1
Omar Morabet
5th year, gr. 13
Comparative analysis of techniques and materials used for
obturation of wide canals and open apex of the root
Master’s Thesis
Supervisor
Med.m.dr., Neringa Skučaitė
2 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
DEPARTMENT OF DENTAL AND ORAL PATHOLOGY
Comparative analysis of techniques and materials used for obturation of wide canals and open apex of the root
Master’s Thesis
The Thesis was done
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Kaunas, 2018
3 OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE
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Introduc-tion, aim and tasks
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justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks formed clearly and
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5 Are the aim and tasks interrelated? 0.2 0.1 0 6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0 7 Were the eligibility criteria of articles for the selected protocol
determined (e.g., year, language, publication condition, etc.) 0.4 0.2 0 8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
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Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
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Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
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Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
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12 Are all the variables (for which data were sought and any
assumptions and simplifications made) listed and defined? 0.4 0.2 0 13
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0.2 0.1 0
14 Were the principal summary measures (risk ratio, difference in
means) stated? 0.4 0.2 0 15 Systemiza-tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
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Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
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Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18 Are the extracted and systemized data from studies presented
in the tables according to individual tasks? 0.6 0.3 0 19
Discussion (1.4 points)
Are the main findings summarized and is their relevance
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20 Are the limitations of the performed systemic review
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21 Does author present the interpretation of the results? 0.4 0.2 0 22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and tasks of the
Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed material? 0.2 0.1 0 24 Are the conclusions clear and laconic? 0.1 0.1 0 25 References Is the references list formed according to the requirements? 0.4 0.2 0
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29 Annexes Do the presented annexes help to understand the analysed
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Practical
recommen-dations
Are the practical recommendations suggested and are they
related to the received results? +0.4 +0.2 0 31 Were additional methods of data analysis and their results used
and described (sensitivity analyses, meta-regression)? +1 +0.5 0 32 Was meta-analysis applied? Are the selected statistical methods
indicated? Are the results of each meta-analysis presented? +2 +1 0
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General require-ments
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<15 pages (-5 points) 34 Is the thesis volume increased artificially? -2 points -1 point
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scientifically, logically and laconically? -0.5 point -1 points 37 Are there any grammatical, style or computer
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its structural parts balanced? -0.2 point -0.5 points 39 Amount of plagiarism in the thesis. >20%
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-0.2 point -0.5 points
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TABLE OF CONTENTS
SUMMARY……….6
ABBREVIATIONS ……… 7
INTRODUCTION ………... 8
1. SEARCH METHODS AND STRATEGY………..9
1.1.Comprehensive selection path of review………9
1.2.Search terms and criteria………..10
1.2.1.Inclusion criteria………11
1.2.2.Exclusion criteria………...11
2. DATA ANALYSIS………12
2.1. Specification of wide canals ...12
2.1.1. Anatomically found teeth with wide/open apex...12
2.1.2.Genetically found teeth with wide apex ……… 12
2.1.3.Iatrogenic factors and wide apex ………... 13
2.2. Materials used for obturation of wide canals and open apex……….14
2.2.1. Comparative Analysis of materials used for obturation of wide canals and open…………16
2.2.2.Methods used for obturation of wide canals and open apex………...18
2.3.Comparative Analysis of obturation techniques………..21
DISCUSSION ………...22
3.CONCLUSIONS ………...23
PRACTICAL RECOMMENDATION ……….23
ANEXES………24
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SUMMARY
Dental practitioners providing endodontic treatment sometimes are encountered with cases (wide canal and open apex due to periapical resorption or immature root) that require particular materials and methods for obturation of root canals.
The aim of this systematic review is to compare materials and techniques intended for obturation
of wide canals and open apex.
Materials and methods. Articles search was carried out in the three databases - Pubmed-Medline,
Science Direct, Willey online library. Researchgate and Endoexperience sites were searched as well. After screening, full-text analysis of selected studies was done.
Results. After full-text analysis 31 publications was included into the study. Most studies showed
that bioceramic materials regarding their properties are intended to use for obturation of wide canals and open apices. Preference is based on properties of bioceramic material and on favorable
treatment results. An apical “barrier” creation with different cements was evaluated as preferable method for obturation of wide canals and open apex. Techniques of filling of root canals differ according to authors and selected materials.
Conclusions. Bioceramic cement is the material of choice for obturation of wide canals and open apex. Vertical condensation of particular cement and apical plug creation is widely used method for obturation of wide canals and open apex.
1. One or two steps obturation techniques are recommended.
Key words: immature root, open apex, root canal obturation, biomaterials,calcium silicate materials, bioceramic, endodontics.
7
ABBREVIATIONS
CH – Calcium hydroxide
MTA – mineral trioxide aggregate CEM – calcium enriched mixture
ISO – International Standards Organization CEM – calcium enriched mixture
PRF – Platelet-rich fibrin
IRM – intermediate restorative material EBA – ethoxy benzoic acid
GP – gutta percha
EDTA- Ethylenediaminetetraacetic acid EARR - External apical root resorption
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INTRODUCTION
Dental practitioners providing endodontic treatment sometimes are encountered with cases (wide canal and open apex due to periapical resorption or immature root) that require particular materials and methods for obturation of root canals. As it was known till now the best material for that kind of cases was MTA and Calcium hydroxide in some cases (apexofication). There are known new generation bioceramic materials used for solving such kind of problems as well ...
It is essential to know materials and techniques of obturation of wide /open apices with high quality sealing in order to .extend tooth presence, improve treatment prognosis and save the treatment time.
The aim of this study was to compare techniques and materials used for obturation of wide canals and open apex.
Tasks:
After evaluation of scientific studies published:
1. Compare biomaterials used for obturation of wide canals and open apex. 2. Compare techniques used for obturation of wide canals and open apex 3. Evaluate factors affecting the prognosis of obturation of wide canals
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1. SEARCH METHODS AND STRATEGY
1.1. Comprehensive selection path of review
This systematic review was provided according to PRISMA recommendations [33]. Articles search was carried out online in the three databases - Pubmed-Medline, Science Direct, Willey online library. Some of articles were found in scientific sites such as „Researchgate“, „Endoexperience“. Articles published in the last 5 years ( 2013-2018) were searched. In this systematic review the initial search objective was to find out cases of treatment of wide/open apex and evaluate the choice of materials and methods used for obturation of wide canals
The selection of article‘s type: research articles and case reports in English Language.
1.2.Search terms and criteria
All the information for this systemic review was searched in period of 2018 february/ march/ april.
According to keywords and search terms in different databases 1912 articles matching the keywords in title were selected (Table 1). After removal of duplicates, 220 were selected for assessment of inclusion/exclusion criteria (written below). Out of the search results, 31 articles had been chosen for the abstract to be read based on relevance for this particular study.
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Scheme.1 Flow diagram . “PRISMA 2009 Flow Diagram”[33]
Table 1. Search terms and keywords.Pubmed.
Pubmed
Found Selected
wide root apex 34 3
calcium silicate materials 489 42
bioceramic 364 29
root canal obturation 684 41
Immature root 153 45
open apex 144 38
biomaterials in wide canals 3 1
open apex 26 16
wide diameter canals 6 1
MTA in wide apices 4 2
methods of filling wide root canals 5 2
TOTAL 1912 220
1912 of records identified through database searching
1692 of records after duplicates removed
220 of records screened 136 of records excluded (repeating the topic.)
84 of full-text articles assessed for eligibility
31 of studies included in qualitative synthesis
53 of full-text articles excluded, with reasons where only mention some
treatment of wide root apices 31 of studies included in quantitative synthesis Systematization Identificat ion Screening Eligibilit y Included
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1.2.1.Inclusion criteria:
Studies in vivo and in vitro, case reports where materials and techniques used for obturation of wide canals and open apex were analysed.
Clinical studies or case reports where treatment on mature as well as on immature teeth was analysed.
1.2.2.Exclusion criteria:
Studies concerning:
a) working length determination in wide canals;
b) pulp capping and revascularisation of immature teeth; c) classic endodontic obturation techniques were excluded;
d) literature that wasn‘t written in english or required special access in order to download the full version were excluded;
e) repeating articles from different sources were excluded f) shaping and cleaning of wide open apices;
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2. DATA ANALYSIS
2.1.Specification of wide canals
There are particular cases when practitioners have to deal with obturation of wide canals and open apex of the root. Those cases include mature as well as immature roots of the teeth. The wide/open apex can be formed anatomically/geneticaly or can be created by different iatrogenic factors. Additionally, apical part of the root canal becomes wide due to resorption of the root apex induced by periapical pathology, orthodontic treatment or trauma.
The definition of “ wide apex” is usually used to describe the size of apical foramen when the size by ISO starts from #40. Different authors mention different size of “wide apex”. [1]
Table 2. Size of wide apex according different authors.[1]
Author Size
Mente et al. 2009 ISO 40# Van Hassel &Natkin 1970 ISO 45# Sarris et al. 2008, ElAyouti et al. 2009 ISO 60 # Friend 1966, Moore et al. 2011 ISO 80# Andreasen & Andreasen 2000 ISO 100#
2.1.1. Anatomically found teeth with wide/open apex
Immature wide apex
The wide/open apexes are detected in the stages of the development of teeth as a result of necrotic pulp caused by trauma or caries, or as a result of pathological or physiological dental resorption due to permanent tooth germination. [1]
Acording to the width of the apical foramen and length of the root, root development stages are classified by Cvek as: very immature, immature, mature [2] (Attachment 1).
Immature teeth present a problem due to their anatomy as the roots are short and thin and routine canal obturation is difficult due to the root canal configuration. The thin dentine walls are also at risk of fracture. [3]
2.1.2. Genetically found teeth with wide apex
Some other causes of incomplete development are dens in – dente , dentin dysplasia (type II). (Fig.1,2,3.).
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Fig. 1. .Dens- in dente(Type III), known as dens invaginatus or dilated composite odontome[5]
Fig.2.Dentin Dysplasia (type II)/rootless teeth
(http://www.jdrntruhs.org/article.asp?issn=2277-8632;year=2015;volume=4;issue=4;spage=282;epage=285;aulast=Hemachandrika)
Fig.3.Features of hypophosphatasia (https://doi.org/10.3389/fphys.2015.00307)
2.1.3. Iatrogenic factors that induce a wide/open apex
Resection of root apex during periradicular surgery
Apicoectomy- (apico-+ - ectomy), root resection, retrograde root canal treatment (c.f. orthograde root canal treatment) or root- end filling, is an endodontic surgical procedure whereby a
14 tooth’s root tip is removed and a root end cavity is prepared and filled with a biocompatible
material. (Attachment 2)
Apicoectomy is done when previous endodontic treatment was not successful and after follow up tooth was with a lesion.
After apicoectomy new apical foramen becomes much more wider. There are rare cases in clinical practice when dental practitioners could consider to retreat and refill root with created wide apex after unsuccessful apicoectomy.
Over-instrumentation
Iatrogenic overinstrumentation promotes the enlargement of apical foramen, which may permit an increased influx of exudate and blood into the root canal [8]
Overinstrumentation or widening of root apex can happen during endodontic re-treatment when dental practitioner have to remove old cements, remove broken instruments or due to secondary chronic apical periodontitis.
The perforation caused by incorrect or over instrumentation of the canal can lead to difficulties during the obturation of the root canal and cause decreased success rate. [10]
Complication of root canal preparation
Canal transportation is an undesirable deviation from the natural canal path. It can result in endodontic retreatment using rotary instruments for cleaning and shaping of root canals.
Apical transportation is managed by different treatment strategy. Type II cases –need to make a barrier to control bleeding and provide a backstop to pack against during subsequent obturation procedures. In type III - requires obturation as best as possible after which is corrective surgery done.[6,7]
Apical resorption due to periapical pathology, orthodontics or trauma
2.2. Materials used for obturation of wide canals and open apex
Portland cement used in the construction industry is hydraulic. Since most dental
procedures are performed in a wet environment, Portland cement was introduced as an endodontic material; it was patented and became known as Mineral Trioxide Aggregate (MTA) [19]. This material is a modification form of Portland cement with bismuth oxide radiopacifier. The first reported use of Portland cement in dental literature dates back to 1878 when Dr. Witte from Germany published a case report on using Portland cement to fill root canals. [24,19]
MTA was the first bioceramic (BC) material introduced to clinical use as a rootend filling material and for repair of root perforations in endodontics in the mid-1990s. Its uses were later broadened to include its use as a root canal sealer, and also for apexification procedures .Since then
15 the indications for the use of MTA have widened, and several other bioceramic or “hybrid”
materials have been introduced.
Endodontic cements based on Portland cement have shown a higher level of trace elements, as waste materials are used as raw materials in its manufacturing for the construction industry.
Traces of arsenic, lead and chromium have been reported in both grey and white MTA. Although the levels of acid extractable trace elements are high, the amounts leached in solution are negligible. [19,20].
Due to these clinical problems, second-generation materials were developed that addressed the issue of trace elements and aluminium by using pure tricalcium silicate cement rather than Portland cement. [19]
With the introduction of the second-generation materials, a new term has also been introduced—bioceramics. With bioceramics, the purity of the materials, inert behaviour and their biocompatibility needed to be stressed.[19]
Bioceramic materials are based on tricalcium silicate or hydraulic calcium silicates.[19]. Such materials materials used in endodontics include : Alumina, Zirconia, Bioactive glass, Glass ceramics, Hydroxyapatite, resorbable Calcium phosphates[34]
Staining of tooth structure and slow setting times have been some of the potential downsides of the bioceramic cements, depending on the clinical situation.
Some of available materials in the market are presented in Table 3.
Table 3. Bioceramics used in endodontics.[39,34,40]
Company Matterial Radiopacifier
Calcium silicate based – Cements- Portland Cement, Mineral trioxide aggregate (MTA), Biodentine
Angelus(Brazil) MTA Fillapex Bismuth oxide,Barium
sulphate,Calcium tungstate
Septodont( France) Biodentine
EGO SRL,(Buenos Aires, Argentina
Endo CPM Sealer
Septodont, (France) BioRoot RCS Zirconium oxide
Profident, Kielce, Poland DRFP Ltd, Stanford, UK
TechBiosealer Smartpaste bio
Calcium phosphates/ tricalcium phosphate/ hydroxyapatite based Mixture of calcium silicates and calcium phosphates
16 Brasseler/FKG Savannah, GA, USA Endosequence BC/TotalFill [41]Root Repair Material Zirconium oxide
Innovative Bioceramix Inc., Vancouver, Canada);
Bioaggregate
developed at Argonne National Lab, Illinois, USA)
Tech Biosealer Ceramicrete
Innovative Bioceramix Inc., Vancouver, (Canada),
iRoot BP, iRoot BP Plus,iRoot FS
Zirconium oxide
Innovative Bioceramix Inc., Vancouver, Canada
Bioaggregate
Experimental calcium alumino-silicates.
Binderware, (São Carlos, SP, Brazil);
EndoBinder
Primus Consulting, Bradenton, FL, USA
Capasio
Quick-Set Capasio powder has been refined and renamed as Quick-set. Dentsply Tulsa Dental
Specialties, Tulsa, OK, USA
Generex A
BioniqueDent, Tehran, Iran CEM
Egeo CPM Bismuth oxide,barium sulphate
Maruchi Endoseal MTA Dicalcium silicate, Bismuth oxide, zirconium oxide
2.2.1. Comparative Analysis of materials used for obturation of wide canals and open apex
Many researchers concluded that MTA and Portland cement had similar microbiological, chemical, physical and biological properties.[24]. According to some authors, a apical plug for least amount of microleakage and superior sealing ability it is better to choose CEM/PRF than MTA [24].
Advantages and disadvantages of most widely used materials for obturation of open apex are presented in Table 4.
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Table 4..Materials used for obturation of wide open apex. Advantages and disadvantages.[ 4,19, 22,26].
Material Advantages Disadvantages Results
MTA 1)Biocompatibility 2) less cytotoxic nature
3) Suitable for apexofication because of
hydraulic nature and also the properties related to the formation and release of calcium hydroxide. 4)having the capacity to attract blastic cells and promote favorable conditions for cementum deposition 5) hydrophilic
6)Single visit apexofication 7) one visits application, 8) hard tissue induction 9)good-sealing properties 10)an alternative to the use of calcium hydroxide.
1)The initial setting time for MTA is 2 h 45 min to 3h.This extended setting time is a major drawback of MTA.
2) MTA being hydrophylic requires moisture to set( wet cotton)
3) discoloration potential, 4) difficult manipulation; . Mostly used in daily dental practice for apexofication and one single visit
obturation of wide open apices.
Biodentine 1)Dicreased setting time compared with MTA( by adding calcium chloride to liquid, it can harden in 9-12min.)
2)does not require a two step obturation, resulting in the
completion of treatment on the same day. With biodentine + PRF barrier+warm gutta percha we can do everything in one visit because of faster setting time, while doing calcium sulfate barrier +MTA at one visit and at second visit warm gutta
18 percha aplication. Bioceramic CEM TOTAL FILL (FKG, Brasseler) 1)biocompatibility, 2)non toxicity, 3)dimensional stability 4) bio-inert- most important in endodontics
5) similarity to Hydroxyapatite, an intrinsic osteo conductive activity 6) an ability to induce regenerative responses in the human body. 7) inorganic
8) non-metallic materials made by the heating of raw minerals at high temperatures [1]. Bio-ceramics are biocompatible ceramic materials or metal oxides with enhancedsealing ability, antibacterial and antifungal activity applied for use in medicine and dentistry. 9)heat resistant Nowadays number 1 used in endodontics for treatment of wide/open apices.
2.2.2.Methods used for obturation of wide canals and open apex
The aim of obturation is to establish a fluid-tight barrier with the aim of protecting the periradicular tissues from microorganisms that reside in the oral cavity [16]. While a perfect airtight or hermetic seal is unachievable in reality, every effort should be made to reach this target. The establishment of a well obturated system would serve three main functions:
1. Prevent coronal leakage of microorganisms or potential nutrients to support their growth into the dead space of the root canal system
2. Prevent periapical or periodontal fluids percolating into the root canals and feeding microorganisms
3. Entomb any residual microorganisms that have survived the debridement and disinfection stages of treatment, in order to prevent their proliferation and pathogenicity. [18]
19 The classical root canal obturation of a mature adult tooth relies on hermetic seal to prevent microbial recolonisation of the root canal. This is achieved through a barrier composed of gutta-percha and a sealer, which are impervious to percolation.
The classical treatment methods for filling the root canals of immature teeth are quite well-established in clinical practice. Open apices were treated with calcium hydroxide paste for an extended period of time to stimulate barrier formation at the apex, and the roots were then obturated in a similar way to adult teeth using a solid cone and root canal sealer.
With the introduction of bioceramics and related materials, treatment of the immature apex has been shortened to one to two visits. The introduction of these materials has certainly changed the clinical outcomes of filling the root canals. Treatment time has been reduced, which is
beneficial for the treatment of paediatric patients.[19]
Depending on the age of the patient and development stage of the tooth roots, treatment methodologies have been devided to fill the root canal, thus obliterating the dead space resulting after pulp removal. Two treatment methodologies exist for filling the root canal, with the choice depending on root development:
Apexification - procedures for immature roots(with wide root apices) Root canal obturation for fully formed roots.
For both procedures, the classical treatment methodologies have changed in the last 2 decades by way of the introduction of a new class of dental materials, which were introduced to overcome the deterioration of material properties in contact with moisture. [19]
Obturation of wide/open apices can be achieved in two visits apical plug ; one visit apical plug and apical plug using barrier material such as PRF.
Table 5. Methods and materials used for wide canal obturation. [4,19,22, 25, 27, 35,36,37]
Materials Used for Application
Apexofication- obturation for immature teeth Pure calcium
hydroxide powder is mixed with sterile saline (or anesthetic solution) to a thick (powdery) consistency
to create a calcific bridge, leaving a stunted root. Treatment involves several visits over a number of months. Also used for pulpotomy.
The CH is packed against the apical soft tissue with a plugger or a thick point to initiate hard tissue formation. (This step is followed by backfilling with calcium hydroxide to completely fill the canal thus ensuring a bacteria-free canal with little chance of reinfection during the 6 to 18 months required for the hard tissue formation at the apex. The calcium hydroxide is meticulously removed from the access cavity to the level of the root orifices, and a well-sealing temporary filling is placed. When a radiograph is
20
MTA(Table 6.)
to create a hard tissue barrier at the root end to one or two clinical session and after the tooth could immediately be restored normally.
Retrograde fillings, orthograde fillings(apical), pulp capping, perforation repair; treatment of teeth with open apexes, and repair of resorption defects.
taken, the canal should seem to have become calcified, indicating that the entire canal has been filled with the calcium hydroxide).
MTA is aplicated after desinfection of root canal.Calcium sulfate (or similar material) is pushed through the apex to provide a resorbable extraradicular barrier against which the MTA is packed. The MTA is mixed and placed into the apical 3 to 4 mm of the canal in a manner similar to the placement of calcium hydroxide. A wet cotton pellet can be placed against the MTA and left for at least 6 hours and then the entire canal filled with a root filling material or the filling can be placed immediately because the tissue fluids of the open apex may provide enough moisture to ensure that the MTA sets sufficiently.
Root canal obturation for fully formed roots
MTA, BioDentine,
Bioceramics
Sealers and GP
Modified cold lateral compaction
Endodontic uses- sealers, obturation, perforation repair, retrograde filling, pulpotomy, resorption, apexification, regenerative endodontics. Restorative uses- Dentin substitute, pulp capping, dentin hypersensitivity, dentin remineralization.[36][37]
Calcium silicate-based sealers (MTAfillaplex, iRoot SP, smartpaste bio).(Table 3.) given the excellent sealing properties and biocompatibility.
Biodentine is similar to MTA with its basic composition and has the addition of setting accelerators (calcium chloride) which can be used as its substitute.
These sealers need moisture present in the root canal to set. Bioceramic sealers can be used with either gutta-percha solid cones or bioceramic-coated cones. Hygroscopic points (CPoints) have also been suggested for use with bioceramic sealers.The single-cone obturation technique has been suggested for use with bioceramic sealers.Their hydraulic nature necessitates the presence of moisture in the root canal, which is further exacerbated by the existence of premixed sealers such as Root SP,Endosequence BC, TotalFill and Endoseal MTA.
MAP system are used to apply (Products Dentaires, Vevey, Switzerland)
For retrograde placement, either a carrier can be used or the material can be shaped in a Lee block
Used in combination with a GP points .
Warm lateral compaction using ultrasonics (energised spreading).Energised spreading is a modification of cold lateral compaction and follows the same A peizoelectric
21
Warm gutta-percha
the interrupted wave compaction technique is recommended for wider canals.
ultrasonic unit is required, as well as a file adaptor and a k-file.
Warm vertical compaction:
1)The continuous wave compaction technique –for
downpack :master GP cone System B (Sybroendo),Machtou orBuchanan plugger(Dentsply Maillefer,are used.; for backfilling -thermoplasticised GP(Obtura-Sybroendo; Calamus-Densply; D&L Super beta endo- D & L Biotech); 2) the interrupted wave compaction technique-very similar to the continuous wave, with the difference being that the downpack is carried out in multiple waves rather than one continuous wave is described.
Artificial Wide Apical barrier(that allows immediate obturation of the canal)
MTA Biodentine CEM(Calcium enriched mixture) PRF(Platelet rich fibrin); Tricalcium phosphate; Calcium sulfate.
a matrix of autologous fibrin, embedded with a large quantity of platelet and leukocyte cytokines during centrifugation can be successfully used as an apical membrane.[22]
as easy preparation, lack of biochemical handling of blood making this preparation strictly autologous, promotion of wound healing, bone growth, bone maturation, and hemostasis.A membrane can be obtained as a result of squeezing out the fluids in the fibrin clot of the prepared PRF.
2.3.Comparative Analysis of obturation techniques
The main difficulty associated while treating teeth with wide open apices are preventing the overfilling of the restorative materials that serve as an artificial barrier. Use of a matrix overcomes this challenge. Successful endodontic treatment needs to prevent leakage of intracanal irritants into the peri radicular tissues. Microbial tight seal of biomaterials as apical plug is mandatory. The considerable test is encountered by an operating clinician, especially treating teeth with wide open apices, is the successful prevention of periapical extrusion of the restorative material when used as an artificial apical plug, into the periodontal tissues. The extruded material may result in an inflammatory process, complicating to such an extent that the repair would impossible.
Care must be taken to avoid excessive lateral force during filling because of the thin walls of the root as well. It has been reported that approximately 30% of these teeth will fracture during
22 or after endodontic treatment . Restorative procedures should be assessed to ensure that they do not promote root fractures [4].
Conventional approach of apexification was to induce the formation of an apical barrier using multiple calcium hydroxide dressings, while the recent approach is to form an artificial apical barrier by the placement of restorative material as an apical plug.At present, there is no prospective long-term outcome study that compares the success rate of this technique with that of the traditional calcium hydroxide technique.[22]
Successful one step apexification and completion of the treatment on the same day of the
tooth with open apex using PRF membrane and an apical plug of Biodentine followed by the obturation of the root canal using injectable thermoplastisized gutta percha .
In comparison to MTA, using the CEM plugs in simulated opened apex teeth had a better result.[25].
MTA+ (Cerkamed), Biodentine (Septodont), and gutta-percha with AH Plus paste were compared. The lowest optical density was found for Biodentine. This material demonstrated the smallest X-ray contrast as compared with dentin. The best radiographic visibility was found for gutta-percha with AH Plus paste.[26]
According to setting time for MTA it is better two step obturation techniques (when obturation with gutta-percha is done after 24hours). After apical plug MTA requires adequate time for setting in the presence of the moisture, and final obturation with gutta-percha should be delayed until final MTA setting.
3. DISCUSSION
Wide open apex obturation may not accure very often in daily practise. As it is possibility to have such a cases 5% or even less of all the endodontic cases. By this review we should know that these kind of cases my occur more often at young age patients, patients with trauma, first upper incisors, can be also lower first premolars and also distal roots of lower molars and palatal root canals of upper molars.
It is known that wider canals have a statistically significant difference on non-preformed surfaces compared to narrow canals.[4] This also exacerbates the prognosis of endodontic treatment as unprotected surfaces increase the risk of secondary infection or failure of treatment. Successful apical obturation and coronal part of canal closure during endodontic treatment leads to a perfect prognosis and longevity for the tooth.
23 According to studies in vitro it is know that Calcium hydroxide as intra canal medicament used inter appointments had adverse effects : it can reduce white MTA properties for sealing[24]
Acording to studies in vitro ph enviroment and liquid used for mixture has significant effect for apical plugs [24]. Least amount of micro leakage was with Pro Root MTA mixed with normal saline.
EDTA, a routine irritant used to remove the smear layer, affects the chemistry of these calcium-containing materials as it is an established calcium chelator.
CONCLUSIONS
1. Bioceramic cements are materials of choice for obturation of wide canals and open apex. 2. Vertical condensation of particular cement and apical plug creation is widely used method for
obturation of wide canals and open apex. . One or two steps obturation techniques are recommended.
PRACTICAL RECOMMENDATIONS
Considering information from this systemic review in cases of wide root canals and with wide apices ( >#60) when obturation with gutta-percha main cone and sealer is doubtable and risky the use of apical plug of selected bioceramic cement would be recommended.
24
ANEXES
Attachment nr.1
Classification of root development stages: Very immature root development = the tooth has incomplete root formation or complete root formation with a wide-open apex. Immature root development = the tooth has full root formation and half-closed apex. Mature root development = the tooth has full root formation and a closed apex. [2]
Attachment nr. 2
Fig. 6. Periapical radiograph showing the previous apicoectomy, apical rarefaction and post of the
mesiobuccal root. [12] Attachment nr. 3
25 Apexification with MTA. The canal is disinfected with light instrumentation, copious irrigation, and a creamy mix of calcium hydroxide for 1 month, calcium sulfate is placed through the apex as a barrier to the placement of MTA, and 4-mm MTA plug is placed at the apex. The body of the canal is filled with Resilon obturation system (Pentron Clinical Technologies, Wallingford, CT, USA), and a bonded resin is placed to below the cementoenamel junction to strengthen the root. (Courtesy of Marga Ree, DDS, MSc, Purmerend, Netherlands.) [4]
26
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