Endodontic therapy on immature permanent teeth Flashcards
Indications for indirect pulp treatment in young permanent teeth
vital permanent tooth with deep caries and reversible pulpitis
Objectives of indirect pulp treatment in a young permanent tooth
Completely seal carious dentine from oral cavity - inhibit caries progression (reduce number of bacteria)
Preserve vitality
Promote pulp healing
Prevent post op pain sensitivity or swelling
Prevent root resorption or pathology
Root development and apexogensis in immature teeth
Apexification definition
inducing root end closure by a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in non vital young permanent teeth with a necrotic pulp
Allows the formation of an apical barrier against which a root filling material can be placed
Immature teeth vs mature teeth
Immature teeth have a wide open apex, are difficult to obturate, weaker and shorter root with thiner dentine walls
better blood supply = better prognosis
Apexogenesis
Continued physiological development and formation of root apex in a vital young permanent tooth
Accomplished by the appropriate vital pulp therapy
(indirect pulp cap, direct pulp cap or partial pulpotomies for carious/traumatic exposures
Preserves vitality of tooth
Which procedures aim to allow apexogenesis to occur?
CVEK’s (partial) PULPOTOMY
indirect and direct pulp capping
conventional pulpotomy
Methods of achieving apexification
Removing coronal and non vital radicular pulp and cleaning
Intracanal CaOH dressing 2-4 weeks (change 3 monthly) to disinfect canals
-Inducing the formation of a natural barrier at the apex?
Artificial barrier produced with MTA
Pulp revascularisation
Cvek pulpotomy (partial pulpotomy) definition
Inflammed pulp tissue beneath an exposure is removed to a depth of around 1-3 mm to reach deeper, healthier tissue
Two indications for partial pulpotomies
Carious pulp exposure
Traumatic pulp exposure (Cveks)
Objectives of partial pulpotomy in young permanent teeth (carious/traumatic)
Maintain vitality of remaining pulp
Prevent adverse clinical sensitivity, pain or swelling
Prevent signs of internal/external resorption, pulp canal obliteration or apical pathology
Continue normal physiological root development and apexogenesis
Procedure for Cvek’s Pulpotomy (traumatic exposure)
LA
Rubber dam
Remove pulpal tissue within 2mm apical to exposure with high speed diamond bur and water
Irrigate with saline/CHX/sodium hypochlorite soaked cotton pellet to stop bleeding
Non-setting CaOH layer to cover pulp/MTA (whiter for ant teeth, CaOH better long term success but MTA more predictable dentin bridge and pulp health)
Seal with setting CaOH and GIC
Restore with composite/RMGIC
Re-evaluate in 6-8 weeks, 3m, 6m , 1 year for root development and vitality
Why is CaOH used in apexification ?
bactericidal due to high pH
Initiates a zone of liquefaction and coagulation necrosis adjacent to apical healthy tissues = formation of cementum like calcific barrier
Disadvantages of CaOH for apexification
weakening of dentine walls and root fracture risk due to long application of CaOH
long procedure = compliance
costly procedure
When is apexification contrindicated?
when the tooth is vital
with very short roots
Apexification procedure
Access
Chemomechanical cleaning to 0.5-1 mm short of the apex
Moderate lateral pressure and vertical movements against the dentine wall
Chlorhexidine or 0.5% NaOCl irrigation
Fill with CaOH compressed with cotton pellet to make sure is is in contact with vital apical tissue
repeat 3 monthly for around 18 mths - 2 years
if no barrier forms, place artificial MTA barrier
