Updat Dent. Coll .

j 2013; 3(2):39-42

Case Report

Management of an upper central incisor having periapical pathology

with unusual presentation
*Mohammad Aminul Islama , Tasnim Wakiab, Shamima Afroza, Md. Ali Asgor Moralc

a
BDS, FCPS trainee. Dept. of Conservative Dentistry & Endodontics, BSMMU, Dhaka, Bangladesh
b
BDS, FCPS. Private Practitioner, Dhaka, Bangladesh
c
Professor, Dept. of Conservative Dentistry & Endodontics, BSMMU, Dhaka, Bangladesh

ARTICLE INFO ABSTRACT

Article History: The aim of this report is to discuss a case about a traumatized
Received : 10 October 2012
Accepted : 17 March 2013 upper left central incisor presented with chronic periapical
pathology with unusual presentation. In this case, the apical
area of the tooth was exposed for a long period and the apex
Key Words: was open due to loss of affected tooth materials and its
Upper central incisor surrounding bone and soft tissue loss. The apical area was
Periapical pathology corrected with apical curettage and retrograde filling with
MTA retrograde filling
Mineral Trioxide Aggregate (MTA) as well as soft tissue
managed with pedicle flap design. The discolouration and mild
shortening of the crown due to intrusive effect was managed
by lamination of cosmetic restorative material. After 12
months follow up, the offending tooth was accepted both
functionally and aesthetically.

Introduction The objectives of surgical approach are to

Surgical endodontics is a reliable method for the remove diseased tissue, debride the canal system
treatment of teeth with periapical lesions that do as far as possible and to seal the cavity or defect
not respond to conventional root canal treatment to prevent or reduce the spread of
or when orthograde treatment is not feasible.1 microorganism in the periradicular tissues,
Also an immature or mature tooth with an open thereby providing an environment conducive of
apex causes the problems of overfilling and poor regeneration of a normal periodontal apparatus.2
apical seal. So an apical barrier is extremely An ideal retrograde filling material have some
needed. Retrograde filling is necessary to fill the qualities like easy and moisture independent
apical canal space and to obtain a three application, high sealing capacity,
dimensional seal between the periodontium and biocompatibility, radiologically confirmable seal
root canal system. and non-absorbable properties etc. MTA is more
preferable because it is insensible to moisture,
biocompatible and has the property of good seal.
MTA provides superior seal when compared
with Amalgam, IRM and Super EBA.3 The
marginal adaptation of MTA is better with or
without finishing when compared to IRM and
Super EBA.4 As a root-end filling material,
MTA showed evidence of healing of the
*Address of Correspondence:
Dr. Mohammad Aminul Islam
surrounding tissues.5-7
BDS, MS. FCPS trainee, Dept. of Conservative Dentistry
& Endodontics, BSMMU, Dhaka, Bangladesh
Telephone: 01715-255155
E-mail: aminul_info@yahoo.com
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 Update Dental College Journal Vol 3 Issue 2, October-2013

The ideal healing response after periradicular root resection was done to gain fresh dentinal
surgery is the re-establishment of an apical surface while applying less stress to avoid
attachment apparatus and osseous repair.(8,9) fracture of apical root area.
However, histological examination of biopsy
specimens reveals three types of tissue
response;(10) healing with reformation of the
periodontal ligament; healing with fibrous tissue
(scar); and moderate-to-severe inflammation
without scar tissue. The deposition of cementum
on the cut root face is considered a desired
healing response and a prerequisite for the Pre-operative Retrograde filling
reformation of a functional periodontal
attachment.(8) Cementum deposition occurs from
the circumference of the root end and proceeds
centrally toward the resected root canal. The
cementum provides a ‘biological seal,’ in
addition to the ‘physical seal’ of the rootend After 3 months After Lamination
filling, thereby creating a ‘double seal’.(11) Figure 1: Photograph of clinical procedure
Different studies showed better sealing ability
regarding MTA(12-17) while permitted
cementoblast attachment and growth. The
production of mineralized matrix gene and
protein expression indicated that MTA could be
considered cementoconductive.(18)

Case report
A 22 year-old-male patient reported with chronic Preoperative After MTA After 12
pus discharge from the apical area of upper left Placement months
central incisor for 4 years. He also gave a history Figure 2: Radiograph (before & after)
of sports trauma about 9 years back and the
apical area of tooth begun to expose for last 2 The root end was prepared biomechanically
years. On clinical examination, upper left central thorough and thorough up to get a fresh dentin
incisor was dark greyish in colour, slightly surface at canal wall. After preparation of apical
intruded and the apex of the tooth was with open area for the purpose of retrograde filling,
apex. The apical area of the tooth was exposed Mineral Trioxide Aggregate (ProRoot MTA,
with discharging pus but no significant mobility Dentsply) was placed at apical 3-4 mm and a
was found. Radiograph showed apical bone radiograph was taken. After radiological
resorption as well as apical root resorption with evaluation, the soft tissue of wound area was
wide pulpal space. The treatment plan of the closed with suturing and a moist cotton pillet
symptomatic tooth was to manage the apical was in the canal orifice and the access was
problem by surgical management, sealed with interim restoration (Cavit, GC,
simultaneously with apical curettage and Japan). Antibiotics and analgesics were advised
retrograde filling followed by management of along with tetracycline mouth wash during
the discoloured and intruded crown. After mouth immediate post-operative period. After 7 days,
preparation, local anaesthesia was administered the suture was removed and prepared root canal
at the surgical area. Then the inflamed and coronal to the MTA placement was filled with
unhealthy gingival margin of exposed apical gutta percha by vertical compaction technique
tooth area was removed to regain normal fresh followed by composite resin restoration at the
margin with no. 15 BP blade. Then a pedicle flap same day. Regular follow-up was done from the
was designed and the flap was reflected from the time of operating procedure as 1 month, 3
bone. The apical area was curetted and minimal months and every 6 months. After 3 months

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 Central incisor with unusual presentations Islam MA et all

follow up, there was no significant sign and precise root-end fillings that satisfy the
symptoms clinically. Radiograph showed requirements for mechanical and biological
formation of new bone at periapical area and the principles of endodontic surgery.
lesion size was reduced. So, the discoloration of
that tooth was managed by lamination of the Anatomical study of the root apex showed that at
crown with a cosmetic restoration (Giomer, least 3 mm of the root-end must be removed to
Sofu, Japan). After 12 months follow up, the reduce 98% of the apical ramifications and 93%
offending tooth was accepted both functionally of the lateral canals(25) ; in this case, minimal
and aesthetically. removal up to a level of fresh root dentinal
surface because short root length by previously
Discussion loss of tooth apex pathologically. The soft tissue
In this case, MTA was chosen as a retrograde was managed by flap surgery in a pedicle flap
filling material than other due to its ideal design but free gingival graft or periosteal
properties. Easy and moisture independent pedicle flap may also be designed in different
application, superior seal, biocompatibility and consideration. Also, bone cell formation
ability to increase the vulnerable root strength initiating material or bone grafting along with
was the considerable factors. Also, at longer surgery may causes beneficial sometimes.
duration, new cementum was found on the Er:YAG laser was superior in comparison with
surface of the material.(19) In a two year follow- CO2, Nd:YAG, and Ho:YAG.(26) it showed root
up study with MTA as root-end filling material surfaces devoid of charring. Clinically it’s use
resulted in a high success rate.(20) improved healing and diminished post-operative
discomfort.(27) The use of laser for apiceoctomy
The periapical pathology regarding this case was procedure has some merits, but it takes more
chronic abscess in nature where buccal cortical time to perform when compared to more
bone was lost. But the most common type of conventional methods.
periapical radiolucency is granuloma (73%) than
cystic (15%) or abscess (12%) type of lesion. (21- Reference:
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