Mineralization of the newly formed collagen starts with dystrophic calcification, which is then followed by tubular dentin formation8 (Fig. The response of the vital tissue is a self-limiting inflammatory reaction, followed by the proliferation of cells and new collagen. Many different materials have been used for pulpal wound dressing, however, the use of calcium hydroxide has been shown to be the most predictable with regard to long-term clinical success.7 Pure calcium hydroxide paste, which has a pH of about 12.5, causes a limited and shallow chemical injury to the vital pulp tissue. 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. A coronal restoration should then be placed that will ensure the maximum long-term seal. Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely. Care must be taken to avoid placing the calcium hydroxide on a blood clot6 and the entire pulp surface must be covered. Once the pulpal bleeding is controlled, calcium hydroxide paste is placed over the amputation site. Air should not be blown on the exposed pulp, as this may cause desiccation and additional tissue damage. The excess liquid should then be carefully removed via vacuum or sterile cotton pellets. Following coronal pulp amputation, the pulp chamber is rinsed with sterile saline or sterile water to remove all debris. The goal is to minimize any further damage to the underlying pulpal tissue. According to Granath et al,5 the instrument of choice for tissue removal is an abrasive diamond bur at high speed with adequate water-cooling. Most or all of the coronal pulp is removed, often to the level of the canal orifices, and calcium hydroxide paste is placed as a wound dressing.4-8 An aseptic technic combining the use of the rubber dam and sterile burs is strongly recommended. The goal of apexogenesis is the preservation of vital pulp tissue so that continued root development with apical closure may occur. As such, subsequent endodontic procedures and the remaining strength of the root structure may be compromised, resulting in a poor long-term prognosis.3Īpexogenesis is a procedure that addresses the shortcomings involved with capping the inflamed dental pulp of an incompletely developed tooth. The resulting wide-open apical foramina, canals with reverse taper (blunderbuss) and thin dentinal walls, represent three major clinical concerns when an incompletely developed tooth fails to mature. It has been shown that when a direct pulp capping procedure is performed on a tooth with an exposed and inflamed pulp, the probability of pulp repair and long-term success is low.1,2 This often will lead to pulp necrosis and arrested tooth development of the involved immature tooth. When such a clinical situation presents itself, an assessment of the pulpal status and the degree of tooth development must be made in order to develop an appropriate treatment plan that is conducive to long-term tooth retention. In clinical practice it is not uncommon to find incompletely developed teeth that require some form of endodontic intervention due to extensive caries or traumatic injury.
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