apex if ication

8/20/2019 Apex if Ication

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CONTENTSCONTENTS

Introduction Apexogenesis

a)Defnition

b)Objectivec) Indirect pulp capping

d)Direct pulp capping

e)Apical closure

pulpotomy- Calcium hydroxide

pulpotomy

- MA pulpotomy

Apexifcation


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INTRODUCTIONINTRODUCTION

OPEN APEX: Probe!sProbe!s

- Canals have larger apical diametervs smaller coronal canal diameter

ma!es debridement di"cult

- #ac! o$ an apical stop ma!esobturation impossible%

- he thin root canal &alls becomeprone to $racture


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Soution " Surgery?

Dra#bac$s:Dra#bac$s:

'% Inade(uate cro&nroot ratio

*% +hysically and psychologically traumatic

to the patient,% oung patients are not very cooperative%

.% Apical &alls are thin and could shatter&hen touched by a rotating bur

/% hin &alls &ould ma!e condensation o$ aretrograde flling di"cult

0% 1urgery &ould remove the root sheathand prevent any possibility o$ $urther root

development% 2Morse et al)


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APEXO%ENESIS & 'ITA(APEXO%ENESIS & 'ITA(

PU(P T)ERAP*+PU(P T)ERAP*+Defnition:

1. “ The physiologic root enddevelopment and formation.” 3

American Association of Endodontists

*% 'ita Pup t,erap-: 4Treatment of

a vital pulp in an immature tooth to permit continued dentin formationand apical closure” - Walton and

Torabinejad


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Ob.ecti/e:

Maintain the vitality o$ radicular pulp

Achieved through:

'% Indirect pulp capping

*% Direct pulp capping

,% Apical closure pulpotomy


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INDIRECT PULP CAPPING

Defnition:

4Application o$ a medicament over a

thin layer o$ remaining carious dentina$ter deep excavation5 &ith no

exposure o$ the pulp6 3 Ingle

Rationae:


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DIRECT PULP CAPPING

Defnition: 4+lacement o$ a biocompatible agent

on healthy pulp tissue that has been

inadvertently exposed $rom cariesexcavation or traumatic injury%6 - Ingle

Ob.ecti/e:

Indication: 1mall traumatic exposures o$ less than 'mm

diameter and only a $e& hours duration%


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Contraindication:

Carious exposures in an immaturetooth as the extent o$ in7ammationand contamination cannot be

determined clinically% (Seltzer andBender)

0aterias Used:'%Calcium hydroxide

*%MA


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APICAL CLOSURE PULPOTOMY

Defnition:

4 8emoval o$ damaged and in7amedtissue to the level o$ a clinically healthy

pulp5 $ollo&ed by a calcium hydroxidedressing6 (Anderson)

Indication:

'%An immature permanent tooth &ith anopen apex and reversible pulpitis su9ers acarious exposure

*%#arge diameter 2more than 'mm)traumatic pulpal exposure5 o$ any duration


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T-pes:

1.Partial pulpotomy 2 shallo&5 lo&-level or Cveks pulpotomy!

.!ervical pulpotom y 2deep5 high-

level5 total or conventional pulpotomy)0aterias used:

'%Calcium :ydroxide

*%MA

,%;one gro&th $actors

.%;one morphogenic proteins


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Caciu! ,-droxide

pupoto!-Partia pupoto!-:

'%Anestheti


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Ad/antages:

'% Minor injury to the pulp and undisturbed

physiologic apposition o$ dentin5 especiallyin the critical cervical area o$ the tooth%

*% he limited loss o$ coronal pulp allo&s $orvitality testing%

,% #imited loss o$ cro&n precludes need $orpost and core%

Co!pared #it, pup capping it

i!pies: ;etter &ound control%

;etter sealing against micro lea!age%


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0TA Pupoto!-


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Disad/antage: @xpensive

#ong setting time5 re(uiring anadditional appointment in certain cases

Di"culty in manipulation

Ad/antage o/er Ca&o,+1

'%?ood seal

*%?ood 1trength

,%:as cell inductive potential

.%+roduces signifcantly more dentinalbridging in a shorter period o$ time &ithsignifcantly less in7ammation

(!ohen).


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Reca 2or Apexogenesis


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Treat!ent 2aiure Cessation o$ root gro&th

Development o$ signs and symptoms orperiapical lesion%

Calcifc metamorphosis 2i%e% calcifcobliteration) o$ canal or internalresorption

%oas:'%1ustaining a viable :ert&igs epithelial

root sheath*%Maintaining pulpal vitality,%+romoting root end closure.%?enerating a dentinal bridge at the site

o$ pulpotomy


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Restoration:

Institute root canal therapy a$terapexogenesis (!ve"# $e%%er#Seltzer and Bender)

Prognosis: "ulp capping 3 >*-BB

"artial pulpotomy 3 .-0

Cervical pulpotomy 3 >*->


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APEXI3ICATIONAPEXI3ICATION

#on-surgical approaches $discussed by%orse!& ;lunt end or rolled cone 2customi


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Defnition:

4%ethod of inducing apical closure by the

formation of osteocementum or a similarhard tissue or the continued apicaldevelopment of the root of an incompletelyformed tooth in 'hich the pulp is no longer

vital%6 & American Association o'ndodontics

Root end cosure tec,ni4ue (ora%ine*ad)

(The process of creating an environment

'ithin the root canal and periapical tissues

after pulp death that allo's a calci)c barrierto form across the open ape*”


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Indication 8estorable immature tooth &ith pulp

necrosis%

Contraindications :'%All vertical and un$avorable hori


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Properties o2 CaO)1 reated to its,ig, p) (Andreasen):

p, " &66"61+

+.Capacity to dissolve necrotic pulpremnants&

,.trong antibacterial eect&

% o$ bacteria $rom the common

root canal 7ora are !illed &ithin a $e&minutes upon direct contact &ithCaO:*


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Apexifcation using caciu!

,-droxide


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Paste #oud need to be c,anged at t,irdreca &7 #ee$s+ i2

+aste is $ound to be &et in apical hal$ due to exudates%

8adiographic evidence o$ dilution o$ paste +aste is overextended at second appointment% +atient develops sinus tract or symptoms

6183ina fing o2 t,e cana: 1ymptomless tooth &ith healing o$ any sinus tract% 8adiographic observation o$ osseous deposition in the

periapical o$ lateral de$ect 8adiographic observation o$ hard tissue deposition at

the apex% Ginding the CaO:* paste to be dry &hen tested by

probing% Confrmation o$ a calcifc barrier by probing &ith light

fnger pressure &ith smaller 2*H-*/) fles% Drying o$ canal system &ith paper points elicits no

hemorrhage or tissue 7uids%


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T,ere can be f/e outco!es o2apexifcation procedure &$eine)

'% Eo radiographic change is apparent but i$instrument is inserted5 a bloc!age at theapex is encountered%

*% 8adiographic evidence o$ calcifed materialis seen at or near the apex%

,% Apex closes &ithout any change in canalspace%

.% Apex continues to develop &ith closure o$the canal apace%

/% Eo radiographic evidence o$ change is seen5and clinical symptom andJor development o$or the increase in si


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Disad/antages o2 caciu! ,-droxide

apexifcation:

Cost o$ multiple visits

+atient compliance &ith multipleappointments over 0-*. months

+ossibility o$ root $racture during theextended period because o$ the thin roots andincidence o$ traumatic injuries in children%

he dentin becoming more brittle as it

continues to be in contact &ith CaO:*5 &hich5along &ith thin &alls &ill predispose to$ractures.(Ingle)


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ONE 'ISIT APEXI3ICATION

0aterias used:

'% ricalcium phosphate

*%8esorbable ceramic%,%Caph*

.%Gree


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One /isit apexifcation

#it, 0TATec,ni4ue'% A$ter thorough debridement5 the canal is

medicated &ith CaO:* $or ' &ee! $or disin$ection%

*% On re-entry5 canal is cleansed and rinsed &ith

EaOCl%,% he canal is dried and a ,-. mm plug o$ MA ispac!ed into the apical end &ith pluggers or paperpoints%

.% he placement is confrmed radiographically and

then a moist pellet is placed against the MA andaccess cavity is sealed $or .-0 hours to allo& thematerial to harden

/% he canal is then obturated &ith gutta-percha orbonded composite%


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Osteogenic Protein 9 6 $bone

morphogenetic protein!'% Attract and recruit mononuclear

phagocytes to sites bone $ormation%

*%1timulates the proli$eration o$mesenchymal cells that subse(uentlydi9erentiate into osteogenic cells%

Material is used &ith a collagen carrier

&hich allo&s its release over a longperiod%


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'itait- testing 2or i!!ature -oungper!anent teet,:

hermal tests%@+

Ot,er appications o2 apexifcation:'% #ateral per$oration

*% Aggressive external resorption

$Weine!

Ape+ogenesis vs. Ape+i,cation


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CONC(USION

apex if ication

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