p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Original Article

Apical sealing and marginal adaptation of MTA

apical plug subjected to obturation after different
time intervals

Mosa A. Torky, Lecturer of Pedodontics, Assistant Professora,b,

Sukumaran Anil BDS, MDS, PhD, FDS RCPS (Glas), FICD, FPFA, Professor
and Consultantc,*
a
Faculty of Dental Medicine, Al-Azhar University, Egypt
b
College of Dentistry, Taiba University, Madina Munawara, Saudi Arabia
c
Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Post Box: 60169,
Riyadh 11545, Saudi Arabia

article info abstract

Article history: Objective: This study compares the apical seal and marginal adaptation of an MTA apical
Received 9 January 2014 plug in incisors obturated at three time intervals.
Received in revised form Method: Forty extracted central incisors were prepared with wide apex and divided into 4
3 August 2014 groups. The first group was obturated with gutta-percha and AH26 sealer, which served as
Accepted 11 September 2014 the positive control. The second group received an MTA apical plug and obturation
Available online xxx immediately. In the third and fourth group, obturation was delayed for 48 h and one week,
respectively. The apical seal was assessed by the dye penetration method and quantified
Keywords: using image analysis software. The marginal adaptation was studied using SEM.
Sealing ability Results: A significantly better apical seal was observed in the groups obturated after 48 h
Marginal adaptation and one week after MTA placement. The dye penetration did not show any significant
Mineral trioxide aggregate changes between the 48 h and one week groups. The marginal adaptation also showed a
Root-end filling materials minimal gap in the control and in samples with delayed obturation.
Apexification Conclusion: Based on this in vitro study, delaying obturation for 48 h after setting the MTA is
Obturation recommended for maximum apical sealing and marginal adaptation.
Copyright © 2014 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All
rights reserved.

constriction and the divergent apical architecture of the root

1. Introduction canal hamper complete debridement, canal disinfection and
obturation [1,2]. The apexification technique using calcium
Dental injuries in immature permanent teeth often result in hydroxide is still the most widely accepted technique for
endodontic complications. The absence of an apical

* Corresponding author. College of Dentistry, King Saud University, Post Box: 60169, Riyadh 11545, Saudi Arabia. Fax: þ966 1 467 9017.
E-mail addresses: drsanil@gmail.com, Ksucod@gmail.com (S. Anil).
URL: http://www.perio.in
http://dx.doi.org/10.1016/j.pdj.2014.09.004
0917-2394/Copyright © 2014 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
2 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
managing such conditions. However, drawbacks such as cor-
onal micro-leakage, tooth susceptibility to fracture, and mul-
tiple session treatment necessitate the development of an
alternative method for managing the situation [3].
Mineral trioxide aggregate (MTA) has been proposed as an
alternative material for apexification by combining biocom-
patibility and a bacteriostatic action with favorable sealing
ability when used to repair pulp chamber perforations or as a
root-end filling material [2,4,5]. MTA is non-resorbable, has
good biocompatibility and low cytotoxicity, and promotes
dental pulp and periradicular tissue regeneration. MTA has a
pH of 12.5 after setting, which is similar to the pH of calcium
hydroxide and this characteristic may impart some antimi-
crobial properties [6]. Studies have shown that MTA stimu-
lates natural dentin repair at pulpal exposure sites during
direct pulp capping [6]. Furthermore, MTA has relatively less
micro-leakage and can stimulate tissue regeneration, when it
is in direct contact with pulp and periradicular tissues [7].
MTA has been successfully used as an apical barrier in the
treatment of teeth with necrotic pulps and open apexes
[2,8e11].
Several studies have shown that MTA can be used for one
visit apexification [12]. MTA provides scaffolding for the for-
mation of hard tissue and has the potential to provide a better
biological seal. MTA apexification is a viable option for treat-
ing immature teeth with necrotic pulps and should be
considered as an effective alternative to calcium hydroxide
[8,13].
Although MTA has several advantages, one of the main
drawbacks is the long setting time, which could jeopardize the
sealing ability and marginal leakage [14]. So far, only limited
studies have been conducted to evaluate the setting of MTA on
the quality of the marginal adaptation and sealing. Hence, the
present study evaluates the apical sealing and adaptation of
open apexes that were obturated immediately, 48 h and 1
week after placing an MTA apical plug in an in vitro model.
2. Materials and methods
The study was approved by the Institutional Review board of
the Al-Azhar University, College of Dentistry, Egypt. A total of
40 freshly extracted permanent maxillary central and lateral
incisor teeth were used in this study. Teeth with a single non-
calcified canal, as confirmed by radiographs taken from
bucco-lingual and mesio-distal views, were selected. Any
tooth with abnormalities, such as internal resorption, oblit-
eration, pulp stones, cracks and fractures, were excluded and
replaced. The selected teeth were stored in normal 0.9% saline
solution during the experiment. Then, they were examined
with a magnifying glass to discard the specimens with any
cracks or fractures.
2.1. Tooth preparation and open apex simulation
Preparation of the access cavities were done using a water-
cooled round bur in a high-speed handpiece (NSK, Japan).
The working length was determined by placing a size 30 K-file
(Dentsply-Maillefer Instruments SA, Ballaigues, Switzerland)
in the canal until it was visible at the apical foramen and
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
subtracting 1 mm from this measurement. The canals were
prepared with Gates Glidden Burs (Dentsply-Maillefer In-
struments SA, Ballaigues, Switzerland) sizes 4, 3, and 2 for the
coronal third. The glide path was established by hand filling
with K-files sizes 15, 20, and 25 to a full working length.
Instrumentation was completed with a high torque motor at
300 rpm and 0.06 Taper Profile nickeletitanium rotary in-
struments (Dentsply Tulsa Dental, Tulsa, Oklahoma, USA).
The apical third of the canals were instrumented up to size
120 to simulate open apex teeth. To simulate immature teeth,
the canals were further enlarged using peeso reamers (No.
1e6, Mani, Japan) with gentle pressure and under copious
water spray until the No. 6 peeso could be passed beyond the
apex [15]. Irrigation was carried out using 2 ml of 2.5% sodium
hypochlorite (NaOCl). After preparation, each canal was irri-
gated with 5 ml of 17% EDTA (Calcinase EDTA, lege artis,
Dettenhausen, Germany) for 3 min to remove the smear layer,
followed by 2 ml of 2.5% sodium hypochlorite solution. The
final irrigation was performed with 5 ml of distilled water. The
canals were then dried with paper points.
The 40 prepared teeth were divided randomly into 4
groups.
Group 1: Obturated with gutta-percha and AH26 sealer.
Group 2: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
OK, USA) of approximately 5 mm thickness was placed.
The canal was sealed with gutta-percha and AH26 sealer
immediately after the initial setting of white MTA apical
plugs as per manufacturer recommendations.
Group 3: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
OK, USA) of approximately 5 mm thickness was placed.
The canal was sealed with gutta-percha and AH26 sealer
after 48 h of MTA setting.
Group 4: An MTA apical plug (ProRoot; Tulsa Dental, Tulsa,
OK, USA) of approximately 5 mm thickness was placed.
The canal was sealed with gutta-percha and AH26 sealer
after 1 week.
The obturation of all specimens was performed through
active lateral condensation technique. In this technique, the
main gutta-percha point was advocated as the endodontic
sealer and introduced into the root canal. Following that,
secondary points were added up for the complete filling of the
root canals.
2.2. Micro leakage
Following obturation, the coronal cavity was sealed with glass
ionomer cement (GC Fujirock EP; GC Europe NV, Leuven,
Belgium). The root segments from all groups were double-
coated with nail varnish except at the apical 3 mm. The
coated roots were suspended in 2% methylene blue dye in a
petridish and incubated at 37  C with 100% humidity for 48 h.
The teeth were then sectioned longitudinally along the
long axis in the bucco-lingual direction through the center of
the root. To prevent any damage to the inside of the canal, the
sectioning was done with water cooled diamond disc along
the root, short of reaching the obturation material, thereby
creating a stress canal. A chisel was used to wedge and split
the teeth.
 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6 3

Table 1 e The apical dye penetration of incisors obturated

with an MTA apical plug and gutta-percha immediately,
after 48 h and after one week.
Materials Micro leakage (mm)
(n ¼ 10) Mean ± SD
GP þ AH26 3.18 ± 0.82
MTA (immediate) 1.06 ± 0.27
MTA (48 h) 0.4 ± 0.11
MTA (1 week) 0.34 ± 0.1

Linear dye penetration was determined using a stereo-

microscope (Carl Zeiss, Oberkochen, Germany). The dye
leakage was measured with a millimeter scale from the apical
constriction to the longest point of dye penetration along the
Fig. 2 e Maxillary central incisor obturated with gutta-
canal walls and obturation material itself. Measurements
percha and AH24 sealer showing apical dye penetration.
were performed twice each by two independent examiners
and repeated jointly only if disagreement occurred in reaching
consensus.
extent of the gap between the MTA apical plug and radicular
dentin was observed, and the gap-free and gap-containing
2.3. Marginal adaptation
area along the filling-dentin interface was evaluated.

The marginal adaptation was evaluated in the 30 segments.

2.4. Statistical analysis
These segments were gold-sputtered and analyzed with SEM.
For evaluation of the marginal adaptation of the root canal
Statistical analysis of the data was performed using the
filling, photographs were taken at 2000 magnifications and
GraphPad InStat® software (InStat, GraphPad InStat, Inc. San
analyzed with an image analysis software (The imageJ soft-
Diego, CA). Differences between the three study groups for all
ware, National Institutes of Health, Bethesda, Maryland). The
variables were determined with One-way Analysis of Variance
(ANOVA). When an overall ANOVA showed statistical signifi-
cance, post hoc testing (TukeyeKramer Multiple Comparisons
Test) was performed to explore the differences between any
two groups. p-values <0.05 were considered significant.

3. Results

The highest mean value of apical dye penetration was recor-

ded with teeth obturated with gutta-percha and AH24 sealer
without an apical plug, and the lowest value was recorded
with teeth obturated with an MTA apical plug, gutta-percha

Fig. 1 e The apical dye penetration of incisors obturated Fig. 3 e Maxillary central incisor with an MTA apical plug
with an MTA apical plug and gutta-percha immediately, that was obturated after 48 h showing minimal dye
after 48 h and after one week. penetration.

Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
4 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
and AH24 sealer after one week. One way analysis of variance
(ANOVA) revealed that the difference was statistically signif-
icant (p  0.01).Tukey's post hoc test revealed that the differ-
ence between the MTA apical plug groups at 48 h and 1 week
was statistically non-significant at p > 0.01 (Table 1, Fig. 1).
Comparing the apical dye penetration of the MTA groups at
different periods showed that the greatest mean value of dye
penetration was recorded in the immediate group, while the
lowest value was recorded in the group obturated after 1 week.
One way analysis of variance test revealed that the difference
was statistically significant (p < 0.01). Tukey's post hoc test
revealed that the difference between the MTA group at 48 h
and 1 week was not statistically significant (Table 1, Figs. 1e3).
3.1. Scanning electron microscopic observations
SEM was used to qualitatively assess the mechanisms
responsible for the leakage, by evaluating the adaptation of
the MTA apical plug to the dentinal walls. The present study
found that delayed MTA apical plug and gutta-percha filling
had better sealing ability than the control and immediate
obturation. The results were also confirmed by the SEM. Ex-
amination of the photomicrographs of the samples demon-
strated variable gaps at the dentin-MTA interfaces. Delayed
obturation presented much smaller gaps at the dentin-MTA
apical plug interface than the immediate MTA apical plug
(Figs. 4e6).
4. Discussion
Endodontic treatment of traumatized immature teeth with
periapical lesions is performed by inducing apical closure by
apexification and then forming an adequate seal in the root
Fig. 4 e Scanning electron microscope (SEM) of the apical
third of the incisor showing a gap area between the MTA
apical plug and the radicular dentin with immediate
obturation.
Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
apex. Although calcium hydroxide is the first choice for an
intra-canal dressing in apexification; some drawbacks such as
coronal micro-leakage, tooth susceptibility to fracture, and
multisession treatments have led to the exploration of
appropriate alternatives [6,16,17]. MTA-based sealers have
been reported to be biocompatible and can stimulate miner-
alization and encourage apatitelike crystalline deposits along
the apical thirds of canal walls [18].
Several methods are used to determine the sealing ability
of apical plugs, such as polymicrobial leakage, linear dye
leakage, diaphanization, fluid filtration, radioisotope labeling,
and the electrochemical method [19]. In this study the meth-
ylene blue dye solution method was selected because of its
advantages over the other tracing materials, including its
solubility in water, ability to easily penetrate into the water
compartment of the tooth, non-absorbability into the dentinal
matrix or apatite crystals and ability to penetrate further than
any isotope traces.
The apical sealing ability of MTA has been shown to exhibit
good sealing ability [20e22]. Because the setting time of MTA is
longer in the current study, the sealing ability was tested
against the delayed obturation of the root canal. The obtura-
tion of the root canal after 48 h showed maximal sealing
ability and adaptation compared to immediate obturation.
Obturation of the root canal after 1 week did not show any
significant improvement in the apical sealing of MTA
compared to obturation after 48 h. The assumption is that
obturation after 48 h showed better sealing ability of the MTA
plug compared to immediate obturation.
MTA has been shown to prevent micro-leakage and to
stimulate tissue regeneration when in direct contact with pulp
and periradicular tissues [23]. Clinical studies of open apex
teeth obturated with MTA in one appointment demonstrated
healing rates that ranged from 81 to 100% [24,25], with 94.1%
Fig. 5 e SEM of the apical third of incisor showing a
minimal gap between the MTA apical plug and radicular
dentin that was obturated after 48 h.
 p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1 e6
Fig. 6 e SEM of the apical third of incisor showing a
minimal gap between the MTA apical plug and the
radicular dentin that was obturated after one week.
clinical success and 76.5% radiographical success when used
as an apical plug in permanent incisors [26,27]. The hydro-
philic nature of the particles from MTA powder allows its use
even in the presence of moisture contamination, specifically
from blood, and does not affect its sealing ability, which is
often a problem with other materials typically used in apex-
ification [28].
The setting time of MTA has been reported to range from
75 min to 72 h for an initial set and 21 days for complete curing
[29,30]. Hence, a two-visit procedure is advocated to obtain
good apical sealing of the material [31].
5. Conclusion
Within the limitations of this in vitro study it can be assumed
that the two-visit protocol is ideal for obtaining maximum
apical sealing and marginal adaptation for MTA. Further
studies in a clinical setting are essential to reinforce the cur-
rent observations in the in vitro model.
Conflict of interest
None.
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obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004
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Please cite this article in press as: Torky MA, Anil S, Apical sealing and marginal adaptation of MTA apical plug subjected to
obturation after different time intervals, Pediatric Dental Journal (2014), http://dx.doi.org/10.1016/j.pdj.2014.09.004