Apexogenesis & apexification


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apexification and apexogenesis

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  • considered that bacterial control and infection control can be achieved especially in radicular pulp
  • Considered that the pulp is vitalconcomitant presence of all three classical signs of pulp necrosis; coronal discolouration, loss of pulp sensitivity and periapical radiolucency, can in rare cases be followed by pulp repairfracture: Consider if the line of fracture is passing thro. the gingival crevice and the portion involvedpulp exposure??Caries: reversible pulpitis
  • Take home messageAim: stop the infection; save the pulp; the tooth will heal itself
  • Considering amount of expore and insult to the tooth
  • creating an environment within the root canal and periapical tissues after pulp death that allows a calcified barrier to form across the open apex.
  • Apical closure occurs approximately 3 years after eruption. However, when the pulp undergoes necrosis before root growth is complete, dentin formation ceases, and root growth is arrested. Therefore, the canal and the apex remain wide; the root may also be shorter.An open apex may develop also as a result of extensive resorption of a mature apex after orthodontic treatment, or from periradicular inflammation,or as part of healing after trauma. The normal mature permanent tooth often has an apical constriction of the canal approximately 0.5 to 1.0 mm from the anatomic apex. An immature root has an apical opening that is comparatively very large.
  • Pulp dead => no physiologic development possible
  • Formation of osteocementum or bone like tissueapexification is to stimulateapical barrier formation, in the belief thatcontinued root formation cannot occur. However, there are anumber of reports of continued apical developmentin spite of a necrotic pulp.It has been suggested that for continued root development to occur the area of calcific scarring must not extend to Hertwig’s root sheath or to the odontoblasts in the apical area
  • Thought to have Osteogenic property
  • Alkaline pH
  • factors most critical to success are thorough debridement of the pulp space and a complete coronal sealminimize dentin removal
  • Produces an artificial barrier, against which an obturating material can be condensed;Hardens (sets) in the presence ofmoistureSuccess rate???
  • Apexogenesis & apexification

    1. 1. Apexogenesis & Apexification Ujwal Gautam Roll no. 431 BDS 4th year (2009 batch) BPKIHS Moderator: Dr. Bandana Koirala, Additional Professor Dr. Abhishek Kumar, Assistant Professor Dept. of Pedodontics, CODS, BPKIHS
    2. 2. APEXOGENESIS  Physiologic process  Formation of apex in vital, young, permanent teeth with appropriate vital pulp therapy
    3. 3. • If normal pulp tissue with minimal inflammation is present, normal root end development occurs However, in immature teeth with pulp necrosis and bacterial infection, the long-term prognosis is related to the stage of root development and the amount of root dentine present at time of injury APEXOGENESIS
    4. 4. Rationale • Poor long-term prognosis of endodontically treated immature teeth Relatively thin dentine in obturated canal of incompletely formed roots and open apices are at risk of fracture • pulp revascularization and repair will more readily occur in teeth with a wide apical foramen • pulp of immature teeth has a significant repair potential APEXOGENESIS
    5. 5. Indication traumatic luxation fractured tooth with pulpal exposure carious exposures APEXOGENESIS
    6. 6. goals • Sustaining a viable Hertwig’s sheath to allow continued development of root length for favourable crown:root ratio • Treatment strategies of traumatized, immature permanent teeth should aim at preserving pulp vitality to secure further root development and tooth maturation. • Promoting a root end closure • Generating dentinal bridge at the site of pulpotomy APEXOGENESIS
    7. 7. Keep the Pulp ALIVE!!
    8. 8. Involves – Direct pulp capping – Indirect pulp capping – Pulpotomy APEXOGENESIS
    9. 9. Materials Ca(OH)2 (calcium hydroxide) or MTA (mineral trioxide aggregate). • MTA is the material of choice. APEXOGENESIS
    10. 10. Contraindications • 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 • Necrotic pulp APEXOGENESIS
    11. 11. A vital pulp therapy performed to encourage continued physiological development and formation of the root end
    12. 12. APEXIFICATION  The process of inducing the development of the root and apical closure in an immature pulpless tooth with an open apex
    13. 13. Why apexification instead of conventional RCT?  Open apex  Blunderbuss canals  thin and fragile canal walls  absolute dryness of canals difficult to achieve APEXIFICATION
    14. 14. Indication Young permanent, nonvital teeth APEXIFICATION
    15. 15. Objective Induce root end closure to form a complete calcific barrier at the apex with no apparent pathoses APEXIFICATION
    16. 16. Contraindications • Very short roots • Marginal periodontal breakdown • Vital pulps APEXIFICATION
    17. 17. Materials Calcium hydroxide Collagen calcium phosphate gel Mineral Trioxide Aggregate Osteogenic Protein I and II APEXIFICATION
    18. 18. Use of Calcium hydroxide - alkaline pH - bactericidal - stimulate apical calcification. reaction of periapical tissues to calcium hydroxide is similar to that of pulp tissue. Calcium hydroxide produces a multilayered sterile necrosis permitting subsequent mineralization. APEXIFICATION
    19. 19. Serious disadvantages of Calcium Hydroxide – long treatment period, usually takes 6-9 months, & may extend up to 21 months. – must be replaced at monthly intervals & removed some months after placement before final obturation. – multiple visits by the patient. – possible recontamination may occur. – weaken the root dentin & the risk of teeth fracture. APEXIFICATION
    20. 20. MTA as Choice of material for apexification • Saves treatment time • Can induce formation (regeneration) of dentin, cementum, bone & periodontal ligament. • Excellent biocompatibility and appropriate mechanical properties. • Excellent sealing ability. • Produces an artificial barrier, against which an obturating material can be condensed. • Hardens (sets) in the presence of moisture. • More radiopaque than calcium hydroxide • Vasoconstrictive APEXIFICATION
    21. 21. Technique i. Anaesthesize the tooth and isolate it with rubber dam ii. Gain staight line access to canal orifice iii. Extirpate the pulp tissue remnants from the canal and irrigate it with sodium hypochlorite iv. Establish the working length of canal v. Place appropriate material for apexification procedure in the canal vi. Effective temporary seal between visits is critical. Fortified zinc oxide- eugenol cement (IRM) is preferred. vii. Second visit at 3 months for monitoring the tooth. If symptomatic; canal is cleaned and again filled with calcium hydroxide viii. Patient is again recalled and examined for radiographic evidence of root formation ix. Confirm the Progress of apexification by passing an instrument through the apex after removal of calcium hydroxide x. Repeat the process if no satisfactory result found  Treatment time from 6 wks to 18 months APEXIFICATION
    22. 22. Frank has described four successful results of apexification treatments: I. continued closure of the canal and apex to a normal appearance, II. a dome shaped apical closure with the canal retaining a blunderbuss appearance, III. no apparent radiographic change but a positive stop in the apical area, and IV. a positive stop and radiographic evidence of a barrier coronal to the anatomic apex of the tooth. Evidence of root apical closure… APEXIFICATION
    23. 23. Final obturation only if;  Absence of any symptoms  Absence of any fistula or sinus  Absence or decrease in mobility  Evidence of firm stop clinically as well as radiographically Evidence of root apical closure… APEXIFICATION
    24. 24. 1 mo 6 mo 11 mo 12 mo
    25. 25. One visit apexification  Disadvantages of conventional technique:  Poor patient compliance as many fail to return for scheduled visits  The temporary seal may fail resulting in reinfection and prolongation or failure of treatment. o The rationale is to establish an apical stop that would enable the root canal to be filled immediately. o No attempt at root end closure. Rather an artificial apical stop is created.  use of MTA in one-visit apexification APEXIFICATION
    26. 26. Tooth restoration following apexification • High incidence of root fractures in teeth after apexification due to thin dentinal walls • Restorative efforts should be directed towards strengthening the immature root • Teeth to be used as overdenture abutments APEXIFICATION
    27. 27. References  Walton, Torabinejad; Principles and practice of Endodontics; W. B. Saunders company; 3/e; 2002  McDonald, Avery, Dean; Dentistry for the child and adolescent; Mosby. Inc; 8/e; 2004  Garg N., Garg A.; Textbook of Endodontics; JPBMP; 1/e; 2007  Tandon S.; Textbook of Pedodontics; Paras Medical Publisher; 2/e; 2009  Rafler M.; Apexification: a review; Dent Traumatol 2005; 21: 1–8;Blackwell Munksgaard, 2005  Witherspoon, Ham; One-visit Apexification: Technique for inducing root- end barrier ormation in apical closures; Pract proced Aesthet Dent 2001; 13(6)