Clinical evaluation of mineral trioxide aggregate in the surgical management of degree I and degree II furcation defects

Rajneesh Parimoo; Baljeet Singh; Rajesh Gupta

doi:10.4103/SDJ.SDJ_22_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 3 | Page : 79-83

Clinical evaluation of mineral trioxide aggregate in the surgical management of degree I and degree II furcation defects

Rajneesh Parimoo¹, Baljeet Singh², Rajesh Gupta³
¹ Department of Periodontology and Oral Implantology, Desh Bhagat Dental College and Hospital, Fatehgarh, Punjab, India
² Department of Periodontology and Oral Implantology, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh, India
³ Department of Periodontology and Oral Implantology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana, India

Date of Submission	18-Jun-2020
Date of Decision	09-Jul-2020
Date of Acceptance	01-Sep-2020
Date of Web Publication	17-Oct-2020

Correspondence Address:
Rajneesh Parimoo
H. No 131/2 Lane 3, Govind Nagar, Talab Tillo, Jammu - 180 002, Jammu and Kashmir
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_22_20

Abstract

Background: Mineral trioxide aggregate (MTA) is known as a strong bioactive material which induces hard tissue formation. It does not get contaminated with tissue fluids or blood and has low cytotoxicity with good antibacterial effects. Objectives: This study aims to evaluate the clinical effectiveness of MTA in the surgical management of Degree I and Degree II furcation defects. Methods: Individuals were 15 patients exhibiting clinical and radiographic evidence of Degree I and Degree II furcation defects. The pocket probing depth, plaque index, gingival index, relative vertical clinical attachment level, relative horizontal clinical attachment level, and gingival recession level of subjects were recorded at baseline, 3 months, and 6 months. Data were analyzed at a significance level of P < 0.05 using paired t-test. Results: The purpose of this study was to maintain furcation involved teeth with the use of MTA. Regeneration of periodontal attachment apparatus by MTA was not the goal of the treatment technique used in this study. However, MTA application results improvement in the recorded clinical parameters.
Conclusion: MTA is effective in obliterating the Degree I and Degree II furcation defects. There are no signs and symptoms of any adverse effect to this treatment.

Keywords: Furcation defects, mineral trioxide aggregate, obliterate, periodontitis

How to cite this article:
Parimoo R, Singh B, Gupta R. Clinical evaluation of mineral trioxide aggregate in the surgical management of degree I and degree II furcation defects. Sci Dent J 2020;4:79-83

How to cite this URL:
Parimoo R, Singh B, Gupta R. Clinical evaluation of mineral trioxide aggregate in the surgical management of degree I and degree II furcation defects. Sci Dent J [serial online] 2020 [cited 2023 Jun 9];4:79-83. Available from: https://www.scidentj.com/text.asp?2020/4/3/79/298170

Background

Furcation involvement relates to bone destruction and attachment loss in the interradicular space that results mainly from plaque-associated periodontal disease. This condition considerably raises the chances of tooth loss. The maxillary first molars are usually more affected than mandibular first molars.^[1] Once the lesion has developed, the variance of bacterial insult between the root surfaces and the periodontal soft tissues is responsible for a reduced healing response. A significant periodontal attachment and osseous structure loss occurs, resulting in a guarded long-term prognosis.^[2] The ideal end result of the furcation therapy is its closure.

Once the osseous defect develops, the surgical modalities for the management includes: Open flap debridement alone in the furcation, open flap debridement in conjuction with bone grafts, and bone grafts with or without guided tissue regeneration. The common observation in the last few years is that the outcomes have improved due to understanding of the disease process and wound healing. Recently, materials such as amalgam, glass ionomer, and polymeric reinforced zinc oxide eugenol have proven to obliterate furcations and improve hygiene by removing the anatomic niches within the furcation, where bacteria go and accumulate.^[3]

All the strategies are directed at regenerating the lost periodontal structures. Recently, an innovative material, mineral trioxide aggregate (MTA) has been tried in the management of furcation defects.^[4] MTA was first introduced by Torabinejad et al. at Lomalinda University and was reported in the dental literature in 1993.^[5] MTA is a powder comprising of fine hydrophilic particles which gets set in the presence of moisture. It is basically a combination of a refined Portland cement and bismuth oxide with inclusion of dicalcium silicate, tricalcium silicate, tricalcium aluminate, and tetra calcium aluminoferrite and is also known to contain minor quantity of other mineral oxides such as S_iO₂, CaO₂, MgO, K₂ SO₄, and Na₂ SO₄, which affects its physical and chemical properties.^[6] Similar to calcium hydroxide which possesses antimicrobial properties too, MTA, after setting has a pH of 12.5.^[6]

MTA is known as a strong bioactive material which induces hard tissue formation, and is biocompatible.^[7] It does not get contaminated with tissue fluids or blood and has low cytotoxicity with good antibacterial effects. In addition, MTA enhances cement oblast attachment, growth, and production of mineralized matrix. Apart from this, it results in differentiation of osteoblasts and cement oblasts in human periodontal ligament cells, which results in expression of calcium sensing receptors and bone morphogenetic protein-2 receptors that are potentially involved in osteogenesis.

Considering these novel properties and abilities of the MTA in promoting regeneration, present study was planned and carried out with an aim to clinically evaluate the effectiveness of MTA in the surgical management of Degree I and Degree II furcation defects.^[8]

Materials and Methods

This study was approved by the institutional ethical committee and was carried out on 15 patients in the age group of 20–65 years, from either sex, in the Department of Periodontology and Oral Implantology, Bhojia Dental College and Hospital, Baddi (Himachal Pradesh). All the patients received verbal information regarding the study protocol and a written informed consent was obtained from each patient for participation in the study.

Patients exhibiting clinical and radiographic evidence of Degree I (Horizontal loss of periodontal tissue support <3 mm) and Degree II (Horizontal loss of periodontal tissue support exceeding 3 mm but not encompassing the total width of the defect) furcation defects^[9] in the mandibular 1^st and 2^nd molars (buccal and lingual defects) were selected from amongst the patients visiting the department. The study was carried out on 18 patients with 18 defects, in the age group of 20–65 years. Out of these, 15 patients (13 males and 2 females) with 15 defects completed the follow-up of 6 months.

Inclusion criteria

Systemically healthy controls
Patients in the age group of 20–65 years
Patients exhibiting clinical and radiographic evidence of Degree I and Degree II furcation defects
Asymptomatic teeth, without any pulpal or periapical pathology
Teeth with no mobility
Patients willing to sign the consent form.

Exclusion criteria

Smokers
Patients with complicated medical history
Patients with metabolic bone diseases, for example, osteoporosis and rheumatoid arthritis
Patients undergoing radiotherapy or chemotherapy
Pregnant and lactating female patients
Untreated, nonvital teeth.

Clinical parameters

After performing the oral prophylaxis and occlusal adjustments (where necessary), customized acrylic stent was fabricated for each patient on the study casts. Acrylic stent was trimmed to the height of contours of the teeth and apical border of the stent acted as the fixed reference point. To ensure the reproducibility in the placement of the periodontal probes, for vertical and horizontal probing of the furcation defects, a vertical groove (mid buccal or lingual) was prepared in the stent. Clinical parameters (full mouth/site specific) were recorded as the baseline data: plaque index (PI), gingival index (GI), pocket probing depth (PPD), relative vertical clinical attachment level (RVCAL), relative horizontal clinical attachment level (RHCAL), and gingival margin level/gingival recession (GR).

Intraoral periapical radiographs were taken to confirm the evidence of furcation involvement and include the teeth in study. Radiographs were again taken at baseline, 3 months, and 6 months, postoperative to assess the status of MTA in the furcation defects and evidence of bone fill, if any.

Surgical procedure

Before proceeding with the surgical procedure, detailed history and all the clinical parameters were recorded as the baseline data. After proper isolation of the surgical field, the site to be operated upon was adequately anesthetized using local anaesthesia. Intracrevicular incision was performed extending two teeth anterior and one tooth posterior to the tooth/teeth under consideration and a full thickness flap was raised [Figure 1]. Defect debridement and root planing was carried out carefully with hand and ultrasonic instruments to remove subgingival plaque, calculus, and inflammatory granulation tissue. After debridement, the MTA was placed at the defect site (degree I and degree II furcations) [Figure 2]. The material was compacted into the defect [Figure 3]. The flap was sutured back as far as possible at a coronal position in an attempt to cover the furcation defect [Figure 4].

Figure 1: Tooth No. 46-showing furcation defect

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Figure 2: Tooth No. 46-mineral trioxide aggregate being placed in the furcation defect

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Figure 3: Mineral trioxide aggregate being compacted in the furcation defect

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Figure 4: Tooth No. 46-sutures given after placement of mineral trioxide aggregate

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Postoperative care and follow-up intervals

All the patients were prescribed necessary antibiotics, analgesic anti-inflammatory drugs, and 0.2% chlorhexidine mouth wash. Routine postsurgical instructions were given to the patients and the patients were asked to report after 1 week for suture removal and at any time in case of an adverse event. Seven days following the surgery, sutures were removed and the surgical site was irrigated with saline. Patients were recalled at 3 months and 6 months. At each visit oral hygiene instructions were reinforced, and the same clinical parameters (i.e., PPD, PI, GI, RVCAL, RHCAL, and GR) were recorded and standardized intraoral periapical radiographs were taken.

Data analysis

After the completion of the study, statistical analysis was carried out. The results of the study were subjected to statistical analysis by applying paired t- test IBM SPSS statistical analysis software was used.

Results

The present study was carried out with the aim of evaluating efficacy of MTA in obliterating the Degree I and Degree II furcation defects.

Plaque index, gingival index-full mouth

Mean scores for PI at first visit, baseline, 3 months and 6 months, postoperative were 1.21 ± 0.72, 0.20 ± 0.23, 1.07 ± 0.80, and 1 ± 0.88, respectively. The difference from baseline to 3 months was highly significant (P < 0.001) and from baseline to 6 months was also highly significant (P < 0.001). Mean scores for GI at first visit, baseline, 3 months, and 6 months, postoperatively were 1.39 ± 0.69, 1.12 ± 0.58, 1.07 ± 0.74, and 1.07 ± 0.80, respectively. The difference from baseline to 3 months was statistically nonsignificant (P > 0.05) and from baseline to 6 months was also statistically nonsignificant (P > 0.05) [Figure 5].

Figure 5: Comparison of plaque and gingival indices at different time intervals

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Pocket probing depth

In comparison with baseline, there was statistically significant (P < 0.05) reduction in PPD at 3 and 6 months following surgery on mesiobuccal, buccal, and lingual surfaces. However, there was no statistically significant reduction (P > 0.05) in PPD at 3 and 6 months on the distobuccal surface [Table 1].

Table 1: Comparison of mean scores±standard deviation of pocket probing depth at different time intervals

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Relative vertical clinical attachment level

When compared to the baseline values, there was statistically significant (P < 0.05) reduction on the mesiobuccal, buccal, and lingual surfaces at 3 months and 6 months, postoperatively [Table 2]. There was no statistically significant (P > 0.05) reduction observed on distobuccal surface after 3 months.

Table 2: Comparison of mean scores±standard deviation of relative vertical clinical attachment level at different time intervals

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Relative horizontal clinical attachment level

The mean RHCAL values at baseline on the buccal and lingual surfaces were 10.07 ± 1.75 and 9.60 ± 2.26, respectively. There was statistically significant (P < 0.05) reduction in the RHCAL on the buccal and lingual surfaces at 3 and 6 months' postoperatively [Table 3].

Table 3: Comparison of mean scores±standard deviation of relative horizontal clinical attachment level at different time intervals

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Gingival margin level/gingival recession

The mean GR on mesiobuccal, buccal, distobuccal, and lingual tooth surfaces was recorded at baseline, 3 months, and 6 months. When compared to the baseline value 5.73 ± 1.33, there was reduction only on lingual surface at 3 months 5.67 ± 1.39 and 6 months 5.67 ± 1.39.

Discussion

The main goal of periodontal therapy is to provide patients with a dentition that functions in health and comfort for the remainder of their lives. Molars are the tooth type demonstrating the highest rate of periodontal destruction in untreated disease and suffer the highest frequency of loss for periodontal reasons. Furcation defects have presented a major challenge to therapists because of their unique anatomical characteristics and their variable response to treatment.^[10]

As shown by many longitudinal studies, resective, and tissue attachment techniques have slowed the progression of disease but have been unable to stop attachment loss. Consequently, furcation involvement has been synonymous with more advanced forms of periodontitis and a more guarded prognosis for long-term tooth retention.^[11]

In the past, restorative materials such as polymeric-reinforced zinc oxide eugenol intermediate restorative, amalgam, glass ionomer, and resin ionomer restorative materials have been used to obliterate furcation. The goal was to improve plaque control by eliminating the anatomic niches within the furcation where bacteria can accumulate.^[12]

van Swol et al. compared amalgam, zinc oxyphosphate cement, and glass ionomer in the treatment of surgically created furcation in nonhuman primates.^[13] The authors reported the greatest biocompatibility with glass ionomer through radiographic and histological evaluation.^[13] Scherer and Dragoo utilized modified resin ionomer restorations subgingivally and gave histological evidence of epithelial and connective tissue adherence to the resin ionomer restorative materials.^[14]

Ghanbari et al. evaluated the efficacy of MTA and calcium enriched mixture cement in class II furcation defects in human mandibular molars. The evaluation of soft-tissue outcomes at 3 months' postoperation showed significant improvements in vertical clinical attachment level and horizontal clinical attachment level in both groups compared to baseline. The evaluation of hard tissue outcomes at the 6 months re-entry showed significant improvements in vertical and horizontal bone fills in both the groups in comparison to baseline. The improvements in vertical bone fill and horizontal bone gain in the MTA group were 3.5 mm (P < 0.001) and 3.76 mm (P = 0.002), respectively.^[4] Singhal reported a case involving the use of glass ionomer cement (GIC) as an occlusive barrier in the management of Class III furcation defect involving mandibular first molar, patient was asymptomatic on 1-year recall visit and was able to maintain the oral hygiene easily.^[15]

In an animal study conducted by Miranda et al. reported significant reduction in PPD, where he used GIC in Degree II furcation defects.^[16] Results of the study conducted by Patil et al. stated that use of GIC in Degree III furcation defects proved to reduce probing depth and gain in clinical attachment level.^[12] Reddy et al. presented two cases with Class III furcation defects involving all three furcation in the right and left maxillary first molars. Their results showed that the gingival margin was maintained without much recession.^[17]

Since, no re-entry procedures permitting direct observation of the bone fill and histological studies were performed; it is not possible to make any comment regarding the regeneration of periodontal attachment apparatus.

Based on the results of the present study, it appears that MTA is an efficacious material in managing the Degree I and Degree II furcation defects. Therefore, MTA can be considered as an alternative to other more expensive regenerative treatment modalities for furcation defects. Further long term, randomized, controlled clinical trials are needed to know the effects of such treatment modalities.

Conclusion

The use of MTA has proven to be a viable method in obliterating the furcation defects. The excellent handling properties and excellent tissue response to the material are definite benefits. The purpose of selecting this mode of therapy was simply to obliterate and to prevent further attachment loss in mandibular molars with Degree I and Degree II furcation defects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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