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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 43-47  

Comparison of the success rate of mineral trioxide aggregate, endosequence bioceramic root repair material, and calcium hydroxide for apexification of immature permanent teeth: Systematic review and meta-analysis

1 DMD Student, Rutgers School of Dental Medicine, Newark, NJ, USA
2 DMD Student, Sri Venkata Sai Institute of Dental Sciences, Hyderabad, Telangana, India
3 Dental Surgeon, Faculty of Dentistry and Oral Medicine, Pharos University, Alexandria, Egypt
4 Dental Surgeon, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
5 Dental Surgeon, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India
6 Department of OMFS, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India

Date of Submission06-Dec-2020
Date of Decision07-Dec-2020
Date of Acceptance08-Dec-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Izaz Shaik
Rutgers School of Dental Medicine, Newark, NJ
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpbs.JPBS_810_20

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This systematic review aims to compare the success rate of Endosequence bioceramic root repair material (BCRRM), mineral trioxide aggregate (MTA), and calcium hydroxide for apexification of necrotic immature permanent teeth. Indexed Journals such as Google Scholar, PubMed, Scopus, Cochrane, Research Gate, Wiley Online Library, and other related journals were hand searched from inception till November 2020 and articles were selected for review based on PRISMA guidelines. Of the 410 studies that were identified, 150 articles were selected after title/abstract reading. After full-text reading and based on inclusion and exclusion criteria, 9 studies were finalized for systematic review. Clinical, radiographic success, and the time taken for apical barrier formation were reviewed. All the three materials had almost similar success rate in terms of clinical symptoms, but the time taken for apical barrier formation and also single visit treatment makes MTA and Endosequence BCRRM superior to calcium hydroxide. Studies comparing EndoSequence Root Repair Material and MTA are very limited and need further evaluation in the future.

Keywords: Apexification, bioceramic, calcium hydroxide, endosequence, mineral trioxide aggregate, randomized controlled trials

How to cite this article:
Shaik I, Dasari B, Kolichala R, Doos M, Qadri F, Arokiyasamy JL, Tiwari RV. Comparison of the success rate of mineral trioxide aggregate, endosequence bioceramic root repair material, and calcium hydroxide for apexification of immature permanent teeth: Systematic review and meta-analysis. J Pharm Bioall Sci 2021;13, Suppl S1:43-7

How to cite this URL:
Shaik I, Dasari B, Kolichala R, Doos M, Qadri F, Arokiyasamy JL, Tiwari RV. Comparison of the success rate of mineral trioxide aggregate, endosequence bioceramic root repair material, and calcium hydroxide for apexification of immature permanent teeth: Systematic review and meta-analysis. J Pharm Bioall Sci [serial online] 2021 [cited 2023 Jan 27];13, Suppl S1:43-7. Available from:

   Introduction Top

Traumatic injuries are very common in childhood and toddlers and upper front teeth are more vulnerable for fracture. The root apex closes only after 3 years of eruption. The necrosed open apex might have some residual vital pulp tissues and some residual apical papilla cells in the periapical tissue.[1],[2] The stem cells present in the apical papilla favor root development. Apexification is the accepted nonsurgical treatment of choice for the necrotic immature permanent teeth. Several materials are available for apexification until now. The gold standard treatment initially was calcium hydroxide with camphorated monochlorophenol to induce the formation of the apical barrier at the apex was proposed by Kaiser in 1964. However, this material required almost 5–20 months to form the hard-tissue barrier.[3] Mineral trioxide aggregate (MTA) is used as reparative material for perforations and also used in pulp capping and pulpotomy procedures, apical barrier for open apex, and retrograde filling.[4] Several clinical studies of role of MAT in apexification is present in literature.[5],[6] MTA is a mixture of Portland cement and bismuth oxide, dicalcium silicate, tricalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite, as well as other mineral oxides.[7] The pH of 12.5 after setting is almost the same as calcium hydroxide.[7] MTA is the first material that had allowed overgrowth of cementum and promotes regeneration of periodontal tissues.[8] Nevertheless, MTA had some disadvantages like discoloration of the tooth and it weakened dentine walls like calcium hydroxide.[9] Recently, newer bioceramic materials such as calcium-enriched cement, Biodentine, and EndoSequence Root Repair Material (ERRM) have been marketed for various other endodontic procedures.[10] ERRM contains calcium silicates, tantalum oxide, calcium phosphate monobasic, and little amount of filler agents. The nanosphere particles present in the cement pass through the dentin tubules and react with moisture present in dentin. ERRM has a bioactive nature which simulates tissue fluid and results in the precipitation of apatite crystals.[11] This systematic review is done to compare the effectiveness of MTA and Endosequence bioceramic root repair material (BCRRM) and calcium hydroxide in clinical success of apexification of immature permanent teeth, thus solving the problem for a clinician in choosing the material for apexification is the main objective of the present study.

   Materials and Methods Top

PICO: Population, Intervention, Comparison, Outcome is described in [Table 1].
Table 1: PICO question

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Search module for identification of studies

A detailed search of all databases were done for doing this systematic review. The computer database list for reviewing the article is listed in [Table 2].
Table 2: Search strategy

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Strategy of publication research

An electronic search was performed with keywords and filter in database as listed in [Table 2]. Comparative studies of apexification of necrotic immature permanent teeth that met the inclusion criteria were evaluated. The reference list of relevant articles was also searched and evaluated.

Inclusion criteria and exclusion criteria for the review are listed in [Table 3].
Table 3: Inclusion and exclusion criteria

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Data extraction and characteristics of the study for review

The following information/data were extracted from shortlisted studies: author's name, year of publication, design of the study, number of teeth studied, age and sex of the participants, clinical success and radiographic success, time taken for apical barrier formation, and follow-up details evaluated.

Study selection

Of the 410 studies that were identified, 150 articles were selected after title/abstract reading. After full-text reading and based on inclusion and exclusion criteria, 9 studies were finalized for systematic review. A flowchart for selecting the articles for review was generated with PRISMA guidelines listed in [Figure 1].
Figure 1: PRISMA guidelines for study selection

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Study characteristics

El Meligy and Avery[12] aimed to compare the clinical and radiographic success by conducting a study on 15 children with minimum 2 necrotic immature permanent teeth. Apexification was done after root canal treatment protocol with calcium hydroxide or MTA. The evaluation was carried out every 3, 6, and 12 months. Only two teeth among 15 teeth that were treated with calcium hydroxide showed clinical symptoms such as tenderness on percussion and persistent periradicular inflammation. None of the teeth that were treated with MTA showed failure on every 3-, 6-, and 12-month follow-up visit. Pradhan et al.[13] conducted this study to compare the efficacy and the time taken for apical biologic calcific barrier formation and resolution of periapical radiolucencies on 20 teeth with unformed apices. Teeth were stratified based on radiolucency in the periapical region. After routine root canal treatment, Group I was packed with MTA and obturated with gutta percha. In Group II, calcium hydroxide dressing was done till the apical stop was achieved and then obturated. The result showed that it took 3 ± 2.9 months for apical barrier formation in MTA groups and 7 ± 2.5 months in calcium hydroxide groups. There was no significant difference in healing time of periapical radiolucencies. Simon et al.[14] conducted a prospective study (randomized) from June 2001 to June 2005 on 57 immature permanent teeth on 50 patients. The same operator treated all teeth in one appointment. The operator placed gray MTA in cases 1–11 and white MTA in cases 11–57. The remaining part of the canal was obturated with warm vertical compaction of gutta percha. Two examiners assessed the pretreatment, posttreatment, and review radiographs using magnifiers taken every 6 months, 12 months, and every year thereafter. Eighty-one percent of cases showed a decrease in size of the periapical lesion. Apical foramen closure was 88%. Bonte et al.[16] conducted a randomized clinical trial on children with necrotic permanent teeth with calcium hydroxide or MTA apexification and evaluated after 6 and 12 months. Fifty percent of the teeth treated with calcium hydroxide group showed mineralized barrier and 82% in the MTA apexification. However, four teeth treated with calcium hydroxide showed radicular fractures and 82% in the MTA group. Lee et al.[17] conducted apexification study on 40 necrotic immature open apex incisors and evenly divided them into diffrent groups (calcium hydroxide and MTA with hand and ultrasonic filing). Two conclusions derived, that root length elongation was better in teeth treated with calcium hydroxide and short time need for apical barrier in MTA apexification with ultrasonic filing. A comparative study by Damle et al.[18] compared and evaluated the apexification potential of calcium hydroxide and MTA in 22 traumatized young permanent anterior teeth among the age group of 10–11 years, and the study revealed MTA showing superior clinical outcome compared to calcium hydroxide with MTA showing 90.9% success and calcium hydroxide showed only 81.8% success rate. Sarnowski[19] had done a thesis on open apex treated with bioceramic apical barrier and studied its success and survival rates at Virginia Commonwealth University in 2019. Patient record taken from resident cases completed at the university from January 1, 2010 to May 31, 2018. A total of 119 teeth were identified that were treated for open apex with BCRRM. Only 36 teeth were under follow-up in which 72% were considered healed and 2% were healing which shows bioceramic apical had showed a good clinical outcome. Study by Barakat and Fethi.[20] The study was composed of sixty teeth from 54 children with age ranged from 7 to 10 years. Children were divided in to two equal groups: 1-Group A: teeth were received apexification with MTA 2-Group B: teeth were received apexification with bioceramic root canal sealer. All patients were followed clinically and radiographically immediate postoperatively, 3 and 6 months [Table 4].
Table 4: Studies investigated for systematic review

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   Results Top

The success rate in both bioceramic and MTA was 93.3% and 90%, respectively, with no statistically significant difference. Conclusions: both MTA and bioceramic sealer show good results.

   Discussion Top

The purpose of this systematic review was to determine whether Endosequence BCRRM, MTA or calcium hydroxide provides better clinical and radiologic outcomes for the apexification of immature permanent teeth. These three materials have their unique advantages and drawbacks and also there is no literature evidence comparing these three materials. There are few systematic reviews and meta-analysis comparing calcium hydroxide and MTA only. Three systematic reviews and meta-analysis by Lin et al.,[21] Chala et al.[22] and Nicoloso et al.,[23] compared calcium hydroxide and MTA for apexification of immature permanent teeth, studies reviewed and concluded that MTA showed better healing in terms of clinical and radiographic success, and the apical barrier was formed within a short period of time compared to calcium hydroxide. Although MTA proved to be a promising material for apexification, it carries some disadvantages such as discoloration and weakening of dentine walls.[9] Duraivel[24] in 2014, described a series of cases where apexification was performed in single visit in three different patients using ERRM, MTA, and Biodentin. All the patients were recalled after 1 month for follow-up and it proved that ERRM can be used as an alternative to MTA. Although ERRM is considered as a substitute for MTA, only very few articles compared Endosequence and MTA for apexification of nonvital immature permanent teeth. Further clinical trials need to be conducted to compare it with other apexification materials. Few stidues were baised due to lack of proper random sequencing, improper employed blinding and no long term follow up. Therefore, more studies are required to compare all apexification materials with an appropriate allocation concealment, randomization technique, and blinding.

   Conclusion Top

Based on the above studies evaluated, all the three materials had almost similar clinical success rates, radiographic success rates, and apical barrier formation rates. However, MTA and Endosequence BCRRM were associated with a significantly shorter time to achieve apical barrier formation than the calcium hydroxide. Although MTA and ERRM showed good results, there are only limited studies to evaluate MTA and ERRM. Hence, more comparative studies are required to prove the best material for apexification of immature permanent teeth.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YH, Chiang CP. Regenerative endodontic treatment for necrotic immature permanent teeth. J Endod 2009;35:160-4.  Back to cited text no. 1
Huang GT, Sonoyama W, Liu Y, Liu H, Wang S, Shi S. The hidden treasure in apical papilla: The potential role in pulp/dentin regeneration and bioroot engineering J Endod 2008;34:645-51.  Back to cited text no. 2
Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: A review. Br Dent J 1997;183:241-6.  Back to cited text no. 3
Anthonappa RP, King NM, Martens LC. Is there sufficient evidence to support the long-term efficacy of mineral trioxide aggregate (MTA) for endodontic therapy in primary teeth? Int Endod J 2013;46:198-204.  Back to cited text no. 4
Damle SG, Bhattal H, Loomba A. Apexification of anterior teeth: A comparative evaluation of mineral trioxide aggregate and calcium hydroxide paste. J Clin Pediatr Dent 2012;36:263-8.  Back to cited text no. 5
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Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives of bio-ceramic technology in endodontics: Calcium enriched mixture cement – Review of its composition, properties and applications. Restor Dent Endod 2015;40:1-13.  Back to cited text no. 10
Damas BA, Wheater MA, Bringas JS, Hoen MM. Cytotoxicity comparison of mineral trioxide aggregates and endoSequence bioceramic root repair materials. J Endod 2011;37:372-5.  Back to cited text no. 11
El Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. J Pediatr Dent 2006;28:248-53.  Back to cited text no. 12
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;73:79-85.  Back to cited text no. 13
Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: A prospective study. Int Endod J 2007;40:186-97.  Back to cited text no. 14
Neveu B, Bonte E, Baune B, Serreau S, Aissal F, Quinquis L, et al. Mineral trioxyde aggregate versus calcium hydroxide in apexification of non vital immature teeth: Study protocol for a randomized controlled trial. Trials 2011;12:174.  Back to cited text no. 15
Bonte E, Beslot A, Boukpessi T, Lasfargues JJ. MTA versus Ca(OH)2 in apexification of non-vital immature permanent teeth: A randomized clinical trial comparison. Clin Oral Investig 2015;19:1381-8.  Back to cited text no. 16
Lee LW, Hsieh SC, Lin YH, Huang CF, Hsiao SH, Hung WC. Comparison of clinical outcomes for 40 necrotic immature permanent incisors treated with calcium hydroxide or mineral trioxide aggregate apexification/apexogenesis. J Formos Med Assoc 2015;114:139-46.  Back to cited text no. 17
Damle SG, Bhattal H, Damle D, Dhindsa A, Loomba A, Singla S. Clinical and radiographic assessment of mineral trioxide aggregate and calcium hydroxide as apexification agents in traumatized young permanent anterior teeth: A comparative study. Dent Res J 2016;13:284-91.  Back to cited text no. 18
[PUBMED]  [Full text]  
Sarnowski A. Management of Open Apex Using a Bioceramic apical Barrier-its Success and Survival Rates at Virginia Commonwealth University. VCU: Virginia Common Wealth University; 2019.  Back to cited text no. 19
Barakat IF, Fethi A. Clinical and radiographical evaluation of bioceramic root canal sealer and MTA in apexification of immature permanent teeth. Egypt Dent J 2020;66:2057-63.  Back to cited text no. 20
Lin JC, Xuan Lu JX, Zeng Q, Zhao W, Li WQ, Ling JQ. Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis. J Formos Med Assoc 2016;115:523-30.  Back to cited text no. 21
Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: Systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e36-42.  Back to cited text no. 22
Nicoloso GF, Pötter IG, Rocha RO, Montagner F, Casagrande L. A comparative evaluation of endodontic treatments for immature necrotic permanent teeth based on clinical and radiographic outcomes: A systematic review and meta-analysis. Int J Paediatr Dent 2017;27:217-27.  Back to cited text no. 23
Duraivel D. Management of non vital teeth with open apex using endosequence root repair material, mineral trioxide aggregate and biodentin – A case series. J Conserv Dent 2014;17:340-3.  Back to cited text no. 24


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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