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APEXOGENESIS &
APEXIFICATION
Presented By : Vipul D. Giratkar
Final Year - II
Contents
• Introduction
• Treatment Modalities of pulpal pathology
• Apexogenesis – Defination
Rationale
Goals
Indications...
• Apexification – Defination
Objectives
Indications
Contraindications
Procedure
Medicaments
• Difference between Apexogene...
Introduction - Pulp
 The dental pulp is the part in the centre of the tooth made
up of living connective tissues and cell...
Treatment Modalities
PULP TREATMENT
MODALITIES
Vital pulp therapy
1. Protective base.
2. Indirect Pulp capping.
3. Direct ...
 Young Permanent teeth are those recently
erupted teeth in which normal apical
physiological root closure has not occurre...
 Young permanent teeth are in developmental
stage in children, from 6 years of age until mid
teens .
 Human tooth with i...
Apexogenesis
• Definition – It is defined as the treatment of a vital pulp
by capping or pulpotomy in order to permit cont...
Rationale
• Maintenance of integrity of the radicular pulp
tissue to allow continued root growth.
• Root end development o...
Goals of Apexogenesis :
1. Sustaining a viable Hertwig’s sheath to allow continued
development of root length for a favour...
Indications
1. Indicated for traumatized or pulpally involved vital
permanent tooth when root apex is incompletely formed....
Contraindications
1. Evidence that radicular pulp has undergone degenerative
changes.
2. Tooth with unfavourable horizonta...
PROCEDURE
Remove all of carious tooth strucuture and open up the pulp chamber
Remove coronal pulp with excavators, care is...
`
Medicament
• Calcium Hydroxide
• Formocresol
• Glutaraldehyde
• MTA (Mineral Trioxide Aggregate)
• Zinc Oxide Eugenol Past...
Apexification
• Definition : It is defined as a method to induce
development of the root apex of an immature pulpless
toot...
Objectives
• To induce either closure of open apical third of root canal
or the formation of an apical calcific barrier ag...
Indications
• For young, immature, nonvital permanent tooth with
open apex
• Open apex
• Blunderbuss
canals
• Thin and fra...
Contraindications
• Very short roots
• Vital Pulp
• Compromised Periodontium
Materials used
• Zinc oxide Eugenol
• Metacresylacetate – campahorated
parachlorphenol
• Tricalcium Phosphate + β – trical...
Procedure – Single Visit
Preoperative asessment includes clinical evaluation of
colour, mobility , tenderness, and swellin...
Working length is determined
Circumferential enlargement done by the file and irrigation is
done with saline to remove inf...
Second Visit
This is after 6 – 24 months
Tooth is re-entered and
apexification is verified
It is complete when RCT is
done.
Follow - Up
• Apical development is monitored by comparison of
preoperative and postoperative radiograph.
• 1. Formation o...
Use of calcium Hydroxide
1. Alkaline pH
2. Bactericidal
3. Stimulate apical calcification
Reaction of periapical tissue to...
Serious Disadvantages
• Long treatment period usually takes 6 – 9 months and
may extend upto 21 months.
• Must be replaced...
MTA as choice of material for Apexification
• Saves treatment time
• Can induce formation (regeneration ) of dentin, bone,...
Composition
• Tricalcium aluminate
• Tricalcium silicate
• Silicate oxide
• Tricalcium oxide
• Bismuth oxide
Types
Gray MTA White MTA
Contains tricalcium
aluminoferrite (ferrous oxide)
which is responsible for gray
disccoloration. ...
Properties
• Biocompatible
• Sealing ability better than amalgam or ZOE
• Initial pH – 10.2 and set pH – 12.5
• Setting ti...
Comparative assessment of Apexification
using MTA and Calcium Hydroxide
Difference between Apexogenesis and Apexification
Apexogenesis Apexification
It is defined as the treatment of a vital
pul...
Conclusion
• Apexogenesis and Apexification are two variants of
procedures performed.
• It is very important to use approp...
Reference
• Textbook of Pediatric Dentistry (3rd Edition) – By
Nikhil Marwah
• Textbook of Pedodontics (2nd Edition) – By ...
Apexogenesis & apexification in pediatric dentistry
Apexogenesis & apexification in pediatric dentistry
Apexogenesis & apexification in pediatric dentistry
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Apexogenesis & apexification in pediatric dentistry

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

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Apexogenesis & apexification in pediatric dentistry

  1. 1. APEXOGENESIS & APEXIFICATION Presented By : Vipul D. Giratkar Final Year - II
  2. 2. Contents • Introduction • Treatment Modalities of pulpal pathology • Apexogenesis – Defination Rationale Goals Indications Contraindications Procedure Medicaments
  3. 3. • Apexification – Defination Objectives Indications Contraindications Procedure Medicaments • Difference between Apexogenesis & Apexification • Conclusion • Reference
  4. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 14. `
  15. 15. Medicament • Calcium Hydroxide • Formocresol • Glutaraldehyde • MTA (Mineral Trioxide Aggregate) • Zinc Oxide Eugenol Paste • Iodoform Paste
  16. 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. 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. 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. 19. Contraindications • Very short roots • Vital Pulp • Compromised Periodontium
  20. 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. 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. 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. 23. Second Visit This is after 6 – 24 months Tooth is re-entered and apexification is verified It is complete when RCT is done.
  24. 24. 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
  25. 25. 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.
  26. 26. 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.
  27. 27. 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
  28. 28. Composition • Tricalcium aluminate • Tricalcium silicate • Silicate oxide • Tricalcium oxide • Bismuth oxide
  29. 29. 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
  30. 30. 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 )
  31. 31. Comparative assessment of Apexification using MTA and Calcium Hydroxide
  32. 32. 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
  33. 33. 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.
  34. 34. Reference • Textbook of Pediatric Dentistry (3rd Edition) – By Nikhil Marwah • Textbook of Pedodontics (2nd Edition) – By Shobha Tandon • Internet sources
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SDDCH Parbhani Presented by : Vipul GIratkar Dept. of Pediatric dentitstry Guided by . Dr. Rehan Khan DIscussion regarding apexification and apexogenesis

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