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Dentistry www.dentistry.co.uk

6 February 2014

clinical

Non-surgical endodontic treatment


Rupal Shah, Young Dentist Endodontic Award's
second place winner, presents her case report nonsurgical endodontic treatment of the maxillary right
central incisor with incomplete root formation
This report discusses the successful
management of an anxious 10-year-old
patient, who required root canal treatment
of her immature UR1, following a previous
history of trauma.
She was initially referred to the
paediatric department at Birmingham
Dental Hospital by her general dental
practitioner (GDP).
Following assessment and diagnosis,
she underwent root canal therapy of her
UR1, which was deemed to be non-vital
and had an open apex.

Patient details

Ten-year-old female, school pupil.

History

Presenting complaint
The patients chief complaint was her
fractured front teeth that she did not like
the appearance of.
History of presenting complaint
History of presenting complaint revealed
that she had suffered trauma in November
2011, when she had fallen in the school
playground and knocked her front teeth on
metal railings. Both upper central incisors
had fractured, but there was no obvious
displacement at the time of injury.
No loss of consciousness or head injuries
had been noted, but there was a laceration
to the upper lip.
She initially attended Heartlands
Hospital, from which she was referred to
Birmingham Childrens Hospital for a chest
X-ray, as the tooth fragments had not been
accounted for. The chest X-ray reported no
abnormalities.
The patient then saw her GDP one day
after the injury, and had adhesive composite
restorations placed on the UR1 and UL1.
However, these were subsequently lost after
six weeks, and were not replaced.
Medical history
The patient suffers from asthma and uses
Ventolin and Becotide inhalers as and when
required. She has not had any previous
hospitalisations due to her asthma.
Dental history
There is no history of any other previous
trauma. Cooperation appeared to be
reduced as the patient had not had any
previous extensive dental treatment, and

was therefore quite nervous.

Examination

Extraoral
Scarring was noted in the midline of the
patients upper lip; she had sustained a
Figure 1: Preoperative periapical
laceration to this area at the time of injury. radiographs
Intraoral
Soft tissues: oral hygiene was fair, but some
gingival inflammation was present. Hard
tissues: teeth present were upper right, lower
right, upper left, lower left 1, 2, c, d, e, 6.
Unrestored, enamel-dentine fractures
were evident on the UR1 and UL1, with the
UL1 fracture being fairly extensive. Caries
was noted on the LLd.

Figure 3: Upper standard


occlusal radiograph
Figure 2: Preoperative periapical
radiographs

and UL1
2. Likely non-vital UR1; chronic apical
periodontitis secondary to trauma
3. Caries LLd
4. Anxious patient.

Treatment options

given to the patient


2. Extraction of the UR1 with or without
prosthetic replacement (carried out by the
GDP).

Treatment plan

1. Immediate: cover exposed dentine UR1


and UL1 with glass ionomer cement (GIC)
1. Test cavity UR1, and proceed to
(at the Birmingham Dental Hospital)
non-surgical root canal therapy with
2. Oral hygiene index, dietary analysis and
mineral trioxide aggregate (MTA) apical
Occlusion
advice, bitewing radiographs (carried out
plug if non-vital +/- relative analgesia
Occlusal analysis revealed a class I incisor (RA) sedation (at the Birmingham Dental
by the GDP)
relationship with class II right molars, and Hospital). The patient was quite nervous,
3. Scale and polish, restore caries LLd,
class I left molars.
fissure seal first permanent molars (carried
so the use of RA sedation was discussed;
out by the GDP)
an RA sedation information sheet was
Special investigations
All maxillary incisors responded positively
to ethyl chloride. The UR2, UL1 and UL2
responded positively to electric pulp tester
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while the UR1 tested negative. None of the
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maxillary incisors were tender to percussion
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Radiographic examination

Periapical radiographs
Long cone periapical radiographs UR2
and UR1, UL1 and UL2 (Figures 1 and
2) revealed open apices on all maxillary
incisors, and periodontal ligament (PDL)
widening around the apex of the UR1. It
also showed the unrestored enamel-dentine
fractures on both maxillary central incisors.
Figure 3 shows a radiograph confirmed
PDL widening around the UR1, with
associated periapical pathology. It also
shows the open apices of all four upper
incisors, as well as the presence of maxillary
canines.
Soft tissue X-ray
The soft tissue radiograph of the upper lip
revealed no abnormalities, and no evidence
of any tooth fragments in the lip.

Diagnoses

1. Enamel-dentine crown fractures UR1

Dr Rupal Shah BDS (Hons) MJDF RCS (Eng). Rupal qualified from Kings
College London Dental Institute. After graduating with honours, she
successfully obtained a DFY1 (dental foundation year) position in London.
Thereafter, she commenced a DFY2 post in oral surgery and paediatric
dentistry at Birmingham Dental Hospital, and is currently working as a dental
core trainee in restorative dentistry. She has a keen interest in orthodontics,
endodontics and periodontology.
In her final year of dental school, she was also awarded the A.M. Clover prize,
and was vice-president for KCL Dental Society.
She has travelled to Vietnam with a charity called East Meets West, and was involved in
providing dental care to disadvantaged children in rural Vietnam.

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32

Dentistry www.dentistry.co.uk

6 February 2014

clinical

Figure 5: Diagnostic radiograph to


determine working length; 21mm

Figure 6: Master cone periapical


radiograph

4. Test cavity UR1 and proceed to root canal treatment if


non-vital +/- RA sedation. Dress with non-setting calcium
hydroxide until stable. (At the Birmingham Dental
Hospital)
5. Adhesive composite restorations UR1 and UL1 +/- RA
sedation (at the Birmingham Dental Hospital)
6. Review (at the Birmingham Dental Hospital).

Figure 7: 4mm mineral trioxide


aggregate apical plug

Figure 8: Postoperative
radiograph

Treatment protocol

Appropriate verbal and written consent was obtained prior


to commencing treatment. As a test cavity was carried out
on the UR1, no local anaesthetic was required.
Isolation was achieved with dry dam, wedges and
Oroseal caulking material. The tooth, as expected, was
found to be non-vital, extirpated and dressed with nonsetting calcium hydroxide as an intracanal medicament. A

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temporary dressing of a cotton wool pledget and GIC was


placed in the access cavity. This initial management was
carried out under RA sedation.
At two subsequent visits, the GIC fillings on the UR1 and
UL1 were removed and replaced with adhesive composite
restorations, and the UR1 root canal was further prepared.
The root canal length was determined radiographically
(Figure 5), and the working length was measured as 21mm.
Chemo-mechanical cleaning of the canal was carried
out using K-Flex handfiles, interdental brushes, and 2.5%
sodium hypochlorite irrigation. The final apical size of the
canal was ISO 80, due to the immature apex and lack of
apical barrier. An apical step back technique was used to
prepare the wide canal. The canal was again dressed with
non-setting calcium hydroxide, a cotton wool pledget and
GIC in the access cavity. After this visit, the patient felt less
anxious, and opted to have future treatment without RA
sedation.
At the next visit, the patient mentioned the tooth had
been symptomatic. Therefore, it was decided to re-access
and re-irrigate with 2.5% sodium hypochlorite solution.
The tooth was again temporarily dressed with calcium
hydroxide, a cotton wool pledget and GIC.
At the following appointment, the patient was
asymptomatic. The canal was re-irrigated with sodium
hypochlorite and dried with paper points. A master cone
periapical radiograph was taken (Figure 6) to confirm the
length, and a 4mm apical plug of mineral trioxide aggregate
was placed using the Micro-Apical Placement System
(Figure 7). The remaining canal space was obturated with
thermoplasticised gutta-percha (GP) (obtura) and sealer
using warm vertical compaction. A Vitrebond lining was
placed over the GP, and the access cavity was restored with
composite resin to create an effective coronal seal (Figure
8).

Review

The patient recently attended for a six-month review,


which reported no symptoms associated with the UR1.
With regards to the UL1, there was a query whether
there was some periodontal ligament widening, however
the sensibility tests were inconclusive and the tooth was
asymptomatic. It was therefore decided to continue to
monitor the UL1 for now, and review the patient again in a
further six months.

Discussion

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The patients traumatic incident had resulted in pulpal


necrosis of the UR1 and consequently, an incomplete
formation of the root. Effective cleaning of the canal walls
was achieved with large K-Flex handfiles, interdental
brushes and sodium hypochlorite irrigation. The MTA
technique allowed for successful obturation of the maxillary
central incisor with an open apex.
I successfully completed this treatment on an anxious
10-year-old girl, who had not had any previous extensive
dental treatment. I overcame this by using different
behaviour management techniques including tell/show/do,
and ensuring that all appointments were not of too long a
duration. This meant compliance was not lost. In fact, the
patient initially began treatment under RA sedation due to
her anxiety, but at subsequent visits, decided she no longer
wanted it, and appeared to cope well without it.
I decided to submit this case because I feel that I
obtained an excellent final outcome, both clinically and
radiographically.
The tooth was symptom free at the six-month review
appointment at Birmingham Dental Hospital. The
4mm MTA apical plug was to the correct length, and
radiographically, there were no voids in the thermoplastic
GP. The access cavity was sealed with a Vitrebond lining,
followed by adhesive composite restoration, ensuring a
good coronal seal.
The endodontic prognosis for this tooth is good, however
the patient is fully aware of the long-term consequences of
trauma, and the subsequent need for regular dental
monitoring and sensibility testing of the traumatised upper
incisor teeth.
For a list on further reading, contact Julian English on
julian@dentistry.co.uk.

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