Endodontics E-Book

 
 
Elsevier (Verlag)
  • 4. Auflage
  • |
  • erschienen am 26. Januar 2014
  • |
  • 336 Seiten
 
E-Book | ePUB mit Adobe DRM | Systemvoraussetzungen
E-Book | PDF mit Adobe DRM | Systemvoraussetzungen
978-0-7020-5425-9 (ISBN)
 
This lavishly illustrated, practical guide to endodontic treatment covers the latest developments in instrumentation and filling techniques. Ideal for all dental practitioners involved in endodontic therapy [root canal treatment], this new edition has been fully updated throughout and now includes a new author team from the Eastman Dental Institute.
  • Englisch
  • London
  • |
  • Großbritannien
Illustrations, unspecified
  • 342,39 MB
978-0-7020-5425-9 (9780702054259)
0702054259 (0702054259)
weitere Ausgaben werden ermittelt
1 - Front cover [Seite 1]
2 - Endodontics [Seite 2]
3 - Copyright page [Seite 5]
4 - Table of Contents [Seite 6]
5 - Foreword [Seite 7]
6 - Preface [Seite 8]
7 - Acknowledgements [Seite 9]
8 - Contributors [Seite 10]
9 - Introduction to endodontology and endodontics [Seite 12]
9.1 - Definition of Endodontology and Endodontics [Seite 12]
9.2 - Brief introduction to pulpal/periapical disease [Seite 12]
9.3 - References [Seite 12]
10 - 1 Rationale for disease management [Seite 13]
10.1 - 1 Tooth organogenesis, morphology and physiology [Seite 13]
10.1.1 - Tooth development [Seite 13]
10.1.1.1 - Early development of teeth [Seite 13]
10.1.1.2 - Primary epithelial band, vestibular band and dental lamina [Seite 13]
10.1.1.3 - Enamel organs [Seite 13]
10.1.1.4 - Dental papilla [Seite 13]
10.1.1.5 - Vestibule formation [Seite 14]
10.1.1.6 - Changes to and further development of dental lamina for permanent molars [Seite 14]
10.1.1.7 - Development of successional permanent teeth [Seite 15]
10.1.1.8 - Differentiation of enamel organs [Seite 15]
10.1.1.9 - Differentiation of dental papilla, dental follicle and sheath of Hertwig [Seite 16]
10.1.1.10 - Differentiation and function of the tooth germ [Seite 16]
10.1.1.11 - Molecular regulation of tooth development [Seite 17]
10.1.2 - Anatomical anomalies [Seite 17]
10.1.3 - Tooth morphology [Seite 17]
10.1.4 - Tooth and root shapes [Seite 17]
10.1.4.1 - Variation by tooth type [Seite 17]
10.1.4.2 - Variation by race [Seite 17]
10.1.4.3 - Variation by time [Seite 21]
10.1.5 - Pulp space and its morphologic patterns [Seite 21]
10.1.5.1 - Classifications of pulp systems [Seite 21]
10.1.5.2 - Characteristics of the pulp space [Seite 22]
10.1.5.2.1 - Lateral, secondary and accessory canals [Seite 24]
10.1.5.3 - Dimensions of the pulp space [Seite 25]
10.1.6 - Tooth, root and canal morphology by tooth type [Seite 25]
10.1.6.1 - Maxillary incisors [Seite 25]
10.1.6.2 - Mandibular incisors [Seite 26]
10.1.6.3 - Maxillary and mandibular canines [Seite 26]
10.1.6.4 - Maxillary premolars [Seite 27]
10.1.6.5 - Mandibular premolars [Seite 27]
10.1.6.6 - Maxillary first molars [Seite 28]
10.1.6.7 - Maxillary second molars [Seite 29]
10.1.6.8 - Mandibular first molars [Seite 29]
10.1.6.9 - Mandibular second molars [Seite 30]
10.1.6.10 - Maxillary and mandibular third molars [Seite 30]
10.1.7 - Clinical interpretation and mental imaging [Seite 31]
10.1.8 - Anatomy and physiology of the pulp-dentine complex [Seite 32]
10.1.8.1 - The dental pulp [Seite 32]
10.1.8.2 - The vascular supply [Seite 35]
10.1.8.3 - Functional aspects of the blood supply [Seite 36]
10.1.8.4 - The nerve supply [Seite 37]
10.1.8.5 - Functional aspects of the nerve supply [Seite 37]
10.1.9 - The periradicular tissues [Seite 39]
10.1.9.1 - Cementum [Seite 39]
10.1.9.1.1 - Functions [Seite 39]
10.1.9.2 - Periodontal ligament [Seite 40]
10.1.9.2.1 - Blood supply [Seite 41]
10.1.9.2.2 - Nerve supply [Seite 41]
10.1.9.2.3 - Functions [Seite 41]
10.1.9.3 - Alveolar bone [Seite 42]
10.1.10 - References and further reading [Seite 42]
10.2 - 2 Biological and clinical rationale for vital pulp therapy [Seite 44]
10.2.1 - Functions of the pulp [Seite 44]
10.2.2 - Causes of pulp injury [Seite 44]
10.2.3 - Severe inflammatory and degenerative changes in the pulp [Seite 47]
10.2.3.1 - Spread of pulpal inflammation [Seite 47]
10.2.3.2 - Dystrophic pulp calcification [Seite 48]
10.2.3.3 - Principles of pulp disease prevention and treatment [Seite 49]
10.2.4 - Rationale for vital pulp therapy [Seite 49]
10.2.4.1 - Regenerative pulp therapy [Seite 50]
10.2.5 - Assessment of success of vital pulp therapy procedures [Seite 50]
10.2.6 - Probability of success of vital pulp therapy procedures [Seite 51]
10.2.6.1 - Conservative management of caries [Seite 51]
10.2.6.1.1 - Fissure sealing of occlusal caries [Seite 51]
10.2.6.1.2 - Atraumatic restorative therapy (ART) [Seite 51]
10.2.6.1.3 - Indirect pulp capping (one-step versus step-wise excavation) [Seite 51]
10.2.6.1.4 - Direct pulp capping [Seite 51]
10.2.6.1.5 - Pulpotomy [Seite 51]
10.2.6.2 - Factors affecting outcome of vital pulp therapy [Seite 52]
10.2.7 - Future approaches to pulp regeneration and vital pulp therapy [Seite 52]
10.2.8 - References and further reading [Seite 52]
10.3 - 3 Biological and clinical rationale for root-canal treatment and management of its failure [Seite 54]
10.3.1 - Aetiopathogenesis of periapical disease [Seite 54]
10.3.1.1 - Aetiological factors implicated [Seite 54]
10.3.1.1.1 - Bacteria [Seite 54]
10.3.1.1.2 - Bacterial products [Seite 54]
10.3.1.1.3 - Fungi [Seite 54]
10.3.1.1.4 - Archaea [Seite 54]
10.3.1.2 - Host factors implicated [Seite 54]
10.3.1.2.1 - Viruses [Seite 58]
10.3.2 - A synthesized model of pathogenesis and natural history of periapical disease [Seite 59]
10.3.2.1 - Acute periapical inflammation [Seite 61]
10.3.2.2 - Chronic periapical inflammation [Seite 62]
10.3.2.3 - Epithelial proliferation and cysts [Seite 62]
10.3.2.4 - Chronic suppurative periapical inflammation [Seite 64]
10.3.2.5 - Acute periapical abscess/cellulitis [Seite 64]
10.3.2.6 - Periapical osteomyelitis [Seite 66]
10.3.2.7 - Periapical osteosclerosis or condensing osteitis [Seite 66]
10.3.3 - Nature of the periapical lesion associated with treated teeth [Seite 66]
10.3.4 - Association between root-canal microbiota and periapical lesion development [Seite 70]
10.3.5 - Nature of the root-canal microbiota [Seite 73]
10.3.5.1 - Species richness or qualitative analysis of microbiota (Table 3.3) [Seite 75]
10.3.5.2 - Species evenness or quantitative analysis of microbiota (Table 3.4) [Seite 76]
10.3.6 - Distribution and physiological status of intraradicular microbiota [Seite 78]
10.3.6.1 - Culture studies [Seite 78]
10.3.6.2 - Microscopy studies [Seite 78]
10.3.6.3 - In situ hybridization microscopy studies [Seite 79]
10.3.7 - Importance of microbial ecology and biofilm physiology in the treatment of root-canal infection [Seite 81]
10.3.7.1 - Microbial ecology [Seite 81]
10.3.7.2 - Biofilm and planktonic physiology [Seite 86]
10.3.8 - Prevention and treatment of periapical disease [Seite 87]
10.3.8.1 - Biological and clinical perspective on a technically driven chemomechanical procedure [Seite 87]
10.3.8.2 - Technical aspects of the chemomechanical procedure [Seite 89]
10.3.8.3 - Effect of chemomechanical and obturation procedures on biological events [Seite 91]
10.3.8.4 - Effect of persistent bacteria on root-canal treatment outcome [Seite 92]
10.3.8.5 - Factors affecting outcome of root-canal treatment [Seite 94]
10.3.9 - Causes of root-canal treatment failure [Seite 94]
10.3.9.1 - Intraradicular microbiota associated with failed root-canal treatment [Seite 95]
10.3.9.2 - Extraradicular microbiota associated with failed root-canal treatment [Seite 95]
10.3.9.3 - Cysts and their management [Seite 96]
10.3.9.4 - Foreign body response and its management [Seite 97]
10.3.9.5 - Fibrous healing [Seite 99]
10.3.9.6 - Initial misdiagnosis [Seite 99]
10.3.9.7 - Management of failed previous treatment and outcome of root-canal retreatment [Seite 99]
10.3.9.8 - Periapical surgery and retrograde seal [Seite 100]
10.3.9.9 - Factors affecting the outcome of surgical retreatment [Seite 100]
10.3.10 - Alternative approaches to root-canal treatment [Seite 101]
10.3.11 - References and further reading [Seite 101]
11 - 2 Preparation for delivery of endodontic treatment [Seite 104]
11.1 - 4 Diagnosis of endodontic problems [Seite 104]
11.1.1 - The nature of endodontic diagnosis [Seite 104]
11.1.2 - The nature of endodontic problems [Seite 104]
11.1.3 - Patient assessment [Seite 105]
11.1.3.1 - Informed consent and record-keeping [Seite 105]
11.1.3.2 - The nature of presenting complaints [Seite 105]
11.1.3.3 - History taking [Seite 106]
11.1.3.4 - Medical history [Seite 106]
11.1.3.5 - Dental history [Seite 107]
11.1.3.6 - Social history [Seite 107]
11.1.3.7 - Clinical examination [Seite 107]
11.1.3.7.1 - Extraoral [Seite 107]
11.1.3.7.2 - Ease of oral access [Seite 107]
11.1.3.7.3 - Intraoral [Seite 108]
11.1.3.8 - Soft tissue examination [Seite 109]
11.1.3.9 - Periodontal examination [Seite 109]
11.1.3.10 - Tooth examination [Seite 110]
11.1.3.11 - Pulp testing [Seite 111]
11.1.3.11.1 - Electric pulp tester [Seite 111]
11.1.3.11.1.1 - Pulp testing technique [Seite 111]
11.1.3.11.2 - Thermal pulp testing [Seite 112]
11.1.3.11.3 - Heat [Seite 112]
11.1.3.11.3.1 - Dry heat [Seite 112]
11.1.3.11.3.2 - Hot water [Seite 112]
11.1.3.11.4 - Cold [Seite 112]
11.1.3.12 - Location of source of pain [Seite 112]
11.1.3.12.1 - Cutting a test cavity [Seite 113]
11.1.3.12.2 - Further tooth evaluation [Seite 113]
11.1.3.13 - Occlusal examination [Seite 113]
11.1.4 - Imaging techniques [Seite 113]
11.1.4.1 - Conventional radiographic assessment [Seite 114]
11.1.4.1.1 - Conventional films versus digital image recording [Seite 114]
11.1.4.1.2 - Comparing the different technologies [Seite 115]
11.1.4.1.3 - Film holders [Seite 115]
11.1.4.1.4 - Radiation safety and regulations [Seite 117]
11.1.4.1.4.1 - Patients [Seite 117]
11.1.4.1.4.2 - Operators and other staff [Seite 117]
11.1.4.1.5 - Viewing and storage equipment [Seite 118]
11.1.4.1.5.1 - Viewers [Seite 118]
11.1.4.1.5.2 - Mounts [Seite 118]
11.1.4.1.6 - Radiographic techniques [Seite 118]
11.1.4.1.6.1 - Paralleling periapical projections [Seite 118]
11.1.4.1.6.2 - Bisecting angle periapical projections [Seite 119]
11.1.4.1.6.3 - Parallax techniques [Seite 119]
11.1.4.2 - Cone-beam computed tomography (CBCT) [Seite 120]
11.1.4.3 - Quality assurance [Seite 122]
11.1.4.4 - Interpretation of radiographs [Seite 122]
11.1.4.5 - Normal radiographic landmarks [Seite 123]
11.1.4.5.1 - Enamel, dentine and cementum [Seite 123]
11.1.4.5.2 - Cancellous bone [Seite 123]
11.1.4.5.3 - Periodontal ligament [Seite 123]
11.1.4.5.4 - Lamina dura [Seite 123]
11.1.4.5.5 - Pulp space [Seite 123]
11.1.4.5.6 - Maxillary antrum [Seite 123]
11.1.4.5.7 - The anterior maxillary region [Seite 123]
11.1.4.6 - Common errors in interpretation [Seite 123]
11.1.4.6.1 - False widening of the periodontal ligament space [Seite 123]
11.1.4.6.2 - The maxillary antrum [Seite 123]
11.1.4.6.3 - Incisive foramen [Seite 124]
11.1.4.6.4 - Inferior dental canal [Seite 124]
11.1.4.6.5 - Mental foramen [Seite 124]
11.1.4.7 - Lesions involving the periodontal ligament space [Seite 125]
11.1.4.7.1 - Periradicular lesions [Seite 125]
11.1.4.7.2 - Lateral periradicular lesions [Seite 125]
11.1.4.8 - Fractured root lesions [Seite 125]
11.1.4.9 - Perforation lesions [Seite 125]
11.1.4.10 - Sclerosing osteitis [Seite 125]
11.1.4.11 - Lesions not of intrapulpal origin [Seite 125]
11.1.4.11.1 - Periodontal lesions [Seite 125]
11.1.4.11.2 - Idiopathic osteosclerosis [Seite 126]
11.1.4.11.3 - Fibro-cemento-osseous dysplasia [Seite 126]
11.1.4.11.4 - Other local and systemic pathosis [Seite 127]
11.1.5 - Diagnostic categories [Seite 127]
11.1.5.1 - Normal pulp [Seite 127]
11.1.5.2 - Concussed pulp [Seite 127]
11.1.5.3 - Reversible pulpitis [Seite 127]
11.1.5.4 - Irreversible pulpitis [Seite 127]
11.1.5.5 - Pulpal necrosis [Seite 127]
11.1.5.6 - Acute periapical inflammation [Seite 128]
11.1.5.7 - Acute apical abscess [Seite 128]
11.1.5.8 - Chronic apical periodontitis [Seite 128]
11.1.5.9 - Resorption [Seite 129]
11.1.5.9.1 - Internal [Seite 129]
11.1.5.9.2 - External [Seite 129]
11.1.5.10 - Cracked or fractured teeth [Seite 129]
11.1.5.10.1 - Fractured crown with vital pulp (cracked tooth syndrome) [Seite 129]
11.1.5.10.2 - Fractured crown with non-vital pulp [Seite 129]
11.1.5.10.3 - Fractured crown and root with a non-vital pulp [Seite 129]
11.1.5.10.4 - Fractured root with a vital or non-vital pulp [Seite 129]
11.1.5.11 - Periodontal pain [Seite 129]
11.1.5.12 - Non-odontogenic pain [Seite 130]
11.1.6 - Further reading [Seite 130]
11.2 - 5 Treatment planning [Seite 131]
11.2.1 - Overall health and oral care of patients and the role of endodontics within it [Seite 131]
11.2.2 - Treatment option selection and treatment planning [Seite 131]
11.2.3 - The ideal treatment-planning scenario [Seite 132]
11.2.4 - The reality of practice, informed consent and medical records [Seite 133]
11.2.5 - Factors influencing treatment planning [Seite 134]
11.2.5.1 - Illustration of factors affecting treatment decision making using maxillary incisors as an example [Seite 134]
11.2.5.2 - Scenario 1 [Seite 134]
11.2.5.3 - Scenario 2 [Seite 134]
11.2.5.4 - Scenario 3 [Seite 135]
11.2.5.5 - Scenario 4 [Seite 135]
11.2.5.6 - Scenario 5 [Seite 136]
11.2.5.7 - Scenario 6 [Seite 137]
11.2.5.8 - Scenario 7 [Seite 137]
11.2.5.9 - Summary of factors affecting treatment planning [Seite 138]
11.2.6 - The sequence of treatment delivery [Seite 139]
11.2.6.1 - Planned initial treatment [Seite 139]
11.2.6.1.1 - Immediate relief of symptoms [Seite 139]
11.2.6.1.2 - Stabilization [Seite 140]
11.2.6.1.3 - Prevention [Seite 140]
11.2.6.2 - Planned definitive treatment [Seite 140]
11.2.6.2.1 - General restorative considerations [Seite 140]
11.2.6.2.2 - Strategic importance of teeth [Seite 140]
11.2.6.2.3 - Periodontal support [Seite 141]
11.2.6.2.4 - Implants [Seite 141]
11.2.6.2.5 - Restorability of teeth [Seite 142]
11.2.6.2.6 - Access to the tooth and root-canal system [Seite 142]
11.2.6.2.7 - Tooth anatomy and orientation [Seite 143]
11.2.6.2.8 - Canal anatomy [Seite 143]
11.2.6.2.9 - Sclerosed canals [Seite 143]
11.2.6.2.10 - Single or multiple visit treatment [Seite 143]
11.2.6.2.11 - Previous root-canal treatment [Seite 145]
11.2.7 - Decision-making process for root canal retreatment, surgery or extraction [Seite 146]
11.2.7.1 - Anatomical considerations for surgical retreatment [Seite 147]
11.2.7.2 - Systemic consideration for surgical retreatment [Seite 147]
11.2.7.2.1 - Root fractures [Seite 147]
11.2.7.2.2 - Root resorption [Seite 150]
11.2.7.3 - Planned review [Seite 151]
11.2.8 - References and further reading [Seite 152]
11.3 - 6 Pre-endodontic management [Seite 153]
11.3.1 - The clinical area [Seite 153]
11.3.1.1 - Equipment location, storage and delivery [Seite 153]
11.3.1.2 - Work surface organization [Seite 154]
11.3.1.2.1 - Contamination zones [Seite 154]
11.3.1.2.2 - Water supplies [Seite 155]
11.3.1.3 - Instrumentation and storage [Seite 155]
11.3.1.3.1 - The basic instrument pack [Seite 156]
11.3.1.3.2 - Operation microscope [Seite 156]
11.3.1.3.3 - X-ray machine [Seite 156]
11.3.1.3.4 - X-ray viewer [Seite 157]
11.3.1.4 - Non-surgical retreatment devices [Seite 157]
11.3.1.5 - Surgical armamentarium [Seite 159]
11.3.2 - Cleaning and sterilization [Seite 159]
11.3.2.1 - Presterilization cleaning [Seite 161]
11.3.2.2 - Sterilization [Seite 161]
11.3.2.2.1 - Checking successful sterilization [Seite 161]
11.3.2.3 - Storage [Seite 162]
11.3.2.3.1 - File holders and stands [Seite 162]
11.3.2.3.2 - Pastes and medicaments [Seite 162]
11.3.2.4 - Infection control [Seite 162]
11.3.3 - The dental nurse [Seite 163]
11.3.3.1 - Anticipation [Seite 163]
11.3.3.2 - Close support [Seite 163]
11.3.3.3 - Instrument transfer [Seite 164]
11.3.4 - The operator and medico-legal considerations [Seite 164]
11.3.4.1 - Negligence [Seite 165]
11.3.4.2 - Dental and medical records [Seite 165]
11.3.4.3 - Consent [Seite 165]
11.3.4.4 - Treatment complications [Seite 166]
11.3.4.5 - Protection of the patient [Seite 166]
11.3.4.6 - Referral for treatment [Seite 166]
11.3.5 - The patient [Seite 166]
11.3.5.1 - Education and information [Seite 166]
11.3.5.2 - Anaesthesia and analgesia [Seite 167]
11.3.5.2.1 - Routine root-canal treatment [Seite 167]
11.3.5.2.2 - Acute hyperaemic pulp [Seite 167]
11.3.5.2.3 - Surgical retreatment [Seite 167]
11.3.5.2.4 - Anxious patient [Seite 167]
11.3.5.2.4.1 - Gag reflex [Seite 167]
11.3.5.2.4.2 - Relative analgesia [Seite 167]
11.3.5.2.4.3 - Oral sedation [Seite 168]
11.3.5.2.4.4 - Nasal sedation [Seite 168]
11.3.5.2.4.5 - Intravenous sedation [Seite 168]
11.3.5.3 - Medication [Seite 168]
11.3.5.4 - Patients requiring antibiotic cover [Seite 168]
11.3.5.5 - Patients with HIV/HBV [Seite 168]
11.3.6 - The tooth [Seite 168]
11.3.6.1 - Removal of calculus and plaque from teeth [Seite 168]
11.3.6.2 - Removal of caries/restorations [Seite 168]
11.3.6.3 - Assessment of restorability of teeth [Seite 169]
11.3.6.4 - Provisional restoration of broken-down teeth [Seite 169]
11.3.6.5 - Periodontal tissue management [Seite 170]
11.3.6.6 - Isolation using rubber dam and other devices [Seite 170]
11.3.6.7 - Rubber dam kits [Seite 171]
11.3.6.8 - Applying the dam [Seite 171]
11.3.6.9 - Other devices [Seite 173]
11.3.7 - References and further reading [Seite 173]
12 - 3 Delivery of endodontic treatment [Seite 174]
12.1 - 7 Vital pulp therapy [Seite 174]
12.1.1 - Management of the primary dentition [Seite 174]
12.1.2 - Morphology of primary teeth [Seite 174]
12.1.3 - Pulp disease in primary teeth [Seite 174]
12.1.4 - Techniques of pulp therapy [Seite 174]
12.1.4.1 - Indirect pulp capping [Seite 174]
12.1.4.2 - Direct pulp capping [Seite 174]
12.1.4.3 - Vital pulpotomy [Seite 174]
12.1.4.3.1 - Procedure: quick reference guide [Seite 175]
12.1.4.4 - Development of alternative approaches to vital pulpotomy in primary teeth [Seite 176]
12.1.4.4.1 - Bone morphogenic proteins [Seite 176]
12.1.4.4.2 - Other methods [Seite 177]
12.1.4.5 - Restoration of endodontically treated primary teeth [Seite 177]
12.1.4.6 - Follow up and complications [Seite 177]
12.1.5 - Management of the secondary or permanent dentition [Seite 177]
12.1.5.1 - Optimal management of caries [Seite 177]
12.1.5.2 - Principles of restoration of cavities [Seite 177]
12.1.5.3 - Smear layer and its management [Seite 178]
12.1.5.4 - Practical approaches to management of caries and restoration of teeth [Seite 179]
12.1.5.5 - Treatment of the deep cavity and "compromised" pulp [Seite 180]
12.1.5.5.1 - Indirect pulp capping [Seite 180]
12.1.5.5.2 - Direct pulp capping [Seite 181]
12.1.5.5.3 - Pulpotomy [Seite 182]
12.1.5.5.4 - Regenerative pulp therapy [Seite 183]
12.1.6 - Further reading [Seite 184]
12.2 - 8 Non-surgical root-canal treatment [Seite 185]
12.2.1 - Principles of root-canal system management [Seite 185]
12.2.1.1 - Principles of mechanical intraradicular preparation [Seite 185]
12.2.1.2 - Principles of chemical intraradicular preparation and intra-appointment root canal irrigation [Seite 185]
12.2.1.3 - Principles of chemical intraradicular preparation and interappointment intracanal medication [Seite 189]
12.2.1.4 - Principles of root-canal system obturation [Seite 189]
12.2.2 - Coronal access cavities [Seite 190]
12.2.2.1 - Principles of cutting a coronal access cavity [Seite 190]
12.2.2.2 - Cutting the coronal access cavity [Seite 191]
12.2.2.3 - Outline shape [Seite 192]
12.2.3 - Location of the canal terminus and determination of canal and working length [Seite 192]
12.2.3.1 - Point of termination of canal preparation [Seite 192]
12.2.3.2 - Clinical location of the root-canal system terminus/termini [Seite 194]
12.2.3.2.1 - Radiographic method [Seite 194]
12.2.3.2.2 - Electronic apex-locator method [Seite 195]
12.2.3.2.3 - Tactile method [Seite 198]
12.2.3.2.4 - Paper-point method [Seite 198]
12.2.3.2.5 - Combined method for determining position of canal terminus [Seite 198]
12.2.3.3 - Determination of working length [Seite 198]
12.2.3.4 - Maintaining canal instrumentation to its terminus [Seite 199]
12.2.4 - Relationship between the radicular access, its dimensions and root-canal anatomy [Seite 200]
12.2.4.1 - Simple canal systems (types a, b and c) [Seite 200]
12.2.4.2 - Complex canal systems [Seite 201]
12.2.5 - Mechanical preparation of the tapered radicular access cavity [Seite 203]
12.2.5.1 - Mechanical preparation of the radicular access by hand instrumentation [Seite 203]
12.2.5.1.1 - Rotary motion [Seite 204]
12.2.5.1.2 - Push-pull filing [Seite 205]
12.2.5.1.3 - Design of hand instruments [Seite 205]
12.2.5.1.4 - Twisted instruments [Seite 206]
12.2.5.1.5 - Machined instruments [Seite 206]
12.2.5.2 - Mechanical preparation of the radicular access by automated devices [Seite 206]
12.2.5.2.1 - Nickel-titanium rotary instruments [Seite 207]
12.2.5.2.1.1 - Radial lands [Seite 207]
12.2.5.2.1.2 - Flutes [Seite 207]
12.2.5.2.1.3 - Safety tip [Seite 208]
12.2.5.2.1.4 - Unconventional instrument design [Seite 208]
12.2.5.3 - Preparation of the radicular access in curved canals [Seite 209]
12.2.5.3.1 - Maintaining curvature with a push-pull filing mode of instrument manipulation [Seite 209]
12.2.5.3.1.1 - Reducing the restoring force [Seite 210]
12.2.5.3.1.2 - Reducing or controlling the length or area of file actively engaged in cutting [Seite 212]
12.2.5.3.2 - Maintaining curvature with a rotational mode of hand instrument manipulation [Seite 213]
12.2.5.3.3 - Maintenance of double curves [Seite 213]
12.2.5.3.4 - Preparing a regularly tapered radicular access and gauging it [Seite 214]
12.2.5.4 - Recommended approach to preparing the radicular access [Seite 215]
12.2.5.4.1 - Coronal preflaring [Seite 215]
12.2.5.4.2 - Negotiation to the full length of canal and length verification [Seite 216]
12.2.5.4.3 - Negotiation to the full length of canal and its apical enlargement [Seite 216]
12.2.5.4.4 - Final shaping of the radicular access [Seite 216]
12.2.5.5 - Chemical treatment of root-canal systems and root-canal irrigation [Seite 217]
12.2.5.6 - Mechanics of root-canal irrigant delivery and its actions [Seite 219]
12.2.5.7 - Dynamic irrigation after mechanical preparation of the canal system is complete [Seite 223]
12.2.5.8 - Photoactivated disinfection [Seite 226]
12.2.6 - Interappointment intracanal medication [Seite 226]
12.2.6.1 - Phenol-based agents [Seite 226]
12.2.6.1.1 - Phenol and camphorated monochlorophenol (CMCP) [Seite 226]
12.2.6.1.2 - Metacresyl acetate or cresatin [Seite 227]
12.2.6.2 - Aldehydes [Seite 227]
12.2.6.3 - Halides [Seite 227]
12.2.6.4 - Antibiotics [Seite 227]
12.2.6.5 - Steroids [Seite 228]
12.2.6.6 - Calcium hydroxide [Seite 228]
12.2.6.6.1 - Calcium hydroxide preparations [Seite 230]
12.2.6.6.2 - Placement of calcium hydroxide [Seite 230]
12.2.6.6.3 - Removal and replacement of calcium hydroxide [Seite 230]
12.2.7 - Temporary coronal access cavity seal [Seite 231]
12.2.7.1 - Zinc oxide/eugenol cement [Seite 232]
12.2.7.2 - Glass ionomer cements [Seite 232]
12.2.7.3 - Other materials [Seite 232]
12.2.8 - Root-canal system obturation [Seite 232]
12.2.8.1 - When should the root-canal system be obturated? [Seite 233]
12.2.8.2 - Where should the root filling terminate in relation to the apex? [Seite 233]
12.2.8.3 - The ideal root-filling material [Seite 234]
12.2.8.3.1 - Solid cores [Seite 234]
12.2.8.3.2 - Pastes [Seite 234]
12.2.8.3.3 - Gutta-percha [Seite 235]
12.2.8.3.4 - Alternative materials [Seite 235]
12.2.8.3.4.1 - Resilon® [Seite 235]
12.2.8.3.4.2 - SmartSeal® [Seite 235]
12.2.8.3.5 - Experimental materials [Seite 235]
12.2.8.3.6 - Sealers [Seite 236]
12.2.8.4 - Obturation techniques [Seite 237]
12.2.8.5 - Principles of obturation [Seite 237]
12.2.8.5.1 - Preparation of canal surface [Seite 237]
12.2.8.5.2 - Dry canal [Seite 237]
12.2.8.5.3 - Controlled apical placement [Seite 237]
12.2.8.5.4 - Efficient and effective backfill [Seite 239]
12.2.8.5.5 - Coronal seal [Seite 239]
12.2.8.6 - Lateral compaction [Seite 239]
12.2.8.7 - Warm vertical compaction [Seite 242]
12.2.8.8 - Injection of thermoplasticized gutta-percha [Seite 244]
12.2.8.9 - Thermoplasticized gutta-percha carriers [Seite 244]
12.2.8.10 - Thermomechanical compaction technique [Seite 245]
12.2.8.11 - Hybrid technique [Seite 246]
12.2.9 - Coronal seal [Seite 246]
12.2.9.1 - Post-preparation/restorative considerations [Seite 246]
12.2.10 - Further reading [Seite 247]
12.3 - 9 Management of non-surgical root-canal treatment failure [Seite 248]
12.3.1 - Diagnosis of non-surgical root-canal treatment failure [Seite 248]
12.3.2 - Decision-making process [Seite 248]
12.3.3 - Non-surgical root-canal retreatment [Seite 248]
12.3.3.1 - Indications for non-surgical root-canal retreatment [Seite 248]
12.3.3.2 - Principles of root-canal retreatment [Seite 250]
12.3.3.2.1 - Removal of coronal restorations [Seite 250]
12.3.3.2.2 - Removal of bridges [Seite 250]
12.3.3.2.3 - Removal of posts [Seite 250]
12.3.3.2.4 - Removing gutta-percha [Seite 252]
12.3.3.2.5 - Removing gutta-percha with a central core (Thermafil®) [Seite 253]
12.3.3.2.6 - Removing cement material [Seite 253]
12.3.3.2.7 - Negotiating a ledge [Seite 253]
12.3.3.2.8 - Packed dentine debris [Seite 253]
12.3.3.2.9 - Sclerosed canals [Seite 253]
12.3.3.2.10 - Removal of metal instruments and silver points [Seite 254]
12.3.3.2.11 - Perforations [Seite 256]
12.3.4 - Surgical root-canal retreatment [Seite 256]
12.3.4.1 - Indications and classification of endodontic surgical procedures [Seite 256]
12.3.4.2 - Emergency surgery [Seite 257]
12.3.4.2.1 - Incision and drainage [Seite 257]
12.3.4.2.2 - Trephination [Seite 257]
12.3.4.3 - Biopsy [Seite 258]
12.3.4.4 - Periapical surgery and root-end management [Seite 258]
12.3.4.4.1 - Flap design [Seite 258]
12.3.4.4.1.1 - Full mucoperiosteal flaps [Seite 259]
12.3.4.4.1.2 - Limited mucoperiosteal flaps [Seite 259]
12.3.4.4.1.3 - Incisions [Seite 261]
12.3.4.4.1.4 - Flap elevation [Seite 261]
12.3.4.4.1.5 - Flap retraction [Seite 261]
12.3.4.4.1.6 - Osteotomy [Seite 261]
12.3.4.4.1.7 - Curettage [Seite 262]
12.3.4.4.1.8 - Root-end resection [Seite 262]
12.3.4.4.1.9 - Root-end cavity preparation [Seite 263]
12.3.4.4.1.10 - Haemostasis [Seite 264]
12.3.4.4.1.11 - Root-end filling [Seite 265]
12.3.4.4.1.12 - Through and through surgery [Seite 266]
12.3.4.4.1.13 - Wound closure [Seite 267]
12.3.4.4.1.14 - Wound healing [Seite 268]
12.3.4.5 - Corrective surgery [Seite 268]
12.3.4.5.1 - Perforation repair [Seite 268]
12.3.4.5.2 - Root resection [Seite 269]
12.3.4.5.3 - Hemisection [Seite 270]
12.3.4.6 - Intentional replantation and transplantation [Seite 270]
12.3.4.7 - Regenerative procedures [Seite 271]
12.3.4.8 - Decompression [Seite 273]
12.3.5 - References and further reading [Seite 274]
12.4 - 10 Management of acute emergencies and traumatic dental injuries [Seite 275]
12.4.1 - Principles of management of pain [Seite 275]
12.4.2 - Diagnostic accuracy [Seite 275]
12.4.3 - Effective intraoperative pain control [Seite 275]
12.4.3.1 - Local analgesic agents and their actions [Seite 275]
12.4.3.2 - Local analgesic agent delivery [Seite 276]
12.4.3.2.1 - Gow-Gates technique [Seite 276]
12.4.3.2.2 - Akinosi technique [Seite 276]
12.4.3.3 - Intraligamental injections [Seite 277]
12.4.3.4 - Intrapulpal injections [Seite 277]
12.4.3.5 - Intraosseous technique [Seite 277]
12.4.3.6 - Management of the "hot" pulp [Seite 277]
12.4.4 - Effective postoperative pain control [Seite 278]
12.4.5 - Emergency scenarios [Seite 279]
12.4.6 - Preoperative emergencies [Seite 279]
12.4.6.1 - Emergencies of pulpal origin [Seite 279]
12.4.6.1.1 - Diagnosis [Seite 279]
12.4.6.1.2 - Treatment [Seite 280]
12.4.6.1.3 - Medication [Seite 281]
12.4.6.2 - Emergencies of periradicular origin [Seite 281]
12.4.6.2.1 - Diagnosis [Seite 281]
12.4.6.2.2 - Treatment [Seite 283]
12.4.6.2.3 - Medication [Seite 284]
12.4.6.3 - Emergencies resulting from acute dentoalveolar trauma [Seite 285]
12.4.6.3.1 - Triage [Seite 285]
12.4.6.4 - Acute management [Seite 286]
12.4.6.4.1 - Crown fractures [Seite 286]
12.4.6.4.2 - Crown-root fractures [Seite 286]
12.4.6.4.3 - Root fractures [Seite 286]
12.4.6.4.4 - Treatment of luxated teeth [Seite 288]
12.4.7 - Intraoperative emergencies [Seite 288]
12.4.7.1 - Medical emergencies [Seite 288]
12.4.7.2 - Sodium hypochlorite [Seite 289]
12.4.8 - Interappointment and postoperative emergencies [Seite 290]
12.4.9 - Medium- to long-term management of dentoalveolar injuries [Seite 291]
12.4.9.1 - Healing patterns, trends and salient features [Seite 292]
12.4.9.1.1 - Template for wound healing, repair and regeneration [Seite 292]
12.4.9.1.2 - Pulp [Seite 292]
12.4.9.1.3 - Periodontal ligament [Seite 292]
12.4.9.1.4 - Root fracture and apical development [Seite 292]
12.4.9.1.5 - Alveolar bone [Seite 292]
12.4.9.2 - Clinical data for prognostication on outcomes of traumatic injuries [Seite 293]
12.4.10 - References and further reading [Seite 295]
12.5 - 11 Management of tooth resorption [Seite 296]
12.5.1 - Aetiology and pathogenesis [Seite 296]
12.5.1.1 - Internal resorption [Seite 296]
12.5.1.1.1 - Transient internal resorption [Seite 296]
12.5.1.1.2 - Progressive internal resorption [Seite 296]
12.5.1.2 - External resorption [Seite 299]
12.5.1.2.1 - Transient external resorption [Seite 299]
12.5.1.2.2 - Progressive external resorption without persistent inflammation of the periodontal tissue [Seite 299]
12.5.1.2.3 - Progressive external resorption with persistent inflammation of the periodontal tissue sustained by [Seite 300]
12.5.1.2.3.1 - 1. Root-canal infection [Seite 300]
12.5.1.2.3.2 - 2. Pressure [Seite 301]
12.5.1.2.3.3 - 3. Irritation by foreign material [Seite 303]
12.5.1.2.3.4 - 4. Subgingival plaque [Seite 303]
12.5.1.2.4 - Progressive external resorption associated with systemic disease [Seite 308]
12.5.1.2.5 - Progressive external resorption associated with no obvious local or systemic disease (idiopathic) [Seite 308]
12.5.2 - References and further reading [Seite 309]
13 - 4 Multidisciplinary aspects of endodontic management [Seite 310]
13.1 - 12 The perio-endo interface [Seite 310]
13.1.1 - Comparison of apical and marginal periodontitis [Seite 310]
13.1.1.1 - Preceding disease states in apical or marginal periodontitis [Seite 310]
13.1.1.2 - Progression, clinical manifestation and measurement of apical and marginal periodontitis [Seite 310]
13.1.1.3 - Cell profiles in apical and marginal periodontitis [Seite 312]
13.1.1.4 - Microbiota associated with apical or marginal periodontitis [Seite 312]
13.1.1.5 - Risk factors for progression of apical or marginal periodontitis [Seite 313]
13.1.1.6 - Natural history of apical and marginal periodontitis [Seite 313]
13.1.1.7 - Association of apical and marginal periodontitis with systemic diseases [Seite 313]
13.1.2 - Pathways of communication between pulp and periodontium [Seite 314]
13.1.2.1 - Lateral and accessory canals [Seite 314]
13.1.2.2 - Dentinal tubules [Seite 314]
13.1.2.3 - Development defects [Seite 314]
13.1.2.4 - Cementum coverage defects [Seite 315]
13.1.2.5 - Iatrogenic perforations and root fracture [Seite 315]
13.1.3 - Effect of pulp disease and its treatment on the periodontium [Seite 316]
13.1.3.1 - Pulpo-periapical inflammation and bone loss [Seite 316]
13.1.3.2 - Pulpo-periapical inflammation and periodontal wound healing [Seite 316]
13.1.3.3 - Effect of iatrogenic problems [Seite 316]
13.1.4 - Effect of periodontal disease and its treatment on the pulp [Seite 317]
13.1.4.1 - Effect of periodontal disease on the pulp [Seite 317]
13.1.4.2 - Effect of periodontal treatment on the pulp [Seite 317]
13.1.5 - Definition and classification of perio-endo lesions [Seite 317]
13.1.5.1 - Definition of perio-endo lesions [Seite 318]
13.1.5.2 - Classification of perio-endo lesions [Seite 318]
13.1.6 - Diagnosis of perio-endo lesions [Seite 318]
13.1.6.1 - History of dentinal, pulpal and periapical pain [Seite 318]
13.1.6.2 - History of periodontal symptoms [Seite 318]
13.1.6.3 - Signs of pulpal or periapical disease [Seite 318]
13.1.6.4 - Periodontal charting including the probing profile of the tooth [Seite 318]
13.1.6.5 - Radiographic pattern of bone loss [Seite 320]
13.1.7 - Causes of perio-endo lesions and their aetiology-based management [Seite 321]
13.1.7.1 - Single isolated perio-endo lesion [Seite 321]
13.1.7.1.1 - Root-canal infection [Seite 321]
13.1.7.1.2 - Root cracks or fractures [Seite 322]
13.1.7.1.3 - Root perforation [Seite 324]
13.1.7.1.4 - Root resorption [Seite 327]
13.1.7.1.5 - Anatomical tooth anomalies [Seite 328]
13.1.7.1.6 - Orthodontic treatment [Seite 331]
13.1.7.1.7 - Tooth transplantation and replantation [Seite 331]
13.1.7.1.8 - Poorly designed restorations [Seite 331]
13.1.7.1.9 - Localized periodontal disease [Seite 331]
13.1.7.2 - Multiple perio-endo lesions [Seite 332]
13.1.7.2.1 - Isolated lesion(s) superimposed upon generalized periodontitis [Seite 332]
13.1.7.2.2 - Chronic periodontitis [Seite 332]
13.1.7.2.3 - Aggressive periodontitis (juvenile periodontitis [JP] [Seite 333]
13.1.8 - Management of perio-endo lesions [Seite 334]
13.1.8.1 - Estimation of prognosis [Seite 334]
13.1.8.2 - Treatment of perio-endo cases [Seite 334]
13.1.9 - Root amputation [Seite 335]
13.1.10 - Role of regenerative techniques in treatment of perio-endo lesions [Seite 336]
13.1.11 - References and further reading [Seite 339]
13.2 - 13 The ortho-endo interface [Seite 340]
13.2.1 - The nature of contemporary orthodontic management [Seite 340]
13.2.2 - Effect of orthodontic tooth movement on the pulp [Seite 340]
13.2.3 - Effect of orthodontic tooth movement on root resorption [Seite 341]
13.2.4 - Effect of orthodontic tooth movement on resorption of vital, non-vital or root-treated teeth [Seite 342]
13.2.5 - Effect of previous traumatic injuries on orthodontically-mediated resorption and tooth movement [Seite 342]
13.2.6 - Effect of orthognathic/orthodontic treatment on teeth and their pulps [Seite 343]
13.2.7 - Effect of orthodontic tooth movement on endodontic treatment and its outcome [Seite 343]
13.2.8 - Role of orthodontics in endodontic-restorative treatment planning [Seite 343]
13.2.9 - References and Further Reading [Seite 344]
13.3 - 14 The restorative-endo interface [Seite 345]
13.3.1 - Principles of restoration of root-treated teeth [Seite 345]
13.3.2 - Restorability of the tooth [Seite 345]
13.3.3 - When to restore after endodontic treatment [Seite 349]
13.3.4 - How to restore teeth after endodontic treatment [Seite 349]
13.3.4.1 - Restoration of anterior teeth [Seite 349]
13.3.4.1.1 - Relatively intact teeth [Seite 349]
13.3.4.1.2 - Teeth with proximal cavities [Seite 349]
13.3.4.1.3 - Teeth with inadequate tissue for retention without auxiliary aids [Seite 351]
13.3.4.2 - Characteristics of dowels or posts [Seite 353]
13.3.4.2.1 - Material of composition [Seite 353]
13.3.4.2.2 - Shape [Seite 353]
13.3.4.2.3 - Length [Seite 354]
13.3.4.2.4 - Determinants of dowel length [Seite 354]
13.3.4.2.5 - Diameter [Seite 355]
13.3.4.2.6 - Surface configuration [Seite 356]
13.3.4.2.7 - Diaphragm [Seite 357]
13.3.4.3 - Restoration of posterior teeth [Seite 357]
13.3.4.3.1 - Relatively intact teeth [Seite 357]
13.3.4.3.2 - Teeth with proximo-occlusal cavity [Seite 358]
13.3.4.3.3 - Teeth with MOD (mesio-occluso-distal) cavities [Seite 360]
13.3.4.3.4 - Teeth with inadequate tissue for retention without auxiliary aids [Seite 363]
13.3.5 - Core materials [Seite 365]
13.3.5.1 - Amalgam [Seite 365]
13.3.5.2 - Composite [Seite 365]
13.3.5.3 - Cermets [Seite 366]
13.3.5.4 - Cast cores [Seite 366]
13.3.6 - Root-treated teeth as abutments [Seite 366]
13.3.7 - Occlusal loading [Seite 366]
13.3.8 - Restoration of a tooth with a resected root [Seite 368]
13.3.9 - Restoration of a hemisected tooth [Seite 368]
13.3.10 - Treatment of tooth discoloration [Seite 368]
13.3.10.1 - Vital bleaching [Seite 368]
13.3.10.2 - Non-vital bleaching [Seite 368]
13.3.10.3 - Composite or porcelain veneers [Seite 370]
13.3.10.4 - Ceramometal or ceramic crowns [Seite 370]
13.3.11 - Extraction of root-treated teeth and replacement with implant-retained crowns [Seite 370]
13.3.12 - References and further reading [Seite 371]
13.4 - 15 The medical-endo interface and patients with special needs [Seite 372]
13.4.1 - Overall patient care and the role of endodontics [Seite 372]
13.4.2 - Patient assessment [Seite 372]
13.4.3 - Management of the medically-compromised patient [Seite 373]
13.4.3.1 - Cardiovascular disease [Seite 373]
13.4.3.2 - Infective endocarditis [Seite 373]
13.4.3.3 - Stroke [Seite 373]
13.4.3.4 - Bleeding disorders [Seite 373]
13.4.3.5 - Respiratory disease [Seite 374]
13.4.3.6 - Latex allergy [Seite 374]
13.4.3.7 - Diabetes [Seite 374]
13.4.3.8 - Bisphosphonate-related osteonecrosis [Seite 375]
13.4.3.9 - Multiple sclerosis [Seite 375]
13.4.3.10 - Cerebral palsy [Seite 376]
13.4.3.11 - Parkinson's disease [Seite 376]
13.4.3.12 - Dementia [Seite 376]
13.4.4 - Endodontics and patients with learning disability [Seite 376]
13.4.4.1 - Down's syndrome [Seite 377]
13.4.4.2 - Autistic spectrum disorders [Seite 377]
13.4.4.3 - Epilepsy [Seite 377]
13.4.4.4 - Consent [Seite 377]
13.4.4.5 - Best interest meetings [Seite 378]
13.4.4.6 - Independent mental capacity advocates (IMCA) [Seite 378]
13.4.5 - Endodontics and the management of anxiety [Seite 378]
13.4.5.1 - The gag reflex [Seite 378]
13.4.5.2 - Endodontics and conscious sedation [Seite 379]
13.4.5.2.1 - Assessment [Seite 379]
13.4.5.2.2 - Inhalation sedation [Seite 379]
13.4.5.2.3 - Intravenous sedation with midazolam [Seite 379]
13.4.5.2.4 - Oral and intranasal sedation [Seite 379]
13.4.6 - References and further reading [Seite 379]
13.5 - 16 The orofacial pain-endo interface [Seite 380]
13.5.1 - Definition of pain [Seite 380]
13.5.2 - Orofacial pain prevalence [Seite 380]
13.5.3 - Neurophysiological basis of orofacial pain [Seite 380]
13.5.4 - Classification of orofacial pain [Seite 380]
13.5.5 - Diagnosis of orofacial pain [Seite 380]
13.5.6 - Characteristics of orofacial pain [Seite 381]
13.5.7 - Orofacial pain and endodontics [Seite 382]
13.5.8 - Case histories of typical orofacial/endodontic pain dillemas [Seite 383]
13.5.9 - Concluding remarks [Seite 383]
13.5.10 - References and further reading [Seite 383]
13.6 - 17 The oral medicine and oral surgery-endo interface [Seite 385]
13.6.1 - Differential diagnosis of orofacial lumps and bumps [Seite 385]
13.6.1.1 - Soft tissue swellings [Seite 385]
13.6.1.2 - Hard tissue swellings [Seite 385]
13.6.2 - Differential diagnosis of radiolucent and radiopaque lesions [Seite 385]
13.6.2.1 - Cysts [Seite 385]
13.6.2.2 - Bone lesions [Seite 385]
13.6.2.2.1 - Idiopathic osteosclerosis [Seite 385]
13.6.2.2.2 - Fibro-cemento-osseous dysplasia [Seite 385]
13.6.2.3 - Odontogenic tumours [Seite 385]
13.6.2.4 - Metastases to the jaws [Seite 386]
13.6.3 - Differential diagnosis of mucosal lesions [Seite 386]
13.6.4 - Further reading [Seite 392]
14 - Index [Seite 393]
14.1 - A [Seite 393]
14.2 - B [Seite 393]
14.3 - C [Seite 393]
14.4 - D [Seite 394]
14.5 - E [Seite 394]
14.6 - F [Seite 394]
14.7 - G [Seite 395]
14.8 - H [Seite 395]
14.9 - I [Seite 395]
14.10 - J [Seite 395]
14.11 - K [Seite 395]
14.12 - L [Seite 395]
14.13 - M [Seite 395]
14.14 - N [Seite 396]
14.15 - O [Seite 396]
14.16 - P [Seite 396]
14.17 - Q [Seite 397]
14.18 - R [Seite 397]
14.19 - S [Seite 399]
14.20 - T [Seite 399]
14.21 - U [Seite 399]
14.22 - V [Seite 399]
14.23 - W [Seite 399]
14.24 - X [Seite 399]
14.25 - Z [Seite 399]
1

Tooth organogenesis, morphology and physiology


K Gulabivala and Y-L Ng

Tooth development


Many readers approach human embryology with a view to satisfying academic test requirements and may even believe such academic knowledge to be far removed from clinical practice. Yet this book begins with this fascinating subject, not merely to lay an academic foundation for the knowledge of endodontics but because contemporary practice recognizes that these biological processes hold the key to future therapeutic strategies. Regenerative treatment approaches depend upon insight from developmental processes to engineer the growth of new tissues to replace those that are diseased or damaged. The ultimate may even be to grow whole replacement teeth on demand, in situ or for implantation. Among the clinicians involved should be endodontists in whose field of knowledge and practice these procedures should lie. Any clinician involved in delivering procedures that even border on regenerative techniques should have a basic understanding of tooth development and its associated structures.

The “intelligence” or “activating force” that directs the precise coordination of multiple cell line activity, growth, migration, induction, fusion and disintegration with such control and symphonic grace, still eludes us. In our current state of knowledge, we are left merely to describe the observable and timed changes gleaned through various biological studies. Experimental studies also give us some insight about the genomic and proteomic involvement in the process, even though the picture is far from complete. Yet there is already sufficient intuitive knowledge to enable the culture of tooth tissues and whole teeth in the laboratory, albeit in a neophytic way (Fig. 1.1).

Fig. 1.1 Something to chew on (courtesy of Takashi Tsuji, Tokyo University of Science)

Early development of teeth


The primitive mouth cavity is evident as a slit-like space lined by ectoderm in the 3–4-week-old human embryo. It is located under the surface of the brain capsule and above the pericardial sac where the heart forms. The mouth cavity is still separated from the primitive pharynx by the oropharyngeal membrane. The mandibular processes grow ventrally on each side of the head to meet gradually in the midline, where they form the lower border of the mouth opening. The maxillary processes arise from the upper surfaces of the origin of the mandibular process and likewise grow towards the midline, to form the upper border of the mouth below the brain capsule (Fig. 1.2). The maxillary and mandibular processes are essentially extensions of mesenchyme tissue covered by ectoderm. The ectoderm is a layer of low columnar epithelial cells, resting on a basal lamina which separates them from the mesenchymal tissue, which originates from the neural crest cell line. In some regions, such as the tooth-bearing part, the epithelium has a more superficial part, which consists of 2–3 layers of flattened cells. At this stage, the maxillary and mandibular processes do not show separate lip or gum regions; the development of the lips, cheeks and gum regions is closely associated with the development of the dental lamina, from which teeth arise.

Fig. 1.2 Maxillary and mandibular processes in the head of human embryo (approx. 5 weeks)

Primary epithelial band, vestibular band and dental lamina


The first indication of formation of tooth development structures becomes evident at 6 weeks of embryonic life when the oral epithelium in the lateral regions of the maxillary and mandibular processes proliferate and then spread towards the midline where they become continuous into horseshoe-shaped bands. These bands are not evident on the surface but project into the underlying mesenchyme and are called the primary epithelial bands.

During the seventh week of embryonic life, the primary epithelial band divides on its deep surface into two processes; the outer, thicker one becomes the vestibular lamina (responsible for the later separation of lips/cheeks from gums) and the inner, smaller one becomes the dental lamina (which later gives rise to the teeth) (Fig. 1.3). As the dental lamina grows in length, it penetrates deeper into the mesenchyme; at the front of the mouth in a lingual direction, to form a shelf-like projection and at the back of the mouth remaining more vertical (Fig. 1.4). It is not known whether this results from active invagination of the lamina or upward proliferation of the mesenchyme.

Fig. 1.3 The dental lamina

Fig. 1.4 The primary enamel organ

Enamel organs


A short while after formation, the dental lamina thickens into small rounded swellings, involving the whole thickness from free edge to the base of attachment to the oral epithelium. These are the enamel organs of the deciduous teeth with four in each quadrant (2 incisors, canine and first deciduous molar) (see Fig. 1.4). The dental lamina continues to grow backwards, giving rise to further enamel organs for the second deciduous molar (10-week embryo), and the permanent molars (first permanent molar at 16-week embryo; second and third permanent molars after birth). At 10 weeks of embryonic life, the enamel organs and dental lamina conform to a catenary curve. As the tooth germs grow, the spacing between them is reduced. There is at this early stage no indication of the successional permanent teeth, which develop later by budding off from the lingual aspects of each deciduous enamel organ.

Dental papilla


The mesenchymal tissue surrounding the developing enamel organ responds by proliferation to form a dense mass of cellular tissue. This gives rise to the dental papilla (primitive pulp) and the follicular sac for each tooth bud. The enamel organ in the “bud” stage appears as a simple, spherical to ovoid, epithelial condensation that is poorly morpho- and histo-differentiated. The epithelial component is separated from the adjacent mesenchyme by a basement membrane. The combination of enamel organ, dental papilla and follicular sac are collectively known as the tooth germ (Fig. 1.5). The enamel organ becomes concave on its papillary surface and begins to grow at the rims so as to encircle the dental papilla, which, at this stage, is partly capped by the enamel organ (hence “cap” stage) (Fig. 1.6) and progressively embraces a greater volume of it, to be called the “bell” stage (Fig. 1.7). At the cap stage, the centre of the concavity develops a projection of epithelium called the enamel knot (Fig. 1.6), which soon disappears by programmed cell death (apoptosis) and seems to contribute cells to the enamel cord. The enamel knot represents an important regulatory signalling centre during tooth development by producing bone morphogenetic proteins (BMP-2, BMP-7), fibroblast growth factor (FGF–p21 cyclin-dependent kinase inhibitor), sonic hedgehog (Shh), WNT and transcription factors. These signals regulate growth and development of the epithelial folds that correspond to the cusp pattern of the mature tooth. The primary enamel knot also determines the position of the secondary enamel knots corresponding to the site of the future cusps. The enamel cord is a strand of cells seen at the early bell stage of development. When present, it overlies the incisal margin of a tooth or the apex of the first cusp to develop. It has been suggested that the enamel cord may be involved in the process, by which the cap stage is transformed into the bell stage or that it is a focus for the origin of stellate reticulum cells.

Fig. 1.5 The tooth germ

Fig. 1.6 The enamel organ at “cap” stage

Fig. 1.7 The enamel organ at “bell” stage

Vestibule formation


Concurrent with the enamel organ development, the vestibular band growth continues apace. At around the time of the cap stage, a vertical cleft becomes established in the vestibular band, separating the formative lips and cheeks from the formative gums (Fig. 1.8). As for the dental lamina, the vestibular band development progresses backwards.

Fig. 1.8 The formative lips and cheeks separated from the formative gums at the advanced “bell” stage

Changes to and further development of dental lamina for permanent molars


As the enamel organ is reaching the cap stage, so the dental lamina lengthens and divides into buccal and lingual parts, though the function of this is unknown. By the time the enamel and dentine formation begins during early bell stage, the dental lamina connecting the tooth germs to the oral epithelium starts to degenerate leaving a network of strands and clumps of epithelial cells. At the same time, the dental lamina continues to grow backwards to give rise to the permanent molars but, by this stage, is separated from the oral epithelium.

Development of successional permanent teeth


The enamel organs for the successional teeth arise so differently from the permanent molars that it raises...

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