Evidence-based approach to apexification: a literature review and novel clinical protocol

Apexification, a well-established endodontic treatment for managing immature permanent teeth with pulp necrosis, aims to create a calcified apical barrier to seal communication with the periapical tissues and allow gutta percha placement. This literature review explores advancements of apexification and introduces a systematic, evidence-based procedure for achieving optimal outcomes for apexification procedures. The discussion compares the materials most commonly used in apexification: calcium hydroxide [Ca(OH)₂], mineral trioxide aggregate (MTA), and Biodentine. Compared with Ca(OH)₂, contemporary calcium silicate-based materials such as MTA and Biodentine have significantly greater predictability, biocompatibility, and fracture resistance, increasing the longevity of the immature tooth. In addition, the article discusses alternatives to apexification, including regenerative endodontic therapy. A review of the scholarly literature reveals that apexification has long been a cornerstone of treatment for immature permanent teeth with necrotic pulp, offering a predictable method to create a calcified barrier at the apex and enable tooth restoration. While apexification does not promote further root growth, it remains a reliable solution, particularly for cases requiring immediate treatment and a high degree of predictability.