Apexification: A Clinical Guide step by step

what is apexification?

Understanding Immature Teeth

Immature lower first molar

Immature teeth, typically seen in children and adolescents, have an underdeveloped root structure. The apex, or the tip of the root, remains open, and the walls of the root canal are thin and fragile. This condition is often the result of trauma or infection before the root has fully formed. In a mature tooth, the apex is closed, providing a natural seal that prevents bacteria from entering the tooth's pulp. However, in immature teeth, this open apex makes conventional endodontic procedures challenging.

When is Apexification Necessary?

Apexification is indicated in cases where the tooth's pulp becomes necrotic (dead) before the root has fully developed. Common causes include:

- Trauma: A blow to the tooth that disrupts blood supply and damages the pulp.

- Infection: Deep decay or untreated cavities that lead to pulp necrosis.

- Developmental issues: Conditions that prevent normal root development.

The primary goal of apexification is to create a hard tissue barrier at the root's apex, enabling the dentist to seal the root canal effectively and prevent reinfection.

Apexification Procedure

how to do apexification?

Apexification is a multi-step process that typically requires several visits to the dentist. The procedure involves the following steps:

1. Initial Assessment: 

The dentist begins with a thorough examination of the tooth, often involving X-rays to assess the extent of root development and determine the condition of the surrounding tissues.

Patient has trauma 3 months ago! pain with percussion, no response to cold or hot test

access cavity preparation

2. Pulp Removal:

 The necrotic pulp tissue is removed from the root canal system. The dentist carefully cleans and disinfects the canal to eliminate any bacteria that could cause further infection.

working length determination then remove all necrotic pulp

3. Inducing Hard Tissue Formation:

 Traditionally, calcium hydroxide paste is placed inside the root canal to stimulate the formation of a calcified barrier at the apex. This paste encourages the deposition of hard tissue over several months.

   - Mineral Trioxide Aggregate (MTA): In recent years, MTA has emerged as a popular alternative to calcium hydroxide. MTA is a biocompatible material that forms a more predictable and durable barrier, often requiring fewer visits than calcium hydroxide treatment.

Mineral Trioxide Aggregate (MTA) application

The following video explains MTA placement in distal root in lower molar 

4.follow up:

 After placing the calcium hydroxide or MTA, the dentist temporarily seals the tooth and schedules follow-up appointments to monitor the progress. X-rays are taken periodically to check for the formation of the calcified barrier.

5. Final Root Canal Treatment: 

Once the barrier has formed, the dentist completes the root canal treatment by filling the canal with a permanent material, such as gutta-percha, and sealing the tooth with a crown or filling.

obturation after apexification

Advantages and Challenges of Apexification

Apexification offers several benefits, including the preservation of the natural tooth, prevention of further infection, and restoration of normal function. It is particularly valuable for young patients, as it allows time for continued root development and strengthens the tooth over time.

However, apexification also presents challenges. The procedure can be time-consuming, often requiring multiple visits and extended monitoring periods. Additionally, immature teeth with thin root walls remain vulnerable to fracture, even after successful apexification.

Recent Advances

With advancements in dental materials and techniques, apexification has become more predictable and efficient. The introduction of MTA has significantly reduced the time required for barrier formation, leading to better outcomes for patients. Furthermore, regenerative endodontic procedures, which aim to stimulate natural root development, are emerging as a promising alternative to traditional apexification.

Conclusion

Apexification remains a crucial procedure in the management of immature teeth with necrotic pulps. By creating a calcified barrier at the root apex, dentists can preserve the tooth and restore its function. While the procedure has its challenges, advancements in materials and techniques continue to improve success rates and patient outcomes. For young patients with developing teeth, apexification offers a vital opportunity to save their natural teeth and maintain oral health.