SDDCH Parbhani Presented by : Vipul GIratkar Dept. of Pediatric dentitstry Guided by . Dr. Rehan Khan DIscussion regarding apexification and apexogenesis

1. APEXOGENESIS &
APEXIFICATION
Presented By : Vipul D. Giratkar
Final Year - II

2. Contents
• Introduction
• Treatment Modalities of pulpal pathology
• Apexogenesis – Defination
Rationale
Goals
Indications
Contraindications
Procedure
Medicaments

3. • Apexification – Defination
Objectives
Indications
Contraindications
Procedure
Medicaments
• Difference between Apexogenesis & Apexification
• Conclusion
• Reference

4. Introduction - Pulp
 The dental pulp is the part in the centre of the tooth made
up of living connective tissues and cells called
odontoblasts
 The dental pulp is a part of dental pulp
complex(Endodontium)
 The vitality of the dental pulp complex , both during
healthy and after injury depends on pulp cell activity and
the signaling process that regulates the cell’s behaviour.
 Functions – Nutritive
Sensory
Protective
Formative

5. Treatment Modalities
PULP TREATMENT
MODALITIES
Vital pulp therapy
1. Protective base.
2. Indirect Pulp capping.
3. Direct Pulp capping.
4. Pulpotomy.
5. Apexogenesis.
6. Regeneration.
Nonvital Pulp
Therapy :
1. Pulpectomy
2. Apexification
3. Root filling

6.  Young Permanent teeth are those recently
erupted teeth in which normal apical
physiological root closure has not occurred.
 Normal physiological root closure of
permanent teeth may take 2-3 year after
eruption

7.  Young permanent teeth are in developmental
stage in children, from 6 years of age until mid
teens .
 Human tooth with immature apex : is a
developing organ.
 The proliferation and differentiation of various
cells are activated especially in the apical
region of young tooth to make it complete.

8. Apexogenesis
• Definition – It is defined as the treatment of a vital pulp
by capping or pulpotomy in order to permit continued
growth of the root and closure of the open apex

9. Rationale
• Maintenance of integrity of the radicular pulp
tissue to allow continued root growth.
• 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 dentin in obturated canals of
immature roots and open apex are prone to fracture

10. Goals of Apexogenesis :
1. Sustaining a viable Hertwig’s sheath to allow continued
development of root length for a favourable crown : root ratio
2. Maintaining pulp vitality to help maturation of root.
3. Promoting root-end closure to create a natural apical
constriction.
4. Generating a dentinal bridge at the site of pupotomy.
(a sign that the pulp has maintained it’s vitality).

11. Indications
1. Indicated for traumatized or pulpally involved vital
permanent tooth when root apex is incompletely formed.
2. No history of spontaneous pain.
3. No sensitivity on percussion.
4. No Hemorrhage.
5. Normal Radiographic appearance.
6. Traumatic Luxation.

12. Contraindications
1. Evidence that radicular pulp has undergone degenerative
changes.
2. Tooth with unfavourable horizontal root fracture i.e. close to
gingival margin
3. Purulent drainage.
4. History of prolonged pain.
5. Necrotic debris in canal.
6. Periapical Radiolucency.

13. PROCEDURE
Remove all of carious tooth strucuture and open up the pulp chamber
Remove coronal pulp with excavators, care is taken to prevent damage to radicular pulp
Rinse all the residual debris and control hemorrhage by placement of a moist cotton
pellet over the amputed pulp
Calcium hydroxide mixture is placed over the pulp stumps, followed by temporary
restoration
Follow-up radiograph are taken periodically to check the root development
Once the root development is complete, the conventional root canal treatment is done.

14. `

15. Medicament
• Calcium Hydroxide
• Formocresol
• Glutaraldehyde
• MTA (Mineral Trioxide Aggregate)
• Zinc Oxide Eugenol Paste
• Iodoform Paste

16. Apexification
• Definition : It is defined as a method to induce
development of the root apex of an immature pulpless
tooth by formation of osteocementum / bone like tissue.
( Cohen )

17. Objectives
• To induce either closure of open apical third of root canal
or the formation of an apical calcific barrier against which
obturation can be achieved.

18. Indications
• For young, immature, nonvital permanent tooth with
open apex
• Open apex
• Blunderbuss
canals
• Thin and fragile
canal walls
• Absolute dryness
of canal difficult to
achieve
Why apexification
preferred over RCT

19. Contraindications
• Very short roots
• Vital Pulp
• Compromised Periodontium

20. Materials used
• Zinc oxide Eugenol
• Metacresylacetate – campahorated
parachlorphenol
• Tricalcium Phosphate + β – tricalcium phosphate
• MTA (mineral trioxide aggregrate)
• Collagen calcium phosphate gel
• Calcium hydroxide

21. Procedure – Single Visit
Preoperative asessment includes clinical evaluation of
colour, mobility , tenderness, and swelling
Periapical radiograph should be evaluated
When acute signs and symptoms are absent,
instrumentation is recommended
Application of rubber dam following local anesthesia
Access is gained in the pulp chamber
Barbed broach is used to remove debris and
necrotic pulp tissue along the canal
Irrigation is performed with saline

22. Working length is determined
Circumferential enlargement done by the file and irrigation is
done with saline to remove infected dentin from the canal
walls
Canal dried with paper points
Calcium Hydroxide is used to fill 2mm short of the radiographic
apex
Remaining of the canal filled with calcium hydroxide and saline
Barium sulfate added to radiopacity
Dry pledged of calcium hydroxide is then ejected into the pulp
chamber and forced against the paste ahead of it
Place temporary Restoration

23. Second Visit
This is after 6 – 24 months
Tooth is re-entered and
apexification is verified
It is complete when RCT is
done.

26. Follow - Up
• Apical development is monitored by comparison of
preoperative and postoperative radiograph.
• 1. Formation of calcific bridge
• 2. Continued apical development
• 3. Absence of internal resorption or periapical
radiolucency

27. Use of calcium Hydroxide
1. Alkaline pH
2. Bactericidal
3. Stimulate apical calcification
Reaction of periapical tissue to calcium hydroxide is
simillar to that of pulp tissue.
Calcium Hydroxide produces a multilayered sterile
necrosis permitting subsequent mineralization.

28. Serious Disadvantages
• Long treatment period usually takes 6 – 9 months and
may extend upto 21 months.
• Must be replaced at monthly intervals and removed some
months after placement before final obturation
• Multiple visits by the patient
• Possible recontamination may occur
• Weaken the root dentin and the risk of teeth fracture.

29. MTA as choice of material for Apexification
• Saves treatment time
• Can induce formation (regeneration ) of dentin, bone,
cementum and 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
• Vasocontrictive

30. Composition
• Tricalcium aluminate
• Tricalcium silicate
• Silicate oxide
• Tricalcium oxide
• Bismuth oxide

31. Types
Gray MTA White MTA
Contains tricalcium
aluminoferrite (ferrous oxide)
which is responsible for gray
disccoloration. So it causes
discoloration of teeth.
Therefore, it is not used for
anterior teeth.
Ferrous oxide is replaced by
magnesium oxide. So no tooth
discolouration.
Large particles Small particle with narrower
size distribution
Longer setting time Shorter setting time
Greater compressive strength Less compressive strength

32. Properties
• Biocompatible
• Sealing ability better than amalgam or ZOE
• Initial pH – 10.2 and set pH – 12.5
• Setting time – 4 hours
• Compressive strength – 70 Mpa
• Low Cytotoxicity ( it presents with minimal
inflammation of extended beyond the apex )

33. Comparative assessment of Apexification
using MTA and Calcium Hydroxide

34. Difference between Apexogenesis and Apexification
Apexogenesis Apexification
It is defined as the treatment of a vital
pulp by capping or pulpotomy in order
to permit continued growth of the root
and closure of the open apex
It is defined as a method to induce
development of the root apex of an
immature pulpless tooth by formation of
osteocementum / bone like tissue.
(Cohen)
It is physiological process of
redevelopment in vital infected tooth
It is the method of inducing the
regenerative potential in a non-vital tooth
Normal or pulp tissue with minimal
inflammation is present :
1. Completely (Direct Pulp Capping)
2. In the radicular portion (Pulpotomy)
Indicated in cases where there is no
normal pulp tissue i.e., where the pulp
has undergone irreversible pulpal
necrosis.
Normal root end development takes
place
Normal root development takes place
rarely. Calcific barrier is formed clinically,
on a radiograph or both

35. Conclusion
• Apexogenesis and Apexification are two variants of
procedures performed.
• It is very important to use appropriate procedure at appropriate
age in presenting conditions.
• Ideal material suitable for the condition of the pulp should be
selected and used.
• Proper care should be taken following these procedures.

36. Reference
• Textbook of Pediatric Dentistry (3rd Edition) – By
Nikhil Marwah
• Textbook of Pedodontics (2nd Edition) – By Shobha
Tandon
• Internet sources