Research Article: Fracture resistance of simulated immature teeth treated with a regenerative endodontic protocol

Date Published: January 31, 2019

Publisher: Taylor & Francis

Author(s): Mohamed Raouf W. Ali, Manal Mustafa, Asgeir Bårdsen, Athanasia Bletsa.


This study aims to evaluate fracture resistance of simulated immature teeth after treatment with regenerative endodontic procedure (REP) using tricalcium silicate cements (TSCs) as cervical plugs. Bovine incisors were sectioned to standard crown/root ratio. Pulp tissue was removed and canals were enlarged to a standardized diameter. Teeth were then treated with a REP protocol consisting of NaOCl and EDTA irrigation, intracanal medication with triple-antibiotic paste for 14 days followed by a TSC cervical seal and composite restoration. Teeth were divided into groups according to the material used; Mineral-Trioxide-Aggregate (MTA), Biodentine, TotalFill. Teeth filled with guttapercha (GP) and intact teeth served as controls. All teeth subjected to an increasing compressive force (rate of 0.05 mm/s at a 45° angle to the long axis of the tooth) until fracture. All treated teeth exhibited significantly lower resistance to fracture compared to the intact teeth but no difference was found between the TSC groups (Kruskal-Wallis, Dunn’s multiple comparison, p < .05). TSCs applied at the cervical area of simulated immature teeth treated with REP did not reinforce fracture resistance.

Partial Text

Endodontic treatment of non-vital immature permanent teeth presents quite a challenge in dental clinics due to wide open apices and thin dentinal walls. A relatively high incidence of cervical root fracture (>60%) has been reported in such teeth teeth after a long-term intra-canal treatment with calcium hydroxide (CH) in order to achieve a hard-tissue barrier at the apical area (apexification) [1,2]. These fractures may occur with minor impacts or spontaneously over time [1,3]. In the latest years, tricalcium silicate cements (TSC) have been widely used as endodontic repair materials and dentin substitutes [4]. The use of TSC materials to achieve a root-end closure at the apical area of necrotic immature teeth (direct apexification) has replaced the traditional treatment with CH. However, with this method the dentinal walls remain thin, and the risk of fracture is still present [5,6].

The experiment model in this study emphasizes the immediate effect of the TSCs on treated immature teeth with REPs. We implemented a continuously increasing load of force model to measure fracture resistance. Traumatic dental injuries involve mostly anterior teeth [2]. The absence of high occlusal forces at the incisors may imply that the type of force that leads to dental trauma in such cases is a single impact that overwhelms the structural integrity of the tooth at that moment. Untreated immature bovine teeth had a higher fracture resistance than immature bovine teeth treated with TSCs therefore, the null hypothesis was rejected. Under the experimental set-up, the treated immature teeth fractured at the cervical area and thus, REP and cervical seal with bioceramic materials does not seem to reinforce fracture resistance of bovine teeth.

Within the limitations of this study, we can conclude that TSC such as MTA, TotalFill and Biodentine do not influence either negatively or positively, the fracture resistance of immature teeth during regenerative endodontic therapy. Further material tests and clinical trials are necessary to validate these results.




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