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Management of pulpal

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... Pulpal & periradicular pathology Pulp disease Classification of periapical disease Radiographic lesions of non-endodontic origin ... Hand instruments 7-2 ... – PowerPoint PPT presentation

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Title: Management of pulpal


1
Management of pulpal periradicular disease
  • GDC
  • ???

2
  1. Introduction
  2. Pulpal periradicular pathology
  3. Pulp disease
  4. Classification of periapical disease
  5. Radiographic lesions of non-endodontic origin
  6. Management of pulpal periradicular disease
  7. Chemomechanical debridement
  8. Root canal preparation
  9. One-visit root canal treatment
  10. Root canal obstruction
  11. Assessment of root canal treatment

3
1.Introduction
4
Pulpal Periradicular Ds.
Bacteria
origin
aim of Tx.
5
2.Pulpal periradicular pathology
6
Sources
  • Bacterial
  • Mechanical Injury/Irritation
  • Chemical

7
Modes of entry for bacteria into the root canal
system
  • Caries
  • Periodontal disease(dentine tubules, furcal
    canals, lateral canals)
  • Erosion, attrition abrasion(dentinal tubules)
  • Trauma with or without pulpal exposure
  • Developmental anomalies
  • Anachoresis(the passage of microorganisms into
    the root canal system from the bloodstream)

8
3.Pulp disease
  • 3-1.Soft tissue change
  • 3-2.Hard tissue change

9
3-1.Soft tissue change
  • Reversible pulpitis
  • Irreversible pulpitis
  • Hyperplastic pulpitis
  • Pulp necrosis

10
3-1-1.Reversible pulpitis
  • Sx.
  • Pain
  • ?? ?? ? ??(?)
  • ?? ?? ???
  • XR ??
  • P/R(-)
  • Tx.
  • ??? D ??
  • ??? ??

11
3-1-2.Irreversible pulpitis
  • Sx.
  • Pain
  • ?? ?? ? or ???
  • ?? ?? ? ??(?)
  • ???? ??
  • ?? ?? ??(if PDL involved)
  • XR PDL widening
  • Tx.
  • RCT
  • Ext.

12
3-1-3.Hyperplastic pulpitis
  • Pulp polyp
  • a form of irrv. pulpitis
  • ?? ??? young pulp? ??
  • Tx.
  • RCT
  • Ext.

13
3-1-4.Pulp necrosis
  • end result of irrv. pulpitis
  • Tx.
  • RCT
  • Ext.

14
3-2.Hard tissue change
  • Pulp calcification
  • Internal resorption

15
Pulp calcification
  • 2D
  • physiologic
  • ?? ?/?? ?? ?
  • ???? floor / ceiling
  • 3D
  • ?? ?? ?
  • reactionary D mild stimuli
  • reparative D strong stimuli
  • Tx.
  • ??? ??

16
Internal resorption
  • dentinoclastic activity
  • pink spot
  • ???
  • ??
  • punched-out outline
  • XR
  • pulp cavity? ??
  • Tx.
  • RCT ?? ??
  • Ext. ?? ?? ?

17
4.Classification of periapical disease
  • 4-1.Acute apical periodontitis
  • 4-2.Chronic apical periodontitis
  • 4-3.Condensing osteitis
  • 4-4.Acute apical abscess
  • 4-5.Chronic apical abscess

18
4-1.Acute apical periodontitis
  • Sx.
  • P/R()
  • PDL widening
  • Tx.
  • occl. adjustment
  • RCT
  • Ext.

19
4-2.Chronic apical periodontitis
  • Sx.
  • V/S(-)
  • P/R() mild
  • Td() apex
  • XR ??(PDL wideningperiapical destruction)
  • Tx.
  • RCT
  • Ext.

20
4-3.Conensing osteitis
  • Chr. apical periodontitis? ??
  • diffuse increase in trabecular b.
  • XR concentric radio-opacity
  • Tx.
  • ?? ??? ??

21
4-4.Acute apical abscess
  • Sx.
  • moderate discomfort swelling/systemic
    involvement(?? ??, ???)
  • P/R(), Td()
  • XR well defined radiolucency
  • Phoenix abscess
  • acute exacerbation of a chr. situation during tx.
  • Tx.
  • 1
  • ??? ?? ??
  • Drainage
  • Ax.
  • 2
  • RCT
  • Ext

22
4-5.Chronic apical abscess
  • Discharge
  • intraoral sinus
  • extraoral sinus
  • PDL(perio. pocket? ??)
  • Tx.
  • RCT
  • Ext.
  • ?? ? ?? ?? ??(???)

23
5.Radiographic lesions of non-endodontic origin
24
Radiograghic lesions of non-endodontic origin
  • Normal anatomical structures
  • Maxillary sinus
  • Mental foramen
  • Nasopalatine foramen
  • Benign lesions
  • Cementoma
  • Fibrous dysplasia
  • Ossifying fibroma
  • Primordial cysts
  • Lateral periodontal cyst
  • Dentigerous cyst
  • Traumatic bone cyst
  • Central giant cell granuloma
  • Central haemangioma
  • Ameloblastoma
  • Malignant lesions
  • Squamous cell carcinoma
  • Osteosarcoma
  • Chondrosarcoma
  • Multiple myeloa

25
DDx.
  • pulp vitality test
  • XR (?? ???? ??)
  • Bx.

26
6.Management of pulpal periradicular disease
27
Tx. sequence
  • 1. pulpal perio. pain ?? ??
  • 2. hopless teeth ??
  • 3. ? ?? ?? ???
  • 4. ?? ?? ? ?? ??

28
Endo. Tx.
  • part of an overall plan of care? ??
  • antiseptic principles ??
  • chemomechanical debridement of the pulp cavity
  • removal of infected dentine
  • use of antimicrobial agents
  • R/D ?? ??

29
Rubber dam ??
  • Improved visibility
  • Soft tissue protection
  • Confinement of excess irrigant
  • Prevention of saliva contamination
  • Reduced liability in the medicolegal sense

30
7.Chemomechanical debridement
  • 7-1.Hand instruments
  • 7-2.Automated instrumentation
  • 7-3.Irrigation
  • 7-4.Summery

31
Irrigating soln(chemo)hand auto.
Instruments(mechanical)
  • Chemomechanical

32
7-1.Hand instruments
  • Barbed broach
  • Hedstrom file
  • k type file

33
Barbed broach
7-1.Hand instruments
  • ?? ? ???? ???? 90??
  • ?? ??
  • vital pulp ??
  • soft foreign object ??

34
Hedstrom file
7-1.Hand instruments
  • sharp cutting edge
  • ???
  • linear manner(?)
  • rotation(?)
  • ??
  • flaring canals
  • re-tx.

35
K type file
7-1.Hand instruments
  • most commonly used
  • standard taper 0.02mm/mm
  • tip size
  • ??(0.061.40mm)
  • ??? ??(?)

36
Filing motion
7-1.Hand instruments
  • Watchwinding
  • gentle side-to-side rotation
  • ?? 30??
  • Balanced force
  • efficient cutting
  • 60CW 120 CCW
  • C/E C/S? ??

37
NiTi files
7-1.Hand instruments
  • hyperelasticity
  • greater taper (0.020.12mm/mm)
  • 360 rotation ??
  • shape memory

38
Grater taper files
7-1.Hand instruments
  • increased taper hand file
  • tip size 20
  • taper
  • 0.06, 0.08, 0.10, 0.12
  • Balanced force movement ??
  • step back ???

39
7-2.Automated instrumentation
  • easier quicker
  • ex)
  • GG bur
  • Reciprocating handpieces
  • Ultrasonic sonic units
  • Rotary NiTi instrumentation

40
Reciprocating handpieces
  • watchwinding type motion(60/90)
  • light touch
  • fine calcified canal?? ??

M4 reciprocating handpiece
41
Ultrasonic sonic units
  • vibratory system
  • C/I (?)
  • C/S (?)
  • ??
  • post, ??? ?? ??
  • ?? ?? ??
  • apical sx.

Piezon ultrasonic unit
42
Spartan ultrasonic unit
43
Rotary NiTi instrumentation
  • ??
  • debris removal(?)
  • canal transportation(?)
  • smoother, faster canal prep.
  • operator fatigue(?)
  • ??
  • ?? file? ?? ???? taper??? ?
  • Orifice shapers
  • ProFiles/ProTaper
  • rotary GTs
  • GG bur? ??? cutting bud? thin shaft? ?? ?
  • Lightspeed

44
Rotaty nickel titanium files
  • Orifice shapers
  • ProFile
  • Rotary GT
  • Pro Taper

45
  • Lightspeed(NiTi)
  • GG bur(stainless steel)

46
7-3.Irrigation
  • NaOCl accident
  • Needle binding ??
  • ?? ?
  • ?? ?????
  • 30?? ?? ??
  • ??? ?? ? 24?? ?? ??
  • ???/??? ??
  • ?? ??
  • ?? ??? ???
  • ?? 23? filing ? ?? ??
  • EDTA ??
  • Smear layer?? ???

47
Acoustic microstreaming (ultrasonic irrigation)
  • Ultrasonic handpiece
  • ?? ? ?? ???debris??? ??
  • NaOCl ??? ?? ?? ??

48
7-4.Summery
  • RTC? ??
  • bacteria-free!!!

49
8.Root canal preparation
  • 8-1.Access
  • 8-2.Canal identification
  • 8-3.Straight-line radicular access preparation
    of coronal 2/3
  • 8-4.Length determination
  • 8-5.Apical preparation
  • 8-6.Rotaty nickel titanium instrumentation
    techniques

50
Root canal prep.
  • Biological objectives
  • ??, ??, ??? ??
  • Mechanical objectives
  • continuous tapering
  • original anatomy??
  • foramen?? ??
  • foramen? ??? ?? ??

51
Sequence
  • 8-1.Access
  • 8-2.Canal identification
  • 8-3.Straight-line radicular access preparation
    of coronal 2/3
  • 8-4.Length determination
  • 8-5.Apical preparation

52
8-1.Access
53
8-1.Access
  • Coronal access
  • unimpeded path
  • pulp chamber roof ??
  • ?? ??? floor?? ????? ??
  • divergent wall
  • straight-line path
  • Radicular access

54
8-1.Access
  • ?? ??? ??? ??
  • But!! root prep.? ????? ??? ??
  • esp. curved root in coronal 1/3

55
8-1.Access
  • A/O? ?? ??
  • ?? ??
  • ?? ?? ? ???
  • ?? ??
  • ?? ??? ??(?? ???? ??)
  • ??? ??, ??? ??
  • ?????? ??(Max. safe depth??)
  • ?? ??? ??? ??
  • ?? ?, ?? ???, ?? ??? ??

56
A/O
8-1.Access
  • Mx. Incisor
  • triangular
  • Mx. Mn. Canine
  • more ovoid triangular
  • Mn. Incisor
  • triangular
  • 2nd canal 40

57
A/O
8-1.Access
  • Premolar
  • Mx. 1st PM
  • ??? ? ovoid
  • 2 canals
  • 3rd canal 5(??)-tirangular
  • Mx.2nd PM Mn. Premolar
  • narrow oval shape
  • 1 canal

?? ??
??
58
A/O
8-1.Access
  • Mx. Molar
  • triangular
  • 4th canal 70
  • Mn. Molar
  • trapezoidal
  • D root 2nd canal 33

59
Access technique
8-1.Access
  • A/O ?
  • ?? ???
  • ?? ???
  • Crown
  • ??

??
60
Access technique
8-1.Access
  • A/O ?
  • R/D??
  • Broken wall B/U
  • (Am., copper band, temporary Cr. )
  • Crown lenthening
  • Occlusal reduction
  • ??? ??? ?? ????
  • canal ?? / ?? ?? ??
  • ??? reference point

61
Access technique
8-1.Access
  • ??
  • round(?)/flat(?) ended bur
  • excavator (coronal pulp ??)
  • barbed broach (radicular pulp ??)
  • low speed round bur (roof ??)
  • tapered bur

62
8-2.Canal identification
  • ?? ??, ??? ????? undulation (?, dentinal map)
  • ???, ??(coaxial)
  • NaOCl ??
  • straight probe/DG16 endodontic explorer
  • color
  • dentine yellow/brown
  • pulpal floor grey

63
8-2.Canal identification
  • ??? ???.
  • STOP TAKE XRAY!!!!

64
Straight line access
8-2.Canal identification
  • Refinement
  • Troughing
  • LN(long neck)bur
  • Ultrasonic tip
  • 4th canal

65
8-3.Straight-line radicular access preparation
of coronal 2/3
  • Pre-enlargment
  • gradual opening up narrow canal orifices
  • 1035 filies / watchwinding
  • GG bur / Orifice shaper?? ?? ?? ??

66
8-3.Straight-line radicular access preparation
of coronal 2/3
  • ??
  • debris ?? ??, ??? ??
  • file needle ?? ??(passive fit binding ??)
  • precurved file ?? ??
  • irrigant ?? ??(??? space)
  • WLD? ? file?? ??

67
Danger zone
  • curved canal? furcation ??
  • over-enlargement ??
  • Limit the size of enlargement!!!!!
  • if notstrip perforation!!!!!

68
GG bur
  • ??? ?? ??
  • 5,6
  • cavity wall??? ??
  • 4
  • orifice??? ??
  • 3
  • mid-canal ?? ?? ??
  • 2
  • curvature?? ???? ?? ??
  • 1
  • fragile
  • ultra-slow speed?? ??

69
Crown-down technique
  • ?? ??
  • blocking with dentine debris??
  • apical patency ?? ??
  • small file with/without chelating agents??

70
8-4.Length determination
  • Pre-op radiograph(????)
  • ?? ?? ??(???, ?? ?? ??)
  • Tactile feel (pre-enlargement?)
  • Electronic apex locator

71
Radiograph
  • ?? ??
  • elongation/foreshortening ??
  • ??? 2mm?? ?? ?? ??

72
Electronic apex locator
  • AFA (left)
  • Root ZX
  • ????
  • ??? ???? ?? ??? file??
  • ??? ??, ???? minimal fluid
  • ?? ??(?? ???, ??? ??)

73
8-5.Apical preparation
  • Vital case
  • radiographic apex?? 2mm??? ??
  • Non-vital case
  • radiographic apex?? 2mm???? ??
  • MAF
  • curved canal 30
  • very curved canal 25
  • Flaring
  • step-back
  • greater taper hand file
  • final apical prep? 0.02 taper? ???!!!

74
8-5.Apical preparation
  • Recapitulation
  • 15 file
  • Apical patency
  • must be maintained at all times.
  • 8,10 file (without binding or enlarging)
  • re-tx., necrotic case?? ??
  • ??
  • apical blockage ???ledge, transportation ?? ??
  • pulpal remnant ??
  • intentional cleaning of full canal length

75
Ledge
  • ??
  • too large file
  • canal blockage

76
Apical stop vs Apical seat
  • overfilling ?? ???? resistance form ??

77
Zip Elbow
  • ?? ???? ???? ? file?? ?

78
8-6.Rotary NiTi
  • for enlargement!!!
  • not for canal negotiation!!!

79
8-6.Rotary NiTi
  • effective in
  • pre-enlargement
  • coronal flaring
  • crowndown manner
  • file separation??
  • Discard damaged files!!!

80
Instrumentation sequence
  • large ? small
  • larger taper ? smaller taper

81
Orifice shaper 0.06 ProFiles
  • Orifice shaper 60/0.08
  • Orifice shaper 50/0.07
  • Orifice shaper 40/0.06
  • ProFile 35/0.06
  • ProFile 30/0.06
  • ProFile 25/0.06
  • ProFile 20/0.06

82
Rotary GT
  • all size 20 at tip
  • Rotary GT 0.10
  • Rotary GT 0.08
  • Rotary GT 0.06

83
Guidelines for rotary NiTi
  • 150300 rpm
  • light touch
  • touch/retract/touch/retract technique
  • advance files no more than 1mm at a time
  • 4 seconds for each file
  • damaged file ? discard
  • caution!!
  • calcified canal
  • apical 1/3? 20/0.02 taper file ?? ? rotary file
    ??
  • sharp curvature
  • 2 canal ? 1 canal ? join?? ??
  • large canal? ??? narrow??? ??

84
  • Rotary NiTi file ??? ??
  • ??? ??? ?? ??? ?? ??? ?!!!!

85
9.One-visit root canal treatment
86
9.One-visit root canal treatment
  • Single-visit tx. is appropriate for vital
    non-infected cases
  • Infected cases benefit from a dressing of Ca(OH)2
  • Coronal seal must be maintained to prevent
    recontamination

87
10.Root canal obstruction
  • 10-1.Reuqirements before root canal filling
  • 10-2.Properties of root filling materials
  • 10-3.Types of root filling materials
  • 10-4.Gutta-percha filling techniques
  • 10-5.Under- overfilling
  • 10-6.Root fracture
  • 10-7.The remainder of the seal

88
10-1.Reuqirements before root canal filling
  • Requirements
  • chemomechanical prep. ??
  • canal dry
  • asymptomatic
  • no serous exudate
  • Persistent seepage?
  • ??
  • over-instrumentation
  • periapical tissue damage
  • WL ???
  • Ca(OH)2 ??

89
10-2.Properties of root filling materials
  • root canal filling mat.
  • easily introduced into the root canal
  • not irritate periradicular tissue
  • not shrink
  • seal laterally, apically, coronally
  • impervious to moisture
  • easily sterilized
  • bacteriostatic
  • radio-opaque
  • not stain
  • easily removed if necessary
  • sealer
  • ?
  • good adhesion
  • fine powder / 2-paste system
  • set slowly

90
10-3.Types of root filling materials
  • solid semisolid ( GP cone, silver point)
  • sealers cements (Tubliseal, AH Plus, Pulp Canal
    Sealer, Roths Sealer, AH 26)
  • medicated paste not recommended

91
10-4.Gutta-percha filling techniques
  • 1.Cold condensation
  • 2.Warm condensation

92
Cold condensation
  • Single cone(not recommended as it does not seal
    laterally and coronally)
  • cold lateral condensation

93
Warm condensation
  • Warm lateral condensation
  • Thermomechanical compaction
  • Vertical condensation
  • Thermoplasticised gutta-percha
  • Carrier-based techniques

94
Cold Lat. condensation
95
Lat. condensation
  • tapered canal prep ??
  • Master GP cone
  • tug back
  • full length?? 0.5mm trimming
  • Sealer
  • master cone? apical 1/3 coating
  • ??? ??

96
Lat. condensation
  • Spreader
  • long handle/finger spreader
  • 1mm ?? ? ??
  • firm pressure in an apical direction for 20s
  • lateral pressure
  • bend or break the spreader/root fx.
  • GP cutting
  • CEJ 1mm ??
  • gingival level

97
Warm lateral condensation
  • denser root filling
  • ??
  • heated spreader (in a hot bead sterilizer)
  • friction of ultrasonic vibration

98
Thermomechanical compaction
  • compactor?? (inverted H file ??)
  • low-speed handpiece
  • frictional heat ??
  • ??
  • ?? ???
  • ??? straight part? ??

99
Vertical condensation
  • heat downpack backfill
  • ??
  • 1. classical interrupted tech.
  • pointed heat carrier
  • flat ended plugger
  • 2. continuous-wave tech.
  • TouchN Heat/System B
  • Buchanan plugger
  • Obtura II

100
Classical interrupted tech
  1. Heat carrier coronal ?? GP cone ??
  2. Plugger loosely fitting plugger? condensing
  3. Sustained push GP cone??? ( second wave of
    condensation)
  4. ? 1,2,3 ? until 5mm from the canal terminus

101
Continuous-wave tech
  • one continous wave of condensation
  • ??
  • GP cone plugger ??(WL-57mm)
  • 23?? activation ???? condensing (binding point
    ????)
  • 10 ?? inactivation ???? vertical pressure
    (sustained push)
  • 1.5?? activation ???? ???? binding?? ??

102
Obtura II
  • Backfill
  • Internal resorption ? ??
  • Apical resistance form ?? ??

103
Carrier-based system
  • Thermafil
  • solid central core GP covering
  • ??
  • solid core post ??
  • ??? ? ?? ??(?)
  • ???

104
10-5.Under- overfilling
  • Underfilling
  • debridement???
  • ????, ??? ?? failure??
  • Overfilling
  • ??? ???? ???? ???? ?? ?? ??

105
Excess obturation material
106
10-6.Root fracture
  • ???? ?? ??, ?? ??, over-instrumented canal?? ??
  • ??
  • passively fitting plugger/spreader??
  • excessive obturation force?? ??

107
10-7.The remainder of the seal
  • core ASPS
  • Rec) bonding resin, GI over floor orifice

108
Am core
109
11.Assessment of root canal treatment
  • 11-1.Success failure of root canal therapy
  • 11-2.Management of failed root canal treatment

110
11-1.Success failure of RCT
  • 14??? F/U? ???
  • Success
  • no loss of Fø
  • no pain swelling
  • no sinus tract
  • normal PDL

111
Indication of failure of root canal therapy
  • A lesion occurring subsequent to root canal tx.
  • A pre-existing lesion increases in size
  • A lesion has remained the same or only decreased
    in size over the 4-year observation period
  • There is pain, swelling or loss of function
  • A sinus tract is present
  • Signs of continuing root resorption or
    hypercementosis are present

112
Post perforation
113
11-2.Management of failed root canal treatment
  • Re-endo
  • Periradicular sx.
  • Extraction
  • root fx.(???)
  • gross caries(?? ??)

114
Root canal re-tx.
  • surgical intervention ??? ??
  • Pre-op XR ?? ??
  • post
  • filling material
  • curves, perforation, ledge

115
Root canal re-tx.
  • Rec)
  • Loupes
  • Headlamp
  • Microscope

116
Root canal re-tx.
  • ?? ??? ??
  • surgical bur(high speed), long neck bur(low
    speed) ??
  • ??
  • ?? ?? ??
  • crack ?? ??
  • missing canal ??? ?? ??? ??

117
Root canal re-tx.
  • furcation/canal orifice ??
  • ultrasonic tip
  • ?? ??? ?? ? ? ??
  • endodontic explorer
  • ???/??? ??
  • ???? rougher

118
Root canal re-tx.
  • Post ??
  • ?? ?? ??? ??? ? ?? ??
  • ultrasonic vibration
  • ?? cement seal ??
  • too high power ? ??? microcrack
  • post extractor

119
Root canal re-tx.
  • post fx. within a root canal
  • post ?? cement ??? troughing
  • small long-neck bur / ultrasonic tip??
  • Masserann post removal kit
  • trepan
  • 2mm troughing ? ?? ??

120
GP removal
  • H file (poorly condensed GP )
  • GG bur (10001500rpm)
  • NiTi rotary instrument(700 rpm)
  • GP solvent (curvature??)

121
Steiglitz forceps(silver point removal)
  • silver point
  • sealing
  • not good
  • cement? ??
  • ?? ??
  • Steiglitz forcep / pin plier??
  • forcep holding ???? ultrasonic vibration??

122
(No Transcript)
123
Instrument fx.
  • file fx. ???
  • maintaining a good quality control program
  • discarding any damaged instruments
  • not forcing instruments
  • using instruments in the correct sequence
  • not rotating ss instruments more than a ¼ turn CW.

124
Instrument fx.
  • fx. file ???
  • Masserann trapan ultrasonic vibration
  • microscope
  • magnification lighting
  • Loupes headlamp

125
Fx. / Bypass
  • ???? ?? ??? ?
  • apical ?? ?? ???
  • ? ??? rounder
  • Bypass ??? ?
  • ?? ????? obturation
  • ???? ?? ??(?)

126
Root canal re-tx.
  • ???, ?? ?? ?? ? ????
  • Ledge
  • sharply curved file? bypass
  • linear filing motion?? smoothening
  • Blocked canal
  • sharply curved file? penetrate
  • unblock ??? ? ??
  • over-instrumentation / perfortation

127
Root canal re-tx.
  • ???
  • technical improvement? ?? re-endo
  • 9498
  • periapical lesion?? ?
  • 6278
  • Re - endo ??? ???
  • perforation
  • ?? ??
  • compromised cleaning obturation

128
Apical Sx
  • Alternative to RCT
  • ??? ??? ???? conventional RCT? ????? ?
  • ???
  • extensive expensive restoration
  • large post
  • sclerosed canal
  • broken instrument
  • biopsy
  • root crack/fracture??

129
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