2.

Periodontium (morphology and functions)

The periodontium (also known as marginal periodontium) is the supporting structure of a tooth,
helping to attach the tooth to surrounding tissues and to allow sensations of touch and pressure.

The periodontium consists of FOUR principal components :

• gingiva or the gum

• cementum, covering the root of the tooth
• alveolar bone
• periodontal ligament

Gingiva

Gingiva is a soft tissue that overlays the jaw bone and surrounds the teeth providing a seal around
them. Gingival tissue is tightly bound to the underlying bone creating an effective barrier (when
healthy) for periodontal insults to deeper tissues.

Healthy gingiva is usually pink, but may contain melanin pigmentation. Healthy gingiva has a smooth
"arcuate"1 appearance around each tooth, a firm texture that is resistant to movement and no reaction
(such as bleeding) to normal disturbance such as brushing or periodontal probing.

Interdental papilla – pointed part of gingiva which fills the space between teeth
The marginal gingiva is a 1.5 mm strip of gingival tissue which surrounds the neck of the tooth and is
known as such due to the fact that the inner wall forms the gingival wall of the sulcus.
1 Arcuate: shaped like a bow, curvedIn a healthy mouth,
2 WHO probe can be inserted up to 3mm into the sulcus
3 formed between the tooth and the mucosa, due to the fact that the soft tissue is moveable.

The attached gingiva is the gingival tissue which lies between the mobile gingiva and the alveolar
gingiva. It is 4-5mm in width and is irremovable from the underlying structures without causing
damage.

The free gingival margin is the interface between the sulcular epithelium and the epithelium of
the oral cavity. This interface exists at the most coronal point of the gingiva, otherwise known as the
crest of the marginal gingiva.

Cementum

Cementum is a specialized calcified substance covering the root of a tooth. It is the part of the
periodontium that attaches the teeth to the alveolar bone by anchoring the periodontal ligament.

Cementum is formed continuously throughout life because a new layer of cementum is deposited to
keep the attachment intact as the superficial layer of cementum ages. It has a light yellow colour and
the highest fluoride content of all mineralized tissues.

Secreted by cementoblasts in the root of the tooth

Cellular cementum: occurs on the apical half

Acellular cementum: does not incorporate cells into its structure and usually predominates on the
coronal half of the root

Alveolar bone
The alveolar bone is the bone of the jaw that contains the tooth sockets (also known as dental alveoli
or alveolar process) on bones that hold teeth.

The alveolar process contains a region of compact bone (called the lamina dura) which is attached to
the cementum of the roots by the periodontal ligaments.

Like any other bone in the human body, alveolar bone is modified throughout life under the effect of
various external factors, it may suffer processes of bone resorption or bone formation.

Periodontal ligament

The periodontal ligament is a specialized connective tissue that attaches the cementum of a tooth to
the alveolar bone. They are a network of elastic fibres that help support the tooth inside the alveolar
bone socket.

The functions of the periodontal ligaments include attachment of the tooth to the bone, support for
the tooth, formation and resorption of bone during tooth movement, sensation, and eruption.

When pressure is exerted on a tooth, such as during chewing or biting, the tooth moves slightly in its
socket and puts tension on the periodontal ligaments. This is called tooth physiologic mobility.
The periodontium exists for the purpose of supporting teeth during their function ; a constant state of
balance always exists between the periodontal structures and the external forces.

Most of the times, periodontal diseases are caused by bacteria from the dental plaque which is
adherent to tooth surfaces.

In case of bacterial infections, the first barrier is the gum. In the absence of treatment, the infection
progresses to the periodontal ligaments and the alveolar bone involving the progressive loss of the
alveolar bone around the teeth which can lead to the loosening and subsequent loss of teeth.
3. Pathomorphology and pathophysiology of dental pulp (classification)

The dental pulp (pulpa dentis) fills the pulp cavity and root canals of teeth.
It consists of thin ligament with numerous cells, vessels and nerves.
The presence of a large amount of free nerve endings causes extreme pain in the case of damage or
injury.
Odontoblasts are the most important cells in the dental pulp, being located on the border between the
dental pulp and dentin. They produce dentin for their entire life. Their thin fibres span into dentin
tubules (Tomes fibres).
The dental pulp also contains a large number of multipotent cells and stem cells which may
differentiate into other cell elements.
Root canals communicate with the periodontium by means of the apical foramen through which the
nerve and blood vessels pass entering the dental pulp. There are also additional canals that
communicate with the periodontium, i.e. ramification.
Inflammation and trauma are the most common disease of the dental pulp. Degenerative diseases of
the dental pulp are only of limited clinical significance.

Causes of pathology of dental pulp

Physical
Mechanical
Trauma – accidental, iatrogenic dental procedures
Pathological wear
Crack through the tooth

Thermal
Heat from cavity preparation
Exothermic heat from setting of cements

Electrical
Galvanic current from metallic filling2

Chemical
Phosphoric acid, acrylic monomer
Erosion (acids)

Bacterial
Toxins associated with caries
Direct invasion of pulp from caries or trauma
Microbial colonization in pulp by blood-borne micro-organisms

Diseases of dental pulp

Inflammation of dental pulp (PULPITIS)
Reversible pulpitis
Irreversible pulpitis

Pulp degeneration
Calcific degeneration
Atrophic degeneration
Fibrous degeneration

Necrosis of pulp

2 Galvanic: relating to or involving electric currents produced by chemical action

 4. Factors influencing dental pulp (infectious, physical, chemical)

Infection
Caries
Anomalous crown morphology, fractures
Periodontal disease
anachoresis
Physical causes
Acute trauma
Chronic trauma
Thermal causes
Chemical causes

Infection
Dental Caries
• the most common source
• Pulp´s inflamatory response is rather to the toxins than to bacteria themselves
• Mostly lipopolysacharide (LPS) and lipotechoic acid (LTA)

• Increased likehood of pulpal inflamation

• Mostly secondary to caries

• Toxins may enter dental pulp through lateral canals or through the apical foramen.
Anachoresis
• Bacteria in circulating blood may be deposited in the pulp (only in harmed one)
• Very rare

Physical causes
Acute trauma
• Usually causes disruption of blood circulation. As consequence chronic
inflamation (sterila) can occur and acute flare-up can happen after bacteremia.
Chronic trauma
• Improper articulation of restorations
• Same mechanism as with acute
trauma Thermal trauma
• Usually iatrogenic
• Faulty preparation

Chemical causes
• Irritation from certain dental materials
• Irritation from erosion (extrinsic or intrinsic)
5. Regressive and degenerative changes in dental pulp

Regressive changes of dental pulp (changes with age)

Diameter of pulp chamber decreases

Cell changes:
Appearance of fewer cells in aging pulp
Decrease in size and no of cytoplasmic organelles
Active pulpal fibrocytes hadrough surfaces endoplasmic reticulum, notable golgi complex, numerous
mitochondria

Fibrosis – accumulation of both diffuse fibrillar components AND bundles of collagen fibers
Fiber bundles seen in longitudinally in the radicular pulp and more spread out (diffuse) in the coronal
part
Collagen accumulation occurs in older pulps
External trauma (caries, deep restorations) cause localised fibrosis or scarring effect
Increase in size of collagen fibers will decrease the size of the pulp

Vessel changes
atherosclerotic plaques may appear in pulpal vessels
calcifications are found that surround in vessels calcification
found most often in region near apical foramen

Denticuli (pulp stones) -

Appear at both coronal and root portions of the pulp organ
Not associated with any other pathology
Asymptomatic until they impinge (come into contact with) nerves or blood vessels
Seen in functional as well as embedded unerupted teeth

Classification
1. True denticles – inclusion of remnants of epithelial root sheath within the pulp
These epithelila remnants induce cells of pulp to differentiate into odontoblasts then form the
dentin mass
2. False denticles – do not exhibit dentinal tubules. Appear as concentric layers of calcified tissue.
Sometimes appear in a bundle of collagen, sometimes appear in pulp free of collagen.
Some cases arise around vessels
The center of these layers of calcified tissues maybe filled with remnants of necrotic and
calcified cells
Calcification of thrombi in blood vessels called phleholiths may also serve as a nidus for
false denticles
3. Diffuse calcifications – irregular calcific deposits in the pulp
tissue Sometimes they develop into a larger mass
Usually found in the root canal and less often coronal area
Calcification surrounds blood vessels
These calcifications may be classified as dystrophic calcification
Age changes
Formation of secondary dentin through out life, reduces the size of pulp chamber and root canals
Decrease in cellularity
Odontoblast decrease in size and number and may disappear in certain areas. Especially on pulpal floor
over bifurcation and trifurcation

Degenerative changes of dental pulp

6. Inflammation of dental pulp- histopathological classification

• Pulpitis acuta: hyperaemia pulpae

serosa
purulenta: abscedens
phlegmonosa
• Pulpitis chronica clausa: abscedens
atroficans
fibrosa
• Pulpitis chronica atergo
• Pulpitis chronica granulomatosa interna
• Pulpitis chronica aperta: ulcerosa (in the middle and old age)
polyposa (deciduous or young permanent teeth)
• Pulpitis chronica acute exacerbans

Pulp hyperemia
 Initial form of inflammation
 Widening of capilars

Serous pulpitis
 Reactionary dentin
 Widening of capillaries
 Transudate, extravascular inflammatory cells
 Partial
 Total

Purulent pulpitis
 Abscedens
 Occur more often
 Rich leukocytes infiltration followed by necrosis
 Necrosis is demarcated by granulation tissue
 Phlegmonous

 Necrosis is not demarcated and inflammatory infiltration is spreading through whole

pulp

Pulpitis aperta
 Ulcerous
Mostly adult patients
 Pulp is exposed, under the necrotic surface is ulcus.
 Granulomatous
 Mostly child patients (rather deciduous)
 As called as polypous – granulation tissue forms prominence out of pulp chamber
 Soft, bleeding

Chronic pulpitis clausa

 Usually no clinical signs
 Connected with caries penetrating to pulp
Chronic abscess
Tendency to calcifications and production of denticles

6. Pathological states of dental pulp (clinical classification)

Classification of pulp according to Baum

1. intact pulp
2. reversible damaged pulp
3. irreversibly damaged pulp
4. pulp necrosis

Intact pulp
• Reaction on temperature changes is adequate
• Test on cooling and hot agents is positive
(uncomfortable feeling upto pain)
• After stimulus removal sensitivity will disappear
• The same reaction with comparison with neighbouring teeth
• Reaction intensity can be different according to pain threshold
• Tooth is not sensitive to the percussion
• Reaction on electrical stimulus is positive

Reversibly damaged pulp

Clinical symptoms:
• Large tooth decay, new filling or prosthetic construction, trauma of the tooth, states after
periodontological operations, tooth bleaching, etc.
• Pain on cool or hot stimuli, that immediately disappears
• Pain after food press into carious cavity or interdental space
• Pain on sweet, salty, acid stimuli
• It is a problem to exactly localise the pain
• Absence of spontaneous pain

Clinical tests:
• Immediate and high reaction on cooling agents with comparison with intact teeth (++)
• Pain immediately disappears after stimulus removal (absence of pain persisting)
• Absence of spontanneous pain
• Absence of pain on hot stimuli – this rule is not present in all the cases
• Tooth is not sensitive on the percussion (exception: new nonarticulated fillings or prosthetical
constructions)
Dif. dg. papilitis!
Irreversibly damaged pulp

linical symptoms: large tooth decay, new filling or prosthetic construction, trauma of the tooth,
states after periodontological operations, tooth bleaching, etc.

• more intensive stimulus

• lower immunity of dental pulp
• longer time effect of damaging substances

Anamnesis:
• Acute, strong, neuralgiforme pain
• Pain has fits with different intervals of rest
• Pain can be permanent
• Spontanneous pain without reason, frequently in the night or evening
• Pain has shooting character
• Patient can not detect reasoned tooth
Chronical pulpitis: anamnesis is poor

Clinical tests:
• Pain persists for some time
• Lower and delayed reaction on cool stimuli
• High reaction on hot stimuli
• Spontanneous pain
• Pain on the percussion in the initial stages is absent
• In advanced stages pain on percussion is strong
• Reaction on electrical current is not conclusive
• Pain localization is complicated
• Chronical pulpitis has not conclusive reaction on thermal stimuli

Pulp necrosis
Causes of the loss of dental pulp vitality:
• infection
• trauma with damage of blood supply
• chemical influences
Anamnesis:
• Patient does not have any problems
• Change of tooth colour (loss of transparence)
• Sometimes the patient remembers about the toothache some months ago. This fact says about
underwent inflammation of dental pulp

Clinical tests:
• Absence of the reaction on thermal and electrical stimuli
• Absence of pain on the percussion; patient can have another sensitivity than intact tooth
• Grey colour of the tooth
• Absence of periapical lesions on radiograms
• There are dry or moist residues of tissue with bacteria products in the pulp chamber (smell)
• Collicvated contain of pulp chamber is localized in dentinal tubules and periodontium
8. The signs of reversibility and irreversibility in dental pulp diseases
Reversible forms:
• Pain on cool stimuli
• Negative reaction on hot stimuli and percussion
• Pain is caused by stimulus and disappears immediately after the stimulus removal
• Absence of spontaneous pain

• Pain on hot stimuli

• Subsiding or absent reaction on cooling agents
• Pain persisting after stimulus removal
• Spontaneous pain
• Sensitivity and pain on the percussion

Difference between reversible and irreversible forms in initial stages is complicated, because one form
fluently goes to another one

For decision, if to wait or exstirpate dental pulp, it is necessary keep in mind:

• Spontanneous pain and persisiting pain
• The pulp age
• Cariosity and oral hygiene
• Loss of hard dental tissues
• Future prosthetical treatment

More radical treatment is provided in the case of elder teeth, high cariosity, poor oral hygiene, large
tooth decay, tooth that is part of prosthetical construction or with damaged periodontal tissues.

9. Healthy and reversibly affected dental pulp

Intact pulp
• Reaction on temperature changes is adequate
• Test on cooling and hot agents is positive
(uncomfortable feeling upto pain)
• After stimulus removal sensitivity will disappear
• The same reaction with comparison with neighbouring teeth
• Reaction intensity can be different according to pain threshold
• Tooth is not sensitive to the percussion
• Reaction on electrical stimulus is positive

Reversibly damaged pulp

Clinical symptoms:
• Large tooth decay, new filling or prosthetic construction, trauma of the tooth, states after
periodontological operations, tooth bleaching, etc.
• Pain on cool or hot stimuli, that immediately disappears
• Pain after food press into carious cavity or interdental space
• Pain on sweet, salty, acid stimuli
• It is a problem to exactly localise the pain
• Absence of spontaneous pain

Clinical tests:
• Immediate and high reaction on cooling agents with comparison with intact teeth (++)
• Pain immediately disappears after stimulus removal (absence of pain persisting)
• Absence of spontanneous pain
• Absence of pain on hot stimuli – this rule is not present in all the cases
 • Tooth is not sensitive on the percussion (exception: new nonarticulated fillings or prosthetical
constructions)
Dif. dg. papilitis!

10. Irreversibly affected dental pulp

Irreversibly damaged pulp

Clinical symptoms: large tooth decay, new filling or prosthetic construction, trauma of the tooth states
after periodontological operations, tooth bleaching, etc.

• more intensive stimulus

• lower immunity of dental pulp
• longer time effect of damaging substances
Anamnesis:
• Acute, strong, neuralgiforme pain
• Pain has fits with different intervals of rest
• Pain can be permanent
• Spontanneous pain without reason, frequently in the night or evening
• Pain has shooting character
• Patient can not detect reasoned tooth
Chronical pulpitis: anamnesis is poor

Clinical tests:
• Pain persists for some time
• Lower and delayed reaction on cool stimuli
• High reaction on hot stimuli
• Spontanneous pain
• Pain on the percussion in the initial stages is absent
• In advanced stages pain on percussion is strong
• Reaction on electrical current is not conclusive
• Pain localization is complicated
• Chronical pulpitis has not conclusive reaction on thermal stimuli

Pulp necrosis
Causes of the loss of dental pulp vitality:
• infection
• trauma with damage of blood supply
• chemical influences

• Patient does not have any problems

• Change of tooth colour (loss of transparence)
• Sometimes the patient remembers about the toothache some months ago. This fact says about
underwent inflammation of dental pulp

Clinical tests:
• Absence of the reaction on thermal and electrical stimuli
• Absence of pain on the percussion; patient can have another sensitivity than intact tooth
• Grey colour of the tooth
• Absence of periapical lesions on radiograms
• There are dry or moist residues of tissue with bacteria products in the pulp chamber (smell)
• Collicvated contain of pulp chamber is localized in dentinal tubules and periodontium
11. Etiology of dental pulp inflammation
• Infection
o Caries
o Anomalous crown morphology, fractures
o Periodontal disease
o anachoresis
• Physical causes
o acute trauma
o Chronic trauma
o Termical causes
• Chemical causes

• Infection
o Caries
▪ the most common source
▪ Pulp´s inflamatory response is rather to the toxins than to bacteria themselves
▪ Mostly lipopolysacharid (LPS) and lipotechoic acid (LTA)
o Anomalous crown morphology, fractures
▪ Increased likehood of pulpal inflamation
▪ Mostly secondary to caries
o Periodontal disease

▪ Toxins may enter dental pulp through lateral canals or throught apical foramen.
o Anachoresis
▪ Bacteria in circulating blood may be deposited in the pulp (only in harmed one)
▪ Very rare

• Physical causes
o Acute trauma
▪ Usually causes disruption of blood circulation. As consequence chronic
inflamation (sterila) can occure and acute flare-up can happened after
bacteremia.
o Chronic trauma
▪ Inproper articulation of restorations

▪ Same mechanism as with acute trauma o

Thermal trauma
▪ Usually iatrogenic
▪ Faulty preparation
 12. Caries ad pulpam penetrans (diagnostics, treatment)

 Necrotic tissues layered directly on the dental pulp

 The floor of carious lesion is formed by soft infected dentin

 There is no enough time for tertiary dentin formation due to fast progress of tooth decay

 In the place, where soft dentin is in contact with dental pulp, the pulp inflammation arises (acute or
chronic)
 Requirements:
fast progress of tooth decay
bad defensive capacity of dental pulp

Diagnostics:
 Anamnesis:
• irritation of lesion’s shape edge
• rapid stinging pain during chewing of hard foodstuffs
 Clinical tests:
• large carious lesion with a lot of soft dentin
• pain due to probing
• papilitis
• positive reaction to cold stimuli, reaction is lightly late
• negative reaction to percussion (dif. dg papilitis)
 RVG: large carious lesion penetrating into the pulp
 Pulp: often pulpitis chronica partialis

Treatment:
Caries penetrating into the pulp:
 Pulpectomy and endodontic treatment
 Pulpotomy, eventually partial pulpotomy according to Cvec- in young patients

13. Clinical manifestations of dental pulp diseases

1. gingivitis and pulpitis- pain on percussion of two neighbouring teeth, sometimes can imitate pulpitic
pain, localised pain, red and swollen gingiva
2. indirect pulp capping – large destruction of hard dental tissues, pain on thermal stimuli, without
prolongation, asymptomatic tooth
3. direct pulp capping – asymptomatic tooth, no bleeding after perforation
4. cracked tooth syndrome – pain on bite, tooth is vital, use of selective load of different cusps (tooth
slot), tooth is painful in bite and releasing of mastication pressure
5. hyperemia of dental pulp – pain on cold/sweet/acid stimuli without prolongation, higher reaction
onto vitality test without prolongation. No spontaneous pain
6. acute pulpitis, acute exacerbation of chronic periodontitis
7. rest pulpitis
8. acute apical periodontitis, acute exacerbation of chronic apical periodontitis
9. flare up
10. sinusitis maxillaris
11. TMJ pain
14. Clinical manifestations of pulpitis

From a pathological - histological point of view, the inflammations of the dental pulp (pulpitis) can be
divided into subgroups, which is of very limited importance for clinical practice. One important thing is
to distinguish on the basis of a clinical finding whether or not a particular disease is reversible.
The inflammation of the dental pulp is usually caused by the spread of infection from dental caries or a
traumatic defect in the dental crown. Microbes can also penetrate into the pulp via the apical foramen
or ramifications in the case of periodontal pockets or rarely due to bacteria present in blood
(bacteremia).
The dental pulp can also be damaged chemically by filling materials applied into the close vicinity of the
dental pulp, or thermally (in the case of vast and unsupported amalgam filings or metal inlays).

The inflammation of the dental pulp is accompanied with typical spontaneous pain that occurs in the
form of attacks, usually at night or any time during the day. Initially, the episodes of pain are short and
can easily be relieved by analgesics.

Later, the intensity of pain increases, and intervals between attacks become shorter. Pain is
neuralgiform and spreads into the surrounding regions of the head and neck. The patient is usually
unable to identify the tooth that causes the pain.

After elapsing a differently long period of time, the inflammation has spread in the apical direction
from the dental pulp to the periodontium.
The sensitivity of the tooth upon chewing or percussion is detected (pulpal-periodontal syndrome). The
tooth affected with the inflammation of the dental pulp shows significant sensitivity to thermal and
chemical stimuli.

Pain persists for several minutes or attacks of neuralgiform pain occur. If pain is short-lasting and can be
alleviated with analgesics, the disease is reversible. In the case of long-lasting pain that cannot be
alleviated with analgesics, being accompanied with percussion sensitivity and a significant positive
reaction to heat, the disease is irreversible.

15. Acute pulpitis (diagnostics)

17. Necrosis of dental pulp (histopathology and clinical manifestations)

pulp necrosis is partial or total death of dental pulp from long term interruption of blood supply of
blood supply to the pulp

Untreated irreversible pulpitis such as caries exposed pulp or trauma to tooth

tooth discoloration, dull/opaque (lack of normal translucency)

grayish brownish discoloration

episodes of spontaneous pain/discomfort, pain on pressure

pain on heat application – thermal expansion of gases present in RC space

necessary to undergo endodontic treatment

pulp is nonresponsive to pulp testing and is asymptomatic (adjacent teeth are responsive to pulp
testing)
pulp necrosis by itself does not cause apical periodontitis unless the canal is infected

some teeth may be nonresponsive to pulp testing because of calcification, recent history of trauma, or
simply the tooth is not responding

Histopathology-
no odontoblastic layer can be identified, but individual odontoblast are in their normal position.
Some odontoblastic nuclei have been displaced into the dentinal tubules
The cells in the subodontoblastic region are well delimited to the exposed dentinal tubules and they
comprise neutrophilic and mononuclear leukocytes as well as fibroblasts and undifferentiated cells
Many capillaries are present

18. Gangraena of dental pulp (histopathology and clinical manifestations)

19. Pathomorphology and patophysiology of periodontium (classification)

The spread of inflammation from the dental pulp into the periodontium causes a disease called
periodontitis (apical periodontitis).

Periodontitis can be caused by trauma or the chemical irritation of the periodontium with substances
inserted in the root canal.

Inflammatory changes are initially limited only to the close surroundings of the apex (the periodontal
stage).
Later, inflammation will gradually spread into adjacent tissues (the endosseal phase), penetrating under
the periosteum (the subperiosteal phase) and mucosa after the necrosis of the periosteum (the
submucosal phase).
Periodontitis may be acute or chronic. Chronic periodontitis can start and become acute any time
(chronic acutely exacerbated periodontitis). Unlike chronic periodontitis that is usually clinically silent
manifesting itself by occasional pain upon chewing or percussion, acute and acutely exacerbated
chronic periodontitis is characterized by severe pain.

Patients identify the painful tooth that is always sensitive to chewing and percussion, and often report
a feeling of a protruding tooth and shooting pain.
Examination usually reveals the presence of swollen soft tissue or a fistula with the leak of purulent
exudate, in the vicinity of the tooth.
Regional lymph nodes can also be swollen and the organism may show general alteration.

Periodontitis in the subperiostal and submucous phases is accompanied with facial swelling.
Subperiostal and submucous abscess is characterized by fluctuation upon palpation. The subperiosteal
phase is the most painful whereas pain relief is observed in the submucous phase.

X-ray examination is a valuable tool to complete the examination.

Acute periodontitis is usually characterized by enlarged periodontal fissure whereas chronic
periodontitis shows brightening adjacent to the apical region which may have distinct borders
(periodontitis circumscripta) or vague contours (periodontitis diffusa).
There is granulation tissue in this region, often containing the patches of epithelium originating from
the stage of development, i.e. epithelial cell rests of Malassez. The proliferation of such epithelial cells
may give rise to a radicular cyst.
 20. Acute inflammation of apical periodontium

acute apical periodontitis – a common condition accompanied by excruciating pain, a necrotic pulp,
and radiographic thickening of the apical periodontal ligament space

Etiology
Large tooth decay that leads to pulp gangrene (caries + infection)
Trauma. Nonarticulated fillings

Clinical symptoms
4 phases
Periodontal
Endosseal
Subperiosteal
Submucous – exudate goes through mucosa

No reaction to vitality test

Grey, dark pulp
Pain can be localised on mastication

Treatment
According to the phase
1. Phase 1: periodontal – root canal treatment with calcium hydroxide in the case of a dry canal
In other cases, the tooth will be free without filling for 1-3 days

2. Phase 2: intraosseal – root canal treatment, the tooth will be free for 1-3 days
Trepanation of apex, sometimes trepanation of alveolus

3. Phase 3: subperiosteal – root canal treatment, trepanation of apex, intraoral incision,

antibiotics (in case of elder, risk patient and patient with general alteration)

4. Phase 4: submucosal – root canal treatment, trepanation of apex, intraoral incision, antibiotics
(in case of elder, risk patients and patient with general alteration)

High virulency and low imunity can lead to spreading inflamation to jaw spaces and then (especially
flegmonous) even to brain or mediastinum
Sometimes the pus can get out through the periodontal pocket out (pyorhea)

Inflamation changes to chronical form, on X-ray you see the changes of lesion (getting to
marginal bone level)

Radiologically: no changes or widening of periodontal space

Whereas acute exacerbation of chronic apical periodontitis – radiolucency
 21. Chronic inflammation of apicalperiodontium

Etiology

• Iatrogenic, leads to chronical pulpitis periodontitis

Granulation tissue

Fibroblasts transform to osteoclasts – bone resorption

• It can start to resorb apical cement (external inflamatory resorption)

More ligament tissue in granulom makes bounded unit sticking on apex

• On X-ray well bounded lesion – Periodontitis apicalis chronica circumscripta
• Too big – Ostitis chronica circumscripta

More capillaries and microabscesses in granuloma makes non bounded, diffuse unit
• On X-ray non bounded lesion – Periodontitis apicalis chronica diffusa
• Too big – Ostitis chronica diffusa

If granulation tissue grow in place where is embryonic epithelium, it can start its proliferation

Small follicles with proliferating epithelium – cystic fluid (cholesterol) – grows to radicular cyst

Chronic with acute exacerbation

Weakening immunity

Higher virulence of microorganisms

Granulation tissue – leucocytar infiltration – pus production… same stages as acute

• Periodontitis chronica acutae exacerbans

If you have strong immunity and lower virulence of microorganisms

• Chronical periapical periodontitis with tipical osteosclerosis (hypermineralization +
condensation of bone tissue)
• Condensing ostitis (sometimes connecter with hypercementosis)

in connection with periodontium

Periodontium and pulp can both be changed by inflamation
• One affects the other and can combine
• Acute and chronical forms, chronical with acute exacerbation

Primary endodontic (endodontic treatment)

good prognosis

• Periodontium – initial marginal periodontitis, exposed furcation, resorbtion of bone (not too
much), atrophy of periodontium,
• Pulp – caries, chronical inflamation, necrosis, gangrene – periapical acute periodontitis – pus can
go thru periodontal fissure – formation of periodontal pocket (sinus tract), if the proces is chronical
– you can see it on X-ray and on acute exacerbation it hase same symptoms as acute
Primary periodontal (endodontic treatment, periodontal treatment)
lower prognosis

• Periodontium – progressive heavier form of marginal periodontitis, vertical defects, totally exposed
furcation,
• Pulp – teeth are intact, retrograde pulpitis (chronical) – necrosis – gangrene – chronical apical
periodontitis (exacerbation)

Combinated lesion (endodontic treatment, periodontal treatment (surgical), hygiene on top level)
infaust prognosis

• Periodontium - huge destruction of marginal periodontium, horizontal and vertical deffects, open
furcation
• Pulp – can be intact or damaged by caries, some fillings – degenerative changes (fibrosis,
calcifications, denticles), chronical inflamation, necrosis, gangrene.

23. Iatrogenic damages of dental pulp and apical periodontium

Medical/dental history Past/recent treatment, drugs

Chief complaint (if any)
Clinical exam
Clinical testing - pulp tests
How long, symptoms, duration of pain, location, onset,
stimuli, relief, referred, medications
Facial symmetry, sinus tract, soft tissue, periodontal status
(probing, mobility), caries, restorations (defective, newly
placed?)
Cold, electric pulp test, heat

periapical tests Percussion, palpation, Tooth Slooth (biting)

Radiographic analysis New periapicals (at least 2), bitewing, cone beam-computed
tomography
Additional tests Transillumination, selective anesthesia, test cavity
B
1. Examination of patient in endodontics

Examination procedures required to make an endodontic diagnosis

The extraoral examination involves consideration of normal findings as well as pathological changes,
and it is enhanced by the patient’s own statements.

External facial form and features are re- corded as symmetrical or exhibiting asymmetric defects. The
facial skin may exhibit ab- normalities such as fistulae, erythema, or pallor, which may necessitate
further clarification because they may indicate possible intraoral pathology.

The neurologic examination includes testing of motor function, sensitivity, and movement function. A
bilateral comparison of the sensation of external stimuli is used to test the patient’s ability to
differentiate between a blunt and a sharp stimulus.

Examination of the lymph nodes in the face and jaw region can provide clues about inflammatory,
infectious, or tumor-like disorders. Palpation is performed bimanually and with comparison left to
right; painful lymph nodes are an indication of an acute inflammation.

The visual intraoral examination consists of a search for swelling, erythema, fistula, suppuration,
dental caries, tooth discoloration and mobility, dental restorations, and a comprehensive evaluation of
the periodontal sup- portive apparatus and the entire dentition.

Some or all of these examination proce- dures should be employed: palpation, percussion,
determination of tooth mobility, perio- dontal examination, functional occlusal analysis, infraction test,
sensitivity/vitality test, transillumination, selective anesthesia test, and radiographic examinations.

The percussion of an affected tooth may provide a sure sign, even in the earliest pathological
involvement. The question is whether a periodontal or an endodontic etiology is present, or an occlusal
trauma in combination with marginal periodontitis. The percussion test should also be performed on
adjacent teeth in order to ascertain clear differences in the intensity of elicited pain.

Palpation in the vestibular fold near the apical region of the root tips will provide clues concerning
pressure sensitivity and infiltration as well as the presence of swelling and even fluctuation. Applying
pressure to the vestibular tissue can aid in the diagnosis of a fistula because pressure may elicit efflux
of exudate.

In addition to the radiograph, transillumi- nation may expose caries, tooth fracture, or other pathologic
conditions. The use of targeted anesthesia may make it possible to de- tect the affected tooth. The
percussion test may also provide additional important diagnostic clues; especially vertical or horizontal
percussion sensitivity provides differential di- agnostic conclusions. Having the patient bite upon a
wooden tongue blade can provide evidence concerning tooth fracture or infraction during loading or
unloading of the occlusion.

Before initiating endodontic treatment it is important to examine all of the remaining dentition. Does
the affected tooth have an antagonist that justifies maintaining the affected tooth, and is prosthetic
reconstruction even possible? Endodontic treatment is indicated only if maintenance of the tooth is
necessary for prosthetic or other functional reasons.

2. Acute examination in endodontics

3. Test of tooth vitality

Cold Test and Electric Sensitivity Test

Electrical or thermal sensitivity tests provide clues as to whether the pulpal tissue has been severely
damaged or not. Cold tests are the most predictive. Any exact differentiations be- tween clinically
healthy pulp, reversible pulpi- tis, or irreversible pulpitis is, however, usually not possible using this test
alone, because in- tact nerve tissue generally persists even in ar- eas with severe inflammation and
tissue necro- sis. Even when periapical radiolucencies are noted, the sensitivity test may still be
positive.

The cold test using dry ice has significant advantages over other sensitivity tests. Be- cause an isolating
moisture layer is formed beneath the CO2 ice at temperatures above 0 C,,̊ this test procedure is not
damaging to the tooth or its surrounding tissue. Only after con- tact for two minutes or more will
enamel be compromised.

Electric sensitivity test procedures are based upon the special conductivity of tooth hard structure.
Within the device, the electri- cal impulse is established according to the im- pedance of the tooth, so
that if the test probe inadvertently slides onto the oral mucosa the current is broken; thus, a false-
positive result is prevented.

The electrode, usually made of conductive rubber, is placed onto the dried tooth surface. The electrical
circuit is closed via the hand- piece, and via a metal mouth mirror in the cli- nician’s hand.

Young teeth with wide-open apical fo- ramina have not yet fully developed their sen- sitivity, thus
false-negative responses can occur. In addition, following trauma, the sensitivity test may prove
negative for days or even weeks.

The electrical sensitivity test cannot be used on teeth with metal crowns, or on ce- ramic crowns
because of the isolator effect.

False-negative responses may occur in 34 teeth with expansive and advanced caries. The electrical test
is contraindicated in patients

with a cardiac pacemaker.

Heat Test

The heat test is indicated for the diagnosis of advanced pulpitis, but is only a confirmatory test.

Clinical Examination

A A temperature of 26–30 CC is achieved after four seconds of cold application. This elicits a pain
reaction. Within the pulp, the temperature actually drops only about 0.2 CC. Ice cubes drop the
temperature to –20 C;,̊ cryogenic sprays, applied to the tooth surface on a cot- ton pellet, drop the
temperature to –40 CC. Compressed dry ice may achieve even –70 CC.

B The electrical sensitivity test is simple and reliable. The tooth surface must be dry. The end of the
pulp tester probe must be moistened, e.g, with toothpaste. Using the device with rubber gloves can
lead to false readings because of the insulation. Simplest is to permit the electrical circuit to close
when the metal portion of an instrument handle contacts the clinician’s hand.

C Extraoral bimanual palpation of the lymph nodes.

D The buccal surface of the root is palpated in the vestibule, and the patient is asked about any
sensitivity.

E Palpation of the palate follows the course of the root surfaces and adjacent tissues.

F Percussion sensitivity of a tooth is a sign of the presence of periapical inflammation. Root fractures
can also be detected by percussion or by the biting test. The vital percussion test should also always be
performed on the adjacent teeth for comparative purposes.

G Horizontal percussion using a mirror handle.

H Biting test on a wooden tongue blade. Pain upon release of biting force indicates an infraction, a
vertical or horizontal tooth fracture

4.Additional methods of examination in endodontics

5. Radiographic examination in endodontics

C. Treatment with maintenance of vital pulp

1. Caries pulpae proxima

‘’Deep caries close to the pulp.’’
This treatment aims to treat the carious dentin without affecting the pulp itself.
-Removal of all infected and affected dentin to prevent further cariogenic activity and provide well-
mineralized base of dentin for restoration.
Can be accomplished by using the Indirect Capping technique, pulpotomy or in extreme cases
pulpectomy to preserve the vitality of the pulp.
 Is the removal of the carious dentine but when getting close to the pulp some carious dentin is left behind so
there will not be exposure of the pulp.
 CaOH is then placed on the carious dentin and continue with the restoration. (sandwich technigue
 
– CaOH GIC Composite)
 With this method the bacteria that are left behind do not have any nutrition source and at some point they die
and then tertiary dentine can be produced.

2.Indirect pulp capping (mechanism of healing,conditions)

: a procedure where the deepest layer of the affected carious dentine is covered with a
biocompatible (CaOH,MTA) material in order to prevent pulpal exposure and further trauma to the
pulp .
The objective of this procedure is to preserve the vitality of pulp by completely removing the carious-
infected dentine followed by a placement of a material that will help the odontoblasts to produce
tertiary dentine.

Physiological remineralization can only occur when the affected dentine contains sound collagen fibres.

Because of the removal of the most superificial layers of the carious dentin the bacteria that are left behind do
not have nutrients and so cannot produce acid.

When the lesion is sealed there is arrest of the carious process and the reparative mechanism is able to lay down
additional dentin and avoid pulp exposure
The mechanism :
1. Remaining dentin thickness : 0.5-2 mm of dentin has a good prognosis as the secretion of
reactionary dentin is more .When is lower than 0.5 mm the dentine production is reduced due to
reduced amount of odontoblastic activity.
The rate of reparative dentin has be shown to be 1.4μm/day and decreases a lot after 48 days.
2. Choice of the indirect pulping agent: CaOH has the most lasting record for killing the bacteria
below the cavity and restoring the dentin because of its alkality and the bridge that makes with
dentin

3.Indirect Pulp Capping (Working procedure)

Can be done in one step or two step procedure
Fisrt Appointment:
- Local anesthetic and rubber dam are used
- High-speed bur for the enamel
- Low-speed tungsten bur for the dentin until deep enough that if go further the pulp wil be
exposed.
- Spoon-shaped excavators to remove the remaining carious dentin form periphery.
- Wash and dry the area
- Calcium Hydroxide is placed on the top of the dentin
- Zing-Oxide Eugenol or any other temporary material (polyxarboxylate) can be used and the

restoration is finished with ZOE you CANNOT use composite.
- 6-8 weeks for reparation

Second Appointment
- X-ray to see if the pulp is okay and not carious and also to see if there is any periapical lesions
- Local anesthesia and rubber dam
- All the restorative materials are removed
- Brownish red colour of affected dentine now has to be brownish-gray and harder
- Wash and dry out the cavity
- CaOH placed again and a permanent restoration is placed (composite or sandwich technigue)

4.Direct Pulp Capping (mechanism of healing, conditions)

:is the procedure which the exposed vital pulp is covered with a base or a protective dressing in
order to preserve the vitality of the pulp
The pulp can be perforated by mistake from the dentist while preparing the cavity. The capping has to
be made immediately!!!!
Mechanism of Healing:
- When the CaOH is placed it neutralizes the the attack of inorganic acids and their products
- Can induce mineralization even in tissues that are not programmed to mineralize
- It is an initiator
- Hard-Setting Calcium hydroxide is recommended because they release less hydroxyl ions and are
gentler to the pulp.
 
- Calcium is released which reduces capillary permeability reduced flow decreses the

pyrophosphates mineralization occurs
  
- Hydroxyl ions neutralizes acid in osteoclasts ptimum pH for pyrophosphates increased levels of calcium
 
ion- dependent pyrophosphates reduced levels of inhibitory pyrophosphates mineralization

MTA use:
- Produces more dentinal bridges than CaOH in shorter life span
- Ability to resist future bacterial penetration
- Highly biocompatible with pulp and periodontal tissues
- Hydrophillic

Conditions:
- Maintain pulp vitality
- Stimulate reparative dentine
- Bactericidal or bacteriostatic
- Sterile
- Radiopaque

5. Direct Pulp Cavity (working procedure)

2 tecnhiques:
Clacium Hydroxide Technique
MTA technique
Common procedure:
1. Local anesthesia and isolation
2. Undermined enamel removed
3. Carious dentine removal with tungsten bur and excavator
 
4. If mild bleeding cotton with 3-6% Sodium Hypochloride Hemostasis
5. CaOH or MTA chosen

Ca(OH)2 technique

 Hard-setting CaOH used over the exposed pulp and is followed by a GIC lining.
 One step or two step restoration

MTA technique
  MTA mixed
 Minimum of 1.5mm over the exposed pulp

 Cotton pellet placed on top of it

 Temporary filling is placed and the patient will come back in 5-10 days

If the capping will be done in one visit :

 MTA  GIC  etching  Composite
6.Pulpotomy (cervical and partial) with anesthesia
: removal of coronal portion of dental pulp to preserve the vitality and function of the remaining
radicular portion
Objectives
- Preservation of vitality of pulp
- Relief of pain

Indications:
- Cariously exposed deciduous teeth, when their retention is more advantageous than extraction.
- Vital tooth with healthy periodontium
- Hemorrhage from the perforation is easy to control and stop

Contraindications:
- Irreversible pulpitis
- Abnormal sensitivity to heat and cold
- Periradicular changes resulting from a pulpal disease
- Calcification

Classification depending on the Pulpal tissue removed

a) Cervical Pulpotomy – coronal removal of the pulp
b) Partial Pulpotomy- removal of the infected pulp only until reaching healthy tissue

a)Cervical Pulpotomy
- Xray
- Anesthesia – local or general
- Isolation and caries removal and straight line access to pulp cavity
- Hemorrhage control (3-6% sodium hypochlorite)
- Coronal portion is removed with sharp sterile spoon excavator or periodontal currete
- As much tissue as possible has to be left
- Placement of medicament with cotton pellet [CaOH/MTA/Formocresol(only deciduous dentition) ]
- 2mm of material
- Base is placed (GIC or flowable compomer) over the CaOH/MTA
- Permanent restoration
- Rubber dam removed
- Occlusion checked and x-ray is taken for future reference
- Vitality tests and x-ray have to be made after a period of 3 months

- If pain and death of root RCT should be made
b)Partial Pulpotomy
: Removal of the inflamed coronal pulp only
- inflammatory changes occur when the pulp is exposed by trauma or caries
- uninfected pulp tissue is preserved in root canal by surgical excision

- removal of inflammatory pulp rapid relief of pain and can undergo repair while completing
apexogenesis (root-end development and calcification)
D. Morphology of root system
1. General anatomy of root system
Anatomical root: Portion of root covered by cementum.
Clinical root: Portion of the tooth not visible in the mouth.
The root is the portion of the tooth which sits inside the alveolar bone, inside the root we find the root
canals which descend the full length of the root, these canals contain the radicular portion of the pulp,
which contains blood vessels, nerves, lymph vessels and connective tissue which enter via the apical
foramen. Here we can also find lateral canals and apical ramifications.

Number of roots and root canals per tooth:

Maxillary:
Central incisor: Evenly tapered singular root, 1 root canal
Lateral incisor: Slightly convex root, 1 root canal.
Canine: 1 root (strongest and longest of all), 1 root canal.
First premolar: 2 roots usually buccal and lingual, variants include 1 and 3 roots. Canals: 2 root canals
Second premolar: 1 root, tapered towards apex and lingually.
First molar: 3 roots, two buccal and one palatal root. Palatal root is long with a blunted end. 4 roots
canals. (1 palatal, 2 mesiobuccal and 1 distobuccal). Mesiobuccal root is broader and curves distally,
while distobuccal root is narrower at the base and straighter.
Second molar: 3 roots, 2 buccal and one palatal, the roots incline more distally. 3/4 root canals

Mandibular:
Central incisor: 1 root, narrower on lingual side, compared to labial side. 1/2 root canals.
Lateral Incisor: 1 root, longer than mandibular central incisor. 1/2 root canals.Canine: 1 root, slightly
shorter than maxillary canine. 1/2 canals.
First premolar: 1 root, tapers more on lingual side. 1/2 canals
Second premolar: 1 root, larger and longer than mandibular first premolar. Usually wide with blunt
apex. 1/2 canals.
First molar: 2 roots: 1 mesial and 1 distal. Mesial root is curved, while distal is straighter. 3 root canals,
2 in mesial root and 1 in distal root.
Second molar: 2 roots, straighter than mandibular first molars, and the roots are closer together. 3
root canals, but is there is fusion of the roots, there will be fewer canals.

2. Types of root canals

• Weine’s classification

Type I: 1 orifice, 1 apical foramen, 1 root canal

Type II: 2 orifices, 1 apical foramen, 2 root canal
Type III: 2 orifices, 2 apical foramens, 2 root canals
Type IV: 1 orifice, 2 apical foramens, 1 root canal.

• Vertucci’s classification

Type I: Single canal

Type II: Two separate canals that converge at the root.
Type III: A canal divided in to 2 in the root, converging
to a single canal near the apex.
Type IV: Two separate canals from pulp chamber to apex.
Type V: A canal divided in to 2 before the apex.
Type VI: Two canals that converge within the root and
then divide in to two separate canals before the apex.
Type VII: A canal that diverges and then converges within
the root, before diverging once more in to two separate
canals.
Type VIII: 2 separate canals from the pulp chamber to
apex.
Any accessory foramina are due to a defect in epithelial
root sheath, failure in induction of dentinogenesis or the
presence of blood vessels. More prevalent in the apical third of the tooth.

3. Anatomy of apex
Classic concept is that there are 3 major landmarks at the apex.
a) Apical constriction/physiological foramen:
b) Cementodentinal junction
c) Apical foramen/anatomical foramen

a) Canal preparations and obturations should be

carried out until the apical
constriction/physiological foramen.

The shape of the physiological foramen is oval.

The natural narrowing provides a mean for rapid development of solid apical dentin during
obturation, enhancing the chance of retaining the sealants and filling materials places inside
the canal.
b) The CDJ is the point where the pulp ends and the periodontal tissue begins, it is estimated to
be 1mm above the apical foramen.
c) From the apical constriction, the canal widens as it approaches the apical foramen. It’s funnel
shaped and differentiates the termination of the cemental canal, from the exterior surface of
the root. In a young person, the distance between the apical constriction and apical foramen is
about 0.5mm, while in adults it is about 0.67mm, owing to an increase in cementum build up.
Apical foramen doesn’t usually exit at anatomical apex, but instead is found 0.5-3mm away.
Normally, more than one apical foramen is found in teeth, but not in, distal roots of mandibular
molar and palatal roots of maxillary molars. Mostly likely roots with more than 1 apical
foramen: mesial root of mandibular molars, maxillary premolars, mesial root of maxillary
molars.

4. Physiological and pathological changes of root morphology.

Accessory canals- Furcation, lateral or apical 1/3 of root. Have a small potential for pathological
problem, because they can potentially harbour irritants.
Resorption: Shallow dentin resorption in apical portion of the root is normal. Mainly due to ortho
treatment or inflammation of apical pulp and periapical. If it’s caused by inflammation, when it
subsides, secondary cementum is deposited in area of resorption, changing anatomy of root apex, with
a shift of principal apical foramen to one side.
Pulp stones/denticles: Age related or due to local pathological changes. These are formed around foci
of mineralising pulp tissue components (collagen, nerve fibres, necrotic cells etc). Either attached of
embedded, with dentin surrounded it.
Apical calcification: Chronic inflammation and aging. If apical 1/3 is calcified, then complete obturation
is difficult. EDTA and thin files should be used.
Irregular secondary dentin: Usually, secondary dentin is deposited continuously by radicular pulp
tissues, seen on root canal walls of some teeth and in greater amounts in periodontally involved teeth.
If dentin and cementum are continuously deposited, it will reduce the size of apical foramen, but not
completely close it as long as vital pulp tissue is present.
Isthmus: Narrow communication between two root canals, it contains pulp or pulpally derived tissue.
They can function as bacterial reservoirs. Any root with 2 or more canals may have an isthmus.
Enamel pearls: Found in bi/trifurcation of teeth. May cause stagnation at gingival margin.
 E. Instrumentation and devices in endodontics

1. Standardisation and classification of endodontical instruments.

Standardisation:
Instruments shall be numbered from 10-100, increasing by 5 units up to size 60, and then by 10, up to
100. Then revised to start from 6 to go up to 140.
Each ISO number will represent the diameter of the instrument, in hundredth of a millimetre eg
ISO 10- 10/100= 0.1mm.
Working blades will start at the tip of the instrument, designated D₀ and they will extend 16mm up
the shaft, terminating at D₁₆.
The diameter at D₁₆ for each ISO instrument, will be 0.32mm greater that the ISO value it has.
This sizing will ensure a constant taper increase of 0.02mm for each instrument.
The angle of the tip should be 75˗⁺ 15ᵒ, with the diameter increasing by 0.05mm between ISO 10-
60 and 0.1mm between ISO 60-140.
Classification:
Endodontic instruments are classified according to their method of
use: Group I: Hand-operated- including broaches, reamers and files.
Group II: Non-rotary used with hand piece- engine driven instruments and ultrasonic and
sonic instruments.
Group III: Rotary instruments used with a hand piece- Low speed instruments with latch type
attachment that hold them in place inside the hand piece. E.g Gates Glidden drills and Peeso
reamers. Rotary Ni-Ti instruments are also used here.

2. Sizes and colour signs of root instruments

Pink- ISO 6
Grey- ISO 8
☺
Purple (Lilac for Demetris )- ISO 10
White- ISO 15, 45, 90
Yellow- ISO 20, 50, 100
Red- ISO 25, 55, 110
Blue- ISO 30, 60, 120
Green- ISO 35, 70, 130
Black- ISO 40, 80, 140

3. Classification of endodontical instruments

Group I: Hand operated

a) Barbed broaches and rasps: Used to extirpate the pulp, remove necrotic debris, paper
points and any other foreign materials from the canal. It’s also used to enlarge the canal.
Easy to break, especially if they bind in the root canal. These are not used, until the canal
has been enlarged via the use of ISO reamer/file up to size 20/25. Sized from triple extra
fine, to extra coarse. Through comparison with the last sized ISO instrument used, the
broach should be picked which will fit loosely in the apical third of the canal.
Use 5.2% Sodium hypochlorite, irrigate, then add broach until there is unforced contact
with canal wall. Withdraw 1mm, turn 360ᵒ and then remove from canal.

b) K-reamers and K-files: Reamers are used with a push and rotate motion, while files are used with a
rasping and pulling motion. Made from stainless steels blanks. Traditionally reamers were made from
 triangular blanks, while files were made from square blanks. Now they are made from similar blanks,
with the number of flutes distinguishing the two apart. Reamers have looser/more spaced flutes,
while files have tighter/closer flutes. Square blanks are more resistant to fracture, therefore they are
used for smaller, fragile instruments, while triangular blanks are used when fracture isn’t a critical
factor, as they cut more efficiently. The instruments should be periodically removed from the canal,
to reduce chance of deformation, pressure should never be applied to the instruments while they
are in the canal as this increases the chance of deformity and fracture. K-flex files are made from
rhomboidal blanks which increase flexibility and cutting efficiency, they have alternating high and
low flutes to help with debris removal. Flex-R-File- Memory to return to original position increases
tendency to transport or ledge the canal, but the reduction in the cutting angle tip allows the file to
stay more centred in the canal, leading to a more circumferential cutting action.
c) Hedstroem files (H files): Spiral fluted instruments with higher cutting efficiency that K-files but are
more prone to fracture. The better cutting action is owed to the more positive rake angle of the
blade tip. Should only be employed in one direction, with no other movement inside the canal.
Safety H-file: Non-cutting edge to prevent ledging of curved canals.
Hyflex file: S shaped cross section unlike normal teardrop cross section.
Unifiles: Less likely to fracture but are less efficient too.
d) C-files: Stiffer files with active end-cutting tips, unlike K-files which have non-cutting tips. The C+ -file
can engage the dentin much better in calcific conditions with the extra stiffness and the active cutting
tip, the stiffness is a result of the file having a square cross section which gives it more bulk in the
core of the file.

Group II: Non-rotary instruments with handpiece:

a) Engine driven: Used with hand pieces and perform two motions:
① Reciprocating or quarter turn movement- Access to apical foramen must firstly be done with
hand instruments before engine driven instruments are used. K files can be used with a turning of
90ᵒ, while the safety H file can be used with a turning of 30ᵒ in the hand pieces.

②Vertical stroke with one quarter turn motion- Air/electrically driven device which provides a
vertical stroke of 0.3-1mm, with a quarter turn too when the instrument makes contact with the
canal wall.

b) Ultrasonic/Sonic: Used for cleaning and shaping of root canals. Ultrasonic instrument is built to hold
a K-file piece or a diamond file. The oscillating movement provides the cutting action of the file while
also increasing the chemical effectiveness of the root canal through heat generation. The apical third
of the root should be should be instrumented to at least ISO 30/40 to allow free oscillation of the
instrument in the canal. When using ultrasonic with sodium hypochlorite, precautions should be
taken as it can create a mist that irritates the eyes and respiratory system. Use of a rubber damn and
glasses is important here. Sonic instruments are similar to dental hand pieces, and it uses water as
the irrigant here and requires special instruments for its use: Rispi sonic, Shaper sonic and Trio sonic.

Group III: Rotary instruments used with handpiece:

a) Slow speed rotary stainless steel instruments:
①Gates Glidden- Long thin shaft ending in a flame shaped head with a safety tip to prevent
perforation. Flame head cuts laterally and is used with gentle apical motion. If the instrument breaks,
it’s easily removed due to the fracture occurring at the neck, near the handpiece. It is used to
remove the lingual shoulder during access preparation of anterior teeth and to enlarge root canal
orifices (coronal flaring).
②Peeso Reamer- Has long, sharp flutes connected to a thick shaft. It cuts laterally and is used
mainly for the preparation of post space when gutta percha has to be removed from the
obturated root canal.
These instruments must be used at a slow speed to prevent overinstrumentation and
perforation.
 b) Nickel-Titanium rotary instruments: These are made of a superelastic alloy which is very stress
resistant and won’t fracture unless this stress threshold is met/exceeded. The crystalline
structure of the Ni-Ti structure exhibits shape memory, this can allow it to undergo a 360ᵒ
revolution within a curved root canal. They are operated at a speed between 150-800rpm. The
higher speed improves cutting efficiency, but equally increases loss of control, risk of instrument
breakage and changing the canal’s shape. Components of these instruments:
Taper: Per mm increase in file diameter from tip towards handle. Traditionally ISO instruments
have a 2% taper. Tapered intruments help with the preparation of wider diameter canals without
overenlarging them.
Flute: Groove or relief on working
surface of file which collects debris
as the file curs through the
substrate.
Blade: The cutting edge of the file
with the greatest diameter, following
the flute as it rotates. Land: Found in
certain files. It is the surface that
projects axially from the central core
to the cutting edge between the
flutes. Its purpose is to reduce canal
transportation and to support the
cutting edge.
Pitch: Distance from one cutting edge
to the next. A file with a short pitch
will have more spirals than one with
a longer pitch.
Rake angle: If a cross section is
made of a file, the rake angle is that
which forms between the leading
edge and the radius of the file. A
positive rake angle is when the
angle is obtuse (90-180) while a
negative rake angle is when the
angle is acute (<90).
Helix angle: Angle the cutting edge
forms with the long axis of the
tooth.
We use Protaper Universal NiTi instruments with a convex triangular shape, sharp cutting edges
and no radial lands (displayed in Profile (A)). The taper is variable along the length of the
instruments, with balanced pitch and helix angles to prevent instruments screwing in to the
canal. Colours correlate to ISO sizes.

The use of electric motors over air powered one provide several advantages: Preset rotations
per minute, preset maximum torque for each different instrument and system, to prevent
fracture of instruments and autoreverse when maximum torque level is reached.

4) Instruments for trepanation (access cavity) of pulp cavity

• Red handpiece-Enamel.
• Blue/Green handpiece-Dentin,
• Speed should be slow, with water cooling.
• Diamond burs (fissure or round) are used to create the basic shape of the access cavity.
 • Tungsten burs (round) are used to smooth the dentin and open the pulp chamber, it
removes the roof of the pulp chamber.
• Dome ended bur with fissures is used to penetrate the pulp chamber.
• Safe ended burs- Batt bur, endo Z burr, used for the end of pulp chamber removal
and smoothing of access cavity.

5) Instruments for widening of root canal’s entry.

• Firstly to probe the canals, we use C files and root canal explorer to detect their entrances
in the pulp chamber.
• To widen the entrance, we use rotary instruments for coronal flaring. Gates Glidden are
flexible so as to follow the canal’s shape, it can prepare 2/3 of the coronal region, and also
remove gutta percha from the canal during post space preparation, retreatment or can
widen the canal when an instrument has fractured. ProTaper can also be used here.

6) Instruments for removing content of pulp cavity and root canal

Dental pulp removal- Endodontic spoon excavator is used to remove pulp from the coronal
chamber. Barbed broach is used to remove intact pulp or its residues in wide canals, they snag
the pulp to allow removal. As mentioned before, the broaches should be rotated 360ᵒ before
being removed.

7) Instruments for root canal shaping

• K-file- clockwise ½ twist
• K-reamer- Clockwise ¼ twist.
• K-flexfile- Clockwise ½ twist followed by counter clockwise ½ twist.
• Flexofile- Clockwise ½ twist.
• H-file- Filing, NO rotations.

8) Instruments for rotary endodontics

(See question 3, Group III Rotary instruments)
9) Instruments for root canal fillings
Root canal filling instruments
1. Spreaders
Cold lateral compaction using gutta-percha requires either long-handled or finger spreaders . These
have a long, tapered shank with a sharp point. The instrument is used to compact gutta-percha
laterally against the walls of the root canal and provide a space for the insertion of further gutta-
percha points. There are several sizes available, and these are selected according to the canal size
and the size of the gutta-percha point. The choice of long-handled spreaders or finger spreaders
depends on personal preference. The advantage of finger spreaders is that less force can be used,
and this reduces the risk of root fracture.

Figure : Cold lateral compaction may be carried out with

either finger spreaders or long-handled spreaders.

2. Heat carriers
The application of heat to the gutta-percha filling permits improved lateral and vertical compaction of
the softened material. Ordinary hand and finger spreaders are not designed for this purpose. They are
of various sizes, and have both a pointed tip for lateral spreading, and a flat tip for vertical compaction.
 Figure : Machtou heat carrier/pluggers for warm lateral
and vertical compaction.

3. System B
for the controlled and precise application of heat to the gutta-percha filling.

4. Obtura machine
used to deliver heated gutta-percha directly to the root canal.

10) Apex locator in endodontics

This is used to accurately locate the distance to the apical foramen (anatomical foramen) using the
principle of electrical resistance between the oral mucosa and periodontal ligament.
Should not be used in patients with pacemakers!
F. Disinfectants in Endodontics

F1. irrigation of root canals

purpose
through mechanical and chemical treatment of root canal
system removing dental pulp and its residues preparation for
hermetic filling

Chemical treatment
contact of instrument with the root canal wall forms SMEAR LAYER – potentially occlude dentinal
tubules and spaces between them

Therefore there must be washing of the root canal to remove this

layer Other function: antimicrobial effect, decalcification, lubrication

Smear layer
Defn: organic – anorganic microcrystalline layer of cutting debris covering wall

Inner: lying on dentinal tubules and block the dentinal fluid movement
External: lying on dentinal tubules and intertubular dentin
Sealer may have better adhesion after removal of smear layer

Instruments
Syringe w/. special endo tip –
Special devices – endovac, endorinse = rinsendo
Macro/microneedle
Handpiece used instead of turbine w/.o H 2O cooling

F2. Agents for root canal irrigation

Requirements
ability to remove smear layer/debris
antimicrobial effect
lubrication
decalcification
dissolution of dental pulp residue
proteolytic effect

Disinfectants (irrigants)

1. NaOCl – sodium hypochlorite (clinical choice)

1-5.25% pH
12-13
good antimicrobial effect
low lubricant effect/irritae soft tissue / bleaching of clothes / hypersensitivity (rare)

2. Chlorhexidine diglucuronate
0.12-2%
can be used for final irrigation protocol
used for gram +ve and gram –ve microorganisms
efficiency not so high
ALLERGY – recently discovered, can cause anaphylaxis

3. Hydrogen peroxide – H2O2 3%

not suitable before definitive filling
applying with pressure may lead to emphysema no
antimicrobial or proteolytic effect

4. Sterile water & physiologic solution – NaCl

0.9%
allergy

Disinfectants (chelators)
Chelator: soften dentine by demineralization (esp. for a calcified canal)

5. EDTA
17% solution or gel pH
6-7
lubricant/good for dissolving smear layer low
antibacterial effect

Final irrigation protocol

2.5% sodium hypochlorite
17% EDTA
 2.5% sodium hypochlorite

if severely infected
5% sodium hypochlorite
17% EDTA
2.5% sodium hypochlorite

3. Disinfectious temporary root fillings

Calcium hydroxide agent used in temporary root fillings

• Destroys bacterial endotoxins and organic 3ssues
• Applica3on through out the apex leads to irrita3on and pain (for 12–24 h)
• pH 12–13 (high an3microbial e ect)
• Biocompa3ble
• Remineraliza3on
• Ca(OH)2+H2CO3→CaCO3+2H2O
• Zone of demarca3on
• Self-limited necrosis
• Calcifica3on
• Dentinoid or osteoid tissue

Indications
• Incomplete development of root
• Internal resorp3on
• Chronical apical periodon33s
• Exacerba3on of chronical apical periodon33s
• Impossibility of canal drying
• Disinfec3on material/remineraliza3on support

Application
• Lentulo spiral drill used
• Syringe and endodon3cal needle
• For short and long 3me applica3on
• In the simple cases- for 1–2 weeks
• In the complicated cases- change aVer 2 weeks, applica3on for 3–4 months
• Tephlon tape + temporary filling

Controversy
• Some authors do not recommend to applicate Ca(OH)2 like temporary root filling
• AVer its applica3on the den3ne of root canals may be more fragile
• There is impossible to remove all of the its residues from root canal wall
4. Agents for disinfectious temporary root fillings
 Calcium hydroxide agent used in temporary root fillings
• Destroys bacterial endotoxins and organic tissues
• Application throughout the apex leads to irritation and pain (for 12–24 h)
• pH 12–13 (high an3microbial e ect)
• Biocompatible
• Remineralization
• Ca(OH)2+H2CO3→CaCO3+2H2O
• Zone of demarcation
• Self-limited necrosis
• Calcification
• Dentinoid or osteoid tissue

5. Ca(OH)2 in endodontics

CALCIUM HYDROXIDE - Ca(OH)2

Function: destroy bacterial endotoxin and organic tissues
pH: 12-13

high antibiotic effect/biocompatible

remineralization/ self limited necrosis
zone of demarcation and bacteria can not leave

promote formation of dentinal or osteoid tissue – healing process

(effective in 7-10 days, as pH decreases during time -> disappears by 7 months)

Indications of calcium hydroxide

Internal resorption -> necrotic pulp in RTG
Chronic apical periodontitis and acute exacerbation of chronic apical periodontitis

Application using the lentulo/syringe and Teflon tape and temp. filling
(before application, rinse with EDTA)

Time: short -> simple case: 1-2 weeks

Long -> complication, change every 2 weeks/needs 3-4 weeks

6. Temporary fillings of crown material

for sealing of canal entries
• Flow composite
• GIC (not often used, hardens within 5 mins)
• Self cured composite resin (48 hours for complete setting)

Temp fillings
Depends on amt of hard tissue loss

Types
Temp cement – caviton, MD temp
GIC
Zinc oxide phosphate
Zinc oxide eugenol
Temp cement
Not so hard and mechanically resistant
Good abrasion
Nonporous
Use: minimal loss of hard tissue

GIC
hard and resistant
Good adhesion (chemical)
Non porous
Use: great loss and long time temp filling

Zinc oxide phosphate

Hard, cheap
Bad adhesion
Porous – bacterial toxin may penetrate

Zinc oxide eugenol

Hard
Good adhesion
Adequate porosity
Inhibit the polymerization of composite

7. Pharmacology in endodontics (ATBs, Analgesics, Anxiolytics, sedatives)

Analgesics – relief of pain

Canal debridement
Primarily used is aspirin
Tylenol can also be used
If more needed, analgesic can be given with 0.25g of codeine

Canal debridement where considerable overinstrumentation has occurred

Analgesic with 0.25g codeine

Canal filling where overfilling has occurred and periapical tissues are
normal give analgesics with 0.25g codeine

root amputation without flap

aspirin and tylenol can be given

periapical or amputational surgery with minimal

trauma aspirin and Tylenol can be used

extensive surgery with considerable trauma

analgesics with 0.5g codeine

pain management strategy

diagnosis
definitive treatment (pulpotomy, pulpectomy. Root canal treatment, extraction, incision and drainage) Drug
(pretreatment with NSAIDs, long acting LA (local anaesthetic), flexible prescription plan

sedatives -
sedatives, barbituates
pentobarbital – hypnotic dose 100mg at bed time, to be reduced in elderly and debilitated patients
secobarbital – 50mg at bed time and 50mg 30mins before appointment

sedatives, non-barbituates
Flurazepam – hypnotic dose is 15-30mg at bed time, 15mg for elderly or debilitated patients

Triazolam – 0.125-0.25 mg for adult patients

Diazepam(Valium) – 5 to 10mg tablets. 1 tablet at bedtime, 1 tablet 1-2 hours before appointment

Oxazepam – 10-30mg capsules and tablets. 1 tablet at bedtime and 1 tablet 1-2 hours before
appointment

Antibiotics
Help against especially virulent bacteria (gram+ve or gram-ve), physiological depression of the host
defence, help against a defective immune system

Indications for antibiotic therapy

Acute onset infection, diffuse swelling, compromised host defence, severe pericoronitis, cellulitis,
involvement of facial spaces, osteomyelitis

Contraindications for antibiotic therapy

Reversible/irreversible pulpitis, acute apical/periodontal abscess, gingival/periodontal abscess, dry
socket, chronic well localised abscess, mild pericoronitis, minor vestibular abscess

Selection of correct antibacterial agent

Establish a clear indication – malaise, fever, chills, trismus, rapid respiration, swelling, abscess and
cellulitis
Determine patient’s health status – systemic considerations, polypharmacy, history of adverse drug
reactions
Selecting an appropriate agent – with a narrow spectrum, low toxicity, correct antibiotic to match the
clinical criteria, antibiotic to treat the correct gram staining of bacteria (Gram positive or negative)
Dosage
Duration of therapy
Patient compliance (allergy)

Antibiotic prophylaxis (treatment given or action taken to prevent disease)

Heart patients – artificial valves, bacterial endocarditis

Artificial joint patients – immunocompromised, rheumatoid arthritis, radiation, immunosuppression
Hemophilia

Prophylaxis needed in dental treatment needed in

Extractions
Periodontal procedures
Subgingival antibiotic fiber placement
Implants
Instrumentation beyond apex
Intra ligamentary injection
Orthodontic band placement

Prophylaxis regimen for dental procedures

ADULTS
3g Amoxycillin 1 hour prior to procedure
1.5g Amoxycillin 6 hours after initial dose

CHILDREN
40mg/kg amoxicillin orally 1 hour prior to procedure
20mg/kg amoxicillin 6 hour after initial dose

other drugs given are clindamycin, cephalexin, azithromycin, clarithromycin

GOLDEN RULES FOR ANTIBIOTIC USE

Don’t use antibiotics unnecessarily
Avoid broad spectrum antibiotics as far as possible
Don’t prolong the antibiotic therapy unnecessarily
In cases of chronic infection like TB, leprosy, etc. employ multiple drug regime
 G.Indications and contraindications of endodontic treatment

1. Indication for endodontical treatment

1. the necrotic or gangrene pulp

2. traumatic injury ( can’t do filling )
3. prosthetic or orthodontic reason
4. autograft tooth
5. irreversible pulp damage
6. horizontal fracture
7. internal resorption ( from pulpal inflammation )

2. Contraindications for endodontical treatment (classification) A.

General contra-indication:

• inadequate access due to trismus

• poor oral hygiene
• general medical condition like old patient, asthma patient, anaemic patient.
• Patient attitude
• Non-cooperative patient

B. Local contra-indication:
• Insufficient periodontal support

• Non-restorable teeth:
- Short crown
- Root caries
- Caries to bifurcation point
- Fracture below the gingival margin

• Canal instrumentation not practical:

- Excessive curvature of root
- Small pulp
- Pulp stone
- Internal resorption

• Massive resorption

• Bizzare anatomy
3. Contraindications for endodontical treatment (from conservative view)

A conservative view:

• Heavy marginal periodontonts

• vertical fracture of root
• Deep Root caries
• Huge Resorption of root
• Wisdom tooth
• Focal Infection

A Social View:

• lack of time
• economic constraints
• restless patients (downs syndrome)
• Lack of interest from patient
• Poor oral hygiene
• Patient prefers other solution (dental bridge, denture)

A Technical view:

• Extreme RC anatomy

• Fractured root instruments

• non removable root canal fillings or cast post

• unsatisfactory equipment of the dentist

4. Endodontical treatment and focal infection

• Focal Infection

Definition: It is localized or general infection caused by the dissemination of microorganisms or

toxic products from a focus of infection.

• Focus of Infection

Definition: This refers to a circumscribed area of tissue, which is infected with exogenous
pathogenic microorganisms and is usually located near a mucous or cutaneous surface.

• Theory Related to Focal Infection

- William Hunter first suggested that oral microorganisms and their products involved in number of systemic diseases, are
not always of infectious origin.

- In year 1940, Reimann and Havens criticized the theory of focal infection with their recent findings
• Mechanism of Focal Infection

- There are generally two most accepted mechanisms considered responsible for initiation of focal
infection:
2. Metastasis of microorganisms from infected focus by either hematogenous or lymphogenous
spread.
2. Carrying of toxins or toxic byproducts through bloodstream and lymphatic channel to site where they
may initiate a hypersensitive reaction in tissues.

For example: In scarlet fever, erythrogenic toxin liberated by infected streptococci is responsible for
cutaneous features of this disease.

• Oral Foci of Infection

Possible sources of infection in oral cavity which later on may set up distant metastases are:

1. Infected periapical lesions such as:

i. Periapical granuloma

ii. Periapical abscess

iii. Periapical cyst

2. Teeth with infected root canals.

3. Periodontal diseases with special reference to tooth extraction.

H. Endodontical treatment

1. Extirpation of dental pulp in injection anaesthesia.

Pulp extirpation, enlarging the canal when vital tissues are present, and at times even obturation can
be extremely painful if successful anesthesia is not achieved. Irreversible pulpitis should be treated by
pulp extirpation.
Pulp extirpation stops internal root resorption.
Tools and technique used for Extirpation:
Penetrate the barbed broach along the canal wall towards the apex
↓
As it reaches to the apical constriction, move it into the center of mass of pulp tissue
↓
Rotate the broach several times in a watch winding manner to entrap the pulp which is then
withdrawn from the canal.

Broach

Uses of broach
• Extirpation of entire pulp tissue.
• Removal of cotton or paper points lodged in the canal.
• Removal of necrotic debris from canal.

Final irrigation protocol, Vital Extirpation:

1. 2.5% NaClO (minimally 30min)
2. 17% EDTA (1 min)
3. 2.5% NaClO

Use of broaches for pulp tissue extirpation is usually avoided in older patients, because very few
canals of older teeth have adequate diameter to allow safe and effective uses of broaches.

2. Mortal pulpectomy (principle, indications, agents, working procedure, current view)

Pulpectomy for primary teeth refers to the complete removal of pulp tissue from a tooth. The goal of
these treatments is to keep the remaining tooth healthy and prevent root resorption, until it is time for
the baby tooth to naturally fall out.

Indications
• Presence of excessive bleeding at pulpal stump during pulpotomy procedure
• History of spontaneous pain
• Tooth with irreversible pulpitis or necrosis (Figs 34.26 and 34.27)
• Internal resorption that does not perforate root.

Contraindications
• Internal resorption perforating root
• A nonrestorable tooth
• Extensive bony loss
• Pathologic root resorption involving more than 1/3rd of the root.
 Clinical Technique
• Give adequate local anesthesia
• Apply rubber dam to isolate the area
• Remove all carious dentin (Fig. 34.28)
• Penetrate pulp chamber with the help of slow speed round bur (Fig. 34.29)
• Remove pulp tissue with fine barbed broach and take the working length X-ray
• Complete the biomechanical preparation of canals. Take care to avoid over instrumentation (Fig.
34.30).
• Avoid using Gates-Glidden drill, sonic and ultrasonic instruments. Because of presence of narrow
and slender canals in primary teeth, there are increased chances of perforation.
• Copious irrigation is necessary to flush out debris. Usually sodium hypochlorite is preferred for
irrigation of the canals (Fig. 34.31).
• 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. 34.32).
Thereafter, tooth is restored with
Commonly used material for filling the canals are:
• Zinc oxide eugenol
• Iodoform paste stainless
• Ca(OH)2 and zinc oxide paste. steel crown
(Fig. 34.33).
The main criteria of filling material to be used in
deciduous teeth is that it should be resorbable so
that it is resorbed along with the roots, so does
not interfere with the eruption of the permanent
teeth.
 3. Vital pulpotomy (cervical and partial)

Pulpotomy refers to coronal extirpation of vital pulp tissue.

Objectives of pulpotomy:
• To preserve the vitality of pulp
• To promote apexogenesis by retaining pulp in the canal of an immature young permanent tooth.
• To provide pain relief in case of acute pulpitis

Calcium Hydroxide Pulpotomy

Indications
It is indicated in young permanent teeth with incomplete root formation to promote apexogenesis (Fig.
34.14).
Partial Pulpotomy
It implies removal of the coronal pulp tissue to the level of healthy pulp. Calcium hydroxide is material
of choice for pulpotomy in young permanent teeth to stimulate the formation of dentine bridge in
cariously exposed pulp. Technique: After anesthetizing the tooth, rubber dam is applied.
After this 1 to 2 mm deep cavity into the pulp is prepared using a diamond bur (Fig. 34.15). A thin
coating of calcium hydroxide mixed with saline solution or anesthetic solution is placed over it (Fig.
34.16) and the access cavity is sealed with a temporary restoration like IRM (Fig. 34.17)

Cervical or Complete Pulpotomy

Cervical or complete pulpotomy involves removal of entire coronal pulp to the level of root orifices. It
is performed when pulp is inflamed to deeper levels of coronal pulp.

Technique: Coronal pulp is removed same as in partial pulpotomy except that pulp is extirpated to
level of root orifice (Figs 34.18 and 34.19).
4. Anaesthesia in endodontics

Local Anesthesia
It is defined as a loss of sensation in a circumscribed area of the body caused by depression of
excitation in nerve endings or an inhibition of the conduction process in peripheral nerves.
Classification of Local Anesthetic Agents
All local anesthetics except cocaine are synthetic. They are broadly divided into two groups, i.e. ester
and amide (non- ester) group.
1. Based on chemical structure

• Ester group
– Cocaine
– Benzocaine
– Procaine

– Tetracaine
• Amide (Nonester group)
– Lidocaine
– Mepivacaine
– Prilocaine
– Etidocaine
– Bupivacaine.
2. Based on duration of action

• Short acting
– Procaine
• Intermediate acting
– Lidocaine
• Long acting
– Bupivacaine
The primary action of the local anesthetics agent in producing a nerve conduction block is to
decrease the nerve permeability to sodium (Na+) ions, thus preventing the inflow of Na+ ions
into the nerve. Therefore, local anesthetics interfere with sodium conductance and inhibit the
propagation of impulse along the nerve fibers (Fig. 12.1).
In tissues with lower pH, local anesthetics show slower onset of anesthesia while in tissues
with higher pH, local anesthetic solution speeds up the onset of anesthesia. This happens
because at alkaline pH, local anesthetic is present in undissociated base form and it is this form
which penetrates the axon (Fig 12.2).

Following Factors should be kept in Mind Prior to Administration of Local Anesthesia

 Age: In very young and extremely old persons, lesser therapeutic dose should be given.

Allergy: Since it is life-threatening in most of the cases, proper history about allergy should be
taken before administering local anesthesia.

Pregnancy: It is better to use minimum amount of local anesthetic drugs especially during pregnancy.

Thyroid disease: Since patients with uncontrolled hyperthyroidism show increased response to
the vasoconstrictor present in local anesthetics. Therefore, in such cases, local anesthesia
solutions without adrenaline should be used.

Hepatic dysfunction: In hepatic dysfunction, the biotransformation cannot take place properly,
resulting in higher levels of local anesthetic in the blood. So, in such cases low doses of local
anesthetic should be administered.

Precautions to be taken before Administration of Local Anesthesia

• Patient should be in supine position as it favors good blood supply and pressure to the brain. •
Before injecting local anesthesia, aspirate a little amount in the syringe to avoid chances of
injecting solution in the blood vessels.
• Do not inject local anesthesia into the inflamed and infected tissues as local anesthesia does not
work properly due to acidic medium of inflamed tissues.
• Always use disposable needle and syringe in every patient. Needle should remain covered with cap
till its use.
• To make injection a painless procedure, temperature of the local anesthesia solution should be
brought to body temperature.

• Clean the site of injection with a sterile cotton pellet before

injecting the local anesthesia.
• Insert the needle at the junction of alveolar mucosa and vestibular mucosa. If angle of needle is
parallel to long axis, it causes more pain.
• Inject local anesthesia solution slowly not more than 1 ml per minute and in small increments to
provide enough time for tissue diffusion of the solution.
• Needle should be continuously inserted inside till the periosteum or bone is felt by way of slight
increase in resistance of the needle movement. The needle is slightly withdrawn and here the
remaining solution is injected.
• Check the effect of anesthesia two minutes after injection.
• Patient should be carefully watched during and after local anesthesia for about half an hour for
delayed reactions, if any.
• Discard needle and syringe in a leak-proof and hard walled container after use.

Techniques for Anesthetizing Maxillary Teeth

Supraperiosteal Technique
It is also known as local infiltration and is most frequently used technique for obtaining anesthesia in
maxillary teeth.
Technique: The needle is inserted through the mucosa and the solution is slowly deposited in close
proximity to the periosteum, in the vicinity of the apex of the tooth to be treated (Fig. 12.3).
Advantage
It is simple to learn.

Disadvantage
Multiple injections are required for large area.

Anterosuperior Alveolar Nerve Block

Nerve anesthetized with this block are anterior, and middle superior alveolar nerve and infraorbital
nerve; inferior palpebral, lateral nasal, superior labial nerves. It is given for anesthetizing the maxillary
incisors, canines, premolars and mesiobuccal root of first molar (in 70% of cases). In this the target
area is infraorbital foramen.

Technique: Needle is inserted in the mucobuccal fold over the maxillary first premolar and directed
towards the infraorbital foramen, once you have palpated. After aspirating, slowly deposit the solution
0.9 to 1.2mL in the vicinity of the nerve (Fig. 12.4).

Middle-Superior Alveolar Nerve Block

It is used for anesthetizing the middle-superior alveolar nerve and its terminal branches. It is given
for anesthetizing the maxillary first and second premolars and mesiobuccal root of the first molar.
Technique: Needle is inserted into the mucobuccal fold above the second premolar. After aspirating,
slowly deposit local anesthetic solution (i.e. 0.9–1.2mL).
Posterosuperior Alveolar Nerve Block
It is used for posterosuperior alveolar nerves. It is given for anesthetizing the maxillary third, second
and first molar (sometimes mesiobuccal root is not anesthetized) (Fig. 12.5) and overlying structures
(buccal mucosa and bone).
Technique: Needle is inserted distal to the zygomatic process in the mucobuccal fold over the maxillary
molar teeth. After aspirating slowly deposit local anesthetic solution.

Greater Palatine Nerve Block

It is used for anesthetizing greater palatine nerve. It is given for anesthetizing posterior portion of hard
palate and its overlying soft tissue, up to the first bicuspid.
Technique: In this target area is greater palatine foramen. The needle is inserted from the opposite
side of mouth at a right angle to the foramen which lies 1 cm from palatal gingival margin towards
midline (Fig. 12.6). After aspirating, deposit the solution slowly.
Nasopalatine Nerve Block
It is used for anesthetizing anterior portion of the hard palate (soft and hard tissues), extending from
one side premolar to other side of first premolar.
Technique: Needle is inserted in intraseptal tissue between the maxillary central incisors.
Deposit slowly the local anesthetic solution in the tissue (Fig. 12.7).

Maxillary Nerve Block

It is used for anesthetizing the maxillary nerve of trigeminal nerve. In this, different techniques
which can be used are:
• High tuberosity approach
• Greater palatine canal approach
• Extraoral technique.

Periodontal Ligament Injection

It is used for anesthetizing terminal nerve endings in vicinity of the injection. The local
anesthetic solution is deposited into the periodontal ligament or membrane.
Techniques: Needle is inserted along the long axis of the tooth either on mesial or distal of the root
(Fig. 12.8). Deposit local anesthetic solution (0.1–0.2 mL) slowly.
Advantages
• Rapid onset of action
• It is a useful adjunct to normal local anesthesia
• Provides specific analgesia to isolated tooth.
Disadvantage
Post injection discomfort due to temporary extrusion

Techniques for Anesthetizing Mandibular Teeth

Inferior Alveolar Nerve Block
It is used for anesthetizing inferior alveolar nerve, lingual nerve and its terminal branches, i.e. mental
and incisive. The areas anesthesized are:
• Mandibular teeth
• Body of the mandible and inferior portion of the ramus
• Buccal mucous membrane and its underlying tissues only up to first molar
• Anterior twothird of tongue, lingual soft tissues, floor of the oral cavity.

Technique: The target in this technique is inferior alveolar nerve. The operator should first palpate the
anterior border of the ramus. Its deepest concavity is known as coronoid notch which determines the
height of injection. The thumb is placed over the coronoid notch and also in contact with internal
oblique ridge. The thumb is moved towards the buccal side, along with buccal sucking pad. This gives
better exposure to pterygomandibular raphe (Fig. 12.9). Insert the needle parallel to occlusion of
mandibular teeth from opposite side of mouth. Needle is finally inserted lateral to pterygomandibular
raphe in pterygomandibular space. Bone must be contacted as it determines the penetration depth.
Solution required in this block vary from 1.5 to 1.8mL.

Long Buccal Nerve Block

It is used for anesthetizing buccal mucosa of mandibular molar teeth. Technique: In this, target is
buccal nerve. Insert needle in the mucosa distal and buccal to last lower molar tooth in the oral cavity
(Fig. 12.10).
Mandibular Nerve Block
For complete anesthetizing the mandibular nerve, following techniques may be used:
• GowGates technique
• Extraoral approach.

Vazirani-Akinosi Closed Mouth Technique

It is usually preferred in patients who have limited/restricted mouth opening. The areas anesthetized
by this technique is very much similar to the area anesthetized by inferior alveolar nerve block. Target
area is pterygomandibular space.
Technique: In this technique first patient is asked to bring teeth in the occlusion. Needle is positioned
at the level of mucogingival junction of maxillary molars. Needle is penetrated through the mucosa in
the embrasure just medial to the ramus (Fig. 12.11). When tip of the needle reaches the target area,
approximate 2 mL of solution is deposited slowly.

Mental Nerve Block

It is used for anesthetizing the buccal soft tissues anterior to the mental foramen and up to the
midline. Technique: Insert the needle in the mucobuccal fold just anterior to mental foramen (Fig.
12.12). Slowly deposit the solution into the tissue.
 5. Preparation of the tooth before trepanation (access cavity formation)

Access cavity preparation is defined as an endodontic coronal preparation which enables unobstructed
access to the canal orifices, a straight-line access to apical foramen, complete control over
instrumentation and accommodate obturation technique.
Before going for access cavity preparation, a study of preoperative periapical radiograph is necessary
with a paralleling technique.
Radiographs help in knowing
• Morphology of the tooth
• Anatomy of root canal system
• Number of canals.
• Curvature of branching of the canal system.
• Length of the canal.
• Position and size of the pulp chamber and its distance from occlusal surface.
• Position of apical foramen.
• Calcification, resorption present if any.

An ideal access preparation should have following features:

• An unobstructed view into the canal.
• No remaining caries should be present in access cavity.
• Obturating instruments should pass into the canal without touching any portion of the access cavity.

Instruments for Access Cavity Preparation:

➢ Access Opening Burs - They are round burs with 16 mm bur shank (3 mm longer than standard
burs).
➢Access Refining Burs - These are coarse grit flame shaped, tapered round and diamonds for
refining the walls of access cavity preparation.

➢ Müller Burs

• These are long shaft, round carbide tipped burs which are used in low speed handpiece.
• Their long shaft increases visibility of cutting tip.
• They are used for locating calcified canals because their long shaft is useful for working deep
in the radicular portion.
• But since they are made up of carbide, they do not tolerate sterilization cycles and become
dull quickly.
 Guidelines for access cavity preparation
• Before starting the access cavity preparation, one should check the depth of preparation by
aligning the bur and handpiece against the radiograph. This is done to note the position and depth
of the pulp chamber
• Place a safe ended bur in handpiece, complete the outline form. The bur penetrates the crown until
the roof of pulp chamber is penetrated. Round ended carbide burs are used for access opening into
cast restorations because these burs have distinct tactile sense when “drop in” to the pulp chamber.
Access finishing is best carried out by using burs with safe noncutting ends.
Advantage of using these burs is that they are less likely to damage or perforate the pulp
chamber floor. But these burs cut in lateral direction and cannot drop into small canal orifices.
• When locating the canal orifices is difficult, one should not apply rubber dam until correct
location has been confirmed.
•Remove all he unsupported tooth structure to prevent tooth fracture during treatment.
•Remove the chamber roof completely as this will allow the removal of all the pulp
tissue, calcifications, caries or any residuals of previous restorations.

Access Cavity for Anterior Teeth

Maxillary Central Incisor

• Outline form of access cavity of maxillary central incisor is a rounded triangular shape with
base facing the incisal aspect.
• Width of base depends upon the distance between mesial and distal pulp horns.
• Shape may change from triangular to slightly oval in mature tooth because of less prominence of
mesial and distal pulp horns.

Maxillary Lateral Incisor

Shape of access cavity is almost like that of maxillary central incisor except that:
• It is smaller in size.
• When pulp horns are present, shape of access cavity is rounded triangle.
• If pulp horns are missing, shape is oval.

Maxillary Canine

Shape of access cavity of canine has following differences from incisors:

• Canine does not have pulp horns
• Access cavity is oval in shape with greater diameter labiopalatally.

Mandibular Incisors

Access cavity of mandibular central and lateral incisors is almost similar in shape. Access cavity of
mandibular incisors is different from maxillary incisors in following aspects:
• It is smaller in shape.
 • Shape is long oval with greater dimensions directed incisogingivally.

Access Cavity preparation for premolars

Maxillary First Premolar

Shape of access cavity is ovoid in first premolar in which

boundaries should not exceed beyond half the lingual incline of
buccal cusp and half the buccal incline of lingual cusp.

Maxillary Second Premolar

It is like that of maxillary first premolar and varies only by anatomic structure of the pulp chamber.

Mandibular First Premolar

Following differences are seen in case of mandibular first premolar from the maxillary premolars:
• There is presence of 30° lingual inclination of the crown to the root, hence the starting point of bur
penetration should be halfway up the lingual incline of the buccal cusp on a line connecting the cusp
tips.
• Shape of access cavity is oval which is wider mesiodistally, when compared to its maxillary
counterpart.

Mandibular Second Premolar

The access cavity preparation is like mandibular first premolar except that in mandibular second
premolar:
• Enamel penetration is initiated in the central groove because its crown has smaller lingual tilt.
• Because of better developed lingual half, the lingual boundary of access opening extends halfway
up to the lingual cusp incline, i.e. pulp chamber is wider buccolingually.
• Root canals are more often oval than round.
•
• Ovoid access opening is wider mesiodistally.

Access Cavity for Maxillary Molars

Maxillary First Molar

• The shape of pulp chamber is rhomboid with acute mesiobuccal angle, obtuse distobuccal angle and
palatal right angles.
• Palatal canal orifice is located palatally. Mesiobuccal canal orifice is located under the mesiobuccal
cusp. Distobuccal canal orifice is located slightly distal and palatal to the mesiobuccal orifice.
Maxillary Second Molar
Basic technique is like that of first molar but with following differences:
• Three roots are found closer which may even fuse to form a single root.
• MB2 is less likely to be present in second molar.
• The three canals form a rounded triangle with base towards buccal side.
• Mesiobuccal orifice is located more towards mesial and buccal than in first molar.

Access Cavity for Mandibular Molars

• Mesiobuccal orifice is under the mesiobuccal cusp. Mesiolingual orifice is located in a depression
formed by mesial and the lingual walls. The distal orifice is oval in shape with largest diameter
buccolingually, located distal to the buccal groove.
• Orifices of all the canals are usually located in the mesial two-thirds of the crown.
• Shape of access cavity is usually trapezoidal or rhomboid irrespective of number of canals present.
• The mesial wall is straight, the distal wall is round. The buccal and lingual walls converge to meet the
mesial and distal walls.

Mandibular Second Molar

Access opening of mandibular second molar is similar to that of first molar except for following
differences:
• Pulp chamber is smaller in
• One, two or more canals may be present.
• Mesiobuccal and mesiolingual canal orifices are usually located closer.
• When three canals are present, shape of access cavity is almost similar to mandibular first molar,
but it is more triangular and less of rhomboid shape.
• When two canal orifices are present, access cavity is rectangular, wider mesiodistally and narrower
buccolingually.
• Because of buccoaxial inclination, sometimes it is necessary to reduce a large portion of the
mesiobuccal cusp to gain convenience form for mesiobuccal canal.
 6. Isolation of working area

Following components of oral environment need to be controlled during operative procedures:

• Saliva
• Moving organs
– Tongue
– Mandible
• Lips and cheek
• Gingival tissue
• Buccal and lingual vestibule.

Isolation of the tooth requires proper placement of the rubber dam/dental dam. It helps to isolate the
pulp space from saliva and protects oral tissues from irrigating solutions, chemicals and other
instruments.

Advantages of using a rubber dam

• It helps in improving accessibility and visibility of the working area
• It gives a clean and dry aseptic field while working
• It protects the patient from inhalation or ingestion of instruments and medicaments
• It potentially improves the properties of dental materials

Disadvantages of using a rubber dam

• Takes time to apply
• Communication with patient can be difficult
• Incorrect use may damage porcelain crowns/crown margins/ traumatize gingival tissues
• Insecure clamps can be swallowed or aspirated.

Contraindications of use of rubber dam

• Asthmatic patients
• Allergy to latex
• Mouth breathers

Rubberdam equipment
• Rubberdam sheet –
o The Rubberdam sheet is normally available in size 5 × 5 or 6 × 6 squares in green or
black color
o It is available in three thicknesses, i.e. light, medium and heavy
o Latex-free dam is necessary as number of patients are increasing with latex allergy
o Flexi dam is latex-free dam of standard thickness with no rubber smell
• Rubberdam clamps
o Rubber dam clamps, to hold the rubber dam onto the tooth are available in different
shapes and sizes.
o Clamps mainly serve two functions: 1. They anchor the rubber dam to the tooth. 2. Help in
retracting the gingiva.
• Rubberdam forceps
 o Rubber dam forceps are used to carry the clamp to the tooth.
o They are designed to spread the two working ends of the forceps apart when the handles
are squeezed together.
o The working ends have small projections that fit into two corresponding holes on the rubber
dam clamps.
• Rubberdam frame
o Supports the edges of Rubberdam.
• Rubberdam punch.
o Rubber dam punch is used to make the holes in the rubber sheet through which the teeth can
be isolate.

Rubber dam accessories

• Lubricant/petroleum jelly
• Dental floss
• Wedges

7. Rubber dam in
endodontics Refer to question 6

8. Access cavity
formation Refer to question 5

9. Probing of root canal (instruments, technique)

Instruments for root canal probing:

• root canal explorer
• C+ file, C-pilot, K-reamer, K-file of small sizes (ISO 08, 10, 15)
• Detection of canal entrances within the pulp chamber; gentle reaming action

Reaming technique:
o Indication:
✓ Straight root canals of circular diameter o
Complication:
✓ Straightening of root canals.
✓ Zip-elbow
o Instruments:
✓ K-reamer (rotation 45°)
✓ K-file (rotation less than 45°)
The instrument is passed passively through root canal and rotate round 45° wit small pressure, then
take of instrument.

C+ file:
▪ C+ file is used for difficult and calcified canals. It has better buckling resistance than K-file.
▪ It is available in size 8, 10 and 15 and in length 18, 21 and 25 mm.
▪ It is made up of stainless steel and has a square crosssection.

K-reamer:
▪ It cuts by inserting into the canal, twisting clockwise one quarter to half turn and then withdrawing,
i.e. penetration, rotation and retraction.
▪ K-reamer has triangular or square blank and lesser number of flutes than k-file.
K-file:
▪ Can be manufactured by twisting a square or triangular blank by machine

▪ the blank is twisted into a tighter series of spiral than reamer also K-file are more flexible than reamer

▪ K-files with a triangular cross-section tend to have superior cutting characteristics and are more flexible,
and hence less likely to transport the canal during preparation
Action
▪ clock wise half–turn twist

K-flex file:
• A blank that is rhomboid in cross-section; this forms both cutting and non-cutting edges
• The files are more flexible than an equivalent-sized K-file
Action
clock wise half–turn twist

• machined from a tapered cylindrical block

• In cross-section has the appearance of a series of intersecting cones
• highly efficient at removing dentin on the outstroke when used in a filing motion, but have
poor fracture resistance in rotation

Action
withdrawal stroke – filing action

10. General rules of root canal shaping

Refer to question 1

11. General rules of root canal shaping

Shaping
Its purpose is to prepare a shape of root canal which respects original anatomy and makes possible
thorough cleaning and hermetic obturation.

Contemporary Approach:

 Direct view on the whole pulp chamber floor and its morphology (root canal orifices)
 Straight line access
 Continuously narrowing preparation
• Allows irrigation and removing of debris
• Allows hermetic obturation
 Respecting original anatomy
• Shape of root canal preparation respects and follow original anatomy
 Protecting healthy teeth structures
• Increase resistance against fracture
• Decrease probability of perforation
• Apical preparation should be as small as it is possible to procede adequate cleaning

CONCEPTS USED DURING PREPARATION

 Straight line access (SLA)
Ideally should working instrument reach foramen physiologicum (or first curvature)
without bending.
Influenced by: Shape of access cavity and Coronal flaring.
 Coronal flaring
 Before we reach working length with ours instrument we should procede coronal flaring.
Remove the most infected tissue in root canal.
Create reservoir for irigation sollution.
Allows straight line access.
Use of:
Gates-Glidden
Rotatory endodontic files
ProTaper SX
ProFile orifice shapers
 Working length (WL)
Length of working instrument from reference point to foramen physiologicum (boundary
between cement and dentin)
We can find it out:
Average values – very unprecise. Can be used only as safe length.
Radiologically – unprecise. Fysiological foramen is usually about 1-1,5 mm from
anatomical apex.
Electronically– electronic apex locator (EAL) are based on pricipal that resistance between
oral mucosa and periodontal ligaments is constant.
 Apical width (AW)
Depends on original diameter and shape of root canal, used taper of instrume
and diagnosis.

 Patency
Keeping apical foramen free of debris by using patency file (usually K-file size #10 or #15)
that is passively extended just through apical foramen. Helps to maintain working
length.
Helps to removing preparation debris.
 Recapitulation
Checking the working lenght with the working instruments with a 1 ISO smaller
diameter than working instrument we have used before. Helps to maintain working
length.

Helps to remove preparation debris.

 Glidepath
Using of (usually) stainless steel files before Ni-Ti rotarory files.
Producing smooth reproducible glide path for rotatory instruments.
Preparation at least to ISO 15(allows removing preparation debris).
Checking straight line access.
Valuable information about root canal anatomy.

12. Mechanical-chemical treatment of root canals, current view

13. Coronal flaring

 Coronal flaring
Before we reach working length with ours instrument we should procede coronal flaring.
Remove the most infected tissue in root canal.
Create reservoir for irigation sollution.
Allows straight line access.
Use of:
Gates-Glidden
Rotatory endodontic files
ProTaper SX
ProFile orifice shapers

Rotary instruments for coronal flaring (widening of canal entrance)

❖ These files are used to flare the coronal part of the root canal
❖ relatively inflexible

❖The use of these instruments is therefore best restricted to the relatively straight parts of the root
canal to avoid strip perforation

❖ used in a handpiece driven by an electric motor at 150–300 rpm

14. Shaping of the middle and apical third of root canal

✓ Purpose of shaping
- to prepare a shape of root canal which respects original anatomy
- makes cleaning possible and hermetic obturation

- Shaping of middle and apical third is done by CROWN DOWN PREP

Indication
- Formerly invented for molars
- Mildly curved, rather oval root canals

Complication
- Reduction of occurence
- Time demanding

Instruments
Combination of K-file, H-file, Gates-Glidden

AIMS:

- Determine working lenght which is constant

 - Minimalize the possiblity of extrusion the debris throught apex
- Precise recognition of apical width

METHOD

STEP 1

- Preparation of coronal 2/3 of root canal

- with filing technique (H-files ISO15,20,25),
- working lenght can be determined with ISO 8 instrument.

STEP 2

- Coronal flaring with Gates-Glidden (1-4), or ProTaper/ProFile

STEP 3

- Preparation to working lenght (min. ISO 35)

- with balanced force technique and
- followed by step-back technique

15. Technique of root canal shaping

- Technique – instrumentation with one file

- 4 TECHNIQUES:
1. Standarized (watch-winding)
o Indication
▪ Initial probing of root canal
▪ Recapitulation

▪ Retreatment

o Complication
▪ Extrusion of preparation debris beyond apex
▪ Ledge

o Instruments
▪ K-reamer, K-file

o Instrument is pushing apically during rotating in clock-wise and anti clock-

wisedirection (about 45°)

2. Reaming
o Indication
▪ Straight root canals of circular diameter
 o Complication
▪ Straightening of root canals
▪ Zip-elbow

o Instruments
▪ K-reamer (rotation 45°)
▪ K-file (rotation less than 45°)
o We pass instrument passivelly to root canal and then we rotate it around 45° with
small presure.Then we take the instrument out

3. Filing
o Indication
▪ Oval shape root canals
▪ Retreatment

▪ Smoothing the preparation

o Complication
▪ Extruding debris through apex
o Instrument
▪ H-file

o We insert instrument passivelly and then pull it up 2-3mm agains root canal wall. It´s
neccesary to irigate very often and equal preparation of walls.

4. Balanced force
o Indication
o Complicated root canal anatomy
o The most universal technique for glidepath
o Complication
o Straightening of root canal
o Instrument
o K-flexofile (Flex-R file)
o K-file
o Insert instrument passively which has 1ISO diameter larger than current master apical file.

16. Balanced force technique of root canal shaping

Balanced force
o Indication
o Complicated root canal anatomy
o The most universal technique for glidepath
o Complication
o Straightening of root canal
 o Instrument
o K-flexofile (Flex-R file)
o K-file

STEPS:
1. Insert instrument passively which has 1ISO diameter larger than current master apical file.
2. With small pressure we rotate instrument around 90° in the clock-wise direction. Instrument
will engage dentin of the root canal wall
3. With minimal pressure we rotate instrument around 180-270° counter clockwise direction.
Pressure should maintain instrument at or near the clockwise insertion depth. It will break
loose the engaged dentin chips from root canal wall.
4. The file is then removed from root canal by a slow clockwise rotation around 360° that loads
debris into the flutes and elevates is away.

Because we don´t use prebend files the straightening of root canal can occur. If root canal is
complicated we suggest instead of step 4 go on with step 1 until the working lenght is reached.
(ledge and breakage are more probable)

17. Methods of root canal shaping

o Apicocoronal – we prepare from beginning with complete working length or we shorten it.
▪ Combined (reaming-filing)
▪ Step-back
o Coronoapical – we prepare with shortened working length which is further prolonged.
▪ Step-down
▪ Double flared
▪ Crowndown pressureless

o Indication
▪ Straight canals (oval)

▪ Recreation of apical stop after overinstrumentation of apex o

Complication
▪ Zip-elbow, perforation (in case of curvature in apical part of root canal) o
Instruments
▪ Changing of K-file and H-file
o By K-file we prepare with balanced force technique up to working length o
Then passively insert H-file and with filing technique we prepare root canal o
We repeat whole procedure with files 1 ISO larger.

STEP BACK METHOD

❖ Indication
o Mediate to severe curved canals
o ComplicationReduction of their occurence
o Time demanding
❖ Instruments
o In the past prebend H-file, these days are prefered K-files
❖Main idea is continuous shortening the working length of instruments with larger
diameter
 ❖ It consists of two steps
o Preparation of apical stop
o Preparation of continuously widening taper
❖Preparation of the apical stop which has adequate diameter at the correct working length ( for
example ISO 35)
❖ Next instrument is insterted to shortened working lenght (original working length – 0,5
mm) and preparation is repeated
❖ In the end we prepare with master apical file to make root canal walls smooth
STEP DOWN METHOD
✓ Indication
o Formerly invented for molards
o Mildly curved, rather oval root canals
✓ Complication
o Reduction of occurence
o Time demanding
✓ Instruments
o Combination of K-file, H-file, Gates-Glidden
✓ Contains 3 steps
✓ Aim is to:
o Determine working lenght which is constant
o Minimalize the possiblity of extrusion the debris throught apex o
Precise recognition of apical width
1.Step
✓ Preparation of coronal 2/3 of root canal with filing technique (H-files ISO15,20,25), working
lenght can be determined with ISO 8 instrument.
2.Step
✓ Coronal flaring with Gates-Glidden (1-4), or ProTaper/ProFile 3.Step
✓ Preparation to working lenght (min. ISO 35) with balanced force technique and
followed by step-back technique

DOUBLE FLARED METHOD

 Indication
 Almost no restriction
 Complication
 Reduction of occurence
 Instruments
 K-file, Gates-Glidden

 In fact it´s step-down method where the first step is missing. Thorought coronal flaring brings
same advantages as with step-down method. In the same time is reduced possibility of
extruding infection apically
 coronal flaring + step-back
1.Step
 Coronal flaring with Gates-Glidden (1-4), či ProTaper/ProFile 2.Step
 Preparation to working lenght(min. ISO 35) by balanced force technique and followed by step-back
method

CROWNDOWN PRESURELESS METHOD

• Indication
o Curved root canals of round diameter
 o Excellent shape of preparation
• Complication
o Same occurence as with step-back and double flared methods
• Instruments
o K-file
• Working with no pressure
• Determining working lenght (For example ISO 15)
• Firstly we use instruments of larger diameters and rotate counter clockwise direction (we do
not insert them to full working length) (For example from ISO 50)
• Then we would repeat whole sequence, this time with files of 1ISO larger diameter (For
example now from ISO 55),so many to times, to obtain apical width which is desired
• This method is used by the most of rotatory endodontic systems

18. Step back method

❖ Indication
o Mediate to severe curved canals
❖ Complication
o Reduction of their occurence
o Time demanding
❖ Instruments
o In the past prebend H-file, these days are prefered K-files
❖Main idea is continuous shortening the working length of instruments with larger
diameter
❖ It consists of two steps
o Preparation of apical stop
o Preparation of continuously widening taper
❖Preparation of the apical stop which has adequate diameter at the correct working length ( for
example ISO 35)
❖ Next instrument is insterted to shortened working lenght (original working length – 0,5
mm) and preparation is repeated
❖ In the end we prepare with master apical file to make root canal walls smooth
19. Working length in endodontics
Length of working instrument from reference point to foramen physiologicum (boundary
between cement and dentin)
o We can find it out:
Average values – very unprecise. Can be used only as safe length (usually 2-3mm).
Radiologically – unprecise. physiological foramen is usually about 1-1,5 mm from anatomical
apex.
Electronically– electronic apex locator (EAL) are based on pricipal that resistance between oral
mucosa and periodontal ligaments is constant.
Instrument ISO 15 introduced into the root canal, stop at the referential point
 Estimation of location of apical constriction (1 – 1,5 mm distance from x-ray apex. If there is
difference in the radiogram more than 2 mm - repeat If 2 mm or less – add to the safe length
= working length

20. Safe length in

endodontics Refer to question 19

21. Rotary endodontics

 Mechanical shaping of whole root canal
 Long history

 Early mechanical endodontic systems used stainless steel files and vibrating /
reciprocating motion (continuous rotation of stainless steel instrument would lead to
cyclic fatigue and fracture)

NiTi Systems
• Introduction of nickel-titanium alloy to endodontics was a huge step forward
• Invented in 1963 (Nitinol = Nickel Titanium Naval Ordnance Laboratory)
• 50-60% Ni + 40-50% Ti
• Used in endodontics since 1988
• Files made of either conventional NiTi wire
• ProTaper Universal, Mtwo, Wizard Navigator,...
• Or M-wire (additional thermomechanical treatment) increased wear-resistance
and significantly greater elasticity
• WaveOne, Reciproc, Unicone,…

• Superelasticity
• Shape memory
• Resistant to cyclic
fatigue Disadvantages
• Higher price

Endodontic Motors
• Controlled speed of rotation
• 150-800 rpm
• Higher speed means
– More cutting efficiency
– Loss of control
– Higher risk of instrument breakage
– Higher risk of changig the canal‘s shape
Controlled torque
• Ability to withstand lateral pressure on the rotating instrument without decreasing its speed
or reducing its cutting efficiency
• Low torque values reduce the incidence of instrument locking, deformation or separation
Automatic reverse-rotation
• When the instrument is subjected to high torque levels

• Faster preparation
• Less instruments needed
• Better centering of the file inside a root canal
• Less debris pushed beyond apical foramen
• Predictable shape of the root canal respecting its original anatomy
• Ideal shape for 3D obturation
ProTaper Universal
• Complete system for shaping and obturation
• Rotary and manual version of instruments
• Crown-down method
• Easy-to-remember sequence of instruments
• Including instruments for secondary
endodontics Advantages
• 4 files are enough for majority of root canals
• Instruments are color-marked according to ISO
• High-tapered apical preparation assures sufficient disinfection

SX:

• Length only 19mm (14mm working part)

• Progressive taper
• D0 = 0.19mm, D14 = 1.2mm
• Used for coronal flaring instead of whole sequence of Gates-Gliden burs

S1 / S2:
• Shaping File 1
– Shaping of the coronal part o the root canal
– Variable taper 2-11%
• Shaping File 2
– Widening of previous preparation plus shaping the mid-root area
– Variable taper 4-11.5%

• Finishing Files
– Designed to finish the preparation with at least 7% taper
– Variable taper (reduced further from the tip)
– They leave the coronal parts of the root canal untouched and work mainly in the apical
1/3
F4 / F5:
• Optional
• Wide root canals
• Finishing File 4 (ISO 40/06)
• Finishing File 5 (ISO 50/05)
• Both have deeper flute ridges (reduced core for more elasticity)

Principles of rotary endodontics:

• Glide path
• Speed and torque control
• Crown-down method
• Never push the instrument apically against a resistance (high risk of fracture)
• Clean the flutes frequently
• Never work with an instrument inside a root canal longer than 10s continuously
• Don‘t use NiTi files to overcome a ledge
• Keep track of how many times the instrument have been used
 22. Complications in endodontics (classification)
Local complications:

Via falsa
• Perforation of the bottom of the pulp chamber or the coronal part of the root canal
• Perforation in the middle part of the root canal
• Apical perforation

Regional Complications - Damage of periodontium or surrounding tissues.

Systemic Complications
Periodontitis
Inflammation of soft tissues (face, neck)
Gulp of the instrument (X ray, remnant diet, information)- cough
Aspiration of the instrument -emesis

23. Complications of root canal shaping

24. Prevention of complications in endodontics

I. Root canal filling

1.Root canal filling and its function

Function

• Long lasting barrier between outer and inner space

• Perfect obturation of root canal system
• Allows reconstruction of treated tooth
Aims

• Root canal filling should permanently prevent penetration of bacteria and humidity to root
canal system
• Root canal filling should prevent growth and enlargement of bacteria, which remained in the
root canal system
o Preventing the supply of nutrients
o Filling of space which bacteria needs for their growth
• Prevent of penetration of the rest of toxins and bacteria to periodontal tissues
• Create biocompatible closure of apical end, which allows healing of periapical tissues

2.Conditions for definitive root canal filling

• Absence of clinical signs

• Dry root canal (no exsudation or bleeding)
• No foetor from root canal
• Perfect shaping and cleaning of root canal
• Negative microbial cultivation

3.Root canal filling materials (classification, requirements)

Classification

• Solid
o Silver cones
• Semisolid
o Guttapercha
▪ Alpha phase
▪ Beta phase

▪ Gamma phase

• Paste
• Sealers

Requirements

• Nonirritating
• Biocompatible
• Hermetic obturation
 • Visible at X-ray image
• Not discolouring tissues
• Adhesion to root canal wall and gutta-percha
• Easy preparation
• Sufficient setting time
• Mild expansion
• Volume stability
• Not dissolving in transudate
• Easy removal from root canal

4.Sealers (classification, functions)

Classification

• Zinc oxide eugenol (ZOE)

✓ Long time of hardening

✓ Possibility of removal from root canal

✓ Absence of colouring of hard dental tissues

✓ Antibacterial effect

✓ Adhesion onto hard dental tissues

✓ Cytotoxic effect: overfilling is not allowed

✓ Bad mechanical properties

✓ Inhibition of resin composites polymerization

✓ Pulp Canal Sealer (Kerr, USA), Tubli-Seal (Kerr, USA), Caryosan (SpofaDental), Czech Republic

• Resin
1. Epoxid
2. Polyketone
3. Methacrylate

Epoxid
Advantages
• Long time of hardening (48 h)
• Hydrophility and penetration onto the
ramifications, lateral canals, etc.
• Excellent adhesion onto the dentin
• Longtime volume stability
• Resistance against infuse
 • Antibacterial properties in the beginning of hardening

Disadvantages (Epoxid)
• Bad removal from root canal
• Colouring of hard dental tissues
• Toxic during hardening

Polyketone Resin sealers

✓ Similar properties like AH 26
✓ High adhesiveness of freshly mixed material

✓ Relatively high toxicity

✓ Impossibility of removal from root canal

✓ Diaket, Diaket A (3M ESPE)

Methacrylate Resin Polymer

✓ EndoREZ (Ultradent, USA)UDMA
✓ Part of special root canal filling system

✓ Time of hardening 60 min

Glass-ionomer Sealers
✓ Chemical adhesion onto hard dental tissues
✓ Strength

✓ Absence of colouring of hard dental tissues

✓ Antibacterial properties

✓ Hydrophility

✓ Short working time (4–6 min), bad removal, porosity, nonresorbable

✓ Ketac-Endo (3M ESPE), Endion (VoCo, Germany)

• With Ca(OH)
✓ Active effect on periapical tissues
✓ It is supposed that they can stimulate the dentinoid tissue formation

✓ Antibacterial effect

✓ Absence of colouring of hard dental tissues

✓ Easy handling

✓ Excellent tissue tolerance

✓ Durable sealing of the root canal due to the slight setting expansion

✓ Long working time (can be used over 3 hours at room temperature)

✓ Sealapex (Kerr), Apexit (Vivadent)

 • Silicone
✓ They are based on polyvinylsiloxane
✓ Biocompatibility

✓ Hydrophility

✓ Absence of colouring of hard dental tissues

✓ Easy removal

✓ RSA sealer

Functions of sealers
• Adhesion onto the walls of root canal
• Filling of ramifications, lateral canals, etc.
• Lubricant for easier application of guttapercha cone
• Bacteriostatic effect

5.Gutta-percha in endodontics

Guttapercha

• From Malay „getah pertja“- fibers of sticky tree sap

• Alpha, beta, gamma phase
• Composition of guttapercha cones:
• 20 % guttapercha (trans-polyisopropen)
• 60–75 % ZnO
• 1.5–17 % sulphate of metallic elements
• 1–4 % wax and resins
Phases of gutta-percha

• Alpha (Obtura, Thermafil, Ultrafil)

• Beta (cones), at 42–49° C it is changed onto alpha phase, at 53–59° C it is changed onto
amorphous phase
• Gamma phase is amorphous

6.Condensation methods of root canal filling

• Compaction methods o
Cold
▪ Lateral compaction
 o Warm
▪ Warmed in root canal
▪ Warm lateral compaction

▪ Warm vertical compaction

▪ Thermomechanical compaction

▪ Warmed outside of root canal

▪ Thermoplastic injection technique

▪ Carrier based guttapercha

• Single cone method

7.Method of root canal filling using lateral condensation of gutta-percha

Cold Lateral Compaction

Best technique to achieve 3D seal

1. Apply Rubber dam
2. Sterilize the field of operation
3. Dry canal with absorbent paper point
4. Master cone (MC) fitted into the prepared canal (to establish working length; should fit-
snugly and resist removal)
5. X-ray (to determine apical and lateral fit of MC)
6. Gutta percha adjusted if it protrudes through the apical foramen
7. X-ray taken – verify the fit of cone
8. MC fits well, removed, canal is dried again
9. Mix sealer; coat wall with sealer using lentulospiral
10. Apical half of MC coated with sealer
11. Place MC in root canal
12. Spreader inserted along MC to 1mm short of working length (ensures lateral compaction
of apical 1/3 of gutta-percha point)
13. Spreader removed by rotating
14. Accessory cone inserted into root canal
15. Repeat until entire canal is filled
16. X-ray taken
17. End of gutta percha cut off with hot instrument
18. Chamber cleaned
19. Restoration placed.

Size of spreader

 determined by width of prepared canal & lateral fit of MC

 GREATER the space between canal and end of gutta percha => LARGER the spreader used.

 Spreader size ; within 1-2mm of working length -> optimum apical

compaction Can be ensured by placing a silicon stopper on spreader

Conditions of lateral compaction

 • Tapered root canal (>6 %) with apical seat
• Master apical cone has to have same diameter as master apical file
• Spreader which can be insert up to 1–2 mm to working length (usually half diameter of
master apical cone)
• Accessory cones are 1–2 ISO smaller diameter than spreader
• Sealer
• Plugger of adequate diameter
Use pressure around 15 N on spreader (1.5 kg)

The choice of spreader and accessory cones (according to wein)

Master apical cone Spreader Accessory cones

> ISO 55 C, D (large, medium) ISO 25, 30

ISO 30–40 or larger

ISO 35–55 B (fine) ISO 20, 25

ISO 25

< ISO 35 A (extra fine) ISO 15, 20

ISO 20

Advantages of lateral compaction

• Simple
• Undemanding for material and devices
• Low threat of overfill
• Low threat of leakage because contraction of cooling guttapercha
• Good long-term results

Disadvanatges of lateral compaction

• Time consuming
• High occurence of vertical fracture
• Usually not homogenous
 8.Filling using warm gutta-percha

➢ Huge force on spreader is not used = small occurrence of vertical fracture

➢ EndoTwinn (MDCL N.V. Corporation)

➢ Used with step back technique of RC preparation

➢ Using heated pluggers,

➢ apply pressure in a vertical direction

➢ softens gutta percha in canal

➢ causes it to flow and fill lumen of canal

steps :
1. MC same size of last instrument is used
2. Canal coated with thin layer of root canal cement
3. MC is seated up to working length
4. Coronal end of cone is cut off with heated instrument
5. HEAT CARRIER: heated until red, immediately forced in coronal third
of gutta percha
6. Plugger inserted, apply pressure
7. Repeat until lumen filled

Advantages

✓ Perfect obturation
✓ Excellent seal of canal (apically and laterally)

Disadvantages

✓ Time and skill demanding

✓ Risk of vertical root fracture from undue force

• Thermomechanical compaction - Guttapercha cone is put into the canal, using special
rotary instrument (guttapercha compactor) the guttapercha compaction is provided
Advantages:
o Quick
o Excellent filling of lateral canals
Disadvantages:
o Unsuitable for curved canals or larger apical foramen
o Need of skill
o Heat inside root canal

Carrier based gutta percha

Thermafil is a carrier based gutta-percha obturation
Made of plastic core carrier coated with alpha phase gp
Technique :
1. After prep ; size of canal assessed with thermafil verifier instrument
2. Canal dried and lightly coated with sealer
3. Silicone stopper on carrier adjusted to working length
4. Carrier placed in thermaprep plus oven (10sec)
5. Carrier inserted into canal (firmly, uniform pressure applied WITHOUT rotating )
6. Position verified using X-RAY
7. Gp allowed to cool for 2-4 min before removing carrier

• Advantages: quick and simple

• Risk:
• possibility of overfill
• unsuitable for curved canals
• loss of guttapercha if not hit orifice for a first tim

9.Technique of single cone

Root canal is filled with sealer and only one guttapercha cone, which should fit precisely

Advanatges
✓ Cheap
✓ Quick

Disadvantages
✓ Connected with fact, that shaping must be very precise
✓ Fissure between guttapercha and root canal wall can occur because of sealer contraction

✓ Inadequate filling of lateral canals and ramification (almost no compaction)

✓ Luting of sealer

✓ Overfill of cone if the apical seal is not produce precisely

10.Criteria of successful endodontical treatment, check up

Success of convential endodontic treatment: 65–94 %

Combination of clinical and radiographic symptoms:

 Clincial:

➢ Treated tooth ; fully functional without signs of oedema or fistule

➢ Patient does not have any problems with this tooth

➢ No tenderness to precussion

➢ Normal tooth mobility

➢ no signs or infection or swelling

➢ minimal to no scarring or discolouration

Radiogram:

➢ periapical region without any changes (exception; healing of periapical lesion (for 4
years)
➢ Restoration of periodontal space can take some months or even years (4 years)

➢ Radiogram after the filling is comparised with images made for 6, 12, 24 or 48 months
➢ Normal-slightly thickened periodontal ligament space

➢ No resorption of the bone

➢ Normal lamina dura

➢ Dense 3D obturation of canal space

11.Root canal re-endodontic treatment (indications)

Failure of endo treatment:

➢ Bad diagnostics and nonadequate therapy

➢ Violation of endodontic treatment’s principles (absence of radiograms, bad

evaluation of radiograms, mistakes in working procedure)

➢ Complicated anatomy of root canals

➢
Complications of endodontic treatment (infection, insufficient sealing of root
system, via falsa and perforation, overcrowding of the filling material thorough out periapical
regio, bend of root instrument)
Iatrogenic errors

- Separated instrument due to overuse and forcing them in curved canals

- Perforations due to lack of knowledge of tooth anatomy
- Incompletely filled tooth
- Overfilled roots
- Root fractures
- Traumatic occlusion (effects peridontium)

Anatomic factors
- Overly curved canals
- Calcifications
- C/S shaped canals
- Numerous lateral or accessory canals

Systemic factors causing endo failures

- Nutritional deficiencies
- Diabetes Mellitus
- Renal failure
- Autoimmune disorders
- Oppturnistic infections
- Long term steroid therapy

12.Root canal re-endodontic treatment (technique, risks)

➢ Endo treatment =unsuccessful -> re-endo treatment =unsuccessful ->

surgical intervention
❖ Surgical endodontics (surgical intervention) => can not replace endodontic
treatment

Indications for surgical endo:

• complications during root canal treatment

• failure of conservative therapy

• can be used in acute and chronic phases of diseases

• Operations for drainage of periapical regio

• Operations in the periapical regio that allow the removal of periapical lesion and hermetic
sealing of root canal
 • Correction surgical operations

• Microsurgical endodontics

Operation for drainage of periapical region

In acute phase of periapical disease imp to provide the outflow of inflammation exsudate

Insufficient drainage or RC filled with non-removable filling =>Surgical intervention is neccesary

 Incision of subperiostal or submucosal abscess

 Trepanation of alveolus

The part of the treatment is the opening and disinfection of root system of causal
tooth (RCRT)!

Periapical surgery

Indications:

• Unsuccessful endodontic treatment: largening of periapical lesion on control radiogram for 6

months/ patient has problems with the tooth

• Mistakes or complications of working procedure

(separated root instrument, apical fracture, via falsa or perforation)

• Nonadequate filling of root canal using nonremovable filling material or root pin

• Revision of old root filling and new endodontic treatment is the risk for the tooth
(weakening of the root wall, separation of root filling, via falsa)

• Overcrowding of filling material thorough out apex, if the patient has problems

• Calcification of root canal

• can be done in two ways:

1. Resection of the apex (apectomy)

2. Periapical curettage

Working procedureCareful examination before the operation

1. Evaluation of radiogram
 2. Adequate anaesthesia

3. Incision

4. Take off mucoperiostal lobe

5. Bone removal

6. Resection of apical part of the root

7. Curettage of periapical tissues

8. Preparation of retrograde cavity and its filling

9. Control radiogram during the operation, suture

Resection of the apex

Risks of root apex resection

1. Incomplete healing=> abcess formation
2. Cold sores (lips)
3. Damage to the gum
4. Face swollen

Correction surgery

Used for correction of perforations on roots

- Reasons for perforations:
1. Iatrogenic
2. Pathological:
a) resorption (external and internal)
b) caries of dentin
c) perforation during endodontic treatment
d) perforation during the try of removal of separated root instruments

TYPES OF CORRECTION TREATMENT

 1. Hemiextraction, eventually hemisection (premolarization) -
Removal of damaged root with the part of the crown

• Root separation
• extraction of the root with the lesion
• prosthetic treatment

2. Root amputation
Removal of the whole damaged root without part of the crown It is
used in the most cases in the upper jaw
- take off the lobe
- bone removal
- root amputation
- modelation of furcation
- and bone

3. Treatment of perforations (in the middle part of the root)

Small perforations treated with MTA + BIODENTINE

MTA (Dentsply Maillefer)=> Mineral Trioxide Aggregate

Ingredients:
- Tricalcium + dicalcium silicate,
- tricalcium aluminate,
- tetracalcium aluminoferrite,
- calcium sulfate,
- bismuth oxide
Portland cement- differs by radioopacity, chemical purity,
arsenic trioxide (a really little amount)

Biodentine (Septodont)
• bioactive dentin replacement
• with mechanical properties similar to natural dentin
Ingredients:
- powder of triphosphate silicate,
- aqeous solution of calcium chloride and additives

4. Replantation
Microsurgical endodontics
Surgical endodontics using operation microscope
• magnificance (2x–40x)
• special instruments

uses:
• microsurgery of the apex
• treatment of via falsa or perforation
• treatment of internal and external resorption
• removal of separated root instrument
• reendodontics
• use in the primary endodontics:
• finding and treatment of root canals, lateral or accessorial canals, obliterated canals

Procedure Microsurgery Surgery

 Osteotomy Small Large

Clarity Easy Complicated

of root surface
Angle of bevel Gentle (<100) Sharp (450)

Finding of the Easy Impossible

isthmus
Preparation of Parallel with the root Approximate
retrograde cavity
Retrograde filling Exact Nonexact

J. Acute treatment in endodontics

1. Acute states in endodontics (classification, general rules of treatment)

Classification

 Gingivitis and papilitis

• Cause:
o Malhygiene

o Foreign object (toothpick, bristles of toothbrush, foodstuffs residues)

o Overhanging fillings

• Clinical symptoms:

o Pain on percussion of two neighbouring teeth, sometimes can imitate pulpitic pain,
localized pain, red and swollen gingiva

• Treatment: removal of cause, adjustment of oral hygiene, removal of foreign object,

adjustment of overhanging fillings, disinfection

 Indirect pulp capping

Cause:
 • Caries near the dental pulp, further preparation can lead to dental pulp perforation

Clinical symptoms:

• large destruction of hard dental tissues, pain on the thermal stimuli without prolongation,
asymptomatic tooth

Treatment:

• Removal of carious tissues, it is possible to leave a thin layer of soft but noninfected
dentin, cavity disinfection, application of material with Ca(OH) 2, hermetic filling

 Direct pulp capping

Cause:

• random opening of cavum pulpae during the preparation, perforation is not caused by
carious process

Clinical symptoms:

• asymptomatic tooth, there is no bleeding after perforation (dif. dg. chronic pulpitis)
Treatment:
• direct pulp capping vs. root canal treatment

Clinical conditions:

• age of patient, size of perforation, stage of root development, tooth isolation

Realization (in slide… supposed to be recanalisation?!)

• excavation until the hard dentin is present, cavity disinfection,

• application of material for direct pulp capping,
• hermetic reconstruction

 Crack tooth syndrome

Cause:

• large filling,
• overload by mastication,
• parafunctions (bruxismus, malocclusion),
• masticatory/accidental trauma; pins, posts, amalgam filling, endodontic treatment

Clinical symptoms:

• pain on bite, tooth is vital,

• use of selective load of different cusps (tooth slot),
• tooth is painful in bite and releasing of mastication pressure

Diagnostic special tests

• The bite test

• Sensibility/vitality tests
• Transillumination
• Use of dye
• Radiographs

Treatment:

• according to state– root canal treatment,

• prosthetic reconstruction,
• extraction
Definitive treatment depends on:
 • the extent of the crack
• the loss of any tooth structure subgingivally
• the restorative material to be used
• the patient’s preference for a particular type of treatment

Extent and position of the crack


1. Full coverage crown if fracture involves crown portion


2. Endodontic treatment and restoration if fracture involves root canal system


3. Extraction if fracture of root extends below alveolar crest

Fracture of tooth cusp

• Two or more fracture lines are connected and form the tooth fragment
• Line of fracture frequently ends subgingivally, but pulp chamber is not damaged
• Treatment: adhesive reconstruction, prosthetic reconstruction, monitoring

Fracture of tooth cusps and roots

• Reparable tooth fracture

• Line of fracture goes through the whole crown

• Fracture line ends subgingivally

• Pulp chamber is damaged. Endodontic therapy is necessary.

• Treatment: endodontic therapy, prosthetic reconstruction (overlay, crown)
 Fracture of root

• Nonreparable fracture of tooth crown and root

• Line of fracture goes through the larger part of the root

• Treatment: tooth extraction

 Hyperaemia of dental pulp

Cause:

• tooth decay, large new filling

Clinical symptoms:

• pain on cold or sometimes sweet,

• acid stimuli without prolongation;
• higher reaction onto vitality test without prolongation; there is no spontanneous pain

Management:

• removal of cause,
• removal of filling and tooth decay,
• making of new restoration with perfect marginal quality

 Acute pulpitis, acute exacerbation of chronic pulpitis

Acute pulpitis – inflamation of pulp

Etiology:

 Infection

 Caries:
➢ most common ,

➢ Pulp´s inflamatory response to toxins than to bacteria themselves

➢ Mostly lipopolysacharid (LPS) and lipotechoic acid (LTA)

 Anomalous crown morphology, fractures

 ➢ Increased likehood of pulpal inflamation

➢ Mostly secondary to caries

 Periodontal disease

➢ Toxins enter dental pulp through lateral canals or through apical foramen.

 Anachoresis

○ Bacteria in circulating blood may be deposited in the pulp (only in harmed

one)

○ Very rare

 Physical causes

Acute trauma

➢ Usually causes disruption of blood circulation. As consequence chronic inflamation

(sterila) can occure and acute flare-up can happened after bacteremia.

Chronic trauma

➢ Inproper articulation of restorations

➢ Same mechanism as with

acute trauma Thermal trauma

➢ Usually iatrogenic

➢ Faulty preparation

 Chemical causes- erosion, inappropriate use of acidic dental appliances

Classification of pulpitis

 Clinical= Reversible + irreversible

 Histopathological ;
1. Acute ;
o Hyperemia
- Initial form of inflammation
- Widening of capilars
active + peristatic => REVERSIBLE
passive => IRREVERSIBLE

o Serous pulpitis
- Reactionary dentin
- Widening of capillaries
- Transudate, extravascular inflammatory cells
PARTIAL/ TOTAL

o Purulent pulpitis
▪ Abscedens
- more often
- Rich leukocytes infiltration followed by necrosis
- Necrosis is demarcated by granulation tissue

▪ Flegmonous
- Necrosis is not demarcated
- inflammatory infiltration is spreading through whole pulp

2. Chronic
o Aperta
▪ Ulcerous : Mostly adult patients
- Pulp is exposed,
- under the necrotic surface is ulcer
▪ Granulomatous
- Mostly child patients (rather deciduous)
- As called as polypous – granulation tissue forms prominence out
of pulp chamber
- Soft, bleeding

o Clausa
➢ Usually no clinical signs
➢ Connected with caries penetrating to pulp

➢ Chronic absces

➢ Tendency to calcifications and production of denticles

▪ Chronic absces
▪ Fibrous
 ▪ atrofic
o Internal resorption
- Production of granulation tissue which is produced mostly by
fibriblast, which can change to cells with resorbing character
- Mostly frontal upper teeth
- Mostly in roots
o Radiolucency of oval shape
o Pink spot if occur close to pulp chamber
- Etiology
o Acute/chronical trauma

3. Chronic with acute exacerbation

 Acute apical periodontitis, acute exacerbation of chronic apical periodontitis

APICAL PERIODONTITIS => Inflammation around

root end -
Etiology: mostly due to dead pulp, bacterial invasion, trauma, products of bacterial invasion and
pulp necrosis

- Cause: large tooth decay that leads to pulp gangraena, trauma, nonarticulated fillings,
- Clinical symptoms: 4 phases
- X-Ray:
o Acute apical periodontitis: no changes or widening of periodontal space, change
of
bone image
o Acute exacerbation of chronic apical periodontitis: radiolucency
- Treatment: according to periodontitis phase

 Flare up

• Cause: acute exacerbation of infection after endodontic treatment

• The change of bacteria, pushing of infected content of root canal thorough the apex

• Clinical symptoms: pain of the treated tooth, swelling of the cheek at the next day
after the treatment; swelling is soft, painful during the palpation, without fluctuation

• Treatment: removal of root canal content- Ca(OH)2, irrigation, the tooth will be free
without filling, intraoral incision, analgetics, antibiotics
• After 2–3 days- elimination of symptoms
  Sinusitis maxillaris

Cause:

• acute inflammation of sinus maxillaris

mucosa Clinical symptoms:

• pain on percussion of upper teeth (premolars, first or second molar), dull pain in the
upper jaw, increase of pain after bending forward, general symptoms

• The blurred sinus maxillaris on OPG

Treatment:

• examination on otorhinolaryngology

 Pain of TMJ

• Cause: TMJ disorders, artritis, general diseases

• Clinical symptoms:
1. diffusion of the pain onto the ear (dif. dg. acute pulpitis),
2. upper and lower teeth,
3. neck
4. Headache like in migraine

OPG in special joint projection

Treatment: on the special maxillofacial surgical department, rehabilitation

2. Treatment of pulpitis acuta
 Early detection-> PULPOTOMY (removal of coronal
pulp) And filling with calcium hydroxide, gutta
percha
(talk about procedure RCT)

✓ Examination, radiographic examination

✓ Differential diagnosis

✓ Decision: endodontic treatment

✓ Anaesthesia

✓ Preendodontic core

✓ Application of rubberdam

✓ It is preferable to provide endodontic treatment in one visit

3. Treatment of periodontitis acuta (periodontal and enosseal phases)

Acute periodontitis – inflammatory condition, accompanied by pain, necrotic

pulp + radiographic thickening of apical periodontal ligament

Etiology (acute apical periodontitis)

1. Pulp disease(deep caries)

2. Bacterial irritation
3. Bacterial toxins

Stages

1. Periodontal stage – hyperemia of bv & odema of periodontium

Clinical features (CF) ; painful tooth (on touch by bite), feeling of elevated tooth
2. Endosseus stage – (bone involved) hyperemia of vessels, leukocytic infilteration,
formation of pus
CF: Intensive, constant, throbbing pain + strong feeling of elevated tooth
3. Subperiostaeal stage –Pus beneath periosteum-subperiosteal abcess
CF: throbbing pain (increased instensity) , extremely sensitive tooth, swelling
4. Submucous stage- submucous
abscess CF; decreased painful
symptoms

Diagnosis ; history (pain-instensity/duration, sensitivity, supraocclusion), facial asymmetry

(swelling), pyrexia, lymph node invol. Tenderness to percussion + X-ray (widenend
periodontal space)

LAP = LOCALISED AGGRESSIVE PERIODONTITIS

4. Treatment of periodontitis acuta (subperiostal and submucose phases)

GAP= GENRALISED AGGRESSIVE PERIODONTITIS

 - Root canal treatment with intraoral incision vs. tooth extraction
- Anaesthesia
- Drainage of the exudate through:
o Root canal
o Intraoral incision
o Extraction

5. Flare up

• Cause: acute exacerbation of infection after endodontic treatment

• The change of bacteria, pushing of infected content of root canal thorough the apex

• Clinical symptoms: pain of the treated tooth, swelling of the cheek at the next day after
the treatment; swelling is soft, painful during the palpation, without fluctuation

• Treatment: removal of root canal content- Ca(OH)2, irrigation, the tooth will be free
without filling, intraoral incision, analgetics, antibiotics

• After 2–3 days- elimination of symptoms

6. Differential diagnostics of acute states in endodontics

DD: identifying conditions by comparing symptoms of all other pathological processes

Gingivitis &Palpitis :

Pain on percussion of two neighbouring teeth, sometimes can imitate pulpitic pain, localized
pain, red and swollen gingiva

Indirect pulp capping:

large destruction of hard dental tissues, pain on the thermal stimuli without
prolongation, asymptomatic tooth

Direct pulp capping

asymptomatic tooth, there is no bleeding after perforation (dif. dg. chronic pulpitis)

Crack tooth syndrome

pain on bite, tooth is vital, use of selective load of different cusps (tooth slot), tooth is painful in
bite and releasing of mastication pressure
7. Trauma of teeth
1.
Concussion
- Tooth is not mobile
- Not displaced
- Periodontal lig. Absorbs injury + inflamed
- Leaving tooth tender to biting pressure +precussion

Precussion test : tender on touch/tapping

Pulp sensitivity testing: positive

No radiographic findings

Treatment ; monior tooth for 1 year,

Precaution tips to patient: soft drinks once a week, soft brushing , chlorohexidine prevent
plaque formation

2. Luxation

- Tooth is displaced in a labial, lingual, lateral directions

- PDL usually torn
- Alveolar fracture may occur
- Similar to extrusion injuries : partial/ total separation of PDL

Visual signs: displaced in palatal/lingual and labial direction

Precussion test: gives metallic (ankylotic) sound

Mobility test: usually immobile

Pulp sensitivity test: lack of response

Radiograghic findings: widened periapical ligament space (best seen on eccentric exposures)

Treatment : splints and repositioning of teeth

3. Fracture
1. Enamel fracture – loss of tooth structure
 Visual signs: visual loss of enamel, exposed dentine,

Precussion –not tender (if tender; evaluate tooth for fracture of root, luxation)

Mobility test: normal mobility

Pulp sensitivity test: positive

Radiograghic findings: enamel loss visible

Treatment :

Tooth fragment available=> can be bonded

Restoration with composite resin

2. Enamel –dentine fracture

- fracture confined to enamel –dentine
- loss of tooth structure
- no pulpal involvement

Visual signs: visual loss of enamel+ dentine, no exposed pulp

-
- Precussion –not tender (if tender; evaluate tooth for fracture of root,
luxation)
-
-
- Mobility test: normal mobility
- Pulp sensitivity test: positive
- Radiograghic findings: enamel dentine loss visible
- Treatment :
- Tooth fragment available=> can be bonded
- Exposed dentine covered with GIC
- Or permanent restoration with bonding agent + composite resin

3. Enamel-denitne-pulp fracture
 - Complicated root fracture
- fracture confined to enamel –dentine pulp
- loss of tooth structure
- pulpal involvement

Visual signs: visual loss of enamel+ dentine+ exposed pulp

- Precussion –not tender (if tender; evaluate tooth for fracture of root,
luxation)
- Mobility test: normal mobility
- Pulp sensitivity test: positive
- Radiograghic findings: tooth structure loss visible

Treatment :

- Young patients – imp to preserve pulp, pulp capping/ partial pulpotomy

- Calcium hydroxide +MTA used
- Older patients with closed apices +luxation injury = RCT

CROWN ROOT FRACTURE WITHOUT PULPAL INVOLV.

Fracture includes- enamel, dentine, cementum, loss of tooth structure, but NO EXPOSING PULP

Visual signs- crown fracture extending below gingival margin

Precussion test- Tender

Mobitltiy –coronal fragement mobile

Sensibility – positive for apical fragment

Radiogrpahic signs –apical extension of fracture usually not visible

Treatment – fragment removal only + subsequent restoration of dentine above gingiva

- Fragment removal + gingivectomy (coronal segment removal +restoration

with post retained crown)
- Orthodontic extrustion of apical fragement
- Surgical extrustion
 - Decornation
- Extraction
CROWN ROOT FRACTURE WITH PULPAL INVOLV.

Fracture includes- enamel, dentine, cementum, loss of tooth structure, but EXPOSING PULP

Visual signs- crown fracture extending below gingival margin

Precussion test- Tender

Mobitltiy –coronal fragement mobile

Sensibility – positive for apical fragment

Radiogrpahic signs –apical extension of fracture usually not visible

Treatment – fragment removal only + subsequent restoration of dentine above gingiva

- Fragment removal + gingivectomy (coronal segment removal +restoration

with post retained crown)
- Orthodontic extrustion of apical fragement
- Surgical extrustion
- Decornation
- Extraction

Root fracture

Fracture involving cementum, dentine, pulp

Visual signs : coronal segment mobile, some cases displaced , transient crown
discoloration , subgingival bleeding

Precussion test- Tender

Mobitltiy –coronal fragement mobile

Sensibility – negative intially => indictaing transient/ permanent neural damage

Radiogrpahic signs –root fracture line is visible (involves root of tooth in

horizontal +diagonal planes)

Treatment – rinse exposed root surface with saline solution before respostioning ,
check radiographically
 - Stablise tooth using splint (4 wks)
- Monitor healing for 1 year
- If pulp necrosis develops => RCT

K. Postendodontical treatment

1.Postendodontical treatment and its functions

The goal of the endodontic restoration is to provide optimal oral health, esthetics and function.
Therapeutic efforts made to result in easily maintainable and reliable treatment over long term.
Endodontic therapy, restorative dentistry and periodontal health are intimately related.

2.Postendodontical treatment of anterior teeth

Postendodontic treatment depends on

• hard tissue loss( small, medium, big)

• components of final restoration(post, core, prosthodontics)

Small loss-> composite filling(almost everytime without FRC post)

Medium loss-> width of hard dental tissues under cups and fracture checking(onlay, overlay, crown)

Big loss-> metallic post(crown), get new ferrula + RFC + build up (osteoplastic -> overlay,
crown ; orthodontic extrusion-> overlay, crown)

Post:

• metallic-> stainless steel, titanium, titanium alloy, gold plated brass

• non metallic-> carbon fibre, ceramic, glass-fibre reinforced composite, composite

Core:

• Direct-> composite resin, amalgam, glassionomer resin

• Indirect-> Casting

Post refers to a cylindrical or tapered object that fits into the prepared root canal of a tooth

Core refers to a build up restoration, usually amalgam/composite placed in a badly broken

down tooth to restore the bulk of the coronal portion of the tooth to facilitate subsequent
restoration by means of an indirect extracoronal restoration.
3.Postendodontical treatment of posteriori teeth
L. Endodontic surgery
• Surgical procedures additional to endodontic treatment (classification, indication)

Endodontic surgery – is a surgical procedure performed to remove or correct the causative agent
of radicular and periradicular disease and to restore these tissues to functional health.

Is often the last hope for retention of a tooth requires the greatest skill.
Indications:

• Inability to eliminate pathology by conventional RCT (calcified canal, perforation)

• Inability to clean and fill the entire root canal by conventional method (severe
dilacerations, post & core)
• Iatrogenic problems (broken instrument, via falsa or perforation, apical fracture)
• Unsuccessful endodontic treatment – there is an increase in size of periapical
lesion after 6 months/ patient has problems with the tooth
• Overcrowding of filling material throughout the apex, if the patient has problems
• Microsurgical endodontics

Contraindications:

- Pathology resolved by conventional RCT

• Health contraindications (anticoagulation therapy, severely debilitated patients)
• Anatomic considerations (proximity to great palatine foramen)
• Periodontal considerations

Classification of endodontic surgery:

1) Fisulative surgery:
- Incision and drainage
- Cortical trephination
- Decompressionprocedures

2) Periradicular surgery:
Curettage
Root-end resection
Root-end preparation
Root-end filling
3) Corrective surgery
• Perforation repair:
Mechanical
(iatrogenic)
Resorptive
 • Periodontal
management:
Root resection
Tooth resection
• Intentional replantation
Types of flaps used in endodontic surgery:

= incisions
2) Gingival – intrasacular horizontal incision without vertical release; - not used for
apical surgery
- used for root resects, root amps, hemisections, repair of cervical perforations,
resorptive defects
3) Semilunar – full-thickness flap in alveolar mucosa at level of tooth apex - Indication for long
tooth only (max canine)
- Seldom used due to poor access & scarring - Hemostasis
may be a problem
4) Triangular – most commonly used;
• One vertical releasing incision, can extend to rectangular flap
• Full – thickness flap
• Has an excellent wound healing potential, minimal disruption of vascular supply,
excellent visibility and access to defect, easy to suture
• Rectangular = trapezoidal = intrasucular – extension of triangular flap - 2 vertical
releasing incisions
- Horizontal intrasucular incision
• Submarginal (Ochsenbein – Luebke) – scalloped horizontal incision in attached
gingiva & 2 vertical releasing incisions
- Must be adequately attached gingiva (3-5 mm)
- Best for epithelial wound closure
- Doesn’t involve marginal or interdental gingiva nor expose crestal bone minimal crestal
bone loss and recession of gingiva (aesthetics)

Types of endodontic surgery:

1) Incision for drainage – soft tissue

2) Trephination – throughout the bone procedure used to alleviate acute pain caused by
an accumulation of purulent material when drainage throughout the root canal is
impossible
3) Perirdicular surgery:
- Apical curettage
- Apicoectomy
- Apicoectomy with retrograde
filling 4) Repair of perforation
5) Hemi-section and root amputation
6) Intentional replantation

2.Drainage of periapical region

 surgical drainage is indicated when the purulent or/ and hemorrhagic exudates form within
the soft tissues and alveolar bone as a result of symptomatic periradicular abscess.

Drainage may be achieved by:

- Incision and drainage

- Cortical trephination

Incision for drainage is

designed to:

- Release accumulated by-products of tissue breakdown (pus)

- Collect samples for bacteriologic analysis
- Provide a more favorable gradient and pathway for drainage
In acute phase of periapical abcess it is necessary to provide the outflow of inflammation
exsudate. If the drainage thorough root canal is insufficient or if the root canal is filled by
nonremovable filling the surgical intervention is necessary:

- Incision of subperiostal or submucosal abscess

- Trepanation of alveolus

The immediate task is to releive pressure by establishing drainage and it can be achieved by
opening up the pulp chamber. We can use a small round daimond bur in a turbine to reduce
the trauma of the operation. Regional anasthesia may be necessary.

Incision to establish drainage:

- Indication is the presence of a collection of pus which points from a fluctuant abscess in
the soft tissues. Surface analgesia will be applied (ethyl chloride; topical lignocaine
ointment). Regional anesthesia may not be effective due to presence of pus – the
administration of a local analgesic solution may spread the infection further into the
tissues.
- Incision of the swelling with scalpel blade or aspirate using wide-bore needle and
disposable syringe
- Once access and initial drainage have been achieved, a rubber dam should be applied
to the tooth; the pulp chamber should be thoroughly irrigated with a solution of
sodium hypochlorite to remove as much superficial organic and inorganic debris as
possible and endodontic treatment performed.

3. Periapical and corrective

surgery

Periapical surgery:

Indications:
 - Unsuccessful endodontic treatment – largening of periapical lesion on control
radiogram for 6 month; patient has problems with the tooth
- Mistakes or complications of working procedure (separated root instrument,
apical fracture, via falsa or perforation)
- Nonadequate filling of root canal using nonremovable filling material or root pin
- Revision of old root filling and new endodontic treatment is the risk for the tooth
weakening of the root wall, separation of root filling, via falsa
- Overcrowding of filling material throughout the apex if the patient has problems
- Calcification of root canal
Periapical surgery:

Resection of the apex (apectomy)

Periapical curettage

Working procedure:

1) Careful examination before the operation

2) Evaluation of radiogram
3) Adequate anaesthesia
4) Incision
5) Take off mucoperiostal love
6) Bone removal
7) Resection of apical part of the root
8) Curettage of periapical tissues
9) Preparation of retrograde cavity and its filling
10) Control radiogram during the operation
11) Suture

Types of flaps used in endodontic surgery:

= incisions

1) Gingival – intrasacular horizontal incision without vertical release; - not

used for apical surgery
- used for root resects, root amps, hemisections, repair of cervical perforations,
resorptive defects
2) Semilunar – full-thickness flap in alveolar mucosa at level of tooth apex -
Indication for long tooth only (max canine)
- Seldom used due to poor access & scarring - Hemostasis
may be a problem
3) Triangular – most commonly used;
- One vertical releasing incision, can extend to rectangular flap
- Full – thickness flapHas an excellent wound healing potential, minimal disruption of
vascular supply, excellent visibility and access to defect, easy to suture
4) Rectangular = trapezoidal = intrasucular – extension of triangular flap - 2 vertical
releasing incisions
- Horizontal intrasucular incision
5) Submarginal (Ochsenbein – Luebke) – scalloped horizontal incision in attached
gingiva & 2 vertical releasing incisions
- Must be adequately attached gingiva (3-5 mm)
 - Best for epithelial wound closure
- Doesn’t involve marginal or interdental gingiva nor e minimal
crestal bone loss and recession of gingiva (aesthetics)

Correction surgery:

It is used in the mot cases for correction of the perforation on roots. Reasons of perforations:

1) Iatrogenic
2) Pathological process:
- Resorption (external and internal)
- Caries of dentin
- Perforation during the removal of separated root instrument

Small perforations are treated conservatively using MTA (mineral trioxide aggregate –
based sealer) or Biodentin

MTA (Dentsply Maillefer): Mineral Trioxide Aggregate

Ingredients: tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium

aluminoferrite, calcium sulfate, bismuth oxide; portland cement-differs by radioopacity,
chemical purity), arsenic trioxide (a really little amount).

Biodentine (Septodont):

bioactive dentin replacement with mechanical properties similar to natural dentin

Ingredients: powder of triphosphate silicate, aqeous solution of calcium chloride and additives

Correction surgery types:

1) Hemiextraction removal of damaged root with the part of the crown - Used for
upper and lower teeth
- Roots separation
- Extraction of the root with the lesion -
Prosthetic treatment

2) Root amputation removal of the whole damaged root without part of the
crown - Used in the most cases in the upper jaw
- Take of the
love - Bone
removal
- Root amputation
- Modelation of furcation and bone

3) Treatment of perforations (in the middle part of root)

4) Intentional replantation a purposeful extraction of a tooth in order to repair a defect
or cause of treatment failure and thereafter the return of the tooth to its original socket
Indications for replantation:
 - all other endodontic non-surgical and surgical treatmentshave failed or are
deemed impossible to perform;
- limited mouth opening that prevents the performance of non-surgical or peri-
radicular surgical endodontic procedures;
- root-canal obstructions;
- restorative or perforation root defects that exist in areas that are not
accessible via the usual surgical approach without excessive loss of root
length or alveolar bone

4. Endodontic microsurgery

a surgical procedure on exceptionally small and complex structures with an operation

microscope

- magnification (2-40x)
- special instruments

Use of operation microscope in endodontics:

 • microsurgery of the apex
• treatment of via falsa or perforation
• treatment of internal and external resorption
• removal of separated root instrument
• reendodontics
• use in the primary endodontics finding and treatment of root canals, lateral or
accessorial canals, obliterated canals

Contraindications:

- Periodontal health of tooth

- Patient health consideration
- Surgeons skill and ability

Hard tissue management:

1) Osteotomy
2) Periradicular curettage
3) Apical resection

https://www.slideshare.net/abhijeet1104/endodontic-surgery-1-32624795 (for more info)

M. Endodontic treatment of teeth with incomplete development

1. Morphology of the permanent teeth with incomplete development
2. Treatment
3. Working procedure of endodontic treatment of these teeth

1. Hyperdontia = Supernumerary teeth

- extra amount of teeth – supplemental or accessory teeth

Causes:

- Developmental disturbance creating intracellular activity during the first stage of tooth
development (bud stage)
- Many of them never erupt, but may delay eruption of nearby teeth or cause other dental
problems

Treatment:

- Most common treatment is extraction

Mesiodens:

- Most common malformed, peg – shaped tooth that occurs between the maxillary central
incisors

Treatment extraction

2. Hypodontia:

- oligodontia, partial odontia congenital absence of one or more teeth (3d

molars are common)

Cause:

- Interferences such as radiation exposure or a hereditary disturbance (ectodermal

dysplasia)

Treatment:

- Depends on their location in the mouth

3. Abnormalities in crown size:

1) Megadontia – teeth exceed normal range of variations (max & mand incisors,
mand second premolar)
2) Microdontia – teeth smaller than the normal (usually normal form or
peg/conical shaped)

4. Anomalies in root size:

- large root size (max canines)

- small root size – generalized reduction in root length, may be associated with
dentine and pulp dysplasia

5. Abnormalities of tooth form:

1.Concrescence – cementum overlaying the roots of 2 teeth joins together

- Cause – trauma, crowding of teeth
- Treatment – surgical separation may be necessary if one tooth is to be extracted
2.Fusion – 2 developing teeth merge into one
 - Cause – union of 2 normally separated teeth depends upon the stage of
development and may be complete or incomplete fusion
- Treatment – there is a groove running down the back of the tooth and is prone to
decay and may require a filling (patient is missing one tooth)
3.Germination – developing tooth splits into 2 separate teeth
- Cause – 2 teeth develop from 1 patient has a larger tooth but normal amount
of teeth
- Treatment – groove that runs down the back of the tooth that is prone to decay
may need a filling

4) Dens evaginatus:
- Rare dental anomaly involving an extra cusp or tubercle that protrudes from the tooth
(premolars)
- Cause – genetics or disruption of tooth during development
- Treatment – monitoring as the tooth can lose it blood and nerve supply and may need root
canal treatment

5) Talon cusp:
- Extra cusp that resembles an eagle’s talon and appears as a projection from cingulum in
incisors
- Cause – genetic or disruption of the tooth during development
- Treatment – talon cusps interfere with occlusion; contain a prominent pulp horn; tooth
requires monitoring and may require RCT

6) Dens invaginatus / Dens in dente:

- Tooth within the tooth
- Cause – invagination of the epithelium associated with coronal
development into the area that was to be pulp space
- Most affected teeth are max lateral incisors
- Malformations often result in early pulp necrosis and death
- Treatment – RCT can be complicated due to complex anatomy of teeth

7) Taurodontism:

- Morphoanatomical change in the shape of tooth which occurs in multirooted

teeth, An enlarged body and pulp chamber and apical displacement of the
pulpal flood are characteristic features
- “bull-like teeth” – on X – ray tooth looks rectangular without apical taper; the pulp
chamber looks extremely large
- Cause – oral – facial digital syndrome; amelogenesis imperfecta; Down syndrome
- Treatment – RCT is challenging – requires special care in identifying number of
root canals

Disturbances in formation:

1) Dilaceration – developmental disturbance in shape of teeth. It refers to an angulation or a

sharp bend or curve in the root or crown of a formed tooth
- Cause – due to trauma during the forming period
 - Treatment – no treatment; extractions is more complicated
2) Regional odontodysplasia – developmental abnormality of teeth, localized to a certain area
and nonhereditary. Enamel, dentin and pulp are effected
and on X-rays teeth are described as “ghost teeth” (often max ant teeth)
- Cause – trauma, irradiation, hypophosphatasia, hypocalcemia, hyperpyrexia
- Treatment – most common is extraction and prosthetic replacement

Hereditary disturbances in structure or formation:

1) Amelogenesis imperfecta:
- Abnormal enamel with yellow, brown or grey appearance
- Higher risk of dental caries and hypersensitivity to t
- Cause malfunction of proteins in enamel
- Treatment crowns, implants, dentures
2) Dentinogenesis imperfecta:
- Opalescent dentin – discolored (blue-grey or yellow-brown color) and translucent
- Weaker teeth than normal – rapid wear, breaks, loss
- Treatment crowns, complete dentures (overdentures)