Use of Apical Barriers & Apexification in Endodontics 2010

Objectives and Goals

  • discuss the rationale for the use of an apical barrier.
  • be familiar with the various techniques and materials used to obtain an apical  barrier.
  • describe the indications, contraindications, pros, and cons of apical barriers in general, and those made with dentin chips and calcium hydroxide in particular.
  • support your use or non use of apical barriers.
  • discuss the different treatment options available for the incompletely developed root before the advent of the calcium hydroxide apexification procedure and their drawbacks.
  •  describe alternative medications and procedures that have been tried for apexification and their clinical success. 

Cohen's Pathways of the Pulp; Cohen S and Hargreaves KM, 10th eds. Mosby Co. 2011:847 – 852;

Ingle's Endodontics; Ingle JI Bakland LK and Baumgartner JC, 6th eds. Becker 2008:1336-1339.

*Steiner JC, Van Hassel HJ. Experimental root apexification in primates. Oral Surg 31:409-415. 1971.

Cvek, M. Treatment of non-vital permanent incisors with calcium hydroxide. I. Follow-up of periapical repair and apical closure of immature roots. Odont Revy 23:27. 1972.

*Torneck CD, Smith J S. Biologic effects of endodontic procedures on developing incisor teeth. IV. Effect of debridement procedures and calcium hydroxide. Oral Surg 35:541-554. 1973.

Binnie, WH and Rowe, AHR.  A histologic study of the periapical tissues of incompletely formed pulpless teeth filled with calcium hydroxide. J Dent Res 52:1110-1116. 1973.

*Roberts SC, Brilliant, J.D. Tricalcium phosphate as an adjunct to apical closure in pulpless permanent teeth. J Endodon 1:263-269. 1975.

*Tronstad L. Tissue reactions following apical plugging of the root canal with dentin chips in monkey teeth subjected to pulpectomy. Oral Surg 1978;45:297-304.

*Coviello J, Brilliant JD. A preliminary clinical study on the use of tricalcium phosphate as an apical barrier. J Endodon 1979;5:6-13.

*Holland R, de Souza V, Nery MJ, de Mello W, Bernabe PFE, Filho JAO. Tissue reactions following apical plugging of the root canal with infected dentin chips. Oral Surg 1980;49:366-369.

*Oswald R, Friedman CE.  Periapical response to denin filings.  Oral Surg 1980;49:344.

 *Webber RT, Schwiebert KA, Cathey GM.  A technique for placement of calcium hydroxide in the root canal system.  JADA 103:417-421. 1981.

*Cvek M, Cleaton-Jones PE, Austin JC, Andreasen JO. Pulp reactions to exposure after experimental crown fractures or grinding in adult monkeys. J Endodon 8:391-397. 1982.

Pappin J B. Biologic sealing of the apex in endodontically treated human teeth. Thesis. 1982; OHSU.

*Petersson K, Hasselgren G, Petersson A, Tronstad L. Clinical experience with the use of dentin chips in pulpectomies. Int Endod J 1982;4:161-167.

*Holland R, Nery MJ, Souza V, Bernabe PFE, Mello W, Otoboni Filho JA. The effect of the filling material in the tissue reactions following apical plugging of the root canal with dentin chips. Oral Surg 1983;55:398-401.

*Holland GR. Periapical response to apical plugs of dentin and calcium hydroxide in ferret canines. J Endodon 1984;10:71-74.

*Brandell WD, Torabinejad M, Bakland LK, Lessard GM. Demineralized dentin, hydroxyl apatite and dentin chips as apical plugs. Endod Dent Traum 1986;2:210-214.

Shabahang S, Torabinejad M, Boyne PP, Abedi H, McMillan P. A comparative study of root-end induction using osteogenic Protein-1, calcium hydroxide, and Mineral Trioxide Aggregate in dogs. J Endodon 25:1-5. 1999.

Lawley G, Schindler W, Walker W, Kolodrubetz D. Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification. J Endod 30:167. March, 2004.

Oviir T, Pagoria D, Ibarra G, Geurtsen W. Effects of Gray and White Mineral Trioxide Aggregate on the proliferation of oral Keratinocytes and Cementoblasts. J Endodon 32:210-213. March, 2006.

Felippe WT, Felippe MCS, Rocha MJC. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endo J 39:2-9. 2006.

Yueng P, Liewehr FR, Moon PC. A quantitative comparison of the fill density of MTA produced by two placement techniques. J Endodon 32:456-459. May, 2006.

Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endodon 34:812-817. July 2008.

Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endodon 34:1171-1176. October, 2008.

Al Ansary M AD, Day PF, Duggal, MS, Brunton PA. Dent Traumtol 25:367-379. August, 2009.


*Gollmer L. The use of dentin debris as a root canal filling. Int J Ortho 1937;23:101.

Cooke C, & Rowbotham TC.  Root canal therapy in non-vital teeth with open apices. Brit Dent J 108:147-150. 1960.

*Pisanti S. Origin of Calcium in the repair wall after pulp exposure in the dog. J Dent Res 1964;43:641.

*Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. JADA 72:87-93. 1966.

Friend, LA. The treatment of immature teeth with non-vital pulps. Brit Endod Soc 1:28-33. 1967.

*Haga CS.  Microscopic measurements of root canal preparations following instrumentation. Brit Endod Soc 1968;2:41.

Steiner, JC, Dow, PR and Cathey, GM. Inducing root end closure of nonvital permanent teeth.  J Dent Child 35:47-54. 1968.

*Heithersay GS. Stimulation of root formation in incompletely developed pulpless teeth. Oral Surg 29:620-630. 1970.

Laws AJ. Condensed calcium hydroxide root filling following partial pulpectomy. New Zeal Dent J 1971;67:161.

Dylewski, JJ. Apical closure of nonvital teeth.  Oral Surg 32:82-89. 1971.

*Erausquin Jorge. Periapical tissue response to the apical plug in root canal treatment. J Dent Res 1972;

Ham J, Patterson SS et al. Induced apical closure of immature pulpless teeth in monkeys. Oral Surg 33:438. 1972.

Winstein and Goldman. Apical hard tissue depositionin adult teeth of monkeys with the use of calcium hydrxide. J Endodon 1974;1

Goldman, M. Root end closure techniques including apexification. DCNA 18:297-308. 1974.

*Klein SH & Levy BA. Histologic evaluation of induced apical closure of a human pulpless tooth. Oral Surg 38:954-959. 1974.

Seidler B. Remission of pain of acute apical periodontitis after blockage of apex with filings: case report. J Endodon 1976; 2: ppgs?

*Walton RE. Histologic evaluation of different methods of enlarging the pulp canal space. J Endodon 1976;2:304-311.

Heithersay, GS. Calcium hydroxide in the treatment of pulpless teeth with associated pathologhy. J Brit Endo Soc 8:74. 1975.

Barker BCW, Mayne JR. Some unusual cases of apexification subsequant to trauma. Oral Surg 39:144-150. 1975.

Cvek ML,  Hollender L et al. Treatment of non-vital permanent incisors with calcium  hydroxide. VI. A clinical, microbiological, and radiological evaluation of treatment in one sitting of teeth with mature or immature root. Odont Revy 27:97.1976.

Piekoff, MD and Trott, JR. Apexification: report of a case. J Endodon 2:182-185. 1976.

Nevins, A et al.  Induction of hard tissue into pulpless open apex teeth using collagen-calcium phosphate gel.  J Endodon 4:76-81. 1978.

Adams et al. The effect of the apical dentinal plug on broken endodontic instruments. J Endodon !979;5:121-128.

Holland RV, deSouza V et al. A histologic study of the effect of calcium hydroxide in the treatment of pulpless teeth of dogs. J Brit Endo Soc 12:15-23. 1979.

Citrome GP, Kaminski EJ, Heuer MA.  A comparative study of tooth apexification in the dog.  J Endodon 5:290-297. 1979.

*Holland R, Souza V, Nery M et al. Apical hard-tissue deposition in adult teeth of monkeys with the use of calcium hydroxide. Aus Dent J 1980.

Chawla HS, Tewari A et al. A study of apexification without a catalyst paste. J Dent Child:431-434. 1980.

Das, S. Apexification in a non-vital tooth by control of infection. JADA 100:880-881. 1980.

Ferguson, F. S., S. Friedman, et al. (1980). "Successful apexification technique in an immature tooth with dens in dente." Oral Surg 49(4): 356-359.

Guttman, JL Heaton, JF. Management of the open immature apex. 2. Non-vital teeth. Int Endo J 14:173-178. 1981.

Cvek, M. and M. Lundberg (1983). "Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing." J Endodon 9(1): 8 - 11.

Smith, G. N. and S. Woods (1983). "Organic iodine: a substitute for BaSO4 in apexification procedures." Journal of Endodontics 9(2): 153 - 155.

DiFiore, P. M., D. D. Peters, et al. (1983). "The antibacterial effects of calcium hydroxide apexification pastes on streptococcus sanguis." Oral Surg 55(1): 91.

Pomeranz, H. H. (1983). "A very active case of idiopathic external root resorption." Oral Surg 55(5): 521-523.

*Lieberman J, Trowbridge H.  Apical closure of nonvital permanent incisor teeth where no treatment was performed.  J Endodon 9:257-260. 1983.

Schlindler, WG and Walker, WW. Continued root development after apexification of an immature tooth with dens invaginatus. J Endodon 9(10). 1983.

*ElDeeb ME, Thuc-Quyen NT, Jensen JR. The dentinal plug: its effect on confining substances to the canal and on the spical seal. J Endodon 1983;9:355-359.

Rossmeisl R, Reader A, Melfi R, Marquard,J.  A study of freeze-dried (lyophilized) dentin used as an apical barrier in adult monkey teeth. Oral Surg 1983;53:303-310.

*Jacobsen EL, Bery PF, BeGole EA. The effectiveness of apical dentin plugs in sealing endodontically treated teeth. J Endodon 1984;1:289-293.

Pitts DL, Jones JE, Oswald RJ. A histological comparison of calciumhydroxide plugs and dentin plugs used for the control of gutta-percha root canal filling material. J Endodon 1984;10:283-293.

Smith JW, Leeb IJ, Torney DL. A comparison of calcium hydroxide and barium hydroxide as agents for inducing apical closure. J Endodon 10:64-70. 1984.

Leonardo et al. Immediate root canal filling: the use of cytophylactic substances and noncytotoxic solutions. J Endodon 1984;10:1-7.

*Yee RDJ, Newton CW, Patterson SS, Swartz ML. The effect of canal preparation on the formation and leakage characteristics of the apical dentin plug. J Endodon 1984;10:308-317.

Webber, RT. Apexogenesis versus Apexification. DCNA 28:669-697. 1984.

Krell KV, Madison S. The use of the Messing gun in placing calcium hydroxide powder. J Endodon 11:233-234. 1985.

Feiglin, B. Differences in apex formation during apexification with calcium hydroxide.  Endo Dent Traumatol 1:195-199. 1985.

Dumsha, TC and Guttman, JL. Clinical techniques for the placement of calcium hydroxide. Comp Cont Educ Dent 6:482-89. 1985.

Safavi K, Horsted P, Pascon EA, Langeland K. Biological evaluation of the apical dentin chip plug. J Endodon 1985;11:18-24.

Callis and Santini. Response of rat and guiena-pig subcutaneous tissue to implanted human roots containing collagen/hydroxyapatite preperations. Int Endo J 1985;18:267-273.

Yosida T, Arita M. An experimental study on the construction method of an apical barrier using dentin filings. Jpn J Conserv Dent 1986;29:422-429.

Torabinejad M, Owen R, Danforth RA, Howell RE. Periapical tissue responses to dentin and vitreous carbon plugs in apical perforations of dogs' teeth. Endo Dent Traum 1986;1:17-21.

Chawla, HS. Apical closure in a nonvital permanent tooth using one calcium hydroxide dressing. J Dent Child Jan/Feb 1986.

Anthony, D. R. (1986). "Apexification during active orthodontic movement." Journal of Endodontics 12(9): 419 - 421.

*Weisenseel JAJ, Hicks ML, Pelleu GBJ. Calcium hydroxide as an apical barrier. J  Endodon 1987;13:1-5.

Ghose, L. J., V. S. Baghdady, et al. (1987). "Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide." Journal of Endodontics 13(6): 285 - 290.

Patterson SM, Patterson SS, Newton CW, Kafrawy AH. The effect of an apical dentin plug in root canal preparation. J Endodon 1988;14:1-6.

*Yates JA. Barrier formation time in non-vital teeth with open apices. Int Endo J  21:313-319. 1988.

*Beeler WJ, Marshall FJ, Brown AC. The permeability of apical barriers. J Endodon 1989;15:422-426.

Pissiotis E, Spangberg LSW. Biological evaluation of collagen gels containing clacium hydroxide and hydroxyapatite. J Endodon 1990; 16(10):468-473.

Morse DR , O'Larnie JO and Yesiloy C. Apexification: review of the literature. Quint Int 21:589-598. 1990.

Yang, S. F., Z.-P. Yang, et al. (1990). "Continuing root formation following apexification treatment." Endod Dent Traumatol 6(5): 232.

Morfis AS, Siskos G. Apexificatioon with the use of calcium hydroxide: A clinical study. J Clinical Ped Dent 16:13-19. January 1991.

*Klier DJ, Barr ES. A study of endodontically apexified teeth. Endod Dent Traumatol 7:112-117. 1991.

Guttman JL and Fava LRG. Periradicular healing and apical closure of a non-vital tooth in the presence of bacterial contamination. Int Endo J 25:307-3111. 1992.

*Scott AC, Vire DE. An evaluation of the ability of a dentin plug to control extrusion of thermoplasticized gutta-percha. J Endodon 1992; 18:52-57.

Hasegawa M, Tanaka S. An experimental study of the sealing ability of a dentinal apical plug treated with bonding agent. J Endodon1993;19:570-572.

Leonardo M, de Silva L et al. Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. J Endodon 19:348-352. 1993.

Schmalz G and Schweikl H. Characterization of an in vitro dentin barrier test using a standard toxicant. J Endodon 1994;20:592-594.

Mackie I, Hill F et al. Comparison of two calcium hydroide pastes used for endodontic treatment of non-vital immature incisor teeth. Endo Dent Traum 10:88-90. 1994.

Hayashi Y and Imai M. Application of Ca-B-glycerophosphate for artificial apical barrier formation. J Endodn 1995;21:205-207.

Harbert, H. (1996). "One-step apexification without calcium hydroxide." J Endodon 22(12): 690-692.

Caliskan, M. Periapical repair and apical closure of a pulpless tooth using calcium hydroxide. Oral Surg 84:683-687. 1997.

Chosack A, Sela J et al. A histological and quantitative histomorphic study of apexification  of nonvital permanent incisors of veret monkeys after repeated root filling with a calcium hydroxide paste. Endo Dent Traum 13:211-217. 1997.

Das S,

Das AK et al. Experimental apexogenesis in baboons. Endo Dent Traum 13:31-35.1997.

Goodell, G. G., O. M. Thomas, et al. (1997). "Linear dye penetration of a calcium phosphate cement apical barrier." J Endodon 23(3): 174-177.

Katebzadeh N, Dalton BC, Trope M. Strengthening immature teeth during and after apexification. J Endodon 24:256-259. 1998.

Capurro  M, Zmner O. Delayed apical healing after apexification treatment of non-vital immature tooth: a case report. Endo Dent Traumatol 15:244. 1999.

Finucane D, Kinirons M. Non-vital immature permanent incisors factors that may influence  treatment outcome. Endo Dent Traumatol 15:273. 1999.

Viloria T, Yanagiguchi K, Hayashi Y. Structure and chemical composition of an experimentally formed apical barrier after the application of calcium-glycerophosphate. J Endod 26:605. 2000.

Daoudi M. Conservative management of an accidentally resected root: A 3-year follow up. J Endod 27:543. 2001.

Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with flaring apices. Dent Traumatol 17:86. 2001.

Seldon H. Apexification : An interesting case. J Endodon 28:44. January 2002.

Hachmeister D, Schindler W, Walker W, Thomas D. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endon 28:386. May, 2002.

Duarte M, Demarchi A, Yamashita J, Kuga M, Fraga S. pH and calcium ion release of 2 root-end filling materials. Oral Surg 95:345. March, 2003.

Saidon J, He J, Zhu Q, Safavi K, Spaangberg L. Cell and tissue reaction to mineral trioxide aggregate and Portland cement. Oral Surg 95:483. April, 2003.

Kamburis J, Barker T, Barfield R, Eleazer P. Removal of organic debris from Bovine dentin shavings. J Endod 29:559. September, 2003.

Aminoshariae A, Hartwell G, Moon P. Placement of mineral trioxide aggregate using two different techniques. J Endod 29:679. October, 2003.

Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatabilty of two commercial forms of Mineral Trioxide Aggregate. Int  Endo J 37:699. 2004.

Ham, K. A., D. E. Witherspoon, et al. (2005). "Preliminary evaluation of BMP-2 expression and histological characteristics during apexification with calcium hydroxide and mineral trioxide aggregate." J Endodon 31(4): 275-279.

Felippe, M. C. S., W. T. Felippe, et al. (2005). "The effect of the renewal of calcium hydroxide paste on the apexification and periapical healing of teeth with incomplete root formation." Int Endod J 38: 436-442.

Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of Mineral Trioxide Aggregate J Endodon 31:97.February, 2005.

Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical differences between white and gray Mineral Trioxide Aggragate. J Endodon 3d1:101. February, 2005.

Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In-vitro evaluation of microleakage of an orthograde apical plug of Mineral Trioxide Aggregate in permanent teeth with simulated immature apices. J Endodon 31:117. February, 2005.

Fridland M, Rosado R, Eng C. MTA solubility: A long term study. J Endodon 31:376-379. May, 2005.

Santos AD, Moraes JCS, Araújo EB, Yukimitu K, Valério Filho WV. Physico-chemical properties of MTA and a novel experimental cement. Int Endo J 38:443-447. 2005.

Islam I, Chng HK, Yap AUJ. Comparison of t6he physical and mechanical properties of MTA and Portland Cement. J Endodon 32:193-197. March, 2006.

Souza NJA, Justo GZ, Oliveira CR, Haun M, Bincoletto C. Cytotoxicity of materials used inperforation repair tested using thr V79 fibroblast cell line and the granulocyte-macrophage progenitor cells. Int Endo J 39:40-47. 2006.

Ribeiro DA, Matsumoto MA, Duarte MAH, Marques MEA, Salvadori DMF. Ex vivo biocompatibility tests of regular and white forms of mineral trioxide aggregate. Int Endo J 39:26-30. 2006.

Cbueb L-H, Huang G T-J. Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: A paradigm shift. J Endodon 32:1205-1213. December. 2008.

Hatibović-Kofman S, Raimundo L, Zheng L, Chong L, Friedman M, Andreasen JO. Fracture resistance and histological findings of immature teeth treated with mineral trioxide aggregate. Dent Traumatol 24:272-276. 2008.

Raldi DP, Mello I, Habitante SM, Lage-Marques JL, Coil J. J Can Dent  Ass 75:591-596. October, 2009.

*Board Review Articles