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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 66-68

Endodontic management of blunderbuss canal with open apex and Ellis Class IV fracture using mineral trioxide aggregate and compo-post


1 PG Student, Department of Conservative Dentistry and Endodontics, Jaipur Dental College, Rajasthan, India
2 Senior Lecturer, Department of Oral Medicine and Radiology, Mahatma Gandhi Dental College, Jaipur, Rajasthan, India
3 Private Practitioner, Department of Conservative Dentistry and Endodontics, Imphal West, Manipur, India

Date of Submission21-Oct-2019
Date of Acceptance22-Oct-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Shashank Gupta
Department of Oral Medicine and Radiology, Mahatma Gandhi Dental College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_52_19

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  Abstract 


The permanent teeth with open apex, blunderbuss canal, and Ellis Class IV fracture are difficult to treat as a traditional root canal procedure. Apexification is induction of apical closure, the treatment of choice for necrotic teeth with immature or resorbed root. Mineral trioxide aggregate (MTA) has been proposed as a potential material for formation of hard tissue apical barrier. Use of anatomical post results in better prognosis of the present case. This case report presents endodontic management of a fractured maxillary right central incisor with apexification and compo-post to support weak canal and to provide tooth structure. A 21-year-old male patient came to the Department of Conservative Dentistry and Endodontics, Jaipur Dental College and Hospital, Jaipur, with the chief complaint of broken upper front tooth due to accidental fall (6–7 years). Dental history of discontinued endodontic treatment 1-year back was observed. Treatment includes two phases – endodontic phase and re-construction phase followed by full-crown porcelain-fused metal prosthesis. This case report discussed an improved option of application of chairside customized made fiber posts are preferred as they stimulate the root canal anatomy, provides increased retention and adaptation and also esthetics.

Keywords: Apexification, blunderbuss canal, compo-post, Ellis Class IV fracture, Mineral trioxide aggregate, open apex


How to cite this article:
Das T, Gupta S, Atom J, Lairenlakpam R, Gupta S, Chaudhary A. Endodontic management of blunderbuss canal with open apex and Ellis Class IV fracture using mineral trioxide aggregate and compo-post. Int J Prev Clin Dent Res 2019;6:66-8

How to cite this URL:
Das T, Gupta S, Atom J, Lairenlakpam R, Gupta S, Chaudhary A. Endodontic management of blunderbuss canal with open apex and Ellis Class IV fracture using mineral trioxide aggregate and compo-post. Int J Prev Clin Dent Res [serial online] 2019 [cited 2019 Dec 10];6:66-8. Available from: http://www.ijpcdr.org/text.asp?2019/6/3/66/271530




  Introduction Top


The maxillary anterior teeth tend to undergo many impact injuries because of its position in the jaw. Traumatic injuries sustained before the closure of apex interrupts in the root development. Long-term history of trauma causes external root resorption. In such conditions, apexification or root-end closure becomes the treatment of choice.[1] Apexification is defined as a method of inducing a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulp. In recent times, mineral trioxide aggregate (MTA) has gained widespread popularity to induce apexification in young permanent tooth.[2],[3] The restoration of endodontically treated tooth involves restorative procedures which are complicated further by various post and core systems. Prefabricated posts over custom-made posts add advantage of reduced clinical time. Hence, an improved option of application of chairside customized-made fiber post provides increased retention and adaptation and also esthetics.[4],[5] As an alternative to traditional cast or prefabricated metal posts, various types of fiber reinforcement post are available for restoration of endodontically treated teeth. The advantage of using reinforces fiber as intracanal post includes resin composite crown reinforcement, translucency, and ease of manipulation. The case report presents endodontic management of a fractured maxillary right central incisor with apexification by MTA followed by custom-made (modified prefabricated fiber post) compo-post to support weak canal and to provide tooth structure.


  Case Report Top


A 21-year-old male patient came to the Department of Conservative Dentistry and Endodontics, Jaipur Dental College and Hospital, Jaipur, with the chief complaint of broken upper front tooth due to accidental fall (6–7 years). Dental history of discontinued endodontic treatment 1 year back was observed. Clinical examination reveals Ellis Class IV fracture, with discoloration of upper right central incisor [Figure 1]. On radiographic examination, it revealed periapical radiolucency indicating external apical root resorption, intracanal radiopacity indicating improper obturation, and blunderbuss canal with open apex [Figure 2]. Treatment plan includes endodontic treatment, i.e., apexification with MTA, and restoration using modified custom-made compo-post and core, followed by porcelain-fused metal crown.
Figure 1: Preoperative clinical view

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Figure 2: Preoperative radiograph

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Previous remaining gutta-percha was removed, and working length determination was confirmed using RVG. Canal was cleaned and irrigated thoroughly with normal saline. Calcium hydroxide (Ca[OH]2) dressing was placed for disinfection of root canal. The patient was recalled after 2 weeks. On the second visit, the Ca (OH)2 dressing was removed. An apical barrier of 3–4 mm was established using MTA. A sterile damp pellet of cotton was placed over the canal orifice, and the access was sealed with Cavit G (3M ESPE). Moreover, the placement of MTA was confirmed with RVG. The patient was recalled after 2 days. As per the canal anatomy after endodontic treatment, no prefabricated post could satisfactorily adapt to walls. Furthermore, the amount of residual dentin contraindicated further preparation for the adaptation of the post. Now, a prefabricated fiber post (Tenax Fiber Trans, Coltene) 1.5 mm was taken and try in done. Post was etched and bonding agent was applied and cured for 20 s. Incremental build-up of composite was done (Ivoclar Vivadent Tetric N-Ceram) with curing time for 40 s to form the post. Once minimum thickness was prepared, the post was placed in the canal and radiograph was taken to confirm the canal width and length. Further build-up of post was done by applying a layer of composite and was placed in the canal to record the canal space and step by step curing of the composite material and then confirmed by radiograph. After adequate thickness of the post, canal was etched and bonding agent was applied and cured for 20 s. Post cementation was done with resin-based GIC Para Core Automix (Coltene) and core build-up was done with the same composite material used for post [Figure 3].
Figure 3: Post cementation

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  Discussion Top


Achievement of a perfect seal at the apex using an inert filling material is the single most factor affecting success in endodontics.[3] The endodontic treatment of nonvital immature anterior teeth after trauma remains complicated because of necrotic pulp tissue, large open apices, divergent root walls, thin dentinal walls, and frequent periapical lesion. The main aim of root-end filling material is to fill the apical canal space and obtain hermetic seal between periodontium and root canal system.[4],[5],[6],[7] Apexification is a procedure to induce calcific barrier in a root with open apex which is mandatory to allow the compaction of root filling material.[8] Due to these reasons, one-visit apexification has been suggested by Morse et al., 1990. Combination of its biocompatibility and bacteriostatic makes it as a material of choice for apexification. MTA has also been shown to have superior characteristics as a direct pulp-capping agent when compared with Ca (OH)2.[9],[10] With the above-discussed disadvantages of Ca (OH)2, MTA was used as material for apexification procedure. Furthermore, MTA plug technique Ca (OH)2 was used as interappointment of dressing as to disinfect the canal. This is because chemomechanical preparation alone is not effective for complete elimination of microorganisms. For past many years, metallic prefabricated posts have dominated for the restoration of endodontically treated teeth.[9] Yet, newer systems like compo-post have evolved which focused on physical properties such as modulus of elasticity for reduction stress concentration and incidence of further fracture. In addition, the advantage of esthetics over metal posts leads to increase use of the composite and fiber-reinforced posts.[10] In the present case, composite was selected as the material of choice for post and core after endodontic treatment.


  Conclusion Top


During the last 20 years, there have been many changes in the rationale governing the treatment of teeth with open apex. Recent material like MTA is a promising material and plays an important role in healing and sealing of root canal and thus saving patient from psychological trauma of surgical procedures. MTA can be considered as an ideal filling for apexification. As it results in good periapical seal in few visits and allows fabrication of biological post providing ample strength and eliminating laboratory procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Dent Clin North Am 2010;54:313-24.  Back to cited text no. 1
    
2.
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 1966;72:87-93.  Back to cited text no. 2
    
3.
Corrêa-Faria P, Alcântara CE, Caldas-Diniz MV, Botelho AM, Tavano KT. “Biological restoration”: Root canal and coronal reconstruction. J Esthet Restor Dent 2010;22:168-77.  Back to cited text no. 3
    
4.
Galindo VA, Nogueira JS, Yamasaki E, Koìs Miranda D. Biological posts and natural crowns bonding—alternatives for anterior primary teeth restoration. J Bras Odontoped Odontol Bebe 2000;16:513-20.  Back to cited text no. 4
    
5.
Cohen S, Hargreaves K, editors. Pathways of the Pulp. 9th ed. Mosby; 2006:813-6.  Back to cited text no. 5
    
6.
Batista A, Lopes CG. Performed dentin post reinforcing teeth with immature apexes. Rev Bras Prot Clin Lab 1999;3:199-21.  Back to cited text no. 6
    
7.
Barjau-Escribano A, Sancho-Bru JL, Forner-Navarro L, Rodríguez-Cervantes PJ, Pérez-Gónzález A, Sánchez-Marín FT. Influence of prefabricated post material on restored teeth: Fracture strength and stress distribution. Oper Dent 2006;31:47-54.  Back to cited text no. 7
    
8.
Hemamalathi S, Nagendrababu V, Kandaswamy D. A single step apexification and intra radicular rehabilitation of fractured tooth- a case report. J Conserv Dent 2007;10:48-52.  Back to cited text no. 8
  [Full text]  
9.
Hayashi M, Shimizu A, Ebisu S. MTA for obturation of mandibular central incisors with open apices: Case report. J Endod 2004;30:120-2.  Back to cited text no. 9
    
10.
Salgar AR, Chandak MG, Manwar NU. Blunder buss canal: A challenge for endodontist. Endodontology 2011;23:75-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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