Immature tooth with apical periodontitis and sinus tract undergoes apexogenesis. A case report.

Fig. 1

The Preoperative X-ray by referral dentist shows tooth 15 with immature root, open apex and periapical radiolucency.

Cause of the lesion is not known.

Fig. 2

Sinus tract tracing with GP cone, confirms that tooth 15 is the cause. Cold test was negative.

Based on the examination, diagnosis was pulp necrosis with chronic apical abscess.

Treatment plan was to do calcium hydroxide dressing, and MTA apexification in the next visit.

Given that the tooth seems to be intact, tooth was opened intentionally without anesthesia (aka drill test). The coronal part of the pulp was necrotic. However, inserting a file inside the canal provoked pain and bleeding deep in the canal, which means that there is some remnants of vital pulp.

So, the pulp status is partial necrosis.

Without any instrumentation, 3.25% sodium hypochlorite irrigation and Calcium Hydroxide dressing was done.

Fig. 3

2 months later, the tooth is asymptomatic, and the buccal sinus tract has healed.

A PA radiograph was taken before the treatment. We can see reduction of the size of the PA lesion and we can notice the formation of a calcified barrier at apical third, with slight thickening of canal walls.

Fig. 4

Calcium Hydroxide from previous visit.

Fig. 5

Calcified barrier

Fig. 6

Calcified barrier in high magnification.

The barrier is stable and sealing the canal.

Fig. 7

Length confirmation

Fig. 8

The apical part of the root was sealed with MTA, then thermoplasticized GP, and a permanent filling.

MTA was positioned in increments by using MAP system (Produits Dentaires, Vevey, Switzerland).

Fig. 9

An intra operative x-ray was taken to confirm the position of initial MTA increment

Fig. 10

MTA plug is ready

Fig. 11

MTA plug

Fig. 12

The coronal portion if the canal is filled by thermoplasticized Gutta Percha

Fig. 13

Immediate Post Operative

Fig. 14

5 months follow up

The tooth is asymptomatic. The PA lesion has healed, with further thickening of canal walls at apical third, but apex is still open.

Fig. 15

13 Months follow up. 

The tooth is asymptomatic.

Radiographically, apex is closed, mainly by canal walls thickening and minimal elongation.

We can notice canal obliteration, and PDL formation, with continuous lamina dura.

Fig. 16

The author:

Dr. Foad Ganem

Graduated in 2010 from Jordanian University of Science and Technology (Jordan).

Since 2012, practice limited to Endodontics, with a lot of experience in immature teeth and open apex management.

In the last few years, interested in dental photography and video documentation