- Email: [email protected]
Management of a Perforating Internal Resorptive Defect with Mineral Trioxide Aggregate: A Case Report
Case Report/Clinical Techniques
Management of a Perforating Internal Resorptive Defect with Mineral Trioxide Aggregate: A Case Report Emre Altundasar, DDS, PhD,* and Becen Demir, DDS, PhD† Abstract Introduction: A radicular perforation caused by an inflammatory internal root resorption was present in a maxillary lateral incisor. Methods: The root canal preparation was completed with hand files and thorough irrigation. Calcium hydroxide was placed as a temporary dressing for 10 days. At the second visit, the root canal with resorption lacuna was filled with warm vertical compaction of gutta-percha. The coronal access was restored with composite resin. A surgical flap was elevated to repair the resorption defect with gray mineral trioxide aggregate. The bony defect adjacent to the perforated lesion was filled with Unigraft (Unicare Biomedical, Laguna Hills, CA). Results: The tooth was in function with satisfactory clinical and radiographic results after 48 months. Conclusions: According to the long term results of this case, successful sealing of a perforating defect is possible with mineral trioxide aggregate. (J Endod 2009;35:1441–1444)
Key Words Inflammatory internal resorption, mineral trioxide aggregate, root perforation
From the *Department of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey; and †Private Practice, Istanbul, Turkey. Address requests for reprints to Dr Emre Altundasar, Hacettepe University, Faculty of Dentistry, Department of Endodontics, Sihhiye 06100, Ankara, Turkey. E-mail address: [email protected]. 0099-2399/$0 - see front matter Copyright ª 2009 American Association of Endodontists. doi:10.1016/j.joen.2009.06.017
JOE — Volume 35, Number 10, October 2009
I
nternal root resorption has been described as a resorptive defect of the internal aspect of the root following necrosis of odontoblasts as a result of chronic inflammation and bacterial invasion of the pulp tissue. Resorption has been associated with multinucleated giant cells adjacent to a pulpal granulation tissue (1). Clinically, internal root resorption is usually asymptomatic and is detected coincidentally through routine radiographs. Pain or discomfort may be the chief complaint if the granulation tissue has been exposed to oral fluids. The granulation tissue can clinically manifest itself as a ‘‘pink spot’’ in cases in which crown dentin destruction is severe (2). Radiographic examination usually reveals a fairly uniform radiolucent area with disrupted outline of the root canal. The progression of internal resorption depends on vital tissues (3). Therefore, root canal treatment should be initiated as soon as possible once an inflammatory resorptive lesion is detected to prevent further hard tissue loss and eventually root perforation (2). In cases without a perforation, the removal of the granulation tissue and the blood supply to the resorbing cells by root canal treatment should be sufficient. However, in cases in which a pathway between the pulp canal space and the periodontal tissues is present, root canal treatment should be followed by repair of the perforation site with a suitable sealing material (4). Mineral trioxide aggregate (MTA) has been proposed as a favorable perforation repair material with its superior sealing ability (5), biocompatibility (6, 7), fibroblastic stimulation (8), and antimicrobial activity (9). MTA can create an environment conducive to periodontal healing, allowing new cement growth on its surface (10). The material has been used in several applications including pulpotomy, pulp capping, and perforation repair (11–13). This case report describes the 48-month follow-up of a perforating internal root resorption in a maxillary lateral incisor in which gray MTA was used to seal the perforation area after endodontic therapy.
Case Report A 42-year-old male patient presented with a localized mild swelling on the attached gingiva between the central and the lateral incisor teeth. There was no history of pain or discomfort. The patient was aware of the swelling for almost 2 months. As reported by the patient, the color and size of the swelling were stable because it was recognized. The swelling had a radius of approximately 5 mm with regular borders. The patient’s medical status was noncontributory, and he mentioned that he had no trauma to the related area. An old composite resin restoration was noted on the distal aspect of the maxillary lateral incisor tooth. The tooth responded positively to electric pulp vitality test, and no discomfort was noted on percussion. On the mesiobuccal aspect of the crown, the probing depth measured 4 mm, whereas the mobility of the tooth was within normal limits. Radiographic examination revealed a uniform radiolucent lesion in the middle third of the root canal (Fig. 1). The centrally localized image of the lesion did not shift when additional radiographs were taken from different angulations. An access cavity was prepared, and the working length was determined by x-ray images. The root canal was instrumented with stainless steel hand files until an apical stop of ISO #50 could be created. The persistent seeping of blood through the root canal diminished gradually with instrumentation. The root canal was frequently irrigated with 1.3% NaOCl followed by a final rinse with 5 mL of sterile saline. Subsequently, calcium hydroxide (Ultracal XS; Ultradent Products Inc, South Jordan, UT) was placed as a temporary dressing to control bleeding. The access cavity was temporarily sealed with Cavit G (3 M ESPE, St Paul, MN). After 10 days, the root canal was reentered and irrigated alternately with 1.3% NaOCl and sterile saline to remove the temporary
Perforating Internal Resorptive Defect with MTA
1441
Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph showing internal resorption lesion of the maxillary lateral incisor tooth with irregular borders. An unfavorable coronal restoration is evident. (B) Swelling as clinical manifestation of the perforating resorption. (C) Postoperative radiograph after 48 months. (D) Healthy appearance of gingiva after 48 months.
dressing; 17% EDTA solution was left flooded in the cavity for 5 minutes, which was later rinsed with 5 mL of sterile saline. The root canal was filled with warm vertical compaction of gutta-percha combined with AH-26 sealer (Dentsply De Trey, Konstanz, Germany). After radiographic confirmation of a satisfactory obturation, the access cavity was restored with composite resin. A flap that exposed the granulation tissue and the bone destruction was elevated at the same appointment. The granulation tissue (Fig. 2) was removed, and the irregular borders of the perforation site were smoothed with a bur attached to a straight surgical handpiece. MTA powder was mixed according to the manufacturer’s instructions and placed with an MTA carrier. MTA was firmly condensed by using a plugger and wet cotton pellets (Fig. 2). Bone graft material (Unigraft; Unicare Biomedical, Laguna Hills, CA) was placed over MTA to fill the cavity of the bony defect (Fig. 2). The flap was sutured, and the patient was recalled 1 week later for suture removal. At the next visit, the patient reported no postoperative pain or discomfort. The first follow-up was planned at the postoperative sixth month. Subsequent controls were planned as 12-month intervals. However, the patient moved to another city and could not be controlled for 48 months because of this relocation. When he returned after 48 months, he reported that he experienced no pain or swelling during this period. Clinical examinations and radiographic findings revealed satisfactory results at the postoperative 48 months (Fig. 1).
Discussion Internal and external root resorptions are considered as inflammatory type of root resorptions and it is often challenging to distinguish 1442
Altundasar and Demir
them from each other. It has been suggested that diagnosis should always be confirmed while the treatment is proceeding (13). Because resorptive defects are often asymptomatic, they are usually recognized by routine radiographs. However, in this case, the patient recognized the swollen gingiva between central and lateral incisors, which prompted him to seek treatment. According to the study of Wedenberg et al (14), internal root resorption lesions can be either transient or progressive. The progressive nature of this type of root resorption has been associated with an ongoing inflammation from a source of infection. In this case, an old composite filling was present, which could be regarded as a pathway for entrance of oral microorganisms to pulp cavity. The granulation tissue responsible for internal resorptive defect is often confined to the inner aspect of the root canal. However, in this case, having perforated the root wall, the granulation tissue migrated to the external root surface and consequently caused breakdown of adjacent bone structure. The bone destruction was hard to detect on radiographs because the localization of the defect was superposed by intact bone structure. In majority of the previous studies (12, 15, 16), the root canal filling has been placed after repair of the perforation defect. On the other hand, Yıldırım et al (17) has repaired an iatrogenic root perforation with MTA after root canal filling has been completed. In this case, we also preferred sealing the root canal before placement of MTA. Otherwise, special precautions would have to be taken to prevent MTA from blocking the root canal space. Previously placed gutta-percha acting as a barrier material allowed successful condensation of MTA. Moreover, filling the root canal after placement of MTA involves the
JOE — Volume 35, Number 10, October 2009
Case Report/Clinical Techniques
Figure 2. (A) Flap elevation and removal of the granulation tissue (inset). (B) Appearance of the perforation defect after removal of the granulation tissue. Guttapercha can be seen through the defect. (C) Mineral trioxide aggregate sealing the perforation defect. (D) Filling of the bone cavity with Unigraft.
risk of displacing MTA from the perforation site during condensation of gutta-percha. In this case, MTA was firmly condensed against the root dentin and the gutta-percha. Subsequently, the bone cavity was filled with Unigraft, which also covered and protected MTA until set. Failure to take special care while handling MTA may result in wash-out or displacement of the material. Vanderweele et al (18) used MTA to seal furcal perforations in molar teeth and evaluated the resistance of the material to displacement at 24 hours, 76 hours, and 7 days. According to the findings of that study, significantly greater force was required to displace all samples at 7 days than was required at 24 hours and 72 hours, which implied that MTA continued setting at the seventh day after placement in the presence of moisture. Same study reported inferior resistance to displacement when MTA was placed to blood contaminated perforation defects. One of the disadvantages of MTA is related to its color. Discoloration of marginal gingiva after perforation repair with gray MTA has been reported (19). In that case, changing gray MTA with recently introduced white MTA allowed complete resolution of discoloration. In our case, no gingival discoloration was observed after 48 months. The potential of gingival discoloration should be considered in perforations located proximal to the marginal area. White MTA can be the material of choice to repair defects in which direct contact with gingival tissues is expected. Previous animal studies have evaluated the repair of noncontaminated and contaminated lateral root perforations sealed with MTA and the effect of temporary filling of the contaminated perforations with a calcium-hydroxide based dressing before MTA placement (20, 21). According to the results of those studies, the lateral root perforations sealed with MTA after contamination presented inferior repair than the noncontaminated perforations and placement of an antibacterial agent between visits failed to improve repair of contaminated perforations. The timely sealing of perforation defects prevents bacterial contamination between periodontium and the root canal space. Pace et al (22) presented a case series including furcal perforations. In
JOE — Volume 35, Number 10, October 2009
the cases presented, the time elapsed from the creation of the perforation to repair of the defect did not exceed 6 months. They reported successful results after 5 years. Sealing ability of different formulations of MTA (MTA Bio and MTA-Angelus [both items Angelus, Londrina, PR, Brazil]) has been compared with various materials including IRM (Caulk, Dentsply, Milford, DE) and Portland cement (Irajazinho TYPO II; Votorantim Cimentos, Rio Branco, SP, Brazil) (23, 24). It has been suggested that the use of IRM to seal large perforations should be limited, whereas all other formulations of MTA and Portland cement had somewhat similar ability to seal perforations. The treatment of this case involved removal of the granulation tissue followed by the repair of the perforation site and the adjacent bone defect. The patient returned after 48 months with no signs or symptoms. The tooth was in function with no discomfort or pain during that time. The gingiva appeared healthy with normal color and texture. There was no mobility or bleeding upon probing. There was no increase in probing depth. Finally, treatment of the defect with MTA was considered successful as evidenced by clinical and radiographic findings after 48 months.
Acknowledgment The authors wish to thank Dr. Zafer Cehreli for his valuable help with the composite figures.
References 1. Trope M, Blanco L, Chivian N, et al. The role of endodontics after dental traumatic injuries. In: Cohen S, Hargreaves KM, eds. Pathways of the pulp. 9th ed. St. Louis, MO: Mosby-Elsevier; 2006:635. 2. Haapasalo M, Endal U. Internal inflammatory root resorption: the unknown resorption of the tooth. Endod Topics 2006;14:60–79. 3. Andreasen JO. Traumatic injuries of the teeth. 2nd ed. Copernhagen, Denmark: Munksgaard International Publishers; 1981:193.
Perforating Internal Resorptive Defect with MTA
1443
Case Report/Clinical Techniques 4. Heithersay GS. Clinical endodontic and surgical management of tooth and associated bone resorption. Int Endod J 1985;18:72–92. 5. 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. 6. Torabinejad M, Hong CU, Pitt Ford TR, et al. Cytotoxicity of four root end filling materials. J Endod 1995;21:489–92. 7. Koh ET, McDonald F, Pitt Ford TR, et al. Cellular response to mineral trioxide aggregate. J Endod 1998;24:543–7. 8. Guven G, Cehreli ZC, Ural A, et al. Effect of mineral trioxide aggregate cements on transforming growth factor beta1 and bone morphogenetic protein production by human fibroblasts in vitro. J Endod 2007;33:447–50. 9. Zhang H, Pappen FG, Haapasalo M. Dentin enhances the antibacterial effect of mineral trioxide aggregate and bioaggregate. J Endod 2009;35:221–4. 10. Holland R, Filho JA, de Souza V, et al. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001;27:281–4. 11. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205. 12. Hsien HC, Cheng YA, Lee YL, et al. Repair of perforating internal resorption with mineral trioxide aggregate: a case report. J Endod 2003;29:538–9. 13. Uyanik MO, Nagas E, Sahin C, et al. Effects of different irrigation regimens on the sealing properties of repaired furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e91–5. 14. Wedenberg C, Lindskog S. Experimental internal resorption in monkey teeth. Endod Dent Traumatol 1985;1:221–7.
1444
Altundasar and Demir
15. Meire M, De Moor R. Mineral trioxide aggregate repair of a perforating internal resorption in a mandibular molar. J Endod 2008;34:220–3. 16. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J 2008;41:905–12. 17. Yıldırım GDK. Treatment of lateral root perforation with mineral trioxide aggregate: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102: 55–8. 18. Vanderweele RA, Schwartz SA, Beeson TJ. Effect of blood contamination on retention characteristics of MTA when mixed with different liquids. J Endod 2006;32: 421–4. 19. Bortoluzzi EA, Araujo GS, Guerreiro Tanomaru JM, et al. Marginal gingiva discoloration by gray MTA: a case report. J Endod 2007;33:325–7. 20. Ford TR, Torabinejad M, McKendry DJ, et al. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:756–63. 21. Holland R, Bisco Ferreira L, de Souza V, et al. Reaction of the lateral periodontium of dogs’ teeth to contaminated and noncontaminated perforations filled with mineral trioxide aggregate. J Endod 2007;33:1192–7. 22. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate as repair material for furcal perforation: case series. J Endod 2008;34:1130–3. 23. Hashem AA, Hassanien EE, ProRoot MTA. MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod 2008;34:59–61. 24. De-Deus G, Reis C, Brandao C, et al. The ability of Portland cement, MTA, and MTA Bio to prevent through-and-through fluid movement in repaired furcal perforations. J Endod 2007;33:1374–7.
JOE — Volume 35, Number 10, October 2009
Management of a Perforating Internal Resorptive Defect with Mineral Trioxide Aggregate: A Case Report Emre Altundasar, DDS, PhD,* and Becen Demir, DDS, PhD† Abstract Introduction: A radicular perforation caused by an inflammatory internal root resorption was present in a maxillary lateral incisor. Methods: The root canal preparation was completed with hand files and thorough irrigation. Calcium hydroxide was placed as a temporary dressing for 10 days. At the second visit, the root canal with resorption lacuna was filled with warm vertical compaction of gutta-percha. The coronal access was restored with composite resin. A surgical flap was elevated to repair the resorption defect with gray mineral trioxide aggregate. The bony defect adjacent to the perforated lesion was filled with Unigraft (Unicare Biomedical, Laguna Hills, CA). Results: The tooth was in function with satisfactory clinical and radiographic results after 48 months. Conclusions: According to the long term results of this case, successful sealing of a perforating defect is possible with mineral trioxide aggregate. (J Endod 2009;35:1441–1444)
Key Words Inflammatory internal resorption, mineral trioxide aggregate, root perforation
From the *Department of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey; and †Private Practice, Istanbul, Turkey. Address requests for reprints to Dr Emre Altundasar, Hacettepe University, Faculty of Dentistry, Department of Endodontics, Sihhiye 06100, Ankara, Turkey. E-mail address: [email protected]. 0099-2399/$0 - see front matter Copyright ª 2009 American Association of Endodontists. doi:10.1016/j.joen.2009.06.017
JOE — Volume 35, Number 10, October 2009
I
nternal root resorption has been described as a resorptive defect of the internal aspect of the root following necrosis of odontoblasts as a result of chronic inflammation and bacterial invasion of the pulp tissue. Resorption has been associated with multinucleated giant cells adjacent to a pulpal granulation tissue (1). Clinically, internal root resorption is usually asymptomatic and is detected coincidentally through routine radiographs. Pain or discomfort may be the chief complaint if the granulation tissue has been exposed to oral fluids. The granulation tissue can clinically manifest itself as a ‘‘pink spot’’ in cases in which crown dentin destruction is severe (2). Radiographic examination usually reveals a fairly uniform radiolucent area with disrupted outline of the root canal. The progression of internal resorption depends on vital tissues (3). Therefore, root canal treatment should be initiated as soon as possible once an inflammatory resorptive lesion is detected to prevent further hard tissue loss and eventually root perforation (2). In cases without a perforation, the removal of the granulation tissue and the blood supply to the resorbing cells by root canal treatment should be sufficient. However, in cases in which a pathway between the pulp canal space and the periodontal tissues is present, root canal treatment should be followed by repair of the perforation site with a suitable sealing material (4). Mineral trioxide aggregate (MTA) has been proposed as a favorable perforation repair material with its superior sealing ability (5), biocompatibility (6, 7), fibroblastic stimulation (8), and antimicrobial activity (9). MTA can create an environment conducive to periodontal healing, allowing new cement growth on its surface (10). The material has been used in several applications including pulpotomy, pulp capping, and perforation repair (11–13). This case report describes the 48-month follow-up of a perforating internal root resorption in a maxillary lateral incisor in which gray MTA was used to seal the perforation area after endodontic therapy.
Case Report A 42-year-old male patient presented with a localized mild swelling on the attached gingiva between the central and the lateral incisor teeth. There was no history of pain or discomfort. The patient was aware of the swelling for almost 2 months. As reported by the patient, the color and size of the swelling were stable because it was recognized. The swelling had a radius of approximately 5 mm with regular borders. The patient’s medical status was noncontributory, and he mentioned that he had no trauma to the related area. An old composite resin restoration was noted on the distal aspect of the maxillary lateral incisor tooth. The tooth responded positively to electric pulp vitality test, and no discomfort was noted on percussion. On the mesiobuccal aspect of the crown, the probing depth measured 4 mm, whereas the mobility of the tooth was within normal limits. Radiographic examination revealed a uniform radiolucent lesion in the middle third of the root canal (Fig. 1). The centrally localized image of the lesion did not shift when additional radiographs were taken from different angulations. An access cavity was prepared, and the working length was determined by x-ray images. The root canal was instrumented with stainless steel hand files until an apical stop of ISO #50 could be created. The persistent seeping of blood through the root canal diminished gradually with instrumentation. The root canal was frequently irrigated with 1.3% NaOCl followed by a final rinse with 5 mL of sterile saline. Subsequently, calcium hydroxide (Ultracal XS; Ultradent Products Inc, South Jordan, UT) was placed as a temporary dressing to control bleeding. The access cavity was temporarily sealed with Cavit G (3 M ESPE, St Paul, MN). After 10 days, the root canal was reentered and irrigated alternately with 1.3% NaOCl and sterile saline to remove the temporary
Perforating Internal Resorptive Defect with MTA
1441
Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph showing internal resorption lesion of the maxillary lateral incisor tooth with irregular borders. An unfavorable coronal restoration is evident. (B) Swelling as clinical manifestation of the perforating resorption. (C) Postoperative radiograph after 48 months. (D) Healthy appearance of gingiva after 48 months.
dressing; 17% EDTA solution was left flooded in the cavity for 5 minutes, which was later rinsed with 5 mL of sterile saline. The root canal was filled with warm vertical compaction of gutta-percha combined with AH-26 sealer (Dentsply De Trey, Konstanz, Germany). After radiographic confirmation of a satisfactory obturation, the access cavity was restored with composite resin. A flap that exposed the granulation tissue and the bone destruction was elevated at the same appointment. The granulation tissue (Fig. 2) was removed, and the irregular borders of the perforation site were smoothed with a bur attached to a straight surgical handpiece. MTA powder was mixed according to the manufacturer’s instructions and placed with an MTA carrier. MTA was firmly condensed by using a plugger and wet cotton pellets (Fig. 2). Bone graft material (Unigraft; Unicare Biomedical, Laguna Hills, CA) was placed over MTA to fill the cavity of the bony defect (Fig. 2). The flap was sutured, and the patient was recalled 1 week later for suture removal. At the next visit, the patient reported no postoperative pain or discomfort. The first follow-up was planned at the postoperative sixth month. Subsequent controls were planned as 12-month intervals. However, the patient moved to another city and could not be controlled for 48 months because of this relocation. When he returned after 48 months, he reported that he experienced no pain or swelling during this period. Clinical examinations and radiographic findings revealed satisfactory results at the postoperative 48 months (Fig. 1).
Discussion Internal and external root resorptions are considered as inflammatory type of root resorptions and it is often challenging to distinguish 1442
Altundasar and Demir
them from each other. It has been suggested that diagnosis should always be confirmed while the treatment is proceeding (13). Because resorptive defects are often asymptomatic, they are usually recognized by routine radiographs. However, in this case, the patient recognized the swollen gingiva between central and lateral incisors, which prompted him to seek treatment. According to the study of Wedenberg et al (14), internal root resorption lesions can be either transient or progressive. The progressive nature of this type of root resorption has been associated with an ongoing inflammation from a source of infection. In this case, an old composite filling was present, which could be regarded as a pathway for entrance of oral microorganisms to pulp cavity. The granulation tissue responsible for internal resorptive defect is often confined to the inner aspect of the root canal. However, in this case, having perforated the root wall, the granulation tissue migrated to the external root surface and consequently caused breakdown of adjacent bone structure. The bone destruction was hard to detect on radiographs because the localization of the defect was superposed by intact bone structure. In majority of the previous studies (12, 15, 16), the root canal filling has been placed after repair of the perforation defect. On the other hand, Yıldırım et al (17) has repaired an iatrogenic root perforation with MTA after root canal filling has been completed. In this case, we also preferred sealing the root canal before placement of MTA. Otherwise, special precautions would have to be taken to prevent MTA from blocking the root canal space. Previously placed gutta-percha acting as a barrier material allowed successful condensation of MTA. Moreover, filling the root canal after placement of MTA involves the
JOE — Volume 35, Number 10, October 2009
Case Report/Clinical Techniques
Figure 2. (A) Flap elevation and removal of the granulation tissue (inset). (B) Appearance of the perforation defect after removal of the granulation tissue. Guttapercha can be seen through the defect. (C) Mineral trioxide aggregate sealing the perforation defect. (D) Filling of the bone cavity with Unigraft.
risk of displacing MTA from the perforation site during condensation of gutta-percha. In this case, MTA was firmly condensed against the root dentin and the gutta-percha. Subsequently, the bone cavity was filled with Unigraft, which also covered and protected MTA until set. Failure to take special care while handling MTA may result in wash-out or displacement of the material. Vanderweele et al (18) used MTA to seal furcal perforations in molar teeth and evaluated the resistance of the material to displacement at 24 hours, 76 hours, and 7 days. According to the findings of that study, significantly greater force was required to displace all samples at 7 days than was required at 24 hours and 72 hours, which implied that MTA continued setting at the seventh day after placement in the presence of moisture. Same study reported inferior resistance to displacement when MTA was placed to blood contaminated perforation defects. One of the disadvantages of MTA is related to its color. Discoloration of marginal gingiva after perforation repair with gray MTA has been reported (19). In that case, changing gray MTA with recently introduced white MTA allowed complete resolution of discoloration. In our case, no gingival discoloration was observed after 48 months. The potential of gingival discoloration should be considered in perforations located proximal to the marginal area. White MTA can be the material of choice to repair defects in which direct contact with gingival tissues is expected. Previous animal studies have evaluated the repair of noncontaminated and contaminated lateral root perforations sealed with MTA and the effect of temporary filling of the contaminated perforations with a calcium-hydroxide based dressing before MTA placement (20, 21). According to the results of those studies, the lateral root perforations sealed with MTA after contamination presented inferior repair than the noncontaminated perforations and placement of an antibacterial agent between visits failed to improve repair of contaminated perforations. The timely sealing of perforation defects prevents bacterial contamination between periodontium and the root canal space. Pace et al (22) presented a case series including furcal perforations. In
JOE — Volume 35, Number 10, October 2009
the cases presented, the time elapsed from the creation of the perforation to repair of the defect did not exceed 6 months. They reported successful results after 5 years. Sealing ability of different formulations of MTA (MTA Bio and MTA-Angelus [both items Angelus, Londrina, PR, Brazil]) has been compared with various materials including IRM (Caulk, Dentsply, Milford, DE) and Portland cement (Irajazinho TYPO II; Votorantim Cimentos, Rio Branco, SP, Brazil) (23, 24). It has been suggested that the use of IRM to seal large perforations should be limited, whereas all other formulations of MTA and Portland cement had somewhat similar ability to seal perforations. The treatment of this case involved removal of the granulation tissue followed by the repair of the perforation site and the adjacent bone defect. The patient returned after 48 months with no signs or symptoms. The tooth was in function with no discomfort or pain during that time. The gingiva appeared healthy with normal color and texture. There was no mobility or bleeding upon probing. There was no increase in probing depth. Finally, treatment of the defect with MTA was considered successful as evidenced by clinical and radiographic findings after 48 months.
Acknowledgment The authors wish to thank Dr. Zafer Cehreli for his valuable help with the composite figures.
References 1. Trope M, Blanco L, Chivian N, et al. The role of endodontics after dental traumatic injuries. In: Cohen S, Hargreaves KM, eds. Pathways of the pulp. 9th ed. St. Louis, MO: Mosby-Elsevier; 2006:635. 2. Haapasalo M, Endal U. Internal inflammatory root resorption: the unknown resorption of the tooth. Endod Topics 2006;14:60–79. 3. Andreasen JO. Traumatic injuries of the teeth. 2nd ed. Copernhagen, Denmark: Munksgaard International Publishers; 1981:193.
Perforating Internal Resorptive Defect with MTA
1443
Case Report/Clinical Techniques 4. Heithersay GS. Clinical endodontic and surgical management of tooth and associated bone resorption. Int Endod J 1985;18:72–92. 5. 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. 6. Torabinejad M, Hong CU, Pitt Ford TR, et al. Cytotoxicity of four root end filling materials. J Endod 1995;21:489–92. 7. Koh ET, McDonald F, Pitt Ford TR, et al. Cellular response to mineral trioxide aggregate. J Endod 1998;24:543–7. 8. Guven G, Cehreli ZC, Ural A, et al. Effect of mineral trioxide aggregate cements on transforming growth factor beta1 and bone morphogenetic protein production by human fibroblasts in vitro. J Endod 2007;33:447–50. 9. Zhang H, Pappen FG, Haapasalo M. Dentin enhances the antibacterial effect of mineral trioxide aggregate and bioaggregate. J Endod 2009;35:221–4. 10. Holland R, Filho JA, de Souza V, et al. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001;27:281–4. 11. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205. 12. Hsien HC, Cheng YA, Lee YL, et al. Repair of perforating internal resorption with mineral trioxide aggregate: a case report. J Endod 2003;29:538–9. 13. Uyanik MO, Nagas E, Sahin C, et al. Effects of different irrigation regimens on the sealing properties of repaired furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e91–5. 14. Wedenberg C, Lindskog S. Experimental internal resorption in monkey teeth. Endod Dent Traumatol 1985;1:221–7.
1444
Altundasar and Demir
15. Meire M, De Moor R. Mineral trioxide aggregate repair of a perforating internal resorption in a mandibular molar. J Endod 2008;34:220–3. 16. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J 2008;41:905–12. 17. Yıldırım GDK. Treatment of lateral root perforation with mineral trioxide aggregate: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102: 55–8. 18. Vanderweele RA, Schwartz SA, Beeson TJ. Effect of blood contamination on retention characteristics of MTA when mixed with different liquids. J Endod 2006;32: 421–4. 19. Bortoluzzi EA, Araujo GS, Guerreiro Tanomaru JM, et al. Marginal gingiva discoloration by gray MTA: a case report. J Endod 2007;33:325–7. 20. Ford TR, Torabinejad M, McKendry DJ, et al. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:756–63. 21. Holland R, Bisco Ferreira L, de Souza V, et al. Reaction of the lateral periodontium of dogs’ teeth to contaminated and noncontaminated perforations filled with mineral trioxide aggregate. J Endod 2007;33:1192–7. 22. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate as repair material for furcal perforation: case series. J Endod 2008;34:1130–3. 23. Hashem AA, Hassanien EE, ProRoot MTA. MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod 2008;34:59–61. 24. De-Deus G, Reis C, Brandao C, et al. The ability of Portland cement, MTA, and MTA Bio to prevent through-and-through fluid movement in repaired furcal perforations. J Endod 2007;33:1374–7.
JOE — Volume 35, Number 10, October 2009