Apexogenesis

&

Apexification

Moderator:
Dr. Bandana Koirala, Additional Professor Ujwal Gautam
Dr. Abhishek Kumar, Assistant Professor Roll no. 431
Dept. of Pedodontics, BDS 4th year (2009 batch)
CODS, BPKIHS BPKIHS
APEXOGENESIS
 Physiologic process
 Formation of apex in vital, young, permanent teeth with
appropriate vital pulp therapy
 APEXOGENESIS

• 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 luxation
fractured tooth with pulpal exposure
carious 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
Keep the Pulp
ALIVE!!
 APEXOGENESIS

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
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
 APEXIFICATION

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

Materials
Calcium hydroxide
Collagen calcium phosphate gel
Mineral Trioxide Aggregate
Osteogenic 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

Technique
i. Anaesthesize the tooth and isolate it with rubber dam
ii. Gain staight line access to canal orifice
iii. Extirpate the pulp tissue remnants from the canal and irrigate it with
sodium hypochlorite
iv. Establish the working length of canal
v. Place appropriate material for apexification procedure in the canal
vi. 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 hydroxide
viii. Patient is again recalled and examined for radiographic evidence of root
formation
ix. Confirm the Progress of apexification by passing an instrument through
the apex after removal of calcium hydroxide
x. Repeat the process if no satisfactory result found
 Treatment time from 6 wks to 18 months
 APEXIFICATION

Evidence of root apical closure…

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.
 APEXIFICATION

Evidence of root apical closure…

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
 1 mo

6 mo 11 mo 12 mo
 APEXIFICATION

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
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;
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