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Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 63-65

MTA apexification of an endodontically failed tooth with wide open apex in multiple visits

Department of Conservative Dentistry and Endodontics, Dr. G.D. Pol Foundation’s Y.M.T. Dental College and Hospital, Mumbai, Maharashtra, India

Date of Submission25-Jun-2020
Date of Acceptance24-Jul-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Rahul Paresh Ved
Department of Conservative Dentistry and Endodontics, Dr. G.D. Pol Foundation’s Y.M.T. Dental College and Hospital, Institutional Area Sector 4 Kharghar, Navi Mumbai, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJO.INJO_27_20

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Success of endodontic therapy is dependent on multiple factors such as thorough preoperative evaluation, magnification and isolation techniques, complete debridement of diseased pulp tissue with disinfection of the canal and three-dimensional obturation. The process of root formation can be hampered in young permanent teeth due to trauma. Endodontic treatment of such cases with open apex is a challenge and retreatment in such cases is an even bigger challenge. Use of contemporary materials such as mineral trioxide aggregate, thermoplasticized gutta percha, and magnification in the form of a dental operating microscope can help in achieving predictable and long-term success in such cases.

Keywords: Mineral trioxide aggregate, open apex, retreatment

How to cite this article:
Paresh Ved R, Hegde V. MTA apexification of an endodontically failed tooth with wide open apex in multiple visits. Int J Oral Care Res 2020;8:63-5

How to cite this URL:
Paresh Ved R, Hegde V. MTA apexification of an endodontically failed tooth with wide open apex in multiple visits. Int J Oral Care Res [serial online] 2020 [cited 2021 Oct 24];8:63-5. Available from: https://www.ijocr.org/text.asp?2020/8/3/63/296225

  Introduction Top

Management of teeth with wide open apex is a challenge. Apart from achieving debridement and disinfection of the canal obtaining a three-dimensional seal is like a prerequisite for success in such cases. A common cause of incomplete root development is trauma.[1] Apexification, that is, establishing an apical barrier is the treatment of choice in such cases. Calcium hydroxide has been widely used for the induction of hard tissue barrier; however, this material requires 5–20 months to form the hard tissue barrier.[2] In recent times mineral trioxide aggregate or MTA has gained popularity as a material for apexification procedure and it produces a hard barrier of significantly better quality than calcium hydroxide.[3] The case discussed in the paper presents the successful retreatment of an upper central incisor with open apex by MTA apexification followed by obturation with injectable thermoplasticized gutta percha.

  Case Report Top

A 19-year-old young healthy male patient was referred to the operatory with complain of pain in previously endodontically treated upper left central incisor as seen from radiograph A of [Figure 1]. After taking a detailed case history it was revealed that he had an experience of a traumatic injury in the same region 9 years back but had taken only palliative medication for pain at that moment in time, 2 years post the trauma he experienced pain and also complained of discharge from buccal sulcus. On visiting a private practioner root canal treatment and subsequent delivery of emax crown was done. Clinical examination revealed the presence of the same. Preoperative radiograph revealed the presence of unsatisfactory obturation and a periapical lesion with a wide open apex suggestive of nonhealing chronic pathology as seen in [Figure 1]. It was decided to perform endodontic retreatment along with MTA apexification. Access opening was performed through the crown under rubber dam isolation along use of Carl Zeiss dental operating microscope for magnification. Removal of gutta percha was done with help gp solvent and H files. Complete removal of gutta percha from canal was obtained followed by copious irrigation with 1% sodium hypochlorite and 2% chlorhexidine with sonic activation and placement of calcium hydroxide as intracanal medicament. Recall was planned after 2 weeks for assessment and if all parameters are fulfilled then MTA apexification was to be performed. Mid treatment flare-up was encountered in this case 2 days after the first visit and was managed by removing the intracanal medicament followed by drainage of exudate and copious irrigation with saline and replacing intracanal medicament in form of double antibiotic paste. Medication in the form of analgesic and antibiotic coverage including for Gram-negative bacteria in the form of metronidazole were prescribed for a duration of 5 days. The patient was recalled after 14 days and was asymptomatic. Removal of intracanal medicament and copious irrigation was done on the next visit followed by drying of canal. Try- in of MTA carrier and plugger was done. A 5 mm apical plug of MTA was achieved by placing MTA in increments with the help of the carrier and condensed with a plugger till 5 mm of the apical barrier was obtained as seen in [Figure 1]. The judicious use of periapical radiographs helped in determining the placement of MTA (radiograph B in [Figure 1]). Moist cotton pellet was placed in the access and cavity was temporized. The patient was recalled after 24h and the obturation of the remaining canal was done with the help of injectable thermoplasticized gutta percha with help of EQ-V device and coronal restoration with composite resin as seen in [Figure 1]. The patient was instructed for periodic recall.
Figure 1: (A) Preoperative radiograph showing unsatisfactory obturation and periapical lesion. (B) MTA apical plug completed. (C) Complete obturation with MTA plug and thermoplasticized gutta percha. (D) One-year follow-up showing gradual resolution of lesion

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  Case Discussion Top

Success in such cases is dependent on multiple factors. Traditionally multiple calcium hydroxide dressing was the choice of treatment in such cases,[4] but its disadvantages include prolonged treatment time,[5] which may result in contamination and finally resulting in reinfection and also requires a high level of patient’s acceptance.[6] To overcome all these disadvantages MTA was selected as the choice of material. It is known to have lesser leakage, better anti-bacterial properties, high marginal adaptation, short setting time (4h), and a pH of 12.5 and superior biocompatibility and it also provides a scaffolding and stimulation for hard tissue formation.[7],[8]

The preoperative radiograph (as seen from radiograph A in [Figure 1]) showed the presence of a periapical radiolucency and history of previous endodontic therapy were all determining factors in deciding against a single visit approach as they are often precursors to a mid-treatment flare-up.[9]Also the microflora involved in such cases is a combination of Enterococcus faecalis and yeast, mainly Candida albicans along with Gram-negative anaerobic rods such as Fusobacterium nucleatum, Prevotella speices, and Campylobacter rectus and Gram-positive bacteria such as Streptococci (Streptococcus mitis, S. gordonii, S. anginosus, S. oralis), Lactobacilli (Lactobacillus paracasei and L. acidophilus) and Staphylococci.[10] Therefore, special attention was given in the above case to the irrigation strategies and use of intracanal medicament.

The field of endodontics is ever-evolving. Use of advanced aids of magnification such as dental operating microscope and modern techniques of obturation such as thermoplasticized gutta is important for long-term success in such cases, especially when we are dealing with irregular and large canals like in this case.[11]

  Conclusion Top

A meticulous approach must be considered when dealing with such cases. Multiple factors such as the microflora involved, management of mid-treatment flare-ups use of materials such as MTA and contemporary obturation techniques all contribute to the long-term success in such situations. Long-term controlled clinical trials are required to determine the predictability of such techniques.

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Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  References Top

Gaitonde P, Bishop K Apexification with mineral trioxide aggregate: An overview of the material and technique. Eur J Prosthodont Restor Dent 2007;15:41-5.  Back to cited text no. 1
Purra AR, Ahangar FA, Chadgal S, Farooq R Mineral trioxide aggregate apexification: A novel approach. J Conserv Dent 2016;19:377-80.  Back to cited text no. 2
Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod 1999;25:1-5.  Back to cited text no. 3
Sheehy EC, Roberts GJ Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: A review. Br Dent J 1997;183:241-6.  Back to cited text no. 4
Lin JC, Lu JX, Zeng Q, Zhao W, Li WQ, Ling JQ Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis. J Formos Med Assoc 2016;115:523-30.  Back to cited text no. 5
Pawar AM, Pawar SM, Pawar MG, Kokate SR . Retreatment of endodontically failed tooth with wide-open apex using platelet rich fibrin membrane as matrix and an apical plug of Biodentine. Eur J Gen Dent 2015;4:150-4.  Back to cited text no. 6
  [Full text]  
Vijayran M, Chaudhary S, Manuja N, Kulkarni AU . Mineral trioxide aggregate (MTA) apexification: A novel approach for traumatised young immature permanent teeth. BMJ Case Reports 2013;2013:bcr2012008094.  Back to cited text no. 7
Güneş B, Aydinbelge HA Mineral trioxide aggregate apical plug method for the treatment of nonvital immature permanent maxillary incisors: Three case reports. J Conserv Dent 2012;15:73-6.  Back to cited text no. 8
Walton RE Interappointment flare-ups: Incidence, related factors, prevention, and management. Endodontic Topics 2002;3: 67-76.  Back to cited text no. 9
Narayanan LL, Vaishnavi C Endodontic microbiology. J Conserv Dent 2010;13:233-9.  Back to cited text no. 10
Collins J, Walker MP, Kulild J, Lee C A comparison of three gutta-percha obturation techniques to replicate canal irregularities. J Endod 2006;32:762-5.  Back to cited text no. 11


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