Clinical Solution

Mineral Trioxide Aggregate as an Apical Plug in Teeth with a Necrotic Pulp and an Immature Apex

By Dr. Barry H. Korzen

One of the most challenging clinical situations we face in endodontic treatment are cases where there is an immature apex associated with a necrotic pulp and a periapical lesion. Not only is there the possibility of the apical region of the tooth potentially being compromised due to the thinness of the dentin walls, but the absence of an apical constriction and moisture contamination from the periapical lesion makes sealing the root difficult and long-term healing questionable.

A clinically accepted solution in dealing with these cases is the placement of an apical plug of MTA, using an orthograde approach, against which a conventional filling of gutta percha can be placed. In the August 2014 issue of the Journal of Endodontics Pace et al reported on a 10-year study that 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 technique.”

The authors followed the healing progress of 17 teeth, 7 of which showed complete healing after one year. After 5 years the number of teeth healed increased, and after 10 years one tooth failed due to a vertical root fracture, one patient dropped out of the study and the remaining 15 teeth showed complete healing.

Not only were the authors able to conclude  “that the MTA apical plug technique permits suitable management of teeth with necrotic pulp, open apices, and periapical lesions” but also that “longer recall intervals could be an important factor for a more predicable treatment outcome”.

The authors’ published abstract appears below:



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 technique.


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 intracanal 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 differences between baseline and the 1-, 5-, and 10-year PAI scores.


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.


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.

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