Apexification of an Immature Permanent Incisor with the Use of Calcium Hydroxide: 16-Year Follow-Up of a Case

Abstract

Apexification is a process of forming a mineralized apical barrier and had been performed by using calcium hydroxide paste, due to its biological and healing performances in cases of existent trauma. This clinical report aims to report the results of a 16-year follow-up study of an apexification treatment applied to nonvital tooth 22 of a healthy 8-year-old male after a trauma. Clinical inspection of the tooth showed fractures of the incisal edge and mesial angle, absence of coronal mobility, and negative pulp vitality under cold testing. Radiographic analysis of the root revealed incomplete apex formation. The possibility of fracture into the root or luxation injury was rejected, and the diagnosis of pulp necrosis was verified. Apexification by calcium hydroxide and subsequent endodontic treatment were planned. Initial formation of the mineralized apical barrier was observed after 3 months, and the barrier was considered to be completed after 8 months. Clinical, radiographic, and CBCT examinations after 16 years verified the success of the treatment, although the choice of calcium hydroxide for apexification treatment is discussed.

Figure 1

The initial periapical radiograph revealed the absence of fracture lines on the root structures, increased periodontal ligament spaces apically, or any radiolucent lesion in apical area of the injured incisors (first session; March 1998).

Figure 2

Periapical radiograph of the initial exploration of root canals (first session; March 1998).

Figure 3

Periapical radiograph showing the root canal treatment of tooth 21 after 1 month (third session; April 1998).

Figure 4

Periapical radiograph after 1 year of starting treatment showing the apical barrier formation after 8 months (seventh session; March 1999).

Figure 5

Periapical radiograph: root canal treatment finished in tooth 22 and tooth 21 in good condition after 1 year (seventh session; March 1999).

Figure 6

Radiograph of thirteen-year follow-up (March 2012).

Figure 7

Radiograph showing the long-term success of apexification and root canal treatment of tooth 22 after fourteen and half years of follow-up and root canal treatment of tooth 21 after fifteen and half years (October 2013).

Figure 8

Clinical aspect showing the normal function of teeth 21 and 22 (October 2013).

Figure 9

Cone beam computerized tomography and 3D rendering of tooth 22, visualized by the use of Avizo Fire software for Windows (Visualization Science Group, 33700 Mérignac, France). (a) 3D anterior view showing the apexification of tooth 22. (b) Anteroposterior slide in the same position of (a). (c) 3D posterior view. (d) 3D distal view. (e) Mesiodistal slide in the same position of (d). (f) Mesial view. (g) Frontal slide in the middle of tooth 22 showing a complete formation of periapical bone around apex. (h) The same view from (g), but with lower bone density performed by the software. It can be observed that the periapical bone was maintained. (i) Diagonal slides mixing 2D and 3D views, where the complete apexification and formation of periapical bone can also be found.