Objectives

Apexogenesis is a vital pulp therapy procedure that encourages the continued physiological development of the immature root. At the end of this case, the reader should understand the importance of preserving the vitality of the pulp in immature teeth and identify clinical situations that would benefit from this treatment.

Introduction

A 9‐year‐old female patient presented for evaluation of the upper right central incisor after the onset of discomfort of a previously traumatised tooth.

Chief Complaint

The patient reported ‘My tooth started hurting two to three weeks ago. It stings.’

Medical History

Unremarkable.

Dental History

The patient was a regular attender and visited her dentist every six months. The patient experienced a traumatic injury one year previously when a playground trapeze bar hit her on the upper right central incisor (UR1) and the incisal edge fractured. There was no pulp exposure at the time and her dentist restored the tooth without complications. The tooth remained asymptomatic until recently.

Clinical Examination

Extraoral examination was unremarkable and intraoral examination revealed a mixed dentition with good oral hygiene. An incisal composite restoration was present on the UR1. The UR1 was tender to percussion and palpation. All four maxillary incisors had a positive response to thermal testing (cold). The UR1 responded normally to pulp sensibility testing.

Diagnosis and Treatment Planning

Diagnosis of the UR1 was reversible pulpitis associated with the prior incidence of trauma. The tooth had an immature root anatomy with a large root canal space.

Treatment

Local anaesthetic was administered and dental dam isolation was performed. The external surface of the tooth was disinfected with sodium hypochlorite. The pulp appeared to be inflamed and bled easily (Figure 3.1.2). The coronal pulp was removed stepwise using a sterile round diamond bur in a high‐speed dental handpiece with water coolant until haemostasis could be achieved. Placement of a cotton pellet moistened with 2.5% sodium hypochlorite gently over the exposed pulp was done for several minutes to control the bleeding in healthy non‐inflamed pulp tissue. In this case the pulp tissue had to be removed to the level of the cemento‐enamel junction before healthy non‐bleeding tissue was observed (Figure 3.1.3). Subsequently, 3 mm of a calcium silicate material was placed directly over the exposed pulp, followed by glass ionomer and composite to seal the access opening (Figures 3.1.4 and 3.1.5). Mineral trioxide aggregate (MTA) was used in this case as other calcium silicate materials were not yet available. Currently, however, Biodentine or bioceramic putty is preferred due to the tendency for MTA to cause discolouration of dentine.

The patient was monitored post treatment and the discomfort resolved. Clinical examination one month later revealed the tooth to be non‐tender to percussion and palpation and responsive to pulp sensibility tests. A five‐month review revealed formation of a calcific bridge adjacent to the MTA (Figure 3.1.6). The tooth was monitored at regular intervals and continued thickening of the calcific bridge, apical closure and root maturation were observed (Figures 3.1.7 and 3.1.8). Eight years after treatment, the patient returned with a slight grey discoloration of the cervical area of the crown (Figure 3.1.9). The restorative material and the MTA were removed to reveal a hard dentine layer in the floor of the chamber (Figure 3.1.10