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Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 110-114

Mineral trioxide aggregate obturation in retreatment with regenerative adjuncts of bioceramic allograft in large periapical defects

1 Department of Conservative Dentistry and Endodontic, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Oral Pathology, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Orthodontics, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission05-Sep-2015
Date of Acceptance15-Dec-2015
Date of Web Publication16-Nov-2016

Correspondence Address:
Dr. Sajid Ali
Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College and Hospital, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-6944.194239

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Endodontic overfills and incomplete obturation is usually associated with an array of local complications and results in persistent periapical infection and inflammation. In addition, imprecise management of immature roots also leads to treatment failure. Here, a case of open apices of maxillary central incisors with extrusion of Gutta-percha and associated large periapical lesion is presented. Mineral trioxide aggregate (MTA) was used to obturate the blunderbuss canals, and an alloplastic graft (biphasic calcium phosphate) was filled in the bony defect after surgical curettage. At the 6th month postoperatively, periapical osseous healing was satisfactory. The advantages and indications of MTA as obturation material and bone graft in periodontal regeneration are discussed. Clinically and radiographically, the case was followed for 5 years to assess the outcomes of MTA obturation.

Keywords: Hydroxyapatite-beta tricalcium phosphate, mineral trioxide aggregate, periapical granuloma, root canal obturation

How to cite this article:
Zoya A, Ali S, Khan MH, Mian F. Mineral trioxide aggregate obturation in retreatment with regenerative adjuncts of bioceramic allograft in large periapical defects. Indian J Oral Sci 2016;7:110-4

How to cite this URL:
Zoya A, Ali S, Khan MH, Mian F. Mineral trioxide aggregate obturation in retreatment with regenerative adjuncts of bioceramic allograft in large periapical defects. Indian J Oral Sci [serial online] 2016 [cited 2020 Feb 19];7:110-4. Available from: http://www.indjos.com/text.asp?2016/7/2/110/194239

  Introduction Top

Traumatic injury or caries in young permanent teeth can cause pulpal inflammation, necrosis, and subsequent incomplete development of dentinal wall thickness and root apex. Highly immature apices with divergent and flaring foramen are called "blunderbuss." The problems associated with these canals are weaker roots prone to fracture, poor crown to root ratio, and more susceptible to periodontal involvement. Besides, complete debridement, disinfection, and three dimensional obturation of canals with open apices are daunting tasks as they lack apical constriction.[1] Thus, treatment in these cases aims at developing the apical stop for confinement and condensation of obturating material three-dimensionally.

Apexification and apical barrier technique are the two commonly employed methods for management of immature permanent teeth with open apices. Although apexification using calcium hydroxide has high success rate, decrease in fracture resistance of the tooth, long duration of treatment, multiple appointments, and requirement of patient compliance are the disadvantages. Apical barrier technique using mineral trioxide aggregate (MTA) has become the standard for treatment of immature roots with necrotic pulps. In this technique, an artificial stop is created that would enable the root canal to be filled immediately.[2] MTA apical barrier has the distinct advantages of shorter treatment time, good apical seal, and cementum deposition leading to a more biological healing of periapical tissues which has been shown to have long-term success.

Apart from establishing apical barrier, complete corono-apical obturation is imperative for prevention of endodontic disease and resolution of periapical pathosis. Three-dimensional obturation allows inhibition of further ingress of bacteria and entombs remaining microorganisms blocking their nutrient supply.[3] MTA provides remarkable physiochemical and bioactive properties, offering an excellent advantage when used as canal obturation material.[4]

Apical periodontitis is an immune-inflammatory reaction resulting in destruction of periradicular tissues in response to etiologic agents of endodontic origin. Although nonsurgical root canal therapy, apical microsurgery, and extraction are the different treatment modalities for the management of periapical inflammatory lesion. However, surgical intervention allows thorough debridement which leads to a faster healing rate and also permits placement of different biomaterials to improve the new bone formation, especially for large defects.[5]

This case report presents the successful surgical retreatment of large periapical lesion associated with overextended filling materials using bioactive graft and MTA obturation in blunderbuss canals of maxillary central incisors.

  Case Report Top

A 17-year-old female presented with chief complaint of pain and swelling in relation to upper incisors along with staining of crown margins [Figure 1]. Her medical history was not significant. The patient gave history of treatment by a general practitioner for the same teeth. Clinically, the teeth 11 and 21 were covered with a defective FPD revealing plaque and calculus at the margins. Teeth 12 and 22 were tender on percussion. Tooth 12 was having grade II mobility along with root exposure. Radiographic examination revealed that both central incisors were having wide open apices with large periapical radiolucencies. Single cones of Gutta-percha (GP) points were overextended periapically in both 11 and 21 [Figure 2]. Pulp testing was done for tooth 12 and 22 and was found nonresponsive. A diagnosis of persistent/chronic apical periodontitis in relation to teeth 11, 12, 21, and 22 was made.
Figure 1: Presenting clinical photograph

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Figure 2: Preoperative radiograph

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After removal of prosthesis [Figure 3], oral prophylaxis was completed and intracanal filling material was removed using Hedstrom files (Dentsply Maillefer, Ballaigues, Switzerland). Access cavities were refined using Endo-Z (Dentsply/Tulsa Dental, Tulsa, OK). The root canals were instrumented with K-file (Dentsply Maillefer, Ballaigues, Switzerland) up to working length (19 mm), irrigated with 1% sodium hypochlorite (NaOCl) with side vented needle, 0.9% normal saline (Fresenius, Kabi, India), and 2% chlorhexidine as final rinse and then dried with paper points. Calcium hydroxide (Ultracal XS; Ultradent, South Jordan, UT) was placed in the root canals for 3 weeks. All the treatment options (nonsurgical, surgical, extraction, and implant) were described to the patient, and surgical approach was planned in the next appointment after taking patient consent.
Figure 3: Condition after removal of crowns

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At the second appointment, i.e., after 3 weeks, calcium hydroxide was flushed out using normal saline. The canals were dried with paper points. Local anesthetic (1.8 mL 2% lidocaine with 1:100,000 epinephrine) was used to give infraorbital nerve block. A full-thickness rectangular mucoperiosteal flap was reflected by a sulcular incision starting from distal of tooth 12 to distal of tooth 22 to with the aim to expose periapical the periapical region. Cortical plate was absent in relation to teeth 11 and 12. Pathological mass [Figure 4] of size approximately 1 inch × 1 inch in dimension was curetted out, and osseous defect and root canals of tooth 11 and 21 were copiously irrigated with betadine and sterile saline solution [Figure 5].
Figure 4: Pathologic mass curetted out of bony defect

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Figure 5: Clean bony cavities after curettage of pathologic tissue

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Gauze pieces were placed in bony defect and root canals were dried. MTA (Pro root MTA; Tulsa Dental, Johnson City, TN) was mixed according manufacture's instruction and packed into the canals with open apices, i.e., teeth 11 and 21 using amalgam carrier and hand pluggers. These canals were completely obturated with MTA which was condensed both coronally and apically using straight and root-end condensers [Figure 6]. The tooth 22 with closed apex was obturated by GP and eugenol-based sealer.
Figure 6: Radiograph after surgical curettage and mineral trioxide aggregate obturation of root canals

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The walls of the cavity were curetted again to induce bleeding and a nanocrystalline graft material SyboGraf Plus (Eucare Pharmaceuticals, Chennai, India) was placed in the defects and adapted along all the surfaces of the defect [Figure 7]. The graft material was packed with light pressure up to the level of surrounding cortical plate. The flap was gently repositioned and a slight pressure was applied to adapt it to the bony margins. Once it was confirmed that the flap was being supported by the graft material, the flap was sutured using 4-0 silk. Postsurgical instructions were given, and medication was prescribed. The sutures were removed after 5 days, and satisfactory healing was observed.
Figure 7: Bioceramic graft material packed in the bony defect

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As the mobility of tooth 12 did not diminish, owing to the deep pocket and much bone loss, therefore, it was extracted later. After healing of extraction socket, porcelain fused to metal bridge extending from tooth 13 to tooth 22 was fixed with dual cure resin cement (Paracore, Coltene Whaledent, Altstätten, Switzerland). Radiographs were taken during follow-up visits at 1 month [Figure 8]a, 9 months [Figure 8]b, 24 months [Figure 8]c, and 5 years [Figure 8]d. During these visits, the patient was asymptomatic and highly satisfied. The case was deemed successful both clinically and radiographically. It can be emphasized that MTA obturation provided superior sealing and strength to the weak and infected roots. Furthermore, the bone graft aided in faster regeneration of such large defects.
Figure 8: Follow-up radiographs after (a) 1 month, (b) 9 months, (c) 24 months, and (d) 5 years

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  Discussion Top

Nonvital teeth with immature roots make the treatment more challenging with a reduced prognosis as the open apices do not permit the standard root canal protocols such as biomechanical preparation, disinfection, and three-dimensional obturation due to risk of extrusion of irrigant and obturating material. Furthermore, the thin and fragile roots and associated chronic infection impart the danger of fracture or perforation making thorough biomechanical preparation impractical. These difficulties can be managed by minimal instrumentation of canal, formation of hard tissue barrier at apex, placement of an artificial apical barrier, and by reinforcing the weakened root against fracture.[6] This case report describes the MTA obturation of blunderbuss canals and surgical management of associated large periapical lesion.

Several in vitro cell culture studies demonstrated that periapically extruded GP can be toxic to human dental pulp cells, mouse fibroblasts, and associated with delayed healing at periapex. Extruded GP points also form a favorable substrate for microbial colonization in the form of biofilm and houses a wide range of bacterial species on their surfaces thereby sustaining periapical inflammatory processes and present as long-standing periapical infection.[7] Thus, in the present case, overfilling, inadequate obturation, and lack of fluid impervious seal might be the contributing factors in the development of such large periapical pathology.

Apexification and nonsurgical treatment of periapical lesion using calcium hydroxide were not chosen in this case. The reasons for not selecting such a treatment plan were long duration of treatment with multiple appointments, requirement of patient compliance, unpredictable prognosis, risk of reinfection, and fracture between the appointments.[8] In addition, the present case had the possibility of the presence of resistant microbial flora as it had been previously treated.

Trope and others have recommended low concentration of NaOCl for root canal irrigation and debris removal in teeth with open apices because there may be chances of periapical extrusion resulting in cytotoxicity.[6] Therefore, 1% NaOCl was employed in this case. However, the reduced concentration can be compensated by the higher volumes of irrigant used.

Several leakage studies have shown that GP is highly susceptible to microleakage when a deficient coronal seal is present irrespective of the obturation technique used. MTA provides superior marginal adaptation as it forms a mineralized dentin - MTA interstitial layer and its particles occludes and penetrate the dentinal tubules.[4],[9] This sealing ability of MTA produces challenging environment for bacterial survival. Both bacteriostatic and bactericidal potentials of MTA make it potent against Enterococcus faecalis and Candida albicans and thus refractory endodontic diseases.[10] Therefore, MTA obturation was preferred over other methods in this case as has been advocated by Bogen and Kuttler.[3]

Numerous alloplastic materials are proposed for filling bony defects. These grafts prevent hematoma formation, act as scaffold, and facilitate bone regeneration like in healing with primary intention. Therefore, with the aim of regeneration of new bone in large periapical defect, biphasic calcium phosphate (BCP) ceramic was used in this case. The beneficial effects of BCP in periapical healing have been emphasized by several authors.[11] BCP is biphasic consist of soluble hydroxyapatite (70%) and soluble beta-tricalcium phosphate (30%). The faster resorption of beta-tricalcium phosphate helps in the process of bone mineralization; however, slower resorbability of hydroxyapatite helps for bone in-growth providing a scaffold for calcification. Pure phase beta-tricalcium phosphate is resorbed and replaced by vital bone over 6 months' time and complete substitution may take 15-18 months as shown histologically in animal studies. Hydroxyapatite acts as volumetric fillers and scaffolds upon which new bone is deposited. Although hydroxyapatite will neither be resorbed nor replaced by bone, the resultant structure will be firmer than a graft encased in nonmineralized connective tissue alone. Advantages of using BCP are biocompatibility, osteoconductive effect, structure similar to apatite of bone, and cost effectiveness.[12] Osteoinduction has also been seen with beta-tricalcium phosphate.[13]

After taking radiographs during the follow-up visits, it was observed that MTA in root canal and BCP in the periapical defect facilitate significant, progressive, and predictable periapical healing along with osseous regeneration.

The presented report describes the successful management with long-term follow-up of a retreatment case of blunderbuss canals associated with large periapical lesion by MTA obturation and BCP ceramic.

  Conclusion Top

On the basis of the findings of studies addressed in the literature and the 5-year clinical and radiographic outcomes of this case, it might be concluded that (1) MTA, a well-known osteoinductive and cementogenic material demonstrate superior healing rates when used for obturation of root canal system in retreatment cases compromised by microleakage, inadequate disinfection and obturation, and large periapical lesions. (2) Large bony defects should be filled with biocompatible, bioactive, and osteoconductive materials that allow regenerative tissue process rather repair and ensure faster healing.

This case report adds some knowledge to the limited literature available on long-term clinical outcome of MTA obturation. However, further experimental studies are necessary to investigate the effects of MTA as obturation material and coadministered biomaterials on periapical healing and endodontic success.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hargreaves K, Law A. Cohen′s Pathways of the Pulp. 10 th ed. St. Louis, MO: Mosby Elsevier; 2011.  Back to cited text no. 1
Morse DR, O′Larnic J, Yesilsoy C. Apexification: Review of the literature. Quintessence Int 1990;21:589-98.  Back to cited text no. 2
Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90.  Back to cited text no. 3
Komabayashi T, Spångberg LS. Particle size and shape analysis of MTA finer fractions using Portland cement. J Endod 2008;34:709-11.  Back to cited text no. 4
Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: A comparative histomorphometrical study. Int Endod J 2002;35:255-63.  Back to cited text no. 5
Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Endod Topics 2006;14:51-9.  Back to cited text no. 6
Noiri Y, Ehara A, Kawahara T, Takemura N, Ebisu S. Participation of bacterial biofilms in refractory and chronic periapical periodontitis. J Endod 2002;28:679-83.  Back to cited text no. 7
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 8
Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-5.  Back to cited text no. 9
Santos AD, Moraes JC, Araújo EB, Yukimitu K, Valério Filho WV. Physico-chemical properties of MTA and a novel experimental cement. Int Endod J 2005;38:443-7.  Back to cited text no. 10
Favieri A, Campos LC, Burity VH, Santa Cecília M, Abad Eda C. Use of biomaterials in periradicular surgery: A case report. J Endod 2008;34:490-4.  Back to cited text no. 11
Bölükbasi N, Yeniyol S, Tekkesin MS, Altunatmaz K. The use of platelet-rich fibrin in combination with biphasic calcium phosphate in the treatment of bone defects: A histologic and histomorphometric study. Curr Ther Res Clin Exp 2013;75:15-21.  Back to cited text no. 12
Yuan H, Kurashina K, de Bruijn JD, Li Y, de Groot K, Zhang X. A preliminary study on osteoinduction of two kinds of calcium phosphate ceramics. Biomaterials 1999;20:1799-806.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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