Reliability of determining the age of majority: a comparison between measurement of open apices of third molars and Demirjian stages

AIM

This study examines the open apices of third molars indiscriminating between individuals who are or are not 18 years of age or older and to assign a cut-off for estimation of the age of 18 years. Furthermore, this method was compared to those based on Demirjian's stages 8 and 9.

METHODOLOGY

Orthopantomographs (OPGs) of 1062 individuals (14 and 23 years) were assessed, to verify Cameriere's third molar maturity index (I3M). The apical ends of the roots of the left mandibular third molar were analysed. Mineralization of the third molar was also evaluated.

RESULTS

A cut-off value of I3M =0.08 was taken. The sensitivity of this test was 70.76% and specificity was 82%. The results of the test showed a better specificity for Stage 9 and better sensitivity for stage 8 for adult age. Accuracy was 74.58% for third molar maturity index as compared to 72.41% for stage 9.

Preliminary Evaluation of Platelet Rich Fibrin-Mediated Tissue Repair in Immature Canine Pulpless Teeth

OBJECTIVE

To evaluate the use of platelet-rich fibrin (PRF) in the regenerative therapy of immature canine permanent teeth.

METHODS

Eight immature premolars of beagle dogs were pulp extracted and cleaned with irrigation, then divided into two groups of empty root canals and those filled with a PRF clot. All of the eight premolars were sealed with mineral trioxide aggregate and glass ionomer cement. Two premolars were left naturally grown as a positive control. The root development was assessed radiographically and histologically after 12 weeks.

RESULTS

The radiological findings showed greater increases in the thickness of lateral dentinal wall in the PRF group than in the vacant group. Histologically, dental-associated mineral tissue, connective tissue, and bone-like mineral tissue grew into the root canals independent of PRF clot use. The PRF was able to increase the thickness of dental-associated mineral tissue. However, the vital tissue differed from the pulp dentin complex.

CONCLUSION

Our study demonstrated the feasibility of using PRF-mediated regenerative therapy in pulpless immature teeth for improving tissue repair.

Recombinant Amelogenin Protein Induces Apical Closure and Pulp Regeneration in Open-apex, Nonvital Permanent Canine Teeth

INTRODUCTION

Recombinant DNA-produced amelogenin protein was compared with calcium hydroxide in a study of immature apex closure conducted in 24 young mongrel dogs.

METHODS

Root canals of maxillary and mandibular right premolars (n = 240) were instrumented and left open for 14 days. Canals were cleansed, irrigated, and split equally for treatment with recombinant mouse amelogenin (n = 120) or calcium hydroxide (n = 120).

RESULTS

After 1, 3, and 6 months, the animals were sacrificed and the treated teeth recovered for histologic assessment and immunodetection of protein markers associated with odontogenic cells. After 1 month, amelogenin-treated canals revealed calcified tissue formed at the apical foramen and a pulp chamber containing soft connective tissue and hard tissue; amelogenin-treated canals assessed after 3- and 6-month intervals further included apical tissue functionally attached to bone by a periodontal ligament. In contrast, calcified apical tissue was poorly formed in the calcium hydroxide group, and soft connective tissue within the pulp chamber was not observed.

CONCLUSIONS

The findings from this experimental strategy suggest recombinant amelogenin protein can signal cells to enhance apex formation in nonvital immature teeth and promote soft connective tissue regeneration.

Third molar development by measurements of open apices in an Italian sample of living subjects

The aim of this study is to analyse the age-predicting performance of third molar index (I3M) in dental age estimation. A multiple regression analysis was developed with chronological age as the independent variable. In order to investigate the relationship between the I3M and chronological age, the standard deviation and relative error were examined. Digitalized orthopantomographs (OPTs) of 975 Italian healthy subjects (531 female and 444 male), aged between 9 and 22 years, were studied. Third molar development was determined according to Cameriere et al. (2008). Analysis of covariance (ANCOVA) was applied to study the interaction between I3M and the gender. The difference between age and third molar index (I3M) was tested with Pearson's correlation coefficient. The I3M, the age and the gender of the subjects were used as predictive variable for age estimation. The small F-value for the gender (F = 0.042, p = 0.837) reveals that this factor does not affect the growth of the third molar. Adjusted R(2) (AdjR(2)) was used as parameter to define the best fitting function. All the regression models (linear, exponential, and polynomial) showed a similar AdjR(2). The polynomial (2nd order) fitting explains about the 78% of the total variance and do not add any relevant clinical information to the age estimation process from the third molar. The standard deviation and relative error increase with the age. The I3M has its minimum in the younger group of studied individuals and its maximum in the oldest ones, indicating that its precision and reliability decrease with the age.

Treatment outcome of mineral trioxide aggregate in open apex teeth

INTRODUCTION

This cohort study is the second phase of a previously reported trial. The primary aim was to assess the outcome of the treatment of teeth with open apices managed by the orthograde placement of mineral trioxide aggregate (MTA) apical plugs. The secondary goal was to identify potential outcome factors for this kind of treatment with a larger sample size and longer follow-up periods than in the first phase of the project.

METHODS

Two hundred twenty-one patients who had been treated between 2000 and 2010 were contacted for follow-up examination 12-128 months after treatment (median, 21 months). At the time of treatment, these patients presented a total of 252 teeth with open apices caused by apical root resorption or excessive apical enlargement or with immature apices. Treatment was performed by supervised undergraduate students (12% of teeth), general dentists (49%), and dentists whose practice was limited to endodontics (39%). The investigated outcome relied on clinical and radiographic criteria and was dichotomized as healed or diseased.

RESULTS

Of 252 examined teeth (88% recall rate), 90% were healed. Teeth with and without preoperative periapical radiolucencies demonstrated healed rates of 85% and 96%, respectively. Forty-five percent of the teeth (113/252) were followed up at least 2 years later and 21% (53/252) at least 4 years later. Univariate survival analyses identified 4 prognostic factors: preoperative apical periodontitis, the experience of the treatment providers, the number of treatment sessions, and the apical extrusion of MTA. Multiple regression analyses confirmed an increased risk of disease for teeth with preoperative apical periodontitis (hazard ratio = 4.59; 95% confidence interval, 1.57-13.4; P = .005). In addition, the experience of the treatment provider was found to influence the outcome (hazard ratio = 0.25; 95% confidence interval, 0.09-0.75; P = .03).

CONCLUSIONS

Orthograde placement of MTA apical plugs appears to be a promising treatment option for teeth with open apices. The healed rates for such teeth were high in this study, even after follow-up periods of more than 4 years. The presence of preoperative apical periodontitis was identified as an important prognostic factor.

Revascularization: a treatment for permanent teeth with necrotic pulp and incomplete root development

INTRODUCTION

Endodontic treatment of immature permanent teeth with necrotic pulp, with or without apical pathosis, poses several clinical challenges. There is a risk of inducing a dentin wall fracture or extending gutta-percha into the periapical tissue during compaction of the root canal filling. Although the use of calcium hydroxide apexification techniques or the placement of mineral trioxide aggregate as an apical stop has the potential to minimize apical extrusion of filling material, they do little in adding strength to the dentin walls. It is a well-established fact that in reimplanted avulsed immature teeth, revascularization of the pulp followed by continued root development can occur under ideal circumstances. At one time it was believed that revascularization was not possible in immature permanent teeth that were infected.

METHODS

An in-depth search of the literature was undertaken to review articles concerned with regenerative procedures and revascularization and to glean recommendations regarding the indications, preferred medications, and methods of treatment currently practiced.

RESULTS

Disinfection of the root canal and stimulation of residual stem cells can induce formation of new hard tissue on the existing dentin wall and continued root development.

CONCLUSIONS

Although the outcome of revascularization procedures remains somewhat unpredictable and the clinical management of these teeth is challenging, when successful, they are an improvement to treatment protocols that leave the roots short and the walls of the root canal thin and prone to fracture. They also leave the door open to other methods of treatment in addition to extraction, when they fail to achieve the desired result.

Case series: management of immature permanent teeth with pulpal necrosis: a case series

The management of immature permanent teeth with necrotic pulps has changed in recent years from apexification techniques to regenerative endodontic procedures, which enable apexogenesis with physiologic maturation of the roots. This regenerative technique lies squarely in the endodontist's scope of practice, but children presenting with necrotic immature incisors may pose behavior management problems that endodontists are untrained and unwilling to handle. Treatment of these immature permanent teeth provides an excellent opportunity for collaboration and shared patient management between pediatric dentists and endodontists that can yield optimal clinical outcomes. The purpose of this paper was to report a series of 32 regenerative endodontic cases in 28 children treated at the Nationwide Children's Hospital, Columbus, Ohio. The report describes procedural and patient management issues and the need for a collaborative relationship between pediatric dentists and endodontists in tackling these challenging cases.

Pulp revascularization in an immature necrotic tooth: a case report

Immature permanent teeth damaged by caries or trauma can present a challenge to dentistry. Currently, triple antibiotic paste (TAP) containing ciprofloxacin, metronidazole, and minocycline is used to attempt revascularization in necrotic immature teeth. Therefore, the purpose of this report was to present a case of pulp revascularization in an immature necrotic tooth. An 8-year-old male presented with trauma to the permanent maxillary left and right central incisors. Upon clinical and radiographic examination, the left central incisor was deemed necrotic. Revascularization therapy was performed over multiple visits. At 11 months follow-up, healing of the periapical area and apexogenesis were found to be complete. With an increasing breadth of clinical evidence and practitioner acceptance, regenerative techniques may become a standard technique in treating immature necrotic permanent teeth.

Revascularization of immature permanent incisors after severe extrusive luxation injury

Pulp necrosis is an uncommon sequel to extrusive luxation in immature teeth with incomplete apical closure. In this report, we describe the management of severely extruded immature maxillary incisors and the outcome of revascularization to treat subsequent pulp necrosis. An 8.5-year-old boy with severe dentoalveolar trauma to the anterior maxillary region as a result of a fall was provided emergency treatment consisting of reduction of the dislodged labial cortical bone and repositioning of the central incisors, which had suffered extrusive luxation. When he presented with spontaneous pain involving the traumatized incisors a week later, the teeth were treated via a revascularization protocol using sodium hypochlorite irrigation followed by 3 weeks of intracanal calcium hydroxide, then a coronal seal of mineral trioxide aggregate and resin composite. Complete periradicular healing was observed after 3 months, followed by progressive thickening of the root walls and apical closure. Follow-up observations confirmed the efficacy of the regenerative treatment as a viable alternative to conventional apexification in endodontically involved, traumatized immature teeth.

[Revascularization: a new treatment method in endodontics]

Recently a number of published articles concerning a new treatment method in traumatized young permanent teeth with a wide open apex that have lost vitality, with or without periapical lesions have shown success. This new treatment is entitled "Revascularization" and its aim is to promote root maturation in infected immature teeth with open apices. This procedure stimulates the formation of hard tissue as well as elongation and thickening of the dentinal walls and closure of the root apex. Sometimes the vitality of the teeth is regained. The aim of the present publication is to describe the revascularization technique and to clarify the indications of its use.

Clinical and radiographic evaluation of vital pulp therapy in open apex teeth with MTA and ZOE

The purpose of this study was to report the success rate of using mineral trioxide aggregate (MTA) and zinc oxide eugenol (ZOE) as vital pulp therapy agents in immature permanent teeth with carious or traumatic pulp exposure. Subjects were children with permanent teeth requiring pulpotomy (apexogenesis) and without systemic diseases. Both ZOE and MTA treatments as pulpotomy agents showed clinical and radiographic success in immature permanent teeth. Although MTA was more successful, it is more expensive, and dentin bridges may develop over canal orifices, complicating future root canal therapy.

Emerging therapies for the management of traumatized immature permanent incisors

Early loss of immature permanent teeth due to pulpal necrosis secondary to trauma can have dire consequences for a child's growth and development. The treatment alternatives include surgical endodontics, traditional calcium hydroxide apexification, and mineral trioxide aggregate (MTA) apexification. These options pose potential complications, including: arrest of root development; weakened dentinal walls; and increased potential for fracture. Revascularization of the dentin-pulp complex is a new approach that involves disinfecting the root canal system followed by tissue repair and regeneration while allowing for continued root development and thickening of the lateral dentinal walls through deposition of new hard tissue. The purpose of this report was to present the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption. Six months later, internal bleaching was performed to remove cervical discoloration from the triple antibiotic paste. At 18 months, the tooth remained vital and had evidence of continued root development.

Correlation between cervical vertebral and dental maturity in Iranian subjects

Determination of the skeletal maturation is extremely important in clinical orthodontics. Cervical vertebral maturation is an effective diagnostic tool for determining the adolescent growth spurt. The aim of this study was to investigate the correlation between the stages of calcification of teeth and the cervical vertebral maturity stages.

Age estimation in archaeological skeletal remains: evaluation of four non-destructive age calculation methods

Estimation of age at death is an essential part of reconstructing information from skeletal material. The aim of the investigation was to reconstruct the chronological age of an archaeological sample from Croatia using cranial skeletal remains as well as to make an evaluation of the methods used for age estimation. For this purpose, four age calculation methods were used: palatal suture closure, occlusal tooth wear, tooth root translucency and pulp/tooth area ratio. Cramer's V test was used to test the association between the age calculation methods. Cramer's V test showed high association (0.677) between age determination results using palatal suture closure and occlusal tooth wear, and low association (0.177) between age determination results using palatal suture closure and pulp/tooth area ratio. Simple methods like palatal suture closure can provide data about age at death for large number of individuals, but with less accuracy. More complex methods which require qualified and trained personnel can provide data about age for a smaller number of individuals, but with more accuracy. Using different (both simple and complex) age calculation methods in archaeological samples can raise the level of confidence and percentage of success in determining age.

Continued root-end growth and apexification using a calcium hydroxide and iodoform paste (Metapex®): three case reports

AIM

The aim of these case reports is to present a treatment to promote root-end growth and apexification in nonvital immature permanent teeth in children.

METHODS AND MATERIALS

Three cases were presented where the calcium hydroxide and iodoform paste Metapex® was placed in the root canals of immature permanent teeth using disposable plastic tips. The teeth involved were evaluated radiographically at regular intervals for the first 12 months after placement of the paste. At the end of 12 months all the cases showed continued root growth and apical closure (apexification) with no evidence of periapical pathology. Conventional endodontic treatment was then performed.

RESULTS

In all three of the clinical cases presented, a combination of calcium hydroxide and iodoform paste (Metapex®) was used and showed promising results in inducing root-end growth and closure after 12 months.

CONCLUSION

In these three clinical cases, the calcium hydroxide and iodoform paste Metapex® (Meta Biomed Co. Ltd., South Korea) was found to induce apical closure when assessed radiographically. Over a period of 12 months all the cases showed continued root growth.

CLINICAL SIGNIFICANCE

The calcium hydroxide and iodoform paste Metapex® promoted continued root-end growth with apexification in the nonvital immature permanent teeth treated.

Evolution of apical formation on immature necrotic permanent teeth

PURPOSE

To evaluate the evolution of apical formation on 28 necrotic immature permanent teeth treated with calcium hydroxide at different stages of root development.

METHODS

Apical formation in 28 necrotic incisors was carried out (27 upper and one lower incisors), in children between the ages of 6 and 13 years old (11 males, 10 females). Following anesthesia and rubber dam isolation, the chamber was opened and the coronal and root pulp tissue was removed. Next, after measuring the canal, the root canal was irrigated with 5% sodium hypochlorite. Once the canal was dried, it was filled with the CaOH2 powder mixed with physiologic saline solution to a dense consistency but malleable. This paste was compressed into the canal using a cotton pellet. The canal was completely filled up to the apex. Finally, the cavity opening was sealed with zinc oxide-eugenol (IRM) and glass-ionomer (Vitrebond). Follow-up appointments were made every 3 months in order to evaluate the evolution of the periapical radiolucency and the formation of the apical barrier.

RESULTS

The duration of the apical induction was 8.6 +/- 5.36 months. Increase or lack of growth in the length of the root canal and the type of root end closing was as follows: cementoid tissue (85.72%); osseous tissue (14.28%), with a 100% overall success rate. The evolution of these teeth was monitored over a 2-year period with re-infections occurring in 7.1 percent of the cases.

Apexogenesis treatment with a new endodontic cement: a case report

INTRODUCTION

This article describes an apexogenesis report of an 8-year old boy referred to our clinic 4 weeks after an impact trauma to the maxillary left central incisor that caused a complicated crown fracture and pulpal exposure.

METHODS

In the radiographic examination, the tooth was observed to be immature. After access cavity preparation, cervical pulpotomy was performed, and the remaining pulp was capped with calcium enriched mixture (CEM) cement. The crown was restored by using the fractured incisal segment on the next day.

RESULTS

The radiographic and clinical examinations on the 6-month and 12-month follow-ups showed that the tooth remained functional, root development was completed, and the apex was formed. A calcified bridge was produced underneath the capping material. No further endodontic intervention was necessary.

CONCLUSIONS

Considering the healing potential of traumatized immature vital pulp, the use of CEM cement for apexogenesis might be an applicable choice; however, further clinical studies with longer follow-up periods are recommended.

Dental age related tables for children of various ethnic groups in South Africa

The standard age estimation methods of Moorrees, Fanning & Hunt (1963) and that of Demirjian, Goldstein & Tanner (1973) have been shown by several authors to be inaccurate when applied to their juvenile population. This was similarly found to be true in South African children. Pantomographic radiographs of samples of South African children of White, Coloured, Indian and Black origin were used to develop dental age related tables for these ethnic groups. These dental age estimation tables were tested and are presented.

Evidenced-based review of clinical studies on the root apex

The practice of endodontics requires expertise in a number of clinical domains in order to reliably treat or prevent the development of apical periodontitis. In this topic area, we review clinical studies that focus on issues related to the apex of the root canal system. This might include anatomic studies or outcome studies. In this year, we review a recently published case series evaluating obturation of immature teeth with mineral trioxide aggregate (MTA).

The comparison between measurement of open apices of third molars and Demirjian stages to test chronological age of over 18 year olds in living subjects

This paper concerns a method for assessing adult age based on the relationship between age and the third molar maturity index (I(3M)), which is related to the measurement of the open apices of the third molar. Furthermore, this method was compared to those based on Demirjian's stages G and H. The sample consisted of 906 Caucasian individuals aged between 14 and 23 years (53.6% females and 46.4% males). Orthopantomographs were analyzed by two observers and calibrated by means of the concordance correlation coefficient for the reproducibility of the third molar maturity index (I(3M)) and kappa statistics for reproducibility of the Demirjian stages. Probabilities for an individual to be older than 18 years of age (adult age) were derived using the measurements of the third molar maturity index (I(3M)). These results were exploited to set out a threshold value to assign an individual to juvenile or adult age. A cutoff value of I(3M) = 0.08 was taken. The sensitivity of this test was 70% and specificity was 98%. Furthermore, the proportion of individuals with a correct classification was 83%. The results of the test showed a better specificity when compared to the choice of stage G and a better sensitivity when compared to the choice of stage H for adult age.

Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth

Pulp necrosis in immature teeth subsequent to caries has a major impact on long-term tooth retention. The aim of vital pulp therapy is to maintain pulp viability by eliminating bacteria from the dentin-pulp complex and to establish an environment in which apexogenesis can occur. A complicating factor in treating immature teeth is the difficulty predicting the degree of pulpal damage. The ability of the clinician to manage the health of the remaining pulpal tissue during the procedure is paramount. Currently, the best method appears to be the ability to control pulpal hemorrhage by using sodium hypochlorite. Mineral trioxide aggregate (MTA) currently is the optimum material for use in vital pulp therapy. Compared with the traditional material of calcium hydroxide, it has superior long-term sealing ability and stimulates a higher quality and greater amount of reparative dentin. In the medium-term clinical assessment, it has demonstrated a high success rate. Thus, MTA is a good substitute for calcium hydroxide in vital pulp procedures.

Regeneration potential of the young permanent tooth: what does the future hold?

During the last 10-15 years, there has been a tremendous increase in our clinical "tools" (ie, materials, instruments, and medications) and knowledge from the trauma and tissue engineering fields that can be applied to regeneration of a functional pulp-dentin complex. In addition, recent case reports indicate that biologically based endodontic therapies can result in continued root development, increased dentinal wall thickness, and apical closure when treating cases of necrotic immature permanent teeth. The purpose of this review was to summarize these findings and illustrate a path forward for the development and evaluation of regenerative endodontic therapies.

Diagnosis dilemmas in vital pulp therapy: treatment for the toothache is changing, especially in young, immature teeth

The literature is almost devoid of scientific studies of diagnosis of pulpal pathology in primary and permanent teeth with open apices. Most reports are empirical or retrospective studies without adequate prior knowledge of preexisting conditions or histologic findings leading to the necessity of pulpal procedures. Appropriate diagnostic tests and their effectiveness are documented for both groups. This article reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apex. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.

New emphasis in the treatment of dental trauma: avulsion and luxation

There are several protocols for the successful management of dental trauma emergencies. However, these existing protocols are inconsistent regarding several issues. As the Israeli dental community and patients have specific characteristics, a modified and adaptable protocol was required. This new protocol contains simple and straightforward clinical guidelines, arranged in table format, according to the nature of the trauma. The present study shows the protocol for luxation and avulsion injuries, with new recommendations for the treatment of luxated closed-apex teeth, the preferred at-site treatment and storage medium for avulsed teeth, and the conditioning of the root surface in these cases. To emphasize and explain the modification of this new protocol, research-based information has been incorporated.

Use of MTA for orthograde obturation of nonvital teeth with open apices: report of two cases

The purpose of this report is to present the treatment of 2 immature necrotic permanent incisors with the use of apical plugs of mineral trioxide aggregate (MTA) for apexification. With this technique, MTA mixture is used to create an artificial stop against which to condense gutta-percha in pulpless teeth with open apices. The report of these cases confirms that MTA acts an apical barrier and can be considered as an effective material to support regeneration of apical tissue in immature necrotic teeth. The treated teeth were asymptomatic, and radiographic follow-ups showed healing of periradicular tissues and new hard tissue formation in the apical area of the affected teeth.

Combined apexification and orthodontic extrusion of a hypoplastic permanent canine

Localized infection in the primary teeth was reported as an etiological factor in the formation of a hypoplastic defect in the underlying permanent teeth. The purpose of this report is to present the case of a 10-year-old girl with an unusual local hypoplasia in the mandibular left permanent canine and emphasize the importance of multidisciplinary management, including combined apexification and orthodontic extrusion. The 12-month recall examination revealed no pathology associated with the rehabilitation, and the patient's esthetic and functional expectations were satisfied.

Immunohistochemical Localization of Syndecan-1 in the Dental Follicle of Postnatal Mouse Teeth

BACKGROUND

Syndecans are cell surface heparan sulfate proteoglycans that modulate the action of growth factors and extracellular matrix components. Syndecan-1 plays important roles during early tooth development, and it is expressed in the dental follicle of fetal tooth germ. However, no studies have followed its expression in the dental follicle during the postnatal period. We hypothesized that syndecan-1 protein expression in the dental follicle may be important for postnatal tooth development, and, thus, examined its expression patterns.

METHODS

Syndecan-1 protein expression in the dental follicle of the lower first molar was investigated by immunohistochemistry using embryonic day (E) 18.5 to 21-day-old (d 21) mice. Immunoelectron microscopy was applied to the dental follicle and pulp cells to confirm its membrane localization in mesenchymal cells.

RESULTS

Strong syndecan-1 immunostaining was maintained in the dental follicle and the adjacent dental pulp surrounded by the Hertwig's epithelial root sheath (HERS) from d 4 to d 14, but reduced staining was noted at d 21 with the near-completion of tooth eruption. Three dimensionally, syndecan-1-positive areas plugged the apical foramina surrounded by HERS. However, immunostaining was detected constantly in the dental follicle and the dental pulp of the lower incisor at d 21. In addition, membrane localization of syndecan-1 protein was confirmed for the first time in mesenchymal cells, including dental follicle and pulp cells, by immunoelectron microscopy.

CONCLUSION

The spatial and temporal expression of syndecan-1 in the dental follicle suggests that this proteoglycan is important for the maintenance of proliferation and/or movement of cells in this region during tooth eruption.

Pulp Revascularization of Immature Dog Teeth With Apical Periodontitis

This study examined the ability of a collagen solution to aid revascularization of necrotic-infected root canals in immature dog teeth. Sixty immature teeth from 6 dogs were infected, disinfected, and randomized into experimental groups: 1: no further treatment; 2: blood in canal; 3: collagen solution in canal, 4: collagen solution + blood, and 5: negative controls (left for natural development). Uncorrected chi-square analysis of radiographic results showed no statistical differences (p >or= 0.05) between experimental groups regarding healing of radiolucencies but a borderline statistical difference (p = 0.058) for group 1 versus group 4 for radicular thickening. Group 2 showed significantly more apical closure than group 1 (p = 0.03) and a borderline statistical difference (p = 0.051) for group 3 versus group 1. Uncorrected chi-square analysis revealed that there were no statistical differences between experimental groups for histological results. However, some roots in each of groups 1 to 4 (previously infected) showed positive histologic outcomes (thickened walls in 43.9%, apical closure in 54.9%, and new luminal tissue in 29.3%). Revascularization of disinfected immature dog root canal systems is possible.

The measurement of open apices of teeth to test chronological age of over 14-year olds in living subjects

Age determination in living subjects is a problem of increasing interest in our community, due to the increasing numbers of individuals without identification papers, who have immigrated illegally or committed crimes, and for whom it is necessary to verify whether they have reached the age of 14 years in order to be charged legally. Although the most widespread methods for age estimation refer to skeletal or dental analysis, these methods do present some drawbacks for identification of the age of 14. The aim of the present study is to discriminate between children who are or are not 14 years of age or older by measuring the open apices of teeth. We evaluated the OPGs of 447 persons aged between 12 and 16 years, of Italian, Croatian and Slovenian nationality. For each individual, dental maturity was estimated using the number of the seven left permanent mandibular teeth with root development complete, and normalized measurement of the open apices of the third molar. The results revealed that an individual is considered to be 14 years of age or older if all seven left permanent mandibular teeth have closed apices and the normalized measurement of open apices of the third molar is lower than 1.1.

Contemporary treatment of class II dens invaginatus

AIM

To present the nonsurgical management of a tooth with class II dens invaginatus with an open apex utilizing contemporary techniques.

SUMMARY

Root canal treatment of teeth with complex root canal anatomy such as dens invaginatus can be problematic because infected pulpal tissues may remain in inaccessible areas of the canal system. The cleaning and debridement of such root canal systems are therefore challenging and may sometimes be considered impossible. An immature apical root-end development is another challenge in root canal treatment especially in controlling the apical extent of the filling material and achieving an apical seal. When difficulties in cleaning and filling combine, management options may include surgical intervention or extraction. This article reports the nonsurgical endodontic treatment of a case of an open apex and dens invaginatus utilizing the operating microscope, endodontic ultrasonic instruments and mineral trioxide aggregate.

KEY LEARNING POINT

Teeth with class II dens evaginatus and an open apex may be managed successfully with contemporary nonsurgical materials and techniques.

Sealing Properties of Mineral Trioxide Aggregate Orthograde Apical Plugs and Root Fillings in an In Vitro Apexification Model

One-visit mineral trioxide aggregate (MTA) apexification is gaining in popularity over the use of calcium hydroxide barriers. This study examined the sealing properties of two MTA apexification procedures using an in vitro apexification model. White MTA was introduced into instrumented single-rooted canals with standardized artificially created open apices to form 3- to 5-mm-thick orthograde apical plugs or complete orthograde fillings of the root segments. The remaining canal spaces in the former group were backfilled with thermoplasticized gutta-percha without a sealer. A Flodec fluid filtration device was used to record fluid flow across filled root canals at 48 hours and after 4 weeks of immersion in phosphate-buffered saline (PBS). Although MTA root fillings exhibited a better seal than MTA apical plugs at 48 hours, seals of these two groups were not significantly different after 4 weeks. Interaction of MTA with PBS may result in apatite deposition that improves the seal of MTA apical plugs with time.

The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study

AIM

To assess the outcome of apexification using mineral trioxide aggregate (MTA).

METHODOLOGY

Fifty-seven teeth with open apices on 50 patients referred for root canal treatment received an apexification procedure in one appointment with MTA by the same operator. Patients were recalled at 6 months, 12 months and every year thereafter. Blind to the treatment record, two examiners assessed the pre-treatment, post-treatment and control radiographs of the study patients in a dark room using a magnifier. Each apex visible on the radiographs was scored with the periapical index (PAI), and the size of the apical lesion was measured. The presence of an apical bridge was also noted. Kappa-Cohen test was used for examiners calibration. The paired t-test was used for statistical analysis of apical healing.

RESULTS

Forty-three cases were included with at least 12 months follow-up. When considering the PAI score and the decrease in size of the apical lesion, healing occurred in 81% of cases.

CONCLUSION

Apexification in one step using an apical plug of MTA can be considered a predictable treatment, and may be an alternative to the use of calcium hydroxide.

Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: a paradigm shift

Four clinical cases of immature teeth that developed periradicular periodontitis or abscess underwent a conservative treatment approach, i.e. without canal instrumentation. Instead, only copious 2.5% NaOCl irrigation was performed. All cases presented herein developed mature apices after 7 months to 5 years after the initial treatment without complications, although narrowing canal space was observed. Our clinical observations support a shifting paradigm toward a conservative approach by providing a favorable environment for tissue regeneration. The mechanism of this continued development and formation of the root end is discussed.

Preserving pulpal health of a geminated maxillary lateral incisor through multidisciplinary care

AIM

To report the multidisciplinary care of an unaesthetic geminated maxillary lateral incisor tooth, which allowed its preservation in the mouth.

SUMMARY

Preoperative examination of an unsightly geminated maxillary lateral incisor (tooth 22) demonstrated two pulp chambers and open apices, with normal pulp sensitivity responses. At surgery, a periodontal mucoperiosteal flap was reflected and the distal part of the geminated tooth was removed. The exposed root canal of the preserved tooth was sealed with mineral trioxide aggregate (MTA). The extraction socket and osseous defect was grafted with decalcified freeze-dried bone allograft (DFDBA) before flap closure. During follow-up, distal caries in tooth 22 and a diastema between tooth 22 and 23 were managed with composite resin restorations. Forty-two months postoperatively, normal thermal and electrical pulp sensitivity tests confirmed pulp health. Convincing apexogenesis and dentinogenesis of the developing root was confirmed by radiographic examination. Acceptable periodontal health including 3-4 mm clinical probing depths was achieved. Optimizing aesthetics and occlusion was accomplished without orthodontic treatment.

Comparison of apexification with mineral trioxide aggregate and calcium hydroxide

PURPOSE

The aim of this study was to compare mineral trioxide aggregate (MTA) with calcium hydroxide [Ca(OH)2] clinically and radiographically as materials used to induce root-end closure in necrotic permanent teeth with immature apices (apexification).

METHODS

Fifteen children, each with at least 2 necrotic permanent teeth requiring root-end closure (apexification), were selected for this study. All selected teeth were evenly divided into 2 test groups. In group 1, the conventional calcium hydroxide apexification (control) was performed, whereas in group 2, the MTA apexification (experimental) was done. The children were recalled for clinical and radiographic evaluations after 3, 6, and 12 months.

RESULTS

The follow-up evaluations revealed failure due to persistent periradicular inflammation and tenderness to percussion detected at 6 and 12 months postoperative evaluation in only 2 teeth treated with Ca(OH)2. The remaining 13 teeth appeared to be clinically and radiographically successful 12 months postoperatively. None of the MTA-treated teeth showed any clinical or radiographic pathology.

CONCLUSIONS

Mineral trioxide aggregate showed clinical and radiographic success as a material used to induce root-end closure and is a suitable replacement for calcium hydroxide for the apexification procedure.

The complete endodontic obturation of an avulsed immature permanent incisor with mineral trioxide aggregate: a case report

The use of mineral trioxide aggregate (MTA) for complete endodontic obturation of an immature maxillary central incisor is reported. The injured tooth of a 9-year-old male was avulsed secondary to a sports-related traumatic event. Early attempts at pulpal revascularization of the replanted tooth proved unsuccessful, as evidenced by radiographic signs of external inflammatory root resorption in the middle to cervical thirds of the root. Calcium hydroxide apexification over a 1-year period promoted cessation of the resorptive process, but was unable to adequately form an apical root canal barrier. Due to the extent of external resorption and the lack of an apical stop, a novel endodontic treatment using mineral trioxide aggregate was utilized. At 865 days post-injury, the tooth remained asymptomatic with clinical and radiographic evidence of periodontal health.

Radiographic appearance of apical closure in apexification: follow-up after 7-13 years

AIM

This was the radiographic evaluation of 15 maxillary incisors apexification treatment carried out on 7-9 years old patients with periapical pathology due to pulpal necrosis after dental trauma.

MATERIALS AND METHODS

The treatment consisted of two phases. The aim of first phase was the formation of a calcified apical barrier through calcium hydroxide medications repeated twice with a three months interval. The aim of the second phase was the obturation of the root canal system once achieved a radiographic evidence of the formation of an apical barrier. The treated teeth were radiographed at six months and then periodically once a year for a period of 7 and 13 years.

RESULTS

The radiographic analysis allowed to underline three different kinds of apical formation: a physiological development of the apical portion with a final root length equal to the contralateral tooth; the formation of a cap tissue and an apical development with the final root length slightly shorter than the contralateral tooth; or the formation of different layers of mineralised tissue that aggregate together trough the years.

CONCLUSION

Apexification is not a static phenomenon and the apexified area undergoes through the years to a conspicuous readjustment involving bone, apical root tissues and root filling material.

Association between growth stunting with dental development and skeletal maturation stage

The aim of this study was to determine the influence of growth stunting on the maturation stage of the medium phalanx of the third finger (MP3) and the dental development of the left mandibular canine in 280 high school children (140 stunted and 140 normal controls; equally distributed by sex) between 9.5 and 16.5 years of age, from a representative Peruvian school. Periapical radiographs of the MP3 from the left hand were used to determine the skeletal maturity stage, according to an adaptation of the Hägg and Taranger method. Panoramic radiographs were used to determine the dental maturity stage of the lower left canine, according to Demirjian method. Stunting was determined by relating height and age, according to the World Health Organization recommendations. There was no statistically significant difference in the skeletal maturation stage (P = .134) and the dental development stage (P = .497) according to nutritional status, even when considering different age groups (P > .183). A high correlation (r = 0.85) was found between both maturity indicators regardless of the nutritional status (growth stunted, r = 0.855 and normal controls, r = 0.863) or sex (boys, r = 0.809 and girls, r = 0.892). When skeletal level was considered, correlations values were similar between advanced (r = 0.903) and average (r = 0.895) maturers but lower (r = 0.751) for delayed maturers. Growth stunting was not associated with dental development and skeletal maturity stages in Peruvian school children.

Apexogenesis of a symptomatic mandibular first permanent molar with calcium hydroxide pulpotomy

Vital pulp therapy of immature, symptomatic permanent posterior teeth presents a challenge in pediatric endodontics. A case report is presented in which cervical pulpotomy with calcium hydroxide was performed on a cariously exposed mandibular first permanent molar. The patient was seen every 3 months for a total of 18 months for a clinical and radiographic follow up. During the follow-up period, root development, as evidenced by root lengthening, was observed. Apical closure was evident at the end of 19 months. As the root canals showed a tendency toward calcification, root canal treatment was carried out, followed by restoration of the tooth with a stainless-steel crown. The success of this single-visit apexogenesis procedure supports the contention that young pulp possesses remarkable reparative capacity, as well as resistance to bacterial infection due to greater vascularity, and that apexogenesis with calcium hydroxide apical closure pulpotomy can be attempted for continued root development of symptomatic, vital, permanent teeth.

Continued root formation of a pulpless permanent incisor following root canal treatment: a case report

AIM

To present a case of a pulpless permanent incisor that continued root formation following root canal treatment.

SUMMARY

A healthy 8-year-old girl with a history of dental trauma resulting in a coronal fracture involving enamel, dentine and pulp was referred by her general dental practitioner for treatment and evaluation of tooth 21. The tooth had a necrotic pulp and periapical rarefaction was evident radiographically. The canal was prepared, dressed with Ca(OH)2 and then filled with a rolled gutta percha cone and Roth's root canal sealer. A radiograph exposed eight years post-treatment, showed evidence of continued apical formation.

KEY LEARNING POINTS

*Teeth with necrotic pulps and periapical rarefaction may show evidence of continued apical formation after root canal treatment. *Hertwig's epithelial root sheath may be more resistant than expected to trauma and infection.