8332 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No.

Management of Open Apex Using Alternative Techniques:

Series of 3 Case Reports

Satabdi Pattanaik1, Satyajit Mohapatra2, Naomi Ranjan Singh1, K. Swapna Kumari3

1
Senior Lecturer, 2Former Post Graduate Trainee, 3Tutor, Department of Conservative Dentistry and Endodontics,
Institute of Dental Sciences, Siksha ‘O’ Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India

Abstract
Traumatic injuries during early childhood interfere with root development leading to the formation of a
tooth with an open apex. Apexification is considered as the best choice for the treatment of such cases. Use
Mineral Trioxide Aggregate (MTA) as apical plug material optimizes the treatment outcome. Other than
MTA different techniques are also used to restore the function and stability of the immature permanent
tooth. In this case report 3 different techniques are used to treat the open apex. In the first case, MTA apical
plug along with backfill was done. Complete canal obturation with MTA and custom cone technique were
performed for the second and third cases respectively.

Keywords: Apexification; Mineral Trioxide Aggregate; Complete canal obturation; Open acces management.

Introduction treatment.1 These types of teeth are more commonly

associated with periapical pathology.2
It is quite natural to achieve proper canal disinfection,
adequate debridement and optimum apical sealing of the Early necrotized pulp and inflammatory apical root
root canal in a completely formed and well-developed resorption are the most common etiological factors for the
root, whereas achieving these parameters in a tooth with formation of immature teeth.3,4 Apical barrier formation
incompletely formed root is a challenge in the field of facilitates 3-dimensional cleaning and well adaptation of
dentistry. Lack of apical stop in cases with open apex obturating materials leading to a successful endodontic
puts the clinician in an uncertain circumstance. In every treatment. Materials used for such cases should have
step of root canal starting from chemo-mechanical properties like, antimicrobial, should be bioactive, should
preparation including irrigation till the apical sealing of create a fluid-tight seal, should have high strength and
the root canal clinician need to be very careful to avoid should reinforce root dentin.5 Earlier calcium hydroxide
peri-apical extrusion of the materials, which may lead to was used for the process of apexification, but it takes
post-operative symptoms like pain and swelling. Besides 5 to 20 months to form a calcific barrier.6 This lengthy
this an additional problem while treating this immature course of treatment offers a challenge like – difficulty
permanent tooth is the thickness of the radicular dentin, in patient follow up management, increases the risk
which may fracture during or after the root canal of tooth fracture with intracanal calcium hydroxide
dressing for an extended period and also there is a delay
in the completion of treatment.7 Various authors have
also confirmed that long term use of calcium hydroxide
as intracanal dressing increases the risk of fracture in the
Corresponding Author:
future.4,7,8
Dr. Satabdi Pattanaik
Senior Lecturer, Department of Conservative Dentistry Recently interest has focused on the use of MTA
and Endodontics, Institute of Dental Sciences, (mineral trioxide aggregate) for apexification. Its powder
Siksha ‘O’ Anusandhan (Deemed to be University), consists of hydrophilic compounds, which can set in the
Bhubaneswar, Odisha, India presence of moisture. Good biocompatibility, excellent
e-mail: satabdipattanaik@soa.ac.in sealing ability, high compressive strength, tissue
 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 8333
regeneration capacity are also added to its properties.9 hypochlorite (Prime Dental, India) and saline solutions.
Importantly MTA reduces the appointment time, even 5 ml of 17 % Ethylenediaminetetraacetic acid (Prevest
allows single visit apexification. MTA offers a good Denpro, India) was used for smear layer removal. On
apical barrier that allows vertical condensation of warm completion of preparation calcium hydroxide dressing
gutta-percha. (Avue Cal, Dental Avenue, India)was given for 1 week.

Technique 1: A 21-year male patient named After a 1-week tooth was again re-accessed under
Satyanarayan Sabat reported to the Department of rubber dam isolation. 5 ml of 17 % EDTA and Copious
Conservative Dentistry and Endodontics, Institute of amount of saline solution was used to remove the calcium
Dental Sciences, SOA University, Bhubaneswar with hydroxide dressing from the canal. Canal was aspirated
the chief complaint of the discoloured tooth in the upper and dried thoroughly with absorbent paper points. MTA
front tooth region. The patient gave the history of trauma (Angelus, Londrina, PR, Brazil) was mixed according to
12 years back. Clinical examination revealed discolored the manufacturer’s instructions and 4 mm of the apical
tooth with open access and tender on percussion to the plug was created using hand pluggers. A gutta-percha
tooth 21. An intraoral periapical radiograph revealed an point was introduced into the canal to confirm the apical
incompletely formed root apex with irregular periapical barrier (Figure 1b). a moist cotton pellet was placed over
radiolucency (Figure 1a). Hence, the final diagnosis was the MTA and the canal was sealed with a temporary
pulpal necrosis with symptomatic apical periodontitis restoration. Next day, the remaining portion of the root
in tooth 21. After rubber dam isolation (Hygienic canal was coated with silicate-based sealers (MTA
Dental Dam, Coltene Whaledent Inc., Germany), Filapex; Angelus, Londrina, SP, BR) and obturation
chemomechanical preparation of root canal was done was done by back-filling of gutta-percha using system
upto F5 (Dentsply Maillefer, Switzerland) along with B (Sybrondental, Orange, CA, USA) setting 200ᵒC upto
circumferential filing using # 80 K-file (Mani Inc., the level of CEJ (Figure 1c). Glass ionomer cement
Japan). Chemomechanical preparation performed in (3M ESPE, USA) was used for access cavity restoration
conjunction with a copious amount of 3% Sodium (Figure 1d).

Figure 1: 4mm apical plug of MTA followed by backfilling of gutta percha

8334 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Technique 2: Another male patient aged 18 restoration. After 1 week of intracanal dressing tooth
came to the Department of Conservative Dentistry & was irrigated with 17% EDTA (Prevest Denpro, India)
Endodontics, Institute of Dental Sciences, Bhubaneswar, and copious amount of saline solution to remove
with the chief complaint of unpleasant smile and gave the calcium hydroxide from the canal. Canal was aspirated
history of trauma 10 years back. On clinical examination and dried thoroughly with absorbent paper points. MTA
discolored tooth was noticed in 21. Intraoral periapical (Angelus, Londrina, PR, Brazil) was mixed according to
radiographic examination revealed a wide-open apex the manufacturer’s instructions and the entire radicular
with a thin radicular dentinal wallalong with periapical portion of the canal was packed with MTA (Figure 2c).
radiolucency in tooth 21 (Figure 2a). Under rubber dam moist cotton pellet was placed over MTA and temporary
isolation chemo-mechanical preparation for the tooth restoration was used to maintain the coronal seal for
was performed similarly as described in technique 1. the particular tooth. After 24 hours cotton pellet was
Calcium hydroxide dressing (Avue Cal, Dental Avenue, removed and coronal restoration was done using glass
India)was given for 1 week followed by temporary ionomer cement.(3M ESPE, USA) (Figure 2d).

Figure 2. Entire canal was filled with MTA

 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 8335
Technique 3: A 14-year-old male patient requested technique using a resin-based sealer, AH Plus (Dentsply
dental treatment in the upper right central incisor Maillefer, Switzerland). Gutta-percha points were
following trauma before 5 years due to fall from the softened by heat and rolled together between glass slabs.
bike. Radiographic examination revealed incompletely Tip of gutta-percha points were elasticized by using a
formed root with no periapical changes (Figure 3a). heated instrument and then introduced into the canal
Clinical examination revealed a discolored tooth in to record the internal morphology of the apical portion
11. All the necessary protocols were maintained under of the canal (Figure 3b). This process was repeated till
rubber dam isolation. Chemomechanical preparation proper tug back was achieved. Canalwas sealed upto
of the canal including calcium hydroxide dressing was the level of CEJ and the access cavity was filled with
carried out the same way as described in the technique 1. glass ionomer cement restoration (3M ESPE, USA)
After the removal of calcium hydroxide from the canal,it (Figure 3c).
was obturated by the custom cone technique or roll cone

Figure 3. Custom cone/Roll cone technique

Discussion was used to form the apical barrier in non-vital immature

teeth. One study has investigated thatfor apexification,
Successful treatment of permanent immature teeth
apical barrier formed by calcium hydroxide is porous
mainly depends on the proper cleaning of the root
and even contains some amount of soft tissue.13
canal system as mechanical instrumentation can not
be used appropriately. So, the disinfection of the entire MTA has excellent biological properties and has
root canal relies on the chemical action of sodium the potential to create a good apical seal, therefore it has
hypochlorite and on calcium hydroxide which is used been strongly recommended to use as an artificial barrier
as an intracanal medicament.10 At high concentration in the teeth with open apices, thus reducing the treatment
Sodium hypochlorite is known to be toxic especially appointment to 1-3 visits. High pH of MTA allows it
when it extrudes apically. Therefore, the use of a low to destroy surrounding microorganisms and its bioactive
concentration of sodium hypochlorite is advisable for nature encourages blastic cells to promote the process
disinfection in cases of immature teeth.11 17 % EDTA of healing.5,15 Along with this, it also facilitates the
solution was used to rinse the canal before placement deposition of cementum on it because of the presence
of calcium hydroxide as it removes the smear layer and of calcium and phosphorous ions (15). In a prospective
opens up the dentinal tubule for penetration of calcium study apexification using MTA has shownan increased
hydroxide through the dentin.12 Along with this use of prevalence of healing and apical closure.16 Thus, an
EDTA ensures better removal of calcium hydroxide from apical seal with MTA favours regeneration. Taking all
the canal before obturation.12 Initially calcium hydroxide the advantages of MTA into consideration, it was used
8336 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
for the apexification process in the first two cases of this pulp. 10th ed. India: Elsevier; 2011.
case report. 3. Parirokh M, Torabinejad M. Mineral trioxide
aggregate: a comprehensive literature review--
In the first technique-the apical plug of MTA was
Part III: Clinical applications, drawbacks, and
given and obturation was performed by backfilling
mechanism of action. J Endod. 2010;36(3):400-13.
of soften gutta-percha. 4-5 mm of MTA apical barrier
has proven to be significantly stronger and showed less 4. Trope M. Treatment of the immature tooth with a
leakage than a 2 mm apical plug. In this case,a 4 mm non-vital pulp and apical periodontitis. Dent Clin
apical barrier of MTA was given. MTA apical plug North Am. 2010;54(2):313-24.
facilitated obturation by condensation without any over 5. Shikha D, Mukunda KS, Aruna A, Rao SM.
extrusion of gutta-percha. In technique 2,the tooth was Apexification. J Dent Sci Res 2012;3(1):41-44.
very immature and the thickness of radicular dentin is 6. Sheehy EC, Roberts GJ: Use of calcium hydroxide
less, thus making the tooth more vulnerable to fracture. for apical barrier formation and healing in non-vital
In such cases adaptation of gutta-percha master cone immature permanent teeth: a review. British Dental
to the dentinal wall would be difficult. Additionally, it Journal 1997; 183, 241-246.
has been confirmed the use of MTA strengthens root
7. Andresen JO, Munksgaard EC, Bakland LK:
dentin.17,18 Considering the above-mentioned factors
Comparison of fracture resistance in root canals
root canal was completely obturated using MTA. As
of immature sheep teeth after filling with calcium
an experiment, a conventional method of obturation
hydroxide or MTA. Dent Traumatol 2006; 22, 154-
(tailor-made gutta-percha obturation) was attempted
156.
in technique 3. Rootend closure was achievedby
customized gutta-percha cone. Considerably successful 8. Yassen GH, Platt JA. The effect of nonsetting
treatment along with complete resolution of symptoms calcium hydroxide on root fracture and mechanical
was observed when the tooth was obturated with a properties of radicular dentine: a systematic review.
custom cone technique.19 The choice of treatment for Int Endod J. 2013;46(2):112-8.
teeth with open apex depends on the selection of case, 9. Uppal AS, Bhullar MK, Bhushan J, Kochhar GK.
operator’s experience as well as on the handling of Apexification. Dent J Adv Stud 2013;1:55-57.
various materials. 10. Siqueira JF Jr, Guimarães-Pinto T, Rôças IN.
Effects of chemomechanical preparation with 2.5%
Conclusion sodium hypochlorite and intracanal medication
There are various ways to manage a tooth with an with calcium hydroxide on cultivable bacteria in
open apex. MTA has numerous applications in the field infected root canals. J Endod. 2007;33(7):800-5.
of endodontics starting from pulp capping including 11. Hülsmann M, Hahn W. Complications during
pulpotomy to apexification. Due to its excellent root canal irrigation— literature review and case
biocompatibility and strength it is used for apical barrier reports. Int Endod J. 2000;33(3):186-93.
formation in immature young permanent teeth. Apart 12. Hülsmann M, Heckendorff M, Lennon A.
from all the advantages of apexification materials, proper Chelating agents in root canal treatment: mode of
canal disinfection, achieving a fluid-tight seal, limiting action and indications for their use. Int Endod J.
the apical barrier and obturation within the canal, play 2003;36(12):810-30.
an important role in a successful endodontic treatment.
13. Binnie WH, Rowe AH. A histological study of the
Funding Statement: None periapical tissues of incompletely formed pulpless
teeth filled with calcium hydroxide. J Dent Res.
Conflict of Interest: None 1973;52(5):1110-6.

Ethical Permission: Approved 14. Schmitt D, Lee J, Bogen G. Multifaceted use of

ProRoot MTA root canal repair material. Am Acad
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