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Table of Contents
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 36-38

Management of an open apex with mineral trioxide aggregate apexification: A case report

1 Reader, Triveni Institute of Dental Sciences, Hospital and Research Centre, Bilaspur, Chhattisgarh, India
2 Senior Lecturer, Triveni Institute of Dental Sciences, Hospital and Research Centre, Bilaspur, Chhattisgarh, India
3 Senior Lecturer, MDS Conservative Dentistry and Endodontics, Sri Sukhmani Dental College and Hospital, Derabassi, Punjab, India
4 BDS, Sri Sukhmani Dental College and Hospital, Derabassi, Punjab, India
5 Reader, MDS Conservative Dentistry and Endodontics, Triveni Institute of Dental Sciences, Hospital and Research Centre, Bilaspur, Chhattisgarh, India

Date of Submission12-Mar-2020
Date of Acceptance22-Apr-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
Dr. Suyash Thakur
Triveni Institute of Dental Sciences, Hospital and Research Centre, Bilaspur, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INPC.INPC_6_20

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Mineral trioxide aggregate (MTA) has the advantage of being less soluble than calcium hydroxide and offers an enhanced seal due to its setting expansion which hermetically seals the pulp space, preventing bacterial contamination from the outside. The use of MTA as an alternative material to calcium hydroxide for apexification has gained popularity. This case report presents the use of MTA as an apical plug for an open apex central incisor with periapical lesion.

Keywords: Apexification, matrix, mineral trioxide aggregate, periapical lesion

How to cite this article:
Thakur S, Thakur S, Parthi A, Bakshi S, Kridutt V. Management of an open apex with mineral trioxide aggregate apexification: A case report. Int J Prev Clin Dent Res 2020;7:36-8

How to cite this URL:
Thakur S, Thakur S, Parthi A, Bakshi S, Kridutt V. Management of an open apex with mineral trioxide aggregate apexification: A case report. Int J Prev Clin Dent Res [serial online] 2020 [cited 2021 Sep 18];7:36-8. Available from: https://www.ijpcdr.org/text.asp?2020/7/2/36/288189

  Introduction Top

The anatomy of the apical foramen changes with age as root formation has yet to be completed when teeth erupt. The completion of root development and closure of the apex occurs up to 3 years after eruption.[1]

Patients who present with immature apical formation [Figure 1] pose a challenge due to the presence of large open apices along with divergent and thin dentinal walls that are susceptible to fracture. Historically, we have tried to generate the formation of an apical barrier by the repeated placement of calcium hydroxide over many months, or more recently by immediate barrier formation with a mineral trioxide aggregate (MTA) plug.[1],[2]
Figure 1: Preoperative

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  Case Report Top

A 22-year-old male patient reported with a chief complaint of pain and discoloration in the upper right front tooth region. The patient's history revealed that he had suffered a trauma 10 years back, for which he did not undergo any treatment. The medical history was not significant. On clinical examination, right maxillary central incisor was discolored and tender on percussion. On doing the pulp- vitality test, there was a negative response to heat and electric pulp testing. Periapical radiograph showed a wide open apex associated with periapical lesion in relation to the right maxillary central incisor. With the evident clinical and radiographic findings, final diagnosis of necrotic pulp with an open apex in relation to upper right central incisor was established [Figure 1]. After discussing different treatment options with the patient's, we opted to go for MTA apexification with the use of an apical matrix.

On the first appointment, access opening was done using round bur No. 2 and endoaccess bur. Working length was determined. Biomechanical preparation was completed with copious irrigation of 2.5% sodium hypochlorite and a final flush of 2% chlorhexidine digluconate for 5 min. On the second appointment, the length of the hand plugger that was to be used for MTA plug was confirmed radiographically. Thereafter, MTA (angelus white reparative cement) was mixed and loaded into the canal in increments with MTA carrier and gently condensed against the matrix to form 4 mm of apical plug [Figure 2]. The access cavity was restored with Temp Paste (pyrAx Co. Add. Roorkee, India). Thereafter, the patient was recalled for the next visit. For the third visit, master cone was selected and confirmed radiographically. Obturation was done with lateral condensation with zinc oxide eugenol sealer [Figure 3]. Postobturation filling was done with composite restoration, and the patient was recalled for follow-up visit. At 6 months follow-up, the patient was completely asymptomatic, and the periapical lesion had evidently healed [Figure 4].
Figure 2: Mineral trioxide aggregate 4 mm plug

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Figure 3: Postobturation

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Figure 4: Six months follow-up

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  Discussion Top

MTA has been extensively studied and is currently used for perforation repairs, apexifications, regenerative procedures, apexogenesis, pulpotomies, and pulp capping. External resorption may occur when the tooth undergoes any sort of trauma such as intrusion and luxation, thereby resulting in an early necrosis of pulp with incomplete root formation, resulting in an blunted or open apex.[3],[4]

Apexification is defined as a method to induce a calcified barrier in a root with an open apex or the continued apical development of an incomplete root in teeth with necrotic pulp.[5] This barrier is mandatory to allow the compaction of the root-filling material. Calcium hydroxide has been considered as an efficient material for this purpose. Single-visit apexification technique using MTA as osteoconductive apical barrier has gained popularity.[6],[7] MTA stimulates cementogenesis and is relatively noncytotoxic.

This material generates a high-alkaline aqueous environment by leaching the calcium and hydroxyl ions, rendering its bioactive by forming hydroxyappatite in the presence of phosphate-containing fluids.[8],[9] The apical plug created with MTA can thus serve as an artificial barrier to condense the subsequent root canal filling material, thereby preventing reinfection of the canal system.

Hence, the first choice of material suitable for single-visit apexification is MTA[9],[10] because of it is highly biocompatible, shows high bacteriostatic activity[11],[12] and good sealing ability and acts as root end filling material.[13]

MTA offers an alternative for conventional treatment with Ca(OH)2. Clinical and radiographic examination showed success after MTA treatment.[14],[15]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Dent Clin North Am 2010;54:313-24.  Back to cited text no. 1
Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications. J Endod 2000;26:751-5.  Back to cited text no. 2
Cvek M, Hollender L, Nord CE. Treatment of non-vital permanent incisors with calcium hydroxide. VI. A clinical, microbiological and radiological evaluation of treatment in one sitting of teeth with mature or immature root. Odontol Revy 1976;27:93-108.  Back to cited text no. 3
Kakani AK, Chandrasekhar V, Muralidhar T, Chandrakanth M, Rakesh D. Mineral trioxide aggregate as an apical plug material in tooth with open apex: A case report. Int J Sci Stud 2015;2:21821.  Back to cited text no. 4
Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate in the treatment of external invasive resorption: A case report. Int Endod J 2008;41:258-66.  Back to cited text no. 5
Araújo RA, Silveira CF, Cunha RS, De Martin AS, Fontana CE, Bueno CE. Single-session use of mineral trioxide aggregate as an apical barrier in a case of external root resorption. J Oral Sci 2010;52:325-8.  Back to cited text no. 6
Torabinejad N, Chiavian N. Clinical applications of mineral trioxide aggregate. J Endod 1993;25:1972059.  Back to cited text no. 7
Darmawi A. Mta as an apical plug in nonvital tooth with open apex; A case report. JB DENT 2018;21:58795.  Back to cited text no. 8
Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodontics Aesthet Dent 2000;12:315-20.  Back to cited text no. 9
Koh ET, Torabinejad M, Pitt Ford TR, Brady K, McDonald F. Mineral trioxide aggregate stimulates a biological response in human osteoblasts. J Biomed Mater Res 1997;37:432-9.  Back to cited text no. 10
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. 11
Holland R, Filho JA, de Souza V, Nery MJ, Bernabé PF, Junior ED. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001;27:2814.  Back to cited text no. 12
Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root end filling materials. J Endod 1995;21:403-6.  Back to cited text no. 13
Ajwani P, Saini N. Nonsurgical management of a mutilated maxillarycentral incisor with open apex and large periapical lesion. Indian J Dent Res 2011;22:4757.  Back to cited text no. 14
[PUBMED]  [Full text]  
Felippe WT, Felippe MC, Rocha MJ. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J 2006;39:2-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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