Management of non-vital anterior tooth with open apex by MTA apical plug-A case report

A 15 year old boy was presented with pain in his upper anterior teeth. On clinical examination both the maxillary central incisor revealed slight discoloration and fracture of the crown. Radiographic evaluation revealed open apex of the left central incisor and apex of the right central incisor was fully developed. Apexification with MTA apical plug was carried out in left central incisor and conventional root canal treatment was done in right central incisor. In two months follow up both the tooth were clinically and radiographically asymptomatic and the healing of the apical area of the left central incisor was continued. These finding suggests that MTA can induce formation of apical barrier in the case of non-vital tooth with open apex.


Introduction:
Apexification is an endodontic treatment option which is done with a aim of apical repair as a hard tissue barrier across an open apex of a tooth .The treatment processes is usually used for treatment of the permanent tooth with non vital pulp and an open apex.Complete disinfection by biomechanical preparation 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.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. 1ifferent materials utilized in several procedures are used around the world to initiate formation of root end barrier.Calcium hydroxide with or without antiseptic, freeze dried allogenic dentin powder, bone ceramic, tricalcium phosphate, osteogenic protein, collagen, calcium gel and recently MTA and Portland cement are materials which have been used previously to see the clinical outcome to manage the tooth with open apex..In 1999 Torabinejad and Chivian for the first time showed the use of mineral trioxide aggregate (MTA) as an apical plug 2 .Apexification with MTA may be done with single visit that gives many advantages over conventional calcium hydroxide apexification which requires 5-20 months of treatment time to i form apical calcific barrier. 3This treatment modality is unpredictable ,often lengthy and presents with challenges.This includes the dislodgement tendency of the coronal temporary restoration leading to re-infection. 4It also has several drawbacks like long duration of treatment time (average 12.9 months) 5 , very often it is difficult to recall the patients for follow-up , multiple appointments in the treatment make it delay and the risk of tooth fracture is increased the forr dressing with calcium hydroxide for long

AFFILIATION:
Website: https://www.banglajol.info/index.php/UpDCJtime. 6Considering those reasons now a days researchers around the globe suggests single visit apexification 7 .Hence the first choice of material, suitable for single visit apexification is Mineral trioxide aggregate. 4,8,9,10,because of it is highly biocompatible 11,12 , shows high bacteriostatic activity when comes in contact with body tissues 13 , good sealing ability leading very low micro leakage 12 and as root end filling material 12 .MTA helps to form the barrier at the root end root canal in teeth with necrotic pulps and open apex 8  The treatment plan : apexification with apical plug of MTA on the left tooth and conventional root canal treatment on the right tooth followed by composite veneer on the both incisors.

Treatment procedure:
Large straight line access cavity was prepared with round diamond bur which help to remove all the necrotic tissue from the pulp chamber.Radicular pulp was removed with barbed broach .Irrigation was done with 2.5% sodium hypochlorite and normal saline.High volume suction was used to evacuate the irrigating debris.Working length was estimated by radiographic technique within 1 mm of the radiographic apex and they were as ,left incisor-24 mm, right incisor 25mm.Gentle circumferential filing, starting with a relatively large file and progressing through the apex.canal were dried the help of sterile paper point.Calcium hydroxide mixed with glycerin (slurry mix) was placed in to the canal with Lentulo.The access cavity was filled with cotton pellet & E-temp temporary cement .Patient was recall after one week.Both of the tooth were symptoms free on the next visit.Access was reopened and Calcium hydroxide was flushed from left incisor with normal saline.Irrigation protocol for non vital tooth was followed.The canal was dried with sterile paper point.MTA was mixed according to manufacturers instructions and introduced in to the canal with Lentulo 1 mm short of the radiographic apex and condensed into the apical 1/3 (4mm) by gentle packing with apical plugger (4 mm short of the working length).Confirmation of apical plug with radiograph A dam sterile cotton pellet was placed over the canal orifice and the access cavity was sealed with temporary filling.Website: https://www.banglajol.info/index.php/UpDCJFollow-up : Both of the teeth was clinically and radiographically asymptomatic and healing of the apical area is continued after 3 months of the procedures.

Discussion:
An immature permanent incisor tooth is considered as a tooth with an open apex.A root end closure technique is required before Root canal treatment of these teeth so that a calcific barrier can be formed at the apex and against with which a root canal filler and sealer filling can be condensed.By this we can prevent the possibility of sealer and filler from passing through apex into the periapical areas.Bacterial course of the infection is eliminated by root canal treatment.So irrigating solution with antimicrobial property like sodium hypochlorite and EDTA were used and intracanal medicament with potential antimicrobial activity like calcium hydroxide was placed as intra canal medicament for one week.Previous clinical studies has shown that this procedure can elimination the bacterial content in the root canal significantly within one week.H files were used to eliminate debris from the root canal walls but not to "shape" the canal because immature non vital permanent teeth usually have wide pulp chamber and thin dentinal walls.Torabinejad et.al in 1990 developed MTA at Loma Linda University while working on management of tooth with open apex.MTA is usually available as two types such as grey and white MTA.MTA is composed of tricalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, calcium sulphate dehydrate and silicate oxide.Bismuth oxide is added to make the cement radioopaque. 13MTA has a high pH of 12.5 which makes the material more antibacterial and it has a very good seating time which provide the operator enough working time.It has osteoinductive activity & also act as cementogenic agent which helps to stimulate the immune cells.As a result the cells release lymphokines that is required for the repair & regeneration of cementum & stimulate bone coulpling factors necessary for bioreminaralisation and healing of osseous periapical defect 14 .MTA have the ability to provoke interleukin (IL) production by osteoblast that can exibit raised level of IL-1 alpha, IL-1 beta, IL-6 & macrophage-colonystimulating factor 11 .The process of the biologic sealing by cementum disposition is not clear but may occur by the diffusion of calcium ions through dentinal tubules towards the root surface and inhibit bacterial colonization & survival 15.Both of the white & Gray MTA are capable of inducing PDL-cell attachment regeneration, stimulate PDL fibroblasts to initiate osteogenic phenotype and promote the production of osteonectin, osteopontin & osteoridogen & increase alkaline phosphates level 16,17 It also resist bacterial leakage against E. faecalis, Enterobacter aerogenes, & staphylococcus epidermidis.However Gray MTA appears better sealing agent than white, due to its less leakage property (Gray : 9.1%, white : 36.4% after 42 days).Clinical studies have reported that 77% to 85 % open apex healed completely 1-3 year with MTA plug 12,18,19,20 As it is hydrophilic, the presence of exudate, blood or tissue fluid enhance setting.A moist cotton pellet over MTA is also indicated to achieving hermetic seal due to setting expansion.MTA has high compressive strength which is comparable to IRM and Super EBA (It reaches to maximum strength in 72 hours 19 ).So usually obturation is done after 72 hours placement of MTA.Aminoshariae et al. at 2003 has shown that MTA placement by hand condensation technique results in better adaptation and leave very few voids than that of ultrasonic condensation. 20According to this, MTA was compacted in the apex using hand condensation.Unless there is specific reasons for delay & as one of the common cause that results in failure of apexification is the bacterial re-contamination due to loss of coronal restoration, the definitive restoration should complete as soon as possible.For more extensively damaged tooth ie.trauma, complete coronal coverage supported by post is indicated.However, In the presented case possible restoration of the access is light cured composite filling due to minimum tooth structure, requiring a durable semi permanent restoration, ease of placement & cost.

Conclusion:
In modern clinical practice MTA has many clinical use in surgical and non surgical endodontics ranging from apexification, pulpotomy to apical surgery.The main advantages of MTA is when it is used as an apical plugin, it reduces in the number of appointments, develop a hermetic apical seal leading no micro leakage and excellent biocompatibility.This case report shows one of the indications of MTA as apexification material and it ensures that MTA can be used as an apical barrier & considered as highly effective for treatment of immature non vital permanent teeth with open apex.Though more clinical studies with larger sample size will revel the outcome more effectively.

References:
1 that allows the vertical condensation of fillers and sealers in the remainder of the canal.The clinical techniques and case report are shown in which MTA was used for apexification in cases with open apex to develop an apical barrier and the effectiveness of MTA regarding those cases is well established.in this case report MTA was used for apexification tooth with open apex.Case Report: A 15 years old male patient with noncontributory medical history, came to the department of conservative dentistry and endodontics, Update Dental College And Hospitals, with the chief complain of pain in his upper anterior teeth & history of trauma 2 yrs.prior to the time of reporting.He did not consult with any dentist.Clinical examination revealed slight discoloration and fractured crown on both upper central incisors.Percussion was normal.Vitality test with ethyl chloride revealed negative result on both incisor.Radiological examination revealed an immature tooth with wide open apices on the left central incisor and closed apex on the right one.The Diagnosis : Left Incisor : Necrosis with open apex.Right Incisor : Necrosis with complete apex.