The document discusses apexification, a dental procedure used to encourage continued root development or induce formation of a calcified barrier in a tooth with an open apex or incomplete root formation. It reviews various treatment modalities for apexification including the traditional calcium hydroxide method requiring multiple visits over many months and more recent one-visit methods using biocompatible materials like mineral trioxide aggregate which can induce apical closure in a single appointment. The document provides details on the clinical protocols and materials used for different apexification techniques.
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Apexification /prosthodontic courses
1. APEXIFICATION : A REVIEW
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
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2. APEXIFICATION : A REVIEW
• INDIAN DENTAL ACADEMY
• Leader in continuing Dental Education
www.indiandentalacademy.com
3. • CONTENTS
• NEED FOR APEXIFICATION
• DIAGNOSIS AND CASE ASSESSMENT
• TREATMENT MODALITIES FOR TEETH WITH OPEN
APEX
• APEXIFICATION
• ONE VISIT APEXIFICATION
• TOOTH RESTORATION FOLLOWING
APEXIFICATION
• CONCLUSIONS
• REFERENCES
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5. Root development
• Inner & outer enamel epithelia fuse at cervix of the crown to form
Hertwig’s epithelial root sheath
-template for outlining the shape and size of the root
-Differentiation of new odontoblasts from cells of dental papilla
or newly developed pulp
-Epithelial cells of the root sheath loose their continuity,
permitting the ingrowth of CT cells from the surrounding dental
follicle
-Cells of the follicle nearest to the dentin – cementoblasts
-Cells of the follicle farthest to the dentin-osteoblasts
-Intermediate cells forms the Collagen
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6. Pulpal injury in teeth with developing roots
• Root formation can continue even in the presence of
pulpal inflamation and necrosis
• Complete destruction of HERS results in cessation of
normal root development
• Hard tissue forms by cementoblasts & fibroblasts
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7. DIAGNOSIS AND CASE ASSESSMENT
• History of subjective symptoms
• Careful clinical and radiographic examination
• Diagnostic tests
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8. • APEXOGENESIS
‘A vital pulp therapy procedure performed to
encourage continued physiological development and
formation of the root end’
• Goals (webber) :
-sustaining a viable HERS
-Maintaining the pulpal vitality
-Promoting root end closure
-Generating a dentinal bridge at the site of the pulpotomy
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9. • APEXIFICATION
‘A method to induce a calcified barrier in a root
with an open apex or the continued apical development of
an incomplete root in teeth with necrotic pulp’
Reason:
-To eliminate the periapical infection
-To induce the apical closure, if possible continued root
growth
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10. • INDICATIONS:
-Immature nonvital permanent tooth with open apex
-Open apex in matured teeth due to periapical osteoclastic
action
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11. DIFFERENT METHODS
1.Large(blunt) end of gutta-percha cone or customized gutta-
percha cones with sealer
2.Filling the root canal well short of the apex with gutta-
percha and sealer
3.Periapical surgery with or without reverse seal
4.Inducing apical closure by formation of apical stop
5.Placing a biologically acceptable substance in the apical
portion (One visit apexification)
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12. • Blunt end or rolled cone :
-Apical foramen is wider
than orifice
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13. • Short fill (Moodnick)
-Filling the root canal short of the apex
- No Healing due to incomplete obturation
• Periapical surgery:
-Reduction in crown : root
-Physical and psychological trauma
-Less possibility of further root development
-Apical walls are thin and shatter when touched by rotating bur,
Retrograde filling difficult
-Periapical tissues may not adapt to the wide and irregular surface of
amalgam
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14. • Nygard-ostby:Laceration of the periapical tissues inducing
apical closure
• Moller et al: Removal of the infected pulp tissue
• Mc Cormick: Debridement of the root canal, removal of
the necrotic pulp tissue and microorganisms
• Cooke and Robotham:Remnants of HERS
• Antibiotic pastes, antiseptic pastes
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15. APICAL CLOSURE INDUCTION BY Ca(OH)2:
APEXIFICATTION TECHNIQUE:
Access:
-Straight line access
Instrumentation:
-Working length is determined
-Carefull debridement is a primary factor to induce
apical closure
-Canals enlarged upto a size 120-140
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16. • Filing motion is needed
Avoid over instrumentation
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17. • Drying of the canals:
-An inverted coarse paper point is desirable
-A dry pre fitted paper points
• Introduction of paste:
- A Carrier with a teflon or plastic sleeve is recommend
• Condensation:
-A plugger that occludes the canal at a distance of 2-
3mm short of the radiographic apex is selected
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23. APICAL CLOSURE INDUCTION BY Ca(OH)2:
-Kaiser (1964), Ca(OH)2 + CMCP
-Frank (1966)
-Apex closure with definite , although minimal canal
recession
-Apex closure without root space change
-Radiographically apparent bridge formation
immediately coronal to apex
-No radiographic evidence of apical closure,
however, upon instrumentation, definite apical stop
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24. APICAL CLOSURE INDUCTION BY Ca(OH)2:
• Klein and Levy
-Ca(OH)2 + Cresatin (minimal inflammatory potential)
-less toxic than CMCP
• Ca (OH)2 + Saline
Distilled water
L A Solution with out vasoconstrictor
• Heithersay & others
-Ca (OH)2 + Methyl cellulose
- solubility & a firm physical consistency
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25. APICAL CLOSURE INDUCTION BY Ca(OH)2:
• Mitchel & Shankwalker
-Osteogenic potential by forming heterotopic bone
• Holland etal
-Multilayered necrosis with subjacent mineralization
• Schroder and Granath
-Layer of firm necrosis generates a low-grade irritation
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26. • Javelet etal
-Compared the ability of Ca(OH)2 (PH 11.8)
• Antibacterial efficacy :
-Hydroxyl ions are highly oxidant , show extreme
reactivity
-Damage to the bacterial cytoplasmic membrane,
protein denaturation, damage to bacterial DNA
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27. • Heithersay
-Ca(OH)2 increases the Ca concentration at the pre
capillary sphincter, reducing the plasma flow
-Stimulates the enzyme pyrophosphatase (collagen
synthesis)
• Hard tissue Barriers:
Ghose et al:
-Cap, bridge or ingrown wedge and may be composed
of cementum , dentin , bone or ‘osteodentine’
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28. • Hard tissue barriers:
Torneck et al
- Deposition of bone like material
Steiner and van Hassel
-Calcific bridge (cementum)
• Cementum formation proceeds from the periphery of the
original apex towards the center in decreasing concentric
circles
• Histologically barrier is porous
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29. • SEM and Histologic study:
- Outer surface of the bridge extended in a ‘cap’ like
fashion over the root apex , displaying irregular
topography with indentations and convexities
- The outer layer appear to be composed of a dense
acellular cementum like tissue , surrounding a central mix
of irregular dense fibrocollagenous CT containing foreign
material with irregular fragments of highly mineralized
calcIfications
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30. • How often the dressing should be changed?
Chawla : Place the paste only once and wait for
radiographic evidence of barrier formation
Chosak et al:Ca (OH)2 only required to initiate the healing
reactions
Others:
-Should be replaced only when symptoms develop or the
material appears to have washed out of the canal
Abbots :Regular replacement is advantageous
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31. • Time required for apical barrier formation:
Sheey and Roberts : 5- 20 mnths
Finucane and Kinirons: 34.2 weeks ( range :13-67 weeks)
Cvek : presence of infection delays the closure
Kleier and barr : 5 – 15.9 mnths delay in the prescence of
infection
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33. • Disadvantages of apexification:
- Long time span with multiple appointments
-Patient compliance may be poor
-Reinfection and prolongation or failure of treatment
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34. One visit Apexification :
• One visit Apexification :
-Non surgical condensation of a biocompatible material into the
apical end of the root canal( Morse et al)
Materials:
-Tricalcium phosphate
-Ca (OH)2
-Freeze dried bone and Freeze dried Dentin
-A Resorbable ceramic (Ca Po4 ) Koings etal
-Matrix for invasion of blastic cells
-Allows for cellular defferentiation and proliferation
- Permits deposition of hard tissues
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35. One visit Apexification :
Surgicel ,Ethicon ltd ( Dimashkieh):
-Oxidised regeneration cellulose , non irritating and
resorbable
Dentinal shavings or chips:
Gollmer (1937), Tronstad : Osteo cementum
Collagen- calcium phosphate gel: Nevins et al
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36. One visit Apexification
• Mineral trioxide aggregate: 1993, 1998 (FDA Approval)
- Fine hydrophilic particles of Tricalcium silicate, Tri
calcium aluminate,Tricalcium oxide and silicate oxide
-PH of 12.5, Antibacterial properties
-low solubility, radiopacity greater than dentin
-good sealability, biocompatibility
-Stimulate the cytokine release and the production of
interleukins
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38. • Clinical procedure:
-Access cavity preparation and irrigation with Na O Cl
EDTA(17%), Citric acid(7%)
-Working length is determined, dry the canals by using
paper points
-Canal is dressed with non setting Ca (0H)2 for one to
two weeks.
Re-access, Ca (OH)2 is removed
-MTA is mixed with sterile water to a thick slurry,
placed and condensed into the canal
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39. - Radiographically position of MTA is
checked
-A moist cotton pellet is placed in
canal,Temporary dressing is given(settin
time-3-4 hr)
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40. • Advantages :
- Time saving
-Better apical seal, nonresorbable
-Better strengthening of the roots
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41. Tooth restoration following apexification:
• Strengthening the immature root by using newer dentin
bonding techniques
• Goldbreg et al : Reinforcing effect of RMGIC
• Katebzadeth et al : access is restored with composite
restoration
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42. Tooth restoration following apexification
• Clinical procedure for internal rehabilitation of root canal:
-Select the proper light transmitting post
-Etch , Apply DBA into root canal
- Composite resin is packed into the canal
-Post is coated with vaseline, inserted centrally
into the canal and cured
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