Konser Joss

C l i n i c a l D e n t i s t r y , M u m b a i • S e p t e m b e r 2 0 1 220

Abstract|| Brief Background

Immature teeth with necrotic pulp and large periapical lesion are difficult to treat via conventional endodontic therapy. The role of materials such as calcium hydroxide and mineral trioxide aggregate in apexification is indispensable.These case reports demonstrate the successful single visit apexification using MTA.

|| Materials and Methods

Radiographic examination revealed open apex with a periapical lesion in association with 21 in case 1 and 11 in case 2. RCT followed by MTA placement and sectional obturation; place-ment of fibre post with dual cure composite followed by metal ceramic crown restorations.

|| Discussion

Apexification treatment is supposed to create an environment to permit Hertwig's epithelial root sheath to continue its function of root development. The goal of this treatment is to obtain an apical barrier to prevent the passage of toxins and bacteria into the periapical tissues from the root canal. Technically, this bar-rier is also necessary to allow the compaction of the root filling material. The advantages of using MTA in single visit apexifica-tion are discussed.

|| Summary and Conclusions

Single visit apexification with a novel, biocompatible material like MTA is a new boon in effective management of teeth with open apex. This innovative procedure is predictable and less time consuming one. But long-term studies are warranted to prove pros and cons.

|| Key Words

MTA, calcium hydroxide , apexification.

Single visit apexification with MTA: A report of two cases.

Dr. Abhishek AgrawalM.D.S. Senior Lecturer

Correspondence AddressDr Abhishek AgrawalSharad Pawar Dental College & HospitalWardha 442004Maharastra

Endodontics

NEW CD September 2012.indd 20 9/13/2012 2:01:42 PM

C l i n i c a l D e n t i s t r y , M u m b a i • S e p t e m b e r 2 0 1 2 21

|| Introduction

The primary objective in endodontic therapy is the complete obturation of the root canal space to prevent re-infection. In teeth with incomplete root development caused by trauma, caries and other pulpal pathosis, the absence of the natural constriction at the end of the root canal presents a challenge and makes control of filling materials difficult.[1] The aim is to seal a sizeable communication between the root canal system and the periradicular tissue and provide a barrier against which obturation material can be compacted.

Several procedures utilizing different materials have been recommended to induce root end barrier formation. These include: calcium hydroxide paste, calcium hydroxide powder; mixed with different vehicles, tricalcium phosphate, collagen calcium phosphate, osteogenic protein-1, bone growth factor and oxidized cellulose, proplast (a polytetrafluor-ethylene and carbonfelt-like porous material), true bovine bone ceramics, and dentin chips. Antibacterial such as paste of metronidazole, ciprofloxacin, and cefaclor has effectively encouraged apexification. Deliberate over instrumentation of the periapical area to produce a blood clot that will induce apical closure has also been described.[2,3,4]

Mineral trioxide aggregate (MTA) is a biomaterial that hasbeen investigated for endodontic applications since the early1990s. MTA was first described in the dental scientific literature in 1993 and was given approval for endodontic use by the U.S. Food and Drug Administration in 1998.[5]

Mineral trioxide aggregate (MTA) has been proposed as a material suitable for one visit apexification because of its biocompatibility, bacteriostatic activity, favourable sealing ability and as root end filling material.

These case reports demonstrate the successful single visit apexification using MTA.

|| Case Report I

A 22 year old male patient reported to the department of Conservative Dentistry & Endodontics with the chief complaint of discolouration with upper anterior tooth.

On intraoral examination grayish black discolouration with 21 was present. The patient gave history of trauma 10 years back with the same tooth. Tooth

showed no response to vitality test. Radiographic examination revealed open apex with a periapical lesion in association with 21.[Fig.1a , 1b]

Fig. (1) (a): Preoperative photograph

Fig. (1) (c): Access opening under rubber dam

Fig. (1) (b): Preoperative radiograph

The treatment plan was explained to the patient and informed consent was obtained.

In the same visit root canal treatment was initiated under rubber dam application. [fig.1c] Calcium hydroxide paste was given as an intra canal medicament.



In the next visit (after 2 weeks) intracanal dressing was removed. After determination of the working length by radiographic method [fig.1d] canal was irrigated with 3% sodium hypochlorite 17% EDTA alternatively. Final irrigation was done with 2% chlorhexidine.

Fig. (1) (d): working length determination

Mineral Trioxide Aggregate (Pro-root MTA, Dentsply USA) was mixed according to manufacturer’s instructions and was placed in the canal with a MTA carrier, i.e., Messing Gun.

Increments of MTA was condensed in apical portion of root with hand pluggers till a thickness of 4 mm. [fig.1e] A moist cotton pallet was placed in the canal and sealed with temporary filling material. In the next appointment after 24 hrs the canal was filled with guttapercha by sectional obturation method.[fig.1f] After sectional obturation and post space preparation fibre post(Fibrapost Produits Dentaires Switzerland) was cemented with dual core composite material (CalibraDentsply L.D Caulk).[fig.7] the patient was recalled after 15 days for crown preparation. Metal ceramic crown was given. The clinical follow-up at 6 months and 1year revealed an adequate clinical function. The radiographic follow-up at six months to one year revealed a decrease and disappearance of the periapical rarefaction & radiolucency. [fig.1g,1h,1i]

Fig. (1) (e): MTA Plug

Fig. (1) (f): Sectional obturation and fibre post.

Fig. (1) (g): One year followup



Fig. (2) (b): Preoperative radiograph

Fig. (2) (c): working length

Fig. (2) (d): MTA Plug

Fig. (2) (e): Gutta percha filling and composite built up

Fig. (1) (h): Photograph showing one year followup

Fig. (2) (a): Preoperative photograph

|| Case Report II

A 22 year old male patient reported to the department of Conservative Dentistry & Endodontics with the chief complaint of discolouration and fracture with upper anterior tooth. On intraoral examination grayish black discolouration with 11 was present. The patient gave history of trauma 5 years back with the same tooth. Tooth showed no response to vitality test. Radiographic examination revealed open apex with a periapical lesion in association with 11.[fig.2a,2b]



Fig. (2) (f): Radiograph showing one year follow up

The treatment plan was explained to the patient and informed consent was obtained.

The protocol for the creation of an apical plug with MTA mixture was implemented, as in Case 1 [fig.2c,2d]. The canal was filled with guttapercha by sectional obturation and built up with composite material [fig.2e]. The patient was recalled after 15 days and metal ceramic crown was placed.

The radiographic follow-up at six months to one year revealed a decrease and disappearance of the periapical rarefaction & radiolucency.[fig.2f,2g]

|| Discussion

Apexification treatment is supposed to create an environment to permit Hertwig's epithelial root sheath to continue its function of root development. The goal of this treatment was to obtain an apical barrier to prevent the passage of toxins and bacteria into the periapical tissues from the root canal. Technically, this barrier was also necessary to allow the compaction of the root filling material.

Fig. (2) (g): Photograph showing one year follow up.

Calcium hydroxide pastes have been considered as the material of choice to induce the formation of a hard tissue apical barrier. Its efficiency has been demonstrated by many authors, even in the presence of an apical lesion.

The problem in apexication technique with calciumhydroxide is the duration of the therapy, which is from 3 to 21 months.[6] The duration depends on factors such as size of the apical opening, the traumatic displacement of the tooth and the repositioning method sused. During application procedure the root canal is susceptible to reinfection because it is covered by a temporary seal. In addition, the canal is susceptible to fracture during treatment.

In 1993, Mohammad Torabinejad centered his research in the development of MTA at Loma Linda University, California. MTA was first described in the dental scientific literature in 1993 and was given approval for endodontic use by the U.S. Food and Drug Administration in 1998.

MTA induces the formation of apical calcific barriers and resolution of periapical disease of unformed apices in teeth with necrotic pulps.[7]Using MTA in teeth with immature apices can induce apexogenesis by stimulating the mesenchymal stem cells from the apicalpapilla to promote complete root maturation in the presence of periapical pathosis or abscesses.[8]

The advantages of using MTA in single visit apexification are stimulus to adhesion and cell proliferation, osseous and cementum-conductive effect, allows normal healing response, sufficient setting time, attract blastic cells, biocompatibility, Least leakage and alkaline pH.[9]

The clinical cases reported here demonstrate that when MTA is used as an apical plug in necrotic teeth with immature apices, the canal can be effectively sealed. Both clinical and radiography follow-ups in the reported cases showed healing of the periapical lesion and new hard tissue formation in the apical area of affected teeth.

|| Conclusion

Single visit apexification with a novel, biocompatible material like MTA is a new boon in effective management of teeth with open apex. This innovative



Dr. Manoj G. ChandakProfessor & H.O.D.

Dr. N.U. ManwarProfessor & Guide

About Co-author

|| References

1. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. International Endodontic Journal.2007; 40:478–484.

2. Schumacher JW, Rutledge RE. An alternative to apexification. J Endod 1993;19:529-31.

3. Yoshida T, Itoh T, Saitoh T, Sekine I. Histopathological study of the use offreeze-dried allogenic dentin powder and True Bone Ceramic as apical barrier materials. J Endod 1998;24:581-6.

4. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29:47-50.

5. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR.

Physical and chemical properties of a new root-end filling material. J Endod 1995;21:349-53.

6. Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with flaring apices. Dent Traumatol 2001;17:86.

7. George Bogen, Sergio Kuttler.Mineral Trioxide Aggregate Obturation: A review and case series.J Endod2009;35:6:777-90.

8. Shalin Desai, Nicholas Chandler. The restoration of permanent immature anterior teeth,root filled usingMTA: A review. journal of dentistry 2009;37:652–657.

9. Giuliani V,BaccettiT,PaceR,Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dental Traumatology. 2002;18: 217–21.

procedure is predictable and a less time consuming one. But long-term studies are warranted to prove pros and cons.


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