, and Tricia-Rhino- Phalangeal syndrome [4,5]. Also, mesiodentes may vary in shape from simple conical form to a larger, more complicated crown shape with several tubercles [6]. The dysfunctional nature of mesiodens is known to cause a variety of clinical complications such as being unaesthetic, pathological disturbances in the normal eruption and positions of adjacent teeth, altered growth and development in the area, retention of primary teeth, odontogenic cysts, caries, pulp necrosis of the adjacent teeth, dilaceration of developing tooth, nasal teeth, gingival and periodontal problems [2,7]. Accordingly, their early diagnosis and management is vital to waive off complications of such kind.

Case Report

A 9-year old female patient reported to the department of Pedodontics and Preventive Dentistry with the complaint of irregularly placed upper front teeth and wanted it to be corrected. The patient was normal and healthy with non-contributory medical and dental histories. The extra oral examination did not reveal any abnormalities. Intraoral examination revealed a Class I mixed dentition with a missing upper right central incisor and an erupted molariform mesiodens in its place. In addition, there was a firm bulge palpable in the upper right central incisor area which suggests the impediment in the path of eruption of the central incisor by the erupted mesiodens (Figure 1). An occlusal radiograph was taken to rule out the possibility of multiple supernumerary teeth and surprisingly another unerupted and impacted inverted mesiodens with an incomplete root was found mesial to the upper left central incisor (Figure 2). The SLOB technique confirmed that the impacted mesiodens was present palatially. Both informed and written consent was obtained from the parents before initiating the treatment. We decided to extract both mesiodentes under local anesthesia. The erupted mesiodens was extracted by intra- alveolar extraction. The impacted mesiodens was surgically removed by raising a mucoperiosteal flap from maxillary first premolar to contralateral first premolar (Figure 3). Rotary cutting instruments with simultaneous irrigation were used for removing enough bone around the impacted mesiodens for its easy retrieval. Soft tissue uncovering was done for the unerupted right central incisor by placing an elliptical incision over the incisal portion of the palpable bulge (Figure 4). The extraction socket was checked for any pathological tissue and the flap was relocated and sutured with interrupted sutures (Figure 5). The patient was recalled after a week for suture removal and followed-up after 3 months. Uneventful healing with no associated symptoms was observed.

Figure 1: Preoperative view showing erupted molariform mesiodens along with unerupted maxillary central incisor.

Figure 2: Occlusal radiograph showing unerupted and impacted inverted mesiodens with an incomplete root.

Figure 3: Surgical removal of impacted mesiodens by raising a mucoperiosteal flap from maxillary first premolar to contralateral first premolar.

Figure 4: Soft tissue uncovering for the unerupted right central incisor by placing an elliptical incision over the incisal portion of the palpable bulge.

Figure 5: Interrupted sutures placed.

Discussion

The realm of pediatric dentistry incorporates the practice of interceptive orthodontics, thereby bestowing upon the pediatric dentist, opportunities of providing timely guidance in the development of occlusion. The current case report presents the management of developing malocclusion in the anterior region due to the presence of mesiodens. A mesiodens occurring in the primary dentition is a rarity even though, it being the most common dental abnormality in the permanent dentition [8]. Most cases of mesiodens are discovered during the first decade as maxillary central incisors are erupting and radiographic examinations are performed as an aid to screening for any other malformations and abnormalities [1]. Various theories regarding the etiology of mesiodens have been reported in the literature but the subject remains controversial [3]. Heredity has been suggested to be an etiologic factor based on the observation that supernumeraries are more common in family members; however, it does not follow a simple Mendelian pattern [9]. It was originally postulated that the mesiodens represented a phylogenetic relic of the extinct ancestors who had three central incisors. This is known as phylogenetic theory reversion (atavism) which has now been discarded by the embryologists [10]. The dichotomy theory states that, a mesiodens arises due to the splitting of the tooth bud. On the contrary, Taylor argued that splitting of the tooth bud may either form two equal sized teeth or one normal and one dysmorphic tooth [8]. The hyperactivity theory states that development of mesiodens is due to the hyperactivity of the dental lamina. The ‘field model’, proposes that a tooth bud which is forming at a given location develops according to its position within the field, further determining its shape. The ‘clone model’ postulates that that each tooth class is derived from a clone of ectomesenchymal cells which are programmed by epithelium to produce teeth of a given pattern. Depending upon the specific factors expressed from these ectomesenchymal cells, the shape of the accessory tooth germ forms in the vicinity of the incisors class of teeth becomes evident at the bell stage [11]. This case report presented with an erupted molariform mesiodens and an unerupted tuberculate mesiodens with an undeveloped root (Figure 6). Since the molariform mesiodens was impeding the eruption of the maxillary right central incisor, the surgical removal of both mesiodentes was planned and executed. Timing of interceptive treatment should be as soon as possible following clinical detection of an abnormal eruption pattern. It has been suggested that a tooth delayed in its eruption by more than six months with respect to its antimere should be radiographically investigated. Hogstrum and Andersson [12] suggested two alternatives exist.

The first option involves removal of the supernumerary as soon as it has been diagnosed. This could lead to an unpleasant experience that may have a psychological effect on a very young child and has been said to cause devitalization or deformation of adjacent teeth. Secondly, the supernumerary could be left until root development of the adjacent teeth is complete. The potential disadvantages associated with this deferred surgical plan include; loss of eruptive force of adjacent teeth, loss of space and crowding of the affected arch, and possible midline shifts. In the present case, since the roots of the adjacent teeth were completely formed and the child was at an age where she could sustain a surgical procedure, the surgery was undertaken with utmost attention to detail and caution. Access to mesiodens during surgery must dealt carefully considering the quantity of bone amputation and the possible damage to the adjacent teeth [7]. Follow up is indispensable in such cases since the eruption status should be monitored. The patient revealed satisfactory healing and suitable eruption of the maxillary central incisor. Pediatric dentists are the firsts to usually identify developing malocclusions and thus it is their responsibility to intervene and intercept in an apt manner to prevent future unfavorable sequalae.

Figure 6: Molariform and tuberculate mesiodens.

Acknowledgements

Authors are thankful to their colleagues and faculty.

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