Apexogenesis & apexification

apexification and apexogenesis

1. Apexogenesis & Apexification Ujwal Gautam Roll no. 431 BDS 4 th year (2009 batch) BPKIHS Moderator: Dr. Bandana Koirala , Additional Professor Dr. Abhishek Kumar, Assistant Professor Dept. of Pedodontics , CODS, BPKIHS

2. APEXOGENESIS Physiologic process Formation of apex in vital, young, permanent teeth with appropriate vital pulp therapy

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. 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. Indication traumatic luxation fractured tooth with pulpal exposure carious exposures APEXOGENESIS

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. Keep the Pulp ALIVE!!

8. Involves Direct pulp capping Indirect pulp capping Pulpotomy APEXOGENESIS

9. Materials Ca (OH)2 (calcium hydroxide) or MTA (mineral trioxide aggregate). MTA is the material of choice. APEXOGENESIS

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. A vital pulp therapy performed to encourage continued physiological development and formation of the root end

12. APEXIFICATION The process of inducing the development of the root and apical closure in an i mmature pulpless tooth with an open apex

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. Indication Young permanent, nonvital teeth APEXIFICATION

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

16. Contraindications Very short roots Marginal periodontal breakdown Vital pulps APEXIFICATION

17. Materials Calcium hydroxide Collagen calcium phosphate gel Mineral Trioxide Aggregate Osteogenic Protein I and II APEXIFICATION

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. 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. 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. Technique Anaesthesize the tooth and isolate it with rubber dam Gain staight line access to canal orifice Extirpate the pulp tissue remnants from the canal and irrigate it with sodium hypochlorite Establish the working length of canal Place appropriate material for apexification procedure in the canal E ffective temporary seal between visits is critical. Fortified zinc oxide- eugenol cement (IRM) is preferred. Second visit at 3 months for monitoring the tooth. If symptomatic; canal is cleaned and again filled with calcium hydroxide Patient is again recalled and examined for radiographic evidence of root formation Confirm the Progress of apexification by passing an instrument through the apex after removal of calcium hydroxide Repeat the process if no satisfactory result found Treatment time from 6 wks to 18 months APEXIFICATION

22. Frank has described four successful results of apexification treatments: continued closure of the canal and apex to a normal appearance , a dome shaped apical closure with the canal retaining a blunderbuss appearance, no apparent radiographic change but a positive stop in the apical area, and a positive stop and radiographic evidence of a barrier coronal to the anatomic apex of the tooth. Evidence of root apical closure… APEXIFICATION

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. 1 mo 6 mo 11 mo 12 mo

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. The rationale is to establish an apical stop that would enable the root canal to be filled immediately. No attempt at root end closure . Rather an artificial apical stop is created . use of MTA in one-visit apexification APEXIFICATION

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. 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 P edodontics ; 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)