|Year : 2021 | Volume
| Issue : 1 | Page : 79-84
Evaluation of the average pulp cavity volume of primary second molar and canine for obturation of a single primary tooth: A preliminary cone-beam computed tomographic study
Ritesh Kalaskar1, Sudhindra Baliga2, Shruti Balasubramanian1
1 Departments of Pediatric & Preventive Dentistry, Government Dental College & Hospital, Nagpur, Maharashtra, India
2 Preventive Dentistry, Sharad Pawar Dental College & Hospital, Wardha, Maharashtra, India
|Date of Submission||10-Nov-2020|
|Date of Acceptance||02-Apr-2021|
|Date of Web Publication||22-Apr-2021|
Dr. Ritesh Kalaskar
Government Dental College and Hospital, Medical College Premises, Medical Square, Nagpur - 440 003, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Metapex/Vitapex is one of the most commonly used obturating materials in pediatric dental practice in recent times. It is available in a premixed syringe which poses numerous practical difficulties. This study aimed to calculate the root canal volume of maxillary and mandibular canine and second molar using cone-beam computed tomography (CBCT) to determine the quantity/grams of obturation material to obturate a single tooth (mass = density × volume). Materials and Method: This nonrandomized clinical trial is comprised of two parts. The first part involved calculation of average root canal volume using CBCT which was used to calculate the quantity/grams of obturating material. This predetermined quantity was used to obturate primary mandibular second molars and canines, and the quality of obturation was assessed. Results: Assessment of quality of obturation showed optimum length obturation in 53.33% primary second molars and 66.66% primary canines. Conclusion: It can be inferred that even with the use of exact predetermined quantity/grams of obturating material, optimum quality obturation could be achieved, thus avoiding wastage, preventing cross contamination, and simultaneously offering good clinical results. Hence, this study opens further gateways to device ampules containing predetermined mass of obturating material for a single use for obturation of a single primary tooth.
Keywords: Obturation, predetermined quantity, primary teeth, pulp cavity volume
|How to cite this article:|
Kalaskar R, Baliga S, Balasubramanian S. Evaluation of the average pulp cavity volume of primary second molar and canine for obturation of a single primary tooth: A preliminary cone-beam computed tomographic study. J Indian Soc Pedod Prev Dent 2021;39:79-84
|How to cite this URL:|
Kalaskar R, Baliga S, Balasubramanian S. Evaluation of the average pulp cavity volume of primary second molar and canine for obturation of a single primary tooth: A preliminary cone-beam computed tomographic study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Jun 21];39:79-84. Available from: https://www.jisppd.com/text.asp?2021/39/1/79/314365
| Introduction|| |
Pulpectomy is the most commonly undertaken endodontic treatment modality for preservation of primary teeth which are essential for guidance and eruption of permanent teeth. The prognosis of pulpectomy is known to depend on many variables, one of them being the technique and quality of obturation. With the advent of newer materials for obturation, various innovative obturation techniques have also been described in the literature. These include incremental filling technique, lentulospiral technique, syringe techniques such as mechanical syringe, endodontic pressure syringe, tuberculin syringe, insulin syringe, local anesthetic syringe, and NaviTip syringe.
Metapex/Vitapex (Calcium hydroxide-iodoform mixture) has been extensively used extensively in pediatric dentistry due to its antibacterial and periapical healing properties., They are commercially available in a standardized premixed syringe with disposable tips for obturation of multiple teeth. These premixed syringes pose numerous disadvantages which include wastage of material leading to increased expense, chances of overextension of material, and risk of cross contamination. Furthermore, the thickness of needle and lack of flexibility causes difficulty in the material to reach the apex which prompts the practitioner to take repeated radiographs. Besides this, the needle phobia of premixed syringe form contributes to disrupting patient's cooperation.
To overcome these shortcomings, a custom-made ampule with predetermined quantity/grams of material for obturating a single tooth can be devised as an alternative. Before this in order to predetermine the quantity/grams of obturating material to obturate a single primary tooth, the knowledge of average root canal volume of both primary anterior and posterior teeth is necessary to enable calculation of quantity/grams of material required (mass = density × volume).
Therefore, this preliminary study was planned to calculate the root canal volume of maxillary and mandibular canine and second molar using cone-beam computed tomography (CBCT) followed by obturation of a single primary tooth using predetermined quantity/grams of obturating material.
| Materials and Methods|| |
After obtaining the approval from the institutional ethics committee, the study was conducted in two parts: The first part involved calculation of the average root canal volume using CBCT and the second part involved obturation of mandibular primary canines and second molars using predetermined quantity/grams of obturation material (Vitapex).
Part 1: Calculation of average root canal volume using cone-beam computed tomography
This part primarily focused on calculation of average root canal volume using existing CBCT scans of 5–9-year-old children. Scans showing deciduous maxillary and mandibular canines and second molars without periapical pathology and internal and external resorption were included. The sample size was estimated to be 30 based on the pilot analysis using an online Epi Info sample size calculator (Centers for Disease Control and Prevention version 3.01). The average root canal volume of maxillary and mandibular primary canine (63 and 73) and maxillary and mandibular second molar (65 and 75) was calculated in the sagittal section of Planmeca Romexis 5.2.0.R software (Planmeca Oy, Helsinki, Finland). The root canal volume of maxillary and mandibular canine was measured using the ellipsoid tool where the region of interest was selected. Following this, using the three-dimensional (3D) region growing tool and by selecting the root cavity option, the exact area was shaded [Figure 1]a and [Figure 1]b. For calculation of average root canal volume of primary maxillary and mandibular second molars, the sagittal section was divided into 9 sections (3 × 3) of 0.4 mm thickness each. Then, using the manual segmentation tool, the entire root canal was delineated in all the sections in which the tooth of interest was visible [Figure 2]a, [Figure 2]b and [Figure 3]a, [Figure 3]b. The resultant average root canal volume was obtained in cm3. Using this root canal volume and density of Metapex (2.07 g/cm3), the mass required for obturation of a single primary tooth was calculated [Figure 4]a, [Figure 4]b and [Figure 5]a, [Figure 5]b which was used in the second part of the study for obturating root canals of primary teeth (mass = density × volume).
|Figure 1: Average root canal volume of (a) primary maxillary left canine, (b) primary mandibular left canine|
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|Figure 2: (a) Calculation of average root canal volume of primary maxillary left second molar in sagittal section (9 sections). (b) Average root canal volume of primary maxillary left second molar|
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|Figure 3: (a) Calculation of average root canal volume of primary mandibular left second molar in sagittal section (9 sections). (b) Average root canal volume of primary mandibular left second molar|
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|Figure 4: (a) Photograph of aluminum foil weighing 0.07 g used for measuring obturating material for primary left mandibular canine, (b) Quantity/grams of obturating material used for obturation of primary left mandibular canine|
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|Figure 5: (a) Photograph of aluminum foil weighing 0.07 g used for measuring obturating material for primary left mandibular second molar, (b) Quantity/grams of obturating material used for obturation of primary left mandibular second molar|
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| Results|| |
The mean root canal volume of primary mandibular left second molar is 0.1289 cm3 representing the root canal volume for posterior teeth. The mean root canal volume of primary mandibular left canine is 0.0513 cm3 representing the root canal volume for anterior teeth [Table 1].
Part 2: Obturation of mandibular primary canine (73) and second molar (75) using predetermined grams of obturating material
Primary mandibular canines are the tooth with the largest pulp canal space in the anterior region representing pulp canal space for individual primary anterior teeth, whereas primary mandibular second molars are the tooth with the largest pulp canal space in the posterior region representing pulp canal space for individual primary posterior teeth. Therefore, to assess the quality of obturation using predetermined quantity/grams of obturating material, primary mandibular left second molar (representative of posterior primary teeth) and primary mandibular left canine (representative of all anterior primary teeth) which were indicated for pulpectomy were included in the study. A pilot study was conducted on 30 teeth (15 – primary mandibular left second molar and 15 – primary mandibular left canine). Children in the age group of 5–9 years with a history of spontaneous pain, clinically nonvital tooth with or without pus discharge, continuous bleeding from the amputated pulp stump, and radiographs showing furcation involvement or periapical pathology were included in the study. Unrestorable tooth, tooth with periapical pathology involving crypt of permanent successor, tooth with periapical cyst, granuloma or calcification in canals, and tooth with external or internal root resorption were excluded from the study. Root canals of primary mandibular left second molars and primary mandibular left canines were obturated using file method using predetermined quantity/grams of obturating material (Vitapex). The predetermined quantity/gram of obturating material was calculated using the formula:
Mass = density × volume.
Mass = Predetermined grams of obturating material to be calculated.
Density = Density of obturating material, i.e., Vitapex.
Volume = Average root canal volume of primary mandibular second molar and canine (in cm3) obtained using CBCT.
Therefore, the quantity/gram of obturating material required was calculated as follows:
- Obturation of primary mandibular left canine
Average root canal volume of primary left mandibular canine = 0.0513 cm3.
Density of Metapex = 2.07 g/cm3.
Mass of obturating material required for obturation of single primary canine = 0.1061 g.
For the purpose of measurement, aluminum foil of weight 0.07 g was used [Figure 4]a. Therefore, the total weight was 0.1761 (0.18) g [Figure 4]b.
- Obturation of primary mandibular left second molar
Average root canal volume of primary mandibular left second molar = 0.1289 cm3.
Density of Metapex = 2.07 g/cm3.
Mass of obturating material required for obturation of single primary canine = 0.2668 g.
For the purpose of measurement, aluminum foil of weight 0.07 g was used [Figure 5]a. Therefore, the total weight was 0.3368 (0.34) g [Figure 5]b.
The tooth was anesthetized using local anesthesia, and a rubber dam was applied. After gaining access to the pulp chamber using round bur, the pulp was extirpated using a barbed broach. Working length was determined 1 mm short of the radiographic apex. Biomechanical preparation of the canals was done using standard hand files (Mani Co., Tokyo, Japan) up to size 40. Normal saline was used to irrigate the canals. Canals were dried using absorbent paper points (Diadent) and obturated using predetermined quantity/grams of obturating material, i.e., Vitapex. File method was used to obdurate the root canals of primary mandibular second molars and canines. Care was taken to use entire predetermined grams of obturating material that was dispensed from the Vitapex syringe. Immediate postoperative intraoral periapical (IOPA) radiograph was taken to assess short obturation. In case of short obturation, extra Vitapex paste was taken from the Vitapex syringe to ensure optimal obturation of root canals, such that no child is deprived of quality endodontic treatment. For data analysis, immediate postoperative IOPA radiograph was considered. For mandibular primary left second molar, two canals (mesiobuccal and distal) were considered for radiographic evaluation of root canal obturation). Mesiolingual canal was not considered in assessment because, in majority of cases radiographically, this canal is superimposed over mesiobuccal canal. For mandibular primary left canine, the only canal was considered for radiographic evaluation as primary mandibular canine has only one canal. The quality of obturation was assessed based on the modification criteria put forth by Coll and Sadrian.
- Under filling (Score 1) – Canal filled more than 2 mm short of the apex
- Optimal filling (Score 2) – Canal filling ending at the radiographic apex or up to 2 mm short of apex
- Overfilling (Score 3) – Any canal showing filling outside the root apex.
The obturation was assessed by two investigators, and in cases of disagreement, the radiograph was re-evaluated and a diagnostic consensus was reached.
For the second part of the study, the scoring was interpreted and results were expressed in percentages.
| Results|| |
The determined quantity of obturation was sufficient for both mandibular second molars and mandibular canines. Optimal filling was observed in 53.33% and 66.66% of root canals in primary mandibular second molars and mandibular canines, respectively [Table 2], [Table 3] and [Figure 5]. Six-month follow-up of these patients revealed a 100% success rate with no signs of clinical and radiographic failure.
|Table 3: Quality of obturation in mandibular primary second molar (75) and canine (73)|
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| Discussion|| |
Preservation of primary teeth with nonvital pulp always poses a challenge for pediatric dentists. Pulpectomy is the preferred treatment modality in such scenarios which aims to completely debride the necrotic and irreversibly infected pulp. Owing to the complex root canal morphology of primary teeth, proper cleansing is difficult with chemomechanical preparation and irrigation alone., Therefore, to increase the success of endodontic treatment, obturating materials with antimicrobial properties are highly advocated.
Due to the high antimicrobial efficacy, periapical healing, resorption of material, and radiopacity, Metapex/Vitapex has gained immense popularity as an obturating material in the last decade. It is available in a premixed syringe with disposable tips containing 2.2 g paste. Despite its popularity, clinicians experience numerous practical difficulties with these premixed syringes. There exists an innate lack of flexibility of the disposable tips which causes difficulty in material to reach till the apex, and after usage, some amount of material always hardens in the tip itself. These factors lead to wastage of material adding to its expense. In addition, these premixed syringes despite having disposable tips have a risk of contamination due to the contact of some amount of material present in the syringe with intraoral fluids during obturation. Furthermore, the associated needle phobia aids in disrupting the cooperation in pediatric patients where this material finds maximum usage. Therefore, to overcome these practical disadvantages of the premixed syringe, it is advocated to device an ampule with predetermined quantity of material. This single-use ampule permits obturation of only one primary tooth, thereby also eliminating the risk of cross contamination.
To determine the quantity/gram of obturating material required for a single primary tooth, it was an essential prerequisite to calculate the average root canal volume. Root canal volume finds application in various areas ranging from age estimation, forensic odontology, orthodontic diagnosis to determining the periodontal prognosis., This literature search prompted us to use this volume for determining the quantity of obturating material to be used for single primary tooth obturation. The calculation of average root canal volume of primary molars and canines using CBCT was the first part of this study. There are various methods to assess root canal morphology, namely canal staining and tooth clearing, conventional radiographs, digital and contrast medium, enhanced radiographic techniques, radiographic assessment enhanced with contrast media, computed tomography, and CBCT. Among these, CBCT is readily available to dentists and has shown high accuracy in calculation of root canal volume and is considered as a gold standard in identifying root canal anatomy. This accuracy is mainly due to its 3D imaging, and CBCT voxels are isotropic. The purpose of considering root canal volume of primary canines and primary second molars was due to its large pulp cavity which makes it representative of the anterior and posterior dentition, respectively. Therefore, the results of these teeth can be extrapolated to the entire dentition. Besides the objectives of this study, the average root canal volume can be used additionally for purpose of records of central India population.
The average root canal volume was multiplied with density of Metapex (2.07 g/cm3) to determine the quantity/grams of obturating material to obturate a single tooth. The determined quantity/gram of obturating material was sufficient for obturation of primary mandibular canines and second molars. Left mandibular canines and mandibular second molars were considered representative of the contralateral as well as the counter tooth of the opposing arch. Hence, if the determined mass of material suffices the mandibular canine and mandibular second molar, it would definitely be sufficient for the maxillary canines and second molars. To attempt obturation with this predetermined quantity of material, it was of paramount importance to achieve clinical success. This was evaluated using radiograph based on the criteria given by Coll and Sadrian which assessed the quality of obturation. The results showed a significant number of teeth with quality obturation of optimum length (53.33% for primary mandibular second molars and 66.66% for primary mandibular canines). Therefore, it can be inferred that even with the use of exact predetermined quantity/grams of obturating material, optimum quality obturation could be achieved simultaneously avoiding wastage and preventing cross contamination. In addition, 6-month follow-up of these patients did not reveal any signs of clinical and radiographic failure.
Hence, this study opens further gateways to device and market ampules containing predetermined mass of obturating material for a single use for obturating a single primary tooth. These ampules could replace the existing premixed syringes. Therefore, this study could serve as a backbone for further research on the use of single-use devices for obturation.
| Conclusion and Clinical Implications|| |
- This study opens gateways to device ampules containing predetermined quantity of obturating material
- These ampules overcome the practical disadvantages of existing obturation techniques
- They reduce the time required for obturation and repeated use of radiographs, thereby gaining patient's cooperation which is the prime focus for pediatric dentists.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thomas AM, Chandra S, Chandra S, Pandey RK. Elimination of infection in pulpectomized deciduous teeth: A short-term study using iodoform paste. J Endod 1994;20:233-5.
Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J 2002;35:229-38.
Guelmann M, McEachern M, Turner C. Pulpectomies in primary incisors using three delivery systems: An in vitro
study. J Clin Pediatr Dent 2004;28:323-6.
Estrela C, Estrela CR, Hollanda AC, Decurcio Dde A, Pécora JD. Influence of iodoform on antimicrobial potential of calcium hydroxide. J Appl Oral Sci 2006;14:33-7.
Nurko C, Ranly DM, García-Godoy F, Lakshmyya KN. Resorption of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth: A case report. Pediatr Dent 2000;22:517-20.
Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent 1996;18:57-63.
American Academy of Pediatric Dentistry. Guideline on pulp therapy for primary and young permanent teeth. Pediatr Dent 2009;31:179-86.
Bodrumlu E, Semiz M. Antibacterial activity of a new endodontic sealer against Entercoccus faecalis
. J Can Dent Assoc 2006;72:637.
Estrela C, Pécora JD, Souza-Neto MD, Estrela CR. Effectof vehicle on antimicrobial properties of calcium hydroxide pastes. Brazil Dent J 1999;10:63-72.
Nurko C, Garcia-Godoy F. Evaluation of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth. J Clin Pediatr Dent 1999;23:289-94.
Jagannathan N, Neelakantan P, Thiruvengadam C, Ramani P, Premkumar P, Natesan A, et al
. Age estimation in an Indian population using pulp/tooth volume ratio of mandibular canines obtained from cone beam computed tomography. J Forensic Odontostomatol 2011;29:1-6.
Puttaravuttiporn P, Wongsuwanlert M, Charoemratrote C, Leethanakul C. Volumetric evaluation of root resorption on the upper incisors using cone beam computed tomography after 1 year of orthodontic treatment in adult patients with marginal bone loss. Angle Orthod 2018;88:710-8.
Neelakantan P, Subbarao C, Subbarao CV. Comparative evaluation of modified canal staining and clearing technique, cone-beam computed tomography, peripheral quantitative computed tomography, spiral computed tomography, and plain and contrast medium-enhanced digital radiography in studying root canal morphology. J Endod 2010;36:1547-51.
Michetti J, Maret D, Mallet JP, Diemer F. Validation of cone beam computed tomography as a tool to explore root canal anatomy. J Endod 2010;36:1187-90.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]