Clinical Management of Endodontic Cases

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Clinical Management ofEndodontic Cases

Dr. Abhishek Parolia

International Medical University


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Learning Objectives

To be able to analyze the criteria for patient selection for root canal procedure

To be able to apply the objectives of access cavity preparation

To be able to understand the clinical importance of anatomy of root apex

To be able to understand the need of debridement of root canal

To be able to select a suitable irrigant and use them in various clinical scenario

outcome for the best

To be able to understand the role of biofilm

To be able to explain the need of intracanal medicament

To be able to correlate the importance of coronal seal with the endodontic success

To be able to understand the mechanism of tissue regeneration


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To follow the Hippocratic Oath whichsays ”First, do not harm” the vital

healthy surrounding tissues


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Healthy tooth


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Oh NO…..

Let me

read

first..

Shocked

This is my

first time,

GOD please

save me


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Root canal treatment usually fails when treatment

falls short of acceptable standards

PROCEDURAL

ERRORSMICROBES FOREIGN

BODY

REACTION

In most cases, procedural errors do not jeopardize theoutcome of endodontic treatment unless a concomitant

infection is present.


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Microbes-responsible for success and failure in Endodontics

Elimination= SuccessPersistence= Failure


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ROOT CANAL THERAPY

The complete removal of all vital, necrotic tissue

and micro-organisms from the complex root

canal system

What is it ?


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OBTURATION AND

POST ENDODONTIC

RESTORATION

SHAPING AND CLEANING

DISINFECTION

CORONAL CAVITY

PREPARATION1

3

2


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Ray HA, Trope M (1995). Periapical status of endodontically treated teeth in relation

to the technical quality of the root filling and the coronal restoration. Int Endod J28:12-18.

The technical

quality of the

coronal

restoration

The technical

quality of the

endodontic

treatment

Poor coronal restorations even in

combination with good endodonticfillings

Negative impact onoutcome


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What percentage of success

after root canal treatment ?

8.6%

Endodontic59.4%

Restorative

Reason for failures of endodontically

treated teeth ( Vire 1991)

32%

Periodontal

?


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Kirkevang LL, Ørstavik D, Hörsted-Bindslev P, Wenzel A (2000).

Periapical status and quality of root fillings and coronal restorations

in a Danish population. Int Endod J 33:509-515.

Both the quality of the endodontic treatmentand the coronal restoration affect the health

of the periradicular

tissues in a synergistic way


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Knowledge

• Basic knowledge of the tooth and root canal

morphology of all the teeth and anatomical

variations in the number and locations of root

canals is crucial in endodontic treatmentoutcome.


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Accurate Diagnosis;

the first stage of successful therapy


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ACCURATE DIAGNOSIS

Is a result of the synthesis of

Scientific knowledge-recognizeoutside/inside the scope of the dentist

Clinical experience- very important

Interest- attitude

Curiosity –to suspect the unusualIntuition

Patience- to know the details


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CBCT

PULSE OXIMETRY

DENTA SCAN

ULTRASOUND


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Chief complaint

Medical

history

Dental

history

Patient

interaction

Physical

inspection

Diagnostic

tests

Radiographic Interpretation

Data Evaluation

Consult Referral

Diagnosis

Treatment


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Factors to be considered before

initiating endodontic therapy

Infection control


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FEAR OF LAW


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Isolation (Rubber Dam)


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Anesthesia and Pre-operative radiographs


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Application of Radiography to Endodontics

Diagnosis of hard tissue alterations of the teeth and periradicularstructures

Determine the number, location, shape, size, and direction ofroots and root canals

Estimate and confirm the length of root canals before

instrumentation

Aid in locating a pulp that is markedly calcified and/or receded

Determine the relative position of vital structures in the facial –lingual dimension

During following periradicular surgery

Evaluate the outcome of endodontic treatment


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INTERNAL ANATOMY OF TOOTH

Complex root canal system


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Major apical diameter

Minor apical diameter/

Apical constriction/

Histological foramen

Root apex

Cementodentinal junction

Apical foramen

Cementum

Dentin

(Morning glory appearance)


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CORONAL CAVITY PREPARATION

Factors to be considered

Assessment of tooth restorability Presence of caries/ old restorative material

Removal of the Remaining Carious Dentin and Defective

Restorations

1. To mechanically eliminate as many bacteria as possible2. To eliminate the discoloured tooth structure that may

ultimately lead to staining of the crown

3. To reduce the risk of bacterial contamination and

blocking of the root canal space


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Radiographic measurement of the depth of the pulpchamber from the occlusal table

Position of teeth in jaws

Number, position and curvature of entire root canal

Use of magnifying loupes/ microscope


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50% of all molars (maxillary and mandibular) have a

fourth canal, more than 30% of all premolars have a

third canal, and close to 25% of all anterior teethhave two canals.

S. Kim, S. Baek / Dent Clin N Am 2004 ;48 :11– 18

Exploration of

hidden canals at

high magnification

MICRO-OPENER


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Diagnosis

Detection of microfractures

Locating hidden canals Management of calcified canals

Perforation repair


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Achieve straight-line access to the apical foramen

locate all root canal orifices

Conserve sound tooth structure

Optimal access results in straight entry into the

canal orifice, with the line angles forming a funnel

that drops smoothly into the canal(s).


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The cementoenamel junction (CEJ) is the most important

anatomic landmark for determining the location of pulp

chambers and root canal orifices.

Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. J Endod

2004;30(1):5.

Ceiling of the pulp chamber

At the level of the cementoenamel junction in 97 percent

to 98 percent of the maxillary and mandibular molars

Deutsch AS, Musikant BL. Morphological measurements of anatomic

landmarks in human maxillary and mandibular molar pulp

chambers. J Endod 2004;30:388 – 90.


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oLaw of orifice location 1

The orifices of the root canals are always located atthe junction of the walls and the floor

oLaw of orifice location 2oThe orifices of the root canals are located at the

angles in the floor wall junction

Law of orifice location 3The orifices of the root canals are located at the

terminus of the root development fusion lines


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ARMAMENTARIUM

LONG SHANK

ROUND BUR

LONG SHANK

SPOON

EXCAVATOR

DG 16 PROBE/

ENDODONTIC

EXPLORER

GATES GLIDDEN

ENDO

ACCESS

SAFE ENDED

DIAMOND

ABRASIVE


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Access cavity

The occlusal projection of the access cavity must be larger

than the base, to allow better visualization of the floor.

OCCLUSAL LOADOCCLUSAL LOAD


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OCCLUSAL LOADOCCLUSAL LOAD

REMEMBER!!!


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REMEMBER!!!

• Pulp extirpation should be done completely.

• Tissues from the pulp horns should be carefully removed

• Always check the patency of canal

•Periapical instrumentation should be avoided-Post-op pain

Don’t use an air syringe - possibility of an air embolism

Use Sodium hypochlorite (NaOCl)

• Disinfection

• Removal of hemorrhagic or purulent fluids

• Flushing action of debris and dentin chips


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Patency is important

Significant debris toremain harbored in the

canal’s apical third

(predisposing the case to

failure) Blockage can be a major

factor in causing

iatrogenic events (most

commonly, ledging andseparated instruments)


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Determine Correct working length


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Shaping and Cleaning


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BIOLOGICALMECHANICAL

OBJECTIVES


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Shaping facilitates cleaning by removing restrictive

dentin which allows for a more effective reservoir of

irrigant.

Shaping is the development of a “logical” cavity

preparation that is specific for the anatomy of any

given root.

Shaped canals hold a larger volume of irrigant that can

potentially circulate, penetrate, and clean into all

aspects of the root canal system.


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PROFILE

RaCe


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Greater tactile awareness of the apical constriction Reduce coronal binding of instruments

Less risk of inoculation of endodontic pathogens into

the periradicular tissues

Enhance penetration of irrigant into the root canalsystem

Less likelihood for a change in the working length

measurement during preparation

More effective performance of electronic apex locators

Crown down technique is preferred


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Shortening of

the working

length


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Mechanical instrumentation of root

canals can reduce bacterial

population

Effective elimination of bacteria

cannot be achieved without the use of

antimicrobial root canal irrigationand medication


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DISINFECTION

Disruption and

removal of the

biofilm

Elimination of the

smear layer

Debridement of

pulp remnants and

irritants


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A biofilm is a structured community of bacteriaenclosed in a protective, sticky polysaccharide matrixthat can adhere to a root canal surface.

Further, planktonic, free floating organisms withinbiofilm fragments disrupt, drift, and reattach to anysurface within the root canal system, including within

dentinal tubules

Biofilm


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Deposition ofa conditioning

film,

adhesionplanktonicmicrobes

colonization ofplanktonic

microorganism

s in a

polymeric

matrix

co-adhesion ofother

organisms

detachment ofbiofilm

microorganisms into

surroundings Endodontic Infectionand

Biofilm

BIOFILM


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BIOFILM

R.C.S.-Microenvironment; dense biofilm adhere to dentin


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There is convincing evidence that

microorganisms organized in this manner are farless susceptible to antimicrobial agents than

their planktonic counterparts, which have

traditionally been used to test the antimicrobialefficacy of substances in vitro.

• Wilson M. Susceptibility of oral bacterial biofilms to antimicrobial

agents. J Med Microbiol 1996;44:79– 87.

• Matthias Zehnder. Root Canal Irrigants. J Endod 2006;32:]389– 398


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IRRIGATION

Irrigation


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Irrigation

• NaOCl-2.5%,1%,0.5%

• CHX gluconate-0.2%,2%

• Ozonated water

• Bio Pure MTAD

• EDTA-17%

• Ultrasonics

•

Photo-activated disinfection• ECA

• LASER


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Significant factors that influence cleaning

SEQUENCE

TIME

VOLUME

FREQUENCY

STRENGTH


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The potential to debride and disinfect is further

influenced by alternating between specific typesof intracanal solutions, or using them in

combination.

“Final Rinse Solutions”

Advocated to enhance root canal cleaning

MTAD (Dentsply Tulsa Dental Specialties) Smear Clear (SybronEndo Specialties)

Chlorhexidine (CHX)


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Vital pulp tissue can defend against microorganisms and isthus largely noninfected until it gradually becomes necroticLangeland K. Tissue response to dental caries. Endod Dent Traumatol

1987;3:149 – 71.

Treatment of vital cases should focus

on asepsis, i.e. the prevention ofinfection entering a primarily sterile

environment (apical portion of the root

canal)


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In contrast, the pulp space of nonvital teeth with

radiographic signs of periapical rarefaction always harbors

cultivable microorganisms Zehnder M. Root Canal Irrigants. J Endod 2006;32:389– 398

Antisepsis key issue in nonvital cases

NaOCl


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NaOCl

• Tissue solvent-Best property

• Effective on biofilm and against micro-organism

present in dentinal tubules

• Removes organic components of smear layer

• Tissue irritant-confine to root canal system .

• 2.5-3% Best concentration

• Combine with chelating agent for better action

• Heat it, combine with ultrasonics –better action


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ULTRASONICS


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ULTRASONICS• 25 gauge irrigating needle connected to ultrasonic

unit+ 6% NaOCl solution for 1 min.- Very cleancanals

GutartsR. Et al. In vivo debridement efficacy of ultrasonic irrigation

following hand – rotary instrumentation in human mandibular

molars J.Endod 2005;31;166

Device for

heating syringes

filled withirrigation

solution (e.g.,

NaOCl) before

use


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CHX


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CHX• Antibacterial, Substantive properties

• Various forms- Acetate/Hydrochloride/Digluconate

(Prferred)• Effective against E faecalis, A israelli,

P intermedia, F nucleatum…

•

Ability to inhibit adherence of certain pathogens• Lacks tissue dissolving property

• Does not remove smear layer

• 2% concentration Best as a final irrigant

• Zamany A, Safavi K, Spångberg LS. The effect of chlorhexidine as an endodonticdisinfectant. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:578 – 81.


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EDTA


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EDTA

It removes inorganic component of the smear layer

It detaches biofilm adhering to the root canal

It reacts with calcium ions of dentin

and forms soluble calcium chelates.It decalcifies dentin upto the depth

of 20-30 micrometer in 5 minutes

A continuous irrigation of 5 ml of 17% EDTA for 1 minute

Erosive EDTA-Use it carefully


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Erosive EDTA-Use it carefully

Use 7% Maleic acid instead of 17% EDTA

N. Vasudev Ballal,, K. Sreenesh,, M. Kundabala,, K.S. Bhat,

Shashirashmi Acharya. Comparison of the Efficacy of Maleic Acid

and EDTA in Smear Layer Removal From Instrumented Human Root

Canal: A Scanning Electron Microscopy Study . J Endod. 2009


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Improves working

time of the irrigant

Improves cutting

efficacy of hand

instruments

Reduces torsional loadon rotary nickel-

titanium instruments

Sodium Hypochlorite


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17 % EDTA

After the smear

removingprocedure a finalrinse with an

antisepticsolution appears

beneficial


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Antibiotics

The local application of antibiotics -more effectivemode for delivering drugs than systemic routes ofadministration.

BioPure (MTAD) is effective in removing the smearlayer.

Tetraclean, is a mixture of an antibiotic(doxycycline), an acid and a detergent (like MTAD),with a very low surface tension and high degree ofefficacy against bacterial biofilms.

MTAD


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A) Tetracycline:

i) Broad spectrum antibiotic

Bacteriostatic in nature.

ii) Low pH

iii) Calcium chelator

Surface demineralization similar to citric acid

iv) Substantive property

v) Promotes healing

vi) Removes smear layer

B) Citric Acid – also removes smear layer, Bactericidal

C) Detergent – Tween 80, decreases surface tension.

Electrochemically activated (ECA)


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Electrochemically activated (ECA)

solutions

• Produced from tap water and low concentration

salt solutions

•

ECA solution found to be similar to NaOCl in debrisremoval but was more effective than NaOCl in

smear layer removal.

• Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal

irrigation with electrochemically activated anolyte and catholyte

solutions: a pilot study. Int Endod J 2000;33:494-504.

Lasers assisted canal preparation


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Lasers assisted canal preparation

• Nd:YAG,erbium:YAG laser, Diode laser

• induces lethal photosensitization on canal

microbiota

• Adjuant to chemomechanical preparation

• High cost of lasers

• No access into severely curved canals

•

Not cleaned where optic fiber has not been touched

Light activated disinfection


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g

or photodynamic therapy(PAD)

• In combination with chemomechanical preparation ,the

advanced non-invasive LAD significantly inactivated

bacteria in biofilms

Z.Lim et.al. Light activated disinfection: an alternative

endodontic disinfection strategy. Aust Dent J 2009;54;108-

114.

Recent techniques


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Recent techniques

• Ozonated water

• Ozone (Healzone)

• High frequency current (Endox)

Efficacy on endodontic microbiota in biofilms, there is

good evidence that none of these aproaches canmatch a simple sodium hypochlorite irrigation

Intracanal Medication


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Intracanal Medication• Ca(OH)2- Universal for chronic infections

• Triple antibiotic paste (ciprofloxacin, metronidazole,and

minocycline)-Acute as well as chronic infections

• Ledermix – for acute infections and to prevent resorptions

• Ledermix and Ca(OH)2-chronic infection & to prevent

resorption

• IKI- resistant infections

• Eugenol- as obtundent

• CMCP-tissue fixative


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Calcium Hydroxide

The lethal effects of calcium hydroxide are due to severalmechanisms

Chemical action Damage to the microbial cytoplasmic membrane by the

direct action of hydroxyl ions

Suppression of enzyme activity and disruption ofcellular metabolism

Inhibition of DNA replication by splitting DNA

Calcium hydroxide


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Calcium hydroxide

The biological properties

• Biocompatibility (due to its low solubility inwater and limited diffusion)

• The ability to encourage periapical hard tissuehealing around teeth with infected canals

Inhibition of root resorption and stimulation of periapical healing after trauma.


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Calcium Hydroxide

• The ability of E. faecalis to colonize within

dentinal tubules and thus evade the hydroxyl ions

• Promotes the adhesion of bacteria to collagen (the

main organic component of dentine) which

increases the extent of tubule invasion and therebyresistance to further disinfection.


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T i i


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Tri- mix

A triple antibiotic paste consisting ofmetronidazole, ciprofloxacin and minocycline, has

been reported to be very effective in the

disinfection of the root canal system.

Windley et.al.,2005,Disinfection of immature teeth with a triple

antibiotic paste. J. Endod,31,439-43

I i i l i


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Irrigating solutions

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• To achieve success -follow sound biologic principles


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• To achieve success -follow sound biologic principles.

•

Gentle manipulations carried out locally would give better and faster results – Avoid systemic drugs such asantibiotics and analgesics.

• It is fallacy to think that use of newer endodonticequipment and instrument would give higher successrate, these should be taken only as adjuncts.

• The real factor being the sound knowledge and skill ofhandling the biologic tissues.

FUTURE


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FUTURE

Tissue engineering

• Enamel crystals

• Implanting -Pulp dentin complex

• Revascularization


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TOOTH

ENAMEL

PULP-DENTIN

PERIODONTALLIGAMENT

Scaffold

Morphogen

Stem cell

Tissue-Engineered

Tissues

F

-


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F Amelogenin

Fluorapatite Nanorods


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Pulp-Dentin

Complex3-D Tissue Culture

BMP’s

Stem Cells

Scaffold

TransplantationRegeneration of

Dentin

R E V A S C U L A R I Z A T I O N


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CLOT

FORMATION

APICAL

TERPHINATION ANGIOGENESIS

PULPAL

NECROSIS

R E V A S C U L A R I Z A T I O N

Success of revascularization depends on canal disinfection during

the process with triple antibiotic paste

THANK YOU


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THANK YOU

Clinical Management of Endodontic Cases

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