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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 1-5

Rehabilitation of fractured nonvital immature tooth by nonsurgical treatment and post and core restoration: A case report and literature review

1 Private Pediatric Dental Practice, Aligarh, Uttar Pradesh, India
2 Department of Pediatric and Preventive Dentistry, Faculty of Medicine, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission24-Sep-2021
Date of Acceptance12-Apr-2022
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Mohammad Kamran Khan
Hamdard Nagar-A, Civil Line, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_38_21

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Nonvital immature permanent tooth presents several challenges to a clinician in performing conventional endodontic therapy due to the lack of apical constriction and thin root walls. Apexification has been serving as the gold standard therapeutic modality for managing nonvital teeth with wide-open apex. The present case report demonstrates the successful rehabilitation of fractured immature nonvital permanent tooth of a healthy 8.5-year-old male patient by apexification procedure using the premixed mixture of calcium hydroxide and iodoform with vehicle of silicone oil (Metapex). The dental procedure resulted in favorable treatment outcomes with Frank's Type-1 apical closure of root and optimum periapical healing within comparatively shorter duration. Subsequently, fractured crown was successfully restored for function and esthetics using fiber-reinforced post and core and composite restoration. In follow-up visits, the patient was found asymptomatic and satisfactory with the treatment results.

Keywords: Apexification, calcium hydroxide, iodoform, Metapex, post and core, rehabilitation, young permanent tooth

How to cite this article:
Khan MK, Jindal MK. Rehabilitation of fractured nonvital immature tooth by nonsurgical treatment and post and core restoration: A case report and literature review. J Interdiscip Dentistry 2022;12:1-5

How to cite this URL:
Khan MK, Jindal MK. Rehabilitation of fractured nonvital immature tooth by nonsurgical treatment and post and core restoration: A case report and literature review. J Interdiscip Dentistry [serial online] 2022 [cited 2023 May 29];12:1-5. Available from: https://www.jidonline.com/text.asp?2022/12/1/1/344464

   Clinical Relevance to Interdisciplinary Dentistry Top

  • This case report demonstrates the successful management of fractured immature permanent tooth with necrotic pulp in a pediatric patient by apexification
  • The fractured crown was restored with fiber-reinforced resin post and core which reestablished the form, function, and esthetic of the tooth
  • This article highlights the importance of nonsurgical approach in treating pediatric endodontic pathologies with favorable healing in comparatively shorter duration.

   Introduction Top

Permanent tooth usually takes approximately 3 years to complete its root length and apical closure after eruption into the oral cavity. When the young tooth is affected with pulpal necrosis and consequently, cessation of normal root development with open root apex occurs.[1] Delayed or improper treatment can result in loss of infected permanent tooth, impairment of masticatory functions, and speech and facial esthetics.[1] Thus, timely and correct treatment is paramount to save such nonvital permanent teeth with blunderbuss canal.

Young permanent tooth with necrotic pulp and open root apex poses several challenges to dentists in performing conventional endodontic therapy due to the lack of root's natural apical constriction and thin root walls. Various endodontic treatment modalities have been described in the literature for nonvital teeth with open apex which creates the apical stop either by induction of apical closure or by intracanal apical barrier before obturation procedure to confine the root canal filling material within the root canal space and also to prevent its extrusion into periradicular region.[2]

Apexification has been the treatment of choice for treating such pulpless immature permanent teeth. Apexification is a nonsurgical therapeutic approach of inducing calcific barrier at the root apex of young nonvital permanent tooth.[3] The multiple visit apexification procedure using calcium hydroxide as intracanal medicament has been the traditional approach for tooth with necrotic pulp and open apex.[4] Despite the popularity of calcium hydroxide (Ca [OH]2) for the apexification, it has shown some disadvantages. Ca (OH)2 intracanal medicament is not radiopaque on radiograph that leads to difficult in evaluation of its intracanal placement. The frequency of changes of intracanal Ca (OH)2 medicament is variably reported. The time required for forming the calcified apical barrier varies from 5 to 20 months, as reported in the literature. Hence, the mixture of Ca (OH)2 and iodoform has been used for apexification purposes as reported in previous studies. Commercially available paste is Metapex® (Meta Biomed Co., Ltd, Korea) which is composed of Ca (OH)2, iodoform, and silicone oil (vehicle). It is oil-based Ca (OH)2 paste. It has several advantages over conventional Ca (OH)2 alone; it comes in single syringe with premixed form of Ca (OH)2 and iodoform with disposables tips, it offers antibacterial effect and radio-opacity in radiographic evaluation. Cwikla et al. reported that the combination of Ca (OH)2 with iodoform is more effective in disinfecting the root canals as compared to other Ca (OH)2 combinations.[5] Few studies have been published on investigating the clinical performance of apexification using the combination of Ca (OH)2 and iodoform paste.[6],[7],[8]

This article presents a report of a case in which the paste of Ca (OH)2 and iodoform were used successfully to induce root apex closure in nonvital young permanent tooth by apexification procedure in 6 months, followed by post and core restoration with.

   Case Report Top

An 8.5-year-old healthy male patient reported to the outpatient department of pediatric and preventive dentistry with chief complaints of pain in the broken upper front tooth region for the past 3 days. The patient's parents gave a history of trauma and subsequently swelling in the maxillary anterior teeth region due to a fall during playing 5 months ago. His medical and family history was not significant.

Clinical examination of the patient revealed fractured and discolored permanent maxillary left central incisor with Ellis class-IV [Figure 1]a and [Figure 1]b. Tenderness on percussion was present in relation to fractured 21. Radiographic examination revealed a fractured tooth with open apex (Cvek's stage-IV) and small irregular periapical radiolucency. Pulp sensitivity tests (heat test and electric pulp tests) were performed and showed negative response and that confirmed pulpal necrosis of fractured 21. A clinical diagnosis of chronic apical periodontitis with open apex of fractured nonvital tooth 21 was determined.
Figure 1: (a) Preoperative photograph of the fractured tooth 21 showing discoloration; (b) Preoperative radiograph showing fractured tooth 21 with open apex and periapical radiolucency; (c) Working length radiograph of fractured tooth 21; (d) Radiograph showing intracanal calcium hydroxide medicament and coronal seal

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The patient's parents were explained about the treatment options, procedures, objectives, and advantages. Apexification of the affected tooth using Ca (OH)2-iodoform paste followed by postcore restoration was determined as treatment plan as per the clinical situation. Written informed consent was obtained from parents. For having a co-operative behavior of the pediatric patient, the tell-show-do approach was followed.

First, access opening was prepared, with straight-line access to the root canal and then the working length was determined by radiographic method using K-file (No. 15, 25 mm length, Dentsply, Switzerland) [Figure 1]c. Complete necrotic pulpal tissue was extirpated. Cleaning and shaping were done 2 mm short of radiographic apex. The root canal was irrigated with 10 ml sterile normal saline solution without any force apically with side-vented needle (Dental Endo Irrigation Needle Tip, Maruti Madhav Enterprise, India) followed by drying of canal with paper points. Ca (OH)2 (PrevestDenpro, India) dressing was given to disinfect the dentinal tubules of the root canal for 2 weeks [Figure 1]d. The access cavity was sealed with premixed noneugenol zinc oxide cement (Cavit, 3M ESPE, Germany).

After 2 weeks, the tooth was reevaluated clinically and radiographically and found asymptomatic. Ca (OH)2 dressing was removed from canal followed by instrumentation was performed with gentle circumferential filing motion, aided by irrigation with 5.25% of sodium hypochlorite diluted with normal saline using side-vented needle. The canal was made dried using sterile paper points and was filled with a paste of Ca (OH)2 and iodoform paste (Metapex®, Meta Biomed Co., Ltd, Korea) with the help of disposable plastic tips under rubber-dam isolation (Dental Dam Kit, GDC). Access cavity was sealed with glass-ionomer cement (GC Gold Label-2 Glass Ionomer Restorative Cement, India).

Parents were advised to bring their child for regular follow-up for clinical and radiographic evaluation.

On follow-up visits, radiographic evaluation showed favorable and successful outcomes in terms of progressive apical closure and resolution of periapical radiolucency [Figure 2]a and [Figure 2]b. Tooth remained asymptomatic throughout follow-up duration.
Figure 2: Radiographic images after placement of Metapex into the canal of fractured tooth #21: (a) threemonths: Open apex and relatively reduced periapical radiolucency; (b) six-months: Closure of open apex with radiopaque calcified barrier and resolution of periapical radiolucency

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After 6 months, radiopaque calcified apical closure and complete resolution of periapical radiolucency of tooth 21 was revealed on radiographic examination and subsequently was rechecked clinically with a paper point. After that, obturation was done with gutta-percha points [Figure 3] and the restoration using fiber post and core with composite build-up of crown was done [Figure 4]a,[Figure 4]b,[Figure 4]c. The patient remained asymptomatic during the entire follow-up visit on clinical and radiographical assessment [Figure 5]a and [Figure 5]b.
Figure 3: Radiograph image showing the obturation of the tooth 21

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Figure 4: Photographic images showing the restorative procedures stepwise: (a) radiograph showing creation of postspace in the canal; (b) photograph showing placement of fiber post into the prepared postspace; (c) Photograph showing postcore and composite restoration of tooth 21

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Figure 5: Follow-up evaluation images: (a) photograph; (b) radiograph after 1 week of postcore composite restoration

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   Discussion Top

Traumatic dental injuries involving permanent teeth are common among children. Thirty percent of pulp necrosis in immature permanent teeth occurs due to dental trauma.[9] Proper addressal of such injured teeth at the right time is critical for favorable outcomes of treatment. However, the lack of accessibility and affordability act as obstacles to it and the affected tooth becomes nonvital and the normal natural development of root apex closure gets hindered.

Various treatment modalities for such immature nonvital teeth have been suggested in the dental literature. Among them, apexification approach has being used widely for such clinical conditions. Frank (1966) popularized the procedure of apical closure using Ca (OH)2 and also classified radiographic aspect of the apical closure achieved after apexification into four types according to the presence or the absence of the Hertwig's epithelial root sheath (HERS) and apical residues of the pulp tissue (odontoblasts).

Apexification approach has been employed using various kinds of medicaments. However, Ca (OH)2, because of its many favorable characteristics, has been used extensively and successfully to induce apical closure in nonvital young teeth. Hermann introduced Ca (OH)2 in 1920 for endodontic procedures. Granath (1959) was the first who reported the use of Ca (OH)2 for apical closure. However, some of the reported demerits of Ca (OH)2 are such that Ca (OH)2 has been shown to be less effective against Enterococcus faecalis and Candida albicans.[10] It takes longer and variable time taken for the formation of apical hard tissue barrier that may be inconvenient for the patient and for the clinician also. Ca (OH)2 alters the mechanical properties of dentinal tissue on using for longer duration rendering the tooth prone to fracture.[11]

Calcium hydroxide powder can be mixed with normal saline solution, propylene glycol, and glycerine as vehicles. Most of these vehicles do not impart significant antimicrobial activity.[12] However, due to the relative inability of Ca (OH)2 in the eradication of both facultative anaerobic bacteria and yeasts fungi from pulp canal, it has been combined with other substances such as 2% CHX gel, iodoform, and camphorated paramonochlorophenol, to obtain a wide spectrum antimicrobial action.[10] Multiple studies have been conducted to evaluate the effect of various types of CH-based medicaments.[13] Cwikla et al.[5] did comparative evaluation of various combinations of Ca (OH)2 with other medicaments and vehicles such as Ca (OH)2 mixed with water, Ca (OH)2 mixed with iodine-potassium iodide, and Ca (OH)2 mixed with iodoform and silicone oil (Metapex). They reported that the combination of Ca (OH)2 with iodoform and silicone oil is more effective in disinfecting the root canals as compared to other combinations.[5] Iodoform in oil vehicle is claimed to enhance its antimicrobial activity against E. faecalis.[5],[13] Metapex contains silicone oil as its vehicle. The superior properties of Metapex may be due to the addition of iodoform and also silicone oil as viscous and oily vehicle, which may prolong the duration antimicrobial action of Metapex.[14] In the present case also, the apical closure was achieved after 6 months of apexification procedure with single placement of Metapex into the canal without changing the medicament.

However, Estrela et al. reported that addition of vehicles for Ca (OH)2 does not affect the antimicrobial activities.[15] They also concluded that addition of iodoform into Ca (OH)2 does not improve the antimicrobial spectrum.[13],[15] Frank (1966) classified the radiographic outcomes of apical closure by apexification procedures into four types.[15] In the present case, apical closure was of Frank's Type-1 apexification. Frank's Type-1 apexification indicates that the affected tooth's HERS and the apical odontoblasts cells are vital, the root will develop normally with a physiological process of apexogenesis.[15]

In the present case, after achieving apical closure with apexification, fractured crown was restored with fiber postcore and composite build-up. With the evolution of adhesive dentistry, fiber-reinforced resin-based posts have being used in restoration of tooth structure. These fiber posts demonstrate hardness and elastic modulus similar to dentin that results in increased strength of tooth structure and resistance to fracture during function.[16] Furthermore, these are preformed ready-made posts available in various sizes, whereas in conventional metal posts, more laboratory and clinical time are needed.[17] These advantages made the fiber posts suitable for restoring the fractured tooth in the present case. The clinical success of fiber posts in endodontically treated has been compared with metal posts in previously reported studies.[18]

   Conclusion Top

The present case report showed the complete and successful rehabilitation of fractured nonvital immature permanent tooth by apexification procedure using the paste of Ca (OH)2 -iodoform and restored with fiber postcore composite restoration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hargreaves KM, Diogenes A, Teixeira FB. Treatment options: Biological basis of regenerative endodontic procedures. Pediatr Dent 2013;35:129-40.  Back to cited text no. 1
Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Endod Top 2006;14:51-9.  Back to cited text no. 2
Shabahang S. Treatment options: Apexogenesis and apexification. J Endod 2013;39:S26-9.  Back to cited text no. 3
Agrafioti A, Giannakoulas DG, Filippatos CG, Kontakiotis EG. Analysis of clinical studies related to apexification techniques. Eur J Paediatr Dent 2017;18:273-84.  Back to cited text no. 4
Cwikla SJ, Bélanger M, Giguère S, Progulske-Fox A, Vertucci FJ. Dentinal tubule disinfection using three calcium hydroxide formulations. J Endod 2005;31:50-2.  Back to cited text no. 5
Sridhar N, Tandon S. Continued root-end growth and apexification using a calcium hydroxide and iodoform paste (Metapex®): Three case reports. J Contemp Dent Pract 2010;11:063-70.  Back to cited text no. 6
Lu YM, Qin JN. A comparison of the effect between Vitapex paste and antibiotic paste in apexification. Shanghai J Stomatology 2004;13:449-51.  Back to cited text no. 7
Weng QF. Clinical study on the effect of Vitapex paste in apexification. West China J Stomatology 2004;22:214-5.  Back to cited text no. 8
Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Hoboken, New Jersey: John Wiley & Sons; 2013.  Back to cited text no. 9
Mohammadi Z, Dummer PM. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J 2011;44:697-730.  Back to cited text no. 10
Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J 2001;34:113-9.  Back to cited text no. 11
Sokhi RR, Sumanthini MV, Shenoy VU, Bodhwani MA. Effect of calcium hydroxide based intracanal medicaments on the apical sealing ability of resin based sealer and guttapercha obturated root canals. J Clin Diagn Res 2017;11:C75-9.  Back to cited text no. 12
Motiwala MA, Habib S, Ghafoor R, Irfan S. Comparison of antimicrobial efficacy of Calcipex and Metapex in endodontic treatment of chronic apical periodontitis: A randomised controlled trial study protocol. BMJ Open 2021;11:e048947.  Back to cited text no. 13
Gautam S, Rajkumar B, Landge SP, Dubey S, Nehete P, Boruah LC. Antimicrobial efficacy of metapex (calcium hydroxide with iodoform formulation) at different concentrations against selected microorganisms – An in vitro study. Nepal Med Coll J 2011;13:297-300.  Back to cited text no. 14
Estrela C, Estrela CR, Hollanda AC, Decurcio Dde A, Pécora JD. Influence of iodoform on antimicrobial potential of calcium hydroxide. J Appl Oral Sci 2006;14:33-7.  Back to cited text no. 15
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 1966;72:87-93.  Back to cited text no. 16
Hayashi M, Sugeta A, Takahashi Y, Imazato S, Ebisu S. Static and fatigue fracture resistances of pulpless teeth restored with post-cores. Dent Mater 2008;24:1178-86.  Back to cited text no. 17
Uthappa R, Mod D, Kharod P, Pavitra S, Ganiger K, Kharod H. Comparative evaluation of the metal post and fiber post in the restoration of the endodontically treated teeth. J Dent Res Rev 2015;2:73-7.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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