Endodontic treatment – from acces to the working length [USEMAP] RCT – root canal treatment • •Irreversible pulpitis •Necrosis •Gangraena •Periodontitis [USEMAP] Phases of the endodontic treatment •Investigation, diagnostic radiogram, consideration ( local, regional, systemic factors) • •Preendodontic treatment • • [USEMAP] Preendodontic treatment •Removal of old fillings, carious dentin, temporary restoration - contours of treated tooth. •Gingivectomy or elongation of clinical crown if necessary. radixretrakspona [USEMAP] • • •Dry operating field – rubber dam • •See presentation Dry operation field • • [USEMAP] trepanace Access [USEMAP] Phases of the endodontic treatment •Opening of root canals •Initial flaring and removal of content of root canal •WL (working length) •Root canal shaping and cleaning (irrigation) •Recapitulation •Drying •Filling •Radiogram •Postendodontic treatment • • [USEMAP] Shapes of endo cavities See special material on is [USEMAP] Number of root canals First maxillary molar – 4 root canals MB1, MB2, D, P First mandibulary molar – 3 root canals ML MB D, also 4 ML MB DL DB 2 M and D [USEMAP] diatrepan Dia trepan diakulicky kuličky Dia balls Ball burs Instruments [USEMAP] lenka.roubalikova@tiscali.cz 11 diatrepan Dia trepan Fissure bur battovy Safe ended tips Batt´s instruments fissurka Preparation of the endodontic cavity [USEMAP] Find of root canals microopenery sondy uzšpičky Endodontic probes, microopeners Ultrasound tips [USEMAP] Opening of root canals kuličky millery gatesgliddeny peesolarga1 Ball burs Miller‘s burs Gates Glidden‘s burs Peeso – Largo [USEMAP] lenka.roubalikova@tiscali.cz 14 Finding of the root canal orifice FO 20 pré preshaping01 FO 20 post Kopie preshaping1 [USEMAP] cavity_access_z_set.tif cavity_acces_set.jpg Access kits [USEMAP] fraise diamronde [USEMAP] fraise trans metal 2 [USEMAP] Pr_s ronde carbure [USEMAP] effraction 3 [USEMAP] lenka.roubalikova@tiscali.cz 20 0614203717_1 0614203717_5 0614203717_7 Gates - Glidden Peeso-Largo [USEMAP] lenka.roubalikova@tiscali.cz 21 Gates – Glidden: Tupá, neaktivní vodící špička Naprogramované místo zlomu gates 0614203717_7 [USEMAP] preshaping01 Opening of root canal orificies [USEMAP] Kopie preshaping1 After opening of the access and shaping of the root canal orifice [USEMAP] X-Gates X-GATES Velikost hrotu : Gates 1 Maximální průměr – Gates 4 Dřík: Gates 3 Místo zlomu [USEMAP] Xgate1 [USEMAP] cavit_ finie [USEMAP] lenka.roubalikova@tiscali.cz 27 Rozšíření vstupu do kořenových kanálků 0511192039_7 GTprehl Ni-Ti nástroje S velkou kónicitou (kónusem) Např.: ProFile O.S., ProTaper SX, IntroFile aj. [USEMAP] Ultrasound • • • • Less invasive – better overview • 5 pointes Start-X.jpg [USEMAP] [USEMAP] [USEMAP] lenka.roubalikova@tiscali.cz 31 0613234012_62 The pulp chamber correctly open [USEMAP] 32 Finding and opening of rot canal orifices microopenery sondy uzšpičky Endodontic probes Microopeners Ultrasound tips [USEMAP] lenka.roubalikova@tiscali.cz 33 Finding and opening of root canal orifices kuličky millery gatesgliddeny peesolarga1 Rounded burs - balls Miller´s burs Gates Glidden´s burs Peeso – Largo [USEMAP] lenka.roubalikova@tiscali.cz 34 0614203717_1 0614203717_5 0614203717_7 Gates - Glidden Peeso-Largo [USEMAP] lenka.roubalikova@tiscali.cz 35 Gates – Glidden: Blunt, non active tip Programm point of breakage gates 0614203717_7 [USEMAP] 36 dren Pulpextractor 0614211119_3 C:\Users\Elite\Desktop\vajbar pulpa.jpg Soft wire Prickles like harpune Insertion Rotation Exstirpation histol Dental pulp [USEMAP] Initial flaring – glide path • - -Learn the morpholoogy of root canals - Minimize the risk of fractures [USEMAP] Hand instruments •C- file, C-pilot, ProFinder File etc. • •Instruments should be precurved • •Manual preflaring - – – [USEMAP] N:\DM_Marketing\5-MARKETING PRODUITS\A-ENDO\A2 - Treatment\C+ File_A012X\Images\JPEG\Cover.jpg N:\DM_Marketing\5-MARKETING PRODUITS\A-ENDO\A2 - Treatment\C+ File_A012X\Images\JPEG\Tip.jpg N:\DM_Marketing\5-MARKETING PRODUITS\A-ENDO\A2 - Treatment\C+ File_A012X\Images\JPEG\Prod.jpg N:\DM_Marketing\5-MARKETING PRODUITS\A-ENDO\A2 - Treatment\C+ File_A012X\Images\JPEG\Square.jpg C- File [USEMAP] couv_profinder ProFinder File Regressive taper Silicone grip, regressive taper [USEMAP] ProFinder File shema-profinder10 Regressive taper [USEMAP] lenka.roubalikova@tiscali.cz 42 Canal shaping • Ø Reamers (penetration) Ø ØFiles ( shaping) [USEMAP] lenka.roubalikova@tiscali.cz 43 Reamer • •K -reamer •Triangl or square wire spun • •Symbol reamer [USEMAP] 44 Reamer reamer reamerdetail Bladed part Shank Stopper Grip Blades Space for dentin chips [USEMAP] 45 Reamer reamerdetail 20° Blades Space for dentin chips Rotation – reaming achtion - panetration [USEMAP] 46 Reamer • •Rotation (clockwise) – penetration • •Application of plastic material (contraclockwise) [USEMAP] 47 Files 1.K-file 2.K-flexofile, flexicut, flex-R •3. K-flex •4. H-file, S-file 1. 1. 1. • • [USEMAP] 48 K file •Wire triangl or square kfile Symbol is always square [USEMAP] 49 K-file • • •Filing •Also rotation •45° – 90° kfiledetail 40° [USEMAP] 50 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 • [USEMAP] 51 K- flex • Rhombus Two blades in action Enough space for dentin chips Flexibility, effifacy [USEMAP] lenka.roubalikova@tiscali.cz 52 • reamer a kfile K-file and reamer: the difference [USEMAP] lenka.roubalikova@tiscali.cz 53 H-file •= Hedstroem file • •Ring hedstrom1 hfile [USEMAP] lenka.roubalikova@tiscali.cz 54 H- file • hedstroemdetail 60° No rotation!! Pull motion only!! Risk of breakage in small sizes [USEMAP] lenka.roubalikova@tiscali.cz 55 ISO ØDiameter of the tip ØLength of the cutting part ØTaper reamer [USEMAP] lenka.roubalikova@tiscali.cz 56 06 08 10 15 45 20 50 25 55 30 60 35 70 40 80 Úzký svislý Size – diameter at the tip [USEMAP] Stainless steel • [USEMAP] lenka.roubalikova@tiscali.cz 58 d1 d2 d2= d1 + 0,32 Taper 2% 0,02 mm na 1mm d1 – d2 = 16 mm [USEMAP] lenka.roubalikova@tiscali.cz 59 •Niti alloy • •56 % nickel, 44% titanium, •60% nickel, 40 % titanium •flexibility •memory effect •Cutting effifacy? • • flexmaster [USEMAP] d1 d2+ 0, 64 d2 0,04mm na 1 mm [USEMAP] lenka.roubalikova@tiscali.cz 61 d1 d2 d2=d1+0,96 Taper 6% 0,06mm na 1 mm [USEMAP] lenka.roubalikova@tiscali.cz 62 drat drat1 kk [USEMAP] lenka.roubalikova@tiscali.cz 63 protaperprurez flex radial [USEMAP] Working length • Distance between the referential point and apical constriction • •Radiographically • Apexlocators • Combination flexmaster LR [USEMAP] Why apical constriction •Small apical communication •Minimal risk of damage of periodontium • Prevention of overfilling • Prevention of extrusion of infection • Good decontamination • Godd condition for root canal filling LR [USEMAP] Radiogram •X-ray with inserted root canal instrument • •Safe length: average length of teeth reduced for 2 – 3mm • •Tooth with clinical crown [USEMAP] Safe length Averige length of the tooth less 2 mm • Maxilla: •I1 20 •I2 18 •C22-24 •P20 •M 18 mkk,20 P [USEMAP] Safe length Averige length of the tooth less 2 mm • Mandible •I 18 •C20 -22 •P18 •M18 [USEMAP] Procedure • Instrument ISO 15 inserted 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 diference in the radiogram more than 2 mm - repeat • If 2 mm or less – add to the safe length [USEMAP] Endometry, odontometry • •Endometry edevices based on measurement of electrical resistance LR [USEMAP] LR [USEMAP] odsatuitekutiny mereniapexlokatorem mereniapexlokatorem1 LR [USEMAP] RAYPEX® 6 RAYPEX® 6 [USEMAP] RAYPEX® 6 RAYPEX® 6 [USEMAP] lenka.roubalikova@tiscali.cz 75 Canal shaping and cleaning • Basic rules ØElimination of infection ØEnlargement till the apical constriction – simplify the shape Ø6% taper of thr rot canal at teh end of the shaping Ø Gangraena – clean chips • • • [USEMAP] lenka.roubalikova@tiscali.cz 76 Canal cleaning q Elimination of infection • •Mechanically – instrumentation, irrigation • •Chemically – irrigiation, temporary root canal • filling [USEMAP] lenka.roubalikova@tiscali.cz 77 Canal shaping •Coronal flaring (Weine 1982, Peřinka 2003) • • • Kopie preshaping1 gatesgliddeny [USEMAP] lenka.roubalikova@tiscali.cz 78 Gates Glidden 50 70 90 110 K-File 15 Gates Glidden 50 Simple canals gatesgliddeny [USEMAP] lenka.roubalikova@tiscali.cz 79 Hand instruments till 50 Gates Glidden 50 70 90 110 K-File 15 Gates Glidden 50 Narrow canals gatesgliddeny [USEMAP] 80 NiTi systém – decreasing size speed 250 - 300 rpm 0511192039_7 [USEMAP] 81 Importance •Protection against fracture •Better cleaning of coronal part (effective transport of debris) •Effective irrigation •Better conditions for measurement of working length •Better conditions for apical preparation •Less risk of complication [USEMAP] lenka.roubalikova@tiscali.cz 82 Shaping technique •Rotation • K – reamer K- file [USEMAP] lenka.roubalikova@tiscali.cz 83 Shaping technique •Rotace 45° tlak and pull motion • K – reamer K- file Risk of ledging Zip, elbow effect Via falsa - perforation [USEMAP] lenka.roubalikova@tiscali.cz 84 Shaping technique •Filing - push and pull motion. The file is in action durinh the pull motion H- file S- file K – file Risk of periapical infection Risk of plug [USEMAP] Balanced force technique – 1st step • • •Insertion of the instrument one ISO size bigger than apical size of the root canal untill the instrument comes to the contact with the root canal wall. Rotation 90 – 180°Very slight pressure – the instrument is reaches the WL. • • • • [USEMAP] Balanced force technique – 2nd step step • • •Rotation of the instrument conmtraclockwise 180 -270°, pressure forward. Dentin chips are broken. • • • [USEMAP] Balanced force technique – 3rd step • •The instrumentid is being pulled out and is rotating clockwise – the debris is being removed. • • [USEMAP] 88 Shaping technique • Balanced force • K- flex- O- file K – flex- R - file 90-180° 180 – 270° [USEMAP] Methods of shaping • • •Combination of various technique lenka.roubalikova@tiscali.cz 89 [USEMAP] Methods of shaping • •Circumferential filing • • •Filing around the root canal – circumferentially. The shape of the root canal is kept. • lenka.roubalikova@tiscali.cz 90 [USEMAP] lenka.roubalikova@tiscali.cz 91 nastroje1 Dr. Sedlmayer [USEMAP] lenka.roubalikova@tiscali.cz 92 Methods of shaping •Step back H- file K-file K-flexofile Apical stop Prevention of the ledge [USEMAP] weinekonus 30 Apex 0,30 mm 35 1 mm 0,35 mm 40 2 mm 0,40 mm 45 3 mm 0,45 mm 2% taper od the root canal instrument 6% taper of the root canal [USEMAP] weinekonus Initial flaring Establishment of WL Shaping till the WL, the last instrument MAF Shortening of next instruments (2-3 instruments) Final flaring with the MAF [USEMAP] lenka.roubalikova@tiscali.cz 95 Methods of root canal shaping •Modified double flared with balanced force 1.Coronal flaring) 2.Apical preparation balanced force 3.Step back 4.Final flaring (filing) 5. [USEMAP] Method modified double flaerd •I. Opening of root canal •- Coronal third – coronal flaring •II. Apical preparation •Cathetrization,measurement, shaping till ISO 30 – 35 balanced force. Master file – MAF (till WL) •III.Step back •Final flaring (MAF) [USEMAP] Root canal irrigation qDebris removal q Disinfection [USEMAP] aet3 [USEMAP] acko [USEMAP] nesnadne1 CANTATORE G. Irrigation Canalaire: avantages potentialisation et sequence operatoire Endo Contact 1999 - 5:13-21 NaOCl Cantoresmear acko1a Irrigants •NaOCl (sodiumhypochlorit) • • 2 – 6% -Oxidation and chloration -Irritation, risk of heamorrgagic necrosis [USEMAP] Irrigants •Chlorhexidin • •0,12% -0,2% (a 2%) •Long term binding to surfaces •Good antimikrobial spectrum • •No dissolving effect • [USEMAP] Irrigants •EDTA • 17% • •No antimicrobial efec •Dissolves smear layer •It is a part of irrigation protocols •It is a components of lubricants tohether with urea peroxide and carbopol [USEMAP] Irrigants •Saline solution • •When an inert irrigants is necessary •(surgical treatmen, widely open apex) [USEMAP] Syringe and canula •Blunt, side perforations, flexible tip • •Screw • •Irrigant must not be applied with pressure • •The liquid is streaming in the root canal • • • DSC_0100 [USEMAP] Activation of irrigation •Increasing of effectivity • •Vibration • •Increasing of temperature • •Decomposition of sodiumhypochlorite [USEMAP] Activation •Hydrodynamic •Sonic •Ultrasonic •Laser [USEMAP] Activation •Sodium hypochlorite (3x 20s) • •EDTA (1 min) • •Activation of other irrigants without any effect • [USEMAP] Protocol of irrigation •Hand instrumentation - NaOCl • •Power driven instrumentation – NaOCl. • •Recapitulatiom – NaOCl • •Final protocol – EDTA + NaOCl + activation • •Amount of irrigants – 10ml/root canal, velocity 1ml/min. • •Never combine sodium hypochlotite and chlorhexidim [USEMAP]