This document discusses apexogenesis, apexification, and revascularization procedures for immature permanent teeth. Apexogenesis aims to encourage continued root development by maintaining pulp vitality. It is used for teeth with damaged coronal pulp but healthy root pulp. Apexification induces a calcific barrier at an open apex in pulpless immature teeth using calcium hydroxide or MTA. Revascularization aims to regenerate pulp-like tissue by inducing bleeding into the root canal and using a blood clot and scaffold. It is used for teeth with necrotic pulp and an immature apex. The procedures involve disinfection, medication placement, and temporary fillings, with calcium hydroxide or MTA used to encourage apex closure

1. APEXOGENESIS APEXIFICATION
AND REVASCULARIZATION
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2. APEXOGENESIS
DEFINITION
• APEXOGENESIS IS DEFINED AS A VITAL PULP THERAPY PROCEDURE PERFORMED TO ENCOURAGE
CONTINUED PHYSIOLOGIC DEVELOPMENT AND FORMATION OF THE ROOT END.
0BJECTIVES
• SUSTANING A VIABLE HERTWIG'S SHEATH TO ALLOW CONTINUED DEVELOPMENT OF ROOT LENGTH
FOR FAVOURABLE CROWN ROOT RATIO
• TREATMENT STRATEGIES OF TRAUMATIZED, IMMATURE PERMANENT TEETH SHOUD AIM AT
PRESERVING PULP VITALITY TO SECURE FURTHER ROOT DEVELOPMENT AND TOOTH MATURATION
• PROMOTING A ROOT END CLOSURE
• GENERATING DENTINAL BRIDGE AT THE SITE OF PULPOTOMY
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3. INDICATIONS
DAMAGED CORONAL PULP with HEALTHY RADICULAR PULP
• TRAUMATIC EXPOSURE
• FRACTURE TOOTH WITH PULPAL EXPOSURE
• CARIOUS EXPOSURES
CONTRAINDICATION
• AVULSED / SEVERELY LUXATED TOOTH
• CROWN ROOT FRACTURE
• HORIZONTAL ROOT FRACTURE
• UNRESTOREABLE TOOTH
• NECROTIC PULP
APEXOGENESIS
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4. MATERIALS
• CALCIUM HYDROXIDE
• DENTIN BONDING AGENTS
• MINERAL TRIOXIDE AGGREGATE
TREATMENT OF VITAL PULP (OPEN APEX)
• PARTIAL PULPOTOMY( CVEK PULPOTOMY)
• FULL PULPOTOMY(CERVICAL)
APEXOGENESIS
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5. anesthetize the tooth and isolate with rubber dam
all carious material is removed with excavators or slow speed round bur
coronal pulp is removed
after arrest of hemmorrage , Ca(OH)2 is appplied to the exposed pulp, ensuring that there is
no blood clot
bacterial tight seal is achieved (with zinc oxide eugenol or glass ionomer cement)
then permanent restoration is done
PULPOTOMY
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7. APEXIFICATION
DEFINITION
APEXIFICATION IS DEFINED AS A METHOD TO INDUCE A CALCIFIC
BARRIER ACROSS AN OPEN APEX OF AN IMMATURE, PULPLESS TOOTH
BY FORMATION OF OSTEOCEMENTUM/BONE LIKE TISSUE.
OBJECTIVE
TO INDUCE EITHER CLOSURE OF THE OPEN APICAL THIRD OF THE ROOT
CANAL OR THE FORMATION OF AN APICAL CALCIFIC BARRIER AGAINST
WHICH 0BTURATION CAN BE ACHIEVED.
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8. APEXIFICATION
INDICATIONS
• YOUNG PERMANENT, NON VITAL TOOTH
CONTRAINDICATIONS
• VITAL PULPS
• MARGINAL PERIODONTAL BREAKDOWN
• VERY SHORT ROOTS
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9. APEXIFICATION
WHY APEXIFICATION INSTEAD OF CONVENTIONAL RCT?
• OPEN APEX
• BLUNDERBUSS CANALS
• THIN AND FRAGILE CANAL WALLS
• ABSOLUTE DRYNESS OF CANALS DIFFICULT TO ACHIEVE
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10. APEXIFICATION
MATERIALS
• CALCIUM HYDROXIDE
• COLLAGEN CALCIUM PHOSPHATE GEL
• MNERAL TRIOXIDE AGGREGATE
• OSTEOGENIC PROTEIN I AND II
TYPES
• MULTIPLE STEP APEXIFICATION WITH CALCIUM HYDROXIDE
• SINGLE STEP APEXIFICATION WITH MTA
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11. Anesthesia, rubber dam isolation and access opening
working length should be at least 2mm short of the radio-graphic apex of the tooth
circumferential enlargement is affected by lateral pressure against the walls with a large file
drying the canal with paper points and Ca(OH)2 is mixed with sterile water or anesthetic solution to a thick
consistency
the paste is delivered into the canal with an amalgam carrier and condensed with finger pluggers
the entire root canal is filled with Ca(OH)2 paste, ensuring that the material is in contact with the periapical
tissues
the access cavity is sealed with RMGIC
patient recalled after 3 months
MULTIPLE STEPS APEXIFICATION
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12. RADIOGRAPHIC EVIDENCE OF CALCIFIC BARRIER AT OR NEAR THE ROOT APEX
IF YES OBTURATION USING THERMOPLASTICIZED TECHNIQUE
if no Ca(OH)2 DRESSING IS CHANGED AND PATIENT RECALLED EVERY 3 MONTHS
TILL EVIDENCE OF CALCIFIC BARRIER IS SEEN
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13. Anesthesia, rubber dam isolation and access opening
working length should be at least 2mm short of the radio-graphic apex of the tooth
circumferential enlargement is affected by lateral pressure against the walls with a large file
drying the canal with paper points MTA is mixed in a 3:1 ratio using sterile distilled water to a wet sand
consistency
the paste is delivered into the canal with an MTA carrier and condensed with prefitted pluggers
the material is condensed into a 3-4mm apical plug
moist cotton pallet is placed over the MTA
patient is recalled after 48hours and the set of MTA is verified
SINGLE STEP APEXIFICATION
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14. REVASCULARIZATION
DEFINITION
REVASCULARIZATION IS THE RESTORATION OF THE VASCULARITY TO A TISSUE
OR ORGAN
OBJECTIVE
• REGENERATE PULP LIKE TISSUE, IDEALLY THE PULP DENTIN COMPLEX
• REGENERATE DAMAGED CORONAL DENTIN, SUCH AS FOLLOWING A
CARIOUS EXPOSURE
• RREGENERATE RESORBED ROOT, CERVICAL OR APICAL DENTIN
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15. REVASCULARIZATION
• INDICATIONS
• TEETH WITH NECROTIC PULP AND AN IMMATURE APEX
• PULP SPACE NOT NEEDED FOR POST/CORE FINAL RESTORATION
• PATIENT COMPLIANCE
• NO ALLERGY TO THE MEDICAMENTS TO BE USED
COMPONENTS OF REGENERATIVE ENDODONTICS
• STEM CELLS
• GROWTH FACTORS
• SCAFFOLD
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17. Anesthesia, rubber dam isolation and access opening
irrigation with 20ml of 1.5% NaOCl/5mins and saline (20ml/canal, 5 mins)
dry the canal with paper points
placement of intracanal medicament
Ca(OH)2 or low concentration triple antibiotic paste
temporary seal with 3-4mm of cavit/IRM/glass ionomer
patient recalled after 1-4 weeks
REGENERATIVE ENDODONTIC THERAPY (FIRST APPOINTMENT)
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18. assess response to initial treatment
no signs/symptoms
local anesthesia (3% mepivacaine without a vasoconstrictor) and rubber dam isolation
irrigation with 20ml of 17% EDTA, drying the canals with paper points
intentionally evoked intracanal bleeding (k-file is passively extended 2mm past the apical foramen)
canal filled with blood to the level of CEJ
stop the bleeding at a level that allows for 3-4mm of the restorative material
placement of a Resorbable matrix over the blood clot (collaplug)
white MTA/Ca(OH)2 as capping material covered with a3-4 mm layer of GIC
REGENERATIVE ENDODONTIC THERAPY (SECOND VISIT)
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21. QUESTIONS
• YOUNG IMMATURE, NON VITAL TOOTH, TREATMENT OPTIONS??
• YOUNG IMMATURE VITAL TOOTH WITH PULPAL EXPOSURE??
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