Mineral Trioxide Aggregate Obturation in Retreatment with Regenerative Adjuncts of Bioceramic Allograft in Large Periapical Defect: A Case Report with 5 Year Follow Up

Case Presentation

J Dent App. 2015; 2(7): 274-277.

Mineral Trioxide Aggregate Obturation in Retreatment with Regenerative Adjuncts of Bioceramic Allograft in Large Periapical Defect: A Case Report with 5 Year Follow Up

Zoya A, Ali S*, Tewari RK, Mishra SK, Kumar A and Iftekhar H

Department of Conservative Dentistry & Endodontics, Dr. Z. A. Dental College, Aligarh Muslim University, India

*Corresponding author: Ali S, Department of Conservative Dentistry and Endodontics, Dr. Z. A. Dental College and Hospital, Aligarh Muslim University, India

Received: February 09, 2015; Accepted: September 10, 2015; Published: September 12, 2015


Endodontic overfills and incomplete obturation is usually associated with an array of local complications and results in persistent periapical infection and inflammation. Endodontic challenges further aggravates in such cases if the tooth actually is young with incomplete root formation, i.e. presence of blunderbuss canal. Herein, a case of wide open apices in maxillary central incisors with over extrusion of gutta percha and associated large periapical lesion is presented. Mineral Trioxide Aggregate (MTA) was used to obturate the blunderbuss canals and an alloplastic graft, Biphasic Calcium Phosphate (BCP) were filled in the bony defect after surgical curettage. At the 6th month postoperatively, periapical osseous healing was satisfactory. The advantages and indications of MTA as obturation material and bone graft in periodontal regeneration are discussed. Clinically and radiographically the case was followed for next 5 years to assess the outcome of MTA obturation.

Keywords: Biphasic calcium phosphate; Blunderbuss canal; Retreatment; MTA obturation


BCP: Biphasic Calcium Phosphate; GP: Gutta Percha; MTA: Mineral Trioxide Aggregate.


Traumatic injury or caries in young permanent teeth results in pulpal inflammation or necrosis and subsequent incomplete development of dentinal wall and root apices [1]. Such type of canals often called “blunderbuss” as they have divergent and flaring foramen. The problems associated with these canals are: weaker roots prone to fracture, poor crown to root ratio, and more susceptible to periodontal involvement [2].

Complete debridement, disinfection and three dimensional obturation of these canals is a daunting task as they lack apical constriction [3]. Thus, treatment in these cases are aimed at developing the apical stop for confinement and condensation of obturating material.

Apexification and apical barrier technique are the two commonly employed methods for management of immature permanent teeth with open wide apices. Although apexification using calcium hydroxide has very high success rate [4] but decrease in fracture resistance of the tooth, longer duration of treatment, multiple appointments, and high patient compliance are the disadvantages. Apical barrier technique using MTA is becoming the standard for treatment of immature roots with necrotic pulps. In this technique an artificial stop is created that would enable the root canal to be filled immediately [5]. With the advantages of shorter treatment time, development of a good apical seal, and MTA induced hard-tissue deposition in periradicular area [6], apical barrier technique have shown long term success [7].

Prevention of development of endodontic disease and resolution of periapical pathosis is only possible when the filling materials obturate the canal three dimensionally and prevents further ingress of bacteria, entombs remaining microorganisms, and block their nutrient supply [8,9]. MTA provides remarkable physiochemical and bioactive properties, offering an outstanding edge when used as canal obturation material [9].

Apical periodontitis is an immunoinflammatory reaction resulting in destruction of periradicular tissues in response to etiologic agents of endodontic origin [10]. Although, nonsurgical root canal therapy, apical microsurgery, and extraction are the different treatment modalities for the management of periapical inflammatory lesion. Nonetheless, surgical intervention allows thorough debridement which leads to a faster healing rate and also permits placement of different biomaterials (Biphasic calcium phosphate, Platelet rich fibrin, Calcium enriched mixture etc.) to improve the new bone formation especially for large defects [11].

This case reports presents the successful management of large periapical lesion associated with overextended filling materials followed by MTA obturation in blunderbuss canals of maxillary central incisors.

Case Presentation

A 17 year old female presented with chief complaint of pain and swelling in relation to upper front teeth along with blackening of crown margins (Figure 1). Her medical history was not significant. The patient gave history of treatment by a general practitioner for the same teeth. Clinically, the teeth 11 and 21 were covered with a defective prosthesis revealing plaque and calculus at the margins. Teeth 12 and 22 were tender on percussion. Tooth 12 was having grade II mobility along with root exposure. Radiographic examination revealed that both central incisors were having wide open apices with large periapical radiolucencies. Single cones of gutta percha points were overextended periapically in both 11 and 21 (Figure 2).