Young Permanent

Teeth

Introduction
Are those in which root development & apical closure have
not been completed.
Present in children from 6 yrs of age until 2-3 yrs after
eruption of 3rd molars
The aim of all treatment planning for young permanent teeth is
to preserve pulp vitality, so providing conditions for
continuous root development & physiologic dentin apposition

 Development

What
makes
them
special???

Root
development
Maturation

Diagnosis
Vitality testing

Treatment
planning
Apexogenesis
Apexification

Tooth development
Enamel and dentin future
CE junction
IEE & OEE separated by
Stratum intermediun &
stellat reticulum
hertwigs epithelial root
sheath
HERS - Shape of root and
number
Epithelial diaphragm
apical foramen
Hertwigs & Epithelial
diaphragm - sensitive to
trauma

Apical Foramen
Average size
Maxillary 0.4mm
Mandibular 0.3mm

Location and shape changes as a result of functional influence

on the teeth.

Eruption and Maturation

Although eruption commences at the time the root of the tooth
begins to form, a growing root is not required for eruption to
proceed
2-4 yrs for complete eruption
Length of root 2/3rd complete- Erupts most rapidly
Once emerged in oral cavity: 1-2 yrs to reach occlusal plane.

Posteruption maturation

Continues 2-4 yrs after eruption.

Teeth more susceptible to caries
Presence of Fluoride increases rate of posteruptive maturation
Aid enamel to form fluorapatite, which increases surface
hardness : especially effective in preventing smooth surface
caries

Difference between
posteruptive
maturation &
remineralization

Root completion

In permanent teeth, root formation is not completed until 14

years after eruption into the oral cavity.
Because of the shorter roots of primary teeth, root formation is
completed faster than for permanent teeth..

Diagnosis of pulp status

Correct pulpal and periapical diagnosis is of paramount
importance
Preserve the vitality - until maturation has occurred.
Loss of pulpal vitality before completion of dentin
deposition leaves a weak root more prone to fracture as a
result of the thin dentinal walls.

 The diagnosis begins with a thorough medical history and any

implications related to the anticipated treatment.
The dental history and characteristics of associated pain might
be helpful in determining pulpal status.
The nature, type, length, and distinction between provoked
and spontaneous pain are recorded.
Provoked pain caused by thermal, chemical, or mechanical
irritants usually indicates pulpal inflammation of a lesser
degree and is often reversible.
Spontaneous pain, on the other hand, is usually associated
with widespread, extensive, degenerative, irreversible pulpal
inflammation or necrosis.

Vitality testing
Electric pulp tests and thermal tests are of limited value
Full development of the plexus of Rashkow does not occur
until 5 years after tooth eruption (Johnsen 1985).
Unreliable responses from children because of
fear,
management problems, and
inability to understand or communicate accurately

Advisable to compare the results with those of an

antimere or with an uninvolved tooth.

 In immature permanent teeth testing with cold is a more

effective method (Fuss et al. 1986).
Most diagnoses - observation of clinical symptoms and radiographic

evidence of pathosis.

 In the pulp chamber coronal nerve bundles diverge and branch out
towards the pulpo-dentine border (Dahl & Mjor 1973, Gunji 1982).
Nerve divergence continues until each bundle looses its integrity
and smaller fibre groups travel towards the dentine.
This route is relatively straight until the nerve fibres form a loop
resulting in a mesh that is termed the plexus of Rashkow.
The density of this nerve plexus is well developed in the peripheral
pulp along the lateral wall of coronal and cervical dentine and along
the occlusal wall of the pulp chamber.
The nerve fibres emerge from their myelin sheaths and branch
repeatedly to form the subodontoblastic plexus.
Finally, the terminal axons exit from their Schwann cell investiture
and pass between the odontoblasts as free nerve endings (Byers &
Narhi 2002).

Two types of sensory fibres are present in the pulp, the

myelinated (A fibres) and unmyelinated C fibres
The A fibres predominantly innervate the dentine and are
grouped according to their diameter and conduction velocities
into Ab and Ad fibres
The Ab fibres may be more sensitive to stimulation than the
Ad fibres, but functionally these fibres are grouped together.
Approximately 90% of A fibres are Ad fibres
The C fibres innervate the body of the pulp

 The Ad fibres have lower electrical thresholds than the C

fibres and respond to a number of stimuli which do not
activate C fibres (Olgart 1974).
Ad fibres mediate acute, sharp pain and are excited by
hydromechanical events in dentinal tubules such as drilling or
air-drying (Byers 1984).
Ad fibres may act as mechanoreceptors that trigger withdrawal
reflexes so that potentially damaging forces may be avoided
(Dong et al. 1985, Olgart et al. 1988, Byers & Narhi 1999).
The C fibres mediate a dull, burning and poorly located pain
and are activated only by stimuli reaching the pulp proper
(Narhi 1985, Markowitz & Kim 1990).

 C fibres have a high threshold and can be activated by intense

heating or cooling of the tooth crown.
C fibre pain is associated with tissue injury and is modulated
by inflammatory mediators, vascular changes in blood volume
and flow, and increases in pressure (Narhi 1990).
As the intensity of the stimulus increases, more sensory nerves
are activated and this results in a progressive increase in the
sensory response

 Numerous studies have reported the unreliability of electric

pulp tests in permanent teeth with open and developing apices.
Inconsistent results ranging from 11percent in 6- to 11-yearolds with completely open apices to 79 percent in older
children have been reported.
It is also possible to obtain a false-positive in teeth with
liquefaction necrosis.
Thus, electric pulp tests are of little value during the period of
root formation, because the data are not reliable.

 Radiographic interpretation:
Can be difficult, due to their normally
large & open apex
Because the faciolingual width of most
roots and canals is greater than the
mesiodistal width, apical closure cannot
usually be determined radiographically.

 Universal agreement exists that immature teeth have the greatest

potential to heal after trauma or caries, particularly when the apical
foramen is wide open.
This group of teeth also has the greatest chance of misdiagnosis and
mistreatment.
To avoid mistakes, treatment must not be undertaken on the basis of
negative responses to pulp testing.
Radiographic and symptomatic assessment is currently the principal
diagnostic criterion. The following factors are key in making the
diagnostic determination:

symptoms of irreversible pulpitis or apical periodontitis;

clinical signs of periradicular infection including swelling, tenderness to percussion
Mobility
parulis formation
radiographically detectible bone loss; progressive root resorption; and arrested root
development compared with other adjacent teeth.

 Because pulp vitality is purely the function of vasculature

health, a vital pulp with an intact vasculature may test nonvital
if only the nerve fibers are injured.
This situation is commonly encountered in recently
traumatized teeth.
On the other hand, pulp fibres are more resistant to necrosis
than the vascular tissue.
Therefore, thermal and electric tests may give a false-positive
response if only the pulp vasculature is damaged

 Laser Doppler flowmetry

Very reliable
Histologic study

In nonvital pulp : accurate in 95 % cases,

vital :74%
Cautioned against relying solely on this test.
Blood pigment within a discolored tooth crown interferes with laser
light transmission

 Photons that hit stationary tissue

cells are scattered, but their
frequency is not shifted.
Photons that hit moving blood cells
are scattered, and the light frequency
is shifted according to the Doppler
principle.
A small proportion of the light,
containing both Doppler-shifted and
transmitted light, is backscattered to
a photodetector (or more commonly,
in newer instruments, to two or more
photodetectors) built into the probe
from which the laser light is beamed.
A signal is then calculated with a
preset algorithm in the LDF machine

Threats to developing teeth???

Dental
caries

Trauma

Loss of pulpal vitality in young permanent

teeth creates special problems. Because
pulp is necessary for the production of
dentin, if the pulp is lost before root length
is completed, the tooth has a poor crown to
root ratio.

Vital
pulp
Open apex

Closed apex

Pulpotomy (vital)

RCT

Pulpotomy

Restoration

Pulpectomy

RCT

Non vital

(with or without associated periapical

pathology)
Open
apex

Closed apex

Apexification

RCT

RCT

Pit and fissure sealants

Pattern of cusp form and fissure pattern genetically
determined- Axelson
Newly erupted, immature tooth enamel is more permeable and
therefore more susceptible to caries attack because of its
relatively high organic content.
As enamel matures, the organic content of enamel reduces,
and permeability decreases.
Therefore, it is critical to protect newly erupting tooth surfaces to
enhance overall longevity.

Additionally, the operculum covering the distal half of teeth

during eruption allows for the retention of plaque and the
initiation of the caries process before complete eruption.

 Pits and fissures present a challenging environment for caries

control.
Inherently, the morphology of pits and fissures provides an environment
for plaque and bacteria retention.
Moreover, enamel is thinner in pits and fissures, which allows accelerated
demineralization into the dentin.
This is especially true for erupting molars that are in the process of
maturation.

The eruption time for first molars and second molars is roughly
11/2 to 21/2 years, respectively.
accounts for the increased decay rate of the molars.

Fluorides aid enamel to form fluorapatite, which increases surface

hardness.
This treatment is especially effective in preventing smooth
surface caries.

Retention rates???
Newly erupted & 1st molars higher
Mandibular > maxillary
Operator access is better
Gravity assists the sealant in flowing into the fissures.

Candidates for vital pulp

therapy???

Teeth exhibiting provoked pain of short duration relieved

with over-the-counter analgesics, by brushing, or upon the
removal of the stimulus and without signs or symptoms of
irreversible pulpitis, have a clinical diagnosis of reversible
pulpitis

Apexogenesis
A vital pulp therapy procedure performed to encourage
continued physiological development and formation of the
root end.
Maturogenesis
physiologic root development, not restricted to apical segment.
The continued deposition of dentin occurs throughout the
length of the root, providing greater strength and resistance to
fracture

Goals: (Webber,
1984)
-Sustaining a
viable HERS
-Maintaining the
pulpal vitality
-Promoting root
end closure
-Generating a
dentinal bridge at the
site of the
pulpotomy

Continued development of
root length
Favourable crown root ratio

Remaining odontoblasts to
lay down dentin
Thicker root
Resistance to fracture

Natural apical constriction

Bridging is not essential
for the success of the
procedure
Suggests that pulp is vital

 Indirect
pulp
capping

Direct
pulp
capping

pulpoto
my

Indirect pulp capping

A procedure where in a small amount of carious dentin is
retained in deep areas of cavity preparation to avoid exposure
of the pulp and placement of a medicament to seal the dentin,
and encourage pulp recovery.

Rationale

Demineralization precedes bacterial invasion

Asymptomatic till bacteria within 0.5 mm from pulp
Softened dentin close to pulp no bacteria
Absence of substrate kills or inactivates the few left behind
Therapeutic pulp capping agents may aid in dentin-bridge
formation

 Case selection

Reversible pulpitis

Symptoms :

Thermal stimulus

Percussion

Vitality

momentary pain

Non tender

Normal or slightly

Radiography : Absence of
Periodontal ligament thickening
Periapical rarefaction

exaggerated

Direct pulp capping

Case selection
Traumatic exposure of pulp provided the patient reports early
Small mechanical exposure of the pulp in an asymptomatic vital tooth with
sound dentin at the periphery
Small carious exposures in an asymptomatic vital tooth with incomplete root
formation

Benefits far out weigh the risks

Carious exposures in mature teeth should be discouraged (Not a
contraindication) (Seltzer & Bender)
Microbes and inflammation invariably associated
Operative procedures add insult to injury
Ailing pulp may not respond favorably

Therefore advocated only when time, economics or any other factors don not
permit R.C.T. (Cohen)

Factors determining success of direct pulp

capping
Size of exposure
: Large exposure poor prognosis
Traumatic exposure size does not
interfere as long as pulp is healthy.
Hemorrhage
: Necessary to arrest bleeding

Continued bleeding indicates

irreversible inflammation
Location of exposure : Compared to occlusal or incisal,
exposure on the axial wall poor
prognosis.
Isolation from saliva : Rubber dam isolation to prevent
flooding of microorganisms
mandatory.

 Dentin chips intrusion: Severe foreign body reaction

worsens inflammation Chipitis
Marginal seal: coronal seal crucial to prevent microbial
leakage irrespective of pulp capping material. Improper seal
worsens pulpal inflammation.
Age of Tooth: Younger tooth responds better than older onescapacity to heal better.
Extrapulpal clot: Presence of extrapulpal clot impairs healing
- Acts as bacterial substrate
- Barrier between capping material and the pulp

 More recently, the step-wise excavation of deep caries has been

revisited

Objective

Removal
of carious
Change
the dentin along the DEJ
infected dentin
cariogenic
3-6 months environment
to decrease the
number of
Removal
of remaining caries- final
bacteria,
restoration
close the
remaining caries
from the biofilm
slow or arrest the
caries
development

Pulpotomy
Surgical removal of a portion of an affected vital coronal pulp
tissue, while leaving the radicular tissue in situ to allow for
normal root development.

 establish a bacteria tight

seal.
induce mineralization
the ability of the
material to kill bacteria

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.

Partial pulpotomy
A procedure in which the inflamed pulp tissue beneath an
exposure is removed to a depth of 1 to 3 mm or deeper to
reach healthy pulp tissue.
Pulpal bleeding must be controlled by irrigation -covered with
calcium hydroxide or MTA.
Calcium hydroxide : long-term success.
MTA : predictable dentin bridging and pulp health.

Nonvital teeth
5 methods(Morse et al )
1. A customized cone (Blunt end, rolled cone)
2. A short fill technique
3. Periapical surgery (with or without a retro grade seal)
4. Apexification (Apical closure induction)
5. One visit apexification

Apexification
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 necrotic pulp
Is a method of inducing development of the root apex of an
immature pulpless tooth by formation of osteocementum /
bone like tissue
Morse et al (1990)
Apexification is a method of inducing apical closure through
the formation of mineralized tissue in the apical pulp region of
a non vital tooth with an incompletely formed root

 Frank (1966)
Described a
technique based on
the normal
physiologic pattern
of root
development that
brings about the
resumption of
apical development
so that the root
canal can be
obliterated by
conventional RCT

Rubber dam and access opening

Working length
Avoid injury to epithelial diaphragm
Remove pulp with barbed broach
Irrigate with H2O2 to remove debris
Irrigate with NaOCl and saline
Dry the canal
Thick paste of calcuim hydroxide and CMCP
/calcuim hydroxide with methyl cellulose
paste
Cotton pleget placed over the

Weine, 2004
Recommended two appointments
First appointment
Sealing a sterile, dry cotton for 1 to 2 weeks
Placing calcium hydroxide dressing is optional

Second appointment
Calcium hydroxide and CMCP

One/two appointment
Determined by clinical signs and symptoms

Active infection
To be elminated
Absence of tenderness to percussion-a good sign

Wide open apex

Difficult to achieve dryness
If canal continue to weep, but other signs and symptoms of active infection is
absent
Proceed with calcium hydroxide paste treatment

 General rule
Treatment paste -6 months
Reopened to assess the apical stop
Radiographic assessment

Frank, 1966
No apparent radiographic change
but positive stop
at apex
Dome shaped apical closure with
canal retaining a
blunderbuss
appearance
Continued root growth and closure
of canal and apex
to a normal
appearance
A positive stop and radiographic
evidence of a
barrier coronal to
the anatomic apex of the tooth

 If apical closure not occurred in 6 months

Retreat with calcium hydroxide

Usually apical closure in 6 months, may take upto 2 years

Retreatment at 3 to 6 month interval

Currently, CMCP not used

Calcium hydroxide is the major ingredient
Its also an antibacterial
CMCP does not enhance repair

 According to Sheehy and Roberts the use of calcium

hydroxide for apical barrier formation is successful in 74100% of cases
Morse et al - antibacterial action and the calcificationinducing action of calcium hydroxide
Calcific barrier

Cementum
Bone
Dentin
Combination of all three tissues, with connective tissue and calcium
hydroxide sometimes mixed in with them
Histologically, its characteristics may be of dentin, cementum or
osteodentin.

Limitations of Ca(OH)2
Apexification
Long Duration 3 to 21 months
Size of apical opening, age of Patient

Porous & not continues

Apical barriers not allows root development
Ca(OH)2 makes tooth more brittle hydroscopic and
proteolytic properties
Cvek et al 77%
Anderson et al - >100 days increases chances upto 81%

High pH toxic to normal vital cells

How Ca(OH)2 induces hard tissue formation???

High alkalinity -activation of

alkaline phosphatase
calcium ions reduce the
permeability of new capillaries
formed in repairing tissue
It may provide a source of Ca ions for
mineralization
May stimulate the activity of Cadependent pyrophosphatase, which
reduces the level of mineralization
inhibitory pyrophosphate ions within the
tissues.

Single visit apexification

Nonsurgical condensation of a biocompatible material into the
apical end of root canal. Morse et al
Gupta, Sharma and Dang, 1999 conducted a single visit
apexification in a non-vital and immature mandibular premolar
and concluded that frequent changing of the calcium
hydroxide dressing is not always required to induce apical
closure.

This procedure
Should induce root end closure.
No adverse post-treatment clinical signs or symptoms.
No radiographic evidence of external root resorption, lateral
root pathosis, root fracture, or breakdown of periradicular
supporting tissues during or following therapy.
The tooth should continue to erupt, and the alveolus should
continue to grow in conjunction with the adjacent teeth.

Anesthesia and isolation

Access cavity
Guiliani et al, ,
1998
Use MTA to
form apical plug
for apexification

Removal of necrotic tissue

Working length-2mm short of
apex

Gentle circumferential filing

with minimal dentin removal
Dry the canal
MTA- apical 3-4 mm barrier
Wet pellet left on top of the
MTA
Temporary restoration
Recall after 48 hours
Obturation with
thermoplasticized GP and

Revascularization
Nygard Ostby , a pioneer of regenerative endodontic
procedures in the early 1960s, showed that new vascularized
tissue could be induced in the apical third of the root canal of
endodontically treated mature teeth with necrotic pulps and
apical lesions.
This was accomplished by the creation of a blood clot in the
apical third of a cleaned and disinfected root canal by using an
apically extended root canal file just before root canal filling.
He proposed that through formation of a clot (scaffold), a
vasculature could be established to support growth of new
tissue into the unfilled portion of the root canal.
He provided histologic evidence in support of his concept that
was taken surgically from teeth that had been treated in this
manner.

 In 2001, Iwaya et al described a procedure, which they termed

revascularization, that was undertaken on a necrotic immature
mandibular second premolar with a chronic apical abscess.
After 30 months they noted thickening of the root canal walls
by mineralized tissue and continued root development.
Subsequent to this case report, Banchs and Trope, 2004
described a revascularization procedure for the treatment of a
necrotic immature mandibular second premolar with an open
apex and a large apical lesion.

 They stated that many thought that regeneration of pulp tissue

in a necrotic infected tooth with apical periodontitis was
impossible.
It had been radiographically proven that regeneration was
possible in a re-implanted tooth, the same could be
accomplished in an infected tooth if a favorable environment
was established.

 After accessing the root canal, they irrigated it with sodium

hypochlorite (NaOCl) and chlorhexidine gluconate (CHX) and
sealed in a combination of 3 antibiotics in an attempt to
disinfect it and stimulate periapical repair.

After 24 months, they found that the root development in the

treated tooth was progressing in a manner similar to that of
adjacent and contralateral teeth.

 Although the predictability of this procedure and the true

nature of the tissue that developed in the root canal
posttreatment were unknown, they believed that the benefits of
the procedure, when successful, made it one worth the attempt.

Supported by Murray et al 2007 , who also added that the

procedure was technically simple, inexpensive, and adapted to
currently available instruments and medicaments.

 At present, the use of the term revascularization is debatable.

Trope , 2008 claimed that the term revascularization was

chosen because the nature of the tissue formed posttreatment
was unpredictable, and the only certainty was the presence of
a blood supply; hence it was revascularized.

 Huang and Lin , 2008 challenged the term revascularization as

applied to endodontic procedures and believed it was more
applicable to events that followed dental trauma.
suggested the term induced or guided tissue generation and
regeneration.

Lenzi and Trope 2012 suggested the term revitalization as

being more appropriate because it is descriptive of the
nonspecific vital tissue that forms in the root canal.

 In 2003, Weisleder and Benitez suggested the term

maturogenesis for a direct pulp-capping procedure of a tooth
with deep caries that resulted in the complete development of
the tooth.
They claimed maturogenesis best describes the physiologic
development of the root that occurs rather than development
restricted to the apical segment.
Patel and Cohenca (2006) also agreed that the term
maturogenesis was equated with physiological root
development and not simply apical development.

 Regenerative endodontic procedures are

biologically based procedures designed to restore
function to a damaged and nonfunctioning pulp
by stimulation of existing stem and progenitor
cells present in the root canal and/or the
introduction and stimulation of new stem and
dental pulp progenitor cells into the root canal
under conditions that are favorable to their
differentiation and reestablishment of function

Guidelines for
revascularization

Appointment - I
An assessment of the patient should be performed
state of tooth development
extent and history of the endodontic infection
restorability of the crown

Immature permanent teeth with necrotic pulp, with or without

apical pathosis, and an incomplete developed root with an
apical opening that measures 1 mm or larger are considered
suitable candidates for treatment, providing the crown, when
damaged, is restorable

Appointment - I
Anesthesia, isolation, access cavity
Debridement and Disinfection
Removal of necrotic pulp tissue
Mechanical cleaning is contraindicated
because it may weaken the thin dentinal root walls
remove vital tissue remnants that might be present in the apical part of the
canal

WL determination
Removal of necrotic tissue from the root canal is accomplished by gently
irrigating the root canal with a minimum of 20 mL 2.5% NaOCl
dispensed through a syringe and a 20-gauge needle
irrigation with 5 mL sterile saline
10 mL 2% CHX
CHX is recommended because of its antimicrobial activity and its
substantivity, ie, the ability to extend antimicrobial action by interacting with
the dentin

Appointment- I
Root Canal Medication
carefully dried with large, sterile paper points
root canal can then be medicated with 1 of 2 dressings

Antibiotic Combination
Hoshino et al 1996 introduced a triple antibiotic combination of
ciprofloxacin, metronidazole, and minocycline that they claimed was
sufficiently potent to eradicate bacteria from the dentin of the infected
root and promote healing of the apical tissues.
Problems associated

Antibiotic resistance
Allergic reaction
Cytotoxic to apical cells
Discoloration
Cefaclor (Thibodeau and Trope)
Bonding agent (Reynolds et al)

Appointment- I
Temporary Restoration
Preventing coronal leakage of bacteria
Double coronal restoration is recommended
placing a sterile cotton pellet over the root canal medicament and then
covering the pellet with Cavit cement
covered with glass ionomer cement
advisable to use non-eugenol temporary cements
Can contaminate the preparation
inhibiting the polymerization of certain resin composites subsequently used as
permanent restorative filling material

Medication Period
No agreement exists concerning the preferred medication or the
optimal period for leaving medication in the root canal.
Different clinicians have used different periods that have ranged from 7
days to several weeks

Appointment- II
ensure that all clinical signs and symptoms have abated
If clinical signs or symptoms persist
procedures performed in the first appointment should be repeated

Anesthesia
An anesthetic without vasoconstrictor should be chosen to prevent constriction
of the blood vessels in the apical region or a limited flow of blood when
bleeding is mechanically induced

Remove temporary restoration

20 mL 2.5% NaOCl
10 mL 17% EDTA instead of CHX as a final rinsing solution
chelating agent, it can decalcify the surface of the root canal dentin and expose
its collagen fibers
Collagen possesses adhesion motifs for the adhesion of new cells, whereas the
decalcification of the dentin releases bound growth factors that can attract new
cells and promote their differentiation into cells with odontoblast-like
properties

 Scaffold
Scaffolds are used in regenerative procedures to provide a framework through
which cells and a vasculature can grow
a stable blood clot can act as a scaffold in the revascularization
introduction of a sterile #20 K-file into the apical tissues 2 mm past the apical
foramen to initiate bleeding into the root canal

Bleeding should be controlled so that it does not extend beyond a

point approximately 3 mm apical to the CEJ. T
applying intracanal pressure with a sterile saline soaked cotton pellet until a clot
is formed.

Estimated mean time for the establishment of a stable blood clot is 15

minutes
The clot can be carefully touched with the reverse end of a large
sterile paper point to confirm its stability.
Once stability is confirmed, the clot should be carefully covered with
MTA cement that is back-filled to the level of the CEJ.

Shah , 2008
Possible mechanism for the process of revascularization

Few vital cells may remain at the apical end

Multipotent dental pulp stem cells
Stem cells in the PDL
Stem cells from the apical papilla or bone marrow
Blood clot itself

Trauma - Avulsion
Extra oral dry time < 60 min
Soaked in doxycycline 0.005% for 5 min before replantation.

Extra oral dry time > 60 min

Eliminate the necrotic tissue from the root surface
mechanically-curettage
Chemically- EDTA, citric acid, sodium hypochlorite
Hold the tooth by the crown and irrigate the root surface with sterile
saline.
Soak the tooth in a 2% stannous flouride for 5 min and replanted .

Splinting- 7-10 days

Conclusion
Common problems associated with open apices

Thin dentinal walls

Short roots
Fractures of crown.
Discoloration in long standing cases.

Over the years, there have been significant changes in the

clinical management of infected immature permanent teeth
Like all dental procedures, careful case selection and
understanding the goals and limitations of the treatment are
essential

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Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the
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