•Prenatal history:

TM's mother maintained good health throughout her pregnancy. Apart from the routine pregnancy regimen, which included multivitamins and iron supplements, she did not take any other medications. She followed a regular diet without any special dietary restrictions.

•Natal history:

TM was born full-term with no reported neonatal jaundice, birth complications, injuries, or congenital abnormalities.

•Postnatal history:

TM was breastfed for two months before transitioning to bottle-feeding, which continued for two years. During this time, he was given only formula and water in the bottle. TM's mother did not wipe his mouth after feeding, and he occasionally slept with the bottle. After weaning, his diet included milk with added sugar, sugary juice, and tea consumed from a regular cup.

Social history: 

TM lives with his single mother and two grandparents. While his mother works, his grandparents care for him. For the first visit, TM was accompanied by both his mother and grandfather. For subsequent appointments, he was brought by his grandfather. 

Medical history:

TM is a healthy child with no significant childhood illnesses. He has received all his vaccinations, has no known allergies, and has not undergone any previous operations.

Dental history and oral hygiene practice:

TM was 8 years old at his first dental visit when he sustained the trauma. No dental procedures have been performed under sedation or general anaesthesia. TM brushes his teeth once a day in the morning using adult toothpaste since he was four years old. Prior to this, his grandparents and mother assisted him with brushing. Flossing is not part of his oral hygiene routine.

TM is a confident and relaxed child, showing no signs of anxiety or nervousness. He is very intelligent and has an excellent academic record at school. TM has a passion for watching Formula 1 races and enjoys collecting race car toys. He loves skiing and dreams of becoming a professional skier. Additionally, he is very sociable and makes friends easily.

Extra-oral examination: TM has a symmetrical face with no palpable lymph nodes. The temporomandibular joint (TMJ) functions normally. However, the mentalis muscle appears stretched.

Morphological examination of the face:

A Convex profile. The maxilla is prognathic, while the mandible is slightly retrognathic. Additionally, TM has incompetent lips.

Molar Classification: Right class I, Left class I

Midlines: Maxillary midlines: 2mm to the left.

; Mandibular midlines Coincide with the midsagittal plane.

Overjet: 12 = 7.5mm, 21 = 5mm

Overbite: 21 = 3mm

Open Bite: 12 = 3.5mm

Crossbite: None

Buccal Canine Bulges: Palpable

Habits: None. 

No abnormalities were found in the tongue, frenum, or mucosa. However, there is a 2mm gingival recession on tooth 11 (Class I; Miller's classification), visible plaque, and mild gingival inflammation. Food impaction was detected in the fourth quadrant, between teeth 46 and 85.

The bony and soft tissue anatomy appear normal, with all teeth accounted for. Tooth 11 is intruded. The canines are in a favourable position. However, the eruption sequence is unfavourable in the third and fourth quadrants, with teeth 33 and 43 appearing ahead of teeth 34 and 44. The leeway space is compromised due to interproximal caries in quadrants one (55, 54), two (64, 65), and four. Tooth 46 has started to tilt due to distal caries on tooth 85. The dental age is approximately eight years, corresponding to the first transitional stage.

Maxilla/Mandible

Molar classification: Class I on both sides.

• Increased overjet

TM is considered a high-caries-risk child due to several factors. He only brushes his teeth once a day and does so improperly, does not floss, and has multiple cavities in both his primary and permanent teeth, along with visible plaque. Furthermore, he has not received professional topical fluoride treatment and does not have regular dental check-ups.

According to Frankl's behaviour rating scale, TM's attitude was positive (Shao et al., 2016).

The behaviour management techniques that were used included tell-show-do, distraction, and positive reinforcement. Noting TM's love for collecting race car toys, I promised him a toy car if he behaved and followed instructions. Given that his treatment involved injections and this was only his second exposure to a dentist, we aimed to ensure he maintained a positive attitude toward dental treatment.

Treatment sequence: We started with tooth 11 as it was an emergency. After relieving the pain, we proceeded with the least invasive procedures to gain TM's trust. Although TM's grandfather mentioned that he had been cooperative and motivated during the emergency treatment after sustaining the trauma, we did not want to take it for granted and risk losing his cooperation.

Restorative Phase:

16o: Sealant restoration

55m&d (D1)

21: Enamel #

65mo: D3 possible pulp therapy

26o: sealant restoration

36ob: sealant restoration

75ob: D1.

Pulp Therapy

A periapical view showed open apices in teeth 12, 11, 21, and 22.

An upper occlusal radiograph was taken to rule out root fractures, and none were found.

According to Bourguignon et al. (2020), diagnosing root fractures requires one parallel periapical radiograph, two additional radiographs with different angulations, and an occlusal radiograph.

The final diagnosis, based on history, clinical, and radiographic examination, was pulpal necrosis with apical periodontitis in tooth 11.

Treatment: Apical Barrier Formation (ABF) Using MTA

Other Options:

Apical Barrier Formation (ABF) Using Biodentine.

Ca(OH)2 Apexification.

Regenerative endodontic.

• Evidence Review for MTA Plug Use:

In reviewing the evidence for MTA use, it is clear that currently available evidence does not meet the strict criteria set out by the Cochrane Collaboration. However, despite all the limitations in the reported studies in the literature, most, if not all, have demonstrated excellent clinical outcomes for non-vital immature teeth where MTA was used to create an apical plug, followed by root canal obturation. MTA apexification appears to produce better clinical and radiographic success rates overall among endodontic treatments available in immature necrotic permanent teeth (Duggal et al., 2017, Nicoloso et al., 2017).

• Purpose of ABF: To prevent bacterial invasion and allow for a root-filling material and permanent restoration to be placed. This barrier also reduces the amount of root-filling material that is in contact with the periapical tissues, therefore minimising the risk of sealer extrusion into the surrounding tissue fluid. In this environment, the sealer dissolves and can allow leakage of the tissue fluid into the root canal system, which can supply nutrients to any harbouring bacteria  (Shah et al., 2022).

Oral surgery

• 85: XLA. Unrestorable. There is no need for a space maintainer as no bone covers the 45 (Watt et al., 2018).

Orthodontics

• Consultation regarding the increased overjet.

First Visit

• Emergency RCT

TM reported no pain or discomfort.

1/ Diagnosis and treatment plan.

2/ Oral Hygiene Instruction and Demonstration:

Active brushing and flossing using a disclosing agent. Although TM is 9 years old and can tie his shoelaces neatly and write, TM's grandfather was advised to assist him in brushing his teeth twice a day and to floss as much as possible, as he never learned how to brush properly.

3/ Fissure sealant: 46. As TM is a high-caries-risk child and good moisture control was achieved, the resin-based fissure sealant 3M™ Clinpro™ Sealant was selected for its fluoride-releasing, caries-preventive benefits (Simonsen, 2002).

4/ 36: Sealant restoration. Dyract Flow was used as the restorative material. This choice was made because good moisture control was achieved, TM was cooperative during the procedure, and the material's fluoride-releasing properties were beneficial.

5/ Fluoride application

Because of the controlled swallowing reflex at his age, and he could understand the instructions. Acidulated phosphate fluoride gel ([APF]; 1.23% F, 12,300 ppm F) 4 times per year as he is a high-risk child.

Professionally applied topical fluoride treatments are efficacious in reducing the prevalence of dental caries. APF has a low pH, enabling it to deliver fluoride faster into enamel (AAPD).

However, in the following visits, 5% sodium fluoride varnish (2.26% fluoride, 22,600 ppm F) will be applied instead of APF as multiple resin-based restoration has been implemented. APF should be avoided on teeth with certain dental restorations, such as porcelain crowns or composite fillings, as the acidic environment can etch and damage these materials (Shabzendedar et al., 2011).

Tooth 11:

After the administration of LA ( one ampule of 2% lidocaine with 1:100,000 epinephrine via the STA system) and rubber dam placement. 

The temporary filling was removed, and the canal was thoroughly irrigated with 5% sodium hypochlorite. 

A K file with a circumferential filing motion was used to remove the Ledermix, followed by a final irrigation with 17% EDTA to remove the smear layer.

An appropriate plugger was selected—one size smaller than the one that binds 1-2 mm short of the working length (Steinig et al., 2003). 

NuSmile NeoMTA2 was mixed according to the manufacturer's instructions and delivered to the canal using the MAP system. 

After placing three loads of MTA, a periapical radiograph showed the MTA plug appeared smaller than expected, so an amalgam carrier was used to place a larger load of MTA.

A subsequent periapical radiograph revealed a small radiopaque body approximately in the middle of the MTA plug. The procedure was halted to determine the cause, and it was concluded that a remnant of amalgam, likely stuck in the amalgam carrier, had been inadvertently introduced into the canal along with the MTA. The radiopacity is consistent with amalgam.

Thermoplastic backfill technique with Gutta-Smart from Dentsply Sirona was used to fill the rest of the canal.

It is not recommended to use a master cone after placing an MTA plug because it can result in over-extrusion of gutta-percha (Shah et al., 2022). This over-extrusion can compromise the seal created by the MTA plug (Shah et al., 2022). The MTA plug is specifically designed to create a barrier at the apex, and using a master cone can damage this barrier. Instead, it is preferred to use a thermoplastic backfill technique because it allows the gutta-percha to be melted and pushed into the canal, creating a three-dimensional seal without the risk of over-extrusion (Shah et al., 2022).

The access cavity was sealed with composite resin restoration.

•16o: Sealant restoration (Dyract flow).

•55m&d: Both cavities were filled with compomer Dyract XP, chosen due to TM's cooperation and the good isolation achieved. Given that both cavities were in high-stress-bearing areas and TM is a high caries risk child, the fluoride-releasing properties of compomer Dyract XP made it the material of choice. Other options included Vitremer, both with similar failure rates (Pummeret, 2019).

•Additionally, the fluoride-releasing properties will control the mesial caries on the 16.

• Impressions for the orthodontic study models and mouth guard.

• Delivery of the mouth guard.

TM has incompetent lips and an increased overjet (7.5mm). Increased overjet, particularly with dental protrusion and inadequate lip coverage, significantly raises the risk of dental trauma, with a global increase in trauma risk of about 21% (Cobourne et al., 2022). Mouth guard Shields teeth from potentially traumatic blows and absorbs/dissipates energy (de Wet et al., 1999). Additionally, TM practices skiing even though it is not a contact sport; it still carries the risk of dental trauma. Any activity involving a risk of injury necessitates protective consideration (Polmann et al., 2020; Navarro et al., 2018).

• The orthodontic department has been consulted regarding the increased overjet. They advised waiting until TM reaches full permanent dentition, as extractions will be required to create sufficient space for correcting the overjet. TM has been placed on the orthodontic waiting list for future treatment.

• The periodontal department has been consulted regarding the 2 mm gingival recession on tooth 11. They recommended waiting until orthodontic treatment is complete before addressing the recession. In the meantime, they advised brushing tooth 11 gently and closely monitoring it for signs of ankylosis. Should management via decoronation be considered, apicectomy would be necessary to remove the MTA plug and the piece of amalgam filling.

·       Schedule appointments every three months and a radiograph every six months as he is a high caries risk.

·       Fluoride application every 3 months

·       monitor the non-cavitated lesions on the 16m (E1), 65d (E2), 26m (E1)&46m (E1)

·       monitor the 11&21: Look for external resorption and signs of ankylosis, especially for the 11, as it was severely luxated.

• Intrusion luxation in permanent teeth can lead to significant healing complications (Abbott, 2016), particularly in severe cases such as TM's. These complications include inflammatory radicular resorption, ankylosis, pulp necrosis, pulp canal obliteration, and calcifications (Sapir and Shapira, 2008). In TM's case, pulp necrosis has already occurred, and the tooth has been treated with an apical plug using MTA. Currently, the main concerns are inflammatory radicular resorption and ankylosis.

Ledermix intracanal medicament has been used in TM’s case as it is effective in preventing and managing external inflammatory resorption (Abbott, 2016).

Ankylosis in permanent incisors can result in the early loss of the traumatized tooth, along with localized arrest of alveolar bone development. Potential complications include:

• Aesthetic issues: Changes in the tooth's position lead to disharmony in the smile.

• Orthodontic problems: Including arch irregularity, tilting of adjacent teeth, and arch length loss.

• Alveolar bone deficiency: This may compromise future prosthetic solutions, potentially requiring complex regenerative procedures to ensure sufficient bone and soft tissue for an esthetic outcome with an implant (Abbott, 2016).

In children aged 7–16 years, tooth loss typically occurs within 3–7 years after the onset of root resorption, while in adults, the process is slower, and the tooth may survive for 20 years or more (Sapir and Shapira, 2008). Early signs of ankylosis include reduced physiologic tooth mobility and a metallic tone upon percussion. Radiographically, ankylosis presents as a loss of periodontal ligament space and the replacement of root dentin with bone. Notably, the metallic sound on percussion often precedes radiographic confirmation (Andreasen et al., 2018).

Although early detection of ankylosis does not change the ultimate outcome of tooth loss in growing children, planning treatment earlier can help improve management, preparing both the patient and family for short, medium, and long-term treatment strategies (Abbott, 2016). The aim is to maintain the ankylosed tooth for as long as it provides acceptable function and aesthetics without compromising future rehabilitation.

Management options for ankylosis include:

• Autogenous tooth transplantation using a premolar to replace the traumatized maxillary central incisor.

• Decoronation to preserve the alveolar bone.

• Intentional reimplantation after extraction.

• Distraction osteogenesis.

• Early extraction and replacement with a removable prosthetic appliance (Abbott, 2016).

The potential complications were discussed with TM and his grandfather. They were informed that, should complications arise, the management options will be thoroughly reviewed and discussed to determine the most appropriate course of action.

TM was my first comprehensive case, and I gained significant experience in managing his treatment. However, looking back, I believe there were areas where improvements could have been made. One notable aspect is that the procedures could have been better organized to reduce the number of visits.

During the apexification procedure on tooth 11, I initially applied three layers of MTA using the MAP system. The volume appeared smaller than anticipated, so I switched to an amalgam carrier to deliver a larger quantity of MTA. Unfortunately, I neglected to inspect the carrier beforehand, and a piece of amalgam that had been stuck inside was inadvertently introduced into the canal along with the MTA. Although the amalgam carrier was sterilized, and amalgam has been used as a root-end filling material since 1884, serving as a standard for comparison to other materials (Seedat et al., 2018), this incident could have been avoided with more attention to detail.

Additionally, calcification observed in the mesial part of the apical third may be attributed to the elimination of necrotic pulp tissue and bacteria during canal preparation. Thorough instrumentation and removal of necrotic tissue can create a sufficient stimulus for apical closure, even without the use of medicaments (Steinig et al., 2003). However, the time between the first and second appointments was 8 weeks, which exceeded the l interval recommended by the European Society of Endodontology (ESE., 2021). This extended time may have impacted the overall outcome, emphasizing the importance of adhering to clinical guidelines and timelines.

In the pulpotomy performed on tooth 65, I used 3M™ Vitrebond™ Light Cure resin-modified glass ionomer (RMGI) liner/base material to protect the MTA, followed by 3M™ Vitremer™ Core Buildup/Restorative B2. In retrospect, there was no point in using Vitrebond in this situation, as Vitrebond and Vitremer are essentially the same material. Applying a liner to protect the MTA would have been relevant if I had used composite for the restoration, but this was not recommended in this case, as it involved a deciduous tooth and TM is a child with a high caries risk. Using Vitrebond was unnecessary in this context and could have been avoided with better material selection.

This experience has taught me the importance of thorough preparation, timing, material selection, and careful management in all aspects of a procedure.

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