APEXOGENESIS AND

APEXIFICATION

BY:-

PRINCE SONI

MAUSAMI CHAUDHARY

B.D.S. FINAL YEAR (2015-16)DEPARTMENT OF PEDODONTICSGOVT. COLLEGE OF DENTISTRY, INDORE

APEXOGENESIS• Physiologic process • Formation of apex in young, vital, immature, permanent

teeth with appropriate pulp therapy

RATIONALE

• Root end Development occurs in a tooth with a normal pulp and minimal inflammation

• Pulp of immature teeth has significant reparative potential

• Pulp revascularisation and repair occurs more efficiently in tooth with an open apex

• Poor long term prognosis of an endodontically treated immature teeth

Relatively thin dentine in obturated canals of Immature roots and open apex are prone to fracture

GOALS

• Sustaining a viable Hertwig’s sheath to stimulate continues development of root

• To attain favourable crown:root ratio • To attain root end closure • To preserve pulp vitality to secure further root development and maturation

• Generating dentinal bridge at the site of pulpotomy

INDICATIONS

• Fractured tooth with pulpal exposure

INDICATIONS

• Carious exposure

INDICATIONS

• Traumatic luxation

INVOLVES

• Direct pulp capping

When pulp

chamber is

exposed

INVOLVES

• Indirect pulp capping

When a thin dentin layer

is present between

pulp and cavity

INVOLVES

• Pulpotomy

Extirpation of pulp is restricted

strictly to the coronal portion of

pulp chamber

MATERIALS USED

• MTA (Mineral trioxide aggregrate)

MATERIALS USED

• Calcium hydroxide

MATERIALS USED

• Formocresol (as an alternative to calcium hydroxide)

PROCEDURE

•  Anesthesia application and rubber dam isolation

• The instrument of choice for tissue removal is an abrasive diamond bur at slow speed with adequate water-cooling

• Access is gained into the pulp chamber and infected dentin partly removed

• Peripheral carious lesion removed with a spoon excavator

PROCEDURE

•  Anesthesia application and rubber dam isolation

• The instrument of choice for tissue removal is an abrasive diamond bur at slow speed with adequate water-cooling

• Access is gained into the pulp chamber and infected dentin partly removed

• Peripheral carious lesion removed with a spoon excavator

PROCEDURE

•  Anesthesia application and rubber dam isolation

• The instrument of choice for tissue removal is an abrasive diamond bur at slow speed with adequate water-cooling

• Access is gained into the pulp chamber and infected dentin partly removed

• Peripheral carious lesion removed with a spoon excavator

PROCEDURE

•  Anesthesia application and rubber dam isolation

• The instrument of choice for tissue removal is an abrasive diamond bur at slow speed with adequate water-cooling

• Access is gained into the pulp chamber and infected dentin partly removed

• Peripheral carious lesion removed with a spoon excavator

• Following coronal pulp amputation, the pulp chamber is rinsed with sterile saline or sterile water to remove all debris

• The excess liquid should then be carefully removed via vacuum or sterile cotton pellets.

• Air should not be blown on the exposed pulp, as this may cause desiccation and additional tissue damage.

PROCEDURE (CONT.)

• Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site

• Care must be taken to avoid placing the calcium hydroxide on a blood clot and the entire pulp surface must be covered

• Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely

• A coronal restoration should then be placed that will ensure the maximum long-term seal

PROCEDURE (CONT.)

• Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site

• Care must be taken to avoid placing the calcium hydroxide on a blood clot and the entire pulp surface must be covered

• Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely

• A coronal restoration should then be placed that will ensure the maximum long-term seal

PROCEDURE (CONT.)

• Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site

• Care must be taken to avoid placing the calcium hydroxide on a blood clot and the entire pulp surface must be covered

• Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely

• A coronal restoration should then be placed that will ensure the maximum long-term seal

PROCEDURE (CONT.)

• Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site

• Care must be taken to avoid placing the calcium hydroxide on a blood clot and the entire pulp surface must be covered

• Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely

• A coronal restoration should then be placed that will ensure the maximum long-term seal

PROCEDURE (CONT.)

PROCEDURE (CONT.)

• The patient should be re-evaluated every three months for the first year, and then every 6 months for 2 to 4 years to determine if successful root formation is taking place and that there are no signs of pulp necrosis, root resorption or periradicular pathosis

Open apex Root formation complete

CONTRAINDICATIONS

• Severe crown-root fracture which requires intra-radicular retention for restoration

CONTRAINDICATIONS

• Tooth with unfavourable horizontal root fracture i.e. close to gingival margin

CONTRAINDICATIONS

• Necrotic or non vital pulp

CONTRAINDICATIONS

• Unrestorable carious tooth

APEXIFICATION

The process of inducing a calcific barrier across an open apex of an immature, pulpless tooth

Definition:-

OBJECTIVE

To induce root end closure to form a complete calcific barrier at the apex with no apparent pathosis

INDICATIONS

• Young immature,permanent non-vital teeth • Open apex

• Blunderbuss canals

• Thin and fragile canal walls

• Absolute dryness of canal difficult to achieve

Why apexification preferred over RCT

MATERIALS USED

• MTA (mineral trioxide aggregrate)• Collagen calcium phosphate gel • Calcium hydroxide • Osteogenic protein I and II

PROCEDURE

• Anaesthetize the tooth and isolate with rubber dam• Gain straight 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 2mm short of the radiographic apex of tooth

• Dry the canal with paper points• Placement of appropriate material for apexification• Material condensed with finger pluggers• Effective temporary seal between visits is critical. Zinc oxide

Eugenol cement or resin modified glass-inomer cement is used

• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and again filled with calcium hydroxide

PROCEDURE (CONT.)

• Establish the working length of canal 2mm short of the radiographic apex of tooth

• Dry the canal with paper points• Placement of appropriate material for apexification• Material condensed with finger pluggers• Effective temporary seal between visits is critical. Zinc oxide

Eugenol cement or resin modified glass-inomer cement is used

• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and again filled with calcium hydroxide

PROCEDURE (CONT.)

• Establish the working length of canal 2mm short of the radiographic apex of tooth

• Dry the canal with paper points• Placement of appropriate material for apexification• Material condensed with finger pluggers• Effective temporary seal between visits is critical. Zinc oxide

Eugenol cement or resin modified glass-inomer cement is used

• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and again filled with calcium hydroxide

PROCEDURE (CONT.)

• Establish the working length of canal 2mm short of the radiographic apex of tooth

• Dry the canal with paper points• Placement of appropriate material for apexification• Material condensed with finger pluggers• Effective temporary seal between visits is critical. Zinc oxide

Eugenol cement or resin modified glass-inomer cement is used

• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and again filled with calcium hydroxide

PROCEDURE (CONT.)

• Establish the working length of canal 2mm short of the radiographic apex of tooth

• Dry the canal with paper points• Placement of appropriate material for apexification• Material condensed with finger pluggers• Effective temporary seal between visits is critical. Zinc oxide

Eugenol cement or resin modified glass-inomer cement is used

• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and again filled with calcium hydroxide

PROCEDURE (CONT.)

PROCEDURE (CONT.)• Patient is examined for radiographic

evidence of calcific barrier at or near root apex

• 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

• If apical barrier present, obturation is done

PROCEDURE (CONT.)• Patient is examined for radiographic

evidence of calcific barrier at or near root apex

• 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

• If apical barrier present, obturation is done

PROCEDURE (CONT.)• Patient is examined for radiographic

evidence of calcific barrier at or near root apex

• 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

• If apical barrier present, obturation is done

open apex fixation of root end

CONTRAINDICATIONS

• Very short roots

CONTRAINDICATIONS

• Vital pulp

CONTRAINDICATIONS

• Compromised periodontium

Thank You