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Review Article

Apexification: A systematic review

Fabricio Guerrero, Asunción Mendoza1, David Ribas1, Karla Aspiazu2
Department of Odonto‑Stomatology, Faculty of Dentistry, University of Barcelona, Barcelona, 1Department of Odonto‑Stomatology,
Faculty of Dentistry, University of Seville, Seville, Spain, 2Department of Research, School of Medicine, Catholic University of Cuenca,
Cuenca, Ecuador

Abstract
Pulpal necrosis in permanent teeth that have not completed their root development leads to teeth with a very short root, roots
with very thin walls, and an inadequate crown‑root ratio, which overshadows their survival prognosis. Currently, there are various
therapies to treat immature permanent teeth with pulpal pathology such as the case of apexification. An electronic search was
performed in the PubMed database ([Link]), Scopus ([Link]), Cochrane ([Link]) to
identify the clinical investigations related to evolution of the cases. The search of the literature of clinical studies on permanent
teeth with open apex that present pulpar pathology and that need treatment, have been found 11 clinical studies of treatments
with apexification. The apexification by calcium hydroxide has been applied for many years back to the present as a valid
therapy to perform the treatment of apexification.
Keywords: Apexification; endodontic treatment; immature permanent teeth; pulp regeneration; revascularization

INTRODUCTION as necrotic.[3] The apexification may involve one or multiple

monthly appointments to place calcium hydroxide (Ca(OH)2)
Pulpal involvement as a consequence of trauma or caries inside the root canal and achieve the elimination of
in immature permanent teeth can trigger the loss of pulpal the intracanal infection, which stimulates calcification
vitality as well as directly affect root development, resulting and produces the apical closure. After several monthly
in short roots with very thin walls producing a greater risk appointments, radiologically, the walls of the root canal of
of fracture and thus hindering the treatment conventional the tooth should show more thickness and a rounded apex,
ducts.[1,2] which allows the root canals to be sealed with conventional
techniques using gutta‑percha and a sealant.[2] Ca(OH)2 can
The treatment to be carried out against these pulpal alter the mechanical properties of dentin and make these
pathologies is the elimination of the pulp tissue, the teeth more susceptible to root fracture.[4,5] The traditional
disinfection of the root canal system through the different use of Ca(OH)2 to achieve apexification is being gradually
irrigants that we have at present, among the most used replaced by mineral trioxide aggregate (MTA) as a one‑step
are sodium hypochlorite and ethylenediaminetetraacetic technique.[6,7] The MTA can be placed as an apical plug with
acid. Among the possible treatments to perform in a previous applications intracanal with Ca(OH)2 to produce
permanent tooth with short roots that need endodontic the disinfection of the same[8] or even the MTA can be used
therapy, we have the apexification that is a procedure of as a material of canal filling.[9]
induction of a calcified apical barrier in the apical zone of an
incompletely formed root, in which the pulp is diagnosed METHODOLOGY OF PUBLICATION
SEARCH
Address for correspondence:
Dr. Fabricio Guerrero, Department of Odonto‑Stomatology,
School of Dentistry, Barcelona, Spain. An electronic search was performed in the PubMed databases
E‑mail: [Link]@[Link] ([Link]. gov), Scopus ([Link]),
Date of submission: 15.03.2018 This is an open access journal, and articles are distributed under the terms
Review completed : 23.05.2018 of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Date of acceptance : 12.07.2018
License, which allows others to remix, tweak, and build upon the work
Access this article online non‑commercially, as long as appropriate credit is given and the new
Quick Response Code: creations are licensed under the identical terms.
Website:
[Link] For reprints contact: reprints@[Link]

How to cite this article: Guerrero F, Mendoza A, Ribas D,

DOI: Aspiazu K. Apexification: A systematic review. J Conserv Dent
10.4103/JCD.JCD_96_18
2018;21:462-5.

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Guerrero, et al.: Apexification: A systematic review

Cochrane ([Link]) to identify the investigations gutta‑percha matrix as an alternative to Ca(OH)2 paste for
of reported clinical cases related to the evaluation of use as intraconducting medication. Within the limitations
apexification and revascularization in immature permanent of the study, CHPP provides acceptable results in the
teeth. The terms “apexification” and “immature permanent treatment of apexification and can be used successfully
teeth” and “treatment” were used. The research was limited in cases where apexification with Ca(OH)2 is indicated.
to publications written in English. An additional manual However, there is only one study analyzed by Oktem et al.[11]
electronic search was carried out in the leading endodontics in which CHPP tips were used on a tooth with a follow‑up
and pediatric dentistry journals: Dental Traumatology; time of 24 months in which the apex closure of the treated
International Journal of Pediatric Dentistry; Journal of Clinical tooth was obtained. Due to this, the two authors cited
Pediatric Dentistry; Pediatric Dentistry; Journal of Endodontics; above Bezgin et al.[10] and Oktem et al.[11] report that clinical
International Endodontic Journal; The Journal of the American studies are needed with a larger sample size and a longer
Dental Association; European Journal of Oral Sciences; and follow‑up time.
Australian Endodontic Journal. The keywords “Apexification”
and “Pulp regeneration” and “Revascularization” and Apexification with MTA several clinical studies[8,12‑15] report
“Immature Permanent teeth” were used. The search that MTA provides a viable alternative to achieve root
included articles from the start date of each source until closure in immature teeth or root fracture, even in cases
February 28, 2018. After the removal of the duplicate with an open apex. The time required for the formation
articles, the revision of the title and the selection of of the barrier is significantly less in teeth treated with
abstracts, full‑text articles were used to verify that the MTA compared to teeth treated with Ca(OH)2. There is
content of the article was relevant [Figure 1]. currently a study conducted by Mente et  al.[16] in which
it presents the largest sample number treated with
apexification (252 samples) and with a 10‑year follow‑up
RESULTS period, which concludes that the success rates of teeth
with open apices reported in this cohort study suggest that
In the results of the literature search referring to clinical
the placement of apical plugs with MTA is an appropriate
studies of permanent teeth with open apex treated with
treatment option for teeth with an open apex. The presence
apico formation, 11 clinical articles have been found either of preoperative apical periodontitis was identified as the
using the Ca(OH)2 technique or the apical barrier technique. most important prognostic factor, success rates remain
Among the variables are the year of publication, the size constantly high, even after follow‑up periods of more than
of the sample studied in each article, the diagnosis of the 4 years.
tooth treated with apexification, and the time of follow‑up
of the patients [Table 1]. Chan et al.[9] studied whether MTA favors apexification and
periapical scarring even when a considerable amount of
DISCUSSION this material has been inadvertently extruded. Although it
is recognized that the extrusion of MTA through an open
Apexification apex is not a common mishap during the apexification
Bezgin et  al.[10] carried out a study this right (Roeko, procedure, the extruded material does not adversely affect
Langenau, Germany) designed to release said drug from a the healing of the periapical tissues, as verified in the

Table 1. Representation of the results of clinical studies of apexification.

Author Year Sample size Diagnosis Tracing
Bezgin et al. (10)
2012 Group I: Calcium Hydroxide :10 Pulp necrosis 3,6,9,12 and 15 months
Group II: Calcium hydroxide tips
CHPP: 12
Damle et al.(11) 2012 Group I: MTA apical stopper: 15 Pulp necrosis 1,3,6,9 and 12 months
Group II: Calcium Hydroxide: 15
Albadri et al.(12) 2013 Group I: Plug MTA: 3 Pulp necrosis with apical periodontitis 3, 6 and 18 months
(1 dens invaginatus)
Chang et al.(9) 2013 Group I: Plug MTA: 3 Pulp necrosis with chronic apical abscess 1,6,12, 24 and 36 months
Mente et al.(13) 2013 Group I: Plug MTA: 252 Pulp necrosis with and without apical 12 and 21 months median (128)
periodontitis
Park & Ahn.(14) 2014 Group I: Plug MTA: 2 Dens evaginatus fractured 2,10, 12 and 15 meses
Pace et al.(8) 2014 Group I: Plug MTA: 17 Pulp necrosis 12, 60 and 120 months
Bonte et al.(15) 2015 Group I: Calcium Hydroxide: 16 Pulp necrosis with and without apical 1, 3,6 and 12 months
Group II: MTA apical stopper: 17 periodontitis
Yadav et al.(7) 2015 Group I: Plug MTA: 1 Symptomatic apical periodontitis 1, 3, 6, 9, 18 and 24 months
(failed case of revascularization)
Martens et al.(16) 2016 Group I: Plug Biodentine: 3 Pulp necrosis 6,12,16 and 24 months
Vidal et al.(17) 2016 Group I: Plug Biodentine: 1 Symptomatic apical periodontitis 3, 6, and 18 months

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Guerrero, et al.: Apexification: A systematic review

There is an evolution in the endodontic materials to

Apexification
perform apexification through an apical barrier, and among
them, we have the repair cement biodentine which is
presenting favorable clinical and radiographic results,
Registries Additional
which can be an effective alternative when performing an
Identification
identified records identified
through the through apicoformation.[21,22]
PubMed other
database sources
(n = 6) (n = 93)
CONCLUSIONS

The apexification by Ca(OH)2 has been applied for many

Screening

Records after deleting duplicates years back to the present as a valid therapy to perform an
(n = 75)
apexification treatment.

The MTA barrier as a treatment of apexification is a technique

Excluded records
Eligibility

Selected records
(n = 75) (n = 38) that is applied as a substitution to Ca(OH)2 apexification;
this technique does not require several appointments, and
Full-text article the conformation of the barrier does not need an external
Full-text articles excluded according
evaluated for to exclusion factor to develop, as in the case of the apexification with
eligibility (n = 37) criteria (n = 26) Ca(OH)2, as well as in the regeneration of the pulp.

Financial support and sponsorship

Included

The included studies (n = 11) Nil.

Conflicts of interest
Figure 1: A flow diagram of records There are no conflicts of interest.

present study with clinical observations and X‑rays with a REFERENCES

follow‑up of cases of 36–54 months; Nosrat et al.[17] analyzed
whether after the extrusion of MTA in periradicular tissues, 1. Lauridsen E, Hermann NV, Gerds TA, Kreiborg S, Andreasen JO. Pattern
bone healing, and reabsorption of MTA may occur or may of traumatic dental injuries in the permanent dentition among children,
adolescents, and adults. Dent Traumatol 2012;28:358‑63.
remain unactivated, and affect the healing process. Physical 2. Shabahang  S. Treatment options: Apexogenesis and apexification.
irritation of the oral mucosa after the extrusion of MTA Pediatr Dent 2013;35:125‑8.
3. Nicoloso GF, Pötter IG, Rocha RO, Montagner F, Casagrande L.
is another possibility when the endodontic material is A comparative evaluation of endodontic treatments for immature
sandwiched between the bone and the mucosa, so that the necrotic permanent teeth based on clinical and radiographic
result of the treatment after the extrusion of MTA in the outcomes: A systematic review and meta‑analysis. Int J Paediatr Dent
2017;27:217‑27.
periradicular tissues can not be limited and therefore it is 4. Andreasen JO, Farik B, Munksgaard EC. Long‑term calcium hydroxide
unpredictable. as a root canal dressing may increase risk of root fracture. Dent
Traumatol 2002;18:134‑7.
5. Iwaya S, Ikawa M, Kubota M. Revascularization of an immature
Among the current studies using MTA to perform apex permanent tooth with periradicular abscess after luxation. Dent
Traumatol 2011;27:55‑8.
barrier apposition, we have the study by Yadav et  al.,[7] 6. Purra AR, Ahangar FA, Chadgal S, Farooq R. Mineral trioxide aggregate
who analyzed the apexification in one visit by placing a apexification: A novel approach. J Conserv Dent 2016;19:377‑80.
platelet‑rich fibrin apical plug (PRF) and MTA, in which PRF 7. Yadav P, Pruthi PJ, Naval RR, Talwar S, Verma M. Novel use of platelet‑rich
fibrin matrix and MTA as an apical barrier in the management of a failed
was used as an apical matrix and subsequent placement revascularization case. Dent Traumatol 2015;31:328‑31.
of the MTA since the fibrin rich in platelets have several 8. Pace R, Giuliani V, Nieri M, Di Nasso L, Pagavino G. Mineral trioxide
aggregate as apical plug in teeth with necrotic pulp and immature
advantages, including ease of preparation and lack of apices: A 10‑year case series. J Endod 2014;40:1250‑4.
biochemical manipulation of the blood, which makes this 9. Chang SW, Oh TS, Lee W, Cheung GS, Kim HC. Long‑term observation
preparation strictly autologous. PRF is also associated with of the mineral trioxide aggregate extrusion into the periapical lesion:
A case series. Int J Oral Sci 2013;5:54‑7.
slow and continuous increase in cytokine levels. Leukocytes 10. Bezgin T, Sönmez H, Orhan K, Ozalp N. Comparative evaluation of
in the PRF act as anti‑inflammatory, an anti‑infective Ca(OH)2 plus points and Ca(OH)2 paste in apexification. Dent Traumatol
2012;28:488‑95.
agent, the regulator of the immune response, and provide 11. Oktem  ZB, Cetinbaş T, Ozer  L, Sönmez H. Treatment of aggressive
the vascular endothelial growth factor to promote external root resorption with calcium hydroxide medicaments: A case
angiogenesis. An apical plug of MTA in the last 5 mm of the report. Dent Traumatol 2009;25:527‑31.
12. Albadri S, Chau YS, Jarad F. The use of mineral trioxide aggregate
canal is used in the present case since it avoids the risk of to achieve root end closure: Three case reports. Dent Traumatol
fracture during apexification traditional Ca(OH)2,[18‑20] which 2013;29:469‑73.
13. Damle  SG, Bhattal  H, Loomba  A. Apexification of anterior teeth:
allows this new protocol with PRF and MTA is a predictable A comparative evaluation of mineral trioxide aggregate and calcium
and reproducible clinical procedure. hydroxide paste. J Clin Pediatr Dent 2012;36:263‑8.

464 Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018

[Downloaded free from [Link] on Sunday, October 17, 2021, IP: [Link]]

Guerrero, et al.: Apexification: A systematic review

14. Park M, Ahn BD. Immature permanent teeth with apical periodontitis of root development: A case report. J Endod 2013;39:719‑22.
and abscess treated by regenerative endodontic treatment using 19. McTigue DJ, Subramanian K, Kumar A. Case series: Management of
calcium hydroxide and MTA: A report of two cases. Pediatr Dent immature permanent teeth with pulpal necrosis: A case series. Pediatr
2014;36:107‑10. Dent 2013;35:55‑60.
15. Bonte E, Beslot A, Boukpessi T, Lasfargues JJ. MTA versus ca(OH)2 20. Valera MC, Albuquerque MT, Yamasaki MC, Vassallo FN, da Silva DA,
in apexification of non‑vital immature permanent teeth: A  randomized Nagata JY, et al. Fracture resistance of weakened bovine teeth after
clinical trial comparison. Clin Oral Investig 2015;19:1381‑8. long‑term use of calcium hydroxide. Dent Traumatol 2015;31:385‑9.
16. Mente J, Leo M, Panagidis D, Ohle M, Schneider S, Lorenzo Bermejo J, 21. Vidal K, Martin G, Lozano O, Salas M, Trigueros J, Aguilar G, et al.
et al. Treatment outcome of mineral trioxide aggregate in open apex Apical closure in apexification: A review and case report of apexification
teeth. J Endod 2013;39:20‑6. treatment of an immature permanent tooth with biodentine. J Endod
17. Nosrat A, Nekoofar MH, Bolhari B, Dummer PM. Unintentional extrusion 2016;42:730‑4.
of mineral trioxide aggregate: A report of three cases. Int Endod J 22. Martens L, Rajasekharan S, Cauwels R. Endodontic treatment of
2012;45:1165‑76. trauma‑induced necrotic immature teeth using a tricalcium silicate‑based
18. Chen X, Bao ZF, Liu Y, Liu M, Jin XQ, Xu XB, et al. Regenerative bioactive cement. A report of 3 cases with 24‑month follow‑up. Eur J
endodontic treatment of an immature permanent tooth at an early stage Paediatr Dent 2016;17:24‑8.

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