Indian Journal of Dental Research

: 2011  |  Volume : 22  |  Issue : 3  |  Page : 475--477

Non-surgical management of a mutilated maxillary central incisor with open apex and large periapical lesion

Puneet Ajwani1, Nalini Saini2,  
1 Department of Conservative Dentistry and Endodontics, Kalka Dental College, Meerut, Uttar Pradesh, India
2 Department of Periodontics, Kalka Dental College, Meerut, Uttar Pradesh, India

Correspondence Address:
Puneet Ajwani
Department of Conservative Dentistry and Endodontics, Kalka Dental College, Meerut, Uttar Pradesh


A 24-year-old female patient reported with a mutilated maxillary left central incisor. The coronal tooth structure remaining was very less, discolored, and brittle. She gave history of trauma about 15 years back when the tooth got fractured. An intraoral periapical radiograph revealed an open apex and a large periapical lesion. The case was managed successfully by conservative means using intracanal calcium hydroxide and mineral trioxide aggregate (MTA) apical barrier followed by a fiber post and a core. The final crown restored back esthetics and function. A 6-month follow-up demonstrated a clinically asymptomatic and adequately functional tooth, with radiological signs of healing.

How to cite this article:
Ajwani P, Saini N. Non-surgical management of a mutilated maxillary central incisor with open apex and large periapical lesion.Indian J Dent Res 2011;22:475-477

How to cite this URL:
Ajwani P, Saini N. Non-surgical management of a mutilated maxillary central incisor with open apex and large periapical lesion. Indian J Dent Res [serial online] 2011 [cited 2019 Aug 24 ];22:475-477
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Full Text

 Case Report

A 24-year-old female presented to the Department of Conservative Dentistry and Endodontics with a mutilated (complicated crown fracture with remaining coronal tooth structure in the range of 25 - 50%), discolored maxillary left central incisor [Figure 1] compromising esthetics as well as function. She gave history of trauma about 15 years back when the tooth got fractured. She got an artificial jacket crown placed on the same tooth from a local dentist. There was no history of pain, swelling, or any other symptom. Recently, that crown had got dislodged due to which her facial appearance had become highly unesthetic. This made her psychologically upset and she wanted immediate treatment for the same. The radiographic examination of the tooth showed a wide canal with an open apex and a large periapical lesion [Figure 2]. Electric Pulp Testing was done on teeth in the area of trauma i.e. from maxillary left canine to maxillary right canine. All the teeth gave a positive pulpal response indicating their vitality except the involved maxillary left central incisor. So, considering the patient's expectations and as per current guidelines, it was decided to treat the case non-surgically by placing an MTA apical barrier followed by a bonded fiber post and core. [1] Adequate isolation was achieved with the use of cotton rolls and saliva ejectors. After determining the working length, the canal was cleaned thoroughly using K-files and gentle but copious irrigation with 0.5% sodium hypochlorite. Calcium hydroxide (Metapex, Meta Biomed Co., Ltd.) was placed as an intracanal medicament for canal disinfection and the tooth was temporized. The patient was recalled after 1 month. The canal was instrumented and irrigated and calcium hydroxide removed. White mineral trioxide aggregate (MTA) (ProRoot® , Dentsply Tulsa Dental) was mixed to a paste consistency with sterile water and delivered to the canal using an amalgam carrier in about 4 mm thickness. An appropriate sized endodontic plugger was used to condense the MTA at the apex. A radiograph was taken to confirm its position [Figure 3]. A moist cotton pellet was sealed inside for setting of MTA. The patient was recalled the next day and the hard set of the MTA was verified with an endodontic file. An appropriate sized fiber post (Reforpost® , Angelus) was tried and cemented into the canal using dual cure resin cement (Variolink II, Ivoclar Vivadent). Core build up was done with composite (3M™ Z100™) and a radiograph was taken. Tooth preparation for the crown was done and impression made with a rubber base impression material (Aquasil Ultra, Dentsply Caulk). The final crown was cemented in place the next day restoring esthetics and function [Figure 4] and [Figure 5]. The 6-month follow-up revealed asymptomatic and adequately functioning tooth with radiological signs of healing [Figure 6].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}


Though calcium hydroxide has been used with great success to effect an apical hard tissue barrier in immature open apices, the time interval for calcium hydroxide apexification has been reported to be variable, ranging from 12 to 24 months. [1] This presents problems due to patient compliance, reinfection due to loss of temporary restoration, and also predisposes the tooth to fracture. [2] Moreover, the barrier produced by calcium hydroxide apexification has been reported to be incomplete having Swiss cheese appearance and can allow apical microleakage.

Pulp revascularization remains a good treatment option for such cases but the patient wanted immediate treatment. So, single step apexification with MTA was decided for this case. It implies non-surgical compaction of a biocompatible material into the apical end of the root canal, thus creating an apical stop and enabling immediate filling of the root canal. [3]

MTA has been widely recommended for plugging open apices. It has good apical seal, biocompatibility, pulpal, and periodontal regenerating capabilities. [4] White MTA was preferred over the gray MTA as it has shown significantly less leakage. [5] Studies have reported that MTA root fillings placed at the cemental canal limit showed better results than overfillings. [6]

Glass fiber posts bonded to root canal dentin via resin cement offer numerous advantages over previously used conventional metallic posts. Most fiber posts allow near normal light transmission throughout the tooth and root and thus are highly esthetic. Along with the advantages of preserving precious natural tooth structure, they have an elastic modulus similar to that of dentin (~18.6 MPa) and are non-corroding unlike metal posts. They have excellent transverse strength and act as a shock absorber, dissipating much of the stress placed on the finished restoration, transmitting only a small fraction of these forces to the dentinal walls. [7] Thus, they show much lesser incidence of root fracture as compared to metal posts. In the above mentioned case, fiber post (bonded using dual cure composite resin cement) was placed directly after forming the MTA apical barrier as the remaining coronal tooth structure was less (~ 25 - 50%) [1] and use of intracanal composite resin has demonstrated significantly greater resistance to root fracture than MTA followed with gutta-percha and sealer. [8] The flexural strength of a fiber-reinforced post is significantly greater than stainless steel or titanium posts, while maintaining an elastic modulus nearly identical to dentin. They also exhibit less evidence of cyclic fatigue or fracture. Fiber posts have a lower allergenic potential and are considered to be more biocompatible. Also, fiber-reinforced posts can be removed/retrieved expediently without much trauma by drilling down directly through them hollowing the post-out from the center.

0.5% sodium hypochlorite (low concentration) was selected for irrigation as it was an open apex case. Higher the concentration, the more cytotoxicity it can cause and even slight extrusion of this higher concentration beyond the apex can cause lot of periapical tissue irritation with resultant pain and swelling and even permanent mimic musculature and nerve damage in some cases. [9] So, gentle but copious irrigation was used during instrumentation to compensate for the low concentration used. [1] Moreover, there have been studies that report no significant difference between 0.5% and 5% sodium hypochlorite solution regarding its antibacterial or tissue dissolving ability. [10]

Other treatment options for the above mentioned case include performing a periapical surgery and root-end filling with MTA. Another treatment alternative may be extraction of the involved tooth followed by replacement with prosthesis such as fixed or removable partial denture or an immediate implant.

Intracanal disinfection using calcium hydroxide and use of MTA apical plug showed a positive initial clinical outcome for the immature tooth. Use of the fiber post and core followed by final crown restored back esthetics as well as function. The 6 months' follow-up showed clinical and radiological signs of healing.

The above-mentioned technique definitely saves lot of time as compared to calcium hydroxide apexification and gives a predictable apical barrier in a single visit. A long-term follow up is however necessary to ensure success.


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