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LECTURE OUTLINE
METHODS OF DETERMINING PULP ANATOMY Textbook Knowledge Radiographic Evidence Exploration GENERAL CONSIDERATIONS Root and Canal Anatomy Identification of Canals and Roots ALTERATIONS IN INTERNAL ANATOMY Age Irritants Calcifications Internal Resorption
COMPONENTS OF THE PULP SYSTEM Pulp Horns Pulp Chamber Root Canals Accessory Canals Apical Region VARIATIONS OF ROOT AND PULP ANATOMY Dens Invaginatus (Dens in Dente) Dens Evaginatus High Pulp Horns Lingual Groove Dilaceration
Textbook Knowledge
Gaining knowledge of anatomy from textbooks is the most important and most useful method of learning. Common and frequent variations must be memorized for each tooth. This means having a working knowledge of the number of roots, number of canals per root and their location, longitudinal and cross-sectional shapes, most frequent curvatures (particularly in the faciolingual plane), and root outlines in all dimensions
Radiographic Evidence
Certainly, radiographs are useful, but they are somewhat overrated for determining pulp anatomy, particularly conventional periapical films. The standard parallel facial projection gives just two dimensions; a common error is to examine only this view, overlooking the important third dimension. In addition, radiographs tend to make the canals look relatively uniform in shape and tapered. In fact, the aberrations often found are generally not visible
Standard projections indicate general anatomic features. Special radiographic techniques disclose missed canals and determine curvatures.
Exploration
Additional determinations of pulp anatomy are made during access preparation and when searching for canals. These methods also have limitations because canals often are neither readily apparent nor easily discovered with instruments.
GENERAL CONSIDERATIONS
Root and Canal Anatomy Identification of Canals and Roots
GENERAL CONSIDERATIONS
A basic tenet in pulp root anatomy is the shape of the pulp system reflects the surface outline of the crown and root. Because the pulp tends to form the surrounding dentin uniformly on opposite walls, the pulp is generally a miniature version of the tooth and conforms to the tooth surface
Different shapes may appear at any level in a single root It is important to note that a canal is seldom round at any level. To assume that it is may result in improper canal preparation
Root canals take various pathways to the apex. The pulp canal system is complex; canals may branch, divide, and rejoin. Canal systems have been categorized into four basic types (Weine classification). Vertucci et al utilized precise techniques and found a complex canal system and identified eight pulp space configurations. Both gender and ethnic origin should be considered during the preoperative evaluation stage.
Type I
Type II
Type III
Type IV
Type V
Type VI
Type VII
Type VIII
3.Orifices location 1: Canal orifices are located at the junction of the walls and the floor. 4. Orifices location 2: Canal orifices are located at the line angles in the floorwall junction. 5. Orifices location 3: Canal orifices are located at the terminus of the root development fusion lines. 6. Color change: Pulp chamber floor color is always darker than the walls
Age
Although dentin formation tends to occur with age on all surfaces, it occurs predominately in certain areas. For example, in molars, the roof and floor of the chamber show more dentin formation, eventually making the chamber almost disclike in configuration. Treatment implications (difficulty in locating chamber and canals) are obvious.
Irritants
Anything that exposes dentin to the oral cavity can potentially stimulate increased dentin formation at the base of tubules in the underlying pulp. Causes of such dentin exposure include caries, periodontal disease, abrasion, erosion, attrition, cavity preparations, root planing, and cusp fractures. Vital pulp therapy, such as pulpotomy, pulp capping, or placement of irritating materials in a deep cavity, may cause an increase in dentin formation, occlusion, or other unusual configurations in the chamber or canals. These tertiary (irregular secondary) dentin formations tend to occur directly under the involved tubules.
Calcifications
Calcifications take two basic forms within the pulp: pulp stones (denticles) and diffuse calcifications. Although pulp stones are usually found in the chamber and diffuse calcifications within the radicular pulp, the reverse may also occur. These calcifications may form either normally or in response to irritation. Pulp stones are often seen on radiographs; diffuse calcifications are visible only histologically. Pulp stones in the chamber may reach considerable size and can markedly alter the internal chamber anatomy Although they do not totally block a canal orifice, pulp stones often make the process of locating an orifice challenging. These large pulp stones may be attached or free and are often removed during access preparation. Although pulp stones are not common in canals, if present, they are usually attached or embedded in the canal wall in the apical region. Rarely do they form a barrier to instrument passage.
Internal Resorption
Such resorptions are uncommon. They are a response to irritation that is sufficient to cause inflammation. Most resorptions are small and are not detectable on radiographs or during canal preparation. When visible radiographically, they are usually extensive and often perforate. Internal resorptions usually create operative difficulties
Pulp Horn
Accessory Canal
Apical Delta
Apical Region
Pulp Horns
Pulp horns represent what the dentist does not want to locate during restorative procedures but does want to locate during access preparation. Although they may vary in height and location, a single pulp horn tends to be associated with each cusp in a posterior tooth, and mesial and distal horns tend to be in incisors. Generally, the occlusal extent of the pulp horns corresponds to the height of contour in a younger tooth but because of continued dentin formation lies closer to the cervical margin in an older tooth.
Pulp Chamber
The pulp chamber occupies the center of the crown and trunk of the root. In mature molars, the roof of the chamber is approximately at the level of the cemento-enamel junction
Root Canals
Root canals extend the length of the root, beginning as a funneled orifice and exiting as the apical foramen. Most canals are curved, often in a faciolingual direction. Therefore a curved canal is often undetectable on facial projection radiographs. The operator should always assume that a canal is curved.
Canal shape varies with root shape and size, degree of curvature, and the age and condition of the tooth Irregularities and aberrations are common in posterior teeth. The chamber tends to occupy the center of the crown; a canal occupies the center of the root. When there are two canals in a root, each will often occupy the center of its own root bulge.
Accessory Canals
Accessory (or lateral) canals are lateral branches of the main canal that form a communication between the pulp and periodontium. They contain connective tissue and vessels and may be located at any level from furcation to apex but tend to be more common in the apical third and in posterior teeth. They do not supply collateral circulation and therefore contribute little to pulp function and probably represent an anomaly that occurred during root formation. These canals do form an exit for irritants from the pulp space to the lateral periodontium. They probably cannot be dbrided during cleaning and shaping but are occasionally filled with obturating materials during canal filling. Dbriding and obturating lateral canals are not important for success of root canal treatment
Apical Region
Development The apex is the root terminus. It is relatively straight in the young mature tooth but tends to curve more distally with time. This curvature results from continued apicaldistal apposition of cementum in response to continued mesial-occlusal eruption. Alterations in the apical region may also result from resorption and irregular cementum apposition. Thus apical anatomy tends to be nonuniform and unpredictable.
Apical Foramen The apical foramen varies in size and configuration with maturity. Before maturation, the apical foramen is open. With time and deposition of dentin and cementum, it becomes smaller and funneled. The foramen usually does not exit at the true (anatomic) root apex but is offset approximately 0.5 mm and seldom more than 1.0 mm from the true apex. For this reason, root canal preparation and obturation end short of the anatomic root apex as seen in the radiograph Usually, the apical foramen is not visible radiographically.
Variations in Anatomy The only consistent aspect of the apex region is its inconsistency. The canal may take twists and turns, divide into several canals to form a delta with ramifications on the apical root surface, or exhibit irregularities in the canal
Apical Constriction The presence of an apical constriction is unpredictable. Frequently there is no apical constriction. It has been proposed that the cementodentinal junction forms the apical constriction; however, this concept is incorrect. In fact, the junction is difficult to determine clinically with accuracy, and the intracanal extent of cementum is variable. If an apical constriction is present, it is not visible on a radiograph and usually is not detectable with tactile sense using a file, even by the most skilled practitioner
Dens Evaginatus
Dens evaginatus is most common in mandibular premolars Clinically, dens evaginatus initially appears as a small tubercle bulge on the occlusal surface, but it may not be obvious radiographically. These tubercles often contain an extension of the pulp. When these fragile tubercles fracture off, the pulp is exposed and will become necrotic, requiring apexification. One method to prevent pulp exposure , before the tubercle fractures, is to remove the tubercle with a bur and then cap, followed by a good sealing restoration
Lingual Groove
Usually found in maxillary lateral incisors, a lingual groove appears as a surface infolding of dentin oriented from the cervical toward the apical direction Frequently, this results in a deep narrow periodontal defect that occasionally communicates with the pulp, causing an endodontic/periodontal problem Treatment is difficult and unpredictable, so prognosis is poor. Usually these teeth require extraction
Dilaceration
By definition, dilaceration is a severe or complex root curvature . During root formation, structures, such as the cortical bone of the maxillary sinus or the mandibular canal or nasal fossa, may deflect the epithelial diaphragm, resulting in a severe curvature. Many of these curvatures are found in a faciolingual plane and are not obvious on standard radiographic projections
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