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MTA dissolution following successful endodontic periapical surgery after 7-

year recall: A unique case report.

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 CASE REPORT „ 35

Georgia E. Nikoloudaki, Eleni Meliou, Nikolaos P. Kerezoudis

MTA dissolution following successful endodontic

periapical surgery after 7-year recall: A unique
case report
Georgia E. Nikolou-
daki, DDS, MSc
Department of Endodontics,
Key words endodontic surgery, follow-up, MTA dissolution, periapical healing School of Dentistry, National
and Kapodistrian University
of Athens, Athens, Greece
The aim of the present report is to describe the unusual finding of mineral trioxide aggregate’s
(MTA) disappearance from the root-end cavity, several years after successful periapical surgery and Eleni Meliou, DDS,
MSc, PhD
complete wound healing. A 32-year-old male patient was referred by a general practitioner for Department of Endodontics,
School of Dentistry, National
root canal treatment of the right maxillary central and lateral incisors with a sinus track and a large and Kapodistrian University
periapical radiolucent lesion. After completion of the root canal treatment, endodontic surgery was of Athens, Athens, Greece

performed since symptoms persisted. The retrograde cavity of the lateral incisor was sealed with MTA Nikolaos P.
and the patient was monitored in the subsequent years, in order to evaluate the surgical outcome. Kerezoudis, DDS,
Dr. Med. Sc.
Recall examination after 4 months revealed absence of signs and symptoms and reduction of the Assistant Professor, Depart-
radiolucent lesion, indicating normal healing. After 2 years, the follow-up radiographic examination ment of Endodontics, School
of Dentistry, National and
revealed further healing of the periapical lesion, with the MTA apical retrograde filling remaining in Kapodistrian University of
its place but with signs of disintegration. However, follow-up radiographic examination after 7 years Athens, Athens, Greece

revealed that the former radiolucent area is diminished and the root apex is completely covered Corresponding author:
Georgia E. Nikoloudaki
by normal periodontal ligament and alveolar bone, whilst the retrograde filling is not visible at all, 1151 Richmond Str,
possibly due to disintegration. Long-term follow-up of apicoectomy cases is mandatory and further London, Ontario, N6A 5C1
Canada
research is deemed necessary for the long-term evaluation of MTA, when in contact with periapical Tel: +1 226-224-8705
and periodontal tissues. Email: nikgogo@dent.uoa.gr

„ Introduction In such cases, a surgical intervention is deemed

Non-surgical root canal treatment is a reliable method
of treating non-vital teeth associated with apical per-
iodontitis, as success rates range from 75% to 94%1.
However, persistence of signs and symptoms may
occur. Several causes of nonresolving radiolucent le-
sions have been reported, including: (i) the anatom-
ical complexity of the root canal system and in most
cases the presence of apical true cysts, due to their
self-sustaining nature, (ii) actinomycosis, (iii) extra-
radicular infection due to bacterial biofilms, (iv) the
presence of cholesterol crystals in periapical lesions
and (v) foreign body reaction2.
mandatory. The aim of the surgical treatment is the
elimination of the causative factors and the obtu-
ration of the root canal system, which will subse-
quently lead to the resolution of the symptoms and
the healing of the periapical pathosis. Successful out-
comes of surgical endodontics have been reported
to range from 68.7% to 96.8%3,4. The significant
increase in the success rates of surgical procedures
over the past decade can be attributed to modern
microsurgical techniques5, the aid of magnification
by means of a dental operative microscope6, the
invention of microsurgery instruments and ultrasonic
tips for retrograde cavity preparation7, as well as the

ENDO (Lond Engl) 2016;10(1):35–40

36 „ Nikoloudaki et al MTA dissolution after 7-year recall
availability of improved retrograde filling materials,
like mineral trioxide aggregate (MTA).
The purpose of the following case report is to
describe and discuss the non-surgical and surgical
root canal treatment of a maxillary lateral incisor with
a 7-year follow-up. In this case report a favourable
healing process occurred with the root to be com-
pletely covered by normal periodontal ligament and
alveolar bone, despite the disintegration of the MTA
retrograde filling material.
„ Case report
A 32-year-old male, with non-contributory medi-
cal history and without history of orofacial trauma,
was referred to the endodontic private practice for
evaluation and possible root canal treatment of teeth
11 and 12. The patient’s chief complaint was inter-
mittent pain when biting on the anterior teeth and
occasional swelling. The dental history revealed that
about a year ago, the patient had visited a general
practitioner, who initiated root canal treatment of
the right maxillary lateral incisor and left it open for
drainage.
Extraoral examination did not reveal any patho-
logical signs, while during intraoral clinical examin-
ation, a sinus track was observed at the periapical
area between the two teeth which were tender to
percussion. Palpation at the corresponding buccal
periapical area produced mild pain; thermal and elec-
trical pulp testing elicited a negative response on
both teeth, while adjacent teeth reacted normally
and did not present any other pathological signs
or symptoms. Periodontal examination was within
normal limits without signs of mobility. Regarding
tooth 11, inadequate Class III aesthetic restorations
with composite resin were observed with prominent
secondary caries on their margins. Preoperative in-
traoral radiographic examination showed a large,
clearly defined periapical lesion, exhibiting defined
margins along with a circular radiographic outline,
associated mainly with tooth 12 but also with the
adjacent tooth 11. The sinus tract was traced with
a gutta-percha point, indicating its origin from the
periapical area of tooth 12 (Fig 1b). An access cav-
ity was present in the right lateral incisor, due to the
previous attempt of root canal treatment.
ENDO (Lond Engl) 2016;10(1):35–40
Based on the history, clinical tests and radiographic
findings, a diagnosis of pulp necrosis with asympto-
matic apical periodontitis was established and it was
decided root canal treatment to the right maxillary
central and lateral incisors would be performed.
The patient was informed that conventional root
canal treatment might be supplemented by surgical
intervention if signs and symptoms persisted. The
patient consented to the proposed treatment plan.
„ Root canal treatment
After administrating local anaesthesia (1.7 ml Ub-
istesin forte, articaine hydrochloride 4% with epi-
nephrine 1:100.000; 3M Espe, Seefeld, Germany),
the maxillary anterior teeth were isolated using mul-
tiple tooth isolation technique with a rubber dam. In
tooth 11, filling materials and caries were meticu-
lously removed, and an access cavity preparation was
performed using a round diamond bur and a high-
speed handpiece under constant irrigation with air
and water spray. With regard to the lateral incisor, the
former access cavity was slightly corrected to achieve
straight-line access to the root canal. The root canal
systems of the teeth were initially explored using a size
10 K-file (VDW, Munich, Germany) and the absence
of vital tissue was confirmed in both of them. The
working length was determined using an electronic
apex locator (Root ZX, J. Morita, California, USA) and
the chemo-mechanical preparation was performed
with stainless steel Flexicut-Files (VDW) and rotary
nickel-titanium instruments (ProTaper Universal,
Dentsply Maillefer, Ballaigues, Switzerland), accord-
ing to the manufacturer’s instructions, under copious
irrigation with 2.5% sodium hypochlorite solution,
to size F2. After the preparation, the root canal sys-
tems of the teeth were copiously irrigated with 2.5%
sodium hypochlorite solution and thoroughly dried
with sterile paper points. Calcium hydroxide paste
(Ca(OH)2) was placed as an intracanal dressing using
a lentulo spiral and the access cavities were sealed
using Cavit G temporary filling material (3M Espe).
The patient returned 1 week later. The teeth were
tender to percussion and palpation at the buccal peri-
apical area and the sinus track was still present. The
intracanal medicament was removed by copious irri-
gation with 2.5% sodium hypochlorite and circum-

a b
ferential hand filling with Hedstrom files (Dentsply
Maillefer) and freshly prepared Ca(OH)2 paste was
placed in the root canals again. The access cavities
were sealed with Zinc Oxide Eugenol (ZnOE) and the
next appointment was scheduled 2 weeks later. In
the following appointment, the sinus track was still
present and it was decided the obturation of the ca-
nals would be performed and the surgical treatment
would be completed during the subsequent appoint-
ment. After administration of local anaesthesia, mul-
tiple tooth isolation technique was performed using
a rubber dam, and the Ca(OH)2 paste was removed
by passive ultrasonic irrigation (PUI) and thorough
irrigation using 17% ethylenediaminetetraacetic
acid (EDTA) and 2.5% sodium hypochlorite solution,
along with PUI, in order to remove the smear layer.
The root canals were obturated using medium non-
standardised gutta-percha cones and AH 26 sealer
(Dentsply DeTrey, Konstanz, Germany), and System B
Heat Source (SybronEndo, California, USA) was used
to cut, soften and compact the cone at 3 mm from
the working length. The backfilling was performed
with thermoplasticised gutta-percha from Obtura II
(Obtura, Missouri, USA) and additional vertical con-
densation. The access cavities were temporarily sealed
with ZnOE. At the postoperative radiographic exam-
ination, the extrusion of obturation material was ob-
served beyond the apex of tooth 12 (Fig 1b).
One week after the completion of the root canal
treatment, the patient returned to the office for the
surgical management of the case and a written in-
formed consent form was signed by the patient prior
to surgery.
Nikoloudaki et al MTA dissolution after 7-year recall „ 37
Fig 1 a) Preoperative
radiograph: sinus tract
traced with gutta-per-
cha point. b) Postop-
erative radiograph:
extrusion of obturation
material beyond the
apex of tooth 12. c)
Radiographic examin-
ation after the comple-
tion of the surgical
intervention. Note the
adequate root-end cav-
ity filling with MTA.
c
„ Surgical intervention
After successful administration of regional anaes-
thesia, both at the buccal and at the palatal mucosa,
with local infiltrations (three cartridges of 1.7 ml
Ubistesin forte, 4% articaine hydrochloride with
epinephrine 1:100.000; 3M Espe) and nasopalatal
block anaesthesia, a full-thickness, mucoperiosteal
flap was raised, extending from the mesial side of
tooth 14 to the distal side of tooth 21. The cortical
plate at the apex of tooth 12 was fenestrated and
an inflamed lesion surrounded by a connective tis-
sue capsule was observed. Great care was taken to
circumferentially separate the lesion from the bony
crypt and the teeth. The obtained lesion was fixed in
10% buffered formalin for further histological exam-
ination. The apical and lateral root surfaces of the
central and lateral incisors were curetted with Gracey
curettes, the osteotomy was completed and the
apices of the involved teeth were examined under
high magnification (x16). After complete removal
of the inflamed tissue and meticulous cleaning and
irrigation of the surgical site with sterile saline solu-
tion, fenestration of the palatal cortical bone was
observed (through-and-through bone lesion). It was
decided that apicoectomy was performed only in the
lateral incisor, due to the fact that the central incisor
presented adequate root canal filling, and 3 mm of
its root apex was resected. The root-end cavity prep-
aration was carried out with ultrasonic retrotips (EMS
diamond-coated) under magnification and White
ProRoot MTA (Dentsply Tulsa Dental, Oklahoma,
USA) was used as a retrograde material (Fig 1c).
ENDO (Lond Engl) 2016;10(1):35–40
38 „ Nikoloudaki et al MTA dissolution after 7-year recall

Fig 2 Four month-recall radiograph:
the periapical radiolucent area appears
to be reduced in size, indicating a
normal healing process.
Fig 3 Two year-recall radiograph.
The radiolucent area is remarkably
diminished and separated from the
root apex, by a layer of bone. The root
apex is completely covered by normal
periodontal ligament and alveolar
bone. The MTA apical retrograde filling
shows signs of disintegration.
Fig 4 Recall examination after 7
years. The minor radiolucent area is
still evident, indicating healing with
scar tissue. However, the retrograde
filling material completely vanished.

The mucoperiosteal flap was repositioned and „ Discussion

sutured in place with 5-0 nylon sutures and a post-
operative radiograph was taken to evaluate the out-
come of the surgical procedure. The next appoint-
ment was scheduled 6 days later for suture removal
and evaluation of the initial healing process. The
patient did not report any postoperative pain and
overall healing was uneventful.
The removed tissue from the periapical lesion
was sent for histopathological examination and
diagnosed as an inflamed periapical cyst.
Four months later, the patient returned for radio-
graphic evaluation, which revealed substantial heal-
ing with a significant reduction of the radiolucent
area, indicating a normal healing process (Fig 2).
Two years later, the radiographic examination re-
vealed that the former radiolucent area was dimin-
ished and separated from the root apex by a layer of
bone while the root apex was completely covered
by normal periodontal ligament and alveolar bone.
The MTA apical retrograde filling showed signs of
disintegration (Fig 3).
Seven years later, during the recall radiographic
examination, a small residual radiolucent region was
detected, possibly representing healing with scar tis-
sue. It is interesting to note that the retrograde filling
material was no longer radiographically visible (Fig 4).
The present case report describes for the first time,
the disappearance of MTA from the root-end filled
cavity, several years after successful periapical sur-
gery, whilst complete periapical healing occurred.
Four months after periapical surgery, recall examina-
tions revealed the absence of signs and symptoms
and reduction of the radiolucent lesion, indicating
a normal healing process. After 2 years, the recall
radiographic examination revealed a further reduc-
tion in the size of the periapical lesion, with the MTA
remaining in place, but with slight signs of disin-
tegration. Surprisingly, the follow-up radiographic
examination 7 years after the surgical intervention
revealed that although the former radiolucent area
was diminished and the root apex was completely
covered by normal periodontal ligament and alveolar
bone, the retrograde filling material was not visible
at all, possibly due to disintegration. A minor radio-
lucent area was still evident, which is an indication
of healing with scar tissue. There is evidence that if
both cortical bone plates are resorbed, as in large
cyst-like periapical lesions, fibrous connective tissue
will be developed in place of mature bone, due to
the subsequent extensive periosteum destruction. It
has been proposed that periapical scar tissue prob-

ENDO (Lond Engl) 2016;10(1):35–40


ably develops because the ingrowth of fibroblasts
from periosteum or submucosa into the defect colo-
nize both the root tip and periapical tissue, before
the appropriate cells, which have the potential to
restore various structural components of the apical
periodontium, are able to do so. Recent studies using
histological examination of biopsies obtained during
periapical surgery or tooth extraction found that the
incidence of scar tissue formation is 1% to 3%8,9. Al-
though radiographic differential diagnosis is difficult,
special characteristics have been proposed, such as
the radiolucent area is smaller than in the preopera-
tive radiograph, but not completely gone and it ap-
pears to be separated from the root apex by a layer
of bone. Root apex is completely covered by normal
periodontal ligament and alveolar bone, as it can be
clearly observed in this case (Figs 3 and 4).
To our knowledge there are no previous studies
describing the long-term cellular and tissue interac-
tions with MTA. Thus, the purpose of this unique
case report was to draw attention to the need for
further in vivo studies, aiming to elucidate the long-
term behaviour of MTA within the tissues, in an
effort to provide an explanation for this unusual
finding.
Wound healing is a complex process, which re-
quires interactions between different type of cells,
interactions between cells and extracellular ma-
trix and a wide variety of cytokines, growth fac-
tors, neuropeptides and apoptosis. This process in
periapical pathosis follows the same fundamental
mechanisms of wound healing of connective tis-
sues elsewhere in the body10, including granulation
tissue formation and activation of macrophages in
order to digest necrotic tissue remnants and dead
bacteria, resulting in regeneration and/or repair of
the involved tissue.
There are only a few case reports describing the
fate of unintentionally extruded MTA, when used in
cases with an open apex in the periapical tissues, and
with a long observation period11,12. Interestingly,
Asgary et al11 reported the complete resorption of
unintentionally extruded MTA in the periapical tis-
sues after 7 years. The authors attributed this obser-
vation either to the increased solubility of MTA, after
long-term exposure to tissue fluids, and to resorptive
mechanisms mediated by macrophages and osteo-
clasts. However, the above-mentioned cases refer
Nikoloudaki et al MTA dissolution after 7-year recall „ 39
to extruded materials into periapical tissues, thus
cannot explain or correlate with the observations of
the present case, as the filling material was placed
into the retrograde cavity where it can be adequately
compacted.
The degree of MTA’s solubility is a controversial
issue. Recent evidence supports the idea that calcium
ion release from MTA is time-dependent13. Increased
solubility has been revealed in an in vitro long-term
study period, which consisted of 78 days14. More-
over, it has been reported that the powder/water ra-
tio might influence the material’s properties, with an
increased water-to-powder ratio negatively affect-
ing MTA’s porosity and solubility, due to increased
calcium ion release from it. However, it is unlikely
that this parameter has contributed to the disintegra-
tion of the material in the present case, as MTA was
mixed according to the manufacturers’ instructions
to produce a homogeneous paste with thick consist-
ency, thus allowing its proper compaction towards
the root canal walls and ensuring its optimal adap-
tivity. Furthermore, a disturbed powder/water ratio
could possibly occur during exposure of the unset
MTA to the body tissue fluids, which may be partially
responsible for MTA’s initial resorption14. It has also
been proposed that the low pH of the inflammatory
lesions may have a detrimental effect on MTA, in
terms of its physical and chemical properties and its
hydration process15.
While these processes are pivotal in the initial
stages of the unset material, the hydrated and set
MTA cannot be affected or resorbed by these mech-
anisms. In orthopaedics, both cemented and unce-
mented prosthesis and implant components may
aseptically wear out or loosen. It has been docu-
mented that, in cases of host bone resorption, the
macrophages existing between loose implant com-
ponents and the resorptive bone area usually engulf
the wear particles derived from organic polymers
and metal implant biomaterials. Furthermore, there
is strong evidence that all biomaterial particle-con-
taining foreign-body macrophages differentiate into
osteoclastic cells16, which are capable of phagocy-
tosis of inert particles. Additionally, it has been pro-
posed that osteoclasts are able to engulf a wide size
range of particles, such as particles of polymeric and
metallic biomaterials, after which they maintain their
functionality11,18.
ENDO (Lond Engl) 2016;10(1):35–40
40 „ Nikoloudaki et al MTA dissolution after 7-year recall
Regarding the retrograde filling materials, cur-
rently MTA remains the material of choice, which
has been proven to be advantageous in terms of its
sealing ability, marginal adaptation and biocompat-
ibility18. Another aspect that should be considered
for the successful outcome of this case is the resec-
tion of the root apex, which may harbour bacteria
and their toxic by-products, as well as the retrograde
cavity preparation with ultrasonic tips. The aim of
the root-end preparation is not only to remove the
gutta-percha from the root canal and irritants, but
also to create a cavity that can be effectively sealed.
Over the years, several studies agree that the retro-
grade preparation with ultrasonic tips is more effec-
tive than the previous techniques with burs and a
micro handpiece7. The advantages of this technique
are reported to include minimal or no bevel root-end
resection; the deeper preparation in the retrograde
cavity; the conservative root-end preparations which
are centred in the canal, thus minimising the risk of
perforations; and better preparation for anatomical
difficulties, such as an isthmus and fins, resulting in
more efficient debridement of tissue debris. Further-
more, although heat is produced, the operator has
the ability to condense the remaining gutta-percha
in the canal, thus promoting the overall sealing of the
retrograde preparation.
In conclusion, to our knowledge, a similar clin-
ical case describing the complete dissolution of MTA
after favourable healing of the periapical area has
not been previously reported. Even though MTA still
remains the material of choice as a retrograde ma-
terial in periapical surgery, further studies investigat-
ing the long-term cellular interactions with MTA are
deemed necessary.
„ Acknowledgements
The authors deny any conflicts of interest related to
this study.
ENDO (Lond Engl) 2016;10(1):35–40
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