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Case Report
Combined Therapy of Mineral Trioxide Aggregate and
Guided Tissue Regeneration in the Treatment of External
Root Resorption and an Associated Osseous Defect
Cecil White Jr.* and Nathaniel Bryant†
Background: The treatment of external root resorp-
tion and associated periodontal defects can be chal-
lenging to the most astute clinician. In this case report,
a multidisciplinary approach was performed to treat
a maxillary central incisor that presented with a sinus
tract. An amalgam restoration had been placed approx-
imately 10 years earlier to repair an area of external
root resorption.
Methods: A full-thickness mucoperiosteal flap was
reflected from teeth #8 to #9. Following degranula-
tion of the area, an amalgam restoration was found
on the distal root surface of tooth #8. A 2-wall osseous
lesion was also associated with the distal surface of
#8. The amalgam was removed and the defect was
restored with mineral trioxide aggregate (MTA). The
root surface was chemically conditioned with tetra-
cycline, and the osseous defect was grafted with
decalcified freeze-dried bone allograft (DFDBA) and a
calcium sulfate barrier.
Results: An 8 mm gain in clinical attachment, as
well as an increase in radiodensity, was noted on the
distal surface of tooth #8 at 15 months postsurgery.
The patient was also asymptomatic, with no clinical
signs of inflammation present.
Conclusions: A combined approach utilizing MTA
for root surface repair, and DFDBA and calcium sul-
fate to address an associated osseous lesion, appears
to be a viable modality in the treatment of chronic
endodontic/periodontal lesions. J Periodontol 2002;73:
1517-1521.
KEY WORDS
Biocompatible materials; bone substitutes;
calcium sulfate/therapeutic use; grafts, bone;
guided tissue regeneration; membranes, barrier;
membranes, bioabsorbable; tooth root; tooth
resorption/prevention and control.
* Department of Periodontics, Naval Dental Center Mid-Atlantic, Norfolk, VA.
† Department of Endodontics, Naval Dental Center Mid-Atlantic, Norfolk, VA.
J Periodontol • December 2002
Root resorption can be one of the most challenging
problems that dental practitioners face. Trope1 clas-
sified root resorption based on its etiology. He stated
that 2 requirements must be fulfilled in order for root
resorption to occur: 1) an alteration in the protective
attachment layer (predentin internally or precemen-
tum externally) of the root, and 2) the presence of
an inflammatory process adjacent to the altered root
surface. Trope also stated that root resorption is clas-
sified as either transient or progressive.1 Non-surgi-
cal endodontic therapy has a relatively high rate of
success2 in the resolution of contained periapical
lesions and intact root canals. However, when root
canals suffer perforation from an iatrogenic proce-
dure or a root resorption phenomenon, associated
inflammatory periodontal lesions may also develop
and warrant treatment.
The treatment of chronic periodontal lesions that
may be associated with these defects often poses a
significant treatment challenge. While many materi-
als and techniques3-9 are used to effectively address
the lesions associated with chronic periodontitis, the
role of an effective and biocompatible material to
restore or repair the site of root perforation is also of
significant concern. An effective execution of regen-
erative therapy for the periodontal lesion and repair
of the root surface defect are, therefore, crucial. This
case report documents the treatment of a patient
who presented with a history of trauma to the max-
illa and subsequent development of external root
resorption, and a periodontal lesion to a maxillary
central incisor.
CASE REPORT
Patient History
The patient is a 41-year-old African-American male
who was referred by the Department of Oral Diag-
nosis to the Department of Endodontics for evalua-
tion of the maxillary right central incisor with a radi-
olucency on the distal surface of the midroot area.
Tooth #8 had a history of external root resorption
that was treated in April 1990 with open flap debride-
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Case Report
ment and placement of an amalgam restoration in
the area of root resorption on the distal surface of
the tooth. The site healed uneventfully and was
asymptomatic until a sinus tract was noted on the
facial gingiva between teeth #7 and #8 in Septem-
ber 1999. It should be noted that an exam in March
1999 noted no probing depth (PD) of #8 greater
than 3 mm; tooth #7 tested vital and exhibited PD
≤3 mm. Examination of tooth #8 revealed a PD ≤3
mm in all sites except the distal surface of the tooth,
which probed 12 mm. Radiographic evaluation
revealed a periradicular radiolucency on the distal
surface of #8, and the presence of an amalgam
restoration. Following consultation with the patient,
the decision was made to perform a surgical explo-
ration of the site.
Prior to surgery, the patient rinsed for 60 sec- Figure 1.
Facial view of debrided 2-wall osseous defect on the distal root
onds with a 0.12% chlorhexidine mouthrinse.‡ Local surface of tooth #8. Area of root perforation has had amalgam
anesthesia was administered (72 mg of lidocaine restoration removed and replaced with MTA.
and 0.036 mg of epinephrine). An intrasulcular in-
cision was made from the distofacial surface of #7
to the distofacial surface of #9. Intrasulcular inci-
sions were made on the palatal surface that
extended from the distal surface of #7 to the mesial
surface of #9. A vertical incision was placed at
the distofacial line angle of #7. Full-thickness flaps
were reflected both facially and palatally. Follow-
ing degranulation, a 2-wall (distal and palatal walls)
osseous lesion was noted (Fig. 1). The lesion mea-
sured 11 mm in height, 5 mm in width, and 7 mm
in depth. The amalgam restoration was approxi-
mately 6 mm × 4 mm and was associated with the
distal root surface of #8. A #2 round bur was used
in a high-speed handpiece to remove the restora-
tion. The root surface was planed with hand and
ultrasonic instruments. Following copious irrigation
of the site with sterile saline solution, a firm mix-
ture of MTA§ was placed into the root surface defect Figure 2.
and filled to the surface of the defect margin. The Facial view of osseous defect with DFDBA in place.
root surface was conditioned with tetracycline
hydrochloride (250 mg/5 ml saline) for 2 minutes.
patient subsequently received periodontal main-
Decalcified freeze-dried bone allograft (DFDBA)

tainence on a 3-month interval.
was then placed into the defect utilizing light pres-
Presurgical photographs were not available, since
sure (Fig. 2). Calcium sulfate was mixed for use
photography was initiated by the periodontist who
as a bioabsorbable barrier,¶ and was placed to cover
was called in at the point of restoration of the root
the DFDBA graft and at least 3 mm of the sur-
resorption site.
rounding osseous lesion (Fig. 3). The flaps were
repositioned with interrupted 4-0 polyglactin 910
sutures# (Fig. 4). Doxycyline was prescribed post- ‡ Peridex, Zila Pharmaceuticals, Inc., Phoenix, AZ.
operatively, with a regimen of 100 mg per day, for § ProRoot, Dentsply Tulsa Dental, Tulsa, OK.

LifeNet, Inc., Virginia Beach, VA.
10 days. A 0.12% chlorhexidine rinse b.i.d was uti- ¶ Capset, Lifecore Biomedical, Chaska, MN.
lized during the first 30 days following surgery. The # Ethicon, Inc., Somerville, NJ.

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Figure 3.
Calcium sulfate barrier placed over DFDBA graft and adjacent
border of osseous lesion.
Figure 4.
Closure of defect with 4-0 polyglactin 910 sutures.
DISCUSSION
Root lesions caused by external root resorption
have been treated with different materials, including
amalgam,10 composite resin,11 and glass ionomer
cement.12 MTA was utilized as the restorative mate-
rial in this case because of its reported ability to
provide a biocompatible surface for the possible
adhesion/attachment of bone and cementum.13,14
DFDBA was utilized as a graft material because of
its potential osseoinductive properties.15,16 Numerous
studies17-19 support the osseoinductive nature of
J Periodontol • December 2002
Case Report
this material, and attribute this property to the de-
mineralization of the cortical bone allograft and the
consequent exposure of bone morphogenetic protein
(BMP).20 This series of proteins has been reported
to support differentiation of host cells into osteoblasts.21
The fact that the lesion was well contained with
2 osseous walls (palatal and distal) was advantageous
in retention of the graft material and may have served
to enhance the outcome. Tetracycline hydrochloride
was utilized to condition the root surface following the
placement of MTA, and prior to the placement of
DFDBA. It was selected because of its ability to
remove the smear layer from the root surface.22
The use of periodontal barriers in anterior areas of
the mouth is of great concern due to the potential
for barrier exposure and subsequent gingival reces-
sion. Calcium sulfate was utilized as a barrier in an
attempt to minimize these potential complications.
Several clinical reports have noted minimal material
exposure when calcium sulfate is used in conjunction
with bone grafts,23 primarily because of the ability of
soft tissue to migrate over it.24 No exposure of the
calcium sulfate barrier or gingival recession was evi-
dent during the postoperative phase of therapy. The
use of calcium sulfate as a bioabsorbable barrier may
have several other advantages, including good adap-
tation to root surfaces, lack of a second surgical pro-
cedure for its removal, and ease of use.25
Numerous investigators25-27 have reported on the
use of calcium sulfate barriers in conjunction with
composite grafts of calcium sulfate and DFDBA
placed into osseous defects. Each of these investi-
gators utilized a composite graft that consisted of
20% calcium sulfate and 80% DFDBA. The combi-
nation of calcium sulfate and DFDBA has been exam-
ined by some authors.28 A comparison of a DFDBA-
calcium sulfate composite graft and calcium sulfate
barrier to gingival flap surgery alone revealed com-
parable clinical parameters for probing depth re-
duction and clinical attachment gains at both 6 and
12 months. However, probing bone level gain was
significantly greater in the DFDBA-calcium sulfate
composite group than in the gingival flap surgery
alone group at both time intervals. In our case report,
calcium sulfate was utilized only as a barrier and not
as part of a composite graft with DFDBA since the
graft material was well contained in the osseous
defect.
MTA is often utilized as a perforation repair and
root-end filling material. It is composed of tricalcium
silicate, tricalcium aluminate, tricalcium oxide, and sil-
icate oxide.29 It has a pH of approximately 12.5,30 and
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Case Report
setting time of approximately 4 hours.30 The powder
consists of fine hydrophilic particles that become a col-
loidal gel in the presence of moisture,31 and ultimately
reaches a hard consistency. Osorio et al.32 compared
the cytotoxicity of MTA to that of amalgam, Gallium
GF2, Ketac Silver, and Super-EBA (ZOE-base) in 2
different mammalian cell lines and 2 different cyto-
toxicity assays. MTA exhibited no cytotoxicity in either
system. Torabinejad et al.33 showed MTA to have sig-
nificantly less microleakage than amalgam, Super EBA,
and IRM when used as a root-end filling material.
Another study13 revealed the presence of cementum
and fibrous connective tissue in direct apposition to
the MTA root-end filling material. The regeneration of
cementum was a unique occurrence and had not been
demonstrated with any other material.
The favorable clinical outcome precluded tooth
extraction and subsequent histological analysis. A
conclusion relative to the type of interface between
the MTA material and the surrounding bone cannot,
therefore, be determined. A review of the preopera-
tive radiograph and the radiograph at 9 months post-
surgery reveals an increased radiodensity in the area Figure 6.
of the osseous lesion and suggests some degree of Periapical radiograph of tooth #8 at 9 months postsurgery.
bone formation (Figs. 5 and 6). The reduction of

Figure 7.
Facial view of surgical site at 9 months postsurgery.

probing depth and absence of clinical signs of inflam-

mation also support the clinical assessment of a
healthy dentogingival attachment (Fig. 7).
This case documents the presence of an osseous
defect in association with a lesion of external root
Figure 5.
Periapical radiograph of tooth #8 presurgery. resorption. The favorable outcome using a combina-
tion of MTA, DFDBA, and calcium sulfate demon-

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Case Report
strates that these materials, used in tandem, may be 16. Bowers GM, Chadroff B, Carnevale R, et al. Histologic
effective in the treatment of advanced root resorption evaluation of new attachment apparatus formation in
humans. Part II. J Periodontol 1989;60:675-682.
lesions and their associated osseous lesions. While
17. Urist MR. Bone formation by autoinduction. Science
this case report presents a favorable outcome, these 1965;150:893-899.
results may not be repeatable. 18. Urist MR, Dowell TA, Hay PH, Strates BS. Inductive sub-
strates for bone induction. Clin Orthop 1968;59:59-96.
ACKNOWLEDGMENT 19. Urist MR, Iwata H. Preservation and biodegradation of
The authors thank Dr. Everett B. Hancock for his the morphogenetic property of bone matrix. J Theor
mentorship and continued moral support in the exe- Biol 1973;38:155-167.
20. Urist MR, Strates B. Bone formation in implants of par-
cution of this case report.
tially and wholly demineralized bone matrix. Clin
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J Periodontol • December 2002 White, Bryant 1521