This document discusses apexification and indirect pulp capping procedures. Apexification is used to induce calcification at the open apex of an immature tooth to allow for root canal treatment. Materials used include calcium hydroxide, tricalcium phosphate, and MTA. Calcium hydroxide is placed in the canal and replaced every 3 months until radiographic evidence of apical barrier formation. MTA can also be used by placing it at the apex. Indirect pulp capping covers the deepest carious dentin with a biocompatible material like calcium hydroxide to prevent pulpal exposure while removing infected dentin, allowing for pulp preservation.

1. APEXIFICATION
 Method to induce a calcific barrier across an
open apex of an immature pulpless tooth.
 Objective:
 To induce either closure of open apical
third of root canal or formation of apical
calcific barrier against obturation

2. MATERIALS USED FOR APEXIFICATION
 Collagen calcium phosphate gel
 Tricalcium phosphate
 Calcium hydroxide
 MTA

3. APEXIFICATION WITH CALCIUM
HYDROXIDE
Preoperative radiograph taken to find
apparent length of tooth
Tooth anesthetized, rubber dam
isolation
Access opening done
Irrigation done with sterile
water/saline
Working length determination is done
using a radiograph

4. APEXIFICATION WITH CALCIUM
HYDROXIDE
Working length 2 mm short of tooth length
to prevent injury to apical tissue and thin
walls in apical third
After cleaning and shaping the root canal
is dried using blunt absorbent paper points
Calcium hydroxide mixed with sterile water
to thick consistency on sterile glass slab
By means of thick blunt finger plugger the
paste is forced into root canal

5. APEXIFICATION WITH CALCIUM
HYDROXIDE
dry pellet is forced into root canal with
blunt finger plugger until entire root
canal is filled with Ca(OH)2
Seal access cavity with intermediate
restorative material
Recall patient in 3 months to determine
whether a calcific barrier has developed
at or near root apex (radiographically)

6. APEXIFICATION WITH CALCIUM
HYDROXIDE
If not a fresh supply of calcium hydroxide
is applied into root canal and patient recall
every 3 months until one sees
radiographic evidence of apical barrier
Old CH is removed using large files and
copious irrigation with saline
Root canal obturated after completion of
apexification

7. APEXIFICATION WITH MTA
After proper isolation and anesthesia
access cavity is prepared to allow
debridement of necrotic pulp tissue
Working length kept 2 mm short of working
length and gentle circular filing is done
Irrigation with sodium hypochlorite
Paper points to dry the canals

8. APEXIFICATION WITH MTA
MTA is mixed according to manufactures
instruction and introduced into canal using
MTA carrier
MTA is condensed into apical 3-4mm
Moist cotton pellet is placed on top of MTA
to ensure setting and temporary
restoration is placed
Patient recalled after 48hours for
obturation and permanent restoration.

10. MTA
MINERAL TRIOXDE AGGREGATE

11. MTA
 Mohammad Torabinejad (1993)
 Composition:
• Tricalcium silicate
• Dicalcium silicate
• Tricalcium aluminate
• Tetracalcium aluminoferrite
• Bismuth oxides
• Traces of free crystalline silica
• Traces of calcium oxide magnesium oxide potassium
and sodium sulfate compounds

12. MTA
 Available in two forms
 Gray and white MTA
 Difference between two is lack of iron in
tetracalcium aluminoferrite in white MTA.

13. MTA
 Advantage:
 Biocompatible
 Acceptable biological performance
 Superior structural integrity of dentinal bridging
 Resist future bacterial penetration
 Antimicrobial property
 Hydrophillic
 Alkaline ph – induce dentinogenesis
 Less microleakage

14. MTA
 Application:
 Root end fillings
 Perforation repair
 Pulp capping
 Pulpotomy
 Apexification

15. MTA
 Setting reaction:
 On hydration
 MTA result in formation
of crystalline gel of
hydrated components of
MTA with trace formation
of CH.
 It hardens in 3hours time

16. IPC
INDIRECT PULP CAPPING

17. INDIRECT PULP CAPPING
 Procedure wherein the deepest layer of
remaining affected carious dentin is covered with
layer of biocompatible material in order to
prevent pulpal exposure and further trauma to
pulp

18. INDIRECT PULP CAPPING
 Objective:
 To preserve vitality of pulp by completing removing
carious infected dentin

19. INDIRECT PULP CAPPING
 Diagnostic data:
a) History: tolerable, dull pain with mild discomfort
associated with eating, thermal stimulation.
b) Clinical examination:
a) large carious lesion without any frank pulpal exposure
b) Positive response to electric test, thermal test, test cavity
c) Normal to percussion

20. INDIRECT PULP CAPPING
 Diagnostic data:
c) Radiographic examination:
 large carious lesion
 Involves 3/4th thickness of dentin
 Lamina dura is intact

21. INDIRECT PULP CAPPING
 Clinical Procedure:
 1st appointment:
Local anesthesia and isolate with rubber
dam
Cavity outlined using high speed air turbine
handpiece
Slow speed handpiece with large #6/#8
round bur majority of softened infected
dentin is removed till firm resilient dentin is
felt

22. INDIRECT PULP CAPPING
Peripheral carious dentin can
be removed with spoon
shaped excavators
Site is covered with hard set
calcium hydroxide preparation
and sealed with overlying base
of ZOE
Sealed cavity is not disturbed
for 6-8weeks

23. INDIRECT PULP CAPPING
(2nd appointment)
Between 2 appointment history
must be negative and IRM should
be intact
Bitewing radiograph of treated
tooth is obtained
LA and rubber dam isolation
Careful removal of temporary
restoration and CH

24. INDIRECT PULP CAPPING
(2nd appointment)
Previously remaining soft deep
brownish red color affected dentin
changes to lighter brownish gray
color harder in nature
Cavity washed and dried very gentle
Entire floor is cover with hard set CH
When clinical and radiographic
finding is negative the final
restoration is placed

25. INDIRECT PULP CAPPING
 Reason for 2 steps:
a) Avoids unintentional pulpal exposure which might
deteriorate pulpal prognosis.
b) Gain information about changes in caries activity

26. INDIRECT PULP CAPPING
 Treatment outcome:
a) Remaining Dentin Thickness:
a) 2.0-0.5 mm- good prognosis as secretion of
reactionary dentin is more
b) 0.5-0.25 mm- prognosis decreases as reduce
number of odontoblastic activity.
b) Choice of IPC agents:
1. Calcium hydroxide
2. MTA
3. Biodentin