Open apex management: A complex clinical case

Advanced strategies for open apex management: Apical control and material selection

Overview

In this video we're delving deeper into managing challenging open apex cases, specifically where achieving apical control is difficult due to a lack of natural constriction. We discuss techniques for creating an apical barrier using bioceramic materials like MTA or Biodentine, emphasising the importance of precise placement, length determination, and understanding the material properties to promote hard tissue formation. We also cover the subsequent steps of obturation and coronal restoration to ensure long-term success.

Key topics covered

• The critical challenge of achieving apical control in teeth with wide open, non-tapered (blunderbuss) apices, where traditional obturation techniques are insufficient
• A detailed "sandwich technique" for open apex management:
  • Creating an apical barrier/plug (e.g., MTA, Biodentine, putty-based materials) of approximately 4-5mm
  • Placing gutta-percha coronal to this barrier as a space filler
  • Restoring the tooth coronally, often with a composite resin build-up, potentially incorporating a fibre post for reinforcement
• The use of a collagen sponge (e.g. Hemocollagene) as a resorbable matrix or backstop to aid in the placement and condensation of the apical barrier material, preventing over-extrusion
• Precise length determination using an apex locator in conjunction with radiographic checks, and the importance of selecting appropriately sized pluggers for condensing the apical barrier material
• The rationale for using specific materials like dual-cure composites or low-viscosity bulk-fills for the coronal portion, considering factors like C-factor, shrinkage stress, and fracture resistance in these compromised teeth

Clinical relevance

This section offers highly practical and advanced techniques for managing complex open apex cases that many dentists find daunting. The step-by-step approach to creating an apical barrier, including the use of a collagen matrix and specific material handling, provides a clear protocol that can significantly improve predictability and outcomes when faced with immature teeth requiring endodontic intervention.

Learning outcomes

After watching this, dentists should be better able to:

• Understand the principles and techniques for creating a predictable apical barrier in teeth with wide open apices
• Select and appropriately use bioceramic materials (MTA, Biodentine, putties) for apical plug placement
• Utilise adjuncts like collagen sponges and accurately sized pluggers to control the placement of apical barrier materials
• Appreciate the importance of the coronal restoration in reinforcing teeth with open apices and make informed decisions about restorative strategies