Mineral Trioxide Aggregate (MTA) in apexification


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Mineral Trioxide Aggregate (MTA) in apexification

  1. 1. Case Report ENDODONTOLOGY Volume: 25 Issue 2 December 2013 Mineral Trioxide Aggregate (MTA) in apexification Abu-Hussein Muhamad # Abdulghani Azzaldeen ## Abu-Shilabayeh Hanali ## ABSTRACT Mineral Trioxide Aggregate (MTA) was introduced as an alternative to traditional materials for the repair of root perforations, pulp-capping and as a retrograde root filling due to its superior biocompatibilty and ability to seal the root canal system. Traditionally, calcium hydroxide has been the material of choice for the apexification of immature permanent teeth but MTA holds significant promise as an alternative to multiple treatments with calcium hydroxide. The paper discusses the use of calcium hydroxide as a traditional apexification material and provides an overview of the composition, properties and applications of Mineral Trioxide Aggregate with emphasis on its use in apexification of immature permanent teeth. A case report is presented to highlight its use. Key Words : Open-apex, mineral trioxide aggregate Introduction regeneration.5 It has the ability to stimulate cytocline Trauma causes cessation of root development. release from the bone cells, indicating that it actively Fragile root canals becomes weak. It is difficult to promotes hard tissue formation.6 create an artificial barrier or induce closure of Case Report apical foramen with calcified tissue.1 MTA was first A 14-year old girl suffering from painful described in dental scientific literature in 19932 and symptoms caused by her central incisors was was given approval for endodontic use by the US examined in the Department of Pediatic Dentistry, Food and Drug Administration in 1998. Upto 2002, Al-Quds University, Jerusalem for evaluation and only one MTA material consisting of grey coloured treatment. powder was available and then white MTA was introduced. Both formulae contain 75% Portland Investigation revealed a trauma (4 years ago) cement, 20% bismuth oxide and 5% gypsum by associated with an enamel/dentin fracture. No weight. The aim of this procedure is to limit bacterial treatment was performed at that time. infection and production of mineralized apical Approximately two years later, a fluctuant swelling tissues in immature anterior tooth. The inadequacy developed in the apical area of the teeth. Symptoms of calcium hydroxide apexification due to its long also included tenderness to percussion. Drainage time span and re-infection because of temporary was established by lingual access in the pulp seal chamber. Treatment was interrupted by the patient 3,4 led to the use of MTA. for no reason, and four years later, an attempt of This forms a barrier and prevents micro apexification using calcium hydroxide paste was leakage. It is bio - compatible and forms dentinal carried out for six months by another dentist, but bridge, cementum and periodontal ligament no apexification was observed on either tooth. # University of Napoli, ## Al-Quds University, Palestine 97
  2. 2. ABU-HUSSEIN MUHAMAD, ABDULGHANI AZZALDEEN, ABU-SHILABAYEH HANALI When patient was referred to our department, incompletely formed with open apices and extra and intra-oral examinations (including periapical lesions (fig.1). Cleaning and shaping of radiology) were performed: they revealed central root canals system was achieved under rubber dam left and right incisors in normal position with isolation. The solution used for irrigation was 2.5% enamel/dentin fracture. Root canals were wide, roots sodium hypochlorite. Root canal length was Fig.1. Radiographic examinationshows implication of pulpal tissues and presence of periapical lesions due to dental trauma Fig. 2. First attempt to place MTA in the right maxillary Fig. 3. Apical plug of MTA in the apical third of the canal Fig. 4. Conventional obturation with gutta-percha 98
  3. 3. MINERAL TRIOXIDE AGGREGATE (MTA) IN APEXIFICATION Fig.5 Radiographic follow-up at 6 months Fig. 6. Radiographic follow-up after 12 months determined using an apex locator and confirmed Two days later, coronal and middle thirds of radiographically. Calcium hydroxide paste was the canals were filled with gutta-percha by a vertical placed in the canals for 1 week for disinfection. warm compaction technique and access cavities During the second appointment, were sealed in conjunction with the final restoration (fig. 4).Periradicular healing was assessed clinically Calcium hydroxide was eliminated by and radiographically at 6, 8 (fig. 5) and 12 months mechanical instrumentation and rinsed out of root (fig. 6). The use of MTAR completed with a canals by means of sterile water irrigation. The conventional endodontic treatment resulted in canals were dried using sterile paper points. MTAR apical formation of the two central incisors (fig. 6). was prepared immediately before use, placed into Discussion the canals with an MTAR carrier and compacted with a hand plugger to create an apical plug of 3 to The traditional use of calcium hydroxide apical 4 mm as described by the manufacturer. barriers has been associated with unpredictable Radiography was taken to check if no apical apical closure, time taken for barrier formation, extension occured. patient compliance, risks of re-infection resulting from the difficulty in creating long term seals with The apical plug failed in the first attempt on the provisional restorations and susceptibility to root right maxillary central incisor (fig. 2), MTAR was rinsed fractures arising from the presence of thin roots or out with sterile water and the procedure was repeated prolonged exposure of the root dentin to Ca(OH)27. (fig.3). Moist paper points were placed in the canals Thus there is increasing popularity with one visit and access cavities were closed with a temporary apexification techniques. One visit Apexification has restorative material, IRMR (Dentsply, Caulk, USA)*. been defined as the non surgical condensation of a 99
  4. 4. ABU-HUSSEIN MUHAMAD, ABDULGHANI AZZALDEEN, ABU-SHILABAYEH HANALI biocompatible material into the apical end of root Torabinejad12 reported the ingredients in MTA canal. The rationale is to establish an apical stop as tri calcium silicate, tricalcium aluminate, that would enable the root canal to be filled tricalcium oxide and silicate oxide with some other immediately. Torneck and others have indicated mineral oxides that were responsible for the that when apical closure takes place clinically with chemical and physical properties of aggregate. The Ca(OH)2, there is no complete bridging of the apex powder consists of fine hydrophilic particles that histologically. Periapical inflammation persists set in the presence of moisture. The hydration of about the apices of many teeth because necrotic the powder results in a colloidal gel with a pH of tissue exists in corners and crevices of the bridge. 12.5 that will set in approximately 3 hours. MTA A major target area of biomedical research has a compressive strength equal to intermediate is a mechanism to restore lost bone. restorative material and Super - EBA but less than A resorbabletricalcium phosphate ceramic has been that of amalgam. It is commercially available as developed. Koenig’s, Brilliant and Driskell found ProRoot MTA ,and has been advocated for use in that use of this material induced apical closure in the immediate obturation of open root apex. 8 9 vital teeth of primates with open apices. MTAhas the ability to induce cementum like Regeneration of periodontal ligament occurred hard tissue when used adjacent to the periradicular around the apices of teeth and it was associated tissues. MTAis a promising material as a result of with minimal inflammatory response.Harbert its superior sealing property, its ability to set in the documented the long term success of using a tri presence of blood and its biocompatibility. Moisture calcium phosphate plug as an apical barrier for one contamination at the apex of tooth before barrier step apexification. In other studies teeth with open formation is often a problem with other materials apices were obturated using an apical barrier with used in apexification. As a result of its hydrophilic dentin and Ca(OH)2 plugs or dentin chips and property, the presence of moisture does not affect hydroxyappatite10. its sealing ability. Shabahang13 et al examined hard tissue There is increasing popularity with one visit formation and inflammation apexification technique using Mineral Trioxide histomorphologically after treating open apices in Aggregate (MTA) as osteoconductive apical barrier. canine teeth with osteogenic protein-1, MTA and MTA is relatively non cytotoxic and stimulates calcium hydroxide. MTA induced hard tissue cementogenesis. This Portland cement based formation with the most consistency, but the amount material generates a highly alkaline aqueous of hard tissue formation and inflammation was not environment by leaching of calcium and hydroxyl statistically different among the three materials. ions, rendering it bioactive by forming MTA has demonstrated the ability to stimulate hydroxyappatite in presence of phosphate cells to differentiate into hard tissue – forming cells containing fluids. Unlike the extended use of and to produce a hard tissue matrix. A number of Ca(OH)2 in immature roots, prolonged filling of animal studies have demonstrated a more these roots with MTA did not reduce their fracture predictable healing outcome when MTA is used resistance11. 100
  5. 5. MINERAL TRIOXIDE AGGREGATE (MTA) IN APEXIFICATION 4. Andreasen JO, Farik B, Munksgaard BC. Long term calcium hydroxide as a root canal dressing can increase the risk of root canal fracture. Dental Traumatology 2002; 18 : 134-7. when compared with teeth treated with calcium hydroxide14. In a prospective human outcome study, 57 teeth with open apices were obturated with MTA 5. Holah G, eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent 2005; 27:129-36. in one appointment. Forty – three of these cases were available for recall at 12 months, of which 6. Koh ET, Pittford TR, Torabinejad M, Mcdonald F. Mineral trioxide aggregate stimulates cytokine production in human osteoblasts J Bone Min Res 1995; 10S:S406. 81% of cases were classified as healed15. Despite its good physical and biologic properties, extended setting time has been a main disadvantage. Calcium 7. Andreasen JO, Farik B, Munksgaard EC. Long term calcium hydroxide as a root canal may increase risk of root fracture. Dent Traumatol 2002;18:134-7 chloride was used with intention to stimulate hardening process of MTA. Studies have shown that 8. Torneck CD, Smith JS, Grindall P. Biologic effects of endodontic procedures on developing incisor teeth. Oral Surg 1973;35:541 not only the sealing ability but its physicochemical property was improved by addition of CaCl2 . 9. Koenigs JF, Brilliant D, Driskell TD. Induced apical closure of permanent teeth in adult primates using a resorbable form of tricalcium phosphate ceramic.JEndod 1975; 3(1):102-106 Conclusion Based on this study’s results, the following conclusions can be made: 10. Brandell DW, Torabinajed M, Bakland L K. Demineralised dentin, hydroxyappatite and dentin chips as apical plugs.Endod Dent Traumatol 1986;2:210-4 1. Mineral trioxide aggregate showed clinical and radio-graphic success as a material used to 11. Rebecca L, Martin BS, Francesca M et al.Sealing properties of mineral trioxide aggregate orthograde apical plugs and root fillings in an in vitro apexification model. J Endod 2007;33:272-275 induce root-end closure in necrotic immature permanent teeth. 12. Torabinejad M, ChivianN.Clinical applications of mineral trioxide aggregate.JEndod 1999;25:197-205 2. MTA is a suitable replacement for calcium hydroxide for the apexification procedure. 13. Shabahang S, TorabinejadM.Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodont Aesthet Dent 2000;12:315-20 References : 1. Seltzer S. Endodontology; Biologic Considerations in EndodonticProcedures, 1988, 2nd edn. Philadelphia; Lea and Febiger. 14. El-Meligy OA, Avery DR. Comparison of Apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent 2006;28:248-53 2. Lee SJ, Monset M, Torabinejad M. Sealing ability of a mineral trioxideaggregate for repair of lateral root perforations. J. Endod 1993; 19 : 541-4. 15. Simon S, Rillard F, Berdal A et al ,The use of mineral trioxide aggregate in one visit Apexification treatment: a prospective study. IntEndod J 2007;40:186-97 3. Schmitt d, Bogen g. Multifaceted use of ProRoot MTA root canal repair material. Pediatr Dent 2001:23:326-30. 101