Management of the

Immature Apex

Kanika Sharma, DMD

(Marielena Gamboa-Ruiz, DDS)
 OPEN (IMMATURE)
VS.
CLOSED (MATURE) APEX
CLOSED


OPEN

OPEN OPEN
CLOSED
CLOSED
 Pulpal Diagnosis

▫ Normal
▫ Reversible Pulpitis
▫ Asymptomatic Irreversible Pulpitis
▫ Symptomatic Irreversible Pulpitis
▫ Necrotic
 If the tooth needs a root canal, why
not just do a root canal?
• Increased fracture risk!
▫ Thin dentinal walls
▫ Short roots
▫ “Blunderbuss”- reverse taper

• Open apexdifficulty packing gutta percha

• Difficulty in instrumentation
 Is the tooth in question Vital?
(i.e., does the tooth respond to cold?)

YES NO
(i.e., a/symptomatic (i.e., Necrotic)
irreversible pulpitis)

1. Apexification
Apexogenesis (MTA or
Ca(OH)2)
2. Regeneration
Apexogenesis
 APEXOGENESIS
• WHEN?
▫ Vital & Open Apex

• HOW?
▫ MTA or Calcium Hydroxide Pulpotomy

• GOAL?
▫ Promote Apical Closure
▫ Maintain Pulp Vitality
 APEXOGENESIS
• Steps:
▫ RD isolation
▫ Caries Removal / Access
▫ Remove superficial 2-3 mm of inflamed pulpal tissue from
chamber
▫ 3-4 mm MTA condensed into chamber
▫ Final restoration
▫ Recall at 6 – 8 weeks & then every 3 months for vitality
tests
• If irreversible inflammation/necrosis/resorption:
APEXIFICATION should be initiated
Cvek M, Cleaton-Jones PE, et al. Pulp reactions to exposure after experimental crown fracture or grinding in the adult
monkey. J Endod 1982;8:391–7.
Webber RT. Apexogenesis versus apexification. Dent Clin N Am 1984;28:669–97.
APEXOGENESIS: Clinical Case

 Amalgam Restoration
MTA

10/2011 MTA 6/2012

12/2012
Pulpotomy
Tooth #20 8 month follow up
1 year follow up
Vital, Open apex Asymptomatic,
Asymptomatic,Vital
Vital

Dr. Josh Goldfein

APEXOGENESIS: Clinical Case

Composite
Restoration
 MTA

10/2013 1/2013
Tooth #30 3 month follow up
Vital, Open apex Asymptomatic, Vital

Dr. Marielena Gamboa-Ruiz

After Apexogenesis, is RCT eventually
necessary?
• Almost impossible to test vitality after removal
of coronal pulp
• Many advocate root canal therapy after
maturation of root

• Consistent and long-term follow-up is necessary!

 Is the tooth in question Vital?
(i.e., does the tooth respond to cold?)

YES NO
(i.e., a/symptomatic (i.e., Necrotic)
irreversible pulpitis)

1. Apexification
Apexogenesis (MTA or
Ca(OH)2)
2. Regeneration
 APEXIFICATION

“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”

Sheely EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in
non-vital immature permanent teeth: a review. Br Dent J. 1997;183:241–246
 APEXIFICATION
• WHEN?
▫ Non-Vital (Necrotic) & Open Apex

• HOW?
▫ Long-Term Calcium Hydroxide
▫ MTA Barrier
▫ COMBO: Long-Term Calcium Hydroxide + MTA Barrier

• GOAL?
▫ Create Apical Barrier:
 Ca(OH)2: Root-End Closure
 MTA: Artificial Apical Stop
 LONG TERM Ca(OH)2 APEXIFICATION
 Steps:
 RD isolation & Access
 Irrigation w/ NaOCl
 Obtain working length
 Minimal instrumentation
 Dry with Sterile Paper points
 Calcium hydroxide in entire canal to working length
 Temporary restoration
 Replace Ca(OH)2 after 1 month & every 3 months
thereafter
Frank AL. Therapy for the divergent pulpless tooth by
continued apical formation. J Am Dent Assoc 1966;72:87–93.
Webber RT. Apexogenesis versus apexification. Dent Clin North Am 1984;28:669-97.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk
of root fracture. Dent Traumatol 2002;18:134-7.
LONG TERM Ca(OH)2 APEXIFICATION

The interrupted process of apical development continues to

its potential after root canal debridement

The epithelial sheath of Hertwig remains intact

&
resume its function once the source of infection has been
removed.
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation.
J Am Dent Assoc 1966;72:87–93.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk
of root fracture. Dent Traumatol 2002;18:134-7.
LONG TERM Ca(OH)2 APEXIFICATION

ADVANTAGES DISADVANTAGES

▫ High success rate ▫ Increased risk of

fracture with CaOH >30
days
▫ Long-term clinical trials
▫ Temporary restoration
between appointments
▫ Multiple appointments: 3-
24 months for formation
of calcified barrier
▫ Patient compliance
Frank AL. Therapy for the divergent pulpless tooth by
continued apical formation. J Am Dent Assoc 1966;72:87–93.
Webber RT. Apexogenesis versus apexification. Dent Clin North Am 1984;28:669-97.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk
of root fracture. Dent Traumatol 2002;18:134-7.
LONG TERM Ca(OH)2 APEXIFICATION

9/2009 Working
Calcium
3Length
month
CaOH
Hydroxide
follow-up
replaced
MTA Final
at 3Fill
Tooth #8 month follow-up
Necrotic, Open
apex
Dr. Jill Young
 MTA APEXIFICATION
• Steps:
▫ RD isolation - Access
▫ Irrigation w/ NaOCl
▫ Obtain working length
▫ Minimal instrumentation
▫ Dry with sterile paper points
▫ Collagen plug at working length (or 1 mm short)
▫ 3-4mm MTA plug at working length
▫ Warm gutta percha
▫ Final restoration
Witherspoon DE, Ham K. One-visit apexification: technique for inducing root end barrier formation in apical closures. Pract Proced
Aesthet Dent 2001;13:455–60.
Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Hargreaves KM. Mahidol Study 1: Comparison of radiographic and survival
outcomes of immautre teeth treated with either regenerative endodontics or apexification methods: restrospective study. J Endod 2012;
38:1330-1336.
 MTA APEXIFICATION

• Higher Success Rate

• Increased Root Length

• Less reliance on pt compliance

• 95% Tooth retention

Witherspoon DE, Ham K. One-visit apexification: technique for inducing root end barrier formation in apical closures. Pract Proced
Aesthet Dent 2001;13:455–60.
Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Hargreaves KM. Mahidol Study 1: Comparison of radiographic and survival
outcomes of immautre teeth treated with either regenerative endodontics or apexification methods: restrospective study. J Endod 2012;
38:1330-1336.
 MTA APEXIFICATION

Advantages Disadvantage
• Faster • Technique
• Higher success Rate sensitive/operator skills

Witherspoon DE, Ham K. One-visit apexification: technique for inducing root end barrier formation in apical closures. Pract Proced
Aesthet Dent 2001;13:455–60.
Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Hargreaves KM. Mahidol Study 1: Comparison of radiographic and survival
outcomes of immautre teeth treated with either regenerative endodontics or apexification methods: restrospective study. J Endod 2012;
38:1330-1336.
 MTA
• MTA: Mineral Trioxide Aggregate
• Tricalcium silicate + tricalcium oxide + silicate oxide
• Radiopaque
• Good seal
• Biocompatible
• pH 12.5
• Antimicrobial
• Effective in the presence of moisture/blood
• PDL regeneration
• Cementum regeneration
Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root end filling material. J
Endod 1995;21:349–53.
Baek S, Plenk H, Kim S. Periapical tissue responses and cementum regeneration with amalgam, SuperEBA, and MTA as root
end filling materials. J Endod 2005; 31: 444-49.
MTA Apexification: Clinical Case

 Gutta Percha

 3 mm MTA plug

Tooth #30 Working

MTA Lengths
Plugs
Previously Initiated Therapy, Final: MTA + Warm Gutta Percha
Open Apex

Dr. Rebekah Lucier

MTA Apexification: Clinical Case

Case courtesy of Dr. Matteo Sferlazzo

MTA Apexification: Clinical Case
 MTA Apexification
• MTA apexification has a high success rate with
greatly decreased number of appointments and
time to completion
▫ (Mente J, Hage N, Pfefferle T, JOE 2009)
• Neither treatment strengthens the root nor
fosters further root development. Thus, the roots
remain thin and fragile, suggesting the need for
another treatment approach.
REGENERATION:
Replacement of damaged structures,
including dentin and root structures, as well
as cells of the pulp-dentin complex.
REVASCULARIZATION:
Re-establishment of the vascular supply to existing pulp in
immature permanent teeth
 REGENERATION
MURRAY, GARCIA-GODOY, HARGREAVES / AAE Glossary

Biologically based procedures designed to replace

damaged structures, including dentin and root
structures, as well as cells of the pulp-dentin
complex.

Murray P, Garcia-Godoy F, Hargreaves K. Regenerative Endodontics: A Review of Current Status

and a Call for Action. JOE 2007, 33(4):377-390.
 REGENERATION

Nygaard-Ostby and Hjortdal (1971)

Showed ingrowth of fibrous connective tissue

and cementum in mature teeth with previously
necrotic pulp tissue.

Law, AS. Considerations for Regeneration Procedures. JOE 2013, 39(38):S44-S56.

 REGENERATION-Objectives
• DISINFECTION
• DISINFECTION
• DISINFECTION
• Formation of new tissues reproducing both the
anatomy and function of the original tissue

Murray P, Garcia-Godoy F, Hargreaves K. Regenerative Endodontics: A Review of Current Status

and a Call for Action. JOE 2007, 33(4):377-390.
What was the function of the original
tissue?
• Innervate the tooth
• Vascular supply to odontoblasts, fibroblasts and
nerves
• Generation of new dentin by odontoblasts and
odontoblast-like cells
• Immune response via odontoblasts and WBCs
(via vasculature)
 REGENERATION – GOAL?
LAW:
• No pain and soft tissue healing
• Resolution of Periapical radiolucency (several months)
• Increase root width
• Increase root length
• Promote apical closure
• Sensation: Induce vitality

Law, AS. Considerations for Regeneration Procedures. JOE 2013, 39(38):S44-S56.

Goals of Regeneration

So how do we do
this?

(Images from Banchs and Trope, JOE 2007)

REGENERATION – WHEN?
HARGREAVES:
• Non- Vital Tooth
• Open Apex

AAE CLINICAL CONSIDERATIONS FOR REGENERATION:

• Necrotic tooth
• Immature apex
• Pulp space does not need a post or core
• Compliant patient
• Pt not allergic to medicaments needed for treatment
• Informed consent
REGENERATION – REQUIREMENTS

SCAFFOLD

STEM
CELLS
GROWTH
FACTORS
REGENERATION – REQUIREMENTS
Provide support for cell
SCAFFOLD organization,
proliferation,
differentiation, and
vascularization
• Blood clot
• Platelet rich plasma
• Natural (collagen) or Synthetic material

Hargreaves KM, Geisler T, Henry M,Wang Y. Regeneration potential of the young permanent tooth: what does the future
hold? J Endod 2008;34:S51-S56.
REGENERATION – REQUIREMENTS

Undifferentiated cells that

STEM continue to divide & have the
CELLS ability to self-regenerate

•Dental pulp stem cells:

• SCAP
• Stem cells from human exfoliated
deciduous teeth
GRWTH
• PDL stem cells FACTORS
Hargreaves KM, Geisler T, Henry M,Wang Y. Regeneration potential of the young permanent tooth: what does the future
hold? J Endod 2008;34:S51-S56.
 Post-natal Stem Cells

(Image from Hargreaves, Diogenes and Teixeira, JOE 2013)

Demonstrated that laceration of apical papilla by
overinstrumentation resulted in a significant
accumulation of undifferentiated stem cells into
the canal space
Stem Cells as Musicians
(analogy courtesy of Dr. Kenneth Hargreaves)
 Stem Cells as Musicians
A source of cells capable of differentiating into the
desired tissue component.
All postnatal stem cells are “multipotent”
Can only differentiate into cells of the tissue from which
they were derived.

So how do we make these stem cells play the right

music? (i.e, How do we make them differentiate into the
cells we need in the pulp?)
REGENERATION – REQUIREMENTS

SCAFFOLD
Protein that binds to
GROWTH receptors on the cell and
FACTORS act as signals to induce
cellular proliferation
and/or differentiation

Hargreaves KM, Geisler T, Henry M,Wang Y. Regeneration potential of the young permanent tooth: what does the future hold?
J Endod 2008;34:S51-S56.
 Growth Factors as Conductors
A. Undifferentiated B. Odontogenic
Stem Cells Differentiation
von Kassa stain
shows
mineralized
matrix
C. Odontogenic D. Adipogenic
Differentiation Differentiation
Positive Oil Red O staining
immunostaining showing lipid
of DSP vacuoles

E. Chondrogenic F. Chondrogenic
Differentiation Differentiation
Proteglycans Immunostaining of
stained with Alcian Collagen Type II
blue
Wei, Ling, Wu, Liu and Xiao, JOE 2007
So which growth factors are important
in odontoblastic differentiation?
• The key growth factors in pulp and dentin formation
include:
▫ Bone morphogenetic protein (Nakashima M.)
▫ Transforming growth factor-beta (Chan CP, Lan WH,
Chang MH)
▫ Fibroblastic growth factor (Ishimatsu H, Kitamura C,
Morotomi T)
• These growth factors are sequestered in the dentin
and can be released by injury or conditioning agents
▫ 17% EDTA (Zhao S, Sloan AJ, Murray PE, Lumley PJ)
 REGENERATION - PROTOCOL
• CASE SELECTION
▫ Necrotic tooth
▫ Open Apex
▫ No Post needed
▫ Compliant pt

• INFORMED CONSENT
▫ Two or more app
▫ Use of antimicrobials
▫ Possible Adverse Effects: staining of crown/root, lack of
response to treatment, pain/infection.
▫ Alternatives: MTA Apexification, No Treatment, Extraction
 First Appointment: Disinfection
Regeneration Procedure
▫ Minimal or no instrumentation of the
dentinal walls
▫ Irrigation with 1.5% NaOCl 20ml for 10
minutes
▫ Ca(OH)2 or TAP dressing
▫ 1-4wk between 1st and 2nd appointment

Law A, JOE 2013

 INTRACANAL MEDICAMENT
• Triple Antibiotic Paste
▫ Ciprofloxacin + Minocycline + Metronidazole
▫ Cell toxicity (detrimental effect on SCAP)
▫ Staining

• Calcium Hydroxide
▫ No cell toxicity
▫ No staining
▫ More readily available
Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a
mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125–30.
Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod
2004;30:196-200.
Ruparel NB, Teixeira FB, Ferraz CC, et al. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla.
J Endod 2012;38:1372-5.
 First Appointment

Preoperative Radiograph Ca(OH)2 Dressing

Courtesy of Dr. Samantha Synenberg

Second Appointment: Growth Factors,
Stem Cells & Blood Clot (Scaffold)
▫ Assess response to initial treatment
▫ Anesthesia without vasoconstrictor
▫ Remove Ca(OH)2
▫ Slow irrigation with 20ml 17% EDTA to remove
smear layer, release growth factors from dentinal
tubules
▫ Over instrument with file/explorer to induce
bleeding from apex
 Access stem cells from apical papilla
 SCAFFOLD
Law A, JOE 2013
Second Appointment: Growth Factors
& Blood Clot

▫ Collaplug + MTA just below CEJ

▫ Coronal seal with permanent restoration

NO post placement in teeth with

regenerative treatment

Law A, JOE 2013

Second Appointment

Preoperative Radiograph Ca(OH)2 Dressing

Courtesy of Dr. Samantha Synenberg

 FOLLOW UP – Clinical &
Radiographic
▫ No pain or swelling

▫ Resolution of Periapical radiolucency (6-12 months)

▫ Increased Dentin wall thickness (12-24 months)

▫ Increased root length / Apical closure

 When should you expect to see
outcomes?
“Apical lesions showed complete regression in 3-21
months (mean: 8 months) after initial treatment”

“All necrotic immature permanent teeth achieved a

nearly normal root development 10-29 months
(mean: 16 months) after initial treatment”

(Chueh et al., JOE 2009)

Regeneration #8
Initial Clinical Picture-Buccal Initial Clinical Picture-Lingual

Courtesy of Dr. Marielena Gamboa-

Ruiz
 Regeneration #8
Ca(OH)2 Intracanal
Initial PA Radiograph
Medication
Regeneration #8

Blood Clot – Scaffold, Stem

Cells
 Regeneration #8

MTA Plug MTA Plug-PA Radiograph

Regeneration #8

Final PA
 Regeneration #8

6-month follow-up 9-month follow-up

 Regeneration #8

Initial PA Radiograph 2-year follow-up

Regeneration #29
Initial PA Radiograph Initial Sinus Tract Tracing

Courtesy of Dr. Kevin Burke

Regeneration #29

Final PA-MTA Plug

 Regeneration #29

Initial PA Radiograph 9-month Follow-up

 Regeneration #20

Initial PA Radiograph Final PA-MTA Plug

Courtesy of Dr. Rebekah Lucier

 Regeneration #20
Initial PA Radiograph 9-month Follow-up
When regeneration vs. (MTA)
apexification?
Width of root dentin

VS
• Clinical outcome data from 61 cases:
22 Calcium hydroxide apexification
19 MTA apexification
20 Regeneration
• Outcome measures
Clinical success and survival
Percentage increase in root length and width
Mahidol Study
Mahidol Study
Mahidol Study
 Restorative Considerations: Staining
• Staining
▫ MTA
▫ Triple Antibiotic Paste (specifically
minocycline)(used in lieu of Ca(OH)2)
▫ Bleeding into the coronal area

(Images
from Ding et
al., JOE
Restorative Considerations

Posts cannot be placed in teeth that have

undergone regenerative procedures
 Regeneration #29
Ca(OH)2 Intracanal
Initial PA Radiograph
Medication
 Regeneration #29

Final PA-MTA Plug 6-month follow-up

 Regeneration #29
Second Attempt

Ca(OH)2 Intracanal
6-month follow-up
Medication
 MTA Apexification #29

Immediate Post-op PA 4-month follow-up

Regeneration #20
What’s in the canal space?
9-month follow-up 3 years later…

Courtesy of Dr. Scott Johnson

What is in the canal space?

Removal of MTA Final Fill

Courtesy of Dr. Scott Johnson

Is survival an acceptable outcome?
• Does it matter what kind of tissue is in the canal
space?

• Regenerative endodontic procedures hold the

promise of restoring the pulp/dentin complex in
teeth with immature roots and necrotic pulps.
▫ Increase root wall and thickness