Apexogenesis and revascularization treatment procedures for two traumatized immature permanent maxillary incisors: a case report
A 9-year-old boy was referred to the Department of Endodontics with pain on chewing and localized swelling on the anterior region of maxilla and a history of prior impact trauma three months previously. His medical history was non-contributory. Clinical examination showed complicated crown fracture on both maxillary central incisors. A large pulpal exposure, sensitivity to palpation and percussion and also localized swelling on the buccal mucosa of the right central incisor was observed. Cold thermal test elicited no response in this tooth. Left central incisor with a pinpoint pulpal exposure had no sensitivity in periapical tests and showed lingering painful response to cold test. Radiographic examination revealed that the fractured teeth had immature apices, and a radiolucent periapical lesion was observed adjacent to the right central incisor (). Based on clinical and radiographic examinations, the definitive diagnosis was irreversible pulpitis in the left central incisor and pulpal necrosis with symptomatic apical abscess in the right central incisor. Considering the immaturity of the teeth, the first treatment option was vital pulp therapy for the left central incisor and revascularization of the right one.\nUnder local anesthesia with 2% Lidocaine and 1 : 800,000 epinephrine (Xylocaine 2%, Dentsply, Addlestone, UK) and rubber dam isolation, an access cavity was prepared for the left central incisor. Coronal pulp tissues were removed by using a high-speed sterile long shank round diamond bur under copious water spray. The area was rinsed with normal saline solution and hemostasis was achieved by a cotton pellet moistened with 5% sodium hypochlorite (NaOCl). White Mineral Trioxide Aggregates (ProRoot MTA, Dentsply, Tulsa, OK, USA) powder was mixed with distilled water according to manufacturer's instructions and placed without pressure over the exposed clot-free pulpal wound (). The material was gently patted down with a moist cotton pellet. Then a moistened cotton pellet was placed over MTA and the tooth was temporarily filled with Cavit (Asia Chemi Teb Co., Tehran, Iran). One day later, the teeth were restored permanently with composite resin (Filtek Z350, 3M ESPE, St. Paul, MN, USA).\nAn access cavity was prepared for the right central incisor using the same procedure. On entering the pulp chamber, purulent drainage was observed. Length was estimated radiographically using a size #15 K-file (K-file, Mani Corp., Tokyo, Japan). The canal was passively irrigated with 20 mL of 5.25% NaOCl and gently dried with paper points. A creamy mixture of equal proportions of ciprofloxacin, metronidazole and minocycline, as described by Hoshino et al., was placed in the root canal with a #25 K-file up to 3 mm short of the radiographic apex. The access cavity was sealed temporarily with Cavit. After 3 weeks the patient was asymptomatic and the localized swelling had resolved. The tooth was anesthetized with a local injection of 3% plain Mepivacaine (Septodont, Cedex, France) without vasoconstrictor. After rubber dam isolation and removal of Cavit dressing, the antibiotic dressing material was removed by irrigation with 10 mL of 5.25% NaOCl and saline. The canal was then dried with paper points. A #40 K-file was used to irritate the apical tissues to create some bleeding into the root canal. The bleeding was allowed to reach the middle part of the canal. Ten minutes later, after the formation of a blood clot, white MTA was mixed and placed over the clot carefully (). A moistened cotton pellet was placed over MTA and the tooth was restored temporarily with Cavit. One day later the patient was referred for permanent restoration of this tooth.\nThe patient was recalled 6, 12 and 18 months after the treatment. In clinical examination, the teeth were asymptomatic. In radiographic examinations, both teeth showed increased root lengths and apical closure. Root wall thickness had also increased, but the left central incisor showed greater improvements. The radiolucent lesion adjacent to the right central incisor had healed ( and ).