3

Dr Nizar Al Chaar

London Unervisty

Definition

A physiological process
Formation of apex in young, vital, Immature, permanent teeth with appropriate pulp therapy.

Root end development occurs in a tooth with a normal pulp and minimal inflammation

Pulp of immature teeth has significant reparative potential.
Pulp revascularization and repair occurs more efficiently in tooth with an open apex.
Poor long term prognosis of an endodontically treated immature teeth
Relatively thin dentine in obturated canal/s of immature root/s and open apex prone to fracture fracture

Sustaining a viable Hertwing’s sheath to stimulate continues development of root

To attain favorable crown: root ratio
To attain root end closure
To preserve pulp vitality to secure further root development and maturation.
Generating dentinal bridge at the site of pulpotomy


1-Fractured tooth with pulpal exposure

2-Carious exposure

3- Traumatic Luxation

1-Direct pulp capping

When
pulp
Camber
is
exposed

2- Indirect pulp capping

When
a thin dentin layer is present
Between
pulp and cavity

3- Pulpotomy

Extirpation of pulp is
Restricted strictly to the
Coronal portion of pulp
chamber


1-MTA (Mineral trioxide aggregate)

2-Calcium hydroxide

3- Formocresol(as an alternative to calcium hydroxide

Anesthesia application and rubber dam isolation

The instrument of choice tissue removal is an abrasive diamond bure at slow speed
Access is gained into the pulp chamber and infected
dentin partially removed
Peripheral carious lesion removed with a spoon
excavator

Following coronal pulp amputation, the pulp chamber is rinsed with sterile saline or sterile saline or sterile water to remove all debris
The excess liquid should then be carefully removed via vacuum or sterile cotton pellets.
Air should not be blow on the exposed pulp, as this may cause desiccation and additional tissue damage.

Once the pulpal bleeding is controlled, Calcium hydroxide paste is placed over the amputation site.
Care must be taken to avoid placing the calcium hydroxide on a blood clot and the entire pulp surface must be covered
Once this is accomplished , a restoration base material should be placed over the calcium hydroxide and then allowed to set completely.
A coronal restoration should then be placed that will ensure the maximum long-term seal.


The patient should be re-evluated every three months for the first year ,and then every 6 months for 2-4 years to determine if successful root formation is taken place and that there are no sign of pulp necrosis, root resorption or periarticular pathosis

1-Severe crown-root fracture which intra-radicular retention for restoration

2-Tooth with unfavorable horizontal
root fracture i.e. closed to gingival margin

3- Necrotic or non vital pulp

4-Unrestorable carious tooth

Definition:

The process of inducing a calcific barrier across an open apex of an immature pulpless tooth

To Induce root closure to from a complete calcific barrier at the apex with no apparent pathosis

Young immature, permanent non-vital tooth/teeth

Why Apexification preferred over RCT
• Open apex
• Blunderbuss canals
• Thin and fragile canal walls
• Absolute dryness of canal difficult to achieve


MTA (mineral trioxide aggregate)
Collagen calcium phosphate gel
Calcium hydroxide
Osteogenic protein I and II

Anaesthetize the tooth and isolate with rubber dam

Gain straight access to canal orifice
Extirpate the pulp tissue remnants from the canal and irrigate it with sodium hydroxide
Establish working length of canal ,dry, Placing an appropriate material for
a pexification .
Placing temporary seal between visits is critical. Zinc Eugenol or resin cement modified GIC

1-Very short roots

2-Vital pulp

3- Compromised periodontium