Precision at the apex: Apexification under magnification: A case report

Abstract

BACKGROUND

Advanced materials and techniques are used to successfully manage the apexification of immature teeth with open apices. The use of mineral trioxide aggregate (MTA), bioceramic sealers, and sodium hypochlorite (NaOCl), combined with internal heating and ultrasonic activation, ensures that canals are cleaned, disinfected, and sealed properly. Magnification devices, such as dental operating microscopes (DOM), provide precise visualization for accurate material placement, while the micro apical placement system ensures void-free MTA delivery. This modern approach improves procedural outcomes, lowers iatrogenic errors, and increases long-term success in apexification, making it a dependable and predictable treatment option for immature teeth.

CASE SUMMARY

Apexification is a regenerative endodontic procedure that involves creating a calcified barrier at the apex of a nonvital tooth with an open apex. This technique is commonly used in immature teeth with necrotic pulps to ensure proper root canal sealing. Traditionally, calcium hydroxide was the preferred material, but advances have introduced bioceramic cements like MTA or Biodentine, which provide superior results with less treatment time. Apexification not only helps to maintain the tooth's structural integrity but also prevents further complications, making it an important procedure in such cases.

CONCLUSION

This case demonstrates the effectiveness of integrating advanced materials, precise irrigation protocols, and magnification tools in the apexification of immature teeth with open apices. The use of MTA created a stable apical barrier, while bioceramic sealers enhanced the seal and promoted long-term healing. NaOCl with internal heating, ultrasonic activation, and double-sided vented needles ensured thorough irrigation and disinfection, especially in complex canal anatomy.

Key Words: Bioceramics; Magnification; Mineral trioxide aggregate; Apexification; Irrigation; Case report

Core Tip: Advanced materials and techniques are used to successfully manage the apexification of immature teeth with open apices. The use of mineral trioxide aggregate (MTA), bioceramic sealers, and sodium hypochlorite, combined with internal heating activation, ensures that canals are cleaned, disinfected, and sealed properly. Magnification devices, such as dental operating microscopes, provide precise visualization for accurate material placement, while the micro apical placement system ensures void-free MTA delivery. This modern approach improves procedural outcomes, lowers iatrogenic errors, and increases long-term success in apexification, making it a dependable and predictable treatment option for immature teeth.

INTRODUCTION

Apexification is a specialized pediatric procedure aimed at managing immature teeth with necrotic pulp and open apices, often caused by trauma, caries, or pulp pathosis. The procedure focuses on inducing the formation of a calcified apical barrier, enabling proper sealing and long-term retention of the affected tooth[1]. Historically, calcium hydroxide was the material of choice for apexification due to its ability to stimulate the formation of hard tissue barriers[2]. However, its use necessitated a longer treatment period and multiple visits, increasing the risk of root fractures and patient noncompliance. These limitations paved the way for the adoption of bioactive materials like mineral trioxide aggregate (MTA), biodentine (Septodont, Saint-Maur-des-Fosses, France), and bioceramic putty as a superior alternative[3].

MTA has revolutionized apexification due to its exceptional biocompatibility, sealing ability, and capacity to promote cementogenesis and osteogenesis. Unlike calcium hydroxide, MTA provides predictable results in a much shorter amount of time and improves the long-term prognosis of immature teeth[4]. It creates a strong apical barrier that effectively seals the root canal system and prevents bacterial infiltration. Furthermore, its ability to promote periapical healing and stimulate hard tissue deposition has made it the preferred material for apexification procedures[5].

The use of advanced magnification devices, such as dental operating microscopes (DOMs), has increased the precision and efficacy of apexification. Magnification is essential for identifying the complex anatomy of immature teeth with open apices, which frequently exhibit irregularities or resorption[6]. The use of DOMs provides clinicians with unparalleled visualization, allowing for meticulous canal debridement, accurate apical defect assessment, and precise MTA placement. This level of precision minimizes procedural errors like overfilling and void formation, both of which can jeopardize the outcome[7].

In the context of apexification, the combination of MTA and magnification results in superior clinical outcomes. MTA's regenerative properties, combined with the increased accuracy provided by DOMs, allow for optimal apical barrier formation even in difficult cases[8]. This combination has significantly improved the predictability and success rate of apexification procedures, allowing teeth to be saved that would otherwise be extracted[9]. This case report demonstrates the successful management of an open apex with MTA under magnification, highlighting the importance of these advancements in modern pediatric and endodontic practice.

CASE PRESENTATION

Chief complaints

A 13-year-old female patient presented with severe pain and discomfort in her upper front tooth, which had persisted for the previous 2 months following trauma 2 years prior.

History of present illness

The pain was described as spontaneous, intermittent, and aggravated by biting and thermal stimuli. The patient's discomfort had progressively worsened, limiting her ability to eat and speak comfortably.

Upon further investigation, the patient stated that he had noticed occasional swelling and the presence of a sinus tract near the affected teeth in the previous few weeks. There was no history of fever or underlying illness. The patient had not taken any pain relievers before coming to the clinic.

History of past illness

The patient described a dental trauma that occurred approximately two years ago, resulting in an injury to the maxillary central incisors (teeth #11 and #21). There was no immediate treatment sought, and the teeth remained asymptomatic until two months ago, when pain began.

Personal and family history

No family history.

Physical examination

Clinical examination revealed an Ellis class IV fracture of the permanent maxillary right and left central incisor, i.e., 11, 21, which was accompanied by a sinus tract near the root apex. The teeth did not respond to electric or thermal pulp sensibility tests.

Laboratory examinations

None.

Imaging examinations

A radiographic examination revealed a blunderbuss canal and a periapical lesion for both teeth.

FINAL DIAGNOSIS

Based on these findings, a periapical abscess wrt 11 and 21 was diagnosed.

TREATMENT

Following a discussion of various treatment options, it was decided to proceed with apexification using MTA wrt 11 and 21 under magnification, followed by cast post and zirconia crowns wrt 11 and 21. Rubber dam isolation was done on 11 and 21, and an access cavity was created on both teeth (Figure 1). A #80H file (Mani, Prime Dental Product Pvt. Ltd., India) (Figure 2) was used to determine the working length, while JIZAI (Mani, Prime Dental Product Pvt. Ltd., India) rotary files were used for canal instrumentation. The canal was then thoroughly cleaned with mechanical instruments and extensively irrigated with 2.5% sodium hypochlorite (NaOCl) (Bharat Chemical, India) administered through a 30 G double-sided vented needle (Master Clean, Amplemeds, India). Internal heating at 180 degrees Celsius for 5 seconds and ultrasonic activation was done to improve canal disinfection.

Figure 1 Shows access cavities. A: Wrt 11; B: Wrt 12.

Figure 2 Shows the working length wrt 11 and 21.

The canal was irrigated again with NaOCl (Bharat Chemical, India), followed by 17% EDTA to remove the smear layer. To control bleeding, a collagen sponge (Hemospon; Technew, Rio de Janeiro, Brazil) was placed in the apical third of the canal, and MTA (BioStructure, SafeEndo, India) was placed (Figure 3) incrementally using the micro-apical placement (MAP) system (Produits Dentaires SA, Vevey, Switzerland) under magnification. Each increment of MTA was condensed using a paper point (Diadent, Chungju, Korea) and a pre-fitted plugger (Meta Biomed, Chungcheongbuk-do, Korea) to form a 5 mm apical plug. Radiographs were taken to confirm MTA's precise placement at the apex (Figure 4)

Figure 3 Shows the clinal picture of mineral trioxide aggregate placement. A: Under magnification at 16×; B: Under magnification at 20×.

Figure 4 Shows the radiographs of 5 mm mineral trioxide aggregate plug.

After the initial set, moist cotton was placed over the MTA plug, and the patient was recalled after 24 hours. The cast post impressions were made (Figure 5) with the help of wax wrt 11 and 21. Then, after 1 week, the cast posts were cemented, a radiograph was taken (Figure 6), and crown preparations were done wrt 11 and 21, followed by crown cementation after 1 week (Figure 7).

Figure 5 Shows the cast post-impression clinically and radiographically. A: Clinical pictures show the cast post impressions; B: Radiographically showing show the cast post impressions.

Figure 6 Shows the radiograph of cast post cementation.

Figure 7 Shows the clinical picture. A: Cast post cementation; B: zirconia crown cementation

OUTCOME AND FOLLOW-UP

At follow-up visits, the patient remained asymptomatic, and radiographs at 3, 6, and 12 months (Figure 8) revealed significant healing of the periapical lesion.

Figure 8 Shows radiograph. A: 3 months follow up; B: 6 months follow up; C: 1 year follow up.

DISCUSSION

Apexification in immature teeth with open apices is a technically challenging procedure due to the lack of a natural apical barrier, irregular root canal anatomy, and high risk of microbial invasion[10]. This case demonstrates the use of advanced materials, precise irrigation protocols, magnification, and delivery systems, such as the MAP system, to achieve a predictable and successful clinical result[11].

MTA remains the primary apexification material, providing biocompatibility, superior sealing properties, and the ability to induce hard tissue formation. Its application in this case resulted in a strong apical barrier, which prevented reinfection and promoted periapical healing[12]. In addition to MTA, the use of a bioceramic sealer improved the seal and ensured the canal system's hermetic seal. Bioceramic sealers are well-known for their excellent adhesion, dentin bonding ability, and bioactivity, all of which contribute to long-term success by preventing microleakage and encouraging tissue regeneration[13].

Apexification relies heavily on apical seal and efficient irrigation systems. NaOCl, the gold standard irrigant, was used because of its ability to dissolve necrotic tissue while also eliminating microbial biofilms[14]. In this case, activation and internal heating of NaOCl at 180 degrees Celsius for 5 seconds under magnification increased its efficacy, allowing for thorough disinfection of the canal system, especially in the intricate apical anatomy[15]. The use of double-sided vented irrigation needles improved irrigant distribution and penetration, resulting in thorough cleaning while lowering the risk of extrusion. The combination of NaOCl, advanced irrigation techniques, and magnification ensured that all inaccessible areas were adequately debrided, resulting in an ideal environment for healing[16].

Magnification was essential throughout the procedure, allowing the clinician to see the intricate details of the canal system and apical defect. The DOM enabled the precise removal of necrotic tissue, accurate assessment of the defect, and meticulous placement of MTA[17]. The MAP system helped to deliver MTA incrementally and without voids, ensuring precise adaptation to the desired area. This method reduced procedural errors and improved the stability of the apical barrier[18].

The use of advanced materials and technologies (MTA, bioceramic sealer, NaOCl with internal heating activation, double-sided vented needles, magnification, and the MAP system) demonstrates a modern, comprehensive approach to apexification. This case demonstrates how these innovations address the challenges of managing open apices while also improving procedural efficiency and clinical outcomes, paving the way for predictable and patient-centered endodontic care[19].

CONCLUSION

This case demonstrates the effectiveness of integrating advanced materials, precise irrigation protocols, and magnification in the apexification of immature teeth with open apices. The use of MTA created a stable apical barrier, while bioceramic sealers enhanced the seal and promoted long-term healing. NaOCl with internal heating, ultrasonic activation, and double-sided vented needles ensured thorough irrigation and disinfection, especially in complex canal anatomy. Magnification tools, particularly the DOM, allowed for precise visualization, careful tissue removal, and accurate placement of MTA. The MAP system facilitated void-free delivery of MTA, optimizing treatment outcomes.

Overall, combining these technologies has revolutionized apexification, improving procedural efficiency and clinical success. The use of these advanced techniques reduces the risk of iatrogenic errors, enhances material adaptation, and ensures long-term tooth preservation. This case emphasizes the importance of a modern, comprehensive approach to apexification in achieving predictable and successful results.