Indian Journal of Oral Health and Research

: 2019  |  Volume : 5  |  Issue : 2  |  Page : 46--48

Heal and seal: Management of an open apex with mineral trioxide aggregate apexification

Prachi Maniar, Dipti Choksi, Barkha Idnani 
 Department of Conservative Dentistry and Endodontics, Faculty of Dental Science, Dharmsinh Desai University, Nadiad, Gujarat, India

Correspondence Address:
Dr. Prachi Maniar
2257, B/3, Prachi Bungalow, Fulwadi Chowk, Hill Drive, Bhavnagar - 364 001, Gujarat


The use of mineral trioxide aggregate (MTA) as an alternative material to calcium hydroxide for apexification has gained popularity over reasons such as good sealing ability and biocompatibility and to avoid longer periodic appointments. The case report presents use of MTA as an apical plug for an open apex central incisor which gives a favorable outcome with periapical lesion.

How to cite this article:
Maniar P, Choksi D, Idnani B. Heal and seal: Management of an open apex with mineral trioxide aggregate apexification.Indian J Oral Health Res 2019;5:46-48

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Maniar P, Choksi D, Idnani B. Heal and seal: Management of an open apex with mineral trioxide aggregate apexification. Indian J Oral Health Res [serial online] 2019 [cited 2020 Jan 18 ];5:46-48
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Full Text


The immature root with a necrotic pulp and an open apex lesion presents challenges to successful treatment such as that the infected root canal space cannot be disinfected with the standard root canal protocol with the advent use of endodontic files. Once the microbial phase of the treatment is complete, obturating the root canal is difficult as the open apex does not provide any barrier for stopping the root filling material before impinging on the periodontal tissues.[1]

Even when the challenges described earlier are overcome, the roots of these teeth are structurally thin, with a higher susceptibility to fracture. These problems are overcome by disinfecting without any instrument usage, stimulating the formation of a hard tissue barrier or providing an artificial apical barrier to allow for optimal filling of the canal, and reinforcing the weakened root against fracture during and after an apical stop is provided.[2],[3]

 Case Report

A 20-year-old female patient was referred to the Department of Conservative Dentistry and Endodontics, Faculty of Dental Science, Dharmsinh Desai University, with a chief complaint of pain in the upper right front tooth region. The patient's dental history revealed that she had suffered a trauma to the right maxillary central incisior 9 years back, for which she did not undergo any treatment. The right maxillary central incisor was discolored and was tender on percussion. On doing the pulp vitality test, there was a negative response to heat and electric pulp testing. On radiographic examination of the associated tooth, a large canal with associated peripaical lesion was noticed in relation to 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]. Treatment plan of root canal therapy with single-step mineral trioxide aggregate (MTA) apexification was decided.{Figure 1}

On the first appointment access, opening was done using round bur No. 2 and endoaccess bur. Working length was determined using hand K file radiographically [Figure 2]. Biomechanical preparation was completed with copious irrigation of 2.5% sodium hypochlorite and a final flush of 2% chlorhexidine digluconate for 5 min. The patient was then recalled for the next visit.{Figure 2}

On the second appointment the length of the hand plugger that was to be used for MTA plug was confirmed radiographically [Figure 3]. Thereafter, MTA was mixed and loaded into the canal in increments with MTA carrier and condensed with the hand plugger. The apical plug of approximately 4–5 mm was thus condensed and confirmed radiographically [Figure 4]. Thereafter, the patient was recalled for next visit.{Figure 3}{Figure 4}

For the third appointment visit, master cone was selected and confirmed radiographically. Obturation was done with lateral condensation with zinc oxide eugenol sealer [Figure 5]. Postobturation filling was done with composite restoration and the patient was recalled for follow-up visit.{Figure 5}

At 6-month follow-up, the patient was completely asymptomatic and the periapical lesion had evidently healed [Figure 6].{Figure 6}


External resorption may occur when the tooth undergoes any sort of trauma such as intrusion and luxation,[4] thereby resulting in an early necrosis of pulp with incomplete root formation, resulting in an blunted or open apex.[5],[6]

Single-visit apexification technique using MTA as osteoconductive apical barrier has gained popularity. 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.[7] The extended use of calcium hydroxide (Ca(OH)2) in immature roots reduce their fracture resistance, while prolonged filling of these roots with MTA did not. 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.[8]

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

Although Ca(OH)2 was used most commonly for the process of apexification, the long duration in the range of 12–24 months is a disadvantage. Moreover, the barrier formed by apexification using Ca(OH)2 has an incomplete structure having a Swiss cheese appearance, which can allow apical microleakage leading to reinfection. To overcome these disadvantages of using Ca(OH)2 as apical sealing material, a “one-visit apexification” using MTA was introduced.[14]

The formation of an apical barrier is necessary to fill the root canal system without the risk of overfilling as well as prevent reinfection of the root canal system. Hence, apexification with MTA offers an alternative for conventional treatment with Ca(OH)2. Clinical and radiographic examination showed success after MTA treatment.[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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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