Comparison of MTA and Ca(OH)2 for the

apexification of necrotic immature permanent

teeth
An Evidence Based Report

Allison Clark, Anthony Pino, Danielle Attoe,

Fatemeh Farzin, Keith Li, Malisa Gambacorta

DEN 207Y1
Community Dentistry, DDS II

University of Toronto, Faculty of Dentistry, Toronto, Canada

ABSTRACT

As new treatment options become available, it is of utmost importance that

dental professionals research these options in an evidence‐based manner to determine

the most appropriate treatment approach. This research was conducted in an attempt

to find the best treatment for necrotic immature permanent teeth, specifically mineral

trioxide aggregate (MTA) compared to the standard treatment, calcium hydroxide

(Ca(OH)2). A systematic search of scientific literature was conducted in order to identify,

select, and critically appraise the relevant literature. To formulate a list of keywords for

the systematic search, a preliminary non‐systematic search was conducted. Following

the selection of key search words, the PubMed literature database was utilized.

Inclusion criteria selected for studies in English, and only those that had been completed

on humans in vivo. The systematic search and critical appraisal of the relevant literature

resulted in one article by El‐Meligy & Avery that compared MTA and Ca(OH)2

apexification in a randomized split‐mouth controlled clinical trial with blinding. The

results of this study determined that the clinical and radiographic success rate for MTA

was 100% and for Ca(OH)2 was 87%. MTA and Ca(OH)2 each have advantages and

disadvantages, this report identifies these differences, but determines that further

randomized controlled studies are required before it can be stated that either option is

superior to the other.

INTRODUCTION

Approximately 30% of children will experience trauma to their young permanent

teeth.1 Traumatic injuries to immature permanent teeth may eventually result in pulpal

necrosis and the arrest of root development.2 Apexification is the treatment of choice

for immature necrotic teeth.1 In such non‐vital teeth, the root has not yet completely

developed and thus it is comprised of thin dentinal walls which are prone to fracture

during normal masticatory forces.3 Furthermore, the root apex of a non‐vital immature

tooth is relatively large and open to the neighbouring environment.3 Due to the lack of

apical closure, an intact seal of the root canal to retain the root canal filling material is

not possible.4 As a result, when such a tooth requires endodontic treatment, it presents

itself as a lengthy and technique sensitive procedure.3

In premature necrotic teeth, the open root apex is closed by an apexification

technique prior to performing root canal therapy. Apexification permits a barrier to be

formed at the root apex, allowing for proper condensation and retention of the root

canal filling.5 The standard treatment is currently the apexification procedure involving

the use of calcium hydroxide (Ca(OH)2). This treatment option has been fairly successful,

yet it poses some problems that could be addressed as new materials emerge and as

research in this area continues. Albeit popular and the standard treatment option,

Ca(OH)2 may not be the most ideal material for apexification due to the variability in

treatment time and difficulty in patient follow‐up.6 Apexification performed with

Ca(OH)2 is quite time consuming, requiring about 7 to 8 months on average for apical

barrier formation.2 Also, the time required to achieve apical closure is not reliable and
can range anywhere from 3 to 21 months4, which undoubtedly can be frustrating for the

patients who have to attend multiple appointments over such a prolonged treatment

time. Due to the lengthy treatment time, there is a risk of the patient not returning for

follow‐up appointments, which in turn increases the likelihood of failure. 2 Multiple

appointments results in more time lost from work, costing the patients’ parents the cost

of additional treatment as well as time lost from work. Another concern is that the

tooth remains prone to fracture until the treatment is successful. Dr. Malkhassian, an

endodontist at the University of Toronto, suggests that the longer the tooth has been

necrotic, the less likely that Ca(OH)2 will lead to apical closure. Such issues with Ca(OH)2

are the reason that new materials may replace Ca(OH)2 as the standard treatment for

apexification in the future.

Recently, mineral trioxide aggregate (MTA) has received a great deal of interest

among dental clinicians.1 In 1998, the US Food and Drug Administration approved MTA

for use in endodontic procedures.6 MTA allows for an immediate apical barrier to be

formed and thus immediate obturation of the root canal system.2 MTA may therefore

solve some of the problems currently experienced in apexification using Ca(OH)2.

Aside from apexification, two other techniques have just recently evolved as

treatment options for immature necrotic teeth: revitalization and tissue engineering.7

These two treatment modalities were not included in this paper because more research

into these areas is needed. As new treatment options become available, it is of utmost

importance to research what options are the best in an evidence‐based manner in order

to strive to give patients the best possible treatment. The purpose of this paper is to
compare apexification techniques using the traditional Ca(OH)2 method and the more

recent and promising MTA.

METHODS

A systematic search of scientific literature was conducted to determine the best

treatment option for a necrotic immature permanent tooth, specifically comparing

apexification of MTA versus Ca(OH)2. A systematic method was used in order to identify,

select, and critically appraise the relevant literature in order to answer a formulated

PICOC (Population, Intervention, Control, Outcome, Critical Appraisal) question in an

evidence‐based manner. The PICOC used was: permanent immature necrotic teeth

(population), MTA (intervention), Ca(OH)2 (control), clinical and radiographic success

(outcome), and randomized controlled trial (critical appraisal).

To compile a list of keywords for the PICOC question and systematic search, a

preliminary non‐systematic search was conducted, including a MeSH term search on

PubMed. The keywords (Fig. 1) and inclusion criteria were then used to search for

relevant literature using PubMed. The inclusion criteria for the PubMed search were

“human” and “English.”

The PubMed search produced 162 results. The titles were read by the authors as

a group, and 31 articles deemed potentially relevant to the topic were kept for further

analysis. The abstracts of the 31 remaining articles were then assessed by the group and

6 articles were judged as relevant to the topic according to inclusion criteria. These
inclusion criteria were: in vivo, minimum of 15 cases, studied either Ca(OH)2 or MTA, not

a case report, and not a review article.

Each of the 6 articles were read and critically appraised by at least two group

members independently, who compared their appraisals and came to an agreement

afterward. The critical appraisals were completed using a detailed checklist to assess

evidence of efficacy of therapy or prevention (Fig. 2). Of the 6 articles critically

appraised, only one article compared MTA and Ca(OH)2 (Fig. 3). The other 5 articles

were one‐sided, investigating only one material, and therefore did not meet all of the

inclusion criteria. However, these additional articles were included in the discussion as

they were able to demonstrate the efficacy of each individual treatment. Evidence was

extracted from all 6 articles and summarized (Tables 1 and 2).

Fig. 1. Keywords and search strategy entered into PubMed to search for relevant
literature
Population: Intervention: (Apexification* OR
apexogenesis OR
(necrotic OR non‐vital (MTA OR mineral trioxide apexogeneses)
OR nonvital OR necrosis aggregat* OR portland
OR necroses OR cement)
pulpless)
OR
AND AND
AND
Control:
(premature OR
immature OR (Calcium hydroxide OR
underdeveloped OR Ca(OH)2 OR CaOH2)
under‐developed OR
undeveloped)
Fig. 2. Checklist to Assess Evidence of Efficacy of Therapy or Prevention
1. Was the study ethical? ___
2. Was a strong design used to assess efficacy? ___
3. Were outcomes (benefits and harms) validly and reliably measured? ___
4. Were interventions validly and reliably measured? ___
5. What were the results?
Was the treatment effect large enough to be clinically important? ___
Was the estimate of the treatment effect beyond chance and relatively precise? ___
If the findings were “no difference” was the power of the study 80% or better ___
6. Are the results of the study valid?
• Was the assignment of patients to treatments randomised? ___
• Were all patients who entered the trial properly accounted for and attributed at its
conclusion?
i) Was loss to follow‐up less than 20% and balanced between test and controls ___
ii) Were patients analysed in the groups to which they were randomised? ___
• Was the study of sufficient duration? ___
• Were patients, health workers, and study personnel “blind” to treatment? ___
• Were the groups similar at the start of the trial? ___
• Aside from the experimental intervention, were the groups treated equally? ___
• Was care received outside the study identified and controlled for ___
7. Will the results help in caring for your patients?
Were all clinically important outcomes considered? ___
Are the likely benefits of treatment worth the potential harms and costs? ___

Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd
ed. 996, and Sackett et al. Evidence‐based medicine: how to practice and teach EBM.
1997

Fig. 3. Search results flowchart

Titles: 162 results

Abstract: 31 articles

Read‐through: 6 articles

Accepted: 1 article
RESULTS

The systematic search and critical appraisal of the literature resulted in one

article that compared apexification results using either MTA or Ca(OH)2 in a randomized

split‐mouth controlled clinical trial with blinding (Fig. 4). This article provided the

strongest evidence compared to the other five articles which used weaker study designs

(Table 2). In this study, El‐Meligy and Avery compared the clinical and radiographic

findings of each treatment option in its ability to close root apices in necrotic permanent

teeth with immature (open) apices.4 Since radiographs and clinical findings were used as

opposed to histological evidence, some error in detecting a seal formation could have

been possible. Evidence extracted from this article, including the critical appraisal, was

summarized in Table 1.

For their study, El‐Meligy and Avery selected 15 healthy and cooperative children

ranging from 6 to 12 years old, who had at least 2 necrotic permanent teeth requiring

apexification treatment. These children were selected from the Pediatric Dental Clinic at

the Faculty of Dentistry, Alexandria University, Alexandria, Egypt, and they were invited

for a 12‐month treatment period. A total of 30 teeth were evenly divided into either the

control group (Ca(OH)2 apexification) or the experimental group (MTA apexification).

Clinical and radiographic evaluations were conducted after 3, 6, and 12 months.4

El‐Meligy and Avery found that the clinical and radiographic success rate for MTA

was 100% and for Ca(OH)2 was 87%. Both examiners in the study reported identical

clinical success (no pain, no tenderness to percussion, no swelling or fistula) and

radiographic success (normal periodontal ligament, no periapical radiolucency, no

external root resorption).4 However, El‐Meligy and Avery stated that there was no

statistically significant difference between the two apexification treatments, clinically or

radiographically, according to the chi‐square test (chi‐square=2.14; P=0.16). They

concluded that MTA could potentially be an appropriate substitute for Ca(OH)2 in

apexification treatment.4

Fig. 4. Design of study by Meligy and Avery (2006)4

30 immature necrotic permanent teeth from

15 children

2 randomly selected groups

Split‐mouth trial

15 treated with Ca(OH)2 15 treated with MTA

Blinded examiners looked at clinical and

radiographic success of treatment at 3, 6, and 12
months

DISCUSSION

Based on the results, the merits of using MTA instead of Ca(OH)2 can be seen,

mainly for its ability to achieve apical closure as successfully as Ca(OH)2, but in less

time4,8‐11. Calcium hydroxide has been deemed the standard treatment for apexification,

but the duration of treatment is variable and can range from 3 to 21 months.4 The

diameter of the apical opening, the level of damage and necrosis of the tooth, and the
variable repositioning methods are some of the factors that may affect the duration of

treatment.4 During that time frame, the tooth is vulnerable to re‐infection from coronal

leakage if the temporization technique fails. In addition, the root canal is still in the

midst of apexification for this prolonged period of time, so it is weak and prone to

fracture.4

These disadvantages can be avoided by using MTA as it can be placed

immediately after disinfection. MTA is an effective apical plug and demonstrates good

adaptation at the margins of the root apices. Furthermore, MTA sets relatively fast, in

approximately four hours, and is biocompatible at the root apex.4 Due to its fast setting

time, patient compliance is much less of a concern as there are fewer follow‐up

appointments required compared to Ca(OH)2. However, the sandy consistency of MTA

makes it more difficult to work with compared to Ca(OH)2 and it is much more expensive

for the initial treatment.4 A single 1‐gram packet of MTA intended for one use costs

approximately $300.4 However, the overall cost may not be much more for MTA,

considering that it may take a few treatments for Ca(OH)2 to work, and more

appointments can results in lost income due to missing work for those appointments.

Based on the results of El‐Meligy and Avery, the success rates of MTA and

Ca(OH)2 had no statistically significant difference.4 While they failed to achieve a

statistically significant difference, the relative difference of 13% that they found could

be clinically significant. From a statistical standpoint, it is widely known that very

unimpressive P‐values can result from studies showing a strong treatment effect if there

is a low sample size. Using a conventional power of 80%, a relative difference of 15%
between treatment options, we found that a sample size of 76 patients would be

needed to achieve statistical significant. Therefore, if larger randomized controlled trials

are performed in the future, MTA may show a significantly higher success rate than

Ca(OH)2.

The study by El‐Meligy and Avery had little bias as the control and experimental

groups were randomized and the observers were blinded to treatment when examining

the results.4 Clinical examination and radiographic observations were recorded, which

generated thorough details of successful or non‐successful treatment. Clinical

observation without the use of radiographs would not have been a sufficient

examination as a patient may not experience pain, sensitivity or any other noticeable

symptom following incomplete apexification. A radiographic exam enhances detection

of apex formation following either treatment. The greatest weakness in this study was

that too few subjects were used (only 15 samples in each group).4 A larger sample size

would have strengthened the results.

According to the current research available, MTA and Ca(OH)2 have similar

success rates.4,8‐11 Thus, the decision to use either treatment depends on other factors,

such as cost, ease of treatment, and patient compliance. If a patient opts for the

Ca(OH)2 treatment because it is less expensive, the patient should also keep in mind the

intrinsic cost of time as treatment takes 3 to 21 months and the risk due to the inherent

vulnerability of the tooth during that time.4 In addition, if the treatment fails, the cost of

re‐treatment will have to be paid again and the patient will need to spend considerably

more time at the dentist office, potentially resulting in further expenses and lost wages.
Choosing MTA treatment will certainly cost more initially, however the treatment will be

done within the first appointment and the failure rate after the first treatment is lower

than with Ca(OH)2.4,8‐11

Five studies were found during the systematic search (Table 2) that tested either

MTA or Ca(OH)2 , but did not compare the two techniques.8‐12 All five studies showed

that the individual treatments were highly successful. Interestingly and possibly raising

suspicion of their findings, all of the papers studying Ca(OH)2 claimed that it was 100%

effective.9‐12 This was due to the fact that the clinicians continued treating the subjects

until apical closure was achieved, and focussed on the duration of treatment as opposed

to initial success. That being said, the major limitation of this systematic review of the

literature is that it was limited to only one well‐performed study.4 Additional resources

and the results of other randomized controlled trials would have been largely

advantageous. Contacting the author would have added more insight into the topic,

however there were time constraints with the submission of this review. In addition, the

research was limited to publications in the English language, and grey literature was not

included as it was not part of the systematic search method while it may have provided

further insight.

In conclusion, additional research, especially randomized controlled trials with

more subjects, comparing MTA and Ca(OH)2 for apexification is recommended. MTA has

several apparent advantages and has the potential to replace Ca(OH)2. Dr. Calvin

Torneck, an endodontist from the University of Toronto, suggested that MTA will only

have a place in endodontic therapy if cheaper synthetic materials are made in the
future. He also stated that a synthetic MTA is currently being developed in Brazil. There

are also other upcoming and exciting treatment options for the apical closure of a

permanent necrotic immature tooth, such as the regeneration of the apex.

Revascularization, which is the regeneration of the apex via blood clot stimulation13 and

stem cell regeneration, the regeneration of the apex using stem cells14 are two new

areas of research. Ca(OH)2 has been the standard material for apexification for many

years and has been shown to achieve success, while undoubtedly possessing multiple

drawbacks. With the addition of MTA to the option list and apical regeneration being

considered, the future for successful treatment of necrotic immature permanent teeth

is promising. Continued research will certainly lead to faster and more reliable

treatment options for patients with necrotic immature permanent teeth.

REFERENCES

1. Rafter M. Apexification: a review. Dent Traumatol. 2005;21:1‐8.

2. Pradhan DP, Chawla HS, Gauba K, Goyal A. Comparative evaluation of endodontic

management of teeth with unformed apices with mineral trioxide aggregate and
calcium hydroxide. J Dent Child (Chic). 2006;73(2):79‐85.

3. Al Ansary MA, Day PF, Duggal MS, Brunton PA. Interventions for treating traumatized
necrotic immature permanent anterior teeth: inducing a calcific barrier & root
strengthening. Dent Traumatol. 2009;25(4):367‐79.

4. El‐Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate
and calcium hydroxide. Pediatr Dent. 2006;28(3):248‐53.

5. Friedlander LT, Cullinan MP, Love RM. Dental stem cells and their potential role in
apexogenesis and apexification. Int Endod J. 2009;42(11):955‐62.

6. Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. Mineral trioxide aggregate:
a new material for endodontics. J Am Dent Assoc. 1999;130(7):967‐75.

7. Huang GT. Apexification: the beginning of its end. Int Endod J. 2009;42(10):855‐66.

8. Sarris S, Tahmassebi JF, Duggal MS, Cross IA. A clinical evaluation of mineral trioxide
aggregate for root‐end closure of non‐vital immature permanent incisors in children‐a
pilot study. Dent Traumatol. 2008;24(1):79‐85.

9. Dominguez Reyes A, Muñoz Muñoz L, Aznar Martín T. Study of calcium hydroxide

apexification in 26 young permanent incisors. Dent Traumatol. 2005;21(3):141‐5.

10. Finucane D, Kinirons MJ. Non‐vital immature permanent incisors: factors that may
influence treatment outcome. Endod Dent Traumatol. 1999;15(6):273‐7.

11. Walia T, Chawla HS, Gauba K. Management of wide open apices in non‐vital
permanent teeth with Ca(OH)2 paste. J Clin Pediatr Dent. 2000;25(1):51‐6.

12. Kinirons MJ, Srinivasan V, Welbury RR, Finucane D. A study in two centres of
variations in the time of apical barrier detection and barrier position in nonvital
immature permanent incisors. Int J Paediatr Dent. 2001;11(6):447‐51.

13. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature

permanent tooth: case report and review of the literature. Pediatr Dent. 2007;29(1):47‐
50.
14. Friedlander LT, Cullinan MP, Love RM. Dental stem cells and their potential role in
apexogenesis and apexification. Int Endod J. 2009;42(11):955‐62.
 Author, Date, Population Intervention Control Outcome Critical Appraisal Conclusion, Strength of Number of
Location (number (number Comments Evidence and Sessions
studied) studied) Classification

Meligy & Avery 15 children, MTA Ca(OH)2 Ca(OH)2‐ 87% Randomized controlled Concluded that there Recall
each with 2 N=15 N=15 clinical and trial, split mouth, blinded, was no statistically examination at
2006 necrotic radiographic valid with good efficacy; significant difference 3, 6, & 12
permanent success however, small sample between the months
Comparison of teeth with size, & the follow‐up radiographic and
Apexification immature MTA – 100% period was only 1 year clinical success of
With Mineral apices (24 clinical and Ca(OH)2 and MTA
Trioxide maxillary radiographic
Aggregate and central success
Calcium incisors and 6
Hydroxide lateral
incisors); age
Alexandria, 6‐12yrs
Egypt

Randomized
Controlled Trial
Table 1. Evidence‐based table for the randomized controlled trial comparing MTA and Ca(OH)2
 Author, Date, Population Intervention Control Outcome Critical Appraisal Conclusion, Strength Number of
Location (number (number Comments of Evidence and Sessions
studied) studied) Classification

Sarris et al. 17 non‐vital MTA None Apical closure: A pilot case study, no MTA has advantages 3 visits in total:
immature N=17 Clinical control groups, no over Ca(OH)2, but 1‐root canal, 2‐
2006 permanent Success=94.1%, blinding cost and difficulty MTA placement
incisors from Radiographic should be (only 1 for MTA
Leeds Dental 15 children (12 Success=76.5% considered. Further itself), 3‐
Institute, UK males, 3 studies required. obturation
females);
mean age 11.7
years
Domingeuz et 26 non‐vital Ca(OH)2 None Apical closure was Case study, no control, no Apexification with Mean 3.23
al. permanent N=26 obtained in 100% follow up after Ca(OH)2 is effective in sessions
incisors with of cases treatment, no blinding inducing apical
2005 open apices; closure
19 children (14
University of boys, 5 girls);
Seville, Spain age 6‐9 years
Finucane D & 44 non‐vital Ca(OH)2 None Apical closure This is a case series; it had Apexification is Mean number of
Kinirons MJ immature N=44 obtained in 100% no control group, no successful and is sessions is 1.9
permanent of cases, follow up after treatment determined by rate and the average
1999 incisors; age of and no blinding of change of Ca(OH)2 duration was 8
children not and the number of months
Northern mentioned Ca(OH)2
Ireland, UK dressings placed
Walia et al. 15 Ca(OH)2 None 100% success Retrospective study, no Ca(OH)2 is successful Mean 1.8
discoloured, N=15 within 1 year, with control group, no treatment for sessions
2000 non‐vital, 80% requiring 1 or blinding, no follow up apexification; factors
permanent 2 dressings after apical closure was are periapical
Chandigarh, incisors with obtained infection, frequency
India open apices; of dressings and age
12 children,
age 7‐16 years
Kinirons et al. 107 non‐vital Ca(OH)2 None Apical closure Retrospective study, not Strong evidence to Pts were seen 6
immature N=107 obtained in 100% randomized, not blinded show frequently weeks after
2001 permanent of cases; changing changing the Ca(OH)2 initial placement
incisors; the Ca(OH)2 more dressings the faster and at 3 month
UK children frequently the formation of an intervals
increased rate of apical barrier thereafter until
closure however it did not barrier
compare this to MTA formation was
nor was the study of detected
preferred design ie
not a RCT

Table 2. Summary of one‐sided reports on MTA or Ca(OH)2