Year : 2010 | Volume
: 28 | Issue : 2 | Page : 110--112
Calcium hydroxide induced apical barrier in fractured nonvital immature permanent incisors
Assistant Professor, College of Dentistry, University of Sharjah, PO Box 27272, Sharjah, United Arab Emirates
K G Vellore
College of Dentistry, University of Sharjah, PO Box 27272, Sharjah
United Arab Emirates
Management of trauma to an immature permanent incisor is a challenge, especially when the pulp is necrotic. The aim of this study is to discuss the management of fractured maxillary right and left central incisors with immature root apex. Radiographic evaluation revealed that the tooth 11 had convergent apical walls, whereas tooth 21 had parallel apical walls; both the incisors were treated with pure calcium hydroxide paste to induce apical development. Follow-up clinical and radiographic examinations confirmed apical barrier at 3 months. Radiograph of tooth 11 with convergent roots showed continued apical development, whereas tooth 21 showed apical bridging, following which root canal was completed in both the teeth. Therefore, in view of the simplicity of this method, we believe that calcium hydroxide can be reemphasized as one of the treatment alternatives for fractured nonvital immature permanent incisors to induce apical barrier.
|How to cite this article:|
Vellore K G. Calcium hydroxide induced apical barrier in fractured nonvital immature permanent incisors.J Indian Soc Pedod Prev Dent 2010;28:110-112
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Vellore K G. Calcium hydroxide induced apical barrier in fractured nonvital immature permanent incisors. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2022 May 24 ];28:110-112
Available from: https://www.jisppd.com/text.asp?2010/28/2/110/66750
Management of traumatic injuries to immature permanent incisors with necrotic pulp tissues is a challenge due to the fact that these teeth have inadequate radicular development. An open apex in a permanent tooth takes approximately 3 years to develop after tooth eruption.  Therefore, following dental injures to an immature permanent incisors with open apex where the dental pulp has undergone necrosis, the best treatment options will be to induce apical closure by apexification procedure followed by complete filling of the root canal. 
Calcium hydroxide has been used as a temporary material for filling nonvital tooth with immature apex, with promising results, where apical closure is achieved in an average period of 12 months.  Controversies exist regarding the need to change calcium hydroxide dressing during the course of treatment before apical closure is achieved. Advocators of a single application claim that calcium hydroxide is only required for initial healing reaction. , However, a few studies have shown that replacing the dressing could be beneficial when symptoms develop or when the material appears to be washed out of the canal when viewed radiographically. ,
Previously, we have reported that fractures in the anterior teeth among 12-year-old Malaysian school children were 11.2%. The interesting observation was that maxillary central incisor was the most traumatized teeth.  The objective of this study is to discuss the management of fractured maxillary right and left central incisors with immature root apex.
A 9-year-old boy came to the dental clinic of Hospital Universiti Sains Malaysia, Malaysia, with the chief complaint of fractured right and left central incisors. The injury occurred at school while he was playing and he reported to the dental clinic after a week. Intraoral examination of the affected teeth showed that fracture involved the pulp and a negative result was obtained when these teeth when tested for vitality. Assessment of the apical root development and periapical regions was done with radiograph. It revealed that the root apex was open in both right and left central incisors with apical radiolucency [Figure 1]. It was also observed that tooth 11 had convergent apical walls, whereas tooth 21 had parallel apical walls. Both the incisors were treated to induce apical development.
After local anesthesia and rubber dam, the pulp chamber was perforated with high-speed round diamond bur with coolant. The necrotic pulp tissues in the chamber were removed with slow-speed round bur and the remnant tissues in the canal were removed with broaches. This was followed by irrigation with 5% sodium hypochlorate and saline. The working length of the root canal was determined with K-file (number 30); this was done to avoid surpassing the apical construction during instrumentation of the canals. The root canals were enlarged with two to three larger caliber files. After this step, the canals were flushed with 5% sodium hypochlorate, moisture form the canal was removed with paper points and then filled with pure calcium hydroxide powder dissolved in distilled water. In order to facilitate further treatment, a cotton pellet was placed on the pulp chamber and sealed with IRM [Figure 2]. Calcium hydroxide treatment was repeated after 30 days due to the presence of symptoms, following which both the incisors were placed under observation.
Follow-up clinical and radiograph examinations were conducted on the first recall visit at 3 months. The incisors were clinically healthy. Radiograph of tooth 11 with convergent roots showed continued apical development, whereas tooth 21 showed apical bridging [Figure 3]. It was decided to open both the teeth to confirm our radiograph findings; to our surprise we were able to appreciate an apical stop clinically. Hence, root canal filling was completed on both incisors [Figure 4].
Calcium hydroxide dressing used in the management of fractured immature upper permanent incisors with necrotic pulp showed apical closure in 3 months. The present findings are in line with previous reports of calcium hydroxide induced barrier formation at 13-67 weeks in 44 nonvital immature incisors.  Interestingly, it was observed that tooth 11 with convergent roots showed continued apical development similar to physiological closure, whereas tooth 21 showed apical bridging, which is in line with previous reports. , Encouraging results in this report where apical closure was observed at 3 months indicated that calcium hydroxide dressing is an efficient material to induce apical closure in nonvital immature permanent incisors.
Although calcium hydroxide induced apexification procedure is well accepted, it still has its inherent clinical problems with reference to patient compliance and thin root canal walls which are vulnerable to fracture during or after treatment.  There is also a concern about the nature of barrier which might be porous or sometimes contain soft tissues.  Patient compliance was not a problem in this study as apical barrier was observed in a short period of 3 months. With regard to tooth root fracture during and after treatment, we are certain that tooth 11 which showed continued apical development similar to physiological closure will not be affected. However, tooth 21 which had parallel apical walls but later showed apical bridging with calcium hydroxide dressing, needs to be placed under observation.
Calcium hydroxide dressing to induce apical closure in immature permanent incisors is well documented in a 12-year follow-up study indicating good clinical results.  In view of the simplicity of this method, we believe that calcium hydroxide can be reemphasized as one of the treatment alternatives for fractured nonvital immature permanent incisors to induce apical barrier.
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