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Journal of
Dental Sciences
SINGLE VISIT MTA APEXIFICATION
Case
TECHNIQUE FOR FORMATION Series
OF ROOT-END BARRIER IN
OPEN APICES- A CASE SERIES
1
Bhumika Kapoor, 2Osama Adeel Khan Sherwani, 3Rajendra K Tewari, 4Surendra K Mishra.
1,2
Junior Resident, 3,4Professor, Department of Conservative Dentistry and Endodontics.
Dr. Z. A. Dental College & Hospital, Aligarh Muslim University, Aligarh

ABSTRACT: Mineral trioxide aggregate apexification is a viable option for treatment of open
apex. MTA forms an apical barrier at the root end against which endodontic treatment can be
successfully completed. The multiple advantages of MTA such as its biocompatibility, sealing Keywords :
ability, antimicrobial properties, bioactivity along with single appointment treatment option for Mineral trioxide aggregate,
open apex is a boon in the field of endodontics. Using calcium hydroxide for root end formation open apex, apexification.
has many disadvantages like decrease in strength of radicular dentin and long follow up visits.
Therefore, MTA is material of choice for such cases. However, using calcium hydroxide dressing Source of support : Nil
before MTA placement increases pH of acidic environment and hence maintains hydrated gel like Conflict of interest : None
structure of MTA.The following case series represents 4 cases of open apex in which MTA was
used for root end barrier formation against which obturation was done successfully.

INTRODUCTION : Apexification is defined as a method to appointment apexification was done with MTA.
induce a calcified barrier in a root with an open apex or
continued apical development of an incompletely formed root CASE REPORT 1: An 11 year old boy was referred to
in teeth with necrotic pulp tissue(1). Several materials are Department of Conservative Dentistry and Endodontics,
used for the management of open apices. The most widely Aligarh Muslim University, Aligarh with the chief complaint
used material until recently was calcium hydroxide that was of spontaneous pain in upper front teeth. He had a trauma 3
replaced over intervals for several months, to stimulate years back but was asymptomatic till recently.
calcific barrier formation. Torabinejad and Chivian Clinical examination revealed fracture of tooth 11. The tooth
introduced mineral trioxide aggregate (MTA) as an apical was tender on percussion and labial mucosa of the concerned
plug and now it is an accepted material for apexification till tooth showed inflammation. The tooth was painful on
date. palpation.
The use of calcium hydroxide affects various mechanical Intraoral radiograph showed incomplete root end formation
properties of radicular dentin (2). The alkaline pH of calcium of 11. The dentinal walls were thick. (Fig1)
hydroxide increases the chances of fracture due to
denaturation of dentinal organic proteins. Hence, it is not
recommended in teeth with thin dentinal walls.
Mineral Trioxide Aggregate is a powder consisting of fine
hydrophilic particles of tricalcium silicate, tricalcium
aluminate, tricalcium oxide and silicate oxide. It also contains
small amounts of other mineral oxides, which modify its
chemical and physical properties. Radio opacity is provided Fig1: Preoperative radiograph revealed open apex in tooth 11.
by bismuth oxide. The pH of MTA IS 12.5 which imparts it
antimicrobial activity(3). MTA has good sealing ability, good Pulp testing was done with pulp tester (Parkell inc, USA) and
biocompatibility, excellent long term prognosis and ability of thermal test with heated gutta percha, showed no response in
tissue regeneration. These properties prove it to be a material the suspected tooth when compared to adjacent, contralateral
of choice for cases with high failure rates. The following case tooth. The tooth was diagnosed with pulp necrosis with
series consist of 4 cases with open apex in which single periradicular periodontitis.

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The patient was discussed with various treatment plans and CASE REPORT 2:
consent was obtained. Following isolation with a rubber dam, A 14 year old boy was referred to the Department of
an endodontic access opening was made. Working length was conservative dentistry and endodntics, AMU Aligarh with the
established with the help of intraoral periapical radiograph chief complaint of pus discharge from the openings near the
using 80K file. Minimum instrumentation was done and the root apex of tooth 11. He had trauma 4 years back but was not
walls of canal were circumferentially cleaned with 80K file. symptomatic till last 2 months.
The root canal was copiously irrigated with 5.25% sodium Clinical examination revealed fractured tooth 11 involving
hypochlorite and normal saline. Intracanal dressing with the pulp. Sinus opening was present near the root apex. The
calcium hydroxide (Ultradent Products inc, USA) was given tooth was not tender on percussion and there was no pain on
for one week and the provisional restoration with Cavit(Cavit palpation. Labial mucosa adjacent to the concerned tooth was
GTM) was given. On recall visit, the tooth was asymptomatic. inflamed.
The temporary restoration was removed and canal was Intraoral periapical radiograph showed open apex of tooth 11.
irrigated with normal saline and dried with size 80 absorbent The dentinal walls were thin.(fig 4)
paper point(Ultradent Products inc, USA). A suitable plugger
size that fitted loosely within 2mm of apex was chosen. MTA
was mixed with distilled water to a consistency of wet sand
and placed in increments in the apical region of the canal
using Micro Apical Placement (MAP) system(DENTSPLY
Tulsa).Mineral trioxide aggregate was compacted with the
plugger previously fitted to the root canal system. Care was
taken to prevent extrusion of the material into the periapical Fig 4: IOPA revealed open apex in tooth 11
area. The final adjustment was done with inverted cut end of
gutta percha size 80(Dentsply, USA) with the help of Treatment protocols included apexification with calcium
radiograph till a minimum thickness of 5mm. Once the MTA hydroxide, single visit MTA apexification and
layer is adequately compacted to the working length and revascularization technique. The patient gave consent for
confirmed with a radiograph,(fig 2) the excess was removed single appointment apexification as he could not report at
from the coronal and middle third of the canal with the help of regular intervals.
sterile wet fine brush.A moist cotton pellet was placed against Following isolation with a rubber dam, an endodontic access
it, as the presence of moisture is essential for the material to opening was made. Working length was established with the
set.The access cavity was temporized. The patient was help of intraoral periapical radiograph using 80K file.
recalled after 24 hours. At the next appointment, the MTA felt Minimum instrumentation was done and the walls of canal
hard to an endodontic explorer DG-16 (Hu-Friedy were circumferentially cleaned with 80K file. The root canal
International).The remaining part of the root canal was back- was copiously irrigated with 5.25% sodium hypochlorite and
filled with injection molded thermoplastic gutta-percha normal saline. Intracanal dressing with calcium hydroxide
(Obtura III, USA) and sealer (AH 26, Dentsply, Germany). (Ultradent Products inc, USA) was given for one week and
Post obturation radiograph was taken.The patient was asked access cavity was temporized with Cavit ( Cavit GTM). On
to report after a week for clinical evaluation and the post recall visit, the tooth was asymptomatic. The temporary
endodontic restoration. During recall, the tooth was restoration was removed and canal was irrigated with normal
asymptomatic and post endodontic composite (Tetric Ceram, saline and dried with size 80 absorbent paper point (Ultradent
Ivoclar Vivadent Inc) restoration was placed(fig 3) and Products inc, USA). A suitable plugger was chosen. MTA
patient was recalled after 3,6,12 months for the follow-up. was mixed with distilled water to a consistency of wet sand
and placed in increments in the apical region of the canal
using Micro Apical Placement (MAP) system
(DENTSPLYTulsa).Mineral trioxide aggregate was
compacted with the help of plugger. Care was taken to prevent
Fig 2: Mineral trioxide aggregate plug Fig 3: Post obturation radiograph extrusion of the material into the periapical area. The

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thickness of MTA was kept 5mm and a moist cotton pellet help of suitable carrier gun. The material was then condensed
was placed against it for proper setting(fig 5).Access cavity to a thickness of 5mm and confirmed radiographically. A wet
was given temporary restoration. Patient was recalled next cotton pellet was placed over cement for proper setting.
day for obturation. Obturation was done with Patient was recalled further for custom made cast post and
thermoplastisized technique using Obtura III (Obtura crown fabrication (fig 8). The patient was kept on follow up.
Spartan,Canada). The patient was asked to report after a week
for clinical evaluation and the post endodontic restoration (fig
6). During recall, the tooth was asymptomatic and post
endodontic composite (Tetric Ceram, Ivoclar Vivadent Inc)
restoration was placed and patient was recalled after 3,6,12
months for the follow-up.
Fig 7: Preoperative radiograph Fig 8: MTA condensed at
showing open apex and the apex. Cast post and
crown in tooth 21 with crown fabricated
no endodontic treatment

CASE REPORT 4: An18 year old female patient reported in

department of conservative dentistry and endodontics, AMU
Fig 5: MTA condensed at the apex Fig 6: Post obturation radiograph Aligarh. She complained of pain in upper front teeth. The
patient had trauma 7 years back.
CASE REPORT 3: A 21 year old female patient reported to On examination, tooth 11 was fractured. There was a sinus
Department of Conservative Dentistry and endodontics, tract in relation to tooth 11 and 12 and there was pain on
AMU Aligarh. She complained of pain in upper front left palpation
tooth since last 4 months. Intra oral radiograph revealed large periapical pathology in
On examination , tooth 21 had a crown placed on it. The tooth relation to tooth 11 and 12. Tooth 11 showed open apex and
was tender on percussion and there was pain on palpation. exposed pulp. (fig 9)
Intraoral periapical radiograph revealed open apex of tooth Endodontic management of both teeth were decided with
21. The tooth was not endodontically treated and the crown single appointment MTA apexification for tooth 11 and root
was placed on it. The dentinal walls were thick (fig 7) canal treatment for tooth 12.The teeth were isolated by rubber
Single appointment MTA apexification was planned. On the dam and access cavity was made. The working length was
first appointment the crown was removed using crown established with the help of intraoral radiograph. The canal
removal system(Safe crown and bridge removal, Anthogyr) walls of tooth 11 were circumferentially cleaned with 80K file
The tooth was isolated by rubber dam and access cavity was and copious irrigation was done with 5.25% hypochlorite and
made through remaining tooth structure. The working length normal saline. For tooth 12, chemomechanical preparation
was established with the help of intraoral radiograph. The was performed with hand K Files (Dentsply, USA).Calcium
canal walls were circumferentially cleaned with 80K file and hydroxide ( Ultradent Products inc, USA) dressing was
copious irrigation was done with 5.25% hypochlorite and placed for 1 week. The tooth was given temporary restoration
normal saline. Calcium hydroxide (Ultradent Products inc, with cavit (Cavit GTM3M ESPE, Seefeld, Germany). After 1
USA) dressing was placed for 1 week. The tooth was given week, the patient was symptomatic, therefore, second
temporary restoration with cavit (Cavit GTM3M ESPE, calcium hydroxide dressing was placed. On the next
Seefeld, Germany) After 1 week, patient was asymptomatic appointment, the provisional restoration was removed and
and tooth was not tender on percussion. The temporary irrigation was performed to remove all calcium hydroxide.
restoration was removed and irrigation with hypochlorite and The canal was dried with paper points and MTA was mixed
normal saline was performed to remove calcium hydroxide with distilled water and placed in apical region with help of
from the canal. Absorbent paper points (Ultradent Products suitable carrier gun. The material was then condensed to a
inc, USA) was used to dry the canal completely. MTA was thickness of 5mm and confirmed radiographically(fig 10). A
mixed with distilled water and placed in apical region with wet cotton pellet was placed over cement for proper setting.

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Patient was recalled next day for obturation and post Open apices are usually seen in young individuals and hence
endodontic restoration. Tooth 11 was obturated using obtura surgery is not a desirable treatment for this. The thin, fragile
III and tooth 12 was obturated with lateral condensation (fig dentinal walls poses a threat to fracture on compaction of root
11) end filling material. Also, patent dentinal tubules of young
dentin cannot be sealed completely by root end filling
material.
Many materials have been reported to induce calcific barrier
formation. The use of non setting calcium hydroxide was
done by Kaiser in 1964(5) and later Frank(6) brought this to a
Fig 9: Preoperative radiograph
higher level. Coviello and Brilliant in 1979 introduced
showing fractured 12 with open apex
tricalcium phosphate(7)Later, Schumache and Rutledge in
1993 suggested calcium hydroxide as a permanent apical
barrier (8).
The Frank's technique of placing calcium hydroxide
sometimes provides inconsistent results like: 1) The periapex
closes with a definite (though minimal) recession of the root
canal. The apical aspect continues to develop with a
Fig 10: MTA apical plug Fig 11: Post obturation radiograph
seemingly obliterated apex. 2) The obliterated apex develops
DISCUSSION : without any change in the root canal space. 3) A thin, calcific
Open apices have always been a challenge to an endodontist bridge that is not radiographically discernable develops. 4) A
since it requires an apical barrier against which the canal can calcific bridge forms just coronal to the apex and can be
be successfully obturated. Premature loss of permanent tooth determined radiographically.
can lead to various problems such as wide, diverging or One of the major drawbacks of calcium hydroxide is that it is
parallel canals, inappropriate crown root ratio, thin dentinal a multiple visit procedure. In this procedure, the calcium
walls etc. These problems can pose a threat to successful hydroxide dressing is replaced every three months until a
treatment. Apart from this, fear of dentist of the young barrier is formed, which may require up to 24 months. So,
individual and discontinuation of any treatment procedure are such repetitive procedures are difficult to maintain.
other risk factors that may not lead to successful treatment. The long term and short term of calcium hydroxide can affect
Apexification is the last treatment option of an immature the mechanical properties of radicular dentin.(9,10,11) The
permanent tooth which has lost its pulpal vitality. It causes pH of calcium hydroxide is 11.8 which is highly alkaline.
root end closure by forming an apical plug but does not cause Some authors have proposed that the alkaline pH of Ca(OH)2
increase in root length and thickness or root end development may lead to neutralization and denaturation of dentin organic
unlike apexogenesis or revascularization technique. proteins. This may cause collagen degradation leaving the
Apexogenesis is treatment to preserve vital pulp tissue in the root more prone to fracture(2,12)
apical part of a root canal in order to complete formation of Infection control is an upmost factor for any successful
root apex(4).Therefore, apexogenesis is only possible when procedure. Similar, is the case with apexification where
some vital pulp is remaining . It was not possible in our cases presence of infection can cause delay in root end
as all of them had necrotic pulp. Revascularization technique closure(12,13) . However, some authors have claimed that
has an added advantage of complete formation of pulp dentin there is no significant difference in apexification time when
complex. The defense mechanisms of pulp dentin complex is infection is present(14,15,16) The long term procedures also
also completely established by regenerative techniques. exposes the risk of loss of coronal seal. This further can
However, long term follow up and uncertainty of the results increase the duration of procedure as infection free
are disadvantages of revascularization protocol. Also, till date environment cannot be maintained.
only case reports and case series have been reported for Thus, keeping all facts in mind a single appointment, non
regeneration technique. The randomized controlled trails are surgical approach to open apex is best treatment plan. A
still lacking for a definite evidence. desirable material which can form an apical plug is required

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for this procedure. To, the best of our knowledge Mineral by using MTA carrier or amalgam carrier and condensed with
trioxide aggregate (MTA) is material of choice for single suitable pluggers and cut end of inverted GP cone no. 80. It is
appointment apexification and till date no material has been at placed 4 to 5mm in thickness(27). The adequacy of material is
par with MTA. Torabinejad et al discovered orginal form of verified radiographically. As the setting time of MTA is long
MTA which was gray MTA(17) The main constituents are and it needs moisture during setting procedure a moist cotton
calcium silicate(CaSiO4), bismuth oxide(Bi2O3), calcium is placed in the canal. While, placing the cotton it is kept in
carbonate(CaCO 3 ), calcium sulfate(CaSO 4 ), Calcium mind that cotton is not directly placed above MTA as cotton
Aluminate(CaAl2O4). MTA cement contains a hydrophilic fibers may get entrapped in the material. The tooth is then
powder that reacts with water and produces a calcium given suitable provisional restoration with tight coronal seal
hydroxide and calcium silicate hydrated gel. and canal is usually condensed with obturating material in the
A major advantage of MTA is its biocompatibility next appointment keeping in mind it's long setting time.
(18,19,20,21) and hard tissue formation. This hard tissue It is difficult to prevent extrusion of material from
formation is because of ability of MTA to induce blunderbuss canals. Hence, placement of MTA is done with
cementoblastic cells(22) Scanning electron caution and it is placed 1 to 3mm short of root end. While,
microscope(SEM) analysis has shown that cementoblasts condensing MTA any voids should be avoided and it should
have ability to attach and grow on MTA. MTAforms a be condensed in a single plane. Any excess MTA sticking on
biologic barrier at the apical end which prevents regress of the walls should be removed by scrubbing wet cotton or brush
microorganisms(23) It causes deposition of new cementum against canal walls.
and periodontal regeneration. MTA is also not affected by blood contamination(28).
MTA has longest setting time of 2 hours and 45 minutes. The Holland et al theorized that the tricalcium oxide in MTA
compressive strength is low 40MPa but it increases to 67MPa reacts with tissue fluids to form calcium hydroxide, resulting
in 21 days. The initial pH is 10.2 which rises to 12.5 in 3 hours in an apical barrier (29).Since , apexification is done in
after mixing. Gray MTA had a disadvantage of discoloration necrotic pulp it is important to create an environment free
which was solved by discovery of white MTA in 2002 .The from microbes. This further renders the need of a material
composition of both varieties is similar and a difference of with antibacterial properties . MTA is proved to possess some
less than 6 % is seen in any one of the component. The antibacterial properties. Torabinejad et al tested MTA,
radioopacity of both kinds is similar and it is 3.04mm of amalgam, ZOE and SuperEBA against nine facultative
aluminum. However, placing gray MTA at the apex is not bacteria and seven strict anaerobes(3). Mineral trioxide
unaesthetic in anyway. aggregate was found to have an antibacterial effect on five of
The use of MTA as an apical barrier was first reported in nine facultative bacteria but no effect on any of the strict
1996.(24) Shabahanget al compared MTA, osteogenic anaerobes. The other materials had similar effects. It was
protein- 1 and Calcium hydroxide for apexification in concluded that none of the test materials had all of the
dogs(25) and found that MTA induced hard-tissue formation antibacterial effects desired for a root-end filling material.
more often than any other test materials. Thus, MTA was Hachmeister et al emphasized that the apical plug thickness
suitable for use as an apical barrier for apexification in may only have a significant impact on displacement
immature roots. In 2007, Simon et al used MTA on 57 teeth resistance(30) while in the present case the thickness of
had showed successful results(26) .He concluded that that use apical plug of MTA was 5 mm and the remaining part of the
of MTA reduces root fracture risk, had better patient root canal was back-filled with injection molded
compliance and showed early results. thermoplastic gutta-percha (ObturaIII, USA) and sealer (AH
Before placement of MTA it is advocated to place calcium 26, Dentsply, Germany).
hydroxide in the canal for 1 week interval for disinfection of
canal. The acidic pH raises which reduces inflammation of CONCLUSION : The development of MTA is a milestone in
periapical tissues . After one week interval if the tooth is free field of dentistry. The properties of MTA like its bioactivity,
from symptoms then the tooth is isolated with the help of sealing ability and biocompatibility prove it to be an excellent
rubber dam and calcium hydroxide is washed away. After tool for cases that have poor prognosis. Many advantages of
drying of canal by paper points MTA is placed in increments this material along with single appointment apical closure

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outweigh any disadvantage of MTA. As discussed previously commonly used Root end Sahebi S, Moazami F, Abbott
single appointment is better than multiple appointments. P. The effects of short-term calcium hydroxide
Therefore, MTA apexification can be a feasible and effective application on the strength of dentine. Dent Traumatol
treatment option for open apices. 2010;26:43–6.
11. Marending M, Stark WJ, Brunner TJ, et al. Comparative
ACKNOWLEDGMENT: The authors are grateful to assessment of time-related bioactive glass and calcium
Professor Ashok Kumar (Department of Conservative hydroxide effects on mechanical properties of human
Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental root dentin. Dent Traumatol 2009;25:126–9.
College, AMU , Aligarh) for his support and guidance in the 12. Cvek M: Treatment of non-vital permanent incisors with
above cases. calcium hydroxide. I. Follow-up of periapical repair and
apical closure of immature roots. Odontol Rev,
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