3.2
Apexification
Elizabeth Shin Perry
Objectives
Apexification is the induction of a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in a tooth with a necrotic pulp. At the end of this case, the reader should understand the management of a non‐vital tooth with immature root anatomy and open apex with the current protocols for apexification and be able to identify clinical situations that would benefit from this treatment.
Introduction
A 7‐year‐old girl presented with discoloration and tenderness associated with her upper left central incisor (UL1). Three months previously the patient had experienced a traumatic dental injury when she fell and hit her central incisors on the corner of a table. The teeth were palatally displaced and she was seen immediately by her dentist, who repositioned the teeth and splinted them with a flexible wire splint for two weeks.
Chief Complaint
The patient’s tooth was discoloured (grey) and was tender to touch.
Medical History
Unremarkable.
Dental History
Regular attender at her dentist and visited the hygienist every six months.
Clinical Examination
Extraoral examination was unremarkable. Intraoral examination revealed a mixed dentition. Oral hygiene status was good.
The UL1 appeared grey (Figure 3.2.1a) and was tender to percussion. The UL1 did not respond to thermal (cold) or electric vitality testing. The UR1 responded within normal limits to sensibility testing and was not tender to percussion. Both central incisors were incompletely erupted.
What did the radiograph reveal about the UL1?
- Periapical radiolucency.
- Incomplete root anatomy with thin canal walls and open apex.
- Arrested or slower root development compared to the UR1 (Figure 3.2.1b).
It is not uncommon for immature teeth to have periapical radiolucent areas in the region of the developing root apices. In this case, the radiolucent area associated with tooth UL1 was larger than the radiolucent area around the apex of UR1, indicating that an area of pathology may be present.
Diagnosis and Treatment Planning
What was the diagnosis and treatment plan?
The diagnosis was pulpal necrosis with symptomatic apical periodontitis.
What were the potential treatment options for this patient?
- Apexification (endodontic therapy) with root end closure
- Regenerative endodontics
- Extraction
- No treatment
As with all types of endodontic treatment, the objective of treatment is prevention of periapical periodontitis in teeth with irreversible pulpitis and resolution of periapical periodontitis in teeth with infected, necrotic root canal spaces. Apexification with root end closure allows for the formation of a calcific barrier at the apical extent of teeth with incomplete root development.
Today regenerative endodontics is an exciting treatment option for teeth with immature root development (see Case 3.3). However, when there is a concern for regenerative endodontic treatment or follow‐up, apexification is a viable option to save a necrotic tooth with incomplete root formation. Extraction of a tooth in a young child is never a desirable option, as this commits the patient to a lifetime of prosthodontic procedures to replace the missing tooth.
What are the challenges in the treatment of teeth with immature root anatomy?
Teeth with immature root anatomy present unique challenges for treatment. These teeth have wide root canals with open apices and thin, divergent canal walls. The large root canal space does not allow for traditional mechanical instrumentation, as the large canal diameter can exceed the size of root canal instruments. In addition, dentine preservation of the already delicate root structure is important. The open apex presents a challenge for obturation with traditional methods, as the canal has minimal or no resistance form for compaction of root canal materials. In addition, application of any irrigants or medicaments must be carefully controlled to prevent extrusion into the periapical tissues.
Treatment
Endodontic treatment was carried out with local anaesthetic and dental dam isolation. The root canal was accessed, and the canal was irrigated with sodium hypochlorite and a pre‐measured syringe tip. The working length was measured on the pre‐operative radiographs and confirmed with a working length radiograph (Figure 3.2.2
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