Management of the Open Apex

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MANAGEMENT OF THE OPEN APEX

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STAGES OF ROOT DEVELOPMENT

• Cvek classified 5 stages of rootdevelopment according to:

- the width of the apical foramenand

- the length of the root,

12/3/20123 Dr. Soliman Kamha

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• Stage 1Teeth with:

-wide divergent apical opening and

-a root length estimated to less than half of the final root length.


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-a root length estimated to half of the final root length.


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-a root length estimated to two thirds of the final root length.


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-wide open apical foramen and-nearly completed root length.


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-closed apical foramen and -completed root development.


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12/3/2012Dr. Soliman Kamha9

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TYPES OF OPEN APICES

• These can be of two configurations:1- non-blunderbuss 2- blunderbuss


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• Non –blunderbuss:The walls of the canal may be:-parallel or -slightly convergent as the canal exits the

root

• The apex, therefore can be:- broad (cylinder shaped) or -tapered (convergent)


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• Blunderbuss:The word ‘blunderbuss’ basicallyrefers to an 18th century weaponwith a short and wide barrel. Itderives its origin from the Dutchword ‘DONDERBUS’ which means‘thunder gun’.


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- The walls of the canal aredivergent and flaring, moreespecially in the buccolingualdirection.-The apex is funnel shaped andtypically wider than the coronalaspect of the canal.


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CAUSES OF OPEN APICES

1. Incomplete developmentThe open apex typically occurs whenthe pulp undergoes necrosis as aresult of caries or trauma, beforeroot growth and development arecomplete (i.e. during stages 1-4)


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2. Extensive apical resorption due to:-orthodontic treatment, -periapical pathosis or -trauma

3. Root end resection during periradicularsurgery

4. Over-instrumentation


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What is the line of treatment ?

• Before considering any directionof treatment, it is important todecide the vitality and integrity ofcanal contents.


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• It has been established that apulpotomy procedure is thetreatment of choice when there isvital healthy pulp remaining in thecanal.

• Following this partial removal of thepulp and the introduction of calciumhydroxide, apical development cancontinue.


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:Apexogenesis• It is defined as treatment of the vital

pulp by pulp capping or pulpotomy in order to permit:

- continued closure of the open apex and

- growth of the root.


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• The course of treatment for theunderdeveloped tooth with itswide open apex becomes morecomplex when the pulp is nolonger vital and when there isapical pathology.


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Apexification(Root end induction of calcific barrier)

• It is the process in which anenvironment is created within theroot canal and the periapical tissuesafter death of the pulp, which allowsa calcific barrier to form around theopen apex.


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Indications of apexification:

• It is indicated for teeth with necroticpulps & open apices in whichstandard instrumentation techniquescannot create an apical stop tofacilitate effective obturation of thecanal.


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• This usually results in blunting of theend of the root and very little, if any,increase in tooth length.

• New root growth (apexogenesis) mayresult in few necrotic cases, but thisis the exception rather than the rule.


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Idea of apexification• It involves the reduction of the

contaminants ( disinfection ) withinthe canal by instrumentation,followed by partial reduction of thecanal space through the use of atemporary filling material.


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• A paste of calcium hydroxide issuggested as a temporary fillingmaterial because :

1- It is anti-bacterial.2- It is readily available & simple to

prepare.3- It can be easily removed from the canal4- There is no difficulty if excess is

expressed into the periapical area, sinceit is resorbable.


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• Calcium hydroxide is used in a non-setting form :

1- calcium hydroxide powder mixedwith distilled water, saline , oranesthetic solution

2- premixed Calcium hydroxidesuspension in ready made tubes( Hypocal & Reogan rapid.)


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• Stimulation of the hard tissue barrier:• The formation of the hard-tissue barrier

at the apex requires a similarenvironment to that required for hard-tissue formation in vital pulp therapywhich means;

i) mild inflammatory stimulus to initiatehealing

ii) bacteria-free environment to ensurethat inflammation is not progressive.


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• It is important that a root canal filling beplaced as soon as apical developmentand closure occur.

• Though the absorbable paste seal isadequate to reduce the canal space andits contaminants, it should be replacedwith a permanent root canal filling toprevent the possible recurrence ofperiapical pathology.


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• Therapy is not consideredcomplete until:

- Adequate apical developmenthas been achieved

- A permanent filling materialhas been placed.


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Technique of apexification:1- Isolate the involved tooth with

rubber dam.

2- Prepare the access opening.

3- Establish the accurate toothlength.


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4- prepare and clean the canal as far asthe radiographic apex.

N.B. It is important to file the walls withlateral pressure since the largestinstrument is often loose in the canal.

• Proceed until all the available necroticmaterial is removed.

• Flush frequently and generously withsodium hypochlorite.


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5- Dry the canal• Paper points are usually

inadequate making itnecessary to use aninstrument ( endodontic file)with cotton wrapped aroundit.


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6- Prepare a thick paste of calciumhydroxide.

7- Pack the paste inside the canalagainst the apical soft tissuesusing a plugger or thick Gutta-percha point to initiate hardtissue formation.


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• This is followed by back-fillingwith Ca(OH)2 to completelyobturate the canal, thus ensuringa bacteria-free canal with littlechance of re-infection during the6-18 months required for hard-tissue formation at the apex.


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8- Take a radiograph : the canalshould appear as if has becomecalcified (indicating that theentire canal has been filled withCa hydroxide)


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9- Place a cotton pellet followed by a durable seal.

• The seal should remain intact till the next appointment.

N.B. If symptoms occur repeat the 1st

appointment procedure.• If a fistula remains or appears, repeat

the 1st appointment procedure.12/3/201242 Dr. Soliman Kamha

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2nd appointment:

• It should not be delayed morethan one month to:

- avoid washing out of Ca(OH)2 bytissue fluids through the openapex,

- leaving the canal susceptible forreinfection.


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1- Take a radiograph for comparativeevaluation to evaluate whether ahard-tissue barrier has formed or ifcalcium hydroxide has washed out.

2- It is necessary to take a radiographto re-establish the tooth length,since the length may change.


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3- Recall the patient at 4-6 weeksintervals until a radiographicclosure of the apex is verified byopening the canal and test withinstruments; a definite stopshould be encountered.


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• It is not necessary to havecomplete closure beforepreceding with the permanentroot canal filling.

• It is only necessary to have abetter designed apex that allowsfor a point to be rolled and fittedfor a condensation fillingtechnique.


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• If the degree or quality ofapexification remainsquestionable, repeat the firstappointment procedures.


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The hard-tissue barrier • It consists of irregularly arranged layers of

coagulated soft tissue, calcified tissue, andcementum -like tissue. Also included areislands of soft connective tissue, giving thebarrier a “Swiss cheese’ consistency.

• Because of the irregular nature of the barrier,it is not unusual for cement or softened gutta-percha to be pushed through it.


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• Formation of the hard-tissue barriermay be some distance short of theradiographic apex, because the barrierforms wherever the calcium hydroxidecontacts vital tissues.

• In teeth with wide open apices, vitaltissues can survive & proliferate fromthe periodontal ligament a fewmillimeters into the root canal.


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• Obturation should be completed to thelevel of the hard-tissue barrier & notforced towards the radiographic apex.

• The last step is to complete the casewhen a permanent gutta-percha fillingcan be accomplished.

• Apexification takes too long time


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Do we have other solutions?

• In some mild cases we can doobturation of the wide canalwith rolled technique if the rootshape permits


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• Another solution is:• Placement of artificial barriers

(root-end filling materials)- mineral trioxide aggregate (MTA)- MTA is a hydrophilic material. It sets

in 3 to 4 hours in the presence ofmoisture.


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• Insert collacote beyond the apex• Insert MTA against the collacote• Insert wet cotton or paper point

since it does not set in dry canal.• Condense GP against MTA in another

visit


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Collacote


MTAG.P.

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• Another appraoch is to combine:• A better approach to

apexification may be one inwhich a combination procedure isdone.


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1. Use calcium hydroxide for ashort period of time, about 2weeks, to assist in disinfection ofthe root canal.

2. Place MTA in the apical part ofthe canal to serve as an apicalplug that promotes apical repair.

3- Fill with GP.12/3/201258 Dr. Soliman Kamha

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Thank you


• Another recent solution isInduction of blood clot in theperiradicular region after cleaningand disinfecting the canal tocreate an environment wherepulp regeneration can occur.


Management of the Open Apex

Documents

soliman kamhaslide

soliman kamha slide

soliman kamha20 slide

soliman kamha9slide

soliman kamha21slide

soliman kamha13slide

open apex slide

final root length