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Uitgebreide Samenvatting Endodontologie Tandheelkunde 3e bach KUL: NIEUW S. Pedano

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Course
Endodontologie

Institution
Katholieke Universiteit Leuven (KU Leuven)

Deze samenvatting bevat alle slides en notities van het vak ENDODONTIE, gedoceerd door S. Pedano. Alles is vertaald in het Nederlands.

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endodontie
pedano
enododontologie

Institution
Katholieke Universiteit Leuven (KU Leuven)
Education
Tandheelkunde
Course
Endodontologie

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3e BACH Tandheelkunde

ENDODONTOLOGIE

2021

,Endodontologie

Inhoudsopgave

1 Inleiding .................................................................................................................................................. 7

2 Het dentine-pulpa complex ..................................................................................................................... 7
2.1 Definitie ................................................................................................................................................ 7
2.2 Anatomie en structuur ......................................................................................................................... 8
2.3 Embryologie ......................................................................................................................................... 8
2.4 Functie .................................................................................................................................................. 8
2.5 Fysiologie ............................................................................................................................................. 9
2.6 Wortelkanaal anatomie ....................................................................................................................... 9
2.6.1 Weine’s classificatie ........................................................................................................................ 9
2.6.2 Vertucci’s classificatie ..................................................................................................................... 9
2.7 Apicale anatomie ............................................................................................................................... 12

3 Pijn van endodontische oorsprong ........................................................................................................ 12
3.1 Inleidinging......................................................................................................................................... 12
3.2 Lokale anesthetica ............................................................................................................................. 13
3.3 Mogelijke neveneffecten .................................................................................................................... 13
3.3.1 Cardiovasculair .............................................................................................................................. 13
3.3.2 Systemisch ..................................................................................................................................... 13
3.3.3 Methemaglobinemia ..................................................................................................................... 14
3.3.4 Perifere zenuw paresthesie ........................................................................................................... 14
3.3.5 Allergie .......................................................................................................................................... 14
3.4 Effecten van systemische ziekte of condities op LA ............................................................................ 14
3.5 Klinische factoren ............................................................................................................................... 14
3.6 Inferior alveolair nerve block.............................................................................................................. 15
3.6.1 LA technieken ................................................................................................................................ 16
3.6.2 Technieken op succes van IAN block te verhogen ........................................................................ 16
3.6.3 Redenen van falen ......................................................................................................................... 16
3.7 Bovenkaak verdoving ......................................................................................................................... 17
3.7.1 Alternatieven ................................................................................................................................. 17
3.7.2 Duurtijd verhogen ......................................................................................................................... 17
3.7.3 Alternatieve technieken ................................................................................................................ 17
3.8 Supplementaire anesthesie ................................................................................................................ 18
3.9 Efficiëntie bij pulpitis .......................................................................................................................... 18
3.10 Cases .................................................................................................................................................. 18
3.10.1 Symptomatische elementen met irreversiebel pulpitis ........................................................... 18
3.10.2 Symptomatische tand met pulpa necrose en periapicaal abces .............................................. 18
3.10.3 Asymptomatische tanden met pulpa necrose en periapicale opklaring .................................. 19
3.10.4 Tijdelijke behandeling voor irreversibele pulpitis via pulpotomy ............................................ 19

4 Diagnose in endodontie ........................................................................................................................ 19
4.1 Inleiding.............................................................................................................................................. 19
4.2 Factoren die pulpa pathologie veroorzaken ....................................................................................... 19
4.3 Definities en termen ........................................................................................................................... 20
4.4 Pulpa inflammatie .............................................................................................................................. 21

1

,Endodontologie

4.4.1 Oorzaak ......................................................................................................................................... 21
4.4.2 Begrip ............................................................................................................................................ 21
4.4.3 Stimulatie van sympatische zenuwen ........................................................................................... 22
4.4.4 Expressie van neuropeptides in pulpa en hun rol ......................................................................... 22
4.4.5 Hoe kunnen bacteriën de pulpa bereiken? ................................................................................... 22
4.5 Initiele imuunsysteem ........................................................................................................................ 23
4.6 Pijnvrije pulpitis .................................................................................................................................. 24
4.7 Periapicale aandoening ...................................................................................................................... 24
4.7.1 Oorzaken van periapicale inflammatie ......................................................................................... 25
4.7.2 Differentiele diagnose ................................................................................................................... 26
4.8 Diagnose data verzameling................................................................................................................ 26
4.9 De toekomst: biomarkers is de endodontie ........................................................................................ 33

5 Behandeling van vitale pulpa condities ................................................................................................. 34
5.1 Minimale invasieve cariës verwijdering ............................................................................................. 34
5.2 Welke techniek? ................................................................................................................................. 35
5.2.1 Stapsgewijze excavatie: 2-staps .................................................................................................... 35
5.2.2 Partiële cariës verwijdering: 1-staps ............................................................................................. 35
5.3 Welke materialen? ............................................................................................................................. 36
5.3.1 Hars vrij GI ..................................................................................................................................... 36
5.3.2 Hars vrije calcium hydroxide cementen ........................................................................................ 36

6 Endodontische microbiologie ................................................................................................................ 37
6.1 Inleiding.............................................................................................................................................. 37
6.2 Route van bacteriën ........................................................................................................................... 37
6.3 Definities ............................................................................................................................................ 37
6.4 Anatomie ............................................................................................................................................ 37
6.5 Biofilm en community gebaseerde microbiële pathogenese ............................................................. 38
6.6 Apicale parodontitis als een biofilm-gerelateerde ziekte ................................................................... 38
6.7 Methoden voor microbiële identificatie ............................................................................................. 39
6.8 Diversiteit van bacteriën .................................................................................................................... 39
6.9 Typen van interadicualire infectie ...................................................................................................... 40
6.10 Conclusie ............................................................................................................................................ 40

7 Endodontische noodgevallen ................................................................................................................ 41
7.1 Inleiding.............................................................................................................................................. 41
7.2 Pulpa diagnose ................................................................................................................................... 41
7.3 Periapicale diagnose .......................................................................................................................... 41
7.4 Pulpitis................................................................................................................................................ 42
7.4.1 Reversiebele pulpitis ..................................................................................................................... 42
7.4.2 Irreversibele pulpitis...................................................................................................................... 42
7.4.3 Pulpa necrose ................................................................................................................................ 43
7.5 Periapicale parodontitis ..................................................................................................................... 43
7.5.1 Symptomatische/acute apicale parodontitis ................................................................................ 43
7.5.2 Symptomatisch acuut apicaal abces ............................................................................................. 44

2

,Endodontologie

7.6 Reeds behandelde tand ...................................................................................................................... 47
7.7 Tand open laten ................................................................................................................................. 47
7.8 AB in endodontie ................................................................................................................................ 47
7.9 Pijn controle tijdens endodontisch noodgeval ................................................................................... 47
7.10 Besluit................................................................................................................................................. 48

8 Manuele instrumenten ......................................................................................................................... 49
8.1 Introductie .......................................................................................................................................... 49
8.2 Karakteristieken handvijlen................................................................................................................ 49
8.2.1 K vijl voorbeeld .............................................................................................................................. 49
8.3 Classificatie van handinstrumenten ................................................................................................... 50
8.3.1 Op basis van het metaal ................................................................................................................ 50
8.3.2 Op basis van hun de vorm van cross-sectie .................................................................................. 51
8.3.3 Aanvullende instrumenten ............................................................................................................ 52
8.4 K-vijlen................................................................................................................................................ 53
8.5 K-flexovijlen ........................................................................................................................................ 53
8.6 Hedström vijlen .................................................................................................................................. 53

9 Roterend instrumentarium ................................................................................................................... 54
9.1 Inleiding.............................................................................................................................................. 54
9.2 Classificatie ........................................................................................................................................ 54
9.2.1 Instrumenten voor toegangspreparatie/coronale verbreding ...................................................... 54
9.2.2 Instrumenten voor wortelkanaal preparatie................................................................................. 55
9.2.3 Overige roterende instrumenten .................................................................................................. 60
9.3 Protocol in UZ leuven ......................................................................................................................... 60

10 Openingscaviteit ................................................................................................................................... 62
10.1 Algemene dentale anatomie - radiografie ......................................................................................... 62
10.2 Kanaal openingen – visueel................................................................................................................ 63
10.2.1 Pulpakamer anatomie .............................................................................................................. 63
10.2.2 Wortelkanaal curvatuur ........................................................................................................... 65
10.3 Toegangscaviteit per tand ................................................................................................................. 65
10.3.1 BCI............................................................................................................................................. 65
10.3.2 BLI ............................................................................................................................................. 66
10.3.3 BHT ........................................................................................................................................... 66
10.3.4 OCI ............................................................................................................................................ 67
10.3.5 OLI............................................................................................................................................. 68
10.3.6 OHT ........................................................................................................................................... 68
10.3.7 BPM .......................................................................................................................................... 70
10.3.8 OPM .......................................................................................................................................... 71
10.3.9 BM ............................................................................................................................................ 73
10.3.10 OM ............................................................................................................................................ 74
10.3.11 3de molaren ............................................................................................................................... 75

11 Wortelkanaal instrumentatie ................................................................................................................ 76
11.1 Intro.................................................................................................................................................... 76
11.2 Classificatie ........................................................................................................................................ 77
11.3 Afhankelijk van de richting ................................................................................................................. 77

3

,Endodontologie

11.3.1 Standaard techniek................................................................................................................... 77
11.3.2 Step-back techniek ................................................................................................................... 77
11.3.3 Step-down of kroon-down techniek ......................................................................................... 79
11.3.4 Hybride techniek ...................................................................................................................... 79
11.4 Afhankelijk van het gebruikte instrument .......................................................................................... 79
11.4.1 Hybride techniek ...................................................................................................................... 79
11.5 Wortelkanaal preparatie met gates-glidden en handvijlen ............................................................... 81
11.6 Wortelkanaal preparatie met Wave-one gold en handvijlen ............................................................. 83
11.7 Conclusie ............................................................................................................................................ 84

12 Wortelkanaal desinfectie ...................................................................................................................... 85
12.1 inleidining ........................................................................................................................................... 85
12.2 Hoofddoel van wortelkanaal irrigatie ................................................................................................ 86
12.3 Desinfecterende oplossingen ............................................................................................................. 87
12.3.1 Sodium hypochloriet (NaOCl) ................................................................................................... 87
12.3.2 Chloorhexidine ......................................................................................................................... 88
12.3.3 Andere oplossingen .................................................................................................................. 89
12.4 Oplossingen om inorganisch weefsel op te lossen ............................................................................. 89
12.4.1 Ethylenediamine tetra-acetic acid (EDTA) ................................................................................ 89
12.4.2 Citroenzuur ............................................................................................................................... 90
12.4.3 Tetracycline .............................................................................................................................. 90
12.5 Interkanaal medicatie ........................................................................................................................ 90
12.5.1 Calcium hydroxide .................................................................................................................... 91
12.6 Hydrodinamiciteit van wortelkanaal irrigatie .................................................................................... 91
12.6.1 Diameter ................................................................................................................................... 91
12.6.2 Penetratiediepte van de naald ................................................................................................. 93
12.6.3 Binnen en buitendiameter van de naald .................................................................................. 93
12.6.4 Spoeldruk.................................................................................................................................. 93
12.6.5 Tip en oriëntatie van de bevel .................................................................................................. 93
12.6.6 Activeren van spoelmiddel ....................................................................................................... 93

13 Endodontische materialen .................................................................................................................... 95
13.1 Cores & sealers ................................................................................................................................... 95
13.2 Materialen voor de kern obturatie ..................................................................................................... 95
13.2.1 Medicatiepasta’s ...................................................................................................................... 95
13.2.2 Zilver cones ............................................................................................................................... 95
13.2.3 Hars gebaseerde kern ............................................................................................................... 95
13.2.4 Gutta percha ............................................................................................................................. 95
13.3 Sealer ................................................................................................................................................. 96
13.3.1 Hars gebaseerde sealers of epoxy sealers ................................................................................ 97
13.3.2 Calcium hydroxide gebaseerde sealer ...................................................................................... 97
13.3.3 Calciumsilicaat gebaseerde sealers .......................................................................................... 97
13.3.4 Zink-oxide eugenol cementen .................................................................................................. 98
13.3.5 Silicone gebaseerde sealers ...................................................................................................... 98
13.3.6 GI sealers .................................................................................................................................. 99
13.4 Materielen voor interkanaal medicatie.............................................................................................. 99
13.4.1 Calcium hydroxide .................................................................................................................... 99
13.4.2 Triple AB pasta.......................................................................................................................... 99
13.4.3 Andere interkanaal medicatie .................................................................................................. 99
13.4.4 Materiaal voor tijdelijke restauratie ......................................................................................... 99

4

,Endodontologie

13.5 Materialen voor intercanale medicatie ............................................................................................ 100
13.6 Materialen op kanalen te beschermen (sealen van openingscaviteit) en voor definitieve restauratie
101
13.7 Materialen voor retrograde vullling ................................................................................................. 101

14 Kanaal obturatie ................................................................................................................................. 103
14.1 Hoe belangrijk is obturatie ............................................................................................................... 103
14.2 Timing van obturatie ........................................................................................................................ 103
14.3 Definities volgens het boek .............................................................................................................. 104
14.4 Definities volgens realiteit ................................................................................................................ 104
14.5 Lengte van obturatie ........................................................................................................................ 105
14.6 Preparatie voor obturatie ................................................................................................................ 106
14.7 Technieken ....................................................................................................................................... 107
14.7.1 Koude laterale compactie ....................................................................................................... 107
14.7.2 Warme verticale compactie ................................................................................................... 107
14.7.3 Warme laterale compactie ..................................................................................................... 107
14.7.4 Thermaplastische injectie of squirting techniek ..................................................................... 107
14.7.5 Carrier bases obturation......................................................................................................... 107
14.7.6 Continous wave compaction techniek = BESTE ...................................................................... 107
14.7.7 Single cone techniek ............................................................................................................... 108

15 Endodontische herbehandeling ........................................................................................................... 109
15.1 Oorzaken .......................................................................................................................................... 109
15.2 Diagnose van posttreament disease ................................................................................................ 110
15.2.1 Methoden van diagnose ......................................................................................................... 110
15.3 Behandeling ..................................................................................................................................... 110
15.4 Niet-chirurgische herbehandeling .................................................................................................... 112
15.5 Micro-chirurgie of periapicale micro-chirurgie ................................................................................ 113

16 Restauratie van een endodontisch behandelde tand .......................................................................... 114
16.1 Belang van een goede restauratie ................................................................................................... 114
16.2 Restauratie ....................................................................................................................................... 114
16.2.1 Anterieur ................................................................................................................................ 114
16.2.2 Posterieur ............................................................................................................................... 116
16.3 Stift of niet........................................................................................................................................ 120
16.3.1 Ferulle ..................................................................................................................................... 120

17 Tandtraumatologie ............................................................................................................................. 121
17.1 Inleiding............................................................................................................................................ 121
17.2 Voorbeschikkende factoren .............................................................................................................. 121
17.3 Ethiologie ......................................................................................................................................... 121
17.4 Classificatie ...................................................................................................................................... 122
17.4.1 Beschadiging van hard tandweefsel en pulpa ........................................................................ 122
17.4.2 Beschadigingen van periodontale weefsel ............................................................................. 124
17.4.3 Beschadigingen van het ondersteunde bot ............................................................................ 125
17.4.4 Beschadiging van de gingiva of orale mucosa ........................................................................ 126

5

,Endodontologie

18 Herstel en regeneratie ........................................................................................................................ 128
18.1 Definitie ............................................................................................................................................ 128
18.2 Weefsel in endodontologie .............................................................................................................. 128
18.3 Feiten en mythes over regeneratie .................................................................................................. 128
18.3.1 Regeratie is iets nieuws .......................................................................................................... 128
18.3.2 Tandregeneratie vs tandvascularisatie (behandeling) ........................................................... 129
18.3.3 Tandregeneratie VS tandmaturatie ........................................................................................ 129
18.3.4 Tandrevascularisatie VS apexificatie (lange termijn).............................................................. 130
18.4 Wat betekent regeneratie ................................................................................................................ 131
18.4.1 Cel-homing ............................................................................................................................. 132
18.4.2 Cel-based ................................................................................................................................ 133
18.5 Revascularisatie ............................................................................................................................... 133

19 Endo-paro relatie ................................................................................................................................ 134
19.1 Intercommunicatie tussen pulpa en parodontaal weefsel ............................................................... 134
19.2 Invloed van pulpa pathologie op het parodontium .......................................................................... 135
19.3 Invloed van paro-inflammatie op de pulpa ...................................................................................... 135
19.4 Classificatie ...................................................................................................................................... 135
19.4.1 Primair endodontisch letsel .................................................................................................... 136
19.4.2 Primair endodontisch letsel met secundair paro betrokkenheid ........................................... 136
19.4.3 Primaire parodontaal letsel .................................................................................................... 136
19.4.4 Primair parodontaal letsel met secundair endo betrokkenheid ............................................ 137
19.4.5 Echt gecombineerd endo-paro letsel ..................................................................................... 137
19.5 Differentiële diagnose ...................................................................................................................... 137
19.5.1 Verticaal wortelfractuur ......................................................................................................... 138

20 Advanced endodontic pathology......................................................................................................... 139
20.1 Ontwikkelingsgroeve ........................................................................................................................ 139
20.2 Dens invaginatus/Dens in dente ...................................................................................................... 139
20.2.1 Oehler’s classificatie ............................................................................................................... 140
20.3 Dens evaginatus of talon cusp ......................................................................................................... 141
20.4 Geminatie ......................................................................................................................................... 142
20.5 Externe cervicale resorptie ............................................................................................................... 142
20.6 Classificatie ...................................................................................................................................... 143
20.6.1 Voorbeelden ........................................................................................................................... 143
20.6.2 Behandeling ............................................................................................................................ 144
20.7 Interne wortelresorptie .................................................................................................................... 147
20.8 Glazuurparels ................................................................................................................................... 148
20.9 Cementtranen .................................................................................................................................. 148

21 Evidence-based endodontics ............................................................................................................... 150
21.1 Definitie ............................................................................................................................................ 150
21.2 Beschikbare evidence ....................................................................................................................... 150

6

,Endodontologie

1 Inleiding
Doel van endo: preventie en behandeling van apicale parodontitis veroorzaakt door microbiële
contaminatie van de pulpa en wortelkanaal = biologisch doel → behouden en redden van natuurlijke
tanden in functie en esthetiek

Biologisch doel • Hoofddoel van endo
• Preventie of behandeling van apicale pardonotitis door desinfectie
van de kanalen en posterieure sealing om bacteriële penetratie te
vermijden
• Wordt gehaald door:
➢ Verwijderen van geïnfecteerd zacht en harde weefsels
➢ Maken van genoeg ruimte om de spoelmiddelen en
medicamenten naar apicaal te laten komen en obturatie van
de kanalen toe te laten
➢ Behoud van integriteit van het resterende tandstructuur
• Om dit te bereiken moeten twee andere doelen worden voldaan
Mechanisch doel • Alle kanaaloppervlakken prepareren en de kanalen in de juiste
vormgeving prepareren
Technisch doel • Een continue taper bereiken dat overeenkomt met de originele
vorm en curvatuur van een bestaand wortelkanaal, finale apicale
preparatie grootte dat toelaat voldoende te prepareren van
geïnfecteerd dentine en proper maken inbegrepen.

Mechanisch en technisch doel = secundaire doelen, het verbeteren van deze is contradictoir.
Minimaal invasieve behandelingen kunnen het biologische doel aantasten: preventie van goede
zichtbaarheid, toegang, irrigatie en obturatie vd kanalen

2 Het dentine-pulpa complex
2.1 Definitie
• Pulpa = zenuwen en bloedvaten
• Bindweefsel, embryonaal weefsel maar toch met
complexe innervatie
• Odontoblasten, die nergens anders voorkomen.
• Dentine – predentine – odontoblasten – cel free zone –
cel rich zone
o Pr = predentine
o Net onder odontoblasten, cf = cel free zone
(capillaire, ongemyeliniseerde zenuwvezels)
o Cr: cel rijke zone (meestal fibroblasten)
• Ook stamcellen in kern
• Ouder worden =  vezels (minder fibroblasten) en
 collageen
• Ingebed in gelatineuze massa = stevigheid

7

,Endodontologie

2.2 Anatomie en structuur

• Celuitlopers van odontoblasten liggen binnen het dentine
• Kroongedeelte: meer cellen, minder colllageen vezels, wortelpulpa is veel fibreuzer met
minder cellen
• Op centrale pulpa streng ligt er een zone die heel rijk is aan ongediff cellen die tot
odontoblaste, osteoblaste of osetoclasten kunnen diff = stamcellen, in het middel van pulpa
(een niche vol met stamcellen)
• Meest perifere cellaag is odontoblasten cellaag = palicade uit odontoblasten
• Ododntoblasten kunnen niet delen. Maar stam cel kan ododntoblast like cell vormen →
dentine aanmaak
• Aantal rijen van odontoblasten is kleinst in het apical derde, maar meer bovenop, bij de
kroon
• Aan predentine zijde is de terplaatse celwand continue van de aanliggende odontoblasten →
lijkt microscopisch op een membraan = pulpodentinepseudomembraan
• Iedere odontoblast heeft celuitloper die zich uitstrekt in dentine = thomes uitlopers
• Celuitloper kan tot dicht bij dentine-glazuur grens iggen, andere onderzoekers zeggen dat dit
niet zo is

2.3 Embryologie

1) Oraal epitheel + neurale lijst mesenchym
2) Primaire dentale lamina
3) Placode (dentale placode + mesenchymaal condensatie)
4) Bud stage (stella reticulum)
5) Cap stage ( primair glazuur knoop + cervicale loop vorming(bevatten meer stamcellen))
6) Bel stage (secundaire galzuurknaap)
7) Late bel stage (epitheliale stamcel niches)
8) ALLE ONTWIKKELING GERICHT OP KROON
9) Ameloblsten vh epithelial deel (G)
10) Odontoblasten vh mesenchymaal deel (D)

2.4 Functie
• Sensitiviteit

8

, Endodontologie

• Proprioceptie
• Immuno-modulatie
• Aanmaak van secundair en tertiair dentine
• Defensie mechanisme

2.5 Fysiologie
• A: stimuli op dentine → direct cel stimulatie. Celuitloper kan pijn opvangen en doorgeven.
Maar dat is niet altijd zo.
• B: stimuli op odontoblast laat de odontoblast synaptisch signaal sturen. Maar dit kan ook
niet.
• C: Hydrodynamische theorie van brännström: vloeistof beweging gebeurt binnen tubuli en
die stimuli wordt overgebracht. Koude lucht geeft pijn → a en b kan niet. Beweging van
vloeistof veroorzaakt gevoeligheid, sensitivitiet.

2.6 Wortelkanaal anatomie
Goede kennis van anatomie is essentieel; het heeft een directe impact op de praktijk en procedures
voor toegangscaviteit preparatie, kanaal vormgeving en obturatie.

2.6.1 Weine’s classificatie
• 4 types
• Adhv 3 factoren
o # openingen
o # kanalen
o # foramina
• Type I: 1 o – 1 k – 1 f
• Type II: 2 o – 2 k – 1 f
• Type III: 2 o – 2 k – 2 f
• Type IV: 1 o – 1k – 2 f
• Later: type V: 1 o – 3 k – 3 f

2.6.2 Vertucci’s classificatie

9

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Uitgebreide Samenvatting Endodontologie Tandheelkunde 3e bach KUL: NIEUW S. Pedano

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