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CLINICAL ARTICLE
Apex formation during orthodontic treatment in an
adult patient: report of a case

L. R. G. Fava
Endodontic Practice, SaÄo Paulo, Brazil

Abstract treatment. The pulp of the tooth had become necrotic

Fava LRG. Apex formation during orthodontic treatment in
an adult patient: report of a case (Clinical Article). International
Endodontic Journal, 32, 321±327, 1999.
This clinical report describes an apexification procedure
on a maxillary left central incisor in a 34-year-old
male who was also receiving active orthodontic
following a traumatic injury when the patient was
8 years of age. Despite the tooth undergoing active
orthodontic repositioning with fixed appliances, root-
end closure occurred uneventfully and within 3 years.
Keywords: Keywords: calcium hydroxide, dental
trauma, incomplete root formation, orthodontics.

Case report et al. 1973, England & Best 1977, Nicholls 1977, Lasala
1979, Weine 1989).
Introduction Many materials, as well as calcium hydroxide, have
been employed in apexification to act as inductors for
Apexification is a procedure to induce apical closure
hard tissue deposition (Cooke & Rowbotham 1960,
through the deposition of a mineralized tissue barrier at
Ball 1964, Bouchon 1966, Rule & Winter 1966,
the apical root-end in a non-vital tooth with an open or
Friend 1967, Rowe & Binnie 1974, Koenigs et al.
immature apex. The first report suggesting this procedure
1975, Vojinovic & Srnie 1975, Coviello & Brilliant
was by Marmasse (1953) whilst Granath (1959)
1979). Other studies have shown that apical healing
reported clinical cases in traumatized teeth. However, the
occurs only after control of infection (Chawla et al.
clinical guidelines for apexification only became popular
1980, Das 1980). However, the use of calcium
after verbal presentations by Frank (1964) and Kaiser
hydroxide powder alone or as a paste has become the
(1964) and subsequent publications (Maisto & Capurro
most accepted medicament to achieve the objectives of
1964, Frank 1966). Many studies have been performed
apexification, which are apical healing and the
in both humans and laboratory animals dealing with the
deposition of a mineralized barrier at the root apex.
presence or absence of Hertwig's root sheath, the nature
Generally the paste is composed of calcium hydroxide
of the mineralized tissue (osteocementum, osteodentine,
powder, a vehicle, a radiopacifier and other substances
bone or combinations), whether the barrier is porous or
to improve its physical properties such as flow and
not, the types of barriers and where they are located, and
consistency (Fava 1991).
whether root development or lengthening may or may
One of the most frequent causes of pulp necrosis in
not take place (Cooke & Rowbotham 1960, Ball 1964,
immature permanent anterior teeth is traumatic injury
Frank 1966, Friend 1967, Michanowicz & Michanowicz
(Sheehy & Roberts 1997). Often the injury occurs
1967, Heithersay 1970, Dilewski 1971, Holland et al.
when the patient is a child, but signs and symptoms of
1971, Ham et al. 1972, Holland et al. 1973, Torneck
periradicular inflammation do not appear until
adulthood. In these cases, the patient frequently
Correspondence: L.R.G. Fava DDS, Av. Nove de Julho, 5483 98 andar complains of the characteristic symptoms of inflamma-
s. 91, 01407-200 SaÄo Paulo, Brazil. tory periapical disease and history of trauma during

q 1999 Blackwell Science Ltd International Endodontic Journal, 32, 321±327, 1999 321
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Apex formation during orthodontic treatment Fava

childhood. Radiographic examination often shows an

immature tooth with an open apex and bone
resorption. Occasionally, the image reveals a routine
root canal treatment with gutta-percha obturating the
root canal is often noted. Failure or inadequate
treatment because teeth with a wide or funnel-shaped
open apex are difficult to prepare and obturate satisfac-
torily (Mandel & Bourguignon-Adelle 1996).
Apexification in adult patients is a reliable
treatment. Although no studies have been published
dealing with success and failure rates, it seems that
success is independent of the age of the patient (Van
Hassel & Natkin 1969, Oswald & Van Hassel 1983,
Rotstein et al. 1990, Schumacher & Rutledge 1993,
Sousa Neto et al. 1996, Parashos 1997).
Other clinical problems occur when apexification
procedures are performed in conjunction with
orthodontic treatment. Indeed, it is unclear whether
orthodontic treatment should be undertaken at the same
time as apexification. The forces generated by orthodontic
appliances predispose to resorption and apposition of the Figure 1 Preoperative radiograph.
periradicular hard tissue structures. This may impair the
deposition of the calcific barrier at the apex. procedure some filling material was pushed through
This paper discusses the apexification of a previous the open apex into the periradicular lesion. It is
traumatized maxillary incisor concomitant with interesting to note that the gutta-percha was so
orthodontic treatment. dispersed within the root canal that no solvent was
necessary; the removal was performed with HedstroÈm
files alone. A crown-down biomechanical preparation
Case report
was started until the instrument reached the apical
In October 1995, a 34-year-old man was seen who was third of the root canal (Fig. 2). The working length
complaining of some discomfort on biting and the was determined and the preparation was performed
presence of a `strange area' on the gingival mucosa with until clean dentinal chips were removed from the root
intermittent discharge of pus and exudate that had canal. During the whole procedure, the root canal was
occurred during the previous 2 weeks. A fixed repeatedly irrigated with 1% sodium hypochlorite
orthodontic appliance was in place to correct the position solution. About 2 mL of the solution was delivered
of various teeth including the affected one. A history of a after the use of each instrument using a syringe and a
traumatic injury on his upper left central incisor when 27-gauge needle. Only triangular cross-sectioned files
he was about 8 years old was obtained. The patient also for hand use (Flexofile; Dentsply Maillefer, Ballaigues,
related that on that occasion his mother took him to the Switzerland) were employed and the master apical file
family dentist who performed endodontic treatment of was size 80 although the diameter of the root canal
the affected tooth because of pulp necrosis. The tooth was larger than that of the last file.
remained asymptomatic until this episode. The canal was then dried and dressed with a
The clinical examination revealed the presence of a calcium hydroxide paste composed of calcium
sinus tract and a slight positive reaction to palpation hydroxide (2.5 g), zinc oxide (0.5 g), staybelite resin
and vertical percussion tests. The radiographic (0.05 g) and polyethyleneglycol 400 (1.75 mL) (Calen;
examination showed an area of periapical radiolu- S.S. White Artigos DentaÂrios, Rio de Janeiro, RJ, Brazil)
cency, an open apex and some gutta-percha filling using a Lentulo spiral filler. Some paste was extruded
material within the root canal (Fig. 1). into the periradicular tissues as shown in Fig. 3.
During this appointment the tooth was isolated with A sterilized cotton pellet was used to remove the
rubber dam, access to the root canal gained and the excess of the paste from the access cavity and another
filling material removed. Unfortunately, during this one was placed in the root canal orifice. The access

322 International Endodontic Journal, 32, 321±327, 1999 q 1999 Blackwell Science Ltd

Figure 2 Root length determination. Note a small piece of
gutta-percha within the periradicular tissues.
cavity was sealed with Cavit (ESPE, Seefeld, Germany).
The reviews were carried out in November 1995
(Fig. 3) and January 1996 (Fig. 4). At both appoint-
ments the sinus was still active with some discharge of
Figure 3 Forty-five days after the start of the treatment.
Note the calcium hydroxide paste inside the root canal along
with some extrusion into the periapical lesion.
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Fava Apex formation during orthodontic treatment
exudate. The root canal was re-entered, irrigated with
5 mL of 1% sodium hypochlorite solution, dried and
re-dressed with the same calcium hydroxide paste.
Again Cavit was employed to seal the access cavity.
During the following year (1996), reviews and re-
dressings were performed at 3-month intervals and the
final one was carried out in December (Fig. 5). During
this year the sinus became inactive and radiographic
examination showed healing of the periradicular
lesion, although there was no evidence of hard tissue
deposition at the root apex.
During 1997 the reviews and re-dressings with the
paste were performed in March, July and November
(Fig. 6) using the same procedures and materials. At
that time no signs of the periradicular lesion could be
observed either clinically or radiographically. A few
days before the last review the orthodontic appliance
had been removed.
In February 1998 there were no further signs and
symptoms, a calcified barrier was detected at the root
apex and healing was evident radiographically. The
root canal system was definitively filled with gutta-
percha and a calcium hydroxide-based root canal
sealer (Sealapex; Sybron/Kerr, Romulus, MI, USA)
using cold lateral condensation (Figs 7 and 8). Unfor-
tunately, no more review appointments have been
scheduled because the patient has moved to another
city.
Figure 4 Three months after the start of treatment.
International Endodontic Journal, 32, 321±327, 1999 323

Apex formation during orthodontic treatment Fava
Figure 5 Fourteen months after the start of treatment. Note
the evidence of healing of the periradicular lesion although
the root apex is still open.
Figure 6 Two years after the start of the calcium hydroxide
therapy. Note the apical remodelling and the absence of the
periradicular lesion.
Discussion
Dental injuries occur most often between the ages of 8
and 11 years and consequently may involve immature
324 International Endodontic Journal, 32, 321±327, 1999
13652591, 1999, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1365-2591.1999.00230.x by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [09/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Figure 7 Mineralized barrier at the root apex. Two size 80
gutta-percha points were custom-fitted to the apical barrier.
Figure 8 Final obturation of the root canal system.
teeth (Jacobsen 1986). On the other hand, many cases
that require orthodontic correction fall in the age
range between 12 and 16 years (Anthony 1986).
However, it is rare for both situations to occur in
adulthood.
Clinically, apexification in adults follows the same
q 1999 Blackwell Science Ltd

steps as that in children. This means the elimination of
infection by adequate debridement and correct
preparation of the root canal system followed by an
inter-appointment dressing which will allow repair of
the pre-existing periapical lesion and induce healing
and deposition of a hard tissue barrier at the root apex.
Calcium hydroxide is the material of choice for apex-
ification, although its overall mechanisms of action to
initiate repair are not fully understood. It is believed
that the high pH and calcium and hydroxyl ions acting
alone or in synergy play an important role in the
process. However, it must be remembered that the
velocity of the ionic release is directly dependent on the
viscosity of the vehicle of the paste. Vehicles with low
viscosity promote a rapid ionic release whilst viscous
vehicles promote a more gradual and slower ionic
release (Estrela 1994). As the paste used in this clinical
case has a viscous vehicle, calcium and hydroxyl ions
were released with a low velocity which enabled them
to remain in the affected area for a longer period to
exert their beneficial actions (Silva 1988). This allowed
the review and re-dressing appointments to be
separated by extended time intervals as has been
described previously for apexification in immature
teeth of children using the same formulation of paste
(Leonardo et al. 1978). However, successful reports
have also been described using calcium hydroxide
pastes containing aqueous or oily vehicles in adults
(Van Hassel & Natkin 1969, Rotstein et al. 1990).
In contemporary endodontics, great emphasis has
been placed on the interim restoration between ap-
pointments. Deveaux et al. (1992) stated that the ideal
temporary restorative material should avoid the con-
tamination of the root canal system by food debris, oral
fluids or microorganisms and also prevent the escape of
the dressing medicament from the access cavity to the
oral cavity. Apart from these properties, the material
should not be dissolved by saliva and allow recontami-
nation of the root canal system leading to a possible
flare-up or failure of the treatment (Gutmann &
Heaton 1981, Webber et al. 1981, Dumsha &
Gutmann 1985). Furthermore, Siqueira (1997)
believes the material should also have some antibacter-
ial activity to eliminate or at least reduce the number
of bacteria that have remained in the pulp chamber or
penetrated into the core of the temporary restoration
material.
Cavit (ESPE, Seefeld, Germany) is a universally
accepted material for temporary sealing of the access
cavity. Its main advantages are the ease of insertion
and its good sealing quality (Madison & Anderson
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Fava Apex formation during orthodontic treatment
1992), but this sealing quality is only achieved when
its thickness reaches 3.5 mm or more (Webber et al.
1978, Rocha & Soares 1988). On the other hand, this
material has some disadvantages such as solubility and
disintegration and low resistance to compression, so it
should not be used in teeth where part of the wall of
the access cavity has been lost by caries or other
problems like post-traumatic crown fractures (Parris &
Kapsimalis 1960, Widerman et al. 1971, Webber et al.
1978, Chohayeb & Bassiouny 1985, Anderson et al.
1988, Bobotis et al. 1989).
With regard to the periodical reviews and re-
dressings, the clinician should keep in mind that there
are occasions when these re-dressing appointments
will not follow a predetermined time interval.
According to Mandel & Bourguignon-Adelle (1996),
calcium hydroxide should be replaced when: (i) it is
not possible to obtain a dry canal in the preceding
application; (ii) it is not possible to determine the
correct working length exactly; (iii) the sensitivity to
percussion is not resolved; (iv) there is a persistent
fistula; (v) there has been calcium hydroxide wash-out,
empty spaces or a `Swiss cheese' appearance detectable
radiographically; and (vi) there has been an
unexpected flare-up.
A variable time mean for the development of the
apical barrier has been observed in children but this
factor does not depend on the existence or absence of
infection or the stage of radicular development
(Heithersay 1970, Cvek 1972, Biesterfield & Taintor
1980, Chawla 1986, Ghose et al. 1987, Malo et al.
1987, Mackie et al. 1988, Thater & MareÂchaux 1988,
Yates 1988, Kleier & Barr 1991, Alventosa 1992,
Mackie et al. 1994). Because apexification procedures
are seldom performed in adult patients, it is difficult to
correlate the time interval from the beginning of the
treatment until the final obturation of the root canal
and restoration of the involved tooth. In the present
case, the time interval for complete root-end closure
was 2 years and 4 months.
With regard to the orthodontic treatment being
performed concomitantly with apexification, it is
accepted that the maintenance of the calcium
hydroxide paste within the root canal system may
reduce the risk of resorption when active forces are
being applied to induce teeth movements (Malmgren et
al. 1993, Roberts & Longhurst 1996). Anthony (1986)
has described a clinical case in which an active
orthodontic movement did not retard or inhibit the
deposition of a calcified barrier at the root apex in a
15-year-old boy.
International Endodontic Journal, 32, 321±327, 1999 325

Apex formation during orthodontic treatment Fava
This clinical report describes the same phenomenon
in an adult patient. It seems that, even in adults, apexi-
fication of a root may be undertaken even when
orthodontic movement of the tooth is being performed.
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