Management of permanent necrotic teeth with inflammatory root resorption. Case report

Fig. 1

A 45-year-old male patient was referred to our office for an evaluation of the upper left central incisor after the referring colleague detected an unusual canal anatomy on a periapical radiograph. The patient reported little to no discomfort and an intermittent discharge of pus through a sinus tract. After carefull clinical and radiological examination the maxillary left central incisor was diagnosed with previous root canal therapy and chronic apical abscess. The computed tomography ( CB-CT) examination revealed a well-defined radiolucency in the apical third of tooth 2.1, compatible with inflammatory root resorption as seen in Figure 1.

Fig. 2

For the treatment plan, non-surgical endodontic treatment was proposed and accepted by the patient. The treatment was performed under an operating microscope and rubber dam isolation. After removing the crown and establishing access with Ultrasonic tips, the canal was scouted with 10k and 15k stainless-steel hand files. Working length was established with the help of an electronic apex locator and confirmed by CB-CT measurement. The canal was shaped with Reciproc blue files until  40/06 and the apical one third was prepared by hand files until 60/02. NaOCl 5.25% was used throughout the endodontic procedure to facilitate chemical disinfection and removal of debris. After shaping, the hypochlorite was activated with sonic tips and, once cleansing was completed, we proceeded with 17% EDTA irrigation in order  to remove the smear layer.  After the final irrigation, the canal was dried using paper points and the working lenght was again checked by the paper point technique as a third complementary method to ensure the corect initial measurement of the working lenght [7]. A collagen sponge was placed as a resorbable internal matrix (apical barrier) beyond the apical foramen to prevent extrusion of filling materials [8] as seen in Figure 2. This colagen sponge acts as a stable base for compacting the filling material, allowing for a single-session, safe, and efficient root canal treatment of open apices [8]. 

Fig. 3

The canal was sealed using mineral trioxide aggregate (MTA) apical barrier and warm gutta-percha with resin sealer as seen in Figure 3.  Intracoronal sealing was done with a dual cure flowable composite resin.

Fig. 4

Post endodontic treatment status of tooth 2.1 CB-CT view.

Fig. 5

At the 6 months recall, the patient remained free of symptoms and the CB-CT examination showed signs of healing, as seen in Figure 5.

Fig. 6

Moreover, at the 6 months recall the clinical aspect shows good signs of healing and the sinus tract appers to be closed.

The complex anatomic irregularities of the root canal and the resorption defect provide technical difficulties for thorough cleaning and obturation of the root canal [9]. A useful tool for such cases is the CB-CT, which is part of the current armamentarium in modern endodontics, together with the electronic apex locator (EAL) [10]. EAL demonstrated 87% accuracy as evaluated by CB-CT measurements [11]. For the obturation of the root canal a blockage of the apical foramen can be performed using MTA but other materials may be used such as Ca(OH)2 based materials or other bioceramic material [6].