MTA resorption and periradicular healing in an open-apex incisor: A case report

Periapically Extruded Calcium Silicate Cements in Retreated Teeth: A Case Report and Literature Review

Calcium silicate-based materials, known for their bioactive properties, are increasingly being used in endodontic therapy. Accidental extrusion of these materials into the periapical tissue is a relatively common phenomenon that can impede periapical healing. The aim of this article is to present three endodontically retreated case reports with moderate to extensive periapical lesions and to review the literature on this topic. The comprehensive search and analysis of the relevant literature included a review of 51 articles, of which nine case reports/series from 2010 to 2023 were considered. Based on the summarized data, over 80% of the retreated cases showed complete healing of the periapical lesions, while the success rate in initially treated teeth was over 90%. Healing of periapical lesions is the most common therapeutic outcome, even in cases where extrusion occurs. Despite this conclusion, extrusion of materials into periapical tissues should be avoided. Further case reports on the extrusion of calcium silicate-based materials other than MTA are recommended. When evaluating the success rate of periapical healing in such cases, it is recommended to extend the follow-up periods to several years.

Management and saving a traumatized poor prognosis maxillary central incisor for 18 years: A patient-centered treatment

Key clinical message

With today's increasing desire to preserve natural teeth, managing teeth with a poor prognosis is a new challenge for clinicians. A dentist's attention to patient-centered care is essential, which improves dental outcomes.

Abstract

Nowadays, patients' interest in preserving their natural teeth has increased. In the patient-centered care model, the clinician should consider the patient's preferences and values in the treatment plan. This strengthens the patient's responsibility toward his own body, resulting in more patient satisfaction and effective cooperation. Therefore, the skill of saving teeth with a poor prognosis, in which there was no other choice but to extract them, becomes essential in patients who want to preserve their natural teeth. This case report presents the successful 18-year treatment and management of a maxillary central incisor of a 17-year-old male with a horizontal root fracture, who was incompletely treated in another medical center when the trauma occurred. The patient presented to us after 6 months. Due to the short length of the root, the patient underwent regenerative endodontic treatment first, but he did not attend follow-ups. Finally, after 8 years, the patient returned with symptoms of infection and periapical radiolucency. The apical part of the root was resorbed during this time. Finally, it was decided to place an apical plug with MTA. MTA was extruded from the apical part of the root canal during the placement of the apical plug. In the 1-, 2-, 4-, and 10-year follow-ups, the patient was completely asymptomatic, and the radiolucent periradicular lesion had healed. However, the extruded MTA was still present in the radiographic images without interfering with the healing process. Finally, the tooth has remained functional for 18 years.

Nonsurgical Endodontic Management of Large Periapical Lesion with Cold Ceramic: A Literature Review and Case Series

Introduction

The purpose of this review is to investigate the contribution of non-surgical endodontic treatment in the healing process of large periapical lesions as well as looking over other potential non-surgical endodontic treatment options.

Materials and Methods

two females and one male patient were referred to the private office, complaining of having pain in the anterior maxillary region which was pertinent to the presence of a large periapical lesion, and subsequently were managed by a non-surgical endodontic approach using cold ceramic. The archive of PubMed and Google Scholar databases was also searched for finding relevant articles in which a nonsurgical endodontic approach was performed to improve the healing process of large periapical lesions.

Results

Clinical examination of the case series subjects revealed no signs and symptoms following treatment while relative improvement of the lesion and apical closure was apparent in radiographs 7 months, 9 months, and 4 years subsequently. In twenty-two reviewed clinical trials, a total number of 107 teeth with large periapical lesions were treated by nonsurgical endodontic approaches using MTA, biodentine, gutta-percha, and bioceramic iRoot Bp plus. Complete healing occurred in 38 cases (35.5%) after 12-17 months.

Conclusions

Although surgical interventions have been used previously in the management of large periapical lesions, a nonsurgical endodontic approach with cold ceramic seems to be effective, leading to complete healing of the periapical lesion in treated subjects. Further clinical research is recommended to identify the effectiveness of cold ceramic for the treatment of extensive periapical lesions.

Clinical outcome of bioceramic sealer iRoot SP extrusion in root canal treatment: a retrospective analysis

Background

During the obturation procedure, sealer extrusion occurs in some cases. iRoot SP is a kind of bioceramic sealer with superior physicochemical and biological properties. This article reports the outcome of iRoot SP extrusion in root canal treatment and the potential factors associated with the outcome.

Methods

Ninety-nine patients and one hundred and eighty-five teeth treated between 2014 and 2020 were included in this retrospective study. All of the cases were filled with a single-cone technique and the iRoot SP sealer. The minimum follow-up visit period was 1 year. The outcome was evaluated by clinical examination and radiographic examination at recall and was classified as healed, healing (success), or not healed (failure).

Results

The overall success rate of all teeth was 96.8%. The success rate of adequately filled teeth was 97.3%, while that of iRoot SP extrusion was 95.8%; the difference was not statistically significant. Factors such as gender, age, tooth position, follow-up visit period, size of periapical lesion, treatment type and extruding sealer amount had no influence on the outcome of iRoot SP extruded teeth.

Conclusions

The results suggested that iRoot SP extrusion has no adverse effect on the outcome of root canal treatment, which may contribute to the endodontic treatment.

What is the best long-term treatment modality for immature permanent teeth with pulp necrosis and apical periodontitis?

PURPOSE

To evaluate and assess the current knowledge about apexification and regenerative techniques as a meaningful treatment modality and to map the scientific evidence for the efficacy of both methods for the management of traumatised immature teeth with pulp necrosis and apical periodontitis.

METHODS

This systematic review searched five databases: PubMed, Web of Science, Cochrane Library, Ovid (Medline), and Embase. Published articles written in English were considered for inclusion. The following keywords were used: Regenerative endodontic treatment OR regenerat* OR revital* OR endodontic regeneration OR regenerative endodontics OR pulp revascularization OR revasculari* OR 'traumatized immature teeth'. Only peer-reviewed studies with a study size of at least 20 cases followed up for 24 months were included. Eligibility assessment was performed independently in a blinded manner by three reviewers and disagreements were resolved by consensus. Subgroup analyses were performed on three clinical outcomes: survival, success, and continued root development.

RESULTS

Seven full texts out of 1359 citations were included and conventional content analysis was performed. Most of the identified citations were case reports and case series.

CONCLUSIONS

In the present systematic review, the qualitative analysis revealed that both regenerative and apexification techniques had equal rates of success and survival and proved to be effective in the treatment of immature necrotic permanent teeth. Endodontic regenerative techniques appear to be superior to apexification techniques in terms of stimulation of root maturation, i.e. root wall thickening and root lengthening. Knowledge gaps were identified regarding the treatment and follow-up protocols for both techniques.

Evaluation of different Apexification treatments of teeth with immature apices and apical periodontitis on the fractal dimensions of trabecular bone

The aim of the present study was to investigate in the fractal dimension (FD) time-dependent changes of periapical bone after two different apexification treatments in teeth with immature apices and apical periodontitis. This study included 55 cases treated with apexification. Cases were divided into two groups: a calcium hydroxide group and a mineral trioxide aggregate group. In each case, the lesion area was evaluated by fractal analysis on periapical radiographs obtained before and 1-year after treatment via Image-J program. The FD of each region of interest on the radiographs was calculated using the fractal analysis method. The data were statistically analysed. In both groups, the FD values increased compare to initial at 1-year follow-up after treatment (P < .05). There was no statistically significant difference between the groups in terms of the time-dependent increase in FD values (P = 0.118). In the present study, time-dependent changes in FD were independent of the apexification method.

Successful Use of MTA Fillapex as a Sealant for Feline Root Canal Therapy of 50 Canines in 37 Cats

Intentional or unintentional pulp exposure of cat canines can lead to periapical disease, osteomyelitis, and oral pain. Root canal therapy (RCT) allows the retention of cat canines with pulp exposure by removing the infected pulp and replacing it with an inert material. This study used MTA Fillapex™ as a root canal sealant with gutta percha single cone obturation in 37 cats (50 canine teeth). Roots were classified as "successful," "no evidence of failure (NEF)," or "failed" at 6-month radiographic reviews. Therapy was considered "successful" if a preoperative periapical lucency had healed or not formed after treatment and any preoperative external inflammatory root resorption (EIRR) had stabilized without progression. Therapy was categorized as "NEF" if a periapical lucency had remained the same or decreased in size but not completely resolved and any preoperative EIRR had stabilized without progression. "Failed" if a periapical lucency had occurred or increased in size posttreatment or if EIRR had developed or progressed posttreatment. Thirty-two canine teeth (64%) were classified as "successful," 14 canine teeth (28%) were classified as "NEF," and 4 canine teeth (8%) were classified as "failed". The study concluded that RCT using MTA Fillapex as a root canal sealant is a suitable endodontic treatment for fractured cat canines, especially those that are periodontally or endodontically challenged.

Periodontal healing following non-surgical repair of an old perforation with pocket formation and oral communication

Iatrogenic perforations negatively impact the outcome of endodontic treatments. Studies on prognostic factors showed that perforations in the coronal third of the root with periodontal pocket formation have an unfavorable prognosis. A 36-year-old female was referred for endodontic evaluation of tooth #13 with a history of an iatrogenic perforation, happened 3 years ago. There was a sinus tract associated with perforation, 10 mm probing on the mesial and mesio-palatal, bleeding on probing, radiolucent lesion adjacent to the perforation and complete resorption of the interdental bone between teeth #13 and #12. After the treatment options were discussed, she chose to save the tooth. The tooth was accessed under rubber dam isolation, the perforation site was cleaned and disinfected using 0.5% sodium hypochlorite and sealed with calcium-enriched mixture cement. Eighteen months after treatment the tooth was functional and asymptomatic. The probing depths were normal without bleeding on probing. Radiographically, the interdental crestal bone formed between teeth #13 and #12. Despite all negative prognostic factors in this case (i.e., perforations in the coronal third, pocket formation, and radiolucent lesion), healing was unexpectedly achieved via non-surgical repair of the perforation. Further research on biological aspects of healing in the periodontium following iatrogenic perforations are recommended.

Double Antibiotic Paste for Management of External Inflammatory Root Resorption

External inflammatory root resorption (EIRR) is one of the common complications following dental trauma which when remained untreated, may lead to tooth loss. Successful treatment outcomes depend on elimination of bacteria from root canal system and apical sealing. This case presents the endodontic management of an EIRR that was nonresponsive to calcium hydroxide (CH) therapy. An 11-year-old boy was referred for management of a traumatized maxillary central incisor. Tooth #8 was symptom-free, nonresponsive to vitality pulp tests and had an immature root with sever EIRR. Using chemomechanical debridement and CH dressing, the treatment was initiated. The tooth was remained asymptomatic; however, after five weeks the size of periradicular lesion increased and intracanal exudate was present, signifying a resistant endodontic infection. In second appointment, double antibiotic paste (DAP; ciprofloxacin/metronidazole) was applied to the canal. Eight weeks later, the tooth continued to be asymptomatic and the size of the lesion decreased. Finally, the root canal was entirely obturated with calcium-enriched mixture (CEM). At 18-month follow-up, the tooth was asymptomatic/functional, EIRR did not further progress and tooth discoloration was not observed. Based on the results, DAP has the potential to be used to manage the CH-resistant endodontic infection. Furthermore, CEM root filling/sealing seems to be an applicable choice in EIRR management.

Retrospective evaluation of healing of periapical lesions after unintentional extrusion of mineral trioxide aggregate

BACKGROUND

During the apexification procedure for teeth with open apices, mineral trioxide aggregate (MTA) may be unintentionally extruded. The aim of the present study was the retrospective evaluation of the healing of periapical lesions in permanent incisor teeth with open apices after the unintentional extrusion of MTA.

METHODS

The clinical and radiographic records of 55 maxillary permanent central teeth treated by MTA apexification were evaluated. Filled teeth with unintentionally extruded MTA were selected as group 1 (n = 21), whereas the teeth with no MTA extrusion were selected as group 2 (n = 34). For each tooth, the clinical and radiographic records from a 3-year follow-up were investigated.

RESULTS

Complete healing (CH) was observed in 19 teeth (90.4%) in group 1, whereas the same type of healing was observed in all 34 teeth (100%) in group 2 (p>0.05). At the 6-month follow-up appointment, 25 teeth (73.5%) showed CH in group 2, whereas 15 teeth (71.4%) showed CH at the 1-year follow-up in group 1 (p<0.001). At the end of the 3-year follow-up period, the amount of MTA extrusion was reduced in 17 teeth (85%) (p<0.05), whereas it was almost absent in 2 teeth (10%).

CONCLUSIONS

The unintentional extrusion of MTA does not prevent the healing of periapical lesions, but may be a delaying factor for periapical healing.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

Long-term Success of Nonvital, Immature Permanent Incisors Treated With a Mineral Trioxide Aggregate Plug and Adhesive Restorations: A Case Series from a Private Endodontic Practice

This case series evaluated the long-term clinical outcome of nonvital immature teeth treated with mineral trioxide aggregate (MTA) as an apical barrier and an adhesive restoration with or without a fiber post. Eighty-three teeth in 72 patients were treated by the first author with an apical MTA plug and an adhesive restoration of composite resin and in 45 of the 83 teeth 1 or more fiber posts. All of the patients had been referred to the first author's private endodontic practice with at least 1 immature tooth with signs of pulpal necrosis and subsequent apical periodontitis that had been caused by a variety of traumatic dental injuries. Three teeth presented had dens invaginatus. Of 83 teeth, 69 teeth in 60 patients were available for follow-up after 5 to 15 years (recall rate = 83%). The mean follow-up time was 8.29 years. No teeth were lost because of a root fracture. Ninety-six percent (66/69) of the recalled teeth were characterized as healed. Based on periapical radiographs and clinical examination, 96% of teeth treated with the MTA barrier technique and adhesive restorations were characterized as "healed" and were in function after 5 to 15 years (mean = 8.29 years). These results indicate that this is a viable and predictable treatment approach for the long-term success of nonvital immature teeth.

The Effect of Mineral Trioxide Aggregate on the Periapical Tissues after Unintentional Extrusion beyond the Apical Foramen

Introduction. Single-step apexification procedures using mineral trioxide aggregate (MTA) have been reported as favorable treatment options for teeth with an open apex, posing greater benefits compared to the other available medicaments. However, controlled apical placement of MTA is a challenging procedure to perform using orthograde approach. This case series describes the outcome of the unintentional extrusion of MTA into periradicular tissues during apexification, in three separate cases. Methods. Three adult patients reported to the Department of Conservative Dentistry and Endodontics for the management of maxillary incisors with open apices. After isolation, conventional access, and cleaning and shaping procedures, one-step MTA apexification was performed. On subsequent radiographs, a considerable amount of MTA was seen to be extruded in all the three cases. Results. During follow-up examination the teeth were seen to be asymptomatic in all cases and radiographically demonstrated repair of the periapical lesion. Conclusion. The results of these cases suggest that extrusion of MTA into the periapical tissues does not cause any detrimental effect, which could be attributed to the biologic properties of MTA.

Surgical management of a failed internal root resorption treatment: a histological and clinical report

This article presents the successful surgical management of a failed mineral trioxide aggregate (MTA) orthograde obturation of a tooth with a history of impact trauma and perforated internal root resorption. A symptomatic maxillary lateral incisor with a history of perforation due to internal root resorption and nonsurgical repair using MTA was referred. Unintentional overfill of the defect with MTA had occurred 4 yr before the initial visit. The excess MTA had since disappeared, and a radiolucent lesion adjacent to the perforation site was evident radiographically. Surgical endodontic retreatment was performed using calcium enriched mixture (CEM) cement as a repair material. Histological examination of the lesion revealed granulation tissue with chronic inflammation, and small fragments of MTA encapsulated within fibroconnective tissue. At the one and two year follow up exams, all signs and symptoms of disease had resolved and the tooth was functional. Complete radiographic healing of the lesion was observed two years after the initial visit. This case report illustrates how the selection of an appropriate approach to treatment of a perforation can affect the long term prognosis of a tooth. In addition, extrusion of MTA into a periradicular lesion should be avoided.

Cone Beam Computed Tomography Evaluation of the Periapical Status of Nonvital Tooth with Open Apex Obturated with Mineral Trioxide Aggregate: A Case Report

Management of a tooth with open apex is a challenge to the dental practitioners. Evaluation of the periapical healing is required in such cases by radiographic techniques. The objective of this paper was to assess the healing of a periapical lesion in a non-vital tooth with open apex treated with mineral trioxide aggregate (MTA) obturation using cone beam computed tomography (CBCT). The endodontic treatment of a fractured non-vital discolored maxillary left lateral incisor with an open apex was done with MTA obturation. The clinical and radiographic followup done regularly showed that the tooth was clinically asymptomatic and that the size of the periapical lesion observed by intraoral periapical (IOPA) radiographs and CBCT was decreased remarkably after two years. CBCT and IOPA radiographs were found to be useful radiographic tools to assess the healing of a large periapical lesion in a non-vital tooth with open apex managed by MTA obturation.