Title Page:

Title of the article: Management of teeth with blunderbuss canals and its esthetic
rehabilitation.

Type of the manuscript: Case Report.

Primary Author:1) Dr Nitesh Patil.

Final yr PG.(MDS)
Department of Conservative dentistry and Endodontics.
Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai.

Corresponding Author:2) Dr Ashish Jain, BDS, MDS.

Head of Department,
Professor,
Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai.

3) Dr Deepak Hegde, BDS, MDS.

Associate Reader,
Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai.

4) Dr Amit Patil, BDS, MDS.

Associate Reader,
Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai.

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 Main Text:

Title of Article: Management of teeth with blunderbuss canals and its

esthetic rehabilitation. A Case report.

Abstract: The management of open apex with pulpal necrosis and periapical pathology poses a great
endodontic challenge for obturation of the canal and obtaining a hermetic seal. The conventional
apexification using calcium hydroxide has certain drawbacks such as the need for long term therapy to
enable barrier formation. The recent trends include formation of an artificial apical stop. To treat such
open apices and induce barrier, mineral trioxide aggregate is the calcium silicate material which has
gained popularity recently. Access cavity were prepared and working length was determined. Canals
were medicated with intracanal medicament for two weeks. Then MTA apical plug was place in apical
third of the canal and rest was filled with thermoplasticized gutta-percha. MTA(Mineral tri oxide
aggregate) seems as an effective material for the apical plug method for the treatment of nonvital
permanent teeth with open apices.

Key-words: Apexification, Apical plug, Bio dentine, Blunderbuss canal, MTA(Mineral tri oxide
aggregate), Open apex.

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 Introduction

The most important factor in endodontics is proper debridement of the canal, to obturate it effectively
and three dimensionally as possible.1 This leads to proper apical seal with a “fluid-tight” obturation
which prevents bacterial ingress and ensures favorable outcome.2

However, having a proper apical seal becomes difficult in patients with open apices. Obturation
becomes a challenge due to the large open apex, diverging walls, thin dentinal walls that are
susceptible to fracture, and associated frequent periapical lesion.1

The most common teeth with open apex are maxillary anterior. This is due to its position in the jaw
which is more prone to trauma and less due to caries.3

There are two types of open apex:1

1. Non-blunderbuss type.
2. Blunderbuss type.

Non-blunderbuss type: - Walls are parallel or slightly convergent as the canal exits the root.

Apex can be broad (Cylinder shape) or slightly tapered (Convergent).

Blunderbuss type: - Walls of the canal are divergent, flaring, especially in buccolingual direction.

Mostly apex is funnel shaped, wider than the coronal aspect.

“Blunderbuss” is referred to as 18th century weapon which have a short and wide barrel. It derives its
origin from the Dutch word ‘DONDERBUS’ which means ‘thunder gun’.

Causes of open apices are:1

1. Incomplete development of the tooth due to necrosis of pulp due to caries or trauma before
root formation is completed.
2. Extensive apical resorption due to orthodontic treatment, periapical pathosis or trauma.
3. Root‑end resection in periapical surgeries.
4. Over instrumentation.

Treatment options:

1. Blunt-end or rolled cone (Customized cone obturation)

2. Induction of root end formation. (Apexogenesis)
3. Root end closure. (Apexification)
4. Revascularization by SCAP (Stem cells of apical papilla) and multipotent pulp stem cells.

Indications of apexification (Abu-Hussein Muhamad et al., 2016):

1. Immature teeth with an infected pulp.

2. No history of spontaneous pain.
3. No sensitivity on percussion.
4. No hemorrhage.
5. Teeth must be ultimately restorable.
6. No vertical or horizontal root fracture.

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 7. No radiographic evidence of replacement resorption (ankylosis).
8. Root length must be approximately half or more established.
9. Periapical radiolucency.

Contraindications of apexification (Abu-Hussein Muhamad et al., 2016)

1. Purulent drainage.
2. History of prolonged pain.
3. Very short roots.
4. Marginal periodontal breakdown.
5. Vital pulp.

Advantages of apexification (Abu-Hussein Muhamad et al., 2016)

1. It is successful in resolving periapical lesions.

2. MTA apexification could be completed in one appointment.
3. Avoids surgical treatments as surgical removal of tooth structure further weakens the
remaining tooth.
4. Induces root end closure in necrotic immature permanent teeth.

Disadvantages of apexification (Abu-Hussein Muhamad et al., 2016)

1. High incidence of root fractures in teeth after apexification due to thin dentinal walls.
2. Restorative efforts should be directed towards strengthening the immature root.
3. Teeth to be used as overdenture abutments.
4. Although MTA has more benefits, using MTA in teeth with funnel shape apices and large
periapical lesions is difficult and it often spreads beyond the apex.

Materials and methodology:

In current case reports apexification was the treatment option employed.

Materials used for the clinical procedures are:

1. Mineral trioxide aggregate.

2. Calcium hydroxide

Apexification treatment protocol was used in these case reports. After trauma if the patients report
after 24 hours of pulp exposure or there are no signs of vitality of the pulp, apexification is the
conservative treatment option.

Apexification is a method to induce a calcified barrier in a root with an open apex or the continued apical
development of an incomplete root in teeth with necrotic pulp. (American Association of Endodontists
2013)

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 Chemo-mechanical debridement of the canal is necessary in apexification process followed by
intracanal medicament to assist or stimulate apical healing and formation of apical barrier at the apical
end of the root canal to facilitate the obturation of the canal without excess material extruding in the
periapical tissues.4

Apexification was the choice of treatment because the teeth presented in these case reports were
nonvital and patients did not agree to long span of time as in other treatment options such as
revascularization and calcium hydroxide apexification.

Also, apexification with calcium-hydroxide and length of the time required for this ranges from 3 to
18 months. Problems associated with using calcium hydroxide is patient’s compliance, reinfection due
to loss of temporary restoration and also it disposes tooth to fracture.5

MTA has been described as a good material for this procedure owing to its good canal sealing
property, biocompatibility and ability to promote dental pulp and periradicular tissue regeneration.
Therefore, MTA can be used for inducing hard-tissue barrier allowing prompt obturation of the canal
leading to longevity of the tooth and maintain proper function and aesthetics.5

Other calcium-silicate based material use to induce hard tissue barrier is biodentine. A modified
composition of powder, which has additional setting accelerators and softeners, and pre-dosed
capsule formulation for use in a mixing device, enhanced the physical properties of the biodentine
making it more user-friendly with a shorter setting time. 6

In the current case report, a clinical case report of teeth with open apex are treated by creating an
apical barrier by apexification process, mineral tri-oxide aggregate and esthetically rehabilitated
with all ceramic crown.

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 Case Report:
A twenty-six-year old patient came to department of conservative dentistry and endodontics, with a
chief complaint of pus discharge and discoloration in upper front surface of the region of jaw and
wants to get it treated. Patients gave no history of pain or discomfort associated with the tooth of chief
complaint (i.e. 11,21)(Figure 1a). Patient had noticed discoloration for 2 years. He had history of
trauma in the front region of jaw two and half year before. He gave history of intermittent pus
discharge from the vestibule area from 6 months. Patients medical history was non-contributory.
Clinical examination revealed Ellis class III fracture with 11 and 21.

The teeth were not tender to percussion. There was no evidence of swelling and mobility. The
periodontal probing depths were within normal limits and there was no bleeding on probing. Thermal
and electrical pulp testing showed no response. Radiographic examination revealed open apex with
teeth 11 and 21 and radiolucency seen with periapical region for same(Figure 1b). Pus draining sinus
were seen in the vestibule area above teeth 11 and 21(Figure 1a).

On basis of above subjective and objective findings, a final diagnosis of pulp necrosis with chronic
apical abscess was made.

In first appointment, teeth were isolated with rubber dam and wedgets. Gingival barrier was applied
and access opening was done. Working length determination was done with the help of radio-visual
graphic (Figure 2). The canal was debrided and irrigated throughout the procedure with 2.5%
sodium hypochlorite. The canals were debrided slightly as remaining dentin thickness is important in
cases with open apices.
Cleaning and shaping were done with circumferential filing up to #60 K-file.

After cleaning and shaping, the calcium hydroxide dressing was placed in the canals. Two dressings
of intra canal medicament were placed in the canal. The dressing was changed after 15 days. After
two dressings of intra canal medicament the draining sinuses were completely healed.
An apical barrier of 3 to 4 mm was placed in the canals with MTA carrier and condensed with hand
plugger. (Figure 3a) A moist cotton pellet was placed in the canal and the access opening were
sealed with temporary restoration.

Patient was recalled after 2 days and setting of MTA was confirmed using finger plugger and root
canals were obturated with thermoplastized gutta-percha (Figure 3b).

As the teeth were present in the esthetic zone and according to patients desire it was decided to give
patient an all ceramic (E-max) crown.

The E-max crowns are usually translucent and it would reflect the dark color of the underlying teeth
which would look esthetically unpleasant, so before proceeding with teeth preparation, 11 and 21
were bleached so that teeth will have a lighter shade and not the dark discolored one.

2mm of gutta-percha was removed from the canal space to a level below the cemento-enamel
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 junction. At the same visit, a RMGIC (Fuji II LC, GC) barrier of 2mm was placed over the gutta-

percha and light cured to prevent apical penetration of the bleaching material and minimize the
possibility of internal resorption.

In office (inside-outside) bleaching was the technique employed.

The teeth were isolated using rubber dam and the adjacent teeth i.e. 12 and 22 were wrapped with
Teflon tape so that bleaching material does not come in contact with them which would adversely
bleach them.

Bleaching was done with Pola-office kit and the contents of the syringe were carefully extruded into
the pot and both powder and liquid was immediately mixed using a brush applicator to get a
homogeneous gel. A thick layer of gel was then applied to the buccal and palatal surface of teeth
undergoing treatment. The gel was also applied inside the canal using applicator tip.

The gel was left on tooth and light cured using a LED curing light (BT cool machine) for 10 minutes.
Both operator and patient were given protective eye glasses. The gel was changed and the procedure
was repeated for 3 times. Three cycles of bleaching were completed for 10 minute each. The same
procedure was repeated for next appointment also.

After 3 visits, a drastic change in tooth color with satisfactory results was achieved. There was
visible difference in shade of teeth was seen. Later, teeth were restored with packable
composite and teeth preparation were done (Figure-4a) and restored with all ceramic crown
(E-max) thus restoring function and aesthetics (Figure-4b). Crowns were luted with bio-
ceramic luting cement (Calibra).

After 3 months the patient was recalled for follow-up on which complete resolution of the
periapical lesion was seen.

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 Discussion

The outcome of the above treatment results in closure of the apex by formation of the apical barrier
which prevent extrusion of gutta percha material from the apex. It also prevents passage of bacteria’s
and toxins into the periradicular region from the root canal.1 Certain biocompatible materials used for
apexification reduces leakage in sealing material and allows healing of the periodontal tissues and
apexification.
Other treatment options available for these cases could be calcium hydroxide apexification0,
biodentine apexification and pulp revascularizion.
According to some studies apexification by calcium hydroxide results in apical barrier associated
with: 7
1. Unpredictable apical closure,
2. Extended time taken for barrier formation,
3. Difficulties in patient compliance, and the risk of reinfection resulting from the difficulty in
creating long term seals with provisional restorations and
4. Susceptibility to root fractures arising from the presence of thin roots or prolonged exposure
of the root dentine to calcium hydroxide.
Calcium hydroxide leads to incomplete barrier production which results in swiss cheese appearance.
This leads to an apical microleakage.
Pulp revascularization remains a good treatment option for such cases but this treatment was not
agreeable due to the time constraints. So, apexification with MTA and biodentine was decided for
these cases.
Apexification was done in three steps, in first step canal debridement and placement of calcium
hydroxide placement in canal was done, second step includes forming an apical plug and third step
includes obturation.
Calcium hydroxide stimulates formation of mineralized and fibrous tissue formation in apical part of
the root canal by stimulation of granulation tissue cells. This stimulation is due to alkalinity of the
non-setting calcium hydroxide.7
MTA has an alkaline pH exhibit superior biocompatibility and cytotoxicity. MTA provides a
favorable environment for the cementum deposition because of the presence of calcium and
phosphorus ion which induces osteoblastic or cementoblastic activity and provides favorable
environment for cementum deposition. The high pH creates an antibacterial environment.3
MTA has superior sealing property, its ability to set in the presence of blood and its biocompatibility.
Moisture contamination at the apex of tooth before barrier formation is often a problem with other
materials used in apexification. Because of its hydrophilic property, the presence of moisture does not
affect its sealing ability.5
The major drawback with MTA is its long setting time and presence of toxic elements in its
composition.8
Biodentine can be used as an effective alternative to MTA. Apexification with Biodentine requires
significantly less time. This can reduce the time period from the patient's first appointment to the final
restoration. The importance of this approach lies in the effective cleaning and shaping of the root
canal, followed by apical seal with a material that favors regeneration. This also reduces fracture of
immature teeth with thin roots, because of immediate placement of bonded core within the root
canal.6

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 The thickness of the Ca-and Si-rich layers increased over time, and the thickness of the Ca-and Si-rich
layer was significantly larger in Biodentine™ compared to MTA after 30 and 90 days, concluding that
the dentine element uptake was greater for Biodentine™ than for MTA. 6
Kokate and Pawar conducted a study that compared the microleakage of glass ionomer cement, MTA,
and Biodentine when used as a retrograde filling material and concluded that Biodentine exhibited the
least microleakage when compared to other materials used. 9
Research suggests that a high pH and released calcium ions are required for a material to stimulate
mineralization in the process of hard tissue healing.
Sulthan carried out a study to evaluate the pH and calcium ion release of MTA and Biodentine when
used as root end fillings. He concluded that Biodentine presented alkaline pH and ability to release
calcium ions similar to that of MTA. The 24-h push-out strength of MTA was less than that of
Biodentine. Blood contamination affected the push-out bond strength of MTA Plus irrespective of the
setting time.9
Biodentine does not require a two-step obturation as in the case of MTA. Since the setting time is
quicker this reduces the risk of bacterial contamination.6
Different materials which can be used for apexification are:
1. Calcium hydroxide
2. Mineral Trioxide Aggregate
3. Biodentine
4. Tricalcium Phosphate
5. Dentin chips
6. Calcium Phosphate Ceramics and Hydroxyapatite
7. Bone Morphogenic Proteins
8. Bioceramics

Other important factor while placing silicate cements at the apex is that they tend to extrude from the
apex. In order to avoid these extrusion PRF (Platlet rich fibrin) should be used. PRF consists of
leukocyte‑PRF matrix composed of a tetramolecular structure with cytokines, platelets, and stem cells
within it which acts as a biodegradable scaffold that guides epithelial cell to migrate to its surface.
The cells involved in tissue regeneration may be carried by PRF and release growth factors in a period
between 1 and 4 weeks.
Thus, MTA sets in canal in presence of moisture and does not require moisture free environment.
Another advantage of using PRF as a matrix is that it promotes wound healing and repair.10
According to previous studies, it was noted that initial periapical healing was better in tooth filled
with biodentine. Also MTA filled tooth had long term periapical healing. This may due to the fact that
MTA has superior marginal adaptation.4
Due to all these, MTA was the choice of the material for this case considering its longevity.

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 Conclusion

It can be concluded that MTA and Biodentine both as a calcium silicate material can be successfully
used for closure of open apex. Also, calcium hydroxide plays an important role in periapical healing
and induction of root formation. Platelet rich fibrin can also be used to prevent extrusion of the filling
material. Single visit apexification can also be done with these materials in cases presenting with open
apex. From the above case reports, and the available data from previous studies it can be concluded,
that biodentine showed better initial healing while MTA had better long-term effect.

Acknowledgement

We would like to thank all my colleagues and my juniors, Dr Malavika Mohan and Dr Sonal Agrawal
for all their help and constant support.

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