Comparative Evaluation of Mineral Trioxide Aggregate, Biodentine, and Calcium Hydroxide for Apical Closure in Nonvital Immature Teeth: A Randomized Controlled Trial

Young permanent teeth may often tend to lose vitality due to trauma or severe caries, resulting in incomplete root development and open apices.When the root canal flares widely toward the apex, it is referred to as a "blunderbuss" canal, often presenting a greater buccolingual divergence.The management of nonvital immature teeth is challenging due to thin root walls, a poor crownto-root ratio, and difficulties in achieving an apical stop. 1 Traditional endodontic techniques may be less effective, increasing the risk of root fractures. 2,3Advanced approaches such as apexification and regenerative endodontic therapies (RETs) are utilized to promote root maturation and apical closure. 4Clinically, an "open apex" is identified by an unusually wide apical foramen, often assessed by the minimum ISO file size that passes freely, typically ranging from ISO 40 to ISO 100.Nonvital immature permanent teeth can be managed through apexogenesis, which preserves pulp vitality for continued root development, or apexification, which promotes a calcified barrier in necrotic teeth with open apices. 5While calcium hydroxide has been widely used for apexification since 1960, its drawbacks, including prolonged treatment time, reinfection risk, and dentin weakening, have led to the adoption of single-visit apexification techniques. 6oot-end closure in immature necrotic teeth remains challenging due to the lack of an apical stop, difficulty in obturation, and the risk of overfilling or fractures. 7To address these limitations, biomaterials such as mineral trioxide aggregate (MTA) and Biodentine are now preferred for their superior sealing ability, biocompatibility, and ability to promote hard tissue formation.Mineral trioxide aggregate and Biodentine are widely used bioceramic materials in pediatric endodontics, especially for 1,