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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 4  |  Page : 77-80

Restoring biomechanics in immature young maxillary permanent central incisor


1 BDS, MDS, Department of Conservative Dentistry and Endodontics, Sri Siddartha Dental College and Hospitals, Tumkur, Karnataka, India
2 Professor, Department of Conservative Dentistry and Endodontics, Sri Siddartha Dental College and Hospitals, Tumkur, Karnataka, India
3 Reader, Department of Conservative Dentistry and Endodontics, Sri Siddartha Dental College and Hospitals, Tumkur, Karnataka, India

Date of Web Publication29-May-2019

Correspondence Address:
Dr. C M Jayashankara
Sri Siddartha Dental College and Hospitals, Tumkur, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_8_19

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  Abstract 

Treatment of immature young permanent tooth is complex owing to the presence of open apex and thin fragile dentinal walls. To create an apical seal, the treatment of choice would be apexification. The present clinical case is a report of immature permanent young central incisor associated with the periapical lesion treated with single-visit Biodentine® apexification and restored with glass fiber post in the aid of dual-cured resin composite to achieve monobloc effect. The concept of accomplishing monobloc with root dentin is imperative for the durability of the foundation.

Keywords: Apexification, Biodentine®, immature tooth, open apex


How to cite this article:
Amith M R, Venugopal P, Jayashankara C M, Kumar S A, Kumar P S, Girish S A. Restoring biomechanics in immature young maxillary permanent central incisor. Int J Prev Clin Dent Res 2018;5:77-80

How to cite this URL:
Amith M R, Venugopal P, Jayashankara C M, Kumar S A, Kumar P S, Girish S A. Restoring biomechanics in immature young maxillary permanent central incisor. Int J Prev Clin Dent Res [serial online] 2018 [cited 2019 Sep 24];5:77-80. Available from: http://www.ijpcdr.org/text.asp?2018/5/4/77/259264




  Introduction Top


Trauma to the young permanent tooth prior to the completion of root development necrotizes the pulp and inhibits further root development due to the destruction of Hertwig's epithelial root sheath.[1] Treatment of immature young permanent tooth is complex owing to the presence of open apex and thin fragile dentinal walls. To create an apical seal, the treatment of choice would be apexification, which induces the apical closure through the formation of mineralized tissue in the apical region of an incompletely formed root (open apex).[2] Several materials have been advocated to perform apexification. Conventionally, calcium hydroxide was the chosen material, but prolonged exposure of the calcium hydroxide to the root dentin may alter the mechanical properties and the root dentin would be vulnerable to fracture;[3] this led to the advent of mineral trioxide aggregate which comprises hydrophilic particles of tricalcium silicate, tricalcium oxide, and silicate oxide. This material has exhibited good sealability and biocompatibility.[4],[5] The drawbacks such as prolonged setting time and difficult handling characteristics [6] have led to the advent of a novel material called Biodentine ®, which is regarded as a dentine substitute and one of the first calcium silicate cements containing pure tri-calcium silicate. Biodentine is bioactive and has acceptable handling characteristics because of its excellent viscosity and short setting time.[7],[8] To preclude the catastrophic fracture of thin fragile dentinal walls, the remaining canal ought to be obturated with the material which has relatively similar mechanical properties to that of dentin which is believed to cause monobloc effect.[9] Apparently, there are few consensuses pertaining to the efficiency of Biodentine and glass fiber post in restoring the normal biomechanics in the immature young permanent central incisor using monobloc concept.


  Case Report Top


A 30-year-old male patient reported with the chief complaint of fractured and discolored teeth in the upper front region of the mouth and desired to get it corrected. On clinical examination, the patient had no symptoms of pain, but the tooth was slightly tender on percussion and he reported regarding the few episodes of sinus tract on the labial mucosa. The involved tooth 11 responded to neither of the neural sensitivity tests. On radiographic examination, an intraoral periapical radiograph manifested an open apex associated with the periapical lesion [Figure 1]. The treatment plan was one-visit apexification using Biodentine followed by the cementation of glass fiber post and core.
Figure 1: Open apex

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Local anesthesia was administered followed by rubber dam application and access cavity preparation for tooth 11. Working length was determined by keeping the file 2 mm short of the apex using an electronic apex locater and later confirmed with a radiograph. Shaping was done with a no. 60 H-file using circumferential filing motion. Cleaning was done using 1.5% NaOCl and saline and final rinse was made with 2% chlorhexidine. Calcium hydroxide dressing was placed as an intracanal medicament. The patient was recalled after 1 week and the intracanal medicament was replaced with triple antibiotic paste (doxycycline, metronidazole, and ciprofloxacin in 1:1:1 ratio) mixed with distilled water.

The patient was recalled after 2 weeks, and after ensuring the canal's dryness, Biodentine was mixed according to the manufacturer's instructions, introduced into the canal, and condensed with a hand plugger up to 4-mm thickness.

The patient was recalled after 10 days; the tooth was asymptomatic and glass fiber post adaptability was checked. After the selection of an appropriate size of the post, the remaining canal was obturated using glass fiber post and dual-cured resin composite according to the manufacturer's instructions to achieve monobloc effect. The patient was recalled at 6 months, 1 year, and 1½ year. Clinical, patient, and radiographic outcomes were assessed at each appointment. The tooth is still surviving with no symptoms of pain and no signs of the sinus tract; resolution of the lesion is evident and faint calcific barrier is also observed [Figure 2], [Figure 3], [Figure 4].
Figure 2: Six-month follow-up

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Figure 3: One-year follow-up

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Figure 4: One-and-half-year follow-up

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  Discussion Top


Calcium hydroxide is the most accepted intracanal medicament in use. Calcium hydroxide has the potential to hydrolyze the lipid moiety of bacterial lipopolysaccharides, consequently inactivating the biologic activity of the lipopolysaccharide and reducing its effectiveness.[10],[11]

The triple antibiotic paste is recommended in an immature nonvital permanent tooth to accomplish the disinfection. Triple antibiotic paste (ciprofloxacin 200 mg, metronidazole 400 mg, and doxycycline 100 mg) was observed to be effective in sterilizing the infected canal and was found that the blend of antibiotics is adequately potent to eradicate the bacteria.[12]

Biodentine, with active biosilicate technology, a class of new material which possesses excellent biocompatibility and mechanical properties, would be the appropriate material for apical closure.[13] The properties of Biodentine are relatively similar to that of dentine whose modulus of elasticity and microhardness of dentine are 14–19 GPa and 45–55 VHN, respectively, whereas those of Biodentine are 22 GPa and 60 VHN, respectively.[14] Considering the favorable properties of Biodentine, in the present case, single-visit Biodentine apexification was performed.

The objective of the final restoration is to reinforce or maintain the strength of the tooth against the masticatory load or external traumatic forces. Rehabilitation of the weakened roots of the immature nonvital permanent tooth is paramount. A well-adapted adhesively cemented fiber post is considered the most retentive, with the least stress generated on the canal walls. A light-transmitting post results in better polymerization of resin composites in the apical area.[15]

The theory of mechanics states that, when a post and core with a high modulus of elasticity, such as prefabricated metallic posts, is used, the stress is transferred from the rigid post to the less rigid dentin, whereas the modulus of elasticity of glass fiber post (18–23 GPa) is relatively similar to that of dentin.[16]

It is advised to use dual-curing resin composites for cementation of fiber post for effective curing of resin cement, which minimizes the risk of light attenuation and reduces polymerization shrinkage. Contraction stress of light-curing resin composite is higher than that of dual-cured resin composite while using it in the root canal.

The use of Biodentine for apexification helps in achieving primary monobloc effect in the root canal. The use of glass fiber post and dual-cured resin composite in the present case also helps in achieving secondary monobloc effect in the root canal.


  Conclusion Top


With appreciable properties and the ability to achieve biomimetic mineralization, Biodentine has great potential to revolutionize the management of affected tooth in operative dentistry and endodontics. In the present case, glass fiber post and core supported by Biodentine improved the fracture resistance of an immature young permanent central incisor. The concept of accomplishing monobloc with root dentin is imperative for durability of the foundation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 1
    
2.
Guerrero F, Mendoza A, Ribas D, Aspiazu K. Apexification: A systematic review. J Conserv Dent 2018;21:462-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 3
    
4.
Kahler B, Rossi-Fedele G, Chugal N, Lin LM. An evidence-based review of the efficacy of treatment approaches for immature permanent teeth with pulp necrosis. J Endod 2017;43:1052-7.  Back to cited text no. 4
    
5.
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review – Part I: Chemical, physical, and antibacterial properties. J Endod 2010;36:16-27.  Back to cited text no. 5
    
6.
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review – Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.  Back to cited text no. 6
    
7.
Camilleri J, Sorrentino F, Damidot D. Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement, Biodentine ® and MTA angelus. Dent Mater 2013;29:580-93.  Back to cited text no. 7
    
8.
Vidal K, Martin G, Lozano O, Salas M, Trigueros J, Aguilar G. Apical closure in apexification: A review and case report of apexification treatment of an immature permanent tooth with Biodentine ®. J Endod 2016;42:730-4.  Back to cited text no. 8
    
9.
Belli S, Eraslan O, Eskitascioglu G, Karbhari V. Monoblocks in root canals: A finite elemental stress analysis study. Int Endod J 2011;44:817-26.  Back to cited text no. 9
    
10.
Safavi KE, Nichols FC. Effect of calcium hydroxide on bacterial lipopolysaccharide. J Endod 1993;19:76-8.  Back to cited text no. 10
    
11.
Safavi KE, Nichols FC. Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment. J Endod 1994;20:127-9.  Back to cited text no. 11
    
12.
Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod 2007;33:680-9.  Back to cited text no. 12
    
13.
Butt N, Talwar S, Chaudhry S, Nawal RR, Yadav S, Bali A. Comparison of physical and mechanical properties of mineral trioxide aggregate and Biodentine ®. Indian J Dent Res 2014;25:692-7.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Ferrari M, Roberto S. Fiber Posts – Characteristics and Clinical Applications.  Back to cited text no. 14
    
15.
Ferrari M, Cagidiaco MC, Goracci C, Vichi A, Mason PN, Radovic I, et al. Long-term retrospective study of the clinical performance of fiber posts. Am J Dent 2007;20:287-91.  Back to cited text no. 15
    
16.
Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for the restoration of endodontically treated teeth: A systematic review of the literature – Part 1. Composition and micro- and macrostructure alterations. Quintessence Int 2007;38:733-43.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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