Post on 06-Feb-2018
12/08/15'
1'
Management of the open apex
Artika Soma BDS, DClin Dent (Endodontics)
What'is'an'“open”'apex?'
• Wide'canal'• Lack'of'apical'stop'due'to'failure'of'comple?on'of'root'development'
• Cvek’s'classifica?on'of'root'forma?on'(according''to'root'length'and'apical'opening)'
'
What'does'a'“normal”'apex'look'like?' What'does'a'“normal’'apex'look'like?'
• Dummer'et#al#1984'• 270'fully'formed'teeth'analysed'
'
• Closure'of'apex'occurs'up'to'3'years'aMer'erup?on'
• This'process'can'be'interrupted'due'to''• Trauma'• Infec?on'(caries,'dens'in/evaginatus)''• Physical'interferences'such'as'surgery'or'over'instrumenta?on''
12/08/15'
2'
Davidovich'et'al'2008'
2'year'review''
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
Vital#pulp#therapies#performed#in#teeth#with#some#vital#pulp#4ssue#to#encourage#forma4on#of#the#root#end##
Forma4on#of#a#calcific#barrier##in#a#tooth#with#open#apex##
Terminology'
• Apexogenesis'• Vital'pulp'therapies'performed'in'teeth'with'some'vital'?ssue'to'encourage'forma?on'of'the'root'end'(Wigler'et#al#2013)'
• Apexifica?on'• Forma?on'of'a'calcific'barrier''in'a'tooth'with'open'apex'(Weine'2004)'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
12/08/15'
3'
Vital'pulp'therapy'
• “Review”'• Pulp'capping'
• Direct'and'indirect'• Pulpotomy'
• Cvek,'“full”'pulpotomy'
Reimplanta?on'allowing'apexogenesis'
8'year'old'21'avulsion'
4'year'review'
Courtesy'–'Dr'Luke'Maloney'
Pulp'capping'allowing'apexogenesis' Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
Apexifica?on'before'1960s'
• Before'1966'–'surgical'approach'to'place'an'apical'seal'
• Custom'fit'GP'cones'
12/08/15'
4'
Ca(OH)2'apexifica?on'
• Introduced'in'1960s''• Removal'of'necro?c'pulp'• Placement'of'Ca(OH)2'• Mul?ple'visits'to'change'dressing'• 6U18'months'for'apical'barrier'forma?on'• GP'and'sealer'root'filling''• Mul?ple'treatment'appointments'• Weakens'den?ne''• Leaves'tooth'suscep?ble'to'fractureU''interim/long'term'
Andreasen'et#al'2002,'Kaiser'1964''
Courtesy'–'Dr'Luke'Maloney'
8'years'old''11,'21'Avulsion'
10'years'old''RootUfilled'
16'years'old''Ver?cal'root'fracture'
17'year'old''RCT'done'at'age'8'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
12/08/15'
5'
MTA'apexifica?on'• Introduced'in'1990s'• A'lot'of'“hype”'with'this'material'• Most'researched'dental'material'• Single'visit'• MTA'plug'(6mm)'• Back'fill'with'GP'and'sealer'
MTA'apexifac?on'
Advantages*
Most'researched'material'
Single'visit'apexifica?on'
Maintains'the'integrity'of'the'root'
Provides'an'excellent'seal'
Disadvantages*
Difficult'to'mix'
Difficult'to'apply'par?cularly'in'thin'canals'
Stains'teeth'
Long'sedng'?me'
Retreatment'op?on'limited'
Does'not'strengthen'tooth'
Bioceramics'in'endodon?cs'
• What'is'bioceramics?'• Materials'(eg'calcium'phoshpates,'alumina,'hydroxyapa?tes)'which'are'present'in'the'human'body'making'them'biocompa?ble''
• MTA'was'the'first'bioceramic'material'in'den?stry'• MTA'Angelus,'BioAggregate,'Bioden?n,'Root'repair'material'
• New'BC'materials'seem'to'show'improvement'• Staining'• Sedng'?me'• Ease'of'mixing'• Applica?on'
• High'pH'• Biocompa?ble'• Good'seal'• Different'packaging'and'applica?on''Most'studies'report'on'MTA'hence'can'ASSUME'that'BC'materials'will'perform'comparably'to'MTA'
Trope'et#al#2015'
Bioceramics'in'endodon?cs'
12/08/15'
6'
Artendo'Enterprises'LTD'7'year'old''
4'months'aMer'trauma'12'month'review'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
“?”'
Iwaya'2001'33'months'later'
Immature'permanent'tooth''
NonUvital'tooth''Vital'tooth''
Apexogenesis''
MTA'apexifica?on'Ca(OH)2'apexifica?on''Pulp'capping''
Apexifica?on''
Review'only'
“!”'
Regeneration
Revitalisation'
Revascularisation
12/08/15'
7'
Terminology'• Revascularisa?on'
• No'certainity'of'nature'of'?ssue.'But'it'has'a'blood'supply'(Trope'2008)'
• Regenera?on'• Argued'that'revascularisa?on'is'applied'to'dental'trauma'cases'(Huang'&'Lin'2008)'
• Revitalisa?on'• NonUspecific'vital'?ssue'(Lenzi'&'Trope'2012)'
• Maturogenesis'• Complete'development'of'tooth'not'localised'to'the'apex'
Terminology'• Revascularisa?on'
• No'certainity'of'nature'of'?ssue.'But'it'has'a'blood'supply'(Trope'2008)'
• Regenera?on'• Argued'that'revascularisa?on'is'applied'to'dental'trauma'cases'(Huang'&'Lin'2008)'
• Revitalisa?on'• NonUspecific'vital'?ssue'(Lenzi'&'Trope'2012)'
• Maturogenesis'• Complete'development'of'tooth'not'localised'to'the'apex'
AAE'2015'
What'is'regenera?ve'endodon?cs?' What'is'regenera?ve'endodon?cs?'
“biologically'based'procedures'designed'to'predictably'replace'damaged,'diseased'or'missing'structures'including'cells'of'pulpUden?ne'complex,'den?ne'and'root'structure'with'live'viable'?ssues,'preferably'of'the'same'origin'that'restore'the'normal'physiological'func?ons'of'the'pulpUden?ne'complex”''
Hargreaves'et'al'2007'
“biologically'based'procedures'designed'to'predictably'replace'damaged,'diseased'or'missing'structures'including'cells'of'pulpUden?ne'complex,'den?ne'and'root'structure'with'live'viable'?ssues,'preferably'of'the'same'origin'that'restore'the'normal'physiological'func?ons'of'the'pulpUden?ne'complex”''
Hargreaves'et'al'2007'
No.'of'p
ublica?
ons/year'
'
300'''''''200'''''100''''''''0''
Year'of'publica?on'200
1U02''
2002U0
3''
2004U0
5''
2005U0
6''
2006U0
7''
2007U0
8''
2009U1
0''
2010U1
1''
2008U0
9''
2003U0
4''
Modified'from'Geisler'2012'
12/08/15'
8'
Goals'of'regenera?on'techniques'
• Eliminate'symptoms'• Space'maintenance''• Bony'healing'• Increase'in'root'wall'thickness'• Increase'in'root'length''• Posi?ve'response'to'vitality'tests'
'
Can'we'reUgrow'the'pulp?'
The'role'of'blood'clot'in'pulpal'healing''
• Pulp'?ssue'removed'• OverUinstrumenta?on'to'induce'bleeding'
• Obturated'canals'short'of'the'apex''
• 3'years'later'extrac?on'and'histological'examina?on'
'47'pa?ents'
NygaardUØstby'&'Hjortdal'1961,1971''
Fibrous'connec?ve'?ssue'found'in'the'canals'
'Recognised'that'pulp'like'?ssue'can'grow'into'the'canal'and'a'blood'clot'is'essen?al'for'apical'healing''
''''''''''''''''''NygaardUØstby'&'Hjortdal'(1961,1971)'
'
The'role'of'blood'clot'in'pulpal'healing''
12/08/15'
9'
The'role'of'bacteria'in'pulpal'healing'
Germ (bacteria) free rats Conventional lab rats
Pulpal exposure
Pulpal histology Kakehashi'et#al'1965''
Without'bacteria,'the'pulp'is'able'to'heal'and'repair'itself'
'
The'role'of'bacteria'in'pulpal'healing'
Kakehashi'et#al'1965''
Can'we'reUgrow'the'pulp?'Yes'
How?'
The'reUbirth'of'pulpal'regenera?on''
Hoshino'et#al'1993,'1996'
• Took'den?ne'samples'from'infected'teeth'• Incubated'on'agar'plates'with'various'combina?ons'of'an?bio?cs'
• Looked'at'the'efficacy'of'4'an?bio?cs''''
Found'combina?on'of''''minocycline,'ciprofloxacin,'metronidazole'
'was'an'effec?ve'an?bacterial'Utrian?bio?c/Hoshino’s'paste'''
''
12/08/15'
10'
CocaUCola' Trian?bio?c'paste'
Iwaya'et#al#2001'
• Tooth'45'–'immature'with'a'draining'sinus'
• Visit'1''• Open'and'drain'(leM'open)'
• Visit'2'''• Vital*/ssue*noted*apically,'irriga?on,'dressing'of'metronidazole'and'ciprofloxacin'placed'for'4'weeks'
• Visit'3''• Ca(OH)2'followed'by'GIC'restora?on'
Iwaya'et#al#2001'
PreUop' 5'months' 2'½'years'
Banchs'et#al#2004'
• Tooth'45'–'immature'with'draining'sinus'' • Visit'1''
• Access,'necro/c*/ssue*noted,'irrigated,'dressing'of'minocycline,'ciprofloxacin,'metronidazole'
• Visit'2'''• Bleeding'induced,'sealed'with'MTA'
Banchs'et#al#2004'
11'year'old' 24'month'review'
Tissue'engineering'1990s'
Recognised'the'need'for''1. Stem'cells''2. Growth'factors'3. Scaffold'for'regenera?on'
12/08/15'
11'
Papilla'cells'' Pulp'cells' PDL'cells' Alveolar'cells'
Diogenes'et#al2013,'Andreasen'2012'
Corner'stones'of'regenera?ve'endodon?cs'
Disinfec?on' Stem'cells'
Growth'factors'
Scaffold'
Stem*cells*
Scaffold*
Growth*factors*
Huang'et#al'2008'Shimizu'et#al'2012'
Apical'papilla'
Sterile'necro?c'pulp'Blood'clot'
'
Platelets'Den?ne'
Disinfec/on*Irriga?on,'medica?on'
Role'of'the'apical'papilla'in'regenera?on'• Source'of'stem'cells'
(“stem'cells'of'the'apical'papilla”U'SCAP)'
• Differen?ate'into'den?ne'forming'cells'
• These'can'survive'infec?ons'BUT'survival'following'trauma'is'ques?onable'due'to'damage'to'PDL'and'Hertwig’s'sheath'
Huang'et#al#2008'
Apical'papilla'Stem*cells*
Role'of'a'blood'clot'in'regenera?on'
• Forms'the'scaffold'• Becomes'the'route'
to'introduce'stem'cells'into'the'canal'
• IntraUcanal'blood'clot'has'x600'more'stem'cells'than'systemic'blood'
'Lovelace'et'al'2011'
Sterile'necro?c'pulp'Blood'clot'
'
Scaffold*
• NaOCl'• Disinfects'• Decreases'the'survival'of'SCAP'cells'• The'higher'the'concentra?ons,'the'more'the'detrimental'effect'on'SCAP'
Diogenes'et#al'2013'Galler'et#al'2011'Trevino'et#al#2011'
'
• EDTA'• Removes'smear'layer'• Reverses'the'detrimental'effects'of'NaOCl'• Exposes'collagen'and'growth'factors'• Growth'factors'supports'cell'survival''
'''
Aim'of'irrigants'in'regenera?ve'procedures'does'not'only'have'to'have'bacteriocidal'proper?es,'but'should'also'allow'stem'cell'survival'and'prolifera?on''
Role'of'a'irriga?on'in'regenera?on'
12/08/15'
12'
• TriUan?bio?c'paste'(not'FDA'approved)'• 200mg'ciprofloxacin'
500'mg'metronidazole'100'mg'minocycline'
• Mul?ple'case'reports'• Allows'increase'in'root'canal'wall'thickness'and'root'length'• Found'to'be'detrimental'towards'SCAP'survial''
• Ca(OH)2'• Also'allows'root'canal'wall'to'thicken'and'grow'in'length'• Found'to'be'nonUtoxic'towards'SCAP'
Ruparel'et#al#2012,'Cahreli'et#al'2011,'Hargreaves'et#al'2009'
Role'of'medica?on'in'regenera?on'
Author* Year* Cases*Iwaya' 2001' 1'
Bachs'' 2004' 1'
Chueh'' 2006' 4'
Petrino'' 2007' 1'
Thibodeau' 2007' 1'
Jung'' 2008' 9'
Cod'' 2008' 1'
Shah'' 2008' 9'
Cheuh'' 2009' 23'
Ding'' 2009' 3'
Reynolds' 2009' 2'
Shin'' 2009' 1'
Kim'' 2010' 1'
Petrino'' 2010' 6'
Cahreli'' 2011' 6'
Nosrat'' 2011' 2'
Torabinejad' 2011' 1'
Chen'' 2011' 20'
Lenzi'' 2012' 2'
Cahreli'' 2012' 1'
Agggraval' 2012' 1'
Chen' 2012' 20'
Narayana' 2012' 1'
Nosrat' 2012' 2'
Shivashankar' 2012' 1'
Jadhav' 2012' 20'
Koror' 2013' 1'
Mar?n' 2013' 1'
Yang' 2013' 1'
• Pa?ent'selec?on'• Treatment'protocol'• Measuring'success''• Review'
Key'concepts' Pa?ent'selec?on'• Pa?ent'
• Compliant'• Healthy''• Young'(8U16'years'old)''
• Tooth'• Necro?c'canal''• Immature'apex'(>0.8mm)'• Short'root'• Length'of'?me'the'infec?on'has'been'present'• Cause'of'necrosis'(trauma'vs.'dental'anomaly)''
• Restora?ve'• Pulp'space'required'for'post'or'restora?on'
'
Local'anaesthesia'
Access'
Assess'the'pulpal'status'
Necro?c'Vital'?ssue'apically'
Irrigate'2mm'short'
Dress'with'TriUan?bio?c'paste'OR'Ca(OH)2'and'temporise'
Irrigate'lightly'
MTA'barrier,'GIC'and'composite'
Recall'for'up'to'2'years'
Single'visit' Two'visits'
Current'protocol'
12/08/15'
13'
Local'anaesthesia'without'adrenalin'
Irrigate'with'NaOCl'
Final'irriga?on'with'EDTA'
MTA'barrier,'GIC,'composite'
Induce'bleeding'
Recall'for'up'to'2'years' Drs'Kim'Dang'&'Luke'Maloney'
Measuring'success'of'regenera?on'procedure'
• Symptoms'• Sensibility'tes?ng'
• Lack'of'pulp'response'does'not'indicate'lack'of'vitality'
Law'2012'Banchs'et#al#2004'
• Radiographs'
Review'
• 3U21'months'–'apical'bony'healing'• 10U29'months'–'root'development''''Review'for'2'years'before'condemning'a'case''
Cehreli'et#al#2011'Chueh'et#al#2009'
Author* Year* Cases* Success*Iwaya' 2001' 1' 1'
Bachs'' 2004' 1' 1'
Chueh'' 2006' 4' 4'
Petrino'' 2007' 1' 1'
Thibodeau' 2007' 1' 1'
Jung'' 2008' 9' 9'
Cod'' 2008' 1' 1'
Shah'' 2008' 9' 9'
Cheuh'' 2009' 23' 23'
Ding'' 2009' 3' 3'
Reynolds' 2009' 2' 2'
Shin'' 2009' 1' 1'
Kim'' 2010' 1' 1'
Petrino'' 2010' 6' 2'
Cahreli'' 2011' 6' 6'
Nosrat'' 2011' 2' 2'
Torabinejad' 2011' 1' 1'
Chen'' 2011' 20' 20'
Lenzi'' 2012' 2' 1'
Cahreli'' 2012' 1' 1'
Agggraval' 2012' 1' 1'
Chen' 2012' 20' 20'
Narayana' 2012' 1' 0'
Nosrat' 2012' 2' 0'
Shivashankar' 2012' 1' 1'
Jadhav' 2012' 20' 18'
Koror' 2013' 1' 1'
Mar?n' 2013' 1' 1'
Yang' 2013' 1' 1'
Author* Year* Cases* Success*Iwaya' 2001' 1' 1'
Bachs'' 2004' 1' 1'
Chueh'' 2006' 4' 4'
Petrino'' 2007' 1' 1'
Thibodeau' 2007' 1' 1'
Jung'' 2008' 9' 9'
Cod'' 2008' 1' 1'
Shah'' 2008' 9' 9'
Cheuh'' 2009' 23' 23'
Ding'' 2009' 3' 3'
Reynolds' 2009' 2' 2'
Shin'' 2009' 1' 1'
Kim'' 2010' 1' 1'
Petrino'' 2010' 6' 2'
Cahreli'' 2011' 6' 6'
Nosrat'' 2011' 2' 2'
Torabinejad' 2011' 1' 1'
Chen'' 2011' 20' 20'
Lenzi'' 2012' 2' 1'
Cahreli'' 2012' 1' 1'
Agggraval' 2012' 1' 1'
Chen' 2012' 20' 20'
Narayana' 2012' 1' 0'
Nosrat' 2012' 2' 0'
Shivashankar' 2012' 1' 1'
Jadhav' 2012' 20' 20'
Koror' 2013' 1' 1'
Mar?n' 2013' 1' 1'
Yang' 2013' 1' 1'
Author* Year* Cases* Success*Iwaya' 2001' 1' 1'
Bachs'' 2004' 1' 1'
Chueh'' 2006' 4' 4'
Petrino'' 2007' 1' 1'
Thibodeau' 2007' 1' 1'
Jung'' 2008' 9' 9'
Cod'' 2008' 1' 1'
Shah'' 2008' 9' 9'
Cheuh'' 2009' 23' 23'
Ding'' 2009' 3' 3'
Reynolds' 2009' 2' 2'
Shin'' 2009' 1' 1'
Kim'' 2010' 1' 1'
Petrino'' 2010' 6' 2'
Cahreli'' 2011' 6' 6'
Nosrat'' 2011' 2' 2'
Torabinejad' 2011' 1' 1'
Chen'' 2011' 20' 20'
Lenzi'' 2012' 2' 1'
Cahreli'' 2012' 1' 1'
Agggraval' 2012' 1' 1'
Chen' 2012' 20' 20'
Narayana' 2012' 1' 0'
Nosrat' 2012' 2' 0'
Shivashankar' 2012' 1' 1'
Jadhav' 2012' 20' 20'
Koror' 2013' 1' 1'
Mar?n' 2013' 1' 1'
Yang' 2013' 1' 1'
Shah'et#al#2008'
12/08/15'
14'
Jhadav'et#al#2012'
Ques?ons'to'ponder'on....'
1. E?ology'of'necrosis'–'does'it'marer'whether'the'cause'of'necrosis'is''trauma'related'or''dental'anomaly?'
2. What'type'of'?ssue'grows'in'the'canal?'Is'it'den?ne,'cementum,'bone'or'a'combina?on?'
3. What'are'the'poten?al'complica?ons?''
Can'regenera?on'be'applied'to'trauma'cases?'
Author* Year* Cases* Success* Cause*Iwaya' 2001' 1' 1' Dens'
Bachs'' 2004' 1' 1' Dens'
Chueh'' 2006' 4' 4' Dens'
Petrino'' 2007' 1' 1' Dens'
Thibodeau' 2007' 1' 1' Trauma'
Jung'' 2008' 9' 9' Dens'&'caries'
Cod'' 2008' 1' 1' Trauma''
Shah'' 2008' 9' 9' Trauma'
Cheuh'' 2009' 23' 23' Dens'&'caries'
Ding'' 2009' 3' 3' Trauma'X'1'''''''''''Dens'X'2'
Reynolds' 2009' 2' 2' Dens'
Shin'' 2009' 1' 1' Dens'
Kim'' 2010' 1' 1' Trauma''
Petrino'' 2010' 6' 2' Trauma'X'4'''''''''''''Caries'X'2'
Cahreli'' 2011' 6' 6' Caries'
Nosrat'' 2011' 2' 2' Caries'
Torabinejad' 2011' 1' 1' Trauma'
Chen'' 2011' 20' 20' Trauma'x'10'''''Caries'x'10'
Lenzi'' 2012' 2' 1' Trauma''
Cahreli'' 2012' 1' 1' Trauma''
Agggraval' 2012' 1' 1' Trauma'
Chen' 2012' 20' 20' Trauma'x10''''Dens'&'caries'x10'
Narayana' 2012' 1' 0' Dens'
Nosrat' 2012' 2' 0' Trauma'
Shivashankar' 2012' 1' 1' Trauma'
Jadhav' 2012' 20' 18' Trauma'
Koror' 2013' 1' 1' Trauma'
Mar?n' 2013' 1' 1' Caries'
Yang' 2013' 1' 1' Dens'
Author* Year* Cases* Success* Cause*Iwaya' 2001' 1' 1' Dens'
Bachs'' 2004' 1' 1' Dens'
Chueh'' 2006' 4' 4' Dens'
Petrino'' 2007' 1' 1' Dens'
Thibodeau' 2007' 1' 1' Trauma'
Jung'' 2008' 9' 9' Dens'&'caries'
Cod'' 2008' 1' 1' Trauma''
Shah'' 2008' 9' 9' Trauma'
Cheuh'' 2009' 23' 23' Dens'&'caries'
Ding'' 2009' 3' 3' Trauma'X'1'''''''''''Dens'X'2'
Reynolds' 2009' 2' 2' Dens'
Shin'' 2009' 1' 1' Dens'
Kim'' 2010' 1' 1' Trauma''
Petrino'' 2010' 6' 2' Trauma'X'4'''''''''''''Caries'X'2'
Cahreli'' 2011' 6' 6' Caries'
Nosrat'' 2011' 2' 2' Caries'
Torabinejad' 2011' 1' 1' Trauma'
Chen'' 2011' 20' 20' Trauma'x'10'''''Caries'x'10'
Lenzi'' 2012' 2' 1' Trauma''
Cahreli'' 2012' 1' 1' Trauma''
Agggraval' 2012' 1' 1' Trauma'
Chen' 2012' 20' 20' Trauma'x10''''Dens'&'caries'x10'
Narayana' 2012' 1' 0' Dens'
Nosrat' 2012' 2' 0' Trauma'
Shivashankar' 2012' 1' 1' Trauma'
Jadhav' 2012' 20' 18' Trauma'
Koror' 2013' 1' 1' Trauma'
Mar?n' 2013' 1' 1' Caries'
Yang' 2013' 1' 1' Dens'
Can'regenera?on'be'applied'to'trauma'cases?'
Difficult'to'arain'success'due'to''• Damage'to'PDL'cells'• Damage'to'Hertwig’s'sheath''
' ' ' ''
Cehreli'et#al'2010'
Nature'of'?ssue'occupying'the'pulp'space'
Animal'studies'have'iden?fied'the'4'types'of'?ssue'growth'''
1. 'Den?ne'forma?on'(PCO)''2. 'Cementum'and'PDL'3. 'Cementum,'PDL'and'bone'4. 'Bone'and'bone'marrow'
'Thibodeau'et#al'2007,'Wang'et#al'2010,'Andreasen'&'Bakland'2011'Andreasen'2012'
Papilla'cells'' Pulp'cells' PDL'cells' Alveolar'cells'
12/08/15'
15'
Shimizy'et'al'2012' Mar?n'et'al'2013'
Complica?ons'U'discoloura?on'
Courtesy'U'Dr'Kim'Dang' Courtesy'–'Dr'Kehn'Yapp'
Jan'2008' 'Jan'2012' May'2012'
Complica?ons'U'treatment'failure'
Current'status'• $2.5million'towards'research'• Regenera?on'codes'introduced'2011U12'• Introduced'regenera?ve'endodon?cs'to'the'carriculum'2014'
• Stated'that'regenera?ve'procedures'is'part'of'endodon?cs'
• Clinical'considera?on'for'regenera?ve'procedures'developed'
12/08/15'
16'
“If#you#are#performing#regenera4ve#endodon4c#procedures,#please#report#them#in#the#ASE#Regenera4ve#Database#to#establish#a#best#prac4ce#for#treatment#and#future#research”#
American'Society'of'Endodontology'2015'
Future'direc?ons'
• Prospec?ve'randomised'clinical'trials'underway'
• Need'regulated'clinical'protocols'
Conclusion'
• Need'an'opera?ng'microscope'• Familiarity'with'use'of'MTA'• Watch'the'space'for'newer'materials'–'Bioceramics'
• For'regenera?ve'procedures,'consider'the'cause'of'necrosis'and'be'familiar'with'case'selec?on'
• Don’t'throw'away'the'MTA'and'GP'(yet!!)'
Conclusion'
Regenera?on'• Allows'root'growth'
• Allows'root'strengthening'
MTA'apexifica?on'• Maintains'root'strength'
Ca(OH)2'apexifica?on'• Weakens'root'strength'
Less'evide
nce'