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Apexification with the use of calcium hydroxide

Article  in  Bangladesh Journal of Medical Science · July 2012

DOI: 10.3329/bjms.v11i2.11483

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 Bangladesh Journal of Medical Science Vol. 11 No. 02 April’12

Case report

Apexification with the use of calcium hydroxide

1 2 3
R Nahar , F Chowdhury , M.K. Alam

Abstract:

After traumatic injuries the pulps of young permanent teeth often necrose. This occurs most commonly in
the permanent maxillary incisors leaving the teeth with incomplete radicular development and open apices.
In these cases treatment is aimed at promoting complete apical closure. At a later date a complete filling of
the root canal is carried out in order to prevent inflammatory stimulators affecting the periapex.
Apexification is a method of treatment intended to induce formation of a calcific barrier in an immaturely
developed or pulpless tooth. The intent of apexification is to attain narrowing of the canal or closure of the
apex. Apexification is indicated in young patients, for reasons such as trauma, fracture or caries involving
the pulp require root canal treatment prior to the apex fully developing and closing.

Key words: Permanent tooth, Open apex, Ca (OH)2, Calcific barrier, Apexification.
5
Introduction: reduced thickness of the root canal walls . Moreover,
An open apex refers to the absence of sufficient root during root filling, there is a risk of extruding gutta-
development to provide a conical taper to the canal1. percha and sealer, as well as poor apical sealing
The shape of the open apices was classified before because of the often divergent walls of the apical
treatment in the following way: convergent walls portion. These conditions may ultimately cause dis-
5-6
(CAW), parallel apical walls (PAW), or blunderbuss ease to persist . Conversely, the possibilities of sur-
(DAW); after treatment as closed form, physiologi- gical correction by root-end resection and filling
cal closure (PC) or similar, round apical closure presents management problems when performed in
1
(RC) and straight bridge (SBC) . young patients as well as a doubtful prognosis
because of the fragile apical anatomy, which often
Depending on its intensity, dental trauma may tear implies the need for extensive root resection, there-
3
the apical neurovascular bundle and cause pulp by considerably reducing the crown/root ratio . In
necrosis, consequently arresting root formation in these cases, a conservative approach may be adopt-
2-3
immature teeth . In some cases of dental trauma, ed by the induction of an apical closure, by the intra-
the pulp cavity is exposed and unprotected from canal application of biomaterials to induce the apical
invasion by the oral flora with its related conse- and periapical repair, in a procedure called apexifi-
3
quences . Within this context, young patients may cation. Ca (OH)2 apexification has been the standard
present with teeth whose pulps are necrotic and method in treating the open apex teeth for many
7
whose apices are unfavourable for conventional root years .
canal treatment, that is, thin and fragile walls with
4
extensive foraminal openings . This condition may Case report:
limit biomechanical preparation, as removal of den- A 13-year-old male patient came with the complaints
of swelling in his maxillary labial gingiva. The den-
tine should be performed gently because of the
1. Raihana Nahar,, Dept. of Conservative Dentistry & Endodontics, Bangabandhu Sheikh Mujib Medical
University
2. Farhana Chowdhury, Assstant Professor, Department of Oral anatomy and physiology, Bangladesh Dental
College
3. Mohammad Khursheed Alam, Senior Lecturer, Orthodontic Unit School of Dental Sciences, Health Campus,
University Sains Malaysia
Corresponds to: Farhana Chowdhury, BDS, DDS, Assstant Professor,Department of Oral anatomy and physiology,
Bangladesh Dental College

143
 Apexification with the use of calcium hydroxide

tal history revealed a traumatic injury to his upper saliva ejector.

central incisors teeth (11 and 21) nearly 4 / 5 years Access cavity prepared in the pulp chamber using a
previously during a bicycle accident. high speed hand piece with diamond round bar.
Necrotic pulp tissue was removed.
Clinically, 1/3 of the crown of upper left central inci- A file was placed in the canal and x-ray was taken to
sor teeth with open apex. There was sensitivity to establish working length radiographically(Fig II).
palpation in both teeth. Both teeth were sensitive to Debris removed from the canal by irrigating with
vertical percussion and non vital on vitality test. sodium hypoclorite solution frequently.
The canal was cleaned thoroughly by alternate filing
Radiographically, both teeth exhibited incompletely and irrigation (rasping).
formed root, characterized by wide root canal space; After through debribement the canal was dried with
thin and fragile dentinal walls, especially on the api- reamer and cotton wool and Ca (OH)2 paste was
cal root end; and an increased foraminal opening placed as a intracanal medicament(Fig III).
associated with periapical radiolucency (Fig I). A pellet of cotton was placed in the chamber and
access was closed with ZnO eugenol cement.

Figure II: Establishment of working length.

Figure I: Maxillary central incisor (11 and 21) teeth

with open apex and periapical radiolucency.

Diagnosis: Maxillary central incisor teeth with open

apex.
Treatment Plan: Treatment plan may be sub divid-
ed into 3 phases:
Phase 1: Sterilization and canal preparation phase-
We achieve sterility of the environment to resolve
primary symptoms & signs.
Phase 2: Barrier induction phase- To achieve hard
tissue barrier by inducting Ca (HO)2.
Phase 3: Obturation phase.

Treatment Procedure:
igure III: Cotton wool and Ca (OH)2 paste was
placed as a intracanal medicament.
On first visit:
Isolation of the teeth was done by cotton role and nd
On 2 visit: After one week

144
 R Nahar, F Chowdhury, M.K. Alam

The patient presented complete resolution of acute

symptoms and treatment using calcium hydroxide
intracanal dressings.
It was re-isolated and canal was reopened.
Thoroughly irrigated and cleaned of all the Ca
(OH)2.
The canal walls were again rasped to remove debris
and the canal was dried.
The canal was filled with Ca (OH)2 paste with help
of a lentulo at proper working length to deliver paste
uniformly in the canal.
Excess Ca (OH)2 paste was removed from the pulp
chamber and the chamber was sealed with thick
mixed of zinc oxide eugenol cement.
Intraoral periapical radiograph was taken. Figure V: Final obturation of right and left central
Follow up: The patient visited again after one incisors.
month. The following procedures done.
Isolation done and canal was reopened.
Irrigation and drying was done.
Paper point was used to check whether calcific bar-
rier formed or not.
Introduced number 60 paper point to feel tactile sen-
sation. In case of upper right incisor it felt hard,
incase of upper left incisor it was spongy.
Than introduced number 30 paper point in the upper Figure VI: Changes in the apex of 11 and 21, a.
right incisor and felt hard and no exudation or blood. Before treatment, b. after treatment
But in case of left incisor exudation found.
Calcific barrier was formed in the apex of right and Discussion:
left central incisors(Fig IV0). Obturation done by Physiological completion of apical root formation
lateral condensation technique on the same visit (Fig depends on the maintenance of vitality of the tissues
V and VI). that form root dentine and apical periodontal liga-
Again Ca (OH)2 paste refilled in the left incisor and ment. From an embryonic standpoint, Hertwig’s
the patient advised to visit after one month. epithelial root sheath (HERS) is formed from the
cervical loop, between the tissues of dental papilla
and the dental follicle. Its inductive action leads to
the differentiation of cells of the dental papilla into
odontoblasts, which progressively form the root
8
dentine . Upon the onset of root formation, the initial
formation of dentine induces fragmentation of the
HERS, which then becomes discontinuous and is
permeated by cells of the dental follicle. These cells
undergo differentiation into cementoblasts close to
the newly formed dentine. Completion of root for-
mation in permanent teeth occurs 3–5 years after
eruption. At this period the apical third of the root
canal exhibits an apical constriction; both anatomi-
cally and histologically, called the apical dentinoce-
mental junction, which establishes the limit between
dentine and cementum. The dentine root canal is the
Figure IV: Calcific barrier was formed in the apex of
main field of work of endodontists and extends to
right and left central incisors.
between 1 and 2 mm from the root end. In endodon-

145
 Apexification with the use of calcium hydroxide

tic practice, this represents the histological reference bilization and diffusion of calcium hydroxide into
limit for the establishment of an apical stop, thus the tissue fluids, especially via the apical foramen, it
limiting the root canal filling to the dentine root should be periodically renewed. The action of calci-
canal. Apexification is defined as a method to induce um ions and hydroxyls would promote the progres-
a calcified barrier in a root with an open apex of an sive reorganization of periapical tissues, characteriz-
1
incomplete root in teeth with necrotic pulp . The ing the evolutive stages of repair, which could be
degree of continued root development is associated didactically divided as follows: stage I, the reduction
with the maintenance of HERS integrity. of the intensity of the periapical inflammatory
process; stage II, the transformation of inflammato-
Similarly, it might be stated that, in this repair ry granulation tissue into reparative granulation tis-
process, a reactivation of HERS remnants occurred sue; stage III, cytodifferentiation of undifferentiated
which in turn promoted the root formation genetical- mesenchymal cells into repair cells, e.g. fibroblasts,
ly programmed for that tooth. However, no root cementoblasts and osteoblasts. In this process, calci-
canal was observed in this newly formed mineral- um hydroxide could possibly establish zones of tis-
ized tissue segment of approximately 5 mm, but sue response through the formation of calcite
rather the segment appeared to have a diffuse miner- (Ca2CO3) in the deepest regions as a result of the
alization structure similar to that induced by calcium reaction of calcium hydroxide with tissue carbon
hydroxide. Thus, it can be speculated that, in this dioxide.These mineral aggregates have a high affin-
regeneration process, a positive interaction between ity toward plasma glycoproteins, such as fibronectin.
the HERS and the calcium hydroxide root canal Consequently, the adhesion, proliferation and differ-
dressing occurred. Therefore, the epithelial root entiation of totipotent cells into repair cells on these
sheath externally limited the area and contour of the fibronectin-covered crystals would occur, initiating
new root formation, whereas calcium hydroxide the following stage: stage IV, the formation of a hard
internally determined the diffuse mineralization. tissue barrier through secretion of and extracellular
Therefore, the possible activation of HERS cells by organic matrix containing collagen and glycopro-
calcium hydroxide should also be taken into consid- teins. In this organic framework, enzyme-controlled
8
eration . mechanisms would cause the deposition of crystals
containing insoluble phosphates and carbonates,
The favorable clinical, radiographic and histological thus leading to the biological closure of the apical
responses obtained with calcium hydroxide are relat- foramen.
ed to the participation of Ca++ and OH) ions in sev-
eral mechanisms which would provide: (i) control of One-visit apexification with a mineral trioxide
the inflammatory reaction (by hygroscopic action; aggregate (MTA) apical plug also represents an ade-
formation of calcium proteinate bridges and inhibi- quate treatment option. Filling of the root canal with
tion of phospholipase); (ii) the neutralization of MTA may reinforce the tooth against root fracture,
acidic products of osteoclasts (acidic hydrolases and especially when associated with ametallic post. In
lactic acid); (iii) the induction of mineralization cases of extreme foraminal openings associated with
(activation of alkaline phosphatase and calcium- periapical lesions the orthograde application of
MTA presents several technical limitations, resulting
dependent ATPases); (iv) the induction of cell differ-
in deficient sealing and possibly causing periapical
entiation; (v) the depolymerization of endotoxins;
extrusion. To minimize these risks, the use of a
and (vi) antibacterial action by means irreversible resorbable collagen sponge, hydroxyapatite, or
damage to DNA, proteins, enzymes and bacterial decalcified freeze-dried bone as apical barriers rep-
lipids. Consequently, calcium hydroxide applied to 8
resents an alternative .
root canals acts directly on mineralized dental tis-
sues through the passive diffusion of Ca++ and OH) For many years, calcium hydroxide pastes have been
ions. Because of the physical and chemical barriers considered as the materials of choice in the forma-
posed by the dentine to this process, the achievement tion of a hard tissue apical barriers, even in the pres-
of the beneficial effects of calcium hydroxide in ence of an apical lesion. To date, no clinical case
teeth with completely formed apices requires a peri- report, clinical radiographic or histological research,
od of 2 to 3 weeks, whilst the process of apexifica- has reported apical root development in apexifica-
tion depends on maintenance in the root canal over tion using MTA. MTA hydration forms by-products,
9
several months . Thus, through the progressive solu- such as calcium hydroxide, which stimulate hard tis-

146
 R Nahar, F Chowdhury, M.K. Alam

sue deposits. Nonetheless, in the MTA reaction, the ing post should significantly increased resistance to
resulting hydrate was observed to be poorly crystal- root fracture.
lized and produced a porous material that may be
defined as a rigid gel, which may in turn justify the Many materials have been reported to successfully
reduced release of Ca++ and OH ions to the sur- stimulate apexification. The use of Ca (OH)2 alone
rounding medium and hypothetically reduce the or combination with other drugs had become most
inductive action of calcific barrier formation. widely accepted to promote apexification. The Ca
Calcium hydroxide presents an even greater advan- (OH)2 powder has been mixed with CMCP.
tage in this aspect, because it remains soluble and
Tricalcium phosphate, osteogenic protein – 1, bone
presents progressive diffusion and interaction with
9 growth factor and MTA have been reported to pro-
cells and fluids in the periapical region . It should
also be noted that continued apical root develop- mote apexification similar to that found with Ca
ment, coupled with a concomitant wall thickness, (OH)2. The addition of barium sulfate to Ca (OH)2 to
can consequently cause a natural root support to enhance radiopacity has been shown to produce
9
occur, thus reducing the risk of vertical root fracture apexification .
from originating in this newly formed mineralized
tissue segment.
Conclusion:
Post treatment restoration (Apexification): High Dental trauma in teeth with incompletely formed roots
percentage of root fracture during and after apexifi- may cause pulp necrosis, the arrest of root formation,
cation occurs because of thin dentinal walls and and the later development of periapical lesions.
immature apex. Restoration of the immature tooth Apexification by means of chemo-mechanical
after placement of filling material must be designed debridement and maintenance of regularly renewed
to strengthen the tooth as much as possible. calcium hydroxide dressings is a justified alternative
for the biological sealing of an extensive foraminal
The placement of acid etch bonded composite resin opening, with concomitant repair of periapical lesions
has virtually eliminated these fracture. and continued calcific barrier formation.
Resin modified glass inomer with a translucent cur-

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