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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''

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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'

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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'

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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'

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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'

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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

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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'

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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''

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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'''

''

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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'

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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'

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•  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'

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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'

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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'