doi:10.1111/iej.

12237

CASE REPORT

The use of MTA/blood mixture to

induce hard tissue healing in a root
fractured maxillary central incisor.
Case report and treatment
considerations
A. Chaniotis
Warwick Dentistry, The University of Warwick, Coventry, UK

Abstract
Chaniotis A. The use of MTA/blood mixture to induce hard tissue healing in a root fractured maxillary
central incisor. Case report and treatment considerations. International Endodontic Journal.

Aim To report the use of MTA/blood mixture for the induction of hard tissue healing of
multiple horizontal root fractures in a maxillary incisor.
Summary An 18-year-old male patient was referred after suffering trauma to the anterior
maxilla. Radiographic evaluation revealed multiple horizontal fractures in the middle and cervical third of his maxillary right central incisor. Clinical evaluation revealed third grade mobility of the coronal segment. The patients accompanying radiographs revealed that root
canal treatment of all segments had been previously initiated and both segments had been
rendered pulpless. The coronal segment was repositioned and stabilized. A bi-antibiotic
mixture, containing equal parts of ciprofloxacin and metronidazole, was used for the disinfection of the root canal segments. A blood clot was induced from the periapical area and
MTA powder was mixed with the blood creating a bioceramic mixture covering all the fractures. Thick MTA was placed as a coronal barrier and the tooth was restored. Recall examination after 24 months revealed healing of the horizontal fractures. The MTA mixed with
the blood lost its radio-opacity over time. Tooth mobility returned to normal limits.
Key learning points
A low range of 525% of all horizontally root fractured cases develop pulp necrosis,
confined in the coronal segment, leaving the apical segment with vital tissue.
In the unfortunate situation that the pulp of both segments becomes necrotic or the
entire pulp tissue is removed, the use of MTA/blood mixture may be beneficial for
the induction of hard tissue healing.
MTA when mixed with blood seems to lose its radio-opacity over time.

Keywords: healing, horizontal fracture, MTA/blood mixture.

Received 18 March 2013; accepted 18 December 2013

Correspondence: Antonis Chaniotis, Faculty of Warwick Dentistry, University of Warwick, El.

Venizelou 140, Kalithea 17676, Greece (Tel.: 00302109562380; Fax: 00302109562398;
e-mails: antch@otenet.gr, c.antonios@warwick.ac.uk)

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Introduction
Amongst all dental injuries, root fractures comprise 0.57% (Orhan et al. 2010) and are
characterized by separation of the fragments, affecting dentine and cementum. This
separation results in an apical segment, which usually is not displaced, and into a coronal segment, which is often displaced. Horizontal root fractures usually affect maxillary
central incisors of male patients as a result of trauma associated with accidents, sports
injuries or fights. They also occur more frequently in fully erupted permanent teeth with
closed apices (Roig et al. 2011).
In root fracture injuries, the trauma often results in rupture of the neurovascular supply at the level of the fracture. From the moment of impact, wound healing processes
are initiated that attempt to repair or regenerate the damaged tissues, including the
pulp (Andreasen 1989). The four categories of root fracture healing that have been
defined by Andreasen & Hjorting-Hansen (1967) consist of (i) healing by hard tissue
union, (ii) healing by interposition of connective tissue, (iii) healing by interposition of
bone and connective tissue and (iv) nonhealing, characterized by interposition of granulation tissue. The type of fracture healing is influenced by several factors, such as stage
of root formation, location of fracture, degree of displacement of the coronal fragment
and interval between trauma and treatment (Roig et al. 2011).
According to the recommendations of the International Association of Dental Traumatology (IADT; Flores et al. 2007), the initial treatment approach for root fractured
teeth consists of the repositioning of the coronal fragment and immobilization through
fixation to the neighbouring teeth by means of a semirigid or rigid splint and maintaining the splint for 23 months. Unfortunately, in 525% of the horizontally root fractured cases, the pulp will become necrotic (Andreasen & Andreasen 1994) and
endodontic treatment will be required. In most of the cases, root canal treatment of
the coronal fragment is sufficient, as the pulp in the apical fragment remains healthy
(Cvek et al. 2004).
On the rare occasion that the pulp in both fragments are rendered necrotic, root
canal treatment of both fragments can be attempted. However, treatment of both fragments is always complicated, difficult and the prognosis poor, because the accumulated
debris is not completely removed from the space between the fragments (Jacobsen &
Kerekes 1980). Other treatment options include the endodontic treatment of the coronal fragment and surgical removal of the apical fragment or extraction of the coronal
fragment, and endodontic treatment and orthodontic extrusion of the apical fragment.
In cases of increased mobility of the coronal segment, intraradicular splinting has been
reported to provide a viable alternative (Subay et al. 2008).
Recently, various revascularization procedures have been described for the management of immature roots with pulp necrosis. The key characteristics of these procedures
include the disinfection of the immature root and the stimulation of residual stem cells
via blood clot formation. The ultimate objective is the induction of new hard tissue on
the existing dentinal wall and the continued root development of the immature root
(Wigler et al. 2013). Although revascularization is a regenerative treatment modality for
permanent teeth with necrotic pulps and incomplete root development, under certain
circumstances, similar techniques could be used for the induction of hard tissue healing
of horizontal root fractures.
In the present case, the use of tissue regeneration principles for the management
of multiple horizontal fractures in a fully formed necrotic permanent maxillary central
incisor is presented.

Case report
An 18-year-old male patient was referred for the evaluation and possible treatment of
his right maxillary central incisor. His medical history was noncontributory. In his dental
history, he reported that he had suffered multiple injuries to his upper anterior teeth

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(a)

(b)

(c)

(e)

(f)

(g)

CASE REPORT

during kick-boxing games. He started participating in kick-boxing games 1 year previously, and he had been injured in the same area three times.
He had suffered the first impact approximately 1 year previously, and after the injury,
he visited immediately his paediatric dentist for emergency care. The periapical radiograph of tooth 11 was provided by the paediatric dentist and can be seen in Fig. 1a.
Radiographic evaluation revealed a horizontal root fracture located in the middle root
segment of tooth 11 (Fig. 1a).
Four months later, the patient suffered a second impact in the same area and
returned to the paediatric dentist for an emergency visit. The periapical radiograph of
tooth 11 taken by the paediatric dentist can be seen in Fig. 1b. Radiographically, there
was an indication of multiple transverse fractures apically and coronally to the previous
one (Fig. 1b).
Seven months later, the patient suffered a third impact and returned for an emergency visit to the same paediatric dentist. The paediatric dentist cleaned and sutured
the lip lacerations that were created and evaluated the maxillary anterior teeth. The fixation was in place and all the maxillary anterior teeth responded positively to cold testing. Tooth 11 responded negatively both to thermal and electrical pulp testing.
Unfortunately, radiographic evaluation revealed the existence of another horizontal
fracture located in the coronal root segment of tooth 11 (Fig. 1c). As the fixation was
not damaged, the patient was advised to take a soft diet, practice meticulous oral
hygiene and was rescheduled 1 week later for suture removal.
According to the paediatric dentist, 1 day before the scheduled appointment, the
patient attended with a buccal swelling and pain on percussion. A diagnosis of acute
apical periodontitis associated with the tooth 11 was made. The fixation was removed
to assess the mobility of the coronal tooth segment. Mobility had increased to grade 3.
The paediatric dentist tried to provide palliative treatment and accessed the root canal
to the terminus (Fig. 1d). A temporary filling was placed and the tooth was splinted to
the adjacent teeth using composite resin without any wire. The prognosis was consid(d)

(h)

Figure 1 (a) Periapical radiograph of tooth 11 after the first impact demonstrating mid-root fracture,
(b) Periapical radiograph of tooth 11 after the second impact demonstrating multiple horizontal fractures and the arch wire splint, (c) Periapical radiograph after the third impact demonstrating clearly
the mid-root and cervical fractures, (d) Length determination radiograph after splint removal demonstrating that all segments were rendered pulpless, (eh) Periapical radiographs with different angulations for the evaluation of the multiple fractures.

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ered poor and the patient was advised to consult an endodontist before extraction and
implant placement.
At the time of the initial appointment with the endodontist, the tooth was asymptomatic. The temporary restoration was leaking; the composite resin fixation was broken;
and the crown of tooth 11 seemed to be displaced palatally (Fig. 2a,b).
After photographic documentation, four radiographs with different angulations were
taken to assess the situation (Fig. 1eh).
From the radiological evaluation, multiple horizontal and transverse fractures were
revealed. The distally directed cervical fracture and the mesio-distally directed mid-root
fracture were visible in all 4 radiographs (Fig. 1eh). A third transverse fracture line
directed mesially, between the previously mentioned fractures, was suspected (Fig. 1g,
h). This double contour may sometimes indicate a deep buccal or high palatal fracture
line. However, the exact number, contour and direction of all fracture lines cannot
always be evaluated accurately by periapical radiographs. Periodontal probing was
within normal limits all around the tooth. Increased tooth mobility was detected.
A decision was made to try and save this tooth by attempting the regeneration of the
pulpdentine complex for the induction of hard tissue repair of the multiple fractures.
A rubber dam was placed and secured with wedjets rubber dam stabilizing cord (Coltene/Whaledent, Cuyahoga Falls, OH, USA). The remnants of the temporary restoration
were removed, and the root canal was accessed (Fig. 2c). Positive pressure irrigation of
the infected canal was performed with sterile water for safety reasons. By using an
electronic root canal length measurement device (Root ZX, J Morita MFG Corp, Kyoto,
Japan), the level of the most coronal fracture was assessed and verified with a radiograph (Fig. 2d).
Apical negative pressure (Endo Vac, Axis/Sybron Endo, Coppell, TX, USA) was used
for the delivery of 6% NaOCl solution (Canal pro plus, Coltene/Whaledent, Langenau,
Germany) through the entire canal length. No instrumentation was performed, as the
canal was already enlarged by the paediatric dentist. After delivering 20 mL of NaOCl
6% through the endovac macrocannula, the canal was rinsed with sterile water and
dried. Equal parts of metronidazole powder and ciprofloxacin powder were prepared
and mixed by a pharmacy. A fresh mixture of bi-antibiotic dressing was prepared in a
sterile dish by mixing the bi-antibiotic powder with sterile water to a slurry consistency
(Fig. 2e). The bi-antibiotic dressing was placed inside the canal using a lentulo spiral.

(a)

(c)

(b)

(d)

(e)

Figure 2 (a,b) Labial and palatal view of the maxillary anterior teeth after the third trauma incidence, (c) Access cavity view after the removal of the leaking temporary restoration, (d) Length
determination radiograph for the evaluation of the level of the cervical fracture, and (e) Ciprofloxacin/metronidazole powder (1 : 1) mixed with sterile water.

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(e)

(b)

(c)

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The access cavity was temporized with Cavit G, and the tooth was repositioned and
stabilized again with the adjacent central incisor by using composite resin fixation.
One month later, the tooth was asymptomatic. Nonvasoconstrictor containing (Mepivastesin, 3M ESPE, ESPE Platz, Seefeld, Germany) infiltration anaesthesia was delivered. The
rubber dam was placed and secured. The antibiotic paste dressing was removed by positive
sterile water irrigation. Apical negative pressure irrigation of NaOCl solution 6% was delivered, and the canal was flooded with EDTA 17% for 5 min. The final rinse was achieved by
sterile water apical negative pressure irrigation. The canal was dried with sterile paper
points (Medium, Roeko cell pack, Coltene/Whaledent). A sterile size 30 K file, 31 mm
length, was introduced through the coronal and the apical root segments and was used to
induce bleeding from the periapical area. Bleeding was successfully induced and a blood
clot formed up to the level of the cervical fracture line (Fig. 3d). MTA (MTA angelus white,
Londrina, PR, Brazil) was mixed according to the manufacturers instructions and delivered
through the blood clot with an MTA carrier (Denstply Maillefer, Ballaigues, Switzerland;
Fig. 3e). The MTA was mixed with the blood. Care was taken for the MTA/blood mixture to
cover all the fracture lines (Fig 3ac). A second blood clot was allowed to form. A coronal
barrier of thick MTA was placed over the second blood clot with an amalgam carrier just
below the cementenamel junction to avoid discoloration of the crown (Fig. 3f).
The tooth was restored with a composite resin restoration and splinted with the adjacent central incisor (Fig. 3g). The occlusion was adjusted, and the patient was rescheduled for periodic follow-ups.
The patient missed all the follow-ups and returned 24 months later for evaluation.
Clinical evaluation revealed no signs and symptoms. The composite resin fixation had
been broken. Interestingly, tooth mobility was considered within normal limits. No discolouration of the crown was noticed. Periodontal probing was within normal limits all
around the tooth. The labial and palatal view of the maxillary central incisors can be
seen in Fig. 4d,e.
Three periapical radiographs with different vertical angulations (0, +15, 15) were
taken to assess healing as suggested by Molina et al. (2008). The radiologic evaluation
revealed that the cervical fracture lines had healed with a tissue that wasnt visible radiographically, whilst the mid-root fracture had healed with a radiographically visible tissue
(Fig. 4ac). The MTA/blood mixture seemed to lose its radio-opacity over time. However,
the coronal set MTA appeared completely radiopaque. Lamina dura was visible on the

(d)

(g)

Figure 3 (a,b) Gradual placement of the MTA through the blood clot to cover all the fracture lines,
(c) Postoperative radiograph, (d) Microscopic image of the successful bleeding induction, (e) MTA
carrier during the placement of the MTA, (f) Microscopic view of the cervical MTA barrier located
just below the dentinoenamel junction, and (g) Composite resin restoration of the access cavity.

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periapical radiographs around the periphery of the root, suggesting healthy periodontal
ligament. No signs of root resorption were detected. All the remaining anterior teeth
responded positively to cold sensibility testing and were clinically normal.

Discussion
Horizontal root fractures predominantly affect the maxillary incisor region with the
central incisor tooth being the most commonly involved (Andreasen 1979). The overall
incidence of horizontal root fractures has been reported to range from 0.57% of all
dental injuries (Orhan et al. 2010).
The International Association of Dental Traumatology (IADT) has developed a
consensus statement for the management of horizontal root fractures (Flores et al.
2007). According to these guidelines, repositioning of the displaced coronal segment
and flexible stabilization for 4 weeks are indicated. If the root fracture is near the cervical
area of the tooth, stabilization for a longer period (up to 4 months) maybe beneficial.
The importance of standardized clinical, radiographic and photographic techniques in
diagnosis and monitoring of luxation injuries has been stressed many times. Andreasen
& Andreasen (1985) concluded that standardized radiographic techniques are necessary
and that photographic registration adds important information about the extent and
direction of displacement, a factor to be considered in retrospective studies. Keeping
that in mind, a complete photographic and standardized radiographic documentation of
all the available data of this case is reported.
In the present case, the traumatized incisors were initially evaluated and treated by
the paediatric dentist, according to the recommendations and guidelines of IADT. However, multiple incidents of impact injuries resulted in treatment complications. Additional
cervical and mid-root fractures were induced, resulting in increased mobility of the coronal segment and the eventual necrosis of the pulp. Pulp necrosis was diagnosed and
verified by the paediatric dentist.

(a)

(d)

(b)

(c)

(e)

Figure 4 (ac) 24-month recall periapical radiographs from different angulations demonstrating
undetectable hard tissue healing of the cervical fracture, detectable healing of the mid-root fractures and progressive resorption of the MTA scaffold (Vertical angulations 0, +15, 15), (d,e)
Labial and palatal view of the maxillary anterior teeth.

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The level of the most coronal fracture was assessed using an electronic root canal
length measurement device (ERCLM). An impedance ratio-based ERCLM device such
as the Root ZX (J Morita MFG Corp) may be used effectively for the determination of
the cervical fracture line (Nekoofar et al. 2006). However, the readings of the ERCLM
device used in the present case were also verified radiographically.
Recently, Heithersay & Kahler (2013), after an historical review of healing responses
following transverse fractures, reported the histology of two cases showing healing
with calcified tissue and dense fibrous connective tissue. They reported three patterns
of hard tissue deposition. The first pattern is fibrillar in appearance interspersed with
a number of small and somewhat larger channels containing some soft tissue/cell
inclusions. The second pattern includes a deeper area of irregular tubular dentine and
an outer layer of more regular tubular dentine with varying orientations surrounded by
an overlying layer of odontoblasts. The third pattern includes uniform structureless
deposits that could be described as sclerotic calcifications. Interestingly, the radioopacity of the hard tissue deposited at the fracture site was significantly less than
the normal tooth structure, suggesting that hard tissue healing is not always undetectable in the periapical radiograph. Therefore, the type of healing cannot be estimated
correctly only by radiological methods. The histology of the second case revealed
Sharpeys fibre insertion into the repaired fracture surfaces. Both cases provided
further evidence regarding the cellular responses involved in the healing of horizontal
root fractures. It seems that for hard tissue healing, the pulp is providing the initial
callus followed by hard tissue formation from cells derived from the periodontal
ligament.
In the present case, hard tissue healing potential was halted because of pulp necrosis and previously initiated treatment of both fragments. Moreover, the cervical root
fracture complicated the healing process.
In the present case, an attempt was made to induce hard tissue healing of the multiple transverse fractures by using regenerative endodontics principles.
Regenerative endodontic procedures are biologically based and designed to restore function to a damaged and nonfunctioning tissue (Wigler et al. 2013). Tissue regeneration
requires an appropriate source of stem/progenitor cells, growth factors and scaffolds to
control the development of the targeted tissue (Hargreaves et al. 2013). The cells suspected of giving rise to new hard tissue and root formation seen after debridement and disinfection of the root canal in immature teeth appear to be surviving perivascular stem cells
found in niches located in the apical papilla, stem or progenitor cells from the periodontal
ligament and bone marrow-derived mesenhymal stem cells (Wigler et al. 2013). The blood
clot acts as the scaffold for the participation of these cells in the regenerative response.
The blood clot that forms is in itself a rich source of growth factors that may play an important role in the regeneration process. These growth factors have the potential to stimulate
differentiation, growth, and maturation of fibroblasts, odontoblasts and cementoblasts
(Wigler et al. 2013).
In the present case, the target of tissue engineering would be the regeneration of
the pulp tissue and the hard tissue healing of the ruptured structures with dentine and
cementum.
Several local stem cells sources are reported to be available for clinical dental procedures. Potential sources of postnatal stem cells in the oral environment include tooth
germ progenitor cells, dental follicle stem cells, salivary gland stem cells, apical papilla
stem cells, dental pulp stem cells, inflamed periapical tissue stem cells, stem cells from
human exfoliated deciduous teeth, periodontal ligament stem cells, bone marrow stem
cells, the oral epithelial stem cells, gingival-derived mesenchymal stem cells and periosteal stem cells (Egusa et al. 2012).
In the case presented here, it was hypothesized that initial bleeding induction
resulted at the introduction of different types of stem cells inside the root canal. The
blood clot may have acted as a growth factor enriched, initial scaffold for the participation of these cells in the healing response.

CASE REPORT

It was speculated that mixing MTA with the blood clot resulted in the formation of a
scaffold-like material that may have remained unset and may have created favourable
conditions for the subsequent healing of horizontal fractures.
Scaffolds are believed to play a key role in regulating stem cell differentiation by local
release of growth factors or by the signalling cascade triggered when stem cells bind
to the extracellular matrix and to each other in a three-dimensional environment
(Hargreaves et al. 2013).
According to Galler et al. (2011), an ideal scaffold should facilitate the attachment,
migration, proliferation and three-dimensional spatial organization of the cell population
required for structural and functional replacement of the target tissue. Biocompatibility
is of utmost importance to prevent adverse tissue reactions. As the host cells will, in
any case, interact with the scaffold, biodegradability should be tunable, to facilitate constructive remodelling, which is characterized by scaffold degradation, cellular infiltration,
vascularization, differentiation and spatial organization of the cells, targeting, eventually,
replacement of the scaffold by the appropriate tissues.
It was speculated that mesenchymal stem cells from the periapex were introduced
inside the root canal space and in the space between the fractured surfaces. The placement of freshly mixed MTA through the blood clot resulted in the formation of a scaffold-like MTA/blood mixture. Under the MTA/blood mixture stimulation, it was
hypothesized that the migrating stem cells can differentiate to odontoblast-like cells and
produce mineralized dentine-like tissue in the pulpal side of the fracture. In the periodontal ligament side of the fracture, stimulation of periodontal ligament stem cells
might have resulted in the formation of a sclerotic cementum-like calcification. Both
types of mineralized tissues should be capable of bridging the gap created by the
trauma-induced rupture of dentine and cementum. The result of hard tissue healing that
was achieved in this case is speculated to be very similar to the one recently described
by Heithersay & Kahler (2013).
The idea of incorporating MTA particles in a scaffold for dentine regeneration is not
new. Budiraharjo et al. (2009) evaluated the bioactivity of a novel carboxymethyl chitosan (CMSC) scaffold in a tooth model. Bioactivity of CMCS was improved by incorporating MTA, which has an excellent mineralization potential.
Moreover, MTA material when placed in direct contact with dental pulp stem cells is
reported to promote upregulation of important odontoblastic genes (Paranjpe et al.
2011). After culturing the cells in contact with set MTA, the secreted levels of vascular
endothelial growth factor (VEGF) were significantly increased. VEGF is a potent inducer
of angiogenesis that has been implicated in the regulation of dentine and dental pulp
repair. Thus, these results suggested that MTA activates cells towards pulpal repair.
Moreover, the levels of OCN and DSP were significantly upregulated, suggesting
increased differentiation of the human dental pulp stem cells (DPCs) into odontoblastlike cells. The odontogenic differentiation of dental pulp stem cells cultured in direct
contact with MTA has been also demonstrated by Seo et al. (2013). Interestingly, MTA
significantly upregulated genes associated with cell migration not only in the uninduced
dental pulp stem cells but also in the odontogenic differentiated cells. It was found that
more than 10 genes that are related to the differentiation of osteoblast/odontoblast
were changed more than 2.5-fold by exposure to MTA. These results suggested that
MTA can stimulate both the migration and the odontogenic differentiation of dental pulp
stem cells at the injured site. Extrapolating from the aforementioned papers, it was
speculated that MTA mixed with blood may create a superior scaffold for stem cell
differentiation. This scaffold may be advantageous for the regeneration of the pulp
dentine complex and frequently can be inadvertently created during current regenerative procedures.
For the disinfection of the fractured segments, a bi-antibiotic mixture of equal parts
of ciprofloxacin and metronidazole was used. The most widely used intracanal medicament in endodontic regeneration is the triple antibiotic paste described by Hoshino
et al. (1996), which is a mixture of metronidazole, ciprofloxacin and minocycline. The

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double antibiotic mixture of only metronidazole and ciprofloxacin that was used in the
present case has been used successfully in endodontic regeneration (Iwaya et al. 2001)
and was suggested as a substitute for triple antibiotic mixture to avoid the discolouration effect of minocycline (Trope 2010).
Rigid stabilization and application of the bi-antibiotic mixture may be in part responsible for the initial reduction in tissue swelling and inflammation that resulted in the
initial re-approximation of the root fragments. However, the use of MTA/Blood
mixture seemed to have created and sustained a favourable environment for healing
of these re-approximated root fragments. To what extend the MTA/blood mixture or
stabilization and disinfection is responsible for healing is not known. However, in the
present case, the 24-month follow-up revealed favourable healing. No discolouration
was detected. Mobility was within normal limits and was no different than the adjacent teeth. Interestingly, the apically located MTA seemed to lose its radio-opacity
over time.
Nosrat et al. (2012) reported three cases of unintentional MTA extrusion into the periradicular tissues. In the first case, a considerable amount of tooth coloured MTA (ProRoot MTA, Dentsply Tulsa Dental Specialties, Johnson City, USA) had been extruded
into the periradicular tissues. The 4-year follow-up revealed that the extruded material
had disappeared and been gradually replaced by new bone. In the second case,
although apical surgery was performed, the 27-month periapical radiograph revealed
partial healing and almost complete resorption of the extruded MTA. Taken that certain
physical and chemical properties of MTA material may change following blood (Nekoofar et al. 2010a, 2011) and serum (Nekoofar et al. 2010b) contamination as well as in
the presence of an acidic pH (Namazikhah et al. 2008), the authors assumed that following extrusion of MTA into periradicular lesions, the material may remain unset. As
the composition of unset MTA differs from set MTA, the tissue response to extruded
unset MTA is unpredictable and unknown.
Similar to the extrusion of MTA material in the periradicular tissues, it can be
assumed that mixing MTA with blood in the present case resulted in nonsetting of the
material. MTA sets in contact with water by undergoing a hydration process. During the
initial stage of this process, Ca2+ and OH ions are released from tricalcium silicate
(C3S) into the surrounding environment which, at supernaturation levels, forms calcium
hydroxide precipitate (portlandite) and amorphous calcium silicate hydrate (CSH) gel
(Camilleri 2007). However, in a microstructure and chemical analysis of blood contaminated MTA, Nekoofar et al. (2011) concluded that mixing MTA with blood resulted in
the lack of formation of the crystalline calcium hydroxide in the early stage of the hydration process. The formation of calcium hydroxide in the early stage is crucial for the
hydration process. How much MTA will set and how much will remain unset is largely
unknown and further research is needed to clarify this subject. However, the blood contaminated MTA used in the present case report seems to have remained unset and
exhibits slow biodegradation 24 months after placement.

Conclusion
White MTA when mixed with blood may remain unset, creating a favourable environment for tissue regeneration. Amongst other possible clinical applications, this mixture
might be advantageous for the induction of hard tissue healing in pulpless horizontally
fractured teeth. More studies to support or reject these suggestions are recommended.

Disclaimer
Whilst this article has been subjected to Editorial review, the opinions expressed,
unless specifically indicated, are those of the author. The views expressed do not
necessarily represent best practice, or the views of the IEJ Editorial Board, or of its
affiliated Specialist Societies.

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10

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International Endodontic Journal, 0, 111, 2014

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

Chaniotis MTA/blood in fractured incisor

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

International Endodontic Journal, 0, 111, 2014

CASE REPORT

Paranjpe A, Smoot T, Zhang H, Johnson J (2011) Direct contact with mineral trioxide aggregate
activates and differentiates human dental pulp cells. Journal of Endodontics 37, 16915.
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a case report with a 10-year follow-up. Dental Traumatology 27, 4603.
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odontogenic differentiation in dental pulp stem cells. Journal of Endodontics 39, 2428.
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central incisor: a case report. Dental Traumatology 24, 6804.
Trope M (2010) Treatment of the immature tooth with a non-vital pulp and apical periodontitis.
Dental Clinics of North America 54, 31324.
Wigler R, Kaufman AY, Lin S, Steinbock HH-M, Torneck CD (2013) Revascularization: a treatment
for permanent teeth with necrotic pulp and incomplete root development. Journal of Endodontics
39, 31926.

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