Chapter18

VitalPulpTherapyandApexificationChapter18

VitalPulpTherapy

掌握：直接蓋髓術、間接蓋髓術、牙髓切斷術的原理及適應證根尖誘導成形術的修復機制和愈合類型學習要點熟悉：直接蓋髓術、間接蓋髓術、根尖誘導成形術操作步驟了解：根尖屏障術的原理和操作步驟掌握：直接蓋髓術、間接蓋髓術、牙髓切斷術的原理及適VitalPulpTherapy

活髓保存治療Directpulpcapping直接蓋髓術Indirectpulpcapping間接蓋髓術Pulpotomy牙髓切斷術“Principlesandpracticeofendodontics”

VitalPulpTherapy

活髓保存治療Direc1.Pulpcapping

1.1DirectpulpcappingIndications:Accidentalormechanicalpulpexposure(normalpulp)CavitypreparationPlacementofpinsTraumaMainlyforimmaturepermanentteethwithrecent(<24hr)traumaticpulpexposureormechanicalexposureduringcavitypreparation1.Pulpcapping

1.1DirectpulShouldmatureteethbepulpcapped?Sizeofexposurelimitedtoo.5mmContraindicatedforcarioustoothwithpulpinvolvementEnamel-dentinfracturewithpulpalinvolvementDirectpulpcappingShouldmatureteethbepulpcaHemostaticreagents

止血劑Saline鹽水Hydrogenperoxide雙氧水Dilutedsodiumhypochlorite次氯酸鈉Chlorhexidine洗必泰Hemostaticreagents

止血劑SalinePulpcappingmaterialsCalciumhydroxideMineraltrioxideaggregates(MTA)

礦化三氧化聚合物

PulpcappingmaterialsCalciumMTAExcellentbiocompatibilityandhydrophilicityInducehardtissueregeneartionIndicatedforapicalbarrier,perforationrepair,retrofillingandvitalpulpaltherapySettingtime:4~5hrsMTAProceduresCa(OH)2orMTAappliedtotheexposuretostimulatedifferentiationofnewodontoblast-likecellsandformationofsecondarydentinTemporaryrestorationplacedoverCa(OH)2orMTAFollow-upPermanentrestorationPulpotomyorendodontictreatmentforsymptomatictoothProceduresCa(OH)2orMTAappl1.2IndirectpulpcappingIndicationsDeepcariouslesionsNohistoryofpulpalgia牙髓痛NosignsofirreversiblepulpitisNopulpexposureafterexcavationofcariousdentine1.2IndirectpulpcappingIPulpCappingMaterialsCalciumhydroxide氫氧化鈣Themostcommonly-used (direct)pulp-cappingmaterialWater-basedcalciumhydroxideResin-basedcalciumhydroxidee.g.Dycal,TimelinePulpCappingMaterialsCalciumZincoxide-eugenolcement(ZOE)OnlyforindirectpulpcappingBactericidaleffectandhermeticmarginalsealCytotoxicity:useofZOEasalinerindeepcariouslesionsisstillcontroversialZincoxide-eugenolcement(ZOEProcedures1.Removeallsoftened,mushyorleatherydentine2.EitherZOEorCa(OH)2placedontheremainingdentintokillorsuppressbacteria3.Base4.TemporaryorpermanentrestorationProcedures1.Removeallsoften2.PulpotomyIndicatedforimmaturepermanentteethTraumaticpulpexposureMechanicalpulpexposureCariouspulpexposure2.PulpotomyIndicatedforimmaProceduresRemovalofallcariousdentinandpulptissuetotheleveloftheradicularpulpVitalpulpstumpcappedwithCa(OH)2

TemporaryrestorationFollow-upAsymptomatic:permanentrestorationSymptomatic:endodontictreatmentProceduresRemovalofallcariPotentialproblemswithpulpotomy

asapermanenttreatmentImpossibletodeterminewhetheralldiseasetissuehasbeenremovedTheremainingradicularpulptissuemayundergomineralizationMakingfurtherendodontictreatmentdifficultorimpossibleInternalresorptionPotentialproblemswithpulpotConclusionsThevitalpulptherapiesarepredictableinteethwithtraumaticormechanicalpulpexposureDirectpulpcappingiscontraindicatedforteethwithcariouspulpexposure--PulpotomymightbethechoicebutisconsideredunprovenWhen–forfinancialorotherreasons–extractionistheonlyalternative,pulpotomycertainlyshouldbeconsideredforthebenefitofthepatientConclusionsThevitalpulpther4.Apicalbarriertechnique4.Apicalbarriertechnique4.1PrincipleApicalbarriertechniqueUseMineraltrioxideaggregate(MTA)toformacalcifiedbarrierattherootterminusthathelpsobturatingtherootcanalsystem4.1PrincipleApicalbarrierteMTAExhibitsoutstandingbiocompatibility,antibacterialproperties,hydrophilicity,sealingabilityandlong-termsuccessStimulateshardtissueformationProvidesasealagainstmicroleakageEstablishesahardapicalbarrierinordertoobturatetherootcanalsystemMTAExhibitsoutstandingbiocomMTAMTAplacementcanbedoneinfewerclinicaltreatmentvisitsCalciumhydroxidetypicallyincludesmultipleappointmentsovermonthsandalsorequirespotentialtissueforcontinuedtoothdevelopmentMTAusedto

①Induceanartificialbarrierinopen-apexcases②Repairperforation③Sealtheretro-preparationinsurgicalendodontics④ProtectthepulpindirectpulpcappingMTAMTAplacementcanbedonei4.2Indication

PulpalnecrosisteethwithapicalperiodontitisImmatureteethwithopenapicesFailtoclosetherootendwithlong-termtraditionalapexification4.2Indication

Pulpalnecrosis4.3Procedure

(1)Cleaningandshapingoftherootcanals

Coronal-radicularaccesstothedefecttoremoveallnecroticpulptissueandmicrobialinfectionNottoheavilyinstrumentthealreadythinandrelativelyfragilewallsoftheroot4.3ProcedureCoronal-radicul(2)Irrigation

CentraltothedebridementofimmatureteethBenefitfromtheantimicrobialandtissue-solventpropertiesofNaOClOftenwiththehelpofultrasonicsAfterthoroughdebridement,thecanalisdriedandmedicatedwithCa(OH)2pasteCentraltothedebridementof(3)PlacementoftheMTAWashouttheCa(OH)2paste,drythecanalDeliveredtothecanalwithadedicatedMTAcarrier,condensedwithpluggersThecanalisfilledincrementallywithMTAAnapicalplugof4-5mmthicknessisusuallyconsideredoptimal(3)PlacementoftheMTAWashoAllexcessMTAisremovedfromthecanalwallsbyscrubbingwithmoistenedpaperpointsorbrushes.Awetcottonpelletisplacedinthecanaltoprovidemoistureforthesettingreaction.ThepelletshouldnotbeincontactwiththeMTATheadequacyoftheapicalplugisverifiedradiographicallyAllexcessMTAisremovedfrom(4)FillingthecanalsystemMTArequires4-5hforsettingThehardsetoftheMTAverifiedwithanendodonticfileorprobe.Theendodontictherapyisconductedasnormal(BondedresinmaybeusedinsteadofGP)IftheMTAhasnothardened,thecanalcanberecleansedandtheprocedurerepeatedbeforefinalbondedrestoration.(4)FillingthecanalsystemMT(5)Regularre-evaluationRe-evaluatethetoothat3-6monthsImmatureteeth,andparticularlythosewhicharepulplessareathighriskoffracture.(5)Regularre-evaluationRe-4.4Prognosis

ReducetheradiolucencyaroundtheperiapicalareaAcementum-likematerialhasbeenconsistentlyshowntogrowCombinationwiththeplacementofbondedcompositeresinappearstohavevirtuallyeliminatedcervicalrootfractures.

4.4PrognosisReducetheradio5.NewHorizonsforPulpRegeneration

DentalpulprevascularizationDisinfectionoftherootcanalandstimulationofresidualstemcellscaninduceformationofnewhardtissueontheexistingdentinwallandcontinuedrootdevelopment.IwayaSI,DentTraumatol,20015.NewHorizonsforPulpRegenChapter18

VitalPulpTherapyandApexificationChapter18

VitalPulpTherapy

掌握：直接蓋髓術、間接蓋髓術、牙髓切斷術的原理及適應證根尖誘導成形術的修復機制和愈合類型學習要點熟悉：直接蓋髓術、間接蓋髓術、根尖誘導成形術操作步驟了解：根尖屏障術的原理和操作步驟掌握：直接蓋髓術、間接蓋髓術、牙髓切斷術的原理及適VitalPulpTherapy

活髓保存治療Directpulpcapping直接蓋髓術Indirectpulpcapping間接蓋髓術Pulpotomy牙髓切斷術“Principlesandpracticeofendodontics”

VitalPulpTherapy

活髓保存治療Direc1.Pulpcapping

1.1DirectpulpcappingIndications:Accidentalormechanicalpulpexposure(normalpulp)CavitypreparationPlacementofpinsTraumaMainlyforimmaturepermanentteethwithrecent(<24hr)traumaticpulpexposureormechanicalexposureduringcavitypreparation1.Pulpcapping

1.1DirectpulShouldmatureteethbepulpcapped?Sizeofexposurelimitedtoo.5mmContraindicatedforcarioustoothwithpulpinvolvementEnamel-dentinfracturewithpulpalinvolvementDirectpulpcappingShouldmatureteethbepulpcaHemostaticreagents

止血劑Saline鹽水Hydrogenperoxide雙氧水Dilutedsodiumhypochlorite次氯酸鈉Chlorhexidine洗必泰Hemostaticreagents

止血劑SalinePulpcappingmaterialsCalciumhydroxideMineraltrioxideaggregates(MTA)

礦化三氧化聚合物

PulpcappingmaterialsCalciumMTAExcellentbiocompatibilityandhydrophilicityInducehardtissueregeneartionIndicatedforapicalbarrier,perforationrepair,retrofillingandvitalpulpaltherapySettingtime:4~5hrsMTAProceduresCa(OH)2orMTAappliedtotheexposuretostimulatedifferentiationofnewodontoblast-likecellsandformationofsecondarydentinTemporaryrestorationplacedoverCa(OH)2orMTAFollow-upPermanentrestorationPulpotomyorendodontictreatmentforsymptomatictoothProceduresCa(OH)2orMTAappl1.2IndirectpulpcappingIndicationsDeepcariouslesionsNohistoryofpulpalgia牙髓痛NosignsofirreversiblepulpitisNopulpexposureafterexcavationofcariousdentine1.2IndirectpulpcappingIPulpCappingMaterialsCalciumhydroxide氫氧化鈣Themostcommonly-used (direct)pulp-cappingmaterialWater-basedcalciumhydroxideResin-basedcalciumhydroxidee.g.Dycal,TimelinePulpCappingMaterialsCalciumZincoxide-eugenolcement(ZOE)OnlyforindirectpulpcappingBactericidaleffectandhermeticmarginalsealCytotoxicity:useofZOEasalinerindeepcariouslesionsisstillcontroversialZincoxide-eugenolcement(ZOEProcedures1.Removeallsoftened,mushyorleatherydentine2.EitherZOEorCa(OH)2placedontheremainingdentintokillorsuppressbacteria3.Base4.TemporaryorpermanentrestorationProcedures1.Removeallsoften2.PulpotomyIndicatedforimmaturepermanentteethTraumaticpulpexposureMechanicalpulpexposureCariouspulpexposure2.PulpotomyIndicatedforimmaProceduresRemovalofallcariousdentinandpulptissuetotheleveloftheradicularpulpVitalpulpstumpcappedwithCa(OH)2

TemporaryrestorationFollow-upAsymptomatic:permanentrestorationSymptomatic:endodontictreatmentProceduresRemovalofallcariPotentialproblemswithpulpotomy

asapermanenttreatmentImpossibletodeterminewhetheralldiseasetissuehasbeenremovedTheremainingradicularpulptissuemayundergomineralizationMakingfurtherendodontictreatmentdifficultorimpossibleInternalresorptionPotentialproblemswithpulpotConclusionsThevitalpulptherapiesarepredictableinteethwithtraumaticormechanicalpulpexposureDirectpulpcappingiscontraindicatedforteethwithcariouspulpexposure--PulpotomymightbethechoicebutisconsideredunprovenWhen–forfinancialorotherreasons–extractionistheonlyalternative,pulpotomycertainlyshouldbeconsideredforthebenefitofthepatientConclusionsThevitalpulpther4.Apicalbarriertechnique4.Apicalbarriertechnique4.1PrincipleApicalbarriertechniqueUseMineraltrioxideaggregate(MTA)toformacalcifiedbarrierattherootterminusthathelpsobturatingtherootcanalsystem4.1PrincipleApicalbarrierteMTAExhibitsoutstandingbiocompatibility,antibacterialproperties,hydrophilicity,sealingabilityandlong-termsuccessStimulateshardtissueformationProvidesasealagainstmicroleakageEstablishesahardapicalbarrierinordertoobturatetherootcanalsystemMTAExhibitsoutstandingbiocomMTAMTAplacementcanbedoneinfewerclinicaltreatmentvisitsCalciumhydroxidetypicallyincludesmultipleappointmentsovermonthsandalsorequirespotentialtissueforcontinuedtoothdevelopmentMTAusedto

①Induceanartificialbarrierinopen-apexcases②Repairperforation③Sealtheretro-preparationinsurgicalendodontics④ProtectthepulpindirectpulpcappingMTAMTAplacementcanbedonei4.2Indication

PulpalnecrosisteethwithapicalperiodontitisImmatureteethwithopenapicesFailtoclosetherootendwithlong-termtraditionalapexification4.2Indication

Pulpalnecrosis4.3Procedure

(1)Cleaningandshapingoftherootcanals

Coronal-radicularaccesstothedefecttoremoveallnecroticpulptissueandmicrobialinfectionNottoheavilyinstrumentthealreadythinandrelativelyfragilewallsoftheroot4.3ProcedureCoronal-radicul(2)Irrigation

CentraltothedebridementofimmatureteethBenefitfromtheantimicrobialandtissue-solventpropertiesofNaOClOftenwiththehelpofultrasonicsAfterthoroughdebridement,thecanalisdriedandmedicatedwithCa(OH)2pasteCentraltothedebridementof(3)PlacementoftheMTAWashouttheCa(OH)2paste,drythecanalDeliveredtothecanalwithadedicatedMTAcarrier,condensedwithpluggersThecanalisfilledincrementallywithMTAAnapicalplugof4-5mmthicknessisusuallyconsideredoptimal(3)PlacementoftheMTAWashoAllexcessMTAis