Question Paper Discussion-Conservative Dentistry & Endodontics-Part 8

[Music] Hello everyone, welcome back to another section of dentistry and more. Today we are going to discuss the last section of previous year question paper that has comes under the topics restoration of endodonically treated tooth, management of traumatic injuries, tooth resorption and last one is magnification. So we are moving to first topic that is restoration of endodonically treated tooth and the probable short notes are postendodontic restoration types of post ferule effect and last one is core. Now we are moving to the components of resto tooth that is uh the com components includes residual tooth structure restorative components that is post core and looting agent. So in the figure you can see the coronal restoration core buildup post and there is three uh 3 to 5 mm of guture for a C. Next one is post. So it is a relatively rigid restorative material that is placed in root of a nonvital teeth for restoration of the core to transmit the forces on the core of the root. So traditionally this endodonically treated tooth it receives a post to reinforce them and crown to protect them. Uh so what are the purpose of using this post there? It helps to retain the core. It helps to distribute the stress through the radicular denting to the root aex. So these are the ideal requirements of the post. It's very important. And the post should provide maximum protection to the root to resist the root fracture. It provide maximum retention to core and crown. Uh be easy to place, be less technique sensitive. So be visible, be biompactable. So these are the idea requirements you can follow this. Now we are moving to the classification of the post. So this post can be classified according to how they are made. So it is classified into pre-fabricated post and custom cast post. In case of pre-fabricated post it includes metallic post and non-metallic post and in case of metallic there is gold alloy high platinum alloy and non-metallic there is carbon fiber cords fiber somewhere like that and in case of cast uh custom cast post it includes custom cast metal post and core or ceramic and polyethylene fiber post. uh in case of custom cast metal there is gold alloy, platinum, paladium alloy uh like that. So this is according to how they are made. Next one is according to the shape they classified into tapered and parallel sized. Uh so in case of tapered that is self- threatening and also smoothsided. Now we are moving to according to a method of engagement of the dentine that is classified into passive and also active. In case of passive it includes cast, smooth and serrated. Next one is according to material of the post it is classified into metal, fiber post and also ceramic. So these are the classification. Uh now we are moving to the fur effects. It's a very important question. It's a frequently asked question. So it is defined as a metal ring or band that is used to fit the crown or crown of the tooth. It can be correlated to wine barrels and the metal band which encompasses the wooden barrel that gives support when the barrel is full. So it's a gram uh diagrammatic representation of the furlay effect. So this figure is very important and if you wrote this figure or if you mention this figure you can score more marks and this one is the requirements of the ferule that the axial wall height of the furlet must be greater than or equal to 1 to 2 mm. The furlet should consist of parallel axial walls and the margins of the preparation should rest on the sound to structure. So uh this requirements this you can mention it. Next one is functions of ferule. So it includes uh it protects the integrity of the tooth and it reduces the lateral forces. It resist wedging effect and it resist the functional liver forces. So the functions are also important. Now we are moving to the core. Uh so this core it is a supra gingial portion that replaces the missing coronal to structure and forms the center of the new restoration. So it can be available as dental amalgam resin modified glass composite resins like that and the ideal requirements includes uh this compressive strength to resist the interal forces ease of manipulation low cost easily available. So these are some of the idle requirements and the materials used are mainly amalgam. Uh so as we mentioned early amalgam glass anoma compositives and its advantages, disadvantages, indications and precautions these are all given. So these all about the restoration of the endodonically treated tooth. Now we are moving to the next topic that is management of traumatic injuries. So from this chapter there is long essay includes the part what is aulion describe the management healing pattern and prognosis of aulion and the short essays includes classify traumatic injuries of the teeth and explain in detail about management of crown fracture that involving the pulp and uh next one is same question as that of the long essay and third uh that is healing after root fracture and aulion fourth classification and describe about root fracture management the short is that is very important Apexification, aexogenesis, cracked tooth syndrome and spinting. So first we are moving to avulsion. So this aulion it is defined as complete or total displacement of the tooth from its socket. So mainly this maxillary central incizes are uh frequently a teeth and in case of management there is immediate management that includes the teeth has tooth has already uh been re-implanted to the site and the patient is asked to rinse mouth and the tooth uh is replaced in its socket using gentle or steady finger pressure. After that it is um washed under tap water and the patient is asked to take to the dentist immediately and at the dental office that leave the tooth in its place. Clean the affected area with water saline or 0.12%age chlorhexidine. Now suture the ginger have a laceration. After that apply a flexible spleen for one to two weeks and intra canal corticosteroids medication can be placed immediately or shortly following re-implantation or it is left for at least 2 weeks. And if the patient or parent is not replaced the tooth in it or cannot replace the tooth in its socket then uh the tooth is placed in a storage medium while transporting it to the dental office. And as we have mentioned earlier storage media it includes HBSS patients own saliva that includes vestibule or container into which the patient's piece milk coconut butter and these are some of the storage mediums and this is the management of the aster teeth in case of extraoral dry time of less than 60 minutes and this is more than 60 minutes. Now we are moving to first one is less than 60 minutes. In that case administer the local anesthesia. After that irrigate the socket with the saline. And now examine the socket for possible fracture or any reposition. And two parapical radioraph from the mesial and distal angulation they are taken. Um and also while CBCT should be considered to confirm the reposition of the tooth and rule out the alvola bone. In case of closed apex, this necrotic tissue is removed from the root surface and after that the socket is irrigated with saline and this tooth is replanted gently into the with digital pressure. After that apply passive or flexible spring for 2 weeks and initiate the RCT with 2 weeks of re uh replantation calcium hydroxide intraanal medicin for 4 weeks that is followed by opturation and follow uh at 2 weeks 4 weeks 3 months 6 months 1 year and then yearly at least for at least 5 years. This is in case of closed aex and now we are moving to open aex. It's also same that is remove necrotic tissue from the root and after that it is regated with the saline and the tooth is gently replant into the socket with the digital pressure. After that uh the spleen is applied for at least 2 weeks and this antibiotics they are recommended if there is any infection and spontaneous revascularization is the primary goal. So if does not occurs epoxification or root canal treatment can be done and followup is 2 weeks, 4 weeks, 3 months, 6 months, 1 year and yearly at least for 5 years. Same as that of the closed depex. Now in case of more than 60 seconds uh all these are somewhat same and that is administer local anesthesia. After that you get the socket with saline. exam in the socket for proximal any possible fracture or reposition and this radioraph is taken. Uh so in case of closed aexics this necrotic tissue is removed and the socket is irrigated and the tooth is generally replaced into the socket with digital pressure. After that the spleen is placed for 2 weeks and RCT is recommended with two weeks of replantation. And here this calcium hydroxide intraanal medicamment for 4 weeks is done. It is followed by opturation and followup is done. Case of open aex also uh the first step is similar. After that uh spontaneous revascularization, pexification or root canal treatment is done and followup is also done. Next one is prognosis. uh this replanted tooth it can be monitored by frequent controls during first years that is once a week during the month of 1 3 6 or 12 and then yearly thereafter and uh the favorable outcomes include in case of closed aex uh the tooth is asytomatic with normal mobility and normal percussion sound and there is no radioraph evidence of resorption or peradicular oitis and the laminina dura will appear normal normal. So these are the symptoms and in case of open aexics uh this there will be normal mobility with normal percussion and there is radioraph evidence of arrested or continued root formation and the ruption is also found. But in case of unfavorable outcomes in case of closed aics the tooth will be symptotomatic with mobility or there is no mobility that is ankylosis and there is high pitched percussion sound and in radioraph there will be resorption present uh with inflammatory infection related resorption and in case of open aex the tooth will be uh symptomatic with mobility uh or ankylosis and there is high pitched percussion sound same as that of the closed apex. And in case of ankylosis the crown of the tooth will appears to be infraial position. So this there will in case of radiographic uh diagnosis there will be resorption or ankylosis. Now we are moving to the management of fractures involving the crown. So this crown fracture it involves enamel, dentine and pulp. They are called as complicated crown fracture. So the diagnosis can be patients history, clinical examination, radioraph and vitality test. The fact is determining the choice of treatment plan that is first one is stage of development of the tooth. In case of an immature vital teeth, this uh vital pulp therapy like pulp capping, partial palpotomy or full palpotomy can done uh until this aex is completely formed. Or in case of immature nonvital tooth the aexification is done using this calcium hydroxide or MTA that is followed by maturation and in case of mature tooth this root canal treatment can be done. Next factor time between the accident and the treatment. So if the pulp is exposed for less than 48 hours then this pulpotomy is preferred and if the pulp is exposed more than 48 hours then palpecttomy or RCD is more preferred. Next one is associated periodontal injury that is palpto is indicated in such cases where the surrounding parodonium is damaged. So and the nutritional supply of the tooth is also affected there. And last one is restorative treatment plan. In case of composite treatment partial palputum is decided. However to receive a complex restoration then palpto is more preferred. Now we are moving to aexogenesis. So this is uh mainly done in immature vital teeth. This vital pulp therapy like pulp capping or partial pulpotomy or full pulpotomy. It is done till aex is completely formed that is known as aexogenesis. And next one is direct pulp capping that involves the placement of biompactable agent on healthy pulp tissue that have been in a tently exposed due to excavation of carries or dramatic injury. So these are some of the indications of direct pulp capping that is pinpoint exposure. There will be control hemorrhage, no palpal necrosis and absence of swelling and tenderness. And the agents used for pulp capping are calcium hydroxide, MTA, enamel matrix derivative, triricalium phosphate and bone morphogenic proteins. So now we are moving to the procedure of the pulp capping that is anesthesia is administrated first that is followed by rubber placement. After that the bleeding is controlled with the sterile moist cotton pellet. Then the exposure site it is converted by a pulp capping agent that is followed by bacteria seed restorative material and the patient should be recalled after 6 weeks to evaluate the formation of heart tissue barrier. Next we are moving to palpotomy and first one is shallow palpotomy or uh partial palpotomy. So uh it is also known as modified pulpotomy procedure and the materials used are usually calcium hydroxide or MTA and the indications includes pulp exposure is less than 1 mm in diameter. Pulp have been exposed for less than 24 hours. Pulp responds positively to vitality test and there is absence of infection and the procedure includes that is anesthesia is administrated first that is followed by rubber dam isolation 1 to 2 mm pulp it is removed with the sterile diamond b and the uh copious water coolant with the help of intermittent light strokes the low tooth structure is the replaced with acid composite resid so this treatment It is considered to be successful when there is no evidence of peradicular pathological changes, no evidence of resorption and evidence of continued tooth formation. Now we are moving to uh full palpotomy. Its indications include traumatic pulp exposure beyond 72 hours, carries exposure, pulp response positively to vitality test, absence of infection and primarily indicated if root appex is not yet completely developed. The materials used in case of full palpoam is calcium hydroxide and MTA. And the procedure includes anesthesia is administrated followed by rubber dam isolation and the inter coronal pulp up to the level of root orifice. It is removed by using a sterile bur uh or laser palptomy. Then it is run through with the sterile saline and then the bleeding is controlled with sterile cotton pellet. After that calcium hydroxide dressing is placed that is followed by zinc phosphate or glass anoma cement as a base and it is restored to provide a bacterial tight seal. Now we are moving to aexification. Its indications includes uh necros pulp in the developing tooth with incomplete root formation. open aexes with thin dentinal walls in which instrumentation techniques cannot create an aallel stop to facilitate effective root obturation. The materials used in case of a pexification includes calcium hydroxide MTA triricalium phosphate bond morphogenic proteins and the procedure for aexification is the affected tooth. It is isolated using rubber dam. After that the assist cavity is prepared and the pulp reminants are removed by using barbed bres and a file it is placed into the root canal to determine the working length. After that uh the canal it is irrigated using 0.5%age um sodium hypogchloride and it is dried with pulp paper points and the canal it is disinfected using calcium hydroxide that is mixed in a creamy consistency and it is recalled after one week and the debridement procedure is repeated that is followed by placement of thick paste of pure calcium hydroxide and it is mixed with the sterile saline with the help of plug And the canal it is back filled to provide bacterial seal canal. The assist cavity is then restored with a temporary filling and the patient is recalled after 3 months to evaluate the heart tissue barrier and if the epical barrier is not formed the procedure is again repeated and if the ale barrier is formed it gives a cy cheese consistency and the thickness of the heart tissue barrier formation it is confirmed radiographically by taking the radioraph. While a hand file it is used with light pressure to prop the apical strobe and calcium hydroxide it is removed with sodium hypogchloride along with ultrasonic followed by opturation. Next we are moving to palpecttomy. So it is defined as the complete removal of the pulp to the level of apical forammen and the indications includes uh if the exposure is longer than 72 hours during or uh duration or the pulp is damaged beyond the recovery and when the pulp is degenerated or questionable vitality. The procedure is of the palpecttomy is affected tooth. It is isolated with rubber dum as this cavity is prepared and the pulp reminants are removed. File is placed to establish the working length. Shape cleaning and shaping is done uh with sodium hypogchlorite. Then the canal is dried with paper points and suitable intra cananal medicines is placed and after that the assist cavity is restored with temporary filling and in case of next visit the canal is checked for any drainage and if the canal is dry then the opturation is completed with assist cavity is restored with resin restoration. Now we are moving to the classification of traumatic injuries of teeth. First one is alis classification. The nine classes that is first one is enamel fracture class one class two enamel and dendine fracture without pulp exposure class three fractures involving enamel dendine and pulp class four nonvital teeth class five aulion class six root fracture without involvement of crown structure class seven displacement of tooth without fracture of the crown class eight loss of crown uh class 9 trauma to decided teeth. Next one is other modification that includes enamel infraction, enamel fracture, enamel dentendine fracture, complicated crown fracture, uncomplicated crown root fracture somewhere like that. Now we are moving to types of root fractures and management. So it can be defined as vertical, oblique or horizontal fracture of the cementum, dentine or pulp. So it can be complete or incomplete. And so this fracture of the root can occurs at three levels that is coronal, midroot and apical root. And the clinical features include there will be tenderness on percussion and palpation. Tooth will be mobile displacement and bleeding from the gingial sulcus uh and also negative response to tooth to vitality test. The treatment in case of coronal root fracture that if the fracture line it will if it is above the crest of alvola bone then the coronal fragment is extracted. The aallel portion is endonically extruded for post and core restoration and if the fracture line is below the crest of alvola bone it is printed as for mid root fracture. And in case of midappial root fracture first one is splinting and the tooth exhibit normal mobility without displacement. No splint it is required and when the tooth exhibit displacement and mobility the fracture it is reduced and a rigid splint it is placed for a period of 4 to 8 weeks. So this will promote healing which is verified radiographically and splinting can be done using composite orthonic brackets acrylic or cast splint cementation and fiber splint and most common the pulp in the coronal segment it is necros leaving the apical segment vital. uh in in these cases this palpecttomy RCT or aexification of the coronal segment can be done and when both these segments contain necrotic pulp within then an endodonic treatment is preferred in the coronal segment that is followed by surgical removal of the aal segment. So these are the difference between aexogenesis and aexification. In aexogenesis as we have mentioned earlier it is defined as treatment of vital pulp by capping or palpotomy in order to prevent the continued growth of the root and closure of the open aex. But in case of aexification it is defined as the method to induce a calcific barrier across an open aex of an immature pulpless tooth. Now we are moving to healing after the root fracture. So uh this root fracture it shows healing in following ways like healing with calcified tissues in which fractured fragments are in close contact healing with in interproximal connective tissue in which the radiographically fragments are separated by radolucent line and healing with interroximal bone and connective tissue. Here the bone fragments they are separated by a distinct bony bridge and interroximal inflammatory tissue without healing and radiographically it shows widening of fracture line. Now we are moving to cracked tooth syndrome. So uh cracked tooth syndrome in this uh you column you can see the ethiology factors and examples. Ethiology this cracked tooth syndrome can occurs due to res in case of restorative procedures factors that is inadequate tooth preparation and stress concentration. Case of occlusionally there will be masticatory trauma and parapunction and miscellaneous that is thermal cycling and dental instruments. This is the American Association of Endodonist classification of cracked teeth. So you can go through this column. Next one is the treatment plan for the fractured tooth. Uh that is in case of small crack the treatment is uh remove the fractured segment and after that restoration of the tooth. But in case of large crack that is pulp involved, pulp not involved and hopeless prognosis. In case of pulp involved that is endodonic therapy with immediate stabilization with orthodontic band. After that final restoration is done. And if the pulp is not involved then the occlusal adjustment is done with immediate stabilization and permanent stabilization using bonded restoration. And in case of hopeless prognosis like vertical crack or poor uh crown root ratio, the only uh treatment is extraction. That's all about the management of traumatic injuries. Now we are moving to next section that is tooth resorption. And the probable short nodes are cervical root resorption, internal root resorption, internal and external root resorption, inversive cervical resorption. It's a classification of the root resorption. So it's classified into three type that is trauma induced root resorption, infection induced root resorption and hyperlastic invasive root resorption. And the case of trauma induced there is surface transient apical internal pressure orthodontic and replacement resorption. In case of infection there is internal inflammatory external inflammatory and also communicating internal and external inflammatory resorption. And last hyperlastic that is internal resorption, inversive coronal uh resorption, inversive cervical resorption and inversive radicular resorption. So this is the classification of root resorption. Now we are moving to cervical root resorption or extraanal invasive resorption. So it is a type of inflammatory root resorption that is occurs immediately below the epical epithelial attachment of the tooth and some of the ethiologies are orthodontic treatment, trauma, bleaching of nonvital teeth, bxism, parodontal treatment etc. These are the classification. Now we are moving to internal resorption that is according to Schaefer this internal resorption. It is an unusual form of tooth resorption that begins centrally within the tooth apparently initiated in most cases by a pecular inflammation of the pulp. So it is characterized by an oval enlargement oval-shaped enlargement of root canal space and ethiology includes longstanding chronic inflammation of the pulp carries related pulpitis traumatic injuries atrogenic injuries like deep restorative procedures application of heat over the pulp pulpotomy using calcium hydroxide and the synonyms includes chronic perforating hypo hyperplasia of the pulp Internal granuloma, odendroblast, pink tooth of memory and some of the clinical features includes it is usually asytomatic until the root is perforated and the patient may complains of pain when the lesion perforates and the tissue is exposed to oral fluids and the mostly affected teeth are maxillary central incizes. Usually a single teeth is involved but sometimes there will be multiple teeth and it occurs in permanent as well as the decidious teeth and in case of permanent it will spread more rapidly and this granulation tissue it can clinically manifest as a pink spot where the crown dentine destruction it is severe that leads to pink tooth appearances and the radiographic features include outline of lesion that appears as uniform from round to oval radolucent enlargement of the pulse space and the root canal that is distortion of original root canal outline. Next is the type of internal resorption that is internal replacement resorption and internal inflammatory resorption. So the treatment options includes uh if that is without perforation then anodontic therapy is done with per perforation then it is non-surgically calcium hydroxide therapy followed by opturation surgically there is surgical flap root resection and intentional replantation. So these are the differences between the internal and external resorption. So definition uh you can read and the canal space in case of internal it is oval shaped and it causes expansion of the canal and in case of external the canal shape it is not altered and the pink tooth uh that is hypoplastic vascular pulp tissue showing through the tooth and here the pink tooth is not seen so the pulp is non vital symmetry it is symmetrical ical defect through uh though may be eccentric and in case of external it will be usually asymmetrical. So these some of the differences are here you can see the figure you can see the internal resorption and external resorption. So that's all about the tooth uh resorption. Now we are moving to last section that is magnification. This includes loops, dental or surgical operating microscopes. First we are moving to dental loops. Um so it is classified by the optical method in which they produce magnification and it is also based on how the lenses are lenses are mounted on the frame. So the classification uh there are three types that is uh diopter flat plane single lens or surgical telescope and last one is surgical telescope with the so these are classified based on how the lens are mounted to the frame classified in two types that is flip up and through the lens and the features uh of both these are that includes mobility of the lens adjustment ment of the optics ability to share between operators cost and weight. Now we are moving to dental or surgically operated microscope. It incl uh it improves the clinical proficiency and deliver better treatment outcomes for the patient and the parts of microscopes includes uh eyepiece lens binoculars magnification changer and objective lens. So here you can see the dental operating microscope. Next one is how the dental operating microscope works. To appreciate what a surgical operating microscope can do, it is essential to understand the various aspect of its working. So that includes magnification, illumination, documentation and mounting a microscope. So clinical uses of microscope at different levels of magnification includes low magnification, medium magnification and high magnification. In case of low magnification, it is ideal for tooth examination and initial assist preparation. The wider field of view is useful to gain orientation in relation to adjacent teeth and anatomic structures. In case of medium magnification, it is most commonly used for most non-surgical and surgical andic procedures. And the range of magnification, it provides adequate field of view and also depth of field. Now we are moving to high magnification. It is used sparingly during minute procedures such as instrument retrieval. It also used during documentation of the clinical work. However, the limited field of view and loss of focus of magnification a challenge during minor moments make clinical work at these levels of magnification. Now we are moving to clinical application of dental operating microscope in endodonics. So some of the clinical applications are first one is enhanced clinical visualization of area of interest, diagnosis of cracks, conservative assess refinement, removal of pulp stones and tracing mist or calcified canals. Identify atypical root canal anatomy. Assessment of assessment during shaping, cleaning and obturation procedures. prevention and management of endodonic misshapes that includes perforation management, retrieval of separated instruments. Uh retreatment of endodonic failures and last one is microsurgical endodonics for creating smaller osteotomy. Inspection of resected root surface, retrop preparation, retrofill and micro suturing. So here ends the magnification and uh so here ends the conservative dentistry and endodonics question paper. Hope you all understood and if you have any doubts you can put it in the comment box. Thank you for hearing my words. Thank you. [Music]