Fig. 1

A 30-year-old female came into the clinic because she noticed the presence of a bump at the gingival tissues below the left mandibular premolars.

The clinical examination revealed sinus tract and a first mandibular premolar (tooth 3.5) with the appearance of a tubercle compatible with a DE. Teeth 3.3 and 3.5 responded to sensibility tests while tooth 3.4 did not.

The radiographic examination showed a periapical radiolucency involving tooth 3.5 and the presence of an immature apex.

The final diagnosis was pulp necrosis and chronic apical abscess with the presence of a DE.

The established treatment plan considering the root development stage of the tooth was apexification using MTA for the apical plug.

Fig. 2

Rubbed dam isolation and access cavity

First Appointment: Access Cavity and Canal Location

After rubber dam isolation, access cavity was performed with a round burr. Canal inspection was done with Deppeler’s mirror which offers an excellent vision while being an easy handle instrument that can work in small field of views as in bigger ones.

Explora instrument, with its thinner tip, allowed us to locate the main canal and interferences from the coronal aspect of the tooth. 

Furthermore, ultrasonic tips were used to modify the access cavity.

Fig. 3

Working Length Radiograph

Due to the complexity of achieving a correct working length in an open apex tooth, WL was determined by using EAL and confirmed radiographically. A minimal instrumentation was then performed using an R25 file.

Copious irrigation was performed with 4.25% NaOCl. CaOH2 and a temporary restoration were placed until the following appointment.

MTA mixture and plugger measurement

Multiplo (attached to the mirror) helped us to measure our plugger to place the MTA in the desired length. Furthermore, it was used to mix the bioceramic cement in a clean way. 

After copious irrigation, NaOCl was activated sonically and the canal was dried with paper points.

A 5-mm apical plug was then performed with MTA. The bioceramic material was placed using an MTA-gun and compacted with Prexo-M. 

The middle third of the root canal system was filled with injected gutta-percha and compacted with Prexo-M, while the coronal part was sealed with dual-cure resin. After that, a direct restoration with composite was done.

Fig. 4

MTA Apical Plug

Fig. 5

Postoperative radiograph


Dens evaginatus cases represent a great challenge for clinicians in their diagnosis and treatment. When facing a DE premolar, the status of the pulp and root development is essential to establish a correct approach. In cases where the pulp is necrotic and in presence of an immature apex, apexification and regenerative endodontic preocedures are the most common proposed treatments.

According to the literature, the reported success rates after apexification procedures are high.  MTA has become the ‘gold standard’  material for performing root-end closure procedures. Combined with the use of precise instruments such as the ones form the Smart Endo Kit from Deppeler, the management of those cases have become much more predictable.

One of the more difficult tasks in apexification procedure is to perform a proper MTA plug into the desired length. Prexo-M offers the clinician a double-side plugger to easily manage the different anatomical situations of the root canal space. 

Its rounded edges in one side of the plugger facilitates the penetration inside the root canal anatomy compacting the material in a more precise way.


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