Apexogenesis & Apexification

Maxillary Teeth (Root Completion)

TOOTH BEGINNING OF ERUPTION (yrs)

COMPLETION OF ROOT FORMATION

(yrs)Central Incisor 6.7 – 8.1 8.6 – 9.8

Lateral Incisor 7.0 – 8.8 9.6 – 10.8

Canine 10.0 – 12.2 11.2 – 13.3

First Premolar 9.6 – 10.9 11.2 – 13.6

Second Premolar 10.2 – 11.4 11.6 – 14.0

First Molar 6.1 – 6.7 9.3 – 10.8

Second Molar 11.9 – 12.8 12.9 – 16.2

Mandibular Teeth (Root Completion)

TOOTH BEGINNING OF ERUPTION (yrs)

COMPLETION OF ROOT FORMATION

(yrs)Central Incisor 6.0 – 6.9 7.7 – 8.6

Lateral Incisor 6.8 – 8.1 8.5 – 9.6

Canine 9.2 – 11.4 10.8 – 13.0

First Premolar 9.6 – 11.5 11.0 – 13.4

Second Premolar 10.1 – 12.1 11.7 – 14.3

First Molar 5.9 – 6.9 7.8 – 9.8

Second Molar 11.2 – 12.2 11.0 – 15.7

Stage of Root Development

Open Apex Closed Apex

Open Apex

•Caries

•Trauma

•Orthodontic Treatment

•Periradicular Inflamation

•Developmental Anomaly (E.g., Dens invaginatus)

Walls of Immature Root

Divergent (Blunderbuss) Parallel Slightly Convergent

Subjective Examination

History Symptoms

Objective Examination

Visual Examination Percussion Thermal Testing Electric Pulp Testing Radiographic Finding

Case Selection

Reversible Pulpitis

Vital pulp therapy(apexogenesis)

Pulp capping orpulpotomy

Irreversible Pulpitis/necrotic pulp

Closed apex Open apex

Root-end-closure(apexification)and obturation

Root canal therapy

Clinical Treatment ConsiderationsVital Tooth

Trauma and exposure of dentinal tubules

Small exposure of the pulp < 24 hrs

Large exposure ofpulp> 72 hrs

Lining

Composite

Asymptomatic Pulp

Pulp Capping

Composite

Asymptomatic Pulp

CVEK pulpotomy(partial pulpotomy)

or pulpotomy

Radicular Pulpcovered withCaOH/MTA

Continue root formation

Good coronal seal

Apexogenesis (vital pulp therapy)

Indications in Immature Teeth Damaged coronal pulp Healthy radicular pulp

Treatment of Vital Pulp (open apex)

Partial Pulpotomy (Cvek pulpotomy)

Full pulpotomy (cervical)

Contraindication

Avulsed / Severely luxated Tooth Crown root fracture Horizontal root fracture Unrestorable tooth Necrotic pulp

Apexification (root end closure)

Indications Immature tooth with necrotic pulp

This technique involves cleaning and filling the canal with a temporary paste to stimulate the formation of calcified tissue at the apex. The temporary paste is later removed after radiographic evidence of apical closure has been obtained and a permanent filling of gutta percha is placed in the canal.

Ca++ of apical Barrier comes from the blood

Contraindications

Vertical/horizontal root fracture Replacement resorption (ankylosis) Very short roots Vital pulp

Followup

Six Months

Apexogenesis Vital Pulpotomy Coronal Seal (imp) RCT (not necessary)

Apexification Non vital Pulpectomy Coronal Seal (imp) RCT (mandatory)

MTA

INTRODUCTIONINTRODUCTION Mineral trioxide aggregate, or MTA, Mineral trioxide aggregate, or MTA,

A new material developed for A new material developed for endodonticsendodontics

First restorative material that First restorative material that consistently allows for the consistently allows for the overgrowth of cementumovergrowth of cementum

May facilitate the regeneration of the May facilitate the regeneration of the periodontal ligament. periodontal ligament.

Developed by Dr. Torabinejad at Loma Developed by Dr. Torabinejad at Loma Linda University in 1993.Linda University in 1993.

A compound mixture of A compound mixture of hydrophilic tricalcium silicate, hydrophilic tricalcium silicate, tricalcium oxide, and tricalcium tricalcium oxide, and tricalcium aluminate with some other aluminate with some other oxides.  oxides. 

An independent analysis reveals that An independent analysis reveals that MTA is identical to Portland cement MTA is identical to Portland cement with the addition of bismuthoxidewith the addition of bismuthoxide. . 

Has a pH of 12.5, some of its Has a pH of 12.5, some of its biological and histological properties biological and histological properties can be compared to those of can be compared to those of Ca(OH)2. Ca(OH)2. 

Sets in a moist environment Sets in a moist environment

Has low solubility Has low solubility

Working time 5 min, setting time 4-6 hrsWorking time 5 min, setting time 4-6 hrs

Compressive strength of MTA is equal to Compressive strength of MTA is equal to that of IRM and Super EBA but less than that of IRM and Super EBA but less than that of amalgam (Nahmias and Bery). that of amalgam (Nahmias and Bery).

MTA BENEFITSMTA BENEFITS Allows normal healing responseAllows normal healing response

Allows formation of new Allows formation of new cementumcementum

Least leakageLeast leakage

Sufficient setting timeSufficient setting time

MTA USES:MTA USES: Furcation perforationFurcation perforation Extra-radicular perforation repairExtra-radicular perforation repair ApexificationApexification Retrograde fillingsRetrograde fillings Internal and external resorption Internal and external resorption

repairrepair Pulp cappingPulp capping PulpotomyPulpotomy