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Objectives of RCTObjectives of RCT

To render the affected toothTo render the affected tooth

a)a) Biologically acceptableBiologically acceptable

b)b) Symptoms freeSymptoms freec)c) Functioning without a diagnosable pathosisFunctioning without a diagnosable pathosis

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Phases of Endodontic TreatmentPhases of Endodontic Treatment

A) Diagnostic phaseA) Diagnostic phase

B) Cleaning and shaping phaseB) Cleaning and shaping phase

C) Obturation phaseC) Obturation phaseD) Follow upD) Follow up

1) Condition of the tooth is

Determined2) Plan of treatment is

developed

Pulp chamber and root canalsare cleaned and enlarged to

receive the filling

Root canals are filled with an

inert material to achieve aFluid tight seal as close to the

Anatomic apex as possible

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Contraindications for RCTContraindications for RCT

A) Patient related factorsA) Patient related factors

B) Tooth related factorsB) Tooth related factors

1) Uncooperative patient2) Indifferent patient

3) Cost

1) Insufficient periodontal

Support

2) Extensive root resorption

3) Non restorable tooth4) Non strategic tooth

5) Vertical root fracture

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Diagnosis

Diagnosisa)a) Patient information (symptoms)Patient information (symptoms)

b)b) Clinical examination (signs)Clinical examination (signs)

1. Chief complaint

2. Type, duration and site complaint

A) Observations E/O swelling

I/O swelling

Tooth discoloration

Deep carious lesion Recurrent caries between old restorations

Fistula

B) Tests:Vitality tests

Radiograph

Percussion test

Palpation testPeriodontal probing

Mobility test

Transillumination

Cavity test

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Radiographic Film

Hemostat

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DiagnosisDiagnosis

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Other diagnostic toolsOther diagnostic tools

Ice

CO2 Snow

Ethyl Chloride

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DiagnosisDiagnosis

Specialized Devices

(Vascular pulp elements)

b- Pulp Oximetrya- LaserD

oppler Flowmetry

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DiagnosisDiagnosis

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Watch out?????????Watch out?????????

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Limitations of thermal testsLimitations of thermal tests

False +ve response in case ofFalse +ve response in case ofliquifactive necrosisliquifactive necrosis

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Limitations of electric pulp testersLimitations of electric pulp testers

A)A) Variables:Age, stress, Drugs, pain thresholdVariables:Age, stress, Drugs, pain threshold

B)B) FalseFalse ve :ve :1.1. Recently erupted toothRecently erupted tooth

2.2. Recent traumaRecent trauma

3.3. Pulp calcificationPulp calcification

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Limitations of electric pulp testersLimitations of electric pulp testers

C) False +veC) False +ve1. Multi1. Multi--rooted teethrooted teeth

2. Liquifactive necrosis2. Liquifactive necrosis

3. Wrong position of tip on gingiva3. Wrong position of tip on gingiva

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Pulp diseasesPulp diseases

Just to know:Just to know:The inflammatory process in the pulp is basically the sameThe inflammatory process in the pulp is basically the same

as elsewhere in the body C.T, but two main factorsas elsewhere in the body C.T, but two main factorschange the normal reparative process into irreversiblechange the normal reparative process into irreversibleprocessprocess

1.1. Totally surrounded by hard tissue : limiting tissueTotally surrounded by hard tissue : limiting tissueexpansion restricting pulp ability to tolerate pulpexpansion restricting pulp ability to tolerate pulp

edemaedema2. Lack of collateral circulation2. Lack of collateral circulation

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Causes of pulp diseasesCauses of pulp diseases

A)A) MicrobialMicrobial

B)B) ThermalThermal

C)C) TraumaticTraumaticD)D) ChemicalChemical

E)E) Idiopathic (internal resorption)Idiopathic (internal resorption)

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A) Inflammatory diseases of the pulpA) Inflammatory diseases of the pulp

1)1) Reversible pulpitis (Hyperaemia)Reversible pulpitis (Hyperaemia)

2)2) Acute pulpitis (Irreversible pulpitis):Acute pulpitis (Irreversible pulpitis):

a)a) Stage I: pain hot (V.D.Pressure)Stage I: pain hot (V.D.Pressure)

pain cold (V.C. Pressure)pain cold (V.C. Pressure)

b)b) Stage II: pain with hot and cold due toStage II: pain with hot and cold due toagglutination of exudates and clotagglutination of exudates and clotformationformation

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A) Inflammatory diseases of the pulpA) Inflammatory diseases of the pulp

3) Chronic pulpitis3) Chronic pulpitis

a)a) Chronic ulcerative pulpitis (open pulpitis)Chronic ulcerative pulpitis (open pulpitis)

b)b) Chronic hyperplastic pulpitis (pulpal polyp)Chronic hyperplastic pulpitis (pulpal polyp)

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B)Additional diseases of the pulpB)Additional diseases of the pulp

11-- Necrosis:Necrosis:

a)a)

Liquifactive necrosis: occurs with good bloodLiquifactive necrosis: occurs with good bloodsupply (i.e.: acute or chronic pulpitis) it causessupply (i.e.: acute or chronic pulpitis) it causespuss formationpuss formation

b)b) Coagulative necrosis: occurs with poor bloodCoagulative necrosis: occurs with poor bloodsupply as it is the case with traumasupply as it is the case with trauma

22-- pulp changes:atrophy, calcifications(pulp stonepulp changes:atrophy, calcifications(pulp stonedenticles, root calcification)denticles, root calcification)

33-- internal resorptioninternal resorption

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Periapical diseasesPeriapical diseases

A)A) SymptomaticSymptomatic

11-- Acute apical peridontitisAcute apical peridontitis

22-- Acute periapical abscessAcute periapical abscess33-- Recurdescence abscess (phoenix)Recurdescence abscess (phoenix)

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Periapical diseasesPeriapical diseases

B) AsymptomaticB) Asymptomatic

11-- Chronic apicalChronic apical periodontitisperiodontitis::

ChronicChronic periapicalperiapical abscessabscess PeriapicalPeriapical granulomagranuloma

PeriapicalPeriapical cystcyst

22-- CondensingCondensing osteitisosteitis

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Rubber dam isolationRubber dam isolation

Protects from file swallowingProtects from file swallowing

Clear fieldClear field

Less time and effortLess time and effort Retraction of cheeks and tongueRetraction of cheeks and tongue

Easy irrigationEasy irrigation

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Principles of endodontic cavityPrinciples of endodontic cavity

preparationpreparation

1)1) Outline form: the external outline form mustOutline form: the external outline form must

evolve from the internal anatomy of the toothevolve from the internal anatomy of the tooth

2)2) Convenience form: all orifices should beConvenience form: all orifices should be

visualized without moving the mouth mirrorvisualized without moving the mouth mirror

(i.e.: unobstructed access to the canal orifices(i.e.: unobstructed access to the canal orificesto allow easy placement of the instrumentsto allow easy placement of the instruments

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3) Straight line direct access to the apical foramen3) Straight line direct access to the apical foramen

How to be verified?????How to be verified?????

a)a) Parallism between file handlesParallism between file handles

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b. To see all the orifices in without moving theb. To see all the orifices in without moving the

mirrormirror

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DL

DB

ML

MB2MB1

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4) Complete authority over the enlarging4) Complete authority over the enlarging

instrumentinstrument

5) Removal of the remaining carious dentine and5) Removal of the remaining carious dentine anddefective restorationsdefective restorations

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Cleaningand shaping the R.C.Cleaningand shaping the R.C.

systemsystem

A)A) Length determinationLength determination

Anatomical considerations and definitionsAnatomical considerations and definitions

Methods of length determination:Methods of length determination:

1.1. radiographicallyradiographically

2.2. Electronic : apex locatorsElectronic : apex locators

3.3. Digital tactileDigital tactile

4.4. PaperpointPaperpoint

5.5. Periodontal sensitivityPeriodontal sensitivity

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Pulp StonesPulp Stones

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Pulp StonesPulp Stones

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Basic objectives of cleaningandBasic objectives of cleaningand

shapingshaping

1. removing infected soft and hard tissues1. removing infected soft and hard tissues

2. giving the irrigants access to the apical space.2. giving the irrigants access to the apical space.

3. Creating space for obturating material3. Creating space for obturating material4. Retaining the integrity of the radicular4. Retaining the integrity of the radicular

structures.structures.

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Mechanical objectives of cleaningMechanical objectives of cleaning

and shapingand shaping

1. development of a continuously tapering preparation1. development of a continuously tapering preparationwith the smallest cross section diameter at the apicalwith the smallest cross section diameter at the apical

terminus of the canal.terminus of the canal.

2. maintaining the original anatomy of the canal.2. maintaining the original anatomy of the canal.

3. maintaining the position of the apical foramen3. maintaining the position of the apical foramen

4. keeping the apical foramen4. keeping the apical foramen as small as possible.as small as possible.

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Biological Principles in cleaningandBiological Principles in cleaningand

shapingshaping

1.Assume every canal is curved (photographs give1.Assume every canal is curved (photographs give

only M&D curvatures)only M&D curvatures)

2. precurvature of files2. precurvature of files

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shapingshaping

3. Avoid aggressive apical instrumentation, this3. Avoid aggressive apical instrumentation, this

might lead to :might lead to :

a) Transportation of mud and debrisa) Transportation of mud and debrisbeyond apex.beyond apex.

b) Change canal and apical pathb) Change canal and apical path

(zipping), place a photo of zipping(zipping), place a photo of zipping

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shapingshaping

4. Avoid canal blockage..........How?4. Avoid canal blockage..........How?

a) copious irrigationa) copious irrigation

b) no filing action at apical terminusb) no filing action at apical terminusc) the use of patency filesc) the use of patency files

d) recapitulations between filesd) recapitulations between files

e) the use of noncutting file tipse) the use of noncutting file tipsF) proper estimation of working lengthF) proper estimation of working length

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shapingshaping

5) Avoid overzealous canal shaping (to prevent5) Avoid overzealous canal shaping (to prevent

strip profanations )strip profanations )

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shapingshaping

6) develop a 3 dimensional image of the canal.6) develop a 3 dimensional image of the canal.

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Techniques of mechanical canalTechniques of mechanical canal


A)A)Apical coronal techniques (step back)Apical coronal techniques (step back)

advantages:advantages:1. shaping apical 1/3 with small flexible files, while1. shaping apical 1/3 with small flexible files, while

larger stiffer files are working away from apexlarger stiffer files are working away from apex

2. relocate the file away from dangerous zone, especially2. relocate the file away from dangerous zone, especiallywhen knowing that canals are not typically centeredwhen knowing that canals are not typically centeredanatomically within their roots, instead they are oftenanatomically within their roots, instead they are oftenskewed toward the furcal concavities.skewed toward the furcal concavities.

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A)A)Apical coronal techniques (step back)Apical coronal techniques (step back)

DisadvantagesDisadvantages

1.1. Extrusion of debris through the apexExtrusion of debris through the apex2.2. Apical blockageApical blockage

3.3. Tendency for canal deviationTendency for canal deviation

4.4. Time consumingTime consuming

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B) Coronal apical technique (crown down)B) Coronal apical technique (crown down)

AdvantagesAdvantages

1.1. Elimination of cervical constriction.Elimination of cervical constriction.

2.2. Straighter and more direct access.Straighter and more direct access.3.3. removes the bulk of pulp tissue and bact. and theirremoves the bulk of pulp tissue and bact. and their

toxins thus decreases post treatment flare upstoxins thus decreases post treatment flare ups

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Coronal apical techniqueCoronal apical technique

4) Pre4) Pre--enlarged canals hold larger volume ofenlarged canals hold larger volume of

irrigants.irrigants.

5) Dramatically promote the removal of dentin5) Dramatically promote the removal of dentin

mud (increase the volume of the irrigant withmud (increase the volume of the irrigant withwide pathway for liberating dentin mud).wide pathway for liberating dentin mud).

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Coronal apical techniqueCoronal apical technique

6. Improves identifying the foramen: since larger6. Improves identifying the foramen: since larger

file could be easily inserted into the apical 1/3file could be easily inserted into the apical 1/3and could be easily viewed at the xand could be easily viewed at the x--rayray

photograph than the smaller files.photograph than the smaller files.

7. Gives the clinician a better tactile control7. Gives the clinician a better tactile control

especially at the apical 1/3.especially at the apical 1/3.

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Instruments for canal shapingInstruments for canal shaping

Hand instruments ( barbed broaches,Hand instruments ( barbed broaches,

reamers, Kreamers, K--files, Hfiles, H--files).files).

Rotary instruments:Rotary instruments:

* Stainless steel ( gates glidden burs, Peeso* Stainless steel ( gates glidden burs, Peeso

reamers).reamers).

* Nickel titanium ( ProFile, ProTaper, Hero,* Nickel titanium ( ProFile, ProTaper, Hero,K3etc).K3etc).

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Reamer

*St St

*Twisting

counterclockwise

*Hand driven

*Reaming action only:Insertionbinding

1/4 clockwise turn..pull

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Tight twists

KK-- F

ileF

ile

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KK-- FileFile*St St

*Tight Twisting

counterclockwise

*Hand driven

*Universal file:

Reaming action:

Insertionbinding1/4 clockwise turn..pull

Filing action:

Push..pull against

wall

Reaming action

Filing action

Basic Instruments:

K-File

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H- File

Filing action

*St St

*Machine grindingintersecting cones,

larger towards the

handle, sharp edge at

the base

*Hand driven

Filing action Only:

Push..pull against

wall

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H- File

Machine grinding

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ISO Standardization

6 8 10 15 20 25 30 35 40

45 50 55 60 70 80

90 100 110 120 130 14021 Instruments

Numbering

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Length and TaperLength and Taper

D2 > D1 by 0.32mm

16 mm

Taper

D1D2

Taper: 2%

0.02mm/mm

D2-D1= 0.32

16mm 16

0.3mm0.62 mm

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Othermaterials

11-- carbon steelcarbon steel

Superelastic

*H file*H file

*K file*K file

2- Ni Ti alloy

Hand and Rotary Ni Ti

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Irrigants for canal cleaningIrrigants for canal cleaning

Ideal properties of irrigants:Ideal properties of irrigants:

* Tissue or debris solvent.* Tissue or debris solvent.

* Antimicrobial activity.* Antimicrobial activity.* Low toxicity.* Low toxicity.

* Smear layer removal.* Smear layer removal.

* Lubrication.* Lubrication.

* low surface tension.* low surface tension.

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Types of irrigantsTypes of irrigants

Sodium hypochlorite (NaOCl)(5.25%,2.6%).Sodium hypochlorite (NaOCl)(5.25%,2.6%).

Chlorhexidine (CHX),(0.12%,0.2%,2%)Chlorhexidine (CHX),(0.12%,0.2%,2%)

MTADMTAD

Hydrogen peroxide (3%).Hydrogen peroxide (3%).

Chelating agents (EDTA),(17%).Chelating agents (EDTA),(17%).

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Ob i f hOb i f h

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Obturation of the rootObturation of the root

canalObjectivescanalObjectives

Prevention of apical leakage.Prevention of apical leakage.

Prevention of coronal leakage.Prevention of coronal leakage.

To seal within the system any irritants thatTo seal within the system any irritants that

cannot be fully removed from the root canal.cannot be fully removed from the root canal. Allows the healing of the periapical tissues byAllows the healing of the periapical tissues by

creating a favorable environment.creating a favorable environment.

Ch i i f id l lCh i i f id l l

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Characteristics of ideal root canalCharacteristics of ideal root canal

filling materialfilling material

Easily introduced.Easily introduced.

Seal canal laterally and apically.Seal canal laterally and apically.

No setting shrinkage.No setting shrinkage.

Antimicrobial action.Antimicrobial action. Biocompatible.Biocompatible.

Easily removed.Easily removed.

Radiopaque.Radiopaque.

Can be sterilized.Can be sterilized.

Bonding to the tooth structure.Bonding to the tooth structure.

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Root canal filling materialRoot canal filling material

Solid filling material:Solid filling material:

* Gutta percha.* Gutta percha.

* Resilon (resin based filling material).* Resilon (resin based filling material).

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Root canal filling materialRoot canal filling material

Sealers:Sealers:* Zinc oxide based sealers (Tubliseal, Grossman sealer).* Zinc oxide based sealers (Tubliseal, Grossman sealer).

* Calcium hydroxide based sealers (Sealapex, Apexit).* Calcium hydroxide based sealers (Sealapex, Apexit).

* Resin based sealers (AH 26, AH Plus, Top seal, EndoRez).* Resin based sealers (AH 26, AH Plus, Top seal, EndoRez).

* Glass ionomer based sealer (KetacEndo).* Glass ionomer based sealer (KetacEndo).

* Silicon based sealer (RoekoSeal).* Silicon based sealer (RoekoSeal).

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Obturation techniquesObturation techniques

Cold lateral compaction (condensation) technique.Cold lateral compaction (condensation) technique.

Vertical thermal condensation technique:Vertical thermal condensation technique:

* Enhanced heat system (System B).* Enhanced heat system (System B).

* Core carrier techniques (Thermafil system).* Core carrier techniques (Thermafil system).

* Injectable gutta percha (Obtura system).* Injectable gutta percha (Obtura system).* Thermomechanical compaction (McSpadden* Thermomechanical compaction (McSpaddencompactors).compactors).

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Step by step procedure Case #1Step by step procedure Case #1

1. Take a preoperative photograph1. Take a preoperative photograph

2. Notice Curvature, Shadow of the canals,2. Notice Curvature, Shadow of the canals,Periapical tissues,Periapical tissues,

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3. Make a convenience form of cavity straight line3. Make a convenience form of cavity straight line

access.access.

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P

MB2

MB1

DB

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4. Make sure u have a straight line angle4. Make sure u have a straight line angle

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5) Scout the canals: Patency of the canals, confirm5) Scout the canals: Patency of the canals, confirm

presence or absence of straight line access (Placepresence or absence of straight line access (Placea photo of double curved file )a photo of double curved file )

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6. Take The working length (Apex locator or6. Take The working length (Apex locator or

Radiographic)Radiographic)

7. Create space for the rotary instrument (enlarge7. Create space for the rotary instrument (enlarge

till 15 in straight canals and 20 in curved ones).till 15 in straight canals and 20 in curved ones).

8. use the rotary system u prefer.8. use the rotary system u prefer.

9. recapitulate9. recapitulate

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10. use patency file10. use patency file

11. finish preparation.11. finish preparation.

12. Obturation.12. Obturation.

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MB1

MB2

DB

P

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Case 2Case 2

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EndodonticAccidentsEndodonticAccidents

A) LedgesA) Ledges

B) PerforationsB) Perforations

C) Broken instrumentsC) Broken instruments D) CracksD) Cracks

E) VRFE) VRF

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PerforationsPerforations

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LedgesLedges

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Fractured InstrumentsFractured Instruments

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CracksCracks

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Vertical Root FracturesVertical Root Fractures

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محاضرة الاطباء الجدد 6-12-2009

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