Medicine

Treatment of periodontitis of temporary teeth in children

Treatment of periodontitis of temporary teeth in children. Indications for choice of treatment. The method of treatment.

Treatment of periodontitis of deciduous teeth

Clinical and morphological features of chronic periodontitis in childhood

causing difficulties facing children's dentist in the development of his

therapeutic approach, which should be aimed at achieving the ultimate goal - to save the

tooth and removal of foci of chronic infection. Conservative treatments for periodontitis is

not always possible to achieve the complete elimination of odontogenic source of

infection, so there is a need for surgical intervention, followed by removal of the tooth.

It is believed that in severe chronic diseases of children (pneumonia and chronic

bronchitis, chronic kidney disease, frequent respiratory infections, severe sore throat)

dramatically expanded the indications for radical restructuring, but the children of tooth

extraction at the present level of Endodontics is an extreme measure.

nent tooth germ involvement in the inflammatory process.

Inflammatory processes in the pulp and periodontium in children are closely interrelated. Among the 32% of chronic periodontitis developed because of improperly treated pulpitis , 38 % - because untreated caries and 30% - as a result of trauma.

Treatment of periodontitis baby teeth is a very complex manipulations. The challenge children's dentist - to be able to properly assess the condition of the milk tooth with periodontitis .

Methods of treatment of periodontal conditions deciduous teeth can ¬ but divided into conservative , aimed at preserving ana ¬ nomic and functional integrity of the tooth and surgery - removal of tooth Periodontal infection as a source .

Contraindications to conservative method of treating periodontitistion of deciduous teeth:

- A situation where the tooth is causing acute septic condition, chronic infection and intoxication ;

- Damage compact plate surrounding the follicle pos ¬ of continuous tooth (according to X-ray );

- Pathological or physiological root resorption of more than 1/ 3 of its length;

- The complete destruction of the crown , if his physiological changes remain less than 1.5 years;

- Perforation of the wall or floor of the root of the tooth;

- The lack of effect of conservative treatment (preservation signs of acute inflammation, tooth germ nevytrymuvannya cal closure , etc);

- Retention of the tooth in the jaw when the eruption of permanent teeth .

The goal of conservative treatment of periodontitis of deciduous teeth is by careful mechanical and pharmacological volopment of root canal obturation and his , to ensure proper ¬ nd and timely flow of physiological process of root resorption and prevent damage and disruption of folikula permanent tooth.

The basic principles of treatment of periodontal ¬ that is the effect on the system makrokanaliv (elimination putrydnoho decay removal of infected predentynu , disposal microorganisms body naturally ) microchannels (blocking infection of dentinal tubules) and periapical tissues ( eliminate inflammation and enabling environment for periodontal tissue regeneration ).

The choice of treatment strategy of periodontitis of deciduous teeth depends on the etiology and course of the process (acute , chronic , worsening of chronic ) , stage of root stock and the size of the fire periapical destruction, physical and mental condition of the child.

On the basis of clinical presentation alone is not always possible to make a correct decision . Sometimes shallow carious cavity without fistula on the gums or even intact tooth can occur with significant resorption or early termination of root formation . Therefore, there is strict rule : before you treat any tooth in chronic periodontitis, especially in children , do the x-ray to evaluate the root periapical tissues and permanent tooth germ involvement in the inflammatory process.

Treatment of acute periodontitis of deciduous teeth

Figure 1. Apical periodontitis temporary tooth

Figure 2. Endodontic treatment of apical periodontitis.

Conservative treatment of acute infectious periodontitis aimed at eliminating periodontal inflammation , relieving pain and preventing the spread inflammation in other parts of the maxillofacial area . Fluid formed in periodontal tissues can find out several ways: through root canal through the jaw bone under the periosteum of the vestibular or language , because of the holes tsevyy course ( an exacerbation of chronic periodontitis ), through the gingival sulcus, through the cell tooth extraction . We're best cosdig outflow of serous or purulent exudate from periodontal through Korea unused channel. In the absence of fluid from the discharge channel at SFORnating apical aperture is obligatory opening it , but the temporary teeth are usually such a need arises. Treatment of multiple visits.

In the first visit should be implemented as follows:

- Anesthesia. The high analgesic efficacy with the group anesthetics Articaine: Ultracain

DS Forte (Hochst), Septanest (Septodont), Ubestesin (ESPE). They contain in their

composition vasoconstrictor whose content is strictly dose tures. In pediatric practice

anesthetics should be used with minimal vasoconstrictor (1:200 000), for example

Ultracain DS (Hochst);

- Opening the cavity of the tooth using a high-speed handpiece;

- Remove the channel putrydnyh mass submerged antiseptic solution using pulpekstraktora appropriate size, if sometimes very wide channels must be used for this purpose multiple pulpekstraktoriv, in teeth with immature root or its resorption during this phase is performed very carefully;

- In the absence of fluid outflow through the root canal and SFORnating root apex - the opening of the apical foramen for my help file or rymera;

- If pid'yasennoho or nadkisnychnoho abscess - his incision and drainage;

- Assign trays with 0.5% solution of sodium bicarbonate in to rinse the mouth;

- Appointment sulfanilamides in case of severe intoxication - antibiotics, analgesic and desensitizing agents in the dosage according to age;

- Appointment of a large amount of fluid nepodrazlyvoyi food that does not require heavy chewing, a general

therapy.

After the first visit the tooth remains open. ment has to come to the reception each day, each assessed her condition, if necessary, is correction treatment policy, pereviryayet be complete drainage of the presence of periodontal gap and carried antiseptic root canal.

Continued treatment is possible after calming down for sharp inflammatory phenomena: spontaneous pain, collateral edema, expressed Woman bolisnosti during palpation of the gums in the area of the patient's tooth bolis ness during percussion of the tooth.

At the next visit is made: The next visit is conducted:

- Full instrumental and antiseptic root caduct using nayefek tyvnishyh medicines

(0.5-1% solution of sodium hypochlorite, 3% hydrogen peroxide solution);

- Putting into channel drug antiseptic protyzacombustible action on turundas or as a paste (Kamfokrezol, Krezofen, Krezodent);

- Insulation cavity of the tooth with a tight bandage Volyn NGO temporary filling material (dentin-paste, etc.).

Completion of treatment depends on the optimal duration of action of drugs that are part of the root bands (1-6 days). In the absence of exacerbation of manifestations, smooth percussion, absence of exudationness of the channel (as evidenced by the lack of change coloring turundas of yodynolom entered in the channel) is performed plom accommodated root canal paste dissolves, and restoration of the form ¬ tooth permanent sealing materials (after renthenolohichnoho quality control filling of the root canal).

Treatment of chronic periodontitis of deciduous teeth in the acute stage is the same as the treatment of acute periodontal that infectious origin.

Chronic periodontitis baby tooth can affect the germ of the constant in the following cases:

1. If inflammation has emerged at a time when there began calcification of permanent teeth, the teeth of the follicle dies.

2. With the penetration of infection into permanent tooth follicle, also in the early stages of formation, there may be a violation of enamel calcification. Clinically it is manifested by the presence of erosions or no enamel (tooth Turner).

3. If a permanent tooth crown or a portion of its already established and chewing surface area reached its sprout, then crown dies, which leads to the termination at the formation of the tooth and it sekvestruyetsya. On radiographs in this case instead of a zone of growth seen fire dilution with fuzzy

contours and offset crown toward the alveolar ridge.

4. In the long-term course of the inflammatory process observed change of the rudiments of the permanent teeth under the influence hranulyatsiynoyitkanyny or manure.

5. Early destruction of bone separating the roots of deciduous teeth, the beginnings of permanent, chronic periodontitis sets the earlier eruption of permanent teeth.

It should be remembered that the emerging roots can easily take zony growth by To distinguish them from each other in the following ways: the presence of periodontal gap rostkovoyi zone has formed a uniform width of the root and then merges with the zone of growth. Cortical plate interalveolar septum is an extension that limits the growth zone. With the death zone growth observed disappearance of the cortical plate, fireplace dilution has different dimensions and fuzzy boundaries.

Treatment of acute toxic periodontitis of deciduous teeth

not fundamentally different from the treatment of periodontitis in the permanent teeth of children.

In the first visit should be taken:

- Removal of pulp devitalization

- Treatment of root canal preparation antidote: when mysh'-kovystomu Periodontitis - 5% solution unitiola (it is less toxic and more effective), sodium thiosulfate, 5% iodine solution, 1% solution yodynolu in the event of damage to periodontal tissues ¬ tion phenol - Castor (castor) oil or 10% emulsion anestezina in castor oil;

- Making an antidote to the root canal on turundas;

- Hermetic closure of the cavity of the tooth for 24 h.

A child is prescribed an appointment to come every day. When you gathertion of pain and painful percussion antidote treatment is repeated restored root dressing for another day. A root canal is sealed after the disappearance of symptoms of acute periodontitis. The tooth can not be left open as possible infection perio donta through the root canal.

Treatment of chronic periodontitis of deciduous teeth

Treatment of chronic periodontitis of deciduous teeth can be done in one or two visits. If the fistula at Yastries, no channel gangrenous disintegration of putrid odor , subject to availability immediately carry out a full instrumental and drug processing channel in somatic healthy children who are not currently taken orally antibiotics, corticosteroids , or other means of immunosuppressive action possible treating in one visit. Active full instrumental and shalldykamentozna root canal treatment and filling it netverdnuchoyu paste (Iodent, Kalasept, Multykal, tsynkodsydevhenolova pasta, etc.).

with the restoration of coronal permanent filling materials.

Most periodontal treatment is carried out in two visits.

In the first visit made:

- Nekrotomiya and forming cavity ;

- Opening cavity of the tooth;

- Remove the channel putrydnyh mass submerged antiseptic solution by pulpekstraktora appropriate size or by several pulpekstraktoramy by In the first visit made:

very large channels , in the teeth of the root or immature during its resorption that stage is done very carefully;

- If necessary - removal of granulation that is fundamentally rooted ¬ ing channel after processing kamforofenolom or a mixture of phenol anestezin introduced in a channel on turundas (procedure has pro ¬ hobnob with caution because of the risk of burns of the mucous membrane roto ¬ ing cavity) ;

- Full instrumental and antiseptic root canal using nayefek ¬ tyvnishyh drugs;

- Filling the root canal treatment or paste contribu ¬ Senna turundas with certain medicines;

- Insulation cavity of the tooth with a tight bandage ¬ Volyn NGO temporary filling material ( dentin - paste , etc.).

For the purpose of impregnation of macro-and microchannels and for koahu ¬ modulation growths of granulation in the channel is sometimes used formalinvmisni drugs , including resorcinol - formalin liquid, and ¬ and also silver nitrate solution. The structure of resorcinol - formalin fluid ¬ HN includes formalin ( 36,5-37,5 % formaldehyde solution , which Dan ¬ tour and sequesters the protein body tissues and bacterial cells , acting through the release of formaldehyde vapor , thus realizing its bactericidal and withering effect ) and resorcinol (has protymikrob ¬ well activity). 4% alcoholic solution of silver nitrate (following his recovery solution 4% hydroquinone ) diffuses well into dentinal tubules, has an antibacterial effect , eliminates protein mass putrydnoho collapse , forming with them albuminates silver. After treatment of the root canal silver nitrate and restoration ¬ tions on its walls formed silver film impermeable to tank ¬ Terry . However, remember that during the emerging root resorption or use of these substances can lead to periodontal care . For impregnation root canal can use the drug " Arhenat " ( VladMyVa ) containing incorporates fluid number 1 (containing silver), liquid № 2 (containing a reducing ionic form of silver ), liquid to protect the mucous membrane of silver (medical liquid paraffin ) . With varying processing liquids number 1 and number 2 infected canals silver recovery can be observed after 30-60 seconds. Turundas pochorniye , which is a measure of successfully conducted silvering channels. Then the tooth cavity closed with a cotton swab and a temporary filling material. In subsequent visits ( 1-2 days ) channel fastened in the usual way .

Permanent sealing channel netverdnuchymy pastes, radiological monitoring and restoration of anatomic form permanent tooth filling materials is carried out following a visit to the absence of complaints and fluid in the channel.

Filling (obturation) channels temporary tooth

Filling (obturation ) channels temporary tooth at any stage of their formation is carried out after careful instrumental and drug treatment and disappearance of clinical signs of acute inflammation of the periodontium. Feature of root fillings in this case is its ability to resorption root resorption of simultaneous temporary tooth. Thus, root canal teeth so ¬ time should be netverdnuchymy paste with antiseptic and anti-inflammatory effects . For this purpose, most often used on pasta from zinc oxide and eugenol (pasta Grossman , Cariosan), yodoformni paste (KRI- paste Pharmachemie; Switzerland ) containing iodoform , camphor, menthol and parahlorfenol , pasta Maisto, who , in addition to the above components , contains as zinc oxide, thymol , lanolin , Tempophor company Septodont, Yododent (Russia) - kaltsiyhidroksydvmisna yodoformna paste. In the stage of root resorption is almost always used 5% or yodoformnu yodoformtymolovu paste. Filling the root canal tooth pa ¬ stand by using kanalonapovnyuvacha (Fig. 2 and 3). Even if a certain amount of pasta you will receive at the tip , it will be fully rezorbovana (Figure 1)

Treatment of periodontitis of deciduous teeth

It is believed that in severe chronic diseases of children ( pneumonia and chronic bronchitis , chronic kidney disease , frequent respiratory infections , severe sore throat ) dramatically expanded the indications for radical restructuring, but the children of tooth extraction at the present level of Endodontics is an extreme measure.

Treatment of periodontitis baby teeth is a very complex manipulations. The challenge children's dentist - to be able to properly assess the condition of the milk tooth with periodontitis .

Methods of treatment of periodontal conditions deciduous teeth can but divided into conservative , aimed at preserving ananomic and functional integrity of the tooth and surgery - removal of tooth Periodontal infection as a source .

Contraindications to conservative method of treating periodontitistion of deciduous teeth :

- A situation where the tooth is causing acute septic condition, chronic infection and intoxication ;

- Damage compact plate surrounding the follicle pos of continuous tooth (according to X-ray );

- Pathological or physiological root resorption of more than 1/ 3 of its length;

- The complete destruction of the crown , if his physiological changes remain less than 1.5 years;

- Perforation of the wall or floor of the root of the tooth;

- The lack of effect of conservative treatment (preservation signs of acute inflammation, tooth germ nevytrymuvannyacal closure , etc);

- Retention of the tooth in the jaw when the eruption of permanent teeth .

The goal of conservative treatment of periodontitis of deciduous teeth is by careful mechanical and pharmacological volopment of root canal obturation and his , to ensure proper and and timely flow of physiological process of root resorption and prevent damage and disruption of folikuLa permanent tooth.

The basic principles of treatment of periodontal that is the effect on the system makrokanaliv (elimination putrydnoho decay removal of infected predentynu , disposal microorganisms body naturally ) microchannels (blocking infection of dentinal tubules) and periapical tissues ( eliminate inflammation and enabling environment for periodontal tissue regeneration ).

The choice of treatment strategy of periodontitis of deciduous teeth depends on the etiology and course of the process (acute , chronic , worsening of chronic ¬ Night ) , stage of root stock and the size of the fire periapical destruction, physical and mental condition of the child.

Treatment of acute periodontitis of deciduous teeth

Conservative treatment of acute infectious periodontitis aimed at eliminating periodontal inflammation , relieving pain and preventing the spread ¬ inflammation in other parts of the maxillofacial area . Fluid formed in periodontal tissues can find out several ways: through root canal through the jaw bone under the periosteum of the vestibular or language , because of the holestsevyy course ( an exacerbation of chronic periodontitis ), through the gingival sulcus, through the cell tooth extraction . We're best cosdig outflow of serous or purulent exudate from periodontal through Korea ¬ unused channel. In the absence of fluid from the discharge channel at SFOR ¬ nating apical aperture is obligatory opening it , but the temporary teeth are usually such a need arises. Treatment of multiple visits.

У перше відвідування необхідно здійснити наступне:

— знеболювання. Високу знеболювальну ефективність мають анестетики групи артикаїну: Ultracain DS Forte (Hochst), Septanest (Septodont), Ubestesin (ESPE). Всі вони містять у своєму складі вазоконстриктори, вміст яких суворо дозований. У дитячій практиці доцільно використовувати анестетики з мінімальним вмістом вазоконстрикторів (1:200 000), наприклад Ultracain DS (Hochst);

— розкриття порожнини зуба із застосуванням високошвидкісного наконечника;

— видалення з каналу путридних мас під шаром антисептичного розчину за допомогою пульпекстрактора відповідного розміру; у разі дуже широких каналів іноді доводиться застосовувати з цією метою одразу кілька пульпекстракторів; у зубах із несформованим коренем або в період його резорбції цей етап виконується дуже обережно;

— за відсутності відтоку ексудату через кореневий канал і сформованої верхівки кореня — відкриття апікального отвору за допомогою файла або римера;

— за наявності під'ясенного або надкісничного абсцесу — його розтин і дренування;

— призначення ванночок з 0,5 % розчину гідрокарбонату натрію для полоскання ротової порожнини;

— призначення сульфаніламідних препаратів, у разі вираженої інтоксикації — антибіотиків, десенсибілізувальних та аналгезуючих засобів у дозуванні, відповідно до віку;

— призначення великої кількості рідини, неподразливої їжі, що не потребує інтенсивного розжовування, загальнозміцнювальної

терапії.

Після першого відвідування зуб залишається відкритим. Дитина має приходити на прийом щодня, щоразу оцінюється її стан, за необхідності проводиться корекція лікувальної тактики, перевіряється наявність повноцінного дренування періодонтальної щілини і здійснюється антисептична обробка кореневого каналу.

Продовження лікування можливе після стихання гострих запальних явищ: мимовільного болю, колатерального набряку, вираженої болісності під час пальпації ясен у ділянці хворого зуба, болісності під час перкусії зуба.

У наступне відвідування проводиться:

— повна інструментальна і антисептична обробка кореневого каналу із застосуванням найефективніших лікарських засобів (0,5-1% розчин гіпохлориту натрію, 3 % розчин перекису водню);

— уведення в канал лікарського засобу антисептичної протизапальної дії на турунді або у вигляді пасти (Камфокрезол, Крезофен, Крезодент);

— ізоляція порожнини зуба герметичною пов'язкою з тимчасового пломбувального матеріалу (дентин-пасти тощо).

Завершення лікування залежить від оптимальної тривалості дії лікарських засобів, які входять до кореневої пов'язки (1-6 діб). За відсутності проявів загострення процесу, безболісної перкусії, відсутності ексудації з каналу (що підтверджується відсутністю зміни забарвлення турунди з йодинолом, уведеної в канал) проводиться пломбування кореневих каналів пастою, що розсмоктується, і відновлення форми зуба постійними пломбувальними матеріалами (після рентгенологічного контролю якості заповнення кореневого каналу).

Treatment of periodontitis baby teeth is a very complex manipulations. The challenge children's dentist - to be able to properly assess the condition of the milk tooth with periodontitis .

Contraindications to conservative method of treating periodontitis ¬ tion of deciduous teeth :

- A situation where the tooth is causing acute septic condition, chronic infection and intoxication ;

- Damage compact plate surrounding the follicle pos ¬ of continuous tooth (according to X-ray );

- Pathological or physiological root resorption of more than 1/ 3 of its length;

- The complete destruction of the crown , if his physiological changes remain less than 1.5 years;

- Perforation of the wall or floor of the root of the tooth;

- The lack of effect of conservative treatment (preservation signs of acute inflammation, tooth germ nevytrymuvannya cal closure , etc);

- Retention of the tooth in the jaw when the eruption of permanent teeth .

The goal of conservative treatment of periodontitis of deciduous teeth is by careful mechanical and pharmacological vol ¬ opment of root canal obturation and his , to ensure properind and timely flow of physiological process of root resorption and prevent damage and disruption of folikuLa permanent tooth.

The basic principles of treatment of periodontal ¬that is the effect on the system makrokanaliv (elimination putrydnoho decay removal of infected predentynu , disposal microorganisms ¬ body naturally ) microchannels (blocking infection of dentinal tubules) and periapical tissues ( eliminate inflammation and enabling environment for periodontal tissue regeneration ).

The choice of treatment strategy of periodontitis of deciduous teeth depends on the etiology and course of the process (acute , chronic , worsening of chronic Night ) , stage of root stock and the size of the fire periapical destruction, physical and mental condition of the child.

Treatment of acute periodontitis of deciduous teeth

Conservative treatment of acute infectious periodontitis aimed at eliminating periodontal inflammation , relieving pain and preventing the spread inflammation in other parts of the maxillofacial area . Fluid formed in periodontal tissues can find out several ways: through root canal through the jaw bone under the periosteum of the vestibular or language , because of the hole tsevyy course ( an exacerbation of chronic periodontitis ), through the gingival sulcus, through the cell tooth extraction . We're best cosdig outflow of serous or purulent exudate from periodontal through Korea unused channel. In the absence of fluid from the discharge channel at SFOR ¬nating apical aperture is obligatory opening it , but the temporary teeth are usually such a need arises. Treatment of multiple visits.

Treatment of chronic periodontitis of deciduous teeth

Treatment of chronic periodontitis of deciduous teeth can be done in one or two visits. If the fistula at Yas tries, no channel gangrenous disintegration of putrid odor , subject to availability immediately carry out a full instrumental and drug processing channel in somatic healthy children who are not currently taken orally antibiotics, corticosteroids , or other means of immunosuppressive action possible treat ¬ ing in one visit. Active full instrumental and shall dykamentozna root canal treatment and filling it netverdnuchoyu paste ( Iodent , Kalasept , Multykal , tsynkodsydevhenolova pasta , etc.). Coronal restoration of permanent filling materials.

Most periodontal treatment is carried out in two visits.

In the first visit made:

- Nekrotomiya and forming cavity ;

- Opening cavity of the tooth;

- Remove the channel putrydnyh mass submerged antiseptic solution by pulpekstraktora appropriate size or by several pulpekstraktoramy by very large channels , in the teeth of the root or immature during its resorption that stage is done very carefully;

- Full instrumental and antiseptic root canal using nayefektyvnishyh drugs;

- Filling the root canal treatment or paste contribu Senna turundas with certain medicines;

- Insulation cavity of the tooth with a tight bandage Volyn NGO temporary filling material ( dentin - paste , etc.).

For the purpose of impregnation of macro-and microchannels and for koahu ¬ modulation growths of granulation in the channel is sometimes used formalinvmisni drugs , including resorcinol - formalin liquid, and also silver nitrate solution. The structure of resorcinol - formalin fluid HN includes formalin ( 36,5-37,5 % formaldehyde solution , which Dan tour and sequesters the protein body tissues and bacterial cells , acting through the release of formaldehyde vapor , thus realizing its bactericidal and withering effect ) and resorcinol (has protymikrob well activity). 4% alcoholic solution of silver nitrate (following his recovery solution 4% hydroquinone ) diffuses well into dentinal tubules, has an antibacterial effect , eliminates protein mass putrydnoho collapse , forming with them albuminates silver. After treatment of the root canal silver nitrate and restoration ¬ tions on its walls formed silver film impermeable to tankTerry . However, remember that during the emerging root resorption or use of these substances can lead to periodontal care . For impregnation root canal can use the drug " Arhenat " ( VladMyVa ) containing incorporates fluid number 1 (containing silver), liquid № 2 (containing a reducing ionic form of silver ), liquid to protect the mucous membrane of silver (medical liquid paraffin ) . With varying processing liquids number 1 and number 2 infected canals silver recovery can be observed after 30-60 seconds. Turundas pochorniye , which is a measure of successfully conducted silvering channels. Then the tooth cavity closed with a cotton swab and a temporary filling material. In subsequent visits ( 1-2 days ) channel fastened in the usual way .

Filling (obturation) channels temporary tooth

Filling (obturation) channels temporary tooth at any stage of their formation is carried out after careful instrumental and drug treatment and disappearance of clinical signs of acute inflammation of the periodontium. Feature of root fillings in this case is its ability to resorption root resorption of simultaneous temporary tooth. Thus, root canal teeth so ¬ time should be netverdnuchymy paste with antiseptic and anti-inflammatory effects. For this purpose, most often used on pasta from zinc oxide and eugenol (pasta Grossman, Cariosan), yodoformni paste (KRI-paste Pharmachemie; Switzerland) containing iodoform, camphor, menthol and parahlorfenol, pasta Maisto, who, in addition to the above components, contains as zinc oxide, thymol, lanolin, Tempophor company Septodont, Yododent (Russia) - kaltsiyhidroksydvmisna yodoformna paste. In the stage of root resorption is almost always used 5% or yodoformnu yodoformtymolovu paste. Filling the root canal tooth pa ¬ stand by using kanalonapovnyuvacha (Fig. 2 and 3). Even if a certain amount of pasta you will receive at the tip, it will be fully rezorbovana (Fig. 1).

Chart. 1. Tsynkevhenolova paste vyve ¬ Dan at the top of the tooth 85. (B) after 3 months. vidmichayetsya complete resorption of materyalu peryapikalnyh tissues.

Chart. 2. Kanalonapovnyuvach fillings root canal should be one size smaller last tool you used for root canal treatment. This is done to prevent it jams or fracture in the root canal. With sharp scissors kanalonapovnyuvach obrizayetsya half its length, which facilitates manipulation of the baby's mouth and prevents binding materyalu output seal for the tip.

Chart. 3. The powder of zinc oxide and eugenol paste zamishuyutsya to the state. With kanalonapovnyuvacha (a) paste is introduced into the root canals. (b) If the doctor is not familiar with spiral kanalonapovnyuvachamy are advised to make tsynkevhenolovu paste in root canals using root needle or a thin rubberized stick several times to assure adequate filling Canalfields.

Chart. 4. Root canals milk incisors sealed paste.

Treatment of periodontitis permanent teeth in children

Treatment of periodontitis permanent teeth involves action on the root canal , microchannels and periapical inflammation, and in the case of incomplete root formation - the basal cell zone, able to provide closure emerging apical foramen dense tissue ( apexification ) on fibroblasts tsementoblasty , osteoblasts .

Make a quality tool and drug treatment of root canals in permanent teeth Periodontitis in children requires a clear knowledge of topographic and morphological features of root canals of teeth.

Choice of treatment of periodontitis permanent teeth in children

Methods of treatment of periodontal permanent teeth in children can be divided into three groups:

1. Conservative methods aimed at preserving the anatomical and functional integrity of the tooth.

2. Conservative and surgical techniques, which include :

- Resection of the root apex - cutting off the tops and remove the affected root adjacent abnormal tissue ;

- Coronal - radicular separation - the lower section mole ¬ ra into two parts in the region of the bifurcation followed by curettage of the area and the tooth covering both segments fused to ¬ Ronco ;

- Root hemisection - removal of the affected root with in ¬ subordinate to him coronal part of the tooth;

- Amputation of the root - the removal of all diseased root to the place of his discharge without removing the crown of the tooth ;

- Replantation of teeth - the placement of the tooth is removed and sealed to the position of the jaw ;

- Kompaktoosteotomiyu followed curettage pryverhivkovyh tissues.

3. Surgical technique - removal of tooth Periodontal infection as a source .

Indications for surgical or conservative surgical techniques is inefficiency or impossibility of conservative treatment or the presence of contraindications to its pro ¬ conduct , namely:

- A situation where the tooth is causing acute septic condition, chronic infection and intoxication ;

- The complete destruction of the crown if its recovery impossibility ¬ lyve ;

- Extensive perforation of the wall or floor of the root of the tooth.

The goal of conservative treatment of periodontal permanent tooth is to eliminate pockets of periodontal infection ( the root microflora Channel ) by careful mechanical and pharmacological treatment of root canal obturation and its creating conditions for regeneration radioperiodontal and periapical bone. During the treatment of periodontitis permanent teeth with incomplete root formation is an important goal of ensuring closure of the apical foramen ( apexification ) to create opportunities for quality obturation of the canal.

The choice of treatment strategy of periodontitis in a child depends on the etiology and course of the process (acute , chronic , worsening of chroniction ), the stage of formation of the root , the presence of cell periapical bone resorption , the general condition of the child.

Treatment of chronic periodontitis permanent teeth with incomplete root formation

Treatment of chronic periodontitis permanent teeth with incomplete root formation is of great complexity , even for an experienced doctor and often ends in failure. Root formed has different lengths in different age periods. The walls are parallel root , root canal wide and in the emerging elite overlooks delivery mouth . Periodontal gap is projected only in the region of the root formed along the sidewalls . Compact disc turns over the top , but at the level of the emerging kolbopodibno expanding, limiting sprout area that resembles the appearance of granules ( Fig. 5, 6.14) .

Chart. 5. Central incisor child 7 years

Area growth maintained, wide root canal.

When the root is of normal length , begins forming its apex. There immature stages and uncovered the top. Radiologically the stage immature apex root canal has a smaller width of the neck of the tooth and large in the apex of which is formed , which gives it a funnel-shaped appearance. Periodontal gap is the same width throughout the root and merges at the top of the sprout area. Treatment of chronic periodontitis permanent tooth at the stage of immature apex - a very time consuming process even with knowledge of the anatomical features of the period of the root. In these cases prevalent chronic granulating periodontitis.

Chronic granulating periodontitis develops in immature permanent incisors (usually in the upper jaw ) in children 6 - 8 years as a result of injury and first molars due to acute decompensated current decay. The frequency of each of these reasons is in chronic periodontitis about 30%.

During exacerbation of chronic periodontitis reveal the tooth cavity , gently remove decay from the channel and hold it antiseptic . Tooth leave open the complete elimination of inflammation.

During the treatment of chronic periodontitis permanent teeth with incomplete root formation of a full instrumentaltion and drug treatment in the first visit is often difficult due to ingrowth of granulation tissue into the canal . It must be removed using pulpekstraktoriv under local anesthesia aplikation (10% lidocaine ). Leave channel drug antiseptic and anti-inflammatory action . In subsequent visits ¬ tion filled channel drugs on the basis of calcium hydroxide .

In severe cases, prescribe antibiotics and sulfa drugs in doses appropriate age. Recommended drinking liquids , liquid calorie food.

In the etiology and pathogenesis of chronic periodontitis significant role played by the association of different types of microorganisms , as a positive clinical effect can be obtained by applying a set of drugs that act on the aerobic and anaerobic flora . In dental practice for the treatment of root canals using various antiseptics: 0.5-1 % solution of sodium hypochlorite , 3% hydrogen peroxide solution , 0.2 % chlorhexidine , 1% solution hinozola and enzymes.

Great difficulties in the treatment of chronic periodontitis with incomplete root formation also caused some morphological features : low strength walls, small thickness of the root canal , excess mineralized dentin on the root canal walls , hopper extension apical lumen of the root canal , and others. Some pathomorphological features also complicate the treatment of teeth: productive inflammation predominates , there is a great amount of affection because of weak mineralization and bone structure krupnopetlystoyi , granulating tissue tends to grow into the lumen of the root canal with foci of chronic inflammation in the periapical region.

In chronic periodontitis in immature teeth , unfortunately , the zone of growth almost always dies and ceases to root formation.

Method of endodontic treatment in chronic periodontitis teeth with incomplete root formation , aimed at stimulating the formation osteotsementu or similar hard tissue called apexification . The pulp of the tooth that is not viable , sprout area was lost, and the closure of the apical foramen may result in the formation of its lumen mineralizovannoho barrier.

For the treatment of teeth with incomplete root formation using a paste from calcium hydroxide . These medicinal paste is used temporarily. In gangrenous teeth with destructive forms of periodontitis calcium hydroxide change after 5-7 days, 1 month, 3 months, 6 months and 1 year.

X-ray control of apical barrier formation is carried out every 6 months after starting treatment. The final sealing of the root canal constant stopping material is carried out after the completion of the apical stop and completion of the root radiographically detected , the formation mineralizovannoho osteotsementnoho barrier.

Features of the root canals of permanent teeth in children with him Incomplete formation of roots

Given the anatomical and physiological features zubo - jaw apparatus in children and adolescents (wide lumen of the root canal , funnel-shaped extension in the root apex in teeth with immature roots , lack of secondary dentin and stonshenist root at the top ), new technologies endodontic treatment can not be fully transferred to nursery practice.

In permanent teeth with immature roots can not spend quality cleaning and root canal enlargement to form the apical stop, neutralize microflora concentrated solutions of sodium hypochlorite as their use leads to not only dissolve necrotic tissue , as well as the death zone sprout . Nor can obturuvaty quality three-dimensional root canal under pressure using sylleriv and gutta-percha pins due to the anatomical features of the root structure . Therefore, in pediatric endodontic practice in teeth with immature roots applies gentle method aimed at preserving the zone sprout in the living pulp ( apeksohenez ) and distinguishing infected root canal of periodontal through the creation of a natural ( or artificial) mineralized barrier ( apexification).

Formation of dense natural , mineral barrier is achieved by applying well -known in the dental product - calcium hydroxide , which has unique properties :

bactericidal effect in respect of all types of pathogens due to the high alkalinity of the drug ( pH = 12.4 );

proteolytic action of protein structures relative tissue decay root canal that is virtually indistinguishable from that action of sodium hypochlorite ;

ability of dense mineralized barrier between root canals and periodontal ( granulation with periodontitis) .

Algorithm for use of calcium hydroxide to form dense mineralized natural barrier , according A.M.Solovyovoyi , the following :

diagnosis of the disease ;

imposition kofferdama ;

forming access to the root canal;

working length (in children apekslokatsiyi principle as a way to determine the working length in teeth with immature roots is not applicable );

gentle cleansing and widening of root canal using neutral chemical substances with antibacterial properties (0.5 % -1% Mr. sodium hypochlorite , 0.05 % chlorhexidine district , yodynol );

immediately prior to the introduction of calcium hydroxide root canal is needed: rinse with distilled water ;

temporary filling of the root canal calcium hydroxide ;

imposing a temporary seal.

If living pulp in the root canal calcium hydroxide is replaced every 3-4 weeks. In gangrenous teeth with destructive forms of periodontitis calcium hydroxide change after 5-7 days, 1 month, 3 months, 6 months and 1 year.

The first signs of mineralized apical barrier usually appear after 3 months. It can be seen on radiographs. However, it is still not tight, not fully formed , so it must change the final formation of calcium hydroxide in the root canal after 6 months , 1 year , and even after 1.5 years. The criterion for the formation of dense mineralized apical barrier is light sensing K- file ISO size 30-40 and X-rays .

Multiple entry of calcium hydroxide in the root canal is dictated by the requirements for material apeksohenezu apexification and he must have an active form of pasty consistency, freeze and not easily removed from the root canal. When using calcium hydroxide , depending on the clinical situation in 1-1,5 years formed a dense mineralized apical barrier in 70-100 % of cases ( A.M.Solovyova ).

However , natural apical barrier formed after repeated administration of calcium hydroxide has poroznuyu structure. Therefore, it does not guarantee complete endodontic treatment, and only creates favorable conditions for the completion of treatment endodontychyoho teeth with immature roots. In other words , the formation of apical , barrier using calcium hydroxide are provided for the action , allowing you to further complete the endodontic treatment of restoring the anatomical shape of the tooth.

It is comparatively simple and inexpensive method , but the main drawback of forming mineralized natural barrier between the lumen of the root canal and periodontal treatment is the length and porosity structure formed .

After the formation of mineralized natural barrier is made the traditional root-canal using new technologies ( sealing three-dimensional channel using sylleriv and gutta-percha pins or thermoplastic gutta-percha ). In restoring the shattered crown also applied new technology ( the use of traditional and hybrid cements skloyionomernyh , kompomeriv , chemical and composite curing light and flexible reinforcing structures if indicated ). Metal anchor pins and porcelain crowns to strengthen shattered in pediatric practice are not shown.

To address key deficiencies formation of dense mineralized natural barrier between the root and periodontal using calcium hydroxide (its porosity and duration of treatment ) was offered a new alternative method.

For quick formation of mineralized artificial barrier between root canals and periodontal company Dentsply offered a unique new drug MTA ( Mineral Trioxide Aggregate ) - ProRoot.

Method of application ProRoot for accelerated (artificial) method apexification

After completion of the chemical and mechanical processing channel in the treatment of destructive forms of periodontitis in the permanent teeth with immature root apex of the root canal 5-7 days injected calcium hydroxide (to achieve sterility of the root canal ). In the second visit to completely remove calcium hydroxide , washed with distilled water and the apical portion of the root canal filled with distilled water mixed with MTA ProRoot. Wait 5-10 minutes. At the same visit after hardening cement fastened root canal using new technology of three-dimensional filling of the channel.

The advantage of using the MTA to create an artificial barrier between mineralized apical root canals and periodontal is to shorten treatment compared with calcium hydroxide . When creating an artificial apical barrier in the treatment of periodontitis due to the high biocompatibility of drug ITA ProRoot almost turns into a dense root structure and tsementoblasty complete the creation of a single set of tissues that performs its function. Application ProRoot also shown at the closing perforations , fractures of the crown and root of the tooth to the root of the extension shattered beneath the gum , followed by restoration of the tooth.

Thus, the use of calcium hydroxide and MTA ProRoot in endodontic treatment of permanent teeth with immature roots can achieve natural and artificial formation of dense mineralized barrier between the lumen of the root canal and periodontal and endodontic complete treatment using modern technologies used in adults.

Treatment of acute periodontitis permanent teeth in children

Conservative treatment of acute infectious periodontitis aimed at eliminating periodontal inflammation , relieve pain and prevent the spread of inflammation to other parts of the maxillofacial area . The presence of serous or purulent exudate ¬ lyuye brings about the need to create its outflow from periodontal least May ¬ matic way - through the root canal , which is achieved by the removal of necrotic masses of the channel. In the absence of selection eq ¬ sudatu of channel binding is the opening of the apical foramen . The treatment is done in several visits.

In the first visit should be taken :

- Pain ;

- Opening the cavity of the tooth using a high-speed handpiece ;

- Remove the channel putrydnyh mass submerged antiseptic solution by pulpekstraktora appropriate size , with a very wide channels sometimes have to apply this Me ¬ Meanwhile multiple pulpekstraktoriv ;

- In the absence of fluid outflow through the root canal and SFOR ¬ nating root apex - the opening of the apical foramen for my help file or ¬ rymera ;

- If pid'yasennoho or pidokisnoho abscess - its devel ¬ ting and drainage ;

- Appointment mouthparts baths with 1% sodium carbonate hydro ¬ ;

- Appointment sulfanilamides in case of severe intoxication - antibiotics, analgesic and desensitizing agents in the dosage according to their age ;

Destination of a large amount of liquid without irritating food that does not require heavy chewing , general strengthening therapy.

After the first visit the tooth remains open. A child is prescribed an appointment to come every day , allowing you to control its state ¬ wool , make correction treatment strategy according to the clinical course of the pathological process. Every checked for patency ¬ good drainage periodontal gap and carry antiseptic root canal.

Continued treatment is possible after decrease acute inflammation : spontaneous pain, collateral edema, severe gum bolisnosti palpation in the region of the patient's tooth bolisnosti during percussion of the tooth.

At the next visit is conducted:

- Full instrumental and antiseptic root canal using the most effective drugs;

- Input Channel medicinal antiseptic and anti- inflammatory actions in ¬ turundas or as a paste ( Krezofen , Krezodent );

- Insulation cavity of the tooth with a tight bandage temporary filling material ( dentin - paste , etc.)

For prolonged exudation from the root canal to clean it can be used sorbents with immobilized them medicinal substances or paste from calcium hydroxide .

Last visit is assigned a certain time , which depends ¬ pends on the optimal duration of action of drugs on the root ¬ bundles (usually 1-6 days). In the absence of manifestations su ¬ sharpening process , smooth percussion carry out root canal ¬ it from the described methods ( if formed top ), X-ray quality control ¬ tion -filled root canal and restore tooth form permanent filling material or continue treatment calcium hydroxide (if not formed top ). Treatment of chronic periodontitis in acute princi ¬ Tipova no different from the treatment of acute periodontal infections ¬ tion of origin.

The success of treatment of acute toxic periodontitis ensure rapid evacuation hear ¬ contents of the root canal , the abandonment of the use of potent drugs and the use of antidotes. Reducing exudative phenomena can be achieved by the use of drugs ¬ that work protyeksudatyvnu action ( means nitrofuran , hydrocortisone ).

In the first visit should be taken :

- Remove devitalizovanoyi pulp;

- Treatment of root canal preparation antidote : when arsenic Periodontitis - 5 % solution unitiola , ¬ thiosulfate to sodium , 5% iodine solution , 1 % solution yodynolu at Jenny tissue damage ¬ periodontal phenol - Castor oil or 10% emulsion in castor anestezina oil;

- Making an antidote to the root canal on turundas ;

- Hermetic closure of the cavity of the tooth for up to 24 hours.

Second visit to appoint the next day. When you gather ¬ tion of pain and bolisnosti percussion repeated handling antidote and restore root bandage another day. The final obturation of the root canal is possible after the disappearance of symptoms of acute periodontitis. Acute toxic periodontitis tooth can not be left open, as this can result in periodontal infection through root canal.

Acute periodontitis caused by combined mechanical and chemical damage output due to periodontal filling material (especially formalinvmisnyh paste ) with apical opening or hematomas associated with the formation of periodontal hysterectomy due to traumatic pulp is treated mainly Physiotherapeutic ¬ cal methods. Assign 5-6 sessions UHF or microwave therapy, pain syndrome - flyukturyzatsiyu momentary electrophoresis with 10 % calcium chloride. Recom ¬ yutsya mouth trays with 0.5-1 % sodium bicarbonate, inside - receiving analgesic drugs. In the case of state troto purulent periodontal infection due to hematoma sealing mass removed from the channel and the treatment is carried out according to the scheme of treatment of acute periodontal infection origin.

Treatment of chronic periodontitis permanent teeth in children

Treatment of chronic periodontitis permanent tooth with external check vanym root can be done in one or two visits.

For sermon for the treatment of periodontitis odnoseansnoho :

- Chronic granulating periodontitis in the presence of fistula on the gums and no relapses and gangrenous decay hnylis smell it in the channel ;

- Chronic fibrotic periodontitis in the absence of relapse and gangrenous disintegration of putrefactive odor in the channel ;

- Good pass channels;

- Somatically healthy children who are not currently receiving InAmong well, antibiotics, corticosteroids , or other means of immunosuppressive effect.

On one visit is made complete tool and pharmacological treatment of root canal obturation and its constant root seal with the restoration of coronal permanent filling materials.

With the difficulty of passing root canal treatment , inability to conduct a complete tool and drug treatment channel , reducing the protective functions of orga ¬ nism treatment is carried out in two visits.

In the first visit made:

- Nekrotomiya and forming cavity ;

- Opening cavity of the tooth;

- Removal of channel putrydnyh mass submerged antiseptic solution by pulpekstraktora appropriate size , for a very wide channels sometimes have to use multiple pulpekstraktoriv ;

- Full instrumental and antiseptic root canal by the above methods using the most effective medicines;

- Filling the root canal treatment or paste contribu Senna turundas a specific remedy ;

- Insulation cavity of the tooth with a tight bandage Volyn NGO temporary filling material ( dentin - paste , etc.).

Permanent obturation channel X-ray control and restoration of anatomic form permanent tooth filling materials perform in the next visit in the absence of complaints and fluid in the channel.

Marginal periodontitis treatment is to eliminate the etiological factor , the use of antiseptic and anti-inflammatory drugs .

In the case of marginal periodontitis infectious origin of the lead antiseptic agents and broad-spectrum anti-inflammatory therapy. If manure reveal pid'yasennyy abscess stupid by under local anesthesia. Traumatic injury If you want to audit periodontal remove foreign body, if it is detected and implement anti-inflammatory treatment . Poorly imposed seal to be removed . Toxic damage requires the use of appropriate antidotes.

Complications that may occur during treatment of periodontitis permanent teeth in children

reason

Consequences

Measures to prevent and eliminate complications

Traumatic injury navkoloverhivkovyh tissue

Exacerbation of inflammation , pain

Graphed length of root, anti-inflammatory treatment

The use of drugs tsytotok ¬ sychnoyi ACTION

Acute inflammation in the tooth

Choosing the right medicines

Vidlomlennya endodontic instrument channel

Failure to seal the root canal

Wreck removal tool , and if this is not possible , conduct vnutrishnokanalnoho electrophoresis and root-canal

Perforation of the wall of the tooth root

Acute inflammation , the withdrawal of filling material through the perforated hole

Trying to pass a root canal and seal the main channel

Excessive vyve ing filling material at the root apex

Exacerbation of inflammation , pain

physical treatment - UHF , UHF- therapy

Incomplete filling of the root canal

Complete sealing of the root canal

Use of nonment of effective physician means for antiseptic vol opment of root canal

Acute inflammation after dressing

Analysis of clinical characteristics and replacement antiseptics

In the treatment of periodontitis of deciduous teeth may occur as a complication during treatment or after stopping. Young children are very difficult to tolerate complications, and this often necessitates the premature extraction of deciduous teeth .

Exacerbations during treatment may occur in cases where the physician seeks to pass a channel to remove its contents without first prosterylizuvavshy last. Such manipulation, especially if they are not careful, lead to the fact that the tooth no longer maintain tight closure and, in some cases, the pain subsides and not in the open cavity of the tooth.

Complications during treatment can be explained by the fact that under the current long-term inflammation in periodontal tissues developed hypersensitivity to bacteria , toxins and products of protein decomposition. Under the influence of interference observed inadequate response periodontal tissues that have heightened sensitivity to the stimulus. To avoid these complications , you should be extremely careful in root canals to disposal of their contents do not administered instruments .

The frequency of complications and their nature is largely dependent on the overall health of the child. You should not start treatment of chronic periodontitis when he recently had a cold or infection , as in this case increases the risk of acute inflammation .

To a condition that may predispose or encumber possible complications after sealing , include runny nose, catarrh of the upper respiratory tract , headache , malaise , etc.

Great source of destruction of bone proliferation process in the germ of the permanent tooth is an indication for removal of the causative temporary tooth in all cases, regardless of the child's age and condition of the crown of the tooth. However, removal of temporary tooth , unfortunately, does not always prevent the development process.

The final stage of the conservative treatment of all forms of periodontitis regardless of the method used, must be complete filling of root canal filling materials tverdeyuschym .

For the prevention of periodontitis is recommended to improve treatments for the prevention of caries and pulpitis .

treatment protocol

Call ICD K04.4 Acute periodontitis temporary tooth

Clinical forms - acute periodontitis, acute phase

Diagnostic criteria :

Clinical:

- Constant pain in the tooth , which increases with dotorkuvannya and at nakushuvanni

- Fever

- Facial asymmetry due to swelling in the area of the affected tooth

- An increase in regional lymph nodes , pain at palpation of

- Presence in the tooth cavity of any size or seal

- Painless in probing the walls and bottom of the cavity

- The lack of sensitivity of the teeth to thermal and chemical stimuli

- Redness and swelling of the mucous membrane in the area of projection of the root ( root )

- Pain on palpation of the mucous membrane in the area of the projection of the root ( root )

- Pain with percussion

Ancillary diagnostic criteria

- None - acute periodontitis , with X-ray - a possible extension of periodontal gap without damaging the cortical plate

Treatment:

1. Conservative treatment is carried out in the absence of :

- Situations where tooth is causing acute septic condition, chronic infection and intoxication ;

- Damage compact plate surrounding the follicle permanent tooth ;

- Pathological or physiological root resorption more than 1/ 3 of its length;

- The complete destruction of the crown , if it has lost the physiological changes of 1.5 years;

- Perforation of the wall or floor of the root of the tooth;

- Delayed tooth in the jaw when the eruption of permanent teeth

- Opening the cavity of the tooth using a high-speed handpiece

- Remove the channel putrydnyh mass submerged antiseptic solution

- Instrumental handcrafted root canal ( channel ) on the full working length using endodontic files with regular washing with antiseptic solutions nepodraznyuyuchymy

- 0.5 % sodium bicarbonate ( locally )

- Temporary obstruction of the channel ( channels) nepodraznyuyuchoyu paste or preparation for turundas which has a strong anti-microbial and anti-inflammatory effects , and closing the cavity in a tooth with a temporary bandage filling material

- Permanent obstruction of the channel ( channels) tsynkoksydevhenolovoyu paste tsynkoksydevhenolovoyu paste with the addition of thymol, iodoform , yodoformnoyu paste the absence of exudation or gangrenous odor from the channel after washing ;

- Restoration of tooth dental cements kompomernymy or composite materials , silver amalgam , standard crowns

General treatment

- Antibiotics - in the case of severe intoxication

- Desensitizing agents

- Pain medications in the dosage according to age

- Advice to take plenty of fluids nepodraznyuyuchu food that does not require heavy chewing .

Performance measures of treatment:

- The elimination of the clinical manifestations of the disease ;

- Restoration of the anatomical shape of the tooth.

Clinical examination :

- Clinical supervision to replace the deciduous teeth of constant

- Review every 6 months

Treatment of acute and chronic periodontitis

Periodontal disease is common , being one of the more common causes of inflammatory diseases of the maxillofacial area and udaleniya teeth. Being a chronic inflammatory odontogenic fireplace, periodontitis is a source of sensitization of the patient , leading to significantly change the immune status , reducing nonspecific rezistentnosti , development and complications of various somatic diseases.

Effectiveness of conservative treatment of periodontitis on average 85%, and that the figure varies depending on the clinical form of the disease , means and methods of treatment, the resistance of the patient and many other factors. NTrudnosti treatment of periodontitis caused lasting regeneration processes Ochag destruction periapikalnoy area that is mostly observed in 6 - 12mes . or more after completion of endodontic treatment. Another problem zatrudnyayuschey or even exclude the possibility of direct endodontic treatment of exposure to periodontal feature is the anatomical structure of the root canals of teeth.

One of the most important causes of the possible complications of the treatment of periodontitis may serve as the severity of the mechanisms of nonspecific resistance of the organism and the activity of tissue regeneration processes . Due to this promising use of drugs and physical therapy factors okazyvayuschih immune- stimulating effect, correcting immune status, aktiviziruyuschih sanogenesis mechanisms and physiological processes of reparation.

The purpose of the treatment of periodontitis - the elimination of inflammation in periapikalnoy area, isklyuchenie pathogenic effects on the body odontogenic inflammatory foci , regeneration of periodontal tissue structure and function of the tooth restoration .

Endodonticheskoe treatment involves three main stages: mechanical preparation ( enlargement treatment) , antiseptic treatment ( disinfection) and sealing channels.

Mehanicheskaya processing is carried out to the complete removal of disintegrated pulp and root dentin layer infected with the channel walls . For successful implementation etogo stage must create a full access to the root canals with the calculation to the longitudinal axis of the working part of endodontic instrument maksimalno coincides with the direction of the move canal. Delete the contents of the channel sleduet phases, fractional portions , from the mouth of the channel under prikrytiem antiseptic solutions , constantly replacing it with fresh portions.

You can use 3% solution of hydrogen peroxide, Furacilinum 1: 5000 , 0,5 - I% solution of chlorine bleach , 0.02% chlorhexidine , 1% solution yodinola 1% solution yodopirona 40 % solution of dimethyl sulfoxide , 1% alcohol rastvor chlorophyllipt 0.01 % solution mefenaminata sodium salt , 0.5 % solution ekteritsida 1 - 3% solution metakrezolsulfonovoy acid ( gravity ) and other antiseptiki .

For antiseptic treatment of feed with periodontitis can be applied sleduyuschie drugs : Endoperox as a solution , Endotine, Rarsan (3 % solution of sodium hipohlorita firm Septodont), Histolith solution of sodium hypochlorite (LegeArtis).

To facilitate the machining of root canal helatiruyuschie widely used drugs can cause rapid local demineralization dentina kanalu.Demineralizovanoyi root dentin walls while significantly razmyahchaetsya and easily removed instrumentally. Drugs in this group include etilendiamintetrauksusnuyu acid ( EDTA ). Famous domestic product - Trilon- B, as well as imported - Largal Ultra ( company Septodont) as a solution , 'Canalt'- Gel suitable for use , Calcinase (LegeArtis) as a solution . NEti drugs have also disinfectant action.

Drugs administered in feed no more than 5 minutes. Then , following mehanicheskuyu treatment should be abundantly rinsed with distilled water channels or saline to neutralize the environment , or ongoing violations will result in demineralization adhesion and inability hermetichnoy canal obturation with further sealing.

Mehanicheskuyu root canal treatment should begin with the extension uhlubleniya and forming the mouth of the channel with small diameter spherical hog ( bend the tip have to use extra long burs - 27 mm) or special root forests. Formation of the mouth involves providing preparirovannoy initial configuration of the channel , making it easy to needy and direction enter endodontic instruments . This increases the effectiveness and quality of processing channel.

Prix the best match to the longitudinal axis of the tool used endodontic root canal and directions decreases the possibility of creating nerovnostey (' steps ') on the walls of the channel , which complicates its processing. The working part of the tool in this position more fully rooted facing walls of the channel across the length and tool efficiently performs its functions. N

For the treatment of root canals using drilbory , drills , reamers and rasps kornevye different standard diameters and lengths. Endodontic instruments mogut have a length of 21 mm , 25 mm , 28 mm and 31 mm. They are used for the mechanical data processing channels of different groups of teeth. The diameters of tools in order increase in : 0.6 , 0.8 , 10, 15, 20, 25 , 30 , 35 , 40 , 45 , 50 , 60 , 70 , 80 , 90 , 100 , 110 120 , 140.

Poocheredno using different types of endodontic instruments, consistently increasing the diameter of the smallest rooms - 0.6 , 0.8 , and 10 for a possible large-diameter channels provide the desired shape and a smooth clean Surface , provides input filling material and its adhesion. NVse processing steps instrumental duty of medication exposure antiseptikom .

Disinfection channel effectively terminate use of ultrasound vnutrikanalno using endodontic needle waveguide radiator , Introduction to channel through the solution antyseptyka.Aktyvne injection solution in mikrokanaltsy dentin at the expense of its vibration and cavitation. NNahrevanie also increases the disinfectant ability rozchynu.Instrumentalna Processing canal apical end with otverstiya physiological and anatomical opening of the apical foramen of the tooth root .

Follows the stage of endodontic treatment - influence aimed at eliminating inflammation in periodontal tissues and stimulation of regenerative processes. NFor this purpose, medications and physiotherapy factors alone, together or in combination .

Proteoliticheskie enzymes provide nekroliticheskoe and mucolytic action facilitates the evacuation of content channels , increase the effectiveness of antimicrobial action of preparativ.Rozchyny trypsin, chymotrypsin, himopsin, terrilitina possess bacteriostatic action and help neutralize bacterial toxins. Prepare medications ex tempore, dissolving enzyme powder in isotonic or oil solution of vitamin E and other good effect daet enzyme lysozyme in a 1% isotonic . Lysozyme is a factor in the natural resistance of body tissues, improves fahotsitarnoy activity of leukocytes , which is beneficial to the current periodontitis . For prolonged enzyme preparations made profezim and immozimaza - enzymes immobilized on an organic matrix.

Treatment of acute periodontitis

Acute drug-induced periodontitis resulting from the toxic action of certain drugs (most often - arsenic .) First stage - intoxication . Toxic drugs irritate the periodontal tissue , which is accompanied by tenderness to nakusyvanii on zub.Spetsyfichni antidotes vstupayut reaction with toxins found in the blood and tissues and form a connection with them netoksichnye and removed .

Browser stage of intoxication , when the symptoms of acute inflammation of the periodontal no signs of severe exudation during anesthesia reveal the tooth cavity , prepared endodonticheskiy access and carry out machining channels. Expand Land physiological narrowing in the apical part of the channel and reveal verhushechnoe small diameter hole drilbora ( without the extension). Spend antisepticheskuyu processing and channel leave turundas one of the used drugs during temporary airtight bandage daily. Over a one day drugs in the channel leaving pointless, because by the time they lose UTB activity in specific environmental conditions of the root canal .

Hvozdichnoe most long oil retains the antiseptic qualities , but when it is used to consider the possibility of irritating effects on periodontal tissues . In this case, the channel can be filled daily pasta Fokalmin ( firm LegeArtis) and tooth cavity is closed temporary seal. Also effective drugs for the treatment of canals and Rarsan Endotine ( company Septodont).

Endodonticheskoe medication is held against the backdrop of laser or magnetic therapy on the first visit. When using IHNL set sleduyuschie parameters: capacity 150-170 mW/cm2 , exposure 2 min. was 3 sessions. Measurements of magnetic therapy: frequency 100 Hz modulation frequency of 0.8 Hz, the duration of one session to 20 minutes. , On treatment of 15 sessions , ezhednevno . On the next visit , repeat drug treatment channel and clinical well-being Prix - fastened to the level of the apical foramen roots. Root Canal Treatment alcohol, ether and air dried before plombirovaniem less effective compared to the effect of the drug Fokaldre (LegeArtis), rastvor which disinfects , cleans and dries very quickly channel. For plombirovaniya can use domestic materials: phosphate cement intradont , Biodent and import : 'Cariosan' ( Slovakia ), 'Hermetic' (LegeArtis), 'Endomethasone', 'Endobtur' (Septodont).

Treatment of acute periodontal infection in stage exudation

Age of intoxication quickly turns into exudative , accompanied narastayuschim edema, accumulation of inflammatory exudate in periapikalnoy area and increased pain. This should provide a flow of fluid from periodontal . Under anesthesia reveal the tooth cavity and produce mechanical obrabotku channels combined with an active drug disinfection.

Anatomicheskoe hole apical root canal tooth reveal and expand to create a flow of inflammatory exudate and gain Medicamentous effects on periodontal tissues . With insufficient outflow through the channel at this stage of periodontitis for proper drainage of periodontal indications to produce periostotomiyu . Patients prescribed overall treatment: broad-spectrum antibiotics , sulfa drugs and desensitizing . The tooth is left open to the termination abundant exudation from the channel. NPri Recommend this patient mouth with antiseptic baths and soda rastvorami and possibly often be repeated drug obrabotku endodontic .

The browser shows this situation, especially the use of proteolytic enzymes in combination with antiseptics. Effective treatment of glucocorticoid channel and use them as applications for transitional fold in the causal tooth. Local ( endodontic ) use of antibiotics in the treatment of periodontitis are currently not widely used in ambulatory practice stomatolohicheskoy allergization due to significant population and complexity soblyudeniya principles of rational antibiotic therapy for local single double use of the drug. Continue treatment after the outflow of fluid carefully obrabatyvaya channels antiseptics.

It is known that when periodontal root canal is a mixed microflora, including anaerobic . Signs of anaerobic infections - dark color soderzhimoe root canals with putrid odor. Thus traditionally in the treatment of periodontitis ispolzuemye antiseptics are ineffective. For endodonticheskoy drug treatment should be used nitrofuranovye drugs dioxidin 1-0,5 % solution , suspension baktrima , as well as metronidazole and fuzidinnatriy (preferably inside).

Can be used for putting pasta in root canals - Grinazole, soderzhaschaya metronidazole and Septomixine forte - endodontic paste deksametazonom.Plombuvaty channels in the most appropriate root filling materials Endomethazone containing corticosteroids and metronidazole (Septodont).

As mentioned above, used laser and magnetic therapy . Parameters used IHNL Colour 180 - 200 mW/cm2 irradiated with 2 fields for 2 minutes . 2-3 sessions, schodnya.Parametry magnetic therapy : frequency 100 Hz modulation frequency 0, 8 Hz , the magnetic induction of 12 mT , exposure time 15 min . , A course of treatment is 10-15 procedures performed daily.

For the prevention of relapse after root canal can be done in'ektsiyu 0.2-0.5 ml emulsion of hydrocortisone in transition crease in lechennoho tooth.

Treatment of chronic periodontitis

Treatment of chronic periodontitis aimed at eliminating inflammation periodonte and creating conditions for the regeneration of the periapical tissues. Features of treatment of chronic periodontitis fibrous . In the first visit , after completion of the mechanical training channel and medicinal , antiseptic Processing , anatomical root apical hole open, but tselenapravlenno not expand. In the left channel turundas with antiseptic solution pod sealed in a temporary bandage tooth cavity . On the next visit , when clinically well-being, after repeated drug treatment plombiruyut channel . To enhance recovery of periodontal structures effectively primenenie IHNL and MT.

Prix laser in this case, a smaller capacity - 60-80 mW/cm2 , but a larger number of radiation fields -4-6 . Exposure - 2 min. for each field . NParametry magnetic therapy : frequency 50 - 60 Hz frequency modulation tion 0.6 Hz nappyazhennoct electromagnetic field - 8 - 10 mT , exposure time 10 min. , On treatment of 10 sessions , every other day .

Treatment of chronic granulomatous granulating periodontitis

These clinical forms of periodontitis are characterized by the vyrazhennymi destructive periodontal changes , the growth of granulation tissue in okoloverhushechnyh foci of chronic inflammation. When machining channel produces gentle opening and expansion of the anatomical apex otverstiya root.

In the treatment of granulating and granulomatous periodontitis shown zaapikalnaya therapy - an introduction to periapikalnye fabric of drugs stimuliruyuschih regeneration of periodontal pockets of destruction . Pre spend tschatelnuyu antiseptic channel , which eliminates withdrawal by , the boundaries Root infected with content and microbial drugs. NLekarstvennye drugs as a solution or paste is injected into the apical portion Root turundas or kanalonapolnitelem . Can be used lizotsima 0.1 % solution for flushing channel and lysozyme -vitamin paste - for zaverhushechnoho vyvedeniya . Pasta contains lysozyme, an oil solution of vitamin A ( or E) and napolnitel .

Browser its composition may include calcitonin. In zaverhushechnoy therapy can be used such biologically active substances as honsurid , Methyluracilum, Heparin mixed with furazolidone and dimethyl sulfoxide , prepared as a paste . Effectively use embrioplasta ( allogeneic embryonic tissue of early development), which stimulates the reparative osteogenesis in Ochag destruction.

Given the resistance of the organism inhibiting factor in chronic inflammatory processes in periodontal should be used for output zaapikalnoho imunomodulyatory.Naybilsh often use levamisole (dekaris ) in the paste . Successfully used a combination thymogen, levamisole and hidrokortizona . Use pentoksil both locally and for general treatment. While assuring normal immune status improves regeneration in early period and in bolshej degrees positive dynamics klinikorenthenolohicheskih indicators , increased the percentage of favorable outcomes.

Izuchena efficiency of the plant for the purpose of preparation of multifunctional action erakonda , 10 to 40% aqueous solution which nativnyy or drug was administered periapikalnye cloth and leave in a channel per day. The drug is nontoxic, has immunomodulatory effect and stimulates physiological processes of tissue repair , thus providing a good therapeutic effect in the treatment of periodontitis.

Shiroko used osteotropic calcium pastes zaverhushechnoho vyvedeniya . Good results are obtained by delayed filling of channels predpolahayuschee zaverhushechnoe output osteoinduktivnyh pastes and calcium channel vremennoe stopping for a few months (usually 3 - 6 months.) . In terms ukazannye observe the dynamics of the source of destruction in periodontal dental radiography osnovanii data and clinical and instrumental examination . NPri starting regeneration of periodontal root canal is sealed indifferentnym permanent filling materials. Often channel tverdeyuschim material fastened to the level of the apical foramen immediately after withdrawal of therapy zaverhushechnoho paste.

Prix chronic granulating periodontitis can be used in almost all known physical therapy techniques. This can be yodosoderzhaschih electrophoresis substances enzyme solution , phonophoresis, mahnitoforez , UHF , microwave - therapy , laser and magnetic therapy . IHNL Options : Power 90-100 mW/cm2 4-6 radiation fields in the mucosa of the causal tooth when exposed to techenie 2 min. for each field . Parameters MT NISMEMP : frequency 70 - 80 Hz, 0.6 Hz modulation , voltage of 10 mT , time - 15 min. , 10 sessions.

Conclusions

In the treatment of periodontitis should use the full range of available funds lechebnogo - medication and physical therapy . The most effective laser ( IHNL ) and magnetic ( NISMEMP ). Results of treatment of periodontitis determines the complete obturation of the root canal and the level of nonspecific rezistentnosti the patient.

Clinical forms of periodontitis are less impact on treatment outcome. The question of the need for radical treatment focus periapikalnoy destruction (use one of the methods odontoplastiki or tooth extraction) should be resolved within 6 - 8 months. Dynamic observation of the periodontal tissues , according to X-rays, high-quality after root-canal .

Surgical treatment of periodontitis

Periodontal surgery is one of the components of the complex treatment of periodontal disease . Surgical treatment is carried out after conservative therapy along with general treatment. Its purpose - the elimination of pathological periodontal pockets and bone , granulation and deposits. Engineering various types of surgery are being developed highly enough. But it can be successful only against good oral hygiene. If this rule is ignored, then the probability of a positive outcome from surgery is very low.

Relative contraindications for surgical treatment are acute infections of the oral mucosa and poor oral hygiene. Surgical treatment is contraindicated in pregnant women and adolescents with acute gingivitis patients with diseases of the hematopoietic system and other background conditions.

A lot of treatments for periodontitis , but the most widely used such as curettage, hinhivotomiya , hinhivoektomiya and patchwork operations in various versions. The first three interventions are carried out on a mass -patient admission in the dental chair, patchwork operations to perform better in the operating conditions .

Regardless of the method used, and the amount of interference effects of treatment will largely depend on the correct preoperative preparation and postoperative care . You can brilliantly technically an operation and did not get the desired result.

In the preoperative period , special attention is paid to the sealing cavities , treatment of apical periodontitis and the elimination of other local factors. Conservative methods of seeking the removal of gingivitis . As already noted, the importance of having a good hygienic condition of the mouth. With poor hygiene , surgery should not be spending .

In addition, the doctor should promptly take care of temporary splinting of loosened teeth before surgery . We know that after surgery (especially scrappy and hinhivoektomii ) teeth become more agile, especially in the first month , when the regeneration have not yet occurred . During this period, the teeth should be well immobilized .

On the day of surgery necessary to a good antiseptic oral rinse through , applications .

All surgical procedures should be performed under local anesthesia , but general anesthesia is sometimes used . Objective postoperative period - Fighting plaque and tooth mobility

Features of development of periodontitis often it will be to meet.

Child's dentistry from heavy complications of caries — sharp and chronic periodontitis. And than sanitation is worse organized, the inflammatory diseases of periodontium are more frequent diagnosed. Periodontium is disposed in space, limited from one side the cortical plate of small hole, and from other — by cement of root.

Child's dentistry must know the features of periodontium of the unformed tooth, in what periodontium stretches from the neck of tooth to part of root of, which was formed, where meets with the area of growth and is in touch with mash of root channel. As far as forming of root the size of sprout area of the apical opening and contact diminish with mash, but length of periodontal crack is increased. Upon termination of development of apex of root yet forming of periodontium proceeds for a year. As far as rarefaction of root of baby tooth length of periodontal crack diminishes and the contact of periodontium is again increased with mash and spongy matter of bone.

Principal reason of periodontitu is an infection, when microbes, their toxins, biogenic amines, which act from the inflamed nekrotizo mash, spread on periodontium. Periodontium for a child presented more loose connecting fabric, contains plenty of cellular elements and blood vessels that does him more reactive at the action of unfavourable factors.

Second place among reasons which cause periodontitu in child's age, the sharp trauma of tooth occupies (dislocation, break of root on that or other level). In this case speech goes mainly about frontal teeth. To put, when begin to walk, fall, struck a person, as a result there are different types of incomplete dislocations, in particular killed, such, that quite often accompanied the break of vascular-nervous bunch. In school age more frequent there is a trauma of the second unformed frontal teeth, when to put for help does not apply and gradually without the expressed clinical displays mash perishes and chronic periodontitu develops. Certain role in the origin of periodontitu a mechanical trauma can play during treatment of root channel by sharp instruments, needles, stopping material shown out for an apex.

In development of periodontitu for children drastic chemical and medical matters which get during treatment of pulpit play a certain role. On occasion inflammation of periodontium can develop gematogenic by a way at the sharp infectious diseases of children. The way of distribution of infection is possible on periodontium from the inflamed fabrics, located next door. Often periodontitis develops as a result of pulpit, if the methods of saving of mash (biological method, congratulatory amputation) apply without strict determination of certificates, with violation of conducting method, without the account of degree of indemnification of caries and state of child health.

At periodontitis both for adults and for children find out the different associations of microorganisms. Gram-positive cocci (mainly streptococci and staphylococci), and also fungi, laktobakterium, aktinomitsetium and other, prevail in composition mikroflora Among microorganisms which are more frequent all selected, on the first place aerobic and anaerobic forms of streptococci, then staphylococci. That clinical classification of periodontitu is utilized in child's dentistry practice, which is accepted for adults.

For localizations distinguish apex (apical) and marginal periodontitis, down stream — sharp and chronic.

Classification of periodontitis.

For classifications of Т.F.Vinogradova (1976), periodontitis are divided:

on etiology :

- infectious,

- traumatic,

- medical;

for localizations:

- apical,

- marginal;

on clinical motion:

-sharp,

-chronic

-in the stage of sharpening;

on pathomorphological changes in fabrics:

- serenity

- festering,

- fibrosis,

- granulematous,

- granulating.

The features of periodontitis of baby teeth.

Frequent all meet chronic forms of periodontitu in the stage of sharpening in temporal teeth, however much it eliminates development of sharp forms of disease. General symptomatic of sharp apical periodontitis for children characterized active motion of inflammatory process in periodontium, rapid passing of the limited process to diffuse. The stage of inflammation usually did not last and passes to festering. At the uncompleted forming of root a process is complicated death of area of growth and stopping of development of tooth. The dynamics of clinic of sharp periodontitu is expressed in growth of pain reaction on Perkasie, increase of intensity of involuntary pain of permanent, aching character, increase of oedema and hyperaemia, gums at a causal tooth with bringing in of surrounding fabrics and regional lymphatic knots.

Sharp serous and festering periodontitis, being the separate stages of one process. At a festering form pain becomes strong and pulsating, goes down from cold, the general state is violated, appeared head pain and indisposition. Complication porosities and osteomielitis is especially often at the uncompleted forming of root, accompanied the sharp worsening of the general state of child with the increase of temperature of body to 38-39°С, increase of SHOE, and more heavy local picture (an enema is expressed, pain reaction of nearby with causal teeth). Especially difficultly sharp periodontitis flows for children with lowering of pressure of organism and after the carried diseases (fig. 1, 2).

fig. 1.

fig. 2.

A prognosis at diagnostics of periodontitu of temporal teeth depends and from as rezorbtion of root: even, uneven, mainly in the area of bifurcation of root. Yes, if at even rezorbtion of root the border of conservative treatment is rarefaction of 2/3 lengths, at bifurcation - extraction of tooth are shown regardless of the state of root.

The result of sharp periodontitu depends on the exit of exudation from periodontal of space:

- Through a root channel; on a periodontal crack by melting of circular ligament; - on spaces to the surface of jaw bone (subperiosteum and subgingival abscess, periostitis, sepsis);

- passing of sharp periodontitu to chronic is possible in default of treatment or at wrong medical tactic.

Chronic periodontitis can be the result of sharp inflammation of periodontium or develop as initially chronic process at the gangrene of mash, to complicate chronic pulpits, chronic trauma of tooth and wrong treatment of pulpits.

Fibrosis and granulematous periodontitis is possible only in the formed teeth. Taking into account importance of hearth of granulation at chronic inflammation of periodontium for medical tactic, it is possible to select two stages of this process:

1 - is expansion of periodontal crack due to thinning and hearth of compact plate by granulation without the expressed destructive process in a spongy bone;

2 - is distribution of hearth outside periodontal of space, origin of defect of bone due to rezorbtsii of compact and spongy matter round the apexes of root, which also can be resorped. A bone plate between a hearth and follicle is diminished, but stored. These stages of disease are subject treatment unlike granulating periostitis, which extraction of temporal tooth is shown at. At elektroodontodiagnostics teeth with absent mash react on the sizes of current of more than 100 mka. By the leading diagnostic signs of chronic inflammation in periodontium of baby tooth, that allow to define not only his presence but also character, degree of distribution, and also state of surrounding fabrics, there are roentgenologic changes.

Kinds and types of resorption of roots in baby teeth.

Physiological and pathological resorption of roots of baby teeth.

To distinguish them it is one from other possible thus: at presence of sprout area a periodontal crack has an even width at the formed part of root and here meets with the area of growth. Cortical a plate of interalveolaris partition is its continuation which limits the area of growth. A cortical plate disappears at death of area of growth; the hearth of dilution has different sizes and unclear scopes. In obedience to these histological researches (T.F. Vinogradova , 1967), resorption of roots of baby teeth from intact periodontium is carried out with participation of osteoklasts. Parallel there is a process of resorption. The source of again well-educated bone is cages of periodontium. Reparation processes take a place simultaneously with resorption which provides saving of structure of bone around resorptive roots.

Such type of rezorbtsii is observed at rezorbtsii of roots of intact of baby teeth, but possible also at rezorbtsii of carious and pulpless teeth at intact periodontitis. Physiology resorption develops unevenly, however takes all of surface of roots. Thus internal surface of roots, located nearer to the rudiment of the second teeth, resorp quick; these can explain physiology resorption on three types. On the late stages of physiology rezorbtsii mash of tooth takes part in a process, carrying out resorption of dentine from the side of cavity of tooth. The source of osteoklasts. Cages of mash.

Together with physiology resorption pathological resorption of roots can develop under act of row of reasons. More frequent all it arises up as a result of chronic inflammation in periodontium of baby teeth.

Pathological resorption of roots of baby teeth is carried out giant cages of foreign bodies and cages of inflammatory infiltrate. In relations with it at pathological rezorbtsii a leading roentgen logic sign is destruction and absence of bone fabric between the roots of baby teeth or round them. Pathological resorption does not submit the laws of physiology rezorbtsii. In this period substituted for natural fabric of periodontium granulation fabric of inflammatory infiltrate. Resorption of root goes shallow deep lacuna, which are filled the cages of inflammation. In fabric of inflammatory infiltrate often there are epitheliums which take large space and can germinate all of layer of fabric and to grow in the channels of root. As far as progress of pathological process scolded baby teeth and follicles of permanent ramification, while at physiological resorption they are drawn together. Rarefaction of unformed root of baby teeth, root, second teeth dissociated from a follicle can come at pathological rezorbtsii, and roots of nearby teeth. The process of pathological rezorbtsii can spread on the follicles of the second teeth, cause premature resorption of bone shell of follicle and dentition of the second teeth. Brings these phenomena over of І.О. Novak (1968) as illustration of speed-up resorption of roots of pulp less baby teeth. However much it follows to talk in parallel instances, at first, about resorption of roots of baby teeth, not simply deprived mash, but about resorption at chronic inflammation; secondly, not about speed-up, but about premature resorption, as a term a «speed-up» can be attributed to the physiology processes and conditioned acceleration. Term «premature» resorption already in itself testifies to pathology.

T.F. Vinogradova (1976) considers that in the clinic of child's dentistry at presence of chronic proliferating inflammation which overcame a bone in the area of bifurcation of root of baby tooth, especially if a pathological process spread on the follicle of the second teeth or on the roots of nearby teeth, a term must be accepted «chronic granulating ». For chronic granulating porosities characteristically violation of conformities to the law of physiological resorption of roots. At him pathological resorption of roots of baby teeth. Under act of chronic granulating porosities there are serious changes in jaw bones, follicles and rudiments of the second teeth.

Yet Terner specified first, that crackpot development of permanent rudiments quite often was investigation of inflammation of periodontium of baby tooth. For Terner, such teeth more frequent meet on a lower jaw and there are mainly second premolars. Clinically these teeth are characterized undevelopment of crown on which an enamel cover absents and which has a brown color; in other cases these teeth have a form of crown and undevelopment of enamel as hypoplasia. Such teeth in a clinic name of Terner's. F.І.Lepidus (1934), Т.І.Alban sky (1934), R.І.Smolyanova(1963) and other researchers described different supervisions as follicle cysts, hearth hypoplasia fabrics of the second teeth, change of the second teeth and etc, which arise up under act of chronic inflammatory processes which develop in periodontium of baby teeth.

At chronic granulating periostitis, when follicles and rudiments of the second teeth are involved in a pathological process, it is roentgenologic possible to select the followings complications:

- violation of the valuable forming of fabrics of permanent premolar, which clinically appears as hypoplasia;

- death of rudiment of the second teeth, which, growing into the infected foreign body, supports motion of chronic inflammation;

- Premature dentition of permanent premolar, in which firmness is reduced in a small hole and through the overload of inferior periodontium inflammation develops and to mash, periodontitis up to tearing away of rudiment;

- distribution of pathological process on fabrics of nearby teeth which stand, and on the follicle of first permanent molar;

- formation of radicularis cysts of suckling and follicle cysts of the second teeth;

- change of rudiments of the second teeth.

Histological a pathological hearth is presented the cages of inflammatory infiltrate with the different amount of germinating epithelium. Consider that it is an epithelium of enamel organ. Clinical supervisions allow asserting that exactly an epithelium hinders the regeneration of fabrics in the hearth of inflammation.

A large role in it belongs to the microbes which constantly enter hearth from resorptive roots and that support inflammation.

Chronic inflammation of periodontium is the protracted process which inflammation and death of mash was preceded. As a result of death of mash and pathological changes in the periodontitis processes of growth and forming of roots violated, pathological resorption of roots is possible. Terms of primary changes, equal as and character them, to take into account is not possible. Consequently, age of child at presence of chronic periodontitu can not specify a doctor on the state of roots.

Clinic of periodontitis of temporal teeth.

Сhronic motion of periodontitu or his sharpening is most widespread In temporal teeth. Chronic periodontitis of infectious origin in temporal teeth can develop as a chronic process without the previous stage of sharp inflammation. It relates with the аanatomic-morphological features of temporal teeth, in particular with absence for the children of stability of structure of periodontitu, and also with the features of functioning of the immune system for the children of junior age. Chronic granulating periodontitis appeared in temporal teeth far more frequent comparatively with other forms of chronic inflammation.

A child complains mainly in the presence of fistulas with a possible selection a pus, and also - carious cavities and change of color of tooth.

A tooth can have a carious cavity, filled mainly rarefaction, something by a second dentine, or to be sealed, changed in a color. Carious cavity at chronic granulematous periodontitis is localized mainly within the limits of interpulp dentine. However disposed it can be and in a cloak dentine. The cavity of tooth is more frequent closed. These features of clinical motion of chronic periodontitu are predefined rapid motion of caries and insufficiency of protective function of mash of temporal teeth (especially in the period of growth and rarefaction of roots) of, which results in infecting of periodontitu. The differences of anatomic structure of hard fabrics of temporal teeth are instrumental in distribution of infection also: more thin layers of enamel and dentine, less degree them mineralization, wide and short dentine canals.

Sounding of bottom of carious cavity at chronic granulematous periodontitis. A reaction absents on thermal irritants, the reaction of tooth on perccusion is painless. Such clinical symptomatic complicates differential diagnostics of chronic periodontitu and caries of temporal teeth substantially. Absence of pain during preparation of enamel-dentin connection testifies to death of mash and development of inflammatory process in periodontium. Sounding of bottom of carious cavity at periodontitis of temporal teeth is painless. Sometimes it cause by an insignificant sickliness and bleeding as a result of granulation fabric from periodontitu in root channels and cavity in tooth, especially in the period of growth or rarefaction of roots.

In most cases on the mucus shell of gums in the projection of apex roots or bifurcation of the staggered tooth fistules is determined with salient granulations and by selection pus (fig. 5, 6, 7). In default of fistulas the mucus shell of gums in the area of causal tooth, has a cianosis tint. The symptom of vasopressin of Locums is positive, namely: after pressure of spatula there is whitishness pressure on gums, which acquires the bright red colouring gradually. Granulating form of chronic periodontitu of temporal teeth for children more frequent than for adults, accompanied regional chronic lymphadenitis, and sometimes - by a chronic porosities reaction.

Roentgen logic in the area of bifurcation of molar and apical part of roots destruction of cortical plate of аalveolus and hearth of dilution of bone fabric is determined with unclear boards. Quite often there is pathological resorption of roots, and also destruction (perforation) of bottom of cavity of tooth in the area of bifurcation. At distribution of pathological process there is destruction of cortical plate of follicle on the rudiment of the second teeth.

Differential diagnostics of chronic granulating periodontitis of temporal teeth is conducted with next diseases.

1. by a chronic middle caries which is characterized with pain during preparing of enamel-dentin connection.

2. by a chronic fibrosis and gangrenous pulpit: between a carious cavity and cavity of tooth and beginning of root channels at a pulpit accompanied sharp pain.

3. by a pulpit which was complicated focal periodontitis: at sounding of the exposed horn mashes arise up great pain and moderate bleeding. The differentiating diagnostic signs of chronic granulematous periodontitis is presence of fistules with a selection a pus granulations on a background filling out of serous shell of gums in the projection of pathological process, destructive changes in the area of bifurcation and apexes of roots of the staggered tooth of, which are determined on a sciagram, and also absence of pain during preparation of enemal-dentin connection.

Chronic granulating periodontitis of temporal tooth can entail development of complications, the degree of weight of what depends on prevalence of inflammatory process and term of follicle of the second teeth.

1. Distribution of pathological process is on the rudiment of the second teeth on the stage of book-mark of enamel organ; differentiation of cages and formations of follicle to beginning of his mineralization can result in death of rudiment.

2. Infecting of follicle of the second teeth on the early stages of his mineralization can entail development of local hypoplasia enamel (forming of tooth of Turner) as a result of violation of function of Almelo- and odontoblasts (fig. 9). The crown of such tooth is underdeveloped, oblate, and yellow, sometimes there is aplasiya of enamel.

3. Distribution of inflammatory process on the rudiment of the second teeth in more late terms can be completed death of area of growth, what the subsequent forming of the second teeth is halted and takes a place his sekvestration.

4. The protracted motion of chronic periodontitu can result in the change of position of follicle of the second teeth in a jaw which clinically shows up the turn of the second teeth round (tortoanomaliya), by his oral or vestibular displacement.

5. Destruction of bone between the roots of temporal teeth and follicles permanent as a result of excrescence of granulation fabric can entail premature dentition of the second teeth with low cage of mineralization of enamel and by the high risk of development of caries.

6. Premature delete of temporal tooth concerning chronic granulating periodontitu, especially in the period of forming of roots and at the beginning of their stabilizing, can result in retention of permanent tooth.

7. Distribution of inflammation on fabrics which surround the rudiment of permanent tooth, in some cases can result in development of follicular cyst.

Fig. 5.

Fig. 6.

Fig. 7.

Chronic fibrosis periodontitis in temporal teeth almost not diagnosed.

Chronic granulematous periodontitis is also determined in temporal teeth very rarely. He more frequent develops in a period the stabilization roots of temporal tooth.

Sharpening of chronic periodontitu in temporal teeth occupies the second place on frequency.

Sharpening of chronic periodontitu of temporal teeth of characterize expressed clinical symptomatic and to the fasts of cages: a phase of inflammation is brief and for a day long outgrows in festering. The features of anatomic structure of jaws for children (low degree of mineralization of cortical layer and bone tissues, thin trabecules of spongy matter and large bone-cerebral intervals, wide folkman and gavers channels) are instrumental in spread of exudates under a periostium, to forming of abscess and phlegmon.

Clinical picture. Patients grumble about permanent aching pain which increases gradually, especially at pressing on a tooth. Renounce to put a meal. At development of festering inflammation and sharp periostitis reaction the general state of patients is quickly worsened in relations with the increase of temperature of body and appearance of signs of intoxication. The pallor of skin, weakness, languor, head pain, bad sleep and appetite, is marked.

During an objective inspection there is a carious cavity of different depth or stopping in the causal tooth. A cavity of tooth can be closed and opened. During its opening can festering exudation. A tooth is mobile due to the accumulation of exudation in periodontium. Touching to the tooth is sickly, comparative perccusion — sharply sickly. The reaction of tooth absents on thermal irritants. Mucus shell of gums in the area of the staggered tooth brightly red, filling out, sickly at palpation. In the case of development of periostal reaction of transitional fold is marked, what appear also nearby teeth. Sometimes on a background the changed mucus shell fistule can be determined with selection pus. Regional lymphatic knots are megascopic, dense, and sickly at palpation.

Roentgenologic at sharpening of chronic periodontitu of temporal teeth the signs of him are diagnosed mainly granulating forms. Sharpening of chronic periodontitu of temporal teeth it follows differentiate with a sharp diffuse pulpit which was complicated perifokal periodontitis: opening of cavity of tooth cause by sharp pain and bleeding.

For sharp motion of chronic periodontitu of temporal teeth the clinical (a dark color of tooth and appearance of fistula or scar is after it on a background filling out, brightly red, sickly at palpation mucus shell) have a diagnostic value and roentgenologic signs (destruction of cortical plate of alveolus and bone is in the area of bifurcation and apexes of roots of temporal teeth).

Sharp periodontitis in temporal teeth diagnosed rarely and has a mainly toxic, traumatic, rarer infectious origin.

Sharp toxic periodontitis of temporal teeth cause as a result of application of arsenium pasture for devitalisation or drastic antiseptics of group of phenol (phenol, kamforofenol, trikrezol, ferezol ) and aldehydes (formalin) for treatment of root channels, especially in periods of growth and rarefaction of roots.

Sharp traumatic periodontitis of temporal teeth can be investigation inflicted a blow or falling of child, and also mistakes, assumed a doctor during endodontic interference during treatment of pulpit (instrumental treatment and stopping of root channel).

Sharp periodontitis of infectious origin more frequent appear as a result of perifokal process in periodontium at the sharp pulpitis of temporal teeth (or festering).

Clinic of periodontitis of the second teeth.

Chronic periodontitis of infectious origin in the second teeth for children after frequency occupies the first place. Chronic inflammation in periodontium can arise up as a result of sharp, however in the second teeth with the uncompleted growth of roots more frequent there is development of process. By the most widespread form of chronic periodontitu of the second teeth for children, especially in the period of formation roots, granulating.

Clinical picture. Chronic granulating periodontitis of permanent teeth for children has run across more frequent.

During an objective inspection in a causal tooth find out stopping or carious cavity a depth of which can be different. Percussion of bottom of carious cavity painless. A reaction absents on thermal irritants. Reaction of tooth on percussion — painless. Between a carious cavity and cavity of tooth often appears connection sounding of which is painless. At chronic granulating periodontitis of the second teeth with the unformed roots often enough there is growing in of granulations in root channels. In such cases deep percussion poorly sickly and accompanied bleeding.

Children have fistulas the leading clinical sign of this form of chronic periodontitis of the second teeth.

Sometimes a scar which testifies to its temporal closing appears in place of fistulas. In default of fistulas near a pecan tooth there is cyanosis of mucus shell of gums. The symptom of vasoparesis of Lukomsky is positive. For children the granulating form of chronic periodontitu of the second teeth is accompanied regional lymphadenitis.

Development of chronic granulating periodontitu in the second teeth with the uncompleted growth of roots can be complicated areas of growth and stopping of the subsequent forming of roots. Roentgenologic chronic granulating periodontitis by characterize destruction of cortical plate of alveolus near a apex root, periodontal crack, and also by the hearth of rarefaction bone near the apexes of roots, which has unclear outlines. Dilution of bone fabric can be observed and in the area of bifurcation of permanent molars. Roentgenologic picture of chronic granulating periodontitis of the second teeth with the uncompleted forming of roots it is needed to distinguish from the area of growth in intact teeth. Safety of cortical plate of alveolus, which surrounds an unharmed sprout area, is it by a differential sign.

Chronic granulating periodontitis of the second teeth for children it is necessary to differentiate with chronic middle and deep caries, by a chronic fibrous and gangrenous pulpit, and also pulpitis, that focal periodontitis was complicated. The final diagnosis of chronic granulating periodontitu can be put on the basis of information of clinical inspection (fistula with salient granulation and by a selection a pus on a background filling out, stagnant hyperaemia of mucus shell of gums or scar after it, the color of tooth is changed) and results of roentgenologic research (destruction of cortical plate of alveolus, periodontal fissure and bones near the apexes of roots of the staggered teeth).

Chronic granulematous periodontitis arises up in permanent teeth for children mainly then, when their roots and periodontium is already formed fully. Development of granules on the first stages it is possible to seeas a protective reaction of organism in reply to the receipt of infection of root channel to the periodontal crack. Limitation of pathological process due to formation of connective capsule is possible in the case of morphofunctional maturity of fabrics of periodontium. However digs up the protective function of granuloma only during time. Gradually its capsule germinates vessels, as a result barer between granuloma and by fabrics, that it is surrounded, violated, that granuloma begins to act part hearth of chroniosepsis.

Clinical picture. Chronic granulematous periodontitis of permanent teeth for children characterized mainly motion. Only in some cases patients grumble about the unpleasant feelings during pressing on a tooth, change of his color. A tooth can be intact (in the case of traumatic origin of periodontitu), sealed or to have a carious cavity, what connect with the cavity of tooth. Sounding of bottom of carious cavity, its connection with the cavity of tooth and beginning of root channels is painless. The reaction of tooth on percussion of tooth is painless. A reaction absents on thermal irritants. Palpation on a mucus shell alveolar sprout, thrusting out of bonewall can be determined in the area of pathological process./

The diagnosis of chronic periodontitu is determined on the basis of roentgenologic research: in the area of apexes of roots of the staggered tooth there is destruction of cortical plate of alveolus and periodontal crack and hearth of dilution of bone fabric of round or oval form with clear outlines, the diameter of which does not exceed 5 mm. Chronic granulematozis periodontitis for children it follows to distinguish from the area of growth in intact teeth with the unformed roots. The roentgenologic signs of sprout area is safety of cortical plate of alveolus, that and surrounds, and also even width of periodontal crack near the formed part of roots.

Differential diagnostics of chronic periodontitis must be conducted with next diseases.

1. By a chronic deep caries which is characterized appearance of pain during preparing of enamel-dentin connection, and also sensitiveness of tooth, to the action of thermal irritants.

2. By a chronic fibrous and gangrenous pulpit, that complicated by focal periodontitis, on the basis of origin of sharp pain during sounding of connection between a carious cavity and cavity of tooth and beginning of root channels.

3. Granulating and fibrous chronic periodontitis after helping information of roentgenologic research. Dilution of bone fabric at the granulating form of periodontitu does not have clear outlines. Fibrous form him characterized deformation of periodontal crack and saving of safety of cortical plate of alveolus.

4. Cystgranuloma and reticular cyst: the hearth of destruction of bone on a sciagram has a diameter more than 5 and 8 accordingly.

Chronic fibrous periodontitis of the second teeth for the children of diagnosis relatively rarely comparatively with other forms of chronic inflammation of periodontium. He is characterized education in apical part of roots of connecting fabric which changes by periodontium. Some authors interpret such changes in periodontium as his fibrous and does not examine this process as inflammatory.

Fibrous periodontium can develop in the second teeth with formed roots as a result of the carried sharp inflammation in anamnesis, mainly traumatic origin. Sometimes fibrous periodontitis is observed in teeth which before were curate concerning pulpitis, and also can arise up after effective treatment of other forms of chronic periodontitu (granulating).

Clinical picture. Fibrous periodontium complaints absented about pain.

Objective. Tooth of intact (in the case of traumatic origin) or sealed, rarer — carious. Percussion of tooth is painless. The mucus shell of gums is not changed. Diagnostics of fibrous changes in periodontium is conducted after helping of roentgenologic research. On a sciagram deformation of periodontal crack appears as uneven it expansion and narrowing — in the areas of hypercementosis. Roentgenologic of fibrous periodontium is very similar to the changes which appear on the sciagram of teeth with uncompleted growth of roots, namely — on the stage of the unclosed apical opening and unformed periodontium. For determination of final diagnosis is necessary to take into account age of child, and also to the period of growth and forming of roots in different teeth.

Sharp periodontitis of the second teeth for children more frequent all arises up as a result of blow or falling of child. A trauma also can cause errors at treatment of pulpit during endodontic treatment. Before development of sharp toxic periodontitu, especially in teeth with the uncompleted forming of roots, the use for devitalisation mash of pastes, which contain a arsenic anhydride, and also application for antiseptic treatment and stopping of root channels of facilities which are toxic characteristics, leads: groups of phenol (to the phenol, kamforphenol, trikrezol, ferezol, to ) and aldehide (to formalin). Sharp periodontitis of the second teeth ofinfective origin for children quite often accompanies motion of sharp or festering pulpitis that is a perifokal process.

Clinical picture of sharp periodontitis. There are patients that complain on protracted pain of aching character in a causal tooth, and та¬кож feeling, that a tooth "grew" as though.

Objective. At a traumatic origin sharp periodontitis tooth of intact or with traumatic of his crown part on a different level. In the case of sharp toxic periodontitu there are signs preparing of carious cavity, partial or full opening of cavity of tooth. At sharp periodontitis of infective origin a carious cavity which is not reported with the cavity of tooth appears in a tooth. In the case of death (to necrosis) of mash and development of focal process in periodontium of probing bottom of carious cavity painless. A reaction absents on thermal irritants. Vertical percussion of tooth is sickly. A tooth can be something mobile due to the accumulation of exudates in periodontium. The mucus shell of gums in the area of the staggered tooth is not changed or the masses insignificant signs of inflammation: pastosis, poorly hyperaemic, during palpation a bit sickly. Regional lymphatic knots sometimes can be megascopic in sizes, poorly sickly during palpation.

Clinical picture of sharp festering periodontitu characterize by permanent intensive pressuring pain. Even the insignificant touching to the tooth (by a language or tooth-antagonist) provokes sharp pain that is why patients hold mouth half-open salivation is possible. In the case of distribution of pus under a periostium pain diminishes. The general state of patients is worsened as a result of increase of temperature of body and development of intoxication. There are a general weakness, head pain, violation of sleep and appetite. A tooth can be intact, curate before or to have a carious cavity which is not reported with the cavity of tooth. A leading clinical sign is intensive pain during vertical and horizontal percussion. Diffuse distribution of process draws origin of pain during percussion research of the teeth located alongside. A causal tooth becomes mobile sharply.

Mucus shell of gums in the area of inflammation brightly hyperaemic, filling out, sickly during palpation. As a result of distribution of festering exudates under a periostium an abscess is formed, what characterized ofsmoothness of transitional fold in an area staggered and nearby teeth.

Asymmetry of person is marked due to the collateral edema of soft fabrics. Submandibular lymphatic knots are megascopic in sizes, dense, sickly during palpation. Changes on a sciagram at sharp periodontitis mainly absent. In some cases as a result of diffuse distribution of pus a clearness of picture of spongy matter of bone in the area of causal tooth can be lost.

It follows to differentiate sharp motion of periodontitu with next diseases.

1. By a sharp diffuse pulpit which was complicated perifokal periodontitis. Objective: sounding of carious cavity is sickly on all of bottom, opening of cavity of tooth is accompanied intensive pain and bleeding, the general state of patient is not broken.

2. Sharpening of chronic periodontitu - on the basis results of roentgenologic research (by the presence of destructive changes in periodontium).

3. By sharp odontogenic periostitis.

Objective: transitional fold in an area causal and the teeth located alongside smoothed out, filling out, hyperaemic, sickly during palpation.

4. Sharp odontogenic osteomielitis.

Objective: determinates mobile of patient and nearby teeth, smoothness transitional fold on either side of alveolar sprout, selection pus from gum pockets.

Sharpening of chronic periodontitis of the second teeth for children with the uncompleted growth of roots is diagnosed far more frequent than his sharp motion. The clinical picture of sharpening of chronic inflammatory process is very similar to sharp motion of periodontitu. In a clinic the differential signs of sharpening are a change of color of tooth, presence of fistula or scar after it, and also connection of carious cavity with the cavity of tooth, mainly in the second teeth with formed roots. In anamnesis can be determined previous sharpening of pathological process. The roentgenologic sharpening is distinguished by such signs:destruction of cortical plate of alveolus, deformation of periodontal crack and hearth of dilution of bone fabric with unclear edge near the apexes of roots. Differential diagnostics between sharpening and sharp motion of periodontitu is conducted taking into account absence or presence of the previous sharpening in anamnesis, fistula or scar after it, changes of color tooth.

Regional (marginal) periodontitis develops as a result of mechanical damage of gingival edge, penetration of infection, chemical matters (acid, meadow) or devitalisation to pasture. Sometimes reason of regional periodontitu is penetration of extraneous body, stopping is unskilled imposed.

Chronic marginal periodontitis develops as a result of the protracted action of mechanical or chemical irritant. A patient can complain on the insignificant pain feelings in the area of defeat. A clinical picture is characterized a moderate edema and stagnant hyperaemia of marginal part of gums. Horizontal percussion something sickly.

Clinical picture of sharp regional periodontitu. Complaints are about permanent pain in the area of the staggered tooth. Gingival edges fillings out, hyperaemic, sometimes covered ulcers, at the festering inflammatory process form sickly infiltrate up to development of subgingival abscess, from a gum pocket a pus is selected, there is a sickliness during horizontal percussion. On the sciagram of destructive changes in a bone is however possible it is to find out an extraneous body or unhigh-quality imposed filling. In the case of sharpening of chronic regional periodontitu a clinical picture is similar to described higher. On a sciagram there is expansion of periodontal crack in overhead third of periodontium and resorption of cortical plate of intracellular partition.

Roentgenologic picture of sharp periodontitu extremely informing and does not have a diagnostic value. There can be insignificant expansion of periodontal crack due to the accumulation of exudates, structure of spongy matter in near root fabrics due to infiltration and edema.

Chronic fibrous periodontitis roentgenologic appears expansion of periodontal crack. The change of its width is observed on the limited area or rarely on all of draught which depends on prevalence of process.

At chronic granulating periodontitis on a sciagram cortical plate not evidently on the limited area and in the same place there is not a characteristic spongy matter which testifies to dilution of bone. This area of dilution does not have clear scopes. Chronic granulematous periodontitis on a sciagram determined as dilution of bone fabric of the rounded or oval form, sometimes at his lateral surface. It is explained that channel or closed on the lateral surface of root, or before apex divided and opened a few mouths on the surface of root. During the perforation of root can be disposed in the places of perforation. Passing of line of periodontium is determined directly to the bone defect, caused granulema.

Root canal instrumentation

Introduction

Accurately prepared root canals that allow effective elimination of soft and hard-tissue elements, disinfection and obturation of the canal system are critical to success- ful endodontic treatment. The procedure, which often is referred to as “cleaning and shaping” , is often a diffi- cult and time-consuming task. Root canal instrumenta- tion therefore requires a systematic approach to avoid underpreparation and iatrogenic injury, errors that may cause a poor prognosis for the treatment. In this chapter concepts for effective root canal instrumentation are reviewed. Materials and guidelines for clinical use are described, based on root canal system anatomy and final shaping objectives. Principles of root canal instrumentation root canal instrumentation is accomplished by the use of endodontic instruments and (antimicrobial) irrigants under aseptic working conditions. A primary objective of this chemomechanical preparation, in teeth with either vital or non-vital pulps, is shaping the root canal space. It is generally accepted that the most appropriate final root canal shape is a tapered (conical) preparation with the smallest diameter at the end-point near the root tip, and the widest at the canal entrance. Special atten- tion should therefore be paid to the apical level and the original path of the canal. As a general rule, the removal of root dentin should be centered, i.e. with respect to the initial root canal anatomy. In the process existing soft- tissue elements, serving as potential substrate for growth of remaining microorganisms, will be removed as well. Root canal instrumentation may be carried out using hand-held or machine-driven (rotary) instruments. These instruments come in many configurations but are conventionally grouped according to ISO (International Organization for Standardization) and ANSI (American National Standards Institute) standards. The quality, s izing and physical properties of endodontic instruments and the materials used for their manufacture are t herefore well defined. Instrument properties (e.g. stiffness) relate to type of alloy (stainless steel versus nickel–titanium), degree of taper (conicity) and cross-sectional design. Stainless steel files have a high inherent stiffness that increases with increasing instrument size. As a result, restoring forces attempt to return the instrument to its original shape when preparing a curved root canal, espe- cially when using a filing motion. An instrument that is too stiff will cut more on the convex (outer) side than on the concave (inner) side, thereby straightening the curve. The resulting “hour-glass shape” and canal aberrations (e.g. ledge, zip and perforation) leave an important portion of the root canal wall uninstrumented and create an irregular canal shape that is difficult to clean, disinfect and fill properly. Over time, researchers and clinicians have found a variety of methods to deal with the stiffness of stainless steel instruments. As a result, various movements for the manipulation of these files and approaches to shape the canal were proposed. While skillful operators can handle these techniques, shaping a curved root canal with stain- less steel hand files remains a time-consuming and most challenging exercise. Besides adaptations in file design and use, the problem of instrument stiffness has been answered by the use of nickel–titanium (Ni–Ti) rather than stainless steel. Nickel–titanium’s unique property of super-elasticity may allow hand (and rotary) files to be placed in curved canals with less lateral force exerted. Conceptually, all such files are made from Nitinol,1 an equiatomic Ni–Ti alloy (using about 55 wt% Ni and 45 wt% Ti, and substi- tuting some Ni with less than 2 wt% Co) with a low modulus of elasticity and a greater resistance to plastic deformation. Recent advances in the field of endodontics have led to the use of Ni–Ti rotary files in general and specialized dental practice. The idea behind this development is the belief that Ni–Ti rotary file design and the adopted crown-down sequence (see further below) could improve both quality and efficacy of root canal preparation. For instance, owing to the existence of a greater taper design, these files could easily provide sufficient shape at the transition between the middle and apical one-thirds of root canals. However, innovation rarely comes without its own set of challenges. Before entering the exciting field of Ni–Ti rotary instrumentation, some basic prepa- ration concepts such as straight-line access and shaping objectives in relation to tooth anatomy should be com- pletely understood. Purely commercially driven use, on the other hand, may cause procedural errors (e.g. high incidence of instrument fracture) and frustration. Root canal system anatomy Root canal(s) versus root canal system.The specific features and complexity of the internal anat- omy of the teeth have been thoroughly studied. Using a replica technique on thousands of teeth, Hess made clear as early as 1917 that the internal space of dental roots is often a complex system composed of a central area (root canals with round, oval or irregular cross- s ectional shape) and lateral parts (fins, anastomoses and accessory canals). In fact, this lateral component may represent a relatively large volume, which challenges the cleaning phase of the instrumentation procedure in that tissue remnants of the vital or necrotic pulp as well as infectious elements are not easily removed in these areas. Thus, the image of root canal(s) having a smooth, conical shape is generally too idealistic and underestimates the limited reach of root canal instrumentation. In dental practice, complete visualization of the lateral component of the root canal system is normally not p ossible. Common radiographic techniques, both con- ventional and digital, have limited resolution and pro-vide only two-dimensional (2D) projection views. Even though the paralleling technique with orthogonal and eccentric projections improves our understanding, part of the lateral anatomy, especially in the buccolingual (or buccopalatal) plane, will remain invisible. Limited perception of root canal system anatomy may cause procedural difficulties and may invite the clinician to follow a 2D-based approach in a routine-like fashion, where instrumentation to the final working length early in the shaping procedure often causes procedural mishaps. A new 3D technique for in vitro dental research, called microfocus computed tomography (micro-CT), has pro- vided detailed and accurate visualizations of the external and internal anatomy of teeth, which are useful for sci- entific and educational purposes. In addition, the ”typical or average anatomy”, as presented for each type of tooth in many textbook tables, has given way to individual appearance being the key to achieving high success of endodontic treatment. Apart from the varying complexity of the lateral component, the a natomy of root canals also differs in terms of curvature, cross-sectional shape, diameter, apical configuration and the extent to which changes have been induced by physi- ological and pathological processes.

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