CASE REPORT „ 263 fo r n Amit Vanka, KS Ravi, ND Shashikiran, Pinky Choudhary, Vinaya Kulkarni ot Q ui by N ht pyrig No Co t fo rP ub lica tio n te ss e n c e Orthograde mineral trioxide aggregate (MTA) placement against an internal matrix of absorbable collagen sponge: outcome of a case series Amit Vanka Department of Pedodontics and Preventive Dentistry, People’s College of Dental Sciences, Bhopal, India KS Ravi Key words absorbable collagen sponge, apexification, apical plug, MTA, open apex The orthograde intracanal placement of mineral trioxide aggregate (MTA) in the treatment of root canals with an open apex is technique sensitive, primarily because of its poor handling properties. Placement of the material within the confines of the root canal is difficult. The current case series presents the results of 12 treated open apex cases, using MTA condensed by hand against an internal matrix of absorbable collagen sponge (ACS) to create an apical plug. The results of the technique are encouraging, while the success of MTA in apexification has been reiterated. Department of Pedodontics and Preventive Dentistry, People’s College of Dental Sciences, Bhopal, India ND Shashikiran Department of Pedodontics and Preventive Dentistry, People’s College of Dental Sciences, Bhopal, India Pinky Choudhary, Department of Pedodontics and Preventive Dentistry, People’s College of Dental Sciences, Bhopal, India Vinaya Kulkarni, „ Introduction Mineral trioxide aggregate (MTA) has recently received much attention as a substitute for calcium hydroxide-based materials, and has demonstrated promising clinical outcomes. MTA has been reported to have desirable properties such as biocompatibility, fibroblast stimulation, antimicrobial activity and sealing capacity, with an ability to set in a moist environment1. It has thus been proposed as a material suitable for a ‘one-visit’ treatment of teeth with open apices by creating an apical MTA plug, compared with the long-term apexification using multiple calcium hydroxide dressings. This has some drawbacks, such as prolonged duration of treatment with multiple visits and increased risk of tooth fracture2. An MTA/distilled water mixture, however, does not exhibit all properties of a good root canal-filling material, especially be- cause it does not present an adequate flow3. The orthograde apical MTA plug can be accomplished using different methods. Commonly, carriers such as Messing Gun (Produits Dentaires, Vevey, Switzerland)4 or Dovgan Carriers (Vista Dental Products, Racine, WI, USA) have been used to deliver the material in the apical portion of the root canal, followed by hand or ultrasonic (direct or indirect) condensation. The use of a microscope has also been suggested to aid in this process5. In large furcation defects with a clinical situation that mimics an open apex, better sealing ability of materials has been reported if an internal matrix of absorbable collagen sponge was used6. The aim of this report is to present the management of 12 treated teeth with non-vital pulps and open root apices with an MTA apical plug technique, using an internal matrix of absorbable collagen sponge (ACS). ENDO (Lond Engl) 2011;5(4):263–266 Department of Pedodontics and Preventive Dentistry, People’s College of Dental Sciences, Bhopal, India Correspondence to: Amit Vanka Peoples College of Dental Sciences, Bhanpur Bypass Road, Bhopal, Madhya Pradesh, India 462037 Email: amitvanka@rediffmail.com Tel: +91-999-396-1890 Fax: +755-400-5315 Vanka et al Orthograde mineral trioxide aggregate (MTA) placement Q ui by N ht pyrig No Co t fo rP ub lica tio n te ss e n c e b Fig 1a Preoperative radiograph of teeth 11 and 21, both showing open apices and periapical radiolucencies subsequent to traumatic injury. Fig 1b Calcium hydroxide dressing for 2 weeks with temporary restorations. c This report includes 12 maxillary incisors in 11 patients aged between 10 and 14 years who suffered a traumatic injury, and was presented to the Department of Pediatric Dentistry. Ethical approval was sought and granted, and informed consent was obtained from the parents. The patients were selected as follows: • the minimum time between the trauma and the first visit was at least 2 years • all traumatised teeth had a necrotic pulp • all patients presented with incomplete development and/or resorption of the root, leading to an open apex corresponding to Nolla’s stage 8 and 9 (Fig 1a)7. „ Procedure The teeth were isolated with a rubber dam. A conventional access cavity was prepared in the palatal surface of the incisors. The working length was measured radiographically and recorded for reference. The canals were debrided gently, 1 mm short of the apex. After 2 weeks of intracanal calcium hydroxide medication (Fig 1b), the dressing was removed by irrigating with alternating solutions of ENDO (Lond Engl) 2011;5(4):263–266 d Fig 1c After disinfection, MTA plugs were created against a barrier of absorbable collagen sponge. „ Materials and methods fo r n a ot 264 „ Fig 1d Root canals were obturated with gutta-percha, AH Plus sealer and adhesively restored with composite. The 9-month radiographic follow-up shows the reduced size of the lesions and regeneration of periodontal ligament space of teeth 11 and 21. sodium hypochlorite 5% and ethylenediaminetetraacetic acid (EDTA) 17%. Small pieces of absorbable collagen sponge (KolSpon, Eucare Pharmaceuticals, Chennai, India) were then condensed beyond the canal apex using endodontic pluggers, until the periapical space was full in order to create a periapical barrier for the MTA. The working length was checked to confirm that the plugger did not traumatise the periapical tissues. The plugger length was then readjusted to 5 mm short of working length, so that a 3 to 5 mm MTA plug could then be formed. Grey MTA-Angelus (Angelus, Londriana, PR, Brazil) was then introduced into the root canal with the help of an amalgam carrier. Previously used pluggers were used to push the MTA towards the apex and then it was condensed against the collagen barrier. Correct placement of MTA was confirmed radiographically (Fig 1c, Figs 2a–2c). A sterile sponge pellet moistened with sterile water was placed over the canal orifice and the access cavity was sealed temporarily with intermediate restorative materials (IRM) (DENTSPLY Caulk, Milford, DE, USA). The MTA was allowed to set for 24 hours (although manufacturers have suggested a final setting time of 15 minutes), after which the root canal was re-entered. The setting of the MTA was confirmed by gentle probing with a file. The Orthograde mineral trioxide aggregate (MTA) placement „ 265 Q ui by N ht pyrig No Co t fo rP ub lica tio n te ss e n c e b c Fig 2a–c Examples of MTA plugs: 3 to 5 mm MTA apical plugs were created in teeth with open apices using the internal matrix of absorbable collagen sponge (ACS). rest of the canal space was then obturated by guttapercha and AH Plus (Dentsply DeTrey, Konstanz, Germany) using a cold lateral compaction technique. At the same appointment, the access cavities were adhesively restored with composite. Patients were followed up for the first week for any postoperative symptoms. Further follow-up appointments based on clinical and radiographic evaluation were scheduled at 3, 6 and 9 months. Clinically, treatment was considered successful when symptoms such as pain, swelling, buccal sinus tract, or tenderness to apical and gingival palpation or percussion were absent. Radiographically, healing was evaluated, taking into consideration the size of lesion and regeneration of periodontal ligament space. „ Results The technique using hand condensation of MTA against an ACS barrier resulted in an apical plug of 3 to 5 mm, placed within the confines of the root canal, as seen radiographically in all cases. Two patients (3 teeth) reported postoperative symptoms within a week and analgesics were prescribed. At the 9-month clinical examination, all teeth were free of symptoms, buccal sinus tracts, and swelling. Radiographic examination (Fig 1d) revealed complete healing in eight teeth, while for the remaining four teeth healing was in process. „ Discussion While the outcome of conventional gutta-percha fillings in immature pulpless teeth is uncertain, MTA has the potential to provide predictable results8. Several studies have reported positive outcomes with the use of MTA, and the outcome in this case series is similar to previously reported cases of successful MTA apical plug procedures in teeth with necrotic pulps and open apices9,10. As postulated by Al-Kahtani et al3, the type of intracanal delivery technique may contribute to the final success when using MTA to create an apical plug. Aminoshariae et al11 suggested that hand condensation of MTA resulted in better adaptation and fewer voids than direct ultrasonic compaction. On the other hand, Yeung et al12 in a quantitative analysis have found indirect ultrasonic condensation to be superior. However, both studies were conducted in vitro and without the use of an internal matrix, preventing comparison with the current cases. The percentage of cases with slight overextension using current techniques seems to be relatively high13 and may be a reason for persistence of periapical lesions14. Holland et al15 reported that overfilling with MTA was associated with an intense, extensive lymphocyte histiocyte-plasmocyte infiltrate with disorganization of the periodontal ligament in animals. Thus regarding the limits of obturation, filling within the root canal space has presented significantly better results than overfilling. ENDO (Lond Engl) 2011;5(4):263–266 fo r n a ot Vanka et al Orthograde mineral trioxide aggregate (MTA) placement 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. ENDO (Lond Engl) 2011;5(4):263–266 by N ht MTA placement within the confines of the root canal is possible with the use of an internal matrix, against which MTA can be manually condensed. With further evaluation, this technique can help in providing consistent success during apical plug procedures, overcoming some of the difficulties being faced with current materials and techniques. n „ Conclusion Q ui The internal matrix technique involves placing a biodegradable material as a barrier, preventing the different reparative materials from extruding into the periapical tissues. The use of such matrices as calcium sulphate or calcium hydroxide has been advocated in the past for the repair of furcal perforations. When used in vitro to repair furcational defects, ACS significantly improved the sealing ability of MTA6. ACS has also been used as an internal matrix in the past16,17. The current case series proposes a repeatable technique of MTA placement and hand condensation against an internal matrix. ACS is being researched extensively for its role as a carrier for bone morphogenetic protein18 but in the current study it is used primarily as a barrier for MTA to be condensed against, besides possibly providing a scaffold for faster deposition of bone in the periapical area19. One of the important considerations while using ACS is that it should not be used in infected wounds. Similarly, the placement of MTA in a single visit without disinfection of the root canal is not advisable, because the acidic environment of the necrotic pulp tissue may hamper its setting20. Thus, the role of calcium hydroxide as a canal disinfectant is indispensable. Even though calcium hydroxide was placed in the canals for 2 weeks in the current study, two cases reported with immediate postoperative pain, a possible indicator that the periapical inflammation had not subsided completely. As such, the placement of calcium hydroxide for a longer duration of up to 4 weeks2, but not beyond21, should be considered. pyrig No Co t fo rP ub „ References lica 1. Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comti parative study of white and gray MTA simulating te a one or on ss e n c e two step apical barrier technique. J Endod 2004;30:876–879. fo r Vanka et al ot 266 „ Andreasen JO, Munksgaard EC, Bakland LK. Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or MTA. Dent Traumatol 2006;22:154–156. Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod 2005;31:117–119. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J 2007;40:186–197. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. Int Endod J 2007;40:478–484. Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness of materials used in furcation perforation in vitro. Int Dent J 2005;55:133–141. Nolla, C. The development of permanent teeth. J Dent Child 1960;27:254–266. de Leimburg ML, Angeretti A, Ceruti P, Lendini M, Pasqualini D, Berutti E. MTA obturation of pulpless teeth with open apices: bacterial leakage as detected by polymerase chain reaction assay. J Endod 2004;30:883–886. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002;18:217–221. Maroto M, Barbería E, Planells P, Vera V. Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA). Dent Traumatol 2003;19:165–169. Aminoshariae A, Hartwell GR, Moon PC. Placement of mineral trioxide aggregate using two different techniques. J Endod 2003;29:679–682. Yeung P, Liewehr FR, Moon PC. A quantitative comparison of the fill density of MTA produced by two placement techniques. J Endod 2006;32:456–459. Xu Q, Lin JQ, Huang F, Liu JW. Treatment of teeth with open apices using mineral trioxide aggregate as apical barrier. Shanghai Kou Qiang Xue 2006;15:7–10. Erdem AP, Sepet E. Mineral trioxide aggregate for obturation of maxillary central incisors with necrotic pulp and open apices. Dent Traumatol 2008;24:e38–41. Holland R, Mazuqueli L, de Souza V, Murata SS, Dezan Júnior E, Suzuki P. Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs’ teeth after root canal filling with mineral trioxide aggregate. J Endod 2007;33:693–697. Bargholz C. Perforation repair with mineral trioxide aggregate: a modified matrix concept. Int Endod J 2005;38:59–69. De-Deus G, Coutinho-Filho T. The use of white Portland cement as an apical plug in a tooth with a necrotic pulp and wide-open apex: a case report. Int Endod J 2007;40:653–660. Visser R, Arrabal PM, Becerra J, Rinas U, Cifuentes M. The effect of an rhBMP-2 absorbable collagen spongetargeted system on bone formation in vivo. Biomaterials 2009;30:2032–2037. Nguyen PD, Lin CD, Allori AC, et al. Scaffold-based rhBMP-2 therapy in a rat alveolar defect model: implications for human gingivoperiosteoplasty. Plast Reconstr Surg 2009;124:1829–1839. Lee YL, Lee BS, Lin FH, Lin CP. Effects of physiological environments on the hydration behaviour of mineral trioxide aggregate. Biomaterials 2004; 25:787–793. Estrela C, Estrela C R, Pécora J D. A study of the time necessary for calcium hydroxide to eliminate microorganisms in infected canals. J Appl Oral Sci 2003;11:133–137.