Management of open apex

Management of open apex in the vital and non-vital tooth. Includes apexogenesis, regenerative endodontics, and recent advances

1. MANAGEMENT OF
OPEN APEX
DR. MRINALINI

2. INTRODUCTION
TREATMENT OPTIONS FOR OPEN APEX
APEXOGENESIS
•INTRODUCTION
•CASE SELECTION
•STEPS
•STUDIES ASSOCIATED (DISINFECTION,
MATERIAL, TIME)
APEXIFICATION
•INTRODUCTION
•MATERIALS USED
•CASE STUDIES(DISINFECTION, PROGNOSIS,
MATERIAL)
•STEPS
REGENERATION
•HISTORY
•TERMINOLOGIES
•CLINICAL CONSIDERATION
•HISTOLOGIC FINDINGS
•SUCCESS
•STUDIES
•ADVERSE EFFECT
•FAILURE
•STEPS
•CASE REPORTS
OTHERS
•ALTERNATIVE OBTURATION
TECHNIQUES
•SURGICAL MANAGEMENT
CONCLUSION

3. Absence of sufficient
root development to
provide a conical taper
to the canal and is
referred to as
blunderbuss canal-
Franklein S Wein, 6
th
edition, 2004

4. Traumatic injury to young
permanent teeth: 30%
Age group: 8-12 years
Maxillary anterior

5. CAUSES OF OPEN APEX
INCOMPLETE
DEVELOPMENT
EXTENSIVE
APICAL
RESORPTION
ROOT
END
RESECTION
OVER
INSTRUMENTATION

6. VITAL NON-VITAL
APEXOGENESIS
APEXIFICATION
REGENERATION
ROLL CONE
SHORT FILL

7. REGENERATIVE
REGENERATIVE,
APEXIFICATION,
ALTERNATIVE
OBTURATION
TECHNIQUES

8. If vital and not
irreversibly inflamed:
Maintenance of
vitality, natural
continued root
development
Deep pulpotomy:
Preserve formative
capacity of radicular
pulp
Physiologic process
Indication: Fractured
tooth with pulp
exposure, Carious
exposure, Traumatic
luxation
Apexogenesis

9. Exposed pulp
maintained
vitality for up to 7 days,
only superficial 2 mm
of the pulp is
inflamed
Material used: Calcium
hydroxide, Bioceramic,
Formocresol,
Gluteraldehyde
Goal: Sustaining HERS,
Maintainenceof vitality
Promotion of root end
closure
Dentin bridge: exposure
site
Apexogenesis
CVEK, 1982

10. CASE SELECTION
Incompletely developed teeeth
Vital pulps
Symptoms(Controversial)
No sensitivity to percussion
No evidence of periradicular
pathosis
No sinus tract, swelling, tooth
discomfort

11. 1 2 3
LA+ Rubber
dam
A/O: Slow
speed round
bur
Bur and spoon
excavator:
infected pulp

12. 4 5 6
Haemostasis
Placement of
CaOH or other
material: pulp
chamber
Final
restoration

13. HEMOSTASIS
Shruti Sial, 2019

14. PJ van der Vyve,
2018

15. Vijay PrakashMathur,
2014

16. MATERIALS

17. Time factor

18. Time for root completion: 1-2 years
Recall: every 3 months( to check vitality)
Use of hypo: Low concentration, 1.5-2.5%
Controversy: further endodontic intervention following the completion
of root development
MejareI, CvekM(1993); SjogrenU et al.(1993) and SjogrenU et al.
(1997): After closure endodontic treatment for better prognosis as
evidences of canal obliteration, root resorptionis seen in few cases
Others: Clinically no need to assess the hard tissue formation, or do
endodontic procedure if asymptomatic as the calcification within the
canal is composed of uninfected vital tissue and not cause any problem

19. Calcium hydroxide: 17 days osteioddevelopment, 80
days hard tissue barrier
MTA: Min et al.(2008)-2 months, Nair et al(2009)-3
months
Bioceramic: seal better, less soluble, better quality of
dentin

20. APEXIFICATION
Apexification: method to induce a calcified barrier in a root with an open apex or the
continued apical development of teeth with incomplete roots and a necrotic pulp
(American Association of Endodontists 2003)
Materials used: CaOH, MTA, Collage Calcium phosphate gel, Osteogenic protein I and II
One or multiple monthly appointments: elimination of the intracanal infection, which
stimulates calcification and produces the apical closure.

21. Absence of any symptom
Absence or decrease in
mobility
Absence of sinus/fistula
Evidence of firm stop
clinically as well as
radiographically
Final obturation

23. 01 02 03
CaOH+ CMCP
CaOH+
Cresatin(Minimal
inflammatory
potential, less
toxic)
CaOH+ distilled
water
Introduced
: Kaiser,
1964
Klein and
Levy, 1974 Later
Calcificbarrier: Osteodentine(Ghoseet al.), Bone like material(Torneck), Cementum(Steiner and
Van Hassel),
Barrier
formation: 13-
67 weeks
Treatment
time: 3-21
months(Giulia
ni V, 2002)

24. CaOH: Unpredictable, Lengthy, Temporary coronal restoration leading to reinfection
MTA: Better predictability, Better seal
Compressive strength comparable to IRM and Super EBA and reaches its maximum
compressive strength in 72 hours.
Obturation: after 72 hours (Nagaveni NB et al. 2010)
5mm better than 2mm(Kubasad GC et al., 2011)
Apical matrix: Collagen, Calcium sulfate, Hydroxyapatite

26. M seal et al., International J of oral care and
research, 2016

28. Biodentine: Fast set thus can be finished
in single appointment

29. (El‐Meligly& Avery2006,
Pradhanetal.2006,
Damleetal.2012,
Bonteetal.2015).
Success rate:CHranging between 73
and 100%, MTA with or without
intermediary CH dressing, 70 and
100%
(Simonetal.2007,
Holdenetal.2008,
Witherspoonetal.2008).
Favourable results in immature teeth
of different age groups ranging from
6 to 82years
Saline (Ghoseetal.1987,
Kinironsetal.2001,
Damleetal.2012), H2O2 (Thater&
Marechaux1988) 0.5% NaOCl
(Dominguez Reyesetal.2005)
NaOCl3–5% (Simonetal.2007,
NaOCl+ 0.12% CHX in retreated teeth
with (Menteetal.2013)5–6%
NaOCl+ 17% EDTA (Paceetal.2014),

30. Preoperative signs and symptoms: no
significant effect on periapicalhealing
(Ghoseetal.1987, Yates1988,
Mackieetal.1993, Finucane&
Kinirons1999, Dominguez
Reyesetal.2005)
CH for extended periods during apexification:
associated with a greater risk of cervical root
fracture due to its ability to denaturateand
dissolute dentine proteins and increase the
brittleness of the tooth
(Andreasenetal.2002, Sahebietal.2010)

31. Matrix: calcium hydroxide,
hydroxyapatite, resorbablecollagen and
calcium sulfate
Calcium sulfate: induce tissue repair,
resorbedafter about 4 weeks, thereby
assisting in the formation of new bone
tissue and more favorablerepair
(MurashimaY,, 2002)
DohanDM, 2006: PRF, autogenous, cost-effective and resorbable, Centrifuged natural blood
without additives, therapeutic potential lies in Platelet alpha (α) granules form an
intracellular storage pool of growth factors including PDGF, TGF-β, vascular endothelial
growth factor (VEGF)which accelerate rate of healing

34. 1 2 3
LA+ Rubber
dam
A/O+ Pulp
extripation+
WL
Disinfection

35. 1 2 3
Apical barrier
Obturation
Permanennt
restoration

36. Not standardised
Trope(2009)
1
st
appointment: 0.5% hypo
CaOH/TAP(Min. 1 week, Not more than 1 month)
2
nd
appointment
CaOHas barrier: 6-18 months for barrier formation
MTA: Calcium sulphate or other resorbablebarrier beyond apex
MTA condensation(4-5 mm)
Wet cotton+ Temporary
Final appointment
72 hours to 1 month
Obturation

37. 1961
NygaardOstby
Concept
Iwayaet al.
2001
Revasculari
sation
2004, 2006
BanchsF, Trope
M; CheuhLH,
Huang GT
TAP &
CaOH

38. Regeneration(endodontics): Organised repair of the dental pulp
Revascularisation: Blood vessels
Revitalisation: Non-Specific vital tissues(European Society
Endoodntology, 2016)
Lenzi R, Trope
M;2012
Regenerative endodontics: Biologically based procedures designed to replace damaged
structures including dentin and root structures as well as cells of pulp-dentin complex
(Diogenes A, 2016)

39. Stem cells
Scaffold
Growth
Factors
Clot, PRF, PRP
Embedded
in dentin
PDL +
Bone
marrow
Tissue engineering

40. Provision of
scaffold
Coronal seal
Disinfection of
the canal
CLINICAL CONSIDERATION

41. Regeneration vsTraditional approach
AlobaidAS,2014 and KahlerB,2017(J endo): Comparable outcome
JeeruphanT,2012( J endo): Revasularisationassociated with significantly greater
increase in root length and thickness than CaOHand MTA apexification.
Survival rate also better for revascases.
Repair vsRegeneration
Dental pulp: Limited regenerative potential
GF embedded in dentin sends signal to pulp stem cells to differentiate into odontoblast
like cell to produce reparative dentin.
But the mesenchymalcells introduced in canal does not differentiate into odontoblast
like cell and produce dentin-pulp complex

42. 01
02
03
04
Becerra P(2014), Lei L(2015),
Shimizu E(2013): Similar to
cementum, bone and CT
resembling PDL
AAE(2016): Success-
Radiographic thickening of walls,
Continued root maturation,
Elimination of signs and symptoms
Lin LM( 2011), Simon SR(2014):
Healing is repair rather
regeneration
Mesenchymalstem cells introduced
incanalduring intracanalbleeding:
might not be from apical papilla but
from periodontal ligament and bone
marrow: Kim SG
Histologic
examination

43. AAE,2016: Primary, Secondary and Tertiary goal
Elimination of
symptoms,
Evidence of bone
healing
Increased root wall
thickness and
length
Positive
response to
vitality
Primary goal:
Objective for all
endo treatments
Tertiary goal:
Indicative of more
organised vital
pulp tissue
Diogenes A(2013):
Review reported
many positive
response to pulp
sensibility testing
Success

44. Secondary goal
91%
SUCCESS RATE
(Torabinejad,2017)
Primary goal
>90% Overall(Diogenes,2016
)

45. 01
02
03
04
Minimal or No instrumentation:
Some degree of mechanical
debridement is important to
disrupt biofilm(Lin LM, 2014)
Medicament: AAE(2016):
TAPs no greater than 0.1mg/ml
CaOHcan also be used
Disinfection: AAE(2016)-1.5%
Hypo, 20ml/canal for 5 min+
EDTA(20ml/canal, 5 min)
Coronal seal: Torabinejad
M(2009): Blood clot+ Collagen
plug+ MTA(3mm)+ 3-4 mm
GIC+ Composite
Clinical considerations

46. Foramen< 1mm,
revascularisation
unpredicatble-
Transplantation
Andreason, 1990
Regenerative
procedure successful
even with 0.5mm dia
Estefan et al., 2016
Dia: 0.5-1mm,
highest clinical
success
Fang et al., 2018
Apical diameter
Cell size: 10-100 micron, osteoblasts, cementoblasts, PDL cells can easily enter the canal space
through the apical foramen even smaller than 0.5 mm in diameter.

47. Kitikuson& Srisuwan
2016: Apical cell
attachment better
with CaOHthan TAP
Increased amount of
TGF-b in combination
with EDTA
Galler, 2015
Augmentin as
effective as TAP
Nosrat et al, 2013
Root canal
disinfection
(Medicament)

48. Martin et al., 2014
Inc SCAP survival
expression, partially
reverse effects of
NaOCl
EDTA
Galler et al., 2015
Release of growth
factors from
dentinal matrix
Yamauchi et al.,
2011; Galler,2016
Expose binding site
for attachment of
new cells

49. Blood clot: Introduce
PDGF &
mesenchymal stem
cells
Induction of bleeding
into the canal: not
always attainable
Nosrat et al. 2012
Allow periapical
healing
SCAFFOLD

50. Lolatoet al. 2016 : Review of
clinical studies, PRP or PRF was
not significantly superior to a blood
clot in promoting thickening of the
canal walls/continued root
development in RET
Zhou et al. 2017 : Combination of
platelet-rich fibrin and blood clot
compared to blood clot alone did
not improve outcomes of RET
Abbaset al. 2007 : Besides blood
fibrin, GF & stem cells, there are
phagocytes, immunoglobulins,
complement components, pro-
inflammatory cytokines, and anti-
bacterial peptides in the blood clot
Antimicrobial
property of
blood clot not
studied

51. Diogenes et al. 2013:
review, multiple
appointments in most
cases
2
AAE & ESE, 2016:
Atleast2 appointments
1
Shin et al. 2009, McCabe
2015, Chaniotis2016:
Single visit with no
intracanal
medicaments
3
3
STUDIES(No. Of
Appointments)

52. Crown discoloration
TAP and MTA
TAP: Due to minocycline, Double antibiotic or CaOH
MTA: Use of GIC liner or DBA over MTA, Biodentineas substitute
Bleaching
Outcome
Torabinejadet al. 2017, Tong et al. 2017(review): Primary goal of RET could be reliably
achieved with high probabilities (91%-94% of periapicalhealing)

53. Failure:
Reinfection
Song et al., 2017:
Intracanal
calcification
62.1% cases
Toubeset el.,
2017: Microscope,
CBCT, Ultrasonics
for failed cases
Chaniotis, 2017:
Regenerative and
Apexification
Treatment
options: Zizkaet
al., 2016: NSRCT
ADVERSE EFFECTS & FAILURE

54. Remains below CEJ to
minimize crown
staining
5
TAP
Seal: Cavit, IRM, GIC,
3-4mm
Call after 1-4
weeks
6
Temporary restoration
CaOH/TAP
TAP: Use of DBA
Alternative:
Double antibiotic
3
Dry canals
Conc.: 0.1-1.0mg/ml,
1:1:1ratio
Cipro:Metro:Mino
Via syringe
4
Medicament
STEPSLocal anesthesia+ Rubber
dam isolation+
Access opening
1
20ml,1.5% NaOCl/canal
for 5 minutes+
20ml/canal, 5 min
saline/EDTA
2
Irrigation
F
I
R
S
T
V
I
S
I
T

55. Resorbablematrix(
Collaplug, Collacote,
Collatapeover clot+
White MTA
5
3-4 mm GIC+ Final
restoration
Alternatives to MTA:
Other bioceramic
material
6
Rotate precurvedK file
2mm beyond foramen
Alternative: PRP, PRF or
Autologousfibrin
matrix
3
Stop bleeding to allow 3-4
mm for restorative
material
4
STEPS
Check for signs, LA: 3%
mepivacainewithout
vasoconstrictor+
isolation
1
20ml, 17% EDTA,
Dry the canals,
Induction of
bleeding
2
Irrigation
S
E
C
O
N
D
V
I
S
I
T

58. (1)Use of an anestheticwithout a
vasoconstrictor when trying to
induce bleeding
(2)Collagen matrix for the controlled
placement of MTA to a desired and
optimal level, with only light
pressure placed on the MTA
during packing
(3) patients should be informed about
the potential for staining,
especially in anterior teeth when
the paste contains minocycline.

59. MATURE TEETH

62. Inadequate
bleeding in mesial
or buccalroot
canals of molar
teeth managed by
transferring some
blood volume from
other root canals

63. Revascularization :
significantly greater
increases in root
length and thickness in
comparison with
CaOHapexification
and MTA apexification
as well as excellent
overall survival rates

68. Pulp-like connective tissue
generated in a human tooth
after treatment with PRP. (B)
Higher magnification of the
soft tissue showing the
presence of collagen fibers,
cells, and blood vessels in this
tissue

69. Both groups revealed
100% clinical and
radiographic success
Decrease in diawith
PRP> PRF
PRF> Discoloration
PRF requires longer to
express

72. Earlier: custom fitted GP cones
Disadvantage: apical portion of root wider than coronal portion,
proper condensation of GP impossible.
Widening coronal segment to make its diagreater than apical
portion: weaken the root and increase the risk of fracture.
Surgical intervention: difficulty of obtaining necessary apical seal
in young pulplesstooth with its thin, fragile, irregular walls at the
root apex.
May shatter during preparation of retrocavityor condensation of
the filling material.
Apicoectomy: reduces the root length resulting in a very
unfavorablecrown root ratio.

73. CONCLUSION

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78. Thank you