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Teeth
Introduction
Are those in which root development & apical closure have
not been completed.
Present in children from 6 yrs of age until 2-3 yrs after
eruption of 3rd molars
The aim of all treatment planning for young permanent teeth is
to preserve pulp vitality, so providing conditions for
continuous root development & physiologic dentin apposition
Development
What
makes
them
special???
Root
development
Maturation
Diagnosis
Vitality testing
Treatment
planning
Apexogenesis
Apexification
Tooth development
Enamel and dentin future
CE junction
IEE & OEE separated by
Stratum intermediun &
stellat reticulum
hertwigs epithelial root
sheath
HERS - Shape of root and
number
Epithelial diaphragm
apical foramen
Hertwigs & Epithelial
diaphragm - sensitive to
trauma
Apical Foramen
Average size
Maxillary 0.4mm
Mandibular 0.3mm
Posteruption maturation
Difference between
posteruptive
maturation &
remineralization
Root completion
Vitality testing
Electric pulp tests and thermal tests are of limited value
Full development of the plexus of Rashkow does not occur
until 5 years after tooth eruption (Johnsen 1985).
Unreliable responses from children because of
fear,
management problems, and
inability to understand or communicate accurately
evidence of pathosis.
In the pulp chamber coronal nerve bundles diverge and branch out
towards the pulpo-dentine border (Dahl & Mjor 1973, Gunji 1982).
Nerve divergence continues until each bundle looses its integrity
and smaller fibre groups travel towards the dentine.
This route is relatively straight until the nerve fibres form a loop
resulting in a mesh that is termed the plexus of Rashkow.
The density of this nerve plexus is well developed in the peripheral
pulp along the lateral wall of coronal and cervical dentine and along
the occlusal wall of the pulp chamber.
The nerve fibres emerge from their myelin sheaths and branch
repeatedly to form the subodontoblastic plexus.
Finally, the terminal axons exit from their Schwann cell investiture
and pass between the odontoblasts as free nerve endings (Byers &
Narhi 2002).
Radiographic interpretation:
Can be difficult, due to their normally
large & open apex
Because the faciolingual width of most
roots and canals is greater than the
mesiodistal width, apical closure cannot
usually be determined radiographically.
Dental
caries
Trauma
Vital
pulp
Open apex
Closed apex
Pulpotomy (vital)
RCT
Pulpotomy
Restoration
Pulpectomy
RCT
Non vital
Closed apex
Apexification
RCT
RCT
The eruption time for first molars and second molars is roughly
11/2 to 21/2 years, respectively.
accounts for the increased decay rate of the molars.
Retention rates???
Newly erupted & 1st molars higher
Mandibular > maxillary
Operator access is better
Gravity assists the sealant in flowing into the fissures.
Apexogenesis
A vital pulp therapy procedure performed to encourage
continued physiological development and formation of the
root end.
Maturogenesis
physiologic root development, not restricted to apical segment.
The continued deposition of dentin occurs throughout the
length of the root, providing greater strength and resistance to
fracture
Goals: (Webber,
1984)
-Sustaining a
viable HERS
-Maintaining the
pulpal vitality
-Promoting root
end closure
-Generating a
dentinal bridge at the
site of the
pulpotomy
Continued development of
root length
Favourable crown root ratio
Remaining odontoblasts to
lay down dentin
Thicker root
Resistance to fracture
Indirect
pulp
capping
Direct
pulp
capping
pulpoto
my
Rationale
Case selection
Reversible pulpitis
Symptoms :
Thermal stimulus
Percussion
Vitality
momentary pain
Non tender
Normal or slightly
Radiography : Absence of
Periodontal ligament thickening
Periapical rarefaction
exaggerated
Therefore advocated only when time, economics or any other factors don not
permit R.C.T. (Cohen)
revisited
Objective
Removal
of carious
Change
the dentin along the DEJ
infected dentin
cariogenic
3-6 months environment
to decrease the
number of
Removal
of remaining caries- final
bacteria,
restoration
close the
remaining caries
from the biofilm
slow or arrest the
caries
development
Pulpotomy
Surgical removal of a portion of an affected vital coronal pulp
tissue, while leaving the radicular tissue in situ to allow for
normal root development.
Partial pulpotomy
A procedure in which the inflamed pulp tissue beneath an
exposure is removed to a depth of 1 to 3 mm or deeper to
reach healthy pulp tissue.
Pulpal bleeding must be controlled by irrigation -covered with
calcium hydroxide or MTA.
Calcium hydroxide : long-term success.
MTA : predictable dentin bridging and pulp health.
Nonvital teeth
5 methods(Morse et al )
1. A customized cone (Blunt end, rolled cone)
2. A short fill technique
3. Periapical surgery (with or without a retro grade seal)
4. Apexification (Apical closure induction)
5. One visit apexification
Apexification
A method to induce a calcified barrier in a root with an open
apex or the continued apical development of an incomplete
root in teeth with necrotic pulp
Is a method of inducing development of the root apex of an
immature pulpless tooth by formation of osteocementum /
bone like tissue
Morse et al (1990)
Apexification is a method of inducing apical closure through
the formation of mineralized tissue in the apical pulp region of
a non vital tooth with an incompletely formed root
Frank (1966)
Described a
technique based on
the normal
physiologic pattern
of root
development that
brings about the
resumption of
apical development
so that the root
canal can be
obliterated by
conventional RCT
Weine, 2004
Recommended two appointments
First appointment
Sealing a sterile, dry cotton for 1 to 2 weeks
Placing calcium hydroxide dressing is optional
Second appointment
Calcium hydroxide and CMCP
One/two appointment
Determined by clinical signs and symptoms
Active infection
To be elminated
Absence of tenderness to percussion-a good sign
General rule
Treatment paste -6 months
Reopened to assess the apical stop
Radiographic assessment
Frank, 1966
No apparent radiographic change
but positive stop
at apex
Dome shaped apical closure with
canal retaining a
blunderbuss
appearance
Continued root growth and closure
of canal and apex
to a normal
appearance
A positive stop and radiographic
evidence of a
barrier coronal to
the anatomic apex of the tooth
Cementum
Bone
Dentin
Combination of all three tissues, with connective tissue and calcium
hydroxide sometimes mixed in with them
Histologically, its characteristics may be of dentin, cementum or
osteodentin.
Limitations of Ca(OH)2
Apexification
Long Duration 3 to 21 months
Size of apical opening, age of Patient
This procedure
Should induce root end closure.
No adverse post-treatment clinical signs or symptoms.
No radiographic evidence of external root resorption, lateral
root pathosis, root fracture, or breakdown of periradicular
supporting tissues during or following therapy.
The tooth should continue to erupt, and the alveolus should
continue to grow in conjunction with the adjacent teeth.
Revascularization
Nygard Ostby , a pioneer of regenerative endodontic
procedures in the early 1960s, showed that new vascularized
tissue could be induced in the apical third of the root canal of
endodontically treated mature teeth with necrotic pulps and
apical lesions.
This was accomplished by the creation of a blood clot in the
apical third of a cleaned and disinfected root canal by using an
apically extended root canal file just before root canal filling.
He proposed that through formation of a clot (scaffold), a
vasculature could be established to support growth of new
tissue into the unfilled portion of the root canal.
He provided histologic evidence in support of his concept that
was taken surgically from teeth that had been treated in this
manner.
Guidelines for
revascularization
Appointment - I
An assessment of the patient should be performed
state of tooth development
extent and history of the endodontic infection
restorability of the crown
Appointment - I
Anesthesia, isolation, access cavity
Debridement and Disinfection
Removal of necrotic pulp tissue
Mechanical cleaning is contraindicated
because it may weaken the thin dentinal root walls
remove vital tissue remnants that might be present in the apical part of the
canal
WL determination
Removal of necrotic tissue from the root canal is accomplished by gently
irrigating the root canal with a minimum of 20 mL 2.5% NaOCl
dispensed through a syringe and a 20-gauge needle
irrigation with 5 mL sterile saline
10 mL 2% CHX
CHX is recommended because of its antimicrobial activity and its
substantivity, ie, the ability to extend antimicrobial action by interacting with
the dentin
Appointment- I
Root Canal Medication
carefully dried with large, sterile paper points
root canal can then be medicated with 1 of 2 dressings
Antibiotic Combination
Hoshino et al 1996 introduced a triple antibiotic combination of
ciprofloxacin, metronidazole, and minocycline that they claimed was
sufficiently potent to eradicate bacteria from the dentin of the infected
root and promote healing of the apical tissues.
Problems associated
Antibiotic resistance
Allergic reaction
Cytotoxic to apical cells
Discoloration
Cefaclor (Thibodeau and Trope)
Bonding agent (Reynolds et al)
Appointment- I
Temporary Restoration
Preventing coronal leakage of bacteria
Double coronal restoration is recommended
placing a sterile cotton pellet over the root canal medicament and then
covering the pellet with Cavit cement
covered with glass ionomer cement
advisable to use non-eugenol temporary cements
Can contaminate the preparation
inhibiting the polymerization of certain resin composites subsequently used as
permanent restorative filling material
Medication Period
No agreement exists concerning the preferred medication or the
optimal period for leaving medication in the root canal.
Different clinicians have used different periods that have ranged from 7
days to several weeks
Appointment- II
ensure that all clinical signs and symptoms have abated
If clinical signs or symptoms persist
procedures performed in the first appointment should be repeated
Anesthesia
An anesthetic without vasoconstrictor should be chosen to prevent constriction
of the blood vessels in the apical region or a limited flow of blood when
bleeding is mechanically induced
Scaffold
Scaffolds are used in regenerative procedures to provide a framework through
which cells and a vasculature can grow
a stable blood clot can act as a scaffold in the revascularization
introduction of a sterile #20 K-file into the apical tissues 2 mm past the apical
foramen to initiate bleeding into the root canal
Shah , 2008
Possible mechanism for the process of revascularization
Trauma - Avulsion
Extra oral dry time < 60 min
Soaked in doxycycline 0.005% for 5 min before replantation.
Conclusion
Common problems associated with open apices
Frank AL. Therapy for the divergent pulpless tooth by continued apical
formation. J Am Dent Assoc 1966;72:8793
Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a
review of current status and a call for action. J Endod 2007;33:377390.
Trope M. Regenerative potential of dental pulp. J Endod 2008;34:S137.
Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the
young permanent tooth: what does the future hold? J Endod 2008;34:S516.
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Pediatric dentistry: infancy through adolescence, 4th edition: Pinkham
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