Apexification

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Boboia Date: 9/4/09
Article title: Apexification
Author(s): M. Rafter
Journal: Dental Traumatology
Volume #; Number; Page #s): 21: 1-8
Year: 2005
Type of Article: Review
Pulapal Injury in Teeth with Developing Roots
Hertwigs epithelial root sheath is sensitive to trauma because of the degree of vascularity in the apical region; all efforts should be made to maintain it’s vitality; its purpose is to provide a source of undifferentiated cells that could give rise to further hard tissue; it may also prevent ingrowth of PDL cells into the root canal; if Hertwig’s ERS is destroyed, hard tissue can still be formed by cementoblasts present in the apical region and by fibroblasts of the dental follicle Apexogenesis:
Done on teeth with immature apices; essentially a Cvek pulptomomy (all inflamed tissue must be removed)
Goals:
1) Sustaining a viable Hertwig’s RS and allowing for continual development of root length for a more favorable crown-to-root ratio
2) maintain pulp vitality
3) promoting root end closure and allowing for a natural apical constriction for RCT
4) generating a dentinal bridge at the pulpotomy site (not essential but suggestive of pulp vitality)
Total time: 1-2 yrs depending on degree of tooth development at time of procedure
3 month recalls for pulp testing and evaluation of extent of apical maturation
Apexify if internal resorption or irreversible pulpitis are present
Apexification: Removal of pulpal tissue with the goal of forming an apical barrier; CaOH and MTA can both be used as medicaments to help induce this.
CaOH:
Was first used for this in 1964; advantageous for its antimicrobial properties; reaction of periapical tissue to CaOH is similar to that of pulp tissue; electron microscopy does reveal porosities in the newly formed apical barrier; single and multiple application approaches to apexification have been purposed; reports of apical barrier formation occurring on average in 5 – 20 months have been published; according to this paper the strongest predictor of rapid barrier formation was the rate of change of calcium hydroxide and a narrow apical width (the more narrow the faster the barrier formation occurred); age may be inversely related to the time required for apical barrier formation.
MTA:
First introduced in 1993 with FDA approval in 1998; Has successfully been used in both surgical and non-surgical applications including root end fillings, direct pulp caps, perforation repairs in roots / furcations, and apexification. In comparison to CaOH, MTA has been shown to produce an apical barrier with SIGNIFICANTLY greater consistency
One Visit Apexification:
No attempt at root end closure; an artifical apical stop with MTA, CaOH, freeze dried bone, or freeze dried dentin is created; for this technique to work the expedient cleaning and shaping of the root canal system and placement of the apical seal must occur; a bonded core is placed immediately to reduce the chance of root fracture; a number of authors reported success with MTA (of course)
Tooth Restoration Following Apexification:
A number of studies have demonstrated the use of newer dentin bonding techniques significantly increase resistance to fracture; one technique describes fabricating a removable plug with a clear curing post; the filling could then provide fracture resistant properties to the tooth and be removed as need for CaOH replacement and subsequent canal obturation.
Assesment: Nice review. Would have liked more detail on the technical aspects of the “one visit apexification” techniqu