Endodontic treatment of immature teeth Asst Prof Boonrat

Endodontic treatment of immature teeth Asst. Prof. Boonrat Sattapan Department of Conservative Dentistry, Faculty of Dentistry, Prince of Songkla University

Topics Ø Ø Ø Open apex Definition of apexogenesis & apexification Indications and contraindications Advantages and disadvantages Regenerative endodontics Procedures

Open apex n n Developing root of immature tooth Pulp necrosis before root growth is complete n n n Dentin formation ceases Root growth is arrested RC remains wide and apex open Root may be shorter Extensive resorption of a mature apex n n n Following orthodontic treatment From periradicular inflammation As part of healing after trauma

Open apex

Apical closure n Three to four years after eruption

Immature root Ø Ø wide root canal thin root canal wall n n n Ø Ø diverse parallel converse short root open apex

Immature root n Vital pulp Ø n Apexogenesis Non-vital pulp Apexification Ø MTA apical plug Ø Regenerative endodontics Ø

Apexogenesis Treatment of a vital pulp in an immature tooth to permit continued root growth and apical closure. n The objective is to maintain the vitality of the radicular pulp. n

Apexification n The process of creating an environment within the root canal and periapical tissues after pulp death that allows a calcified barrier to form across the open apex.

Creation of proper environment n n Cleaning and shaping to remove debris and bacteria Placement of calcium hydroxide The primary factor responsible for apical closure is a thorough debridement to remove bacteria and necrotic tissue from the canal system.

Diagnosis and treatment planning Correct diagnosis Correct treatment

Causes of pulpal damage trauma n caries n mechanical exposure n developmental anomaly ) eg. Dens invaginatus, Dens evaginatus( n

Subjective examination History of trauma n Symptoms n kind of pain n duration of pain n severity of pain n

Objective examination Visual examination: n hard and soft tissue n restoration n tooth fracture n caries n discoloration

Objective examination Visual examination: n swelling n sinus opening n tooth abnormality n n Dens evaginatus Dens invaginatus

Percussion: digital pressure n tapping with a mirror handle n

Thermal testing: n n May be complicated by a lack of neural development nerves may be damage while blood supply remains intact and the pulp is healthy but unresponsive

Electric pulp test (EPT: ( n n n Unreliable in young teeth results must be interpreted with caution lack of response does not necessarily indicate necrosis

Radiographic findings: n n Radiolucent area surrounds the developing open apex of an immature tooth with a healthy pulp compared with contralateral tooth sinus opening : tracing with GP two-dimensional image n n M-D closed La-Li open

Treatment planning n n n Open apex with vital pulp Apexogenesis Open apex with necrotic pulp Apexification MTA apical plug, Regeneative endodontics Other considerations: n n disinterested patient/parents many visits are required risk of root fracture expense

Alternative treatments. 1 Conventional RCT n n well-condensed obturation to the desired level is difficult or impossible presence of excess material periapically as well as large voids

Alternative treatments. 2 Surgery n n complicated by the short root and thin fragile walls at the apex, which compromise cavity preparation for retrofilling root-end resection exaggerates the problem of an already short root . 3 Extraction

Apexogenesis : Indications n n n immature tooth with incomplete root formation damage to the coronal pulp but a healthy radicular pulp crown must be fairly intact and restorable

Apexogenesis : Contraindications n n n avulsed and replanted tooth severely luxated tooth severe crown-root fracture that requires intraradicular retention for restoration unfavorable horizontal root fracture (eg. Close to gingival margin( unrestorable tooth

Pulpotomy Ø Ø Partial pulpotomy (Cvek pulpotomy) Conventional pulpotomy (cervical pulpotomy)

Cvek pulpotomy n n n LA RD + surface disinfection IR exposed dentin and pulp Remove pulp tissue to a depth of 2 mm. below the exposure Create dentin shelf surrounding the pulp wound

Cvek pulpotomy n n IR, Hemostasis hard setting calcium hydroxide liner hard setting cement or GI acid-etched composite

Cvek pulpotomy

Cvek pulpotomy

Cvek pulpotomy 15/2/42 21/9/42 28/12/43 +ve EPT

Conventional pulpotomy n n n LA RD + surface disinfection OC Remove pulp tissue to cervical level Hemostasis Ca(OH)2 powder + distilled water thick consistency placed in PC 1 -2 mm.

Conventional pulpotomy n ZOE cement / hard setting cement n GI n Permanent restoration Recall : every 3 -6 months

Criteria for successful pulpotomy n n n Absence of signs and symptoms of pulp or periapical diseases No periapical pathology No root resorption Respond to pulp testing Continued root development and dentin formation Function properly

Apexogenesis : Prognosis n n good when shallow pulpotomy (Cvek technique) is done correctly following a traumatic exposure subsequent RCT is unlikely to be necessary

Apexogenesis : Complications n n microbial contamination may cause pulpal necrosis and periradicular pathosis if this occurs prior to complete root development, apexification is necessary (MTA apical plug, regenerative endodontics) n if this occurs after complete root formation, RCT is required

Apexification Calcium hydroxide apexification n MTA apexification (MTA apical plug) n Revascularization (regenerative endodontics) n

Apexification : Indications n immature tooth with pulp necrosis n restorable tooth

Apexification : Contraindications n vertical root fracture n horizontal root fracture n replacement resorption n very short roots

Ca(OH) Apexification 2 n n n n RD + surface disinfection OC Remove necrotic pulp WL MI / cleaning Dry canal Ca(OH)2 +distilled water Coronal seal

Ca(OH)2 apexification n Recall : n 4 -6 weeks n Every 3 -6 months Hard tissue barrier Obturation

CH apexification

CH apexification

CH apexification 16/5/43 11/10/43 21/3/44 22/5/45 28/5/46

Criteria for successful apexification n No sign and symptom of periapical diseases n Calcific barrier

CH apexification : Prognosis n Good success rate n High risk of root fracture either during treatment or subsequently

Disadvantages of CH apexification n n n Require multiple visits Long period of time Need patient/parents co-operation Risk of reinfection No root development (short root, thin wall, wide root canal) Risk of root fracture (long tern CH medication, thin wall)

MTA apexification (MTA apical plug) PN with AAP Open apex WL CH MTA (3 -4 h)

MTA apical plug First visit : - RD + surface disinfection - OC, remove necrotic pulp - WL, cleaning and shaping - CH medication, coronal seal Second visit : - IR, dry canal - MTA apical plug 4 -5 mm - moist cotton pellet on MTA - Coronal seal Third visit : - check MTA (setting time 3 -4 h)

Artificial root-end barrier with MTA (Holden et al. , 2008)

MTA apical plug n Advantages n n Require a few visits in a short period of time Disadvantages n n Predispose to root fracture Failure to stimulate root development

Regenerative endodontics Revascularization n Revitalization n maturogenesis n

If it were possible to create a similar environment as described for the avulsed tooth, regeneration should occur n n n If the canal were effectively disinfected A matrix into which new tissue could grow were created The coronal access were effectively seal regeneration should occur

New treatment protocol n n n The canal was disinfected without MI but with -copious irrigation with Na. OCl 2. 5% -use of a mixture of antibiotics (3 Mix-MP) (ciprofloxacin, metronidazole and minocycline) A blood clot was produced to the level of CEJ to provide a scaffold for the ingrowth of new tissue A double seal of MTA in the cervical area and the bonded resin coronal restoration

Thank you for your attention

Any questions ?