The Use of Mta in The Treatment of Cervical Root Perforation: Case Report
The Use of Mta in The Treatment of Cervical Root Perforation: Case Report
The Use of Mta in The Treatment of Cervical Root Perforation: Case Report
Jefferson J. C. mArion1
Thaís Mageste duQue2
Tatiane Silveira sAntos3
Frederico Campos mAnHães4
How to cite this article: Marion JJC, Duque TM, Santos TS, Manhães FC. The » The authors report no commercial, proprietary or inancial interest in the prod-
use of MTA in the treatment of cervical root perforation: case report. Dental Press ucts or companies described in this article.
Endod. 2013 May-Aug;3(2):96-101.
» The patient displayed in this article previously approved the use of her facial
and intraoral photographs.
1
Doctorate student in Dental Clinic – Endodontics, State University of Campinas (UNICAMP). Received: March 12, 2013. Accepted: April 9, 2013.
Professor at the Department of Endodontics of ABOl and Ingá College (UNINGÁ).
2
Doctorate student in Dental Clinic – Endodontics, UNICAMP. Contact address: Jefferson José de Carvalho Marion
3
Graduated in Dentistry, UNINGÁ. Rua Néo Alves Martins, 3176 – 6º andar – sala 64 – Centro
4
Doctorate student in Dental Clinic – Endodontics UNICAMP. CEP: 87.013-060 – Maringá/PR — Brazil
Email: jefferson@jmarion.com.br / atendimento@jmarion.com.br
without temporary restoration or endodontic dress- ing to the manufacturer’s instructions. The MTA was
ing, and with remaining carious tissue. In addition, it inserted with Paiva pressers and its final laying was
showed sensitivity to vertical and horizontal percussion carried out with cotton moistened with distilled water.
and absence of edema, sinus and tooth mobility. As for The MTA was inserted into the perforation with the
the thermic tests performed to check pulpal sensitivity, aid of a microscope and without exerting too much
the responses were also negative. pressure in order to prevent it from extravasating to
The periapical intraoral radiographic revealed the periodontal ligament.
excessive abrasion in the opening and in the cervi- An intraoral periapical radiograph was performed to
cal portion. Mesially, it was possible to see the path check the MTA laying in the perforation. Radiographi-
of the perforation. The image also had a radiopaque, cally, it was observed that the MTA did not extravasate
non-root, suggestive point indicating some type of re- to the periodontal ligament, momentarily excluding the
storative material (Fig 1A). After all tests and clinical possibility of surgical intervention for the case (Fig 1C).
examinations had been performed, the patient was di- The calcium-hydroxide-based intracanal medi-
agnosed with pulp necrosis. cation was applied for a period of three months
The patient was informed about the different and replaced every 45 days. After a period of four
treatment options, for both perforation and root months (October, 2010), the root canal was filled
canal. She chose to undergo endodontic treatment with gutta-percha point (Fig 2A) and, afterwards,
with closure of perforation being performed via the with calcium- hydroxide-based cement and second-
canal, preferably without surgery and application ary gutta-percha points by lateral condensation fol-
of intracanal medication. It was requested that the lowed by means of the vertical condensation tech-
orthodontist discontinued the application of orth- nique (Fig 2B). The pulp chamber was cleaned and
odontic force in this dental element until the end of temporarily sealed with sterile cotton pellet and
the endodontic treatment. Coltosol. The patient was asked to seek his dentist
From this moment on, the endodontic treatment in order to request that definitive restorative proce-
began, with local anesthesia and installation of rubber dures were performed.
dam. Improvements in the access cavity and removal Figure 2B shows the root canal filling, closure of
of carious tissue were carried out with a low-speed perforation with MTA and, in the mesial apical por-
bur. Biomechanical preparation of the root canal was tion, a secondary canal filling which was possible to
performed with manual endodontic files and irrigated be seen in Figure 2A.
with sodium hypochlorite at 2.5%. During the biome- After 10 months of endodontic treatment, the pa-
chanical preparation of the root canal, odontometry tient was asked to have the first follow up radiograph.
confirmation of the length of work and the apical pa- In the intraoral periapical radiograph, it was possible
tency were carried out (Fig 1B). After biomechanical to observe the integrity of the periapical region with
preparation of the root canal, it was dried with sterile continuous lamina dura clinically indicating periapical
paper points and then flooded with trisodium EDTA repair (Fig 2C).
at 17% for 3 minutes, with manual shaking for better
cleaning of the canal. After this period, the EDTA was discussion
removed and new irrigation was performed with so- The success of nonsurgical root perforation pro-
dium hypochlorite, followed by further drying of the cedures is directly related to the severity of the initial
root canal. Afterwards, a calcium-hydroxide-based damage caused to the periodontal tissue, the size and
intracanal medication with propylene glycol was ap- location of the perforation, sealing ability and bio-
plied in order to help in the decontamination of the compatibility of the filling material, and the presence
root canal and of the perforation. or absence of bacterial contamination.23
After 15 days, the intracanal medication was re- In this case report, the cervical perforation was
moved with the purpose of closing the perforation. not sealed immediately after it had occurred, as sug-
The material chosen for final closure of the perfora- gested by Sinai2 and Pitt Ford et al.13 The authors
tion was the white MTA-Angelus, manipulated accord- claim that the prognosis is much more favorable in
A b c
Figure 1. A) Initial radiograph: Excessive coronary abrasion, perforation path to mesial and radiopaque extraradicular point suggesting restorative material.
b) Conirmation of the working length. c) Settling of the MTA in the perforation.
A b c
Figure 2. A) Master cone and presence of accessory mesial canal. b) Final radiograph. c) 10-month follow up.
this case due to lack of bacterial contamination. completes the sanitation promoted by biomechani-
There was the option of treating the perforation and cal preparation. Applying the calcium-hydroxide-
the root canal by means of exchanging the intracanal based intracanal medication with propylene glycol,
medication and irrigating the site with sodium hypo- between sessions, in order to supplement disinfec-
chlorite, since the pulp chamber and the root canal tion and/or deposition of mineralized tissue through
were exposed to the oral cavity. Thus, based on the its antiseptic effect, bactericidal action and high pH,
studies carried out by Estrela and Estrela1 who claim corroborate Holland et al24, Holland et al.25,26
that fighting bacterial infection through copious ir- Estrela and Estrela1 have stated that there is inactiva-
rigation with sodium hypochlorite solution, due to its tion of enzymes intra and extra-cellular due to the re-
organic material and antibacterial solvent properties, lease of hydroxyl ions, which hinders bacterial survival.
However, studies carried out by Felippe et al27 claim In this case, MTA was also used because its radi-
that there is no advantage in exchanging the calcium opacity is superior to that of the dentin and bone tis-
hydroxide paste when treating contaminated canals sue, the IRM, Super Eba and gutta-percha, thus, provid-
and pulpless teeth. ing diagnostic observation, which makes it the material
The choice of propylene glycol as a carrier for the of choice.6 Moreover, studies carried out by Holland
calcium hydroxide is based on studies carried out by et al,26 of which aim was to explain the mechanism of
O’Neil28 which demonstrate that the substance has a inducing mineral formation of MTA, found that MTA
great capacity to solubilize organic materials. Addi- without calcium hydroxide in its composition is capa-
tionally, Seidenfeld and Hanzlik29 claim that the pro- ble of forming mineralized tissue due to the presence
pylene glycol has approximately the same density of of calcium oxide which forms calcium hydroxide when
water and causes no demonstrable cumulative effect. reacted with periapical tissues.
The propylene glycol antimicrobial activity for sys- The authors of this study agree with Marion37
temic use has been studied by Olitzky30 who reported about the difficulties of working with MTA and aque-
that concentrated solutions of this compound have ous carrier (distilled water) together, due to its initial
demonstrated germicidal efficiency and its use as a car- setting time and also its difficulty to be inserted, be-
rier can work in the prevention or treatment of bacterial cause when MTA is handled with this carrier, it seems
infection. Walkevar, Bhat;31 Thomas, Kotian and Bath32 to be little bondable and sandy.
reported that in addition to the fact that propylene gly- According to Namazikhah,38 it is important to em-
col has been well recognized as a carrier for medica- phasize that when the MTA is used in environments
tions, it has also been considered to be less cytotoxic with inflammation, its physicochemical properties may
than other carriers commonly used for intracanal medi- suffer some interferences, causing its acid pH to pre-
cations. Moreover, it presents antibacterial properties vent the MTA setting and reduce its strength and hard-
highly beneficial in endodontic treatment, although the ness. However, once the factors that initiate or perpet-
results found by Nakayama and Safavi33 showed that cal- uate the inflammatory process have been removed, as
cium hydroxide does not dissociate from propylene gly- in the case presented, the environment is able to return
col because it needs water to be dissociated. to normality within a short period of time.
In order to remove the smear layer, the EDTA at 17% Despite the advantages and limitations of the MTA,
was used for 3 minutes before the intracanal medication which have been previously mentioned, studies car-
was applied in all sessions as well as before final filling ried out by Balto,39 Holland et al,11 Juárez Broon et al,3
of the root canal, since several studies have demonstrat- showed that when analyzing the biological behavior of
ed that removal is achieved with the use of this drug.34,35 materials used in sealing root perforations, the MTA
After 15 days, the root perforation closure was has shown similar or less toxic behavior than the oth-
performed with MTA because, according to Torabi- ers. Therefore, MTA proves to have great ability of re-
nejad and Chivian,20 this material is capable of form- pair and the aforementioned information explains its
ing mineralized tissue due to its sealing ability, bio- use in the treatment of cervical root perforations.
compatibility, and alkalinity. Furthermore, according
to Sluyk et al17 the humidity present in periodontal conclusion
tissues can provide the necessary means for adapta- After being clinically applied, the MTA proved to
tion of MTA on the walls of the perforation and also be effective as a filling material of cervical root per-
for setting expansion,20,36 which explains its use in this foration, since after a 10-month follow-up, the tooth
case report, a case of cervical perforation in which continued to perform its primary functions, esthetic
humidity is difficult to control. and masticatory, in the oral cavity.
© 2013 Dental Press Endodontics 100 Dental Press Endod. 2013 May-Aug;3(2):96-101
Marion JJC, Duque TM, Santos TS, Manhães FC
references
1. Estrela C, Estrela CRA. O hidróxido de cálcio é a única medicação 20. Torabinejad M, Chivian N. Clinical applications of mineral trioxide
intracanal para combater a infecção endodôntica? In: Cardoso aggregate. J Endod. 1999;25(3):197-205.
RJA, Gonçalves EAN. Endodontia e trauma. São Paulo: Artes 21. O’sullivan SM, Hartwell GR. Obturation of a retained primary
Médicas; 2002. p. 239-66. mandibular second molar using mineral trioxide aggregate: a case
2. Sinai IH. Endodontic perforations: their prognosis and treatment. report. J Endod. 2001;27(11):703-5.
J Am Dent Assoc. 1977;95(1):90-5. 22. Holland R, Mazuqueli L, Souza V, Murata SS, Dezan Junior E,
3. Juárez Broon N, Bramante CM, Assis GF, Bortoluzzi EA, Suzuki P. Inluence of the type of vehicle and limit of obturation on
Bernardinelli N, Moraes IG, et al. Healing of root perforations apical and periapical tissue response in dogs’ teeth after root canal
treated with mineral trioxide aggregate (MTA) and Portland cement. illing with mineral trioxide aggregate. J Endod. 2007;33(6):693-7.
J Appl Oral Sci. 2006;14(5):305-11. 23. Páttaro ES, Amaral KF, Gavini G. Capacidade selante de materiais
4. Holland R, Souza V, Nery MJ, Otoboni Filho JA, Bernabé PFE, restauradores empregados no preenchimento de perfurações de
Dezan Júnior E. Reaction of dogs’ teeth to root canal illing with furca. Rev Odontol Univ Cid São Paulo. 2004;16(1):47-53.
mineral trioxide aggregate or a glass ionomer sealer. J Endod. 24. Holland R, Souza V, Tagliavini RL, Milanezi LA. Healing process of
1999;25(11):728-30. teeth with open apices. Histological study. Bull Tokyo Dent Coll.
5. Holland R, Souza V, Nery MJ, Faraco Júnior IM, Bernabé 1971;12(4):333-8.
PFE, Otoboni Filho JA, et al. Reaction of rat connective 25. Holland R, Souza V, Nery MJ, Mello W, Bernabé PFE, Otoboni
tissue to implanted dentin tube illed with mineral trioxide Filho JA. Effect of the dressing in root canal treatment with calcium
aggregate, Portland cement or calcium hydroxide. Braz Dent J. hydroxide. Rev Fac Odontol Araçatuba. 1978;7(1):39-45.
2001;12(1):3-8. 26. Holland R, Otoboni Filho JA, Souza V, Nery MJ, Bernabé PFE,
6. Torabinejad M, Hong CU, Lee SJ, Monsef M, Ford TR. Investigation Dezan Júnior E. Reparação dos tecidos periapicais com diferentes
of mineral trioxide aggregate for root-end illing in dogs. J Endod. formulações de Ca(OH)2. Estudo em cães. Rev Assoc Paul Cir
1995;21(12):603-7. Dent. 1999;53(4):327-31.
7. Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. Tissue 27. Felippe MCS, Felippe WT, Marques MM, Antoniazzi JH. The effect
reaction to implant Super-EBA and Mineral Trioxide Aggregate of renewal of calcium hydroxide paste on the apexiication and
in the mandible of guinea pigs: a preliminary report. J Endod. periapical healing of teeth with incomplete root formation. Int Endod
1995;21(11):569-71. J. 2005;38(7):436-42.
8. Torabinejad, M, Hong CU, Pitt Ford TR, Kettering JD. Citotoxicity of 28. O’Neil MJ, editor. The Merck index: an encyclopedia of chemicals,
four root end illing materials. J Endod. 1995;21(10):489-92. drugs and biologicals. 13a ed. New Jersey: Merck; 2001.
9. Kettering JD, Torabinejad M. Investigation of mutagenicity of 29. Seidenfeld MA, Hanzlik PJ. The general properties, actions and
mineral trioxide aggregate and other commoly used root-end illing toxicity of propylene glycol. J Pharmacol. 1932;44:109-21.
materials. J Endod. 1995;21(11):537-9. 30. Olitzky I. Antimicrobial properties of a propylene glycol based
10. Faraco Júnior IM, Holland R. Histomophorlogical response of dogs’ topical therapeutic agent. J Pharm Sci. 1965;54(5):787-8.
dental pulp capped with white mineral trioxide aggregate. Braz 31. Bhat KS, Walkevar S. Evaluation of bactericidal property of
Dent J. 2004;15(2):104-8. propylene glycol for its possible use in endodontics. Arogya J
11. Holland R, Filho JA, Souza V, Nery MJ, Bernabé PF, Dezan Júnior Health Sci. 1975;1(4):54-9.
E. Mineral trioxide aggregate repair of lateral root perforations. 32. Thomas PA, Bath KS, Kotian KM. Antibacterial properties of dilute
J Endod. 2001;27(4):281-4. formocresol and eugenol and propylene glycol. Oral Surg Oral Med
12. Scheerer SQ, Steiman HR, Cohen J. A comparative evaluation Oral Pathol. 1980;49(2):166-70.
of three root-end illing materials: an in vitro leakage study using 33. Safavi K, Nakayama TA. Inluence of mixing vehicle on dissociation
Prevotella nigrescens. J Endod. 2001;27(1):40-2. of calcium hydroxide in solution. J Endod. 2000;26(11):649-51.
13. Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial 34. Cengiz T, Aktener BO, Piskin B. The effect of dentinal tubule
leakage of mineral trioxide aggregate as a root end illing material. orientation on the removal of Smear layer by root canal
J Endod. 1995;21(3):109-12. irrigant. A scanning electron microscopic study. Int Endod J.
14. Arens DE, Torabinejad M. Repair of furcal perforations with mineral 1990;23(3):163-71.
trioxide aggregate: two case reports. Oral Surg Oral Med Oral 35. Meryon SD, Tobias RS, Jakeman KJ. Smear removal agents:
Pathol Oral Radiol Endod. 1996;82(1):84-8. aquantitative study in vivo and in vitro. J Prosthet Dent.
15. Holland R, Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni 1987;57(2):174-9.
Filho JA, Dezan Júnior E. Healing process of dog dental pulp after 36. Ruiz PA, Souza AHF, Amorim RFB, Carvalho RA. Agregado de
pulpotomy and pulp covering with mineral trioxide aggregate or trióxido mineral (MTA): uma nova perspectiva em endodontia. Rev
Portland cement. Braz Dent J. 2001;12(2):109-13. Bras Odontol. 2003;60(1):33-5.
16. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral 37. Marion JJC. Processo de reparo de dentes de cães após
trioxide aggregate for repair of lateral root perforations. J Endod. biopulpectomia e obturação dos canais radiculares com os
1993;19(11):541-4. cimentos SealapexTM ou MTA manipulado com propilenoglicol,
17. Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties associados ao efeito do emprego ou não de um curativo de
and retention characteristics of mineral trioxide aggregate corticosteróide-antibiótico [dissertação]. Marília (SP): Universidade
when used as a furcation perforation repair material. J Endod. de Marília; 2008.
1998;24(11):768-71. 38. Namazikhah MS. The effect of pH on surface hardness and
18. Faraco Júnior IM, Holland R. Response of the pulp of dogs to microstructure of mineral trioxide aggregate. Int Endod J.
capping with mineral trioxide aggregate or a calcium hydroxide 2008;41(2):108-16.
cement. Endod Dent Traumatol. 2001;17(4):163-6. 39. Balto HA. Attachment and morphological behavior of human
19. Shabahang S, Torabinejad M. Treatment of teeth with open apices periodontal ligament ibroblasts to mineral trioxide aggregate: a
using mineral trioxide aggregate. Pract Periodontics Aesthet Dent. scanning electron microscope study. J Endod. 2004;30(1):25-9.
2000;12(3):315-20; quiz 322.
© 2013 Dental Press Endodontics 101 Dental Press Endod. 2013 May-Aug;3(2):96-101