Advanced Endodontic Clinical Topics

• No tenderness to percussion or palpation.

• Normal tooth mobility.

• No sign of infection or swelling.

• No sinus tract or integrated periodontal disease.

Clinical Criteria for Success

• Normal or slightly thickened periodontal ligament space.

• Reduction or elimination of previous rarefaction.

• No evidence of resorption.

• Normal lamina dura

Radiographic Criteria for successful endodontic treatment

• Absence of inflammation.

• Regeneration of periodontal ligament fibers.

• Presence of osseous repair.

• Repair of cementum.

• Absence of resorption.

• Repair of resorbed areas.

• Histologic Criteria for successful endodontic treatment

• Infection

• Incomplete Debridement of
  Root Canal System

• Overinstrumentation

• Chemical Irritants

• latrogenic Errors:

• Separated instruments

• Canal blockage and ledge formation

• Perforations

• Incompletely filled teeth

• Overfilling of root canal

• Anatomic factors (overly curved canals, calcifications, numerous lateral and accessory canals)

• Root fractures

• Traumatic occlusion

Retreatment

Local factors

• Nutritional deficiencies

• Diabetes mellitus

• Renal failure

• Blood dyscrasias

• Hormonal imbalance

• Autoimmune disorder

• Opportunistic infection

• Aging

• Patients on long-term steroid therapy

Retreatment

Systemic factors

• Unfavorable root anatomy (shape, taper, remaining dentin thickness).

• Untreatable root resorptions or perforations

• Root or bifurcation caries

• Insufficient crown/root ratio

CONTRAINDICATIONS for retreating

• CORONAL DISASSEMBLY TO ESTABLISH ACCESS TO ROOT CANAL SYSTEM

• REMOVE CANAL OBSTRUCTION & ESTABLISH PATENCY

• THOROUGH CLEANING, SHAPING AND OBTURATION OF CANAL

STEPS OF RETREATMENT

• CORONAL DISASSEMBLY TO ESTABLISH ACCESS TO ROOT CANAL SYSTEM

remove existing restoration

especially if it has poor marginal adaptation, secondary caries

• REMOVE CANAL OBSTRUCTION & ESTABLISH PATENCY

removing obstructions in the canal like silver points, gutta-percha, pastes, sealers, separated instruments and posts, etc. using ultrasonic, solvent, hand instruments, rotary instruments, Massermann extractor,etc

• Automobile injury

• Battered child

• Child abuse

• Drug abuse

• Epilepsy

• Falls from height

• Sports related injuries

DENTAL TRAUMATIC INJURIES ETIOLOGY

WHO

gave following classification in 1978 with code no. corresponding to International Classification of Diseases.

873.69

Lacerations

- N 902.0

Contusion

- N 910.00

Abrasions

N873.60

Enamel fracture

N873.61

Crown-fractures-uncomplicated (no pulp exposure)

N873.62

Crown-fractures-complicated (with pulp exposure)

N873.64

Crown-root fractures

873.66

• Tooth concussion

• Subluxation

• Extrusive luxation

• Lateral luxation

N873.63

Root fractures

873.67

Intrusive luxation

873.68

- Avulsion

• Alveolar process: maxilla/mandible

• Body of maxilla/mandible

• Temporomandibular joint.

Facial Skeletal Injuries

Pulp capping

treatment for Pulp exposure within 3 hours

Pulp capping

place dressing directly on to pulp exposure

Pulpotomy

treatment for Pulp exposure between 24 to 72 hours:

Pulpotomy

removal of coronal pulp tissue to the level of healthy pulp

• apexification - for young

• pulpectomy - for old

• endodontic therapy - for mature permanent tooth

Pulp exposure beyond 72 hours:

• Horizontal

• Vertical

• Oblique

root fracture According to direction:

• Single

• Multiple

• Comminuted

root fracture According to number

• Partial

• Total

root fracture According to extent

• Apical third

• Middle third

• Cervical third

root fracture According to location

• Displaced

• Not displaced

root fracture According to position of root fragments

• Displacement of coronal segment.

• Radiographs at varying angles (usually at 45°, 90° and 110°).

root fracture diagnosis

splinting for 2-3 weeks

Treatment

If only apical third fracture is suspected, displaced coronal portion should be repositioned and stabilized by

• vertical fracture

• complete extension

• cervical third

• multiple

• fragments displacement

poor prognosis in root fracture

orthodontic band

If crack is visible across the floor of pulp chamber; Tooth is bonded with _____ ; Keeping it in place, endodontic therapy is completed.

Luxation injuries

cause trauma to supporting structures of teeth ranging from minor crushing of periodontal ligament and neurovascular supply of pulp to total displacement of the teeth.

• Tooth is not displaced.

• Mobility is not present.

• Pulp may respond normal to testing.

In concussion

• Teeth are sensitive to percussion and have some mobility.

• Sulcular bleeding is seen showing damage and rupture of the periodontal ligament fibers.

• Pulp responds normal to testing.

In subluxation

AVULSION / EXARTICULATION

complete displacement of the tooth out of socket, can result in formation of infection, loss of space in the dental arch, ankylosis, resorption of root structure, abnormal root development and color changes.

lateral luxation

• trauma displaces the tooth away from its long axis

• sulcular bleeding is present

• sensitive to percussion

extrusive luxation

• trauma displaced from the socket along its long axis

• tooth is very mobile

INTRUSIVE LUXATION

• Tooth is forced into its socket in an apical direction

• Maximum damage occurred to pulp & supporting structures

• Tooth is in infraocclusion

• Radiographic evaluation needed to know position of tooth

• Traumatic repositioning and fixation

• prevents excessive movement during healing. Pulp testing should be performed on regular intervals.

• spontaneous re-eruption

• In immature teeth, ________ is seen.

• orthodontic movement

• If re-eruption stops before normal occlusion is attained, _________ is initiated before tooth gets ankylosed.

surgical extrusion

If tooth is severely intruded, __________ is done.

• Hank's balanced solution

• Milk

• Saline

• Saliva

• Water

• To preserve the maximal number of periodontal ligament cells which have capability to regenerate and repair the injured root surface, avulsed tooth can be stored in:

• 7 days

• Remove splint after _____ unless excessive mobility is present.

• Endodontic therapy

• in luxation injuries ________ should be started in 7-10.

• place it in a tooth-preservation solution, wash out the socket and reimplant the tooth firmly.

• If the tooth has been out of its socket less than 15 minutes,

• soak for 30 minutes to replenish nutrients. Local anesthesia will probably be needed before reimplanting as above.

• If the tooth has been out 15 minutes to 2 hours,

• the periodontal ligament is dead, and should be removed. Tooth should be thoroughly cleaned and disinfected before reimplanting.

• If the tooth was out over two hours,

• soak the tooth for 5 minutes in 5 percent doxycycline to kill bacteria which could enter the immature apex and form an abscess.

• If the patient is between 6 and 10 years old,

ankylosis

• Reimplanted primary teeth heal by

• It will result in cosmetic deformity since the area of ankylosis will not grow at the same rate as the rest of the dentofacial complex.

• Ankylosis can also interfere with the eruption of the permanent tooth.

• Ankylosis of deciduous teeth will have the following consequences:

Pulpotomy

refers only to coronal extirpation of vital pulp tissue.

• No indication of root resorption should be present.

• No radiographic sign of periradicular periodontitis.

• Continued root development should be evident radiographically.

Criteria for Successful Pulpotomy

• A vital tooth with healthy periodontal condition

• No mobility of tooth

• No tenderness to percussion

• A restorable tooth.

indications for pulpotomy

• Presence of sinus or fistula

• Swelling

• History of spontaneous toothache

• Tooth sensitive to percussion

• Mobility present

• Root resorption or radicular disease is present radio-graphically

• Pus at exposure site

• Presence of pulp calcifications.

Contraindications for pulpotomy

Pulpectomy for primary teeth

refers to the complete removal of pulp tissue from a tooth.

• History of spontaneous pain.

• In primary tooth with irreversible pulpitis or necrosis.

• Internal resorption that does not perforate root.

indications for Pulpectomy for primary teeth

• A nonrestorable tooth

• Extensive bony loss.

contraindications for Pulpectomy for primary teeth

Apexification

process of inducing the development of the root and the apical closure in an immature pulpless tooth with an open apex.

• Young permanent teeth with blunderbuss canal and necrotic pulp.

• Long standing fractures of crown involving pulp.

indications for Apexification

• Replacement resorption

• Very short roots

• Horizontal and vertical root fractures.

contraindications for Apexification

Apexogenesis

physiological root end development and formation.

• Immature teeth with incomplete root formation

• Damage to coronal pulp but healthy radicular pulp

indications for Apexogenesis

• Unrestorable teeth

• Avulsed teeth

• Severely luxated teeth

• Teeth with horizontal and vertical root fractures.

contraindications for Apexogenesis

1. Zinc oxide eugenol

2. lodoform paste

3. Ca(OH)2 and zinc oxide paste.

Commonly used material for filling the canals are:

Clinical Sequence

• Give adequate local anesthesia.
  Penetrate pulp chamber with the help of slow speed round bur (Fig. 26.2).

• Remove pulp tissue and take the working length
  X-ray.

• Complete the biomechanical preparation of canals
  (Fig. 26.3).

• Copious irrigation is necessary to flush out debris.

• Now place the paper points moistened with formocresol approximately for five minutes to fix any remaining tissue.

• After this, remove the paper point and fill the canal with zinc oxide eugenol cement (Fig. 26.4).

• Finally, tooth is restored with stainless steel crown.

Pulpectomy

apexification

Technique (Fig. 26.5)

1. Anesthetize the tooth, extirpate the pulp tissue remnants from the canal.

2. Establish the working length of canal.

3. Complete cleaning and debridement of canal, irrigate and then dry the canal.

4. Place an appropriate material for apexification procedure in the canal and the seal it with temporary filling.

5. Second visit is done at the interval of three months for monitoring the tooth. If tooth is symptomatic, canal is cleaned and filled again with calcium hydroxide paste.

6. Patient is again recalled until there is radiographic evidence of root formation.

7. If apexification is incomplete, repeat the above said procedure again. If apexification is complete, radiograph is taken to confirm it. If found satisfactory, final obturation of canal is done with gutta-percha points.

1. Calcium hydroxide

2. Calcium hydroxide in combination with other drugs like (CMCP) Camphorated paramonochlorophenol and Cresanol

3. Zinc oxide paste

4. Antibiotic paste

5. Tricalcium phosphate.

Commonly used material for apexification:

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

• It is physiological process of root development in vital tooth

• Indicated in teeth with vital pulp and minimal inflammation

• Normal root-end development takes place

Apexification

• It is defined as a method to induce development of the root apex of an immature pulpless tooth by formation of osteocementum/bone-like tissue

• It is the method of inducing the regenerative potential in a nonvital tooth

• Indicated in cases where irreversible pulpal damage is present

• Instead of normal root development, a calcific barrier is formed at the apex

• true combined lesions

• are produced when one of these lesion (pulpal or periodontal) which are present in and around the same tooth coalesce and become clinically indistinguishable. These are difficult to diagnose and treat.

ENDODONTIC SURGERY

removal of tissues other than the contents of root canal to retain a tooth with pulpal or periapical involvement

Surgical drainage

indicated when purulent and/or hemorrhagic exudates forms within the soft tissue or the alveolar bone as a result of symptomatic periradicular abscess

Vestibular abscess

is formed due to large periradicular abscess

Surgical drainage

1. Incision and drainage (I and D)

2. Cortical trephination (fistula surgery)

Periradicular surgery

1. Curettage

2. Biopsy

3. Root end resection

4. Perforation repair ii. Root resection iii. Hemisection

Implant surgery

1. Endodontic implants

2. Root-form osseointegrated implants.

Periradicular surgery

(A) Preoperative radiograph; (B) Obturation;

(C) Mucoperiosteal flap raised; (D) Window preparation in 11;

(E) Periapical curettage; (F) Sutures placed

Root Resection

(A) Preop radiograph; (B) After removal of previous root canal filling; (C) Postobturation radiograph; (D) After elevation of flap; (E) After cyst enucleation and root-end resection

Hemisection

(A) Pre-Op radiograph; (B and C) Hemisection of first molar;

(D) Post-surgical radiograph; (E) Postsurgical photograph.

Endodontic Implants

1. The pathology was removed by periapical surgery and one canal was obturated with gutta percha and other with H-file as endodontic implant, with mineral trioxide aggregate based sealer

2. Reamers were extruded to use as endodontic implants.

Endosteal / Endosseous Implants

• Extends into basal bone for support

• It transects into 1 cortical plate