|Year : 2016 | Volume
| Issue : 3 | Page : 147-156
Biologic reinforcement of compromised permanent incisors in children
Talat M Beltagy
Department of Pedodontics, Faculty of Dentistry, Kafr Elsheikh University, Kafr Elsheikh, Egypt
|Date of Submission||18-May-2016|
|Date of Acceptance||18-Jul-2016|
|Date of Web Publication||29-Sep-2016|
Talat M Beltagy
Department of Pedodontics, Faculty of Dentistry, Kafr Elsheikh University, Kafr Elsheikh
Source of Support: None, Conflict of Interest: None
Purpose: The aim of this study was to evaluate the clinical and radiographic success of biologic primary incisors as intraradicular post–core reinforcement in management of compromised permanent incisors in children.
Patients and methods: Twenty-four children patients aged 10–15 years old were selected from Outpatients Clinic of Pedodontic Department, Faculty of Dentistry, Tanta University. The patients had upper permanent central incisors with flared canal indicated for intraradicular reinforcement. The patients were randomly divided into two groups, 12 patients each; biologic group were reinforced by human extracted primary incisors, and fiber post group that their compromised teeth were reinforced by fiber posts (EasyPost) with RelyX Unicem. Clinical assessment of jacket crowns, gingival health, reinforced permanent teeth, and intraradicular reinforcing system was recorded. The healthy periapical area (no pathosis), pathosis did not require immediate treatment and pathosis required immediate treatment were recorded as radiographic assessment. The children were followed up clinically and radiographically at 3, 6, 12, and 18 months after treatment.
Results: The overall clinical success rate of biologic group was 75 and 100% for fiber post group. There were no statistically significant differences in clinical assessment between the two groups (P > 0.05). The overall radiographic success rate of biologic group was 77.8 and 83% for fiber post group at the end of study. There were no statistically significant differences in radiographic assessment between the two groups (P > 0.05).
Conclusion: The use of extracted primary incisors as biologic post–core in rehabilitation of compromised flared upper central incisors have continued to function well for 1.5 years with overall clinical and radiographic success rate of 75 and 77.8%, respectively.
Keywords: biologic reinforcement, children, compromised permanent incisors
|How to cite this article:|
Beltagy TM. Biologic reinforcement of compromised permanent incisors in children. Tanta Dent J 2016;13:147-56
| Introduction|| |
The functional and esthetic rehabilitation of compromised flared endodontically treated teeth presents a unique challenge to the dentists, especially in cases of extensive crown–root destruction. The causes of flaring may be due to serious structural damage by carious lesions, previous restoration with large post diameters, overinstrumentation during root canal therapy, trauma to immature tooth, congenital dentinal defects, pulpal pathosis, internal resorption, or iatrogenic causes .
The restoration of severely damaged teeth that lack dentinal support at the root canal is difficult, even if they have been endodontically treated , and the placement of large cast post will resulted in catastrophic root fracture ,,. It may also cause corrosion, inflammatory reaction, and discoloration at the tooth's gingival margins . Therefore, Christensen  stated that when nonmetal crowns are used, metal posts are contraindicated.
The use of white opaque posts with good physical and optical properties can overcome the disadvantages of large metallic posts . However, a potential drawback of the cosmo-post system is the fairly large diameter of the dowels and is very expensive.
Remaining dentin thickness less than 2 mm should be ideally reinforced before post placement . The use of autocuring composite as intraradicular rehabilitation can be difficult because the dentist has no control of the rapidly polymerizing resin. The use of light-curing resin is preferred, but it only has a depth of 4–5 mm that may limit the transmission of light through the bulk of intraradicularly placed resin .
The commercially available light transmitting posts has been clinically used to reinforce the compromised teeth with thin-walled root ,,,. However, this technique needs professional experience, expensive, more time consuming, still used metal post, and need materials that may be not available in most dental clinics .
Different biologic materials have been developed to restore teeth affected by caries and many techniques have been suggested for restoration of function and esthetic ,,. Natural crowns from a tooth bank have also been suggested as an option for restoring partially or totally lost dental crowns ,. Moreover, extracted permanent teeth have also been employed in removable and fixed prosthesis ,. The technique of bonding teeth fragments was first proposed to repair the permanent teeth in patients own fractured crowns ,,. It has been performed to restore crowns severely destroyed by caries, using fragments from other patients .
Nowadays, secure methods of sterilization and storage are available to ensure the safety of a tooth or tooth fragments from a tooth bank ,,,,. To date, no commercially available premanufactured post–core meets all ideal biological and mechanical properties of tooth structure .
Therefore, the use of biologic post–core represents several potential advantages. It is biologically similar a feasible option for strengthening of the root canal , and improves esthetics of all crowns when compared with metallic and carbon fiber counterpart. It is easily available as it stored extracted, prepared previously, eliminates the laboratory processing, and lastly it is more economic . All these advantages encourage the use of extracted primary incisors in this study as a biologic substitute for intraradicular post–core reinforcement in management of compromised flared upper permanent central incisors in children. Therefore, the objective of this study was to evaluate the clinical and radiographic success of biologic primary incisors (BPIs) as intraradicular post–core reinforcement in management of compromised upper permanent central incisors in children.
| Patients and Methods|| |
This study has been approved from the Ethical Committee at Faculty of Dentistry, Tanta University. Written informed consent was obtained from the parents of each child before the start of the study.
In this clinical trial, 24 children patients aged 10–15 years old were selected from Outpatients Clinic of Pedodontic Department, Faculty of Dentistry, Tanta University.
The patients had compromised upper permanent central incisors with flared canal indicated for root canal therapy due to crown fracture at middle-cervical thirds or severe carious destruction with necrotic pulp. The patients were randomly divided into two groups, 12 patients each; biologic group (group I) and fiber post group (group II). The patients must have normal occlusion and they were also free from any systemic diseases.
Biologic group (group I)
Selection and preparation of biologic primary incisors
The extracted human primary incisors due to trauma, retained deciduous, and serial extraction must have complete crowns and roots or with slight resorption at the root apex were collected. Informed consent was taken from child's parents to use their extracted teeth in the study. The shed, carious and fractured teeth were excluded. The external surface of their roots was cleansed from any soft tissues or debris by hand or rotary instrument under water coolant. After autoclave sterilization of BPIs ,,,, they were endodontically obturated from the apex using gutta percha and root canal sealer (Sealapex; Kerr, Sybron, Romulus, Michigan, USA) to avoid the weakening of their crowns by the preparation of access opening. BPIs were wrapped in moist gauze and stored frozen until they were used.
Preoperative periapical radiograph was taken for each child to evaluate the periapical area and degree of flaring. Conventional root canal therapy was carried out using gutta percha and root canal sealer (Sealapex). The coronal and middle portion of gutta percha was removed with Dentatus Classic Reamers (Dentatus, New York, New York, USA) maintaining at least 4–5-mm apical seal. The canal was cleansed and shaped to receive the intraradicular BPI as a substitute for intraradicular post–core reinforcement.
To aid in easy selection of BPI, a small part of alginate impression was injected into the patient's prepared canal with plastic syringe and a prefabricated large threaded post was inserted within it before setting. An overall alginate impression was obtained to the maxillary arch and poured with stone. To allow a good intraradicular fit of BPI mesiodistally and buccolingually at the stone model, an appropriate stored one was selected. Any adjustment of BPI root or shaping the inner surface of canal wall at the stone model must be carried out at this step.
BPI was kept moist in sterile saline at 37°C to prevent the collapse of collagen fibers of dentin upon dehydration, and minimizes any dimensional changes . In another session, after final intraoral adjustment of BPI within the patient's prepared canal, a periapical radiograph was taken to confirm the position of BPI intraradicular before cementation.
The prepared and adjacent teeth of the patient were dried and isolated with cotton rolls. The selected BPIs and the patient's prepared canal were conditioned with 37% phosphoric acid gel (Ultra-Etch; Ultardent, South Jordan, Utah, USA) according to manufacturer's recommendations.
BPI was cemented in the root canal using RelyX Unicem self-adhesive resin cement (3M ESPE Dental Products). The excess cement was removed by sharp instrument and a periapical radiograph was taken. The crown of BPIs with the remaining part of the patient's crown were prepared to receive a temporary acrylic jacket crown. The temporary crown was cemented with glass ionomer luting cement (3M ESPE Ketac Cem) and postoperative radiograph was taken ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 1: Fifteen years old child indicated for intraradicular reinforcement by biologic primary incisor.|
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|Figure 2: Preoperative radiograph of child showed compromised flared upper central incisor (a). Biologic primary incisors after cementation and crown reduction (b).|
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|Figure 3: Ten years old child with traumatized upper central incisor indicated for intraradicular reinforcement by biologic primary incisor.|
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|Figure 4: Postobturation radiograph of 10 years old child showing flared fractured upper central incisor (a). Biologic primary incisor after cementation and reduction (b). Radiograph at 18 months later (c).|
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Fiber post group (group II)
Preoperative periapical radiograph, root canal therapy, removal of root canal filling, shaping and conditioning of root canal were carried out as in biologic group (group I). RelyX Unicem was dispensed slowly intraradicular using Aplicap Elongation Tip attached to the nozzle from the bottom up till the canal was completely filled. Immediately a prefabricated EasyPost no. 5 (Dentsply Maillefer, Switzerland.) was prepared according to manufacturer's recommendations and centrally inserted within the filled canal up to the apical root filling with an apical twisting motion with moderate pressure to hold in position until set.
The deficient crown was completed by dual-cured core build-up composite (CharmCore, South Korea.). The tooth reduction, crown cementation and postoperative periapical radiograph were carried out as in biologic group ([Figure. 5]).
|Figure 5: Ten years old child with traumatized upper central incisor indicated for intraradicular reinforcement by EasyPost with RelyX Unicem (fiber post group).|
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All children patients were instructed to maintain good oral hygiene. The patients were evaluated clinically and radiographically at 3, 6, 12, and 18 months.
The data were collected, tabulated and statistically analyzed using χ2-test at 5% level.
Clinical assessment 
- Temporary crown:
- A, normal: no cracks, chips, fractures, or discoloration.
- B, crown discoloration.
- C, crown fracture.
- D, complete loss of crown.
- Gingival health:
- A, no obvious signs of inflammation.
- B, mild gingivitis: slightly reddened and edematous.
- C, moderate gingivitis: obvious reddened and edematous.
- D, severe gingivitis: very swollen with spontaneous bleeding.
- Reinforced tooth:
- A, no pain.
- B, pain (history of spontaneous).
- C, pain with percussion.
- D, fractured.
- F, mobility.
- Intraradicular reinforcing system:
- A, intact.
- B, fractured.
- C, displaced.
Radiographic assessment 
- Periapical area:
- A, healthy, no pathosis.
- B, pathosis did not require immediate treatment.
- pathosis required immediate treatment.
The outcome was consider successful if the reinforcing systems were in situ with no displacement or detachment, no post/biologic core or root fracture and no periapical or periodontal pathology requiring removal of reinforcing system for immediate treatment .
| Results|| |
Twenty-four children patients with compromised flared upper permanent central incisors were participated in this study. Twelve children patients were managed with intraradicular extracted primary incisors as biologic post–core reinforcement in their compromised upper permanent central incisors (biologic group or group I). The other 12 patients were reinforced by fiber posts (EasyPost) with a dual-cured RelyX Unicem resin as fiber post group (group II). The overall clinical success rate of biologic group was 75 and 100% for fiber post group at the end of study. There were no statistically significant differences in clinical assessment between the two groups (P > 0.05).
[Table 1] revealed that, the acrylic jacket crowns showed some changes in color during follow-up period. In group I, two patients showed crown discoloration, one at 6 months and the other at 12 months of follow-up. No crown fracture was detected during the follow-up period. In group II, at 18 months of follow-up, there were two cases showed crown discoloration and one case showed complete loss of crown. There were no statistically significant differences between the two groups (P > 0.05).
As regarding the gingival health ([Table 2]), no obvious signs of inflammation in 83% of the cases in group I and 91.7% in group II at the start of study that decline to 55.6 and 66.7% in group I and group II, respectively, at the end of follow-up. In group I, mild gingivitis was found in one case at 3 months and three cases at 6 months that decline to one case at 12 months to become three cases again at 18 months of follow-up. Two cases showed moderate gingivitis at 12 months that became one case at the end of the study. Sinus formation was recorded with radiological changes in two cases that required apicoectomy as immediate treatment ([Figure 6] and [Figure 7]). In group II, mild gingivitis was found in one case at 3 months, two cases at 6 and 12 months that increased to three cases at 18 months of follow-up. Moderate gingivitis was found in one case at each follow-up period. Sinus formation was found in one case at 18 moths that required immediate surgical interference ([Figure. 8]). There were no statistically significant differences between the two groups (P > 0.05).
|Figure 6: Sinus formation related to the biologically reinforced right central incisor (arrow) and biologic primary incisor was cemented in left central (a). Postsurgical interference, and reduction of BPI in left central (b). Final restoration of left central with complete healing of sinus (c).|
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|Figure 7: Preoperative periapical radiograph of 12 years old child showed old endodontically treated upper central incisors (a). Intraradicular biologic primary incisor (BPI) at upper centrals, left BPI before reduction, right BPI after crown cementation with an increase of periapical radiolucency (b). Radiograph after apicoectomy of right central incisor (c). The case at 18 months later (d).|
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|Figure 8: A case of fiber post group (group II) showing displaced crown with sinus formation (arrow) related to the reinforced upper right central incisor that indicated for surgical interference (apicoectomy).|
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The reinforced teeth in both groups showed no fracture during follow-up period. In group I, the mobility was observed in one case at 6 and 12 months that disappeared at 18 months of follow-up, while one case recorded history of spontaneous pain at 6 months. Pain with percussion was recorded in one case at 3 months, two cases at 6 months and one case at 12 and 18 months of follow-up. In group II, one case showed mobility at 12 and 18 months of follow-up. Spontaneous pain was found in one case at 12 months, and one case showed pain with percussion at 12 and 18 months ([Table 3]). There were no statistically significant differences between the two groups (P > 0.05).
In group I, nine (75%) cases showed clinical success of the biologic intraradicular post–core reinforcement during follow-up period, while three (25%) cases showed clinical failure. Two of them showed complete displacement of the biologic restorations, one case after 3 weeks and the other one after 4 months ([Figure. 9]). The third case showed fracture of the biologic post–core at the level of gingival margin after 7 months of follow-up. In group II, the reinforced permanent incisors showed 100% clinical success ([Table 4]). There were no statistically significant differences between the two groups (P > 0.05).
|Figure 9: (a) Complete displacement of biologic primary incisor. (b) The displaced segment.|
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Radiographic evaluation illustrated in [Table 5] and [Figure 2], [Figure 4], [Figure 7], [Figure 10], and [Figure 11]. The overall radiographic success rate of biologic group was 77.8 and 83% for fiber post group at the end of study. The results revealed eight cases showed no periapical changes at 3-month follow-up period that decreased to seven cases and six cases at 6 and 12 months of recall time, respectively, ([Figure. 4]). Two cases showed a symptomatic small periapical pathosis that did not require immediate treatment during follow-up ([Figure. 2]). At 12 months of follow-up, two cases showed periapical pathosis and presented with sinus formation that required immediate treatment ([Figure 7] and [Figure 10]). Later on, the two cases showed radiographic and clinical success at 18 months. In group II, two cases showed periapical pathosis that did not require immediate treatment at 3, 6, and 12 months that became one case at 18 months of follow-up ([Figure. 11]). While only one case showed periapical pathosis that required immediate treatment at 18 months. There were no statistically significant differences in radiographic assessment between the two groups (P > 0.05).
|Figure 10: Postobturation radiograph (a). Biologic primary incisor (BPI) before crown cementation (b). BPI after crown cementation and pins retained composite at other central (c). Postsurgical radiograph (apicoectomy) of reinforced upper central incisor at 12 months (d). The case at 18 months later (e).|
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|Figure 11: Preoperative radiograph of child patient showed compromised flared upper central incisor indicated for reinforcement (control group) (a). The case at 3 and 6 months showed periapical pathosis not require immediate treatment (b, c). The case after 12 and 18 months (d, e).|
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| Discussion|| |
The restoration of severely damaged or decayed teeth that lack the dentinal support at the coronal portion of the root is difficult even if they have been successfully treated . Failures in endodontically treated teeth with over flared canals are more likely due to restorative failures than the endodontic treatment itself. Therefore, the structural rehabilitation of endodontically treated teeth with over flared canals is critically important to ensure a successful restorative outcome. It is very important to plan the treatment with respect to the endodontic technique and the feasibility of successful restoration as well . This study was conducted to use the primary incisors as biologic intraradicular post–core reinforcement in management of compromised upper permanent incisors in children. In teeth with flared canals, it is important that lost dentin is rebuilt with a strong substitute  and to date; no commercially available premanufactured post–core meets all ideal biological and mechanical properties of tooth structure ,. Furthermore, there are no available studies in the use of intraradicular biologic restoration in permanent teeth. The rationale for the use of biologic restoration in primary dentition is well documented by Mandroli  and Ramires-Romito et al. .
For a successful root canal anchored restoration a strong bond between the post, the resin luting cement and the dentin is required . Therefore, in the present study, self-adhesive resin cement was used for cementation based on its strong adhesive properties, improved marginal adaptation, eliminating the need for etching, priming and bonding steps and releasing fluoride over a long period of time (3M ESPE Dental Products). It was found that posts luted with self-etch dual-polymerized resin cements had significantly higher bond strengths , higher fracture loads , and less leakage than glass ionomer cements .
In this study, fiber posts were preferred than cast posts to reinforce the weakened roots as the elastic modulus and biomechanical behavior of fiber posts were reported to be nearly identical to that of dentin . These posts have a homogeneous force distribution that minimizes catastrophic root fracture , biocompatible, good esthetics, anatomically tapered, offers the possibility of orthograde retreatment and easily removed with specific bur within few minutes in cases of endodontic failures ,,.
The results of this study showed that the biologic post–core have continued to function well for 18 months with 75% clinical success compared to 100% in fiber post. There were no statistically significant differences in clinical assessment between them.
The clinical failure in this study represented complete displacement of BPI in two cases which may be attributed to debonding of the cement substance or improper finish lines of the crowns preparation. In excessively flared teeth, large part of permanent crowns being destructed by carious lesion before treatment, thus the ferrule concept is impossible, since ferrule preparation always causes even more loss of the remaining circumferential dentin  and mastication force were concentrated only on the biologic post–core .
The fractured case in this study was due to trauma of child during playing, endodontically treated BPI has lack intrinsic strength of vital tooth and liable to fracture under heavy forces .
The discoloration of acrylic jacket crowns in this study may be due to improper marginal adaptation compared ceramics counterpart, and the patients may not follow oral hygiene instruction, therefore, debris can infiltrate under the crown and accumulate around and beneath the gingival margin causing discoloration of crown and gingival inflammations .
The cases showed pain with percussion in both groups during the study period manifested also tooth mobility and sinus formation at the same time; this may be due to chronic periapical infection that increased with time and later on needed apicoectomy as immediate treatment.
Regarding radiographic evaluation, the success rate in this study was 77.8 and 83% for biologic and fiber post group respectively at the end of follow-up period. There were no statistically significant differences in radiographic assessment between them.
The radiolucency associated with the cases in both groups that did not require immediate treatment not necessarily indicates periapical pathology. This radiolucency may be due to replacement of the lesion with connective tissue, fibrous scar healing or uncertain healing that may be expected to change into complete mineralization and healing or failure with time .
The three cases in this study that showed periapical radiolucency with sinus formation required apicoectomy as immediate treatment. The cause may be due to chronic infection that remain at the periapical site, which was difficult to be seen in radiograph until increase in size ,. Infection may also develop even after apparently apical healing, by dissolution of luting cement .
It was difficult to standardize all cases due to the presence of different variables as age, sex, biting force, nature of food, and the mechanical and anatomical variables of BPIs and patient's permanent teeth, but it must be restricted to a minimal.
Some limitations of this study must be taken in consideration such as patient acceptance, the need of tooth bank, the need of a rigorous sterilization process and crack free dentinal structure. Furthermore, fabrication of biologic post may require a technically sound system to get an exact fit post ,, and the need of high quality bonding agents as resin cement.
In spite of these limitations, the clinical and radiographic success rate in this study was 75 and 77.8%, respectively, and the use of natural teeth as a biologic post systems has been considered acceptable by several investigators ,,,,,,.
| Conclusion|| |
From this study it could be concluded that the compromised upper permanent central incisors of children reinforced by intraradicular primary incisors as biologic post–core have continued to function well for 1.5 years with clinical and radiographic success rate of 75 and 77.8%, respectively.
The natural tooth, which is biologically similar, has adequate strength, improves esthetics of the crowns, easily available (stored extracted), prepared previously, eliminates the laboratory processing, and lastly more economic.
The success of this technique will encourage using it as a biologic substitute for intraradicular post–core reinforcement in endodontically compromised teeth, but it need more follow-up and further researches should focus how the size, length, and design of the biologic post, the cementation technique, and the post insertion parameters influence the biomechanics of the restored teeth. The crossed influence between these parameters should be studied and analyzed to ensure a more robust restoration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]