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62 Restorative Techniques in Paediatric Dentistry

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unaffected by the timing of when the nal restoration was placed. However, at 24 months, preformed metal crowns had better success rates than composites. Preformed metal crowns should be the favoured post-pulpectomy restoration because of the excellent seal it provides.

Step-by-Step Pulpectomy Technique

Step 1: Correct diagnosis and pre-operative radiograph.

FIGURE 4.34 (a) Tooth 85 developed occasional pain soon after a Ketac silver restoration was placed. (b) Aradio-

graph showing rarefaction in the bifurcation area, an indication for pulpectomy. Apre-operative periapical radiograph should always be taken prior to pulpectomy.

Step 2: Give local analgesia and isolate the tooth with rubber dam. Step 3: Remove caries and identify exposure site.

FIGURE 4.35 Point of pulp exposure can be seen following removal of the failed restoration.

Step 4: Remove roof of pulp chamber as described for pulpotomy, and identify opening

of root canals.

FIGURE 4.36 Primary molars usually have the same number of root canals as permanent molars, namely, three or

four for lower molars and three for upper molars. (a) The opening of the mesio-buccal, mesio-lingual, and distal canals in 85. (b) Another lower molar (85) with four root canals, a second distal canal being present in this case. In most cases, the root canals can be identied without much difculty.

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63Pulp Therapy for Primary Teeth

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Step 5: Take a diagnostic radiograph with les in the root canals.

FIGURE 4.37 This step is optional. Aworking-length radiograph can be taken in a very cooperative child. In the

authors’ experience, it is not usually required, and the rough length of the roots can be determined from the preoperative radiograph. (a) Files in the mesial and distal canals of 74. (b) Files have been placed in the mesial, distal, and palatal canals of 65.

Step 6: Clean out root canals with les, and remove remnants of pulp tissue and irrigate

canals with saline.

FIGURE 4.38 (a) The root canals are led to within 1–2mm of the apex. Care is taken not to go beyond the apex in

order to prevent any possible damage to the developing permanent successor. The root canals are led lightly since the roots of primary teeth are fragile and usually curved. Reaming is not advisable for the same reason. (b) Any previous haemorrhage should disappear at this stage. (c) The root canals are led to no more than size 30–35, depending on the initial canal size. (Reproduced from Dental Update by permission of George Warman UK Ltd.)

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64 Restorative Techniques in Paediatric Dentistry

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Step 7: Remove remnants of pulp tissue, and clean root canals with manual or rotary

instrumentation. Biomechanical preparation of the primary root canal should also include regular copious irrigation with 1–5% NaOCl or normal saline.

Step 8: Dry root canals with paper points.

FIGURE 4.39 The root canal system is dried using paper points.

Step 9: Obturate the prepared root canals with resorbable material using appropriate

technique.

FIGURE 4.40 Aspiral root canal ller, one size smaller than the last le used in the root canals, should be used to

ll the root canals. This is to prevent it from engaging and fracturing in the root canal. Using sharp scissors, the spiral ller is cut to half its length. which makes it easier to handle in a child’s mouth and also prevents the lling material from being pushed through the apex.

FIGURE 4.41 Pure zinc oxide and eugenol are mixed into a slurry. This is then carried into the root canals with the

spiral root canal ller (a) and spun into the root canals (b). If the clinician is not familiar with the spiral llers, it is advisable that the zinc oxide and eugenol be carried into the root canals with either a Hedstrom le or a ne gutta-percha point and agitated a few times to ensure adequate lling of the canals.

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65Pulp Therapy for Primary Teeth

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Step 10: After root canal obturation, ll the pulp chamber with hard-setting cement.

FIGURE 4.42 The pulp chamber is lled with one of the proprietary brands of zinc oxide and eugenol cements, such

as Kalzinol.

Step 11: Restore the tooth with a preformed metal crown.

FIGURE 4.43 The 85 treated with a pulpectomy and restored with a preformed metal crown.

Step 12: Take a post-operative radiograph to check root lling.

FIGURE 4.44 Post-operative periapical radiograph should be taken to check adequacy of root lling.

Follow-Up

Teeth that have been treated with the pulpectomy technique should be reviewed both clinically and radiographically at follow-up appointments. The pulpectomy is judged to be clinically successful if there is alleviation of acute symptoms and the tooth is free from pain and mobility. Any draining sinus should have disappeared.

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66 Restorative Techniques in Paediatric Dentistry

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Radiographic assessment should include a minimum of one periapical radiograph taken preoperatively, one immediately post-operatively and as required depending on any residual radiolucency/symptoms. The radiographs should be assessed for furcation pathology. An improvement of the bone condition in the furcation region as shown in Figure4.45, or no further deterioration in the condition of that region, means that the pulpectomy has been successful. Any worsening of the extent of the radiolucency in the furcation region is an indication of radiographic failure, although immediate extraction of such a tooth may not be required if the tooth is symptom-free clinically.

FIGURE 4.45 Pre, post, and follow-up radiographs of an abscessed 74 successfully treated with a pulpectomy technique:

(a) pre-operative radiograph showing an abscessed 74 causing destruction of the bone, typically in the furcation area; (b) immediate post-operative radiograph showing root canal lling in place; (c) radiograph six months later showing resolution of radiolucent area on 74 shown in (a). (Reproduced from Dental Update by permission of George Warman UK Ltd.)

Other Examples of Pulpectomy in Primary Molars

Case 1

FIGURE 4.46 Serial radiographs showing gradual regeneration of bone in the bifurcation area after a pulpectomy was

performed on 75: (a) pre-operative, (b) immediately post-operative, (c) three months later, (d) one year later.

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67Pulp Therapy for Primary Teeth

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Case 2

FIGURE 4.47 Ser ial radiographs showing a successful pulpectomy performed on 74, indicating a continuous improve-

ment of bone in the bifurcation over a six-month period: (a) pre-operative, (b) six months later.

Case 3

FIGURE 4.48 An example of a pulpectomy performed in an upper molar (54): (a) pre-operative, (b) post-operative.

Note the lling in the mesial, distal, and palatal canals.

Case 4

FIGURE 4.49 Periapical radiograph of a root-lled primary molar (74) showing evidence of root lling material in

an accessory canal, marked with arrows.

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68 Restorative Techniques in Paediatric Dentistry

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Case 5

FIGURE 4.50 Aspiral root ller fractured in the distal canal of 75.

Case 6

FIGURE 4.51 Abscesses in primary incisors (51 and 61) treated with a pulpectomy technique: (a) pre-operative view

showing abscess in relation to 51; (b) periapical radiograph showing apical radiolucent areas on both 51 and 61; (c) root llings in place with teeth built up with strip crowns.

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Emergency Management of the Acute Abscess

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Visit 1

When an acute abscess is present, it must be resolved as quickly as possible. This is achieved

either by gaining drainage through the carious cavity or, if a swelling is present, by puncturing it to improve drainage (usually a painless procedure). Local analgesia should be used if possible because it is a common clinical nding to encounter vital pulp tissue in an infected pulp chamber. Root canals are identied, lightly led to drain as much of the abscess as possible, and also irrigated, preferably with sodium hypochlorite. A non-setting calcium hydroxide paste can be introduced into the root canals as it has strong anti-bacterial action. Adry cotton pellet is then sealed in the pulp chamber with a suitable cement. Antibiotics need to be prescribed only in the presence of an acute infection associated with cellulitis or other systemic symptoms.

Visit 2

The patient is recalled seven to ten days later. At this stage, the tooth should be free from clini-

cal symptoms, and any abscess should have resolved or be resolving. The tooth should be opened under rubber dam, root canals accessed, and the pulpectomy procedure completed as described before.

69Pulp Therapy for Primary Teeth

Lesion Sterilization and Tissue Repair (LSTR)

Indications

Primary teeth with extensive periradicular pathosis and/or root resorption make conventional pulpectomy difcult, and such teeth were traditionally recommended for extraction. In such clinical situations, LSTR stands out as an effective treatment option, allowing the infected primary tooth to be retained in the dental arch till its natural exfoliation.

Rationale

LSTR is an endodontic procedure carried out in infected primary teeth that involves noninstrumentation or minimal instrumentation of the root canals, followed by the placement of a triple antibiotic mixture (3Mix) in a propylene glycol–macrogol vehicle to disinfect the root canal systems and the periapical areas. LSTR aims to sterilize the pulp chamber and root canals, decreasing the bacterial load and enhancing the natural defence mechanisms of the host.

Indications

LSTR is indicated in primary teeth that are required to be maintained for a maximum of 12 months, however, exhibiting signs and symptoms of irreversible pulpitis or necrosis with evidence of root resorption. Should these teeth require longer than 12 months, periodic clinical and radiographic assessment is indicated. The reader is instructed to assess the latest guidelines related to this procedure as further research emerges.

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70 Restorative Techniques in Paediatric Dentistry

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Step-by-Step LSTR Technique

Step 1: Preparation of the Triple Antibiotic Mixture (3Mix)

The most important step in LSTR is the preparation of the 3Mix. The impetus for the development of the 3Mix was to provide broad-spectrum anti-bacterial action in the root canal system while also not encouraging bacterial resistance. Different antibiotic combinations have been used over the years, but the current recommendation is to use a 3Mix containing clindamycin, metronidazole, and ciprooxacin. This 3Mix not only showed signicantly higher clinical success but also avoided the concerns of staining associated with the traditional 3Mix, where a tetracycline-like drug was used.

Immediately before the LSTR treatment, the 3Mix is combined with a liquid vector of polyethylene glycol and macrogol to form a paste that is ready to be placed into the medication receptacles and over the pulp oor.

Step 2: Preparation of the Access Cavity

After local anaesthesia and rubber dam isolation, the access cavity is prepared using a round bur, and the necrotic tissue removed, followed by irrigation. If haemorrhage is present, it can be controlled by using sodium hypochlorite. Evidence indicates that clinical success of LSTR is not signicantly inuenced by whether or not the root canals were les or broached, and clinicians can choose as per their personal preference and patient circumstances.

Step 3: Preparation of the Medication Receptacles

The canal orices are enlarged using a large round bur that is approximately 2mm deep and 1mm wide and are meant for retaining the 3Mix at the canal orice.

Step 4: Placement of the 3Mix Paste and Final Restoration

After proper drying, the 3Mix paste is placed directly into the medication receptacles and over the pulpal oor. It is then covered with a glass ionomer cement, and the tooth is restored with a preformed metal crown.

Follow-Up

Following LSTR treatment, the pre-treatment clinical signs and symptoms should resolve, and over time, the periradicular lesions should heal, as evidenced by the bone deposition in the pre-treatment radiolucent areas.