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Endodontics Continued »


How do I obturate the canal? The options for obturation are dependent on whether or not we aim to create an apical barrier. Figure 3 (page 3ı) highlights the different options. Apexification and apexogenesis


are two endodontic procedures which attempt to either induce apical repair by initiating a hard tissue barrier across an open apex or to promote the continued formation of the apical portion of the root9


.


Apexification Calcium hydroxide has been the first choice material for apexifi- cation. Placement and repeated changes over the course of five to 20 months induces the formation of a calcific barrier. The unpredictable and lengthy course of treatment presented challenges, particu- larly as it required a high level of patient compliance. For this reason, one-visit apexification has been suggested. MTA has been proposed as


a material suitable for one visit apexification as it combines a bacte- riostatic action, biocompatibility and a favourable sealing ability. Placement of a 3mm thickness of MTA in the apical portion of an ‘open apex’ permits the vertical condensation of warm gutta percha into the remainder of the canal (See Fig 4).


Apexogenesis Case reports in the literature over the past ı0 years have demonstrated successful revascularisation and regeneration of immature perma- nent teeth with apical periodontitis. Banchs and Tropeı0


irrigated


necrotic teeth with sodium hypochlorite, and placed an anti- biotic tri-paste dressing consisting of metronidazole, minocycline and ciprofloxacin. Four weeks later, the tooth was re-accessed and bleeding encouraged at the apex, allowing a clot to form 3mm below the CEJ. Following this, MTA was placed


on the blood clot and the tooth restored with composite. Follow up radiographs demonstrated complete apical healing and continued root formation. Shin et al,ıı


treated a non-vital mandibular second premolar tooth 32 Ireland’s Dental magazine


using irrigation with 6 per cent sodium hypochlorite and 2 per cent chlorhexidine without instrumenta- tion in a single visit. The successful outcome of this case report suggests that this conservative revascularisa- tion treatment approach can create a suitable environment for pulpal repair, resulting in the completion of root maturation. McCabeı2


recently published a


case report showing disinfection with 5 per cent sodium hypochlorite followed by the induction of a blood clot into the root canal space may be sufficient to promote revascularisa- tion in certain circumstances using a single visit protocol. Most of the case reports regarding


apexogenesis as a treatment modality have shown an increase in dentinal wall thickening and root length, with a reduction in the volume of the pulp canal space visible radiographically. Histological analysis of teeth which had undergone revascularisation treatment demonstrated that the mineralised layer on the walls which was present appeared to be of periodontal origin rather than pulpal originı2


.


What does the future hold? It appears that current treatment approaches tend to stimulate repar- ative rather than regenerative responses in respect of the new tissue generated, which often does not closely resemble the physi- ological structure of dentine-pulp complex. Although patients requiring treat-


ment undoubtedly make up a small proportion of our patients, and despite the biological limitations, such techniques appear to offer significant promise for improved treatment outcomes2


. The main question is whether


our patients are better served by apexification and formation of an apical barrier via an MTA plug, or whether apexogenesis and genera- tion of reparative tissue within the canal space, even if it is periodontal in origin, is better. It could be argued that apexogenesis will make the tooth more suitable for restoration, as teeth which have undergone apexification tend to be more fragile and prone to cervical fractures. Any attempt to undergo biological healing should prove to be more beneficial in the long term. Further


REFERENCES


1. American Association of Endodon- tists. Glossary of endodontic terms, 7th ed. Chicago: American Associa- tion of Endodontists; 2003


2. Simon S., Smith A.J. Regen- erative Endodontics. Br Dent J. 2014 Mar;216(6):E13


3. Cvek, M., Andreasen, J. O. and Borum, M. K. (2001), Healing of 208 intraalveolar root fractures in patients aged 7–17 years. Dental Trauma- tology, 17: 53–62.


4. Vier, F. V. and Figueiredo, J. A. P. (2002), Prevalence of different peri- apical lesions associated with human teeth and their correlation with the presence and extension of apical external root resorption. International Endodontic Journal, 35: 710–719.


5. Kim Y-JA, Chandler NP. Determina- tion of working length for teeth with wide or immature apices: a review. International Endodontic Journal, 46, 483–491, 2013.


6. Marcos-Arenal JL, Rivera EM, Caplan DJ, Trope M (2009) Evaluating the paper point technique for locating the apical foramen after canal prepara- tion. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 108, e101–5.


7. El Ayouti A, Dima E, Löst C (2009) A tactile method for canal length deter- mination in teeth with open apices. International Endodontic Journal 42, 1090–5.


8. Hülsmann, M., Peters, O. A. and Dummer, P. M.H. (2005), Mechanical preparation of root canals: shaping goals, techniques and means. Endo- dontic Topics, 10: 30–76.


9. Rafter, M. (2005), Apexification: a review. Dental Traumatology, 21: 1–8.


10. Banchs F, Trope M (2004) Revas- cularisation of immature permanent teeth with apical periodontitis; new treatment protocol? Journal of Endo- dontics 30, 196–200.


11. Shin SY, Albert JS, Mortman RE (2009) One step pulp revascu- larization treatment of an immature permanent tooth with chronic apical abscess: a case report. International Endodontic Journal 42, 1118–26.


12. McCabe P. (2014) Revasculariza- tion of an immature tooth with apical periodontitis using a single visit protocol: a case report. International Endodontic Journal 47.


13. Simon S., Smith A.J., Lumley P.J. et al. (2012) The pulp healing process: from generation to regeneration. Endodontic Topics 26, 41-56.


research is required into this novel approach to apexogenesis to assess the long-term prognosis of these teeth. Current research on pulp


regeneration is growing and provides exciting possibilities for greater biological approaches to endodontics in the futureı3


.


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