Operative Notes

range of visible light used for composite curing → 460-480nm

best technique for class 2 posterior filling → cervical 1 mm first followed by

sides of the box and occlusal component

NOT a disadvantage of resin composite → low thermal conductivity

body shade → enamel in opacity

preferred location for pin placement → line angles

root caries → progresses rapidly

amalgam condensation → 1min

excellent polymerizable wetting agent for adhesives → HEMA

fluoride concentration is varnish → 22600ppm

PRR → suitable for small discrete lesions of decay often limited to a single pit

Resin based sealants are the first choice for dental sealants

Operative Notes 1
 Chisel → blade aligned with the handle or slightly curved from it

if bleaching treatment relapses in case of obliterated chamber → porcelain

veneers

at home bleaching → 10% carbamide peroxide

amalgam: cavosurface angle → exactly 90 or slightly less

in full smile, incisal edge of maxillary anterior teeth should be cradled by the
lower lip

non vital tooth → walking bleach

NCCL → clinical root

corrosion of carbon steel burs prevention → submerge in sodium nitrite

Recapitulation technique → removal of debris from canal

involves reintroducing the initial file into the canal between uses of larger files to
prevent packing of debris at the apex

DG16 → calcified canal

CBCT → oblique root fractures

articaine → buccal nerve block after IANB

Operative Notes 2
 minimum thickness of amalgam in functional cusps → 2.5mm

remineralised lesion → dull, hard, leathery

extra heavy rubber dam thickness → 0.012 inch

bonded amalgam → zinc phosphate cement

REVERSIBLE PULPITIS IRREVERSIBLE PULPITIS

Pain (sharp, lancinating, quick) Pain (dull, slow, aching, throbbing)

Transient 1-5 seconds Lingering (minutes to hours)

Relieves on removal of stimulus Does not relieve on removal of stimulus

Non-nocturnal Could be Nocturnal

Weak postural association Strong postural association

Reversible pathology Irreversible Pathology

Often aggravated by cold stimuli Aggravated by hot and sweet stimuli

Managed by: Cold provides relief

Removal of stimulus Managed by:
Restorations Pulpectomy
Preventive Care Root canal treatment
Follow up Regenerative Approaches

Pathways of Communication between Pulp and Peridontium:

Physiologic Pathways Pathological

Lateral and accessory canals Perforations

Apical foramen Vertical root fracture

Palatogingival groove Loss of cementum

Dentinal tubules

Retrograde periodontitis → apical to gingival

Cases associated with non-vital pulp have pulpal pathology where as teeth
associated with vital pulp usually have periodontal disease

Operative Notes 3
 Bone loss:

pulpal: generally localized and wider apically. Not associated with vertical bone
loss.

periodontal: bone loss is generalized which is wider coronally. It may be associated

with vertical bone loss.

Pulpal disease Perio disease:

Acute Chronic
caries trauma or pulp exposure is caries trauma or pulp exposure is
common etiology common etiology
Non vital pulp Vital pulp
localized generalized

bone loss: generally localized and bone loss: bone loss is generalized
wider apically. Not associated with which is wider coronally. It may be
vertical bone loss. associated with vertical bone loss.
When pain is associated with pulp Pain associated with periodontal
pathology, it is usually acute and sharp pathology is dull in nature and patient
in nature and patient can not identify can identify the offending tooth
the offending tooth. (because of presence of proprioceptive

swelling is seen on the apical region, nerve fibers in the periodontal

ligament).
swelling: margins or lateral surfaces of
teeth

Operative Notes 4
 Streptococcus mutans and streptococcus sobrinus → smooth surface and pit-
fissure caries

Actinomyces spp. → root caries

Bacteria in the deepest layers of caries are predominantly strict anaerobes

Operative Notes 5
 Anachoresis is a process by which microorganisms are transported in the blood
to an area of inflammation where they establish an infection

Apical actinomycosis is an example of extraradicular infection independent

of intraradicular infection

PROCEDURAL ACCIDENTS
1. PERFORATION:

Causes: Prevention: Recognition

Anatomy of tooth Knowledge of anatomy, Early signs:
Lack of attention to tooth treatment, instruments, Sudden pain
technique etc
axial inclination Sudden hemorrhage
Failure to recognize Radiographs with
different angulations Burning pain or bad taste
when the bur has passed during irrigation
the pulp chamber (CBCT where
required)Magnification Radiographically
Endo on tooth with aids malpositioned file
crown
Referral Apex locator reading
Improper instruments
Hemorrhage on paper
point
Radiograph with a file in
position

Furcation Perforation:

Direct perforation: occurs during search of canal, ‘punched out’ defect into the
furcation with a bur. Usually accessible. Have walls
Stripping perforation: furcation side of the coronal root surface, results from
excessive flaring with files or drills. Inaccessible. Subsequent pocket formation
Non-surgical Tx:
Conventional → amalgam, ZOE, cavit, CaOH, freeze dried bone
Contemporary → MTA, bioceramic, biodentine
Surgical → surgical repair with contemporary materials

Operative Notes 6
 Prognosis:

1. Time delay before perforation

2. Location of perforation

3. Size

4. Level ( at or above crestal bone= favorable)

5. Ability to seal the defect

6. Previous contamination with microbes

7. More apical the perforation the more favorable the prognosis converse is true
for repair

Apical Root Perforation:

Occur through the apical foramen due to (over instrumentation) or through the body
of the root (Transportation)
Indicators: fresh hemorrhage in the canal or on instrument, pain in asymptomatic
tooth during canal preparation, sudden loss of apical stop

Lateral (midroot) Perforation:

Inability to maintain canal curvature--→ ledge---→transportation--→ perforation

tx:
WL 1-2mm short of point of apical perforation
Canal is cleaned and shaped at this new WL
Master cone must have apical stop at the WL before obturation

Placement of MTA as apical barrier where required

Coronal Root Perforation:

Occurs during access preparation while locating orifices,or during flaring,

Reduced tooth structure due to crown or bridge prep tooth,
Retreatment
Tx:

Difficult to treat

Operative Notes 7
 Follow the original canal,
repair the perforation and obturate
Root resection to the level of perforation

Root amputation
Hemi-section
Intentional replantation
Facial perforation better prognosis

2. LEDGE FORMATION:

A ledge has been created when the working length can no longer be negotiated and
original patency of the canal is lost
An artificial irregularity created on the surface of the root canal wall that impedes
the placement of an instrument to the apex of an otherwise patent canal

ETIOLOGY PREVENTION MANAGEMENT PROGNOSIS

The inability to Straight line Difficult to Failure depends
achieve a proper access correct on: the amount of
glide path to the debris left in un-
Proper working Early recognition
apex length by radiograph, instrumented
canal
Forcing the determination CBCT and
instrument into Pre flaring magnification Short and
the canal wall cleaned apical
Recapitulation Crown down
Using a non- preparation ledges better
and irrigation prognosis
curved stainless Bypass the ledge
Use of chelators
steel instrument with patency files Teeth with vital
that is too large Non cutting edge tissue better
Lubricants are
for a curved files prognosis than
canal. helpful necrotic and
One eighth to
File tip 2-3mm is infected
Failing to use the one fourth
instruments in reaming motion sharply bent and
worked in the
sequential order in apical portion
direction of canal
Rotating the file
curvature
excessively at the

Operative Notes 8
 working length “picking” motion
Inadequate is used
irrigation or
lubrication during
instrumentation

Inadvertently
packing debris in
the radicular
portion of the
canal during
instrumentation
curvature 20-30
degrees

3. TRANSPORTATION: Artificial canal creation

“The removal of canal wall structure on the outside curve in the radicular half of the
canal due to the tendency of files to restore themselves to their original linear shape
during canal preparation.”
Deviation from original pathway of the root canal system
Arises from factors that causes ledge
Aggressive use of SS file and filling motion
Management → negotiate the original canal and determine if a perforation has
occurred.
Prognosis depends on the ability of the operator to negotiate the original canal,
prepare the un-instrumented portion and fill the canal
Failure means surgical options

4. INSTRUMENT SEPARATION:

ETIOLOGY RECOGNITION PREVENTION CONTRIBUTING

FACTORS
over use Removal of Recognition of
excessive use shortened file physical Operator
with a blunt tip experience
improper use

Operative Notes 9
 Loss of patency properties and rotational speed
to the original stress limitations
canal curvature
length Continuous
instrument design
Radiograph is lubrication and technique
must Each instrument is
torque setting
examined before
its use manufacturing
process
Small no files
should be type of NiTi alloys
used
discarded
the type of
File should be
rotational motion
worked in the
canal before next
one
Preflaring and
glide path

Cyclic fatigue: “Repetitive compressive and tensile stresses acting on the outer
portion of a file rotating in a curved canal”
Torsional fatigue: “Occurs when the tip of the instrument binds but the shank of the
file (driven by the handpiece) continues to rotate”
Prognosis → Depends on:
How much undebrided and unobturated canal in apical area
Best when separation of large instrument after the preparation

Poor when small instrument separates short of apex or beyond at initial stages
Management:
Attempt to Retrieve
Attempt to Bypass
Prepare and obturate the canal with fractured instrument

5. ASPIRATION OR INGESTION:

patient gags or coughs

Operative Notes 10
 prevented by rubber dam
confirm by radiograph
refer to surgery

6. SODIUM HYPOCHLORITE ACCIDENT

ETIOLOGY SIGNS AND TREATMENT PREVENTION

inaccurate SYMPTOMS pain control Establish an accurate
working facial cold compress working length and avoid
length distention over-
dilute with
instrumentation/enlargement
iatrogenic marked edema normal saline
widening or bruising of the radicular foramen
Use of negative
of the spontaneous If irrigating using positive
radicular pressure pressure, employ a small
and profuse
foramen, syringe with sidevented needle placed no
hemorrhage saline and
Lateral from canal closer than 2 mm from the
cannula placed working length. Express the
perforation space at radicular
of the root fluid slowly and observe that
periorbital pain foramen
it is venting through the
wedging (maxilla) After one day, access cavity
of the
paresthesia warm Carefully assess the canal
irrigation compresses
sensory integrity for signs of
needle are substituted
deprivation perforation or other large
for the cold, portals of fluid egress
loss of upper and warm oral
lip and cheek Avoid wedging the needle
rinses are
function tip in the canal space or
prescribed to
extension into stimulate the inserting it
the local beyond the working length
submandibular, microcirculation Confirm the identity of the
submental or
Antibiotics are solution prior to injection or
sublingual usually irrigation
regions can
prescribed, and
compromise
their
the airway, administration

Operative Notes 11
 commensurate
with the
severity of hard
and soft tissue
destruction and
necrosis
Use of
corticosteroids
Severe cases
should be
treated in
hospital set up

7. ACCIDENTS DURING OBTURATION

i. Underfilling
Etiology: Ledge, insufficient flaring, poorly adapted master cone, inadequate
condensation pressure
Treatment: Removal of under filled GP and retreat
ii. Over filling
Etiology: Increase condensation pressure, poorly adapted GP, inflammatory
resorption, open apex
Treatment: removal of Gutta percha non-surgically or surgically

Operative Notes 12