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 Table of Contents  
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 44-47

Management of a fractured nonvital tooth with open apex using mineral trioxide aggregate as an apical plug

1 Department of Prosthodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Public Health Dentistry, College of Dental Sciences, Davangere, Karnataka, India
3 Department of Conservative and Endodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
4 Department of Paedodontics, College of Dental Sciences, Davangere, Karnataka, India
5 Private Practitioner, Om Dental Clinic, Davangere, Karnataka, India

Date of Web Publication3-Jul-2017

Correspondence Address:
Sunil Lingaraj Ajagannanavar
Department of Public Health Dentistry, College of Dental Sciences, Davangere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_17_17

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A nonvital tooth with open apex is a challenging clinical condition for the dentist as it requires a systematic diagnosis of the problem and a customized treatment plan. A 17-year-old male patient reported to the clinic with fractured upper right central incisor (11– Federation Dentaire Internationale Notation) with discoloration, and the X-ray showed open apex which was treated using calcium hydroxide and mineral trioxide aggregate (MTA) to form apical barrier (apexification) and then obturation was completed using gutta-percha. The metal ceramic crown was placed to restore the function and esthetics. As the tooth lacked natural apical constriction, an alternative to standard root canal treatment called as apexification or root-end closure is advised.

Keywords: Apical barrier, calcium hydroxide, mineral trioxide aggregate, open apex

How to cite this article:
Jain JK, Ajagannanavar SL, Jayasheel A, Bali PK, Jain CJ. Management of a fractured nonvital tooth with open apex using mineral trioxide aggregate as an apical plug. Int J Oral Health Sci 2017;7:44-7

How to cite this URL:
Jain JK, Ajagannanavar SL, Jayasheel A, Bali PK, Jain CJ. Management of a fractured nonvital tooth with open apex using mineral trioxide aggregate as an apical plug. Int J Oral Health Sci [serial online] 2017 [cited 2022 Nov 29];7:44-7. Available from: https://www.ijohsjournal.org/text.asp?2017/7/1/44/209345

  Introduction Top

The ultimate goal in the practice of endodontics is to debride and obturate the canal as efficiently and three dimensionally as possible. However, in patients having nonvital teeth with open apices, achieving an apical seal is a challenge due to the large open apex, diverging walls, thin dentinal walls that are susceptible to fracture, and frequent periapical lesion.

There are two types of open apices. The first one is nonblunderbuss in which walls are parallel to slightly convergent as canal exits the root. Apex is usually tapered (convergent). The other one is blunderbuss in which walls are divergent, flaring, more especially in buccolingual direction. Apex is funnel shaped, wider than coronal aspect.

The causes of open apices are:

  • Incomplete development
  • Necrosis of pulp due to caries or trauma before root formation is completed
  • Extensive apical resorption
  • Root-end resection
  • Over instrumentation.

Endodontic management of pulpless, permanent tooth with a wide open blunderbuss apex has long presented a challenge to dentistry because of the wide open apex at which obtaining an apical seal is difficult. Many materials have been reported to successfully stimulate apexification.

Various materials have been used for apexification which include calcium hydroxide as an intracanal dressing to achieve apexification, use of custom-made gutta-percha cones, and more recently, use of mineral trioxide aggregate (MTA);[1] hereafter known as “MTA.”

  Case Report Top

A 17-year-old male patient visited our clinic with a complaint of fractured and discolored upper right central incisor [Figure 1] compromising the esthetics and function. The patient gave a history of trauma around 9 years ago. Present history revealed no pain or swelling. Local examination showed Ellis Class III fracture and discoloration in maxillary right central incisor impairing the esthetics and function of the patient. The tooth was asymptomatic, and on electric pulp testing, it showed no response. Radiographic examination revealed an immature tooth with wide open apex with mild radiolucency around the periapical region [Figure 2]. Considering the clinical situation above, it was decided to achieve apical barrier using MTA followed by obturation and placement of crown.
Figure 1: Preoperative image of patient showing fractured 11 with discoloration

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Figure 2: Preoperative intraoral periapical radiograph showing fractured 11 with open apex

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Access cavity was prepared, working length established, canal debrided and irrigated using 3% sodium hypochlorite throughout the cleaning and shaping procedures. Intracanal dressing of conventional calcium hydroxide paste (using distilled water as vehicle) was given for 7 days. Access cavity was sealed with an intermediate restorative material (IRM ® – Dentsply International).

One week later, the temporary filling was removed, and the canal was thoroughly irrigated using saline to remove any remnants of calcium hydroxide. After drying the canal, MTA was mixed with distilled water and carried into the canal using amalgam carrier and packed to form an apical plug of approximately 5 mm [Figure 3]. Over this, a moist cotton pellet is placed, and access cavity was sealed. Following day, the cotton pellet was removed; the canal was thoroughly dried with absorbent points followed by obturation using gutta-percha. After a week, tooth preparation [Figure 4] was carried out and metal ceramic crown was cemented thus restoring the function and esthetics [Figure 5] and [Figure 6].
Figure 3: Radiograph showing apical plug using mineral trioxide aggregate

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Figure 4: Tooth preparation completed to receive a metal ceramic crown

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Figure 5: Metal ceramic crown cemented on 11

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Figure 6: Postoperative view of the patient

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  Discussion Top

Incomplete root development requires customized treatment plan because the ape remains wide open and the walls are thin and fragile. Calcium hydroxide was originally introduced to the field of endodontics by Herman in1930 as a pulp-capping agent, but today its uses are widespread in endodontic therapy. Calcium hydroxide has been used for the treatment of nonvital teeth with open apices [2] with considerable success to form artificial barrier, but the time interval for calcium hydroxide apexification has been reported to be variable, ranging from 12 to 24 months. This presents problems due to patient compliance, reinfection due to loss of temporary restoration, and also predisposes the tooth to fracture.[3]

Various other materials such as tricalcium phosphate, collagen calcium phosphate, osteogenic protein-1, bone growth factors, and MTA have been reported to promote apexification similar to that found with calcium hydroxide.[4]

MTA may be an appropriate alternative for performing apexification with good results. MTA has the ability to facilitate normal periradicular architecture by inducing hard tissue barrier.[5] Its excellent biocompatibility, ability to set in the presence of blood, and possibility to restore teeth with minimum delay without changing the mechanical properties of dentine, as seen with calcium hydroxide are a few positives seen with using MTA.[6]

Reviewing the above factors, single-step apexification was carried out using MTA, and obturation was completed using gutta-percha. The tooth was then restored with a crown to re-establish the function and esthetic demands. Posttreatment review was carried out after 4 months with clinical and radiographic examinations. The tooth was completely asymptomatic, and there were no hard- or soft-tissue abnormalities.

Following this procedure definitely saves a lot of time and reduces the number of appointments as compared to calcium hydroxide apexification, and it gives a predictable apical barrier in a single visit. A long-term follow-up is always necessary to ensure success.

Platelet-rich fibrin (PRF) developed in France by Choukroun and Dohan represents a new step in the platelet gel therapeutic concept. PRF obtained from Choukroun's technique is a strong fibrin membrane enriched with platelet and growth factors. The easily applied PRF membrane serves as a matrix to accelerate the healing of wound edges. This is also a recent advancement and more promising therapeutic agent for the closure of open apices.[7]

A recent case series done by Sharma et al. concluded that combination of PRF as a matrix and MTA as an apical barrier is a good option for creating artificial root-end barrier. However, this study further also recommended that controlled clinical trials are necessary to investigate the predictability of the outcome of this technique.[8]

  Conclusion Top

Although the clinical performance and patient compliance of MTA are found to be much better than that of calcium hydroxide, whether to select MTA or calcium hydroxide depends on cost and number of appointments patient can afford. Commercial products made out of MTA are still expensive, thus making use of MTA unaffordable for a number of patients, especially in developing countries.[9]

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.

  References Top

Patil SA, Patil AA. Management of non vital teeth with open apices using MTA as an apical plug. World J Dent 2011;2:45-8.  Back to cited text no. 1
Fidel RA, Carvalho RG, Varela CH, Letra A, Fidel SR. Complicated crown fracture: A case report. Braz Dent J 2006;17:83-6.  Back to cited text no. 2
Ajwani P, Saini N. Non-surgical management of a mutilated maxillary central incisor with open apex and large periapical lesion. Indian J Dent Res 2011;22:475-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
Koenigs JF, Heller AL, Brilliant JD, Melfi RC, Driskell TD. Induced apical closure of permanent teeth in adult primates using a resorbable form of tricalcium phosphate ceramic. J Endod 1975;1:102-6.  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
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. 6
Khetarpal A, Chaudhry S, Talwar S, Verma M. Endodontic management of open apex using MTA and platelet-rich fibrin membrane barrier: A newer matrix concept. J Clin Exp Dent 2013;5:e291-4.  Back to cited text no. 7
Sharma V, Sharma S, Dudeja P, Grover S. Endodontic management of nonvital permanent teeth having immature roots with one step apexification, using mineral trioxide aggregate apical plug and autogenous platelet-rich fibrin membrane as an internal matrix: Case series. Contemp Clin Dent 2016;7:67-70.  Back to cited text no. 8
[PUBMED]  [Full text]  
Cohen S, Burns RC. Pathways of the Pulp. 8th ed. St. Louis, Missouri: Mosby; 2002. p. 833-40.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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