The presentation features the pulp reparative and regenerative procedures which can be carried out in immature teeth. It involves development of mature tooth from an immature one by root formation and root fixation as a preparatory phase for root canal treatment.

1. APEXOGENESIS
AND
APEXIFICATION
BY:-
PRINCESONI
MAUSAMICHAUDHARY
B.D.S.FINALYEAR(2015-16)
DEPARTMENT OF PEDODONTICS
GOVT. COLLEGE OF DENTISTRY, INDORE

2. APEXOGENESIS
• Physiologic process
• Formation of apex in young, vital, immature, permanent teeth
with appropriate pulp therapy

3. RATIONALE
• 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 dentine in obturated canals of Immature roots and
open apex are prone to fracture

4. GOALS
• Sustaining a viable Hertwig’s sheath to stimulate continues
development of root
• To attain favourable 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

5. INDICATIONS
• Fractured tooth with pulpal exposure

6. INDICATIONS
• Carious exposure

7. INDICATIONS
• Traumatic luxation

9. INVOLVES
• Direct pulp capping
When
pulp
chamber
is
exposed

10. INVOLVES
• Indirect pulp capping When
a thin dentin layer
is present
between
pulp and cavity

11. INVOLVES
• Pulpotomy
Extirpation of pulp is
restricted strictly to the
coronal portion of pulp
chamber

12. MATERIALS USED
• MTA (Mineral trioxide aggregrate)

13. MATERIALS USED
• Calcium hydroxide

14. MATERIALS USED
• Formocresol (as an alternative to
calcium hydroxide)

15. PROCEDURE
• Anesthesia application and rubber dam
isolation
• The instrument of choice for tissue removal
is an abrasive diamond bur at slow speed
with adequate water-cooling
• Access is gained into the pulp chamber and
infected dentin partly removed
• Peripheral carious lesion removed with a
spoon excavator

16. PROCEDURE
• Anesthesia application and rubber dam
isolation
• The instrument of choice for tissue removal
is an abrasive diamond bur at slow speed
with adequate water-cooling
• Access is gained into the pulp chamber and
infected dentin partly removed
• Peripheral carious lesion removed with a
spoon excavator

17. PROCEDURE
• Anesthesia application and rubber dam
isolation
• The instrument of choice for tissue removal
is an abrasive diamond bur at slow speed
with adequate water-cooling
• Access is gained into the pulp chamber and
infected dentin partly removed
• Peripheral carious lesion removed with a
spoon excavator

18. PROCEDURE
• Anesthesia application and rubber dam
isolation
• The instrument of choice for tissue removal
is an abrasive diamond bur at slow speed
with adequate water-cooling
• Access is gained into the pulp chamber and
infected dentin partly removed
• Peripheral carious lesion removed with a
spoon excavator

19. • Following coronal pulp amputation, the
pulp chamber is rinsed with 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 blown on the exposed
pulp, as this may cause desiccation and
additional tissue damage.
PROCEDURE(CONT.)

20. • 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 restorative 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
PROCEDURE(CONT.)

21. • 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 restorative 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
PROCEDURE(CONT.)

22. • 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 restorative 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
PROCEDURE(CONT.)

23. • 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 restorative 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
PROCEDURE(CONT.)

24. PROCEDURE(CONT.)
• The patient should be re-evaluated every three months for the
first year, and then every 6 months for 2 to 4 years to determine
if successful root formation is taking place and that there are no
signs of pulp necrosis, root resorption or periradicular pathosis

25. Open apex Root formation
complete

26. CONTRAINDICATIONS
• Severe crown-root fracture
which requires intra-radicular
retention for restoration

27. CONTRAINDICATIONS
• Tooth with unfavourable
horizontal root fracture i.e.
close to gingival margin

28. CONTRAINDICATIONS
• Necrotic or non vital pulp

29. CONTRAINDICATIONS
• Unrestorable carious tooth

30. APEXIFICATION
The process of inducing a calcific barrier across an open apex of an immature, pulpless tooth
Definition:-

31. OBJECTIVE
To induce root end closure to form a complete calcific barrier at the apex with no
apparent pathosis

32. INDICATIONS
• Young immature,permanent non-vital teeth
• Open apex
• Blunderbuss canals
• Thin and fragile
canal walls
• Absolute dryness of
canal difficult to
achieve
Why apexification
preferred over RCT

33. MATERIALS USED
• MTA (mineral trioxide aggregrate)
• Collagen calcium phosphate gel
• Calcium hydroxide
• Osteogenic protein I and II

34. PROCEDURE
• Anaesthetize the tooth and isolate with rubber dam
• Gain straight line access to canal orifice
• Extirpate the pulp tissue remnants from the canal and irrigate it with sodium
hypochlorite

35. • Establish the working length of canal 2mm short of the radiographic apex of tooth
• Dry the canal with paper points
• Placement of appropriate material for apexification
• Material condensed with finger pluggers
• Effective temporary seal between visits is critical. Zinc oxide Eugenol cement or resin
modified glass-inomer cement is used
• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and
again filled with calcium hydroxide
PROCEDURE(CONT.)

36. • Establish the working length of canal 2mm short of the radiographic apex of tooth
• Dry the canal with paper points
• Placement of appropriate material for apexification
• Material condensed with finger pluggers
• Effective temporary seal between visits is critical. Zinc oxide Eugenol cement or resin
modified glass-inomer cement is used
• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and
again filled with calcium hydroxide
PROCEDURE(CONT.)

37. • Establish the working length of canal 2mm short of the radiographic apex of tooth
• Dry the canal with paper points
• Placement of appropriate material for apexification
• Material condensed with finger pluggers
• Effective temporary seal between visits is critical. Zinc oxide Eugenol cement or resin
modified glass-inomer cement is used
• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and
again filled with calcium hydroxide
PROCEDURE(CONT.)

38. • Establish the working length of canal 2mm short of the radiographic apex of tooth
• Dry the canal with paper points
• Placement of appropriate material for apexification
• Material condensed with finger pluggers
• Effective temporary seal between visits is critical. Zinc oxide Eugenol cement or resin
modified glass-inomer cement is used
• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and
again filled with calcium hydroxide
PROCEDURE(CONT.)

39. • Establish the working length of canal 2mm short of the radiographic apex of tooth
• Dry the canal with paper points
• Placement of appropriate material for apexification
• Material condensed with finger pluggers
• Effective temporary seal between visits is critical. Zinc oxide Eugenol cement or resin
modified glass-inomer cement is used
• Second visit at 3 months for monitoring the tooth, if symptomatic; canal is cleaned and
again filled with calcium hydroxide
PROCEDURE(CONT.)

40. PROCEDURE(CONT.)
• Patient is examined for radiographic evidence of calcific barrier at or
near root apex
• Confirm the progress of apexification by passing an instrument
through the apex after removal of calcium hydroxide
• Repeat the process if no satisfactory result found
• If apical barrier present, obturation is done

41. PROCEDURE(CONT.)
• Patient is examined for radiographic evidence of calcific barrier at or
near root apex
• Confirm the progress of apexification by passing an instrument
through the apex after removal of calcium hydroxide
• Repeat the process if no satisfactory result found
• If apical barrier present, obturation is done

42. PROCEDURE(CONT.)
• Patient is examined for radiographic evidence of calcific barrier at or
near root apex
• Confirm the progress of apexification by passing an instrument
through the apex after removal of calcium hydroxide
• Repeat the process if no satisfactory result found
• If apical barrier present, obturation is done

44. open apex fixation of root end

45. CONTRAINDICATIONS
• Very short roots

46. CONTRAINDICATIONS
• Vital pulp

47. CONTRAINDICATIONS
• Compromised periodontium