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J Conserv Dent. 2012 Apr-Jun; 15(2): 196–199. PMCID: PMC3339020

doi: 10.4103/0972-0707.94582 PMID: 22557824

One-step apexification in immature tooth using grey mineral trioxide aggregate as

an apical barrier and autologus platelet rich fibrin membrane as an internal matrix
Kavitarani B Rudagi and BM Rudagi1

Abstract

Immature teeth with necrotic pulp and periapical lesion are difficult to treat via conventional
endodontic therapy. Numerous procedures and materials have been utilized to induce root-
end barrier formation. Traditionally, calcium hydroxide has been the material of choice for the
apexification of immature permanent teeth; however, Mineral Trioxide Aggregate holds signifi‐
cant promise as an alternative to multiple treatments with calcium hydroxide. One of the tech‐
nical problems associated with the placement of the restorative materials used as artificial bar‐
rier is to prevent overfill and underfill. Using a matrix avoids the extrusion of the material into
the periodontal tissues. This case report presents the successful healing and apexification with
combined use of Mineral Trioxide Aggregate as an apical barrier, and autologus platelet rich
fibrin membrane as an internal matrix.

Keywords: Apexification, apical barrier, internal matrix, mineral trioxide aggregate, platelet
rich fibrin

INTRODUCTION

Endodontic management of non-vital young permanent tooth with a wide-open blunder-buss

apex has long presented a challenge. In the past, techniques for management of the open apex
in non-vital teeth were confined to custom fitting the filling material, paste fills and apical sur‐
gery.[1] However, the limited success enjoyed by these procedures resulted in significant inter‐
est in the phenomenon of continued apical development, or establishment of an apical barrier
referred to as “Apexification”.[2] Several procedures utilizing different materials have been rec‐
ommended to induce root end barrier formation. Apexification with calcium hydroxide
[Ca(OH)2] is the most commonly advocated therapy for immature teeth with non-vital pulp.
Whilst the advantages of calcium hydroxide lie in the fact that it has been widely studied and
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has shown success,[3–5] the disadvantages are its prolonged treatment time, the need for mul‐
tiple visits and radiographs.[6] In some cases, root resorption possibly caused by trauma, and
increased risk of root fracture due to dressing the root canal for an extended time with cal‐
cium hydroxide has been reported in teeth undergoing apexification.[7] One alternative to cal‐
cium hydroxide apexification is a single-step technique using an artificial apical barrier. The
one-step apexification has been described as the non-surgical compaction of a biocompatible
material into the apical end of the root canal, thus, creating an artificial apical stop and en‐
abling immediate filling of the root canal.[8] Advantages of this technique include shorter
treatment time, and development of a good apical seal.

A number of materials have been proposed for this purpose including tricalcium phosphate,
[9] calcium hydroxide,[10] freeze dried bone,[11] freeze-dried dentin,[12] collagen calcium
phosphate,[13] proplast (a polytetrafluor-ethylene and carbon felt-like porous material).[14]
Antibacterial pastes like metronidazole, ciprofloxacin, and cefactor have effectively encouraged
apexification.[15] Deliberate over-instrumentation of the periapical area to produce a blood
clot that will induce apical closure has also been described.[16] Over the last decade, mineral
trioxide aggregate (MTA) has been researched extensively and reported as a possible answer
to many clinical endodontic challenges. Various studies involving MTA in apexification proce‐
dures have shown promising results. One of the technical problems associated with the place‐
ment of the restorative material used as artificial barrier is to prevent an overfill and underfill.
Lemon (1992) introduced the “internal matrix concept” for treatment of root perforations. He
recommended the use of amalgam for sealing the perforation, which would be condensed
against an external matrix of hydroxyapatite, carefully pushed through the perforation thus
serving as an external barrier and matrix.[17] The modified internal matrix concept intro‐
duced by Bargohlz uses in contrast to other treatment concepts, collagen as a completely re‐
sorbable barrier material and MTA for sealing of the perforation.[18] Repair of perforations
requires a matrix to control the repair material. The same concept holds true for placement of
the apical barrier in immature tooth.

Platelet Rich Fibrin (PRF) was first described by Choukran et al. in France. PRF belongs to a
new generation of platelet concentrates, which has been shown to have several advantages like
ease of preparation, lack of biochemical handling of blood which makes this preparation
strictly autologus, promotion of wound healing, bone growth, bone maturation, and hemosta‐
sis.[19] PRF can be obtained in the form of a membrane by squeezing out the fluids in the fib‐
rin clot. This case report presents the management of an immature tooth (with an open apex)
with a single step apical barrier placement using MTA and autologus PRF membrane as an in‐
ternal matrix.

CASE REPORT

A 20 year-old female patient presented to the department of Conservative dentistry and

Endodontics, with pain in the right mandibular posterior region. Patient had experienced con‐
tinuous dull pain for 3 weeks. Previous dental history included endodontic root canal therapy
of #46. No history of swelling was given by the patient. On clinical examination, the right
mandibular 2nd premolar was rotated from buccolingual to mesiodistal direction, with the buc‐
cal and lingual cusps placed distally and mesially respectively. The tooth showed no signs of
caries or fracture [Figure 1a]. Examination of the head and neck region revealed no palpable
lymph nodes. Medical history was non-contributory. All vital signs were found to be within nor‐

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8/28/23, 1:14 PM One-step apexification in immature tooth using grey mineral trioxide aggregate as an apical barrier and autologus platelet ric…

mal limits. Oral examination revealed no soft tissue or bony abnormalities. The tooth was not
sensitive to palpation or percussion, and was not mobile as well. Radiographic examination
(Intraoral periapical radiograph) revealed an incompletely formed apex of mandibular right
2nd premolar that tested non-vital in response to thermal and electric pulp vitality testing, and
with a diffuse radiolucency of about 0.5 × 0.5 cm around the apex [Figure 1b]. Occlusal trauma
was considered as the possible etiology for the resulting periapical lesion of the tooth #45.
Obturation with tooth #46 was not acceptable upon radiographic appearance (obturation was
short and IOPA showed some amount of periapical rarefaction). Retreatment with tooth #46
was advised; however, the patient did not give consent for the same.

Figure 1

(a) Pre-operative photograph of the patient in the case study, (b) Pre-operative radiograph of the patient in the
case study revealing an incompletely formed apex of mandibular right 2nd premolar, and with a diffuse radi‐
olucency of about 0.5 × 0.5 cm around the apex. Obturation of #46 is also noted here, and not is not meeting
acceptable standards, (c) Mineral Trioxide Aggregate apical plug placed in the root canal such that an apical
stop approximately 3-4 mm thick is created, (d) Platelet Rich Fibrin Membrane obtained from the patient in
the study, (e): Two month follow-up radiograph the patient in the study showing satisfactory healing, (f): One
year follow-up radiograph the patient in the study showing satisfactory healing

MANAGEMENT

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Local anaesthesia was administered and a rubber dam was applied. Endodontic access cavity
was done on the occlusal surface using a No. 2 round bur and EX 24 bur (non end cutting ta‐
pered fissure; Mani, Tochigi, Japan). The canal was instrumented lightly with K files (Mani,
Japan) with the aim of cleaning the root canal walls of debris. The canal was thoroughly de‐
brided with a copious irrigation of sodium hypochlorite (1%) and saline (0.9%), coupled with
ultrasonic agitation (Irrisafe, Satellec, France) to ensure complete removal of the necrotic pulp
tissue. The canal was dried with sterile paper points, and Calcium hydroxide (Ultracal XS,
Ultradent, South Jordan, and UT) was placed as an intracanal medicament and the access cavity
was temporized with Cavit G (3M ESPE; Germany). The patient was recalled after 1 week.

After 1 week, the tooth was asymptomatic. At this appointment, it was decided to use PRF
membrane as an internal matrix against which MTA would be placed as an apical barrier.
Informed consent of the patient was obtained in writing after thoroughly explaining the clinical
procedures, risks involved and clarifying all questions raised by the patient. The root canal was
flushed with 1% sodium hypochlorite followed by normal saline. The canal was dried with ab‐
sorbent paper points (DENTSPLY, Tulsa Dental).

PRF membrane preparation was performed by using the procedure described by Dohan D M
et al. 30 minutes before the clinical procedure. 8.5 ml of whole blood was drawn by venipunc‐
ture of the antecubital vein. Blood was collected in a 10 ml sterile glass tube without anticoagu‐
lant and immediately centrifuged at 3000 revolutions per minute (rpm) for 10 minutes. The re‐
sultant product consisted of three layers: topmost layer consisting of acellular platelet poor
plasma, PRF clot in the middle and Red Blood Cell's at the bottom. The PRF clot was retrieved
and fluids were squeezed out to obtain a PRF membrane [Figure 1d]. PRF membrane was gen‐
tly compacted using hand pluggers to produce a barrier at the level of the apex with the use of
operating microscope (Carl Zeiss). MTA was introduced into the canal and compacted using
schilders pluggers (DENTSPLY Caulk, Milford, DE) against the PRF membrane. A radiograph
was exposed to confirm adequate placement of MTA to form an apical stop approximately 3-4
mm thick [Figure 1c]. The blunt end of a large paper point was moistened with water and left
in the canal to promote setting. A cotton pellet was placed in the chamber and the access cavity
was sealed with temporary filling material Intermediate Restorative Material (IRM)
(Caulk/DENTSPLY, Milford, DE).

After 1 week, the patient remained asymptomatic and the tooth was isolated and accessed as
before. A hand plugger was lightly tapped against the MTA plug to confirm a hardened set. The
canal was obturated using AH Plus sealer (Dentsply DeTrey, Konztanz, Germany) and injectable
thermoplasticized gutta percha (E and Q plus Meta Biomed Co ltd-Korea). The tooth was re‐
stored with resin composite. Teeth # 45 and 46 were both rehabilitated with crowns after 2
months post-operatively. The patient was recalled 2 months postoperatively, and after 1 year.
Follow-up radiographs at 2 month interval showed reduction in sizeof radiolucency and at 1
year interval showed further healing with calcifc barrier at the apex. [Figure ​1e and ​1f].

DISCUSSION

Calcium hydroxide has been the first choice material for apexification, with repeated changes
over the course of 5-20 months to induce the formation of a calcific barrier.[20] The unpre‐
dictable and often lengthy course of this treatment modality presents challenges, including the
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vulnerability of the temporary coronal restoration to re-infection.[21] Moreover, the treatment

requires a high level of patient compliance. For these reasons, one visit apexification has been
suggested.[22] MTA introduced by Torabinejad and colleagues at Loma Linda University has
shown promising results.[23] MTA has demonstrated minimal leakage of dye and bacteria in
comparison with other restorative materials.[24] MTA, a bio-compatible material, can be used
to create a physical barrier that also helps in formation of bone and periodontium around its
interface.[25] With the use of MTA, the potential for fractures of immature teeth with thin
roots is reduced, because a bonded core can be placed immediately within the root canal.

The major problem in cases of a wide open apex is the need to limit the material to the apex,
thus avoiding the extrusion of a large amount of material into the periodontal tissue. A large
volume of the extruded material may set before it disintegrates and gets resorbed. This might
result in the persistence of the inflammatory process, which may complicate or even prevent
repair of the tissue.[26–28] Using a matrix avoids the extrusion of the material into the peri‐
odontal tissues, reduces leakage in the sealing material, and allows favourable response of the
periodontal tissues. Various materials have been used for the formation of matrix like calcium
hydroxide, hydroxyapatite, resorbable collagen and calcium sulphate.[18,29,30] For the appli‐
cation of MTA, no pressure-resistant support is necessary. Freshly mixed MTA has a soft con‐
sistency and may be applied without pressure. Moreover, MTA does not require a moisture-
free environment as it sets in the presence of moisture. Some studies mention the use of small
pieces of collagen membranes that are packed within the bone space to create a matrix against
which MTA can be packed.[31]

Platelets are known to contain a variety of growth factors, including transforming growth fac‐
tor β, vascular endothelial growth factor, and platelet-derived growth factor. These growth fac‐
tors are released from the platelets when they are activated, secreted, or aggregated by colla‐
gen or epinephrine. PRF is an immune platelet concentrate, collecting on a single fibrin mem‐
brane all the constituents of a blood sample favourable to healing and immunity. PRF has been
considered as a fibrin biomaterial. Its molecular structure with low thrombin concentration is
an optimal matrix for migration of endothelial cells and fibroblasts. It permits a rapid angio‐
genesis and an easier remodelling of fibrin. It features all the necessary parameters permitting
optimal healing. These consist of a fibrin matrix polymerized in a tetra molecular structure, the
incorporation of platelets, leukocyte and cytokines, and the presence of circulating stem cells.
[32] PRF stimulates osteoblasts, gingival fibroblasts, and periodontal ligament cells prolifera‐
tion as a mitogen. Many growth factors such as platelet derived growth factors and transform‐
ing growth factors, are released from PRF. The properties of this natural fibrin biomaterial
thus offer great potential during wound healing.[33] Moreover, PRF is totally autologus and
will definitely be more biocompatible than any other material.

The combination of PRF as a matrix and MTA as an apical barrier could be considered as a
good option for creating artificial root-end barriers. However, controlled clinical trials are nec‐
essary to investigate the predictability of the outcome of the technique.

Footnotes

Source of Support: Nil,

Conflict of Interest: None declared.

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