Apical Closure and Repair of Immature Permanent Teeth Lesion

Using Calcium Hydroxide

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Abstract
A case of large periapical lesion with an open apex in a 10 year old girl is presented. The lesion is
formed as a result of necrosis from trauma. It occurred in maxillary left central incisor 2 years ago.
After endodontic treatment using calcium hydroxide paste, apicial closure and complete healing of
periapical lesion was observed. The report suggests that even large periapical lesion could respond
favorably to endodontic treatment.
Introduction
Apexification therapy is a method to induce development of the root apex of an immature, pulp less
tooth by formation of of osteocemectum or other bone like tissue. Usually when trauma or dental caries
causes a tooth to lose its vitality, the pulp cavity and canals become repositories for a necrotic pulp
tissue. This degenerating tissue (with or without bacteria) produces periapical irritation through the
apical foramina.
The body attempts to combat this irritation by an inflammatory response. If a virile organism is
responsible for the infection, the process is likely to be acute. On the other hand, if the organism is not
virile or if the irritation is produced by toxins toxins of the necrotic pulp, the process is likely to be
chronic. Apexification theraphy is a well-established treatment in immature teeth with necrotic pulp.
Periapical lesion is the most common sequelae of pulp necrosis either due to carious involvement or
trauma, The aim apexifiaction is to induce either closure of the open apical third of the root canal or the
formation of an apical “calcific barrier” against which obturation can be achieved. Treatment option to
manage large periapical lesion with open apex ranges from non surgical root canal treatment and/or
apical surgery of extraction.
Mechanical instrumentation not always completely remove debris from root canal periapical tissue.
Therefore dressing with chemical medicament has been considered as one of the most important steps
to obtain and maintain sterile root after mechanical instrumentation and before root canal obturation.
Gutmann reported periapical healing and apical closer of a non vital tooth even in presence of bacterial
contamination. Calcium hydroxide remains a popular material to accomplish apical closer and
periapical repair because of its apparent ability to permit calcific tissue formation over the apex and has
the potential to maintain a sterile canal by its antibacterial and tissue dissolving respectively. Biologic
appexification was reported to occur in adult teeth with periapical lesion and even in teeth previously
subjected to periapical surgery.
Demonstration of periapical healing an apical closure can occur without surgical intervention, is the
finding of this case report.
Case Report
A ten year old girl with a diffused swelling in the maxillary anterior vestibule reported to the clinical
dental solutions. History revealed trauma 2 years back while pulling tube well. Intraoral examination
revealed Ellis IV fracture in maxillary left central incisor. Maxillary left central incisor was slightly
sensitive to percussion. A sinus tract was present in relation of central incisor and tooth failed to
respond to Electric pulp testing though adjacent teeth were normal.
A large periapical lesion is demonstrated by periapical radio graph approximately 5mm X 6mm in
diameter with a well defined margin around the apices of maxillary left central incisor. Tooth was
anesthetized (Lignacine hydrocloride). Nerotic tissue was removed followed by access cavity
preparation. Canal was prepared 1mm short of apex up to no 70 K files, using step back technique.
Intracanal irrigation is done by normal saline. Calcium hydroxide powder was mixed with normal
saline to form a paste. Reamer was used to place the paste into the canal and condensed properly using
condenser. Access cavity was sealed with zinc-oxide Eugenio cement. After one week the intraoral
examination revealed a healed sinus tract and the tooth became asymptomatic. Intracanal dressing was
removed and a fresh calcium hydroxide paste was placed in to the canal, again sealed with zinc oxide
Eugenio cement. Clinical examination was carried out at monthly interval. Radiograph was taken at an
interval of 3 months. A 3 month post operative radiograph showed a reduced apical lesion about 3mm
X 4 mm in diameter. Six months radiograph showed complete resolution of periapical lesion along with
epical closure. Lateral condensation was done to the canal using g sealed. Guttauttaapurcha points.
Access cavity was sealed and restored with glass Ionomer restoration.
Discussion
In this particular non-surgical technique, calcium hydroxide paste was considered and used as the
intracanal dressing material of choice because of its reputed healing of periapical inflammation and
formation of an hard tissue barrier. The influence of calcium hydroxide on periapical healing could be
attributed to both its antibacterial effects and mineralizing effects. Micro organism’s direct contact with
calcium hydroxide are possibly destroyed by its high alkalinity (usually pH 12 to 13). Once the bacteria
was destroyed and their substrate neutralized, the calcium hydroxide in contact with vital connective
tissue in the apical area exerts basically the same effect as when it is placed on the coronal pulp. A long
standing endodontic treatment allows bacteria to propagate throughout the root canal system which
plays an essential role in the pulpoperiradicular pathosis. The use of intra medication processing
antimicrobial properties. It may eliminate bacteria in the root canal system. The success of root canal
therapy is significantly increased. Use of calcium hydroxide powder with saline as an intracanal
medicament in which large peripical lesion healed completely with in a period of 3 months. Periapical
repair and apical closure of a pulp less tooth using calcium hydroxide powder mixed with saline, which
is in accordance with mehmat Oztan, Ghose 1987 advocated that direct contact between calcium
hydroxide and the periapical tissue was necessary for an adequate inductive action in apexification
therapy.
Caliscan and Sen stated that when lesions with a diameter of more than 5mm were compared the paste
extruded group showed a slightly higher rate of complete healing. They also stated that international
extrusion of calcium hydroxide saline paste has been advocated in non surgical treatment of extraoral
sinus tracts from which anaerobic bacteria were isolated associated with a symptomatic apical
periodontis. In the present case calcium hydroxide saline paste was condensed into the canal so that
calcium hydroxide peste should come in contact with the periapical tissue, but as the calcium hydroxide
paste was radiolucent it was difficult to access it on the radiograph. Sahli 1988 proposed that the
necrotizing ability of calcium hydroxide may destroy any epithelium present, thereby allowing a
connective tissue invagination into the lesion with ultimate healing. Torneck 1970 stated that, hertwig’s
root sleath resume their function, begin matrix formation and subsequent calcification whe the infection
was eliminated and bacteriosis is maintained. I this case report, endodontic treatment with calcium
hydroxide demonstrates a successful method of providing periradicular healing and apical root closure
even in a large peripical lesion. The presence of large peripical lesion does not prevent root end closer
when treated with calcium hydroxide.
Dr. Ali Akbar
Dr. Bushra Marzan
Dr. M.K. Alam