Apexogenesis&

Apexification

Ujwal GautamRoll no. 431

BDS 4th year (2009 batch)BPKIHS

Moderator:Dr. Bandana Koirala, Additional ProfessorDr. Abhishek Kumar, Assistant ProfessorDept. of Pedodontics,CODS, BPKIHS

APEXOGENESIS

Physiologic process 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

APEXOGENESIS

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

Indication

traumatic luxationfractured tooth with pulpal exposurecarious exposures

APEXOGENESIS

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

Keep the Pulp ALIVE!!

Involves

– Direct pulp capping– Indirect pulp capping– Pulpotomy

APEXOGENESIS

Materials

Ca(OH)2 (calcium hydroxide) or

MTA (mineral trioxide aggregate).

• MTA is the material of choice.

APEXOGENESIS

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

A vital pulp therapy performed to encourage continued physiological development

and formation of the root end

APEXIFICATION The process of inducing the development of the root and

apical closure in an immature pulpless tooth with an open apex

Why apexification instead of conventional RCT?

Open apex Blunderbuss canals thin and fragile canal walls absolute dryness of canals difficult to achieve

APEXIFICATION

Indication

Young permanent, nonvital teeth

APEXIFICATION

Objective

Induce root end closure to form a complete calcific barrier at the apex with no apparent pathoses

APEXIFICATION

Contraindications

• Very short roots• Marginal periodontal breakdown• Vital pulps

APEXIFICATION

MaterialsCalcium hydroxideCollagen calcium phosphate gelMineral Trioxide AggregateOsteogenic Protein I and II

APEXIFICATION

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

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

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

Techniquei. Anaesthesize the tooth and isolate it with rubber damii. Gain staight line access to canal orificeiii. Extirpate the pulp tissue remnants from the canal and irrigate it with

sodium hypochloriteiv. Establish the working length of canalv. Place appropriate material for apexification procedure in the canalvi. 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 hydroxideviii. Patient is again recalled and examined for radiographic evidence of root

formationix. Confirm the Progress of apexification by passing an instrument through

the apex after removal of calcium hydroxidex. Repeat the process if no satisfactory result found

Treatment time from 6 wks to 18 months

APEXIFICATION

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

Final obturation only if;

Absence of any symptomsAbsence of any fistula or sinusAbsence or decrease in mobilityEvidence of firm stop clinically as well as radiographically

Evidence of root apical closure…

APEXIFICATION

1 mo

6 mo 11 mo 12 mo

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

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

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)