Journal of Conservative Dentistry
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Year : 2007  |  Volume : 10  |  Issue : 2  |  Page : 48-52
A single step apexification and Intra-radicular rehabilitation of fractured tooth - a case report

Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India

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When teeth with incomplete root formation suffer pulp necrosis, the root development ceases and apical closure cannot be achieved. Root canal treatment at this time is a significant challenge, because of the size of the canal, the thin and fragile dentine walls and the large open apex. The goal of apexification was to obtain an apical barrier to prevent the passage of toxins and bacteria into the periapical tissues from the root canal. MTA appeared to be a valid option for apexification with the added advantage of speed of completion of therapy. The reinforcement of the composite resins by fibers improves their fracture toughness and resistance. The Fiber reinforced composite resin can be a good alternative to conventional post systems. The aim of this article was to present a clinical case of fractured anterior teeth with open apex where single step apexification was done with MTA and intraradicular rehabilitation was done with fiber reinforced composite.

Keywords: Single step apexification, Mineral trioxide aggregate and Fiber reinforced composites.

How to cite this article:
Hemamalathi S, Venkateshbabu N, Kandaswamy D. A single step apexification and Intra-radicular rehabilitation of fractured tooth - a case report. J Conserv Dent 2007;10:48-52

How to cite this URL:
Hemamalathi S, Venkateshbabu N, Kandaswamy D. A single step apexification and Intra-radicular rehabilitation of fractured tooth - a case report. J Conserv Dent [serial online] 2007 [cited 2023 Sep 21];10:48-52. Available from:

   Introduction Top

Cessation of root development caused by trauma or pulpal disease presents both an endodontic and restorative challenge. The divergent apical architecture makes complete debridement and control of the obturation material nearly impossible. Apexification is defined as a method of inducing a calcified barrier in a root with an open apex [1] .

Various materials have been suggested for use in the apexification process, but calcium hydroxide has gained the widest acceptance. Frank in 1966 first described the apexification using calcium hydroxide [2] . Calcium hydroxide is bactericidal with an alkaline Ph that may be responsible for stimulating apical calcification [3] . Despite its popularity, it has some disadvantages including variability of treatment time [4],[5] difficulty in patients follow up, delayed treatment [6] and it reduces the fracture resistance of the tooth [7] .

An alternative for multiappointment apexification procedure has been a single- step technique using an apical barrier. Shabahang et al advocated MTA as an apexification material because it permits an adequate seal of the canal and prevents bacterial leakage [6] . Torabinejad et al advocated the use of Mineral trioxide Aggregate (MTA) as a perforation repair material. MTA is a colloidal gel that solidifies to a hard structure and can be used to seal perforations [8] . Sarkar et al reported the propensity of MTA to release calcium and its ability to form hydroxyapatite and concluded that sealing ability, biocompatibility and dentinogenic activity of MTA is attributed to these physicochemical reactions [9] . MTAhas ability to form dentin bridge. Other applications of MTA include direct pulp capping [8] , external root resorption repair [10] and partial pulpotomy [11] . The initial and final setting time of MTA was found to be 45 minutes and 2 hours 45 minutes respectively [12] .

In open apex teeth, the root canal walls are too fragile and may be too weak to withstand the normal forces of mastication, becoming more prone to fracture [3] . Composite resin materials, capable of bonding to dentin, create the potential to internally rebuild the root, providing dimensional and structural reinforcement. Pene et al demonstrated that the strength of an immature tooth could be improved significantly by using a bonded composite technique to fill the canal space [13] .

Ribbond is a FRC, which is made up of polyethylene fibers. It is a spectrum of 215 fibers with a very high molecular weight. These fibers have a very high coefficient of elasticity (117 Gpa), so it has an excellent resistance to stretch and distortion. They also have a very high resistance to traction (3 Gpa), as a result of their closed stitch configuration and a good adaptability. Bondable reinforcement fibers are also characterized by impact strength five times higher than that of iron. They are translucent and assume the color of the resin to which they are added. Bondable reinforcement fibers easily absorb water because of the gas plasma treatment to which they are exposed. This treatment reduces the fibers superficial tension, ensuring a good chemical bond to composite materials [14],[15],[16] . Eskitascioglu S and Belli S reported a case where a bondable reinforcement fiber was used for post and core build up in endodontically treated teeth [17] .

This case reports, the use of fiber-reinforced composite (Ribbond) and MTA in the management of a fractured tooth with an open apex is discussed.

   Case report Top

A 27 year old male patient came to the Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital with the chief complaint of broken upper front tooth. He gave a history of fall 14 years back. On examination, the maxillary left lateral incisor was fractured. The fracture was present in the middle third of the crown [Figure 1]. Radiograph revealed a middle third crown fracture in maxillary left lateral incisor and apex was not completely formed [Figure 2]. Vitality tests showed no response. No mobility was present. A single step apexification of the tooth with MTA was planned for the maxillary lateral incisor followed by post and core build up with fiber-reinforced composite (Ribbond).

In the maxillary left lateral incisor, local anesthetic agent was administered and the tooth was isolated with rubber dam. Access opening was done by using endo access bur [Figure 3]. Working length was determined by using K file [Figure 4]. Cleaning and shaping was done up to 90 size k-file. The canal was irrigated with 2.5% of sodium hypochlorite and dried with sterile paper point. Pro root MTA (Dentsply Tulsa Dental, Johnson city, USA) was mixed according to manufacturer instructions. When it reached a thick creamy consistency, it was placed inside the canal using a plastic instrument. The material was packed with hand plugger into the canal and a wet cotton pellet was used to condense the material for a thickness of 4mm. Moist cotton was placed over MTA. The placement of MTA was verified by taking radiograph [Figure 5].

On the next day, the length of the pulp space from coronal to the MTA was measured. This length was doubled and length of the fiber was measured. Two pieces of fiber were then cut with special scissors. Ribbon pieces (Ribbond Reinforcement Ribbon, Ribbon, Scottle, WA, USA) were coated with bonding agent (Scotchbond 1,3M Dental products, St.Paul, MN, USA) and excess was blotted out. The ribbons were folded in a V shape and the inside of Vs was coated with dual cure resin (Relyx Arc, 3M ESPE, St paul, USA). The first piece of ribbon was then placed in the post space in a facio lingual orientation [Figure 6]. A second V of ribbon was then placed at right angles to the first ribbon piece [Figure 7]. The ribbons were condensed and a small drop of dual cure resin was then placed between the ribbons. Then the core build up was done with composite resin (3M ESPE, St paul, USA) [Figure 8] and cured [Figure 9]. The patient was followed up for a period of 14 months.

   Discussion Top

During long apexification procedure, the root canal is susceptible to reinfection and the canal is susceptible to fracture during treatment [3] . Hence, single step apexification was planned for this case. MTA had been proved to show good sealing ability [18] , good marginal adaptation [18] and a high degree of biocompatibility [8,] [19] . As observed in radiographs from this case report, periapical radiolucency has been decreased in size. MTA can be placed as an obturating material to promote periapical healing of root canals with open apex [3] .

Composite materials have poor mechanical resistance. Approaches to strengthening composite materials have included reinforcing their resinous matrix with fibers [20] . Poly ethylene fibers improve the impact strength, modulus of elasticity and flexural strength of the composite resins. Marina Consuelo Vitale et al reported two cases using polyethylene fibers and composite resins in restoration of traumatized anterior teeth. The advantages of FRC include minimum tooth structure removal and immediate treatment. This esthetic and flexible fiber- resin composite is reported to minimize micro crack propagation in the root.

Hachmeister et al has reported that a more favorable long term prognosis for pulpless immature teeth can be achieved with an MTA apexification procedure followed by internal bonding with resin materials. The combination of apexification and subsequent internal bonding treatment may eliminate treatment problems that accompany the pulpless immature tooth. This technique of using MTA as an apical barrier and rehabilitation of tooth with FRC decreases treatment time and possibly improves the long term prognosis.

   Conclusion Top

The MTA apexification and FRC (Ribbond) technique for core build-up and internal rehabilitation can potentially eliminate the lengthy apexification procedure and allow internal bonding to be performed much earlier in treatment process.[21],[Figure 10]

   References Top

1.American Association of Endodontists. Glossary of endodontic terms, 7th edn. Chicago: American Association of Endodontists; 2003.  Back to cited text no. 1    
2.Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. JAm Dent Assoc 1966;72:87-93  Back to cited text no. 2    
3.Apexification: a review. Dent Traumatol 2005, 21,1-8  Back to cited text no. 3    
4.Finucane D, Kinirons MJ. Non-vital immature permanent incisors: factors that may influence treatment outcome. Endod Dent Traumatol 1999;15:27-37.  Back to cited text no. 4    
5.Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J 1997;183:2416.  Back to cited text no. 5    
6.Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineraltrioxide aggregate in dogs. J Endod 1999, 25, 15.  Back to cited text no. 6    
7.Andreasen JO, Farik B, Munksgaard EC. Long­-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traum 2005,18,1347.  Back to cited text no. 7    
8.Torabinejad M, Chivian N. Clinical application of mineral trioxide aggregate. J Endod 1999, 25, 197-205.  Back to cited text no. 8    
9.Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kavashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005,31,97-100.  Back to cited text no. 9    
10.White C, Bryant N. Combined therapy of mineral trioxide aggregate and guided tissue reeration in the treatment of external root resorption and an associated osseous defect. J periodont 2002, 73,1517-21.  Back to cited text no. 10    
11.Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate. For partial pulpotomy in cariously exposed permanent teeth. J Endod 2006, 32,731- 5.  Back to cited text no. 11    
12.Nandini S, Suma Ballal, Kandaswamy D Influence of Glass ionomer cement on the interface and setting reaction of mineral trioxide aggregate. When used as a furcal repair material using laser raman spectroscopic analysis. J Endod2007,33, 167-1.  Back to cited text no. 12    
13.Vallittu PK. Ultra high modulus polyethylene ribbon as reinforcement for denture polymethyl methacrylate, a short communication. Dent Mater 1997; 13: 381 382  Back to cited text no. 13  [PUBMED]  
14.Gutteridge DL.The effect of including ultra high modulus polyethylene fiber on the impact strength of acrylic resin. Br Dent J 1988, 164: 177 180.  Back to cited text no. 14  [PUBMED]  
15.Dixon DL, Breeding LC. The transverse strengths of three denture base resins reinforced with polyethylene fibers. J Prosthet Dent 1992; 67:417 419  Back to cited text no. 15  [PUBMED]  
16.Eskitascioglu S, Sema Belli Use of a bondable reinforcement fiber for post and core build up in an endodontically treated tooth: A case report. Quintessence Int 2002, 33: 549-551.  Back to cited text no. 16    
17.Karabucak B, Li D, Lim J. Vital pulp therapy with mineral trioxide aggregate. Dent Trauma 2005,21,240-3.  Back to cited text no. 17    
18.Shahi S, Rahimi S, Lofti M, Yavari HR. A comparative study of the biocompatibility of three root end filling materials in rat connective tissue. J Endod 2006, 32, 776- 9.  Back to cited text no. 18    
19.Samadzadeh A,Kugel G.Fracture strengths of provisional restorations reinforced with plasma treated woven polyethylene fiber. J Prosthet Dent 1997; 78: 447-449.  Back to cited text no. 19    
20.Marina Consuelo Vitale, Claudia Caprioglio, Alessandara Martignone, Umberto Marchesi, A.R.Botticelli. Combined technique with polyethylene fibers and composite resins in restoration of traumatized anterior teeth. Dent Traumatol 2004, 20: 172-177  Back to cited text no. 20    
21.Hornbrook D, Hastings Rj. Use of bondable reinforcement fiber for post and core build up in an endodontically treated tooth: maximizing strength and aesthetics. Pract PeriodontAesthet Dent 1995; 7; 33-42  Back to cited text no. 21    

Correspondence Address:
SenthilKumar Hemamalathi
Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.42291

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

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