apexification and apexogenesis

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APEXIFICATION & APEXIFICATION & APEXOGENISISAPEXOGENISIS

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APEXIFICATION & APEXIFICATION & APEXOGENISISAPEXOGENISIS

These are the Endodontic treatment These are the Endodontic treatment modalities for modalities for InfectedInfected or or Non VitalNon Vital Young Permanent ToothYoung Permanent Tooth with a wide with a wide open blunder bus apex.open blunder bus apex.

Young Permanent ToothYoung Permanent Tooth:- One which :- One which has recently erupted into the oral has recently erupted into the oral cavity & who’s root formation has not cavity & who’s root formation has not yet been completed, hence it has an yet been completed, hence it has an open apexopen apex


Problems in Treating Immature tooth with Necrotic Pulp.There is an open apex hence no hard

tissue stop against which Gutta Percha can be packed

The open apex of the root canal tends to be shaped like a blunder bus making it difficult to obturate the apex with root filling material

Apicectomy is not advisable because the walls of the immature roots are likely to fracture when sealing the root apex.

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ApexificationApexification

DefinitionDefinition :- It is a method to induce :- It is a method to induce development of root apex of an development of root apex of an immature pulp less tooth by the immature pulp less tooth by the formation of osteocementum or other formation of osteocementum or other bone like tissue. bone like tissue.


Non vital Non vital permanent tooth permanent tooth with with incompletely incompletely formed rootsformed roots..


The aim of apexification is to induce The aim of apexification is to induce either closure of the open apical third of either closure of the open apical third of the root canal or the formation of apical the root canal or the formation of apical

calcific barriercalcific barrier against which against which obturation can be achieved obturation can be achieved


Zinc oxide & metacresylacetate-Zinc oxide & metacresylacetate-camphorated para chlorophenol, camphorated para chlorophenol, tri calcium phosphate, collagen-tri calcium phosphate, collagen-calcium phosphate, ceramic, calcium phosphate, ceramic, calcium hydroxide, empty canals calcium hydroxide, empty canals & even no treatment at all.& even no treatment at all.

Ca(OH)2 in methyl cellulose paste available in syringe.rxdentistry.netrxdentistry.net

Most widely used & tested Most widely used & tested material.material.

Available in many forms.Available in many forms. Dry powder can be packed Dry powder can be packed

into the canal.into the canal. Powder can be mixed with Powder can be mixed with

intra canal medicament or intra canal medicament or methyl cellulose.methyl cellulose.

Recently Ca(OH)2 pointsRecently Ca(OH)2 points (58% Ca(OH)2, 42% gutta (58% Ca(OH)2, 42% gutta

percha & coloring agent percha & coloring agent have also been used)have also been used)


Frank in 1966 was the first to describe clinical methods using Ca(OH)2 paste & CMCP to stimulate root closure.

1. The tooth is isolated with rubber dam, & access is gained into the pulp chamber.

2. Using large reamers & files, remove the debris from the coronal half of the pulp & established the file length radiograhically.

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3. Clean the canal, irrigate it and dry it with paper point, repeated gentle use of Sodium Hypochlorite assists debris removal.

4. Seal a pallet of CMCP in the pulp chamber with a provisional restorative material i.e ZnOE.

5. On recall in 1-3 weeks remove the restoration & clean the canal.

6. Take care to avoid any instrumentation of the walls of the dentin near the apex.

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7. Mix a paste of Ca(OH)2 & CMCP on a glass slab carry the paste to the canal & force it into the apex with a large plugger or cone shaped instrument. Objective is to fill the canal completely obtain an X-ray to check the accuracy of the root canal filling.

8. Recall the pt. after 6 months & see radiographic evidence of an apical closure.

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Clinical results of apexification

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9. When you have accomplished apical closure, the root canal filling is completed.

10. If apexification has not been completed, repeat the cleaning & insertion of Ca(OH)2 & CMCP paste.

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Ca(OH)2 placed in pulp chamber following pulp removal (Fig. b)

(a) (b)

Pre treatment showing an open apex (Fig. a)

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(c) (d)

>>Post treatment obturated with gutta percha (Fig (d)).

>>Check X-ray-apical constriction formed by 12-13 months (Fig ©).

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Mechanisms of ApexificationMechanisms of Apexification There are various induced apical depositions by There are various induced apical depositions by

cementum, bone, osteocementum, osteodentin, cementum, bone, osteocementum, osteodentin, cementoid etc. cementoid etc.

When tooth becomes non-vital------>hertwigs When tooth becomes non-vital------>hertwigs epithelial root sheath is not completely epithelial root sheath is not completely destroyed hence helps in apical devlopment.destroyed hence helps in apical devlopment.

High Ph -----> Calcific barrier ----->resulting in High Ph -----> Calcific barrier ----->resulting in closureclosure

** If there is any chance that pulp has vitality in a If there is any chance that pulp has vitality in a tooth with incompletely devloped apex, it is tooth with incompletely devloped apex, it is preferable to attempt a pulpotomy ------> preferable to attempt a pulpotomy ------> Apexogenesis.Apexogenesis.


First evaluation:- After 3 monthsFirst evaluation:- After 3 months a) Radiograph may show hard tissue a) Radiograph may show hard tissue

deposition but it is not considered reliable.deposition but it is not considered reliable.b) It is necessary to test the quality of apical b) It is necessary to test the quality of apical

barrier with a size 35 file.barrier with a size 35 file. If 3 months x-ray shows little or no apical If 3 months x-ray shows little or no apical

change – recall after another3 months.change – recall after another3 months.a) If Ca(OH)2 occupies canal space a) If Ca(OH)2 occupies canal space

adequately ------> no need to change adequately ------> no need to change Ca(OH)2.Ca(OH)2.

b) If any other condition -----> replace b) If any other condition -----> replace Ca(OH)2 & the coronal seal.Ca(OH)2 & the coronal seal.


Obturation of the root canal

When apical barrier has been successfully formed i.e. reverse taper shape of the canal Obturation is performed

by thermo plasticized technique filling gutta percha.

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A routine recall evaluation should be performed to determine the outcome of the root canal procedure.

Teeth treated in this manner are more likely to develop root fractures due to the thin root canal walls.

THEREFORE , the more developed the teeth before apexification , the better is the prognosis.

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Immature Tooth with peri-radicular disease

Working Length measured.

The canal is filled with Ca(OH)2

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AP – Apexification Paste composed of Ca(OH)2 & CMCP or Ca(OH)2 in Methyl Cellulose & is Placed into the canal as closed as possible to the apex

C – Cotton pellet placed in the chamber

ZOE – Zinc oxide eugenol.

T – Temporary Seal.rxdentistry.net

Alternatives to conventional Alternatives to conventional ApexificationApexification

• Use of artificial barrier technique using tri calcium phosphate given by coviello & brilliant in 1979.

Advantages:-

1. Allows immediate obturation of the canal.

2. Multiple appointments eliminated.

3. Less cost.

Disadvantage:-

Increased susceptibility to root fractures.rxdentistry.netrxdentistry.net

• The material is packed into apical 2 mm of the canal against which gutta-percha was condensed .

MTA(MINERAL TRI OXIDE)• It is the RECENTLY ADVOCATED material .• Produce equivalent amount of apical hard

tissue with no more inflammation than Ca(OH)2 or osteogenic protein-1.

• It has good sealing ability & high degree of biocompatibility.


• In MTA apical barrier technique, the canal is thoroughly cleaned & medicated with Ca(OH)2 for 1 week.

• On re-entry into the canal, it is cleaned & rinsed with NaOCl.

• On drying, 3-4 mm plug of MTA is packed into the apical end of the canal.

• A moist cotton pallet is placed against the MTA & the access sealed for at least 4-6 hrs to allow hardening of the material.

• The canal is then obturated with GP or bonded composite .


It is the physiologic process of root It is the physiologic process of root development in vital infected tooth.development in vital infected tooth.

Norma or pulp tissue with minimal inflamation is present.

1)Completely ------------- Direct pulp capping.

2)In the radicular portion ------ pulpotomy .rxdentistry.netrxdentistry.net

In young permanent tooth, when the root In young permanent tooth, when the root formation is not complete & tooth formation is not complete & tooth undergoes small exposure of the pulp undergoes small exposure of the pulp encountered during encountered during

1)1) Cavity preparation.Cavity preparation.

2)2) Following traumatic injury.Following traumatic injury.

3)3) Due to caries, with a sound surrounding Due to caries, with a sound surrounding dentin, is dressed with an appropriate dentin, is dressed with an appropriate bio-compatible radio opaque base in bio-compatible radio opaque base in contact with the exposed pulp tissue contact with the exposed pulp tissue prior to placing restoration is termed as prior to placing restoration is termed as direct pulp capping.direct pulp capping.rxdentistry.netrxdentistry.net

Ca(OH)2 is most commonly used.Ca(OH)2 is most commonly used. When It is used, complete dentinal When It is used, complete dentinal

bridging with healthy radicular bridging with healthy radicular pulp under Ca(OH)2 occurs & pulp under Ca(OH)2 occurs & physiologic root formation occurs.physiologic root formation occurs.

Ca(OH)2 is commercially available Ca(OH)2 is commercially available as dycal, prisma VLC dycal, life & nu as dycal, prisma VLC dycal, life & nu cap.cap.

Ca(OH)2 helps in formation of Ca(OH)2 helps in formation of reparative dentin.reparative dentin.


Definition :- It is the complete removal of coronal portion of the dental pulp, followed by the placement of suitable dressing or medicament that will promote healing & preserve vitality of tooth (FINN 1995).

Thus in pulpotomy vital pulp is present which helps in physiologic root apex completion.


Vital tooth with healthy Vital tooth with healthy periodontium.periodontium.

At least 2/3At least 2/3rdrd of the root has been of the root has been completed.completed.

Tooth should be restorable.Tooth should be restorable. Hemorrhage from the amputated site Hemorrhage from the amputated site

is pale red & easy to control.is pale red & easy to control.


Internal resorption.Internal resorption. Caries penetrating the floor of the Caries penetrating the floor of the

pulp chamber.pulp chamber. Existence of abscesses or the fistula Existence of abscesses or the fistula

in relation to teeth.in relation to teeth. Presence of inter radicular bone loss.Presence of inter radicular bone loss.

Most Commonly used materials are formocresol Ca(OH)2 glutar aldehyde.

Calcium bridge formation occurs using Ca(OH)2


Clinical Success rate is 65%.Clinical Success rate is 65%. Histologic success is 35%.Histologic success is 35%. Bridging may complicate further Bridging may complicate further

endodontic treatment.endodontic treatment.


apexification and apexogenesis

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