International Journal of Dental Research &

Development (IJDRD)
ISSN(P): 2250-2386; ISSN(E): 2321-0117
Vol. 6, Issue 2, Jun 2016, 1-12
TJPRC Pvt. Ltd.

ONE YEAR FOLLOW UP OF AN IATROGENIC ROOT PERFORATION TREATED

WITH MINERAL TRIOXIDE AGGERGATE (MTA) AND VERTICAL BONE LOSS
GRAFTED WITH NOVABONE BONE GRAFT PLUS PLATELET RICH PLASMA
(PRP)
SAGRIKA SHUKLA1, VIDHI GUPTA2 & ASHI CHUG3
1

Senior lecturer, Department of Periodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand , India
2
3

Private practice, New Delhi, India

Assistant professor, Department of Dentistry and Oral and Maxillofacial Surgery,

All India Institute of Medical Sciences, Rishikesh, Uttarakhan , India

ABSTRACT
Aim
To evaluate 12 months post treatment results of Novabone plus PRP in a vertical defect along with MTA
placed in an iatrogenically perforated tooth.

Periodontal flap procedure in relation to 21,22 and 23 was done along with placement of Novabone bone
graft +PRP and closure of perforation with MTA in 22 was done. Post operative recordings of Plaque index
(PI),Gingival index (GI), Clinical attachment level (CAL) and pocket depth upto 12 months with the help of acrylic stent
were taken.

Original Article

Case Presentation

Results
Results showed uneventful healing and decrease in pocket depth in relation to 22 where the bone graft + PRP
was placed.
Conclusion
Pocket depth and CAL showed a significant reduction from baseline to 12 months in site treated with
Novabone bone graft. This means that the graft material was well tolerated by the patients and is effective in
regenerating the lost periodontal tissues. Also, MTA placed in perforated teeth provides good sealing and aids in
periodontal health.
KEYWORDS: Novabone, Bone Graft, Vertical Defect, Periapical Radiolucency, MTA

Received: Apr 04, 2016; Accepted: Apr 19, 2016; Published: Apr 25, 2016; Paper Id.: IJDRDJUN20161

INTRODUCTION
Periodontitis is one of the most common diseases resulting in the loss of connective tissue attachment and
alveolar bone1. The permanent altered morphological features of the bone, in addition to reduced bone height can be
of various shapes, such as horizontal pattern of bone loss, craters, furcation involvement, vertical/angular bone loss
and combination defects. The treatment of periodontal intrabony defects dates back to the work of Oschsenbein

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Sagrika Shukla,Vidhi Gupta & Ashi Chug

(1986) who recommended elimination of angular defects because if remaining, they promote deeper pocket formation that
can lead to disease progression2. Surgical treatment of these types of defects frequently involves either bone grafts, or
autogenous bone from the surgical site along with the use of barrier membranes or growth factors to increase the
probability of bone regeneration in the area3-5.
Autogenous bone is considered as the gold standard for bone regeneration procedures, however, to overcome its
clinical limitations such as, early bone re sorption at the site of bone placement, additional surgical site and limited amount
that can be obtained intraorally6, all oplastic bonegraft materials have been proposed among others for use in the treatment
of intrabony defects. Alloplastic bone graft materials are synthetic bioactive bone substitutes which are mostly
osteoconductive and act as scaffolds for bone regeneration7. One such synthetic material is a third generation bioactive
glass, calcium phosphosilicate putty (CPS putty) (Nova Bone Dental Putty, Nova Bone Products, Alachua, FL), which is
osteostimulative in addition to being osteoconductive and has enhanced handling characteristics8,9. CPS putty is composed
of Calcium Phosphosilicate glass particles and a synthetic absorbable binder that allows it to be premixed in a putty
consistency. Recent evidence on the use of this graft in ridge regeneration procedures has shown superior clinical and
histological results of bone regeneration in comparison to osteoconductive grafts that have been attributed to its
osteostimulative properties10,11.
To enhance the results of graft placement many authors have also recommended the addition of either
recombinant or autologous growth factors in the surgical treatment of intrabony defects12,13 showing clinically comparable
results to those of guided tissue regeneration procedures with barrier membranes. Platelet rich plasma (PRP) is one such
autologous growth factor that is prepared from the centrifugation of autologous whole blood and results in concentration of
the platelet count in the PRP by 338% in comparison to the total platelet count6. Thus when PRP is used, it releases growth
factors, helps in hemostasis and contributes rapid healing of the surgical site14. PRP contains proinflammatory cytokines
which play an important role in the early responses of bone repair, it contains growth factors, which help the regeneration
of tissues with low healing potential, potentially restoring biomechanical properties similar to normal bone15. There are
angiogenesis factors, which promote angiogenesis rapidly in the bone graft in the early stage and other factors are also
found such as serotonin, histamine, dopamine, calcium, and adenosine which have fundamental effects on the biologic
aspects of wound healing15. Mixing PRP with bone alloplastic bone substitutes has been shown to be a safe treatment
modality16.
To the best of our knowledge, this is the first case study to have included both MTA as a sealing agent and
Novabone as a bone graft material in combination for treatment of a tooth with iatrogenic perforation and vertical bone
loss.

METHODS AND. MATERIALS

A male patient aged 47 years old reported to the dental office with pain in the upper front tooth region. Pain was
continuous, mild and non radiating. Upon taking the history the patient revealed that he had undergone root canal treatment
at a private clinic a month before, however even after multiple visits for root canal treatment he did not get relief from pain
and his treatment was not completed and consequently reported to our dental office for further treatment. Patient was
healthy and did not have any adverse habits such as smoking or tobacco chewing. Intraorally, patient had generalized
horizontal bone loss, generalized grade I mobility and missing 16,17,27,28,37,38,47. At baseline, in relation to (irt) 21 and

Impact Factor (JCC): 1.9876

Index Copernicus Value (ICV): 6.1

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate
(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

22 pocket depth was 5 mm and clinical attachment level was 6 mm (figure 1.) with positive TOP and periapical
radiolucency irt 22. On radiographic evaluation with the help of files a perforation was noticed in middle one third irt 22,
which was further confirmed on a CBCT (figure 2).
Observing poor periodontal condition, full mouth periodontal flap surgery was planned along with placement of
bone graft +PRP irt 21 and 22 and closure of perforation with MTA in relation to 22. In between full mouth complete
scaling appointments, retreatment irt 22 was initiated. Study model was made for fabrication of customized acrylic occlusal
stent. The stent was made17 using self cured pink acrylic which covered the occlusal as well as the coronal 1/ 3rd of the
labial and lingual surfaces of the tooth involved and one tooth mesial and distal to the involved area. Vertical grooves were
made to guide the placement of the probe in the same plane and direction repeatedly during measurements to avoid any
variation (figure 1.).
At 4 weeks, before starting with the surgical procedure, PRP was prepared where 10 ml of blood was drawn from
the patient, mixed with anticoagulant EDTA and centrifuged for 15 minutes at 2000 rpm. The centrifugation consisted of
separation spin and concentration spin. After the first spin 3 distinct layers were obtained (figure 3.) out of which first two
layers were pipetted out and placed in another plastic vacutainer blood collection tube without the anticoagulant and was
centrifuged at 3,000 rpm for 15 minutes. After the second spin two distinct layers were obtained, from which the bottom
layer was pipetted out (figure 4.). The time taken for PRP preparation was in accordance to the machine used and was
calculated according to the following formula:
g = (1.118 10-5) R S2
Where g is the relative centrifugal force, R is the radius of the rotor in centimeters, and S is the speed of the
centrifuge in revolutions per minute. This prepared PRP without activation with calcium chloride and thrombin can be
stored upto 8 hours.
Just prior to the commencement of the surgical procedure, the patient was asked to rinse the mouth with 10 ml of
0.2% chlorhexidine digluconate solution. Perioral surface of the patient was swabbed with 5% povidone iodine solution.
The operative site was anaesthetized with 2% Lignocaine HCI with adrenaline (1:80,000) using block and infiltration
techniques. The crevicular incision was given on the facial and lingual/palatal surfaces and interdental incision was given
using the Bard Parker handle No. 3 with blade No.12 and No.11 respectively. A full thickness mucoperiosteal flap was
reflected using the periosteal elevator taking care that the interdental papillary tissue was retained as far as possible. After
reflection of the flap, exposure of osseous defect, thorough surgical debridement of soft and hard tissue with area specific
Gracey curettes (company) and castroveijo scissors and irrigation with copious amount of normal saline the vertical defect
and the perforation could be seen irt 22 (figure 5&6.). Perforation was sealed with the help of MTA -sterile saline paste
(ProRoot MTA, Dental Tulsa; Dentsply, DeTrey Konstanz, Germany) mixed in a 3:1 proportion (figure 7.) after which
obturation with gutta percha points (Dentsply, DeTrey Konstanz, Germany) was completed and was coronally sealed with
Glass Ionomer Cement.
To fill the vertical defect, the PRP thus formed was activated by calcium chloride (figure 8) and patients own
blood instead of using bovine thrombin (figure 9). Within a few seconds, the PRP preparation assumed a sticky gel
consistency, which was mixed with calcium phosphosilicate putty (NovabonePutty, Novabone, Alachua, FL) to be put into
the bony defect (figure 10 & 11). Surgical flaps were repositioned to the pre-surgical level using 3-0 silk suture (figure 12).

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Care was taken not to displace the graft + PRP during suturing, for the very same reason sutures were passed before
placement of the graft material and knot was tied after the graft + PRP placement. A periodontal dressing was placed on
the surgical site.
Routine post operative instructions were given to the patient. He was instructed to abstain from brushing and
flossing around the surgical area until suture removal and to consume only soft food during the first week. He was
prescribed one Cap. Amoxicillin 500 mg TDS (ter die sumendum or three times a day) in the morning, afternoon and at
night after meals for 5 days and was instructed to use Chlorhexidine rinse 0.12 % twice daily in the morning and at night
for a month. Tab. Ibuprofen 400 mg one tablet as per need was prescribed to control pain. Sutures and periodontal dressing
was removed 10 days post surgery. Post operative measurements were made at 1, 3, 6, 9 and 12 months, with the stent in
place to record probing pocket depth and CAL. GI and PI were also recorded.

RESULTS
The patients periodontal health was monitored over a period of 12 months, during which it was observed that the
patient was positively motivated and took good care in maintaining oral hygiene which was reflected by the plaque index
and gingival index scores. There was a reduction in pocket depth (5mm at baseline) to 2mm at the end of 12 months (figure
13 & 14). The CAL also showed a reduction (6mm at baseline) to 2mm at the end of 12 months. Table 1 shows month wise
measurements of CAL and probing pocket depth (PPD).

DISCUSSIONS
Periodontitis, resulting in bone loss forms different types of defects, out of which three walled defects have the
most predictable treatment outcome. Bone lost due to periodontal disease affects the overall health of the patient, thus for
functional and esthetic outcomes, patients health and long-term survival of teeth, a sufficient amount of healthy bone is
required. Autogenous bone is the ideal bone graft, however due to aforementioned clinical limitations other types of bone
grafts have been used widely, such as xenografts and allografts. However controversy exists with respect to the
osteoinductive potential of these materials6. It has been shown that inductive capacity varies from bone bank to bone bank
and also from different batches of the same bone bank. The bioactivity also depends upon the age of the donor, the younger
the donor, the more osteoinductive the graft material will be6,18. Also there are chances of disease transmission19. Due to
these limitations, the use of alloplastic materials has become popular.
The advantage of alloplastic bone substitute is that, because of their completely synthetic nature, they bear no risk
of disease transmission20. The other main reason why alloplasts have gained increasing scientific and clinical attention over
the past several years is the theoretical possibility of designing every single material characteristic individually for a
specific clinical indication20. Novabone putty or 45S5, a third generation bioactive glass has been developed to show such
advantages. Novabone is being designed to activate genes that stimulate regeneration of living tissues21. Xynos et al22,23
reported that the ionic products of the glass dissolution affect gene-expression profile and cause up-regulation of seven
families of genes including cell cycle regulators, growth related gene and apoptosis regulators. Beilby et al24,25 showed
similar bioactive induction of the transcription of extracellular matrix components and their secretion and self-organisation
into a mineralised matrix which may be responsible for the rapid formation and growth of bone nodules and differentiation
of the mature osteocyte phenotype in the presence of bioactive materials such as 45S5 Bioglass. This also activates
several families of genes such as CD44, IGF2, MMP2, 60S ribosomal protein L626 and induces release of chemicals in the

Impact Factor (JCC): 1.9876

Index Copernicus Value (ICV): 6.1

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate
(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

form of ionic dissolution products, or growth factors such as bone morphogenetic protein (BMP), at controlled rates, by
diffusion or network breakdown that activates the cells in contact with the stimuli21.
In literature, many authors have mixed PRP with bone graft materials and have shown that there was an increased
rate of osteogenesis and enhanced bone formation.27-29. PRP releases significant quantities of growth factors, which
promote neovascularization and osseous regeneration27,30, based on this concept Novabone and PRP were mixed. Lucarelli
et al31 investigated mesenchymal stem cell proliferation in culture media supplemented with PRP and verified that the use
of 10% PRP was sufficient to accelerate mineralization in vitro. Carlson and Roach32 showed that PRP and its growth
factors are promising for surgical wound healing. In vitro investigations have identified that the PDGF, a subcomponent of
the PRP, has a significant effect on cell proliferation33,34. Thus when PRP is used, it releases growth factors, helps in
hemostasis and contributes rapid healing of the surgical site14, improves esthetics, shortens duration of treatment and
reduces postoperative symptoms. Mixing PRP with bone graft material can be applied to any class of bone graft, material.
However the regeneration would not have been possible without sealing of the perforation.
There was primary endodontic component involved without the communication present between the periapical
abscess and the vertical defect, however during the previous root canal treatment there was a perforation which made the
communication possible, affecting the prognosis of tooth and resulting in loss of integrity of the root with further
destruction of the adjacent periodontal tissues35,36. Thus it becomes important to close the artificial channel which was
created. The main goal of sealing a perforation is to re-establish periodontal health35, with a suitable perforation repair
material, which is a key element in successful sealing and maintaining the seal. An ideal material should adhere to the root
canal wall, should be biocompatible or bioactive35. In the past years, amalgam, composite resin, and glass ionomer cements
have been used for sealing furcal perforation36. The advantage of GIC is that it facilitates fibroblast adhesion37,38. However,
for cemental repair a material which enables regeneration of cementum should be used and studies have shown that MTA
enables cemental repair. studies have also shown that MTA is apparently superior to these materials with respect to
marginal adaptation39-41, bacterial leakage39-42 and cytotoxicity39,43. Main et al44 concluded that MTA provides an effective
seal of root perforations and can be considered a potential repair material enhancing the prognosis of perforated teeth that
would otherwise be compromised.
MTA enables cell adherence and growth, increased levels of alkaline phosphatase and osteocalcin, interleukin
production (IL-6, IL-8), periodontal ligament attachment, cementum growth, and dentinal bridge formation45-48. It is non
irritating to the soft and hard tissues and has excellent biocompatibility.Of all ions released, Ca is the most dominant which
leads to the precipitation of Hydroxyapatite (HA). Presence of HA on its surface that is in proximity to calcified tissues
forms a chemical bond with the latter49-51. And this is the basis for two of the most important properties of MTA that is
sealing ability and biocompatibility. Keeping these advantages of MTA, it was used for sealing of the root perforation.
Pocket depth was 5 mm which could have been maintained with the help of curettage and good oral maintance by
the patient, however, flap had to be raised for the correction of the perforation, which also made the clinicians to take
measures in treating the vertical defect. The defect was not very pronounced but it required intervention and since the flap
had to be raised, placement of bone graft + PRP was planned. Another reason for bonegraft + PRP placement was that
since perforation had taken place approximately 1 month back which would have seriously affected periodontal health and
prognosis of the treatment, clinicians decided to take extra measures in preventing any such possibility.

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CONCLUSIONS
The improvement in the periodontal health of the patient over the period of 12 months indicated that the graft
material was well tolerated by the patient and was effective in regenerating the lost periodontal tissues, MTA placed in the
perforation provided for a good seal and aided in the periodontal healing. To the best of our knowledge, this is the first case
study to have included both MTA as a sealing agent and Novabone as a bone graft material in combination for treatment
of a tooth with iatrogenic perforation and vertical bone loss.
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(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

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Impact Factor (JCC): 1.9876

Index Copernicus Value (ICV): 6.1

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate
(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

APPENDICES
Figure Legends
Figure 1: Pre-operative image
age showing pocket of 5 mm
Figure 2: CBCT showing root perforation
Figure 3: PRP obtained after first spin
Figure 4: PRP obtained after second spin
Figure 5: Vertical defect after
ter complete debridement.
Figure 6: Root perforation shown with a plugger. To prevent dessication of tissues, wet cotton ball placed in
the interdental region of 22 and 23
Figure 7: Perforation sealed with MTA
Figure 8: Activation of PRP with calcium chloride.
Figure 9: Activation of PRP with patients own blood.
Figure 10: PRP + Novabone bone graft
Figure 11: PRP + Novabone bone graft placed in the vertical defect
Figure 12: Suturing done.
Figure 13: 12 months post op showing
showin reduction in probing depth
Figure 14: RVG post-op
op at 12 months.
Table 1: Month Wise Decrease in Clinical Attachment Levels and Probing Pocket Depth

Figures

Operative Image Showing Pocket of 5 Mm

Figure 1: Pre-Operative

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Figure 2: CBCT Showing Root Perforation

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Sagrika Shukla,Vidhi Gupta & Ashi Chug

Figure 3: PRP Obtained after First Spin Figure 4: PRP Obtained After Second Spin

Figure 5: Vertical Defect after Complete Debridement

Figure 6: Root Perforation Shown With a Plugger.

Pl
to
Prevent Dessication of Tissues, Wet Cotton Ball
Placed in the Interdental Region of 22 and 23.

Figure 7: Perforation Sealed With MTA.

Impact Factor (JCC): 1.9876

Index Copernicus Value (ICV): 6.1

One Year Follow Up of an Iatrogenic Root Perforation Treated With Mineral Trioxide Aggergate
(MTA) and Vertical Bone Loss Grafted with Novabone Bone Graft Plus Platelet Rich Plasma (PRP)

Figure 8: Activation of PRP with Calcium Chloride

11

Figure 9: Activation of PRP with Patients Own Blood

Figure 10: PRP + Novabone Bone Graft

Figure 11: PRP + Novabone Bone Graft

Placed in the Vertical Defect

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Figure 12: Suturing Done

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Sagrika Shukla,Vidhi Gupta & Ashi Chug

Figure 13: 12 Months Post Op Showing

Reduction in Probing Depth

Impact Factor (JCC): 1.9876

Figure 14: RVG Post-Op

Op at 12 Months

Index Copernicus Value (ICV): 6.1