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Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 77-80

Mineral trioxide aggregate plug and conventional root canal treatment of traumatized maxillary central incisor with an open apex: Three-year follow-up

Department of Restorative Dentistry, Faculty of Dentistry, University of Medical Sciences and Technology, Khartoum, Sudan

Date of Submission30-Dec-2018
Date of Decision17-Jan-2019
Date of Acceptance20-Feb-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Elhadi Mohieldin Awooda
Department of Restorative Dentistry, Faculty of Dentistry, University of Medical Sciences and Technology, Sudan, P. O. Box 12810, Khartoum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_148_18

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Traumatic dental injuries may cause the loss of a tooth's pulp vitality before the development of the root has been completed. A 12-year-old boy complained of a broken crown of one of his upper front tooth due to falling down. The tooth had a history of previous trauma 1 year ago. Clinically, the tooth was discolored with complicated crown facture. Intraoral periapical radiograph revealed an open apex of 1 mm in width. Mineral trioxide aggregate (MTA) plug, placed orthogratelly on the apical part, has proven a successful outcome based on a 3-year follow-up. In conclusion, MTA plug is a treatment of choice for cases of small open apex (1-mm diameter or less) of traumatized nonvital permanent teeth.

Keywords: Apexification, immature tooth, maxillary incisors, mineral trioxide aggregate

How to cite this article:
Elgailani RA, Awooda EM. Mineral trioxide aggregate plug and conventional root canal treatment of traumatized maxillary central incisor with an open apex: Three-year follow-up. Saudi Endod J 2020;10:77-80

How to cite this URL:
Elgailani RA, Awooda EM. Mineral trioxide aggregate plug and conventional root canal treatment of traumatized maxillary central incisor with an open apex: Three-year follow-up. Saudi Endod J [serial online] 2020 [cited 2020 Apr 9];10:77-80. Available from: http://www.saudiendodj.com/text.asp?2020/10/1/77/274184

  Introduction Top

Traumatic dental injury (TDI) is common in young children with the majority of injuries being left untreated.[1] The most commonly affected permanent tooth is the maxillary central incisor.[2] The eruption of a maxillary central incisor begins at the age of 7–8 years, and root formation continues for up to 3–4 years.[3] TDI during root development may lead to pulp necrosis resulting in an immature tooth with an open apex and blunderbuss canal anatomy.[4] Challenges associated with treatment of immature nonvital teeth with open apices include effective and safe disinfection of the root canal, as well as obturation of the canal that has no apical stop to prevent extrusion of the root filling material into the periapical tissues. In addition, fracture of the fragile thin roots may occur.[1],[5],[6] Treatment of such cases is, therefore, time-consuming and technically difficult.[1]

There are many treatment options for traumatized nonvital tooth with an open apex, including the use of a rolled blunt-end cone, periapical surgery, short-fill technique, revascularization, and apexification using calcium hydroxide and mineral trioxide aggregate (MTA) or biodentin.[5],[7],[8] Revascularization depends on the stem cells and growth factors by stimulating them to complete the apex closure. It is widely used when the opening diameter of the root canal is large.[9] Apexification induces a calcific bridge formation at the immature open apex.[10] In this technique, the necrotic tissues are removed, followed by irrigation of the canal, and placement of medicaments (such as calcium hydroxide or triple antibiotics) for several weeks in order to control canal(s) and periapical tissues infection.[8] For many years, calcium hydroxide is the most commonly used material in apexification, due to its biological and healing performance. However, it presents substantial drawback. For instance, drawback includes the increased risk of root fracture and poor patient compliance due to the extended treatment time and due to its need for approximately 5 months to 2 years for apical barrier formation.[5],[7],[11] Furthermore, vulnerability of temporary coronal seal to reinfection is a great challenge.[11]

MTA has long been used to induce calcific bridge formation, and it possesses sealing properties and biocompatibility.[12] Several studies have demonstrated its capacity to induce odontoblastic differentiation,[13] good radiopacity, low solubility, high PH,[14] expansion after setting,[15] and antimicrobial activity. On the other hand, MTA presents some notable shortcomings such as prolong setting time, handling difficulties, and possible coronal discoloration.[16],[17]

This report describes a case of young boy with complicated crown fractured of immature, nonvital maxillary central incisor. The treatment plan involved conventional endodontic therapy with apexification using MTA plug.

  Case Report Top

A 12-year-old boy with good health was admitted at the Academy Dental Teaching Hospital Endodontic Department complaining of a discolored and broken front tooth with a history of falling down 1 year ago. He did not seek any treatment until he traumatized the same tooth while playing football a week prior, and noticed he felt (the tooth) again. The child looked well, not pale, or jaundiced, and no abnormalities were mentioned in his past medical history.

Clinical examination revealed a maxillary central incisor (#11) with a complicated crown fracture. The remaining crown was discolored with gingival overgrowth covering 1/3 of the cervical part and overlapped by the left maxillary central incisor [Figure 1]a. The tooth was tender on vertical percussion, with normal physiological mobility and no swelling or palpation on the soft tissues. Intraoral soft-tissues examination revealed marginal gingivitis, and extraoral examination of hard and soft tissues other than the affected tooth revealed no abnormality.
Figure 1: Clinical view showing discolored fractured #11, overlapped by #21, and covered by gingival overgrowth (a). Periapical radiograph reveals a 2 mm in diameter radiolucency surrounding the root of #11 with an open apex (b). Radiograph shows mineral trioxide aggregate inside the canal to a length of 1.5 mm less than the full working length (c). Endodontic plugger checking mineral trioxide aggregate hardness (d). Obturation with gutta-percha cones (e). One-year follow-up shows normal bone trabeculae (f). Three-year follow-up shows the absence of periapical radiolucency with normal bone trabeculae (g)

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Thermal sensitivity test resulted in no response on the affected tooth with normal response for neighboring and opposing anterior teeth. Intraoral periapical radiograph shows radiolucency surrounding the root apex of tooth #11 with an open apex of approximately 1-mm width [Figure 1]b. Based on the clinical and radiographic examination tests, the diagnosis researched was necrotic pulp with symptomatic apical periodontitis. Different treatment modalities for such cases were explained to the parents with justifications for why we opted for MTA plug and conventional root canal treatment. They made a consensus on the treatment by MTA plug and conventional obturation. The patient's mother signed an informed written consent for the opted treatment and the later publication of the case.

Therapeutic intervention

A rubber dam was placed for tooth isolation and moisture control, local anesthesia of one lidocaine ampule was administered (lidocaine 2% with epinephrine 1:100,000 local anesthetic, Box of 50–1.7 ml Cartridges, Septodent, UK), access cavity was prepared with a tapered roundended diamond, necrotic pulp tissues were removed mechanically by hand H-files size 40 (Dentsply Maillefer, Ballaigues, Switzerland), and the canal was debrided and flushed using a 2.5% sodium hypochlorite solution. Calcium hydroxide and iodide paste was placed as an inter-appointment medicament (i-CAL Plus-Calcium Hydroxide Paste with Iodoform by i-DENTAL Dental Supplies), and the tooth was temporized using Cavit G (3M, ESPE, Germany). One week later, the tooth was asymptomatic; the calcium hydroxide flushed out by an irrigant (sodium hypochlorite 1%) and the canal dried using paper points. The working length was determined using size 50 K-file ISO (Dentsply Maillefer, Ballaigues, Switzerland), and the canal was prepared manually up to size 70 H-file ISO as master file. MTA (ProRoot MTA 4 × 0.5GR White, DENTSPLY International, Inc., USA) was mixed on a paper pad in a thick creamy consistency and placed in the canal 2 mm shorter of the working length using an MTA carrier [Figure 1]c. The MTA was pushed into the canal to a length of 1.5 mm less than the full working length, and the walls cleaned with a moist paper point size 70. Radiograph was taken to confirm correct placement of the MTA plug. A moist cotton pellet was placed in the canal, and access cavity was filled temporary with Cavit G (3M, ESPE, Germany) until the next visit.

On the next visit 1 week later, the cotton pellet was then removed, MTA plug hardness was checked by finger endodontic plugger (Finger Pluggers – Plastic Handle, 4/Pkg – Dentsply, Maillefer) [Figure 1]d. The canal was irrigated by normal saline, dried by paper points, and obturated with a cold lateral compaction technique using a master gutta-percha cone of size 80 (GAPADENT gutta-percha-Made in China.com) and zinc oxide eugenol cement as a sealer (Endomet ® plain, Septodent, Pennsylvania, USA) [Figure 1]e. Nanohybrid composite resin (EsCom 100, SPIDENT Co., Ltd, Incheon, Korea) was used as a permanent restoration to achieve the desired esthetics. Although post is needed to increase retention of composite core, it was postponed due to the age of the patient and remaining tooth discoloration that may necessitate artificial crowning. The gingival overgrowth was excised surgically.

Follow-up and outcomes

After 1 month, the tooth was found to be asymptomatic, and build-up with composite resin without post was found to be retentive with good prognosis.

The patient was seen 1 year after, the tooth was asymptomatic and functioning well with acceptable esthetic and no abnormality was detected radiographically [Figure 1]f. Clinical and radiographic examination at 3-year follow-up revealed no symptoms, continuity of periodontal space, absence of refraction, and a thin layer of calcified tissues formed apical to MTA plug [Figure 1]g. Patient and parent's perspectives of the treatment opted was satisfactory.

  Discussion Top

Although the patient was 12 years old, his traumatized tooth had an open apex despite that the normal age of closure is between 9 and 11 years.[3] It can be assumed that his accident 1 year prior had traumatized that tooth and interfered with the normal maturation and consequently resulted in apical pathosis, as suggested by some studies.[18],[19],[20] Following untreated trauma, an immature permanent tooth is subjected to pulpal necrosis, discoloration, and interruption in root formation resulting in an open apex.[4],[21] Due to endodontic treatment techniques rely on presence of an apical closure, it is essential to create an apical plug for an excellent root canal filling.

As a treatment option, apexification using calcium hydroxide has been used in many cases due to its ability to form calcific bridges, its antibacterial properties, and its high success rates.[5] However, there are limitations because of the long-term dressings, multiple visits, and long follow-up time.[7],[11] In addition, it has been claimed that the barrier formed by calcium hydroxide is not often complete, allowing microleakage.[11],[22] Furthermore, a recent systemic review on 2017 based on the available evidence provided by the European Academy of Pediatric Dentistry proposing that the long-term use of calcium hydroxide in the root canals of immature teeth should be avoided, and apexification with calcium hydroxide is no longer advocated.[1]

Revascularization treatment enhanced the root elongation and maturation.[23] It was not used in this case because the tooth length is comparable to neighboring teeth which all had closed apices. Long follow-up terms needed and the patient's gardens when the treatment options were discussed would never commit to do revascularization. In addition, it is evidenced that the incidence of revascularization is enhanced if the apex shows radiographic opening of more than 1.1 mm.[24]

MTA apical plug was the treatment of choice in the present case due to the nearly closed root apex, the short clinical time needed,[25] and patient school age (parent claimed difficulty in commitment of several follow-up visits). In addition, as literature stated, MTA provokes biocompatibility, anti-inflammatory effect and excellent seal,[12],[13],[14],[15] and high survival and success rates.[26] At 1-year and 3-year follow-up periods, the clinical and radiographic appearance of the tooth showed the resolution of the periapical lesions and continued root end development as consistent with others.[21],[27] However, there are contradictory results from different studies on cytotoxicity of MTA,[28] a recent research by Ahmed et al., 2018 demonstrated that addition of calcium chloride dihydrate increases the cytotoxicity but enhances the dentinogenic differentiation potential of white MTA on dental pulp stem cells.[29] Although the clinical and radiographic follow-up of the reported case showed good prognosis, the presence of such controversy about the cytotoxicity may shift the treatment option of immature necrotic pulp toward revascularizations.[30]

  Conclusion Top

The favorable clinical and radiographic outcome of this case has demonstrated that the MTA plug is a very effective alternative to other treatment modalities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Gade P, Mandava J, Varma UL, Konagala RK. Conservative approach for natural restoration of fractured anterior teeth: A review and case series. J Interdiscip Dent 2016;6:146-50.  Back to cited text no. 2
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