Pulpotomy, Apexogenesis and Apexification Part 2


It is defined as physiological root end development and formation – (American Association of Endodontists.)

The current terminology is vital pulp therapy and is defined by (Walton and Torabinejad) as a treatment of vital pulp in an immature tooth to permit continued dentin formation and apical closure.

This is achieved by:

Indirect pulp capping

Direct pulp capping

Apical closure pulpotomy

Indirect Pulp Capping & Direct Pulp Capping

Indirect pulp capping
It is defined as application of medicament over a thin layer of remaining caries dentin after deep excavation, with no exposure of the pulp. It was first described by Pierre Fauchard.
Direct pulp capping
It is defined as a placement of a biocompatible agent on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury.

Materials Used
Calcium hydroxide


Bone morphogenic protein

Clinical Evaluation
No clinical symptoms
No radiogarphic changes in pulp or periapex
Continued root development
Radiographically observed hard tissue barrier at the site of procedure
Sensitivity to vitality testing

Failures of Apexogenesis
Cessation of root growth
Development of signs and symptoms or periapical lesions
Calcific metamorphosis

Goals of apexogenesis:
Sustain viable Hertwigs epithelial root sheet
Maintaining pulp vitality
Promoting root end closure
Generating a dental bridge at the site of pulpotomy


Apexification is a method of inducing apical closure through the formation mineralized tissue in apical pulp region of a non vital tooth with an incompletely formed root.
The mineralized tissue can be osteodentin, osteocementum, or bone or combination of all.

Restorable immature tooth with pulp necrosis

All vertical and unfavourable horizontal root fractures,
Short roots
Periodontally broken down tooth
Vital pulp

Factors Affecting Apexification

Age of the patient
Root development
Location of apex
Apical diameter
Thorough cleaning & debridement
Temporary restorations

Materials used are :
Calcium hydroxide

Tricaclium phosphate
Bone growth factors

Techniques Dealing with OPEN Apex

Custom made roll cone technique
Short fill technique by Moodnick
Obturation done with guttapercha and sealer with periapical surgery
Instrumentation only
Induction of periapical bleeding with instrumentations
Apical closure technique
One visit apexification

What Will The Dentist Do?

Administration of anesthesia.
Access cavity preparation
Drying of the canal
Calcium hydroxide preparation
Introduction of the paste
Temporary restoration
Duration of time: 6 months to 24 months

Are you fit for the treatment?

Tooth should be symptomless
Radiographic observation shows osseous deposition in the periapex
Calcium hydroxide is dry in the canal when tested by probing
Drying of the canal with paper points
Elicits no haemorrhage or tissue fluids
Confirming the calcific barrier with small file

One Visit Apexification

Materials used are :
Resorbable ceramic.
Surgicel with amalgam
Freeze-dried cortical bone and freezed dried dentin
Dentinal shavings
Bone morphogenic protein