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Table of Contents
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 119-121

Apexification in primary central incisor

1 Consultant, Paedodontist, Clove Dental, New Delhi, India
2 Consultant Pedodontist, Practitioner, Mumbai, Maharashtra, India
3 Senior Lecturer, Department of Paedodontist, Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India
4 Consultant Paedodontist, Clove Dental, New Delhi, India
5 Senior Lecturer, Department of Public Health Dentistry, Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India

Date of Submission13-Jul-2020
Date of Acceptance17-Aug-2020
Date of Web Publication29-Dec-2020

Correspondence Address:
Dr. Aarti Kumari
Department of Public Health Dentistry, Hazaribag College of Dental Sciences and Hospital, Demotand, Hazaribag, Jharkhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INPC.INPC_30_20

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The upper deciduous incisors are frequently the teeth most commonly affected either by dental caries or due to the impact of trauma. In such cases, there may be complete coronary destruction of teeth. As they erupt around 7½–9 months of age and the roots only complete at approximately 18–24 months, pulp involvement may occur even before the end of this process. Hereby, we highlight the case of a 15-month-old male patient who reported with a history of trauma. Treatment plan of apexification was made after confirming with multiple radiographs. Root-end closure was obtained after a period of 7 months.

Keywords: Apexification, calcium hydroxide, deciduous incisors, Metapex

How to cite this article:
Mohan N, Sharan S, Patel S, Nigam D, Kumari A, Chatterjee S. Apexification in primary central incisor. Int J Prev Clin Dent Res 2020;7:119-21

How to cite this URL:
Mohan N, Sharan S, Patel S, Nigam D, Kumari A, Chatterjee S. Apexification in primary central incisor. Int J Prev Clin Dent Res [serial online] 2020 [cited 2021 Jan 16];7:119-21. Available from: https://www.ijpcdr.org/text.asp?2020/7/4/119/305286

  Introduction Top

The completion of root development in permanent teeth usually takes place after 3 years of eruption.[1] Therefore, traumatic injuries occurring during this development period can result in inflammation of the pulp, progressing to necrosis, compromising the normal root growth, impairing the apical closure, and hampering the development of young permanent teeth.

Management of such cases has evolved from the standard apexification, apexogenesis protocols using calcium hydroxide, Metapex®, and Vitapex® pastes to the recent techniques of revascularization and regeneration for induction of apical closure.

Apexification is a procedure to promote the formation of an apical barrier to close the open apex of an immature tooth with a nonvital pulp such that the filling materials can be contained within the root canal space.[2] The capacity of various materials evolved over a period of time to induce the formation of this calcific barrier at the apex made the apexification procedure possible and in turn allowed the preservation of many compromised, immature teeth with nonvital pulps by endodontic and restorative means.

Clinically, when the immature tooth is diagnosed as nonvital, apexification is performed to induce root-end closure, but with an understanding that there will be no more development of the root in terms of apical maturation and thickening of its dentin walls. Whether this procedure can be successfully used in primary teeth still remains unknown. Furthermore, in the literature studied, there are few reports on the use of the apexification method in deciduous dentition.[3]

The routine calcium hydroxide method enables development process of the apex to retain its growth potential, allowing the root canal to be filled using routine endodontic procedures.[4] Therefore, the apical closure of immature deciduous teeth, through apexification, would allow the permanent filling material to be restricted to the root canal, thus avoiding dispersion to the periapex and consequently increasing the chances of success of the pulp therapy.[4],[5],[6],[7],[8]

Hereby, we discuss a unique case of root closure achieved after an apexification procedure performed in a traumatized deciduous maxillary right central incisor.

  Case Report Top

A 15-month-old boy reported with a chief complaint of tissue overgrowth in the upper front tooth region for 5 days [Figure 1]. History revealed the presence of trauma 11 days back when he experienced a fall from the stairs and broke one of his upper front teeth. There was the presence of an associated diffuse swelling at the time of fall. He was taken to a private practitioner where medication was prescribed for pain relief. Two days posttrauma, the parents observed the overgrowth in the same region.
Figure 1: Preoperative

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Clinically, intraoral examination showed a developing primary dentition stage with the presence of Ellis Class IX fracture with respect to 51. The cervical third of the clinical crown with the tissue overgrowth resembling the shape of the maxillary right primary central incisor was observed, which, on inspection, appeared pale pink with tenderness on palpation. There was Grade 1 mobility noted with respect to 61. Radiographic interpretation was advised.

Preoperative intraoral periapical radiograph revealed the presence of an open apex with respect to 51 and 61. In addition, a striking feature observed was the presence of bilateral inverted impacted supernumerary teeth superimposed with the permanent central incisors [Figure 2]. The future treatment modality of extractions of the supernumerary teeth as well as the routine follow-up protocol was explained to the parents, after which a provisional diagnosis of hyperplastic pulpitis with respect to 51 and subluxation with respect to 61 was made.
Figure 2: Preoperative radiograph with the presence of open apex with respect to 51 and 61. Also seen is the presence of bilateral supernumerary teeth

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An attempt for an apexification procedure with respect to 51 with esthetic corrections and complete follow-up until the eruption of the permanent successors was planned. Excision of the hyperplastic pulpal tissue was done under local anesthesia, followed by gaining access. The tissue was sent for histopathological evaluation. Following thorough debridement and working length estimation, the canal was irrigated and dried with paper points. The tooth was obturated with Metapex and sealed with glass ionomer cement [Figure 3]a.
Figure 3: (a) Metapex obturation and (b) postoperative intraoral periapical revealing apical root-end closure with respect to 51

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Histopathological report confirmed the diagnosis of pulp polyp with respect to 51. Routine follow-ups were done, and after a period of 7 months, the patient reported with the complaint of dislodgment of the coronal seal. An intraoral periapical radiograph was advised, and it was observed that the apical root closure was attained with respect to 51 and 61 [Figure 3]b. The mobility with respect to 61 had also resolved completely. Therefore, the apexification procedure was rendered successful following a second phase in the treatment. Esthetic restorations were done by the placement of a composite post with strip crown.

  Discussion Top

Physiological completion of apical root formation depends on the maintenance of vitality of the tissues that form root dentin and apical periodontal ligament.[1] If the maxillary central incisor, as in the present case, was left untreated, the permanent successor can develop a hypoplastic lesion.

According to Soares et al. (2008),[1] the favorable clinical, radiographic, and histological responses obtained with calcium hydroxide, the material of choice, are related to the participation of Ca++ and OH− ions in several mechanisms which would provide: (i) control of the inflammatory reaction; (ii) the neutralization of acidic products of osteoclasts; (iii) the induction of mineralization; (iv) the induction of cell differentiation; (v) the depolymerization of endotoxins; and (vi) antibacterial action by means irreversible damage to DNA, proteins, enzymes, and bacterial lipids. The success rates range from 94% to 96% in immature permanent incisors.[9]

The mixture of calcium hydroxide and iodoform (Metapex and Vitapex) is being used to obturate root canals of primary teeth. It resorbs a little faster than the rate of root resorption; it is easily applicable, causing no toxic effect on permanent successors. However, its use in apexification has been reported confined to permanent teeth only.[10] On the contrary, the present case showed clinical and radiographic success in achieving apical root closure in primary teeth. Therefore, the follow-up of the treated tooth with Metapex showed the absence of clinical symptoms and continued hard-tissue formation at the apex.

Although apexification was a success for this case, periodic routine follow-ups are mandatory to examine the eruption of the permanent successors. Sometimes, extraction of primary incisors is necessary to correct lingual eruption of the permanent incisors, usually in the maxillary arch. Starkey believes that this phenomenon occurs when normal physiologic exfoliation is delayed by the bulk of cement contained in the pulp chamber.[11] Although the material is resorbable, the resorption process may get affected.

Therefore, in the case of possible space loss, one may attempt to perform apexification of necrotic immature primary incisors rather than extraction. More studies should be conducted on the success rate and its consequences. As the literature supports only one such similar study conducted in primary teeth, one should not overlook the potential side effects that may develop after pulp therapy has been completed such as iatrogenic damage to the developing tooth bud or possible reinfection of the primary incisor.[11]

  Conclusion Top

Metapex has shown a good clinical and radiographic success in promoting continued root growth and inducing apical closure in primary teeth. Hence, it can be used as an alternative to the traditional calcium hydroxide for apexification procedures to be done in primary teeth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Soares J, Santos S, Ce'sar C, Silva P, Sa'´M, Silveira F, et al. Calcium hydroxide induced apexification with apical root development: A clinical case report. Int Endo J 2008;41:710-9.  Back to cited text no. 1
McDonald RE. Avery DR. Management of trauma to the teeth and supporting tissues in dentistry for the child and adolescent. Elsevier 2000;9:485-542.  Back to cited text no. 2
O'Riordan M. Apexification of deciduous incisor. J Endod 1980;6:607-9.  Back to cited text no. 3
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 1966;72:87-93.  Back to cited text no. 4
Turner JG: Two cases of hypoplasia of enamel. Br J Dent Sci 1912;55:227-28.  Back to cited text no. 5
Englan MC. Best E. Noninduced apical closure in immature roots of dogs' teeth. J Endod 1977;3:411-7.  Back to cited text no. 6
Chawla HS, Tewari A, Ramakrishnan E. A study of apexification without a catalyst paste. J Dent Child 1980;47:431-4.  Back to cited text no. 7
Camp JH. Pediatric endodontic treatment. In: Cohen S. Burns RC. Pathways of the Pulp. Elsevier: 1998. p. 718-58.  Back to cited text no. 8
Kerekes K, Heide S, Jacobsen I. Follow-up examination of endodontic treatment in traumatized juvenile incisors. J Endod 1980;6:744-8.  Back to cited text no. 9
Sridhar N, Tandon S. Continued root-end growth and apexification using a calcium hydroxide and iodoform paste (Metapex®): Three case reports. J Contemp Dent Pract 2010;11:63-70.  Back to cited text no. 10
Trairatvorakul C. Apexification of a primary central incisor: 6-year follow-up. Pediatr Dent 1998;20:425-7.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]


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