{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T13:35:32Z","timestamp":1785418532258,"version":"3.56.0"},"reference-count":39,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T00:00:00Z","timestamp":1784505600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001809","name":"National Natural Science Funds of China","doi-asserted-by":"crossref","award":["81800953"],"award-info":[{"award-number":["81800953"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100001809","name":"National Natural Science Funds of China","doi-asserted-by":"crossref","award":["82001033"],"award-info":[{"award-number":["82001033"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Shanghai Ninth People\u2019s Hospital","award":["2023hbyjxys-rsj"],"award-info":[{"award-number":["2023hbyjxys-rsj"]}]},{"award":["2023hbyjxys-rsj"],"award-info":[{"award-number":["2023hbyjxys-rsj"]}],"id":[{"id":"https:\/\/ror.org\/010826a91","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dentistry Journal"],"abstract":"<jats:p>Objective: To report the conservative management of a complex failed apexification in a permanent premolar complicated by severe internal root resorption, irregular apical calcification, and exceptionally thin root canal walls and to evaluate its long-term (56-month) clinical and radiographic outcomes. Methods: A 27-year-old male presented with chronic apical periodontitis in the right mandibular first premolar. A previous apexification attempt had failed, resulting in arrested root development, an apical calcified bridge, and extensive internal root resorption. CBCT imaging revealed a critical root canal wall thickness of less than 1 mm in the middle and coronal thirds. To avoid extraction or invasive surgery, a non-surgical apical barrier technique was performed. Due to the severe structural compromise and high risk of root fracture, mechanical instrumentation was minimized; instead, chemomechanical debridement was optimized using Er:YAG laser-activated irrigation. The apical region was sealed with a bioceramic material (iRoot BP), and the weakened root structure was reinforced intraradicularly with dual-cure flowable resin, followed by progressive occlusal adjustments. Results: At the 3-month follow-up, the patient was completely asymptomatic, and radiographs indicated initial periapical bone healing. The 56-month follow-up demonstrated progressive formation of mineralized tissue, apparent thickening of the root canal walls at root apex, complete resolution of periapical radiolucency, and a stable, functional occlusion. Conclusions: This case demonstrates that teeth with severe structural compromise and internal resorption following failed apexification are not necessarily hopeless. A tailored conservative approach, integrating advanced laser-assisted disinfection, bioceramic apical barriers, internal resin reinforcement, and meticulous occlusal management, can yield highly successful long-term outcomes, ensuring the preservation of the natural dentition.<\/jats:p>","DOI":"10.3390\/dj14070453","type":"journal-article","created":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T06:09:09Z","timestamp":1784527749000},"page":"453","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Management of Failed Apexification Associated with Internal Root Resorption and Apical Calcification: A 56-Month Case Report"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-7282-1161","authenticated-orcid":false,"given":"Yuzhuo","family":"Wang","sequence":"first","affiliation":[{"name":"Department of Endodontics and Operative Dentistry, Shanghai Ninth People\u2019s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shujun","family":"Ran","sequence":"additional","affiliation":[{"name":"Department of Endodontics and Operative Dentistry, Shanghai Ninth People\u2019s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, National Center for Stomatology, National Clinical Research Center for Oral Disease, Shanghai Key Laboratory of Stomatology, Shanghai 200011, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.joen.2005.10.009","article-title":"Dens Evaginatus: Literature Review, Pathophysiology, and Comprehensive Treatment Regimen","volume":"32","author":"Levitan","year":"2006","journal-title":"J. Endod."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Luan, M., Wang, Q., Fang, Y., and Wang, X. (2025). Treatments of Dentition with Four Dens Evaginatus and Reverse Overbite: A Case Report with a 6-Year Follow-Up. BMC Oral Health, 25.","DOI":"10.1186\/s12903-025-05953-z"},{"key":"ref_3","first-page":"125","article-title":"Treatment Options: Apexogenesis and Apexification","volume":"35","author":"Shabahang","year":"2013","journal-title":"Pediatr. Dent."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1111\/aej.12087","article-title":"What Can Cause the Pulps of Immature, Permanent Teeth with Open Apices to Become Necrotic and What Treatment Options Are Available for These Teeth","volume":"40","author":"Flanagan","year":"2014","journal-title":"Aust. Endod. J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1111\/edt.13015","article-title":"The Calcium Hydroxide Controversy: Does Calcium Hydroxide Weaken Teeth?","volume":"41","author":"Kahler","year":"2025","journal-title":"Dent. Traumatol."},{"key":"ref_6","first-page":"e86471","article-title":"Use of Calcium Silicate-Based Materials in the Management of Open Apices: A Case Report","volume":"17","author":"Doumari","year":"2025","journal-title":"Cureus"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1714","DOI":"10.1016\/j.joen.2024.08.005","article-title":"Effect of Calcium Hydroxide as an Intracanal Medication on Dentine Fracture Resistance: A Systematic Review and Network Meta-Analysis","volume":"50","author":"Sunlakawit","year":"2024","journal-title":"J. Endod."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1016\/j.joen.2010.03.014","article-title":"Internal Root Resorption: A Review","volume":"36","author":"Patel","year":"2010","journal-title":"J. Endod."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1111\/j.1365-2591.2009.01577.x","article-title":"Apexification: The Beginning of Its End","volume":"42","author":"Huang","year":"2009","journal-title":"Int. Endod. J."},{"key":"ref_10","first-page":"375","article-title":"Apexification, Apexogenesis and Regenerative Endodontic Procedures: A Review of the Literature","volume":"63","author":"Corbella","year":"2014","journal-title":"Minerva Stomatol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1111\/iej.13809","article-title":"Review of Guidance for the Selection of Regenerative Endodontics, Apexogenesis, Apexification, Pulpotomy, and Other Endodontic Treatments for Immature Permanent Teeth","volume":"56","author":"Murray","year":"2023","journal-title":"Int. Endod. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1476","DOI":"10.1016\/j.joen.2016.04.028","article-title":"Regenerative Endodontic Procedures for Traumatized Teeth after Horizontal Root Fracture, Avulsion, and Perforating Root Resorption","volume":"42","author":"Saoud","year":"2016","journal-title":"J. Endod."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1016\/j.joen.2022.06.002","article-title":"Failure of Regenerative Endodontic Procedures: Case Analysis and Subsequent Treatment Options","volume":"48","author":"Lee","year":"2022","journal-title":"J. Endod."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1111\/aej.12815","article-title":"Six-Year Clinical Evaluation of iRoot BP Plus as Apical Barrier in Permanent Teeth of Periapical Periodontitis","volume":"50","author":"Wang","year":"2024","journal-title":"Aust. Endod. J."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Anas, M., Sultan, M.U., Ali, S., and Ullah, I. (2026). Clinical Outcomes of Regenerative Endodontic Procedures Compared with Apexification in Young Immature Necrotic Teeth: A Systematic Review of Randomized Controlled Trials. Odontology.","DOI":"10.1007\/s10266-026-01322-6"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.jclinepi.2017.04.026","article-title":"CARE Guidelines for Case Reports: Explanation and Elaboration Document","volume":"89","author":"Riley","year":"2017","journal-title":"J. Clin. Epidemiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1111\/adj.12400","article-title":"Prevention and Management of External Inflammatory Resorption Following Trauma to Teeth","volume":"61","author":"Abbott","year":"2016","journal-title":"Aust. Dent. J."},{"key":"ref_18","first-page":"772","article-title":"Evidence-Based Treatment Planning for the Restoration of Endodontically Treated Single Teeth: Importance of Coronal Seal, Post vs. No Post, and Indirect vs. Direct Restoration","volume":"50","author":"Atlas","year":"2019","journal-title":"Quintessence Int. Berl. Ger."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1367","DOI":"10.1111\/iej.12954","article-title":"Regenerative Endodontics: A Comprehensive Review","volume":"51","author":"Kim","year":"2018","journal-title":"Int. Endod. J."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1111\/iej.12784","article-title":"Regenerative Endodontic Treatment of Perforated Internal Root Resorption: A Case Report","volume":"51","author":"Kaval","year":"2018","journal-title":"Int. Endod. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1814","DOI":"10.1111\/iej.70025","article-title":"Pre-Operative Factors on Prognosis of Regenerative Endodontic Procedures: A Systematic Review and Meta-Analysis","volume":"58","author":"Vitali","year":"2025","journal-title":"Int. Endod. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e70911","DOI":"10.1002\/ccr3.70911","article-title":"Regenerative Endodontic Procedure of a Mature Anterior Tooth with Open Apex and Chronic Apical Abscess: A Case Report with 4-Years Follow-Up","volume":"13","author":"Alcalde","year":"2025","journal-title":"Clin. Case Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1111\/jerd.12859","article-title":"Fracture Resistance of Thin Wall Endodontically Treated Teeth without Ferrules Restored with Various Techniques","volume":"34","author":"Iemsaengchairat","year":"2022","journal-title":"J. Esthet. Restor. Dent."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1007\/s00784-023-05468-3","article-title":"In Vitro and in Vivo Evaluation of iRoot BP plus as a Coronal Sealing Material for Regenerative Endodontic Procedures","volume":"28","author":"Yang","year":"2024","journal-title":"Clin. Oral Investig."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Riandani, A.P., Cahyanto, A., Diab, R.A.L., Widyasari, R., Sidiqa, A.N., Dharsono, H.D.A., and Zakaria, M.N. (2025). Clinical and Radiographic Outcomes of Pulpotomy Materials in Permanent Teeth: A Systematic Review of Calcium Hydroxide, MTA, Biodentine, and iRoot BP Plus. BMC Oral Health, 26.","DOI":"10.1186\/s12903-025-07322-2"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1186\/s13287-019-1345-3","article-title":"iRoot BP plus Promotes Osteo\/Odontogenic Differentiation of Bone Marrow Mesenchymal Stem Cells via MAPK Pathways and Autophagy","volume":"10","author":"Lu","year":"2019","journal-title":"Stem Cell Res. Ther."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"395","DOI":"10.5005\/jp-journals-10024-2528","article-title":"Smear Layer Removing Ability of Root Canal Irrigation Solutions: A Review","volume":"20","author":"Mohammadi","year":"2019","journal-title":"J. Contemp. Dent. Pract."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Fiegler-Rudol, J., Grzech-Le\u015bniak, Z., Tkaczyk, M., Grzech-Le\u015bniak, K., Zawilska, A., and Wiench, R. (2025). Enhancing Root Canal Disinfection with Er:YAG Laser: A Systematic Review. Dent. J., 13.","DOI":"10.3390\/dj13030101"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Bao, P., Liu, H., Yang, L., Zhang, L., Yang, L., Xiao, N., Shen, J., Deng, J., and Shen, Y. (2024). In Vitro Efficacy of Er:YAG Laser-Activated Irrigation versus Passive Ultrasonic Irrigation and Sonic-Powered Irrigation for Treating Multispecies Biofilms in Artificial Grooves and Dentinal Tubules: An SEM and CLSM Study. BMC Oral Health, 24.","DOI":"10.1186\/s12903-024-04042-x"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1111\/j.1365-2591.2007.01243.x","article-title":"Passive Ultrasonic Irrigation of the Root Canal: A Review of the Literature","volume":"40","author":"Versluis","year":"2007","journal-title":"Int. Endod. J."},{"key":"ref_31","first-page":"S107","article-title":"Medicaments Removal with Different Techniques from Internal Resorption Cavities","volume":"74","author":"Uslu","year":"2024","journal-title":"Int. Dent. J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1361","DOI":"10.1016\/j.joen.2010.03.037","article-title":"Effectiveness of Different Final Irrigant Activation Protocols on Smear Layer Removal in Curved Canals","volume":"36","author":"Caron","year":"2010","journal-title":"J. Endod."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Chu, X., Feng, S., Zhou, W., Xu, S., and Zeng, X. (2023). Cleaning Efficacy of EDDY versus Ultrasonically-Activated Irrigation in Root Canals: A Systematic Review and Meta-Analysis. BMC Oral Health, 23.","DOI":"10.1186\/s12903-023-02875-6"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"64","DOI":"10.2341\/14-258-L","article-title":"Composite Resin Core Buildups with and Without Post for the Restoration of Endodontically Treated Molars Without Ferrule","volume":"41","author":"Magne","year":"2016","journal-title":"Oper. Dent."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1007\/s10266-020-00481-4","article-title":"Fracture Strength of Endodontically Treated Teeth Restored with Different Fiber Post and Core Systems","volume":"108","author":"Topkara","year":"2020","journal-title":"Odontology"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1111\/iej.13897","article-title":"Factors That Affect the Outcomes of Root Canal Treatment and Retreatment-a Reframing of the Principles","volume":"56","author":"Gulabivala","year":"2023","journal-title":"Int. Endod. J."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"386","DOI":"10.2340\/aos.v84.43871","article-title":"Comparative Outcomes of Endodontically Treated Teeth versus Dental Implant-Supported Prostheses: A Systematic Review","volume":"84","author":"Borda","year":"2025","journal-title":"Acta Odontol. Scand."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.joen.2025.09.008","article-title":"AAE and AAOMR Joint Position Statement: Use of Cone-Beam Computed Tomography in Endodontics 2025 Update","volume":"52","author":"Fayad","year":"2026","journal-title":"J. Endod."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1675","DOI":"10.1111\/iej.13187","article-title":"European Society of Endodontology Position Statement: Use of Cone Beam Computed Tomography in Endodontics: European Society of Endodontology (ESE) Developed By","volume":"52","author":"Patel","year":"2019","journal-title":"Int. Endod. J."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/7\/453\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T04:11:06Z","timestamp":1784693466000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/7\/453"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,20]]},"references-count":39,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["dj14070453"],"URL":"https:\/\/doi.org\/10.3390\/dj14070453","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,20]]}}}