牙体牙髓病学：Root Canal Obturation

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1、 commercial postsinuspost unfilled canalopen apicesperiapical pathosispermanent fillingcasting postcrownvitapexpreoperation Methods of root canal dressing Obtura Obtura 注射式热牙胶充填仪注射式热牙胶充填仪注射式热牙胶充填仪注射式热牙胶充填仪Maillefer ThermafilMaterials used in obturation It should(be)easily introduced into a root cana

2、l seal the canal laterally as well as apically not shrink after being inserted impervious to moisture bacteriostatic or at least not encourage bacterial growth Materials used in obturationIt should(be)radiopaque not stain tooth structure not irritate periradicular tissue easily and quickly sterilize

3、d immediately before insertion removed easily from the root canal if necessary commercial gutta-percha pointsISO standard.02taperNon-ISO standard gutta percha points .041.2taperThe ruler for selecting different points 20#140#should be tacky when mixed to provide good adhesion between it and the cana

4、l wall when set make a hermetic seal radiopaque not shrink upon setting not stain tooth structure bacteriostatic or at least not encourage bacterial growth set slowly insoluble in tissue fluids tissue tolerant soluble in a common solvent when retreatment not provoke an immune response in periradicul

5、ar tissue neither mutagenic nor carcinogeniczine oxide-eugenol(ZOE)calcium cydroxide containing sealers resin-reinforced chelate formed sealerswidely used in clinic reasonably meets most of Grossmans requirements for sealers Kerr Pulp Canal SealerPowderZinc oxide,reagent 42 partsStaybelite resin 27

6、partsBismuth subcarbonate 15 partsBarium sulfate 15 partsSodium borate,anhydrous 1 partLiquidEugenolcalcium cydroxide containing sealers resin-reinforced chelate formed sealers based on resin chemistry very tacky materials contract slightly while setting has good sealing abilityMethods of obturating

7、 the root canal space Over 100 years countless ways and materials have been developed to fill prepared canals Webster noted“it would seem that the dental profession has not yet decided upon a universal root canal filling material.”Todaymost root canals are being filled with gutta-percha and sealersm

8、ethods vary by the direction of the compaction(lateral or vertical)and/or the temperature of the gutta-percha,either cold or warmwarmed gutta-percha shrinks when it cools lateral compaction of cold gutta-percha vertical compaction of warmed gutta-perchaApical constriction at cementodentinal junction

9、 marks end of root canal From this point to anatomic apex(0.5 to 0.7 mm)tissue is periodontal Ideal end of the preparation and obturationFilling to the radiographic end of the root is actually overfillingoverfillingfilling short of the apexexactly fillingPrimary point size determinationSelection of

10、the master cone the primary point should be selected to match the size of the last instrument used at the apex it should not be able to be forced beyond the working distance the cone should bind in the apical portion of the canalfour methods used to determine the proper fit of the primary point visu

11、al test tactile test patient response radiographic testVisual Test measured and grasped with cotton pliers at a position within 1 mm short of the prepared length of the canal carried into the canal until the cotton pliers touch the external reference point of the tooth.tried in a wet canal If the wo

12、rking length of the tooth is correct and the point goes completely to position,the visual test has been passed If the point can be pushed to the root end,it might well be pushed beyond into the tissue.Either the foramen was originally large or it has been perforated.If the point can be extended beyo

13、nd the apex,the next larger size point should be tried.If this larger point does not go into place,the original point may be used by cutting pieces off the tip.Each time the tip is cut back 1 mm,the diameter becomes larger by approximately.02 mm.By trial and error,the point is retried in the canal u

14、ntil it goes to the correct position.trial and error 试尖试尖Tactile Test the cone should bind in the apical portion of the canal the apical 3 to 4 mm of the canal it should exhibit“tugback”or resistance to withdrawal it should not be able to be forced beyond the working distance.if the point is loose i

15、n the canal,the next larger size point should be tried or the method of cutting segments from the tip of the initial point.Patient Response Patients may feel the gutta-percha penetrate the foramen(not anesthetized during the treatment or nonvital pulp)Adjustments can be made until it is completely c

16、omfortable.This is a good test when the position of the foramen does not appear to be accurately determined by the radiograph or by tactile sensation.Pulp remnants from a short preparation will cause a sensation of much greater intensity than periapical tissueRadiograph Test the final testthe radiog

17、raph the film must show the point extending to within 1 mm from the tip of the preparation is a better criterion of success than either the visual or tactile method It must fit tightly and come to a dead stop Short!the initial point will not go completely into place This condition may arise because

18、the enlarging instrument was not used to its fullest extent there was a larger than standard deviation between the sizes of instruments and gutta-percha debris remains or was dislodged into the canal a ledge exists in the canal on which the point is catching finishingradiograph testthe trial point t

19、estradiograph testthe trial point testmaster conespreader0.51.0mmLateral Compaction of Cold Gutta-perchaLateral Compaction ofCold Gutta-perchasteps Spreader Size Determination Primary Point Size Determination Preparation of the Initial Point Drying the Canal Mixing and Placement of the Sealer Placem

20、ent of the Master Point Multiple-Point Obturation with Lateral CompactionSpreader Size Determination Spreaders are available to match the instruments size(ISO)to reach to within 1.0 to 2.0 mm of the true working length and to match the taper of the preparation should not penetrate the apical orifice

21、 Recommend to choose the spreader of the same apical instrument size or one size largerPrimary Point Size Determination visual test tactile test patient response radiographic testPreparation of the Initial Pointscar the soft point or snipped with the scissors at the reference pointDrying the Canalab

22、sorbent paper pointsexcess moisture or blood may affect the properties of the sealerMixing of the Sealerideal consistency mixture can be held for 10 seconds on an inverted spatula without dropping off mixture can stretch between the slab and spatula 2 cm before breakingPlacement of the SealerRoot ca

23、nal cement/sealer may be placed in a number of ways“Pump”into the canal with a gutta-percha point Carry the sealer in on a file or reamer Use rotary or spiral paste fillers turned clockwise in ones fingers or very slowly in a handpiecerotary paste fillersmaster point coated with sealer about 10mmPla

24、cement of the Master Point The premeasured primary(or master,or initial)point coated with cement Slowly moved to full working length minus 0.5-10mm0.5-10mmLateral compaction,multiple-point filling procedureA Primary point is carried fully to place,to within 1.0 mm of“apical stop.Excess in crown is s

25、evered at cervical with hot instrumentB Spreader(arrow)is inserted to full depth,allowed to remain 1 full minute as gutta-percha is compacted laterally and somewhat apically C Spreader is removed by rotation and immediately replaced by first auxiliary point previously dipped in sealer D Spreader is

26、returned to canal to laterally compact mass of filling.Secondary vertical compaction seals apical foramen E Spreader is again removed,followed by matching auxiliary point.Process continues until canal is totally obturated F All excess gutta-percha and sealer are removed from crown to below free ging

27、ival level.Vertical compaction completes root filling.After an intraorifice barrier is placed,a permanent restoration with adhesives is placed in crown.试试 尖尖主尖作标记主尖作标记试侧压器试侧压器小了小了试侧压器试侧压器合适合适涂封闭剂涂封闭剂主牙胶尖就位主牙胶尖就位侧压器加压侧压器加压加入更多副尖加入更多副尖 Cross-section of middle third of root demonstrating primary and au

28、xiliary cones Gutta-percha cones frozen in a sea of cement Apical part is less condense than middle partDisadvantage 1Gutta-percha cones never merge into homogeneous mass Disadvantage 2 Root fracture occurs when the wedging force is absorbed by the canal wall Premeasuring the spreader depth can redu

29、ce risk of fractureWarm gutta percha techniques Schilder techniquetechniquetechniquetechnique Schilder technique vertical compaction of warm gutta-percha vthree-dimensional obturation of the root canal system with warm gutta-perchavobturated with a maximum amount of gutta-percha and a minimum amount

30、 of sealerVertical Compaction of Warm Gutta-perchaHas proved most effective in filling the canals of severely curved roots and roots with accessory,auxiliary,or lateral canals,or with multiple foraminaPreparation before the step-by-Step procedure thoroughly cleansed and continuously tapering canal(s

31、)6%10%Fitting the master Gutta-percha mone Prefitting the vertical pluggers Heat transfer instrument Root canal sealerthe key to success in this technique-a successful relationship between the radicular preparation and the master coneUsing the conventional cone-shaped gutta-percha points,not the sta

32、ndardized numbered pointsThe cone must fit tightly in the apical third,have“tugback”Fitting the Master Gutta-percha ConeFitting the Master Gutta-percha ConePrefitting the Vertical Pluggers the wider plugger-the coronal third of the canal the narrower plugger-the middle third the narrowest plugger-th

33、e apical thirdSchilder Pluggers(designed by Schilder)Heat Transfer Instrument“Touch n Heat”5004,battery-powered(rechargeable)heat source.Heat carrier heats to glowing within seconds toplasticize gutta-percha in canal.Also used in removal of gutta-percha for postpreparation or re-treatment.Obtura II

34、delivery systemPanel has temperature control and digital temperature display in degrees Celsius.The pistol-grip syringe extrudes plasticized beta-phase gutta-percha through flexible needleRoot Canal SealerStep-by-Step Procedure of Vertical Compaction of Warm Gutta-percha1.Dry the canal!Best achieved

35、 by using 100%alcohol irrigated deep within the root canal system using thin,safe-tipped irrigating“needles”Dried with paper points Confirm the patency of the foramen with an instrument smaller than the last size instrument used to develop the apical preparation.2.Fit the appropriate gutta-percha co

36、ne to the patent radiographic terminus It should visually go to full working length and exhibit tug-back Confirm the position radiographically Cut off the butt end of the cone at the incisal or occlusal reference point3.Remove the cone and cut back 0.5 to 1.0 mm of the tip,reinsert,and check the len

37、gth and tug-back The cones apical diameter should be the same diameter as the last apical instrument to reach the radiographic terminus of the preparation Remove the cone,dip it in alcohol,set the cone aside4.Prefit the three pluggers to the prepared canal first the widest plugger to a 10 mm depth n

38、ext,the middle plugger to a 15 mm depth finally,the narrowest plugger to within 3 to 4 mm of the terminus Record the lengths of the desired plugger depth5.Deposit a small amount of root canal sealer in the canal.Lightly coat all of the walls6.Coat the apical third of the gutta-percha cone with a thi

39、n film of sealer7.Grasp the butt-end of the cone with cotton pliers and slide the cone approximately halfway down the canal 8.Using the Touch n Heat 5004 heat carrier,sear off the cone surplus in the pulp chamber down to the cervical level 9.Using the widest vertical plugger to compact the gutta-per

40、cha in an apical direction with sustained 5-to10-second pressure 10.The second heat wave begins by introducing the heat carrier back into the gutta-percha,where it remains for 2 to 3 seconds and,when retrieved,carries with it the first selective gutta-percha removal11.Immediately,the midsized coated

41、 plugger is submerged into the warm gutta-percha.The vertical pressure also exerts lateral pressure.This filling mass is shepherded apically in 3 to 4 mm waves created by repeated heat and compaction cycles12.The second heating of the heat carrier warms the next 3 to 4 mm of gutta-percha and again a

42、n amount is removed on the end of the heat carrier13.The narrowest plugger is immediately inserted in the canal and the surplus material along the walls is folded centrally into the apical mass so that the heat wave begins from a flat plateau.The warmed gutta-percha is then compacted vertically,and

43、thematerial flows into and seals the apical portals of exit14.The apical“down-pack”is now completed,and if a post is to be placed at this depth,no more gutta-percha need be used15.“Backpacking”the remainder of the canal completes the obturation 16.An alternative method of backpacking may be done by

44、injecting plasticized gutta-percha from one of the syringes,such as Obtura II17.The final act involves the thorough cleansing of the pulp chamber below the CE junction,the addition of an appropriate barrier,and the placement of a permanent restoration Disadvantagescomplexity undesirable stress conce

45、ntrations introduced into the tooth through vertical compaction(-tooth cracks)the temperatures generated within the canal from the warming process(-endanger the lateral periodontium)Selection of the cases complex canal(s)large canal(s)large periapical lesions retreatment canal needs to place the pos

46、tDelta formationfour portals of exit 3-5large canal 140palatal canal of upper first molardistal canal of lower second molar post spaceretreatment retreatmentLateral compationWarm gutta-phacher compation2 to 1 type canalsmultiple canalsEvaluating success and failure根管治疗术的根管治疗术的疗效疗效-牙髓根尖周病通过牙髓根尖周病通过根管

47、治疗术后根管治疗术后,在一定的时间内在一定的时间内,对其成功对其成功与失败与失败,或其最后转归的评估或其最后转归的评估疗效评定的内容疗效评定的内容v 患者的主客观症状患者的主客观症状 有无自发痛或咬合痛有无自发痛或咬合痛 有无肿胀史有无肿胀史,化脓史化脓史 每次疼痛持续的时间、范围和程度每次疼痛持续的时间、范围和程度 疼痛的诱发因素及缓解因素疼痛的诱发因素及缓解因素 咀嚼功能是否良好咀嚼功能是否良好 病史和治疗史病史和治疗史疗效评定的内容疗效评定的内容客观检查客观检查牙体牙体:牙冠修复是否合适牙冠修复是否合适,完整完整,有无叩痛有无叩痛牙周牙周:软组织颜色及结构软组织颜色及结构,牙周袋牙周袋,

48、瘘道瘘道,松动度全身松动度全身包括心理和生理两个方面包括心理和生理两个方面疗效评定的内容疗效评定的内容vX线片线片 根管充填是否严密根管充填是否严密,合适合适 尖周牙周膜腔是否增宽尖周牙周膜腔是否增宽,骨板是否连续骨板是否连续 牙槽骨的密度及纹理是否正常牙槽骨的密度及纹理是否正常 尖周稀疏区的大小尖周稀疏区的大小,形态形态,密度和周边情况密度和周边情况 (术前后对比术前后对比)根尖有无吸收现象根尖有无吸收现象 根管有无旁穿器械折断根管有无旁穿器械折断疗效标准疗效标准成功成功:无症状和体征无症状和体征,咬合功能正常咬合功能正常,有完整的咬合有完整的咬合关系关系,X线片显示根充严密合适线片显示根充

49、严密合适,尖周透射区消失尖周透射区消失,牙牙周膜间隙正常周膜间隙正常,硬板完整硬板完整;或或无症状和体征无症状和体征,咬合功能咬合功能良好良好,X线片显示根尖周透射区缩小线片显示根尖周透射区缩小,密度增加密度增加疗效标准疗效标准失败失败:无症状和体征无症状和体征,咬合有轻度不适咬合有轻度不适,X线片显线片显示根尖周透射区变化不大示根尖周透射区变化不大;或或有较明显症状和体有较明显症状和体征征,不能行使正常咀嚼功能不能行使正常咀嚼功能,X线片显示根尖周透线片显示根尖周透射区变大或原有尖周无异常者出现了透射区射区变大或原有尖周无异常者出现了透射区X线检查的误差线检查的误差 角度的变化角度的变化 胶

50、片的质量胶片的质量 X线层次变化的缺乏线层次变化的缺乏 附近解剖标记的影响附近解剖标记的影响 尖周疤痕组织的尖周疤痕组织的X线透射性线透射性 诊断者个人的偏见诊断者个人的偏见根充后根充后8年年自制充填尖自制充填尖拍照的不同角度拍照的不同角度 Procedural errors and management 1 Postoperative pain wrong working length over preparation not correct instrumentation strong stimulation of the intracanal medicine impropriate f

51、illing time overfilling Procedural errors and management 2instrument separated in the canal deformed instrument fatigued instrument Procedural errors and anagement 3 Perforation not familiar to the tooth morphology chamber and canal system Procedural errors and management 4 swallowing the instrumentThe most serious error for the dentist and the most danger for the patient！