Sealing the Unsealed: Management of Immature Apex: A Case Series

INTRODUCTION

Following tooth eruption, the tooth continues to build its entire root and close the apical foramen for up to three years. Pulp necrosis may occur in young permanent teeth if the pulp is harmed before the apical foramen closes. Wide dentinal tubules in developing teeth allow bacteria and their irritants to enter. As a result, these teeth have root resorption immediately following trauma. To prevent the resorption of the roots, root canal therapy should be performed as soon as possible. Getting an apical seal is the major challenge in the endodontic treatment of these teeth.

Apexification therapy is used on nonvital, immature teeth in order to encourage the development of a strong tissue barrier at the root apex. MTA has been demonstrated to be a highly effective root filling material for sealing young root canals with open apices that could otherwise present technical issues in achieving proper obturation. By stimulating the development of hard tissue, MTA can aid periradicular healing.

The following clinical cases describe the use of MTA as an apical plug. Root canal treatment and follow-ups of nonvital immature permanent teeth.

CASE REPORT 1

A 17-year-old female reported with food lodgement in the left mandibular 2nd molarsince 7 to 8 months . Hard tissue examination revealed presence of deep proximal caries in relation to the lower left back 2nd molar. The tooth did not respond to electric and thermal testing. Radiographic examination revealed deep proximal radiolucency involving pulp and presence of immature apex Apexification using MTA apical plug technique was opted.

Straight line access was made and working length was determined radiographically. Minimum instrumentation using hand files was done under irrigation using 2.5% NaOCl and saline. Intracanal medicament, that is, Ca(OH)2 and iodoform combination dressing, was given. After 2 weeks the patient remained asymptomatic, the tooth was reaccessed, and canals were irrigated. The canals were dried with paper points and MTA was mixed according to the manufacturer’s instructions and applied to the apical portion of canal.

Repeated radiographs were obtained to check adequacy of MTA . The blunt end of a large paper point was moistened with water and left in the canal to promote setting for 72 hours. A cotton pellet was placed in chamber and the tooth restored with temporary cement.

After72 hours, the tooth was isolated and accessed as before. A hand plugger was lightly tapped against MTA plug to confirm a hardened set. The canals were dried using sterile paper points and obturated injectable thermoplasticized gutta-percha.

6 month follow up showed normal pdl space and lamina dura.

CASE REPORT 2

An 17 year old male patient reported with a chief complaint of discoloration and broken teeth in the upper front tooth region since 4 years. On recording the history,it was revealed that patient had met with an accident 4 years back falling from a bike. On clinical examination there was ellis class III fracture w.r.t 11 and 2. on performing the pulp vitality tests the concerned teeth (11 and 21) did not respond to both electric and cold test (11 and 21). The radiographic examination revealed large blunderbuss canals w.r.t 11 and 21 with periapical lesion.Apexification with MTA was planned. Access opening was prepared and working length was determined ; irrigation was done with saline. Biomechanical preparation was carried out using 70 size k file with circumferential filing motion. Root canals debridement was done using alternative irrigation with 2.5% NaoCl and saline. Calcium hydroxide was placed in the root canals and patient recalled after 14 days. At subsequent appointment, canal was irrigated with 2.5% NaoCl and 2% CHX .The canals were dried with paper points and MTA was placed with pluggers until thickness of 5 mm . A wet cotton pellet was placed in the canal and access cavity was sealed with temporary cement. In next appointment, root canals were obturated with using thermoplaztisized gutta percha.

DISCUSSION

The most used material for apexification is calcium hydroxide. There are various drawbacks to this information. One of them is that the course of treatment takes somewhere between three and twenty one months. The amount of time needed depends on the size of the open apex, the speed of tooth displacement, and the technique used to realign the teeth following trauma.

The leakage of the temporary coronal filling has the potential to reinfect the root canal over an extended period of time. In teeth with subpar coronal filling, the success rate drops by 10%.Hence, executing a permanent treatment is preferable since it prevents the root canal from becoming infected again. The fracture resistance decreases after more than 30 days of calcium hydroxide treatment in the root.

As an alternative to lengthy apexification therapy, MTA apical plug creation in one visit has recently been advocated for the treatment of nonvital immature permanent teeth. In the above cases MTA was placed. This material was initially introduced to the dentistry literature in 1993 by Lee and colleagues.MTA is a material that is more biocompatible, has better antibacterial qualities, reduced leakage, a high marginal adaption, a quick setting time ( 4 hours), and a pH of 12.5. MTA offers scaffolding for the hard tissue barrier. MTA, a bioactive substance, promotes the synthesis of cytokines and interleukins. It can therefore encourage the production of rigid tissues. After MTA has been set, the dentist may repair the tooth. As a result, teeth with thin dentinal walls become more fracture-resistant.

Maroto et al. have reported successful apexification with MTA in a tooth that did not respond favorably after 3 years of therapy with Ca(OH)2.

CONCLUSION

When treating nonvital, immature permanent teeth, the MTA apical plug approach is beneficial since it requires less time, appointments, and radiographs and has better fracture resistance.

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