apexogenesis, apexification, regeneration

lecture given 5/20/2026

vital pulp therapy/apexogenesis

techniques are means of preserving the vitality and function of the dental pulp after injury resulting from trauma, caries, or restorative procedures

have traditionally included direct or indirect pulp capping, and partial of complete pulpotomy

how is vital pulp therapy/apexogenesis completed?

removal of part of the pulp allowing the rest of the pulp to remain vital and functional

we assume that by removing a small portion of the superficial imflamed pulp the remaining pulp remains healthy

tldr vital pulp therapy/apexogenesis

treatment designed to preserve the vitality and function of the dental pulp after injury in order to complete formation of the root apex

what are the indications for vital pulp therapy/apexogenesis?

traumatic injuries, fractured teeth with pulp exposure, caries exposure

what is the clinical application of vital pulp therapy/apexogenesis?

direct pulp capping, indirect pulp capping, partial or complete pulpotomy

if you have a pulp exposure of less than 2mm, what should you do?

direct pulp capping (no pulp removed)

if you have a pulp exposure of more than 2mm, what should you do?

pulpotomy

if you have no pulp exposure but deep caries, what should you do?

indrect pulp capping

partial pulpotomy/complete pulpotomy

involves removing only part of the pulp, eliminating tissue that has inflammatory or degenerative changes and leaving the healthy pulp tissue intact

it is covered with a wound dressing agent to promote healing at the site

what are the indications for complete pulpotomy?

traumatic exposure after more than 72 hrs

carious exposure of a young tooth with a partially developed apex

how is a complete pulpotomy perfomed?

anesthetic possibly without a vasoconstrictor

rubber dam placement

complete caries removal followed by removal of the inflamed part of the pulp to the level of the root orifice

hemostatsis achieved using a sterile cotton pellet moist with 5% sodium hypochlorite first and then sterile saline

if bleeding is excessive, the pulp is amputated deeper until only moderate hemorrhage is seen

placement of capping material (calcium hydroxide or MTA) onto the remaining pulp tissue

placement of permanent restoration

calcium hydroxide

Ca(OH)2

most commonly used over th years, easy to place

re-entry is simple if needed in the event of failure to perform apexification or pulp regeneration

MTA

histologically MTA has shown better results with vital pulp therapy/apexogenesis

can discolor the tooth but that is with older generations

demonstrates the least leakage, a substrate for osseous and cementum growth, sets in presence of moisture/blood

stimulates odontogenic differentiation of dental pulp stem cells (DPSCs) and the effects are drastically increased in un-induced pulp cells compared with odontogenic differentiated cells

what are the ideal clinical and radiographic outcomes of vital pulp therapy/apexogenesis?

no symptoms, pulp response (still vital), normal periapical tissue, dentine bridge formation beneath the capping material, continued root development/complete apical closure, no radiographic development of apical periodontitis or root resorption

what should the follow up for vital pulp therapy/apexogenesis be?

a minimum of at least 2 years of recall examination is considered appropriate in cases of immature teeth

patient should be seen periodically for 2-4 years BECAUSE 1.9 years is the minimum time needed for the completion of development

what is the prognosis of partial pulpotomy on immature permanent teeth?

extremely good aka 94-96%

apexification

the process of inducing root end closure in a non vital, immature permanent tooth that has lost the ability for continued root development resulting in the formation of a calcified barrier at the root apex

what are the indications for apexification?

young, permanent immature tooth

nonvital pulp

open apex

why does apexification need to be done, instead of traditional RCT?

lack of apical stop and extrustion of material leads to leakage

thin dentinal walls means the tooth is susceptible to fracture

what is the purpose of apexification?

formation of the hard tissue barrier at the apex

how is apexification completed?

disinfection of the canal

hard tissue apical barrier via traditional method or MTA/bioceramic barrier

cleaning only, no shaping

how is the canal disinfected in apexification?

minimal instrumentation (just to get working length)

copious irrigation with 0.5% NaOCl

low concentration of NaOCL and increased volume

use of creamy mix of calcium hydroxide

hard tissue apical barrier

traditional apexification with Ca(OH)2

takes 4 visits or more

MTA/bioceramic barrier

current standard of care for apexification

allows treatment completion on a short time scale (2 visits or less)

how is apexification completed with MTA?

the canal is disinfected with light instrumentation, copious irrigation, and a creamy mix of calcium hydroxide for at least 1 week

MTA is mixed and condensed into apical 4-5mm

the body of the canal is filled with thermoplasticized gutta percha

bonded resin is placed below the CEJ to strenghen the root

what are the advantages of using MTA/bioceramic for apexification?

reduction in treatment time/better compliance

biocompatible material

osteo-inductive properties

moisture compatible

what is the follow up for apexification?

routinely recall evaluation should be performed to determine success in the prevention or treatment of apical periodontitis

what is the prognosis for apexification?

periapical healing and the formation of hard tissue barrier occur predictably with traditional apexification with calcium hydroxide (76-96%)

success rates of apexification with MTA standing between 81-100% considering 1-15 years reported follow ups

high risk of fracture with a higher incidence of fractures occurring in the roots cervical region

regenerative endodontics

therapeutic procedure performed to encourage continuted physiologic development of the root

a good alternative to apexification in healthy young individuals with immature necrotic permanent tooth

what is the goal of regenerative endodontics?

teeth with incomplete root development have short roots with thin walls, which compromises their longevity

we can help facilitate root development in previously immature teeth with necrotic pulps

how should you select a case for regenerative endodontics?

tooth with necrotic pulp and an immature apex (if tooth is vital, efforts should be made to preserve pulp tissue)

pulp space not needed for post/core, final restoration

young patients (6-18)

compliant patient/parent

how large should the apical opening be in regenerative endodontics, and why?

greater than 1mm

less than 1mm is difficult to deliver medicaments and irrigants to the apex, also difficult to get sufficient bleeding back into the tooth

what kind of tooth is ideal for regenerative endodontics?

short root- crown root ratio approximately 1:1

the longer the root, the more difficult it is to get bleeding to the appropriate level

what kind of patient compliance is needed for regenerative endodontics?

high compliance- these teeth require at least two visits based on the current protocol

there is a need for close follow up

what is generally necessary for regenerative endodontics?

stem cells, scaffold, growth factor

stem cells

clonogenic cells capable of both self renewal and multilineage differentiation

embryonic stems cells

totipotent- any cell type

pluripotent

capable of developing more than 200 cell types

adult stem cells

multipotent

divide and create another cell like itself, also a cell more differentiated than itself

for pulp regeneration one important requirement is to…

obtain stem cells capable of differentiating into odontoblasts

scaffolds

provide support for cell organization, proliferation, differentiation, and vascularization

most utilized are dentin or blood clot

growth factors

proteins that bind to receptor on the cell and act as signals to induce cellular proliferation and/or differentiation

currently most are using growth factors found in platelets or dentin

what is the protocol for the first visit for regenerative endodontics?

informed consent

local anesthesia with epi 1/100,000

dental dam isolation and access cavity

copious, gentle irrigation with 20ml of 1.5-3% NaOCl and then irrigation with saline for EDTA (20ml/canal, 5 minutes)

dry canals with paper points

place calcium hydroxide or low concentration of triple antibiotic paste

seal with 3-4mm with a temporary restorative material

what is the protocol for the second visit for regenerative endodontics?

assess response to initial treatment

anesthesia with 3% mepivacaine without vasoconstrictor, dental dam isolation

copious gentle irrigation with 20ml of 17% EDTA

induce bleeding into canal by over instrumenting

place a resorable matrix such as collaplug, over the blood clot if necessary and 3mm of white MTA as a capping material

followed by 3-4mm layer of glass ionomer restoration

what signifies success during follow up visits of regenerative endodontics?

no pain, soft tissue swelling or sinus tract

resolution of apical radiolucency (often observed 6-12 mo post treatment)

increased width of root walls (width observed prior to length and usually occurs 12-24 mo post treatment)

increased root length

positive pulp vitality test response

recommended yearly follow-up after the first 2 years

CBCT is highly recommended for initial evaluation and follow up visits

elimination of symptoms and bony healing- disinfection

increased root length- apical papilla + HERS or cementum like tissue

increased root thickness- deposition of cementum like tissue

positive response to vitality tests- nerve endings

what are the primary, secondary, and tertiary goals of regenerative endodontics?

primary- elimination of apical periodontitis, elimination of symptoms

secondary- increase in length and/or root wall thickness

tertiary- positive response to vitality testing

triple antibiotic paste

ciprofloxacin, metronidazole, clindamycin (previously minocycline)

carrier of macrogol ointment, propylene glycol

capping materials for regenerative endodontics

MTA- tricalcium silicate, tricalcium aluminate, bismuth oxide, calcium sulfate)

bioceramic putty- calcium silicate, zirconium oxide, calcium phosphate

bioceramic

sealing ability, cytotoxicity, and biocompatibility of bioceramic material are comparable to MTA

unlike MTA, the surface characteristics of set bioceramic materials are similar to human dentin which has the ability to promote hydroxyapatite formation even in normal saline solution and might promote the process of differentiation in stem cells and induced hard tissue formation

what are some post-treatment challenges of regenerative endodontics?

staining/discoloration, ortho?, success/failure (improper case selection, inability to induce bleeding)

what are some reasons for staining after regenerative endodontics?

bleeding into the canals, minocycline, MTA

what is the long term outcome of regenerative endodontically treated traumatized immature incisors?

very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome

do we have some challenges with regenerative endodontics?

yes

is regenerative endodontics better than MTA apical plug?

not yet

is regenerative endodontics procedure producing pulp tissue?

not now