1. Jeena Sara Paul 11th March 2009
Ist year MDS 9.00 AM
Christian Dental College
Ludhiana

2.  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.
 Young permanent teeth are in developmental stage in
children from 6 years of age until mid-teens
 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 .

3.  Developing teeth are essential for development and growth of alveolar
process and periodontal ligament: D Vincent Provenza, Journal of Oral
Histology inheritance and development
 Human tooth with immature apex is a precious tissue source for the
research of human adult stem cell: Shigehiro Abe et al, Oral Science
International Journal, May 2007
 Young permanent teeth possesses a greater potential to rebuild the host
pulp tissue and continue root maturation: Granhoss et al, Journal of
dental research, 2002
 A population of mesenchymal stem cells (MSCs) residing in the apical
papilla of incompletely developed teeth, termed stem cells from the
apical papilla (SCAP), can differentiate into odontoblast-like cells and
produce dentin-like tissue in both in vitro and in vivo study systems:
Huang G, Journal of Dentistry, 2008

4.  Auto transplantation of immature teeth have high success
rate of survival: Wim Laurey et al, American Journal of
Dentofacial Orthopaedics
 Measurement of open apices of teeth can be used to assess
chronological age: Camaerirrice, International Journal of
forensic science

5. YOUNG PERMANENT TEETH MATURE TEETH
 Surfaces of recently erupted teeth  There is generalised loss and
are covered by pronounced flattening of perikymata
enamel rods and perikymata
 No attrition present, Mammelons  Attrition or wear of occlusal
clearly visible surfaces and proximal contacts
as a result of mastication,
Mammelons absent
 Surface of enamel work like a semi  Localised increase of elements
permeable membrane; slow such as nitrogen and fluorine is
passage of water from found in superficial layer of
enamel of older teeth; enamel
surrounding and substances becomes less permeable with
having small molecular size to advancing age
pass through pores.

6. YOUNG PERMANENT TEETH MATURE TEETH
 Primary dentine is present  Secondary dentine present.
which is composed of mantle Sclerotic and reparative
and circumpulpal dentine dentine may also be present
 Young pulp has high number
of undifferentiated  Decreased number of
mesenchymal cells undifferentiated cells in the
• High cellular content pulp
• High vascularity • Low vascularity
• Low calcium and phosphorus • High calcium and phosphorus
content content

7.  Significantly greater proportion of fully erupted teeth
are plaque free compared to partially erupted teeth
 Fully erupted teeth yielded greater number and
proportion of Streptococcus mutans.
 Partially erupted teeth yielded Actinomyces israeli
 Significantly greater numbers and proportions of S
salivarius were isolated from partially erupted teeth
with white spot as compared with greater number of
S mutans in fully erupted teeth with white spots

8.  Caufield et al demonstrated a window of infectivity from
7-31 months when the child is at higher risk
 Krass et al, 1967 and Edrman et al, 1975 reported that a 2-6
year of age the child is less susceptible to acquiring MS.
 The second window of infectivity is present in the young
permanent dentition between 6-12 years of age (Klock
and Kroske, 1977).
 Davey and Rogers, 1984, reported that children acquire
additional strains of MS as they get older and new teeth
erupt.

9.  Evaluation of pulp vitality is an important diagnostic aspect of
treating young permanent teeth.
 The methods mainly used are thermal and electrical testing which
test the vitality based on the neural response of the pulp.
 Immature permanent teeth are not fully innervated with alpha-
myelinated axons: the neural components responsible for the
pulpal pain response.
 This reduced number of pain receptors make them less responsive
to stimuli giving FALSE NEGATIVE results from thermal and
electric pulp testing.
 Hence the need for using methods that test the circulation of the
pulp including laser Doppler flowmetry, pulsoximetry, dual wave
spectrophotometry and plethysmography.

10.  A smooth exchange from the primary to permanent dentition is of
utmost importance.
 Ectopic eruption of permanent teeth may cause disturbance in occlusion
 As the permanent incisors erupt, the arch width increases slightly, the
permanent incisor tips mesially and the primary cuspids move distally
 First molar eruption: In majority of children, the first permanent molars
erupt prior to the central incisors. The first molar is guided into occlusion
by the distal surface of the 2nd primary molar
 Incisor eruption: The mandibular central incisors are the first to erupt
and maxillary laterals the last.
 Second molar eruption: The mandibular 2nd molar erupts before the
maxillary 2nd molar; if otherwise, it can lead to Class II malocclusion.

11.  Young permanent teeth are more sensitive to dental caries than
teeth that have remained free from caries for a few years after
eruption.
 Hence the need for preventive procedures.
 These include:
• Pit and fissure sealants
• Preventive Resin Restoration

12.  Sealants are safe and painless way of protecting young permanent
teeth from decay.
 “A sealant is a protective, plastic coating applied to the occlusal
surfaces of the posterior teeth. The sealant forms a hard shield
that keeps food and bacteria from getting into the tiny grooves in
the teeth and causing decay.’’
 Sealants are often applied as soon as the permanent teeth start to
come through.
 Permanent molars have deeper grooves and more than 80-90% of
caries begin here.
 These natural valleys are harder to clean and the enamel within
the grooves are thinner

13.  The PRR is a conservative occlusal restoration that involves
replacement of discrete areas of carious structure with composite
followed by application of an overlying fissure sealant.
 The resin used in the procedure can be filled or unfilled.

14.  Interim restorations of a broken down or traumatised tooth until
construction of a permanent restoration can be carried out or the
eventual orthodontic status is established.
 Teeth with developmental defects- The crowns are beneficial for
restoring the occlusion and reducing any sensitivity caused by
enamel and dentin dysplasias in young patients.
 Restoration of a permanent molar which requires full coverage but
is only partially erupted.

15. Numerous factors can affect the pulpal health of teeth, but
the two major conditions detrimental to young permanent
teeth are
1. deep caries and
2. traumatic injuries.
 These often lead to pulp necrosis and arrested tooth development
of the involved immature tooth.
 The resulting wide-open apical foramina, canals with reverse taper
(blunderbuss) and thin dentinal walls, represent major clinical
concerns when an incompletely developed tooth fails to mature.

16.  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
-the apex, therefore can be broad or tapered
 Blunderbuss
- The word ‘blunderbuss’ basically refers to an 18th century weapon with
a short and wide barrel. It derives its origin from the Dutch word
‘DONDERBUS’ which means ‘thunder gun’.
- The walls of the canal are divergent and flaring, more especially in the
buccolingual direction
- The apex is funnel shaped and typically wider than the coronal aspect of
the canal.

17.  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
 Extensive apical resorption due to orthodontic
treatment, periapical pathosis or trauma
 Root end resection during periradicular surgery
 Over-instrumentation

18. 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.

19.  Stage 4
Teeth with wide open apical
foramen and nearly
completed root length.
 Stage 5
Teeth with closed apical
foramen and completed root
development.

20.  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
- necessitating post endodontic rehabilitation
of both crown and root
 Discoloration in long standing cases

21.  The main goal in the treatment of an immature tooth
is to maintain a vital root forming organ, as long as
possible, to allow physiological apical root formation.
 If this happens, the rest of the treatment is routine
endodontic treatment
 The second important consideration in treating
immature teeth is to keep the surgical procedure as
superficial as possible, with minimal instrumentation
to not disturb the not yet fully formed roots.

22. Clinical examination
 Carious involvement of pulp may be clinically obvious
 Sensitivity to explorer probing, review of radiographs and clinical
excavation can confirm a suspicion that the lesion is more
advanced than it appears.
 Traumatised teeth may show evidence of injury in many ways.
 With some injuries, the effect on the pulp may be neither apparent
nor diagnosable initially.
 With severe injuries, the pulp is almost always deleteriously
affected and requires immediate or subsequent treatment

23. Clinical Diagnostic Procedures
 Heat, cold and electrical pulp testing are classic tests for pulpal
tests, vitality and viability.
 Interpretation of testing data must be cautious, because an open
apex provides a significantly enlarged vascular supply but an
incompletely developed nervous innervation. (Bernick,1964)
 In traumatised teeth esp., the reactions to pulp test should not be
treated literally because the pulp is in a state of shock for many
days or weeks and may register negatively to tests and then return
later to normal status.
 Tests of mobility and percussion sensitivity should also be
performed for comparison with unaffected teeth.

24. Radiographic Examination
 A diagnostically accurate periapical radiograph is essential for
correct pulpal evaluation of a deeply carious or traumatised young
permanent tooth.
 More than one view of the area of interest, each taken at a
different angle , is helpful for locating subtle changes.
 Pathologic changes should not be confused with normal anatomy
 Internal resorption is possible in permanent teeth but not as
common as in primary teeth. Pathologic external resorption is
seen in severe disruptions of the periodontal ligament
 Treatment induced calcifications may be too thin to visualise
radiographically

25. Direct Pulpal Evaluation
 Careful visual inspection, tactile evaluation
during instrumentation, and even detection
of foul odours given off by a pulp provide
important clues about lesion depth and
pulpal status.

26.  A suggested outline for determining the pulpal status of cariously
involved teeth in children involves the following:
 Visual and tactile examination of carious dentin and
associatedperiodontium
 Radiographic examination of
a. periradicular and furcation areas
b. pulp canals
c. periodontal space
d. developing succedaneous teeth
 History of spontaneous unprovoked pain
 Pain from percussion
 Pain from mastication
 Degree of mobility
 Palpation of surrounding soft tissues
 Size, appearance, and amount of hemorrhage associated with pulp
exposures

27.  Case selection and treatment of choice for
the young permanent tooth depends upon
the

28.  Teeth exhibiting signs and/or symptoms such as a history of
spontaneous unprovoked toothache, a sinus tract, periodontal
inflammation not resulting from gingivitis or periodontitis,
excessive mobility not associated with trauma or exfoliation,
furcation/apical radiolucency, or radiographic evidence of
internal/external resorption have a clinical diagnosis of
irreversible pulpitis or necrosis. These teeth are candidates for
non-vital pulp treatment.
 Teeth exhibiting provoked pain of short duration—which is
relieved upon the removal of the stimulus, with analgesics, or by
brushing—without signs or symptoms of irreversible pulpitis, have
a clinical diagnosis of reversible pulpitis and are candidates for
vital pulp therapy.
 Teeth with a normal pulp requiring pulp therapy are treated with
vital pulp procedures.

29.  Pulp treatment modalities can be classified into 2 categories
• Vital Pulp Therapy:
1. Protective base
2. Indirect pulp capping
3. Direct pulp capping
4. Pulpotomy
5. Apexogenesis
6. Regeneration
• Non vital pulp therapy: Apexification; pulpectomy and root
filling

31.  Term coined by AAPD
 Recommends the placement of a protective base or a liner on the pulpal and axial
walls of the cavity preparation to act as a protective barrier between the
restorative material and the tooth.
 In deep cavities, the dentine covering the pulp is very thin and dentinal tubules
are closely packed; this highly permeable dentine needs a protective base to seal
the dentinal walls.
 In a tooth with a normal pulp, when dentin is exposed and all caries is removed
during the preparation for a restoration, a protective radiopaque base may be
placed between the permanent restoration and the dentin to minimize pulp
injury, promote pulp tissue healing, or minimize postoperative sensitivity.
 A protective base is utilized to preserve the tooth’s vitality, promote pulp tissue
healing and tertiary dentin formation, and minimize microleakage. Adverse post-
treatment signs or symptoms such as sensitivity, pain, or swelling should not
occur.
 Materials: glass ionomers, resin modified glass ionomer cements, dentin bonding
agents

32.  Indirect pulp treatment is a procedure performed in a tooth
with a deep carious lesion adjacent to the pulp.
 The carious dentin near the pulp is left in place to avoid pulp
tissue exposure and is covered with a biocompatible
material.
 A radio-opaque base such as calcium hydroxide, zinc oxide
and eugenol, or glass ionomer cement is placed over the
remaining affected dentin to stimulate healing and repair.
 The tooth then is restored with a material that seals the
involved tooth from microleakage.

33.  Indirect pulp treatment is indicated in a permanent tooth with a normal
pulp or reversible pulpitis when the deepest carious dentin is not
removed to avoid a pulp exposure.
 The pulp is judged by clinical and radiographic criteria to be vital and able
to heal from the carious insult.
 The restorative material should seal completely the involved dentin from
the oral environment.
 The vitality of the tooth should be preserved.
 No post-treatment signs or symptoms such as sensitivity, pain, or
swelling should be evident. There should be no radiographic evidence of
internal or external root resorption or other pathologic changes.
 Teeth with immature roots should show continued root development
and apexogenesis.

34. 1960’s Eastman Dental Center Study
 475 teeth: 75% would have resulted in pulp
exposures with complete removal of carious
dentin yet following treatment with IPT only 3%
experienced clinical failure
AAPD Annual Meeting (1999 & 2001)
 Researchers encouraged the group to reconsider
this method of treating primary teeth
Sensitive topic ‐ not always a clear delineation
where

35. Rationale :
 Establishment of a healthy, intact pulp is desirable over partial or complete surgical
removal
 Affected pulpal tissue, in the absence of a continued insult, is able to heal itself
(3°dentin)
Indications :
 History
a. Mild discomfort from chemical and thermalstimuli
b. Absence of spontaneous pain
 Clinical examination
a. Large carious lesion
b. Absence of lymphadenopathy
c. Normal appearance of adjacent gingiva
d. Normal color of tooth
 Radiographic examination
a. Large carious lesion in close proximity to the pulp
b. Normal lamina dura
c. Normal periodontal ligament space
d. No interradicular or periapical radiolucency

36. Contraindication
 History
a. Sharp, penetrating pain that persists after withdrawing stimulus
b. Prolonged spontaneous pain, particularly at night
 Clinical examination
a. Excessive tooth mobility
b. Parulis in the gingiva approximating the roots of the tooth
c. Tooth discoloration
d. Nonresponsiveness to pulp testing techniques
 Radiographic examination
a. Large carious lesion with apparent pulp exposure
b. Interrupted or broken lamina dura
c. Widened periodontal ligament space
d. Radiolucency at the root apices or furcation areas

38. Two-Appointment Technique (First Sitting).
 Administer local anaesthesia and isolate with a rubber dam.
 Establish cavity outline with a high-speed hand piece.
 Remove the majority of soft, necrotic, infected dentin with a large
round bur in a slow-speed hand piece without exposing the pulp.
Irrigate the cavity and dry with cotton pellets.
 Cover the remaining affected dentin with a hard-setting calcium
hydroxide dressing.
 Fill or base the remainder of the cavity with a reinforced ZOE
cement or a glass-ionomer cement to achieve a good seal.
 Do not disturb this sealed cavity for 6 to 8 weeks. It may be
necessary to use amalgam, composite resin,or a stainless steel
crown as a final restoration to maintain this seal.

39. Two-Appointment Technique (Second Sitting, 6 to 8 Weeks Later).
If the tooth has been asymptomatic, the surrounding soft tissues are free
from swelling, and the temporary filling is intact, the second step can be
performed:
 Bitewing radiographs of the treated tooth should be assessed for the
presence of reparative dentin.
 Carefully remove all temporary filling material, especially the calcium
hydroxide dressing over the deep portions of the cavity floor.
 The remaining affected carious dentin should appear dehydrated and “flaky”
and should be easily removed. The area around the potential exposure
should appear whitish and may be soft; this is “predentin.”Do not disturb!
 The cavity preparation should be irrigated and gently dried.
 Cover the entire floor with a hard-setting calcium hydroxide dressing.
 A base should be placed with a reinforced ZOE or glass ionomer cement, and
the tooth should receive a final restoration.

40. One-Appointment Technique.
 The value of re-entry and re-excavation has been questioned by
some clinicians when viewed in light of numerous studies
reporting success rates of indirect pulp capping with calcium
hydroxide ranging from 73 to 98%
 After cavity preparation, if all carious dentin was removed except
the portion that would expose the pulp, re-entry might be
unnecessary.
 Conversely, if the clinician had to leave considerably more carious
dentin owing to patient symptoms, re-entry would be advised to
confirm reparative dentin and pulp exposure status.
 If a pulp exposure occurs during re-entry, a more invasive vital
pulp therapy technique such as direct pulp capping or pulpotomy
would be indicated.

41. Photomicrograph of four layers of healing under indirect pulp capping of a permanent molar of
a 141⁄2-year-old child. Zinc oxide–eugenol cement capping after excavation of the necrotic
dentin layer only. No pain 480 days later when extracted. 1= carious decalcified dentin; 2 =
rhythmic layers of irregular irritational dentin; 3 = regular tubular dentin; 4 = normal pulp
with slight increase in fibrous elements. Held-Wydler E.

42.  King and associates, Aponte et al. and Parikh et al., determined that the
residual layer of carious dentin, left in the indirect pulp-capping
technique, can be sterilized with either ZOE cement or calcium
hydroxide.
 It cannot be presumed that all of the remaining infected or affected
dentin becomes remineralized. In contrast to ZOE, residual dentin will
increase in mineral content when in contact with calcium hydroxide.
 A minimum indirect pulp post-treatment time period of 6 to 8 weeks
should be allowed to produce adequate remineralisation of the cavity
floor.
 This desirable outcome is essentially dependent on the maintenance of a
patent seal against micro leakage by the temporary and final
restorations. In this regard, the newer resin-reinforced glass ionomer
cements and dentin bonding agents should be considered.

43.  Direct pulp capping involves the placement of a
biocompatible agent on healthy pulp tissue that has been
inadvertently exposed from caries excavation or traumatic
injury.
 The treatment objective is to seal the pulp against bacterial
leakage, encourage the pulp to wall off the exposure site by
initiating a dentin bridge, and maintain the vitality of the
underlying pulp

44. Indications :
 Small mechanical or traumatic exposures in primary or permanent
teeth; optimal chance for favourable response
 The classic indication for direct pulp capping has been for “pinpoint”
mechanical exposures that are surrounded with sound dentin
 Frigoletto noted that small exposures and a good blood supply have
the best healing potential. An empirical guideline has been to limit the
technique to exposure diameters of less than 1 mm.
Contraindications :
 A history of spontaneous and nocturnal toothaches,
 excessive tooth mobility,
 thickening of the periodontal ligament,
 radiographic evidence of furcal or periradicular degeneration,
 uncontrollable hemorrhage at the time of exposure, and
 purulent or serous exudatefrom the exposure.

45. Steps in the procedure
1. Débridement.
 Kalins and Frisbee have shown that necrotic and infected
dentin chips are invariably pushed into the exposed pulp
during the last stages of caries removal.
 This debris can impede healing in the area by causing further
pulpal inflammation and encapsulation of the dentin chips.
Therefore, it is prudent to remove peripheral masses of
carious dentin before beginning the excavation where an
exposure may occur.
 When an exposure occurs, the area should be appropriately
irrigated with non-irritating solutions such as normal saline
to keep the pulp moist

46. 2. Hemorrhage and Clotting
 Hemorrhage at the exposure site can be controlled with cotton
pellet pressure.
 A blood clot must not be allowed to form after the cessation of
hemorrhage from the exposure site as it will impede pulpal
healing.
 The capping material must directly contact pulp tissue to exert a
reparative dentin bridge response.
 Hemolysis of erythrocytes results in an excess of hemosiderin and
inflammatory cellular infiltrate, which prolongs pulpal healing.

47. 3. Exposure Enlargement
 There have been recommendations that the exposure site be
enlarged by a modification of the direct capping technique known
as pulp curettage or partial pulpotomy prior to the placement of
the capping material.
 Enlarging this opening into the pulp itself serves three purposes:
1. it removes inflamed and/or infected tissue in the exposed area;
2. it facilitates removal of carious and noncarious debris,
particularly dentin chips; and
3. it ensures intimate contact of the capping medicament with
healthy pulp tissue below the exposure site.

48. 4. Bacterial Seal
 Watts and Paterson and Cox have emphasized the fact
that bacterial microleakage under various restorations
causes pulpal damage in deep lesions, not the toxic
properties of the cavity liners and/or restorative materials.
 The success of pulp-capping procedures is dependent on
prevention of microleakage by an adequate seal.
 Cox et al. have shown that pulp healing is more dependent
on the capacity of the capping material to prevent
bacterial microleakage rather than the specific properties
of the material itself.

49. Medications and Materials
 Many medicaments and materials have been suggested to cover
pulp exposures and initiate tissue healing and/or hard structure
repair.
 Calcium hydroxide, in one form or another, has been singled out
by a myriad of authors as the medicament of choice for pulp
exposures.
 Antibiotics, calcitonin, collagen, corticosteroids, cyanoacrylate,
formocresol, and resorbable tricalcium phosphate ceramic have
also been investigated, with varying degrees of success. These
compounds, with the exception of formocresol, have not had
sufficient clinical impact to be adopted as the material of choice in
direct pulp capping, especially in the pediatric age groups.

50. A B
C D
Effect of calcium hydroxide and time on the healing of the capped pulp. A, Twenty-four
hours after application of calcium hydroxide. B, After 2 or 3 weeks. C, After 4 or 5 weeks. D,
After 8 weeks. Vermeersch AG

51. Outcome
The salient features of a clinically successful direct pulp capping
treatment (with or without bridging) are
 maintenance of pulp vitality,
 absence of sensitivity or pain,
 minimal pulp inflammatory responses, and
 absence of radiographic signs of dystrophic changes.
 It is generally considered that pulps inadvertently exposed and
asymptomatic in the preoperative period are more apt to survive when
capped.
 The prognosis is far less favorable if an attempt is made to cap an
inflamed pulp infected from caries or trauma.
 Also, the wide-open apices and high vascularity of young permanent
teeth enhance the successful outcome of direct capping techniques

52.  A pulpotomy is defined as the surgical removal of the entire coronal pulp
presumed to be partially or totally inflamed and quite possibly infected,
leaving intact the vital radicular pulp within the canals.
 A germicidal medicament is then placed over the remaining vital
radicular pulp stumps at their point of communication with the floor of
the coronal pulp chamber.
 This procedure is done to promote healing and retention of the vital
radicular pulp. The treatment objective is to maximize the opportunity
for apical development and closure, known as apexogenesis, and
enhance continual root dentin formation.
 Dentin bridging may occur as a treatment outcome of this procedure
depending on the type of medicament used
 Additional variables thought to influence treatment outcome include the
medication type, concentration, and time of tissue contact.

53. Indications
 Pulpotomy candidates should demonstrate
1. clinical and radiographic signs of radicular pulp vitality, absence
of pathologic change,
2. restorability, and
3. at least two-thirds remaining root length.
 Pulpotomised teeth should receive stainless steel crowns as final
restorations to avoid potential coronal fracture at the cervical
region.
 Pulpotomy is recommended for young permanent teeth with
incompletely formed apices and cariously exposed pulps that
give evidence of extensive coronal tissue inflammation.

54. Contraindications
 Teeth with a history of spontaneous pain should not be
considered.
 If profuse hemorrhage occurs on entering the pulp chamber, the
one-step pulpotomy is also contraindicated.
Other contraindications are
 pathologic root resorption,
 roots that are two-thirds resorbed or
 internal root resorption,
 interradicular bone loss,
 presence of a fistula, or
 presence of pus in the chamber

55.  Calcium hydroxide - alkaline, produces superficial necrosis of the pulp
stimulates development of calcified barrier
 Formocresol – formaldehyde/cresol in glycerin-Acts by fixation of
remaining pulp tissue
 Ferric Sulphate may be the material of choice in future - Agglutinates
blood protein without clot formation - Equal results as with dilute
formocresol with less toxicity
 Glutaraldehyde- was found to be less cytotoxic “when used as a
pulpotomy agent.”
 MTA- acts as cell inductive agent
 BMP, Calcium phosphate cements
 Non-pharmaco-therapeutic techniques- Electrosurgery and lasers

56. Steps for Single appt. technique
 Anesthetize the tooth and tissue.
 Isolate the tooth to be treated with a rubber dam.
 Excavate all caries.
 Remove the dentin roof of the pulp chamber with a high-speed
fissure bur
 Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round
bur
 Sharp spoon excavators can remove residual tissue remnants.
 Achieve hemostasis with dry cotton pellets under pressure.
 Apply diluted formocresol to the pulp on a cotton pellet for 3 to 5
minutes.
 Place a ZOE cement base without incorporation of formocresol
 Restore the tooth with a stainless steel crown

57. Step-by-step technique in
one-appointment
formocresol pulpotomy.
A, Exposure of pulp by
roof removal.
B, Coronal pulp
amputation with a round
bur. Hemostasis with dry
cotton or epinephrine.
C, Application of
formocresol for 1 minute.
Excess medicament
is expressed from cotton
before placement.
D, Following formocresol
removal, zinc oxide–
eugenol base and
stainless steel crown are
placed.
Ingle

58. Two-Appointment Pulpotomy.
Indications.
The two-appointment technique is indicated if there is evidence of
 sluggish or profuse bleeding at the amputation site,
 difficult-to-control bleeding,
 Slight purulence in the chamber but none at the amputation site,
 thickening of the periodontal ligament, or
 a history of spontaneous pain without other contraindications.
Procedure.
 A cotton pellet moistened with diluted formocresol is sealed into the
chamber for 5 to 7 days with a durable temporary cement.
 At the second visit, the temporary filling and cotton pellet are removed
and the chamber is irrigated with hydrogen peroxide.
 A ZOE cement base is placed.
 The tooth is restored with a stainless steel crown.
 Verco and Allen found no difference in the success rate between one-
stage and two-stage procedures.

59. Outcome
 The formocresol treatment might be effective
because the open apical foramen of immature
permanent teeth would be conducive to an in-growth
of connective tissue at the apex in the form of
proliferating fibroblasts.
 Because linear osteodentin calcification may develop
as a response to formocresol pulpotomies over time,
there has been considerable concern expressed by
endodontists of the difficulty in renegotiating treated
young permanent canals after the apices have closed.

60.  Because of improved clinical outcomes, calcium hydroxide is the
recommended pulpotomy agent for carious and traumatic
exposures in young permanent teeth, particularly with incomplete
apical closure .
 Following the closure of the apex, it is generally recommended
that conventional root canal obturation be accomplished to avoid
the potential long-term outcome of root canal calcification.
 The rationale was introduced by Teuscher and Zander in 1938, who
described it as a “vital” technique.
 Their histologic studies showed that the pulp tissue adjacent to
the calcium hydroxide was first necrotized by the high pH (11 to
12) of the calcium hydroxide.

61.  This necrosis was accompanied by acute inflammatory changes in the
underlying tissue. After 4 weeks, a new odontoblastic layer and,
eventually, a bridge of dentin developed.
 Later investigations showed three identifiable histologic zones under the
calcium hydroxide in 4 to 9 days: (1) coagulation necrosis, (2) deep-
staining basophilic areas with varied osteodentin, and (3) relatively
normal pulp tissue, slightly hyperemic, underlying an odontoblastic layer.
 As with direct pulp capping, the presence of a dentinal bridge is not the
sole criterion of success.
 The bridge may be incomplete and may appear histologically as
doughnut, dome, or funnel shaped or filled with tissue inclusions. It is
also possible for the remaining pulp to be walled off by fibrous tissue
with no dentin bridge evident radiographically.

62. Procedure.
 Anesthetize the tooth to be treated and isolate under a rubber
dam.
 Excavate all caries and establish a cavity outline.
 Irrigate the cavity with water and lightly dry with cotton pellets.
 Remove the roof of the pulp chamber with a high-speed fissure
bur.
 Amputate the coronal pulp with a large low-speed round bur or a
high-speed diamond stone with a light touch.(Granath et al)
 Control hemorrhage with a cotton pellet applied with pressure or a
damp pellet of hydrogen peroxide.

63.  Place a calcium hydroxide mixture over the radicular pulp stumps
at the canal orifices and dry with a cotton pellet.
 Place quick-setting ZOE cement or resin-reinforced glass ionomer
cement over the calcium hydroxide to seal and fill the chamber.
 If the crown is severely weakened by decay, a stainless steel crown
rather than an amalgam restoration should be used to prevent
cusp fractures
 The patient should be re-evaluated every three months for the
first year, and then every 6 months for 2 to 4 years to determine if
successful root formation is taking place and that there are no
signs of pulp necrosis, root resorption or periradicular pathosis.

64. Calcium hydroxide pulpotomy, young
permanent molar.
A, Pulp of a first permanent molar exposed by
caries (white arrow).
B, Calcified dentin bridges (arrows) over vital
pulp in canals. Note open apices.
C, Pulp recession (arrows) and continued root
development indicative of continuing pulp
vitality.
McDonald RE. Dentistry for the child and
adolescent. 2nd ed.

65.  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
root’s apex.
 Formation of the apex in vital, young, permanent teeth
can be accomplished by implementing the appropriate
vital pulp therapy (ie, indirect pulp treatment, direct pulp
capping, partial pulpotomy for carious exposures and
traumatic exposures).
 The goal of apexogenesis is the preservation of vital pulp
tissue so that continued root development with apical
closure may occur.

66.  The partial pulpotomy for carious exposures is a procedure in which the
inflamed pulp tissue beneath an exposure is removed to a depth of 1 to 3
mm or, in some cases, deeper to reach healthy pulp tissue. Pulpal
bleeding must be controlled, and the site should be covered with calcium
hydroxide or MTA. A restoration that seals the tooth from microleakage
is placed.
 A partial pulpotomy is indicated in a young permanent tooth for a small
(<2 mm) carious pulp exposure in which the pulpal bleeding is controlled
in 1 to 2 minutes.
 The tooth must be vital, with a diagnosis of normal pulp or reversible
pulpitis. The remaining pulp should continue to be vital after partial
pulpotomy. There should be no adverse clinical signs or symptoms such
as sensitivity, pain, or swelling.
 There should be no radiographic sign of internal or external resorption,
abnormal canal calcification, or periapical radiolucency postoperatively.
 Teeth having immature roots should continue normal root development
and apexogenesis.

67.  The partial pulpotomy for traumatic exposures is a procedure in which the
inflamed pulp tissue beneath an exposure is removed to a depth of 1 to 3 mm to
reach the deeper healthy tissue.
 Pulpal bleeding is controlled, and the site then is covered with calcium hydroxide
or MTA. A restoration that seals the tooth from microleakage is placed.
 This pulpotomy is indicated for a vital, traumatically-exposed, young permanent
tooth, especially one with an incompletely formed apex.
 Pulpal bleeding after removal of inflamed pulpal tissue must be controlled.
Neither the time between accident and treatment nor size of exposure is critical if
the inflamed superficial pulp tissue is amputated.
 The remaining pulp should continue to be vital after partial pulpotomy. There
should be no adverse clinical signs or symptoms of sensitivity, pain, or swelling.
There should be no radiographic sign of internal or external resorption, abnormal
canal calcification, or periapical radiolucency postoperatively.
 Teeth having immature roots should show continued normal root development
and apexogenesis.

69.  Apexification is a method of inducing root end closure of an incompletely
formed nonvital permanent tooth by removing the coronal and nonvital
radicular tissue just short of the root end and placing in the canal a
suitable biocompatible agent such as calcium hydroxide (several
treatments with a fresh agent may be necessary) or MTA.
 This procedure is indicated for nonvital permanent teeth with
incompletely formed roots.
 The procedure should induce root end closure (apexification) at the
apices of immature roots or an apical barrier, as evidenced by
radiographic evaluation.
 Adverse post treatment clinical signs or symptoms of sensitivity, pain, or
swelling should not be evident. There should be no radiographic evidence
of external root resorption, lateral root pathosis, or breakdown of
periradicular supporting tissues during or following therapy.

70.  In the apexification technique the canal is cleansed and sanitized in the
routine endodontic manner with the use of a rubber dam.
 The access opening is made,the length of the canal is established
radiographically and the canal is cleansed as thoroughly as possible.
 Frequent irrigation with sodium hypochlorite helps remove debris from
the canal.
 After thorough debridement the canal is dried and just barely medicated
with CMCP or some other suitable intracanal medicament. It is then
sealed with a temporary cement.
 When the tooth is free of signs and symptoms of infection, the canal is
dried and filled with a stiff mix of Ca(OH)2 and CMCP.

71.  After the canal is filled, the access opening must be sealed with a
permanent filling material. If the outer seal is defective, the calcium
hydroxide paste is lost and recontamination of the canal will result
 Composite resin or silicate cement is recommended for anterior teeth
and amalgam for posterior teeth.
 The usual time required to achieve apexification is 6 to 24 months
(average 1 year +/- 7 months).
 Factors that lead to increased time are the presence of a radiolucent
lesion, inter-appointment symptoms, and loss of the external seal with
re-infection of the canal. During this time the patient is recalled at 3-
month intervals for monitoring of the tooth.

72.  If any signs or symptoms of re-infection or pathology occur during
this phase of treatment, the canal is recleaned and refilled with
the Ca(OH)2 paste.
 The patient is recalled until radiographic evidence of apexification
has become apparent.
 Then the tooth is re-entered and clinical verification of
apexification is made by the failure of a small instrument to
penetrate through the apex after removal of the Ca(OH)2 paste.
 If apexification is incomplete, the canal is repacked with Ca(OH)2
paste, and the periodic recall continues.
Source: Cohen S, Burns R: Pathways of the Pulp, 6th edition.

73. Closure of root apex in a non vital carious molar using long term calcium hydroxide
treatment.

74.  Pulpectomy in permanent teeth is conventional root canal
(endodontic) treatment for exposed, infected, and/or
necrotic teeth to eliminate pulpal and periradicular infection.
 In all cases, the entire roof of the pulp chamber is removed to
gain proper access to the canals and eliminate all coronal
pulp tissue.
 Following debridement and shaping of the root canal
system, obturation of the entire root canal is accomplished
with a biologically acceptable, nonresorbable filling material.
 Obturation as close as possible to the cementodentinal
junction should be accomplished with gutta percha or other
filling material acceptable.

75.  Pulpectomy or conventional root canal treatment is indicated for a
restorable permanent tooth with irreversible pulpitis or a necrotic
pulp in which the root is formed fully.
 There should be evidence of a successful filling without gross
overextension or underfilling in the presence of a patent canal.
 There should be no adverse post-treatment signs or symptoms
such as prolonged sensitivity, pain, or swelling, and there should
be evidence of resolution of pretreatment pathology with no
further breakdown of periradicular supporting tissues clinically or
radiographically.

77.  Revascularization of a necrotic pulp has been considered
possible only after avulsion of an immature permanent
tooth.
 Skoglund et al. showed that pulp revascularization was
possible in dog teeth and it took approximately 45 days
 The young tooth has an open apex and a short root that
allows new tissue to grow into the pulp space relatively
quickly.
 The pulp is necrotic but usually not degenerated and
infected so that it can act as a scaffold into which the new
tissue can grow.

78.  Revascularization of the pulp space in a tooth with necrotic
infected pulp tissue and apical periodontitis has been thought to
be impossible until recently.
 Nygaard-Østby and Hjortdal successfully regenerated pulps after
vital pulp removal in immature teeth but were unsuccessful when
the pulp space was infected.
 However, if it were possible to create a similar environment as the
avulsed tooth , revascularization should occur.
 Thus, if the canal is effectively disinfected, a scaffold into which
new tissue can grow is provided and the coronal access effectively
sealed, revascularization should occur similarly to that in an
avulsed immature tooth.

79.  A recent scientific finding, which may explain in part why
apexogenesis can occur in these infected immature permanent
teeth, is the discovery and isolation of a new population of
mesenchymal stem cells (MSCs) residing in the apical papilla of
incompletely developed teeth.
 These cells are termed stem cells from the apical papilla (SCAP),
and they differentiate into odontoblast-like cells forming dentin
 Apical papilla is apical to the epithelial diaphragm, and there is an
apical cell-rich zone lying between the apical papilla and the pulp
.
 Importantly, there are stem/progenitor cells located in both
dental pulp and the apical papilla, but they have somewhat
different characteristics .
 Because of the apical location of the apical papilla, this tissue may
be benefited by its collateral circulation, which enables it to
survive during the process of pulp necrosis

80. Apical papilla. (A) An extracted human third molar depicting three immature roots with two pieces
of apical papilla being removed from their apices (arrow
heads) and one piece of apical papilla being peeled away from the root end but not completely
detached (arrow). (B) A developing root tip with attached apical papilla
was cultured in vitro for 3 days before being processed for hematoxylin and eosin (H&E)
staining. Odontoblasts (black arrows), apical cell-rich zone (open
arrowheads), and apical papilla tissue are indicated. (C) Magnified view of the area indicated by
the yellow rectangle. JOE—Volume 34, Number 6, June 2008

81.  Several case reports have documented revascularization of necrotic
root canal systems by disinfection followed by establishing bleeding
into the canal system via over instrumentation.
 An important aspect of these cases is the use of intracanal irrigants
(NaOCl and chlorhexidine) with placement of antibiotics (e.g. a
mixture of ciprofloxacin, metronidazole, and minocycline paste) for
several weeks.
 This particular combination of antibiotics effectively disinfects root
canal systems and increases revascularization of avulsed and necrotic
teeth, suggesting that this is a critical step in revascularization.
 The selection of various irrigants and medicaments is worthy of
additional research.

82. (A) Radiographic image
showing an incompletely
developed apex and a
periradicular radiolucency of
tooth #29. Note the sinus tract
that traces to the apex
of tooth #29.
(B) Radiographic view
presenting a gutta-percha cone
tracing to tooth #29, and a
periradicular radiolucency
associated with tooth #28.
(C) Radiograph
from 60-day follow-up visit
after both teeth were
medicated with triantibiotic
paste. The sinus tract is still
traced to the apex of tooth
#29.
(D)The radiograph demonstrating complete resolution of the
radiolucency and continued development
of the apex of both teeth at 6-month follow-up. (E) Follow-up
at 5 years. JOE — Volume 34, Number 7, July 2008

83.  Although these case reports are largely from teeth with
incomplete apical closures, it has been noted that reimplantation
of avulsed teeth with an apical opening of approximately 1.1 mm
demonstrate a greater likelihood of revascularization.
 This finding suggests that revascularization of necrotic pulps with
fully formed (closed) apices might require instrumentation of the
tooth apex to approximately 1 to 2mm in apical diameter to allow
systemic bleeding into root canal systems.
 The revascularization method assumes that the root canal space
has been disinfected and that the formation of a blood clot yields
a matrix (e.g., fibrin) that traps cells capable of initiating new
tissue formation.

84. (A) Radiographic image showing an
incompletely developed apex and a
periradicular radiolucency of tooth
#29. Note the sinus tract that traces
to the apex
of tooth #29.
(B) Photograph of a purulent
hemorrhagic exudate discharged
from tooth #29.
(C) Radiograph presenting the
placement of MTA.
(D) 3-month recall
radiograph. A slight increase of the
thickness of the root canal wall and
continued development of the apex
are observed.
(E)Two-year radiograph showing
continued
root development.
Case Report/Clinical Techniques
JOE

85. Advantages
 First, this approach is technically simple and can be completed using
currently available instruments and medicaments without expensive
biotechnology.
 Second, the regeneration of tissue in root canal systems by a patient’s
own blood cells avoids the possibility of immune rejection and pathogen
transmission from replacing the pulp with a tissue engineered construct.
Caution
 The case reports of a blood clot having the capacity to regenerate pulp
tissue are exciting, but caution is required, because the source of the
regenerated tissue has not been identified.
 Animal studies and more clinical studies are required to investigate the
potential of this technique before it can be recommended for general use
in patients.

86.  One of the clinical treatment options for missing teeth is
autotransplantation.
 The process often involves extraction of a supernumerary tooth or
third molar and implantation into a recipient site.
 With regard to the status of pulp survival and root formation of the
transplanted immature teeth, the clinical observations shown by
Tsukiboshi have been that
• in young teeth with some root formation, it will continue to
develop to some extent or to completion after transplantation;
and
• pulp tissue will be eventually replaced by hard tissue.
 Both SCAP and HERS appear to be important for the continued
root development after transplantation.

87.  Based on research in young avulsed teeth and on a recent study on
infected teeth, it is more likely that the newly formed tissue in the
pulp space is more similar to periodontal ligament than the pulp
tissue.
 It appears that there is about a 30% chance of pulp tissue re-
entering the pulp space.
 Future research will need to be done in order to stimulate pulp
regeneration from the pluri-potential cells in the periapical region.
 It may also be a good idea to partially resect the pulp in an
irreversible pulpitis case, and with the help of a synthetic scaffold
it may be possible to re-grow the pulp rather than remove the
entire pulp and replace it with a synthetic filling material.

88.  Endodontics – Fifth Edition - John I. Ingle, Leif K. Bakland
 Dentistry for the adolescent- Castaldi and Brass
 Paediatric Dentistry- Pinkham
 Clinical Pedodontics -Finn
 Dentistry for Child and Adolescent- Mc Donald
 Pathways of the Pulp, 6th edition- Cohen S, Burns R
 Endodontic Practice- Grossman
 Text Book Of Pedodontics - Shobha Tandon
 Martin Trope. Treatment of Immature Teeth; Endodontic Topics 2006
 Jung et al. Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis;
JOE—Volume 34, Number 7, July 2008
 Huang et al. The Hidden Treasure in Apical Papilla; JOE — Volume 34, Number 6, June 2008