Apex o Genesis

8/12/2019 Apex o Genesis

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Good morning


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1. Introduction2. Definition3. Objective4. Indications & contraindications5. Stages of root development6. Open apices7.

Technique8. Conclusion

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Young permanent teeth are those recently erupted teeth inwhich normal physiological apical root closure has notoccurred. Normal physiological root closure of permanent teeth maytake 2-3 years after eruption.

Human tooth with immature apex is a developing organ. The proliferation and differentiation of various cells are activated

especially in the apical region of the young tooth to make itcomplete

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Definition :- The physiologic root end development and

formation. American Association ofEndodontists

Vital Pulp th erapy : Treatment of a vital

pulp in an immature tooth to permitcontinued dentin formation and apicalclosure - Walton and Torabinejad

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According to Avery, the treatment objective of an ideal

pulpotomy agent is to leave the radicular pulp vital and healthy

and completely enclosed within an odontoblast-lined dentinchamber.

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CONTRAINDICATIONS- Purulent discharge.History of prolonged pain.Periapical radiolucencyAvulsed and replanted or

severely luxated toothSevere crown root fracturethat requires intraradicularretention for restorationCarious tooth that isunrestorable

INDICATIONS A cariously exposed pulp ortraumatized vital permanenttooth with incomplete rootformation.For an immature tooth withdamage to coronal pulp butwith a presumably healthyradicular pulp.The crown which is fairly

intact and restorable No history of spontaneous pain


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According to the width of the apical foramen and the length ofthe root, Cvek has classified 5 stages of root development.

Stage 1 - Teeth with wide divergent apical opening and a root

length estimated to less than half of the final root length.

Stage 2 - Teeth with wide divergent apical opening and a rootlength estimated to half of the final root length.

Stage 3 - Teeth with wide divergent apical opening and a rootlength estimated to two thirds of the final root length.

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Stage 4 Teeth with wide open apical foramen and nearlycompleted root length.Stage 5 Teeth with closed apical foramen and completed rootdevelopment.


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usually found in the developing roots of immature teeth.

Apical closure occurs approximately 3 years after eruption.

However, when the pulp undergoes necrosis before root growth

is complete, dentin formation ceases, and root growth is

arrested.

wide apexshorter root

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Incisor with an open apex(divergent walls)

Apical region of an immature CI


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These can be of two configurations

non-blunderbuss

blunderbuss.

Non blunderbuss -the walls of the canal may be parallel to slightly

convergent as the canal exits the root .

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Blunderbuss - weapon with a short and wide barrel.

Dutch word DONDERBUS which means thunder gun .

The walls of the canal are divergent and flaring, more

especially in the bucco-lingual direction

The apex is funnel shaped and typically wider than the coronal

aspect of the canal


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Incomplete development: The open apex typically occurs whenthe pulp undergoes necrosis as a result of caries or trauma,

before root growth and development are complete (i.e. duringstages 1-4) An open apex can also occasionally form in a mature apex(stage 5) , as a result of

1. Extensive apical resorption due to orthodontic treatment, periapical pathosis.

2. Root end resection during periradicular surgery3. Over-instrumentation

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Apexogenesis


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VPT allows continuation of the root formation, which leads toapical closure, stronger root structure, and a greater structuralintegrity.

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A radiograph showing a mature fully erupted tooth (white arrow), animmature partially erupted tooth with an open root (yellow arrow) and animmature unerrupted tooth with dental follicle (red arrow).


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Establishing a correct diagnosis is primary goal in a case of

potential VPT procedure.

radiographs of the problem tooth are essential in order toevaluate furcation or periapical changes of the supporting bone,

periodontal ligament, and extent of root development.

apical closure of an immature tooth can be difficult todetermine radiographically since the mesio-distal width of

most roots is less than the facio-lingual dimension

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severe pain symptoms that are relentless and causing lack of

sleep may be indicative of irreversible pulpitis or an acute

periapical abscess.Spontaneous pain that occurs without provocation frequently

indicates that the damage to the pulp is irreversible

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Calcium hydroxideMineral trioxide aggregateCalcium enriched mixture

Calcium silicate based cementsMTA angelusBioaggregateBiodentine

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Introduced by hermann in 1920Bactericidal, promotes repair and healingExhibits a high pH that stimulate fibroblasts and enzymesystems and it is the most common pulp-capping agent

DISADVANTAGESdissolution of the material over time.

primary tooth resorption,inability to adhere closely to dentin, andthe presence of tunnel defects formed in the reparative dentin

bridge subjacent to the material.

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Tricalcium silicate

Tricalcium aluminate

Tricalcium oxideSilicate oxide Mixed with sterile water in a 3:1 powder-to-

liquid ratio

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Low or no solubility

pH value10.2

Antibacterial effectInduces pulpal cell proliferation

Stimulation of mineralized tissue formation

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Biodentine , calcium Silicate based cement does not produce

genotoxic or cytotoxic effects

short setting time of 10 minutes

can be used as a base/liner under various restorative materials

sealing ability of Biodentine is similar to that of MTA and

forms needle-like crystals

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Water based new endodontic cement.

Introduced as a root-end filling material (Asgary et al. 2008)Major components

51.75wt% Calcium oxide (CaO)

9.53wt%Sulfur trioxide (SO3)

8.49wt% Phosphorous pentoxide (P2O5)

6.32wt% Silicon dioxide (SiO2).

Minor components-

Al2O3, Na2O, MgO, ClMixing the CEM powder and liquid forms a bioactive calcium and

phosphate enriched material, which subsequently results inhydroxyapatite formation.

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1. Local anaesthesia administration.2. Rubber dam isolation.3. Carious tooth structure is removed and access is gained to the

pulp chamber using sterile no.6 bur.4. Remove coronal pulpal tissue up to the estimated level of

gingival crest of bone using a large sharp spoon excavator. Itshould be done without undue trauma to the remainingradicular pulp tissue.

5. According to Garnett, the instrument of choice for tissueremoval is an abrasive diamond bur at high speed withadequate water cooling so as to minimize damage tounderlying pulpal tissue.

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6. Following coronal pulp amputation , rinse all the residual anddentin debris using saline or sterile water. Air should not be

blown on the exposed pulp, as this may cause desiccation andadditional tissue damage.

7. Control haemorrhage by placing several moist cotton pelletover amputated pulp.

8. Appropriate pulpotomy agent ( calcium hydroxide or MTA) is

placed over the pulp stump.9. Restoration is placed ( polycarboxylate cement , composite

restoration)10. Follow up and periodic reviews including radiographs are

performed to check the root development.11.When dentinal bridge and continued root formation evident,the conventional root canal treatment can be performed.


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The total time treatment is 1-2 years, based primarily on

extent of root development at the time of procedure.Recall is at 3 month intervals to determine extent of apical

maturation. In contrast to apexification, the paste does not

need to be changed.

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Clinical evaluation of pulp healing is made on the basis of:

No clinical symptoms.

No radiographic changes in periapical region.

Continued root development.

Radiographically observed (which may be clinically confirmed)

continuous hard tissue barrier at site of the procedure.

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Cessation of root growth

development of signs and symptoms or periapical lesion.

calcific metamorphosis (i.e. calcific obliteration) of canal orinternal resorption.

In such cases, apexification or root end closure is required.

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8-year old boy --- 4 weeks after trauma to the maxillary leftcentral incisor with complicated crown fracture and pulpalexposure.access cavity prepared, cervical pulpotomy was performed, andthe remaining pulp was capped with calcium enriched mixture(CEM) cementResults - radiographic and clinical examinations on the 6-month and 12-month follow up showed that the tooth remained

functional, root development was completed, and the apex wasformed.

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J Endod 2010;36:912 914


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(A) Preop. (B)capping CEM (C) reattachment of separated segme

(D) recall after 6 months

(E) recall after 12 months


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Conclusion: Considering the healing potential of traumatizedimmature vital pulp, the use of CEM cement for apexogenesismight be an applicable choice.


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Aim - This study was designed to compare mineral trioxide aggregate(MTA) with Ca (OH)2 clinically and radiographically as a

pulpotomy agent in immature permanent teeth (apexogenesis).Methods:

Fifteen children, each with at least 2 immature permanent teethrequiring pulpotomy (apexogenesis) were selected for this study.30 teeth were selected and evenly divided into 2 test groups.In group 1, the conventional calcium hydroxide pulpotomy(control) was performed, whereas in group 2, the MTA pulpotomy(experimental) was done. The children were recalled for clinicaland radiographic evaluations after 3, 6, and12 months

Pediatr Dent. 2006 Sep-Oct;28(5):399-404 .

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http://www.ncbi.nlm.nih.gov/pubmed/17036703http://www.ncbi.nlm.nih.gov/pubmed/17036703


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Results:The follow-up evaluations revealed failure due to pain andswelling detected at 12 months postoperative evaluation in only 2teeth treated with calcium hydroxide.


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NA--no radiographic signs of failure

The remaining 28 teeth appeared to be clinically andradiographically successful 12 months postoperatively.

Conclusions: MTA showed clinical and radiographic success as a pulpotomy agent in immature permanent teeth (apexogenesis


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A 9-year old female presented with severe tooth pain in permanentmandibular first molar , symptomatic to percussion had a medicalhistory of spondyloepiphyseal dysplasia .radiographic examination revealed that the roots of the right firstmandibular tooth had open apicesThe tooth (#30) was diagnosed with a necrotic pulp consequent tocariesThe coronal half of the root canal was dbrided with a file #30 toremove necrotic tissue, and irrigated with chlorhexidine 0.12%.Bleeding was evoked to form an intracanal blood clot; the woundwas then dressed with calcium hydroxide medication and

provisionally restored with GIC. This was repeated at intervals of 1,3 and 6 months..

Iranian Endodontic Journal 2010;5(2):93-6] 6/17/2014 40


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After six months, radiographic evidence revealed thickening of dentinalwalls and apical closure. The progressive increase in dentinal wall thickness

and apical development suggests that desirable biologic responses can occurwith this form of treatment for the necrotic open apex of immature permanent teeth

A) Periapical radiograph of first appointment, B) Periapical radiograph 3months after first appointment, C) Periapical radiograph 6 months after firstappointment, and D) Periapical radiograph of final Obturation 9 months afterfirst appointment


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Radiographs taken 1 month after trauma to the anterior teeth. Thediagnosis apical periodontitis form an infected root canal was set based onradiograph (a). The instrumentation length was set according to radiograph(b), followed by instrumentation of the root canal to reamer ISO 100

Based on radiographic and clinical findings, apical periodontitis was diagnosed.


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1. Continued root formation and apical closure is observed during 15months follow-up

2. Radiograph taken after application of mineral trioxide aggregate

(MTA).3. Final follow-up 2 years after the first appointment. Bonded

composite is used to seal the access cavity


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12-year-old girl was referred with a history of lingering pain and pain on chewing in the mandibular right second molar which issensitive to percussion but not to palpation.access cavity was prepared with a diamond fissure bur under high-speed.Associated bleeding indicated pulp vitality. Hemostasis was achieved

by irrigating with sterile normal saline along with gentle applicationof small pieces of moistened sterile cotton pellets for 10 minCEM cement powder and liquid were mixed to achieve a creamyconsistency. An appro. 2-mm-thick layer of CEM cement was placedover the exposed pulp and access cavity was restored with cavit,followed by GIC after 1 day and a coronal restoration with stainlesssteel crown

6/17/2014 47International Endodontic Journal, 43, 940

944, 2010


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Radiographic examination revealed full root development and formationof calcified bridges beneath the CEM cement in both mesial and distalroots at 12-months


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Weber ;

1. Sustaining a viable Hertwig s epithelial root sheath, thus allowing a

continued development of root length for a more favorable crown: root

ratio.

2. Maintaining pulpal vitality, thus allowing the remaining odontoblasts to

lay down dentin, producing a thicker root and decreasing the chance of

root fracture.

3. Promoting root end closure, thus creating a natural apical constriction

for gutta-percha Obturation.

4. Generating a dentinal bridge at the site of pulpotomy. However, bridging

is not essential for success of the procedure as long as root development

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Dentin formation is one of the main functions of the dental

pulp. This action results in thickening of the root canal walls

and closure of the apical foramen.

An ideal material for the repair of pulpal wounds should be

biocompatible and prevent microleakage

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Endodontics Fifth Edition - John I. Ingle, Leif K.

Bakland

Dentistry for the adolescent- Castaldi and BrassPaediatric Dentistry- Pinkham

Dentistry for Child and Adolescent- Mc Donald

Pathways of the Pulp, 6th edition- Cohen S, Burns R Endodontic Practice- Grossman

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Apexogenesis Treatment with a New Endodontic Cement:

A Case Report - J Endod 2010;36:912 914

Apexogenesis of a symptomatic molar with calcium enriched mixture -CASE REPORT - International Endodontic Journal, 43, 940 944, 2010

Apexogenesis After Initial Root Canal Treatment Of An Immature

Maxillary Incisor A Case Report

International Endodontic Journal, 43, 76 83, 2010

Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide as

Pulpotomy Agents in Young Permanent Teeth (Apexogenesis)

Pediatr Dent. 2006 Sep-Oct;28(5):399-404.

Biological apexogenesis of undeveloped tooth in apatient with

spondyloepiphyseal dysplasia: A case report

Iranian Endodontic Journal 2010;5(2):93-6]
http://www.ncbi.nlm.nih.gov/pubmed/17036703http://www.ncbi.nlm.nih.gov/pubmed/17036703http://www.ncbi.nlm.nih.gov/pubmed/17036703http://www.ncbi.nlm.nih.gov/pubmed/17036703http://www.ncbi.nlm.nih.gov/pubmed/17036703


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Apex o Genesis