DOI:10.21276/sjodr.2017.2.2.

Saudi Journal of Oral and Dental Research ISSN 2518-1300 (Print)

Scholars Middle East Publishers ISSN 2518-1297 (Online)
Dubai, United Arab Emirates
Website: http://scholarsmepub.com/

Case Report

Conventional Multivisit Calcium Hydroxide Apexification with Rare

Apexogenesis Like Outcome and Novel Single Visit MTA Apexification Followed
by Root Reinforcement with Fiber Post: Two Case Reports
Dr. Josey Mathew1, Dr. Gibi Syriac2, Dr. Manuja Nair3, Dr. Rahul J3
1
Professor, Dept. of Conservative Dentistry & Endodontics, Pushpagiri College of Dental Sciences, Tiruvalla, Kerala,
India
2
Reader, Dept. of Pedodontics, Pushpagiri College of Dental Sciences, Tiruvalla, Kerala, India
3
Senior Lecturer, Dept. of Conservative Dentistry & Endodontics, Pushpagiri College of Dental Sciences, Tiruvalla,
Kerala, India

*Corresponding Author:
Dr. Josey Mathew
Email: [email protected]

Abstract: Completion of root development takes around 3 years after eruption of permanent teeth. Any pulpal injury in
this period can lead to necrosis of pulp. Pulp necrosis of immature permanent teeth may impair root development and
apical closure of root canals. Management of immature non vital teeth is very challenging for a clinician because teeth
may have wide open apex and thin root canal walls that may diverge towards the apex. Conventional cleaning and
shaping of the canals and obturation may not be possible because of the lack of apical stop. This case report presents two
cases of apexification. First case, managed using Calcium hydroxide and iodoform paste for multiple visit apexification
which had a rare apexogenesis like outcome and second case using MTA for single visit apexification followed by root
reinforcement with Glass fiber reinforced composite post.
Keywords: apexification, immature teeth, calcium hydroxide, mineral trioxide aggregate

INTRODUCTION cellulose and Chlorhexidine have been used for

Apexification is any method to induce a apexification.
calcified apical barrier in a root with an open apex or
continued development of apex of an incomplete root in Single visit apexification is the non surgical
teeth with non vital pulp”. Apexogenesis is the condensation of a biocompatible material into the root
physiological process of root development. apex of a tooth with open apex [2]. Materials that have
Apexogenesis is any vital pulp therapy procedure been used for single visit apexification are tricalcium
performed to promote continued physiological phosphate, calcium hydroxide, freeze dried bone, and
development and formation of the root apex [1]. freeze dried Dentin, dentinal shavings or chips,
Materials such as calcium hydroxide powder or mixed resorbable ceramic, collagen-calcium phosphate gel and
with different vehicles, collagen-calcium phosphate gel, Mineral trioxide aggregate(MTA)[3]. MTA was first
osteogenic protein, bone growth factor, oxidized introduced in 1993 and received FDA approval in 1998.
cellulose, tricalcium phosphate and MTA have been MTA is a mixture of hydrophilic particles of tricalcium
used for apexification. Kaiser obtained successful silicate, tricalcium oxide and silicate oxide in a fine
apexification with calcium hydroxide paste in 1956 and powder form. MTA has low solubility and radiopacity
1964.Frankand Heithersay also obtained similar results greater than dentine. Good sealing ability and
with calcium hydroxide. Calcium hydroxide or its biocompatibility are also positive traits of MTA. After
combination with other materials has been the most setting MTA has a pH of 12.5 similar to Calcium
commonly used material for apexification. hydroxide. This high pH may impart some antibacterial
Apexification with calcium hydroxide involves repeated properties to MTA. Whitherspoon and Ham asserts that
stimulations with calcium hydroxide, over a period of 6- MTA provides a scaffolding for hard tissue deposition
24 months, until apical closure is achieved. The calcium and provides better seal [4]. Other advantages of MTA
hydroxide powder mixed with Saline, distilled or sterile are low cytotoxicity, antimicrobial property, setting
water, local anesthetic solution, CMCP (camphorated ability uninhibited by moisture, effect on the induction
monochlorophenol), metacresyl acetate, mixture of of odontoblasts and formation of a hard barrier. The
CMCP & Metacresylacetate (Cresanol), methyl
43
Josey Mathew et al.; Saudi J. Oral. Dent. Res.; Vol-2, Iss-2(Feb, 2017):43-48
most effective material for apexification among all
these materials is calcium hydroxide or MTA [3].

This article presents two cases of apexification.

In the first case report Calcium hydroxide and iodoform
paste was used for multiple visit apexification which
showed continued root-end growth with closure of root
apex producing a rare apexogenesis like outcome and
the second case was managed using MTA for single
visit apexification followed by root reinforcement with
Glass fiber reinforced composite post.
Fig-2: three months recall
CASE DESCRIPTION
Case Report 1
A 16 year old boy reported to the department
with pain in lower right posterior region. On clinical
examination showed an amalgam restoration with
secondary caries involving dentin in 46 and a deep
caries lesion on 47.IOPA showed caries exposing pulp
in 47 with open apex in both mesial and distal roots
[Fig.1]. The tooth failed to respond to thermal and
electric pulp tests. It was decided to attempt
apexification using Calcium hydroxide and Iodoform
paste in 47.Access opening followed by cleaning and Fig-3: six months recall
shaping of root canals using Protaper
(Dentsplymaillefer, Ballaigues, Switzerland) rotary files
was performed till F2 in mesiobuccal and mesiolingual
canals and F3 in distal canal of 47.Irrigation with
alternate use of 3% Sodium hypochlorite and saline was
done. Canals were dried using paper points. Metapex
(Meta Biomed Co. Ltd, South Korea) was placed into
the canals using the plastic needles supplied by the
manufacturer. On three months recall radiographic
examination showed significant calcific barrier
formation at both mesial and distal root tips of 47
[Fig.2]. Another recall at 6 months showed well defined
apical calcific barrier at both root tips of 47 as well as Fig-4: Postoperative radiograph
increase in root length of 47 [Fig.3]. The Metapex was
removed from the root canals using H-file followed by Case Report 2
irrigation with 1.25% sodium hypochlorite. Canals after An 18year old boy reported to department with
drying with sterile paper points were obturated using complaint of fractured anterior tooth. He had a history
Gutta Percha with cold lateral condensation technique of trauma 10 year backs and had not undergone any
[Fig4]. treatment. On examination Upper Right Central Incisor
(11) had Ellis Class III fracture and pulp chamber was
open with caries on the walls of the pulp
chamber.11showed no response to thermal & electric
pulp testing whereas 21and12 showed normal response.
IOPA radiograph showed a very wide root canal with
thin root walls with blunderbuss root apex in 11 with a
periapical lesion measuring 1x1cm [Fig.5]. It was
planned to perform a single visit apexification using
MTA and reinforcing the root with fiber post followed
by full crown in 11.

Fig-1: preoperative radiograph (Case 1)

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Josey Mathew et al.; Saudi J. Oral. Dent. Res.; Vol-2, Iss-2(Feb, 2017):43-48

Fig-5: Preoperative radiograph (Case 2)

Isolation with rubber dam from canine to

canine was done. No local anesthesia was needed since Fig-7: Fiber post selected
the tooth was non vital. Caries was excavated from 11
followed by modification of access cavity. Canal was
cleaned by circumferential filing to 80 size file at the
established working length of 21mm. Copious irrigation
with alternate use of 3% Sodium hypochlorite and
normal saline was done. MTA (ProRoot, Dentsply,
Maillefer) was mixed as per the manufacturer’s
instruction and was introduced into the canal using a
messing gun. A plugger of 80 size was used to push the
MTA into the apical third of the root [Fig.6]. A moist
Cotton pellet was placed in the canal and access cavity
was sealed with Cavit G (3M ESPE, Germany). Patient
was recalled after 1 day and canal was opened to
remove the cotton pellet. Apical plug of MTA on
evaluation with a DG 16 explorer felt hard. A large
sizeglass fiber reinforced composite post(FRC postec
plus)size 3(Ivoclar Vivadent,)was selected and was Fig-8: Post cemented in canal
cemented into the root canal using resin cement Rely X
U 200(3M, Germany) [Fig 7, Fig8]. Access cavity was
sealed with compositeres in Z350 (3M ESPE, Germany)
and a ceramic crown was placed. A six month recall of
the patient showed reduction in size of the lesion and
evidence of new bone formation in the lesion [Fig.9].

Fig-9: Six months follow up

DISCUSSION
Fig-6: Apical plug of MTA placed Apexification aims to achieve root end closure
in non vital teeth with incomplete root formation. In
1966 Frank classified the outcome of apexification into
4 types: Type 1:Normal apexogenesis which is rare,
Type 2: Dome shaped apical closure with blunderbuss
appearance remaining, Type 3: No apparent
radiographic change but positive stop at apex and Type

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Josey Mathew et al.; Saudi J. Oral. Dent. Res.; Vol-2, Iss-2(Feb, 2017):43-48
4: Hard tissue barrier short of apex leaving thin dentinal This unpredictable and lengthy course of treatment with
walls subject to further trauma [3]. a temporary coronal restoration that may fail in between
treatment increases the chances for re-infection [12].
Calcium hydroxide and Iodoform paste for ii. It is not possible to give a permanent restoration till
root end closure has been reported by Sridhar N and S completion of apexification.
Tandon [5]. They concluded that Calcium hydroxide iii. Cervical root fractures were common in teeth
and Iodoform paste (Metapex) may be used as following calcium hydroxide apexification due to thin
medicament to promote root growth and apexification. dentinal walls as well as weakened tooth structure
Ghose et al has described the apical barrier formed as a induced by calcium hydroxide [13].
cap, bridge or an ingrown wedge made up of cementum, iv. This treatment requires a high level of patient
dentine, bone or osteodentine [6]. Osteodentine is compliance.
supposed to be formed from connective tissue at root
apices when Hertwig’s epithelial root sheath (HERS) Because of these reasons a single visit
are not present. Steiner and Van Hassel reported that apexification with MTA has been suggested. In a study,
histological study of the apical calcific barrier proved it that compared the effectiveness of MTA and Ca(OH)2
to be cementum [5]. The antibacterial efficacy of three for apexification of young permanent incisors with open
Ca(OH)2 formulations were determined by Cwikla et apices, reduced treatment time, good sealing ability,
al and found Ca(OH)2 mixed with iodoform and silicon good biocompatibility makes MTA an effective
oil (Metapex) to be the most effective dentinal tubule material for producing an apical barrier for immediate
disinfectant [7]. obturation [14]. Shababhang et al compared the efficacy
of osteogenic protein-1, Calcium hydroxide and MTA
Calcium hydroxide placed inside the root concluded that amount of hard tissue formed was
canals dissociates into calcium and hydroxyl ions. The similar but apical barrier produced by MTA has greater
hydroxyl ions destroy the lipids resulting in structural consistency [3]. Superior biocompatibility of MTA and
damage of bacterial proteins and nucleic acids. The high presence of calcium and phosphate ions result in
alkaline pH of Calcium hydroxide activates alkaline attraction of blastic cells and promotes a favourable
phosphatase enzyme which releases inorganic environment for calcium deposition [15, 16]. Felippe et
phosphate ions. The inorganic phosphate ions produced al studied the effect of Calcium hydroxide on dog’s
reacts with calcium ions in blood stream forming teeth with open apices treated with MTA. They proved
calcium phosphate. Calcium phosphate, the molecular that the groups treated with and without Ca (OH) 2 prior
unit of hydroxyapatite, produces mineralization [5]. to MTA placement shoved no difference in the apical
closure, bone resorption and root resorption. They also
Hence, in the present Case report 1 we planned proved that placing MTA without pretreating the canals
multi visit apexification using a calcium hydroxide with Ca(OH)2 results in more complete apical barrier
formulation with iodoform (Metapex). Six months formation in comparison with those treated with
radiographic follow up showed that there was continued Ca(OH)2 before placing MTA [17].
root formation as well as apical closure with a definite
apical stop thereby showing Frank’s Type 1 Hand method of placement and condensation
apexification which is rare specially considering the fact of MTA was proven radiograpically and
that tooth was non vital. microscopically to produce better adaptation with fewer
voids than ultrasonic method by Aminosharie et al [18].
Clinical studies have already reported So in the present case reports MTA placement and
conservative treatment resulting in increase of root condensation was done manually with pluggers and no
length and thickness in immature teeth with periapical pretreatment of canals with Ca(OH)2 was done.
lesions and extensive boneresorption [8, 9]. This could However, MTA is much expensive and its sandy
be due to an inaccurate clinical diagnosis of pulp status consistency when hydrated makes manipulation
in teeth that may have vital tissues in apical region. difficult [19].
Continued root development may also result from the
presence of viable HERS and apical papilla [10]. Even In the present case report2 the weak root with
in cases with non vital pulp, HERS and apical papilla wide root canal with thin root canal walls was a
completely lost, root walls may increase in thickness challenge to the clinician because of propensity for root
from ingrowth of cementum from periapical areas into fracture following a conventional root canal treatment
internal root dentine walls [11]. The normal root end and obturation. To reduce the chances of root fracture it
closure obtained in Case report 1 facilitated was decided to reinforce the tooth with placement of
conventional root canal treatment. post inside the root canal after achieving apical closure
with MTA. Fiber post was selected in this case because
There are many disadvantages for calcium available literature shows that tooth with fiber posts
hydroxide apexification. showed failure at a higher load compared to custom
i. Calcium hydroxide apexification requires repeated fabricated metal posts. Mode of failure of fiber posts
changing of the medication over a 5-20 months course. were also more favorable because the teeth with fiber

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Josey Mathew et al.; Saudi J. Oral. Dent. Res.; Vol-2, Iss-2(Feb, 2017):43-48
post fractures more at core level with minimum damage immature teeth: a pilot clinical study. Journal of
to tooth structure, whereas custom metal posts cause endodontics, 34(8), 919-925.
exhibits root fracture resulting in teeth that are non 9. Thibodeau, B., Teixeira, F., Yamauchi, M., Caplan,
restorable [20]. D. J., & Trope, M. (2007). Pulp revascularization
of immature dog teeth with apical periodontitis.
Newer materials like Biodentine and Calcium Journal of endodontics, 33(6), 680-689.
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