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Key Words
Apexification, apexogenesis, immature permanent
teeth, treatment
From the Department of Endodontics, Loma Linda University, Loma Linda, California.
This article is being published concurrently in Pediatric
Dentistry 2013;35(2). The articles are identical. Either citation
can be used when citing this article.
Address requests for reprints to Dr Shahrokh Shabahang, 5
East Citrus Avenue, Suite 201, Redlands, CA 92373. E-mail
address: shahrokh@shabahang.net
0099-2399/$ - see front matter
Copyright 2013 American Academy of Pediatric Dentistry
and American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.11.046
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Shabahang
he dental pulp contains immune cells that allow it to mount a response against offending irritants. The pulp also contains odontoblasts, which are specialized to form
dentin. In the absence of a vital pulp, the tooth structure is susceptible to infection, and
dentin deposition is arrested. Maintenance of pulp vitality is imperative in an immature
permanent tooth to allow continued root development. The pulp tissue is removed when
pathologically inflamed or necrotic.
Although studies are underway to develop materials and techniques for pulp
regeneration procedures, the purpose of this review is to provide an overview of apexogenesis and apexification in immature permanent teeth with pulpal pathosis.
Apexogenesis or Apexication
Proper assessment of the affected tooth is critical in determining an accurate diagnosis and prescribing the appropriate treatment plan. Assessment of pulp vitality will aid
in determining the proper treatment option. If vital and not irreversibly inflamed, maintenance of its vitality will allow natural continued root development. Figure 1 presents
a flow chart to facilitate the decision-making process when treating permanent teeth
with incomplete root development.
Assessment of the tooth in question is made by using radiographic evaluation to
determine the maturity of the developing root and clinical evaluation that is based on
history and clinical testing. Obviously immature teeth are frequently associated with
child patients. Pulp testing in children is a complex procedure and subjective in nature.
Maintenance of pulp vitality by using apexogenesis will allow continued root development along the entire root length. Depending on the extent of inflammation, pulp
capping, shallow pulpotomy, or conventional pulpotomy may be indicated. The dental
pulp in young patients is more cellular and able to recover from injuries. Cvek et al (1)
demonstrated that in teeth with complex crown fractures, the exposed pulp maintained
its vitality for up to 7 days. In these teeth, only the most superficial 2 mm of the pulp is
inflamed and requires removal.
If pulpal necrosis occurs in immature teeth, an alternative treatment approach
must be used because of the presence of an open apex (2). The young pulpless tooth
frequently has thin, fragile walls, which makes it difficult to adequately clean and to
obtain the necessary apical seal (2). Traditionally, the approach has been to use
calcium hydroxide (CH) to induce apexification after disinfection of the root canals
in the conventional manner (3). Completion of endodontic therapy was typically delayed until completion of root-end closure through apexification. Apexification is
defined as a method of inducing a calcified barrier in a root with an open apex or
the continued apical development of an incompletely formed root in teeth with necrotic
pulp (4).
The disadvantages of traditional, long-term CH therapy include variability in
treatment time, unpredictability of formation of an apical seal, difficulty in
following up patients, and delayed treatment. An alternative to CH therapy is
placement of an apical plug. Several investigators have demonstrated the
use of dentin apical plugs in nonsurgical root canal therapy of mature teeth
(59). Mineral trioxide aggregate (MTA) is a material that may be best suited
as an apical plug. In 1999, Shabahang et al (10) showed consistent barrier
formation when MTA was used as an apical plug in an in vivo dog model
with open apices. Several studies have confirmed successful clinical outcomes
including healing of existing periapical lesions in majority of immature teeth
that were treated with an MTA apical plug (11, 12).
Treatment Outcomes
Figure 1. Case selection for treatment of permanent teeth with incomplete
root development.
Disinfection Protocols
Immature permanent teeth pose special challenges during
endodontic procedures not only because of the wide-open root apex
but also because of the thin dentin walls. Therefore, debridement is
completed primarily by chemical means to remove any remaining
pulp tissues and for disinfection. Furthermore, an accurate determination of root length is required to ensure complete canal debridement
and to confine treatment materials to the canal space to avoid damaging
the very valuable remnants of the Hertwig epithelial root sheath. Generally, electronic apex locators are not accurate in teeth with wide-open
apices (13). Radiographic root determination is the best means to
obtain accurate root length measurement.
Sodium hypochlorite (NaOCl) and CH have excellent tissuedissolving properties as well as antimicrobial efficacy (1418).
Whereas NaOCl exerts its effect during the course of the procedure,
CH requires additional exposure time. A 1-week obturation of the
canal space with CH will allow disinfection along with dissolution and
removal of pulpal remnants (19). Despite its convenient availability,
several investigators have reported shortcomings with respect to
NaOCls ability to completely disinfect the root canal space (2022).
Long-term exposure to CH may also have detrimental effects on
dentin. Studies have shown that long-term CH therapy that would expose
root dentin to CH for periods exceeding 1 month results in structural
changes in the dentin, with higher susceptibility to root fracture
(23, 24).
Use of antibiotics has also been documented during the past
years and is regaining popularity in recent years. In 1980, Das
(25) reported successful apexification of a tooth after root canal
debridement and intracanal antibiotic therapy with an oxytetracycline
HCl ointment. In 2003, Torabinejad and his group published a series
of reports to demonstrate the advantages of a mixture of doxycycline, citric acid, and detergent (BioPure MTAD; DENTSPLY Tulsa
Dental Specialties, Tulsa, OK) over NaOCl and other commonly
JOE Volume 39, Number 3S, March 2013
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Shabahang
Technique/material
Investigator(s)
No. of cases
Observation
CH therapy
CH therapy
CH therapy
Heithersay, 1970
Ghose et al, 1987
Morfis and Siskos, 1991
21
43
34
1475 months
310 months
CH therapy
CH therapy
32
15
1014 weeks
CH therapy
26
CH therapy
28
15
20
8 months
MTA plug
11
2 years
MTA plug
MTA plug
MTA plug
MTA plug
MTA plug
MTA plug
5
17
20
38
30
22
MTA plug
MTA plug
43
78
2 years
11.7 years
1244 months
12 months
12 months
Mean follow-up time
23.4 months
12 months
Mean recall time was
19.4 months
A PubMed search was conducted in August 2012 to identify citations with CH, MTA, apical plug, outcomes, and clinical studies.
Outcomes
Apical canal seen radiographically, but no apical barrier clinically
49 of 51 developed an apical barrier
Continued root development in 6 cases, continued root development
and bridge formation in 3 cases, bridge formation in 21 cases, and
in 4 cases no root-end closure
Apical closure in necrotic cases with or without lesion
100% apical closure with porous barrier. Older children with narrow
apex had shorter time; teeth without periapical infection showed
faster results.
Apical closure obtained in 100% of cases; 88.4% needed 34 sessions
(average of 3.23 sessions)
Cementoid tissue (85.72%) or osseous tissue (14.28%)
2 of CH teeth had become reinfected, but all teeth treated with MTA
plug remained successful
Periapical lesions resolved in 4.6 1.5 months for MTA group
and in 4.4 1.3 months for CH group. Total treatment was
completed in 0.75 0.5 months for MTA group and 7 2.5 months
for CH group.
10 of 11 cases healed, and remaining case considered incomplete
healing
4 of 5 teeth healed; 1 case in MTA was extruded
94.1% clinical success, 76.5% radiographic success; 17.6% uncertain
Healing rate was 93.75%
All teeth were clinically and radiographically successful
100% success clinically and radiographically
Clinical and radiographic success rate of 95.5%; discoloration in
22.7% of teeth
81% healed
93.5% of teeth treated in 1 visit healed, and 90.5% of teeth treated in
2 visits healed
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TABLE 1. Outcomes of Clinical Studies with CH Therapy and MTA Apical Plug
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