Australian Dental Journal 2010; 55: 92–95

CASE REPORT
doi: 10.1111/j.1834-7819.2009.01181.x

Usage of white mineral trioxide aggregate in a non-vital

primary molar with no permanent successor
E Sen Tunc, S Bayrak*
*Department of Paediatric Dentistry, Faculty of Dentistry, Ondokuz Mayis University, Samsun, Turkey.

ABSTRACT
The aim of this study was to present the treatment and long-term follow-up of a case in which white mineral trioxide
aggregate (WMTA) was used in the pulpectomy of a non-vital primary molar with no permanent successor.
The physiological, aesthetic and functional consequences of treating primary teeth without permanent successors makes
this a unique challenge. In the present case, WMTA was used in the pulpectomy of a primary molar with no permanent
successor in an 8-year-old child. The treatment was considered successful. Follow-up examinations showed that root
resorption in the mesial root surface, with no infra-occlusion or ankylosis 36 months after treatment.
WMTA may be considered as an alternative pulpectomy material for non-vital primary teeth with no permanent
successors, although long-term clinical studies are still needed.
Keywords: Agenesis, hypodontia, primary teeth, pulpectomy, white mineral trioxide aggregate.
Abbreviations and acronyms: MTA = mineral trioxide aggregate; WMTA = white mineral trioxide aggregate.
(Accepted for publication 15 June 2009.)

retain the pulpally involved primary tooth, pulpotomy

INTRODUCTION
or pulpectomy may be indicated.10,11
Hypodontia, the congenital absence of one or more In the conventional pulpectomy of a pulpally
teeth, is one of the most common dental polymor- involved primary tooth with a missing permanent
phisms to occur in humans.1,2 Hypodontia is classi- successor, the canals are filled with gutta-percha
fied according to the severity of the condition, with following reconstruction of the crown.12 However,
the term ‘‘mild-to-moderate hypodontia’’ used to there are inherent limitations involved in preparing
denote the absence of between two and five teeth curved, fragile primary molar roots to a proper master
and ‘‘severe hypodontia’’ (oligodontia) to denote the apical file size, and it may be difficult to achieve
absence of six or more teeth.1 The frequency of adequate obturation. A recent study recommended the
missing teeth varies among different populations, and use of mineral trioxide aggregate (MTA) for canal
it is generally accepted that the mandibular second obturation in retained primary teeth. However, no
premolar is the most common congenitally missing long-term results were reported.10
tooth (excluding the third molars).3,4 Hypodontia is MTA is an aggregate of fine hydrophilic particles that
often associated with retained and infra-occluded hardens on contact with water.13 It is comprised of
primary molars.5 75% Portland cement, 20% bismuth oxide and 5%
Treatment of retained primary molars with no gypsum by weight, and while the initial compound was
premolar successors presents a challenge for paediatric grey in colour, a white mineral trioxide aggregate
dentists, prosthodontists and orthodontists in terms of (WMTA) has recently become available as well.14,15
managing the missing second premolar successor.6 This colour change has broadened the indications for
There are two main strategies used today; either MTA, enabling its application in anterior teeth. Orig-
extracting the primary second molar, or maintaining inally developed for use in endodontics for the repair of
it for as long as possible and then seeking a prosthetic root perforations,16 MTA was subsequently recom-
solution.7–9 In some cases, when the decision is made to mended for use as a root-end filling material.17 It has
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 White mineral trioxide aggregate in primary molar pulpectomy

also been used in vital pulp therapy18,19 and as an and his parents, who provided their written consent prior
apical barrier in the treatment of immature teeth with to treatment.
non-vital pulp and open apices.20 Potential uses of A regional anaesthetic was administered to block the
MTA in other dental and medical procedures are buccal, lingual and inferior alveolar nerves, and the
continually being explored. tooth was isolated with a rubber dam. A No. 245 bur
This case report documents the treatment and long- (Dentsply Maillefer, Tulsa, OK, USA) in a high-speed
term follow-up of a pulpectomy performed using handpiece was used for coronal access, and coronal
WMTA on a non-vital primary molar with no perma- pulp was removed with a round, spoon-shaped exca-
nent successor. vator. A No. 15 K-File was used to determine the
working length of the canals (15 mm), which were
prepared up to a No. 35 K-File at 14 mm using a step-
CASE DESCRIPTION
back technique. Canals were irrigated with 2.5%
A healthy 8-year-old boy was referred to the paediatric sodium hypochlorite (NaOCl) and dried with sterile
dental clinic with the complaint of a toothache in the paper points. Calcium hydroxide (Kalsin, Aktu Tic,
mandibular left molar region. Clinical examination I_ zmir, Turkey) was placed in the canals using a lentulo
showed the mandibular left second primary molar (75) spiral, and a temporary coronal seal was made with
to be slightly symptomatic to percussion, and a sinus glass ionomer cement (Fuji IX, GC Corporation,
tract was observed and traced to the tooth apex. Japan). After one month, the sinus tract had dis-
Radiographic examination revealed gross caries in the appeared, and the patient was free of symptoms. The
mandibular left second primary molar and absence of calcium hydroxide was removed by repeated rinsing
the successional premolar (Fig 1). It was noted that with 2.5% NaOCl, followed by rinsing with sterile
agenesis of the mandibular left second premolar was water. The canals were dried with sterile paper points,
unilateral. Based upon clinical and radiographic exam- and a WMTA mixture was prepared using sterile water
ination, a diagnosis for the 75 was made of pulp according to the manufacturer’s instructions. The
necrosis and chronic apical abscess with a sinus tract WMTA mixture was placed in the canals with a lentulo
and no evidence of ankylosis or infra-occlusion. spiral and compacted using paper points. The adapta-
According to the patient’s mother, there was no family tion was checked radiographically, a cotton pellet
history of tooth agenesis. moistened with sterile water was placed in the pulp
An orthodontic examination was conducted, and an chamber, and the access cavity was closed with glass
initial treatment plan was developed that aimed to avoid ionomer cement. After three days, the glass ionomer
any future malocclusion by maintenance of the 75 for as cement and cotton pellet were removed, and the set of
long as possible, after which time an implant replacement the WMTA was gently tested. The cavity was then
would be inserted. Accordingly, the decision was made to restored again with glass ionomer cement and a
treat the 75 by pulpectomy using WMTA (ProRoot, stainless steel crown (3M Dental Products, USA)
Dentsply, Tulsa Dental, OK, USA). The treatment (Fig 2).
objectives and alternatives were explained to the patient Regular follow-up appointments were conducted
at six-month intervals. At 36-months of follow-up,
the patient had no clinical signs or symptoms, and

Fig 1. Initial periapical radiograph shows extensive caries and

enlargement of the periodontal ligament in the 75 and absence of the Fig 2. Immediate postoperative radiograph of the tooth treated with
premolar successor. WMTA.
ª 2010 Australian Dental Association 93
E Sen Tunc and S Bayrak

premolar. For this reason, a WMTA pulpectomy was

performed, and regular follow-up appointments were
scheduled to control for pulpal pathology, ankylosis
and infra-occlusion.
Conventionally resorbable pastes such as zinc oxide-
eugenol, iodoform and calcium hydroxide can be used
for primary teeth pulpectomies. In the case of primary
teeth with no permanent successors, pulpectomy treat-
ment is performed in the same manner as with
permanent teeth.12 MTA has been recommended as a
root-canal filling material in pulpectomies of permanent
teeth.25,26 Although obturation with gutta-percha has
been shown to provide a better apical seal than MTA,27
WMTA was selected as a root-filling material in the
Fig 3. 36-month follow-up periapical radiograph shows root
resorption in the mesial root surface. present case because of MTA’s biocompatibility28,29
and its role in enhancing regeneration of periradicular
tissue,30 and because of reported complications in
radiographic examination showed root resorption in gutta-percha pulpectomies related to inherent proper-
the mesial root surface. The tooth was well-functioning, ties of primary molars.10
and no infra-occlusion or ankylosis was detected Optimal dental treatment planning requires an accu-
(Fig 3). rate assessment of the outcome of any required end-
odontic treatment.31 Studies on endodontic prognosis
have addressed a wide range of factors in an attempt to
DISCUSSION
accurately forecast the course of endodontic treatment
Treatment options for congenitally missing mandibular outcome.32–35 These factors include pulpal and periapi-
second premolars vary according to the patient’s age, cal diagnosis,32 residual pulp space infection,32,33 level of
the development stage of adjacent teeth and the root obturation,32 procedural iatrogens,34 and presence and
resorption and infra-occlusion of the primary predeces- quality of the permanent restoration.35 In the present
sor.7,9 Options include maintaining the primary tooth, case, the 75 had been retained for up to 36 months post-
extracting the primary tooth and allowing the space to therapy without clinical signs or symptoms of obvious
close spontaneously, implant replacement, auto-trans- endodontic failure or premature exfoliation. After
plantation, prosthetic replacement and orthodontic 36 months of follow-up, radiographic examination
space closure.7,9 showed root resorption in the mesial root surface.
In growing patients, implants are contraindicated, as However, it is difficult to say this finding is entirely a
they impede the normal alveolar growth process.21 Age physiological root resorption; it could be physiological
is also an issue with regard to conventional fixed partial and ⁄ or pathologic root resorption. It was thought that
dentures, since preparation of the abutment teeth may root resorption in this case could be related to the above-
need to be delayed due to pulp size in young patients, mentioned factors, especially apical periodontitis. The
and lengthy space maintenance may be necessary.7,9 presence of pre-operative root canal infection (apical
Auto-transplantation of a third molar or another periodontitis) was recently defined as a key confounding
premolar is a viable option, if a suitable donor tooth factor in endodontic treatment outcome.36 It often
is available,7,9 although the need for surgical interven- develops without giving any subjective symptoms. Phys-
tion is a disadvantage.22 Extraction and spontaneous iological root resorption may be accelerated or delayed
space closure is a conservative treatment option, but the by local factors such as mechanical-occlusal trauma and
timing of the extraction is critical, as early removal of pathologic processes occurring in the tooth and sur-
the second primary molar can cause a series of changes roundings tissues.37 In the present case, treatment
in the dental arches, including reduction in arch length, prognosis may be affected by root resorption. If the root
inclination of adjacent teeth, alveolar bone resorption resorption will progress agressively, different treatments
and extrusion of the antagonist tooth. In such cases, such as a space maintainer can be applied.
future malocclusion may be avoided by maintaining the
primary molar.23,24
CONCLUSIONS
In the present case, the decision to maintain the 75
for as long as possible before inserting an implant WMTA may be considered as an alternative pulpecto-
replacement was based on the patient’s age, the lack of my material for non-vital primary teeth with no
any malocclusion or arch-length deficiency, and the permanent successors although long-term clinical stud-
unilateral agenesis of the mandibular left second ies are still required.
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 White mineral trioxide aggregate in primary molar pulpectomy

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