Incompletely Developed Apices
Nathaniel T. Nicholson
Chief Complaint
“My dentist said I needed to come see you.”
Medical History
The patient (Pt) was a 12-year-old male. Vital signs were as follows: blood pressure (BP) 112/76 mmHg; pulse 76 beats per minute (BPM). He had no known drug allergies (NKDA), no medical conditions and did not take any medication.
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
The Pt had a history of routine dental care with the general dentist. He had never had any decay or any other oral problems. Pt was asymptomatic and receiving orthodontic treatment with bands and wires. The orthodontist recommended trying to save tooth #31, because the orthodontist did not think he could move tooth #32 into the position of tooth #31. Pt was then treated by a periodontist for gingivectomy of tooth #31 to allow access to treat. Pt was subsequently referred for treatment of tooth #31.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
No swelling or lymphadenopathy was found. The temporomandibular joint showed no popping/clicking or deviation.
Intra-oral Examination (IOE)
There was no swelling, oral cancer screening was within normal limits (WNL) and no pathosis was detected. Tooth #31 appeared intact, except for a small explorer stick on occlusal surface. Teeth #19 and #30 had orthodontic bands with wire running around the arch with brackets on the anterior teeth. Teeth #28 and #29 were unrestored. Tooth #30 also appeared unrestored.
Diagnostic Tests
| Tooth | #29 | #30 | #31 |
| Percussion | – | – | – |
| Palpation | – | – | – |
| Endo Ice® | + | + | + |
| Probing | 2–3 mm | 2–3 mm | 2–3 mm |
| Mobility | – | – | – |
+: Response to percussion or palpation, and normal response to Endo Ice®;-: No response to percussion or palpation, no mobility
Radiographic Findings
Although it was extremely difficult to get a radiograph of the tooth, tooth #31 had a large coronal radiolucency encroaching on the pulp chamber (Figure 24.2). There appeared to be normal root development on tooth #31, but root apices were still open (Figure 24.1). Tooth #30 appeared normal. Tooth #32 crown was partially visible. No other pathosis was observed on periapical (PA) radiograph.
Figure 24.1 Preoperative periapical radiograph of tooth #31 showing incompletely developed apices.
Figure 24.2 Preoperative bitewing radiograph showing the extensive coronal radiolucency encroaching on the pulp.
Pretreatment Diagnosis
Pulpal
Asymptomatic Irreversible Pulpitis, tooth #31
Apical
Normal Apical Tissues, tooth #31
Treatment Plan
Recommended
Emergency:None
Definitive:Pulpotomy for apexogenesis
Alternative
No treatment; Apexification; Direct Pulp Cap; Indirect Pulp Cap; Extraction
Restorative
Coronal Restoration with resin or amalgam, Crown
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): The medical history, vitals recorded, clinical and radiographic evaluation completed were reviewed with grandmother, as were findings, options, risks, benefits, and alternatives. Grandmother elected pulpotomy for apexogenesis on tooth #31 and informed consent was obtained. Benzocaine 20% topical was applied, and 144 mg of 4% articaine with 0.018 mg of epinephrine (epi) (1:200,000) was administered via inferior alveolar nerve block and long buccal nerve blocks. Rubber dam isolation (RDI) was used (Figure 24.3) with OpalDam® (Ultradent, South Jordan, UT, USA) around tooth and clamp. The occlusal of the tooth was opened, and while removing decay, the pulp was exposed (Figure 24.4). All decay was then removed, which resulted in the clamp coming off the tooth. An orthodontic band was fitted and cemented with Ketac™ (3M, Two Harbors, MN, USA) cement (Figure 24.5) after placing a sterile cotton ball over the pulp. The pulp chamber was accessed and the cotton pellet was removed. The coronal pulp tissue was removed with a high-speed diamond with water spray. Hemostasis was obtained (Figure 24.6) with a 2.5% sodium hypochlorite (NaOCl)-saturated cotton pellet after a few minutes and white mineral trioxide aggregate (White ProRoot® MTA; Dentsply Sirona, Johnson City, TN, USA) was placed in the pulp chamber (Figure 24.7). The tooth was then temporized with Fuji Triage® glass ionomer (GC America Inc., Alsip, IL, USA). The RDI was removed, occlusion was checked, a postoperative radiograph (Figure 24.8) was exposed, postoperative instructions were given, the need for coronal restoration was stressed, and the Pt was dismissed in good condition.
Figure 24.3 Preoperative photograph showing intact occlusal surface.
Figure 24.4 Pulp exposure during decay removal.
Figure 24.5 Orthodontic band cemented on with KetacTM cement (rubber dam clamp popped off and building up tooth was necessary in order to reapply clamp).
Figure 24.6 Pulp hemostasis after pulpotomy and decay removal completed.
Figure 24.7 MTA placed in pulp chamber.
Figure 24.8 Postoperative radiograph (taken with sensor vertical).
Post-Treatment Evaluation
Second visit (1 year 1 month follow-up): Clinical and radiographic exams were completed. PA of tooth #31 (Figure 24.9) showed continued root development. The Pt remained asymptomatic; there were no signs of pathosis, but tooth #31 still had a temporary filling. The importance of having the tooth restored was stressed.
Figure 24.9 Follow-up 1 year 1 month.
Third visit (1 year 9 month follow-up): Clinical and radiographic exams were completed. PA of tooth #31 (Figure 24.10) showed continued root development. The Pt remained asymptomatic, with no signs of pathosis, but tooth #31 still had temporary filling. The importance of having the tooth restored was stressed.
Figure 24.10 Follow-up 1 year 9 months.
Fourth visit (2 year 3 month follow-up): Clinical and radiographic exams were completed. PA of tooth #31 (Figure 24.11) showed root development complete. Pt remained asymptomatic, with no signs of pathosis, and tooth had been restored with a porcelain-fused-to-metal crown with margins that were within normal limits (WNL).
Figure 24.11 Follow-up 2 years 3 months.
Fifth visit (3 year 7 month follow-up): Clinical and radiographic exams were completed. PA of tooth #31 (Figure 24.12) showed apices still appearing normal. Pt remained asymptomatic, with no signs of pathosis, and margins of crown were WNL.
Figure 24.12 Follow-up 3 years 7 months.
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