This document discusses apexification and apexogenesis procedures for immature teeth with open apices. It defines open apices as teeth with arrested root development resulting in a large apical opening. For teeth with vital pulp but pulp exposure, the goal is apexogenesis to allow continued root development through calcium hydroxide pulpotomy. For teeth with non-vital pulp, apexification is used to induce apical closure with materials like calcium hydroxide or MTA to create an apical plug for filling. Successful outcomes depend on follow up over 1-2 years to monitor continued root development or closure of the apex.

1. APEXIFICATION
AND
APEXOGENESIS
1
10/12/2017 4:59 AM

2. Definition – open apex
Absence of sufficient root development to provide a conical taper to
the canal and is also referred to as blunderbuss canal.
(Franklein S. Weine 1972 )
Due to trauma or carious exposure, the pulp undergoes necrosis,
dentin formation ceases and root growth is arrested. The resultant
immature root will have an apical opening that is very large. This is
called an open apex, also referred to previously as a blunderbuss
canal.
. (Thomas R.Pittford,1989)
2
10/12/2017 4:59
AM

3. Causes of open apices
 caries with pulp involvement,
 extensive resorption of the mature apex as a result of orthodontic
treatment,
 Periapical pathosis,
 Trauma causing necrosis
This open apex causes two major problems.
 The normal crown /root ratio is compromised and may cause mobility.
 It becomes difficult to achieve an apical seal with conventional root
canal filling.
3
10/12/2017 4:59
AM

4. Types of open apices
These can be of two configurations:
1- non-blunderbuss
2- blunderbuss
4
10/12/2017 4:59
AM

5. Non –blunderbuss:
The apex -
broad (cylinder shaped)
tapered (convergent)
5 Blunderbuss:
The apex is funnel shaped and -typically
wider than the coronal aspect of the
canal.
10/12/2017 4:59
AM

6.  Hertwig Sensitive to trauma – increase vascularity and
cellularity
Important role of Hertwig’s epithelial root sheath in
continued root development after pulpal injury, every
effort should be made to Maintain its viability.
 Unfortunately traumatic injuries to young permanent teeth
are not uncommon and are said to affect 30% of children.
 The majority of these incidents occur before root formation
is complete and may result in pulpal inflammation or necrosis.
6
Pulp injury in teeth with developing roots
10/12/2017 4:59
AM

7. Complete destruction of Hertwig’s epithelial root sheath results in
cessation of normal root development
Hard tissue can be formed by :
Cementoblasts -apical region
Fibroblasts of the dental follicle
Periodontal ligament that undergo differentiation after the injury to
become hard tissue producing cells.
7
10/12/2017 4:59
AM

8. Stages of root development Cvek 19728
In anatomy the apical
foramen is the
opening at the apex of
the root of a tooth,
through which
the nerve and blood
vessels that supply
the dental pulp pass.
Thus it represents the
junction of the pulp &
the periodontal tissue
10/12/2017 4:59
AM

9. Problems associated with immature apex
 Large open apices
 Thin dentinal walls
 Frequent periapical lesions
 Short roots
 Fracture of crown
 Discoloration on long standing
9
10/12/2017 4:59
AM

10. Diagnosis and case assessment
Clinical assessment of pulp status, clinical & radiographic
examination.
Subjective symptoms
Pain history – spontaneous, severe, long lasting
Throbbing, tender to touch - pulpal necrosis with apical
periodontitis or acute abscess
Swelling /sinus tract - indicates pulpal necrosis and acute or chronic
abscess respectively
Tenderness to percussion -inflammation in the periapical tissues.
10
10/12/2017 4:59
AM

11. Vitality testing
Prior to root formation , the sensory plexus of nerves in the
sub odontoblastic region is not well developed.
Radiographic interpretation
11
Diagnosis and case assessment
10/12/2017 4:59
AM

12. Treatment
Treatment is based on the vitality of the pulp.
If the immature tooth has vital pulp, exhibiting reversible pulpitis, then
physiological root end development or apexogenesis is attempted.
On the other hand if irreversible pulpitis is present or pulp is necrotic,
then root end closure or apexification is induced.
12
10/12/2017 4:59
AM

13. 13
Reversible
pulpitis
Open apexClosed apex
Irreversible pulpitis /
necrotic pulp
Vital pulp
therapy
Root canal
therapy
Root end
closure
Pulp
regeneration
10/12/2017 4:59
AM

14. Apexogenesis/ vital pulp therapy
The current terminology is vital pulp therapy (Walton and Torabinejad)
“Apexogenesis is defined as treatment of a vital pulp in an immature tooth
to permit continued root growth and apical closure. A vital pulp of an
immature tooth may have a small exposure after trauma.” - Ingle
“Physiologic root end development and formation” according to American
Association of Endodontists in 1981.
14
10/12/2017 4:59
AM

15. Definition
Apexogenesis as endodontic treatment of partially developed
permanent teeth that clinically and radiographically displays evidence
of pulp necrosis. Stephen Wei (1988)
Treatment of vital pulp in an immature tooth to permit continued root
growth & apical closure. (Thomas R. Pitt Ford, 1989)
The procedure encourages normal root & apex formation of pulpally
involved, vital permanent teeth with immature root development.
(AAPD Guidelines 1998)
The continued formation of the root in the teeth with vital root pulpal
tissue.(McDonald & Aver, 2000)
15
10/12/2017 4:59
AM

16. INDICATIONS
Immature tooth with incomplete root formation and damage to the
coronal pulp but with a presumed healthy radicular pulp.
Lack of abscess formation, excessive haemorrhage, no foul odour
Normal radiographic appearance
Absence of sensitivity to percussion
No abnormal responses to thermal stimuli
16
10/12/2017 4:59
AM

17. CONTRAINDICATIONS
Avulsed and replanted or severely luxated tooth
Severe crown root fracture that requires intraradicular retention for
restoration
Tooth with an unfavorable horizontal root fracture (i.e. close to the
gingival margin)
Carious tooth that is unrestorable
17
10/12/2017 4:59
AM

18. Goals of Apexogenesis : (Weber 1984)
Sustaining a viable Hertwigs Sheath, thus allowing continued development
of root length for a more favorable crown to root ratio.
Maintaining pulpal vitality, thus allowing the remaining odontoblasts to lay
down dentin, producing a thicker root and decreasing the chance of root
fracture.
Promoting root end closure, thus allowing a natural apical constriction for
root canal filling.
Generating a dentinal bridge at the site of pulpotomy
18
10/12/2017 4:59
AM

19. PROCEDURE
Anesthetize and isolate.
After local anesthesia, rubber dam isolation, a conventional
access cavity was made with a high-speed bur using copious
water spray.
Strands of pulp and debris were removed coronal to the
amputation site.
Amputation of the coronal pulp at the cervical level was
performed with a sharp spoon excavator or a large sterile round
bur.
19
10/12/2017 4:59
AM

20. PROCEDURE
 Bleeding of the pulp stump was controlled with saline on a cotton pellet
applied with gentle pressure.
 [Ca(OH)2]: Calcium hydroxide powder was mixed with saline to a thick
consistency. The paste was carefully placed on the pulp stump surface 1 to 2
mm thick.
20
Removal of coronal pulp Haemostasis
10/12/2017 4:59
AM

21. Calcium hydroxide placement
21
10/12/2017 4:59
AM

22. Follow-up
 Time required
 1 and 2 years depending on the degree of tooth development at the time of the
procedure.
 Recalled every 3 months
• Clinically, the treatment was considered successful if there were no
signs or symptoms of pulp or periapical disease (no history of pain and
no clinical evidence of swelling or sinus tract).
• Radiographically, the treatment was considered successful if there was
continued growth of the root and canal narrowing, and no widened
periodontal ligament, no periapical radiolucency and no internal or
external root resorption.
22
10/12/2017 4:59
AM

23. CONTROVERSY EXISTS
As the entire coronal pulp was removed, thermal and electrical testing of
the tooth is no longer possible.
Since it is not possible to determine the pulp vitality or the health of the
remaining pulp tissue, it has been advocated that the tooth should be re-
entered and root canal therapy performed.
23
10/12/2017 4:59
AM

24. • Mejare & Cvek (1993)
• 37 young posterior teeth - deep carious lesions and exposed pulps
• Group 1 - 31 teeth with no clinical or radiographic symptoms
before treatment.
• Group 2 - 6 teeth with temporary pain, widened periodontal space
periapically
•
• After an observation time of 24 to140 months , healing had
occurred in 29 of 31 teeth in Group 1 (93.5%) and in 4 of 6 teeth in
Group 2.
• It was concluded that partial pulpotomy may be an adequate
treatment for young permanent molars with a carious exposure
24
10/12/2017 4:59
AM

25. • Mahmood K et al.,(2006)
• 32 first permanant molars of 23 patients with age of 10 yrs
• Clinically and radiographically within the normal limits
• Partial pulpotomy with grey MTA was done
• GIC base was given and amalgam/ SS crown restoration was done
• Reviewed clinically and radiographically at 3,6,12 & 24 months
• 22 teeth – No clinical and radiographic signs
• 6 teeth - not responded to vitality tests
25
10/12/2017 4:59
AM

26. Kessar et al.,(2006)
• A paradigm shift from apexification to apexogenesis
• Apexogenesis can be done even in a non vital teeth
• No instrumantation should be done
• Copious irrigation with 20 ml of NaOCl, dry with paper points and IRM
restoration
• Apexogenesis occurred over a period of 35 month
26
10/12/2017 4:59
AM

27. Ali Nosrat et al., (2006)
 8 yr old boy with complicated crown fracture wrt 21
 Cervical pulpotomy done with CEM ( Calcium enriched mixture)
After 6 and 12 months follow up tooth is vital , apex has formed and calcific
bridge underneath the cement was found.
 CEM is a new endodontic cement with similar applications as MTA
 Antimicrobial nature comparable to CH and MTA
 Composition of set CEM is similar to dentin
27
10/12/2017 4:59
AM

28. Apexification
Defined as the method of inducing apical closure by the formation of
osteo cementum 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
28
10/12/2017 4:59
AM

29. Definition
A method of inducing apical closure of the roots of an
incompletely formed, nonvital radicular tissue just short of root
end and placing a suitable biocompatible agent in the canal.
(AAPD Guidelines 1998)
The process of creating an environment within the root canal and
periapical tissues after pulp death that allows a calcified barrier to
form across the open apex. (Thomas R. Pitt Ford, 1989)
Inducement to form a calcified apical barrier in teeth that have
pulpal necrosis. (McDonald & Avery, 2000)
29
10/12/2017 4:59
AM

30. ‘Root-End Closure’, introduced by Torabinejad in 2002.
30
Indication – restorable immature tooth with pulp necrosis.
Contraindications
All vertical and unfavorable horizontal root fractures.
Very short roots
Periodontal breakdown
10/12/2017 4:59
AM

31. Objectives
Induce root end closure
No evidence of post treatment signs and symptoms
No evidence of calcification
No internal or external resorption
No breakdown of periradicular supporting tissues
31
10/12/2017 4:59
AM

32. According to Morse et al., (1983) various approaches :
Blunt end or rolled cone (customized cone)
Short fill technique
Periapical surgery (with /without retrograde seal)
Apexification (apical closure induction)
32
10/12/2017 4:59
AM

33. Blunt end or rolled cone (customized cone)
33
Filling the root canal with the large end of gutta percha cone is
customized cone is not advisable because the apical foramen is
generally wider than the root canal orifice.
This would prevent proper condensation of the gutta percha and
proper preparation of the canal would weaken the tooth considerably
It would also be difficult to assess the point of root development
radiographically because root formation in the buccolingual plane is
less advanced than it is in the mesiodistal plane.
10/12/2017 4:59
AM

34. Short fill
Moodnick proposed removal of the bulk of the necrotic
tissue & filling the root canal short of the apex with gutta
percha
He advocated use of Diaket ( premier dental products).
It is a compound of beta ketones & zinc oxide in place of
gutta percha to enhance healing.
However with an incomplete obturation, microbes can be
left remaining within the apical part of the root canal
system & healing may not take place or periapical
breakdown may occur later.
34
10/12/2017 4:59
AM

35. Periapical surgery
The gutta percha/ sealer surgical approach has many
drawbacks. Many clinicians do not advocate this method of
treatment for one or more of the following reasons:
Relative to the already shortened roots, further reduction could result in an
inadequate crown to root ratio.
Surgery could be both physically & psychologically traumatic to the young
patient.
The young patient is non cooperative
Surgery would remove the root sheath & prevent the possibility of further
root development
35
10/12/2017 4:59
AM

36. The apical walls are thin & could shatter when touched by a
rotating bur
The periapical tissue may not adapt to the wide & irregular
surface of the amalgam
The thin walls would make condensation of a retrograde material
difficult. This can result in an inadequate seal.
36
10/12/2017 4:59
AM

37. Apical closure induction
Most widely used approach but exact mechanism unknown
It has been considered that treatment of teeth with necrotic pulp
the basic aim should be stimulation & preservation of the
formative activity of the granulation tissue cells in apical part of
the root canal
This should enhance the formation of a calcified callus in the wide
apical opening.
37
10/12/2017 4:59
AM

38. One visit apexification
Induction of apical healing, regardless of the material used, takes at
least 3–4 months and requires multiple appointments
Patient compliance with this regimen may be poor and many fail to
return for scheduled visits
The temporary seal may fail resulting in re-infection and
prolongation or failure of treatment
For these reasons one-visit apexification has been suggested
Morse et al., (1990) define one-visit apexification as the non-
surgical condensation of a biocompatible material into the apical end
of the root canal
38
10/12/2017 4:59
AM

39. One visit Apexification
The rationale is to establish an apical stop that would
enable the root canal to be filled immediately
There is no attempt at root end closure. Rather an
artificial apical stop is created
39
10/12/2017 4:59
AM

40. Materials to induce Apexification in teeth with
immature apices
Calcium hydroxide
Ca(OH)2 for apexification in the pulpless tooth was first
reported by Kaiser in 1964
The technique was popularised by the work of Frank in
1966
40
10/12/2017 4:59
AM

41. Other medicaments
Tricalcium phosphate
Collagen calcium phosphate.
Resorbable Tricalcium phosphate.
Mineral trioxide aggregate.
Biodentine
Bone morphogenic proteins
41
10/12/2017 4:59
AM

42. Time required for apical barrier formation in apexification using calcium hydroxide
42 Study Findings
Sheehy and Roberts 1997 an average length of time for apical barrier formation ranging from 5 to 20
months
Finucane and Kinirons 1991 calcium hydroxide apexification and found that the mean time to barrier
formation was 34.2 weeks (range 13–67 weeks)
Cvek 1972 infection and/or the presence of a periapical radiolucency at the start of
treatment increases the time required for barrier formation
Kleier and Barr 2013 presence of symptoms the time required for apical closure was extended by
approximately 5 months to an average of 15.9 months. 10/12/2017 4:59
AM

43. Procedure
 Anesthetize and isolate
 Access is made
 Instrumentation
 Initial treatment length
 Acc to Torneck et al & Holland et al.,
 Primary aim- Enlargement
 Acc to Ingel – H files, circumferential filling
43
10/12/2017 4:59
AM

44.  If periapical abscess is present, over-instrumentation with smaller files
(20-25) will establish drainage.
 Ingle recommends that further treatment should be done only when
active lesion has subsided.
 Irrigation
 Sodium hypochlorite
 Alternation with hydrogen peroxide - weine
 Subsequent appointments-sterile water or isotonic saline -Webber
44
10/12/2017 4:59
AM

45. Drying of the canals
Often difficult because of seepage
Paper points are pre measured to working length
An inverted coarse point is often desirable.
In continuous seepage, a pre fitted point can
be left in canal until calcium hydroxide is placed
45
10/12/2017 4:59
AM

46. Techniques of calcium hydroxide placement:
Commercial preparations
Webbers technique
Using amalgam carrier
and endodontic pluggers.
3-4 increments of CH is placed with amalgam carries and pushed apicaly
with a plugger.
46
10/12/2017 4:59
AM

47. Successive increments is placed with amalgam carrier and pushed
apicaly with larger plugger.
Care should be taken to see that material is in contact with periapical
tissue.
47
10/12/2017 4:59
AM

48. Temporary restoration
ZOE /IRM
Material is vertically condensed to make 4-5 mm of space in access.
Break of occlusal seal leads to, contamination and dilution of paste,
also exposure of healing tissues to microorganisms.
48
10/12/2017 4:59
AM

49. Refilling procedure- Holland
First recall is at 6 weeks
Paste is diluted in canal.
Acc to Holland et al.,
Removed 1-2mm short of the original working length
Remaining powder on canal walls removed with larger
size instruments.
49
10/12/2017 4:59
AM

50. Recall
Recalled 6 wks after second replacement, later 2-3 months there after until
calcific barrier is formed radiographically.
Total time 12 – 18 months.
Subsequent replacement depends upon radiographic examination.
If any symptoms develop refilling is necessary.
50
10/12/2017 4:59
AM

51. Procedure to detect barrier formation
Radiographic evaluation
Paper point
51
10/12/2017 4:59
AM

52. Mechanism of action of Ca(OH)2 to induce
formation of a solid apical barrier
Presence of high Ca concentrations increases the activity of calcium
dependent pyrophosphate
Direct effect on the apical and periapical soft tissue
High pH will activate alkaline phosphatase
Antibacterial activity
52
10/12/2017 4:59
AM

53. According to Cruz et al.1998., histological analysis of the apical barrier
Outer surface of the bridge extended in a ‘cap like’.
The histological sections showed distinct layers.
Dense acellular cementum-like tissue.
Irregular dense fibrocollagenous connective tissue with irregular
fragments of highly mineralized calcifications.
53
10/12/2017 4:59
AM

54. Nature and source of cells participating in
Apexification process
Mesenchymal / pluripotent cells in the periapical region
Cells of dental sac
Odontogenic activity of residual pulp cells
Connective tissue cells- mesenchymal /fibroblastic cells
Pluripotent cells –bone tissue
54
10/12/2017 4:59
AM

55. Structure of apical barrier
Conflicting views
Solid structure- cementoid tissue
In a clinical case by H.S Chawla & Krishna et al., it was seen
that the following apical closure , the sealer used with the gutta
percha for obturation had extruded beyond the bridge.
The authors concluded that if the calcified bridge would have been
a solid structure, the sealer could not have gone in the periapex. So
the bridge formed is a porous structure.
55
10/12/2017 4:59
AM

56. 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 occurs. This would need either re-
treatment with CaOH2 or surgery.
56
10/12/2017 4:59
AM

57. Inherent disadvantages of calcium hydroxide apexification
Variability of treatment time
Unpredictability of apical closure
Difficulty to patient follow up
Delayed treatment
57
10/12/2017 4:59
AM

58. 58Study No. of treated teeth CaOH used Time for ABF
range/mean
Success Rates
Heithersday, 1970 21 CaOH & methyl
cellulose
14-75 mo 90%
Cvek, 1972 55 CaOH powder &
saline
18.2 mo 90%
Winter, 1977 34 Reogan-Rapid—27
teeth
CaOH powder &
sterile water-27 teeth
Not stated 74%
Chawla et al., 1986 26 Reogan-Rapid 35% in 12 mo, 65% in 6
mo.
100%
Ghose et al., 1987 51 Calasept 3-10 mo 96%
Studies where CaOH was used to induce apical barrier formation (ABF) and healing.
10/12/2017 4:59
AM

59. 59Study Number of treated
teeth
CaOH used Time for ABF
range/mean
Success Rates
Thater et al., 1988 34 Pulpdent Not stated 74%
Mackie et al., 1988 112 Reogan-Rapid 10.3mo 96%
Yates, 1988 22 teeth-study grp
22 teeth-control grp
CaOH powder &
sterile water or
Hypocal
9 mo study grp
20.2 mo control group
100%
Kleier et al., 1991 48 CaOH paste &
Pulpdent
1.6y, 1-30 mo. 100%
Mackie et al., 1994 19
19
Reogan-Rapid
Hypocal
6.8 mo
5.1mo
100%
100%
Studies where CaOH was used to induce apical barrier formation (ABF) and healing.
10/12/2017 4:59
AM

60. MTA ( Mineral trioxide aggregate)
Mineral trioxide aggregate (MTA) was first developed by
Torabinejad and members at the Loma Linda
University, California, USA
Initially it was used as a root-end filling material in
endodontic treatment
It is a mixture of dicalcium silicate, tricalcium silicate,
tricalcium aluminate, gypsum, tetracalcium aluminoferrite
and bismuth oxide
The addition of bismuth powder makes it radio opaque
Original grey and a newer white
60
10/12/2017 4:59
AM

61. COMPOSITION OF GREY NAD WHITE MTA
10/12/2017 4:59
AM
61

62. Physical and chemical properties
1. Ph
MTA has a pH similar to that of calcium hydroxide of 12.5
This similarity with calcium hydroxide is thought to contribute to
its inductive potential and the resultant hard tissue formation
The pH of MTA as it set was measured with a pH meter using a
temperature-compensated electrode.
62
10/12/2017 4:59
AM

63. 2. Sealing ability & marginal adaptation
The quality of apical seal for different retrograde materials
has been assessed by different research groups, based on
the degree of penetration by
dye
radio-isotope
bacterial
electro-chemical means and
fluid filtration techniques
63
10/12/2017 4:59
AM

64. 2. Sealing ability & marginal adaptation
MTA is also associated with less overfills and the superior
outcome associated with the material is observed with or without
blood contamination of the root cavities
In a study carried out by Fischer et al.1998, using bacterial
leakage model, the time period in which materials began leaking
was 10-63 days for amalgam, 24- 91 days for IRM.
MTA did not begin to leak till day 49.
The superior sealing ability of MTA is thought to be due to the
setting expansion it undergoes in moist environment
64
10/12/2017 4:59
AM

65. COMPRESSIVE STRENGTH
MTA has a relatively low compressive strength; however,
this does not compromise its success as it is used in
situations that experience low compressive forces.
Sluyk et al..(1998) studied setting properties of MTA and
found that MTA reached its maximum resistance level if
left undisturbed for 72 hours before placement of a
permanent restoration
65
10/12/2017 4:59
AM

66. BIOCOMPATIBILTY
Material analysis of MTA shows the material to be divided
into calcium oxide and calcium phosphate.
The scanning electron microscopic studies revealed that
amorphous calcium phosphate showed maximum ingress
and growth of cells.
They concluded that MTA offers a biological substrate for
osteoblasts and the calcium phosphate phase favoured the
change in cell behavior that stimulated growth over MTA
66
10/12/2017 4:59
AM

67. INDUCTIVE POTENTIAL
Torabinejad et al. and colleagues 1995 used infected
premolars in two-year old beagle dogs, which were prepared to
receive gutta-percha root-fillings
The root fillings were left to contaminate by means of open
access cavities and subsequently underwent root resection and
retrograde fillings with either MTA or amalgam
Although periosteum and new bone formation were found in
the presence of both materials, histologic findings at 10-18
weeks post-surgery confirmed the formation of cementum
exclusively over the root ends with MTA, which included the
MTA itself.
67
10/12/2017 4:59
AM

68. INDUCTIVE POTENTIAL
Shabahang et al. 1997 carried out apexification in
immature dog-teeth using Calcium hydroxide
osteogenic protein and MTA.
 MTA induced hard tissue formation more than any
other test material at 12 weeks, resulting in root-
end closure
68
10/12/2017 4:59
AM

69. Cytotoxicity
An in vitro study conducted by Osorio et al. in 1998
compared different root canal sealers and root end
filling materials using two assay systems and two
different mammalian fibroblast cell line .
Their conclusions were based on the fact that if a
material exhibits a strong cytotoxicity in cell culture
tests, it is very likely to do so in living tissue. Of the
materials tested, MTA was the least cytotoxic.
69
10/12/2017 4:59
AM

70.  Sridhar et al.,(2010)
 The aim of the case reports was to present a treatment to promote root-end
growth and apexification in nonvital immature permanent teeth in children.
 Three cases were presented where the calcium hydroxide and iodoform paste
Metapex® was placed in the root canals of immature permanent teeth using
disposable plastic tips.
 The teeth involved were evaluated radiographically at regular intervals for
the first 12 months after placement of the paste.
 At the end of 12 months all the cases showed continued root growth and
apical closure (apexification) with no evidence of periapical pathology.
Conventional endodontic treatment was then performed.
70
10/12/2017 4:59
AM

71. BIODENTINE
 A new calcium silicate-based material, Biodentine, has been introduced.
 It has been developed as a permanent dentine substitute material whenever
original dentine is damaged.
 Powder- tricalcium silicate and dicalcium silicate- the principal component
of Portland cement and MTA. Calcium carbonate, calcium oxide, iron
oxide, and zirconium oxide.
 Liquid-calcium chloride and a water-soluble polymer.
10/12/2017 4:59
AM
71

72. Properties
10/12/2017 4:59
AM
72

73.  Han and Okiji (2011) compared calcium and silicon uptake by adjacent root
canal dentine in the presence of phosphate buffered saline using Biodentine
and ProRoot MTA.
 The results showed that both materials formed a tag-like structure composed
of the material itself or calcium- or phosphate rich crystalline deposits.
 The thickness of the calcium and silicon -rich layers increased over time, and
the thickness of the calcium and silicon -rich layer was significantly larger in
Biodentine compared to MTA after 30 and 90 days, concluding that the
dentine element uptake was greater for Biodentine than for MTA.
10/12/2017 4:59
AM
73

74. 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. However, the most important factors
are debridement of the canal and closure of this space
with a suitable material.
These aspects allow the body to reorganize and repair
the periapical tissues.
74
10/12/2017 4:59
AM

75. References
 Grossman LI: Endodontic practice, 10 edition, Philadelphia. 1981,
Lea & Febiger
 Dentistry for Child and Adolescent. 6th Edition McDonald R.E. and
Avery D.R.
 Textbook of pediatric dentistry 3rd edition. Marwah
 Tandon S. Textbook of Pedodontics. 2nd ed. Delhi: Para; 2008.
 Principles and Practice of Pedodontics. Arathi Rao. 2nd edition.
 Pediatric dentistry in children & adolescent, 8th edit, McDonald,
Avery & Dean, Elsevier pub.
 Camp JH, Barrett EJ, Pulver F. Pediatric endodontics. In: Cohen S,
Burns RC, eds. Pathways of the pulp. 8th ed. St Louis: Mosby; 2002.
pp. 797–844. Ingle: Endodontics 6th edition.
75
10/12/2017 4:59
AM

76. References
 A paradigm shift in endodontic management of immature teeth:
Conservation of stem cells for regeneration. George T.-J. Huang.
Journal of Dentistry 2008
 Apexification: Case report. Peter Parashos. Australian Dental
Journal 1997;42:(1):43-6
 Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: a review of
the constituents and biological properties of the material.
International Endodontic Journal, 39, 747–754, 2006.
 Endodontics, ingle & Bakland, 5th edit, Mosby pub.
 Bhasker SN. Orbans oral histology & embryology, 11th edn. St.
louis: Mosby- year book. 1991.
76
10/12/2017 4:59
AM

77. 77Study Advantages
Heithersday, 1970 calcium hydroxide & methylcellulose has the advantage of decreased solubility in
tissue fluids and a firm physical consistency
Mitchell and
Shankwalker 1958
osteogenic potential of calcium hydroxide
when implanted into the connective tissue of
rats
Calcium hydroxide had a unique potential to
induce formation of heterotopic bone in this
situation
Holland et al.1977 The reaction of the periapical tissues to
calcium hydroxide is similar to that of pulp
tissue
Calcium hydroxide produces a multilayered
necrosis with subjacent mineralization
Schroder and
Granath 1971
the layer of firm necrosis generates a low-
grade irritation of the underlying tissue
sufficient to produce a matrix that mineralizes
It appears that the high pH of calcium
hydroxide is an important factor in its ability
to induce hard tissue formation
Studies of calcium hydroxide products used for Apexification
10/12/2017 4:59
AM

78. Controversies on calcium hydroxide dressing changing
78Study Findings Advantage
Chawla 1986 it suffices to place the paste only once and
wait for radiographic evidence of barrier
formation
Chosack et al 1972 the initial root filling with calcium
hydroxide there was nothing to be gained by
repeated root filling either monthly or after 3
months
Abbot 1998 radiographs cannot be relied upon the ideal
time to replace a dressing depends on the
stage of treatment and the size of the
foramen opening.
It allows clinical assessment of
barrier formation and may
increase the speed of bridge
formation
10/12/2017 4:59
AM

79. Time required for apical barrier formation in apexification using calcium hydroxide
79 Study Findings
Sheehy and Roberts 1997 an average length of time for apical barrier formation ranging from 5 to 20
months
Finucane and Kinirons 1991 calcium hydroxide apexification and found that the mean time to barrier
formation was 34.2 weeks (range 13–67 weeks)
Cvek 1972 infection and/or the presence of a periapical radiolucency at the start of
treatment increases the time required for barrier formation
Kleier and Barr 1991 presence of symptoms the time required for apical closure was extended by
pproximately 5 months to an average of 15.9 months. 10/12/2017 4:59
AM

80. 80
TECHNIQUE/
MATERIAL
INVESTIGATORS NO
CASES
OBSERV
ATIONS
OUTCOMES
Comparison of MTA
plug with CH
therapy
El-Meligy and Avery,
2006
15 12 2 of CH teeth had become reinfected, but all teeth
treated with MTA plug remained successful
Comparison of MTA
plug with CH
therapy
Pradhan et al, 2006 20 12 Periapical lesions resolved in 4.6 1.5 months for MTA
group and in 4.4 1.3 months for CH group. Total
treatment was completed in 0.75 0.5 months for MTA
group and 7 2.5 months for CH group.
MTA plug Pace et al, 2007 11 2 yrs 10 of 11 cases healed, and remaining case considered
incomplete healing
MTA plug Erdem and Sepet, 2008 5 2 yrs 4 of 5 teeth healed; 1 case in MTA was extruded
MTA plug Sarris et al, 2008 17 11.7 yrs 94.1% clinical success, 76.5% radiographic success;
17.6% uncertain
MTA plug Holden et al, 2008 20 12-44
month
Healing rate was 93.75%
10/12/2017 4:59
AM

81. 81
TECHNIQUE/
MATERIAL
INVESTIGATORS NO
CASES
OBSER
VATION
S
OUTCOMES
MTA plug Nayar et al, 2009 38 12
months
All teeth were clinically and radiographically
successful
MTA plug Annamalai and
Mungara, 2010
30 12
months
100% success clinically and radiographically
MTA plug Moore et al, 2011 22 Mean
follow-
up time
23.4
months
Clinical and radiographic success rate of 95.5%;
discoloration in 22.7% of teeth
MTA plug Simon et al, 2007 43 12
months
81% healed
MTA plug Witherspoon et al, 2008 78 Mean
recall
time was
19.4
months
93.5%of teeth treated in 1 visit healed, and 90.5% of
teeth treated in 2 visits healed
10/12/2017 4:59
AM