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Updated: Jun 5, 2025

Quasistatic Mechanical Testing for Computer-Aided Design and Manufacturing Occlusal Veneers Cemented to Milled Dentin Analog Material

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The Calcium Hydroxide Controversy: Does Calcium Hydroxide Weaken Teeth?

Bill Kahler¹, Michael V Swain²

¹Department of Restorative and Reconstructive Dentistry, the Sydney Dental School, The University of Sydney, Surry Hills, Australia.

Dental Traumatology : Official Publication of International Association for Dental Traumatology

|December 12, 2024

Summary

Calcium hydroxide apexification for immature teeth is questioned by new guidelines due to inconsistent science and fracture risks. Alternative treatments like MTA and HCSCs may offer better outcomes and shorter treatment times.

Keywords:

apexification calcium hydroxide clinical guidelines fracture mechanics fracture strength transverse oblique root fracture

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Area of Science:

Dental science
Endodontics
Regenerative dentistry

Background:

Calcium hydroxide apexification has been a long-standing treatment for immature teeth with pulp necrosis.
Recent European Academy of Paediatric Dentistry (EAPD) and American Association of Endodontists (AAE) guidelines do not recommend calcium hydroxide apexification.
This review critically examines the scientific evidence underpinning these guideline changes.

Purpose of the Study:

To analyze the scientific basis for the exclusion of calcium hydroxide apexification from EAPD and AAE regenerative guidelines.
To evaluate the risk of tooth fracture associated with calcium hydroxide apexification, particularly in immature teeth.
To explore alternative treatment options and their potential benefits.

Main Methods:

Systematic review of existing literature on calcium hydroxide apexification.
Analysis of in vitro studies and clinical outcomes.
Development of a fracture mechanics model to assess root fracture risk.
Comparison of calcium hydroxide with alternative materials like MTA and HCSCs.

Main Results:

Inconsistent outcomes in studies of calcium hydroxide apexification due to methodological differences and lack of controls.
Significant risk of tooth fracture (77%) in immature teeth (Cvek Class 3) treated with calcium hydroxide, compared to mature teeth (2%).
Mineral trioxide aggregate (MTA) and hydraulic calcium silicate cements (HCSCs) may offer superior outcomes and reduced treatment time.

Conclusions:

The scientific evidence supporting calcium hydroxide apexification is weak, leading to its exclusion from major guidelines.
Immature teeth treated with calcium hydroxide face a high risk of fracture.
Regenerative endodontic treatment (RET) is recommended for very immature teeth, while MTA and HCSCs present promising alternatives.
Managing pulp necrosis in immature teeth and mitigating fracture risk remain significant clinical challenges.