Upload
shipra-singh
View
220
Download
0
Embed Size (px)
Citation preview
8/20/2019 Apex if Ication
1/39
8/20/2019 Apex if Ication
2/39
CONTENTSCONTENTS
Introduction Apexogenesis
a)Defnition
b)Objectivec) Indirect pulp capping
d)Direct pulp capping
e)Apical closure
pulpotomy- Calcium hydroxide
pulpotomy
- MA pulpotomy
Apexifcation
8/20/2019 Apex if Ication
3/39
INTRODUCTIONINTRODUCTION
OPEN APEX: Probe!sProbe!s
- Canals have larger apical diametervs smaller coronal canal diameter
ma!es debridement di"cult
- #ac! o$ an apical stop ma!esobturation impossible%
- he thin root canal &alls becomeprone to $racture
8/20/2019 Apex if Ication
4/39
Soution " Surgery?
Dra#bac$s:Dra#bac$s:
'% Inade(uate cro&nroot ratio
*% +hysically and psychologically traumatic
to the patient,% oung patients are not very cooperative%
.% Apical &alls are thin and could shatter&hen touched by a rotating bur
/% hin &alls &ould ma!e condensation o$ aretrograde flling di"cult
0% 1urgery &ould remove the root sheathand prevent any possibility o$ $urther root
development% 2Morse et al)
8/20/2019 Apex if Ication
5/39
APEXO%ENESIS & 'ITA(APEXO%ENESIS & 'ITA(
PU(P T)ERAP*+PU(P T)ERAP*+Defnition:
1. “ The physiologic root enddevelopment and formation.” 3
American Association of Endodontists
*% 'ita Pup t,erap-: 4Treatment of
a vital pulp in an immature tooth to permit continued dentin formationand apical closure” - Walton and
Torabinejad
8/20/2019 Apex if Ication
6/39
Ob.ecti/e:
Maintain the vitality o$ radicular pulp
Achieved through:
'% Indirect pulp capping
*% Direct pulp capping
,% Apical closure pulpotomy
8/20/2019 Apex if Ication
7/39
INDIRECT PULP CAPPING
Defnition:
4Application o$ a medicament over a
thin layer o$ remaining carious dentina$ter deep excavation5 &ith no
exposure o$ the pulp6 3 Ingle
Rationae:
8/20/2019 Apex if Ication
8/39
DIRECT PULP CAPPING
Defnition: 4+lacement o$ a biocompatible agent
on healthy pulp tissue that has been
inadvertently exposed $rom cariesexcavation or traumatic injury%6 - Ingle
Ob.ecti/e:
Indication: 1mall traumatic exposures o$ less than 'mm
diameter and only a $e& hours duration%
8/20/2019 Apex if Ication
9/39
Contraindication:
Carious exposures in an immaturetooth as the extent o$ in7ammationand contamination cannot be
determined clinically% (Seltzer andBender)
0aterias Used:'%Calcium hydroxide
*%MA
8/20/2019 Apex if Ication
10/39
APICAL CLOSURE PULPOTOMY
Defnition:
4 8emoval o$ damaged and in7amedtissue to the level o$ a clinically healthy
pulp5 $ollo&ed by a calcium hydroxidedressing6 (Anderson)
Indication:
'%An immature permanent tooth &ith anopen apex and reversible pulpitis su9ers acarious exposure
*%#arge diameter 2more than 'mm)traumatic pulpal exposure5 o$ any duration
8/20/2019 Apex if Ication
11/39
T-pes:
1.Partial pulpotomy 2 shallo&5 lo&-level or Cveks pulpotomy!
.!ervical pulpotom y 2deep5 high-
level5 total or conventional pulpotomy)0aterias used:
'%Calcium :ydroxide
*%MA
,%;one gro&th $actors
.%;one morphogenic proteins
8/20/2019 Apex if Ication
12/39
Caciu! ,-droxide
pupoto!-Partia pupoto!-:
'%Anestheti
8/20/2019 Apex if Ication
13/39
8/20/2019 Apex if Ication
14/39
Ad/antages:
'% Minor injury to the pulp and undisturbed
physiologic apposition o$ dentin5 especiallyin the critical cervical area o$ the tooth%
*% he limited loss o$ coronal pulp allo&s $orvitality testing%
,% #imited loss o$ cro&n precludes need $orpost and core%
Co!pared #it, pup capping it
i!pies: ;etter &ound control%
;etter sealing against micro lea!age%
8/20/2019 Apex if Ication
15/39
8/20/2019 Apex if Ication
16/39
0TA Pupoto!-
8/20/2019 Apex if Ication
17/39
Disad/antage: @xpensive
#ong setting time5 re(uiring anadditional appointment in certain cases
Di"culty in manipulation
Ad/antage o/er Ca&o,+1
'%?ood seal
*%?ood 1trength
,%:as cell inductive potential
.%+roduces signifcantly more dentinalbridging in a shorter period o$ time &ithsignifcantly less in7ammation
(!ohen).
8/20/2019 Apex if Ication
18/39
Reca 2or Apexogenesis
8/20/2019 Apex if Ication
19/39
Treat!ent 2aiure Cessation o$ root gro&th
Development o$ signs and symptoms orperiapical lesion%
Calcifc metamorphosis 2i%e% calcifcobliteration) o$ canal or internalresorption
%oas:'%1ustaining a viable :ert&igs epithelial
root sheath*%Maintaining pulpal vitality,%+romoting root end closure.%?enerating a dentinal bridge at the site
o$ pulpotomy
8/20/2019 Apex if Ication
20/39
Restoration:
Institute root canal therapy a$terapexogenesis (!ve"# $e%%er#Seltzer and Bender)
Prognosis: "ulp capping 3 >*-BB
"artial pulpotomy 3 .-0
Cervical pulpotomy 3 >*->
8/20/2019 Apex if Ication
21/39
APEXI3ICATIONAPEXI3ICATION
#on-surgical approaches $discussed by%orse!& ;lunt end or rolled cone 2customi
8/20/2019 Apex if Ication
22/39
Defnition:
4%ethod of inducing apical closure by the
formation of osteocementum or a similarhard tissue or the continued apicaldevelopment of the root of an incompletelyformed tooth in 'hich the pulp is no longer
vital%6 & American Association o'ndodontics
Root end cosure tec,ni4ue (ora%ine*ad)
(The process of creating an environment
'ithin the root canal and periapical tissues
after pulp death that allo's a calci)c barrierto form across the open ape*”
8/20/2019 Apex if Ication
23/39
Indication 8estorable immature tooth &ith pulp
necrosis%
Contraindications :'%All vertical and un$avorable hori
8/20/2019 Apex if Ication
24/39
8/20/2019 Apex if Ication
25/39
Properties o2 CaO)1 reated to its,ig, p) (Andreasen):
p, " &66"61+
+.Capacity to dissolve necrotic pulpremnants&
,.trong antibacterial eect&
% o$ bacteria $rom the common
root canal 7ora are !illed &ithin a $e&minutes upon direct contact &ithCaO:*
8/20/2019 Apex if Ication
26/39
Apexifcation using caciu!
,-droxide
8/20/2019 Apex if Ication
27/39
8/20/2019 Apex if Ication
28/39
Paste #oud need to be c,anged at t,irdreca &7 #ee$s+ i2
+aste is $ound to be &et in apical hal$ due to exudates%
8adiographic evidence o$ dilution o$ paste +aste is overextended at second appointment% +atient develops sinus tract or symptoms
6183ina fing o2 t,e cana: 1ymptomless tooth &ith healing o$ any sinus tract% 8adiographic observation o$ osseous deposition in the
periapical o$ lateral de$ect 8adiographic observation o$ hard tissue deposition at
the apex% Ginding the CaO:* paste to be dry &hen tested by
probing% Confrmation o$ a calcifc barrier by probing &ith light
fnger pressure &ith smaller 2*H-*/) fles% Drying o$ canal system &ith paper points elicits no
hemorrhage or tissue 7uids%
8/20/2019 Apex if Ication
29/39
T,ere can be f/e outco!es o2apexifcation procedure &$eine)
'% Eo radiographic change is apparent but i$instrument is inserted5 a bloc!age at theapex is encountered%
*% 8adiographic evidence o$ calcifed materialis seen at or near the apex%
,% Apex closes &ithout any change in canalspace%
.% Apex continues to develop &ith closure o$the canal apace%
/% Eo radiographic evidence o$ change is seen5and clinical symptom andJor development o$or the increase in si
8/20/2019 Apex if Ication
30/39
8/20/2019 Apex if Ication
31/39
8/20/2019 Apex if Ication
32/39
8/20/2019 Apex if Ication
33/39
Disad/antages o2 caciu! ,-droxide
apexifcation:
Cost o$ multiple visits
+atient compliance &ith multipleappointments over 0-*. months
+ossibility o$ root $racture during theextended period because o$ the thin roots andincidence o$ traumatic injuries in children%
he dentin becoming more brittle as it
continues to be in contact &ith CaO:*5 &hich5along &ith thin &alls &ill predispose to$ractures.(Ingle)
8/20/2019 Apex if Ication
34/39
ONE 'ISIT APEXI3ICATION
0aterias used:
'% ricalcium phosphate
*%8esorbable ceramic%,%Caph*
.%Gree
8/20/2019 Apex if Ication
35/39
One /isit apexifcation
#it, 0TATec,ni4ue'% A$ter thorough debridement5 the canal is
medicated &ith CaO:* $or ' &ee! $or disin$ection%
*% On re-entry5 canal is cleansed and rinsed &ith
EaOCl%,% he canal is dried and a ,-. mm plug o$ MA ispac!ed into the apical end &ith pluggers or paperpoints%
.% he placement is confrmed radiographically and
then a moist pellet is placed against the MA andaccess cavity is sealed $or .-0 hours to allo& thematerial to harden
/% he canal is then obturated &ith gutta-percha orbonded composite%
8/20/2019 Apex if Ication
36/39
Osteogenic Protein 9 6 $bone
morphogenetic protein!'% Attract and recruit mononuclear
phagocytes to sites bone $ormation%
*%1timulates the proli$eration o$mesenchymal cells that subse(uentlydi9erentiate into osteogenic cells%
Material is used &ith a collagen carrier
&hich allo&s its release over a longperiod%
8/20/2019 Apex if Ication
37/39
'itait- testing 2or i!!ature -oungper!anent teet,:
hermal tests%@+
Ot,er appications o2 apexifcation:'% #ateral per$oration
*% Aggressive external resorption
$Weine!
Ape+ogenesis vs. Ape+i,cation
8/20/2019 Apex if Ication
38/39
8/20/2019 Apex if Ication
39/39
CONC(USION