Endodontic treatment - from acces to the working length
RCT- root canal treatment
Irreversible pulpitis Necrosis Gangraena Periodontitis
Phases of the endodontic treatment
Investigation, diagnostic radiogram, consideration (local, regional, systemic factors)
Preendodontic treatment
Preendodontic treatment
* Removal of old fillings, carious dentin, temporary restoration - contours of treated tooth.
* Gingivectomy or elongation of clinical crown if necessary.
* Dry operating field - rubber dam
See presentation Dry operation field
Access
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
Shapes of endo cavities See special material on is
Number of root canals
First upper molar - 4 root canals
Instruments
Dia trepan
Dia balls
Preparation of the endodontic cavity
Dia trepan
Safe ended tips Batt's instruments
Fissure bur
lenka.roubalikova@tiscali.cz
11
Find of root canals
Endodontic probes, microopeners
Ultrasound tips
4
Opening of root canals
Peeso - Largo
Finding of the root canal orifice
Gates — Glidden: Tupá, neaktivní vodící špička Naprogramované místo zlomu
ler&a. roubalikova@tiscali.cz
Opening of root canal orificies
After opening of the access and shaping of the root canal orifice
X-GATES
Velikost hrotu : Gates 1
Místo zlomu
Maximální prumer - Gates 4
Dřík: Gates 3
Ni-Ti nástroje
S velkou konicitou (kónusem)
Např.: ProFile O.S., ProTaper SX, IntroFile
Ultrasound
The pulp chamber correctly open
lenka.roubalikova@tiscali.cz
31
Finding and opening of rot canal orifices
32
Finding and opening of root canal orifices
Rounded burs - balls    Miller's burs
i ř ř
A i
A A A A
- it i
5 a
Gates Glidden's burs
in
A A A A A
i
I
J i        |i        ii ill
lenka.roubalikova@tiscali.cz
Peeso - Largo
Gates - Glidden: Blunt, non active tip
ProgramrfTpoint of brea
lenka.roubalikova@tiscali.cz
Pulpextractor
Dental pulp
Exstirpation
Initial flaring - glide path
Learn the morpholoogy of root canals Minimize the risk of fractures
Hand instruments
C- file, C-pilot, ProFinder File etc. Instruments should be precurved Manual preftaring
ProFinder File
Regressive taper
Silicone grip, regressive taper
length from tip
0 1   z  3 4 5  fi   ? B J ID 11 1Z 13 U 15 1J5
1 I   I   I   ].........-II
Canalshap
> Reamers (penetration)
> Files (shaping)
lenka.roubalikova@tiscali.cz 42
Reamer
K -reamer
Triangl or square wire spun
Symbol
lenka.roubalikova@tiscali.cz
43
44
45
Reamer
Rotation (clockwise) - penetration
Application of plastic material (contraclockwise)
46
Files
K-file
K-flexofile, flexicut, flex-R K-flex
H-file, S-file
47
Kfile
Wire triangl or square
Symbol is always square
48
K-file
Filing
Also rotation
45°-90°
49
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
4
50
K- flex
Rhombus
Two blades in action
Enough space for dentin chips
Flexibility, effifacy
51
lenka.roubalikova@tiscali.cz
52
H-file
= Hedstroem file Ring
lenka.roubalikova@tiscali.cz
53
H-fil
No rotation!!
Pull motion only!!
Risk of breakage in small sizes
lenka.roubalikova@tiscali.cz 54
ISO
> Diameter of the tip
> Length of the cutting part
> Taper
lenka.roubalikova@tiscali.cz
55
lenka.roubalikova@tiscali.cz
56
Stainless steel
* Niti alloy
56 % nickel, 44% titanium, 60% nickel, 40 % titanium flexibility memory effect Cutting effifacy?
lenka.roubalikova@tiscali.cz
lenka.roubalikova@tiscali.
Vysoce kvalitní NiTi slitina
lenka.roubalikova@tiscali.cz
63
lenka.roubalikova@tiscali.cz
64
lenka.roubalikova@tiscali.cz
65
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
• 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
Safe length Averige length of the tooth less 2
• Maxilla:
11 20
12 18 C22-24 P20
M 18 mkk,20 P
Safe length Averige length of the tooth less 2
• Mandible 118
C20 -22
P18
M18
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
Endometry, odontometry
• Endometry
edevices based on measurement of electrical resistance
Canal shaping and cleaning
• Basic rules
> Elimination of infection
> Enlargement till the apical constriction -simplify the shape
> 6% taper of thr rot canal at teh end of the shaping
> Gangraena - clean chips
<5
lenka.roubalikova@tiscali.cz
78
Canal cleaning
□ Elimination of infection
Mechanically - instrumentation, irrigation
Chemically - irrigiation, temporary root canal filling
lenka.roubalikova@tiscali.cz 79
Canal shaping
Coronal flaring (Weine 1982, Perinka 2003)
lenka.roubalikova@tiscali.cz
80
Simple canals
I I f
A
A
V
Gates Glidden 50 70 90 110
K-File 15
Gates Glidden 50 4}
lenka.roubalikova@tiscali.cz
Narrow canals
A
Si
Hand instruments till 50 Gates Glidden 50 70 90 110
K-Filel5 Gates Glidden 50
lenka.roubalikova@tiscali.cz
NiTi systém — decreasing size
speed 250 - 300 rpm
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 4}
Shaping technique
Rotation
K - reamer
K- file
lenka.roubalikova@tiscali.cz
85
Shaping technique
Rotace 45° tlak and pull motion
K - reamer
K- file
Risk ofledging
Zip, elbow effect
Via falsa - perforation
lenka.roubalikova@tiscali.cz 86
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
lenka.roubalikova@tiscali.cz
87
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.
Balanced force technique - 2nd step
step
Rotation of the instrument conmtraclockwise 180 -270°, pressure forward. Dentin chips are broken.
Balanced force technique - 3rd step
• The instrumentid is being pulled out and is rotating clockwise - the debris is being removed.
Shaping technique
Balanced force
K- flex- O- file
90-180
o
K - flex- R - file
180-270
4
91
Methods of shapin
Combination of various technique
lenka.roubalikova@tiscali.cz
Methods of shaping
Circumferential filing
Filing around the root canal - circumferentially. The shape of the root canal is kept.
4
lenka.roubalikova@tiscali.cz
93
Methods of shaping
Step back
H-file K-file
Apical stop K-flexofile
Prevention of the ledge
lenka.roubalikova@tiscali.cz 95
2 % taper od the root canal instrument 6 % taper of the root canal
30 Apex 0,30 mm
35 1 mm 0,35 mm
40 2 mm 0,40 mm
45 3 mm 0,45 mm
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
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)
lenka.roubalikova@tiscali.cz
98
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)
• Ill.Step back
• Final flaring (MAF)
Root canal irrigation
□Debris removal
CANTATORE G
Irrigation Canalaire: avantages potentialisation et sequence operatoire
Endo Contact 1999 - 5:13-21
Irrigants
• NaOCI (sodiumhypochlorit) 2-6%
- Oxidation and chloration
- Irritation, risk of heamorrgagic necrosis
• Chlorhexidin
0,12%-0,2% (a 2%)
Long term binding to surfaces
Good antimikrobial spectrum
No dissolving effect
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 ^
Irrigants
• Saline solution
When an inert irrigants is necessary (surgical treatmen, widely open apex)
Syringe and canula
Blunt, side perforations, flexible tip
Screw
Irrigant must not be applied with pressure
The liquid is streaming in the root canal
4
Activation of irrigation
• Increasing of effectivity Vibration
Increasing of temperature Decomposition of sodiumhypochlorite
Activation
Hydrodynamic Sonic Ultrasonic Laser
Activation
• Sodium hypochlorite (3x 20s)
• EDTA(lmin)
• Activation of other irrigants without any effect
Protocol of irrigation
• Hand instrumentation - NaOCI
• Power driven instrumentation - NaOCI.
• Recapitulatiom - NaOCI
• Final protocol - EDTA + NaOCI + activation
• Amount of irrigants - lOml/root canal, velocity lml/min
• Never combine sodium hypochlotite and chlorhexidim