Case Report [Link].
in
Successful apexification with resolution of the
periapical lesion using mineral trioxide aggregate and
demineralized freeze-dried bone allograft
Naveen Chhabra, Kiran P Singbal1, Sharad Kamat2
Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly, 1Department of Conservative Dentistry
and endodontics, Vyas Dental College, Jodhpur, 2Department of Conservative Dentistry and endodontics, PMNM Dental college and
hospital, Bagalkot, India
Abstract
Immature teeth with necrotic pulp and large periapical lesion are difficult to treat via conventional endodontic therapy. The
role of materials such as calcium hydroxide and mineral trioxide aggregate in apexification is indispensable. This case report
presents the successful healing and apexification with combined use of white mineral trioxide aggregate and demineralized
freeze-dried bone allograft.
Keywords: Allograft; apexification; calcium hydroxide; mineral trioxide aggregate; root canal therapy.
INTRODUCTION has shown potential outcome in carrying out apexification of
immature permanent teeth.[13,14] Apexification using MTA has
Complete asepsis and three-dimensional obturation of the several advantages such as it neither gets resorbed, nor weakens
root canal system are essential for long-term endodontic the root canal dentin, and also sets in the wet environment.
success. In certain cases such as immature teeth, the Satisfactory compaction of obturating material is achievable as
absence of natural apical constriction creates a challenge. MTA on setting provides a sound and hard apical barrier.
Therefore, one of the aims of endodontic treatment is to
produce an apical barrier or stop, against which one can Bio-resorbable demineralized bone matrix (DMBM) is
place a root canal filling material avoiding overextrusion. the protein component of bone and is widely used in
This technique is termed apexification. various clinical conditions such as periodontal defects
and oral and maxillofacial bone defects. Periodontal
Clinicians have tried several materials to form apical defects grafted with demineralized bone matrix allograft
barrier in the past. These include: calcium hydroxide paste, showed histologic evidence of regeneration of new bone
calcium hydroxide powder; mixed with different vehicles,[1-3] and periodontium.[15] Considering the osteoconductive
tricalcium phosphate,[4] collagen calcium phosphate,[5] potential and proven success of demineralized bone matrix
osteogenic protein-1, bone growth factor and oxidized allograft in the management of periodontal defects, it
cellulose.[6] proplast, (a polytetrafluor-ethylene and carbon provides an excellent alternative for use in management of
felt-like porous material),[7] barium hydroxide,[8] true bovine large periapical radiolucency.
bone ceramics,[9] and dentin chips. Antibacterial such as paste
of metronidazole, ciprofloxacin, and cefaclor has effectively The apical matrix of some resorbable and biocompatible
encouraged apexification.[10] Deliberate over instrumentation material is essential to control extrusion of MTA. “Modified
of the periapical area to produce a blood clot that will induce matrix concept” for repair of perforation utilized resorbable
apical closure has also been described.[11] collagen as a matrix followed by condensation of MTA.[16]
Considering the biocompatible nature of bio-resorbable
Mineral trioxide aggregate (MTA) was developed at Loma demineralized bone matrix, it could be the material of
Linda University for use as a root-end filling material.[12] MTA choice in such cases.
Address for correspondence: Therefore, present case report highlights the nonsurgical
Dr. Naveen Chhabra, Department of Conservative Dentistry and
Endodontics, Institute of Dental Sciences, Bareilly, management of symptomatic tooth with blunderbuss canal
Uttar Pradesh-243 006, India and large periapical radiolucency using bio-resorbable
E-mail: drchabs_1980@[Link] demineralized bone matrix and MTA.
Date of submission: 26.10.2009
Review completed: 10.01.2010 CASE REPORT
Date of acceptance: 10.11.2009
DOI: 10.4103/0972-0707.66723 A 16-year-old male patient of south Indian origin reported to
106 J Conserv Dent | Apr-Jun 2010 | Vol 13 | Issue 2
Chhabra: Apexification using MTA and freeze dried bone graft
the department of conservative dentistry and endodontics, hypochlorite solution. Thereafter, calcium hydroxide and
PMNM Dental College and Hospital, Bagalkot, Karnataka, iodoform combination (MetapexTM, META Biomed Co. Ltd.,
India, with the complain of pain in right mandibular Korea) was placed in canal and patient was recalled after
posterior teeth since 3 weeks. Careful intraoral examination 15 days [Figure 1c]. Recall appointment showed the healing
revealed sinus opening in relation to the right lower second sinus and patient was asymptomatic. The medicament was
premolar. Hard tissue examination revealed the presence of removed from the canal followed by irrigation with 1.25%
“dens evaginatus” and a deep pit in right mandibular second sodium hypochlorite. After confirming dryness of canal, the
premolar [Figure 1a]. Concerned tooth did not respond to apical matrix/barrier was created via pushing decalcified
electric pulp testing. Radiographic examination revealed freeze-dried bone allograft (OsseograftTM, Advanced Biotech
deep pit communicating with the pulp space, presence of Products (P) LTD, India) through the canal using finger
blunderbuss canal, and large periapical radiolucency with pluggers (Dentsply, India) and packing it in periapical area
respect to right mandibular second premolar [Figure 1b]. [Figure 1d]. This was followed by a placement of 5 mm
There were two treatment options- either surgical removal apical plug of white mineral trioxide aggregate (PROROOT
of the periapical lesion followed by retrograde filling or MTATM Dentsply, India) using a finger plugger. Keeping moist
nonsurgical endodontic treatment consisting of routine cotton over the canal orifice achieved complete setting of
endodontic therapy and apexification using mineral trioxide MTA, which was followed by closure of access preparation
aggregate. Nonsurgical treatment was opted considering using an interim restorative material (Cavit GTM 3M ESPE,
the age and amount of trauma expected during surgical India) [Figure 1e]. The patient was asymptomatic at 1-week
treatment. Local anesthesia was not required as tooth was recall visit. Therefore, remaining canal was obturated using
nonvital. Access was prepared under rubber dam isolation. resin-based endodontic sealer (AH 26, Dentsply India)
Pus exuded through the canal immediately after access and thermoplasticized gutta percha (Obtura II, J. Morita
preparation. Canal was irrigated using lukewarm normal Corporation, Japan). The 6-month follow-up radiograph of
saline to assist in exudation. Access preparation was left open the patient showed reduction in the size of the periapical
until exudate stopped coming out. This followed thorough lesion [Figure 1f]. At 2-year recall, the patient was completely
biomechanical preparation, involving circumferential filling asymptomatic and intraoral periapical radiograph of the
with a size 80 K file (Dentsply, India) to remove any debris or same tooth revealed complete resolution of the periapical
necrotic dentin and root canal irrigation with 1.25% sodium lesion [Figure 1g].
a b c d
e f g
Figure 1: (a) Right mandibular second premolar showing the presence of dense evaginatus, (b) Preoperative radiograph of
right mandibular second premolar showing deep pit communicating with pulp space along with blunderbuss canal and large
periapical radiolucency, (c) 15 days recall radiograph after the placement of calcium hydroxide and iodoform paste, (d) Apical
matrix of decalcified freeze dried bone allograft, (e) Apical plug of MTA created over the apical matrix, (f) 3 months follow-
up radiograph showing reduction in the size of the periapical lesion, (g) 2 years follow-up radiograph representing complete
resolution of the periapical lesion
J Conserv Dent | Apr-Jun 2010 | Vol 13 | Issue 2 107
Chhabra: Apexification using MTA and freeze dried bone graft
DISCUSSION DFDBA heal with regeneration of periodontium. [27,28]
Follow-up radiographs also showed the excellent
Despite the higher success rate of apical barrier formation healing with resolution of periapical pathology. Recent
using calcium hydroxide, long-term follow-up is essential. literature reported the successful use of combination
Problems such as failure to control infection, recurrence of hydroxyapatite and platelet rich plasma in surgical
of infection, and cervical root fracture may occur.[17,18] management of the large periapical lesion with open apex.[29]
Apexification using mineral trioxide aggregate provides Combination of hydroxyapatite and platelet-rich plasma
an alternative treatment modality in immature pulpless or demineralized bone matrix and platelet-rich plasma can
teeth. Apexification with MTA requires significantly less also be tried using the method as stated in the present case
time.[19] Mineral trioxide aggregate as an apexification in further case studies.
material represents a contemporary version of the primary
monoblock. Apatite-like interfacial deposits form during ‘Dens evaginatus’ or ‘evaginated odontoma’ is a
maturation of MTA result in filling up of gaps induced during developmental anomaly that occurs more often in
the material shrinkage phase and improve the frictional mandibular premolars;[30] however, it can also affect other
resistance of MTA to the root canal walls. The formation teeth, including supernumerary teeth.[31] It is the result of
of nonbonding, gap-filling apatite deposits probably also an abnormal proliferation of the inner enamel epithelium
accounts for the seal of MTA in orthograde obturations and into the stellate reticulum of the enamel organ.[32] The
perforation repair.[20] resulting tubercle contains a core of dentin surrounding a
pulpal extension, which may be narrow, wide, constricted,
MTA has superior biocompatibility and sealing ability and is an isolated horn, or not present at all.[32] The prevalence
less cytotoxic than other materials currently used in pulpal of Dens evaginatus is between 1% and 4%. It occurs most
therapy.[21] The 5-mm barrier is significantly stronger and commonly in people in the Mongoloid racial group, which
shows less microleakage as compared to the 2-mm barrier includes the Paleo-Asiatics (Indians of North, Central and
of MTA.[22] South America and Eskimos), the Neo-Asiatics (Chinese,
Thais and Japanese), and the Indonesian-Malays (Filipinos).[32]
Apexification using MTA lessens the treatment time In this case, probably invasion of salivary fluids and
between the patient's first appointment and the final microorganisms through the enamel of the occlusal table
restoration. The importance of this approach lies in the caused the damage. Early detection of dens evaginatus
expedient cleaning and shaping of the root canal, followed is important—it may be possible to fissure seal over the
by apical seal with a material that favors regeneration. In defect using bonded restorative, or cut the defect away
addition, there is reduced potential for fracture of immature and perform an MTA pulpotomy.
teeth with thin roots, because of immediate placement of
bonded core within the root canal.[23] This case report presents a novel approach to achieve
single visit apexification of the cases with open apex and
In the present case, combination of calcium hydroxide and large periapical lesion. Present case also stresses the early
iodoform was used as intracanal medicament for 15 days to detection and treatment of ‘dens evaginatus’ which if
make the canal dry and free from infection. Use of calcium undetected can cause undue damage.
hydroxide for such a short term does not adversely affect
the fracture resistance of the tooth.[24] REFERENCES
The demineralized bone matrix acts as an osteoconductive 1. Michanowicz JP, Michanowicz AE. A conservative approach and
and possibly as an osteoinductive material.[25,26] Hence, procedure to fill an incompletely formed root using calcium hydroxide as
an adjunct. J Dent Child 1967;34:42-7.
probably, allograft material could have promoted the 2. Pitts DL, Jones JE, Oswald RJ. A histological comparison of calcium
healing in the present case. However, only objective of hydroxide plugs and dentin plugs used for the control of Guttapercha root
canal filling material. J Endod 1984;10:283-93.
using bone graft material in this case was to produce an 3. Schumacher JW, Rutledge RE. An alternative to apexification. J Endod
apical barrier. Use of the apical matrix of decalcified freeze- 1993;19:529-31.
dried bone allograft material in the present case provided 4. Coviello J, Brilliant JD. A preliminary clinical study on the use of
tricalciumphosphate as an apical barrier. J Endod 1979;5:6-13.
excellent compaction of mineral trioxide aggregate, while 5. Nevins A, Finkelstein F, Laporta R, BordenBG. Induction of hard tissue
minimizing extrusion of mineral trioxide aggregate in the into pulpless open-apex teeth using collagen-calcium phosphate gel. J
Endod 1978;4:76-81.
periapical area. 6. Dimashkieh MR. A method of using silver amalgam in routine
endodontics, and its use in open apices. Br Dent J 1975;138:298-300.
Decalcified freeze-dried bone allograft material has 7. Eleazer PD, McDonald TW, Sinai IH, Fantasia JE, Michelich RJ,
Yagiela JA. Proplast as an apical barrier in root canal therapy. J Endod
been extensively used in the management of extensive 1984;10:487-90.
periodontal defects. Its use results in significant probing 8. Narang R, Wells H. Experimental osteogenesis in periapical areas with
decalcified bone matrix. Oral Surg Oral Med Oral Pathol Oral Radiol
depth reduction, clinical attachment gain, and bone Endod 1973;35:136-43.
fill. Definite evidence exists that sites grafted with 9. Yoshida T, Itoh T, Saitoh T, Sekine I. Histopathological study of the use of
108 J Conserv Dent | Apr-Jun 2010 | Vol 13 | Issue 2
Chhabra: Apexification using MTA and freeze dried bone graft
freeze-dried allogenic dentin powder and True Bone Ceramic as apical of white and gray material trioxide aggregate (MTA) simulating a one- or
barrier materials. J Endod 1998;24:581-6. two-step apical barrier technique. J Endod 2004;30:876-9.
10. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected 23. Steinig TH, Regan JD, Gutmann JL. The use and predictable placement
immature permanent tooth: Case report and review of the literature. of Mineral Trioxide Aggregate in one-visit apexification cases. Aust
Pediatr Dent 2007;29:47-50. Endod J 2003;29:34-42.
11. Ham JW, Patterson SS, Michell DF. Induced apical closure of immature 24. Hasheminia SM, Norozynasab S, Fezianfard M. The effect of three
pulpless teeth in monkeys. Oral Surg Oral Med Oral Pathol Oral Radiol different calcium hydroxide combinations on root dentin microhardness.
Endod 1972;33:438-49. Res J Biol Sci 2009;4:121-5.
12. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and 25. Finkemeier CG. Bone-grafting and bone-graft substitutes. J Bone Joint
chemical properties of a new root-end filling material. J Endod Surg Am 2002;84:454-64.
1995;21:349-53. 26. Meadows CL, Gher ME, Quintero G, Laferty TA. A comparison of
13. Arcangelo DC, Amario DM. Use of MTA for orthograde obturation of polylactic acid granules and decalcified freeze dried bone allograft in
nonvital teeth with open apices: Report of two cases. Oral Surg Oral human periodontal osseous defects. J Periodontol 1993;64:103-9.
Med Oral Pathol Oral Radiol Endod 2007;104:e98-101. 27. Mellonig JT. Freeze dried bone allografts in periodontal reconstructive
14. Gutmann JL. The use and predictable placement of Mineral Trioxide surgery. Dent Clin North Am Reconstr Periodont 1991;35:505-20.
Aggregate in one-visit apexification cases. Aust Endod J 2003;29:34-42. 28. Hiremath H, Gada N, Kini Y, Kulkarni S, Akub SS, Metgud S. Single
15. Mellonig JT. Bone Allografts in periodontal therapy. Clin Orthop Relat step apical barrier placement in immature teeth using mineral trioxide
Res 1996;324:116-25. aggregate and management of periapical inflammatory lesion using
16. Bargholz C. Perforation repair with mineral trioxide aggregate: A platelet rich plasma and hydroxyapatite. J Endod [Link]-4.
modified matrix concept. Int Endod J 2005;38:59-69. 29. Oehlers FA, Leek KW, Lee EC. Dens evaginatus (evaginated odontome):
17. Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8. Its structure and responses to external stimuli. Dent Pract Dent Rec
18. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier 1967;17:239-44.
formation and healing in non-vital immature permanent teeth: A review. 30. Al-Omari MA, Hattab FN, Darwazeh AM, Dummer PM. Clinical problems
Br Dent J 1997;183:241-6. associated with unusual cases of talon cusp. Int Endod J 1999;32:183-90.
19. Pradhan DP, Chawla HS, Gauba K, Goyal A. Comparative evaluation of 31. Echeverri EA, Wang MM, Chavaria C, Taylor DL. Multiple dens
endodontic management of teeth with unformed apices with mineral evaginatus: Diagnosis, management, and complications: Case report.
trioxide aggregate and calcium hydroxide. J Dent Child 2006;73:79-85. Pediatr Dent 1994;16:314-7.
20. Tay FR, Pashley DH. Monoblocks in root canals: A hypothetical or a 32. Hill FJ, Bellis WJ. Dens evaginatus and its management. Br Dent J
tangible goal. J Endod 2007;33:391-8. 1984;156:400-2.
21. Schmitt D, Lee J, Bogen G. Multifaceted use of ProRoot MTA root canal
repair material. Pediatr Dent 2001;23:326-30.
Source of Support: Nil, Conflict of Interest: None declared.
22. Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study
J Conserv Dent | Apr-Jun 2010 | Vol 13 | Issue 2 109
Copyright of Journal of Conservative Dentistry is the property of Medknow Publications & Media Pvt. Ltd. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.
