18 AUG 2020 · CONTRAINDICATIONS OF RCT  Non-restorable tooth  Vertical root fracture  Tooth with insufficient periodontal support / periodontally weak ones FILE CALCULATION :- Length of files available: 21, 25, 31 ISO INSTRUMENTATION IS BY WIDTH OF FILE TIP- Do TO FILE SIZE 34 CUT 2MM FROM FILE 30

18 AUG 2020 · DISCOLOURATIONS YELLOWISH- WHITE - Pulp is inflammed & calcified, non-necrotic - It is calcific metamorphosis - No infection here. Tertiary dentine in formed extensively - Dystrophic calcification, pulp stones may be seen - If asymptomatic – RCT not required – give crown directly YELLOWISH GREY TO BROWN / RED - Pulp is dead & undergoing necrotic changes - Do RCT, some bleach ( GP up to middle 3rd only then rest fill up with GIC – tight seal, because hydrogen peroxide must not fall into the canal - Go for crown if needed TETRACYCLINE STAINS - Yellow brown stain seen in adults - If pregnant mothers take tetracycline – child’s primary teeth will be affected - If child takes tetracycline during early ages – permanent dentition will be affected - Mechanism – during the stage of tooth formation, tetracycline bonds to teeth instead of Calcium - Treatment :– if mild  bleaching ; if severe  veneer / crown PINK TOOTH OF MURMERY - Internal resorption - Pulp is enlarged & hyperactive - Enamel shell shows off the pulp ( because dentine is resorbed here ) - 90% seen in primary teeth - Cause is unknown ……….. Due to inflammatory reaction? - This the reason why DPC is contra-indicated in primary teeth. CaOH is of 12Ph, which will irritate the pulp thus initiating the inflammation - Irreversible type of pulpitis - Radiograph – isolated radiolucency, & not moth-eaten appearance - If asymptomatic, thus usually found during routine radiographs Treatment – single sitting pulpectomy / RCT - If symptomatic, pulp extirpation – followed by CaOH (Pulp chamber which is highly acidic will be neutralized by CaOH) CYSTIC FIBROSIS - They are on tetracycline, thus the stains - They always have a variety of infections - Key feature - thick secretions ERYTHROBLASTOSIS FETALIS - Yellow molars - Bleaching is the treatment, if required only - Treatment not necessary PORPHYRINE STAINS - Red stains AMALGAM BLUEING - Blueish black discoloration due to amalgam BLEACHING Bleaching is the removal of stains that has been formed on the organic content of the tooth. A. NONVITAL TOOTH 1. THERMOCATALYTIC TECHNIQUE  Material used – hydrogen peroxide – 30%  After RCT – remove GP from the coronal top – place GIC filling – about 2mm as protective cement barrier – Place the oxiding agent – 30% hydrogen peroxide- SUPEROXOL – inside the chamber & apply heat  Done in office set up  Done intracoronally – because its more effective.  Dangerous – must not fall into the canal, in the oral mucosa, due to high concentration of hydrogen peroxide 2. WALKING BLEACHING  Material used – sodium perborate  Place mixuture of sodium perborate + water inside the chamber  Changed every 4-7 days  Finish in 2-6 weeks.  In-home bleaching technique  Safer than superoxol B. VITAL TOOTH  IMMEDIATELY AFTER BLEACHING, COMPOSITE IS CONTRAINDICATED – because the content of bleaching agent will hinder the polymerization of composite – therefore always delay the composite restoration by 1 week – by placing temporary restoration for that time period

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18 AUG 2020 · CLASS VII – LUXATION INTRUSION - Chances of cut-off of blood supply is seen in intrusion – in 6 months – revascularization should happen – therefore the wait & watch scheme a. PERMANENT - Wait & watch for 6 months for natural extrusion / eruption - If not orthodontic extrusion b. PRIMARY - Radiograph is must 1st - If tooth is impinging underlying tooth follicle – Extract - If no impingement – wait & watch for 6 months - If impingement on follicle – leads to Turner’s Hypoplasia - Never extract tooth normally – open flap, split the tooth, the extract EXTRUSION / LATERAL LUXATION - Replace into normal position - Followed by flexible splinting for 2 weeks SUBLUXATION - Tooth that is mobile without displacement. Here tooth supporting structure is affected, hence the mobility. - Place back into normal position - Flexible splint for 2 weeks - Wait & watch, then decide if RCT required CLASS VIII – CROWN-EN-MASSE FRACTURE - Treatment – RCT + Post & core build-up of crown CLASS IX – PRIMARY TOOTH FRACTURE - Avulsion in pedo - Never place it back, Discard the tooth - Give space maintainer if needed

18 AUG 2020 · After 60 mins 1. Rinse/soak in 2.4% acidulated fluoride solution at pH 5.5 (citric acid + sodium fluoride) (helps prevent root resorption ) 2. Extra-oral RCT is performed by holding the tooth in fluoride soaked gauze. 3. The socket clot is suctioned and irrigated with saline to remove the clot. 4. Replant with digital pressure, the Splint with flexible splint for 4 weeks 5. Possible complications – a. Here we expect either ankyloses or replacemental root resorption – which will happen within 2 years b. inflammatory external root resorption (IERR) – which is the main reason for failure of reimplantation Therefore can displace the tooth i.e. possibility of avulsion again c. Ankyloses will give better prognosis than ERR, which will lead to failure. Once ankylosed, chances for IERR decreases over time. CLASS VI – ROOT FRACTURE Vertical Root Fracture Causes - Post & core cases - Warm GP / vertical condensation cases - Bite / chewing - Accidental trauma Diagnosis - J-shaped radiographic appearance - Tear-drop shape - Isolated PDL pocket [Other causes for isolated pockets o Endoperio lesion – pathological o Developmental groove (max LI) – normal variant ] Horizontal Root Fracture Apical 1/3rd - Treatment is wait & watch - Small fragment may get resorbed by cementoblasts & odontoblasts - Later do RCT - Best prognosis Middle 2/3rd - Wait & watch - May get resorbed - Then go for RCT for rest of the coronal root - Lesser prognosis Cervical 3rd - Prognosis is very poor - Splint to adjacent teeth with rigid splint such as metallic band / wire - Wait & watch - Extraction if no re-attachment seen

18 AUG 2020 · ELLIS CLASSIFICATION OF FRACTURE CLASS I – ENAMEL FRACTURE CLASS II – ENAMEL + DENTINE FRACTURE  Treatment – Re-attachment of fractured fragment  Or CaOH base (if sensitivity present) + composite build-up CLASS III – ENAMEL + DENTINE FRACTURE + PULP EXPOSURE a) Within 24 hrs o Or if only pin-point exposure (less than 0.5mm) - DPC b) More than 48 hrs / 2 days o Or if exposure more than 0.5- 3mm - Pulpotomy o Consider the age also i.e. young permanent tooth c) More than 72 hrs / 3 days o If young permanent tooth - Apexification o If fully formed permanent tooth - RCT NB: No IPC in fractured / trauma cases CLASS IV – NON-VITAL DISCOLOURED TOOTH a. If young permanent tooth - Apexification b. If fully formed permanent tooth – RCT CALSS V – AVULSION FIVE FACTORS THAT DETERMINE THE SUCCESS a. TIME i. 30 MINS-1 HOUR – best prognosis ii. MORE THAN 1 HOUR - ERR b. STORAGE MEDIA (NB : Never use tap water) iii. Viaspan - best option ( used in heart transplantation ) iv. HBBS - best option in clinical setup v. Cold milk – most commonly used & readily available vi. Physiologic saliva and saline c. TOOTH SOCKET vii. Should not be curetted or disrupted Q. Should you irrigate the socket? Ans. No irrigation required, but if necessary only mild irrigation acceptable. Vigorous irrigation is contraindicated. d. SPLINT STABILIZATION viii. Splint type – flexible splint – that will allow physiologic movement. ix. Splint time – 2 weeks or 1-2 weeks – 7-10 days is ideal* e. ROOT SURFACE x. Should not be dried xi. Should not be scrapped or manipulated with any chemicals Q. How should the tooth be held? Ans. Only at the crown portion. Never touch the root – might hamper the natural PDL. Within 60mins - Viability of PDL cells stays max up to 60mins only – that is the 1st priority of the treatment, re-implantation - If dried beyond that time, pdl dies off - Success rate depends on pdl viability i.e. extra-oral dry time 1. Rinse in tetracycline 2. Replace in socket & splint with adjacent teeth 3. Splint type – flexible splint 4. Splint time – 2 weeks or 1-2 weeks – 7-10 days 5. Start RCT after 2 weeks – if not external root resorption may happen 6. Here we expect normal PDL attachment over a period of 1 year 7. Until then CaOH is placed into the canals, which is replaced every 3 months for 1 year. 8. Possible complication here –– ankyloses or replacement resorption 9. But usually good prognosis

18 AUG 2020 · APICOCECTOMY  Apex removal  RETROGRADE FILLING / ROOT END FILLING  Done if re-infection seen even after re-RCT  Indication o To gain access to are of pathosis – like say a cyst o Poorly filled apical portion o Severe root curvature / non- negotiable canal ends / blockage o Infection after post & core cases – most common cause of opting for apicocectomy o cyst formation cases o Complications happened during RCT – Instrument separation / ledging / perforation o Biopsy  Method: raise flap – curette the apical area – root end resection – condition with EDTA – fill with MTA – then place flap – suture tightly  Grey MTA ( with ferric content, as its not moisture sensitive ) is the material of choice  Success lies in o proper placement of flap o type of flap  Root end resection: o Can cut up to middle 3rd o Flap-- full mucoperiosteal – best flap o 3mm retrograde filling into canal o Usually ideal measurement is about 3-4mm o Ideal angulation is 10° or acute angle o Commonly cut at 45° o Condition – clean – MTA pack – flap – suture

18 AUG 2020 · POST & CORE  When there isn’t enough crown structure  Can put on same day as OBT  Depends on the remaining coronal structure of the nature tooth – indication  Function – retention of core  PIEZO REAMER is used to make post space inside the canal  Continuous wave / sectional GP / system B technique  Resin – modified GIC is ideal to cement post  Factors that affect its efficiency:- a. Length :-  2/3rd of the canal – most imp  4-5mm length from apex  4mm- minimum GP to be left  5mm- ideal GP to be left in the canal b. Diameter :-  Greater the diameter, more the efficiency c. Surface Texture :-  Rough surface is preferable than smooth ones. Roughened / serrated d. Post material :-  Pre-fabricated posts such as fibre posts & metallic posts  Custom made posts such as casted posts e. Post shape :-  Parallel is preferred than tapered ones  More retention CASTED POSTS  Indicated in anteriors & flared canals FIBRE POSTS  Can absorb shock  Best in posteriors  Can withstand masticatory forces METAL POSTS  Least preferred  May fracture the tooth CORE BUILD-UP  Core should take the shape of natural tooth  Should extend to contra-bevel to produce ferrule effect NB: Management of re-infected post & core treated tooth: - Apicocectomy - If not possible go for extraction - Can’t do re-RCT here usually

18 AUG 2020 · LEDGE FORMATION  Ledge is a nick formed on the wall surface of a root canal, especially at the curves that prevent the instrument going further towards the apex- because it gets stuck there.  Caused when instrument that is not pre-curved is inserted into the canal with excessive pressure  Take a small size file – apply EDTA & do circumferential filing for long time- it will help smoothen out the ledge by cutting away excessive dentine.  Thereby bypass the ledge  EDTA helps dissolve & soften the area - chelation property  After correction of ledge & bypass, the wall becomes very thin, therefore chances of perforation - most important complication  Correction at furcation a) Stop RCT b) Place MTA / CaOH / GIC c) Thus the form of a barrier d) Continue with RCT e) Or OBT only after healing  Management of perforation is done after BMP & before OBT PERFORATION a. At furcation / coronal 3rd – good prognosis b. At middle 3rd / apical 3rd – poor prognosis c. If perforation at apical 3rd – poor prognosis d. If at furcation – best prognosis STRIPPING  Danger zone  Mand – mesial aspect of distal root canal- inside aspect of the curved area  Treated with MTA  Rotary instruments  Due to excessive flaring of canals

18 AUG 2020 ·  Correction at furcation a) Stop RCT b) Place MTA / CaOH / GIC c) Thus the form of a barrier d) Continue with RCT e) Or OBT only after healing  Management of perforation is done after BMP & before OBT PERFORATION a. At furcation / coronal 3rd – good prognosis b. At middle 3rd / apical 3rd – poor prognosis c. If perforation at apical 3rd – poor prognosis d. If at furcation – best prognosis