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Apexification in Odontopediatria

Mareo Gorinov Roman 1 Tito Ramirez Erika Yaruska 2

Univ. Third Year Faculty of Dentistry UMSA 2 Univ. Fourth Year Faculty of
Dentistry. writer


Apexification, also called procedure Frank, apexification or apical closure is a

method that aims to return function to the tooth, where the operator is responsible
for removing all the material pulp with the use of endodontic instruments and

This procedure is recommended in the infant stage, especially in cases of dental

trauma with pulp necrosis in acting parts, considered one of the most common
injuries. It is therefore necessary removing bacteria and necrotic tissue ducts, to
stimulate the process of apical closure; for which a paste made based on calcium
hydroxide and water, which also has a bactericidal function, uniform solution and
an alkaline pH is used.

During treatment should be careful not to spread in the walls of the root, because
they decrease in thickness and are prone to any type of fracture, to prevent this
effect , the canal is irrigated with sodium hypochlorite or a non - irritating solution
as the solution sterile saline, which helps to remove necrotic tissue. The advantage
of the apexification, is to take a treatment without discomfort or pain with the help
of local anesthetics that facilitate patient intervention.

KEYWORDS apexification. Endodontics. Necrosis.


A newly erupting permanent tooth has an incomplete root formation, with an open
apex, called immature tooth;in the pulp can be any type of pathology that alters
the apical closure. Therefore, it is considered to apexification as a useful procedure
in cases of pathologies or causing fractures pulp necrosis and lack of development
of dental apices. 1-3

In most young patients treated with this procedure suffered some type of trauma,
usually the anterior teeth are affected causing coronary lesions, as a result absorb
the blow and are fractured, causing discomfort and pain, there dentinal
commitment and pulp. Because of the above injuries you can be classified into:

uncomplicated tooth fracture. Does not affect the pulp

complicated tooth fracture. Having a commitment to the pulp.

Meanwhile in posterior teeth pulp necrosis is the injury that prevails, both poor oral
hygiene and uncontrolled patients cavities, which can affect the root portion of the
teeth by microorganisms that live in these areas . 3

There are several materials to start filling in root pieces, the most prominent are:

1. Calcium Hydroxide: One of the most used materials for this mineralization is
calcium hydroxide, is identified by a bottle containing a poorly soluble white powder
obtained from the combustion of calcium carbonate. It is considered a good sealer
pulp canals and pulp protection while allowing irrigation with sodium
hypochlorite;currently in disuse because it has disadvantages, such as coronary
micro filtration so that consultations are repeated by the patient. Fillings with this
material require adequate control by radiographs, often generating asa result,
deformation of the apical barrier, aesthetic problems and high costs. 4

2. MTA (Mineral Trioxide Aggregate): Some authors cite the use of MTA in
apexification treatments. The first procedure with this material was performed by
Torabinejad M. in 1993. This type of material is composed of tricalcium silicate,
tricalcium oxide, tricalcium aluminate and other minerals existing ducts sealed in
the pulp chamber, root canal system and spaces of the piece perpendicular
destroyed. The advantage of this material is the speed between the first application
and the final restoration process also reduces to nothing about the time between
consultations after the first application.

Although calcium hydroxide and MTA are the compounds most used in treatments
apexification, rescue is possible using other combination, such as tricalcium
phosphate, tricresol and formalin, and calcium phosphate gel. 4-5

At present the discussion on the effectiveness of MTA and calcium hydroxide is

relevant because many professionals mention that the use of MTA produces closed
conduits and ignore its action on inflamed areas;This material is effective in sealing
small lesions in one session, although there are other authors who discuss the
effectiveness of this material. Calcium hydroxide is used as an alternative to control
the evolution of the damaged part, also it is not proven the ability to completely
isolate the ducts.

The use of MTA seeks to establish a rigid defense which can compact the filling
material without waiting for the formation of the barrier osteocemento, while
promoting the formation of the barrier after completion of the procedure. 5


In apexification, all content pulp to the apex appreciable on radiographs with use of
endodontic files and reamers is eliminated. The most commonly used and
recommended are:

Limas K. instruments are made of stainless steel, hand - operated; fulfill the
main function of root canals extend by a sharp action wearing the hardest portion
of the tooth is the dentin, it is also useful for examining and verifying the duct
lengths. K limes, are driven by orders related to clockwise, in one sense, because
its leaves are distributed in one direction.

stretchers are also hand - operated and stainless steel, have the function of
pressing, pushing or enlarge the root canal and thus place some type of sealant
cement, concludes with the seal. 6

These instruments will not fracture unless they have manufacturing defects, or
manual overexertion in the duct causes breakage of the instrument, therefore
should not be reused because wear can cause rupture, abscesses or lesions
in the mouth.


The techniques used in the apexification are:

Technical Frank, is the temporary root canal filling with calcium hydroxide, for
quick and easy separation, the result is similar to uni and multiradicular pieces. The
procedure begins with the isolation, preparation of access ducts and conducting the
Conductometry, ie, take lengths of the roots with the help of K files
radiographically; then clean and dry the canal, an irrigator as sodium hypochlorite
is used to facilitate the process, once the preparation of the dough is made and
introduced together with the dentinal sealants. The patient must make a control
piece 4 to 6 months, the dentist has an obligation to take X - rays and make an
assessment of the apex.

Technical Maisto, differs from the prior art for the last step, this technique
makes the seal and seal with a paste on the conduit; pure calcium hydroxide is
used in powder and distilled water as liquid.

Lasala technique, is distinguished from the prior art by about sealing paste is
removed from the duct at 1.5 to 2 mm. Apex, lavage is performed and reobtura
order to condense the resorbable paste. 7


The abundant irrigation with a solution of sodium hypochlorite or a non - irritating

solution such as sterile saline or local anesthetic solution help to remove all necrotic
tissue living. Calcium hydroxide mixed with distilled water in the apical portion of
the root canal is placed, covered with a sterile cotton pellet, and are sealed with a
temporary restoration.

Calcium hydroxide dissolves progressively; therefore, it is replaced every few

months to producing the apical closure, six months and one year later; an apical
barrier which can be completed with gutta - percha required endodontic procedure
is presented.

Several studies demonstrate the success of calcium hydroxide for its effectiveness
in forming the apical end;between some materials used are the Puldenta consisting
of calcium hydroxide, methylcellulose and barium sulfate, and Reogen Rapid, whose
content is calcium hydroxide, barium sulfate, calcium oxide, magnesium oxide,
casein and distilled water . 8-7

After treatment, X - ray reveals a complete apical closure can be considered a

porous osteodentine or cementoid bridge, so the dentist should perform regular
checks of the piece, careful clinical screening within the root, to confirm the closure.

There are several factors that can influence the time it takes the formation of apical
closure, among which are:

The space teeth apexes <2 mm in diameter, the treatment is short.

The newly erupted teeth require less time for apexification, therefore, it is taken
into account age.
In infections has demonstrated periapical radiolucency appearance early in the
procedure extends the time in forming the closure. The manifestation of discomfort
or pain may delay the time of the apical seal.

The insistence of time calcium hydroxide still not been established and consent to
the rate of change of material. 1

Have detailed two types of bioremediation:

continued root growth

Close the apex with calcified material.

The alkaline pH and calcium ions are involved in separate or synergistic roles,
calcium required for formation of the apical bridge makes a systemic route. Recent
studies show a phenomenon of calcium carbonate crystals, these were the product
of a reaction between carbon dioxide in the pulp tissue material and
calcium; where itwas observed that OH ions induce the development of a superficial
necrotic layer which acts as a bonding surface for pulp cells, directing bridge
formation. Studies report a success rate of 94 to 96% in immature permanent
incisors as a result of the strong antibacterial property of calcium oxide is related to
its high pH 12.1-5-9

Apexification is similar to changes in mature permanent teeth in which the contents

of the root canal is excluded in its entirety and replaced with calcium
hydroxide. This procedure is performed in the presence of external or internal
pathological root resorption after a traumatic injury, in order to stop the
progressive root loss. It is a beneficial treatment for the patient but still
apexification should be required as a last request in the teeth with apex totally
immature 9-10 .

Care should concentrate on the preservation of vitality in the teeth so that it can
become a root, especially if the tooth with incomplete apex is squeezed or develops
a periapical pathology, the preferred treatment is apexification. The direct and
indirect pulp capping and pulpotomy demonstrate their guarantee, in cooperation
with irrigation when the apex is still open. 10


1. Acua C. Apexification. Colombia. National university of Colombia. 2009. URL

available at:
ml . Accessed August 1, 2012.

2. R. Walton Endodontics principles and practices. 4 th

edition. Barcelona,
Spain. Editorial Elsevier. 2006;. 34-39[ Links ]

3. apexogenesis and Apexification. Guadalajara. University of Guadalajara. 2008.

URL available at: . Access
date: August 1, 2012.

4. Technical Endodontics S. Goldberg and

foundations. 1 st edition. Spain. Panamericana Editorial. 2006; 115-121. [ Links ]
5. Apexification as an alternative to maintain a tooth in function. Cartagena. Faculty
of Dentistry at the University of Cartagena. 2006. URL available at:
_mantener_un_diente_en_funcion_reporte_de_un_caso.pdf . Access date: August
3, 2012.

6. S. Cohen Pathways of the Pulp. 9 th

edition. Barcelona, Spain. Editorial
Elsevier. 2008; 878- 889. [ Links ]

7. R. Rivas Endodontics Endodontics Pediatric and Geriatric. Mexico. Available

in: . Access date: August 22,
2012. [ Links ]

8. R. Jimenez Odontopediatria in primary care. 3 rd

edition. Spain. Editorial
Vertex. 2008. 138-142 [ Links ]

9. Muoz. Histology Embryology and Tissue Engineering dental

Buco. 3 rd edition. Madrid Spain. Panamericana Editorial. 2005; 239-242. [ Links ]

10. Bordoni N. Pediatric Dentistry. 1 st

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Editorial. 2006; 498-500. [ Links ]

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