Different techniques for the treatment of teeth with an incomplete root development and pulp necrosis: a systematic review / Diferentes técnicas para o tratamento de dentes com rizogênese incompleta e necrose pulpar: uma revisão sistemática

Introduction: The objective of this systematic review was to compare the apexification techniques of calcium hydroxide (Ca(OH)2), or mineral trioxide aggregate (MTA), with the pulp regeneration technique, using cohort studies, and non-randomized and randomized clinical trials. Methods: The methodology was based on electronic research in the following databases: PubMed, MEDLINE, Google Scholar, SciELO, and LILACS. In addition, a manual search was carried out using the references that were listed in the articles found. Results: A total of 403 potentially eligible studies were found, with seven being included in the inclusion criteria of this systematic review. The seven studies involved a total of 312 teeth. The minimum time of a follow-up period was 12 months. The irrigation solution most used was sodium hypochlorite, for both of the apexification and revascularization techniques. The medication commonly chosen in the apexification groups was Ca(OH)2, with antibiotic triple paste in the revascularization groups. The clinical rate of success in the groups treated with revascularization varied from 76% to 100%, while in the groups treated with apexification, it ranged from 68% to 100%. Only two studies reached a success rate equal to 100%. Conclusions: Variable levels of evidence were observed in relation to the treatments. However, it was confirmed that revascularization is an excellent option since its outcomes produced a greater gain of thickness and root length, besides developing a decrease in the apical foramen.

Introdução: O objetivo desta revisão sistemática foi comparar as técnicas de apexificação, com hidróxido de cálcio (Ca(OH)2) ou agregado trióxido mineral (MTA), com a técnica de regeneração pulpar, utilizando estudos coorte, ensaio clínico não randomizado e randomizado. Métodos: A metodologia foi baseada em pesquisa eletrônica nas seguintes bases de dados: PubMed, MEDLINE, Google Acadêmico, SciELO e LILACS. Além disso, foi realizada uma pesquisa manual utilizando as referências listadas nos artigos encontrados. Resultados: Foram encontrados 403 estudos potencialmente elegíveis, sendo sete incluídos nos critérios de inclusão desta revisão sistemática. Os sete estudos envolveram um total de 312 dentes. O tempo mínimo de um período de acompanhamento foi de 12 meses. A solução de irrigação mais utilizada foi o hipoclorito de sódio, para as técnicas de apexificação e revascularização. O medicamento comumente escolhido nos grupos de apexificação foi o Ca(OH)2, com pasta tripla antibiótica nos grupos de revascularização. A taxa clínica de sucesso nos grupos tratados com revascularização variou de 76% a 100%, enquanto nos grupos tratados com apexificação variou de 68% a 100%. Apenas dois estudos atingiram uma taxa de sucesso igual a 100%. Conclusões: Níveis variáveis de evidência foram observados em relação aos tratamentos. No entanto, confirmou-se que a revascularização é uma excelente opção, pois seus desfechos produzem maior ganho de espessura e comprimento radicular, além de diminuir o forame apical.

Técnica de apexificación con un sustituto bioactivo de la dentina en una sola sesión: caso clínico / Apexification technique with a bioactive dentin substitute in a single session: a clinical case

Las piezas con necrosis pulpar y ápice abierto son un desafío de la práctica clínica endodóntica. Durante mucho tiempo estas piezas han sido tratadas con la técnica de apexificación con hidróxido de calcio. Esta técnica estimula la formación de una barrera calcificada a nivel apical, pero a partir de varias sesiones de tratamiento y los riesgos asociados que esto conlleva. Hoy en día, con el desarrollo de nuevas tecnologías, están a disposición materiales biocerámicos que permiten realizar el protocolo en una sola sesión. El Biodentine es un biocerámico con tiempo de fraguado corto y buena capacidad de sellado, que permite reducir los tiempos clínicos. El objetivo de este trabajo es presentar un caso clínico de una pieza dentaria diagnosticada con necrosis pulpar y con apicoformación incompleta, tratada con una técnica de apexificación con Biodentine en una sesión (AU)

Influence of photobiomodulation therapy on root development of rat molars with open apex and pulp necrosis

Abstract This study aimed to evaluate the role of photobiomodulation (PBM) in apexification and apexogenesis of necrotic rat molars with an open apex. Rat molars were exposed to the oral environment for 3 weeks. Canals were rinsed with 2.5% NaOCl and 17% EDTA, filled with antibiotic paste and sealed. After 7 days, canals were rinsed and divided into six groups (n=6): mineral trioxide aggregate (MTA); blood clot (BC); human dental pulp stem cells (hDPSC); MTA+PBM; BC+PBM; and hDPSC+PBM. In hDPSC groups, a 1% agarose gel scaffold was used. Two groups were not exposed: healthy tooth+PBM (n = 6), healthy tooth (n = 3); and one was exposed throughout the experiment: necrotic tooth (n = 3). In PBM groups, irradiation was performed with aluminum gallium indium phosphide (InGaAlP) diode laser for 30 days within 24-h intervals. After that, the specimens were processed for histological and immunohistochemical analyses. Necrotic tooth showed greater neutrophil infiltrate (p < 0.05). Necrotic tooth, healthy tooth, and healthy tooth+PBM groups showed absence of a thin layer of fibrous condensation in the periapical area. All the other groups stimulated the formation of a thicker layer of fibers (p < 0.05). All groups formed more mineralized tissue than necrotic tooth (p < 0.05). PBM associated with MTA, BC, or hDPSC formed more mineralized tissue (p < 0.05). MTA+PBM induced apexification (p < 0.05). Rabbit polyclonal anti-bone sialoprotein (BSP) antibody confirmed the histological findings of mineralized tissue formation, and hDPSC groups exhibited higher percentage of BSP-positive cells. It can be concluded that PBM improved apexification and favored apexogenesis in necrotic rat molars with an open apex.

Apicificação com MTA para obturação de dente traumatizado: relato de caso / Apexification with MTA for traumatized tooth: a case report

Introdução: o tratamento de dentes jovens traumatizados requer atenção especial, devido à possível presença de ápice incompleto e paredes dentinárias delgadas, o que pode dificultar ou comprometer o tratamento endodôntico convencional. Faz-se necessária a realização de um procedimento para induzir a formação de uma barreira mineralizada, com o auxílio de materiais biocompatíveis, como o hidróxido de cálcio e o agregado trióxido mineral (MTA). Objetivo: relatar um caso clínico em que foi realizada apicificação, com tampão de MTA, em um incisivo lateral superior traumatizado. Conclusão: o uso de MTA como material obturador de dentes com ápice incompleto mostrou- se eficiente, pois permitiu resolução do caso com sucesso e a manutenção do dente na arcada, exercendo suas funções primárias quanto à estética e à mastigação.

A Biological Approach in Repair of Damaged Dental Pulp and Periapical Tissues using Platelet Rich Fibrin, Mineral Trioxide Aggregate and Laser Biostimulation.

This article describes about a biological approach in the repair of dental pulp and periapical tissues using biomaterials (platelet rich fibrin [PRF] and mineral trioxide aggregate [MTA]) and laser biostimulation. Case 1: Pulpotomy with PRF, MTA, and laser biostimulation. Patient follow-up was done at 1, 3, and 6 months. On 6 months follow-up, the patient was asymptomatic and tooth responded positively to pulp tests. Radiograph revealed normal periodontal ligament space and trabecular bone pattern. Case 2: Apexification procedure using PRF, MTA, and laser biostimulation in 31 and 41. Patient follow-up was done at 1, 3, and 6 months. On 6 months follow-up, radiograph revealed relative root lengthening, thickening of the canal walls in the apical one-third of root, and a healing lesion. Repair and regenerative potential of PRF, an enhanced cellular metabolism with laser biostimulation in combination with the sealing ability of MTA enhances the clinical success outcomes in pulpotomy and apexification procedures.

One-step apexification using platelet rich fibrin matrix and mineral trioxide aggregate apical barrier.

The absence of a natural apical constriction in a nonvital young permanent tooth makes endodontic treatment a challenge. There is a need to induce or create an apical barrier against, which the obturating material can be condensed. Traditionally, calcium hydroxide is the material of choice to induce apexification. Due to certain drawbacks such as prolonged treatment duration and unpredictable apical barrier formation, it is being replaced by materials, which have a more predictable outcome like mineral trioxide aggregate (MTA). One‑step apexification with MTA reduces the treatment time when compared with traditional calcium hydroxide apexification, which requires an average time of 12–19 months. In one‑step apexification using MTA, the technical problem encountered is controlling the overfill or underfill of MTA. The use of a matrix material helps to overcome this shortcoming. Platelet rich fibrin (PRF) is an immune platelet concentrate, which can be used as a matrix, it also promotes wound healing and repair. This case report presents a case of one step apexification using MTA as an apical barrier and autologous PRF as an internal matrix.

Endodontic management of open apex using Biodentine as a novel apical matrix.

Aim: Endodontic management of open apex using Biodentine as an apical matrix. Summary: An immature tooth with pulpal necrosis and periapical pathology imposes a great difficulty to the endodontist. Endodontic treatment options for such teeth consist of conventional apexification procedure with and without apical barriers. Biodentine™ is new calcium silicate based cement that exhibits physical and chemical properties similar to those described for certain Portland cement derivatives. This article demonstrates the use of the newer material, Biodentine as an apical matrix barrier in root end apexification procedure. This case reports present apexification and successful healing with the use of Biodentine as an apical barrier matrix. Conclusion: Apexification in one step using an apical plug of Biodentine can be considered a predictable treatment and may be an alternative to mineral trioxide aggregate apexification.

Autotransplantation of a Mandibular Third Molar: A Case Report with 5 Years of Follow-up

This paper describes the autologous transplantation of a mandibular right third molar to replace the residual roots of the second molar in the same quadrant, preserving function and aesthetics. A 5-year clinical and radiographic follow-up was undertaken. After transplantation, the donor tooth received endodontic treatment and placement of calcium hydroxide, which was periodically replaced every 3 months until the filling of the root canals, totalizing a period of 1-year, when apical closure was confirmed. The tooth was in perfect functional and aesthetic conditions 5 years after beginning of treatment. Autotransplantation is a feasible option for replacing missing teeth when a donor tooth is available. The autotransplantation of a right mandibular third molar with compromised function and aesthetics to replace the residual roots resulting from coronal destruction due to extensive carious lesion of the second molar in the same quadrant was a viable treatment alternative.

O objetivo deste trabalho foi descrever o transplante autógeno de um terceiro molar inferior direito para substituir as raízes residuais do segundo molar no mesmo quadrante, preservando a função e a estética. Foi realizado acompanhamento clínico e radiográfico por 5 anos. Após o transplante, o dente doador recebeu tratamento endodôntico e colocação de hidróxido de cálcio, o qual foi substituído periodicamente a cada 3 meses, até a obturação dos canais radiculares, totalizando período de 1 ano quando então, o fechamento apical foi confirmado. O dente encontra-se em perfeitas condições funcionais e estéticas após 5 anos do início do tratamento. O autotransplante é uma opção viável para a substituição de dentes perdidos quando um dente doador está disponível. O autotransplante de um terceiro molar inferior direito com comprometimento estético e funcional afim de substituir raízes residuais (resultado de um processo cariogênio extenso) de um segundo molar do mesmo quadrante foi um tratamento alternativo viável.

Apical Barrier Formation After Incomplete Orthograde MTA Apical Plug Placement in Teeth with Open Apex - Report of Two Cases

Two cases are reported in which incomplete placement of 4 mm mineral trioxide aggregate (MTA) plug was performed unintentionally at the apical third of permanent immature teeth with open apex and apical periodontitis. As confirmed radiographically, there were gaps between MTA and dentinal walls along the MTA-dentin interface. After setting of MTA was confirmed, endodontic treatment was completed and access was sealed with composite resin. At 6 to 16 months follow-up examinations, formation of dentin in contact with the MTA surface, as well as apical closure and periapical healing were ideied radiographically for both cases. The results of these cases showed that apical barrier formation and complete periapical healing is possible despite the incomplete apical placement of the MTA plug. This might be due to the biological properties of the MTA. Even so, an incomplete three-dimensional placement of the filling material is not advocated.

Non-surgical retreatment of a failed apicoectomy without retrofilling using white mineral trioxide aggregate as an apical barrier

Root-end resected teeth with persistent apical periodontitis are usually retreated surgically or a combination of non-surgical and surgical retreatment is employed. However, patients are sometimes unwilling to be subjected to a second surgical procedure. The apical barrier technique that is used for apical closure of immature teeth with necrotic pulps may be an alternative to non-surgically retreat a failed apicoectomy. Mineral trioxide aggregate (MTA) has become the material of choice in such cases because of its excellent biocompatibility, sealing ability and osseoinductive properties. This case report describes the non-surgical retreatment of a failed apicoectomy with no attempt at retrofilling of a maxillary central incisor. White MTA was used to induce apical closure of the wide resected apical area. Four-year follow-up examination revealed an asymptomatic, fully functional tooth with a satisfactory healing of the apical lesion. White MTA apical barrier may constitute a reliable and efficient technique to non-surgically retreat teeth with failed root-end resection. The predictability of such a treatment is of great benefit for the patient who is unwilling to be submitted to a second surgical procedure.

Dentes com periodontite persistente após apicectomia são comumente tratados cirurgicamente ou pela combinação de cirurgia e tratamento não-cirúrgico. Porém, alguns pacientes não aceitam se submeter a um segundo procedimento cirúrgico. A técnica da barreira apical, utilizada para fechamento apical de dentes com ápice aberto com necrose pulpar, pode ser uma alternativa não-cirúrgica para retratamento de casos de apicectomia mal sucedida. O agregado de trióxido mineral (MTA) tornou-se o material de escolha para estes casos devido a sua excelente biocompatibilidade, capacidade de selamento e propriedades osseoindutivas. O relato de caso aqui apresentado descreve o retratamento não-cirúrgico de uma apicectomia mal sucedida, sem retrobturação, de um incisivo central superior. Foi utilizado o MTA branco para induzir o fechamento apical da ampla área de ressecção radicular. O exame de acompanhamento quatro anos após o tratamento mostrou um dente assintomático e totalmente funcional com reparo satisfatório da lesão apical. A barreira apical com MTA branco pode ser uma técnica segura e eficaz para o retratamento não-cirúrgico de dentes com apicectomia mal sucedida. A previsibilidade de tal tratamento é um grande benefício para o paciente que não deseja ser submetido a um novo procedimento cirúrgico.

Non-surgical management of a mutilated maxillary central incisor with open apex and large periapical lesion.

A 24-year-old female patient reported with a mutilated maxillary left central incisor. The coronal tooth structure remaining was very less, discolored, and brittle. She gave history of trauma about 15 years back when the tooth got fractured. An intraoral periapical radiograph revealed an open apex and a large periapical lesion. The case was managed successfully by conservative means using intracanal calcium hydroxide and mineral trioxide aggregate (MTA) apical barrier followed by a fiber post and a core. The final crown restored back esthetics and function. A 6-month follow-up demonstrated a clinically asymptomatic and adequately functional tooth, with radiological signs of healing.

Clinical management of a complicated crown-root fracture: a case report

This report describes the clinical procedures involved in the treatment of a complicated crown-root fracture in the maxillary left central incisor with a wide open apex of a 10-year-old male patient, due to fall from his own height. Post-trauma treatment comprised cervical pulpotomy and adhesive tooth fragment reattachment. After 1 year, clinical and radiograph examinations showed pulp necrosis and an associated periapical lesion. Endodontic therapy with calcium hydroxide-base intracanal dressing, root canal filling and orthodontic extrusion were performed. Extrusion was completed within approximately 16 weeks and the tooth was restored with a post-core system and a prosthetic crown. After a 3 years of follow-up, there was no evidence of apical periodontitis and the tooth was satisfactory both esthetically and functionally.

Este relato de caso apresenta os procedimentos clínicos envolvidos no tratamento de um caso de fratura corono-radicular complicada de um incisivo superior esquerdo com ápice aberto de um paciente de 10 anos de idade devido à queda da própria altura. O tratamento envolveu pulpotomia cervical e fixação do fragmento. Após 1 ano, os exames clínicos e radiográficos demonstraram necrose pulpar e lesão perirradicular associada. O tratamento endodôntico foi realizado com a utilização de pasta de hidróxido de cálcio, obturação endodôntica e extrusão ortodôntica. Após aproximadamente 16 semanas, o processo de extrusão foi finalizado e o dente restaurado com pino e coroa protética. Após acompanhamento de 3 anos, não havia evidência de lesão perirradicular e o dente estava estética e funcionalmente satisfatório.

Sealing ability, marginal adaptation and their correlation using three root-end filling materials as apical plugs

OBJECTIVE: This study used dye leakage assay and scanning electron microscopy to evaluate, respectively, the sealing ability and marginal adaptation of three root-end filling materials used as apical plugs, as well as the possible correlation between these properties. MATERIAL AND METHODS: Ninety-eight single-rooted human teeth were prepared to simulate an open apex. The teeth were allocated to three experimental groups (n = 30), which received a 5-mm thick apical plug of (1) gray MTA AngelusTM, (2) CPM TM and (3) MBPc, and two controls groups (n = 4). After immersion in 0.2 percent Rhodamine B solution for 48 h, the teeth were sectioned longitudinally and analyzed by Image Tool 3.0 software. The marginal adaptation between apical plugs and the root canal walls were analyzed by SEM. RESULTS: MBPc had significantly less (p<0.05) apical leakage than the other materials. Regarding marginal adaptation, CPM TM showed the best numerical results, though without statistical significance from the other materials (p<0.05). There was no correlation between the two properties. CONCLUSIONS: When used as apical plugs, the tested root-end filling materials had similar marginal adaptation to the dentin walls, but MBPc had the best sealing ability, as demonstrated by the least apical leakage from all tested materials.