Non vital pulp therapy

1. SUBMITTED BY – RIYA GUPTA
BDS FINAL YEAR
ROLL NO . -38
Non vital pulp therapy

2. Introduction
The concept of pediatric endodontics being divided into vital
and nonvital pulp therapy has been outlined by most of the
guidelines of pulp therapy [American Academy of Pediatric
Dentistry (AAPD), UK, etc.].

3. Non vital pulp therapy
• A therapeutic procedure intended to maintain a non vital
tooth in a non infected stage.

4. • Their basic recommendation is that if the infection has
spread to radicular pulp and the tooth is showing signs
of irreversible pulpitis, then such teeth be termed as
nonvital . The recommended treatment for such cases
pulpectomy for primary teeth, apexification for young
permanent teeth, and root canal treatment (RCT) for
permanent teeth.

5. Pulpectomy

6. 1. Acc to Mathewson - Complete removal of necrotic pulp
tissue from the root canals and filling them with an inert
resorable material.
2. Acc to finn – removal of all pulpal tissue from the
coronal & radiculur portions of the tooth .

7. Objectives
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 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.

8. indications
• In case of any primary tooth in absence of its
permanent successor.
• Any tooth with severe pulpal necrosis provided
there is no radiographic contraindication.
• Pulpless primary tooth in haemophiliacs.
• A tooth planned for pulpotomy that shows
uncontrollable haemorrhage.
• Tooth with minimum root resorption

9. Contraindictions
• Internal resorption of the pulp chamber and root canal.
• Underlying dentigerous or follicular cyst.
• Pathology extending to the developing permanent tooth bud.
• Less than2/3rd of root length remaining
• Perforation of pulpal floor.
• Medically compromised children
• Excessive tooth mobility.
• Non restorable tooth.

10. Steps for pulpectomy
1. Access opening
2. Biomechnical preparation
3. Obturation

11. Access opening
• It’s the 1st & most important phase of root
canal treatment.
• Objectives:
• Straight line access to apical foramen
• to locate all root canal orifices
• To conserve sound tooth structure

12. Maxillary Central Incisor
• Access Opening:
• The shape, size, and coronal extension of the pulp chamber are
estimated from a diagnostic radiograph.
• The enamel is penetrated in the center of the lingual surface at an
angle perpendicular to it with a No. 4 round bur in a high-speed contra
angle
• After penetration of the enamel, the bur is directed along the long axis
of the tooth until the pulp chamber is reached.
• A “drop” of the bur into the chamber may be felt if the chamber is
large enough.

13. • The overhanging enamel and dentin of the palatal roof of the pulp chamber
are removed, including the pulp horns, with a No. 4 round bur in a slow-
speed contra-angle by working from the inside to the outside following the
internal anatomy .
• Direct access to the apical area of the root canal is gained by removing the
palatal roof and the palatal shoulder of the pulp chamber in an anterior
tooth.
• Direct access can be verified by placing the straight end of the endodontic
explorer into the canal orifice.
• The explorer should follow the path of the canal without impedance from
the walls of the surrounding access preparation.

15. Maxillary Lateral Incisor
• Access Opening:
• The access opening for the maxillary lateral incisor is similar to
that for the maxillary central incisor, but it is smaller and usually
more ovoid.
• The technique for entry is the same as that for the maxillary
central incisor, except that a No. 2 round bur may be used instead
of a No. 4.

16. Maxillary Canine
• Access Opening:
• The access opening for the maxillary canine is basically the same as that
for the maxillary central and lateral incisors.
• The only variation is that the shape of the access opening is circular to
ovoid, as dictated by pulp chamber anatomy.
• The technique for entry is the same as that for the maxillary central and
lateral incisors.

17. Maxillary First Molar
Access Opening
• The internal anatomy of the pulp chamber of the maxillary first molar dictates
the shape and size of the access opening.
• The enamel is penetrated with a high-speed. bur by positioning the instrument
in the central fossa and angling it towards the palatal root
• The bur is directed towards the palatal canal, where the pulp chamber of this
tooth is largest .
• After penetration into the enamel, one uses the bur to penetrate the dentin;
the bur is angled toward the palatal root until the pulp chamber is reached .
• A “drop” of the bur into the pulp chamber may be felt if the chamber is large.

18. • A tapered-cylinder, self-limiting diamond bur is used to remove the remaining
roof of the pulp chamber.
• The walls of the access cavity should be confluent with the walls of the pulp
chamber and slightly divergent towards the occlusal surface.
• The access opening is usually triangular, with round corners extending toward,
but not including, the mesiobuccal cusp tip, marginal ridge, and oblique ridge).
• This triangular preparation permits direct access to the root canal orifices.

20. Maxillary Second Molar
Access Opening:
• The maxillary second molar access opening is basically the same as that for
the maxillary first molar, with the variations that anatomic structure
dictates.

21. Mandibular Central Incisor
• Access Opening:
• The access opening of the mandibular central incisor is made in a similar
manner as for the maxillary anterior teeth, with the variations that its
smaller size demands.
• The shape of the access opening of the mandibular incisor is long and oval,
with its greatest dimension oriented incisogingivally.
• Proper access enables one to explore the cervical third of the root to
determine whether a second root canal is present

22. Mandibular Lateral Incisor
• Access Opening
• The access opening is made in the same manner as for the mandibular
central incisor.
• The mandibular central incisor, it has basically the same configuration.
The majority of the roots are straight or distally or labially curved, as
they are in the central incisor, but the distal curve of the lateral incisors
is sharper.
• The incidence of double-root canals at the apex is about the same as in
the central incisor, and their anatomy in cross-section is also similar.

23. Mandibular First Molar
Access Opening:
• The access opening for the mandibular first molar follows the anatomic features
of the pulp chamber.
• The enamel and dentin are penetrated in the central fossa with the bur angled
towards the distal root, where the pulp chamber is largest .
• The preparation follows the procedures outlined for the maxillary molar.
• The access opening is usually trapezoidal with round corners or rectangular if a
second distal canal is present.
• The access opening extends toward the mesiobuccal cusp to uncover the
mesiobuccal canal, lingually slightly beyond the central groove and distally
slightly beyond the buccal groove.

24. Mandibular second molar
• Access Opening:
• The access opening for the mandibular second molar is created as for the
mandibular first molar, with the variations that a smaller tooth demands.
• Because of the buccoaxial inclination , it is sometimes necessary to reduce
a large portion of the mesiobuccal cusp to clean and shape the mesiobuccal
canal.

25. Biomechanical preparation(bmp)
• Straight line access
• Precurving
• Retaining its original foem & shape
• Irrigation
• Restricting instruments within the canal.
• Recapitulation
• Removal of dentinal debris.

26. Irrigation
• The success of endodontic treatment depends on the
eradication of microbes from the root canal system and
prevention of reinfection. The main goal of instrumentation is
to facilitate effective irrigation, disinfection, and filling.

27. Normal saline
• Normal saline is isotonic to the body fluids.
• It is universally accepted as the most common irrigating solution
in all endodontic and surgical procedures.
• It is also found to have no side effects, even if pushed into the
periapical tissues.
• However, saline should not be the only solution to be used as an
irrigant , it is preferably used in combination with or used in
between irrigations with other solutions like sodium hypochlorite.

28. Sodium hypochlorite (NaOCl)
• Is the most popular irrigating solution.
• NaOCl ionizes in water into Na1 and the hypochlorite ion,
OCl, establishing an equilibrium with hypochlorous acid
(HOCl).
• Hypochlorous acid is responsible for the antibacterial
activity and disrupts several vital functions of the
microbial cell, resulting in cell death.
• However, continuous irrigation and time are important
factors for the effectiveness of hypochlorite.
• It should be used throughout the instrumentation phase.

29. Ethylenediaminetetraacetic acid (EDTA)
• Complete cleaning of the root canal system requires the use of
irrigants that dissolve organic and inorganic material.
• EDTA effectively dissolve inorganic material, including hydroxyapatite.
• Irrigation with 17% EDTA for one minute followed by a final rinse with
NaOCl is the most commonly recommended method to remove the
smear layer.
• EDTA is used for 2–3 minutes at the end of instrumentation and after
NaOCl irrigation.

30. Chlorhexidine digluconate (CHX)
• It is widely used in disinfection in dentistry because of its good
antimicrobial activity.
• CHX does not possess some of the undesired characteristics like bad smell
and strong irritation to periapical tissues).
• CHX has no tissue-dissolving capability .
• In high concentrations , CHX causes coagulation of
intracellular components.
• One of the reasons for the popularity of CHX is its
substantivity.

31. Instruments

32. K–files
• Designed as early as 1904 by Kerr
• Originally made from a square or triangular blank ,machine
twisted to form a tight spiral with more cutting flutes than a
reamer.
• 1½–2½ flutes/mm
• Less susceptible to breakage
• Decreased flexibility
• Lesser cutting efficiency
• Rasping or pulling action.

33. • Reamer
• They are constructed from a square or triangular blank
twisted into a spiral but with fewer cutting than a file
• It cuts only dentin if it is rotated
• ½–1 flute/mm
• More cutting efficiency
• Pushing, rotating, and retracting action.

34. H–files
• They are called Hedstreom files
• They are made of stainless steel and are machined
from a round-tapered blank
• They have good cutting efficiency and are used in
pulling action
• They are flexible and are indicated in tortuous
canals as in primary teeth

35. • The procedure for shaping using H-files is that file is
inserted into the root canal to the apex, laterally
pressed against one side of the canal wall, and
withdrawn with a pulling motion to file the dentinal
wall.
• Sizes—0.10–1.40 mm and Tip size—0.15–0.60 mm
• Disadvantage of H-files is that they tend to fracture.

36. Nickel–Titanium Files
• They are introduced by Elizabeth S Bair in 1999–2000. They have
nickel (55%) and titanium (45%)
• The flexibility and t h e i n s t r ument design allow the files to
closely follow the original root canal path
• The tortuous and irregular canal walls of primary molars are
effectively cleaned with Ni–Ti files since the clockwise
• motion of the rotary files pulls pulpal tissue and dentin out of the
canal as the files are engaged.

37. Advantages
• Tissue and debris are more easily and quickly removed
• Faster results
• Allows easy access to all canals
• It possesses a memory effect.
Disadvantages
• Cost
• Learning the technique.

38. Obturation
Obectives-
• To establish a barrier to the passage of microorganisms from the oral
cavity to the peri radicular tissues by a perfect access cavity
restoration.
• Isolate any microorganisms that may survive the cleaning and shaping
procedures by use of an anti bacterial sealer.
• . Prevent leakage ,into the canal system ,of potential nutrients that would
support biologic growth ..
• To reduce the risk of bacterial movement and fluid percolation into the
canal system from gingival sulcus or a periodontal pocket.

39. procedure

40. The procedure of pulpectomy can be performed in
• Single-visit Partially vital pulp
• Multi-visit Non-vital pulp

41. Single visit pulpectomy

42. Multi visit pulpectomy

45. Steps in pulpectomy-
STEP-1
Give local anaesthesia and isolate
the tooth with rubber dam.

46. Step-2
Remove caries and identify
the exposure site

47. Step-3
Remove roof of pulp chamber and
identify opening of root canals.

48. STEP-4
Take diagnostic radiograph

49. STEP-5
Clean out root canals with hedstroem
files and remove remnants of pulp tissue
and irrigate the canal

50. STEP-6
Dry root canal with paper points and place
a pledget of formocresol in the pulp chamber
for 4 minutes

51. STEP-7
Select a spiral root canal filler
of appropriate size

52. STEP-8
Mix zinc oxide eugenol as a slurry and spin it
into the root canals,using the spiral root canal
filler

53. Material used in pulpectomy:
• Zinc oxide eugenol
• Vitapex
• KRI paste or Iodoform paste
• Endoflas

54. Obturation

55. definition
• The aim in obturating the root canal system is to prevent
recontamination of the canal from either apical or coronal
leakage and to isolate and neutralize any remaining pulpal
tissue or bacteria.

56. objectives
1. To establish a barrier to the passage of microorganisms from the
oral cavity to the peri radicular tissues by a perfect access cavity
restoration.
2. Isolate any microorganisms that may survive the cleaning and shaping
procedures by use of an anti bacterial sealer.
3. Prevent leakage ,into the canal system ,of potential nutrients that would
support biologic growth ..
4. To reduce the risk of bacterial movement and fluid percolation into the
canal system from gingival sulcus or a periodontal pocket.

57. When to obturate?
The root canal system should be obturated
1) after thorough debridement.
2) absence of persistent exudates.
3) without any symptoms of pain and swelling.

58. Techniques of obturation
• The aim of endodontic obturation is to create a fluid- tight seal along
the length of the root canal system , from the coronal opening to the
apical termination. For this purpose, several techniques have been
used for the filling of material into primary teeth root canals, but an
ideal technique is the one that offers consistency, is easy to use, and
can be mastered by the user. Some of the techniques for primary
tooth obturation are (Mahajan N et al.)1 as follows:

59. • Endodontic pressure syringe
• Mechanical syringe
• Jiffy tubes
• Tuberculin syringe
• Incremental filling technique
• Lentulospiraltechnique

60. • Reamer technique
• Insulin syringe technique
• NaviTip
• Bidirectional spiral
• Pastinject ( Micromega)

61. ENDODONTIC PRESSURE SYRINGE
Developed by Greenberg
Described by Spedding & krakow
The apparatus consists of syringe barrel, threaded plunger, wrench
&threaded needles.
Needle is placed 1mm short of apex
it is taken out in a slow withdrawing motion
Disadantages-
1. more time consumption.
2. more ovoids.
3. overfill

62. MECHANICAL SYRINGE
• Proposed by Greenberg
• Cement is loaded into syringe with 30 g needle.
• Pressed using continous pressure while loading it.

63. JIFFY TUBES
• POPULARISED BY RIFFICIN.
• ZOE IS LOADED INTO TUBE
PLACED INTO CANAL ORIFICE
MATERIAL IS EXPRESSED IN DOWNWARD
SQUEEZING MOTION UNTILL ORIFICE APPEARS
VISIBLY FILLED.

64. TUBERCULIN SYRINGE
• SYRINGE USED BY AYLARD & JOHNSON IN 197 WAS A STANDARD 26G,
3/8TH INCH NEEDLE.
• MATERIAL WAS EXPRESSED INTO THE CANAL WITH SLOW FINGER PRESSURE
ON PLUNGER UNTI THE CANAL IS VISIBLY FILLED.
• DISADVANTAGES-
• 1) DIFFICULTY OF SEPERATING TIP DURING INJECTION.
• 2) INCREASE PRESENCE OF VOIDS.

65. INCREMENTAL FILLING TECHNIQUE
• Endodontic plugger corresponding to the size of canal with
rubber stop is used to place thick mixture of cement into
the canal.
• mixture is gently tapped into apical area with the help of
plugger.
disadvantages-
• poor consistency & voids due to incomplete condensation.

66. REAMER TECHNIQUE
• A reamer coated with a zoe paste was inserted into
the canal with clockwise rotation , with vibratory
motion to allow the material to reach the apex ,then
withdrawn from the canal while simultaneously
continuing the clockwise rotary motion.

67. INSULIN SYRINGE TECHNIQUE
• Described by Nagar et al.
• Homogenous mixture of ZOE,is loaded into insulin syringe and a
stopper is used after assessing the working length of the canal.
• The needle is kept 2mm short of apex.
• Needle is pressed into the canal & while doing so the needle is
retrieved from the canal.

68. NAVITIP
• Recently, a thin metal tip was introduced to deliver
root canal sealer.
• It comes in different lengths & rubber stop is
adjusted to it.

69. BIDIRECTIONAL SPIRAL
• Dr. Barry Musikant developed a new obturation technique
with bidirectinal spiral.
• This technique ensures that a minimal amount of
obturating material will past the apex .

70. PASTINJECT(MICROMEGA)
• Specially designed paste carrier with flattend
blades, which improves material placement into
the root canal.
• Acc. to a study this technique is proved to be the
most effective, yielding a higher no. of optimally
filled canals & minimal voids.

71. LENTULO SPIRAL TECHNIQUE
• Advocated by kopel in 1970.
• It was dipped into the mixture & then introduced into the canal to
its predetermined length & then rotated in the canal.
• Additional amount of paste is added to canal till it is filled.
• Take lentulospiral 1 size smaller than your last fill.
followed by coating the canals with thin mixture of
obturating material.

72. • final insertion of obturating material in a thin consistency in
specified motion in a slow speed.
precautions-
• 1) always work short of working length.
• 2)motion should be initiated only when we enter canal orifice.

73. Materials for obturation
Materials
Zinc
Oxide
Eugenol
Calcium
Hydroxide
Iodoform
Vitapex
WalkHoff
Paste
KRI
paste
Maisto
Paste

75. ENDOFLAS
• It is a restorable paste.
• Obtained by mixing powder containing –
• Iodoform
• Calcium hydroxide
• Tri iodomethane dibutylorthocresol
• Barium sulphate
• Liquid consisting of eugenol and paramonochlorophenol.

76. advantages –hydrophilic
good seal
biocompatible
antimicrobial therapy

77. Triple antibiotic paste
• It was developed by Nilgata university school of dentistry.
• It says that repair of damaged tissue might occur if lesions are
disinfected.
• Non instrumentation endodontic treatment which uses triple
antibiotic paste mixture of metronidazole , ciprofloxacin and
minocycline.
• Material can produce vascular changes in pulp involving
inflammation and formation of granulation tissue.

78. IODOFORM PASTE
• These pastes are bactericidal
• Disadvantages-
• Yellowish discoloration of the tooth.
• Irritation to periapical tissues
• Commercially available as waikhoff paste,
maisto paste.

79. Zinc oxide eugenol
• Most commonly used.
• It is the first root canal filling material to be recommended
for primary teeth.
• It is said to have antiinflammatory effects and analgesic
properties.
Limitations –
• Slow resorption
• Irritation to the periapical tissues.
• Necrosis of bone & cementum.
• Thin mixture of ZOE is used to coat the walls followed by
thick mixture to be manually condensed into the canal.

80. Calcium hydroxide
• Introduced by Herman.
• Commercially available as metapex & vitapex.
• Has antibacterial effect
• The rate of resorption of material is faster than physiologic root
resorption . when used in primary teeth with hyperemic pulp
ca(oh)2 comes in contact with some vital pulp tissue remnants &
can trigger cascade of inflammatory root resorption.

81. Apexfication

82. • it is a method of inducing apical
closure by formation of a
mineralized tissue in the apical
region of a nonvital permanent
tooth with an incompletely formed
root apex

83. Causes of open apex:
Incomplete development:
• Pulpal necrosis before
root growth and
development are
complete
Extensive apical root resorption:
• Due to trauma , periapical
pathosis , orthodontic treatment

84. indications
• This procedure is indicated for
non vital permanent teeth with
incompletely formed roots

85. Materials
Used
Zinc oxide eugenol
Metacresylacetate—
Camphorated
parachlorophenol
Resorbable
tricalcium phosphate
Tricalcium phosphate + I2-
tricalcium phosphate
Collagen–calcium
phosphate gel
Mineral trioxide
aggregate.
Calcium hydroxide

86. Procedure
1st visit

88. 2nd visit

89. 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.

90. Frank’s criteria for apexification
• Apex is closed with no change in root space
• Apex is closed, through minimum recession of the canal
• Radiographically apparent calcific bridge at the apex
• There is no radiographic evidence of apical closure, but
upon clinical instrumentation, there is definite stop
at the apex, indicating calcific repair.

91. Thank you

92. Principles of access cavity preparation
BY G.V BLACK ( INITIAL TOOTH PREPARATION)
• Step 1: Outline form and initial depth: Defined as the location that the
peripheries of the completed tooth preparation will occupy on tooth surfaces.
• Step 2: Primary resistance form: That shape and placement of the preparation
walls that best enable both the restoration and the tooth to withstand, without
fracture, masticatory forces delivered principally in the long axis of the tooth.
• Step 3: Primary retention form: It is that shape or form of the conventional
preparation that resist displacement or removal of the restoration from tipping or
lifting forces.
• Step 4: Convenience form: That shape or form of the preparation that provides
for adequate observation, accessibility, and ease of operation in preparing
andrestoring the tooth.

93. Final Tooth Preparation
• Step 5: Removal of any remaining infected dentin and old restorative material, if
indicated.
• Step 6: Pulp protection if indicated.
• Step 7: Secondary resistance and retention forms: Many preparations require
additional retentive features. When tooth preparation includes both occlusal and
proximal surfaces, each of those areas should have independent retention and
resistances features.

94. • Step 8: Procedures for finishing external walls: It is the further
development, when indicated of a specific cavosurface design and
degree of smoothness or roughness that produces the maximum
effectiveness of the restorative material being used. The objectives are
to create best marginal seal possible between the restorative material
and tooth structure, afford a smooth marginal junction and provide
maximum strength of both the restorative material and tooth.
• Step 9: Final procedures: Cleansing, inspecting, and sealing. Includes
removing all chips and loose debris that have accumulated, drying the
preparation and making a final complete inspection of the preparation
for any remaining infected dentin, unsound ename lmargins or any
condition that renders the preparation unacceptable to receive the
restorative material.

95. MODIFICATIONS OF CAVITY PREPARATION
IN PRIMARY TEETH
Class I: Cavity Preparation
• Due to narrow occlusal table, the buccolingual dimensions of occlusal part of
cavity are reduced.
• The chance of inadvertent pulp exposure is minimized by limiting the cavity to
0.5 mm pulpal to enamelodentinal junction.
• Maximum intercuspal cavity width should be limited.
• Walls of preparation should be parallel or slightly convergent occlusally.
• The central pit of lower first primary molar usually becomes carious before
mesial pit, which decays less frequently.
• The outline form should be limited to central pit; it is adjacent buccal and
lingual grooves and distal triangular fossa.
• It is advisable not to cross ridge to join mesiobuccal and mesiolingual cusp
because of its proximity to pulp horns.

96. • Pulpal roof in primary teeth is concave as compared to permanent teeth
where it is nearly flat so cavity floor should be kept little concave.
• Depth should be just 0.5 mm into the dentin, so the total depth from the
cavosurface should not be more than 1.5–2.0 mm.
• Include all pits and fissures and lateral extension should be such so as to just
accommodate the amalgam condenser.
• Flat or slightly concave pulpal floor with rounded line and point angles.
• While extending laterally on the buccal side, bur should be kept parallel to
the buccal surface, and while extending lingually, bur should be parallel to
lingual surface. This makes the occlusal convergence without much cutting.

97. • Class II: Cavity Preparation
• Occlusal box: Same principles applied as for class I, but extension of outline
is different for different teeth:
• For all first primary molars: Extend the occlusal box half the way
mesiodistally in a dovetail-like fashion.
• For mandibular second primary molars: All pits and fissure should be
included in preparation.
• For maxillary second primary molars: Nearest occlusal pit should be
involved. Oblique ridge should not be involved until undermined by the
caries.
• Sharp cavosurface angle.

98. • Rounded/bevelled/grooved axiopulpal line angle in order to reduce stresses on this
point and to allow greater bulk of material.
• Proximal box: Greater width of the proximal box in order to keep the cavity margins
in the self-cleansing areas. More buccolingual extension of the gingival floor or seat.
• Occlusal convergence.
• Axial wall should follow the contour of the external surface.
• The direction of enamel roads at the cervical line is either horizontal or occlusal,
and therefore gingival bevel is not given while preparing class II cavity.
• The distance between mesial surface of lower first mandibular molar and pulp horn
is only 1.6 mm. Although 1.5 mm depth has been suggested for class I cavity,
establishing this depth may lead to pulp exposure, and hence 1 mm of depth is
recommended.