C l i n i c a l D e n t i s t r y , Mu mb a i S e p t e mb e r 2 0 1 2 20

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
apexifcation with
MTA: A report of
two cases.
Dr. Abhishek Agrawal
M.D.S. Senior Lecturer
Correspondence Address
Dr Abhishek Agrawal
Sharad Pawar Dental College & Hospital
Wardha 442004
Maharastra
Endodontics
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C l i n i c a l D e n t i s t r y , Mu mb a i S e p t e mb 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.
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C l i n i c a l D e n t i s t r y , Mu mb a i S e p t e mb e r 2 0 1 2 22
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 manufacturers
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
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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]
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C l i n i c a l D e n t i s t r y , Mu mb a i S e p t e mb e r 2 0 1 2 24
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
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C l i n i c a l D e n t i s t r y , Mu mb a i S e p t e mb e r 2 0 1 2 25
Dr. Manoj G. Chandak
Professor & H.O.D.
Dr. N.U. Manwar
Professor & Guide
About Co-author
|| References
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procedure is predictable and a less time consuming
one. But long-term studies are warranted to prove
pros and cons.
NEW CD September 2012.indd 25 9/13/2012 2:02:14 PM
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