Apexogenesis treatment with mineral trioxide aggregate: long-term follow-up of two cases. Private Practice, Midrand, South Africa. Apexogenesis is the treatment of choice for traumatized or carious teeth which, at the time of exposure, have a vital pulp and open apex. This article describes two cases of permanent teeth with carious exposures, treated with direct pulp capping procedures using mineral trioxide aggregate MTA. METHODS: Radiographic and clinical examination, including testing reaction to cold, showed that both teeth were immature and in a stage of reversible pulpitis.
|Published (Last):||28 September 2004|
|PDF File Size:||12.49 Mb|
|ePub File Size:||13.56 Mb|
|Price:||Free* [*Free Regsitration Required]|
Apexogenesis treatment with mineral trioxide aggregate: long-term follow-up of two cases. Private Practice, Midrand, South Africa. Apexogenesis is the treatment of choice for traumatized or carious teeth which, at the time of exposure, have a vital pulp and open apex. This article describes two cases of permanent teeth with carious exposures, treated with direct pulp capping procedures using mineral trioxide aggregate MTA.
METHODS: Radiographic and clinical examination, including testing reaction to cold, showed that both teeth were immature and in a stage of reversible pulpitis.
The caries was identified using caries detector dye and removed using a rotary bur. Sodium hypochlorite solution was applied to the exposed pulp to achieve haemostasis. MTA paste was then placed on the pulp exposure and surrounding dentine. In the first case, the MTA was covered with a glass-ionomer restorative material; in the second case, the MTA was covered with a glass-ionomer cement and restored with composite resin.
RESULTS: Radiographic and clinical examinations on the initial and long-term follow-up visits showed that root development continued and apices formed. The teeth remained vital and functional, and no further endodontic intervention was necessary. Vital pulp therapy e. According to Trope, 4 the area and depth of inflammation in cariously exposed pulps are very unpredictable, and pulp capping at the superficial exposure site can result in failure.
After observing 49 teeth over a period of 9 years, Bogen et al. Fifteen of the teeth were immature at the time of treatment, and all these subsequently demonstrated continued normal apexogenesis to complete root formation.
Vital pulp therapy on immature teeth allows for continuation of root formation, which leads to apical closure, 10 preservation and maintenance of pulp vitality, 9 stronger root structure and greater structural integrity.
The most successful agent for pulp capping procedures is MTA. This material has a long history of use for both pulp capping and other applications. As a pulp capping material, MTA can induce hard tissue formation in pulpal tissues, produce a thicker dentinal bridge at a faster rate, 2,19 promote longer-term sealing, 2 reduce inflammation, reduce hyperaemia and reduce pulpal necrosis compared with calcium hydroxide.
Despite its biocompatibility as a pulp capping material, it has a delayed setting time, 10 poor handling characteristics 23,24 and is costly.
This article presents two case reports where MTA was used as a direct, single-visit pulp capping material in cariously exposed teeth with immature roots. An 8-year-old boy was referred to our private practice by another practitioner who had exposed the pulp during removal of occlusal decay on the recently erupted mandibular right first premolar.
The patient was seen at the endodontic practice thirty minutes after the carious exposure. The dentist had placed a moist, sterile cotton pledget over the exposure and covered it with a zinc-oxide eugenol temporary restoration Kalzinol, Dentsply De Trey, Konstanz, Germany. According to the referring dentist, the patient had suffered no spontaneous pain preoperatively apart from the main complaint of sensitivity to cold liquids.
Radiographic examination showed that the root formation was immature Figure 1a. The patient's medical history was noncontributory. A dose of local anaesthetic was administered. A rubber dam was placed, and a caries indicator dye Sable Seek, Ultradent, South Jordan, UT, USA was applied to facilitate final caries excavation, which was done using a slow-speed carbide bur in a contra-angle hand piece under 12X microscope magnification Figure 1b.
After three minutes, the NaOCl was rinsed away with water using a two-way syringe, and the area was blot-dried with sterile cotton pledges. Adequate hemostasis was seen to have been achieved. White ProRoot MTA Dentsply Sirona, Philadelphia, USA was mixed according to the manufacturer's instructions, and a thick layer of the cement was placed directly over the exposure site and surrounding dentine Figure 1c. Figure 1d shows an immediate postoperative periapical radiograph. The patient was instructed to call our clinic immediately if any pain or discomfort occurred.
At the ten-day recall visit the patient was asymptomatic and had a normal response to cold testing. The patient was rescheduled for follow up after three months, with instructions to return earlier in case of any discomfort. At this recall visit, the tooth was asymptomatic and had a normal response to cold testing. At the one-year follow-up visit, more root development was observed, with a thickening of root walls and a visible dentine bridge at the exposure site Figure 2a.
At a two-year recall visit, the tooth tested vital, and a periapical radiograph showed additional root formation Figure 2b. The three-year follow-up visit confirmed complete root formation and apex closure Figure 2c. Figure 2d depicts the four-year follow-up radiographic image of the asymptomatic tooth. At that stage, the tooth tested vital and a normal periodontal ligament was demonstrated.
A seven-year-old boy attended our practice for a routine checkup. A bitewing radiograph revealed an occlusalmesial cavity on his mandibular left first permanent molar. Local anesthetic was administered, a rubber dam was placed, and the cavity prepared with a high-speed diamond bur.
Caries indicator was used to ensure complete excavation of caries, which was carried out under 12X microscope magnification using a slow-speed carbide bur in a contra-angle hand piece. Haemostasis was achieved by the application of a 3. The NaOCl was then rinsed away with water using a two-way syringe, and the area was blot-dried with sterile cotton pledges.
Grey ProRoot MTA Dentsply Sirona, Philadelphia, USA was mixed according to the manufacturer's instructions, and a thick layer of the cement was placed directly over the exposure site and surrounding dentine. An immediate postoperative periapical radiograph showed that the roots of the molar were still immature with large open apices Figure 3a.
At the fifteen-day recall visit the patient reported that the tooth was asymptomatic. Testing with the application of cold resulted in a normal reaction. The patient was rescheduled for follow up at three months and at one, two, four and six years, with instructions to return immediately in case of any discomfort. Continued root development was evident, and a 0. At a four-year recall visit, the radiograph revealed closure of the apices of the mesial and distal roots and an increase in the thickness of the dentine bridge formation Figure 3c.
At the six-year follow-up, slight widening of the periodontal ligament around the apical third of the mesial roots was noted. At a year follow-up visit Figure 3d , the tooth was still asymptomatic and had a normal response to cold testing. The periodontal ligament around the apical third of the mesial root was still widened. Also visible on the periapical radiographs at these recall visits was a small calcification or pulp stone that had formed in the pulp chamber of the tooth.
From the time that root formation was complete and the apices closed four-year recall, Figure 3c up to the last follow up at the year recall Figure 3d , the root canal width and pulpal volume remained approximately the same size. Radiographic assessment of both teeth in the two case reports demonstrated that the roots had progressed to complete root formation and apex closure, and cold testing confirmed the preservation and maintenance of pulp vitality.
Dentine bridge formation at the site of pulpal exposure was also noted in both cases. Studies have shown that properties of a pulp capping material such as sealing ability, alkalinity and biocompatibility could be responsible for dentine bridge formation. Farsi et al. Clinical and radiographic success was reported as all the teeth were asymptomatic, showed signs of vitality, lacked periapical radiolucencies and showed evidence of continued root growth.
The use of caries detector dye to confirm all caries had been removed, NaOCl for haemostasis and disinfection, MTA as a pulp capping material, glass-ionomer material to cover unset MTA material and enhanced magnification of all clinical procedures were all factors contributing to the success of these two one-visit pulp capping treatments. Effective operative magnification and careful caries removal have been identified as important prerequisites for success, 9 with the placement of a bioactive pulp capping material enhancing the innate healing capacity of the human dentalpulp.
Haemostasis after pulpal exposure was controlled by applying 3. MTA basically consists of calcium, silica and bismuth oxide, but the two products differ in terms of the presence of aluminum, magnesium and iron GMTA has higher amounts of each.
Several studies have highlighted the importance of achieving a coronal seal after pulp capping. MTA proved to be a reliable pulp capping material on direct carious exposures in immature permanent teeth using a one-visit protocol.
The authors confirm that there are no conflicts of interest related to the case reports depicted in this article. GMTA : grey mineral trioxide aggregate. MTA : mineral trioxide aggregate. PBRN : practice based research network. WMTA : white mineral trioxide aggregate.
Rafter M. Apexification: A review. Witherspoon DE. Vital pulp therapy with new materials: New directions and treatment perspectives-permanent teeth.
Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. Trope M. Regenerative potential of dental pulp. Pulp reactions to exposure after experimental crown fractures or grinding in adult monkeys. Pulp capping of carious exposures: Treatment outcome after 5 and 10 years: A retrospective study.
Capping of the inflamed pulp. Oral Surg. Oral Med. Oral Pathol. The healing of experimentally induced pulpitis. Direct pulp capping with mineral trioxide aggregate: An observational study. Nosrat A, Asgary S. Apexogenesis treatment with a new endodontic cement: A case report. Strengthening immature teeth during and after apexification.
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. Digital and advanced imaging in endodontics: A review. Clinical use of bioceramic materials.
Pulp Revascularization: A Literature Review
Apexification, Apexogenesis and Regenerative Endodontic Procedures: A Review of the Literature
Reestablishing blood flow and allowing the continuation of root development are some of the objectives of pulp revascularization. This procedure is currently indicated for teeth with incomplete root formation as an alternative to the traditional treatment of apecification, which consists of inserting calcium hydroxide paste into the root canal for a determined time period in order to induce the formation of a calcified barrier. Although it is considered as the most classically employed therapy, the permanence of the paste for long time periods may lead to the weakening of the root due to hygroscopic properties, as well as proteolytic activities of calcium hydroxide. Therefore, there has been a permanent search for alternatives which allow the full development of immature teeth. Revascularization has emerged as such an alternative, and a range of treatment protocols can be found in the scientific literature. The aim of this paper is to accomplish a literature review concerning this issue. Conventional endodontic treatment consists in the development and application of techniques designed to accomplish the chemical-mechanical preparation of root canals in order to eliminate an infection, many times difficult to combat due to the complexity of the root canal system.
Apexification, apexogenesis and regenerative endodontic procedures: a review of the literature.
Aim: Aim of this paper was to present the therapeutical approaches to the management of the immature apex and discuss the evolution of materials and techniques. Methods: A Medline search was performed limited to human studies published. The keywords searched were apexogenesis, apexification, pulp regeneration, revascularization. Results: Apexogenesis and apexification techniques using Calcium hydroxide or MTA give a high succes rate. Recent regeneration procedures may be helpful for apexification in non vital elements. Conclusion: Calcium hydroxide is the gold standard material used in apexogenesis and apexification. New technologies are promoting the growing interest in strategies used for vitality preservation and pulp regeneration.