Endodontics IL 1 Healing potential of dental pulp Acute Chronic Necrosis Periodontitis Acute hronic enoseal, subperiostal, submucous phase.... Cummulative trauma of dental Diagnosis History Presenting complaint Medical history Dental history Pain history Location Type and intensity of pain Duration Stimulus Relief (analgetics, antibiotics, sipping cold drinks) Diagnosis Clinical examination Extraoral (swelling, redness, extraoral sinuses, lymph nodes, degree of mouth opening) Intraoral examination Swelling, redness,palpation, percussion, sinus tract examination, teeth mobility,pockets Diagnosis Clinical examination Pulp sensitivity tests, radiographic examination, transillumination Phases of the endodontic treatment Diagnosis Consideration (local, regional and systemic factors). Removal of carious dentin,old fillings, built up the clinical crown or reduction of cusps Local anaesthesia Dry operating field Access to the pulp chamber Root canal shaping Root canal cleaning Root canal filling Xray Postendodontic treatment Access — opening of the pulp chamber Round Burs lenka.roubalikova@tiscali.cz 11 Preparation of the endodontic cavity -facilitating form Dia trepan Instruments with safe ended tips), Acc. to Batt Fissure burs lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz 13 Root canal access ii II11 b II t Endodontic probes Microopeners Ultrasound lenka.roubalikova@tiscali.cz 14 Opening of the root canal orifices lenka.roubalikova@tiscali.cz Peeso-Largo burs 15 lenka.roubalikova@tiscali.cz 16 Gates - Glidden: lenka.roubalikova@tiscali.cz 17 CZ24 Gates — Glidden: r Tupá, neaktivní vodící špička Naprogramované místo zlomu ___________ lenka.roubalikova@tiscali. CZ25 X-GATES Velikost hrotu : / Gates 1 / Místo zlomu Maximální průměr - Gates 4 Dřík: Gates 3 Nalezení a rozšíření vstupu do kořenových kanálků lenka.roubalikova@tiscali. Extraction of the content of the root canal - exstirpation Pulpextraktor - made of soft wire Single use instrument Rotation In wider canals only In narrow canals - the content is extracted using instruments for root canal shaping lenka.roubalikova@tiscali.cz 30 > Rotation and exstirpation! 3 Canal shaping > Reamers > Files lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz Reamer Cuting edges Space for chips Clockwise rotation lenka.roubalikova@tiscali.cz Files 1. K-file 2. K-flexofile, flexicut, flex-R - file 3. K-flex 4. H-file, S-file lenka.roubalikova@tiscali.cz K file K-file Filing and (or) rotation Straight canals 45° - 90°) lenka.roubalikova@tiscali.cz ISO norma > Diameter > Length of the cutting part > Taper lenka.roubalikova@tiscali.cz 06 pink 08 gray 10 purple 15 white 45 white 20 yellow 50 yellow 25 red 55 red lenka.roubalikova@tiscali.cz 43 Taper 4% 2 0,06mm na 1 mm 46 Instrumentation Rotace tam a zpět — 45° K - reamer K- file Instrumentation Rotation K - reamer K- file lenka.roubalikova@tiscali.cz Instrumentation Filing H- file K - file lenka.roubalikova@tiscali.cz Instrumentation Ttechnika balancované síly — nástroj o 1 číslo větší než apikální velikost K- flexofile K - file (?) 180-270c lenka.roubalikova@tiscali.cz Reaming Simple clockwise rotation lenka.roubalikova@tiscali.cz 51 lenka.roubalikova@tiscali.cz 52 Circumferential filing Introduction of th root canal instrument root canal. Pull motion - action. Staying in contact with the root canal wall Rotate without any action Go in and pull with action. lenka.roubalikova@tiscali.cz 53 Balance forced technique Go into the root canal rotating clockwise 90-180° Until the contact Slight pressure and rotate Contraclockwise 270° Pull out the instrument rotating clockwise again lenka.roubalikova@tiscali.cz 54 lenka.roubalikova@tiscali.cz \ > \ 55 / 56 Access — opening of the pulp chamber Round Burs lenka.roubalikova@tiscali.cz 60 Preparation of the endodontic cavity -facilitating form Dia trepan Instruments with safe ended tips), Acc. to Batt Fissure burs lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz 62 Root canal access ii II11 b II t Endodontic probes Microopeners Ultrasound lenka.roubalikova@tiscali.cz 63 Opening of the root canal orifices lenka.roubalikova@tiscali.cz Peeso-Largo burs 64 lenka.roubalikova@tiscali.cz 65 Gates - Glidden: lenka.roubalikova@tiscali.cz 66 CZ73 Gates — Glidden: r Tupá, neaktivní vodící špička Naprogramované místo zlomu ___________ lenka.roubalikova@tiscali. CZ74 X-GATES Velikost hrotu : / Gates 1 / Místo zlomu Maximální průměr - Gates 4 Dřík: Gates 3 Extraction of the content of the root canal - exstirpation Pulpextraktor - made of soft wire lenka.roubalikova@tiscali.cz > Rotation and exstirpation! 79 Canal shaping > Reamers > Files lenka.roubalikova@tiscali.cz Reamer Cuting edges Space for chips Clockwise rotation lenka.roubalikova@tiscali.cz Files 1. K-file 2. K-flexofile, flexicut, flex-R - file 3. K-flex 4. H-file, S-file lenka.roubalikova@tiscali.cz K file K-file Filing and (or) rotation Straight canals 45° - 90°) lenka.roubalikova@tiscali.cz ISO norma > Diameter > Length of the cutting part > Taper lenka.roubalikova@tiscali.cz 06 pink 08 gray 10 purple 15 white 45 white 20 yellow 50 yellow 25 red 55 red lenka.roubalikova@tiscali.cz 91 2 Taper 4% d2+ 0, 64 0,04mm na 1 mm 93 Taper 4% d2 d2=d1+0,96 0,06mm na 1 mm 94 Instrumentation Rotace tam a zpět — 45° K - reamer K- file Instrumentation Rotation K - reamer K- file lenka.roubalikova@tiscali.cz Instrumentation Filing H- file K - file lenka.roubalikova@tiscali.cz Instrumentation Ttechnika balancované síly — nástroj o 1 číslo větší než apikální velikost K- flexofile K - file (?) 180-270c lenka.roubalikova@tiscali.cz 98 Reaming Simple clockwise rotation lenka.roubalikova@tiscali.cz 99 lenka.roubalikova@tiscali.cz 100 Circumferential filing Introduction of th root canal instrument root canal. Pull motion - action. Staying in contact with the root canal wall Rotate without any action Go in and pull with action. lenka.roubalikova@tiscali.cz 101 Balance forced technique Go into the root canal rotating clockwise 90-180° Until the contact Slight pressure and rotate Contraclockwise 270° Pull out the instrument rotating clockwise again lenka.roubalikova@tiscali.cz 102 lenka.roubalikova@tiscali.cz HENTÁ H\ DROXID \ \ľl N \ I N p.a. CrtOHJj M 74.10 Antif logistický Dentinogenní Antimikrobiální efekt Suspenze Cementy Subbase Kořenová výplň - krátkodobě - střednědobě - dlouhodobě - pexCal® a m m • 'm • SPBSShL T iij •fflilr-Miiii ivoclar ". vivadenľ ■ W Indirect pulp capping Intermittent excavation Direct pulp capping Directly on dental pulp Dentin bridge Rests of calcium hydroxide Connectice tissue Calcified connective tissue Dentin Predentin Odontoblasts Access Burs Snesení stropu dřeňové dutiny, vytvoření „usnadňující formy" Batt (safe ended tips), Fissure bur Location of root canals Peeso - Largo Location and shaping ULTRASONICS & ENDODONTICS Main reasons to use ultrasonics in endodontic applications "Improved visualization combined with a more conservative approach when selectively removing tooth structure, particularly in difficult situations in which a specific angulation or tip design permits access to restricted areas, offers opportunities that are not possible with conventional treatment" JOE- "Ultrasonic in Endodontics" Feb 2007 Compared to burs/rotating instruments □ better view of the operative field 1 □ greater cutting precision (better control I of the amount of dentin removed) TECHNICAL FEATURE □ Hard-Tempered Stainless Steel □ Micro Milled Active Part —► minimized risk of potential diamond grit loss in the patient's mouth □ Water port —► cools down the insert and avoids overh^BBH^ the treated tooth (particularly important when removing metal posts) —► the intermittent use of irrigation enables the clinician to alternate between dry precision work and debris evacuation □ Two threads - Satelec type and EMS type START-X™ #1 - ACCESS CAVITY WALLS REFINEMENT m □ Non active tip -> avoids accidentally damaging the pulp chamber Floor □ Active lateral part -> eliminates interferences for a direct access into the canal START-X™ #2 - MB2 CANAL SCOUTER ■ □ Active tip —► transports the orifice of the MB2 from its original location (underneath the mesial wall) to the floor of the pulp chamber □ Active lateral part —► eliminates interferences for a direct access into the canal START-X™ #3 - CANAL OPENINGS SCOUTER - □ Active tip —> removes the obstructions that prevent a straight access to the canal (calcifications, filling materials, pulp stones) START-X™ #4 - METAL POST REMOVAL □ Specific design —*■ suitable for working efficiently both on the top and on the sides of the metal post □ Water port —► avoids over heating START-X™ #5 - PULP CHAMBER FLOOR - □ Active tip —► canal orifice location made easier thanks to the removal of calcifications and filling materials that hide the original floor anatomy iin & cylindrical —► good visibilit GLIDE ProFinder Files Smoother Progression in Tip Diameter Variable Decreasing Taper -(avoids taper lock effect) ^ ^ Depth Mar Silicone Handle ProFinder Files length from tip Decreasing Variable Taper avoids Taper Lock Effect Allows deeper scouting of the canal 0 1 Z 3 4 5 6 ? 8 9 10 1) K 13 14 15 16 » I I ' 1 I I I ' I I...... 9 Scout the canal with ProFinder Files 10,13 & 17 The lubricating action of Glyde helps the instruments to slide in the CFiles The ideal files for initial istrumentation of the root canals (catheterization) A new range of 3 NiTi files for mechanical Glide Path and preflaring PREFLARING & GLIDE PATH- IMPORTANCE □ Glide Path is an essential step: to fully understand and appreciate the anatomy of the canal to be treated (i.e. mentally develop a three dimensional image of the canal system to shape) to reduce the risk of rotary instrument breakage MANUAL PREFLARING - PROBLEMS □ The initial preflaring and glide path are normally carried out with stainless steel hand files. □ Because of the relative stiffness of these instruments, it can be difficult to avoid the Baffin canal transportation ledges apical zip PATHFILE™ - THE NEW SOLUTION PathFile™, a new rotary Nickel-Titanium solution am A new range available in 3 ISO sizes (013, 016 and 019) and 3 lengths (21, 25 and 31mm). e, they offer many advantages compared to manual solutio PATHFILE™ - FEATURES & BENEFITS NiTi - Square Section - 2% Taper □ high strength against cyclic fatigue □ flexibility Tip diameters (013-016-019) □ gradual increase that facilitates the progression of the files without the need for strong axial pressure PATHFILE™ - FEATURES & BENEFITS Tip design (transition angle reduction) Reduced risk of ledges and canal transportation PATHFILE™ - STANDARD SEQUENCE □ Scout and negotiation with a standard K-File #010 until it can move smoothly along the canal □ With same file, working length determination in combination with an Apex locator □ PathFile™ #013 to working length □ PathFile™ #016 to working length athFile™ #019 to working length □ Canal shaping with any NiTi rotary system PATHFILE™ - OTHER SEQUENCES LARGE AND EASY CANALS □ If it is possible to reach the full working length with a K-File #020, the Glide Path is not necessary and no PathFile™ will therefore have to be used. "INTERMEDIATE" CANALS □ If the user feels, during the initial scouting with the K-File 010, that the canal is rather wide, the recommendation is to use either PathFile™ 016 and 019 or even only PathFile™ 019, THIN, CUVED, CALCIFIED CANALS In these cases the standard sequence is recommended, i.e. PathFile™ 013, 016 and 019 PATHFILE™ - DIRECTIONS FOR USE □ Rotation speed - 300 rpm □ Instruments should be used with a delicate in/out movement until they reach the full length. Strong axial forces should therefore be avoided. □ Time needed to reach working length normally does not exceed 3-5 seconds/file □ The rotating motion will carry debris in a coronal direction ^-^^ ProFinder Files Smoother Progression in Tip Diameter Variable Decreasing Taper -(avoids taper lock effect) ^ ^ Depth Mar Silicone Handle Working length ■ Distance between referential point on tooth crown an apical constriction X- ray (safe length, estimation M_ of the position of the apical constriction) Apexlocators Apical morphology 1. X-ray apex 2. Apical foramen 3. Apical constriction 4. Periodontal ligament 5. Root cementum 6. Dentin Why RTC terminates in apical constriction? Small anical communication Less risk of damage pof periodontium Prevention of overfilling Prevention of apical transport of infected metarial Possibility of good removal of debris Good compaction of guttapercha L Principle of apexlocators Measurement of impedance Apexlocator can: find the apical constriction no irradiation fals results (abundant irrigation gingival polyps, metal posts or crowns, too dry root canal) Best results combination apexlocator plus x ray. DL/JM ^ 1 CI M II VJI 1 X - RAYS ? pex Locators DUAL Motor & Apex Locator Root canal shaping hand ower anven Nickeltitanium alloy 56 % nickel, 44% titanium, 60% nickel, 40 % titanium Flexibility Memory effect Cutting effect Fractures di 0,04mm na 1 mm Ni-Ti allows higher flexibility Higher taper can be used, flexible enough d2=d1+0,96 0,06mm na 1 mm Higher taper Good coronal access Higher effectivity of irrigation Good approach to the apical part of the root canal Good conditions for the root canal filling 2% taper 6% taper 30 u apexu 0,30 mm 30 u apexu 0,30 mm 35 1 mm od apexu 0,35 mm 30 1 mm 0d apexu 0,36 mm 40 2 mm od apexu 0,40 mm 30 2 mm od apexu 0,42 mm 45 3 mm od apexu 0,45 mm 30 3 mm 0d apexu 0,48 mm One instrument with the taper 6 % 4 instruments with the taper 2 % Crown down phase Blue - easy Red - middle Yelow - difficult Apical preparation: Green Crown down — from bigger taper and ISO size to smaller Apical preparation — from smaller to bigger ISO size Anical — coronal preparation Open the root canal first Than go to apical constriction with smaller instruments and take biger sizes after Less number of instruments CONTINUING EDUCATION CLINICAL EDUCATION Shaping with Protaper - Rotary and Hand use - Protaper Obturators MAILLEFF r r r UNIVERSAL The "Eiffel - Tower" shape Instrument INSTRUMENTS Variable Taper: - Prevents screw-in effect - Allows increased apical tapers (Finishing Files) - Allows excellent shaping with ew instruments Shaping File (S1 & S2 - Accessory Sx WW Shape the coronal and the middle third of the canal Variable Increasing Taper (Eiffel Tower shape) Shape the Apical part of the cana Fixed Taper Resistance Shaping Files Cutting blade (no radial land): Efficiency Triangular concave cross-section : Flexibility - Triangular convexe cross-section : Resistance Safe non cutting tip : acts as a guide SHAPING SX (accessory) 19 For Relocating Canal Orifice (only when needed) Sx is used with a brushing motion to relocate he orifice and insure a straight line access Basic rules of rotary endodontics Controlled rotation (low rpm - around 250 - 300 Moment of rotation (the instrument must not stop in contact with the root canal wall) Torque control Rotate the instrument before doing ti the root canal Irrigation and lubrication No pressure Push and pull motion Short intervals of shaping - 10 - 15 s Clean the instrument Do recapitulation Do not stay oh one point Touching the apical constriction - go out! Keep the sequency! NTINUING EDUCATION CLINICAL EDUCATION UNIVERSAL Treatment Sequence OR NiTi ROTARY INSTRUMENTS : Pathfiles □ PathFile™ #01 to working length ... 4. Establish to working length W|_ before o working length t&Glyde Vfii f prfp The lubricating action of Glyde helps the instruments to slide in the canal FILE PREP Root Caned Conditioner If need , use SX with a brushing motion to relocate the orifice of the canal and create a straight line access (don't use Sx deep in the canal) Use S1 with a brushing motion and enlarge the canal, no deeper than the level of the Ioenetration of the scouting file > make sure that the tip of S1 is never blocked) Using Pathfile, go to working length that you established right before After going to length with a stainless steel file size 15, use : S1 to working length with a brushing motion. Using Pathfile this step is skipped When S1 reaches working length, use : S2Xo working length with a brushing motion orking length, use : F1 to working length CAUTION ! I NEVER USE A BRUSHING } ACTION WITH THE FINISHING FILES !!! foramen with stainless steel files and if the foramen is larger than 20, use F2, F3, F4 or F5 to orking length, according to the real apical diameter. NEVER USE A BRUSHING ACn ION HTH THE Fh IISHIVG FILES III When a finishing file reaches length, it is immediately withdrawn. nenis sequence CONTINUING EDUCATION CLINICAL EDUCATION Treatment Sequence For Hand Use For Hand SS File Users Less Instruments No Canal Transportation Less Extruded Debris Excellent Apical Taper For NiTi Rotary Users In Case of Contra Indication to Continuous Rotation. (Example : Apical Hooks, joined canals) 3mm RECIPROC Wave One ■ One file endo Reciprocation ■ Minimuam risk of fracture ■ No risk of cross infection □ Reciprokation lulu OS'O lulu gg'o lulu 09'0 lulu gg'o LULU 0 LULU [ LULU Z I LULU £ lulu Of'O lulu 917'0 ww 29'0 lulu gg'n lulu gg'o wlu £C'0 lulu Uť'O lulu fiť'O j i LULU 0 LULU I LULU Z I LULU £ ooadioaa RECIPROC Dr. David Sonntag, Universita Düsseldorf RECIPROC® RECIPROC® sterilní papírové čepy RECIPROC® gutaperčové čepy ■ Metoda jednoho čepu ■ Vertikální kondenzace •Sumadaptedio •Col0u,c0d«J.depihn; •Stenle packWjn o ptia» ten awiwn) point Bigger taper Flaring Irrigation effectivity Good approach to apical area Good conditions for 3D root canal filling Disadvantages Loss of hard dental tissue Hihger risk of stripping Raciproc and Wave One have regressive taper Lower risk of stripping or fracture of the endodontically treated tooth y □ Basic rules of reciprocation instrumentation Switch the motor onafter the insgtmmkent is in the root canal Do three packs up and down (amplitue 3 mm) and take instrument off Create the glide path — ISO 10 for number 25 ISO 20 for instrument 40 Iso 30 for instrument 50 Irrigate the root canal Recapitulate Do not stay on one point Apical — coronal direction Controlled rotation Low rpm Moment of rotation Torque control Motor, handpiece Systems of power driven endodontics ■ ProTaper ■ MTWO Rotation ■ Wizard ■ Revo S □ Tilos 1 Oscillation □ Reciproc J Reciprocative movement Basic rules of power driven endodontics Controlled movement Keep the sequency The instrument moves befor ingoing to the root canal Irrigation, lubrication No pressure Movement up and down Working cycle 10 - 15 s Irrigation □ debridement Irrigation Canalaire: avantages potentialisation et sequence operatoire Irrigation NaOCl ISI LEI 5.0kV X2,000 10^m WD 9.0mm Core-Carrier (PP) - Gutta-Percha Filling Technique Finishing Files (Apical shape) Calibrated Gutta-Percha Cones Sterile Paper Points Obturators - Protaper sizes C -I i r T r r TTT ! IT 1 TT Paper points - Protaper sizes to each Finishing File hermaprep Oven 1st step : Opening cleaning Shaping Gauge the Canal with erifiers, which should snu within 0,5mm form Workin Length Verifier 2 he Canals with Sterile Paper Points Mix the Sealer and coat thewalls of the canal with a thin layer using a Probe or a paper point 0,6 0< 0,8 1.0 Heat Carrier