Irrigation of the root canal ❑ Removal of corpuscular material ❑ Desinfection Irrigants ✓ Sodium hypochlorite – 0,5% – 6% ✓Chlorhexidin (0,12 – 0,2%) ✓EDTA 17% solution or lubrication gel ✓ Hydrogen peroxide 3% ◼ Cannula Opening at sides Activation of irrigation ➢Hand ➢Ultrasound ➢Hydrodynamic ➢Laser Desinfection ➢ Calcium hydroxide ➢Antibiotics and corticosteroids Irrigants Sodium hypochlorite1,5 –6% Desinfection - oxidation a chloration Dissolves organic material (does not dissolve smear layer) Bad smell Risk of hemoragic necrosis in soft tissues lroubalikova@gmail.com 5 Irrigants ◼ Chlorhexidin 0,12%, 0,2%, 2% Good antibacterial spectrum Binding to surfaces Improves biofilm With calcium hydroxide - parachloranilin Does not dissolve smear layer Precipitation with calcium hydroxide lroubalikova@gmail.com 6 Irrigants ◼ EDTA 17% - 18% solution No significant antibacterial effect Dissolves smear layer Slightly decreases effect of sodium hypochlorite Is a part of lubficants (together with carbamide peroxide and vehiculum) lroubalikova@gmail.com 7 Irrigants ◼ Citric acid 20% roztok Dissolves smear layer. lroubalikova@gmail.com 8 Irrigation protocols ◼ Sodium hypochlorite Into access cavity and root canal (combination with lubrication gel on the root canal instrument – not necessary) lroubalikova@gmail.com 9 Irrigation protocols Sodium hypochlorite 2% - 6% (Uctivation with ultrasound 3x 20s v průběhu ošetření) ◼ EDTA 17% irrigation in final phase lroubalikova@gmail.com 10 Irrigation protocols ◼ NaOCl ◼ EDTA gel ◼ EDTA solution 18% 30s – 1min lroubalikova@gmail.com 11 Irrigation protocols ◼ NaOCl ◼ EDTA gel ◼ EDTA solution 18% 30s – 1min ◼ NaOCl 1min ◼ Sterile water ◼ Chlorhexidin 5 min lroubalikova@gmail.com 12 Activation of irrigation ◼ Sonic (Endo Activator) ◼ Ultrasound ◼ Laser (erbium laser, photodynamic activation – chromofor in the root canal) ◼ Hydrodynamic activation ◼ Endovac lroubalikova@gmail.com 13 3 speed sonic motor, 2’000, 6’000 and 10’000 cpm On/Off SONIC SYSTEM Well-shaped root canal. Custom protective barrier sleeves designed to slide over the handpiece Fix the tip Tip could be bent, if necessary the penetration, circulation and flow of irrigant Hydrodynamic activation serves to improve VIDEO Ultrasound EndoVac Active suction of the irrigant lenka.roubalikova@tiscali.cz 26 lenka.roubalikova@tiscali.cz 27 SEM ESEM Smear layer lenka.roubalikova@tiscali.cz 28 Clean root canal wall SEM ESEM Calcium hydroxide ➢Alcaline ➢Antibacterial ➢Stimulation of hard tissue formation ➢Haemostatic and antiphlogictic Calcium hydroxide Temporary root canal filling Subbase Component of sealers Mode of action ➢ Realease of hydroxyl ions ➢ Long term alkalinization ➢ Stimulation of hard tissues formation Koçkapan, C.:Curriculum Endodontie, p. 377-385, Quintessenz, Berlin 2003 Dressing Calcium hydroxide ◼ Short term action 1 – 2 weeks Desinfection, haemostasis Calcium hydroxide ◼ Midle term action 2 – 3 months Apexification Chronic form of apical periodontitis Calcium hydroxide ◼ Long term action 3 months and more Prevention of resprption Magistraliter The powder is mixed with destilled water Lentule 2 mm less than WL !!!!! Apexit® Plus ApexCal® Root canal filling Root canal filling Good coronal, Middle Apical seal. 1 2 3 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 (Pentron) ➢ 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 Sealers Importance Filling of the spaces between the solid cones 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, ČR) Chloropercha Powder Canadian balsam Resins Guttapercha Zinc oxide Liquid: Chloroform Resins Chloropercha Vlastnosti: Good adhesivity Shrinkage Toxicity 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 ➢Metacrylate lenka.roubalikova@tiscali.cz 59 Epoxide resin ➢Base (powder, paste) Bismuth oxid Titanium dioxide Hexametylentetramine (Silver) ➢Catalyst (liquide, paste) Bisphenoldiglycidylether lenka.roubalikova@tiscali.cz 60 Epoxid resin (advantages) ➢ Long working time ➢Hydrophilic (good penetration) ➢Good adhesion to the root canal walls ➢Volume stability ➢No dissolution ➢Antibacterial lenka.roubalikova@tiscali.cz 61 Epoxid resins (disadvantages) ➢ Difficult removal ➢ Staining ➢ Initiatiory toxicity AH 26, AH Plus, 2 Seal lenka.roubalikova@tiscali.cz 62 Polyketone ➢ Base Zinc oxide Bismuth phosphate Hexametylentetramine ➢ Liquid Bisphenolglycidylether and other components lenka.roubalikova@tiscali.cz 63 Polyketon resins Advantages Good adhesion No contraction No dissolution Disadvantages High stickness Not removable Products: Diaket, Diaket A (3M ESPE) lenka.roubalikova@tiscali.cz 64 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 lenka.roubalikova@tiscali.cz 65 Glasionomer sealers ➢Base (powder) Aluminium silicate glass ➢Liquid Polyacrylic acid, polymaleic acid, tartaric acid lenka.roubalikova@tiscali.cz 66 Glasionomer sealers (Advantages and disadvantages) Advantages: Curing under wett conditions, chemical bonding to hard dental tissues, no staining Disadvantages Short working time, difficult removal, porous Products Ketac Endo (3M ESPE), Endion (VOCO) lenka.roubalikova@tiscali.cz 67 Silicon based sealers Polyvinylsiloxane (ev. in mixture with powdered guttapercha Biocompatibility Hydrofillic Calcium hydroxide ➢Alcaline ➢Antibacterial ➢Stimulation of hard tissue formation ➢Haemostatic and antiphlogictic Calcium hydroxide ➢Alcaline ➢Antibacterial ➢Stimulation of hard tissue formation ➢Haemostatic and antiphlogictic Calcium hydroxide Temporary root canal filling Subbase Component of sealers Mode of action ➢ Realease of hydroxyl ions ➢ Long term alkalinization ➢ Stimulation of hard tissues formation Koçkapan, C.:Curriculum Endodontie, p. 377-385, Quintessenz, Berlin 2003 Dressing Calcium hydroxide ◼ Short term action 1 – 2 weeks Desinfection, haemostasis Calcium hydroxide ◼ Midle term action 2 – 3 months Apexification Chronic form of apical periodontitis Calcium hydroxide ◼ Long term action 3 months and more Prevention of resprption Magistraliter The powder is mixed with destilled water Lentule 2 mm less than WL !!!!! Apexit® Plus ApexCal® Calcium hydroxide Temporary root canal filling Subbase Component of sealers Dressing Magistraliter The powder is mixed with destilled water Lentule 2 mm less than WL !!!!! Calcium hydroxide ◼ Short term action 1 – 2 weeks Desinfection, haemostasis Calcium hydroxide ◼ Midle term action 2 – 3 months Apexification Chronic form of apical periodontitis Calcium hydroxide ◼ Long term action 3 months and more Prevention of resprption Apexit® Plus ApexCal® lenka.roubalikova@tiscali.cz 86 Instruments ◼ Paste carries - lentulo ◼ Compactors ◼ Compactors - carriers ◼ Others lenka.roubalikova@tiscali.cz 87 Lentulo ➢ delivers pastes ➢1,5 – 2 mm ahead ➢ for sealers lenka.roubalikova@tiscali.cz 88 Spreader Compactors Pointed Vertical introduction Lateral compaction technique (cold, warm) lenka.roubalikova@tiscali.cz 89 Plugger Not pointed Vertical introduction Vertical - compaction Compactors Filling techniques Cold Warm lenka.roubalikova@tiscali.cz 91 Shrinkage, difficult removal Paste only 92 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 lenka.roubalikova@tiscali.cz 93 94 ◼ Standard cold technique Wesselink, P.: Root filling techniques, Textbook of Endodontology; p. 286-299, Blackwell Munksgaard 2003, Oxford Lateral compaction Good control of WL Risk of the root fracture lenka.roubalikova@tiscali.cz 95 LATERAL CONDENSATION (compaction) F1 F2 F3 F4 F5F1 F2 F3 F4 F5 Standardized and non-standardized Paper Points and Gutta Percha Points 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 Finger Spreader SST and NiTi matching Gutta-Percha A-D Finger Spreader SST lenka.roubalikova@tiscali.cz 99 lenka.roubalikova@tiscali.cz 100 Warm lateral compaction Heated spreader Better 3D filling lenka.roubalikova@tiscali.cz 101 Modifiction – instead of spreader special instrument - rotary Insert a cone with sealer Apply a Finger Spreader along the points Then a new cone and again a Finger Spreader …. Hybrid Technique with Gutta-Condenser (Compaction acc to Mc Spadden) After each point of Gutta-Percha with sealer, use the GuttaCondensor to melt and fill the canal. lenka.roubalikova@tiscali.cz 104 Core-Carrier (PP) - Gutta-Percha Filling Technique Obturators compatible with instruments Calibrated Gutta-Percha Cones F1 F2 F3 F4 F5 Sterile Paper Points Finishing Files (Apical shape) F1 F2 F3 F4 F5 Paper points - Protaper sizes Obturators - Protaper sizes F2 ProTaper Obturator calibrated to each Finishing File F1 F2 F3 F4 F5 3D Filling of the Root-Canal System with THERMAFIL Or PROTAPER OBTURATOR Thermacut bur Post space burSize verifier to measure the apical size Thermaprep Oven 1st step : Opening cleaning Shaping … Core-Carrier Obturator Technique Gauge the Canal with Verifiers, which should snug within 0,5mm form Working Length 1 2 3 Place the Obturators Heat The Obturator Select the right size and start Dry the 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 Topseal MIX 1 2 3 Take it out and insert it in the canal Use of a selected Plugger to ensure homogeneity of the filling. Heat Carrier Plugger 0.5 0,6 0,8 1.0 WARM VERTICAL COMPACTION lenka.roubalikova@tiscali.cz 121 lenka.roubalikova@tiscali.cz 122 Injection Fast technique Possible extrusion of sealer Risk of thermal damage of PL lenka.roubalikova@tiscali.cz 123 Nejúčinnější metoda plnění kořenového kanálku Downpack Backfill HERMETICKY!, RYCHLE, A LEVNĚ zaplním lenka.roubalikova@tiscali.cz 125 3D plnění granulom Warm Vertical Compaction Continuous Wave Technique Heat Carrier Plugger Dr P. Machtou Similar technique to the Warm Gutta-Percha vertical condensation with Calamus device described later in this module SCHILDER Technique Other type of Heat-Carrier / Plugger Plugger Cone Fit & Plugger Selection Irrigation and desinfection of root canal system Manual Pluggers for compaction Fit a master cone Schilder Pluggers Heat-Carrier Plugger Machtou Pluggers Selection large size manual plugger Selection medium size manual plugger Selection small size manual plugger 4-5 mm Selection of the Heat Plugger 4-5 mm Down-Pack handpiece Plugger 3 sizes 1 warm pulp-tester Mesured paper point to Working Length Trim the master cone Insert lubricate (sealer) master cone Heat of the plugger Downpack : Vertical Condensation Activate Calamus and sear off the master cone Select the larger prefit, manual plugger and move Gutta Percha apically Activate Calamus and plunge 3-4 mm into the gutta-percha Desactivate Calamus 1-2 seconds, then remove “bite” of Gutta Percha Select the medium size, manuel plugger and move Gutta Percha apically Press apically for 5 seconds Activate Calamus, plunge deeper 3-4mm and wait 1-2 seconds after desactivate it Select small size manuel Plugger, move gutta-percha apically Press small Plugger 5 seconds into the apical third Downpack : Continuous Wave Technique Activate Calamus and sear off the master cone Select the larger prefit, manual plugger and move Gutta Percha apically Activate Calamus In one continuous motion press until the “stop” is at 2 mm of the reference point Desactivate Calamus, maintain firm apical pressure till the reference point is reached Maintain firm pressure for 10 seconds Activate Calamus for 1-2 seconds and desactivate , then remove the plugger This will separate and remove Gutta-Percha Select the small size, prefit manual plugger and condense the Gutta-Percha Downpack : Hybrid Technique Activate Calamus and sear off the master cone Select the larger prefit, manual plugger and move Gutta Percha apically, press 5 seconds to compact gutta-percha Activate Calamus and plunge 3-4 mm into the gutta-percha Desactivate Calamus maintain 5 seconds pressure to compact gutta.percha Activate Calamus Desactivate and maintain 5 seconds . Maintain apical pressure till the working depth is reached Activate Calamus 1-2 seconds Desactivate and remove the plugger. Select the small size, prefit manual plugger and condense the Gutta-Percha Backpack (backfill) Technique (flow) Calamus flow handpiece Internal view of activated flow handpiece Cartridge of Gutta-Percha Cartridge-tip bender Position the tip against the packed filling material #20(0,8) and #23(0,6) Placing warm tip against packed-material re-thermosoftens gutta-percha Activate Calamus flow , dispense 2-3 mm warm gutta-percha Select smaller prefit manuel plugger and condense material With the same plugger, press 5 seconds to avoid shrinkage during cooling phase Position tip 5 seconds aginst packed material Activate Calamus flow and dispense 3-4 mm warm gutta-percha With a prefit, medium size manual plugger condense the material And press the material for 5 seconds (avoiding shrinkage) Continue the backfilling in the same manner until the canal is full OR stop to accommodate a post for restorative VIDEO Dr Clifford Ruddle © Backpack Technique (flow) Calamus flow handpiece Internal view of activated flow handpiece Cartridge of Gutta-Percha Cartridge-tip bender Position the tip against the packed filling material #20(0,8) and #23(0,6) Placing warm tip against packed-material re-thermosoftens gutta-percha Activate Calamus flow , dispense 2-3 mm warm gutta-percha Select smaller prefit manuel plugger and condense material With the same plugger, press 5 seconds to avoid shrinkage during cooling phase Position tip 5 seconds aginst packed material Activate Calamus flow and dispense 3-4 mm warm gutta-percha With a prefit, medium size manual plugger condense the material And press the material for 5 seconds (avoiding shrinkage) Continue the backfilling in the same manner until the canal is full OR stop to accommodate a post for restorative Heat Carrier Plugger Dr P. Machtou Similar technique to the Warm Gutta-Percha vertical condensation with Calamus device described later in this module SCHILDER Technique Other type of Heat-Carrier / Plugger Plugger lenka.roubalikova@tiscali.cz 158 Complications of endodontic treatment Local Regional Systemic Plug of dentin chips Ledging Transportation of the root canal Via falsa Zipping a elbow Local complications Reasons Insufficient irrigation and recapitulation Loss of the working length Plug Solution Repeated careful instrumentation with a thin instrument Irrigation is not effective in this case!!! Reasons The instrument is not bended in advance! No control of the WL = No recapitulationLoss of the WL Ledging 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 Stripping Reasons Bad orientation in morphology – no diagnostic xInstruments are nod bended Rotary NiTi with a big taper Dangereous zones Mandibular molars – mesial roots Premolars, esp. maxillar Mandibular incisors Oblast isthmu Stripping Důkladný přehled! Šetřit oblast isthmu! Ruční preparace! Menší kónus NiTi ! Stripping Bend the instrument and eventually blunt it ! Insufficient coronal flaring Old root canal instrument Aggresive force Incorrect movement of the root canal instrument Fracture of the root canal instrument Reasons Solution Enlargement of the root canal till the instrument Ultrasound tips Rotating root canal instrument – caution! Bypass Leaving in Surgical treatment Bypass Fractured instrument Obliteration Partial Obliterace Access!!! Hand thion Instrument! Steel or NiTi EDTA Patience Obliterace Úplná - ponechat. Resorption Calcium hydroxide Long term Middle term Short term 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 MTA composition ◼ Dicalcium silicate ◼ Trikalcium silicate ◼ Trikalcium aluminate ◼ Tetrakalcium aluminate ◼ Cuprum sulphate ◼ Bismuthum trioxide = Portland cement MTA ◼ Umožňuje hojení – dobrý okrajový uzávěr ! Zabraňuje přístupu mikroorganismům, umožňuje hojení dřeně a periodoncia tvrdou tkání. Via falsa - treatment ◼ No bleeding ◼ Desinfection ◼ MTA – moisture (wet cotton pellet) ◼ Calcium hydroxide ◼ Filling Via falsa ◼ Perforace apikálně Hydroxid kalcia, kořenová výplň. MTA ◼ Umožňuje hojení – dobrý okrajový uzávěr ! Zabraňuje přístupu mikroorganismům, umožňuje hojení dřeně a periodoncia tvrdou tkání. Zdroj: Manuál firmy Maillefer Regional complications Píštěl Systemic complications Systemic complications ➢Periostitis ➢Inflammation of soft tissues (face, neck) ➢Gulp of the instrument (X ray, remnant diet, information)- cough ➢Aspiration of the instrument -emesis Caution! Always find the loss instrument !!!!!! Obliteration Partial Obliterace Access!!! Hand thion Instrument! Steel or NiTi EDTA Patience Obliterace Úplná - ponechat. Resorption Calcium hydroxide Long term Middle term Short term