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 Table of Contents  
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 239-244

Single-visit apexification in immature necrotic teeth using mineral trioxide aggregate as an apical plug: Case series

1 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
2 Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India

Date of Submission19-Jul-2019
Date of Acceptance20-Nov-2019
Date of Web Publication22-Jan-2020

Correspondence Address:
Dr. Nidhi Singh
Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_41_19

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Apexification is a procedure for closure of the open apex in an immature necrotic tooth. Apexification with calcium hydroxide is considered as the gold standard. However, this technique is associated with certain difficulties such as very long treatment period, possibility of tooth fracture, and incomplete calcification of the bridge. Single-visit mineral trioxide aggregate (MTA) apexification has become popular over the calcium hydroxide technique. In this article, three case reports of 3 months to 1-year follow-up are presented, which were treated by the single visit apexification procedure which includes recent artificial barrier methods with MTA as the apical plug and the rest of the canal was obturated with thermoplastisized gutta-percha.

Keywords: Apexification, apical barrier, apical plug, mineral trioxide aggregate, single visit

How to cite this article:
Singh N, Mittal N, Baranwal HC, Tripathi R, Wang CK. Single-visit apexification in immature necrotic teeth using mineral trioxide aggregate as an apical plug: Case series. SRM J Res Dent Sci 2019;10:239-44

How to cite this URL:
Singh N, Mittal N, Baranwal HC, Tripathi R, Wang CK. Single-visit apexification in immature necrotic teeth using mineral trioxide aggregate as an apical plug: Case series. SRM J Res Dent Sci [serial online] 2019 [cited 2022 Aug 15];10:239-44. Available from:

  Introduction Top

In recent scenario, regenerative endodontics is increasing in popularity over apexification in nonvital tooth due to continued development of length and thickness in root of the tooth but no surety about its outcome. Single-visit apexification is the choice for clinician when sufficient root length is available. The term apexification defined as the method of treatment aimed at inducing apical repair as a hard-tissue barrier across an open apex. This technique is usually prescribed in the management of pulpless permanent tooth with an open apex or even “blunderbuss” canal.[1] There are number of clinical problems in apexification procedure such as (1) lack of specific treatment time, (2) long duration of treatment, (3) uncertain apical closure, and (4) walls of the root are thin and susceptible to fracture. One-visit apexification with apical plug eliminates these problems. It requires the nonsurgical compaction of a biocompatible material into the apical end of the root canals. This creates an apical stop and enables immediate filling of root canal.[2]

In recent years, researchers have been investigating materials capable of being applied permanently at the ends of tooth roots to compress the treatment procedure into one or two visits. In 1979, Coviello and Brilliant found tricalcium phosphate for this purpose and examined that the degree of success achieved was comparable with apexification. Torabinejad and Chivian described the use of mineral trioxide aggregate (MTA) as an apical plug in 1999.[3] Due to hydrophilic particles in MTA, it gets hardened in <4 h upon contact with moisture. Recently, there have been a number of studies that describe the MTA use in single-visit apexification. A number of authors[4],[5],[6],[7],[8] have reported clinical success using MTA for this procedure. In comparison to calcium hydroxide, MTA appears to show more predictable results with consistent of hard-tissue formation.[9] Clinical use of MTA may shorten the treatment period for apexification with more favorable results and improves patients compliance.[5]

In this article, there were three clinical cases which showed nonvital, immature permanent teeth with open apex and treated by a single-visit apexification procedure using MTA as an apical plug.

  Case Report Top

Case A

A 13-year-old male patient visited the Department of Conservative Dentistry and Endodontics, having chief complaint of fracture tooth in the upper right front tooth region about 6–7 years back due to trauma. On clinical examination, sinus was present on labial mucosa near the apex of the root and tenderness on percussion was present. The preoperative intraoral periapical radiograph [Figure 1] revealed that there were large periapical radiolucency and wide open apices. The canal was also incompletely obturated. Hence, the diagnosis was the periapical abscess with sinus and started the root canal treatment.
Figure 1: Preoperative radiograph

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Clinical procedure

The tooth was isolated using a rubber dam. Access cavity was prepared and working length determined. The canal was then carefully mechanically cleaned by intracanal instruments. 2.5% NaOCl was used as intracanal irrigant during instrumentation. The canal was then dried with sterile paper points. Calcium hydroxide intracanal dressing was placed [Figure 2] for 1 week. After 1 week, the calcium hydroxide was removed by repeated careful instrumentation and rinsing with 2.5% NaOCl and finally rinsed with sterile water. The canal was completely dried using sterile paper points.
Figure 2: Calcium hydroxide was placed

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According to the manufacturer's instruction, MTA (Angelus) powder was mixed with sterile water into a thick, grainy paste. The mixture was carried to the canal by carrier. About 4 mm of MTA was placed with the help of MTA carrier carefully and condensed using prefitted pluggers on to the apical end of the canal to create apical plug. To check the correct placement of MTA at apex, a radiograph was taken. Once a plug of 4 mm is confirmed, all excess MTAs were removed to the canal.

The physical barrier of G-bone synthetic hydroxyapatite beyond apex and MTA in apical third of the canal was placed [Figure 3]. Another wet cotton pellet was placed in the pulp chamber, and the access cavity was covered with temporary filling material.
Figure 3: Mineral trioxide aggregate was placed in case A

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The next day, the access filling was removed and gently tested the set of MTA. The remaining canal was backfilled gently [Figure 4] with softened gutta-percha by warm vertical condensation technique (E and Q Master Obturation system).
Figure 4: Obturated with thermoplastized GP by E and Q

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The tooth was coronally sealed with composite resin (Ivoclar Vivadent) permanently on the same day and recalled the patient after 3 months and 12 months for follow-up [Figure 5] and [Figure 6]. Within 3 months, open apex got sealed nicely.
Figure 5: After 3-month follow-up

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Figure 6: After 12-month follow-up of case A

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Case B

An 18-year-old male patient was referred to the Department of Conservative Dentistry and Endodontics. He was been referred by the department of oral surgery, as tooth 21 was noted to have an open apex [Figure 7] while extracting the tooth 11.
Figure 7: Preoperative radiograph of case B

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The patient gave a history of injury to upper front teeth, and there was dull and intermittent pain in the upper left central incisor. On clinical examination, swelling and sinus were present with tenderness on percussion. Hence, the diagnosis was periapical abscess with sinus and started the same procedure as in Case A for apexification that is shown in [Figure 8] and [Figure 9]. This patient was recalled after 6 months [Figure 10] and 12 months [Figure 11] for follow-up.
Figure 8: Mineral trioxide aggregate was placed in case B

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Figure 9: Obturated with thermoplastized GP

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Figure 10: After 6-month follow-up

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Figure 11: After 12-month follow-up of case B

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Case C

A 15-year-old male patient reported to the department with pain in the upper right front tooth region for 2 years. He gave the history of trauma 8–9 years back. At that time, the affected teeth had not been treated properly, and within 1 year, the crown restoration was removed and the patient neglected to consult a dentist. Since then, the teeth had developed apical lesion, and swelling was present.

Radiographic examination showed that periapical lesion was present on the apical region of the right central incisor and wide open apices with incomplete obturation [Figure 12]. Hence, the diagnosis was the periapical abscess without sinus. Now, the root canal treatment was started. The same procedure was continued, and MTA was filled as an apical plug [Figure 13]. This case was indicated for post and core. Hence, post and core were fabricated by using titanium post (Dentatus). Titanium post was bended distally, so that it is parallel to the facial midline [Figure 14]. This patient is recalled after 6 months [Figure 15] and 12 months [Figure 16] for follow-up.
Figure 12: Preoperative radiograph of case C

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Figure 13: Mineral trioxide aggregate was placed in case C

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Figure 14: Titanium post bent distally

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Figure 15: After 6-month follow-up

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Figure 16: After 12-month follow-up of case C

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  Discussion Top

Apexification is the most accepted procedure to treat immature teeth with open apices.[2] The purpose of this procedure is to induce the formation of a hard-tissue barrier, thus allowing proper gutta-percha obturation of the root canal. The most problem regarding with apexification using calcium hydroxide is the long treatment procedure ranging from 3 to 21 months,[10] depending on factors such as the diameter of the open apices, uncertain apical closure, frequent instrumentation, reinfection due to loss of temporary restoration, and also predisposes the tooth to fracture.[2] It can produce a favorable environment to help in the formation of hard tissue, comprising osteocementum at the end of the roots.[11] By the use of calcium hydroxide for apexification, there is a probability of canal reinfection because the crown is only filled with temporary materials and also the chance of cervical fracture.[12] To solve these problems, a single visit apexification procedure is recommended. In 1990, Morse et al. defined single visit apexification as the nonsurgical condensation by a biocompatible material into the apical end of the root canal. The goal is to establish an apical stop that would enable the root canal to be filled immediately. There is no attempt of root-end closure; rather an artificial apical stop is created. Therefore, in present cases, “single visit apexification” procedure is chosen for faster and better results.[13]

Recently, there are a number of reports of using MTA as an apical plug with satisfactory results.[2],[4],[5],[6],[7],[8],[13],[14] Some data[2],[6],[9] suggest that in comparison to traditional calcium hydroxide, MTA becomes more predictable with consistent hard-tissue formation. The use of MTA for apexification may lessen the treatment procedure with more appreciative results and help in patient comfort.[6] MTA also has high sealing ability,[15] excellent marginal adaptation,[16] a high degree of biocompatibility,[17] a suitable setting time (about 4 h),[3] and antibacterial property to promote hard-tissue formation.

MTA is composed of tricalcium silicate, dicalcium silicate, tricalcium aluminate, and bismuth oxide. It may also contain traces of free crystalline silica and trace constituents such as calcium oxide, free magnesium oxide, potassium, and sodium sulfate compounds. Commercial MTA exists in both gray and white forms. After setting, it has a pH of 12.5 which is similar to calcium hydroxide. It is a hydrophilic material and requires moisture to set. MTA has been used in nonsurgical as well as in surgical application for root-end filling, direct pulp caps, perforation repairs of roots or perforations, and apexogenesis. MTA demonstrates the cementoconductive property and total closure of the apex with cementum.[7]

During the apexification procedure, canals were gently instrumented till the correct working length and irrigated with 2.5% NaOCl to disinfect the canal and canal walls. Temporary calcium hydroxide intracanal medicament was placed after completely drying the canals. The calcium hydroxide was left in the canal for 1 week. The rationale is to control bacterial infection and to create an alkaline environment which is more ideal for MTA. After 1 week, again canals were gently instrumented and irrigated with 2.5% NaOCl to remove calcium hydroxide completely from the canal walls.

It is recommended that a 3–5 mm thick plug of MTA should be placed at the apex for apexification procedures. Several authors successfully treated open apex cases by placing 2–5 mm of thickness of MTA at the apical end as a stop.[3],[6],[8],[18] Therefore, in the present case, after canal disinfection with calcium hydroxide, the apical region can be blocked by about 4 mm of MTA as an apical plug and physical barrier of G-bone is used beyond apex. G-bone is modified hydroxyapatite granules and in highly crystalline form blocks are made of calcium hydroxyapatite. In our case, it is used as apical barrier. MTA needs 3–4 h and moisture for complete setting and to become hard.[3],[9],[18] Therefore, moist cotton is left in the canal and sealed temporarily for a day for complete setting.

  Conclusion Top

Single-visit apexification is the recommended procedure for nonvital immature teeth with wide-open apex because the procedure is simple, less time-consuming, predictable, gives immediate result, and well accepted by the patient.

MTA is a promising biocompatible material which is used as an apical plug to seal the wide-open apex.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Steiner JC, Dow PR, Cathey GM. Inducing root end closure of nonvital permanent teeth. J Dent Child 1968;35:47-54.  Back to cited text no. 1
Zarabi HM, Mohtasham N, Sheik-Nezamy M, Bidar M. A comparative study of apical sealing of open apices using MTA and Ca(OH) 2 apical plugs in cats J Dent Tehran Univ Med Sci Tehran Iran 2005;2:58-63.  Back to cited text no. 2
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.  Back to cited text no. 3
Ghaziani P, Aghasizadeh N, Sheikh-Nezami M. Endodontic treatment with MTA apical plugs: A case report. J Oral Sci 2007;49:325-9.  Back to cited text no. 4
Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002;18:217-21.  Back to cited text no. 5
Maroto M, Barbería E, Planells P, Vera V. Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA). Dent Traumatol 2003;19:165-9.  Back to cited text no. 6
Ham KA, Witherspoon DE, Gutmann JL, Ravindranath S, Gait TC, Opperman LA. Preliminary evaluation of BMP-2 expression and histological characteristics during apexification with calcium hydroxide and mineral trioxide aggregate. J Endod 2005;31:275-9.  Back to cited text no. 7
Hachmeister DR, Schindler WG, Walker WA 3rd, Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endod 2002;28:386-90.  Back to cited text no. 8
Shabahang S, Boyne PJ, Abedi HR, McMillan P, Torabinejad M. Apexification in immature dog teeth using osteogenic protein-1, mineral trioxide aggregate, and calcium hydroxide (abstract 65). J Endod 1997;23:265.  Back to cited text no. 9
Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with flaring apices. Dent Traumatol 2001;17:86-92.  Back to cited text no. 10
Leonardo MR, da Silva LA, Leonardo Rde T, Utrilla LS, Assed S. Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. J Endod 1993;19:348-52.  Back to cited text no. 11
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 12
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 13
Soares J, Santos S, César C, Silva P, Sá M, Silveira F, et al. Calcium hydroxide induced apexification with apical root development: a clinical case report. Int Endod J 2008;41:710-9.  Back to cited text no. 14
Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-5.  Back to cited text no. 15
Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod 1995;21:295-9.  Back to cited text no. 16
Koh ET, McDonald F, Pitt Ford TR, Torabinejad M. Cellular response to mineral trioxide aggregate. J Endod 1998;24:543-7.  Back to cited text no. 17
Martin RL, Monticelli F, Brackett WW, Loushine RJ, Rockman RA, Ferrari M, et al. Sealling ability of mineral trioxide aggregate orthograde apical plugs and root filling in an in vitro apexification model. JOE 2007;33:272-275.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]


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