10/3/2013

Non Vital Immature teeth

Dr Tarun Walia

Immature teeth
Most commonly traumatized teeth : C.I Peak incidence of trauma : 8-10 yrs Age when roots of incisors developing If pulp becomes necrotic at this stage No further development & maturation of root Results in an open apex & incomplete root development Endodontic management of such teeth difficult: Walls of root canals divergent Apices being open : debridement & obturation difficult

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Apexification

Apexification
Method of inducing apical closure by formation of osteocementum or similar hard tissue or continued development of roots where pulp is no longer vital Indications : Non vital young permanent teeth with immature root apices with : - Painless discolored tooth with associated sinus - Painful mobile tooth with soft tissue swelling - RG : presence of periapical pathology

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Technique - Apexification
L.A administration & isolation Prepare access cavity straight access to canal Must be sufficiently large to enable proper instrumentation as divergent canal walls in apical area Establish working length Debridement of RC with Naocl Child reclined with chin raised ensuring coronal end of root canal higher than apical end Ca(OH)2 paste introduced in the canals with lentulo Excess paste from chamber removed by excavator Access cavity sealed with reinforced ZnOE

Technique Apexification (Contd)

Tooth to be evaluated every 2 months clinically & RG Ca(OH)2 paste to be replaced after 2 months only, if - if it resorbed in apical 1/3 rd of root canal This is repeated until apical closure occurred Clinical Assessment : Asymptomatic, ABF (apical barrier formation) verified Introduce a GP cone in canal & slowly tapping it with a finger towards apex. - If obstruction met without pain then calicified bridge - If pain, then GP point striking against bone

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Technique Apexification (Contd)

Radiographic Assessment : Healing of periapical lesion Appearance of lamina dura Calcified apical closure (bridge formation) During interim visits, if Ca(OH)2 needs to be removed - Paste does not set (non resorbable paste) - Thorough root canal irrigation with normal saline Once apical barrier formation confirmed, obturation Follow up visits at every 6 months Restore with composite etch technique

Time taken for Apical barrier formation

Size of apical foramen at start of treatment : Apex less than 2 mm shorter time Age : Younger age take relatively longer time Infection : Presence of periapical radiolucency increases barrier formation time Frequency of Ca(OH)2 dressings : no census Interappointment painful symptoms : increases time Average time for ABF using Ca(OH)2 paste: 6-12 months

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Technique - Apexification

Technique - Apexification

10/3/2013

Molar - Apexification

Open apex

Ca(OH)2 paste

After 2 months

GPF

6 mons post GPF

1 year post GPF

Commercially available Ca(OH)2 paste Non resorable paste

Reogan Rapid (Vivadent) Pulpdent Ca(OH)2 paste (Pulpdent) Apexcal Hypocal Ultracal (Ultradent)

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Modes of Apical barrier formation

1. Radiographically identifiable barrier at apex

2. Calcific barrier forms within the canal coronal to apex

Modes of Apical barrier formation

Bridge formation detected clinically but not RG

Continued development of root to give a near normal appearance of apical aspect of root

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MTA
Mineral Trioxide Aggregate Developed in Loma Linda University, California First used as root end filling material in surgical endodontic treatments Now used in various clinical situations : Perforations, Root #, DPC, Pulpotomies, Apexification Composition : Similar to Portland cement Oxides of Zinc, Aluminium & Calcium

Technique Apexification with MTA

Procedure similar to Ca(OH)2 apexification Steps same till introduction of Ca(OH)2 paste in canal MTA Paste available in powder, mixed with water into creamy consistency Insert in canals with special carrier till apical 3rd Initial hardness takes time upto 4 hrs Completely hard in 72 hrs Once hard, proceed with GP obturation conventionally Some researchers advocates initial dressing of Ca(OH)2 paste to sterilize the canal

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MTA - Apexification

Commercially available MTA

ProRoot MTA (Dentsply) White ProRoot MTA (Dentsply) MTA Angelus (Solucoes) MTA Bio (Solicoes)