Patient has deep caries he want to restore it with esthetic restoration what suitable base give STRENGTH to restoration:
1- Calcium hydroxide.
2- Zinc phosphate.
3- GI***
Calcium hydroxide has become today a polyvalent medication characterized by a broad field of indications so that the practitioner who introduces it into his therapeutic arsenal does not know how to do without it anymore. If the effectiveness of endodontic treatment is based on the quality of shaping and canal trimming with sodium hypochlorite, a number of clinical situations require the setting up of a temporary intradermal medication. Calcium hydroxide by its proven therapeutic properties and a recognized biocompatibility character has become an essential product in modern endodontics. As a temporary medication, it helps cleanse the endodont and periapical area, thus optimizing tissue healing.
Material properties and usage protocols
Calcium hydroxide Ca (OH) 2 is obtained from hydrated quicklime and is in the form of a fine white powder. It has a radio-opacity close to that of the dentine, so that a closed channel no longer appears visible on the radiogram. In contact with atmospheric air, it slowly transforms into CaCO3 calcium carbonate. In fact it has been verified that calcium hydroxide, when stored in the absence of air, has excellent stability.
It recognizes several biological properties that fit perfectly into the overall strategy of endodontic treatment.
An antiseptic action:
The strongly alkaline nature of this product renders the medium unfit for bacterial life, since practically no microorganism can survive at pH above 9.5. The gradual and sustained release of Ca ++ and OH- ions contributes to the disinfection of the pulp cavity and the apical periodontium.
An anti-inflammatory action:
The alkaline character of the material, associated with the diffusion of Ca ++ and OH- ions, counteracts the action of osteoclasts by opposing acidosis. This results in a reduction of the inflammation, accompanied by the inhibition of the bone dissolution, this without irritation of the periapical tissues. (TRONSTADT, ANDREASEN).
An anti-exudative action:
The anabolic effect of calcium hydroxide on periapical tissues helps fight serosities and exudates, in the treatment of necrotic teeth. It should also be noted the anti-haemorrhagic action, calcium being one of the factors of blood coagulation.
Osteoinductive activity:
Although Ca + ion calcium hydroxide does not participate directly in the development of hard tissue, the aggressive nature of this biomaterial, cytotoxic in contact with living cells, stimulates the biological processes of repair and neoformation of mineralized tissue .
Depending on the clinical situations and the therapeutic objectives expected, different intervention strategies can be envisaged. A ready-to-use preparation or a master preparation will be chosen, a fluid material will be injected or a compact material rich in Ca (OH) 2 will be condensed.
Commercial preparations:
These products, ergonomic and practical use, are packaged in syringes, carpules or compules. They are used very easily, in fluid consistency, when one seeks only to put in the canal temporary antiseptic medication of short duration (1-2 weeks).
Extemporaneous master preparations:
Performed at the time of the intervention starting from pure powder of calcium hydroxide and sterile physiological serum, their consistency adapts to the clinical situation encountered: fluid mixture to be used with the wadding in temporary medication routine or in the fine channels, or thick paste, more concentrated in calcium hydroxide, so more efficient, to use in vertical condensation in the channel, in cases where the development of a mineralized scar tissue is required. After temporary routine medication between two sessions and in the presence of an asymptomatic canal ready to be closed, we proceed to the definitive ductal filling with gutta percha taking care to remove all the temporary medication, irrigated at sodium hypochlorite (CIONA) and dried the channel. In other cases (in particular for apexogenesis or apexification), the renewal sequence will take into account the degree of evolution of the lesion, the gradual dissolution of the material and the demonstration of healing phenomena.
Calcium hydroxide has become today a polyvalent medication characterized by a broad field of indications so that the practitioner who introduces it into his therapeutic arsenal does not know how to do without it anymore. If the effectiveness of endodontic treatment is based on the quality of shaping and canal trimming with sodium hypochlorite, a number of clinical situations require the setting up of a temporary intradermal medication. Calcium hydroxide by its proven therapeutic properties and a recognized biocompatibility character has become an essential product in modern endodontics. As a temporary medication, it helps cleanse the endodont and periapical area, thus optimizing tissue healing.
Material properties and usage protocols
Calcium hydroxide Ca (OH) 2 is obtained from hydrated quicklime and is in the form of a fine white powder. It has a radio-opacity close to that of the dentine, so that a closed channel no longer appears visible on the radiogram. In contact with atmospheric air, it slowly transforms into CaCO3 calcium carbonate. In fact it has been verified that calcium hydroxide, when stored in the absence of air, has excellent stability.
It recognizes several biological properties that fit perfectly into the overall strategy of endodontic treatment.
An antiseptic action:
The strongly alkaline nature of this product renders the medium unfit for bacterial life, since practically no microorganism can survive at pH above 9.5. The gradual and sustained release of Ca ++ and OH- ions contributes to the disinfection of the pulp cavity and the apical periodontium.
An anti-inflammatory action:
The alkaline character of the material, associated with the diffusion of Ca ++ and OH- ions, counteracts the action of osteoclasts by opposing acidosis. This results in a reduction of the inflammation, accompanied by the inhibition of the bone dissolution, this without irritation of the periapical tissues. (TRONSTADT, ANDREASEN).
An anti-exudative action:
The anabolic effect of calcium hydroxide on periapical tissues helps fight serosities and exudates, in the treatment of necrotic teeth. It should also be noted the anti-haemorrhagic action, calcium being one of the factors of blood coagulation.
Osteoinductive activity:
Although Ca + ion calcium hydroxide does not participate directly in the development of hard tissue, the aggressive nature of this biomaterial, cytotoxic in contact with living cells, stimulates the biological processes of repair and neoformation of mineralized tissue .
Depending on the clinical situations and the therapeutic objectives expected, different intervention strategies can be envisaged. A ready-to-use preparation or a master preparation will be chosen, a fluid material will be injected or a compact material rich in Ca (OH) 2 will be condensed.
Commercial preparations:
These products, ergonomic and practical use, are packaged in syringes, carpules or compules. They are used very easily, in fluid consistency, when one seeks only to put in the canal temporary antiseptic medication of short duration (1-2 weeks).
Extemporaneous master preparations:
Performed at the time of the intervention starting from pure powder of calcium hydroxide and sterile physiological serum, their consistency adapts to the clinical situation encountered: fluid mixture to be used with the wadding in temporary medication routine or in the fine channels, or thick paste, more concentrated in calcium hydroxide, so more efficient, to use in vertical condensation in the channel, in cases where the development of a mineralized scar tissue is required. After temporary routine medication between two sessions and in the presence of an asymptomatic canal ready to be closed, we proceed to the definitive ductal filling with gutta percha taking care to remove all the temporary medication, irrigated at sodium hypochlorite (CIONA) and dried the channel. In other cases (in particular for apexogenesis or apexification), the renewal sequence will take into account the degree of evolution of the lesion, the gradual dissolution of the material and the demonstration of healing phenomena.
Scope and use in endodontics:
The most frequent situations: emergency treatment, routine temporary medication in Endodontics, periapical lesions, more delicate situations such as the treatment of perforations, fractures or root resorptions treatment of immature teeth, various intervention strategies are presented.
Firstly, calcium hydroxide is used in routine intracerebral temporary medication if the endodontic treatment could not be completed (whether the pulp was infected or not). After debridement and trimming, the therapeutic objectives pursued are twofold: to prevent the bacterial development and to continue the antiseptic action in the badly or non-instrumented zones because of a complicated canal anatomy. The haemostatic action of the material is exploited in the case of haemorrhagic pulpitis and its drying action allows the control of exudates from periapical pathology.
In long-term medication, in the presence of large periapical lesion or in the treatment of immature teeth, it will no longer be injected but stepped into a prepared canal. As soon as it is partially dissolved, renewal sequences will lead to obtaining an apical mineral barrier allowing compacted gutta to sit.
In cases of perforation of the pulpal floor, it may be the drug of last resort to preserve the tooth, allowing the drying and disinfection of the orifice before its closure at Super E.B.A.8 in a later session.
For the treatment of horizontal root fractures, the fragments of which are not disjoint, the renewal of calcium hydroxide over several months induces the formation of an osteocemental callus. If the fragments are disjoint, apexification treatment of the coronary part can be considered before closing the canal with gutta and extracting the apical fragment.
In the case of internal resorption, the presence of abundant bleeding associated with dentinal crypts difficult to debride, make unavoidable the use of Ca (OH) 2 associated with a careful irrigation CIONA conveyed by ultrasonic waves.
As for the external resorptions, more difficult to control and of uncertain prognosis, one carries out after biopulpectomy, renewals of Ca (OH), dense so that its diffusion in the dentinal tubuli can stop the evolution of the phenomenon.
To use the material well is also to know its potential disadvantages. In particular, it should be kept in mind that incomplete removal of the material from the root canal can disturb the adjustment of the master cone and cause accelerated setting of eugenol zinc oxide channel cement. Finally, treatments including Ca (OH) 2 renewals over several months require motivated and regular patients. These constraints may be able to disappear with the development of M.T.A. (Mineral Trioxide Aggregate) which although still experimental seems to be promising for the one-time treatment of perforations or apexification cases.
Scope and use in pediatric odontology:
Calcium hydroxide was first recommended as a pulp capping material, then in the 1960s and 1970s (FRANK, CVEK, ANDREASEN), also in the treatment of immature tooth trauma, in the management of apexogenesis and apexification. If certain clinical results are there to show us its merits in the treatment of immature permanent tooth, some therapeutic failures remind us that the mechanisms of its action are still poorly understood. We must analyze the diversity of pathological situations: in the presence of a conjunctive wound during traumatic pulpal exposure, with low bacterial contamination or complications of dislocation of an immature tooth with pulpal necrosis and bone involvement; the material will not be exposed to the same environment, the same cellular processes. The question or questions we are asked are those of the confrontation of the material with the biological complexity. The choice of this material on the temporary tooth is limited by the difficulty of diagnosis of pulpal vitality, anatomical conditions, the feasibility of certain procedures in the very young child. Precise indications, especially in the treatment of pulpal necrosis, can however be considered.
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