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
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
Roll no. 431
BDS 4th year (2009 batch)
Dr. Bandana Koirala, Additional Professor
Dr. Abhishek Kumar, Assistant Professor
Dept. of Pedodontics,
Formation of apex in vital, young, permanent teeth with
appropriate vital pulp therapy
• 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
• Poor long-term prognosis of endodontically treated immature
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
• 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
Ca(OH)2 (calcium hydroxide)
MTA (mineral trioxide aggregate).
• MTA is the material of choice.
• 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
A vital pulp therapy performed to encourage continued physiological development
and formation of the root end
The process of inducing the development of the root and
apical closure in an immature pulpless tooth with an open
Why apexification instead of conventional RCT?
thin and fragile canal walls
absolute dryness of canals difficult to achieve
Young permanent, nonvital teeth
Induce root end closure to form a complete calcific barrier at the
apex with no apparent pathoses
• Very short roots
• Marginal periodontal breakdown
• Vital pulps
Collagen calcium phosphate gel
Mineral Trioxide Aggregate
Osteogenic Protein I and II
Use of Calcium hydroxide
- alkaline pH
- 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.
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.
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
• 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
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
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
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
Frank has described four successful results of apexification
I. continued closure of the canal and apex to a normal
II. a dome shaped apical closure with the canal retaining a
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…
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…
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
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
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
Witherspoon, Ham; One-visit Apexification: Technique for inducing root-
end barrier ormation in apical closures; Pract proced Aesthet Dent 2001;