Calcium Hydroxide Apexification Research Articles

Regenerative endodontic treatment and traumatic dental injuries.

Pulp necrosis is the most common complication following dental trauma and is often associated with apical periodontitis. The management of these teeth is challenging in terms of large root canals, open apices, thin dentinal walls, and short roots. Over decades the conventional treatment for these teeth was calcium hydroxide apexification, a time-consuming procedure despite high success rates. Subsequently after the introduction of mineral trioxide aggregate and hydraulic calcium silicate materials single visit apical plug procedures became increasingly practiced with comparable success rates to the conventional apexification. The search continued afterward for a clinical procedure that may stimulate further root development and apical closure to avoid the long-term complication of root fracture after apexification. Regenerative procedures using stem cells derived from the apical papilla and blood clots as scaffolds were then introduced for the management of immature teeth, with variable protocols and success rates. This review will cover the evidence available and current position of regenerative endodontic procedures in traumatized immature teeth with apical periodontitis, in terms of clinical protocols, outcome, and potential prognostic factors.

Outcomes of apexification in immature traumatised necrotic teeth and risk factors for premature tooth loss: A 20-year longitudinal study.

To evaluate the long-term survival of immature traumatized incisors with pulp necrosis and apical periodontitis after endodontic treatment with two apexification techniques (calcium hydroxide apexification and MTA-apical plug) and to identify major factors affecting the survival of these teeth. Records of 2400 children and adolescents were screened for presence of traumatic dental injuries to immature incisors where endodontic treatment with the two apexification techniques was performed during January 2003 and December 2022, compared to a control group of mature teeth treated with conventional endodontic techniques. The studied variables were age; sex; apexification technique, presence of luxation and hard tissue injuries; preoperative root development stage (RDS), preoperative and postoperative periapical index (PAI), the time-point for tooth loss, and overall survival time in years. Kaplan-Meier estimates were used to graphically present the survival functions and Cox proportional hazard model to calculate hazard ratios (HR, 95% CI). The median survival time was 10 years for calcium hydroxide apexification, 16.1 for MTA-apexification, for luxation injuries other than intrusions and avulsions 15.5 years, for intrusions 12.5 years and for avulsions 6.8 years. The variables with significant negative impact on tooth survival were calcium hydroxide apexification, avulsion and postoperative PAI 3-5. No significant relationships were found for the variables MTA apexification, concussion; subluxation; lateral luxation; extrusion, intrusion, hard tissue injuries, preoperative RDS and PAI scores and postoperative PAI 1-2. After adjustment, the risk for premature tooth loss was 13.5 times higher in calcium hydroxide apexification, approximately 2 to 4 times higher in PAI 3-5, and 5.6 times higher in avulsions. Calcium hydroxide apexification, avulsion, and postoperative PAI 3-5 were identified as prognostic variables with significant negative impact on the risk for premature tooth loss.

Management and outcomes of apexification procedures in traumatized immature teeth

The oral health of pediatric patients is a significant concern, with dental injuries being a common occurrence in this vulnerable population. Traumatic injuries to immature teeth, characterized by incomplete root development and open apices, present unique challenges that require specialized clinical management. Understanding the anatomy and developmental characteristics of immature teeth is crucial for effective management. Historically, apexification procedures relied on calcium hydroxide, but advancements in dental pulp biology led to regenerative endodontics, a transformative approach that preserves pulp vitality while promoting apical closure. Contemporary techniques include calcium hydroxide apexification, mineral trioxide aggregate (MTA) apexification, and regenerative endodontics, each with its advantages and considerations. Patient selection, radiographic assessment, choice of biocompatible materials, and post-operative care are key components of contemporary apexification protocols. Advanced imaging modalities like cone-beam computed tomography (CBCT) enhance diagnostic accuracy. Challenges in apexification procedures include infection control, the risk of root fractures, and dealing with resorption phenomena. Moreover, pediatric patients require special attention to address compliance and psychological factors. The long-term outcomes of apexification procedures extend beyond clinical and radiographic parameters and encompass growth and development as well as the quality of life of pediatric patients. Preservation of arch integrity, prevention of malocclusion, and maintaining oral health-related quality of life are vital considerations.

Treatment outcomes of immature permanent necrotic evaginated teeth: A retrospective study comparing regenerative endodontic procedures with apexification.

Few studies have compared the outcomes of regenerative endodontic procedures (REPs) and calcium hydroxide apexification focusing on necrotic teeth with dens evaginatus. To qualitatively and quantitatively compare the treatment outcomes of REPs and calcium hydroxide apexification in teeth with dens evaginatus. Immature permanent necrotic evaginated teeth treated with REPs or calcium hydroxide apexification for a follow-up period of at least 12 months were included. Tooth success and survival rates were analyzed. Changes in radiographic root length, apical diameter, and radiographic root area (RRA) were quantified. Prognostic factors that might influence RRA were identified via multivariate linear regression analysis. A total of 112 teeth (50 REP cases and 62 apexification cases) with a median follow-up period of 26.5 months were included. Regenerative endodontic procedures and calcium hydroxide apexification exhibited similar satisfactory success and survival rates (p > .05). Additionally, 88 teeth were quantitatively analyzed. The REP group presented a significantly greater percentage increase in RRA and less decrease in apical diameter than the calcium hydroxide apexification group (p < .05). Teeth treated with REPs and with Stages 7 and 8 of root development showed a better gain in RRA (p < .05). While REP and calcium hydroxide apexification had similar success and survival rates, teeth with REPs showed an increase in RRA, indicating that REP is the preferred choice.

A case report of successful apexification in mandibular second molar, using cold ceramics”

Background and Aim: Nowadays, in the treatment of necrotic teeth with open apex, based on the availability of bioceramic biomaterials with the ability of calcified tissue induction on cement and bone and periodontal ligament repairment stimulation using these materials has become more acceptable than the traditional calcium hydroxide apexification method. Cold ceramic is one of these bioceramics that in previous studies has shown successful results in the treatment of apexification.

Apexification of the mineral trioxide aggregate in nonvital immature anterior teeth with and without platelet-rich plasma: A preliminary clinical study

ABSTRACT Introduction: Treatment of permanent teeth with weak root dentin, exposed apex, necrotic pulp, periapical disease, and stunted root growth present a significant challenge to the practicing conservative dentistry. Necrotic immature permanent teeth with open apices are arduous to seal by thermo-plasticized or lateral condensation methods. Apexification methods have traditionally used a variety of materials including calcium hydroxide, biodentine, and mineral trioxide aggregate (MTA). Calcium hydroxide apexification takes a long time to develop an apical barrier and contains large pores, resulting in inadequate sealing ability and a bad outcome. MTA is a biomimetic and bio-inductive substance that has been employed to construct a single-step apical barrier in immature open apices with and without periapical pathology. Endodontic in this 21st century uses regenerative procedures in a nonvital, immature tooth with wide-open apices but it is also a very lengthy procedure and poor patient compliance due to slow biologic healing and long-term follow-up of the patients. Platelet-rich plasma (PRP) contains various growth factors such as platelet-derived growth factors and transforming growth factors and has been proposed as a potentially ideal scaffold for accelerated wound healing. Aims and Objectives: To evaluate and compare the clinical and radiographic outcome of MTA apexification with and without PRP in periapical healing kinetics in nonvital, immature teeth. Materials and Methods: An analysis was performed on patient with immature teeth, open-apex, maxillary front nonvital that were randomly divided into two groups of eighteen patients (eighteen roots permanent upper anterior) each: Group I in which MTA apexification was performed without PRP and Group II consisting of 18 roots where MTA apexification were carried out on a collagen sponge supplemented with PRP. Results: The cases were followed up at 6 months and 12 months after treatment, both clinically and radiographically, by two independent assessors. Periapical healing (PAH) was good in 6–18 roots, and in Group I-11 roots showed excellent healing. In Group II-17 roots showed excellent results. Case number 18 and case number 9 were lost to follow-up due to migration to groups I and II, respectively. Apical closure was 100% in Group II and 77% in Group I. Conclusions: Single-step MTA apexification with PRP is a conservative and effective method for inducing PAH and is time-saving in managing nonvital, immature teeth with an open apex.

Evaluating the radiographic results of apexification treatment in children

Aim: This retrospective study aimed to evaluate the radiographic success of apexification treatments applied with different materials and techniques. Methodology: Periapical radiographs of 224 maxillary incisors in patients between 6 and 12 years of age who had undergone apexification treatment at the Dicle University, Faculty of Dentistry, Department of Pediatric Dentistry were retrospectively examined. Each apex was scored using the periapical index (PAI) on X-rays obtained at 12 months of follow-up after treatment, and the presence or absence of the apical barrier was evaluated. The Kruskal–Wallis H, Mann–Whitney U, and chi-square tests were used for the statistical analysis (p &lt; 0.05). Results: In the maxillary incisors, apexification was most commonly performed on the maxillary right central teeth (74.11%). The cause for this treatment was trauma in 97.77% of the patients. Enlargement in the periodontal space (95.98%), the presence of lesions (60.71%), loss of lamina dura (54.46%), and external resorption (43.75%) were observed. At 12 months of follow-up after treatment, apical closure (87.95%) was observed in all teeth with open apexes, and the ratio of patients with a PAI of &lt; 2 was 89.35% for calcium hydroxide (CH) apexification and 92.73% for mineral trioxide aggregate (MTA) apexification. Conclusion: The radiographic success of apexification treatments with CH and MTA was found to be high in 224 immature upper incisors. How to cite this article: Akleyin E, Polat Y, Harman EB, Çelenk S. Evaluating the radiographic results of apexification treatment in children. Int Dent Res 2022;12(3):158-64. https://doi.org/10.5577/intdentres.2022.vol12.no3.8 Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

Radiographic outcomes and prognostic factors in nonvital immature permanent teeth after apexification with modified calcium hydroxide paste: a retrospective study.

To assess the radiographic outcomes and prognostic factors in nonvital immature permanent teeth after apexification with modified calcium hydroxide paste. Clinical and radiographic data were collected from 115 necrotic immature permanent teeth (71 caused by trauma and 44 caused by dens evaginatus) treated with apexification using a modified calcium hydroxide. Postoperative root morphology and changes in radiographic root area (RRA) on periapical radiographs were determined and statistically evaluated. Regression analysis was performed to identify factors associated with the outcomes of apexification. The average time for a calcified barrier formation was 10.66 ± 6.37months. The root morphology after apexification with calcium hydroxide + iodoform paste was similar to that previously described after calcium hydroxide apexification. Compared with the trauma cases, the dens evaginatus cases revealed more type I (40.91% vs 16.9%) and less type II morphology (45.45% vs 67.61%). Although the changes in RRA were limited, the dens evaginatus cases showed greater increment of RRA than the trauma cases (4.12% ± 5.58% vs 0.70% ± 5.21%, P < 0.001). A significant association was found between the preoperative stage of root development and postoperative percentage change in RRA (P < 0.001). Teeth caused by dens evaginatus had better outcomes after apexification than teeth caused by trauma. Early stages of root development were associated with superior radiographic outcomes. Apexification provided reliable outcomes in the treatment of immature teeth with pulp necrosis and apical periodontitis, even though the root development is limited. Treatment decision should be made with comprehensive evaluation of prognostic factors.

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.

Clinical and radiographic evaluation of platelet-rich fibrin for revascularization of necrotic immature permanent teeth: A controlled clinical trial

Ideal management of necrotic immature permanent teeth to close the blunderbuss apical opening still of challenge and debate. clinical and radiographic evaluation of platelet rich fibrin (PRF) for revascularization of necrotic immature permanent teeth. 28 single-rooted necrotic immature permanent teeth from 28 children (7–13 years old) assigned into two main groups (contaminated and uncontaminated). Teeth of each group divided randomly into two subgroups according to type of treatment; PRF subgroup (experimental) and calcium hydroxide apexification subgroup (control). Clinical and radiographic evaluations assessed at baseline, 3, 6, and 9 months. all subgroups showed clinical success of 100%. Radiographic results presented a significant difference in all intervals regarding root length, diameter of apical foramen and radiographic root area (RRA) in PRF subgroups. Regarding root length, significant difference was for PRF subgroup at 3rd interval in group I. Diameter of apical foramen showed significant differences for PRF subgroups at 2nd and 3rd intervals. RRA revealed significant differences for PRF subgroups in both groups at 2nd and 3rd intervals. platelet-rich fibrin revascularization and calcium hydroxide apexification were successful clinically. Radiographically, platelet-rich fibrin showed significant quantitative measurements than calcium hydroxide apexification regarding all parameters.

Comparative analysis of calcium hydroxide apexification and regenerative endodontic procedure for root dentine growth stimulation in immature incisors with pulp necrosis

Was to compare the efficacy of Ca(OH)2 apexification and regenerative endodontic procedure (REP) in immature teeth with pulp necrosis. The pilot study included 12 children aged 89 to 126 months having pulp necrosis in immature incisors. Dental trauma was the etiology for pulp necrosis in all cases and initial X-rays showed periapical translucency lesions (PTL). The patients were randomly divided in 2 groups with either Ca(OH)2 apexification (group 1, n=6) or REP (group 2, n=6). The root length and the growth of root wall thickness, as well as root to crown ratio and dentinal wall to root canal space ratio was assessed radiologically in 6, 12 and 24 months. The root length increase was detected in 83% of all cases, but the pattern of root dentine growth in the groups was different. Dentin thickness in REP group was more prominent in the apical third and was observed in 100% of cases while in group 1 dentin thickness increased mainly in the coronal and middle third of the root, dentin thickness increased only in 33% of all cases in the apexification group. PTL were successfully eliminated in both groups. Results and complications of both methods allow limiting indications for their usage. Ca(OH)2 apexification is more reliable in cases of pulp necrosis in teeth with III and IV stages of root formation when an estimated time for apexification is 3 to 6 months, under condition of good patient cooperation and possibility for good marginal fit of the restoration. REP is indicated in cases with I, II and III stages of root formation, as well as initial root resorption signs regardless of root formation stage.

Regenerative Endodontic Procedures Using Contemporary Endodontic Materials

Calcium hydroxide apexification and Mineral Trioxide Aggregate (MTA) apexification are classical treatments for necrotic immature permanent teeth. The first tend to fail for lack of compliance given the high number of sessions needed; the second has technical difficulties such as material manipulation and overfilling. With both techniques, the root development is interrupted leaving the tooth with a fragile root structure, a poor crown-to-root ratio, periodontal breakdown, and high risk of fracture, compromising long-term prognosis of the tooth. New scientific literature has described a procedure that allows complete root development of these specific teeth. This regenerative endodontic procedure (REP) proposes the use of a combination of antimicrobials and irrigants, no canal walls instrumentation, induced apical bleeding to form a blood clot and a tight seal into the root canal to promote healing. MTA is the most used material to perform this seal, but updated guidelines advise the use of other bioactive endodontic cements that incorporate calcium and silicate in their compositions. They share most of their characteristics with MTA but claim to have fewer drawbacks with regards to manipulation and aesthetics. The purpose of the present article is to review pertinent literature and to describe the clinical procedures protocol with its variations, and their clinical application.

Evaluation of one-visit apexification with MTA apical plug versus traditional Calcium hydroxide apexification with the help of Platelet Rich Fibrin apical matrix

This study aimed to evaluate one-visit apexification with MTA apical plug versus traditional calcium hydroxide apexification with the help of platelet rich fibrin (PRF) apical matrix. Methods: 18 immature permanent maxillary anterior teeth with non-vital pulp were chosen from 14 children ranging from 9 to15 years old, and were divided randomly into two main groups with 9 teeth in each group [Group I MTA, and Group 2 Ca(OH)2]. Platelet Rich Fibrin was used for both groups as internal apical matrix. In group 1 MTA approximately 4-5 mm thickness of mixed MTA apical plug was placed at the apical end of the root, then the canal was obturated by Obtura II system after 24 hours, while in group 2 Ca(OH)2 ; the apexification was done by Ca(OH)2 and renewed at 3,6 months and after 12 months the canal was obturated by Obtura II system. The radiographs were taken for all cases at preoperatively, post operatively and at 3, 6 and 12 months follow up. Data were subjected to statistically analyze. Results: At 12 months follow up period 100% of teeth with calcific apical barrier were detected in Group 1 MTA, and 88% of teeth with calcific apical barrier were detected in Group 2 Ca (OH)2. However, there was no difference in statistically point of view between the groups. Conclusions: One-visit apexification provides an alternative treatment option over the traditional calcium hydroxide apexification in treating the non-vital cases with open apices.

Induced post-traumatic apexification: 20 year follow-up and morphological study after new fracture

Apexification is an endodontic technique used in immature necrotic teeth, the primary goal of which is to induce a calcified barrier in roots with open apices and to promote the continuation of apical root development. A 7-year-old patient with a coronal fracture in a maxillary central incisor was treated with an apexification technique using calcium hydroxide. The apical closure was obtained after one year, then a permanent root canal filling was performed. The tooth was monitored for a period of 20 years, up to when a trauma caused its extraction. The newly formed root was analyzed macroscopically, histologically and through scanning electron microscopy. A morphologically normal root was observed, with a large apex and accessory foramina, showing a combination of tissue structures similar to secondary and tertiary dentine, close to amorphous mineralized areas. Despite the final evolution of the case, calcium hydroxide apexification is a good therapy in order to treat pulp necrosis in an immature tooth, leading to complete development of the root and allowing the tooth to be kept in the mouth.

Mineral trioxide aggregate apexification a novel approach for the tooth with open apex-A case report

Mineral Trioxide Aggregate (MTA) was introduced as an alternative to traditional materials for the pulpcapping,repair of root perforations and as a retrograde root filling due to its superior biocompatibilty and ability to seal the root canal system. Traditionally, calcium hydroxide has been the material of choice for the apexification of immature permanent teeth but MTA holds significant promise as an alternative to multiple treatments with calcium hydroxide. The inadequacy of calcium hydroxide apexification due to its long time span and re-infection because of temporary seal led to the use of MTA. In this case report of MTA apexification along with backfilling using thermoplasticised Gutta Percha and coronal rehabilitation of a fractured upper central incisor with open apex.

Porovnání terapie stálých zubů s nedokončeným vývojem a nekrotickou dření apexifikací hydroxidem vápenatým a maturogenezí

Porovnání terapie stálých zubů s nedokončeným vývojem a nekrotickou dření apexifikací hydroxidem vápenatým a maturogenezí

EVALUATION OF MATUROGENESIS AND APEXIFICATION TECHNIQUES IN THE MANAGEMENT OF TRAUMATIZED NON-VITAL IMMATURE PERMANENT INCISORS

Introduction: Regenerative endodontics is a promising alternative treatment for immature teeth with necrotic pulps. Aim of the study: The present study was performed to assess healing potential of young permanent immature teeth with necrotic pulp after the following treatment protocols: (1) Calcium hydroxide apexification, (2) the regenerative endodontic protocol (blood clot scaffold). Materials and Methods: Immature necrotic permanent maxillary central incisors (n = 48) were divided into 2 groups according to the treatment protocol: the apexification group (calcium hydroxide), the REG group (regenerative endodontic protocol). Follow-up was done up to 18 months. Standardized radiographs were digitally evaluated for an increase in root length and thickness, a decrease in the apical diameter Follow-up was done up to 18 months. Results: After a follow-up period of 18 months, most of the cases showed radiographic evidence of periapical healing. Groups showed a progressive increase in root length and width and a decrease in apical diameter. Conclusions: The regenerative endodontic procedure allowed the continued development of roots in teeth with necrotic pulps.

Revitalization of an Immature Permanent Mandibular Molar with a Necrotic Pulp Using Platelet-Rich Fibrin: A Case Report

Any insult to the pulp during its development causes cessation of dentin formation and root growth. Pulpal status and degree of root development are the decisive factors in the treatment approach. Various treatment options have been tried like surgery with root-end sealing, calcium hydroxide-apexification, placement of apical plug and regenerative endodontic procedures to induce apexogenesis. An ideal scenario for a necrosed tooth with immature root would be continued root development coupled with regeneration of pulp tissue. We report a case, where revitalization was done using Platelet-Rich Fibrin (PRF) as a scaffold in immature mandibular molar tooth.

Apexification with apical plug of MTA-report of cases

Back ground: Immature teeth with necrotic pulp and large periapical lesion are difficult to treat via conventional endodontic therapy. The role of materials such as calcium hydroxide and Mineral trioxide aggregate (MTA) are indispensable. These case reports present successful healing and apexification using MTA. Methods: The case reports present two cases with traumatized upper anterior teeth. The radiographic evaluation revealed open apices with blunderbuss canals; the canal was cleaned using intracanal instruments and 5.25% NaOCl and final irrigation with 2% chlorohexidine. To obtain canal disinfection slurry of calcium hydroxide was temporized in the canal. In subsequent appointments 3-4mm apical stop was created with mineral trioxide aggregate and allowed to set. Subsequently the root canals were obturated with thermoplasticized guttapercha. A composite resin restoration sealed the access cavity. A 3 month, 6 month and 1 year follow-up revealed clinically asymptomatic and adequately functional tooth. Results: A positive clinical resolution of this case is encouraging for the use of white MTA as a apical plug, in immature teeth with open apex. Conclusion: Apexification in one step using an apical plug of MTA can be considered a predictable treatment and may be an alternative to use a long term calcium hydroxide apexification. Keyword: Apical plug; MTA; Apexification

The management of non-vital immature permanent incisors

The management of pulp necrosis in an immature permanent incisor can pose a significant challenge with regards to both operator technique and patient management. The main aim of this paper is to outline techniques described in the endodontic management of the immature incisor: calcium hydroxide apexification; one-visit apexification; and root revascularization. Clinical Relevance: With 5% of 8-year-olds in the UK reported to have evidence of trauma to the permanent incisors, 1 an awareness of the challenges posed and techniques available for management is essential for general dental practitioners, should these teeth subsequently become non-vital.