Comprehensive Endodontics from Diagnosis to Restoration

Transcription

1 Comprehensive Endodontics from Diagnosis to Restoration Trevor Blattner, DDS Dr. Blattner has no relevant financial relationships to disclose. Presentation sponsored by Delta Dental of Missouri Friday, June 15, :30pm 4:30pm The Missouri Dental Association is an ADA CERP Recognized Provider approved by the Missouri Dental Association. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at

2 Trevor C. Blattner DDS, MS Blattner Endodontic Care Cape Girardeau, MO USA

3 University of Missouri-Kansas City University of Maryland

4 Endodontists only 20% by

5 Is the Chief Complaint reproducible? What s causing the Chief Complaint? Can the complaint be eliminated? Is endodontic treatment the way to alleviate the complaint?

6 Subjective Objective Assessment Plan

7 Patient Questions History of Pain Severity of Pain Frequency of Pain Stimulus of Pain Duration of Pain Location of Pain Spontaneity of Pain

8 Cold Use Endo Ice

9 Heat

10 Must be current 2 PA s/1bw Must show complete tooth and surrounding tissues Consider a CBCT in select cases

11 Pulpal diagnosis Periradicular diagnosis

12 Pulpal diagnosis Normal pulp Reversible pulpitis Irreversible pulpitis Necrotic pulp Previously Treated Previously Initiated Therapy Periradicular diagnosis Normal Apical Tissues Symptomatic Apical Periodontitis Asymptomatic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess

13 Endodontic Therapy Emergency Treatment Elective Treatment Extraction Referral

14 Rubber Dam Isolation Only dental dam isolation minimizes the risk of contamination of the root canal system by indigenous oral bacteria

15 Asepsis Better Vision Irrigation Lost instruments Clinical

16 Protects patient by keeping irrigating solutions confined to the operating field Some irrigants have systemic toxicity Most irrigants cause some local tissue damage NaOCl EDTA Chlorhexidine

17 Protects patient from swallowing or aspirating Instruments

18 1, 2, Glickman Clamp

19 Fundamentals of Access A well-designed access preparation is essential for a good endodontic result

20 1. Removal of the chamber roof and all coronal pulp tissue 2. Location of all canals 3. Unimpeded straight-line access of the instruments in the canals to the apical 1/3 rd or the first curve 4. Conservation of tooth structure

21 You have maximized straight-line access to the canal orifice Canal transportation Separated instruments

22 Missed canals Perforations Separation of instruments Poorly cleaned and shaped canals

23 Access burs Endo

24 Alpen Safe End Endo Carbides

25 When you can hold your mirror over the access and can see every orifice with out moving the mirror.

26 A rotary file only likes to bend one time

27 The ideal access cavity creates a smooth, straightline path to the canal system and ultimately to the apex.

28

29 Anterior Teeth 41%

30 Maxillary 1 st Bicuspid Sometimes 3 (6% of the time)

31 Mandibular 1 st Bicuspid 25 35% ~5%

32

33 90 to 95%

34 Maxillary 1 st Molar But usually 4 canals (MB2)

35 Mandibular 1 st Molar 40% will meet apically 40% of time 2 canals are present in distal root

36 The distance from a predetermined coronal reference point to the point where the cleaning and shaping and obturation should terminate.

37 Apical Constriction (AC) Apical Foramen (AF) Cementodentinal Junction (CDJ)

38 Sometimes referred to as minor apical diameter Considered the part of the root canal with the smallest diameter Reference point for the apical termination for cleaning and shaping and obturation

39 Sometimes referred to as major apical diameter Opening at the apex of the root of a tooth, through which the nerve and blood vessels that supply the dental pulp pass

40 Estimate the working length from the PA Place a #15 at estimated working length Take a PA Adjust to.5 to 1 mm short of radiographic apex If more then 2 mm from apex, readjust file and make a new PA.

41 The radiographic apex is not where the apical foramen is located Working file is usually long 90% of the time If working file is at radiographic apex on PA Subtract 1 mm from working length

42 First investigated by Custer (1918) Suzuki (1942) studied the flow of direct current through the teeth of dogs. Sunada (1962) took these principles and constructed a simple device that used direct current to measure the canal length.

43 CanalPro Apex Locator The CanalPro Apex Locator is dual impedancebased, as opposed to conventional units which operate on the direct current principle It uses the alternating current of two frequencies to measure and compare two electrical impedances that change as the file moves apically The benefit is that these devices are less affected by fluid conductive media in the canal, resulting in more accurate readings No jumping effect when measuring

44 The movement of the file inside the canal from the beginning of the measurements to the end is shown in the tooth image on the left part of the display This provides uninterrupted feedback.

45 The movement of the file inside the canal is shown in the tooth image on the left part of the display and additionally in the enlarged root canal picture on the right Numerical value appears on the left side of the display under the tooth image CanalPro Apex Locator provides audio feedback - as the file advances deeper into the canal, the series of beeps become progressively closer in duration

46 Beginning of the apical zone Middle of the apical zone Apex The apical zone is divided into 11 segments graduated from 1.0 to 0 (Apex) as visual information of file progression When the apex is reached, solid tone is emitted

47 Apical constriction Equals area of the 3 green bars Recommended procedure Working length: length of the file is marked with endodontic stopper and measured (preliminary): no further tolerances have to be considered Apical foramen APEX appears Recommended to take working length file to this area to confirm patiency and PDL space Back working length file back up to bottom of green bar or middle of yellow for a truer Apical Constriction reading

48 accuracy Speed and convenience

49

50 Torsional Stress Cyclic (flexural) Fatigue

51 Torsional fracture Occurs when the tip, or any other part of the rotating instrument, binds to the root canal walls while the rest of the file keeps turning Due to much apical pressure on rotating instrument

52 Cyclic Fatigue (Flexural Fatigue) Occurs when an instrument that has already been weakened by metal fatigue is placed under additional stress The instrument does not bind to the root canal walls but rotates freely until fracture of the instrument occurs at the point of maximum flexure

53

54 S shaped canal system Difficult canals to negotiate, predisposes to ledge/block formation Double curves overstress instruments leading to greater file separation

55 Difficult Access Often requires microscope for increased magnification Difficulties in creating glide path

56 Requires specialized techniques Often times requires an additional follow up surgery depending on resorption type

57 (especially with curves)

58 74-86%

59 Key factors include existence of a long-standing perforation, and a periapical lesion By far the Key factor in retreatment predictability is the ability to respect the original RC morphology during treatment (87% vs. 47%)

60

61

62 Glide Path Before any rotary instrument is introduced into a canal, the canal must be scouted with a hand file and a glide path created.

63 PathFile ProGlider HyFlex GPF ScoutRaCe V-Glide Path 2 Channels

64

65 Ground NiTi (1993-Present) Profile System RaCe System ProTaper System K3 System GT System Hero System HyFlex NT System

66 M Wire NiTi (2007 Present) GT Series X System Profile Vortex System ProTaper Next System

67 R Phase NiTi (2008 Present) Twisted File System K3 XF System

68 Controlled Memory NiTi (2011-Present) HyFlex CM System TyphoonCM System EdgeEndo System 10 Series System ProTaper Gold (2013) Wave Gold (2015)

69 Controlled Memory NiTi EDM 2015

70 Austenite Standard NiTi are in this Phase Martensite Shape Memory/Controlled Memory NiTi are in this Phase

71 under stress), (or martensite

72 austenite

73 austenitic Standard NiTi files remember their shape and bounce back like a swimming pool diving board at room temperature

74 martensitic Controlled memory files hold their shape and DO NOT bounce back like a swimming pool diving board at room temperature

75 Standard NiTi Files are in the Austenite Phase at Room Temperature. They are rigid and do not show plastic deformation visually Controlled Memory Files are in the Martensite Phase at room temperature and are highly flexible and show plastic deformation visually after heat treated (autoclaved)

76 The advantages that trained shape bring to NiTi is the ability to distinguish between different forms of Deformation.

77 Elasticity: Deformation: 1. Elastic Deformation = Reversible

78 Elasticity: Deformation: 2. Plastic Deformation = Irreversible

79 Foto: Polizei Stade 2. Plastic Deformation plastic deformation is irreversible

80 plastic elastic

81 Unexpected Instrument Fractures Files plastically deformed will break pseudo-elasticity of common or standard NiTi files masks the plastic deformation

82 elastic plastic true shape memory properties Controlled Memory Files

83 Shape Memory (Controlled Memory) training material to remember a shape 1.shape deform Change of conditions 1.shape 1.shape Plastically deformed

84 HyFlex CM files are mostly martensitic at room temperature

85 Controlled Memory Benefits Superior Canal Tracking Regenerative properties Outstanding fatigue resistance

86 Controlled Memory Benefits Superior Canal Tracking Regenerative properties Outstanding fatigue resistance

87 1. Superior Canal Tracking take any given shape at room temperature

88 Superior canal tracking Extreme Flexibility = easily follows very curved canals Controlled Memory = stays centered Reduced ledging & transportation No lateral force = no bounce back/spring effect Common NiTi file Hyflex CM NiTi file

89 Controlled Memory Benefits Superior Canal Tracking Regenerative properties Outstanding fatigue resistance

90 2. Regenerative properties Before use After use Excessive resistance straightens spirals: Avoids binding to the walls = reduced fracture risk The file can continue to be used, provided it has not started to wind in the opposite direction. Journal of International Oral Health 2014; 6(6):1-4 Topographic analysis of HyFlex CM NiTi files Al-sudani D

91 HylFex Controlled Memory Files = Multi-Use regains original shape any sign of deformation looks brand new visual confirmation

92 Controlled Memory Benefits Superior Canal Tracking Regenerative properties Outstanding fatigue resistance

93 3. Outstanding Fatigue Resistance > 300% higher fatigue resistance

94 M&M: A total of 120 conventional and controlled memory NiTi rotary instruments were tested at 35 and 45 curvatures. Results: The present study indicated that NiTi instruments made from CM Wire were nearly 300% to 800% more resistant to fatigue failure than instruments made from conventional NiTi wire. Shen et al. JOE Volume 37, Number 7, July 2011

95 A New Era of Controlled Memory Files...HyFlex EDM

96 HyFlex EDM Files (Controlled Memory) Electric Discharge Machining while keeping flexibility hardened surface structure 2015 Mersen 2015 RGF-Funkenerosions-SGmbH

97 new surface hardness cutting performance improves FIRST.

98 High surface hardness High cutting efficiency

99 C. Pirani et al Results: No EDM files fractured and no macroscopic signs of deformation All the instruments, after 10 uses, preserved the crater-like irregular surface without cutting-edge or blunt disruption An increase up to approximately 700% in cyclic fatigue over similar size and taper CM files

100 C. Pirani et al Conclusions: The new manufacturing process of electrical discharge machining had a substantial impact on fatigue lifetime of HyFlex EDM files The spark-machined surface remained unaffected after multiple uses, confirming a high wear resistance EDM files appeared suitable for shaping severely curved canals

101 Up to 700% more breakage resistant then HyFlex CM:

102 any

103 Results:/conclusions: Hyflex EDM was significantly higher WaveOne Primary and WaveOne Gold E. Pedulla et al. 2015

104 Access Glidepath OneFile Finishing Files 25/.12 10/.05 25/.08 40/.04 50/.03 60/.02

105 Recommendations: All EDM NiTi files: Single pass until working length is reach Glidepath file Very Light pecking motion

106 SEVERELY

107 HyFlex EDM Reduction in numbers of files: Without compromising root canal anatomy

108 Severely curved canals -Consider adding HyFlex CM files 15/.04 20/.04

109

110 Instruments Shape & Irrigants Clean

111 ALL

112 Debride the canal Dissolve pulp tissue Remove the smear layer Kill Microbes

113

114 Passive Irrigation Active Irrigation

115 Adding irrigating solutions Minimally effective

116 Actively Agitation Activation Key is keeping the solutions in motion

117 Sodium Hypochlorite (NaOCl)

118 Sodium Hypochlorite (NaOCl)

119 luer lock better

120

121 CanalPro NiTi Tips Gold Standard Extremely flexible Autoclavable

122

123 Dentin Shavings Cell Debris Pulp Remnants With pulp necrosis, the layer becomes contaminated with bacteria and their byproducts

124 Removal 1 minute (EDTA)

125 Cross section of root dentin covered by the smear layer created by Instrumentation. Notice smear plugs in dentin canals. Instrumented canal wall after removal of the smear layer by NaOCl and EDTA.

126 CanalPro EDTA 17% EDTA Solution (ph 8.5) Removes smear layer and dentin mud Opens dentinal tubules for Disinfecting solutions to work more effectively Better adhesion of sealers and obturation material

127 Typically would consist of: NaOCl EDTA

128 Many dentists would use NaOCl again after EDTA NaOCl EDTA NaOCl

129 Using Sodium Hypochlorite again after EDTA cause excessive erosion of the canal wall dentin

130 If tooth is vital, current regiment recommends only the following irrigants NaOCl EDTA

131 If tooth is necrotic, consider adding CHX as a final rinse NaOCl EDTA CHX

132 Broad-spectrum antimicrobial agent effective against gramnegative and gram-positive bacteria Has little toxicity Has an antimicrobial action similar to that of 5.25% NaOCl More effective against E. Faecalis

133 Disadvantages CHX does not dissolve necrotic tissue Does not remove the smear layer Must be used as an adjunct with NaOCl

134 CanalPro CHX-ULTRA 2% 2% Chlorhexidine Gluconate with powerful wetting agents and proprietary surface modifiers Improves the depth of penetration and kills planktonic bacteria 10X faster than normal 2% Chlorhexidine Final Irrigation step for long-lasting disinfection

135 If NaOCl and CHX are used immediately after one another, you will see an orangish-brown precipitate (para chloroaniline) Do not use these irrigants one after the other EDTA neutralizes NaOCl, so typically you should rinse with EDTA after using NaOCl and before using CHX

136 NaOCl Antimicrobial/antibacterial - kills bacteria Dissolves organic material within the canal space - dissolves pulp (nerve) tissue and collagen EDTA Mildly antimicrobial/antibacterial Removes inorganic debris from the canal space - chelating agent that removes smear layer CHX Broad-spectrum antimicrobial/antibacterial Has sustainability - has a prolonged antimicrobial/antibacterial effect lasting for approximately 60 days after use no tissue dissolution properties

137 Cost-effect way to create a dedicated area for syringe filling Syringe activated valve Low level light indicator Helps prevent counter, carpet and scrub damage Several units may be connected to create a convenient station for filling multiple solutions

138

139

140 Automated, simultaneous delivery of multiple wavelengths of sound energy 20k microns 3 microns Frequency Sonendo s Multisonic technology creates a closed system that lets multiple wavelengths of sound reach throughout the entire anatomy

141 Degassed Procedure Fluids Accelerated Chemistry Sealed Environment Advanced Fluid Dynamics Multisonic Energy

142 1 NaOCl 2 Distilled Water Rinse 3 EDTA The GentleWave System with the automated fluid management system prepares and delivers the desired concentration 4 Distilled Water Rinse Complete

143

144 Pre-Op Post-Op

145 Pre-Op Post-Op

146 Pre-Op Post-Op

147 Pre-Op Post-Op

148 Pre-Op Post-Op

149 Pre-Op Post-Op

150

151 Pre-Op Post-Op

152

153

154

155 So now that everything is cleaned and shaped, what s next? Let s Obturate

156 The success of the treatment is directly related to the quality of the obturation

157 Teeth that are poorly obturated are often poorly prepared.

158

159

160

161

162 Regardless of the obturation technique used today, Sealers are an essential component of the process.

163 Seal the space between dentinal wall and the core Fill voids and irregularities in the root canal Ideally flow into lateral and accessory canals Act as a lubricant Adheres to smear layer free dentin

164 Cold Lateral Compaction Single Cone Resilon Custom Cone Injection (Gutta Flow) Warm Warm Lateral Vertical Compaction Warm Vertical Thermo-Mechanical Injection: Obtura, Calamus, Resilon Carrier: Thermafil, GuttaCore Other EndoRez Paste Apical Barrier

165 Guttapercha cones Lateral Condensation Vertical Condensation Sealer

166 Match

167 Advantages Speeds up the root canal obturation process No need for accessory cones Less operator fatigue by operator compared to lateral condensation techniques Disadvantages Perceived to be less effective in sealing root canals than other techniques. Greater volume of cement expected in absence of condensation when used with.02 taper due to canal variation

168 GuttaFlow 2 A Sealer & Flowable Guttapercha in 1 Material Ebert et al., 1999; Roggendorf et al., 2001, 2003; Bouillaguet et al., 2004

169 Cold Flowable Gutta-Percha no shrinkage one material expansion

170 How to Place GuttaFlow 2 1. Use material as sealer & Place sealer 2. Coat matching gutta percha cone 3. Place cone in canal 4. Heat sear off cone 10 minute working time 25 minute set time Can check work on x-ray Can remove & replace if void is found or not happy with fill result within 10 minutes

171 Place master cone to working length (apical stop)

172