Omar Morabet

5th year, gr. 13

Comparative analysis of techniques and materials used for

obturation of wide canals and open apex of the root
Master’s Thesis

Supervisor

Med.m.dr., Neringa Skučaitė

Kaunas, 2018
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 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY

FACULTY OF ODONTOLOGY

DEPARTMENT OF DENTAL AND ORAL PATHOLOGY

Comparative analysis of techniques and materials used for obturation of wide canals and
open apex of the root

Master’s Thesis

The Thesis was done

by student ………………………………….. Supervisor …………………………..

(signature) (signature)

…………………………………….. ………………………………………………
(name surname, year, group) (degree, name surname)

…………………….. 20…. …………………….. 20….

(day/month) (day/month)

Kaunas, 2018

EVALUATION TABLE OF THE MASTER’S THESIS

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 OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE

Evaluation: ............................................................................................................................. .......

Reviewer: ...................................................................................................................................
(scientific degree. name and surname)
Reviewing date: ...........................................
Compliance with MT
z MT parts MT evaluation aspects requirements and evaluation
Yes Partially No
Is summary informative and in compliance with the thesis
1 Summary (0.5 0.3 0.1 0
content and requirements?
point)
2 Are keywords in compliance with the thesis essence? 0.2 0.1 0
Are the novelty, relevance and significance of the work
3 0.4 0.2 0
Introduc-tion, justified in the introduction of the thesis?
aim and tasks Are the problem, hypothesis, aim and tasks formed clearly and
4 0.4 0.2 0
(1 point) properly?
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Is the protocol of systemic review present? 0.6 0.3 0
Were the eligibility criteria of articles for the selected protocol
7 0.4 0.2 0
determined (e.g., year, language, publication condition, etc.)
Are all the information sources (databases with dates of
8 coverage, contact with study authors to identify additional 0.2 0.1 0
studies) described and is the last search day indicated?
Is the electronic search strategy described in such a way that it
could be repeated (year of search, the last search day; keywords
9 0.4 0.1 0
and their combinations; number of found and selected articles
Selection
according to the combinations of keywords)?
criteria of the
Is the selection process of studies (screening, eligibility,
studies, search
10 included in systemic review or, if applicable, included in the 0.4 0.2 0
methods and
meta-analysis) described?
strategy
Is the data extraction method from the articles (types of
(3.4 points)
11 investigations, participants, interventions, analysed factors, 0.4 0.2 0
indexes) described?
Are all the variables (for which data were sought and any
12 0.4 0.2 0
assumptions and simplifications made) listed and defined?
Are the methods, which were used to evaluate the risk of bias
13 of individual studies and how this information is to be used in 0.2 0.1 0
data synthesis, described?
Were the principal summary measures (risk ratio, difference in
14 0.4 0.2 0
means) stated?
Is the number of studies screened: included upon assessment
15 for eligibility and excluded upon giving the reasons in each 0.6 0.3 0
stage of exclusion presented?
Are the characteristics of studies presented in the included
Systemiza-tion
16 articles, according to which the data were extracted (e.g., study 0.6 0.3 0
and analysis of
size, follow-up period, type of respondents) presented?
data
Are the evaluations of beneficial or harmful outcomes for each
(2.2 points)
17 study presented? (a) simple summary data for each intervention 0.4 0.2 0
group; b) effect estimates and confidence intervals)
Are the extracted and systemized data from studies presented
18 0.6 0.3 0
in the tables according to individual tasks?
Are the main findings summarized and is their relevance
19 0.4 0.2 0
indicated?
Discussion
Are the limitations of the performed systemic review
20 (1.4 points) 0.4 0.2 0
discussed?
21 Does author present the interpretation of the results? 0.4 0.2 0
Do the conclusions reflect the topic, aim and tasks of the
22 0.2 0.1 0
Conclusions Master’s thesis?
23 (0.5 points) Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25 References Is the references list formed according to the requirements? 0.4 0.2 0

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 (1 point) Are the links of the references to the text correct? Are the
26 0.2 0.1 0
literature sources cited correctly and precisely?
27 Is the scientific level of references suitable for Master’s thesis? 0.2 0.1 0
Do the cited sources not older than 10 years old form at least
28 0.2 0.1 0
70% of sources, and the not older than 5 years – at least 40%?
Additional sections, which may increase the collected number of points
Do the presented annexes help to understand the analysed
29 Annexes +0.2 +0.1 0
topic?
Practical
Are the practical recommendations suggested and are they
30 recommen- +0.4 +0.2 0
related to the received results?
dations
Were additional methods of data analysis and their results used
31 +1 +0.5 0
and described (sensitivity analyses, meta-regression)?
Was meta-analysis applied? Are the selected statistical methods
32 +2 +1 0
indicated? Are the results of each meta-analysis presented?
General requirements, non-compliance with which reduce the number of points
Is the thesis volume sufficient (excluding 15-20 pages (- <15 pages (-
33
annexes)? 2 points) 5 points)
34 Is the thesis volume increased artificially? -2 points -1 point
Does the thesis structure satisfy the requirements
35 -1 point -2 points
of Master’s thesis?
Is the thesis written in correct language,
36 -0.5 point -1 points
scientifically, logically and laconically?
Are there any grammatical, style or computer
37 -2 points -1 points
literacy-related mistakes?
Is text consistent, integral, and are the volumes of
38 -0.2 point -0.5 points
its structural parts balanced?
General
>20%
39 require-ments Amount of plagiarism in the thesis.
(not evaluated)
Is the content (names of sections and sub-sections
40 and enumeration of pages) in compliance with the -0.2 point -0.5 points
thesis structure and aims?
Are the names of the thesis parts in compliance
41 with the text? Are the titles of sections and sub- -0.2 point -0.5 points
sections distinguished logically and correctly?
Are there explanations of the key terms and
42 -0.2 point -0.5 points
abbreviations (if needed)?
Is the quality of the thesis typography (quality of
43 -0.2 point -0.5 points
printing, visual aids, binding) good?
*In total (maximum 10 points):

*Remark: the amount of collected points may exceed 10 points.

Reviewer’s comments: ___________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

________________________________ ___________________________
Reviewer’s name and surname Reviewer’s signature

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TABLE OF CONTENTS
SUMMARY………………………………………………………………………………………….6
ABBREVIATIONS ………………………………………………………………………………… 7
INTRODUCTION ………………………………………………………………………………...... 8
1. SEARCH METHODS AND STRATEGY………………………………………………………..9
1.1.Comprehensive selection path of review…………………………………………………………9
1.2.Search terms and criteria………………………………………………………………………..10
1.2.1.Inclusion criteria………………………………………………………………………………11
1.2.2.Exclusion criteria……………………………………………………………………………...11
2. DATA ANALYSIS………………………………………………………………………………12
2.1. Specification of wide canals ......................................................................................................12
2.1.1. Anatomically found teeth with wide/open apex......................................................................12
2.1.2.Genetically found teeth with wide apex …………………………………………………… 12
2.1.3.Iatrogenic factors and wide apex …………………………………………………………... 13
2.2. Materials used for obturation of wide canals and open apex………………………………….14
2.2.1. Comparative Analysis of materials used for obturation of wide canals and open…………16
2.2.2.Methods used for obturation of wide canals and open apex………………………………...18
2.3.Comparative Analysis of obturation techniques………………………………………………..21
DISCUSSION ……………………………………………………………………………………...22
3.CONCLUSIONS ………………………………………………………………………………...23
PRACTICAL RECOMMENDATION …………………………………………………………….23
ANEXES……………………………………………………………………………………………24
REFERENCES …………………………………………………………………………………….26

5
 SUMMARY

Dental practitioners providing endodontic treatment sometimes are encountered with cases (wide
canal and open apex due to periapical resorption or immature root) that require particular materials
and methods for obturation of root canals.
The aim of this systematic review is to compare materials and techniques intended for obturation
of wide canals and open apex.
Materials and methods. Articles search was carried out in the three databases - Pubmed-Medline,
Science Direct, Willey online library. Researchgate and Endoexperience sites were searched as
well. After screening, full-text analysis of selected studies was done.
Results. After full-text analysis 31 publications was included into the study. Most studies showed
that bioceramic materials regarding their properties are intended to use for obturation of wide canals
and open apices. Preference is based on properties of bioceramic material and on favorable
treatment results. An apical “barrier” creation with different cements was evaluated as preferable
method for obturation of wide canals and open apex. Techniques of filling of root canals differ
according to authors and selected materials.
Conclusions. Bioceramic cement is the material of choice for obturation of wide canals and open
apex. Vertical condensation of particular cement and apical plug creation is widely used method for
obturation of wide canals and open apex.
1. One or two steps obturation techniques are recommended.

Key words: immature root, open apex, root canal obturation, biomaterials,calcium silicate
materials, bioceramic, endodontics.

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ABBREVIATIONS
 CH – Calcium hydroxide
 MTA – mineral trioxide aggregate
 CEM – calcium enriched mixture
 ISO – International Standards Organization
 CEM – calcium enriched mixture
 PRF – Platelet-rich fibrin
 IRM – intermediate restorative material
 EBA – ethoxy benzoic acid
 GP – gutta percha
 EDTA- Ethylenediaminetetraacetic acid
 EARR - External apical root resorption

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 INTRODUCTION

Dental practitioners providing endodontic treatment sometimes are encountered with cases
(wide canal and open apex due to periapical resorption or immature root) that require particular
materials and methods for obturation of root canals. As it was known till now the best material for
that kind of cases was MTA and Calcium hydroxide in some cases (apexofication). There are known
new generation bioceramic materials used for solving such kind of problems as well ..........

It is essential to know materials and techniques of obturation of wide /open apices with high
quality sealing in order to .extend tooth presence, improve treatment prognosis and save the treatment
time.

The aim of this study was to compare techniques and materials used for obturation of wide
canals and open apex.

Tasks:

After evaluation of scientific studies published:

1. Compare biomaterials used for obturation of wide canals and open apex.

2. Compare techniques used for obturation of wide canals and open apex

3. Evaluate factors affecting the prognosis of obturation of wide canals

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 1. SEARCH METHODS AND STRATEGY

1.1. Comprehensive selection path of review

This systematic review was provided according to PRISMA recommendations [33].

Articles search was carried out online in the three databases - Pubmed-Medline, Science Direct,
Willey online library. Some of articles were found in scientific sites such as „Researchgate“,
„Endoexperience“. Articles published in the last 5 years ( 2013-2018) were searched. In this
systematic review the initial search objective was to find out cases of treatment of wide/open apex
and evaluate the choice of materials and methods used for obturation of wide canals

The selection of article‘s type: research articles and case reports in English Language.

1.2.Search terms and criteria

All the information for this systemic review was searched in period of 2018 february/ march/
april.

According to keywords and search terms in different databases 1912 articles matching the keywords
in title were selected (Table 1). After removal of duplicates, 220 were selected for assessment of
inclusion/exclusion criteria (written below). Out of the search results, 31 articles had been chosen for
the abstract to be read based on relevance for this particular study.

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 Scheme.1 Flow diagram . “PRISMA 2009 Flow Diagram”[33]
Identification

1912 of records identified through

database searching

1692 of records after duplicates removed

Screening

220 of records screened 136 of records excluded

(repeating the topic.)

84 of full-text articles 53 of full-text articles

Eligibility

assessed for eligibility excluded, with reasons

where only mention some
treatment of wide root
apices
31 of studies included in
qualitative synthesis
Included

31 of studies included in
quantitative synthesis
Systematization

Table 1. Search terms and keywords.Pubmed.

Pubmed
Found Selected
wide root apex 34 3
calcium silicate materials 489 42
bioceramic 364 29
root canal obturation 684 41
Immature root 153 45
open apex 144 38
biomaterials in wide canals 3 1
open apex 26 16
wide diameter canals 6 1
MTA in wide apices 4 2
methods of filling wide root canals 5 2
TOTAL 1912 220

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1.2.1.Inclusion criteria:

Studies in vivo and in vitro, case reports where materials and techniques used for obturation
of wide canals and open apex were analysed.

Clinical studies or case reports where treatment on mature as well as on immature teeth was analysed.

1.2.2.Exclusion criteria:

Studies concerning:

a) working length determination in wide canals;

b) pulp capping and revascularisation of immature teeth;
c) classic endodontic obturation techniques were excluded;
d) literature that wasn‘t written in english or required special access in order to download the
full version were excluded;
e) repeating articles from different sources were excluded
f) shaping and cleaning of wide open apices;

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 2. DATA ANALYSIS
2.1.Specification of wide canals
There are particular cases when practitioners have to deal with obturation of wide canals
and open apex of the root. Those cases include mature as well as immature roots of the teeth.
The wide/open apex can be formed anatomically/geneticaly or can be created by different iatrogenic
factors. Additionally, apical part of the root canal becomes wide due to resorption of the root apex
induced by periapical pathology, orthodontic treatment or trauma.

The definition of “ wide apex” is usually used to describe the size of apical foramen
when the size by ISO starts from #40. Different authors mention different size of “wide apex”. [1]

Table 2. Size of wide apex according different authors.[1]

Author Size
Mente et al. 2009 ISO 40#
Van Hassel &Natkin 1970 ISO 45#
Sarris et al. 2008, ElAyouti et al. 2009 ISO 60 #
Friend 1966, Moore et al. 2011 ISO 80#
Andreasen & Andreasen 2000 ISO 100#

2.1.1. Anatomically found teeth with wide/open apex

Immature wide apex
The wide/open apexes are detected in the stages of the development of teeth as a result of
necrotic pulp caused by trauma or caries, or as a result of pathological or physiological dental
resorption due to permanent tooth germination. [1]
Acording to the width of the apical foramen and length of the root, root development stages are
classified by Cvek as: very immature, immature, mature [2] (Attachment 1).
Immature teeth present a problem due to their anatomy as the roots are short and thin and
routine canal obturation is difficult due to the root canal configuration. The thin dentine walls are
also at risk of fracture. [3]

2.1.2. Genetically found teeth with wide apex

Some other causes of incomplete development are dens in – dente , dentin dysplasia (type II).
(Fig.1,2,3.).

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Fig. 1. .Dens- in dente(Type III), known as dens invaginatus or dilated composite odontome[5]

Fig.2.Dentin Dysplasia (type II)/rootless teeth (http://www.jdrntruhs.org/article.asp?issn=2277-

8632;year=2015;volume=4;issue=4;spage=282;epage=285;aulast=Hemachandrika)

Fig.3.Features of hypophosphatasia (https://doi.org/10.3389/fphys.2015.00307)

2.1.3. Iatrogenic factors that induce a wide/open apex

Resection of root apex during periradicular surgery
Apicoectomy- (apico-+ - ectomy), root resection, retrograde root canal treatment (c.f.
orthograde root canal treatment) or root- end filling, is an endodontic surgical procedure whereby a

13
tooth’s root tip is removed and a root end cavity is prepared and filled with a biocompatible
material. (Attachment 2)
Apicoectomy is done when previous endodontic treatment was not successful and after follow up
tooth was with a lesion.
After apicoectomy new apical foramen becomes much more wider. There are rare cases in
clinical practice when dental practitioners could consider to retreat and refill root with created wide
apex after unsuccessful apicoectomy.
Over-instrumentation
Iatrogenic overinstrumentation promotes the enlargement of apical foramen, which
may permit an increased influx of exudate and blood into the root canal [8]
Overinstrumentation or widening of root apex can happen during endodontic re-treatment when
dental practitioner have to remove old cements, remove broken instruments or due to secondary
chronic apical periodontitis.
The perforation caused by incorrect or over instrumentation of the canal can lead to difficulties
during the obturation of the root canal and cause decreased success rate. [10]
Complication of root canal preparation
Canal transportation is an undesirable deviation from the natural canal path. It can result in
endodontic retreatment using rotary instruments for cleaning and shaping of root canals.
Apical transportation is managed by different treatment strategy. Type II cases –need to make a
barrier to control bleeding and provide a backstop to pack against during subsequent obturation
procedures. In type III - requires obturation as best as possible after which is corrective surgery
done.[6,7]
Apical resorption due to periapical pathology, orthodontics or trauma

2.2. Materials used for obturation of wide canals and open apex
Portland cement used in the construction industry is hydraulic. Since most dental
procedures are performed in a wet environment, Portland cement was introduced as an endodontic
material; it was patented and became known as Mineral Trioxide Aggregate (MTA) [19]. This
material is a modification form of Portland cement with bismuth oxide radiopacifier. The first
reported use of Portland cement in dental literature dates back to 1878 when Dr. Witte from
Germany published a case report on using Portland cement to fill root canals. [24,19]
MTA was the first bioceramic (BC) material introduced to clinical use as a rootend filling
material and for repair of root perforations in endodontics in the mid-1990s. Its uses were later
broadened to include its use as a root canal sealer, and also for apexification procedures .Since then

14
the indications for the use of MTA have widened, and several other bioceramic or “hybrid”
materials have been introduced.
Endodontic cements based on Portland cement have shown a higher level of trace
elements, as waste materials are used as raw materials in its manufacturing for the construction
industry.
Traces of arsenic, lead and chromium have been reported in both grey and white MTA.
Although the levels of acid extractable trace elements are high, the amounts leached in solution are
negligible. [19,20].
Due to these clinical problems, second-generation materials were developed that addressed the issue
of trace elements and aluminium by using pure tricalcium silicate cement rather than Portland
cement. [19]

With the introduction of the second-generation materials, a new term has also been
introduced—bioceramics. With bioceramics, the purity of the materials, inert behaviour and their
biocompatibility needed to be stressed.[19]

Bioceramic materials are based on tricalcium silicate or hydraulic calcium silicates.[19].

Such materials materials used in endodontics include : Alumina, Zirconia, Bioactive glass, Glass
ceramics, Hydroxyapatite, resorbable Calcium phosphates[34]

Staining of tooth structure and slow setting times have been some of the potential
downsides of the bioceramic cements, depending on the clinical situation.

Some of available materials in the market are presented in Table 3.

Table 3. Bioceramics used in endodontics.[39,34,40]

Company Matterial Radiopacifier

Calcium silicate based – Cements- Portland Cement, Mineral trioxide aggregate

(MTA), Biodentine
Angelus(Brazil) MTA Fillapex Bismuth oxide,Barium
sulphate,Calcium tungstate

Septodont( France) Biodentine

EGO SRL,(Buenos Aires, Endo CPM

Argentina Sealer

Septodont, (France) BioRoot RCS Zirconium oxide

Profident, Kielce, Poland TechBiosealer

DRFP Ltd, Stanford, UK Smartpaste bio

Calcium phosphates/ tricalcium phosphate/ hydroxyapatite based Mixture of

calcium silicates and calcium phosphates

15
 Brasseler/FKG Savannah, Endosequence Zirconium oxide
BC/TotalFill
GA, USA
[41]Root
Repair Material
Innovative Bioceramix Inc., Bioaggregate
Vancouver, Canada);
developed at Argonne Tech Biosealer
Ceramicrete
National Lab, Illinois, USA)

Innovative Bioceramix Inc., iRoot BP, Zirconium oxide

iRoot BP
Vancouver, (Canada),
Plus,iRoot FS
Innovative Bioceramix Inc., Bioaggregate
Vancouver, Canada
Experimental calcium alumino-silicates.

Binderware, (São Carlos, EndoBinder

SP, Brazil);
Primus Consulting, Capasio
Bradenton, FL, USA
Quick-Set Capasio powder has been refined
and renamed as Quick-set.
Dentsply Tulsa Dental Generex A
Specialties, Tulsa, OK, USA
BioniqueDent, Tehran, Iran CEM
Egeo CPM Bismuth oxide,barium sulphate

Maruchi Endoseal MTA Dicalcium silicate, Bismuth

oxide, zirconium oxide

2.2.1. Comparative Analysis of materials used for obturation of wide canals and open apex
Many researchers concluded that MTA and Portland cement had similar microbiological,
chemical, physical and biological properties.[24]. According to some authors, a apical plug for least
amount of microleakage and superior sealing ability it is better to choose CEM/PRF than MTA
[24].
Advantages and disadvantages of most widely used materials for obturation of open apex are
presented in Table 4.

16
 Table 4..Materials used for obturation of wide open apex. Advantages and disadvantages.[ 4,19,
22,26].
Material Advantages Disadvantages Results

MTA 1)Biocompatibility 1)The initial setting time for MTA is 2 h 45 min Mostly used in
2) less cytotoxic nature to 3h.This extended setting time is a major daily dental
3) Suitable for apexofication because drawback of MTA. practice for
of 2) MTA being hydrophylic requires moisture to apexofication
hydraulic nature and also the set( wet cotton) and one single
properties related to the formation 3) discoloration potential, visit
and release of calcium hydroxide. 4) difficult manipulation; obturation of
4)having the capacity to attract . wide open
blastic cells and promote favorable apices.
conditions for cementum deposition
5) hydrophilic
6)Single visit apexofication
7) one visits application,
8) hard tissue induction
9)good-sealing properties
10)an alternative to the use of
calcium hydroxide.

Biodentine 1)Dicreased setting time compared With

with MTA( by adding calcium biodentine +
chloride to liquid, it can harden in 9- PRF
12min.) barrier+warm
2)does not require a two step gutta percha
obturation, resulting in the we can do
completion of treatment on the same everything in
day. one visit
because of
faster setting
time, while
doing calcium
sulfate barrier
+MTA at one
visit and at
second visit
warm gutta

17
 percha
aplication.
Bioceramic 1)biocompatibility, Nowadays
2)non toxicity, number 1 used
3)dimensional stability in endodontics
4) bio-inert- most important in for treatment
endodontics of wide/open
5) similarity to Hydroxyapatite, an apices.
intrinsic osteo conductive activity
6) an ability to induce regenerative
responses in the human body.
7) inorganic
8) non-metallic materials made by the
heating of raw minerals at high
temperatures [1]. Bio-ceramics are
biocompatible ceramic materials or
metal oxides with enhancedsealing
ability, antibacterial and antifungal
activity applied for use in medicine
and dentistry.
9)heat resistant
CEM
TOTAL FILL
(FKG, Brasseler)

2.2.2.Methods used for obturation of wide canals and open apex

The aim of obturation is to establish a fluid-tight barrier with the aim of protecting the
periradicular tissues from microorganisms that reside in the oral cavity [16]. While a perfect airtight
or hermetic seal is unachievable in reality, every effort should be made to reach this target. The
establishment of a well obturated system would serve three main functions:
1. Prevent coronal leakage of microorganisms or potential nutrients to support their growth into
the dead space of the root canal system
2. Prevent periapical or periodontal fluids percolating into the root canals and feeding
microorganisms
3. Entomb any residual microorganisms that have survived the debridement and disinfection
stages of treatment, in order to prevent their proliferation and pathogenicity. [18]

18
 The classical root canal obturation of a mature adult tooth relies on hermetic seal to prevent
microbial recolonisation of the root canal. This is achieved through a barrier composed of gutta-
percha and a sealer, which are impervious to percolation.

The classical treatment methods for filling the root canals of immature teeth are quite well-
established in clinical practice. Open apices were treated with calcium hydroxide paste for an
extended period of time to stimulate barrier formation at the apex, and the roots were then obturated
in a similar way to adult teeth using a solid cone and root canal sealer.

With the introduction of bioceramics and related materials, treatment of the immature apex
has been shortened to one to two visits. The introduction of these materials has certainly changed
the clinical outcomes of filling the root canals. Treatment time has been reduced, which is
beneficial for the treatment of paediatric patients.[19]

Depending on the age of the patient and development stage of the tooth roots, treatment
methodologies have been devided to fill the root canal, thus obliterating the dead space resulting
after pulp removal. Two treatment methodologies exist for filling the root canal, with the choice
depending on root development:

 Apexification - procedures for immature roots(with wide root apices)

 Root canal obturation for fully formed roots.
For both procedures, the classical treatment methodologies have changed in the last 2
decades by way of the introduction of a new class of dental materials, which were introduced to
overcome the deterioration of material properties in contact with moisture. [19]
Obturation of wide/open apices can be achieved in two visits apical plug ; one visit apical
plug and apical plug using barrier material such as PRF.

Table 5. Methods and materials used for wide canal obturation. [4,19,22, 25, 27, 35,36,37]
Materials Used for Application
Apexofication- obturation for immature teeth
Pure calcium to create a calcific bridge, leaving a The CH is packed against the apical soft tissue with a
hydroxide powder is stunted root. Treatment involves plugger or a thick point to initiate hard tissue formation.
mixed with sterile several visits over a number of months. (This step is followed by backfilling with calcium hydroxide
saline (or anesthetic Also used for pulpotomy. to completely fill the canal thus ensuring a bacteria-free
solution) to a thick canal with little chance of reinfection during the 6 to 18
(powdery) months required for the hard tissue formation at the apex.
consistency The calcium hydroxide is meticulously removed from the
access cavity to the level of the root orifices, and a well-
sealing temporary filling is placed. When a radiograph is

19

MTA(Table 6.)
to create a hard tissue barrier at the root
end to one or two clinical session and
after the tooth could immediately be
restored normally.
Retrograde fillings, orthograde
fillings(apical), pulp capping,
perforation repair; treatment of teeth
with open apexes, and repair of
resorption defects.
Root canal obturation for fully formed roots
MTA,
BioDentine,
Bioceramics Endodontic uses- sealers, obturation,
perforation repair, retrograde filling,
pulpotomy, resorption, apexification,
regenerative endodontics. Restorative
uses- Dentin substitute, pulp capping,
dentin hypersensitivity, dentin
remineralization.[36][37]
Calcium silicate-based sealers
Sealers and GP
(MTAfillaplex, iRoot SP, smartpaste
bio).(Table 3.) given the excellent
sealing properties and biocompatibility.
Modified cold lateral
compaction
taken, the canal should seem to have become calcified,
indicating that the entire canal has been filled with the
calcium hydroxide).
MTA is aplicated after desinfection of root canal.Calcium
sulfate (or similar material) is pushed through the apex to
provide a resorbable extraradicular barrier against which the
MTA is packed. The MTA is mixed and placed into the
apical 3 to 4 mm of the canal in a manner similar to the
placement of calcium hydroxide. A wet cotton pellet can be
placed against the MTA and left for at least 6 hours and then
the entire canal filled with a root filling material or the
filling can be placed immediately because the tissue fluids of
the open apex may provide enough moisture to ensure that
the MTA sets sufficiently.
Biodentine is similar to MTA with its basic composition and
has the addition of setting accelerators (calcium chloride)
which can be used as its substitute.
These sealers need moisture present in the root canal to set.
Bioceramic sealers can be used with either gutta-percha
solid cones or bioceramic-coated cones. Hygroscopic points
(CPoints) have also been suggested for use with bioceramic
sealers.The single-cone obturation technique has been
suggested for use with bioceramic sealers.Their hydraulic
nature necessitates the presence of moisture in the root
canal, which is further exacerbated by the existence of
premixed sealers such as Root SP,Endosequence BC,
TotalFill and Endoseal MTA.
MAP system are used to apply (Products Dentaires, Vevey,
Switzerland)
For retrograde placement, either a carrier can be used or the
material can be shaped in a Lee block
Used in combination with a GP points .
Warm lateral compaction using ultrasonics (energised
spreading).Energised spreading is a modification of cold
lateral compaction and follows the same A peizoelectric
20
 ultrasonic unit is required, as well as a file adaptor and a k-
file.

Warm gutta-percha Warm vertical compaction:

the interrupted wave compaction
technique is recommended for wider
canals.
Artificial Wide Apical barrier(that allows immediate obturation of the canal)
1)The continuous wave compaction technique –for
downpack :master GP cone System B (Sybroendo), Machtou
or Buchanan plugger(Dentsply Maillefer,are used.; for
backfilling - thermoplasticised GP(Obtura-Sybroendo;
Calamus-Densply; D&L Super beta endo- D & L Biotech);
2) the interrupted wave compaction technique- very similar
to the continuous wave, with the difference being that the
downpack is carried out in multiple waves rather than one
continuous wave is described.

MTA a matrix of autologous fibrin, as easy preparation, lack of biochemical handling of blood
Biodentine embedded with a large quantity of making this preparation strictly autologous, promotion of
CEM(Calcium platelet and leukocyte cytokines during wound healing, bone growth, bone maturation, and
enriched mixture) centrifugation can be successfully used hemostasis.A membrane can be obtained as a result of
PRF(Platelet rich as an apical membrane.[22] squeezing out the fluids in the fibrin clot of the prepared
fibrin); PRF.
Tricalcium
phosphate;
Calcium sulfate.

2.3.Comparative Analysis of obturation techniques

The main difficulty associated while treating teeth with wide open apices are preventing
the overfilling of the restorative materials that serve as an artificial barrier. Use of a matrix
overcomes this challenge. Successful endodontic treatment needs to prevent leakage of intracanal
irritants into the peri radicular tissues. Microbial tight seal of biomaterials as apical plug is
mandatory. The considerable test is encountered by an operating clinician, especially treating teeth
with wide open apices, is the successful prevention of periapical extrusion of the restorative
material when used as an artificial apical plug, into the periodontal tissues. The extruded material
may result in an inflammatory process, complicating to such an extent that the repair would
impossible.
Care must be taken to avoid excessive lateral force during filling because of the thin walls
of the root as well. It has been reported that approximately 30% of these teeth will fracture during
21
or after endodontic treatment . Restorative procedures should be assessed to ensure that they do not
promote root fractures [4].
Conventional approach of apexification was to induce the formation of an apical barrier
using multiple calcium hydroxide dressings, while the recent approach is to form an artificial apical
barrier by the placement of restorative material as an apical plug.At present, there is no prospective
long-term outcome study that compares the success rate of this technique with that of the traditional
calcium hydroxide technique.[22]
Successful one step apexification and completion of the treatment on the same day of the
tooth with open apex using PRF membrane and an apical plug of Biodentine followed by the
obturation of the root canal using injectable thermoplastisized gutta percha .
In comparison to MTA, using the CEM plugs in simulated opened apex teeth had a
better result.[25].
MTA+ (Cerkamed), Biodentine (Septodont), and gutta-percha with AH Plus paste were compared.
The lowest optical density was found for Biodentine. This material demonstrated the smallest X-ray
contrast as compared with dentin. The best radiographic visibility was found for gutta-percha with
AH Plus paste.[26]
According to setting time for MTA it is better two step obturation techniques (when
obturation with gutta-percha is done after 24hours). After apical plug MTA requires adequate time
for setting in the presence of the moisture, and final obturation with gutta-percha should be delayed
until final MTA setting.

3. DISCUSSION
Wide open apex obturation may not accure very often in daily practise. As it is possibility
to have such a cases 5% or even less of all the endodontic cases. By this review we should know
that these kind of cases my occur more often at young age patients, patients with trauma, first upper
incisors, can be also lower first premolars and also distal roots of lower molars and palatal root
canals of upper molars.
It is known that wider canals have a statistically significant difference on non-preformed surfaces
compared to narrow canals.[4] This also exacerbates the prognosis of endodontic treatment as
unprotected surfaces increase the risk of secondary infection or failure of treatment. Successful
apical obturation and coronal part of canal closure during endodontic treatment leads to a perfect
prognosis and longevity for the tooth.
Factors which could affect the obturation quality should be assessed

22
 According to studies in vitro it is know that Calcium hydroxide as intra canal medicament
used inter appointments had adverse effects : it can reduce white MTA properties for sealing[24]
Acording to studies in vitro ph enviroment and liquid used for mixture has significant
effect for apical plugs [24]. Least amount of micro leakage was with Pro Root MTA mixed with
normal saline.
EDTA, a routine irritant used to remove the smear layer, affects the chemistry of these
calcium-containing materials as it is an established calcium chelator.

CONCLUSIONS
1. Bioceramic cements are materials of choice for obturation of wide canals and open apex.
2. Vertical condensation of particular cement and apical plug creation is widely used method for
obturation of wide canals and open apex. . One or two steps obturation techniques are
recommended.

PRACTICAL RECOMMENDATIONS
Considering information from this systemic review in cases of wide root canals and with
wide apices ( >#60) when obturation with gutta-percha main cone and sealer is doubtable and risky
the use of apical plug of selected bioceramic cement would be recommended.

23
ANEXES
Attachment nr.1

Classification of root development stages: Very immature root development = the tooth has
incomplete root formation or complete root formation with a wide-open apex. Immature root
development = the tooth has full root formation and half-closed apex. Mature root development =
the tooth has full root formation and a closed apex. [2]
Attachment nr. 2

Fig. 6. Periapical radiograph showing the previous apicoectomy, apical rarefaction and post of the
mesiobuccal root. [12]
Attachment nr. 3

24
Apexification with MTA. The canal is disinfected with light instrumentation, copious irrigation, and
a creamy mix of calcium hydroxide for 1 month, calcium sulfate is placed through the apex as a
barrier to the placement of MTA, and 4-mm MTA plug is placed at the apex. The body of the canal
is filled with Resilon obturation system (Pentron Clinical Technologies, Wallingford, CT, USA),
and a bonded resin is placed to below the cementoenamel junction to strengthen the root. (Courtesy
of Marga Ree, DDS, MSc, Purmerend, Netherlands.) [4]

25
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