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Management Strategies for Teeth with Open Apex: From Apexification to Regenerative Endodontics

Year 2025, Volume: 28 Issue: 3, 462 - 468, 30.09.2025

Duygu Aksoy , Sibel Kocak

https://doi.org/10.7126/cumudj.1728795

Abstract

The management of teeth with open apices, typically resulting from trauma or developmental anomalies, remains a clinical challenge in endodontics. Historically, apexification with long-term calcium hydroxide therapy was the primary approach to induce apical closure. However, this method is associated with extended treatment duration and increased risk of root fracture. Bioceramic materials such as mineral trioxide aggregate (MTA), artificial apical barriers have gained popularity due to their reduced treatment time and favorable sealing properties. More recently, regenerative endodontic procedures (REPs) have emerged as a biologically based alternative aiming to restore the pulp–dentin complex and promote continued root development. This review provides a comprehensive overview of current treatment strategies for immature permanent teeth, comparing traditional apexification with modern regenerative techniques. Clinical indications, protocols, advantages, limitations, and prognosis are discussed in detail to guide evidence-based clinical decision-making.

Keywords

open apex apexification regenerative endodontics MTA calcium hydroxide immature teeth apical barrier

References

  • 1. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18(3):134-7.
  • 2. Cvek M. Prognosis of luxated non‐vital maxillary incisors treated with calcium hydroxide and filled with gutta‐percha. A retrospective clinical study. Dent Traumatol 1992;8(2):45-55.
  • 3. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25(3):197-205.
  • 4. Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: what does the future hold? Pediatr Dent 2008;30(3):253-60.
  • 5. Diogenes A, Ruparel NB, Shiloah Y, Hargreaves KM. Regenerative endodontics: a way forward. J Am Dent Assoc 2016;147(5):372-80.
  • 6. Sarnowski A. Management of the Open Apex Using a Bioceramic Apical Barrier: Success and Survival Rates at Virginia Commonwealth University. 2019, Virginia Commonwealth University, Richmond, VA.
  • 7. Panda P, Mishra L, Govind S, Panda S, Lapinska B. Clinical outcome and comparison of regenerative and apexification intervention in young immature necrotic teeth—A systematic review and meta-analysis. J Clin Med 2022;11(13):3909.
  • 8. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in endodontics–a review. Int Endod J 2015;48(1):3-15.
  • 9. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod 2009;35(6):777-790.
  • 10. Shaik I, Tulli M, Unnam P, Karunakaran S, Vaddi DS, Jabeen R, Tiwari RVC. Regenerative endodontic therapy in the management of nonvital immature permanent teeth: a systematic review and meta-analysis. J Pharm Bioallied Sci 2021;13(Suppl 1):S36-S42.
  • 11. Lin J-C, Lu J-X, Zeng Q, Zhao W, Li W-Q, Ling J-Q. Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis. J Formos Med Assoc 2016;115(7):523-530.
  • 12. Alyahya SAS, AlMuhaya SFA, Alqahtani AN, Adwan TA, Aleisa AF, Alsabeh YS, Albishi AKA, Binmuqbil BA, Alqoair AI, Almaymoon HS. Comparison between Calcium Hydroxide and MTA When Used for Apexification: A Systematic Review. Pharmacophore 2022;13(2-2022):115-20.
  • 13. Rosenberg B, Murray PE, Namerow K. The effect of calcium hydroxide root filling on dentin fracture strength. Dent Traumatol 2007;23(1):26-9.
  • 14. Kahler B, Swain MV. The Calcium Hydroxide Controversy: Does Calcium Hydroxide Weaken Teeth? Dent Traumatol 2025;41:53-63.
  • 15. Adel M, Nima MM, Shivaie Kojoori S, Norooz Oliaie H, Naghavi N, Asgary S. Comparison of endodontic biomaterials as apical barriers in simulated open apices. ISRN Dent 2012;2012(1):359873.
  • 16. Tabrizizade M, Asadi Y, Sooratgar A, Moradi S, Sooratgar H, Ayatollahi F. Sealing ability of mineral trioxide aggregate and calcium-enriched mixture cement as apical barriers with different obturation techniques. Iran Endod J 2014;9(4):261-265
  • 17. Haapasalo M, Parhar M, Huang X, Wei X, Lin J, Shen Y. Clinical use of bioceramic materials. Endod Topics 2015;32(1):97-117.
  • 18. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives—permanent teeth. Pediatr Dent 2008;30(3):220-224.
  • 19. Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Khewsawai P, Hargreaves KM. Mahidol study 1: comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexification methods: a retrospective study. J Endod 2012;38(10):1330-1336.
  • 20. Dong X, Xu X. Bioceramics in endodontics: updates and future perspectives. Bioengineering 2023;10(3):354.
  • 21. Ekçi ES. A General Outlook to Regenerative Pulp Therapy. Cumhuriyet Dent J 2017;19(3):238-246.
  • 22. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. J Endod 2007;33(4):377-390.
  • 23. Demir P, Demircan B, Bulut ET, Şimşek N. Knowledge and clinical experiences of pediatric dentists and endodontists regarding regenerative endodontic procedures. Ann Clin Anal Med 2022;13(4):451-456.
  • 24. Naik SV, Prakash AJ, Attiguppe RP. A survey on awareness and knowledge among dentist practicing regenerative endodontics towards current regenerative endodontic protocols and the scaffolds used in regenerative dentistry. Saudi Dent J 2023;35(5):559-566.
  • 25. Diogenes A, Ruparel NB. Regenerative endodontic procedures: clinical outcomes. Dent Clin North Am 2017;61(1):111-125.
  • 26. Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112(4):36-42.
  • 27. Prasad Kumara PAAS, Cooper PR, Cathro P, Gould M, Dias G, Ratnayake J. Bioceramics in Endodontics: Limitations and Future Innovations—A Review. Dent J (Basel) 2025;13(4):157.
  • 28. Staffoli S, Plotino G, Nunez Torrijos BG, Grande NM, Bossù M, Gambarini G, Polimeni A. Regenerative endodontic procedures using contemporary endodontic materials. Materials. 2019;12(6):908.
  • 29. Boufdil H, Mtalsi M, El Arabi S, Bousfiha B. Apexification with calcium hydroxide vs. revascularization. Case Rep Dent 2020;2020(1):9861609.
  • 30. Ghose LJ, Baghdady VS, Hikmat BY. Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide. J Endod 1987;13(6):285-290.
  • 31. Savannah G. Bioceramic technology–the game changer in endodontics. Endod Pract 2009;13:13-17.
  • 32. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of bioceramics in endodontics-literature review. Clujul Med 2016;89(4):470-473.
  • 33. Wei X, Yang M, Yue L, Huang D, Zhou X, Wang X, Zhang Q, Qiu L, Huang Z, Wang H, Meng L, Li H, Chen W, Zou X, Ling J. Expert consensus on regenerative endodontic procedures. Int J Oral Sci 2022;14(1):55.
  • 34. Lopes LB, Neves JA, Botelho J, Machado V, Mendes JJ. Regenerative endodontic procedures: an umbrella review. Int J Environ Res Public Health 2021;18(2):754.
  • 35. Tatullo M. The regenerative dentistry: Current approaches and future insights. Cumhuriyet Dent J 2020;23(1):1-3.
  • 36. Murray PE. Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth. Int Endod J 2023;56:188-199.
  • 37. Edanami N, Yoshiba K, Shirakashi M, Ibn Belal RS, Yoshiba N, Ohkura N, Tohma A, Takeuchi R, Okiji T, Noiri Y. Impact of remnant healthy pulp and apical tissue on outcomes after simulated regenerative endodontic procedure in rat molars. Sci Rep 2020;10(1):20967.
  • 38. Almutairi W, Yassen GH, Aminoshariae A, Williams KA, Mickel A. Regenerative endodontics: a systematic analysis of the failed cases. J Endod 2019;45(5):567-577.
  • 39. Lee C, Song M. Failure of regenerative endodontic procedures: case analysis and subsequent treatment options. J Endod 2022;48(9):1137-1145.

Açık Apeksli Dişler İçin Yönetim Stratejileri: Apeksifikasyondan Rejeneratif Endodontiye

Year 2025, Volume: 28 Issue: 3, 462 - 468, 30.09.2025

Duygu Aksoy , Sibel Kocak

https://doi.org/10.7126/cumudj.1728795

Abstract

Genellikle travma veya gelişimsel anomalilerden kaynaklanan açık apeksli dişlerin yönetimi, endodontide klinik bir zorluk olmaya devam etmektedir. Tarihsel olarak, uzun süreli kalsiyum hidroksit tedavisiyle apeksifikasyon, apikal kapanmayı sağlamak için birincil yaklaşımdı. Ancak, bu yöntem daha uzun tedavi süresi ve kök kırığı riskinin artmasıyla ilişkilidir. Mineral trioksit agregatı (MTA) gibi biyoseramik malzemeler, yapay apikal bariyerler, tedavi süresini azaltmaları ve elverişli sızdırmazlık özellikleri nedeniyle popülerlik kazanmıştır. Daha yakın zamanlarda, rejeneratif endodontik prosedürler (REP'ler), pulpa-dentin kompleksini restore etmeyi ve sürekli kök gelişimini desteklemeyi amaçlayan biyolojik tabanlı bir alternatif olarak ortaya çıkmıştır. Bu inceleme, geleneksel apeksifikasyonu modern rejeneratif tekniklerle karşılaştırarak, olgunlaşmamış daimi dişler için mevcut tedavi stratejilerine kapsamlı bir genel bakış sunmaktadır. Klinik endikasyonlar, protokoller, avantajlar, sınırlamalar ve prognoz, kanıta dayalı klinik karar almaya rehberlik etmek için ayrıntılı olarak tartışılmaktadır.

Keywords

açık apeks apeksifikasyon rejeneratif endodonti MTA Kalsiyum Hidroksit apikal bariyer

References

  • 1. Andreasen JO, Farik B, Munksgaard EC. Long‐term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18(3):134-7.
  • 2. Cvek M. Prognosis of luxated non‐vital maxillary incisors treated with calcium hydroxide and filled with gutta‐percha. A retrospective clinical study. Dent Traumatol 1992;8(2):45-55.
  • 3. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25(3):197-205.
  • 4. Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: what does the future hold? Pediatr Dent 2008;30(3):253-60.
  • 5. Diogenes A, Ruparel NB, Shiloah Y, Hargreaves KM. Regenerative endodontics: a way forward. J Am Dent Assoc 2016;147(5):372-80.
  • 6. Sarnowski A. Management of the Open Apex Using a Bioceramic Apical Barrier: Success and Survival Rates at Virginia Commonwealth University. 2019, Virginia Commonwealth University, Richmond, VA.
  • 7. Panda P, Mishra L, Govind S, Panda S, Lapinska B. Clinical outcome and comparison of regenerative and apexification intervention in young immature necrotic teeth—A systematic review and meta-analysis. J Clin Med 2022;11(13):3909.
  • 8. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in endodontics–a review. Int Endod J 2015;48(1):3-15.
  • 9. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod 2009;35(6):777-790.
  • 10. Shaik I, Tulli M, Unnam P, Karunakaran S, Vaddi DS, Jabeen R, Tiwari RVC. Regenerative endodontic therapy in the management of nonvital immature permanent teeth: a systematic review and meta-analysis. J Pharm Bioallied Sci 2021;13(Suppl 1):S36-S42.
  • 11. Lin J-C, Lu J-X, Zeng Q, Zhao W, Li W-Q, Ling J-Q. Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: A systematic review and meta-analysis. J Formos Med Assoc 2016;115(7):523-530.
  • 12. Alyahya SAS, AlMuhaya SFA, Alqahtani AN, Adwan TA, Aleisa AF, Alsabeh YS, Albishi AKA, Binmuqbil BA, Alqoair AI, Almaymoon HS. Comparison between Calcium Hydroxide and MTA When Used for Apexification: A Systematic Review. Pharmacophore 2022;13(2-2022):115-20.
  • 13. Rosenberg B, Murray PE, Namerow K. The effect of calcium hydroxide root filling on dentin fracture strength. Dent Traumatol 2007;23(1):26-9.
  • 14. Kahler B, Swain MV. The Calcium Hydroxide Controversy: Does Calcium Hydroxide Weaken Teeth? Dent Traumatol 2025;41:53-63.
  • 15. Adel M, Nima MM, Shivaie Kojoori S, Norooz Oliaie H, Naghavi N, Asgary S. Comparison of endodontic biomaterials as apical barriers in simulated open apices. ISRN Dent 2012;2012(1):359873.
  • 16. Tabrizizade M, Asadi Y, Sooratgar A, Moradi S, Sooratgar H, Ayatollahi F. Sealing ability of mineral trioxide aggregate and calcium-enriched mixture cement as apical barriers with different obturation techniques. Iran Endod J 2014;9(4):261-265
  • 17. Haapasalo M, Parhar M, Huang X, Wei X, Lin J, Shen Y. Clinical use of bioceramic materials. Endod Topics 2015;32(1):97-117.
  • 18. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives—permanent teeth. Pediatr Dent 2008;30(3):220-224.
  • 19. Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Khewsawai P, Hargreaves KM. Mahidol study 1: comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexification methods: a retrospective study. J Endod 2012;38(10):1330-1336.
  • 20. Dong X, Xu X. Bioceramics in endodontics: updates and future perspectives. Bioengineering 2023;10(3):354.
  • 21. Ekçi ES. A General Outlook to Regenerative Pulp Therapy. Cumhuriyet Dent J 2017;19(3):238-246.
  • 22. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. J Endod 2007;33(4):377-390.
  • 23. Demir P, Demircan B, Bulut ET, Şimşek N. Knowledge and clinical experiences of pediatric dentists and endodontists regarding regenerative endodontic procedures. Ann Clin Anal Med 2022;13(4):451-456.
  • 24. Naik SV, Prakash AJ, Attiguppe RP. A survey on awareness and knowledge among dentist practicing regenerative endodontics towards current regenerative endodontic protocols and the scaffolds used in regenerative dentistry. Saudi Dent J 2023;35(5):559-566.
  • 25. Diogenes A, Ruparel NB. Regenerative endodontic procedures: clinical outcomes. Dent Clin North Am 2017;61(1):111-125.
  • 26. Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112(4):36-42.
  • 27. Prasad Kumara PAAS, Cooper PR, Cathro P, Gould M, Dias G, Ratnayake J. Bioceramics in Endodontics: Limitations and Future Innovations—A Review. Dent J (Basel) 2025;13(4):157.
  • 28. Staffoli S, Plotino G, Nunez Torrijos BG, Grande NM, Bossù M, Gambarini G, Polimeni A. Regenerative endodontic procedures using contemporary endodontic materials. Materials. 2019;12(6):908.
  • 29. Boufdil H, Mtalsi M, El Arabi S, Bousfiha B. Apexification with calcium hydroxide vs. revascularization. Case Rep Dent 2020;2020(1):9861609.
  • 30. Ghose LJ, Baghdady VS, Hikmat BY. Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide. J Endod 1987;13(6):285-290.
  • 31. Savannah G. Bioceramic technology–the game changer in endodontics. Endod Pract 2009;13:13-17.
  • 32. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of bioceramics in endodontics-literature review. Clujul Med 2016;89(4):470-473.
  • 33. Wei X, Yang M, Yue L, Huang D, Zhou X, Wang X, Zhang Q, Qiu L, Huang Z, Wang H, Meng L, Li H, Chen W, Zou X, Ling J. Expert consensus on regenerative endodontic procedures. Int J Oral Sci 2022;14(1):55.
  • 34. Lopes LB, Neves JA, Botelho J, Machado V, Mendes JJ. Regenerative endodontic procedures: an umbrella review. Int J Environ Res Public Health 2021;18(2):754.
  • 35. Tatullo M. The regenerative dentistry: Current approaches and future insights. Cumhuriyet Dent J 2020;23(1):1-3.
  • 36. Murray PE. Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth. Int Endod J 2023;56:188-199.
  • 37. Edanami N, Yoshiba K, Shirakashi M, Ibn Belal RS, Yoshiba N, Ohkura N, Tohma A, Takeuchi R, Okiji T, Noiri Y. Impact of remnant healthy pulp and apical tissue on outcomes after simulated regenerative endodontic procedure in rat molars. Sci Rep 2020;10(1):20967.
  • 38. Almutairi W, Yassen GH, Aminoshariae A, Williams KA, Mickel A. Regenerative endodontics: a systematic analysis of the failed cases. J Endod 2019;45(5):567-577.
  • 39. Lee C, Song M. Failure of regenerative endodontic procedures: case analysis and subsequent treatment options. J Endod 2022;48(9):1137-1145.
There are 39 citations in total.

Details

Primary Language English
Subjects Endodontics
Journal Section Review
Authors

Duygu Aksoy 0000-0002-9987-6381

Sibel Kocak 0000-0003-2354-7108

Publication Date September 30, 2025
Submission Date June 30, 2025
Acceptance Date July 9, 2025
Published in Issue Year 2025 Volume: 28 Issue: 3

Cite

EndNote Aksoy D, Kocak S (September 1, 2025) Management Strategies for Teeth with Open Apex: From Apexification to Regenerative Endodontics. Cumhuriyet Dental Journal 28 3 462–468.
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Cumhuriyet Dental Journal (Cumhuriyet Dent J, CDJ) is the official publication of Cumhuriyet University Faculty of Dentistry. CDJ is an international journal dedicated to the latest advancement of dentistry. The aim of this journal is to provide a platform for scientists and academicians all over the world to promote, share, and discuss various new issues and developments in different areas of dentistry. First issue of the Journal of Cumhuriyet University Faculty of Dentistry was published in 1998. In 2010, journal's name was changed as Cumhuriyet Dental Journal. Journal’s publication language is English.


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