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Brazilian Journal of Dental Traumatology (2009) 1(2): 40-44

2009 Sociedade Brasileira de Traumatologia Dentaria
ISSN 2175-6155
http://www.sbtd.org.br/journal

MTA AS A FILLING MATERIAL IN INTERNAL ROOT RESORPTION

Georgiana Amaral1 , Renata Santiago Goncalves Kattenbach2 ,
Rivail Antonio Sergio Fidel3 and Sandra Rivera Fidel4
Received on July 20, 2009 / Accepted on August 3, 2009

ABSTRACT
Root resorption is a dental complication caused by dental trauma, surgical procedures, excessive pressure or irritation from bleaching agents
that can lead to dental loss. As mineral trioxide aggregate (MTA) has been indicated in the literature for the treatment of resorptions, the aim of
this paper is to present two internal root resorption case-reports using MTA as a root-filling material. Both cases resembled dental loss due to
the extensive destruction caused by an internal resorption associated with dental trauma. In an attempt to save them, the teeth were completely or
partially filled with white MTA (Angelus) and the 24 months follow-up showed favorable results.
Keywords: Dental trauma, root resorption, MTA.

Correspondence to: Georgiana Amaral

Rua Siqueira Campos 43/1102, Copacabana, 22231-070 Rio de Janeiro, RJ, Brazil. Phone: +55 21 2257-0680.
1 DDS, MSc, PhD, Substitute Professor, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E-mail: gamaral@globo.com
2 DDS, MSc, Professor of Endodontics Department, Estacio de Sa University, Rio de Janeiro, Brazil. E-mail: renatasgk@ig.com.br
3 DDS, MSc, PhD, Endodontics Department, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil. E-mail: rivailfidel@globo.com
4 DDS, MSc, PhD, Department of Integrated Clinical Procedures (ProClin), School of Dentistry, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
E-mail: sandrafidel@gmail.com

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GEORGIANA AMARAL, RENATA SANTIAGO GONCALVES KATTENBACH, RIVAIL ANTONIO SERGIO FIDEL and SANDRA RIVERA FIDEL

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INTRODUCTION

CASE REPORT

Root resorption is a dental complication that can lead to dental loss.

According to the cause and location this process admits different classifications. One of them includes the inflammatory root resorption
and can be noticed either on the internal surface of the root, that is,
predentin or on the external, the precementum. Dental trauma, surgical procedures, excessive pressure or irritation from bleaching agents
may cause both of them [1]. The internal resorption occurs in vital
teeth and can be coronal or radicular regardless the third. The internal resorption represents pathological issues of difficult treatment
and often is related to the pulpal inflammation and to the bacterial
invasion [7].
Since it is asymptomatic the diagnosis is commonly observed
through radiography and sometimes it can be discovered in an advanced stage that no guarantee of success is certain even in a well-done
treatment.
In order to control the internal root resorption it is necessary to
treat the root canal aiming to remove all the pulp tissue and achieve
a posterior better sealing. So as to avoid gaps and infection, thermoplasticized gutta-percha fillings are the most commonly techniques
used.
The mineral trioxide aggregate (MTA) was proposed by Torabinejad et al. [10] and has been indicated in the literature for the treatment of resorptions, specially when there is communication with the
periodontium; these are the communicating or perforating resorptions.
This indication is due to the fact that the MTA has properties such as
a good capacity of sealing, biocompatibility, radiopacity and also
because it does not suffer alterations in the presence of humidity.
Hsien et al. [5] reported a clinical case of an internal resorption
with buccal perforation in a maxillary central incisor. The apical third
was obturated with gutta-percha and the perforated lesion was repaired with MTA (Pro Root, Dentsply). The authors showed success
after 1 year of clinical and radiographic follow up. Sari & Sonmez [9]
published a study about the treatment of an internal resorption with
MTA in deciduos molar, with an accompaniment of 18 months. Based
on the obtained results the authors state that the MTA seems to be an
adequate material for the treatment of internal resorptions of deciduous
teeth too.
Very satisfactory results were also observed by Meire & De Moor
[8] when treating a perforating internal resorption in the mesial root
of a mandibulary second molar using MTA, observed a complete
recovery of the alveolar bone and periodontal ligament.
The purpose of this paper is to present two internal root resorption
case-reports using MTA as a root-filling material.

At first both cases resembled dental loss due to the extensive destruction caused by the internal resorption. With the respective acknowledgement of the patients, we purposed a protocol in an attempt to try
to maintain the tooth instead of replace them with a dental implant.
Aware of the risks, the patients accepted the challenge.

Brazilian Journal of Dental Traumatology, Vol. 1(2), 2009

Case 1
Patient male, aged 40, described an accident when he was 18 that
suggested an extrusive luxation of the left mandibular lateral incisor and canine. He himself repositioned the tooth and then went
to dentist and he was submitted to constantly clinical and radiographical supervision for some years. It seems that the pulp vitality was observed because no treatment was proposed at this time. Twenty two
years later he saw a fistula between the two teeth described and the
radiographic image showed an extensive destruction in the middle
third of the root of the canine (Fig. 1). With a gutta-percha point
it was possible to conclude that the internal root resorption was the
cause of the fistula (Fig. 2). It was agreed to try to treat the root
canal which it was difficult but possible. Cleaning and shaping was
performed using sodium hypochlorite at 2,5% and, after instrumentation, a calcium hydroxide dressing (with a viscous hydrosoluble
vehicle propylene glycol) was placed for 10 days to help healing
and check the filling of the resorption. The dressing was changed
and reapplied for 4 times till the complete filling occurred (Fig. 3).
Once this was achieved the obturation was performed. At first with
lateral condensation technique but as there was a large resorption in
the middle third of the root, two problems were observed:

 Figure 1 Initial internal root resorption (case 1).

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MTA AS A FILLING MATERIAL IN INTERNAL ROOT RESORPTION

a) the risk of over-filling (material extravasations, mainly cement)

due to the communication of the internal root resorption and
the periodontal ligament and;
b) the risk of not filling the resorption cavity completely.

 Figure 2 Gutta-percha point through the fistula.

follow-up showed signals of success lack of pain, fistula, mobility

and an image suggesting a bone with no lesion, that is, a favorable
periapical tissue response, with neoformation of cemental coverage
over MTA (Figs. 5 and 6).

 Figure 4 Root canal filled with gutta-percha (a) and white MTA (b).

 Figure 5 Two years follow-up.

 Figure 3 Calcium hydroxide dressing (case 1).

In an attempt to solve both of them, as the tooth has a coronal

structure that doesnt indicate a post, we decided to cut the guta-percha
with a heat carrier right below the resorption to fill the residual canal
space completely with white MTA (Angelus) (Fig. 4). The tooth was
sealed with a composite and maintained under clinical and radiographical control. After a month the fistula was healed and the two years

 Figure 6 Two years follow-up.

Brazilian Journal of Dental Traumatology, Vol. 1(2), 2009

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GEORGIANA AMARAL, RENATA SANTIAGO GONCALVES KATTENBACH, RIVAIL ANTONIO SERGIO FIDEL and SANDRA RIVERA FIDEL

Case 2
Patient male, aged 52, attended to a private office for evaluation and,
if possible, treatment of maxillary left canine. Clinically the tooth
showed up healthy, except for an alteration of color. The patient did
not present any symptoms but the radiographical exam showed a
large internal resorption, which was communicating with the periodontal ligament (Fig. 7). The coronary access was performed and the
chemical-mechanical preparation was difficult, the root canal system
was extensively irrigated with sodium hypochlorite at 2,5%. It was
used as an intracanal dressing a calcium hydroxide paste with a viscous hydrosoluble vehicle (polyethylene glycol) and iodoform. The
dressing was changed and reapplied for six weeks till the complete
filling of the pulpal cavity (Fig. 8).

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month, 6 months, 12 months and two years after the conclusion of the
case. It is worth to highlight that the patient had no pain, no increasing of volume, normal space on the periodontal ligament, no mobility
of the tooth and the radiography indicated that the resorption was
paralyzed (Fig. 10).

 Figure 9 Root canal filled in all its extension with white MTA.

 Figure 7 Initial internal root resorption (case 2).

 Figure 10 Two years follow-up.

DISCUSSION

 Figure 8 Calcium hydroxide dressing last change (case 2).

As the resorption was very extensive the canal was filled in all its
extension with white MTA (Angelus) (Fig. 9). The coronal cavity was
sealed with glass ionomer cement. Follow-up were perfomed after 1

Brazilian Journal of Dental Traumatology, Vol. 1(2), 2009

Sodium hypochlorite was chosen because it acts as an organic solvent. Dissolution of organic tissue can be verified in the saponification reaction when sodium hypochlorite is used. It has been observed
pulp tissue dissolution capacity, reporting that 5% sodium hypochlorite dissolves this tissue in 20 min to 2 h [2, 7]. Sodium hypochlorite is
recommended and used by the majority of dentists because this solution presents several important properties: antimicrobial effect, tissue
dissolution capacity and acceptable biologic compatibility [2].

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MTA AS A FILLING MATERIAL IN INTERNAL ROOT RESORPTION

Knowledge about the mechanisms of microbial aggression after

pulpal infection and therapeutic resources to neutralize them has motivated the study of substances with antimicrobial and biocompatible
characteristics [3]. Calcium hydroxide has been the most used and
studied intracanal dressing [2]. And is an excellent therapeutic option when the clinical situation requires the use of an intracanal dressing [3]. Well-conducted research about the characteristics of calcium
hydroxide, such as antimicrobial potential, physico-chemical aspects
and histocompatibility, gives credibility to the choice of this medication in several clinical situations. This medication presents two fundamental enzyme properties: the inhibition of bacterial enzymes leading to an antimicrobial effect and the activation of tissue enzymes leading to a mineralizing effect [3, 7]. The calcium hydroxide is indicated
as an important dressing trying to control the internal root resorption
[5, 7, 8, 9].
Nowadays literature proposed that the MTA should be maintained
in the root canal to fill the resorption area and the placement of MTA
for non-surgical treatment may be a good option, provided it is carefully placed and condensed on the resorption area.
In these cases, as inflammatory resorption was observed, MTA
was suggested to be applied. As both teeth had a good coronal structure and no post was indicated, it was possible to fill the middle and
coronal third of the root canal with this material. MTA showed a favorable periapical tissue response, with neoformation of cemental coverage
over MTA.
It is worthwhile to emphasize that, in spite of the excellent results
obtained with MTA in the treatment of perforations, the prognosis is
directly related to the lapse of time in which the perforation remained
without treatment, allowing contamination to occur. The same can be
applied to resorptions. Holland et al. [6] showed in their experiment
with dogs teeth, that when the lateral perforations were sealed with
MTA immediately, that the results were very favorable, having occurred the healing of the periodontal ligament. Not so favorable results
were observed when these perforations were sealed only after 7 days.
Or even in those cases when a calcium hydroxide based paste was
used and only after 14 days the perforations were sealed with MTA.
Favieri et al. [4] shared this idea and reported that MTA is a material that induces osteogenesis, being indicated as a retrograde filling
material due to its excellent marginal sealing and to the fact that it
stimulates the osteoblasts adherence.

CONCLUSIONS
On the basis of the review of literature and the clinical-radiographic
outcomes hereby presented, it might be concluded that (1) large internal root resorptions might and should be treated as in an attempt
to save the tooth. (2) Because of its characteristics of promoting excellent marginal sealing and stimulating osteoblastic adherence to the
root surface, MTA has been considered as a good filling material to be
used in communicating or perforating internal root resorption.
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[3] Estrela C, Pecora JD, Souza-neto MD, Estrela CRA & Bammann LL. 1999.
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[7] Lopes HP & Siqueira Junior JF. 2004. Endodontia: biologia e tecnica.
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Brazilian Journal of Dental Traumatology, Vol. 1(2), 2009