|Year : 2014 | Volume
| Issue : 4 | Page : 172-176
Treatment of inflammatory root resorption using mineral trioxide aggregate: A case report
Roohollah Sharifi1, Masoud Parirokh2, Seyed Amir Razavi Satvati3, Mahmoud Torabinejad4
1 Department of Endodontics, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Department of Oral and Dental Diseases Research Center, Kerman University of Medical Sciences, Kerman, Iran
3 Department of Endodontic, North Khorasan University of Medical Sciences, Bujnord, Iran
4 Department of Endodontic, Loma Linda Dental School, Loma Linda, USA
|Date of Web Publication||12-Sep-2014|
Prof. Masoud Parirokh
Oral and Dental Diseases Research Center, Kerman University of Medical Sciences, Kerman
Source of Support: None, Conflict of Interest: None
Introduction: This report presents a case to show inflammatory root resorption can be successfully treated by using mineral trioxide aggregate (MTA). Case Report: A central maxillary incisor of an eight-year-old boy was avulsed associated with crown fracture secondary to a fall. The tooth was stored in ice. Early attempts at pulpal revascularization of the replanted tooth proved unsuccessful. To stop inflammatory root resorption, long-term calcium hydroxide therapy was employed. Despite the use of calcium hydroxide, resorption continued. Subsequent to the failure of that treatment, MTA was used as a root canal filling material. At 20-month follow-up, the tooth was asymptomatic and had clinical signs of ankylosis but external inflammatory root resorption had stopped. Discussion: MTA may be considered as an alternative option for the treatment of continuous external inflammatory root resorption.
Keywords: Tooth avulsion, root resorption, mineral trioxide aggregate
|How to cite this article:|
Sharifi R, Parirokh M, Satvati SR, Torabinejad M. Treatment of inflammatory root resorption using mineral trioxide aggregate: A case report. Dent Hypotheses 2014;5:172-6
|How to cite this URL:|
Sharifi R, Parirokh M, Satvati SR, Torabinejad M. Treatment of inflammatory root resorption using mineral trioxide aggregate: A case report. Dent Hypotheses [serial online] 2014 [cited 2019 Oct 15];5:172-6. Available from: http://www.dentalhypotheses.com/text.asp?2014/5/4/172/140610
| Introduction|| |
Tooth avulsion is a dental emergency that often affects the anterior teeth of children. The success of replantation depends on when and how this procedure is performed. , One of the most frequent complications after replantation is root resorption. When the root surface of the avulsed tooth is damaged, it becomes susceptible to root resorption.  The degree of resorption is dependent on the stage of root development, extra-alveolar tooth storage, and length of time the tooth is kept out of the alveolar socket. ,
The conventional therapy of dental injury in a tooth with incomplete root formation and root resorption includes the use of calcium hydroxide (CH) in an attempt to stop the inflammatory root resorption and formation of a hard tissue apical barrier, a process that requires several months. ,, Recently, mineral trioxide aggregate (MTA) has been suggested for use as a root canal filling material.  MTA is a mineral powder that consists of hydrophilic particles, whose principal components are calcium, silica, and bismuth in their oxide forms. The material has a pH of 12.5 and sets in the presence of moisture in approximately four hours.  MTA has good sealing ability, biocompatibility, and low cytotoxicity.  It has been used as the material of choice for vital pulp therapy, root-end filling, and perforation repair and as an apical barrier for teeth with necrotic pulp and open apices. 
The purpose of this case report is was to present a case of tooth replantation, which developed inflammatory root resorption and was treated with MTA as a root canal filling material.
| Case Report|| |
An eight-year-old boy was referred by a dentist to the postgraduate clinic of the Department of Endodontic, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran for continuing treatment of a traumatic injury to his permanent maxillary central incisor teeth after falling from the roof of his home two days prior to his visit. The permanent left maxillary central incisor was avulsed; the permanent right maxillary central incisor was extruded [Figure 1]a. In addition, both central incisors had suffered enamel-dentin crown fractures. The general dentist replanted the avulsed tooth, repositioned the extruded tooth, and splinted both, then covered the dentinal tubules with dycal and glass ionomer. According to the report of the boy's mother, the tooth had been stored in ice for 15 minutes before their arrival at the office of the general dentist.
|Figure 1: (a) Initial periapical radiograph revealing avulsion of the permanent maxillary left central incisor and extrusion of the permanent maxillary right central incisor (b) Periapical radiographic examination showed the immature open apices|
Click here to view
Radiographic examination of the teeth showed two central incisors with immature open apices [Figure 1]b. Both incisors were tender to percussion and did not respond to vitality tests. The mother and child were instructed about oral hygiene during this visit. Two weeks after trauma, the splint was removed and crown fractures of both teeth were restored with light cure resin composite. Because of the short extra-oral time and the presence of the open apex of the avulsed tooth, the clinical decision was made for follow-up awaiting revascularization.
Unfortunately, the patient failed to present as scheduled for a follow-up appointment two weeks after removing the splint. When he arrived two months later, external resorption of the left maxillary central incisor was observed [Figure 2]a. At this time, an attempt for apexification using long-term calcium hydroxide (CH) to arrest root resorption was initiated. After isolation of the teeth with a rubber dam, an access cavity was made using a sterile carbide bur. The root canal was instrumented, irrigated with 1.0% sodium hypochlorite, dried with paper points, and filled with CH powder (Golchai-Tehran-Iran) mixed with sterile normal saline (Samen, Mashhad, Iran) and condensed with a large hand plugger. Further follow-up appointments and changes of CH were carried out every 30 days after the first CH insertion. After three months, because of continuous root resorption [Figure 2]b, this procedure was stopped and the root canal was obturated with MTA (Tooth colored ProRoot MTA, Dentsply, Maillefer, Balleagues, Switzerland) [Figure 3].
|Figure 2: (a) Two months later, external resorption of left maxillary central incisor detected (b) Calcium hydroxide therapy could not stop resorption after three months|
Click here to view
|Figure 3: After three months, because of continuous root resorption, the root canal was obturated with MTA|
Click here to view
MTA was mixed with sterile water in a 3:1 powder-to-liquid ratio based on manufacturer's instruction. The filling of root canals was performed with an MTA carrier, and condensation was performed with the large end of extra large paper points. MTA was placed to a correct working length, and its condensation was checked by a periapical radiograph. After complete root canal obturation with MTA, a wet cotton pellet was placed over MTA, and the tooth was temporarily sealed with Coltosol (Asia Shimiee Teb, Tehran, Iran). Twenty-four hours later, after removal of the Coltosol and cotton pellet, the access cavity was restored with composite resin. Radiographic examinations six months after trauma revealed that the external inflammatory root resorption of the left central maxillary incisor had stopped. At this time, periapical radiolucency was observed around the apex of the right central maxillary incisor; root canal treatment was immediately initiated for this tooth. After cleaning and shaping of the root canal in this tooth, CH was placed in the canal for one week as an intracanal medication. After placing a 4-mm MTA plug and wet cotton pellet over it, the access cavity was filled with Coltosol. Twenty-four hours later, after removal of the Coltosol and cotton pellet, the coronal portion of the root canal was backfilled with gutta-percha and AH-26 (Dentsply De Trey, Konstanz, Germany) root canal sealer. The access cavity was then restored with composite resin. At 12 months after trauma, periapical lesion of right maxillary incisor was healed and left maxillary incisors showed normal radiographic appearance. At 20-month follow-up, both teeth were asymptomatic, the external inflammatory root resorption had stopped, and the apical radiolucency around the right central maxillary incisor had disappeared [Figure 4]. However, the signs of ankylosis were present in the left maxillary incisor.
|Figure 4: At 20-month follow-up, both teeth were asymptomatic, the external infl ammatory root resorption had stopped, and apical radiolucency disappeared|
Click here to view
| Discussion|| |
In the present case, inflammatory root resorption treated by MTA. At 20-month follow-up, the tooth was asymptomatic and had clinical signs of ankylosis but external inflammatory root resorption had stopped. Andreasen et al.  showed that periodontal ligament healing following replanted permanent incisors depends on the stage of root development, length of extra alveolar dry storage, and length of wet storage. In this case, storing the avulsed tooth in ice for 15 minutes may have adversely influenced the viability of the periodontal ligament. There is no available data on the effect of storing avulsed teeth in ice on viability of periodontal ligaments; however, ankylosis of this case may show an adverse effect of ice as a storage medium. Schwartz et al.  showed that in dry conditions, keeping avulsed teeth in very low temperatures (−18°C) adversely affects the periodontal ligament.
Ankylosis is the most common complication following reimplantation of an avulsed tooth.  Previous investigations reported that dry extra oral time for 10 minutes or longer is a likely cause of ankylosis. , Although ankylosis will eventually lead to failure of the replantation procedure, there are several reasons that encourage dentists to replant avulsed teeth with a presumably poor prognosis. These reasons can be listed as follows. ,,
No prospective clinical trial has evaluated the predictive factors for success and failure of avulsed teeth; preserving teeth despite progressive resorption, particularly in very young children, gives the dentist time to be prepared for permanent and definitive treatment; replantation offers psychological comfort to both the injured child and his/her parents following an accident, and it preserves alveolar bone for future implant insertion or fixed prosthesis.
A recent meta-analysis on removing pulp from the root canals in avulsed teeth concluded that the pulp should be extirpated within 10-14 days following avulsion to avoid inflammatory resorption.  In this case, pulp extirpation was performed two months after avulsion because of incomplete root formation and the possibility for revascularization of the tooth.
Andreasen et al.  have examined the factors that decrease the chance of pulpal revascularization. These factors include wet storage of the tooth for less than five minutes prior to replantation and extended extraalveolar dry storage prior to replantation of the avulsed tooth. In this case, storing the avulsed tooth in ice for 15 minutes may have adversely affected pulp vitality.
Petrovic et al.  demonstrated that early root canal treatment was beneficial for patients who failed to present at follow-up appointments. In fact, our intention for performing root canal therapy instead of long-term CH therapy was the patient's frequent failure to maintain follow-up and treatment appointments.
When a tooth is traumatized, the pulp can lose its blood supply. Although revascularization is possible, the canals often become infected. , An infected pulp predisposes a tooth to root resorption.  Root resorption is common, with a reported prevalence of 57-80%. ,,, In immature teeth, this process occurs rapidly because of the large dentinal tubules that allow penetration of bacterial irritants. , When radiographic signs of external resorption are observed, resorption could be arrested by endodontic therapy. ,, The use of CH has a high rate of success in cases of traumatized immature permanent teeth. ,, On the other hand, one negative aspect of the apexification with CH for extended periods is the possibility of increased root fracture. , The duration of the treatment, which is usually very long, depends on factors such as size of the apical opening. MTA has been reported as a filling material in traumatized immature permanent teeth. ,,
In this case, MTA was used to stop inflammatory root resorption, and it prevented the need for long-term CH therapy. Based on this case report, it appears that MTA should be considered for treatment of inflammatory root resorption in traumatized immature permanent teeth.
Although this case report presents a favourable outcome, further studies are encouraged to support the use of MTA to treat inflammatory root resorptions.
| Acknowledgment|| |
The authors would like to thank Dr. Jens Andreasen for his valuable input and review of this case report.
| References|| |
|1.||Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76-89. |
|2.||Andreasen L, Bodin I. Avulsed human teeth replanted within 15 min - a long-term clinical follow-up study. Endod Dent Traumatol 1990;6:37-42. |
|3.||Tronstad L. Root resorption - etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4:241-52. |
|4.||Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8. |
|5.||El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent 2006;28:248-53. |
|6.||Huang GT. Apexification: The beginning of its end. Int Endod J 2009;42:855-66. |
|7.||Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90. |
|8.||Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review- part I: chemical, physical, and antibacterial properties. J Endod 2010;36:16-27. |
|9.||Torabinejad M, Parirokh M. Mineral trioxide aggregate: A comprehensive literature review- part II. Leakage and biocompatibility investigations. J Endod 2010;36:190-202. |
|10.||Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review- part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-12. |
|11.||Schwartz O, Andreasen FM, Andreasen JO. Effects of temperature, storage time and media on periodontal and pulpal healing after replantation of incisors in monkeys. Dent Traumatol 2002;18:190-5. |
|12.||Barrett EJ, Kenny DJ. Avulsed permanent teeth: A review of the literature and treatment guidelines. Endod Dent Traumatol 1997;13:153-63. |
|13.||Duggal MS, Toumba KJ, Russell JL, Paterson SA. Replantation of avulsed permanent teeth with avital periodontal ligaments: Case report. Endod Dent Traumatol 1994;10:282-5. |
|14.||Andreasen JO, Malmgren B, Sae-Lim V, Bakland L. Tooth avulsion in children, to replant or not. A survey article. Endod Topics 2006;14:28-34. |
|15.||Malmgren B, Malmgren O, Andreasen JO. Alveolar bone development after decoronation of ankylosed teeth. Endod Topics 2006;14:35-40. |
|16.||Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part I: Timing of pulp extirpation. Dent Traumatol 2009;25:32-42. |
|17.||Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995;11:59-68. |
|18.||Petrovic B, Markovic D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26:52-9. |
|19.||Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod 1995;21:109-12. |
|20.||Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of Permanent Teeth. Dent Traumatol 2007;23:130-6. |
|21.||Donaldson M, Kinirons MJ. Factors affecting the time of onset of resorption in avulsed and replanted incisor teeth in children. Dent Traumatol 2001;17:205-9. |
|22.||Al-Badri S, Kinirons M, Cole BO, Welbury RR. Factors affecting resorption in traumatically intruded permanent incisors in children. Dent Traumatol 2002;18:73-6. |
|23.||Kinirons MJ, Gregg TA, Welbury RR, Cole BO. Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption. Br Dent J 2000;189:263-6. |
|24.||Gonda F, Nagase M, Ghen RB, Yakata H, Nakajima T. Replantation: An analysis of 29 teeth. Oral Surg Oral Med Oral Pathol 1990;70:650-5. |
|25.||Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. Na epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:83-9. |
|26.||Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann JL, Oikarinen K, et al. International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001;17:145-8. |
|27.||Humphrey JM, Kenny DJ, Barret EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dent Traumatol 2003;16:266-73. |
|28.||Leonardo MR, Silva LA, Leonardo RT, Utrilla LS, Assed S. Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. J Endod 1993;19:348-52. |
|29.||Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta-percha. A retrospective clinical study. Endod Dent Traumatol 1992;8:45-55. |
|30.||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;22:154-6. |
|31.||Doyon GE, Dumsha T, Von Fraunhofer JA. Fracture resistance of human root dentin exposed to intracanal calcium hydroxide. J Endod 2005;31:895-7. |
|32.||Maroto M, Barberia E, Planells P, Vera V. Treatment of a nonvital immature incisor with mineral trioxide aggregate (MTA). Dent Traumatol 2003;19:165-9. |
|33.||Villa P, Fernandez R. Apexification of a replanted tooth using mineral trioxide aggregate. Dent Traumatol 2005;21:306-8. |
|34.||Felippe WT, Felippe MC, Rocha MJ. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J 2006;39:2-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]