Case Report/Clinical Techniques
Mineral Trioxide Aggregate as Apical Plug in Teeth with
Necrotic Pulp and Immature Apices: A 10-year Case Series
Riccardo Pace, DMD, Valentina Giuliani, PhD(c), Michele Nieri, DMD, Luca Di Nasso, PhD(c),
and Gabriella Pagavino, DMD
Abstract
Introduction: This 10-year study evaluated the clinical
and radiologic outcomes of teeth with necrotic pulp,
immature apices, and periapical lesions treated with
the mineral trioxide aggregate (MTA) apical plug tech-
nique. Methods: Seventeen single-rooted immature
teeth with necrotic pulp and periapical lesion from 17
patients treated between January 2001 and December
2001 were included in this study. Apical obturation on
all teeth included in the study was completed in 2 visits:
first using calcium hydroxide as an interappointment in-
tracanal medication and a second visit for the creation of
the artificial apical barrier with MTA. The outcome,
based on clinical and radiographic criteria, was assessed
by 2 calibrated investigators using the periapical index
(PAI). The Friedman test was used to verify the differ-
ences between baseline and the 1-, 5-, and 10-year
PAI scores. Results: Of the 17 patients treated, 1 patient
dropped out at 5 years. At the 10-year follow-up, 15
teeth were healed (PAI #2), and 1 tooth had been
extracted because of the presence of a longitudinal
root fracture. The PAI score exhibited a significant
decrease between baseline and 1 year and between 1
and 5 years. The difference between 5 and 10 years
was not significant. Conclusions: The apical plug with
MTA was a successful and effective technique for
long-term management of this group of teeth with
necrotic pulps with immature root development and
periapical lesions. (J Endod 2014;-:1–5)
Key Words
Apical plug, mineral trioxide aggregate, necrotic teeth
with immature apices
From the Department of Endodontics, University of Flor-
ence, Florence, Italy.
Address requests for reprints to Dr Valentina Giuliani,
Department of Endodontics, University of Florence, 50100, Flor-
ence, Italy. E-mail address: valesoho@alice.it
0099-2399/$ - see front matter
Copyright ª 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.12.007
JOE — Volume -, Number -, - 2014
C onventional root canal filling procedures are challenging in cases of teeth with
necrotic pulp, immature apices, and periapical lesions because of the absence of nat-
ural apical constriction and the presence of moisture contamination (Fig 1). In these
cases, the risk of extrusion of the root filling materials and the difficulty in managing api-
cal seals compromise the long-term outcome of treatment (1–3). The apexification
procedure with mineral trioxide aggregate (MTA; Dentsply Tulsa Dental Specialties,
Tulsa, OK) is one of the most reliable methods for the treatment of these teeth (4–7).
Creating an artificial apical barrier with MTA is an alternative to long-term apexification
with calcium hydroxide (Ca[OH]2), and this approach might offer a more predictable
and better long-term prognosis (6, 8, 9).
Ca(OH)2-based apexification procedures require excellent patient compliance
because of the necessary long-term application of the dressing material from 3–24 months
to obtain complete closure of the root apex (10, 11). Although the traditional Ca(OH)2
apexification treatment results in successful outcomes (12–14), there may be a
weakening of the root structure as well as susceptibility to reinfection (13, 15, 16–18).
MTA is 1 of the most effective materials for sealing both iatrogenic and pathological
communication between endodontic and periodontal spaces (19–21), and the presence
of moisture does not affect its sealing ability (22). The biocompatibility of MTA is widely
documented in the literature (23–25). Used in contact with periradicular tissue, MTA has
the ability to induce cementum-like hard tissue (26–29). An MTA plug in the apical
portion of the root promotes apical repair and prevents root canal overfilling, thus
ensuring that the permanently bonded restoration enhances the retention of natural
teeth, and it can increase the fracture resistance of immature teeth (30, 31).
A previous case series and other prospective studies reported a high percentage of
successful outcomes at 1- or 2-year follow-ups when MTA was used as the apical plug in
teeth with necrotic pulp and immature root development (4–8). Various techniques
have been proposed for delivering MTA to the apical portion, the number of
treatment visits (1 or 2 appointments), and the use of intermediate medication with
Ca(OH)2 as intracanal dressing. The lack of consensus regarding techniques and the
limited follow-up studies encouraged the development of this 10-year case series study
aimed at evaluating the outcomes of the MTA apical plug technique (5–9).
Materials and Methods
All patients, for a total of 17 teeth, who had received endodontic treatment or
orthograde retreatment with MTA on teeth with immature root development at the
Department of Endodontics of the University of Florence Dental School, Florence,
Italy, from January 2001–December 2001 were followed up until December
2011. An a priori sample size calculation was not performed. From this search,
cases were selected on the basis of the following criteria: (1) patients with noncom-
promised systemic health, (2) the presence of at least 1 single-rooted necrotic tooth
with immature root development, and (3) teeth without mobility or/and periodontal
probing depth. Seventeen patients were chosen for this study. As required for
routine dental care, all the patients received a detailed explanatory form and gave
their informed consent for treatment and for the use of their data in possible future
studies (parental consent was obtained for minors). All patients, for a total of 17
teeth, were treated in a similar manner during routine care sessions by the same
operator (RP).
Mineral Trioxide Aggregate as Apical Plug 1
Case Report/Clinical Techniques
Clinical preoperative testing included electric pulp testing, percus- Radiographic and Clinical Outcome Assessment
sion, palpation, and evaluation of tooth mobility. The presence of any All the patients were recalled by telephone at 1, 5, and 10 years
swelling was recorded by digital photos, and any sinus tract was after treatment. If the patient did not respond after 3 calls, the case
detected by an endo-oral radiographic examination with gutta-percha was considered a dropout. The recorded clinical findings included
cone. At least 1 preoperative radiograph was taken of each patient to the presence or absence of clinical signs and symptoms (sensitivity to
view the status of the periapical tissues and the quality of any existing percussion, sinus tract, pain, or discomfort), root or tooth fracture,
root filling. The teeth were isolated with a rubber dam, caries were loss of function, tooth mobility, and pathological probing depths. The
removed if present, and the coronal access was created using diamond seal of the coronal restoration was assessed clinically by visual inspec-
burs with continuous water irrigation. tion using a mirror and radiography; any marginal gaps or decay were
Subsequently, the access cavity was refined with an RT2 ultrasonic recorded. The status of periradicular tissue was verified by radiography.
tip (EMS, Nyon, Switzerland) powered by an ultrasonic unit (Piezon The signs of apical extrusion of MTA were recorded. All radiographs
Master 600, EMS). RT2 ultrasonic tips with a limited diamond-coated from this study were evaluated by 2 calibrated investigators in random
extension offer cutting efficiency and enhance control while working order and in a blinded manner using the PAI. Based on the clinical and
in the pulp chamber and minimize the removal of tooth structure to radiographic features as described in a previous study (8), teeth that
obtain a direct access to the apical portion of the root canal. In the 2 scored PAI #2 and displayed no symptoms or clinical signs were
cases of teeth needing orthograde retreatment, gutta-percha was classified as healed.
removed with hand files or rotary nickel-titanium instruments used For any disagreement on the PAI score for a particular tooth, the
in a crown-down manner. The canals were frequently irrigated with a investigators jointly revaluated the radiograph and reached a consensus
5.25% sodium hypochlorite solution (Niclor 5; Ogna, Milan, Italy). score. Median and interquartile intervals for quantitative data (PAI
The working length was measured by radiograph with a K-file and score) and frequency and percentage for qualitative data (clinical signs
recorded for reference. The root canal was cleaned with copious irri- and symptoms) were calculated for descriptive analysis.
gation of 5.25% sodium hypochlorite delivered to the apical portion of The radiographic analyses were controlled by the intrarater and
the root with disposable flexible polymer tips inserted until they reached inter-rater agreement procedures. A 2-way intraclass correlation coef-
the working length minus 2 mm. The irrigation was performed for ficient was calculated. The intraclass correlation coefficient was consid-
10 minutes, alternating 10% EDTA solution (Ogna) and 5.25% sodium ered excellent if it was greater than 0.75 (33). The Friedman test was
hypochlorite, delivered in the same manner, until a total amount of
10 mL 5.25% sodium hypochlorite was used.
During the same appointment, the canal was dried with paper
points at the working length, after which a temporary root canal filling
with Ca(OH)2 (Ultracalx Ultradent Inc, South Jordan, UT) was applied.
The cement was delivered into the canal by means of capillary tips, and
the access opening was filled with Cavit (3M ESPE). After 1 week, the
rubber dam was placed as described previously, and the tooth was re-
accessed; Ca(OH)2 was removed by rinsing with 2 solutions: 5.25%
NaOCl and 17% EDTA. A final rinse was performed with 5.25% NaOCl.
ProRoot MTA (Dentsply Tulsa Dental, Tulsa, OK) was mixed according
to the manufacturer’s instructions, and a 4-mm-thick apical plug was
created. The MTA was introduced into the apical portion of the canal
from the orthograde direction with a Messing gun (MTA Endo Gun;
Dentsply Maillefer, Ballaigues, Switzerland) and adapted to the canal
walls with an endodontic plugger hand instrument. Correct placement
of the MTA was confirmed with a radiograph. The access chamber was
temporarily filled with a cotton pellet dampened with sterile water and
Cavit. During the next appointment, 1 week later, after the isolation of
the tooth by means of a rubber dam, the canal was reaccessed and back-
filled with injection-moulded thermoplastic gutta-percha (Obtura Corp,
Spartan, Fenton, MO) and sealer (Pulp Canal Sealer Kerr, Romulus,
MI). All the procedures described were performed under 10 magni-
fication using a dental operative microscope. The teeth were restored
with a dentine bonding agent and resin composite, and an immediate
post-treatment radiograph was taken.

Calibration
Two investigators (VG and GP) who had specialized in endodon-
tics for at least 10 years were designated to perform the clinical and
radiographic follow-up examinations on all patients. The radiographic
calibration was conducted on the basis of the periapical index (PAI). A
calibration kit of 100 original periapical radiographs not associated
with the study and representing a wide range of periapical bone
densities (32) was used. Agreement between and within examiners Figure 1. A radiographic image of failed root canal treatment of a maxillary
was determined by using the intraclass correlation coefficient. central incisor with open apices in a 20-year-old woman.

2 Pace et al. JOE — Volume -, Number -, - 2014


Figure 2. (A) A preoperative radiograph of a maxillary central incisor with a periradicular lesion. A small amount of extruded MTA is evident in the distal root.
(B) At the 1-year recall, the radiograph shows a significant reduction of the periradicular radiolucent lesion. (C) The radiograph taken at the 5-year recall exhibits a
complete resolution of the periradicular endodontic lesion. (D) The final radiographic examination after 10 years; the tooth is classified as healed.
used to ascertain the differences about the outcome between the base-
line, 1-, 5-, and 10-year PAI scores. MedCalc Version 12.3.0.0 (MedCalc
Software, Mariakerke, Belgium) statistical software was used for all
statistical calculations. The significance was set at a = 0.05.
Results
At the 10-year follow-up, 15 teeth were healed (PAI #2 and no
signs or symptoms), and 1 tooth had been extracted because of a lon-
gitudinal root fracture. The PAI score and the presence of pathological
signs and/or symptoms before treatment and at the 1-, 5-, and 10-year
follow-ups were recorded (Fig. 2A–D).
At the 1-year follow-up, the PAI score was improved in 10 teeth
(58%) and remained the same in 7 teeth (41%) with respect to the
baseline; all treated teeth were symptom free. At 5 years in 9 teeth,
the PAI score improved versus the 1-year follow-up and without signs
or symptoms and a total of 13 teeth (81%) were classified as healed.
At 10 years, the number of teeth classified as healed was 15 (94%);
1 tooth was considered a dropout, and 1 tooth was classified as a failure
(Table 1).
The Friedman test indicated that differences in PAI scores were sig-
nificant (P < .001). In particular, the PAI score decreased significantly
between baseline and 1 year and between 1 and 5 years. The difference
between 5 and 10 years was not significant (Table 2).
Discussion
The standardized study protocol was established before the study
was initiated, and it did not include clinical or radiographic results
from previous studies (4, 5). The PAI index score was used to
define the absence or presence of periapical lesions, and it was
associated with clinical parameters to determine the results at the
various follow-ups. This method was adopted in previous studies
and is considered a reproducible and unbiased method for validating
clinical and radiographic healing (3, 30, 32, 34–36). Only a small
number of studies discuss the clinical outcomes of the treatment of
immature teeth with pulp necrosis using MTA as an artificial apical
barrier and those that do have a maximum median follow-up of
30.9 months (4, 5, 8, 9, 37, 38). Before the introduction of MTA,
Ca(OH)2 was used to establish apical closure by the induction of a
JOE — Volume -, Number -, - 2014
Case Report/Clinical Techniques
hard tissue barrier (11). The long-term outcome of Ca(OH)2 apexifi-
cation treatment is well documented in the literature with a mid-90%
range of success (12–14), even if weakening of the root has been
observed (8, 12, 15, 16). The use of alkaline chemical intracanal
medication for a period of more than 30 days can dissolve and
denature the organic components of dentine tissue (8), compromising
the fracture resistance of the tooth. In immature teeth, the mechanical
debridement of the root canal system is often limited because of both
the large canal diameter that exceeds the largest instruments available
and thin root walls. Disinfection of the root system is of primary impor-
tance for dissolving necrotic pulp tissue, especially when periapical
drainage through the canal cannot be controlled (9). In these cases,
a minimal period of Ca(OH)2 application could improve the disinfec-
tion of the canal (4, 5, 8, 28, 37) without reducing root strength (39).
The use of Ca(OH)2 could be avoided when the canal is dried during
the first visit. In these cases, an MTA apical plug could be realized
immediately. During the long apexification with the Ca(OH)2 proce-
dure, there is sufficient time to achieve healing of the periapical tissue.
The studies in the literature do have follow-ups of more than 2.5 years
(5) on teeth with necrotic pulp and open apices treated with MTA.
Indeed, longer recall intervals could be an important factor for a
more predicable treatment outcome for both techniques (5, 13).
In this study, complete healing was observed in 7 of 17 teeth at the
1-year follow-up, and the cases of complete healing increased at 5 years
(13/16 teeth). The results remained stable at 10 years (15/16 teeth)
without significant differences. As per previous studies (2, 5, 9),
longer recall intervals (more than 1 year) could be an important
factor for a better treatment outcome, particularly in cases of necrotic
teeth with pulp necrosis and large periapical lesions (5, 31). In the
present study, a change in outcome was observed from the time
of initial therapy and the 1- and 5-year recalls. The results remained sub-
stantially stable between the 5- and 10-year follow-ups. Because the
present study covered a small sample of treated teeth, further prospective
studies on larger populations would be needed to confirm the results. In
the present case series, only 1 case was documented as a failure (6%).
This percentage could be significant in case studies with bigger sample
sizes. The failure case, which was documented 10 years after treatment,
was associated with a longitudinal root fracture that could have been
caused by an immature thin and fragile root. As stated earlier, dentin
Mineral Trioxide Aggregate as Apical Plug 3
 Case Report/Clinical Techniques
TABLE 2. PAI Score, Frequency of PAI #2, and Signs and/or Symptoms at
PAI score
Baseline and 1, 5, and 10 Years
at 10 y
2
1
2
1
1
2
1
1
1
1
1
1
1
1
3

2
Baseline 1y 5y 10 y
(n = 17) (n = 17) (n = 16) (n = 16)
PAI score (median and 3 (2.5–4) 3 (2–3) 2 (1–2) 1 (1–2)
interquartile interval)
PAI #2 (frequency and 4 (24) 7 (41) 13 (81) 15 (94)

probing depth palatal site

percentage)
Signs and/or symptoms 4 (24) 0 (0) 0 (0) 1 (6)
symptoms at 10 y

Presence of 7 mm
(frequency and
Signs and/or

percentage)
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
PAI, periapical index.

thickness that is correlated with the stage of root development is 1 of the

most important factors in tooth fracture (13). In cases of immature teeth
with thin root(s), the current data reveal that, unlike Ca(OH)2, the use of
MTA does not negatively impact the dentin (40, 41), but it has a slightly
positive effect on root strength (42). The use of internal root reinforce-
PAI score

ment, such as a post, does not seem able to prevent root fracture, which
at 5 y
2
3
3
2
1
2
3
1
1
1
1
1
2
1
2

instead could be related to cyclical loading. Mouth guard protection is

strongly suggested, especially for young patients, to protect against
possible further trauma (42).
In the present study, to reduce the weakening of immature roots,
the debridement of the canal was accomplished only by irrigation. The
symptoms at 5 y

management of MTA in the apical portion of the canal has been widely
Dropout
and/or

discussed in the literature.

Signs

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No

Ultrasonic instruments, MTA, a Messing gun or amalgam carrier,

manual pluggers, and K-files have been proposed for delivering the MTA
TABLE 1. Descriptive Signs and/or Symptoms and PAI Score of All Treated Teeth at 1-, 5-, and 10-year Follow-ups

apical plug (37, 43, 44). The difficult management of MTA in the apical
portion of the canal could lead to an extrusion of the root filling
material. Operator skill in delivering MTA to the apical portion of
root is a determining factor, especially in cases with curved root
score at 1 y

canals (19, 44, 45). In this investigation, as in previous studies,

PAI

extrusion of the MTA beyond the apex did not affect the healing rates
3
3
3
3
2
2
4
1
3
3
1
2
3
1
2

3
3

(36, 46).
Several authors have speculated that this finding could be attrib-
uted to the biocompatibility and sealing ability of MTA (19, 23–26).
Cementum and the periodontal ligament have also been observed on
symptoms at 1 y

the surface of MTA (26). To enhance the sealing ability of MTA, the dres-
Signs and/or

sing material (Ca[OH]2) must be completely removed to avoid creating

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No

or leaving open spaces between the canal walls and filling materials
where bacteria can remain (26). Given the high rate of successful man-
agement of immature permanent teeth at the 10-year follow-up, the re-
sults of this long-term study suggest that the MTA apical plug technique
permits suitable management of teeth with necrotic pulp, open apices,
and periapical lesions.
PAI score
Initial

4
3
3
3
3
2
4
2
4
4
2
3
3
1
3

5
4

Acknowledgments
The authors deny any conflicts of interest related to this study.
signs and/or

References
Sinus tract

Sinus tract
symptoms

Abscess

abscess
Initial

No
No
No
No
No

No
No
No
No
No
No
No
No

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