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Management of a Perforating

Internal Resorptive Defect with

Mineral Trioxide Aggregate:

A Case Report

Ehsen Abdelmoumen*, Sonia Zouiten Skhiri**, Abdelatif Boughzela# * Post graduate student, Department of Conservative Dentistry and Endodontics , Faculty of Dentistry of

Monastir, Tunisia ** Professor ,Department of Conservative Dentistry and Endodontics, EPS FarhatHached-

Sousse, Tunisia #Professor, chief department of dental medicine, EPS FarhatHached-Sousse, Tunisia.

Address for correspondence: EhsenAbdelmoumen, Faculty of dentistry of Monastir , department of conservative dentistry and endodontics, Street Avicenne 5000 Monastir Telephone No.: +21698383315 Email: dr.ehsen@hotmail.fr Abstract : Internal root resorption is a chronic inflammatory process initiated within the pulp space with the loss of dentin along the

middle and apical thirds of the canal walls as a result of clastic activities and is generally found in teeth with previous history of trauma. It

is important to diagnose this condition and institute treatment as early as possible to improve the prognosis of such teeth. The use of

biocompatible materials like mineral trioxide aggregate (MTA) may improve the prognosis of teeth with root perforation. This paper

reports a clinical case of perforating internal root resorption treated surgically with MTA.

Keywords: calcium hydroxide, internal resorption, mineral trioxide aggregate, root perforation, surgery.

INTRODUCTION

Internal root resorption is a relatively rare

resorption of dentin which starts in the

pulpal cavity or in the root canal and

destroys surrounding dental hard tissues.

The initiating factor in internal root

resorption is thought to be trauma or

chronic pulpal inflammation, but other

etiological factors have also been

suggested like caries, pulpitis, plup

capping with calcium hydroxide, cracked

tooth, excessive heat generated during

restorative procedures on vital teeth,

orthodontic treatment (3,2,1,6,11)The

progression of the resorption phenomena

can cause the perforation of the root and

the tooth structure been compromised.

(1,2, 3, 5, 6, 7).Clinically, internal root

resorption is usually asymptomatic and is

detected coincidentally through routine

radiographs or by the clinical sign of the

crown with pinkish color known as 'pink

spot' occurs late, when integrity of crow

has been compromised.(1, 2, 3, 5, 6, 7,9).

Radiographic examination usually reveals a

fairly rounded uniform radiolucent area. It

appears as an expansion of the pulp chamber

or canal and pulp chamber.(1,4,6,7)

The prognosis for treatment of small lesions

of internal resorption is good.

However, if the tooth structure is greatly

weakened and perforation has occurred, the

prognosis is poor and tooth extraction must

be considered.

After considering the differential diagnosis,

including external root resorption, treatment

ust aim at complete extirpation of the pulp

CASE REPORT

Abdelmoumen E et al

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which stops the internal resorptio

in an attempt to prevent further l

tissue.

The mineral trioxide aggregate (

proposed by Torabinejad et al an

used in several applications. It's

as a favorable perforation repair

with its superior sealing ability,

biocompatibility, fibroblastic stim

and antimicrobial activity becom

weak.(3)

Histopathologically it is characte

osteoclastic activity and the pres

lacunae which may be filled in b

tissue, presence of multinucleate

or dentinoclasts. The pulp is usu

chnonicallyinflammed and meta

pulp may occur.(6)

Case report:

A 48 years- old female patient co

department of Conservative Den

Endodontics of University Hosp

FarhatHached -Sousse Tunisia w

complaint of a fistula related to t

The patient reported a history of

trauma at the age of 30 at the ant

and at that time tooth 11 and 21

crowned. The tooth was treated p

by another praticien.

Clinical examination revealed th

of fistula. Tooth 22 respond nega

pulp vitality test with discomfort

percussion.(Fig.1)

Figure 1: fistula reperated with Gutta

IJRD

tion process,

r loss of hard

e (MTA) was

and has been

t's considered

ir material

y,

timulation,

ome too

cterized by an

resence of

by osteoid

ated giant cells

sually

taplasia of

t consulted the

entistry and

spital of

with the chef

o tooth 22.

of dental

anterior region

1 were

d previously

the presence

egatively to

ort on

ttapercha

Radiographic examinat

radiolucency in the mid

canal, an enlargement o

ligament space with lat

(sign of periodontal co

Figure 2: Preoperative rad

perforating internal resorpt

Postoperative radiograph s

obturation.

The diagnosis highligh

fistulizingabcsess with

root resorption.

The prognosis of the to

the extension and lengt

But cooperation and th

patient to keep her toot

it.

After isolation of the to

dam ,the access cavity

working lenght was de

images. The canal was

Heroshaper®system( M

France) and irrigated w

hypochlorite with the p

the necrosis tissues of t

resorption area. Subseq

hydroxide was placed a

of intracanal medicatio

environment, remove r

and control bleeding at

After 10 days, the root

and irrigated to remove

ISSUE 3, 2013

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nation revealed an oval

iddle third of the root

t of the periodontal

latero-radicular lesions

communication). (Fig.2)

adiograph showing a

rption lesion and

h showing the canal

ghted that toot 22 had a

ith a perforating internal

tooth was reserved for

gth of the perforation.

the intense desire of the

oth motivated us to treat

tooth with a rubber

ty was rectified and the

determined by x-ray

as prepared with

( Micro Mega-Besançon,

with 2,5% sodium

e purpose of dissolving

f the concavities in the

sequently, calcium

d as temporary dressing

tion to alkalinize the

e remaining pulp tissue

at the perforation.

ot canal was reentered

ve the temporary

Abdelmoumen E et al

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dressing. After this, it was filled

thermoplasticized gutta-percha

technique(E&Q Wireless™, Me

co, Korea).(Fig.3)

Figure 3: Localization of the perforat

remove of the granulation tissue.

An excess filling material was re

the coronal pulp chamber, which

promptly sealed with a provision

An immediate postoperative radi

taken , showing satisfactory fillin

root canal with material extravas

perforation area due to the comm

between the internal root resorp

periodontal ligament.

Surgical treatment was necessar

the seat and extension of the per

A flap that exposed the granulati

and the perforation was elevated

granulation tissue and the excess

percha was removed. (Fig.4) . M

(Micro-Mega,Besançon, France)

and firmly condensed by using p

(Fig.5).

Finally, the flap was sutured. At

visit, the patient reported no pos

pain or discomfort.

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ed with

eta biomed

ration and

removed from

ich was

ional cement.

adiograph was

lling of the

asations in the

munication

rption and the

sary because of

perforation.

ation tissue

ed. The

ess of gutta-

MM-MTA®

ce) was placed

g plugger

At the next

ostoperative

A eight-month follow u

tooth clinically asympt

radiographic signs of h

Figure 5: Use of the MTA

repair the perforation.

Figure 6: Clinical and rad

showing satisfactory result

Discussion:

Internal inflammatory

insidious pathological

within the pulp space a

loss of dentine.

Because resorptive def

asymptomatic, they are

by routine radiograph.(

Once internal root reso

diagnosed, the clinician

decision on the progno

tooth is deemed restora

reasonable prognosis, r

must be considered, aim

cellular activity respon

resorptive activity.(Tro

The endodontic treatme

internal root resorption

the difficulty in removi

resorption cavity(8).

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up demonstrated a

ptomatic with

f healing .(Fig.6)

A as a suitable material to

adiographic follow-up

ults.

y root resorption is an

al process, initiated

e and associated with

efects are often

are usually recognized

h.(4,10,11)

sorption has been

ian must make a

nosis of the tooth. If the

orable and has a

s, root canal treatment

aiming to arrest the

onsible for the

rope 2002)

ment of teeth with

on is complicated due to

oving the tissue of the

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However, the use of ultrasonic instruments

to agitate the irrigant (sodium hypochlorite)

has been shown to improve the removal of

necrotic debris and biofilm from inaccessible

areas of the root canal. Complementing the

action of the sodium hypochlorite , we use

the intracanal medication with calcium

hydroxide for a prolonged period.(8,9) The

use of calcium hydroxide-based sealer as an

antibacterial medicament would improve

disinfection of the inaccessible root

resorption defects, allow the alkalinity of the

environment , control periodontal bleeding

and prevent a resorption recurrence. (5,11)

The root canal treatment is followed by

obturation of the disinfected canal with an

appropriate root-filling material to prevent it

from reinfection. The internal root resorption

defects can be difficult to obturate

adequately. According to Culbreath et al. (

2000), the treatment for internal resorption

can include several materials such as gutta-

percha, zinc oxide eugenol, glass ionomer

cement, super EBA, amalgam alloy.

However, these materials do not provide

strength to the tooth structure and may be

responsible for considerable tooth

discoloration. Gencoglu et al, Goldman et al,

concluded that the ObturaII thermoplastic

gutta-percha technique performed

statistically better in obturating resorptive

defects than cold lateral condensation,

Thermafil and a hybrid

technique.(1,3,7,10,11)

Actually, In situation when the root wall has

been perforated , mineral trioxide

aggregate(MTA) should be considered the

material of choice to seal the perforation.

The indication is due to the fact that the

biocompatibility of MTA, and its sealing

properties in the presence of moisture and

even blood are important characteristics that

may result in greater success rates when used

for treating perforating internal root

resorption. (2, 5,11,9)

Conclusion:

Root resorption is a complex process.

Because it is asymptomatic, internal root

resorption needs an early detection and a

correct differential diagnosis for successful

management of the outcome of internal

resorption to prevent overweakening of the

remaining root structures and root

perforation.

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