Fig. 1

A 10-year-old patient was referred for a root canal treatment on his mandibular first molar. The diagnosis was pulp necrosis and asymptomatic apical periodontitis. 

The initial radiograph shows an immature distal root (reverse anatomy) with an apical radiolucency. However, the mesial root appears fully developed, therefore Regenerative Endodontic Treatment was not an option (5).

Fig. 2

Once shaping was done, gutta-percha cones were fitted in the mesial canals. A tug-back could be achieved. These canals were filled using the warm condensation technique. 

As for the distal canals, the main focus was put on irrigation and sonic activation while avoiding aggressive instrumentation on the already thin canal walls (3). 

Fig. 3

Obturation of the mesial canals. Note the sealer in the isthmus between the 2 canals. 

A 4mm apical plug of MTA was done in the DL canal, using the MAP One (Produits Dentaires, Switzerland).

A moist cotton pellet was put under the temporary cement. A second appointment was scheduled 24 hours later for backfill in the distal canals.

Fig. 4

Final radiograph after backfill in the joining distal canals. 


The patient was referred back to the pediatric dentist for the final coronal restoration.  

Step by step video


In immature necrotic permanent teeth where conventional canal obturation is impossible,  apexification is a predictable alternative for creating an apical seal, especially when using devices that allow the delivery of MTA into the apical area directly. 


1: Wigler R, Kaufman A, Lin S, et al. Revascularization: A Treatment for Permanent Teeth with Necrotic Pulp and Incomplete Root Development. J Endod 2013;39:319–326. 

2: Harlam SC. Management of incompletely developed teeth requiring root canal treatment. Australian Dental Journal 2016; 61:(1): 95–106.

3: Tolibah, Y.A.; Droubi, L.; Alkurdi, S.; Abbara, M.T.; Bshara, N.; Lazkani, T.; Kouchaji, C.; Ahmad, I.A.; Baghdadi, Z.D. Evaluation of a Novel Tool for Apical Plug Formation during Apexification of Immature Teeth. Int. J. Environ. Res. Public Health 2022, 19, 5304. ijerph19095304. 

4: Nicoloso GF, Goldenfum GM, Dal Pizzol T, et al. Pulp Revascularization or Apexification for the Treatment of Immature Necrotic Permanent Teeth: Systematic Review and Meta Analysis. JOCPD 2019; 43 (5): 305-313. 


 5: Panda, P.; Mishra, L.; Govind, S.; Panda, S.; Lapinska, B. Clinical Outcome and Comparison of Regenerative and Apexification Intervention in Young Immature Necrotic Teeth—A Systematic Review and Meta-Analysis. J. Clin. Med. 2022, 11, 3909. jcm11133909.