Apexification with apical plug of MTA- report of cases

Back ground: 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 (MTA) are indispensable. These case reports present successful healing and apexification using MTA. Methods: The case reports present two cases with traumatized upper anterior teeth. The radiographic evaluation revealed open apices with blunderbuss canals; the canal was cleaned using intracanal instruments and 5.25% NaOCl and final irrigation with 2% chlorohexidine. To obtain canal disinfection slurry of calcium hydroxide was temporized in the canal. In subsequent appointments 3-4mm apical stop was created with mineral trioxide aggregate and allowed to set. Subsequently the root canals were obturated with thermoplasticized guttapercha. A composite resin restoration sealed the access cavity. A 3 month, 6 month and 1 year follow-up revealed clinically asymptomatic and adequately functional tooth. Results: A positive clinical resolution of this case is encouraging for the use of white MTA as a apical plug, in immature teeth with open apex. Conclusion: Apexification in one step using an apical plug of MTA can be considered a predictable treatment and may be an alternative to use a long term calcium hydroxide apexification. Keyword: Apical plug; MTA; Apexification Access this article online Quick Response Code: Website: www.innovativepublication.com DOI: 10.5958/2394-2738.2016.00030.3 Introduction Complete asepsis and three dimensional obturation of the root canal system are essential for long term endodontic success. In certain cases such as immature teeth, absence of natural apical constriction creates a challenge. Therefore one of the aims of endodontic treatment is to form an apical barrier or a stop against which one can place root canal filling material avoiding over extrusion. This technique is termed as apexification. Clinicians have tried several materials to form apical barrier in the past. These include, calcium hydroxide powder, calcium hydroxide mixed with different vehicles, collagen calcium phosphate, osteogenic protein, bone growth factor and oxidized cellulose. Deliberate over instrumentation to produce blood clot that will induce apical closure has also been described. Mineral trioxide aggregate (MTA) was developed at Loma Linda University as root end filling material. Using MTA apexification can be carried out in single visit which is advantageous over traditional calcium hydroxide apexification which requires treatment time of 5–20 months to induce the formation of a calcific barrier. Apexification using MTA has several advantages as it neither gets resorbed nor weakens the root canal dentin and also sets in wet environment. Satisfactory compaction of filling material can be achieved as MTA forms hard and non-resorbable apical barrier. Torabinejad et al. (1995), Xavier et al. (2005) suggested that mineral trioxide aggregate is most biocompatible and bacteriostatic material with good sealing property, which stimulates cell growth, adhesion and proliferation. Therefore the present case reports highlight the non surgical management of asymptomatic tooth with blunderbuss canal using MTA apical plug technique. Case Reports Case 1: A 18 year old male patient, reported to the Department of Conservative Dentistry & Endodontics, Vananchal Dental College, Gharwa (Jharkhand) with a chief compliant of discoloured right maxillary central incisor with the history of trauma at the age of 9. The concerned tooth did not respond to both electric and heat test. Detailed radiographic examination revealed a large blunderbuss canal with associated periapical lesion in relation to maxillary right central incisor (Fig. 1). There are two treatment options either surgical removal of periapical lesion and retrograde filling or non surgical root canal treatment followed apexification using apical plug of MTA. Considering the amount of Abhishek Shukla et al. Apexification with apical plug of MTAreport of cases The Journal of Community Health Management, July-September 2016;3(3):144-147 145 surgical trauma and the age of the patient non-surgical treatment was opted. Access opening was prepared under rubber dam isolation and working length was determined (Fig. 2). Pus was extruded from the root canal immediately after access preparation; luke warm water was used to irrigate the root canal and was left open till exudate stopped draining out of the canal. Biomechanical preparation was done using no 80 K-file using circumferential filing motion. Root canal debridement was done using alternate irrigation with 2.5% NaOCl and saline. Calcium hydroxide and iodoform combination was placed in the root canal and patient recalled after one week. At subsequent appointment after removal of dressing root canal was found completely dry and canal was debrided with 2.5% NaOCl followed by 17% EDTA and final rinse with 2% chlorohexidine. The canal was dried with paper points and Mineral trioxide aggregate was placed with MTA carrier in the apical portion of the canal, subsequent increments were condensed with hand pluggers till thickness of 2-5mm (Fig. 3). A wet cotton pellet was placed, access cavity sealed with temporary cement. In subsequent appointment root canal was back filled with Obtura II access cavity sealed with composite (Fig. 4).