JICDRO is a UGC approved journal (Journal no. 63927)

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ORIGINAL RESEARCH - BASIC AND CLINICAL
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 48-51

Mineral trioxide aggregate endodontic revascularization of nonvital anterior tooth


1 Department of Prosthodontics, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Maharashtra, India
2 Department of Dentistry, GMERS Medical College and Hospital, Gotri, Vadodara, Gujrat, India
3 Department of Prsothodontics and Crown & Bridge, Sharavathi Dental College and Hospital, Alkola, Shivamogga, Karnataka, India
4 Department of Dentistry, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
5 Department of Orthodontics and Dentofacial Orthopedics, NITTE (Deemed to be University) AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore, Karnataka, India
6 Department of Public Health Dentistry, Rural Dental College, PIMS, Loni, Maharashtra, India

Date of Submission03-Jun-2021
Date of Acceptance15-Jan-2022
Date of Web Publication4-Jul-2022

Correspondence Address:
Dr. Azhar Mohammed
Reader, Department of Orthodontics and Dentofacial Orthopedics, NITTE (Deemed to be University) AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_31_21

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   Abstract 


Context: Management of nonvital immature teeth requires careful management due to higher risk of root fracture. Aims: The aim of this study was done to evaluate the mineral trioxide aggregate (MTA) endodontic revascularization of permanent nonvital anterior tooth. Materials and Method: Forty patients in the age group of 18–30 years were included in the study. MTA revascularization procedure was done on immature necrotic upper anterior tooth with the presence or absence of periapical condition. The success was assessed with root lengthening, healing, apical closure, and dentinal wall thickness. Age group 18–23 years comprised 12 males and 10 females and 24–30 years had 10 males and 8 females. In 20% of cases, good healing and 80% had excellent healing were seen. Statistical Analysis Used: The obtained data were statistically evaluated using Mann–Whitney U-test for the comparison. Significance of the study was labeled at 0.05, highly significant at 0.01. Results: Mann–Whitney U-test showed a significant difference (P < 0.05). Twenty percent of teeth had fair, 30% had well, and 50% had excellent root lengthening. Apical closure was fair in 40%, good in 20%, and excellent in 40% teeth. Dentinal wall thickening was fair in 35%, good in 40%, and excellent in 25%. Conclusions: A successful revascularization procedure in nonvital permanent anterior teeth was seen both clinically and radiographically in terms of apical closure, greater healing, improved dentinal wall thickening, and root lengthening.

Keywords: Endodontic, mineral trioxide aggregate, nonvital tooth, revascularization


How to cite this article:
Sonkar TP, Pathak N, Shetty S, Rathi AJ, Mohammed A, Viragi P. Mineral trioxide aggregate endodontic revascularization of nonvital anterior tooth. J Int Clin Dent Res Organ 2022;14:48-51

How to cite this URL:
Sonkar TP, Pathak N, Shetty S, Rathi AJ, Mohammed A, Viragi P. Mineral trioxide aggregate endodontic revascularization of nonvital anterior tooth. J Int Clin Dent Res Organ [serial online] 2022 [cited 2022 Aug 7];14:48-51. Available from: https://www.jicdro.org/text.asp?2022/14/1/48/349754




   Introduction Top


Management of nonvital immature teeth requires careful management due to higher risk of root fracture with thin dentinal walls.[1] Apexification is the most frequently done for closure of immature root apex. Stem cells are totipotent cells which aid in the proliferation and production of cells, capable of differentiating into specialized cells.[2]

Embryonic stem cells and adult stem cells (a clonogenic cells) are two types of stem present commonly in apical papilla, pulp, and periodontal ligament cells help in pulp revascularization.[3] With differentiation, these cells induce the formation of dentin–pulp regeneration. Odontoblasts after differentiating from stem cells induce hard tissue apposition.[4]

Revascularization is the procedure for closure of immature nonvital tooth.[5] Mineral trioxide aggregate (MTA) and calcium hydroxide (Ca(OH)2) are the most commonly used material for apexification and apexogenesis (root closure in vital immature tooth). It is obvious that MTA induces apical barrier artificially and calcium hydroxide initiates apical calcified barrier.[6]

For immature nonvital teeth, the formation of a functional pulp–dentin complex is observed as substitute method to conventional apexification procedure to initiate root formation and to improve dentinal walls thickness. A study by Windley et al.[7] evaluated the benefits of antibiotic paste in the disinfection of immature dog teeth with apical periodontitis. It was determined that disinfection of canal, insertion of scaffold matrix for permitting tissue growth, and effective coronal seal against microorganism can be the deciding pints in endodontic revascularization of necrotic immature teeth.[8] The present study was done to evaluate the MTA endodontic revascularization in nonvital permanent anterior.


   Materials and Methods Top


Study design

The study was done in the department of conservative dentistry and endodontic after obtaining informed consent from participants and approval from institutional ethics committee. Forty subjects within age range 18–30 years of both genders were included for the study. Inclusion criteria were nonvital maxillary anterior tooth due to either trauma or caries, tooth with the presence or absence of periapical conditions with immature root apex. Exclusion criteria were subjects with mature root apex.

Methods

The teeth in all participants were cautiously clinically examined by endodontist. All procedures such as pulp vitality test, percussion test, palpation, depth of clinical pocket, and occurrence of sinus were done. Radiographic evaluation with digital intraoral radiographs was achieved such as the presence of radiographic bone loss and widening of periapical pathology.

All the procedures were with aseptic method. The procedure was done with access opening, determination of working length, followed by biomechanical preparation, and irrigation with sodium hypochlorite (NaOCl). Canals were dried with the help of sterile paper points, and then, triple antibiotic dressing paste was placed inside the canal.

Over root canal medicament, a cotton pellet was placed, followed by insertion of temporary filling material and Cavit. Subjects were re-evaluated after 2 weeks. Triple antibiotic dressing paste was removed if tooth found asymptomatic at recall visit, and canal was irrigated with 2.5% sodium hypochlorite and saline. Bleeding at the apical end was induced with 20K-file. Blood clot was formed which was verified after 15 min. Over the blood clot, MTA was placed, followed by cotton pellet and Cavit. Patients were recalled after 1 week and temporary filling material, Cavit, and cotton pellet were removed and composite resin was used to seal the coronal access. Patients were recalled at regular intervals on 6, 12, and 24 months to assess teeth clinically and radiographically. Signs of healing, apical closure increase in root length, and dentinal wall thickness were recorded.

Statistical analysis

The obtained data were statistically evaluated using Mann–Whitney U-test for the comparison. Significance of the study was labeled at 0.05, highly significant at 0.01.


   Results Top


The study consisted of forty patients in an age group 18–23 years comprised 12 males and 10 females and 24–30 years had 10 males and 8 females. There was good healing in 20% cases, and excellent healing in 80% cases. Mann–Whitney U-test showed significant variation (P < 0.05) [Table 1]. Twenty percent of teeth had fair, 30% had good, and 50% had excellent root lengthening. Mann–Whitney U-test showed significant difference (P < 0.05) [Table 2]. Apical closure was fair in 40%, good in 20%, and excellent in 40% teeth. Mann–Whitney U-test showed significant difference (P < 0.05) [Table 3]. Dentinal wall thickening was fair in 35%, good in 40%, and excellent in 25%. A nonsignificant difference was obtained (P > 0.05) [Graph 1].
Table 1: Assessment of healing

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Table 2: Assessment of root lengthening

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Table 3: Assessment of apical closure

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   Discussion Top


Regenerative endodontic is widely used treatment option nowadays. Dentinal wall thickening and root lengthening are extensively seen with it as compared to apexification.[9] The occurrence of sufficient occlusal seal is possible with it, helping in inhibition of reinfection. Immature nonvital maxillary anterior tooth is not suitable for endodontic therapy due to their thin dentinal walls.[10] Artificial barrier of MTA offers superior results in terms of apical closure and root lengthening. Revascularization of immature, necrotic maxillary anterior teeth proved to be beneficial for regeneration of apical tissue to initiate apexogenesis.[11] In the present study, we attempted to assess endodontic revascularization of necrotic permanent anterior teeth with the help of MTA.

In this study, we enrolled thirty teeth which had 18 males and 12 females. Age group 15–25 years comprised ten males and seven females and 20–25 years had eight males and five females. El Ashiry et al. conducted a study on twenty patients for determining pulp revascularization process. MTA was used as material of choice. Patients were routinely recalled and found that in all cases, symptoms disappeared. After 2 weeks, three patients had no sinus. After 1 year, there was loss of periapical radiolucency around tooth. Within the span of 12–24 months, there were progressive increases in dentinal wall thickness, root length, and continued root development.[12]

We found good healing in 20% cases, and excellent healing in 80% cases. Twenty percent of teeth had fair, 30% had good, and 50% had excellent root lengthening. This can be explained by the fact that the blood clot serves as a matrix onto which vital cells from the periapical are seeded to re-establish pulp vascularity.[13]

In this study, it was observed that apical closure was fair in 40%, good in 20%, and excellent in 40% of teeth. Dentinal wall thickening was fair in 35%, good in 40%, and excellent in 25%. The concept of revascularization has been explained by numerous researchers. It is hypothesized that at apical end of the root canal, a small amount of vital pulp tissue containing dental pulp stem cells remains which retain tissue regeneration potential and can multiply into the newly formed blood clot matrix.[14] It has tendency for differentiation into odontoblasts and deposits tertiary or tubular dentin. MTA shows its antimicrobial effect against facultative bacteria.[15] MTA also leads to the formation of cemented bridges due to its osteoinductive capacity. It has the capacity of overgrowth of PDL fiber over its surface.[16]

The revascularization procedure is possible due to the presence of stem cells in the apical papilla of incompletely developed teeth.[17] The presence of collateral circulation at the apical papilla region promotes survival during the process of pulp necrosis. It also promotes the regeneration of pulpal tissues. In the presence of surviving epithelial cells from Hertwig's roots sheath, it may differentiate into primary odontoblasts to induce root formation completion.[18]

Ding et al. evaluated the effect of a pulpal revascularization procedure in 12 immature necrotic teeth with apical periodontitis. A tri antibiotic mix was used to disinfect the pulp for 1 week. MTA was placed. Patients exhibited complete root development, with a positive response to pulp testing.[19]

Taha et al. determined the efficacy of MTA complete pulpotomy with carious exposures in 52 molar teeth. Gray MTA was placed as the pulpotomy agent. Results of the study demonstrated that at the end of 1 year, an overall 100% clinical and 97.5% radiographic success and at 3 years, 92.7% success rate was observed. All cases with periapical rarefaction showed improvement in the periapical index score. A hard tissue barrier was seen in five teeth radiographically and seven teeth showed canal narrowing.[20]

The limitation of the study is small sample size. Only MTA material was included in this study. Inclusion of more materials could have shown better results.


   Conclusions Top


A successful revascularization procedure in necrotic permanent anterior teeth was observed both clinically as well as radiographically in terms of apical closure, superior healing, dentinal wall thickening, and root lengthening.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zhang W, Yelick PC. Vital pulp therapy-current progress of dental pulp regeneration and revascularization. Int J Dent 2010;2010:856087.  Back to cited text no. 1
    
2.
Thomson A, Kahler B. Regenerative endodontics – Biologically-based treatment for immature permanent teeth: A case report and review of the literature. Aust Dent J 2010;55:446-52.  Back to cited text no. 2
    
3.
Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: A review and report of two cases with a new biomaterial. J Endod 2011;37:562-7.  Back to cited text no. 3
    
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Logani SA, Bhaskar U, Aggarwal V. Efficacy of revascularization to induce apexification/apexogenesis in infected, non- vital, immature teeth: A pilot clinical study. J Endod 2008;34:919-92.  Back to cited text no. 4
    
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Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 5
    
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Parirokh M, Torabinejad M, Dummer PM. Mineral trioxide aggregate and other bioactive endodontic cements: An updated overview – Part I: Vital pulp therapy. Int Endod J 2018;51:177-205.  Back to cited text no. 6
    
7.
Windley W 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43.  Back to cited text no. 7
    
8.
Torabinejad M, Watson TF, Pitt Ford TR. The sealing ability of a mineral trioxide aggregate as a retrograde root filling material. J Endod 1993;19:591-5.  Back to cited text no. 8
    
9.
Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study of white and gray mineral trioxide aggregate (MTA) simulating a one- or two-step apical barrier technique. J Endod 2004;30:876-9.  Back to cited text no. 9
    
10.
Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth. Dent Traumatol 2012;28:33-41.  Back to cited text no. 10
    
11.
Langer R, Vacanti JP. Tissue engineering. Science 1993;260:920-6.  Back to cited text no. 11
    
12.
El Ashiry EA, Farsi NM, Abuzeid ST, El Ashiry MM, Bahammam HA. Dental pulp revascularization of necrotic permanent teeth with immature apices. J Clin Pediatr Dent 2016;40:361-6.  Back to cited text no. 12
    
13.
Lin JC, Lu JX, Zeng Q, Zhao W, Li WQ, Ling JQ. Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis. J Formos Med Assoc 2016;115:523-30.  Back to cited text no. 13
    
14.
Damle SG, Bhattal H, Loomba A. Apexification of anterior teeth: A comparative evaluation of mineral trioxide aggregate and calcium hydroxide paste. J Clin Pediatr Dent 2012;36:263-8.  Back to cited text no. 14
    
15.
Bonte E, Beslot A, Boukpessi T, Lasfargues JJ. MTA versus Ca (OH) 2 in apexification of non-vital immature permanent teeth: A randomized clinical trial comparison. Clin Oral Investig 2015;19:1381-8.  Back to cited text no. 15
    
16.
Huang GT. A paradigm shift in endodontic management of immature teeth: Conservation of stem cells for regeneration. J Dent 2008;36:379-86.  Back to cited text no. 16
    
17.
Yang M. Regenerative endodontics: A new treatment modality for pulp regeneration. JSM Dent 2013;1:1011.  Back to cited text no. 17
    
18.
Prescott RS, Alsanea R, Fayad MI, Johnson BR, Wenckus CS, Hao J, et al. In vivo generation of dental pulp like tissue by using dental pulp stem cells, a collagen scaffold, and dentin matrix protein 1 after subcutaneous transplantation in mice. J Endod 2008;34:421-6.  Back to cited text no. 18
    
19.
Ding RY, Cheung GS, Chen, Yin X, Wang QQ, Zhang CF. Pulp revascularization of immature teeth with apical periodontitis: A clinical study. J Endod 2009;35:745-9.  Back to cited text no. 19
    
20.
Taha NA, Ahmad MB, Ghanim A. Assessment of Mineral Trioxide Aggregate pulpotomy in mature permanent teeth with carious exposures. Int Endod J 2017;50:117-25.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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