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Table of Contents
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 148-151

Surgical management of overfilled gutta-percha and root capping with mineral trioxide aggregate in a young patient

1 Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Melaka Manipal Medical College, Manipal University, Melaka, Malaysia
2 Department of Paedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India

Date of Web Publication18-Dec-2014

Correspondence Address:
Suprabha Baranya Shrikrishna
Department of Paedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5194.147336

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Overfilled gutta-percha (GP) can lead to failure of root canal treatment. Management of overfilled GP may require periradicular surgery with root end procedures. However, these procedures have drawbacks, particularly in a young patient. This article describes a case of periradicular cyst due to overfilled GP managed by periradicular surgery. Root capping at the apex was carried out with mineral trioxide aggregate (MTA) instead of root end procedures. MTA root capping promoted apical build up, sealing and periapical healing.
Clinical Relevance To Interdisciplinary Dentistry

  1. The article describes a technique called "root capping" that can be carried out during periradicular surgery instead of root end procedures in a young patient.
  2. This technique is of clinical importance due to challenges encountered during endodontic treatment in permanent teeth of young patients such as thin dentinal walls.
  3. The need for periradicular surgery in the management of periapical lesions due to overfilled gutta-percha is emphasized.

Keywords: Gutta-percha, mineral trioxide aggregate, periradicular surgery

How to cite this article:
Vivekananda Pai A R, Shrikrishna SB, Shah N. Surgical management of overfilled gutta-percha and root capping with mineral trioxide aggregate in a young patient . J Interdiscip Dentistry 2014;4:148-51

How to cite this URL:
Vivekananda Pai A R, Shrikrishna SB, Shah N. Surgical management of overfilled gutta-percha and root capping with mineral trioxide aggregate in a young patient . J Interdiscip Dentistry [serial online] 2014 [cited 2023 Mar 29];4:148-51. Available from: https://www.jidonline.com/text.asp?2014/4/3/148/147336

   Introduction Top

Overfilled root canals occur due to inflammatory apical root resorption, incompletely formed root apex, faulty working length and instrumentation through the apical foramen. [1] Overfilling in these cases occurs due to difficulty in obtaining an apical stop. This results in lower success rate of only 76%, although in general, 85-95% success has been reported for root canal treatment. [1],[2] Treatment failures following overfilled gutta-percha (GP) is due to factors such as persistent root canal infection, reinfection resulting from apical transportation of bacteria during over instrumentation and foreign body reaction elicited by the overfilled GP itself. [3]

Root canal failure following GP overfilling can be managed by nonsurgical method or periradicular surgery or both. Periradicular surgery is indicated in case of significant overextension of filling material resulting in periradicular pathosis with symptoms, true periradicular cysts with completely enclosed epithelium-lined cavities which are not expected to resolve after nonsurgical dental treatment, persistent periradicular pathosis and correction of deficiencies in previous treatment. [4] Periradicular surgery in a young patient is less satisfactory, as it often results in a less desirable outcome due to the associated discomfort, need for patient cooperation and possibility of behavior management problems during future dental appointments. [5]

The aim of endodontic surgery is to remove the periradicular pathosis and restore health and function of tooth periodontium. This includes curettage of the periapical pathosis followed by root end resection, preparation and filling for apical sealing. The root end procedures are associated with many drawbacks such as limited accessibility, risk of perforation and fractures or cracks at the root end and the need for high cost equipment such as ultrasonic systems and surgical microscopes. [6] Additionally, in a young permanent incisor, root end cavity preparation can be a challenge due to the presence of thin dentin walls and potential for its further thinning during preparation. [3],[5] Moreover, the process of root end resection and cavity preparation often results in microcracks within dentin and weakens the remaining root structure. [7] In general, a root end resection of minimum 3 mm is recommended. [6] This can lead to a significant shortening of the root, resulting in decreased crown-root ratio, particularly in the presence of an undeveloped or open root apex. [5] Similar drawbacks can also be anticipated in case of a weakened and shortened apical portion due to over instrumentation. Under these circumstances a novel method called "root capping" procedure explained in this article may be considered for apical build up and sealing.

This case report illustrates successful surgical management of overfilled GP and root capping with mineral trioxide aggregate (MTA) in a young patient.

   Case report Top

A 13-year-old male patient was referred with a chief complaint of pus discharge and foul smell in the upper front region since 8 months. He gave a history of mild intermittent pain and occasional swelling. The patient gave a history of fall in playground resulting in crown fracture of upper central incisors followed by root canal treatment in both, 2 years back. Clinical examination revealed a draining sinus in relation to 21 and faulty composite restoration in both 11 and 21. Intraoral periapical radiographic examination showed GP obturation in both 11 and 21. However, 21 showed about 8 mm of grossly overfilled GP extending into large periapical radiolucency (approximately size 7 mm × 15 mm). Overfilled GP in 21 seemed to have occurred following loss of apical stop due to over instrumentation as there was external transportation, thinning of apical portion and slight shortening of root length (as compared to 21). Further, the GP in coronal one-third canal was loosely compacted and extended into the pulp chamber [Figure 1]a. Sinus tracing with a GP point confirmed its origin to 21. Considering the above findings, a clinical diagnosis of infected periradicular cyst was made and a treatment consisting of periapical surgery and root capping with MTA was carried out.

Following adequate local anesthesia and surface disinfection of the surgical site, a submarginal (Ochsenbein-Luebke) flap was elevated. Upon flap reflection, a large alveolar bony defect with a protruding mass of granulation tissue and purulent discharge was noticed. The granulation tissue was gently lifted away from the lateral borders of the bony defect and curetted out using scraping motion and sent for histopathological examination. Following curettage, overfilled GP portion became evident [Figure 1]b and was resected [Inset, [Figure 1]c using a surgical blade. After achieving hemostasis, the GP at the root tip was burnished with a hot burnisher and then root capping with MTA (Angelus, Londrina, PR, Brazil) was carried out. MTA was mixed with distilled water as per the manufacturer's instructions. It was carried using an amalgam carrier, directly deposited over the apical portion and contoured into a dome shaped root capping for apical build up and sealing [Figure 1]c. Any excess was removed and following radiographic verification [Figure 1]d, the flap was repositioned and sutured in place. The patient was given the postoperative instructions. Histopathologic examination report confirmed that the lesion associated with 21 was a periradicular cyst.
Figure 1: (a) Preoperative periapical radiograph, (b) clinical view after curettage of periapical lesion (c) clinical view showing root capping with mineral trioxide aggregate (MTA) (Inset shows the resected overfilled gutta-percha portion). (d) Immediate post-operative periapical radiograph following MTA root capping

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The deficient part of the coronal third obturation in 21 was removed and filled with type II glass ionomer cement (GC Corporation, Tokyo, Japan). The defective restorations in 21 and 11 were removed and restored with composite resin (Z350, 3M ESPE, St. Paul, USA). In a subsequent visit, both the teeth were prepared and cemented with acrylic provisional crowns. At 3 and 6 months follow-up, the patient was clinically asymptomatic with radiographic evidence of significant amount of periapical healing. However, interestingly in the 6 month follow-up radiograph, a portion of MTA capping was seen to be lifted off from the apical root portion [Figure 2].
Figure 2: (a) At 3 months, periapical radiograph shows initial signs of periapical healing. (b) At 6 months periapical radiograph shows good periapical healing

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   Discussion Top

The occurrence of the periradicular cyst after root canal treatment in our case can be attributed to over instrumentation resulting in trauma to the periapical tissues, apical transportation of the intracanal bacteria, lack of apical seal and overfilled GP during the previous root canal treatment. This evokes a persistent chronic inflammation with a tendency toward epithelial proliferation leading to cyst formation. [3],[8]

Though patient was young, periapical surgery was employed in this case as the endodontic failure was associated with periradicular cyst, over instrumented apical portion and overfilled GP, which was dense and significant in size. Retreatment by removal of GP filling using Hedstrom files and solvents such as chloroform or xylene may be considered only in case of poorly condensed GP fillings. In case of overextended obturation with good adaptation of GP cones, if the same method is used, GP fragments often remain in the periapical tissue. [9] Further, failed root canal treatment cases with periradicular cysts due to apical transportation or procedural errors are best treated by surgical endodontics as the complexity of the canal anatomy does not allow 100% success in nonsurgical endodontic therapy. [6]

Since the major cause of periapical lesions is an improper apical seal along with egress of microorganisms and their toxins, obtaining an apical seal with root end materials having good sealing ability is important. [6] Hence, root capping must employ a material promoting superior apical sealing in order to be successful and advantageous in the absence of root end procedures.

Mineral trioxide aggregate is often preferred as root-end filling material due to its favourable biological properties such as biocompatibility with periradicular tissues, capacity to stimulate osteogenesis and cementum deposition, has antibacterial activity, better marginal adaptation and sealing properties compared to other root end materials. In addition, it is dimensionally stable, resistant to dissolution, radiopaque, hydrophilic and can be used in the presence of blood . [3],[10],[11] Due to these reasons, MTA was considered as the most suitable material for root capping.

Root capping with MTA done in this case maintained the root length and crown-root ratio. It avoided the need for root end procedures with their associated drawbacks in the presence of a weakened or thinned apical portion due to over instrumentation. The dislodgement of a portion of MTA from the root end and intermingling with regenerated bone was seen at 6 month follow up. This can be attributed to pressure during bone remodeling as a part of periapical healing. Similar healing pattern has been reported in cases with apically extruded MTA. [12] It may be anticipated that periapical tissue are naturally programmed to heal with a memory to get restored back to their original form, displacing any material found in its way. This coupled with absence of any form of retention for MTA capping may have led to its dislodgement during periapical healing. This could be a potential drawback of a root capping procedure over root-end filling. In this regard, use of a material that bonds to root surface and yet has all the benefits of MTA may be more beneficial. Nevertheless, root capping with MTA can have potential clinical advantage over root end procedures in selected cases, as it maintains apical seal and promotes periapical healing.

   Conclusion Top

Periradicular surgery can be the treatment of choice in a young patient to manage endodontic failure associated with over instrumentation and overfilled GP. Root capping with MTA is potentially advantageous over root end procedures for sealing the shortened over instrumented apical portion.

   References Top

Lin LM, Rosenberg PA, Lin J. Do procedural errors cause endodontic treatment failure? J Am Dent Assoc 2005;136:187-93.  Back to cited text no. 1
Khabbaz MG, Papadopoulos PD. Deposition of calcified tissue around an overextended gutta-percha cone: Case report. Int Endod J 1999;32:232-5.  Back to cited text no. 2
Johnson BR, Fayad MI, Witherspoon DE. Periradicular surgery. In: Hargreaves KM, Cohen S, Berman LH, editors. Pathways of the Pulp. 10 th ed. Missouri: Elsevier Inc.; 2011. p. 720-76.  Back to cited text no. 3
Nair PN. New perspectives on radicular cysts: Do they heal? Int Endod J 1998;31:155-60.  Back to cited text no. 4
Weine FS. Endodontic Therapy. 6 th ed. St. Louis, Missouri: Elsevier Mosby; 2004. p. 349-422.  Back to cited text no. 5
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006;32:601-23.  Back to cited text no. 6
Layton CA, Marshall JG, Morgan LA, Baumgartner JC. Evaluation of cracks associated with ultrasonic root-end preparation. J Endod 1996;22:157-60.  Back to cited text no. 7
Ektefaie MR, David HT, Poh CF. Surgical resolution of chronic tissue irritation caused by extruded endodontic filling material. J Can Dent Assoc 2005;71:487-90.  Back to cited text no. 8
Metzger Z, Ben-Amar A. Removal of overextended gutta-percha root canal fillings in endodontic failure cases. J Endod 1995;21:287-8.  Back to cited text no. 9
Bernabé PF, Gomes-Filho JE, Rocha WC, Nery MJ, Otoboni-Filho JA, Dezan-Júnior E. Histological evaluation of MTA as a root-end filling material. Int Endod J 2007;40:758-65.  Back to cited text no. 10
Castellucci A. The use of mineral trioxide aggregate in clinical and surgical endodontics. Dent Today 2003;22:74-81.  Back to cited text no. 11
Chang SW, Oh TS, Lee W, Cheung GS, Kim HC. Long-term observation of the mineral trioxide aggregate extrusion into the periapical lesion: A case series. Int J Oral Sci 2013;5:54-7.  Back to cited text no. 12


  [Figure 1], [Figure 2]

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