Fig. 1

A 22 year old female patient presented to practice with a chief complaint of discolored maxillary central incisors with sinus track opening. Dental history revealed that the patient had suffered a trauma 10 years ago and had neglected to consult a dentist. Clinical examination revealed discolored tooth no.11 and 12. Radiographic examination revealed central incisors with open apex and lateral incisor associated with periapical lesion.

Treatment planning was done and patient was advised to do root canal therapy followed by apexification procedure with MTA followed by prosthetic rehabilitation for discolored central incisors.

Fig. 2

After application of rubber dam (Hygienic Dental Dam, Colténe Whaledent, Germany) access cavity preparation was done. At this step, ISO 90 no.K-file(Dentsply Maillefer, Ballaigues, Switzerland) was placed in the canal till the working length (Figure 2)

The canal was then irrigated with 2.5% sodium hyopochlorite using a 30 gauge side vented needle to avoid its apical extrusion and walls of the canal were cleaned using a circumferential filing motion.

Fig. 3

Intracanal medication with Ca(OH)2 paste(Ultracal, Ultradent, USA) and sealing of the access cavity was done using a glass ionomer.

Three weeks later , the tooth was again isolated under rubber dam and the canals thoroughly irrigated with saline to wash out any remnants of the Ca(OH)2 dressing and 17% liquid EDTA Smear Clear(SybronEndo, CA, USA) for removal of the smear layer and the canal was then dried with paper points

Fig. 4

MTA carrier or Messing Gun or Dovgan carrirer used under operating microscope to place the MTA in open apex.

White MTA was then mixed with distilled water according to manufacturer’s instructions and 3-5 mm of MTA plug was subsequently placed at the apex

Butt end of a paper point was used to compact the material and clear out any excess from the walls. Subsequently, backfill was performed using Denjoy backfill gun and the access cavity was sealed using core build up material. A radiograph confirmed the completion of the endodontic therapy.

Fig. 5

Apical plug with MTA - a 30 months follow-up revealed complete healing and bone formation

Fig. 6

About the author:

Saurabh Doshi

2015: Diploma in laser dentistry (Austria)

2017: Master with honors in Endodontics from M.A. Ragoonwala Dental College and research centre, Pune, India

2021: Diplomate of Indian Board of Endodontics from prestigious India Endodontic Society

Author of book "The root canal obturation - Past, Present and Future

Speaker in various Indian Dental Association Forums

A passionate clinician, avid sportsman and doting father


Nonsurgical management of periapical lesions have shown a high success rate. A nonsurgical approach should always be adopted before resorting to surgery. The decompression and aspiration–irrigation techniques can be used when there is drainage of cystic fluid from the canals. These techniques act by decreasing the hydrostatic pressure within the periapical lesions. When there is no drainage of fluid from the canals, calcium hydroxide or the triple antibiotic paste can prove beneficial. Periodic follow-up examinations are essential and various assessment tools can be used to monitor the healing of periapical lesions. The surgical approach can be adopted for cases refractory to nonsurgical treatment, in obstructed or non-negotiable canals and for cases where long-term monitoring of periapical lesions is not possible.


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