Lec.4&5 (A.M.

) Pedodontics Forth stage

Assist. Prof. Dr. Aseel Haidar

Treatment of Immature Permanent Teeth with

Pulpal Necrosis
Apexification
The conventional treatment of pulpless anterior teeth usually requires apical
surgery. There is a less traumatic endodontic therapy called apexification, which has been
found to be effective in the management of immature, necrotic permanent teeth. The
apexification procedure should precede root canal therapy in the management of teeth
with irreversibly diseased pulps and open apices. The procedure has been demonstrated
to be successful in repeated clinical trials stimulating the process of root end
development, which was interrupted by pulpal necrosis, so that it continues to the point of
apical closure. Often a calcific bridge develops just coronal to the apex. When the closure
occurs, or when the calcific “plug” is observed in the apical portion, routine endodontic
procedures may be completed; the possibility of recurrent periapical pathosis is thus
prevented.

a) A preoperative radiograph of maxillary left central incisor with an open apex (b) Radiographic evaluation of Mineral trioxide
aggregate level (c) Follow-up after 6 months (d) Follow-up at 18 months

Regenerative Endodontic Procedures (REPs)

It is defined as biologically based procedures designed to replace damaged
structures, which include dentin, root structures, and cells of the pulp–dentin complex.
These procedures provide a biological alternative to induce continuous root development
and reduce the risk of fracture associated with traditional treatments of immature teeth
with necrotic pulps, such as calcium hydroxide or MTA or biodentin apexification, where
the root remains thin and weak.

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REACTION OF THE PULP TO VARIOUS

CAPPING MATERIALS

ZINC OXIDE–EUGENOL
Zinc oxide–eugenol was used more often than any other pulp capping material
before calcium hydroxide came into common use. Although dentists have apparently had
good clinical results with the use of zinc oxide–eugenol, it is not recommended as a direct
pulp-capping material.

CALCIUM HYDROXIDE
Calcium hydroxide used as a biological dressing. Because of its high
alkalinity (pH 12), it is so caustic that when it is placed in contact with vital pulp tissue,
the reaction produces a superficial necrosis of the pulp. The irritant qualities seem to be
related to its ability to stimulate development of a calcified barrier. The superficial
necrotic area in the pulp that develops beneath the calcium hydroxide is demarcated from

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the healthy pulp tissue below by a new, deeply staining zone comprised of basophilic
elements of the calcium hydroxide dressing.
The original proteinate zone is still present. However, against this zone is a
new area of coarse fibrous tissue likened to a primitive type of bone. On the periphery of
the new fibrous tissue, cells resembling odontoblasts appear to be lining up. One month
after the capping procedure, a calcified bridge is evident radiographically. This bridge
continues to increase in thickness during the next 12 months. The pulp tissue beneath the
calcified bridge remains vital and is essentially free of inflammatory cells.

PREPARATIONS CONTAINING FORMALIN

The clinical success experienced in the treatment of primary pulps with these
materials is due to the drug’s germicidal action and fixation qualities than to its ability to
promote healing.
Some studies have indicated that the formocresol pulpotomy technique may
be applied to permanent teeth, but its use in permanent teeth remains an interim
procedure, to be followed by conventional endodontic therapy.

Notes:
Recently, because of formocresol negative systemic properties, its use
should be limited. Formaldehyde has a known carcinogenic, immunogenic, toxic,
and mutagenic potential, which makes it questionable and unsuitable for use in
pedodontic endodontics.
Therefore, Biodentin and MTA can be used instead of it and other
experimental capping materials alternative to formocresol are:
➢ Laser Pulpotomy
➢ Electrosurgical Pulpotomy
➢ Bone morphogenic protein
➢ Calcium hydroxide Dentin chips

FERRIC SULFATE
Ferric sulfate (15.5% Fe2SO4) has been used as pulpotomy agent as a
substitute for formocresol for 15–20 years. Ferric sulfate in contact with blood forms a
ferric ion–protein complex, which seals the cut blood vessels mechanically, producing
hemostasis. The effect of ferric sulfate is hemostatic but not bactericidal or fixative. After
application of ferric sulfate for 15 seconds, the pulp is covered with zinc oxide–eugenol
and the cavity sealed.

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Glutaraldehyde
It has been widely tested, to replace formocresol. Studies have shown that
application of 2-4% produces rapid surface fixation of the underlying pulp tissue.
Attributes of glutaraldehyde over formocresol
1) Forms strong intra- and intermolecular protein bonds leading to superior
fixation by cross linkage.
2) Diffusability is limited, thus reducing the apical extension of the material
3) Excellent antimicrobial property
4) Less dystrophic calcification
5) Produces initial zone of fixation that does not proceed apically
6) Readily excreted from the body. About 90% will be eliminated in 3 days.
7) 15-20 times less toxic than formocresol and have little potential for
chromosomal interference or mutagenecity.

MINERAL TRIOXIDE AGGREGATE

MTA is emerging as a popular product for pulpotomies secondary to a variety
of factors. Torabinejad described the physical and chemical properties of MTA in 1995.
It is ash colored powder made primarily of fine hydrophilic particles of:
1) Tricalcium silicate
2) Tricalcium aluminate
3) Tricalcium oxide
4) Silicate oxide and bismuth oxide is added for radio-opacity.

MTA should mixed with sterile water or other sterile liquids in 3: 1

(powder /liquid) ratio to obtain a putty consistency or a thick grainy paste. If the paste
is, too dry it will fall when one try to pick it up. Hydration of the powder results in a
colloidal gel composed of calcium oxide crystals in an amorphous structure. This gel
solidifies into a hard structure in less than three hours (2 hours and 45 minutes).
MTA has an antibacterial effect on some facultative bacteria but no effect on
strict anaerobic bacteria. This limited antibacterial effect is less than that demonstrated by
calcium hydroxide pastes. The ability of MTA to resist the penetration of microorganisms
appears to be high. – The use of MTA as an agent for pulp capping or for providing
apical seal is well documented. Recent studies have indicated that MTA can be used
successfully as a pulpotomy agent also.

Properties of MTA

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It is biocompatible material and its sealing ability is better than that of amalgam or
ZOE.
Initial pH is 10.2 and set pH is 12.5
Antimicrobial activity.
The setting time of cement is 4 hours
The ability to set in the presence of moisture and blood.
Low cytotoxicity
It presents with minimal inflammation if extended beyond the apex.

The negative attributes include:

 Difficulty of handling
 Exceptional cost.
 MTA can cause pulp canal obliteration.

MECHANISM OF ACTION
The successful usage of MTA in endodontic applications can be
attributed to its biocompatibility, bioactivity and mechanism of action. The four actions
of MTA after direct placement in contact with living tissues are:
(i) Creation of an unfavorable environment for growth of bacteria due to its alkaline pH.
(ii) Formation of hydroxyapatite like mineral structure on its surface and provide the
biological seal.
(iii) Formation of calcium hydroxide, which dissociates to release Ca ions, to promotes
cellular attachment and proliferation.
(iv) Modulation of cytokine production and encouragement of hard tissue forming cells to
differentiate and migrate.

Clinical applications of MTA

1) Pulp capping:
a) Direct Pulp Capping:
MTA is suitable as a pulp capping because it stimulates dental bridge
formation and the bridge formed adjacent to MTA will be thick and continuous with
regional dentin. No bacteria were observed on the cavity wall when MTA was used,
due to sealing ability, biocompatibility, alkalinity, and ability of MTA to stimulate
dentin bridge formation.

b) Pulpotomy of immature permanent teeth:

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The pulp responds favorably to the protection provided by an MTA layer,

and the reparative dentin is consistently uniform and thicker under MTA
more than that with Ca (OH) 2.
c) Pulpotomy of primary teeth
MTA seems to be a suitable replacement for T.C.F.
2) Root resorption
3) Apexification
4)Furcal repair
5) Perforation repair
6) Root ending filling

FAILURES AFTER VITAL PULP THERAPY

Factors that may lead to failure in the formation of a calcified bridge across the vital
pulp may involve:
1) The age of the patient
2) Degree of surgical trauma
3) Sealing pressure
4) Improper choice of capping material
5) Low threshold of host resistance
6) Presence of microorganisms with subsequent infection.

This failure may appears as:

Internal resorption
Alveolar abscess
Early exfoliation or over retention of primary teeth with pulp treatment

INTERNAL RESORPTION
One of the most frequently seen evidence of an abnormal response in primary
teeth within the pulp canal several months after the pulpotomy procedure is the
radiographic evidence of internal resorption.
Internal resorption is a destructive process
generally caused by odontoclastic activity, and it
may progress slowly or rapidly. Occasionally,
secondary repair of the resorbed dentinal area
occurs. No satisfactory explanation for the post
pulpotomy type of internal resorption has been

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given. However, that with a true carious exposure of the pulp, an inflammatory
process will be present to some degree. The inflammation may be limited to the
exposure site, or it may be diffused throughout the coronal portion of the pulp.
Amputation of all pulp showing the inflammatory change may be difficult or
impossible, and abnormal pulp tissue may be allowed to remain. If the inflammation
extended to the entrance of the pulp canal, odontoclasts may have been attracted to
the area; if it were possible to examine the tooth histologically; small bays of
resorption would be evident. This condition may exist at the time of pulp therapy,
although there is no way to detect it. The only indication would be the clinical
evidence of a hyperemic pulp. Inflammatory cells drawn to the area because of the
placement of an irritating capping material might well attract odontoclastic cells and
initiate internal resorption. This may explain the occurrence of internal resorption
even though the pulp is normal at the time of treatment. Because the roots of primary
teeth are undergoing normal physiologic resorption, vascularity of the apical region
is increased. When an irritant in the form of a pulp-capping material is placed on the
pulp, odontoclastic activity present in the area and may predispose the tooth to
internal resorption.

ALVEOLAR ABSCESS
Some months after pulp therapy has been
completed, an alveolar abscess occasionally
develops. The tooth usually remains asymptomatic,
and the child is unaware of the infection, which may
be present in the bone surrounding the root apices or
in the area of the root bifurcation.
A fistulous opening may be present,
which indicates the chronic condition of the infection.
Primary teeth that show evidence of an alveolar abscess should be removed.
Endodontic treatment may be considered for permanent teeth that have previously
been treated by pulp capping or by pulpotomy and later show evidence of pulpal
necrosis and apical infection.

EARLY EXFOLIATION OR OVER-RETENTION OF PRIMARY

TEETH WITH PULP TREATMENTS
Occasionally a pulpally treated tooth previously believed to be successfully
managed will loosen and exfoliate (or require extraction) prematurely for no apparent
reason. It is believed that such a condition results from low-grade, chronic,
asymptomatic, localized infection. Usually, abnormal and incomplete root resorption

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patterns of the affected teeth are also observed. When this occurs, space management
must be considered.
Another sequela requiring close
observation is the tendency for primary teeth
undergoing successful pulpotomies or
pulpectomies to be over-retained. This situation
may have the untoward result of interfering with
the normal eruption of permanent teeth and
adversely affecting the developing occlusion.
Close periodic observation of pulpally treated
teeth is necessary to intercept such a developing
problem. Extraction of the primary tooth is usually sufficient. This phenomenon may
occur when normal physiologic exfoliation is delayed by the bulky amount of cement
contained in the pulp chamber. Even though the material is resorbable, its resorption
is slowed significantly when large quantities are present.

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