The Saudi Dental Journal (2012) 24, 55–59

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

MTA resorption and periradicular healing in an open-apex

incisor: A case report
a,* b
Saeed Asgary , Sara Ehsani

a
Iranian Center for Endodontic Research, Dental Research Center, Dental School, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
b
Dental Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Received 7 April 2011; revised 21 June 2011; accepted 18 August 2011

Available online 27 August 2011

KEYWORDS Abstract This case report describes the periradicular healing and resorption of an unintentional
Extrusion; extrusion of mineral trioxide aggregate (MTA) in an open-apex central incisor. A 22-year old
Healing; female with a symptomatic open-apex right maxillary central incisor associated with a periradicular
MTA; lesion was referred for evaluation and treatment. After chemomechanical debridement, the apical
Periradicular lesion; third of the root canal was filled with MTA to create an apical plug. Postoperative radiographs
Resorption showed the extrusion of MTA into the periradicular lesion. The tooth was then restored with a post
and crown. At the 2-year follow-up, the tooth was asymptomatic and radiographs revealed com-
plete healing of the periradicular area. At the 7-year follow-up, complete resorption of the extruded
MTA was evident. The results of this case study indicate that complete resorption of extruded MTA
is possible in the long term; however, the extrusion of MTA in open-apex tooth should still be
avoided.
ª 2011 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction

In teeth with open apices, the absence of normal apical constric-

* Corresponding author. Address: Iranian Center for Endodontic
Research, Shahid Beheshti Dental School, Evin, 1983963113, Tehran,
Iran. Tel.: +98 21 22405648; fax: +98 21 22427753.
E-mail address: saasgary@yahoo.com (S. Asgary).
1013-9052 ª 2011 King Saud University. Production and hosting by
Elsevier B.V. All rights reserved.
Peer review under responsibility of King Saud University.
doi:10.1016/j.sdentj.2011.08.001
Production and hosting by Elsevier
tion of the root canal complicates the management of root filling
materials (Pitts et al., 1984). Occasionally, the filling materials
extrude beyond the apex into the periradicular tissues. Overfil-
lings have a harmful effect on the prognosis for RCT; teeth filled
within 0–2 mm from the apex have a 94% success rate, which
falls to 76% if the teeth are overfilled ( Sjögren et al., 1990).
The use of biomaterials has been advocated to encourage peri-
apical regeneration and prevent complications if overfilling oc-
curs (Tahan et al., 2010).
Apexification with calcium hydroxide (CH) was the treat-
ment of choice in necrotic open-apex teeth in the last decades
(Rafter, 2005). This method has been successful but the long-
term use of CH has several disadvantages, including multiple
56
visits by the patient, possible recontamination of the root-canal
system during the treatment period and increased brittleness of
the root dentin (Sheehy and Roberts, 1997; Andreasen et al.,
2002).
Mineral trioxide aggregate (MTA) has been proposed as an
ideal filler as it can create an apical plug at the end of the root-
canal system, thus preventing the extrusion of filling materials
(Shabahang and Torabinejad, 2000). According to the manufac-
turer, MTA is a mechanical mixture of three powder ingredients:
Portland cement, bismuth oxide, and gypsum (ProRoot MTA,
product literature); lime (CaO), silica (SiO2), and bismuth oxide
(Bi2O3) are the three main oxides in the cement (Asgary et al.,
2009a). When mixed with sterile water, hydration reaction oc-
curs and MTA sets (Camilleri, 2007). The pH of MTA increases
from 10 to 12.5 3 h after mixing (Dammaschke et al., 2005). It
is assumed that in a high pH environment the calcium ions that
are released from MTA react with phosphates in the tissue fluid
to form hydroxyapatite (Sarkar et al., 2005; Asgary et al.,
2009b). This would explain the favorable sealing ability and bio-
compatibility (Parirokh and Torabinejad, 2010). MTA has
shown potential as a root-end filling material (Bates et al.,
1996; Asgary et al., 2008b), for the repair of root/furcal perfora-
tions sealing material (Mente et al., 2010; Samiee et al., 2009), as
well as a direct pulp capping agent after pulp exposure (Asgary
et al., 2006; Asgary et al., 2008a), pulpotomy agent (Eghbal
et al., 2009; Ng and Messer, 2008; Tabarsi et al., 2010), and
root-canal filling in teeth with complete (Holland et al., 1999a)
and incomplete root development (Shabahang et al., 1999). De-
spite its outstanding tissue biocompatibility, MTA has several
disadvantages, which include a delayed setting time, poor han-
dling characteristics, unpredictable antibacterial effects, and
high costs (Parirokh and Torabinejad, 2010; Asgary and Kam-
rani, 2008).
The following case report describes periradicular healing
and the complete resorption of unintentionally extruded
MTA in an open-apex maxillary right central incisor with a
periradicular lesion.
2. Case report
A 22-year old female with a symptomatic maxillary right central
incisor was seen at a private clinic (Asgary Endodontic Clinic,
Tehran, Iran). The patient reported that the incisor had been
root-treated 4 years previously, and the tooth was restored with
porcelain-fused metal bond crowns. The medical history was
non-significant. Extra-oral evaluation revealed normal soft tis-
sue structures with no apparent pathosis. Intra-oral examina-
tion revealed a local swelling in the apical area of the tooth,
class II tooth mobility and tenderness to percussion.
Radiographic examination revealed periradicular radiolu-
cency surrounding the open-apex incisor; which was due to
persistent infection as a result of poor quality root-canal ther-
apy. Interestingly the metallic post spanned the entire length of
the tooth root. The apical seal was inadequate (Fig. 1A).
Once a diagnosis of localized acute apical abscess has been
made, the clinician has several treatment options available.
These include tooth extraction with or without replacement,
multiple visits for CH apexification and a MTA plug. The
patient had inadequate spare time and insisted on saving the
tooth and, therefore, the MTA apical plug was chosen. The
patient was informed of the possible risks of treatment as well
S. Asgary, S. Ehsani
as the long-term prognosis of the tooth. An informed consent
form signed by the patient was obtained.
Following the administration of local anesthesia and isola-
tion of the tooth, the crown in combination with the metallic
post/core was easily/totally removed using a crown remover.
Then, the entire root-canal fillings (luting agent and gutta-
percha) were simply exhausted using endodontic explorer/files.
The root-canal working length was established radiographi-
cally. The root canal was gently cleaned with manual instru-
ments using 5% NaOCl. Calcium hydroxide (CH) was
placed in the root canal for a 2-week interval (Fig. 1B).
At the 2-week postoperative appointment, the local swelling
had disappeared and no other symptoms were observed. The
CH was subsequently removed by rinsing with alternating solu-
tions of 5% NaOCl and 17% EDTA (Fig. 1C). A final rinse
with sterile normal saline solution was performed. The canal
was dried with sterilized paper points (Aryadent, Tehran, Iran).
The tooth-colored ProRoot MTA (Dentsply Tulsa, OK, USA)
was prepared according to the manufacturer’s instructions. As
hand condensation of MTA resulted in better adaptation and
fewer voids than the ultrasonic method, and there was no sig-
nificant difference in the results for any of 3–10 mm lengths
of MTA plug placed by the hand method (Aminoshariae
et al., 2003), MTA was applied to the apical portion of the canal
using a calibrated measured plugger.
MTA placement was assessed radiographically; it illustrated
appropriate obturation of the apical third of the root canal
(3 mm) in addition to a slight extrusion of MTA into the per-
iradicular lesion (Fig. 1D). A sterile cotton pellet moistened
with water was placed over the material within the root canal
and the access cavity was sealed temporarily.
At the following appointment, the cotton pellet was removed
and the setting reaction of MTA was evaluated. A new cast
metallic post-core was prepared and cemented with glass iono-
mer cement (GC International Corp., Tokyo, Japan). The tooth
was then restored with a porcelain-fused metal bond crown.
Clinical examination performed at the 2-year follow-up vis-
it revealed adequate clinical function, the absence of pain and
tenderness to percussion or palpation, as well as the absence of
mobility and sign or symptoms of inflammation or infection;
moreover, radiography displayed the re-establishment of the
PDL and lamina dura (Fig. 1E).
At the 7-year follow-up appointment, there were no clinical
signs or symptoms. Remarkably, the radiographs displayed
complete resorption of the extruded MTA (Fig. 1F).
3. Discussion
In the present case, the 2-year follow-up evaluation revealed an
excellent treatment outcome with regeneration of the periradic-
ular tissue. This outcome is comparable with similar previously
reported cases of successful MTA apical plug procedures in ne-
crotic teeth that had open apices and periradicular lesions
(Giuliani et al., 2002; Maroto et al., 2003; Pace et al., 2007; Ta-
han et al., 2010). In such teeth, the outcome of conventional
gutta-percha fillings would be doubtful, while MTA has the po-
tential to provide an effective seal by the intracanal delivery
technique with predictable results (de Leimburg et al., 2004;
Hachmeister et al., 2002). Furthermore, several studies have
confirmed the superior biocompatibility of MTA as a root-end
filling material for the periodontal tissues and the regeneration
MTA resorption and periradicular healing in an open-apex incisor: A case report 57

Figure 1 (A) Pre-treatment periapical radiograph of tooth #8 with an unsuccessful root-canal therapy; (B) calcium hydroxide placement
for two weeks; (C) after calcium hydroxide removal prior apical plug insertion; (D) postoperative periapical radiograph after MTA
placement shows material extrusion into the periradicular tissues; (E) hard tissue formation and remarkable healing of the periradicular
tissues after 2 years. Note: the unintended extrusion of filling materials in tooth #7. (F) 7 years radiographic examination revealed
complete regeneration of periradicular tissues and absorption of the overfilled materials in both teeth.

of periradicular tissues to an almost normal condition (Tora-
binejad et al., 1995; Asgary et al., 2010).
In order to limit bacterial infection, short intracanal CH
medication was placed within the canal. Researchers showed
that the remains of CH on the dentinal walls had no significant
effect on MTA microleakage (Hachmeister et al., 2002). In
contrast, others suggested that the remnants of CH react to
form calcium carbonate, and interfere with the seal (Porkaew
et al., 1990). In the present case, complete removal of CH from
the canal walls was accomplished by alternate irrigation with
5% NaOCl and 17% EDTA (Calt and Serper, 1999). Others
have suggested that the combination of MTA and CH in
apexification procedures may favorably influence the regener-
ation of the periodontium (Ham et al., 2005).
In teeth with necrotic pulps and open apices, the absence of
the apical constriction complicates the adaptation of MTA to
the root canal. A hand condensation technique was used in this
current case to overcome this difficulty; this technique resulted
in improved adaptation and fewer voids than ultrasonic
compaction (Aminoshariae et al., 2003). Due to the physical
and handling properties of MTA (Ng and Messer, 2008; As-
gary et al., 2008c; Vizgirda et al., 2004), this material is more
likely to extrude apically in an open apex. When extruded
root-canal filling material contacts the periradicular tissues, a
range of reactions can occur, such as mild to severe inflamma-
tion, allergic reactions, and neurotoxic effects (Seltzer et al.,
1973; Serper et al., 1998). Gutta-percha, CH, and sealers that
contain eugenol/paraformaldehyde are the most common
materials associated with these complications (Seltzer et al.,
1973; Serper et al., 1998; Nitzan et al., 1983; Orucoglu and
Cobankara, 2008). Conversely, the extrusion of the MTA
root-canal filling biomaterial from a necrotic open-apex tooth
into a periradicular lesion does not produce complications (Ta-
han et al., 2010), which concurs with our finding. Low cytotox-
icity and the induction of mineralization are two desirable
properties of MTA that may explain the bioregenerative and
biocompatibility of this biomaterial (Mente et al., 2010; Sa-
miee et al., 2009; Eghbal et al., 2009; Tabarsi et al., 2010; Ng
and Messer, 2008; Asgary et al., 2008a; Holland et al.,
1999a; Shabahang et al., 1999).
The remarkable finding in this study was the complete
resorption of extruded MTA after 7 years. Although the
degree of solubility of MTA is debatable, the endodontic liter-
ature supports a relationship between time and calcium ion
58
release from MTA (Maeda et al., 2010; Amini Ghazvini et al.,
2009). Increased solubility has been reported in a long-term
study (Fridland and Rosado, 2005). On the other hand, the
powder/water ratio might influence the solubility. Higher
water to powder ratios increased MTA porosity and solubility
(Fridland and Rosado, 2003). Investigators have reported that
using higher water ratios would increase calcium release from
MTA. This condition can occur during a direct contact
between extruded MTA and body tissue fluids, which may
be partially responsible for MTA resorption.
Bismuth oxide, an insoluble radiopacifier, cannot be
resorbed in this way and, therefore, the aforementioned mecha-
nism of action is not applicable to this component. The aseptic
loosening of implant components is a common and important
complication of both cemented and uncemented prosthetic joint
replacements in the field of orthopedics. Wear particles derived
from organic polymers and metal implant biomaterials are com-
monly found within macrophages between loose implant com-
ponents and the host bone that is undergoing resorption. It
has also been shown that all biomaterial particle-containing,
foreign-body macrophages differentiate into osteoclastic cells
(Sabokbar et al., 1998). These cells are known to be capable of
phagocytosis of inert particles. Other researchers have demon-
strated that osteoclasts are capable of the phagocytosis of an ex-
tended size range of particles, including particles of polymeric
and metallic biomaterials, after which they remain fully func-
tional (Wang et al., 1997a,b). We postulate that this mechanism
of action may be responsible for the normal bone remodeling
process that occurs over the long term (>7 years).
Another interesting aspect of the present case was that the
tooth showed apical closure of the root. Although some
researchers believe that the root sheath remains intact and
resumes its function once the source of inflammation/infection
has been eliminated, the exact mechanism of apical closure in
such cases remains unclear (Mohammadi, 2011). The produc-
tion of CH as a byproduct of the hydration reaction of MTA
has been demonstrated (Fridland and Rosado, 2003), whereby
MTA releases calcium and hydroxyl ions and promotes an
alkaline pH (Fridland and Rosado, 2005; Amini Ghazvini
et al., 2009). Recently, the biological basis for the favorable
properties of MTA has been attributed to the production of
hydroxyapatite as the principal mineral in teeth and bones.
Calcium ions that are released from MTA react with phos-
phates in the tissue fluid (Sarkar et al., 2005; Asgary et al.,
2009b). This assumption is supported by the presence of gran-
ulations found when MTA is used as a biocompatible end-
odontic material, which is similar to the calcite crystals
observed after the use of CH (Holland et al., 1999b). Further-
more, the deposition of cellular cementum adjacent to MTA as
a root-end filling has been demonstrated (Torabinejad et al.,
1995; Asgary et al., 2010).
4. Conclusion
This case report conducted a successful one-step apexification
procedure in a necrotic central incisor with MTA. The acci-
dentally extruded MTA caused no ill effects on healing at
the 2-year follow-up visit. At 7 years, the extruded MTA
was no longer present in the apical tissues and the preopera-
tive lesion had resolved with re-establishment of a normal
PDL space and lamina dura.
S. Asgary, S. Ehsani
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