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CONTENTS

Introduction
Apexogenesis
a) Definition
b) Objective
c) Indirect pulp capping
d) Direct pulp capping
e) Apical closure

pulpotomy
- Calcium hydroxide
pulpotomy
- MTA pulpotomy

Apexification

INTRODUCTION
OPEN APEX:
Problems
- Canals have larger apical diameter

vs smaller coronal canal diameter


makes debridement difficult
- Lack of an apical stop makes
obturation impossible.
- The thin root canal walls become
prone to fracture

Solution - Surgery?
Drawbacks:
1. Inadequate crown:root ratio
2. Physically and psychologically traumatic
to the patient
3. Young patients are not very cooperative.
4. Apical walls are thin and could shatter
when touched by a rotating bur
5. Thin walls would make condensation of a
retrograde filling difficult
6. Surgery would remove the root sheath
and prevent any possibility of further root
development. (Morse et al)

APEXOGENESIS ( VITAL
PULP THERAPY)
Definition:
The physiologic root end
development and formation.
American Association of Endodontists
2. Vital Pulp therapy: Treatment of
a vital pulp in an immature tooth to
permit continued dentin formation
and apical closure - Walton and
Torabinejad
1.

Objective:
Maintain the vitality of radicular pulp
Achieved through:
1. Indirect pulp capping
2. Direct pulp capping
3. Apical closure pulpotomy

INDIRECT PULP CAPPING


Definition:
Application of a medicament over a
thin layer of remaining carious dentin
after deep excavation, with no
exposure of the pulp Ingle

Rationale:

DIRECT PULP CAPPING


Definition:
Placement of a biocompatible agent
on healthy pulp tissue that has been
inadvertently exposed from caries
excavation or traumatic injury. - Ingle

Objective:
Indication:

Small traumatic exposures of less than 1mm


diameter and only a few hours duration.

Contraindication:
Carious exposures in an immature
tooth as the extent of inflammation
and contamination cannot be
determined clinically. (Seltzer and
Bender)

Materials Used:
1.Calcium hydroxide
2.MTA

APICAL CLOSURE PULPOTOMY


Definition:
Removal of damaged and inflamed

tissue to the level of a clinically healthy


pulp, followed by a calcium hydroxide
dressing (Anderson)

Indication:
1.An immature permanent tooth with an

open apex and reversible pulpitis suffers a


carious exposure
2. Large diameter (more than 1mm)
traumatic pulpal exposure, of any duration

Types:
1.Partial pulpotomy ( shallow, low-

level or Cveks pulpotomy)


2.Cervical pulpotomy (deep, highlevel, total or conventional pulpotomy)
Materials used:
1.Calcium Hydroxide
2.MTA
3.Bone growth factors
4.Bone morphogenic proteins

Calcium hydroxide
pulpotomy
Partial pulpotomy:

1. Anesthetize and isolate.


2. Diamond bur, corresponding to the size of

the exposure is used in a high speed


contra-angle handpiece
3. Cutting is performed intermittently
4. Level of amputation is 2 mm below the
exposure site.
5. Pulpal wound is rinsed with saline till
bleeding ceases..
6. Wound is covered with calcium hydroxide.
7. Cavity is sealed with IRM or GIC.

Advantages:
1. Minor injury to the pulp and undisturbed

physiologic apposition of dentin, especially


in the critical cervical area of the tooth.
2. The limited loss of coronal pulp allows for
vitality testing.
3. Limited loss of crown precludes need for
post and core.

Compared with pulp capping it


implies:
Better wound control.
Better sealing against micro leakage.

MTA Pulpotomy

Disadvantage:
Expensive
Long setting time, requiring an

additional appointment in certain cases


Difficulty in manipulation

Advantage over Ca(oh)2


1. Good seal
2. Good Strength
3. Has cell inductive potential
4. Produces significantly more dentinal

bridging in a shorter period of time with


significantly less inflammation (Cohen).

Recall for Apexogenesis

Treatment failure
Cessation of root growth
Development of signs and symptoms or

periapical lesion.
Calcific metamorphosis (i.e. calcific
obliteration) of canal or internal
resorption

Goals:
1. Sustaining a viable Hertwigs epithelial

root sheath
2. Maintaining pulpal vitality
3. Promoting root end closure
4. Generating a dentinal bridge at the site
of pulpotomy

Restoration:
Institute root canal therapy after
apexogenesis (Cvek, Webber,
Seltzer and Bender)
Prognosis:
Pulp capping 72-88%
Partial pulpotomy 94-96%
Cervical pulpotomy 72-79%

APEXIFICATION
Non-surgical approaches (discussed by

Morse):
Blunt end or rolled cone (customized cone)
Short fill technique (by Moodnick)
Instrumentation only
No treatment
Induction of periapical bleeding with

instruments (by Nygaard-Ostby)


Apexification and apical barrier technique

Definition:
Method of inducing apical closure by the
formation of osteocementum or a similar
hard tissue or the continued apical
development of the root of an incompletely
formed tooth in which the pulp is no longer
vital. American Association of
Endodontics
Root end closure technique (Torabinejad)
The process of creating an environment
within the root canal and periapical tissues
after pulp death that allows a calcific barrier
to form across the open apex

Indication :
Restorable immature tooth with pulp
necrosis.

Contraindications :
1. All vertical and unfavorable horizontal

root fractures.
2. Replacement resorption
3. Very short roots
4. Periodontal breakdown
5. Vital pulps

Factors affecting apexification

Root development
Location of apex
Patient
Cleaning and debridement of canal
Apical diameter
Interim restoration

Materials Used:
1. Calcium hydroxide (Material of choice)
2. Tricalcium phosphate
3. Collagen calcium phosphate
4. Osteogenic protein- 1
5. Bone growth factors
6. Mineral trioxide aggregate

Properties of CaOH2 related to its


high pH (Andreasen):
ph - (11-12)
1.Capacity to dissolve necrotic pulp
remnants:
2.Strong antibacterial effect:
99.9% of bacteria from the common
root canal flora are killed within a few
minutes upon direct contact with
CaOH2

Apexification using calcium


hydroxide

Paste would need to be changed at third


recall (6 weeks) if:
Paste is found to be wet in apical half due to exudates.
Radiographic evidence of dilution of paste
Paste is overextended at second appointment.
Patient develops sinus tract or symptoms

12.Final filling of the canal:


Symptomless tooth with healing of any sinus tract.
Radiographic observation of osseous deposition in the

periapical of lateral defect


Radiographic observation of hard tissue deposition at
the apex.
Finding the CaOH2 paste to be dry when tested by
probing.
Confirmation of a calcific barrier by probing with light
finger pressure with smaller (20-25) files.
Drying of canal system with paper points elicits no
hemorrhage or tissue fluids.

There can be five outcomes of


apexification procedure (Weine)
1. No radiographic change is apparent; but if
instrument is inserted, a blockage at the
apex is encountered.
2. Radiographic evidence of calcified material
is seen at or near the apex.
3. Apex closes without any change in canal
space.
4. Apex continues to develop with closure of
the canal apace.
5. No radiographic evidence of change is seen,
and clinical symptom and/or development of
or the increase in size of periapical lesion.

Disadvantages of calcium hydroxide


apexification:
Cost of multiple visits
Patient compliance with multiple

appointments over 6-24 months


Possibility of root fracture during the
extended period because of the thin roots and
incidence of traumatic injuries in children.
The dentin becoming more brittle as it
continues to be in contact with CaOH2, which,
along with thin walls will predispose to
fractures.(Ingle)

ONE VISIT APEXIFICATION


Materials used:
1.Tricalcium phosphate
2.Resorbable ceramic.
3.Caph2
4.Freeze-dried bone or dentin
5.MTA
6.Bone morphogenetic proteins (e.g.
osteogenic protein-1)
7.Bone growth factors

One visit apexification


with
MTA
Technique
1. After thorough debridement, the canal is

medicated with CaOH2 for 1 week for disinfection.


2. On re-entry, canal is cleansed and rinsed with
NaOCl.
3. The canal is dried and a 3-4 mm plug of MTA is
packed into the apical end with pluggers or paper
points.
4. The placement is confirmed radiographically and
then a moist pellet is placed against the MTA and
access cavity is sealed for 4-6 hours to allow the
material to harden
5. The canal is then obturated with gutta-percha or
bonded composite.

Osteogenic Protein 1 (bone


morphogenetic protein)
1. Attract and recruit mononuclear
phagocytes to sites bone formation.
2.Stimulates the proliferation of
mesenchymal cells that subsequently
differentiate into osteogenic cells.
Material is used with a collagen carrier
which allows its release over a long
period.

Vitality testing for immature young


permanent teeth:
Thermal tests.

EPT

Other applications of apexification:


1. Lateral perforation
2. Aggressive external resorption
(Weine)
Apexogenesis vs. Apexification

CONCLUSION