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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 378-380

Mineral trioxide aggregate-induced apical closure in nonvital immature permanent maxillary incisor

1 Department of Pediatric Dentistry, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
2 Department of Pediatric Dentistry, Surendra Dental College and Research Institute, Sri Ganganagar, India
3 Department of Pediatric Dentistry, People Dental Academy, Bhopal, Madhya Pradesh, India
4 Department of Conservative Dentistry and Endodontics, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Virinder Goyal
Department of Pedodontics and Preventive Dentistry, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_240_16

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Treatment of nonvital immature permanent teeth with calcium hydroxide is associated with few difficulties such as weakened tooth root, root canal reinfection, and long treatment time. Mineral trioxide aggregate (MTA) apical plug method is an alternative treatment method for open apices and has gained popularity in the recent times. This case report describes the management of a late-referral case of periapically involved, traumatized immature permanent incisor by endodontic treatment and the use of MTA apical plug. After preparing the access cavity, the working length was determined. The root canals were irrigated with 3% sodium hypochlorite and disinfected with metapex for 2 weeks. MTA was then placed in the apical 3 mm of the root canal. The remaining part of the root canal was filled with thermoplastic gutta-percha, and the coronal restoration was finished with composite resin. After 1-year follow-up, radiograph showed successful healing of periradicular radiolucency.

Keywords: Calcium hydroxide, mineral trioxide aggregate, nonvital, open apex

How to cite this article:
Bhola M, Goyal V, Tyagi P, Kumar T. Mineral trioxide aggregate-induced apical closure in nonvital immature permanent maxillary incisor. J Indian Soc Pedod Prev Dent 2017;35:378-80

How to cite this URL:
Bhola M, Goyal V, Tyagi P, Kumar T. Mineral trioxide aggregate-induced apical closure in nonvital immature permanent maxillary incisor. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2022 Dec 5];35:378-80. Available from: http://www.jisppd.com/text.asp?2017/35/4/378/214920

   Introduction Top

Complete formation of the root and closure of the apical foramen continues for up to 3 years following eruption of the tooth.[1] If the pulp of young permanent teeth is damaged due to trauma or caries before the closure of the apical foramen, the primary treatment objective should be focused to preserve the vitality of the radicular pulp so that physiological apical closure could be obtained. In certain clinical situations, it is not possible to preserve the vitality of radicular pulp because the patient reports with a nonvital tooth, or in the later stage, where pulp gets necrosed. In immature teeth, dentinal tubules are wide and allow the ingress of bacteria and their irritants. Hence, root resorption occurs instantly after trauma in these teeth. Root canal treatment should be done as soon as possible to inhibit the root resorption. A major problem in performing endodontics in immature teeth with necrotic pulp and wide open apices is to obtain an optimal apical seal of the root canal system.[2]

In the past decade, calcium hydroxide has been used extensively to induce a hard tissue barrier at the tooth apex (apexification). In spite of its successful outcomes, there are number of shortcomings which have been reported. The major shortcomings are length of time required (6–18 months), incomplete apical hard tissue barrier because of vascular inclusions, and loss of organic and inorganic component of dentin due to calcium hydroxide.[3]

Recently, synthetic apical barriers with a variety of materials have been proposed as alternatives to the traditional apexification treatment method with calcium hydroxide.[4] Mineral trioxide aggregate (MTA) is one of the most preferred materials for this purpose.

MTA has been recognized as a bioactive material that is hard tissue conductive, hard tissue inductive, and biocompatible. It consists of fine hydrophilic particles of tricalcium silicate, silicate oxide, and tricalcium oxide. When MTA is mixed with sterile water, it forms a colloidal gel, and its setting time is 3–4 h in the presence of moisture.[2]

Observations from published reports support MTA as a potentially effective material in regenerating normal periradicular architecture in teeth with immature apices and continued root maturation when pulpal necrosis is present.[4],[5]

The following case describes the successful use of MTA as an apical plug in nonvital immature permanent left maxillary central incisor #21.

   Case Report Top

A 14-year-old boy reported to the Department of Pedodontics and Preventive Dentistry, at Dasmesh Institute of Research and Dental Sciences, Faridkot, with the chief complaint of pus drainage and mild swelling in upper anterior tooth region. The past medical history was not significant. In past dental history, the patient gave a history of fall 4 years back with orofacial trauma to permanent maxillary left incisor.

The clinical examination revealed a labial sinus tract in upper left incisor region accompanied by swelling. The tooth was not tender to percussion and did not respond to the vitality tests. A preoperative intraoral periapical radiograph revealed an immature tooth with a wide open apex and a radiolucent area in the apical region of the maxillary left incisor [Figure 1]a]. On the basis of clinical and radiographic findings, the tooth was diagnosed as having chronic irreversible pulpitis with pulp necrosis. After weighing all the treatment options, it was decided to carry out apical barrier formation using MTA.
Figure 1: Radiographic record of the patient in sequence. (a) Preoperative radiograph. (b) Working length radiograph. (c) Metapex placement. (d) Mineral trioxide aggregate plug formed at the apex. (e) Follow-up 6 months. (f) Follow-up 1 year

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The patient and parents were informed about an endodontic treatment plan involving MTA apical plug, and written consent was obtained. On approval of the treatment plan, root canal treatment was initiated at the same appointment.

After the application of the rubber dam, an access cavity was prepared. Approximate working length was established with both radiographic method and the apex locator (Propex II, Dentsply) [Figure 1]b. The root canal was gently cleaned using Hedstroem files under irrigation with 3% sodium hypochlorite (NaOCl; Percan, Septodont, India).

Then, the canal was dried with sterile paper points and metapex (Meta Biomed Co. Ltd., Korea) was placed [Figure 1]c. After 2 weeks, the metapex was removed by repeated rinsing with 3% NaOCl followed by rinsing with sterile water. MTA (White Pro-Root MTA; Dentsply Maillefer, Ballaigues, Switzerland) was prepared according to the manufacturer's instructions, and a small portion of the material was deposited in apical region, 1 mm short of the working length using ProRoot MTA delivery gun (Dentsply). Then, MTA was gently condensed with an endodontic plugger. The correct position of the MTA mixture was controlled and confirmed with a periapical radiograph [Figure 1]d. A wet cotton pellet with sterile water was then placed in the pulp chamber, and the access cavity was closed with temporary filling material (Cavit; 3M/Espe, Seefeld, Germany). After a week, the temporary filling material and the cotton pellet were removed, and the setting of MTA was gently tested. The rest of the canal was obturated with thermoplastic gutta-percha technique. The tooth was later coronally sealed with composite resin. The clinical follow-up at 6 months and 1 year revealed an adequate clinical function, an absence of clinical symptoms (voluntary and induced pain), and the absence of the labial sinus tract.

The radiographic follow-up at 6 months revealed a decrease in size of the periapical lesion [Figure 1]e, and 12-month follow-up showed a complete resolution of the periapical radiolucency with evidence of regeneration of the periradicular tissue and apical barrier formation at the end of the root [Figure 1]f. At 12-month recall, full maturogenesis of root apex has taken place. Root maturation was observed to have significantly progressed when compared with preoperative radiographs and was similar to the status of root development and maturation of contralateral tooth. Eighteen-month recall and 24-month recall are still be awaited.

   Discussion Top

Calcium hydroxide had a high success rate when used for apexification treatment in several studies. It creates an environment conducive to the formation of an apical barrier formed by osteocementum tissue at the end of the root canal in teeth with open apices.[6],[7] However, there are some disadvantages of this material. One of them is that the treatment requires a very long time which is from 6 to 18 months. During this period of time, root canal may get reinfected by the leakage of the temporary coronal restoration. The success rate decreases by 10% in teeth with poor coronal seal. Hence, performing a permanent treatment is better to avoid reinfection of the root canal. Furthermore, there is possibility of fracture of the weakened teeth.[3] After leaving calcium hydroxide in the root for more than 30 days, the fracture resistance reduces.[4]

MTA apical plug in one visit is an alternative method to long-term apexification treatment. Lee et al.[8] first described this material to dental literature in 1993. With the MTA apical plug technique, a one-step obturation after short canal disinfection with calcium hydroxide could be performed. The MTA mixture created an artificial stop to the filling material. In agreement with other studies, MTA has less leakage, better antibacterial properties, high marginal adaptation, short setting time (~4 h), a pH of 12.5 and is more biocompatible.[9] From a practical point of view, MTA can be used in the presence of moisture in the root canal. This property is important in teeth with necrotic pulps and inflamed periapical lesions because one of the problems found in these cases is the presence of exudates at the apex of the root.

In most cases, the procedure can be completed in a maximum of two sessions, making it possible to restore the teeth without adversely affecting the mechanical properties of root dentin. In addition to its well-documented biocompatibility,[9] the production of bone morphogenetic protein-2 and transforming growth factor beta-1 could be two important contributors to the favorable biologic response stimulated by MTA in human periapical tissues.[10] Several cell culture studies have shown production of type I collagen and osteocalcin expression in the presence of MTA. MTA also induces cementoconductivity, cementoinductivity, and osteoconductivity.

However, the application of MTA mixture should be preceded by a temporary calcium hydroxide dressing to limit bacterial infection in the tooth.

The present case confirms that MTA acts an apical barrier and can be considered to be a very effective material to support regeneration of apical tissue and to promote apical obturation in traumatized, infected immature teeth with open apices. Both clinical and radiographic follow-ups showed optimal healing of the apical periodontitis and new hard tissue formation in the apical area of the traumatized incisor. Thus, it can be concluded that MTA plug offers the advantage of high predictability of apical closure, along with shorter treatment time and less dependence on the patient compliance.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: A prospective study. Int Endod J 2007;40:186-97.  Back to cited text no. 1
Güneş B, Aydinbelge HA. Mineral trioxide aggregate apical plug method for the treatment of nonvital immature permanent maxillary incisors: Three case reports. J Conserv Dent 2012;15:73-6.  Back to cited text no. 2
Bakland LK, Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review. Dent Traumatol 2012;28:25-32.  Back to cited text no. 3
Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod 2008;34:812-7.  Back to cited text no. 4
El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent 2006;28:248-53.  Back to cited text no. 5
Leonardo MR, da Silva LA, Leonardo Rde T, Utrilla LS, Assed S. Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. J Endod 1993;19:348-52.  Back to cited text no. 6
Binnie WH, Rowe AH. A histological study of the periapical tissues of incompletely formed pulpless teeth filled with calcium hydroxide. J Dent Res 1973;52:1110-6.  Back to cited text no. 7
Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993;19:541-4.  Back to cited text no. 8
Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999;130:967-75.  Back to cited text no. 9
Guven G, Cehreli ZC, Ural A, Serdar MA, Basak F. Effect of mineral trioxide aggregate cements on transforming growth factor beta1 and bone morphogenetic protein production by human fibroblasts in vitro. J Endod 2007;33:447-50.  Back to cited text no. 10


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