See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/300389718

MANAGEMENT OF OPEN APEX IN PERMANENT TEETH WITH CALCIUM

HYDROXIDE PASTE. ISSN2348-5280,Impact Factor;2,78

Article · April 2016

CITATIONS READS

2 10,788

4 authors, including:

Abu-Hussein Muhamad Azzaldeen Abdulgani

Al-Quds University
597 PUBLICATIONS 2,822 CITATIONS
258 PUBLICATIONS 1,756 CITATIONS
SEE PROFILE
SEE PROFILE

All content following this page was uploaded by Azzaldeen Abdulgani on 05 April 2017.

The user has requested enhancement of the downloaded file.

 International Journal of Dental and Health Sciences
Case Report Volume 03, Issue 01

MANAGEMENT OF OPEN APEX IN PERMANENT

TEETH WITH CALCIUM HYDROXIDE PASTE
Abu-Hussein Muhamad* , Jabareen Ayah , Abdulgani Mai , Abdulgani Azzaldeen

ABSTRACT:
Calcium hydroxide is a multi purpose agent, and there have been an increasing number of
indications for its use in endodontics. Some of its indications include inter-appointment
intracanal medicaments, endodontic sealers, pulp capping agents, apexification, pulpotomy
and weeping canals. The aim of this study was to report the 10 year follow-up data of an
apexification treatment applied to a permanent incisor of a young patient treated with
calcium hydroxide.
Key Words: Calcium hydroxide , Apexifacation, one-visit apexification

INTRODUCTION:

Endodontic treatment of immature the apical portion of the root is frequently

necrotic teeth with necrotic pulps and wider than the coronal portion, making
open apex involves induction of apical proper condensation of the gutta-percha
closure by apexification procedures to impossible. Sufficient widening of the
create optimal conditions for conventional coronal segment to make its diameter
root canal filling[1]. Apexification therapy greater than that of the apical portion
is initiated when clinical and radiographic would signi? cantly weakens the root and
evidence of pulpal necrosis has been increases the risk of fracture. The
unequivocally established and the disadvantages of surgical intervention
incompletely formed root has an apical include the difficulty of obtaining the
diameter greater than coronal diameter. necessary apical seal in the young pulp
Apexogenesis, in contrast refers to vital less tooth with its thin, fragile, irregular
pulp therapy to encourage continued walls at the root apex.[1,2,3,4]
physiological root and apex formation
Apicoectomy further reduces the root
with its normal dentin and cementum
length resulting in a very unfavourable
composition[2].
crown root ratio. The limited success
In the past, techniques for management enjoyed by these procedures resulted in
of the open apex in non-vital teeth were signi? cant interest in the phenomenon of
confined to custom ? tting the ? lling continued apical development or
material[1], paste ? lls[1] and apical establishment of an apical barrier, ? rst
surgery[1,2]. Anumber of authors[3] have proposed in the 1960s[1,3]
described the use of custom ? tted gutta-
percha cones, but this is not advisable as

*Corresponding Author Address: Dr Abu-Hussein Muhamad Email: [email protected]

 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
Most of these techniques involve removal been conclusively demonstrated that a
of the necrotic tissue followed by medicament is necessary for induction of
debridement of the canal and placement apical barrier formation.[4,5] Table.1
of a medicament. However, it has not

Table.1; Flow chart of treatments for traumatized or diseased immature teeth

Nygaard- Ostby hypothesized that organic proteins. Hence, it is not

laceration of the periapical tissues until recommended in teeth with thin dentinal
bleeding occurred might produce new walls.[7]
vital vascularised tissue in the canal. He
Calcium hydroxide can be mixed with a
suggested that this treatment may result
number of different substances
in further development of the apex[6]
(Camphorated mono chlorophenol,
The most widely used material until distilled water, saline, anesthetic
recently was calcium hydroxide that was solutions, chlorhexidene, cresatin) to
replaced over intervals for several induce apical closure[8]. The mechanism
months, to stimulate calcific barrier by which calcium hydroxide induces the
formation. Torabinejad and Chivian formation of a solid apical barrier are not
introduced mineral trioxide aggregate fully understood. Some attribute its action
(MTA) as an apical plug and now it is an solely to its antibacterial activity, while
accepted material for apexification till others emphasize its high pH or its direct
date. effect on the apical and periapical soft
tissues[9]. The alkaline pH and calcium
The use of calcium hydroxide affects
ions might play a role either separately or
various mechanical properties of radicular
synergistically. The calcium required for
dentin (2). The alkaline pH of calcium
apical bridge formation comes through
hydroxide increases the chances of
fracture due to denaturation of dentinal
1306
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
thesystemic route as demonstrated by left in the canal for at least one week to
Pisanty andSciacky[10]. be effective in accomplishing disinfection[
13].
Siqueira and Lopes discussed the
mechanism of its antimicrobial activity in At the second visit, a thick paste of
detail. Calcium hydroxide assists in the calcium hydroxide will be packed in the
debridement of the root canal, as it root canal. Ca(OH)2 placement methods
increases the dissolution of necrotic tissue vary from injection of paste, using lentulo
when used alone or in combination with spirals and condensation or even using
sodium hypochlorite.[11] packed dry powder. Many authors
consider a continuous intimate contact of
Mitchell and Shankwalker studied the
calcium hydroxide with apical and
osteogenic potential of calciumhydroxide
periapical tissue as desirable[14].
and other materials when implanted into
Therefore it should be beneficial to use
the connective tissue of rats[12] . Of
calcium hydroxide placement method that
the[11]materials used in comparative
will provide the best retention of the
studies, only three gave any evidence of
material in the canals.
induced calcification. They concluded that
calcium hydroxide had a unique potential Metzger[] et al concluded from their study
to induce formation of heterotopic bone that injection of calcium hydroxide paste
in this situation.[11,12] was the easiest method to use.[14]

Since in the vast majority of cases non However, the injected paste was poorly
vital teeth are infected, the first phase of retained in the canals. Condensation of
treatment is to disinfect the root canal calcium hydroxide with hand pluggers was
system to ensure periapical healing. The the most demanding and time consuming
canal length is estimated with a parallel procedure, yet retention of the paste in
preoperative radiograph and confirmed the canals was superior to retention with
radiographically with the first endodontic either of the two methodsfilling with
instrument. The root length cannot be lentulo spirals and injection method
determined with apex locator as it is not used[15].
reliable in teeth with open apices[20].
Reports vary as to the time required to
Preparation of the canal owing to the thin
achieve the goal of apical barrier
dentinal walls is performed very lightly
formation. Heithersay achieved apical
and with copious irrigation using 0.5%
closure in the time range of 14 to 75
sodium hypochlorite (NaOCl). Lower
months. Chawla[15] used calcium
strength of NaOCl is used because of the
hydroxide paste and achieved closure
increased danger of extruding NaOCl
within 6 to 12 months. Kleier[16] found
through open apex .The canal is dried with
closure of apex within 1 to 30 months.
paper points and a creamy mix of calcium
hydroxide is spun into the canal with
lentulo spiral. The calcium hydroxide is
1306
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
The aim of this study was to report the mixture was placed into the canal and
10year follow-up data of an apexification pushed to the short of apex using plugger.
treatment applied to a permanent incisor Access opening was restored with glass
of a young patient treated with calcium ionomer cement . [Fig.3] Patient was
hydroxide. called after 3 months. After 3 months
when patient came back, a periapical
CASE DETAILS:
radiograph was taken, which showed
A 10-year-old female patient reported complete formation of the root apex in
complaining of pain in the upper front maxillary right central incisor, without any
tooth since 3 days. [Fig.1]There was a signs and symptoms and periapical
history of trauma to the same tooth due radiolucency. Clinically, apical barrier
to fall about 4 days back. On clinical formation was confirmed by using a size
examination, Elli's Class III fracture in 30 Gutta-percha (GP) point to check for
permanent maxillary right central incisor the presence of a resistant "stop" and
was evident. Periapical radiograph absence of hemorrhage, exudates or
showed incomplete root formation with sensitivity In the next visit, complete
wide open apices for the same tooth obturation was carried out with GP using
[Fig.2] . Apexification with calcium lateral condensation technique followed
hydroxide dressing was planned. In the by composite restoration. [Fig.4]
first visit, an access cavity was prepared
with a straight line entry into the root
canal . The working length was
established within one mm of the
radiographic apex by using size 30
Hedstrom file. Next, pulp extirpation and
complete debridement of the canal was
done using H file number 40 followed by
Figure 2: Periapical radiograph showing
copious irrigation with normal saline.
placement of CaOH dressing
After drying of the canal using paper
points, calcium hydroxide powder was DISCUSSION
mixed with normal saline and this
The purpose of this paperwas to show the
capacity of calcium hydroxide to ensure
the long-term success of apexification in a
case study. In powder form, calcium
hydroxide (molecular weight = 74.08) is a
strong base (pH = 12.5–12.8) that has
poor water solubility (≈ 1.2 gL−1 at 25∘C)
with thixotropic behavior and is insoluble
Figure 1: Periapical radiograph showing in alcohol. It dissociates (dissociation
wide open apex in relation to 21 coefficient = 0.17) into calcium (54.11%)
1307
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
and hydroxyl (45.89%) ions [3]. It was increased root length, and thickening of
introduced as a biocompatible endodontic lateral dentinal walls, however, these
agent for direct pulp-capping in 1920 [17]. preliminary reports still needs to be
Since 1966, it has also been employed in analyzed before its clinical application.[21]
apexification [18].

Figure 4: Radiograph showing complete

obturation of 21
Figure 3: Periapical radiograph taken
Calcium hydroxide should be refreshed
after 3 months shows confirmation of
every three months, which requires
apical barrier with gutta-percha point
multiple visits with inevitable clinical costs
The drawbacks of calcium hydroxide and the increased risk of tooth fracture
apexification are, multiple visits leading to since many dressing changes are
inevitable high costs; increased risk of necessary till the formation of a calcified
root fracture; long time-span; root length barrier [22]. In this case when new, clean
compromised; thin lateral dentinal walls calcium hydroxide paste had been
increasing the chances of root fracture; introduced into the canal, it was changed
prevent apical pulp tissue regeneration in every three months. However, in very
due to calcific barrier formation; and it young patients with ‘blunderbuss’ apex,
may damage the Hertwig’s epithelial root the paste may dissolve and wash out from
sheath. To overcome the drawbacks of the root canal so quickly that, at least at
calcium hydroxide, mineral trioxide the beginning of the treatment, it may
aggregate (MTA) was used which induced have to be changed more often than
hard tissue formation within a short time- every three months. Granulation tissue
span and improved patient which often grows into the apical area of
compliance.[19,20] a wide open root canal is sometimes
difficult to remove with instruments.
A new technique known as Revitalization/ However, like in the presented case it
Revascularization which is an attempt to necrotizes when calcium hydroxide is
revitalize tissues in the pulp space and packed into the canal, and at the
continued root formation in immature subsequent visit can be rinsed out of the
nonvital pulps is being investigated. The canal with sodium hypochlorite[22,23,24]
results of clinical trials shows high success
rate in terms of regeneration of pulp,
1308
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
There are two schools of taught regarding the presence of inflammatory exudates in
the need to replace the calcium hydroxide the canal.
paste, some authors suggest a single
The majority of dental trauma patients
application is sufficient to induce hard
require multidisciplinary cooperation.
tissue barrier apically, because the
Adequate integrated treatment planning,
calcium hydroxide paste acts only as a
coordination, and execution are necessary
catalyst for deposition of calcified tissue
for the proper management of complex
and as a filler material in the canal
cases .In the presented case, the patient
space.[25]
regained his esthetic and function due to
Another group of authors recommend cooperation of Endodontics, Operative
that renewal of paste is necessary in Dentistry, Periodontology and
presence of a very wide foramen and Prosthodontics departments.[26,27]
inflammatory exudates in the apical
One of the long-term failures that have
region which increases the rate of
been reported in the literature are root
dissolution of the paste. Therefore,
fractures of teeth after apical barrier
renewal of calcium hydroxide paste in the
formation and obturation. This has been
initial stages cannot be under-estimated
attributed to the prolonged use of calcium
in infected immature teeth for the
hydroxide as an apexification agen The
successful apical closure.[26]
hypothesis was that long-term exposure
The frequency of periapical healing and to calcium hydroxide may weaken the
apical hard tissue closure of non-vital dentine, thus making the roots more
immature teeth after long-term calcium susceptible to fracture.[19]
hydroxide treatment is in the range of 90-
In a retrospective study of 885 luxated
95%, which shows that the treatment has
non-vital immature incisor teeth, treated
predictable outcome. On the other hand,
with calcium hydroxide and followed-up
if an apexification procedure is not
for four years ,it was observed that the
performed prior to obturating the root
main root fractures were at the cervical
canal of immature tooth, the success rate
region in 77% of immature teeth
of the treatment is less than 50%.[24]
compared to 2% in mature teeth. These
In the present case report, the case 1 was results indicated that the thin dentine
treated with replacement of calcium walls in immature incisors could be one of
hydroxide paste because the tooth was the reasons. This view was supported by
necrotic with inflammatory exudates finding a significant relationship between
present in the canal, while in case 2, the fracture and defects after inflammatory
tooth was left without renewal. The rate resorption of the root had arrested.[28]
of barrier formation in case 2 was faster
Al-Jundi, performed an analysis of the
than the tooth in which replacement of
outcomes of their previously reported
paste was done. This may be due to the
retrospective study regarding
very wide open apex in the first case or
1309
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
complications due to the late presentation problems in interpretation of the results
of dental trauma. Examination of dental was related to a real-life situation, i.e.
records and radiographs of 195 children human teeth are functioning in the oral
with 287 teeth aged from 15 months to 14 environment and lying within a unique
years old were performed then a clinical system of highly specialised periodontium.
and radiographic follow-up was scheduled The behaviour of these teeth under the
at 3, 6, 12, 24 and 36 months. Among the experimental conditions when stored in
outcomes assessed in this study were root saline for prolonged periods of time and
fractures as a long-term complication then subjected to mechanical forces while
following apexification. It was reported in embedded in plaster may be totally
83 patients who had apexification different from teeth that are subjected to
treatment, 32% had root fractures, 85% of physiological forces, and surrounded by
these which had occurred spontaneously. the periodontium. Other forces may play
The technique of apexification and type of a more important role in the increased
restorations provided were among some fracture susceptibility (if present) in these
key information that was not reported in teeth e.g. thin week dentine walls of
the study.[29] immature teeth.[30]

Andreasen et al., in an in vitro study on Kawamoto et al., in vitro study that

sheep’s immature teeth concluded that a exposure to calcium hydroxide over 90
marked decrease in fracture strength days increased the elastic modulus of
occurred with increasing storage time (in dentine, making the effected tooth more
saline) for teeth treated with calcium prone to fracture[31]. The same finding
hydroxide dressing. It was also concluded was found in Twati et al.,[32]that the
that the fracture strength of calcium dentine was weakening by 50% after eight
hydroxide-filled immature teeth was months of calcium hydride application. A
halved in about a year due to the root more recent study stated that the
filling and this might explain the prolonged contact of calcium silicate–
frequently reported fractures observed based mineral had an adverse effect on
with long term use of calcium hydroxide the integrity of dentine collagen matrix
or mineral trioxide aggregate. [19] that led to root fracture [33]

Rosenberg et al., in an in vitro study on Although calcium hydroxide is the gold

human teeth concluded that the intra- standard root canal disinfection material,
canal calcium hydroxide weakened the it is not recommended to be used for
dentine strength by 43.9% after 84 days of teeth that are going to be treated with
application. In this study all teeth were regenerative endodontic techniques.
embedded in plaster blocks that were Banches and Trope [34] have suggested
carved to end at the cervical margins of that the use of calcium hydroxide might
teeth and tested for fracture strength be lethal to the remaining pulpal stem
using a testing machine. One of the cells, which affect future regenerative

1310
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
treatment[35] or possibly disrupt the and thus discontinued root
apical papilla cell reproduction .This is development.[34]
ultimately critical for stem cell survival
CONCLUSION in a number of treatment modalities in
endodontics. Calcium hydroxide is an
Introduction of techniques for one-visit
amazing material which has a number of
apexification provide an alternative
applications in dentistry and especially in
treatment option in these cases. Success
endodontics, apart from being very
rates for calcium hydroxide apexification
economical and ease in handling
are high although risks such as reinfection
properties compare to other material like
and tooth fracture exist. Prospective
MTA (mineral trioxide aggregate) which is
clinical trials comparing multiple and one-
also being used in endodontics recently.
visit apexification techniques are
Calcium hydroxide is still a material of
required. Calcium hydroxide has been
choice which is widely being used for
included within several materials and
various reasons in endodontics, especially
antimicrobial formulations that are used
in rural practice.

REFERENCES:

1. American Association of association of dental traumatology

Endodontics. American Association guidelines for the management of
of Endodontics Glossary of traumatic dental injuries: 1.
th
endodontic terms, 7 edition. Fractures and luxations of
Chicago, IL: American Association of permanent teeth,” Dental
Endodontics, 2003. Traumatology2012, vol. 28, no.1, pp.
2. Andreasen JO. Traumatic injuries of 2–12 .
the teeth. 3. ed. Copenhagen: 6. Nygaard-Ostby B. The role of the
Munksggard;1984. 478p. blood clot in endodontic therapy.
3. T. A. Strom, A. Arora, B. Osborn, N. Acta Odontol Scand 1961;19:323–
Karim, T. Komabayashi, and X. Liu, 46.
“Endodontic release system for 7. Torabinejad M, Chiavian N ; Clinical
apexification with calcium hydroxide application of mineral trioxide
microspheres,” Journal of Dental aggregate. Journal of
Research2012 , vol. 91, no. 11, pp. Endodontics1993, 25, 197–205.
1055–1059 8. Estrela C, Sydney GB. EDTA effect at
4. L. R. G. Fava and W. P. Saunders, root dentin pH then exchange of
“Calcium hydroxide pastes: calciumhydroxide paste.BrazEndod
classification and clinical J. 1997;12-7.
indications,” International 9. O’Neil MJ (Ed.). The Merck index: an
Endodontic Journal1999, vol. 32, no. encyclopedia of chemicals, drugs
4, pp. 257–282 andbiologicals. 13. ed. New Jersey:
5. A. J. DiAngelis, J. O. Andreasen, K. A. Merck & Co., Inc.; 2001
Ebeleseder et al., “International

1311
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
10. Pisanti S, Sciaky I. Origin of calcium 19. Andreasen JO, Farik B, Munksgaard
in the repair of wall after pulp EC. Long-term calcium hydroxide as
exposure in the dog. J Dent Res a root canal dressing may increase
1964;43:641-644 risk of root fracture. Dent
11. Siqueira JF, Lopes HP. Mechanism of Traumatol. 2002; 18:134–7.
antimicrobial activity of calcium 20. Cvek M. Prognosis of luxated non-
hydroxide: a critical review.IntEndod vital maxillary incisors treated with
J1999;32:361 calcium hydroxide and filled with
12. Mitchell DF and gutta-percha: A retrospective
ShankwalkerGB.Osteogenic clinical study. Endod Dent
potential of calcium hydroxide and Traumatol. 1992; 8:45–55.
other materials in soft tissue and 21. Shabahang S, Torabinejad M, Boyne
bone wounds. J Dent Res PP, Abedi H, McMillan P. A
1958;37:1157-1163 comparative study of root-end
13. Bakland LK. Traumatic dental induction using osteogenic protein-
injuries.In: Ingle JI, 1, calcium hydroxide, and mineral
BaklandLK,Endodontics, 4th ed. trioxide aggregate in dogs. J Endod.
Baltimore: Williams and Wilkins 1999; 25:1-5.
1994:764-814 22. Huang GTJ. Apexification: the
14. Metzger Z, Solomonov M, Mass E. beginning of its end. Int Endod J.
Calcium hydroxide r e t e n t i o n i n 2009; 42(10):855-66.
wi d e r o o t c a n a l s wi t h f l a r i n 23. Andreasen JO, Farik B, Munksgaard
g apices.DentTraumatol 2001;17:86- EC. Longtermcalciumhydroxideas a
92 root canal dressing may increase the
15. Walia T, Chawla H, Gauba K. risk of root fracture. Dent
Management of wide open apices in Traumatol.2002;18:134-7.
non vital permanent teeth with 24. Rafter M. Apexification: a review.
calcium hydroxide paste. Dent Traumatol. 2005;21:1-8.
JClinPediatr Dent 2000 ;25(1):51-56 25. Leif Tronstrad ; Clinical Endodontics:
16. KleirDJ,Barr ES.A study of A Textbook, 2nd revised edition
endodontically apexifiedteeth. edn., NY: Thieme.2007
Endod Dent Traumatol 1991;7:112- 26. Chawla HS. Apical closure in a
117 nonvital permanent tooth using one
17. Z. Mohammadi and P. M. H. Ca(OH)2 dressing. ASDC J Dent
Dummer, “Properties and Child. 1986; 53:44-7.
applications of calcium hydroxide in 27. Leonardo MR, Silva LAB, Leonardo
endodontics and dental RT, Utrilla LS, Assed S. Histological
traumatology,” International evaluation of therapy using a
Endodontic Journal2011, vol. 44, no. calcium hydroxide dressing for teeth
8, pp. 697–730 with incompletely formed apices
18. A. L. Frank, “Therapy for the and periapical lesions. J Endod.
divergent pulpless tooth by 1993; 19:348–52.
continued apical 28. Ertugrul F, Eden E, Ilgenli T.
formation,”TheJournal of the Multidiciplinary treatment of
AmericanDental Association1966, complicated subgingivally fractured
vol. 72, no. 1, pp. 87–93 permanent central incisors: two

703
 Muhamad A. et al., Int J Dent Health Sci 2016; 3(1): 1305-1310
case reports. Dent Traumatol. elastic modulus of bovine dentine
2008;24:61-6. with exposure to a calcium
29. Leroy RL, Aps JK, Raes FM, Martens hydroxide paste. Journal of
LC, De Boever JA. A multidisciplinary Dentistry2008, 36, 959-64.
treatment approach to a 34. TWATI, W., WOOD, D., LISKIWEICZ,
complicated maxillary dental T., WILLMOTT, N. & DUGGAL, M.
trauma: a case report.Endod Dent An evaluation of non setting calcium
Traumatol. 2000;16:138-42. hydroxide on human dentine: a pilot
30. CVEK, M ; Prognosis of luxated non- study. European Archives of
vital maxillary incisors treated with Paediatric Dentistry 2009,10, 104-
calcium hydroxide and filled with 109.
gutta-percha. A retrospective clinical 35. LEIENDECKER, A., QI, Y., SAWYER, A.,
study. Endodontics & Dental NIU, L., AGEE, K., LOUSHINE, R.,
Traumatology1992, 8, 45-55. WELLER, R., PASHLEY, D. & TRAY, F.
31. AL-JUNDI, S. ; Dental emergencies Effects of Calcium Silicate–based
presenting to dental teaching Materials on Collagen Matrix
hospital due to complications from Integrity of Mineralized Dentin. J
traumatic dental injures. Dental DentinEndod2012, 38, 829–833.
Traumatology2002, 18 181-185. 36. BANCHS, F. & TROPE, M. ;
32. ROSENBERG, B., MURRAY, P. & Revascularization of immature
NAMEROW, K. ;The effect of calcium permanent teeth with apical
hydroxide root filling on dentin periodontitis: new treatment
fracture strength. Dental protocol? J Endod 2004,30, 196 -
Traumatology2007, 23, 26-29. 200.
33. KAWAMOTO, R., KUROKAWA, H., 37. LIU, H., GRONTHOS, S. & SHI, S.
TAKUBO, C., SHIMAMURA, Y., Dental pulp stem cells. Methods
YOSHIDA, T. & M., M. Change in Enzymol2006, 419, 99 -113.

704

View publication stats