Clinical Perspectives on Apexogenesis, Apexification

Transcription

The Compromised Immature
Permanent Tooth
Clinical Perspectives on
Apexogenesis, Apexification
& Revascularization
Open apex
Thin dentin walls
Frederic Barnett, DMD
Diplomate, American Board of Endodontics
Chairman & Program Director
IB Bender Division of Endodontics
Albert Einstein Medical Center, Phila., PA
The Compromised Immature
Permanent Tooth
Compromised pulp:
Traumatic injuries to immature
permanent teeth
•
•
•
•
Caries
Trauma
Compromised
pulp
Affects ~30-40% of children (Andreasen et al, 1994)
Untreated pulp exposures: necrosis
Displacement injuries: 50-100% pulp necrosis
Tx methods depend on pulp status:
– ‘vital pulp’: Apexogenesis
– ‘necrotic pulp’: Apexification or Revascularization
Apexification
Apexogenesis
A vital pulp therapy performed to encourage continued
physiological development and formation of the root end
AAE glossary 2003
A method to induce a calcified barrier in a root with
an open apex or the continued apical development
of an incomplete root in teeth with a necrotic pulp
AAE glossary 2003
Endodontic Tx of Immature Teeth
“Complicated” Crown Fracture:
Pulpal Diagnosis
VITAL
Apexogenesis
Pulp Cap
Ca(OH)2
MTA
NON-VITAL
Apexification
Ca(OH)2
Partial Pulpotomy
Pulpotomy
Traumatic Exposures
MTA
Revascularization
Collagen-phosphate
gel
Antibiotics; Tri-Mix
Crown Fractures
Crown Fractures
Complicated Crown Fx
Pathology: 24 hours
hemorrhage
fibrin clot
minimal inflammation,
<1.5mm in depth
Complicated Crown Fx
Pathology: 7 days
proliferation of
granulation tissue
superficial inflammation,
<2mm in depth
• Cvek, 1982
• Cvek, 1982
Crown Fractures
Crown Fractures
Partial pulpotomy w/ Ca(OH)2
Complicated Crown Fracture
4h after exposure
2d after exposure
Pre-op
Cvek, 1994
4 months
1.5 years
Cvek, 1994
MTA: Mineral Trioxide
Aggregate
Composition of MTA
• Powder consisting of hydrophilic particles of
– Tricalcium silicate
– Tricalcium aluminate
– Tricalcium oxide
– Silicate oxide
– Small amounts of other mineral oxides
– Bismuth oxide for radiopacity
• Main molecules present are calcium and
phosporous ions (Torabinejad et al. 1995)
Dr. Marga Ree
MTA; Pulp Capping
MTA
Aeinehchi et al, 2003
• Biocompatible (Torabinejad et al. 1995, 1998, Mitchell 1999,
Keiser et al. 2000)
• Non mutagenic
(Kettering et al. 1995)
• Good sealing ability
(Torabinejad et al. 1993, 1995,
Fischer et al.1998, Wu et al. 1998)
• Stimulates a biologic response in human
osteoblasts (Koh et al. 1997, 1998, Zhu et al. 2000)
• Stimulates reparative dentin formation
Human teeth, 22 third molars
0.5mm exposures
MTA vs. Ca(OH)2 paste
ZOE coronal seal
extracted; 1w, 2m, 3m, 4m, 6m.
(Tziafas et al. 2003)
• Antimicrobial properties (Torabinejad et al. 1995)
MTA had less inflammation and thicker hard
tissue bridge formation than Ca(OH)2.
Crown Fractures
Complicated Crown Fracture
Indications for pulp therapy:
immature tooth; open apex
thin dentin walls
mature teeth, simple
restoration
pulp MUST be vital
Traumatic Exposures
Treatment Methods:
pulp
capping
“Cvek” pulpotomy
pulpotomy
partial
Partial “Cvek” Pulpotomy
pulp exposures >24h (Cvek, 1994)
all traumatic exposures (?)
size, time interval not critical
anesthesia, isolation, surface
disinfection
• Cvek, 1978
Traumatic Exposures
Traumatic Exposures
high-speed, copious water
spray
2-3mm deep pulp
amputation
stop bleeding
blood clot inhibits repair
Ca(OH)2 paste, USP
MTA
Schroder et al, 1971; Granath et al, 1971
Ravn, 1982; Cvek, 1994
Cvek, 1994
Cvek, 1994
Traumatic Exposures
Traumatic Exposures
bacteria-tight
lightly compress the capping
material
ensures tissue-material
contact
GI,
protection
composite resin
Cvek, 1994
Traumatic Exposures
recall 3w, 3m, 6m, 12m
sensitivity testing:
• EPT, thermal, percussion, color
radiographs:
• dentin bridge formation
• continued development
• (apical & lateral)
• PA lesion, resorption, arrested
development
Cvek, 1994
Traumatic Exposures
Endodontic Tx of the Immature
Tooth
Crown Fractures
Partial “Cvek” Pulpotomy, Ca(OH)2
No.
Healed
Cvek, 1978
1-5y
60
96%
Fuks et al, 1987
1-4y
63
94%
Cvek, 1992
3-15y
178
95%
Ravn, 1982
>2y
111 p/pulp cap
91%
142 pulpotomy 90%
‘Cervical’ Pulpotomy
Indications
• immature tooth
• pulp exposure
• trauma, caries
• inflamed or necrotic
coronal pulp
• vital pulp tissue at level
of orifice
Traumatic Exposures
Pulpotomy
Pulpotomy:
LA, isolate, disinfect
amputate pulp to orifice
level
await
of ‘vital’ tissue
hemostasis
NaOCl
Ca(OH)2,
MTA
GI, composite resin
Pulpotomy
Pulpotomy
Follow-up
can’t
do sensitivity tests
3w, 3m, 6m, 12m…..
until completed root development
complete root canal therapy
Prognosis w/
Ca(OH)2
72-79% Hallet et al, 1963; Gelbier et al, 1988
90%
Ravn, 1982
Post-op
6 weeks
Dr. Fred Barnett
Pulpotomy
9 mos.9m
1 year
Cvek, 1994
Pulpotomy; Ca(OH)2
1 yr
post-op
Barington & Barnett, 2004
2 yr
MTA Pulpotomies; Outcome
MTA Pulpotomies; Outcome
Witherspoon et al, 2006
Caries exposures, 23 teeth
Mean age, 10y
Pulpotomy performed
Hemostasis w/5.25% NaOCl rinse
moist cotton pellet, ~time
MTA, ~2mm thick
18m
Results:
19/23 teeth recalled
Mean follow-up, ~20 months
18/19 teeth: healed or healing
1/19: persisting disease
Keep the
pulp
alive!!!
Endodontic Treatment of Immature
Teeth with Apical Periodontitis
Immature Teeth, AP
Challenges:
1. Canal disinfection
2.Root filling, open
apex
3. Weak dentin walls
Apexification
Apexification
Treatment Outcome
Hard-tissue formation, Ca(OH)2:
< 50% without apical hard
tissue barrier
> 90% with apical hard
tissue barrier
Cvek, 1972
Ghose et al, 1987
Mackie et al, 1988
Kleier et al, 1991
Mackie et al, 1994
Finucane et al, 1999 (p)
(d)
Kerekes K, Heide S, Jacobsen I: Follow-up examination of
endodontic treatment in traumatized juvenile incisors. J
Endod 6:744, 1980
Apexification
PA healing frequency: Ca(OH)2
No. Healed
Kerekes et al, 1980
66
94%
Mackie et al, 1988
112
96%
Cvek, 1992
328
96%
Apexification
Procedure:
WL; EAL (?), paper points
Irrigate; NaOCl
Instrument minimally
Hedstrom files
sonics, ultrasonics
EDTA, CHX
Dry
Place Ca(OH)2 paste
3-4w recall
Apexification
Procedure:
take radiograph
At 3-4 weeks, replace Ca(OH)2
3m recall, radiograph
repack Ca(OH)2
Recall in q3m
PA healing
hard-tissue barrier
No. Barrier
55
96%
51
96%
112
96%
48 100%
38 100%
34 100%
10 100%
Apexification
Procedure:
Follow for apical barrier
Root fill
Restore w/bonded resin
Time
18
3-10
10
7.6
5-7
7.8
11
Apexification
Hard-tissue formation, Ca(OH)2:
location of barrier
apex:
64%
1-5mm: 36%
Finucane et al, 1999
Apexification
Hard tissue barrier:
cementum-like tissue
Apexification
Ca(OH)2
(Granath 1959, Frank 1966)
Significant factors :
Width of apical foramen (Yates 1988, Finucane et al. 1999)
Rate of change of Ca(OH)2 (Yates 1988, Finucane et al. 1999)
q3m
Symptoms (Kleier et al. 1991)
Dr. Leif Tronstad
Disadvantages of long-term apexification
with Ca(OH)2
Cervical Root Fracture
Requires an average period of 5-12 months (Yates
1988, Kleier et al. 1991, Sheehy & Roberts 1997, Finucane et al. 1999)
Tooth has to be restored temporarily and may be
prone to fracture
Hard tissue barrier is porous and irregular
Requires patient compliance due to the number
of treatment sessions
Long term Ca(OH)2 may affect the fracture
strength of dentin (Cvek et al 1994, Andreasen & Farik 2002)
during apical closure procedure
Courtesy of Dr. Walter van Driel
Cervical Root Fracture
Immature Teeth, AP
Alternate Treatment
MTA Apical
Barrier
after definitive obturation
Courtesy of Dr. Walter van Driel
Apexification
Apexification
Alternative materials
Hard tissue formation; BMP’s, MTA:
BMP
MTA:
reduce time required for barrier
reduce number of visits
temporary fillings
patient compliance
promotes bone formation (Sampath et al, 1990)
osteogenic protein-1 (Rutherford et al, 1993)
MTA
promotes hard tissue formation
good sealing qualities
(Torabinejad et al, 1993;
Pitt Ford
et al, 1996; Tittle et al, 1996)
Apexification
Apexification
induced PA lesions, dogs
immature teeth, open apices
instrumentation, irrigation, Ca(OH)2, 7d
OP-1, MTA, Ca(OH)2, carrier; 12w
Shabahang et al, 1999
Apical closure, 12w
(% of teeth
with closure
at 12w)
Apexification
Pre-op
Post-op
Hard tissue formation; MTA:
15m
Apexification
Hard tissue formation; MTA:
root canal infection MUST be eliminated
Ca(OH)2 medicament of choice
consider: CHX gel, antibiotic paste
long-term clinical studies required
Materials for one-step apical closure
Dentin chips (Holland et al. 1984)
Ca(OH)2 (Schumacher et al.1993)
Tricalcium phosphate (Harbert 1996)
Freeze-dried allogenic dentin (Yoshida et al.1998)
Osteogenic protein-1 (Shabahang et al. 1999)
MTA (Shabahang et al. 1999, Schwartz et al. 1999, Torabinejad et al. 1999,
Whitherspoon et al. 2001, Pradhan et al, 2006, Pace et al, 2007, Simon et al, 2007)
One-visit apexification
The orthograde placement of a
biocompatible material to the
apical end of the root canal
Rationale: to establish an apical
stop that would enable a root canal
to be filled immediately
MTA vs Ca(OH)2
Pradham et al, 2006
20 immature teeth, AP
Stratified according to stage of root
development, size of PA lesion
MTA group:
7d Ca(OH)2, MTA plug, gp root filling
Ca(OH)2 group:
Root filling place after barrier formation
MTA vs Ca(OH)2
One-visit Apexification
Pradham et al, 2006
100% periapical lesions healed
Single Visit Apexification. Simon et al, 2007
MTA group:
43/57 cases were followed, 1yr
Barrier formation apical to MTA: 7/10 cases
Mean time for barrier formation: 3m
Apical closure: 26%
Healing: 81%
Ca(OH)2 group:
Barrier formation: 10/10 cases
Mean time for barrier formation: 7m
Two-visit Apexification
Two Visit Apexification. Pace et al, 2007
D&D, 5% NaOCl
Ca(OH)2, 7d
MTA plugs
11 cases were followed, 2yr
Healing: 91%
Pace et al. Int Endod J 2007
Comparative study of white and gray mineral trioxide
aggregate (MTA) simulating a one- or two-step apical barrier
technique.
Matt et al, J Endodont 2004; 30: 876-879.
n=44
Thickness
of
Apical Plug
white
gray
2 mm
1
2
5 mm
1
2
2 mm
5 mm
1
1
2
2
Conclusions: gray MTA, 5mm plug and 2-visit method
was sig. better.
%
Leakage
100
%
75
75
50
50
25
25
0
Leakage
100
0
gray MTA
white MTA
one step
two step
.
Evaluation of ultrasonically placed MTA and fracture
resistance with intracanal composite resin in a model of
apexification.
Lawley et al. J Endod. 2004 Mar;30(3):167Mar;30(3):167-72.
Ultrasonication
of
Apical Plug
n=18
4 mm MTA
with U/S
n=18
4 mm MTA
without U/S
n=18, 4 mm MTA
with U/S and
composite
Leakage study
• After 90 days the U/S-composite group provided a significantly better seal than
group without U/S
• U/S condensed MTA appeared radiographically denser with fewer voids
Summary
Root wall strengthening
Application of Ca(OH)2 for at least 1 week for
disinfection, tissue dissolution and to obtain a dry
canal
A 5 mm apical barrier of gray MTA, using twosteps, provided the best apical barrier
Use of indirect U/S produces a better condensed
filling with fewer voids
MTA + composite greater resistance to root
fracture than MTA + gp/sealer
Dr. F. Barnett
Radiograph courtesy of Dr. Jose Luis Mejia
Andreasen JO, Farik B, Munksgaard EC: Long term calcium hydroxide as a root
dressing may increase risk of root fracture Dent Traumatol 2002 18(3) 134-7
Root wall strengthening
Without strengthening
~ 30% of the teeth are
expected to fracture
Strengthening weak(ened) roots
Intracoronal acid-etched bonded resins can
internally strengthen endodontically treated
teeth and increase their resistance to fracture
(Reeh et al. 1989, Trope et al. 1985, 1986, Rabie et al. 1985)
New generation dentin bonding systems can
strengthen rct teeth to levels close to that of
intact teeth (Hernandez et al. 1994, Ausiello et al. 1997)
Jacobsen I. Root fracture in permanent teeth with incomplete root
formation, Scand J. Dent Res 84:210, 1976
Dual-cured dental adhesive with a chemicalcured core build-up composite
Lawley GR, Schindler WG, Walker WA 3rd, Kolodrubetz D.
Evaluation of ultrasonically placed MTA and fracture resistance
with intracanal composite resin in a model of apexification.
Composite Working time Setting time
(min)
(min)
LuxaCore
1,0 min
4,0 min
Clearfil
Core
3,5 min
5,0 min
Apical periodontitis #9
J Endod. 2004 Mar;30(3):167Mar;30(3):167-72.
n=12
4 mm U/S MTA
+ no treatment
n=12
4 mm U/S MTA
+ self-cure
composite
n=12
4 mm U/S MTA
+ gutta-percha
and AH plus
Fracture resistance study
MTA+composite group significantly stronger than other groups
CaSO4
Dr. M. Ree
Resilon
Apical plug of MTA
Dr. M. Ree
Dr. M. Ree
Immature Teeth, AP
Build-up of LuxaCore
Alternate Treatment for Apexification
& Root strengthening….
Grow ‘new pulp’ to
allow for continued
root development
Dr. M. Ree
Revascularization of Pulp
Space?
Pulp Regeneration?
Maturogenesis?
Revascularization- blood clot
Nygaard--Östby 1960
Nygaard
Skoglund A, Tronstad L, Wallenius K. A microradiographic study of vascular
changes in replanted and autotransplanted teeth in young dogs. 1978
Nygaard--Östby (1960): The role of the blood clot
Nygaard
4d
Pre-op
2y
10d
1y
4y
30d
180d
Revasc. in Human ReplantedTeeth
size of apical foramen:
foramen =/> 1.1mm: 18% (Kling et al, 1986)
1/2 open-open= 34% (Andreasen et al, 1995)
foramen =/< 1.0mm: 0%
extra-alveolar time & conditions:
wet storage, physiologic media
contamination adversely effects revasc.
Skogland et al, 1978
Avulsion injury, 5min extra-alveolar dry-time,
30min saliva
4w
2y
5y
Avulsion injury, 30min extra-alveolar dry-time
6y
2w
• continued root development; apical & lateral
4m
12m
2y
• continued root development; apical & lateral
Kling, Cvek, Mejare, 1986
5min extra-alveolar dry-time, saliva 40min
5min extra-alveolar dry-time
4w
3m
2y
3y
• arrested root development
3w
1y
3y
7y
• arrested root development
• ingrowth of hard tissue
• ingrowth of hard tissue
Bacterial contamination is a principle
factor for failure of revascularization
TOPICAL TREATMENT WITH
DOXYCYCLINE BEFORE REPLANTATION
Increases the incidence of revascularization from:
Cvek et al, 1990
1. 18% to 41%, monkeys (Cvek et al,1990)
2. 30 to 60%, dogs (Yanpiset et al, 1999)
Pulp revascularization of replanted immature
dog teeth after treatment with minocycline
assessed by laser Doppler flowmetry,
radiology and histology.
Alessandra L.S. Ritter, DDS
Department of Endodontics – Graduate Program
Thesis Committee: Dr Martin Trope (advisor),
Dr Asgeir Sigurdsson, Dr Valerie Murrah
G 1 (n=11): specimens were kept dry for 5 min,
covered with minocycline hydrochloride
microspheres (Arestin, OraPharma Inc.,
Warminster, PA), and replanted.
Percentage of vital pulp findings after
histological evaluation
Group
Procedure/Treatment
n
n vital pulp
% vital pulp
G1
Minocycline HCl
11
10
91
G2
Doxycycline
11
8
73
G3
Saline (- control)
6
2
33
G4
Not extracted (+ control)
6
6
100
34
26
% vitality
Total
10 0
90
80
70
60
50
40
30
20
10
0
Pulp Revascularization
Avulsed/Replanted
Immature Tooth
No Canal Bacteria
Necrotic Pulp
Scaffold
No Coronal Access
Minocycline
Doxycycline
Sa line
Infected
Immature Tooth
Canal Bacteria
No Scaffold
Coronal Access
Control
Pulp Revascularization
Revascularization
Infected Immature Tooth
Challenges
Canal Bacteria
Coronal leakage
No Scaffold
Solutions?
Disinfect
Bacteria tight seal
Artificial Scaffold
Revascularization
Revascularization
Canal opened for drainage, suppuration
5% NaOCl, 3% H2O2
Ciprofloxacin + Metronidazole paste
Vital tissue observed in apical 1/3
3D CT image
Iwaya S, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with
apical periodontitis and sinus tract. Dent Traumatol 2001;17:185-7.
NO blood clot induced
Coronally sealed
Revascularization
Banchs F, Trope M: Revascularization
of immature permanent tooth with
apical periodontitis: a new
treatment protocol?
30m
J Endod 2004; 30(4),196-200
5m
Revascularization
5.25% NaOCl, Peridex (0.12% CHX)
Cipro, Metro, Minocycline paste, 4wks
Irrigated with NaOCl
Bleeding induced with explorer
MTA on blood clot
Coronal seal
Pre - op
Preop 8/7/06
Pre-op
24 month recall
7 month recall
TriMix, Clot incuced and MTA placed 9/15/06
19 month recall 3/3/08
Revascularization
Immature Teeth With AP or
Abscess Undergoing
‘Apexogenesis’: A Paradigm Shift
Chueh L-H, Huang GT. J Endod 2006
2.5% NaOCl
Ca(OH)2 paste (???)
Should NOT be used
• 4 cases, AP
• no debridement; 2.5% NaOCl
• Ca(OH)2, repeatedly
Preserve HERS cells & apical stem cells
7 months
11m
20m
Pre-op
blood clot.
7 months
Pre-op
35m
6 months
12 months
10 months
Ciprofloxacin, metronidazole, cefaclor;
Dr. Blayne Thibodeau, 2007
Dr. Linda Levin
Antibiotic Paste
1. Hoshino E et al, 1988. Bactericidal efficacy of metronidazole
against bacteria of human carious dentin in vitro.
2. Sato T et al, 1993. In-vitro antimicrobial susceptibility to
combinations of drugs on bacteria from carious and endodontic
lesions of human deciduous teeth.
3. Hoshino E et al, 1996. In-vitro antibacterial susceptibility of
bacteria taken from infected root dentine to a mixture of
ciprofloxacin, metronidazole and minocycline.
2y
TriMix, blood clot
TriMix
4. Sato I et al, 1996. Sterilization of infected root-canal dentine by
topical application of a mixture of ciprofloxacin, metronidazole
and minocycline in situ.
Disinfection of immature teeth with a
triple antibiotic paste
Windley W, Teixeira F, Levin L, Sigurdsson A, Trope M. JOE 2005
In-vitro antibacterial susceptibility of bacteria taken from infected
root dentine to a mixture of ciprofloxacin, metronidazole and
minocycline. Hoshino et al, 1996
Materials and Methods
Bacteria taken from carious dentine (25 cases) and
infected pulps (12 cases) were killed.
Bactericidal efficacy of TriMix is sufficiently potent
to eradicate bacteria from the infected dentine of
root canals.
STAINING occurs!!
PrePre-op
6 weeks
5cc 1% NaOCl, S2 taken
Triple Antibiotic Paste, 2w
Lentulo
spiral
Canal Disinfection, NaOCl
Microbial Sampling,
Immature teeth in dogs w/AP
S3 (taken at 2w): 5ml saline rinse
S1
S2
Infection
1.25% NaOCl
Mean
CFU’s
1.7 X 108
1.4 X 104
%
Positive
100
90
Disinfection of immature teeth with a triple antibiotic paste
Canal Disinfection, NaOCl
Results of Microbial Sampling
Microbial Sampling,
Immature teeth in dogs w/AP
S2
S3
6
Infection
1.25% NaOCl
TriMix
5
1.7 X 108
1.4 X 104
26
4
log 10 means
Mean
CFU’s
Bac terial reduction following irrigation with 1% NaOCL and 2
we ek application of a triple antibiotic paste
S1
S1S1-Initial
S2S2-NaOCL
S3S3-Antibiotic
3
2
%
Positive
100
90
30
1
0
S1
S2
S3
Sample s
Efficacy of Revascularization
Shah et al. J Endod 2009
1st visit:
• 14 immature teeth, AP
• Irrigation; H2O2, 2.5% NAOCL
• Formocresol, cotton pellet
• IRM temporary
2nd visit:
• Copious irrigation; H2O2, NaOCl
• Sterile 23g needle, 2mm long
• Induced bleeding to cervical level
• Allowed clot to form, cotton pellet
• GI over clot
Results: follow-up, 6m-3.5y
• Healing of PA lesion: 11/14 (79%)
• Thickening of walls:
8/14 (57%)
• Increased root length: 10/14 (71%)
• No failing cases.
Stem Cells of Apical Papilla
Huang et al. J Endod 2008
SCAP:
Population of mesenchymal stem cells
Source of odontoblasts
Formation of root dentin
Continued root development
Potential for pulp/dentin regeneration
Revascularization
• Disinfection: NaOCl, Ca(OH)2,
antibiotic paste
• Scaffold
Huang et al. J Endod 2008
Purpose
To examine the ability of a collagen scaffold
to aid revascularization of the necrotic
infected root canal system in immature dog
teeth.
Temporary restorations
Mechanical pulp exposure and infection with
autologous plaque bacteria (randomly assigned)
Radiographic monitoring for development of apical
periodontitis
Radiographic monitoring for development of apical
periodontitis
Triple antibiotic paste
placed with lentulo
Chlorhexidine
Tincture Iodine
Group 1:
12 teeth
(Infected → disinfected)
Closed permanently
Triple antibiotic paste
with lentulo
Groups 2 – 4:
Closed temporarily
4 weeks for disinfection
of root canal system
Group 2: Type I collagen solution application
Group 3: Blood clot stimulation
Group 4: Type I collagen solution+blood clot
stimulation
Results
Group 5: negative controls (no treatment)
Group 1: disinfected
Results
Results
Results
Results
Group 3: blood clot
Group 3: blood clot
Results
Group 3: blood clot
Statistical Analyses: Radiographic Results
Uncorrected Chi-squared analysis
120
100
80
60
40
20
0
Thickened walls
Apical closure
significantly more apical closure
Group 3 (Infected → disinfected → blood clot) than
Group 1 (Infected → disinfected) (p = 0.01)
PAR healing
% of roots with and without apical closure
80
70
60
50
40
30
20
10
0
Apical closure
t)
+c
lo
(c
l
ge
n
3
4
(c
ol
la
ge
n
ct
e
(c
ol
la
2
in
fe
1
(d
is
Experimental groups
ot
)
)
No apical closure
d)
Percentage
Percentage
Radiographic outcomes
Experimental group
Statistical Analyses: Histological Results
Challenges
Uncorrected Chi-squared analyses
no statistical differences (p ≥ 0.05) between experimental
groups
Hard tissue on internal dentin root walls
Apical closure
Vital tissue within canal space
Apical closure
2
4
3
(c
lo
t)
(c
oll
ag
en
+c
lo
t)
(c
oll
ag
en
)
Tissue in canal
in
fe
ct
ed
)
Percentage
Compliance
Hard tissue
1
(d
is
Collagen plug
Staining
Histological outcomes
70
60
50
40
30
20
10
0
Blood clot
Experimental group
Petrino et al. JOE 2010
Challenges
Challenges
Blood clot
Blood clot
Collagen plug
Collagen plug
Challenges
Staining
Ding et al, JOE 2009
Retrospective Evaluation
Retrospective Evaluation
54 regenerative case evaluated
Results:
Calculated continued root development
and dentin wall thickness
Regenerative procedures using TriMix or
Ca(OH)2 had sig. greater increases in root
length than formo or apexification
Control group- 20 apexification cases and
20 NSRCT
Bose et al. JOE 2009
Bose et al. JOE 2009
6m
Courtesy: Dr. R. Corr
TriMix: sig. > root wall thickness than others
6/12/08
10m
Conclusions
Revascularization of necrotic infected immature
root canal spaces is a possibility and should be
studied further as a viable treatment modality.
A blood clot seems to be of importance in
promoting revascularization in disinfected canals.
Future research ongoing into predictable scaffold
materials, growth factors, stem cells.
2y
TriMix, blood clot
Regeneration of
diseased tissues is
the future!
Thank You
barnettf@einstein.edu

Clinical Perspectives on Apexogenesis, Apexification

Transcription

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