Apexification and Apexogenisis
Apexification is the method of inducing the development of root apex in an immature pulpless tooth by the formation of osteocementum or other bone like tissue. Apexogenesis is the physiologic process of the root development in the vitally infected tooth. In this article there is a brief discussion about apexification and apexogenesis. Let us examine them.
Apexification:It is the method of inducing the development of root apex in an immature pulpless tooth by the formation of osteocementum or other bone like tissue. It is indicated in cases where there is no normal pulp tissue i.e., where the pulp has undergone irreversible pulpal necrosis. Normal root development takes places rarely. More commonly calcific barrier is formed clinically on a radiograph or both.
Apexogenesis:It is the physiologic process of the root development in the vitally infected tooth. Normal or pulp tissue with minimal inflammation is present. 1. Completely (direct pulp capping) 2. In the radicular portion (pulpotomy) Normal root end development takes place. Endodontic management of infected or non vital of young permanent tooth with a wide-open blunderbuss apex has long presented a challenge. An immature permanent tooth is defined as one where the apex can be considered to be open.
Problem of treating immature incisor with a necrotic pulpThe anatomy of the non-vital immature incisor presents several problems.
- 1. There is an open apex hence no hard tissue stop against which gutta percha can be packed.
- 2. The open apex of the root canal tends to be shaped like blunderbuss making it difficult to obdurate the apex with root filling material.
- 3. Apicectomy is not advisable because the walls of the immature roots are likely to fracture when scaling the root apex.
Indications:This procedure is indicated for nonvital permanent teeth with incompletely formed roots.
Objectives:This procedure should induce root end closure at the apices of immature roots, as evidenced by periodic radiographic evaluation. Post treatment, adverse clinical signs or symptoms such as a prolonged sensitivity, pain or swelling should not be evident. There should be no evidence of abnormal canal calcification or internal or external root resorption, lateral root pathosis or breakdown of periradicular supporting tissues during or following treatment.
Materials:A number of materials and procedures have been recommended for apexification procedure: antiseptic and antibiotic paste (as reported by Frank), Zinc oxide and metacresylacetate-camphorated para-chlorophyenopl, tricalcium phosphate, collagen-calcium phosphate gel, resorbable tricalcium phosphate, ceramic, calcium hydroxide, empty canals and even no treatment at all.
Calcium hydroxide:This is available in many forms and is the most widely used and tested material, Dry powder can be packed into the canal, powder can be mixed with water: or powder can be mixed with intracanal medicaments or with methyl cellulose. Recently, calcium hydroxide points (58% calcium hydroxide, 42% gutta percha and coloring agent) have also been used. There seems little justification, however, for mixing the powder with an intracanal toxic. The antibacterial effect is provided by calcium hydroxide.
Procedure:Frank (1966) was one of the first to describe the clinical methods using calcium hydroxide paste and camphorated monochorophenol (CMCP), to stimulate root closure. The procedure for apexification is as follows:
- 1. The tooth is isolated with rubber dam, and access is gained into the pulp chamber.
- 2. Using large reamers and files, remove the debris from the coronal half of the pulp and establish the file length radiographically.
- 3. Clean the canal, irrigate it and then dry it with a paper point. Repeated gentle use of sodium hypochlorite assists debris removal.
- 4. Seal a pellet of CMCP in the pulp chamber with a provisional restorative material.
- 5. On recall, in 1 to 3 weeks, remove the restoration and clean the canal.
- 6. Take care to avoid any instrumentation of the walls of the dentin near the apex.
- 7. Mix a paste of calcium hydroxide and CMCP on a glass slab. Carry the paste to the canal and force it into the apex with a large plugger or coneshaped instrument. The objective is to fill the canal completely. Obtain a radiographic to check the accuracy of the root canal filling.
- 8. On a 6 month recall, you should see radiographic evidence of an apical closure. Weine, 1976 noted five alternatives evident at this time.
- No apparent apical closure, but a resistance point when a file is inserted.
- Radiographic evidence of a calcified bridge at the apex.
- Apical closure without canal space changes.
- Normal continuance of apical closure.
- Increased radiographic evidence of resolution of apical pathology.
- 9. When you have accomplished apical closure, the root canal filling is completed.
- 10. If apexification has not been completed, repeat the cleaning and insertion of a calcium hydroxide and CMCP paste.