Apexogenesis and apexification.pptx endodontics final year

apexogenesis and apexification

1. Apexogenesis and apexification Presented by: Swopnil Subedi Roll no:25 1

2. Contents: Apexogenesis Introduction Rationale Indications Goals Materials Procedure Apexification Introduction Objectives Rationale Multiple step apexification Single step apexification 2

3. Apexogenesis Apexogenesis is an endodontic treatment of partially developed permanent teeth that clinically and radiographically displays evidence of pulp necrosis. Stephen Wei (1988) Treatment of vital pulp in an immature tooth to permit continued root growth & apical closure. (Thomas R. Pitt Ford, 1989) The procedure encourages normal root & apex formation of pulpally involved, vital permanent teeth with immature root development. (AAPD Guidelines 1998) The continued formation of the root in the teeth with vital root pulpal tissue.(McDonald & Avery, 2000) 3

4. Apexogenesis In normal pulp tissue with minimal inflammation is present, normal root end development occurs. However, in immature tooth with pulp necrosis and bacterial infection, the term prognosis is related t o the stage of root development and the amount of root dentine present at the time of injury. 4

5. 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 wide apical foramen Pulp of immature teeth has a significant repair potential. 5

6. Apexogenesis Indications Traumatic luxation Fractured tooth with pulpal exposure Carious exposures No hemorrhage Normal radiographic appearance No sensitivity on percussion No history of spontaneous pain 6

7. Apexogenesis Goals ( Weber 1984) Sustaining a viable Hertwig’s sheath to allow continued development of root length for favorable crown: root ratio. P reserving pulp vitality, thus allowing the remaining odontoblasts to lay down dentin, producing a thicker root and decreasing the chance of root fracture.. Promoting a root end closure, thus allowing a natural apical constriction for root canal filling. Generating dentinal bridge at the site of pulpotomy 7

8. Apexogenesis Materials -Ca(OH) 2 (calcium hydroxide ) -MTA ( mineral trioxide aggregate) – material of choice 8

9. Apexogenesis Contraindications: Severe crown-root fracture that requires intraradicular retention for restoration Tooth with an unfavourable horizontal root fracture( i.e. close to the gingival margin) Carious tooth that is unrestorable Necrotic pulp 9

10. Apexogenesis Procedure The procedure that induces apexogenesis is undertaken to preserve the remaining vital tissue and allow completion of root formation and apical maturation . Apexification is then performed to treat immature teeth with non-vital pulp by inducing a calcified barrier at the open apex. 10

11. Apexogenesis After local anesthesia, rubber dam isolation, a conventional access cavity was made with a high-speed bur using copious water spray. Strands of pulp and debris were removed coronal to the amputation site. Amputation of the coronal pulp at the cervical level was performed with a sharp spoon excavator or a large sterile round bur. Bleeding of the pulp stump was controlled with saline on a cotton pellet applied with gentle pressure . Calcium hydroxide powder was mixed with saline to a thick consistency. The paste was carefully placed on the pulp stump surface 1 to 2 mm thick. 11

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14. Apexogenesis Follow up Time required: 1 and 2 years depending on the degree of tooth development at the time of the procedure. Recalled every 3 months Clinically , the treatment was considered successful if there were no signs or symptoms of pulp or periapical disease (no history of pain and no clinical evidence of swelling or sinus tract). Radiographically , the treatment was considered successful if there was continued growth of the root and canal narrowing, and no widened periodontal ligament, no periapical radiolucency and no internal or external root resorption. 14

15. Apexogenesis Controversy: As the entire coronal pulp was removed, thermal and electrical testing of the tooth is no longer possible. Since it is not possible to determine the pulp vitality or the health of the remaining pulp tissue, it has been advocated that the tooth should be re- entered and root canal therapy performed. 15

16. Apexogenesis Instrumentation beyond the confines of the root canal are susceptible to induce bleeding.  This  may also transplant mesenchymal stem cells from the bone into the canal lumen . These cells have extensive proliferating capacity. The blood clot ,  being a rich source of growth factors, could play an important role in  regeneration. These include platelet-derived growth factor, vascular endothelial growth factor(VEGF), platelet-derived epithelial growth factor, and other tissue growth factors which could stimulate differentiation, growth, and maturation of fibroblasts, odontoblasts, and cementoblasts   . 16

17. Apexification Method of inducing apical closure by the formation of osteo cementum or a similar hard tissue or the continued apical development of the root of an incompletely formed tooth in which the pulp is no longer vital. – American Association of Endodontics 17

18. Apexification Objectives: Induce either closure of the open apical third of root canal Or formation of an apical calcific barrier against which obturation can be achieved 18

19. Apexification Rationale: Speculations about apexification are that the residual pulp tissue, if any, and the odontoblastic layer associated with the pulp tissue resume their matrix formation and subsequent calcification, guided by the reactivated sheath of Hertwig . The fact that the sheath of Hertwig and the pulp tissue were once damaged may explain why some of the apical formations appear atypical If apexification is successful, a hard substance, histologically described variously as bone, dentin, osteodentin , or cementum, will develop against which dense obturation of the root canal can be done. 19

20. Apexification Several materials have been used, such as collagen-calcium phosphate gel or tricalcium phosphate, yet none is as effective in promoting a calcific barrier as calcium hydroxide or MTA . 20

21. Apexification Clinical Note : Apexification differs from apexogenesis , which is defined as the physiological process of root development in a tooth . 21

22. Apexification MULTIPLE-STEP APEXIFICATION WITH CALCIUM HYDROXIDE Calcium hydroxide is the most common and traditional material employed for inducing apexification . However, this technique is typically a multiple-visit approach W hich takes a period of 6 months to 4 years to complete. 22

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26. Apexification Clinical Note • Long-term use of intracanal Ca(OH) 2 can cause weakening of root dentin leading to root fracture. • In apexification procedures, every effort should be made to preserve any vital apical pulp tissue that will help the closure of the immature apex. • Apexification is usually complete in 6 months, or 2 years at most. 26

27. Apexification II . SINGLE-STEP APEXIFICATION WITH MTA/CSC CEMENTS Calcium hydroxide has been the most widely used material for induction of an apical barrier . However, the time needed to induce a barrier varies from months to even years . The advent of MTA/CSCs has provided the clinician with a simple and more effective method of creating an apical barrier. MTA/CSCs has demonstrated good biocompatibility and a better ability to seal and produce a superior barrier. 27

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31. Conclusion In addition to direct or indirect capping stimulating reparative dentin formation, apexogenesis is the most usual tool for the treatment of endodontic lesions, namely when the pulp is still alive . Apexification constitute the most viable endodontic method for a dental pulp either necrotic , infected or not. After disinfection using a triple antibiotic therapy, the radicular pulp may regenerate, become functional and restore most of its activities. 31

32. Reference Gopikrishna V;Grossman’s endodontic practice;Wolters Kluwer;2021 Garg N; Textbook of endodontics; Jaypee medical publishers;2019 Tandon S; Textbook of pedodontics;Paras medical publisher; 2009 Goldberg M; Apexogenesis and apexification ; J biomed allied res 2019 32