Endodontic treatments for immature necrotic teeth


Teeth traumatized in childhood and adolescence can develop pulp necrosis leading to interrupted root development. This can result in teeth with wide apexes presenting endodontic challenges. A range of techniques are employed to encourage the formation of a calcific barrier or apexification.

The aim of this review was to compare the endodontic treatments available in the management of immature necrotic permanent teeth and determine which one provides the best clinical and radiographic outcomes.


Searches were conducted in the Medline/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials (www.- clinicaltrials.gov) databases. Randomised controlled trials in patients with immature necrotic permanent teeth undergoing pulpectomy where success was assessed based on clinical and radiographic outcomes were considered.

Two reviewers independently selected studies, abstracted data and assessed study quality using the Cochrane risk of bias assessment tool. Meta-analysis was conducted using a random effects model.


  • 7 studies published between 2006-2015 were included.
  • A total of 148 patients and 179 teeth were included in the 7 studies.
  • 2 studies were at high risk of bias, the others at moderate risk.
  • 4 studies compared MTA and calcium hydroxide.
  • 3 studies compared outcomes of regenerative endodontic procedures (REPs).
  • MTA apexification presented overall better clinical and radiographic outcomes among the endodontic treatments evaluated for apical closure.


The authors concluded

Although almost all the identified studies presented moderate risk of bias, MTA apexification seems to produce overall better clinical and radiographic success rates among the endodontic treatment available in immature necrotic permanent teeth.


The reviewers have searched two major databases so there is the potential that a broader search of a wider range of databases may uncover further relevant studies.  A earlier review of this topic by Chala et al (Dental Elf- 25th Jul 2011) included 2 studies so a number of new RCTs were available for this current review.  As noted by the authors the included studies are all quite small and have been evaluated over a relatively short time frame. The longest follow period being 18 months while it has been suggested by the  American Association of Endodontics that 24 months should be a minimum for this type of study. All the studies were also assessed as being at moderate to high risk of bias so the findings of the review should be interpreted with caution.


Primary paper

Nicoloso GF, Pötter IG, Rocha RO, Montagner F, Casagrande L. A comparative evaluation of endodontic treatments for immature necrotic permanent teeth based on clinical and radiographic outcomes: a systematic review and meta-analysis. Int J Paediatr Dent. 2016 Aug 16. doi: 10.1111/ipd.12261. [Epub ahead of print]Review. PubMed PMID: 27529749.

Other references

Original review protocol on PROSPERO


Dental Elf- 25th Jul 2011

Calcium hydroxide or MTA for apex formation in immature permanent teeth



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