The Use of Mineral Trioxide Aggregate to Repair ... - DentalCEToday

Continuing EducationCourse Number: 105.2The Use of Mineral TrioxideAggregate to RepairLatrogenic PerforationsAuthored by Arnaldo Castellucci, MD, DDSUpon successful completion of this CE activity 1 CE credit hour may be awardedA Peer-Reviewed CE Activity byDentistry Today is an ADA CERPRecognized Provider.Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2006 to May 31, 2009AGD Pace approval number: 309062Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention ofspecific product names does not infer endorsement by Dentistry Today. Information contained in CE articles andcourses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urgedto contact their state dental boards for continuing education requirements.

Continuing EducationRecommendations for Fluoride Varnish Use in Caries ManagementThe Use of Mineral TrioxideAggregate to RepairLatrogenic PerforationsLEARNING OBJECTIVES:After reading this article, the individual will learn:• the prognosis of iatrogenic perforations, and• techniques and materials for treating perforations,with the focus on mineral trioxide aggregate (MTA).ABOUT THE AUTHORSDr. Castellucci graduated in medicine atthe University of Florence (Italy) in 1973and specialized in dentistry at the sameuniversity in 1977. As well as maintaininga practice limited to endodontics inFlorence, he is past president of the ItalianEndodontic Society, past president of the InternationalFederation of Endodontic Associations, an active member ofthe European Society of Endodontology, an active member ofthe American Association of Endodontists, and a visitingprofessor of endodontics at the University of Florence DentalSchool. He is editor of The Italian Journal of Endodontics andof The Endodontic Informer. An international lecturer, he is theauthor of the text Endodontics, which is now available inEnglish. He can be reached at castellucci@dada.it.INTRODUCTIONPerforations are pathologic or iatrogenic communicationsbetween the root canal system and the attachmentapparatus. The clinician must be particularly concernedabout avoiding perforations of the tooth during endodontictherapy, since a perforation will necessitate additionaltreatment. If a perforation occurs, the tooth does notnecessarily require surgery, intentional replantation, orextraction; in fact, it can be treated successfully in aconservative manner and continue to function as it did beforethe perforation. Today, there is no reason to believe that thetooth will be lost prematurely because of this complication. 1An inflammatory reaction is established in thesurrounding periodontium at the perforation site. This is dueboth to mechanical trauma and to the introduction ofmicrobially derived substances that inevitably accompanythe perforation. The perforation creates a portal of exit inthe root canal system. Once identified, it must be sealed asquickly as possible, since periodontal involvement arisingfrom the perforation can become irreversible with time.Treating a perforation often requires a multidisciplinaryapproach in order to establish the appropriate treatmentplan. The decision must be made either to extract the toothor direct efforts toward nonsurgical retreatment, surgicalcorrection, or both. When evaluating a perforated tooth, 4variables should be considered: level, location, size andshape, and time. 21. Level. Perforations can be considered to occur in thecoronal, middle, or apical one third of the tooth. Theprognosis of radicular perforations of the apical andmiddle third is much better than perforations of the coronalthird or of the pulp chamber floor of multirooted teeth. 1,3-72. Location. Perforations occur circumferentially on thebuccal, lingual, mesial, or distal aspects of the roots.This is an important consideration if surgical access isconsidered, while it is not as important in the case ofnonsurgical retreatment.3. Size and shape. The dimension and shape of theperforation primarily influence the establishment of agood seal. The larger the bur causing the perforation,the bigger the area to seal. Furthermore, lateralperforations are never round, but are elliptical in shape,since the bur meets the canal wall at a 45° angle.Finally, the perforating cavity has no taper, and thismakes it difficult to establish a good apical seal withoutdisturbing the surrounding periodontium.4. Time. As stated, perforations create an inflammatoryreaction in the adjacent tissues, and consequently aloss of attachment. Therefore, to discourage furtherloss of attachment and periodontal breakdown,perforations should be sealed as soon as possible,preferably during the same appointment they occur.1

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic Perforationscontains the placement of the restorative material, andprevents overfilling. The use of MTA does not requirebarrier material.PERFORATION REPAIR WITH MTAThe prognosis for a perforation has improved with theuse of the operating microscope 14 and with the availabilityof MTA to seal the defects. 15 MTA was developed byTorabinejad and colleagues. 16 It is an endodontic cementthat is extremely biocompatible, hydrophilic, and capable ofstimulating the healing processes and osteogenesis. 17,18MTA is a powder that consists of fine trioxides and otherhydrophilic particles that set in the presence of moisture.Hydration of the powder results in a colloidal gel thatsolidifies to a hard structure in about 4 hours. This cementis different from all other materials used because of itsbiocompatibility, its antibacterial activity, its marginaladaptation and sealing properties, and of primaryimportance because it is hydrophilic and therefore resistantto moisture.Concerning biocompatibility, 19,20 Koh, et al 21,22 and PittFord, et al 23 demonstrated that MTA was not cytotoxic forfibroblasts or osteoblasts, and promoted the formation ofdentin bridges when used in direct pulp capping. 24 Otherstudies 25,26-29 demonstrated the formation of cementum,periodontal ligament, and bone adjacent to MTA when usedto seal perforations and as a retrofilling material in surgicalendodontic procedures. 30Concerning antibacterial activity, 31,32 Torabinejad, et al 33have demonstrated that MTA is superior to amalgam, zincoxideeugenol cement, and SuperEBA. Nonetheless, itsspectrum of activity is limited, and if a bacterialcontamination is suspected, it is advisable to use calciumhydroxide before MTA. 33 Marginal adaptation and sealingproperties of MTA are far superior to those of amalgam,IRM (DENTSPLY Caulk), and SuperEBA. 27,10,34-39As noted, the characteristic that distinguishes MTAfrom all the other materials used to repair iatrogenicperforations is that it is hydrophilic. Materials used to repairperforations, seal the retro-preparation in surgicalendodontics, close open apices, or protect the pulp in directpulp cappings are inevitably in contact with blood and otherFigure 1. Strippingof the mesial root ofthe mandibular leftfirst molar, caused bythe introduction of ascrew post into themesiobuccal canal.Preoperativeradiograph.Figure 2. The recallradiograph after 5years demonstratescomplete healing.Figure 3. Perforationof the mesial aspectof the distal root of amandibular right firstmolar caused bypreparation for anamalgam pin.Preoperativeradiograph.Figure 4. Clinicalaspect of theperforation adjacentto the old amalgam.Figure 5. Theamalgam has beenremoved, and theperforation has beenrepaired with MTA. Atthe following visit theMTA is set.3

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic Perforationstissue fluids. MTA is the only material that is not affected bymoisture or blood contamination. 28 On the other hand, MTAsets only in contact with moisture. Due to the abovementionedcharacteristics and primarily because it ishydrophilic, MTA can be considered the ideal material toseal perforations 40,41-57 (Figures 1 and 2).The following is the operative sequence to treat aperforation of the root or of the floor of the pulp chamber:At the patient’s first visit, (1) isolate the operative fieldwith rubber dam, (2) clean the perforation site; in case ofbacterial contamination, medicate with calcium hydroxidefor one week, (3) apply a 2-to-3mm thick layer of MTA;radiograph to verify the correct positioning of the material,(4) apply a small wet cotton pellet in contact with MTA, and(5) place temporary cement.At the second visit (after 24 hours), remove thetemporary cement to check if the MTA has set and thencomplete therapy.As far as the operative sequence is concerned, it isimportant to differentiate between a perforation that has theconfiguration of a cavity with 4 walls having no associationwith the root canal space (eg, the perforation of the pulpchamber floor in a molar), and one that is a strip perforationinside the canal space. If the perforation is in the floor of thepulp chamber and therefore is a cavity completelyindependent of the canal orifices, the situation is differentfrom a perforation that is in the middle third of a root and iscaused by stripping due to excessive enlargement of theroot canal. In the latter case, the perforation is notindependent from the root canal but is inside the root canal(in a root canal wall). It is not a cavity with 4 walls, but israther a thinning of the root.In the first instance, it is advisable to seal the perforationbefore obturating the root canals (Figures 3 to 8). Thisapproach is easier and saves time. Since one considerationfor prognosis is the time interval between perforation andtreatment, the longer treatment is delayed, the more likely theperforation site will be contaminated, with resultant periodontalinvolvement. After positioning small amounts of gutta-perchaat the orifices of the canals using the Obtura III (ObturaSpartan), or in a retreatment case before removing theprevious obturating material to prevent blockage of the canalsFigure 6.The radiograph showsthe MTA in place.Figure 7.Postoperativeradiograph.Figure 8.A 3-yearpostoperativeradiograph.Figure 9.In the attempt to findthe mesiobuccal canal,a perforation was madein the floor of the pulpchamber. Preoperativeradiograph.Figure 10.Clinical aspect of theaccess cavity. The redtissue on the left is thepulp tissue in thelingual canal. On themesial aspect of theperforation the orificeof the buccal canalis visible.4

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic Perforationswith MTA, MTA is used to completely fill the perforation. Oncethe complete set of the material is verified at the second visit,the cleaning, shaping, and obturation of the root canal systemis completed in the standard fashion.In the case of a strip perforation due to a thinning of theroot dentinal wall, it is extremely difficult to repair theperforation site with MTA before obturating the root canalwithout blocking the canal itself with MTA. Therefore, it isadvisable to obturate the canal space apical to the perforationfirst, and then to repair the perforation using MTA to seal theperforation site and fill the entire coronal portion of the rootcanal, to the orifice (Figures 9 to 20). In order to do this, it isnecessary to measure the level of the perforation using theoperating microscope and then to partially cut or score theprefitted gutta-percha cone just apical to that level. Once it isintroduced into the root canal, the gutta-percha cone is digitallyrotated, separating it into 2 pieces: the coronal fragment pullsaway, leaving the apical fragment in the canal, which is justapical to the perforation. After compaction of the apical guttaperchacone, the canal is filled with MTA to the orifice, sealingthe perforation site.CRITERIA FOR DETERMINING SUCCESSTo achieve success following treatment of a perforation,the treated tooth must meet the following requirements: 58• absence of symptoms, such as spontaneous pain, orpain on palpation or percussion• absence of excessive mobility• absence of a communication between the perforationand the gingival crevice• absence of a fistula• the tooth must be functional• absence of radiographic signs of demineralization ofthe bone adjacent to the perforation• thickness of the periodontal ligament adjacent to theobturating material should be no more than double thethickness of the surrounding ligament.If only one of these criteria cannot be met, therapycannot be considered as a success.Figure 11.A No. 10 K-Filenegotiating themesiobuccal canal.Figure 12.Working length ofthe mesiobuccalcanal.Figure 13.After cleaning andshaping, theperforation is seen asthe small openingabout7 mm below thecanal orifice.Figure 14.Fitting thegutta-percha cones.Figure 15. The guttaperchacone of themesiobuccal canalhas been partiallypre-sectioned apicalto the perforation,and is bent andcoated with sealerbefore beingintroduced in thecanal.5

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic PerforationsREFERENCES1. Harris WE. A simplified method of treatment for endodonticperforations. J Endod. 1976;2:126-134.2. Ruddle CJ. Micro-endodontic nonsurgical retreatment. DentClin North Am. 1997;41:429-454.3. ElDeeb ME, ElDeeb M, Tabibi A, et al. An evaluation of theuse of amalgam, Cavit, and calcium hydroxide in the repairof furcation perforations. J Endod. 1982;8:459-466.4. Himel VT, Brady J Jr, Weir J Jr. Evaluation of repair ofmechanical perforations of the pulp chamber floor usingbiodegradable tricalcium phosphate or calcium hydroxide. JEndod. 1985;11:161-165.5. Jew RC, Weine FS, Keene JJ Jr, et al. A histologicevaluation of periodontal tissues adjacent to rootperforations filled with Cavit. Oral Surg Oral Med OralPathol. 1982;54:124.6. Martin LR, Gilbert B, Dickerson AW II. Management ofendodontic perforations. Oral Surg. 1982;54:668-677.7. Seltzer S, Sinai I, August D. Periodontal effects of rootperforations before and during endodontic procedures. JDent Res. 1970;49:332-339.8. Kim S. Principles of endodontic microsurgery. Dent ClinNorth Am. 1997;41:481-497.9. Beavers RA, Bergenholtz G, Cox CF. Periodontal woundhealing following intentional root perforations in permanentteeth of Macaca mulatta. Int Endod J. 1986;19:36-44.10. Benenati FW, Roane JB, Biggs JT, et al. Recall evaluationof iatrogenic root perforations repaired with amalgam andgutta-percha. J Endod. 1986;12:161-166.11. Frank AL, Weine FS. Nonsurgical therapy for the perforative defectof internal resorption. J Am Dent Assoc. 1973;87:863-868.12. Lantz B, Persson PA. Periodontal tissue reactions aftersurgical treatment of root perforations in dogs’ teeth: ahistologic study. Odontol Revy. 1970;21:51-62.13. Ruddle CJ. Nonsurgical endodontic retreatment. J Calif DentAssoc. 1997;25(11):769-799.14. Ruddle CJ. Endodontic perforation repair: using the surgicaloperating microscope. Dent Today. 1994;13:48-53.15. Cantatore G, Castellucci A, Dell’agnola A, et al. Applicazionicliniche dell’MTA. G Ital Endod. 2002; 16:29-34.16. Torabinejad M, Hong CU, McDonald F, et al. Physical andchemical properties of a new root-end filling material. JEndod. 1995;21:349-353.17. Sarkar NK, Caicedo R, Ritwik P, et al. Physicochemicalbasis of the biologic properties of mineral trioxide aggregate.J Endod. 2005;31:97-100.18. Thomson TS, Berry JE, Somerman MJ, et al.Cementoblasts maintain expression of osteocalcin in thepresence of mineral trioxide aggregate. J Endod.2003;29:407-412.19. Ribeiro DA, Duarte MA, Matsumoto MA, et al.Biocompatibility in vitro tests of mineral trioxide aggregateand regular and white Portland cements. J Endod.2005;31:605-607.20. Ribeiro DA, Matsumoto MA, Duarte MA, et al. Ex vivobiocompatibility tests of regular and white forms of mineraltrioxide aggregate. Int Endod J. 2006;39:26-30.21. Koh ET, McDonald F, Pitt Ford TR, et al. Cellular responseto Mineral Trioxide Aggregate. J Endod. 1998;24:543-547.22. Koh ET, Torabinejad M, Pitt Ford TR, et al. Mineral trioxideaggregate stimulates a biological response in humanosteoblasts. J Biomed Mater Res. 1997;37:432-439.23. Pitt Ford TR, Torabinejad M, Abedi HR, et al. Using mineraltrioxide aggregate as a pulp-capping material. J Am DentAssoc. 1996;127:1491-1494.24. Karabucak B, Li D, Lim J, et al. Vital pulp therapy with mineraltrioxide aggregate. Dent Traumatol. 2005;21:240-243.25. Camilleri J, Montesin FE, Papaioannou S, et al.Biocompatibility of two commercial forms of mineral trioxideaggregate. Int Endod J. 2004;37:699-704.26. Holland R, de Souza V, Nery MJ, et al. Reaction of ratconnective tissue to implanted dentin tubes filled withmineral trioxide aggregate or calcium hydroxide. J Endod.1999;25:161-166.27. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability ofmineral trioxide aggregate when used as a root end fillingmaterial. J Endod. 1993;19:591-595.28. Torabinejad M, Higa RK, McKendry DJ, et al. Dye leakageof four root end filling materials: effects of bloodcontamination. J Endod. 1994;20:159-163.29. Torabinejad M, Pitt Ford TR, McKendry DJ, et al. Histologicassessment of mineral trioxide aggregate as root-end fillingin monkeys. J Endod. 1997;23:225-228.30. Baek SH, Plenk H Jr, Kim S. Periapical tissue responses andcementum regeneration with amalgam, SuperEBA, and MTAas root-end filling materials. J Endod. 2005;31:444-449.31. Al-Hezaimi K, Naghshbandi J, Oglesby S, et al. Humansaliva penetration of root canals obturated with two types ofmineral trioxide aggregate cements. J Endod. 2005;31:453-.32. Sipert CR, Hussne RP, Nishiyama CK, et al. In vitroantimicrobial activity of Fill Canal, Sealapex, MineralTrioxide Aggregate, Portland cement and EndoRez. IntEndod J. 2005;38:539-543.33. Torabinejad M, Hong CU, Pitt Ford TR, et al. Antibacterialeffects of some root end filling materials. J Endod.1995;21:403-406.34. Adamo HL, Buruiana R, Schertzer L, et al. A comparison ofMTA, Super-EBA, composite and amalgam as root-endfilling materials using a bacterial microleakage model. IntEndod J. 1999;32:197-203.7

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic Perforations35. Al-Kahtani A, Shostad S, Schifferle R, et al. In-vitroevaluation of microleakage of an ortho-grade apical plug ofmineral trioxide aggregate in permanent teeth with simulatedimmature apices. J Endod. 2005;31:117-119.36. Bates CF, Carnes DL, del Rio CE. Longitudinal sealingability of mineral trioxide aggregate as a root-end fillingmaterial. J Endod. 1996; 22:575-578.37. Fischer EJ, Arens DE, Miller CH. Bacterial leakage ofmineral trioxide aggregate as compared with zinc-freeamalgam, intermediate restorative material, and Super-EBAas a root-end filling material. J Endod. 1998;24:176-179.38. Torabinejad M, Smith PW, Kettering JD, et al. Comparativeinvestigation of marginal adaptation of mineral trioxideaggregate and other commonly used root-end fillingmaterials. J Endod. 1995;21:295-299.39. Wu MK, Kontakiotis EG, Wesselink PR. Long-term sealprovided by some root-end filling materials. J Endod.1998;24:557-560.40. Bargholz C. Perforation repair with mineral trioxideaggregate: a modified matrix concept. Int Endod J.2005;38:59-69.41. De-Deus G, Petruccelli V, Gurgel-Filho E, et al. MTA versusPortland cement as repair material for furcal perforations: alaboratory study using a polymicrobial leakage model. IntEndod J. 2006;39:293-298.42. Main C, Mirzayan N, Shabahang S, et al. Repair of rootperforations using mineral trioxide aggregate: a long-termstudy. J Endod. 2004;30:80-83.43. Yildirim T, Gencoglu N, Firat I, et al. Histologic study offurcation perforations treated with MTA or Super EBA indogs’ teeth. Oral Surg Oral med Oral Pathol Oral RadiolEndod. 2005;100:120-124.44. Lee SJ, Monsef M, Torabinejad M. Sealing ability of amineral trioxide aggregate for repair of lateral rootperforations. J Endod. 1993;19:541-544.45. Pitt Ford TR, Torabinejad M, McKendry DJ, et al. Use ofmineral trioxide aggregate for repair of furcal perforations.Oral Surg Oral Med Oral Pathol Oral Radiol Endod.1995;79:756-762.46. Fuss Z, Trope M. Root perforations: classification andtreatment choices based on prognostic factors. Endod DentTraumatol. 1996;12:255-264.47. Nakata TT, Bae KS, Baumgartner JC. Perforation repaircomparing mineral trioxide aggregate and amalgam usingan anaerobic bacterial leakage model. J Endod.1998;24:184-186.48. Sluyk SR, Moon PC, Hartwell GR. Evaluation of settingproperties and retention characteristics of mineral trioxideaggregate when used as a furcation perforation repairmaterial. J Endod. 1998;24:768-771.49. Weldon JK Jr, Pashley DH, Loushine RJ, et al. Sealingability of mineral trioxide aggregate and super-EBA whenused as furcation repair materials: a longitudinal study. JEndod. 2002;28:467-470.50. Ferris DM, Baumgartner JC. Perforation repair comparingtwo types of mineral trioxide aggregate. J Endod.2004;30:422-424.51. Regan JD, Witherspoon DE, Foyle DM. Surgical repair of rootand tooth perforations. Endodontic Topics. 2005;11:152-178.52. Arens DE, Torabinejad M. Repair of furcal perforations withmineral trioxide aggregate: two case reports. Oral Surg OralMed Oral Pathol Oral Radiol Endod. 1996;82:84-88.53. Bryan EB, Woollard G, Mitchell WC. Nonsurgical repair offurcal perforations: a literature review. Gen Dent.1999;47:274-278.54. Holland R, Filho JA, de Souza V, et al. Mineral trioxideaggregate repair of lateral root perforations. J Endod.2001;27:281-284.55. Hamad HA, Tordik PA, McClanahan SB. Furcationperforation repair comparing gray and white MTA: a dyeextraction study. J Endod. 2006;32:337-340.56. Zou L, Liu J, Yin S, et al. In vitro evaluation of the sealingability of MTA used for the repair of furcation perforationswith and without the use of an internal matrix. Oral SurgOral Med Oral Pathol Oral Radiol Endod. 2008;105:61-65.57. Yildirim G, Dalci K. Treatment of lateral root perforation withmineral trioxide aggregate: a case report. Oral Surg OralMed Oral Pathol Oral Radiol Endod. 2006;102:55-58.58. Stromberg T, Hasselgren G, Bergstedt H. Endodontictreatment of traumatic root perforations in man: a clinicaland roentgenological follow-up study. Sven Tandlak Tidskr.1972;65:457-466.8

Continuing EducationThe Use of Mineral Trioxide Aggregate to Repair Latrogenic PerforationsPOST EXAMINATION INFORMATIONTo receive continuing education credit for participation in thiseducational activity you must complete the program postexamination and receive a score of 70% or better.Traditional Completion Option:You may fax or mail your answers with payment to Dentistry Today(see Traditional Completion Information on following page). Allinformation requested must be provided in order to process theprogram for credit. Be sure to complete your “Payment”, “PersonalCertification Information”, “Answers” and “Evaluation” forms, Yourexam will be graded within 72 hours of receipt.. Upon successfulcompletion of the post-exam (70% or higher), a “letter ofcompletion” will be mailed to the address provided.Online Completion Option:Use this page to review the questions and mark your answers.Return to dentalCEtoday.com and signin. If you have notpreviously purchased the program select it from the “OnlineCourses” listing and complete the online purchase process. Oncepurchased the program will be added to your User History pagewhere a Take Exam link will be provided directly across from theprogram title. Select the Take Exam link, complete all the programquestions and Submit your answers. An immediate grade reportwill be provided. Upon receiving a passing grade complete theonline evaluation form. Upon submitting the form your Letter OfCompletion will be provided immediately for printing.General Program Information:Online users may login to dentalCEtoday.com anytime in thefuture to access previously purchased programs and view or print“letters of completion” and results.POST EXAMINATION QUESTIONS1. Once a perforation is identified, ____.a. it must be sealed as quickly as possibleb. it should be monitored radiographically for3 to 6 monthsc. the tooth should be immediately extractedd. surgical intervention is the only treatment option2. Variables for evaluating a perforated toothinclude ____.a. level of the perforationb. location of the perforationc. size and shape of the perforationd. all of the above3. Which of the following perforations has theworst prognosis?a. coronal thirdb. radicularc. middle thirdd. both b and c4. Location of a perforation ____.a. is important if it can be treated nonsurgicallyb. is not important if it can be treated nonsurgicallyc. is not important if it is treated surgicallyd. both a and c5. The following restorative material does not require adry field to ensure proper seal of a perforation ____.a. amalgamb. MTAc. SuperEBA resin cementd. composite bonded material6. Mineral trioxide aggregate (MTA) is ____.a. hydrophobicb. hydrophilicc. not biocompatibled. not antibacterial7. Hydration of MTA powder results in a colloidal gelthat solidifies to a hard structure in ___.a. about 1 hourb. about 2 hoursc. about 3 hoursd. about 4 hours8. The following statement is TRUE:a. MTA is affected by moisture or bloodcontamination.b. If bacterial contamination is suspected, it isadvisable to use calcium hydroxide before MTA.c. The antibacterial spectrum of activity of MTA isvery broad.d. For a strip perforation inside the root canal space,the perforation should be sealed before obturatingthe canals.9