Root Development

J. A. P. Figueiredo
Pontifical Catholic University of Rio Grande do Sul, PUCRS, Porto Alegre,
RS, Brazil

A. H. G. Alencar

2
Federal University of Goiás, Goiânia, GO, Brazil

S. S. Murata
São Paulo State University, Araçatuba, SP, Brazil

C. Estrela
Federal University of Goiás, Goiânia, GO, Brazil

Chapter contents

Introduction
Root Formation
Clinical Managment of Teeth with Incomplete Rhizogenesis
Diagnosis of the pulpal state
Apexogenesis
Apexification
Apexification Technique
Decisive Factors in Root Development
Pulpal condition
Stage of root formation
Presence of periapical lesion
Intensity of traumatic injury
Endodontic Technique
Forms of Periapical Repair
Complete and normal root completion
Complete and normal root completion, with pulp necrosis
Root and apical completion with foreshortening of the root
Apical completion with a mineralized tissue barrier
Absence of apical completion
Area in which the apical papilla is
present. The apical cell-rich zone would
be responsible for the apexogenesis,
including dentine formation (Courtesy
Prof. Dr. Roberto Holland39-41).

2.1 Introduction
The knowledge of dental root formation
is very important for clinical management of
possible dental injuries.
When the teeth emerge in the oral cavity,
two thirds of the length of their roots has been
formed, and full length will only be complete
three years after eruption9. In young perma-
nent teeth with incomplete rhizogenesis,
histologically the apex of the root does not
present the apical dentin covered by cemen-
tum, and radiographically the apical end of
the root does not reach the stage 10 of Nolla,
that is, a complete root apex9,40,41,61.
Completely formed teeth present the root
canal with the approximate shape of the ex-
ternal form of the root, resembling a cone,
with the widest base at the pulpal chamber,
and the narrowest in the apical third. Next
to the apical third, a natural constriction is
observed, called cementum-dentin-canal
junction (CDC), which limits endodontic pro-
cedures and serves as reference so that the
filling can be confined inside the dentinal
root canal. Teeth with incomplete rhizogen-
esis have their own characteristics: very wide
root canals, and may also have a conical
shape, but with the wider base in the apical
portion. The apical foramen, still not formed,
has a larger diameter than the root canal62,73.
When root canal treatment is necessary
in teeth with incomplete rhizogenesis, these
characteristics can make treatment difficult.
The thin and fragile walls hinder root canal
preparation, and frequently make it impos-
sible. The thin walls prevent any convention-
al preparation being performed in the root
canal. Consequently, the root canal filling is
affected, since no “apical stop” can be de-
termined in the root canal preparation, and
there is always a risk of overfilling60-63,73.
25
The traumatic injuries to the teeth have
been one of the reasons for indicating root ca-
nal treatment in teeth with incomplete rhizo-
Endodontic Science
genesis. Teeth, such as recently erupted first
permanent molars that do not have the maxi-
mum fluoride incorporated into the enamel
become more susceptible to caries. More-
over, due to the great volume of the pulpal
chamber in the young teeth, pulpal exposure
occurs faster, especially in the presence of de-
Chapter 2
cay or while operative procedures are being
performed90.
When the pulp is affected in teeth in the
process of root formation, it is of fundamental
importance to evaluate the pathological state
of the tissues involved in the root completion.
The need for performing different procedures
in teeth with pulp vitality and in those with
pulp necrosis shows the importance diagnos-
ing the state of the pulp60-63,73.
2.2 Root Formation
Starting during the fifth week of intra-
uterine life, teeth form as the result of a se-
ries of specific, reciprocal, and sequential
epithelial-mesenchymal signals between
the oral epithelium and the underlying neu-
ral crest derived ectomesenchyme45. Until
the twelfth week of intrauterine life, this
process is directed by the epithelium, but
control subsequently shifts to the ectomes-
enchymal cells57.
The tooth bud (sometimes called the
tooth germ) is an aggregation of cells that
forms a tooth. These cells are derived from
the ectoderm of the first branchial arch and
the ectomesenchyme of the neural crest. The
tooth bud is organized into three parts: the
enamel organ, the dental papilla and the
 dental follicle. Enamel is the only tooth tissue
26 to derive from ectoderm, whilst the dentine-
pulp complex and periodontium are derived
from ectomesenchyme82.
The signaling events depend on the par-
ticipation of BMP2, BMP4 (bone morpho-
genetic proteins), FGF (fibroblast growth
factor), Wnt families, hedgehogs, and the
homeobox proteins MSX1 and MSX284,92.
There is a progressive restriction of the de-
velopmental potential that culminates in the
Root Development
specific signals that cause the terminal dif-
ferentiation of the odontoblasts and amelo-
blasts, which culminate in the formation of
dentin and enamel, such as enamelin, tubu-
lin, GAD, NeuN, nestin, neurofilament M,
NSE, CNPase31,57,85. When control is shifted
to the ectomesenchyme, the dental papilla
is responsible for maintaining the induction
of the odontogenic events, more clearly
through the bud, cap and bell stages57.
A sequence of orchestrated events occurs

differentiation of the mesenchymal-derived and in human teeth the chronology, although

odontoblasts and epithelial-derived amelo-
blasts, the cells responsible for producing
the extracellular matrices that form dentin
and enamel, respectively10,15. In addition to
the known molecular factors, there are other
Chapter 2
subject to some variations, can be consid-
ered predictable. Below (Table 2.1) there is
the expected sequence for all tooth groups.
Note that root completion is a process that
occurs at a much later stage.

Table 2.1 - A sequence of orchestrated events occurs and in human teeth the chronology

Maxillary teeth

Central Lateral First Second First Second Third

Permanent teeth Canine
incisor incisor premolar premolar molar molar molar

3-4 10–12 4–5 1.5–1.75 2–2.25 2.5–3 7–9

Initial calcification at birth
months months months years years years Years

4–5 4–5 6–7 5–6 6–7 2.5–3 7–8 12–16

Crown completion
years years years years years years years Years

10 11 13–15 12–13 12–14 9–10 14–16 18–25

Root completion
years years years years years years years Years

 Mandibular teeth 

3–4 3–4 4–5 1.5–2 2.25–2.5 2.5–3 8–10

Initial calcification at birth
months months months years years years Years

4–5 4–5 6–7 5–6 6–7 2.5–3 7–8 12–16

Crown completion
years years years years years years years Years

9 10 12–14 12–13 13–14 9–10 14–15 18–25

Root completion
years years years years years years years Years
 The first sign of tooth development is a
localized thickening of dental epithelium, the
dental lamina, which subsequently invagi-
nates into underlying neural-crest-derived
ectomesenchyme, forming a bud, after which
proliferative mesenchyme condenses around
the developing epithelial bud54,84.
Tooth shape specification occurs early in
tooth development, at the dental lamina stage,
by homeobox genes, which are specifically
expressed in the pre-dental mesenchyme88,92.
The physical morphological processes be-
gin at the cap stage and are coordinated by
enamel knots, via transient signaling centers
that lie in the epithelium and which, in some
way, are directed by the earlier expression of
homeobox genes44,83,89.
Additional enamel knots appear and pat-
tern the crown. By the late cap stage, enamel
knots disappear by apoptosis.89 After the
mesenchyme receives the early odontogenic
signals from the epithelium, the ectomesen-
chyme becomes the source of signals50. The
epithelium further differentiates into enamel-
secreting ameloblasts, whereas the adjacent
mesenchyme differentiates into dentine-se-
creting odontoblasts92.
At the bell stage, a recognizable tooth
germ is formed that consists of an enamel
organ, dental papilla and dental follicle.
The enamel organ is composed of the outer
enamel epithelium, inner enamel epithelium,
stellate reticulum and stratum intermedium44.
These cells give rise to ameloblasts, which
produce enamel and the reduced enamel ep-
ithelium. The location where the outer enam-
el epithelium and inner enamel epithelium
join is called the cervical loop. The growth
of cervical loop cells into the deeper tissues
forms Hertwig’s epithelial root sheath, which
determines the root shape of the tooth82.
The dental papilla contributes to tooth
formation and eventually converts to pulp
tissue18,53,66,67 which is a living connective tis-
sue composed of fibroblasts, blood vessels,
nerves, lymphatic ducts and odontoblasts.
Odontoblasts are the cells derived from the
mesenchymal cells in the dental papilla ad-
jacent to the inner enamel epithelium82. Dif-
ferentiated odontoblasts are postmitotic cells
27
that have withdrawn from the cell-cycle, and
cannot proliferate to replace irreversibly in-
jured odontoblasts66. Functional odontoblasts
show polarized columnar morphology that
shift into a resting state and become small and
flat after primary dentin formation. However,
odontoblasts remain functional throughout
their life and can produce secondary dentin if
trauma is mild72,80.
Endodontic Science
The dental follicle gives rise to three im-
portant entities: cementoblasts, osteoblasts,
and fibroblasts, and appears as a transient
structure when teeth undergo morphogen-
esis. Cementoblasts form the cementum of
a tooth. Osteoblasts give rise to the alveolar
bone around the roots of teeth. Fibroblasts
Chapter 2
develop the periodontal ligaments which
connect teeth to the alveolar bone through
cementum. In developing teeth, root for-
mation starts as the epithelial cells from the
cervical loop proliferate apically and influ-
ence the differentiation of odontoblasts from
undifferentiated mesenchymal cells and ce-
mentoblasts from follicle mesenchyme. This
apically extending two-layered epithelial wall
(merging with the inner and outer enamel
epithelium) forms Hertwig’s epithelial root
sheath, which is responsible for determining
the shape of the root(s) and forms cementum
through epithelial-mesenchymal transition77.
The periodontal ligament functions as a
cushion when force is applied, as a source of
sensation, and it is regarded as the main impe-
tus for the tooth eruption process. The com-
plex structure that includes the periodontal
ligament, adjacent cementum and alveolar
bone is called the periodontium. After tooth
eruption into the oral cavity, a tooth is clinically
divided into two parts: crown and root. Crowns
are the visible structures in the oral cavity,
whereas roots are the regions that connect the
surrounding alveolar bone with the cementum.
Anatomically, crowns are the part covered by
enamel and lie above the level of the cemen-
toenamel junction; roots are covered with ce-
mentum and lie below the junction92.
 There is a lot more knowledge about the
28 way that crowns are formed, than the man-
ner in which roots develop, little being known
about the signal mechanisms of root devel-
opment. Among the factors involved, FGF10
signaling stands out as a candidate for root
initiation93. A transcription factor NFI-C (nu-
clear factor I) is essential for root formation78.
Because the root continues to develop after
the bell stage, the location of the dental pa-
pilla becomes apical to the pulp tissue. The
Root Development
apical papilla appears to be histologically dis-
tinct from the pulp. There is a loose physical
connection between apical papilla and pulp,
as the papilla can be easily detached from the
apex and readily placed next to the pulp76.
As the differentiated odontoblasts lay
down the primary dentine, the dental papilla
Chapter 2
becomes encased within the dentine struc-
ture and develops into pulp tissue. The apical
end of the dental papilla, however, has not
been discussed much in the literature. It is
generally believed that the formation of root
dentin is the result of signaling from Hertwig’s
epithelial root sheath to the adjacent undif-
ferentiated mesenchymal cells, which then
turn into odontoblasts that are responsible
for the root dentine formation. The anatomic
location of these undifferentiated mesen-
chymal cells has not been clearly elucidated.
They may reside either in ­the pulp or the api-
cal papilla. Dental pulp also harbors undiffer-
entiated mesenchymal cells that are known to
be capable of differentia­ting into new odon-
toblasts to replace the lost original odonto-
blasts. The primary odontoblasts are derived
from dental papilla during the developing
stage and make primary and secondary den-
tin, whilst the replacement odon­toblasts (or
odontoblast-like cells) are derived from the
dental pulp to replace primary odontoblasts
and make tertiary dentin or, more specifically,
the reparative dentin. Replacement odonto-
blasts derive from underlying mesenchymal
cells and are located in the cell-rich zone and
cell proper, particularly in the perivascular re-
gion28,29,81.
Sonoyama et al.76 have recently published
an elegant study, detecting stem cells of the
apical papilla. From histological sections,
they verified that there is a cell-rich zone be-
tween the pulp and the apical papilla, term-
ing it “apical cell–rich zone.” This is impor-
tant, as the apical papilla appears to contain
fewer blood vessels and cellular components
than the dental pulp and the apical cell–rich
zone, and once the tissues are placed in cul-
tures, cells in the apical papilla start to enter
the growth cycle more readily than those in
the pulp. With regard to osteo/dentinogenic
markers in the apical papilla, DSP, ALP, BSP
and OCN were detected only in odontoblasts
lined against newly formed dentine, and
were not detected in the apical papilla. Den-
tal pulp and apical papilla stem cells express
similar osteo/dentinogenic markers and
growth factor receptors, but fewer amounts
of most of them in the apical papilla. Figure
2.1 demonstrates the area in which the apical
papilla is present. The apical cell-rich zone
would be responsible for apexogenesis, in-
cluding the dentine formation.
 29

Endodontic Science
a b

Chapter 2

Figure 2.1 - (A-C) Area in which the apical papilla is present. The apical cell-rich zone would be responsible for the apexogenesis, including dentine formation
(Courtesy Prof. Dr . Roberto Holland39-41).
 The stem cells from dental pulp reside in
30 the perivascular and perineural sheath re-
gions70. This finding corresponds to one con-
cerning the source of replacement odonto-
blasts: the perivascular regions where stem/
progenitor cells reside. At present, however,
it is unknown where the stem cells in the pulp
come from. The vascular density in the api-
cal papilla appears to be lower than that of
the pulp. However, the proliferation rates of
apical papilla stem cells are faster than those
Root Development
of the dental pulp stem cells76. This can be
explained because adult stem cells generally
remain in a non-proliferative, quiescent state
until stimulated by the signals triggered by
tissue damage and remodeling74,75. They are
capable of self-renewal and give rise to pro-
genitor cells that eventually differentiate into
Chapter 2
specialized cells.
The apical papilla is fundamental to root
development. If the apical papilla is removed
at an early stage of development, despite the
pulp tissue being intact, the dental root will
not develop. It could be inferred that the stem
cells from the apical papilla, and not the dental
pulp stem cells, are the cell source for primary
odontoblasts that produce root dentine76. This
would explain why apexogenesis can occur
in teeth with open apexes and infected pulp
and apical periodontitis or abscesses5,13,43. The
surviving cells from the apical papilla and the
Hertwig’s epithelial root sheath would per-
form the remaining apexogenesis following
sanitization of the root canal system.
Pulp tissue in immature teeth with open
apices has a rich blood supply and contains a
structure at a developing stage that is more
potent to regenerate in response to dam-
age. The general consensus for clinical treat-
ment of immature teeth with vital pulps is to
preserve the remaining normal vital tissue
to allow continued physiological develop-
ment and complete formation of apexogen-
esis. Whereas for teeth with nonvital pulps,
treatment is to clean and fill the canals with
calcium hydroxide, the most commonly used
material, to induce the formation of a calci-
fied barrier at the open apex–apexification63.
After successful apexogenesis teeth de-
velop a normal thickness of dentine and root
length. In contrast, those receiving apexifica-
tion normally gain only an apical hard tissue
bridge, not dentin, because of the loss of vital
pulp tissues, odontoblasts, and Hertwig epi-
thelial root sheath, needed for complete root
development. However, this paradigm has
been challenged by recent reports convinc-
ingly showing that immature teeth, clinically
diagnosed with nonvital pulp and periradic-
ular periodontitis or abscess, can undergo
apexogenesis5,43. These reports stimulated a
new perspective of how we treat these cases.
It has been advocated that immature teeth
should be treated as conservatively as prac-
tical, to allow any possible apexogenesis to
occur91. After successful apexification, teeth
inherit thin and weak roots that are suscepti-
ble to fracture. Shifting apexification to apex-
ogenesis even for nonvital pulps with apical
periodontitis or abscess would be a clinically
beneficial approach for patients if we gath-
ered more clinical experience to help predict
the outcome of the treatment. The treatment
below is an example of how apexogenesis
can occur in the absence of dental pulp vital-
ity. Therefore, the vitality of the apical papilla
is the key to the completion of root develop-
ment (Fig. 2.2AM-2.5AF).
 31

Endodontic Science
a b

Chapter 2
c d

e f

Figure 2.2 - (A-F) Apexogenesis. The maintenance of pulp vitality will make the normal root development possible
(Courtesy Prof. Dr. Rinaldo Mattar).
32
Root Development

g h
Chapter 2

i j

l m

Figure 2.2 - (G-M) Apexogenesis. The maintenance of pulp vitality will make the normal root development possible
(Courtesy Prof. Dr. Rinaldo Mattar).
 33

Endodontic Science
Chapter 2
a b

c d

e f

Figure 2.3 - (A-F) Apexogenesis. Dental injury of the right central incisor. First premolar was transplanted for this place. It was observed root
developed associated with pulp canal obliteration (Courtesy Prof. Dr. Armelindo Roldi).
34

a
Root Development
Chapter 2

c b

d e

Figure 2.4 - (A-E) Apexogenesis. The maintenance of pulp vitality will make the normal root development possible.

a c
b d
Figure 2.5 - (A-F) Apexogenesis. Root development.
2.3 Clinical Managment of Teeth with Incomplete Rhizogenesis
Diagnosis of the pulpal state
Permanent teeth with incomplete rhizo-
genesis can receive root canal treatment,
under two basic and fundamental conditions:
with or without pulp vitality.
The clinical evaluation of the pulpal state
requires meticulous anamnesis, physical and
radiographic exams. A critical clinical exam
and determining the characteristics of pain
will help to achieve this diagnosis. The pulp
vitality test should also be used, but its results
should be interpreted carefully. Two kinds of
nerves are observed in the pulp, amyelinic
nerves, responsible for the vasoconstriction
and vasodilatation, and the myelinic nerves
that respond to painful incentives. As the
number of myelinic fibers increases with the
35
e
Endodontic Science
Chapter 2
f
rhizogenesis of the tooth, teeth with incom-
plete rhizogenesis have a reduced threshold
for electrometrical stimulus, consequently
they do not respond to pulp vitality tests in
the usual way8,34,46.
The radiographic exam will provide infor-
mation about the stage of root development
and the condition of the periapical tissues.
The radiographic exam should be discerning,
because the image of the dental sac, which
is an embryonic structure that originates the
periodontal tissues and that surrounds the
apex of the teeth in formation, is frequently
confused with periapical lesion62,63.
By providing a two-dimensional image,
the radiographic exam will, in some cases, be
capable of showing the image of a complete
 root formation, which is not always the reality.
36 Because root formation completes faster in the
mesial-distal direction than in the buccal-lingual
direction, and due to the proximity of the root
walls in this direction, particularly in anterior
teeth, the radiographic image presented shows
complete root formation21. Despite the diffi-
culties presented in determining the extent of
apical closure radiographically, it should be em-
phasized that incorrect evaluation of the stage
of the root development can lead to failure.
Root Development
Unfortunately, it has not been possible to
establish a direct relationship between the
clinical diagnosis and the histological diag-
nosis, but combination of the findings of the
anamnesis, physical exam and pulp vitality
test can lead to improved clinical diagnosis
of pulp vitality63.
Chapter 2
In cases with pulp vitality apexogenesis
can be indicated. The clinical diagnosis of
pulp necrosis leads to treatment for apexifi-
cation. The success is directly related to cor-
rect diagnosis and understanding that the
biological process of repair can be facilitated
by the treatment performed63.
2.4 Apexogenesis
Whenever pulp vitality is diagnosed, and
endodontic intervention is necessary, a con-
servative treatment should be performed.
The maintenance of pulp vitality will make
the normal root development possible. This
physiologic formation is known as apexo-
genesis, and is observed in cases of conser-
vative treatment in teeth with incomplete
rhizogenesis, when the physiologic process
of normal closure of the apex allows the de-
velopment of root end dentin, as well as the
formation of the cementum canal, produc-
ing the root canal anatomy, shape and nor-
mal length. For the American Association
of Endodontics2, apexogenesis is “the vital
pulp therapy procedure, performed to en-
courage continued physiological develop-
ment and formation of the root end“.
Considering the advantages of apexogen-
esis, the following can be included14,33,36,52,56,58,90:
1. Maintenance of the Hertwig’s root sheath,
thus the length and the normal shape of
the tooth will be maintained, which are im-
portant future factors for its resistance and
fixation in the dental arch. The favorable
crown-root relationship will avoid peri-
odontal disease with bone loss that places
the stability of these teeth at an early risk.
2. Maintenance of vital pulp, thus assuring
odontoblasts will continue to deposit
dentin on the root canal walls and reduce
the possibility of root fracture.
3. Complete formation of the root apex, thus
creating conditions for future convention-
al root canal treatment, if necessary (Fig.
2.2-2.5).
When root canal treatment is required in
canals with incomplete rhizogenesis, there is
little probability of successful root canal filling,
therefore teeth in the developmental stage
must be treated with a biological focus90.
In cases of small accidental pulp expo-
sure during cavity preparation, when the pul-
pal tissue is healthy, direct pulp protection
should be the preferred treatment. If there is
wide pulp exposure as a result of removing
decayed dentin or crown fractures, and other
possible conditions, the elected treatment
should be pulpotomy.
When the basic principles of pulpotomy
are respected, pulp vitality can be proved by
the root formation and development of the
root walls, as well as by the normal closure of
the root apex observed radiographically two
years after the pulpotomy, depending on the
degree of tooth development at the time of
the endodontic intervention63.
2.5 Apexification
One of the main dogmas of endodon-
tics is root canal filling in three dimensions
with emphasis on filling the apical third of
the root. The filling becomes more predict-
able when the walls of the root canal con-
verge at the apex, with a final constriction
in the cementum-dentin junction. The apical
preparation of root canals creates a stop that
facilitates the appropriate application of con-
densation pressure for filling in three dimen-
sions33,36,52,56,58,64,90.
Although the incidence of caries in young
patients has fallen considerably over the last
few decades, has been a significant increase
in the number of traumatic dental injuries
due to the incentive to practice sports, in-
creasing number of automobile accidents
and violence3. Frequently the incisors are the
most affected teeth, and depending on the
intensity of the traumatic injury, rupture of
the vascular-nerve fibers can occur, causing
pulp necrosis and interrupting the comple-
tion of the root formation.
Until 1960, non vital permanent teeth with
incomplete rhizogenesis were usually treated
by conventional methods. However, root ca-
nal filling with gutta-percha cones, even when
they were rolled or done by the professional,
did not have good results, because the api-
cal foramen was usually wider and did not al-
low condensation. The lack of apical stop fre-
quently led to overfilling the periapical region.
It was frequently necessary do apical surgery
to remove the excess gutta-percha or do a
retrograde filling to obtain the apical seal35.
Nevertheless, the apical surgery technique as-
sociated with retrograde filling was not satis-
factory, because of various inconveniences.
The technique of root canal filling with
gutta-percha cones under the root apex has
shown a low clinical success rate. With in-
complete root canal filling, microorganisms
can remain in the apical region and healing
cannot take place. When the root canal is
37
not infected, but the filling was made under-
neath, there can be secondary invasion of the
unfilled portion by microorganisms coming
from the blood stream or from the periodon-
tal ligament, and lead to the development of
periapical lesion59.
Another method also used in the treat-
ment of teeth with pulp necrosis and open
apex, is the non surgical condensation of bio-
Endodontic Science
compatible material at the extremity of the
root canal. The objective is to establish apical
stop to enable immediate root canal filling.
Although this technique offers the advantage
of requiring only a few sessions, the need for
retreatment should be considered some time
later, if there has been completion of the root.
Chapter 2
Several biocompatible materials have been
proposed, such as calcium hydroxide40,41,65, re-
sorption ceramic49, mineral trioxide aggregate
(MTA)19 and others. However, from the clini-
cal point of view, it is difficult to place these
materials at apical level only, without leaving
residues along the walls of the root canal and
without overfilling the periapical area.
Nowadays, authors are unanimous in af-
firming that the best treatment for teeth with
incomplete rhizogenesis and pulp necrosis is
to stimulate apical closure, by temporary root
canal filling with intracanal dressings (calcium
hydroxide paste) until there are anatomical
conditions that allow appropriate root filling
to be definitively performed 40,41,59,62,63.
Apexification is defined as a method of
inducing apical closure by mineralized tissue
formation or by continuation of root devel-
opment of an incompletely formed tooth,
whose pulp is not vital. The American Asso-
ciation of Endodontics2 defines apexification
as “a method to induce a calcified barrier in
a root with an open apex or the continued
apical development of an incomplete root in
teeth with necrotic pulp”.
 The nature of the tissue that contributes to
38 the apical closure has been suggested as be-
ing cementum, osteodentin, osteocementum
or bone. The apical seal can occur in a hood,
barrier or bridge form. With apical sealing,
root development may or may not increase
the length of the root, but either way, root
development is usually irregular, unlike the
apexogenesis, which results in a regular apical
seal and normal root development59,63.
Kerekes et al.47 evaluated the results of root
Root Development
canal treatment in 166 traumatized incisors of
patients between 9 and 18 years of age. They
observed that the group of teeth treated by
apexification produced a success rate of 95%
in comparison with the group of teeth treated
conventionally, with a rate of 60%.
Apexification has become the most used
Chapter 2
method of treating teeth with non vital pulp,
with incomplete rhizogenesis, because it al-
lows appropriate root canal filling, which
would be impossible to treat conservative-
ly, in addition to reducing the possibility of
overfilling. With apexification the need for
apical surgery is eliminated.55 Although many
materials and methods are proposed for api-
cal barrier formation, calcium hydroxide has
had wiser acceptance, due to the high level
of clinical success related to its use32,48,40,42,63.
Chapter 20 discusses the biological and an-
timicrobial action mechanism of calcium hy-
droxide medications.
The basic principles of endodontic therapy
continue to be of fundamental importance in
the treatment of permanent teeth with incom-
plete rhizogenesis. Thus, some peculiar aspects
of this treatment should be emphasized.
Apexification technique
1. Before operative intervention, peria-
pical radiography should be performed for
diagnosis, to evaluate the stage of the root
development and the condition of the peria-
pical tissues.
2. The operative field should be isolated
with a rubber dam.
3. Conventional coronal opening does
not always offer direct or enough access to
the root canals and does not allow the instru-
ments to reach all the walls of the root canal
in these teeth, frequently resulting in areas
not being instrumented. Although coronal
openings should be wide, excessive wear of
the crown should be avoided.
4. To conclude the coronal opening, the
pulp chamber and entrance of the root canal
should be irrigated with 1% sodium hypochlo-
rite, always associated with aspiration.
5. Exploration of the root canal should be
carefully done. One must consider that in teeth
with incomplete rhizogenesis, with the apical
portion of the root not completely formed, the
radiographic image of the root is not well de-
fined, hindering determination of the length of
the tooth, required for exploring the root ca-
nal. The presence of pain or hemorrhage dur-
ing this maneuver indicates the need to keep
the exploration instrument at a shorter distance
than that of the pre-established length.
6. Preparation of the cervical third.
7. Sanitization process.
8. The real working length should be placed 1
mm short of the radiographic apex. If the patient
presents sensitivity, or if there is hemorrhage,
the working length should be reevaluated.
9. Emptying the root canal.
10. Root canal preparation in the teeth
with incomplete rhizogenesis depends on
the anatomical form of the root canal, whose
walls can come in three forms: divergent, par-
allel or convergent to apical.
When the roots present an early stage of
rhizogenesis and the root canal is divergent to
apical, modeling is hindered since the instru-
ments do not entirely reach the dentinal walls,
annulling the file actions and enlargement, so
that the objective is only to clean the infected
dentinal walls. Quite often the use of third se-
ries instruments is necessary, which should ex-
ert negative pressure during penetration and
positive pressure against all the walls when
they are withdrawn.
 In these cases, one must remember that be-
cause the dental tubules have not yet received
the important deposition of intratubular den-
tin, and the peritubular dentin has not been
completely mineralized, the walls become frag-
ile and very thin. Therefore no intense action
should be performed against them. Special at-
tention should be paid during the biomechani-
cal preparation, because the absence of an api-
cal stop favors over instrumentation. Another
precaution should be the placement of cursors
in the irrigation needle, to avoid its excessive
penetration, injuring the periapical tissues.
In cases of convergent walls to apical, the
action of the K-file instrument during the mod-
eling can be accompanied by an enlarging
movement to improve removal of necrotic res-
idues and bacteria from the root canal walls.
11. Drying and application of EDTA.
12. New irrigation and drying of the root
canals.
13. Placement of the calcium hydrox-
ide based dressing. The calcium hydroxide
placement technique is described under a
topic about calcium hydroxide (Chapter 20).
Calcium hydroxide placement with a file, ab-
sorbent paper points and vertical pluggers
presented the lowest frequency of empty
spaces in the three thirds of the root canal.
14. Radiography to evaluate the quality
of the root canal filling, to check whether it
is complete or whether there are radiolucent
spaces that show absence of the paste. The
presence of spaces in the root canal with cal-
cium hydroxide paste is an indication of the
absence of intracanal dressing, which de-
mands more care during placement. When
well condensed, the calcium hydroxide will
make the lumen of the root canal disappear.
15. Temporary cavity sealing is of funda-
mental importance to avoid contamination and
damage to the reparative process. Dissolution
of the intracanal dressing and consequent con-
tamination of the root canal can result in new
infection and determine clinical failure.
16. After the placement of the intracanal
dressing, it is important to maintain clinical
and radiographic control. The clinical condi-
tion of the tooth, filling with the calcium hy-
39
droxide paste, root and periapical tissue con-
dition should be considered.
There are controversies about whether
or not the intracanal dressing should be re-
newed, and what the ideal interval of time
for the performing the renewals would be.
Chawla11 and Chosack et al.12 suggest the
placement of calcium oxide only once until
there is radiographic evidence of mineral-
Endodontic Science
ized tissue barrier formation. They support
the clinical application because they believe
that the calcium hydroxide is only required to
begin the reparative process, and therefore,
nothing would be gained by the repeated
application, monthly or quarterly.
According to Cvek17 and Fleiglin30, every
Chapter 2
time that clinical-radiographic control dem-
onstrates signs of treatment failure (persistent
fistula, tumefaction, increase of the lesion or
absence of apical seal) it would be indispens-
able to reevaluate the treatment performed,
to improve the root canal preparation and
put back the calcium hydroxide.
Renewal of the calcium hydroxide paste
is supported by the statement that when in
contact with the carbon dioxide of the tis-
sues, this substance becomes calcium car-
bonate, altering its inductive capacity of
mineralization32,40,41.
Among the clinical-radiographic controls,
the time interval ranges from 30 days, 60 days
and 90 days24-27,71,87,90, depending on the vehicle
used in the calcium hydroxide paste, the type
of lesion and stage of rhizogenesis. When the
apical opening is quite wide, and there is the
presence of periapical fluids determining the
faster solubilization of the paste, it is necessary
to renew the calcium hydroxide after 30 days.
Radiolucent (empty) areas in the root canal
can be radiographically observed, mainly in
the apical third, indicating calcium hydroxide
dispersion, and the need for replacing it17,30.
Abbot1 emphasizes that the radiographic
image of the root canal filling with calcium
hydroxide paste is not reliable for determining
 the presence of calcium hydroxide or to dem-
40 onstrate whether or not the mineralized tis-
sue barrier is complete. He emphasizes that
the regular changes present many advantag-
es, and affirms that the ideal time interval for
changes depends on the stage of rhizogen-
esis at the time of treatment and the size of
the apical diameter.
The presence of the patient under treat-
ment for clinical-radiographic control is of
fundamental importance. His/her absence
Root Development
can lead to unexpected clinical and radio-
graphic results: partial sealing or periapical
recurrence could occur. In the session fol-
lowing after absolute isolation and removal
of the temporary restoration, the root canal
should be irrigated with saline solution with a
needle length ranging from 1 to 2 mm short
Chapter 2
of the working length.
Using the memory file, the solution should
be agitated inside the root canal, which will
aid the removal of calcium hydroxide paste.
The file should be passed smoothly against
the walls of the root canal to remove the in-
tracanal dressing. The root canal should be
dried with absorbent paper cones adapted
and refilled with calcium hydroxide.
17. In order to detect apical closure in a
radiographic exam, after the absolute isola-
tion and removal of the temporary restora-
tion, the root canal should be irrigated with
saline solution and the intracanal dressing
removed. With the memory instrument, with-
out executing pressure, probe the presence
of the apical barrier. Pass the memory instru-
ment again, smoothly against the walls of the
root canal, irrigate-aspirate, and dry with ab-
sorbent paper cones.
The period necessary for the apical closure
can vary from 3 to 18 months87,90. Cvek17 said
that the absence or the presence of periapi-
cal lesions can be one of the decisive factors
at / during this time.
18. Because teeth with incomplete rhizogen-
esis usually present very wide root canals, they
are difficult to fill and there is the need to use
resources like: filling, using inverted gutta-per-
cha cones to get a better adaptation in the api-
cal third, molding of the apical third of the root
canal, by the superficial plastification with xylol
of the selected gutta-percha cone, filling using
gutta-percha cones of the third series, or filling
using a self-made main gutta-percha cone.
In wide root canals, where even cones
#140 are not adjusted to the apical diameter,
a gutta-percha cone can be made. Three or
more gutta-percha cones of the second se-
ries should be heated, uniting them to form a
single bunch. After quick heating, the bunch
of cones should be rolled between two glass
plates forming one homogeneous cone. After
cooling and hardening, the cone is in condi-
tion to be selected.
In the case of using the classical filling tech-
nique with active lateral condensation, a great
deal of care should be taken during the con-
densation maneuvers not to exert excessive
pressure on the root canal walls (Fig. 2.6-2.9).
 41

Endodontic Science
Chapter 2
a b

Figure 2.6 - (A-B) Apical closure by mineralized tissue formation of an incompletely formed tooth.

Figure 2.7 - (A-F) Apical closure by mineralized

tissue formation of an incompletely
formed tooth.

b c d e f
42

a b
Root Development
Chapter 2

c d e f

Figure 2.8 - (A-F) Apical closure by mineralized tissue formation of an incompletely formed tooth.

Figure 2.9 - (A-E) Apical closure by mineralized tissue

formation of an incompletely formed tooth.

b c d e
2.6 Decisive Factors in Root Development
The process of periapical tissue repair af-
ter endodontic treatment has been the object
of numerous studies7,27,39-41,51,60,71,86. One of the
particularities of great interest in this subject
concerns teeth with incomplete rhizogenesis
and pulp necrosis that have suffered endo-
dontic intervention.
The mechanism of root completion and api-
cal closure post-treatment in teeth with pulp
necrosis and incomplete rhizogenesis, still re-
mains obscure. Some authors believe that the
dental papilla and the Hertwig’s epithelial root
sheath stay intact and resume their functions
when the infection is eliminated32,38. Klein &
Levy48 believe that the cells of the dental follicle
around the root keep their genetic codes pre-
disposing them to form cementoblasts, which
consequently deposit cementum. Some re-
searchers have suggested that calcium hydrox-
ide stimulates the undifferentiated mesenchy-
mal cells to differentiate into cementoblasts,
which begin the cementogenesis in the apex41.
Holland & Leonardo39, observed that af-
ter root canal treatment, in the reparative
process of teeth with incomplete rhizogen-
esis, root completion occurred exclusively
through the deposition of hard tissue, with
morphologic characteristics of cementum.
Steiner & Van Hassel79 also demonstrated
apical closure with the formation of a miner-
alized tissue barrier that met the criteria for
identification as cementum.
The occurrence of root completion seems
to maintain a close relationship with different
factors. There are indispensable factors for
the occurrence of apical and periapical repa-
ration of teeth with incomplete rhizogenesis,
as well as important factors that make it the
most organized and closest form of the mor-
phology of a normal apical third. These fac-
tors can be related to the pulpal status, stage
of root development at the time of endodon-
tic intervention, presence of periapical lesion,
intensity of the traumatic injury suffered and
endodontic technique used in the treatment.
Pulpal condition
When the pulp vitality is maintained,
43
through conservative treatment, such as direct
pulp protection or pulpotomy, there is great-
er possibility of complete root formation, by
dentin deposition and root cementum23.
Stage of root formation
The embryonic structures existent in the
apical area of teeth with pulp necrosis and in-
complete rhizogenesis can assume an impor-
Endodontic Science
tant role in the genesis of the morphologic
alterations after root canal treatment68.
When the dental papilla and Hertwig’s
epithelial root sheath are preserved, even if
disorganized, their cells can differentiate into
odontoblasts, to produce dentin formation
and root completion23.
Chapter 2
However, when the pulp shows necrosis
at an early stage of rhizogenesis, the possi-
bility of complete apical formation becomes
reduced, and the result is usually a shortened
root. While teeth at more advanced stages of
root development can present a reparation
process to determine root completion similar
to that of normal teeth.
Presence of periapical lesion
During the physiological process of root
completion, the Hertwig’s epithelial root
sheath begins to disintegrate and follicle cells
differentiate into cementoblasts, depositing
cementum on the dentin. Since the root does
not conclude its normal development, cells of
the dental sack close to the open apex, which
retain the genetic code, predispose them to
differentiate into cementoblasts69.
Most of the authors have defended that
root formation is dependent on the presence
of Hertwig’s root sheath, which would remain
intact even in the presence of periapical le-
sions16,38,86.
For Heithersay38 because it is an epithelium,
Hertwig’s epithelial root sheath would be more
resistant to inflammatory alterations, therefore
it would be possible, in cases of teeth with
 incomplete rhizogenesis, pulp necrosis and
44 periapical lesion, for Hertwig’s epithelial root
sheath to survive and remain capable of con-
tinuing to organize root development when
the inflammatory process is eliminated. An-
dreasen et al.4 suggest a regenerative poten-
tial of Hertwig’s epithelial root sheath, where
fragments of these remain viable in the face of
certain aggressions, with the capacity to recre-
ate a new Hertwig’s epithelial root sheath and
then to complete root formation.
Root Development
However, histological studies have not
demonstrated the presence of Hertwig’s root
sheath in the cases of teeth with periapical le-
sion22,37,41,42. Diab & Stallard20 reported that ce-
mentum formation does not depend on the
presence or absence of Hertwig’s root sheath,
and this would explain the root completion,
Chapter 2
mainly in teeth with periapical lesion.
Esberard et al.23 related that teeth with in-
complete rhizogenesis with periapical lesion
tend to have apical and periapical reparation
exclusively due to cells originated from the
periodontal ligament, only capable of produc-
ing hard tissue of the cementoid type. The ex-
tent of the lesion can influence this process,
because the larger the root involvement of the
periapical lesion, the smaller will be the num-
ber of cells with the capacity of synthesizing
cementoid matrix, migrating to the root apex
in order to reconstitute it.
Intensity of traumatic injury
Hertwig’s epithelial root sheath is usu-
ally sensitive to the traumatic dental inju-
ries, but because of the vascularization and
amount of cells in the apical area, root for-
mation can continue in the presence of pulp
inflammation or necrosis63.
In addition to inducing the inflammatory
process in the apical area, associated with
pulp necrosis, traumatic injury can disorga-
nize the dental papilla still present in the final
phase of the rhizogenesis, as well as disartic-
ulate the components Hertwig’s root sheath,
fundamental for the formation of the root.
The fragmentation of Hertwig’s root sheath
and the disorganization of the dental papilla
are unfavorable conditions for restructuring
the normal dental anatomy23.
2.7 Endodontic technique
Some procedures performed during the
treatment of these teeth are of considerable
importance in root completion: root canal
preparation, removal of the necrotic tissue,
decrease in the number of microorganisms in
the root canal, the intracanal dressing used,
and root canal filling.
The inflammatory process presents a
vascular-exudative phenomenon, associat-
ed with cellular and humoral phenomenon,
which interact with the aggressor agent
that promotes destructive events in the api-
cal and periapical area. Infection of the root
canal of teeth with incomplete rhizogenesis
exacerbates these destructive events. The
persistence of the infection leads to a pro-
gressive destruction of the osteogenic api-
cal structures and periapical remainders,
impeding their functions, among them root
completion. Infection is always undesirable,
and when it is present, the possibility of api-
cal completion, morphologically similar to
normality, is reduced; therefore it becomes
indispensable to removal all necrotic tissue
present in the root canal, by appropriate bio-
mechanical preparation23,86.
The use of irrigant solutions and medica-
tions that are harmful to the apical and pe-
riapical tissues, also make the desired apical
completion difficult.
Therefore, the factors inherent to the en-
dodontic technique used, which can be de-
cisive in root completion are: absence of in-
fection in the root canal, use of medications
or solutions non aggressive to the apical and
periapical tissues, biomechanics appropriate
to the biology of the remaining tissues, her-
metic root canal filling and compatible filling
material, and if possible, stimulation of hard
tissue matrix synthesis.
2.8 Forms of Periapical Repair
The periapical reparation and the forma-
tion of hard tissue after treatment with cal-
cium hydroxide occur, in long term, in 79% to
96% of the cases. However, the permanence
of these teeth in the buccal cavity is reduced
by the potential of cervical fracture due to
the thinness of the dental walls87.
Reconstruction of the apical third in teeth
with incomplete rhizogenesis, due to several
factors previously discussed, can promote
several forms of root completion.6,32 For Hei-
thersay38 a greater number of types of miner-
alized tissue, which can be deposited in the
apical area, and varied forms of repair seem
to be possible. The periapical environment
and its response seem to dictate a particular
pattern of repair individually in each case.
Complete and normal root completion
This completion takes place when the
root pulp is preserved in the root canal after
a direct pulp protection, pulpotomy or when
endodontic intervention is performed in a
tooth in which the root was already formed,
however, with the apical foramen still open23.
Complete and normal root completion,
with pulp necrosis
In this form of reparation there is a great
formation of mineralized tissue, even with
pulp necrosis. This occurs when the apical tis-
sues have not suffered significant damage and
the cells in the area have been preserved. In
the etiopathogenesis of these cases there is
usually a history of light traumatic injury, but
sufficient to have caused pulp necrosis, with-
out infection37,38.
Root and apical completion with
foreshortening of the root
In these cases apical completion is in-
complete, because when compared with the
homologous tooth, the root is shorter. This
condition usually occurs when there is pulp
necrosis and the root is at an initial stage of
45
rhizogenesis, with the maximum formation of
the medium third23.
The dental papilla in this condition is wide
and its destruction is partial. Thus, elimina-
tion of the necrotic pulp offers biological
conditions for the remainders of the dental
papilla and Hertwig’s root sheath to promote
the apical completion, but without reestab-
lishing the normal length of the root23.
Endodontic Science
Apical completion with a mineralized
tissue barrier
In some cases, the apical closure is a min-
eralized barrier, but without root develop-
ment90. Complete destruction of Hertwig’s
root sheath results in cessation of normal
Chapter 2
root development. Once the dental papilla is
destroyed there will be no differentiation of
cells into odontoblasts. However, hard tissue
can be formed by cementoblasts, which are
usually present in the apical area and by fi-
broblasts of the dental follicle and periodon-
tal ligament, which differentiate into hard tis-
sue producer cells86.
Radiographic and clinical evidence of the
complete formation of the hard tissue barri-
er, and histological analyses have shown that
the barrier is porous, and sometimes partial.
However, for the clinical success, a barrier of
impermeable material is not necessary79.
Absence of apical completion
This clinical condition can occur in teeth
in which the apical and periapical area have
suffered extensive damage with necrosis of
the cells that had the potential to promote
the formation of hard tissue. After the harmful
agents have been eliminated, none of these
cells remain in the apical area of dental papilla
or even in periodontal ligament cells, which
could favor the formation of hard tissue, even
if they were rudimentary and disorganized23.
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