|Year : 2014 | Volume
| Issue : 1 | Page : 14-20
Membrane-assisted mineral trioxide aggregate apical plug for management of traumatized immature anterior teeth: Clinical case reports
Raji Viola Solomon, Parupalli karunakar, Sevvana Sree Soumya, Puppala Siddhartha
Department of Conservative Dentistry and Endodontics, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, Telangana, India
|Date of Web Publication||5-Sep-2014|
Sevvana Sree Soumya
Department of Conservative Dentistry and Endodontics, Panineeya Mahavidyalaya Institute of Dental Sciences, Kamala Nagar, Dilsuknagar, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Apexification using calcium hydroxide has many disadvantages, such as, it needs more time for the treatment, chance for fracture of the tooth, and incomplete calcification of the bridge. There are many alternative treatments introduced, which have gained popularity, such as, forming an apical plug using mineral trioxide aggregate (MTA), for excellent results. In cases of wide open apices, it is difficult to limit the restoration to the working length, as such situations lead to the apical extrusion of the material into the periapical region, which prevents further healing. Such conditions can be best treated with the use of a resorbable collagen membrane, which limits the restoration till the working length and prevents the extrusion of the material beyond the apex. The present case reports highlight the non-surgical management of immature teeth by using a membrane as a barrier, with an MTA apical plug, followed by crown rehabilitation.
Keywords: Apexification, collagen membrane, MTA, regeneration
|How to cite this article:|
Solomon RV, karunakar P, Soumya SS, Siddhartha P. Membrane-assisted mineral trioxide aggregate apical plug for management of traumatized immature anterior teeth: Clinical case reports. J Oral Res Rev 2014;6:14-20
|How to cite this URL:|
Solomon RV, karunakar P, Soumya SS, Siddhartha P. Membrane-assisted mineral trioxide aggregate apical plug for management of traumatized immature anterior teeth: Clinical case reports. J Oral Res Rev [serial online] 2014 [cited 2019 Jan 23];6:14-20. Available from: http://www.jorr.org/text.asp?2014/6/1/14/140198
| Introduction|| |
Dental injuries are the most common problems addressed by children within the age group of six to twelve years. The highest rate of these injuries occurs before complete root development and ends in inflammation and pulpal necrosis in most of the cases. 
Hertwigs epithelial root sheath helps in complete root development. Injury to this protective sheath leads to further cessation of root development. Cases with incomplete root development show roots with open apices that need to be sealed with the formation of a hard tissue barrier, to prevent bacterial infection and to create a suitable environment for the formation of a calcified tissue in the apical area.
Apexification is defined as, 'a method of inducing a calcific barrier in a root with an open apex or the continued apical development of an incomplete formed root in the teeth with necrotic pulp'.  A three-dimensional obturation and complete disinfection of the root canal system plays a key role for successful endodontic therapy. Earlier, calcium hydroxide was the choice of material and many other techniques were used like collagen, calcium phosphate, osteogenic protein, bone growth factor, and oxidized cellulose. 
Calcium hydroxide as a treatment of choice possesses few disadvantages like multiple appointments and poor patient compliance, and long-term application of calcium hydroxide decreases the fracture resistance of the tooth.  The nature of the barrier formed with calcium hydroxide is incompletely calcified and porous.  Apexification using MTA as a choice of material has many advantages, as it does not weaken the dentin and it sets in a moist environment and long-term appointments are not required.
Torbinejad et al. 1995, stated that it is the most biocompatible, has the highest sealing capacity, and induces cell growth. 
It is not possible to confine MTA within the apical third in case of CVEK stage 1, 2 and 3, wherein, it has to be complemented with the membrane [Figure 1].
The collagen membrane is filled into the bone defect in the periapical area, which not only creates a roof to obstruct the extrusion of the MTA, but also hinders the invasion of unwanted cells types, thus allowing the preferred cells to grow into the bone defect.  This further helps in the healing of the periapical tissues and further bone regeneration.
The purpose of this article was to present cases with necrotic pulp and open the apices treated using MTA and the collagen membrane for regeneration and obstruction of MTA beyond the apex.
| Case Reports|| |
Case report 1
A 23-year-old male patient had reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of a fractured and discolored tooth, with relation to 11, with a history of trauma at the age of nine [Figure 2]. The concerned tooth did not respond to vitality when using the heat and electric test. A detailed radiographic examination revealed a large open apex with associated per apical lesion in relation to the maxillary right central incisor [Figure 3].
There are two treatment options either surgical removal of the perapical lesion and retrograde filling or non-surgical root canal treatment followed by MTA (Dental Tulsa DENTSPLY, DeTrey, Germany) apical plug, which is Apexification. Taking into consideration the age of the patient and the need for limiting the restoration within the apex and formation of the lost bone structure, a non-surgical treatment with the collagen membrane was opted for. The access opening was prepared and the working length was determined [Figure 4].
Biomechanical preparation was done using the conventional technique. Copious irrigation was done using 2.5% sodium hypochlorite (NaOCl) and saline alternately. Calcium hydroxide dressing was placed and the patient was recalled after one week. The root canal was found to be dry at subsequent appointments and the canal was debrided with 2.5% NaOCl followed by 17% Ethylenediaminetetraacetic acid (EDTA), and a final rinse with 2% chlorohexidene. Using paper points the canal was dried and the GTR Collagen membrane (HEALIGUIDE/Biotech products, ENCOLL Fermont, CA, USA) was cut into suitable pieces, placed in the periapical region using hand plugger till the working length until a hard obstruction was gained [Figure 5].
The MTA was placed in the canal using the MTA carrier [Figure 6]. Subsequent increments were placed and condensed with hand pluggers till a thickness of 4 mm was attained [Figure 7]. A wet cotton pellet was placed and the access was sealed with temporary cement. In the subsequent appointment the temporary cement was removed and obturation was done using thermoplastisized gutta percha (Obtura/Spartan, Fenton, MO, USA) [Figure 8].
In the next appointment, composite build-up [Figure 9] was done, followed by crown preparation [Figure 10], and the upper and lower impressions were taken. Crown cementation was done in the subsequent appointment [Figure 11]. The periapical radiograph was taken at the end of the first year of treatment, which showed reduction in the size of the periapical lesion [Figure 12].
|Figure 5: Collagen membrane placed beyond the apex till the working length|
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|Figure 12: One-year follow-up, with reduced size of the periapical lesion|
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Case report 2
A 20-year-old female patient has reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of fractured tooth with relation to 21, with a history of trauma at the age of nine [Figure 13]. The concerned tooth did not respond to vitality when using the heat and electric test. A detailed radiographic examination revealed a large open apex with an associated periapical lesion in relation to the maxillary left central incisor [Figure 14].
There are two treatment options either surgical removal of the periapical lesion and retrograde filling or non-surgical root canal treatment followed by the MTA apical plug, which is Apexification. Taking into consideration the age of the patient, a non-surgical treatment was opted for the access opening was prepared and the working length was determined [Figure 15]. The biomechanical preparation and irrigation protocol was similar to case report 1.
Similar to the first case report, the collagen membrane was placed, to prevent extrusion of the MTA beyond the apex. Later the MTA was placed in the canal using the MTA carrier. The subsequent increments were placed and condensed with hand pluggers till a thickness of 4 mm was attained and the extension of the apical plug and collagen membrane was verified radiographically [Figure 16].
A wet cotton pellet was placed and the access was sealed with temporary cement.
After a week, the temporary cement and cotton pellet were removed and the setting of MTA was gently tested. The canal was reinforced with a fiber post and a core was built with reinforced Composite resin [Figure 17]. Subsequently, the crown preparation was done [Figure 18] and [Figure 19] and finally a metal ceramic crown was cemented [Figure 20].
A periapical radiograph was taken at the end of the first year, which showed a reduction in the size of the periapical lesion, with closure of the apex [Figure 21]. The patient was recorded to be asymptomatic and completely satisfied with the treatment.
| Disscussion|| |
Dental trauma has become a major problem in dentistry, which is seen more in the age group of five to ten years. The end result of these traumas are pulp necrosis.  The pulp necrosis of immature permanent teeth creates an interruption for further root formation and apical closure. In such situations it is always necessary to implement a therapy called Apexification, to create a hard calcific barrier at the apical end of the root. 
The major disadvantage with calcium hydroxide associated with Apexification is its treatment period, which is about three to twenty-one months, and the structure formed with it is more porous.  It has other disadvantages like failure to control infection and every chance of reinfection because of a temporary seal, and cervical fracture. 
Apexification using MTA acts as a primary monoblock. The MTA fills the gap produced during material shrinkage by formation of Appetite-like interfacial deposits. The non-bonding and gap-filling appetite crystals create a seal of MTA.  MTA has superior properties - it is less cytotoxic due to its high alkaline pH and is highly biocompatible.  It has the capacity to release calcium and phosphate ions, which activate the blastic cells, which help in the formation of a barrier  and even set in a wet environment.
A wide open apex has difficulty in limiting the restorative material to the apex and in preventing it from extruding into the periodontal tissues. On account of lack of disintegration and resorption, extrusion of these materials into the periodontal tissues leads to persistence of the inflammatory process and prevents the repair of the tissue. A major problem in cases of a wide open apex is the need to limit the material to the apex, thus avoiding the extrusion of a large amount of material into the periodontal tissue. 
Lemon advocated the use of a matrix when the perforation diameter was larger than 1 mm, to avoid extrusion of the sealing material.  The use of a matrix was advisable, as its placement in the area of bone destruction provided a base on which the sealing material, especially MTA, could be placed and packed.
Using a matrix avoids the extrusion of the material into the periodontal tissues, reduces leakage in the sealing material, and allows favorable response of the periodontal tissues. Various materials have been used for the formation of matrix, like, calcium hydroxide, hydroxyapatite, a collagen membrane and calcium sulfate. 
The important properties that are needed for selection of a barrier membrane include biocompatibility, cell occlusivity, tissue integration, space making effect, and clinical manageability. Two types of membranes are used for barrier formation, synthetic non-resorbable membranes and synthetic resorbable membranes. Non-resorbable membranes have all the superior properties like porosity, strength, and flexibility, but the reason for it not being preferred is its non-resorbable property, where its needs to be surgically removed (Gotfredsen et al. 1993; Becker et al. 1994; Simion et al. 1994). , It also causes patient discomfort, increased cost, and possibly suboptimal bone regeneration.
Absorbable membranes are made of collagen or of poly-glycolic acid, polylactic acid or copolymers (Hutmacher et al. 1996; Wang and MacNeil 1998). These collagen membranes are mechanically malleable, adaptable, and easy to manipulate, which may be beneﬁcial in clinical application. Other advantageous properties of collagen include hemostatic function, semi-permeability, allowing nutrient passage, natural enzymatic degradation, and chemotactic ability to attract ﬁbroblasts. 
Even in wet or dry states resorbable membranes have superior tear strength and tear propagation resistance. The collagen membrane has a hydrophilic property, where, in a wet state, its exhibits good adherence, allowing various layers to stick to each other. When moist the membrane is more elastic, which allows adequate covering of irregular or uneven surfaces gained due to loss of bone at the periapical region.
These collagen membranes can be cut into the required shapes and placed easily into the bony spaces created due to loss of bony structure in the periapical area. In the present study, a resorbable collagen membrane has been used for effective obstruction of MTA beyond the apex and to create an environment for further bone formation. 
A barrier of 4 to 5 mm provides adequate strength and an effective seal with limited leakage when compared with a barrier of 2 to 3 mm.  There is a relatively high incidence of fracture in teeth treated with Apexification, because of thin dentinal walls. Efforts should be made to strengthen the immature root. In the present case report after preparation for the access was done, the working length was determined using a k-file and not the apex locaters, as they have been reported to give inaccurate results.
Instrumentation was done up to 80 k-file circumferentially, without applying excess pressure, to prevent fracture of the thin dentinal walls. Water-based calcium hydroxide was placed into the canal to ensure complete disinfection, after which a 4 mm MTA plug was placed to form a hard barrier, which could help to accommodate obturation. Obturation was completed with thermoplastisized gutta percha, which did not need compaction force to prevent fracture of the thin dentinal walls.
Hachmeister et al. have reported that a more favorable long-term prognosis for pulpless immature teeth can be achieved with the MTA Apexification procedure followed by internal bonding with resin materials. The combination of Apexification and subsequent internal bonding treatment may eliminate treatment problems that accompany the pulpless immature tooth. This technique of using MTA as an apical barrier and rehabilitation of the tooth with composite and crown decreases the treatment time and possibly improves the long-term prognosis. 
| Conclusion|| |
Use of MTA in the Apexification procedures has been justified in various in vitro and in vivo studies. It has various advantages of being used at open apices, for example, it can be completed in a single visit, thereby, reducing the number of clinical appointments and increasing patient compliance, and it provides a good sealing ability. It also has the ability to set in the presence of moisture. Hence, it is considered to be a boon to dentistry, where it can be used as a viable alternative to the prolonged application procedure of calcium hydroxide.
The collagen barrier is a biodegradable material that has been used in the present case report. It prevents the extrusion of the material and confines it to the apex. It can also act as a scaffold for the regeneration of hard tissues.
The membrane-assisted Apexification procedure remains a viable and reliable technique, prior to the conventional root canal treatment, especially in cases of immature apices. A literature review reveals high success rates in membrane-assisted and non-membrane-assisted one-step Apexification. However, prospective long-term clinical trials comparing these methods are required, to determine their efficacy, in such kind of cases.
A successful clinical and radiographic outcome is recorded with the current case report.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21]