Use of MTA for orthograde obturation of nonvital teeth with open apices: report of two cases

The purpose of this report is to present the treatment of 2 immature necrotic permanent incisors with the use of apical plugs of mineral trioxide aggregate (MTA) for apexification. With this technique, MTA mixture is used to create an artificial stop against which to condense gutta-percha in pulpless teeth with open apices. The report of these cases confirms that MTA acts an apical barrier and can be considered as an effective material to support regeneration of apical tissue in immature necrotic teeth. The treated teeth were asymptomatic, and radiographic follow-ups showed healing of periradicular tissues and new hard tissue formation in the apical area of the affected teeth.     

Regenerative Potential of Immature Permanent Teeth with Necrotic Pulps after Different Regenerative Protocols

Introduction

Regenerative endodontics is a promising alternative treatment for immature teeth with necrotic pulps. The present study was performed to assess the regenerative potential of young permanent immature teeth with necrotic pulp after the following treatment protocols: (1) a mineral trioxide aggregate (MTA) apical plug, (2) the regenerative endodontic protocol (blood clot scaffold), and (3) the regenerative endodontic protocol with a blood clot and an injectable scaffold impregnated with basic fibroblast growth factor.

Methods

Immature necrotic permanent maxillary central incisors (n = 36) of patients 9–13 years old were divided into 3 groups according to the treatment protocol: the MTA group (MTA apical plug), the REG group (regenerative endodontic protocol [blood clot]), and the FGF group (regenerative endodontic protocol [blood clot + injectable scaffold]). Follow-up was done up to 18 months. Standardized radiographs were digitally evaluated for an increase in root length and thickness, a decrease in the apical diameter, and a change in periapical bone density.

Results

After a follow-up period of 18 months, most of the cases showed radiographic evidence of periapical healing. Groups 2 and 3 showed a progressive increase in root length and width and a decrease in apical diameter.

Conclusions

The regenerative endodontic procedure allowed the continued development of roots in teeth with necrotic pulps. The use of artificial hydrogel scaffold and basic fibroblast growth factor was not essential for repair.     

The effect of frequency of calcium hydroxide dressing change and various pre- and inter-operative factors on the endodontic treatment of traumatized immature permanent incisors

Abstract – Aim: The objectives of this clinical study were as follows: (i) to determine the effect of frequency of calcium hydroxide [Ca(OH)₂] dressing change on the apical barrier formation in immature permanent incisors with necrotic pulps and (ii) to investigate the effect of various clinical factors before and during treatment that may be associated with the frequency of Ca(OH)₂ dressing changes. Methods: The study involved 21 healthy subjects, 8–12 years old. Twenty‐three immature traumatized permanent maxillary central incisors were treated using Ca(OH)₂ powder mixed with barium sulfate and distilled water. The progress of barrier formation was reviewed after 6 months of first placement of Ca(OH)₂ and then every 3 months until the detection of an apical barrier. Clinical and radiographic evaluations were performed before and after treatment. Data were evaluated using a chi‐square test. Results: Apical barrier formation was successful for all 23 teeth. Seventeen teeth (74%) needed only a single application of Ca(OH)₂, while six teeth (26%) required more than one application. The average time of apical barrier formation was 30 weeks, and the mean number of Ca(OH)₂ dressing changes was 1.3. A significant positive association was found between teeth that presented with displacement and the number of Ca(OH)₂ dressing changes (P = 0.004). Conclusion: An initial 6‐month application of Ca(OH)₂ dressing followed by 3‐month replacements (usually in teeth presenting with displacement and/or sinus tracts) may be successfully used in apexification treatment. This would assist in reducing the number of Ca(OH)₂ dressing changes, number of appointments, cost of treatment and radiation exposure.     

MTA治疗成年患者根尖孔未闭合患牙的疗效评价

目的 评价无机三氧化聚合物（MTA）治疗成年患者根尖孔未闭合患牙的临床疗效。方法 选取成年患者根尖孔未闭合的前牙及前磨牙共41颗,随机分为2组,试验组21颗牙,在完成根管预备和消毒后,在手术显微镜下将MTA充填于根尖孔及根管下段,厚约3-5 mm,硬固后采用热牙胶完成根管中上段的充填;对照组20颗牙,采用氢氧化钙类根管糊剂Vitapex行根尖诱导成形术,定期复查,在根尖部有硬组织形成后完成根管治疗。记录患者就诊次数、治疗周期及治疗效果。结果 试验组术后X线片显示15颗患牙适充,6颗牙超充约0.5-2 mm,根管内充填物致密;平均就诊次数3.5次,平均治疗周期11.8 d,复查时多数患牙窦道闭合,根尖周病变明显缩小或消失,无新的暗影出现;对照组11颗患牙诱导成功,根尖有硬组织形成,9颗牙无明显根尖屏障形成,平均就诊次数6次,平均治疗周期306.8 d。结论 与根尖诱导成形术比较,MTA治疗成年患者根尖孔未闭合患牙的周期短,疗效好。     

MTA应用于穿孔修补和根尖屏障的临床效果观察

目的:临床观察MTA(mineraltrioxideaggregate)用于根尖屏障术和根管或髓室穿孔修补的治疗效果。方法:收集临床上使用MTA治疗的病例11例,其中无髓恒牙根尖孔敞开病例7例( 7个患牙)行MTA根尖屏障术,在手术显微镜下完成MTA根尖屏障的制备,垂直加压充填根管。治疗过程仅需1 ~2次复诊。使用MTA进行根管或髓室穿孔修补病例4例共5个患牙。11例观察期0. 5 ~4年多不等。结果:经追踪观察, 11例患牙在临床症状的控制和获得骨愈合方面都有良好的效果。结论:本研究结果提示,MTA对穿孔修补和根尖屏障术方面是一种满意的材料。     

Literature survey of apexification in connection with three cases

Endodontic treatment of three non-vital immature teeth is discussed. According Moorrees et al. root formation was in the stage two, six and four respectively. After access to the root canal, removing necrotic pulp and effective chemo-mechanical cleansing, Ca(OH)2 paste was used as a temporary filling material in each case. In two cases after closing the apical opening, permanent obturation was performed with half heated gutta-percha and lateral condensation to obtain a good seal. In one case permanent filling of the canal occurred with gutta-percha and AH26 as a sealer. In the first case two years, in the second case five years after obturation of the root canal with gutta-percha, periapical healing was evident in the control radiograph. In the third case using gutta-percha with AH26 as a sealer after two years new periapical lesion has developed. On the bases of literature data and our experiences in the case of non-vital immature teeth. Ca(OH)2 paste is the best temporary filling material to induce apexification process, and the half heated gutta-percha obturation is the most suitable permanent root filling material.     

A Retrospective Evaluation of Radiographic Outcomes in Immature Teeth With Necrotic Root Canal Systems Treated With Regenerative Endodontic Procedures

IntroductionSeveral case reports on endodontic regeneration involving immature permanent teeth have recently been published. These case series have used varying treatments to achieve endodontic regeneration including triple antibiotic paste, Ca(OH)₂, and formocresol. However, no study has analyzed the overall results.MethodsIn this retrospective study, we collected radiographs from 54 published and unpublished endodontic regenerative cases and 40 control cases (20 apexification and 20 nonsurgical root canal treatments) and used a geometrical imaging program, NIH ImageJ with TurboReg plug-in, to minimize potential differences in angulations between the preoperative and recall images and to calculate continued development of root length and dentin wall thickness.ResultsThe comparison to the 2 control groups provided a validation test for this method. Forty-eight of the 54 regenerative cases (89%) had radiographs of sufficiently similar orientation to permit analysis. The results showed regenerative endodontic treatment with triple antibiotic paste (P < .001) and Ca(OH)₂ (P < .001) produced significantly greater increases in root length than either the MTA apexification or NSRCT control groups. The triple antibiotic paste produced significantly greater differences in root wall thickness than either the Ca(OH)₂ or formocresol groups (P < .05 for both). The position of Ca(OH)₂ also influenced the outcome. When Ca(OH)₂ was radiographically restricted to the coronal half of the root canal system, it produced better results than when it was placed beyond the coronal half.ConclusionsCa(OH)₂ and triple antibiotic paste when used as an intracanal medicament in immature necrotic teeth can help promote further development of the pulp-dentin complex.     

Mineral trioxide aggregate for obturation of maxillary central incisors with necrotic pulp and open apices

Abstract – There are few reports on treatment of necrotic pulps with mineral trioxide aggregate (MTA) for apexification. Five immature teeth with necrotic pulps were treated with the use of an apical plug of MTA for apexification. All teeth were central incisors that had premature interruption of root development caused by a previous trauma. According to the treatment protocol, the root canals were rinsed with 5% NaOCl; then calcium hydroxide paste was placed in the canals for 1–6 weeks. The apical portion of the canals were filled with MTA. The rest of the canals were obturated with lateral condensation of the gutta‐percha applied with a canal sealer. At 6 months, 1 year and 2 year follow‐up periods the clinical and radiographic appearance of the teeth showed the resolution of the periapical lesions and continued root end development in all except in the one case in which the MTA was extruded out the apex. MTA can be considered a very effective option for apexification with the advantage of reduced treatment time, good sealing ability and high biocompatibility.     

三氧化物多聚体应用于活髓切断术的临床疗效研究

目的评价三氧化物多聚体(MTA)用于活髓切断术的临床效果。方法选取外伤冠折露髓的年轻恒前牙48颗,随机分为2组,每组24颗。氢氧化钙组用氢氧化钙盖髓,MTA组用MTA盖髓,追踪观察3年并进行临床评价。结果MTA组成功22颗,失败2颗,氢氧化钙组成功20颗,失败4颗,2组差异无统计学意义。结论MTA是一种较理想的直接盖髓剂。     

Management of teeth with necrotic pulps and open apices

When the pulp of a tooth is irreversibly inflamed or necrotic and the apex is open, conventional root canal treatment is difficult to perform and the outcome is uncertain. Traditionally, the apexification procedure has consisted of multiple and long‐term applications of calcium hydroxide [Ca(OH)₂] to create an apical barrier to aid the obturation. Recently, artificial apical barriers such as those made with mineral trioxide aggregate (MTA) have been used in teeth with necrotic pulps and open apices. More recently, procedures referred to as regenerative endodontics have received much attention as an option for these teeth. The purpose of this article is to provide a comprehensive literature review from May 1952–May 2011 regarding the management of teeth with necrotic pulps and open apices. This review covers the articles published in dental journals and book chapters regarding the definition, history, materials used, animal and human studies, mechanisms of action, prognosis, as well as advantages and disadvantages of apexification, apical plugs, and regenerative endodontics.     

Comparative evaluation of endodontic management of teeth with unformed apices with mineral trioxide aggregate and calcium hydroxide

PURPOSE: The purpose of this study was to compare mineral trioxide aggregate (MTA) and calcium hydroxide (Ca(OH)2) for their efficacies and time taken for formation of apical biological calcific barriers and resolution of periapical radiolucencies, if present at baseline, in teeth with unformed apices. METHODS: Twenty nonvital permanent maxillary incisors with unformed apices, stratified according to the size of periapical radiolucencies and stage of root development, were equally allocated to MTA and Ca(OH)2 groups. In group 1 (MTA group), after 7 days of disinfection with Ca(OH)2, MTA was packed into the apical one third of the root canals and obturation with gutta percha (GP) was performed in 90% (9/10) of cases within 15 to 30 days. In group 2 (Ca(OH)2 group), obturation was performed following clinical and radiographic depiction of the apical stop. RESULTS: The mean time taken for apical biological barrier formation was 3 +/- 2.9 months for group 1 and 7 +/- 2.5 months for group 2 (P=.008). The periapical radiolucencies were resolved in 4.6 +/- 1.5 months for group 1 and 4.4 +/- 1.3 months for group 2 (P=.83). The total treatment was completed in 0.75 +/- 0.4859 months and 7 +/- 2.5 months for groups 1 and 2, respectively. CONCLUSION: The 2 materials were found to be equally efficacious in the management of nonvital teeth with unformed apices. Time taken to complete the treatment and the biological barrier formation in group 1 was significantly less than that for group 2. The healing time for periapical radiolucencies was almost identical.     

Regenerative Endodontic Procedures for Traumatized Immature Permanent Teeth with Severe External Root Resorption and Root Perforation

External root resorption (ERR) is often a complication of traumatic injury to the teeth. Traditionally, external inflammatory root resorption is treated with calcium hydroxide. The outcome of ERR, especially replacement resorption, is unpredictable. The purpose of the present case report was to describe regenerative endodontic procedures (REPs) for 1 replanted avulsed tooth with severe external root resorption and root perforation (tooth #9) and 1 extruded tooth (tooth #8). A 9-year-old girl was referred for the treatment of teeth #8 and #9 4 months after the initial trauma. Clinical examination showed that tooth #9 had a sinus tract present near the periapical area, was tender to percussion and palpation, and did not respond to pulp sensibility tests. Tooth #8 responded to pulp sensibility tests. Periapical radiographic and cone-beam computed tomographic examination showed that tooth #9 had a periapical radiolucent lesion and severe ERRs with a root perforation. Tooth #9 was diagnosed with a necrotic pulp and symptomatic apical periodontitis. Regenerative endodontic procedures (REPs) were initiated. Tooth #8 became nonresponsive to pulp sensibility tests and developed a periapical lesion 12 months after REPs of tooth #9 and was also treated with REPs. The clinical symptoms and apical lesions resolved for both teeth after REPs. The severe ERRs were arrested, and root perforation was repaired for tooth #9. Teeth #8 and #9 underwent canal obliteration by hard tissue formation after REPs and were in function at 18 months and 30 months, respectively. REPs may be used to manage traumatized immature permanent teeth with a necrotic pulp and apical periodontitis associated with severe ERR and root perforation.     

Effects of Apical Barriers and Root Filling Materials on Stress Distribution in Immature Teeth: Finite Element Analysis Study

PurposeA finite element analysis (FEA) study was performed to determine whether the material of apical barrier used for root apexification and/or the use of canal reinforcement affect the stress distribution in an endodontically treated immature permanent tooth in order to infer in which clinical scenarios a fracture is more likely to occur based on the ultimate tensile strength threshold of dentin.Methods and MaterialsAn extracted human immature mandibular premolar was selected as the reference model and scanned by micro-computed tomography (micro-CT). The digital model was segmented and converted to STL (Standard Tessellation Language) using Simpleware Scan-IP and exported in IGES (Initial Graphics Exchange Specification) to Ansys 19. Six experimental models were designed with different combinations of composite, mineral trioxide aggregate (MTA), and Biodentine (BIO). Using FEA, a static 300 N load at a 135 angle with respect to the axis of the tooth was applied to each model and von Mises stress values (MPa) were measured at the sagittal, apical 8-mm, 5-mm, 2-mm, and 1-mm levels.ResultsIn all regions examined, the control (NT model) had lower stress in the root compared WITH experimental models. At the mid-root level, models with composite, MTA, and BIO reinforcement exhibited lower stresses in the root dentin than those with pulp or gutta-percha. BIO models had equal or greater average von Mises stress values than those of MTA models in all regions. Both, MTA and BIO, caused increases in stress of surrounding root dentin, with BIO causing a greater increase than MTA.ConclusionsStress distribution in immature permanent teeth treated by apexification is affected by the types of materials used. Root dentin's stress was lower when the mid-root canal was reinforced by composite, MTA, or BIO, which provided similar stress reduction to the root dentin. MTA is a more favorable apical barrier material from a mechanical standpoint because it induces less stress on apical root dentin than BIO.     

Comparative in vitro study of the sealing efficiency of white vs grey ProRoot mineral trioxide aggregate formulas as apical barriers

Abstract –  Mineral trioxide aggregate (MTA) has been proposed as one of the materials which can be used in a one-visit apexification technique. Recently conventional grey MTA has been replaced by a new white MTA formula. The aim of this study was to compare the root canal adaptation of white MTA to that of grey MTA when used as an apical barrier in teeth with open apices. We also examined whether a previous calcium hydroxide intracanal medication affects MTA's sealing ability and investigated the ability to remove calcium hydroxide from the root canal walls. Forty-nine teeth were prepared in a manner to simulate a divergent open apex of immature teeth. Four teeth were used in a preliminary experiment to demonstrate the inefficacy of calcium hydroxide removal from the canal walls in teeth with open apices. Four groups of 10 teeth each were created: groups A and B were treated with calcium hydroxide intracanal medication and then received an apical plug of grey and white MTA respectively. Groups C and D received an apical plug of grey and white MTA respectively without previous intracanal medication. Four teeth served as negative and one as a positive control. The marginal adaptation and sealing ability of the apical barrier were tested by means of a dye tracer (basic fuchsine) after longitudinal sectioning. It was found that MTA apical barrier resisted displacement during gutta-percha condensation. Calcium hydroxide pretreatment, adversely affected white MTA sealing ability ( P  < 0.05).     

Mineral Trioxide Aggregate as Apical Plug in Teeth with Necrotic Pulp and Immature Apices: A 10-year Case Series

Introduction

This 10-year study evaluated the clinical and radiologic outcomes of teeth with necrotic pulp, immature apices, and periapical lesions treated with the mineral trioxide aggregate (MTA) apical plug technique.

Methods

Seventeen single-rooted immature teeth with necrotic pulp and periapical lesion from 17 patients treated between January 2001 and December 2001 were included in this study. Apical obturation on all teeth included in the study was completed in 2 visits: first using calcium hydroxide as an interappointment intracanal medication and a second visit for the creation of the artificial apical barrier with MTA. The outcome, based on clinical and radiographic criteria, was assessed by 2 calibrated investigators using the periapical index (PAI). The Friedman test was used to verify the differences between baseline and the 1-, 5-, and 10-year PAI scores.

Results

Of the 17 patients treated, 1 patient dropped out at 5 years. At the 10-year follow-up, 15 teeth were healed (PAI ≤2), and 1 tooth had been extracted because of the presence of a longitudinal root fracture. The PAI score exhibited a significant decrease between baseline and 1 year and between 1 and 5 years. The difference between 5 and 10 years was not significant.

Conclusions

The apical plug with MTA was a successful and effective technique for long-term management of this group of teeth with necrotic pulps with immature root development and periapical lesions.     

A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study.

The aim of this pilot study was to evaluate the clinical efficacy of mineral trioxide aggregate (MTA) as an apexification material when used in non-vital immature permanent incisors in children. Fifteen children with a mean age of 11.7 years and 17 non-vital permanent incisors were ajudged suitable for inclusion. Standard endodontic procedures were followed and an apical plug of 3-4 mm was created by using MTA after a calcium hydroxide intracanal dressing had been applied for at least 1 week. Final obturation was completed by using thermoplastisized Gutta-Percha (Obtura II) at least 1 week following MTA placement. Subjects were reviewed clinically and radiographically at 3-month intervals. Mean follow-up time for MTA was 12.53 months (+/-2.94 SD). Of the total of 17 teeth treated, MTA placement was considered to be adequate in 13 teeth. The procedure showed clinical success in 94.1% of the cases, radiographic success was found to be 76.5% and in further three cases (17.6%) the outcome was considered to be uncertain. This is one of the very few studies that have reported the out coming of MTA as an apexification material in children with non-vital teeth and incomplete root development. However, larger clinical studies are required to evaluate the long-term success of this procedure.     

Obturation of immature non-vital tooth using MTA. Case report

The purpose of this report was to present the treatment of an immature necrotic permanent mandibular second molar using mineral trioxide aggregate (MTA) as an orthograde root filling. In such cases, the canal remains large, with thin and fragile walls, and the apex architecture remains divergent. This case demonstrates the efficacy of MTA in this particular situation as an effective material to support regeneration of apical tissue in immature necrotic teeth. The treated tooth was asymptomatic. At the one-year follow-up, there were no clinical symptoms, but there was radiographic healing of periradicular tissues and new hard-tissue formation in the apical area of the affected tooth.     

Outcome Assessment of Teeth with Necrotic Pulps and Apical Periodontitis Treated with Long-term Calcium Hydroxide

IntroductionThe aim of this retrospective, cohort case series was 2-fold: (1) to evaluate the outcomes of teeth with necrotic pulps and apical periodontitis using long-term calcium hydroxide (Ca[OH]₂) (healing was assessed via the periapical index [PAI] system) and (2) to explore the possible association of fractures in relation to long term Ca(OH)₂ exposure.MethodsA total of 242 cases, diagnosed with pulpal necrosis and apical periodontitis, were treated with long-term Ca(OH)₂ using a standardized protocol. Injectable and powdered Ca(OH)₂ were placed sequentially in the root canal system. All cases were re-evaluated within a 3-month period until radiographic healing was observed. Clinical and radiographic evaluations were performed annually. Pre- and postoperative periapical radiographs were evaluated using the PAI system.ResultsOf the 242 cases, 219 participants completed their treatment with annual follow-up. The average Ca(OH)₂ time was 5.4 months with a range of 1–12 months. Overall, by the latest follow-up visit, 90.0% (197/219) were classified as "healed." The overall mean preoperative and postoperative PAI scores were 4.07 (±0.80) and 1.76 (±0.70), respectively. Kappa statistics showed an almost perfect agreement for inter-rater (κ = 0.91) and intrarater (κ = 0.95) reproducibility for both examiners.ConclusionsWithin the limitations of this study, the use of long-term Ca(OH)₂ in the treatment of teeth with necrotic pulps and apical periodontitis resulted in a predictable high outcome. There was no association observed between long-term Ca(OH)₂ use and the incidence of fractures during this study. Ca(OH)₂ is a suitable material of choice as an interappointment dressing for teeth diagnosed with pulpal necrosis and apical periodontitis.     

Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA)

Abstract  – A case of severe crown fracture and luxation in the upper permanent incisors of a 9-year-old boy is reported. The treatment of one of the injured teeth included apexification with calcium hydroxide and endodontic treatment with gutta-percha obturation. The other incisor was also treated with calcium hydroxide, but as there was no apical stop after 3 years of treatment, it was decided to use a new root-end filling material: mineral trioxide aggregate (MTA). At follow-up 12 months later, the tooth was asymptomatic and radiographically showed the initial repair of the radiolucent apical lesion.     

Vitapex治疗成年患者根尖孔闭合不全并发慢性根尖周炎的疗效观察

目的：观察Vitapex对成年患者根尖孔闭合不全并发慢性根尖周炎患牙的临床疗效.方法：选择成年患者根尖孔发育不全并发慢性根尖周炎患牙36例,完成根管预备、消毒后,用氢氧化钙类糊剂Vitapex行根尖诱导术.经随访1～3a,在确认根尖有硬组织形成时,行注射式热牙胶根管充填,术后定期复查.结果：根尖发育完成者7例,占19.4%;根尖处有钙化桥形成者27例,占75%;失败2例,占5.6%.总有效率为94.4%,平均治疗周期为13.0周.结论：Vitapex对成年患者根尖孔发育不全并发慢性根尖周炎的患牙具有良好的临床疗效,值得临床推广应用.