Apexification

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Apexification is a method of dental treatment to induce a calcific barrier in a root with incomplete formation or open apex of a tooth with necrotic pulp. [1] Pulpal involvement usually occurs as a consequence of trauma or caries involvement of young or immature permanent teeth. As a sequelae of untreated pulp involvement, loss of pulp vitality or necrotic pulp took place for the involved teeth.

Contents

The main purpose of apexification includes restoring the original physiologic structures and functions of the pulp-dentin complex of the teeth. [1] In addition to that, the elimination of the pulp tissue within a tooth, the disinfection of root canal system by using irrigants such as sodium hypochlorite and ethylenediaminetetraacetic acid are the necessary steps to ensure that the purpose of apexification is being met. [2]

The apexification procedure will normally requires several monthly appointments or follow-ups to observe any calcific changes induced at the apex of tooth concerned. In these visits, a material known as calcium hydroxide ( Ca(OH)2 ) will be placed inside the root canal systems to eliminate intracanal infection, stimulates calcification and achieves apical barrier seal at the apex of tooth root. The success rate of applying the traditionally used calcium hydroxide to induce calcific barrier is between 74%-100%. Nowadays, a newer material known as  mineral trioxide aggregate (MTA) is widely used as well. [1]

Some difficulties are said to be a major clinical challenge when carrying out apexification, including difficulty in achieving appropriate apical seal with an open apex. Besides that, the termination of development of dentinal walls after pulpal pathologies occur will result in roots with thin dentinal wall and thus, producing a higher risk of tooth fracture. [2]

Indication and objectives

Apexification is indicated for immature permanent teeth that are non-vital with incompletely formed roots. [3] The objective of this procedure is to induce root end closure (apexification) at the apices of immature roots through the formation of mineralized tissue. Apical closure can take various forms but in most cases, it appears to be irregular and aberrant. Along with apical closure, root development may or may not continue. [4]

Materials

There are different materials to be used in apexification such as Mineral trioxide aggregate (MTA), Bioceramics and Biodentine.

Mineral trioxide aggregate

Mineral trioxide aggregate (MTA) is composed primarily of tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide. It has been used in endodontics as a root-end filling material, and sets in the presence of moisture. [5] It presents in either grey or white form, the difference between the two being that white MTA lacks iron. [6]

After numerous testing and analysis, MTA showed superior properties from its physical properties and biocompatibility. It is shown to have less marginal gap formation, less leakage  and better adaptation than other filling materials. Besides, root ends filled with MTA showed good healing with absence of periradicular inflammation over the root-end filling material, as compared to amalgam. [5] The use of MTA as endodontic repair material stimulates bone formation as well as inhibits bone resorption. [6]

Due to its physical properties and biocompatibility, MTA has been used in numerous clinical situations other than as a root-end filling. It is widely used to repair perforations, to close open apices in apexification, as a direct pulp capping material for deep carious tooth, and to cover pulp stumps for apexogenesis. This material possesses great sealing ability, good antimicrobial activity, great biocompatibility, and enhances dentin biomineralization. [5] However, there is some known drawbacks to the use of MTA such as the potential release of hazardous substances, potential for discoloration, and inconvenience of handling. [6]

Bioceramics

In order to overcome the limitations of MTA, recent advance in dental materials has introduced bioceramics as a new root canal obturation and repair material. Its composition mainly includes zirconium oxide, calcium silicates, calcium phosphate monobasic, calcium hydroxide, filler, and thickening agents. [6]

As a pre-mixed form, it is easy to use and is applied in root canal therapy. Biodentin has similar to or better than those of MTA, from biocompatibility, antimicrobial activity, sealing ability and ability to enhance dentin biomineralization. The bonding ability in a high-humidity environment and color stability of biodentine were significantly better than those of MTA. [6]

Biodentine

Biodentine is a tricalcium silicate-based material, as an alternative to permanent dentin. It is biocompatible and is a new bioactive dentin substitute cement, which is composed of powder that consists of tricalcium silicate, dicalcium silicate, calcium carbonate, calcium oxide, zirconium oxide, and calcium hydroxide. It allows good marginal sealing, thus preventing marginal leakage as well as protecting the underlying pulp by inducing the formation of tertiary dentin. [7]

Unlike other dentin substitutes, biodentine application does not require any conditioning of the dentin surface in providing good sealing property. This is because tag like structures are formed after the penetration of biodentine material into the dentin tubules. Besides, it can also be bonded with different types of adhesives before finishing the final restoration with composite resin. [7]

The setting time of biodentine is shorter as compared with that of MTA, In conclusion, this material is clinically indicated for permanent dentin substitute, direct and indirect pulp capping, pulpotomy, repair of furcation and root perforations, retrograde root-end filling, and apexification. [7]

Procedure

Proper assessment of the tooth is important in determining an accurate diagnosis in order to formulate an appropriate treatment plan. Clinical evaluation of pulpal status includes a comprehensive history and diagnostic tests. Radiographic examination is used to determine the maturity of the developing root. However, immature teeth are commonly associated with young patients and pulp testing in children is complex and subjective to nature. [8] [9]

The following steps are included in this procedure: [10]

  1. The affected tooth is isolated using rubber dam
  2. An access opening is made to reach the pulp chamber
  3. A file is placed in the root canal and a radiograph is taken to establish the root length. Care should be taken to avoid pushing instruments through the apex
  4. Remnants of the pulp are then removed using barbed broaches and files
  5. The canal is flushed with hydrogen peroxide to remove debris and is then irrigated with sodium hypochlorite and saline
  6. The material of choice is placed in the canal and an endodontic plugger is used to push the material to the apical end
  7. A cotton pledget is placed and the cavity is sealed with reinforced zinc oxide-eugenol cement

Apexification procedure can be completed in one or two appointments depending on the initial clinical sign and symptoms. The procedure may also vary depending on the materials or medication used. Generally, the treatment paste is allowed to remain for six months before the evaluation for an apical closure. [10]

Follow up

If apical closure has not occurred within six months, the root canal is retreated again with the material of choice. Ideally, the tooth should demonstrate continued apical growth and closure or an apical stop. When closure is observed, the canal is filled with a root canal filling material known as gutta-percha. [10]

Related Research Articles

<span class="mw-page-title-main">Root canal</span> Hollow part of the root of a tooth

A root canal is the naturally occurring anatomic space within the root of a tooth. It consists of the pulp chamber, the main canal(s), and more intricate anatomical branches that may connect the root canals to each other or to the surface of the root.

Dental products are specially fabricated materials, designed for use in dentistry. There are many different types of dental products, and their characteristics vary according to their intended purpose.

<span class="mw-page-title-main">Endodontics</span> Field of dentistry

Endodontics is the dental specialty concerned with the study and treatment of the dental pulp.

<span class="mw-page-title-main">Pulp (tooth)</span> Part in the center of a tooth made up of living connective tissue and cells called odontoblasts

The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour.

<span class="mw-page-title-main">Deciduous teeth</span> First set of teeth in diphyodonts

Deciduous teeth or primary teeth, also informally known as baby teeth, milk teeth, or temporary teeth, are the first set of teeth in the growth and development of humans and other diphyodonts, which include most mammals but not elephants, kangaroos, or manatees, which are polyphyodonts. Deciduous teeth develop during the embryonic stage of development and erupt during infancy. They are usually lost and replaced by permanent teeth, but in the absence of their permanent replacements, they can remain functional for many years into adulthood.

<span class="mw-page-title-main">Apicoectomy</span> Endodontic root end surgery

A root end surgery, also known as apicoectomy, apicectomy, retrograde root canal treatment or root-end filling, is an endodontic surgical procedure whereby a tooth's root tip is removed and a root end cavity is prepared and filled with a biocompatible material. It is an example of a periradicular surgery.

Dens invaginatus (DI), also known as tooth within a tooth, is a rare dental malformation where there is an infolding of enamel into dentine. The prevalence of condition is 0.3 - 10%, affecting more males than females. The condition is presented in two forms, coronal and radicular, with the coronal form being more common.

Dens evaginatus is a rare odontogenic developmental anomaly that is found in teeth where the outer surface appears to form an extra bump or cusp.

<span class="mw-page-title-main">Dentin dysplasia</span> Medical condition

Dentin dysplasia (DD) is a rare genetic developmental disorder affecting dentine production of the teeth, commonly exhibiting an autosomal dominant inheritance that causes malformation of the root. It affects both primary and permanent dentitions in approximately 1 in every 100,000 patients. It is characterized by the presence of normal enamel but atypical dentin with abnormal pulpal morphology. Witkop in 1972 classified DD into two types which are Type I (DD-1) is the radicular type, and type II (DD-2) is the coronal type. DD-1 has been further divided into 4 different subtypes (DD-1a,1b,1c,1d) based on the radiographic features.

<span class="mw-page-title-main">Root canal treatment</span> Dental treatment

Root canal treatment is a treatment sequence for the infected pulp of a tooth which is intended to result in the elimination of infection and the protection of the decontaminated tooth from future microbial invasion. Root canals, and their associated pulp chamber, are the physical hollows within a tooth that are naturally inhabited by nerve tissue, blood vessels and other cellular entities. Together, these items constitute the dental pulp.

Mineral trioxide aggregate (MTA) was developed for use as a dental root repair material by Mahmoud Torabinejad. It is formulated from commercial Portland cement, combined with bismuth oxide powder for radio-opacity. MTA is used for creating apical plugs during apexification, repairing root perforations during root canal therapy, and treating internal root resorption. This can be used for root-end filling material and as pulp capping material. Originally, MTA was dark gray in color, but white versions have been on the market since 2002.

<span class="mw-page-title-main">Pulpotomy</span>

Pulpotomy is a minimally invasive procedure performed in children on a primary tooth with extensive caries but without evidence of root pathology. The minimally invasive endodontic techniques of vital pulp therapy (VPT) are based on improved understanding of the capacity of pulp (nerve) tissues to heal and regenerate plus the availability of advanced endodontic materials. During the caries removal, this results in a carious or mechanical pulp exposure (bleeding) from the cavity. During pulpotomy, the inflamed/diseased pulp tissue is removed from the coronal pulp chamber of the tooth leaving healthy pulp tissue which is dressed with a long-term clinically successful medicament that maintains the survival of the pulp and promotes repair. There are various types of medicament placed above the vital pulp such as Buckley's Solution of formocresol, ferric sulfate, calcium hydroxide or mineral trioxide aggregate (MTA). MTA is a more recent material used for pulpotomies with a high rate of success, better than formocresol or ferric sulfate. It is also recommended to be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled, the tooth is restored with a filling material that seals the tooth from microleakage, such as a stainless steel crown which is the most effective long-term restoration. However, if there is sufficient remaining supporting tooth structure, other filling materials such as amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. The medium- to long-term treatment outcomes of pulpotomy in symptomatic permanent teeth with caries, especially in young people, indicate that pulpotomy can be a potential alternative to root canal therapy (RCT).

<span class="mw-page-title-main">Apical foramen</span> Opening in the tip of the root of a tooth

In dental anatomy, the apical foramen, literally translated "small opening of the apex," is the tooth's natural opening, found at the root's very tip—that is, the root's apex—whereby an artery, vein, and nerve enter the tooth and commingle with the tooth's internal soft tissue, called pulp. Additionally, the apical foramen is the point where the pulp meets the periodontal tissues, the connective tissues that surround and support the tooth.

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

In dentistry, the smear layer is a layer found on root canal walls after root canal instrumentation. It consists of microcrystalline and organic particle debris. It was first described in 1975 and research has been performed since then to evaluate its importance in bacteria penetration into the dentinal tubules and its effects on endodontic treatment. More broadly, it is the organic layer found over all hard tooth surfaces.

<span class="mw-page-title-main">Pulp stone</span>

Pulp stones are nodular, calcified masses appearing in either or both the coronal and root portion of the pulp organ in teeth. Pulp stones are not painful unless they impinge on nerves.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

<span class="mw-page-title-main">Pulp capping</span>

Pulp capping is a technique used in dental restorations to prevent the dental pulp from necrosis, after being exposed, or nearly exposed during a cavity preparation, from a traumatic injury, or by a deep cavity that reaches the center of the tooth causing the pulp to die. When dental caries is removed from a tooth, all or most of the infected and softened enamel and dentin are removed. This can lead to the pulp of the tooth either being exposed or nearly exposed which causes pulpitis (inflammation). Pulpitis, in turn, can become irreversible, leading to pain and pulp necrosis, and necessitating either root canal treatment or extraction. The ultimate goal of pulp capping or stepwise caries removal is to protect a healthy dental pulp and avoid the need for root canal therapy.

Biofilling, also known as orthograde canal grafting technique or 4D sealing, is an endodontic root canal obturation technique with a Bioceramic material after root canal preparation and enlargement procedure.

In the dental specialty of endodontics, periradicular surgery is surgery to the external root surface. Examples of periradicular surgery include apicoectomy, root resection, repair of root perforation or resorption defects, removal of broken fragments of the tooth or a filling material, and exploratory surgery to look for root fractures.

References

  1. 1 2 3 Wen, Ping-Han; Liou, Ji-Uei; Duh, Bor-Ren (June 2009). "Apexification of nonvital immature mandibular premolars using two different techniques". Journal of Dental Sciences. 4 (2): 96–101. doi: 10.1016/s1991-7902(09)60014-3 . ISSN   1991-7902.
  2. 1 2 Guerrero, Fabricio; Mendoza, Asunción; Ribas, David; Aspiazu, Karla (2018). "Apexification: A systematic review". Journal of Conservative Dentistry. 21 (5): 462–465. doi: 10.4103/jcd.jcd_96_18 . ISSN   0972-0707. PMC   6161512 . PMID   30294103.
  3. ↑ "Overview". www.aapd.org. Retrieved 2020-01-24.
  4. ↑ Morse, D. R.; O'Larnic, J.; Yesilsoy, C. (July 1990). "Apexification: review of the literature". Quintessence International. 21 (7): 589–598. ISSN   0033-6572. PMID   2094860.
  5. 1 2 3 Gatewood, R. Scott (July 2007). "Endodontic Materials". Dental Clinics of North America. 51 (3): 695–712. doi:10.1016/j.cden.2007.04.005. ISSN   0011-8532. PMID   17586151.
  6. 1 2 3 4 5 Tu, Ming-Gene; Sun, Kuo-Ting; Wang, Tong-Hong; He, Yun-Zhen; Hsia, Shih-Min; Tsai, Bi-He; Shih, Yin-Hwa; Shieh, Tzong-Ming (October 2019). "Effects of mineral trioxide aggregate and bioceramics on macrophage differentiation and polarization in vitro". Journal of the Formosan Medical Association. 118 (10): 1458–1465. doi: 10.1016/j.jfma.2019.07.010 . PMID   31358435.
  7. 1 2 3 Vidal, Karla; Martin, Gabriela; Lozano, Oscar; Salas, Marco; Trigueros, Jaime; Aguilar, Gabriel (May 2016). "Apical Closure in Apexification: A Review and Case Report of Apexification Treatment of an Immature Permanent Tooth with Biodentine". Journal of Endodontics. 42 (5): 730–734. doi:10.1016/j.joen.2016.02.007. PMID   26994597.
  8. ↑ Rafter, Mary (2005). "Apexification: a review". Dental Traumatology. 21 (1): 1–8. doi:10.1111/j.1600-9657.2004.00284.x. ISSN   1600-9657. PMID   15660748.
  9. ↑ Shabahang, Shahrokh (March 2013). "Treatment options: apexogenesis and apexification". Journal of Endodontics. 39 (3 Suppl): S26–29. doi:10.1016/j.joen.2012.11.046. ISSN   1878-3554. PMID   23439042.
  10. 1 2 3 Jones, James; Spolnik, Kenneth; Yassen, Ghaeth H. (2015-09-22). "Management of Trauma to the Teeth and Supporting Tissues". McDonald and Avery's Dentistry for the Child and Adolescent: Tenth Edition: 563–602. doi:10.1016/B978-0-323-28745-6.00027-2. ISBN   9780323287456.
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