Clinical cases. Repeated canal treatment.

Features of dental canal treatment

Differences in the structure and functions of the “representatives” of the dentition largely determine the nature of the treatment approach. Treatment of canals for different groups of teeth has its own nuances.

Front tooth canal treatment

The front teeth most often have one canal. They are often curved and difficult to pass through for instruments. In order to preserve aesthetics, the opening of the cavity of these teeth is carried out from the vestibule of the oral cavity. Due to their frontal location, it is important to prevent tooth enamel from darkening, so filling materials containing dyes are not used.

Treatment of wisdom tooth canals

Wisdom teeth can have more than 5 canals; they often have a branched structure, which is not always revealed by x-ray examination. These factors, along with the marginal location of the “eights”, significantly complicate the high-quality treatment of root canals. At the final stage of treatment, various filling pastes are traditionally used.

Root canal treatment of temporary teeth

Endodontic treatment of tooth root canals is usually used only at the stage of root stabilization. When choosing the optimal treatment tactics, it is necessary to take into account the specific structure of temporary teeth. The small thickness of the canal walls, the insignificant degree of dentin mineralization and the relatively large size of the apical foramen are the main reasons for special caution during instrumentation. Zinc oxide eugenol and iodoform pastes, as well as materials based on calcium hydroxide, are usually used as filling agents. They are not toxic to the permanent tooth germ and are able to dissolve along with the temporary root.

Crown of the tooth

The crown of a tooth (lat. corona dentis) is the part of the tooth protruding above the gum. The crown is covered with enamel - hard tissue, 95% consisting of inorganic substances and subject to the most powerful mechanical stress.

There is a cavity in the crown of the tooth - dentin (hard tissue 2-6 mm thick) comes closer to the surface, then pulp, which fills both part of the crown and the root part of the tooth. The pulp contains the blood vessels and nerves of the tooth. Teeth cleaning and removal of dental deposits are carried out specifically from the crowns of the teeth.

Tooth neck

The neck of the tooth (lat. collum dentis) is the part of the tooth between the crown and root, covered by the gum.

Tooth roots

The root of the tooth (lat. radix dentis) is the part of the tooth located in the dental alveolus.

Fissure

On the chewing surface of the back teeth, between the cusps of the teeth there are grooves and grooves - fissures. The fissures can be narrow and very deep. The relief of the fissures is individual for each of us, but dental plaque gets stuck in the fissures of everyone.

It is almost impossible to clean the fissures with a toothbrush. Bacteria in the oral cavity, processing plaque, form acid, which dissolves tooth tissue, forming caries. Even good oral hygiene is sometimes not enough. In this regard, fissure sealing has been successfully used throughout the world for 20 years.

Tooth enamel

Tooth enamel (or simply enamel, Latin enamelum) is the outer protective shell of the crown part of human teeth.

Enamel is the hardest tissue in the human body, which is explained by the high content of inorganic substances - up to 97%. There is less water in tooth enamel than in other organs, 2-3%.

Hardness reaches 397.6 kg/mm? (250-800 Vickers). The thickness of the enamel layer differs in different areas of the crown of the tooth and can reach 2.0 mm, and disappears at the neck of the tooth.

Proper care of tooth enamel is one of the key aspects of human personal hygiene.

Dentine

Dentin (dentinum, LNH; lat. dens, dentis - tooth) is the hard tissue of the tooth, constituting its main part. The coronal part is covered with enamel, the root part of the dentin is covered with cement. Consists of 72% inorganic substances and 28% organic substances. Consists mainly of hydroxyapatite (70% by weight), organic material (20%) and water (10%), permeated with dentinal tubules and collagen fibers.

Serves as the foundation of the tooth and supports tooth enamel. The thickness of the dentin layer ranges from 2 to 6 mm. The hardness of dentin reaches 58.9 kgf/mm2.

There are peripulpal (internal) and mantle (external) dentin. In peripulpal dentin, collagen fibers are located predominantly condensally and are called Ebner fibers. In mantle dentin, collagen fibers are arranged radially and are called Korff fibers.

Dentin is divided into primary, secondary (replacement) and tertiary (irregular).

Primary dentin is formed during the development of the tooth, before its eruption. Secondary (replacement) dentin is formed throughout a person’s life. It differs from the primary by a slower pace of development, a less systemic arrangement of dentinal tubules, a larger number of erythroglobular spaces, a larger amount of organic substances, higher permeability and less mineralization. Tertiary dentin (irregular) is formed during tooth trauma, tooth preparation, caries and other pathological processes, as a response to external irritation.

Dental pulp

Pulp (lat. pulpis dentis) is loose fibrous connective tissue that fills the tooth cavity, with a large number of nerve endings, blood and lymphatic vessels.

Along the periphery of the pulp, odontoblasts are located in several layers, the processes of which are located in the dentinal tubules throughout the entire thickness of the dentin, performing a trophic function. The processes of odontoblasts include nerve formations that conduct pain sensations during mechanical, physical and chemical influences on dentin.

Blood circulation and innervation of the pulp are carried out thanks to dental arterioles and venules, the nerve branches of the corresponding arteries and nerves of the jaws. Penetrating into the dental cavity through the apical opening of the tooth root canal, the neurovascular bundle breaks up into smaller branches of capillaries and nerves.

The pulp helps stimulate regenerative processes, which manifest themselves in the formation of replacement dentin during the carious process. In addition, the pulp is a biological barrier that prevents the penetration of microorganisms from the carious cavity through the root canal beyond the tooth into the periodontium.

The nerve formations of the pulp regulate the nutrition of the tooth, as well as the tooth’s perception of various irritations, including pain. The narrow apical opening and the abundance of vessels and nerve formations contribute to the rapid increase in inflammatory edema in acute pulpitis and compression of the nerve formations by the edema, which causes severe pain.

Tooth cavity

(lat. cavitas dentis) The space inside the tooth formed from the cavity of the crown and root canals. This cavity is filled with pulp.

Cavity of the tooth crown

(lat. cavitas coronae) Part of the tooth cavity, located under the crown and repeating its internal contours.

Tooth root canals

The root canal of a tooth (lat. canalis radicis dentis) is an anatomical space inside the root of a tooth. This natural space within the coronal part of the tooth consists of a pulp chamber, which is connected by one or more main canals, as well as more complex anatomical branches that can connect the root canals to each other or to the surface of the tooth root.

Nerves

(lat. nervae) Neuron processes passing through the apex of the tooth and filling its pulp. The nerves regulate the nutrition of the tooth and conduct pain impulses.

Arteries

(lat. arteriae) Blood vessels through which blood from the heart flows to all other organs, in this case - to the pulp of the tooth. Arteries nourish dental tissues.

Vienna

(lat. venae) Blood vessels through which blood returns from organs back to the heart. The veins enter the canals and penetrate the pulp of the tooth.

Cement

Cement (lat. - cementum) is a specific bone tissue that covers the root and neck of a human tooth, as well as the teeth of other mammals. Serves to firmly secure the tooth in the bone alveolus. Cement consists of 68-70% inorganic components and 30-32% organic substances.

Cementum is divided into acellular (primary) and cellular (secondary).

Primary cement is adjacent to the dentin and covers the lateral surfaces of the root.

Secondary cement covers the apical third of the root and the bifurcation area of ​​multi-rooted teeth.

Tops of tooth roots

(lat. apex radicis dentis) The lowest points of the teeth, located on their roots. At the tops there are openings through which nerve and vascular fibers pass to the tooth.

Apical foramina

(lat. foramen apices dentis) Places of entry of vascular and nerve plexuses into the dental canals. The apical foramina are located at the apex of the tooth roots.

Alveolus (alveolar socket)

(alveolar socket) (lat. alveolus dentalis) A notch in the jaw bone into which the roots of the tooth enter. The walls of the alveoli form strong bone plates impregnated with mineral salts and organic substances.

Alveolar neurovascular bundle

(lat. aa., vv. et nn alveolares) A ​​plexus of blood vessels and nerve processes passing under the alveolus of the tooth. The alveolar neurovascular bundle is enclosed in an elastic tube.

Periodontium

Periodontium (lat. Periodontium) is a complex of tissues located in the slit-like space between the cementum of the tooth root and the alveolar plate. Its average width is 0.20-0.25 mm. The narrowest section of the periodontium is located in the middle part of the tooth root, and in the apical and marginal sections its width is slightly greater.

The development of periodontal tissue is closely related to embryogenesis and teething. The process begins in parallel with the formation of the tooth root. The growth of periodontal fibers occurs both from the side of the root cement and from the side of the alveolar bone, towards each other. From the very beginning of their development, the fibers have an oblique course and are located at an angle to the tissues of the alveoli and cementum. The final development of the periodontal complex occurs after tooth eruption. At the same time, the periodontal tissues themselves are involved in this process.

It should be noted that, despite the mesodermal origin of the constituent components of the periodontium, the ectodermal epithelial root sheath takes part in its normal formation.

Gingival grooves

(lat. sulcus gingivalis) Crevices that form where the crown of the tooth adheres to the gums. The gingival grooves run along the line between the free and attached parts of the gum.

Gum

Gums (lat. Gingiva) is a mucous membrane that covers the alveolar process of the upper jaw and the alveolar part of the lower jaw and covers the teeth in the cervical area. From a clinical and physiological point of view, the gums are divided into interdental (gingival) papilla, marginal gum or gingival margin (free part), alveolar gum (attached part), mobile gum.

Histologically, the gum consists of stratified squamous epithelium and the lamina propria. There are oral epithelium, junctional epithelium, and sulcal epithelium. The epithelium of the interdental papillae and attached gingiva is thicker and can become keratinized. In this layer, there are basal, spinous, granular and stratum corneum. The basal layer consists of cylindrical cells, the spinous layer consists of polygonal cells, the granular layer consists of flattened cells, and the stratum corneum is represented by several rows of completely keratinized and nucleated cells that are constantly exfoliated.

Mucous papillae

(lat. papilla gingivalis) Fragments of gums located at their elevation in the area between adjacent teeth. The gingival papillae are in contact with the surface of the dental crowns.

Jaws

(lat. maxilla - upper jaw, mandibula - lower jaw) Bony structures that are the basis of the face and the largest bones of the skull. The jaws form the mouth opening and determine the shape of the face.

Stages of tooth canal treatment

Endodontic treatment usually lasts several hours and includes a number of stages.

1. Removal of the pulp (pulpectomy).
   The inflamed soft tissue of the tooth is eliminated.
2. Root canal sanitation.
   The procedure is a “cleaning” of bacteria and dead tissue elements. Pulpectomy and canal sanitation pursue one of the most important goals - eliminating existing inflammation.
3. Channel formation.
   The root canal, freed from pathological contents, undergoes appropriate treatment. In addition to ensuring good passage of the canal, it is imperative to ensure that its apex reaches the apical part of the tooth.
4. Canal filling.
   The last stage of the intervention is filling the root canal with filling material, followed by grinding.

Treatment of teeth with problematic root canals

Filling dental canals

A relatively simple technology for treating tooth canals is filling with a special paste with or without a pin. According to the “gold standard” of endodontics, the canals are also filled with a latex-like material - gutta-percha. Several methods of its use have been developed, including the Termafil system, lateral condensation, injection or liquid thermogutta-percha (vertical condensation). In some cases, in particular when treating a tooth canal cyst, filling is carried out with a substance based on calcium hydroxide (copper-calcium hydroxide “depopheresis” method). However, special nanocomposite materials are increasingly used in dentistry.

Treatment under a microscope

The age-old “tough nut to crack” for the dentist is curved or branched root canals of the teeth. A dental microscope, often in combination with a laser, allows you to completely pass through them and adequately process them along their entire length to reduce tissue trauma. Sometimes it becomes necessary to treat a sealed tooth canal with the evacuation of remaining material of various nature, for example, fragments of fillings, tissue fragments and even instruments. Then a microscope also comes to the rescue. Read more about the technology in a separate article.

Features of the structure of the root system in children

Each baby tooth has one nerve, just like the molars. In addition, they have a similar root system structure. In pathological processes, temporary elements are also opened, processed and filled, but the tactics largely depend on how long ago they erupted and how much time is left before the bite changes. Thus, the roots of baby teeth are usually filled with a special paste, which dissolves as the root system dissolves.

The process of root formation in permanent incisors, canines and molars takes about three years. If the root system is still at the stage of its development, special compounds are chosen for filling it - pastes with a high concentration of fluorine and calcium.

The photo shows the process of resorption of the roots of baby teeth

If your tooth hurts after root canal treatment

If after root canal treatment your tooth hurts when you press it, this is normal. This phenomenon is associated with insufficient anesthesia in the area of ​​endodontic intervention. Another reason why a tooth hurts after canal treatment is excessive treatment with the instrument moving beyond the apical foramen.

How long does a tooth hurt after root canal treatment? Sometimes pain persists for several days due to intensive intervention in the tissue structure in such a limited area. A similar situation occurs when an excess amount of filling material is placed into the canal, which causes discomfort when pressure is applied to the walls. As a result, the tooth “aches” after canal treatment. In any case, the presence of post-filling pain signals the need for a second visit to the dentist.

What is pulpitis of a single-canal tooth?

Inflammation of the neurovascular bundle located inside a tooth with one root canal is called pulpitis.
The disease develops as a result of infection getting inside the tooth. The main reason for the development of pulpitis is the advanced stage of caries. When inflamed, the pulp swells and puts pressure on the inner walls of the tooth. The person experiences severe pain. Symptoms of the development of pulpitis of a single-canal tooth are:

• Acute pain. In some cases, pain becomes stronger when a person moves to a horizontal position.
• The presence of a reaction to temperature changes. The symptom manifests itself when eating cold or hot food.
• Reaction to sour and sweet foods.
• Attacks of throbbing pain that appear at regular intervals.

If symptoms occur, you should contact a qualified professional. Failure to visit the dentist in a timely manner can lead to the development of the disease and its development into a chronic form. The constant use of painkillers is not advisable, since they eliminate pain but do not have a therapeutic effect. Failure to contact a specialist in a timely manner will lead to gradual tooth decay.

Possible complications

Not all cases go smoothly. Let's consider the main problems that arise after the procedure.

• Perforation.
  The phenomenon is the formation of holes between the dental canals and surrounding tissues. Treatment of perforation consists of medicinal treatment and filling.
• Cheek swelling.
  The reason why the cheek is swollen after root canal treatment is believed to be the impregnation of the periodontal tissues and mucous membranes with an anesthetic drug, which themselves are quite loose and easily absorb liquid.
• Instrument fracture.
  The probes for passing through the channels are very thin. If they break during medical procedures, the fragments are removed with special devices. Modern dental instruments made of nickel-titanium alloys are less susceptible to wear and break less often.
• Adverse reactions to medications.
  The range and severity of side effects of modern anesthetics are minimal. Before treatment, the doctor must collect an allergic history - information about drug intolerance - and the likelihood of a full-blown allergic reaction is practically reduced to zero. Adverse reactions of moderate and minor degrees are mostly short-term, can be easily corrected or can be overcome by changing the drug.
• Other complications.
  Situations such as swallowing particles of fillings, tooth dust, and small instruments now practically do not occur thanks to the use of a rubber dam - a latex plate that separates the tooth or teeth being treated from the oral cavity.

When inflammation begins - diseases and treatment

The internal structures of the tooth can become inflamed as a result of rapid development, caries, pulpitis or periodontitis. To determine the exact cause of the problem and the stage of development of the pathology, the patient must undergo an x-ray examination. The standard treatment regimen is as follows:

1. the doctor removes an old filling or opens a carious cavity to open access to the insides of the teeth,
2. if the nerve is still there, it is removed using a special instrument - depulpation is performed,
3. Next, the doctor carefully cleans the canals and treats the walls with an antiseptic,
4. fills the canals and fixes the filling on top. When treating periodontitis, to ensure the elimination of inflammatory processes, it is usually necessary to apply medication and install a temporary filling - and this procedure will have to be completed more than once.

“My root canals were cured in just 2 visits. It’s a pity, of course, that the nerve had to be removed. They say the tooth can darken. But the treatment was quite quick and easy, and there were no problems afterwards. I heard that sometimes people go for several months to clean out the roots, but at my second appointment they gave me a permanent filling. By the way, it was the first time they filled with gutta-percha, and it still has the same smell!”

KirillMigo, from correspondence on the forum www.32top.ru

The photo shows a treatment regimen for periodontitis.
The treatment regimen described above is a universal scenario that can be changed depending on the type, shape and stage of the pathological process. But the essence remains the same: it is important that all passages are thoroughly cleaned and sealed. Otherwise, relapses of inflammatory processes are possible, and then the risk of complete tooth loss will increase significantly.

When is tooth extraction necessary after root canal treatment?

It happens that you have to part with a treated tooth. Typically, such a sad outcome is due to the following factors:

• initially unsatisfactory root canal treatment with the development of poorly controlled inflammation;
• some cases of wisdom teeth treatment;
• the complexity of the anatomical structure of roots and canals in a particular patient;
• late request of the patient for specialized help, in which adequate therapeutic measures do not lead to the desired result.

Number of roots and canals

The human mouth contains special organs – teeth. They are endowed with a specific shape and structure. They are systematized into dairy and indigenous ones. There are 20 milky ones, 32 indigenous ones. In the rarest cases, organs appear beyond the set.

Any unit contains a crown, root and neck. The chewing organs are endowed with 2 and 3 roots with canals. On top of the crown there is enamel, which protects the masticatory organs from injury and is considered a durable tissue (A collection of different and interacting tissues form organs)

human body.

What is the cost of treatment?

How much does root canal treatment cost? The cost largely depends on the method used and the quality of the materials. When using laser and microscopic technology, nanocomposites and other advanced developments, the cost of tooth treatment with canal filling increases significantly. Approximate prices for root canal treatment in Moscow with gutta-percha filling and composite filling are presented in the table below.

The cost of root canal treatment should not be the determining factor in choosing a clinic. Contact only dentistry with a good reputation and experienced specialists who use modern equipment and the latest techniques in their work. Remember - the future fate of your teeth and the aesthetics of your smile depend on the quality of canal treatment!

Differences in the structure of incisors, canines and molars on the upper and lower jaws - table

As mentioned above, the number of channels is largely determined by the range of the element. The essence is the same: the very last chewing teeth bear the maximum chewing load, so they must be strong and resilient, and for this they need abundant nutrition - this is provided by a developed internal system. The table below shows average data on the number of passages in the tooth roots in the upper and lower jaws.

On the upper jaw

The teeth on the upper jaw have their own structural characteristics, and therefore they are somewhat different from their antagonists on the lower jaw. Here are the main distinguishing features:

• second molars (sixes) most often have three canal passages, but in some cases there are 4,
• premolars usually have 2 canals, although in some situations their number can vary from 1 to 3.

The photo shows the teeth of the upper jaw.
It should be noted that the roots on the upper jaw usually have a more complex and branched structure. Therefore, upper molars are more difficult to treat, which explains the higher percentage of complications due to incompletely healed cavities.

On the lower jaw

The structure of the upper and lower jaws is different, which is partly due to the peculiarities in the distribution of chewing load. In the lower teeth, as a rule, there are fewer canals, but here much depends on the individual anatomical parameters of the jaw apparatus. Therefore, the patient must undergo an X-ray examination, and with the image in hand, the doctor will be able to begin treatment directly.

The following are the features in the internal structure of the incisors, canines and molars of the lower jaw:

• in the first molars (sixes) there can be from 2 to 4 moves - there is no exact number to focus on,
• the lower second premolar (five) most often has one canal, although in approximately 10% of cases specialists find two canals at once1,
• the first premolar usually has only one root, but in about a third of cases there are 2,
• Eights are the most unpredictable - the exact number of roots located inside can only be determined using radiography. As a rule, there are no more than 3 of them, but often during treatment specialists identify additional cavities. This is one of the reasons why wisdom teeth are difficult to treat therapeutically.

The photo shows the teeth of the lower jaw.
Regardless of the type and stage of the disease, competent dental treatment necessarily involves a preliminary x-ray diagnosis. Otherwise, any wrong move by the doctor can easily lead to serious complications.

Eights - third molars

A wisdom tooth usually has a complex and intricate root system - this is the only element in which the number of roots can reach 5. But this is extremely rare, and more often the figure eight has from 3 to 4 roots, while the lower third molar may not have any. more than 3.

The photo shows wisdom teeth

We are talking about a rudiment that we inherited from our ancient ancestors. Now we do not need to carefully crush very tough foods, such as raw meat. Therefore, there was no longer any urgent need for the figure eight, and due to the reduction in the size of the jaws, there was practically no free space left for it.

Because of this, the tooth almost always erupts with problems, since it initially begins to grow in the wrong position and often half remains under the gum - retention and dystopia. All this significantly complicates the treatment of pathological processes that are localized in this area. Therefore, most often the eight has to be deleted.