Restoring Immature Permanent Teeth After Trauma
The use of dentin substitutes offers bioactive benefits to preserve vitality
It is common for immature permanent teeth to experience trauma. Approximately two thirds of all of the dental trauma reported occurs among children and adolescents, and the anterior permanent teeth are the most affected. Traumatic injuries may result in pulp exposure, which can lead to infection and, if not appropriately treated, the consequences of tooth loss.
Premature tooth loss due to dental trauma can lead to space loss. When deciding to implement space maintenance for patients with primary and mixed dentition, there are many factors to consider. Specific criteria include the amount of time that has passed since tooth loss, the chronological age of the child, the dental age or developmental age of the child, the amount of space already lost, the location of the tooth loss in the arch, the direction of space closure, the timing of eruption of the succedaneous teeth, and the amount of bone remaining over the unerupted permanent teeth. The premature loss of primary molars poses a significant risk for space loss in the dental arch. When this occurs, patients are three times more likely to require orthodontic treatment after all of their permanent teeth have erupted. The premature loss of primary anterior teeth does not pose the same risk for space loss in the dental arch; however, the premature loss of immature permanent maxillary anterior teeth has a profound impact on the esthetics and self-esteem of the patient.
Complicated crown fractures in immature permanent teeth present unique challenges for the dentist. Regarding the restorative approach, the main idea is to preserve the pulp inside the root to allow the tooth to complete the process of root formation and apex closure. When preserving the pulp, it is advantageous to use a highly biocompatible material. A favorable material will help to ensure the long-term survival of the tooth and avoid the need for extraction. Various dental materials have been recommended for use in direct contact with the pulp.
Mineral trioxide aggregate (MTA) and calcium silicate-based restorative materials demonstrate excellent properties that help to protect the vitality of the traumatized tooth pulp. MTA (or Portland cement), which has been available since 2002, is composed mainly of tricalcic silicate, tricalcic aluminate, and bismuth oxide. Calcium silicate materials are newer and more nuanced, but all of these materials were specifically designed to serve as "dentin substitutes." In restorative dentistry, the spectrum of applications of MTA and calcium silicate restoratives is wide and includes endodontic repair, indirect pulp capping, direct pulp capping, and use as a liner and dentin replacement. In situations in which achieving a perfect seal is essential, such as in direct pulp capping treatment, both of these material types excel and offer significant benefits. The antibacterial properties of MTA and calcium silicate restoratives are attributed to the high pH of these materials. This high alkalinity has an inhibitory effect on the growth of microorganisms. In addition, the biocompatibility of MTA and calcium silicates is outstanding and has been probed in multiple studies when the materials were placed with fibroblasts from the pulp.
Preserving the vitality of primary and immature permanent teeth that have undergone trauma is a critical task of contemporary dentistry. Placing a material in direct or indirect contact with the pulp is a common option that the dentist has in the treatment armamentarium to achieve preservation of the pulp tissue. When a young patient presents with a fractured tooth and the pulp has been exposed, isolating the pulp exposure, cleaning it with saline, and placing a direct pulp cap using a highly biocompatible dentin substitute, such as MTA or a calcium silicate restorative, followed by a temporary composite restoration can improve the chances of saving the tooth and play a critical role in preserving the esthetics during his or her further growth and development.
About the Author
Juan F. Yepes, DDS, MD, MPH, is a professor in the Department of Pediatric Dentistry at the Indiana University School of Dentistry and practices at the Riley Hospital for Children in Indianapolis, Indiana.