nonsurgical retreatment

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92 2015 Journal of Restorative Dentistry | Published by Wolters Kluwer - Medknow

Nonsurgical retreatment and

reinforcement of an immaturepermanent tooth with periapical lesionof endodontic originAmit Malhotra, Jyoti Ahlawat, Chirag Bansal1, H Murali Rao2

Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, Departments of 1Conservative Dentistry and Endodonticsand 2Conservative Dentistry, RV Dental College, Bangalore, Karnataka, India

Address for correspondence:Dr. Jyoti Ahlawat, Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi - 110 002, India.E-mail: [email protected]

INTRODUCTION

Traumatic dental injuries in immature permanent teethoften lead to loss of pulp vitality and interruption of rootdevelopment. Endodontic treatment of such teeth canpresent a challenging clinical situation due to the thindentinal walls and a divergent apical architecture. Thiscreates diculty in performing instrumentation andprepares an adequate apical stop; hence, an alternative

to conventional root canal treatment, apexication orroot-end closure, has been advocated.[1]

Apexification involves inducing the formationof mineralized tissue in the apical portion of animmature nonvital tooth.[2] Calcium hydroxide (CH)was traditionally used as the material of choicefor apexification. It had also been combined withother material such as sterile water, camphoratedmonochlorophenol, methylcellulose, cresatin, iodoform,and Ringers solution. However, treatment with CHruns a lengthy course of time and may often result

in unpredictable results including root resorption

Endodontic management of immature traumatized teeth usually involves carrying out conventional

(apexogenesis and apexication) or regenerative endodontic treatment. While continued development of

the radicular tooth structure should be the desired outcome of treating teeth with open apex, in cases of

necrotic teeth or retreatment procedures, the formation of apical barrier via apexication is a more feasible

approach. A 21yearold boy reported with a traumatized maxillary central incisor with incomplete root

development, previously treated 13 years ago; it was decided to retreat the tooth endodontically and carry out

rehabilitation via reinforcement of the root using ber post. The post was customized by relining it with direct,

visiblelightcured composite resin and nal cementation was carried out using dual cure composite resin.

This paper aims to present and discuss different treatment modalities possible in a young traumatized tooth.

Keywords:Anatomic post, apexication, mineral trioxide aggregate, retreatment

ABSTRACT

How to cite this article:Malhotra A, Ahlawat J, Bansal C, Rao HM.Nonsurgical retreatment and reinforcement of an immature permanent

tooth with periapical lesion of endodontic origin. J Res Dent 2015;3:92-5.

This is an open access article distributed under the terms of the Creative

Commons AttributionNonCommercialShareAlike 3.0 License, which allows

others to remix, tweak, and build upon the work noncommercially, as long as the

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Case Report

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Malhotra,et al.: Non surgical management of immature permanent tooth with periapical pathology

Journal of Restorative Dentistry / Vol - 3 / Issue - 3 / Sep-Dec 2015 93

showed inadequate obturation of the immature rootwith presence of a diuse radiolucency surroundingthe apical region of the involved tooth [Figure 1b].The treatment plan included retreatment of the tooth

by formation of apical MTA plug followed by deniterestoration with post and core.

Access cavity was prepared under rubber dam isolation.The previous lling material was removed from the canalwith Hedstrom les (Dentsply Maillefer, Ballaigues, Vaud,Swierland) of size 3550. A radiograph was taken to checkfor the presence of any residual lling material and workinglength was established with a size 80 Ktype le (Dentsply,Maillefer Baillaigues, Swierland) [Figure 2a]. Minimalinstrumentation was done with this le. Canal disinfectionwas achieved by irrigation with 1% NaOCl using EndoVacirrigation system (Discus Dental, Culver City, CA, USA).Interappointment CH medicament (RC Cal, Prime Dental,Thane, Maharashtra India) was placed using a lentuloafter drying the canal space with sterile paper points.

At the next appointment, the tooth was reassessed. CHwas removed and the canal was prepared to receivelling material. Proroot MTA (Dentsply, Tulsa, OK, USA)was mixed according to the manufacturers instructionsand carried to the canal with an amalgam carrier.Apical plug of 4 mm of MTA was placed and conrmedradiographically [Figure 2b]. A sterile cotton pelletmoistened with sterile water was placed over the canalorice and the access cavity was sealed with Cavit (3MESPE, Seefeld, Bavaria, Germany).

The next visit was scheduled after 3 days whenrestoration of the tooth was done with post and core.It was decided that a ber post would be customizedsuch that it would adapt precisely with canal anatomy,adequate adhesion with the canal walls, and provideaesthetics as well. Minimal post space preparation was

or fracture.[3]Mineral trioxide aggregate (MTA) wasintroduced as a substitute for single visit apexicationsince it provides immediate sealing, along with superior

biocompatibili ty. [4] MTA is available in the form ofpowder that sets in the presence of moisture. It iscomposed of tricalcium silicate, tricalcium aluminate,tetracalcium aluminoferrite, calcium sulfate dihydrate,

and silicate oxide. Bismuth oxide was added forradiopacity. MTA is available in the following two forms:Grey MTA and white MTA. The dierence between thetwo is the absence of tetracalcium aluminoferrite inwhite MTA. The alkaline pH and presence of calciumand phosphate ions in MTA promote conditions forcementum deposition.[5]

Postendodontic restoration of fractured anterior teethoften requires postplacement. Due to the irregularand wider root canal space and fragile dentinal walls,custom-made posts are preferred over prefabricated ones.Application of a chairside customized ber post that

simulates the canal anatomy as well as provides superiorretention and aesthetics is advantageous in such cases.[6]

This case report presents the retreatment of an immaturepermanent anterior tooth with MTA apical plug followed

by the placement of anatomic post.

CASE REPORT

A 21-year-old male patient reported with the chiefcomplaint of a discolored and fractured maxillaryincisor tooth. The patient had a history of trauma tothe maxillary anterior region at the age of 8 years forwhich he had visited a dental practitioner. Root canaltreatment of the traumatized tooth was carried out

by the clinician at that time. His medical history wasnoncontributory. Clinical examination revealed crownfracture of the maxillary right central incisor withtenderness on percussion [Figure 1a]. Radiographs

Figure 1:Preoperative clinical (a) and radiographic (b) views

b

a

Figure 2: (a) Working length determination, (b) application of MTAplug, (c) used ber post, (d) application of the post into the root canal

dc

ba



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94 Journal of Restorative Dentistry / Vol - 3 / Issue - 3 / Sep-Dec 2015

done with Peeso drills (Dentsply Maillefer, Baillaigues,Swierland) to remove any undercut present on surfaceof canal wall. A light transmiing post (DT Light Post,RTD, Grenoble, France) was selected and veried foring inside the canal. Post space was dried followed

by application of a separating agent. The ber post wasconditioned by the application of etchant and bonding

agent. The labial surface of the post was marked with apencil for verifying the position and achieving correctorientation of the post during customization. Prebondedpost was coated with a resin composite (Filtek Z350; 3MESPE, USA) and inserted inside the canal to adapt withthe canal anatomy. The composite was cured inside thecanal through the translucent ber post for 5 s. The postwas then removed from the canal and cured for another20 s. Incremental addition of composite was continued tillthe post had an adequate t inside the canal [Figure 2c].Post adaptation and t inside the canal was conrmedradiographically [Figure 2d].

The canal space was rinsed to remove the separatingagent. After drying, etchant (phosphoric acid) and

bonding agent were applied inside the canal. Light curingwas done for 20 s. Luting of anatomic ber post was donewith dual cure resin cement (Rely X ARC; 3M ESPE). Thetooth surface was etched, rinsed, and bonded. Thereafter,core buildup was done followed by tooth preparationfor metal ceramic crown. Crown cementation was donewith luting glass ionomer cement [Figure 3a]. Followupradiographs after 1 year revealed complete healing of theperiapical lesion [Figure 3b].

DISCUSSION

Although the ideal endodontic outcome in immaturenecrotic teeth is regeneration of the pulpal tissueresulting in continued root development, such atreatment approach is not always feasible, especiallyin teeth where endodontic treatment has already

been aempted previously but has resulted in failure.The alternative procedure that is often indicated in suchcases is the formation of an articial apical barrier againstwhich gua percha is condensed.

CHinduced apexication is not a reliable procedure

in nonvital immature teeth due to various drawbacksincluding deterioration of mechanical properties of theroot canal dentin.[5] Longterm CH therapy has beensubstituted by one or twostep apexication proceduresthat employ bioactive and biocompatible materials toform the apical plug.

The most extensively researched and clinically evaluatedbiomaterial in endodontics over the last couple ofdecades is MTA that seems to have become a standardof care in the management of immature nonvital

teeth. Apart from reducing the treatment time forapexication, MTA provides eective periradicular seal

and is extremely resistant to the acidic environment ofperiapical infections.[7]Being a bioactive material, MTApromotes the healing of periradicular defects by inducingregeneration of the cementum and periodontal ligament.The literature consists of reports where the application ofMTA as an apical matrix has demonstrated exceptionalresults in the management of immature teeth, allowingcontinued root development even in cases of necroticpulpal tissue.[8]

The primary issue while restoring an immature tooth isthe weakened radicular structure due to thin and fragiledentinal walls.[9] Therefore, in order to minimize the

risk of fracture postendodontic restoration should beplanned keeping in mind the objective of strengtheningthe root architecture. Lui et al. had previously suggesteda procedure for reinforcing the root structure bylining the internal root canal walls with a chemicallycured composite after etching and bonding the canalwall dentin.[10,11]The limitation in such a technique isthe inability to control the polymerization reactionin the apical areas of the canal space. Fiber posts arecommonly advocated for postendodontic managementof traumatized anterior teeth with decient residualtooth structure due to their aesthetic as well as adhesive

properties.[12]

The current case was deemed appropriatefor the use of customized post due to the irregularand wide anatomy of the canal space. Placement ofprefabricated posts in canals with such a cross sectionoften compromises the adaptation of post with thecanal walls. Consequently, excessive space left betweenthe post surface and canal wall dentin gets lled withluting agent.

A thick layer of luting cement is detrimental to bondquality and predisposes to adhesive failure and

Figure 3:(a) Metal ceramic crown cementation, (b) 1-year follow-upradiograph showing resolution of the periapical lesion

b

a



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Journal of Restorative Dentistry / Vol - 3 / Issue - 3 / Sep-Dec 2015 95

improve the long-term survival of traumatized immatureteeth with missing coronal tooth structure, rehabilitationof canal space with an anatomic ber post and coreappears to be a satisfactory treatment approach.

Financial support and sponsorshipNil.

Conicts of interest

There are no conicts of interest.

REFERENCES

1. DArcangelo C, DAmario M. Use of MTA for orthograde obturation

of nonvital teeth with open apices: Report of two cases. Oral Surg

Oral Med Oral Pathol Oral Radiol Endod 2007;104:e98-101.

2. Morse DR, Larnie J, Yesilsoy C. Apexication: Review of the

literature. Quintessence Int 1990;21:589-96.

3. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical

barrier formation and healing in non-vital immature permanent

teeth: A review. Br Dent J 1997;183:241-6.

4. Torabinejad M, Chivian N. Clinical applications of mineral trioxideaggregate. J Endod 1993;25:197-205.

5. Kubasad GC, Ghivari SB. Apexification with apical plug of

MTA-report of cases. Arch Oral Sci Res 2011;1:104-7.

6. Grandini S, Sapio S, Simonetti M. Use of Anatomic post and core

for reconstructing an endodontically treated teeth: A case report.

J Adhes Dent 2003;5:243-7.

7. Saghiri MA, Lot M, Saghiri AM, Vosoughhosseini S, Fatemi A,

Shiezadeh V, et al. Effect of pH on sealing ability of white

mineral trioxide aggregate as a rootend lling material. J Endod

2008;34:1226-9.

8. Rule DC, Winter GB. Root growth and apical repair subsequent

to pulpal necrosis in children. Br Dent J 1966;120:586-90.

9. Tait CM, Ricketts DN, Higgins AJ. Weakened anterior

roots-intraradicular rehabilitation. Br Dent J 2005;198:609-17.

10. Lui JL. Composite resin reinforcement of ared canals using

light-transmitting plastic posts. Quintessence Int 1994;25:313-9.

11. Lui JL. A technique to reinforce weakened roots with post canals.

Endod Dent Traumatol 1987;3:310-4.

12. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture

resistance of endodontically treated teeth restored with composite

posts. J Prosthet Dent 2003;89:360-7.

13. Ferrari M, Vichi A. Mannoci F, Mason PN. Retrospective study

of clinical behaviour of several types of posts. Am J Dent

2000;13:15-B8.l

14. Bolhuis P, de Gee A, Feilzer A. Inuence of fatigue loading on

four post-and-core systems in maxillary premolars. Quintessence

Int 2004;35:657-67.

debonding of the post.[13] Apart from debonding,polymerization shrinkage stresses associated with resincements may further increase the risk of tooth fractureduring functional loading in case of such wide andirregular canal spaces.[14]Additionally, the chances ofoccurrence of voids and bubbles in the luting cementthat represent areas of weakness within the material

are minimized if a thin layer of cement is requiredduring post cementation.[6]Just like all of the resinbasedmaterials, the relining resin surrounding the anatomicpost shrinks as it cures. Although this aspect needsfurther evaluation, it logically seems that the shrinkageshould favor the extrusion of the anatomic post fromthe canal after its relining. Keeping in mind all theabove factors, it was decided to customize the berpost according to the root canal anatomy in order toachieve complete adaptation with root radicular dentinwalls. In addition to reinforcing the remaining toothstructure, placement of ber post reduces patient visitsfor fabrication of a postendodontic restoration since it is

usually accomplished in a single visit.

An alternate treatment modality could have been theplacement of direct composite resin material insidethe root canal after etching and bonding followed byinsertion of light transmiing post precoated with aseparating media through the composite and curing withlight activation. After curing, the post is removed witha rotating and pulling motion, creating a patent spaceinside the reinforced canal. Tait et al. advocated restoringthis patent canal space with either composite resin incases of teeth with sucient residual coronal structureor placing a quar ber post followed by composite core

buildup in cases where inadequate sound tooth structurewas remaining.[9]

CONCLUSION

The most successful approach in endodontic therapy ofnonvital immature teeth includes the use of bioinductiveand reparative materials like MTA that acceleratesperiapical tissue healing, along with ensuring eectivesealing of ared canal architecture apically. In order to


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