1. 1. Pediatric endodontics DR. SWAPNIL PAKHALE
2. 2. Introduction Definition: Pediatric endodontic is relatively new terminology, which deals with the management of pulpally involved teeth in children. Goals of Pulp Therapy: To allow a tooth to remain in the Oral cavity in a non pathological state. To maintain the arch length and tooth space. To restore a tooth to its functional form. To prevent speech abnormality. To maintain esthetic of child.
3. 3. Reversible Pulpitis Pulp with reversible pulpits has mind inflammation and it is capable of healing once the irritating stimulus has been removed. Pain is only felt when a stimulus is applied to the tooth and the pain ceases within a few seconds or immediately upon removal of the stimulus. The pain is short and sharp in nature but it is never spontaneous. There are no radiographic changes evident in the periapical region.
4. 4. Reversible Pulpitis Treatment: As Grossman has stated, The best treatment for reversible pulpits is its prevention. Removal of noxious stimulus generally is sufficient to allow the pulp to return back to its healthy state.
5. 5. Irreversible Pulpitis In case of irreversible pulpitis, the pulp has been damaged beyond repair, and even the removal of the noxious stimulus will not allow its proper healing. Once the classic symptoms of irreversible pulpitis is lingering pain induced by thermal stimuli. The initial reaction is a very sharp pain to hot or cold stimuli followed by dull ache or throbbing pain for minutes to hours after the stimulus is removed. Pain increases on bending or lying down.
6. 6. Irreversible Pulpitis Spontaneous pain is another hallmark feature of irreversible pulpitis. If the periapical tissues are involved, the tooth is tender to percussion. In the most cases, radiographs are not useful in diagnosis but they can be helpful in identifying the possible cause of the disease, e.g. Associated caries, or fracture of tooth, etc. Treatment: The treatment comprises of pulp extirpation and endodontic therapy if the tooth is salvageable and extraction otherwise.
7. 7. Hyperplastic Pulpitis Hyperplastic pulpitis is a productive inflammatory response of pulp. It usually involves chronically inflamed young pulp, widely exposed by caries on its occlusal aspect. It is characterized by proliferative growth of inflamed connective tissue rising out of the carious crown. The tissue is mostly firm, insensitive to the touch and occasionally may cause mild discomfort during mastication. No significant radiographic changes are evident unless there is also periapical involvement.
8. 8. Hyperplastic Pulpitis Treatment: Extraction is usually indicated. On the other hand, if the tooth can be restored, pulpectomy and endodontic therapy are recommended prior to restoration.
9. 9. Necrosis There are no true symptoms of complete pulp necrosis with its sensory nerves, is totally destroyed. Treatment: If the both is salvageable endodontic therapy is indicated, else extraction is the only solution.
10. 10. Internal Resorption The term internal Resorption is applied to the destruction of predentin and dentin. Treatment: Since the pulp tissue cells are responsible for the destructive process, its removal by endodontic therapy arrests any further Resorption.
11. 11. PERIAPICAL LESIONS Teeth with normal periradicular tissues are nonsensitive to percussion and palpation testing. Radiographically, periradicular tissues are normal with an impact lamina dura and a uniform periodontal ligament space.
12. 12. PERIAPICAL LESIONS Acute Apical Periodontitis: It is painful inflammation of the periodontal tissues. The patient will generally complain of discomfort to biting or chewing. Sensitivity to percussion is a hallmark diagnostic test result of acute periradicular periodontics. Tooth is usually not sensitive to hot or cold.
13. 13. PERIAPICAL LESIONS Acute Apical Periodontitis: Depending on the cause of inflammation, it may or may not respond to vitality tests. Palpation testing may or may not produce a sensitive response. Radiographically, the PDL space may appear normal, widened, or there may be a distinct radiolucency. Treatment: Determination of cause and relieving the symptoms. In case it is because of pulpal involvement, endodontic therapy is indicated.
14. 14. PERIAPICAL LESIONS Acute Perirapical abscess It refers to painful localized collection of plus in the periapical connective tissue. It is characterized by rapid onset, spontaneous pain, pus formation, and often swelling of the associated tissues. Percussion testing produces a response that is usually exquisitely sensitive. The tooth gives negative response to vitality tests. Radiographically, the PDL space may be normal, slightly widened, or demonstrate a distinct radiolucency.
15. 15. PERIAPICAL LESIONS Acute Perirapical Abscess: Treatment: Endodontic treatment concomitant with the drainage of abscess. Suitable measures must also be taken to control any systematic manifestations.
16. 16. PERIAPICAL LESIONS Chronic Periradicular Abscess: An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and intermittent discharge of pus through an associated sinus tract. Treatment: Endodontic therapy if the tooth can be restored otherwise extraction is the solution.
17. 17. PERIAPICAL LESIONS Recrudescent Abscess: It refers to an acute exacerbation arising from a pre- existing chronic lesion. Tooth feels elevated in its socket. The tooth is severely tender. The radiograph shows a well defined radiolucency. Treatment: Endodontic treatment concomitant with the drainage of abscess.
18. 18. PERIAPICAL LESIONS Focal Sclerosing Osteomyelitis:The involved tooth will have an etiologic factor for low grade, chronic inflammation such as a necrotic pulp, extensive restorative history or a crack. Radiographically, the involved tooth will present with increased radiodensity and opacity around one or more of the roots. Treatment: These periradicular radiodensities resolve after endodontic therapy if they have pulpal diagnosis of irreversible pulpitis.
19. 19. PERIAPICAL LESIONS Periapical Granuloma: This disease entity is characterized by growth of granulation tissue in relation to the periodontium at the apex in response continued bacterial irritation. Treatment: Root canal therapy of the concerned tooth.
20. 20. PERIAPICAL LESIONS Periapical Cyst: The radicular cyst is a chronic inflammatory lesion with a closed pathologic cavity, lined either partially or completely by epithelium Radiograph shows a distinct rarefaction at the apex with a thin radiopaque border. Treatment: Treatment of periapical cyst is conservative initially by root canal treatment. Surgical intervention is advisable only if the conservative means fail.
21. 21. OBJECTIVES of pulp therapy 1. Preservation of the arch space. 2. Enhances aesthetics, mastication, prevent aberrant tongue habits, aid in speech and prevent psychologic effects associated with tooth loss. 3. Helps in maintenance of a healthy oral environment, relief of pain. 4. Prevention of deleterious effects on the succedaneous tooth, and the periapical tissue and on the systematic condition of the child.
22. 22. Indirect pulp capping It is defined by INGLE as procedure involving a tooth with a deep carious lesion where carious dentin removal is left incomplete, and the decay process is treated with a biocompatible material for some time in order to avoid pulp tissue exposure is termed as indirect pulp capping.
23. 23. Indirect pulp capping Objective of Indirect Pulp Capping: These were given by Eidelman in 1965: 1. Arresting the carious process. 2. Promoting dentin sclerosis. 3. Simulating formation of tertiary dentin. 4. Remineralization of carious dentin.
24. 24. Indirect pulp capping Indications: Ideally, used when pulpal inflammation has been judged to be minimal and complete removal of caries would cause a pulp exposure. Contraindications: Any signs of pulpal or periapical pathology. Soft leathery dentin covering a very large area of the cavity, in a non restorable tooth.
25. 25. Indirect pulp capping
26. 26. Indirect pulp capping Treatment Procedure: First Appointment: Use local anesthesia and isolation with rubber dam. Establish cavity outline with high speed handpiece. Removal all caries using caries detector dye, i.e. infected dentin has to be removed. Stop the excavation as soon as the firm resistance of sound dentin is felt If there is a probability of exposure while removing further caries, then a conservative approach is chosen by placing a hard set calcium hydroxide and temporizing the tooth.
27. 27. Indirect pulp capping First Appointment: Site is covered with Calcium Hydroxide. Remainder cavity is filled with reinforced Zinc Oxide Eugenol cement. Cavity flushed with saline and dried with cotton pellet.
28. 28. Indirect pulp capping Second Appointment: If a reparative dentin bridge is formed a permanent restoration followed by full coverage restoration is chosen. But if there is some amount of caries remaining on re-entry, carefully removal of caries, now somewhat sclerotic may reveal a sound base of dentin without pulp exposure. Between the appointment history must be negative and temporary restoration should be intact
29. 29. Indirect pulp capping Second Appointment: Previous remaining carious dentin will have become dried out, flaky and easily removed The area around the potential exposure will appear whitish and may be soft; which is predentin. Do not disturb this area. The cavity preparation is washed out and dried gently. Cover the entire floor with Ca(OH)2 Base is built up with reinforced ZOE cement or GIC Final restoration is then placed.
30. 30. direct pulp capping It is defined by KOPEL (1992) as the placement of a medicament or non-medicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma. Objective: To create new dentin in the area of the exposure and subsequent healing of the pulp.
31. 31. direct pulp capping Rationale: To achieve a biologic closure of the exposure site by deposition of hard tissue barrier between pulp tissue and capping materials thus walling off the exposure site. Indications: Small mechanical exposure surrounded by sound dentin in asymptomatic vital primary teeth or young permanent teeth. Exposure should have bright red hemorrhage that is easily controlled by dry cotton pellet with minimal pressure.
32. 32. direct pulp capping Contraindications: Serve toothache at night Spontaneous pain. Tooth mobility Radiographic appearance of pulp, Peri-radicular degeneration. Excess of hemorrhage at the time of exposure. External/ Internal root resorption. Swelling/Fistula.
33. 33. direct pulp capping Treatment Considerations: Debribement: Necrotic and infected dentin chips have be removed. Hemorrhage and clothing: A blood clot should not be allowed to form at the exposure site because it may impede pulpal healing. Exposure Enlargement: The exposure site must be enlarged because : 1. It removes inflammation and infected tissue in the exposed area. 2. It facilitate washing away, Carious and non-carious debris.
34. 34. direct pulp capping Treatment Considerations: 3. It allows a closer contact of more capping medicament material to the actual pulp tissue.
35. 35. Direct pulp capping Technique of Direct Pulp Capping: Rubber dam provides only means of working in a sterile environment, so it has to be used. Once an exposure is encountered, further manipulation of pulp is avoided. Cavity should be irrigated with saline, chloramine T or distilled water. Hemorrhage is arrested with light pressure from sterile cotton pellets
36. 36. Direct pulp capping Technique of Direct Pulp Capping: Place temporary restoration Final restoration is done after determining the success of pulp capping which is done by determination of dentinal bridge, maintenance of pulp vitality, lack of pain and minimal inflammatory response Place the pulp capping material, on the exposed pulp with application of minimal Pressure so as to avoid forcing the material into pulp chamber.
37. 37. pulp capping agents Materials, medicaments, antiseptics, anti- inflammatory agents, antibiotics and enzymes have been utilized as pulp-capping agents. Calcium hydroxide is generally accepted as the material of choice for pulp capping. Calcium Hydroxide: Herman (1930) introduced Calcium Hydroxide for Pulp Capping. When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the adjacent pulp tissue and an inflammation of the contiguous tissue.
38. 38. pulp capping agents Calcium Hydroxide: Dentin bridge formation occurs at the junction of the necrotic tissue and the vital inflamed tissue. The three main calcium hydroxide products are Pulpdent , Dycal and Hydrex (MPC). Advantages Disadvantages Initially bacterial then bacteriostatic Does not exclusively stimulate dentinogenesis Promotes healing and repair Does exclusively stimulate reparative dentin High pH stimulates fibroblasts Associated with primary tooth resorption.
39. 39. pulp capping agents Calcium Hydroxide: Advantages Disadvantages Neutralizes low pH of acids May dissolve after one year with cavosurface dissolution. Stops internal resorption May degrade during acid etching Inexpensive and easy to use Degrades upon tooth flexure. Particles may obturate open tubules Marginal failure with amalgam condensation. Does not adhere to the dentin or resin restoration.
40. 40. pulp capping agents Isobutyl Cyanoacrylate: Berkman in 1971 used it as capping agent and proved it to be an excellent hemostatic agent as well as a reparative dentin bridge stimulator. The disadvantage of this material is that it is cytotoxic when freshly polymerized. Mineral Trioxide Aggregate (MTA) : Properties: It is biocompatible material and its sealing ability is better than that of amalgam or ZOE.
41. 41. pulp capping agents Mineral Trioxide Aggregate (MTA) : Properties: Initial pH is 10.2 and set pH is 12.5. The setting time of cement is 4 hours. The compressive strength is 70 MPA, which is comparable with that of IRM. Low cytotoxicity- It presents with minimal inflammation if extended beyond the apex. Action: It has ability to stimulate cytokine and interleukins release from bone cells, indicating that it actively promotes hard tissue information.
42. 42. pulp capping agents Other Materials: Corticosteroid and antibiotics, Inert materials (Isobutyl Cyanoacrylate and tricalcium phosphate ceramic ), Collagen fibers (Influence mineralization), 4-META Adhesive, Denatured albumin, Laser, Bone morphogenic protein (BMP).
43. 43. pulpotomy Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.
44. 44. pulpotomy Classification of pulpotomy: Vital Pulpotomy: Types Other Name Features Examples Devitaliza- tion Mummification , Cauterization It is intended to destroy or mummify the vital tissue Single sitting Formocresol Electrosurgery Laser Two stage Gysi Triopaste Easlicks formaldehyde Paraform devitalizing paste.
45. 45. pulpotomy Classification of pulpotomy: Vital Pulpotomy: Types Other Name Features Examples Preserva- tion Minimal Devitalization, noninductive This implies maintaining the maximum vital tissue, with no induction of reparative dentin. ZnO Eugenol Glutaraldehyde Ferric Sulphate Regenra- tion Inductive, Reparative This has formation of dentin bridge Ca(OH)2 Bone Morphogenic Protein Mineral Trioxide Aggregate Enriched Collagen Freezed dried bone Osteogenic Protein.
46. 46. pulpotomy Classification of pulpotomy: Non-Vital Pulpotomy: Types Other Name Features Examples Mortal pulpotomy It is done in comprised cases Beechwood cresol Formcresol.
47. 47. pulpotomy Objectives: Removal of inflamed and infected pulp at the site of exposure thus preserving the vitality of the radicular pulp and allowing it to heal. Rationale: Radicular pulp is healthy and capable of healing after surgical amputation of the infected pulp. Preserves vitality of the radicular pulp. Removal of infected or inflamed pulp. Maintains tooth in a physiologic condition.
48. 48. pulpotomy Indications of Pulpotomy: 1. Pulp exposure in primary teeth. 2. Teeth showing a large carious lesion but free of radicular pulpitis. 3. History of only spontaneous pain. 4. Hemorrhage from exposure site bright red and controlled. 5. Absence of abscess or fistula. 6. No interradicular bone loss. 7. No interradicular radiolucency. 8. At least 2/3rd of root length still present to ensure reasonable functional life. 9. In young permanent tooth with vital exposed pulp and incompletely formed apices.
49. 49. pulpotomy Contraindications of Pulpotomy: 1. Persistent toothache. 2. Tenderness on percussion. 3. Root resorption more than 1/3rd of root length. 4. Large carious lesion with non-restorable crown. 5. Highly viscous, sluggish hemorrhage from canal orifice, which is uncontrollable. 6. Medical contradictions like heart disease, immunocompromised patient. 7. Swelling or fistula. 8. External or internal resorption. 9. Pathological mobility. 10. Calcification of pulp.
50. 50. Formocresol: Formocresol was introduced by Buckley in 1904.
51. 51. Formocresol: Procedure: Anesthetize the tooth and isolate with rubber dam Removal of all caries using high-speed straight fissure bur without entering the pulp chamber Remove the dentinal roof with large diamond stone or slow speed round bur for minimal trauma Enlarge the exposed area and deroof the pulp chamber Remove any ledges or overhanging enamel with slow speed round bur
52. 52. Formocresol: Procedure: Sharp spoon excavators are used to scoop out coronal pulp and pulpal remnants Clean the pulp chamber with saline and removal all debris Place cotton pellet over the pulp stumps to achieve hemostasis Using a cotton pellet apply diluted Formocresol to the pulp for 4 mins
53. 53. Formocresol: Procedure: Place a small dry pellet over this to avoid contact of tissues with Formocresol Remove cotton pellets and check for fixation, brownish discoloration of the pellet as well as the pulp stump is an indicator of fixation Place ZOE cement in the pulp chamber Recall after one week and restore with a permanent restoration if patient is asymptomatic Place a stainless steel crown
54. 54. Two-visit Devitalization Pulpotomy: This is the two stage procedure involving the use of paraformaldehyde to fix the entire coronal and radicular pulp tissue. Indications: 1. There is evidence of sluggish bleeding at the amputation site that is difficult to control. 2. Pus in the chamber, but none at the amputation site. 3. There is thickening of the pd1. 4. History of pain.
55. 55. Two-visit Devitalization Pulpotomy: Two-visit Devitalization Pulpotomy: Contraindications : Non- Restorable tooth. Tooth with necrotic pulp.
56. 56. Two-visit Devitalization Pulpotomy: Procedure: First Visit: Anesthetize the tooth and isolate with rubber dam Preparation of the cavity Deep caries excavated Enlarge the exposure with round bur
57. 57. Two-visit Devitalization Pulpotomy: Procedure: First Visit: Incorporate paraformaldehyde paste into the pellet and place over exposure Seal the tooth for 1-2 weeks so that formaldehyde gas liberated from paraformaldehyde enters coronal and radicular pulp, thereby fixing the tissue.
58. 58. Two-visit Devitalization Pulpotomy: Second Visit: Pulpotomy is carried out under local anesthesia. Remove the old cotton pellet and deroof the pulp chamber Clean the cavity with saline and dry with cotton pellet Pulp chamber filled with antiseptic paste and tooth is restored.
59. 59. Modified Formocresol pulpotomy This technique was used by Trask (1972) in young permanent morals. In this technique Formocresol pellet is sealed permanently in the tooth.
60. 60. Cveks pulpotomy Indication: Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means. Rationale: To preserve vitality of radicular pulp and allow for normal root closure.
61. 61. Cveks pulpotomy Procedure: Anesthetize the tooth and isolate with rubber dam All carious material is removed with excavators or slow speed round bur Coronal pulp removed, to perform a pulpotomy After arrest of the hemorrhage, Ca(OH)2 is applied to the exposed pulp, ensuring that there is no blood clot.
62. 62. Cveks pulpotomy Procedure: The cavity is then sealed with temporary restorative material A tooth should remain symptom free at recall and radiograph should show information of a secondary dentine bridge. Then permanent restoration with amalgam is done.
63. 63. Glutaraldehyde pulpotomy: It was first suggested by S.Gravenmade . Mechanism of Action: Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue. A narrow zone of eosinophilic, stained, and compressed fixed tissue is found directly beneath the area of application.
64. 64. Advantages of Glutaraldehyde over Formocresol 1. It is bifunctional reagent, which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkage. 2. It is excellent antimicrobial. 3. Causes less necrosis of the pulpal tissue. 4. Causes less dystrophic calcification in pulp canals. 5. Less toxicity does not perfuse through the pulp tissue to the apex. 6. Demonstrates less systematic distribution. 7. It is low tissue binding, readily metabolized, eliminated in urine and expired in gases-90% of the drug is gone in 3 days. 8. Antigenecity- Less as compared to Formocresol.
65. 65. Laser Pulpotomy In 1985, Ebimara reported the effects of Nd: YAG laser on the wound healing of amputed pulps. After complete extirpation of pulp from pulp chamber exposure to Nd: YAG laser at 20 Hz was done. Then IRM paste was placed over the pulp stumps and restoration was done. Electrosurgical Pulpotomy It is a non chemical Devitalization, whereas mummification eliminates pulp infection and vitality with chemical cross linking and denaturation. The disadvantage of Electrosurgery is that the contaminated pulp tissue does not promote adequate current penetration.
66. 66. Mortal Pulpotomy Non-vital pulpotomy. Ideally, non-vital tooth should be treated by pulpectomy, but sometimes it is impracticable due to non-negotiable root canals and limited patient cooperation. Procedure: First Appointment: Necrotic coronal pulp is removed. Pulp chamber irrigated with saline and dried with cotton pellet.
67. 67. Mortal Pulpotomy Procedure: First Appointment: Second Appointment: Infected radicular pulp is treated with strong antiseptic solution like beechwood cresol. Seal cavity with temporary cement for 1-2 weeks. If the tooth is asymptomatic the pulp chamber is filled with an antiseptic paste. The tooth then restored with stainless steel crown.
68. 68. Pulpectomy Mathewson(1995) defined it as the complete removal of the necrotic pulp from the root canals of primary teeth and filing them with an inert resorbable material so as to maintain the tooth in the dental arch. Indications and Contraindications of Pulpectomy: General Indications 1. Patient should be in good general health with no serious disease. 2. Maximum cooperation of patient and parents.
69. 69. Pulpectomy Indications and Contraindications of Pulpectomy: General Contraindications 1. Young patient with systemic illness such as congenital ischemic heart disease, leukemia. 2. Children on long term corticosteroids therapy. Clinical Indications 1. A tooth previously planned for a pulpotomy that shows either a dry pulp chamber or uncontrolled pulpal hemorrhage. 2. Indicated for any primary tooth in absence of its permanent successor. 3. Any deciduous tooth with severe pulpal necrosis provided there is no radiographic contraindication.
70. 70. Pulpectomy Indications and Contraindications of Pulpectomy: Clinical Indications 4. Primary teeth with necrotic pulps and minimum of root resorption. 5. Pulpless primary teeth with stomas 6. Pulpless primary teeth without permanent successors. 7. Pulpless primary teeth in hemophiliacs. 8. Pulpless primary anterior teeth when speech, aesthetics are a factor. 9. Pulpless primary molars holding orthodontic appliance.
71. 71. Pulpectomy Indications and Contraindications of Pulpectomy: Clinical Contraindications 1. Excessive tooth mobility. 2. Communication between the oral cavity and area of furcation. 3. Communication between the roof of the pulp chamber, and the region of furcation. 4. Insufficient tooth structure to allow isolation by rubber dam and extra coronal restoration.
72. 72. Pulpectomy Radiographic Indications: 1. Adequate periodontal and bony support 2. Incipient internal root resorption in the occlusal portion of the root canal. Radiographic Contraindications: 1. External root resorption. 2. Internal root resorption in the apical 3rd of the root. 3. Radicular cyst, dentigerous/follicular cyst in association with the primary tooth. 4. Interradicular radiolucency that communicates with the gingival sulcus.
73. 73. Single visit pulpectomy Indication: Vital primary teeth but with inflammation extending beyond coronal pulp, indicated by hemorrhage from the amputated radicular stumps that is dark red, a slowly oozing and uncontrollable.
74. 74. Single visit pulpectomy Procedure: Tooth is anesthetized and isolated Access cavity is prepared. Pulp chamber is deroofed All accessible coronal and radicular pulp tissue is removed with broaches. Irrigate with saline. A diagnostic file radiograph is taken.
75. 75. Single visit pulpectomy Procedure: The canals should be filled with the aim of enlarging them to permit condensation of root canal filling material Flush out all debris and dentin shavings with the help of irrigating solutions Dry the canals with adsorbent paper points Obturate the tooth completely sealing the coronal and radicular pulp. Place the final restoration and stainless steel crown.
76. 76. Multi visit pulpectomy Indications: Given by Paterson and Curzon in 1992 Indicated where infection, an abscess or chronic sinus exists. Non-vital primary teeth. Teeth with necrotic pulp and periapical involvement.
77. 77. Multi visit pulpectomy Procedure: First Appointment(Access Opening) Tooth is anesthetized and isolated. Access cavity is prepared Pulp chamber is deroofed All accessible coronal and radicular pulp tissue is removed with broaches. Formocresol cotton pellet is placed in chamber and a temporary restoration is done
78. 78. Multi visit pulpectomy Procedure: Second Appointment(Cleaning and Shaping) Appointment should be 5-7 days apart Remove the temporary restoration Fill the canals, progressively increasing the file diameter and complete the biochemical (BMP) preparation Determine the working length
79. 79. Multi visit pulpectomy Procedure: Second Appointment(Cleaning and Shaping) Irrigate the canals Indication of complete BMP is smooth canals that have the same shape as the external walls Irrigate and debride Dry the canals and place temporary restoration after placing a sterile cotton pellet in chamber
80. 80. Multi visit pulpectomy Procedure: Third Appointment(Obturation) Remove the temporary restoration Irrigate and dry the canals Start Obturating First coat the walls of canals with thin watery mix of cement with the help of a reamer and then use thick mix and fill the canals using lentulospirals
81. 81. Multi visit pulpectomy Procedure: Third Appointment(Obturation) Keep an adding fresh mix till no further cement can be incorporated in canals Now seal the pulp chamber with temporary restoration. Recall after 1 week and if the patient is asymptomatic, do the final restoration and give a stainless steel crown
82. 82. Ideal requirements of root canal filling material 1. The material should resorb as the primary tooth root resorbs. 2. It should not irrigate the periapical tissues nor coagulate any organic remnants in the canal. 3. It should have a stable disinfecting power. 4. Any surplus material passed beyond the apex should be resorbed easily. 5. It should be inserted easily into the root canal and also removed easily if necessary. 6. It should not be soluble in water. 7. It should not discolor the tooth. 8. It should be harmless to the adjacent tooth germ.
83. 83. Root canal materials MATERIAL COMPOSITION Zinc oxide Eugenol Zinc oxide powder + Eugenol oil Calcium Hydroxide ----------- Iodoform Derivative of iodine Vitapex Calcium hydroxide + Iodoform + Oil additives Walkhoff paste Parachlorophenol + Camphor + Menthol KRI paste Iodoform + Parachlorophenol + Camphor + Menthol Maisto paste Zinc oxide + Iodoform + Thymol + Chlorphenolcamphor + Lanolin
84. 84. Root canal materials MATERIAL COMPOSITION Mineral trioxide aggregate Tricalcium aluminate + Tricalcium silicate + Silicate Oxide + Tricalcium Oxide + Bismuth Oxide. Endoflas Barium sulphate + Calcium Hydroxide + Iodoform + Zinc Oxide Eugenol.
85. 85. Root canal materials Calcium Hydroxide: This material is generally not used in pulp therapy for primary teeth. This material was found to be easy to apply and resorbs at a slightly faster rate than that of root. It has no toxic effects on permanent successor and its radiopaque. For these reasons, Calcium hydroxide Iodoform mixture can be considered to be nearly ideal primary tooth root canal filling material. Gutta- Percha (Not indicated for primary teeth): Since Gutta Percha is not a resorbable material, its use is contraindicated in the primary teeth.
86. 86. APExogenesis It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued growth of the root and closure of the open apex. Rationale: Maintenance of integrity of the radicular pulp tissue to allow for continued root growth. Indications: Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed. No history of spontaneous pain
87. 87. APExogenesis No sensitivity on percussion. No hemorrhage. Normal radiographic appearance. Contraindications: Evidence that radicular pulp has undergone degenerative changes. Purulent Drainage. History of prolonged pain. Necrotic debris in canal. Periapical radiolucency.
88. 88. APExogenesis Procedure: Application of rubber dam following local anesthesia Remove all carious tooth structure and open up the pulp chamber Remove cornal pulp tissue with excavators, care is taken to prevent damage to radicular pulp. Rinse all the residual debris and control hemorrhage by placement of a moist cotton pellet over the amputed pulp
89. 89. APExogenesis Procedure: Ca(OH)2 mixture is placed over the pulp stumps, followed by temporary restoration. Follow-up radiographs are taken periodically to check the root development. Once root development is complete, the conventional root canal treatment is done.
90. 90. Apexification It is defined by Cohen as a method of induce development of the root apex of an immature Pulpless tooth by formation of osteocementum/bone like tissue. Indication: For non-vital permanent teeth with open apex (Blunderbuss canals) Objective: To induce either closure of open apical third of root canal or the formation of an apical calcific barrier against which Obturation can be achieved.
91. 91. Apexification Materials used: ZnOE Metacresylacetate Camphorated Parachlorophenol Tricalcium Phosphate + -tricalcium phosphate Resorbable tricalcium phosphate Collagen calcium phosphate gel Ca(OH)2 Mineral trioxide aggregate
92. 92. Apexification
93. 93. Apexification Procedure: First Visit: Preoperative assessment includes clinical evaluation of color, mobility, tenderness and swelling. Periapical radiograph should be evaluated When acute signs and symptoms are absent, instrumentation is recommended Application of rubber dam following local anesthesia
94. 94. Apexification Procedure: First Visit: Access is gained in the pulp chamber Barbed broach used to remove debris and necrotic pulp tissue from the canal Irrigation is performed with saline Working length is determined
95. 95. Apexification Procedure: First Visit: Circumferential enlargement done by the file and irrigation is done with saline to remove infected dentin from the canal walls Canal dried with paper points Ca(OH)2 powder is used to fill 2 mm short of the radiographic apex
96. 96. Apexification Procedure: First Visit: Remaining of the canal filled with Ca(OH)2 and Saline Barium sulphate added to radio - opacity Dry pledget of Ca(OH)2 is then ejected into the pulp chamber and forced against the paste ahead of it. Place temporary restoration.
97. 97. Apexification Procedure: Second Visit: This is after 6-24 months tooth is re-entered and Apexification is verified If it is complete then RCT done.
98. 98. Apexification Franks Criteria for Apexification: 1. Apex is closed, through minimum recession of the canal. 2. Apex is closed with no change in root space. 3. Radiographically apparent calcific bridge at the apex 4. There is no radiographic evidence of apical closure.
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