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CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 45-48 Case Report

Correspondence

Çiğdem Çetin Canbazoğlu, DDSDepartment of Endodontics,

Faculty of Dentistry,

Hacettepe University,

06100 Sıhhiye, Ankara, Turkey

Phone : +90 312 3052260

Fax: +90 312 3104440

E-mail: cigdem.cetin@hacettepe.edu.tr

Çiğdem Çetin Canbazoğlu DDSDepartment of Endodontics, Faculty of Dentistry,

Hacetepe University,

Ankara, Turkey

Selen Küçükkaya, DDSDepartment of Endodontics, Faculty of Dentistry,

Hacetepe Universıty,

Ankara, Turkey

A CASE SERIES OF THE TREATMENT OF IMMATURE PERMANENT TEETH BY APICAL PLUG TECHNIQUE USING MINERAL TRIOXIDE

AGGREGATE

ABSTRACT

The aim of this case series is to present successfull treatment

finalization by creating apical plugs with MTA in non-vital

immature teeth with open apices. Four cases of non-vital

immature teeth with wide open apices were treated by

creating MTA plugs. In the first three cases, MTA plugs were

placed at the apical parts orthogradely. Thereafter, the

remained part of the roots were obturated with gutta-percha

by lateral condensation. In the forth case, retrograde approach

was applied due to the excessive wideness of the apex. Apical

surgery was performed and the entire canal was obturated

with MTA retrogradely. The graft material was established. The

follow-ups were done for all four cases.One year clinical and

radiological follow-ups revealed clinically functional teeth and

the healing of the periapical area in all cases. MTA apical plug

technique is efficient on treating non-vital immature teeth wih

open apices.

Key words: Apical Plug, Immature Teeth, MTA, Open Apex

Submitted for Publication : 05.30.2013

Accepted for Publication : 09.04.2013

CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 45-48 Olgu Bildirimi

Sorumlu Yazar

Çiğdem Çetin Canbazoğlu Hacettepe Üniversitesi, Diş Hekimliği Fakültesi,

Endodonti Anabilim Dalı,

Sıhhiye 06100 Ankara Türkiye

Telefon : +90 312 3052260

Faks: +90 312 3104440

E-mail: cigdem.cetin@hacettepe.edu.tr

Çiğdem Çetin CanbazoğluHacettepe Üniversitesi, Diş Hekimliği Fakültesi,

Endodonti Anabilim Dalı,

Ankara Türkiye

Selen KüçükkayaHacettepe Üniversitesi, Diş Hekimliği Fakültesi,

Endodonti Anabilim Dalı,

Ankara Türkiye

MİNERAL TRİOXİDE AGGREGATE KULLANARAK APİKAL PLUG TEKNİGİYLE İMMATURE DAİMİ DİSLERİN TEDAVİSİ VAKA SERİSİ

ÖZET

Açık apeksli non-vital dişlerde MTA ile apikal plug yaratarak

başarılı bir final tedavi sağlamak. Geniş, açık apeksli dört

immatür diş MTA plug yapılarak tedavi edildi.ilk üç vakada, MTA

pluglar apikal kısma otograde yolla yerleştirildi. Daha sonra

kök kanallarının kalan kısımları lateral kondenzasyon tekniği

kullanılarak gutta perka ile dolduruldu. Dördüncü vakada,

apeksin aşırı genişliği nedeniyle retrograde yaklaşım uygulandı.

Apikal cerrahi uygulandı ve tüm kanal MTA ile retrograd olarak

dolduruldu. Greft materyali uygulandı. Dört vaka için takip

uygulandı.Bir yıllık klinik ve radyolojik takipler tüm vakalarda

periapikal bölgede iyileşme olduğunu ve dişlerin klinik olarak

fonksiyonel olduğunu gösterdi. MTA apikal plug tekniği açık

apeksli immature non-vital dişlerin tedavisinde etkili bir tekniktir.

Anahtar Kelimeler: Apikal Plug, İmmature Diş, MTA, Açık

Apeks

Yayın Başvuru Tarihi : 30.05.2013

Yayına Kabul Tarihi : 04.09.2013

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MTA PLUG IN NON-VITAL TEETH WITH OPEN APICES

INTRODUCTION

Incomplete root development which is usually caused by trauma, caries or other pulpal pathosis, represents a challenge for endodontic treatment. To induce a hard tissue barrier at the apex is the major purpose when performing root canal treatment to such teeth.1 Recently, mineral trioxide aggregate (MTA) has been proposed as a promising material in the treatment of immature necrotic teeth.2 It consists hydrophilic particles that set in the presence of moisture. MTA is composed of dicalcium and tricalcium-silicate, bismuth-oxide and calcium-sulfate.3 MTA can be placed in single visit, induce hard tissue formation,4 is biocompatible and has good sealing properties.5 The following four cases describe the treatment of immature teeth by using MTA as apical plug.

CASE REPORT 1

A 22-year-old male patient with sinus tract in the apical region of the maxillary right central incisor was referred to our clinic. The patient had no general health problems and reported that he suffered a trauma years ago. Radiographic examination demonstrated that tooth had an open apex and radyolucency at the periradicular area of the maxillary right central incisor (Figure 1a). The tooth was not responsitive to the percussion and sensitivity tests. The tooth was isolated with rubber dam and the access cavity was prepared. The working length was estimated with radiographic method. The root canal was gently instrumented under irrigation with 2.5% sodium hypochlorite (NaOCl). Thereafter, Ca(OH)2 dressing was placed and temporary coronal seal was established.After two weeks, the tooth was asymptomatic and the sinus tract was healed. Ca(OH)2 dressing was removed. The root canal was dried with sterile paper points. MTA (Angelus, Londrina, PR, Brazil) was placed in the canal and compacted with pluggers. A moist cotton pellet was placed and the cavity was sealed with glass ionomer cement (GIC) temporarily. After two days,the set of the material was tested gently. The remaining part of the canal was obturated with gutta-percha. Finally, the access cavity was restored with composite resin.One year follow-up revealed an adequate clinical and radiographic healing (Figure 1b).

CASE REPORT 2

A 14-year-old male patient with no general health problems was referred to our clinic. According to the patient, the mandibular right second premolar was traumatized four years ago and he has been suffering pain from time to time. The tooth was sensitive to percussion. No sinus tract was

observed in the clinical examination. Radiographic examination revealed an immature tooth with an open apex and a lesion at the periapical area (Figure 1c). The same procedures were applied as in Case 1. After one year follow-up, the tooh was asymptomatic and functional clinically . Radiographic healing was also observed at the apex of the tooth (Figure 1d).

CASE REPORT 3

A 30-year-old male patient with mild pain at maxillary left central incisor referred to our clinic. He had no contributory medical problems. He had a trauma history. According to the clinical examination, there was no sinus tract and the tooh was tender to percussion. Radiographic examination showed an immature tooth with a wide open apex (Figure 1e). The tooth did not respond to the sensitivity tests. The same treatment protocol in Case 1 was applied. One year follow-up showed a functional tooth with no symptoms clinically, and a healthy area at the apex (Figure 1f).

CASE REPORT 4

A 34-year-old male patient with a noncontributory medical history was referred to our clinic. The patient reported having experienced pain and swelling before, but at the time of the examination he had no symptoms. The patient had no known trauma history. Intaoral examination showed the presence of a sinus tract at the apical site of the maxillary left lateral incisor (Figure 2a). Radiographic examination demonstrated an immature tooth with a wide open apex (Figure 2b). The tooth was not responsitive to the sensitivity tests.The same treatment protocol in Case 1 was accomplished at the first session. After two weeks, the patient was free of symptoms and the sinus tract had closed. The temporary filling was removed and Ca(OH)2 was cleaned out. Because of the wideness of the apex, it was decided to fill the canal retrogradely. The access cavity was sealed with GIC. Parch incision was performed and the root canal was irrigated and dried with paper points. MTA was placed in the canal and compacted with pluggers retrogradely (Figure 2c). The graft material was applied to the surgical site and gingiva was sutured. The access cavity was restored with composite resin. One year clinical and radiograhic follow-up revealed a satisfactory healing (Figure 2d).

DISCUSSION

Apexification is a conventional treatment method that encompasses the filling of the root canal system with a medicament that stimulates hard tissue formation at the apex. When there is a clinical and radiological evidence of an apical closure, the medicament is removed and the

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CLINICAL DENTISTRY AND RESEARCH

permanent obturation is performed. Ca(OH)2 has been commonly used for apexification treatment. Although this technique is efficient, it has several disadvantages especially the long treatment time. The prolonged time increases the risk of reinfection, reduces the fracture resistance and also makes patient follow up difficult.6

Recently, MTA was introduced for creating an artificial barrier at the apex. MTA is a bioactive material that is capable of promoting hard tissue formation by stimulating the production of interleukins and cytokine realese.7 Before creating MTA apical plug, the disinfection of the root canal system should be obtained since the clinical success depends on the ability to disinfect the root canal system.8 For this purpose, Ca(OH)2 medication was applied to all four cases before the placement of MTA plugs. Despite the multiple benefits, MTA has poor handling properties.9 In the current cases, no extrusion happened owing to the very mild condensation and the proper determination of the working length. One year clinical and radiological follow-ups revealed the healing of the periapical area in all cases. Our results corroborate with previous studies, which showed the healing of such cases.8,10 In conclusion, MTA apical plug technique is efficient on treating immature teeth.

ACKNOWLEGEMENT

We thank to Associate Professor Özgür Uyanık and Dr. Derya Deniz Sungur for their clinical support.

REFERENCES

1. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002; 18: 217-221.

2. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993; 19: 591-595.

3. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999; 25: 197-205.

4. Yasuda Y, Ogawa M, Arakawa T, Kadowaki T, Saito T. The effect of mineral trioxide aggregate on the mineralization ability of rat dental pulp cells: an in vitro study. J Endod 2008; 34: 1057-1060.

5. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review--part II: leakage and biocompatibility investigations. J Endod 2010; 36: 190-202.

6. Shabahang S. Treatment options: apexogenesis and apexification. J Endod 2013; 39: S26-29.

7. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005; 31: 97-100.

8. D’Arcangelo C, D’Amario 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.

9. Nosrat A, Nekoofar MH, Bolhari B, Dummer PM. Unintentional extrusion of mineral trioxide aggregate: a report of three cases. Int Endod J 2012; 45: 1165-1176.

10. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. Int Endod J 2007; 40: 478-484.

Figure 1. Preoperative and one year follow-up radiographs.(a) and (b):

Case 1, (c) and (d): Case 2, (e) and (f) : Case 3.

Figure 2. Clinical and radiological images of Case 4. A sinus tract can

be seen in (a). Preoperative radiograph represents a wide open apex

in (b). In (c) retrograde approach can be viewed. One year follow-up

radiograph represents a healthy periradicular area (d).