ENDODONTICS

Dr. Ebtisam ElHamalawy

MFDS RSC (Edh.), MJDF RSC (Lon.), BDS (Misr International University)
ISO INSTRUMENTS
 All instruments have 16m cutting flutes
 X-sectional diameter at first rake angle of any file is termed
Do
 1mm coronal to Do is termed D₁2mm coronal is termed
D₂
 D16 represents the largest diameter and most active part of
the instrument
 Each file receives it’s numeric designation from it’s diameter
at Do
 ISO files have a standard taper of .32 mm over 16mm of
cutting blade
 Standard taper for any file is .02mm/mm e.g. no. 10
file .10mm in diameter at Do and .42 at D16
 Pulp vitality test
a. Thermal – hot or cold or both
b. EPT (electric pulp test)
c. Pulse Oximetry
d. Laser Doppler Flowmetry
 Radiography
 Special test – Crown removal
- Selective anaesthesia test
BIOMECHANICAL PREPARATION
CLEANING AND SHAPING
 Also called CHEMICO-MECHANICAL preparation.
 Principal aim is to remove pulpal tissue and sterilize the root
canal system
 Impossible to sterilize the root canal system
Mechanical objectives
 A continuously tapering preparation
 Original anatomy maintained
 Position of foramen maintained
 Foramen as small as is practical
MODIFIED CROWN DOWN
BALANCED FORCE TECHNIQUE
 The technique entails crown down from the coronal third to
the middle third of the canal followed by step back from the
apical third to the middle third of the canal using the
balanced force instrumentation action at all times.
 The philosophy:
Most of the bugs (bacteria) are located in the coronal pulp and
the coronal third of the root canal system,
 the apical third is relatively free of bacteria
 hence coronal third of the root canal system must be bio-
mechanically cleansed before the middle or apical third of the
canal is approached.
 If the apical third of the root canal is approached first, the
instruments used will carry the bacteria from the coronal pulp
into the radicular pulp.
Balanced force
 The name of the technique used to work the files in a root
canal system.
1. The file is rotated CLOCKWISE 90-120 degrees and no
more than one full rotation with slight apical pressure till the
flutes bite into the dentin (power phase).
2. Then the file is de-rotated ANTI-CLOCKWISE 120-360
degrees keeping adequate apical pressure to stop the file
backing out of the canal. This POPS the dentin (control
phase).
Access cavity preparation
 To remove roof of pulp chamber to provide visual and tactile
access to entrances of root canals
 Provide straight line access to first curve of root canal
 Avoid damage to floor of pulp chamber
 Conserve as much tooth structure as possible
 Provide coronal and apical resistance form for the temporary
access cavity seal (temp. fill)
CROWN DOWN
TECHNIQUE
 ADVANTAGES
Bulk of infected material found in pulp chamber and coronal
third of root canal, removal of this material reduces bacterial
load and prevents inoculation of the periapical tissues with
bacteria
Development of straight line access into pulp chamber
Early flaring of coronal part removes dentine constrictions
This prevents binding of instruments and eliminates errors in working
length determination
Ease of removal of pulp stones
Enhanced apical movement of instruments into canal
Less stress on instruments, less chances of fracture or breakage of
files
Early movement of large volumes of irrigants and lubricant to apical
third
Rapid removal of pulp tissue in coronal third
Elimination of first curve of canal
Straight line access to subsequent curves
Enhanced movement of debris coronally
Decrease in canal blockages and dentinal mud build up
Predictable quality of canal shaping
Predictable quality of canal cleaning
Reduction of post-operative pain resulting from apical
extrusion of debris
Easier smear layer removal
Faster preparation
Crown down technique
 Gates-Glidden 4321 or 1234 or orifice shapers used at the
canal orifice
 Coronal to mid-root enlargement using instruments from
large to small
 Establish actual working length (AWL)
 Start step-back technique
Step-back technique
 Lubricate instrument place to actual working length with
watch-winding” motion
 Now start balanced force for all files
 Place next larger file to length
 Repeat process till preparation accomplished to minimal
no.25 file (or a file three to four sizes larger than first file)
 Always recapitulate and irrigate
 Place next file to 1mm short of actual working length
 Next larger file to 2mm short of AWL
 Repeat process and carry preparation into the mid-third of
the root
Joining the crown-down and step-
back
 Joining the coronal preparation (crown-down) and apical
preparation (step-back) in the middle third can be done with
Gates Glidden burs, files or reamers
 There should be no ledges
 Each part of the preparation should merge with the next part
without any hindrances or steps
OBTURATION
When to obturate?
 Absence of pain and swelling
 No tenderness to percussion
 No patent sinus tract
 Canal is dry
 Canal is odour free
 Clean and shaped canal has medicament placed for at least
one week
Sealants
 Zinc Oxide/Eugenol (Tubliseal, Roths, Grossmans, Pulp
canal sealer
 Calcium hydroxide (Sealpex, Apexit)
 Glass Ionomer ( Ketac-Endo)
 Resins (AH-26, AH-26 plus, Diaket)
 Silicones (Lee Endo-Fill)
Gutta-Percha
 Gutta-percha 20%
 Zinc Oxide 60-75% (for stiffness)
 Metal Sulphates 1.5-1.7% (radiopacity)
 Waxes/resins 1-4 % (handling)
 Colouring agent < 1% (visual contrast)
Obturating techniques
 Cold lateral compaction
 Warm lateral compaction
 Warm vertical compaction
 Thermocompaction (mechanical or ultrasonic)
 Injection of thermoplasticised GP
 Chloropercha
INTRA-CANAL MEDICAMENTS
Properties
 Able to kill root canal bacteria
 Long-lasting antibacterial effect
 Not activated by the presence of organic material
 Degrade residual organic tissue
 Degrade residual microbial biofilm
 Non-irritating to periapical tissues
 No systemic toxicity
 Not affect physical properties of temp restoration
 Not diffuse through temp seal
 Be easily placed and removed
 Be radiopaque
 Not stain the tooth
Types of Sealants
Phenol-based compounds
- Camphorated parachlorophenol
- Camphorated monoparachlorophenol (CMCP)
- cresol – Eugenol – Thymol
Anti-bacterial effects not long lasting
Diffuse through temp. seal cause bad odour in mouth
Soften the filling material
 Anti-biotics
- bacitracin,neomycin, polymixin, chloramphenicol, nystatin etc.
Problems are limited spectrum and development of sensitivity
Steroids
- prednisolone, triamcinolone, hydrocortisone
Mainly for pain relief, useful when mixed with anti-biotics (Ledermix –
Steroid + tetracycline)
 Calcium Hydroxide
Effective against most root canal bacteria
Able to degrade residual organic tissue
Extrusion into peri-apical tissues is very painful and can
cause peri-apical necrosis (quality used in apexification)
GUIDELINES TO SURGICAL
ENDODONTICS
INDICATIONS
 Presence of periradicular disease, with or without symptoms
in a root filled tooth, where non surgical root canal treatment
cannot be undertaken or has failed or where conventional
retreatment maybe detrimental to the retention of the tooth.
 Presence of periradicular disease in a tooth where iatrogenic
or developmental anomalies prevent non surgical root canal
treatment
 Where a biopsy of periradicular tissue is required
 Where visualization of the periradicular tissues and tooth root
is required when perforation, root crack or fracture is
suspected
 Where procedures are required that require either tooth
sectioning or root amputation
 Where it may not be expedient to undertake prolonged non
surgical root canal re-treatment because of patient
considerations
CONTRAINDICATIONS
(ABSOLUTE)
 Patient factors including the presence of severe systemic
disease and psychological considerations.
 Anatomic factors including
- unusual bony or root configuration
- lack of surgical access
- possible involvement of neurovascular bundle
- where tooth is subsequently unrestorable
- where there is poor supporting tissue
 Skill, training and experience of operator
 Current guidance issued by the Faculty of General Dental
Practitioners12 recommends all teeth should have
radiographs taken immediately following obturation, with a
further follow up radiograph to assess (radiographic) healing
after one year and then annually until (radiographically
judged) healing occurs.
 coronal restoration is more important than the radiographic
appearance or perceived quality of root filling in determining
the success of root filled teeth
 Restoration with a crown may imply a lower risk of post-
operative tooth fracture and better coronal seal although this
needs further investigation