Dental Traumatology 2015; doi: 10.1111/edt.

12164

Endodontic management of immature teeth

with spontaneous apical closure and
periapical lesions: case series and review of
the literature

ß alıs
Mehmet Kemal C ß kan, Mehmet
Emin Kaval
Department of Endodontology, School of
Dentistry, Ege University, Izmir, Turkey
Key words: Calcium hydroxide; endodontic
therapy; immature teeth; periapical healing;
spontaneous apical closure
Correspondence to: Dr. Mehmet Emin Kaval,
Department of Endodontology, School of
Dentistry, Ege University, 35100 Izmir, Turkey
Tel.: +90 232 311 46 06
Fax: +90 232 388 03 25
e-mail: mehmetkaval@hotmail.com
Accepted 22 December, 2014
Abstract – Spontaneous apical closure in non-vital immature teeth has been
rarely encountered and outcome of non-surgical endodontic treatment of
related teeth associated with periapical lesions has not yet been adequately
elucidated. The aim of this article was to report endodontic management of
spontaneous apical closure of infected untreated immature teeth with peri-
apical lesions and to review previously proposed mechanisms for the devel-
opment of spontaneous hard tissue barrier. Three patients were referred at
different time intervals to the endodontic clinic for treatment of their maxil-
lary anterior incisors with acute or chronic apical periodontitis. Dental histo-
ries indicated that related teeth had been subjected to trauma approximately
12–18 years previously. Radiographically, the involved teeth exhibited
incomplete root formation with spontaneous apical closure and were associ-
ated with an apical radiolucency. After biomechanical preparation, calcium
hydroxide paste was applied and was changed once or twice within
3 months. All canals were then filled with gutta-percha and AH Plus and the
follow-up period was 16–50 months; both clinical and radiographic examina-
tions revealed adequate function, the absence of clinical symptoms and sig-
nificant healing of the periapical radiolucency.

Traumatic injuries which are frequently encountered in
children and adolescents may cause pulp necrosis in
immature teeth (1). As apical closure process has not
been completed, obturation of the canals during the
endodontic therapy could be challenging. First step of
the treatment protocol in these teeth group is providing
the formation of the apical barrier using intracanal
medicaments following the root canal preparation. His-
torically, several biologic activators have been advo-
cated to obtain the apical barrier (2, 3); but up to date,
the most preferred materials have been calcium hydrox-
ide (3–7) and mineral trioxide aggregate (MTA) (8, 9).
On the other hand, previous animal studies showed
formation of apical closure in teeth which had been left
open after pulpectomy (10–13) and the authors dis-
cussed possible mechanisms involved in spontaneous
apexification. However, the exact biologic mechanism
of apical closure has not yet been adequately eluci-
dated. Review of the literature revealed relatively few
case reports which demonstrated spontaneous apical
closure of human immature teeth following pulp necro-
sis and consequent development of periradicular patho-
sis (14–20). Even though spontaneous apical closure
cases have been reported previously, endodontic treat-
ment has not been performed in all of those teeth.
Among 11 teeth reported in the literature, three were
extracted (14, 15), one had incomplete endodontic ther-
apy (18), and one had received no treatment at all (14).
Only six teeth with spontaneous apical closure were
treated endodontically (14, 16, 17, 19, 20). The purpose
of this article is to present three cases of spontaneous
apical closure of teeth that required endodontic treat-
ment due to pulpal necrosis and apical periodontitis,
and to review previously proposed mechanisms for the
occurrence of non-induced apical closure.
Case reports
Case 1
A 25-year-old male with a non-contributory medical
history was referred to the clinic of Endodontic
Department, School of Dentistry, Ege University for
evaluation and treatment of a diffuse swelling in the
maxillary left anterior vestibule, after his patient’s fam-
ily dentist had performed the initial dental intervention,
and prescribed antibiotics and anti-inflammatory
agents. His dental history revealed that the maxillary
left central incisor had sustained a crown fracture at
the age of 7 years during a bicycle accident.
The maxillary left central incisor was slightly sensi-
tive to percussion and palpation and failed to respond

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
2 ß alısßkan & Kaval
C
to thermal or electrical pulp sensibility testing, while
the left lateral incisor showed a delayed response.
Other adjacent teeth responded within normal limits.
There was no periodontal pocketing. There was radio-
graphic evidence of a large periapical lesion which
extended from the left central incisor to the displaced
lateral incisor. The left central incisor had a wide root
canal with spontaneous apical closure (Fig. 1a). The
diagnosis was an acute apical abscess.
The root canal of the left central incisor was
accessed under rubber dam isolation, and apical prob-
ing with a 40# K-file elicited no sensation and demon-
strated an apical barrier, and there was no exudate
drainage evident. Root canal irrigation and preparation
using K-files to size 140# and 2.5% sodium hypochlo-
rite was followed by irrigation with distilled water and
a final rinse with 17% EDTA. The canal was then
dried with large paper points, and the access cavity was
sealed with zinc oxide-eugenol cement (Austenal, Har-
row, UK). At the next appointment 10 days later, the
patient was asymptomatic with no swelling. The instru-
mentation of the central incisor was completed, and
calcium hydroxide paste (Merck, Darmstadt, Germany)
was placed into the canal with a lentulo spiral. Before
sealing access cavity, a cotton pellet held by forceps
was used to pack the calcium hydroxide paste to the
apical barrier (Fig. 1b). Patient was recalled monthly
for evaluation. At the first and second month follow-
up calcium hydroxide dressing was renewed. At the
3 month evaluation, calcium hydroxide paste was
removed and the root canal of the involved tooth was
obturated with a custom-rolled master cone (Hygenic,
Akron, OH, USA) and root canal sealer (AH Plus,
Dentsply De Trey, Konstanz, Germany) using the lat-
eral condensation technique. At this time, the left lat-
eral incisor became non-responsive to thermal and
electrical pulp sensibility testing and accordingly, end-
odontic therapy was carried out, the root canal being
filled with gutta percha and AH Plus using lateral con-
densation.
One year later, the radiographic examination dis-
closed a reduction in the size of the periapical radiolu-
cency (Fig. 1c). The recall examination after 50 months
revealed asymptomatic maxillary central and lateral
incisors, and there was radiographic evidence of a sig-
nificant periapical healing (Fig. 1d).
(a)
Fig. 1. (a) Preoperative radiograph demonstrating large periradicular lesion associated with osseous extension involving apices of
maxillary left central and lateral incisors and extremely large root canal space with apparent apical closure of the left central
incisor. (b) Radiograph demonstrating the presence of calcium hydroxide paste in the root canal. (c) One-year recall examination
after completion of endodontic treatment. Note the decrease in size of the periradicular radiolucency. (d) Four years follow-up
radiograph, showing significant healing of the periapical lesion.
Case 2
A 20-year-old female with a non-contributory medical
history suffered from pain in her maxillary right central
incisor a week earlier. Her family dentist performed the
emergency endodontic treatment and referred her to
our clinic for further treatment. Her dental history
revealed that the involved tooth had sustained an
uncomplicated crown fracture at the age of 8 years
from a fall. The adjacent teeth appeared clinically nor-
mal and were responsive to electric pulp testing.
Radiographic examination of the maxillary right
central incisor revealed an incompletely formed root
with spontaneous apical closure and it was associated
with a diffuse apical radiolucency (Fig. 2a). The diag-
nosis was chronic apical periodontitis.
After biomechanical preparation and irrigation, cal-
cium hydroxide was applied into the canal and the
access cavity was sealed (Fig. 2b). Two months later,
calcium hydroxide paste was removed and the root
canal therapy was completed.
The 3-year follow-up revealed no signs or symptoms,
and there was radiographic evidence of periapical bone
repair (Fig. 2c).
Case 3
A 22-year-old woman patient referred with the com-
plaint of discoloration of her maxillary right lateral
incisor. She had a history of a traumatic accident
14 years ago with enamel crown fractures of both max-
illary right central and lateral incisors that had no pre-
vious operative treatment. The maxillary right lateral
incisor was non-responsive to electric pulp testing,
while the adjacent teeth were responsive. The root
length of the involved tooth was shorter than its con-
tralateral counterpart. The periapical radiograph
revealed a wide root canal with spontaneous apical clo-
sure, and it was associated with diffuse periapical
radiolucency (Fig. 3a). The diagnosis was chronic api-
cal periodontitis.
After biomechanical instrumentation, the root canal
was filled with calcium hydroxide paste. Three months
later a control radiograph was taken, and extrusion of
the calcium hydroxide through the apical barrier into
the lesion was detected (Fig. 3b). Then, the calcium
(b) (c) (d)
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

(a) (b) (c)
Fig. 2. (a) Preoperative radiograph of maxillary right central
incisor with extremely large size of root canal space and
apparent apical closure associated with large periapical lesion.
(b) Note the presence of calcium hydroxide paste in the root
canal. (c) Follow-up 2 years radiograph after completion of
endodontic treatment, showing complete healing of the
periapical lesion.
(a) (b) (c)
Fig. 3. (a) Radiograph of maxillary right lateral incisor is
revealing periapical radiolucency, root end closure and large
root canal. (b) Three months after placement of calcium
hydroxide paste in the root canal. Note extrusion of calcium
hydroxide through the apical barrier into the lesion. (c)
Eighteen months follow-up radiograph showing significant
healing of periapical lesion.
hydroxide paste was removed and the root canal was
filled permanently. Eighteen months after the comple-
tion of the endodontic treatment, there was radio-
graphic evidence of significant healing of the periapical
lesion (Fig. 3c).
Discussion
The patients in the present report had histories of trau-
matic accidents ranging from approximately 12 to
18 years prior to presentation, with uncomplicated
crown fractures in their maxillary incisors. These trau-
matic injuries had occurred approximately 3 or 4 years
before the completion of root development of the
affected maxillary incisors. Therefore, the chronological
age of the patients at the time of injury presumptively
ranged from 8 to 9 years. This finding was supported
by radiographic examination of presented cases. The
related pulpless teeth with crown fractures had wide
root canal, thin dentinal walls and short root length
according to their developmental stages. These observa-
tions were in accordance with similar cases reported in
the literature (14, 15, 17).
All affected teeth in present report had an uncompli-
cated crown fracture without periodontal pocketing
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Endodontic management of immature teeth 3
and dislocation. Although the overall risk of pulp
necrosis after dentin fracture ranges from 1 to 6%,
pulp necrosis of untreated dentin fracture associated
with luxation injuries such as concussion or subluxa-
tion varies from 25 to 54% (21). It is suggested that
traumatically necrotic but sterile pulp tissue can persist
over a prolonged period without becoming infected
(22, 23); however, an untreated dentin fracture is a pos-
sible pathway for bacterial invasion of the pulp and
ultimately the development of apical periodontitis.
After pulpal infection develops, bacteria invading the
canal play a decisive role in the development of a peri-
apical lesion (23).
There have been varying explanations regarding the
mechanism of the non-induced apical barrier formation
in non-vital immature teeth. Hertwig’s epithelial root
sheath (HERS) is the most important tissue on the
development of the root and the formation of the api-
cal hard tissue barrier. When HERS is damaged, root
development is also interrupted, however apical hard
tissue formation can still continue by means of the dif-
ferentiation of the reservoir cells (24, 25). If HERS is
completely destroyed, apical hard tissue can be formed
by cementoblasts and fibroblasts in the apical area
(26). Torneck et al. (11, 12) have proposed that apical
closure process may occur in immature pulpless teeth
without any medication or therapy. According to their
hypothesis, residual pulp cells and connective tissues
which derive from mesenchymal cells are responsible in
this process.
Evidence of apical closure should not be taken as an
indication that infection of the pulp has not extended
to the periapical tissues. Histological examination of
the apical hard tissue barrier has disclosed the presence
of an irregular morphology and a porous structure (11,
12, 15). Additionally, there are often junctional defects
at the site of the apical hard tissue deposit (19). This
finding was supported by the radiographic image of the
3rd case in which calcium hydroxide extruded beyond
the apical barrier into the periapical tissues.
In all cases, favourable healing of the periapical
lesions was achieved by means of biomechanical
debridement and the use of calcium hydroxide as an
antibacterial dressing, despite the presence of the apical
barrier. This was in accordance with previously
reported cases (14, 16, 17, 19, 20). Additionally, the
healing of the cyst-like periapical lesion in Case 1 has
resulted in the gradual repositioning of the displaced
lateral incisor. In the follow-up radiographs of Cases 1
and 3, a significant but incomplete reduction in the size
of the periapical radiolucencies is evident at this stage.
This may be indicative of a slow and continuous heal-
ing process or conversely that a chronic inflammatory
lesion remains. Despite the apparent reduction, the
complete removal of the infective organisms may not
be possible due to the porous nature of the apical
dome which is an ideal site for the establishment of
microorganisms, protected from endodontic debride-
ment and normal cellular defence mechanisms. When
the body resistance decreases or the number and viru-
lence of the microorganisms increases, the reversal of
apparent healing can occur. Nevertheless at the time of
4 ß alısßkan & Kaval
C
this report, as the teeth are asymptomatic and the asso-
ciated periapical radiolucencies have either completely
or partially resolved following intracanal calcium
hydroxide therapy, there could be cautious optimism
for their long-term retention.
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