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Year : 2011  |  Volume : 14  |  Issue : 4  |  Page : 427-431
Calcium-enriched mixture cement as artificial apical barrier: A case series

1 Department of Endodontics, School of Dentistry, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
2 Iranian Center for Endodontic Research, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Dental Research Center, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
5 Dental School, Tehran University of Medical Sciences, Tehran, Iran

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Date of Submission28-Jan-2011
Date of Decision03-Feb-2011
Date of Acceptance12-Jun-2011
Date of Web Publication5-Nov-2011


In comparison to the conventional apexification using calcium hydroxide, artificial apical barrier technique is more valuable and less time consuming. This article describes successful use of calcium-enriched mixture (CEM) cement as an artificial apical barrier in open apices. In this study, 13 single-rooted teeth with necrotic pulps and open apices were treated non-surgically. After copious irrigation of the root canals with NaOCl 5.25% and gentle filing, based on need for interappointment dressing, treatments were followed by CEM cement (BioniqueDent, Tehran, Iran) apical plug insertion in the first or second appointment. All cases were then permanently restored. All subjects were followed until radiographic evidence of periradicular healing was seen (mean 14.5 months). Clinically, all cases were functional and asymptomatic and complete osseous healing was observed in all the teeth. Considering the biological properties of CEM cement, this new endodontic biomaterial might be appropriate to be used as artificial apical barrier in the open apex teeth.

Keywords: Apexification; apical plug; calcium enriched mixture; CEM cement; healing; open apex

How to cite this article:
Nosrat A, Asgary S, Eghbal MJ, Ghoddusi J, Bayat-Movahed S. Calcium-enriched mixture cement as artificial apical barrier: A case series. J Conserv Dent 2011;14:427-31

How to cite this URL:
Nosrat A, Asgary S, Eghbal MJ, Ghoddusi J, Bayat-Movahed S. Calcium-enriched mixture cement as artificial apical barrier: A case series. J Conserv Dent [serial online] 2011 [cited 2023 Sep 29];14:427-31. Available from:

   Introduction Top

A nonvital open apex tooth presents a number of difficulties for efficient root canal therapy. The apex is considerably wide and there is no barrier to stop root canal filling material from being pushed to the periapical tissues and to create effective apical seal. Apexification is the induction of a calcified apical barrier or creation of an artificial apical barrier across the open apex after the elimination of necrotic tissues and bacteria from root canal space. [1] The conventional apexification uses densely packed calcium hydroxide (CH) as an intracanal medicament for the induction of calcified apical barrier. [2] Although the technique is efficient with predictable outcomes, [3] it has several disadvantages. The required time for induction of a calcified apical barrier varies between 6 and 24 months, [1] and the prolonged treatment time increases the risk of bacterial recontamination. [3] Studies have shown that the long-term contact between CH and root dentine increases dentine brittleness and the risk of cervical fractures. [4]

An alternative treatment to apexification with CH is the artificial apical barrier technique, which is done by placing a barrier material in the apical portion of the root canal. The material proposed for this technique is mineral trioxide aggregate (MTA). [5] MTA is a biocompatible material with well-documented cementogenic properties. [5],[6] Because of its biocompatibility, [7] the ability to set in the presence of moisture and blood, [8] and superior sealing ability, [7] MTA is a promising material in obturation of the open apex teeth. Several human studies have shown the high clinical and radiographic success rates of MTA apical plugs. [9],[10],[11] However, MTA has questionable antimicrobial activity, [12] is difficult to handle, and has the potential of discolorating the tooth. [13]

Calcium-enriched mixture (CEM) cement has been recently introduced as a hydrophilic tooth colored cement. CEM cement powder is composed of calcium oxide, calcium sulfite, phosphorus oxide, and silica as major elements. [14] CEM is an alkaline cement with superior antibacterial properties to that of MTA, [12] which releases CH during and after setting. [14],[15] In vitro studies have shown similar sealing ability for CEM cement and MTA as retrograde filling materials. [16] Animal studies have revealed that, like MTA, PDL regeneration, cementogenesis, and dentinogenesis occur in contact with CEM cement. [6],[17]

This paper describes the treatment outcomes of CEM cement as an artificial apical barrier in immature human teeth or teeth with apical root resorption.

   Case Reports Top

The study was peer reviewed and approved by a local board of research and ethics. Included were 13 necrotic single-rooted teeth with open apices (immature [n = 7]; mature with apical root resorption [n = 6]) which were treated in an endodontic private clinic. Patients were between 8 and 35 years old. Medical histories of all patients were non contributory. Except for three cases, which were referred for retreatment, cold test was conducted for all teeth using Endo-Frost cold spray (Roeko, Coltene Whaledent, Langenau, Germany) to establish a pulpal diagnosis. None of the teeth responded to the cold test. All of the teeth had normal periodontal probing and showed physiologic mobility. Palpation and percussion tests were carried out. A summary of the descriptive data of cases in the first visit are shown in [Table 1].
Table 1: Descriptive data at the first visit

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Informed written consents were obtained from all patients. The teeth were treated with or without interappointment CH dressing. A tooth was treated with interappointment dressing if in the first visit, the root canal could not be dried at the end of cleaning procedure and there was continuous suppuration or exudation.

Treatment without interappointment dressing

After local anesthesia with 2% lidocaine and 1:80000 epinephrine (Daroupakhsh, Tehran, Iran) and rubber dam isolation, root canals were accessed using a diamond-coated fissure bur (Diatech, Heerbrugg, Switzerland) and were cleaned using passive irrigation with 20 mL of NaOCl 5.25% and gentle filing with a size 50 K-file (Dentsply Maillefer, Ballaigues, Switzerland). Then, the root canals were dried with size 50 paper points (Ariadent, Tehran, Iran).

Treatment with interappointment dressing

The treatment procedure for teeth treated with interappointment dressing was the same as the aforementioned group, except using CH as an interappointment root canal dressing. After drying canals with paper points, the CH powder (Ariadent, Tehran, Iran) was mixed with normal saline to a creamy consistency and was placed into the root canals by the counterclockwise rotation of a size 50 K-file and the teeth were temporized with Cavite (Ariadent, Tehran, Iran). After 2 weeks, the patients were recalled and the CH dressings were removed by irrigating with alternating solutions of 5.25% NaOCl and 17% EDTA (Ariadent, Tehran, Iran); the canals were then dried.

Apical plug insertion and obturation

Once the canal was dry at the working length with no exudates, CEM cement powder and liquid (BioniqueDent, Tehran, Iran) were mixed according to the manufacturer's instructions and delivered to the dried canals using a sterile amalgam carrier and gently adapted to the apical portion of the canals using pre-fitted endodontic pluggers (M-series, Dentsply Maillefer, Tulsa, USA) until the apical plug reached the length of 4-5mm. Correct placement of CEM cement apical plugs was assessed radiographically [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]. The root canals were filled with normal saline, and the teeth were temporarily restored. One day later, the CEM cement setting was checked. Except one case (case 10) [Figure 5] which was fully obturated with CEM cement because of internal resorption in the mid-root area, in other cases the remainder of canal space was either back-filled using sectional warm vertical compaction of gutta-percha (Ariadent, Tehran, Iran) and sealer (Pulp Canal Sealer, Kerr, MI, USA); or restored with a prefabricated post and composite material applied directly on the CEM cement. Finally, all teeth were permanently restored.
Figure 1: (a) Preoperative periapical radiograph of case1; a 24-year-old male with history of impact trauma to the anterior upper jaw which was referred for retreatment of tooth #9. Clinically, buccal and palatal swellings were present, and tooth 9 was sensitive to palpation and percussion. Radiographically, a large periapical radiolucent lesion was present on tooth #9, teeth #9 and 8 were immature, and both were inadequately obturated. (b) Postoperative radiograph after retreatment of teeth #9 and 8, and placement of CEM cement apical plug in tooth #9 and MTA apical plug in tooth #8, warm vertical obturation of remained canal spaces in both teeth with gutta-percha and sealer, and permanent coronal restoration of access cavities with bonded composite resin. (c) Follow-up radiograph at 18 months after treatment. Both teeth were functional and asymptomatic. The periapical lesion of tooth #9 completely healed

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Figure 2: (a) Preoperative periapical radiograph of case 7; a 12-year-old female which was referred with swelling and pain in palpation in the right side of mandible. Clinically, the tooth #29 had occlusal carries and was necrotic and immature. (b) Postoperative radiograph after root canal disinfection and placement of CEM cement apical plug without interappointment dressing. (c) Follow up radiograph at 15 months after treatment. The tooth was asymptomatic without recurrence of swelling, and the periapical lesion completely healed

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Figure 3: (a) Preoperative periapical radiograph of case 11; an 18-year-old male with chief complaint of sinus tract on maxillary left central incisor which was an immature necrotic tooth with history of trauma. (b) Postoperative radiograph after placement of CEM cement apical plug, warm vertical compaction of gutta-percha and sealer in the remained root canal space, and permanent coronal restoration. (c) Followup radiograph at 15 months after treatment. Sinus tract resolved and periapical lesion healed completely

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Figure 4: (a) Preoperative periapical radiograph of case 6; an 18-year-old male with chief complaint of buccal swelling and pain in palpation on right mandibular second premolar under a bridge. The tooth had a previous inadequately obturated root canal treatment with recurrent caries and apical resorption. The tooth treated with inter-appointment dressing, CEM cement apical plug, and prefabricated post and bonded composite resin. (b) Follow-up radiograph at 15 months after operation. The tooth is functional without sensitivity to percussion or palpation

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Figure 5: (a) Preoperative periapical radiograph of case 8; a 35-year-old female with chief complaint of buccal swelling and pain in palpation on maxillary left central incisor. The tooth had a previous inadequately obturated root canal treatment with apical resorption and a very slight apical rarefaction. (b) Post-operative periapical radiograph. (c) Follow-up radiograph at 12 months after treatment. The tooth was functional without recurrence of swelling and sensitivity to percussion and palpation.

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Figure 6: (a) Preoperative periapicel radiograph of case 10; a 30-year-old female with chief complaint of sinus tract on maxillary left central incisor and history of impact trauma. The tooth was necrotic with internal and apical resorption. Treatment was performed without inter-appointment dressing. Because of presence of internal resorption in midroot, the canal space completely obturated with CEM cement. (b) Follow-up radiograph at 12 months after treatment. The sinus tract resolved and preiapical osseous lesion healed.

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Cases 1, 6, and 8 [Figure 1],[Figure 4] and [Figure 5], had previous inadequate obturations. Therefore, prior to cleaning procedure, gutta-percha was removed using Gates Glidden drill size 3 (Dentsply Maillefer, Tulsa, OK, USA) in the coronal two-thirds and size 40 H-file (MANI, Mani Inc, Japan) in the apical portion of the canals. Then, the cleaning and irrigation and interappointment procedures were followed as described. In case 1, the patient was referred for retreatment of tooth #9, since the tooth #8 was immature and inadequately obturated too [Figure 1]a, the clinician decided to retreat it. It was an opportunity to use CEM cement and MTA apical plugs in the same patient. Thus, after removing gutta-percha and irrigating the tooth #8, the MTA powder (ProRoot tooth colored MTA, Dentsply, Tulsa Dental, OK, USA) and distilled water were mixed according to the manufacturer's instructions and placed in the apical portion of the canal [Figure 1]b).

Subjects were followed clinically and radiographically at 3-month intervals until radiographic healing was completed. Summary of treatments and follow-up periods are represented in [Table 2]. The mean follow-up time period was 14.5 months. All of the cases were functional without clinical signs/symptoms of periradicular diseases including sensitivity to percussion/palpation, presence of soft tissue swelling/redness, and presence of sinus tract. Radiographically, complete osseous healing of the lesions was observed in all of the teeth [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6].
Table 2: Summary of treatments and follow up-periods

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s It has been postulated that the material of choice for apexification procedure should have a cemento-conductive potential. [5] MTA has the ability of hard tissue induction with a high degree of structural integrity when used as the apical plug in open apex teeth [5],[18] . In a human study, the outcomes of apexification with either MTA or CH were compared. After a 12-month follow-up period, unlike CH group, all 15 cases treated with MTA were clinically and radiographically successful. [9] Other studies reported high clinical and radiographic success rates for one or two visit MTA apical plug techniques. [10],[11] Therefore, MTA is seemingly the biomaterial of choice for the artificial apical barrier technique.

Torabinejad et al[19] hypothesized that cementogenic properties of MTA might be due to several features such as biocompatibility, alkalinity, and sealing ability. Biocompatibility of MTA is revealed in several ex vivo and in vivo studies. [7] The pH value of MTA is 10.2 after mixing, which rises to 12.5 3 hours after mixing. MTA keeps its high pH for a long period of time (78 days) after its setting, which is thought to be attributable to its sustained CH release. [20] MTA has demonstrated superior seal as a root-end filling material, perforation repair material, and apical plug material in several studies. [7] On the other hand, comparable biocompatibility of CEM cement and MTA is demonstrated in several ex vivo[21] and in vivo[6] studies. CEM cement is an alkaline biomaterial (pH>10.5) [14] with sealing ability similar to MTA as a root-end filling material. [16]

The calcium ion released from MTA can induce a reaction with environmental phosphorus, which leads to hydroxyapatite crystal formation on the surface of MTA [15] and MTA-dentine interface. [22] It has been concluded that this bioactive reaction is responsible for biocompatibility, sealing ability, and cementogenic/dentinogenic properties of MTA. [15],[22] In addition, sealing ability of MTA, as a root-end filling material, increases when stored in phosphate buffer saline (PBS); a phenomenon which does not happen in normal saline. [23] However, CEM cement releases calcium and phosphorus ions from indigenous sources and, unlike MTA, has the ability of induction of hydroxyapatite crystal formation in the absence of environmental phosphorus. [15] This ability of CEM cement can partially explain its biocompatibility and hard tissue induction potential demonstrated in several studies. [17] Studies have revealed that the cementogenic properties of CEM cement are similar to MTA when used as a root-end filling material. [6] In this study, case 1 [Figure 1] represents a unique comparison between CEM cement and MTA apical plugs within 18 months. The same biological properties of these two biomaterials can partly explain the successful findings in this case.

The effects of CH premedication on sealing ability of MTA apical plugs have been studied before. Studies have revealed that CH pretreatment adversely affects the sealing ability of white MTA apical plugs. [24] Using scanning electron microscopic examination, one study has demonstrated that alternating irrigation with NaOCl and EDTA results in complete removal of CH from dentinal walls [25] Although there is no evidence of the effects of CH remnants on sealing ability of CEM cement apical plugs, we decided to use a promising method for removing CH; the same as Pace et al.[10]

In the presented case series, use of CEM cement as an artificial apical barrier showed successful clinical and radiographic outcomes in an average follow-up time of 14.5 months. The importance of long-term follow-up for apexification cases is emphasized in several studies. [3],[10] Thus, annual follow-up of these cases is recommended.

In conclusion, considering the advantages of CEM cement over MTA, especially its improved color, handling, and bactericidal effects, the authors believe that CEM cement might be an appropriate biomaterial to be used as an artificial apical barrier in open apex teeth. However, more clinical studies with longer follow ups and more samples are recommended.

   References Top

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3.Sheehy E, Roberts G. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J 1997;183:241-46.  Back to cited text no. 3
4.Andreasen J, Farik B, Munksgaard E. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 4
5.Shabahang S, Torabinejad M, Boyne P, Abedi H, McMillan P. A Comparative Study of Root-End Induction Using Osteogenic Protein-I, Calcium Hydroxide, and Mineral Trioxide Aggregate in Dogs. J Endod 1999;25:1-5.  Back to cited text no. 5
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9.El meligy O, Avery D. Comparison of Apexification With Mineral Trioxide Aggregate and Calcium Hydroxide. Pediatr Dent 2006;28:248-53.  Back to cited text no. 9
10.Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: Results from a case series. Int Endod J 2007;40:478-84.  Back to cited text no. 10
11.Witherspoon D, Small J, Regan J, Nunn M. Retrospective Analysis of Open Apex Teeth Obturated with Mineral Trioxide Aggregate. J Endod 2008;34:1171-6.  Back to cited text no. 11
12.Asgary S, Kamrani F. Antibacterial effects of five different root canal sealing materials. J Oral Sci 2008;50:469-74.  Back to cited text no. 12
13.Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: A Comprehensive Literature Review-Part III: Clinical Applications, Drawbacks, and Mechanism of Action. J Endod 2010;36:400-13.  Back to cited text no. 13
14.Asgary S, Shahabi S, Jafarzadeh T, Amini S, Kheirieh S. The Properties of a New Endodontic Material. J Endod 2008;34:990-3.  Back to cited text no. 14
15.Asgary S, Eghbal M, Parirokh M, Ghoddusi J. Effect of two storage solutions on surface topography of two root-end fillings. Aust Endod J 2009;35:147-52.  Back to cited text no. 15
16.Asgary S, Eghbal M, Parirokh M. Sealing ability of a novel endodontic cement as a root-end filling material. J Biomed Mater Res 2008;87A:706- 9.  Back to cited text no. 16
17.Tabarsi B, Parirokh M, Eghbal M, Haghdoost A, Torabzadeh H, Asgary S. A comparative study of dental pulp response to several pulpotomy agents. Int Endod J 2010;43:565-71.  Back to cited text no. 17
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19.Torabinejad M, Pitt Ford T, Mckendry D, Abedi H, Miller D, Kariyawasam S. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod 1997;23:225-8.  Back to cited text no. 19
20.Fridland M, Rosado R. MTA solubility: A long term study. J Endod 2005;31:376-9.  Back to cited text no. 20
21.Mozayeni M, Milani A, Marvasti L, Asgary S. Cytotoxicity of calcium enriched mixture cement compared with mineral trioxide aggregate and intermediate restorative material. Aust Endod J 2011;[In press].  Back to cited text no. 21
22.Sarkar N, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005;31:97-100.  Back to cited text no. 22
23.Parirokh M, Askarifard S, Mansouri S, Haghdoost A, Raoof M, Torabinejad M. Effect of phosphate buffer saline on coronal leakage of mineral trioxide aggregate. J Oral Sci 2009;51:187-91.  Back to cited text no. 23
24.Stefopoulos S, Tsatsas D, Kerezoudis N, Eliades G. Comparative in vitro study of the sealing efficiency of white vs grey ProRoot mineral trioxide aggregate formulas as apical barriers. Dent Traumatol 2008;24:207-13.  Back to cited text no. 24
25.Calt S, Serper. A Dentinal tubule penetration of root canal sealers after root canal dressing with calcium hydroxide. J Endod 1999;25:431- 3.  Back to cited text no. 25

Correspondence Address:
Ali Nosrat
Department of Endodontics, School of Dentistry, Rafsanjan University of Medical Sciences, Aliebneabitaleb Blvd., Rafsanjan, Kerman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.87218

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]

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