Endodontics
Endodontics - terms
• Endodont (dentin + pulp)
• Pulp chamber
• Root canal
• Apical constriction
• Apical foramen
• Ramifications
• Radiographic apex
• Periodontal space
Morphology
>The root canal is not round it is usually oval (long axis mesiodistal direction)
>The root canal is not straight - it deflects distal
> Apical foramen is not on the top of the root but under it (distal or distooral side)
Morphology
> Between apical constriction and apical foramen the wall of root canal are divergent towards periodontal space
> The root canal system has usually more foramina (ramifications)
> The ramifications are situated mostly in apical area (first apical mm)
> All apical foramina are situated in cementum
Apical morphology
1.
2.
3.
4.
5.
6.
Rtg apex
Foramen apicale
Apikälni konstrikce
Periodoncium
Cement
Dentin
Guidener a Langeland
Phases of the endodontic
treatment
* Investigation, diagnostic radiogram, consideration (local, regional, systemic factors)
* Removal of old fillings, carious dentin, temporary restoration - rubber dam.
* Dry operating field
* Preparation of the access (endodontic cavity)
Phases of the endodontic
treatment
• Opening of root canals
• Initial flaring and removal of content of root ca
• WL (working length)
• Root canal shaping and cleaning (irrigation)
• Recapitulation, final irrigation
• Drying
• Filling
• Radiogram
• Postendodontic treatment
Shapes of endo cavities
Number of root canals
Instruments
Ball burs
Preparation of the endodontic cavity
. ■	
	
	'J*
1	
	
1	i M
	i m
Dia trepan
Safe ended tips Batt's instruments
Fissur bur
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Endodontic probes
Opening of root canals
Peeso - Largo burs
Opening of the root cana
Insertion of root canal instrument after opening the pulp chamber and root canal orifice
Access cavity
Pulpextractor
Soft wire
Prickles like harpune Insertion
Contact with root canal wall - pull 1 mm Rotation
Exstirpation during pull motion
Canal shaping
> Reamers (penetration)
> Files (shaping)
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Reamer
K -reamer
Triangl or square wire spun
Symbol
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Parts of root canal inst
Bladed part Shank Stopper Grip
ents
Blades
pace for dentin chips
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Reamer
Rotation (clockwise) - penetration
Application of plastic material (contraclockwise)
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Files
1. K-file
2. K-flexofile, flexicut, flex-R file
3. K-flex
4. H-file, S-file
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Kfile
Wire triangl or square
Symbol is always square
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K-file
Filing
Also rotation
45° - 90°
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K-flexofile, flexicut, flex-R
Triangle wire always
Flexibility
K- flexofile a flex - R file: non cutting tip and first blades are blunt
Like K-file
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= Hedstroem file Ring
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H-fil
No rotation!!
Pull motion only!!
Risk of breakage in small sizes
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ISO
> Diameter of the tip
> Length of the cutting part >Taper
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d2= d! + 0,32
The diameter increases for 0,02 mm On 100 length
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Working length
• Distance between the referential point and apical constriction
• Radiographically
• Apexlocators
• Combination
Why apical constriction
Small apical communication
Minimal risk of damage of periodontium
Prevention of overfilling (extrusion of filling material)
Prevention of extrusion of infection
Good decontamination
Godd condition for root canal filling
Radiogram
X-ray with inserted root canal instrument
Safe length: average length of teeth reduced for 2 - 3mm
Tooth with clinical crown
Procedure
• Instrument ISO 15 introduced into the root canal, stop at the referential point
• Estimation of location of apical constriction (1 - 1,5 mm distance from x-ray apex.
If there is diference in the radiogram more than 2 mm - repeat
If 2 mm or less - add to the safe length = working length
Safe length
• Maxilla:
11 20
12 18 C22-24 P20
M 18 mkk,20 P
Safe length
• Mandible 118
C20 -22
P18
M18
Remember- the length is for teeth with complete crown !!!
Endometry, odontometry
• Endometry
devices based on measurement of electrical resistance
Apexlocator
Irrigation
Irrigants
• Sodium hypochlorite (1,5 - 6%)
• Chlorhexidin (0,12% - 0,2%)
• EDTA - etylendiaminotetraacetic acid 17%
Irrigants
• Sodiumhypochlorite
2-6%
- Oxidation a chloration
- Dissolving efect (dissolvs organic material biofilm, rests of dental pulp)
- Bad smell, irritation of soft tissues.
Irrigants
Chlorhexidine 0,12%-0,2%
- Antimicrobial effect - long term
- Do not dissolve smear layer
- Improves stability of biofilm
Irrigants
• EDTA 17%
Dissolves inorganic material (chelator) Important part of irrigation protocols
Irrigation protocols
• Combination of irrigants and their activation
Syringe and cannula
Blunt, side apertures,smallest ISO 35
Activation of irrigation
• Increased effectivity
Vibration - movement of liquid
Increasing of temperature of irrigants
Decomposition of irrigants - dissociation (dute to heating)
Shaping techniques
• Rotation -45° clockwise and contraclockwise
K - reamer K- file
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Shaping techniques
Rotation clockwise 45° pressure and pu motion
K - reamer
K- file
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Risk of ledging Zip, elbow effect Via falsa
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Shaping techniques
Filing - circumferential filing (filing along root canal walls - circumferentially)
H- file
K-file
Risk of periapical infection infection Risk of plug
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Shaping techniques
Balanced force
5«	
1 ^	
90-180°	
	
K- flexofile
K-file (?)
180-270'
180°-360°
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Balanced force
• Insert instrument one size bigger than apical size rotating 90° -180° clockwise
• With slight pressure forward rotate 180°-270°contraclockwise - dentinchips are cut
• Pull the instrument out (dentin chips are beibg transported out) - rotate 108°-360°clockwise
Methods of shaping
• Combination of rotation and filing K - reamer H-file Or K-file
Start with rotation
Finishing with filing
Suitable for straihgt root canals
Methods of shaping
• Step back method
Increasing size with decreasing length. Insertion of root canal instrument - WL Next - 1 mm shorter
Taper
Final flaring with
the smallest instrument
H- File nebo K - Flexofile. Prevention of extrusion of filling
Good for curved root canals
- rigidity of instruments
- is increaseing with increasing size
Method modified double flae
• I. Opening of root canal
- Coronal third
• II. Apical preparation
Cathetrization,measurement, shaping till ISO 30 -using balanced force. Master file - MAF (last instrument inserted to WL)
• III.Step back 3 -4times
• Final flaring (MAF)
Root canal filling
Good coronal, Middle Apical seal.
Quality guidelines for endodontic treatment, European Society of of Endodontology (ESE), 1994
Ideal root canal filling (Grossman 1988)
1. Easy mixing
2. Sufficient working time
3. Good seal
4. X- ray contrast
5. Easy removal
6. No shrinkage
7. Long term volume stability
8. No bacterial growing
9. No permeability for fluids
10. Biocompatibility
11. No staining
Classification of root canal fillings
> Solid
> Semisolid
> Pastes
Guttapercha
Dried juice of the Taban tree (Isonandra percha) (gutta)
1,4 - polyisoprene Crystallin structure (60%) Brittle
Guttapercha
* Beta phase
• Alpha phase 42-49 °C
- plastic
- Gamma phase 56 - 62° (amorfní) Cooling process
very slowly (less than 0,5°C) - alpha phase normal cooling- beta phase
Composition of guttapercha materials in endodontic
Guttapercha 19%-22% Zinc oxide 59 - 79% Heavy metal salts 1% - 7% Wax or resin 1% - 4%
Resilon
(Pent r o n)
> Thermoplastic synthetic polymer
> Points or material for injection
Composition: Polyester polymers Bioactive glass
Radioopaque fillers (bismuthum oxichlorid a and baryum sulphate)
Silver or titanium cones
>No good seal
>Silver cones - corrosion
Sealers
Chemically curing materials
(their consistency is paste, cements)
Good adhesion to root canal walls as well as solid cones
X- ray contrast
Biocompatibility
Importance
Filling of the spaces between the solid Seal of the root canal filling
Sealers
Zinc Oxide-Eugenol Chloropercha Calciumhydroxide Resins
Glasionomer Silicone
Zinc - Oxid Eugenol
Powder: Zinc oxide
Liquid: Eugenol Acidic resins
Good adhesivity, antimicrobial effect, cytotoxicity? Resorbable, no compatible with adhesive materials)
Zink Oxid Eugenol sealers
Pulp Canal Sealer (Kerr, USA)) Tubuli- Seal (Kerr, USA) Caryosan (Spofa Dental, CR)
Calciumhydroxide sealers
Base ( powder) Calcium hydroxide Zinc oxide
Other components and vehicula
Calcium hydroxide sealers
Catalyst (paste) Zinc stearat Titanium dioxide Baryum sulphate or
Eugenol,. Eukalypt Other components...
Kalciumhydroxide sealers
> Increase of the healig potential of periapical tissues
> Antibacterial effect
> Easy manipulation But!
Resorbable if not homogeneus
Not suitable for the single cone technique
Resins
>Rezorcin formaldehyd (toxic, obsolete) > Epoxide >Polyketone >M eta cry I ate
Epoxide resin
>Base (powder, paste) Bismuth oxid Titanium dioxide Hexametylentetramine (Silver)
> Catalyst (liquide, paste) Bisphenoldiglycidylether
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Epoxid resin (advantages)
> Long working time
> Hydrophilic (good penetration) >Good adhesion to the root canal walls
> Volume stability >No dissolution >Antibacterial
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Epoxid resins (disadvantages)
> Difficult removal
> Staining
> Initiatiory toxicity
AH 26, AH Plus, 2 Seal
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Polyketone
> Base Zinc oxide Bismuth phosphate Hexametylentetramine
> Liquid
Bisphenolglycidylether and other components
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Polyketon resins
Advantages Good adhesion No contraction No dissolution
Disadvantages High stickness Not removable
Products: Diaket, Diaket A(3M ESPE)
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Methacrylate resins
Endo ReZ (Ultradent) - UDMA
For injection - single cone technique
Epiphany (Pentron)
Bis- GMA, etoxy bif- GMA, hydrophilic bifunctional methacrylates
Calcium hydroxide, baryum sulphate, baryum glass silica.
Sealer in combination with Resilon
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Glasionomer sealers
>Base (powder) Aluminium silicate glass
> Liquid
Polyacrylic acid, polymaleic acid, tartaric acid
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Glasionomer sealers (Advantages and disadvantages)
Advantages:
Curing under wett conditions, chemical bonding to ha dental tissues, no staining
Disadvantages
Short working time, difficult removal,
porous
Products
Ketac Endo (3M ESPE), Endion (VOCO)
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Silicon based sealers
Polyvinylsiloxane (ev. in mixture with powdered guttapercha
Biocompatibility Hydrofillic
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Instruments
• Paste carries - lentulo
• Compactors
• Compactors - carriers
• Others
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i
>delivers pastes
>1,5 - 2 mm ahead
> for sealers
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Compactors
Spreader
Pointed
Vertical introduction
(cold, warm)
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Piu
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Use of a selected Plugger to ensure homogeneity of the filling.
Filling techniques
Cold Warm
Shrinkage, difficult removal
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Single cone technique
• Easy
• Fast
• Good control of WL
• Standard round preparation - risk of leakage
Wesselink, P.: Root filling techniques, Textbook of Endodontology; p. 286-299, Blackwell Munksgaard 2003, Oxford
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Lateral compaction
• Standard cold technique
Good control of WL Risk of the root fracture
Wesselink, P.: Root filling techniques, Textbook of Endodontology; p. 286-299, Blackwell Munksgaard 2003, Oxford
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LATERAL CONDENSATION
(compaction)
Lateral Condensation
A sealer is placed in the canal followed by a fitted gutta percha Master Point compacted laterally by a tapering Spreader to make room for additional accessory points
Complications of endodontic
treatment
Local Regional Systemic
Zipping a elbow
Local complications
Reasons
Insufficient irrigation and recapitulation
Loss of the working length
Solution
Repeated careful instrumentation with a thin instrument
Irrigation is not effective in this c&se111
Ledging
Reasons
The instrument is not bended in advance!
No control of the WL
No recapitulationLoss of the WL
Solution
The instrument must be bended in advance
Careful but complete rotation
Finishing with the fine filing
No NiTi!!!
Ledging
Zipping a Elbow
The instrument is not bended in advance!
Rotation in curved canals
Reasons
Bad orientation in morphology - no diagnostic Instruments are nod bended Rotary NiTi with a big taper
>. Oblast isthmu
Stripping
Bend the instrument and eventually blunt it!
FVil£IJjrS DJ xliS TOOL fiilJJilJ jusiriiiiisii'j;
Insufficient coronal flaring
Old root canal instrument
Aggresive force
Incorrect movement of the root canal instrument
Solution
Enlargement of the root canal till the instrument
Ultrasound tips
Rotating root canal instrument - caution!
Bypass
Leaving in
Surgical treatment
Fractured instrument
Via falsa
• Perforation of the bottom of the pulp chamber or the coronal part of the root canal
• Perforation in the middle part of the root canal
• Apical perforation
Regional complications
Damage of periodontium or surrounding tissues
Pištěl
Systemic complications
Systemic complications
> Periostitis
> Inflammation of soft tissues (face, neck)
>Gulp of the instrument (X ray, remnant diet, information)-
> Aspiration of the instrument -
Caution!
Always find the loss instrument
Safe work in endodontics
• Rubber dam
• Glassses