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PULP THERAPY INPRIMARY TEETH

Dr Feda ZawaidehBDS, ADC(Vic), GradDipClinDent, DClinDent(Melb), FRACDS,

FRACDS (Paed), JDB

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PULP BIOLOGY

Pulp-dentine complex

Primary dentinogenesis

Secondary dentinogenesis

Tertiary dentinogenesis

Reactionary dentine

Reparative dentine

Tziafas, Smith, Lesot. Designing new treatment strategies in vi tal pulp therapy.

Journal of Denti stry 2000; 28: 77-92.

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Tziafas, Smith, Lesot. Designing new treatment strategies in vi tal pulp therapy.

Journal of Dentistry 2000; 28: 77-92.

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PULP THERAPY

The goal of pulp therapy in the primary& mixed dentitions are:

Successful treatment of the cariously

involved pulp to maintain the tooth in a non-pathological state

Maintenance of arch length and tooth space

Restoration of comfort with the ability to

chew Prevention of speech abnormalities and

abnormal habits

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INDICATIONS &

CONTRAINDICATIONS OF

PULP THERAPY

Factors influencing the decision to retain

primary teeth:

Medical history

Behaviour factors

Dental factors

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MEDICAL HISTORY

CONTRAINDICATIONS:

Congenital cardiac disease

Immunosuppressed patients

Children with poor healing potential

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MEDICAL HISTORY

INDICATIONS:

Bleeding disorders and coagulopathies

Oligodontia as in Ectodermal

Dysplasia

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BEHAVIOUR FACTORS

CONTRAINDICATIONS:

Uncooperative or non-compliant

patient/parent

INDICATIONS:

Dentally aware patient/family

Cooperative child

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DENTAL FACTORS

CONTRAINDICATIONS:

Grossly neglected dentition

Acute odontogenic infection

Unrestorable tooth

Advanced tooth mobility/rootresorption

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DENTAL FACTORS

INDICATIONS:

Well-maintained arch with intact

primary dentition Orthodontic considerations and space

maintenance

Lack of a permanent successor

Minimal root resorption and nomobility

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CASE ASSESSMENT

Chief complaint and pain history

- Area involved

- Duration of the problem- Precipitants and relieving factors

- Duration of pain

- Spontaneous or precipitated by a

stimulus- Analgesia required

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CASE ASSESSMENT

Medical history

Dental history and attitude totreatment

Clinical examination Special tests

- Pulp sensitivity tests

- Mobility and tenderness onpercussion

- Radiographic examination

- Direct visual examination of the pulp

chamber

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PULPAL DIAGNOSIS

Healthy

Reversible pulpitis

Irreversible pulpitis

Total pulp necrosis

Differentiation between reversible and

irreversible pulpitis is extremely

difficult

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PULP THERAPY OPTIONS

Conservative or vital

pulp therapy

- Indirect pulp treatment- Direct pulp treatment

- Pulpotomy

Radical or non-vital pulptherapy

- Pulpectomy

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DIRECT PULP CAPPING

The placement of a dressing or

medicament on a pulp exposure in an

attempt to preserve pulp vitalityIt is generally not recommended in

primary molars due to its un

predictable results, high failure rateand high incidence of internal

resorption or acute dentoalveolar

abcesses

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INDIRECT PULP

TREATMENT

The procedures or steps taken to

protect or maintain the vitality of

the carious tooth that, ifcompletely excavated, the decay

would result in a pulp exposure

Al -Zayer M . Pediatr ic Dentistry, 25(1): 29-36, 2003

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INDIRECT PULP

TREATMENT

Indicated in an asymptomatic tooth

that has a carious lesion near the

dental pulp, a protective dressing orcement is placed over a layer of the

remaining carious dentine to prevent

pulpal exposure and stimulate healingand repair

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INDIRECT PULP

TREATMENT

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INDIRECT PULP

TREATMENT

All caries at the DEJ must be removed

Remove the infected dentine

(superficial layer)This layer contains the majority of

microorganisms and their toxic products that are also the source ofcontinuous insult to the pulp. The infected layer must be removed

to allow the healing of the dental pulp.

Leave the affected layer (the deep

decalcified layer)this layer has only a few microorganisms. The affected layer can be left in

place without any adverse effect on the dental pulp

Apply liner/base

Restore the tooth

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Clinical Technique

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INDIRECT PULP

TREATMENT

Re-entry into the cavity after 6-12

months demonstrated no evidence of a

pulp exposure, the existence of onlyfew microorganisms (reduced by 70-

100%), medium to hard consistency of

the residual dentine

Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003

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INDIRECT PULP

TREATMENT

Re-entry into the cavity has been

questioned especially if a durable

restoration is placed initially and noadverse symptoms develop

An excellent coronal seal is required to

ensure good success rate with thistechnique

Stepwise excavation technique-re-

entry in 2-3 weeks (unjustified)

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Stepwise Excavation

Bjorndal L . Indirect pulp therapy and stepwise excavation. Pediatr ic Denti stry 2008;

30:225-9.

Diagrams demonstrating the

less invasive stepwise excavation

procedure. A closed lesion

environment before and after

first excavation (a, b) followed

by a calcium hydroxide

containing base material and aprovisional restoration. During

the treatment interval the

retained demineralized dentin

has clinically changed into signs

of slow lesion progress,

evidenced by a darker

demineralized dentin (c, d).

After final excavation (e) the

permanent restoration is made

(f ). Red zones indicate plaque.

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Example of using glass ionomer caries control to diagnose reversible

pulpitis or food impaction in a mandibular first primary molar with

a history of pain to chewing sweets and solid foods for 23 weeks. (a)

Preoperative view. (b) Preoperative radiograph. (c) View

immediately after glass ionomer placement. (d) Two months after

caries control. Pain stopped from day glass ionomer placed. No

clinical or radiographic sign of irreversible pulpitis. (e) View of IPT

with a glass ionomer base. (f ) Tooth 16 months after treatment

without signs of pain or irreversible pulpitis clinically or on the

radiograph.

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Prognosis

Variable 75-100%, recent studies over 90%

Farooq et al (2000) using GIC for IPT had

a success rate of 93% vs single visitpulpotomy with formocresol 74% followed

for 2-7 years

In addition, formocresol puloptomy

hastened the exfoliation of treated primarymolars whereas IPT did not

Al-Zayer et al (2003) had a success rate of

95%

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INDIRECT PULP

TREATMENT

Success rates improved when:

A base is used over the liner

A SSC is used to restore the tooth

Treatment performed on second

primary molar than a first primary

molar

Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003

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INDIRECT PULP

TREATMENT

The ideal material for vital pulp treatment should

be able to resist long-term bacterial leakage and

stimulate the remaining pulp tissue to return to a

healthy state, promoting the formation of dentin

Materials used

- Calcium hydroxide Cement (CH)

- Zinc Oxide Eugenol Cement (ZOE)

- Glass Ionomer Cement (GIC)

- Adhesive resin system

- MTA

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Radiographic evaluation of a mandibular first and second primary molar that received indirect pulp

treatment with adhesive resin only and were considered successful outcomes after 2 years. Preoperative

radiograph (a), immediate postoperative (b), and 6 months (c), 12 months (d), 18 months (e) and 24

months (f) after indirect pulp treatment.

Radiographic evaluation of a mandibular first primary molar that received indirect pulp treatment with adhesive

resin only and was considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b),

and 6 months (c), 12 months (d) and 18 months (e) after indirect pulp treatment. The interradicular lesion

accompanied by external and internal root resorption observed in panel (e) was indicative of treatment failure.

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Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with

calcium hydroxide and was considered a successful outcome after 2 years. Preoperative radiograph (a),

immediate postoperative (b) and 6 months (c), 12 months (d), 18 months (e) and 24 months (f) after IPT

Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with calcium

hydroxide and was

considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b) and 6 months (c), 12

months (d) and 18 months (e)

after indirect pulp treatment. The interradicular lesion accompanied by external root resorption observed in panel (e)was indicative of treatment failure.

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PULPOTOMY

Involves the amputation of the coronal

portion of the affected or infected dental

pulp. Treatment of the remaining vital

radicular pulp tissue surface should

preserve the vitality and function of all or

part of the remaining radicular portion of

the pulp. The coronal pulp chamber is filled

with a suitable base and the tooth restored

The American Academy of Pediatric Dentistry Reference

Manual

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PULPOTOMY

Indications:

Large carious lesion involving more

than 1/3 of marginal ridge in a

restorable tooth

Vital tooth free of radicular pulpitis

with pain of short duration, no

swelling, mobility, tenderness or pus

discharge, no periapical pathosis or

inter-radicular bone loss

At least 2/3 of root remaining

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PULPOTOMY

Clinical contraindications:

Unrestorable tooth

History of spontaneous/persistent pain

Irreversible pulpitis or pulp necrosis

Pus discharge

Pathological mobility Swelling of pulpal origin

Sinus tract or fistula

Hyperaemic pulp

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PULPOTOMY

Radiographic contraindications:

External or internal root resorption

Periapical or furcal pathology

Radicular bone loss

Pulp calcification

Less than 2/3 root left Permanent tooth close to eruption

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PULPOTOMY MATERIALS

Ranly D 1994 stated that pulpotomy therapy has

been developed along three lines according to the

method of action of the material used:

1. Devitalization with the use of formocresol and

electrosurgery where the intent is to destroy the

radicular pulp

2. Preservation of the remaining radicular pulp with

the use of gluteraldehyde and ferric sulphate

3. Regeneration of the radicular pulp by stimulation

of a dentinal bridge that, in humans, has been

accomplished with the use of calcium hydroxide,

MTA and bone morphogenic proteins and enamel

matrix proteins

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PULPOTOMY-MATERIALS

Formocresol

Ferric sulphate

Gluteraldehyde

CH cement

Ledermix Cement

Sodium Hypochlorite

Electrosurgery

Laser therapy

Mineral Trioxide Aggregate (MTA)

Bone morphogenic proteins (BMPs)

FORMOCRESOL

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FORMOCRESOL

PULPOTOMY

Buckleys Formocresol

Tricresol-35%

Formaldehyde-19%glycerol-15%

water-31%

1:5 dilution

The pulp remains half dead, half vital, and

chronically inflamed.

Success rate ranges from 70-97% but

diminishes with time.

O OC SO

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FORMOCRESOL

PULPOTOMY

Fixation of the pulp

tissue by direct contact

Bactericidal

3 layers form: fixation,coagulation necrosis,

vital tissue

Concern regarding

systemic toxicity,

carcinogenicity and

mutagenicity

Successrate:70-100%

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Irrigate the pulp chamber with saline to remove debris

Control the haemorrhage with slightly damped cotton

wool pledget

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FERRIC SULPHATE

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FERRIC SULPHATE

PULPOTOMY

Was first used with CH to aid in the control

of haemorrhage, now used without CH

A ferric ion complex is formed in contact

with blood which promotes haemostasis

Clinically proven to be as effective as

Formocresol

Less toxic

GLUTERALDEHYDE

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GLUTERALDEHYDE

PULPOTOMY

Rapid fixation of the pulp tissues

Less penetration into the periapical

tissues Toxicity concerns

Eye irritation and allergic reaction

Short shelf life

Higher success rates than Formocresol

CALCIUM HYDROXIDE

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CALCIUM HYDROXIDE

PULPOTOMY

Antibacterial activity

Surface layer of coagulation necrosis

Associated with high rates of internalresorption

Success rate of 60%

Recently questioning low success rateattributing that to incorrect diagnosis

and contact with the blood clot

T t t O t ith diff t

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Treatment Outcome with different

agents

When outcomes of ferric sulphate were compared to ZOE RCTs

at 2 & 3 year follow up periods following carious exposures in

primary teeth, the reported outcomes for FS were poorer than RCT

outcomes at 2 years; however, at 2 years, the survival rates were not

statistically different. On the other hand, no statistical difference inoutcomes was demonstrated at 3-year assessment, however, RCT-

treated molars demonstrated significantly greater survival than FS

treated molars 3 years after treatment. Casas et al ( 2002 & 2003)

Pulpotomies performed with either FC or FS are likely to have

similar clinical and radiographic successes. The mean clinical andradiographic success rates of treatment with ferric sulphate were

91.6% and 73.5%, respectively. Due to the deleterious effect of FC,

it is suggested that FS be recommended as a replacement. (Peng

2007)

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MTA

Mineral trioxide aggregate (MTA):

It has excellent sealing ability, biocompatibe, induces hard

tissue formation, has antimicrobial properties, maintains pulp

integrity & promotes healing without cytotoxic effect, It hashigher long term clinical and radiographic success rate than

pulp dressing materials like FC.

MTA is a powder composed of a mixture of a refined Portland

cement and bismuth oxide, reported to contain trace amounts

of SiO2, CaO, MgO, K2SO4, and Na2SO4.

MTA powder is mixed with sterile water in a 3:1 powder/liquid

upon hydration, a colloidal gel is formed that solidifies to a

hard structure in approximately 34h, with moisture from the

surrounding tissues assisting the setting reaction.

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Hydrated MTA products have an initial pH of 10.2, which

rises to 12.5 three hours after mixing. MTAs compressive

strength after setting is 70 Mpacomparable to that of IRM

and Super-EBA but less than that of amalgam.

Preparation with saline and 2% lidocaine anesthetic solution

increases setting time without significantly affecting the

compressive strength.

Ragarding leakage, MTA frequently performs better thanamalgam, IRM or Super EBA. Compared with composite

resins placed under ideal conditions, MTAs leakage patterns

are similar & the presence of blood has little impact on the

degree of leakage.

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(GMTA) and White MTA (WMTA) have been introduced.

WMTA has a lighter color, smaller particle size, being

significantly less soluble & more radiopaque than GMTA.

MTA vs FC: procedure requires less time & risk of re-

bleeding is absent.

MTA is costly, it cannot be kept once the envelope is opened

so its use in pediatric dentistry becomes almost prohibitive.

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Evidence on MTA

MTA vs FC:

MTA-treated teeth showed no clinical or radiographic

pathology whereas internal resorption was detected in the FC

group after follow up periods ranging from 6-30 months .(Eidelman & Holan 2000)

The success rate of pulpotomy was 97% for MTA and 83%

for FC after a follow up period of 74months , internal

resorption occurred more in FC pulpotomy. (Holan 2005)

MTA was superior to FC in pulpotomy and might be FCs

suitable replacement resulting in a lower failure rate & lower

undesirable responses. (Peng 2006)

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GMTA vs WMTA & FC:

GMTA appeared to be better than WMTA and FC because

it presented the closest to normal pulp architecture.

(Agamy 2004)

FC vs FS, WMTA ,WPC :

Beta-TCP, WMTA are histologically more effective

pulpotomy agents than FC and FS in primary pig teeth since

FC & FS provoked more pulp inflammatory response.

(Shayegan 2008)

E l M t i D i ti (EMD)

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Enamel Matrix Derivative (EMD)

Emdogain gel has been successfully employed for

pulpotomies in noninfected teeth in animal studies. Its effect

was also investigated on experimentally exposed human

permanent pulps, but seems ineffective for formation ofhard tissue barriers.

Emdogain gel is a bioinductive material that is compatible

withvital human tissues. It offers a good healing potential

and is capable of inducing dentin formation, leaving theremaining pulp tissue healthy and functioning, it may act in

a multitude of ways on mesenchymal cells that provide pulp

protection. (Sabbarini 2006)

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EMD vs FC: success rates at 6 months didnt differ.

However, after 6 months the radiographic success rates for

FC and EMD were 13% and 60 %, respectively. EMD-

treated teeth had less periodontal membrane widening, lessperiapical and/or furcation Radiolucencies & no pulp

calcifications. Therefore, When compared with FC, EMD

appears to be clinically and radiographically superior.(Sabbar ini 2008)

EMD disadvantages: difficult application due to the gel

consistency, almost impossible to condense any material over

it, the whole amount of gel should be used within 2 hours or

it will lose its effect therefore its not cost effective.

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Calcium Hydroxide: pulpal repair vs internal resorption,

success rate reaches 70%.

The greater the area of carious exposure, the lower the

success rate in pulpotomies at follow up period of 1 year.

Internal resorption being the main reason for failure,

however, it was not affected by physiological root resorption.(Snmez 2007)

When Ca(OH)2was compared to FC, FS & MTA inpulpotomies at a follow up period of 2 years, the success rate

was 76.9% for FC, 73.3% for FS, 46.1% for Ca(OH)2, and

66.6% for MTA. Therefore, Ca(OH)2is less appropriate for

primary teeth pulpotomies than the other pulpotomy agents.(Snmez 2008)

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ND:YAG vs FC pulpotomy

Nd:YAG laser may be considered as an alternative

to formocresol for pulpotomies in primary teeth

giving success rates of 85.71% & 71.42% vs90.47% for FC pulpotomy at 12 months.

(Odabas 2007)

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B4 ttt with ND:YAG 9 months after ttt 36 months after ttt

I nternational Congress Ser ies 1248 (2003):

251256

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PULPOTOMY-PROGNOSIS

Regardless of the

material used

success depends on

pulp status

Reasons for failure:

- Incorrect diagnosis

- Inadequate coronalseal

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PULPECTOMY

Involves gaining access to the root

canals which are then debrided,

enlarged and disinfected. The canals

are filled with a resorbable material

The American Academy of Pediatric Dentistry Reference Manual

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PULPECTOMY

Indications:

Tooth with irreversible pulpitis or

necrotic pulp tissue Non-vital tooth with prolonged history

of pain, swelling, mobility,

radiolucency involving the furcationarea

Persistent bleeding during a

pulpotomy

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PULPECTOMY

Contraindications:

Periradicular involvement extending

to the permanent tooth bud Pathological resorption of > 1/3 root

Excessive internal root resorption

Perforation of the floor of the pulpchamber

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Table. Root canal length of maxillary

incisors and mandibular molars

Length in mm

Mean RangeTooth

Central 16.5 16-17

Lateral 15 14-16

Tooth and

Canal

First molar

Mesiobuccal 16.4 15-17Mesiolingual 14.2 9-15

Distobuccal 13.1 12-15

Distolingual 12.7 10-15

Second molar

Mesiobuccal 15.8 13-17

Mesiolingual 14.4 11-16

Distobuccal 14.9 13-16

Distolingual 14.9 12-16

I n 1992, Salama et al

attempted to determine the

length of the root canals of

pr imary maxi l lary incisors

and mandibular molars

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Step 6: Dry the canals

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TWO-STAGE PULPECTOMY

Presence of an acute abscess

Persistence of discharge

Patient is in pain 2 stage pulpectomy with Formocresol

intermediate dressing and antibiotics

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Criteria for an ideal filling in primary teeth

It should resorb at the same rate as the primary root;

be harmless to periapical tissue and the permanent tooth

germ;

resorb readily if pressed beyond the apex;

be antiseptic;

easily fill the canals and adhere to canal walls;

not shrink; be easily removed;

be radiopaque;

not discolor the tooth; and be nontoxic.

Historical re ie of root filling materials for

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Historical review of root filling materials for

primary teeth

Pure ZOE.

A mixture of ZOE with formocresol and glycerine.

Iodoform paste.

Kri paste; a mixture of iodoform, camphor, parachlorophenol &

menthol.

The Overall success rate for KRI paste was 84% versus 65% for

ZOE, Overf i l l ing with ZOE led to a failure rate of 59% as

opposed to 21% for KRI , Conversely, underf i l l ing led to similar

resul ts, with a failure rate of 17%f or ZOE and 14% for KRI .

(Holan & Fuks 1993)

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Vitapex, a commercial

product containing a viscous

mix of calcium hydroxide

and iodoform in a syringewith disposable tips. The

main ingredients are

iodoform, calcium

hydroxide, and silicone.

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Pediatr Dent 2000; 22:517-520.

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Vitapex vs ZOE: Vitapex appears to resolve

furcation pathology at a faster rate than ZOE at 6

months as demonstrated by a success rate of 78%

vs 48%, while at 12 months, both materials yield

similar results of 89% vs 85%.

(Trairatvorakul 2008)

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Failure of zinc oxide-eugenol (ZOE) long-filled tooth.

(A)Immediate postoperative X-ray of ZOE-overfilled primary mandibular RT Dshowing thickening of periodontal space at the furcation area.

(B) Accelerated resorption of supporting bone at 6 months, showing large

radiolucent area at the furcation and resorption of the entire mesial root

considered a failure at 6 months.

(C) Retained ZOE with premature eruption of the first premolar.

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Failure of zinc oxide-eugenol-treated tooth at 6 months, which turned out

to be successful at 12 months.

(A)Immediate postoperative X-ray of primary mandibular RT E withradiolucency involving more than half of the distal root length.

(B) At 6 months, although there is an increase in radiopacity of the

furcation area from bone regeneration, the tooth was considered a

failure due to a large rarefied area at the mesial root apex involving the

crypt of the underlying permanent tooth bud.

(C) At 12 months, the consistent radiopacity of the furcation area and thecomplete resolution of the rarefied area at the mesial root along with

reunion of bony crypt walls of first premolar. The fulfillment of these 2

criteria constitutes success.

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Root filling materials for primary teeth, Contd

Calcium hydroxide pastes:

Sealapex showed less leakage than ZOE and Apexit in sealer-

only obturation of pulpectomized primary teeth. (Kielbassa 2006)

The overall success rate for sealapex was 92.3% during a follow-

up period of 3 years, sealapex didnt show evidence of complete

resorption in the canals. (Sar 2008)

Maisto paste; similar to kri paste but with added thymol & ZnO.

PROBLEMS IN PULP

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THERAPY

Pain/poor patient cooperation

Acute infection

Persistent draining sinus

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RESTORATIONS

Ideally SSC

Amalgam

Resin-modified GIC Composite resin

SEQUELAE OF PULP

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THERAPY

Effect on eruption time of permanent

successor

Enamel defects on permanentsuccessor possible related to the pre-

exciting infection

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Stainless Steel Crown

procedures for PrimaryMolars

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Indications

Extensive caries

Pulpotomy/pulpectomy

Malformed teeth

Hypoplasia

Hereditary Conditions (AI, DI) If used as an attachment for

a crown and loop SM

Habit-breaking Appliance

Distal Shoe appliance

Fractured teeth Severe attrition of primary teeth

Mesial lesions on first primary molars

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Contraindications

Esthetics

Teeth that are nearing exfoliation

Mechanical problems

space loss

caries beneath the level of the bone

Permanent restoration in the permanent

dentition

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Use of Stainless Steel Crowns

Introduced to pediatric dentistry by Dr. WilliamHumphrey in 1950

prior to that orthodontic bands filled withamalgam were a last resort

necessity is the mother of invention

Considered superior to large multisurface amalgamrestorations and have a longer clinical lifespan thantwo or three surface amalgams (Dawson et al., 1981)

Composition of Stainless Steel

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Crowns

Alloy: nickel- chrome (ion crowns, 3M)

77% nickel

15% chromium

7% iron

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What you will need

Burs and Stones

Flame shaped diamond (Occlusal reduction)

Tapered diamond (Proximal reduction)

Heatless stone

Pliers and instruments

Crimping plier

Contouring plier Polishing

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Step By Step

Caries Removal

Complete pulp therapy if necessary

Proceed with crown preparation

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Overview

Occlusal reduction

Proximal reduction

Buccal and Lingual

reduction

Beveling

Round all sharp line

angles and corners

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Occlusal Reduction

1.01.5 mm

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Completed Occlusal Reduction

Check reduction with

opposing arch

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Proximal Reduction

Contact with adjacent teeth must be broken gingivally

and buccolingually

proximal slices converge slightly toward the occlusal

and lingual

DO NOT OVER TAPER

The gingival margins should have a feather-edge finish

line

Adjacent tooth structure must not be damaged

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Proximal Slices

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Angulation of Slices

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Ledging

Proximal slice must be

extended below tissue to

avoid leaving a ledge

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Buccal-Lingual Reduction

Reduction is optional and is undertaken only if thebuccal or lingual bulges are so prominent that theconstricted margin of the crown will not go over heheight of contour

When required, no more than .5-1mm should beremoved

Reductions must end in a feather edge

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Beveling

A bevel at an angle of 30-45 degrees removes

the sharp cusp tips and creates a gentle slope

in the occlusal third of the lingual and buccal

surfaces

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Round Sharp Line Angles

The buccal and lingual proximal line angles

are rounded by holding the bur parallel to the

tooths long axis and blending the surfaces

together The finished contour should conform to the

internal contour of the stainless steel crown

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Round Sharp Line Angles

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Selection of the Crown

Goal:to place the smallest crown that can beseated on the tooth and to establish pre-existing proximal contacts

Hint: Size 4 is the most frequently used crownsize for molars

The selected crown is seated ligually firstthen buccally.

Friction should be felt as the crown slips over thebuccal surface into the gingival sulcus

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C Ad i

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Crown Adaptation

Mark gingival line with ascaler and trim 1 mm

beneath the mark using C& B scissors.

Margins should be trimmedto lie parallel with thecontour of the gingivaltissue and consist of a seriesof curves without sharp

angles.

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Gingival Contours

Buccal gingival contour of second primary molar--

smile

Buccal gingival contour of first

primary molar-- stretched-out S

Proximal gingival contour of

primary molars --frown

C h C

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Contour the Crown

Use contouring pliers,

bend the gingival third

of the crowns margins

inward to restoreanatomic margins and

to reduce the marginal

circumference ensuring

a good fit

C i h

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Crimp the crown

With the crown-

crimping plier (ball &

socket plier) crimp the

margin

Replace crown on tooth

and check margins with

an explorer

G id li

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Guidelines

Resistance in seating without tissue blanching.

Check for

high spots on occlusal surface

ledges

Resistance in seating with tissue blanching.

Check for

crown too wide (preliminary contouring)

crown too long

tissue caught in margin

Fi i hi d P li hi

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Finishing and Polishing

Use heatless stone to

smooth jagged edges

Then use a rubber

wheel to remove smallscratches and make it

smooth

Polish surface of crown

to a high shine withtripoli and rouge

C t ti

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Cementation

Clean crown and tooth

Fill crown with the

appropriate cement

Seat crown, expressing

cement form all marginsand press into occlusion

Remove excess cement

when partially set

P t i t ti ?

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Post-op instructions ?

Although a well-

adapted and cemented

crown should not come

off under thesecircumstances, patients

and parents should be

warned of the

possibility

Pain & analgesics

M i Cli i l V i ti

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Managing Clinical Variations

Space Loss

M i S L

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Managing Space Loss

May need to increase

the buccal and lingual

reductions

May need to compresscrown form on mesial

and distal with Howe

pliers

Cli i l V i ti

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Clinical Variations

Back-to-back chromecrowns

Second primary molars

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Any Questions???