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Original Article
Article history: Objective: This study compares the apical seal and marginal adaptation of an MTA apical
Received 9 January 2014 plug in incisors obturated at three time intervals.
Received in revised form Method: Forty extracted central incisors were prepared with wide apex and divided into 4
3 August 2014 groups. The first group was obturated with gutta-percha and AH26 sealer, which served as
Accepted 11 September 2014 the positive control. The second group received an MTA apical plug and obturation
Available online xxx immediately. In the third and fourth group, obturation was delayed for 48 h and one week,
respectively. The apical seal was assessed by the dye penetration method and quantified
Keywords: using image analysis software. The marginal adaptation was studied using SEM.
Sealing ability Results: A significantly better apical seal was observed in the groups obturated after 48 h
Marginal adaptation and one week after MTA placement. The dye penetration did not show any significant
Mineral trioxide aggregate changes between the 48 h and one week groups. The marginal adaptation also showed a
Root-end filling materials minimal gap in the control and in samples with delayed obturation.
Apexification Conclusion: Based on this in vitro study, delaying obturation for 48 h after setting the MTA is
Obturation recommended for maximum apical sealing and marginal adaptation.
Copyright © 2014 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All
rights reserved.
* Corresponding author. College of Dentistry, King Saud University, Post Box: 60169, Riyadh 11545, Saudi Arabia. Fax: þ966 1 467 9017.
E-mail addresses: drsanil@gmail.com, Ksucod@gmail.com (S. Anil).
URL: http://www.perio.in
http://dx.doi.org/10.1016/j.pdj.2014.09.004
0917-2394/Copyright © 2014 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
2 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
managing such conditions. However, drawbacks such as cor- subtracting 1 mm from this measurement. The canals were
onal micro-leakage, tooth susceptibility to fracture, and mul- prepared with Gates Glidden Burs (Dentsply-Maillefer In-
tiple session treatment necessitate the development of an struments SA, Ballaigues, Switzerland) sizes 4, 3, and 2 for the
alternative method for managing the situation [3]. coronal third. The glide path was established by hand filling
Mineral trioxide aggregate (MTA) has been proposed as an with K-files sizes 15, 20, and 25 to a full working length.
alternative material for apexification by combining biocom- Instrumentation was completed with a high torque motor at
patibility and a bacteriostatic action with favorable sealing 300 rpm and 0.06 Taper Profile nickeletitanium rotary in-
ability when used to repair pulp chamber perforations or as a struments (Dentsply Tulsa Dental, Tulsa, Oklahoma, USA).
root-end filling material [2,4,5]. MTA is non-resorbable, has The apical third of the canals were instrumented up to size
good biocompatibility and low cytotoxicity, and promotes 120 to simulate open apex teeth. To simulate immature teeth,
dental pulp and periradicular tissue regeneration. MTA has a the canals were further enlarged using peeso reamers (No.
pH of 12.5 after setting, which is similar to the pH of calcium 1e6, Mani, Japan) with gentle pressure and under copious
hydroxide and this characteristic may impart some antimi- water spray until the No. 6 peeso could be passed beyond the
crobial properties [6]. Studies have shown that MTA stimu- apex [15]. Irrigation was carried out using 2 ml of 2.5% sodium
lates natural dentin repair at pulpal exposure sites during hypochlorite (NaOCl). After preparation, each canal was irri-
direct pulp capping [6]. Furthermore, MTA has relatively less gated with 5 ml of 17% EDTA (Calcinase EDTA, lege artis,
micro-leakage and can stimulate tissue regeneration, when it Dettenhausen, Germany) for 3 min to remove the smear layer,
is in direct contact with pulp and periradicular tissues [7]. followed by 2 ml of 2.5% sodium hypochlorite solution. The
MTA has been successfully used as an apical barrier in the final irrigation was performed with 5 ml of distilled water. The
treatment of teeth with necrotic pulps and open apexes canals were then dried with paper points.
[2,8e11]. The 40 prepared teeth were divided randomly into 4
Several studies have shown that MTA can be used for one groups.
visit apexification [12]. MTA provides scaffolding for the for-
mation of hard tissue and has the potential to provide a better Group 1: Obturated with gutta-percha and AH26 sealer.
biological seal. MTA apexification is a viable option for treat- Group 2: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
ing immature teeth with necrotic pulps and should be OK, USA) of approximately 5 mm thickness was placed.
considered as an effective alternative to calcium hydroxide The canal was sealed with gutta-percha and AH26 sealer
[8,13]. immediately after the initial setting of white MTA apical
Although MTA has several advantages, one of the main plugs as per manufacturer recommendations.
drawbacks is the long setting time, which could jeopardize the Group 3: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
sealing ability and marginal leakage [14]. So far, only limited OK, USA) of approximately 5 mm thickness was placed.
studies have been conducted to evaluate the setting of MTA on The canal was sealed with gutta-percha and AH26 sealer
the quality of the marginal adaptation and sealing. Hence, the after 48 h of MTA setting.
present study evaluates the apical sealing and adaptation of Group 4: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
open apexes that were obturated immediately, 48 h and 1 OK, USA) of approximately 5 mm thickness was placed.
week after placing an MTA apical plug in an in vitro model. The canal was sealed with gutta-percha and AH26 sealer
after 1 week.
2. Materials and methods The obturation of all specimens was performed through
active lateral condensation technique. In this technique, the
The study was approved by the Institutional Review board of main gutta-percha point was advocated as the endodontic
the Al-Azhar University, College of Dentistry, Egypt. A total of sealer and introduced into the root canal. Following that,
40 freshly extracted permanent maxillary central and lateral secondary points were added up for the complete filling of the
incisor teeth were used in this study. Teeth with a single non- root canals.
calcified canal, as confirmed by radiographs taken from
bucco-lingual and mesio-distal views, were selected. Any 2.2. Micro leakage
tooth with abnormalities, such as internal resorption, oblit-
eration, pulp stones, cracks and fractures, were excluded and Following obturation, the coronal cavity was sealed with glass
replaced. The selected teeth were stored in normal 0.9% saline ionomer cement (GC Fujirock EP; GC Europe NV, Leuven,
solution during the experiment. Then, they were examined Belgium). The root segments from all groups were double-
with a magnifying glass to discard the specimens with any coated with nail varnish except at the apical 3 mm. The
cracks or fractures. coated roots were suspended in 2% methylene blue dye in a
petridish and incubated at 37 C with 100% humidity for 48 h.
2.1. Tooth preparation and open apex simulation The teeth were then sectioned longitudinally along the
long axis in the bucco-lingual direction through the center of
Preparation of the access cavities were done using a water- the root. To prevent any damage to the inside of the canal, the
cooled round bur in a high-speed handpiece (NSK, Japan). sectioning was done with water cooled diamond disc along
The working length was determined by placing a size 30 K-file the root, short of reaching the obturation material, thereby
(Dentsply-Maillefer Instruments SA, Ballaigues, Switzerland) creating a stress canal. A chisel was used to wedge and split
in the canal until it was visible at the apical foramen and the teeth.
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6 3
3. Results
Fig. 1 e The apical dye penetration of incisors obturated Fig. 3 e Maxillary central incisor with an MTA apical plug
with an MTA apical plug and gutta-percha immediately, that was obturated after 48 h showing minimal dye
after 48 h and after one week. penetration.
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
4 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
and AH24 sealer after one week. One way analysis of variance apex. Although calcium hydroxide is the first choice for an
(ANOVA) revealed that the difference was statistically signif- intra-canal dressing in apexification; some drawbacks such as
icant (p 0.01).Tukey's post hoc test revealed that the differ- coronal micro-leakage, tooth susceptibility to fracture, and
ence between the MTA apical plug groups at 48 h and 1 week multisession treatments have led to the exploration of
was statistically non-significant at p > 0.01 (Table 1, Fig. 1). appropriate alternatives [6,16,17]. MTA-based sealers have
Comparing the apical dye penetration of the MTA groups at been reported to be biocompatible and can stimulate miner-
different periods showed that the greatest mean value of dye alization and encourage apatitelike crystalline deposits along
penetration was recorded in the immediate group, while the the apical thirds of canal walls [18].
lowest value was recorded in the group obturated after 1 week. Several methods are used to determine the sealing ability
One way analysis of variance test revealed that the difference of apical plugs, such as polymicrobial leakage, linear dye
was statistically significant (p < 0.01). Tukey's post hoc test leakage, diaphanization, fluid filtration, radioisotope labeling,
revealed that the difference between the MTA group at 48 h and the electrochemical method [19]. In this study the meth-
and 1 week was not statistically significant (Table 1, Figs. 1e3). ylene blue dye solution method was selected because of its
advantages over the other tracing materials, including its
3.1. Scanning electron microscopic observations solubility in water, ability to easily penetrate into the water
compartment of the tooth, non-absorbability into the dentinal
SEM was used to qualitatively assess the mechanisms matrix or apatite crystals and ability to penetrate further than
responsible for the leakage, by evaluating the adaptation of any isotope traces.
the MTA apical plug to the dentinal walls. The present study The apical sealing ability of MTA has been shown to exhibit
found that delayed MTA apical plug and gutta-percha filling good sealing ability [20e22]. Because the setting time of MTA is
had better sealing ability than the control and immediate longer in the current study, the sealing ability was tested
obturation. The results were also confirmed by the SEM. Ex- against the delayed obturation of the root canal. The obtura-
amination of the photomicrographs of the samples demon- tion of the root canal after 48 h showed maximal sealing
strated variable gaps at the dentin-MTA interfaces. Delayed ability and adaptation compared to immediate obturation.
obturation presented much smaller gaps at the dentin-MTA Obturation of the root canal after 1 week did not show any
apical plug interface than the immediate MTA apical plug significant improvement in the apical sealing of MTA
(Figs. 4e6). compared to obturation after 48 h. The assumption is that
obturation after 48 h showed better sealing ability of the MTA
plug compared to immediate obturation.
MTA has been shown to prevent micro-leakage and to
4. Discussion stimulate tissue regeneration when in direct contact with pulp
and periradicular tissues [23]. Clinical studies of open apex
Endodontic treatment of traumatized immature teeth with teeth obturated with MTA in one appointment demonstrated
periapical lesions is performed by inducing apical closure by healing rates that ranged from 81 to 100% [24,25], with 94.1%
apexification and then forming an adequate seal in the root
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6 5
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
6 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
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Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004