Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis

PURPOSE

This systematic review and meta-analysis assessed outcomes in primary teeth for the vital pulp therapy (VPT) options of indirect pulp therapy (IPT), direct pulp capping (DPC), and pulpotomy after a minimum of 12 months to determine whether one VPT was superior.

METHODS

The following databases were searched from 1960 to September 2016: MEDLINE, EMBASE, CENTRAL, EBSCO, ICTRP, Dissertation abstracts, and grey literature for parallel and split-mouth randomized controlled trials of at least 12 months duration comparing the success of IPT, DPC, and pulpotomy in children with deep caries in primary teeth. Our primary outcome measure was overall success (combined clinical and radiographic). Three authors determined the included RCTs, performed data extraction, and assessed the risk of bias (ROB). Meta-analysis and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done.

RESULTS

Forty-one articles qualified for meta-analysis (six IPT, four DPC, and 31 pulpotomy) from 322 screened articles. The 24-month success rates were: IPT=94.4 percent, and the liner material (calcium hydroxide [CH]/bonding agents) had no effect on success (P=0.88), based on a moderate quality of evidence; DP =88.8 percent, and the capping agent (CH/alternate agent) did not affect success (P=0.56), based on a low quality of evidence. The combined success rate for all pulpotomies was 82.6 percent based on 1,022 teeth. Mineral trioxide aggregate (MTA) (89.6 percent) and formocresol (FC) (85.0 percent) success rates were the highest of all pulpotomy types and were not significantly different (P=0.15), with a high quality of evidence. MTA's success rate (92.2 percent) was higher than ferric sulfate (FS) (79.3 percent) and approached significance (P=0.06), while FS's success rate (84.8 percent) was not significantly different from FC (87.1 percent), both with a moderate quality of evidence. MTA and FC success rates were significantly better than CH (P=0.0001), with a moderate quality of evidence. At 18 months, sodium hypochlorite (NaOCl) success rate was significantly less than FC (P=0.01) with a low quality of evidence.

CONCLUSIONS

The highest level of success and quality of evidence supported IPT and the pulpotomy techniques of MTA and FC for the treatment of deep caries in primary teeth after 24-months. DPC showed similar success rates to IPT and MTA or FC pulpotomy, but the quality of the evidence was lower. Systematic Review Registration Number: PROSPERO 2015: CRD42015006942.

Endodontic Treatment Outcomes

The primary goal of conventional endodontic treatment is prevention and/or elimination of apical periodontitis for both mature permanent teeth and immature teeth with an open apex. Besides these goals, the objectives of endodontic treatment of immature teeth include preservation of pulp vitality and often further root maturation. Robust criteria for outcome assessment are an essential determinant for any measure of treatment success for both mature and immature teeth.

Modern Endodontic Microsurgery Concepts: A Clinical Update

Increased use of the surgical operating microscope in endodontic surgery has elucidated many shortcomings of previous techniques and along with microsurgical instruments and new more biologically acceptable root-end filling materials has started the new microsurgical era in surgical endodontics. Endodontic microsurgery is a minimally invasive technique that results in less postoperative pain and edema and faster wound healing. It offers a significantly higher success rate than traditional apical surgery technique. The components, key concepts and procedural steps of endodontic microsurgery as well as the prognosis and predictability of modern root-end procedures are presented in this review.

[The importance of pulp therapy in deciduous teeth]

Preserving primary teeth is crucial for maintaining the maxillary growth, aesthetics, mastication, and speech and for preventing from abnormal habits. Given the peculiar anatomy of the primary tooth, caries grow faster and more frequently to the pulp. In pediatric dentistry, new methods and enhanced material have been recently released on the market and broadened the field of treatments. In this paper, we review the pulp diseases affecting children and focus on the current root canal therapies that favour the physiological primary tooth loss.

Endodontic management of symptomatic pulpal pathosis by single -visit root canal therapy

Single-visit root canal therapy is one of the reality in modern endodontics globally, both for vital and non-vital teeth, despite many research efforts and much controversy, specially when post-operative pain is concerned. There are increased post-operative complications as pain, swelling, discomfort in managing teeth having symptomatic pulpal pathosis. To clinically verify the possibility to treat symptomatic vital and non-vital teeth in one visit technique, 126 patiens were selected and advised to undergone single visit endodontic treatment at the Department of Conservative Dentistry and Endodontics, Bangabandhu Sheikh Mujib Medical University, Dhaka. Endodontically involved symptomatic vital and symptomatic non-vital teeth were enrolled in two groups and advised to undergone single visit endodontic treatment. Both groups were assessed at 24 hours, 48 hours, 72 hours and long term post operative evaluation up to 10 months. The main outcome measure was post operative pain. The result of our study indicates that single visit root canal treatment is a safe, effective and practical method of treatment of an endodontically involved tooth both in vital and non vital cases when applied in appropriate situation. Significantly fewer patients of symptomatic vital cases reported pain in immediate follow up i.e. 24 hours, 48 hours and 72 hours in comparison to non vital cases (12.69% vs. 22.2%, 4.16% vs. 11.11%, 1.58% vs. 7.93%). At 10 months of long term follow up the recall rate was 74.35% and 90(71%) of patients were comfortable after receiving treatment. Post operative pain incidence in single visit was equivalent to that of multi visit endodontics, provided one had an accurate diagnosis, proper case selection and skilled technique.

Immediate implant placement and restoration in infected sites

The long-standing assumption that active infection is a contraindication for immediate implant placement has been challenged recently. High implant survival rates have been reported even when implants were placed immediately in infected extraction sockets and provisionalized within 36 hours. To further evaluate the impact of nonocclusal loading on implants placed in cleaned periodontically or endodontically infected extraction sites, this retrospective study examined the results of 77 implants placed in 63 patients and followed for between 3 and 24 months. Initial primary stability was achieved for all implants, and reverse torque testing at 3 and 4 months postoperatively showed 76 of 77 implants (98.7%) to be successfully osseointegrated.

Endodontic microsurgery

The field of endodontics has seen vast improvements in technology and techniques over the past several years. Perhaps the one area of endodontics that has improved the most is the way in which surgery is performed. With the use of state-of-the-art instruments, new and improved materials, and a surgical operating microscope, the gap has narrowed between biological concepts and the ability to achieve consistently successful clinical results. The practice of these techniques is now referred to as endodontic microsurgery.

Early Loading of Interforaminal Implants Immediately Installed after Extraction of Teeth Presenting Endodontic and Periodontal Lesions

BACKGROUND

Infection in tooth extraction sites has traditionally been considered an indication to postpone implant insertion until the infection has been resolved.

PURPOSE

The aim of this study was to evaluate the survival rate of early-loaded implants placed immediately after extraction of teeth with endodontic and periodontal lesions in the mandible.

MATERIALS AND METHODS

Twenty patients in need of mandibular implant treatment and with teeth showing signs of infection in the interforaminal area were included in the study. The patients received four to six implants (Brånemark System, Nobel Biocare AB, Göteborg, Sweden) in or close to the fresh extraction sockets and received a provisional prosthesis within 3 days. Final prostheses were delivered after 3 to 12 months. The surgical protocol paid special attention to the preservation of high implant stability and control of the inflammatory response. The patients were followed up for 15 to 44 months.

RESULTS

No implants were lost, resulting in a 100% survival rate. A mean marginal bone loss of 0.7 mm (SD 1.2 mm) was registered during the observation period. No signs of infection around the implants were detected at any follow-up visit.

CONCLUSION

A high survival rate can be achieved for immediately placed and early-loaded implants in the mandible despite the presence of infection at the extracted teeth.

To extract or not to extract? Factors that affect individual tooth prognosis

A dentist evaluates a natural tooth for its quality of health. Once this is accomplished, the clinician obtains an estimate of longevity and decides whether to extract or to treat and maintain the tooth. There often are questions and doubts involved in the decision-making process in regard to the prognosis of an individual tooth. Unfortunately in dentistry, as in all biologic sciences, there are no straightforward answers to questions. This article will look at the literature in this area to help the practitioner in the decision-making process with regard to the compromised tooth. The article will concentrate on the single tooth or implant restoration. Other factors, such as the strategic value of a tooth and financial limitations in relation to long-term prognosis, will also be discussed.

Lasers in endodontics

With the rapid development of laser technology, new lasers with a wide range of characteristics are now available and being used in various fields of dentistry. In the past two decades, much experience and knowledge has been gained. This article provides an overview of the current and possible future clinical applications of lasers in endodontics, including their use in alleviating dentinal hypersensitivity, modification of the dentin structure, pulp diagnosis, pulp capping and pulpotomy, cleaning and shaping of the root canal system, and endodontic surgery. Endodontic procedures for which conventional treatments cannot provide comparable results or are less effective are emphasized.

Management of a hyperdivergent class III malocclusion, maxillary midline diastema, and infected mandibular incisors in a young adult

This is a case report of a 20-year-old woman with a hyperdivergent Class III malocclusion, infected mandibular incisors, maxillary midline diastema, and a mild tongue thrust. Extraction of the infected incisors and orthodontic treatment involving partial mesial movement of the remaining mandibular teeth produced a well-intercuspated Class III occlusion. After successful orthodontic treatment, a 4-unit bridge with pontics for the mandibular central incisors completed the rehabilitation and met the functional, esthetic, and occlusal treatment goals. Occlusal stability of the treatment result has been excellent in the 3-year follow-up.

Apicomarginal defects in periradicular surgery: classification and diagnostic aspects

The prognosis of periradicular surgery is affected by the amount and location of bone loss. Apicomarginal defects are localized bony defects encompassing the total root length, and periradicular surgery on these teeth is associated with a lower success rate. This paper reviews the etiology, pathogenesis, and morphology of apicomarginal defects as encountered in periradicular surgery on the basis of a series of 24 consecutively treated patients. Periodontal data were recorded before surgery in all patients, and apicomarginal defects were diagnosed after flap reflection or, if applicable, apicoectomy. On the basis of the findings in these cases and on theoretic considerations, a classification system for apicomarginal defects with potential therapeutic and prognostic implications is presented and several criteria for differential diagnosis are discussed.

The pulpectomy in primary teeth

BACKGROUND

The pulpectomy is an underutilized treatment modality for severely infected primary teeth.

CASE DESCRIPTION

The author presents two pulpectomy cases that were filled with Vitapex.

CLINICAL IMPLICATIONS

Vitapex is an excellent filling material for primary tooth pulpectomies. Its clinical characteristics and ease of use may make the pulpectomy procedure a more-attractive alternative to extraction.

Long-term follow-up of cases considered healed one year after apical microsurgery

A previous report demonstrated 96.8% healing within 1 yr after apical surgery was performed with the surgical operating microscope and Super-EBA as the root-end filling material. The purpose of this paper is to report on the long-term follow-up of those cases that were considered healed at the short term. Clinical examinations were made and radiographs were evaluated 5 to 7 yr after the case had first been considered healed. Criteria for determining healed cases were the same as those used in the first report. Of the 59 roots evaluated, 54 (91.5%) remained healed, whereas 5 (8.5%) showed evidence of apical deterioration.

Endodontic instruments for root canal therapy

This article on endodontic instrumentation includes endodontic instruments and techniques of root-canal preparation of teeth in veterinary patients. Familiarity with instruments covered in this article and with advances in veterinary endodontics has become necessary for the veterinary dental practitioner who wishes to practice dentistry using current techniques. Veterinary endodontic techniques that help to retain the teeth longer are increasing in demand as an option to extracting damaged teeth. Endodontic treatment involves removal of the irreversibly damaged pulp, followed by cleaning and shaping of the root canal space using endodontic instruments and subsequent filling, or obturation, with a semisolid material and a sealer.

Restorative procedures after root canal therapy

One of the most common indications for veterinary dental restoration involves replacing tooth structure after a root canal procedure. Special considerations are necessary due to the interaction of the restorative material with materials used to obturate the root canal. The restoration must provide a hermetic seal of the pulp chamber, as well as restore function. Combining several different restorative materials provides the best overall performance. In certain instances, full crown coverage is required to restore functional length or cervical anatomy.

Endodontic decisions based on radiographic appearance

Endodontic disease or disease that affects the internal portion of the tooth is a frequently encountered oral problem of the cat and dog. There are many etiologies that can cause the tooth's health and longevity to be adversely affected. Trauma, tooth malformations of either congenital or acquired origin, and bacterial periodontal ascending infections all can lead to pulpal inflammation, necrosis, and tooth death. One must correlate history, physical exam and radiographic impressions of the tooth, and its supporting structures and adjacent teeth in determining proper treatment options and aftercare. Based on extent, timing, and involvement of adjacent structures, resulting pathology of the tooth may be endodontically treated with either a vital pulpectomy, standard root-canal therapy, surgical root-canal therapy, or when the disease is too extensive by extraction. Through a case presentation, we will discuss some of the decisions that enter into the therapy used to treat presenting pathology. It is the authors' intent to present a thought process for deriving a treatment plan to promote healing. There are many ways to achieve this healing, and therefore, there is no right or wrong plan, but rather one that is based on all the presenting factors.

Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: a proposal of classification and literature review

Periradicular surgery has become an established treatment option in endodontic surgery. The major objective of this surgery is to obtain periradicular tissue regeneration, including the formation of a new attachment apparatus, by exclusion of any potentially noxious agent within the physical confines of the affected root. However, in a substantial number of cases, the endodontic lesion has a concomitant marginal periodontal lesion that may complicate the healing success. In periodontology, the guided tissue regeneration (GTR) principle using a barrier membrane has been extensively studied and successfully used, and thus may become an adjunct in endodontic surgery. This article presents a classification system of endodontic and periodontal lesions with respect to the application of the membrane technique and reviews the pertinent literature based upon this classification system.

Retrospective case series analysis of the factors determining immediate implant placement

Implant placement at the time of extraction has become an acceptable treatment option. The formation of a restorative treatment plan frequently requires the removal of questionable and hopeless teeth. This retrospective case series analysis reports the reasons for tooth removal before immediate implant placement and provides a rationale for removing questionable and hopeless teeth. Root length is also analyzed as related to tooth loss. Between September 1986 and December 1998, 460 teeth were removed from 282 patients. Reasons for removal were advanced periodontal disease, endodontic complications, nonrestorable caries, roots fractures, short roots (< 14 mm in length), root resorption, and loosened posts. Implants were placed at the time of extraction. Tallies, frequency distributions, and percentages were used to determine individual and multiple reasons for extraction. For teeth with short roots, computerized measurements were made from periapical x-rays. Advanced periodontal disease and restored endodontically treated teeth with posts were the primary reasons for tooth extraction. Dental implants replaced 305 maxillary and 155 mandibular teeth.

Applications for guided bone regeneration in endodontic surgery

Regeneration of apical bony defects remains a significant problem in endodontic surgery. When a resorbable membrane is placed over a defect, it acts as a barrier between the defect and the overlying gingival tissue. This barrier membrane provides sufficient time for bone to regenerate while preventing the faster growing connective tissue from invaginating into the area. When new tissue replicates the structure and function of the lost tissue, then apical regeneration has occurred.

Complications of dental surgery

Both retrospective data and clinical experience indicate that complications of dental surgery are occasionally encountered and, to some extent, are inevitable. Many of the reported complications related to dental surgery such as incomplete removal of diseased teeth or removal of the wrong tooth can be avoided with sound preoperative planning and intraoperative technique. Diseased teeth should be properly identified prior to and during surgery. In addition, complete removal of the diseased tooth must be performed. Use of intraoperative radiographic examination to confirm the location of the diseased tooth and to document its removal cannot be overemphasized. Iatrogenic fracture of the maxillary or mandibular alveolar walls or palatine bone can be avoided by proper placement of the dental punch. The chances of developing incisional drainage or secondary sinusitis can be reduced by use of appropriate systemic antibiotics. These factors should guide the surgical approach to dental surgery to reduce the likelihood of developing common complications.

The microscope. Its effect on your practice

A number of different areas in which the microscope can help you and your practice have been covered. The bottom-line success depends on you and your commitment. If you make an honest, sincere effort, you will find yourself rejuvenated, and your practice will become more successful and endodontics more enjoyable.

Relationship between apical and marginal healing in periradicular surgery

OBJECTIVE

The purpose of the present study was to evaluate the relationship between apical and marginal periodontal healing after periapical surgery.

STUDY DESIGN

The investigation was conducted on 59 patients referred for periradicular surgery. A radiographic examination as well as assessments of periodontal attachment and pocket depth of teeth undergoing surgery and control teeth were performed at the time of surgery and 1 year after surgery. The radiographic periapical healing pattern was evaluated.

RESULTS

After an observation time of 1 year, 85% of the healing patterns were classified as successful or uncertain. Teeth within the surgical area showed a significant loss of clinical attachment during the observation period. The mean clinical attachment loss in teeth with an unsuccessful healing was 0.85 mm and differed significantly from successfully healed cases (mean, 0.15 mm).

CONCLUSIONS

A persisting endodontic infection may be regarded as a contributing risk factor for a progressing marginal attachment loss.

A new approach to the treatment of true-combined endodontic-periodontic lesions by the guided tissue regeneration technique

Clinicians often have difficulty in the diagnosis and treatment of the combined endodontal and periodontal (endo-perio) lesion. A case of an endo-perio true-combined lesion on a maxillary premolar was first treated with conventional endodontic therapy. Periodontal surgery was then completed, which included scaling and root planing and apical curettage on the tooth. The facial bony defect was then filled with a decalcified freeze-dried bone allograft mixed with tetracycline powder. A non-resorbable Teflon membrane was then used to cover the bone material and the periodontal flap sutured over this. This combined treatment resulted in minimal probing depth (2 mm), maximal clinical attachment gain (8 mm), as well as radiographic evidence of alveolar bone gain. This case report demonstrates that proper diagnosis, followed by removal of etiological factors and utilizing the guided tissue regeneration technique combined with osseous grafting, will restore health and function to a tooth with severe attachment loss caused by an endo-perio lesion.

Endodontic retreatment. 1: Indications and case selection

Conventional root canal treatment, despite having a reportedly high success rate may not invariably lead to the desired healing response in clinical practice because of shortcomings in the treatment. This is the first of two articles on this subject, and will cover indications and case selection for root canal retreatment. Part 2 will discuss methods of retreatment.

A comparison of pulpectomy alone versus pulpectomy with trephination for the relief of pain

Patients who when initially seen have pain of endodontic origin have a higher incidence of posttreatment pain than those who are pain-free pretreatment. The purpose of this study was to compare two methods of treatment--pulpectomy alone or pulpectomy with trephination--for the reduction of posttreatment pain in patients presenting with acute periradicular pain of pulpal origin. Seventeen patients with pretreatment pain were studied. Eleven received a pulpectomy to the radiographically determined working length. Six patients received a pulpectomy and trephination using a #4 round bur through a vertical incision. Visual analog scales were used preoperatively to measure pain intensity and unpleasantness, and postoperatively to measure intensity, unpleasantness, and pain relief at 4, 8, 16, 24, 48, 72, and 96 h. Analysis of preoperative data showed no difference between control and experimental groups. Posttreatment, at 4 h, the trephination group reported significantly more pain intensity and unpleasantness and less pain relief than the control group. Pulpectomy alone provided significantly better postoperative pain relief at 4 h compared with pulpectomy with trephination. At no time interval did the trephination group have less pain than the group without trephination.

New directions in surgical endodontics; immediate implantation into an extraction site

Endodontic surgical procedures may reveal compromising factors that indicate a modification of the treatment (e.g. tooth extraction, root amputation, etc.). To take advantage of the osseous height and width, as well as the natural tooth angulation, immediate placement of implants after extraction is a reasonable alternative treatment. In this study, 32 titanium alloy implants were inserted immediately after extraction of teeth diagnosed during endodontic surgery as having root fractures, perforations, or endodontic-periodontal complications. After 4 to 6 months of osseointegration, only one implant failed to integrate, and the remaining implants were prosthetically restored. Sixteen months after occlusal loading, bone loss was approximately 1.5 mm for the 31 implants remaining. It seems that the immediate placement of implants following tooth extraction due to endodontic complications is a reliable procedure.

Multidisciplinary approach to apical surgery in conjunction with the loss of buccal cortical plate

The treatment of advanced periodontal breakdown as a result of an associated endodontic lesion continues to challenge the practitioner. Two cases of teeth with endodontic pathologic conditions that required apical surgery are presented. On raising the flap, no buccal cortical plate was found, significantly lowering the prognosis of the surgery. A barrier membrane was used in addition to the apical surgery, which on postoperative follow-up appears to have resulted in the reestablishment of the buccal cortical plate.

Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants

The hemostatic effect of tranexamic acid solution (4.8%) used as a mouthwash was compared with a placebo solution in 93 patients on continuous, unchanged, oral anticoagulant treatment undergoing oral surgery. The investigation was a randomized, double-blind, placebo-controlled, multicenter study. Before suturing, the surgically treated region was irrigated with 10 mL of tranexamic acid (46 patients) or placebo (47 patients) solution. The patients then performed mouthwash with 10 mL of the solution for 2 minutes four times daily for 7 days. The treatment groups were comparable regarding age, smoking habits, and surgery. Laboratory variables measuring vitamin K-dependent coagulation factors were within therapeutic ranges (international normalized ratio 4.00 to 2.10). One of the clinics used a different method for these measurements and therefore the levels of coagulation factor X in plasma obtained for the three clinics were compared. No significant difference in the range at which surgery was performed was found between clinics. In the placebo group, 10 patients developed bleeding requiring treatment, while none of the patients treated with tranexamic acid solution had bleeding. This difference was statistically significant (P < .01). The treatment with mouthwash was well tolerated. It was concluded that patients on oral anticoagulants can undergo oral surgery within the therapeutic range without reducing the dosage of anticoagulants, provided that local antifibrinolytic treatment with tranexamic acid solution is instituted.

Principles of endodontic therapy

Endodontics is that branch of dentistry concerned with the treatment of damaged or diseased dental pulp. Veterinarians are now being asked to preserve tooth function and structure rather than to extract injured or diseased teeth. A variety of instruments are available that facilitate endodontic treatment. Endodontic treatment involves preparation (filing), sterilization, and obturation (filling) of the pulp cavity. Properly performed, endodontic therapy can effectively preserve dental structure and function. Complications of endodontic therapy will be discussed in "Problem Solving in Veterinary Endodontics" on page 165 in this issue.

Use of dental operating microscope in endodontic surgery

Endodontic surgery is an alternative therapeutic approach to endodontic treatment. The outcome of the technique is affected by several factors, some of which can be eliminated by the use of a dental operating microscope. The microscope was used during the performance of 50 apicoectomies, with or without retrograde fillings. For clinical evaluation cases treated with the dental operating microscope were compared to cases treated without it. The postoperative evaluation showed a reduced incidence of symptoms in the cases treated with the dental operating microscope. More important, the dental operating microscope enhanced and facilitated each phase of endodontic surgery. Its use is highly recommended.

Electrosurgical pulpotomy: a retrospective human study

While the formocresol pulpotomy has enjoyed long-term clinical use and success, concerns over its toxicity and mutagenicity have prompted research into other pulpotomy techniques. The purpose of this study was to observe retrospectively the results of the electrosurgical pulpotomy technique used on primary molar teeth requiring pulp therapy, secondary to carious involvement. The mean age at the time of treatment was 5 years, 11 months and the mean postoperative observation time was 2 years, 3 months. Of the 164 teeth studied, 127 were normal at the last observation visit; 32 had undergone exfoliation; 4 had an abnormality associated with the pulpotomized tooth, but were not considered failures; and 1 was considered a failure. This is a 99.4 percent success rate. Compared to a formocresol pulpotomy study of similar design, the success rate for the electrosurgical pulpotomy procedure in this study is higher at the statistically significant level of p < 0.01.

Bacteriological investigation of infected root canals in Benin City, Nigeria

Possible viable bacteria were isolated and determined through culture based on paper point inoculation from infected root canals of 50 patients who presented for endodontic therapy at the school of Dentistry, University of Benin Teaching Hospital and Central Hospital, Benin City. Eighty-one strains of bacteria were isolated from 50 patients. The bacterial isolates were Streptococcus species, (51), Klebsiella species (17), E. coll (5), Staphylococcus aureus (3), Micrococcus species (2), Neisseria spp. (2) and Lactobacillus. The isolation of Klebsiella spp from the study is particularly interesting, constituting 21% of all the isolated bacteria. The implications of these findings in root canal infections are presented.

Surgical management of endodontically treated teeth

Surgical endodontics has become an important treatment modality in modern dentistry. The evolution and development of this modality has suffered from decades of empiricism, as techniques, concepts, and root-end filling materials were advocated without supporting scientific evidence. The techniques and concepts of periodontal surgery and oral and maxillofacial surgery were long assumed to directly apply to endodontic surgery. Evidence now suggests that certain procedures adopted from other specialties are not indicated for surgical endodontics and, in fact, may be counterproductive. During the past year, the most important developments have emerged in the area of surgical wound healing as it relates to soft tissue management procedures. New techniques and concepts that enhance rapid wound healing and decrease untoward postsurgical sequelae have been proposed.

Coronal access of the canine dentition

Access preparation for endodontic treatment should be very exact, and knowledge of the anatomy of the teeth is a very important requirement for success. The use of radiographs is indispensable and should be used throughout endodontic treatment. The purpose of this paper is to discuss and illustrate correct coronal access for endodontic treatment in regard to the anatomy of the endodontic system. The most common teeth that require endodontic treatment are the canines, fourth maxillary premolars, first mandibular molars, incisors, and then the remaining premolars and molars. Special emphasis will be placed on coronal access of the canine, carnassial and incisor dentition.

Comparative obturation techniques in the canine

Recent technological advances have created new approaches and techniques in endodontics while enhancing traditional criteria. The goal of this article is to present the best aspect of current techniques and materials to enable the practitioner to achieve success in the clinical practice of root canal therapy.