CAUSES OF OPEN APICES

1. Incomplete development The open apex typically occurs when the pulp undergoes necrosis as a result of caries or trauma, before root growth and development are complete (i.e. during stages 1-4) An open apex can also occasionally form in a mature apex (stage 5) as a result of 2. Extensive apical resorption due to orthodontic treatment, periapical pathosis or trauma 3. Root end resection during periradicular surgery 4. Over-instrumentation

Stage 1
Teeth with wide divergent apical opening and a root length estimated to less than half of the final root length.

Stage 2
Teeth with wide divergent apical opening and a root length estimated to half of the final root length.

Stage 3
Teeth with wide divergent apical opening and a root length estimated to two thirds of the final root length.

Stage 4
Teeth with wide open apical foramen and nearly completed root length.

Stage 5
Teeth with closed apical foramen and completed root development.

MANAGEMENT OF INCOMPLETELY DEVELOPED NON VITAL TEETH

_ Management

of open apices

_ Obturation without creating apical barrier3 _ Customized cone technique using - blunted tips - inverted cones - apical impression heat chemicals - rolled cone heat chemicals _ Thermoplasticized obturation _ Short fill technique Obturation after creating apical barrier _ Root end induction of calcific barrier/ apexification3,5 - induction of blood clot in the periradicular region - antibiotic pastes - calcium hydroxide mixed with various materials - collagen calcium gel

- bone morphogenic proteins - tricalcium phosphate _ Placement of artificial barriers (root-end filling materials) - amalgam - glass ionomer cement - composite - mineral trioxide aggregate6 - calcium hydroxide powder - freeze dried bone/dentin - resorbable ceramic - tricalcium phosphate - dentinal shavings This is the case of a 28-year-old male patient with a history of trauma to tooth number 8 when he was a child. As Figure 1 clearly shows, there was incomplete root formation including the absence of apical closure. There was also evidence of a periapical radiolucency. The patient came in with symptoms of abscess, including pain and periapical swelling. I placed him on antibiotics and analgesics to control the acute symptoms and we scheduled another appointment for treatment. Initially, it looked as if it would be a cut-and-dried case of obturation and immediate apicoectomy. When he returned in two weeks, the acute symptoms had abated, and I initiated treatment. I opened the access as wide as possible without compromising the crown, achieved measurement control with an apex locater, confirmed it by radiograph (Figure 2), and accomplished instrumentation with instruments as wide as a #140 reamer. I utilized large-diameter hedstrom files along the canal walls to check for tissue and debris. Now, how in blazes was I going obturate? I was able to dry the canal and then pack MTA cement to the apical measurement, using the reverse side of a coarse paper point until there was some apical resistance, thus creating a stop. Using cotton wrapped around a large diameter file, I cleaned the excess cement from the canal walls. I then placed EZ-Fill cement, using the bi-directional spiral, and thus the canal was flooded with sealer. I reversed a large gutta-percha cone, dipped it into solvent for three seconds, and placed it to measurement control. Using a spreader with no apical pressure, I laterally condensed the mass of gutta-percha, then coated a second large cone with sealer and placed it into the canal in the normal direction. Since research has shown that AH-26 based EZ-Fill sealer alone would be good enough to seal the canal, the gutta-percha core only helps to force the sealer against the MTA stop and the canal walls, leading to the final result seen in Figure 3. Immediate surgery was not necessary, and the patient walked out very happy. The dentist also felt satisfied with the result, but only time will decide the ultimate success in the case of this blunderbuss.