Endodontic management of immature central incisor by apexification

Fig. 1

12 year old patient reported with H/O recurrent pain and pus discharge from upper front tooth region.

H/O trauma 4 years ago.

H/O RCT 6 months ago. 

IOPA shows blunderbuss canal (reverse apical anatomy) in 11 with conventional RCT done using gutta percha points and deficient apical seal and periapical lesion.

Fig. 2

Under rubber dam isolation and using dental operating microscope, 

removal of coronal restoration showed poorly compacted GP.

Existing GP points were removed using re-treatment rotary files and H files using minimal apically directed pressure. 

Upon in toto retrieval of GP there was evidence of pus discharge from the canal.

Fig. 3

Arbitrary WL determination was done with apex locator and confirmed with IOPA.

Since 140 size K file was freely passing through the apex, a decision for apexification was made.  

Fig. 4

Minimal instrumentation and circumferential filing was done with K files to remove infected dentin and sealer remnants. 

Owing to the open apex, Sodium hypochlorite was diluted in saline and expressed in the canal using 30 gauge side vented needle. Irrigation activation was done with Endoactivator (Dentsply) kept 3 mm short of the determined WL to avoid inadvertent extrusion. 

Fig. 5

Calcium hydroxide interim intracanal medicament given for 2 weeks due to weeping canal.

Fig. 6

Canal was rinsed with saline and EDTA to rinse out CaOH and smear layer.

Canal was finally disinfected with diluted NaOCL.

Fig. 7

Plugger fit check was done at 2^nd appointment after confirming dry canal using paper points and inspection under microscope.

Fig. 8

Incremental placement of White MTA (Angelus) was done at apex, using Angelus MTA carrier.

After placement, MTA was compacted with pluggers (Dentsply Maillefer) and butt end of paper points, to form an apical plug.

Excess MTA along the walls was removed using moist paper points.

Fig. 9

The remainder canal was later backfilled with thermoplastic gutta percha (EQV –Meta Biomed) and Bio-C sealer (Angelus).

Immediate composite coronal restoration done. 

Fig. 10

Inverted immediate post-op IOPA

Fig. 11

1 month Recall IOPA

Shows uneventful healing in progress

Subsided pain and healing sinus tract clinically.

Fig. 12

Case 2:

18 year old patient complained of intermittent swelling, throbbing pain and occasional pus discharge.

H/O trauma 8-9 years ago

H/O RCT 2 years ago and development of symptoms since 1.5 years.

Clinically tooth 11 was discoloured. 

IOPA showed conventional RCT done with gutta percha point and incomplete apical seal and large periapical lesion and dislodged coronal restoration.

Fig. 13

Under rubber dam isolation, using Dental operating microscope, existing coronal restoration was removed, access opening was modified and GP was removed.

Canal was cleaned and shaped with minimal instrumentation.

Since 60 size K file was freely passing through the apex, a decision for apexification was made.  

Sodium hypochlorite diluted in saline was used for irrigation using 30 gauge side vented needle. Agitation of NaOCL was done with Endoactivator (Dentsply) kept 3 mm short of the determined WL to avoid extrusion. 

Fig. 14

2 cycles of Interim calcium hydroxide dressing were given, each spanning 2 weeks, to arrest weeping canal.  

Fig. 16

Immediate post-op IOPA

Backfilling from Biodentine apical plug till coronal third was done with thermoplastic gutta percha (EQV –Meta Biomed) and Bio-C sealer (Angelus).

Composite coronal restoration was done in the next visit. 

Fig. 18

15 months post-op IOPA

Shows significant healing with complete cessation of symptoms.