Fig. 1

Preoperative XRAY analysis:

1)Mesial caries near mesial pulp horn.

2)Mesial root apex is closed but its wide.

3)Distal root has an open apex.

Fig. 2

Rubber dam placement from the very first start because apexogensis success rate depends on proper isolation and healthy pulp tissues.

Fig. 3

Complete caries removal first before access to avoid placing any infected dentine inside the pulp tissues.

However we faces uncontrolled inflammation inside the tooth and couldn’t reach any healthy pulp tissues.

Fig. 4

Shifting the treatment plan to full mechanical debridement of all pulp tissues and conventional root canal treatment for the mesial canal system and for the distal canals I decided Apexification while using MTA apical plug followed by thermoplastic GP.

Fig. 5

The apex is so wide that you can see the periapical tissues under the microscope!

Fig. 6

Bioceramic sealer in mesial canals and using Hot Modified Technique to obturate it like a conventional root canal treatment.

MTA apical plug using MAP system followed by thermoplastic GP injection till orifice level.

Fig. 7

Postoperative XRAY

Showing homogeneity between apical plug and thermoplastic GP and obturation with good apical tugback for mesial root canal system.

Fig. 8

About the author: Khaled Khalifa

B.D.S. Misr International University

Endodontic Specialist

Course Director “The Endo Formula”

Endodontic Consultant in multiple private clinics

Member of The Royal College of Surgeons England (MJDF)

Member of The American Association Of Endodontics (AAE)

Member of British Association Of Endodontics (BES)

Practice limited to Endodontics


In conclusion, you have to have knowledge and to think fast. The ability to think fast and switch to a better treatment plan for your patient is considered a quality you should have as a dentist to be versatile.

In order to achieve this you have to be equipped with tools and knowledge.


The Apical Extent of Mineral Trioxide Aggregate Apical Barrier Does not Influence the Treatment Outcome in a Nonvital Immature Permanent Anterior Tooth: A Split-Mouth Clinical Study Published online 2021 Feb 2. doi: 10.14744/eej.2020.08760 Krunal M Tabiyar and Ajay Logani

MTA apical plugs in the treatment of traumatized immature teeth with large periapical lesions  Zafer C Cehreli , Sezgi Sara, Serdar Uysal, Melek D Turgut DOI: 10.1111/j.1600-9657.2010.00941.x 

Management of the open (immature) apex. 1. Vital teeth J. L. GUTMANN DDS, J. F. HEATON DMD

Importance of “Time” on “Haemostasis” in Vital Pulp Therapy Saeed Asgary1 and Ardavan Parhizkar1 doi: 10.14744/eej.2020.82574