Endo 5th

Endodontic Diagnosis and
Treatment Plan
Doç. Dr. Atakan KALENDER

Diagnosis:
to identify the nature of the disease
in detail as a result of the analysis of
the symptoms
To diagnose….?
 Medical History
 Dental History
 Objectif Tests
 Analyze
 Treatment Plan
Medical History
 Written and approved form of medical and dental history

 Medicines used
 Allergy
 The need for prophylaxis
 Systemic diseases
 Pregnancy
Medical history
Prophylaxis
 2 gr Amoxicillin (1/2 hour before treatment)
 Klindamycin 600 mg (if penicillin alergy)
Medical history
Systemic diseases
 Under control
Medical history
Pregnancy
 1st and 3rd trimester contraindicated
 Radiography minimum
 Consultation
Medical history
Anesthesic Solutions Allergy,
…………………………
………………………..
Latex Allergy
 Non-latex rubber dam
 Latex-free gloves
 Consultation
Subjective History
Complains of the patient……?

 With his/her own words
???????
???????
Pain history
Subjective History
 Location
 Density
 Time
 Situmulator
 Type
 Cure
Pulpal pain
Pulpal pain
Difficult to Localize…..
 intermittent
 pulsative
 increase with hot, cold or chewing
 Decrease with cold
 Mostly unbearable
Periodontal Pain
Periradiküler pain
 Itcan be localized
 Deep pain
 increase with chewing
 mild - severe
Subjective History
 Not enough
 Examination and objective tests needed

Objective Tests
 İnspection
 Radiography
 Percussion
 Palpation
 Mobility
 Vitality Tests
Objective Tests
 Periodontal probe
 Selective anesthesia
 Cavity tests
 Transillumination
 Occlusion
inspection
 Extra-oral examination
 Facial asimetry
 swelling
 Extra oral fistula
 TMj
Extra-oral swelling
inspection
Intra-oral examination
 Soft tissue lesions
 swelling
 redness
 Fistula
Acute apical abcess
inspection
Hard tissues
 caries
 restorations
 Colorchange
 Abrasion, erosion, atrission
Color change
Radiography
 Always take your radiograph

 Never diagnose only with radiograph
Radyographs
Percusion test
 Determinant
 compare with symmetrical tooth
 Inflammation in peridontal ligament
 The result of inflammation of pulp or
periodonsium
Percusion Test
Vertikal Horizontal
Palpation Test
 Extraoral
 Lymph nodüles
 Intraoral
 Periapical sensitivity
 Swelling of soft tissues
 compare
Palpation
Mobility

Serious inflammation of peridontal ligament
 Compare with neighboring and symmetrical
teeth
 There are other reasons
thermal Tests
 Cold mostly
 Hot rarely
 Compare with neighboring and
symmetrical teeth
 10 minutes needed to be repeated
thermal Tests
thermal Tests
CO2
ıce stick
Thermal Tests
Cold
Normal Pulp Acceptable pain
Reversible Pulpitis: sharp pain; quick reduction
Irreversible pulpitis: continuous pain
Necrosis: no response or false positive
Electrical Pulp Test
 A direct stimulus for nerves in the pulp

 Vital or devital - Vital pulp is normal or is it
inflammed
 Multiple root?; False positive
False Positive;
 Metal restoration or contact with gingiva
 Patients concern
 Likefaction necrosis
 Inadequate isolation
False negative
 Aneshtesia
 Enamel and elektrod contact
 Trauma
 Open apex
 Partial necrosis
Periodontal Examination
 The presence of deep pockets in the

Abcessnce of periodontal disease
 Poor periodontal prognosis, contraindication to
root canal treatment
İzole derin cep varlığı

Selective Anesthesia
 Cause of pain
 Local anesthesia for
single tooth???
Cavity Test
 Cavity preparation without local anesthesia

Transillumination
 Vertical crown fracture

Transillumination
Occlusion
 Hyperocclusion
Analyze
 Analyze
 History
 Examination
 Specific test
Clinical diagnosis (not histological)

 Pulpal diagnosis
 Periapical diagnosis
Probable Pulpal Diagnosis
 Normal
 Reversible pulpitis
 Irreversible pulpitis
 Necrosis
 Previous root canal treatment
Normal Pulp
 Symptom no
 Radiography no Periapical lesion
 Pulp Test normal
 Periapical testler no Percusion ve Palpation
Reversible Pulpitis
 Symptom may be thermal sensitivity

 Pulp Test yes, but not long time
 Periapical test No Percusion Palpation
Irreversible Pulpitis
 Symptom
 Radiography
 Pulp Test
 Periapical test
Necrotic Pulp
 Symptom no thermal sensitivity

 Radiography it depends
 Pulp Test no
 Periapical tests it depende on the periapical status
Probable Periapical Diagnosis
 Normal
 Acute apical periodontitis
 Chronic apical periodontitis
 Acute apical abcess
 Chronic apical abcess
 Condensing osteitis
Normal Periapeks
 Symptom no
 Pulp tests Normal
 Periapical test no Percusion and Palpation
Acute Apical Periodontitis
 Symptom
 Radiography
 Pulp tests +/-
 Periapical test
Chronic Apical Periodontitis
 Symptom
 Radiography
 Pulp test
 Periapical test
Acute Apical Abcess
 Symptom
 Radiography
 Pulp test
 Periapical test
Chronic Apical Abcess
 Symptoms
 Radiography
 Pulp Test
 Periapical test
Condensing Osteitis
 Symptoms
 Radiography
 Pulp Test
 Periapical test
Treatment Plan
 Pulpal diagnosis
 Periapical diagnosis
 Restorability
 Periodontal status
 Diificulty level of the case
 Financial status
Treatment Plan
Two basic questions;

 Is root canal treatment indicated?
 Can I perform it ?
Factors Affecting Endodontic Treatment
 Status of the patient

 Objective clinical findings
 Other factors
Status of the Patient
 Medical history
 Indication for local anesthesia
 Systemic health
Objective Clinical Findings
 Diagnosis
 Radiographic findings
 Pulp chamber
 Root morphology
 Apical morphology
 Malposition
Other Factors
 Restorability
 Existing restoration
 Fracture
 Resorption
 Endo-periodontal lesion
 Trauma
 Perforation
DIAGNOSİS OF PULPAL DISEASES
Assoc. Prof. Dr. Atakan Kalender

Diagnosis is defined as utilization of scientific
knowledge for identifying a diseased process and
to differentiate from other disease process
The diagnostic process actually consists of 4 steps:
1. Assemble all the available facts gathered from
chief complaints, medical and dental history,
diagnostic tests and investigations
2. Analyze and interpret the assembled clues to reach
the tentative or provisional diagnosis
3. Make differential diagnosis of all possible diseases
which are consistent with signs symptoms and test
results gathered
4. Select the closet possible choice.
• The diagnostic process actually consists
of four phases.
• PHASE I
• Subjective phase
• Chief complaint
• History of present illness
• Medical history
• Dental history
• Objective phase
• Visual examination
• Palpation
• Percussion
• Mobility and depressibility tests
• Transillumination
PHASE II
• Radiographs
PHASE III
• Heat test, Cold test, and Electric pulp test
PHASE IV
• Anesthesia test and test cavity
Grossmans clinical classification of
pulpal diseases.
PULPITIS
A. Reversible pulpitis
• - Symptomatic (acute)
• -Asymptomatic (chronic)
B.Irreversible pulpitis
• Acute irreversible pulpitis
• Abnormally responsive to cold
• Abnormally responsive to heat
• Chronic irreversible pulpitis
• Asymptomatic with pulp exposure
• Hyperplastic pulpitis
• Internal resorption
PULP DEGENERATION
• Calcific (radiographic degeneration)
• Other(histopathological diagnosis)
NECROSIS
PULPITIS
ACUTE PULPITIS CHRONIC PULPITIS

Symptomatic Asymptomatic
ACUTE PULPITIS
pulpitis serosa pulpitis purulenta

CHRONIC PULPITIS
pulpitis ulseroza pulpitis polypoza

DIAGNOSTIC CRITERIA FOR PULPAL
DISEASES
NORMAL PULP:
• A normal pulp gives moderate response to pulp
test and this response subsides when the stimulus is
removed.
• The tooth is free of spontaneous pain
• Radiograph shows intact lamina dura,absence of
any pulpal abnormality, calcification and resorption.
PULPITIS
 Inflammation of dental pulp resulting from untreated
caries,trauma or multiple restorations.its principal symptom
is pain.
 Diagnosis is based on clinical findings and is confirmed by x
rays.
 Treatment involves removing decay, restoring the damaged
tooth and some times, performing root canal treatment or
extracting the tooth.
 Infectious sequele of pulpitis include apical periodontitis,
periapical abscess, cellulites and osteomyletis of the jaw,
spread from maxillary teeth may cause purulent sinusitis,
meningitis, brain abcess, orbital cellulites and cavernous sinus
thrombisis.
 Spread from mandibular teeth may cause ludwigs angina,
parahrangeal abcess , mediastinitis, pericarditis and
empyema.
Reversible pulpitis/ hyperemia /
hyperactive pulpalgia:
 Reversible pulpitis is the general category which histologically
may represent a range of responses varying from dentin
hypersensitivity without concomitant inflammatory response
to an early phase of inflammation.
It is an indication of peripheral A delta fiber stimulation.
Symptoms:
 Symptomatic reversible pulpitis is characterized by sharp pain
lasting for a moment,commonly caused by cold stimuli. Pain
doesn’t occur spontaneously and doesn’t continue when
irritant is removed.
 Asymptomatic reversible pulpitis may result from incipient
caries and is resolved on removal of caries and proper
restoration of tooth.
• Diagnosis:
• Pain:it is sharp but of brief duration ,ceasing when
• Visual examination and history: may show caries
,traumatic occlusion and undetected fracture.
• Radiograph :show normal PDL and lamina dura
• -depth of caries or cavity penetration may be evident.
• Percussion: shows negative or positive response
• Vitality test:
• Pulp responds readily to cold stimuli.
• Electric pulp tester requires less current to cause pain.
•
IRREVERSIBLE PULPITIS:
 It is a persistent inflammatory condition of the pulp ,symptomatic
or asymptomatic ,caused by noxious stimulus. It has both chronic
stages in pulp.
 Etiology:
 bacterial involvement of pulp through caries.
 Chemical ,thermal,mechanical injuries of pulp
 Reversible pulpitis may turn into irreversible pulpitis.
Symptoms
 Rapid onset of pain.,which can be caused by sudden temperature
change ,sweet or acidic food . pain remains even after removal of
stimulus.
 Pain can be spontaneous in nature which is sharp,piercing
,intermittent or continous in nature.
 Pain exacerbated on bending down or lying down due to change in
intrapulpal pressure.
Diagnosis:
 Examination of involved tooth may reveal previous symptoms
.on inspection,one may see deep cavity involving pulp or
secondary caries under restorations.
Radiographic findings:
 -may show depth and extent of caries.
 -slight widening may be evident .
 percussion:
 tooth is tender on percussion.
Vitality tests:
 Thermal test: hyperalgesic pulp responds more readily to cold
stimulation than for normal tooth.pain may perisist even after
removal of irritant.
Electrical test:
 Less current is required is required in initial stages.
 As tissue becomes more necrotic ,more current is required.
CHRONIC PULPITIS:
• It is an inflammatory response of pulpal connective tissue to an irritant. It can be
of three types
• Ulcerative type
• Hyperplastic form
• Closed form of chronic pulpitis
Etiology: same as that of irreversible pulpits.it is normally caused by by slow and
progressive carious exposure of pulp.
Sign and symptoms:
• Pain is absent
• Symptoms develop only when there is interference with drainage of exudates
• Diagnosis
• Hyperplastic form shows a fleshy ,reddish pulpal mass which fills most of the of
pulp chamber of cavity .it is less sensitive than normal pulp but bleeds easily when
probed.
• Radiographic changes shows areas of dense bone around apices of involved teeth.
• Vitality tests
• Tooth may respond feebly or not at all to thermal tests.
• More current than normal is required to elicit response by electric pulp tester.
CHRONIC PULPITIS –
Hyperplastic form
PULP NECROSIS
• Pulp necrosis is a condition following untreated pulpitis.necrosis may
be partial or total ,depending on extent of pulp tissue involvement.
Pulp necrosis is of two types
• Coagulation necrosis:cell protoplasmbecomes fixed and opaque.cell
mass is recognizable histologically,intracellular details are lost
• Liquefaction necrosis:entire cell outline is lost. The liquefied area is
surrounded by dense zone of PMNS,chronic inflammatory cells.
Etiology:
• Necrosis is caused by noxious insult and injuries to pulp by
trauma,bacteria and chemical irritation.
Symptoms
• Discoloration of tooth
• Tooth might may be asymptomatic.
Diagnosis
• Pain is absent in complete necrosis
• History of patient reveals past trauma or past
history of severe pain
• Radiographic changes-shows a large cavity or filling
or normal appearance unless there is concomitant
periodontitis or codendensing osteitis
• Vitality tests-nonresponding to vitality tests.but
multirooted tooth may show mixed response
because only one canal may have necrotic tissue.
• Visual examination-tooth show color changes like
dull or opaque appearance due to lack of normal
translucency.
 Normal
 Necrosis
Normal Pulp
 Symptom no
Reversible Pulpitis

 Symptom spontaneous pain

 Radiography no
 Pulp Test persistant pain
 Periapical test no
Necrotic Pulp

 Pulp Test no
PERIRADICULAR PAHOLOGIES
ACUTE APICAL PERIODONTITIS:
• It is defined as painful inflammation of the
periodontium as a result of trauma,irritation or
infection,through the root cnal ,regardless of whether
the pulp is vital or non vital.
Signs and symptoms:

• Dull ,throbbing and constant pain
• Pain occurs over a short period of time
• Negative or delayed vitality test
• No swelling
• Pain on biting
• Cold may relieve pain or no reaction
• No radiographic sign sometimes widening of
periodontal ligament space.
ACUTE APICAL PERIODONTITIS
Acute apical abscess
 It is a localized collection of pus In the alveolar bone at the root
apex of the tooth,following the death of pulp with extention of the
infection through the apical foramen into periradicular tissue.
Etiology;
 Most common cause is bacterial invasion of dead pulpal tissue but
can also occur by trauma,chemical or mechanical injury.
Signs and symptoms
 Tooth is non vital
 Pain is localized
 Tooth becomes increasingly tender on percussion
 Swelling-palpable,fluctuant
 Tooth may be in hyperocclusion
Radiograph-no change to large periapical radiolucency can be seen
Pulp tests-EPT,COLD,HEAT TEST –no response.
PERIAPICAL GRANULOMA:
It is one of the most common sequelae of pulpitis.it is usually
described as a mass of chronically inflamed granulation tissue
found at the apex of non vital tooth
Signs and symptoms:
 Mostly asymptomatic
 Tooth is not sensitive to percussion
 No mobility
 Soft tissue overlying my or may not b tender
 No response to thermal or electrical pulp test
Radiographic features
 Mostly discovered on routin radiographic examination.
 Thickening of pdl ligament at the root apex
 Lesion may be well circumscribed or poorly defined.
 Size may vary from small lesion to large radiolucency.
Periapical granuloma
Radicular cyst
• It is an inflammatory cyst which results from
because of extension of infection from pulp into the
surrounding periapical tissues.
Signs and symptoms

• Asymptomatic
• Involved tooth found to be non vital.
Radiographic features:
• Radicular cyst appears as round ,pear or ovoid
shaped radiolucency,outlined by a narrow
radiographic margin.
Radicular cyst
External root resorption:
• It is a condition associated with either physiological or a
pathological process that result in loss of tooth
substance from tissue such as dentin,cementum or
alveolar bone.
Symptoms
• Asymptomatic during development
• When external root resorption extends to crown ,it
gives ‘pink tooth ‘experience.
• When root is completely reorbed tooth becomes
mobile.
Radiographs
• Radiolucency at root and adjacent bone.
• Loss of lamina dura.
External root resorption
Sources of non odontogenic pain.
• Myofascial toothache-any deep somatic tissue in
the head and neck region has tendency to induce
referral pain in the teeth,in these structures pain
of muscular origin appear to be most common.
• Muscles which are commonly affected are
masseter and temporalis,but in some cases
pterygoids and digastric muscles are also
affected.
• Palpation of the involved muscles at specific
points(trigger points)may induce pain
Cluster headache
• It is commonly found in age group 20-50 years
• Cluster headaches derive their name from the
temporal behaviour and usually occur in series i.e
one to eight attacks per day
• Pain is unilateral ,excruciating and continous in
nature and usually found in orbital ,supraorbital
and temporal region.
• Autonomic symptoms such as nasal
stuffness,lacrimation,rhinorrhea or edema of
eyelids and face are found.
Cardiac toothache
• Severe referred pain felt in mandible and maxilla from area outside
the head and neck region is commonly from the heart
• Cardiac pain is clinically chracterized by heaviness,tightness or
throbbing pain in the substernal region which commonly radiates to
left shoulder,arm ,neck and mandible.
• Cardiac pain is most commonly experienced on the left side rather
than right,
• In advance cases ,the patient may complain of severe pain and rubs
jaws and chest.
• Usually the cardiac toothache is decreased by taking rest or dose of
sublingual nitroglycerin.
• A complete medical history should be taken when cardiac
toothache is suspected and refererred to cardiologist.
Diseases Of
Periapical Tissues
• Once infection has established in the
dental pulp, spread of the process can be
in one direction- through the root canals
and into the periapical region.
• Number of different tissue reaction may

occur, depending upon a variety of
circumstances.
• Transformation occur from one type of

lesion into another type in most cases
Classification (Alaçam)
a) Acute apical periodontitis
b) Acute apical abscess
c) Chronic apical periodontitis (Periapical

granuloma)
d) Chronic apical abscess
e) Periapical cyst (true and bay)
f) Condensing osteitis
– 1 mm to 10-12 mm
Attention !
Ekstraoral şişlik
Drainage of abscess
bye,
1- Pulp chamber
2- Incision
3- Trepanation
Chronic apical
abscess
Fistulous tract(+)
Pain(-)
Apical radyolusency in
radyography
İntraoral fistül
Mandibular kesicilerden
kaynaklanan eksternal
fistül ağzı
Ekstraoral
ENDODONTIC COMPLICATIONS
Yrd. Doç. Dr. Fatma KERMEOĞLU

Injection of the wrong solution
a. Inadequate opening of the access

cavity
b. Wide opening of the access cavity
c. Perforations
a. Root perforations
b. Working length problems
-Ledge formation
-Canal blockage
c. Zipping
d. File fracture
e. File aspiration or swallow
a. Under or overfilling
b. Nerve paresthesia
c. Root fracture
a. Post perforation
b. Tissue Emphysema
1. ANESTHESIA COMPLICATIONS
• Anesthetics should be prepared next to the
patient
• Syringe used for irrigation should be
distinguishable
• Carpule injection systems may be preferred
If wrong solution is injected!!!
• Acute pain is relieved, anesthesia is performed near this area.
• Analgesic is given.
• Cold compresses are applied for the first 24 hours and warm
compresses are applied on the following days.
• Antihistamines and corticosteroids are given against allergic
reactions.
• Antibiotics are given against secondary infection.
• The patient should be followed. Necrosis and infections that
occur in the region should be observed.
2. ACCESS CAVITY COMPLICATIONS
2a. Small and inadequate opening of access cavities
 Error on entry in root canal
 Accessory canals are skipped
 Remaining pulp residues cause tooth coloring
2b. Wide opening of access cavities
2c. PERFORATIONS
Reasons of the Complications during the
Access Cavity Preparation
• Pulp chamber and canal morphology not well

known
• Inadequate examination of radiographs
• Inadequate visibility
• Opening the access cavity without removing the
crown restoration!!!!!!!!!
2a. Inadequate Opening of the Access
Cavity;
• In areas where pulp horns are present, residual infected tissue

remains
• Tooth color changes,
• Some canals can not be entered,
• Additional canals can not be detected
• Since the canal does not provide a straight entry, it causes the
canal preparation not to be done properly.
There may be more canals than you
find !!!!!!!
2b. Wide Opening of the Access Cavities
The wide opening of the access cavities can lead to a serious

loss of material in the crown, resulting in fractures.
2c. Access Cavity Perforations
Reasons for Perforation:
• Careful examination of radiographs is not done
• Failures during access cavity preparation
• Insufficient knowledge of anatomic structure
• During the search for a canal when the canal system is reduced
by dystrophic changes
• Not to consider the tooth axis
• Opening the access cavity in the presence of artificial crowns

that mask the anatomy of the tooth
Radiographic examination is important in the
access cavities!!!
• Calcifications in the pulp chamber should be considered.

• When opening the access cavity, the drill and the tooth
long axis must be parallel to each other.
• The access cavity must be opened in the correct size and
position
• The crowns must be removed before endodontic treatment.
• A specially manufactured safe and blunt drills must be used
to open the endodontic access cavity.
• The root canals can be localized more easily by illuminating
of the cavity and pulp chamber with fiber optic rays.
Prognosis of a perforated tooth;
Localization of perforation
Contamination of perforation
Open time of perforation
The possibility of closure of perforation
The main canal is entered or not?
Treatment of a perforated tooth;
• Perforation repair with appropriate repair material in case
of access to the perforation area from the access cavity
• If perforation can not be achieved, surgery should be
performed to close the perforation
Perforation Repair Materials:
• Cavit
• Amalgam
• Gutta-percha
• Calcium hydroxide
• Glass ionomer cement
• Tricalcium Phosphate
• Bone graft materials
• Mineral trioxide agregate (MTA)
Crown Perforation on Alveolar Crest
3. CANAL PREPARATION COMPLICATIONS
3a. Root perforations
3b. Working length problems
 Ledge formation
 Canal blockage
 File fracture
 Apical transportation and zipping
3c. File aspiration or swallow

3a. Root Perforations
Cervical
Middle
Apical
Perforations occurring in the cervical
part of the root
1. Searching canal orifices

2. Preparing root canals or
3. Improper use of Gates-Glidden burs
Lateral perforations in the middle part
of the root
Strip Perforation
• Strip perforation usually occurs in the mesiobuccal roots of maxillary
molars and mesial roots of mandibular molars.
• Roots with thin mesiodistal diameters should be subjected to
anticurvature preparation.
• Hedström files must be careful in the coronal area as they make rapid
and effective cutting.
• The use of large diameter Gates-Glidden and Peeso burs on the
coronal part of the canal should be avoided.
MTA treatment of strip perforation
Perforations occurring in the apical part
of the root
Reasons:
• Use of non-curved files in curved canals
• Rotation on curved canals at the point where file is forced
• Extreme apical use of large numbered files in apical preparation
• Non-use of flexible files
Treatment of Apical Perforations
• If the apical part of the canal is reached, the preparation of the main
canal is completed. Sterile distilled water or saline is used as irrigation
solution. Sealers (containing calcium hydroxide or MTA) should be
used to provide biological healing. Heated gutta-percha techniques
are preferred.
• If the apical is not reached, the treatment is completed until the
perforation occurs and the patient is called to the periodic controls.
• Endodontic surgery is performed if signs and symptoms indicate that
endodontic treatment is unsuccessful.
3b. Working Length Problems
 Ledge formation
 Canal blockage
 File fracture
Ledge formation
Ledge is the artificial irregularities created in the root canal

wall that prevent the instruments from reaching the apical
region.
• Canal curvatures and working length should be
determined well by pre-operative radiographs,
• Files must be used without excessive apical pressure in
the canal and without bending,
• Non-cutting files (Ni-Ti files) should be preferred in
curved canals.
Removing ledge;
• Radiography is taken and ledge position is determined.
•Try to reach the apex from the side of the ledge with a
smaller and curved instrument.
•After the ledge area is passed, small vertical movements are
used to remove the ledge.
•Then surface regularity is ensured by circumferential
preparation.
Canal blockage
.
Prevention of canal blockage may be possible with
recapitulation and adequate irrigation.
File fracture
• The physical properties of the file and the way it is used in the canal
must be known
• Files must be used in a wet canal
• Files should be used along the main axis in a straight line
• Debris on files must be cleaned after every use
• Hedström files have more risk of break (first use K-files then
Hedström files)
• After enough preparation, you must go to the big file number and
the files must be used without trimming the number
• Use it by rotation to move the file further to the apex or excessive
apical pressure cause break
• Recapitulation should done.
• Bending and malformations should be examined before each use
• Use Ni-Ti flexible files in curved canals
When the file is broken in the canal;
• The position of the broken part,
• The shape of file and
• The degree of blockage
• The pulp and periapical tissue status before
treatment
is important for the prognosis of root canal therapy.
Treatment options of file fracture:
 Attempt to remove file
 Bypass the broken file and reach the apex
 Obturate the canal to the broken file part
 Apical surgery
If broken file is at the coronal 1/3 of root canal:
If broken file is at the middle 1/3 of root canal:
• Place a lightly curved #10 file in canal and

rotate it a quarter turn.
• A piece of 1 mm is cut from the #10 file by
aerator.
• The #15 file is used for the by-pass after #10
file was reached the working length.
• After finishing preparation, the canal is
obturated.
If the broken part can not be bypassed; try chemical
methods.
The canal is expanded with a file or with Gates-
glidden burs and EDTA is placed and waited for 5
minutes on the canal.
Masseran Kit
If broken file is at the apical 1/3 of root canal:
If the broken file is not blockage canal, if the
treatment fails or if it can’t be coordinated with
the patient, periapical surgery and retrograde
filling will be used.
The broken part may cause irritation to the
periapical tissues when it comes out from apex. In
such cases, the fragment is removed by apical
surgical procedures.
Zipping
Zipping is the transportation or transposition of
the apical part of the canal.
It is also advisable to use the instruments, especially
in the apical 3-4 mm section of the canal, with short
back and forth movement and without rotation and
without changing the position of the curved canal.
3d. File aspiration or swallow
When the file is aspirated:
• The instrument is either attached to the trachea or goes
to the bronchi
• Severe hiccups, coughs, nausea, sore vomiting and
respiratory distress are seen when its in trachea
• Attempts to remove foreign body with cough reflex
• The file that resides in the bronchi can stay long-term
without symptoms
Radiographic follow-up is important when the
instrument is swallowed.
4. IRRIGATION COMPLICATIONS
Factors affecting prognosis if irrigation solution is
overflowed from apex:
• Type of solution (Sodium
hypochlorite, chlorhexidine,
oxygenated water, chelating
agents, distilled water, saline)
• Concentration
• Volume
If the irrigation solution is removed
from the apex;
• Sudden swelling
• Severe pain
• Amphysema
• Hemorrhage
• Ecchymosis
If the irrigation solution is overflowed from the
apex;
• LIGHT REACTIONS: •SERIOUS REACTIONS:
• The patient is informed • Referral to the hospital
• Acute pain is reduced (anesthesia, analgesic) • Surgical approaches
• Canal irrigate with sterile saline
• Cold applied
• Antihistamines and corticosteroids are given

against allergic reactions
• Antibiotics are given against secondary

infections
• ANAMNESIS NaOCl allergy must be

questioned !!
What to look for in irrigation?
When performing irrigation solutions, the syringe must not be squeezed in the canal
and the solution should not be sent with pressure to the apex. The use of special
endodontic injectors with specially prepared tip openings and openings on the side
faces for canal irrigation will help prevent this error.
5. OBTURATION COMPLICATIONS
Root canal filling material sometimes passes the apical stop of the
root canal, reaching the alveolar bone around the root, the maxillary
sinus or mandibular canal, or even the cortical bone. This leads to
apical perforation, which disrupts the apical constriction.
Under or overfilling
Complications that may occur with overfilling
is due to;
 Sealer type
 For the amount of overflow
 Ability to resorb
 Sealer toxicity
Treatment
The first treatment option is retreatment.
In the canals filled with thermoplastic process, the gutta-
percha breaks away from the point and remains in
periradicular tissues.
• If the symptoms are asymptomatic and the lesion does
not occur, there is no need to remove the canal filling and
the patient is followed up long term.
• If the lesion is present or has occurred and the tooth is
symptomatic, apical curettage may be applied.
Different clinical complaints in overfilling:
• Hypoesthesia
• Paresthesia
• Neurological consultation
Vertical Root Fracture
Vertical root fractures have a very poor prognosis and
usually can not be treated.
6. OTHER COMPLICATIONS
6a. Post Perforations
6b. Tissue Emphysema

6a. Post perforations
• Root canal anatomy is well known and radiography should be
examined in detail before post preparation.
• The appropriate drills must be selected and the drills must be used
at the right angle.
• Also, while preparing the post space, suitable Gates-Glidden burs,
heated pluggers or endodontic files should be preferred.
• Post position should be checked by radiography before cementing.
Tissue emphysema is a complication that occurs
when the compressed air escapes into the facial
tissue spaces.
Reasons:
• Air flow inside the canal to dry the canal during
chemomechanical preparation,
• The use of high-cycle drills during endodontic surgery
Endodontic
MicroSurgery
• Endodontic surgery is a procedure that is done to treat the root lesion
that are not amenable to endodontic root canal treatment .
• The majority of these surgical procedures involve resection of the
root apex (apicectomy) and retrograde obturation of the root canal to
get ride of persistent lesion that has not resolved following an
acceptable root canal treatment.
Pathogenesis of periapical lesions
Pulpal and subsequent periapical disease is caused by microbial
contamination. This commonly occurs via a carious lesion and some
time occurs due to periodontal disease . As resultant necrosis of the
pulpal tissue lead to inflammatory products and pathogens and their
byproducts to exit through the apical foramen.This frequently results in
the formation of a periapical lesion , mostly an apical granuloma.
• caries
• pulp necrosis
• periapical abscess or granuloma
• radicular cyst(inflammatory cyst)
Treatment options of tooth with periapical lesion ;
1. Extraction if the tooth is unuseful or un restorable.
2. Root canal filling if the tooth restorable and there is some evidence
that small periapical cystic lesion may resolved following successful
root canal filling .
3. Endodontic surgery , when there is failure of root canal filling or
there are some obstacle to do root canal filling .
Indications for endodontic surgery ;
• Apical anomaly of root tip (dilacerations, intracanal calcification, open
apex)
• Presence of lateral/accessory canal/apical region perforations
• Roots with broken instruments/overfillings
• Fracture of apical third of the root
• Formation of periapical granuloma/cyst
• Draining sinus tract/ non responsive to RCT
• Extension of root canal sealant cement/filling beyond the apex
• Teeth with ceramic crowns
• When patient with chronic periapical infection, will not be available for
follow-up.
Contraindications for endodontic surgery ;
• Presence of systemic diseases—leukemia, uncontrolled diabetes, anemia,
thyrotoxicosis, etc.
• Teeth damaged beyond restoration
• Teeth with deep periodontal pockets and grade III mobility (Pre-existing
bone loss)
• When traumatic occlusion cannot be corrected
• Short root length
• Acute infection which is nonresponsive to the treatment
• Root tips close to the nerves, e.g. mental nerve, inferior alveolar nerve or in
maxilla close to the maxillary sinus.
Complications of endodontic surgery ;
intraoperative
• Bleeding ; can controlled by using local application of adrenaline pack , pressure
pack,Gelfoam or surgical.
• Damage to the neighboring root.
• Entry into sinus/inferior alveolar canal,nasal cavity.
Postoperative
• Abscess formation.
• Fenestration, sinus tract formation.
• Increased mobility of the tooth.
• Staining of the mucosa due to amalgam that remained at the surgical field.
Follow up for endodontic surgery ;
Healing of the periapical area is checked every 6–12months
radiographically, until ossification of the cavity is ascertained. In order
to evaluate the result, a preoperative radiograph is necessary, which will
be compared to the postoperative radiographs later.
Microsurgery ?
CONVENTIONEL MICROSURGERY
Osteotomy area 8-10mm 3-4mm
Angel 45-65 degrees 0-10 degrees
Examination of root end - possible
Detection of isthmus - possible
Apical preperation Some cases always

Apical preperation Bur Ultrasonic
Retrograd filling Amalgam MTA
Sutures 4.0 silk 5.0, 6.0 monoflament
Healing after 1 year %40-90 %85-96.8

Benefits of the Operating Microscope
Loupes and microscopes offer different ranges of magnification. An

increase in magnification decreases the focal depth. Wearing loupes,
especially at magnifications higher than ×4, requires the practitioner
to stay in a narrow range from the object to stay in focus. In contrast,
even at high magnifications, a microscope remains stable and the
practitioner can work in an upright and ergonomically non-stressful
position. Moreover, microscope use reduces strain on eye muscles,
fatigue, and soreness compared to loupes. Through a microscope the
light reaching the left and right eyes appears to be essentially
parallel, achieving the effect of far distance observation and avoiding
short accommodation stress as with the naked eye. Binoculars of
loupes and thus the viewing direction are convergent, resulting in
similar eye strain. In addition, microscopes provide imaging virtually
free of shadows, allowing excellent image quality for clinical
operations and documentation.
Operasyon mikroskop
görüntüsü
• ‘’Büyütme ne kadar büyük olursa, o kadar iyi çalışılır’’ fikri YANLIŞTIR!
• Deneyimler periapikal cerrahide 30X’ten fazla büyütmenin çok işe
yaramadığını göstermektedir çünkü en küçük hareketlerde –hatta
hasta nefes aldığında bile- çalışma alanı görüş alanı dışına çıkar.
Cerrah tekrar mikroskobu çalışma alanına odakladığı için çok zaman
kaybetmektedir.
Anesthesia and Hemostasis
Adequate hemostasis is essential for microsurgery. In the past, achieving
effective hemostasis was a challenge. Many endodontic surgeons performed
surgery in a pool of blood, guessing at anatomic landmarks and structures. In
order for endodontic microsurgery to be successful, the surgeon needs to
examine the root surface at high magnification with the microscope.
It is practically impossible to do that without effective hemostasis. The
anesthetic solution of choice for endodontic surgery is Lidocaine 2% HCl with
1:50000 epinephrine. This high concentration of epinephrine is preferred for
surgery because it produces effective, lasting vasoconstriction via activation of
the α-adrenergic receptors in the smooth muscle of the arterioles. This
prevents the anesthetic from being washed out prematurely by the
microcirculation
Flap Outline
There are four major flap designs in endodontic microsurgery
1. Submarginal rectangular flap.
2. Submarginal triangular flap.
3. Sulcular rectangular flap.
4. Sulcular triangular flap.
Root End Resection
Endodontic literature over the last two decades supports several

reasons for resection of the apica lpart of the root during periapical
surgery:
• Removal of pathologic processes.

• Removal of anatomic variations (apical deltas, accessory canals, apical
ramifications, severe curves).
• Removal of iatrogenic mishaps (ledges, blockages, perforations, strip
perforations, separated instru-ments).
• Enhanced removal of the granulation tissue.
• Creation of an apical seal.
• Evaluation of the apical seal.
• Reduction of fenestrated root apices.

• Access to the canal system when the coronal Access is blocked or when coronal
access with non-surgical retreatment is determined to be impractical, time
consuming, and too invasive.
• Evaluation for complete or incomplete vertical root fractures.

Root End Resection: Steep Bevel versus Shallow Bevel
Microsurgery suggests a 0◦ bevel, perpendicular to the long axis of the tooth.

A 0 degree bevel fulfills the following requirements:
• Preservation of root length.
• Less chance of missing lingual anatomy and multi-ple accessory canals.
• Complete root end resection.
• Less exposed dentinal tubule
• Dentinal tubules are more perpendicularly oriented to the long axis of the tooth
and therefore a short bevel will expose fewer tubules.
• Easier to perform a root end preparation coaxially with the root. The root end
preparation should be kept within the long axis of the root to avoid risk of a
perforation. The longer the bevel, the more difficult it is to orient and perform a
preparation coaxially with the tooth
Isthmus
• The term “Isthmus” derives from the Greek Word “Iσθμoζ”, which
describes a narrow strip of land connecting two larger land masses.
Endodontically speaking, an isthmus is defined as a narrow, ribbon-
shaped communication between two root canals that contains pulp,
or pulpally derived tissue
Types of Isthmus
• Hsu and Kim (1997) described five different types of isthmus. Type I
was defined as either two or three canals with no noticeable
communication. Type II was defined as two canals that had a definite
connection between the two main canals. Type III differs from type II
in that there are three canals instead of two. Incomplete C-shapes
with three canals were also included in a type IV isthmus. Type V is
identified as a true connection or corridor throughout the section
Ultrasonic Root End Preparation
Root end filling
• The main purpose of placement of a root end fill-ing material is to
provide an adequate apical seal that inhibits the leakage of irritants
that might remain in the root canal after root resection and rootend
preparation, which may cause surgical failure. Besides sealing ability,
other essential properties for an ideal root end filling material are
• Well tolerated by periapical tissues
• Bactericidal or bacteriostatic
• Dimensionally stable
• Easy to manipulate
• Does not stain teeth or tissue
• Non-corrosive
• Resistant to dissolution
• Adheres to the tooth structure
• Dentino, osteo, and cementogenic
• Radiopaque
Advantages of MTA
• Sealing Ability
• Biocompatibility and Bioactivity
Other Types of Cements for RootEndFilling
• Intermediate Restorative Material (IRM)
• SuperEthoxybenzoic Acid (SuperEBA)
• Geristore and Retroplast
• Several modified types of MTA-like materials
• Amalgam
Healing after Apical Microsurgery
• Following apical microsurgery, there is healing in two components: (1)
osseous healing involving trabecular and cortical bone and (2)
dentoalveolar healing that results in repair or regeneration of apical
attachment apparatus (alveolar bone, periodontal ligament and
cementum. After apical surgery, the resected cavity is occupied by a
coagulum, which is slowly replaced by granulation tissue originating from
the periodontal ligament and endosteum. The formation of new bone
begins in the internal area and progresses externally toward thel evel of
the former cortical plate.As newly laid woven bone reaches the
laminapropria, the overlying membrane becomes functiona lperiodontium
(osseoushealing). Progenitor cells from the periodontal ligament
differentiate into periodontal ligament cells and cementoblasts to cover the
resected root surface and lead to regeneration of the cementum and the
periodontal ligament (dentoalveolar healing)
Factors for Healing
• Systemic status
• Bone loss,
• Previous root canal treatment or retreatment
• Coronal restoration
• Occlusion
• Material and technique
• Surgeon’s experience
• Healing after Ultrasonic technique %85-95
• Conventionel technique %65-68
• Endodontic surgery is now replaced by endodontic microsurgery
Thanks to,
ISOLATION IN ENDODONTICS

THE GOALS OF ISOLATION ARE:
• Moisture control
• Retraction
• Harm prevention
WHAT NEEDS TO BE CONTROLLED DURING ENDODONTIC
PROCEDURES?
• Saliva
• Tongue
• Mandible
• Lips & Cheek
• Gingival tissue
• Buccal & Lingual Vestibule
• Floor of the mouth
• Adjacent teeth and restoration
• Respiratory moisture
PATIENT RELATED ADVANTAGES
• Provides comfort to the patient

• Protect patients from swallowing or aspirating foreign bodies
• Protect patient’s soft tissues by retracting them
OPERATOR RELATED ADVANTAGES
• A dry clean field

• Infection control
• Increased accessibility
• Improved properties of materials
• Improved visibility & less fogging of mirror
• Prevents contamination of root canal preparation
CLASSIFICATION OF THE METHODS USED TO
OBTAIN ISOLATION
1. Moisture Isolation
• Direct methods
• Indirect methods
2. Soft Tissue Isolation
• Retraction of the lips, cheek and tongue
• Retraction of the gingiva
DIRECT METHODS OF MOISTURE ISOLATION
1. Rubber dam
2. Cotton rolls & gauze
3. Absorbent cellulose wafers
4. Suction devices
5. Gingival retraction cord
INDIRECT METHODS OF MOISTURE ISOLATION
1. Comfortable patient position & relaxed surroundings

2. Local anesthesia
3. Drugs
RUBBER DAM
• It is a flat thin sheet of latex/non-latex that is

held by a clamp and a frame, that is preferred
to allow the tooth/teeth to protrude through
the perforations, while all other teeth are
covered.
ADVANTAGES OF RUBBER DAM
ISOLATION
• Long term moisture control
• Maximum accessibility and visibility
• Provides dry and clean operating field
• Reducing the risk of cross-infection
• Protects dentists against infections which can be transmitted by
the patient‘s saliva
• Protects lips, cheek and tongue against possible trauma
from rotary and hand instruments
• Prevent accidental swallowing and aspirating of
endodontic instruments, medicaments, irrigating solutions
and debris
• Minimizes patients conversation during root canal
treatment and encourages them to open their mouth
• Eliminates need for repeated change of cotton rolls due
to flooding of saliva or root canal irrigants
• Improves the performance of materials used
DISADVANTAGES OF RUBBER DAM
ISOLATION
• Takes time to be applied
• Communication with the patient is difficult
• Possible damages to crowns and gingival tissues
• Insecure clamp maybe swallowed or aspirated
POSSIBLE CONTRAINDICATIONS FOR
RUBBER DAM ISOLATION
• Asthmatic patients
• Latex allergy
• Mouth breathers
• Malposed, tilted teeth
PRECAUTIONS
• The rubber dam should not obstruct patient’s
airway and thus should not cover his nose.
• Holes should be prepared in rubber dam for
patients with upper respiratory tract obstruction.
• On patients with allergy to latex, latex free rubber
dam should be used. Rubber dam napkin can be
used to prevent the latex rubber dam from
contacting the patient’s tissues.
COMPONENTS OF THE RUBBER DAM
ARMAMENTARIUM
1. Rubber dam sheet
2. Rubber dam clamps
3. Rubber dam forceps
4. Rubber dam frame
5. Rubber dam punch
6. Rubber dam template
7. Scissors
Accessories
1. Lubricant
2. Dental floss
3. Rubber dam napkin
RUBBER DAM SHEET
Material
• Latex
• Non-latex
Sizes
• 5’’x5’’
• 6’’x6’’
Thickness
• Light
• Medium
• Heavy
Different colors
RUBBER DAM CLAMPS
Functions
• Secures the dam to the teeth
• Retract to gingiva
Types
• Winged
• Wingless
ANTERIOR TEETH
PREMOLAR TEETH
MOLAR TEETH
RUBBER DAM FRAME
Functions
• Maintains the border of the dam in position
• Support the edges of the rubber dam
• Retract the soft tissues
RUBBER DAM FORCEPS
Function
• Used to place and remove clamp on the tooth
RUBBER DAM PUNCH
Function
• Make holes in the sheet through which the teeth can be isolated
Parts
• Rotating disc with different sized holes
• Sharp pointed plunger
ACCESSORIES
• Dental floss: It is used as flossing agent for rubber
dam in tight contact areas.
• Rubber dam napkin: This is a sheet of absorbent
material placed between the rubber dam and skin.
• Lubricant: A lubricant is applied in the area of
punch holes facilitates the passing of dam septa
through proximal contacts.
APPLICATION OF RUBBER DAM
• Winged technique
• Wingless technique
• Rubber first
WINGED TECHNIQUE
• The appropriate winged clamp is selected and
flossed.
WINGED TECHNIQUE
• The rubber dam is punched and aligned
with the quadrant to be treated.
WINGED TECHNIQUE
• The clamp is held in the forceps and retained with

the ratchet.
WINGED TECHNIQUE
• The hole in the rubber is stretched across the
wings of the clamp, positioning the bow of the
clamp towards the back of the arch.
WINGED TECHNIQUE
• The clamp is placed onto the tooth to be treated.

WINGED TECHNIQUE
• The frame and gauze are applied.
WINGLESS TECHNIQUE
flossed.
• The rubber dam is punched and aligned with the
quadrant to be treated.
• The clamp, held in the forceps and retained with
the ratchet, is placed securely on the tooth.
• One advantage of this method is that the
opportunity now exists to verify the fit of the clamp
before proceeding.
• The rubber dam is now held in both hands, and
the index fingers used to stretch out the punched
hole, which is slipped over the bow of the clamp
and pulled forward and down onto tooth.
• The frame and gauze are applied, the floss
removed and the seal verified or adjusted as
necessary.
RUBBER FIRST
• The dentist stretches out the rubber and places the hole over the tooth in
question, holding it down on each side with light finger pressure.
• At the same time the dental nurse picks up the flossed clamp in the
forceps and places it over the tooth, retaining the dam in place.
• Once again, the frame and gauze are applied.
3.Class
2019-2020
ROOT CANAL OBTURATION TECNIQUES

Assoc.Prof.Dr.Umut Aksoy
SUCCESS IN ENDODONTIC THERAPY

DEPENDS ON THE MAIN 3 FACTORS:
•ACCURATE DIAGNOSIS
•COMPLETE CHEMO-MECHANICAL
PREPARATION
•3 DIMENSIONAL OBTURATION OF
ROOT CANALS FROM THE CORONAL
PORTION OF THE CANAL TO THE
APICAL FORAMEN
After disinfection, the obturation stage:
Fill the root canal- hermetic (fluid tight) seal from

the coronal orifice of the canal to the apical foramen
at the CDJ
The responsibility does not end here
Coronal seal- an integral part of endodontic treatment

& important role in the treatment’s success

at the CDJ

& vital role in the treatment’s success
OBJECTIVES OF ROOT CANAL OBTURATION

1-To prevent leakage of bacterial organisms, bacterial elements and
nutritional elements from the oral environment to the root canal
(coronal leakage)
2-To inhibit growth of any surviving bacteria in dentinal tubules and
uninstrumented parts of the root canal space
3-To prevent release of bacterial elements in the other direction, i.e.
from the root canal to the apical environment (apical leakage)
4-To prevent leakage of nutritional elements from the periapical
tissue to the canal space.
5-To allow proper healing of the periapical tissues
3 MAIN FUNCTIONS OF ROOT CANAL FILLING
KÖK KANAL DOLGUSUNUN 3 ANA GÖREVİ:
1.KORONAL SIZINTIYI DURDURUR
2.CANLI KALABİLMİŞ BAKTERİLERİ
ELİMİNE EDER
3.PERİAPİKAL DOKU KAYNAKLI
SIVILARIN KÖK KANALINA
ULAŞMASINA ENGEL TEŞGİL EDER
Effective obturation of the

root canal space and coronal
restoration prevents apical
and coronal leakage and
eliminates the pulp cavity as
a reservoir of infection.
Obturation of the radicular space:

1.Eliminates leakage
2.Reduces coronal leakage & bacterial
contamination
3.Seals the apex from the periapical tissue
fluids
4.Entombs the remaining irritants in the
canal
Inadequate obturation of the root

canal invites failure and requirement
for surgical procedures
such as:
periapical surgery or extraction
Criterias for Root Canal Obturation

The root canal can be obturated when:
• There is an absence of pain and swelling.

• There is no tenderness to percussion and palpation.
• There is no patent sinus tract.
• The canal is dry.
• The canal is odour-free.
• Temporary filling material is intact.
• Negative culture is obtained (not required in clinic).
Ideal Properties of Root Canal Obturation Materials
★ It should be easily introduced into the root canal system
★ It should seal the canal laterally as well as apically.
★ It should not shrink after being inserted.
★ It should be impervious to moisture.
★ It should be bacteriostatic or at least not encourage bacterial
growth.
★ It should be radiopaque
★ It should not stain tooth structure.
★ It should not irritate periapical tissue. (Biocompatibility)
★ It should exhibit a slow set.
★ It should be easily removed from the root canal if necessary.
_________________________________________
__________________________________
•SILVER CONE 
•GUTTA-PERCHA  
•RESILON  
•COATED CONES  
__________________________________
Today, the most recommended

material for filling the root
canals is gutta percha with a
root canal sealer.
Gutta-percha
• The concrete juice of Isonandra gutta, Palaquium
gutta and Dichopsis gutta are the main trees from
where, we obtain Gutta-percha material.
• Gutta-percha has been used in Endodontics for over

100 years and is currently the most frequently used
core material for permanent obturation of root canals.
Composition and mechanical properties of
gutta-percha endodontic points
Material % Function
Gutta percha 18-22 Matrix

Zinc oxide 59-76 Filler
Wax/Resin 1-4 Plasticizer
Metal sulfates 1-18 Radiopacifier
Major advantages of gutta-percha
• 1- Compactible
• 2- Minimal toxicity
• 3- Dimensional stability
• 4- Radioopacity
• 5- Inert (not resorbable)
• 6- Plasticity
• 7- Ease of removal with heat or solvents

Disadvantages of gutta-percha
• 1- Lack of rigidity
• 2- Lack of adhesion to dentin
ROOT CANAL OBTURATION TECNIQUES WITH GUTTA PERCHA:
I.SOLID CORE TECHNIQUES
1) SINGLE CONE TECHNIQUE
2) COLD LATERAL COMPACTION
II.SOFTENED CORE TECHNIQUES

1) WARM LATERAL COMPACTION
2) WARM VERTİCAL COMPACTİON
3) THERMOMECHANICAL COMPACTİON
4) INJECTION-MOLDED GUTTA PERCHA
5) CORE CARRIER TECHNIQUE
6) CHLOROPERCHA TECNIQUE
COLD LATERAL COMPACTION TECHNIQUE:
KANAL DOLDURMA SİSTEMLERİ
The objective is to fill the canal

with gutta-percha cones by
compacting them laterally against
the sides of the canal walls.
Master cone selection
• After root canal system preparation, a

standard cone should be selected that
has a diameter consistent with the
prepared canal diameter at the working
length. This is “master cone”.
• For exp. If we used file no: 40 at the
working length
Master cone should be no: 40
Master Cone
How to fit that master gutta-percha cone?
• Clinical examination
• Radiographic examination
1- Clinical Examination
• This “master cone” is measured and grasped
with cotton plier so that the distance from
the tip of the cone to the reference point on
the plier is equal to the prepared length. A
reference point on the cone can be made by
pinching the cone.
• The cone is placed in the canal, and if an
appropriate size is selected, there will be
resistance to displacement: “tug-back”.
Clinical Examination
• If there is no tug-back and the cone is loose it
can be adapted by removing small increments
from the tip until a good fit is obtained.
• If the master cone fails to go to the prepared
length, a smaller cone can be selected. Or
make the preparation again.
• When the cone extends beyond the prepared
length a larger cone must be adapted or the
existing cone shortened until there is
resistance to displacement at the corrected
working length.
Ideal Master Cone Features
• 1- Should be fitted at working length
• 2- Master cone should be fitted laterally at the apical

portion of tooth and there must a well tug-back feeling
• 3- Master cone should be at the point of

cementodentinal junction and 0,5 - 1 mm short from
the radiographic apex.
• 4- Never extend beyond the apical foramen

2- Radiographic Examination
• After adaptation and clinical examination of

master cone, a radiograph should be taken to
make sure that the master cone is at the
working length. It must be 0.5 - 1 mm short of
SOĞUK LATERAL KOMPAKSİYON YÖNTEMİ:
•that's all for now
• to be continued…
• love endo…
Tooth Resorptions
Resorption is defined as:

A condition associated with either a physiologic or a pathologic process resulting in the loss of dentin,
cementum or bone.
• Physiologic tooth resorption is seen in deciduous teeth during eruption of permanent teeth
• Pathologic tooth resorption is seen in both deciduous as well as permanent teeth due to underlying
pathology.
CELLS INVOLED IN TOOTH RESORPTION
1. MONOCYTES
2. MACROPHAGES
3. OSTEOCLASTS
4. ODONTOCLASTS
5. CYTOKINES
6. ENZYMES
7. HORMONES
Root Resorption
Andreasens’ classification (1970)
 Internal resorption
- Internal replacement resorption
- Internal inflammatory resorption
 External resorption
- Surface resorption
- Inflammatory resorption
- Replacement resorption
-Internal Resorption
An inflammatory process initiated within the pulp space with loss of dentin and possible
invasion of the cementum
It is characterized by oval shaped enlargement of root canal space
Internal Resorption = Internal Granuloma
When the pulp chamber is affected, it may appear as «pink spot» as the enlarged pulp is
visible through the thin wall of the crown.
Etiology: Internal resorption may also be caused while doing restorative procedure like preparation of
tooth for crown, deep restorative procedures, application of heat over the pulp or pulpotomy
using calcium hydroxide, i.e. iatrogenic in origin.
Etiology of internal resorption:
 Long standing chronic inflammation of the pulp

 Caries related pulpitis
 Traumatic injuries
a. Luxation injuries
 Iatrogenic injuries
a. Preparation of tooth for crown
b. Deep restorative procedures
c. Application of heat over the pulp
d. Pulpotomy using Ca(OH)2
 idiopathic
Histopathology
Longstanding injury leads to chronic pulp inflammation and circulatory changes within the pulp. Active
hyperemia with high oxygen pressure supports and induces the osteoclastic activity. Thereby the
resorption process starts
Pulp tissue shows chronic inflammation reaction and resorption lacunae irregularly occupied by
‘dentino-clasts’ similar to osteoclasts. The granulation tissue present in this type of resorption is highly
proliferating in nature. Scanning Electron Microscope studies have shown rough and uneven dentin
surface with numerous resorption lacunae.
Clinical features of internal resorption
 The pulp usually remains vital and asymptomatic until root has been perforated and become
necrotic.
 Patient may present pain when the lesion perforates and tissue is exposed to oral fluids.
 It is commonly seen in maxillary central incisors, but any tooth of the each can be affected
 It can occur in permanent as well as deciduous teeth. In primary teeth it spreads more rapidly.
 In internal resorption cases, thermal and electrical pulp tests have low vitality value in teeth.
 Internal resorption may develop in as short a period as a few months, sometimes it can take
years to develop.
 When the pulp chamber is affected, it may appear as “pink spot” as the enlarged pulp is visible
through the thin wall of the crown.
Radiographic features of internal resorption
 The expansion in the root canal or pulp chamber and its boundaries appear as a regular circular,
radiolucent area.
 There is enlargement of root canal which is well demarcated, enlarged «ballonning area» of
resorption
 Outline of canal is distorted
 Root canal and resorptive defect appears contiguous
 Does not involve bone, so radiolucency is confined to root. Bone resorption is seen only is lesion
perforates the root.
Treatment Options in Teeth with Internal Resorption
 Without perforation—Endodontic therapy

 With perforation
1. Non-surgical:
a. Ca(OH)2 therapy—Obturation
b. MTA therapy—Obturation
2. Surgical:
a) Surgical flap
b) Root resection
c) Intentional replantation
1. without perforation—Endodontic therapy

Root canal treatment
 Removal of all inflamed tissue from the resorption defect is the basis of successful treatment.
 Irrigation with 5.25% NaOCl will dissolve attached pulpal remnants as it is a strong antimicrobial
agent and excellent solvent for necrotic tissue.
 When the tissue remnants persist, an internal calcium hydroxide dressing may be placed after
initial intracanal cleaning and at the next visit, obturation can be done after flushing the calcium
hydroxide and tissue debris from the canal.
 Because of the size, irregularity and in accessibility of the resorption defects, obturation of the
canal may be technically difficult.
 The canal apical to the defect is filled with solid gutta-percha while the resorptive area is usually
filled with material that will flow in the irregularities. The warm gutta-percha technique,
thermoplasticized gutta-percha technique and use of chemically plasticized gutta-percha are
methods of obturation to be used.
Management of Perforating
 When the internal root resorption has progressed through the tooth into the periodontium,
there are additional problem of periodontal bleeding, pain and difficulty in obturation.
 Presence of a perforation cannot be determined radiographically unless a lateral radiolucent
lesion is present adjacent to the lesion.
 Clinically in some cases a sinus tract may be present and there will be continued hemorrhage in
the canal after the pulp is removed.
1) Non-surgical Repair: Ca(OH)2 therapy — Obturation
Indications: Non-surgical repair is indicated in following cases:
1. When the defect is not extensive.

2. When defect is apical to epithelial attachment.
3. When hemorrhage can be controlled.
 In this technique, after thorough cleaning and shaping of the canal, the intracanal calcium
hydroxide dressing is placed and over it a temporary filling is placed to prevent
interappointment leakage.
 Patient is recalled after three months for replacement of calcium hydroxide dressing and for
radiographic confirmation of the barrier formation at the perforation site. Afterwards two
months recall visits are scheduled until there is a radiographic barrier at resorption defect. After
the barrier is formed, the canal is obturated with gutta-percha as in the non-perforating
2) Surgical: Ca(OH)2 therapy — Obturation
If the calcium hydroxide treatment is unsuccessful or not feasible, surgical repair of the defect should be
considered.
1. Surgical flap
- Here the defect is exposed to allow good access. The resorptive defect is curetted, cleaned and
restored. The restoration of the defect can be done using an alloy, composite, glass ionomer
cement, super EBA or more recently MTA. Finally the obturation is done using gutta-percha.
2. Root resections:
-If the resorbed area is located in the radicular third, root may be resected coronal to the defect
and apical segment is removed afterwards. Following root resection, retrofilling is done. If one
root of a multirooted tooth is affected, root resection may be considered based on anatomical,
periodontal and restorative parameters.
3. Intentional replantation
If the perforating resorption with minimal root damage occurs in an inaccessible area,
intentional replantation may be considered.
EXTERNAL ROOT RESORPTION
- Surface Resorption
- External Inflammatory Root Resorption
- Replacement Resorption
- Surface Resorption
 It is associated with trauma to teeth in which the injury damages cementum and cementoblasts.
 It is transient and least destructive type of resorption.
 The tooth has a vital, healthy pulp that has recovered from traumatic event. In such cases,
the resorbed area will be restored completely to normal surface contour by deposition of new
cementum.
 Treatment: No need to treatment
- External Inflammatory Root Resorption
 It is the most common and the most destructive type of resorption

 Starts from the periodontium
 Can be seen on apical, lateral or cervical root surfaces.
1. Pressure
-In pressure-induced externa inflammatory resorption, the pulp is generally unaffected,
and the resorption stops when the causative agent is removed.
a) Orthodontic forces
-Orthodontic tooth movement using excessive forces
-Such resorptions are usually localized to the apical region and are diagnosed
by shortening the root in the radiograph.
b) impacted tooth, tumor, cyst
-Pressure resorption occurring from pressure exerted by tumors, cysts and
impacted teeth
2. Root Canal Infections
- Root canal infections are the major cause of external resorption.
- Can be seen in the apical or the lateral region of root
- The most classic example is apical periodontitis, which causes apical external
resorption due to pulp necrosis.
- Apical external inflammatory resorptions are asymptomatic and may include minor
changes that cannot be seen on radiographs, as well as conditions in which a significant
part of the root is being destroyed.
-it can also be seen in the lateral region of the root, the most important reason is
traumatic injuries
-Trauma leads to pulpal necrosis which may further cause periodontal inflammation
due to the passage of the toxins and microorganisms from the infected pulp, lateral
canals, apical foramen, accessory canals, dentinal tubules where there is a
discontinuity of cementum
-Treatment for inflammatory resorption is based on removal of the source of infection
- If the sustaining infection is pulpal, root canal treatment has been shown to be a very
successful, means of treating inflammatory resorption.
3. Sulcular Inflammations
 Invasive Cervical Root Resorption
Causes:
a) Orthodontic treatment
b) Trauma
c) Beaching
d) Periodontal treatment
e) Bruxism
f) Idiopathic
 Clinical Features:
a) Initially asymptomatic
b) Pulp is vital in most cases
c) Normal to sensitivity tests
 Resorption of coronal dentine and enamel often creates a clinically obvious
pinkish colour in the tooth crown as highly vascular resorptive tissue becomes
visible through thin residual enamel.
 In other instances there may be no obvious outward sign of this process and its
detection may be by routine radiographs.
 The condition is usually painless unless there is superimposed secondary
infection when pulpal or periodontal symptoms may arise.
 Invasive cervical resorption has been and continues to be, misdiagnosed as a
form of internal resorption.
 Invasive Cervical Root Resorption
Treatment
 The main aim of the treatment is to restore the lost tooth structure and to
disrupt the resorptive process.
 A traditional approach is to treat the tooth endodontically first, followed by
repair of the resorbed area either from an internal approach or an external
one.
 Another treatment approach has been recommended without removing
the pulp. →Surgically exploring the resorbed lacuna → Trichloracetic
acid → curetting the soft tissue→ restoration
Replacement Resorption (Dentoalveolar Ankylosis)

-This is a serious condition for the teeth involved because the teeth become part of the alveolar bone
remodeling process and they are therefore, progressively resorbed.
-The injury results in damage to periodontal ligament cells and cementum, causing discontinuity in the
cementum.
-It occurs most frequently as a result of complications following avulsions in which the periodontal
ligament dries and loses its vitality.
-Clinical Features: A tooth with dentoalveolar ankyloses shows:
 Lack of mobility
 Dull metallic sound on percussion (may be evident even before the appearance of the
radiograph)
 Infraocclusion because of lack of the normal growth of the alveolar process
 Treatment: Currently there is no treatment offered for replacement resorption.
Differential features of internal and external resorption
Internal resorption External resorption

Radiographic features 1- There is ragged area, "scooped out" area on
1- There is enlargement of root canal which is the side of the root.
well demarcated, enlarged "Ballooning area" of 2- Lesion moves may from the canal as
resorption angulation changes
2- Lesion close to appears canal even if 3- Outline of root canal is normal.
angulations of radiograph changes 4- Root canal can be seen running through the
3- Outline of canal is distorted defect.
4- Root canal and resorptive defect appears 5- It is almost always accompanied by resorption
contiguous of bone, so radiolucency appears in both root and
5- Does not involve bone, so radiolucency is adjacent bone
confined to root. Bone resorption is seen only if 6. Involves commonly infected pulp space, so
lesion perforates the root. gives negative response to pulp tests 7. Pulp is
Pulp testing non vital, granulation tissue which produces pink
6- Commonly occurs in teeth with vital pulp so spot Is not present.
gives positive response to pulp tests. but negative
response is seen when pulp gets involved.
Pink spot (pink tooth of mummery)
7- Pathognomic feature.
It represents the hyperplastic vascular pulp
tissue fitting the resorbed area showing off
through the tooth structure.
TRAUMATIC DENTAL INJURIES AND ENDODONTIC
The Role of Endodontics after Dental Traumatic Injuries
• Most dental trauma occurs in the 7- to 12- year-old age group
• It occurs primarily in the anterior region of the mouth, affecting the maxillary more than the
mandibular jaw.
• Maxillary central incisor > Maxillary lateral incisor > Mandibular incisors.
• The knowledge and skill of the dentist is of great importance in the face of such an
urgent need for treatment and the fact that initial treatment is extremely important
on the prognosis.
Classification (Andreasen, WHO, International Association of Dental Traumatology)

1. Soft Tissue Injury
a) Laceration: Tearing of the skin that results in an irregular wound. Lacerations may be
caused by injury with a sharp object or by impact injury from a blunt object or force.
b) Contusion: A type of hematoma of tissue in which capillaries and sometimes venules are
damaged by trauma, allowing blood to seep, hemorrhage, or extravasate into the
surrounding interstitial tissues.
c) Abrasion: Superficial wounds in which the topmost layer of the skin (the epidermis) is
scraped off
2. Tooth Fractures
• Enamel fractures
• Crown-fractures-uncomplicated (no pulp exposure)
• Crown-fractures-complicated (with pulp exposure)
• Crown-root fractures
• Root fractures
3. Luxation Injuries (Periodontal tissue injuries)
• Tooth concussion
• Subluxation
• Extrusive luxation (Extrusion)
• Lateral luxation
• Intrusive luxation (Intrusion)
• Avulsion
4. Facial Skeletal Injuries
• Fracture of alveolar process of mandible
• Fracture of alveolar process of maxilla
• Fracture of body of mandible
• Fracture of body of maxilla
EXAMINATION AND DIAGNOSIS

CHIEF COMPLAINT
Patient should be asked for pain and other symptoms. These should be listed in order of importance to
the patient
HISTORY OF PRESENT ILLNESS
When, how, where of the trauma are significant.
Another important question to ask is whether treatment of any kind has been given elsewhere for injury
before coming to dental office.
MEDICAL HISTORY
Patient should be asked for:
• Allergic reaction to medication

• Disorders like bleeding problems, diabetes, epilepsy, etc.
• Any current medication patient is taking
• Condition of Tetanus immunization
CLINICAL EXAMINATION
• Extraoral examination
• Any facial bone fracture?
• Soft tissues such as lips, tongue, cheek, floor of mouth ought to be examined.
• Lacerations of lips and intraoral soft tissues must be carefully evaluated for presence of any
tooth fragments and/or other foreign bodies.
• Occlusion and temporomandibular joints should also be examined carefully. Abnormalities
in occlusion can indicate fracture of jaws or alveolar process.
• Teeth must be checked after proper cleaning of the area.
• Explore the extent of tooth fracture involvement, i.e. enamel, dentin, cementum and/or
pulp.
• Change in color? (Old case?)
• Root fracture can be felt by placing finger on mucosa over the tooth and moving the crown.
• Reaction to percussion is indicative of the damage to the periodontal ligament.
• Check mobility in all the directions. (If adjacent teeth move along with the tooth being
tested, suspect the alveolar fracture)
• Vitality tests should be performed at the time of initial examination.
-Electric pulp testing? (9 months later)
-Thermal testing (Dry ice)
RADIOGRAPHIC EXAMINATION
One occlusal + 3 periapical
• Fractures of teeth
• Tooth displacements
• Apical root development
• Closeness of fracture to pulp
• Presence of any foreign objects
• Root canal anatomy
• Clinical photographs are essential!
• Record all the findings such as fractures, color changes, pulp injuries or any other associated
injuries and treatment planning is made following the final diagnosis.
Tooth Fractures
Enamel Fracture
CLINICAL FINDINGS
• A complete fracture of the enamel. Loss of enamel. No visible sign of exposed dentin
• Not tender. If tenderness is observed, evaluate the
• Tooth for a possible luxation or root fracture injury.
• Normal mobility.
• Sensibility pulp test usually positive.
RADIOGRAPHIC FINDINGS
• Enamel loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposures. They are
recommended in order to rule out the possible presence of a root fracture or a luxation injury.
• Radiograph of lip or cheek to search for tooth fragments or foreign materials.
TREATMENT
• If the tooth fragment is available, it can be bonded to the tooth
• Contouring or restoration with composite resin depending on the extent and location of the
fracture.
• FOLLOW-UP
• 6-8 weeks – Clinical and radiographic examination.
• 1 year – Clinical and radiographic examination.
Uncomplicated Crown Fracture (Enamel-Dentin)

CLINICAL FINDINGS
• A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or
root fracture injury.
• Sensibility pulp test usually positive.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth
displacement or possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.
TREATMENT
• If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform a provisional
treatment by covering the exposed dentin with glass Ionomer or a more permanent restoration
using a bonding agent and composite resin or other accepted dental restorative materials.
• If the exposed dentin is within 0.5 mm of the pulp (pink, no bleeding), place calcium hydroxide
base and cover with a material such as a glass ionomer.
FOLLOW-UP
Complicated Crown Fracture (Enamel-Dentin-Pulp)

CLINICAL FINDINGS
• A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or
root fracture injury.
• Exposed pulp sensitive to stimuli.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth
displacement or possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.
TREATMENT
• In young patients with immature, still developing teeth, it is advantageous to preserve pulp
vitality by pulp capping or partial pulpotomy. Also, this treatment is the choice in young patients
with completely formed teeth.
• Calcium hydroxide is a suitable material to be placed on the pulp wound in such procedures.
• In patients with mature apical development, root canal treatment is usually the treatment of
choice, although pulp capping or partial pulpotomy also may be selected.
• If tooth fragment is available, it can be bonded to the tooth.
• Future treatment for the fractured crown may be restoration with other accepted dental
restorative
FOLLOW-UP
CROWN-ROOT FRACTURES
CLINICAL FINDINGS
• Crown root fracture involves enamel, dentin and cementum with or without the involvement of
pulp
• It is usually oblique in nature involving both crown and root.
• Crown fracture extending below gingival margin
• Percussion test: Tender.
• Coronal fragment mobile.
• Vitality test usually positive
• Apical extension of fracture usually not visible.
• Radiographs recommended: periapical and occlusal exposure.
TREATMENT
• Fragment removal only.
• Fragment removal and gingivectomy (sometimes ostectomy) Removal of the coronal fragment
with subsequent endodontic treatment and restoration with a post-retained crown.
• Orthodontic extrusion of apical fragment
• Surgical extrusion
• Extraction
FOLLOW-UP
• 1 year – Clinical and radiographic examination
Root Fractures
• These are uncommon injuries
• Involvement of dentin, cementum, pulp and periodontal ligament
• They form the 3 percent of the total dental injuries.
CLINICAL FINDINGS
• The coronal segment may be mobile and may be displaced.
• Tender to percussion.
• Bleeding from the gingival sulcus may be noted.
• Vitality testing may give negative results initially, indicating transient or permanent neural
damage
• The fracture involves the root of the tooth and is in a horizontal or oblique plane.
• Fractures that are in the horizontal plane can usually be detected in the regular periapical 90o
angle film with the central beam through the tooth. This is usually the case with fractures in the
cervical third of the root.
• CBCT  Useful
TREATMENT
• Reposition, if displaced, the coronal segment of the tooth as soon as possible.
• Check position radiographically.
• Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area
of the tooth, stabilization is beneficial for a longer period of time (up to 4 months).
• It is advisable to monitor healing for at least 1 year to determine pulpal status.
• If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line
is indicated to preserve the tooth.
FOLLOW-UP
• 4 weeks – Splint removal, clinical and radiographic examination.
• 4 months – Splint removal in cervical third fractures, clinical and radiographic examination.
• 6 months – Clinical and radiographic examination.
• 5 years – Clinical and radiographic examination.
PROGNOSIS
• Healing with calcified tissue in which fractured fragments are in close contact.
• Healing with interproximal connective tissue in which radiographically fragments appear
separated by a radiolucent line.
• Healing with interproximal bone and connective tissues.
• Interproximal inflammatory tissue without healing,
• radiographically it shows widening of fracture line
Classification (Andreasen, WHO, International Association of Dental Traumatology)

Luxation Injuries (Periodontal Tissue Injuries)
• Tooth concussion
• Subluxation
• Extrusive luxation (Extrusion)
• Lateral luxation
• Intrusive luxation (Intrusion)
• Avulsion
Concussion
CLINICAL FINDINGS
• The tooth is tender to touch or tapping; it has not been displaced and does not have increased
mobility.
• Tooth is not displaced.
• Mobility is not present
• Tooth is tender to percussion because of edema and hemorrhage in the periodontal ligament.
• No radiographic abnormalities.
TREATMENT
• No treatment is needed.
• Monitor pulpal condition for at least one year.
FOLLOW-UP
• 4 weeks – Clinical and radiographic examination.
Subluxation
CLINICAL FINDINGS
• The tooth is tender to touch or tapping and has increased mobility; it has not been displaced.
• Bleeding from gingival crevice may be noted.
• Sensibility testing may be negative initially indicating transient pulpal damage.
• Monitor pulpal response until a definitive pulpal diagnosis can be made.
• No radiographic abnormalities.
TREATMENT
• Normally no treatment is needed, however, a flexible splint to stabilize the tooth for patient
comfort can be used for up to 2 weeks.
FOLLOW-UP
Extrusion
CLINICAL FINDINGS
• The tooth appears elongated and is excessively mobile.
• Sensibility tests will likely give negative results.
• Increased periodontal ligament space apically.
TREATMENT
• Reposition the tooth by gently reinserting it into the tooth socket.
• Stabilize the tooth for 2 weeks using a flexible splint.
• In mature teeth where pulp necrosis is anticipated, or if several signs and symptoms indicate
that the pulp of mature or immature teeth is becoming necrotic, root canal treatment is
indicated.
FOLLOW-UP
• 1 year – Clinical and radiographic examination yearly.
• 5 years – Clinical and radiographic examination
Lateral luxation
CLINICAL FINDINGS
• The tooth is displaced, usually in a palatal/lingual or labial direction.
• It will be immobile and percussion usually gives a high, metallic (ankylotic) sound.
• Fracture of the alveolar process present.
• The widened periodontal ligament space is best seen on eccentric or occlusal exposures.
TREATMENT
• Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently
reposition it into its original location.
• Monitor the pulpal condition.
• If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.
FOLLOW-UP
• Yearly for 5 years – Clinical and radiographic examination.
Intrusion
CLINICAL FINDINGS
• The tooth is displaced axially into the alveolar bone.
• It is immobile and percussion may give a high, metallic (ankylotic) sound.
• The periodontal ligament space may be absent from all or part of the root.
• The cemento-enamel junction is located more apically in the intruded tooth than in adjacent
non-injured teeth, at times even apical to the marginal bone level.
TREATMENT
Teeth with incomplete root formation:
• Allow eruption without intervention.

• If no movement within few weeks, initiate orthodontic repositioning.
• If the tooth is intruded more than 7 mm, reposition surgically or orthodontically.
Teeth with complete root formation:
• Allow eruption without intervention if the tooth is intruded less than 3 mm. If no movement
after 2-4 weeks, reposition surgically or orthodontically before ankyloses can develop.
• If the tooth is intruded 3-7 mm, reposition surgically or orthodontically.
Teeth with complete root formation:
• If the tooth is intruded beyond 7 mm, reposition surgically.

• The pulp will likely become necrotic in teeth with complete root formation. Root canal therapy
using a temporary filling with calcium hydroxide is recommended and treatment should begin 2-
3 weeks after repositioning.
• Once an intruded tooth has been repositioned surgically or orthodontically, stabilize with a
flexible splint for 4 weeks.
FOLLOW-UP
Avulsion
• It is defined as complete displacement of the tooth out of socket.
First aid for avulsed teeth

• Keep the patient calm.
• Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
• If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try
to encourage the patient/parent to replant the tooth. Bite on a handkerchief to hold it in
position.
• If this is not possible, place the tooth in a suitable storage medium, e.g. A glass of milk or a
special storage media for avulsed teeth if available (e.g. Hanks balanced storage medium
or saline). The tooth can also be transported in the mouth, keeping it between the molars and
the inside of the cheek. If the patient is very young, he/she could swallow the tooth- therefore it
is advisable to get the patient to spit in a container and place the tooth in it.
• Seek emergency dental treatment immediately.
Closed Apex:
(IF TOOTH REPLANTED PRIOR TO THE PATIENT’S ARRIVAL AT THE DENTAL OFFICE OR CLINIC)
TREATMENT
• Leave the tooth in place.
• Clean the area with water spray, saline, or chlorhexidine.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both clinically and radiographically.
• Apply a flexible splint for up to 2 weeks.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per
day for 7 days at appropriate dose for patient age and weight). The risk of discoloration
of permanent teeth must be considered before systemic administration of tetracycline
in young patients (In many countries tetracycline is not recommended for patients under 12
years of age). In young patients Phenoxymethyl Penicillin (Pen V) or amoxicillin, at an
appropriate dose for age and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to
physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.
PATIENT INSTRUCTIONS
• Avoid participation in contact sports.
• Soft food for up to 2 weeks.
• Brush teeth with a soft toothbrush after each meal.
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.
• Follow-up
• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal
medicament for up to 1 month followed by root canal filling with an acceptable material.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly
thereafter.
CLOSE APEX (IF EXTRAORAL DRY TIME LESS THAN 60 MIN. THE TOOTH HAS BEEN KEPT IN PHYSIOLOGIC
STORAGE MEDIA OR OSMOLALITY BALANCED MEDIA (MILK, SALINE, SALIVA OR HANK’S BALANCED SALT
SOLUTION) AND/OR STORED DRY LESS THAN 60 MINUTES)
TREATMENT
• Clean the root surface and apical foramen with a stream of saline and soak the tooth in
saline thereby removing contamination and dead cells from the root surface.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a
suitable instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Verify normal position of the replanted tooth both, clinically and radiographically.
• Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days
at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth
must be considered before systemic administration of tetracycline in young patients (In
many countries tetracycline is not recommended for patients under 12 years of age). In young
patients Phenoxymethyl Penicillin (Pen V) or amoxicillin, at appropriate dose for age and weight,
is an alternative to tetracycline
• Initiate root canal treatment 7-10 days after replantation and before splint removal.
FOLLOW-UP
thereafter.
CLOSED APEX: EXTRAORAL DRY TIME EXCEEDING 60 MIN OR OTHER REASONS SUGGESTING
NON-VIABLE CELLS
TREATMENT
• Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic
and cannot be expected to heal. The goal in delayed replantation is, in addition to restoring the
tooth for esthetic, functional and psychological reasons, to maintain alveolar bone contour.
However, the expected eventual outcome is ankyloses and resorption of the root and the tooth
will be lost eventually.
• Remove attached non-viable soft tissue carefully, with gauze.
• Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
• Administer local anesthesia
• Examine the alveolar socket. If there is a fracture of the socket wall,
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint. Reposition it with a suitable instrument.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days
at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth
must be considered before systemic administration of tetracycline in young patients (In many
countries tetracycline is not recommended for patients under 12 years of age). In young patients
Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an
alternative to tetracycline.
• To slow down osseous replacement of the tooth, treatment of the root surface with fluoride
prior to replantation has been suggested (2 % sodium fluoride solution for 20 min.)
FOLLOW-UP
Alternatively an antibiotic- corticosteroid paste may be placed immediately or shortly following
replantation and left for at least 2 weeks.
thereafter
AVULSION:
Factors affecting the success of reimplantation:
1. Periodontal ligament
2. Extraoral time
3. Transportation
4. Splinting
5. Root Canal Treatment Timing
6. Calcium Hydroxide Therapy
7. Fluoride Application
PROGNOSIS:
1. Periodontal ligament healing
2. Surface resorption
3. Replacement resorption (ankylosis)
4. Inflammatory resorption
Storage media for avulsed tooth (from the best to the worst)
1. In its own socket
2. Hank’s Balance Salt Solution
3. Milk
4. Saline
5. Intraorally
6. Saliva
7. Tap Water
8. Dry
Factors affecting the
evaluation of success and success and failure in all cases: success and failure in some Very less factors affecting
failure in endo treatment cases: success and failure
1- observer has a different 1- radiographic evaluation 1- the condition of the pulp 1- age and gender of the patient
success criteria 2- root canal system anatomy 2- operative complications 2- etiology of pulp damage and
2- different evaluation of and presence of extra canal (perforation, instrument necrosis
radiography 3- degree of adequate chemo- breakage) 3- tooth localization
3- patient’s complaints of mechanical cleaning and apical 3- crown-root fracture
various levels instrumentation of the root 4- periodontal status
4- patient response in subjective canal system 5- occlusal incompatibility
5- difference in tissue response 4- the degree of apical blockage 6- type of periapical lesion
6- validity of evaluation method in the cement-dentin zone 7- patients pain threshold
7- differences in control 5- the degree coronal closure 8- the status of canal obturation
variables and the type of restoration (flood or incomplete)
8- variability of observation 6- asepsis in treatment 9- canal classification degree
periods 7- health and systemic condition 10- presence of root resorption
of the patient 11- presence of accessory canals
8- clinician’s ability 12- evaluation period after
treatment
Clinical evaluation
Subjective and objective criteria Clinically success criteria: Clinical suspicious cases: Clinically failure criterias:
have been used in post treatment
clinical evaluation:
1- palpation sensitivity 1- absence of percussion and 1- often recurrent unclear 1-having stubborn
2- tooth mobility palpation symptoms subjective symptoms
3- periodontal disease 2- normal mobility 2- the feeling of fullness 2- recurrent fistulas or
4- fistula 3- no fistula 3- mild discomfort in swelling
5- percussion sensitivity 4- no periodontal disease percussion, palpation and 3- severe discomfort in
6- tooth function 5- the tooth is function chewing percussion and palpation
7- infection and swelling 6- no infection and no swelling 4- sensitivity with tongue 4- the presence of
8- subjective symptoms 7- absence of subjective symptoms pressure irreparable root and
5- sinusitis superposing on the chronical fractures
treated teeth 5- excessive tooth
6- minimal disturbances mobility and advanced
requiting analgesic periodontal destruction
6- relevant tooth function
Radiographic evaluation:
Radiographic success criteria: Radiographically suspicious cases: Radiographically failure criteria:

1-slightly thickened PDL space (<1mm) 1-expansion of the periodontal space (>1- 1-excessive expansion of the
2- elimination of previous radiolucent 2mm) periodontal ligament space (>2mm)
3- the neighboring teeth and the lamina are the 2-whether the radiolucent is the same size or 2- periradicular radiolucency dose not
same very little repair result in expected bone repair or
4- no resorption 3- irregular shape of lamina relative to increase in radiolucency size
5- a well canal obturation was performed to the adjacent teeth 3- lack of new lamina dura formation
cement-dentin junction 4- signs of mild expansion of resorption 4- presence of lateral and apical
5- empty areas of obturation especially in the radiolucency not previously found in
apical zone periradicular area
6- overfilling
Endodontic failure reasons: Failure factors:

1- Faults in diagnosis and treatment plane 1- Preoperative factors
2- Lack of information in pulp anatomy 2- Operative factors
3- Inadequate chemomechanical preparation 1- due to mechanical causes
4- Operative errors 2- due to biologic causes
5- Errors in filling 3- Postoperative factors
6- Errors in restorative procedures
7- Coronal leak
8- Vertical root fracture
Cause of failure: 1- the presence of necrotic material in the root canal due to the inability to identify all canals or to work
short in canals
2- contamination of root canals during treatment which are sterile at the begging of root canal
treatment
3- the persistent infection in the root canal after treatment
4- lack of elimination of bacteria in accessory or lateral canals
5- re-infection of the disinfected and filled root canal system due to the loss of coronal filling
Signals and symptoms of failure: 1- presence of a fistula in the drainage
2- pulpal pain or sensitivity during bite
3- the appearance of periapical radiolucent areas on the diagnostic radiographs or the case that the
periapical lesion grows after the RCT done
4- in some cases, only restorative treatment may be planned for the teeth with asymptomatic lesions,
although the RC filling is short
Treatment of failures: 1- retreatment

2- periapical surgery
3- extraction
Factors affecting success of retreatment:
1- the story of the patient a- previous radiograph

b- symptoms of past\
c- elapsed time after treatment)
2- the story of the 1st treatment a- 1st treatment significantly affects case selection
b- surgery may be preferred if retreatment is previously done and the outcome is still
unsuccessful or if vertical fracture is suspected)
3- previous treatment standard
4- clinical condition a- symptoms
b- restorable
c- periodontal support
5- anatomy of the tooth a- untreatable canals
b- canal structure
6- filling a- apical length
b- type of material
7- iatrogenic factors a- canal blockage
b- perforations
c- overfillings
8- patient opinion a- time inadequacy
b- material resources
c- progniosis
9- physician ability a- time capability
b- equipment to be used
c- mastery
Access preparation:
1- removal of crown 2- removal of post 3- removal of cement and pat 4- silver removal 5- gutta-percha removal 6- removal of broken
instrument 7- repair of perforation
Coronal restoration should 1- presence of post-core material

be completely removed: 2- leaking from the restoration edges
3- the presence of secondary caries
Removal of restorations: 1- all caries can be removed
2- cracks can be observed
3- ensures access to previously untreatable channels
Removal of crown: 1- hand tools
2- ultrasonic tools
3- active tools
Removal of post-core 1- if the force required to remove the posts from the root canals is too great to break, the post should not be
removed
2- ultrasonic devices should be used to attenuate the bond of the adhesive cement by vibration
3- in some cases, the ultrasonic vibration may release the post in the root canal, but where it cannot be
released the post-core must be removed from the root canal using a device
Removal of cement and 1- Sealers can usually be removed by continuous irrigation (EDTA & sodium hypochlorite).
sealer 2- Solvents (endosolve-R, endosolve-E halothane or chloroform) can be used during this process to solve
canal sealer.
Removal of silver cone 1-depends on whether the silver cone extends into the pulp chamber or whether it is visible from pulp
(since its cross section is chamber
round, it’s difficult to fill the 2-the silver cone are checked by holding them with steiglitz forceps to see how much they are stuck in the
canal enough) root canal, and then is removed gently by being supported and powered by the coronal section
3-handstorm number 15 can be advanced by moving a file from one side to the other
4-if the silver cone is cut in the canal orifices and it will not be possible to hold it; a gap is created around the
canal with an ultrasonic tip. When the gab is 2mm deep, many different extraction techniques such as the
masserann extractor or ruddle IRS can be used to remove silver cone from the root canal
Removal of gutta-percha 1-removal with rotary files
2- removal with ultrasonic files
3- removal with heat
4- removal of heat and file
5- removal of file and chemical material
6- removal of paper point and chemical material
- removed from root canal by one or two H-type files by squeezed around or between the gutta-percha
where the lateral condensation is insufficient or the overfilling of root canal
- removal of the root canal filling should be done step by step from the coronal to the middle and apical
regions.
- The gates-Glidden burs can be selected in accordance with the canal to be used in the coronal region of the
canal
- a solvent (chloroform, turpentine oil, halothane) can be used and the gutta-percha can be softened and
removed. Small drop of solvent is placed to canal orifice, the top of the gutta-percha is softened and removed
using the file. Solvent applied frequently, softening gutta-percha Is removed and processing is continued until
reaching apex. As solvent have potentially toxic effects, they should be used as little as possible in the root
canal.
Removal of broken file 1-the thickness & length of the broken instrument
2- steel or nickel titanium
3- location of broken file
4- in which stage the instrument is broken
5- cross sectional area of the canal
6- presence of a curvature and the portion of the broken instrument in this curvature
7- acute clinical symptoms
Prognosis of retreatment:
1- single-appointment treatment or unsuitable retreatment cases may result in periapical irritation
2- complications such as previous treatment perforations, broken file, over-preparation or under-preparation may make the success of
retreatment is difficult
3- it has been determined that the success rate in retreatment applied to teeth which have periapical lesion is 62-68%.
Regenerative endodontics
1- Steam cells
2- growth factors
3- scaffolds
The developing dentition is at risk for pulpal necrosis due to trauma, caries, and developmental dental
anomalies such as dens evaginatus. Loss of an immature permanent tooth in young patients with mixed
dentition can be devastating, leading to loss of function, malocclusion, and inadequate maxillofacial
development.
Apexification: is defined as a method to induce a calcified barrier in a root with an open apex or the
continued apical development of an incompletely formed root in teeth with necrotic pulp tissue. This is
distinct from revascularization, since apexification does not attempt to regain vital tissue in the canal
space.
Apexogenesis: is defined as a vital pulp therapy procedure performed to encourage continued

physiologic development and formation of the root end. An important distinction is that apexogenesis is
indicated for teeth in which there has been no loss of vascularity, thus no need to "revascularize" the
canal space.
REGENERATIVE ENDODONTIC PROCEDURES (REPS): Defined as biologically based procedures designed

to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex.
Aims:
1. Healing apical periodontitis.

2. Promote normal pulpal physiologic functions.
3. Continued root development.
4. Immune efficiency.
5. Normal nociception.
• Thus, the ultimate goal of these procedures is to regenerate the components and normal function of
the pulp dentin complex.
Regenerative endodontics is founded on the seminal work of Dr. Nygaard-Østby, completed in the 1960s.
He hypothesized that a blood clot could be the first step in the healing of a damaged dental pulp, similar
to the role of the blood clot in the healing process observed in other area.
Revascularization: is a term better used for the reestablishment of the vascularity of an ischemic tissue,
such as the dental pulp of an avulsed tooth. From this perspective, a focus on revascularization would
ignore the potential importance of growth factors and scaffolds that are required for histologic
recapitulation of the pulp- dentin complex.
Pioneering work supporting the concept of regenerating dental tissues was reported more than 50 years
ago when Dr. B.W. Hermann described the application of calcium hydroxide (Ca[OH]2) for vital pulp
therapy, and Professor Nygaard-Østby evaluated a revascularization method reestablishing a pulp-
dentin complex in permanent teeth with pulpal necrosis.
The field of regenerative endodontics has seen a dramatic increase in knowledge gained from
translational basic science studies evaluating the interplay of the tissue engineering components (stem
cells, growth factors, and scaffolds) applied to the clinical need and challenges.
Dental pulp can be viewed as a core of innervated and vascularized loose connective tissSue surrounded
by a layer of odontoblasts.
1- STEAM CELLS
Steam cells: are defined as a distinct subpopulation of undifferentiated cells with self-renewal and
differentiation potential.
They can be classified as pluripotent or multipotent cells.
-Pluripotent stem cells: have the capacity of becoming specialized cells and belong to all three germ
layers. Embryonic stem cells are the best example of pluripotent cells.
There is a significant body of research on embryonic stem cells, but ethical, legal, and medical (tissue-
rejection) issues can render these cell types unsuitable for clinical applications.
-Multipotent stem cells: All adult mesenchymal stem cells are more restricted in their capacity to
differentiate, only forming tissues of mesenchymal origin, and therefore are classified as multipotent.
These cells can be found compartmentalized within tissues in "stem cell niches."
The mesenchymal tissues appear to have an enriched population of adult stem cells. They were initially
called stromal stem cells but later received the now widely accepted name mesenchymal stem cells
(MSCS).
Although stem cells have been identified in most oral tissues. The stem cells more likely to be involved in
REPS are localized around the periapical region.
These include stem cells of the
 Apical papilla (SCAP),

 Periodontal ligament stem cells (PDLSCS),
 Inflammatory periapical progenitor cells (¡PAPCS),
 Bone marrow stem cells (BMSCS),
 Dental pulp stem cells (DPSCS). .
Odontoblasts are one of the most specialized cells of the pulp dentin complex with dentinogenic,
immunogenic, and possibly sensorial functions.
At least five different types of postnatal mesenchymal stem cells, in addition to DPSCS, have been
reported to differentiate into odontoblast-like cells, including SHED, SCAP, IPAPCS, DFPC, and BMMSC.
2- GROWTH FACTORS/MORPHOGENS
Growth factors and transcription factors are central to the cascade of molecular and cellular events
during tooth development and are responsible for many of the temporospatial morphologic changes
observed in the developing tooth germ. For these reasons, they are also likely involved in the
regeneration process.
Dentine is composed of collagen fibers (90%, collagen type I) and noncollagenous matrix molecules
(proteoglycans, phosphoproteins, and phospholipids). The collagen fibers act as a grid or matrix, and this
structure behaves as a scaffold upon which mineralization can occur.
Several growth factors have been evaluated for their ability to trigger the differentiation of selected
mesenchymal stem cell populations into odontoblast-like cells.
These growth factors/ cytokines are secreted by the odontoblasts during primary dentinogenesis,
becoming sequestered and "fossilized" into the after they dentine biomineralization. However, become
may solubilized by demineralization of the matrix, bacterial acid (caries decay), chemical treatment
(EDTA rinsing solution, calcium hydroxide or acid etching for bonded restorations), or restorative
materials such as mineral trioxide aggregate and Biodentine
Morphogens are not only naturally occurring factors found within teeth. Several growth factors have
also been evaluated for their ability to trigger the differentiation of selected mesenchymal stem cell
populations into odontoblast-like cells
3- SCAFFOLDS
An important component of tissue engineering is a physical scaffold.
Tissues are organized as three-dimensional structures, and appropriate scaffolding is necessary to,
1. Provide a spatially correct position of cell location

2. Regulate differentiation, proliferation, or metabolism while promoting nutrient and gaseous
exchanges.
Extracellular matrix molecules are known to control the differentiation of stem cells, and an appropriate
scaffold might selectively bind and localize cells, contain growth factors, and undergo biodegradation
over time. Thus, a scaffold is far more than a simple lattice to contain cells, but instead can be viewed as
the blueprint of the engineered tissue.
Scaffolds can be classified as either,
1. Natural.
Examples of natural scaffolds include collagen, glycosaminoglycans, hyaluronic acid (HA),
demineralized or native dentin matrix, and fibrin.
2. Synthetic.
Examples of synthetic scaffolds include poly-L-lactic acid (PLLA), polyglycolic acid (PGA),
polylactic-coglycolic acid (PLGA), polyepsilon caprolactone, hydroxyapatite/tricalcium phosphate,
bioceramics, and hydrogels such as self-assembly peptide hydrogels.
The great majority of currently published regenerative endodontic procedures involve evoked bleeding
and the formation of a blood clot to serve as a scaffold.
Another approach for creating a scaffold involves the use of autologous platelet-rich plasma (PRP). It
requires minimal ex vivo manipulation, being fairly easy to prepare in a dental setting. PRP is rich in
growth factors, degrades over time, and forms a three-dimensional fibrin matrix. Platelet rich fibrin (PRF)
is an alternative to PRP, as it has a three-dimensional architecture conducive with stem cell proliferation
and differentiation and contains bioactive molecules
Clinical Procedures Related to Regenerative Endodontics (Important Points)

Why it is difficult to perform root canal treatment in incompletely formed root?
1. Because the apex is not fully developed and often has a blunderbuss shape, cleaning and
shaping of the apical portion of the root canal system can be difficult.
2. The process is further complicated by the presence of thin, fragile dentinal walls that may be
prone to fracture during instrumentation or obturation.
3. 3. The open apex increases the risk of extruding material into the periradicular tissues.
Traditionally, an immature tooth with an open apex is treated by apexification, which involves creating
an apical barrier to prevent extrusion. In many cases, this entails an involved, long-term treatment with
Ca(OH)2, resulting in the formation of a hard- tissue apical barrier.
Disadvantage of the traditional apexification procedures is that the short-term or long-term use of
Ca(OH)2 has the potential to reduce root strength.
 A primary advantage of regenerative endodontic procedures in these cases is the greater

likelihood there will be
 An increase in root length
 Root wall thickness,
 In addition to the possibility that the patient will regain vitality responses.
Most of the published procedures reported minimal to no instrumentation. This might be due, at least in
part, to the concern of further weakening fragile dentinal walls and the difficulty of mechanically
debriding canals of such large diameters and avoiding generation of a smear layer that could occlude the
dentinal walls or tubules. Because of the lack of mechanical debridement, clinicians relied on copious
irrigation for maximum antimicrobial and tissue dissolution effects.
Approximately 51% of the cases included the use of a triple antibiotic paste (a 1:1:1 mixture of
ciprofloxacin/ metronidazole/ minocycline), whereas 37% used Ca(OH)2 as an intracanal medicament.
- The patient age appears to be an important factor in case selection

-Some studies suggest that younger patients have a greater healing capacity or stem cell regenerative
potential.
-Another important factor related to is the stage of root development, because the large diameter of
the immature (open) apex may foster the ingrowth of tissue into the root canal space and may indicate
a rich source of mesenchymal stem cells of the apical papilla.
Sodium hypochlorite, either alone or in combination with other irrigants, has been used to disinfect the
canal space in most cases.
A combination of triple antibiotic (minocycline, metronidazole, and ciprofloxacin) was left in the canal
space, so the disinfection protocol was primarily a chemical method rather than the chemomechanical
approach used in conventional nonsurgical endodontic therapy.
TREATMENT PROCEDURES FOR REGENERATIVE ENDODONTICS

First Treatment Visit:
1. Informed consent, including explanation of risks and alternative treatments or no treatment.

2. After ascertaining adequate local anesthesia, rubber dam isolation is obtained.
3. The root canal systems are accessed and working length is determined (radiograph of a file
loosely positioned at 1 mm from root end).
4. The root canal systems are slowly irrigated first with 1.5% NaOCl(20 mL/canal, 5 min) and then
irrigated with saline (20 mL/canal, 5 min), with irrigating needle positioned about 1 mm from
root end.
5. Canals are dried with paper points.
6. Calcium hydroxide or an antibiotic paste or solution (combined total of 0.1 to 1 mg/mL) is
delivered to canal system.
7. Access is temporarily restored.
Final (Second) Treatment Visit:

(Typically 2 to 4 Weeks after the First Visit)
1. Aclinical exam is first performed to ensure that that there is no moderate to severe sensitivity to
palpation and percussion. If such sensitivity is observed, or a sinus tract or swelling is noted,
then the treatment provided at the first visit is repeated.
2. After ascertaining adequate local anesthesia with 3% mepivacaine (no epinephrine), rubber dam
isolation is obtained.
3. The root canal systems are accessed; the intracanal medicament is removed by irigating with
17% EDTA (30 mL/canal, 5 min) and then a final flush with saline (5 mL/canal, 1 min).
4. The canals are dried with paper points.
5. Bleeding is induced by rotating a precurved K-file size #25 at 2 mm past the apical foramen with
the goal of having the whole canal filled with blood to the level of the cementoenamel junction.
6. Once a blood clot is formed, a premeasured piece of Collaplug is carefully placed on top of the
blood clot to serve as an internal matrix for the placement of approximately 3 mm of white MTA
or Biodentin.
7. A (3- to 4-mm) layer of glass ionomer layer is flowed gently over the bioactive coronal barrier
and light cured for 40 secs. 8. A bonded reinforced composite resin restoration is placed over
the glass ionomer.
8. The case needs to be followed-up at 3 months, 6 months, and yearly after that for a total of 4
years.
CLINICAL MEASURES OF TREATMENT OUTCOME
 The measures of success for revascularization are not only radiographic evidence of
periradicular health but also radiographic and other clinical evidence of functioning vital tissue
in the canal space.
 Radiography evidence of functioning pulp (or pulp- tissue would include continued root growth,
both in length and wall thickness,
 Other measures of the presence of vital, functioning tissue in the canal space include laser
Doppler blood flowmetry, pulp testing involving heat, cold, and electricity; and lack of signs
symptoms.
 The ideal clinical outcome an asymptomatic tooth that does not require retreatment
 Although achieving regeneration of pulp tissue continues to be a preferred objective, an
alternative acceptable outcome, retention of a tooth with healed apical tissue, could be
considered satisfactory.
 Responses to electric palp tester (EPT) are more commonly reported than cold responses.
 These responses to vitality testing (with either cold or EPT), as well as the lack of signs and
symptoms of pathosis, suggest the presence of functioning tissue in the canal space.
 Vitality responses, in addition to continued root development, are a desirable outcome.
Endodontic diagnosis and treatment
Diagnosis: to identify the nature of the disease in detail as a result of the analysis of the symptoms.
Prophylaxis: 2gr amoxicillin (1/2 hour before treatment), clindamycin 600mg (if penicillin allergy).
Pulpal pain: difficult localize, intermittent, pulsative, increase with hot/cold/chewing, decrease with cold, mostly
unbearable.
Periodontal pain: localized, deep pain, increase with chewing, mild-severe.
Objective tests:
1) inspection: extra oral: facial asymmetry, swelling, fistula, TMJ. /Intra oral: soft tissue lesion, swelling, redness, fistula.
/Hard tissue: caries, restoration, color change, abrasion, erosion, atrission.
2) Radiography: may be root fracture if J shape radiolucent
3) Percussion: determinate, inflammation in PDL, the result of inflammation of pulp or periodontium.
4) Palpation: extra oral: lymph nodes, intra oral: periapical sensitivity, swelling, soft tissues, compare.
5) Mobility: serious inflammation of PDL, compare to symmetrical or neighbor tooth.
6) Vitality test:
A-(thermal test): cold/hot, 10 min to be repeated, compare to symmetrical tooth.
Normal pulp: acceptable pain, reversible pulpitis: sharp pain/quick reduction,
irreversible pulpitis: continuous pain, necrosis: no response or false positive.
B-(electrical test): direct stimuli for nerves in pulp, multiple roots give false positive.
-false positive: metal resto, contact gingiva, patient concern, liquefaction necrosis, inadequate isolation
-false negative: anesthesia, enamel & electrode contact, trauma, open apex, partial necrosis.
7) periodontal: the presence of deep pockets in the absence of periodontal disease, poor periodontal prognosis,
contraindication to RCT, if there is deep pocket maybe there is vertical root fracture.
8) Selective anesthesia: cause of pain, local anesthesia for single tooth.
9) Cavity test: cavity preparation without anesthesia, chronic apical periodontitis has no pain.
10) Transillumination: vertical crown fracture.
11) Occlusion: hyper occlusion, acute apical periodontist cause high filling.
Analyze: history, examination, specific test, clinical diagnosis (pulpal/periapical)
normal Reversible pulpitis Irreversible pulpitis Necrotic pulp

symptoms no Thermal sensitivity Spontaneous pain No thermal
sensitivity
radiography No periapical No periapical change No periapical change It depends
change
Pulp test normal Not long time Sharp pain-last longer no
Periapical test No percussion or No percussion or no percussion or Depend on
palpation palpation palpation periapical status
symptoms radiograph Pulp test Periapical test
normal no No periapical change Normal No percussion or palpation
Acute Apical Pain on pressure No periapical change +/- Depend on Tender to percussion and/ or
Periodontitis pulp status palpation
Chronic None Periapical radiolucent No response Not Tender to percussion and/
Apical or palpation
Periodontistis
CAP+ Pain on pressure Periapical radiolucent No response Tender to percussion and/ or
symptoms palpation
Acute Apical Sever pain, swelling +/- periapical radiolucent No pain Tenderness to percussion and
Abcess palpation
Chronic No pain/ drainage +/- periapical radiolucent No pain Not Tender to percussion and/
Apical Abcess sinus or palpation
Condensing Mild pain/ vairable Increase bone density Depend on pulp +/- Tender to percussion and
Ostetits status palpation
Treatment plane:
- Pulpal diagnosis
- Periapical diagnosis
- Restorability
- Periodontal status
- Difficulty level of the case
- Financial status
Factors Affecting Endodontic Treatment
1- Status of the patient

- Medical history
- Indication for local anesthesia
- Systemic health
2- Objective clinical findings

- Diagnosis
- Radiographic findings
- Pulp chamber
- Root morphology
- Apical morphology
- Malposition
3- Other factors
- Restorability
- Existing restoration
- Fracture
- Resorption
- Endo-periodontal lesion
- Trauma
- Previous root canal treatment
- Perforation
* Endodontic surgery: is a procedure that is done to treat the root lesion that are not amenable to endodontic root canal treatment. The majority of these surgical
procedures involve resection of the root apex (apicectomy) and retrograde obturation of the root canal to get rid of persistent lesion that has not resolved following
an acceptable root canal treatment.
Endodontic Microsurgery Pathogenesis:

-of periapical lesions Pulpal and subsequent periapical disease is caused by microbial contamination. This commonly occurs via a carious lesion and sometime occurs
due to periodontal disease. As resultant necrosis of the pulpal tissue lead to inflammatory products and pathogens and their byproducts to exit through the apical
foramen. This frequently results in the formation of a periapical lesion, mostly an apical granuloma.
1. Caries
2. Pulp necrosis
3. Periapical abscess of granuloma
4. Radicular cyst (inflammatory cyst)
Treatment options of tooth with periapical lesion;
1. Extraction if the tooth is unuseful or unrestorable.

2. Root canal filling if the tooth restorable and there is some evidence that small periapical cystic lesion may resolved following successful root canal
filling
3. Endodontic surgery, when there is failure of root canal filling or there are some obstacle to do root canal filling.
Indications for endodontic surgery:
1. Apical anomaly of root tip (dilacerations, intracanal calcification, open apex)

2. Presence of lateral/accessory canal/apical region perforations
3. Roots with broken instruments/overfillings
4. Fracture of apical third of the root
5. Formation of periapical granuloma/cyst Draining sinus tract/ non responsive to RCT
6. Extension of root canal sealant cement/filling beyond the apex
7. Teeth with ceramic crowns
8. When patient with chronic periapical infection, will not be available for follow-up.
Factors to be considered before performing endodontic surgery
Factors to consider Clinical or radiological signs

Quality of coronal restoration 1- Leaking margins
2- Lack of cuspal coverage
Quality of endodontic 1- Poorly condensed
2- Presence of voids
3- Absence of orthograde filling material
4- More than 2mm short of radiographic apex
Periodontal health 1- Mobility
2- Bleeding on probing
3- Pathological pocketing
4- Perio-endo lesions
5- Vertical or horizontal bone loss
Caries 1- Stickness on probing crown margins (secondary caries in extra coronal restorations can be difficult to diagnose
radiographically )
Root fractures 1- Localized, deep areas of pocketing
2- Mobility of a post crown
3- A history of de-bonding of post crowns
Tooth morphology 1- Poor crown root ratio
Appropriate treatment strategies for different causes of endodontic disease
Etiology disease Considerations Primary treatment strategy

Persistent intrararadicular infection 1- Missed anatomy No surgical retreatment
2- Inadequate shaping
3- Cleaning and/or obturation
4- Failed coronal seal
5- Root fracture
6- Iatrogenic damage
Foreign body response 1- Overfill Surgical endodontics
2- Overextension of obturation material
Extraradicular infection 1- biofilm development on the external root surface Surgical endodontics
Cysts 1- multiple theories of cystic development Surgical endodontics
Contraindications for endodontic surgery:
1- Presence of systemic diseases-leukemia, uncontrolled diabetes, anemia, thyrotoxicosis, etc.

2- Teeth damaged beyond restoration
3- Teeth with deep periodontal pockets and grade III mobility (Pre-existing bone loss) When traumatic occlusion cannot be corrected Short root length
4- Acute infection which is nonresponsive to the treatment
5- Root tips close to the nerves, e.g. mental nerve, inferior alveolar nerve or in maxilla close to the maxillary sinus.
Complications of endodontic surgery:
-intraoperative
1- Bleeding; can controlled by using local application of adrenaline pack, pressure pack, Gelfoam or surgical.
2- Damage to the neighboring root.
3- Entry into sinus/inferior alveolar canal, nasal cavity.
Postoperative
1. Abscess formation.
2. Fenestration, sinus tract formation.
3. Increased mobility of the tooth.
4. Staining of the mucosa due to amalgam that remained at the surgical field.
Follow up for endodontic surgery:

- Healing of the periapical area is checked every 6–12months radiographically, until ossification of the cavity is ascertained.
- In order to evaluate the result, a preoperative radiograph is necessary, which will be compared to the postoperative radiographs later.
Radiographic and clinical features of endodontic success
Outcome of surgical treatment Radiographic features Clinical signs/ symptoms

Successful 1- Resolution of apical radiolucency Asymptomatic
2- Intact periodontal space of normal width
3- Intact lamina dura
Incomplete 1- Decreased but incompletely resolved radiolucent Asymptomatic
2- Radiolucency with irregular outline
3- Asymmetry of radiolucency around the apex
4- Course bone structure peripheral to lamina dura
5- Radiolucency with angular extension into the periodontal space
Uncertain As with incomplete 1-Mild discomfort
2-Sensation of pressure from the
tooth
unsuccessful 1- Periodontal membrane of more than twice normal width 1-Tenderness to percussion
2- Circular or semi-circular radiolucency’s 2-presence of a sinus tract
3- Radiolucency with funnel shaped extension into the periodontal space 3-abscess formation
4-tenderness within the buccal sulcus
acute pain
A comparison between traditional apicectomy and modern apicectomy
Comparable factors Traditional apicectomy Modern apicectomy

Imaging Radiographic films CBCT
Magnification Loupes High-power operating microscope
Flap choice Semi-lunar or full thickness Submarginal or papilla preservation
Access armamentarium Standard size surgical bur Speed increasing hand pieces and piezo-driven
Size of osteotomy Large Small: >5mm
Instruments Large Small-micro instruments
Bevel angle Acute Perpendicular to the root surface
Root-end filling material Amalgam Bioceramic cements
Suture 4-0 silk 5-0 monofilament
Conventional Microsurgery
Osteotomy area 8-10 mm 3-4 mm
Angle 45-65 degrees 0-10 degrees
Examination of root end Possible
Detection of isthmus Possible
Apical preparation Some cases always
Apical preparation Bur Ultrasonic
Restored filling Amalgam MTA
Sutures 4.0 silk 5-6 monofilament
Healing after 1 year 40-90% 85-96.8%
Benefits of the Operating Microscope:
Loupes and microscopes offer different ranges of magnification.
1- An increase in magnification decreases the focal depth.

2- Wearing loupes, especially at magnifications higher than ×4, requires the practitioner to stay in a narrow range from the object to stay in focus.
3- In contrast, even at high magnifications, a microscope remains stable and the practitioner can work in an upright and ergonomically non-stressful
position.
4- Microscope use reduces strain on eye muscles, fatigue, and soreness compared to loupes.
5- Through a microscope the light reaching the left and right eyes appears to be essentially parallel, achieving the effect of far distance observation and
avoiding short accommodation stress as with the naked eye.
6- Binoculars of loupes and thus the viewing direction are convergent, resulting in similar eye strain.
7- Microscopes provide imaging virtually free of shadows, allowing excellent image quality for clinical operations and documentation.
Anesthesia and Hemostasis:
-Adequate hemostasis is essential for microsurgery
-Many endodontic surgeons performed surgery in a pool of blood, guessing at anatomic landmarks and structures.
-In order for endodontic microsurgery to be successful, the surgeon needs to examine the root surface at high magnification with the microscope.
-It is practically impossible to do that without effective hemostasis.
-The anesthetic solution of choice for endodontic surgery is Lidocaine 2% HCl with 1:50000 epinephrine.
-This high concentration of epinephrine is preferred for surgery because it produces effective, lasting vasoconstriction via activation of the a-adrenergic receptors in
the smooth muscle of the arterioles.
-This prevents the anesthetic from being washed out prematurely by the microcirculation
Topical hemostatic agent
Mechanicl agents 1- Bone wax

2- Calcium sulfants
Chemical agents 1- Apinephrine
2- Ferric sulfant
Biologic agent 1- Thrombine USP
Absorbable hematostatic agent 1- Instrinsic action
-gelfoam
-absorable collagen
-microfibrillar collagen hemostats’
2- Extrinsic action
-surgical
3- Mechanical action
-calcium sulfate surgiplast
Flap outline: (flap designs in endodontic microsurgery)
1. submarginal rectangular flap

2. submarginal triangular flap
3. sulcular rectangular flap
4. sulcular triangular flap
Root and resection: several reasons for resection of the apical part of the root during periapical surgery Removal:
1. Removal of pathologic processes.

2. Removal of anatomic variations (apical deltas, accessory canals, apical ramifications, severe curves).
3. Removal of iatrogenic mishaps (ledges, blockages, perforations, strip perforations, separated instruments).
4. Enhanced removal of the granulation tissue.
5. Creation of an apical seal.
6. Evaluation of the apical seal.
7. Reduction of fenestrated root apices.
8. Access to the canal system when the coronal Access is blocked or when coronal access with non-surgical retreatment is determined to be impractical,
time consuming, and too invasive.
9. Evaluation for complete or incomplete vertical root fractures.
Root end resection: steep bevel versus shallow bevel:

-Microsurgery suggests a 0⁰ bevel, perpendicular to the long axis of the tooth.
-A 0 degree bevel fulfills the following requirements:
1. Preservation of root length.

2. Less chance of missing lingual anatomy and multiple accessory canals.
3. Complete root end resection.
4. Less exposed dentinal tubule
5. Dentinal tubules are more perpendicularly oriented to the long axis of the tooth and therefore a short bevel will expose fewer tubules.
6. Easier to perform a root end preparation coaxially with the root. The root end preparation should be kept within the long axis of the root to avoid risk
of a perforation. The longer the bevel, the more difficult it is to orient and perform a preparation coaxially with the tooth
Isthmus
- a Greek word describes a narrow strip of land connecting two larger land masses.
-Endodontically speaking, an isthmus is defined as a narrow, ribbon- shaped communication between two canals that contains pulp, or pulpally derived tissue
Types of Isthmus
Type 1: was defined as either two or three canals with no noticeable communication.
Type 2: was defined as two canals that had a definite connection between the two main canals.
Type 3: differs from type II in that there are three canals instead of two.
Type 4: Incomplete C-shapes with three canals.
Type 5: is identified as a true connection or corridor throughout the section
Ultrasonic Root End preparation

• during root end preparation a Class I cavity coaxial with the root is made by use of ultrasonic tips with walls parallel to and within the anatomic outline of the root
canal space.
• Root end preparations are made at least 3 mm deep into root dentine.
• Root end preparation begins with aligning a selected ultrasonic tip along the root prominence on the buccal plate under low magnification (x4 to x8) to ensure
that the preparation follows the long axis of the root.
• Once the ultrasonic tip is aligned, the preparation is carried out under midrange magnification (x10 to x12).
• Ultrasonic tips are used in a light, sweeping motion short forward/backward and upward/ downward strokes result in effective cutting action. Interrupted strokes
are more effective than continuous pressure on the dentine surface.
Root end filling

- The main purpose of placement of a root end filling material is to provide an adequate apical seal that inhibits the leakage of irritants that might remain in the root
canal after root resection and rooted preparation, which may cause surgical failure. Besides sealing ability, other essential properties for an ideal root end filling
material are:
1. Well tolerated by periapical tissues

2. Bactericidal or bacteriostatic
3. Dimensionally stable
4. Easy to manipulate Does not stain teeth or tissue
5. Non-corrosive Resistant to dissolution
6. Adheres to the tooth structure
7. Dentino, osteo, and cementogenic
8. Radiopaque
Advantage of MTA:
1. Sealing ability
2. Biocompatibility
Other Types of Cements for Root End Filling
1. Intermediate Restorative Material (IRM)

2. SuperEthoxybenzoic Acid (SuperEBA)
3. Geristore and Retroplast
4. Several modified types of MTA-like materials
5. Amalgam
Healing after Apical Microsurgery: Following apical microsurgery, there is healing in two components:
1. osseous healing involving trabecular and cortical bone and

2. dentoalveolar healing that results in repair or regeneration of apical attachment apparatus (alveolar bone, periodontal ligament and cementum.
-After apical surgery, the resected cavity is occupied by a coagulum, which is slowly replaced by granulation tissue originating from the periodontal ligament
and endosteum.
-The formation of new bone begins in the internal area and progresses externally toward the level of the former cortical plate.
-As newly laid woven' bone reaches the lamina propria, the overlying membrane becomes functional periodontium (osseous healing).
-Progenitor cells from the periodontal ligament differentiate into periodontal ligament cells and cementoblasts to cover the resected root surface and lead to
regeneration of the cementum and the periodontal ligament (dentoalveolar healing).
Factors for Healing
1. Systemic status
2. Bone loss,
3. Previous root canal treatment or retreatment
4. Coronal restoration
5. Occlusion
6. Material and technique
7. Surgeon's experience
-Healing after ultrasonic technique 85-95%

-Conventional technique 65-68%
Endodontic posts
-if a tooth is lacks the structure to support a core, a post may be required
-the primary purpose of a post is to retain a core that in turn will support a final restoration, contrary to some beliefs, posts do not reinforce
endodonticlly treated tooth structure present to support the final restoration
-as a role there are two indications for post placement and both must be present to justify its use: the remaining coronal tooth structure is
inadequate for retention of the restoration and there is sufficient root length to accommodate the post while maintaining and adequate apical
seal
-characteristics of an ideal post:
1. A post must be as long as the crown (post/crown ratio)

2. Have a parallel sides with a maximum coverage of 3-5⁰
3. Achieve a precision fit in the canal
4. A post should be require minimal preparation, has resistance to fatigue, an elastic modulus that equals dentin and be non-corresive
5. easy to fit and adjust, radiopaque, allow easy removal
6. the post body and head should be highly retentive
-classification of posts:
(selection of post is multifaceted and based on a varity of classifications including mode of fabrication, surface types and material composition
1. posts can be custom-made of fabrication

2. Prefabricated posts can be further grouped based on shape
1- tapered or parallel
2- smooth, serrated or threaded
-a post bearing a smooth surface offers the least retention, while serrated surface is preferable as it provides mechanical undercuts
for cement. A threaded surface, while being the most retentive, creates the most significant stress of the three.
3. Posts classified based on material type as metallic and non-metal. Metallic posts can be made from a wide variety of materials
including precious, semi-precious and base metals. In the presence of microleakage, corrosion can be negative factor with base
metals, often due to the presence zinc and copper, whereas titanium posts show the greatest corrosion resistance. Non-metallic
posts can be manufactured from zirconium oxide, ceramic, and fibrous containing carbon, glass and quartz.
It is recommended that the obturation material be emptied immediately in the session when it is filled. The process that is done before the full
curing of the sealing material affects the microleakage less. On the other hand, some researchers stated that it is more appropriate to prepare
the post space 48 hours or 1 week after the canal filling. Regardless of the method, the obturation should be renewed when the apical seal is
suspected. In some cases, the root canal can be segmented. In other words, only the apical part of the canal can be filled and post placement
begins.
Contraindications for Post Placement:
-There are several unfavorable conditions that may preclude post placement. These includes
1. Severe root curvature, perforated roots, and poor crown-root ratio.

2. Signs and symptoms that prohibit post placement in endodontically treated teeth are sensitivity, inflammation, exudate, and a poor
apical seal among others.
By placing a post under any of these conditions, there is an increased likelihood that an operative case will fail and that the long-term health of
the tooth will be poor.
Post Design:
- In regard to design, “threaded posts have been found to cause the highest strain and incidence of root fracture. in fact, this and other studies
have shown that threaded posts with a taper
Post Shape:
- While a tapered post requires less removal of tooth structure, it behaves like a wedge. Exertion of lateral forces can result in vertical root
fracture. And while a parallel shaped post requires removal of more tooth structure (than a tapered post), it is more retentive and decreases
force distribution. According to Ya- mamoto et al, tapered posts produced the greatest stress at the coronal shoulder and parallel posts
generate their greatest stress at the apex of the canal preparation. * In a study by Johnson and Sakamura, "parallel posts resisted tensile, shear
and torqueing forces better than tapered posts and distributed stress more uniformly along their length during function".
Post Material:
For today's practitioner, the ability to replace a fractured post is an easy choice when faced with the alternative of a non-restorable root
fracture. According to Kivanç et al. "endodontically treated anterior teeth restored with glass fiber posts exhibited higher failure loads than
teeth restored with zirconia and titanium posts." Self-etching adhesives are better alternatives to etch-and-rinse adhesive systems for luting
post systems". This idea that fiber posts are a reliable fail-safe method has been substantiated in the literature. Garbin et al. found that in
regard to root stress distribution, metal posts were less favorable than glass fiber posts. “Silva found that "fiber posts show more homogeneous
stress distribution than metallic posts. The post material seemed to be more relevant for the stress distribution in endodontically treated teeth
than the posts' external configuration"." Based on research by Akayyan and Gülmez "significantly higher failure loads were recorded for root
canal treated teeth restored with quartz fiber posts. Fractures that would allow repeated repair were observed in teeth restored with quartz
fiber and glass fiber posts".
Importance of the ferrule:

The ferrule provides bracing or a casing action to protect the integrity of the root. Crowns whose margins encompass a ferrule alter the
distribution of forces. These restorations have a subgingival collar, which acts vis-a-vis a ‘hugging” action and prevents vertical fracture of the
tooth. To be effective, the margin must encompass at least 1.5-2.0mm of tooth structure. A study by so-rensen and Engelman "evaluated the
fracture resistance of pulp- less teeth with various ferrule designs and amounts of coronal tooth structure. The results demonstrated that one
millimeter of coronal tooth structure above the crown margin substantially increased the fracture resistance of endodontically treated teeth. "3
Because root fracture is one of the most serious complications following restoration of endodontically treated teeth, it is worth evaluating the
effect of a crown ferrule on the fracture resistance of endodontically treated teeth restored with prefabricated posts.
The ideal post :

-is comprised of many components in the form of materials and engineering features. While there is no absolute agreement in the world's
dental community on the ideal, there are certain rules that may be followed to provide a best-case scenario. The design should be one that is of
the parallel non-threaded nature. It should also be both tapered and parallel at strategic points along its body. Finally, glass fiber offers a
material that is both strong and kind to the root. This is all true in a concentric canal space where volumetric shrinkage is kept to a minimum.
However, there are many canal space configurations that do not conform to the perfect round shape. Studies such as those by Martelli et al.
have shown that a single post in a non-concentric canal will have a larger amount of cement/core material. Once set, this large amount of
cement undergoes volumetric shrinkage and microleakage, which is one of the main causes of endodontic failure.
Dental anomalies in endodontics
1- Genetic factors
1- polygenic
2- more than 300 genes have been identified to be expressed in teeth that are responsible for odontogensis. Defects in these agens
have been found to be one of the reasons for variation of the morphology of teeth
2- Local factors:
1- trauma 2- infection 3- chemical 4- nutritional
Why diagnosis is important in dental anomalies:

1- early prophylactic treatment
2- elimination of esthetic concerns
3- different treatment options in pulpal complications
4- to diagnosis some syndromes and disease through tooth anomalies
Dental anomalies: 1- number 2- size 3- structure 4- shape
1- Number of anomalies:
1- missing teeth (Hypodontia) 2- supernumerary teeth (Hyperdontia)
*hypodontia: missing teeth *hyperdontia: supernumerary teeth

-the most common dental anomaly -teeth developing in addition to the normal 32 permanent and 20
-absence of normal dentition deciduous teeth
- 90% maxillary area
- single or multiple
- erupted or impacted
-hypodontia: missing 1 or 2 permanent teeth -4th and 5th molars that form behind the 3rd molars
-oligodontia: missing 6 or more permanent teeth -PREMOLAR (buccal or lingual located 4 molar)
-anodontia: missing all primary or permanent teeth -DISTOMOLAR (distally located 4 molar)
-3rd molars are the most commonly affected - the anterior maxilla & mandible premolar regions are quite
followed by (MAN 2nd premolar, MAX lateral incisors, MAN central common locations
incisors) - the most common supernumerary tooth is a MESIODENS which is
malformed, peg-like tooth that occurs between the maxillary central
incisors
-may be seen in: -multiple supernumerary teeth may be associated with some
1- ectodermal dysplasia syndromes
2- Down syndrome 1- cleidocranial dysplasia
3- Rieger’s syndrome 2- Gardner’s syndrome
4- Book’ syndrome 3- Sturge-Weber syndrome
- clinical significant: -clinical significant:
1- unfavorable positions of remaining present teeth 1- crowding
2- common issues faced in treating hypodontia patients include 2- displacement of a permanent teeth
space management of the deep overbite and retention 3- failure to erupt
3- long term multidisciplinary management from pedodoontics to 4- esthetic problems
orthodontics, prosthodontics, implantology and so on genetic 5- dentigerous cyst formation
counselling is important -treatment decision may affected from several factors, such as the
ST are erupted or nonerupted, stage of the crown and root
development, the distance between the supernumerary teeth and
root of the adjacent teeth and the condition of the dentition
(malocclusion, crowding, missing teeth)
-id ST is not discernable adverse effect on adjacent teeth and if no
future orthodontic treatment foreseen, surgical intervention is not
essential.
2- Number of anomalies
1- Microdontia 2- Macrodontia
Microdontia Macrodontia
-smaller than normal teeth -Larger than normal teeth
-most commonly affecting 3rd molars & MAX lateral incisors -MAX incisors and 3rd molars
-often demonstrates altered morphology ex: a microdontic lateral -true generalized macrodontia is very rare. Macrodontia of a single
incisors often has a conical (peg0shaped) crown tooth is more common
-may contribute to impactions and crowding
3- Shape anomalies:
1- dens evaginatus 2- talon cusps 3- dens inevaginatos (dens in dente) 4- fusion 5- delaseration 6- gemination 7- concresence
8- palatogingival groove 9- taurodontism 10- enamel pearl
Dens evaginatus - early detection is important so that preventive management can be started as early as possible
-selective reduction of the opposing occluding teeth can be done
-in a situation where the tubercle has fractured, it can be sealed with resin
-in the case of pulp exposure during the early phase of root development, pulpotomy is suggested
-in the pulp necrotic root canal treatment should be performed
Talon Cusps - an additional cusp of an incisors, thought to be treated to an extremely prominent cingulum
- more commonly affecting maxillary lateral incisors
-syndromes: 1- Rubinstein-Taybi syndrome 2- Mohr syndrome 3- Ellis-VanCreveld syndrome
-complications:
1- may contribute to impactions
2- susceptible to dental caries
3- susceptible to endodontic infections
4- occlusal trauma, esthetic problems
5- irritations of soft tissues and tongue during mastication and speech
-treatment:
1- fissure sealing
2- composite resin restoration
3- reduction of cusp
4- pulpotomy
5- RCT
6- extraction
Dens invaginatus -invagination of enamel into the crown, to varying extent
(dens in dente) -occurs most frequently in the maxillary lateral incisors
-associated with increased risk of pulpal and periapical inflammatory disease
-in folded enamel is often defective, including canals which lead to the pulp
-usually a deep pit connects this with oral cavity with resultant increased caries risk
-endodontic management:
1. The anatomy of DL lesions can be extremely complex. Therefore, adequate chemo
mechanical debridement and obturation of these malformations can be challenging
2. the invagination can be removed with high-speed carbide or diamond burs (long
shanked)
3. the invagination should be thoroughly debrided using ultrasonic instruments and
hypochlorite
4. irregular internal morphology → irrigation is important
5. calcium hydroxide dressing
-clinical tips:
1. lateral-vertical condensation
2. thermoplastic Gutta-percha
Gemination -is a partial cleavage of a single tooth germ resulting in 2 partially or total separated crowns with
enlarged pulp chamber and root canal
-endodontic management
1. it’s important to create or achieve functional and esthetic success in these cases
2. several treatment methods have been described with respect to the different types
and morphological variations of geminated teeth, including endodontic, restorative,
surgical and Periodontal treatment
Schizodontia -it would only fit complete splitting which results in "twining” and thus leading to hyperdontia
Fusion - Union of two normally separate tooth germs to varying extents
-complete fusion - more common in the deciduous dentition
-partial fusion - one teeth is absent. Rarely there may be fusion of a normal tooth with supernumerary tooth
- more common in the deciduous dentition. More commonly associated with anterior teeth
-Endodontic management:
1. teeth are joined by dentin: pulp chambers and canals may be linked or separated
depending on the developmental stage when the union occurs
2. in the anterior region this anomaly also causes an unpleasant aesthetic tooth shape
due to the irregular morphology
3. presence of tissues or grooves at the union between fused teeth predisposes it to
caries and periodontal disease
4. restorative treatment
5. endodontic treatment
6. endodontic surgery
7. reimplantation
concrescence - The joining of roots of normally separated teeth with cementum.
-concrescence is the most frequently noted in maxillary molars, especially a 3rd molar and
supernumerary tooth.
- Concrescence may occur during root formation or after the radicular phase of development is
complete. If the condition occurs during development, it’s called true concrescence.
When developmental, it might be associated with failed eruption of one or more teeth.
-if the union does not affect aesthetics or cause eruption pathologies, no treatment is required
- Concrescence should be carefully identified to reduce the risk of complications associated with
surgical procedure. It may affect the extraction of adjacent tooth and may fracture the tuberosity
or floor of the maxillary sinus.
Palatogingival grooves - a type of invagination is a sharp, somewhat irregular, funnel-like groove, running from the paatal
enamel of the crown and extending along the root
-this particularly occurs in the permanent maxillary lateral incisors
-the groove commonly starts at the junction of the marginal ridge and the cingulum, and then
continues along the proximal surface of the root, extending to the apical third of the root or to the
apex itself.
-Endo+ Perio (1- flap reflection 2- removal of granulation tissue 3- grinding and flattering of the
groove)
-odontoplasty
-restorations
Taurodontism - longer body of the tooth with shorter roots
1-hypotaurodontism -pulp chamber is extremely large with a greater apico-occlusal height
2- mezotaurodontism -the molars are the mostly affected, followed by premolars
3- hypertaurodontism -occurs in the deciduous and the permanent dentitions
-can occur uni/bilaterally
-may be associated with some syndromes:
1. klinefelter’s syndrome
2. Down syndrome
3. Ectodermal syndrome
4. Mohr syndrome
-clinical management
1. Size and shape of the pulp chamber → hemostasis
2. Apically positioned canal orifices → locating
3. Extraordinary root canals in terms of shape and number
4. Because the pulp of a taurodontism is usually voluminous, in order to ensure complete
removal of the necrotic pulp, (sodium hypochlorite) has been suggested initially as an
irrigant to digest pulp tissue
5. Application of final (ultrasonic) irrigation may ensure that no pulp tissue remains
delaseration - a distinct bend of a tooth crown or root, root delaseration are much more common
-most are likely to be developmental in nature. Some may be related to trauma during tooth
development
- dilacerated roots interfere with endodontic treatment, orthodontics and extractions
Enamel pearls - an enamel pearl is a small oval to round enamel bulb, which may or may not have dentine and
pulp tissue
- its typically found on/within the root, and sometimes on the crown
- a true pearl consists of enamel, a composite pearl contains dentine, enamel-dentie pearl are
rarely on enamel-dentin-pulp pearl may also occur
-larger pearls may interfere with the removal of calculus and there is a risk of fracture of the tip of
the scaler. Small pearls may show up on radiographs, resembling calculus. Unless the pearls are
associated with localized periodontal destruction, treatment is not required
Oehler’s classification:
-type 1: the invagination is confined to within the crown of the tooth and does not extend beyond the level of the amelo-cemental junction
-type 2: the invagination extends into the pulp chamber but remains within the root canal with no communication with the PDL
-type 3: the invagination extend through the root and communicates laterally with the PDL space through a pseudo-foramen
-type 4: the invagination extends through the root and communicates with the PDL at the apical foramen
Dens invaginatus (dens in dente) treatment:
Type 1: type 2: type 3:

1-preventative treatment (ex: oral hygiene 1-preventative treatment (ex: oral hygiene 1-preventative treatment (ex: oral hygiene
instructions, fissure sealant) instructions, fissure sealant) instructions, fissure sealant)
2- restorations 2-restorations 2-restorations
3-endodontic treatment 3-endodontic treatment 3-endodontic treatment
4-endo surgery 4-endo surgery
5-intentional reimplantation
6-extraction
4- Structural anomalies
1- amelogensis imperfecta
2- dentinogensis imperfecta
3- dentin dysplasia
4- odontodysplasia
amelogensis imperfecta -consists of heterogeneous structural and morphological enamel defects of genetic origin occurring in the
absence of systemic disorders.
-Insufficient occlusal enamel leads to reduced vertical dimension, worsened by shipping and wear and a deep
overbite
-the dentine is normal, as is the pulp, although a considerable amount of secondary and tertiary dentine is
deposited in the hypoplastic rough form. The hypocalcified subtypes are more prone to caries than the hypoplatic
ones.
-is an inherited anomaly of dentinal structure, which presents with and without osteogenesis imperfecta with
bulbous crowns of an apalescent (translucent) soft brown (amber or apal) colour, thin and short, often
transparent, roots and pulpal obliteration after tooth eruption
-early loss and excessive wear of the teeth (attrition)
-clinical management:
1- Objectives of early treatment of the deciduous dentition are maintenance of the dentition (vitality,
form, size). Aesthetics, prevention of loss of vertical dimension, maintenance of arch length, and
normal growth of facial bones and the TMJ
2- The use of crowns possibly prevents periapical pathology. However, dental abscesses are also thought
to arise due to disruption of the new pulpal vascular supply in association with the abnormal pulpal
calcifications. Which leads to pulp necrosis. Sequential radiographs are therefore desirable.
Endodontic treatment in case of pulpal pathosis is difficult if initiated after pulp canal obliteration, and
may make extraction unavoidable. The outcome of endodontic treatment may be unfavorable and
short roots are a contraindication for endodontic surgery
3- Root canals are obliterated → endodontic treatment Is difficult
4- Selective endodontic treatment is recommended early in strategic teeth.
5- Chelating irrigants are not recommended because dentin is hypomineralized
6- Vitality test are unreliable
Dentin dysplasia -hereditary dentin abnormality
-similar appearance to dentinogensis imperfecta but rare
-two types:
1- Radicular
2- Coronal
-pulp spaces are largely obliterated
-higher risk of non-carious-related periapical inflammatory lesions
-clinical management:
1- In radicular dentine dysplasia, pulp necrosis and apical granulomas/cysts may be present pre-
eruptively. Posteruption, abscesses are common because of bacterial ingress into the pulp through the
dysplastic dentine after the loss of the enamel. Surface protection with crowns may prevent pulp
pathosis and excessive wear. Abscesses may also be the result of endo-perio lesions. Meticulous oral
hygiene has been shown to be effective.
Odontodysplasia -regional odontodysplasia is a rare developmental disorder of, in general, a few teeth, where the enamel and
dentine are hypomineralised, hypoplastic, thin and discoloured, and the pulp cavity is wide
-the teeth are seen on radiographs are vague images the term “ghost teeth” has been generally adopted. The
cementum is involved and many teeth do not erupt.
Endodontic periodontal lesion
Pathway of communication between pulp and periodontium:
1) apical foramen:
-it’s the principles and the most direct route of communication between the pulp and periodontium
-bacterial and inflammatory by products may exit rapidly through it to cause periapical pathologies
-apex may serve as a partial of entry of inflammatory by products from deep periodontal pockets to pulp
2) lateral & accessory canals:
-may present anywhere along the root
-may serve a potential pathway for the spread of bacterial by products
-30-40% of all teeth have it and the majority found in apical third of root
3) dentin tubules:
-exposed dentin tubules in areas of denuded cementum
-in the root it extend from the pulp to CDJ, they range in size from 1-3 microns in diameter (bacterial and their toxins are
smaller in size)
-the tubules may be denuded of their cementum coverage as result of perio disease, surgical procedures or
developmentally when cementum & enamel do not meet at CEJ thus leaving areas of exposed dentin
-patient’s experiencing cervical dentin hypersensitivity are example of such phenomenon
4) additional avenues of communication between pulp & periodontium:
1) developmental malformations: such as palate-gingival grooves of maxillary incisors, usually begins in central fossa,
cross the cingulum, and extend apically with varying distances
2) perforations: may result from extensive carious lesions, resorption, or from operator error
3) vertical root fractures: can produce deep periodontal pocketing and localized destruction of alveolar bone, the
fracture site provides a portal of entry for irritants from RC to PDL
Endodontic disease and the periodontium:

-when pulp becomes inflamed or necrotic, inflammatory products may leach out through apex, lateral and accessory
canals and dentinal tubules to trigger an inflammatory vascular response in periodontium
-the effect of periodontal inflammatory on pulp is controversial and conflicting studies exist :
a) periodontal disease has no effect on the pulp at least it involves the apex
b) effect of perio disease on pulp is degenerative by nature including an increase in calcifications, fibrosis and collagen
resorption in the pulp.
c) Pulpal changes resulting from periodontal disease more likely to occur when apical foramen involved
Differential diagnosis of ENDO/PERIO lesions:-classification system developed by Simon, Glick & frank
1) primary endodontic disease
2) primary periodontal disease
3) primary endo secondary perio
4) primary perio secondary endo
5) true combined lesions
Primary endodontic disease: (its non-vital tooth)
-Endo lesions resorb bone apically & laterally & destroy attachments adjacent to a non-vital tooth
-it is possible for an acute exacerbation of a chronic periapical lesion on a tooth with necrotic pulp to drain through the
PDL into the gingival sulcus, this clinical presentation mimics the presence of a periodontal abscess, or a deep
periodontal pocket
-when endodontic infection drains through the PDL, the pocket is very narrow and deep. It is a sinus tract of pupal origin
that opens through PDL and not breakdown due to periodontal disease.
-drainage from the apex of molar tooth extends coronally into furcation area. These case resemble a “through-and-
through” furcation defect (Grade III) of periodontal disease
-for diagnostic purposes, it’s imperative to trace the sinus tract by inserting gutta-percha cone and exposing one or more
radiographs to determine the origin of the lesion.
-the sinus tract of endodontic origin is readily probed down to the tooth apex, where no increased probing depth would
otherwise exist around the tooth
-It will heal following RCT
-the sinus tract extending into the gingival sulcus or the furcation area disappears at an early stage once the necrotic
pulp has been removed and RC sealed
Primary periodontal disease: (is vital tooth)

-caused by periodontal pathogens
-result of progression of chronic periodontitis apically along the root surface
-pulp test yield a clinically normal pulp reaction
-frequently accumulation of plaque and calculus are seen throughout the dentition
-periodontal pockets are wider, and are generalized
-the prognosis depends on the stage of periodontal disease and the efficacy of periodontal treatment
A periapical lesion of endodontic origin will not occur in the presence of normal vital pulp
Primary endo with secondary perio: (if no healing after endo & perio treatment we extract the tooth)
-happens with time as suppurating primary endodontic disease remains untreated, may become secondarily involved
with periodontal breakdown
-plaque forms at gingival margin of the sinus tract and leads to plaque induced periodontitis in the area
-the pathway of inflammation into periodontium is through apical foramen, accessory and lateral canals
-treatment and prognosis are now different than those of teeth simply having endo or perio disease
-tooth now requires both endo and perio treatment
-if RCT is adequate the prognosis depends on the severity of plaque-induced periodontists and efficacy of periodontal
treatment
-with RCT alone, only part of lesion will heal to the level of secondary periodontal lesion
-root fractures and perforations may also be involvement
Primary perio with secondary endo: (extract tooth and place implant)
-apical progression of periodontal pocket continues until apical tissues involved
-pulp may become necrotic as a result of infection entering via the apical foramen
- progression of periodontitis by way of lateral canal and apex to induced a secondary endodontic lesion
-in single-rooted tooth prognosis is poor, as periodontal breakdown is very severe, extraction necessary
-in molar teeth the prognosis may be better, since not all roots may suffer same loss of supporting periodontium. Root
resection considered as treatment alternative
-treatment of periodontal disease can also lead to secondary endodontic involvement. Lateral canals and dentinal
tubules may be opened to oral environment by scaling and root planning or surgical flap
True combined disease: (non-vital tooth with bone loss and lesion)
-true combined endo/perio disease occurs less frequently than other endo-perio problems
-formed when endodontic disease progressing coronally joins with an infected periodontal pocket progressing apically
-degree of attachment loss in this type of lesion is large and the prognosis is thus guarded particularly for single rooted-
teeth.
-concomitant endo-perio lesion is an additional classification that has been proposed to describe the presence of endo
and perio disease as two separate and distinct entities
Diagnosis
-data collected must include:
1) periapical radiographs 2) pulp vitality testing 3) percussion 4) palpation 5) pocket probing
6) sinus tract tracking 7) cracked tooth testing (transillumination, tooth-slooth, staining )
Treatment decision-making and prognosis:

-depends primarily on the diagnosis of the specific endodontic &/or periodontal disease
-main factors to consider are pulp vitality and type and extent of the periodontal defect
-diagnosis of primary endo & primary perio disease usually present no clinical difficulty, in primary endo pulp is non vital,
in primary perio pulp is vital
-diagnosis of combined endo/perio lesions present clinically and radiographically very similar. The diagnosis is often
tentative with a definitive diagnosis formulated following treatment
-prognosis and treatment of each endo/perio disease type varies
-primary endo should only be treated by endodontic therapy and has a good prognosis
-primary perio should only be treated by periodontal treatment, prognosis depend on severity of the perio disease and
the patient respond to the treatment
-combined lesion should be treated with endodontic therapy first, evaluated in 2-3 months, and only then periodontal
treatment be considered. This sequence allows for sufficient time for initial tissue healing and better assessment of the
periodontal condition to determine if the tooth needs SC/RP or surgical treatment. Prognosis depends on the
periodontal involvement and treatment
-cases of true combined disease usually have a more guarded prognosis.
Drugs used in endodontics
When do we use antibiotics?
1) Treatment of infection in periapical region 2) prophylaxis
1)Treatment of an infection in periapical region:

-only pain, localized swelling, symptomatic pulpitis, chronic apical abscess(drainage from the sinus tract)
-antibiotics are only used as adjuncts to treatment with RCT & drainage
-in the presence of clinical manifestations suggesting the possibility of (systemic spread of the infection) or in the
presence of (widespread and unhealed infections)
-systemic symptoms: 1) fever, chills, chills within 24 hours 2) malaise, tiredness, fatigue, dizziness, rapid breathing 3)
trismus 4) lymphadenopathy 5) cellulitis (non-localized widespread infection in soft tissue)
Acute apical abscess:

-when its associated with diffuse swelling leading to develop cellulitis with infectious process dissemination to other
anatomic spaces, or when its exhibits evidence of systemic involvement such as fever, malaise, regional lymphadenitis or
trismus, antibiotics are necessary as adjuvant treatment to drainage because the patient’s immune system is incapable
of stopping the infection advance.
-antibiotic treatment may be applied in the case of (flare-up) which defines pain and swelling after RCT in accordance
with the criteria stated
-antibiotics are necessary in severe (traumatic injury) cases and after replantation of the (avulsed teeth)
-another condition requiring systemic antibiotics use in periapical (actinomycosis) which is a persistent periapical
infection. In these cases it’s necessary to apply apical surgery with penicillin application.
-if the (sodium hypochlorite solution) used for irrigation in delivered to the periapical region, or if its accidentally
injected instead of the anesthetic solution as a more serious complication, antibiotics should be given to prevent
secondary infection of the tissues, which is likely to become necrotic, in addition, to emergency procedures.
Which antibiotic? (These factors should be evaluated together)

1) detection of microorganisms 2) the severity of infection 3) general health status of the patient
-endodontic infections are (polymicrobial) and most of these isolated microorganisms are (obligate) or (facultative
anaerobic) bacteria
-(spectrum of the antimicrobial activity) is the range of bacterial types against which the antibiotic is effective
-selection the (narrowest spectrum antibiotics) sensitive to the causative microorganisms
-ideally, pre-treatment specimens should be taken to identify the causative microorganisms by (culture) and to give the
appropriate antibiotic according to the (susceptibility test) result
-takes several days to weeks –we know approximately the microorganisms found in endo infection
-empiric selection of (antibiotic)
-persistent infection → cultivation methods
-preferred antibiotics for endodontic infections:
1) penicillin V
2) amoxicillin
3) clarithromycin or azithromycin
4) metronidazole
5) clindamycin
-penicillin V:
-it’s a (narrow spectrum) antibiotic for infections caused by aerobic gram-negative cocci, facultative and anaerobic
microorganisms
-it can be a good first option for endodontic infections due to its effectiveness and low toxicity, but there is a risk of
(allergy)
-a loading dose of 1000 mg of penicillin V should be administrated orally followed by 500 mg every 6h to achieve a
steady serum level
-amoxicillin:
-is an analogue of penicillin that is rapidly absorbed and has a (longer half-life).
-This is reflected in higher and more sustained serum levels than penicillin V is.
-often used for antibiotic prophylaxis of the patients that are medically compromised.
-May be used for serious odontogenic infections
-its extended spectrum may select for additional resistant strains of bacteria.
-The usual oral dosage (1000 mg loading dose) followed by (500 mg every 8h) for 5-7 days
-the combination of (amoxicillin with clavulanic acid) is the most effective antibiotic combination
-(clavulanic acid and sulbactam) are competitive inhibitor of the betalactomas enzyme produced by bacteria to inactive
penicillin.
-Ampicillin:
- ampicillin + sulbactam combination
-Azithromycin and Clarithromycin:
-these are macrolide antibiotics such as erythromycin
-unlike erythromycin they are effective on some anaerobic species seen in endodontic infections
-(in the case of penicillin allergy) Azithromycin and Clarithromycin should be preferred to (moderate infections).
-They less likely to cause gastrointestinal side-effect than erythromycin
-the oral dosage of Clarithromycin is a 500 mg loading dose followed by 250 mg every 12h for 5-7 days
-the oral dosage for Azithromycin is a 500 mg loading dose followed by a 250 mg once a day for 5-7 days
-Metronidazole:
-it’s a synthetic antimicrobial agent that is bactericidal and has activity against anaerobes, but lacks activity against
aerobes and facultative anaerobes
-( metronidazole) may be used in (combination with) penicillin or clindamycin
-if patients symptoms worsen 48-72 hours after initial treatment and the prescription of either penicillin or clindamycin,
metronidazole may be added to the original antibiotic
-its (important) that the patient continue to take penicillin or clindamycin, which are effective against the facultative
bacteria and those resistant to metronidazole.
-the oral dosage for metronidazole is a 1000 mg loading dose followed by 500 mg every 6h for 5-7 days
-Clindamycin:
-is effective against gram-positive facultative microorganisms and anaerobes
-it’s a god choice if the patient has allergy to penicillin or a change in antibiotic is indicated
-penicillin and clindamycin have shown to produce good results in treating odontogenic infections
-the oral dosage for serious endodontic infection is a 600 mg loading dose followed by 300 mg every 6h for 5-7 days
2) Prophylaxis:
-(transient bacteremia) due to viridans group streptococci
1) manipulation of gingival tissue 2) manipulation of gingival region 3) all dental procedures involving oral mucosa
perforations
-(dental antibiotic prophylaxis) is the administration of antibiotics to a dental patient for prevention of harmful
consequences of bacteremia, that may be caused by invasion of the oral flora into an injured gingival or periapical vessel
during dental treatment
-it’s used to prevent the development of complications such as (infective endocarditis) or (post-surgical infection) in
dentistry
-antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions associated with the
highest risk of adverse outcomes from endocarditis, including:
1) prosthetic cardiac value or prosthetic material used in value repair
2)previous endocarditis
3) congenital heart disease (CHD)
4) cardiac transplantation recipients with cardiac valvular disease
-recommended:
-all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the
oral mucosa
-surgical/periodontal/endodontic procedures
-intraligamenter anesthesia
-re-implantation of avulsed tooth
-dental implant procedures
-not recommended:
-routine anesthetic injection through non-infected tissue
-taking dental radiographs
-placement of RD or orthodontic appliance / brackets
-shedding of deciduous teeth
-post placement
Antibiotic prophylactic regimens for dental procedures
situation agent adults children

oral amoxicillin 2g 50 mg / kg
Unable to take oral Ampicillin OR 2g IM or IV 50mg / kg IM or IV
medication cefazolin or ceftriaxone 1g IM or IV 50mg / kg IM or IV
Allergy to penicillin / Cephalexin OR 2g 50mg/kg
ampicillin oral regimen clindamycin OR 600 mg 20mg/kg
azithromycin 500 mg 15mg/kg
Allergy to penicillin / Cefazolin or 1g IM or IV 50mg / kg IM or IV
ampicillin to take oral ceftriaxone OR
medication clindamycin 600 mg IM or IV 20mg / kg IM or IV
Prophylaxis:
-if several sessions are required and if the practitioner uses antibiotics prophylaxis, the sessions must be scheduled at
least 10 days apart if possible
-a single prophylaxis can be planned for various dental procedures within 6 hours
-if a prophylactic antibiotic was not administered by mistake in a patient in need of treatment, the same dose can be
administered up to 2 hours after the procedure
-for patients who are taking antibiotics for another reason they should be taken with another class of antibiotics before
treatment (such as clindamycin if taking penicillin)
Analgesics:
intervention:-should be directed to the source of the pain 1) acute pulpitis 2) dentolveolar abscess → extirpation of
dental pulp, drainage, extraction of the tooth
-use of analgesics usually for postoperative pain
-3D approach for treating acute pain: 1) diagnosis 2) definitive treatment 3) drugs
-which analgesics: 1)narcotic 2)non-narcotic
-narcotic:
-influences the central nervous system
-psychological and physical dependency characteristics ex: codeine
-not used dentistry practice
-non-narcotic:
-most of the drugs in this group have both antipyretic and anti-inflammatory properties at the same time
-the most preferred drug group is non-steroidal analgesics and anti-inflammatory drugs (NSAIDs).
- NSAIDs:
- inhibit the synthesis of prostaglandins
-prostaglandin is the most important hyperalgesia and inflammatory mediator
-cyclooxygenases is the enzyme that mediate the formation of prostaglandins (COX)
- NSAID inhibit the prostaglandin synthesis by inhibiting the enzyme cyclooxygenases (COX)
-paracetamol: (acetaminophen)
-unlike NSAIDs the inflammatory effect of acetaminophen is very weak
-the anti-inflammatory effect is minimal but it is safer in terms of side effects
-to be selected in cases where NSAIDs are contraindicated
-is generally considered during pregnancy and while breastfeeding
DIAGNOSİS OF PULPAL DISEASES
Assoc. Prof. Dr. Atakan Kalender

Diagnosis is defined as utilization of scientific
knowledge for identifying a diseased process and
to differentiate from other disease process
The diagnostic process actually consists of 4 steps:
1. Assemble all the available facts gathered from
chief complaints, medical and dental history,
diagnostic tests and investigations
2. Analyze and interpret the assembled clues to reach
the tentative or provisional diagnosis
3. Make differential diagnosis of all possible diseases
which are consistent with signs symptoms and test
results gathered
4. Select the closet possible choice.
• The diagnostic process actually consists
of four phases.
• PHASE I
• Subjective phase
• Chief complaint
• History of present illness
• Medical history
• Dental history
• Objective phase
• Visual examination
• Palpation
• Percussion
• Mobility and depressibility tests
• Transillumination
PHASE II
• Radiographs
PHASE III
• Heat test, Cold test, and Electric pulp test
PHASE IV
• Anesthesia test and test cavity
Grossmans clinical classification of
pulpal diseases.
PULPITIS
A. Reversible pulpitis
• - Symptomatic (acute)
• -Asymptomatic (chronic)
B.Irreversible pulpitis
• Acute irreversible pulpitis
• Abnormally responsive to cold
• Abnormally responsive to heat
• Chronic irreversible pulpitis
• Asymptomatic with pulp exposure
• Hyperplastic pulpitis
• Internal resorption
PULP DEGENERATION
• Calcific (radiographic degeneration)
• Other(histopathological diagnosis)
NECROSIS
PULPITIS
ACUTE PULPITIS CHRONIC PULPITIS

Symptomatic Asymptomatic
ACUTE PULPITIS
pulpitis serosa pulpitis purulenta

CHRONIC PULPITIS
pulpitis ulseroza pulpitis polypoza

DIAGNOSTIC CRITERIA FOR PULPAL
DISEASES
NORMAL PULP:
• A normal pulp gives moderate response to pulp
test and this response subsides when the stimulus is
removed.
• The tooth is free of spontaneous pain
• Radiograph shows intact lamina dura,absence of
any pulpal abnormality, calcification and resorption.
PULPITIS
 Inflammation of dental pulp resulting from untreated
caries,trauma or multiple restorations.its principal symptom
is pain.
 Diagnosis is based on clinical findings and is confirmed by x
rays.
 Treatment involves removing decay, restoring the damaged
tooth and some times, performing root canal treatment or
extracting the tooth.
 Infectious sequele of pulpitis include apical periodontitis,
periapical abscess, cellulites and osteomyletis of the jaw,
spread from maxillary teeth may cause purulent sinusitis,
meningitis, brain abcess, orbital cellulites and cavernous sinus
thrombisis.
 Spread from mandibular teeth may cause ludwigs angina,
parahrangeal abcess , mediastinitis, pericarditis and
empyema.
Reversible pulpitis/ hyperemia /
hyperactive pulpalgia:
 Reversible pulpitis is the general category which histologically
may represent a range of responses varying from dentin
hypersensitivity without concomitant inflammatory response
to an early phase of inflammation.
It is an indication of peripheral A delta fiber stimulation.
Symptoms:
 Symptomatic reversible pulpitis is characterized by sharp pain
lasting for a moment,commonly caused by cold stimuli. Pain
doesn’t occur spontaneously and doesn’t continue when
 Asymptomatic reversible pulpitis may result from incipient
caries and is resolved on removal of caries and proper
restoration of tooth.
• Diagnosis:
• Pain:it is sharp but of brief duration ,ceasing when
• Visual examination and history: may show caries
,traumatic occlusion and undetected fracture.
• Radiograph :show normal PDL and lamina dura
• -depth of caries or cavity penetration may be evident.
• Percussion: shows negative or positive response
• Vitality test:
• Pulp responds readily to cold stimuli.
• Electric pulp tester requires less current to cause pain.
•
IRREVERSIBLE PULPITIS:
 It is a persistent inflammatory condition of the pulp ,symptomatic
or asymptomatic ,caused by noxious stimulus. It has both chronic
stages in pulp.
 Etiology:
 bacterial involvement of pulp through caries.
 Chemical ,thermal,mechanical injuries of pulp
 Reversible pulpitis may turn into irreversible pulpitis.
Symptoms
 Rapid onset of pain.,which can be caused by sudden temperature
change ,sweet or acidic food . pain remains even after removal of
stimulus.
 Pain can be spontaneous in nature which is sharp,piercing
,intermittent or continous in nature.
 Pain exacerbated on bending down or lying down due to change in
intrapulpal pressure.
Diagnosis:
 Examination of involved tooth may reveal previous symptoms
.on inspection,one may see deep cavity involving pulp or
secondary caries under restorations.
Radiographic findings:
 -may show depth and extent of caries.
 -slight widening may be evident .
 percussion:
 tooth is tender on percussion.
Vitality tests:
 Thermal test: hyperalgesic pulp responds more readily to cold
stimulation than for normal tooth.pain may perisist even after
removal of irritant.
Electrical test:
 Less current is required is required in initial stages.
 As tissue becomes more necrotic ,more current is required.
CHRONIC PULPITIS:
• It is an inflammatory response of pulpal connective tissue to an irritant. It can be
of three types
• Ulcerative type
• Hyperplastic form
• Closed form of chronic pulpitis
Etiology: same as that of irreversible pulpits.it is normally caused by by slow and
progressive carious exposure of pulp.
Sign and symptoms:
• Pain is absent
• Symptoms develop only when there is interference with drainage of exudates
• Diagnosis
• Hyperplastic form shows a fleshy ,reddish pulpal mass which fills most of the of
pulp chamber of cavity .it is less sensitive than normal pulp but bleeds easily when
probed.
• Radiographic changes shows areas of dense bone around apices of involved teeth.
• Vitality tests
• Tooth may respond feebly or not at all to thermal tests.
• More current than normal is required to elicit response by electric pulp tester.
CHRONIC PULPITIS –
Hyperplastic form
PULP NECROSIS
• Pulp necrosis is a condition following untreated pulpitis.necrosis may
be partial or total ,depending on extent of pulp tissue involvement.
Pulp necrosis is of two types
• Coagulation necrosis:cell protoplasmbecomes fixed and opaque.cell
mass is recognizable histologically,intracellular details are lost
• Liquefaction necrosis:entire cell outline is lost. The liquefied area is
surrounded by dense zone of PMNS,chronic inflammatory cells.
Etiology:
• Necrosis is caused by noxious insult and injuries to pulp by
trauma,bacteria and chemical irritation.
Symptoms
• Discoloration of tooth
• Tooth might may be asymptomatic.
Diagnosis
• Pain is absent in complete necrosis
• History of patient reveals past trauma or past
history of severe pain
• Radiographic changes-shows a large cavity or filling
or normal appearance unless there is concomitant
periodontitis or codendensing osteitis
• Vitality tests-nonresponding to vitality tests.but
multirooted tooth may show mixed response
because only one canal may have necrotic tissue.
• Visual examination-tooth show color changes like
dull or opaque appearance due to lack of normal
translucency.
 Normal
 Necrosis
Normal Pulp
 Symptom no
Reversible Pulpitis

 Symptom spontaneous pain

 Radiography no
 Pulp Test persistant pain
 Periapical test no
Necrotic Pulp

 Pulp Test no
PERIRADICULAR PAHOLOGIES
ACUTE APICAL PERIODONTITIS:
• It is defined as painful inflammation of the
periodontium as a result of trauma,irritation or
infection,through the root cnal ,regardless of whether
the pulp is vital or non vital.
Signs and symptoms:

• Dull ,throbbing and constant pain
• Pain occurs over a short period of time
• Negative or delayed vitality test
• No swelling
• Pain on biting
• Cold may relieve pain or no reaction
• No radiographic sign sometimes widening of
periodontal ligament space.
ACUTE APICAL PERIODONTITIS
 It is a localized collection of pus In the alveolar bone at the root
apex of the tooth,following the death of pulp with extention of the
infection through the apical foramen into periradicular tissue.
Etiology;
 Most common cause is bacterial invasion of dead pulpal tissue but
can also occur by trauma,chemical or mechanical injury.
Signs and symptoms
 Tooth is non vital
 Pain is localized
 Tooth becomes increasingly tender on percussion
 Swelling-palpable,fluctuant
 Tooth may be in hyperocclusion
Radiograph-no change to large periapical radiolucency can be seen
Pulp tests-EPT,COLD,HEAT TEST –no response.
PERIAPICAL GRANULOMA:
It is one of the most common sequelae of pulpitis.it is usually
described as a mass of chronically inflamed granulation tissue
found at the apex of non vital tooth
Signs and symptoms:
 Mostly asymptomatic
 Tooth is not sensitive to percussion
 No mobility
 Soft tissue overlying my or may not b tender
 No response to thermal or electrical pulp test
Radiographic features
 Mostly discovered on routin radiographic examination.
 Thickening of pdl ligament at the root apex
 Lesion may be well circumscribed or poorly defined.
 Size may vary from small lesion to large radiolucency.
Periapical granuloma
Radicular cyst
• It is an inflammatory cyst which results from
because of extension of infection from pulp into the
surrounding periapical tissues.
Signs and symptoms

• Asymptomatic
• Involved tooth found to be non vital.
Radiographic features:
• Radicular cyst appears as round ,pear or ovoid
shaped radiolucency,outlined by a narrow
radiographic margin.
Radicular cyst
External root resorption:
• It is a condition associated with either physiological or a
pathological process that result in loss of tooth
substance from tissue such as dentin,cementum or
alveolar bone.
Symptoms
• Asymptomatic during development
• When external root resorption extends to crown ,it
gives ‘pink tooth ‘experience.
• When root is completely reorbed tooth becomes
mobile.
Radiographs
• Radiolucency at root and adjacent bone.
• Loss of lamina dura.
External root resorption
Sources of non odontogenic pain.
• Myofascial toothache-any deep somatic tissue in
the head and neck region has tendency to induce
referral pain in the teeth,in these structures pain
of muscular origin appear to be most common.
• Muscles which are commonly affected are
masseter and temporalis,but in some cases
pterygoids and digastric muscles are also
affected.
• Palpation of the involved muscles at specific
points(trigger points)may induce pain
Cluster headache
• It is commonly found in age group 20-50 years
• Cluster headaches derive their name from the
temporal behaviour and usually occur in series i.e
one to eight attacks per day
• Pain is unilateral ,excruciating and continous in
nature and usually found in orbital ,supraorbital
and temporal region.
• Autonomic symptoms such as nasal
stuffness,lacrimation,rhinorrhea or edema of
eyelids and face are found.
Cardiac toothache
• Severe referred pain felt in mandible and maxilla from area outside
the head and neck region is commonly from the heart
• Cardiac pain is clinically chracterized by heaviness,tightness or
throbbing pain in the substernal region which commonly radiates to
left shoulder,arm ,neck and mandible.
• Cardiac pain is most commonly experienced on the left side rather
than right,
• In advance cases ,the patient may complain of severe pain and rubs
jaws and chest.
• Usually the cardiac toothache is decreased by taking rest or dose of
sublingual nitroglycerin.
• A complete medical history should be taken when cardiac
toothache is suspected and refererred to cardiologist.
Diseases Of
Periapical Tissues
• Once infection has established in the
dental pulp, spread of the process can be
in one direction- through the root canals
and into the periapical region.
• Number of different tissue reaction may

occur, depending upon a variety of
circumstances.
• Transformation occur from one type of

lesion into another type in most cases
Classification (Alaçam)
a) Acute apical periodontitis
b) Acute apical abscess
c) Chronic apical periodontitis (Periapical

granuloma)
d) Chronic apical abscess
e) Periapical cyst (true and bay)
f) Condensing osteitis
– 1 mm to 10-12 mm
Attention !
Ekstraoral şişlik
Drainage of abscess
bye,
1- Pulp chamber
2- Incision
3- Trepanation
Chronic apical
abscess
Fistulous tract(+)
Pain(-)
Apical radyolusency in
radyography
İntraoral fistül
Mandibular kesicilerden
kaynaklanan eksternal
fistül ağzı
Ekstraoral
ENDODONTIC MICROBIOLOGY

 The vast majority of microorganisms that can enter the
periapex or infected root canal and cause disease are

bacteria.
 Most are anaerobic and each can be isolated from root
canal culture.
Even if they are not pathogenic in the mouth, by
 Metabolism products
 Physicochemical changes
 Virulence factors
they can cause infection in the root canal.

Host defense also affects the disease.
Virulence Factor x Number of Microorganism

Disease
Host defense
The ways of bacterial access to pulp:
1. Coronal
2. Retrograde
3. Hematogenous (Anachoresis)
1. Coronal ways
 Pulpal perforations,
 Crown preparation,
 Pulpal perforation by trauma,
 Operative procedures, saliva contamination or decay,
 Removal of the smear layer formed during the preparation
by the acid etching application ,
 The application of impression material, temporary filling
and cements by pressure,
 Crown anomalies (Dens in dente, Dens evaginatus,
Palatogingival groove)
2. Retrograde ways
 Periodontal disease
 Decreasing gingival fluid
 Local/systematic immunodeficiency
 Bad oral hygiene, bacterial plaque, calculus
 Bruxism
 Trauma and microtrauma

3. Hematogenous way (Anachoresis)
 A bacterium that has passed through blood or
lymphatic circulation by chance from anywhere in the

organism may drift into root canal and initiate infection.
ECOLOGY OF INFECTED ROOT CANAL
 The determinants of which bacteria can be

placed in an infected root canal are called the
ecological determinants of that flora.
1. Low O2 Pressure
2. Blocked Blood Circulation
3. Necrotic Pulp Tissue
4. Dentine Lymph
5. Serum Leakage from Periapex to Root Canal
6. Adhesion to Root Canal Wall
7. Host Defense
1. Low O2 Pressure
 In root canal infections that are caused by caries; O2
pressure on crown pulp is more than root canal.
 In aseptic pulp necrosis or root canal infections caused by
periodontal destruction; O2 pressure of root canal may
increase more that pulp chamber by enlarged periodontal
ligament space
 In both cases, at least oxygen is in the tubules of the dentin
and every environment where oxygen is limited invites
anaerobic microorganisms.
2. Blocked Blood Circulation
 Blood circulation increases in the early period of the
cases of hyperaemia and serous pulpitis
 However, the blood circulation in the pulp stops
completely as the infection progresses.
 This indicates that pulp necrosis has begun, and the
infection has progressed to chronic stage.
 Especially obligatory proteolytic anaerobes develop in
this environment.
3. Necrotic Pulp Tissue
 Necrotic pulp is attractive for bacteria.
 First, carbohydrates are used as energy after glycoproteins
are broken down by bacteria.

4. Dentin Lymph
 Protein-rich liquid in dentin tubules are an early
nutritional source of proteolytic bacteria.

5. Serum Leakage from Periapex to Root Canal
 When the periapex accumulates, the serum
enters the canal via the foramen apical.

 Serum albumin in serum is a separate source
of nutrients for proteolytic bacteria in root

canal.
6. Adhesion to Root Canal Wall
Bacteria attach to enamel and dentin in two ways;
1. Direct Adhesion: Bacteria and host tissue are in direct
contact with one another and do not mediate with
other bacteria or chemicals.
2. Indirect Adhesion: The bacteria need a mediator such
as adhesives, kryptitop-mediated, glucan-binding and
coagulation bridges to hold the host tissue.
Host Cell
The Most Common Microorganisms in the Infected Root Canal
Anaerob
(-) rod Bakterioides, Fusobacterium

(+) rod Actinomyces, Aracnialar
(-) rod Veilonella
(+) rod Peptokok, Peptostreptokok
Aerob
(-) rod Actinobacillus, Hemaphilus, Captophage

(+) rod Streptokok, Enterokok
Anaerobs if root canal is closed, aerobes if it is open.

 In recent years, anaerobes have been shown to play a dominant
role in root canal infections.

 Anaerobs are responsible for the;
 Neutrophil chemotaxis
 Phagocytosis inhibition
 Release of enzymes and endotoxins
 Persistent painful periapical lesions.

 Fungi (Candida albicans) often increase
in open root canals for drainage.

Microbial Virulence Factors in Root Canals
 Coagulase
 Collagenase
 Hemolysin
 Necrotoxin
 Gelatinase (Gelatinase)
 Compleman
 Chemotaxis inducing factors
 Chemotaxis inhibiting factors
 Hyaluronidase
 Edema forming factor
 Catalase
 Exotoxins
Endotoxins are found in the wall of Gram (-)
microorganisms.
 Chemotactic for PMNs.
 Cause platelet damage in blood.
 Degranulate mast cells to release histamine.

 Activates the Hageman factor (initiates blood
clotting and produces bradykinin).

 Stimulates and attracts osteoclasts.
 Stimulates bone resorption.
 Promotes leukopenia and hypoglycemia.

 Raises the fire.
 Causes hypotension.
 Encourage concussion.
 Promotes Hypersensitivity Arthus reaction
and may cause death.

Endotoxin in Root Canal
 Many chronic apical lesions occur when

anaerobic microorganisms are present alone or in
combination with other species.
 Even very small quantities of endotoxins can
cause periapical inflammatory response.
Endotoxin and Pulpal Pain
 It has been suggested that endotoxins increase vasoactive and
neurotransmitter substances at the nerve endings in inflammatory

periapical lesion.
 Bacterioides melaninogenicus produces collagenolytic and

fibrinolytic enzymes. This bacteria’s endotoxin has the capacity to
activate the Hageman factor, which is effective in mediating pain
mediator bradykinin.
Collection of Samples from Root Canal
Culture technique was used to;
 Determination of microorganisms responsible for pulp and
periapical tissue diseases,
 In testing whether an aseptic technique is applied in endodontic
therapy,
 Determination whether the root canal is ready for filling,
 When a resistant and persistent infection can not be resolved,
identification of microorganisms and antibiotics and drugs to
which they are specifically susceptible.
 Sterility of root canal (number of microorganisms
in root canal) can not be determined definitively by
smell or appearance.
 Whether or not the root canal are ready for filling is
most reliably understood by bacteriological
controls. It is important to obtain negative culture.
Culture Method
1. Rubber dam is applied. The temporary filling is removed

and root canal medication is removed with a sterile tirner.
2. The cover or cotton in the mouth of the culture tube is
loosened next to a burning bunsen beaker. A paper point
smaller than the size of the last used file is placed on the
apical side of the canal by a sterile presel. Remove the tube
by rotating it and place it in the test tube.
3. On the tube, the patient's name, the date and culture
taken tooth are recorded.
4. The tube is incubated at 37 ° C for a minimum of 72 hours.
Problems That Can Happen When Applying
Cultural Techniques
 The region with bacteria in the root canal can not be
reached or a sufficient number of germs are not
transported to the culture medium.
 Contaminations that occur during culture can lead to
wrong provisions about the condition of the root canal.
 More importantly, periapical inflammation can develop
without producing bacteria.
 Despite the negative culture, canal contamination can
occur during culturing and filling sessions.
ENDODONTIC
PERIODONTAL
LESIONS
Doç. Dr. Atakan KALENDER

Anatomic Considerations
 There is an intimate relationship between

the periodontium and pulpal tissues
 As the tooth develops and the root is

formed, 3 main avenues for
communication are created:
1. Apical Foramen
2. Lateral and Accessory Canals
3. Dentinal Tubules
Apical Foramen
 It is the principal and the most direct route of

communication between the pulp and
periodontium
 Bacterial and inflammatory byproducts may exit

readily through the apical foramen to cause
periapical pathosis
 The apex may also serve as a portal of entry of

inflammatory byproducts from deep periodontal
pockets to the pulp
Apical Foramen
SEM of the apical third of a root. Note the opening of an
accessory canal at ninety degrees from the main canal
Lateral and Accessory
Canals
 These may be present anywhere along the
root
 Patent accessory and lateral canals may

serve as a potential pathway for the spread
of bacterial byproducts
 30-40% of all teeth have lateral or

accessory canals and the majority of them
are found in the apical third of the root
Lateral Canals
Dentin Tubules
 Exposed dentinal tubules in areas of

denuded cementum may serve as
communication pathways between the pulp
and PDL
 In the root, dentinal tubules extend from

the pulp to the dentinocemental junction.
They range in size from 1 to 3 microns in
diameter (bacteria and their toxins are
smaller in size)
Dentinal Tubules
Scanning electron micrograph of open dentinal tubules

Dentin Tubules
 The tubules may be denuded of their

cementum coverage as a result of perio
disease, surgical procedures or
developmentally when the cementum and
enamel do not meet at the CEJ thus
leaving areas of exposed dentin
 Patients experiencing cervical dentin

hypersensitivity are examples of such a
phenomenon
Additional Avenues of
communication between the
Pulp and the Periodontium
 Developmental malformations – such as
palatogingival grooves of maxillary incisors. These
usually begin in the central fossa, cross the
cingulum, and extend apically with varying
distances
 Perforations – these may result from extensive

carious lesions, resorption, or from operator error
 Vertical root fractures – these can produce deep

periodontal pocketing and localized destruction of
alveolar bone. The fracture site provides a portal
of entry for irritants from the root canal to the PDL
Endodontic Disease and
the Periodontium
 When the pulp becomes inflamed or

necrotic, inflammatory byproducts
may leach out through the apex,
lateral and accessory canals as well
as the dentinal tubules to trigger an
inflammatory vascular response in the
periodontium
Seltzer and Bender 1967
Periodontal Disease and the
Pulp
 The effect of periodontal inflammation on the pulp
is controversial and conflicting studies exist:
 It has been suggested that periodontal disease has no

effect on the pulp, at least until it involves the apex
(Czarnecki & Schilder, ‘79)
 On the other hand, some studies suggest that the effect

of perio disease on the pulp is degenerative in nature
including an increase in calcifications, fibrosis and
collagen resorption in the pulp (Langeland et al ‘74 and
Mandi ‘72)
 It has been reported that pulpal changes resulting from

periodontal disease are more likely to occur when the
apical foramen is involved (Langland et al ’74)
Differential Diagnosis of
Endo/Perio Lesions
 The following classification system was

developed by Simon, Glick and Frank in
1972:
 Primary Endodontic Disease
 Primary Periodontal Disease
 Primary Endo Secondary Perio
 Primary Perio Secondary Endo
 True Combined Lesions
Primary Endodontic
Disease
 Typically, endodontic lesions resorb bone
apically and laterally and destroy the
attachment apparatus adjacent to a
nonvital tooth
 It is possible for an acute exacerbation of a

chronic periapical lesion on a tooth with a
necrotic pulp to drain through the PDL into
the gingival sulcus. This clinical
presentation mimics the presence of a
periodontal abscess, or a deep periodontal
pocket
Primary Endodontic
Disease
 When endodontic infection drains through
the PDL, the pocket is very narrow and
deep. In reality, it is a sinus tract of pulpal
origin that opens through the PDL, and not
breakdown due to periodontal disease
 A similar situation can occur where

drainage from the apex of a molar tooth
extends coronally into the furcation area.
These cases resemble a “through-and-
through” furcation defect (Grade III) of
periodontal disease
Primary Endodontic
Disease
 For diagnostic purposes, it is imperative to
trace the sinus tract by inserting a gutta-
percha cone and exposing one or more
radiographs to determine the origin of the
lesion
 The sinus tract of endodontic origin is

readily probed down to the tooth apex,
where no increased probing depth would
otherwise exist around the tooth
Primary Endodontic
Disease
 Primary endodontic disease will heal
following root canal treatment
 The sinus tract extending into the

gingival sulcus or the furcation area
disappears at an early stage once the
necrotic pulp has been removed and
the root canals are well sealed
Primary Endodontic
Disease
Pre-op Post-op 2 yr follow-up
Primary Endodontic
Disease
Pre-op: periapical and furcal RL + a deep narrow perio defect
Primary Endodontic
Disease
1 yr follow-up: complete healing of RL and buccal defect
Primary Periodontal
Disease
 Caused by periodontal pathogens
 It is the result of progression of

chronic periodontitis apically along
the root surface
 Pulp tests yield a clinically normal

pulpal reaction
Primary Periodontal
Disease
 Frequently accumulation of plaque and
calculus are seen throughout the dentition
 Periodontal pockets are wider, and are

generalized
 The prognosis depends on the stage of

periodontal disease and the efficacy of
periodontal treatment
Primary Periodontal
Disease
Pre-op: alveolar bone loss + a periapical lesion, a deep narrow
pocket was traced on the mesial aspect of the root, the
tooth tested vital
Primary Periodontal
Disease
The tooth was extracted. Note the deep mesial radicular
developmental groove
Primary Periodontal
Disease
was referred for RCT. The tooth tested vital to cold
Primary Periodontal
Disease
Referring dentist insisted that endo be done. However, since
the etiology was periodontal disease, no bony healing took
place
A periapical lesion of
endodontic origin will not
occur in the presence of a
normal vital pulp!!!
Primary Endo with
Secondary Perio
 This happens with time as
suppurating primary endodontic
disease remains untreated, it may
become secondarily involved with
periodontal breakdown
 Plaque forms at the gingival margin

of the sinus tract and leads to plaque-
induced periodontitis in the area
Primary Endo with
Secondary Perio
 The pathway of
inflammation into the
periodontium is
through the apical
foramen, accessory
and lateral canals
Primary Endo with
Secondary Perio
 The treatment and prognosis are now
different than those of teeth simply having
endo or perio disease
 The tooth now requires both endodontic

and periodontal treatments
 If the endodontic treatment is adequate,

the prognosis depends on the severity of
the plaque-induced periodontitis and the
efficacy of periodontal Treatment
Primary Endo with
Secondary Perio
 With endodontic treatment alone,
only part of the lesion will heal to the
level of the secondary periodontal
lesion
 Root fractures and perforations may

also peresent as primary endo with
secondary periodontal involvement
Primary Endo with Secondary
Perio
Pre-op: interradicular
defect extends to the apex Post-op
Primary Endo with
Secondary Perio
1 yr follow-up: resolution of most of the periradicular lesion,
however, a bony defect at the furcal area remained. Perio
Treatment is necessary for further healing
Primary Perio with
Secondary Endo
 In this case, the apical progression of
a periodontal pocket continues until
the apical tissues are involved
 The pulp may become necrotic as a

result of infection entering via the
apical foramen
Primary Perio with Secondary
Endo
 The progression of
periodontitis by way
of lateral canal and
apex to induce a
secondary endodontic
lesion
Endo
 In single-rooted teeth the prognosis is
usually poor, as the periodontal breakdown
is very severe, extraction may be necessary
 In molar teeth the prognosis may be

better, since not all the roots may suffer
the same loss of supporting periodontium.
Root resection may be considered as a
treatment alternative
Endo
 Even though unusual, the treatment
of periodontal disease can also lead
to secondary endodontic involvement.
Lateral canals and dentinal tubules
may be opened to the oral
environment by scaling and root
planing or surgical flap procedures
True Combined Disease
 True combined endo/perio disease occurs

less frequently than other endo/perio
problems
 It is formed when an endodontic disease

progressing coronally joins with an infected
periodontal pocket progressing apically
 The degree of attachment loss in this type

of lesion is large and the prognosis is thus
guarded, particularly for single-rooted
teeth.
 Concomitant endo-
perio lesion is an
additional
classification that has
been proposed to
describe the presence
of endo and perio
disease as two
separate and distinct
entities
Radiograph shows separate progression of endodontic disease

and periodontal disease. The tooth remained untreated and
consequently the two lesions joined together
Radiograph shows bone loss in 2/3 of the root with periapical

radiolucency. Clinical exam revealed coronal color change
and pus exuding from the gingival crevice. Pulp vitality tests
were negative
Diagnosis
 A thorough clinical and radiographic examination is

imperative for developing a diagnosis
 Data Collected must include:

 periapical radiographs
 pulp vitality testing: cold, EPT, cavity test
 percussion
 palpation
 pocket probing
 sinus tract tracking
 cracked tooth testing: transillumination, tooth-slooth,
staining
Treatment Decision-Making
and Prognosis
 Treatment decision-making and

prognosis depend primarily on the
diagnosis of the specific endodontic
and/or periodontal disease
 The main factors to consider are pulp

vitality and type and extent of the
periodontal defect
and Prognosis
 Diagnosis of Primary endo and Primary

perio disease usually present no clinical
difficulty. In primary endo the pulp is
nonvital. In primary perio the pulp is vital
 However, the diagnosis of the combined

endo/perio lesions could present a challege
as they present clinically and
radiographically very similar. The diagnosis
is often tentative with a definitive diagnosis
formulated following treatment
and Prognosis
 The prognosis and treatment of each
endo/perio disease type varies
 Primary endo should only be treated by

endodontic therapy and has a good
prognosis
 Primary perio should only be treated by

periodontal treatment. The prognosis
depends on severity of the perio disease
and patient response to treatment
and Prognosis
 Combined lesions should be treated with
endodontic therapy first. Treatment should
be evaluated in 2-3 months, and only then
should periodontal treatment be
considered. This sequence allows for
sufficient time for initial tissue healing and
better assessment of the periodontal
condition to determine if the tooth needs
SC/RP or surgical treatment. Prognosis
depends on the periodontal involvement
and treatment
 Cases of True Combined disease usually

have a more guarded prognosis
ISOLATION IN ENDODONTICS

THE GOALS OF ISOLATION ARE:
• Moisture control
• Retraction
• Harm prevention
WHAT NEEDS TO BE CONTROLLED DURING ENDODONTIC
PROCEDURES?
• Saliva
• Tongue
• Mandible
• Lips & Cheek
• Gingival tissue
• Buccal & Lingual Vestibule
• Floor of the mouth
• Adjacent teeth and restoration
• Respiratory moisture
PATIENT RELATED ADVANTAGES
• Provides comfort to the patient

• Protect patients from swallowing or aspirating foreign bodies
• Protect patient’s soft tissues by retracting them
OPERATOR RELATED ADVANTAGES
• A dry clean field

• Infection control
• Increased accessibility
• Improved properties of materials
• Improved visibility & less fogging of mirror
• Prevents contamination of root canal preparation
CLASSIFICATION OF THE METHODS USED TO
OBTAIN ISOLATION
1. Moisture Isolation
• Direct methods
• Indirect methods
2. Soft Tissue Isolation
• Retraction of the lips, cheek and tongue
• Retraction of the gingiva
DIRECT METHODS OF MOISTURE ISOLATION
1. Rubber dam
2. Cotton rolls & gauze
3. Absorbent cellulose wafers
4. Suction devices
5. Gingival retraction cord
INDIRECT METHODS OF MOISTURE ISOLATION
1. Comfortable patient position & relaxed surroundings

2. Local anesthesia
3. Drugs
RUBBER DAM
• It is a flat thin sheet of latex/non-latex that is

held by a clamp and a frame, that is preferred
to allow the tooth/teeth to protrude through
the perforations, while all other teeth are
covered.
ADVANTAGES OF RUBBER DAM
ISOLATION
• Long term moisture control
• Maximum accessibility and visibility
• Provides dry and clean operating field
• Reducing the risk of cross-infection
• Protects dentists against infections which can be transmitted by
the patient‘s saliva
• Protects lips, cheek and tongue against possible trauma
from rotary and hand instruments
• Prevent accidental swallowing and aspirating of
endodontic instruments, medicaments, irrigating solutions
and debris
• Minimizes patients conversation during root canal
treatment and encourages them to open their mouth
• Eliminates need for repeated change of cotton rolls due
to flooding of saliva or root canal irrigants
• Improves the performance of materials used
DISADVANTAGES OF RUBBER DAM
ISOLATION
• Takes time to be applied
• Communication with the patient is difficult
• Possible damages to crowns and gingival tissues
• Insecure clamp maybe swallowed or aspirated
POSSIBLE CONTRAINDICATIONS FOR
RUBBER DAM ISOLATION
• Asthmatic patients
• Latex allergy
• Mouth breathers
• Malposed, tilted teeth
PRECAUTIONS
• The rubber dam should not obstruct patient’s
airway and thus should not cover his nose.
• Holes should be prepared in rubber dam for
patients with upper respiratory tract obstruction.
• On patients with allergy to latex, latex free rubber
dam should be used. Rubber dam napkin can be
used to prevent the latex rubber dam from
contacting the patient’s tissues.
COMPONENTS OF THE RUBBER DAM
ARMAMENTARIUM
1. Rubber dam sheet
2. Rubber dam clamps
3. Rubber dam forceps
4. Rubber dam frame
5. Rubber dam punch
6. Rubber dam template
7. Scissors
Accessories
1. Lubricant
2. Dental floss
3. Rubber dam napkin
RUBBER DAM SHEET
Material
• Latex
• Non-latex
Sizes
• 5’’x5’’
• 6’’x6’’
Thickness
• Light
• Medium
• Heavy
Different colors
RUBBER DAM CLAMPS
Functions
• Secures the dam to the teeth
• Retract to gingiva
Types
• Winged
• Wingless
ANTERIOR TEETH
PREMOLAR TEETH
MOLAR TEETH
RUBBER DAM FRAME
Functions
• Maintains the border of the dam in position
• Support the edges of the rubber dam
• Retract the soft tissues
RUBBER DAM FORCEPS
Function
• Used to place and remove clamp on the tooth
RUBBER DAM PUNCH
Function
• Make holes in the sheet through which the teeth can be isolated
Parts
• Rotating disc with different sized holes
• Sharp pointed plunger
ACCESSORIES
• Dental floss: It is used as flossing agent for rubber
dam in tight contact areas.
• Rubber dam napkin: This is a sheet of absorbent
material placed between the rubber dam and skin.
• Lubricant: A lubricant is applied in the area of
punch holes facilitates the passing of dam septa
through proximal contacts.
APPLICATION OF RUBBER DAM
• Winged technique
• Wingless technique
• Rubber first
WINGED TECHNIQUE
flossed.
WINGED TECHNIQUE
• The rubber dam is punched and aligned
with the quadrant to be treated.
WINGED TECHNIQUE
• The clamp is held in the forceps and retained with

the ratchet.
WINGED TECHNIQUE
• The hole in the rubber is stretched across the
wings of the clamp, positioning the bow of the
clamp towards the back of the arch.
WINGED TECHNIQUE
• The clamp is placed onto the tooth to be treated.

WINGED TECHNIQUE
• The frame and gauze are applied.
WINGLESS TECHNIQUE
flossed.
• The rubber dam is punched and aligned with the
quadrant to be treated.
• The clamp, held in the forceps and retained with
the ratchet, is placed securely on the tooth.
• One advantage of this method is that the
opportunity now exists to verify the fit of the clamp
before proceeding.
• The rubber dam is now held in both hands, and
the index fingers used to stretch out the punched
hole, which is slipped over the bow of the clamp
and pulled forward and down onto tooth.
• The frame and gauze are applied, the floss
removed and the seal verified or adjusted as
necessary.
RUBBER FIRST
• The dentist stretches out the rubber and places the hole over the tooth in
question, holding it down on each side with light finger pressure.
• At the same time the dental nurse picks up the flossed clamp in the
forceps and places it over the tooth, retaining the dam in place.
• Once again, the frame and gauze are applied.
3.Class
2019-2020

Assoc.Prof.Dr.Umut Aksoy
SUCCESS IN ENDODONTIC THERAPY

DEPENDS ON THE MAIN 3 FACTORS:
•ACCURATE DIAGNOSIS
•COMPLETE CHEMO-MECHANICAL
PREPARATION
•3 DIMENSIONAL OBTURATION OF
ROOT CANALS FROM THE CORONAL
PORTION OF THE CANAL TO THE
APICAL FORAMEN

at the CDJ

& important role in the treatment’s success

at the CDJ

& vital role in the treatment’s success
OBJECTIVES OF ROOT CANAL OBTURATION

1-To prevent leakage of bacterial organisms, bacterial elements and
nutritional elements from the oral environment to the root canal
(coronal leakage)
2-To inhibit growth of any surviving bacteria in dentinal tubules and
uninstrumented parts of the root canal space
3-To prevent release of bacterial elements in the other direction, i.e.
from the root canal to the apical environment (apical leakage)
4-To prevent leakage of nutritional elements from the periapical
tissue to the canal space.
5-To allow proper healing of the periapical tissues
3 MAIN FUNCTIONS OF ROOT CANAL FILLING
KÖK KANAL DOLGUSUNUN 3 ANA GÖREVİ:
1.KORONAL SIZINTIYI DURDURUR
2.CANLI KALABİLMİŞ BAKTERİLERİ
ELİMİNE EDER
3.PERİAPİKAL DOKU KAYNAKLI
SIVILARIN KÖK KANALINA
ULAŞMASINA ENGEL TEŞGİL EDER
Effective obturation of the

root canal space and coronal
restoration prevents apical
and coronal leakage and
eliminates the pulp cavity as
a reservoir of infection.
Obturation of the radicular space:

1.Eliminates leakage
2.Reduces coronal leakage & bacterial
contamination
3.Seals the apex from the periapical tissue
fluids
4.Entombs the remaining irritants in the
canal
Inadequate obturation of the root

canal invites failure and requirement
for surgical procedures
such as:
periapical surgery or extraction
Criterias for Root Canal Obturation

The root canal can be obturated when:
• There is an absence of pain and swelling.

• There is no tenderness to percussion and palpation.
• There is no patent sinus tract.
• The canal is dry.
• The canal is odour-free.
• Temporary filling material is intact.
• Negative culture is obtained (not required in clinic).
Ideal Properties of Root Canal Obturation Materials
★ It should be easily introduced into the root canal system
★ It should seal the canal laterally as well as apically.
★ It should not shrink after being inserted.
★ It should be impervious to moisture.
★ It should be bacteriostatic or at least not encourage bacterial
growth.
★ It should be radiopaque
★ It should not stain tooth structure.
★ It should not irritate periapical tissue. (Biocompatibility)
★ It should exhibit a slow set.
★ It should be easily removed from the root canal if necessary.
_________________________________________
__________________________________
•SILVER CONE 
•GUTTA-PERCHA  
•RESILON  
•COATED CONES  
__________________________________
Today, the most recommended

material for filling the root
canals is gutta percha with a
root canal sealer.
Gutta-percha
• The concrete juice of Isonandra gutta, Palaquium
gutta and Dichopsis gutta are the main trees from
where, we obtain Gutta-percha material.
• Gutta-percha has been used in Endodontics for over

100 years and is currently the most frequently used
core material for permanent obturation of root canals.
Composition and mechanical properties of
gutta-percha endodontic points
Material % Function
Gutta percha 18-22 Matrix

Zinc oxide 59-76 Filler
Wax/Resin 1-4 Plasticizer
Metal sulfates 1-18 Radiopacifier
Major advantages of gutta-percha
• 1- Compactible
• 2- Minimal toxicity
• 3- Dimensional stability
• 4- Radioopacity
• 5- Inert (not resorbable)
• 6- Plasticity
• 7- Ease of removal with heat or solvents

Disadvantages of gutta-percha
• 1- Lack of rigidity
• 2- Lack of adhesion to dentin
ROOT CANAL OBTURATION TECNIQUES WITH GUTTA PERCHA:
I.SOLID CORE TECHNIQUES
1) SINGLE CONE TECHNIQUE
2) COLD LATERAL COMPACTION
II.SOFTENED CORE TECHNIQUES

1) WARM LATERAL COMPACTION
2) WARM VERTİCAL COMPACTİON
3) THERMOMECHANICAL COMPACTİON
4) INJECTION-MOLDED GUTTA PERCHA
5) CORE CARRIER TECHNIQUE
6) CHLOROPERCHA TECNIQUE
The objective is to fill the canal

with gutta-percha cones by
compacting them laterally against
the sides of the canal walls.
Master cone selection
• After root canal system preparation, a

standard cone should be selected that
has a diameter consistent with the
prepared canal diameter at the working
length. This is “master cone”.
• For exp. If we used file no: 40 at the
working length
Master cone should be no: 40
Master Cone
How to fit that master gutta-percha cone?
• Clinical examination
• Radiographic examination
1- Clinical Examination
• This “master cone” is measured and grasped
with cotton plier so that the distance from
the tip of the cone to the reference point on
the plier is equal to the prepared length. A
reference point on the cone can be made by
pinching the cone.
• The cone is placed in the canal, and if an
appropriate size is selected, there will be
resistance to displacement: “tug-back”.
Clinical Examination
• If there is no tug-back and the cone is loose it
can be adapted by removing small increments
from the tip until a good fit is obtained.
• If the master cone fails to go to the prepared
length, a smaller cone can be selected. Or
make the preparation again.
• When the cone extends beyond the prepared
length a larger cone must be adapted or the
existing cone shortened until there is
resistance to displacement at the corrected
working length.
Ideal Master Cone Features
• 1- Should be fitted at working length
• 2- Master cone should be fitted laterally at the apical

portion of tooth and there must a well tug-back feeling
• 3- Master cone should be at the point of

cementodentinal junction and 0,5 - 1 mm short from
• 4- Never extend beyond the apical foramen

• After adaptation and clinical examination of

master cone, a radiograph should be taken to
make sure that the master cone is at the
working length. It must be 0.5 - 1 mm short of
SOĞUK LATERAL KOMPAKSİYON YÖNTEMİ:
•that's all for now
• to be continued…
• love endo…
ENDODONTIC COMPLICATIONS

a. Inadequate opening of the access

cavity
b. Wide opening of the access cavity
c. Perforations
a. Root perforations
b. Working length problems
-Ledge formation
-Canal blockage
c. Zipping
d. File fracture
e. File aspiration or swallow
a. Under or overfilling
b. Nerve paresthesia
c. Root fracture
a. Post perforation
b. Tissue Emphysema
1. ANESTHESIA COMPLICATIONS
• Anesthetics should be prepared next to the
patient
• Syringe used for irrigation should be
distinguishable
• Carpule injection systems may be preferred
If wrong solution is injected!!!
• Acute pain is relieved, anesthesia is performed near this area.
• Analgesic is given.
• Cold compresses are applied for the first 24 hours and warm
compresses are applied on the following days.
• Antihistamines and corticosteroids are given against allergic
reactions.
• Antibiotics are given against secondary infection.
• The patient should be followed. Necrosis and infections that
occur in the region should be observed.
2. ACCESS CAVITY COMPLICATIONS
2a. Small and inadequate opening of access cavities
 Error on entry in root canal
 Accessory canals are skipped
 Remaining pulp residues cause tooth coloring
2b. Wide opening of access cavities
2c. PERFORATIONS
Reasons of the Complications during the
Access Cavity Preparation
• Pulp chamber and canal morphology not well

known
• Inadequate examination of radiographs
• Inadequate visibility
• Opening the access cavity without removing the
crown restoration!!!!!!!!!
2a. Inadequate Opening of the Access
Cavity;
• In areas where pulp horns are present, residual infected tissue

remains
• Tooth color changes,
• Some canals can not be entered,
• Additional canals can not be detected
• Since the canal does not provide a straight entry, it causes the
canal preparation not to be done properly.
There may be more canals than you
find !!!!!!!
2b. Wide Opening of the Access Cavities
The wide opening of the access cavities can lead to a serious

loss of material in the crown, resulting in fractures.
2c. Access Cavity Perforations
Reasons for Perforation:
• Careful examination of radiographs is not done
• Failures during access cavity preparation
• Insufficient knowledge of anatomic structure
• During the search for a canal when the canal system is reduced
by dystrophic changes
• Not to consider the tooth axis
• Opening the access cavity in the presence of artificial crowns

that mask the anatomy of the tooth
Radiographic examination is important in the
access cavities!!!
• Calcifications in the pulp chamber should be considered.

• When opening the access cavity, the drill and the tooth
long axis must be parallel to each other.
• The access cavity must be opened in the correct size and
position
• The crowns must be removed before endodontic treatment.
• A specially manufactured safe and blunt drills must be used
to open the endodontic access cavity.
• The root canals can be localized more easily by illuminating
of the cavity and pulp chamber with fiber optic rays.
Prognosis of a perforated tooth;
Localization of perforation
Contamination of perforation
Open time of perforation
The possibility of closure of perforation
The main canal is entered or not?
Treatment of a perforated tooth;
• Perforation repair with appropriate repair material in case
of access to the perforation area from the access cavity
• If perforation can not be achieved, surgery should be
performed to close the perforation
Perforation Repair Materials:
• Cavit
• Amalgam
• Gutta-percha
• Calcium hydroxide
• Glass ionomer cement
• Tricalcium Phosphate
• Bone graft materials
• Mineral trioxide agregate (MTA)
Crown Perforation on Alveolar Crest
3. CANAL PREPARATION COMPLICATIONS
3a. Root perforations
3b. Working length problems
 Ledge formation
 Canal blockage
 File fracture
3c. File aspiration or swallow

3a. Root Perforations
Cervical
Middle
Apical
Perforations occurring in the cervical
part of the root
1. Searching canal orifices

2. Preparing root canals or
3. Improper use of Gates-Glidden burs
Lateral perforations in the middle part
of the root
Strip Perforation
• Strip perforation usually occurs in the mesiobuccal roots of maxillary
molars and mesial roots of mandibular molars.
• Roots with thin mesiodistal diameters should be subjected to
anticurvature preparation.
• Hedström files must be careful in the coronal area as they make rapid
and effective cutting.
• The use of large diameter Gates-Glidden and Peeso burs on the
coronal part of the canal should be avoided.
MTA treatment of strip perforation
Perforations occurring in the apical part
of the root
Reasons:
• Use of non-curved files in curved canals
• Rotation on curved canals at the point where file is forced
• Extreme apical use of large numbered files in apical preparation
• Non-use of flexible files
Treatment of Apical Perforations
• If the apical part of the canal is reached, the preparation of the main
canal is completed. Sterile distilled water or saline is used as irrigation
solution. Sealers (containing calcium hydroxide or MTA) should be
used to provide biological healing. Heated gutta-percha techniques
are preferred.
• If the apical is not reached, the treatment is completed until the
perforation occurs and the patient is called to the periodic controls.
• Endodontic surgery is performed if signs and symptoms indicate that
endodontic treatment is unsuccessful.
3b. Working Length Problems
 Ledge formation
 Canal blockage
 File fracture
Ledge formation
Ledge is the artificial irregularities created in the root canal

wall that prevent the instruments from reaching the apical
region.
• Canal curvatures and working length should be
determined well by pre-operative radiographs,
• Files must be used without excessive apical pressure in
the canal and without bending,
• Non-cutting files (Ni-Ti files) should be preferred in
curved canals.
Removing ledge;
• Radiography is taken and ledge position is determined.
•Try to reach the apex from the side of the ledge with a
smaller and curved instrument.
•After the ledge area is passed, small vertical movements are
used to remove the ledge.
•Then surface regularity is ensured by circumferential
preparation.
Canal blockage
.
Prevention of canal blockage may be possible with
recapitulation and adequate irrigation.
File fracture
• The physical properties of the file and the way it is used in the canal
must be known
• Files must be used in a wet canal
• Files should be used along the main axis in a straight line
• Debris on files must be cleaned after every use
• Hedström files have more risk of break (first use K-files then
Hedström files)
• After enough preparation, you must go to the big file number and
the files must be used without trimming the number
• Use it by rotation to move the file further to the apex or excessive
apical pressure cause break
• Recapitulation should done.
• Bending and malformations should be examined before each use
• Use Ni-Ti flexible files in curved canals
When the file is broken in the canal;
• The position of the broken part,
• The shape of file and
• The degree of blockage
• The pulp and periapical tissue status before
treatment
is important for the prognosis of root canal therapy.
Treatment options of file fracture:
 Attempt to remove file
 Bypass the broken file and reach the apex
 Obturate the canal to the broken file part
 Apical surgery
If broken file is at the coronal 1/3 of root canal:
If broken file is at the middle 1/3 of root canal:
• Place a lightly curved #10 file in canal and

rotate it a quarter turn.
• A piece of 1 mm is cut from the #10 file by
aerator.
• The #15 file is used for the by-pass after #10
file was reached the working length.
• After finishing preparation, the canal is
obturated.
If the broken part can not be bypassed; try chemical
methods.
The canal is expanded with a file or with Gates-
glidden burs and EDTA is placed and waited for 5
minutes on the canal.
Masseran Kit
If broken file is at the apical 1/3 of root canal:
If the broken file is not blockage canal, if the
treatment fails or if it can’t be coordinated with
the patient, periapical surgery and retrograde
filling will be used.
The broken part may cause irritation to the
periapical tissues when it comes out from apex. In
such cases, the fragment is removed by apical
surgical procedures.
Zipping
Zipping is the transportation or transposition of
the apical part of the canal.
It is also advisable to use the instruments, especially
in the apical 3-4 mm section of the canal, with short
back and forth movement and without rotation and
without changing the position of the curved canal.
3d. File aspiration or swallow
When the file is aspirated:
• The instrument is either attached to the trachea or goes
to the bronchi
• Severe hiccups, coughs, nausea, sore vomiting and
respiratory distress are seen when its in trachea
• Attempts to remove foreign body with cough reflex
• The file that resides in the bronchi can stay long-term
without symptoms
Radiographic follow-up is important when the
instrument is swallowed.
4. IRRIGATION COMPLICATIONS
Factors affecting prognosis if irrigation solution is
overflowed from apex:
• Type of solution (Sodium
hypochlorite, chlorhexidine,
oxygenated water, chelating
agents, distilled water, saline)
• Concentration
• Volume
If the irrigation solution is removed
from the apex;
• Sudden swelling
• Severe pain
• Amphysema
• Hemorrhage
• Ecchymosis
If the irrigation solution is overflowed from the
apex;
• LIGHT REACTIONS: •SERIOUS REACTIONS:
• The patient is informed • Referral to the hospital
• Acute pain is reduced (anesthesia, analgesic) • Surgical approaches
• Canal irrigate with sterile saline
• Cold applied
• Antihistamines and corticosteroids are given

against allergic reactions
• Antibiotics are given against secondary

infections
• ANAMNESIS NaOCl allergy must be

questioned !!
What to look for in irrigation?
When performing irrigation solutions, the syringe must not be squeezed in the canal
and the solution should not be sent with pressure to the apex. The use of special
endodontic injectors with specially prepared tip openings and openings on the side
faces for canal irrigation will help prevent this error.
5. OBTURATION COMPLICATIONS
Root canal filling material sometimes passes the apical stop of the
root canal, reaching the alveolar bone around the root, the maxillary
sinus or mandibular canal, or even the cortical bone. This leads to
apical perforation, which disrupts the apical constriction.
Under or overfilling
Complications that may occur with overfilling
is due to;
 Sealer type
 For the amount of overflow
 Ability to resorb
 Sealer toxicity
Treatment
The first treatment option is retreatment.
In the canals filled with thermoplastic process, the gutta-
percha breaks away from the point and remains in
• If the symptoms are asymptomatic and the lesion does
not occur, there is no need to remove the canal filling and
the patient is followed up long term.
• If the lesion is present or has occurred and the tooth is
symptomatic, apical curettage may be applied.
Different clinical complaints in overfilling:
• Hypoesthesia
• Paresthesia
• Neurological consultation
Vertical Root Fracture
Vertical root fractures have a very poor prognosis and
usually can not be treated.
6. OTHER COMPLICATIONS
6a. Post Perforations

6a. Post perforations
• Root canal anatomy is well known and radiography should be
examined in detail before post preparation.
• The appropriate drills must be selected and the drills must be used
at the right angle.
• Also, while preparing the post space, suitable Gates-Glidden burs,
heated pluggers or endodontic files should be preferred.
• Post position should be checked by radiography before cementing.
Tissue emphysema is a complication that occurs
when the compressed air escapes into the facial
tissue spaces.
Reasons:
• Air flow inside the canal to dry the canal during
chemomechanical preparation,
• The use of high-cycle drills during endodontic surgery
2019-2020 4. Class
DRUGS
USED IN
ENDODONTICS
ASSOC.PROF.DR.UMUT AKSOY
PAIN
 BEFORE TREATMENT
 DURING TREATMENT AND/OR
 AFTER TREATMENT
SWELLING
CLINICAL MANAGEMENT Systemic medication

ANTIBIOTICS
ANTIBIOTICS
¿WHEN?
ANTIBIOTICS
Treatment of an
infection in the Prophylaxis
periapical region
1 2
Treatment of an
infection in the
periapical region
Only Pain
Localized Swelling
Symptomatic pulpitis
Chronic apical abscess

draining from the sinus tract
Treatment of an
infection in the
periapical region
 In Endodontics,
 Antibiotics are only used as adjuncts to
treatment with
Root canal treatment + Drainage
 In the presence of clinical manifestations
suggesting the possibility of
Systemic spread of the infection
or
In the presence of widespread and
unhealed infections.
Treatment of an
infection in the
periapical region
SYSTEMIC SYMPTOMS
The presence of symptoms such as fever, chills, chills
within the last 24 hours
Malaise, tiredness, fatigue, dizziness, rapid breathing
Trismus
Lymphadenopathy
Cellulitis (Non-localized widespread infection in soft

tissues)
Treatment of an
infection in the
periapical region

When acute apical abscess is associated with
diffuse swelling leading to develop cellulites with
infectious process dissemination to other anatomic
spaces, or when acute apical abscess exhibits
evidences of systemic involvement, such as fever,
malaise, regional lymphadenitis or trismus,
antibiotics are necessary as adjuvant treatment to
drainage because the patient’s immune system is
incapable of stopping the infection advance
Treatment of an
infection in the
periapical region
Treatment of an
infection in the
periapical region
Antibiotic treatment may

be applied in the case of
"flare-up", which defines
pain and swelling after root
canal treatment, in
accordance with the
criteria stated.
Treatment of an
infection in the
periapical region
Antibiotics are
necessary in severe
traumatic injury cases
and after the
replantation of the
avulsed teeth.
Treatment of an
infection in the
periapical region
Treatment of an
infection in the
periapical region
Actinomyces israelii
Another condition requiring systemic

antibiotic use is periapical
actinomycosis, which is a
persistent periapical infection. In
these cases, it is necessary to apply
apical surgery with penicillin
application.
Treatment of an
infection in the
periapical region
If the sodium hypochlorite solution used for

irrigation is delivered to the periapical region,
or if it is accidentally injected instead of the
anesthetic solution as a more serious
complication, antibiotics should be given to
prevent secondary infection of the tissues,
which is likely to become necrotic, in addition
to emergency procedures.
Treatment of an
infection in the
periapical region
ANTIBIOTICS
¿Which
Antibiotic?
Which Antibiotic?
Detection of microorganisms
The severity of the infection
General health status of the

patient
These factors should be evaluated together!!!

Which Antibiotic?
Endodontic infections are

polymicrobial and most of
the isolated microorganisms
are obligate or facultative
anaerobic bacteria
Which Antibiotic?
Spectrum of the
antimicrobial
activity
is the range of bacterial types
against which the antibiotic is
effective
Which Antibiotic?
Select the narrowest

spectrum antibiotic
sensitive to the causative
microorganism!!!
Which Antibiotic?
Ideally, pre-treatment
specimens should be taken
to identify the causative
microorganism by culture
and to give the appropriate
antibiotic according to the
susceptibility test result.
Which Antibiotic?
Takes several
days to
weeks
We know approximately
the microorganisms
found in endodontic
infections.
Which Antibiotic?
Empiric
selection of
an Antibiotic
Which Antibiotic?
Persistent Cultivation
Infections methods
Which Antibiotic?
Peferred
Antibiotics for
endodontic
infections
Preffered Antibiotics for
Endodontic Infections:
Penicillin V
Amoxicillin
Clarithromycin and Azithromycin
Metronidazole
Clindamycin
Penicillin V
Penicillin V is a narrow-spectrum antibiotic for

infections caused by aerobic gram-negative cocci,
facultative and anaerobic microorganisms
It can be a good first option for endodontic

infections due to its effectiveness and low toxicity.
However, there is a risk of allergy.
A loading dose of 1000 mg of penicillin V should be
administered orally followed by 500 mg every 6 h to
achieve a steady serum level.
Penicillin V
Amoxicillin
Amoxicillin is an analogue of penicillin that is rapidly

absorbed and has a longer half-life. This is reflected
in higher and more sustained serum levels than
penicillin V. Amoxicillin is often used for antibiotic
prophylaxis of patients that are medically
compromised. Amoxicillin may be used for serious
odontogenic infections, however, its extended
spectrum may select for additional resistant strains
of bacteria. The usual oral dosage for amoxicillin is
1,000 mg loading dose followed by 500 mg every
eight hours for five to seven days.
Amoxicillin
The combination of amoxicillin with clavulanic acid

is the most effective antibiotic combination.
Clavulanic acid and sulbactam are competitive

inhibitors of the betalactamase enzyme produced
by bacteria to inactivate penicillin.
Amoxicillin
Amoxicillin
Amoxicillin
Amoxicillin+Clavulanic acid
combinations
Ampicillin
Ampicillin+sulbactam
combinations
Azithromycin and Clarithromycin
These are macrolide antibiotics such as erythromycin.

However, unlike erythromycin, they are effective on some
anaerobic species seen in endodontic infections.
In the cases of penicillin allergy, Azithromycin or
clarithromycin should be preferred for moderate infections.
They less likely to cause gastrointestinal side-effects than
erythromycin.
The oral dosage for clarithromycin is a 500 mg loading dose
followed by 250 mg every 12 hours for five to seven days. The
oral dosage for azithromycin is a 500 mg loading dose
followed by 250 mg once a day for five to seven days.
Clarithromycin
Azithromycin
Metronidazole
Metronidazole is a synthetic antimicrobial agent that

is bactericidal and has activity against anaerobes,
but lacks activity against aerobes and facultative
anaerobes.
Metronidazole may be used in combination with
penicillin or clindamycin.
If a patient’s symptoms worsen 48-72 hours after initial
treatment and the prescription of either penicillin or
clindamycin, metronidazole may be added to the
original antibiotic.
Metronidazole
It is important that the patient continue to take

penicillin or clindamycin, which are effective against
the facultative bacteria and those resistant to
metronidazole.
The usual oral dosage for metronidazole is a 1,000 mg

loading dose followed by 500 mg every six hours for
five to seven days.
Metronidazole
Clindamycin
Clindamycin is effective against gram-positive facultative

microorganisms and anaerobes. Clindamycin is a good
choice if a patient is allergic to penicillin or a change in
antibiotic is indicated. Penicillin and clindamycin have
been shown to produce good results in treating
odontogenic infections.
The oral adult dosage for serious endodontic infections is a
600 mg loading dose followed by 300 mg every six hours
for five to seven days.
Clindamycin
ANTIBIOTICS
Treatment of an
infection in the Prophylaxis
periapical region
1 2
Prophylaxis
Manipulation of
gingival tissues
Transient
bacteremia due
Manuplation of the
periapical region
to Viridans
group
All dental streptococci
procedures
involving oral
mucosa perforation
Prophylaxis
Dental antibiotic prophylaxis is the

administration of antibiotics to a dental
patient for prevention of harmful
consequences of bacteremia, that may be
caused by invasion of the oral flora into an
injured gingival or peri-apical vessel during
dental treatment.
Prophylaxis
It is used to prevent the

development of complications
such as infective endocarditis or
post-surgical infection in
dentistry.
Prophylaxis
Prophylaxis
 Recommended:
 All dental procedures that involve manipulation of
gingival tissue or the periapical region of teeth, or
perforation of the oral mucosa
 Surgical procedures
 Periodontal procedures
 Endodontic procedures
 Intraligamenter anesthesia
 Reimplantation of avulsed tooth
 Dental implant procedures
Prophylaxis
 Not Recommended:
 Routine anesthetic injections through noninfected tissue
 Taking dental radiographs
 Placement of removable prosthodontics or orthodontic
appliances
 Placement orthodontic brackets
 Shedding of decidious teeth
 Post placement
Prophylaxis
Prophylaxis
If several sessions are required, and if the practitioner uses

antibiotic prophylaxis, the sessions must be scheduled at
least 10 days apart if possible
A single prophylaxis can be planned for various dental

procedures within 6 hours.
If a prophylactic antibiotic was not administered by

mistake in a patient in need of treatment, the same dose
can be administered up to 2 hours after the procedure.
For patients who are taking antibiotics for another reason,

they should be taken with another class of antibiotics
before treatment (such as clindamycin if taking penicillin).
Analgesics
FIRST INTERVENTION
Should be directed to the source of the pain
DENTOALVEOLAR
ACUTE PULPITIS
ABSCESS
EXTIRPATION OF DENTAL PULP
DRAINAGE
OR ETRACTION OF THE TOOTH

Use of Analgesics
 Usually for postoperative pain

3D Approach for
Treating Acute Pain
DIAGNOSE
DEFINITIVE TREATMENT
DRUGS
Which Analgesics?
Narcotic
Non-narcotic
Which Analgesics?
Narcotic
Influences the central nervous system
Psychological and physical dependency characteristics.

Exp: Codein
Not Used in Dentistry Practice

Which Analgesics?
Non-narcotic
Most of the drugs in this group have both antipyretic
and antiinflammatory properties at the same time.
The most preferred drug group is non-steroidal

analgesic and anti-inflammatory drugs.
(NSAIDs).
NSAIDs
 NSAIDs inhibit the synthesis of prostaglandins
 Prostaglandin is the most important hyperalgesic
and inflammatory mediator
 Cyclooxygenase is the enzyme that mediates the
formation of prostoglandins (COX).
 NSAID inhibits the prostoglandin synthesis by
inhibiting the enzyme cyclooxygenase (COX).
PARACETAMOL
 Acetaminophen (Paracetamol):
 Unlike NSAIDs, the antiinflammatory
effect of acetaminophen is very weak.
 The antiinflammatory effect is minimal,
but it is safer in terms of side effects
 To be selected in cases where NSAIDs
are contraindicated
Paracetamol
is generally considered
safe during pregnancy
and while breastfeeding
SUCCESS OR FAILURE
IN ENDODONTICS

SUCCESS RATES
 There have been many studies to

determine the success rates of root canal
treatment.
 The results range from 35% to 60%.
Some studies have reported that these
rates are between 70-97%.
 At the beginning of endodontic treatment,
the patient should always be told that there
is a possibility of failure.
PROGNOSIS
 It
is based on a prediction that the case will
be successful or unsuccessful.
 Determination or estimation of results can
be done at different times;
 Before treatment
 During treatment
 After treatment
 The prognosis usually depends on what
happens between these stages, before and
after the treatment.
 Itis difficult to evaluate the results of the
study because there are many factors for
the success of the prognosis.
 Improvement of current treatment methods
is an advantage in understanding prognosis
of root canal treatment and prevention of
high-failure factors and better healing.
DESCRIPTION OF PROGNOSIS TO PATIENT
 The first approach is to give

information by generalizing on the
desired, suspicious and undesirable
situation.
 The second approach is to make
estimates using percentages on the
end of the treatment.
FACTORS AFFECTING THE EVALUATION
OF SUCCESS AND FAILURE IN
ENDODONTIC TREATMENT
1. Observer has different success criteria
2. Different evaluation of radiography
3. Patient complaints of various levels
4. Patient response is subjective
5. Differences in tissue response
6. Validity of evaluation method
7. Differences in control variables
8. Variability of observation periods
THE FACTORS AFFECTING SUCCESS
AND FAILURE IN ALL CASES
1. Radiographic evaluation
2. Root canal system anatomy and presence of
extra canal
3. Degree of adequate chemo-mechanical
cleaning and apical instrumentation of the
root canal system
4. The degree of apical blockage in the cement-
dentin zone
5. The degree of coronal closure and the type of
restoration
6. Asepsis in treatment
7. Health and systemic condition of the patient
8. Clinician's ability
FACTORS AFFECTING SUCCESS AND
FAILURE IN SOME CASES
1. The condition of the pulp

2. Operative complications (perforation,
instrument breakage)
3. Crown-root fractures
4. Periodontal status
5. Occlusal incompatibility
6. Type of periapical lesion
7. Patient’s pain threshold
8. The status of canal obturation (flood or
incomplete)
9. Canal calcification degree
10. Presence of root resorption
11. Presence of accessory canals
12. Evaluation period after treatment
VERY LESS FACTORS AFFECTING
SUCCESS AND FAILURE
1. Age and gender of the patient

2. Etiology of pulp damage and necrosis
3. Tooth localization
EVAULATION TIME
In general, postoperative follow-up should be

done between 6 months and 4 years.
EVAULATION METHODS
 Clinical
 Radiographic
 Histologic
CLINICAL EVALUATION
The following subjective and objective criteria

have been used in post-treatment clinical
evaluations.
1. Palpation sensitivity
2. Tooth mobility
3. Periodontal disease
4. Fistula
5. Percussion sensitivity
6. Tooth function
7. Infection and swelling
8. Subjective symptoms
CLINICALLY SUCCESS CRITERIES
1. Absence of percussion and palpation

sensitivity
2. Normal mobility
3. No fistula
4. No periodontal disease
5. The tooth is functional
6. No infection and no swelling
7. Absence of subjective symptoms
CLINICALLY SUSPİCİOUS CASES
1. Often recurrent unclear symptoms

2. The feeling of fullness
3. Mild discomfort in percussion, palpation and
chewing
4. Sensitivity with tongue pressure
5. Sinusitis superposing on the treated tooth
6. Minimal disturbances requiring analgesic
CLINICALLY FAILURE CRITERIES
1. Having stubborn subjective symptoms
2. Recurrent fistulas or swelling
3. Severe discomfort in percussion and
palpitation
4. The presence of irreparable root and
chronical fractures
5. Excessive tooth mobility and advanced
periodontal destruction
6. Relevant tooth function
RADIOGRAPHIC EVALUATION OF
SUCCESS AND FAILURE
RADIOGRAPHICALLY SUCCESS CRITERIES
1. Slightly thickened periodontal ligament space

(<1 mm)
2. Elimination of previous radiolucent
3. The neighboring teeth and the lamina are the
same
4. No resorption
5. A well canal obturation was performed to the
cement-dentin junction
RADIOGRAPHICALLY SUSPİCİOUS CASES
1. Expansion of the periodontal space (> 1-2 mm)

2. Whether the radiolucence is the same size or
very little repair,
3. Irregular shape of lamina relative to adjacent
teeth
4. Signs of mild expansion of resorption
5. Empty areas of obturation especially in the
apical zone
6. Overfilling
RADIOGRAPHICALLY FAILURE CRITERIES
1. Excessive expansion of the periodontal

space (> 2mm)
2. Periradiculer radiolucency does not result
in expected bone repair or increases in
radiolucency size
3. Lack of new lamina dura formation
4. Presence of lateral and apical radiolucency
not previously found in periradicular areas
 It is incorrect to determine success and
failure based only on radiographic criteria.
Clinical criteria must be added to the
findings.
HISTOLOGICAL EVALUATION OF SUCCESS
AND FAILURE
Histological evaluation of success and failure is

relatively meaningless in practice.
ENDODONTIC FAILURE
REASONS
1. Faults in diagnosis and treatment plan
2. Lack of information in pulp anatomy
3. Inadequate chemomechanical preparation
4. Operative errors
5. Errors in filling
6. Errors in restorative procedures
7. Coronal leak
8. Vertical root fractures
FAILURE FACTORS
Preoperative Factors
Operative Factors
*Failure due to mechanical causes
*Failure due to biological causes
Postoperative factors
FAILURE FACTORS
Operative Factors
FAILURE FACTORS
Operative Factors
FAILURE FACTORS
Operative Factors
RETREATMENT

Causes of Failure
1. The presence of necrotic material in the root canal due to the
inability to identify all canals or to work short in canals.
2. Contamination of root canals during treatment, which are
sterile at the beginning of root canal treatment.
3. The persistent infection in the root canal after treatment.
4. Lack of elimination of bacteria in accessory or lateral canals.
5. Re-infection of the disinfected and filled root canal system due to
loss of coronal filling.
SIGNALS AND SYMPTOMS
OF FAILURE
 Presence of a fistula in the drainage
 Pulpal pain or sensitivity during
bite
 The appearance of periapical
radiolucent areas on the diagnostic
radiographs or the case that the
periapical lesion grows after the root
canal treatment done.
In some cases, only restorative
treatment may be planned for the
teeth with asymptomatic lesions,
although the root canal filling is
short.
TREATMENT OF FAILURE
 Retreatment
 Periradicular surgery
 Extraction
FACTORS AFFECTING SUCCESS
OF RETREATMENT
1. The story of the patient
2. The story of the first treatment
3. Previous treatment standard
4. Clinical condition
5. Anatomy of the tooth
6. Filling
7. Iatrogenic factors
8. Patient opinions
9. Physician's ability
THE STORY OF THE PATIENT
 Previous radiographs
 Symptoms of past
 Elapsed time after treatment
THE STORY OF THE FIRST
TREATMENT
First treatment significantly affects case selection.
Surgery may be preferred if retreatment has previously
done and the outcome is still unsuccessful, or if vertical
fracture is suspected.
CLINICAL CONDITION
 Symptoms
 Restoreable
 Periodontal support
ANATOMY OF THE TOOTH
 Untreatable canals
 Canal structure
FILLING
 Apical length
 Type of material
IATROGENIC FACTORS
 Canal blockages
 Perforations
 Overfillings
PATIENT OPINIONS
 Time inadequacy
 Material resources
 Prognosis ?
PHYSICIAN'S ABILITY
 Time capability
 Equipment to be used
 Mastery
ACCESS PREPARATION
1. Removal of crown
2. Removal of post
3. Removal of cement and pat
4. Silver removal
5. Gutta-percha removal
6. Removal of broken instrument
7. Repair of perforation
The condition of the coronal restoration
should be examined before opening the
access cavity.
When coronal restoration is sufficient,
the entire restoration should be
unscrewed so as not to lose the coronal
boundaries of the tooth, paying attention
to the burr angle before dismantling.
Coronal restoration should be completely
removed
 Presence of post-core material
 Leaking from the restoration edges
 The presence of secondary caries.
Removal of restorations;
 All caries can be removed,
 Cracks can be observed,
 Ensures access to previously untreatable
channels.
For teeth with too much material loss, a
copper ring may be placed on the tooth to
ensure that the rubber-dam can fully
conform to the tooth in the margins before
the treatment begins.
REMOVAL OF CROWN
Hand tools
Ultrasonic tools
Active tools
REMOVAL OF POST-CORE
Post-cores are cast or
composite core materials which
can used together with ready-
made posts.
The second can be observed
after removing the used core
materials.
If the force required to remove the posts
from the root canals is too great to break,
the post should not be removed.
Ultrasonic devices should be used to
attenuate the bond of the adhesive cement
by vibration.
In some cases, the ultrasonic vibration may
release the post in the root canal, but
where it can not be released the post-core
must be removed from the root canal using
a device.
REMOVAL OF CEMENT AND
SEALER
Sealers can usually be removed by
continuous irrigation. Irrigation
using ethylenediaminetetraacetic
acid (EDTA) and sodium
hypochlorite is recommended.
Solvents such as Endosolve-R,
Endosolve-E halotane or chloroform
can also be used during this
process to solve canal sealers.
REMOVAL OF SILVER CONE
Since the cross sections of the
silver cones are round, it is
difficult to fill the canal
enough. The method to choose
to remove depends on whether
the silver cone extends into the
pulp chamber and whether it is
visible from the pulp chamber.
In such cases, the silver cones
are checked by holding them
with the Steiglitz forceps to
see how much they are stuck in
the root canal, and then is
removed gently by being
supported and powered by the
coronal section.
 Hendström number 15 can be advanced by moving
a file from one side to the other.
 If the silver cone is cut in the canal orificies and
it will not be possible to hold it; a gap is created
around the canal with an ultrasonic tip. When the
gap is 2 mm deep, many different extraction
techniques such as the Masserann extractor or
Ruddle IRS can be used to remove silver cone
from the root canal.
REMOVAL OF GUTTA-PERCHA
1. Removal with rotary files
2. Removal with ultrasonic files
3. Removal with heat
4. Removal of heat and file
5. Removal of file and chemical material
6. Removal of paper point and chemical
material
Gutta-percha was removed from
root canal by one or two H-type
files are squeezed around or
between the gutta-percha,
where the lateral condensation is
insufficient or the overfilling of
root canal.
If this fails, removal of the root
canal filling should be done step
by step, starting from the
coronal to the middle and apical
regions.
The Gates-Glidden burs can be selected in
accordance with the canal to be used in the
coronal region of the canal.
A solvent (chloroform, turpentine oil,
halothane) can be used and the gutta-percha
can be softened and removed.
A small drop of solvent is placed to canal
orifice, the top of the gutta-percha is
softened and removed using the file.
Solvent is applied frequently, softening gutta
percha is removed and processing is
continued until reaching apex.
As solvents have potentially toxic effects,
they should be used as little as possible in
the root canal.
REMOVAL OF BROKEN FILE
1. The thickness and length of the
broken instrument
2. Steel or nickel titanium?
3. Location of broken file
4. In which stage the instrument is broken
5. Cross-sectional area of the canal
6. Presence of a curvature and the
portion of the broken instrument in this
curvature
7. Acute clinical syptoms
PROGNOSIS OF RETREATMENT
Single-appointment treatment or unsuitable
retreatment cases may result in periapical
irritation.
Complications such as previous treatment
perforations, broken file, over-preparation or
under-preparation may make the success of
retreatment difficult.
It has been determined that the success rate
in retreatment applied to teeth which have
periapical lesion is 62-68%.
THANKS…
When and How ?
• It is recommended that the obturation material be
emptied immediately in the session when it is filled.
The process that is done before the full curing of the
sealing material affects the microleakage less. On the
other hand, some researchers stated that it is more
appropriate to prepare the post space 48 hours or 1
week after the canal filling. Regardless of the method,
the obturation should be renewed when the apical seal
is suspected. In some cases, the root canal can be
segmented. In other words, only the apical part of the
canal can be filled and post placement begins.
Prefabricated Post
Systems
Dentatus
Fiber posts
Remaining tooth structure
Root morphology
Endodontic
MicroSurgery
• Endodontic surgery is a procedure that is done to treat the root lesion
that are not amenable to endodontic root canal treatment .
• The majority of these surgical procedures involve resection of the
root apex (apicectomy) and retrograde obturation of the root canal to
get ride of persistent lesion that has not resolved following an
acceptable root canal treatment.
Pathogenesis of periapical lesions
Pulpal and subsequent periapical disease is caused by microbial
contamination. This commonly occurs via a carious lesion and some
time occurs due to periodontal disease . As resultant necrosis of the
pulpal tissue lead to inflammatory products and pathogens and their
byproducts to exit through the apical foramen.This frequently results in
the formation of a periapical lesion , mostly an apical granuloma.
• caries
• pulp necrosis
• periapical abscess or granuloma
• radicular cyst(inflammatory cyst)
Treatment options of tooth with periapical lesion ;
1. Extraction if the tooth is unuseful or un restorable.
2. Root canal filling if the tooth restorable and there is some evidence
that small periapical cystic lesion may resolved following successful
root canal filling .
3. Endodontic surgery , when there is failure of root canal filling or
there are some obstacle to do root canal filling .
Indications for endodontic surgery ;
• Apical anomaly of root tip (dilacerations, intracanal calcification, open
apex)
• Presence of lateral/accessory canal/apical region perforations
• Roots with broken instruments/overfillings
• Fracture of apical third of the root
• Formation of periapical granuloma/cyst
• Draining sinus tract/ non responsive to RCT
• Extension of root canal sealant cement/filling beyond the apex
• Teeth with ceramic crowns
• When patient with chronic periapical infection, will not be available for
follow-up.
Contraindications for endodontic surgery ;
• Presence of systemic diseases—leukemia, uncontrolled diabetes, anemia,
thyrotoxicosis, etc.
• Teeth damaged beyond restoration
• Teeth with deep periodontal pockets and grade III mobility (Pre-existing
bone loss)
• When traumatic occlusion cannot be corrected
• Short root length
• Acute infection which is nonresponsive to the treatment
• Root tips close to the nerves, e.g. mental nerve, inferior alveolar nerve or in
maxilla close to the maxillary sinus.
Complications of endodontic surgery ;
intraoperative
• Bleeding ; can controlled by using local application of adrenaline pack , pressure
pack,Gelfoam or surgical.
• Damage to the neighboring root.
• Entry into sinus/inferior alveolar canal,nasal cavity.
Postoperative
• Abscess formation.
• Fenestration, sinus tract formation.
• Increased mobility of the tooth.
• Staining of the mucosa due to amalgam that remained at the surgical field.
Follow up for endodontic surgery ;
Healing of the periapical area is checked every 6–12months
radiographically, until ossification of the cavity is ascertained. In order
to evaluate the result, a preoperative radiograph is necessary, which will
be compared to the postoperative radiographs later.
Microsurgery ?
CONVENTIONEL MICROSURGERY
Osteotomy area 8-10mm 3-4mm
Angel 45-65 degrees 0-10 degrees
Examination of root end - possible
Detection of isthmus - possible
Apical preperation Some cases always

Apical preperation Bur Ultrasonic
Retrograd filling Amalgam MTA
Sutures 4.0 silk 5.0, 6.0 monoflament
Healing after 1 year %40-90 %85-96.8

Benefits of the Operating Microscope
Loupes and microscopes offer different ranges of magnification. An

increase in magnification decreases the focal depth. Wearing loupes,
especially at magnifications higher than ×4, requires the practitioner
to stay in a narrow range from the object to stay in focus. In contrast,
even at high magnifications, a microscope remains stable and the
practitioner can work in an upright and ergonomically non-stressful
position. Moreover, microscope use reduces strain on eye muscles,
fatigue, and soreness compared to loupes. Through a microscope the
light reaching the left and right eyes appears to be essentially
parallel, achieving the effect of far distance observation and avoiding
short accommodation stress as with the naked eye. Binoculars of
loupes and thus the viewing direction are convergent, resulting in
similar eye strain. In addition, microscopes provide imaging virtually
free of shadows, allowing excellent image quality for clinical
operations and documentation.
Operasyon mikroskop
görüntüsü
• ‘’Büyütme ne kadar büyük olursa, o kadar iyi çalışılır’’ fikri YANLIŞTIR!
• Deneyimler periapikal cerrahide 30X’ten fazla büyütmenin çok işe
yaramadığını göstermektedir çünkü en küçük hareketlerde –hatta
hasta nefes aldığında bile- çalışma alanı görüş alanı dışına çıkar.
Cerrah tekrar mikroskobu çalışma alanına odakladığı için çok zaman
kaybetmektedir.
Anesthesia and Hemostasis
Adequate hemostasis is essential for microsurgery. In the past, achieving
effective hemostasis was a challenge. Many endodontic surgeons performed
surgery in a pool of blood, guessing at anatomic landmarks and structures. In
order for endodontic microsurgery to be successful, the surgeon needs to
examine the root surface at high magnification with the microscope.
It is practically impossible to do that without effective hemostasis. The
anesthetic solution of choice for endodontic surgery is Lidocaine 2% HCl with
1:50000 epinephrine. This high concentration of epinephrine is preferred for
surgery because it produces effective, lasting vasoconstriction via activation of
the α-adrenergic receptors in the smooth muscle of the arterioles. This
prevents the anesthetic from being washed out prematurely by the
microcirculation
Flap Outline
There are four major flap designs in endodontic microsurgery
1. Submarginal rectangular flap.
2. Submarginal triangular flap.
3. Sulcular rectangular flap.
4. Sulcular triangular flap.
Root End Resection
Endodontic literature over the last two decades supports several

reasons for resection of the apica lpart of the root during periapical
surgery:
• Removal of pathologic processes.

• Removal of anatomic variations (apical deltas, accessory canals, apical
ramifications, severe curves).
• Removal of iatrogenic mishaps (ledges, blockages, perforations, strip
perforations, separated instru-ments).
• Enhanced removal of the granulation tissue.
• Creation of an apical seal.
• Evaluation of the apical seal.
• Reduction of fenestrated root apices.

• Access to the canal system when the coronal Access is blocked or when coronal
access with non-surgical retreatment is determined to be impractical, time
consuming, and too invasive.
• Evaluation for complete or incomplete vertical root fractures.

Root End Resection: Steep Bevel versus Shallow Bevel
Microsurgery suggests a 0◦ bevel, perpendicular to the long axis of the tooth.

A 0 degree bevel fulfills the following requirements:
• Preservation of root length.
• Less chance of missing lingual anatomy and multi-ple accessory canals.
• Complete root end resection.
• Less exposed dentinal tubule
• Dentinal tubules are more perpendicularly oriented to the long axis of the tooth
and therefore a short bevel will expose fewer tubules.
• Easier to perform a root end preparation coaxially with the root. The root end
preparation should be kept within the long axis of the root to avoid risk of a
perforation. The longer the bevel, the more difficult it is to orient and perform a
preparation coaxially with the tooth
Isthmus
• The term “Isthmus” derives from the Greek Word “Iσθμoζ”, which
describes a narrow strip of land connecting two larger land masses.
Endodontically speaking, an isthmus is defined as a narrow, ribbon-
shaped communication between two root canals that contains pulp,
or pulpally derived tissue
Types of Isthmus
• Hsu and Kim (1997) described five different types of isthmus. Type I
was defined as either two or three canals with no noticeable
communication. Type II was defined as two canals that had a definite
connection between the two main canals. Type III differs from type II
in that there are three canals instead of two. Incomplete C-shapes
with three canals were also included in a type IV isthmus. Type V is
identified as a true connection or corridor throughout the section
Ultrasonic Root End Preparation
Root end filling
• The main purpose of placement of a root end fill-ing material is to
provide an adequate apical seal that inhibits the leakage of irritants
that might remain in the root canal after root resection and rootend
preparation, which may cause surgical failure. Besides sealing ability,
other essential properties for an ideal root end filling material are
• Well tolerated by periapical tissues
• Bactericidal or bacteriostatic
• Dimensionally stable
• Easy to manipulate
• Does not stain teeth or tissue
• Non-corrosive
• Resistant to dissolution
• Adheres to the tooth structure
• Dentino, osteo, and cementogenic
• Radiopaque
Advantages of MTA
• Sealing Ability
• Biocompatibility and Bioactivity
Other Types of Cements for RootEndFilling
• Intermediate Restorative Material (IRM)
• SuperEthoxybenzoic Acid (SuperEBA)
• Geristore and Retroplast
• Several modified types of MTA-like materials
• Amalgam
Healing after Apical Microsurgery
• Following apical microsurgery, there is healing in two components: (1)
osseous healing involving trabecular and cortical bone and (2)
dentoalveolar healing that results in repair or regeneration of apical
attachment apparatus (alveolar bone, periodontal ligament and
cementum. After apical surgery, the resected cavity is occupied by a
coagulum, which is slowly replaced by granulation tissue originating from
the periodontal ligament and endosteum. The formation of new bone
begins in the internal area and progresses externally toward thel evel of
the former cortical plate.As newly laid woven bone reaches the
laminapropria, the overlying membrane becomes functiona lperiodontium
(osseoushealing). Progenitor cells from the periodontal ligament
differentiate into periodontal ligament cells and cementoblasts to cover the
resected root surface and lead to regeneration of the cementum and the
periodontal ligament (dentoalveolar healing)
Factors for Healing
• Systemic status
• Bone loss,
• Previous root canal treatment or retreatment
• Coronal restoration
• Occlusion
• Material and technique
• Surgeon’s experience
• Healing after Ultrasonic technique %85-95
• Conventionel technique %65-68
• Endodontic surgery is now replaced by endodontic microsurgery
Thanks to,
22.03.2020
DENTAL ANOMALIES AND

ENDODONTICS
DENTAL  Genetic Factors
ANOMALIES AND Poligenic

More than 300 genes have been identified to be
expressed in teeth that are responsible for
odontogenesis. Defects in these genes have been
ENDODONTICS found to be one of the reasons for variation of the
morphology of tooth
 Local Factors
ASSOC.PROF.DR. UMUT AKSOY Trauma
NEAR EAST UNIVERSITY, FACULTY OF DENTISTRY, Infection
DEPARTMENT OF ENDODONTICS Chemical
Nutritional
1 2
Why is diagnosis important DENTAL

in dental anomalies?
ANOMALIES
 Early prophylactic treatment
 Elimination of aesthetic concerns •Number • Size
 Different treatment options in pulpal complications
•Structure • Shape
 To diagnose some syndromes and diseases through
tooth anomalies
3 4
Hypodontia
I.Number anomalies
• The most common dental anomaly
• Absence of normal dentition
Missing teeth (Hypodontia)
Supernumerary teeth (Hyperdontia) Usually missing 1 or 2 permanent teeth
 HYPODONTIA
In the case where there are 6 or more missing permanent teeth

 OLIGODONTIA
Absence of all primary or permanent teeth

 ANODONTIA
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Hypodontia
• Third molars are most commonly affected
• Followed by
Mandibular second premolars,
Maxillary lateral incisors and
Mandibular central incisors.
7 8
Congenital absence of 25, 35 and 45; 65, 75 and 85 are retained
9 10
Hypodontia
May be seen in:
Ectodermal Dysplasia
Down Syndrome
Rieger’s Syndrome
Book’s Syndrome
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Hypodontia Hyperdontia
Clinical Significance
• Unfavourable positions of remaining present teeth Supernumerary teeth
Teeth developing in addition to the normal 32 permanent and
• Common issues faced in treating hypodontia patients 20 deciduous teeth.
include space management, uprighting and aligning teeth,
management of the deep overbite, and retention  90% Maxillary area
 Single or Multiple
• Long-term multidisciplinary management from pedodontics
to orthodontics, prosthodontics, implantology and so on.  Erupted or Impacted
Genetic counselling is important.  The Anterior Maxilla and Mandibular Premolar regions are
quite common locations.
13 14
Hyperdontia
• The most common supernumerary tooth is a
MESIODENS, which is a malformed, peg-like tooth that
occurs between the maxillary central incisors.
• Fourth and fifth molars that form behind the third

molars are another kind of supernumerary teeth.
PARAMOLARBuccally or lingually located 4. molar

DISTOMOLARDistally located 4. molar
15 16
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19 20
Multiple supernumerary teeth

may be associated with
some syndromes.
 Cleidocranial Dysplasia
 Gardner’s Syndrome
 Sturge-Weber Syndrome
21 22
Hyperdontia
 Crowding
 Displacement of a permanent tooth
 Failure to erupt
 Esthetic problem
 Dentigerous cyst formation
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Hyperdontia II.Size Anomalies

Treatment decision may affected from several factors, such as
 Microdontia

the ST are erupted or nonerupted, stage of the crown and root
development, the distance between the Supernumerary Teeth
and root of the adjacent teeth and the condition of the
dentition (malocclusion, crowding, missing teeth)  Macrodontia
 If ST do not cause any discernable adverse effect on adjacent
teeth and if no future orthodontic treatment foreseen, surgical
intervention is not essential
25 26
Microdontia
• Smaller than normal teeth

• Most commonly affecting third molars and
maxillary lateral incisors.
• Often demonstrates altered morphology, e.g. a
microdontic lateral incisor often has a conical
(peg-shaped) crown.
27 28
Macrodontia
• Larger than normal teeth.

• Maxillary incisors and third molars
• True generalized macrodontia is very rare.
Macrodontia of a single tooth is more
common.
• May contribute to impactions and crowding.
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31 32
33 34
III.Shape Anomalies Dens evaginatus
 Dens evaginatus  Gemination  Small focal enamel prominence at the occlusal surfaces of
posterior teeth or lingual surfaces of anterior teeth.
 Talon Cusps  Concresence  Often demonstrates dentin centrally and there may be an
 Dens invaginatus associated pulp horn.
 Palatogingival
(Dens In Dente)  More commonly affecting mandibular premolars and maxillary
 Fusion
groove lateral incisors.
 Dilaseration  Taurodontism  Associated with increased risk of pulpal and periapical

inflammatory disease.
 Enamel pearl
 Often causing occlusal interference
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22.03.2020
Dens evaginatus
 Early detection of these conditions is important so that
preventive management can be started as early as possible
 Selective reduction of the opposing occluding teeth can be
done
 In a situation where the tubercle has fractured, it can be
sealed with resin.
 In the case of pulp exposure during the early phase of root
development, pulpotomy is suggested.
 If the pulp is necrotic root canal treatment should be
performed
37 38
39 40
Talon Cusps
 An additional cusp of an incisor, thought to be related to an

extremely prominent cingulum.
 More commonly affecting maxillary lateral incisor
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43 44
Talon Cusps - syndromes
 Rubinstein-Taybi Syndrome
 Mohr Syndrome
 Ellis-vanCreveld Syndrome
45 46
Talon cusp Talon cusp

complications complications
 May contribute to impactions  May contribute to impactions
 Susceptible to dental caries  Susceptible to dental caries
 Susceptible to Endodontic infections  Susceptible to Endodontic infections
 Occlusal trauma, esthetic problems  Occlusal trauma, esthetic problems
 Irritation of soft tissues and tongue during  Irritation of soft tissues and tongue
mastication and speech
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Talon Cusps
Treatment
Some common treatments include:
 Fissure sealing
 Composite resin restoration
 Reduction of cusp
 Pulpotomy
 Root canal treatment
 Extraction
49 50
51 52
Dens invaginatus
dens in dente
 Invagination of enamel into the crown, to varying

extents.
 Occurs most frequently in the maxillary lateral
incisors.
 Associated with increased risk of pulpal and
periapical inflammatory disease:
◦ Infolded enamel is often defective, including
canals which lead to the pulp.
◦ Usually, a deep pit connects this with the oral
cavity, withresultant increased caries risk.
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Oehler’s Classification
 Type I: the invagination is confined to within the crown of the
tooth and does not extend beyond the level of the amelo-
cemental junction.
 Type II: the invagination extends into the pulp chamber but
remains within the root canal with no communication with the
periodontal ligament.
 Type IIIA: the invagination extends through the root and

communicates laterally with the periodontal ligament space
through a pseudo-foramen.
 Type IIIB: the invagination extends through the root and

communicates with the periodontal ligament at the apical
foramen
55 56
57 58
Dens invaginatus - treatment

Type I
• Preventative treatment - e.g. Type III
oral hygiene instructions, fissure  Preventative treatment -
sealant e.g. oral hygiene
instructions, fissure sealant
• Restorations
 Restorations
• Endodontic treatment
 Endodontic treatment
Type II  Endo-surgery
• Preventative treatment -
 Intentional Reimplantation
e.g. oral hygiene
instructions, fissure sealant  Extraction
• Restorations
To be continued…
• Endo-surgery
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Dens invaginatus - treatment

Type I
DENTAL • Preventative treatment - e.g.
oral hygiene instructions, fissure
Type III
 Preventative treatment -
sealant e.g. oral hygiene
ANOMALIES AND • Restorations

instructions, fissure sealant
Restorations
ENDODONTICS II Type II


Endodontic treatment
Endo-surgery
• Preventative treatment -
 Intentional Reimplantation
ASSOC.PROF.DR. UMUT AKSOY e.g. oral hygiene
instructions, fissure sealant  Extraction
NEAR EAST UNIVERSITY, FACULTY OF DENTISTRY,
DEPARTMENT OF ENDODONTICS • Restorations
• Endo-surgery
61 62
63 64
Dens invaginatus
Endodontic management
 The anatomy of DI lesions can be
extremely complex. Therefore,
adequate chemomechanical
debridement and obturation of
these malformations can be
challenging
 The invagination can be

removed with high-speed
carbide or diamond burs (long
shanked).
 The invagination should be

thoroughly debrided using
ultrasonic instruments and
hypochlorite
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Dens invaginatus Dens invaginatus

Endodontic management Clinical Tips
 Irregular internal
morphology  Irrigation is  Lateral-vertical
important
 Calcium Hydroxide Dressing condensation
 Thermoplastic
gutta-percha
67 68
Double teeth Gemination

a) geminasyon  Gemination is a partial cleavage of a single tooth germ
resulting in 2 partially or totally separated crowns with
b) şizodonti enlarged pulp chamber and one root.
c) fusion (sinodonti)  Normal number of teeth are maintained. The anomalous tooth
has a large bifid crown
d) concresens  Most often seen in the maxillary primary incisors and the
canines.
 The anomaly causes tooth malalignment, spacing problems,
arch asymmetry, unacceptable appearance, periodontal
involvement and impedes the eruption of the adjacent tooth.
 If geminated tooth is present in anterior region, then it gives
unaesthetic appearance.
Gemination
(Partial Schizodontia) Schizodontia Fusion Concrescence
69 70
Schizodontia
 The term schizodontia would only fit complete
splitting, which results in “twinning” and thus
leading to hyperdontia.
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Gemination
Endodontic management
 It is important to create or achieve functional and esthetic

success in these cases.
 Several treatment methods have been described with respect

to the different types and morphological variations of
geminated teeth, including endodontic, restorative, surgical
and periodontal treatment.
73 74
Fusion  Complete fusion

 Partial fusion
 Union of two normally separate tooth germs,
to varying extents.
 More common in the deciduous dentition.
 One tooth is absent. Rarely, there may be fusion
of a normal tooth with a supernumerary tooth.
 More common in the deciduous dentition. More
commonly associated with anterior teeth
75 76
Fusion
Endodontic Management
 Teeth are joined by the dentine; pulp chambers and canals
may be linked or separated depending on the developmental
stage when the union occurs.
 In the anterior region this anomaly also causes an unpleasant
aesthetic tooth shape due to the irregular morphology.
 Presence of fissures or grooves at the union between fused
teeth predisposes it to caries and periodontal disease.
 Restorative treatment
 Endodontic treatment
 Endodontic surgery
 Reimplantation
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Concrescence
 The joining of roots of normally separate teeth with
cementum
 Concrescence is most frequently noted in maxillary

molars, especially a third molar and a supernumerary
tooth.
 Concrescence may occur during root formation or after

the radicular phase of development is complete. If the
condition occurs during development, it is called true
concrescence; if it occurs later, it is acquired
concrescence.
 When developmental, it might be associated with failed

eruption of one or more teeth.
79 80
Concrescence
 If the union does not affect aesthetics or cause eruption
pathologies, no treatment is required.
 Concrescence should be carefully identified to reduce

the risk of complications associated with surgical
procedures. It may affect the extraction of an adjacent
tooth and may fracture the tuberosity or floor of the
maxillary sinus.
81 82
Palatogingival grooves
 A type of invagination, is a sharp,

somewhat irregular, funnel-like groove,
running from the palatal enamel of the
crown and extending along the root.
 This particularly occurs in the permanent
maxillary lateral incisors.
 The groove commonly starts at the
junction of the marginal ridge and the
cingulum, and then continues along the
proximal surface of the root, extending to
the apical third of the root or to the apex
itself.
83 84
22.03.2020
Palatogingival groove
• Endo + Perio
*Flap reflection
*Removal of
granulation tissue
*Grinding and
flattening of the
groove
• Odontoplasty
• Restorations
85 86
Taurodontism Taurodontism
 Longer body of the tooth with shorter roots.
 Pulp chamber is extremely large with a greater apico-occlusal height
 Radiological appearance of a longer body with short roots, and a normal

crown.
 The molars are the mostly affected, followed by the premolars.
 Occurs in the deciduous and the permanent dentitions
 Can occur uni- or bilaterally
87 88
89 90
22.03.2020
 Hipotaurodontism
 Mezotaurodontism
 Hipertaurodontism
91 92
Taurodontism
may be associated with some syndromes.
 Klinefelter’s Syndrome
 Down Syndrome
 Ectodermal Dysplasia
 Mohr Syndrome
93 94
Clinical Management Clinical Management
 Size and shape of the  Because the pulp of a
pulp chamber  taurodont is usually voluminous,
Hemostasis in order to ensure complete
removal of the necrotic pulp,
 Apically positioned sodium hypochlorite has been
canal orifices  suggested initially as an irrigant
Locating to digest pulp tissue
 Application of final ultrasonic

 Extraordinary root irrigation may ensure that no
canals in terms of pulp tissue remains
shape and number
95 96
22.03.2020
Dilaceration
 A distinct bend of a tooth crown or root. Root

dilacerations are much more common.
 Most are likely to be developmental in
nature. Some may be related to trauma
during tooth development.
 Dilacerated roots interfere with endodontic
treatment, orthodontics and extraction.
97 98
Dilaceration Dilaceration
99 100
Dilaceration Dilaceration
101 102
22.03.2020
Enamel Pearls
 An enamel pearl is a small oval to round enamel

bulb, which may or may not have dentine and
pulp tissue.
 It is typically found on/within the root, and
sometimes on the crown.
 A “true pearl” consists of enamel, a “composite
pearl” contains dentine (“enamel-dentine
pearl”), and rarely an “enamel-dentine-pulp
pearl” may also occur.
103 104
105 106
Enamel Pearls IV. Structural Anomalies

 Larger pearls may interfere with the removal
• Amelogenesis Imperfecta
of calculus and there is a risk of fracture of
• Dentinogenesis Imperfecta
the tip of the scaler. Small pearls may show
up on radiographs, resembling calculus. • Dentine Dysplasia
Unless the pearls are associated with
localised periodontal destruction, treatment • Odontodysplasia
is not required.
107 108
22.03.2020
Amelogenesis Imperfecta Amelogenesis Imperfecta

Amelogenesis imperfecta consists of heterogeneous
structural and morphological enamel defects of  Insufficient occlusal enamel leads to reduced
genetic origin occurring in the absence of systemic
disorders.
vertical dimension, worsened by chipping and
wear, and a deep overbite.
 The dentine is normal, as is the pulp, although a
considerable amount of secondary and tertiary
dentine is deposited in the hypoplastic rough
form. The hypocalcified subtypes are more
prone to caries than the hypoplastic ones.
109 110
Dentinogenesis Imperfecta
• Dentinogenesis imperfecta is an inherited anomaly of dentinal
structure, which presents with and without osteogenesis
imperfecta, with bulbous crowns of an opalescent (translucent)
soft brown (amber or opal) colour, thin and short, often
transparent, roots, and pulpal obliteration after tooth eruption.
• Early loss and excessive wear of the teeth (attrition)
111 112
Dentinogenesis Imperfecta Dentinogenesis Imperfecta
113 114
22.03.2020
Dentinogenesis Imperfecta
Dentinogenezis Imperfecta
Clinical Management
• Objectives of early treatment of the deciduous

dentition are maintenance of the dentition
(vitality, form, size), aesthetics, prevention of
loss of vertical dimension, maintenance of arch
length, and normal growth of facial bones
and the temporomandibular joint.
115 116
Dentinogenezis Imperfecta
Clinical Management
 The use of crowns possibly prevents periapical pathology. However, dental
abscesses are also thought to arise due to disruption of the pulpal vascular
supply in association with the abnormal pulpal calcifications, which leads to
pulp necrosis. Sequential radiographs are therefore desirable. Endodontic
treatment in case of pulpal pathosis is difficult if initiated after pulp canal
obliteration, and may make extraction unavoidable. The outcome of
endodontic treatment may be unfavourable and short roots are
a contraindication for endodontic surgery.
 Root canals are obliterated  Endodontic treatment is difficult
 Selective endodontic treatment is recommended early in strategic teeth.
 Chelating irrigants are not recommended because dentin is hypomineralized
 Vitality tests are unreliable
117 118
Dentin Dysplasia Dentin Dysplasia

Clinical Management
 Hereditary dentin abnormality  In radicular dentine dysplasia, pulp necrosis and
 Similar appearance to dentinogenesis imperfecta but apical granulomas/cysts may be present pre-
rarer eruptively. Posteruption, abscesses are common
because of bacterial ingress into the pulp through
 Two types: type I (radicular) and type II (coronal). the dysplastic dentine after the loss of the enamel.
 Pulp spaces are largely obliterated Surface protection with crowns may prevent pulp
 Higher risk of non‐caries‐related periapical pathosis and excessive wear. Abscesses may also
inflammatory lesions. be the result of endo-perio lesions. Meticulous
oral hygiene has been shown to be effective.
119 120
22.03.2020
Odontodysplasia Odontodysplasia
• Regional odontodysplasia is a rare developmental disorder of, in
general, a few teeth, where the enamel and dentine are
hypomineralised, hypoplastic, thin and discoloured, and the
pulp cavity is wide.
• The teeth are seen on radiographs as vague images
the term “ghost teeth” has been generally adopted. The
cementum is involved, and many teeth do not erupt.
121 122
123 124
27/05/2020
Crown-Root Fractures
TRAUMATIC DENTAL
INJURIES AND
ENDODONTIC
APPROACHES II
Assoc. Prof.Dr. Umut Aksoy
1
Crown-Root Fractures Crown-Root Fractures

CLINICAL FINDINGS CLINICAL FINDINGS
• Crown root fracture involves enamel, dentin and • Percussion test: Tender.
cementum with or without the involvement of pulp • Coronal fragment mobile.
• It is usually oblique in nature involving both crown • Vitality test usually positive
and root.
• Crown fracture extending below gingival margin
3 4
Crown-Root Fractures Crown-Root Fractures

RADIOGRAPHIC FINDINGS TREATMENT
• Apical extension of fracture usually not visible. • Fragment removal only.
• Radiographs recommended: periapical and occlusal • Fragment removal and gingivectomy (sometimes ostectomy) Removal of
the coronal fragment with subsequent endodontic treatment and
exposure.
restoration with a post-retained crown.
• Orthodontic extrusion of apical fragment
• Surgical extrusion
• Extraction
5 6
27/05/2020
Crown-Root Fractures
FOLLOW-UP
7 8
Root Fractures Root Fractures

• These are uncommon injuries
• Involvement of dentin, cementum, pulp and
periodontal ligament
• They form the 3 percent of the total dental injuries.
9 10

CLINICAL FINDINGS RADIOGRAPHIC FINDINGS
• The coronal segment may be mobile and may be displaced. • The fracture involves the root of the tooth and is in a
horizontal or oblique plane.
• Tender to percussion.
• Bleeding from the gingival sulcus may be noted. • Fractures that are in the horizontal plane can usually be
detected in the regular periapical 90o angle film with the central
• Vitality testing may give negative results initially, indicating beam through the tooth. This is usually the case with fractures
transient or permanent neural damage in the cervical third of the root.
• CBCT  Useful
11 12
27/05/2020

TREATMENT FOLLOW-UP
• Reposition, if displaced, the coronal segment of the tooth as soon as • 4 weeks – Splint removal, clinical and radiographic examination.
possible.
• Check position radiographically. • 4 months – Splint removal in cervical third fractures, clinical and
• Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture radiographic examination.
is near the cervical area of the tooth, stabilization is beneficial for a
longer period of time (up to 4 months).
• It is advisable to monitor healing for at least 1 year to determine pulpal
status. • 5 years – Clinical and radiographic examination.
• If pulp necrosis develops, root canal treatment of the coronal tooth
segment to the fracture line is indicated to preserve the tooth. 13 14
Root Fractures
• PROGNOSIS
1. Healing with calcified tissue in which fractured
fragments are in close contact.
2. Healing with interproximal connective tissue in
which radiographically fragments appear separated by a
radiolucent line.
3. Healing with interproximal bone and connective
tissues.
4. Interproximal inflammatory tissue without healing,
radiographically it shows widening of fracture line. 15 16
17 18
27/05/2020
19 20
21 22
Classification
(Andreasen, WHO, International Association of Dental Traumatology)
• Luxation Injuries (Peridontal tissue injuries)

• Luxation Injuries
Tooth concussion
(Peridontal Tissue Injuries) Subluxation
Ekstrusive luxation (Extrusion)
Lateral luxation
Intrusive luxation (Intrusion)
Avulsion
23 24
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Concussion Concussion
CLINICAL FINDINGS
• The tooth is tender to touch or
tapping; it has not been displaced and
does not have increased mobility.
25 26
• Tooth is not displaced. • No radiographic abnormalities.
• Mobility is not present
• Tooth is tender to percussion because of
edema and hemorrhage in the periodontal
ligament.
27 28
TREATMENT FOLLOW-UP
• No treatment is needed. • 4 weeks – Clinical and radiographic examination.
• Monitor pulpal condition for at least one year. • 6-8 weeks – Clinical and radiographic examination.
29 30
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Subluxation Subluxation
CLINICAL FINDINGS
• The tooth is tender to touch or tapping and has
increased mobility; it has not been displaced.
• Bleeding from gingival crevice may be noted.
• Sensibility testing may be negative initially indicating
transient pulpal damage.
• Monitor pulpal response until a definitive pulpal
31 diagnosis can be made. 32
Subluxation Subluxation
• No radiographic abnormalities. • Normally no treatment is needed, however, a

flexible splint to stabilize the tooth for patient
comfort can be used for up to 2 weeks.
33 34
Subluxation
FOLLOW-UP
• 2 weeks – Splint removal, clinical and radiographic
examination.
35 36
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Extrusion Extrusion
CLINICAL FINDINGS
• The tooth appears elongated and is excessively
mobile.
37 38
39 40
Extrusion Extrusion
• Increased periodontal ligament space apically. • Reposition the tooth by gently reinserting it into the
tooth socket.
• In mature teeth where pulp necrosis is anticipated, or
if several signs and symptoms indicate that the pulp
of mature or immature teeth is becoming necrotic,
root canal treatment is indicated.
41 42
27/05/2020
Extrusion Lateral luxation

FOLLOW-UP
• 2 weeks – Splint removal, clinical and radiographic
examination.
• 1 year – Clinical and radiographic examination yearly.
• 5 years – Clinical and radiographic examination. 43 44
Lateral luxation Lateral luxation

• The tooth is displaced, usually in a palatal/lingual or • The widened periodontal ligament space is
labial direction. best seen on eccentric or occlusal exposures.
• It will be immobile and percussion usually gives a
high, metallic (ankylotic) sound.
• Fracture of the alveolar process present.
45 46
Lateral luxation Lateral luxation

TREATMENT FOLLOW-UP
• Reposition the tooth digitally or with forceps to
disengage it from its bony lock and gently reposition • 4 weeks – Splint removal, clinical and radiographic examination.
it into its original location. • 6-8 weeks – Clinical and radiographic examination.
• Stabilize the tooth for 4 weeks using a flexible splint. • 6 months – Clinical and radiographic examination.
• Monitor the pulpal condition.
• If the pulp becomes necrotic, root canal treatment is
indicated to prevent root resorption. 47 48
27/05/2020
Intrusion Intrusion
CLINICAL FINDINGS
• The tooth is displaced axially into the alveolar bone.
• It is immobile and percussion may give a high,
metallic (ankylotic) sound.
49 50
Intrusion Intrusion
• The periodontal ligament space may be Teeth with incomplete root formation:
absent from all or part of the root. • Allow eruption without intervention.
• The cemento-enamel junction is located more • If no movement within few weeks, initiate
orthodontic repositioning.
apically in the intruded tooth than in adjacent
non-injured teeth, at times even apical to the • If the tooth is intruded more than 7 mm, reposition
marginal bone level. surgically or orthodontically.
51 52
Intrusion Intrusion
TREATMENT TREATMENT
Teeth with complete root formation: Teeth with complete root formation:
• Allow eruption without intervention if the tooth is • If the tooth is intruded beyond 7 mm, reposition surgically.
intruded less than 3 mm. If no movement after 2-4 • The pulp will likely become necrotic in teeth with complete
weeks, reposition surgically or orthodontically before root formation. Root canal therapy using a temporary filling
ankylosis can develop. with calcium hydroxide is recommended and treatment should
begin 2-3 weeks after repositioning.
• If the tooth is intruded 3-7 mm, reposition surgically • Once an intruded tooth has been repositioned surgically or
or orthodontically. orthodontically, stabilize with a flexible splint for 4 weeks.
53 54
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Intrusion
FOLLOW-UP
55 56
57 58
59 60
27/05/2020
Avulsion Avulsion
• It is defined as complete displacement of the tooth

out of socket.
61 62
Avulsion Avulsion
First aid for avulsed teeth First aid for avulsed teeth
• Keep the patient calm. • If this is not possible, place the tooth in a suitable storage
medium, e.g. a glass of milk or a special storage media for
• Find the tooth and pick it up by the crown (the white part). avulsed teeth if available (e.g. Hanks balanced storage
Avoid touching the root. medium or saline). The tooth can also be transported in the
• If the tooth is dirty, wash it briefly (10 seconds) under cold mouth, keeping it between the molars and the inside of the
running water and reposition it. Try to encourage the patient cheek. If the patient is very young, he/she could swallow the
/ parent to replant the tooth. Bite on a handkerchief to hold tooth- therefore it is advisable to get the patient to spit in a
it in position. container and place the tooth in it.
• Seek emergency dental treatment immediately.
63 64
Avulsion Avulsion
Closed Apex: Closed Apex:
Tooth replanted prior to the patient’s arrival at the dental office or clinic Tooth replanted prior to the patient’s arrival at the dental office or clinic
Treatment Treatment
• Leave the tooth in place. • Administer systemic antibiotics. Tetracycline is the first choice
(Doxycycline 2x per day for 7 days at appropriate dose for patient age
• Clean the area with water spray, saline, or chlorhexidine.
and weight). The risk of discoloration of permanent teeth must be
• Suture gingival lacerations if present. considered before systemic administration of tetracycline in young
• Verify normal position of the replanted tooth both clinically and patients (In many countries tetracycline is not recommended for patients
radiographically. under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen
V) or amoxycillin, at an appropriate dose for age and weight, is an
• Apply a flexible splint for up to 2 weeks. alternative to tetracycline.
65 66
27/05/2020
Avulsion Avulsion
Tooth replanted prior to the patient’s arrival at the dental office or clinic Tooth replanted prior to the patient’s arrival at the dental office or clinic
Treatment Patient instructions
• If the avulsed tooth has been in contact with soil, and if tetanus • Avoid participation in contact sports.
coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before • Brush teeth with a soft toothbrush after each meal.
splint removal.
67 68
Avulsion Avulsion
Tooth replanted prior to the patient’s arrival at the dental office or clinic Extraoral dry time less than 60 min. The tooth has been kept in physiologic
storage media or osmolality balanced media (Milk, saline, saliva or Hank’s
Follow-up Balanced Salt Solution) and/or stored dry less than 60 minutes
• Root canal treatment 7-10 days after replantation. Place calcium Treatment
hydroxide as an intra-canal medicament for up to 1 month followed by
root canal filling with an acceptable material.
• Clean the root surface and apical foramen with a stream of saline and
soak the tooth in saline thereby removing contamination and dead cells
• Splint removal and clinical and radiographic control after 2 weeks. from the root surface.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 • Administer local anesthesia
year and then yearly thereafter.
69 70
reposition it with a suitable instrument.
Avulsion Avulsion
Extraoral dry time less than 60 min. The tooth has been kept in physiologic Extraoral dry time less than 60 min. The tooth has been kept in physiologic
storage media or osmolality balanced media (Milk, saline, saliva or Hank’s storage media or osmolality balanced media (Milk, saline, saliva or Hank’s
Balanced Salt Solution) and/or stored dry less than 60 minutes Balanced Salt Solution) and/or stored dry less than 60 minutes
Treatment Treatment
• Replant the tooth slowly with slight digital pressure. Do not use force. • Administer systemic antibiotics. Tetracycline is the first choice
(Doxycycline 2x per day for 7 days at appropriate dose for patient age
and weight). The risk of discoloration of permanent teeth must be
• Verify normal position of the replanted tooth both, clinically and considered before systemic administration of tetracycline in young
radiographically. patients (In many countries tetracycline is not recommended for patients
• Apply a flexible splint for up to 2 weeks, keep away from the gingiva. under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen
V) or amoxycillin, at appropriate dose for age and weight, is an
71 alternative to tetracycline 72
27/05/2020
Avulsion Avulsion
Extraoral dry time less than 60 min. The tooth has been kept in physiologic Extraoral dry time less than 60 min. The tooth has been kept in physiologic
storage media or osmolality balanced media (Milk, saline, saliva or Hank’s storage media or osmolality balanced media (Milk, saline, saliva or Hank’s
Balanced Salt Solution) and/or stored dry less than 60 minutes Balanced Salt Solution) and/or stored dry less than 60 minutes
Treatment Patient instructions
• If the avulsed tooth has been in contact with soil, and if tetanus • Soft food for up tp 2 weeks.
coverage is uncertain, refer to physician for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before • Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 week.
splint removal.
73 74
Avulsion Avulsion
Extraoral dry time less than 60 min. The tooth has been kept in physiologic Extraoral dry time exceeding 60 min or other reasons suggesting non-viable
storage media or osmolality balanced media (Milk, saline, saliva or Hank’s cells
Balanced Salt Solution) and/or stored dry less than 60 minutes
Treatment
Follow-up
• Delayed replantation has a poor long-term prognosis. The periodontal
• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as ligament will be necrotic and can not be expected to heal. The goal in
an intra-canal medicament for up to 1 month followed by root canal filling delayed replantation is, in addition to restoring the tooth for esthetic,
with an acceptable material. functional and psychological reasons, to maintain alveolar bone contour.
• Splint removal and clinical and radiographic control after 2 weeks. However, the expected eventual outcome is ankylosis and resorption of
the root and the tooth will be lost eventually.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year
and then yearly thereafter.
75 76
Avulsion Avulsion
Extraoral dry time exceeding 60 min or other reasons suggesting non-viable Extraoral dry time exceeding 60 min or other reasons suggesting non-viable
cells cells
Treatment Treatment
• Remove attached non-viable soft tissue carefully, with gauze. • Replant the tooth slowly with slight digital pressure. Do not use force.
• Root canal treatment can be performed prior to replantation, or it can be • Suture gingival lacerations if present.
done 7-10 days later.
• Verify normal position of the replanted tooth clinically and
• Administer local anesthesia radiographically.
• Irrigate the socket with saline. • Stabilize the tooth for 4 weeks using a flexible splint.
reposition it with a suitable instrument. 77 78
27/05/2020
Avulsion Avulsion
cells cells
Treatment Treatment
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x • To slow down osseous replacement of the tooth, treatment
per day for 7 days at appropriate dose for patient age and weight). The risk of
discoloration of permanent teeth must be considered before systemic of the root surface with fluoride prior to replantation has
administration of tetracycline in young patients (In many countries tetracycline is been suggested (2 % sodium fluoride solution for 20 min.)
not recommended for patients under 12 years of age). In young patients
Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age
and weight, is an alternative to tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is
uncertain, refer to physician for a tetanus booster.
79 80
Avulsion Avulsion
cells cells
Patient instructions Follow-up
• Soft food for up to 2 weeks. • Root canal treatment 7-10 days after replantation. Place calcium
hydroxide as an intra-canal medicament for up to 1 month followed by
• Brush teeth with a soft toothbrush after each meal. root canal filling with an acceptable material. Alternatively an antibiotic-
corticosteroid paste may be placed immidiately or shortly following
• Use a chlorhexidine (0.1 %) mouth rinse twice a day for 1 replantation and left for at least 2 weeks.
week.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1
81 year and then yearly thereafter. 82
83 84
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85 86
87 88
89 90
27/05/2020
91 92
93 94
95 96
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97 98
Avulsion
Factors affecting the success of reimplantation :
1-Periodontal ligament
2-Extraoral time
3-Transportation
4-Splinting
5-Root Canal Treatment Timing
6-Calcium Hydroxide Therapy
99
7-Floride Application 100
Avulsion Avulsion
Storage media for avulsed tooth (from the best to the worst)
Prognosis:
1.In its own socket
1—Periodontal ligament healing
2.Hank’s Balance Salt Solution
2—Surface resorption 3.Milk
3—Replacement resorption (ankylosis) 4.Saline
5.Intraorally
4—Inflamatory resorption 6.Saliva
7.Tap Water
101
8.Dry 102
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103 104
105 106
107
17.04.2020
-Tooth Resorptions I- -Kök Rezorpsiyonları-
Assoc.Prof.Dr. Umut Aksoy
Bate, C.S. (1856). On absorption. Transactions

Odontological Society of London, s.21.
According to the American Association of Endodontics CELLS INVOLED IN TOOTH RESORPTION

resorption is defined as:
• A condition associated with either a physiologic or a pathologic process MONOCYTES

resulting in the loss of dentin, cementum or bone. CYTOKINES
MACROPHAGES
ENZYMES
• Physiologic tooth resorption is seen in deciduous teeth during
eruption of permanent teeth OSTEOCLASTS
• Pathologic tooth resorption is seen in both deciduous as HORMONES
well as permanent teeth due to underlying pathology.
ODONTOCLASTS
MONOCYTE
MACROPHAGE
1
17.04.2020
-Genel Bilgiler-
-Kök Rezorpsiyonları- -Kök Rezorpsiyonları-
OSTEOCLAST ODONTOCLAST
-Genel Bilgiler-
-Kök Rezorpsiyonları- -Kök Rezorpsiyonları-

Predentin
Cementum
-Root Resorptions- -Internal Resorption-

Andreasens’ classification (1970) – Internal replacement resorption
• Internal resorption – Internal inflammatory resorption
– Internal replacement resorption
– Internal inflammatory resorption
• External resorption
– Surface resorption
– Inflammatory resorption
– Replacement resorption
2
17.04.2020
-Internal Resorption-
An inflammatory process initiated
within the pulp space with loss of
dentin and possible invasion of the
cementum
It is characterized by oval shaped

enlargement of root canal space
Internal Resorption = Internal

Granuloma
When the pulp chamber is affected, it

may appear as «pink spot» as the
enlarged pulp is visible through the
thin wall of the crown.
-Internal Resorption- -Internal Resorption-

Etiology:
Internal resorption may also be caused while
doing restorative procedure like preparation of
tooth for crown, deep restorative procedures,
application of heat over the pulp or pulpotomy
using calcium hydroxide, i.e. iatrogenic in origin.
Internal resorption can also be idiopathic in
origin.
3
17.04.2020
Etiology of internal resorption: -Internal Resorption-
• Long standing chronic inflammation of Longstanding injury leads to chronic
pulp inflammation and circulatory
the pulp changes within the pulp. Active
• Caries related pulpitis hyperemia with high oxygen pressure
• Traumatic injuries Histopathology supports and induces the
a. Luxation injuries osteoclastic activity. Thereby the
• Iatrogenic injuries resorption process starts
a. Preparation of tooth for crown
b. Deep restorative procedures Pulp tissue shows chronic inflammation reaction and resorption lacunae
irregularly occupied by ‘dentino-clasts’ similar to osteoclasts. The
c. Application of heat over the
granulation tissue present in this type of resorption is highly proliferating in
pulp nature. Scanning Electron Microscope studies have shown rough and
d. Pulpotomy using Ca(OH)2 uneven dentin surface with numerous resorption lacunae.
• Idiopathic
-Genel Bilgiler-
-İnternal Kök Rezorpsiyonları- -İnternal Kök Rezorpsiyonları-
X1000
TBB,X2 TBB,x16 TBB,x400

Patel, S., Ricucci, D., Durak, C. ve Tay, F. (2010). Internal root Patel, S., Ricucci, D., Durak, C. ve Tay, F. (2010). Internal root
resorption: a review. Journal of Endodontics, 36(7), 1107-1121. resorption: a review. Journal of Endodontics, 36(7), 1107-1121.
H&E, x25 H&E, x100

4
17.04.2020
H&E, x400 H&E, x1000

-İnternal Kök Rezorpsiyonları- -İnternal Kök Rezorpsiyonları-
Clinical features of internal resorption
 The pulp usually remains vital and asymptomatic until root has Clinical features of internal resorption
been perforated and become necrotic.
 In internal resorption cases, thermal and electrical pulp tests
 Patient may present pain when the lesion perforates and tissue have low vitality value in teeth.
is exposed to oral fluids.
 Internal resorption may develop in as short a period as a few
 It is commonly seen in maxillary central incisors, but any months, sometimes it can take years to develop.
tooth of the each can be affected
 When the pulp chamber is affected, it may appear as “pink
 It can occur in permanent as well as deciduous teeth. In spot” as the enlarged pulp is visible through the thin wall of
primary teeth it spreads more rapidly. the crown.
5
17.04.2020
Radiographic features of internal resorption
 The expansion in the root canal or pulp chamber
Treatment Options in Teeth
and its boundaries appear as a regular circular,
radiolucent area.
with Internal Resorption
 There is enlargement of root canal which is well • Without perforation—Endodontic therapy
demarcated, enlarged «ballonning area» of
resorption • With perforation
a. Non-surgical: Ca(OH)2 therapy—Obturation
 Outline of canal is distorted MTA therapy—Obturation
b. Surgical:
 Root canal and resorptive defect appears
i. Surgical flap
contiguous
ii. Root resection
 Does not involve bone, so radiolucency is confined iii. Intentional replantation
to root. Bone resorption is seen only is lesion
perforates the root.

1.Without perforation—Endodontic therapy 1.Without perforation—Endodontic therapy
Root canal treatment Root canal treatment

• Removal of all inflamed tissue from the resorption • When the tissue remnants persist,
defect is the basis of successful treatment. an internal calcium hydroxide
dressing may be placed after initial
• Irrigation with 5.25% NaOCl will dissolve attached intracanal cleaning and at the next
pulpal remnants as it is a strong antimicrobial visit, obturation can be done after
agent and excellent solvent for necrotic tissue. flushing the calcium hydroxide and
tissue debris from the canal.
Treatment Options
Root canal treatment - obturation
• Because of the size, irregularity and in accessibility of
the resorption defects, obturation of the canal may be
technically difficult.
• The canal apical to the defect is filled with solid gutta-

percha while the resorptive area is usually filled with
material that will flow in the irregularities. The warm
gutta-percha technique, thermoplasticized gutta-
percha technique and use of chemically plasticized
gutta-percha are methods of obturation to be used.
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17.04.2020

Management of Perforating Management of Perforating
1.With perforation — Internal Resorption 1.With perforation — Internal Resorption
a) Non-surgical Repair: Ca(OH)2 therapy — Obturation
• When the internal root resorption has progressed
through the tooth into the periodontium, there are
additional problem of periodontal bleeding, pain and
difficulty in obturation. Indications: Non-surgical repair is indicated in following cases:
• Presence of a perforation cannot be determined i. When the defect is not extensive.
radiographically unless a lateral radiolucent lesion is ii. When defect is apical to epithelial attachment.
present adjacent to the lesion. iii. When hemorrhage can be controlled.
• Clinically in some cases a sinus tract may be present and
there will be continued hemorrhage in the canal after
the pulp is removed.

a) Non-surgical Repair: Ca(OH)2 therapy — Obturation a) Surgical: Ca(OH)2 therapy — Obturation
• In this technique, after thorough cleaning and shaping of
the canal, the intracanal calcium hydroxide dressing is placed If the calcium hydroxide treatment is unsuccessful or not feasible,
surgical repair of the defect should be considered.
and over it a temporary filling is placed to prevent
interappointment leakage.
• Patient is recalled after three months for replacement of i. Surgical flap
ii. Root resections
calcium hydroxide dressing and for radiographic confirmation
of the barrier formation at the perforation site. Afterwards two iii. Intentional replantation
months recall visits are scheduled until there is a radiographic
barrier at resorption defect. After the barrier is formed, the
canal is obturated with gutta-percha as in the non perforating
internal resorption.

a) Surgical: Ca(OH)2 therapy — Obturation a) Surgical: Ca(OH)2 therapy — Obturation
i. Surgical flap
7
17.04.2020
Management of Perforating
1.With perforation — Internal Resorption
a) Surgical: Ca(OH)2 therapy — Obturation
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28-May-20
• The developing dentition is at risk for pulpal

necrosis due to trauma, caries, and
developmental dental anomalies such as dens
evaginatus. Loss of an immature permanent
tooth in young patients with mixed dentition can
be devastating, leading to loss of function,
malocclusion, and inadequate maxillofacial
development.
 Apexification is defined as a method to induce a calcified barrier in a

root with an open apex or the continued apical development of an
incompletely formed root in teeth with necrotic pulp tissue. This is
distinct from revascularization, since apexification does not attempt
to regain vital tissue in the canal space.
 Apexogenesis is defined as a vital pulp therapy procedure performed

to encourage continued physiologic development and formation of
the root end. An important distinction is that apexogenesis is
indicated for teeth in which there has been no loss of vascularity, thus
no need to “revascularize” the canal space.
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28-May-20
REGENERATIVE ENDODONTIC PROCEDURES (REPS)
Defined as biologically based procedures designed to replace

damaged structures such as dentin, root structures, and cells of the
pulp-dentin complex. Regenerative endodontics is founded on the seminal work of
Dr. Nygaard-Østby, completed in the 1960s.
He hypothesized that a blood clot could be the first step in
Aims; the healing of a damaged dental pulp, similar to the role
1.Healing apical periodontitis. of the blood clot in the healing process observed in other
2.Promote normal pulpal physiologic functions. areas.
3.Continued root development.
4.Immune efficiency.
5.Normal nociception.
• Thus, the ultimate goal of these procedures is to regenerate the
components and normal function of the pulp dentin complex.
• Revascularization is a term better used for the

reestablishment of the vascularity of an ischemic tissue, The field of regenerative endodontics has seen a
such as the dental pulp of an avulsed tooth. From this dramatic increase in knowledge gained from
perspective, a focus on revascularization would ignore translational basic science studies evaluating the
the potential importance of growth factors and scaffolds interplay of the tissue engineering components (stem
that are required for histologic recapitulation of the pulp- cells, growth factors, and scaffolds) applied to the
dentin complex. clinical need and challenges.
Pioneering work supporting the

concept of regenerating dental tissues
was reported more than 50 years ago Dental pulp can be viewed as a core of
when Dr. B.W. Hermann described the innervated and vascularized loose
application of calcium hydroxide connective tissue surrounded by a layer
(Ca[OH]2) for vital pulp therapy, and of odontoblasts.
Professor Nygaard-Østby evaluated a
revascularization method for
reestablishing a pulp-dentin complex
in permanent teeth with pulpal
necrosis.
2
28-May-20
1. Stem Cells
• Stem cells are defined as a distinct subpopulation of

undifferentiated cells with self-renewal and differentiation Multipotent stem cells; All adult mesenchymal stem
potential. cells are more restricted in their capacity to
• They can be classified as pluripotent or multipotent cells. differentiate, only forming tissues of mesenchymal
origin, and therefore are classified as multipotent. These
• Pluripotent stem cells have the capacity of becoming specialized cells
cells can be found compartmentalized within tissues in
and belong to all three germ layers. Embryonic stem cells are the best
“stem cell niches.”
example of pluripotent cells.
• There is a significant body of research on embryonic stem cells, but The mesenchymal tissues appear to have an enriched population of adult
ethical, legal, and medical stem cells. They were initially called stromal stem cells but later
(tissue-rejection) issues can received the now widely accepted name mesenchymal stem cells (MSCs).
render these cell types unsuitable
for clinical applications.
• Although stem cells have been identified in most

oral tissues. The stem cells more likely to be • Odontoblasts are one of the most specialized
involved in REPS are localized around the cells of the pulp dentin complex with
periapical region. dentinogenic, immunogenic, and possibly
sensorial functions.
• These include stem cells of the
o apical papilla (SCAP), • At least five different types of postnatal mesenchymal stem
o periodontal ligament stem cells (PDLSCs), cells, in addition to DPSCs, have been reported to
o inflammatory periapical progenitor differentiate into odontoblast-like cells, including SHED,
cells (iPAPCs), SCAP, IPAPCs, DFPC, and BMMSC.
o bone marrow stem cells (BMSCs),
o and dental pulp stem cells (DPSCs).
3
28-May-20
Several growth factors have been evaluated for their ability to trigger the
2. Growth Factors/Morphogens differentiation of selected mesenchymal stem cell populations into
• Growth factors and transcription factors are central to odontoblast-like cells.
the cascade of molecular and cellular events during
tooth development and are responsible for many of These growth factors/ cytokines are
the temporospatial morphologic changes observed in secreted by the odontoblasts during
the developing tooth germ. For these reasons, they are primary dentinogenesis, becoming
also likely involved in the regeneration process. sequestered and “fossilized” into the
dentine after biomineralization.
• Dentine is composed of collagen fibers (90%, collagen type I) and However, they may become
solubilized by demineralization of the
noncollagenous matrix molecules (proteoglycans, phosphoproteins, and
matrix, bacterial acid (caries decay),
phospholipids). The collagen fibers act as a grid or matrix, and this
chemical treatment (EDTA rinsing
structure behaves as a scaffold upon which mineralization can occur. solution, calcium hydroxide or acid
etching for bonded restorations), or
restorative materials such as mineral
trioxide aggregate and Biodentine
Morphogens are not only naturally occurring factors found within teeth. Several
growth factors have also been evaluated for their ability to trigger the 3. Scaffolds
differentiation of selected mesenchymal stem cell populations into
odontoblastlike cells • An important component of tissue engineering is a physical
• scaffold. Tissues are organized as three-dimensional
structures, and appropriate scaffolding is necessary to,
(1) provide a spatially correct position of cell location and
(2) regulate differentiation, proliferation, or metabolism while
promoting nutrient and gaseous exchanges.
• Extracellular matrix molecules are known to control the

differentiation of stem cells, and an appropriate scaffold might
selectively bind and localize cells, contain growth factors, and
undergo biodegradation over time. Thus, a scaffold is far more than
a simple lattice to contain cells, but instead can be viewed as the
blueprint of the engineered tissue.
4
28-May-20
• Scaffolds can be classified as either, • The great majority of currently published regenerative endodontic
1. natural or procedures involve evoked bleeding and the formation of a blood
2. synthetic. clot to serve as a scaffold.
• Examples of natural scaffolds include collagen,
glycosaminoglycans, hyaluronic acid (HA), demineralized or • Another approach for creating a scaffold involves the use
of autologous platelet-rich plasma (PRP). It requires
native dentin matrix, and fibrin.
minimal ex vivo manipulation, being fairly easy to
• Examples of synthetic scaffolds include poly-L-lactic acid
(PLLA), polyglycolic acid (PGA), polylactic-coglycolic acid prepare in a dental setting. PRP is rich in growth factors,
(PLGA), polyepsilon caprolactone, hydroxyapatite/tricalcium degrades over time, and forms a
phosphate, bioceramics, and hydrogels such as self-assembly three-dimensional fibrin matrix.
peptide hydrogels. Platelet rich fibrin (PRF) is an
alternative to PRP, as it has a
three-dimensional architecture
conducive with stem cell proliferation
and differentiation and contains
bioactive molecules
Clinical Procedures Related to Regenerative Endodontics

(Important Points)
Why it is difficult to perform root canal treatment in incompletely
formed root?
1. Because the apex is not fully developed and often has a
blunderbuss shape, cleaning and shaping of the apical portion of
the root canal system can be difficult.
2. The process is further complicated by the presence of thin,
fragile dentinal walls that may be prone to fracture during
instrumentation or obturation.
3. The open apex increases the risk of extruding material into the
Regenerative Endodontics
5
28-May-20
Most of the published procedures reported minimal to no instrumentation.

• Traditionally, an immature tooth with an open apex is treated by This might be due, at least in part, to the concern of further weakening fragile
apexification, which involves creating an apical barrier to prevent dentinal walls and the difficulty of mechanically debriding canals of such
extrusion. In many cases, this entails an involved, long-term large diameters and avoiding generation of a smear layer that could occlude
treatment with Ca(OH)2, resulting in the formation of a hard- the dentinal walls or tubules. Because of the lack of mechanical debridement,
tissue apical barrier. clinicians relied on copious irrigation for maximum antimicrobial and tissue
dissolution effects.
• Disadvantage of the traditional apexification procedures is that
the short-term or long-term use of Ca(OH)2 has the potential to • Approximately 51% of the cases included the use of a triple
reduce root strength. antibiotic paste (a 1 : 1 : 1 mixture of ciprofloxacin/ metronidazole/
minocycline), whereas 37% used Ca(OH)2 as an intracanal
• A primary advantage of regenerative endodontic procedures in
medicament.
these cases is the greater likelihood there will be
 an increase in root length and
 root wall thickness,
 in addition to the possibility that the patient will regain vitality
responses.
 Sodium hypochlorite, either alone or in combination with other

irrigants, has been used to disinfect the canal space in most cases.
 The patient age appears to be an important factor in case  A combination of triple antibiotic (minocycline, metronidazole, and
selection ciprofloxacin) was left in the canal space, so the disinfection protocol
 Some studies suggest that younger patients have a greater was primarily a chemical method rather than the chemomechanical
healing capacity or stem cell regenerative potential.
approach used in conventional nonsurgical endodontic therapy.
 Another important factor related to age is the stage of
root development, because the large diameter of the
immature (open) apex may foster the ingrowth of tissue
into the root canal space and may indicate a rich source
of mesenchymal stem cells of the apical papilla
6
28-May-20
Treatment Procedures for Regenerative

Endodontics 4. The root canal systems are slowly irrigated first with 1.5% NaOCl (20
mL/canal, 5 min) and then irrigated with saline (20 mL/canal, 5 min), with
First Treatment Visit : irrigating needle positioned about 1 mm from root end.
5. Canals are dried with paper points.
1. Informed consent, including 6. Calcium hydroxide or an antibiotic paste or solution (combined total of
explanation of risks and alternative 0.1 to 1 mg/mL) is delivered to canal system.
treatments or no treatment. 7. Access is temporarily restored.
2. After ascertaining adequate local
anesthesia, rubber dam isolation is
obtained.
3. The root canal systems are accessed
and working length is determined
(radiograph of a file loosely positioned
at 1 mm from root end).
Final (Second) Treatment Visit : 4. The canals are dried with paper points.
(Typically 2 to 4 Weeks after the First Visit) 5. Bleeding is induced by rotating a precurved K-file size #25 at 2 mm past
the apical foramen with the goal of having the whole canal filled with blood
1. A clinical exam is first performed to the level of the cementoenamel junction.
to ensure that that there is no moderate 6. Once a blood clot is formed, a premeasured piece of Collaplug is carefully
to severe sensitivity to palpation and placed on top of the blood clot to serve as an internal matrix for the
percussion. If such sensitivity is placement of approximately 3 mm of white MTA or Biodentin.
observed, or a sinus tract or swelling 7. A (3- to 4-mm) layer of glass ionomer layer is flowed gently over the
is noted, then the treatment provided bioactive coronal barrier and light cured for 40 secs.
at the first visit is repeated. 8. A bonded reinforced composite resin restoration is placed over the glass
2. After ascertaining adequate local ionomer.
anesthesia with 3% mepivacaine (no 9. The case needs to be followed-up at 3 months, 6 months, and yearly after
epinephrine), rubber dam isolation is that for a total of 4 years.
obtained.
3. The root canal systems are accessed; the
intracanal medicament is removed by
irrigating with 17% EDTA (30 mL/canal, 5
min) and then a final flush with saline (5
mL/canal, 1 min).
7
28-May-20
Clinical Measures of Treatment Outcome Clinical Measures of Treatment Outcome
• The measures of success for • Other measures of the • Although achieving • These responses to vitality
revascularization are not only presence of vital, functioning regeneration of pulp tissue testing (with either cold or
radiographic evidence of tissue in the canal space continues to be a preferred EPT), as well as the lack of
periradicular health but also include laser Doppler blood objective, an alternative signs and symptoms of pathosis,
radiographic and other clinical flowmetry; pulp testing acceptable outcome, retention suggest the presence of
evidence of functioning vital involving heat, cold, and of a tooth with healed apical functioning tissue in the canal
tissue in the canal space. electricity; and lack of signs tissue, could be considered space.
• Radiographic evidence of or symptoms. satisfactory. • Vitality responses, in addition to
functioning pulp (or pulp- • The ideal clinical outcome is continued root development, are a
like) tissue would include an asymptomatic tooth that desirable outcome.
• Responses to electric pulp tester
continued root growth, both in does not require retreatment (EPT) are more commonly
length and wall thickness. reported than cold responses.
8
28-May-20

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Endodontic Diagnosis and

Doç. Dr. Atakan KALENDER

 Written and approved form of medical and dental history

Complains of the patient……?

 increase with hot, cold or chewing

 Decrease with cold

 Examination and objective tests needed

 Extra oral fistula

 Always take your radiograph

 A direct stimulus for nerves in the pulp

 The presence of deep pockets in the

İzole derin cep varlığı

 Cavity preparation without local anesthesia

 Vertical crown fracture

Clinical diagnosis (not histological)

 Symptom may be thermal sensitivity

 Symptom no thermal sensitivity

 Diificulty level of the case

Two basic questions;

 Status of the patient

Assoc. Prof. Dr. Atakan Kalender

ACUTE PULPITIS CHRONIC PULPITIS

pulpitis serosa pulpitis purulenta

pulpitis ulseroza pulpitis polypoza

 Symptom may be thermal sensitivity

 Symptom spontaneous pain

 Symptom no thermal sensitivity

Signs and symptoms:

Signs and symptoms

• Number of different tissue reaction may

• Transformation occur from one type of

a) Acute apical periodontitis

b) Acute apical abscess

c) Chronic apical periodontitis (Periapical

d) Chronic apical abscess

e) Periapical cyst (true and bay)

Yrd. Doç. Dr. Fatma KERMEOĞLU

a. Inadequate opening of the access

• Pulp chamber and canal morphology not well

• In areas where pulp horns are present, residual infected tissue

The wide opening of the access cavities can lead to a serious

• Failures during access cavity preparation

• Insufficient knowledge of anatomic structure

• Not to consider the tooth axis

• Opening the access cavity in the presence of artificial crowns

• Calcifications in the pulp chamber should be considered.

3b. Working length problems

3c. File aspiration or swallow

1. Searching canal orifices

Ledge is the artificial irregularities created in the root canal

• Place a lightly curved #10 file in canal and

• Antihistamines and corticosteroids are given

• Antibiotics are given against secondary

• ANAMNESIS NaOCl allergy must be

6a. Post Perforations

6b. Tissue Emphysema

Osteotomy area 8-10mm 3-4mm

Angel 45-65 degrees 0-10 degrees

Examination of root end - possible