3-Fifth Year Notes (1) Signed

TRAUMATIC INJURIES TO
PERMANENT ANTERIOR TEETH
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Traumatic Injuries to Permanent Anterior Teeth
Objectives:
 Classification of Traumatic Injuries.

 Diagnosis and Management of Different Injuries to Crown of the Tooth.
 Diagnosis of Root Fractures.
 Treatment Consideration for Management of Horizontal Root Fractures.
 Types of Trauma-Induced Tooth Displacement.
 Immediate and Definitive Management of Teeth Partial displacement.
 Treatment of Avulsed Teeth.
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Tooth trauma has been and continues to be a common occurrence that

every clinician should be prepared to assess and treat.
Statistics show that more than half of all children traumatize either their
primary or permanent dentition before leaving school. Multiple causes
contribute to tooth trauma mainly falls, collisions, sports, violence and
automobile accidents.
The extent of any traumatic injuries depends on several factors among,
which are the energy of impact, shape of impacting object and the direction of
impact.
Causes of Traumatic Dental Injuries:
Multiple causes contribute to tooth trauma mainly falls, collisions, sports,

violence and automobile accidents.
The extent of any traumatic injuries depends on several factors among,
which are the energy of impact, shape of impacting object and the direction of
impact.
- Traffic accidents
- Falling while running
- Violence
- Sports trauma
Incidence:
- Age: 2-5 years for deciduous dentition and 7-12 years for permanent
dentition
- Sex: boys more than girls
- Site: mostly maxillary central incisors followed by maxillary lateral incisors.
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CLASSIFICATION OF TRAUMATIC INJURIES TO TEETH:

Many classifications of injuries and supporting tissues have been
suggested, among which are:
Ellis Classification (1970):

Class I: Crown and root intact.
Class II: Crown fracture without pulp exposure.
Class III: Crown fracture with pulp exposure.
Class IV: Coronal fracture extending sub-gingival.
Class V: Root fracture.
Class VI: Tooth displacement.
Class VII: Injuries to deciduous teeth.
WHO Classification (1978):

- Soft tissue injuries.
- Tooth fracture.
- Tooth luxation injuries.
- Facial skeleton injuries.
Andreasen modified that classification into a more practical classification

based on anatomic and therapeutic considerations:
- Enamel fracture.
- Coronal fracture without pulp exposure.
- Coronal fracture with pulp exposure.
- Root fracture.
- Tooth luxation.
- Avulsion.
- Fracture of alveolar process.
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However, for simplicity another classification is considered, which is the

classification presented by Mahmoud Torabinejad from Loma Linda University.
He classified traumatic dental injuries into:
I- Injury to Tooth:
A- Crown Fracture
B- Root Fracture
II- Injury to Periodontium:
A- Luxation Injuries
B- Avulsion
Examination and Diagnosis

The examination process of trauma patients is similar to the regular
examination of all endodontic patients including case history, clinical
examination with the aid of the vitality test and radiograph
Chief Complaint
The chief complaint may appear obvious in traumatic injuries. However,
the patient should be asked about severe pain and other significant symptoms .
History of Injury
- To provide information about the accident in a chronologic order and to
determine what effect it had on the patient .
- How did the injury happen?
- To assist in locating specific injuries and teeth involved .
- When and where did the injury happen ?
- Have you had dental treatment before ?
- Have you noticed any symptoms since the injury?
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Medical History
The patient medical history is often significant specially to clear:
- Allergic reactions to medications.
- Disorders e.g. Bleeding problems ,diabetes and epilepsy
- Current medications; to avoid unwanted drug interaction.
- Tetanus immunization status.
Clinical Examination
Extra-oral Examination
- Head and neck neurological examination for:
o Abnormal signs and symptoms.
o Abnormal affirmative response.
- Facial bones; the maxilla, mandible and TMJ are palpated externally to
detect any possible fractures, or deviation from the normal bony contour.
- Laceration of the soft tissues .
Intra-oral Examination
 Soft Tissue Examination
- Lacerations of lips and tongue must be radiographically examined for
embedded foreign objects.
- Areas adjacent to fractured teeth should be carefully examined and palpated
for areas of swelling, tenderness and bruising .
 Hard Tissue Examination
- Several teeth are out of alignments  fracture of mandible or maxilla .
- Loose tooth displacement from alveolar socket .
- Movement of several teeth alveolar fracture
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- Displaced tooth is tender to percussion due to accumulation of extra-vasated

fluid and hemorrhage in the gingival sulcus is a common finding .
- Mobility of the tooth is recorded and crown mobility should be differentiated
from tooth mobility .
- The mandible should be examined for fractures by placing the fore fingers
on the occlusal plane of the posterior teeth with the thumbs under the
mandible and then rocking it gently but with firm pressure from side to side
and from anterior to posterior direction, sound of the broken parts may be
heard
Sensitivity Tests
The electrical pulp test and carbon dioxide ice test are generally reliable
in evaluating and monitoring pulpal status. However, it may take as 9 months
for normal blood flow to return to coronal pulp of a traumatized fully formed
tooth.
So teeth that respond negatively to pulp testing can't be assumed necrotic
and may give positive response later . Also teeth that respond positively at the
initial test had to be followed up later .
Laser Doppler Flowmetry can detect pulp vitality within 4 weeks after injury .
Radiographic Examination
It revels root fractures, sub-gingival crown fracture, tooth displacements,
bone fracture .
Limitations of the radiograph include inability to reveal fracture line
running in mesio-distal direction, diagonal fracture line in bucco-lingual
direction and hairline fracture .
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Dimension of root canal space, apical closure and proximity of the

fracture line to pulp are outlined from the radiographs .Occlusal or panoramic
radiographs are helpful tools for bone fracture detection
Recently, Cone Beam a new 3D image device that aids in detecting accurately
the position of fracture lines .
Treatment Considerations:
When determining the treatment options for traumatically injured teeth, the
status of both the pulp and the Periodontium should be considered. Treatment
considerations should be always directed toward:
 Immediate Needs (Emergency Visit)
 Definitive Care (Subsequent Visits)
It is worth mentioning that thorough diagnosis of the case is mandatory before
initiating any treatment.
I- INJURY TO TOOTH
A- Crown Fracture
Fracture of the coronal portion can result in an injury, which can be
categorized as follows:
(1) Crown Infraction.
(2) Uncomplicated Crown Fracture (Enamel) Without Pulp Exposure.
(3) Uncomplicated Crown Fracture (Enamel & Dentin Fracture) Without Pulp
Exposure.
(4) Complicated Crown Fracture in Which the Fracture Line Exposes the Pulp
Chamber.
(5) Crown-Root Fracture (Fracture Involving the Crown and the Root).
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(1) Crown Infraction:
This is a situation in which the trauma did not cause any loss of tooth
structure i.e. tooth is intact and not displaced. This type of impact usually
results in craze lines, which can be easily visualized by trans-illumination.
No line of treatment is required at the emergency visit; however, careful
follow-up of the case is a must.
Sequelae of Crown Infraction:

Follow-up of such cases may reveal an injury to the pulp, which can result in
any of these conditions:
- Calcific Metamorphosis (Calcification).
- Internal Resorption.
- Pulpal Necrosis.
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(2) Enamel Fracture:

This injury involves the loss of a portion of enamel. This condition usually
does not require any emergency treatment except smoothening the rough
surface.
If larger part of enamel is lost, acid-etch the surface and restore the lost part
with composite. Tooth should be followed up.
(3) Enamel & Dentin Fracture (Without Pulp Exposure):

This type of fracture exposes large number of dentinal tubules to the oral
environment. To avoid undesirable esthetic and biologic sequelae, the missing
tooth structure should be replaced immediately (during the emergency visit).
Diagnosis:
- Sensitivity to air or cold.
- Pulp status using sensitivity tests.
- Normal periodontal ligament status.
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Emergency Treatment:
- Sealing dentinal tubules using calcium hydroxide, which will stimulate
closure of dentinal tubules rendering them less permeable to noxious stimuli.
- Restoration using dentin bonding and create tight seal
- Fragment reattachment if available.
Prognosis:
- 3,6,12 months up to 5 years. Factors affecting prognosis:
 Proximity to the pulp.
 Exposed dentin area.
 Time elapsed.
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(4) Crown Fracture with Pulp Exposure:

In this type of fracture there are several factors to be considered:
- Length of time the pulp was exposed.
- Maturity of the tooth (open / closed apex).
- Amount of pulpal tissue exposed (size of exposure).
Treatment options depending on the previously mentioned factors are:

1) Vital Pulp Therapy
a) Direct Pulp Capping
b) Pulpotomy
2) Apexification
3) Pulp Regeneration
4) Surgical Treatment.
5) Complete Root Canal Treatment
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1)Vital Pulp Therapy
a) Direct Pulp Capping:

This is indicated in teeth with immature teeth (open apex). Direct pulp
capping is the treatment of choice when size of exposure is less than 1 mm and
patient was seen in less than 6 hours after trauma. The technique is as follows:
- Wash the exposure site with saline.
- Careful dryness with cotton pellet.
- Apply calcium hydroxide to exposed pulp.
- Acid etch the tooth surface and restore with composite.
- Follow-up the case radiographically every 3-6 months to monitor root
development (apexogenesis).
b) Pulpotomy:
Again, this procedure is indicated in case of immature teeth (open apex)
where the size of the exposure is larger than 1 mm and patient was seen directly
after the trauma. The chances here for the pulp to get contaminated is higher
and therefore, it is expected that the superficial layer of the pulp tissue gets
inflamed. The technique is as follows:
- Remove 1-2 mm depth of the exposed coronal pulpal tissue using a large
sterile round bur revolving at high speed with coolant.
- Irrigate the exposure site
- Place calcium hydroxide on exposed pulp
- Acid etch the surrounding tooth structure and cover by composite resin.
- Follow up the case and once root development is complete
(radiographically) complete root canal treatment should be done.
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The success of pulp capping and pulpotomy is assessed clinically and

radiographically by the absence of any signs of pulpal inflammation and /or
necrosis, which are:
- Pain.
- Swelling either localized or diffuse.
- Radiographic changes.
- Presence of sinus tract.
- Discoloration of the coronal portion of the crown.
- Stoppage of root development i.e. failure of apexogenesis.
If any of the aforementioned signs is present, the pulpal tissue is undergoing
pathological changes. This situation requires complete root canal treatment i.e.
complete pulpal extirpation and thorough cleaning and shaping, however, the
fact that the tooth have an open apex is considered a great challenge for proper
obturation. Apexification should be initiated following the cleaning and
shaping.
2) Apexification: Treatment of Non-Vital Pulp:

The apexification procedure in brief is as follows:
- Complete pulpal extirpation.
- Proper cleaning and shaping of the root canal system using copious amounts
of irrigant (preferable to use Na OCL).
- Application of calcium hydroxide paste by special syringe starting apically
and moving coronally until the entire pulpal space is filled with the paste.
- Sealing of the access opening.
- Case is followed up every 3 months with reapplication of the calcium
hydroxide paste if it appears on the radiograph that it is starting to dissolve.
- Apexification is expected to be complete within 9-24 months.
- Once the apex is closed, root canal obturation is to be finished.
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3) Pulp Regeneration:
- Canal disinfection without instrumentation.
- Application of the triple antibiotic paste (ciprofloxacin, metronidazole and
minocycline) for 3-4 weeks.
- Provide matrix for new tissue growth. (blood clot to the level of CEJ)
- Effective coronal seal: MTA covered by bonded resin.
- Follow up: for root increase in length and thickness accompanied by clinical
normalcy. Otherwise apexification is considered if no progress noticed after
3 months.
4) Surgical Treatment: surgical closure of the open apex using MTA.
6) Root Canal Therapy:

This treatment option is considered when large pulpal exposure occurs in a
mature tooth i.e. closed apex. Proper root canal treatment should be performed
(access, cleaning & shaping and obturation).
(5) Crown-Root Fracture:

This is considered a complicated type of fracture as the fracture line passes
through the crown and the root i.e. supra and sub-gingival (oblique fracture).
Treatment of such cases is as follows:
- Removal of the coronal segment of the tooth.
- Complete root canal treatment.
- Placement of post and core followed by full coverage.
N.B.: In treating such cases it is difficult to place the margin of the restoration
on solid tooth structure. To achieve this two treatment options are considered:
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a- Crown Lengthening:
This procedure is done to expose the root margin by performing
gingivectomy and contouring of the alveolar crest (if needed).
b- Root Extrusion:
This is done by extruding the root out of the socket bringing its margin
supragingival. Root extrusion can be done either surgically or
orthodontically.
B- Root Fracture
Trauma to anterior teeth can result in root fracture, imply fracture of
cementum, dentin and pulp.
The fracture might be complete/ incomplete, having single or multiple
lines.
Fracture could be horizontal or vertical, Unlikely to happen, trauma may
cause vertical root fracture. This injury if happened indicates tooth extraction.
More likely, root fractures are horizontal (transverse).
N.B.: Before going into the details of horizontal root fracture, it is important to
note that horizontal root fractures, tooth extrusion and fractures of the alveolar
process appear clinically the same. Therefore, thorough differential diagnosis is
of prime importance as the line of treatment for each of the aforementioned
situations is different.
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Diagnosis of Horizontal Root Fracture:
Clinically:
 Tooth appears slightly extruded.
 Tooth mobility: The more coronal the fracture line, the greater the mobility.
Horizontal fractures at the apical 1/3 may not present any mobility.
 Pain on biting & Tenderness to palpation.
Radiographically:
Horizontal root fractures are easily visualized on the radiograph; however,
multiple radiographic exposures with different vertical angulations are needed.
Treatment of Horizontal Root Fracture:
No Mobility No Treatment
Mobility or Displacement  Emergency Treatment:
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The emergency care for root fracture is similar to any other bony fracture
which is repositioning and fixation (if needed).
Displaced tooth due to horizontal root fracture should be repositioned by
adjusting the occlusion and removing any occlusal interference.
Fixation is done by splinting the traumatized tooth with neighboring teeth
using an orthodontic wire and composite resin. Tooth should be fixed for 8-10
weeks to give a chance for hard tissue union.
N.B.: If the tooth position following trauma is not changed with minimal
mobility therefore, nothing should be done in the emergency visit.
Definitive Treatment:
Patient with horizontal root fracture should be seen one week after
emergency visit for evaluation and treatment planning. The line of treatment
depends basically on the level of fracture.
(1) Fracture at the Apical 1/3 (Best Prognosis):

Most of teeth with horizontal root fracture at the level of the apical 1/3 needs
no treatment. If any sign of irreversible pulpal damage of the coronal segment
appears, root canal treatment in the coronal segment should be done without
touching the apical segment.
In the future, during the follow up of the case it appeared that the apical
segment shows signs of necrosis (radiographic changes), it should be removed
surgically.
(2) Fracture at the cervical 1/3 (good prognosis):

This situation is similar to crown-root fracture (look under crown fracture)
where the coronal segment is removed and the root is exposed either by crown
lengthening or root extrusion.
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(3) Fracture at the Middle 1/3 (Worst Prognosis):

This situation is unfavorable because it is difficult to retain either of the
coronal or apical segments. The treatment options depend basically on the
presence or absence of displacement between the two segments:
(i) If the two segments are facing each other i.e. no displacement, then
perform root canal treatment of the two segments and place a rigid
stabilizer (post) inside the root canal after obturation.
(ii) If there was displacement, perform root canal treatment in the coronal
segment only hoping that apical segment can retain its vitality.
(iii) If signs of apical segment necrosis appeared in the follow up period,
remove the apical segment surgically and place an endodontic
endosseous implant to stabilize the tooth.
(iii) If there was displacement with great mobility of the coronal segment,
extract the coronal half and extrude the apical segment orthodontically.
Once the apical segment is brought supra-gingival, complete root canal
treatment is to be done and restore the tooth with post/core and full
coverage.
Prognosis of Horizontal Root Fracture:

There are four possibilities for healing:
1- Union of the two segments by calcified tissue which is considered the most
favorable type of healing (unlikely to happen)
2- Union of the two segments by fibrous tissue (more likely to happen)
3- Lack of union due to ingrowth of hard and soft connective tissue between
the two segments.
4- Lack of union due to ingrowth of inflammatory tissue between the two
segments which is considered the worst type of healing.
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N.B.: The healing by any one of the first three possibilities is considered
favorable. Each one of these four possibilities is likely to take place depends on:
 Time between trauma and initiation of treatment.
 Level of fracture (coronal, middle or apical 1/3). The level of fracture is
considered the deciding factor because it is responsible for the amount of
tooth mobility and the absence or presence of communication between the
fracture site and the oral environment.
 Degree of dislocation and mobility.
 Communication between the fracture line and gingival sulcus.
 Quality of treatment.
Complications:
 Pulp necrosis.
 Pulp obliteration.
Treatment of complications:
 Root canal treatment of the coronal segment only.
 Root canal treatment of both segments.
 Root canal treatment of the coronal segment only with surgical removal
of the apical segment (in case of adequate crown root ratio).
 Extraction.
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II- Injury to Periodontium

These injuries involve injury to the periodontium only or injury to both of
pulp and periodontium. Therefore, our diagnosis and treatment should be
directed toward both tissues. These injuries involve:
(A) Luxation injuries:

Displacement of the tooth while still in the socket.
(B) Avulsion
Displacement of the tooth outside the socket.
A- Luxation injuries
Classification:
(1) Concussion & Subluxation
(2) Extrusion & Lateral luxation
(3) Intrusive luxation (Intrusion)
(1) Concussion & Subluxation:

The concussion is considered the least severe form of luxation injuries where
no recognized changes occur. The subluxation is another mild form of luxation
where slight mobility without displacement is the only clinical sign.
Diagnosis:
Clinically the traumatized tooth is very tender to percussion with or without
slight mobility. Usually pulp is vital with no radiographic changes.
Treatment:
Only palliative treatment is needed with relief of occlusion and follow up the
case.
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(2) Extrusion and Lateral Luxation:

This type of injury involves either partial extrusion of the tooth out of the socket
or displacement in a lingual, buccal, mesial or distal direction (lateral luxation).
Diagnosis:
- Clinically, tooth may appear longer than neighboring dentition (extrusion) or
abnormally inclined in any one of the four planes (lateral luxation).
- Tooth is mobile
- Usually the injured tooth interferes with the normal occlusion.
- Radiographically, widening of the periodontal membrane space.
Treatment:
Similar to horizontal root fractures, our first concern in the emergency visit
is to reposition the tooth and stabilize it. This is done as follows;
- Reposition the tooth in its socket by application of firm pressure being
guided by the surrounding teeth and the normal occlusion.
- Stabilize the tooth in its normal position by splinting it with the neighboring
teeth by composite resin and orthodontic wire.
N.B. In case of injuries to the periodontium tooth should not be splinted for
more than 1-2 weeks to prevent ankylosis and/or external root resorption.
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Definitive Treatment (After 1-2 weeks)

- Remove the splint
- Assess pulp vitality. Usually these teeth will need root canal treatment.
- After cleaning and shaping and before root canal obturation, the root canal
should be injected with calcium hydroxide paste to prevent external root
resorption.
(3) Intrusive Luxation (Intrusion):

This type of injury is characterized by displacement of the tooth inside the
socket. It is considered the most severe form of luxation as it usually results in
damage of the alveolar socket with greater incidence of external root resorption.
Diagnosis:
- Tooth is more fixed than the surrounding dentition.
- Tooth is shorter or even not visible at all in its position (complete intrusion
inside the socket).
- Radiographically, intruded tooth appears as if it is in the eruption phase.
Alveolar fracture can be seen if present.
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Treatment:
Most of the clinicians prefer not to do anything in the emergency visit
and give the tooth the chance to re-erupt again (the younger the patient, the
better the chance for this to happen).
Definitive Treatment (After 1 week):

If tooth appears to be re-erupting in one-week period, then it is better to
give it the chance and patient should be seen every week to monitor the
condition.
If complete eruption occurred, pulp vitality should be assessed and root
canal treatment should be done if pulp affection was found.
If no re-eruption occurred, tooth extrusion orthodontically appears to be
the best line of treatment. This procedure is expected to take 3-4 weeks. Once
tooth returns to its normal position, it should be splinted for 1-2 weeks to
prevent re-intrusion.
Root canal treatment in this situation is a must and the root canal must be
packed with calcium hydroxide paste before obturation to prevent external root
resorption.
Sequelae of Luxation Injuries:

NECROSIS CALCIFICATION RESORPTION
CONCUSSION 2% 2% 0%
SUBLUXATION 6-47% 10-26% 4%
EXTRUSION 64% 30% 36%
&LAT. LUXATION
INTRUSION 100% < 10% 86%
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AVULSION
This type is characterized by complete extrusion of the tooth out of the socket.
Factors affecting treatment:

1. Extra oral time, the sooner the better
2. Tooth handling do not scrub
3. Storage medium: the socket is the best, HBS, milk, saline, saliva then water
Treatment of Avulsion:
1- Management outside the dental office:
All efforts are to be made to minimize the damage to the remaining
periodontal membrane cells and fibers on the root surface. Viability of such
cells and fibers is greatly affected by dryness (prolonged extra-oral time) and by
aggressive handling of the tooth. Factors to be considered are:
(i)Tooth Handling:
Tooth should be handled from the crown and avoid any scrapping of the
root surface only wash the tooth under running water to remove surface debris.
(ii) Extra-Oral Time:
The most critical factor in the success of replantation of an avulsed tooth
is the speed with which the tooth is returned to its socket (ideally 30 minutes
and not to exceed 2 hours). Instructions over the phone to the person at the
scene of the accident can guide in immediate placement of the tooth in its
socket before transferring the patient to the dental clinic. If this is impossible,
tooth should be placed in a transport media and brought with the patient to the
dental clinic.
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(iii)Transport Media:
If tooth cannot be placed in the socket, then a storage media is suggested as
milk, water or saline. Milk is considered the most appropriate storage media as
it is readily available and have a pH and osmolarity compatible to vital cells. If
none of these storage media is available, tooth can be placed in the buccal
vestibule of the patient’s mouth.
(2) Emergency Management in the Dental Office:
(i) Root Surface:

If the tooth was not replanted at the site of the accident, then the dentist must
minimize the extra-oral time as much as possible by quickly replanting the tooth
in the socket. Scrapping the external root surface should be avoided to preserve
as much periodontal cells as possible. Again, performing root canal treatment
extra-orally should be avoided.
(ii) Socket:
Minimal manipulation should be done to the socket. Avoid curetting the
inside of the socket only irrigate it with saline to remove formed blood clot
which can prevent the tooth from being well placed in the socket.
(iii) Splinting:
Once the tooth is placed in the socket, it should be stabilized by splinting
it to the neighboring teeth. Apply acid etch on the labial surface of the
surrounding teeth and cover it by composite resin reinforced by an orthodontic
wire. Tooth should be splinted for 1-2 weeks.
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Extra oral dry time less than 60 minutes

Closed apex:
- Rinse with saline or water m replant, functional splint by composite resin.
Open apex:
- Soak in minocycline for 5 minutes then replant. Revascularization may
occur
Extra oral time more than 60 minutes

Closed apex:
- Remove periodontal ligament by placement in acid etching for 5 minutes.
- Then soak in 2% stannous fluoride for 5 minutes then replant.
- Emdogain (enamel matrix protein) makes root more resistant to restoration
and stimulate periodontal ligament formation.
Open apex:
- Prognosis of replantation is not good, however trial to replantation can be
done preceded by extra oral root canal treatment better than long term
apexification.
Adjunctive Therapy:
- Systemic antibiotic, at emergency visit till splint removal for 7 days to
prevent bacterial invasion of necrotic pulp and subsequent inflammatory
resorption.
- Tetracycline, decrease root resorption: affect motility of osteoclasts and
reduce effectiveness of collagenase.
- Chlorohexidine rinse as analgesics and tetanus booster.
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(3) Management during the second visit (7-10 days after the emergency
visit):
 Extra oral dry time less than 60 minutes:

Closed apex:
- Root canal treatment, calcium hydroxide application might be beneficial in
cessation of inflammatory response.
Open apex: Monitor evidence for pulp revascularization.
 Extra oral dry time more than 60 minutes:

Closed apex:
- Root canal treatment, calcium hydroxide application might be beneficial in
cessation of inflammatory external restoration.
Open apex:
- Apexification
Sequelae of Replantation:
When a tooth is avulsed, the attachment apparatus of the tooth
(periodontium) is damaged together with the vascular and the neural supply.
On replantation of such tooth some tissue reactions take place which
should be considered.
(i) Healing with Normal Periodontal Ligament.
(ii) Surface Resorption:

- This occurs with mild forms of trauma being characterized by superficial
resorption of the cementum followed by formation of new cementum and
periodontal ligament.
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(iii) Replacement Resorption:

- This occurs with extensive trauma where an abnormal attachment occurs
leading to a condition that bone comes into direct contact with the root
without the presence of periodontal ligament (ankylosis). Un arrested
replacement resoroption leads to continous replacement by bone till loss of
the tooth.
(iv) Inflammatory Resorption:

- This occurs as a consequence to pulpal necrosis where toxins pass from
inside the root canal to the outer surface of the root.
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References
 Cohn S, Hargreaves K, editors: Pathways of the pulp, ninth edition, 2006.

 Ingle J, Himel V, Hawrish C, Glickman G, Buchanan S.,editors:
Endodontics, fifth edition, 2002.
 Walton & Torabinjad, editors: Principles and practices of endodontics, Third
edition, 2002.
 Weine F, editors: Endodontic therapy, sixth edition, 2004.
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ROOT RESORPTION
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Root Resorption
Objectives:
 Different types of resorption.

 Etiological causes of root resorption.
 Management options for root resorption.
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Root Resorption
Definition
Root resorption is a physiologic or a pathologic process, which results in
loss of the cementum and/or dentine of the root of a tooth.
Classification
Root resorption could be classified according to the site of origin into:
a. Internal Root Resorption:

 Affecting inner surface of the pulp space.
It can be sub-classified to:
a. Transient: self-limiting that repairs by itself.
b. Inflammatory: that progresses due to presence of inflammation, requiring
continuous stimulation by infection.
c. Replacement: in which the resorbed dentine is replaced by bone.
b. External Root Resorption:

 Affecting outer surface of the root.
It can be sub-classified to:

a. Surface: small superficial cavities in cementum and outermost dentine. It
is self-limiting and heals by itself.
b. Inflammatory: resorption reaches dentinal tubules that progresses due to
presence of inflammation allowing possible communication with the
pulp. It is generally related to the presence of bacteria.
c. Replacement (ankylosis): in which the resorbed root surface is replaced
by bone. It usually occurs in severe trauma disrupting and injuring the
periodontal ligaments.
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Root Resorption
 Another classification of External root resorption is according to its

location in the root:
a- Apical
b- Cervical
c- Lateral
 Heithersay classified External Cervical Resorption according to the extent

of the lesion into: (Figure 1)
Class 1: a small invasive resorptive lesion near the cervical area with shallow
penetration into dentin.
Class 2: a well- defined invasive resorptive lesion that has penetrated close to
the coronal pulp chamber but shows little or no extension into radicular dentin.
Class 3: a deeper invasion of dentin by resorbing tissue, not only involving the
coronal dentin but also extending at least to the coronal third of the root.
Class 4: a large invasive resorptive process that has extended beyond the
coronal third of the root canal.
Figure 1: Heithersay classification of External Cervical Resorption
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Root Resorption
Main Etiology for Root Resorption
Internal Root Resorption:

- Damage of protective odontoblast/ predentine layer, exposing the underlying
mineralized dentine to odontoclasts and micro-organisms. May be caused
by:
Pulpal Metaplasia, Trauma, Inflammation/Infection of the pulp, Endocrine
Dysfunction and systemic disease, Herpes Zoster, Idiopathic changes
- These causes leads to damage of odontoblasts and predentine layer.
- This damaged necrosed tissue leads to chronic inflammatory reaction with
odontoclasts differentiation and resorption begins.
External Root Resorption:

- Damage of protective cementoblast/ PDL/ pre-cementum layer, exposing
mineralized cementum to osteoclasts and micro-organisms. May be caused
by:
Inflammation, Infection, Replantation, Pressure from Orthodontic treatment,
Pathological (tumor or cyst), or Impaction
- Systemic: Root resorption might be caused by Hypoparathyroidism,
Goucher's disease, Turner syndrome, Calcinosis, Herps Zoster and other
disease affecting endocrine system and disturb normal physiologic calcium
metabolism.
- Idiopathic: Root resorption is associated with Hemifacial Atrophy (Parry-
Romberg Syndrome). The active stage of the disease coincides with root
formation period of the permanent teeth (from the middle of the first decade
into adolescent years)
For External Cervical Resorption, damage of protective cementum layer at
CEJ initiating might be due to intra-coronal bleaching, periodontal therapy,
dental trauma, orthodontic treatment and idiopathic etiology.
35
Root Resorption
Diagnosis and Differential Diagnosis
1- Clinical Signs and Symptoms:

- Clinically internal and external root resorption is asymptomatic and only
detected during routine radiograph or clinical examination.
- Pink spot that was diagnostic for internal resorption was also found for
external cervical resorption that needs further differential diagnosis to
identify the condition.
- Sometimes external cervical resorption could be identified by probe
catching, spontaneous profused bleeding on probing, sharp and thinned out
edges around the resorptive cavity.
- Ankylosed teeth give high metallic sound.
2- Sensitivity Testing:
- Internal root resorption usually occurs in teeth with vital pulps and gives a
positive response to sensitivity testing.
- However, the pulp might have become necrotic after active resorption has
taken place for long time.
- External inflammatory resorption in the apical and lateral aspects of the root
involves an infected pulp space, so gives a negative response to sensitivity
tests.
- While, cervical external root resorption is usually associated with positive
response to sensitivity testing unless there is pulpal involvement (in
advanced cases).
So to differentiate between internal or external root resorption is very

challenging and needs radiographic examination.
36
Root Resorption
3- Radiographic Examination:
- Radiograph is essential for root resorption detection but smaller lesions are
more difficult to identify than larger ones.
- It appears as radiolucent cavitation of root surface.
- Internal resorption has well defined margin and the shadow of the pulp space
fades out in the resorptive lesion, while external root resorption has ragged
margins and the shadow of the pulp space passes unaltered through the
resorptive lesion. (Figure 2)
- They are better differentiated by mesial or distal Shift Technique as the
internal resorption defect will not change position in different angled
radiographs as it is within the confines of the root.
- While external resorption defect will change position as it is on the root
outer surface superimposed over the canal. (Figure 4)
- Recently CBCT (Cone Beam CT) is very diagnostic and more precise in
differentiating between internal and external resorption as well as identifying
the defect size and if it was perforating defect or not.
- Radiographically, in replacement external resorption, the root is not apparent
with no periodontal space delination and replaced by bone trabeculation.
Figure 2: Schematic drawing representing radiographic appearance of internal

resorption (left side) and external resorption (right side).
37
Root Resorption
Treatment of Internal Resorption:
1- Non-Surgical Endodontic treatment:

Endodontic treatment is done provided that the defect does not perforate the
canal wall and the endodontic triad can be fulfilled.
Problems faced and how to solve:
a. Hemorrhage due to vital pulp which can be controlled by irrigation with
5.25% NaOCl, heamostatic agents and vasoconstrictors.
b. Remnants of pulp tissues in the inaccessible recesses contribute to treatment
failure with a widened void inside the canal cannot be adequately
instrumented. This defect needs Ultrasonic debridement, irrigation with
5.25% NaOCl to dissolve necrotic pulp tissue and long term Ca(OH)2
medication.
c. Filling technique of choice should seal canal apical to the resorbed area with
guttapercha by lateral or vertical condensation. Then the defect is sealed
with Thermo-plasticized injected warm gutta-percha as it gives an
impression like reproduction of the irregularities of the root canal space.
2- Re-calcification with Ca(OH)2:

Teeth with perforating resorptive defect of moderate size that do not
communicate with gingival sulcus or periodontal pocket were successfully
treated with long term Ca(OH)2 re-calcification. Ca(OH)2 powder mixed with
saline, distilled water or anesthetic solution to a thick paste was found to
promote hard tissue formation in small to moderate defects.
Repair is by deposition of cementum like or osteoid like tissue at site of
the defect. This is followed up every 3 months up to 2 years, clinically by direct
examination through the access and radiographically for evidence of hard tissue
repair. When a physical barrier has been established, the defect is filled with
gutta-percha.
38
Root Resorption
3- MTA Application:
Recently in perforated resorptive cases, MTA is recommended to seal the
perforation through the root canal. MTA is the most recommended filling to
seal such defects for its setting in presence of moisture or blood, bio-
compatibility and high alkalinity allowing for hard tissue repair. It is better than
re-calcification with Ca(OH)2 as after MTA setting it allows immediate
permanent restoration. Also long term Ca(OH)2 makes the tooth more prone to
fracture.
4- Surgical Treatment:
When non-surgical approach and re-calcification requirements cannot be
met or have been unsuccessful, a surgical approach is required. This approach is
to expose and seal the resorptive defect surgically. MTA is the most
recommended filling to seal such defects.
Indications for surgical treatment:
- Altered anatomy of root apex by the resorptive process.
- Uncontrollable bleeding from the perforation defect.
- Perforation near or at the epithelial attachment.
- Unsuccessful re-calcification
5- When internal resorption defect occurred in an inoperable site or has
rendered the tooth untreatable or un-restorable, the available treatment
options are root resection, intentional replantation or extraction.
Treatment of External Resorption

It is imperative in all diagnosed cases of External resorption to remove
resorptive tissue and the cause of resorption if still present. Then the defect
should be sealed with repair materials as amalgam, IRM, Cavit, composite resin
or glass ionomer. More recently MTA and bioceramic repair materials were
used with higher success rate.
39
Root Resorption
External Cervical Resorption
- It is usually due to trauma, bleaching, replanted teeth, or consequence of

orthodontic treatment.
- As it may be a consequence of bleaching the following steps are essential to

minimize its probability:
a. Protect the dentinal tubules by placing a layer of cement over the gutta-
percha at the cervical line to prevent ingress of bleaching materials through
dentinal tubules.
b. Eliminate the use of heat of thermos-catalytic procedure.
c. Avoid etching of dentine as it opens dentinal tubules and lead to direct path
to the gingival tissues.
d. Beware of the caustic nature of superoxol.
The treatment of such case depends on position of the defect in relation to

epithelial attachment. If accessible defect (above or at the epithelial
attachment), resorptive tissue should be curetted from the defect.
1. The 90% trichloracetic acid should be topically applied to resorptive defect

after protecting adjacent soft tissues with glycerol.
2. Glass ionomer cement should be used to restore the defect.
3. Elective endodontic treatment in the root canal to gain access to deeper and
encircling infiltrative channels or when resorptive defect involve or
approximate pulp. Ca(OH)2 or Ledermix paste intra-canal dressing is
recommended, followed by obturation.
40
Root Resorption
4. If inaccessible resorptive defect (below epithelial attachment), expose the

resorptive defect by orthodontic extrusion or surgically with full-thickness
periosteal flap/ periodontal flap reflection, to allow complete access for
curetting of the resorptive lesion and defect restoration with MTA. Elective
endodontic treatment might be done as above.
5. Leave untreated and monitor. Or
6. Lesions that are not amenable to treatment, should be extracted and replaced
with an implant.
- The surgical restoration of resorptive defect of External Cervical Resorption
can result in development of a periodontal pocket because the tissue cannot
attach to the filling material. MTA repair allow cementum deposition and
attachment.
- A recent study reported a higher success rate with the application of GTR
techniques (Guided tissue regeneration) for the treatment of Cervical
resorption.
According to Heithersay classification:

- Class 1 and 2 just need topical application of 90% trichloracetic acid,
curettage, and glass ionomer cement restoration.
- While Class 3 needs topical application of 90% trichloracetic acid to
resorptive tissue, curettage, elective endodontic treatment with Ledermix
paste intra-canal dressing, followed by root filling and final glass ionomer
cement restoration.
- It might be necessary to use adjunctive orthodontic extrusion or periodontal
flap reflection, curettage, trichloracetic acid application to the defect,
endododontic therapy and restoration.
- Class 4 Leave untreated and monitor or extract and implant.
41
Root Resorption
Lateral Root Resorption

Luxative injury is a major cause for external root resorption on the lateral
aspect of the root. Intrusion trauma produces higher incidence of external
resorption than other luxative injuries.
Prevention of root resorption following replantation of mature tooth
could be done by pulp extirpation and Ledermix paste dressing as soon as
possible.
If lateral root resorption is caused by pulp necrosis and it is non
perforating, non-surgical endodontic treatment with Ca(OH)2 dressing is
needed and follow up.
If Perforating lesions, the external resorption reaches dentine and
perforates the root canal, re-calcification with Ca(OH)2 or MTA application to
seal the resorptive defect.
If caused by other causes not from the pulp and non-perforating, or
recurrence occur after endodontic treatment or re-calcification, surgical
treatment is needed with MTA or other repair materials to restore the defect.
If irrestorable or inaccessible for treatment, extraction is needed.
Apical Root Resorption

- Periapical inflammation may result in apical root resorption.
- Non-surgical Endodontic treatment with apical stop formation during
cleaning and shaping is needed against which gutta-percha is condensed.
- The removal of necrotic pulp should be followed by intra-canal medication
with Ledermix paste.
- If resorption is severe inverted cone or tailor made technique are indicated.
- If resorption has enlarged the apical portion of the canal precluding proper
instrumentation and sealing, apical closure techniques (recalcification with
long-term Ca(OH)2 or apical barrier with MTA) should be used.
- Root canal obturation when resorption is controlled.
42
Root Resorption
- Usually non-surgical treatment is the initial approach for external resorption.

When recall radiographs at 6 months or 1year show continued resorption or
persistant periapical pathosis, apical surgery should be performed.
Intra-canal medications used in inflammatory root resorption:

- Ca(OH)2 is the most widely used medication. But other medicaments were
investigated.
- Ledermix, an antibiotic / corticosteroid paste has been shown to be effective
in treating inflammatory resorption by inhibiting the spread of dentinoclasts.
Its release and diffusion has been enhanced when used in combination with
Ca(OH)2.
- Calcitonin, a hormone known to inhibit osteoclastic bone resorption was
found to be an effective medication for the treatment of inflammatory root
resorption and could be a useful therapeutic adjunct in difficult cases of
external root resorption. Calcitonin is applied as a root canal dressing that
passes via the dentinal tubules directly to the external cervical resorptive
lesion.
External Replacement Resorption Treatment:(Ankylosis)

Mature tooth in Normal Occlusion:
leave and monitor for ultimate implant replacement.
Mature / Immature Tooth in Infra-Occlusion:
1- Surgical reposition with root surface treatment with Emdogain
2-Decoronation and submerge to maintain alveolar growth
3- Vertical distraction
4- Prosthetic elongation
5- Implant therapy, if necessary, when alveolar growth completed.
43
Root Resorption
References

 Ingle J, Himel V, Hawrish C, Glickman G, Buchanan S.,editors:
edition, 2002.
44
RETREATMENT OF
ENDODONTIC FAILURES
45
Retreatment of Endodontic Failures
Objectives
 Understand the rationale behind non-surgical retreatment and causes of

initial root canal treatment failure.
 Master different techniques of removal of obturation materials from root
canals, remove Carrier based obturation from the root canals and remove
posts.
 Repair pulp floor perforations, and perform apical plugs with biocompatible
materials.
 Manage root canal blockage, ledges, and broken instruments using advanced
techniques and tools.
46
In recent years, the number of people seeking endodontic treatment has

dramatically increased because of the public's choice of root canal treatment over
tooth extraction. The growing use of endodontics can be described as the "Good -
news, and Bad-news dilemma". The good news is that hundreds of millions of
teeth are saved from extraction. The bad news is that tens of millions are
endodontically failing for a variety of reasons causing post treatment disease.
Longitudinal endodontic outcome studies performed in university-based
institutions or by specialists have shown a high percentage of success estimated
from 90% to 95%. Assuming that 90% of the treatments are successful over time,
the reciprocal failure rate is 10%. In the United States alone, where the number of
canals treated per year now exceeds 50 million, a 10% failure rate could represent
five million treatment failures per year. Extrapolating these numbers over the past
three to four decades reveals that the number of failing endodontically treated teeth
is very high and could approach tens of millions.
Endodontic failure" post treatment disease" can be attributable to inadequate
cleaning, shaping and obturation, iatrogenic events or reinfection of the root canal
system when the coronal seal is lost after completion of root canal treatment.
Regardless of the initial cause, the sum of all causes is leakage.
Non-surgical versus Surgical Retreatment

Endodontic failure must be evaluated so that a decision can be made among
nonsurgical retreatment (NSRCT), surgical retreatment (SRCT), or extraction.
Non-surgical retreatment is a procedure to remove materials from the root
canal space if present, address deficiencies or repair defects that are pathologic
or iatrogenic in origin. These disassembly and corrective procedures allow the
clinician to 3D clean, shape and pack the root canal system.
Surgical retreatment is restricted in the ability to eliminate pulp, bacteria
and related irritants from the root canal system. In non-surgical retreatment, root
canal systems can be cleaned, shaped and packed in 3-D, also many pathologic
and iatrogenic events can be repaired nonsurgical.
47
Factors Influencing Retreatment Decisions:
1. Root Canal Treatment Quality:

- However, they may fulfill the definition of success. These teeth may be
watched rather than retreated, unless the tooth is decided to receive a new
restoration, then a decision need to make retreatment.
2. What Does the Patient Want?
- Patients can choose the treatment options that best fulfill their wishes.
3. Is It Strategic Tooth?
- Clinicians need to look carefully at a tooth that is failing if the tooth is
essential (functionally or esthetically).
4. Restorative Evaluation:
- Broken-down teeth should be evaluated for crown-lengthening procedures.
The crown lengthening creates pulp chamber that retain solvent, irritant and
inter-appointment temporary filling.
5. Periodontal Evaluation:
- Endodontically failing teeth that are evaluated need to be examined for
pocket depth, mobility, crown-root ratio, hard and soft tissue defect and any
other anomalies that affect attachment apparatus.
6. Chair Time and Cost:
- The chair time and cost associated with any procedures must be analyzed
and understood by the clinician and communicated to the patient.
7. Referral:
- It is better to refer the patient to a specialist who has more experience, better
training and the technology necessary to achieve success. Clinician should
treat the patients as they would like to be treated themselves.
48
Impact of Cone Beam Computed Tomography (CBCT) On

Cone beam computed tomography (CBCT) has been introduced into
endodontics, and its usefulness in the management of endodontic retreatment is
unquestioned. It has provided a quantum leap in our ability to determine the
causes of post-treatment apical periodontitis by giving the clinician, for the first
time, the ability to easily, safely, and inexpensively visualize the tooth and
surrounding structures in three dimensions (3D). The CBCT is especially
helpful, it allows the clinician to determine the true size, extent, and position of
periapical and resorptive lesions and gives added information about tooth
fractures, missed canals, root canal anatomy, and the nature of the alveolar bone
topography around teeth.
CBCT technology has greatly enhanced pre-surgical diagnosis and
treatment planning, because the relationship of adjacent anatomic structures
such as the maxillary sinus and inferior alveolar nerve to the root apices can be
clearly visualized. This helps the clinician to decide on when to perform
endodontic retreatment surgically or non-surgically. CBCT is more accurate
than periapical radiography in the diagnosis of apical periodontitis, and it can
reveal the details of the lesions and adjacent structures, thus providing enhanced
clinical diagnosis and treatment planning (Figure 1).
There are many manufacturers and brands of CBCT machines on the
market today, but the most useful ones for endodontic retreatment are those that
produce the clearest image with the highest resolution. These would be the
small field of view (FOV) machines that image a small volume and use the
smallest picture element (voxel) dimensions available. Radiation exposure to
the patient with these machines is in the range of 23 to 488 μSv, which is very
small, but the “as low as reasonably achievable” (ALARA) principle applies, so
its use in every diagnostic case cannot be encouraged.
49
In a joint position statement in 2010, the American Association of

Endodontists and the American Association of Oral and Maxillofacial
Radiologists stated that “CBCT should only be used when the question for
which imaging is required cannot be answered adequately by lower dose
conventional dental radiography or alternate imaging modalities.” When
managing post-treatment disease, however, almost every case will benefit from
the use of three-dimensional imaging.
1- Conventional Radiograph 2- Sagittal View
3- Coronal view
4- Axial view
Figure 1: Vertical Root fracture of the palatal root: (1) conventional radiograph. (No sign of
fracture) (2) CBCT Sagittal view. (3) CBCT coronal view. reaction. (4) CBCT Axial view
50
One major cause of post-treatment apical periodontitis is untreated

canals, and the CBCT gives an unprecedented ability to discover those.
Avoiding treatment, which will lead to a predictable failure, is beneficial for
both the clinician and the patient. The ability to obtain 3D images of teeth will
help the clinician to avoid these mishaps. The diagnosis of root fractures
frequently frustrates the clinician, as a definitive diagnosis is often difficult and
treating these teeth has a high likelihood of a poor outcome. Although
visualizing root fractures in teeth with root fillings is still not predictable using
CBCT, the patterns of bone loss indicative of root fracture can sometimes be
seen, and this helps the clinician to infer their presence.
The prognosis for the treatment of root resorption is directly related to the
extent of the resorption, and this usually cannot be determined accurately using
conventional radiography. Using small FOV CBCT, however, the extent of the
lesions and the prognosis can be determined, usually saving the patient from an
exploratory procedure that may be doomed to fail.
Though most clinicians believe that CBCT is not necessary for every
patient treated, there are many retreatment situations where the additional
information gained (relative to conventional radiography) is extremely valuable.
In the future, specific protocols for use will be developed; but for now, the
authors recommend that clinicians use their best judgment on when to use this
new technology.
When all diagnostic information is collected, a diagnosis must be
developed. It is important to record the diagnosis in the patient’s record so that
anyone reading the record can discern the clinician’s rationale for treatment.
The pulpal diagnosis will usually be recorded as previous endodontic treatment,
but the peri-radicular diagnosis will vary depending on the clinical picture
presented.
51
Root Canal Retreatment Procedures

When infection is present the aim of root canal retreatment is to eliminate
microorganism that have survived previous treatment or reentered the root canal
system.
The retreatment depends on the operator's ability to gain access to the
root canal system particularly the apical third.
Pre-operative radiograph should be made to show whether or not a post
has been used, the type of root filling material (paste, gutta-percha, silver point)
and potential problems such as curves, perforation or ledger. The use of
magnification and lighting is useful in root retreatment procedures.
I- GAINING ACCESS TO THE ROOT CANAL/CORONAL DISASSEMBLY
A- Coronal Access:
Care should be given to the quality of the coronal restoration prior to
access. The presence of an integral post and core or evidence of leakage around
the restoration margins indicates that it should be removed.
Sectioning and removal of crowns or bridges is preferred to tapping them
off with a crown remover. The latter method may result in fracture of tooth
structure. It is advisable to make sectioning with diamond bur if porcelain is
involved, while the trans metal bur provides excellent means of cutting through
metal crowns.
To preserve the restoration, two approaches can be taken: access through
the crown or crown removal and replacement when retreatment is completed.
The simplest choice is to prepare an access cavity through the existing crown,
although there is a significant risk of damaging the restoration resulting in the
need to replace it. This risk must be communicated to the patient prior to
instituting therapy.
52
If the clinician decides to access through the existing restoration, there are
several choices of access burs to use, depending on what material the preparation
will be cut through. However, if the crown is to be preserved, then a more
conservative approach must be used.
Two considerations, which may influence the decision about removal of a
crown or bridge, are what material the restoration is made of and what is it
cemented with. Conservative removal efforts are difficult with traditional, all-
metal restorations cemented with non-bonded cements. This situation has been
even more of a concern lately due to the increasing popularity of tooth-colored
restorations, mainly different types of porcelain or porcelain fused to metal (PFM)
restorations, which are being bonded to the tooth. These restorations are less likely
to withstand the stresses of removal than those fabricated entirely of metal, and
restorations that are bonded are much more difficult to remove due to the adhesive
strengths of bonding agents. Each new generation of bonding agent is stronger than
the previous, making removal increasingly more difficult as cosmetic dentistry
advances.
The Metalift (Figure 2) is designed to safely remove inlays, onlays, three-
quarter crowns, full crowns and fixed bridges in a minimally-invasive way so these
restoratives can be reused. The kit includes all items needed to perform the
procedure, as follows: One, in the instance of a porcelain crown or bridge, the
cylindrical diamond bur is utilized to precisely remove the porcelain and expose
the underlying metal. Two, with the help of magnification, create a pilot hole with
a small carbide round bur through the metal and to solid structure. Three, a twist
drill is used to create a precision channel in the metal that exactly matches the size
of the Metalift instrument to be used later in step five. Four, substructure material
is carefully removed on the bottom side of the metal so as to not damage the
precision channel and to prevent threading the Metalift instrument into tooth
structure. Five, the Metalift instrument is threaded through the metal until its distal
end contacts tooth structure and rotation is continued to lift off the crown.
53
Figure 2: The Metalift
54
B- Radicular Access:
a) Removal of Restorative Materials:
Once coronal access has been gained the attention is addressed towards
radicular access. Core materials will either be tooth or non-tooth colored
materials or cast metal. The most common non-tooth colored material is
amalgam, which can be removed using surgical round carbide burs in high-
speed hand piece, followed by long bur used at slow speed deeper in the access
cavity. When the floor of the pulp chamber is approached, ultra-sonic tips
should be used (Figure 3). After removal all the core materials the access cavity
should re-evaluated, in regard to its extent, to look for previously untreated
canals [missed canal].
Figure 3: Ultrasonic Tips Suitable for Use in Retreatment
55
B) Removal of Post:
The removal of a post should not be attempted if the force to remove

could result in root fracture. Ultrasonic vibration may be used to break the
cement of the post using special tip size with water spray coolant and moderate
power.
In some situations, ultrasonic vibrations may result the post become free
within the canal. If the post does not remove, it is necessary to use a device to
extract the post; this can be accomplished using the Ruddle post removal system
(PRS) (Figure 4). It consists of a series of trephine burs to machine the post
head, tubular taps to engage the post and extraction pliers to provide the
elevation force.
Figure 4 (A): The Ruddle Post Removal System Including the Extractor.
(B): A Domer Bur, Trephine and Tap Used to Modify and Engage the Post
56
II- GAINING ACCESS TO THE CANAL TERMINUS
During the diagnostic phase, it is very important to ascertain the nature of

the root filling to minimizing surprises when attempting retreatment.
 Gutta-Percha Removal:
One of the greatest advantages of using gutta-percha for root filling, its relative
ease of removal.
Techniques used for removal of gutta-percha:

1) Rotary Removal:
Nickel and titanium (Ni Ti) 0.04 and 0.06 tapered rotary files are the
most effective instruments for removing Gutta-percha (Figure 5). The rotation
of the files softens the gutta-percha and auger it coronally.
Figure 5: Removing Gutta-Percha Using Ni Ti Rotary Instrument, Protaper Universal
57
2) Heat and Instrument Removal:

A hot instrument is plunged into the Gutta-perch and immediately withdrawn to
heat and soft the material. A size 35, 40, or 45 Hedstrom file is selected and
quickly, but gently, screwed into the thermo-softened mass. The gutta-perch
cools, it will freeze on the flutes of the file. By removing the file, it eliminates
the engaged gutta-percha.
3) Heat Removal:
Systems B (Figure 6) have been used to thermo-soften and remove "bites" of
gutta-percha from the root canal system.
Figure 6: System B
4) Gates – Glidden Burs:

Used coronally in the straight part of appropriately sized canals. These
are available in a range of size and have a safe cutting tip that reduce the risk of
perforation, providing too large is not used. Care should be taken during their
use with a suitable speed 1000 – 1500 rpm.
58
5) File and Chemical Removal:

This technique involves filling pulp chamber with chloroform (Figure 7).
The file and chemical removal option is best utilized to remove gutta-percha
from small, curved, and densely filled canals. A pilot hole is first created in the
coronal portion of the canal with either a hot heat carrier or by using the
Retreatment rotary instrument as Protaper D1 instrument. Two or three drops of
chloroform are then introduced into the newly created reservoir inside the root
canal. Chloroform is still the reagent of choice and plays an important role in
chemically softening gutta-percha.
A sequential technique is advocated to remove the filling material. It
involves the use of H-type files, 21mm length in descending order to gently
“pick” into the chemically softened gutta-percha, this procedure can be
facilitated by using pre-curved, rigid files such as the C+ file in the apical
curved part of the canal. Shorter instruments are preferred since they provide
more stiffness and have less tendency to flex. Without trying to engage the
more apical material, a lateral motion is used with the H-file to remove gutta-
percha remnants at this level. This method is repeated to progress apically until
gutta-percha is no longer evident on the cutting flutes of the file when it is
withdrawn from a solvent-filled canal. The solvent should be replenished
frequently, and when the last loose-fitting instrument is removed clean, the
canal is flooded with the solvent, which then acts as an irrigant. The solvent is
then removed with paper points. The wicking action of the absorbent points187
will remove much of the remaining film of gutta-percha and sealer that remains
adhered to the canal walls and in the irregularities of the canal system.
Figure 7: Paper Point and Chemical Removal
59
 Silver Point Removal

Access preparation must be planned and carefully performed to minimize
the risk of shortening the silver points. Initial access is done with high speed
surgical length cutting tools. Subsequently, ultrasonic instruments carefully
used within the pulp chamber to cut any restorative materials and expose the
silver paint.
1) Pliers' Removal:
After completing access and exposing the part of the silver point in the
pulp chamber, a suitable grasping instrument, such as Stieglitz pliers is used to
remove silver point (Figure 8)
Figure 8: Steiglitz forceps
2) Indirect Ultrasonic:
When a segment of a silver point is below the orifice and space is
restricted, the CPR 3, 4, and 5 ultrasonic instruments may be used. The
ultrasonic instruments trephine circumferentially around the silver point, break
up cement and expose part of the silver point. The ultrasonic instruments are not
used directly on the silver points because it soft and erode the silver points. So
ultrasonic energy can also be transmitted directly on grasping pliers to enhance
the retrieval efforts.
60
3) Files, solvent and Chelators:

Using solvent and a size 10 or 15 SS file, the chamber is filled with
solvent and the files are used laterally to the silver point to break up cement and
to undermine and loosen the silver point for removal. If space exist between the
silver point and the canal wall, a 35, 40 or 45 Hedstrom file can be inserted and
engage the silver point.
4) Microtube Removal Options:

This technique uses a microtube and an appropriate sizes Hedstrom file.
In this removal method, a microtube was selected and placed over the exposed
coronal aspect of the obstruction. A Hedstrom file was then passed down the
length of the tube until it engaged itself tightly between the obstruction and
internal lumen of the microtube, these techniques will be discussed later in this
chapter; broken files removal techniques.
 Carrier-Based Gutta-percha removal
Carrier obturation techniques consist of a core surrounded by gutta-

percha. A combination of techniques used for the removal of Gutta-percha and
silver point is indicated. Modified gutta-percha has been introduced as a core
material for solid core obturation. This obturation system is called GuttaCore
and, at first glance, it appears similar to plastic carrier-based systems. With
GuttaCore, however, the carrier is fabricated from cross-linked gutta-percha
rather than plastic. The cross-linking connects the polymer chains, which
changes the material and gives the carrier different properties than the plastic
carriers.
61
 Paste Removal
1) Ultrasonic instruments in conjunction with the microscope used in removing

paste from the straight portion of the canal. The CPR-3,4 and 5 Zirconium
nitride-coated used below the orifice to remove brick-hard resin-type paste.
To remove paste apical to canal curvature, a pre-curved file is attached to a
special adaptor that mounts on is activated by ultrasonic handpiece (Figure
9).
2) Heat: Certain resin pastes soften with heat.
3) Rotary instruments: By using end cutting Ni Ti rotary instruments.
Figure 9: Ultrasonic Files Used to Break Up the Hard Paste
62
 Broken Instruments Removal

Before beginning retrieval efforts, attention is directed toward
preoperative radiographs and working films that reveal the thickness of the
dental walls.
Coronal access is the first step in the removal of broken instruments.
Then radicular access is the second step required in the successful removal of a
broken instrument. GGs are then use like "brushes" to create additional space
and maximize visibility coronal to the obstruction. The bud- shaped tip of the
gates Glidden can be modified and used to create a circumferential "staging
platform".
The staging platform facilitates the introduction of the zirconium nitride-
coated CPR-3,4, if restricted by space, the longer and thinner CPR-6,7, and 8
ultrasonic instruments can be used.
The ultrasonic action sands away dentin and trephines around the coronal
few millimeters of the obstruction, which begins to loosen, unwind and spin out
of the canal. Gentle wedging the energized tip of ultrasonic between the tapered
file and the canal wall causes the broken instruments to "jump out" of canal
(Figure 10).
Figure 10: Broken Instrument Removal by Ultrasonics
63
The I.R.S Option:

The instrument retrieval system provides a breakthrough in the retrieval
of broken instruments lodged deep within the root canal space.
The I.RS is composed of different sized microtubes and inserts wedges,
the microtube has a small handled to enhance vision, and its distal end has a
bevel and cut out window. The microtube can passively slide into the canal and
drop over the exposed, broken instruments, in a such way that the beveled end
is oriented to the outer wall of the canal to "scoop-up" the head of the broken
instruments then the inserted wedge is placed through the open end of the micro
tube until it contacts the broken obstruction.
The wedge screw in a CW rotation causing the head of the broken file
entering through the microtube's cutout window. The obstruction is retrieved by
lifting the microtube and insert wedge assembly (Figure 11).
Figure 11: Broken Instrument Removal by IRS
64
III- Negotiation of Blocked or Ledged Canals:
Managing Blocked Canal:

When encountering a blocked canal, the tooth is first flooded with
sodium hypochlorite. Well angulated radiographs are observed, and. No 10 file
is pre-curved to simulate the expected curvature of the canal and a
unidirectional rubber stop is oriented to match the file curvature.
The pre-curved file is used in an apical directed picking action in the
hopes of negotiating the rest of the canal. Short pecking strokes ensure safety,
carry irrigant deeper, and increase the possibility of canal negotiation and
reaching the foramen passively and establish patency.
If no progress is made the sodium hypochlorite is replaced by viscous
chelator and the same previous techniques are used.
Managing Ledged Canal:

An internal transportation of the canal is termed a ledge, often ledges
result when clinicians work short of length and "get blocked".
Many ledges are bypassed using the techniques described for blocks.
Once the tip of the file is apical to the ledge, it is moved in and out of the canal
using very short push-and pull movements and emphasizing the tip of the file is
apical to the ledge.
If the file is sliding easily, it is turned CW upon withdrawal, because this
motion will rasp, reduce, smooth, or eliminate the ledge.
65
IV- Perforations
Perforation represents pathologic or iatrogenic communications between

the root canal space and the attachment apparatus. Root perforations are created
pathologically by resorption and caries and iatrogenic ally during root canal
therapy (zip, strip, and furcation perforations).
Frequently, cervical and occasionally mid root perforations are associated
with epithelial downgrowth and subsequent periodontal defects, so thorough
periodontal assessment is required.
If there were no evidence of post-treatment disease associated with the
defect or tooth, then no treatment would be indicated. If, however, there is
evidence of peri-radicular periodontitis, repair may be instituted in one of two
ways, either non-surgically by approaching the defect internally through the
tooth, or surgically by using an external approach.
If the perforation is to be repaired non-surgically through the tooth,
Coronal-radicular access to the defect is prepared as stated previously. First, the
root canals are located and preliminarily instrumented to create enough coronal
shape to allow them to be protected from blockage by the repair material.
The defect is cleaned and sometimes enlarged with the use of ultrasonics.
Use of a disinfectant irrigating solution such as sodium hypochlorite should be
considered if the perforation is small in diameter. However, If the perforation is
large, sterile saline should be used as an irrigant, and disinfection of the margins
of the defect is performed using mechanical dentin removal.
After the defect has been cleaned, vigorous bleeding may result.
Hemostasis should be undertaken using collagen, calcium sulfate, or calcium
hydroxide. When the bleeding has been controlled, some easily removable
material should be placed over the entrances to the deeper portion of the canals
to prevent its blocking e.g. with cotton, gutta-percha cones, paper points, Teflon
pieces or shredded collagen.
66
Following preparation of the defect, the repair material is placed. It may

be carried in a small syringe or amalgam carrier, and it is condensed with
pluggers or micro spatulas. In the case of MTA in an accessible defect, MAP
system can be used to carry the material to perforation site (Figure 12). The butt
end of paper points makes an excellent compactor, since they can wick some of
the water out of the material, giving it a firmer consistency.
Figure 12: MAP System
Several materials have been advocated for managing for perforation, with
the current one of choice being mineral trioxide aggregate (MTA) in view of its
tolerance of moisture and sealing ability. Many materials have been used of the
management of perforation such as Amalgam, Glass ionomer, EBA, and
composite.
67
References
 Rotstein I, Ingle J: Ingles Endodontics, seventh edition, 2019.

 Hargreaves K, Berman L: Cohens Pathways of the pulp, Eleventh edition,
2016.
68
ENDODONTIC MICROSURGERY
69
Endodontic Microsurgery
Objectives
 Understand the Rationale Behind Surgical Retreatment.

 Know Different Considerations Taken Before Performing Endodontic
Surgery.
 Master Different Procedures of Peri-Radicular Surgery.
 Differentiate Between Microsurgery and Traditional Surgery.
70
Surgical endodontics is defined as surgical procedures performed to

remove the causative agents of radicular and peri-radicular disease and to
restore these tissues to functional health.
 INDICATIONS
- Failure of non-surgical retreatment (has been rendered at least two times).
- Failure of non-surgical (initial) treatment and retreatment is not possible or
practical or would not achieve a better result.
- When a biopsy is necessary.
 PREVALENCE
- Periapical Granuloma 73%
- Periapical Abscess 12%
- True Cyst 9%
- Pocket Cyst 6%
 CONTRA-INDICATIONS
1. Indiscriminate Surgery:
- Surgery should not be made to cover the lack of skill in non-surgical
treatment and it should not be a routine for every case with a lesion.
2. Patient Medical Status:
- Systemically affected patient is contra-indicated to surgery unless
consultation with physician is done.
3. Psychological Impact:
- Patient should be allowed to verbalize his thoughts and fear after he has been
informed about the operation itself.
4. Local Anatomic Factors:
- Short root length.
- Poor bony support.
- Relation to vital structures e.g. mandibular canal and maxillary sinus.
71
5. Situations requiring Professional Judgment

- Non-strategic teeth.
- Non-restorable teeth.
- Periodontal condition.
- Un-cooperative or un-willing patient.
 CLASSIFICATION
I. Surgical Drainage:
1. Incision & Drainage.
2. Cortical Trephination (Fistulative Surgery).
II. Peri-Radicular Surgery
III. Corrective Surgery:

1. Perforation Repair:
A. Mechanical.
B. Resorptive.
2. Periodontal Repair:
A. Root Resection
B. Hemi-sectioning
C. Bi-cuspidization
IV. Replacement Surgery:
1. Replant Surgery
A. Intentional Replantation.
B. Post-traumatic Replantation.
2. Implants Surgery:
A. Endodontic Implants.
B. Osseo-integrated Implants (Endosseous).
72
 ANATOMIC CONSIDERATIONS
1. Maxillary Anterior Region:

 Nasal Floor
- The proximity of the roots to the nasal floor should be evaluated.
 Labial Cortical Plate

- Thin labial cortical plate needs special management to avoid root
fenestration.
2. Maxillary Posterior Region:

 Buccal Cortical Plate
- Thin buccal cortical plate of bone needs special management to avoid
root fenestration.
 Maxillary Sinus
Proximity of premolars and molars roots to the maxillary sinus should be
evaluated. CBCT is an effective method to study the position of the posterior
roots to the maxillary sinus floor. Perforation of the sinus during surgery is
fairly common (10% to 50%).
Even without peri-radicular pathosis, the distance between the root apices of
the maxillary posterior teeth and the maxillary sinus sometimes is less than 1
mm. Membrane usually regenerates, and a thin layer of new bone often
forms over the root end, although osseous regeneration is less predictable.
Variation in proximity measurements was found by age, with those under the
age of 40 showing a greater likelihood of position of maxillary roots
above/inside the sinus floor.
73
 Palatal Root
- Take care of anterior palatine artery while taking the palatal approach.
- Ligation of the external carotid artery if artery is severed.
- Palatal apex was palate-coronal or palate-corono-distal to buccal apex.
3. Palate: The flap design must avoid the greater palatine vessels.
4. Mandibular Anterior Region:

- Due to reduced labio-lingual dimensions of the alveolar bone, great care
must be taken to avoid perforation of the lingual plate of bone.
5. Mandibular Posterior Region:

- Increased thickness of buccal cortical plate produces surgical difficulties.
- Relation of roots to mandibular canal and mental nerve should be
evaluated.
 Mental Foramen
- Average location was 16 mm inferior to the CEJ of the second premolar,
although the range was 8 to 21 mm.
- CBCT is the best current available imaging technology to determine the
accurate location of the mental foramen (Figure 1).
Figure 1: showing Location of Mental Foramen
74
 Mandibular Canal
- Average vertical distance from the superior border of the mandibular
canal to the distal root apex of the mandibular second molar is
approximately 3.5 mm.
- This increases gradually to approximately 6.2 mm for the mesial root of
the mandibular first molar and to 4.7 mm for the second premolar
6. Course of Blood Vessels Supplying Alveolar Mucosa and Gingiva

 Four interconnected pathways of blood supply exist:
1. The sub-epithelial capillaries of gingiva and alveolar mucosa.
2. The vascular network within the periosteum.
3. The intra-septal arteries in the bone marrow.
4. The plexus of the periodontium.
 PSYCHOLOGICAL CONSIDERATIONS
Pre-surgical Procedures:
1. Patient Interview
 The patient must be thoroughly advised of the benefits, risks and other
treatment options and must be given an opportunity to ask questions.
2. Patient Pre-Medication
 NSAID
 Antibiotics
 Chlorhexidine Gluconate
 Conscious Sedation
See Chapter "Therapeutics"
75
I. SURGICAL DRAINAGE
1. INCISION AND DRAINAGE (I & D)
 Indications:
An acute apical abscess should be drained in order to:
- Eliminate toxins.
- Alleviate pain, as the pain from the tremendous pressure that develops in an
apical abscess is best relieved by surgical drainage.
 Challenges:
1. Proper time for intervention:
When the swelling is soft and fluctuant (when the pus is accumulated in
soft tissue), assures that great flow of pus can be evacuated.
If intervention is made when the lesion is still indurated, only hemorrhage
will result and cellulitis persists, but some relief will occur due to decreased
pressure.
2. Obtaining adequate anesthesia:

- Difficulty to obtain proper anesthetic action in the presence of acute
inflammation due to increased acidity.
- Not wanting to inject this area.
- Spread of infection by injection.
 Technique:
1. Topical anesthesia should be applied to the site of incision.
2. Using No. 11 scalpel, perform sweeping incision through the pointed area of
the swelling.
3. Aspiration of the infected fluid and irrigation with saline.
76
4. Hot mouth-wash speeds up the collection of pus and fluctuation.

5. Oral rinses 2 times/ day with chlorhexidine gluconate 0.12% to reduce
surface bacteria.
6. Root canal treatment is completed when the region is comfortable.
2. CORTICAL TREPHINATION
Indications:
- To drain pus and exudate trapped in cancellous bone behind the cortical
plate (Figure 2).
Technique:
1. Anesthesia.
2. Mini-vertical flap.
3. Creating a path for drainage through bone removal or perforation by surgical
bur.
4. Aerosol (air) or irrigation to drain pus.
5. T-drain may be inserted in cases of need for more drainage.
6. Repositioning and suturing of the flap.
Figure 2: showing Cortical Trephination

77
II. PERI-RADICULAR SURGERY
Indications
1. Irretrievable Root Canal Filling
2. Procedural Errors:
a) Instrument Fragmentation
b) Non-Negotiable Ledges
c) Over Instrumentation & Apical Fracture
d) Symptomatic Over-filling
3. Calcified Canals
4. Presence of Dowels
5. Anatomic Variations
6. Apical Cyst
7. Biopsy
Technique:
1. LOCAL ANESTHETICS FOR PERIRADICULAR SURGERIES

2. SURGICAL ACCESS
A. Soft Tissue Management
B. Hard Tissue Management
3. CURETTAGE & BIOPSY
4. LOCALIZED HEMOSTASIS
5. ROOT-END MANAGEMENT
A. Root-End Resection
B. Root-End Cavity Preparation
C. Root-End Filling Procedures
6. Closure & Suturing
7. Post-Operative Care
78
1. LOCAL ANESTHETICS FOR PERI-RADICULAR SURGERIES:

See Chapter "Pain"
2. SURGICAL ACCESS
General principles for designing access to a diseased region:
- The surgeon must have a thorough knowledge of the anatomic structures in
relation to each other, including tooth anatomy.
- The surgeon must be able to visualize the 3D nature of the structures.
- The trauma of the surgical procedure itself must be minimized.
- The tissue and instruments must be manipulated within a limited space, with
the aim of removing diseased tissues and retaining healthy tissues.
A. SOFT TISSUE MANAGEMENT

 Instruments and Operatory Setup
 The #15C blade meets most endodontic flap needs.
 The seldom-used #12 blade is helpful in reaching difficult to incise areas,
such as distal cervical walls of maxillary and mandibular molars.
 INCISION
a. Vertical Incision
 The incision must be made with a firm continuous stroke (Figure 3).
 It should not extend into muco-buccal fold as it contains muscle fibers and
connective tissue that are highly vascular & bleed extensively when severed.
Figure 3: showing Vertical Incision
79
 Incision should be placed directly over healthy bone (Figure 4).

 Incision should not be placed superior to a bony eminence.
Figure 4: showing Vertical Incision Placed Over Healthy Bone
 Dental papilla should be included or excluded but not dissected (Figure 5).
Figure 5: showing Vertical Incision in Relation to the Papilla

b. Horizontal Incision
Intra-sulcular incision that includes the dental papilla
It extends from the gingival sulcus through the PDL fibers and terminates
at the crestal bone of the alveolar bone proper. It passes in a bucco-lingual
direction adjacent to each tooth of the dental papilla and includes the mid-col
region of each dental papilla. Entire dental papilla is completely mobilized.
To include or exclude dental papilla???
Papillary-based incision resulted in rapid, recession free healing. In
contrast, complete mobilization of the papilla led to a marked loss of papillary
height. The use of the papillary-based incision in aesthetically sensitive regions
could help prevent papillary recession and surgical cleft, or double papilla.
80
 Flap Design
 Guidelines & Principles:
a. Adequate blood supply to the reflected tissue is maintained with a wide flap
base.
b. The flap should be designed for maximum access by avoiding limited tissue
reflection.
(The actual bone resorption is larger than the size observed radiographically)
c. Acute angles in the flap are avoided.
Sharp corners are difficult to reposition and suture and may become
ischemic and slough, resulting in delayed healing and possibly scar
formation.
d. Incisions and reflections include periosteum as part of the flap.
Any remaining pieces or tags of cellular non-reflected periosteum will bleed,
compromising visibility.
 TYPES OF FLAP
1. Full Muco-periosteal
 Triangular: one vertical relieving incision.
 Rectangular: two vertical relieving incisions.
 Trapezoidal: two angled vertical relieving incisions.
 Horizontal: no vertical relieving incision.
2. Limited Muco-periosteal
 Mini-vertical
81
1. Single Vertical Flap:

- Also called triangular or intra-sulcular flap.
- It is composed of horizontal incision along the gingival crest and one
relaxing vertical incision. The vertical incision is one or two teeth mesial or
distal to the surgical site and between the root eminences (Figure 6).
- This incision extends from a point 1-2 mm short of entering the muco-buccal
fold to a point at the mesial or distal labial line angle of the selected tooth.
- Horizontal incision extends 2 to 3 teeth to opposite side of the surgical site.
Advantages:
1. Possibility of horizontal incision crossing the osseous defect is eliminated.
2. Advantageous when treating short roots or defects in coronal 1/3 of the root.
3. The flap is easily repositioned.
4. The blood supply to the flap is maximal.
Disadvantages:
1. Vertical and horizontal incisions must be long to gain access to the apex of
long roots.
2. Slight gingival retraction occurs as a result of crestal bone resorption and
remodeling.
3. Suturing is difficult.
Figure 6: showing Single Vertical Flap
82
2. Double Vertical Flap:

- Also called trapezoidal, rectangular or modified intra-sulcular flap.
- It is similar to the single vertical flap but a second tissue relaxing vertical
incision is made at the terminal end of the horizontal leg of the triangular
flap, so a rectangular or trapezoidal flap is created (Figure 7).
Advantages:
1. Visibility is increased.
2. Access to the surgical site is improved.
3. Greater access for lateral root repairs.
4. Excellent for treating long roots.
Disadvantages:
1. Elevation is more difficult to initiate.
2. Gingival recession could occur.
3. Suturing is more difficult.
Figure 7: showing Double Vertical Flap
3. Mini-Vertical Flap:
- Short oblique incision to a proximal side of the apex of the involved tooth.
- Used in procedures such as trephination and minor curettage.
- Easy to suture, heals faster and with less scaring.
- It is contraindicated in large lesions or expanded visibility is needed.
83
 TISSUE REFLECTION
Flap reflection is the active movement of raising the soft tissue off the bone,
usually with periosteal elevator.
The surface of an efficient elevator has slight concavity or convexity at its
working end.
 TISSUE RETRACTION
Flap retraction is the holding in position of the reflected flap during surgery.
The edge of any tissue retractor must rest on bone and not impinge tissue of
the flap. The most common cause of post-surgical swelling and ecchymosis is
inadvertent crushing of the reflected flap by retractor(s) (Figure 8).
Figure 8: showing Tissue Retraction

84
B. HARD TISSUE MANAGEMENT (OSTEOTOMY)
- When the overlying bone is dense and intact, locating the target root and
lesion may pose problems.
- It is the best to approach the entry level by one of the following methods:
1. The tooth is measured in the radiograph, and then a sterile ruler is lined
up at the length alongside the long axis of the tooth to mark the root apex.
2. The measurement of the last file used for canal enlargement may be used.
3. Computing the length from a digitally produced image.
4. A small bony window is cut and a radiograph is taken with a broken-off
head of sterile bur, lead foil, silver point placed in the bony depression.
5. Sequential radiographs especially if the apex is far to the lingual.
6. The body of the root is located coronal to the apex where the facial bone
is thinner and the root is followed to the apical area.
7. CBCT.
Distinction between Bone and Root Tip Under the Microscope
Root Bone
Dark Yellow White
Hard Soft
- Bleeds when
Scrapped
Methylene
Blue Stain
85
Biological consideration:
- Heat generation during the process must be minimized.
- Healthy hard tissue must be preserved.
 Osteotomy should be as small as possible but as large as necessary to

accomplish the clinical objective (Figure 9).
 A lesion smaller than 5 mm would take on average 6.4 months to heal.
 A 6 to 10 mm size lesion takes 7.25 months.
 Larger than 10 mm requires 11 months to heal.
 The height of the buccal bone plate has a role in the healing outcome.
 Favorable prognosis when teeth are covered with a buccal bone plate that is
>3 mm in height regardless of the amount of marginal bone loss.
Figure 9: showing Osteotomy Size
3. CURETTAGE & BIOPSY
Curettage:
 To remove all pathologic tissue and bone particles from peri-radicular area.
Biopsy:
 To establish a definitive diagnosis.
86
4. LOCALIZED HEMOSTASIS
Topical hemostats or local hemostatic agents are useful adjuncts for hemostasis.
 Minimizes surgical time, surgical blood loss, and post-operative hemorrhage
and swelling.
 Enhances visibility and assessment of the root structure.
 Ensures the appropriate environment for placement of the current root-end
filling materials and minimizes root-end filling contamination.
 Requirements of Ideal Hemostatic Agents

1. Achieves hemostasis within a short period of time.
2. Biocompatible.
3. Does not impair or retard healing.
4. Reliable and works best for the particular surgical procedure.
5. Inexpensive.
 Local Hemostatic Agents
87
5. ROOT-END MANAGEMENT
A. ROOT-END RESECTION (APICOECTOMY)
 AIM:
- It removes the untreated apical portion of the root and enables the operator to
determine the cause of failure.
- Provides a flat surface to prepare a root-end cavity and pack it with root-end
filling material.
 How Much Should Be Resected?

 At least 3 mm of the root-end must be removed to reduce 98% of the apical
ramifications and 93% of the lateral canals (Figure 10).
Figure 10: showing Amount of Root Section

 BEVEL:
 A Bevel Of 45º:
- It was first recommended to improve visibility and accessibility.
 Zero Bevel Approach is now recommended (90º):
- From a biologic perspective, the most appropriate angle of root-end resection
is perpendicular to the long axis of the tooth.
o It gives more depth of retro-filling.
o Less exposed dentinal tubules.
o Less leakage.
88
Zero Bevel (90º) A Bevel Of 45º

Buccal Plate Minimal Loss Greater Loss
Dentinal Tubules Exposure Less More
Root-End Preparation Size Small Large
Root-End Preparation Shape Round Oval
(More Retention) (Non-Retentive)
Root-End Preparation Margin Less Leakage More Leakage
Regeneration Chance High Low
Force on Attachment Apparatus Less More
B. ROOT-END CAVITY PREPARATION
 Aim
 Remove the intra-canal filling material and irritants.
 Create a cavity that can be properly filled.
 Size
 Ideal preparation is a class I cavity prepared along the long axis of the tooth
to a depth of at least 3 mm with walls parallel to and coincident with the
anatomic outline of the root canal (Figure 11).
Figure 11: showing Root-End Cavity Preparation
89
 ISTHMUS
A narrow strip of land connecting two larger land masses or a narrow
anatomic part or passage connecting two larger structures or cavities.
 Incidence:
 90% of mesio-buccal roots of maxillary first molars.
 30% of the maxillary and mandibular premolars.
 Over 80% of the mesial roots of the mandibular first molars.
 Management:
 Complete isthmus is easily prepared with ultrasonics.
 Incomplete isthmus should be easily prepared with thin ultrasonic tips so
that the cavity and the isthmus should be prepared to a depth of 3mm.
 Old Classic Cavities:

a) Class I or Design I:
- Small enlargement of the canal using micro-head contra-angle with round
bur having a depth of 2-3 mm in the center of the root. Then inverted cone
bur is used to make undercut.
b) Class II, Design II or Slot Preparation:

- It was recommended when access is limited (mandibular region).
- The canal is prepared to a vertical length of 3-5 mm with a bur in straight
hand piece.
c) Class III or Design III:

- A hole drilled extending from the labial surface of the root perpendicular to
the long axis reaching the root canal. Undercuts are made at the end of the
cavity then filled.
- Finally, the root apex is resected to the level of filling.
Conventional Bur Root-End Preparation
90
Limitations:
1. Leads to loss of bone and/or root length.
2. Unnecessarily increasing the dimensions of the retro canal material – bone
interface.
3. The angle severity of root bevel exposes excessive dentinal tubules to
leakage.
4. Necrotic isthmus tissue cannot be removed
 Recent Cavities:
Ultrasonic Root-end Preparation

 Advantages:
 Superior operator control.
 Decreased risk of perforation.
 Ultrasonics tips also made cleaner and deeper root-end cavity preparations,
aiding retention of the root-end filling material and disinfection by removing
infected dentin.
 Limitations:
 Crack formation in the walls of the cavity, which may increase the chance of
apical leakage.
 Micro-fractures when using the tips at higher power settings.
 Root Surface Conditioning

 It removes the smear layer and provides a surface conducive to mechanical
adhesion and cellular mechanisms for growth and attachment.
 Three solutions have been advocated for root surface modification: citric
acid, tetracycline and EDTA.
91
C. ROOT-END FILLING
 ROOT END FILLING MATERIALS

The purpose of a root end filling is to:
1. Hermetically seal the resected root end.
2. Effectively trapping any remaining irritant within the canal system and
thereby preventing their ingress into the periodontal ligament space.
3. Successful sealing in turn promotes a cementogenic repair of the root end,
the most critical step in dento-alveolar wound healing.
Requirement of an ideal root end filling material:

1. Ease of manipulation with ample working time.
2. Easily placed & easily removed if necessary.
3. Have dimensional stability; not to shrink after being inserted.
4. Provide hermetically seal.
5. Biocompatible and promote cemento-genesis the most critical step in dento-
alveolar wound healing (cementum deposition with Sharpey’s fibers formed
in contact with restoration).
6. Non carcinogenic.
7. Unaffected by moisture.
8. Radiopaque or easily discernible on radiographs.
9. Not discolor tooth structure or the surrounding tissues.
Types:
- MTA
- Biodentine
See Chapter "Vital Pulp Therapy"
92
TRADITIONAL AND MICROSURGICAL TECHNIQUES
The Triad of Surgery:

- Magnification
- Illumination
- Micro-Instruments
THE OPERATING MICROSCOPE
Why is it Essential for Microsurgery?

1. Small but important anatomical details can be identified and managed.
2. Integrity of the root can be examined with great precision.
3. Removal of diseased tissues is precise and complete.
4. Distinction between the bone and root tip.
5. Osteotomy can be made small (3-4 mm) and these results in faster healing.
6. Occupational and physical stress is reduced.
7. The number of radiographs may be reduced or may be eliminated.
8. Video recordings of procedures can be used for education of students.
9. Communication with the referring dentists is improved significantly.
93
III. CORRECTIVE SURGERY

Corrective surgery is categorized as surgery involving the correction of
defects in the body of the root other than the apex.
When the coronal and middle thirds of the root are involved, it is imperative
to physically observe, diagnose and repair the defect.
A full flap, such as the single or double vertical design, must be utilized to
gain adequate vision and access.
1. PERFORATION REPAIR
A. MECHANICAL:
Mid-root and apical third perforations should be immediately sealed if
possible, or calcium hydroxide should be used prior to sealing.
If the perforation is excessively large or long standing, a full vertical flap
should be reflected and the area repaired with super EBA.
If the location of the perforation is near the root apex, an apicectomy is a
more effective and efficient way of handling the case.
B. RESORPTIVE:
Eventual repair of a defect on root surface, from either internal or external
resorption, depends on whether there is a complete communication from the
pulp to the oral cavity.
- If the lesion has destroyed an area of the root into the periodontal
structures, but has not communicated with the oral cavity,
 Placing calcium hydroxide into the prepared root canal to promote
cemento-genesis.
- In the event, cemento-genesis and new bone formation do not occur, Or
In the event, the lesion has broken through to communicate with the oral
cavity and will not respond to cemento-genesis,
94
 Corrective surgery is indicated.

- If the clinician is unsure about the lesion, a flap should be raised to inspect
the defect.
 Circular or scalloped flaps are seldom used in corrective surgery, for the
full length of a root must be inspected.
 If the lesion is near the gingiva, a single vertical flap may be used.
 A double vertical flap must be used if the defect extends to or beyond the
apex.
2. PERIODONTAL REPAIR
ROOT AMPUTATION
Root amputation procedures are a logical way to eliminate a weak, diseased
root to allow the stronger to survive, whereas if retained together they would
collectively fail.
Selected root removal allows improved access for home care and plaque
control with resultant bone formation and reduced pocket depth.
Indications for Root Amputation:
1. Existence of periodontal bone loss to the extent that periodontal therapy and
patient maintenance do not sufficiently improve the condition.
2. Destruction of a root through resorptive process, caries or perforations.
3. Surgically inoperable roots that are calcified, contain broken instruments or
grossly curved.
4. The fracture of one root that does not involve another.
Contra-indications for Root Amputation:
1. Teeth not strategically located. These teeth are better served with a bridge.
2. Lack of osseous support for the remaining roots or poor crown/root ratio.
3. Fused roots, endodontically inoperable roots.
4. Lack of patient motivation.
95
Different approaches to resection are available:
A. ROOT RESECTION
To amputate horizontally or obliquely the involved root at the point where it
joins the crown (Figure 12).
Figure 12: showing Root Resection
B. HEMI-SECTIONING
To cut vertically the entire tooth in half from mesial to distal in upper molars
and premolars and from buccal to lingual in mandibular molars, removing in
either case the pathologic root (Figure 13).
Figure 13: showing Hemi-sectioning
96
C. BISECTION or BI-CUSPIDIZATION
A division of the crown that leaves the two halves yet forms a more favorable
position for the remaining segments that leaves them easier to clean and
maintain.
If the remaining roots are too close to each other, minor orthodontic
movement may be necessary to properly align them.
This procedure is successful in molars in which periodontal disease has
invaded the bifurcation.
The type of cut is the same as that used in hemisection, except the location is
centered to evenly divide the crown at the center of the furcation.
Single root amputation in mandibular arch is indicated where splint or bridge
is in place. However, uneven exertion of occlusal forces tends on the
remaining root, causing a fracture (Figure 14).
Figure 14: showing Bicuspidization

97
IV. REPLACEMENT SURGERY
1. REPLANT SURGERY
A. INTENTIONAL REPLANTATION
Indications:
- Inability to perform adequate non-surgical root canal therapy on a tooth as
well as on the inadvisability of performing endodontic surgery.
- The following conditions are examples:
a) Some teeth requiring root canal therapy are absolutely inoperable in situ:
1. Mouths with a small orifice that instrumentation are impossible.
2. Obstructed canals from calcification, posts or separated instruments.
3. Because of an oversized external oblique ridge that blocks safe access.
b) Perforations or lateral aberrations that repair in situ are impossible.
Steps of Intentional Replantation:
1. The tooth should be extracted as atruamatically as possible and received in a
sterile gauze sponge saturated with normal saline solution.
2. Standard access is made to the pulp chamber and the canals are prepared and
filled; the coronal access sealed in hand as carefully as in situ.
3. Apicectomy, prior to retro-filling, is done to reduce hydrostatic pressure
during replacement.
4. Preparations in teeth with perforation or resorptive defects are similarly
done. Root canal filling should be completed before the repair of defects.
5. Before replantation, the alveolus should be curetted and irrigated with saline
to remove the clot, being careful not to detach viable periodontal ligament.
6. The tooth is replanted and stabilized with a splint in necessary.
Problems:
1) Impossibility of extraction without compression pressure to periodontium.
2) Crown fractures during extraction & Root fracture of multi-rooted tooth.
3) External Resorption.
98
B. POST-TRAUMATIC REPLANTATION
An avulsed tooth is a true dental emergency that needs replantation to save
the tooth.
See chapter "Traumatic Injuries".
2. ENDOSTEAL IMPLANT SURGERY
A. ENDODONTIC IMPLANTS
It makes great sense that, if a rigid implant can safely extend out the apex of
the tooth into sound bone, and by so doing stabilize a tooth with weakened
support, the patient is well served and perhaps has avoided a fixed bridge.
Indications:
1) Increasing the crown / root ratio by embedding a metallic implant extending
through the root canal and periapical area into osseous structure.
2) To add for stabilizing a periodontally involved tooth.
3) If extraction & replacement of periodontal involved tooth necessitate
restorative effort.
4) Incomplete chisel or horizontal fracture in the middle third of the root.
5) When it is necessary to have additional root length to serve as satisfactory
bridge abutment.
Problems:
- Placing endodontic implants is a technique sensitive operation.
- Fractured roots.
B. OSSEO-INTEGRATED IMPLANTS
- Branemark, in 1985 defined osseo-integrated implants as “the direct
structural and functional connection between ordered, living bone and
surface of a load carrying implant”.
99
References
 Rotstein I, Ingle J: Ingles Endodontics, seventh edition, 2019.

 Hargreaves K, Berman L: Cohens Pathways of the pulp, Eleventh edition,
2016.
100
ENDODONTIC PERIODONTAL
LESIONS
101
Endodontic Periodontal Lesions
Objectives
 Communication Between Pulp and Periodontium.

 Pathogenesis (Influence of Pulpal Pathologic Condition On the
Periodontium, Influence of Periodontal Inflammation On the Pulp).
 Classification of Endodontic – Periodontic Diseases (Primary Endodontic
Lesions, Primary Endodontic Lesion with Secondary Periodontal Lesion,
Primary Periodontal Lesion, Primary Periodontal Lesion with Secondary
Endodontic Lesion, True Combined Lesions).
 Differential Diagnosis.
 Treatment Alternatives for Endodontic / Periodontic Pathosis
102
Inter-communication between pulpal and periodontal tissues is quite

established through different communicating channels. This close relation
between these two tissues provides a great chance for the trading of different
pathological conditions.
Communication Between Pulp and Periodontium:
Channels between pulp and periodontium do exist some of which are
natural while others are pathological or iatrogenic. These channels include:
1- Apical Foramen:
This is considered the most direct route of communication between the pulp and
periodontium.
2- Accessory Canals:
Different studies have demonstrated the presence of accessory canals in
permanent dentition. Accessory canals can be present along the whole length of
the root canals; however, the apical third and the furcation areas are the most
frequent sites.
3- Dentinal Tubules:
Exposed dentin due to malunion between enamel and cementum (10%) can
result in patent dentinal tubules, which are another source for communication.
4- Palato-Gingival Groove:
This is a developmental anomaly that occurs mostly in upper lateral incisors
causing a longitudinal defect along the whole length of the root communicating
the pulp and the periodontium.
5- Perforations:
Iatrogenic problems as root perforations result in an artificial communication
between the pulp and the periodontium.
6- Vertical Root Fracture:
Excessive condensation forces during root canal obturation, overzealous canal
instrumentation or wedging action of posts are considered the most common
causes for vertical root fracture.
103
Pathogenesis
Influence of Pulpal Pathologic Condition on the Periodontium

Pulpal degeneration results in necrotic debris, bacterial byproducts, and
other toxic irritants that can move toward apical foramen causing periodontal
tissue destruction apically then migrating toward the gingival margin;
"retrograde periodontitis". This term is differentiated from "marginal
periodontitis" in which the disease proceeds from the gingival margin towards
the root apex.
The unresolved pulpal infections can result in egress of infections
products into the periodontium via the apex and accessory canals. These
infections products may aggravate periodontal pocket formation, bone loss and
impair wound healing which in turn accelerate periodontal disease progression.
Medicaments used for root canal therapy (e.g. calcium hydroxide,
corticosteroids and antibiotics) can also irritate the periodontal attachment
apparatus. However, it has been agreed that periodontal disease with pulpal
origin should heal with proper endodontic treatment.
Influence of Periodontal Inflammation on the Pulp

Periodontal disease and periodontal treatments could be regarded as
potential causes of pulpitis and pulpal necrosis.
Clinically, it is common to observe advanced periodontitis spreading to
the apical foramen and causing pulpal necrosis. In addition, bacterial products
and toxins may also gain access to the pulp via exposed dentinal tubules. Thus
the presence of an intact cementum layer is important for the protection of the
pulp.
The type of periodontal treatment such as scaling and root planning and
administration of medication may damage the blood vessels supplying the pulp
via accessory canals as well as they may affect the root cementum.
104
It has been reported that pulps of teeth with long standing periodontal
disease develop fibrosis. Varying forms of mineralization and the root canals
become narrower than canals of non periodontally involved teeth. These are
considered to be a reparative process than an inflammatory response. It is rare
that a periodontal disease affects the vitality of the pulp except if the blood
supply through the apical foramen was jeopardized.
Classification of Endodontic – Periodontal Diseases:
I- Primary Endodontic Lesions:

Pathological conditions of the pulp of bacterial origin can invade the
periodontium through the apical foramen or accessory canals resulting in
clinical condition that can be misdiagnosed as a periodontal pathosis.
Diagnosis:
1- Non vital pulp.
2- Presence of clinical etiology for pulpal affection.
Treatment: Conventional root canal treatment
II- Primary Endodontic Lesion with Secondary Periodontal Lesion:

Long standing pulpally affected teeth will cause bacterial invasion of the
periodontium causing breakdown of the hard and soft tissues causing localized
periodontal lesion.
Diagnosis:
1- Non- vital pulp.
2- Presence of clinical etiology for pulpal affection
3- Localized periodontal affection:
a) Localized plaque and calculus accumulation.
b) Localized bone loss
c) Localized migration of epithelium attachment
Treatment: Both endodontic and periodontal treatment
105
III- Primary Periodontal Lesion:
Periodontal pathosis can cause longitudinal bone loss along the external
surface of roots in the offended quadrant, which can be misdiagnosed as
endodontic pathosis.
Diagnosis:
1- Pulp is vital
2- Absence of clinical etiology of pulp affection
3- Generalized periodontal affection
a) Generalized plaque and calculus accumulation.  
b) Generalized bone loss  
c) Generalized migration of epithelium attachment

Treatment: Periodontal treatment
IV- Primary Periodontal Lesion with Secondary Endodontic Lesion:
Prolonged periodontal pathosis can permit bacteria or bacterial

byproducts to invade the pulpal tissues starting a sequence of pulpal pathosis.
Diagnosis:
1- Pulpal affection (vital inflamed / non-vital)
2- Absence of clinical etiology for pulpal affection
3- Generalized periodontal affection.
a) Generalized plaque and calculus accumulation.
b) Generalized bone loss.
c) Generalized migration of epithelium attachment.
Treatment: Endodontic and periodontal therapy.
106
V- True Combined Lesions:
In this case both of the periodontal and endodontic lesions exist

separately in and around the same tooth.
Diagnosis:
1- Non vital pulp.
2- Presence of clinical etiology for pulpal affection.

3- Generalized periodontal affection
a) Generalized plaque and calculus accumulation.
b) Generalized bone loss.
c) Generalized migration of epithelium attachment.
Treatment: Both of endodontic and periodontic therapies are indicated
Differential Diagnosis:
Pain, swelling, sinus tract, pulp testing, Radiographic examination and
diagnostic flap & Lighting and magnification.
Pain:
Periodontal disease in the acute phase may be accompanied by moderate
degree of pain. Pain of endodontic origin is usually more severe.
Swelling:
In teeth with pulpal involvement the swelling is seen apical to the muco-
gingival junction in alveolar mucosa.
In periodontal abscess formation the swelling tends to be within the zone
of the attached gingiva, often close to the gingival margin. Swelling of the face
may occur with endodontic involvement.
107
Sinus Tract:
Where a sinus tract opens into the gingival sulcus or at muco-gingival
junction, the origin of the lesion can be determined by the insertion of Gutta-
percha point.
The Gutta-percha point has the advantage that being pliable, it can follow
a tortuous pocket around the root of the tooth Sinus tracts of endodontic origin
are narrow periodontal lesion tend to be more broad based.
Pulp Testing:
The problem with vitality test especially with heavy restored teeth and
teeth with sever attrition.
Occasionally false positive responses may be obtained due to the
transmission of electric current to the periodontal ligament. Also confusion may
also occur where the vitalities differ between the roots of the molar tooth.
Radiographic Examination:
Long cone radiographs are essential for good diagnosis. Sinus tract is not
visible on radiographs and a radiopaque marker, such as a gutta-percha point,
can be used to establish the origin of the lesion. It is also important to look at
the radiographic evidence from other parts of the mouth. Sever bone loss one
tooth or all around teeth.
Root fractures present a severe problem in a radiographic diagnosis
hairline defects are nor visible unless the fractured parts are displaced.
Diagnostic Flap Surgery:

Some authors in case of root fracture is suspected and impossible to
establish diagnosis, they recommend flap procedure to expose the root and
demonstrate the presence of fracture.
108
Lighting and Magnification:

The use of fiber optic light source together with x 2 magnification
binocular loops will often provide valuable information when examining and
treating furcation areas and in searching for root fracture and perforation.
Furcation Involvement:
Progressive periodontal disease leading to exposure of a furcation region
of posterior teeth. Destruction of the furcation attachment may also occur
following spread of pulpal inflammation, as a result of tooth fracture or the
consequence of poor restorative dentistry.
Treatment Alternatives for Endodontic / Periodontic Pathosis
Management of any of the different endo/ perio lesions involves

endodontic and or periodontal treatment. However, advanced conditions may
require in addition to the classic treatment another alternative treatment
modality.
These alternative approaches include:

1. Resective Approaches:
This includes: Root resection, Hemisection, and Bicuspidization
2. Regenerative Approaches: 
This includes all types of guided tissue regeneration.
109
References
  Ingle J, Himel V, Hawrish C, Glickman G, Buchanan S.,editors:

edition,   2002.

 Gutman J, Dumsha T, Lovdal P, editors: Problem solving in endodontics,
fourth edition, 2006.  
110
ENDODONTIC OUTCOME
111
Endodontic Outcome
Objectives
 Recognize The Primary Factors Influencing Endodontic Success and Failure.

 Identify The Criteria for Successful Endodontic Treatment.
 Pre-Operative Causes of Endodontic Failures.
 Operative Causes of Endodontic Failures.
 Post-Operative Causes of Endodontic Failures.
112
Endodontic Outcome
When a clinician is involved in treatment planning with a patient, one of

the questions that must be answered: What is the success rate of root canal
therapy?
If a decision is made to save a natural tooth by performing root canal
therapy, a patient has the right to know the prognosis of the proposed treatments
to make an informed decision.
‘Prognosis’ is the forecast of the course of a disease. In the context of
apical periodontitis, therefore, this term applies to both the time course and
chances of healing.
Success Rate of Primary Endodontic Treatment
This rate is about 95% which is high enough, provided that there are no
periapical lesions associated with the treated tooth.
Evaluation Periods After Treatment to Designate It as Successful
A recall follow-up after 3months then 6 months, then yearly for five
years is mandatory. Clinical and radiographic follow ups are done through-out
these five years. However, unfortunately apparent success may revert to failure
at a later time as a result of coronal leakage.
Criteria for A Successful Endodontic Treatment
A. Clinical Criteria
B. Radiographic Criteria
113
Endodontic Outcome
A. Clinical Criteria:
1. No tenderness to percussion or palpation.

2. Normal mobility.
3. No sinus tracts or associated periodontal disease.
4. Tooth in function.
5. No signs of infection or swelling.
6. No evidence of subjective discomfort.
Presence of Persistent signs (swelling – sinus tract) or symptoms
(spontaneous pain –dull continuous ache- mastication sensitivity) is usually an
indication of disease and of failure, However the absence of symptoms doesn't
portray success.
B. Radiographic Criteria:
1. Normal periodontal ligament space or slight widening (less than 1mm).

2. Elimination or a decrease in the size of a previous periapical lesion (apical
bone resorption) and non-development of a new one.
3. No evidence of root resorption.
4. Dense obturation of the root canal space.
A Radiographically questionable status: indicates the status of
uncertainty, in which a radiolucent lesion has neither become larger nor
significantly decrease in size, with a possibility of healing by fibrous tissue
rather than bony tissue.
Nowadays, CBCT, cone beam computed tomography renders
radiographic examination more accurate with minimal distortion, reproducible,
devoid of anatomic superimposition and with the ability to show multiple
sections of the tooth and lesions that are not readily apparent on normal
radiography.
114
Endodontic Outcome
Causes of Endodontic Failures
The causes of failure are classified into three phases: pre-operative,

operative and post-operative.
I. Pre-Operative Causes:
Failure of root canal treatment is often traced to misdiagnosis, errors in
treatment planning and poor case selection.
A. Failures Caused by Incorrect Diagnosis:

Diagnosis should rely on a combination of tests rather than a single test.
- Incorrect diagnosis of Periapical Lesions:

Non-inflammatory periapical cysts or tumors may often resemble
periapical lesions of endodontic (pulpal) origin. Misinterpretation of anatomic
landmarks; e.g. Mental foramen – Incisive canal as being lesions.
- Incorrect diagnosis of Pulpal Pain:

Pulpal pain can usually be diagnosed best with a thermal stimulus (cold or hot).
Abnormal responses can be in the form of:

- Pain is made worse but disappears immediately after the stimulus is
removed.
- Pain is made worse by the application of the stimulus and lingers.
- Tooth is asymptomatic but elicits pain when stimulated and the pain
continues after the stimulus is removed (lingering pain).
It is important to note that pulpal pain of a specific tooth is sometimes referred
to other teeth which might result in misdiagnosis by the clinician.
115
Endodontic Outcome
B. Failures Caused by Pre-Operative Case Selection & Treatment

Planning:
Case selection determines the feasibility and practicality of treatment.
Failures may result due to a number of reasons:
i) Non-restorable teeth being treated.
ii) Failure due to anatomic variation.
iii) Failure due to altered canal space.
i) Non-Restorable Teeth:
- Some teeth may be non-restorable and extraction would be a more viable
option.
ii) Failures Caused by Anatomic Variations:

- Pre-operative failure to notice the presence of “extra roots and canals”
prior to preparation: Extra canals are usually found in mandibular
incisors, mandibular premolars, mesio-buccal roots of maxillary first
molars, distal roots of mandibular molars and accessory apical canals.
- Dilacerated and S-curved canals: Roots with severe curvatures are
difficult to correctly clean and / shape. A specialist is usually needed in
these circumstances.
iii) Failures Caused by Altered Canal Space:
- Calcifications
Calcifications that alter the root canal space can make canal cleaning,
shaping and obturation difficult. Developmental diseases such as
dentinogenesis imperfecta can cause a constriction of the existing space
with secondary dentin.
116
Endodontic Outcome
- Internal Resorption:
Internal resorption is a highly destructive form of inflammatory response
by the pulp to injury. It is usually asymptomatic until the root has been
perforated. Early diagnosis (which can be made only with a radiograph)
may prevent lateral perforation of the root or crown. Complete
extirpation of the pulp is necessary to arrest further resorption of dentin.
- External Resorption:
It may alter the canal space by perforating the root or destroying the
natural canal constriction at the apex. Root end resorption usually
produces a cup-shaped crater. When the resorption involves the apical
foramen of the tooth, the canal constriction is destroyed and proper filling
is then difficult. An apical seat is difficult to be created, over-extension of
the filling may result. Such canals should be cleaned and shaped short of
the radiographic apex.
II. Operative Causes:
Errors During Different Treatment Phases:
A. During Access Cavity Preparation:
1) Perforations:
The most common causes of failures related to access preparations are
furcation perforations which may result from over extension apically by the bur
after dropping in the pulp chamber space. Also being misaligned from the long
axis of the tooth may result in a perforation.
117
Endodontic Outcome
 Prevention:
Pre-operative radiographic assessment for the size, location and
angulation of the pulp chamber. From previous knowledge that the pulp
chamber is always located in the center of the tooth at the cemento-enamel
junction. Avoid apical motion by the bur after dropping in the pulp chamber i.e:
move horizontally.
2) Under-extended Cavity:
Under-extended access cavities do not necessarily lead to failure of
treatment, but they certainly complicate therapy.
- Discoloration and infection: The most common problems are failure to
remove the pulpal tissue in the pulp horns and under the dentine roof,
resulting in coronal discoloration or continual contamination of the canal by
bacteria.
- Missed canals: The prevalence of additional canals in certain roots has been
well demonstrated. Without adequate visual access to the pulp chamber,
additional canals can easily be missed and failure results.
3) Over-extended Preparation:
Overextended preparations are generally not as disastrous as under-
extended preparations however; they can severely weaken the clinical crown.
4) Treating the Wrong Tooth:

Performing an access cavity in a wrong tooth for example if the rubber
dam is placed on another tooth as lower incisors.
118
B. During Canal Preparation:
1) Length Determination:
Of primary significance is the principle of locating all canals and
determining their length and curvatures. Failure to properly measure the actual
working length will result in the inability to properly clean and shape (disinfect)
the canal.
2) Separated Instruments:
From time to time, even the most careful clinician will have an
endodontic instrument fracture during root canal preparation. For this reason,
the endodontist refers to a fractured root canal file as a separated instrument.
Prognosis for Teeth with Separated Instruments:

The prognosis for teeth with separated instruments depends on several factors:
- The Pulp Vitality
- Level of File Fracture
- Degree of Canal Cleaning Before Fracture.
3) Over Flaring & Over Instrumentation:
- Excessive over-shaping of the canal leads to weakening of the tooth root and
even fracture of that root can occur (vertical root fracture).
- Over-flaring of the canal can cause stripping perforations particularly in
mandibular molars in the dangerous zone and maxillary premolars.
- Apical over-instrumentation mainly results from a wrong working length
determination with the consequential problem of loss of the apical stop and
periapical inflammation.
119
4) Ledge Formation:
This can result from:

- Introducing large inflexible files in curved canals.
- Failure to coronally flare the canal to allow direct straight access to the
apical canal one third.
- Failure to create a glide path in the canal before attempting to shape the
canal
5) Perforations:
Iatrogenic perforations may be classified based on location into cervical,

mid root and apical perforations.
Perforations may be caused by:
- Starting a ledge by the file and then drilling out through the side of the root.
- Creating a cervical strip perforation due to over-enlarging the dangerous
zone of the root.
- Perforating the apical foramen and enlarging it due to wrong working length
measurement.
- Inability to overcome a blocked canal by a file, with that file perforating the
canal wall next to the block.
6) Canal Blockage:
When a canal suddenly does not permit a working file to be advanced to

the apical stop, a situation sometimes referred to as a “block” has occurred.
Blockage occurs when:
- Files compact apical debris into a hardened mass.
- Vital pulp tissue is compacted and solidified against the apical constriction.
120
C. During Obturation
1) Under Extension:
Fillings that are short of the apical foramen fail for several reasons.
 If the canal wasn’t cleaned short of the minor apical constriction and the
obturation is subsequently short too, remaining unremoved pulpal tissue
along with the microorganisms present in the canal will result in periapical
infection.
 If the canal was originally cleaned but incompletely filled (short obturation),
tissue fluid break-down by bacteria from that empty space along with
bacterial enzymes will extrude by time through the apex and result in a
chronic periapical lesion.
2) Over-Extension:
Gutta-percha by itself is tolerable by the body (periapical tissues),

however the mechanical irritation caused by the extruded part during
mastication by the occlusal forces on the tooth will result in apical
inflammation.
Also the extruded part of the GP could be inoculated by microorganisms
which would result in periapical inflammation.
III. Post-Operative Failure:
Failure can occur after completion of treatment despite reasonable root

canal treatment due to the following causes:
121
Etiology of Post-Treatment Disease
There are many causes for “failure” of initial endodontic therapy that
have been described in the endodontic literature.
These include iatrogenic procedural errors such as poor access cavity
design, untreated canals, canals that are poorly cleaned and obturated,
complications of instrumentation (ledges, perforations, or separated
instruments), and overextensions of root-filling materials.
Coronal leakage has also been blamed for post-treatment disease, as has
persistent intra-canal and extra canal infection and radicular cysts.
The most important causative factors for the clinician, however, are those
related to treatment planning and determination of prognosis.
To treatment plan effectively, the clinician may place the etiologic factors into
four groups (Figure 1):
1. Persistent or re-introduced intra-radicular microorganisms
2. Extra-radicular infection
3. Foreign body reaction
4. True cysts
Figure 1: The Causes of Post-Treatment Disease. (1) Intra-Radicular

Microorganisms. (2) Extra-Radicular Infection. (3) Foreign Body Reaction.
(4) True Cysts
122
1) Persistent or Re-introduced Intra-Radicular Microorganisms:
When the root canal space and dentinal tubules are contaminated with
microorganisms or their by-products and if these pathogens are allowed to
contact the peri-radicular tissues, apical periodontitis ensues.
As stated earlier, inadequate cleaning, shaping, obturation, and final
restoration of an endodontically diseased tooth can lead to post-treatment
disease.
If initial endodontic therapy does not render the canal space free of
bacteria, if the obturation does not adequately entomb those that may remain, or
if new microorganisms are allowed to reenter the cleaned and sealed canal
space, then post-treatment disease can and usually does occur.
In fact, it has been asserted that persistent or re-introduced
microorganisms are the major cause of post-treatment disease. While infected
root canals of endodontically untreated teeth generally contain a polymicrobial,
predominantly anaerobic flora, cultures of infected, previously root filled teeth
produce very few or even a single species.
The infecting flora are predominantly gram positive, not anaerobic, and a
commonly isolated species is Entero- coccus faecalis, which has been shown to
be resistant to canal disinfection regimens.
Interestingly, if the previous root canal treatment is done so poorly that
the canal space contains no obturating material in the apical half of the root
canal space, its flora is more typical of the untreated necrotic infected pulp than
that of classic “failed” root canal therapy. Though post-treatment disease has
been primarily blamed on bacteria in the root canal system, certain fungi,
notably Candida albicans, are found frequently in persistent endodontic
infections and may be responsible for the recalcitrant lesion.
123
2) Extra-Radicular Infection
Occasionally bacterial cells can invade the peri-radicular tissues either by
direct spread of infection from the root canal space via contaminated
periodontal pockets that communicate with the apical area, extrusion of infected
dentin chips, or by contamination with overextended, infected endodontic
instruments.
Usually, the host response will destroy these organisms, but some
microorganisms are able to resist the immune defenses and persist in the peri-
radicular tissues, sometimes by producing an extracellular matrix or protective
plaque. It has also been shown that two species of microorganisms,
Actinomyces Israeli and Propionibacterium propionicum, can exist in the
periapical tissues and may prevent healing after root canal therapy.
3) Foreign Body Reaction

Occasionally, persistent endodontic disease occurs in the absence of
discernible microorganisms and has been attributed to the presence of foreign
material in the peri-radicular area. Several materials have been associated with
inflammatory responses, as cellulose fibers from paper points.
There has been much discussion about the effect of over-extended root
canal filling materials upon apical healing. Outcomes assessments generally
show that filling material extrusion (root filling flush to the radiographic apex
or gross overextension) leads to a lower incidence of healing. Many of these
cases involved not only overextension but also inadequate canal preparation and
compaction of the root filling whereby persistent bacteria remaining in the canal
space could leak out.
Gutta-percha and sealers are usually well tolerated by the apical tissues,
and if the tissues have not been inoculated with microorganisms by vigorous
over instrumentation, then healing in the presence of overextended filling
materials can still occur.
124
4) True Cysts
Cysts form in the peri-radicular tissues when nests of epithelial cells,
retained from tooth development, begin to proliferate due to the chronic
presence of inflammatory mediators. These epithelial cell rests of Malassez are
the source of the epithelium that lines cystic walls, and cyst formation may be
an attempt to help separate the inflammatory stimulus from the surrounding
bone.
The incidence of periapical cysts has been reported to be 15% to 42% of
all periapical lesions, and determining whether a periapical radiolucency is a
cyst or the more common periapical granuloma cannot be done with available
radiographic methods.
There are two types of periapical cysts: the periapical true cyst and the
periapical pocket cyst. True cysts have a contained cavity or lumen within a
continuous epithelial lining and are therefore isolated from the tooth, whereas
with pocket cysts, the lumen is open to the root canal of the affected tooth. True
cysts, due to their self-sustaining nature, probably do not heal following
nonsurgical endodontic therapy and usually require surgical enucleation.
When a patient present with post-treatment disease, clinical decision
making depends on determining the cause of the persistent disease and then
making an assessment of how best to treat the pathologic condition. The
following section presents a rationale and methods for performing endodontic
diagnosis that offer the greatest likelihood of a successful outcome.
125
References
 Cohen S, Hargreaves K, editors: Pathways of the pulp, Eleventh edition

2015.
 Walton & Torabinjad, editors: Principles and practices of endodontics, Fifth
edition, 2014.
 Ingle J, Himel V, Hawrish C, Glickman G, Buchanan S, editors: Ingle’s
Endodontics 6, sixth edition, 2008.
126
APPLICATION OF LASER
TECHNOLOGY IN ENDODONTICS
127
Application of Laser Technology in Endodontics
Objectives
 Basic Principles of Laser Physics.

 Different Wave Lengths of Light.
 Interaction of Laser with Matter.
 Currently Used Dental Lasers.
 Application of Laser in Endodontics.
128
INTRODUCTION
- Laser is an acronym for:

Light Amplification by Stimulated Emission of Radiation.
- Laser is the brightest mono-chromatic light existing today.
- After invention of laser it has found wide spread application in various fields
like communication, industry, defense, and medicine.
- Lasers are the single most important advancement in the field of
Endodontics and they changed the ways in which many procedures can be
done.
HISTORY
129
LASER PHYSICS
BASIC PRINCIPLES OF LASER
130
ELECTROMAGNETIC SPECTRUM
Types of Lasers:
 Based On Wave Length:
 Based on the Target Tissue Where They Are Effective
1. Soft Tissue Lasers

- Diode, CO2, Argon, Nd: YAG
2. Hard Tissue Lasers

- Er: YAG, Er,Cr: YSGG
131
Laser-Tissue Interaction
 Reflection
- It results in little or no absorption, so that there is no thermal effect on the
tissue.
 Transmission
- Light transfers energy through the tissue without any interaction and thus
does not cause any effect or injury.
 Dispersion
- When scattered, light travels in different directions and energy is absorbed
over a greater surface area, producing a less intense and less precise thermal
effect.
 Absorption
- When absorbed, light energy is converted into thermal energy.
132
Laser Effect On Tissues

1. Photo-Chemical Interaction
2. Photo-Thermal Interaction
3. Photo-Mechanical Interaction
4. Photo-Electrical Interaction
1. Photo-Chemical Interactions
Certain wave lengths of laser are absorbed by naturally occurring
chromophores and induce certain biochemical reactions.
- Bio-Stimulation:
It is a stimulatory effects of laser light on biochemical and molecular processes
that induce healing and repair of tissues.
- Photo-Dynamic Therapy:
It is the therapeutic use of lasers to induce reactions and produce biochemically
reactive form of oxygen. This oxygen disrupts the membrane of micro-
organisms.
2. Photo-Thermal Interactions
- Photo-ablation, or the removal of tissue by vaporization and super-heating of
tissue fluids.
- Coagulation and hemostasis.
- Photo-pyrolysis or the burning away of tissues.
Type of thermal reaction depends:

- Spot Size
- Power Density
- Pulse Duration
- Pulse Frequency
- Optical Properties and Composition of Irradiated Tissue.
133
3. Photo-Mechanical Interactions
Non-thermal interactions produced by high energy short pulsed laser light.
- Photo-Disruption:
Shock waves by laser that rupture the inter-molecular and atomic bonds.
- Photo-Disassociation:
Breaking structures apart.
- Photo-Acoustic Interactions:
Shock waves explode or pulverize the tissue, produces a crater.
4. Photo-Electrical Interactions
- Photo-Plasmolysis:
Tissue is removed through the formation of electrically charged ions and
particles that exist in a semi-gaseous, high-energy state.
ABSORPTION SCALE
134
CURRENT DENTAL LASERS
Diode Laser
Diode (940 nm) is deeply transmitted through dentin, therefore providing
a sufficient depth of penetration (1000 µm), prerequisite to the good bactericidal
effects.
135
Erbium Laser
Er,Cr:YSGG (2780 nm) is well absorbed in water and hydroxyapatite,
so that smear layer, organic material and infected root canal wall dentin can be
well removed showing open dentinal tubules.
136
LASER APPLICATION IN ENDODONTICS
The first use of laser in endodontics was reported by Weichman and

Johnson in 1971 who attempted to seal the apical foramen in vitro with a high
power carbon dioxide (CO2) laser.
1. PULP VITALITY:
Laser Doppler Flowmetry

- It is used to assess blood flow in microvascular systems (pulpal blood flow).
- The Doppler principle states that the light beam’s frequency will shift when
hitting moving red blood cells but will remain un-shifted as it passes through
static tissue.
- A diode is used to project an infrared light beam through the crown and pulp
chamber of a tooth. The infrared light beam is scattered as it passes through
the pulp tissue.
- Several studies have found LDF to be an accurate, reliable and reproducible
method of assessing pulpal blood flow.
- One of the great advantages of pulp testing with devices such as the LDF is
that the collected data are based on objective findings rather than subjective
patient responses.
- Certain luxation injuries will cause inaccuracies in the results of electric and
thermal pulp testing. LDF has been shown to be a great indicator for pulpal
vitality in these cases.
137
2. VITAL PULP THERAPY
Indirect Pulp Capping

- In cases of deep and hyper-sensitive cavities, a reduction in the permeability
of the dentin is achieved by sealing the dentinal tubules with no post-
operative pain.
Direct Pulp Capping

- Laser treatment causes direct stimulation of dentin formation and successful
pulp restoration after direct capping of inflamed pulps with laser irradiation.
3. ROOT CANAL DISINFECTION

Bacterial colonisation in root canal dentin was up to a depth of 1.100 µm.
However, chemo-mechanical enlargement only results in bacterial reduction up
to 100 µm depth.
Er,Cr: YSGG and Diode Lasers could be a valuable tool for root canal
disinfection during endodontic treatment due to:
- Antibacterial efficiency.
- Ability to remove Smear layer.
- Depth of penetration in dentinal tubules.
Lasers Application in Disinfection Varies from:

 Direct Irradiation
 Indirect Irradiation:
- Laser Activated Irrigation (LAI)
- Photon Induced Photoacoustic Streaming (PIPS)
- Photo-activated Disinfection (PAD)
138
 Laser-Activated Irrigation (LAI)

 It has been documented in several studies that CO2, Argon, Nd:YAG, Er:YAG
laser has the ability to remove smear layer and debris.
 A final application of the Er:YAG laser with EDTA after standardized
instrumentation can result in improved cleaning of the canal walls with a higher
quantity of open tubule .
 Photon Induced Photo-acoustic Streaming (PIPS™)

- PIPS™ uses an Erbium laser to pulse extremely low energy levels of laser
light to create turbulent photo-acoustic agitation of irrigants throughout the
entire root canal system.
- It pumps the tissue debris out of the canals while cleaning, disinfecting and
sterilizing each main canal, lateral canals, by activating the tip in the access
cavity and outside the root canal system. Thus eliminating the need to
enlarge and remove more tooth structure to deliver standard needle irrigation
to the more delicate apical anatomy, commonly seen in the apical one third.
- PIPS™ is not a thermal event, the extremely low energy needed to activate
the unique PIPS™ tip is below the threshold of ablation for dentin
139
 PHOTO-ACTIVATED DISINFECTION (PAD)

Photodynamic therapy (PDT) or light activated therapy: light
→activation Photo-sensitizer (toluidine blue dye, methylene blue dye, etc.) →
membrane damage of microorganisms. It is a two-step procedure.
The canal is filled with a photo-sensitizer and then illuminated with a
light source (laser, white light, red light, or light-emitting diode). The
photosensitizer molecule in its ground state is a spectroscopic singlet (S0). After
absorption of the photon, it passes from the ground state to its first excited state
(S1).
From this state, the photosensitizer can return again to the ground state or
it can pass into a triplet excited state (T1).
The photosensitizer in the triplet state is extremely reactive; it can then
react further by one or both of the following pathways to destroy the cell.
Type I reaction:
- The photosensitizer in the triplet state can react with a target other than
oxygen by hydrogen or electron transfer, resulting in radical ions that can
react with oxygen to yield cytotoxic species such as hydrogen peroxide,
superoxide anion, hydroxyl, and lipid-derived radicals.
Type II reaction:
- The photosensitizer in the triplet state can transfer the excitation energy to
ground-state molecular oxygen to produce excited-state singlet oxygen.
- Singlet oxygen is a strong oxidizing agent that lead to cell death.
- The two basic mechanisms that have been proposed to account for this lethal
damage to bacterial cells are DNA damage and cytoplasmic membrane
damage.
- Recently, PDT has focused on the use of polymer-based nanoparticles (Poly
lactic co- glycolic acid) for photosensitizer delivery.
140
Inactivation
4. ENDO-SURGERY
- Improved haemostasis & concurrent visualization of the operative field.
- Potential disinfection of the contaminated root apex.
- Potential reduction of the permeability of the root surface dentin.
- Sealing root defects.
- A reduced risk of surgical site contamination by eliminating the use of
aerosol producing air turbine hand pieces for apicoectomy.
- Retrograde cavity preparation.
- Potential reduction in post-operative pain.
141
References
 Bansode PV ET AL, Lasers in Endodontics – A review article, 2017.
142
MAGNIFICATION
IN ENDODONTICS
143
Magnification in Endodontics
Objectives
 Highlight Value of Magnification and Magnification Continuum.

 Classify Loupes and Identify Advantages, Disadvantages and Applications
of Each Type.
 Recognize The Different Parameters to Take into Consideration During
Loupe Selection.
 Identify Major Components of the Dental Operating Microscope
 Understand Value of Magnification in Ergonomics.
 Identify The Uses of Magnification in Endodontics.
144
Introduction
In clinical dentistry, the human skill and manual dexterity have great
significance. Visualizing the oral cavity has always been a challenging task for
the dentists. Earlier radiographs were the only way to see inside a root canal,
and tactile sensation was used to perform endodontic procedures. The American
Endodontist Dr. Syngcuk Kim, founder of modern microscopic dentistry,
famously said: “You can only treat what you see”. Undoubtedly, the clinician
can better evaluate and treat something, if he or she sees it more clearly and in
magnified form. Size of the image can be enhanced by getting closer to the
objects or by magnification. Currently, to improve the quality of treatment, the
endodontists have been trying to develop new technologies to achieve success.
Clinical procedure may be carried out successfully with the use of
magnification that ensures precision and, hence, increases the quality of work.
Presently, Loupes, Dental Operating Microscope, Orascope, Modular
Endoscope system (Micro-endoscope), Miniature endoscope systems are the
magnification devices used in dentistry.
DENTAL LOUPES
Loupes are not an invention. Magnifying loupes were innovated to

address the problem of proximity, decreased depth of field, and eyestrain
occasioned by moving closer to the subject. Normal range of loupe
magnification in dentistry is 2X to 6X. If magnification is beyond 5X, loupes
tend to become heavy and a microscope would be a better option.
145
Loupes Are Classified in to:
A. According to Their Different Optical Construction:
 Single Lens Loupes: (Figure 1)
Figure 1: Single Lens Loupes
Advantages and Disadvantages:

The only advantage is that it is the most inexpensive system; however, it
is less desirable because the plastic lenses that are used are not always optically
correct. Furthermore, the increased image size depends on the proximity with
the object being viewed, which can lead to postural problems and create stresses
and abnormalities in the musculoskeletal system. However, they cannot be
practically used in dentistry due to size and weight limitations.
 Galileian Lens Loupes: (Figure 2)
Figure 2: Galileian Lens Loupes
146

They are economical and simple to operate having only 2 or 3 lenses
makes these loupes lighter in weight. However, they create blurry peripheral
border of the visual field because of limited magnification (2.5- or 3.5- fold).
 Keplerian Loupes: (Figure 3)
Figure 3: Keplerian Loupes

Prism loupes provide broader fields of view, wider depths of field and
longer working distance. However, they are heavier and costlier due to
increased number of lenses.
B. Based On Design
 Flip-Up Loupes: (Figure 4)
Figure 5: Flip-Up Loupes
147
 Through the Lens Loupes (TTL): (Figure 5)
Figure 5: Through the Lens Loupes
Advantages of Loupes:
i. It does not acquire much space, as it is small.
ii. No formal training is required as it can be easily operated.
iii. Surgeon's position is not restricted.
iv. Neither are they expensive as a microscope is nor do they need higher
maintenance.
Disadvantages of Loupes:
i. It does not provide depth perceptions due to lack of Stereoscopic view.
ii. With loupes, magnification beyond 5x is uncomfortable on nose or head
due to their large size and increased weight. For higher magnification
microscope should be considered.
iii. Head movement makes image unstable.
iv. Illumination is less in comparison to microscope.
v. The operating field must be covered by clinician’s eyes: however,
eyestrain, fatigue and changes in vision can be experienced if poorly
fixed loupes are used for longer time.
vi. Accessories such as beam splitter, video camera, T.V camera or movie
camera cannot be attached to a loupe to capture the magnified field.
148
Ergonomic Criteria for Loupe Selection

Considering ergonomic guidelines is imperative when selecting loupes,
since poorly designed or poorly adjusted loupes can cause or worsen pain.
Three most significant ergonomic factors to consider when purchasing loupes:
1. Declination Angle:
The angle created by the eyes being downwardly inclined to the work
area is called declination angle.
To help operator to attain a comfortable working position with minimal
forward head posture the angle should be steep enough (less than 25°).
2. Working Distance:
The distance between the eyes and the work area is called working
distance. The working range is decreased in scopes with higher magnification.
It is essential to measure the working distance slightly longer than normal
to compensate for the natural tendency to drift closer to a working area as it
gives an operator a more flexible working range.
3. Frame Size/ Shape:

In comparison to smaller oval frames, large frames that sit low on the
cheek will allow lower placement of the TTL scope.
Dental Operating Microscope
The emergence of Endodontic operating microscope is the most

important development that took place in the field of endodontic. The
microscope not only provides better magnification from 3x up to 30x but also
better illumination.
149
The microscope through its enhanced vision has greatly contributed to

improved surgical as well as conventional endodontic treatment.
The introduction of the microscope includes numerous ergonomic
changes. Possible reduction in consequent stress for the operator can be ensured
by maintaining the traditional working positions previously used without the
microscope by the clinicians. The range of working positions is usually from the
9 o’clock to the 12 o’clock position.
The Operating Microscope Consists of Three Basic Components
1. The Supporting Structure:

It should be mounted on the floor, ceiling or wall to ensure stability of
microscope. Decrease in the distance between the fixation point and the body of
the microscope will increase the stability. The floor mount is preferable in
clinical settings with high ceiling or distant walls.
2. The Body of Microscope:

It is the most crucial element and consists of eyepieces, binoculars,
magnification change factor, and the objective lens.
a. Eyepiece:
Magnifying the image is the most important function of the operating
microscope. The power of eyepiece determines magnification. Eyepieces are
usually available in powers of 10x, 12.5x, 16x, and 20x. To adjust the
accommodation of lens of eyes, diopter settings should range from -5 to +5.
b. Binocular:
They are available with straight, inclined or inclinable tubes with
provision to hold the eyepieces.
150
c. Magnification Changer:
It is situated within head of the microscope and is available as 3, 5 or
6 step manual changer, or a power zoom changer.
d. Objective Lens:
It is the final optical element, and its focal length determines the
working distance between the microscope and the surgical field. The focal
length ranges from 100 mm to 400 mm. A 200 mm focal length permits
approximately 20 cm of working distance, which is generally appropriate for
utilization in endodontics. A layer of antireflective coating ensures
absorption of only a minimum amount of light in order maintain the
illumination of the operative field.
3. The Light Source:

It is one of the key features and responsible for working in operative
fields that are small and deep like the root canal. For natural color
representation, light with daylight temperature of between 5,000 and 6,000
kelvins is optimal. Halogen, Xenon or LED illumination are the commonly used
types of light source. Illumination and line of sight share the same axis, which
means that light is focused between the eyepieces so that no shadows will be
visible.
Advantages of Dental Operating Microscope

1) Increased visualization, and hence improved the quality and precision of
treatment.
2) Enhanced ergonomics.
3) Ease of proper digital documentation and; It contains integrated video,
which makes the communication skill better.
151
Disadvantages
1) It’s expensive.
2) It is difficult to fit in a small operation because of its size.
3) It takes the operator some time to get used to the equipment.
4) Need for expertise by auxiliary staff and adaptation is quite difficult.
5) It provides narrower field of vision.
6) Un-transferable.
Ergonomics (Figure 6)
152
Uses of Magnification in Endodontics
Implications of endodontic magnification devices can be categorized into

following areas:
1. Diagnosis:
By nature of the specialty, an endodontist should be a master
diagnostician. Any equipment or methodology that assists in diagnosis should
be appreciated. The use of magnification in cases such as cracked or vertically
fractured teeth has a tremendous help in visualizing how far these fracture lines
extend and where they end.
2. Non-Surgical Endodontics:
Magnification helps in conventional root canal treatment like preparing
and finishing the access cavity; shaping the root canal precisely; filling the
system completely in three dimensions. Another uses such as detection of root
canal orifice, location of missed canal, removal of fractured post and
instrument, perforation repair.
153
Magnification devices have more chances to detect MB2 canals in

comparison to naked eye. However, Operating Microscope has better outcome
than loupes in detecting MB2 canals. A combination of Operating Microscope
& ultrasonics is an effective method for removing fracture instrument than
conventional method.
3. Role of Magnification in Surgical Endodontics:

The introduction of the operating microscope and ultrasonic instruments
has taken endodontic surgery to another level of sophistication i.e., the
microsurgical approach. Magnification, illumination and instruments constitute
a microsurgical triad.
Apical surgery can now be performed with accuracy and predictability,
eliminating the guess factor inherent in a conventional endodontic surgery.
Using a microscope to perform endodontic surgery, the higher magnification
and illumination allow the operator to more easily distinguish between cutting
bone (whiter appearance) and cutting the root tip (more yellow), aid in complete
removal of granulomatous material, no or less than 10° bevel is given through
the microscope.
4. Documentation:
Another aspect of endodontic practice that is enhanced by the
magnification is documentation. Digital documentation capabilities enable the
clinician to efficiently capture and share with patients what is seen during an
examination pre-operatively, intra-operatively and post-operatively and stored
in patients’ chart.
This is especially useful when unforeseen problems are encountered. The
usage of documentation for medico-legal, insurance, patient communication,
and lecturing purposes, as well as for communication with staff or colleagues, is
also impressive.
154
5. Ergonomics:
It comes from the Greek words- ergon, which means work, and nomos,
which means correctness which means working correctly.
Magnification increases the image in order to see small object accurately.
Magnification reduces the eye fatigue and posture problems as well.
155
References
 Singla MG. et al. Magnification in Endodontics: A Review. Ind j cons

endod, 2018.
156
APPLICATION OF
NANOTECHNOLOGY IN
ENDODONTICS
157
Application of Nanotechnology in Endodontics
Objectives
 Update knowledge of nanotechnology terminology.

 Highlight characteristics of nanomaterial.
 Explore the idea about incorporation of nanotechnology in the medical
industry, with different methods of fabrication.
 Identify the applications of nanotechnology in endodontics
 Understand hazard related with the growing nanotechnology trend.
158
A. Introduction
Biomaterial:
A biomaterial is any matter, surface, or construct that interacts with
biological systems. Biological materials are discussed in terms of tissue
engineering and stem cell research and nanotechnologies.
Nanotechnology:
The term Nano is adapted from Greek word means: Dwarf (relating to
their extremely small size). These small scientific scales were first
revolutionized by Richard Feynman at his famous speech at the annual meeting
of the American Physical Society in 1959.
Nanometer (nm):
It is one billion (10-9) of a meter, or roughly the length of three atoms side
by side. DNA double-helix has a diameter around 2.5nm wide; a human hair is
approximately 10000 nm thick.
Nanoscience:
It is the study of phenomena and manipulation of materials at the
nanoscale (1-100 nanometers).
Nanotechnology:
It is also known as molecular engineering and sometimes shortened to
“nanotech”. It is the production of functional materials and structures in the
range of 1-100 nm. It involves the tailoring of materials at atomic level to attain
unique properties, which can be suitably manipulated for the desired
application.
B. Nanomaterials
Categorized according to their dimensions as (Figure 1):
1. All three dimensions less than 100nm, e.g. Nanoparticles.
2. Two dimensions less than 100nm, e.g. Nanofilms
3. One dimension less than 100nm, e.g. Nanorods
159
Figure 1: Categorization of Nanomaterials
What makes Nano special?

1. Quantum Effect:
At the NANOMETER SCALE, the properties of matter, like electrical
conductivity, color, strength or weight change. This is the consequence of the
small size of the nanomaterials, physically explained as Quantum effect. For
example, bulk of silver is nanotoxic, whereas nanosilver has antibacterial
properties.
2. Surface to Volume Ratio:

Nanomaterials have an increased surface to volume ratio compared to
bulk materials; this means that for a given volume of a material, the external
surface is greater if it’s made of nanomaterials sub-units than of a bulk material.
3. Nanoparticles possess an extremely Large Surface Free Energy:

It affects its chemical reactivity and increased production of reactive
oxygen species (ROS) that have potent antimicrobial effect. Also, cause the
nanoparticles to agglomerate to form either clusters or larger particles to
minimize the total surface or interfacial energy of the system.
160
Nanotechnology in Medical Science

Nanometer-sized particles are in the same range of dimension as
antibodies, membrane receptors, nucleic acids and proteins, among other
biomolecules. These biomimetic features, together with their high surface to
volume ratio, make nanoparticles powerful tools for imaging, diagnosis and
therapy.
 Targeted Drug Delivery
 Disease Diagnosis and Prevention (Nanobots)
 Tissue Reconstruction
 Improved Imaging of Tumors (Quantum Dots)
C. Nanotechnology and Nano-biomaterials in Dentistry
New potential treatment opportunities in dentistry may include different

approaches
a) Bottom-up approach; construction of structure atom-by-atom or
molecule-by-molecule. This is applied in local anesthetics,
hypersensitivity cure, dentifrices, orthodontic treatment, photosensitizer
and carriers in addition to diagnosis and treatment of oral cancer.
b) Top-down approach; Starting material is reduced in size. Examples
include nanocomposites, impression materials, nano-solutions, nano-
needles, nano-tweezers and bone replacement materials.
c) In addition to bottom up and top down approaches, there is the functional
approach. This approach disregards the method of production of a
nanoparticle; and the objective is to produce a nanoparticle with a
specific functionality.
161
D. Nano-biomaterials and Endodontics

Almost every aspect in endodontics has gained advantage of the newly
emerging nanotechnology:
1. Radiography
Advances in digital imaging techniques are also expected with
nanotechnology. In digital radiographies obtained by nanophosphor
scintillators, the radiation dose is diminished and high quality images are
obtained.
2. Local Anesthesia:
To induce oral anesthesia, professionals will install a colloidal suspension
containing millions of active analgesic dental nanorobot particles on the
patient’s gingiva. Moving nanorobots reach dentin by migrating into the
gingival sulcus and passing painlessly through the lamina. This analgesic
technique is patient friendly, as it reduces anxiety, needle phobia, and most
importantly, is a quick and completely reversible action.
3. Dentin Hypersensitivity:
Dental nanorobots could selectively and precisely occlude selected
tubules in minutes using native biological materials, offering patients a quick
and permanent cure. For example, one of the methods of closing sub-micron
sized dentinal tubules involved highly concentrated gold nanoparticles that were
brushed into exposed open ends of tubules.
4. Root Canal Disinfection:

Nanoparticles exhibit antibacterial activity as a result of their
polycationic/ polyanionic nature with the higher surface area and density.
162
The size of nanoparticles plays an important role in their antibacterial

activity; smaller particles show higher antibacterial activity than the macro-
scaled ones. Direct or close contact between the nanoparticles and the bacterial
membrane were essential for effective destruction of bacteria.
Antimicrobial mechanisms of nanomaterials include:

 Photocatalytic production of ROS that damage cellular and viral
components.
 Compromising the bacterial cell wall/ membrane.
 Interruption of energy transduction.
 Inhibition of enzyme activity and DNA synthesis.
Examples:
a. Silver Nanoparticles (Agnps):

They are effective in destruction of E. faecalis biofilm when incorporated in
intra- canal medicaments or irrigation solution either alone or as part of a
mixture. The surface charge on AgNPs was important in efficacy against E.
faecalis. Positively charged AgNPs were effective against E. faecalis and
exhibited a high level of cyto-compatability.
b. Chitosan:
Its use is limited because of its insolubility in water, high viscosity and
tendency to coagulate with proteins at high pH.
Chitosan shows its antibacterial activity only in acidic medium because of its
poor solubility above pH 6.5. Yeasts and moulds are the most sensitive group,
followed by gram positive bacteria and finally gram negative bacteria.
163
c. Zinc oxide NPs (ZnONPs):

When incorporated in sealer it didn’t alter the flow characteristics, but
improved the direct antibacterial property and ability to leach out of the
antimicrobial component, with significant reduction in adherence of E. faecalis
to treated dentin.
d. Photodynamic Therapy (PDT)/ Photosensitizers:

The recent advances towards achieving predictable endodontic
disinfection have focused on newer alternatives such as PDT. PDT is based on
the injection, ingestion or topical application of photosensitizer dyes followed
by visible light activation.
E.g. Rose Bengal and Methylene blue
Coating or surface attachment of photosensitizers to nanoparticles

significantly improved antibacterial properties.
 Allows higher concentration of photosensitizer uptake per cell.
 Reduces the efflux of photosensitizer from target cell.
 Greater interaction with cells because of the surface charge.
 Allow control release of ROS.
E.g. - Polylactic co- glygolic acid nano particles (PLGA) + MB - Chitosan +
rose Bengal
e. Nanoparticles of Gold and Silver (NANOCARE PLUS):

Strong bacteriostatic effect, eliminate E. Faecalis and prevent re-
colonization of canal system by bacteria and fungi leaving a layer of long
lasting nanoparticles on the canal surface when used as a final rinse during root
canal treatment.
164
5. Vital Pulp Therapy:

 Compared to regular bioactive glass (BG) the nano-sized BG can induce
differentiation and mineralization of human dental pulp cells in vitro.
 Testing nano-crystalline hydroxyapatite paste as pulpotomy and pulp
capping agent, it was found biocompatible and superior to formacresol. It
was also recommended as substitute for MTA and Dycal in direct pulp
capping.
6. Regenerative Endodontics:
Recent progress in nanoscience allowed nanostructured surfaces in scaffold
designing which would offer better cellular adhesion and differentiation.
 Nanostructured tissue engineering scaffolds
- Incorporation of nanosized components during scaffold manufacturing.
- Scaffold surface nano-patterning.
- Self-assembled nanomaterials.
7. Endodontic Filling Materials:

- Nano Ag-gutta percha has been developed to improve the antibacterial effect
of gutta percha and several studies have showed similar cytotoxicity to
normal gutta percha.
- Incorporation o nanoparticles decreased the viscosity of endodontic sealers,
leading to enhanced flow.
- CS/Zno nanoparticles incorporation in sealers displayed the ability to leach
out antibacterial components and reach deep into dentinal tubules.
- Addition of insoluble antibacterial quaternary polyethylenimine NPs into
AH Plus and Gutta Flow led to significant and stable antimicrobial
properties of both sealers.
165
- ‘Nanoseal’, a sealer similar to various epoxy resin-based sealers, but with a

HA nanofiller. Reactive nanoparticles can slow down the growth of bacteria,
size of active nanoparticles can enter the accessory canals and besides the
nano size, the similarity between the structure of the material and that of the
teeth also increases the biocompatibility between the material and the teeth,
thereby increasing its adhesive strength.
8. Endodontic Surgery:
a) Root End Filling Materials:

- Addition of Nano-silica to MTA accelerated the hydration process, reduced
the setting time.
- Nano white MTA was capable of producing lower porosity in set materials,
better hydration and strength even in acidic environment.
- Addition of AgNPs to MTA improved its antimicrobial efficacy.
b) Bone Replacement Materials:

- Nano-sized HA is the main component of mineral bone. Synthetic HA
possesses exceptional biocompatibility and bioactivity properties with
respect to bone cells and tissues; hence, it has been widely used clinically.
- Nanophase HA properties such as surface grain size, pore size, wettability
etc., could control protein interactions modulating subsequent enhanced
osteoblast adhesion and long-term functionality.
E. Risks associated with Nanotechnology

1. Environmental Risks
2. Health Risks
3. Feasibility Problems
166
References
 A. Kishen (ed.), Nanotechnology in Endodontics: Current and Potential

Clinical Applications, 2015.
167

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TRAUMATIC INJURIES TO

PERMANENT ANTERIOR TEETH

 Classification of Traumatic Injuries.

Tooth trauma has been and continues to be a common occurrence that

Causes of Traumatic Dental Injuries:

Multiple causes contribute to tooth trauma mainly falls, collisions, sports,

CLASSIFICATION OF TRAUMATIC INJURIES TO TEETH:

Ellis Classification (1970):

WHO Classification (1978):

Andreasen modified that classification into a more practical classification

However, for simplicity another classification is considered, which is the

Examination and Diagnosis

- Displaced tooth is tender to percussion due to accumulation of extra-vasated

Dimension of root canal space, apical closure and proximity of the

(1) Crown Infraction:

Sequelae of Crown Infraction:

(2) Enamel Fracture:

(3) Enamel & Dentin Fracture (Without Pulp Exposure):

(4) Crown Fracture with Pulp Exposure:

Treatment options depending on the previously mentioned factors are:

1)Vital Pulp Therapy

a) Direct Pulp Capping:

The success of pulp capping and pulpotomy is assessed clinically and

2) Apexification: Treatment of Non-Vital Pulp:

4) Surgical Treatment: surgical closure of the open apex using MTA.

6) Root Canal Therapy:

(5) Crown-Root Fracture:

Diagnosis of Horizontal Root Fracture:

Treatment of Horizontal Root Fracture:

(1) Fracture at the Apical 1/3 (Best Prognosis):

(2) Fracture at the cervical 1/3 (good prognosis):

(3) Fracture at the Middle 1/3 (Worst Prognosis):

Prognosis of Horizontal Root Fracture:

II- Injury to Periodontium

(A) Luxation injuries:

(1) Concussion & Subluxation:

(2) Extrusion and Lateral Luxation:

Definitive Treatment (After 1-2 weeks)

(3) Intrusive Luxation (Intrusion):

Definitive Treatment (After 1 week):

Sequelae of Luxation Injuries:

Factors affecting treatment:

(2) Emergency Management in the Dental Office:

(i) Root Surface:

Extra oral dry time less than 60 minutes

Extra oral time more than 60 minutes

 Extra oral dry time less than 60 minutes:

 Extra oral dry time more than 60 minutes:

(i) Healing with Normal Periodontal Ligament.

(ii) Surface Resorption:

(iii) Replacement Resorption:

(iv) Inflammatory Resorption:

 Cohn S, Hargreaves K, editors: Pathways of the pulp, ninth edition, 2006.

 Different types of resorption.

a. Internal Root Resorption:

b. External Root Resorption:

It can be sub-classified to:

 Another classification of External root resorption is according to its

 Heithersay classified External Cervical Resorption according to the extent

Figure 1: Heithersay classification of External Cervical Resorption

Main Etiology for Root Resorption

Internal Root Resorption:

External Root Resorption:

Diagnosis and Differential Diagnosis