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 root development according to: - the width of the apical foramen and - the length of the root,
Dr. Soliman Kamha
12/3/2012
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Stage 1 Teeth with: -wide divergent apical opening and -a root length estimated to less than half of the final root length.
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Stage 2 Teeth with: -wide divergent apical opening and -a root length estimated to half of the final root length.
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Stage 3 Teeth with: -wide divergent apical opening and -a root length estimated to two thirds of the final root length.
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Stage 4 Teeth with: -wide open apical foramen and -nearly completed root length.
Dr. Soliman Kamha
12/3/2012
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Stage 5 Teeth with: -closed apical foramen and -completed root development.
Dr. Soliman Kamha
12/3/2012
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Dr. Soliman Kamha
12/3/2012
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TYPES OF OPEN APICES

These can be of two configurations: 1- non-blunderbuss 2- blunderbuss
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Dr. Soliman Kamha
12/3/2012
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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 basically refers to an 18th century weapon with a short and wide barrel. It derives its origin from the Dutch word DONDERBUS which means thunder gun.
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Dr. Soliman Kamha
12/3/2012
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- The walls of the canal are divergent and flaring, more especially in the buccolingual direction. -The apex is funnel shaped and typically wider than the coronal aspect of the canal.
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CAUSES OF OPEN APICES

1. Incomplete development The open apex typically occurs when the pulp undergoes necrosis as a result of caries or trauma, before root growth and development are complete (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 periradicular surgery 4. Over-instrumentation
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What is the line of treatment ? Before considering any direction of treatment, it is important to decide the vitality and integrity of canal contents.
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Dr. Soliman Kamha
12/3/2012
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It has been established that a pulpotomy procedure is the treatment of choice when there is vital healthy pulp remaining in the canal. Following this partial removal of the pulp and the introduction of calcium hydroxide, apical development can continue.
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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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Dr. Soliman Kamha
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The course of treatment for the underdeveloped tooth with its wide open apex becomes more complex when the pulp is no longer vital and when there is apical pathology.
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Dr. Soliman Kamha
12/3/2012
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(Root end induction of calcific barrier) It is the process in which an environment is created within the root canal and the periapical tissues after death of the pulp, which allows a calcific barrier to form around the open apex.
Apexification
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Dr. Soliman Kamha
12/3/2012
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Indications of apexification:
It is indicated for teeth with necrotic pulps & open apices in which standard instrumentation techniques cannot create an apical stop to facilitate effective obturation of the canal.
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This usually results in blunting of the end of the root and very little, if any, increase in tooth length. New root growth (apexogenesis) may result in few necrotic cases, but this is the exception rather than the rule.
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Idea of apexification
It involves the reduction of the contaminants ( disinfection ) within the canal by instrumentation, followed by partial reduction of the canal space through the use of a temporary filling material.
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A paste of calcium hydroxide is suggested as a temporary filling material because : 1- It is anti-bacterial. 2- It is readily available & simple to prepare. 3- It can be easily removed from the canal 4- There is no difficulty if excess is expressed into the periapical area, since it is resorbable.
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Calcium hydroxide is used in a nonsetting form : 1- calcium hydroxide powder mixed with distilled water, saline , or anesthetic solution 2- premixed Calcium hydroxide suspension 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 similar environment to that required for hardtissue formation in vital pulp therapy which means; i) mild inflammatory stimulus to initiate healing ii) bacteria-free environment to ensure that inflammation is not progressive.
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It is important that a root canal filling be placed as soon as apical development and closure occur. Though the absorbable paste seal is adequate to reduce the canal space and its contaminants, it should be replaced with a permanent root canal filling to prevent the possible recurrence of periapical pathology.
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Therapy is not considered complete until: - Adequate apical development has been achieved - A permanent filling material has 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 tooth length.
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4- prepare and clean the canal as far as the radiographic apex. N.B. It is important to file the walls with lateral pressure since the largest instrument is often loose in the canal. Proceed until all the available necrotic material is removed. Flush frequently and generously with sodium hypochlorite.
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Dr. Soliman Kamha
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5- Dry the canal Paper points are usually inadequate making it necessary to use an instrument ( endodontic file) with cotton wrapped around it.
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6- Prepare a thick paste of calcium hydroxide. 7- Pack the paste inside the canal against the apical soft tissues using a plugger or thick Guttapercha point to initiate hard tissue formation.
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This is followed by back-filling with Ca(OH)2 to completely obturate the canal, thus ensuring a bacteria-free canal with little chance of re-infection during the 6-18 months required for hardtissue formation at the apex.
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Dr. Soliman Kamha
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8- Take a radiograph : the canal should appear as if has become calcified (indicating that the entire canal has been filled with Ca hydroxide)
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Dr. Soliman Kamha
12/3/2012
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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.
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Dr. Soliman Kamha
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2nd appointment: It should not be delayed more than one month to: - avoid washing out of Ca(OH)2 by tissue fluids through the open apex, - leaving the canal susceptible for reinfection.
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1- Take a radiograph for comparative evaluation to evaluate whether a hard-tissue barrier has formed or if calcium hydroxide has washed out. 2- It is necessary to take a radiograph to re-establish the tooth length, since the length may change.
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3- Recall the patient at 4-6 weeks intervals until a radiographic closure of the apex is verified by opening the canal and test with instruments; a definite stop should be encountered.
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It is not necessary to have complete closure before preceding with the permanent root canal filling. It is only necessary to have a better designed apex that allows for a point to be rolled and fitted for a condensation filling technique.
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If the degree or quality of apexification remains questionable, repeat the first appointment procedures.
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Dr. Soliman Kamha
12/3/2012
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The hard-tissue barrier

It consists of irregularly arranged layers of coagulated soft tissue, calcified tissue, and cementum -like tissue. Also included are islands of soft connective tissue, giving the barrier a Swiss cheese consistency. Because of the irregular nature of the barrier, it is not unusual for cement or softened guttapercha to be pushed through it.
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Formation of the hard-tissue barrier may be some distance short of the radiographic apex, because the barrier forms wherever the calcium hydroxide contacts vital tissues. In teeth with wide open apices, vital tissues can survive & proliferate from the periodontal ligament a few millimeters into the root canal.
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Obturation should be completed to the level of the hard-tissue barrier & not forced towards the radiographic apex. The last step is to complete the case when a permanent gutta-percha filling can be accomplished. Apexification takes too long time
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Do we have other solutions?

In some mild cases we can do obturation of the wide canal with rolled technique if the root shape permits
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Dr. Soliman Kamha
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Another solution is: Placement of artificial (root-end filling materials) barriers
- mineral trioxide aggregate (MTA) - MTA is a hydrophilic material. It sets in 3 to 4 hours in the presence of moisture.
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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 MTA G.P.
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Dr. Soliman Kamha
12/3/2012
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Another appraoch is to combine: A better approach to apexification may be one in which a combination procedure is done.
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Dr. Soliman Kamha
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1. Use calcium hydroxide for a short period of time, about 2 weeks, to assist in disinfection of the root canal. 2. Place MTA in the apical part of the canal to serve as an apical plug that promotes apical repair. 3- Fill with GP.
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Another recent solution is Induction of blood clot in the periradicular region after cleaning and disinfecting the canal to create an environment where pulp regeneration can occur.
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Thank you

Management of The Open Apex

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Slide 1

MANAGEMENT OF THE OPEN APEX

STAGES OF ROOT DEVELOPMENT

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

TYPES OF OPEN APICES

Dr. Soliman Kamha

Dr. Soliman Kamha

CAUSES OF OPEN APICES

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

Dr. Soliman Kamha

The hard-tissue barrier

Do we have other solutions?

Dr. Soliman Kamha

Another solution is: Placement of artificial (root-end filling materials) barriers

Collacote MTA G.P.

Dr. Soliman Kamha

Dr. Soliman Kamha

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