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CAUSES OF OPEN APICES1. Incomplete developmentThe open apex typically occurs when the pulpundergoes 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 amature apex (stage 5) as a result of2. Extensive apical resorption due to orthodontictreatment, periapical pathosis or trauma3. Root end resection during periradicular surgery4. Over-instrumentation

Stage 1Teeth with wide divergent apical opening anda root length estimated to less than half of the finalroot length.

Stage 2Teeth with wide divergent apical opening anda root length estimated to half of the final root length.Stage 3Teeth with wide divergent apical opening anda root length estimated to two thirds of the finalroot length.Stage 4Teeth with wide open apical foramen andnearly completed root length.

Stage 5

Teeth with closed apical foramen andcompleted root development.

MANAGEMENT OF INCOMPLETELYDEVELOPED NON VITAL TEETH_Management of open apices_ Obturation without creatingapical barrier3_ Customized cone technique using- blunted tips- inverted cones

- apical impression heat chemicals- rolled cone heat chemicals_ Thermoplasticized obturation_ Shortfill technique

Obturation after creating apical barrier_ Root end induction of calcific barrier/apexification3,5- induction of blood clot in theperiradicular region- antibiotic pastes- calcium hydroxide mixed with

various materials- collagen calcium gel

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- bone morphogenic proteins- tricalcium phosphate_ Placement of artificial barriers (root-endfilling 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 someapical 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.