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Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 92-95

Nonsurgical retreatment and reinforcement of an immature permanent tooth with periapical lesion of endodontic origin

1 Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Department of Conservative Dentistry and Endodontics, RV Dental College, Bangalore, Karnataka, India
3 Department of Conservative Dentistry, RV Dental College, Bangalore, Karnataka, India

Date of Web Publication30-Oct-2015

Correspondence Address:
Dr. Jyoti Ahlawat
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.168737

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Endodontic management of immature traumatized teeth usually involves carrying out conventional (apexogenesis and apexification) or regenerative endodontic treatment. While continued development of the radicular tooth structure should be the desired outcome of treating teeth with open apex, in cases of necrotic teeth or retreatment procedures, the formation of apical barrier via apexification is a more feasible approach. A 21-year-old boy reported with a traumatized maxillary central incisor with incomplete root development, previously treated 13 years ago; it was decided to retreat the tooth endodontically and carry out rehabilitation via reinforcement of the root using fiber post. The post was customized by relining it with direct, visible-light-cured composite resin and final cementation was carried out using dual cure composite resin. This paper aims to present and discuss different treatment modalities possible in a young traumatized tooth.

Keywords: Anatomic post, apexification, mineral trioxide aggregate, retreatment

How to cite this article:
Malhotra A, Ahlawat J, Bansal C, Rao H M. Nonsurgical retreatment and reinforcement of an immature permanent tooth with periapical lesion of endodontic origin. J Res Dent 2015;3:92-5

How to cite this URL:
Malhotra A, Ahlawat J, Bansal C, Rao H M. Nonsurgical retreatment and reinforcement of an immature permanent tooth with periapical lesion of endodontic origin. J Res Dent [serial online] 2015 [cited 2020 May 28];3:92-5. Available from: http://www.jresdent.org/text.asp?2015/3/3/92/168737

  Introduction Top

Traumatic dental injuries in immature permanent teeth often lead to loss of pulp vitality and interruption of root development. Endodontic treatment of such teeth can present a challenging clinical situation due to the thin dentinal walls and a divergent apical architecture. This creates difficulty in performing instrumentation and prepares an adequate apical stop; hence, an alternative to conventional root canal treatment, apexification or root-end closure, has been advocated.[1]

Apexification involves inducing the formation of mineralized tissue in the apical portion of an immature nonvital tooth.[2] Calcium hydroxide (CH) was traditionally used as the material of choice for apexification. It had also been combined with other material such as sterile water, camphorated monochlorophenol, methylcellulose, cresatin, iodoform, and Ringer's solution. However, treatment with CH runs a lengthy course of time and may often result in unpredictable results including root resorption or fracture.[3] Mineral trioxide aggregate (MTA) was introduced as a substitute for single visit apexification since it provides immediate sealing, along with superior biocompatibility.[4] MTA is available in the form of powder that sets in the presence of moisture. It is composed of tricalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite, calcium sulfate dihydrate, and silicate oxide. Bismuth oxide was added for radiopacity. MTA is available in the following two forms: Grey MTA and white MTA. The difference between the two is the absence of tetracalcium aluminoferrite in white MTA. The alkaline pH and presence of calcium and phosphate ions in MTA promote conditions for cementum deposition.[5]

Postendodontic restoration of fractured anterior teeth often requires postplacement. Due to the irregular and wider root canal space and fragile dentinal walls, custom-made posts are preferred over prefabricated ones. Application of a chair-side customized fiber post that simulates the canal anatomy as well as provides superior retention and aesthetics is advantageous in such cases.[6]

This case report presents the retreatment of an immature permanent anterior tooth with MTA apical plug followed by the placement of anatomic post.

  Case Report Top

A 21-year-old male patient reported with the chief complaint of a discolored and fractured maxillary incisor tooth. The patient had a history of trauma to the maxillary anterior region at the age of 8 years for which he had visited a dental practitioner. Root canal treatment of the traumatized tooth was carried out by the clinician at that time. His medical history was noncontributory. Clinical examination revealed crown fracture of the maxillary right central incisor with tenderness on percussion [Figure 1]a. Radiographs showed inadequate obturation of the immature root with presence of a diffuse radiolucency surrounding the apical region of the involved tooth [Figure 1]b. The treatment plan included retreatment of the tooth by formation of apical MTA plug followed by definite restoration with post and core.
Figure 1: Preoperative clinical (a) and radiographic (b) views

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Access cavity was prepared under rubber dam isolation. The previous filling material was removed from the canal with Hedstrom files (Dentsply Maillefer, Ballaigues, Vaud, Switzerland) of size 35-50. A radiograph was taken to check for the presence of any residual filling material and working length was established with a size 80 K-type file (Dentsply, Maillefer Baillaigues, Switzerland) [Figure 2]a. Minimal instrumentation was done with this file. Canal disinfection was achieved by irrigation with 1% NaOCl using EndoVac irrigation system (Discus Dental, Culver City, CA, USA). Interappointment CH medicament (RC Cal, Prime Dental, Thane, Maharashtra India) was placed using a lentulo after drying the canal space with sterile paper points.
Figure 2: (a) Working length determination, (b) application of MTA plug, (c) used fiber post, (d) application of the post into the root canal

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At the next appointment, the tooth was reassessed. CH was removed and the canal was prepared to receive filling material. Proroot MTA (Dentsply, Tulsa, OK, USA) was mixed according to the manufacturer's instructions and carried to the canal with an amalgam carrier. Apical plug of 4 mm of MTA was placed and confirmed radiographically [Figure 2]b. A sterile cotton pellet moistened with sterile water was placed over the canal orifice and the access cavity was sealed with Cavit (3M ESPE, Seefeld, Bavaria, Germany).

The next visit was scheduled after 3 days when restoration of the tooth was done with post and core. It was decided that a fiber post would be customized such that it would adapt precisely with canal anatomy, adequate adhesion with the canal walls, and provide aesthetics as well. Minimal post space preparation was done with Peeso drills (Dentsply Maillefer, Baillaigues, Switzerland) to remove any undercut present on surface of canal wall. A light transmitting post (DT Light Post, RTD, Grenoble, France) was selected and verified for fitting inside the canal. Post space was dried followed by application of a separating agent. The fiber post was conditioned by the application of etchant and bonding agent. The labial surface of the post was marked with a pencil for verifying the position and achieving correct orientation of the post during customization. Prebonded post was coated with a resin composite (Filtek Z350; 3M ESPE, USA) and inserted inside the canal to adapt with the canal anatomy. The composite was cured inside the canal through the translucent fiber post for 5 s. The post was then removed from the canal and cured for another 20 s. Incremental addition of composite was continued till the post had an adequate fit inside the canal [Figure 2]c. Post adaptation and fit inside the canal was confirmed radiographically [Figure 2]d.

The canal space was rinsed to remove the separating agent. After drying, etchant (phosphoric acid) and bonding agent were applied inside the canal. Light curing was done for 20 s. Luting of anatomic fiber post was done with dual cure resin cement (Rely X ARC; 3M ESPE). The tooth surface was etched, rinsed, and bonded. Thereafter, core buildup was done followed by tooth preparation for metal ceramic crown. Crown cementation was done with luting glass ionomer cement [Figure 3]a. Follow-up radiographs after 1 year revealed complete healing of the periapical lesion [Figure 3]b.
Figure 3: (a) Metal ceramic crown cementation, (b) 1-year follow-up radiograph showing resolution of the periapical lesion

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  Discussion Top

Although the ideal endodontic outcome in immature necrotic teeth is regeneration of the pulpal tissue resulting in continued root development, such a treatment approach is not always feasible, especially in teeth where endodontic treatment has already been attempted previously but has resulted in failure. The alternative procedure that is often indicated in such cases is the formation of an artificial apical barrier against which gutta percha is condensed.

CH-induced apexification is not a reliable procedure in nonvital immature teeth due to various drawbacks including deterioration of mechanical properties of the root canal dentin.[5] Long-term CH therapy has been substituted by one- or two-step apexification procedures that employ bioactive and biocompatible materials to form the apical plug.

The most extensively researched and clinically evaluated biomaterial in endodontics over the last couple of decades is MTA that seems to have become a standard of care in the management of immature nonvital teeth. Apart from reducing the treatment time for apexification, MTA provides effective periradicular seal and is extremely resistant to the acidic environment of periapical infections.[7] Being a bioactive material, MTA promotes the healing of periradicular defects by inducing regeneration of the cementum and periodontal ligament. The literature consists of reports where the application of MTA as an apical matrix has demonstrated exceptional results in the management of immature teeth, allowing continued root development even in cases of necrotic pulpal tissue.[8]

The primary issue while restoring an immature tooth is the weakened radicular structure due to thin and fragile dentinal walls.[9] Therefore, in order to minimize the risk of fracture postendodontic restoration should be planned keeping in mind the objective of strengthening the root architecture. Lui et al. had previously suggested a procedure for reinforcing the root structure by lining the internal root canal walls with a chemically cured composite after etching and bonding the canal wall dentin.[10],[11] The limitation in such a technique is the inability to control the polymerization reaction in the apical areas of the canal space. Fiber posts are commonly advocated for postendodontic management of traumatized anterior teeth with deficient residual tooth structure due to their aesthetic as well as adhesive properties.[12] The current case was deemed appropriate for the use of customized post due to the irregular and wide anatomy of the canal space. Placement of prefabricated posts in canals with such a cross section often compromises the adaptation of post with the canal walls. Consequently, excessive space left between the post surface and canal wall dentin gets filled with luting agent.

A thick layer of luting cement is detrimental to bond quality and predisposes to adhesive failure and debonding of the post.[13] Apart from debonding, polymerization shrinkage stresses associated with resin cements may further increase the risk of tooth fracture during functional loading in case of such wide and irregular canal spaces.[14]

Additionally, the chances of occurrence of voids and bubbles in the luting cement that represent areas of weakness within the material are minimized if a thin layer of cement is required during post cementation.[6] Just like all of the resin-based materials, the relining resin surrounding the anatomic post shrinks as it cures. Although this aspect needs further evaluation, it logically seems that the shrinkage should favor the extrusion of the anatomic post from the canal after its relining. Keeping in mind all the above factors, it was decided to customize the fiber post according to the root canal anatomy in order to achieve complete adaptation with root radicular dentin walls. In addition to reinforcing the remaining tooth structure, placement of fiber post reduces patient visits for fabrication of a postendodontic restoration since it is usually accomplished in a single visit.

An alternate treatment modality could have been the placement of direct composite resin material inside the root canal after etching and bonding followed by insertion of light transmitting post precoated with a separating media through the composite and curing with light activation. After curing, the post is removed with a rotating and pulling motion, creating a patent space inside the reinforced canal. Tait et al. advocated restoring this patent canal space with either composite resin in cases of teeth with sufficient residual coronal structure or placing a quartz fiber post followed by composite core buildup in cases where inadequate sound tooth structure was remaining.[9]

  Conclusion Top

The most successful approach in endodontic therapy of nonvital immature teeth includes the use of bioinductive and reparative materials like MTA that accelerates periapical tissue healing, along with ensuring effective sealing of flared canal architecture apically. In order to improve the long-term survival of traumatized immature teeth with missing coronal tooth structure, rehabilitation of canal space with an anatomic fiber post and core appears to be a satisfactory treatment approach.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

D'Arcangelo C, D'Amario M. Use of MTA for orthograde obturation of nonvital teeth with open apices: Report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e98-101.  Back to cited text no. 1
Morse DR, Larnie J, Yesilsoy C. Apexification: Review of the literature. Quintessence Int 1990;21:589-96.  Back to cited text no. 2
Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: A review. Br Dent J 1997;183:241-6.  Back to cited text no. 3
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1993;25:197-205.  Back to cited text no. 4
Kubasad GC, Ghivari SB. Apexification with apical plug of MTA-report of cases. Arch Oral Sci Res 2011;1:104-7.  Back to cited text no. 5
Grandini S, Sapio S, Simonetti M. Use of Anatomic post and core for reconstructing an endodontically treated teeth: A case report. J Adhes Dent 2003;5:243-7.  Back to cited text no. 6
Saghiri MA, Lotfi M, Saghiri AM, Vosoughhosseini S, Fatemi A, Shiezadeh V, et al. Effect of pH on sealing ability of white mineral trioxide aggregate as a root-end filling material. J Endod 2008;34:1226-9.  Back to cited text no. 7
Rule DC, Winter GB. Root growth and apical repair subsequent to pulpal necrosis in children. Br Dent J 1966;120:586-90.  Back to cited text no. 8
Tait CM, Ricketts DN, Higgins AJ. Weakened anterior roots-intraradicular rehabilitation. Br Dent J 2005;198:609-17.  Back to cited text no. 9
Lui JL. Composite resin reinforcement of flared canals using light-transmitting plastic posts. Quintessence Int 1994;25:313-9.  Back to cited text no. 10
Lui JL. A technique to reinforce weakened roots with post canals. Endod Dent Traumatol 1987;3:310-4.  Back to cited text no. 11
Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture resistance of endodontically treated teeth restored with composite posts. J Prosthet Dent 2003;89:360-7.  Back to cited text no. 12
Ferrari M, Vichi A. Mannoci F, Mason PN. Retrospective study of clinical behaviour of several types of posts. Am J Dent 2000;13:15-B8.l  Back to cited text no. 13
Bolhuis P, de Gee A, Feilzer A. Influence of fatigue loading on four post-and-core systems in maxillary premolars. Quintessence Int 2004;35:657-67.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]


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