case report

the use of mtA in the treatment of cervical root

perforation: case report

Jefferson J. C. mArion1
Thaís Mageste duQue2
Tatiane Silveira sAntos3
Frederico Campos mAnHães4

AbstrAct perforation was sealed with MTA because this material is

capable of forming mineralized tissue due to its sealing abil-
Objective: The aim of this study was to report the treat- ity, biocompatibility and alkalinity. In addition, the humidity
ment of a tooth with cervical root perforation caused present in the periodontal tissues can provide the necessary
during endodontic treatment. Methods: The patient at- means to adapt the MTA on the walls of the perforation
tended the endodontist’s office with painful symptoms and its setting expansion, justifying its use in this case as
resulting from a cervical root perforation exposed to the it is a case of cervical perforation, a difficult site to control
oral cavity. The endodontic treatment was performed humidity. Conclusion: The authors concluded that MTA
in multiple sessions using the dressing with calcium hy- is an excellent material for sealing cervical root perforation.
droxide and propylene glycol, in order to aid the decon-
tamination of the root canal and the perforation. The root Keywords: Root perforation. MTA. Calcium hydroxide.

How to cite this article: Marion JJC, Duque TM, Santos TS, Manhães FC. The » The authors report no commercial, proprietary or inancial interest in the prod-
use of MTA in the treatment of cervical root perforation: case report. Dental Press ucts or companies described in this article.
Endod. 2013 May-Aug;3(2):96-101.

» The patient displayed in this article previously approved the use of her facial
and intraoral photographs.

1
Doctorate student in Dental Clinic – Endodontics, State University of Campinas (UNICAMP). Received: March 12, 2013. Accepted: April 9, 2013.
Professor at the Department of Endodontics of ABOl and Ingá College (UNINGÁ).
2
Doctorate student in Dental Clinic – Endodontics, UNICAMP. Contact address: Jefferson José de Carvalho Marion
3
Graduated in Dentistry, UNINGÁ. Rua Néo Alves Martins, 3176 – 6º andar – sala 64 – Centro
4
Doctorate student in Dental Clinic – Endodontics UNICAMP. CEP: 87.013-060 – Maringá/PR — Brazil
Email: jefferson@jmarion.com.br / atendimento@jmarion.com.br

© 2013 Dental Press Endodontics 96 Dental Press Endod. 2013 May-Aug;3(2):96-101

 Marion JJC, Duque TM, Santos TS, Manhães FC

introduction Since then, several studies have been conducted

Root perforation is an accident in which an artificial with this material, analyzing its biocompatibility,4,5,6,7
opening is made, communicating the pulp chamber, the its physical, chemical and antimicrobial7 properties,
root canals and the periapical tissues. These accidents cytotoxicity,8 mutagenicity,9 pulp capping,10,11 analysis
usually occur due to iatrogenic causes including lack of of its sealing ability in retrograde fillings,12,13 marginal
knowledge of dental anatomy, calcification of the coro- adaptation in Scanning Electron Microscopy (SEM),
nary and cervical thirds, failure in radiographic analysis, and their use in root perforations.14-17
accentuated and misdirected abrasion as well as lack Still on the applications of MTA, it is also indicated
of pre bending of files in case of curved canals. Pathol- in cases of dental pulp conservative treatment,10,15,18
ogies such as cavities, internal and external resorption apixigenesis and apexification treatments19 as sealing
are factors that can also lead to such accidents. material to repair perforations resulting from commu-
Among the factors that affect root perforation nicating internal and external resorptions,20 as filling
prognosis are the location (cervical, middle and api- material for root canals of deciduous teeth21 and per-
cal thirds), the extent, presence or absence of peri- manent teeth,4,15,22 as repair material for vertical and
odontal pockets, the time between perforation and horizontal root fractures20, and as apical plug.
treatment, biological compatibility and sealing ability The ability of MTA to form mineralized tissue can
of the filling material.1 be attributed to its sealing ability, biocompatibility, al-
The faster the perforation is sealed, the more fa- kalinity or even other properties associated with it.20
vorable is the prognosis, especially when it involves The aim of the present study is to report the treat-
the cervical third and the pulp chamber. In this site, ment of a tooth with cervical radicular perforation
because it is closer to the oral cavity, bacterial con- caused during endodontic treatment and sealed with
tamination becomes easier and may establish an in- MTA. In addition, it aims at highlighting the advantag-
fection at the site, resulting in tooth loss if the repair es and disadvantages of employing and including this
is not quickly performed. However, for the middle material in the sealing of the perforation and also in
and apical third of the root, immediate sealing is not the maintenance of the dental element in the oral cav-
necessary if the area is adequately protected from ity, performing its esthetic and masticatory functions.
bacterial infiltration.2
Perforation can be diagnosed not only by sudden case report
onset of bleeding in the root canal or its persistence A 19-year-old patient was referred for endodontic
after the pulp tissue was removed, but also by clinical treatment of #43, in June, 2010. During the anam-
exploration, radiographic features showing the file in nesis, we found that there was no history of system-
the periodontium, examination of lateral lesion and ic disease, but the patient reported being allergic to
pin placed outside the long axis of the root.1 Paracetamol. With regard to her dental history, the pa-
For proper treatment, the perforation must be tient reported being under orthodontic treatment, and
sealed with a biocompatible material, capable of pro- that, due to a leakage in the restoration of #43, the
ducing a good seal with good physical properties, ra- patient was referred to a Dental Surgeon (DS) in order
diopaque, non-resorbable, easy to use and capable of to have the restoration exchanged. When the dentist
promoting osteogenesis and cementogenesis.3 started the restorative procedure, he informed the pa-
Given the quality and limitations of the materials tient that, due to the depth of the restoration, there
routinely used for the sealing of dental perforations, had been pulp exposure and, as a result, endodontic
other materials with characteristics that are similar to treatment would be necessary. After treatment had
the ideal sealing have been sought. With the purpose started, a perforation in the lateral root occurred in an
of filling these gaps and based on the technological attempt to find the root canal. From this time on, the
evolution of new materials, emerged in the 90s at the patient was referred to an endodontist who would seal
University of Loma Linda, California - USA, headed by the perforation and perform root canal treatment.
Professor Torabinejad, a group that developed a new During the intraoral clinical examination, it was ob-
cement called Mineral Trioxide Aggregate (MTA). served that #43 tooth presented open access cavity

© 2013 Dental Press Endodontics 97 Dental Press Endod. 2013 May-Aug;3(2):96-101

[ case report ] The use of MTA in the treatment of cervical root perforation: case report

without temporary restoration or endodontic dress- ing to the manufacturer’s instructions. The MTA was
ing, and with remaining carious tissue. In addition, it inserted with Paiva pressers and its final laying was
showed sensitivity to vertical and horizontal percussion carried out with cotton moistened with distilled water.
and absence of edema, sinus and tooth mobility. As for The MTA was inserted into the perforation with the
the thermic tests performed to check pulpal sensitivity, aid of a microscope and without exerting too much
the responses were also negative. pressure in order to prevent it from extravasating to
The periapical intraoral radiographic revealed the periodontal ligament.
excessive abrasion in the opening and in the cervi- An intraoral periapical radiograph was performed to
cal portion. Mesially, it was possible to see the path check the MTA laying in the perforation. Radiographi-
of the perforation. The image also had a radiopaque, cally, it was observed that the MTA did not extravasate
non-root, suggestive point indicating some type of re- to the periodontal ligament, momentarily excluding the
storative material (Fig 1A). After all tests and clinical possibility of surgical intervention for the case (Fig 1C).
examinations had been performed, the patient was di- The calcium-hydroxide-based intracanal medi-
agnosed with pulp necrosis. cation was applied for a period of three months
The patient was informed about the different and replaced every 45 days. After a period of four
treatment options, for both perforation and root months (October, 2010), the root canal was filled
canal. She chose to undergo endodontic treatment with gutta-percha point (Fig 2A) and, afterwards,
with closure of perforation being performed via the with calcium- hydroxide-based cement and second-
canal, preferably without surgery and application ary gutta-percha points by lateral condensation fol-
of intracanal medication. It was requested that the lowed by means of the vertical condensation tech-
orthodontist discontinued the application of orth- nique (Fig 2B). The pulp chamber was cleaned and
odontic force in this dental element until the end of temporarily sealed with sterile cotton pellet and
the endodontic treatment. Coltosol. The patient was asked to seek his dentist
From this moment on, the endodontic treatment in order to request that definitive restorative proce-
began, with local anesthesia and installation of rubber dures were performed.
dam. Improvements in the access cavity and removal Figure 2B shows the root canal filling, closure of
of carious tissue were carried out with a low-speed perforation with MTA and, in the mesial apical por-
bur. Biomechanical preparation of the root canal was tion, a secondary canal filling which was possible to
performed with manual endodontic files and irrigated be seen in Figure 2A.
with sodium hypochlorite at 2.5%. During the biome- After 10 months of endodontic treatment, the pa-
chanical preparation of the root canal, odontometry tient was asked to have the first follow up radiograph.
confirmation of the length of work and the apical pa- In the intraoral periapical radiograph, it was possible
tency were carried out (Fig 1B). After biomechanical to observe the integrity of the periapical region with
preparation of the root canal, it was dried with sterile continuous lamina dura clinically indicating periapical
paper points and then flooded with trisodium EDTA repair (Fig 2C).
at 17% for 3 minutes, with manual shaking for better
cleaning of the canal. After this period, the EDTA was discussion
removed and new irrigation was performed with so- The success of nonsurgical root perforation pro-
dium hypochlorite, followed by further drying of the cedures is directly related to the severity of the initial
root canal. Afterwards, a calcium-hydroxide-based damage caused to the periodontal tissue, the size and
intracanal medication with propylene glycol was ap- location of the perforation, sealing ability and bio-
plied in order to help in the decontamination of the compatibility of the filling material, and the presence
root canal and of the perforation. or absence of bacterial contamination.23
After 15 days, the intracanal medication was re- In this case report, the cervical perforation was
moved with the purpose of closing the perforation. not sealed immediately after it had occurred, as sug-
The material chosen for final closure of the perfora- gested by Sinai2 and Pitt Ford et al.13 The authors
tion was the white MTA-Angelus, manipulated accord- claim that the prognosis is much more favorable in

© 2013 Dental Press Endodontics 98 Dental Press Endod. 2013 May-Aug;3(2):96-101

 Marion JJC, Duque TM, Santos TS, Manhães FC

A b c
Figure 1. A) Initial radiograph: Excessive coronary abrasion, perforation path to mesial and radiopaque extraradicular point suggesting restorative material.
b) Conirmation of the working length. c) Settling of the MTA in the perforation.

A b c
Figure 2. A) Master cone and presence of accessory mesial canal. b) Final radiograph. c) 10-month follow up.

this case due to lack of bacterial contamination. completes the sanitation promoted by biomechani-
There was the option of treating the perforation and cal preparation. Applying the calcium-hydroxide-
the root canal by means of exchanging the intracanal based intracanal medication with propylene glycol,
medication and irrigating the site with sodium hypo- between sessions, in order to supplement disinfec-
chlorite, since the pulp chamber and the root canal tion and/or deposition of mineralized tissue through
were exposed to the oral cavity. Thus, based on the its antiseptic effect, bactericidal action and high pH,
studies carried out by Estrela and Estrela1 who claim corroborate Holland et al24, Holland et al.25,26
that fighting bacterial infection through copious ir- Estrela and Estrela1 have stated that there is inactiva-
rigation with sodium hypochlorite solution, due to its tion of enzymes intra and extra-cellular due to the re-
organic material and antibacterial solvent properties, lease of hydroxyl ions, which hinders bacterial survival.

© 2013 Dental Press Endodontics 99 Dental Press Endod. 2013 May-Aug;3(2):96-101

[ case report ] The use of MTA in the treatment of cervical root perforation: case report

However, studies carried out by Felippe et al27 claim In this case, MTA was also used because its radi-
that there is no advantage in exchanging the calcium opacity is superior to that of the dentin and bone tis-
hydroxide paste when treating contaminated canals sue, the IRM, Super Eba and gutta-percha, thus, provid-
and pulpless teeth. ing diagnostic observation, which makes it the material
The choice of propylene glycol as a carrier for the of choice.6 Moreover, studies carried out by Holland
calcium hydroxide is based on studies carried out by et al,26 of which aim was to explain the mechanism of
O’Neil28 which demonstrate that the substance has a inducing mineral formation of MTA, found that MTA
great capacity to solubilize organic materials. Addi- without calcium hydroxide in its composition is capa-
tionally, Seidenfeld and Hanzlik29 claim that the pro- ble of forming mineralized tissue due to the presence
pylene glycol has approximately the same density of of calcium oxide which forms calcium hydroxide when
water and causes no demonstrable cumulative effect. reacted with periapical tissues.
The propylene glycol antimicrobial activity for sys- The authors of this study agree with Marion37
temic use has been studied by Olitzky30 who reported about the difficulties of working with MTA and aque-
that concentrated solutions of this compound have ous carrier (distilled water) together, due to its initial
demonstrated germicidal efficiency and its use as a car- setting time and also its difficulty to be inserted, be-
rier can work in the prevention or treatment of bacterial cause when MTA is handled with this carrier, it seems
infection. Walkevar, Bhat;31 Thomas, Kotian and Bath32 to be little bondable and sandy.
reported that in addition to the fact that propylene gly- According to Namazikhah,38 it is important to em-
col has been well recognized as a carrier for medica- phasize that when the MTA is used in environments
tions, it has also been considered to be less cytotoxic with inflammation, its physicochemical properties may
than other carriers commonly used for intracanal medi- suffer some interferences, causing its acid pH to pre-
cations. Moreover, it presents antibacterial properties vent the MTA setting and reduce its strength and hard-
highly beneficial in endodontic treatment, although the ness. However, once the factors that initiate or perpet-
results found by Nakayama and Safavi33 showed that cal- uate the inflammatory process have been removed, as
cium hydroxide does not dissociate from propylene gly- in the case presented, the environment is able to return
col because it needs water to be dissociated. to normality within a short period of time.
In order to remove the smear layer, the EDTA at 17% Despite the advantages and limitations of the MTA,
was used for 3 minutes before the intracanal medication which have been previously mentioned, studies car-
was applied in all sessions as well as before final filling ried out by Balto,39 Holland et al,11 Juárez Broon et al,3
of the root canal, since several studies have demonstrat- showed that when analyzing the biological behavior of
ed that removal is achieved with the use of this drug.34,35 materials used in sealing root perforations, the MTA
After 15 days, the root perforation closure was has shown similar or less toxic behavior than the oth-
performed with MTA because, according to Torabi- ers. Therefore, MTA proves to have great ability of re-
nejad and Chivian,20 this material is capable of form- pair and the aforementioned information explains its
ing mineralized tissue due to its sealing ability, bio- use in the treatment of cervical root perforations.
compatibility, and alkalinity. Furthermore, according
to Sluyk et al17 the humidity present in periodontal conclusion
tissues can provide the necessary means for adapta- After being clinically applied, the MTA proved to
tion of MTA on the walls of the perforation and also be effective as a filling material of cervical root per-
for setting expansion,20,36 which explains its use in this foration, since after a 10-month follow-up, the tooth
case report, a case of cervical perforation in which continued to perform its primary functions, esthetic
humidity is difficult to control. and masticatory, in the oral cavity.

© 2013 Dental Press Endodontics 100 Dental Press Endod. 2013 May-Aug;3(2):96-101
 Marion JJC, Duque TM, Santos TS, Manhães FC

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© 2013 Dental Press Endodontics 101 Dental Press Endod. 2013 May-Aug;3(2):96-101