15
Apexification of a Traumatic Central Incisor with an Apical Plug Technique using Calcium Silicate Cement
Viresh Chopra1,2,3, Harneet Chopra1, and Aylin Baysan3
1 Adult Restorative Dentistry, Oman Dental College, Muscat, Oman
2 Endodontology, Oman Dental College, Muscat, Oman
3 Bart’s London School of Medicine and Dentistry, Queen Mary University, London, UK
15.1 Introduction of the Case
Case of management of a wide open apex traumatic upper right maxillary central incisor associated with periapical radiolucency.
15.1.1 Patient Information
- Age: 20
- Gender: Male
- Medical history: Noncontributory
15.1.2 Tooth Information
15.1.2.1 Identification
Right maxillary central incisor (Tooth 11)
15.1.2.2 Dental History
Chief complaint: Patient reported with a chief complaint of intraoral swelling with tenderness on biting.
15.1.2.3 Clinical Examination Findings
Tooth 11 was tender to percussion. The buccal vestibule had intraoral swelling with tenderness on palpation.
Investigations
Preoperative radiological assessment:
The periapical radiograph revealed periapical radiolucency in relation to (irt) #11. The tooth had a wide open apex (Figure 15.1).
Sensibility Testing
- Hot and cold test: No response
- Electric pulp test (EPT): No response
- Tenderness to percussion: Positive
15.1.2.4 Diagnosis (Pulpal and Periapical)
Necrotic pulp with symptomatic apical periodontitis (SAP)
15.1.2.5 Advice
Root canal treatment with apical plug formation (apexification) using calcium silicate cement followed by obturation of the remaining root canal space
15.2 Treatment Plan
The treatment was planned in different stages:
Figure 15.1 Preoperative periapical radiograph showing wide open apex with periapical radiolucency.
Stage 1
- Gaining entry in the pulp chamber and locating the orifice
- Irrigating the canal
- Cleaning and disinfection of the root canal system
- Placement of intracanal medicament
Stage 2
- Removal of intracanal medicament
- Cleaning and shaping the canals (more of disinfection and less of shaping)
- Placement of calcium silicate cement amd formation of apical plug
Stage 3
- Obturation of the remainder root canal space using thermoplasticized GP
- Core buildup with resin composite
- Postenedodontic full coverage restoration
15.2.1 Treatment Procedure for the First Appointment
Buccal infiltration anesthesia was administered and the tooth was isolated with rubber dam isolation. The endodontic access cavity was initiated under dental operating microscope (DOM). Once the canal was located, it was irrigated with 3% sodium hypochlorite using IrriFlex (Produits Dentaires, Switzerland). The irrigation needle was chosen due to its flexible design and side vented portal of exits.
The canal was already wide, therefore minimal shaping was decided for this case.The canal was filled with the irrigant and cleaned and shaped with Endoshaper file (FKG Dentaire, Switzerland). This file was chosen due to its three‐dimensional design which can throw the irrigant in every corner of the canal, thus helping in adequate disnfection along with minimal shaping. Intracanl medicament was placed and patient recalled after one week.
15.2.2 Treatment Procedure for the Second Appointment
The second appointment was planned to remove the intracanal medicament and attempt to observe the wide open apex which had blood. (Figure 15.2)
Figure 15.2 Wide open apex under dental operating microscope.
The canal was made dry with paper points and the working length reconfirmed with suitable size endodontic plugger. The plugger was used in order to decide the length which will be 2‐3 mm short of the working length where plugger can condense the apical plug. (Figure 15.3)
Once the length was confirmed, the canal was prepared to receive the calcium silicate cement, Mineral trioxide aggregate (MTA) in this case. Manipulation of MTA was done per the manufacturer’s instructions and micro apical plug, i.e. MAP system (Produits Dentaires, Switzerland), was chosen to be used as a carrier to carry MTA up to the open apex (Video 15.1). 
Immediate postoperative radiograph was taken to check the extension of the apical plug (Figure 15.4).
Temporary dressing was provided and the patient was recalled for obturation of the remaining root canal space.
15.2.3 Treatment Procedure for the Third Appointment
The patient was asymptomatic and it was decided to move ahead with the treatment plan. The decision to obturate the canal with thermoplasticized gutta‐percha (GP) using Fast Fill and Fast Pack systems (Eighteeth, China) was made. The root canal space was filled with increments of melted GP with subsequent condensation with a suitable endodontic plugger (Video 15.2). The final obturation was seen clinically (Figure 15.5) as well as radiographically (Figure 15.6). 
Figure 15.3 PA radiograph with endodontic plugger.
Figure 15.4 Apical plug formation.
Core buildup was done using resin composite and the patient was recalled for post endodontic full coverage restoration.
15.2.3.1 Irrigation Protocol
- 2.5% sodium hypochlorite throughout the cleaning and shaping procedure. Rinse with saline.
- 17% EDTA 1 ml/canal with sonic/ultrasonic activation. Rinse with saline.
- Final rinse with 2.5% sodium hypochlorite with internal heating with any instrument, e.g. Touch’n Heat, and sonic ultrasonic activation for 20–30 seconds per canal.
Flushing with saline between irrigants is a must, as it will stop the irrigants from reacting with each other.
Materials used for obturation: MTA for apical plug, thermoplasticized GP for obturation, resin composite for core buildup.
15.3 Technical Aspects
Traumatic injuries during tooth development can lead to failure in complete root development. In such cases, the root fails to achieve a natural constriction and we often see wide open apices accoumpanied with necrotic pulps. This is generally detected when the patient visits the dentist due to feeling tenderness on eating or intraoral swelling or sinus discharge in relation to those teeth. Wide open apex is observed in the PA. It is the result of the traumatic injury few years back. Regeneration can be an option but for that health periapical tissues are required.
Figure 15.5 Final obturation with thermoplasticised GP.
Figure 15.6 PA radiograph immediately after obturation.
In such cases where apexification is the treatment of choice, the following care should be taken:
- Minimal shaping of the root canals
- Maximum disinfection with recommended irrigation protocol
- Not pushing the irrigant beyond the apex in the periapical area
- Measure the extent to which endodontic plugger should go
- Placement of MTA at an adequate length
- Do not use excessive force and push MTA in the periapical area
- Once MTA is set, fill the root canal space with thermoplasticized GP technique with gentle condensation.
Copious irrigation should be maintained throughout the procedure and endodontic files should not be used in dry canals.
15.3.1 Follow‐up
A six‐month followup radiograph shows significant healing of the periradicular area (Figure 15.7).
Figure 15.7 PA radiograph after core buildup.
15.4 Learning Objectives
The reader should be able to understand the following:
- The significance of proper reading of the preoperative radiograph.
- Relate the radiographic findings with dental history of the patient.
- The treatment plan to manage wide open apex cases.
- The significance of sensibility testing to reach a proper diagnosis.
- The role of irrigants for disinfecting the root canal system.
- The choice of correct shaping technique in cases with weak root canal walls.
- How to choose the correct material for apical plug formation.
- The technique, armamentarium required for apical plug formation.
- The technique needed for filling the root canal space.
- The concepts of understanding the prognosis of the tooth and trying to save the tooth instead of straight away extracting it.
15.5 Conclusion
Traumatic anterior teeth with wide open apex can be suitably managed with regeneration or apexification owing to the indications by the tooth and periapical areas.
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