Fig. 1

Figure 1: Preoperative radiographic analysis

-16 years old male patient presented with complain of discomfort on chewing on the upper left side for 2 weeks, with old history of dental trauma.

-On clinical examination teeth are sound with tenderness to percussion on teeth no. 23,24.

-Preoperative radiograph showing large radiolucency related to maxillary canine and premolar region with resorption like lesion to the apex of tooth no. 24

-Clinical tests reveals a non responsive tooth no. 24 to cold and hot test with positive response of neighboring teeth.

-Case diagnosed as necrotic tooth no. 24 with Chronic Apical Periodontitis.

Fig. 2

Figure 2:

CBCT cuts showing the lesion is more related to palatal root

Fig. 3

Figure 2:

After local anesthesia administration, Access opened.

W L confirmed, root canal system disinfected using 5.25% Sodium Hypochlorite , EDTA solution 17% with sonic and ultrasonic activation.

Non setting Calcium Hydroxide kept inside the canal for 2 weeks as intracanal medication as to raise the PH of the environment to be more suitable to receive the plug material.

Fig. 4

Figure 3:

Bioceramic Putty material applied to the apex for a more controlled apical seal followed by backfilling the canal using warm Gutta Percha.

Post operative radiograph showing a well adapted apical plugs of putty Bioceramics material with a well filled pulp space.

In the video a step by step application of the Putty Bioceramic material to the apex and backfilling the root space using warm Gutta Percha.


Diagnosis should be performed in a very systematic method applying all needed clinical tests to avoid over treatment or treatment to teeth that are not involved as a reason for disease.

Managing immature roots providing 3D sealing to the root canal system might represent a challenge to the operator.

Using biocompatible filling materials like MTA or Bioceramics that provide superior sealing properties over conventional Gutta percha in this kind of cases is considered a solution for more predictable results.

The use of magnification and right tools would facilitate the job for the clinician in such challenging procedures.


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Wang Z. Bioceramic materials in endodontics. Endod Top 2015;32(1):3–30.

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Apexification: A systematic review. Fabricio Guerrero, Asunción Mendoza, David Ribas, and Karla Aspiazu J Conserv Dent. 2018 Sep-Oct; 21(5): 462–465.


Sealing properties of Mineral Trioxide Aggregate orthograde apical plugs and root fillings in an In vitro apexification model. JOE 2007 Mar;33(3):272-5. doi: 10.1016/j.joen.2006.11.002.