Management of Traumatized Immature Vital Tooth: A Case Report

Abstract

Trauma to front tooth is one of the disturbing conditions for children and parents. The treatment strategies used to treat the immature young dentition are important for the long-term prognosis of teeth and should aim at preserving pulp vitality to secure tooth maturation and root development. This article describes a case of trauma to upper front tooth with open apex. The patient was treated with vital pulp therapy with mineral trioxide aggregate to induce apexogenesis.

INTRODUCTION

Trauma to front tooth is one of the distressing conditions for children and parents. Various factors should be considered in treating immature young permanent tooth. Among the various factors, the most important are age of the patient and root end completion. Traumatic injuries of immature teeth cause physical, psychological, and esthetic considerations.[1]

The immature young permanent tooth should be treated with strategies that are important for the long-term prognosis of teeth. The treatment strategies should try to preserve the pulp vitality to secure continued root development.[2] The term apexogenesis is used to describe vital pulp therapies performed to allow the continuation of the root end.[3]

Mineral trioxide aggregate (MTA), the newer material, gold standard for vital pulp therapies, provides long-term seal, acceptable biocompatibility, and dentinal bridge formation.[4]

CASE REPORT

A 9-year-old male patient reported with the chief complaint of trauma to upper front tooth 1 day before. Clinical examination revealed Ellis class III fracture in 11 [Figure 1]. Radiographic examination in relation to 11 revealed an open apex [Figure 2]. There was no periapical pathology in relation to 11. Considering the age of the patient and open apex, it was decided to perform apexogenesis in 11 through vital pulp therapy.

Figure 1.

Clinical preoperative

Figure 2.

Preoperative radiograph

Cvek’s pulpotomy was performed and MTA was placed [Figures 3 and 4]. The tooth was sealed coronally with zinc oxide eugenol paste. After 3 days, the coronal seal was performed with glass ionomer cement. When the patient was reviewed after 1 week, there were no signs of inflammation. Then the patient was followed up at 3 months, 6 months, and 1 year. There were no signs of inflammation and mobility clinically. Radiographs at 3 months, 6 months, and 1 year revealed continued root end development [Figures 5–7]. After 1 year, the tooth was restored esthetically [Figure 8].

Figure 3.

Pulpotomy performed

Figure 4.

Mineral trioxide aggregate placed

Figure 5.

Three-month follow-up

Figure 7.

One-year follow-up

Figure 8.

Postendodontic restoration

Figure 6.

Six-month follow-up

DISCUSSION

Traumatic injuries to young permanent teeth are common and affect most of the children. Mostly the traumatic incidents occur before root formation is complete.[5] Trauma to immature tooth causes termination of dentin formation and root end development. Due to this, the root canal remains large with thin walls and wide apex. In such cases, attempts to induce continued root end development (apexogenesis) or closure at current level (apexification) are the treatment options left. Apexogenesis performed within 24 h has positive outcome.[1] In this case considering the age of the patient, an open apex vital pulp therapy was performed to induce apexogenesis.

Calcium hydroxide was once considered as the gold standard for pulp-capping materials. Long-term studies have shown unpredictable results. The material does not closely adapt to dentin and does not induce odontoblast differentiation, and in cell cultures, it is cytotoxic. MTA is a bioactive cement that has been proved to be an effective pulp-capping material. MTA has been proved to induce pulp cell proliferation and hard tissue formation. The material has the advantages of hydrophilic nature, nonabsorbable, a relatively high compressive strength, and a sustained high alkaline pH.[6] Hence in this case, MTA was selected for vital pulp therapy.

CONCLUSION

Trauma to anterior teeth at a young age is a challenging condition. The clinician should try to preserve the vitality of the involved tooth whenever possible. With the invention of newer materials, a positive outcome for vital pulp therapies has increased. So one should be thoughtful before treating a patient with open apex.

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