CliniCal Cases
srinivasan Ramasamy
Management of Overextended Root Canal Filling
of an Immature Maxillary Central Incisor
– Case Report
Postępowanie w przypadku przepchnięcia materiału endodontycznego
w przyśrodkowym siekaczu szczęki z niezakończonym rozwojem
– opis przypadku
Department of Conservative Dentistry and endodontics, Chennai, india
Abstract
Overextension refers to inadequate and poor root canal obturation that extends beyond the periapical region of the tooth. Root canal overextension is often associated with a wide range of local complications and results in sustained periapical infection and inflammation. long term periapical infection delays definitive prosthetic management of the involved tooth. The condition of blunderbuss root canal can be associated with various factors that can render pulp tissue non-vital during apexogenesis. an immature tooth often presents as an endodontic challenge due to the need for meticulous precautions that are required during its management. in the presented case report, the overex-tended contents of the immature tooth were removed by periapical surgery and the contents within the root canal system were removed using an orthograde manner. The main canal was obturated with mineral trioxide aggregate. eight month follow-up showed complete healing clinically and the radiograph showed successful periapical healing
(Dent. Med. Probl. 2014, 51, 3, 397–401).
Key words: biofilm, apexogenesis, mineral trioxide aggregate.
Streszczenie
Przepchnięcie materiału endodontycznego polega na nieprawidłowym wypełnieniu kanału korzeniowego i obec-ności tego materiału w okolicy okołowierzchołkowej zęba. Przepchnięcie takie jest często związane z licznymi powikłaniami miejscowymi i może prowadzić do zapalenia tkanek okołowierzchołkowych. skutkuje to opóźnie-niem ostatecznego wyleczenia takiego zęba. nieprawidłowości w leczeniu endodontycznym zwiększają liczbę czyn-ników wpływających na proces apeksyfikacji. Ząb z niezakończonym rozwojem wymaga szczególnych środków ostrożności w czasie leczenia endodontycznego. W opisanym przypadku przepchnięcia materiału endodontyczne-go poza przyśrodkoweendodontyczne-go siekacza szczęki przepchnięty materiał usunięto chirurgicznie, a kanał korzeniowy wypeł-niono powtórnie. Do wypełnienia kanału głównego użyto Mineral Trioxide aggregate (MTa). Kontrola kliniczna i radiologiczna osiem miesięcy po leczeniu wykazała całkowite wygojenie okolicy okołowierzchołkowej leczonego zęba (Dent. Med. Probl. 2014, 51, 3, 397–401).
Słowa kluczowe: biofilm, apeksogeneza, mineral trioxide aggregate.
Dent. Med. Probl. 2014, 51, 3, 397–401
issn 1644-387X © Copyright by Wroclaw Medical University and Polish Dental society
Overextension refers to poor filling of the root canal system with obturating materials that ex-tend beyond the root apex, reaching the periapi-cal space [1].such overextended root canal materi-als might act as a foreign body, causing mechani-cal or chemimechani-cal irritation of periradicular tissues, leading to treatment failure [2].
Open apex or blunderbuss root canal could
occur as a consequence of pulpal necrosis follow-ing trauma or dental caries compromisfollow-ing the vi-tality of the tooth during the early stages of apexo-genesis. When endodontic treatment is carried out in blunderbuss canals, the apexification process would confine the endodontic instruments, medi-cations and obturating materials within the canal to prevent endodontic complications[3].
perior seal, preventing the passage of bacterial in-fection to the periapical region [4].
This case report presents successful manage-ment of an overextended maxillary central incisor by periapical surgery followed by MTa obturation of the canal and the significance of bacterial bio-film in persistent apical periodontitis.
Case Report
a 20 year old, male patient reported to the den-tal clinic with pain and swelling in his upper front tooth region for the past 2 months. The medical history of the patient was noncontributory. Den-tal history revealed that the patient had undergone endodontic treatment for his upper front tooth 3 years before. Oral examination revealed a discol-ored maxillary right central incisor (11) with poor coronal restoration and with a localized swelling in the alveolar mucosa (Fig. 1a). Percussion of the tooth presented with a dull pain. Radiograph re-vealed an overextended root canal with periapical radiolucency along with root canal filling materi-als extending approximately 5 mm beyond radio-graphic apex (Fig. 1b).
Based on the clinical and radiographic findings, a diagnosis of apical periodontitis involving tooth 11 following an inadequate endodontic treatment was proposed. a treatment plan involving endodontic surgery to remove the overextended material fol-lowed by MTa obturation of 11 was planned.
informed consent of the patient was obtained. after administration of local anesthetic (ligno-caine 2% with 1:80,000 adrenaline), a full thick-ness mucoperiosteal flap was raised. Using a no. 4 round bur, a bony window was created to gain ac-cess to the overfilled gutta-percha (GP) points (Fig. 1c). The GP points inside the root canal were retrieved in an orthograde manner using a no. 60 H file (Mani inc, Tochigi, Japan) and those outside the canal in the periapical region were retrieved using surgical curettes along with the granulation tissue (Fig. 1d). The root canal was irrigated with gentle but copious irrigation of 0.5% sodium hy-pochlorite. intraoperative radiographs were taken periodically to confirm retrieval of GP (Fig. 1e).
The bony cavity was filled with Biphasic calci-um phosphate ceramic (Biograft, iGFl Bioceram-ics ltd) (Fig. 1f). The flap was approximated and
The canal was entered and irrigated to re-move the calcium hydroxide. 2% chlorhexidine (asep RC, stedman Pharmaceuticals Pvt. ltd) was used as a final irrigant. White MTa (ProRoot MTa), mixed according to the manufacturer’s in-structions, was delivered using the MTa Gun sys-tem (Dentsply Maillefer, Ballaigues, switzerland) into the root canal. The MTa was condensed us-ing schilder’s plugger up to the level of the ce-mentoenamel junction (CeJ) incrementally. The MTa was blotted with damp cotton to remove ex-cess moisture. a moist cotton pellet was placed in the access chamber to favor the hydration and set-ting process of MTa. Type ii Glass ionomer Ce-ment (GC Fuji 2 Glass ionomer restorative, Tokyo, Japan) was given as temporary access restorative material.
The patient was reviewed after 24 h. The GiC and cotton were removed from the access chamber and composite (Filtek P60, 3M esPe) was given as a final restoration. a one week review showed absence of vestibular swelling. The tooth was pre-pared for a porcelain fused to metal (PFM) crown. The fabricated crown was luted with resin cement (Fig. 2a). a two month follow-up showed the pa-tient was asymptomatic clinically and the radio-graph revealed healing periapical lesion (Fig. 2b). eight month follow-up showed the patient was as-ymptomatic clinically and the radiograph revealed healed periapical lesion and normal bony trabec-ulae (Fig. 2c).
Discussion
iatrogenic mishaps are common in any treat-ment procedure and endodontics is not an excep-tion. a planned treatment protocol can, howev-er, reduce its chances. extrusion of root canal fill-ing materials was associated with a wide range of local complications, some of them include orbit-al pain, headache, aspergillosus sinusitis and an-esthesia of the inferior alveolar nerve [5–7]. His-tologically, extruded GP are slowly eliminated by macrophages thereby delaying the periapical heal-ing process [8].
Biofilms are surface attached microbial com-munities formed by many organisms [9, 10]. Bioma-terial centered infections (BCis) refers to the ability of bacteria to colonize biomaterials in the form of
biofilms and subsequently infect the adjacent tis-sues [11].extruded GP points form a favorable sub-strate for bacterial colonization and houses a wide range of bacterial species on their surfaces. Biofilms formed over extruded GP are capable of sustain-ing periapical inflammatory processes and
pres-ent as long-standing periapical infection [12–14]. in the presented case report, lack of a proper cor-onal seal could have opened the pathway for oral microflora to permeate through the poorly-filled root canal and subsequently colonize the periapi-cal space and persist as bacterial biofilms.
More-Fig. 1. a – discolored 11 with vestibular swelling; b – overextended root canal filling; c – extruded GP seen through
bony window; d – complete retrieval of GP seen through bony window; e – radiograph showing complete retrieval; f – biphasic calcium phosphate ceramic filled in bony cavity
Ryc. 1. a – przebarwienie zęba 11 z obrzękiem od strony przedsionka; b – przepełnienie kanału korzeniowego;
c – widok GP poprzez okienko kostne; d – całkowite wyszukanie GP poprzez okienko kostne; e – kontrola radiolo-giczna całkowitego usunięcia materiału endodontycznego; f – dwufazowy fosforan wapnia wypełnia ubytek kostny
ration using commonly-used obturation material like GP. in conditions of poor coronal seal, in vitro microleakage studies using dye penetration, fluid filtration and bacterial leakage models had shown the presence of a weak interface between root canal dentin and GP irrespective of cold or warm com-paction techniques [9]. in the presented case re-port, obturation of the entire root canal system with MTa was preferred against the MTa apical plug, as the former showed superior sealing ability sub-sequent to formation of the mineralized interface with the root dentin as discussed in the study by Bogen et al. [9].
Biphasic calcium phosphate ceramic was used in the presented case. it consists of 60% hydroxy-apatite and 40% beta tricalcium phosphate, hav-ing a mineral composition close to that of bone. it’s a bioactive, osteo-conductive, resorbable mate-rial which acts as scaffold for new tissue to devel-op. Reconstruction of natural tissue occurs simul-taneously with resorption of these ceramic mate-rials during the repair process [15].
over, inadequate debridement of the root canal and lack of a fluid impervious seal could have been additional contributory factors to the long-term periapical infection.
a case series study by Bogen et al. [9] docu-ments the advantages of using MTa as an obtu-rating material especially in retreatment of failed endodontically-treated teeth with persistent re-fractory apical periodontitis. according to their study, formation of a mineralized interstitial layer between root dentin and MTa during the setting process of MTa entombs and inhibits the micro-organism within the root canal system, prevent-ing its pathway to the periapical region. accordprevent-ing to Witherspoon et al. [4], MTa obturated blunder-buss canals showed a high percentage of healing in their follow up visits irrespective of single or mul-tiple visit treatment. Their study also highlights the superiority of MTa over calcium hydroxide in the management of an open-apex tooth.
apexification with a MTa apical plug of 4–5 mm had to be subsequently followed by
obtu-Fig. 2. a – PFM crown luted with resin cement; b – 2 month follow-up of MTa obturation and healing periapical
lesion; c – 8 month follow-up showing healed periapical lesion and normal bony trabeculae
Ryc. 2. a – korona protetyczna osadzona na cemencie; b – dwa miesiące po wypełnieniu kanału MTa, gojenie tkanek
okołowierzchołkowych; c – kontrola radiologiczna 8 miesięcy po leczeniu pokazuje wygojenie tkanek okołowierzchoł-kowych oraz prawidłowe beleczkowanie kostne
Conclusions
The eight month follow-up radiograph of the discussed case report showed an absence of peri-apical radiolucency and the presence of a normal
trabecular pattern of the periapical bone. This strongly emphasizes the physiochemical and bio-active properties of MTa when used as obturation material in retreatment of long-term apical peri-odontitis.
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Address for correspondence:
srinivasan Ramasamy
Department of Conservative Dentistry and endodontics Tamil nadu
600042 Chennai india
e-mail: rampoovana@gmail.com Conflict of interest: none declared Received: 20.04.2014
Revised: 18.05.2014 accepted: 23.05.2014
Praca wpłynęła do Redakcji: 20.04.2014 r. Po recenzji: 18.05.2014 r.
