microsurgery treatment saves central incisor tooth

I tried over at least a year to promote apexigenesis using calcium hydroxide dressings. Unfortunately the apex did not respond. Conservative and orthograde root treatment did not work due to the large open apex. A surgical approach was decided that would be the best approach and treatment.

fractured central incisor with open apex











A young adult of 10 years old presented with an upper left fractured central incisor tooth.  His general dentist correctly  tried to manage the tooth with calcium hydroxide dressings over a number of months.  The tooth was not responding to the treatment.  The patient was referred to me to take over the case.  I saw him in September 2014 and opened the tooth to try and initiate apexigenesis.  The x-ray shows a wide open apex with apical change.  Infection was draining from the tooth.

 Over a number of months I tried to initiate apexigenesis with changing of dressings of calcium hydroxide cream.  Some appointments the tooth was draining and other it appeared dry.  The x-ray dated June 2016 shows little change.

calcium hydroxide dressing












I concluded then that the apexigenisis was not working and also from recurring flare ups of abscesses that I would begin completing the treatment with MTA apical closure.













The MTA was placed at the apex providing a nice seal or "cork". 














The coronal back fill would be with warmed vertical gutta percha by means of the Obtura system.  As you can see above, the MTA seal "popped" through into the apical bone cavity when I compacted the gutta percha. 

Now I had to change my strategy as I realised that MTA seal would not "hold" a hermetic coronal seal.  I explained the problem and showed that I would need a surgical approach to retrieve excess gutta percha and achieve a sound root filling.  A full flap was raised with papilla retained incision and relieving incision distal to upper left lateral incisor.  Granulomatous tissue was curretted from the apical lesion together with extruded gutta percha.  The coronal portion was filled by means of the Obtura system and compacted.  An amalgam plugger was used to compact against and provide a cavity that would receive MTA.

coronal gutta percha fill












MTA was then packed in the apical portion providing the state-of-the-art seal.  The bony cavity was packed with calcium sulfate (Nanogen) particles and the flap was closed with 6/0 Ethilon sutures for primary intention healing.  August 2016

completed surgery with bone graft material












The tooth was reviewed in January 2017 and the gum appeared healthy pink and flat.  The tooth was not mobile and not TTP.  There was no periodontal pocketing associated.  The follow up x-ray shows a healed case.

review and healed surgery












The x-ray shows good apical bone integration and trabeculation with normal periodontal ligament appearance.  The composite restoration will need to be corrected in time.  The patient was referred back to their general dentist.

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