Apexification /prosthodontic courses

APEXIFICATION : A REVIEW
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

APEXIFICATION : A REVIEW
• INDIAN DENTAL ACADEMY
• Leader in continuing Dental Education

• 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

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental courses

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

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

DIAGNOSIS AND CASE ASSESSMENT
• History of subjective symptoms
• Careful clinical and radiographic examination
• Diagnostic tests

• 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

• 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

• INDICATIONS:
-Immature nonvital permanent tooth with open apex
-Open apex in matured teeth due to periapical osteoclastic
action

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)

• Blunt end or rolled cone :
-Apical foramen is wider
than orifice

• 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

• 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

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

• Filing motion is needed
Avoid over instrumentation

• 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

APICAL BARRIERS

APEXIFICATTION TECHNIQUE:

-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

• 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

• 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

• 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

• 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’

• 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

• 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

• 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

• 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

• Disadvantages of apexification:
- Long time span with multiple appointments
-Patient compliance may be poor
-Reinfection and prolongation or failure of treatment

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

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

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

Dovgan carrier
Buchanan pluggers
MTA KIT

• 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

- Radiographically position of MTA is
checked
-A moist cotton pellet is placed in
canal,Temporary dressing is given(settin
time-3-4 hr)

• Advantages :
- Time saving
-Better apical seal, nonresorbable
-Better strengthening of the roots

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

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

References
• DCNA 1973,17(1):125-134
• DCNA 1974,18(2):297-308
• DCNA 1982,26(3):481-504
• DCNA 1984,28(4):669-697
• IJPD 2004,14:376-379
• QUINT INT 1990;21:589-598
• INT ENDO J 1981;14:173-178
• BDJ 1997;183:241-246
• DENT TRAUMATOL 2002;18:217-221
• PED DENT 2000;23:326-330
• JADA 1981;103:417-420
• BDJ 2005;198:609-617

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