Case Report/Clinical Techniques
Management of a Perforating Internal Resorptive
Defect with Mineral Trioxide Aggregate: A Case Report
Emre Altundasar, DDS, PhD,* and Becen Demir, DDS, PhD†
Abstract
Introduction: A radicular perforation caused by an
inflammatory internal root resorption was present in
a maxillary lateral incisor. Methods: The root canal
preparation was completed with hand files and thor-
ough irrigation. Calcium hydroxide was placed as
a temporary dressing for 10 days. At the second visit,
the root canal with resorption lacuna was filled with
warm vertical compaction of gutta-percha. The coronal
access was restored with composite resin. A surgical
flap was elevated to repair the resorption defect with
gray mineral trioxide aggregate. The bony defect adja-
cent to the perforated lesion was filled with Unigraft
(Unicare Biomedical, Laguna Hills, CA). Results: The
tooth was in function with satisfactory clinical and radio-
graphic results after 48 months. Conclusions: Accord-
ing to the long term results of this case, successful
sealing of a perforating defect is possible with mineral
trioxide aggregate. (J Endod 2009;35:1441–1444)
Key Words
Inflammatory internal resorption, mineral trioxide
aggregate, root perforation
From the *Department of Endodontics, Faculty of Dentistry,
Hacettepe University, Ankara, Turkey; and †Private Practice,
Istanbul, Turkey.
Address requests for reprints to Dr Emre Altundasar, Hacet-
tepe University, Faculty of Dentistry, Department of Endodon-
tics, Sihhiye 06100, Ankara, Turkey. E-mail address:
altundasar@gmail.com.
0099-2399/$0 - see front matter
Copyright ª 2009 American Association of Endodontists.
doi:10.1016/j.joen.2009.06.017
JOE — Volume 35, Number 10, October 2009
I nternal root resorption has been described as a resorptive defect of the internal aspect
of the root following necrosis of odontoblasts as a result of chronic inflammation and
bacterial invasion of the pulp tissue. Resorption has been associated with multinucleated
giant cells adjacent to a pulpal granulation tissue (1). Clinically, internal root resorption
is usually asymptomatic and is detected coincidentally through routine radiographs.
Pain or discomfort may be the chief complaint if the granulation tissue has been exposed
to oral fluids. The granulation tissue can clinically manifest itself as a ‘‘pink spot’’ in
cases in which crown dentin destruction is severe (2). Radiographic examination
usually reveals a fairly uniform radiolucent area with disrupted outline of the root canal.
The progression of internal resorption depends on vital tissues (3). Therefore, root
canal treatment should be initiated as soon as possible once an inflammatory resorptive
lesion is detected to prevent further hard tissue loss and eventually root perforation (2).
In cases without a perforation, the removal of the granulation tissue and the blood
supply to the resorbing cells by root canal treatment should be sufficient. However, in
cases in which a pathway between the pulp canal space and the periodontal tissues is
present, root canal treatment should be followed by repair of the perforation site with
a suitable sealing material (4).
Mineral trioxide aggregate (MTA) has been proposed as a favorable perforation
repair material with its superior sealing ability (5), biocompatibility (6, 7), fibroblastic
stimulation (8), and antimicrobial activity (9). MTA can create an environment condu-
cive to periodontal healing, allowing new cement growth on its surface (10). The mate-
rial has been used in several applications including pulpotomy, pulp capping, and
perforation repair (11–13). This case report describes the 48-month follow-up of
a perforating internal root resorption in a maxillary lateral incisor in which gray
MTA was used to seal the perforation area after endodontic therapy.
Case Report
A 42-year-old male patient presented with a localized mild swelling on the attached
gingiva between the central and the lateral incisor teeth. There was no history of pain or
discomfort. The patient was aware of the swelling for almost 2 months. As reported by
the patient, the color and size of the swelling were stable because it was recognized. The
swelling had a radius of approximately 5 mm with regular borders. The patient’s
medical status was noncontributory, and he mentioned that he had no trauma to the
related area. An old composite resin restoration was noted on the distal aspect of
the maxillary lateral incisor tooth. The tooth responded positively to electric pulp vitality
test, and no discomfort was noted on percussion. On the mesiobuccal aspect of the
crown, the probing depth measured 4 mm, whereas the mobility of the tooth was within
normal limits. Radiographic examination revealed a uniform radiolucent lesion in the
middle third of the root canal (Fig. 1). The centrally localized image of the lesion did not
shift when additional radiographs were taken from different angulations.
An access cavity was prepared, and the working length was determined by x-ray
images. The root canal was instrumented with stainless steel hand files until an apical
stop of ISO #50 could be created. The persistent seeping of blood through the root canal
diminished gradually with instrumentation. The root canal was frequently irrigated with
1.3% NaOCl followed by a final rinse with 5 mL of sterile saline. Subsequently, calcium
hydroxide (Ultracal XS; Ultradent Products Inc, South Jordan, UT) was placed as
a temporary dressing to control bleeding. The access cavity was temporarily sealed
with Cavit G (3 M ESPE, St Paul, MN). After 10 days, the root canal was reentered
and irrigated alternately with 1.3% NaOCl and sterile saline to remove the temporary
Perforating Internal Resorptive Defect with MTA 1441
Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph showing internal resorption lesion of the maxillary lateral incisor tooth with irregular borders. An unfavorable coronal
restoration is evident. (B) Swelling as clinical manifestation of the perforating resorption. (C) Postoperative radiograph after 48 months. (D) Healthy appearance of
gingiva after 48 months.
dressing; 17% EDTA solution was left flooded in the cavity for 5 minutes,
which was later rinsed with 5 mL of sterile saline. The root canal was
filled with warm vertical compaction of gutta-percha combined with
AH-26 sealer (Dentsply De Trey, Konstanz, Germany). After radio-
graphic confirmation of a satisfactory obturation, the access cavity
was restored with composite resin.
A flap that exposed the granulation tissue and the bone destruction
was elevated at the same appointment. The granulation tissue (Fig. 2)
was removed, and the irregular borders of the perforation site were
smoothed with a bur attached to a straight surgical handpiece. MTA
powder was mixed according to the manufacturer’s instructions and
placed with an MTA carrier. MTA was firmly condensed by using a
plugger and wet cotton pellets (Fig. 2). Bone graft material (Unigraft;
Unicare Biomedical, Laguna Hills, CA) was placed over MTA to fill
the cavity of the bony defect (Fig. 2). The flap was sutured, and the
patient was recalled 1 week later for suture removal. At the next visit,
the patient reported no postoperative pain or discomfort. The first
follow-up was planned at the postoperative sixth month. Subsequent
controls were planned as 12-month intervals. However, the patient
moved to another city and could not be controlled for 48 months
because of this relocation. When he returned after 48 months, he
reported that he experienced no pain or swelling during this period.
Clinical examinations and radiographic findings revealed satisfactory
results at the postoperative 48 months (Fig. 1).
Discussion
Internal and external root resorptions are considered as inflam-
matory type of root resorptions and it is often challenging to distinguish
1442 Altundasar and Demir
them from each other. It has been suggested that diagnosis should
always be confirmed while the treatment is proceeding (13). Because
resorptive defects are often asymptomatic, they are usually recognized
by routine radiographs. However, in this case, the patient recognized the
swollen gingiva between central and lateral incisors, which prompted
him to seek treatment.
According to the study of Wedenberg et al (14), internal root
resorption lesions can be either transient or progressive. The progres-
sive nature of this type of root resorption has been associated with an
ongoing inflammation from a source of infection. In this case, an old
composite filling was present, which could be regarded as a pathway
for entrance of oral microorganisms to pulp cavity.
The granulation tissue responsible for internal resorptive defect is
often confined to the inner aspect of the root canal. However, in this
case, having perforated the root wall, the granulation tissue migrated
to the external root surface and consequently caused breakdown of
adjacent bone structure. The bone destruction was hard to detect on
radiographs because the localization of the defect was superposed by
intact bone structure.
In majority of the previous studies (12, 15, 16), the root canal
filling has been placed after repair of the perforation defect. On the
other hand, Yıldırım et al (17) has repaired an iatrogenic root perfo-
ration with MTA after root canal filling has been completed. In this case,
we also preferred sealing the root canal before placement of MTA.
Otherwise, special precautions would have to be taken to prevent
MTA from blocking the root canal space. Previously placed gutta-percha
acting as a barrier material allowed successful condensation of MTA.
Moreover, filling the root canal after placement of MTA involves the
JOE — Volume 35, Number 10, October 2009

Figure 2. (A) Flap elevation and removal of the granulation tissue (inset). (B) Appearance of the perforation defect after removal of the granulation tissue. Gutta-
percha can be seen through the defect. (C) Mineral trioxide aggregate sealing the perforation defect. (D) Filling of the bone cavity with Unigraft.
risk of displacing MTA from the perforation site during condensation of
gutta-percha. In this case, MTA was firmly condensed against the root
dentin and the gutta-percha. Subsequently, the bone cavity was filled
with Unigraft, which also covered and protected MTA until set. Failure
to take special care while handling MTA may result in wash-out or
displacement of the material. Vanderweele et al (18) used MTA to
seal furcal perforations in molar teeth and evaluated the resistance of
the material to displacement at 24 hours, 76 hours, and 7 days. Accord-
ing to the findings of that study, significantly greater force was required
to displace all samples at 7 days than was required at 24 hours and
72 hours, which implied that MTA continued setting at the seventh
day after placement in the presence of moisture. Same study reported
inferior resistance to displacement when MTA was placed to blood
contaminated perforation defects.
One of the disadvantages of MTA is related to its color. Discoloration
of marginal gingiva after perforation repair with gray MTA has been re-
ported (19). In that case, changing gray MTA with recently introduced
white MTA allowed complete resolution of discoloration. In our case,
no gingival discoloration was observed after 48 months. The potential
of gingival discoloration should be considered in perforations located
proximal to the marginal area. White MTA can be the material of choice
to repair defects in which direct contact with gingival tissues is expected.
Previous animal studies have evaluated the repair of noncontami-
nated and contaminated lateral root perforations sealed with MTA and
the effect of temporary filling of the contaminated perforations with
a calcium-hydroxide based dressing before MTA placement (20, 21). Ac-
cording to the results of those studies, the lateral root perforations sealed
with MTA after contamination presented inferior repair than the noncon-
taminated perforations and placement of an antibacterial agent between
visits failed to improve repair of contaminated perforations.
The timely sealing of perforation defects prevents bacterial
contamination between periodontium and the root canal space. Pace
et al (22) presented a case series including furcal perforations. In
JOE — Volume 35, Number 10, October 2009
Case Report/Clinical Techniques
the cases presented, the time elapsed from the creation of the perfora-
tion to repair of the defect did not exceed 6 months. They reported
successful results after 5 years.
Sealing ability of different formulations of MTA (MTA Bio and
MTA-Angelus [both items Angelus, Londrina, PR, Brazil]) has been
compared with various materials including IRM (Caulk, Dentsply,
Milford, DE) and Portland cement (Irajazinho TYPO II; Votorantim
Cimentos, Rio Branco, SP, Brazil) (23, 24). It has been suggested
that the use of IRM to seal large perforations should be limited, whereas
all other formulations of MTA and Portland cement had somewhat
similar ability to seal perforations.
The treatment of this case involved removal of the granulation
tissue followed by the repair of the perforation site and the adjacent
bone defect. The patient returned after 48 months with no signs or
symptoms. The tooth was in function with no discomfort or pain during
that time. The gingiva appeared healthy with normal color and texture.
There was no mobility or bleeding upon probing. There was no increase
in probing depth. Finally, treatment of the defect with MTA was consid-
ered successful as evidenced by clinical and radiographic findings after
48 months.
Acknowledgment
The authors wish to thank Dr. Zafer Cehreli for his valuable
help with the composite figures.
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JOE — Volume 35, Number 10, October 2009