Dr. Obaid Khursheed. / IJRID Volume 4 Issue 4 Jul.-Aug.

2014

Available online at www.ordoneardentistrylibrary.org ISSN 2249-488X

Case - report

INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY

SINGLE SITTING APEXIFICATION TREATMENT WITH MTA APICAL PLUGS: A CASE SERIES
Dr BurzaIrfana K1, Dr Obaid Khursheed2, Dr Shakeel Mohammad1, Dr BurzaWaseem K1
1. SKIMS Medical College
2. K.D.Dental College,Mathura
Received: 14 June. 2014; Revised:21 Jul 2014; Accepted: 24 Aug. 2014; Available online: 5 Sep 2014

ABSTRACT
The immature tooth with apical periodontitis presents numerous challenges both an endodontic and restorative that inhibit
our ability to provide a predictable long-term treatment outcome. Several procedures utilizing different materials have been
recommended to induce the root end barrier formation. Conventional treatment with calcium hydroxide for such cases is
associated with certain difficulties, such as the very long treatment time required, the possibility of tooth fracture, &
incomplete calcification of the bridge. Use of Mineral Trioxide Aggregate (MTA) apical plug appears to be a promising
alternative due to its high biocompatibility, superior sealing ability & reduced treatment time. Here we present a few cases
where teeth with open apices and periapical lesions have been successfully treated with MTA apical plugs. During treatment
procedure, 1% sodium hypochlorite was used for irrigation and calcium hydroxide paste was placed in the canals for 1 week
before the apical portion of the canals (5mm) was filled with MTA plug.

Key-words:Immature teeth, one visit apexification, Mineral Trioxide Aggregate, monoblock, artificial barrier.

INTRODUCTION

The major challenges associated with endodontic treatment of teeth with open apices are achieving complete
debridement, canal disinfection and optimal sealing of the root canal system.1Despite the clinical success of the
calcium hydroxide apexification technique, there are some disadvantages. The treatment requires high patient
2, 3
compliance and multiple appointments extending over a long period of time An alternative for the
multiappointmentapexification procedure has been a single-step technique using an apical barrier. The rationale
is to establish an apical stop that would enable the root canal to be filled immediately. There is no attempt at
root end closure. Rather an artificial apical stop is created.4 Several materials have been proposed for use as an
apical barrier, One such material, mineral trioxide aggregate (MTA) (ProRoot, Dentsply Tulsa Dental, Tulsa,
OK), has been advocated as an apexification material by Shabahang et al.5, because it permits an adequate seal
of the canal and prevents bacterial leakage.
This article presents three case reports where teeth with open apices were managed using single step
apexification with MTA

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Case 1:
16 year old male presented to the department of dentistry in SKIMS hospital for treatment of maxillary left
lateral incisor tooth. No discoloration and caries were clinically detected. Periapical radiograph demonstrated a
large radiolucent lesion with a well-defined margin around the apex of the maxillary left lateral incisor (Fig. 1).
The access cavity was prepared, necrotic pulp tissue was extirpated and the working length was estimated as
being 1 mm short of the radiographic apex. The canal was lightly instrumented with hand K-files
(DentsplyMaillefer). During the instrumentation, the canal was irrigated copiously with 1%
NaOClsolution.Cleaning and shaping was done by light hand filing since the dentinal walls were thin. After a
final flush with NaOCl, the canal was rinsed with 5 mL 17% EDTA to remove the smear layer. The canal was
dried followed by placement of calcium hydroxide paste as intracanal medicament. The access cavity was
sealed withCavit (3M, ESPE). After 2 weeks, the root canal was found to be completely dry. This dressing was
renewed every 2 months and a radiograph was taken to ensure thorough filling of the root canal with the
dressing, as well as to monitor healing. This procedure was repeated over a year. At 1 year, the canal was
irrigated with 1% NaOClfollowed by 17% EDTA & final rinse with 2% chlorhexidine. The canal was dried.
Mineral trioxide aggregate (MTA) was mixed with distilled water to sandy consistency. The mix was placed
with MTA carrier in the apical portion of the canal. Increments were condensed with hand pluggers till
thickness of 3-4mm (Fig. 2). A wet cotton was placed and access cavity was sealed. In subsequent appointment,
obturation was done by cold lateral condensation technique (Fig. 3). Access cavity was sealed with composite.
The patient returned after 7 month follow-up examination and was asymptomatic. Radiographs showed that the
radiolucent area was absent and that trabecular bone was forming.
Case 2:
19 year old female reported to the Department of dentistry in SKIMS hospital with a chief complaint of pain
and swelling in maxillary anterior region. There was a history of trauma to maxillary left central incisor 1 year
back due to fall. Extraoral examination revealed no swelling. Intraoral examination revealed fracture of
maxillary right central incisor involving enamel and dentin (fig 4)The tooth did not respond on pulp sensibility
testing. The case was managed in a way similar to previous case. The patient returned after 7months showed
progressive healing of lesion (fig 5,6).
Case 3:
16-year-old girl suffered subluxation trauma of her maxillary front teeth at 10 years of age. During intraoral
examination, a sinus tract was found between teeth 11 and 12. A radiographic image revealed that teeth 11 and
12 had open apices and apical periodontitis. Tooth 12 had an inadequate root canal obturation and
overextension of GP points (fig7). Root canal retreatment of tooth 12 was initiated; application of a rubber dam,
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an access cavity was prepared in tooth 12 and the gutta-percha points were retrieved via the root canal using
#70 and #80 Hedströem files (DentsplyMaillefer). The canal was lightly instrumented using hand K-files
(DentsplyMaillefer) at the working length, while irrigating with 1% NaOCl. After a final flush with NaOCl, the
canal was rinsed with 5 mL 17% EDTA to remove the smear layer. After drying the canal with paper points,
calcium hydroxide paste was placed for 2 weeks. Apical closure was done with MTA thickness of 3-4mm In
subsequent appointment, obturation was done by cold lateral condensation technique (fig8)
Discussion:The response to trauma can be varied. Some pulps remain apparently normal with no adverse
effects, whereas others become necrotic. When treating nonvital teeth, a main issue is eliminating bacteria from
the root canal system. As instruments cannot be used properly in teeth with open apices, cleaning and
disinfection of the root canal system rely on the chemical action of NaOCl as an irrigant and calciumhydroxide
as an intracanal dressing.6
NaOCl is known to be toxic, especially in high concentrations. Therefore, it is advisable to use less concentrated
NaOCl, which is less toxic.7In all 3 cases, 1% NaOCl was used. A 17% EDTA rinse was carried out before
placement of the intracanal dressing to remove the smear layer and facilitate diffusion of calcium hydroxide
through the dentin and before obturation to ensure better removal of calcium hydroxide.8
With the MTA apical plug technique, a one-step obturation after short canal disinfection with calcium
hydroxide could be performed. In agreement with other studies, MTA appeared to show good sealing ability,
good marginal adaptation, a high degree of biocompatibility and a reasonable setting time (about 4 h)9. From a
practical point of view, MTA can be used in the presence of moisture in the root canal. This property is
important in teeth with necrotic pulps and inflamed periapical lesions because one of the problems found in
these cases is the presence of exudate at the apex of the root.10
The apical plug created with MTA can be interpreted as an artificial barrier to condense the subsequent root
canal filling material, in order to prevent reinfection of the canal system.11 Some authors have postulated that
possible leakage of MTA could be influenced by the thickness of the apical plug.12Hachmeister et al underlined
that the thickness of the apical plug may have a significant impact only on displacement resistance.13In the
present case reports, the thickness of the MTA apical plug varied from 3 mm to 5 mm.
The novel approach of apexification using MTA lessens thepatient’s treatment time between first appointment
and final restoration. Importance of this approach lies in thorough cleaning of root canal followed by apical seal
with a material that favors regeneration. In addition there is less chance of root fracture in immature teeth with
thin roots because the material immediately bonds with the roots and
strengthens it.14
The clinical case reported here demonstrates that when MTA is used as an apical plug in necrotic teeth with
immature apices, the canal can be effectively sealed. Follow-up radiographs in all 3 cases showed osseous
healing and, during clinical examination, the patients were asymptomatic.
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References
1. Andreasen JO, Flores MT. Injuries to developing teeth. In: Andreasen JO, Andreasen FM, Andersson L,
editors. Textbook and color atlas of traumatic injuries to the teeth. 4th ed. Copenhagen: Munksgaard; 2007. p.
542-76.
2. Weisenseel JA, Hicks ML, Pelleu GB. Calcium hydroxide as an apical barrier. J Endodon 1987;13:1–5.
3. Schumacher JW, Rutledge RE. An alternative to apexification. J Endodon 1993;19:529–31.
4. Rafter M. Apexification: a review. Dent Traumatol 2005;21:1–8.
5. Shabahang S, Torabinejad M, Boyne PJ, Abedi HH, McMillan P. Apexification in immature dog teeth using
osteogenic protein-1, mineral trioxide aggregate, and calcium hydroxide. J Endodon 1999;25:1–5.
6. Siqueira JF Jr, Guimarães-Pinto T, Rôças IN. Effects of chemomechanical preparation with 2.5% sodium
hypochlorite and intracanal medication with calcium hydroxide on cultivable bacteria in infected root canals.J
Endod. 2007;33(7):800-5.
7. Hülsmann M, Hahn W. Complications during root canal irrigation— literature review and case reports.
IntEndod J. 2000;33(3):186-93.
8. Hülsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: mode of action and
indications for their use. IntEndod J. 2003;36(12):810-30.
9. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment
of mineral trioxide aggregate as a root-end filling in monkeys. J Endod. 1997;23(4):225-8.
10. The use of MTA in teeth with necrotic pulps and open apices. DentTraumatol 2002;18:217–22
11. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide
aggregate: results from a case series. IntEndod J 2007;40:478-84.
12. De Leimburg ML, Angeretti A, Ceruti P, Lendini M, Pasqualini D, Berutti E. MTA obturation of pulpless
teeth with open apices: bacterial leakage as detected by polymerase chain reaction assay. J Endod 2004;30:883–
6.
13. Hachmeister DR, Schindler G, Walker WA, Thomas DD. The sealing ability and retention characteristics of
mineral trioxide aggregate in a model of apexification. J Endod 2002;28:386–90.
14. Kubasad GC, Ghivari SB. Apexification with apical plug of MTA Report of cases. Archives of Oral
Sciences & Research 2011;1(2):104-107.

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