Immature teeth: apexification and regenerative endodontics
- Procedure
If a young permanent tooth's pulp dies, its root stops growing, with thin walls and an open end. Treatments seal the end or help the root keep growing.
See it in 3D: Upper right central incisor · Upper left central incisor
What it is
Permanent teeth finish forming their roots about three years after they erupt. If the pulp of an immature tooth dies, usually after trauma or caries in a child, the root stays short with thin walls and a wide-open apex, which is hard to seal and fractures easily. If the pulp is still alive, vital pulp therapy keeps it alive so the root can mature (apexogenesis). If it is necrotic, the options are apexification or regenerative endodontics.
Indications and contraindications
- Apexogenesis: keep a vital pulp (pulp capping or pulpotomy) so the root keeps developing.
- Apexification with calcium hydroxide: repeated dressings over months build a hard barrier, but the root walls stay thin and more fracture-prone.
- Apical plug: a calcium silicate cement barrier placed at the open apex in one or two visits, then the canal is filled.
- Regenerative endodontics: disinfect the canal gently, provoke bleeding into it from the apical tissues, and cap with calcium silicate; the root can thicken and lengthen.
- Regenerative treatment can discolour the crown and does not always produce root growth.
How it is done
- Confirm pulp status with history, tests (often unreliable in young teeth) and radiographs.
- Vital pulp: partial or full pulpotomy with a calcium silicate cement.
- Necrotic pulp: disinfect gently with irrigants and an intracanal dressing.
- Then either place an apical calcium silicate plug and fill the canal, or start regenerative treatment.
- Seal the access with a bonded restoration.
- Review clinically and with radiographs for healing and root development.
Complications and pitfalls
- Pulp tests are unreliable in young and recently injured teeth: decisions combine signs over time.
- Thin root walls make the tooth vulnerable to fracture, which is why root development matters.
- In front teeth, choose materials that do not stain or keep them below the gum line.
Next step / Initial management
- Child with a traumatised or deeply decayed young permanent tooth: refer to the dentist promptly for pulp assessment.
- Signs of necrosis (discoloration, sinus tract, swelling, apical radiolucency): refer to an endodontist or paediatric dentist.
- Follow-up for years with radiographs to check root development and healing.
Test yourself
Think of the answer, then tap the question to see it.
Why is a necrotic immature permanent tooth difficult to treat?
Its root is short with thin walls and a wide-open apex, which is hard to seal and prone to fracture.
What is the aim of regenerative endodontics?
To allow continued root development, thickening and lengthening the root walls after disinfection and induced bleeding into the canal.
What is apexogenesis?
Keeping a vital pulp in an immature tooth, by pulp capping or pulpotomy, so the root can finish forming.
Connections
See it in 3D2
The structures of Durgical's 3D anatomy where it is found.
Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.
Sources: Apexification: A systematic review (Journal of Conservative Dentistry (PMC open access), 2018); Regenerative endodontic therapy: From laboratory bench to clinical practice (Journal of Advanced Research (PMC open access), 2025); Dental Materials: Biodentine, a Calcium Silicate Bioactive (StatPearls Publishing (NCBI Bookshelf), 2024).
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Representative model, for educational purposes only.