CONTENTS

1. Introduction to pulp therapy

2. Factors affecting appropriate pulp therapy
3. Goals of pulp therapy
4. Pathophysiology of pulp
5. Treatment modalities
6. Mortal pulpotomy
7. Pulpectomy
Indications and contraindications of pulpectomy for primary teeth
Access opening for pulpectomy
Anterior primary teeth
Posterior primay teeth
Technique
Canal cleaning and shaping
Isolation
Debridement
Apex locator(Root ZX)
Principles of Root ZX
Operator instructions for Root ZX
Importance of irrigation during treatment
Non vital discolored primary incisors
Decision to obturate
Root filling materials for primary root canals
Zinc Oxide Eugenol paste
Iodoform paste
Colla cote
Endoflas
Calcium hydroxide
Obturation of root canal

8. Follow up after pulpectomy in primary dentition

9. Apexification

Apexification technique
Artifical apical barrier technique
Restoration after apexification

10. Alternative to conventional apexification

Introduction
 Composition
Properties
Mechanism of action
Limitations
Pulp revascularization

11. Summary

12. References

INTRODUCTION

The treatment objectives in non vital pulp therapy for primary teeth are to
 Maintain tooth free of infection
Biomechanical cleanse and obturate the root canal
Promote physiologic root resorption, and
Hold the space for erupting permanent teeth

The treatment of choice to achieve these objectives is pulpectomy which involves the removal of
necrotic pulp tissues followed by filling the root canal with a resorbable cement.

Removal of abscessed primary teeth has been suggested because of their potential to create
developmental defects in underlying permanent successors.

Factors affecting appropriate pulp therapy

It is desirable to attempt to maintain the vitality of pulp of tooth affected or infected by caries,
traumatic injury or other causes. However, a tooth can remain functional without a vital pulp. It
is possible to reduce pulp autolysis or eliminate it entirely without significantly compromising
the function of tooth.

Treatment planning should include the following:

Is child a reasonable patient?

Considered the value of involved tooth in relation to childs overall development and
ability to operate in dental chair
Is the child medically fit?
Medical history is of great importance as those children who are more susceptible to
infections always be questionable cases for a successful pulp therapy.
Is the tooth restorable?
A tooth with extensive caries leading to gross destruction of coronal portion or a tooth
which has caries penetrating the pulp chamber is unrestorable.
Is it necessary to keep the tooth?
The amount of root remaining and the extent of bone loss that has occurred in supporting
structures will have significant bearing on preserving the tooth.
Are parents cooperative and they understand the importance of treatment options?
Parents consent in accepting the treatment and preventive programs, include periodic
evaluation should always be given prior consideration.

Goals of pulp therapy

The primary objective of pulp treatment is to maintain the integrity and health of oral tissues.
This may be achieved by keeping the following goals in mind:
To allow a tooth to remain in oral cavity in non pathological state.
To maintain arch length and tooth space.
To restore a tooth to its functionally efficient form.
 To prevent the development of aberrant habits and speech abnormalities.
To maintain the childs esthetics and thereby prevent any psychological trauma.
Pathophysiology of pulp

1. Painful pulpitis: It is clinically detectable inflammatory response of pulpal connective

tissue to an irritant.
2. Reversible pulpitis: The pulp is inflamed to the extent that thermal stimulae causes a
sharp, quick, hypersensitive response that subsides as soon as stimulus is removed.
Reversible pulpitis is not disease but merely a symptom. If the cause can be removed ,
pulp should revert to an uninflamed state and symptom should subsides.
3. Irreversible Pulpitis:It may be acute, subacute or chronic; it may be total or partial. It can
be symptomatic or asymptomatic Irreversible pulpitis.
4. Periradicular Diseases: It include

Acute alveolar abscess which is localised collection of pus in alveolar bone at

the root apex of pulpless tooth.

Chronic alveolar abscess is characterized by less soreness and better defined

radiographic picture. It results from long standing low grade infection.

Treatment Modalities
Pulp treatment can be classified into two categories:
1. Conservative treatment: which aims at maintaining pulp vitality, which include
Pulp protective base
Indirect pulp treatment
Direct pulp capping
Mortal pulpotomy
2. Radicular treatment: It consists of
Pulpectomy and root filling
Apexification
Mortal pulpotomy
Ideally a non vital tooth should be treated by pulpectomy and root canal filling. However,
pulpectomy of primary molars sometimes by impracticable due to non negotiable root canals and
also due to limited patients cooperation. Hence two stage pulpotomy technique is advocated.

Selection criteria

History of spontaneous pain

Swelling, redness or soreness of mucosa
Tooth mobility
Tenderness to percussion
Pulp at exposed site does not bleed
Nowadays the tooth with above mentioned selection criteria is considered for pulpectomy than
mortal pulpotomy

First appointment: In the first appointment the necrotic coronal pulp is removed the pulp
chamber is irrigated with saline and dried with cotton pellet, infected radicular pulp is treated
with a strong antiseptic solution such as beech wood cresol. Dip the pellet in beech wood cresol
and removed the excess by damping it on sterile cotton and place it in pulp seal with a temporary
cement for one or two weeks.

Second appointment: During the second appointment isolate the tooth, remove the temporary
dressing and the pellet containing beechwood cresol. Note that if the symptoms persists or if
there are no signs of resolution of the sinus, a decision must be made either to repeat the
treatment or to extract the tooth. If there is no symptom the pulp chamber can be filled with an
antiseptic paste. While filling the pup chamber the antiseptic paste can be firmly pushed into root
canals with cotton pellets. The tooth can be restored with stainless steel crown.

Pulpectomy
Pulpectomy and root canal filling procedures on primary teeth have been the subject of much
controversy fear of damage to developing permanent tooth buds and a belief that the tortuous
root canals of primary teeth could not be adequately negotiated, cleaned shaped, and filled have
lead to the needless sacrifice of many pulpally involved primary tooth. Much has been written
regarding potential demand to the developing permanent tooth bud from root canal fillings. The
extration of pulpally involved primary teeth and placement of space maintainers is an alternative
to pulpectomy. However there is no better space maintainer than primary tooth. If a space
maintainer is placed but adequately monitoring and preventive care in not achieved, further
problems often occur

For example, with a band and loop design of space maintainer, loose bands and poor oral
hygiene increases the risk of dental caries and gingival inflammation. Prolonged retention of the
appliance may causes deflection of erupting permanent tooth and premature loss of band can
result in loss of space particularly if the patient delays returning for treatment.

It has been reported that minor hypoplasia is increased in permanent successor teeth after root
canal treatment of the primary precursors. Others have reported no such increased effect and
concluded that defect result from the infection existing before the pulpectomy and not the
procedure itself.

Economics has been advance as an argument against endodontics treatment of primary teeth, but
it is not a reasonable argument when compared with the cost of space maintainers, including the
required follow up treatment.Infact endodontic treatment is probably the less expensive
alternative when the entire treatment sequence in considered.
Success of endodontic treatment on primary teeth is judged by same criteria that are used for
permanent tooth. The treated primary tooth must remain firmly attached and function without
pain or infection radiographic signs of furcal and periapical infection should be resolved with a
normal periodontal attachment.The primary tooth should resorb normally and in no way
interferes with the formation or eruption of the permanent tooth.

Success rate ranging from 75% to 96%have been reported. The usual means of studying root
canal filling on primary teeth have been clinical and radiographic. There exists a great need for
histologic study in this area.

Early reports of endodontics treatment on primary teeth usually involved devitalisaion with
arsenic in vital teeth and the use of creosote, formocresol or paraformaldehyde pastes in nonvital
teeth.

The canals are filled with a variety of materials, usually consisting of zinc oxide and numerous
additives.

Indications of pulpectomy in primary teeth

- Strategically important tooth(eg in case of deciduous second molar where the permanent
first moral has not erupted)
- Irreversible pulpitis
- Minimal periapical change with sufficient bone support
- Atleast 2/3rd of root length available.
- Internal resorption without an obvious perforation.

Contra indications of pulpectomy in primary teeth

- An unrestorable tooth

- Internal resorption in the roots visible on radiographs

- Teeth with mechanical or caries perforation of the floor of the pulp chamber.

- Excessive pathologic root resorption involving more than a third of the root.

- Excessive pathologic loss of bone support, with loss of normal periodontal attachment.

- Periapical or interradicular lesion involving the crypt of developing permanent successor.

- Presence of a dentigerous or follicular cyst.

Access opening for pulpectomy in primary teeth

Although apical foramen must be sealed by endodontic therapy, the root canal is what provides
the pathway to apex. These are the typical confrigurations of root canals. After the establishment
of a diagnosis and treatment plan the first part of treatment directly applied to tooth is access
cavity preparation known as endodontic entry. The canal preparation can be divided into coronal
phase and radicular phase.

Apical moisture proof seal, the first essential for success, is not possible unless the space to be
filled is carefully prepared and debrided to receive the final restoration.The coronal phase must
give direct access to root canals and apical foramina so that these may be properly cleaned and
shaped by intraradicular phase. Therefore all the treatment hinges on the accuracy and
correctness of the entry. If the access is improperly prepared as to position, depth or extent it will
be difficult to reach the optimal result.

Rules for proper access preparation

Endontic dogma : careful cavity preparation and root canal obturation are the keystones to
successful root canal therapy.

1. The objective of entry is to gain direct access to apical foramina and not merely canal
orifices.
2. Access cavity preparations are different from typical occlusal preparations and are not
guided by topography of the occlusal grooves, pits and fissures avoiding the underlying
pulp.
3. The likely interior anatomy of teeth under treatment must be determined for access
opening. Each tooth has a different length number and configurations of root canals and
so radiographs taken from different angles must be considered.
4. As a part of the access preparation, the unsupported cusps of posterior teeth must be
reduced to avoid weakening of the tooth structure.

I Access opening for primary anterior teeth- Access opening for Endodontic treatment on
primary or permanent anterior teeth have tradionally been through the lingual surface. This
continuous to be the surface of choice except for maxillary primary incisor. Because of the
problem associated with discoloration of endodontically treated primary incisors, it has been
recommended to use a facial approach followed by an acid itch composite restoration to improve
esthetics.

II Posterior Primary teeth- Access openings into the posterior primary root canals are essentially
the same as those for the permanant teeth. Important differences between primary and permanent
teeth are the length of crown, the bulbous shape of crowns and the very thin dentinal walls of
pulp chamber is much less than that in permanent teeth likewise, the distance from the occlusal
surface to the pulpal floor of the pulp chamber is much less than in permanent teeth. In primary
molars, care must be taken not to over instrument the relatively thin pulpal floor, owing to the
high risk of perforations.
When the roof of pulp chamber is breached and the pulp chamber identified the entire roof
should be removed. Because the crowns of primary teeth are more bulbous, less extension
toward the exterise of tooth is necessary to uncover the openings of the root canals than in the
permanent teeth.

Technique

As in permanent endodontic therapy, the main objective of the chemical and mechanical
preparation of primary tooth is debridement of the canals

Although an apical taper is desirable, it is not necessary to have an exact shape to canals because
obturation is achieved using a resorbable paste.

Canal cleaning and shaping

Isolation Use of rubber dam is essential in any endodontic treatment as it is the best method of
isolating the teeth from the oral cavity. First introduced by Barnum (1864) it is useful in
providing a clean, dry and sterilizable field.

Debridement : Canal cleaning and shaping is one of the most important phases of primary
endodontic therapy. The main objective of the chemico-mechanical prepartion of primary tooth is
debridement of canals.

The biomechanical preparation in primary teeth can be said to be different enough to warrant the
following considerations

1. Relative pulpectomy : Due to tortuous course of root canal coupled with numerous
accessory canals, the complete removal of pulp in primary teeth may often be difficult, if
not impossible. Thus, all such procedure can be regarded as partial pulpectomy
procedures.
2. Selective filling Resorption in primary teeth may have started at the time of treatment.
Also, the slender roots with apical tips may predispose the tooth to root fracture in case of
excessive preparation. Thus, the proceduce of selective filling of canals should be
followed. It is important to establish the working length to prevent over extension
through the apical foremen it is suggested that the working length be shortened, 2-3 mm
short of radiographic root length , especially in teeth showing apical root resorption signs.
Working length is determined by electronic apex locator.

Electronic apex locator(Root ZX)

Root ZX is a third generation electronic apex locator manufactured by J. Morita corp. It is a
device which can be used for measuring the working length. It consists of LCD monitor, a file
holder tip and a contrary electrode to complete the circuit.
 Working principal of root(ZX)-

The meter in display indicate the position of file tip. As file approaches the apex, audible alarm
will beep slowly when meter reaches 2 then bar indicate apical constriction of root canal flashes
on and off. A meter reading of 0.5 indicates that the tip of file is at apical constriction. At this
point of image of root canal will starting flashing and the sound of alarm will change. It is
essential that file to be taken to anatomic apex and then returned to apical constriction. This
ensure that all constrict ions that can occur in canal have been negotiated. It the file reaches the
major foramen sustained keep and the word Apex will flash.

Operator instruction for rootZX-

The operating instructions for Root ZX states,the working length of canal used to calculate the
length of filling material is actually somewhat shorter. Find the length of apical seat by
substracting 0.5-1.0 mm from working length indicated by 0.5 reading on meter. Clinician
should then adjust working length on endodontics instrument according to margin of safety.

Instruments should be gently curved to help negotiate the canals. This helps in maintaining the
original shape of canal proceeds in much the same manner as is done to receive gutta percha
fillings.

The canals are enlarged several files size past the first file that fit snugly into the canals with
minimum size of 30 to 35.

If the inflammation is beyond the coronal pulp with only interradicular but no periapical
radiolucency, a single visit pulpectomy is preferred. On the other hand, if the pulp is necrotic
with periapical involvement, filling procedure is delayed until a later time. After canal
debridement the canal is again copiously flushed with sodium hypochlorite and are then dried
with sterile paper points, a pellet of cotton is barely moistened with camphorated
parachlorophenol and sealed into pulp chamber with temporary cement. At a subsequent
appointment the canal is reentered. As long as patient is free of all signs and symptoms of
inflammation, the canal is again irrigated with sodium hypochlorite and dried preparatory to
filling.

Importance of irrigation During Treatment

Because many of pulpal infections ramification cannot be reached mechanically,Copious
irrigation during cleaning and shaping must be maintained. Debridement of primary root canal is
more often accomplished by chemical means than by mechanical means. Initially
RC_Prep(Premier Dental Product,Norristown PA) may be used as the canals are negotiated. It
will digest and emulsify pulp tissue and is an effective lubricant. Once a working length has been
established, the use of NaOcl solution to dissolve organic debris can play an important part in
removal of tissue from unaccessible areas of root canal system.

The NonVital discolored primary incisor

If a primary incisor is intrinsically discolored following loss of pulp vitality there may be an
esthetic need to improve the tooth color.Bleaching is not advised in primary dentition. The
anatomy of maxillary primary incisor is such that access may successfully be made from the
facial surface. The only variation to the opening is more extension to incisal edge than with the
normal lingual access to gives as straight approach as possible into the root canal.

The root canal is filled with ZOE near the cervical line. A liner of Dycal is placed over the ZOE
to serve as a barrier between composite resin and root canal filling. The liner is extended over the
darkly stained lingual dentin to serve as an opaque. The access opening and entire facial surface
are Acid etched and restored with composite resin.

The decision to obturate

After canal debridement, the canals are again copiously flushed with NaOCl and are then dried
with sterile premeasured paper points. If the canals are dry and there is no exudates, obturation
cannot be done in the first appointment, a slurry paste of nonsetting Ca(OH) 2 can be injected into
the canals tend the tooth restored with a well-sealing temporary restoration.

At a subsequent appointment, the rubber dam is placed and the canal is reentered. A long as the
patient is free of all signs and symptoms of inflammation the canals are irrigated with NaOCl for
removal of intracanal dressing and dried before obturation. If signs or symptom of inflammation
are present, the canal are recleaned and remedicated and the canal obturation delay until a later
time.

Root-Filling materials for the primary root canals

The ideal root canal filling material for primary-teeth should:

Resorb at a similar rate as the primary root

Be antiseptic

Fill the root canal easily

Adhere to the walls of the root canals

Not shrinks
 Be easily removed if necessary

Be radiopaque.

Not discolor the tooth.

No material currently available meets all these criteria.The filling materials most commonly used
for primary pulp canals are ZoE paste, iodoform paste and Ca(OH)2

1. Zinc Oxide-Eugenol Paste: Zinc oxide eugenol paste (ZOE) is probably the most
commanly used filling material for primary teeth. Most reports in U.S literature have
advocated the use of ZOE as the fitter, where as other parts of world have used iodoform
containing paste. The antibacterial activity of ZOE has been shown to be greater than that
of an iodoform containing paste, whereas its cytotoxicity in direct and indirect contact
with cells is equal to and less than that of KRI. The filling material of choice in US is
ZOE without catalyst. The lack of catalyst is necessary to allow adequate working time
for filling the canals. Camps in 1984 introduced the endodontic pressure syringe to
overcome the problem of underfilling, a relatively common finding when thick mix of
ZOE is employed. Underfilling however is frequently clinically acceptable. Overfilling
may cause a mild foreign body reaction. Another disadvantage of ZOE paste is difference
between its rate of resorption and that of tooth rate.

2. Iodoform paste: Since authors have reported the use of KRI paste, It resorbs rapidly and
has no undesirable effect on succedaneous tooth when used as a pulp canal medication in
abscessed primary teeth. Further, KRI paste that extrudes into the periapical tissue is
rapidly replaced with a normal tissue. It is also found to have a long lasting bactericidal
potential. Since iodoform paste does not set into hard solid mass, it can be removed if
retreatment is required. KRI was found to have a success rate of 84% as compared to
ZOE, which showed a success rate of only 64%

A paste developed by maisto has been used clinically for many years and good results
have been reported with its use. This paste has the same composition as KRI paste with addition
of Zincoxide, thymol and ranolin.

3. Colla cote: It is soft, white, pliable,biocompatible sponge obtained from bovine collagen.
It can be absorbable collagen which prevent or diminishes extravasation of root canal
filling materials during molars pulpectomies. Apart from its use in endodontic therapy it
can also provide a scaffold for bone growth and so it can be applied on the wound.

4. Endoflas: It is a root canal sealer material, which is composed of zincoxide, calcium

hydroxide, eugenol and pentachlorophenol. It can be used as alternative root canal
 material for primary teeth. One condition for the success of endoflos is prevention of
microleakage. A permanent restoration should be placed as soon as possible after clinical
signs and symptoms of inflammation are eliminated.A retrospecific study done on the
primary teeth using endoflos has shown success rate of 70%..

5. Calcuim hydroxide: This material is generally not used in pulp therapy for primary teeth.
However several clinical and histopathological investigations of calcium hydroxide and
iodoform paste have been published by fuchino and nishino(1980). This material was
found to be easy to apply and resorbs at slightly faster rate than that of root. It has no
toxic effect on permanent successor and is radiopaque. For this reason iodoform-calcium
hydroxide mixture can be considered to be nearly ideal primary root canal filling
material.

Chawla et al(1998)carried out a pilot study in mandibular primary molars using calcium
hydroxide paste as a root canal filling material and found it to a success.

Obturation of primary root canal is usually performed without a local anaesthesia. This is
preferable, if possible so that the patients response can be used to indicate the proximity to
apical foramen. It is however, sometimes necessary to anaesthetize the gingival with a drop of
anaesthetic agent to place the rubber dam clamp without pain.

Obturation of root canal

The chosen obturation technique depends upon the material employed and accessibility of canal
to relevant instrument. If using ZOE, it is mixed to thick consistency and carried into pulp
chamber with a plastic instrument or on a lentulo spiral.

A cotton pellet held in cotton plier and acting as a piston within the pulp chamber is quite
effective in forcing the ZOE in the pulp chamber. The endodontic pressure syringe is also
effective in placing ZOE in canal.

When the root canal is filled with a resorbable material such as KRI, maisto or endoflos a lentulo
spiral mounted in low speed handpiece can be used to introduce material into the canal.

When the canal is completely filled, the material is compressed with cotton pellet. Excessive
material is rapidly resorbed.

Regardless of the method used to fill the canal, care should be taken to prevent extrusion of
material into periapical tissue. It has been reported a significantly a greater failure rate occur with
overfilling of ZOE than filling just to apex or slightly underfilled.

In the event a small amount of ZOE is inadvertently forced through the apical foramen it is left
alone.
When canals are satisfactorily obturated a fast setting temporary cement is placed in pulp canal
to seal over the root canal filling. The tooth can be than restored permanently. In the primary
molars it is advisable to place a preformed crown as a permanent restoration to ensure good
coronal seal and prevent possible fracture of tooth.

It a primary teeth requires a pulpectomy and the permanent successor is absent the primary root
canals are filled with gutta percha and sealer in attempt to retain primary tooth long term.

Follow up after pulpectomy in primary teeth

As previously stated the rate of success after primary pulpectomy is high. However these tooth
should be periodically recalled to check for success of the treatment and intercept any problem
associated with a failure. It has been reported that pulpectomized primary tooth may show
delayed exfoliation. It has been reported that 20% incident of cross bite or palatal eruption of
permanent incisors after pulpectomy. In posterior teeth extraction was required in 22% of cases
because of ectopic eruption of premolar or difficulty in exfoliation of treated primary molars.
After normal physiological resorption of root reaches pulp chamber, large amount of ZOE
present may repair the resorptive process and lead to retention of crown. Treatment consist of
simply removing the crown and allow permanent tooth to completely erupt.

Retention of ZOE in tissues is complete sequela to primary pulectomy. Teeth filled short of
apices has significantly less retentive filler and in time most showed complete absorption or
reducing amount. Therefore no attempt is made to remove retained filler from tissue.

While resorbing normally without interference from eruption of permanent tooth, the primary
tooth should remain asymptomatic, firm in alveolus and free of pathosis. Traditionally root
treatments were considered successful when no pathological resorption was associated with bone
rarefaction was present. If evidence of pathosis is detected, extraction and conventional space
maintenance was recommended.

Investigators claimed that most clinicians are prepared to accept pulp treated primary teeth that
have a limited degree of radioluceny or pathological root resorption in absence of clinical signs
and symptoms. This is contingent on the assurance that parent will contact the clinician if there is
an acute problem and the patient will return to review in 6 months. These criteria seem to be
more suitable for pediatric dental practices and have been adopted clilinically by Fukset al, they
consider such teeth to be Successfully treated.

Apexification
Apexification or root end closure is a process whereby a nonvital, immature, permanent tooth
which has lost the capacity for further root development is indicated to form a calcified barrier at
the root terminus. This barrier forms a matrix against which root canal filling restorative material
can be compacted with length control.
Unlike the pulp capping, pulpotomy and apexogenesis procedure , apexification will at best
result in closure of the root end and cannot be expected to cause further root development in
terms of length of wall thickness. Apexification is thus regarded as a treatment of last resort in
immature tooth which has lost pulp vitality. The growing body of recent evidence on pulp
regeneration, even in infected, non vital, immature tooth may also relegate this approach to
history archieves in the years to come.

For now root end closure technique both those involving the generation of biologic calcific
barrier and those involving artificial root end closure with a material such as MTA still have a
place in practice and will be considered.

Before introduction of conventional apical root closure techniques, the usual approach to this
could be successful, psychological and patient management issue in patient who were young
children offered many contraindications.Local dental considerations presented a further
disincentive including the worsening the crown/root ratio if further root reduction was required
to achieve a seal, and the intrinsic difficulties of sealing a fragile, incompletely formed apex with
traditional materials. A predictable and less traumatic approach was desirable.

Until the most widely accepted technique has involved cleaning and filling the canal with a
temporary paste, most commonly Calcium hydroxide, which was replaced at intervals over
several months to stimulate the formation of apical calcified barrier.

Diagnosis of pulp necrosis in tooth with an incompletely formed apex is often difficult with
electronic pulp tester rarely providing meaningful and thermal test often giving equivocal or
false result in children and traumatized tooth. The presence of acute and chronic pain, percussion
sensitivity, mobility, coronal discoloration or a discharging sinus may be helpful guide, whereas
radiographic diagnosis can be complicated by normal radioluciences appearing at the apices of
developing teeth comparison of root formation with contralateral teeth should always be
considered.

If any doubt persist, it is usually wise to adopt a watch and wait approach before entering
primary teeth endodontically. Only when there is convincing evidence of pulp breakdown should
the tooth be entered and exposed dentin in the interim be covered to reduce the risk of microbial
entry to potentially compromised pulp.

Many materials have been reported to successfully stimulate apexification. The use of nonsetting
calcium hydroxide was first reported. For historical perspective calcium hydroxide powder has
been mixed with CMCP, metacresyl acetate, crescenol, physiological saline, ringer solution,
distilled water and anaesthetic solution. The addition of 1:8 barium sulphate to calcium
hydroxide enhanced radiopacity with no apparent adverse effect on apexification.

The most important factor in achieveing apexification seem to be thorough debridement of root
canal and sealing the tooth. Apexification doesnot occur when the apex of tooth penetrate the
cortical plates. To be successful the apex must be completely within the confines of cortical
plates.

Apexification Technique

In apexification technique the canal is cleaned and disinfected in line. The use of rubberdam is
mandatory and resourcefulness may be needed to isolate partially erupted or damaged teeth in
children.

The access opening may require some extension especially in anterior teeth to accommodate the
larger instrument to clean the root canals, but care should be taken not to heavily instrument the
already thin or fragile walls of root. Neither should operator deceive themselves that they are
able to stir the instrument against all the walls system of canal debridement partially in diverging
canals.

The length of canal is established by radiograph since the absence of apical constriction may
make electronic methods unreliable. A constant drying point, determined with paper point,may
provide additional information on length. Irrigation is central to debridement of immature teeth,
Any with proper precautions operator should not hesitate to benefit from antimicrobial and tissue
solvent properties of NAOCL. Sonic or Ultrasonic or any other vibratory devices capable of
activating the irrigant within canal may be advantageous and benefit may also come from use of
small brushes of sort that are designed for interproximal brushing or application of etchants to
post channels.

After thorough debridement canal is dried and medicated with fluid Calcium hydroxide paste,
carried into canal with lentulo spiral or injected from proprietary paste syringe. There is little
evidence to commend any commercial calcium hydroxide paste over another in this application.
The tooth is then sealed coronally and patient is recalled at 3 month interval to wash out calcium
hydroxide paste and inspect clinically and radiographically for development of calcific barrier.
Treatment typically extend over 9 to 24 months with obvious demand of patient and parent
compliances while risking tooth embrittlement and cervical root fracture following long term
medication with calcium hydroxide.

Histologic studies consistenly report the absence of hertwig's epithelial root sheath and normal
root formation should never be anticipated . Instead these appear to be differentiation of adjacent
connective tissue cells into specialized cells there is also deposition of calcified tissue barrier
adjacent to filling material. The calcified mass thus formed over the apical foramen was
histologically identified as osteoid or cementoid material. The closure of apex may be partial or
complete but consistently has minute communication with periapical tissue. For this reason
apexification stimulated by paste should always be followed by obturation of canal with
permanent root canal filling , traditionally of thermoplastic gutta percha and sealer, though MTA
would be cotemporary alternative.

Artificial apical barrier technique

Investigators reported that the use of tricalcium phosphate as an apical barrier in 1979. The
material was packed into apical 2mm of canal against which gutta percha was packed. The
treatment was completed in one appointment, and radiographic assessment confirmed successful
apexification comparible to achieved by Calcium hydroxide. Calcium hydroxide powder has also
been successfully used as an apical barrier against which to pack gutta percha.

MTA barrier technique: In the apexification technique, canal is cleaned and disinfected as
described for calcium hydroxide apexification. Research has suggested that tissue pH may affect
hydration reaction and final physical properties of MTA and it has become standard practice to
medicate canal for 1 week with calcium hydroxide to raise acidic pH of inflamed periapical
tissue before permanently sealing.

When tooth is free of signs and symptoms of inflammation it is reisolated with rubber dam and
calcium hydroxide washed free, often with help of ultrasonics and small brushes. After drying
the canal, the canal is filled incrementally with MTA, delievered to canal to dedicated MTA
carrier or deposited in small canal from amalgam gun.The material can then be worked up canal
with premeasured pluggers and set some 1 to 3mm short of root end, often the help of sonic or
ultrasonic energy to settle the material. An apical plug of 4 to5mm thickness is considered
optimal.

All excess MTA is removed from canal wall by scrubbing with large moistened paper points or
brushes. Meticulous cleanup is important to allow optimal bonding of subsequent composite
resin restoration, which will exceed deeply into canal and offer internal reinforcement of fragile
root.

A very wet cotton pellet is placed in canal to provide moisture for setting reaction. The pellet
should not be in contact with MTA because fibers of cotton will become impregnated into
material. Excess water in access preparation is dried with cotton pellet and opening sealed with
provisional restorative material such as cavit. At subsequent appointment, the tooth is reisolated
and hard set of MTA verified with an endodontic file or probe. If for some reason MTA has not
hardened canal can be recleaned and procedure repeated before final bonded restortion.

Restoration after apexification

Immature teeth and particularly whose which are pulpless and have undergone apexification are
at high risk of fracture. Within 3 yrs of long term calcium hydroxide medication and root filling
with gutta percha it is reported that 28% to77% of immature teeth suffered cervical root fracture.
The degree of dental development appeared to be key variable. Clinically it is impression of
authors that MTA plug technique in combination with internal placement of bonded composite
resin appears to have virtually eliminated cervical root fractures. A 2004 study demonstrated a
significantly greater resistance to root fracture after placement of 4mm thick apical plug of MTA
followed by composite resin when compared gutta percha with MTA and sealer. Root
reinforcement have been reported to improved by cementation of metal post within channel
created by removal of light transmitting composite curing post. The potential of fibers reinforced
post would be also appear great though little clinical evidence has yet been published on
treatment of immature teeth.

Alternative material which has been suggested to bond and reinforce fragile roots include resin
modified glass ionomer cement.

Bonding dual or light curing composite resin directly over MTA plug with no interposing layers
of gutta percha have become an established clinical method.Care should be taken to etch and
bond the canal according to manufacturers instructions with proper wash out of Echant and
avoiding gross pooling of unfilled resin. Complete resin infiltration of dentin cannot be
guaranteed in the depths of root canal, and potential exists that host derived metalloproteinases
liberated by acid etching may degrade resin-dentin bonds with time.

Clear light transmitting posts have been developed to ensure complete bonding of deep
increments of light activated composite. This may be less of an issue with dual curing materials.

If a core is needed for crown placement, Luminex post without serration is used for curing the
composite. Because the composite does not bond to smooth post, It can be gently removed and
corresponding metal dentatus post cemented into space with resin cement. A composite buildup
for crown retention may then be completed.

A variety of commercial quartz and glass fiber post systems are available for use in such
applications, ensuring the delivery of light deep into canal system and offering the potential for
internal reinforcement. The heads of fiber posts should always be covered with composite resin
to prevent them for absorbing oral fluids and delamination.

Alternative to conventional apexification

* A primary objective in endodontic therapy is the complete obturation of root canal space . A
good apical stop is an essential factor in achieving this goal . It effectively confines the filling
material to canal space and allows the application of adequate condensation forces to yield an
acceptably dense filling . Immature pulpless teeth present special problems in adherence to these
objective.These teeth have parallel or divergent walls in apical third which make a normal
development of an apical slop impossible . This lead to an inability to confine the filling material
to canal space .

* Mineral trioxide aggregate or MTA, is a new material developed for endodontics that appear to
be significant improvement over other materials for procedure in bone . It is first restorative
material that consistently allows for overgrowth of cementum, and it may facilitates the
regeneration of periodontal ligament.

* MTA was first describes in dental literature in 1993 by Torabinejad for repair of lateral root
perforations .

It have been evaluated for several applications in dentistry such as root end filling , direct
pulp cap , perforation repairs , apexifications and pulpotomy .

Composition

* Tri calcium silicate .

* Di calcium silicate .

* Tri calcium aluminate .

* Calcium sulphate dehydrate .

* Bismuthoxide .

Properties

* PH is 12.5

* Setting strength is similar to IRM (70 Mpa )

* Has no cytotoxic effect .

* Long term success in primary tooth pulpotomy .

* Biocompatible .

* Provides a good seal .

* Available in form ,which sets in presence of moisture (4 hrs ).

* Promotes hard tissue formation .

* Takes lesser time for biological barrier formation as compared to calcium hydroxide , though
they are equally efficacious in apexification .

Mechanism of action
Stimulated cytokine release from bone cells .

Limitations

* Cost

* Problems of storage

Schwartz et al(1999 )reported the use of MTA as :

1 First appointment :- Calcium hydroxide was used and the tooth was temporized .

2 second appointment ( 3 weeks later ) :- The tooth still had a sinus tract .

3 Third appointment :- The sinus was healed . A thick mix of MTA and saline was introduced
into the canal , left to set overnight . The next day the tooth was obturated with gutta - percha .

The tooth was found to be asymptomatic with normal periapical structures at 9 and 20 months
recall. Metapex ( calcium hydroxide and iodoform ) can also be tried for apexification in young
permanent teeth as it may help in continued root regain instead of barrier formation.

Pulp Revascularization

Pulp revascularization is defined as a biologically based procedure designed to replace damaged

structures and regeneration of cells of pulp - dentin complex .

The goal form an endodontic perspective is to :-

* Regenerate a pulp dentin complex .

* Continued root development for immature teeth.

* Prevent or resolve apical periodontitis

Indications

* Immature tooth . open apex.

* Necrotic pulp.

* Periradicular periodontitis .

* Young patients ( better chances of Revascularization )

Contraindications
* Sensitively to antibiotic medication .

* mature / closed apex.

Critical steps for pulp revascularization

1 An immature tooth with a wide open apex

2 Disinfection

3 Regeneration

4 Coronal seal .

Recent studies have confirmed the potent antibacterial properties of triantibiotic paste used can
find a way to synthetics matrix that will act as more predictable scaffold for new ingrowth of
tissue .

Tri Mix Medications

250 mg ciprofloxacin . ( 1 tablet of 250 mg )

250 mg metronidazol . ( 1 tablet of 250 mg )

250 mg minocycline . ( 5 capsules of 50 mg each ).

* Metronidazol is bactericidal mainly against anaerobes

* Ciprofloxacin , a quinolines , is also bactericidal, but primarily against gram negative bacteria
and partially against gram positive bacteria

* Minocycline , a bacteriostatic against anaerobes mainly and partially against gram positive and
negative bacteria .

Summary

Non vital pulp therapy aims in maintaining tooth free of infection , achieving biomechanical
cleansing and canal obturation , promoting physiological resorption and maintaining space and
function .
 Treatment of choice can be pulpectomy and root filling , apexification or extraction and
placement of space maintainers .

Extraction and placement of space maintainers is the last alternative for non vital tooth ,
however there is no better space maintainer than primary tooth .

Endodontic treatment include the treated primary tooth which remains firmly attached and
function without pain or infection . Radiographic signs resolves with a normal peridontal
attachment and in no way interferes with formation and eruption of permanent tooth .

References
*Textbook of pedodontics - Shobha Tandon

* Pathway of pulp - Cohen Hargreaves

* Textbook of Endodontics - Ingle Bakland .