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MS (PART B) Dept. of Conservative Dentistry & Endodontics BSMMU
Aim: This presentation describes a clinical and radio-graphical outcome of a 8 years old boy who was treated by apexogenesis of a mandibular right first molar. Summary: A 8 years old boy presented at the dept. of Conservative dentistry and Endodontics, BSMMU, with a lingering irradiating and bite pain on his right lower jaw. The tooth responsible was examined clinico-radiographically. On clinical examination, the right mandibular first molar had extensive caries and it was sensitive to percussion but not on palpation. The tooth was sensitive to cold. Radiographic examination revealed immature root with thin dentinal wall of the affected tooth. Conservative treatment (apexogenesis) was performed; caries was removed followed by pulp exposure and access cavity preparation. Pulpotomy was performed and remaining radicular pulp was capped with calcium hydroxide paste. 1 and 3 months later, the tooth was functional with no clinical signs and symptomps. Radiographical examination also revealed continuation of root development. These findings suggested that long term prognosis is required for the complete outcome of the treatment. Keywords: apexogenesis, calcium hydroxide , pain, pulpotomy, tooth apex.
Apexogenesis is defined as a vital pulp therapy procedure performed to encourage continued physiologic development and formation of the root end. The objective is to maintain the vitality of the radicular pulp. Therefore the pulp must be vital and capeable of repair.5 In clinical practice it is not uncommon to find incompletely developed teeth that require some form of endodontic intervention due to extensive caries or traumatic injury. When such a clinical situation presents itself, an assessment of the pulpal status and the degree of tooth development must be made in order to develop an appropriate treatment plan that is conducive to long term tooth retention. It has been shown that when a direct pulp capping procedure is performed on a tooth with an exposed and inflamed pulp, the probability of pulp repair and long term success is low.1,2 This often will lead to pulp necrosis and arrested tooth development of the involved immature tooth. The resulting wide-open apical foramina, canals with reverse taper (blunderbuss) and thin dentinal walls represent three major clinical concerns when an incompletely developed tooth fails to mature. As such, subsequent endodontic
often to the level of the canal orifices. A coronal restoration should then be placed that will ensure the maximum long-term seal. Many different materials have been used for pulpal wound dressing. After removing the roof of the pulp chamber. The tooth was sensitive to cold. Clinical examination showed extensive caries in the mandibular right first molar and sensitivity to percussion but not to palpation. BSMMU with the complaints of lingering and irradiating pain and pain on chewing in the mandibular right jaw. caries were removed and an access cavity was prepared with a diamond round bur and high-speed handpiece with copious water spray.7 CASE REPORT A 8 years old boy. The patient had epileptic history.procedures and the remaining strength of the root structure may be compromised. and calcium hydroxide paste is placed as a wound dressing. Haemostasis was achieved by irrigating with sterile normal saline along with gentle .5 the instrument of choice for tissue removal is an abrasive diamond bur at high speed with adequate watercooling. The excess liquid should then be carefully removed via vacuum or sterile cotton pellets. Air should not be blown on the exposed pulp.3 Apexogenesis is a procedure that addresses the shortcomings involved with capping the inflamed dental pulp of an incompletely developed tooth. The main theme of apexogenesis is the preservation of vital pulp tissue so that continued root development with apical closure may occur. and then every 6 months for 2 to 4 years to determine if successful root formation is taking place and that there are no signs of pulp necrosis. however. the pulp chamber is rinsed with sterile saline or sterile water to remove all debris. a restorative base material should be placed over the calcium hydroxide and then allowed to set completely. hailing from Naril. Associated bleeding indicated pulp vitality. Care must be taken to avoid placing the calcium hydroxide on a blood clot6 and the entire pulp surface must be covered. Informed consent was obtained from the patient’s legal guardians after explanation of the possible risks of treatment. Once this is accomplished. the use of calcium hydroxide has been shown to be the available and most predictable with regard to long-term clinical success. Following coronal pulp amputation. of conservative dentistry and Endodontics. Dizepam 5 mg was administered orally 1 hour before the procedure. Radiological examination shows that the tooth had immature roots with thin dentinal walls. the pulp was removed to the orifice level with a round bur and a high speed handpiece. My diagnosis was it was a case of reversible pulpitis due to caries.calcification or periradicular pathosis.4-8 An aseptic technique combining the use of the rubber dam and sterile burs is strongly recommended. Treatment Plan: Apexogenesis. The goal is to minimize any further damage to the underlying pulpal tissue. as this may cause desiccation and calcium hydroxide paste is placed over the amputation site. root resorption . According to Granath et al. resulting in a poor long-term prognosis. came to the dept. The patient should be re-evaluated every three months for the first year. Most or all of the coronal pulp is removed. Local anaesthesia with 2% lidocaine and 1: 80000 epinephrine was administered.
depending on the degree of root development at the time of procedure. the tooth was functional with no signs/symptoms. the distal root completion process seemed faster than the mesial root. In my presented case. signs and symptoms are monitored. A pulp-capping material needs to be biocompatible. the patient had no pain and was free of any other discomfort. Vital pulp therapy is primarily based on the healing potential of the pulp26. then was rinsed with 2. Vital pulp therapy is the treatment of choice in immature teeth with reversible pulpitis in which damage to the pulp and associated arrested root development occur as a result of carious pulp exposures24. Then. However. The patient was recalled 1. Japan) was then placed. Then on the temporary restoration an approximately 2-mm layer of self-cure Glass–Ionomer (Fuji. calcium hydroxide has some disadvantages such as unpredictable dentinal bridge formation21 that could contain tunnel defects28 and poor adherence to dentine that can compromise the long-term biological seal29. At each recall appointment. Traditionally. and the primary goal is to maintain the health of the pulp to promote root development and apical closure25. There is a body of evidence emphasizing the biocompatibility and sealing ability of MTA19. Here. The patient should be recalled at six months interval to determine the vitality of pulp and the extent of apical maturation. Then the remaining odontoblasts can form dentin. comparing the different radiological films on different visits. Radiologically. the tooth was filled with temporary filling of 1 mm thickness. 3 and 6 months later for clinical/radiographic follow-ups and this follw up visits may be extended upto 3 to 4 years. DISCUSSION The primary goal of apexigenesis is to maintain pulp vitality. Clinically. It has been shown in several animal and human studies that MTA is capable of inducing hard tissue formation adjacent to pulp . pulp vitality tested and radiographs are obtained to determine periapical status. the root completion process advanced more than that it was 3 months ago. thus allowing dentin formation and root end closure.5% hypochloride solution. use of disposable instruments and rubber dam are advised. Radiographic examination revealed advancement of root development beneath the METAPEX in both mesial and distal roots at 3-months. able to provide a biological seal. Hence. the clinical and radiological prognosis was good. An alternative standard pulp-capping biomaterial. Absence of symptoms does not indicate absence of disease. Despite its common use as pulp-capping material. calcium hydroxide was the most popular material for vital pulp therapy27. and able to induce hard tissue formation24. producing a thicker root that is less prone to fracture. The time required to produce a thicker root varies between 1 and 2 years. mineral trioxide aggregate (MTA). At the clinical examinations. after two consequent visits on 1st and 3rd months. I have used Calcium hydroxide as the pulp capping material as it was available. has been introduced for vital pulp therapies.application of small pieces of moistened sterile cotton pellets 2-5 minutes. The success of this treatment mostly depend on the sterility of the instruments. Fuji Corporation. Calcium Hydroxide (METAPEX) paste of approximately 2-mm-thick layer was placed over the exposed pulp with a sterile instrument and gently adapted to the dentinal walls with a dry cotton pellet.
10.25 In the presented case. and presence of adjacent odontoblast-like cells10.23. the canals may not be negotiable. reduced cytotoxicity16. absence of tunnel defects. surgery should be necessary. Tehran. However. The hard tissue formed beneath MTA.13.30. The exact biological mechanism by which Calcium Hydroxide cement promotes dentine bridge formation is currently unknown. CEM (Bionique dent. Iran) in terms of thickness. This characteristic is likely to be the result of several properties such as sealing ability11. Dentine bridge induced by Calcium Hydroxide cement has been shown to be similar to one induced by CEM (Calcium Enriched Mixture) Cement (Bionique dent. The ability of Calcium Hydroxide to induce hard tissue formation in mature permanent teeth has been shown in several animal and human studies9. it can be suggested that apexogenesis using the Ca(OH)2 may be favorable specially in pediatric dentistry. MTA induced dentine bridge formation more frequently. Studies have revealed that the formation of a hard tissue barrier beneath a pulp-capping material is a good indicator for ongoing health of the pulp and might act as a protective pulpal barrier20.17. However. or if internal resorption is evident. caused less pulp inﬂammation. and resulted in a signiﬁcantly thicker dentine bridge21. it has been suggested that root canal therapy should be initiated. Tehran. CONCLUSION Based on the present study. However.tissue21. and similarity to dentine. . biocompatibility10. A recent case report study showed that Calcium Hydroxide has favourable treatment outcomes in terms of dentine bridge formation as well as apexogenesis in traumatic exposure18. MTA has several disadvantages. hydroxyapatite formation12. antibacterial effect11. and high cost19. poor handling characteristics. which can include delayed setting time. However. before making a conclusion. a newly introduced material for apexigenesis.22. is uniform. regular ongoing radiographic and clinical recalls are necessary to ensure long-term success. unlike calcium hydroxide10. high alkalinity14. and it can resemble tertiary dentine with respect to its form and staining for dentine sialoprotein9. If it is determined that the pulp has become irreversibly inflamed or necrotic before root development is complete. apexogenesis with Calcium Hydroxide (METAPEX) paste is intended to be completed within 12 to 24 months and sometime more than that (3-4 years). In comparison with calcium hydroxide.23. This is probably unwarranted as calcific metamorphosis is not in itself pathogenic. long term clinical evaluation is necessary. Iran). the pulp is removed and apexification therapy is initiated.10 Calcific metamorphosis is the main disadvantage of calcium Hydroxide while it is used in pulpotomy or apexigenesis.1823. When there is evidence of such calcification. should the pulp become necrotic at some future date.10.
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