endo

1. MANAGEMENT
OF
NON –VITAL
WIDE OPEN
APEX
Dr. Hadil Abdallah Altilbani
BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .

2. Regeneration of
diseased tissues is
the future!

3. Immature Teeth, AP
Alternate Treatment for Apexification & Root
strengthening….
Grow ‘new pulp’ to allow for
continued root development…..

4.  Revascularization of
Pulp Space?
 Pulp Regeneration?
 Maturogenesis?

6. • Endodontic treatment of immature
permanent teeth with necrotic pulp, with or
without apical pathosis, poses several clinical
challenges.
There is a risk of inducing a dentin wall
fracture or extending gutta-percha into the
periapical tissue during compaction of the root
canal filling.
• Although the use of calcium hydroxide
apexification techniques or the placement
of mineral trioxide aggregate as an apical stop
has the potential to minimize apical extrusion
of filling material, they do little in adding
strength to the dentin walls.
INTRODUCTION

7. Revascularization focuses on triggering
bleeding into an empty root canal space with the
hope that this will trigger a process similar to the
role of the blood clot in triggering wound healing
in surgical procedures.
• Revascularization, as defined by Andreasen, is
a the restoration of the vascularity to a tissue or organ.

8. Case selection
“This treatment should be considered for the incompletely
developed permanent tooth that has an open apex and is
negative to pulpal responsiveness testing.
Although the ultimate goal of this approach is to develop a tissue
engineering–based method of pulpal regeneration in the fully
developed permanent tooth, it should be recognized that current
revascularization protocols have not been developed or evaluated
for these more challenging cases.” Cohen 10th edition
Revascularization protocol

9. •it has been noted that
reimplantation of avulsed teeth
with an apical opening of
approximately 1.1 mm
demonstrate a greater likelihood
of revascularization
•fully formed (closed) apices
might require instrumentation
of the tooth apex to
approximately 1 to 2mm in
apical diameter to allow systemic
bleeding into root canal systems.
Revasc. in Human
ReplantedTeeth
size of apical foramen:
 foramen =/> 1.1mm: 18% (Kling et al, 1986)
 1/2 open-open= 34% (Andreasen et al, 1995)
 foramen =/< 1.0mm: 0%

10. During the first appointment
 Minimal instrumentation by the use of a small
file (determine the working length)
 Copious and slow irrigation with 20 ml of NaOCl
(lower concentration) followed by 20 ml of
0.12% to 2% chlorhexidine (CHX), slow irrigatin
with closed end side vented needle kept at the
apex .
 The root canal system is then dried with sterile
paper points, and the antimicrobial medicament
is delivered into the root canal space.
 The best available evidence supports the use of
either a triple antibiotic paste or Ca(OH)2.
Both medicaments have been shown to be effective
.
After antimicrobial medicament is placed, the tooth
is then sealed with a sterile sponge and a temporary
filling (e.g., Cavit), and the patient is discharged for
3 to 4 weeks.

11. On the second visit:
Patient is evaluated for resolution of any signs or symptoms of an acute
infection (e.g., swelling, sinus tract, pain, etc.) that may have been present at the
first appointment.
The antimicrobial treatment is repeated if resolution has not occurred.
Since revascularization-induced bleeding will be evoked at this appointment, the
tooth should not be anesthetized with a local anesthetic
containing a vasoconstrictor.
Instead, 3% mepivacaine can be used, which will facilitate the ability to trigger
bleeding into the root canal system
the tooth should be copiously and slowly irrigated with 20 ml NaOCl, together
with gentle agitation with a small hand file to remove the antimicrobial
medicament.

12.  After drying the canal system with
sterile paper points, a file is placed a
few mm beyond the apical foramen,
and the apical tissue is lacerated with
bleeding up to 3 mm from the CEJ.
 A small piece of Colla-Plug (resorbable
matrix) may be inserted into the root
canal system to serve as a resorbable
matrix to restrict the positioning of the
MTA.
 About 3 mm of MTA is then
placed, followed by a restoration.
 A 12- to 18-month recall should be
considered as the earliest time point to
conduct the clinical examination and
evaluate continued radiographic
improvement in root development.

15. Clinical Measures of Treatment Outcome
For regeneration not only radiographic evidence of periradicular health but also
radiographic and other clinical evidence of functioning vital tissue in the canal
space is required.
 Radiographic evidence of functioning pulp (or pulp like) tissue
would include continued root growth, both in length and wall
thickness.
 Other measures of the presence of vital, functioning tissue in the
canal space and lack of signs or symptoms.
“ The ideal clinical outcome is an asymptomatic tooth that does not
require retreatment, but to validate that regenerative endodontic
techniques are truly effective, nonsubjective vitality-assessment
methods are essential”

16.  Traditionally an immature tooth with open apex is treated by apexification:
Calcium hydroxide : short-term or long-term use of Ca(OH)2 can reduce
root strength. A large case series using the traditional apexification protocol
showed that a major reason for tooth loss following apexification was root
fracture. In contrast in revascularization there is a greater likelihood
of increase in root wall length and thickness.
 Technically simple : can be completed using currently available
instruments and medicaments without expensive biotechnology.
 Regeneration of tissue in root canal systems by a patient’s own blood cells
avoids the possibility of immune rejection and pathogen
transmission from replacing the pulp with a tissue engineered construct.
Advantages of revascularization

18. Immature tooth with a necrotic infected canal with apical periodontitis. The canal is disinfected with
copious irrigation with sodium hypochlorite and tri-antibiotic paste. After 4 weeks the antibiotic is
removed, and a blood clot created in the canal space. The access is filled with an MTA base, and bonded
resin above it. At 7 months the patient is asymptomatic, and the apex shows healing the apical
periodontitis and some closure of the apex. At 24 months apical healing is obvious, and root wall
thickening and root lengthening have occurred, indicating that the root canal has been revascularized with
vital tissue. (Adapted from Banchs F, Trope M. Revascularization of immature permanent teeth with apical
periodontitis: new treatment protocol? J Endod 2004;30:196; with permission.)

20. 1.First, in the case reports of a blood clot having the capacity to
regenerate pulp tissue are exciting, but caution is required,
because the source of the regenerated tissue has not been
identified.
Animal studies and more clinical studies are required to investigate
the potential of this technique before it can be recommended for
general use in patients.
Generally, tissue engineering does not rely on blood clot
formation, because the concentration and composition of cells
trapped in the fibrin clot is unpredictable.
DISADVANTAGES OF REVASCULARIZATION:

21. 2. Coronal discoloration due to
minocycline
Can be replaced by CEFACLOR
3. Enlargement of the apical
foramen is necessary to promote
vascularizaton and to maintain
initial cell viability via nutrient
diffusion.
It is likely that cells in the coronal portion
of the root canal system either would not
survive or would survive under hypoxic
conditions
4. In older individuals > lesser
stem cells> final outcome unpredictable>
may be calcified canal
DISADVANTAGES OF
REVASCULARIZATION:

22.  To date, only case reports and case series on endodontic revascularization
treatment are available, no randomized controlled clinical trials have been
published
 Nearly all reported cases involve patients 8 to 18 years old and teeth with
immature apices
 The formation of a blood clot might serve as a protein scaffold, permitting
three-dimensional ingrowth of tissue.
 Nearly all of these reports noted continued thickening of the root walls and
subsequent apical closure
 There was a lack of histology in all these clinical cases, hence radiographic
findings of continued root wall thickness does not necessarily indicate that
dentin was formed
 Increased root wall thickness was limited to the midroot and
apical root. There has been no demonstration of increased root thickness in
the cervical area.(prone to fracture in immature teeth with a history of
trauma)
 Very few cases reported about the vitality of pulp, and mainly relied on heat
test
Overview of case reports on revascularization

23.  Revascularization of
Pulp Space?
 Pulp Regeneration?
 Maturogenesis?