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| CASE REPORT |
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| Year : 2019 | Volume
: 5
| Issue : 2 | Page : 175-177 |
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One step MTA apexification with collagen barrier and root reinforcement of traumatized immature teeth
Muthukrishnan Sudharshana Ranjani1, Shanmugam Jaikailash2, Subramanian Dhanalakshmi1, Krishna Prasad Biswas3
1 Assistant Professor, Dept. of Dentistry, Tamil Nadu Government Dental College, Chennai, India
2 Professor, Dept. of Dental Surgery, Coimbatore Medical College and Hospital, India
3 Senior Resident, Dept. of Dental and Oral surgery, Lady Harding Medical College, Delhi, India
| Date of Submission | 07-Jun-2019 |
| Date of Acceptance | 16-Jul-2019 |
| Date of Web Publication | 12-Aug-2019 |
Correspondence Address:
Krishna Prasad Biswas
Senior Resident, Dept. of Dental and Oral surgery Lady Harding Medical College, Delhi
India
 Source of Support: None, Conflict of Interest: None
Endodontic management of nonvital tooth with wide-open blunder-buss apex has long presented a challenge. Mineral Trioxide Aggregate (MTA) apexification is an promising alternative to multiple visit calcium hydroxide apexification . This case report presents single step MTA apexification with collagen barrier and custom made gutta percha condenser followed by intracanal composite resin reinforcement
Keywords: Open apex, MTA apexification, Collagen barrier, Gutta percha condenser, composite resin reinforcement
How to cite this article:
Ranjani MS, Jaikailash S, Dhanalakshmi S, Biswas KP. One step MTA apexification with collagen barrier and root reinforcement of traumatized immature teeth. J Indira Gandhi Inst Med Sci 2019;5:175-7 |
How to cite this URL:
Ranjani MS, Jaikailash S, Dhanalakshmi S, Biswas KP. One step MTA apexification with collagen barrier and root reinforcement of traumatized immature teeth. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Mar 27];5:175-7. Available from: http://www.jigims.co.in/text.asp?2019/5/2/175/301107 |
| Introduction : | |  |
Immature tooth with pulpal necrosis and periapical lesion poses multiple challenges to successful treatment especially in older patients where treatment options are limited. The challenges are due to difficulty in disinfecting the root canal with aggressive use of endodontic files following standard root canal treatment protocol, the presence of open apex with no barrier for stopping the root filling material from being pushed into periapical region and higher susceptibility to fracture due to the presence of thin fragile dentinal walls. Apexification with calcium hydroxide is the most commonly advocated therapy for immature teeth with non-vital pulp.[1],[2] But the disadvantages are its prolonged treatment time, the need for multiple visits and radiographs and increased risk of root fracture.[3],[4] This article presents a case report of Mineral Trioxide Aggregate (MTA) apexification with collagen barrier and custom made gutta percha condenser followed by reinforcement of fragile root canal by intracanal composite build up.
| Case Report : | | |
A 38 year old male patient reported with the complains of recurrent swelling & pus discharge from gum region in relation to broken left upper front tooth since 1 month. Patient gave history of trauma during his school days. On clinical examination, patient had discoloured 21 with Ellis class II fracture. Soft tissue examination revealed discharging sinus in relation to 21 [Figure 1]. Tenderness on percussion and grade 1 mobility was present in 21. Radiographic examination revealed open apex with periapical lesion in relation to 21 [Figure 2]. The patient was diagnosed to have chronic periapical abscess with draining sinus in relation to 21.
| Management : | | |
Under rubber dam, endodontic access cavity was done in 21. The canal was instrumented lightly with K files((Mani, Japan) with the aim of cleaning the root canal walls of debris. The canal was thoroughly debrided with a copious irrigation of sodium hypochlorite (1%) and saline (0.9%), to ensure complete removal of the necrotic pulp tissue. The canal was dried with sterile paper points, and Calcium hydroxide (Ultracal XS, Ultradent, South Jordan) intracanal medicament was placed and the access cavity was temporized with Cavit G(3M ESPE; Germany). The patient was recalled after 1 week.
After one week, dressing was removed and no discharge was seen in the canal. Canal was irrigated with sodium hypochlorite (1%) and saline to remove the calcium hydroxide. The canal was dried with absorbent paper points (DENTSPLY, Tulsa Dental). To condense the MTA inside the canal a custom made Gutta percha condenser was made using roll cone technique to the established working length of 18mm. Intraoral periapical radiograph was taken to confirm the fit and the length of the GP condenser. Markings were made at 15mm. A resorbable collagen sponge barrier (Kolspon, Eucare pharmaceuticals, India) was placed with GP condenser at the apex to limit the MTA within the canal. [Figure 3] GP was again tried in the canal for 18mm to make sure sponge is only at the apex.
MTA(Pro Root MTA, Dentsply Maillefer) was mixed according to the manufacturer’s instructions and placed in the canal entrance using amalgam carrier and condensed using the custom made condenser from apex to 3mm and checked with IOPA radiograph[Figure 4]. A wet cotton was placed in the canal and access cavity was temporarily sealed using Cavit G. The patient was reviewed the next day, temporary restoration removed & the set MTA was assessed.
To reinforce the fragile root canal walls, intracanal composite buildup was planned. The remaining canal space was filled with dual cure composite filling material Paracore (Coltene-Whaledent, USA) according to the manufacturer’s instructions using automixing tips from apical to coronal direction and light cured. A radiograph was taken to assess the intra canal composite build up [Figure 5].
The patient was reviewed after 2 weeks .Crown preparation was done, impression taken & acrylic jacket crown was fabricated & luted with Glass ionomer cement [Figure 6]. The patient was reviewed at 3 months interval [Figure 7].
| Discussion : | | |
The main advantage in MTA Apexification are fewer appointments for the patient, development of an immediate apical seal, less potential to weaken tooth structure as with long-term calcium hydroxide and probably reinforce the root structure.[5],[6]
The major problem in cases of a wide open apex is the need to limit the material to the apex. A large volume of the extruded material may set before it disintegrates and gets resorbed. This might result in the persistence of the inflammatory process, which may complicate or even prevent repair of the tissue.[7],[8],[9] Apical barrier was constructed with collagen sponge to seal MTA at the apex and to prevent its apical extrusion.[10] This collagen resorbs in 10 to 12 days.
In this case, custom made gutta percha condenser was the guide to confine and condense MTA within the canal. Even though the use of GP condenser is quiet technique sensitive, this proves to be an alternative economical method avoiding the usage of expensive MTA placement systems.
Immature pulpless teeth which have undergone apexification are at high risk of root fracture. The degree of tooth development proves to be the key variable.[11] Previous studies reported that the fracture resistance of root seemed to be much greater after placement of 4mm thick apical plug MTA followed by intracanal composite resin compared with MTA followed by GP and sealer.[1213] Bonding dual cure composite resin directly over MTA plug with no interposing layer of gutta percha acts like monoblock improving the fracture resistance of the fragile tooth. So in this case intracanal reinforcement with dual cure composite resin was performed. But a major disadvantage with this procedure is difficulty in non surgical retreatment in case of failure of endodontic treatment.
Apical barrier with collagen and MTA using a custom made GP condenser followed by intracanal composite resin reinforcement could be considered as a good option for treatment of immature pulpless permanent teeth in especially older individuals. However, further controlled clinical trials are necessary to investigate the predictability of the outcome with this technique.
| References | | |
| 1. | Ghose LJ, Baghdady VS, Hikmat BY. Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide. J Endod. 1987;13:285-90.  |
| 2. | Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta percha. A retrospective clinical study. Endod Dent Traumatol. 1992;8:45-55. |
| 3. | Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root canal therapy: A review. Endod Dent Traumatol. 1994;10:105-8. |
| 4. | Andreason JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol. 2002;18:134-7. |
| 5. | Girish. C. Kubasad, Sheetal.B. Ghivari. Apexification with Apical Plug of Mta- Report of Cases. Archives of Oral Sciences & Research. 2011; 1(2):104-107. |
| 6. | Steinig TH, Regan JD, Gutmann JL. The use and predictable placement of Mineral Trioxide Aggregate in one-visit apexification cases. Aust Endod J 2003; 29:34-42. |
| 7. | Benenati F, Roane J, Bigss JT, Simon J. Recall evaluation of iatrogenic root perforations repaired with amalgam and gutta percha. J Endod. 1986;12:161-6. 27. |
| 8. | 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. |
| 9. | Pradhan DP, Chawla HS, Gauba K, Goyal A. Comparative evaluation of endodontic management of teeth with unformed apices with mineral trioxide aggregate and calcium hydroxide. J Dent Child. 2006;73:79- 85 |
| 10. | David Thom: Apexification Procedure Using Mineral Trioxide Aggregate Canadian academy of endodontics. July 2000 |
| 11. | Cohen’s Pathways of the pulp 10th ed, Elsevier Mosby 2011 |
| 12. | Carvalho C. A. T., Valera M. C., Oliveira L. D., and Camargo C. H. R., “Structural resistance in immature teeth using root reinforcements in vitro,” Dental Traumatology, vol. 21, no. 3, pp. 155-159, 2005. |
| 13. | Lawley G. R., Schindler W. G., Walker W. A., and Kolodrubetz D., “Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification,” Journal of Endodontics, vol. 30, no. 3, pp. 167-172, 2004. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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