GD556 - Evidence-based approach to apexification: a literature review and novel clinical protocol-GD556

GD556 - Article

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This literature review examines apexification for immature permanent teeth with necrotic pulp and presents a step-by-step, evidence-based clinical protocol. Apexification is used to create a calcified barrier at the open apex so the root canal can be sealed and restored. It remains a reliable option, especially when immediate, predictable treatment is needed, but it does not promote further root growth.<br /><br />The article compares three main barrier materials: calcium hydroxide, mineral trioxide aggregate (MTA), and Biodentine. Calcium hydroxide is traditional but requires long treatment times, multiple visits, and can weaken fracture resistance over time. Contemporary calcium silicate–based materials, especially MTA and Biodentine, offer better predictability, biocompatibility, sealing ability, and tooth strength. Biodentine has the advantage of a much shorter setting time than MTA.<br /><br />Based on a review of 34 recent English-language studies, the authors outline a practical protocol: confirm the diagnosis, obtain consent, isolate the tooth, disinfect the canal with sodium hypochlorite and EDTA, and minimize instrumentation because immature roots have thin dentin walls. For barrier placement, the protocol recommends Ca(OH)2 only when newer materials are unavailable, and favors MTA or Biodentine as apical plugs, typically 3–5 mm thick. A resorbable collagen matrix may be used to prevent extrusion. Final restoration should be completed with gutta percha and an appropriate coronal build-up, followed by periodic radiographic monitoring.<br /><br />The review also discusses regenerative endodontic therapy as an alternative that may allow continued root development, but notes it is less predictable, more biologically complex, and can involve discoloration or other complications. Overall, apexification—especially with MTA or Biodentine—remains a dependable treatment for immature necrotic teeth.

Keywords

apexification

immature permanent teeth

necrotic pulp

mineral trioxide aggregate

MTA

Biodentine

calcium hydroxide

apical barrier

endodontic protocol

regenerative endodontic therapy