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Year : 2007  |  Volume : 10  |  Issue : 3  |  Page : 93-98
The complete endodontic obturation of immature permanent central incisors with mineral trioxide aggregate and using obturated MTA as barrier for walking bleaching

Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India

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The use of mineral trioxide aggregate (MTA) for both complete obturation and as a coronal barrier for non vital bleaching in immature maxillary central incisor is reported. A 18 year- old female reported with pain and discoloration of upper central incisors. Radiograph revealed immature maxillary central incisors. Single step apexification was done with MTA and root canal system eras obturated with MTA followed, by using this obturated MTA as a barrier for non vital bleaching. After 2 weeks esthetic management was done with direct composite. Follow up radiographs after 6months and one year revealed good bone healing and closure of the apex.

How to cite this article:
Pradeep G, Natesan S, Kandaswamy D. The complete endodontic obturation of immature permanent central incisors with mineral trioxide aggregate and using obturated MTA as barrier for walking bleaching. J Conserv Dent 2007;10:93-8

How to cite this URL:
Pradeep G, Natesan S, Kandaswamy D. The complete endodontic obturation of immature permanent central incisors with mineral trioxide aggregate and using obturated MTA as barrier for walking bleaching. J Conserv Dent [serial online] 2007 [cited 2023 Feb 6];10:93-8. Available from:

   Introduction Top

When teeth with incomplete root formation suffer pulp necrosis, the formation of dentine stops, and root development ceases. Consequently, the canal remains large, with thin and fragile walls, and the apex remains open. These features make instrumentation of the canal difficult and hinder the formation of an adequate apical stop. In such cases, in order to allow the condensation of the root filling material and to promote an apical seal, it is imperative to create an artificial apical barrier (apexification).

Calcium hydroxide has property to induce apexification [1],[2] . Despite its efficacy, calcium hydroxide has several disadvantages, such as variability of treatment time, more number of appointments, difficulty in patient follow-up and possibility of increased tooth fracture after calcium hydroxide use for extended periods [3]

Studies have indicated mineral trioxide aggregate (MTA) as an alternative to calcium hydroxide [4],[5] .MTA is a powder aggregate, containing mineral oxides [6] . Besides its noncytotoxicity [7] , it has good biological action [8],[9] and stimulates repair [10] . Shabahang et al when used in dogs teeth with incomplete root formation and contaminated canals, MTA often induced the formation of apical barrier with hard tissue [4],[5] .

The purpose of root canal treatment is to eliminate microorganisms from the root canal system by mechanical and chemical means and to prevent recontamination by providing a seal barrier between oral microflora and the root canal and periapical tissues. A lack of coronal seal may lead to endodontic failure [11] . A variety of restorative materials were used to produce a coronal barrier for obtaining a tight root canal seal. Recently it has been suggested that Mineral trioxide aggregate (MTA) was able to produce a tight seal with dentin that was superior to many other existing materials [12],[13],[14],[15] .

Currently the most commonly used intracoronal bleaching materials for non vital bleaching are hydrogen peroxide (H 2 O 2 ) and sodium perborate (NaBO 3 ,/NaBO 3 , 4H 2 O) are used for non vital bleaching [16] . The following case report demonstrates the use of MTA as an obturating material to promote periapical healing of root with open apices and using this obturated MTA as a barrier for walking bleaching technique.

   Case report Top

A 18 year old female patient presented to Department of Conservative Dentistry and Endodontics at Meenakshi Animal Dental College and Hospitals in Chennai, India. The patient presented with chief complaint of pain in relation to upper anterior teeth. Clinical examination revealed a buccal sinus tract in proximity to the apex of maxillary left central incisor. The clinical signs and symptoms were discoloration, Ellis II fracture, mobility was within normal limits, pain on percussion and palpation in relation to maxillary right and left central incisors. Patient gave a history of traumatic injury when she was 8 years old for which she hadn't undergone any dental treatment. The radiographic examination revealed immature teeth with wide open apex in maxillary central incisors and demonstrated an apparent radiolucency at the periradicular area.

Infiltration for local anaesthesia with Lignocine and 1/100 000 adrenaline given in relation to upper central incisors. The teeth were isolated with rubber dam. A conventional access cavity was prepared. The canals were then gently cleaned with K- file and 5% NaOCI. The working lengths were measured radiographically with a K-file was 17mm. The canals were dried with sterile paper points and calcium hydroxide (Ultracalxs, Ultradent) was placed in the root canal using an intracanal capillary point (C Tips, Ultradent). After I week, canals were dry and calcium hydroxide was removed by repeated rinsing with 5%NaOCI and 17% EDTA followed by final rinse with sterile water. Once the canal was dry at the working length, with no exudate, the Gray MTA (Dental Tulsa Dentsply) was mixed with sterile water following manufacture's instructions. MTA was placed in the canals using an MTA Endo Gun(Dentsply Maillefer, Ballaigues, Switzerland) and condensed with 9/11 double­ended plugger a stopper was placed to the plugger to the working length. 5mm of apical plug was created with MTA and its extension was checked radiographically. A cotton pellet was placed in pulp chamber over the condensed MTA and access cavity was sealed with Cavit G (3M ESPE AG, Seefeld, Germany). Patient was recalled after 24 hours. And rest of the root canal system was obturated with MTA upto cemento-enamel junction and depth to cemento-enamel junction was confirmed through the introduction of an instrument into pulp chamber and checked radiographically. A cotton pellet was placed in pulp chamber and patient was recalled after 24 hours. After 24hrs walking bleach paste was prepared by mixing sodium perborate with 30% hydrogen peroxide, with a plastic instrument pulp chamber was packed with the paste. Excess of liquid was removed by tamping with a cotton pellet. Excess of bleaching paste was removed and sealed with IRM. Patient was evaluated after 1 week and same procedure was repeated in 2 nd and 3 rd week. Permanent restoration and esthetic treatment is done with composite, 2 weeks after bleaching treatment is over.

The clinical follow-up at 6months and l year revealed an adequate clinical function, an absence of clinical symptoms, the absence of the buccal sinus tract. The radiographic follow-up at 6months revealed a decrease of the periapical rarefaction and at l year the periapical radiolucency had disappeared and apical barrier was formed.

   Discussions Top

In this case we planned for single step apexification with MTA. As patient is 18years old and tooth fracture was involving only enamel and dentin (Ellis II) in relation to maxillary right and left central incisors, nonvital bleaching was planned for discolored maxillary central incisors followed by esthetic treatment with composite resin for fractured teeth to maintain structural integrity instead of crown.

The manufacture of MTA recommends a 3 to 5-mm thickness of MTA be placed at the apex for the apexification procedure. It has been showed the GMTA had less microleakage than WMTA in samples obturated 24hr after MTA placement, in all groups 5mm of MTA material allowed less leakage [17] .

In this case intracanal medication with calcium hydroxide was performed before the canal was dry and ready for filling. The use of calcium hydroxide is still controversial. It showed that remains of calcium hydroxide that remain on the canal walls had no significant effect on MTA leakage or displacement resistance [18] . In the present case, complete removal of calcium hydroxide from the canal walls was accomplished by alternate irrigation with 5% NaOC1 and 17% EDTA [19] However, recent data [20] suggest that the combination of MTA and calcium hydroxide in apexification procedures may favorably influence the regeneration of the peridontium.

Moist cotton pellet was placed over MTA for minimum 4h or until next appointment. With this approach MTA is exposed to moisture from both the intracanal and tissue surface and this moisture allows MTA to set properly [21] .The working length determined in maxillary right and left incisors was 17mm. Length from incisal tip to cementoenamel junction is 7mm.Apically MTA was condensed to 5mm thickness.3mm of coronal barrier of MTA is needed for good seal and to prevent bacterial leakage [22] . MTA was used as an isolating barrier for internal bleaching demonstrated superior performance [23] when compared to conventional GIC So in this case 3mm MTA is used as a barrier for non vital bleaching. And the amount of space left in root canal system for obturation is 2mm. So we obturated the remaining 2mm space with MTA. The microleakage of MTA materials used for root canal obturation has been reported by Hezaimi et al reported that both WMTA and GMTA allowed less apical microleakage than warm, vertically condensed gutta percha [24] .

There was change in discoloration in 1week, after three visits of walking bleaching maxillary central incisors attained normal tooth color. Oxygen is produced during bleaching procedures and they remains in the enamel and dentine for up to 2 weeks after bleaching and interfere with the chemistry of bonding agents. So delay in bonding procedures for composite resin is recommended after bleaching procedures, esthetic management and permanent restoration with composite is done in maxillary central incisors 2 weeks after bleaching is done [25] . Disadvantage when MTA is used as an obturating material is its very difficult to remove MTA form the root canal and retreatment is difficult.

Both clinical and radiography follow-ups in this case showed periapical healing and new hard tissue formation in the apical area of affected teeth. The results are similar clinical report [26],[27] where MTA was used as an obturating material. In conclusion, MTA appeared to be a valid option for apexification with the added advantage of speed of completion of therapy. Long-term outcome studies appear appropriate to test if this method is consistently successful over a large group of teeth.

   References Top

1.Leonardo MR, Silva LAB, Leonardo RT, Utrilla LS, Assed S (1993) Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. Journal of Endodontics 1993, 19,34852.  Back to cited text no. 1    
2.Felippe MCS, Felippe WT, Marques MM, Antoniazzi JH. The effect of renewal of calcium hydroxide paste on the apexification and periapical healing of teeth with incomplete root formation. International Endodontic Journal 2005;38,43642.  Back to cited text no. 2    
3.Andreasen JO, Farik B, Munksgaard EC Long­term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dental Traumatology 2002, 18, 1347.  Back to cited text no. 3    
4.Tittle K, Farley J, Linkhart T, Torabinejad M Apical closure induction using bone growth factors and mineral trioxide aggregate. Journal ofEndodontics 1996, 22,198.  Back to cited text no. 4    
5.Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P.A comparative study of root-end induction using osteogenic protein-1, calcium hydroxide, and mineral trioxide aggregate in dogs. Journal ofEndodontics 1999, 25, 15.  Back to cited text no. 5    
6.Lee SJ, Monsef M, Torabinejad M (1993) Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. Journal of Endodontics 19, 5414.  Back to cited text no. 6    
7.Osorio RM, Hefti A, Vertucci FJ, Shawley AL (1998) Cytotoxicity of endodontic materials. Journal ofEndodontics 24,916.  Back to cited text no. 7    
8.Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP (1995c) Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a preliminary report. Journal of Endodontics 21, 56971.  Back to cited text no. 8    
9.Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD (1995d) Cytotoxicity of four root end filling materials. Journal ofEndodontics 21, 48992.  Back to cited text no. 9    
10.Regan JD, Gutmann JL, Witherspoon DE (2002) Comparison of Diaket and MTA when used as root-end filling materials to support regeneration of the periradicular tissues. International Endodontic Journal 35, 8407.  Back to cited text no. 10    
11.Ray HA, Trope M. periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 1995,28:12-8.  Back to cited text no. 11    
12.Lamb EL, Loushine RJ, Weller RN, Kimbrough WF, Pashely DH. Effect of root recesection on the apical sealing ability of mineral trioxide aggregate. Oral Surg Oral Med Oral Pathol Oral Radio Endod2003, 95:732-5.  Back to cited text no. 12    
13.Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999,25:197-205  Back to cited text no. 13  [PUBMED]  
14.Schmitt D, Lee J, Bogen G. Multifaceted use of ProRoot TM MTA root canal repair material. Am Acad Pediatr Dent2001,23: 326-30  Back to cited text no. 14    
15.Rotstein I, Walton RE (2002) Bleaching discolored teeth: internal and external. In: Walton R, Torabinejad M, eds. Principles and Practice ofEndodontics, 2002, 3rd edn, Chapter 23, pp. 405423. Philadelphia: WB Saunders Company.  Back to cited text no. 15    
16.Rotstein I, Walton RE (2002) Bleaching discolored teeth: internal and external. In: Walton R, Torabinejad M, eds. Principles and Practice of Endodontics, 2002, 3rd edn, Chapter 23, pp. 405423. Philadelphia: WB Saunders Company  Back to cited text no. 16    
17.Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study of white and gray mineral trioxide aggregate (MTA) simulating a one or two-step apical barrier technique. J Endod 2004;30:8769.  Back to cited text no. 17    
18.Hachmeister DR, Schindler G, Walker WA, Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. Journal of Endodontics 2002 28, 38690.  Back to cited text no. 18    
19.Calt S, Seper A.Dentinal tubule penetration of root canal sealers after root canal dressing with calcium hydroxide. Journal of Endodontics 1999,25,431-3.  Back to cited text no. 19    
20.Ham KA, Witherspoon DE, Gutmann JL, Ravindranath S, Gait TC, Opperman LA. Preliminary evacuation of BMP-2 expression and histological characteristics during apexification with calcium hydroxide and mineral trioxide aggregate. Journal of Endodontics 2005,31,2759.  Back to cited text no. 20    
21.Sluyk SR, Moon PC, Hartell GR, Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as furcation perforation repair material. J Endod 1998,24:768-71.  Back to cited text no. 21    
22.Marat Tselink, Craig Baumgartner.J, Gordon Marshall.J. Bacterial leakage with mineral trioxide aggregate or a resin modified glass inomer used as a coronal barrier. Journal of Endodontics 2004, 30:782-84.  Back to cited text no. 22    
23.Cummings GR, Torabinejad M. Mineral trioxide aggregate (MTA) as an isolating barrier for internal bleaching (Abstract 53). Journal of Endodontics 1995,21:228.  Back to cited text no. 23    
24.Al-Hezaimi K, Naghshbandi J, Oglesby S, Simon JHS, Rotstein I. Human saliva penetration of root canals obturated with two types of mineral trioxide aggregate cements. J Endod2005;31:4536.  Back to cited text no. 24    
25.Shear bond strength evaluation of composite resin on enamel and dentin after nonvital bleaching. J Esthet Restor Dent. 2005;17(l): 22-9.  Back to cited text no. 25    
26.Karp J, Bryk J, Menke E, McTigue D. The complete endodontic obturation of an avulsed immature permanent incisor with mineral trioxide aggregate: a case report. Pediatr Dent. 2006 May-Jun;28(3):273-8.  Back to cited text no. 26    
27.Hayashi M, Shimizu A, Ebisu S . MTA for obturation of mandibular central incisors with open apices: case report. J Endod. 2004 Feb;30(2):120-2  Back to cited text no. 27    

Correspondence Address:
Gali Pradeep
Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.42268

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