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Paeds > Endodontics of the traumatized immature incisor > Flashcards

Endodontics of the traumatized immature incisor Flashcards

1
Q

Definition -
An immature permanent incisor

A

defined as one where the apex can be
considered to be open.

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2
Q

Root growth

A

Divergent- Parallel- Convergent

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3
Q

Challenges of non vital immature tooth

A

 Compromised crown root ratio
 Thin root dentine walls
 Lack of dentinal stop against which
root canal materials can be
condensed

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4
Q

Endodontics in non vital immature
tooth

A

 APEXIFICATION
 RCT of these teeth requires a root end
closure technique to form a barrier at apex
to enable a root filling to be condensed
without going through apex
◦ Calcium hydroxide therapy to induce barrier
◦ Artificial plug (MTA)

 Different to APEXOGENESIS – when aim is
to maintain vitality and allow continued root
growth (vital pulpotomy)

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5
Q

Apexification

A

calcium hydroxide (calcific barrier)

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6
Q

Apexogenesis

A

Vital pulpotomy

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7
Q

Apexification

A

MTA

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8
Q

Diagnosis of Loss of Vitality
Signs + Symptoms

A

Pain, swelling, sinus, TTP, mobility, colour
change

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9
Q

Diagnosis of Loss of Vitality
Radiographic examination

A

Periapical radiolucency (PAP), arrest of
root development

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10
Q

Diagnosis of Loss of vitality
Sensibility tests

A

Negative

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11
Q

Diagnosis of Loss of vitality
Any doubt of loss of vitality ?

A

delay endo Rx
◦ Review 3 mths
◦ Better prognosis if no acute abscess

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12
Q

Acute Abscess- Emergency
treatment
 Ideally

A

full extirpation of pulp and dress with
non-setting Calcium Hydroxide paste

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13
Q

Acute Abscess- Emergency
treatment
But if acutely tender

A

 Prescription
 Arrange appt 24 – 48 hrs
 Sedative dressing – e.g. odontopaste

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14
Q

Acute Abscess- Emergency
treatment

A

Ideally… and if accutely tender…

  • Apexification ie
    ◦ Calcium Hydroxide (past)
    ◦ MTA (current method)
  • Regenerative Endodontic Technique
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15
Q

Aims of CH Apexification

A

 Creation of a calcific barrier across the
root apex
 Allows obturation of canal

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16
Q

Method of CH Apexification

A

 Repeated dressing of nonsetting
Calcium hydroxide at 3-6
monthly intervals
 Once barrier achieved remainder of canal
obturated with thermoplastic GP
 Average 9 months to form up to 3 years

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17
Q

Traditional
Apexification of
immature root
canal (see imaged labelled)

A

“Plug” of coarse
mineralised tissue at
apex

Empty root canal

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18
Q

Traditional
Apexification of
immature root
canal
See other images

A

Periodontal ligament
Dentine of root
Canal
“Plug” of coarse osteocementum
material

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19
Q

Traditional CH Apexification

(apical closure and success rates)

A

Can see a barrier
. 90% apical closure with Ca(OH)2
* 85% success @ 5yrs for adequate root
filling

20
Q

Disadvantages of
Apexification

A

Multiple visits
Lengthy treatment - may take up to 30 mths for
barrier
Difficult technique
Position and quality of barrier unpredictable
Discolouration
brittleness (risk of cervical #)

Expensive in terms
1. Clinical time
2. Parent’s time off work
3. Missed school

21
Q

Clinical technique- MTA Barrier

A

Consent
 Isolation
 Access cavity
 Widen cervical constriction (Gates Glidden)
 Extirpation of the pulp
 Estimation of full working length (1mm short of
radiographic apex
 Preparation of root canal, sterile water / 0.5%
Milton irrigation (must avoid extrusion through
apex)
 Needle loose and 2-3mm short of working length
 Dry the root canal
 Interim Root canal dressing (CH) +RMGI

22
Q

Canal morphology

A

Cervical constriction (remove this)

23
Q

Access cavity

A

Triangular shaped access (apex towards gingival
margin
 Larger than access cavity for mature tooth

24
Q

Canal preparation

A

 Straight line access
 May be up to no 140 file
 Ultrasonic activation or bristle brush

25
Q

Canal preparation instruments

A

 Plugger
 Bristle brush
 Fine tip for
placement of non
setting Calcium

26
Q

CaOH brands

A

Hypocal, Calasept,
Ultracal

27
Q

Clinical technique- MTA Barrier review onwards?

A

 Review in 1-2weeks
 Obturation when
 no clinical signs of PAP
 no radiographic signs of PAP or
evidence of healing PAP
 clean dry canal

28
Q

Clinical technique apexification

A

Fine tipped MTA carrier
 Ideally using microscope
 Plugger marker 2 mm short of WL
 Careful condensation until 4mm
thickness
 Clean canal walls and access (MTA
stains)
 Confirm placement with radiograph
 When set obturate (ProRoot
2nd visit reqd)
◦ Thermoplastic GP- diverging/parallel
◦ Fibrepost

29
Q

MTA properties

A

 Hydrophilic
 5 min working time, sets <4hrs
 pH 12.5
 Non-resorbable
 High biocompatibility
 Compressive strength = reinforced ZOE
=EBA<amalgam
 Low leakage <Amalgam + IRM

30
Q

MTA Composition

A

(75% Portland cement)
 Tricalcium silicate
 Bismuth oxide
 Dicalcium oxide
 Tricalcium aluminate
 Gypsum
◦ Silicate oxide
◦ Tetra calcium
aluminoferrite

Add Water
 Colloid gel of
calcium oxide in
 33% calcium
 49% phosphate
 6% silica
 3% chloride
 2% carbon

31
Q

Delivery- using

A

ProRoot MTA or MTA-Angelus/ thermoplastic obturation

32
Q

Pro-root MTA

A

 75% Portland
Cement
 20% Bismuth oxide
 5% Calcium sulfate

33
Q

MTA-Angelus

A

 80% Portland
Cement
 20% Bismuth oxide
 Fast set

34
Q

Radiographic follow up

A

 Check radiograph immediately after RCT
 Follow up visit
◦ Radiograph at 1 year

35
Q

MTA Advantages

A

 Small number of visits
 Biocompatible
 Low leakage
 Radioopaque
 Better success than CH technique
Disadvantages
 Cost
 Discolouration with poor handling
 No reinforcement of canal
 Contributes to brittleness

36
Q

Restoration of immature root treated teeth

A

 Where no bleaching GP removed to cemento
enamel junction
 Direct composite crown build up

Avoid conventional posts +/- crown

can consider DT light post

37
Q

Restoration of immature root treated teeth-

Why avoid conventional posts +/- crown

A
  1. Short root
  2. Leaves inadequate root filling
  3. Fragile canal walls
  4. High risk of root fracture
38
Q

DT light post

A

 Double taper
system
 Fibre composite
post
 Colour matched
posts and drills
 Post colour
changes with water
eases removal
 Reinforces weak
remaining tooth
structure

39
Q

Failures?

A

2 photos?

40
Q

Regenerative Endodontic
Technique

A

 Aims to harness potential of stem cells
at apical papilla
 Repopulation of root canal space by
stem cells from apical papilla
 Cells similar to dental pulp progenitor
cells
 Canal repopulated with vital tissue
 Produces further hard tissue of root

41
Q

Regenerative Endodontic
Technique
 Advantages

A

◦ Thicker root
◦ ↓propensity for root fracture
◦ Success requires no additional treatment
◦ ↓risk of reinfection as ↓reaccess

42
Q

Regenerative Endodontic
Technique
 Disadvantages

A

◦ Lack of long term follow-up data
◦ Not determined stage and duration of
pathosis which leads to destruction of stem
cells
◦ Pulp canal obliteration may complicate future
endodontics

43
Q

Technique 1
Visit 1

A

Consent
 +/-LA estimate
 Rubber dam isolation
 Pulp extirpated with barbed broach
(Working length from preop rads)
 Copious irrigation (1.5% sodium
hypochlorite) of canals with mild
disinfectant 2mm short of apex
 5ml saline flush
 Dry canal

and then …

44
Q

Technique 1
Visit 1 cont.

A

 Antibiotics sealed into canal (avoid pulp
chamber) mixed with sterile water
◦ Ciprofloxacin
◦ Metronidazole
 Cotton pellet
 GIC
 Earlier protocols used TABdiscolouration
◦ Ciprofloxacin
◦ Metronidazole
◦ Minocycline

45
Q

Technique 2
 Visit 2 (2-4 weeks later)

A

 If no signs/ symps of infection
 Epinephrine free LA
 Rubber Dam isolation
 Irrigate with saline
 Irrigate with 10ml 17% EDTA
 Dry with paper points
 Sharp instrument 2 mm beyond apex to
induce bleeding to fill canal
 Induce clot
 Clean coronal portion
 Seal with Calcium silicate cement, GI,
Composite

46
Q

Technique 3

A

Follow-up
 Clinical and radiographic at 6 months
 Clinical and radiographic at 12 months

47
Q

RET Conclusions

A

 Root development and thickening
highly unpredictable
 Until tissue engineering can be
translated into practice RET should be
limited only to those cases where
prognosis of the immature tooth is
deemed to be poor with the use of the
traditional approach (CH/MTA)

Paeds (11 decks)

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