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Good morning
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1. Introduction
2. Definition
3. Objective
4. Indications & contraindications
5. Stages of root development
6. Open apices
7. Technique
8. Conclusion

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Young permanent teeth are those recently erupted teeth in
which normal physiological apical root closure has not
occurred.
Normal physiological root closure of permanent teeth may
take 2-3 years after eruption.

Human tooth with immature apex is a developing organ. The
proliferation and differentiation of various cells are activated
especially in the apical region of the young tooth to make it
complete
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Definition :-
The physiologic root end development and
formation. American Association of
Endodontists

Vital Pulp therapy: Treatment of a vital
pulp in an immature tooth to permit
continued dentin formation and apical
closure - Walton and Torabinejad

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According to Avery, the treatment objective of an ideal
pulpotomy agent is to leave the radicular pulp vital and healthy
and completely enclosed within an odontoblast-lined dentin
chamber.

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CONTRAINDICATIONS-
Purulent discharge.
History of prolonged pain.
Periapical radiolucency
Avulsed and replanted or
severely luxated tooth
Severe crown root fracture
that requires intraradicular
retention for restoration
Carious tooth that is
unrestorable

INDICATIONS
A cariously exposed pulp or
traumatized vital permanent
tooth with incomplete root
formation.
For an immature tooth with
damage to coronal pulp but
with a presumably healthy
radicular pulp.
The crown which is fairly
intact and restorable
No history of spontaneous
pain

According to the width of the apical foramen and the length of
the root, Cvek has classified 5 stages of root development.

Stage 1 - Teeth with wide divergent apical opening and a root
length estimated to less than half of the final root length.

Stage 2 - Teeth with wide divergent apical opening and a root
length estimated to half of the final root length.

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.
Stage 5 Teeth with closed apical foramen and completed root
development.
usually found in the developing roots of immature teeth.
Apical closure occurs approximately 3 years after eruption.
However, when the pulp undergoes necrosis before root growth
is complete, dentin formation ceases, and root growth is
arrested.




wide apex
shorter root
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Incisor with an open apex
(divergent walls)
Apical region of an immature CI
These can be of two configurations
non-blunderbuss
blunderbuss.
Non blunderbuss -the walls of the canal may be parallel to slightly
convergent as the canal exits the root .

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Blunderbuss - weapon with a short and wide barrel.
Dutch word DONDERBUS which means thunder gun.
The walls of the canal are divergent and flaring, more
especially in the bucco-lingual direction
The apex is funnel shaped and typically wider than the coronal
aspect of the canal
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)
An open apex can also occasionally form in a mature apex
(stage 5) , as a result of
1. Extensive apical resorption due to orthodontic treatment,
periapical pathosis.
2. Root end resection during periradicular surgery
3. Over-instrumentation
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Large open apices
convergent
parallel
divergent
Thin dentinal walls - which are susceptible
to fracture before, during or after treatment.
Frequent periapical lesions - with or without associated apical
resorption.
Short roots - thus compromising crown-root ratio.
Fractures of crown - compromising aesthetics especially in the
anterior region.
Discoloration in long standing cases
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Apexogenesis
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Apexogenesis is a histological term that has been used to
describe the result of vital pulp procedures that allow the
continued physiologic development and formation of the roots
apex.
This can be accomplished by implementing the appropriate
vital pulp therapy (i.e., indirect pulp treatment, direct pulp
capping, partial pulpotomy for carious exposures and traumatic
exposures).
VPT allows continuation of the root formation, which leads to
apical closure, stronger root structure, and a greater structural
integrity.
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A radiograph showing a mature fully erupted tooth (white arrow), an
immature partially erupted tooth with an open root (yellow arrow) and an
immature unerrupted tooth with dental follicle (red arrow).
Establishing a correct diagnosis is primary goal in a case of
potential VPT procedure.
radiographs of the problem tooth are essential in order to
evaluate furcation or periapical changes of the supporting bone,
periodontal ligament, and extent of root development.
apical closure of an immature tooth can be difficult to
determine radiographically since the mesio-distal width of
most roots is less than the facio-lingual dimension
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severe pain symptoms that are relentless and causing lack of
sleep may be indicative of irreversible pulpitis or an acute
periapical abscess.
Spontaneous pain that occurs without provocation frequently
indicates that the damage to the pulp is irreversible
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Calcium hydroxide
Mineral trioxide aggregate
Calcium enriched mixture
Calcium silicate based cements
MTA angelus
Bioaggregate
Biodentine


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Introduced by hermann in 1920
Bactericidal, promotes repair and healing
Exhibits a high pH that stimulate fibroblasts and enzyme
systems and it is the most common pulp-capping agent


DISADVANTAGES
dissolution of the material over time.
primary tooth resorption,
inability to adhere closely to dentin, and
the presence of tunnel defects formed in the reparative dentin
bridge subjacent to the material.
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Tricalcium silicate
Tricalcium aluminate
Tricalcium oxide
Silicate oxide Mixed with sterile water in a 3:1 powder-to-
liquid ratio
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Low or no solubility
pH value10.2
Antibacterial effect
Induces pulpal cell proliferation
Stimulation of mineralized tissue formation

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Bio-Aggregate is a non-toxic biomaterial that can induce
mineralization in osteoblast cells by increasing levels of type 1
collagen, osteocalcin, and osteopontin

Indications
Pulp Capping
Repair of Root Perforation
Repair of Root Resorption
increased fracture resistance of the tricalcium silicate cements
(BioAggregate, MTA) when used as apical plugs or as
obturation materials
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Biodentine , calcium Silicate based cement does not produce
genotoxic or cytotoxic effects
short setting time of 10 minutes
can be used as a base/liner under various restorative materials
sealing ability of Biodentine is similar to that of MTA and
forms needle-like crystals
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Water based new endodontic cement.
Introduced as a root-end filling material (Asgary et al. 2008)
Major components
51.75wt% Calcium oxide (CaO)
9.53wt%Sulfur trioxide (SO3)
8.49wt% Phosphorous pentoxide (P2O5)
6.32wt% Silicon dioxide (SiO2).
Minor components-
Al2O3, Na2O, MgO, Cl
Mixing the CEM powder and liquid forms a bioactive calcium and
phosphate enriched material, which subsequently results in
hydroxyapatite formation.

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1. Local anaesthesia administration.
2. Rubber dam isolation.
3. Carious tooth structure is removed and access is gained to the
pulp chamber using sterile no.6 bur.
4. Remove coronal pulpal tissue up to the estimated level of
gingival crest of bone using a large sharp spoon excavator. It
should be done without undue trauma to the remaining
radicular pulp tissue.
5. According to Garnett, the instrument of choice for tissue
removal is an abrasive diamond bur at high speed with
adequate water cooling so as to minimize damage to
underlying pulpal tissue.
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6. Following coronal pulp amputation , rinse all the residual and
dentin debris using saline or sterile water. Air should not be
blown on the exposed pulp, as this may cause desiccation and
additional tissue damage.
7. Control haemorrhage by placing several moist cotton pellet
over amputated pulp.
8. Appropriate pulpotomy agent ( calcium hydroxide or MTA) is
placed over the pulp stump.
9. Restoration is placed ( polycarboxylate cement , composite
restoration)
10. Follow up and periodic reviews including radiographs are
performed to check the root development.
11.When dentinal bridge and continued root formation evident,
the conventional root canal treatment can be performed.
The hard-tissue barrier that has formed does not provide an
impervious seal from the oral environment. As such, a
bacteria- tight coronal restoration is necessary to prevent
oral fluids and microorganisms from reaching the exposed
and healing pulpal tissue.

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The total time treatment is 1-2 years, based primarily on
extent of root development at the time of procedure.
Recall is at 3 month intervals to determine extent of apical
maturation. In contrast to apexification, the paste does not
need to be changed.

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Clinical evaluation of pulp healing is made on the basis of:
No clinical symptoms.
No radiographic changes in periapical region.
Continued root development.
Radiographically observed (which may be clinically confirmed)
continuous hard tissue barrier at site of the procedure.

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Cessation of root growth
development of signs and symptoms or periapical lesion.
calcific metamorphosis (i.e. calcific obliteration) of canal or
internal resorption.
In such cases, apexification or root end closure is required.

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8-year old boy --- 4 weeks after trauma to the maxillary left
central incisor with complicated crown fracture and pulpal
exposure.
access cavity prepared, cervical pulpotomy was performed, and
the remaining pulp was capped with calcium enriched mixture
(CEM) cement
Results - radiographic and clinical examinations on the 6-
month and 12-month follow up showed that the tooth remained
functional, root development was completed, and the apex was
formed.

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J Endod 2010;36:912914
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(A) Preop. (B)capping CEM (C) reattachment of separated segment
(D) recall after 6 months
(E) recall after 12 months
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Conclusion: Considering the healing potential of traumatized
immature vital pulp, the use of CEM cement for apexogenesis
might be an applicable choice.
Aim - This study was designed to compare mineral trioxide aggregate
(MTA) with Ca (OH)2 clinically and radiographically as a
pulpotomy agent in immature permanent teeth (apexogenesis).
Methods:
Fifteen children, each with at least 2 immature permanent teeth
requiring pulpotomy (apexogenesis) were selected for this study.
30 teeth were selected and evenly divided into 2 test groups.
In group 1, the conventional calcium hydroxide pulpotomy
(control) was performed, whereas in group 2, the MTA pulpotomy
(experimental) was done. The children were recalled for clinical
and radiographic evaluations after 3, 6, and12 months
Pediatr Dent. 2006 Sep-Oct;28(5):399-404.
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Results:
The follow-up evaluations revealed failure due to pain and
swelling detected at 12 months postoperative evaluation in only 2
teeth treated with calcium hydroxide.






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NA--no radiographic signs of failure

The remaining 28 teeth appeared to be clinically and
radiographically successful 12 months postoperatively.

Conclusions: MTA showed clinical and radiographic success as a
pulpotomy agent in immature permanent teeth (apexogenesis
A 9-year old female presented with severe tooth pain in permanent
mandibular first molar , symptomatic to percussion had a medical
history of spondyloepiphyseal dysplasia .
radiographic examination revealed that the roots of the right first
mandibular tooth had open apices
The tooth (#30) was diagnosed with a necrotic pulp consequent to
caries
The coronal half of the root canal was dbrided with a file #30 to
remove necrotic tissue, and irrigated with chlorhexidine 0.12%.
Bleeding was evoked to form an intracanal blood clot; the wound
was then dressed with calcium hydroxide medication and
provisionally restored with GIC. This was repeated at intervals of 1,
3 and 6 months..
Iranian Endodontic Journal 2010;5(2):93-6]
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After six months, radiographic evidence revealed thickening of dentinal
walls and apical closure. The progressive increase in dentinal wall thickness
and apical development suggests that desirable biologic responses can occur
with this form of treatment for the necrotic open apex of immature
permanent teeth











A) Periapical radiograph of first appointment, B) Periapical radiograph 3
months after first appointment, C) Periapical radiograph 6 months after first
appointment, and D) Periapical radiograph of final Obturation 9 months after
first appointment
aim of this report is to present a case where a traumatized, immature
tooth still showed capacity for further root development and
apexogenesis even after endodontic instrumentation of the root
canal.
A 9-year-old boy whose maxillary central incisors were subjected to
traumatic dental injury during ice-skating. Immediately after the
accident, the patient was examined and a diagnosis of concussion to
maxillary central incisors was made. No emergency treatment was
performed.
One month later, the patient claimed weak and diffuse symptoms in
the maxillary anterior region.
Vital pulp tissue with normal bleeding was recorded when the pulp
chamber was accessed. The root canal was then instrumented to size
100
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International Endodontic Journal, 43, 7683, 2010
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Radiographs taken 1 month after trauma to the anterior teeth. The
diagnosis apical periodontitis form an infected root canal was set based on
radiograph (a). The instrumentation length was set according to radiograph
(b), followed by instrumentation of the root canal to reamer ISO 100
Based on radiographic and clinical findings, apical periodontitis was diagnosed
.
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1. Radiograph taken at the first appointment shows an immature
tooth with incomplete root length, thin dentinal walls and an
open apex. Calcium hydroxide is visible in the coronal part of
the root canal.
2. One month later, slight growth of the root and mineralization in
the cervical area is noted.
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1. Continued root formation and apical closure is observed during 15
months follow-up
2. Radiograph taken after application of mineral trioxide aggregate
(MTA).
3. Final follow-up 2 years after the first appointment. Bonded
composite is used to seal the access cavity


The radiolucent zone surrounding the apical dental papilla was
interpreted as a periapical lesion from an infected necrotic pulp.
The initial endodontic treatment was based on misinterpretation
of clinical and radiographic findings. Although the root canal
was instrumented to size 100, some odontoblasts and pulp cells
may have been left intact
In addition, the copious solid bleeding from the pulp tissue may
have favored reorganization of surviving pulpal tissue


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12-year-old girl was referred with a history of lingering pain and
pain on chewing in the mandibular right second molar which is
sensitive to percussion but not to palpation.
access cavity was prepared with a diamond fissure bur under high-
speed.
Associated bleeding indicated pulp vitality. Hemostasis was achieved
by irrigating with sterile normal saline along with gentle application
of small pieces of moistened sterile cotton pellets for 10 min
CEM cement powder and liquid were mixed to achieve a creamy
consistency. An appro. 2-mm-thick layer of CEM cement was placed
over the exposed pulp and access cavity was restored with cavit,
followed by GIC after 1 day and a coronal restoration with stainless
steel crown
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International Endodontic Journal, 43, 940944, 2010
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Radiographic examination revealed full root development and formation
of calcified bridges beneath the CEM cement in both mesial and distal
roots at 12-months
Weber ;
1. Sustaining a viable Hertwigs epithelial root sheath, thus allowing a
continued development of root length for a more favorable crown: root
ratio.
2. Maintaining pulpal vitality, thus allowing the remaining odontoblasts to
lay down dentin, producing a thicker root and decreasing the chance of
root fracture.
3. Promoting root end closure, thus creating a natural apical constriction
for gutta-percha Obturation.
4. Generating a dentinal bridge at the site of pulpotomy. However, bridging
is not essential for success of the procedure as long as root development
occurs
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Dentin formation is one of the main functions of the dental
pulp. This action results in thickening of the root canal walls
and closure of the apical foramen.
An ideal material for the repair of pulpal wounds should be
biocompatible and prevent microleakage
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Endodontics Fifth Edition - John I. Ingle, Leif K.
Bakland
Dentistry for the adolescent- Castaldi and Brass
Paediatric Dentistry- Pinkham
Dentistry for Child and Adolescent- Mc Donald
Pathways of the Pulp, 6th edition- Cohen S, Burns R
Endodontic Practice- Grossman
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Apexogenesis Treatment with a New Endodontic Cement:
A Case Report - J Endod 2010;36:912914
Apexogenesis of a symptomatic molar with calcium enriched mixture -
CASE REPORT - International Endodontic Journal, 43, 940944, 2010
Apexogenesis After Initial Root Canal Treatment Of An Immature
Maxillary Incisor A Case Report
International Endodontic Journal, 43, 7683, 2010
Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide as
Pulpotomy Agents in Young Permanent Teeth (Apexogenesis)
Pediatr Dent. 2006 Sep-Oct;28(5):399-404.
Biological apexogenesis of undeveloped tooth in apatient with
spondyloepiphyseal dysplasia: A case report
Iranian Endodontic Journal 2010;5(2):93-6]



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