This case report describes the use of mineral trioxide aggregate (MTA) in apexification of two immature permanent teeth with open apices and periapical lesions in a 14-year old patient. After cleaning and shaping the root canals, MTA was used to create an apical plug in each canal. Follow up radiographs at 6 and 12 months showed periapical healing and apical closure of the teeth. MTA is described as a promising alternative to traditional calcium hydroxide treatment for apexification due to its superior biocompatibility and ability to stimulate hard tissue formation.

1. Case Report
ENDODONTOLOGY Volume: 25 Issue 2 December 2013
Mineral Trioxide Aggregate (MTA) in apexification
Abu-Hussein Muhamad #
Abdulghani Azzaldeen ##
Abu-Shilabayeh Hanali ##
ABSTRACT
Mineral Trioxide Aggregate (MTA) was introduced as an alternative to traditional materials for the repair of root
perforations, pulp-capping and as a retrograde root filling due to its superior biocompatibilty and ability to seal the
root canal system. Traditionally, calcium hydroxide has been the material of choice for the apexification of immature
permanent teeth but MTA holds significant promise as an alternative to multiple treatments with calcium hydroxide.
The paper discusses the use of calcium hydroxide as a traditional apexification material and provides an overview of
the composition, properties and applications of Mineral Trioxide Aggregate with emphasis on its use in apexification
of immature permanent teeth. A case report is presented to highlight its use.
Key Words : Open-apex, mineral trioxide aggregate
Introduction
regeneration.5 It has the ability to stimulate cytocline
Trauma causes cessation of root development.
release from the bone cells, indicating that it actively
Fragile root canals becomes weak. It is difficult to
promotes hard tissue formation.6
create an artificial barrier or induce closure of
Case Report
apical foramen with calcified tissue.1 MTA was first
A 14-year old girl suffering from painful
described in dental scientific literature in 19932 and
symptoms caused by her central incisors was
was given approval for endodontic use by the US
examined in the Department of Pediatic Dentistry,
Food and Drug Administration in 1998. Upto 2002,
Al-Quds University, Jerusalem for evaluation and
only one MTA material consisting of grey coloured
treatment.
powder was available and then white MTA was
introduced. Both formulae contain 75% Portland
Investigation revealed a trauma (4 years ago)
cement, 20% bismuth oxide and 5% gypsum by
associated with an enamel/dentin fracture. No
weight. The aim of this procedure is to limit bacterial
treatment was performed at that time.
infection and production of mineralized apical
Approximately two years later, a fluctuant swelling
tissues in immature anterior tooth. The inadequacy
developed in the apical area of the teeth. Symptoms
of calcium hydroxide apexification due to its long
also included tenderness to percussion. Drainage
time span and re-infection because of temporary
was established by lingual access in the pulp
seal
chamber. Treatment was interrupted by the patient
3,4
led to the use of MTA.
for no reason, and four years later, an attempt of
This forms a barrier and prevents micro
apexification using calcium hydroxide paste was
leakage. It is bio - compatible and forms dentinal
carried out for six months by another dentist, but
bridge, cementum and periodontal ligament
no apexification was observed on either tooth.
# University of Napoli, ## Al-Quds University, Palestine
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2. ABU-HUSSEIN MUHAMAD, ABDULGHANI AZZALDEEN, ABU-SHILABAYEH HANALI
When patient was referred to our department,
incompletely formed with open apices and
extra and intra-oral examinations (including
periapical lesions (fig.1). Cleaning and shaping of
radiology) were performed: they revealed central
root canals system was achieved under rubber dam
left and right incisors in normal position with
isolation. The solution used for irrigation was 2.5%
enamel/dentin fracture. Root canals were wide, roots
sodium hypochlorite. Root canal length was
Fig.1. Radiographic examinationshows implication of pulpal
tissues and presence of periapical lesions due to dental trauma
Fig. 2. First attempt to place MTA in the right maxillary
Fig. 3. Apical plug of MTA in the apical third of the canal
Fig. 4. Conventional obturation with gutta-percha
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3. MINERAL TRIOXIDE AGGREGATE (MTA) IN APEXIFICATION
Fig.5 Radiographic follow-up at 6 months
Fig. 6. Radiographic follow-up after 12 months
determined using an apex locator and confirmed
Two days later, coronal and middle thirds of
radiographically. Calcium hydroxide paste was
the canals were filled with gutta-percha by a vertical
placed in the canals for 1 week for disinfection.
warm compaction technique and access cavities
During the second appointment,
were sealed in conjunction with the final restoration
(fig. 4).Periradicular healing was assessed clinically
Calcium hydroxide was eliminated by
and radiographically at 6, 8 (fig. 5) and 12 months
mechanical instrumentation and rinsed out of root
(fig. 6). The use of MTAR completed with a
canals by means of sterile water irrigation. The
conventional endodontic treatment resulted in
canals were dried using sterile paper points. MTAR
apical formation of the two central incisors (fig. 6).
was prepared immediately before use, placed into
Discussion
the canals with an MTAR carrier and compacted
with a hand plugger to create an apical plug of 3 to
The traditional use of calcium hydroxide apical
4 mm as described by the manufacturer.
barriers has been associated with unpredictable
Radiography was taken to check if no apical
apical closure, time taken for barrier formation,
extension occured.
patient compliance, risks of re-infection resulting
from the difficulty in creating long term seals with
The apical plug failed in the first attempt on the
provisional restorations and susceptibility to root
right maxillary central incisor (fig. 2), MTAR was rinsed
fractures arising from the presence of thin roots or
out with sterile water and the procedure was repeated
prolonged exposure of the root dentin to Ca(OH)27.
(fig.3). Moist paper points were placed in the canals
Thus there is increasing popularity with one visit
and access cavities were closed with a temporary
apexification techniques. One visit Apexification has
restorative material, IRMR (Dentsply, Caulk, USA)*.
been defined as the non surgical condensation of a
99

4. ABU-HUSSEIN MUHAMAD, ABDULGHANI AZZALDEEN, ABU-SHILABAYEH HANALI
biocompatible material into the apical end of root
Torabinejad12 reported the ingredients in MTA
canal. The rationale is to establish an apical stop
as tri calcium silicate, tricalcium aluminate,
that would enable the root canal to be filled
tricalcium oxide and silicate oxide with some other
immediately. Torneck and others have indicated
mineral oxides that were responsible for the
that when apical closure takes place clinically with
chemical and physical properties of aggregate. The
Ca(OH)2, there is no complete bridging of the apex
powder consists of fine hydrophilic particles that
histologically. Periapical inflammation persists
set in the presence of moisture. The hydration of
about the apices of many teeth because necrotic
the powder results in a colloidal gel with a pH of
tissue exists in corners and crevices of the bridge.
12.5 that will set in approximately 3 hours. MTA
A major target area of biomedical research
has a compressive strength equal to intermediate
is a mechanism to restore lost bone.
restorative material and Super - EBA but less than
A resorbabletricalcium phosphate ceramic has been
that of amalgam. It is commercially available as
developed. Koenig’s, Brilliant and Driskell found
ProRoot MTA ,and has been advocated for use in
that use of this material induced apical closure in
the immediate obturation of open root apex.
8
9
vital teeth of primates with open apices.
MTAhas the ability to induce cementum like
Regeneration of periodontal ligament occurred
hard tissue when used adjacent to the periradicular
around the apices of teeth and it was associated
tissues. MTAis a promising material as a result of
with minimal inflammatory response.Harbert
its superior sealing property, its ability to set in the
documented the long term success of using a tri
presence of blood and its biocompatibility. Moisture
calcium phosphate plug as an apical barrier for one
contamination at the apex of tooth before barrier
step apexification. In other studies teeth with open
formation is often a problem with other materials
apices were obturated using an apical barrier with
used in apexification. As a result of its hydrophilic
dentin and Ca(OH)2 plugs or dentin chips and
property, the presence of moisture does not affect
hydroxyappatite10.
its sealing ability. Shabahang13 et al examined hard
tissue
There is increasing popularity with one visit
formation
and
inflammation
apexification technique using Mineral Trioxide
histomorphologically after treating open apices in
Aggregate (MTA) as osteoconductive apical barrier.
canine teeth with osteogenic protein-1, MTA and
MTA is relatively non cytotoxic and stimulates
calcium hydroxide. MTA induced hard tissue
cementogenesis. This Portland cement based
formation with the most consistency, but the amount
material generates a highly alkaline aqueous
of hard tissue formation and inflammation was not
environment by leaching of calcium and hydroxyl
statistically different among the three materials.
ions, rendering it bioactive by forming
MTA has demonstrated the ability to stimulate
hydroxyappatite in presence of phosphate
cells to differentiate into hard tissue – forming cells
containing fluids. Unlike the extended use of
and to produce a hard tissue matrix. A number of
Ca(OH)2 in immature roots, prolonged filling of
animal studies have demonstrated a more
these roots with MTA did not reduce their fracture
predictable healing outcome when MTA is used
resistance11.
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5. MINERAL TRIOXIDE AGGREGATE (MTA) IN APEXIFICATION
4. Andreasen JO, Farik B, Munksgaard BC. Long term calcium
hydroxide as a root canal dressing can increase the risk of
root canal fracture. Dental Traumatology 2002; 18 : 134-7.
when compared with teeth treated with calcium
hydroxide14. In a prospective human outcome study,
57 teeth with open apices were obturated with MTA
5. Holah G, eidelman E, Fuks AB. Long-term evaluation of
pulpotomy in primary molars using mineral trioxide aggregate
or formocresol. Pediatr Dent 2005; 27:129-36.
in one appointment. Forty – three of these cases
were available for recall at 12 months, of which
6. Koh ET, Pittford TR, Torabinejad M, Mcdonald F. Mineral
trioxide aggregate stimulates cytokine production in human
osteoblasts J Bone Min Res 1995; 10S:S406.
81% of cases were classified as healed15. Despite
its good physical and biologic properties, extended
setting time has been a main disadvantage. Calcium
7. Andreasen JO, Farik B, Munksgaard EC. Long term calcium
hydroxide as a root canal may increase risk of root fracture.
Dent Traumatol 2002;18:134-7
chloride was used with intention to stimulate
hardening process of MTA. Studies have shown that
8. Torneck CD, Smith JS, Grindall P. Biologic effects of
endodontic procedures on developing incisor teeth. Oral
Surg 1973;35:541
not only the sealing ability but its physicochemical
property was improved by addition of CaCl2 .
9. Koenigs JF, Brilliant D, Driskell TD. Induced apical closure
of permanent teeth in adult primates using a resorbable form
of tricalcium phosphate ceramic.JEndod 1975; 3(1):102-106
Conclusion
Based on this study’s results, the following
conclusions can be made:
10. Brandell DW, Torabinajed M, Bakland L K. Demineralised
dentin, hydroxyappatite and dentin chips as apical
plugs.Endod Dent Traumatol 1986;2:210-4
1. Mineral trioxide aggregate showed clinical
and radio-graphic success as a material used to
11. Rebecca L, Martin BS, Francesca M et al.Sealing properties
of mineral trioxide aggregate orthograde apical plugs and
root fillings in an in vitro apexification model. J Endod
2007;33:272-275
induce root-end closure in necrotic immature
permanent teeth.
12. Torabinejad M, ChivianN.Clinical applications of mineral
trioxide aggregate.JEndod 1999;25:197-205
2. MTA is a suitable replacement for calcium
hydroxide for the apexification procedure.
13. Shabahang S, TorabinejadM.Treatment of teeth with open
apices using mineral trioxide aggregate. Pract Periodont
Aesthet Dent 2000;12:315-20
References :
1. Seltzer S. Endodontology; Biologic Considerations in
EndodonticProcedures, 1988, 2nd edn. Philadelphia; Lea
and Febiger.
14. El-Meligy OA, Avery DR. Comparison of Apexification
with mineral trioxide aggregate and calcium hydroxide.
Pediatr Dent 2006;28:248-53
2. Lee SJ, Monset M, Torabinejad M. Sealing ability of a mineral
trioxideaggregate for repair of lateral root perforations. J. Endod
1993; 19 : 541-4.
15. Simon S, Rillard F, Berdal A et al ,The use of mineral
trioxide aggregate in one visit Apexification treatment: a
prospective study. IntEndod J 2007;40:186-97
3. Schmitt d, Bogen g. Multifaceted use of ProRoot MTA root
canal repair material. Pediatr Dent 2001:23:326-30.
101