This document discusses various vital pulp therapies including direct and indirect pulp capping. Indirect pulp capping involves covering the deepest layer of remaining carious dentin with a biocompatible material to prevent exposure and further trauma to the pulp. It aims to arrest the carious process and allow reparative dentin formation. Direct pulp capping places a protective material directly over an exposed pulp to maintain its vitality. Materials used include calcium hydroxide and MTA, with each having their own application technique. Factors like exposure size and timing influence the prognosis of direct pulp capping. Maintaining a sterile, adhesive seal over the exposed site is important for treatment success.

1. 1

2. VITAL PULP THERAPY
DR.AJEET SINGH BHALLA
Reader
21-07-22
2
DEPARTMENT OF CONSERVATIVE DENTISTRY &
ENDODONTICS

3. CONTENTS
• INTRODUCTION
• TYPES
• i)Direct pulp capping
• ii)Indirect pulp capping
• AFFECTED AND INFECTED DENTIN
• PULPOTOMY
• i)MTA Pulpotomy
• ii) Formocresol Pulpotomy
• PARTIAL PULPOTOMY
• APEXIFICATION
• APEXOGENESIS
• CONCLUSION
• SUMMERY
• REFERENCES
3

4. INTRODUCTION
• The unaffected ,exposed vital pulp
possess an inherant capacity for healing
through cell reorganization and bridge formation when proper
biological seal is provided and maintained against leakage of
oral contaminations.
4

5. • Throughout the life of a tooth, vital pulp tissue
contributes to the production of secondary
dentin, peritubular dentin and reperative
dentin in response to biological and
pathological stimuli.
5

6. OBJECTIVE
• To treat reversible pulpal injuries in order to
maintain pulp vitality in both primary and
permanent teeth.
6

7. VITAL PULP
THERAPY
• Vital pulp therapy is the treatment initiated on exposed pulp
to repair and maintain the pulp vitality.
• Two distinctive approaches are:
• i)indirect pulp capping: in cases of deep carious lesions
• ii) direct pulp capping :in cases of iatrogenic pulp exposure.
7

8. INDIRECT PULP CAPPING
• Defined as a procedure wherein the deepest layer of
remaining affected carious dentin is covered with a layer of
biocompatable material in order to prevent pulpal exposure
and further trauma to the pulp.
8

9. OBJECTIVE
• To preserve the vitality of pulp by completely removing the
carious infected dentin followed by placement of a material
that would enable the affected dentin to remineralize by
stimulating the underlying odontoblast to form tertiary
dentin.
• With the arrest of carious process,the reperative mechanism
is able to lay down additional dentin and avoid a pulp
exposure.
9

10. RATIONALE
• Disinfection of residual affected dentin is more readily
accomplished.
• Patient comfort is immediate.
• Eliminates the need for more difficult pulp therapy by
arresting the carious process and allowing the pulp reperative
process to occur.
10

11. DIFFERENCE BETWEEN INFECTED AND
AFFECTED DENTIN
Infected dentin Affected dentin
Soft and demineralized dentin teeming
with bacteria
Dimeneralized dentin,not yet invaded by
bacteria
Collagen is irreversibly denatured Collagen cross linking remains
Cannot remineralize Can act as template for remineralization if
a biocompatable material is placed over
it.
Soft necrotic tissue followed by dry
leathery dentin which flakes away with
the instrument
Discolored and softer than normal dentin
that does not flake easily
Dyes:1%acid red in propylene glycol stains
only irreversibly denatured collagen
Does not stain with caries detection dye.
11

12. DIAGNOSTIC DATA
• (i)History
Patient complains of tolerable dull pain with mild discomfort associated
with eating.
• ii)Clinical examination
Large carious lesion is found without any pulpal exposure.Positive
response to electric pulp test.
• iii) Radiographic examination
• Large carious lesion with a possible pulp exposure.
12

13. CLINICAL PROCEDURE
INDIRECT PULP CAPPING
• Can be performed as single or two visit approach.
• First appointment:
• Use local anaesthesia and isolate with the rubber dam.
• Cavity outline is established using a high speed air turbine handpiece.
• A slow speed handpiece with a large round bur(no.6 or 8) is used to remove the
superficial debris and majority of soft infected dentin without exposing the pulp.
• The excavation is stopped as soon as firm resistance of sound dentin is felt.
• Peripheral carious dentin can be removed with sharp spoon excavators
on cavity floor.
• The potential exposure site is covered with a commercial hard set
calcium hydroxide preparation(Dycal) and sealed with overlying
base of reinforced zinc oxide eugenol preparations.(IRM)
13

14. 14

15. This sealed cavity is not disturbed for 6-8 weeks.
Second appointment
• Between the two appointments , the history must be negative and the
intermediatory restoration must be intact.
• A bitewing radiograph of treated tooth is obtained.
• All the temporary filling materials especially calcium hydroxide dressing over the
pulp horns are removed carefully.
• The previous deep brownish red color of affected dentin will have changed to
lighter brownish gray color and most importantly harder in nature.
• The cavity preparation is washed out and dried very gently.
• The entire floor is covered with a commercial hard setting calcium hydroxide
preparation
• When clinical and radiographic findings are negative, the final restoration is
placed.
15

16. TREATMENT OUTCOME
• Two important factors are:
i)Remaining dentin thickness: of 2.0-0.5 mm have good prognosis
as the secreation of reactionary dentin is more in such cases.
• When RDT is between 0.5-0.25 mm , the reactionary dentin is reduced due
to decreased odontoblastic activity which causes reduction in prognosis.
• Rate of reperative dentin deposition has been shown to be avg of 1.4
micrometers/day after cavity preparation in dentin of human teeth.
• Rate of dentin deposition decreases after 48 days. So the maximum
deposition of reperative dentin occurs during first month after indirect
pulp capping.
16

17. • ii)Choice of indirect pulp capping agent:
• All bacterias are destroyed under calcium hydroxide dressing
sealed in deep carious lesions due to its high alkalinity and its
ability to produce a dentinal barrier or dentinal bridge.
17

18. 18

19. Case A Amalgam Restoration
• Classical cavity preparation
• >2 mm dentin thickness
19

20. Case A Amalgam Restoration
• Place cavity sealer
Varnish
OR
Resin bonding agent
20

21. Case A Amalgam Restoration
• Restore with amalgam
21

22. Case B Amalgam Restoration
• Deeper cavity preparation
• 0.5-2mm dentin thickness
22

23. Case B Amalgam Restoration
• Requires a base
23

24. Case B Amalgam Restoration
• Place cavity sealer
– varnish
OR
– resin bonding agent
24

25. Case B Amalgam Restoration
• Restore with amalgam
25

26. Case C Amalgam Restoration
• Deep cavity preparation
• Decalcified dentin adjacent to the
pulp
• < 0.5 mm dentin thickness over
the pulp
• Pulp exposure imminent if all
caries removed at this time
26

27. Case C Amalgam Restoration
• Requires a liner
• E.g., calcium
hydroxide(Dycal) for pulp
capping
27

28. Case C Amalgam Restoration
• Place a base
• E.g., zinc phosphate
• To achieve thermal and
electrical insulation
• Or adhesive bases like resin
modified GIC or
polycarboxylate
28

29. Case C Amalgam Restoration
• Place cavity sealer
– varnish
OR
– resin bonding agent
29

30. Case C Amalgam Restoration
• Restore with amalgam
30

31. DIRECT PULP CAPPING
• It is defined as a procedure in which the exposed
vital pulp is covered with a protective dressing or
base placed directly over the site of exposure in an
attempt to preserve pulp vitality.
32

32. INDICATIONS
• Iatrogenic mechanical exposure of pulp in an asymptomatic
vital tooth with sound dentin at the periphery.
• Small carious exposures in a asymptomatic permanent tooth
with incomplete root formation. The main objective in such
cases with minimum pulp inflammatory responses is to
maintain pulpal vitality.
• Radiographically, there should be no thickening of periodontal
ligament space and no evidence of periradicular lesion.
33

33. CONTRAINDICATION
• Not recommended in cases of carious exposure of primary
tooth as calcium hydroxide causes internal resorption in
primary teeth.
• Large carious exposure in symptomatic permanent tooth.
34

34. FACTORS AFFECTING PROGNOSIS OF
DIRECT PULP CAPPING
• Mechanical exposure always have a better prognosis than carious
exposure.
• Size of exposure: larger exposures always have a lowering healing potential
than smaller pin point exposure.
• Longer the time gap, higher the chances of bacterial microleakage.
• Mechanical exposures should be pulp capped immediately.
35

35. REQUIREMENTS OF IDEAL PULP
CAPPING AGENTS
• Should maintain pulp vitality
• Should stimulate reperative dentin formation
• Should be either bactericidal or bacteriostatic in nature
• Should adhere well to dentin and the overlying restorative material.
• Should be able to resist forces under restoration during the lifetime of
restoration
• Should be sterile.
• Should be radioopaque.
36

36. MATERIALS USED FOR PULP CAPPING
• Calcium Hydroxide
• MTA
37

37. TECHNIQUE OF DIRECT PULP CAPPING
• Two techniques:
• Calcium hydroxide technique
• MTA technique
38

38. Treatment protocol
• After anaesthesia and isolation of involved tooth,the
undermined enamel is removed with a carbide bur and spoon
excavator
• Caries removal is done with no.2 carbide bur and spoon
excavator.
• In cases of mild bleeding,hemostasis is achieved with the help
of cotton pellet soaked with 3-6%sodium hypochlorite.
• This is placed on exposure site for 3- 10 minutes. If bleeding
does not stop in 10 minutes,it signifies irreversable changes.
• After control of bleeding, CaOH or MTA direct pulp capping
procedures can be employed.
39

39. • CaOH Technique:
• A hard setting calcium hydroxide paste is applied over the
exposed pulp followed by glass ionomer lining. In one step
procedure,the final bonded restoration can be placed on top
of set glass ionomer
• In two step,intermediatory restoration is placed over glass
ionomer and patient is called back for final restoration.
40

40. 41

41. • MTA technique:
• After mixing,MTA is carried to the exposure site with the help
of MTA carrier gun or amalgam carrier. A minimum thickness
of 1.5mm of MTA is placed over exposed site and moist cotton
pellet is placed over it. After a period of 5-10 days, permanent
restoration is done.
• One visit: on the top of MTA ,a light cure flowable compomer
or glass ionomer liner is placed. Then it is etched with
37%phosphoric acid, washed and dried and tooth
is restored with bonded composite restoration.
42

42. Pulp Capping
Preoperative radiograph of the
mandibular right quadrant. The young
patient is only 6-years-old and only the
mesial cusps of the mandibular first molar
are erupted. Caries is already present
with a pulpal involvement. The tooth is
completely asymptomatic
After removal of the caries, the pulp exposure
was covered with MTA, a wet cotton pellet,
and a temporary cement.
Seven-month recall
Fifteen-month recall Two-year recall Four-year recall. The tooth tests vital, is
completely asymptomatic, and there is no evidence
of calcification in the pulp chamber.
43

43. Indirect pulp capping Direct pulp capping
Used when complete removal of caries
may cause pulp exposure
•Small pulpal exposure less than 1mm
•Light red bleeding from exposure sight
which can be controlled by cotton pellet
•Traumatic exposure in dry ,clean field
reported within 24 hours.
Contraindications
•Soft leathery dentin
•Non restorable tooth
•Signs of pulpal or periapical pathology
like tenderness on percussion
Contraindications
•Pain at night
•Spontaneous pain
•Tooth mobility
•Excess bleeding at exposure site
44

44. 45

45. PULPOTOMY
• Defined as a procedure in which portion of the exposed
coronal vital pulp is surgically removed as a means of
preserving the vitality and function of the remaining radicular
portion.
• It is quite similar to direct pulp capping except in the amount
and extent of pulp tissue removal.
46

46. OBJECTIVES
• Preservation of vitality of radicular pulp
• Relief of pain in patients with acute pulpalgia and
inflammatory changes in the tissue.
• Ensuring the continuation of normal apexogenesis in
immature permanent teeth by retaining the vitality of
radicular pulp.
47

47. RATIONALE
• A dressing is placed over the pulp stump to protect it and
promote healing.The two most commonly used dressings
contain either Ca(OH) or MTA.
• The severity of inflammatory process dictates the quality and
quantity of reperative dentin produced in the dentinal
bridges.
• Severe inflammation-limited reperative dentin devoid of
dentinal tubules.
• Mild inflammation-reperative dentin with varying number of
dentinal tubules.
48

48. INDICATIONS
• Mechanical or carious exposure in permanent teeth
with incomplete root formation.
• Traumatic exposure of longer duration where coronal
pulp is likely to be inflammed in young permanent
teeth.
• In pulpally involved children’s permanent teeth in
which root apex is not completely formed.
• carious pulp exposure in asymptomatic primary
tooth.
49

49. CONTRAINDICATIONS
• Irreversible pulpitis
• Abnormal sensitivity to heat and cold
• Chronic pulpalgia
• Tenderness to percussion
• Periradicular radiographic changes resulting from extension
of pulpal disease into periradicular tissues.
• Marked constriction of pulp chamber and root canals.
50

50. PROGNOSIS
• Success depends on:
• Vitality of majority of radicular pulp
• Absence of clinical signs or symptoms such as prolong
sensitivity or swelling.
• No radiographic evidence of internal resorption or canal
calcifications
• No breakdown of periradicular supporting tissues.
51

51. CLASSIFICATION
• Classified into two on the basis of :
i)Amount of pulpal tissue removed
• ii)Type of medicament employed
52

52. • Based on amount of pulpal tissue removed
• Two types of pulpotomy:
• i) Cervical pulpotomy:involves complete removal of coronal
portion of pulp, followed by placement of suitable dressing or
medicament that will promote healing and preserve the
vitality of the tooth.
• ii) partial pulpotomy: (Cvek’s pulpotomy) In this only a portion
of coronal pulp is removed until normal tissue that is free of
inflammation is reached before placing a medicament.
53

53. • Based on type of medicament employed
• i)CaOH pulpotomy
• ii)MTA pulpotomy
• iii) Formocresol pulpotomy
54

54. Clinical protocol for cervical
pulpotomy
• Diagnosis
• Diagnostic radiograph should be examined to determine the
approach to pulp chamber ,to evaluate shape and size of root
canals and to acertain the condition of periradicular tissues.
• The tooth should be tested for vitality.
• Anaesthesia
• Tooth should be anaesthetized
55

55. • Isolation and caries removal
• Rubber dam applied
• On removal of carious tooth structure, access is gained to the
pulp chamber along a straight line,using area of exposure as
starting point and removing the roof of pulp chamber entirely
with a sterile bur.
56

56. • Hemorrhage control
Can be done with:
• Hemostatic agent e.g: 3-6%sodium hypochlorite
• Pressure application with moist cotton pellet
• Electrosurgery
• Lasers
57

57. INSTRUMENTATION
• The pulp is amputated with any one of the following
methods:
• Sharp spoon excavator
• Large rotating round bur
• Diamond drill in high speed
• Lasers
• Electrosurgery
58

58. PLACEMENT OF MEDICAMENT
• CALCIUM HYDROXIDE PULPOTOMY
• -preferred medicament in permanent teeth
• -not indicated in primary teeth as an agent for pulpotomy
• Applied to amputated pulp with sterile pledget of cotton
• Pulp chamber should be filled to a depth of atleast 1-2mm with
calcium hydroxide on which glass ionomer cement is applied
•
• It can be used in many forms:
• A paste made by mixing powder with one of the following medium
namely, saline, distilled water, local anaesthesia.
• Non settable paste like Metapex.
• A fast setting commercial paste like Dycal.
59

59. 60

60. • MTA Pulpotomy
• MTA powder is mixed as per manufacturer’s instructions with
distilled water to get a putty consistancy.
• Better material of choice than calcium hydroxide in terms of
healing, quality of seal provided and superior
biocompatability.
• MTA is placed over the amputated pulp with the help of an
MTA carrier gun or amalgam carrier.
• Should be condensed lightly with moist cotton pellet.
• Minimum thickness of 2mm of material is placed.
61

61. • Permanent restoration
• a glass ionomer or a flowable compomer base is
recommended over CaOH /MTA medicament.
• A permanent restoration is placed over this base.
• Rubber dam is removed and occlusion is checked.
• A radiograph is taken as a record for future comparison
of apical closure,bridge formation,internal
resorption,calcific degeneration or development of
periradicular disease.
62

62. • Formocresol pulpotomy
• Indicated for pulpotomy of primary teeth only
• Popular medicament for past 70 years since its
introduction by sweet in 1932.
• A cotton pellet containing formocresol liquid is
placed over amputated pulp for a period of 3-
5 minutes
63

63. 64

64. • Follow up
• Radiographic evaluation should be done in every 3 months.
• In event of pain or death of pulp,the root canal content should be
removed as soon as possible and endodontic therapy should be started if
the apex is mature.
• If apex is immature, apexification therapy should be initiated.
65

65. PARTIAL PULPOTOMY (CVEK’S
PULPOTOMY)
• When the coronal pulp is exposed by trauma or operative
procedures or caries, it produces inflammatory changes in the
tissue.
• Uninfected vital tissues in the root canal can be preserved by
the surgical excision of inflammed coronal pulp.
• Removal of infected portion of pulp affords temporary ,rapid
relief of pulpalgia and further the remaining tissue may
undergo repair while completing apexogenesis(root end
development and calcification)
66

66. • Partial pulpotomy has been recommended for crown fractured teeth that
have a pin point exposure and can be treated within 15-18 hours of
accident and in carious exposure of asymptomatic permanent tooth with
open apex.
67

67. TAKE HOME
MESSAGE
68

68. PRIMARY TEETH
Vital tooth with large pulpal exposure Formocresol pulpotomy
Vital tooth with carious pulpal exposure Formocresol pulpotomy
Pulp less tooth with 2/3rd root length
available
Pulpectomy
Pulp less tooth with minimal periapical
radiolucency
Pulpectomy
Tooth with poor prognosis i.e. vertical
root fracture ,luxation or any other
condition causing damage to permanent
tooth
Extraction
69

69. PERMANENT TEETH
Vital tooth with small pulpal exposure DPC
Vital immature tooth with large pulpal
exposure
CaOH/MTA Pulpotomy
Non vital immature tooth Apexification
Non vital mature tooth RCT
70

70. CLINICAL SITUATIONS TREATMENT
Vital tooth with deep caries IPC
Vital tooth with small pulpal exposure DPC
RDT > 2mm Amalgam-varnish (all walls)n restoration
Composite-no pulp protection required
RDT 1-2mm Amalgam-Varnish (all walls),zinc
phosphate base(internal
walls),restoration
Composite –no pulp protection required
RDT 0.5-1 mm Amalgam-varnish ,ZnPo4 base (internal
walls)
,restoration
Composite- resin modified GIC(internal
walls) ,restoration
RDT <0.5mm Amalgam- Dycal(internal walls),LC GIC,
Varnish (external walls),restoration
Dycal(internal walls),varnish(all
walls),ZnPo4 base(internal
walls)restoration
Composite –Dycal(internal walls),LC
GIC,Restoration
71

71. Questions
• Direct pulp capping
• Indirect pulp capping
• Cvek’s pulpotomy
• Formocresol pulpotomy
72

72. 73

73. 74

74. APEXOGENESIS
• Term used to describe continued physiologic
development and formation of root apex.
• Defined as “A vital pulp therapy procedure
performed to encourage continued
physiological development and formation of
root end “
75

75. INDICATIONS
• In immature teeth when part of pulp tissue
remain vital and uninflammed as in carious
exposures.
• In some trauma cases in which pulp exposure
occurs.
76

76. GOALS
• Sustaining a viable Hertwig’s sheath, thus
allowing continued development of root length
for a more favourable crown to root ratio.
• Maintaining pulp 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 creating a
natural apical constriction for root canal filling.
77

77. PROCEDURE
• Involves removal of inflamed coronal pulp and
placement of calcium hydroxide on the
remaining healthy pulp tissue.
• Calcium hydroxide placed over vital pulp
stump after hemostasis.
• For deeper amputation, calcium hydroxide
powder is packed at the site.
• Radiographic and clinical follow up is
mandatory.
78

78. • Total time ranges between 1-2 years depending
on degree of tooth development at the time of
procedure.
• Recall visit- Every 3 months to determine vitality
of pulp and extent of apical maturation.
• If signs of irreversible damage to pulp or internal
resorption is evident, the pulp should be
extirpated and apexification therapy is indicated.
79

79. • Once root development appears to be
completed, the tooth should be reentered and
root canal therapy should be performed.
80

80. APEXIFICATION
• Defined as a method to induce a calcific barrier
across an open apex of immature pulpless tooth.
• It differs from apexogenesis which is basically the
physiological process of root development.
81

81. OBJECTIVE
• To induce either closure of the open apical third of the root
canal or the formation of an apical “calcific barrier” against
which obturation can be achieved.
82

82. RATIONALE
• Residual pulp tissue,if any, and the odontoblastic layer
associated with pulp tissue resume their matrix formation
and subsequent calcification guided by sheath of Hertwig.
• If the apexification is successful, a hard substance such as
bone,dentin,osteodentin or cementum will develop against
which dense obturation of root canal can be done.
83

83. MULTIPLE STEP APEXIFICATION WITH
CALCIUM HYDROXIDE
• Most common and traditional material to induce
apexification
• Multi visit approach which takes a period of 6 months to 4
years to complete.
• Technique
• In apexification procedure, every effort should be to preserve any vital apical
pulp tissue that will help the closure of immature apex.
• A preoperative radiograph is taken to find the apparent length of the tooth.
• Tooth is anaesthetized, Rubber dam is applied,access is gained to pulp
chamber and root canal and irrigation is performed with sterile water or saline
solution to prevent further irrigation to the periradicular tissues due to sodium
hypochlorite.
• A file is inserted and the stop is set to the apparent length of the tooth and a
radiograph is taken to measure the actual length of a tooth.
84

84. • Working length should be at least 2mm short of the length of the tooth to
prevent injury to the apical tissues and the thin walls at the apical third of
the root.
• Circumferential enlargement is effected by lateral pressure against the
walls with a large file.
• The instrument should follow the natural shape and contour of the root
canal.
• Cleaning and shaping is done to remove any necrotic pulpal tissue and to
prepare the root canal for calcium hydroxide dressing.
• Dried with absorbant point.
• Calcium hydroxide is mixed with sterile water or anaesthetic solution to a
thick consistancy .
• Barium sulfate can be added to the paste (1 part barium sulfate to 10
parts of calcium hydroxide) to increase the radiopacity.
• This paste is picked up with the help of amalgam carrier and is ejected
into the pulp chamber.
• By means of blunt finger plugger, the paste is forced into the canal.
• The dry pledget of calcium hydroxide is forced into root canal with the help
of blunt finger pluggers until the entire canal is filled with calcium
hydroxide paste. 85

85. 86

86. • Calcium hydroxide mixture must be in contact with periapical
tissues to be effective. Access cavity is sealed with intermediate
restorative material.
• Alternative method is to use radiopaque paste of calcium hydroxide
in a methyl cellulose base(pulpdent) available in syringe.
• The patient should be recalled in 3 months to take a radiograph and
determine wheather a calcific barrier has developed at or near the
root apex.Such barrier denotes that apexification has occurred.
• If not, then fresh supply of CaOH paste is applied to the root canal
and the patient is recalled every 3 months until one sees
radiographic evidence of an apical barrier denoting apexification.
• Although apexification usually completes in 6 months or 2 years .
• The root canal is obturated after completion of apexification.
87

87. 88

88. PROPERTIES OF CALCIUM HYDROXIDE
• pH -11-12
• Solubility – high ;gets disintegrated with time
• Compressive strength –Low
• More marginal leakage
• Does not adhere to dentin
• Forms hard tissue barrier slowly which is not very thick
and uniform
• Causes inflammation to pulp and periapical tissues
• Needs to be replenished after 3-6 months
• Good antibacterial activity
• Not expensive
89

89. SINGLE STEP APEXIFICATION WITH
MTA
• Calcium hydroxide is used as a material of choice to induce
apical barrier,but the time needed to induce a barrier varies
from months to years.
• MTA has demonstrated good biocompatability and a better
ability to seal and produce a superior barrier.
90

90. • Technique
• Proper isolation and anaesthesia is given
• Access cavity is prepared to allow the debridement of the necrotic
pulp tissue.
• A barbed broach or hedstroem file may facilitate removal of
necrotic tissue.
• Working length is kept 2mm short of the apex.
• Instrumentation beyond the apex will injure the periapical tissues.
• Gentle circumferential filling is done with minimal dentin removal
with sodium hypochlorite irrigation.
• Paper points are used to dry the canal.
• MTA is mixed according to manufacturer’s instructions and
introduced into the canal with the help of MTA carriers and
sequentially checked with multiple radiographs.
91

91. • Preselected pluggers are used to gently condense the MTA
into an apical 3-4 mm barrier.
• A moist cotton pellet is introduced to condense the final
increment of the MTA apical plug.This wet pellet is left behind
on top of MTA to ensure setting and then temporary
restoration is placed.
• The patient is recalled after a period of 48 hours for
obturating the remaining part of the root canal with a
thermoplasticized system and the placement of permanent
restoration
92

92. Apexification
Preoperative radiograph of the
maxillary left central incisor.
The patient is 55-years-old and
this tooth (with an open apex) has
not responded to previous
therapy
with calcium hydroxide
Intraoperative film with
the Dovgan carrier in place
Three millimeters of MTA
have been positioned at the
foramen to form the apical
barrier
After the MTA is set, the
thermoplastic gutta-percha
has been used to obturate
the root canal.
93

93. 94

94. ADVANTAGES OF MTA
• Excellent biocompatability
• Requires moisture for setting
• Normal healing response
• Least toxic
• Radiopaque
• Bacteriostatic
• Resistance to marginal leakage
95

95. DISADVANTAGES OF MTA
• Difficult to manipulate
• Long setting time 3-4 hours
• Costly
96

96. INDICATIONS OF MTA
• Pulp capping
• Apexification
• Perforation repair
• Root resorptions
• Root end filling material
97

97. PROPERTIES OF MTA
• pH – 12.5 when set
• Setting time 2 hours 45 minutes
• Compressive strength – 40 Mpa and 70 Mpa after 21
days.
• Produces hard setting non resorbable surface in
contrast to calcium hydroxide
• Sets in moist environment
• Low solubility
• Resistance to marginal leakage
• Excellent biocompatability with vital tissues
• Commercially available as Pro root MTA(Dentsply)
98

98. CONCLUSION
• Throughout the life of a tooth, vital pulp tissue
contributes to the production of secondary
dentin, peritubular dentin and reperative dentin in
response to biological and pathological stimuli.
• With such procedures, reversible pulpal injuries
can be treated in order to maintain pulp vitality in
both primary and permanent teeth.
99

99. SUMMERY
APEXOGENESIS APEXIFICATION
It is the physiologic process of root
development in vital infected tooth
It is the method of inducing the
development of root apex in immature
pulpless tooth by formation of
osteocementum or bone
Indicated in normal pulp or pulp with
minimal inflammation
Complete normal pulp(DPC)
Normal pulp in root portion(calcium
hydroxide pulpotomy)
Indicated in cases where pulp has
undergone irreversable pulpal necrosis
Normal root end development occurs Calcific barrier is formed at apex.
100

100. PRIMARY TEETH
Vital tooth with deep caries IPC
Vital tooth with large pulpal exposure Formocresol pulpotomy
Vital tooth with carious pulpal exposure Formocresol pulpotomy
Pulp less tooth with 2/3rd root length
available
Pulpectomy
Pulp less tooth with minimal periapical
radiolucency
Pulpectomy
Tooth with poor prognosis i.e. vertical
root fracture ,luxation or any other
condition causing damage to permanent
tooth
Extraction
101

101. PERMANENT TEETH
Vital tooth with small pulpal exposure DPC
Vital immature tooth with large pulpal
exposure
CaOH Pulpotomy
Non vital immature tooth Apexification
Non vital mature tooth RCT
102

102. REFERENCES
• Grossman .Endodontic Practices.11th edition
• Cohen 10th edition.Pathways of Pulp.
• Ingle 6th edition.Endodontics.
• Seltzer & Blender .Textbook of endodontics.
• Apexification in Endodontics.IEJ 2007.
103

103. 104