Apexification & apexogenesis

1. APEXOGENESIS AND APEXIFICATION
A.Mahesh kumar
II pg student
Dept of Pedodontics & Preventive
dentistry
Drs.Sudha & Nageswara rao
siddhartha dental college
1

2. Contents
• Introduction
• Open apex
• Apexogenesis
• Treatment options
• Review
• Apexification
• Factors affecting Apexification
• Materials and methods
• Apexogenesis vs apexification
• Conclusion
• References
2

3. Introduction
• One of the principle tenets of endodontics is obturation
of the entire root canal system three dimensionally, with
emphasis upon obturation of the apical third of the root.
• This is achieved by apical preparation, which creates an
apical constriction, stop or fixation that facilitates
applying adequate condensation pressure in three
dimensional obturation.
• However, an open apex precludes the achievement of
this goal.
3

4. Open apex
• Tooth eruption 60-80% of root completion.
• If, due to trauma or carious exposure
• Apical opening that is very large.
• This is called an open apex, blunderbuss canal.
• The walls of the canal with an immature root are thinner
and more fragile.
4

5. Problems with an open apex:
1) In these canals the larger apical diameter
vs. smaller coronal canal diameter makes
debridement difficult.
2)Lack of an apical stop makes obturation
impossible.
3)The thin root canal walls become prone
to fracture. Indeed, the most common
cause of treatment failure is cervical
fracture.
5

6. Maturation of permanent
incisors.
(a) Immature incisors showing
short roots with incomplete,
wide-open apices. The lateral
walls of the roots are thin and
structurally weak.
(b) The same teeth 2 years later,
the roots are now almost
complete following continued
dentine deposition by healthy
pulp.
6

7. Periapical surgery with a retrograde
filling ( drawbacks )
1) Relative to the already shortened root,
further root reduction (apicoectomy)
could result in an inadequate crown:root
ratio.
2) Surgery could be both physically and
psychologically traumatic to the patient.
3) Young patients, in whom open apices
are commonly seen, are not very
cooperative.
4) The apical walls are thin and could
shatter when touched by a rotating bur.
7

8. 5) The thin walls would make condensation of a retrograde
filling difficult.
6) The periapical tissue may not adapt to the wide and
irregular surface of amalgam.
7) Surgery would remove the root sheath and prevent any
possibility of further root development. (Morse et al)
8) Concerns that such treatment would generate negative
image of dentistry.
8

9. Treatment
• If the immature tooth has vital
pulp, exhibiting reversible
pulpitis, then physiological root
end development or
apexogenesis is attempted.
• If irreversible pulpitis is
present or pulp is necrotic, then
root end closure or
apexification is induced.
9

10. Apexogenesis
• Defined as the physiologic root end development and
formation. – American Association of Endodontists.
• The current terminology is vital pulp therapy and is
defined (Walton and Torabinejad) as the treatment of a
vital pulp in an immature tooth to permit continued
dentin formation and apical closure.
• Objective: to maintain vitality of the radicular pulp
allowing development of the entire root and just the
apex.
10

11. Goals
• The goals of apexogenesis or vital pulp therapy are:
1) Sustaining a viable Hertwig’s epithelial root sheath, thus
allowing a continued development of root length for a
more favorable crown: root ratio.
2) Maintaining pulpal vitality, thus allowing the remaining
odontoblasts to lay down dentin, producing a thicker
root and decreasing the chance of root fracture.
3) Promoting root end closure, thus creating a natural
apical constriction for gutta-percha obturation.
4) Generating a dentinal bridge at the site of pulpotomy.
However, bridging is not essential for success of the
procedure as long as root development occurs.
11

12. Three distinct procedures:
• Indirect pulp capping
• Direct pulp capping
• Apical closure pulpotomy
12

13. INDIRECT PULP CAPPING
• Definition – (Ingle) it is defined as the
application of a medicament over a thin layer of
remaining carious dentin after deep excavation,
with no exposure of the pulp.
• It was first described by Pierre Fauchard.
13

14. • Decalcification of dentin (affected dentin) precedes
bacterial invasion within the dentin (infected
dentin).
• Thus, by removing the outer layers of carious dentin,
that contains the majority of microorganisms, the
continued demineralization of deeper dentinal
layers by bacterial toxins is reduced; and sealing off
the lesion allows the pulp to generate reparative
dentin and complete root closure.
14

15. 15

16. DIRECT PULP CAPPING
• Definition – (Ingle) it is defined as the placement of a
biocompatible agent on healthy pulp tissue that has been
inadvertently exposed from caries excavation or
traumatic injury.
• Objective: to seal the pulp against bacterial leakage and
encourage the pulp to wall off the exposure site by
initiating a dentin bridge, and hence maintain the vitality
of the underlying pulp.
16

17. • Indication: it is only indicated in small traumatic
exposures of less than 1mm diameter size and only a few
hours duration.
• Contraindication: Seltzer and Bender do not recommend
pulp caps of carious exposures in an immature tooth as
the extent of inflammation and contamination cannot be
determined clinically.
17

18. 18

19. 19

20. Materials
• Calcium hydroxide is the most commonly used
material. Recently, MTA or mineral trioxide
aggregate and biodentine has also come into use
for apexogenesis.
• Other materials that have been used for direct
pulp capping in mature teeth have not been
tried for apexogenesis.
20

21. • Ali Nosrat & Saeed Asgary (2010),
conducted a study on CEM for apexogenesis.
• The radiographic and clinical examinations on
the 6-month and 12-month followups showed
that the tooth remained functional, root
development was completed, and the apex was
formed.
• A calcified bridge was produced underneath the
capping material .
21

22. 22

23. APICAL CLOSURE PULPOTOMY
• Definition –it is defined as the removal of damaged
and inflamed tissue to the level of a clinically healthy
pulp, followed by a calcium hydroxide dressing.
• It was described in 1938 by Teuscher and Zander.
• Kaiser in 1964 and Frank in 1966 popularized the
technique.
23

24. Types
• Depending on the size of exposure and time elapsed
since injury, different levels are described:
1) Partial pulpotomy, also known as shallow, low-level or
Cvek’s pulpotomy.
2) Cervical pulpotomy, also known as deep, high-level,
total or conventional pulpotomy.
Materials: the contemporary materials are calcium
hydroxide and MTA.
24

25. Partial pulpotomy
• Cvek reported a high success rate of 94-96%
with this procedure, when carefully performed.
• This is also a permanent procedure if root
closure occurs, not requiring subsequent RCT
unless there is a need for post and core
treatment.
25

26. Procedure
1) Anesthetize and isolate.
2) A diamond bur, corresponding to the size of the
exposure is used in a high speed contra-angle handpiece
is used with water spray to provide effective cooling.
3) Cutting is performed intermittently for brief periods
and without undue pressure.
4) Level of amputation is 2 mm below the exposure site.
This provides for removal inflamed tissue and adequate
cavity for dressing and sealing material. The cavity is
made box-like with undercuts for retention.
26

27. 5) Pulpal wound is rinsed with saline till bleeding ceases.
Hemorrhage can be controlled with moist cotton pellets
applied with light pressure.
6) Wound is covered with calcium hydroxide, which is
adapted with light pressure. Surplus is removed with
spoon excavator.
7) Cavity is sealed with IRM or GIC.
27

28. Advantages of partial pulpotomy
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.
4) Better wound control.
5) Better sealing against microleakage.
28

29. Cervical pulpotomy
• This is indicated when necrotic tissue or
obviously impaired circulation is present at the
site of exposure in the immature tooth.
• Here, pulp should be amputated to a level at
which fresh bleeding tissue is found i.e. at
cervical level. Bleeding should be controllable.
• When using calcium hydroxide powder, Webber
recommends the addition of barium sulphate, in
the ratio of 4 parts calcium hydroxide and 1 part
barium sulphate.
29

30. 30

31. Histology
• There are three identifiable zones in 4-9 days:
1) Coagulation necrosis
2) Deep staining basophilic areas with varied
osteodentin.
3) Relatively normal pulp tissue, slightly
hyperemic, underlies an osteoblastic layer.
31

32. 32

33. Mineral Trioxide Aggregate – MTA
• Torabinejad introduced this material in 1995 as
a root end filling material and for furcation
perforation repair.
• It consists of tricalcium silicate, tricalcium
aluminate, tricalcium oxide and silicate oxide.
• It also contains opacifiers.
33

34. Advantages
• Good sealing ability on setting.
• Biocompatibility
• Alkaline pH on setting.
• Good compressive strength (70 MPa).
• Induction of cytokine release bone, implying a
cell-inductive potential.
• Hydrophilic nature, unlike other materials, sets
in presence of moisture.
34

35. • Its drawbacks are its expense and its long setting
time, requiring an additional appointment in
certain cases.
• However, its advantages over calcium hydroxide,
i.e. good seal, strength and cell inductive
potential, have made popular.
35

36. • El Meligy, Omar A.S.; Avery, David R.(2006)
compared mineral trioxide aggregate with
calcium hydroxide clinically and
radiographically as a pulpotomy agent in
immature permanent teeth.
• Mineral trioxide aggregate showed clinical and
radiographic success as a pulpotomy agent in
immature permanent teeth and seems to be a
suitable alternative to calcium hydroxide.
36

37. By Using BIODENTINE
• Biodentine is a new bioactive cement with
dentin-like mechanical properties that can be
used as a dentin substitute on crowns and roots.
• It has a positive effect on vital pulp cells and
stimulates tertiary dentin formation. In direct
contact with vital pulp tissue, it also promotes
the formation of reparative dentin.
37

38. • Biodentine is an interesting alternative to
conventional calcium hydroxide-based materials
due to its improved material properties.
• The powder mainly contains tricalcium and
dicalcium silicate as well as calcium carbonate.
Zirconium dioxide is the contrast medium.
• The liquid consists of calcium chloride in
aqueous solution with an admixture of
polycarboxylate.
38

39. • SS Bhat - 2014 used biodentine in apexogenesis
procedure in 8-year-old female diagnosed with
Ellis Class 3 fracture of immature tooth 11
involving the mesial pulp horn.
• He concluded that biodentine can be used as
direct pulpcapping agent.
39

40. 40
Preoperative & postoperative IOPA 12 months follow up IOPA

41. • SM Allazzam - 2015 conducted a study in clinical
application of biodentine in pediatric dentistry .
• It is indicated for pulp capping, pulpotomy,
treatment of deep carious lesions using the
sandwich technique, and also as temporary enamel
restoration or permanent dentine replacement
• It can be use in root includes managing perforations
of furcation or root canals, internal and external
resorption, apexification , apexogenesis and
retrograde root canal obturation
41

42. Recall for apexogenesis
• The total time treatment is 1-2 years, based
primarily on extent of root development at the
time of procedure. Recall is at 3 month intervals
to determine pulpal vitality and extent of apical
maturation.
• In contrast to apexification, the paste does not
need changing.
42

43. Clinical evaluation
• Clinical evaluation of pulp healing is made on the
basis of:
1) No clinical symptoms.
2) No radiographic changes in pulp or periapical
region.
3) Continued root development.
4) Radiographically observed (which may be clinically
confirmed) continuous hard tissue barrier at site of
the procedure. But absence of this barrier is not of
consequence if root development is continuing.
43

44. 5)Sensitivity to vitality testing, especially to
electrical testing. With root development neural
development also occurs, hence the tooth should
become sensitive to electrical testing with root
development.
6)Follow-up of 3-4 years, as research has shown
that failure generally occurs within 26 months.
44

45. Restoration
• Due to concerns over occurrence of calcific
metamorphosis or internal resorption caused by
action of calcium hydroxide, many investigators
prefer to institute root canal therapy after
apexogenesis has been achieved (Cvek, Webber,
Seltzer and Bender).
• On the other hand, Lim and Kirk found little
support for pulp capping resulting in canal
obliteration or internal resorption.
45

46. • Even with partial pulpotomy histologic evidence
does not support the use of routine endodontic
treatment after apical closure.
• Such teeth should be followed up and any sign of
canal calcification or internal resorption will
indicate endodontic treatment.
46

47. Prognosis (Cvek)
• Pulp capping – 72-88%
• Partial pulpotomy – 94-96%
• Cervical pulpotomy – 72-79%
47

48. 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.
• In such cases, apexification or root end closure is
required.
48

49. References
• Pediatric Dentistry infancy through
adolescence- Pinkham 4th edition
• Clinical Pedodontics- Sidney B.Finn 4th edition
• Dentistry for the child and adolescent- Ralph E.
Mcdonald 8th edition
• Path ways of pulp – cohen 9th edition
• Endodontic therapy –frankalin s weine 6th
edition
49

50. Medication with Calcium Hydroxide Improved Marginal
Adaptation of Mineral Trioxide Aggregate Apical Barrier.
Maryam Bidar,Shirin Khoynezhad and Armita Rouhani; JOE
— Volume 36, October 2010
• Management of Dens Invaginatus Type I and Open Apex:
Report of Three Cases.Ma´rcia S. Schmitz et al; JOE —
Volume 36, Number 6, June 2010
• Efficacy of Revascularization to Induce
Apexification/Apexogensis in Infected, Nonvital, Immature
Teeth: A Pilot Clinical Study.Naseem Shah, Ajay Logani,and
Vivek Aggarwal,; JOE — Volume 34,August 2008.
• Reinforcement of Immature Roots with a New Resin Filling
Material Charles H. Stuart, Scott A. Schwartz, and Thomas J.
Beeson. JOE—Volume 32, April 2006
50

51. • Apexification: a review .Dental Traumatology 2005;
21: 1–8
• Apexification with Mineral Trioxide Aggregate: an
overview of the material and technique .P Gaitonde and
K Bishop; Eur. J. Prosthodont. Rest. Dent., Vol.15, No. 1,
pp 41-45
• Single Step Apexification Using White Portland Cement
- Case Series.Reshma S. Hegde Sharathchandra
,Rajkumar. Endodontology 2009.Pg No109-113
• The use of mineral trioxide aggregate in one-visit
apexification treatment: a prospective study S.
Simon1,2, F. Rilliard2, A. Berdal1 & P. Machtou;
International Endodontic Journal, 42, 186–197, 2007.
51

52. 52

53. APEXIFICATION
• Defined as the 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
• This procedure can be employed in both
children and adults.
53

54. • A more recent term is ‘Root-End Closure’,
introduced by Torabinejad in 2002.
• It is defined as 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.
54

55. 55

56. Indication & Contraindication
• Indication – restorable immature tooth with
pulp necrosis.
• Contraindications
• All vertical and unfavorable horizontal root
fractures.
• replacement resorption
• very short roots
• periodontal breakdown
• vital pulps
56

57. Factors affecting apexification
• Root development
• Location of apex
• Patient cooperation
• Apical diameter
• Thorough cleaning and debridement
• Temporary: the interim restoration
57

58. Materials and method
• Traditionally, calcium hydroxide was the
material of choice, supported by the
investigations of many researchers.
• However, other materials e.g.
1) tricalcium phosphate,
2)collagen calcium phosphate,
3)osteogenic protein- 1,
4)bone growth factors and
5)mineral trioxide aggregate
58

59. Apexification using calcium hydroxide
• Anesthetize and isolate
• Access: in immature teeth, the access cavity is
prepared larger than in mature teeth.
• Instrumentation: for this procedure, the initial
treatment length is extended till the radiographic
apex. Torneck et al and Holland et al emphasized
that careful debridement of the root canal is the
primary factor in ensuring root end closure.
• If periapical abscess is present, over-
instrumentation with smaller files (20-25) will
establish drainage.
59

60. • Irrigation: during canal debridement sodium
hypochlorite is the irrigant of choice as it aids in
dissolving necrotic tissue that cannot be reached
by the instruments, and disinfects the canal.
Weine also recommends its alternation with
hydrogen peroxide.
• Drying of canals: this can be difficult due to
seepage of fluids through the wide apex into the
canal.
60

61. Calcium hydroxide preparation
• Ca(OH)2 powder: chemically pure or USP Ca(OH)2
can be used. Previously, CMCP (camphorated
monochlorophenol) was widely used as the vehicle,
but as it showed no advantage over saline or sterile
water, and as (CaOH)2 was itself bactericidal, its use
became less popular, especially as it was tissue toxic.
• Commercial preparations: commercially available
Ca(OH)2 have methylcellulose (Pulpdent) or other
materials or vehicles. These pastes have shown to be
as effective as Ca(OH)2
61

62. Introduction of paste:
• Powder: a plastic amalgam carrier is used for
introducing the powder-saline mix. It is important
that amalgam remnants should not be present in the
carrier.
• Commercial preparations: these are available in
syringes. A cannula that fits loosely at the apex is
selected. The paste is slowly injected and the needle
is withdrawn slowly as the CaOH2 is extruded from
its tip.
• Finally, a cotton pellet is placed and access is sealed
with IRM.
62

63. • Condensation: the canal system is usually packed
with CaOH2 at the instrumentation appointment.
But, in cases of acute apical abscess the canal should
not be packed with the CaOH2 until drainage of the
purulent exudates from the periapical lesion has
occurred.
• Temporary restoration: after condensation, a cotton
pellet is placed against the powder and cavity sealed
with IRM.
• Refilling: the first recall is at 6 weeks. The paste
should be checked for wetness in the apical part,
which indicates exudates.
63

64. • Removal of CaOH2 is done with instruments
half the size of the canal till length 1-2 mm short
of the initial treatment length.
• Recall: the second is at 6 weeks following second
placement of paste and then every 2-3 months
thereafter.
• Average treatment time: 12-18 months
• Range: 6-24 months
64

65. • CaOH2 paste should be replaced as often as
necessary. The paste would need to be changed
at third recall (6 weeks) if:
1)Paste is found to be wet in apical half due to
exudates.
2)Radiographic evidence of dilution of paste i.e.
more radiolucent.
3)Paste is overextended at second appointment.
4)Patient develops sinus tract or symptoms in
early months of treatment.
65

66. Final filling of the canal:
• The final determination of readiness to obturate
the canal with gutta percha is based on the
following criteria:
• Symptomless tooth with healing of any sinus
tract.
• Radiographic observation of osseous deposition
in the periapical of lateral defect (as Periapical
Bridge does not form till closure of osseous
defect).
66

67. EXIFICATIONEXIFICATIONAPEXIFICATIONAPEXIFICATION
67

68. Apexification of a replanted tooth
• 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.
68

69. Apexification of a replanted tooth
69
Apexification of a replanted tooth using mineral trioxide aggregate :Dental Traumatology
2005; 21: 306–308

70. There can be five outcomes of
apexification procedure (Weine)
 No radiographic change is apparent; but if
instrument is inserted, a blockage at the apex
is encountered.
 Radiographic evidence of calcified material is
seen at or near the apex. In some cases, the
degree of calcification might be extremely
extensive.
 Apex closes without any change in canal
space.
70

71.  Apex continues to develop with closure of the
canal apace.
 No radiographic evidence of change is seen,
and clinical symptom and/or development of
or the increase in size of periapical lesion
occurs. This would need either re-treatment
with CaOH2 of surgery.
71

72. • Andreasen reports that the layers of hard tissue
formed are similar those formed after
pulpotomy or pulp capping, the only difference
being that a cementum-like tissue is formed
instead of dentin, indicating involvement of
periodontal involvement.
72

73. • Layer of coagulated and later calcified tissue,
adjacent to CaOH2.
• Layers of first less and then more organized
cementum-like tissue.
• Apical, cementum-like tissue.
• These layers are irregularly arranged and often
include islands of soft connective tissue.
• Other authors have reported bone, dentin,
osteodentin or osteocementum as the material
comprising the apical barrier (Cohen).
73

74. Mechanism of apical closure
• The mechanism of apical closure is unclear;
however, several hypotheses have been set forward,
as discussed by Morse et al:
• Belief that the root sheath remains intact and
resumes its function once the source of infection is
eliminated. However, in studies in which apical
closure was induced, no root sheath was identified.
• Remnants of dental pulp remain vital and function
in spite of inflammation
• Stimulation of undifferentiated mesenchymal cells
by CaOH2 to differentiate into cementoblasts that,
in turn, initiate cementogenesis at the apex.
74

75. • Heithersay achieved apical closure in the time
range of 14 to 75 months.
• Chawla used calcium hydroxide paste and
achieved closure within 6 to 12 months.
• Kleier found closure of apex within 1 to 30
months.
75

76. Various factors that influence the time
taken for apical barrier formation:
• Size of the apical foramen at the start of
treatment.
• Age.
• Infection.
• Inter appointment painful symptoms.
• Frequency of Ca(OH)2 dressings.
76

77. Effects of alkaline pH:
• Buffer to acidic inflammatory reactions, thus,
favorable effect on bone healing.
• Formation of calcium phosphate complexes that
serve as nidi for further calcification.
• Creation of unfavorable environment for
osteoclastic or activation of enzyme alkaline
phosphatase.
77

78. • Pulpal reaction to caoh2 was dependent on oh-
ions rather than ca2+ ions. But use of other
hydroxide compounds showed either a lack of
bridge formation and presence of inflammation
,or inconsistent results.
• Ca2+ ion was important in:
1) Reducing inflammation by decreasing capillary
leakage.
2) Activate enzyme pyrophosphatase that is
involved in collagen synthesis.
78

79. • Once, the apical barrier has formed,
• If there is sufficient dentinal wall thickness then
it is desirable to enlarge the canal by one or two
sizes. Any remaining CaOH2 in apical region can
be gently removed with smaller files.
• Obturation can be done by:
1) Lateral condensation using the rolled cone/
customized cone technique; or
2) Warm vertical condensation or
thermoplasticized gutta percha.
79

80. • Damle SG etal compared the clinical and
radiographic effectiveness of Mineral Trioxide
Aggregate (MTA) and Calcium Hydroxide in
apexification of traumatized young permanent
incisors.
• MTA demonstrated good success and an
effective option for apexification with the
advantage of reduced treatment time, good
sealing ability, biocompatible and provides
barrier for immediate obturation.
80

81. Final restoration
• once obturated, the tooth can be restored with
composite (anterior) or cast restoration
(posterior). Where coronal tooth structure is
insufficient post and core may be done.
81

82. One-Visit Apexification
• This technique is also called the apical barrier
technique. Although Apexification with caph2
pastes has been highly successful, it has certain
disadvantages:
• Cost of multiple visits.
• Patient compliance with multiple appointments
over 6-24 months.
82

83. • Possibility of root fracture during the extended
period because of the thin roots and incidence of
traumatic injuries in children.
• Ingle cites studies which show that Ca(OH)2
may have an adverse effect on dentin.
• The dentin becoming more brittle as it continues
to be in contact with Ca(OH)2, which, along with
thin walls will predispose to fractures.
83

84. • An alternative to CaOH2 therapy is to use an
artificial barrier that allows immediate
Obturation of the canal.
• This was first tried using tricalcium phosphate
in 1979 by Coviello and Brilliant.
• The material was packed into the apical 2 mm of
the canal against which gutta-percha was
condensed.
• The treatment achieved in one appointment,
Using radiographic assessment
84

85. • Recently, MTA was advocated as a barrier
material. Also bone morphogenetic proteins (e.g.
osteogenic protein-1) and bone growth factors
have also been advocated.
The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study
S. Simon1,2, F. Rilliard2, A. Berdal1 & P. Machtou; International Endodontic Journal, 42, 186–
197, 2007.
85

86. MTA
• MTA has been reported to produce equivalent
amounts of apical hard tissue with no more
inflammation than CaOH2 or osteogenic protein-1.
• Bone, cementum and uninflamed periodontal
ligament were demonstrated in direct apposition to
MTA.
• Because of its good sealing ability, biocompatibility,
good strength and ability to induce cytokine release
from bone cells, it seems to be the material of choice
86

87. Technique:
 After thorough debridement, the canal is
medicated with CaOH2 for 1 week for disinfection.
 On re-entry, canal is cleansed and rinsed with
NaOCl.
 The canal is dried and a 3-4 mm plug of MTA is
packed into the apical end with pluggers or paper
points.
87

88. 88

89. 89

90.  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.
 The canal is then obturated with gutta-percha or
bonded composite.
90

91. • Kumar A, Yadav A, Shetty N, conducted a study
on one-step apexification using MTA, the
technical problem encountered is controlling the
overfill or underfill of MTA.
• By using of a matrix material helps to overcome
this shortcoming. Platelet rich fibrin (PRF) is an
immune platelet concentrate.
91

92. 92

93. 93

94. Apexogenesis vs Apexification
• Apexogenesis results in complete root
development and not only apical closure.
• On the other hand, apexification may result in
result in apical closure, but the root still remains
short with thin walls in most cases.
• Thus, it is important to maintain pulpal vitality
by early initiation of treatment so as to achieve
complete root development.
94

95. Revascularization
• Endodontic treatment options for immature, non-vital
teeth conventionally include surgical endodontics,
apexification with calcium hydroxide, or single visit
mineral trioxide aggregate plug.
• A new treatment option of revascularization has recently
been introduced. It involves disinfecting the root canal
system, providing a matrix of blood clot into which cells
could grow, and sealing of the coronal access.
• The present pilot clinical study was undertaken to
evaluate the efficacy of revascularization in 14 cases of
infected, immature teeth.
Efficacy of Revascularization to Induce Apexification/Apexogensis in Infected, Nonvital,
Immature Teeth: A Pilot Clinical Study.Naseem Shah, Ajay Logani,and Vivek Aggarwal,; JOE —
Volume 34,August 2008.
95

96. 96

97. Revascularization
• Endodontic treatment was initiated, and after infection control,
revascularization was performed.
• The cases were followed up at regular intervals of 3 months; the range in
follow-up was 0.5–3.5 years.
• Radiographic resolution of periradicular radiolucencies was judged to be
good to excellent in 93% (13 of 14) of the cases.
• In the majority of cases, a narrowing of the wide apical opening was
evident.
• In 3 cases, thickening of apical dentinal walls and increased root length
were observed.
97

98. Revascularization technique
• In this technique the canal is disinfected with copious irrigation and
a combination of three antibiotics
• After disinfection the apex is mechanically irrigated to initiate
bleeding into the canal to produce the blood clot to the level of
cementoenamel junction
• This blood clot acts as a matrix for the growth of new tissue into the
pulp space.
• The results of this technique was successful with the thickening of
the walls of the root in a conventional manner.
• But the new tissue formed is not clearly understood still.
98

99. • The striking finding was complete resolution of clinical signs and
symptoms and appreciable healing of periapical lesions in 78% (11 of 14)
of cases.
• Thickening of lateral dentinal walls was evident in 57% (8/14) of cases,
and increased root length was observed in 71% (10/14) of cases.
• None of the cases presented with pain, reinfection, or radiographic
enlargement of preexisting apical pathology.
99

100. 100

101. Conclusion
• The practitioner should strive to achieve root
development through apexogenesis wherever
possible.
• If this treatment fails or pulp is necrotic,
apexification should be initiated.
• When apexification is done a variety of materials
and techniques are available, Ca(OH)2 being the
traditional favorite while MTA being the current
panacea.
101

102. References
• Pediatric Dentistry infancy through
adolescence- Pinkham 4th edition
• Clinical Pedodontics- Sidney B.Finn 4th edition
• Dentistry for the child and adolescent- Ralph E.
Mcdonald 8th edition
• Path ways of pulp – cohen 9th edition
• Endodontic therapy –frankalin s weine 6th
edition
102

103. Medication with Calcium Hydroxide Improved Marginal
Adaptation of Mineral Trioxide Aggregate Apical Barrier.
Maryam Bidar,Shirin Khoynezhad and Armita Rouhani; JOE
— Volume 36, October 2010
• Management of Dens Invaginatus Type I and Open Apex:
Report of Three Cases.Ma´rcia S. Schmitz et al; JOE —
Volume 36, Number 6, June 2010
• Efficacy of Revascularization to Induce
Apexification/Apexogensis in Infected, Nonvital, Immature
Teeth: A Pilot Clinical Study.Naseem Shah, Ajay Logani,and
Vivek Aggarwal,; JOE — Volume 34,August 2008.
• Reinforcement of Immature Roots with a New Resin Filling
Material Charles H. Stuart, Scott A. Schwartz, and Thomas J.
Beeson. JOE—Volume 32, April 2006
103

104. • Apexification: a review .Dental Traumatology 2005;
21: 1–8
• Apexification with Mineral Trioxide Aggregate: an
overview of the material and technique .P Gaitonde and
K Bishop; Eur. J. Prosthodont. Rest. Dent., Vol.15, No. 1,
pp 41-45
• Single Step Apexification Using White Portland Cement
- Case Series.Reshma S. Hegde Sharathchandra
,Rajkumar. Endodontology 2009.Pg No109-113
• The use of mineral trioxide aggregate in one-visit
apexification treatment: a prospective study S.
Simon1,2, F. Rilliard2, A. Berdal1 & P. Machtou;
International Endodontic Journal, 42, 186–197, 2007.
104

105. 105