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Pediatric Dental Journal

journal homepage: www.elsevier .com/locate /pdj

Case Report

Management of open apices in thirteen traumatizedpermanent incisors using mineral trioxide aggregate:Case series

Gulhan Koyuncuoglu, Feyza Nur Gorken, Goksen Ikikarakayali, Sevgi Zorlu,Arzu Pinar Erdem*, Elif Sepet, Gamze Aren

Department of Pedodontics, Faculty of Dentistry, Istanbul University, Capa, 34093 Istanbul, Turkey

a r t i c l e i n f o

Article history:

Received 27 January 2012

Received in revised form

9 October 2012

Accepted 17 October 2012

Available online 6 May 2013

Keywords:

Mineral trioxide aggregate

Apexogenesis

Trauma

Partial pulpotomy

Immature teeth

* Corresponding author. Tel.: þ90 212 414202E-mail address: pinararzuerdem@yahoo.c

0917-2394/$ e see front matter ª 2013 The J

http://dx.doi.org/10.1016/j.pdj.2013.03.007

a b s t r a c t

Aim: The partial pulpotomy can offer a successful outcome for the treatment of traumatic

complicated crown fractures. The aim of this clinical report was to evaluate the effect of

mineral trioxide aggregate (MTA) in apexogenesis of traumatized immature permanent

incisors with pulp exposure.

Case report: According to clinical and radiological examinations complicated crown frac-

tures and open apices were identified in 13 permanent upper incisors in ten patients (age

range 7e10 years). Partial pulpotomy procedures were performed and the teeth were

treated with MTA. In this report, periodic clinical and radiological follow-ups were

performed. At recall examinations, all teeth were asymptomatic, and clinical and radio-

logical investigations revealed excellent healing patterns with continued apexogenesis.

Conclusion: Regular examination of immature traumatized permanent teeth is critical for

vitality and apexification. In this report, clinical and radiological findings confirm that

partial pulpotomy with MTA is a reliable and effective treatment approach in apexogenesis

of traumatized immature permanent incisors with pulp exposure.

ª 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

1. Introduction Preservation of pulp vitality is of paramount importance

Regenerative endodontic procedures involving pulp capping

and partial pulpotomy have been in use since the late 1970s [1].

Regenerative endodontic procedures can be defined as biologi-

cally based procedures designed to predictably replace

damaged, diseased, ormissing structures, including dentin and

root structuresaswell as cells of thepulpedentincomplex,with

live viable tissues, preferably of the sameorigin, that restore the

normal physiologic functions of the pulpedentin complex [2].

0x30309; fax: þ90 212 531om (A.P. Erdem).apanese Society of Pediatr

because, a vital functioning pulp is capable of initiating

several defense mechanisms to protect the body from bacte-

rial invasion; it is beneficial to preserve the vitality and health

of an exposed pulp rather than to replace it with a root filling

material following pulp exposure [3].

A tooth fracture involving enamel and dentine that ex-

poses the pulp is defined as complicated crown fracture. If

there is a concomitant luxation injury, the pulp appears

ischemic but otherwise may appear healthy and bleeding [4].

0515.

ic Dentistry. Published by Elsevier Ltd. All rights reserved.

p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 5 1e5 652

Complicated crown fractures represent 18e20% of all

traumatic injuries to permanent teeth [5]. Treatment options

include direct pulp capping, pulpotomy (partial or cervical), or

pulpectomy, depending on factors such as the interval be-

tween the accident and examination, the degree of root

development, and the size of the exposure. The key de-

terminants of success are the extent of pulp damage and the

length of time after exposure of the pulp to the oral environ-

ment [6].

Partial pulpotomy is a form of vital pulp therapy (VPT) that

consists of the surgical amputation of 2e3 mm of damaged,

inflamed, coronal pulp tissue, followed by placing a biocom-

patible agent to promote healing and maintain vitality of the

remaining pulp tissue [7].

Mineral trioxide aggregate (MTA) has been shown to

prevent dye and bacterial leakage and has a high level of

biocompatibility [8,9]. Based on animal and human studies,

MTA is considered a suitable pulp cappingmaterial [10e13]. Its

use has been recommended for the treatment of complicated

crown fractures [14].

In this article we report 10 cases of traumatized permanent

upper central incisors, which were treated with MTA

following partial pulpotomy.

2. Cases

According to clinical and radiological examinations compli-

cated crown fractures, pulpal exposure, and open apices were

identified in 13 permanent upper incisors in 10 patients (age

range 7e10 years). Histories revealed trauma to the teeth

24e72 h previously. The patients experienced pain on stim-

ulus. The patients’ medical histories were noncontributory.

The informed consent of all human subjects who participated

in the experimental investigation reported or described in this

manuscript was obtained after the nature of the procedure

and possible discomforts and risks had been fully explained.

Partial pulpotomy procedures were performed and the teeth

were treated with MTA.

3. Clinical procedure

After the administration of local anesthesia, the superficial

layer of the exposed pulp and the surrounding tissue were

excised to a depth of 2 mm using a high-speed size 2 round

diamond bur with copious water coolant. The surface of the

remaining pulp was irrigated with sodium hypochlorite until

the bleeding stopped. ProRoot WMTA (Dentsply Tulsa Dental,

Tulsa, OK, USA) was freshly mixed and placed over the

exposed pulp, following which a saline-soaked cotton pellet

was placed over the MTA for 45 min to allow it to set. The

exposed dentin and MTA were both sealed with GIC (glass

ionomer cement, Vitrebond, 3M Dental Products Division, St

Paul, MN, USA) and a direct composite restoration (Tetric

N-Ceram; Ivoclar Vivadent, Schaan, Liechtenstein) was

performed, to build up the fractured tooth structure.

Periodic clinical and radiological follow-ups were

performed at 1, 3, 6, and 18 months. The teeth were evaluated

for abnormal signs (gingival swelling, abscess or fistula, pain

on percussion, tooth mobility, restorative condition, and

vitality test) and symptoms (spontaneous pain, tooth hyper-

sensitivity, pain with chewing, abscess or swelling, and his-

tory of taking analgesics). Pulp sensitivity was tested after

24 h and periodic follow-ups. The teeth were found to respond

positively during the follow-up visits. During the 18-month

follow-up period, tooth hypersensitivity in 8 teeth was

reported. Transient spontaneous pain (1e2 s) in 6 teeth was

reported at 1 month after the operation and disappeared at 3

months. No analgesic use was reported. The evaluation of

dentine bridge formation from radiographs revealed the

formation of dentine barrier in 8 teeth. No dentine bridge

formation was observed in 3 teeth and barrier formation was

questionable in 2 teeth.

At 18 months recall examinations, all teeth were asymp-

tomatic; clinical and radiological investigations revealed

excellent healing patterns with continued apexogenesis (Figs

1e4).

The restorations were functionally and aesthetically

acceptable.

Clinical symptoms, presence of radiographic dentine

bridge formation, and vitality test response from each tooth at

18 months post-operation are presented in Table 1.

4. Discussion

Apexogenesis is a histological term used to describe the

continued physiologic development and formation of the

root’s apex. Formation of the apex in vital, young, permanent

teeth can be accomplished by implementing appropriate VPT

[15].

The procedure is performed by amputating coronal pulp

and covering the remaining pulp with suitable capping bio-

materials [16,17]. Unlike apexification, VPT allows continua-

tion of the root formation, which leads to apical closure,

stronger root structure, and a greater structural integrity

[16,18]. One of the advantages of partial pulpotomy, when

compared to cervical or complete pulpotomy, is the preser-

vation of the cell-rich coronal pulp tissue. This tissue pos-

sesses better healing potential and can maintain the

physiological deposition of dentin [19].

The advantage of both pulp capping and partial pulpotomy

procedures in young teeth, if they prove successful, is that a

healthy pulp is maintained throughout the root canal system.

Not only does this ensure apical development, but also pro-

motes the deposition of lateral root dentine which improves

the root strength [20].

The effect of the age of the patients on the clinical outcome

in VPTs is controversial. It has been recommended that VPT

should be performed only in young patients [21]. However,

patients with ages ranging from 6e70 years have been treated

successfully with VPT. The complete removal of the inflamed

pulp is critical rather than the status of the root apex [22].

Due to esthetic concerns, in the anterior region, we used

white MTA in our cases. A waiting period of 45 min followed,

to allow the setting of MTA, before the placement of GIC, as

this was the recommended protocol by Nandini et al. and

Abarajithan et al. [23,24]. Thus, considering the age of the

patient, recently traumatized teeth with pulp exposure, if

Fig. 1 e A: Posttreatment radiograph of mineral trioxide aggregate, placed over the exposed pulp of an immature maxillary

right central incisor in a 9-year-old girl. B: Radiograph taken at the 18-month recall appointment showing dentine bridge

and evidence of continuous apexogenesis.

p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 5 1e5 6 53

treated with partial pulpotomy within 24e48 h after the

injury, can act as a permanent restorative procedure, without

the need for endodontic treatment, provided a bacteria-tight

seal is obtained.

The capping material needs to be biocompatible, bacteri-

cidal, and able to provide a biologic and bacterial-tight seal

and induce hard tissue formation [17].

Studies have shown that bridge formation beneath a pulp

capping material could be due to the properties of capping

materials such as sealing ability, alkalinity, and biocompati-

bility [14].

Histologic evaluations showed that MTA produces a

thicker dentinal bridge, less inflammation, less hyperemia,

Fig. 2 e A: Posttreatment radiograph of mineral trioxide aggreg

incisors in a 9-year-old boy. B: Radiograph taken at the 18-month

of continuous apexogenesis.

and less pulpal necrosis compared with calcium hydroxide

[17,25].

Data on postoperative pain and tooth hypersensitivity are

subjective and difficult to compare between subjects. Kiat-

wateeratana et al., reported pain or discomfort during the first

10 days in teeth which partially pulpotomized and treated

with Ca(OH)2 than enamel matrix derivative gel [26].

This study showed that half of the MTA-treated teeth

exhibited transient spontaneous pain in 6 teeth at 1 month

after the operation. A total of 8 of 13 teeth had hypersensitivity

during the 18-month follow-up period.

Hypersensitivity in the MTA-treated teeth may be due to

pulpal irritation from the pressure of placing the MTA paste

ate, placed over the exposed pulps of immature maxillary

recall appointment showing dentine bridges and evidence

Fig. 3 e A: Posttreatment radiograph of mineral trioxide aggregate, placed over the exposed pulps of immature maxillary

incisors in an 8-year-old boy. B: Radiograph taken at the 18-month recall appointment showing dentine bridge formation at

right central. No bridge formation was detected at left central. Apexogenesis continued in both incisors.

p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 5 1e5 654

on the pulpal wound or from alkalinity of the material.

Response of the pulp varies with the intensity and duration of

tooth injury. All teeth included in this study were traumatized

maxillary permanent central incisors with complicated crown

fractures, so the tooth hypersensitivity may be a protective

response of the pulp tissue to trauma.

Once the odontoblasts suffer injuries, the differentiation of

mesenchymal cells is induced from the precursor cell popu-

lation in the dental pulp [27,28] and these cells are recruited to

the injured site to differentiate into odontoblasts.

Fig. 4 e A: Posttreatment radiograph of mineral trioxide aggreg

maxillary incisor in a 7-year-old boy. B: Radiograph taken at th

formation and continuous apexogenesis.

Subsequently, the newly-differentiated odontoblasts produce

a dentin matrix which is referred to as a “dentin bridge”

following direct pulp capping or partial pulpectomy [29].

In the presented cases, apexogenesis treatments with MTA

are continued with excellent healing patterns in 18 months

and formations of calcified bridges beneath MTA are evident

in most cases.

The physical characteristics and bioactive properties of

MTA enhanced the success of this study. The cement is

hygroscopic, and its ability to set is not affected by the

ate, placed over the exposed pulp of immature right

e 18-month recall appointment showing dentine bridge

Table 1 e Clinical symptoms, presence of radiographicdentine bridge formation, and vitality test response fromeach tooth at 18 months post-operation.

Subjectno

Clinicalsymptoms

Dentinebridge

Vitality-testresponse

1 e þ þ2 e ? þ3 e þ þ4 e þ þ5 e ? þ6 e þ þ7 e þ þ8 e þ þ9 e e þ10 e þ þ11 e e þ12 e þ þ13 e e þ

Clinical symptoms: (e), no symptoms. Dentine bridge (X-ray): (þ),

dentine bridge formation; (e), no dentine bridge formation; (?),

questionable dentine bridge formation. Vitality test response: (e),

no; (þ), yes.

p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 5 1e5 6 55

presence of blood or serum fluids [8]. The high alkalinity of

MTA, its calcium release, and sustained pH of 12.5 most

likely prevented any further microbial growth of residual

microorganisms that were left after caries excavation. The

high pH also extracts growth factors from adjacent dentin

that are thought to be responsible for promoting dentinal

bridging [30]. Furthermore, the release of calcium ions by

MTA generates a reactionary interfacial layer of hydroxy-

apatite on its surface when it comes in contact with tissue

fluids, and their presence also may contribute to reparative

dentin formation [31].

The histologic pulpal response comparing white-MTA

to Ca(OH)2 as pulpotomy dressings was investigated in

premolars extracted for orthodontic purposes, reporting

that white-MTA induced a more homogenous and

continuous dentin bridge with less pulpal inflammation

than Ca(OH)2 at both 4 and 8 weeks after treatment [32].

The high occurrence of pulpal repair and pulp-capping

success appears to be more favorable in teeth of younger

patients; success can be attributed to the presence of

larger apical foramina and greater vascularization of the

pulp, in which active immune cell surveillance may in-

crease chances for repair and intensify vital pulpal main-

tenance [33].

Since our study did not have a control group, the results

provide, within the limitations of the study, a relatively low

level of scientific evidence. All recall examinations showed

continuous or complete apexogenesis of previously immature

apices.

Apexogenesis may indicate the continued normal physio-

logical activity of cementoblasts and odontoblasts in the

absence of irritants. Apical closure allows formore predictable

endodontic treatment if teeth require pulpectomy at a later

stage [10].

The outcomes of this study suggest that MTA is a predict-

able pulp-capping material.

5. Conclusion

Regular examination of immature traumatized permanent

teeth is critical for vitality and apexification. In this report,

clinical and radiological findings confirm that partial pulpot-

omy with MTA is a reliable and effective treatment approach

in apexogenesis of traumatized immature permanent incisors

with pulp exposure.

Disclosure

The authors do not have any actual or potential conflict of

interest including any financial, personal, or other relation-

ships with other people or organizations of the submitted

work entitled ‘Management of Open Apices in Thirteen

Traumatized Permanent Incisors Using Mineral Trioxide

Aggregate: Case Series.’

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