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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 164-168

Pulpectomy using mineral trioxide aggregate of a nonvital primary molar with no permanent premolar successor

1 Department of Conservative Dentistry and Endodontics, University Hospital Farhat Hached, Sousse, Tunisia
2 Department of Dental Medicine, University Hospital Farhat Hached, Sousse, Tunisia

Date of Web Publication6-Nov-2017

Correspondence Address:
Nesrine Tebbeb
Department of Dental Medicine, EPS Farhat Hached, Avenue IBN EL Jazzar, Sousse 4031
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_48_17

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Physiological root resorption is a known phenomenon for deciduous teeth with uncertain etiologic factors. The initiation of root resorption could be due to the injury or the infection of the pulp. The physiological, esthetic, and functional consequences of treating primary teeth without permanent successors make it a unique challenge. The aim of this article was to present the treatment, and long-term follow-up of a case in mineral trioxide aggregate (MTA) was used in the pulpectomy of a nonvital primary molar with no permanent successor in a 14-year-old child. The treatment was root canal treatment and total obturation using MTA. Follow-up examinations were done and showed a radiographic healing of the periapical radiolucency and resorption of mesial root. Furthermore, the tooth was asymptomatic and clinically functional.

Keywords: Mineral trioxide aggregate, pulpectomy, retained primary molar

How to cite this article:
Tebbeb N, Zouiten S, Chafra H, Boughzala A. Pulpectomy using mineral trioxide aggregate of a nonvital primary molar with no permanent premolar successor. Endodontology 2017;29:164-8

How to cite this URL:
Tebbeb N, Zouiten S, Chafra H, Boughzala A. Pulpectomy using mineral trioxide aggregate of a nonvital primary molar with no permanent premolar successor. Endodontology [serial online] 2017 [cited 2022 Dec 8];29:164-8. Available from: https://www.endodontologyonweb.org/text.asp?2017/29/2/164/217717

  Introduction Top

The incidence of agenesis in permanent tooth is between 3.4% and 10.1% and mandibular second premolar presents 3.4%.[1],[2]

The etiologic factors of Rhyzalyse still uncertain. The infection or the injury (mechanically and/or chemically) of the pulp can initiate the root resorption. The treatment depends on the stimulation factors (pulp or periodontium infection, tooth impaction, tumor, or orthodontic forces).[3]

This paper described a case report of a total obturation with mineral trioxide aggregate (MTA) of the canal system of a mandibular primary molar with no successional premolar.

  Case Report Top

A healthy 14-year-old girl was referred to the Department of Dental Medicine, University Hospital Farhat Hached of Sousse, Tunisia, with the complaint of a toothache in the mandibular right molar region and recurrent abscess and sinus tract. Clinical examination showed the mandibular right second primary molar (85) to be slightly symptomatic to percussion, and a double sinus tract was observed on the apex [Figure 1]. The periapical radiographic examination revealed that the sinus tract was traced to the mesial root of the mandibular right second primary molar [Figure 2]. The panoramic radiograph showed an absence of the successional premolar [Figure 3]. It was noted that agenesis of the mandibular right second premolar was unilateral. Based on clinical and radiographic examination, a diagnosis for the 85 was made of pulp necrosis and chronic apical abscess with a sinus tract and no evidence of ankylosis or infraocclusion. According to the patient's mother, there was no family history of tooth agenesis. Root canal treatment was done using Revo-S sequence (Micro Mega, BESANCON Cedex FRANCE) to get the diameter of 25 mm and 4% conicity of SC2 file and the irrigation was done with 2.5% sodium hypochlorite. After drying with sterile paper points, the canal system was obturate with ENDOCEM MTA using lentulo. The powder was mixed with distilled water respecting a ratio P/L = 300 mg/0.12 cc [Figure 4]. After 2 weeks, the cicatrization of sinus tract was noticed, so the access cavity was sealed with composite [Figure 5]. The follow-up done after 6 and 9 months, 1–3 years demonstrated a radiographic healing of the periapical radiolucency and resorption of mesial root [Figure 6], [Figure 7], [Figure 8], [Figure 9]. The tooth was asymptomatic and clinically functional with a gray discoloration of the crown [Figure 10].
Figure 1: Double sinus tract

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Figure 2: Sinus tract traced to the mesial root

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Figure 3: Panoramic radiograph (agenesis of 45)

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Figure 4: Postoperative radiograph (complete canal obturation with mineral trioxide aggregate)

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Figure 5: Coronal obturation with composite and absence of sinus tract

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Figure 6: Six-month follow-up

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Figure 7: Nine-month follow-up

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Figure 8: Twelve-month follow-up

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Figure 9: Twenty-four-month follow-up

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Figure 10: Gray discoloration of the crown and absence of sinus tract

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  Discussion Top

The dentist is faced to a challenge to choose the right treatment in case of retained deciduous molars with missing second premolar because of the multiplicity of etiological factors: the age, the development stage of adjacent teeth, and the root resorption and infraocclusion of the primary predecessor. There is a variety of treatment options such as maintaining the primary tooth or extract it to be replace with an implant or prothesis.[4],[5],[6]

If extraction of the second primary molar is indicated, the timing is imperative because of its harmful effects on dental arches such as arch-length reduction, malalignment of adjacent teeth, alveolar bone resorption, and extrusion of the antagonist tooth. So future malocclusion can be prevented by maintaining it.[7] Hence, if we decide to retain the deciduous tooth, we indicate pulpotomy or pulpectomy depending on pulp status. Bhuria et al. in his case chose maintaining the mandibular left second primary molar with missing successor premolar as long as possible before extraction and replace it with an implant. This choice was based on the young age of the patient, absence of any malocclusion, or arch-length deficiency. Hence, a conventional pulpectomy, gutta-percha obturation, and reconstruction of the crown were done. Regular follow-up appointments were planned to reevaluate pulpal pathology, ankylosis, and infraocclusion. Six-month follow-up showed a complete resorption of the roots, and gutta-percha cones were fixed in the bone.[8]

In 2010, Tunc and Bayrak published another case where the decision was also to maintain the mandibular second primary molar for as long as possible because of the agenesis of the successor premolar. Pulpectomy and total obturation of the canal with white MTA were done. A regular follow-up appointments were programmed to control. Three years later, radiographic examination showed resorption in the mesial root surface, and the tooth was well functioning, and no infraocclusion or ankylosis was detected.[9]

Previously, the pulpectomy of primary tooth with a missing permanent successor was done like permanent tooth and the canals were filled with gutta-percha following reconstruction of the crown.[10] Recently, O'Sullivan and Hartwell showed successful treatment of a primary molar that had no successor permanent tooth using MTA as a root canal filling material. However, no long-term results were reported.[11]

MTA have excellent proprieties such as sterility, radiopacity, resistance to moisture, good sealability against bacterial microleakage, and bioinduction. Due these proprieties, it stimulates mechanisms responsible for the bioremineralization and resolute of periapical disease that can improve treatment outcomes.[12],[13] A study done by Holland et al. showed that MTA consistently induces closure of the main canal foramen by new cementum deposition with an absence of inflammatory cells after 6 months.[14] In 2007, the same researchers examined the influence of the obturation's extent on apical and periapical tissue response in dogs' teeth after filling root canals with MTA. Their results showed closure of the apex in 80% of their samples with hard tissue after 90 days and the presence of chronic inflammatory cells around the majority of periapical tissues.[15]

To use MTA as root canal filling, the procedure of canal treatment requires the same preparation and irrigation protocol executed for gutta-percha placement. Even if the removal or retention of the smear layer before canal obturation still remains controversial because it does not appear to affect the sealability of MTA materials and its presence might actually improve the seal over time.[12],[13] So because of these proprieties, MTA was our choice of root canal filling in this case.

However, in other way, it presents drawbacks discoloration potential, the difficulty to be used in obturation of curved root canals, the impossibility of retreatment, and the high cost.[16]

In other hand, many dentists do not support the complete pulpectomy in primary molars. This negative attitude is mostly due to fear of damage on the developing permanent tooth buds, the difficulty in negotiating, cleaning, shaping and filling a bizarre and tortuous canal anatomy, and the high risk of root resorption.[17]

In our case, we find a root resorption on the mesial root surface such as the case of Tunc and Bayrak. However, we cannot affirm if this resorption is physiological. It was thought that root resorption in this case could be related to the above-mentioned factors, especially apical periodontitis. It can be caused, especially to furcal or preoperative infection, especially apical periodontitis infection. The accessory canals in the furcation area often lead to the endodontic failure and affect the treatment outcome. It often develops without giving any subjective symptoms. Physiological root resorption may be accelerated or delayed by local factors such as mechanical-occlusal trauma and pathologic processes occurring in the tooth and surroundings tissues. In the present case, treatment prognosis may be affected by root resorption. If the root resorption will progress aggressively, the extraction will be indicated.[9],[18]

  Conclusion Top

MTA is recommended as an option pulpectomy material for nonvital primary teeth with no permanent successors, but it is important to improve the long-term clinical studies to confirm its benefit in such cases. Furthermore, Identification of causes of root resorption is useful to provide correct treatment by removing the etiological factor.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Polder BJ, Van't Hof MA, Van der Linden FP, Kuijpers-Jagtman AM. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol 2004;32:217-26.  Back to cited text no. 1
Dhanrajani PJ. Hypodontia: Etiology, clinical features, and management. Quintessence Int 2002;33:294-302.  Back to cited text no. 2
Fuss Z, Tsesis I, Lin S. Root resorption – Diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol 2003;19:175-82.  Back to cited text no. 3
Sabri R. Management of congenitally missing second premolars with orthodontics and single-tooth implants. Am J Orthod Dentofacial Orthop 2004;125:634-42.  Back to cited text no. 4
Fines CD, Rebellato J, Saiar M. Congenitally missing mandibular second premolar: Treatment outcome with orthodontic space closure. Am J Orthod Dentofacial Orthop 2003;123:676-82.  Back to cited text no. 5
Fiorentino G, Vecchione P. Multiple congenitally missing teeth: Treatment outcome with autologous transplantation and orthodontic space closure. Am J Orthod Dentofacial Orthop 2007;132:693-703.  Back to cited text no. 6
Bjerklin K, Bennett J. The long-term survival of lower second primary molars in subjects with agenesis of the premolars. Eur J Orthod 2000;22:245-55.  Back to cited text no. 7
Bhuria P, Khinda VI, Brar GS, Bajaj N. Treated primary molar with missing succedanous permanent premolar: A rare case report. Int J Dent Med Res 2015;1:109-12.  Back to cited text no. 8
Tunc ES, Bayrak S. Usage of white mineral trioxide aggregate in a non-vital primary molar with no permanent successor. Aust Dent J 2010;55:92-5.  Back to cited text no. 9
Camp JH, Barrett EJ, Pulver F. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Cohen S, Burns RC, editors. Pathways of the Pulp. St. Louis: Mosby; 2002. p. 797-844.  Back to cited text no. 10
O'Sullivan SM, Hartwell GR. Obturation of a retained primary mandibular second molar using mineral trioxide aggregate: A case report. J Endod 2001;27:703-5.  Back to cited text no. 11
Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90.  Back to cited text no. 12
Yildirim T, Oruçoǧlu H, Cobankara FK. Long-term evaluation of the influence of smear layer on the apical sealing ability of MTA. J Endod 2008;34:1537-40.  Back to cited text no. 13
Holland R, de Souza V, Nery MJ, Otoboni Filho JA, Bernabé PF, Dezan Júnior E, et al. Reaction of dogs' teeth to root canal filling with mineral trioxide aggregate or a glass ionomer sealer. J Endod 1999;25:728-30.  Back to cited text no. 14
Holland R, Mazuqueli L, de Souza V, Murata SS, Dezan Júnior E, Suzuki P, et al. Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs' teeth after root canal filling with mineral trioxide aggregate. J Endod 2007;33:693-7.  Back to cited text no. 15
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review – Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.  Back to cited text no. 16
Mohamed Aly Ahmed H. Pulpectomy procedures in primary molar teeth. Eur J Gen Dent 2014;3:3-10.  Back to cited text no. 17
Chugal NM, Clive JM, Spångberg LS. A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:342-52.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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