Eur. J. Prosthodont. Rest. Dent., Vol.15, No. 1, pp 41-45 © 2007 FDI World Dental Press Ltd.

Printed in Great Britain

Apexification with Mineral Trioxide Aggregate: an

overview of the material and technique
P Gaitonde* and K Bishop†

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: Mineral Trioxide Aggregrate, Apexification, Immature Apex, Calcium Hydroxide

INTRODUCTION Incomplete root development can provide a challenging

clinical situation since cleaning, shaping and obturation
Root development is through the continuous deposition of during root canal therapy may become difficult and un-
dentine and cementum by stimulation and differentiation of predictable.
Hertwig’s Epithelial Root Sheath (HERS) and surrounding
undifferentiated progenitor cells 1. HERS is a continuous Morse et al.4 reported in their literature review three tech-
sleeve of epithelial cells, which separates the pulp from the niques to obturate an immature tooth, which involved the
dental follicle. It consists of an inner layer of cuboidal cells use of a root-filling material without the induction of the
and an outer layer of more flattened cells. It completely apical closure:
encloses the dental papilla except for an opening in its • placement of a large gutta-percha filling or customized
base, the primary apical foramen. Odontoblastic differen- gutta-percha cone with sealer at the apex;
tiation takes place adjacent to the basal aspect of HERS,
after which mantle dentine is deposited. At this time, the • placement of gutta-percha with sealer or zinc-oxide/
innermost layer of cells in the root sheath secrete an inter- eugenol short of the apex;
mediate material which combines with the mantle dentine • peri-apical surgery.
to from intermediate cementum layer. After odontoblastic
differentiation and formation of intermediate cementum, These techniques did not gain popularity since there was
HERS disintegrates and the epithelial cells migrate away no physical apical barrier to facilitate obturation. How-
from the root surface to form the epithelial cell rests of ever Morse et al. also reported two techniques, which
Malassez. Simultaneously, cells from the dental follicle mi- aimed to provide the formation of an apical barrier:
grate towards the root surface and become cementoblasts. • placement of calcium hydroxide to induce a mineralised
Interruption of this process by trauma or infection can lead apical barrier;
to incomplete root development and the presence of an
open apex and a wide funnel shaped canal. • placement of a biocompatible material such as dentinal
chips against which a root-filling could be placed.
A common cause for the interruption of root development
is trauma. The nature of the injury depends on the loca- Until recently, the traditional approach to the treatment
tion of the tooth, the energy of impact, resiliency and the of non-vital teeth with incompletely developed roots
angle of the impact 2. However, the majority of injuries has been apexification by inducing the formation of
occur in young individuals when the root development mineralised tissue in the apical portion of incompletely
is incomplete 3. Luxation injuries appear to be associated formed apex 4. The barrier facilitates the placement of
with the greatest risk of incomplete root development with an appropriate root-filling whilst reducing the possibility
between 15 and 59% of teeth losing their vitality 3. The of the sealant or root-filling extruding into apical tissues
maxillary central incisor is the most frequently affected
7
. Calcium hydroxide has been the material of choice for
tooth in both dentitions 3. apexification and has been widely studied and reported.
Granath 5 was the first to report the use of the material for
apical closure. Its potential to induce mineralisation was
shown by Mitchell in 1958 6. It has also been combined
with other materials such as sterile water, camphorated
* BDS FDSRCS Ed monochlorophenol, methylcellulose, cresatin, iodoform,
†
BDS, MScD, DRD, MRD, FDS (Rest Dent) and Ringer’s solution 4.
 P GAITONDE AND K BISHOP

Foreman and Barnes 8 in a review of calcium hydroxide which results in hydration (pH 12.5) leading to a set in
reported the findings of several authors with regard to the approximately four hours 12. It is currently dispensed as a
mechanism of action of calcium hydroxide in the induc- powder, in five 1g sachets and should be stored in a dry
tion of mineralization, however it still remains unclear. It is environment. Comparisons between the two commercially
suggested that the calcium ions which are incorporated in available types of MTA 16 have shown no significant dif-
the mineralised repair tissue are derived from the vascular ferences in terms of biocompatibility and micro-leakage.
supply of the pulp and not the material itself 8. A rise in pH However, in another study, Matt et al. 15 found that a 5
due to free hydroxyl ions acts as an initiator of the process, mm apical barrier of grey MTA using the recommended
the alkalinity acting as a buffer against the acidic reactions 2-step apexification procedure leaked significantly less
produced by the inflammation. It is postulated that calcium than the white MTA.
hydroxide activates alkaline phosphatase and stimulates
undifferentiated mesenchymal cells into cementoblasts and
PHYSICAL PROPERTIES
osteoblasts. It is also possible that Hertwig’s epithelial root
sheath remains intact and resumes function once the canal pH
is debrided of the necrotic tissue 9. This would then result
in true apex formation. In the absence of the root sheath, MTA has a pH similar to that of calcium hydroxide of 12.5 at
a calcific barrier is formed and not a true apex. 3 hours 14. This similarity with calcium hydroxide is thought
to contribute to its inductive potential and the resultant
The Royal College of Surgeons of England 7 have published hard tissue formation 14. However conclusive evidence is
guidelines on the management of immature non-vital teeth yet to be proved to demonstrate this. MTA, like amalgam
using calcium hydroxide and details on the technique. and super EBA do not show any signs of solubility in water
Sheehy and Roberts 10 reported a success rate of 74-100% at 7 days as per ISO and ADA specifications 14.
in their review of apexification using calcium hydroxide.
There does not appear to be a consensus on how frequent
the material needs to be changed. However calcium hy- Sealing ability and marginal adaptation
droxide’s inherent solubility means that replacement at 3 Lack of an ideal apical seal is largely responsible for failure
monthly intervals until closure of the apex occurs would of surgical endodontics17. The quality of apical seal for dif-
appear advisable. The duration of treatment is variable ferent retrograde materials has been assessed by different
with between 5.1- 20.2 months being reported as the time research groups, based on the degree of penetration by
before an apical barrier was formed 10. (i) dye (ii) radio-isotope (iii) bacterial (iv) electro-chemical
Whilst the advantage of calcium hydroxide lies in the fact means and (v) fluid filtration techniques 18. These studies
that it has been widely studied and has shown success, have shown superior results for MTA when compared with
the disadvantages are its prolonged treatment time, the other materials 18. MTA is also associated with less overfills
need for multiple visits and radiographs. In some cases,
12
and the superior outcome associated with the material
root resorption 10 possibly caused by trauma and increased is observed with or without blood contamination of the
risk of root fracture 11 due to dressing the root canal for root cavities 19. In a study carried out by Fischer et al.19,
an extended time with calcium hydroxide has been re- using bacterial leakage model, the time period in which
ported in teeth undergoing apexification. In cases where materials began leaking was 10-63 days for amalgam, 24-
apexification does not occur, there are no clear guidelines 91 days for IRM, and 42-101 days for super EBA. MTA did
on the next best approach. not begin to leak till day 49. The superior sealing ability
of MTA is thought to be due to the setting expansion it
Over the last decade, Mineral Trioxide Aggregate (MTA) undergoes in moist environment 19.
has been researched extensively and reported as a possible
answer to many clinical endodontic challenges. The mate-
rial was developed in Loma Linda University, California, Compressive strength
and first appeared in the endodontic literature as a material MTA has a relatively low compressive strength; however,
to repair lateral root perforations 12. It has evoked much this does not compromise its success as it is used in situa-
interest since the first report was published in 1993 13 . tions that experience low compressive forces14. Sluyk et al..
studied the setting properties of MTA and found that MTA
What is MTA? reached its maximum resistance level if left undisturbed for
72 hours before placement of a permanent restoration 20.
Until recently, MTA has been commercially available in
the UK as ProRoot MTA (Dentsply, Tulsa Dental, USA),
in two colours: an original grey and a newer white. White BIOCOMPATIBILTY
Pro-Root was introduced as an aesthetic improvement
over the original grey MTA. Both materials are available In 1997, Koh et al. reported on the biological response
in the form of a biocompatible, hydrophilic powder that triggered by MTA on human osteoblasts in vivo 13. The
sets in the presence of moisture 14. The material consists study examined an osteoblast-like standardized cell line
of tricalcium silicate, tricalcium aluminate, tetracalcium to determine changes in cytokine release, and levels of
aluminoferrite, calcium sulfate dihydrate and silicate oxide osteocalcin (non-collagenous protein characteristic of
but other mineral oxides may also be added to improve osteoblast function) and alkaline phosphatases. This was
physical and chemical properties 14, 15. The addition of set as an indication of matrix production. Cultured MG-63
bismuth oxide powder makes it radio-opaque 15. The cells were trypsinised and seeded into dishes containing
tetracalcium aluminoferrite is reportedly absent in the standard amounts of MTA and polymethylmethacrylate
white MTA 15. The material is mixed with sterile water, (PMA). In this study, all markers of osteoblast function that

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 APEXIFICATION WITH MINERAL TRIOXIDE AGGREGATE: AN OVERVIEW OF THE MATERIAL AND TECHNIQUE

were assessed were increased in the presence of MTA. in dry fields 25. Unfortunately, no single material has all
the ideal properties 19, 23, but MTA with its regenerative
Material analysis of MTA shows the material to be divided
potential, biocompatibility, superior sealing properties
into calcium oxide and calcium phosphate. The scanning
and moisture tolerance appears to offer the best option
electron microscopic studies revealed that amorphous cal-
at present 21.
cium phosphate showed maximum ingress and growth of
cells. They concluded that MTA offers a biological substrate
for osteoblasts and the calcium phosphate phase favoured Pulp capping
the change in cell behaviour that stimulated growth over MTA has been indicated for pulp exposures in vital im-
MTA 13. mature teeth, under isolation using a rubber dam 24. After
rinsing the pulp with dilute sodium hypochlorite, the
procedure of pulpotomy or pulp-capping is carried out
INDUCTIVE POTENTIAL conventionally. After haemostasis is achieved, the mixed
Torabinejad et al. and colleagues used infected premolars MTA is places over the exposed pulp with a moist cotton
in two-year old beagle dogs, which were prepared to pledget, which is left in-situ under a temporary material.
receive gutta-percha root-fillings 21. The root fillings were This is then removed a week later to leave a layer of MTA
left to contaminate by means of open access cavities and over which a definitive filling is placed.
subsequently underwent root resection and retrograde fill- There are a number of case reports by various authors on
ings with either MTA or amalgam. Although periosteum and apexification and furcation repairs using MTA. Main et al.
new bone formation were found in the presence of both 26
recently reported the largest number of repairs of root
materials, histologic findings at 10-18 weeks post-surgery perforations using MTA, with all 16 cases showing radio-
confirmed the formation of cementum exclusively over graphic healing within a range of 12-45 months. However,
the root ends with MTA, which included the MTA itself. there are no long-term studies yet published with regard
This led to the conclusion that MTA could be used as a to other applications of MTA.
root end filling.
Shabahang et al. 22 carried out apexification in immature CLINICAL CASE
dog-teeth using Calcium hydroxide osteogenic protein
and MTA. MTA induced hard tissue formation more than A ten-year-old boy was referred by his general dental prac-
any other test material at 12 weeks, resulting in root-end titioner to the Department of Restorative Dentistry, Morris-
closure. ton Hospital, Swansea due to problems with an upper left
central incisor - 21. This tooth had been traumatised two
years previously and had subsequently lost its vitality. The
Cytotoxicity GDP had attempted apexification with calcium hydroxide
An in vitro study conducted by Osorio et al. in 1998 for 24 months without the desired root end closure. On
compared different root canal sealers and root end filling presentation the tooth was tender to percussion.
materials using two assay systems and two different mam- An immature apex was observed on the radiograph (Figure
malian fibroblast cell line 23. Their conclusions were based 1). The case was considered suitable for apexification with
on the fact that if a material exhibits a strong cytotoxicity MTA. Treatment was carried out under local anaesthetic
in cell culture tests, it is very likely to do so in living tissue. and rubber dam isolation utilising an operating microscope.
Of the materials tested, MTA was the least cytotoxic. Straight-line access was established and the apex was
viewed under magnification. Due to lack of a closed apex,
the peri-apical soft tissue was clearly visible. The canal was
Manipulation debrided using hand and ultrasonic files and irrigated with
ProRoot R MTA is mixed immediately before its use in a copious amounts of 5% sodium hypochlorite. The canal
ratio of 3:1 powder to sterile water ratio 14. The manufac- was dried and dressed with calcium hydroxide for a week.
turers recommend mixing the powder with water for one At the following visit, the calcium hydroxide was removed
minute to ensure hydration of all particles. A thick creamy and the canal again cleaned, irrigated and dried.
consistency is recommended. If the area of application is MTA was mixed according to manufacturer’s guidelines to
too wet, a piece of foam can be applied to remove extra a thick creamy consistency. It was then deposited 1-1.5 mm
moisture. The mix can be carried to the site with plastic short of the working length using a carrier and condensed
or metal instruments 14. with minimal pressure using the broad end of appropriate
sized paper points. This allowed control of the moisture
in the MTA mix, as the paper point can be used to absorb
CLINICAL APPLICATIONS24
or impart moisture as necessary. Due to its hydrophilic
nature, MTA adapts well to the peri-apical tissues. This was
Root-end filling material or repair of a root perfo-
repeated until approximately 5 mm of the material was
ration
deposited in the apical region. A moist cotton wool pledget
Several materials have been advocated as root-end filling was then placed in the canal overnight and the system
materials or to repair root perforations. These include silver temporarily sealed using thermoplasticized gutta-percha
amalgam, glass ionomer, Intermediate restorative material using Obtura II, and a zinc oxide/eugenol dressing. A check
(IRM), and Ethoxybenzoic Acid (super EBA). The ideal radiograph was obtained to evaluate the apical seal. The
material should be biocompatible, have an optimum seal, gutta-percha and cotton wool pledget was removed the
regenerative potential and not be limited in its application following day and a definitive root-filling placed coronal to

43
 P GAITONDE AND K BISHOP

Figure 1. Pre-operative radiograph of 21 showing immature apex Figure 2. One-year post-MTA apexification radiograph showing
complete closure of root

the MTA using thermoplasticized gutta-percha. Composite MANUFACTURERS’ DETAILS

was used to seal the pulp chamber and this was extended
into the cervical region of the tooth to fill the access cav- DENTSPLY Tulsa Dentsply. Distributed by DENTSPLY
ity. The tooth was reviewed at intervals of one month, six Maillefer.
months and twelve months post treatment. A radiograph
was obtained at the one- year interval (Figure 2). ADDRESS FOR CORRESPONDENCE

P Gaitonde, Department of Restorative Dentistry, Charles

DISCUSSION Clifford Dental Hospital, Wellesley Road, Sheffield S10 2SZ,
Regeneration is the ideal desirable outcome for any restora- E-mail: [email protected]
tive procedure. The last decade has seen a quest for a ma-
terial that can regenerate odontogenic tissue successfully, REFERENCES
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 APEXIFICATION WITH MINERAL TRIOXIDE AGGREGATE: AN OVERVIEW OF THE MATERIAL AND TECHNIQUE

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