Calcium-enriched mixture cement as artificial apical barrier: A case series

Abstract

In comparison to the conventional apexification using calcium hydroxide, artificial apical barrier technique is more valuable and less time consuming. This article describes successful use of calcium-enriched mixture (CEM) cement as an artificial apical barrier in open apices. In this study, 13 single-rooted teeth with necrotic pulps and open apices were treated non-surgically. After copious irrigation of the root canals with NaOCl 5.25% and gentle filing, based on need for interappointment dressing, treatments were followed by CEM cement (BioniqueDent, Tehran, Iran) apical plug insertion in the first or second appointment. All cases were then permanently restored. All subjects were followed until radiographic evidence of periradicular healing was seen (mean 14.5 months). Clinically, all cases were functional and asymptomatic and complete osseous healing was observed in all the teeth. Considering the biological properties of CEM cement, this new endodontic biomaterial might be appropriate to be used as artificial apical barrier in the open apex teeth.

Keywords: Apexification; CEM cement; apical plug; calcium enriched mixture; healing; open apex.

Figure 1

(a) Preoperative periapical radiograph of case1; a 24-year-old male with history of impact trauma to the anterior upper jaw which was referred for retreatment of tooth #9. Clinically, buccal and palatal swellings were present, and tooth 9 was sensitive to palpation and percussion. Radiographically, a large periapical radiolucent lesion was present on tooth #9, teeth #9 and 8 were immature, and both were inadequately obturated. (b) Postoperative radiograph after retreatment of teeth #9 and 8, and placement of CEM cement apical plug in tooth #9 and MTA apical plug in tooth #8, warm vertical obturation of remained canal spaces in both teeth with gutta-percha and sealer, and permanent coronal restoration of access cavities with bonded composite resin. (c) Follow-up radiograph at 18 months after treatment. Both teeth were functional and asymptomatic. The periapical lesion of tooth #9 completely healed

Figure 2

(a) Preoperative periapical radiograph of case 7; a 12-year-old female which was referred with swelling and pain in palpation in the right side of mandible. Clinically, the tooth #29 had occlusal carries and was necrotic and immature. (b) Postoperative radiograph after root canal disinfection and placement of CEM cement apical plug without interappointment dressing. (c) Follow up radiograph at 15 months after treatment. The tooth was asymptomatic without recurrence of swelling, and the periapical lesion completely healed

Figure 3

(a) Preoperative periapical radiograph of case 11; an 18-year-old male with chief complaint of sinus tract on maxillary left central incisor which was an immature necrotic tooth with history of trauma. (b) Postoperative radiograph after placement of CEM cement apical plug, warm vertical compaction of gutta-percha and sealer in the remained root canal space, and permanent coronal restoration. (c) Followup radiograph at 15 months after treatment. Sinus tract resolved and periapical lesion healed completely

Figure 4

(a) Preoperative periapical radiograph of case 6; an 18-year-old male with chief complaint of buccal swelling and pain in palpation on right mandibular second premolar under a bridge. The tooth had a previous inadequately obturated root canal treatment with recurrent caries and apical resorption. The tooth treated with inter-appointment dressing, CEM cement apical plug, and prefabricated post and bonded composite resin. (b) Follow-up radiograph at 15 months after operation. The tooth is functional without sensitivity to percussion or palpation

Figure 5

(a) Preoperative periapical radiograph of case 8; a 35-year-old female with chief complaint of buccal swelling and pain in palpation on maxillary left central incisor. The tooth had a previous inadequately obturated root canal treatment with apical resorption and a very slight apical rarefaction. (b) Post-operative periapical radiograph. (c) Follow-up radiograph at 12 months after treatment. The tooth was functional without recurrence of swelling and sensitivity to percussion and palpation.

Figure 6

(a) Preoperative periapicel radiograph of case 10; a 30-year-old female with chief complaint of sinus tract on maxillary left central incisor and history of impact trauma. The tooth was necrotic with internal and apical resorption. Treatment was performed without inter-appointment dressing. Because of presence of internal resorption in midroot, the canal space completely obturated with CEM cement. (b) Follow-up radiograph at 12 months after treatment. The sinus tract resolved and preiapical osseous lesion healed.