Pulpectomy -general

PULPECTOMY

Complete removal of necrotic pulp tissue from the root canals and
coronal portion of devital primary teeth to maintain the tooth in the
dental arch

Justification
1. Removal of diseased tissue
2. Space management
 Pulpectomy -general

OBJECTIVES OF PULPECTOMY

1. Following the treatment , the infectious process should resolve

2. There should be radiographic evidence of successful filling

without gross overextension or underfilling

3. The treatment should permit resorption of the primary root structures at the
appropriate time to permit normal eruption of succedaneous tooth

4. No radiographic evidence of further breakdown of supporting

tissues

5. Should prevent further pain and swelling

6. No internal or external resorption or other pathology

 Pulpectomy -general

INDICATIONS

1. Strategically important tooth

(in case of the deciduous second molar where the permanent first molar
has not erupted)

2. Irreversible pulpits

3. Minimal periapical changes with sufficient bone support

4. At least 2/3rd of the root length available

5. Internal resorption without any obvious perforation

 Pulpectomy -general

CONTRAINDICATIONS

1. Excessively mobile and/or reduced bone support

2. Non restorable tooth

3. Internal resorption of the pulp chamber and root canal

4. Underlying dentigerous or follicular cyst

5. Pathology extending to the developing permanent tooth bud

6. Less than2/3rd of root length remaining

7. Perforation of pulpal floor

8. Medically compromised children

 Pulpectomy -general

The procedure of pulpectomy can be performed in :--

1. Single-visit
2. Multi-visit

Single-visit Partially vital pulp

Multi-visit Non-vital pulp

 Basic steps in pulpectomy

STEP 1 . Give local anaesthesia and isolate the tooth with rubber dam
 Basic steps in pulpectomy

STEP 2 : Remove caries and identify the exposure site

 Basic steps in pulpectomy

STEP 3 : Remove roof of pulp chamber and identify opening of root canals
 Basic steps in pulpectomy

STEP 4 : Take working length radiograph

 Basic steps in pulpectomy

STEP 5 : Clean out root canals with hedstroem files and remove
remnants of pulp tissue and irrigate the canal
 Basic steps in pulpectomy

STEP 6 :Select a spiral root canal filler of appropriate size

 Basic steps in pulpectomy

STEP 7 : mix zinc oxide eugenol as a slurry and spin it into the root canals
Using the spiral root canal filler
 Preoperative

Immediately post operative 3 Months later

Preoperative

After 6 months
 SINGLE VISIT PULPECTOMY TECHNIQUE

1. Access opening for pulpectomy in primary teeth

It is defined as
That endodontic coronal preparation which enables unobstructed
access to the canal orifice , a straight line access to the apical foramen,
complete authority over the enlarging instrument and to accommodate
the filling technique
 SINGLE VISIT PULPECTOMY TECHNIQUE

IDEALS FOR ENDODONTIC ACCESS

1. Complete removal of pulp chamber roof

2. Removal of coronal pulp

3. Straight line access to facilitate placement of endodontic instruments

and obturation material

These ideals are balanced with following constraints

Conservation of tooth structure

Retention and esthetics

Final restoration
 Access openning
OBJECTIVES

3 main objectives
1. obtaining a straight line access to the apical foramen or to the
Initial curvature of the canal to aid in
-improved instrumentation control
-improved obturation
-decreases the incidence of procedural error

2. Conservation of tooth structure

-to minimize weakening of remaining tooth structure

3. Unroofing the pulp chamber and removal of the pulp horns to aid in
-locating the root canal orifice
-maximum visibility
-locate canals
-permit straight line preparation
-prevents discoloration of teeth due to pulpal remnants
 Access openning

To achieve optimal preparation 3 factors of internal anatomy must be considered

1. Size of the pulp chamber

-more extensive preparations due to large pulp chambers

2. Shape of the pulp chamber

-the finished outline form should accurately reflect the
shape of the pulp chamber
Example : the floor of the pulp chamber in molar is usually
triangular --- triangular position of canal orifice
this shape is so extended to the walls of the cavity
onto the occlusal surface---- final outline form is
usually triangular

3. Number position and curvature of root canals

 Access openning

Primary root canal anatomy

The clinician must have a thorough knowledge of the anatomy of the

Primary root canal and the variations that normally exist
 Access openning
PRIMARY ANTERIORS
Maxillary Incisors
The root canals are almost round but somewhat compressed
Normally 1 canal without a bifurcation
Accessory canals are rare , but do occur

Mandibular Incisors
Root canals are flattened on mesial and distal surfaces and sometimes
grooved
2 canals are seen in less than 10% of cases
Lateral or accessory canals are rare

Maxillary and mandibular canine

Root canals correspond to the exterior root shape
A rounded triangular with the base towards the facial surface
Lumen of the canal is sometimes compressed in mesial-distal direction
Lateral and accessory canals are rare
 Access openning

PRIMARY MOLARS

Normally have same number of roots and positions of the roots

as the corresponding permanent molars

The roots of the primary molars are long , slender compared with the
crown length and width

They diverge to allow for a permanent tooth bud formation

 Access openning
Maxillary 1st primary molar
3 roots. 2 facial,1 palatal

Palatal root is often round and longer than 2 facial roots 2-4 canals

Bifurcation of mesiao facial root into 2 canals - 75%

Maxillary 2nd primary molar

3 roots. 2 facial,1 palatal

2 – 5 canals

Mesiofacial root usually bifurcates or contains 2 canals – 85%-95%

 Access openning

Mandibular 1st primary molar

2 roots . 1 Mesial, 1 distal

Usually have 3 canals but may have 2-4 canals

Mesial root contains 2 canals- 75%

Distal root contain more than 1 canal- 25%

Mandibular 2nd primary molar

2 roots . 1Mesial,1 distal

Usually have 3 canals . but may have 2-5 canals

Mesial root has 2 canals – 85%

Distal root contains more than 1 canals – 25%
 2. canal cleaning and shaping

Using local anaesthesia and rubber dam placement, all accessible

radicular pulp is removed

Relative pulpectomy
due to tortuous course of root canal coupled with numerous
accessory canals, complete removal of pulp in the primary
teeth may often be difficult , if not impossible. Thus all such
procedures are regarded as partial pulpectomy procedures

Selective filing
resorption in primary teeth may have started at the time of
Treatment. Also the slender roots , with thin apical ends may
predispose the tooth to a root fracture in cases of excessive
preparation .Thus procedure of selective filing should be used
 Cleaning and shaping

With an endodontic file , remove the diseased pulp tissue from all
The canal.

The canals should be instrumented to the resistance point

Each canal should be enlarged 3 – 4 instrument sizes greater than the

First file capable of working the apex
 Cleaning and shaping
It is not necessary to take an X-ray to determine file length as is done in
Permanent teeth endodontic procedure
Visual comparision of file and root canal length on the pre operative
Periapical radiograph will result in sufficient clinical acccuracy

In the primary tooth attempts to mechanically prepare a circular

apical 1/3rd may result in lateral perforation of the canal because of its
Hour glass shape

Because of the bizzare anatomy of primary molar root canals the use of
barbed broaches as in conventional endodontics may be unsuccessful

Also the ribbon shape of the root canals, with a narrow mesiodistal width
Compared to their buccolingual dimension, discourages gross enlargement
Of the canals

Hedstrom files are recommended since they remove hard tissue only on
withdrawal , which prevents pushing infected through the apices. For this
Reason reamers are not recommended
 Cleaning and shaping

Instruments used in conjunction with irrigating solution reduce the

possibility of fracture because of the lubricant action of the solution

5% solution of sodium hypochlorite has an excellent solvent action and

is dilute enough to cause only mild irritation when contacting periapical
Tissue
-Schilder & Amsterdam,1970

After filing ,the canal should be irrigated and then dried with cotton pellet
Or paper points
 3. Filling of the primary root canals
Ideal requirements are as follows
1. Should resorb at the similar rate as the primary root

2. Should be harmless to the periapical tissues and to the

permanent tooth germ ; if pressed beyond the apex it should
resorb readily

3. Should have a stable disinfecting power

4. Should be inserted into the root canal and be removed easily

if necessary

5. Should adhere to the walls of the canals and should not shrink

6. Should not be soluble in water

7. Should be radiopaque and not discolor the tooth

 Filling of the primary root canals

Gutta Percha
Not indicated for primary teeth
Since it is not a resorbable material, its use is contraindicated in primary teeth

No material currently available meets al the criteria

The filling material most commonly used for primary pulp canals are :
1. Zinc oxide - Eugenol paste
2. Iodoform paste
 Filling of the primary root canals

PROPERTIES
ZOE KRIpaste
Resorbs at the same rate as
the tooth √ 
Harmless
 
Overfill resorbs
√ 
Antiseptic
 
Easily applied
 
Adheres to the wall
 
Easily removed
 
Radiopaque
 
No discoloration
 
 Filling of the primary root canals

Zinc oxide eugenol has extruded through the apex of 85

3 months there is complete disappearance of the material periapically

 MULTI-VISIT PULPECTOMY

This procedure is used for non vital primary teeth

Studied by (Wittch,1956 ; Lawrence,1966 ; Gould,1972) over short term

And by ( starky,1973) over long term

The clinical technique is similar to the single visit pulpectomy

 Multi – visit pulpectomy
Local anaesthesia and rubber dam placement are recommended
In cases of swelling and cellulites this can be omitted

Instrumentation of the canal is not recommended at the first visit in

1. Mobile tooth
2. If swelling or a fistula is present
3. If pus is present in the canals

In absence of signs and symptoms instrumentation can proceed

Between and after instrumentation canals are irrigated

Between appointment antibacterial drug is sealed in the pulp chamber,

maintained with a temporary cement

In some cases the degree of pre operative cellulites will dictate that
drainage will have to be established
A smooth broach is used to perforate the apices and the tooth left open
to drain for no more than 1 day

If kept open for more than 24 hrs usually results in food packing into
the canal
 Multi – visit pulpectomy

Systemic antibiotic therapy is also indicated

External heat should not be applied as this may result in extra-oral

Drainage of the infection

In these cases the coronal pulp chamber can be filled with beechwood
Cresol soaked cotton pellet after 24 hrs drainage

Appointments are 7 – 10 days apart . The number of appointments and

Timing and extent of instrumentation will be determined by signs and
symptoms at each visit

The canals should not be filled until they are dry and all other signs and
symptoms have been eliminated
-(lawrence,1966)
 Follow up – primary teeth with pulpectomy

Final restoration

The ideal restoration for an endodontically treated primary tooth

is a stainless steel crown.

But in some cases it may be acceptable to delay the crown or leave the
tooth with an amalgam restoration
 Assessment of success

Post operative follow up at 6 month interval should include an evaluation

Of signs and symptoms

evidence of failure
Clinical
1. Pathological mobility
2. Presence of fistula
3. Pain on percussion

Radiographic
1. Increased size of radiolucency
2. external or internal root resorption
 Eruption of permanent successor

Non vital teeth treated with pulpectomy , premature root resorption

is more marked

The filling material is not the same texture or hardness as normal tooth
Or vital pulp
When the erupting permanent successor meets root canal filling material
there is increased possibility of deflection

Most problems associated with resorption arise when the erupting tooth
Has resorbed the pulpal floor of the primary molar and is contacting the
material in the coronal pulp chamber
 Vital pulp therapy in an immature vital young
permanent tooth to permit continued root growth
and apical closure.

 Physiologic process
 Formation of apex in vital, young, permanent teeth
with appropriate vital pulp therapy
In case of open apex
What is the treatment of:
• Reversible pulpitis
• Irreversible pulpitis or necrotic pulp

?
* Treatment of reversible pulpitis: apexogenesis

* Treatment of irreversible pulpitis or necrotic

pulp:
- apexification (contraindication: very short
roots and thin walls).
- root canal treatment & surgery
(contraindication: very short roots and thin
walls).
- extraction (if very poor prognosis).
In case of immature open apex
How can we differentiate between:
• Normal radiolucency surrounding immature
open apex
• Pathologic radiolucency resulting from a
necrotic pulp

?
 To differentiate between normal and
pathologic radiolucency
 Knowledge of age.
 Vitality test
 Comparison with the periapex of the
contralateral tooth is helpful, with the other
diagnostic tests.
 If normal pulp tissue with minimal inflammation is
present, normal root end development occurs

However, in immature teeth with pulp necrosis and bacterial

infection, the long-term prognosis is related to the stage of
root development and the amount of root dentine present at
time of injury
Indication
fractured tooth with pulpal exposure
carious exposures
 Considered that the pulp is vital
 concomitant presence of all three classical signs of
pulp necrosis; coronal discolouration, loss of pulp
sensitivity and periapical radiolucency, can not be
followed by pulp repair

 Caries: reversible pulpitis

 Sustaining a viable Hertwig’s sheath to allow
continued development of root length for
favourable crown:root ratio
 Treatment strategies of traumatized, immature
permanent teeth should aim at preserving pulp
vitality to secure further root development and
tooth maturation.
 Promoting a root end closure
 Generating dentinal bridge at the site of pulpotomy
 Take home message

 Aim: stop the infection; save the pulp; the

tooth will heal itself
Involves

◦ Direct pulp capping

◦ Pulpotomy
 Considering amount of expore and insult to
the tooth
 Ca(OH)2 (calcium hydroxide)
or
MTA (mineral trioxide aggregate).

 MTA is the material of choice.

 Severe crown-root fracture that requires
intraradicular retention for restoration
 Tooth with an unfavorable horizontal root fracture
(i.e., close to the gingival margin)
 Carious tooth that is unrestorable
 Necrotic pulp
 APEXIFICATION

It is a method to induce a calcified barrier in a root with an open

apex or the continued apical development of an incomplete root in
teeth with necrotic pulp
(A.A.E.,2003)
 Causes of open apex:-

1. Incomplete development-
Pulpal necrosis before root growth and development are complete

2. Extensive apical root resorption due to trauma , periapical

pathosis , orthodontic treatment
 Types of open apices

They can be of two types:-

1. Blunderbuss
Flaring root canal walls in which apex is funnel shaped
And wider than the coronal aspect of canal

2. Non blunderbuss
root canal walls are parallel or slight tapering
PROBLEMS OF TREATING IMMATURE TEETH WITH A NECROTIC PULP

The anatomy presents several problems

1. There is an open apex , hence no hard tissue stop against which gutta
percha can be packed

2. The open apex of root canal tends to be shaped like blunderbuss making it
difficult to obturate with root filling material

3. Apisectomy is not advisable because the walls of the immature roots are
likely to fracture when sealing the apex
 INDICATIONS

This procedure is indicated for non vital permanent teeth

with incompletely formed roots
 OBJECTIVES

1. Procedure should induce root end closure at the apices

of immature roots

2. Adverse clinical signs and symptoms such as prolonged

sensitivity,pain or swelling should not be evident

3. No evidence of abnormal canal calcification or internal

or external root resorption
 MATERIALS USED

1. Calcium hydroxide

2. MTA

3. Antiseptic and antibiotic paste (Frank)

4. ZnO and metacresylacetate-camphorated parachlorophenol

5. Tricalcium phosphate

6. Collagen Ca phosphate gel

7. Resorbable tri calcium phosphate

Use of CaOH first described by Frank

Calcium hydroxide cement CaOH Ca2+ + 2OH –

antibacterial effect

procedure

1. Access is gained into the pulp chamber

2. removal of coronal pulp and establish file length

3. clean the canal , irrigate & dry it with paper point

4. seal the chamber with CMCP in the pulp chamber with a provisional
restorative material

5. Recall in 1 – 3 weeks
In first recall , remove the restoration and clean the canal

Take care to void any instrumentation of the walls of the dentin near
the apex

paste of CaOH and CMCP is filled in the canal

The objective is to fill the canal completely

Obtain a radiograph to check for the accuracy

 6 month recall

Radiographic evidence of apical closure is seen

It is necessary to test the quality of the apical barrier with a size 35 file

If file easily penetrates

continue apexification

Reschedule the patient for another 3 months recall

The follow up evaluation is repeated every 3 months until successful

apical bridging has occurred
VARIOUS TYPES OF ROOT CLOSURE IN APEXIFICATION
Weine ( 1976 )

1. Continued closure of canal and apex to a normal configuration

 VARIOUS TYPES OF ROOT CLOSURE IN APEXIFICATION

1.

2. Apex closes but canal remains with blunderbuss configuration

 VARIOUS TYPES OF ROOT CLOSURE IN APEXIFICATION

1. 2.

3. No radiographic change, but a thin osteoid like barrier provides

a definite stop at or near apex
 VARIOUS TYPES OF ROOT CLOSURE IN APEXIFICATION

1. 2. 3.

4. Radiographic evidence of a barrier short of apex

 Obturation of the root canal

These canals are probably best suited for obturation by thermoplasticized technique

Obtura
 Alternatives of conventional apexification

1. Mineral trioxide aggregate ( M.T.A. )

1. Allows for the overgrowth of cementum
2. May facilitate the regeneration of PDL

MTA was first described in dental literature in 1993 by torabinejad

Mechanism of action
stimulated cytokine release from bone cells
Composition
Tricalcium silicate
Dicalcium silicate
Tricalcium aluminate
Calcium sulphate dehydrate
Bismuth oxide

P.H. is 12.5

Limitations
cost
storage problems . sets in presence of moisture ( 4 hrs )

2. Metapex { ( CaOH) and Iodoform }

 DISADVANTAGES

1. Patient compliance (for attending the recalls)

2. Increased risk of tooth fracture after dressing with the material for
extended periods.

3. Although the open apex might be closed by a calcific barrier,

apexification does not promote the continued development of the
root