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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 4  |  Page : 663-666  

Retrieval of extruded mineral trioxide aggregate using a novel suction device


1 Department of Conservative Dentistry and Endodontics, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
2 Department of Dentistry, Kalpana Chawla Government Medical College, Karnal, Haryana, India

Date of Web Publication6-Nov-2019

Correspondence Address:
Dr. Meenu Dhiman
Department of Conservative Dentistry and Endodontics, Postgraduate Institute of Dental Sciences, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccd.ccd_578_18

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   Abstract 

Treatment of necrotic immature permanent teeth is an exigently demanding situation for an endodontist. Regenerative endodontic procedures are being employed for such teeth in a hope to restore a functional pulp tissue and continue root development. However, currently advocated techniques may not be effective in retaining mineral trioxide aggregate (MTA) in its coronal position. The present paper describes two immature teeth with pulpal necrosis and apical periodontitis that were treated through revascularization. In both the cases, apical extrusion of the coronal MTA plug occurred. A suction tip was customized to completely retrieve the extruded material. Both cases proved out to be a clinical and radiographic success over extended follow-up periods.

Keywords: Mineral trioxide aggregate, open apex, regenerative endodontics, revascularization


How to cite this article:
Dhiman M, Duhan J, Juneja R, Tewari S, Sangwan P. Retrieval of extruded mineral trioxide aggregate using a novel suction device. Contemp Clin Dent 2018;9:663-6

How to cite this URL:
Dhiman M, Duhan J, Juneja R, Tewari S, Sangwan P. Retrieval of extruded mineral trioxide aggregate using a novel suction device. Contemp Clin Dent [serial online] 2018 [cited 2019 Dec 13];9:663-6. Available from: http://www.contempclindent.org/text.asp?2018/9/4/663/270363


   Introduction Top


Teeth with open apices pose difficulties in root canal debridement and obturation, as the root dentine is thin, weak, and prone to fracture.[1] Traditionally, the treatment for such teeth was apexification using calcium hydroxide that posed various drawbacks such as extended treatment time (average 1 year ± 7 months), uncertain apical closure, and the possibility of root fracture.[2],[3] Recently, mineral trioxide aggregate (MTA) has been used as an artificial apical barrier with high success rate[4],[5],[6] but it cannot promote the maturity of apex, thickening of radicular dentin, or reduce the chances of root fracture.[7],[8]

Of late, regenerative endodontic treatment has been introduced as an alternate conservative option for such teeth with better prognosis.[9] The treatment mainly involves (i) disinfection of the canal, (ii) placement of a suitable scaffold, and (iii) bacteria-tight coronal seal. This promotes repopulation of stem cells from apical papilla, regeneration of pulp tissue, and continued root development.[10] Many technical difficulties associated with the regenerative procedures such as insufficient bleeding, discoloration, lack of root development, calcifications, and empty root canal space have been reported in several publications, and their appropriate management has been discussed.[9],[11],[12]

However, apical displacement of coronal MTA plug adapted over the clot formed during the procedure, and its subsequent management has never been reported. The following case report presents two such conservatively managed cases that were treated successfully after the complete removal of extruded material using a chair-side fabricated suction.


   Case Reports Top


Case report 1

A 17-year-old male patient, with a history of trauma 9 years back, presented with a chief complaint of discolored maxillary left central incisor (tooth #9) [Figure 1]a. The medical history of the patient was noncontributory. Intraoral examination revealed enamel-dentin-pulp fracture of tooth #8 and tooth #9. Both teeth were not sensitive to percussion or palpation, and electric pulp tester produced no response either. Radiographs revealed widened periodontal ligament space in tooth #8 and incomplete root formation with periapical radiolucency in relation to tooth #9 [Figure 1]b. There was no mobility or root/bone fracture. Periodontal probing depths were within normal limits. A diagnosis of pulpal necrosis with chronic apical periodontitis for both the incisors was made. The patient was informed about the treatment options, its risks, complications, and possible outcomes.
Figure 1: Case 1: (a) The initial clinical view of tooth #9. (b) Initial radiograph showing root canal treated tooth #8 and coronal mineral trioxide aggregate plug in tooth #9 after revascularization. (c) Mineral trioxide aggregate plug seen displaced apically. (d) The custom-made suction tip. (e) The fabricated suction of use in tooth #9. (f) Thirty-month radiograph showing root lengthening, closure of the wide-open apex, thickening of lateral root walls regaining the normal apical root morphology, and complete healing of periradicular lesion with the normal trabecular pattern. (g) Thirty-month intraoral view

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After obtaining written informed consent, routine endodontic treatment was carried out in tooth #8. Subsequently, for its first appointment, tooth #9 was anesthetized using 2% lidocaine with 1:1,00,000 epinephrine. After the application of a rubber dam, an access cavity was prepared. No purulent exudate or hemorrhage was observed in the canal. The canal was irrigated gently using 20 ml of 5.25% sodium hypochlorite (NaOCl) 2 mm short of the apical foramen, followed by irrigation with 5 ml of sterile saline. A final rinse of 10 ml of 2% chlorhexidine was given. The canal was carefully dried with large, sterile paper points. The root canal was medicated with triple antibiotic paste prepared by mixing equal proportions of ciprofloxacin, metronidazole, and minocycline to a cream-like consistency. The antibiotic dressing was placed into the canal to a depth 2 mm short of root apex up to the level of cementoenamel junction (CEJ). The access was sealed with a sterile cotton pellet and Cavit G.

The patient was recalled after 21 days. At this appointment, the tooth was asymptomatic. The tooth was anesthetized with an anesthetic without vasoconstrictor to prevent a restricted blood flow from the apical region. The tooth was isolated, and the medicament was removed by gently irrigating with NaOCl until no medicament was evident in the canal. The canal was further irrigated with 5 ml sterile saline, followed by 10 ml of 17% ethylenediaminetetraacetic acid (EDTA) as a final rinsing solution. Revascularization procedure was then carried out. A sterile #20 K-file was introduced into the root canal and taken 2 mm past the apical foramen to irritate the apical tissue and initiate bleeding. The intracanal hemorrhage was controlled 3 mm below the CEJ by applying pressure with a wet, sterile cotton pellet soaked in saline for approximately 15 min to establish a stable blood clot. A collacote barrier was placed above the blood clot over which MTA was packed up to the level of CEJ. A moist cotton was placed over the MTA and the access was sealed with Cavit G [Figure 1]b. The patient was recalled on the next day for the replacement of cotton and Cavit G with adhesive restoration. However, during the removal of Cavit G and moist cotton, MTA extruded apically [Figure 1]c. This extruded MTA was retrieved with a custom-made suction tip [Figure 1]d. The suction tip was constructed using a disposable suction tip and parts of intravenous infusion set. The plastic part of suction tip was removed. Latex and adaptor of the disposable infusion set were cut and attached to the suction tip, and over this, the needle was placed. The modified suction was introduced in the canal, and the dislodged MTA was removed [Figure 1]e. The revascularization procedure including disinfection of canal and introduction of intracanal bleeding and coronal sealing with MTA was repeated. After 1 month, tooth #9 was asymptomatic and nontender on percussion and palpation.

At 30-month follow-up examination, tooth [Figure 1]g did not respond to pulp vitality test. The radiograph demonstrated the evidence of periradicular bone healing and significant root development with maturation of dentine as compared to preoperative radiograph [Figure 1]f.

Case report 2

A 20-year-old male patient reported with a chief complaint of discolored left upper front tooth for 7 years. On clinical examination, tooth #9 was not sensitive to percussion or palpation and displayed Grade 2 mobility. Pulp sensibility tests yielded negative results. Radiographs revealed incomplete root formation with a wide-open apex and diffuse periapical pathology in relation to tooth #9. Based on the clinical and radiographic findings, the patient was diagnosed with asymptomatic chronic apical periodontitis.

The revascularization procedure was carried out according to the protocol mentioned in case 1. The working length was established [Figure 2]a and disinfection of the canal was carried out. Bleeding was induced into the canal [Figure 2]b and a collacote barrier was placed over it. MTA was used as a coronal plug over the collacote barrier. A moist cotton was placed over MTA and access cavity was sealed with Cavit G [Figure 2]c. The patient failed to report for a final adhesive restoration and reported after 1 month. On radiographic examination, the MTA plug was seen displaced apically [Figure 2]d. On canal reentry, it was found to be empty. After the canal was reaccessed, MTA was ultrasonically agitated to disintegrate it taking care not to touch the canal walls [Figure 2]e. A custom-made suction tip was fabricated as described previously. The disintegrated MTA was then completely retrieved using the customized suction [Figure 2]f, [Figure 2]g,[Figure 2]h. Disinfection of the canal was carried out once again using 5.25% NaOCl and 17% EDTA. The MTA was placed 3 mm cervically from the CEJ after clot formation [Figure 2]i. A final restoration of composite over 2 mm GIC was placed. A follow-up of 1 year was maintained [Figure 2]j. The tooth #9 remained asymptomatic with evident periapical healing and regained its mobility within normal limits.
Figure 2: Case 2: (a) Working length determination.(b) K-file taken 2 mm past the apical foramen. (c) Mineral trioxide aggregate backfilled to the level of cementoenamel junction. (d) Disintegrated mineral trioxide aggregate seen in the apical region. (e) Ultrasonic agitation of the displaced mineral trioxide aggregate. (f and g) Customized suction in tooth #9 clinically and radiographically. (h) Radiograph showing complete retrieval of mineral trioxide aggregate from the periapex. (i) A stable clot after inducing bleeding in the canal. (j) One-year follow-up radiograph

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   Discussion Top


The literature available regarding regenerative endodontic procedures (REPs) is constituted mainly of case reports and case series. The technique is undeniably useful especially in cases with weak, underdeveloped roots. However, very little data are available regarding complications that may be encountered during the procedure. This paper is intended to present two untoward incidences that were encountered during revascularization. Retrieval of MTA from periapical region using custom-made suction and from apical root canal in conjunction with ultrasonics has never been reported before.

Forming a clot and maintaining its integrity during a revascularization procedure is highly technique sensitive and a difficult task. In both the cases, the dislodgement of MTA plug occurred. In case 1, the cause for its occurrence could be iatrogenic due to the application of inadvertent force to check the set of MTA. Also, it can be assumed that the blood clot formed beneath was not stable and did not provide sufficient strength to prevent the sagging of MTA. In case 2, the apical extrusion of MTA could be attributed to the fact that the blood clot broke down as a comparatively wider canal space here required a greater volume of blood and thus a bigger clot formed failed to maintain a consistent physical structure.[13] This could also be the reason behind entering into an empty pulp space during the MTA retrieval. Also, the use of matrix such as collaplug or collacote has been recommended to minimize the overextension of pulp space barrier such as MTA.[14] In our case, collacote barrier helped to prevent overextension of MTA during its placement over the blood clot but it failed to maintain it in the same position over a period of time. The use of synthetic scaffolds with high physical strength may help prevent such accidents.

MTA is chosen to be placed over the blood clot as this biocompatible cement can set in the presence of blood and is then highly resistant to bacterial penetration.[12],[15],[16] Apical displacement of MTA may adversely affect the coronal seal and may also hamper the new tissue growth into the root canal.[13],[17] Such displacement may also suggest inadequate maturation of fibrin plug and/or void in the clot, as the three-dimensional filling of the canal with blood clot cannot be verified. We tried to clean the displaced MTA through the canal itself in an orthograde manner. A noncutting ultrasonic tip (ET 40) was used to mechanically agitate the extruded material so that its recovery could be made easy. Extreme care was observed not to touch the already fragile canal walls during the procedure, as it could be highly detrimental to the structural integrity of the tooth. The suction tip made from the disposable infusion set allowed a good access of the periapical area. The smaller gauge needles of suitable size attached onto the fabricated suction tip provided a large bore for sucking back of MTA. The procedure was simple, efficient, less time consuming, and did not add an additional cost to the treatment.

During the follow-up period, none of the teeth showed any response to the sensibility testing. Lack of pulp response in teeth that underwent REP does not necessarily indicate a lack of vitality. According to Torabinejad et al., the thickness of the material used as coronal plug/seal and the coronal extent of regenerated tissue affect pulp response to sensibility testing.[18] Also, it is possible that the tissue that invaginated into the canal space was probably not innervated.


   Conclusion Top


Based on the difficulties encountered during the above cases, it may be recommended that (1) in cases with wide canal diameters, chances of extrusion of MTA are higher as the quality of clot formation may be compromised and (2) one should consider an orthograde approach to remove the apically displaced MTA through suction.

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.
Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF, et al. Pulp revascularization of immature teeth with apical periodontitis: A clinical study. J Endod 2009;35:745-9.  Back to cited text no. 1
    
2.
Kleier DJ, Barr ES. A study of endodontically apexified teeth. Endod Dent Traumatol 1991;7:112-7.  Back to cited text no. 2
    
3.
Mohammadi Z, Dummer PM. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J 2011;44:697-730.  Back to cited text no. 3
    
4.
Mente J, Hage N, Pfefferle T, Koch MJ, Dreyhaupt J, Staehle HJ, et al. Mineral trioxide aggregate apical plugs in teeth with open apical foramina: A retrospective analysis of treatment outcome. J Endod 2009;35:1354-8.  Back to cited text no. 4
    
5.
Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: A prospective study. Int Endod J 2007;40:186-97.  Back to cited text no. 5
    
6.
Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod 2008;34:812-7.  Back to cited text no. 6
    
7.
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 7
    
8.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 8
    
9.
Nosrat A, Homayounfar N, Oloomi K. Drawbacks and unfavorable outcomes of regenerative endodontic treatments of necrotic immature teeth: A literature review and report of a case. J Endod 2012;38:1428-34.  Back to cited text no. 9
    
10.
Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: What does the future hold? J Endod 2008;34:S51-6.  Back to cited text no. 10
    
11.
Nosrat A, Li KL, Vir K, Hicks ML, Fouad AF. Is pulp regeneration necessary for root maturation? J Endod 2013;39:1291-5.  Back to cited text no. 11
    
12.
Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: A case series. J Endod 2010;36:536-41.  Back to cited text no. 12
    
13.
Lenzi R, Trope M. Revitalization procedures in two traumatized incisors with different biological outcomes. J Endod 2012;38:411-4.  Back to cited text no. 13
    
14.
Law AS. Considerations for regeneration procedures. J Endod 2013;39:S44-56.  Back to cited text no. 14
    
15.
Tselnik M, Baumgartner JC, Marshall JG. Bacterial leakage with mineral trioxide aggregate or a resin-modified glass ionomer used as a coronal barrier. J Endod 2004;30:782-4.  Back to cited text no. 15
    
16.
Torabinejad M, Parirokh M. Mineral trioxide aggregate: A comprehensive literature review – Part II: Leakage and biocompatibility investigations. J Endod 2010;36:190-202.  Back to cited text no. 16
    
17.
Yamauchi N, Nagaoka H, Yamauchi S, Teixeira FB, Miguez P, Yamauchi M, et al. Immunohistological characterization of newly formed tissues after regenerative procedure in immature dog teeth. J Endod 2011;37:1636-41.  Back to cited text no. 17
    
18.
Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: A case report. J Endod 2011;37:265-8.  Back to cited text no. 18
    


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