Successful nonsurgical retreatment of resected teeth associated with

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    Successful nonsurgical retreatment of resected teethassociated with persistent periapical lesion by placing tripleAntibiotic paste and mineral trioxide aggregate apical plug- A case report

    Sumanthini.M.V. #Vanitha.U.Shenoy #Rupali Deshmukh #Rahul Kumar #


    This article describes the nonsurgical management of traumatized teeth that had undergone apisectomy and associated

    with a large periapical lesion. A combination of antibacterial drugs consisting of metronidazole, ciprofloxacin and

    minocycline was used for root canal disinfection. The common problem encountered with this drug combination is

    tooth discoloration due to minocycline. Adhesive restoration was used to address this problem. Mineral trioxide

    aggregate apical plug was placed in the lateral incisor that had undergone unsuccessful root resection. On two year

    follow up the patient was asymptomatic and intraoral periapical radiograph showed successful healing with complete

    resolution of the periradicular lesion.

    Key words: Discolouration, mineral trioxide aggregate, retreatment, triple antibiotic paste.

    # Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai

    Introduction Endodontic surgery with root end resection

    often leaves a canal with an apex that is large in

    diameter creating an open apex.1 In the event of

    failure subsequent orthograde retreatment may be

    indicated. It is difficult to obtain a fluid tight apical

    seal in such teeth with open apices by using the

    conventional endodontic treatment methods due to

    absence of an apical barrier, against which

    obturation material can be compacted.

    Traditionally, multiple-visit apexification with

    calcium hydroxide (CH) was the treatment of choice

    in teeth with open apex, which would induce

    formation of an apical hard tissue barrier. Although

    successful, it takes anywhere from 3 to 18 months

    for the creation of physiologic hard tissue barrier.2

    The disadvantages of this technique is multiple

    treatment appointments, coronal leakage, and

    increased susceptibility of tooth fracture.3,4 An

    alternative technique for apexification with CH is

    to seal the open apical foramen with mineral

    trioxide aggregate (MTA) apical plug. Considerable

    success has been reported recently with this

    technique in treating permanent teeth with

    immature apices which is attributed to its ability to

    induce periradicular tissue regeneration,

    biocompatibility, good sealing ability and enables

    treatment to be completed in a short frame of time.5

    MTA has been found to be an appropriate material

    for apical sealing of mature root canals with open

    apex as a result of over instrumentation, resorption

    or former apisectomy.6,7

    The major causative role of microorganisms

    in the pathogenesis of persistent periapical diseases

    is well documented and considered to be


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    polymicrobial. A combination of antimicrobial

    drugs consisting of metronidazole, ciprofloxacin and

    minocycline has been shown to be very effective in

    eliminating endodontic pathogens in vitro and in

    vivo. In combination, these drugs were able to

    consistently sterilize all samples.8Among the

    components of the mixture, minocycline, a

    semisynthetic derivative of tetracycline has the

    potential to induce tooth discolouration.9

    Anticipating this, as a precaution, adhesive

    restorative techniques need to be adopted from the

    beginning of commencement of treatment in order

    to prevent discolouration from occurring.

    The following case report describes nonsurgical

    endodontic retreatment of teeth that had undergone

    apical root resection and was associated with a

    persistent large periradicular lesion.

    Case ReportA 26 year old female patient was referred to

    Department of conservative dentistry and

    endodontics, with a chief complaint of pain and

    swelling in maxillary left central incisor (21) and

    maxillary left lateral incisor (22) since one month.

    The patient gave a history of root canal treatment in

    the 21, 22 and maxillary left canine (23) followed

    by surgical root resection in 21 and 22. Clinical

    examination revealed an intraoral, labial swelling

    and sinus tract at the apex of 21 [Fig 1a]. The access

    cavities were restored with tooth coloured

    restorations. Tooth number 22 was tender on

    percussion and 23 were asymptomatic. Maxillary

    right central incisor (11) had a mesial angle fracture

    involving enamel and tested vital. Intraoral

    periapical radiograph revealed large periapical

    rarefactions in 21 and 22, obturation in both teeth

    were below acceptable standards and the root ends

    were resected [Fig 1b]. A Gutta percha cone is

    radiographically seen tracing the source of infection

    to 21[Fig 1c]. In view of the signs and symptoms

    Fig 1a: Preoperative intraoral picture of maxillary left central andlateral incisors with swelling and sinus tract apical to maxillary leftcentral incisor, mesioangle fracture in maxillary right central incisor.

    Fig 1b: Preoperative intraoral periapical radiograph revealing largeperiapical lesion in relation to maxillary left central and lateral incisors,obturation not meeting acceptable standards and resected root apex

    Fig 1c: Intraoral periapical radiograph showing gutta-percha conetracing the sinus tract to the root apex of 21.


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    presented, a diagnosis of acute exacerbation of

    chronic alveolar abscess was arrived at. Non-

    surgical retreatment of the involved teeth was

    planned. Patients medical history was


    All the clinical steps were performed under

    rubber dam isolation (Hygienic Dental Dam,

    Coltne Whaledent, Germany). The coronal

    restorations and gutta-percha root canal filling was

    removed from 21 and 22. Pus exuded through the

    canal of 22, canal was irrigated with normal saline

    to facilitate drainage. A loose sterile cotton pledget

    was placed in the pulp chambers of both teeth

    followed by thin closed dressing of zinc oxide

    eugenol (DPI, Mumbai, India). Patient was recalled

    the following day; her acute symptom of pain had

    subsided. Canals were re-entered, working length

    established by radiographic method [Fig 1d]. Root

    canals were cleaned and shaped with hand files by

    step back technique to a #60 ISO size K file (Mani

    INC, Japan). During instrumentation, the canals

    were copiously irrigated with 5% sodium

    hypochlorite (NaOCl) (Trifarma, Thane, India)

    intermittently. A thick paste of CH (Deepashree

    Fig 1d: Working length radiograph, note the lack of apical stop inmaxillary left lateral incisor

    Products, Ratnagiri, India) and saline was packed

    within the canal and temporized with zinc oxide

    eugenol cement. The CH dressing was changed

    every week for 3 weeks.

    As the symptoms of pain and swelling were

    not alleviated, triple antibiotic paste (TAP) was

    considered for the intracanal dressing, consisting

    of ciprofloxacin 250mg (Ciplox, Cipla Ltd, Mumbai,

    India) metronidazole 400mg (Flagyl, Abbott Health

    care private limited, Thane, Maharashtra, India ) and

    minocycline 100mg (Minoz, Ranbaxy Laboratories

    Limited, India) after obtaining patients consent.

    Prior to the placement of the paste (TAP), adhesive

    restoration was placed in the pulp chamber. The

    root canal orifices of teeth 21 and 22 were blocked

    with a large gutta percha point. The pulp chamber

    was etched with 37 %phosphoric acid (SS White,

    Dental Pvt.Ltd. England) for 15 seconds and rinsed

    with water. A total etch adhesive (Tetric N-Bond,

    Ivoclar Vivadent, Liechtenstien) was applied

    according to manufacturers instructions, followed

    by placement of composite resin( Tetric N-Ceram,

    Ivoclar Vivadent, Schaan, Liechtenstien) on the

    internal walls of the pulp chamber and light cured.

    Hundred milligrams of each drug was obtained

    after removal of the enteric coating. The drugs were

    pulverized in sterile mortar and pestle separately

    and mixed in 0.5 ml of propylene glycol (Desmo

    exports limited, Mumbai, India) in a sterile dappen

    dish. The TAP was freshly prepared just prior to

    insertion in the canal. It was placed in the canals

    using lentulospirals (Mani INC, Japan) 1mm short

    of the working length and 2 mm short of the canal

    orifice. A cotton pledget was placed and the access

    cavity sealed with Glass ionomer cement (Type II

    GC Universal restorative, Tokyo, Japan). The paste


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    was changed every month for a period of three

    months, after which the symptoms of pain and

    swelling resolved. On examination, sinus tract had

    healed, soft tissues were healthy and the teeth

    showed no signs of discoloration due to

    minocycline (Fig 2a). The antibiotic medication was

    removed with K- files and irrigation with

    5%NaOCl. Root canal of tooth 21was dried with

    sterile paper points (Dentsply Maillefer Ballaigues