|Year : 2013 | Volume
| Issue : 3 | Page : 144-147
Mineral trioxide aggregate root canal filling of traumatized immature tooth
Maha A Kanfar1, Saad A Al-Nazhan2
1 Department of Dental, King Fahad Military Medical Complex, Dharhan, Eastern Province, Riyadh, Saudi Arabia
2 Department of Restorative Dental Science, King Saud University, College of Dentistry, Riyadh, Saudi Arabia
|Date of Web Publication||20-Nov-2013|
Saad A Al-Nazhan
Department of Restorative Dental Science, King Saud University, College of Dentistry, Division of Endodontics, Riyadh 11545
Source of Support: None, Conflict of Interest: None
An 8-year-old female patient reported to the dental clinic seeking a help to save her traumatized maxillary left central incisor. The tooth had been treated with a temporary filling by a general dentist. The coronal tooth structure was intact, discolored, and a temporary filling was placed on the access opening. She gave a history of trauma about 3 years back. An intraoral periapical radiograph revealed an open apex and dentin bridge in the middle of the root canal. The root canal and the access opening were filled with very poor filling. The tooth was managed successfully by conservative means using intracanal calcium hydroxide as an intracanal medicament, followed by mineral trioxide aggregate (MTA) filling. The access opening was filled with glass ionomer and composite resin restoration. One year and 6-month follow-up demonstrated a clinically asymptomatic and adequately functional tooth, with radiological signs of apical regeneration.
Keywords: Immature tooth, mineral trioxide aggregate , open apex, traumatized tooth
|How to cite this article:|
Kanfar MA, Al-Nazhan SA. Mineral trioxide aggregate root canal filling of traumatized immature tooth. Saudi Endod J 2013;3:144-7
| Introduction|| |
Dental caries and trauma are the most common challenges to the integrity of a tooth and both insults can render the dental pulp nonvital. If this occurs prior to complete root formation and apical closure, normal root development is halted.  This condition produces several complications. The apical diameter of the canal is often larger than the coronal diameter, so the debridement is difficult as well as lack of an apical stop which makes the obturation in all dimensions impossible. The thin walls of the root canal are prone to fracture if any attempt to clean and fill is tried. Therefore, the closure of the opened apical foramen by any means is essential to successfully proceed with the root canal treatment. Calcium hydroxide was widely used material for apexification. But in recent times, interest has centered on the use of mineral trioxide aggregate (MTA) for apexification. Revascularization has also been used in many cases. ,, In a clinical retrospective outcome study, 17 of 20 (85%) teeth showed healing when MTA was used as an artificial barrier in teeth with immature apices. 
When the MTA apexification procedure is compared against calcium hydroxide as a control, MTA demonstrated higher clinical and radiographic success at inducing root-end closure. 
The aim of this case report is to demonstrate the use of MTA as a root-filling material of a traumatized immature tooth. The treatment was based on previous poor management.
| Case Report|| |
An 8-year-old Saudi girl accompanied by her mother presented at the dental department of King Fahad Military Medical Complex at Dharhan city, who was asked to save the upper anterior tooth of her daughter because she was told that the tooth is indicated for extraction. The mother reported that her daughter had suffered a traumatic injury to the upper anterior tooth about 3 years ago. The tooth was immediately treated after trauma by a general dentist. Calcium hydroxide was used in two visits. The medical history was noncontributory.
Clinical examination revealed marginal gingivitis, multiple small fillings, and discoloration of the maxillary left central incisor (#21) with glass ionomer temporary filling on the lingual aspect of the tooth [Figure 1]a and b. There was no evidence of either swelling or sinus tract and no periodontal pockets were present. Electric pulp test and cold test were negative. Periapical radiographic evaluation of tooth #21 showed incomplete root formation with wide open apices, poor root filling material, and a dentin bridge in the middle third of the root canal [Figure 1]c.
|Figure 1: (a and b) Clinical photo of the maxillary left central incisor showing discoloration of the crown. (c) Periapical radiograph showed incomplete root formation with wide open apices, poor root filling material, and a dentin bridge in the middle third of the root canal|
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Nonsurgical root canal treatment of #21 was planned. On the first visit, local anesthesia was given and an access opening was prepared under rubber dam isolation. The coronal pulp chamber was cleaned and #70 K-file was placed in the canal, and a periapical radiograph was taken to determine the working length [Figure 2]a. The root canal was lightly cleaned with a hand file under irrigation with 2.5% NaOCl (CLOROX, Manufactured in Saudi Arabia by National Cleaning Products Co. Ltd). White soft material was easily removed from the canal which could be calcium hydroxide. The root canal was then dried with sterile paper point. Next, calcium hydroxide (Ultracal XS calcium Hydroxide Paste, Ulteradent products, Inc., UT, USA) was prepared to a creamy consistency and placed in the root canal. The access opening was temporized with Intermediate Restorative Material (DENTSPLY Caulk, Milford, DE, USA) and the patient was dismissed and instructed to return in 2 weeks.
|Figure 2: (a) Periapical radiograph showed the working length determination and (b) after application of mineral trioxide aggregatefilling|
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When the patient returned in 2 weeks, the calcium hydroxide dressing was removed by hand instrumentation, and irrigation was done with 2.5% NaOCl and ethylenediaminetetraacetic acid (PulpDent, Watertown, MA, USA). The root canal was then dried with sterilizes paper point. A thick mixture of MTA (PRO ROOT MTA, DENTSPLY International, INC, TN, USA) was then prepared and applied to the apical portion of the canal using a small hand plugger and the back end of the sterilized paper point [Figure 2]b. Finally, the access opening was permanently sealed with a layer of glass ionomer (GC Fuji IX Gp fast, GC Corporation 76-1HASUNUMA-CHO, Tokyo. Japan.) and with a bonded composite resin restoration (3MESPE, Filtik Z, ST. Paul, MN, USA).
The radiograph follow-up at 1 year and half showed an absence of the periapical radiolucency and regeneration of the periradicular tissue [Figure 3]. No clinical signs and symptoms were recorded and the patient was functioning well.
|Figure 3: An 18‑month follow‑up radiograph showed bone growth inside the open apex|
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| Discussion|| |
Crown discoloration, pulp necrosis, and interruption in root formation were reported as clinical and radiographic sequelae of traumatized teeth frequently observed in patients with delayed management. , This sequelae has been observed in this reported case despite the early management done by the general dentist.
Calcium hydroxide was used for an apexification procedure. Such treatment if successful will induce further development of the root apex and close the foramina.  The performed treatment of the present case resulted in incomplete tooth formation and development of horizontal dentin bridge in the middle third of the root canal space. In addition, it does not promote the thickness of the entire canal wall leaving the canal lumen large which might cause root fracture. , The formation of the dentin bridge was due to the placement level of the calcium hydroxide in the root canal space which was in direct contact to the remaining vital pulp tissue in the root canal. , The formation of the calcified tissue prevents the regeneration of pulp tissue in the occupied space.
According to Schroder and Granath,the placement of calcium hydroxide in root canal systems prevents revascularization coronal to its location.  The hard tissue barrier formation against the calcium hydroxide material indicates that a biocompatible material with antimicrobial properties is necessary for the formation of a hard tissue barrier.  A prospective clinical study showed that the mean time necessary for the formation of an apical barrier with this technique is more than 12 months. 
In selected cases such as this case, the situation where future nonsurgical retreatment is nonfeasible or may not render better tooth prognosis, and in teeth with immature nonvital pulps and short roots, orthograde root filling with MTA should be considered as a valuable alternative to the multiappointment apexification procedure. 
MTA aggregate material has excellent potential when used as an apical barrier  and might have a profound advantage when used as a canal obturation material because of its superior physiochemical and bioactive properties when compacted against dentin. A dentin-MTA interfacial layer forms in the presence of phosphates.  This interface between dentin and MTA has demonstrated superior marginal adaptation compared with amalgam, intermediate restorative material, or super-EBA under Scanning electron microscope in resin models.  Moreover, the particle size and dimensional shape of MTA can occlude and penetrate dentinal tubules that might harbor microorganisms after cleaning and shaping as the hard tissue bridge formation is usually incomplete. ,,
Studies have demonstrated that MTA has an ability to encourage the regeneration of periradicular tissues, such as periodontal ligament and cementum. ,, The 18-month follow-up of the present case showed osseous repair and apical closure. This was demonstrated by Hayashi et al., who used MTA for obturation of root canal system of two mature mandibular central incisors with apical periodontitis and Bogen et al.,  in a mandibular first premolar with open apex.
Unlike calcium hydroxide, obturation of the root canal system with MTA exhibits higher fracture resistance and the strength of the tooth might increase with time. ,
Revascularization procedure would be better to perform as an alternative to apexification or MTA filling in this case. The advantages of pulp revascularization lie in the possibility of further root development and reinforcement of dentinal walls by deposition of hard tissue thus strengthening the root against fracture. ,
| Conclusion|| |
MTA can be considered to be a very effective material to promote obturation of open apices by the intracanal delivery technique. The main advantage of this procedure is the high predictability of apical closure with the reduction of treatment time, number of appointments, and radiographs.
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[Figure 1], [Figure 2], [Figure 3]