PULP THERAPY OF NON-VITAL TEETH (PULPECTOMY)

SUPERVISOR: DR. HAZEM ALAJRAMI

DONE BY :
ABEER IMAD MEHJEZ
RAFEEF FAYYAD
DIMA HAMAD
HALA ABU HASHEM
MAHMOUD ZOGHBOR
 Video
https://youtu.be/Mgg823uAV0s
PEDIATRIC DENTISTRY PRINCIPLES
AND PRACTICE
Definition

 Pulpectomy involves removal of the non-vital cariously exposed

roof of the pulp chamber and contents of the chamber in order to
gain
access to the root canals which are debrided, enlarged and
disinfected
followed by the obturation with the resorbable material.
 The goal of pulpectomy procedure is to eliminate the bacteria and
the contaminated pulp tissue from the canal.
 In primary teeth, more emphasis has been given on chemical
means in conjunction with limited mechanical debridement to
disinfect and remove necrotic pulp remnants from the ‘so called
inaccessible canals’ rather than the conventional ‘shaping’ of the
canals.
 Many pediatric dentists prefer pulpectomy for primary
anteriors even if the tooth could be treated only by pulpotomy
(having reversible pulpitis) because of the belief that a complete
obturation of the canal is preferable to partial obturation whenever
possible.
 Most negative attitudes towards primary teeth complete
pulpectomy have been based on the difficulty in cleaning and
shaping the bizarre and tortuous canal anatomy of these teeth. It
was especially true for primary molars with their resorbing and open
apices.
 Removal of abscessed teeth has been suggested by a few because
of their potential to create developmental defects on their
successors. In addition to this, behavior management problems that
occur in children have surely added to the reluctance of some
dentists to perform root canal treatment in primary teeth.
 Indications

1. Primary tooth with irreversibly inflamed pulp and having not more than one-third
of root resorbed

2. Primary tooth with an abscess, or sinus opening

3. Traumatized primary anterior tooth with a fracture/caries involving the pulp
irreversibly
4. Alveolar bone free of pathologic resorption
5. Internal resorption in teeth with no visible perforation

6. Presence of pus at the exposure site or in the pulp chamber

7. Pulpless primary teeth without permanent successor

8. Children suffering from hemophilia

9. Teeth next to the line of a palatal cleft

10. Primary molars supporting orthodontic appliances

11. Handicapped children where monitoring of space maintainers
or continuous supervision is not possible

12. Pulpless primary anterior teeth when speech, crowded arches

or esthetics is a factor
Contra-indications
1. A primary tooth with a irreversibly inflamed pulp with excessive root resorption
involving more than two-thirds of the root

2. Tooth with internal resorption

3. Primary tooth with excessive mobility

4. A nonrestorable tooth
5. Primary teeth with underlying dentigerous or follicular cysts
6. Young patients with systemic illnesses
 Technique
 The child with necrotic primary tooth can
present with varied clinical signs and symptoms
ranging from being absolutely asymptomatic to
an acutely or chronically abscessed, mobile and
painful, teeth with swollen periodontal tissues.
In the latter case, the child may be fairly
apprehensive and irritable, making relief of pain
and swelling a top priority.
 In cases of non-draining alveolar abscess and
cellulitis from odontogenic origin, antibiotic
therapy using first or second generation
penicillins for a period of 5 to 7 days must be
the first line of treatment
 Canal instrumentation can be implemented at
the next appointment helping the child also in
allaying his/her apprehension.
 After securing profound anesthesia and placement
of the rubber dam for isolation, all caries is removed
with a slow-speed round bur or a sharp spoon
excavator. The pulp chamber is carefully opened to
relieve any pressure from the infected pulp, with a
high-speed bur.
 The access preparation is made by joining all the
pulp horns with a bur. Remove the roof of the
chamber and the coronal pulp with a low speed
round bur or a sharp spoon excavator. The access
opening is refined to make a straight line access
with slight flaring to allow ease of insertion of the
files.
 1- Access openings Primary anterior teeth:

Access openings for endodontic treatment on primary or

permanent anterior teeth have traditionally been through the
lingual surface.
- This remains the surface of choice except for the primary
maxillary incisors where the recommended approach is to use the
facial surface followed by an acid etched composite restoration to
improve esthetics (Cohen).
- The anatomy of the primary incisors is such that access opening
can be successfully made from the facial surface with more
extension to the incisal edge than with the normal lingual access to
give a straight line access to the root canal.
 Primary posterior teeth: The access openings are essentially similar to
the permanent teeth.
 Some of the differences are:
a. The length of the crown is short.
b. Primary teeth have very thin dentinal walls in the root canals and the
floor.
c. The depth necessary to penetrate into the pulp chamber is much
less than that in the permanent teeth, also the distance from the
occlusal surface to the pulpal floor is much less than permanent teeth.
 Three-dimensional nature of the pulp chamber: (This is made to be cautious
when making an access opening of the primary molars)
 The tooth is compared to a building with basement, first (ground), second and
third floors.
-The basement represents the root portion of the tooth.

-The pulp chamber is represented by the ground or first floor.

-Second floor contributes the dentin and the third floor represents the enamel.

-The roof of the first floor is synonymous with the roof of the pulp chamber and the
floor of the first floor represents the floor of the pulp chamber from where the root
canals originate.
 the bur penetrates the enamel and dentin (i.e. the third
and second floors) and enters the chamber by
penetrating the roof of the first floor.
 Attempt should be made to remove the entire roof of
the pulp chamber (i.e. the roof of the first floor) to
facilitate access to all the root canal orifices and also
to access the necrotic pulp tissue and the infected
dentinal walls immediately below the roof of the
chamber. This can be achieved with a straight fissure
bur or a round diamond bur.
 As mentioned above, the distance from the occlusal
surface to the pulpal floor is much less in primary teeth.
Hence, the dentist or the dental student should be careful
while doing this not to touch the floor of the pulp chamber
with the bur while deroofing as it may cause a perforation
of the floor.
2- Working length determination
 The working length of the root canals is determined from
a radiograph with an endodontic file inside the canal.
The authors recommend the use of the frequency
dependent apex locators which can help in locating the
end of the root canal correctly. To prevent overextension
through the apical foramen, it is advisable to shorten the
working length to 2-3 mm short of the radiographic
length especially in teeth exhibiting signs of apical root
resorption. After the correct length is established, set all
smaller files (Hedstroem files or K- files) to this length for
cleaning and shaping the canals .
3- Pulp extirpation and preparation of
canals
 After the working length determination, the pulp tissue is
extirpated with broaches and Hedstroem or K files. Because
of greater flexibility, nickel-titanium (NiTi) instruments are
recommended rather than stainless steel instruments.
Occasionally, when the pulp has undergone a fibrous
degeneration, it comes out enmasse with a barbed broach.
Avoid excessive cleaning and shaping as it may lead to lateral
wall perforations or floor perforations. The purpose of filling is
to remove the pulp tissue from the canals to create space for
the primary teeth obturating material.
 Frequent irrigation with sodium hypochlorite or sterile normal
saline will aid the pulp extirpation procedure.
 Copious irrigation also helps to clean the pulpal ramifications
which cannot be reached mechanically. The canals are
usually enlarged from the 15 no. file to 25 or 30 no. file. This
debridement helps to remove the necrotic or înfected dentin
from the root canal walls.
 Shaping of the canals proceeds in much the same manner as
is done to receive a gutta-percha filling.
 Care must be taken to avoid over instrumentation through the
apical foramen which can possibly injure the permanent tooth
germ. The scientific data available on the use of rotary
instruments in primary teeth is sparse. More research is
needed in this area of pediatric endodontics.
Obturation techniques
▪ Ideal requirements of a root filling material for primary: -

1. Resorbable
2. Antiseptic
3. Non-inflammatory
4. Non-irritating to the underlying permanent tooth germ
5. Radiopaque
6. Easily inserted
7. Easily removed
8. Should not discolor the tooth
▪ Various Obturating Materials: -

1. Unreinforced zinc oxide eugenol

2. Calcium hydroxide (calcicure)
3. Vitapex (calcium hydroxide and iodoform paste)
 ▪ Obturation using freshly mixed zinc oxide
eugenol: -

With a reamer With wet cotton With lentulo spirals

▪ Obturation using injectable syringes:

Materials used with this technique:-

• Metapex (calcium hydroxide and iodoform

paste)
• Vitapex (calcium hydroxide and iodoform
paste)
• Calcicur (calcium hydroxide paste)
▪ Endodontic pressure syringe

Endodontic pressure syringe:

It consists of an internally threaded barrel with a threaded hub, a threaded
plunger, threaded needle and a small wrench.

The flexibility of the needle allows them to be bent to reach the apex, of even
inaccessible posterior teeth.
THANK
YOU