Pulpal Morphology. Raney J. Deschenes, DMD, MS Pauline Hayes-Garrett, DDS. Contributing Efforts by:

Transcription

1 Pulpal Morphology Contributing Efforts by: Raney J. Deschenes, DMD, MS Pauline Hayes-Garrett, DDS Department of Endodontics, Prosthodontics, and Operative Dentistry University of Maryland, Baltimore

2 This material is taken from: Dental Anatomy and Occlusion, Wheeler, Ninth Ed., The W. B. Sanders Company,2003. Chapter 13 Oral Histology and Embryology, second edition, Gartner, 1999 with permission from Dr. Leslie P. Gartner Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Endodontics: Priciples and Practice, Torabinejad, Walton and Fouad, 5 th Ed., Elsevier Saunders, 2015

3 Assignment Dental Anatomy and Occlusion, Wheeler, Ninth Ed., The W. B. Sanders Company,2003. Chapter 13 responsible for the statistics in this text only.

4 PULP ANATOMY AND MORPHOLOGY Definitions: Pulp tissue: soft connective tissue found in the central portion of the tooth, surrounded by dentin. The primary purpose of the pulp is to form tooth structure Pulp Cavity: the entire central cavity of the tooth, both root and crown, which contains the pulp tissue during the life of the pulp. Pulp Chamber: portion of the pulp cavity which is located in the anatomic crown of the tooth Pulp Horn(s): occlusal projection of the pulp which is located in the anatomic crown of the tooth Apical Foramen: constriction openings at or near the root apex through which the main nutrient and nervous supply to the pulp enter and exit

5 The Dental Pulp Longitudinal section of a mandibular permanent molar Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

6 PULP FUNCTIONS Induction: The pulp participates in the induction and development of odontoblasts and dentin Formation: odontoblasts form dentin Nutrition of dentin: circulatory system via dentinal tubules, nutrients and hydration Innervation of the tooth: myelinated and unmyelinated fibers provide sensation Defense: reparative dentin and inflammatory and immunological responses

7 Structure of the pulp Longitudinal section of an incisor, demonstrating the structure of the pulp Illustration reprinted and modified from: Oral Histology and Embryology, second edition, Gartner, 1999 pg. 46. with permission from Dr. Leslie P. Gartner

8 Zones of the pulp Light micrographs of a decalcified human molar

9 Zones of the Pulp Dentin Cell-free zone (of Weil) Cell-rich zone Odontoblastic layer Predentin Courtesy: Dr. Ashraf Fouad

10 Zones of the pulp Odontoblastic, cell poor and cell rich zones of the pulp. Note that nerve fibers from Raschkow s plexus extend into the dentinal tubules Illustration reprinted and modified from: Oral Histology and Embryology, second edition, Gartner, 1999 pg. 46. with permission from Dr. Leslie P. Gartner

11 Dentin Inner Third Courtesy: Dr. Gary Hack

12 Sensory Types of Pulpal Nerves Afferents of Cranial Nerve V Transmit Pulpal Sensation Effectors on Arterioles, Capillaries, Veins Neuropeptides: (neurogenic inflammation) CGRP Vasodilation Substance P Plasma Extravasation Sympathetic Superior Cervical Ganglion Control Arteriolar Smooth Muscle Parasympathetic (none)

13 Innervation of the Pulp Sensory axons (afferent): myelinated A (1-6 m), predominant Brief, sharp well-localized pain associated with dentin sensitivity located in the periphery A (6-12 m), small percentage Located near apex, deal mainly with proprioception unmyelinated A and A after branching off Plexus of Raschkow C fibers (< 1 m), mainly in pulp core Dull, burning ache, poorly localized, EPT tests nerve response

14 Dentinal Sensitivity A: Dentin innervation B: Transduction through odontoblastic process C: Hydrodynamic theory Adapted From: Torneck C. in Ten Cate, AR. Oral histology development, structure, and function. Fourth Edition, Mosby. P. 209.

15 Innervation of the pulpal layer of dentin (only in pulpal um) nerves odontoblastic process From: Holland G.R., J Dent Res 1985; 64 (spec iss):512

16 Mechanism of Dentin Hypersensitivity Enamel/ cementum Courtesy: Dr. Ashraf Fouad

17 Increased permeability Mechanism of Dentin Hypersensitivity Courtesy: Dr. Ashraf Fouad

18 Dentin Innervation only about um into dentin (Autoradiographic evidence) Byers & Dong, Anat Rec 1983

19 Innervation of the Pulp All teeth are innervated by branches of the Trigeminal nerve (Cranial V) Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

20 Innervation of the Pulp Second & third maxillary molars and P &DB roots of maxillary first molar: Posterior superior alveolar nerve MB root of maxillary first molar and maxillary premolars: Middle superior alveolar nerve Maxillary anterior teeth: anterior superior alveolar nerve Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

21 Innervation of the Pulp All mandibular teeth: Inferior alveolar nerve V3 Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

22 Pulpal blood supply - Arterioles - Venules - Anastomoses - Capillaries - U-turns From: Kim S, J Endod 1985; 11(11): 466..

23 Arterial Supply All teeth are supplied by branches of the Maxillary artery: Posterior superior alveolar artery supplies all maxillary posterior teeth Anterior superior alveolar artery( branch of infraorbital artery) supplies maxillary anterior teeth Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

24 Arterial Supply Inferior alveolar artery supplies all mandibular teeth( note the branching of the mental artery) Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

25 Arterial Supply Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

26 Pulpal Lymphatics Lymph vessels (arrows) in feline dental pulp. (From Bishop MA, Malhorta M; Am J Anat 1990; 187:249

27 Lymph Drainage All mandibular incisors drain into the submental lymph nodes All maxillary teeth(except third molars), the mandibular canines and all lower posterior teeth (except third molar) drain into the submandibular lymph nodes Maxillary and mandibular third molars drain into the upper deep cervical nodes Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

28 Venous Drainage All teeth drain into the facial vein Reprinted from: Atlas of Human Anatomy, Frank H. Netter, Third Edition, Icon Learning Systems, Teterboro, New Jersey, Plate 51.

29 Venous Drainage and Cavernous sinus

30 PUPAL MORPHOLOGY Why study tooth morphology? The hard tissue repository of the human dental pulp takes on many configurations that must be understood before treatment begins. R. Burns, E Herbranson Chap. 7 Pathways of the pulp. 7 th Edition 1998

31 PUPAL MORPHOLOGY Why study tooth morphology? The hard tissue repository of the human dental pulp takes on many configurations that must be understood before treatment begins. R. Burns, E Herbranson Chap. 7 Pathways of the pulp. 7 th Edition 1998 The hard tissue surrounding the dental pulp can take a variety of configuration and shapes. A thorough knowledge of tooth morphology are prerequisites for treatment. F. Vertucci, J. Haddix Chap. 7 Pathways of the Pulp. 10th Edition, 2011

32 MORPHOLOGICAL STUDIES Macroscopic /microscopic sectioning studies. Microscopic sectioning study remains the gold standard when comparing other methods for identification of the RCS in morphologic studies.

33 MORPHOLOGICAL STUDIES Filling and clearing studies Hess, 1925 Vertucci, 2005

34 MORPHOLOGICAL STUDIES Radiography and more recent CBCT/Volumetric Imaging studies and uct studies. 3-D Tooth Atlas Harris et al, 2013

35 MORPHOLOGICAL STUDIES Data and Statistics

36 Assembled Data: Morphology Chart Johnson B, Endodontic access. J Acad Gen Dent 2009; 57(6):

37

38 NOTE: MB = MB1, MP = MB2

39 Maxillary Central Incisor %: One canal Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. 339, with permission from Elsevier.

40 98-100%: One canal Maxillary Central Incisor Illustration from Endodontics: Principle and Practice 5 th Ed.

41 Maxillary Lateral Incisor %: One canal Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.341, with permission from Elsevier.

42 Maxillary Lateral Incisor %: One canal Illustration from Endodontics: Principle and Practice 5 th Ed

43 Maxillary Incisor Central Incisor Lateral Incisor

44 Maxillary Canine %: One canal Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.343, with permission from Elsevier.

45 98-100%: One canal Maxillary Canine Illustration from Endodontics: Principle and Practice 5 th Ed

46 MAXILLARY ANTERIORS

47 SECONDARY ANATOMY Accessory/lateral canal occur 73.5% in the apical third, 11.4% in the middle third and 6.3% in the cervical third of the root Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984: 58:

48 CLASSIFICATION OF ROOT CANAL SYSTEM Weine s Classification Type 1: 1 orifice/ 1 canal/ 1 foramen Type 2: 2 orifices/ 2 canals/ 1 foramen Type 3: 2 orifices/ 2 canals/ 2 foramina Type 4: 1 orifice/ 2 canals/ 2 foramina

49 Weine s Classification CLASSIFICATION OF ROOT CANAL SYSTEM Vertucci s Classification

50 ANGLED RADIOGRAPHS Martinez-Lozano MA, Forner-Navarro L, Sanchez-Cortez JL. Analysis of radiologic factors in determining premolar root canal systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999: 88:

51 BUCCAL OBJECT RULE Richards, AG. The Buccal Object Rule. Dental Radiography & Photography, Vol 53, No. 3, 1980 (published by Eastman Kodak Co.)

52 Maxillary First Premolar 1 root, 1 canal: 9% 1 root, 2 canals, 1 foramen: 13% 1 root, 2 canals, 2 foramina: 15% 2 roots, 2 canals: 57% 3 roots, 3 canals: 6% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.344, with permission from Elsevier.

53 Maxillary First Premolar 1 root, 1 canal: 9% 1 root, 2 canals, 1 foramen: 13% 1 root, 2 canals, 2 foramina: 15% 2 roots, 2 canals: 57% 3 roots, 3 canals: 6% Illustration from Endodontics: Principle and Practice 5 th Ed

54 Maxillary First Premolar One canal - 9% One root - 37% Carns EJ, Skidmore AE. Configuration and deviation of root canal of maxillary first premolars. Oral Surg 1973;36:880-6.

55 Maxillary First Premolar Two canals 85%, Two roots 57% One root 28% Carns EJ, Skidmore AE. Configuration and deviation of root canal of maxillary first premolars. Oral Surg 1973;36:880-6.

56 Maxillary First Premolar Three canals 6% Three roots 6% Carns EJ, Skidmore AE. Configuration and deviation of root canal of maxillary first premolars. Oral Surg 1973;36:880-6.

57 Maxillary Second Premolar 1 canal: 50-65% 2 separate canals: 35-50% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.346, with permission from Elsevier.

58 Maxillary Second Premolar 1 canal: 50-65% 2 separate canals: 35-50% Weine Type III or Vertucci Type 6 Type IV Type II Type 1 Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.346, with permission from Elsevier.

59 Maxillary Second Premolar 1 canal: 50-65% 2 separate canals: 35-50% Illustration from Endodontics: Principle and Practice 5 th Ed

60 Maxillary Second Premolar One canal 48% Two canals/one foramen 27% Two canals/two foramina 24% Three canals 1% Vertucci FJ, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar. Oral Surg 1974; 38:

61 Maxillary Second Premolar One canal 48% Two canals/one foramen 27% Two canals/two foramina 24% Three canals 1% Vertucci FJ, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar. Oral Surg 1974; 38:

62 Maxillary First Molar 3 roots, 4 canals: 59%, in 19% of the cases, MB and ML (MB2)canals have separate foramina 3 roots, 3 canals: 41% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.348, with permission from Elsevier.

63 Maxillary First Molar Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.348, with permission from Elsevier.

64 Maxillary First Molar 3 roots, 4 canals: 59%, in 19% of the cases, MB and ML (MB2)canals have separate foramina 3 roots, 3 canals: 41% Illustration from Endodontics: Principle and Practice 5 th Ed

65 Maxillary Second Molar 3 roots, 3 canals: 60% 2 roots, 2 canals: 13% 2 roots, 2 canals: 12% 1 root, 1 canal: 10% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.350, with permission from Elsevier.

66 Maxillary Second Molar 3 roots, 3 canals: 60% 2 roots, 2 canals: 13% 2 roots, 2 canals: 12% 1 root, 1 canal: 10% Illustration from Endodontics: Principle and Practice 5 th Ed

67 Maxillary Second Molar 3 roots, 3 canals: 60% 2 roots, 3 canals: 13% 2 roots, 2 canals: 12% 1 root, 1 canal: 10% Illustration from Endodontics: Principle and Practice 5 th Ed

68 MAXILLARY MOLARS Variations of the MB Root Type 1 4.8% (no MB2) Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod 1990;16:

69 MAXILLARY MOLARS Variations of the MB Root Type 2 49% Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod 1990;16:

70 MAXILLARY MOLARS Variations of the MB Root Type % Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod 1990;16:

71 Maxillary Third Molar Illustration reprinted from:wheele r s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.353, with permission from Elsevier.

72 Mandibular Central Incisor 1 canal: 70% 2 canals which join: 25% 2 canals, 2 foramina: 5% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.354, with permission from Elsevier.

73 Mandibular Central Incisor 1 canal: 70% 2 canals which join: 25% 2 canals, 2 foramina: 5% Illustration from Endodontics: Principle and Practice 5 th Ed

74 Mandibular Incisor The lingual canal is the one most often overlooked

75 Mandibular Central Incisor Mandibular central incisor with 2 canals Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. with permission from Elsevier.

76 Mandibular Lateral Incisor 1 canal: 56% 2 canals which join: 30% 2 canals, 2 foramina: 15% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. 356,with permission from Elsevier.

77 MANDIBULAR INCISORS One canal/one foramen % Two canals 41.4%, Type %, Type 3 1.3% Benjamin KA, Dowson J. Incidence of two root canals in human mandibular incisor teeth. Oral Surg 1974; 34:

78 MANDIBULAR INCISORS One canal/one foramen % Two canals 41.4%, Type %, Type 3 1.3% Benjamin KA, Dowson J. Incidence of two root canals in human mandibular incisor teeth. Oral Surg 1974; 34:

79 Mandibular Canine 1 canal: 70% 2 canals which join: 15% 2 canals, 2 foramina: 15% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.357, with permission from Elsevier.

80 Mandibular Canine 1 canal: 70% 2 canals which join: 15% 2 canals, 2 foramina: 15% Illustration from Endodontics: Principle and Practice 5 th Ed

81 Mandibular First Premolar 1 canal: 75% 2 canals 24% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.359 with permission from Elsevier.

82 Mandibular First Premolar 1 canal: 75% 2 canals 24% Illustration from Endodontics: Principle and Practice 5 th Ed

83 Mandibular First Premolar First Premolar: One canal 75%, Two canals 24%, Three canals 1% Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc 1978; 97:47-50.

84 Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc 1978; 97: Mandibular First Premolar First Premolar: Second canal may sharply project off primary canal to the lingual: an h-shaped configuration (Weine Type 4)

85 Mandibular Second Premolar 1 canal: 85% 2 canals: 10% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. 361,with permission from Elsevier.

86 Mandibular Second Premolar 1 canal: 85% 2 canals: 10% Illustration from Endodontics: Principle and Practice 5 th Ed

87 Mandibular Second Premolar Second Premolar: One canal 97.5%, Two canals 2.5% Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc 1978; 97:47-50.

88 Mandibular First Molar 2 roots: 98% 3 roots: 2% Mesial root: 2canals 93%(separate foramina 60%), 1 canal 7% Distal root: 2 canals 29% (separate formina 39%), 1 canal 71% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.362, with permission from Elsevier.

89 Mandibular First Molar 2 roots: 98% 3 roots: 2%(radix entomolaris) Mesial root: 2canals 93%(separate foramina 60%), 1 canal 7% Distal root: 2 canals 29% (separate formina 39%), 1 canal 71% Illustration from Endodontics: Principle and Practice 5 th Ed

90 Mandibular First Molar Two canals 7%, Three canals 64%, Four canals 29% Mesial canals: Type 2 40%, Type 3 60% Distal canals: Type 2 60%, Type 3 40% Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar. Oral Surg 1971; 32:

91 Mandibular First Molar 3 roots: Radix Entomolaris Less than 5% in most populations Higher than 5% in populations with Mongolian traits Calberson FL, De Moor RJ, Deroose CA. The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics. J Endod 2007; 33:

92 Mandibular First Molar 3 roots: Radix Entomolaris Less than 5% in most populations Higher than 5% in populations with Mongolian traits Calberson FL, De Moor RJ, Deroose CA. The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics. J Endod 2007; 33: Illustration from Endodontics: Principle and Practice 5 th Ed

93 Mandibular First Molar 3 roots: Radix Entomolaris Less than 5% in most populations Higher than 5% in populations with Mongolian traits Calberson FL, De Moor RJ, Deroose CA. The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics. J Endod 2007; 33:

94 Mandibular second Molar 4 canals: 7% 3 canals: 67% 2 canals: 25% Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.365, with permission from Elsevier.

95 Mandibular second Molar 4 canals: 7% 3 canals: 67% 2 canals: 25% Illustration from Endodontics: Principle and Practice 5 th Ed

96 One Canal 1.3%, Two Canals 4.0%, Three Canals 81%, Four Canals 11.0%, C-shaped canal 2.7% Mandibular Second Molar Weine FS, Pasiewicz RA, Rice RT. Canal configuration of the mandibular second molar using a clinically oriented in vitro method. J Endod 1988; 14:

97 Mandibular Second Molar C-shaped canal: 2.7% Weine FS, Pasiewicz RA, Rice RT. Canal configuration of the mandibular second molar using a clinically oriented in vitro method. J Endod 1988; 14: Illustration from Endodontics: Principle and Practice 5 th Ed

98 Mandibular Second Molar C-shaped canal 2.7% Weine FS, Pasiewicz RA, Rice RT. Canal configuration of the mandibular second molar using a clinically oriented in vitro method. J Endod 1988; 14:

99 Mandibular Third Molar Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg.368, with permission from Elsevier.

100 Aging of the pulp Illustration reprinted from:whee ler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. with permission from Elsevier. Large pulp cavity in a young adult

101 Aging of the Pulp Deposition of dentin and smaller pulp space with age is a physiological process Illustration reprinted from:wheeler s Dental Anatomy, Physiology and Occlusion, Ash, Eighth Edition, Saunders, pg. with permission from Elsevier.

102 Age Changes in the Dentin-Pulp Complex Dentin: Pulp: Decrease in diameter of tubules Decrease in permeability Increase in sclerotic dentin Decrease in size, cell #'s, vascularity and innervation Increase in collagen and calcifications

103 Age Changes in the Dentin- Pulp Complex Section of tooth from an older individual showing Reduced cellular content, increased fibrosis, resorption (lacunae) and calcification Courtesy: Dr. Ashraf Fouad

104 Pulp Calcifications Mild Significant Courtesy: Dr. Ashraf Fouad

105 Questions?