Beruflich Dokumente
Kultur Dokumente
Seminar by
Postgraduate Student
INTRODUCTION 1
DEVELOPMENT OF ROOT 2
LATERAL CANALS 8
ACCESSORY CANALS 10
APICAL DENTIN 14
ROOT RESORPTION 15
APEXIFICATION 26
RECENT ADAVANCES 34
CONCLUSION 36
INTRODUCTION
DEVELOPMENT OF ROOT
The island of HERS which are left behind migrates towards the
dental sac. They remain in the periodontal ligament close to the
cementum. These cells are called cell rests of mallasez. They have the
potential to differentiate into any cell as the need arises, when they are
stimulated.
ROOT LENGTH AND APICAL CLOSURE
Moorrees et al. (1963) studied the rot lengths and apical closure
completion dates by using images on lateral jaw radiographs. They found
that root length completion and apical closure dates by using images on
lateral jaw radiographs. They found that root length completion and
apical closure occurs early in females when compared to males.
The maxillary teeth were not studied because their images could
not be identified clearly on lateral jaw radiographs. But judging from the
data of maxillary incisors and mandibular teeth, they surmise that the
dates fro completion of root lengths and apical closures for maxillary
posterior teeth are slightly later than mandibular teeth.
Clinical significance
A funnel shaped opening exists at apex of young tooth that has
incompletely formed root. This incompletely formed root apex contains
connective tissue, blood vessels, nerves which enters and exit the root
canals. Therefore successful repair of inflammed dental pulps occurs in
teeth within complete apical closure when compared with the teeth with
completed apical closure. This may be possibly due to the unobstructed
metabolism.
The pulp capping and pulpotomy procedures are wide successful in
teeth with open apices and complete endodontic therapy has better
prognosis in teeth with complete root end formation. In young teeth with
incomplete root end formation, partial pulpitis can be treated by pulp
capping or pulpotomy procedures thereby permitting normal root end
development i.e. apexogenesis. But in teeth with severely inflammed or
necrotic pulps, the tissues must be removed and the root canals must be
debrided and cleansed. Ca(OH)2 is placed in root canals and completion
of root canal therapy should be delayed until the root end formations has
been completed. This process is known as apexification.
APICAL FORAMEN
Structure:
In young incompletely developed teeth the apical foramen is funnel
shaped with wider portion extending outward. This mouth of the funnel is
filled with fibrous tissue which later will be replaced by dentin and
cementum. As the root apex becomes lined with cementum which
extends to a short distance into the root canal. This is the cementodentinal
junction. CDJ is not present at the extreme end of the root but a few mm
within the main root canal. The apical foramen is not the most constricted
portion of the root canal.
The diameter of the canal at the site of exiting from the tooth is
called “major diameter”. Major diameter was found approximately twice
as wide as minor diameter. In young patients (18-25 years) the distance
between minor and major diameter is approximately 0.5mm and in the
older patients (55 years and above), the distance between minor and
major diameter is approximately 0.67mm.
Clinical significance
Location:
The apical foramen is not always located at the centre of the apex
of the root. According to Ingle, it is uncommon to find the foramen
exiting at the centre of the apex. It may exit on the mesial, distal, buccal,
lingual portions of the root.
Shape:
materials.
Size and shape of the apical foramen should always be maintained.
It should be neither enlarged nor blocked
Care should be taken to prevent over instrumentation or extrusion
Accessory canal: is the one that branches off from main root canal,
usually in the apical region of the root.
Accessory foramina: are the openings of the accessory and lateral canals
on the root surface.
Development:
They may form when the epithelial root sheath disintegrates before
the dentin is elaborated
They may also result firm lack of dentin elaboration around a blood
Lateral canals: lateral canals are found more in roots of posterior teeth
and occasionally in roots of anterior teeth. More common in bifurcation
and trifurcations regions of molar teeth. Hess in 1925, by the use of
vulcanite corrosion specimens detected, the incidence of 16.9% of lateral
canals in all teeth.
Accessory canals:
Apical delta:
When pulp is extirpated from the main canals, a clot forms at the
site of the wound. Repair of the wound subsequently occurs if
accessory blood supply is present. In case of “Y” shaped branching of
the pulp i.e. apical delta, following endodontic treatment, the pulp
tissue in uninstrumented branches may become inflammed but usually
retains its vitality with passage of time, continous deposition of dentin
or cemntum tends to narrow the lumina of these canals.
Lateral and accessory canals are difficult to clean adequately.
Thorough and effective irrigation techniques should be carried out. A
tooth with multiple accessory canals in the apical third may harbour
microorganisms and debris which may continue to irritate the periapex
and cause pain inspite of proper filling of the principal canal.
Peripaical surgery is indicated in such cases.
Apical pulp tissue:
The apical pulp tissue is mainly found in the apical end of the root
canal. Most probably continuing into the surrounding periapical region.
The apical pulp tissue differs structurally from the coronal pulp tissue.
The coronal pulp tissue contains mainly of cellular connective tissue and
fewer collagen fibers, whereas the apical tissue is more fibrous and
contains fewer cells.
Apical dentin:
Opaque zones are more closely packed and wider than those of
translucent zone. Couhlam concluded that transparency of apical dentin
was due to diminution in width of tubules.
The use of isotope studies by Hampson in 1964 have shown that
apical dentin is more sclerotic than coronal dentin. The sclerotic apical
dentin is considerably less peircable than the coronal dentin. This reduced
permeability has significance because the sclerosed dentinal tubules are
less readily penetrated or are impenetrable by microorganisms or other
irritants.
When the tooth erupts into the oral cavity and becomes functional,
its root formation is not completed. It is wide open and the Hertwig’s
epithelial root sheath, a circular curtain like structure, is active with its
root formative function.
It is made to bear the biting stress which may move the tooth in
mesial direction and
The occlusal load may disturb the curtain like Hertwig’s epithelial
root sheath at the apical third.
Dystrophic mineralisations:
Denticles/pulp stones:
Clinical significance:
Denticles found within the pulp tissue in the apical third of the root
may account for some difficulties in root canal instrumentation. During
reaming or filing of root canal they may become detached and impacted
into the apical foramen rendering further instrumentation difficult.
Clinical significance:
The apical foramen or foramina tend to become obliterate by both
the deposition of secondary dentin within the root canal and by the
deposition of cementum outside the root canal. Continuous dentin and
cementum deposition will reduce the size of apical foramen but complete
closure does not occur as long as vital pulp tissue remain.
If the root canal shadow abruptly stops in the middle third of the
root or if the diameter of the root canal suddenly narrows down then it
denotes that the root canal may be dividing into two. This is very
common occurrence in mandibular premolars. If there is a lateral
radiolucency present in the apical one third of the root, it may indicate the
possibility of lateral canal accessory canals or presence of periodontal
lesions.
Length determination:
The first step in the prepration is the location of the foramen in the
root apex. Although a radiographic assessment with a measured endo
instrument in the canal is an accepted procedure for the determination of
the tooth length, measurements using electronic instruments are
becoming increasingly popular. Electronic measurement of the tooth
length according Grossman (1981), is an effective method in 80 to 90%
of the cases compared to the radiographic method. Neosono D, according
to some clinicans, indicates the exact location of the foramen with
reasonable accuracy. Galland (1985) recommends electronic apex finder
for those who perform endo treatment infrequently.
Flexible files are preferred over stiffer varieties since they may
change the course of the canal, form a ledge or transport the foramen by
ripping. D- type files (produced from rhombus blanks) are more flexible
than regular K- type files (produced from square blanks) in size no: 30
and above (Anderson et al. 1985). The new K- type file (triangular cross
sections ) is more flexible than H- file (Roane et al 1985).
Methods of preparation:
Preparation design has an influence upon the final seal. Step back
or flaring type of preparation of the apex is found to be advantageous
over the conventional method (Allison et al. 1979). Flared preparation
provides a cleaner environment, better receptacle for the obturating
material, and a stronger apical dentin matrix (Weine 1982). Chances of
apical ripping and shifting I foramen are less with step- back technique
(Christie & Peikoff 1980).
Irrigation:
Obturation:
Sealing is done to eliminate all the portals of entry from the root
canal into the adjacent periodontal tissues through which exudates,
bacteria or their toxins might pass; and to make the environment
favourable for healing. Ingle (1956) determined 63% of the root canal
failures to be due to inadequate filling. Accessory foramina if left open
and remain unfilled can lead to failure of treatment. The necessity to
provide hermetic sealing of the apical foramen as well as filling of the
accessory canals has brought forth many dynamic changes in the
obturation techniques.
Apexification:
Method of use:
The dentin chip technique has been used and taught at the
universities of Oregon and Washington. After the canal is totally debrided
and shaped and the dentin no longer “contaminated”, a Gates Glidden
drill or Hedstroem file is used to produce dentin powder in the central
position of the canal. These dentin chips may then be pushed apically
with the butt end and then the blunted tip of a paper point. They are
finally packed into place at the apex using a premeasured file one size
larger than the last apical enlarging instrument. 1-2mm of chips should
block the foramen.
The Japanese found they could totally prevent apical microleakage
if they injected 0.02ml of clearfil bond dentin adhesive into the coronal
half of the dentinal apical plug. Completeness of density is tested by
resistance to perforation by a no. 15 or 20 file. The final gutta-percha
obturation is then compacted against the plug.