Treatment of permanent dentition Paediatric dentistry VI Stages of root development normally – 7 stages, for our purposes only 4 are of significance– crown is out of the bone and is present in the oral cavity (the remaining 3 are intraosseal) The first stage of development – the root is shorter than the crown, maximally of the same length (1:1). Dentine layer is very thinn, dental pulp cavity is large, dentinal walls are divergent apically and the foramen apicale is very large (open apex) – shape of the mesenchymal papilla The second stage of development – the root is longer than the crown, dental pulp is large, dentinal walls of the root are divergent apically, foramen apicale is large (open), dentine layer is very thinn The third stage of development – the root reached almost its expected length, dentine is thicker than in previous stages, dentinal walls are parallel in the apical part, dentine layer is thinn, The fourth stage of development – the root has reached the expected length (2:1), foramen apicale is closed (physioloical constriction), dentine is thicker, but the dental pulp cavity remains large. I. II. III. IV. Stages of the root development Teeth with incomplete root development  Anatomical differences  Larger dental pulp cavity both in the crown and root  Thinner dentine layer  Root shorter  Clinical crown lower  foramen apicale open, no physiological constriction Histological differences  Different mineralization of enamel  Rich vascularization  apex – shape of mesenchymal papila  dental pupls contain many cells  collagen fibres are non oriented  Biological properties  favourable  Rapid removal of noxes  No blood stasis - wide apex  Easy cell differentiation  Rapid formation od tertiary dentine Tooth eruption - complete apex formation ( 3 years) Caries media – D3 - in dentine 1. a 2. stage of development Only occlusially, in buccal grooves In frontal teeth – approximal caries Molars, premolats – approximal caries = caries pulpae proxima 3. a 4.stage of development Similar to the situation in adults Therapy - fillings Molars, premolars Preventive extension 1 2 3 Caries media – D3 Preparation – as narrow as possible (better primary prevention) Minimal preparation into dentine Caries in dentine = caries pulpae proxima (the 1. a 2. stage of development - also in the 3.stage) Fillings glassionomer cement + alkaline cement compomer composite resin Frontal teeth Preparation – the same rules as in adults Fillings glassionomer cement + base (Dycal) compomer Composite resin Caries pulpae proxima DIAGNOSIS caries tertiary dentine Dental pulp Caries pulpae proxima Subjectively patient can feel the cavity Gingival bleeding (irritation by food –inflammation) Loss of point of contact Sharp edges can injure the tongue Mesial shift as a consquence of loss of point of contact Pain On biting (thin dentine layer) On thermic stimuli On chemical stimuli Pain character Is not spontaneous short Disappers when the stimulation is stopped Caries pulpae proxima On examination Large cavity (undermined) approximal caries Soft tissue (dentine) 1. permanent molars –often non cavitated lesion - only on the X-ray X-ray Radiolucency in the dental pulp vicinity Tertiary dentine formation TOOTH VITALITY THREATENED Procedures – to maintain dental pulp vitality Indirect dental pulp capping Carious dentine removal complete (one-step method) incomplete (more visits) Excavation Hand instruments rotatory Low revolutions Round bur Dentine wound – covered by Ca(OH)2 different kinds, most frequently a paste Caries pulpae proxima) One-step method - permanent filling Expectation: Increased tertiary dentine formation remineralization of the soft dentine Destruction of microbs Caries pulpae proxima More visits- temporary filing (intermitent /stepwise excavaction) Removal of carious dentine, Ca (OH)2, IRM 2 months later - removal of: Temporary filling Ca (OH)2 Remnants of carious dentine application: New layer of Ca (OH)2, usually alkaline cement Cemente base permanent filling GIC Composite resin crown Non penetrating carious lesion in the dental pulp vicinity Non exposed dental pulp Removal of all carious masses permanent filling Temporary filling (with Ca (OH)2 ) permanent filling DANGER OF PENETRATION PERIPHERAL DENTINE REMOVAL Caries-totally removedl No dental pulp exposure Only peripheral dentine removed (intermitent excavation) Dental pulp exposure Permanent filling Temporary filling + Ca (OH)2 2 month later Remaining soft dentine removed permanent filling In healthy dentine In soft dentine Direct pulp capping appropriate endodontic treatment Caries pulpae proxima Molars, premolars Central cavity the same preparatory rules as in adults Approximal caries Preparation- very delicate and careful All edges rounded (pulpoaxial wall, gingivo - axial wall) Filling: comp. resin, GIC, may be silver amalgam + base - alkaline cement - alkaline cement + ZnO phosphate cement matrix - in erupting teeth often not possible – shorter clinical crown, strip + wedge or special matrix (T-matrix, sectional matrix, the auto-fix system) Caries pulpae proxima Frontal teeth Preparation the same, minimal preparation (dove-tail on the oral surface – more cervically) Filling - glassionomer cements + Dycal - compomer filling - composite filling Foramen caecum carefully, very close to the dental pulp !!! GIC + base compomer + base composit resin Base - Dycal - Dycal + ZnO phosphate cement + Dycal CS caries superficialis CM caries media CPP I caries pulpae proxima, caries into ½ of the dentine thickness, changes in the dental pulp no signs of the pain CPP II caries pulpae proxima dentine – continuous , but thin microbs present pain on stimulation, not spontaneous Exposure of the dental pulp pain – spontaneous Pulpitis CS caries superficialis CM caries media CPP I caries pulpae proxima, caries into ½ of the dentine thickness, changes in the dental pulp no signs of the pain CPP II caries pulpae proxima dentine – continuous , but thin microbs present pain on stimulation, not spontaneous Exposure of the dental pain – spontaneous Pulpitis Caries pulpae proxima - summary Most frequently in approximal caries Also in occlusial caries especially in the 1. and 2. developmental stage Protection of the complex dentin – dental pulp Ca (OH)2 Intermitent excavation (step-wise) or Indirect dental pulp capping Complication Dental pulp exposure accidental exposure in healthy dentine direct capping (small extent) in carious dentine partial pulpotomy possibly coronal pulpotomy Apexification calcium hydroxide cotton cement hermetic filling A B C D A. hard tissue B. hard tissue, dent.pulp.cavity. shorter C. connective tissue D. con. tiss., d.p.c. shorter Apexification Apexificatioj is a method for treatment of immature permanent teeth in which root growth ceased due the pulp necrosis (total pulpitis). Its purpose is to induce the root end closure with no canal walls thickening and continuous root lengthening. The working procedure is simillar to other treatments in endodontics – local (block) anaesthesia, rubber dam isolation, working length determination. 1 Access opening, rinsing out the necrotic contents, root canal shaping under rinsing. In case of total pulpitis, it is necessary to remove the dental pulp and to stop the bleeding. For irrigation we can use physiological saline in case of pulpitis or necrosis. In case of gangrena, desinfectants shoul be used (chlorhexidine, sodium hypochloride). Root canal shaping should be very gentle using H-file, remnants of the necrotic content will be dissolved by calcium hydroxide which is used as a temporary filling. A calcium hydroxide dressing in a creamy consistency can be applied with a lentulo spiral under low revolutions or with a special syringe. For the compaction of the calcium hydroxide sterile cotton pelet can be used. Then, the tooth is hermetically closed by a filling consisting of a sterile cotton pelet, base (zincoxide phosphate) and a permanent material. 2 The second visit is scheduled from 1 week –in case of bleeding (pulpitis) to 3 weeks in case of necrosis/gangrene. The dressing is exchanged for a new one. 3 The root is monitored clinically and radiographically in 3 months intervals to examine the formation of an apical hard tissue closure. 4 When a completed apical barrier is formed the canal is obturated with a permanent root canal filling material. 5 Because the roots after apexification with calcium hydroxide were found to be fragile (dissication of dentine), MTA or Biodentine have been used recently. After one appointment with calcium hydroxide the bioceramic material can be used. The thickness of MTA and others in the root canal should be about 3-5 mm. The method seems to be very promissing. Diseases of the dental pulp in permanent teeth with incomplete root development Clinically –subjective symptoms not very distinct Significant for therapy  extent of the inflammation  stage of development 1. hyperemia 2. partial inflammation 3. total inflammation Classification of diseases of the dental pulp is the same as in adults: reversible and irreversible inflammations patologico-anatomical classification, chronic, acute necrosis, gangrene reffered pain (synalgia) is present as well (see endodontics I) Hyperemia – momentary pain partial pulpitis  pain – individual differences  no sensitivity on percussion  not longer than 24 h. total pulpitis  reparation no longer possible  intensive, long-lasting pain  sensitivity on percussion differential diagnosis  periodontitis + papillitis  otitis media  tonsilitis  varicella  aphtosis  sinusitis maxill.  neuralgia n. V  incipient herpetic gingivostomatitis Hyperemia frontal and distal teeth, all stages ( I., II., III., IV.) decayed masses removal intermitent excavation (step-wise) + permanent filling 4-8 weeks later indirect dental pulp capping + permanent filling On accidental dental pulp exposure Direct dental pulp capping (sound dentine) Partial pulpotomy (decayed dentine) Pulpitis acuta partialis frontal and distal teeth, all stages Vital pulpotomy (coronal) Pulpitis acuta totalis frontal teeth I. stage - extraction II.stage – dental pulp removal - repeated root canal filling by calcium hydroxid (apexification) - within 6 - 12 months root canal will be closed. Apex closed – permanent root canal filling (central cone, condensation methods using gutta-percha) If the previous method will fail – surgical-conservative treatment. III. a IV. stage - vital exstirpation, root canal filling Pulpitis acuta totalis premolars, molars I. a II. stage – extraction premolars in the II. stage exceptionally – treated by apexification (repeated filling by Ca(OH)2 ) the method fails - upper premolars may be treated by endodontic surgery under favourable conditions III. a IV. stage – vital exstirpation, permanent root canal filling. Mortal exstirpation – only exceptionally In the III. stage - calcium hydroxide may be used – better apical closure. Dental pulp diseases necrosis, gangrene, acute periodontitis frontal teeth I. stage - extraction II. stage Root canal content removal Shaping, cleansing Repeated filling by Ca(OH)2 (apexification) apex closed – permanent root canal filling. If the previous method fails – surgical-conservative treatment. III. a IV. stage – root canal treatment one appointment method periodontitis acuta – management of the acute phase, then shaping and obturation Dental pulp diseases necrosis, gangrene, acute periodontitis distal teeth I. and II. stage - extraction premolars in the II. stage – exceptionally the same procedure as in frontal teeth (apexification) If the previous method fails – surgical-conservative treatment in the upper jaw (favourable conditions) III. a IV. stage – root canal treatment – one-appointment method or multiple visit method periodontitis acuta – management of the acute phase, then root canal treatment, mostly by multiple visit method Chronic periodontitis frontal teeth I. stage - extraction II.stage - surgical - conservative treatment (apexification possible under favourable situation) III. a IV. stage – root canal treatment, one visit method if possible, or multiple visit method. Exsudation persists – endodontic surgery. With the exception of radicular cyst – repeated root canal filling with calcium hydroxide, successfull mainly in the diffuse form. Chronic periodontitis premolars, molars I. and II. stage - extraction in premolars in the upper jaw exceptionally surgical - conservative treatment, possibly apexification III. a IV. stage – root canal treatment – multiple visit method. Method with Ca(OH)2,- possible,particularly in the diffuse form. Exsudation persists - extraction