Preference Of Obturation Techniques used For The Treatment Of Immature Non Vital Teeth By Dental Students

Keywords

Apexification; Apexogenesis; Lateral Compaction; Non Vital; Open Apex; Tooth Fracture.

Introduction

A non vital tooth is the one which has complete loss of blood supply, and immature teeth have incomplete root formation. Causes of immature non vital teeth may be due to trauma. Clinically there will be discoloration of the tooth associated with pain. Radiographically, there is a periapical radiolucency. When a tooth with incomplete root formation suffers pulp necrosis, the formation of dentin is stopped, root development ceases. In such a case, the canal remains large with thin and fragile walls. The root apex remains open. [1]

Endodontic treatment of such teeth has several complications. Two major difficulties involve chemco - mechanical preparation and obtaining an apical seal. The ultimate goal of endodontic treatment is the long retention of the teeth in function. Proper obturation is important for the long-term outcome.[2] Proper obturation involves, filling the root canal as completely as possible in order to prevent ingress of nutrients or oral microorganisms.[3] Sigurdsson et al suggest that immediate obturation of the tooth is the best timing.[4]

Proper assessment of the affected tooth is important in determining an accurate diagnosis and proper treatment planning. Frequently radiographic assessment of the affected tooth is done to assess the root development and clinical evaluation is done using the patient's history and pulp testing procedures. Apexogenesis is a procedure done to maintain the pulp vitality, which allows continued root formation along its entire length. Depending on the severity and the extent of inflammation procedures like pulp capping, shallow pulpotomy, conventional pulpotomy are done. Cvek et al explained that the affected young pulp can maintain its vitality for 7 days and only the most superficial part of the pulp has the inflammation and can be easily removed. This is because the young dental pulp is more cellular and is able to recover from injuries.[5]

If pulp necrosis occurs, an alternative treatment approach is carried out, because of the open apex the major difficulty in immature non vital pulp is that the necrosis of the pulp causes cessation of dentin deposition in the root leaving behind a thin, fragile dentin walls that makes it difficult to clean and obtain the necessary apical seal. Traditional approaches use calcium hydroxide to induce apexification after proper disinfection of the roots. Apexification is a procedure to induce a calcified barrier in a root with an open apex or continued apical development in an incompletely formed tooth with pulpal necrosis. Completion of the endodontic treatment is typically delayed until the formation of the calcified barrier.[6] Later Mineral trioxide aggregate has become the material of choice and overcomes the disadvantages of calcium hydroxide. Studies have confirmed the clinical outcome of MTA that includes proper apical seal and healing of the existing periapical lesion in the majority of the cases. [7]

Immature non vital teeth pose special challenges during endodontic procedures because of the wide open apex and thin dentinal walls. Debridement is primarily done by chemical means to remove the pulp tissue and for disinfection. Sodium hypochlorite and calcium hydroxide have excellent tissue resolving properties and antimicrobial effects.[8] Use of antibiotics have also been reported in previous studies. [9] Previously our team has a rich experience in working on various research projects across multiple disciplines [10-24].

Thus this study was conducted to evaluate the preference of obturation technique used for the treatment of immature non vital teeth by dental students.

Materials and Methods

Study setting

This was a retrospective - university based study. The patients who underwent treatment of the immature non vital teeth are included in the study. Study duration was from June 2019 to March 2020. Ethical approval was obtained from the Institutional Ethical Committee - Saveetha Dental College. (SDC/SIHEC/2020/ DIASDATA/0619-0320). Data of patients treated with immature non vital teeth was retrospectively collected from June 2019 to March 2020. Cases with incomplete data and repeated cases were excluded from the study. The data was cross verified by another reviewer to minimise sampling bias. The age group of patients involved in our study varied from 9 years to 16 years. So, the patients in our study were grouped into 2 categories based on age.

Category 1: 9 to 12 years, Category 2: 13 - 16 years. They were further sorted into 3 groups with respect to obturation technique: Category 1: lateral compaction, Category 2: matched taper single cone technique, Category 3: warm vertical compaction. The data were obtained from the patients visiting the department of Paediatric Dentistry, in our dental institution. Inclusion criteria - patients with immature non vital teeth undergoing endodontic treatment, exclusion criteria - case sheets with incomplete data. Case records were obtained from digital entries and were cross verified prior to being tabulated in Microsoft Excel sheet. Data collected was tabulated with respect to age, gender, tooth involved and obturation technique.The Excel sheet was transferred to the host computer and processed in SPSS v20. Chi square test was done to analyse the association and correlation with age and gender as independent variables and tooth involved and type of observation technique used as dependent variables. The statistical significance was set at 5%.

Results And Discussion

Lateral compaction is the most preferred observation technique with a frequency of 83.3%. Graph 1 represents the frequency of most preferred obturation technique for the treatment of immature non vital teeth. Lateral compaction (83.3%) is the most preferred technique followed by warm vertical compaction and matched cone paper technique.

Graph 2 explains the association between different age groups and teeth involved. There was no statistically significant association between the age groups and teeth involved (p= 0.392). Graph 3 represents the association between different age groups and obturation techniques used. Lateral compaction was the only obturation technique used for children under 13 years of age, however it, was statistically not significant (p= 0.086 ).Graph 4 shows association of gender and affected teeth, Males had the highest frequency of 83% (p = 0.372). Graph 5 shows the association of gender and obturation technique. Lateral compaction was the commonly used technique in both males and females. The association between gender and obturation techniques was statistically not significant (p= 0.424 ). Graph 6 represents the association between affected teeth and obturation technique. Lateral compaction was a commonly used technique for the maxillary anterior, followed by match cone taper technique and warm vertical compaction and was statistically significant (p= 0.028).

Root canal filling or obturation is an integral part of endodontic therapy. The purpose of obturation of the prepared root canal space is to prevent coronal leakage, bacterial contamination, seal the apex from periapical tissue fluids and the remaining irritants in the canal. Cold lateral compaction is the most commonly taught and practiced obturation technique worldwide and is set as a benchmark against other obturation techniques that has to be evaluated. This technique has several advantages that include low cost, the ability to control the length to fill. However certain disadvantages like formation of voids, spreader tracts, incomplete fusion of gutta percha and lack of adaptation leaves the treatment success questionable.[25]

In our study the frequency of most preferred obturation technique for the treatment of immature non vital teeth was assessed (graph 1). Lateral compaction is the most preferred technique with 83.3% followed by warm vertical compaction and matched cone taper technique. Studies have been conducted by Maryam Raoof, in which the findings are similar to the present study. The study states that the most popular obturation technique is cold lateral compaction. [26]

The association between the different age groups and teeth involved was assessed using Chi square test (Graph 2). The patients in our study were categorised into 2 equal groups 9 to 12 years and 13 to 19 years. The frequency of the tooth involved was also equal. There was no statistically significant association between the different age groups and teeth involved (p=0.392) The association between different age groups and obturation techniques used was assessed using chi square test (Graph 3).

Lateral compaction was the only obturation technique used for children under 13 years of age. But for patients above 13 years of age, all three techniques were used - lateral condensation, warm vertical compaction and match cone taper technique. Yet lateral compaction remains the most preferred obturation technique. However, there was no statistically significant association between age group and obturation technique (p=0.086). Al.Omari et al conducted a survey on the attitudes, materials and methods employed in Endodontic treatment by General Dental Practitioners in North Jordan. The results showed 31.3 % used lateral condensation technique, 9.9 % used vertical compaction and 12.2 % used paste. The findings were similar to our present study. [27]

The association of gender and affected teeth was assessed using Chi square test (graph 4). The female participants in our study were only about 16.67% and the involvement of mandibular anterior was only in male participants, this is due to contact sports and trauma. Kumar Reddy assessed the incidence of traumatic dental injuries in children aged 3 - 18 years in Tirupathi. The results showed that highest frequency of Traumatic Dental Injuries were between 10-12 years old, the highest cause being fall and contact sports [28, 29]. There was no statistically significant association between the gender and tooth affected (p = 0.372) On assessing the association between the gender and the obturation techniques used for the treatment of immature non vital tooth with Chi square test (graph 5) we could see the lateral compaction was the only technique used for the females, whereas all three techniques were used for males. As far as research has been conducted, there is no association between gender and the choice of obturation technique. In our study this corresponds to the tooth involved. Since, mandibular teeth are involved only in the male population, all three obturation techniques are involved in the males. However no statistically significant association between the gender and obturation technique (p = 0.424).

The association between affected teeth and obturation technique was assessed using Chi square test (graph 6). Lateral compaction was commonly used technique for the maxillary anterior (83.3%), followed by matched cone taper technique (11.1%) and warm vertical compaction (5.5%) for mandibular anteriors. There was a statistically significant association between the tooth involved and obturation technique.Our institution is passionate about high quality evidence based research and has excelled in various fields [30-40].

The findings of our present study adds up to the overall consensus of the previous similar studies. Yet, the study has few limitations, the sample size is very small and hence the results cannot be generalised to a larger population. The study was conducted in a University in Chennai. Hence, the study is single centered, possible manual errors during data collection. Further studies can be done in a larger population with assessing the obturation material preferred by the students. No contradictory literature findings observed.

×

Figure 1:

Close

Figure 1. Preoperative clinical frontal picture with Gingival inflammation in relation to 13-23 with supra-eruption of 11.

×

Figure 2:

Close

Figure 2. Intraoperative clinical picture of flap surgery with the use of provisional splints, PRF membrane and tetracycline root conditioning.

×

Figure 3:

Close

Figure 3. One-year postoperative clinical picture with non-vital 11 back to normal level of Occlusion with evidence of healthy attached gingiva.

×

Figure 4:

Close

Figure 4. Radiographic evaluation of 11 with preoperative diagnostic RVG and 1 year postoperative RVG: showing no evidence of change in underlying bone.

×

Figure 5:

Close

Figure 5. Intraoperative clinical picture of flap surgery with the use of provisional splints, PRF membrane and tetracycline root conditioning.

×

Figure 6:

Close

Figure 6. One-year postoperative clinical picture with non-vital 11 back to normal level of Occlusion with evidence of healthy attached gingiva.

Conclusion

The preference of obturation techniques for the treatment of immature non vital teeth was assessed. Lateral compaction is the most preferred technique with the frequency of 83%. With proper obturation technique and skills, fracture of the immature teeth can be prevented and successful treatment can be provided.

Author Contributions

First author ( Kalaivani N) performed the analysis, interpretation and wrote the manuscript. Second author (Dr.Mebin George Mathew) contributed to conception, data design, analysis, interpretation and critically reviewed the manuscript. Third author (Dr. Mahesh Ramakrishnan) participated in the study and revised the manuscript. All the three authors have discussed the results and contributed to the final manuscript.

Acknowledgment

The authors are thankful to Saveetha Dental College for providing permission to access the database and for giving a platform to express our knowledge.