Dental Tribune United Kingdom Edition

February 201414 Endo Tribune United Kingdom Edition T his report discusses the successful management of an anxious 10-year old patient, who required root canal treatment of her immature up- per right central incisor, follow- ing a previous history of trau- ma. She was initially referred to the paediatric department at Birmingham Dental Hospital by her general dental practi- tioner. Following assessment and diagnosis, she underwent root canal therapy of her upper right central incisor, which was deemed to be non-vital and had an open apex. Patient details 10 year old female, school pupil History Presenting Complaint: The patient’s chief complaint was her ‘fractured front teeth’ which she did not like the ap- pearance 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 ob- vious 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 attend- ed Heartlands Hospital, from which she was referred to Bir- mingham Children’s Hospital for a chest x-ray, as the tooth fragments had not been ac- counted for. The chest x-ray re- ported no abnormalities. The patient then saw her GDP one day after the injury, and had adhesive compos- ite 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 asth- ma, for which she 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. Co-operation appeared to be reduced as the patient had not had any previ- ous extensive dental treatment, and was therefore quite nerv- ous. Examination Extra – oral Scarring was noted in the mid- line of the patient’s upper lip; she had sustained a laceration to this area at the time of injury. Intra – oral Soft tissues Oral hygiene was fair, but some gingival inflammation was pre- sent. Hard tissues Teeth present were: 6EDC21 12CDE6 6EDC21 12CDE6 Unrestored enamel-dentine fractures were evident on the UR1 and UL1, with the UL1 fracture being fairly extensive. Caries was noted on the LLD. Occlusion Occlusal analysis revealed a class 1 incisor relationship with class 2 right molars, and class 1 left molars. Special Investigations All maxillary incisors responded positively to ethyl chloride. The UR2, UL1 and UL2 responded positively to Electric Pulp Tester whilst the UR1 tested negative. None of the maxillary incisors were tender to percussion and no labial sinus or tenderness, discolouration or mobility was noted. Radiographic examination Periapical Radiographs Long cone periapical radio- graphs UR21, UL12 (Fig 1.1) re- vealed open apices on all maxil- lary incisors, and PDL widening around the apex of the UR1. It also showed the unrestored enamel-dentine fractures on both maxillary central incisors. Upper Standard Occlusal Radiograph This 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 maxil- lary canines. Soft Tissue X-ray The soft tissue radiograph of the upper lip revealed no ab- normalities, and no evidence of any tooth fragments in the lip (Fig 1.3). Diagnoses 1. Enamel-dentine crown fractures UR1 and UL1 2. Likely non-vital UR1; chronic apical periodontitis secondary to trauma 3. Caries LLD 4. Anxious patient Treatment options 1. Test cavity UR1, and pro- ceed to non-surgical root canal therapy with MTA apical plug if non-vital +/- RA sedation (Birmingham Dental Hospital) 2. The patient was quite nerv- ous, so the use of RA seda- tion was discussed; a RA sedation information sheet was given to the patient 3. Extraction of the UR1 with or without prosthetic replacement (GDP). Treatment plan 1. Immediate: cover exposed dentine UR1 and UL1 with GIC (Birmingham Dental Hospital) 2. OHI, dietary analysis and advice, bitewing radio- graphs (GDP) 3. Scale and polish, restore caries LLD, fissure seal 1st permanent molars (GDP) 4. Test cavity UR1 and pro- ceed to root canal treat- ment if non-vital +/- RA sedation. Dress with non- setting calcium hydroxide until stable. (Birmingham Dental Hospital) 5. Adhesive composite res- torations UR1 and UL1 +/- RA sedation (Birmingham Dental Hospital) 6. Review (Birmingham Den- tal Hospital) Treatment protocol Appropriate verbal and writ- ten 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, wedgets and Oroseal caulking material. The tooth, as expected, was found to be non-vital, and ex- tirpated and dressed with non- setting calcium hydroxide as an intracanal medicament. A tem- porary 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 resto- rations, and the UR1 root canal was further prepared. The root canal length was determined radiographically (Fig. 1.4), and the working length was meas- ured as 21mm. Chemo-mechanical cleaning of the canal was carried out us- ing K-flex handfiles, interdental brushes, and 2.5 per cent sodi- um hypochlorite irrigation. The final apical size of the canal was 80, due to the immature apex and lack of apical barrier. An apical stepback technique was used to prepare the wide canal. The canal was again dressed with non-setting calcium hy- droxide, 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 se- dation. At the next visit, the patient mentioned the tooth had been symptomatic. Therefore, it was decided to re-access and re-ir- rigate with 2.5 per cent sodium hypochlorite solution. The tooth was again temporary dressed with calcium hydroxide, a cot- ton wool pledget and GIC. At the following appoint- ment, the patient was asymp- tomatic. The canal was re-irri- gated with sodium hypochlorite and dried with paper points. A master cone periapical ra- diograph was taken (Fig 1.5) to confirm the length, and a 4mm apical plug of mineral trioxide aggregate was placed using the Micro Apical Placement System (Fig 1.6). The remaining ca- nal space was obturated with thermoplasticised 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 ef- fective coronal seal (Fig 1.7). Review Young Dentist Endodontic Award Non surgical endodontic treatment of the maxillary right central incisor with incomplete root formation by Rupal Shah. This is the second place entry for the 2013 Young Dentist Endodontic Award Fig. 1.1 Preoperative periapical radiographs Fig. 1.2 Upper standard occlusal radiograph Fig. 1.3 Soft tissue radiograph of upper lip Fig. 1.4 Diagnostic radiograph to determine working length; 21mm