Escolar Documentos
Profissional Documentos
Cultura Documentos
Dentistry
Indroduction
Despite the modern advances in prevention of
dental caries and an increased understanding
of the importance of maintaining the natural
dentition, many teeth are still lost
prematurely.
The primary objective of pulp treatment of an
affected tooth is to maintain the integrity
and health of oral tissues
Formation
Odontoblasts form dentin. Dentin is formed continuously
throughout the life of the tooth. Odontoblasts can also
form a unique type of dentin in response to injury, such as
occurs with caries, trauma, and restorative procedures.
Nutrition
Via dentinal tubules, pulp supplies nutrients that are
.essential for dentin formation and hydration
Defense
Odontoblasts form dentin in response to injury,
particularly when the original dentin thickness has
been compromised by caries, wear, trauma, or
restorative procedures. Pulp also has the ability to
elicit an inflammatory and immunologic response in an
attempt to neutralize or eliminate invasion of dentin
by caries-causing microorganisms and their
.byproducts
Sensation
Through the nervous system, pulp transmits
sensations mediated through enamel or dentin to
.the higher nerve centers
DIAGNOSIS OF PULP
PATHOLOGY
1. PAIN
An accurate history must be obtained of the type of pain, duration, frequency, location,
spread, aggregating and relieving factors.
Mode: is the onset spontaneous or provoked?
Frequency: have the symptoms persisted since they began/ have they been intermittent?
PERCUSSION. 4
Pain from pressure on a tooth indicates that periodontal ligament is
inflamed. A useful clinical test is to apply finger pressure to the
tooth and check the childs response by watching the eyes. (Ref B,
pg 174-175)
PALPATION. 5
Simple test done with fingertips using light pressure to examine
tissue consistency and pain response. It determines presence,
intensity and location of pain and presence of bony crepitus. (Ref B,
pg 174)
RESTORABILITY. 6
Only a tooth which can be restored after endodontic therapy should
.be considered for pulp therapy
PULP TESTING. 11
Pulp testing is widely used to assess vitality of mature permanent
teeth but these are not reliable in deciduous teeth as fear of
unknown makes the child patient apprehensive of the electric
vitalometer and may give inaccurate results. Another reason is that
newly erupted teeth may have incomplete innervations and there fore
.may not give correct results
Thermal test: This was first reported by jack in 1899 and it(1
involved application of cold or heat to determine sensitivity to
.thermal changes
Cold test: It can be applied in several different ways like stream of
cold air, cold- water bath, ethyl chloride, dry ice, pencil of ice. Agent
is kept on the middle third of the facial structure of crown for 5
.seconds and the response is determined
Heat test: These include warm sticks of temporary stopping, rotating
dry prophycup, heated water bath, hot burnisher, hot gutta - percha
.and hot compound
PHYSIOMETRIC TEST. 14
It describes such tests that assess the state of the pulpal circulation,
rather than the integrity of the nervous tissue thus providing valuable
.information
PHOTOPLETHYSMOGRAPHY. 15
This method involves passing light on the tooth and measuring the
existing wavelength using a photocell and galvanometer. If a tooth
with an intact blood supply is warmed there should be vascular
.dilatation, and this would register as a current from the photo cell
THERMOGRAPHY. 16
A hot object emits infrared radiation in proportion to its
temperature. Measurement of this radiation may provide information
on pulpal circulation. (Ref B, pg 175-176)
PULP HAEMOGRAM. 17
It was suggested that taking the first drop of blood from an exposed
pulp and subjecting it to differential white cell count might be useful
.in diagnosis of pulpal conditions
PULSE OXIMETRY. 22
It is proven atraumatic method of measuring
vascular health by evaluating oxygen saturation.
Pulse oximetry is based on placing arterial blood
between light source and detector. Light source
diode emits both infrared and red light, which
is received by a photo -detector diode. Blood
pulsating through the vessel changes the light
path, which modifies the amount of detected
. light. This determines the pulse rate
EVALUATION OF TREATMENT PROGNOSIS BEFORE PULP
THERAPY
The diagnostic process of selecting teeth that are good candidates
:-for vital pulp therapy has at least two dimensions
Dentist must decide that the tooth has a good chance of . 1
. responding favorably to the pulp therapy
The advisability of performing the pulp therapy and restoring the . 2
.tooth must be weighed against extraction and space management
pulpoctomy
apexogenesis
-Direct
-indirect
- Devetalization
-Preservation
-Regeneration
-Complete
-partial
apexification
pulpectomy
Non-Vital pulpotomy
-Beachcresal
-Formacresol
INDICATIONS
CONTRAINDICATIONS
OBJECTIVES
The restorative material should seal completely the involved . 1
.dentin from the oral environment
.The vitality of the tooth should be preserved. 2
No prolonged post-treatment signs or symptoms of sensitivity, . 3
.pain or swelling should be evident
The pulp should respond favourably and tertiary dentin or. 4
reparative dentin should be formed, as evidenced by radiographic
.evaluation
There should be no evidence of internal resorption or other. 5
pathologic changes. (Ref I, pg 336)
.Arresting of carious process. 6
.Promoting dentin sclerosis. 7
.Stimulating formation of tertiary dentin. 8
. Remineralization of carious dentin. 9
Indirect pulp therapy is a technique for avoiding pulp exposure in the treatment of teeth
with deep carious lesions in which there exists no clinical evidence of pulpal degeneration or
periapical disease.
The procedure allows the tooth to use the natural protective mechanisms of the pulp
against caries. It is based on the theory that a zone of affected, demineralized dentin
exist between the outer infected layer of dentin and the pulp. When the infected dentin is
removed, the affected dentin can remineralize and the odontoblasts form reparative
dentin, thus avoiding pulp exposure
Kopel has identified three distinct layers in active caries:1. Necrotic, soft dentin not painful to stimulation and grossly infected with bacteria.
2. Firm but softened dentin, painful to stimulation but containing few bacteria.
3. Slightly discolored, hard, sound dentin containing few bacteria and painful to stimulation .
Periodic follow up of the tooths history along with pulp vitality testing
and radiographic assessment is necessary. Indirect pulp capping is the
excellent and conservative treatment option for some deep carious
lesions in permanent teeth (especially if it avoids complete root canal
treatment). It should be emphasized that the indirect pulp cap
procedure is intended to avoid direct caries exposure.
Previous remaining carious dentin will have become dried out, flaky and
easily removed.
The area around the potential exposure will appear whitish and may be
soft; which is predentin. Do not disturb this area.
A) CARIOUS
LESION
APPROACHING
B) GROSS CARIES
EXCAVATION
C )MEDICAMENT PLACED
PULP
C )MEDICAMENT PLACED
Affected dentin
Intermediately
demineralized
Remineralizable
Deeper layer
Sensitive
Does not stain
Ultrasyructure:
intertubular dentin
Partially demineralized,
but apatitie
crystals bound like
fringes to the
Sound collagen fibers
with distinct
Cross bands and
interbands.
Should be left
remineralize.
N.Bs
1)In its classical application, the indirect pulp cap was covered with
zinc oxide-eugenol cement, and following several weeks' observation,
the cavity was re-entered to remove all remaining softened dentine.
More commonly, the calcium hydroxide pulp cap is simply covered with
a layer of hard setting cement and the tooth permanently restored at
the same visit. Periodic clinical and radiographic review is then
undertaken to monitor the pulp respons.
2)the presence of carious enamel and dentin at the margins of the
cavity will prevent the establishment of an adequate seal (extremely
important) during the period of repair.
CONTRAINDICATIONS
1. Large pulp exposures.
2. Presence of caries surrounding the exposure site.
3. Excessive bleeding indicates hyperemia or pulpal inflammation.
4. Pain at night.
5. Spontaneous pain.
6. Tooth mobility.
7. Thickening of periodontal membrane.
8. Intraradicular radiolucency.
9. Purulent or serous exudates.
10. Swelling.
11. Fistula.
12. Root resorption.
13. Pulpal calcification.
OBJECTIVES
1. The vitality of tooth should be maintained.
2. No prolonged post-treatment signs or symptoms of sensitivity,
pain or swelling should be evident.
3. Pulp healing and tertiary dentin formation should result.
4. There should be no pathologic change.
5. To create new dentin in the area of the exposure and subsequent
healing of pulp.
TREATMENT CONSIDERATIONS
:Debridement
Necrotic and infected dentin chips have to be removed else they will
invariably be pushed into the exposed pulp during last stages of
caries removal and impede healing and increase pulpal inflammation.
Therefore it is prudent to remove all peripheral caries. If exposure
occurs, non irrigating solution of normal saline or anesthetic solution
is used to cleanse the area and keep he pulp moist.
TECHNIQUES OF DIRECT PULP CAPPINGRubber dam provides only means of working in a sterile environment,
so it has to be used.
Place the pulp capping material, on the exposed pulp with application
of minimal pressure so as to avoid forcing the material into pulp
chamber.
Isobutyl cyanoacrylate:
It is an excellent pulp capping agent because of its haemostatic and
bacteriostatic properties; at the same time it causes less inflammation
than calcium hydroxide. But it can not be regarded as an adequate
therapeutic alternative to calcium hydroxide since it does not produce
a continuous barrier of a reparative dentin following application of the
exposed pulp tissue.
Disadvantage is that it is cytotoxic when freshly polymerized.
Denaturated albumin:
This protein has calcium binding properties. If a pulp exposure is
capped with a protein, the protein may become a matrix for
calcifation, thereby increasing the chances of biologic obliteration.
Laser:
ANDREAS MERITZ 1n 1998 evaluated the effect of direct pulp
capping.
Bone morphogenic protein (BMP):
The demineralized bone matrix could stimulate new bone formation
when implanted to ectopic sites such as muscles.
The implications for pulp therapy are immense as it is capable of
inducing reparative dentin.
APPLICATIONS
1.
2.
3.
4.
5.
PULPOTOMY
DEFINATION-:
Finn (1995) defined it as the complete removal of the
coronal portion of the dental pulp,followed by placement of a
suitable dressing or medicament that will promote healing and
.preserve vitality of the tooth
INDICATION-:
1)Carious or mechanical exposure of vital primary teeth and young
permanent teeth,where inflammation is restricted to coronal
pulp only.
2) History of only spontaneous pain.
3) Hemorrhage from exposure sites bright red and be controlled.
4)
5)
6)
7)
-:CONTRAINDICATION
1. History of spontaneous pain
2. Swelling
3. Fistula
4. Tenderness to percussion
5. Pathological mobility
6. External/internal root resorption
7. Periapical or interradicular radiolucency
8. Pulp calcifications
9. Pus or exudate from exposures site
10. Uncontrolled bleeding from the amputated pulp stump
11. Root resorption more than 1/3rd of root length
12. Large carious lesion with non-restorable crown
13. Highly, viscous, sluggish hemorrhage from canal orifice, which is
uncontrollable
14. Medical contraindications like heart disease,
immunocompromised patient
Other name
Features
Examples
Devitalization Mummification
, cauterization
It is intended to
destroy or mummify
the vital tissue.
Single sitting
Formocresol
Electrosurgery
Laser
Two stage
Gysi triopaste
Easlicks formaldehyde
Paraform devitalizing paste
Preservation
Minimal
devitalization,
noninductive
This implies
maintaining the
maximum vital
tissue,with no
induction of
reparative dentin.
ZnO Eugenol
Glutaraldehyde
Ferric sulphate
Regeneration
Inductive,
reparative
Ca(OH)2
Bone morphogenic protein
NON-VITAL PULPOTOMY
Mortal
pulpotomy
------
TREATMENT OBJECTIVES-:
1.
2.
3.
4.
5.
6.
Vital Pulpotomy
A.DEVITALIZATION (SINGLE SITTING)
FORMOCRESOL PULPOTOMY
Formocresol was introduced by Buckley in 1904 and since then a lot
of modifications have been tried and advocated regarding the
techniques of formocresol pulpotomies
History
Sweet (1930)- formulated the technique and was a multivisit
formocresol technique.
Doyle (1962)- advocated 2 sitting procedure
Spedding (1965)- Gave 5 minute protocol
(partial devitilization).
Venham (1967)- Proposed 15 seconds procedure.
Current concept uses 4 minutes of application time.
Success following formocresol pulpotomy:Clinical success = 90100%Histological success = 70-80%Success depends on accurate
.selection of the case
Mechanical of action : it prevents tissue autolysis by bonding to the
proteins. This bonding is of peptide groups of side chain amino acids
and is a reversible process accomplished without changing the basic
.structure of protein molecules
Histological changes : These were demonstrated by Mass and
.Zilbermann in 1933 and also by Massler and Mansokhani in 1959
.Immediately : Pulp becomes fibrous and acidophilic
:After some days : Three zones appear
A broad eosinophilic zone of fixation
A broad pale staining zone of atrophy with poor cellular definition
Broad zone of inflammatory cells extending cells extending
apically from the border of the pale staining zone
year : Progressive apical movement of these zones with 1
only acidophillic zone left at the end of 1 year
Mechanism Of Action:
Remove any ledges or overhanging enamel with slow speed round bur.
Sharp spoon excavators are used to scoop out coronal pulp and pulpal
remnants.
Clean the pulp chamber with saline and remove all debris.
Place a cotton pellet over the pulp stumps to achieve hemostasis.
Using a cotton pellet apply diluted formocresol to the pulp for 4 min.
Place a small dry pellet over this to avoid contact of tissues with
formocresol.
(a) The figure shows a lower right second primary molar where after removing the roof
of the pulp chamber the coronal pulp is being completely removed using excavators. (b)
Cotton pledget with the medicament placed over the radicular pulp tissue to control the
bleeding. (c) On removal of the cotton pledget bleeding from the amputation sites has
stopped. (d) Kalzinol (or any other zinc oxide eugenol preparation) placed in the pulp
chamber prior to placing the coronal restoration. (e) Periapical radiograph of right
upper first primary molar showing a completed pulpotomy. Note excellent condensation
of cement in the pulp chamber and coronal restoration with stainless-steel crown.
DISADVANTAGES OF FORMOCRESOL
Local toxicity: There is no actual healing of the pulp and the tooth
becomes devitalized.
Systemic toxicity: studies have shown that full strength formocresol,
is absorbed in to the systemic circulation from the pulpotomy site.
Excretion is via the kidney and lungs. Some amount of formocresol
remains cell bound in the liver,kidney and lungs. Cytogenic and
mutagenic effect is observed due to its ability to denature nucleic
acids by forming methylol derivatives and methylene cross links.
Formocresol is also said to produce irreversible damage to the protein
portion of enzymes,genetic material,membranes, and connective
tissue. It affects directly the protein biosynthesis and cell
reproduction by interacting with DNA and RNA and destroys the lipid
component of the cell membrane.
Damage to succedaneous: it is seen that 1ml of formocresol diffuses
through the apical foramen in 3 min.Thus there is high risk for the
formation of enamel defects in the permanent successor following the
use of formocresol in a primary teeth.
1.
2.
3.
4.
5.
Uses
1.
2.
3.
4.
5.
Handling characteristics
IRM powder and liquid should be mixed in less than one minute.
The resulting putty consistency is then inserted into the
cavity. If indicated, conventional methods of matrix application
are appropriate.
Advantages
1.
High strength comparable to zinc phosphate
2. Excellent abrasion resistance
3. Good sealing properties
4. Low solubility
Contraindications
1.
Because of its zinc-oxide eugenol composition, IRM will
interfere with subsequent placement of a resin filling
2. Use of cavity varnishes.
Procedure
1. Complete removal of all coronal pulp.
2. Place ledermix paste over exposed pulp.
3. Cover with sterile cotton pellets.
4. Restore with reinforced zinc oxide eugenol(IRM)or glass
ionomer cement.
5. Plan follow up care.
:N.B
If you have a rather large cavity, you can remove the bulk of the
. decay and place an "IRM" filling, also known as a sedative filling
This will often slow or stop the progression of decay and help the
patient feel better. It also may allow the tooth time to recover and
lay down secondary dentin (sort of a second layer of scar tissue),
sometimes eliminating the need for pulpal treatment like a root canal.
Once the tooth is recovered and less inflamed, any remaining decay
is removed and the final restoration (filling or crown) is placed. You
mix the powder and the liquid together to make a kind of play
PROCEDURE:
The hyfrecator plus 7-797 is set at 40% power and the 705A
dental electrode is used to deliever the electrical arc
Electrical arc is allowed to bridge the gap to the pulpal stump for 1
second,followed by a cool-down period of 5 seconds
LASER PULPOTOMY
Jeng-fen-liuet al in 1999 studied the effect on Nd:YAG laser
pulpotomy in primary teeth and noted 100% success with no signs or
symptoms,and only one tooth had internal root resorption at the sixmonth follow up visit
Contraindication:
1. .Non restorable
2. .Necrotic
3. .Soon to be exfoliated
Incorporate paraformaldehyde paste into the pellet and
Place over exposure.
Clean the cavity with saline and dry with cotton pellet
PRESERVATION
GLUTARALDEHYDE PULPOTOMY
It has been widely tested,to replace formocresol. Studies have shown
that application of 2-4%produces rapid surface fixation of the
.underlying pulp tissue
:Mechanism of action
Glutaraldehyde produces rapid surface fixation of the underlying
pulpal tissue.
A narrow zone of eosinophilic,stained and compressed fixed tissue is
found directly beneath the of application,which blends into vital
normal appearing tissue apically.
With time,glutaraldehyde fixed zone is replaced by macrophagic
action with dense collagenous tissue,thus the entire root canal tissue
is vital.
:Procedure
local anesthesia and a rubber dam are applied.
The operative procedure is in principle the same as for FC pellets
DISADVANTAGES
1. Neither the optimal concentration,nor the amount of time
period of application has been coclusively established.
2. Failure rate is more than formocresol
Ferric sulfate
The ferric sulfate the most suitable alternative to formocresol in the
next few years.
In light of recent evidence, ferric sulfate can be used as a suitable
alternative for those concerned about the toxicity of formocresol or
have difficulty obtaining it in the United Kingdom. However, it must be
remembered that ferric sulfate has no "fixative" effect.
For this reason, an accurate diagnosis of the state of the pulp tissue
being left behind and on which ferric sulfate is being applied will need
to be made.
It is a non aldehyde haemostatic compound
(1)astringent;
(2)forms a ferric ion-protein complex that mechanically occludes
capillaries;
(3) less inflammation than formocresol
(4) 92.7% radiographic success rate.
(5)100% clinical success
(6)root resorption is not accelerated
(7)internal resorption similar to formocresol ,no systemic or local side
effects
Regeneration
An ideal pulpotomy treatment should leave the radicular pulp
vital , healthy and completely enclosed within an odontoblast-lined
dentin chamber.
CVEKS PULPOTOMY
This is called as calcium hydroxide pulpotomy or young permanent
. partial pulpotomy. This was proposed by Mejare Cvek in 1993
Indications
It is indicated in young permanent teeth with incomplete root
information and the radicular pulp is judged vital by the clinical
and radiographic criteria.
PROCEDURE:
Disadvantages
1.
2.
3.
High pH stimulates
fibroblasts
3.
4.
8.
4.
5.
6.
7.
1.
Calcium silicate
Bismuth oxide
:Other uses of MTA are
pulp capping
root end filling
perforation repair in furcation,coronal,mild or apical portion of
the root
repair of resorptive perforation if not too extensive
MORTAL PULPOTOMY
Ideally,non-vital tooth should be treated by( Non vital pulpotomy)
pulpectomy,but sometimes it is impracticable due to nonnegotiable root canals and limited patient cooperation
Selection criteria:
1. History of spontaneous pain
2. Swelling,redness or soreness of mucosa
3. Tooth mobility
4. Tenderness to percussion
5. Radiographic evidence of pathological root resorption or
periradicular bone destruction
6. Pulp at the exposed site does not bleed
PROCEDURE:
FIRST APPOINTMENT:
Necrotic coronal pulp is removed
Pulp chamber is irrigated with saline and dried with cotton pellet
Pulpectomy
Pulpectomy involves removal of the roof and contents of pulp
chamber in order to gain access to the root canals which are
.debrided,enlarged and disinfected
.Canals are filled with RESORBABLE MATERIALS
.
OBJECTIVES
1. Infectious process should resolve
2. Radiographic evidence of successful filling
3. Treatment should allow reosrption of primary root structures
and filling materials at appropriate time
4. No post treatment pain,swelling or sensitivity
5. No radiographic evidence of further break down of
supporting tissue
6. No internal or external resorption.
:General indications
1. Cooperative patient.
2. Pt should be in good health with no serious disease.
3. Maximum cooperation of pt and parent
:General indications
Young pt with systemic illness such as congenital ischemic . 1
.heart disease, leukemia
2.Children on long term corticosteriods therapy.
Clinical indication:
1. Atooth previously planned for apulpotomy that shows either a
dry pulp champer or uncontrolled pulpal hemorrage.
2. Indicated for any primary tooth in absence of its permenant
successor.
3. Any deciduous tooth with severe pulpal necrosis provided
there is no radiographic contraindication.
4. traumatized primary incisors with pulp exposures or acute or
chronic abscesses.
Radiographic contraindication:
1. External root resorption.
2. Internal root resorption in the apical 3rd of the root.
3. Rdicular cyst, dentigrous follicular cyst in assocition with the
primary tooth.
4. Interradicular radiolucency that communicatees with gingival
sulcus.
Pulpectomy Technique
I.
Coronal phase:
Non-vital pulp therapyprimary tooth. (a) A carious, but restorable, non-vital primary molar.
(b) Caries is eliminated and access made to the pulp. Gentle canal debridement is undertaken
with smal files and irrigation. (c) Disinfection of the canal system. A pledget of cotton wool
barely moistened with ledermix is sealed into the pulp chamber for 7-10 days. (d) The tooth
is reopened at a second visit, and after irrigation and drying, a soft mixture of slow-setting
zinc oxideeugenol cement is gently packed into the canals with the cotton-wool
pledget. (e) The pulp chamber is packed with accelerated zinc oxideeugenol cement before
.definitive restoration of the tooth
Periapical radiograph( a)
showing files placed in the root
canals of left lower second primary
molar
Root canals have been filled( b )
with pure zinc oxide eugenol
N.B:
If iflammation is beyond the coronal pulp with only interradicular
but no periapical radiolucency-single visit pulpectomy is done.
If pulp is necrotic with periapical involvement,filling is done at
subsequent appointement.
:Follow-up and review
Though the pulpectomy technique carries a good prognosis, the
. outcome is not as good as a vital pulpotomy
Clinical follow-up augmented by one periapical radiograph on a yearly
basis is required (391HFig. 8.27 (a)-(b)). The following clinical and
:radiographic parameters can be taken as indications of success
Clinical
;alleviation of acute symptoms
.tooth free from pain and mobility
Radiographic
improvement or no further deterioration of bone condition in the
.furcation area
Obturating materials:
I.
ZNO PASTE
:Compostion
.Derivative of iodine
:Advantages
Resorbs rapidly
Extruded paste in periapical tissue is replaced with normal tissue
Bactericidal potential
Can be removed if
retreatment is required
Success rate 84%
III.KRI paste:
:Composition
Iodoform 80.8%,camphor 4.86%,parachlorophenol
2.025%,menthol 1.215%
IV. CALCIUM HYDROXIDE
V. VITAPEX
Composition:
Calcium hydroxide and iodoform mixture-Vitapex,Neo Dental
Chemical Products Co;Tokyo,has been published by Fuchino and
Nishino in 1980.
Properties:
Non toxic
Easy to apply
Resorbs at slightly faster rate than root
Radio opaque
100% success rate.
VI. ENDOFLAS
:Composition
Zno-56.5%,Barium sulphate 1.63%,Iodoform 40.6%,Calcium
hydroxide 1.07%,Eugenol Pentachlorophenol.
Properities:
Microleakage is prevented.
70% success rate.
VII.MTA
OBTURATION TECHNIQUES:
1.Endodontic pressure syringe
-These apparatus consist of syringe barrel, threaded needle.
Needle is withdrawn 3 mm with each quarter turn of the screw
until the canal is visibly filled at the orfice.
-The endodotic pressure syringe is also effective for placing the
ZEO into the canals.
-The Vitapex system also uses a syringe with the material in it.
-The syringe is introduced up to 1/5th the distance from the apex
of the canal and the material is slowly injected as the syringe is
withdrawn from the canal.
2. Mechanical syringe
Cement is loaded into the syringe with 30 gauge needle as per per
the manifactures is recommendation and expressed into the canal.
Press using continous pressure while withdrawing the needle.
Other techniques.5
.a)Amulgum plugger
.b)Paper point
.c)Plugging action with wet cotton pellet
Apexogenesis
. -:DEFINATION
Apexogenesis involves removal of the inflamed pulp and the
placement of calcium hydroxide on the remaining healthy pulp
tissue. Traditionally this has implied removal of the coronal
portion of the pulp to permit continued dentin formation and
apical closure in an immature tooth .
Materials Used
Ca(Oh)2
MTA
Bone morphogenic protein
Clinical Evaluation
-No clinical symptoms
-No radiogarphic changes in pulp or periapex
-Continued root development
-Radiographically observed hard tissue barrier at the site of procedure
-Sensitivity to vitality testing
:Goals of apexogenesis
1 Sustaining a viable Hertwigs sheath, thus allowing continued
development of root length for a more favorable crown-to-root ratio.
2 Maintaining pulpal vitality, thus allowing the remaining odontoblasts to
lay down dentine producing a thicker root and decreasing the chance of
root fracture.
Promoting root end closure, thus creating a natural apical constriction 3
for root canal filling
Generating a dentinal bridge at the site of the pulpotomy. While the 4
bridging is not essential for the success of the procedure, it does
.suggest that the pulp has maintained its vitality
Failures of Apexogenesis
-Cessation of root growth
-Development of signs and symptoms or periapical lesions
-Calcific metamorphosis
Operative procedure
Under local anaesthesia and rubber dam, pulp tissue is excised
with a diamond bur running at high speed under constant water
cooling. This causes least injury to the underlying pulp and is
.preferred to hand excavation or the use of slow-speed steel burs
REVIEW
The total time for achievement of the goals of the apexogenesis
ranges between 1 and 2 years depending on the degree of tooth
development at the time of the procedure
,after a month
,months 3
,monthly intervals for up to 4 years in order to assess pulp vitality 6
periodic radiographic review should also be arranged to monitor
dentine bridge formation, root growth, and to exclude the
development of necrosis and resorption. If vitality is lost, non-vital
pulp therapy should be undertaken whether or not there is a
,calcific bridge (see below)
success rates for partial (Cvek) pulpotomies are quoted at 97%.
.Those for coronal pulpotomies at 75%
Elective pulpectomy and root canal treatment of a vital pulp may be
considered at a later date only if the root canal is required for
restorative purposes.
Apexification
-:DEFINATION
is a method of inducing apical closure through the Apexification
formation mineralized tissue in apical pulp region of a non vital tooth
with an incompletely formed root.
The mineralized tissue can be osteodentin, osteocementum, or bone or
.combination of all
Indications
-Restorable immature tooth with pulp necrosis
Contraindications
1-All vertical and unfavourable horizontal root fractures,
2-Resorptions
3-Short roots
4-Periodontally broken down tooth
5-Vital pulp
Objective:
The aim of apexification is to induce either closure of the open apical
third of the root canal or the formation of an apical calcific barrier
against which obturation can be achieved
Rationale:
The technique of treatment is the usual cleaning and irrigation of the
root canal, followed by sealing with a paste composed of camphorated
chlorophenol and calcium hydroxide.
Radiographic examination is made 3 and 6 months after the
procedure, and when evidence of a root apex cap or barrier appears,
the root canals are obturated. Actual root growth does not occur as a
result of apexification, but radiographic evidence of a calcified mass
at the root apex gives that impression.
:Operative procedure
Access with a high-speed, medium tapered fissure bur. In the pulp
chamber use safe-ended burs to remove the entire roof without the
.danger of overcutting or Perforation
Remove loose debris from the pulp chamber with hand instruments,
accompanied by copious, gentle irrigation with sodium hypochlorite
.solution (1-2%)
Gates Glidden drills may be used to improve access to canals for
instruments and irrigant. They should not be used deep in the canals of
.immature teeth where they may overcut and create a strip perforation
Canal preparation involves two processes: cleaning with irrigants to
free the root canal system of organic debris, micro-organisms and their
toxins; and shaping with enlarging instruments, to modify the form of
the existing canal to allow the placement of a well-condensed root
. filling
In canals which are often as wide as this, little dentine removal and
shaping is needed. Sodium hypochlorite solution (1-2%) as an irrigant
will continue dissolving organic debris and killing micro-organisms deep
Working apically, files are directed around the canal walls with a light
rasping action to remove adherent debris. Instrumentation is
frequently punctuated by highvolume, low-pressure irrigation to flush
.out debris
Irrigant is delivered either by pre-measured, 27 gauge needle and
syringe or with the aid of sonic/ultrasonic energy. The latter involves
flooding the canal with irrigant before inserting a small (size 16-20)
file attached to a sonic/ultrasonic unit to stir the irrigant in the canal.
Wall contact with the file should be avoided, as the action is liable to
.cause turbulence in the irrigant which scrubs the walls of debris
Provisional working length should be 2-3 mm from the radiographic
apex, estimated from an undistorted pre-operative periapical film. A
working length radiograph is then taken to establish a definitive
working length 1 mm short of the radiographic root apex. Further
gentle filing and irrigation is then continued to the definitive working
.length
Dry canal with pre-measured paper points to avoid inadvertent over-
extension and damage to the periapical tissues
REVIEW
monthly to monitor root end closure. At each appointment the 3
calcium hydroxide dressing is carefully washed from the canal and
the presence of a calcified barrier assessed by gently tapping a pre.measured paper point at the working length
Radiographs should be taken to assess the progress of barrier
.formation
If the canal is closed, obturation may proceed. If calcific barrier
formation is not complete, the canal should be redressed for a
further 3 months. Calcific barrier formation is usually complete
.within 9-18 months, but could take up to 2 years