Aims of this session

The cause of pulp death

The various non surgical endodontic technique available to

preserve a tooth .
The instruments and medicaments used in non- surgical
endodontic technique.
The technique of surgical endodontics - Apicectomy
 Endodontics
The dental pulp can be damaged by caries, trauma, periodontal
disease, and operative dental procedures, which can lead to pulp
death and bacterial infection.
Infecting bacteria remain within the pulp, producing toxins that
leach out of the apical foramina and cause a periapical infection.
When the pulp space is cleaned of all infecting material and
sealed, bacteria cannot re-enter, and the periapical lesion heals.
Although a tooth is non-vital following RCT, it can function
properly in the mouth because its periodontal attachment is
healthy.
 Aims of RCT
The aim is to save the tooth from extraction.
To clean canal by removing the dead pulp .
To seal the pulp space to prevent re-infection from periapical
or coronal directions.
To maintain tooth function.
 Endodontics

Endodontics Non surgical Surgical

(root canal endodontics endodontics
treatment) - is
a dental • Pulpectomy • Apicectomy
procedure used • Pulpotomy
to treat • Open apex root
infection at the filling
centre of a • Pulp capping
tooth.
 Reasons for endodontics treatment

Thermal Chemical
Deep caries injury irritation

Severe impact Accidental

Tooth fracture
injury pulp exposure
.

Pulpitis – not causing Irreversible pulpitis –

pulp death and can causing partial or full
be treated by a death and requires
restorative filling of endodontic
the tooth only. treatment.
 Factors to be considered by patient and
dentist when planning endodontics
treatment
Usefulness of the tooth in occlusion

Tooth restoration possibility

Dental health of patient

Patient co-operation

Medical history of the patient

Cost of treatment
 Pulpectomy
Non surgical endodontic treatment.

When tooth suffers irreversible pulpitis.

Used to save a fully formed permanent tooth.

Removal of all pulpal tissue from pulp chamber and root canal.

Replace with a sterile root filling material.

 The stages of procedure
First visit
Administer LA and isolate with a rubber dam.
Gain access to the pulp space or root-canal system by
drilling through the crown of the tooth.
Extirpation of the nerve using a barbed broach.
Disinfect root-canal system by irrigation with sodium
hypochlorite or chlorohexidine.
Shaping and enlarging canal using reamers and hand files.
Working length insert file in the canal and take PA.
radiograph or use an Apex Locator .
 The stages of procedure
First visit
Irrigation with antibacterial disinfectants such sodium
hypochlorite or chlorhexidine .
The canal is dried with absorbable Paper Point .
Place antiseptic dressing and temporally filling to seal the
canal entrance to avoid contamination of the canal between
visits.
 Pulpectomy procedure
Second visit
• At the next visit the temporally filling and dressing are removed .
• If tooth still dry and clean it is obturated with Gutta Percha Points
with same colour code as the last file /reamers used.
• Root canal sealer zinc oxide eugenol cement is inserted in the canal.
• Condensed with Finger Plugger or Lateral Condenser instrument .
• A PA radiograph is taken to ensure the root canal is filled properly.
• Restauration of the tooth to full function, either by filling , or by
cementing a crown or inlay.
 Pulpotomy
In permanent teeth of children, growth of the root is not
complete until up to 3 years after eruption.
Instead of total removal of the pulp from the chamber and
the root is only necessary to remove the infected part of the
pulp within the crown of the tooth only.
The amputated pulp stump at the entrance to the root canal
is then covered with a calcium hydroxide dressing
 Pulpotomy
The very rich blood supply through an open apex allows
healing to occur.
In some cases , it may still then be necessary to do a full
root filling.
The technique of pulpotomy is only successful if the exposed
radicular pulp is vital and can separate itself from the
exposure site by laying down a secondary dentine bridge.
 Open apex root filling
A dead tooth with an open apex must be root filled as no
secondary dentine will form.
The death pulp is removed from crown and root canal.
The canal is shaped, irrigated and dried .
Instead of gutta percha canal is filled with special non setting
calcium hydroxide paste .
A temporally filling is inserted .
Monitor tooth and when apex of tooth is fully formed , the
calcium hydroxide is removed and replaced with conventional root
filling.
 Pulp Capping
The aim is to seal the exposed pulp from the oral cavity so
that no oral micro-organisms contaminate the tooth and
cause an infection.
Carried out on both deciduous and permanent teeth .
As a temporary measure before exfoliation or
pulpotomy/pulpectomy in the latter .
When a small and unexpected pulp exposure due to a
restorative treatment or following a trauma.
 Apicectomy
Surgical endodontics treatment , removal of an infected
apex of a tooth and his surrounded infected tissue.
If root filling impossible to complete or unsuccessful.
Removal of excess root filling material from periapical area
and is acting as source of inflammation.
Elimination of curved of fractured root apices, which cannot
be root filled and acts as a source of infection.
 Apicectomy procedure
Carried out under sterile surgical condition.
Incision is made through the gingiva and flap is raised off
with a periosteal elevator.
With a straight hand piece and bone bur a window is cut in
the exposed bone and gain access to the infected root apex.
The apex is separated from the tooth using burs and
removed from the bone cavity.
 Apicectomy procedure
• The cut end of the tooth is then sealed with permanent
filling material.
• Debris are removed syringing with the sterile saline.
• The mucoperiosteal is sutured back into place.
• Sutures are removed 7 days later and radiograph is taken for
record purpose.
Restorative Dentistry
 Restorative Dentistry
 Restorative dentistry is the branch of dentistry
that deals with rebuilding teeth which have been
affected by decay or trauma.
 The aim is to return the teeth to their natural
anatomical shape so that they can be used
effectively.
 Reasons for restoration

• Dental caries.
• Loss of tooth surface from abrasion, attrition, or erosion.
• The tooth has broken as a result of trauma.
 Aims of restorative treatment

Remove diseased tissue.

Prevent further destruction of remaining tooth structure.
Restore the function and appearance of the tooth.

There are many different types of dental materials that can

be used to restore a tooth.
The types of restorative materials used will depend on the
extent of the damage to the tooth and its location within the
oral cavity.
 Types of restorations
1.Direct restorations
 Fillings - temporally and permanent
2.Indirect Restoration
 Fixed prostheses - Inlays/Onlays , crowns and Bridges
3.Implants
 Cavity preparation

• The removal of diseased tissue, as a first step in restoring

teeth affected by caries, results in cavities of varying shapes
and sizes.
These cavities must be modified according to the following:
• The properties of the restorative material to be used.
• The tooth affected.
• The surface of the tooth affected.
• Whether the cavity involves > 1 surface.
 BBlack’s classification cavity location)
Class I

Occlusal surfaces of molars &
premolars

Palatal of upper incisors

Buccal /lingual pits of lower molars
Class II

Proximal surfaces of molars &
premolars

- mesio-occlusal (MO)

- disto-occlusal (DO)

- mesio-occluso-distal (MOD)
31
 Black’s classification cavity
Class III
 proximal surfaces of incisors &

canines
Class IV
 Proximal surfaces of incisors &

canines involving incisal edge on the

affected side
Class V
Involves the cervical margin of any
tooth.
32
 Temporary restorations
 These are placed only for short periods of time.

Uses:
Relieve pain
Fill a tooth when there is not enough time to place a permanent
filling in one visit.
Fill a tooth when a procedure requires more than one visit e.g.
RCT, inlays/onlays.
 Materials used for temporally restoration
• Zinc oxide and eugenol cement
• Zinc phosphate cement
• Zinc polycarboxylate cement
• Glass ionomer cement

 These materials and calcium hydroxide can also be

used as cavity liners or bases.
 Linings
 A liner is a layer of material placed under a
permanent filling in order to protect the nerve from
chemical, mechanical or thermal irritation that might
be caused by the permanent filling material.

They are also called “Base”.

 Permanent fillings
Are the material used to permanently restore the tooth to it’s
full function.
Plastic fillings (soft and plastic on insertion, set/harden in the
cavity)
Pre-constructed fillings (made in lab after tooth prep and
cemented in place).
The most common used materials are:
• Amalgam Composite
• Glass Ionomer Compomers
 Amalgam
• Amalgam is one of the oldest and most commonly used
materials for restoring posterior teeth. It is made from an
alloy powder that is mixed with liquid mercury. Amalgam
initially sets within a few minutes but it does not set
completely until a few hours later.
Constituents
• Powder: alloy (mixture) of Silver , Copper, Tin and Zinc
• Liquid: Mercury
 Amalgam
Advantages
• Strong and durable (long lasting)
• Easy to use
• Cheap
Disadvantages
• contains mercury – potential health hazard
• grey in colour – anaesthetic – can't be used on front teeth
• it is a thermo-conductor (transmits heat to the pulp) - needs lining
• can discolour natural tooth and soft tissues causing amalgam tattoo
• needs undercuts for mechanical retention – healthy tooth structure
removed
 Cavity preparation for Amalgam
• A cavity prepared for an amalgam filling.
• It has undercuts which will hold the material in place.
• Amalgam is a plastic material – soft but hardens after
insertion.
 Composite restorations
• Composites are the same colour as teeth and ideal for
restoring cavities where appearance is important, such as for
anterior teeth.
• Unlike amalgam, composites can be made to bond directly to
the enamel by use of the acid-etch technique or a bonding
agent, which aids bonding to the dentine.
• For setting, composites can be light, chemical, or dual cured.
 Composite
Constituents
• Inorganic filler in a Resin binder
Chemical cure/self cure systems
• The base and the catalyst come in separate containers and
have to be mixed immediately before placing in the cavity.
Light cure systems
• Base and catalyst are in same syringe or capsule. The
material will set after the catalyst is activated by a blue light.
 Composite Advantages

• Many different shades available.

• Retention is by bonding, less tooth destruction
needed.
• No thermal conductivity .
• Recent research shows that they can be as long
lasting as amalgam.
 Composite Disadvantages

• Shrink on setting (about 2%-3%) /2mm maximum layer

thickness for curing.
• Moisture control essential ( use of rubber dam
recommended).
• More expensive material than amalgam.
• Needs extra materials than amalgam such etching and
bonding agents.
• Much more time consuming compared to amalgam.
 Acid-etch technique
• Composites can be bonded to enamel by use of etch.
• Etch contain a weak acid(35% phosphoric acid), which
is applied directly to the enamel.
• The acid dissolves the surface, forming tiny holes.
• The etch is washed off and composite is placed on top
— the composite flows into the tiny holes, which help
it adhere to the enamel surface.
 Bonding the surface of a tooth
Bonding agents - are resin materials used to make
a dental composite filling material adhere to both dentin
and enamel.

Is a light sensitive resin

Curing light used to set .
 Glass ionomer restorations
• Glass ionomer materials are ‘tooth’-coloured, however, the
material is inferior to composite in terms of appearance and
surface finish.
• Glass ionomer cement can bond to both dentine and
enamel , making it suitable for cavities where retention can
be difficult to obtain.
• Glass ionomer materials can be chemically or light cured.
 Glass Ionomer
Constituents
• Powder = alumino silicate glass
• Liquid = polyacrylic acid
Uses
• Temporary fillings in permanent teeth.
• Permanent fillings in deciduous teeth.
• Fissure sealants.
• Permanent cementation of crowns, bridges, inlays and orthodontic
brackets and bands.
• Cavity liner.
 Glass Ionomer
Advantages
• Sticks to both enamel & dentine without etching.
• Releases Fluoride – cariostatic (stops caries formation).
• Non irritant to pulp except in very deep cavities.
• Used as liner under all permanent filling materials.
Disadvantages
• Not aesthetic enough to be used on front teeth.
• Wears away due to chewing – not good for back teeth.
• Not supplied in as many shades as composite.
 Compomer
This material is a mixture of composite with some glass
ionomer added for its fluoride and adhesiveness.
Advantages
• Very good appearance.
• Release fluoride
Disadvantages
• Do not have the strengths of composite.
• Not suitable for use in posterior teeth occlusal surfaces.
• e.g. Dyract, Compoglas.
 Importance of Moisture Control
Allow good visibility of working field – dentist can see
what he/she is doing.
Filling materials & cements are moisture sensitive – will
not set properly in presence of moisture.
More comfortable for patient – will not choke on water
or saliva.
Saves time as patient doesn't have to spit out all the
time.
 Advantage of Rubber Dam
 Completely isolates one or more teeth from saliva
and bacteria – keeps them dry and safe from
contamination by oral bacteria.
 Gives better visibility as the cheeks, lips and tongue
are retracted.
 Patient can't swallow any instruments or material –
especially useful in RCT and when working with
amalgam.