Apical Barrier Formation Research Articles

Management Strategies for Immature Teeth with Pulp Necrosis: An Umbrella Review of Systematic Reviews.

This review evaluates the effectiveness of treatment modalities for immature teeth with pulp necrosis, focusing on calcium hydroxide (CH) and mineral trioxide aggregate (MTA) apexification, as well as regenerative endodontic treatments (RETs). Recent advancements and clinical outcomes are highlighted. A comprehensive search of MEDLINE (PubMed), Embase, Cochrane Library, Scopus, and grey literature was conducted from inception to July 2024. Systematic reviews and meta-analyses (SR/MAs) assessing apexification and RET outcomes in immature teeth with pulp necrosis were included. Studies were selected based on predefined criteria, and data on study design, interventions, and outcomes were extracted. Methodological quality was evaluated using the AMSTAR-2 tool. 31 SR/MAs were included. The quality ranged from critically low to low, except one rated as high. MTA apexification was more effective than CH for faster apical barrier formation, though overall success rates were similar. MTA is preferred for its efficiency, but standardized protocols are needed, and tooth discoloration was noted as a potential complication. RET generally outperforms apexification in root maturation, with platelet concentrates like platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) showing promising results; PRP was associated with greater root length, while PRF showed superior apical healing. Variability in RET outcomes was noted due to the lack of standardized protocols. Comparative studies of RET versus apexification showed no significant differences in survival or overall success rates. RET often provides better apical closure and root development, though results vary. Both approaches are viable, but more research with standardized protocols and larger samples is needed to establish definitive clinical advantages. MTA apexification and RET are viable alternatives to CH apexification, with RET showing greater potential for root development and apical healing. Future research should focus on developing standardized protocols and uniform RET guidelines, and evaluating long-term outcomes to establish efficacy and safety.

The Differences of the Calcium Hydroxide and the Mineral Trioxide Aggregate in the Apical Closure of Immature, Non-Vital Permanent Teeth

When an immature tooth comes into contact with trauma, the dental pulp in the developing tooth can die, which can cause the absence of root and apical closure. Apexification is a technique used to repair these abnormalities. This method allows us to promote the growth of a hardened root end block. MTA and Ca (OH)2 are two materials that can be used in this process. Either MTA or calcium hydroxide have a good chance of producing positive clinical results. MTA is favored over calcium hydroxide for its significantly shorter time for apical barrier formation, low solubility, easy approach, and ability to prevent root fracture, while calcium hydroxide is preferred over MTA for root length elongation in open apex teeth. The limitations of calcium hydroxide include the fact that it takes more time and multiple visits to form the root-end barrier, is more prone to fracture, and has the potential for reinfection. The goal of this review is to collect revisions on inducing root formation and synthetic barrier approaches and consider the advantages and disadvantages of calcium hydroxide versus MTA.

PARTICULAR FEATURES OF ROOT CANAL FILLING IN TEETH WITH RESORBED APICAL OPENING NEAR THE MANDIBULAR CANAL

When filling root canals of teeth with apical resorption near the mandibular canal, there is a risk that the material will go beyond the apex into the region of mandibular canal, which can lead to serious damage to the innervation of this area. In most cases, modern approaches and technologies in endodontics allow to achieve the formation of dentinal plug in the resorption area, thus minimizing the risk of traumatization of the patient.
 Background. Improving efficiency of endodontic treatment of teeth with apical resorption in the region of mandibular canal.
 Materials and methods. 56 patients aged between 18 and 45 years were examined. All patients had clinical signs of mandibular endodontic treatment failure with a dark radiolucent focus in the region of the apex, which bordered the mandibular canal. Radiological indicators and quality of obturation were assessed on the basis of CBCT, the presence of dentinal bridge was assessed visually using a dental microscope and an apical hermetic test. The results were evaluated after 4, 6, 12, and 24 months.
 Results. After 16 weeks of treatment, more than 70% of apical barrier formation occurred in groups 1 and 2, which allowed us to perform a quality permanent obturation without excessive risks of complications.
 Conclusion. The use of a dental microscope in conjunction with modern endodontic techniques in the treatment of teeth with apical resorption can significantly reduce the treatment time, thereby improving the quality of treatment of patients with this pathology.

NON-SURGICAL MANAGEMENT OF FLOOR PERFORATION OF MAXILLARY FIRST MOLAR USING MTA: A CASE REPORT

In endodontic practice one of the most common iatrogenic errors is furcation perforation. The purpose of treating furcal perforation is to seal the articial communication between the endodontic space and the periradicular tissue to prevent alveolar bone resorption and damage to the periodontal ligament. Endodontic repair material should seal the pathways of communication between the root canal system and its surrounding tissues. In addition, it should be nontoxic, noncarcinogenic, nongenotoxic, biocompatible, insoluble in tissue uids, and dimensionally stable. Because existing materials did not have these ''ideal'' characteristics, mineral trioxide aggregate (MTA) was developed and recommended for pulp capping, pulpotomy, apical barrier formation in teeth with necrotic pulps and open apex, repair of root perforations, rootend lling, and root canal lling.

“BIODENTINE” THE DENTINE IN A CAPSULE AS AN APICAL BARRIER IN TRAUMATIZED MAXILLARY CENTRAL INCISOR WITH TWO YEARS FOLLOW UP.

Immature teeth are difcult to manage with conventional endodontic treatments and thus it becomes very challenging for clinicians. This case report describes an apexication with Biodentine in a maxillary left central incisor. The tooth became necrotic after the traumatic injury. According to the treatment procedure root canals were chemo-mechanically prepared, medicated with triple antibiotic paste followed by Biodentine plug to stimulate hard tissue apical barrier formation. Follow-up clinical and radiographic examinations were done after 1st quarter, 2nd quarter, 4th quarter and 2 years respectively. After two years follow-up the tooth was completely asymptomatic as well as resolution of periapical radiolucency was seen. Biodentine can be considered as basic, simple, biologically active, more limited setting time, improved mechanical properties and worthy cost. Therefore, it is a promising approach to other methods of an apexication.

Single Visit Apexification Using MTA: A Case Report

Trauma to the dentition during the period of root formation may cause incomplete development of root resulting in open apex. In order to eliminate infection from root canal endodontic treatment is a tooth-saving treatment modality. The absence of a natural apical constriction in a nonvital permanent tooth makes endodontic treatment a challenge. Therefore, it is necessary to induce or create an apical barrier against, which the obturating material can be condensed. Traditionally, calcium hydroxide is considered as the gold standard to induce apexification. Due to certain drawbacks such as very long treatment period, possibility of tooth fracture, and incomplete apical barrier formation, it is being replaced by materials, which have a more predictable outcome like mineral trioxide aggregate (MTA). One-step apexification with MTA reduces the treatment time when compared with traditional calcium hydroxide apexification, which requires an average time of 12–19 months. Also, MTA has various other superior properties compared to calcium hydroxide that are discussed below in detail along with successful treatment of an immature permanent tooth with open apex wherein MTA was used for one-step apexification.

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.

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.

English

Traumatic injuries to an immature permanent tooth may result in cessation of dentin deposition and root maturation. Novel revascularisation endodontic procedure (REP) has been considered as an option for treatment of immature teeth with damaged pulp tissue. The continuous development of the root and the root canal has been recognised as a major advantage of this technique over traditional apexification approach. Traditional apexification procedures may resolve pathology but have not been able to prove tooth survival due to absence of continued root development and risk of root fracture. A successful REP results in resolution of signs and symptoms of pathology, radiographic signs of healing, proof of continued root development as well as presence of pulp vitality due to the regeneration of pulp tissue in the root canal. Currently, repair rather than true regeneration of the ‘pulp-dentine complex’ is achieved and further root maturation is variable. According to Glossary of Endodontic terms published by American Association of Endodontists, REP’s are biologically based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as cells of the pulp-dentin complex.1,2 Apexification treatment has been a routine procedure to treat and preserve such teeth for many decades.3 Apexification is the process by which a suitable environment is created within the root canal and periapical tissue to allow for the formation of a calcific barrier across the open apex. Calcium hydroxide [Ca(OH)2] has been the material of choice for apexification as Frank reported its capacity to induce physiological closure of immature pulpless teeth in 1966.4 However, this technique has several disadvantages, including the unpredictability of apical barrier formation and the long duration of treatment, which often requires multiple visits.5 A retrospective study by Jeruphuaan et al.6 has shown a higher survival rate with regenerative endodontic treatment when compared to both mineral trioxide aggregate (MTA) and Ca(OH)2 apexification. The first evidence of regeneration of dental tissues was in 1932 by G.L. Feldman, who showed evidence of regeneration of dental pulp under certain optimal biological conditions.7 In 1971, a pioneer study in regenerative endodontics conducted by Nygaard-Ostby concluded that bleeding induced within a vital or necrotic canal led to resolution of signs and symptoms of necrotic cases and in certain cases, apical closure.8 According to Windley et al. (2005), the successful revascularisation of immature teeth with apical periodontitis is mainly dependent upon: 1. Canal disinfection 2. Scaffold placement in the canal for the growing tissues 3. Bacteria-tight sealing of the access opening.9 The purpose of this case report is to illustrate the outcome of a revascularisation endodontic procedure in a non-vital immature young permanent central incisor.

Mineral trioxide aggregate apical plug and biodynamic intraradicular restoration for rehabilitation of fractured anterior central incisor with open apex: A case report with 1-year follow-up

Restoration of teeth with the extensive loss of coronal structure requires post and core for its rehabilitation. In this context, Biological post prepared from natural tooth offers a feasible and promising treatment option to restore the tooth with a “biologic restoration”. Properties of biologic post similar to dentin make it a good alternative in comparison to conventional post systems. Along with post and core if teeth have open apices, it needs a more rationalized approach. It becomes necessary to create an apical barrier for root canal filling. For this purpose, MTA has gained enough popularity thanks to its biomimetic properties and good sealing ability. This case report discusses the successful management of fractured anterior teeth having an open apex. Treatment was done under three phases- Formation of apical barrier with MTA apical plug causing root formation, followed by thermoplasticised obturation and final rehabilitation with the placement of biological dentin post. Freshly extracted maxillary canine was trimmed and shaped to form biological post. This customized biological post was sterilized and cemented. One year of follow up showed successful structural functioning, performance and esthetics of the tooth along with apical root formation.

Treatment of immature teeth with nonvital pulps in adults: a prospective comparative clinical study comparingMTAwith Ca(OH)2

To evaluate and compare the influence of various predictors on outcomes of apexification using either mineral trioxide aggregate (MTA) or calcium hydroxide (CH) in permanent immature anterior teeth with necrotic pulps and periapical lesions of adults. Ninety immature teeth with necrotic pulps and periapical lesions on adult patients (aged 18-40years) were treated with MTA (45 teeth) or CH (45 teeth) between 2015 and 2018. Patients of both groups were recalled for follow-up examinations after the first intervention at 1,3,6 and 12months for the first year, every 6months for the second year and every year thereafter until the end of the study (median 32.3months). The treatment outcome based on clinical and radiographic criteria was assessed by calibrated examiners and dichotomized as 'healed+healing' or 'not healed'. The age, gender, stage of root development, preoperative signs and symptoms of apical periodontitis and size of periapical lesion were recorded. The cumulative success proportion and mean time were analysed with the Kaplan-Meier test. The generalized logrank statistic was used to describe prognostic clinical variables. Fisher's exact test was applied for the evaluation of the healing rates. Thirty-nine of the 45 teeth treated with MTA were available for recall. Of these, 29 teeth (74%) revealed calcific apical barrier formation with complete resolution of periapical lesions, 7 teeth (18%) were healing, and 3 teeth (8%) had persistent disease. Thirty-four of the 45 teeth in the CH group were available for recall. Of these, 27 teeth (79%) had complete healing of periapical lesions and had calcific barrier formation, 4 teeth (12%) were healing, and the remaining 3 teeth (9%) had not healed. The survival rate of teeth treated with MTA was similar to the survival rates observed in teeth treated with CH (90% and 91%, respectively, P>0.05). The generalized logrank statistic revealed that the cumulative success rate of both materials was not significantly different (P>0.05). None of the tested predictors had an influence on the treatment outcomes of teeth in both groups (P>0.05). Apexification with both MTA and CH was associated with similar treatment outcomes. MTA may be proposed as a material for apexification treatment in immature teeth of adult patients due to the shorter treatment time associated with its use.

Management of non-vital anterior tooth with open apex by MTA apical plug -A case report.

A 15 year old boy was presented with pain in his upper anterior teeth. On clinical examination both the maxillary central incisor revealed slight discoloration and fracture of the crown. Radiographic evaluation revealed open apex of the left central incisor and apex of the right central incisor was fully developed. Apexification with MTA apical plug was carried out in left central incisor and conventional root canal treatment was done in right central incisor. In two months follow up both the tooth were clinically and radiographically asymptomatic and the healing of the apical area of the left central incisor was continued. These finding suggests that MTA can induce formation of apical barrier in the case of non-vital tooth with open apex.
 Update Dent. Coll. j: 2019; 9 (1): 42-45

Endodontic management of blunderbuss canal with open apex and Ellis Class IV fracture using mineral trioxide aggregate and compo-post

The permanent teeth with open apex, blunderbuss canal, and Ellis Class IV fracture are difficult to treat as a traditional root canal procedure. Apexification is induction of apical closure, the treatment of choice for necrotic teeth with immature or resorbed root. Mineral trioxide aggregate (MTA) has been proposed as a potential material for formation of hard tissue apical barrier. Use of anatomical post results in better prognosis of the present case. This case report presents endodontic management of a fractured maxillary right central incisor with apexification and compo-post to support weak canal and to provide tooth structure. A 21-year-old male patient came to the Department of Conservative Dentistry and Endodontics, Jaipur Dental College and Hospital, Jaipur, with the chief complaint of broken upper front tooth due to accidental fall (6–7 years). Dental history of discontinued endodontic treatment 1-year back was observed. Treatment includes two phases – endodontic phase and re-construction phase followed by full-crown porcelain-fused metal prosthesis. This case report discussed an improved option of application of chairside customized made fiber posts are preferred as they stimulate the root canal anatomy, provides increased retention and adaptation and also esthetics.

Properties of a novel polydimethylsiloxane endodontic sealer

AimThe study aims to assess sealing ability of a novel polydimethylsiloxane-based sealer in simulated wet root canals with wide apex, ion release (calcium and pH) and examine samples using ESEM. Materials and methodsGuttaFlow bioseal, GuttaFlow2, and RoekoSeal Automix (Coltène/Whaledent Inc.) were tested.Roots were prepared to obtain an apical diameter #40 using nickel–titanium rotary files (HyFlex CM, Coltène/Whaledent Inc.), each root was filled with single cone technique and immediately inserted into a simulated socket (filled with 0.02mL of simulated body fluid) to reproduce the clinical conditions of a wet apical environment. Sealing ability was evaluated as fluid filtration rate at 1, 14, 28 days, and 10 months.After 28 days in simulated body fluid, apices were examined using an Environmental Scanning Electron Microscope (ESEM).Alkalinizing activity and calcium release was evaluated after 3h and 1, 7, 14, and 28 days.Data were analysed using Kolmogorov–Smirnov test (p<0.05). ResultsFluid filtration analysis showed no significant difference within materials. Significant difference was observed between 10 months observation and other time frames (p<0.05) of the same group.GuttaFlow bioseal showed a significantly higher alkalinising activity (p<0.05). Calcium release ability showed no significant difference through time, however significant differences were observed among materials (p<0.05).Observation using ESEM at 28 days after root obturation showed the presence of the materials sealing the wide apical foramen. ConclusionsAll materials showed satisfying sealing ability. However due to low calcium release, their use is not suggested when apical barrier formation and periapical bone regeneration are needed.

A case report : Apical barrier formation at the apical area after extended-period application of calcium hydroxide

A case report : Apical barrier formation at the apical area after extended-period application of calcium hydroxide

Comparison of the Potential Discoloration Effect of Bioaggregate, Biodentine, and White Mineral Trioxide Aggregate on Bovine Teeth: In Vitro Research

IntroductionTricalcium silicate cements can be used for pulp capping, pulpotomies, apical barrier formation in teeth with open apices, repair of root perforations, regenerative endodontics, and root canal filling. The aim of this study was to evaluate and compare the discoloration potential of 3 different tricalcium cements using a bovine tooth model. MethodsForty bovine anterior teeth have been used for the study. Crowns separated from the roots were randomly divided into 4 groups: the BioAggregate (IBC, Vancouver, Canada) group, the Biodentine (Septodont, Saint Maur des Fosses, France) group, the mineral trioxide aggregate Angelus (Angelus, Londrina, PR, Brazil) group, and the only blood group. Materials have been placed to the standardized cavities on the lingual surfaces of the crowns, and their contact with blood has been provided. The color values of the samples were measured with a digital tooth shade determinator (VITA Easyshade; VITA Zahnfabrik, Bad Sackingen, Germany) before the placement of the materials, after the placement of the materials, in the 24th hour, in the first week, in the first month, in the third month, and in the first year. The mean value of all groups was compared using the Tukey multiple comparison test (α = 0.05). ResultsAll groups displayed increasing discoloration during a period of the first year. The “only blood group” showed the highest color change values, and it was followed as BioAggregate, mineral trioxide aggregate Angelus, and Biodentine, respectively. Statistically significant differences were found for Biodentine when compared with the only blood and BioAggregate groups (P < .05). ConclusionsConsidering the results of the study, Biodentine is found to have the least discoloration potential among the tested materials.

Endodontie in der unreifen bleibenden Dentition — Maßnahmen zur Vitalerhaltung, Apexifikation und Regeneration der Pulpa

Maintaining pulp vitality is the primary goal when treating permanent, immature teeth. Vital pulp therapy allows physiologic completion of root growth (apexogenesis), a favourable crown-root ratio, continuing secondary dentin deposition and thus a better prognosis for the affected tooth. Direct pulp capping is indicated in case of an accidental or trauma based exposure of a healthy or reversibly inflamed pulp. The success rate is high, being in a range between 80–90 %. The most important factor for the success of direct pulp capping is preventing bacterial invasion. With respect to the capping material, Calciumhydroxide (Ca(OH)2) was considered as being the gold standard. Recent studies showed that using MTA as a capping material permitted significantly higher success rates.Pulpotomy includes the excision of reversibly inflamed coronal pulp tissue, leaving the root pulp in a vital condition. According to the extent of removed tissue, a partial or total (cervical) pulptomy is possible. The induction of a hard substance barrier at the interface of the resected tissue and the capping material is the primary intention, thus allowing the remaining pulp to stay vital. Success rates vary between 90–100 %. Removal of the coronal pulp tissue is accomplished by rotary instrumentation in case of partial pulpotomy or manually by cutting instruments in case of cervical pulpotomy. The resected pulp surface is capped using Ca(OH)2 or MTA.In case of irreversible pulp inflammation, infected or necrotic pulp, vital pulp therapy is not indicated. Conventional root canal therapy is difficult in case of immature, permanent teeth. Therapeutic alternatives are apexification by the induction of an apical hard substance barrier using Ca(OH)2 or the establishment of an apical MTA-plug. Success rates are in a range of 77–98 %. Cleaning and chemical disinfection of the root canal system are crucial for the success of apexification therapy. Time required for Ca(OH)2 induced apical barrier formation varies between 3–24 months. Long-term Ca(OH)2 dressing can cause root fractures. Advantages of apexification by MTA include the immediate, predictable apical barrier formation, thus reducing treatment time.Regenerative endodontic therapy aims at re-establishing functional pulp tissue in case of necrotic or infected pulp, thus allowing continued root development. Biological principles of pulp regeneration are based on the triade of tissue engineering with stem cells, growth factors and scaffolds. Clinical regenerative therapy includes disinfection of the root canal system, induction of an apical bleeding into the root canal, subsequent formation of functional pulp tissue and bacteria-tight seal of the access cavity. With today’s clinical protocols a regeneration of true pulp tissue can only partly be achieved. Nevertheless, numerous studies describe healing of apical pathosis, continued root development and positive reaction to sensitivity tests after regenerative endodontic therapy.

Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis.

Calcium hydroxide and mineral trioxide aggregate (MTA) are used for inducing a calcific barrier at an open tooth root (apexification). The purpose of this study was to compare the efficacy of calcium hydroxide and MTA for apexification of immature permanent teeth. Medline, Cochrane, EMBASE, and Google Scholar were searched until November 24, 2015, using the keywords apexification, permanent teeth, MTA, and calcium hydroxide. Of 216 studies identified, four studies were included. There were no differences in the clinical success rate [pooled odds ratio (OR)=3.03, 95% confidence interval (CI): 0.42-21.72, p=0.271], radiographic success rate (pooled OR=4.30, 95% CI: 0.45-41.36, p=0.206), or apical barrier formation rate (pooled OR=1.71, 95% CI: 0.59-4.96, p=0.322) between calcium hydroxide and MTA groups. The time required for apical barrier formation was significantly less in the MTA group (pooled difference in means=-3.58, 95% CI: from -4.91 to -2.25, p<0.001). While both materials provide similar success rates, the shorter treatment time with MTA may translate into higher overall success rates because of better patient compliance.

Clinical and radiographic assessment of mineral trioxide aggregate and calcium hydroxide as apexification agents in traumatized young permanent anterior teeth: A comparative study

To evaluate and compare the efficacy of mineral trioxide aggregate (MTA) and traditionally used calcium hydroxide (Ca(OH)2) in inducing root end formation of immature roots of traumatized young permanent anterior teeth. The study was carried out on 22 nonvital, immature permanent maxillary incisors. Samples were allotted into two groups - Group I MTA and Group II Ca(OH)2 Success rate was determined based upon the time duration required for apical barrier formation. The canals were obturated using gutta-percha points in MTA group, after 24 h, whereas in Ca(OH)2 group, obturation was carried out after radiographic confirmation of the apical barrier. The clinical and radiographic evaluation was carried out at a follow-up periods of 3, 6, and 9 months and statistical analysis was carried out by SPSS version 15.0 statistical analysis software (Chi-square test and fisher exact test). In MTA Group, barrier formation was observed in 90.90% of the patients after 9 months whereas in Ca(OH)2 Group, the same was observed in 81.81%. The mean time required for barrier formation in MTA group was 4.90 months and 5.33 months in Ca(OH)2 group. MTA and Ca(OH)2, as medicaments for apexification, were comparable in terms of the evaluation parameters. However, MTA was beneficial in terms of immediate obturation of immature roots with wide open apices.

Retreatment of endodontically failed tooth with wide-open apex using platelet rich fibrin membrane as matrix and an apical plug of Biodentine™

AbstractThe primary reason for an endodontic failure is the persistence or regrowth of bacteria within the root canal system, and such cases require retreatment. The tooth root development and closure of its apex occurs till 3 years after the eruption. Traumatic injuries during this development period result in endodontic complications. While dealing with a tooth, with an open apex the prime objective was eliminating bacteria from the root canal system with minimum irritation to the periapical tissues and induction of apical closure to produce favorable conditions and to confine the root canal filling within the canal space. Traditionally as supported by literature multiple dressings of calcium hydroxide medicament were advocated to induce apical barrier formation followed by an evolution of the apical artificial barrier technique where the mineral trioxide aggregate (MTA) was used. Recently introduced Biodentine™ is similar to MTA with its basic composition, which can be used as its substitute. The main difficulty associated while treating teeth with wide-open apices are preventing the overfilling of the restorative materials that serve as an artificial barrier. Use of a matrix overcomes this challenge. Platelet-rich fibrin (PRF) a matrix of autologous fibrin, embedded with a large quantity of platelet and leukocyte cytokines during centrifugation can be successfully used as an apical membrane. The present case, reports a novel procedure of apexification of endodontically failed central incisor with open apex using PRF as apical membrane and Biodentine™.

Vertical root fracture associated with prolonged use of calcium hydroxide during apexification. A case report

Apexification is a procedure performed in young permanent teeth seeking an apical closure and root elongation, when the epithelial sheath of Hertwig unmeet irreversibly affected. The aim of this article is to relate to vertical root fracture as a complication during apexification to work for long time with calcium hydroxide. Female patient, student, 9, attended at the Faculty of Dentistry at the University Andres Bello campus Concepcion, presented severe and spontaneous pain, pressure and swelling of the left cheek. Clinically fund lobby edematous around lower left first molar (3.6) and purulent content. Radiographically was observed apical lesions and the presence of open apices. The diagnosis was Pulp necrosis and Acute Apical Abscess, was trepanned for intracanal drainage and oral antibiotic medication was prescribed, before being sent to the specialty of endodontics, where the selected treatment was Apexification with calcium hydroxide until it observed the formation of apical barrier. Upon completion of the objective, a vertical root fracture was discovered, confirming that this use should not be prolonged because processes of dehydration leads to weakening of the walls and therefore of the tooth.