Revascularization of Permanent Premolars; Report of Three Cases with Clinical and Radiographic Outcomes

Case Report

Austin J Dent. 2016; 3(5): 1047.

Revascularization of Permanent Premolars; Report of Three Cases with Clinical and Radiographic Outcomes

Hatipoğlu Z*, Atabek D and Akal N

Department of Pediatric Dentistry, Gazi University, Turkey

*Corresponding author: Hatipoğlu Z, Department of Pediatric Dentistry, Gazi University, Gazi University Faculty of Dentistry No: 4 Emek, Ankara, Turkey

Received: September 29, 2016; Accepted: October 15, 2016; Published: October 17, 2016


Objective: Revascularization is a treatment in immature necrotic teeth which allows the continuation of root development. The aim of the present report was to introduce the successful regenerative endodontic treatment of three immature premolar teeth.

Study Design: The root canals were irrigated with 2.5% sodium hypochlorite with minimal instrumentation, followed by tri-antibiotic paste dressing (metronidazole, ciprofloxacin, amoxicillin). Instead of minocycline that is principally recommended for regenerative procedures, amoxicillin was used in order to avoid the discoloration of the crown. At a subsequent visit, the antibiotic paste was removed. A blood clot aroused in the canal by irritating periapical tissues and the root canals were sealed with MTA or BioAggregate, glass ionomer cement, and composite resin.

Conclusion: After 18, 24, and 30 months of radiographic and clinical followups respectively, the teeth were asymptomatic without discoloration, and the root developments were continued. It can be suggested that amoxicillin can be used successfully instead of minocycline in order to eliminate discoloration for regenerative endodontic treatment procedures.

Keywords: Antibiotics; Revascularization; Endodontics; Tri-antibiotic paste

Case Presentation

Treatment of necrotic immature teeth has always been a challenge in comparison to that of mature teeth [1]. The lack of an adequate apical barrier for condensation of gutta percha has traditionally required an apexification procedure to close the apex, enabling subsequent canal obturation. Apexification techniques originally involved induction of a calcific barrier at the apex with calcium hydroxide (Ca(OH) 2). Long-term use of calcium hydroxide inside the root canal space has several disadvantages such as multiple visits over a period of 9 to 20 months, a shortened root with thin walls, increased the likelihood of root fractures, poor crown-root ratio, probable recontamination of the root canal system, and increased dentin fragility [2].

Placing barrier material such as mineral trioxide aggregate (MTA) in the apical third of the canal is an alternative technique for apexification with calcium hydroxide, and MTA apexification success has been reported [3]. It has a high pH and antibacterial qualities similar to Ca(OH)2 and induces hard tissue formation. Its biocompatibility, an excellent sealing ability in the presence of moisture and efficient mechanical properties as an apical sealing material have also been reported. Especially, the shorter chair time seems to be an important advantage of the MTA apexification [4]. However, either apexification or the barrier technique doesn’t allow the continued root maturation that leads to weak root structure [ 5].

Regenerative endodontic treatment, which is a paradigm shift in the treatment of immature, necrotic teeth allows continued root development of the dentinal walls and apical closure [6]. The continued deposition of dentin occurs throughout the length of the root, providing greater strength and resistance to fracture. It is based on the presence stem and progenitor cells that have the ability to generate osteoid and odontoid structures from the pulp and /or periodontium [7]. The treatment offers regeneration of the stem cells, presence of a protein scaffold, and continuation of root development. These stem cells are dental pulp stem cells (DPSCs), which are more populated in the central-cell-rich zone of the pulp, bone marrow stem cells (BMSCs), stem cells from human exfoliated deciduous teeth (SHED), and stem cells from apical papilla (SCAPs) [8].

Regenerative procedures generally advocate that the placement of a tri- antibiotic paste is for eliminating intra-radicular infection from the root canal system [9]. The tri-antibiotic paste consists of a combination of ciprofloxacin, metronidazole (bactericidal), and minocycline (bacteriostatic), which was found sufficiently potent to eradicate the bacteria whereas the respective drugs used alone only reduced the bacteria [10]. However, crown discoloration, presumably due to minocycline, was reported as a disadvantage of this technique [11]. An alternative approach to discoloration was taken by Thomson and Kahler [12]. where amoxicillin was used instead of minocycline and a successful regenerative endodontic procedure without discoloration of a case was reported.

The other most important stage that affects the success of regenerative treatment occurs when removing the antibioticpaste formation of a blood clot and sealing of the canals with a biocompatible material that allows for the regeneration of new tissue adjacent to it [13]. Although the successful use of MTA as a sealing material is suggested, crown discoloration, depending on the presence of MTA, in the cervical portion of the canal is also reported [14]. In this context, researchers are looking for new, alternative materials. BioAggregate is a relatively new product, and its clinical applications include apexification, repair of root perforation and resorption, and vital pulp therapy [15]. Although MTA and BioAggregate have similar compositions and uses, BioAggregate does not create a risk of discoloration due to aluminum-free content [16].

This paper presents three case reports with successful regenerative endodontic treatment of three immature premolars using triantibiotic paste containing ciprofloxacin, metronidazole, amoxicillin, and BioAggregate as the sealing material.

Case 1

A healthy 10-year-old girl was referred to our clinic with complaints about spontaneous pain and swelling in the right side of her lower jaw. Patient’s medical history revealed no significant medical ailment. Clinical examinations revealed the mandibular right second premolar (LR5) tooth to be intact with no signs of caries and without any history of trauma; however, the developed abscess and the mobility were recognized. After radiographic examination, incomplete root formation (1/3 root formation) and a diffuse periapical radiolucency were diagnosed. A thin dentinal wall at the apex of the root that exhibited a wide- open apex and intracoronal radiolucent lesion was noted.

Considering the outcome of the clinical and radiographic examinations and the immaturity of the tooth, the diagnosis was pulpal necrosis with apical abscess, and the treatment option was revascularization.

After a complete explanation of the treatment procedure, its risks, benefits, and experimental nature, an informed consent was obtained from the patient’s parents. Firstly, local anesthesia with 3% plain mepivacaine (Septodont, Cedex, France) and rubber dam isolation was performed. An access cavity on tooth LR5 was prepared by using a diamond-coated fissure bur (Diatech, Heerbrugg, Switzerland) and a high-speed handpiece. The tooth was irrigated with 2.5% sodium hypochlorite for 10 minutes with minimal instrumentation. The canals were dried with paper points( Dentplus,Korea).The triantibiotic paste consisted of a powder of 20 mg of metronidazole (Flagyl, Eczacibasi, Turkey), ciprofloxacin (Cipro, Biofarma, Turkey), and amoxicillin (Largopen, Bilim, Turkey) each, mixed with 1 mL of sterile water. The paste was introduced into the canal with a lentulo and filled to the level of just below the cemento-enamel junction, and the tooth was restored temporarily with cavite (I-PRO, EU) and glass ionomer cement (Kavitan PRO, SpofaDental, Czech Republic) After three weeks, the patient was recalled, reporting that the tooth had been asymptomatic for that entire time. Moreover, the tooth was not sensitive to percussion and palpation. The temporary restorations were removed, the tooth was irrigated with 2.5% sodium hypochlorite, and the antibiotic paste was removed. The 25 K-file (Antaeos, Germany) was over-extended beyond the root length of the tooth several times in order to irritate the apical tissue until bleeding occurred apically in the root canal space and rose to the crown. By doing this, a biological scaffold for the regenerative process was created. After waiting 10 minutes, BioAggregate (Innovative BioCeramix Inc., Vancouver, British Columbia, Canada) was prepared according to the manufacturer’s directions, and 3 mm of BioAggregate was placed with the aid of a plugger and adapted softly to dentinal walls via a cotton pellet. The access cavity was sealed with glass ionomer cement and the acid etched composite resin (Tetric N-Ceram, Ivoclar Vivadent, Asia).

The patient was recalled at 3, 6, 12, and 30 months after treatment to evaluate the outcome. In clinical examination, the tooth was asymptomatic and functional with a normal periodontal condition. Also, the tooth was not tender to percussion or palpation and there was no presence of swelling. Radiographically, osseous healing of the periapical lesion was evident as well as the thickening of the dentinal wall and root maturation (Figure 1A-C). The appearance of the tooth showed no obvious change in shade or color (Figure 1D).