management of immature root with a necrotic pulp and apical periodontitis is a challenging task . obturation of the root canal is difficult because of lack of apical barrier for containing the root filling material . treatment of choice in such cases is the apexification procedure , i.e. , establishing an apical barrier . it has also been shown that the use of calcium hydroxide weakens the resistance of the dentin to fracture . in recent times , a bonded restoration can be placed without any delay , thus reducing the possibility of root fractures . the major disadvantage of mta is its manipulation due to which its placement in the wide apical area is difficult to achieve . a matrix can be used in apexification procedures against which mta can be placed and condensed . use of an apical matrix allows for the predictable placement and judicious use of this expensive material . several materials have been recommended to create a matrix including calcium sulfate , hydroxyapatite , resorbable collagen , and platelet - rich fibrin . in this case series , we are presenting two cases of mta apexification using polyglactin - based resorbable suture material as the apical matrix . a 16-year - old male patient reported with a chief complaint of discolored maxillary left central incisor . history revealed that the patient had suffered trauma 8 years back and undergone treatment in a private clinic . clinical examination revealed grayish discoloration of tooth 21 and attempted access preparation in the same tooth . periapical radiograph showed well - defined periapical radiolucency and wide open apex in relation to tooth 21 [ figure 1a ] . the final diagnosis was pulpal necrosis with chronic apical periodontitis in relation to tooth 21 . after discussing different treatment options with the patient 's parents , we opted to go for mta apexification with the use of an apical matrix . after rubber dam isolation , the tooth 21 was accessed and working length was established radiographically [ figure 1b ] . root canal was chemo - mechanically debrided with circumferential filing using the international organization for standardization ( iso ) 80 k - file ( dentsply maillefer , switzerland ) in conjunction with copious amount of 0.5% sodium hypochlorite ( shivam industries , india ) . a volume of 3 ml of 17% ethylenediaminetetraacetic acid ( edta ) solution ( prevest denpro , india ) was used for smear layer removal . apexcal medicament paste ( ivoclar vivadent ag schaan , liechtenstein ) was placed in the root canal , and access cavity was restored with temp paste ( pyrex exports , india ) . one week later , tooth was again accessed under rubber dam isolation , and copious amount of normal saline was used to remove any remnants of the calcium hydroxide medicament . one end of the suture material was modified to form a mesh , whereas the other end is left as such so that it could be used to adjust the position of apical matrix [ figure 1c ] . suture material was saturated with iodine - based radiographic contrast medium iopamidol ( bracco , italy ) for 10 min to render it radio - opaque [ figure 1d ] . the matrix was gently placed on working length with the help of preselected hand pluggers [ figure 1e ] , and its position was verified using radiographs [ figure 1f ] . any adjustment required was done using the hand pluggers or free end of the suture material . white mta angelus ( angelus , londrina , pr , brazil ) was mixed according to manufacturer 's instructions and using hand pluggers , gently condensed against the matrix to form 4 mm of apical plug [ figure 1 g ] . after placing a moist cotton pellet , next day , root canal was obturated using lateral condensation of gutta - percha ( meta biomed , korea ) and ah - plus root canal sealer ( dentsply detrey gmbh , germany ) , and tooth was restored with brilliant ng bonded resin restoration ( coltene / whaledent , switzerland ) [ figure 1h ] . the patient was recalled after 3 months for clinical and radiographic evaluation . at the follow - up visit , radiograph demonstrated the resorption of the apical matrix and healing periapical lesion [ figure 1i ] . ( a ) preoperative , ( b ) working length radiograph , ( c - f ) formation and placement of suture matrix , ( g ) mineral trioxide aggregate plug , ( h ) immediate postoperative , and ( i ) 3 month follow - up a 15-year - old female patient presented with the chief complaint of discomfort while chewing in front region of upper jaw . patient gave a history of traumatic incident 9 years back for which she had visited a private clinic . clinical examination revealed slightly grayish discolored tooth 21 and previously attempted treatment in the same tooth . intraoral periapical radiograph showed a well - defined periapical radiolucency surrounding the wide open apex of tooth 21 [ figure 2a ] . after rubber dam isolation , tooth was assessed and working length determined using the radiograph [ figure 2b ] . root canal debridement was done using iso 80 k - file ( dentsply maillefer , switzerland ) and 0.5% sodium hypochlorite ( shivam industries , india ) . a volume of 3 ml of 17% edta solution ( prevest denpro , india ) was used for smear layer removal . root canal was medicated with apexcal paste ( ivoclar vivadent ag schaan , liechtenstein ) for 1 week . after 1 week , 4 mm of mta plug was formed by condensing white mta angelus ( angelus , londrina , pr , brazil ) against vicryl suture ( johnson and johnson ltd . , next day , the tooth was obturated using laterally condensed gutta - percha ( meta biomed , korea ) and ah - plus ( dentsply detrey gmbh , germany ) [ figure 2e ] . bonded composite resin brilliant ng ( coltene / whaledent , switzerland ) was used for definitive restoration . at the 3-month follow - up visit , periapical radiograph revealed resorbed apical matrix and healing periapical lesion in relation to tooth 21 [ figure 2f ] . ( a ) preoperative , ( b ) working length determination , ( c ) suture matrix in place , ( d ) mineral trioxide aggregate plug , ( e ) immediate postoperative , and ( f ) 3 month follow - up a 16-year - old male patient reported with a chief complaint of discolored maxillary left central incisor . history revealed that the patient had suffered trauma 8 years back and undergone treatment in a private clinic . clinical examination revealed grayish discoloration of tooth 21 and attempted access preparation in the same tooth . periapical radiograph showed well - defined periapical radiolucency and wide open apex in relation to tooth 21 [ figure 1a ] . the final diagnosis was pulpal necrosis with chronic apical periodontitis in relation to tooth 21 . after discussing different treatment options with the patient 's parents , we opted to go for mta apexification with the use of an apical matrix . after rubber dam isolation , the tooth 21 was accessed and working length was established radiographically [ figure 1b ] . root canal was chemo - mechanically debrided with circumferential filing using the international organization for standardization ( iso ) 80 k - file ( dentsply maillefer , switzerland ) in conjunction with copious amount of 0.5% sodium hypochlorite ( shivam industries , india ) . a volume of 3 ml of 17% ethylenediaminetetraacetic acid ( edta ) solution ( prevest denpro , india ) was used for smear layer removal . apexcal medicament paste ( ivoclar vivadent ag schaan , liechtenstein ) was placed in the root canal , and access cavity was restored with temp paste ( pyrex exports , india ) . one week later , tooth was again accessed under rubber dam isolation , and copious amount of normal saline was used to remove any remnants of the calcium hydroxide medicament . one end of the suture material was modified to form a mesh , whereas the other end is left as such so that it could be used to adjust the position of apical matrix [ figure 1c ] . suture material was saturated with iodine - based radiographic contrast medium iopamidol ( bracco , italy ) for 10 min to render it radio - opaque [ figure 1d ] . the matrix was gently placed on working length with the help of preselected hand pluggers [ figure 1e ] , and its position was verified using radiographs [ figure 1f ] . any adjustment required was done using the hand pluggers or free end of the suture material . white mta angelus ( angelus , londrina , pr , brazil ) was mixed according to manufacturer 's instructions and using hand pluggers , gently condensed against the matrix to form 4 mm of apical plug [ figure 1 g ] . after placing a moist cotton pellet , next day , root canal was obturated using lateral condensation of gutta - percha ( meta biomed , korea ) and ah - plus root canal sealer ( dentsply detrey gmbh , germany ) , and tooth was restored with brilliant ng bonded resin restoration ( coltene / whaledent , switzerland ) [ figure 1h ] . the patient was recalled after 3 months for clinical and radiographic evaluation . at the follow - up visit , radiograph demonstrated the resorption of the apical matrix and healing periapical lesion [ figure 1i ] . ( a ) preoperative , ( b ) working length radiograph , ( c - f ) formation and placement of suture matrix , ( g ) mineral trioxide aggregate plug , ( h ) immediate postoperative , and ( i ) 3 month follow - up a 15-year - old female patient presented with the chief complaint of discomfort while chewing in front region of upper jaw . patient gave a history of traumatic incident 9 years back for which she had visited a private clinic . clinical examination revealed slightly grayish discolored tooth 21 and previously attempted treatment in the same tooth . intraoral periapical radiograph showed a well - defined periapical radiolucency surrounding the wide open apex of tooth 21 [ figure 2a ] . after rubber dam isolation , tooth was assessed and working length determined using the radiograph [ figure 2b ] . root canal debridement was done using iso 80 k - file ( dentsply maillefer , switzerland ) and 0.5% sodium hypochlorite ( shivam industries , india ) . a volume of 3 ml of 17% edta solution ( prevest denpro , india ) was used for smear layer removal . root canal was medicated with apexcal paste ( ivoclar vivadent ag schaan , liechtenstein ) for 1 week . after 1 week , 4 mm of mta plug was formed by condensing white mta angelus ( angelus , londrina , pr , brazil ) against vicryl suture ( johnson and johnson ltd . , next day , the tooth was obturated using laterally condensed gutta - percha ( meta biomed , korea ) and ah - plus ( dentsply detrey gmbh , germany ) [ figure 2e ] . bonded composite resin brilliant ng ( coltene / whaledent , switzerland ) was used for definitive restoration . at the 3-month follow - up visit , periapical radiograph revealed resorbed apical matrix and healing periapical lesion in relation to tooth 21 [ figure 2f ] . ( a ) preoperative , ( b ) working length determination , ( c ) suture matrix in place , ( d ) mineral trioxide aggregate plug , ( e ) immediate postoperative , and ( f ) 3 month follow - up apexification is defined as a method to induce a calcified barrier in a root with an open apex or the continued apical development of an incomplete root in teeth with necrotic pulp . this chemical has several disadvantages such as difficulty of the patient 's recall management and delay in the treatment . furthermore , there is a risk of tooth fracture after dressing with calcium hydroxide for extended periods . the most promising alternative to calcium hydroxide is mta . the advantages of this material are ( i ) reduction in treatment time , ( ii ) immediate restoration of the tooth , ( iii ) no adverse effect on the mechanical properties of root dentin . in a prospective study , placement of the material in a wide open area is a challenging task and also there is a risk of extruding this expensive material into periapical tissues . lemon advocated the use of a matrix when the diameter of the perforation is larger than 1 mm to prevent the extrusion of sealing material . similarly , a matrix can be used for the predictable placement of mta in apexification procedures . various materials have been advocated to be used as a matrix , for example , calcium sulfate , hydroxyapatite , collagen , platelet - rich fibrin . the common limitation shared by these materials is that once placed their position ca n't be adjusted as required . vicryl is a synthetic absorbable suture material composed of 90% polyglycolic acid and 10% polylactic acid . however , the suture material lacks the radio - opacity which makes it difficult to be viewed in the radiographs . iopamidol was used in our technique to impart radio - opacity to the suture material . it is a water soluble nonionic iodine - based contrast medium which is routinely used for angiography , arteriography , contrast - enhanced computed tomography , and urography . however , a proper history of the patient and sensitivity test should be done before using it . in our technique , one end of the suture material was used for the matrix formation , whereas other end was kept outside the tooth so that the placement of the matrix can be adjusted as required . after the matrix was placed at the desired position , the free end of the suture was cutoff and then mta was condensed against it . the apical matrix mentioned here in our study is cost - effective , easily available , and provides for adjustment of its position . resorbable suture with a contrast agent may be used as a matrix for mta placement but properly designed clinical trials with long - term follow - up are mandatory to support this novel technique as there is no evidence of such procedure available in the literature presently . research concentrating on the effect of suture material and contrast media on the healing kinetics can further through some light on this technique .
the treatment of choice for necrotic teeth with immature root is apexification , which is induction of apical closure to produce more favorable conditions for conventional root canal filling . the most commonly advocated medicament is calcium hydroxide although recently considerable interest has been expressed in the use of mineral trioxide aggregate ( mta ) . 
 mta offers the option of a two - visit apexification procedure so that the fragile tooth can be restored immediately . 
 however , difficulty in placing the material in the wide apical area requires the use of an apical matrix . 
 materials such as collagen , calcium sulfate , and hydroxyapatite have been used for this purpose . 
 this article describes the use of resorbable suture material to form the apical matrix which offers many advantages over the contemporary materials .