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BASIC ENDODONTICS

Someone once asked


Which is worse

Ignorance or Apathy
The answer came I dont know and I dont care

This presentation is not for them. This is about developing Expertise Through the rays of knowledge for those that aspire to become The Best.......

......Dentists!

Overview of the Lecture

Diagnosis
Essential analysis

Instruments/ Armamentarium
Access Opening

Locating canals
BMP/ CMP Irrigation & intracanal medicaments Obturation

Diagnosis

Past medical history (Diabetes, Valv Hrt Disease ) Past dental history Attempted RC, Old RCT done,
Separated instrument, swelling extent & recurrence

Chief complaint Subjective Symptoms (type of pain)

Objective Symptoms

Objective Symptoms

Visual & Tactile inspection


Percussion Palpation Mobility and depressibility

Radiograph Anesthetic test Electric pulp test

Thermal test
Test cavity

Visual Inspection

Anesthetic test for localisation of pain

Radiographs are Indispensible

Multiple angles
Extent of caries and relation to pulp

Pulpal changes (calcification, obliteration)


Number, curvature, patency, canal length

Root fracture, resorption( internal, external)


Periapical pathology (extent of alveolar bone destruction, diff diagnosis) Periodontal status

Extensive caries: save or extract?

Pulp Stones, Calcification

Obliterated pulp chamber

Number, shape of canals,roots...

Radix entomolaris

Shape and length of roots

Root resorption, furcation involvement

Cracked tooth

Tear drop radiolucency vertical #

J shaped lesion , vertical #

Vertical root fracture

Radicular cyst

Periodontal status

Endo Perio lesions


Class 1. Primary endodontic lesion draining through the periodontal ligament Class 2. Primary endodontic lesion with secondary periodontal involvement Class 3. Primary periodontal lesions
Class 4. Primary periodontal lesions with secondary endodontic involvement

Steps in RCT

Pre endodontic buildup

Access opening
Locating and negotiating canals Working length determination

Establishing glide path ( more relevant for rotary)

Cleaning and shaping


Obturation

Pre-endodontic Buildup

Removal of old restoration and caries


Reduce cusps to create point of reference

Rebuild with GIC/ flowable composite


Four walls to isolate, (rubber dam) confine irrigants, prevent fracture in between appointments

Pre-endodontic buildup

Access Cavity
Goals

Straight line access to the canals

Complete deroofing of the chamber


Removal of coronal pulp Shape should aid in locating all canals Conservation of tooth structure Retention and esthetics of final restoration Possibility of functional restoration of the tooth

Balance with the following constraints


Access cavity prep

Access prep

Bur oriented along the long axis

Bur angulation

Complete Deroofing

Deroofing

Special Burs for deroofing


Endo Access Bur

Endo safe-end Bur (SSwhite)

Access opening video

Pulp removal from chamber

Excavating pulp tissue in chamber


Hemorrhage control

Removal of calcifications eg. Pulp stones


Use hypochlorite

Locating Canals

De-roofing and removing dentinal ledges


Know anatomy and read xray

Read Dentinal map


Use Sharp explorer tip, No. 10 K file Small round burs Special Ultrasonic tips Magnification aids / Microscope

Dentinal Map

Attached pulp stones

Removing, attached, detached pulp stones Troughing for hidden orifices

Locating canals

MB1, MB2, MB3

Common apical foramen

Two canals lower incisors

Lingual canal in lower canine

Middle Mesial in lower molar

Cleaning and shaping

Cleaning and Shaping

Cleaning is debridement / removal of vital or necrotic tissue, bacteria with their byproducts & dentinal debrisfrom canal system

(Irrigation & disinfection are integral parts of debridement )

Shaping is preparing the canal for complete obturation

All techniques perform the above concurrently

C& S IMP

Straight line access Glide path preparation

Working length determination


Prepare coronal, middle, apical third Continues taper, prepared in all 3 dimensions

Maintain original canal shape


Maintain apical foramen as small as possible Recapitulation & apical patency absolutely essential Thorough irrigation in between prep & before obturation

Obtaining straight line access

Orifice Shaping & enlargement

Danger Zone.... mind it!


M D

Establish glide path


Carefully negotiate canal with small files, and reestablish the path Glide path is a smooth tunnel from canal orifice to physiologic terminus, minimal size super loose no. 10 file ( can even be no. 15, 20)

Very important for safe rotary instrumentation since most rotary Niti are designed to follow a path not create one

Path Files

Path files are designed to create glide path

Working Length Determination Prep should end at the Physiologic terminus / apical constriction/ cemento-dentinal junction

Physiologic terminus vs Radiographic terminus

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Working length determination


Tacticle perception Radiographs Apex locators Paper point Patient response

Techniques for C & S


Step back Crown Down

Manual Rotary

Step-Back Preparation

Crown Down Technique


Start with the largest files from the upper part of the root canal and goes down with decreasing or smaller files ADVANTAGES:
Do not have to go to the WL from the start Less chance of ledge formation, or canal blockage Reservoir for irrigants. DISADVANTAGES: Not taught in the colleges. More steps than the protaper technique.

Manual Preparation Instruments

Reamers
K file

Flexoreamer
Flexofile H file Niti flexfile Protaper Hand files

Cutting tip. In curved canals ledging easily occurs with even small reamer sizes if instruments are not pre-curved. Reamers are excellent instruments in straight canals but poorly adaptable to curved canals.

The K-file
for the preparation of straight canals. It prepares dentin effectively both in filing motion (up and down) and when rotated. In slightly curved canals : Small resistance : Continuous rotation Greater resistance : Balanced force Curved canals : pre-curve The use of filing motion in curved canals can cause transportation and ledging, and is not recommended.

Hedstroem File

Prepared from round steel wire by grinding. Cutting edge close to right angle. H file = Ledge file Only Up- down motion. Must fit loosely in the canal. Used 1-2 mm shorter than apical prep. Above 25 no. 3-4 mm shorter. Pre-curved in curved canals.

Files must be inspected for possible earlier damage to the instrument and discarded immediately if an asymmetry in the cutting area is found.

Nitiflex file

Rotary Instruments

Protaper

Greater Taper
Profile Race Endo sequence K3 files Light Speed (LSX)

Pro Taper: Recommended use

1. Work instruments to light resistance and never force them. 2. Only use instruments in a well irrigated and lubricated canal. 3.The appropriate finishing file passively follows the canal to the desired length then is immediately withdrawn. 4. Use in constant rotation at a speed of 250-350 rpm. 5. Clean flutes frequently and check for signs of distortion or wear.

Pro Taper: Design and Structure

A progressively tapered file engages a smaller zone of dentine which reduces torsional loads, file fatigue and the potential for breakage. Improve flexibility, cutting efficiency and typically reduces the number of recapitulations needed to achieve length, especially, in tight or more curved canals. ProTaper instruments are prepared from round nickel-titan wire by grinding. Cross-section of the instruments shows a triangular structure with three cutting points and no radial lands. ProTaper instruments have a non-cutting tip to guide the instrument in the canal and reduces the risk for ledge formation. The convex triangular cross-section reduces the contact area between the file and dentine. This greater cutting efficiency has been safely incorporated through balancing the pitch and helical angles.

Hand Protaper

Rotary Protaper Video

Other rotary systems Race (Reamer with Alternating Cutting Edges)

The cross-section of the RaCe instruments is a convex triangle, with the exeption of the two smallest instruments, #15/02 and #20/02 (taper 02), which both have a square cross-section. special attention has been focused on achieving a smooth metal (NiTi) surface Each RaCe instruments has a constant taper ranging from 02 taper to 10 .

Great Taper: Design and Structure

EndoSequence: Design and Structure

K3: Design and Structure

Light speed system (tapered vs non-tapered)

http://www.discusdental.com/endo_videomedia. php

Must, irrespective of technique


Recapitulation, apical patency

Densely packed dentinal debris

Lightly packed dentinal debris

Colonization of Bacteria Obliteration to RCF

Type of Apical Preparation


Apical stop Apical seat Open apex

Complications during shaping

Ledging
Zipping

Transportation of canal, foramen


Perforation

Hour glass preparation


Instrument separation

Ledging, Zipping, Transportation

Hour glass preparation

The standardized preparation technique resulted in procedural errors when used in a curved canal.

Irrigation

Lubricate canal to avoid instrument separation Dissolve the pulp remnants Washing out debris created by instrumentation Kill or remove the micro-organisms in root canal and biofilm Clean the smear layer Canal should be wide enough for irrigant to reach apex,

Most commonly used irrigants


Naocl 5.25% or 3% (bactericidal, cytotoxic, dissolves organic tissuel)

EDTA (17%) liquid, gel (removes smear layer, lubrication)

Chlorhexidine 0.2% (bactericidal)


H202

Saline
Distilled water
Side venting irrigating tips

Most commonly used irrigants

Newer delivery systems


Endovac ( improves exchange of irrigant, eliminates air lock, avoids accidents)

Vibringe (passive ultrasonic irrigation)

Intracanal Medicaments

Ca(OH)2

Chlorhexidine gel 2%
Antibiotics Phenolic compounds

Metapex: Ca(OH)2 + Iododform

Obturation
The success of endodontic treatment depends on meticulous root canal preparation.
What you take out is more important than what you put in This does not mean that root canal obturation is less important.

Hermetic Seal
The purpose of obturation is to seal and prevent:

Microbes from entering & reinfecting the canal

Tissue fluids from percolating back & providing a culture medium for residual microbes

Coronal seal equally important

Obturatation

Patient asymptomatic

Canals should be relatively dry

Apical gauging & Master cone selection Confirm with radiograph

Requirements of RC filling material

Should be easily introduced in canal Should not shrink Should seal laterally as well as apically Impervious to moisture

Bactericidal or at least discourage growth


Radiopaque Should not stain tooth Should not irritate periapical tissues (inert, biocompatible) Quickly sterilisable Easily removable if necessary

Gutta Percha achieves most of the ideal requirenments


Two crystalline phases : alpha, beta (gp cones)
Thermoplasticised gp (alpha) shrinks after cooling hence vertical pressure necessary while cooling Available as:

Standardised ISO Greater taper Protaper GP

Non Standardised (X-F, F-F, M-F, F, F-M, M, M-L, L, X-L)


GP Bars

Techniques

Lateral condensation (cold gutta-percha)


Vertical condensation (Schilder)(warm gutta-percha) Sectional method Compaction method (Mcspadden method) Metal core obturation (silver cone, SS file)

Single gutta-percha point and sealer


Chemically plasticised gutta percha Thermoplasticised technique :

Down pack (system B) & back fill with injectable gp(obtura)


Gutta percha carrier systems( thermafill, simplifill)

LATERAL CONDENSATION
1.MASTER CONE GP WHOSE SIZE CORRESPOND TO THE LAST LARGEST NO. FILE USED TO SHAPE THE CANAL TILL WL IS CHOSEN.

2 FIT AND LENGTH OF THE GP IS CONFORMED WITH A X-RAY.


3 ADDITIONAL SMALLER GP POINTS ARE THEN FILLED IN BY MAKING SPACE WITH SPREADERS.

ADVANTAGES OF THE TECHNIUE:


TAUGHT IN COLLEGES IN INDIA AND IS BEING USED BY MOST OF THE DENTISTS. LESS INVENTORY NEEDED AS COMPARE TO WARM GP TECHNIQUE. LESS EXPENSIVE.

DISADVANTAGES:

ACCESSARY CANALS ARE NOT OBTURATED.


SPACE LEFT B/T THE GP POINTS.

Lateral Condensation

Lateral condensation video

Vertical Condensation (Schilder)

Thermoplasticised GP
System B, Obtura

Down pack Back fill video

Carrier based technique (Thermafill)

THERMAFIL OR THE WARM GP TECHNIQUE


METHOD:
SIZE AND THE LENGTH OF THE THERMAFIL TO BE USED IS DETERMINED BY THE VERIFIER HEAT THE GP IN THE THERMA PREP. APPLY THE SEALER IN THE ROOT CANAL FILL THE ROOT CANAL WITH WARM GP. PLASTIC CARRIER IS SEPARATED USING A BUR

ADVANTAGES :
ALL ACCESSARY CANAL ARE FILLED. NO SPACE LEFT UNFILLED IN THE CANAL.

DISADVANTAGES: CAN LEAD TO THE OVER-OBTURATION OR FILLING BEYOND THE APICAL FOREMEN. EXCESSIVE VERTICAL FORCE CAN LEAD TO ROOT FRACTURE.

Root canal Sealants, properties

Zinc Oxide Eugenol

Zinc Oxide Resin


Endomethasone Ca(OH)2 based Paraformaldehyde Diaket ( polyvinyl resin) Methacrylate based (Epiphany) Epoxy resin (AH26, AH plus)

Sealant puff desirable or not?

Desirable Obturation!

RC Complications and Management .......for next time

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