Management of Anterior Young Permanent Teeth with Apical Periodontitis by Apexification: A Case Report

1. Introduction

Treatment of necrotic immature teeth has always been a challenge in endodontics ⁽¹⁾. Pulp necrosis of immature tooth as a result of trauma or caries could arrest further root development, leaving the tooth with thin dentinal root canal walls and blunderbuss apices ⁽²⁾. Hence, it is difficult to provide proper instrumentation for these canals and to have appropriate apical seal in teeth with open apices by using the conventional endodontic treatment methods ^{(1, 3)}. MTA is used for apexification as an alternative to multiple visit calcium hydroxide apexification for its osteogenic and cementogenic action with low solubility which can create an apical plug at the root end and allow the peri-radicular tissue healing ^(4-7). The advantages of MTA apexification are the reduction in treatment time, lower chance of tooth fracture or reinfection and fewer visits to the dental office ⁽⁸⁾. But even MTA may not result in continued root formation or strengthen the remaining root structure, and may leave the root susceptible to fracture ⁽⁹⁾.

2. Material and Methods:

The patient’s teeth were anesthetized by 1.8-3.6 ml of mepivacaine without vasoconstrictor (Mepivacaine HCl 3%). After the access preparation, the working length determination was done radiographically using k-file size 15 to limit any damage to the canal walls. Then each canal was irrigated with 20 ml of 5.25% sodium hypochlorite using irrigation needles[1]2 mm from the working length. The inner surface of the coronal access cavity was covered by acid-etched flowable resin bonded composite of 1mm layer thickness. Then the canal was dried with paper points and the TAP which consists of metronidazole, ciprofloxacin and doxycycline was prepared as a creamy paste then carefully introduced into the canal 2mm shorter than the working length with a suitable condenser and then further condensed by a finger plugger to the level just below the CEJ. The access cavity was sealed with 4 mm of temporary filling material and 2mm of glass ionomer filling material[2] applied by glass ionomer capsule applicator.

 The patient received the pain diary (VAS) and was instructed to fill in the required intervals (4, 12, 24, and 48 hours after the procedure). Then the patient was recalled 20 days later; showing relief in pain and inflammation.

 At the second visit, the patient was anesthetized and each canal was irrigated with 20 ml of 5.25% NaOCl. The canal was then dried with paper points; the grey MTA was mixed according to manufacturer’s instructions and placed to the apex with a 3-5 mm thickness using hand plugger size 25; the MTA plug was verified radiographically using a periapical radiograph. Then the tooth was restored immediately with glass ionomer material placed over the apically compacted MTA. Then the final restoration of each tooth was done by a composite resin bonded restoration beginning at the level of the MTA and ending at the access cavity ⁽⁸⁾. The postoperative radiograph was taken at the end of the second visit by paralleling technique using an XCP, the prefabricated acrylic stent and an image plate(that was interpreted by Digora) which is considered as a baseline radiograph (figure 1) ⁽¹⁰⁾. The patient received the pain diary and was instructed to fill in the required intervals (4, 12, 24, and 48 hours after the procedure) then the patient was recalled after 1, 3, 6, 9, 12 and 18 months for clinical and radiographic follow up.