Case reports Annals and Essences of Dentistry

NON SURGICAL ENDODONTIC RETREATMENT OF MAXILLARY CENTRAL INCISOR

HAVING BLUNDERBUSS APEX WITH MINERAL TRIOXIDE AGGREGATE (MTA).
*Sirisha K

* Professor, Department of Conservative dentistry and Endodontics, GITAM Dental College and Hospital, Visakhapatnam.

ABSTRACT
The teeth with immature apices pose a problem during obturation of root canal system. This article presents a case report of
failed endodontic treatment in maxillary central incisor with open apex. The obturating material was removed from root canal
system, root canal was cleaned, shaped and packed with calcium hydroxide and left for one week. In the second visit, root
canal system was thoroughly irrigated with sodium hypochlorite and a 3-4 mm of MTA plug was placed at the apical
terminus. The root canal system was sealed with thermoplasticized guttapercha. The access cavity was restored with
coronal radicular composite restoration. Six months follow up demonstrated clinically asymptomatic and adequately
functional tooth with radiographic signs of healing.

KEYWORDS : Apexification, MTA, blunderbuss apex.

INTRODUCTION
Most common causes of endodontic failures are The material was packed into the apical 2mm of the
inadequate cleaning and shaping and incomplete canal against which guttapercha was condensed
1 4
obturation . Teeth with incompletely formed apices (one appointment technique ).
pose problems during obturation of root canals due MTA has been advocated as a material to serve as
to wide open apical foramina. Attention should be an apical barrier for root end induction. In the MTA
focused on maintenance of vitality in these teeth so apical barrier technique, a 3 – 4 mm plug of MTA is
that as much root length and dentin formation as packed into the apical end of the canal. The canal is
possible can occur in the root. Vital pulp therapy then obturated with guttapercha after a period of 4-6
5
techniques like pulp capping and pulpotomy have hours . Advantages are MTA favors apexification
proved to be successful, since they aided by the and periapical healing regardless of the prior use of
tremendous blood supply present within the open calcium hydroxide paste. Other advantages are
apex. Determination of the extent of apical closure predictable apical closure, reduced treatment time
is many times more difficult to ascertain. and number of appointments and also radiographs.
Radiographic interpretation of apical closure is often
misleading since dental radiograph is a two Case report
2
dimensional picture of a three dimensional object . A 24 year old male patient reported to the dental
The use of calcium hydroxide for the apexification in office with a complaint of swelling in relation to
the pulpless tooth was first reported by Kaiser and it upper front tooth. He gave a history of previous root
3
was popularized by the work of Frank . The calcium canal treatment in relation to maxillary central
hydroxide can be used alone or it can be mixed with incisor two years ago. Detailed patient’s history
CMCP, metacresyl acetate, Cresanol (i.e. a mixture revealed childhood trauma to the upper front teeth.
of CMCP and metacrsyl acetate), physiologic saline, Vitality tests were performed to evaluate the pulpal
Ringer’s solution, distilled water and anesthetic status of adjacent teeth. Both the adjacent teeth
solution. The canal would ideally be completely responded normally to the cold stimulus and electric
filled with the paste but not overfilled. The usual pulp tester. Radiographic examination revealed an
time required to achieve apexification is 6 to 24 immature root apex in relation to #21 with
3
months (average 1 year +/- 7 months ). inadequately sealed root canal (Figure 1).
In the year 1975 Roberts and Brilliant reported the Retreatment of #21 was planned using MTA as
use of tricalcium phosphate as an apical barrier. apical barrier. After application of rubber dam, glass

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Case reports Annals and Essences of Dentistry
ionomer restoration was removed from the access tissues creating foreign-body responses and
2
cavity and guttapercha was removed from the root compromising the apical seal .
canal using ‘file braided technique’ (Figure 2). The reduction of contaminants within the canal
Working length for the root canal was determined by instrumentation and medication and reduction of
(Figure 3). The canal was cleaned, shaped and root the canal space with a temporary resorbable
canal was sealed with a fresh mix of Ca(OH)2 paste were more important than the actual
cement. The access cavity was temporarily sealed dressing material used. The importance of apical
with reinforced Zinc Oxide Eugenol cement. seal was emphasized more than development of an
The patient was recalled after one week. The seal apical barrier for obtaining a satisfactory result. A
of the access cavity restoration was intact. There prospective clinical study showed a success rate of
was no percussion tenderness. The access cavity 100% for calcium hydroxide apexification, the mean
restoration was removed and the canal was time necessary for the formation of an apical barrier
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irrigated with Sodium hypochlorite. MTA (ProRoot, being 12.19 months . Disadvantages are longer
Dentsply, Tulsa, OK) was mixed to a paste duration of the procedure and altered properties of
consistency according to manufacturer’s dentin. The Ca(OH)2 apexification treatment
recommendations, and packed into the apical third requires compliance from the patient and many
of the root canal with the help of MTA carrier appointments over a period of time ranging from 3
3
(Messing Gun- Produits Dentaires, Vevey, to 24 months . The fracture strength of immature
Switzerland) (Figure 4). A moist cotton pellet was teeth may be reduced by long-term calcium
7
placed in the root canal to hasten the setting hydroxide treatment .
reaction of MTA and sealed with reinforced Zinc A one-appointment procedure for obturating
Oxide Eugenol cement. permanent teeth with nonvital pulps and open
The patient was recalled after 6 hours and the apices was evaluated clinically. During nine months
remainder of the canal was sealed with of observation, the one-appointment treatment
thermoplasticised guttapercha(Figure 5). Patient using tricalcium phosphate or calcium hydroxide
was recalled after 1 week and the access as a substitute apical barrier was as effective
preparation was sealed with coronal radicular as the conventional multi-appointment technique
8
composite restoration (Figure 6). Four months that seeks a natural apical barrier .
follow up radiograph revealed partially healed To avoid the risk of fracture, a technique of one visit
periapical lesion. The tooth was asymptomatic and apexification was proposed in which an apical plug
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clinically functional. of MTA was placed in the last 5mm of the canal .
Apexification in one visit by placing an apical plug of
Discussion MTA is a predictable and reproducible clinical
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Endodontic management of the pulpless, procedure . Mineral trioxide aggregate is widely
permanent tooth with a wide, open blunderbuss used in procedures ranging from pulp capping to
11
apex has long presented a challenge to dentistry. furcal perforation repair . MTA consists of 50–75%
The treatment options used to be surgical approach, (wt) calcium oxide and 15–25% silicon dioxide.
apical closure technique and apical barrier These two components together comprise 70–95%
technique. Thermal tests are more reliable for of the cement. When these raw materials are
ascertaining vitality in immature pulpless teeth than blended they produce tricalcium silicate, dicalcium
radiographic methods and electric pulp vitality tests. silicate, tricalcium aluminate and tetra calcium
The presence of acute or chronic pain, percussion aluminoferrite. On addition of water the cement
12
sensitivity, mobility and discoloration of the crown hydrates to form silicate hydrate gel .
should be considered in the diagnosis. ‘Watch and After cleaning and shaping of root canal system, an
wait approach’ should be followed in case of apical plug of 3-5 mm MTA is placed and sealed
doubtful cases of pulp exposure. The main with a temporary restoration since it requires a time
challenge in performing root canal treatment in teeth period of 3-4 hours for completion of setting
with necrotic pulps and wide-open apices is to reaction. The rest of the canal is sealed with
13
obtain an optimal apical seal. The wide foramen thermoplasticized gutta-percha . MTA is highly
requires a large volume of filling material that may biocompatible. It has cementogenic, dentinogenic
extrude from the root canal into the periapical and osteogenic potential. Moisture and blood
contamination do not affect the sealing ability
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Case reports Annals and Essences of Dentistry

Fig.2. Radiograph after

Fig.1.Preoperative
removal of Gutta percha
radiograph

Fig.3.Working length Fig.4. Radiograph with MTA

radiograph apical plug

Fig.5. Obturated Fig.6 .Coronalradicular

rootcanal Core of composite

Fig.7.RC preparation for

coronoradicular core
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Case reports Annals and Essences of Dentistry
Main disadvantages are difficulty in manipulation filling material. Journal of Endodontics (1995) 21,
and longer setting time. MTA proves to be an ideal 349–53.
sealing material for teeth with open apices. 13. Shabahang S, Torabinejad M. Treatment of teeth
with open apices using mineral trioxide aggregate.
summary Pract Periodontics Aesthet Dent 2000; 12: 315 - 20.
This article presents a case of endodontically failed
maxillary central incisor with open apex which was
Corresponding Author :
successfully managed by using MTA as apical plug.
Dr K. sirisha
Door No. 7-5-148, Plot Number 23,
CONCLUSION
Ocean View Layout, Pandurangapuram,
MTA has wider range of clinical applications of
Visakhapatnam. Pin : 530003.
which, apexification is one among them. It has
Ph No: 0891 – 2522142,
additional advantages like biocompatibility and good
09848521749.
sealing ability.
E mail: sirishaky@gmail.com

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5. Torabinejad M, Chivian N. Clinical applications of
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T Biological process Study of calcium hydroxide
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