December 1st

Endodontic Treatment Outcome Predictors

Fashioning A Risk Assessment Algorithm

2006

TISCFriday

December 1st

multidisciplinary project managementcreating value chains

QuickTime™ and a decompressor

are needed to see this picture.

Deal or No Deal

Trick or Treat?Trick or Treat?

Trick or Treat?Trick or Treat?

??

Comprehensive Care - The Forest not the TreesComprehensive Care - The Forest not the Trees

option........ when?option........ when?

Retreatment or Biomimetic Retreatment or Biomimetic ReplacementReplacement

A.M. BIO P.M. TECHOA.M. BIO P.M. TECHO

To provide highlights in the assessment and identification of To provide highlights in the assessment and identification of

determinant factors leading to endodontic failures, in order determinant factors leading to endodontic failures, in order

to help in the decision making process whether or not it is to help in the decision making process whether or not it is

adequate to implement a new endodontic approach vs. adequate to implement a new endodontic approach vs.

extraction and replacement with dental implants.extraction and replacement with dental implants.

To provide highlights in the assessment and identification of To provide highlights in the assessment and identification of

determinant factors leading to endodontic failures, in order determinant factors leading to endodontic failures, in order

to help in the decision making process whether or not it is to help in the decision making process whether or not it is

adequate to implement a new endodontic approach vs. adequate to implement a new endodontic approach vs.

extraction and replacement with dental implants.extraction and replacement with dental implants.

RCT - histological successRCT - histological successRCT - histological successRCT - histological success

RCT - functional successRCT - functional successRCT - functional successRCT - functional success

Endodontic TherapyEndodontic Therapy

The prevention or treatment of The prevention or treatment of apical periodontitisapical periodontitis

DebridementDebridement

Asepsis / DisinfectionAsepsis / Disinfection

Root fillingRoot filling

Failure to achieve proper working lengthFailure to achieve proper working length

Failure to debride the root canalFailure to debride the root canal

Failure to achieve proper working widthFailure to achieve proper working width

Failure to seal the entire root canal spaceFailure to seal the entire root canal space

Apical FinishingApical FinishingSCOUTINGSCOUTING

GAUGINGGAUGING

ENLARGEMENTENLARGEMENT

PATENCYPATENCY

CLEARINGCLEARING



cost$?$?$?$?$?cost$?$?$?$?$?

coronal breakdown of involved tooth - overall coronal breakdown of involved tooth - overall

healthhealth

type of bone supporting questionable toothtype of bone supporting questionable tooth

is the tooth to support a single crown or fixed is the tooth to support a single crown or fixed

prosthesis?prosthesis?

occlusion - practitioner’s proficiencyocclusion - practitioner’s proficiency

periodontal condition - overall postoperative periodontal condition - overall postoperative

expectationsexpectations

patient’s perception of treatment - potential patient’s perception of treatment - potential

esthetic resultesthetic result

cost?$?$?$?$?$cost?$?$?$?$?$

Christensen GJ. Implant therapy versus endodontic therapy. JADA: 137 Oct 2006; 1440-43



cost$?$?$?$?$?cost$?$?$?$?$?


healthhealth









cost?$?$?$?$?$cost?$?$?$?$?$


Non-surgical retreatment in conjunction Non-surgical retreatment in conjunction with surgery may have a better with surgery may have a better outcome than either procedure alone outcome than either procedure alone because all possible sites of infection because all possible sites of infection are eliminated...are eliminated...Cohn SA. 2005Cohn SA. 2005



cost$?$?$?$?$?cost$?$?$?$?$?


healthhealth









cost?$?$?$?$?$cost?$?$?$?$?$


?

rhin

osin

usitis

The contemporary determination of The contemporary determination of success, failure or questionability of the success, failure or questionability of the endodontic treatment comes from an endodontic treatment comes from an ample evaluation taking into ample evaluation taking into consideration a sum of clinical, consideration a sum of clinical, radiographical and histological criteria. radiographical and histological criteria.

Gutmann J.L. : Clinical, Radiographic and Histologic perspectives on success and failure in endodontics. Dent Clin North Am 36;2:379-392, 1992.

ENDOENDO RESTREST (Absence of PD)(Absence of PD)inadequateinadequate inadequateinadequate 18,1 %18,1 %

adequateadequate inadequateinadequate 44.1 %44.1 %

inadequateinadequate adequateadequate 67.0 %67.0 %

adequateadequate adequateadequate 91.4 %91.4 %

Correlation between RCT and Correlation between RCT and restoration qualityrestoration quality

Ray H., Trope M.Periapical status of endodontically treated teeth in relation to the technical

quality of the root filling and the coronal restoration. Int. Endodontic J. 28: 12-18, 1995

Klevant FJ, Eggink CO. The effect of canal preparation periapical disease. Int Endod J 1983; 16:68-75.

cleaned and shaped a number of root canals

teeth in the experimental group were not obturated

they used an effective coronal seal

NO RHEOLOGY DUDE!!

Healing took place in Healing took place in each experimentally each experimentally treated tooth in spite treated tooth in spite

of the of the absenceabsence of of obturationobturation

Healing took place in Healing took place in each experimentally each experimentally treated tooth in spite treated tooth in spite

of the of the absenceabsence of of obturationobturation

Coronal sealCoronal seal

Composite buildupComposite buildupComposite buildupComposite buildup

PermaFlo PurplePermaFlo Purple Vit-l-escence A3.5Vit-l-escence A3.5

Vit-l-escence A2Vit-l-escence A2

Vit-l-escence PNVit-l-escence PN Vit-l-escence OSVit-l-escence OS PermaSealPermaSeal

Persistent subjective symptomsRecurrent sinus tract or swellingPredictable discomfort to percussion or palpationEvidence of irreparable tooth fractureExcessive mobility or progressive periodontal breakdownInability to function on the tooth

Clinical Failure

Radiographic FailureIncreased width of periodontal ligament space (< 2 mm)

Lack of osseous repair within a periradicular rarefaction or increase in the size of the rarefactionLack of new lamina dura formation or evidence of increased osseous densityAppearence of new rarefact.Visible, patent canal space that is unfilledExcessive overextensionActive resorption

Gutmann J.L. : Clinical, Radiographic and Histologic perspectives on success and failure in endodontics. Dent Clin North Am 36;2:379-392, 1992.

Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2. A histological study. IEJ 1998 (31), 394-409. The results of an in vivo histological study involving apical and periapical tissues after different observation periods demonstrated the most favourable histological conditions when the instrumentation and obturation remained at or short of the apical constriction. This was the case in the presence of vital or necrotic pulps, also when bacteria had penetrated the foramen and were present in the periapical tissues. When the sealer and/or the gutta percha was extruded into the periapical tissue, the lateral canals and the apical ramifications, there was always a severe inflammatory reaction including a foreign body reaction despite a clinical absence of pain.

Fabricius L, Dahlén G, Sundqvist G, Happonen R-P, Möller ÅJR.Influence of residual bacteria on periapical tissue healing after Influence of residual bacteria on periapical tissue healing after chemomechanical treatment and root filling of experimentally infected chemomechanical treatment and root filling of experimentally infected monkey teeth.monkey teeth.Eur J Oral Sci 2006; 114: 278–285.

When bacteria remained after the endodontic treatment, 79% of the root canals showed non-healed periapical lesions, compared with 28% where no bacteria were found. Combinations of residual bacterial species were more frequently related to non-healed lesions than were single strains. When no bacteria remained, healing occurred independently of the quality of the root filling. In contrast, when bacteria remained, there was a greater correlation with non-healing in poor-quality root fillings than in technically well-performed fillings. In root canals where bacteria were found after removal of the root filling, 97% had not healed, compared with 18% for those root canals with no bacteria detected.

This study demonstrates the importance of obtaining a bacteria-free This study demonstrates the importance of obtaining a bacteria-free root canal system before permanent root filling in order to achieve root canal system before permanent root filling in order to achieve optimal healing conditions for the periapical tissues.optimal healing conditions for the periapical tissues.

Many factors must be considered in determining a course of Many factors must be considered in determining a course of treatment. One is the dentist's experience and clinical skills. Another treatment. One is the dentist's experience and clinical skills. Another

requirement is having the necessary equipment and resources.requirement is having the necessary equipment and resources.

The primary consideration is the patient's values and expectations. The primary consideration is the patient's values and expectations. Patient attitudes must be considered when making treatment Patient attitudes must be considered when making treatment

decisions. The most important is the patient's motivation to retain the decisions. The most important is the patient's motivation to retain the tooth. Poor motivation indicates extraction and not clinical tooth. Poor motivation indicates extraction and not clinical

intervention, while high motivation would indicate non-surgical intervention, while high motivation would indicate non-surgical retreatment or surgery.retreatment or surgery.

If the patient desires the best long-term result, non-If the patient desires the best long-term result, non-surgical retreatment would be the first choice in most surgical retreatment would be the first choice in most

cases.cases.Friedman S.

Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure).

Endod Topics 2002: 1: 54–78

Friedman S.

Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure).

Endod Topics 2002: 1: 54–78

....... to the selection of the appropriate ...... to the selection of the appropriate

option is the assessment of the potential option is the assessment of the potential

for a successful endodontic retreatmentfor a successful endodontic retreatment

CriticalCriticalCriticalCritical

numerous studies have reported success rates for numerous studies have reported success rates for endodontics in the range of 90% +endodontics in the range of 90% +

in teeth with necrotic pulps and apical in teeth with necrotic pulps and apical periodontitis, lesions resolved in 56-84%.periodontitis, lesions resolved in 56-84%.therefore, it is not possible to completely eliminate therefore, it is not possible to completely eliminate an endodontic infection to the extent that apical an endodontic infection to the extent that apical periodontitis is resolved.periodontitis is resolved.

Endodontic Endodontic RetreatmentRetreatmentEndodontic Endodontic RetreatmentRetreatment

Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management of endodontic failures. J Can Dent Assoc 1997: 63: 364–371.

Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endod Topics 2002: 1: 54–78.

Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990: 16: 498–504.

Hoskinson SE, Yuan-Ling N, Hoskinson HE, Moles DR, Gulabivala K. A retrospective comparison of outcome of root canal treatment using two different protocols.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002: 93: 705–715.

Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management of endodontic failures. J Can Dent Assoc 1997: 63: 364–371.

Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endod Topics 2002: 1: 54–78.

Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990: 16: 498–504.

Hoskinson SE, Yuan-Ling N, Hoskinson HE, Moles DR, Gulabivala K. A retrospective comparison of outcome of root canal treatment using two different protocols.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002: 93: 705–715.

““Root canal treatment is not Root canal treatment is not complete until the tooth has complete until the tooth has been restored.”been restored.”

““Root canal treatment is not Root canal treatment is not complete until the tooth has complete until the tooth has been restored.”been restored.”

... the tomb of the... the tomb of the

unknown endodontistunknown endodontist“ …“ …teeth not crowned after obturation were lost teeth not crowned after obturation were lost at a 6.0 times greater rate than teeth crowned at a 6.0 times greater rate than teeth crowned

after obturation”after obturation”

Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent 87:256, 2002Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent 87:256, 2002

Reduced success rates for teeth with apical Reduced success rates for teeth with apical

periodontitis do not imply that such teeth periodontitis do not imply that such teeth

necessarily are candidates for extraction.necessarily are candidates for extraction.

It probably means that different treatment protocols and more precise procedures should be carried out to improve those rates.

It probably means that different treatment protocols and more precise procedures should be carried out to improve those rates.

It is not about changing teeth for implantsIt is not about changing teeth for implants

Its about preserving teeth and Its about preserving teeth and using implants only in edentulous areas using implants only in edentulous areas

To implant, or not to implant: that is the question…To implant, or not to implant: that is the question…

Larz S.W. Spångberg DDS, PhD Larz S.W. Spångberg DDS, PhD

The modern implant is an excellent treatment choice for edentulous areas The modern implant is an excellent treatment choice for edentulous areas where teeth have been lost due to caries, periodontal disease, or physical where teeth have been lost due to caries, periodontal disease, or physical trauma.trauma.

The value of the natural tooth has diminished dramatically among some The value of the natural tooth has diminished dramatically among some dentists, who no longer see themselves as a dentition-preserving health dentists, who no longer see themselves as a dentition-preserving health care provider but rather prefer to work with screws and nuts.care provider but rather prefer to work with screws and nuts.

Even minor concerns about the prognosis of a tooth Even minor concerns about the prognosis of a tooth needing endodontic treatment often lead to extraction needing endodontic treatment often lead to extraction followed by implant replacement. This action, under the followed by implant replacement. This action, under the best circumstances, is probably due to poor knowledge of best circumstances, is probably due to poor knowledge of the true survival rate of endodontically treated teeth. the true survival rate of endodontically treated teeth. Under the worst circumstances, it is pure business.Under the worst circumstances, it is pure business. This is tragic, as we know that with the treatment options available today to an experienced endodontist there are very few structurally sound teeth that need to be removed.

The revision of negative treatment outcomes is a significant part of current endodontic practice.

Both non-surgical and surgical retreatment procedures share the problem of a significant negative outcome in the presence of apical periodontitis.

More positive results may be achieved in certain teeth with a combination of both procedures rather than either alone.

There are pressures to replace 'failed' There are pressures to replace 'failed' endodontically treated teeth with endodontically treated teeth with implants.implants.When comparable criteria are applied to outcomes, the survival rates of endodontic treatment and implant placement are the same.

Time, cost, and more flexible clinical management indicate that endodontic retreatment procedures should always be performed first unless the tooth is judged to be untreatable.

STEVEN A. COHN

Treatment choices for negative outcomes with non-surgical root canal treatment: non-surgical retreatment vs. surgical retreatment vs. implants

Endodontic Topics

Volume 11 Page 4 - July 2005

Volume 11 Issue 1

Put aside preconceived ideas and don’t let financial needs dictate the Put aside preconceived ideas and don’t let financial needs dictate the adviceadvice

Avoid being overly conservative and proceeding with a treatment without Avoid being overly conservative and proceeding with a treatment without critically evaluating the potential for a successful outcome critically evaluating the potential for a successful outcome

When needed, care must be taken to carry out every diagnostic procedure When needed, care must be taken to carry out every diagnostic procedure available, even those more invasive available, even those more invasive

Before arriving at a definitive diagnosis and treatment plan, the operator Before arriving at a definitive diagnosis and treatment plan, the operator should obtain the patient's consent to remove a restoration in order to should obtain the patient's consent to remove a restoration in order to analyze the residual tooth structure and assess the potential for carrying analyze the residual tooth structure and assess the potential for carrying out predictable treatment.out predictable treatment.

Inform the patient of the feasibility and the percentage of success for each Inform the patient of the feasibility and the percentage of success for each treatment option.treatment option.

DOMENICO RICUCCI & ANTONIO GROSSO

The compromised tooth: conservative treatment or extraction?Endodontic Topics

Volume 13 Page 108 - March 2006

Volume 13 Issue 1

Whenever possible the decision should be made to salvage the tooth Whenever possible the decision should be made to salvage the tooth using a multidisciplinary team approach using a multidisciplinary team approach

Negative Cultures 94 %94 %

Positive Cultures 68 %

This study investigated the role of infection on the prognosis of endodontic therapy by following-up teeth that had had their canals cleaned and obturated during a single appointment. The root canals of 55 single-rooted teeth with apical periodontitis were thoroughly instrumented and irrigated with sodium hypochlorite solution. Using advanced anaerobic bacteriological techniques, post-instrumentation samples were taken and the teeth were then root-filled during the same appointment. AII teeth were initially infected; after instrumentation low numbers of bacteria were detected in 22 of 55 root canals. Periapical healing was followed-up for 5 years. Complete periapical healing occurred in 94% of cases that yielded a negative culture. Where the samples were positive prior to root filling, the success rate of treatment was just 68% - a statistically significant difference. Further investigation of three failures revealed the presence of Actinomyces species in each case; no other specific bacteria were implicated in failure cases. These findings emphasize the importance of completely eliminating bacteria from the These findings emphasize the importance of completely eliminating bacteria from the root canal system before obturation. This objective cannot be reliably achieved in a one-visit root canal system before obturation. This objective cannot be reliably achieved in a one-visit treatment because it is not possible to eradicate all infection from the root canal without the treatment because it is not possible to eradicate all infection from the root canal without the support of an inter-appointment antimicrobial dressing.support of an inter-appointment antimicrobial dressing.

This study investigated the role of infection on the prognosis of endodontic therapy by following-up teeth that had had their canals cleaned and obturated during a single appointment. The root canals of 55 single-rooted teeth with apical periodontitis were thoroughly instrumented and irrigated with sodium hypochlorite solution. Using advanced anaerobic bacteriological techniques, post-instrumentation samples were taken and the teeth were then root-filled during the same appointment. AII teeth were initially infected; after instrumentation low numbers of bacteria were detected in 22 of 55 root canals. Periapical healing was followed-up for 5 years. Complete periapical healing occurred in 94% of cases that yielded a negative culture. Where the samples were positive prior to root filling, the success rate of treatment was just 68% - a statistically significant difference. Further investigation of three failures revealed the presence of Actinomyces species in each case; no other specific bacteria were implicated in failure cases. These findings emphasize the importance of completely eliminating bacteria from the These findings emphasize the importance of completely eliminating bacteria from the root canal system before obturation. This objective cannot be reliably achieved in a one-visit root canal system before obturation. This objective cannot be reliably achieved in a one-visit treatment because it is not possible to eradicate all infection from the root canal without the treatment because it is not possible to eradicate all infection from the root canal without the support of an inter-appointment antimicrobial dressing.support of an inter-appointment antimicrobial dressing.

Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis

Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis

U. Sjögren, D. Figdor, S. Persson & G. Sundqvist 1997

International Endodontic Journal 30 (5), 297-306

For intracanal infection, non-surgical For intracanal infection, non-surgical retreatment is generally most beneficial retreatment is generally most beneficial because it seeks to eliminate the bacteria because it seeks to eliminate the bacteria from within the root canal system. from within the root canal system. Surgery for intracanal infections can Surgery for intracanal infections can isolate, but not eliminate, the bacteria isolate, but not eliminate, the bacteria from the root canal, and would be limited from the root canal, and would be limited to those cases where non-surgical to those cases where non-surgical retreatment is not judged to be possible.retreatment is not judged to be possible.

Nair PNR, Sjögren U, Krey G, Kahnberg K-E, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a long- term light and electron microscopic follow-up study. J Endod 1990: 16: 580–588.

Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endod Topics 2002: 1: 54–78

QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.

The possibility of instrumenting the root canal to its

full length and the level of root filling significantly

affect the outcome of treatment. 94 % of periapical

lesions dissapear when the canal is treated whithin

the apical limits (2mm), which constitutes a

significant difference when is compared with

overextended canals (76 %) and undertreated (-

2mm : 68 %).

The possibility of instrumenting the root canal to its

full length and the level of root filling significantly

affect the outcome of treatment. 94 % of periapical

lesions dissapear when the canal is treated whithin

the apical limits (2mm), which constitutes a

significant difference when is compared with

overextended canals (76 %) and undertreated (-

2mm : 68 %). Sjögren U, Hägglund B, Sundqvist G, Wing K.Factors affecting the long-term results of endodontic treatment.J Endod 1990: 16: 498–504.

Overall success rate: 81% Overall success rate: 81%

Results vary significantly based upon Results vary significantly based upon periapical status:periapical status:w/o AP: 97% successw/o AP: 97% successw/ AP: 78% successw/ AP: 78% success

Presence or abscence of perforations:Presence or abscence of perforations:w: 42% successw: 42% successw/o: 89% successw/o: 89% success

Obturation quality:Obturation quality:Adequate: 86% successAdequate: 86% successInadequate: 76% successInadequate: 76% success

Overall success rate: 81% Overall success rate: 81%

Results vary significantly based upon Results vary significantly based upon periapical status:periapical status:w/o AP: 97% successw/o AP: 97% successw/ AP: 78% successw/ AP: 78% success

Presence or abscence of perforations:Presence or abscence of perforations:w: 42% successw: 42% successw/o: 89% successw/o: 89% success

Obturation quality:Obturation quality:Adequate: 86% successAdequate: 86% successInadequate: 76% successInadequate: 76% success Farzaneh M, Abitbol S, Friedman S.Farzaneh M, Abitbol S, Friedman S.

Treatment outcome in endodontics:Treatment outcome in endodontics:

the Toronto Study. Phases I and II : Orthograde the Toronto Study. Phases I and II : Orthograde retreatment.retreatment.

J Endod. 2004 Sep ;30(9):627-33. J Endod. 2004 Sep ;30(9):627-33.

Farzaneh M, Abitbol S, Friedman S.Farzaneh M, Abitbol S, Friedman S.

Treatment outcome in endodontics:Treatment outcome in endodontics:

the Toronto Study. Phases I and II : Orthograde the Toronto Study. Phases I and II : Orthograde retreatment.retreatment.

J Endod. 2004 Sep ;30(9):627-33. J Endod. 2004 Sep ;30(9):627-33.

The prognosis of perforated teeth are associated with three factors — size, location, and time elapsed since occurrence to repair

Fuss Z, Trope M.

Root Perforations: Classification and treatment choices based on prognostic factors.

Endod Dent Traumatol. 1996;12:255–264

Apical periodontitis, although a strong predictor, is secondary to preoperative perforation, in predicting the outcome of retreatment. (absent: 89%; present: 42%)

Farzaneh M, Abitol S, Friedman S

Treatment outcome in endodontics: The Toronto study.

Phases I and II: Orthograde retreatment.

J Endodon 2004;30:627-633

The presence of perforation and stripping are two of the most important elements related to poor success (30-60%) in retreatment

Gorni FGM, Gagliani MM.

The outcome of endodontic retreatment: A 2-yr follow-up.

J Endodon 2004;30:1-4

Edentulous, untreatable, treatableEdentulous, untreatable, treatable

Surgery for intracanal infections Surgery for intracanal infections can isolate, but not eliminate, the can isolate, but not eliminate, the bacteria from the root canal, and bacteria from the root canal, and would be limited to those cases would be limited to those cases where non-surgical retreatment where non-surgical retreatment

is not judged to be possible. is not judged to be possible. When the etiology is independent When the etiology is independent of the root canal system, surgery of the root canal system, surgery is the most beneficial treatmentis the most beneficial treatment

Nair PNR, Sjögren U, Krey G, Kahnberg K-E, Sundqvist G.Nair PNR, Sjögren U, Krey G, Kahnberg K-E, Sundqvist G.Intraradicular bacteria and fungi in root-filled, Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant asymptomatic human teeth with therapy-resistant periapical lesions: a long- term light and electron periapical lesions: a long- term light and electron microscopic follow-up study. microscopic follow-up study. J EndodJ Endod 1990: 1990: 1616: 580–588.: 580–588.

Nair PNR, Sjögren U, Schumacher E, Sundqvist G.Nair PNR, Sjögren U, Schumacher E, Sundqvist G.Radicular cyst affecting a root-filled human tooth: a long-Radicular cyst affecting a root-filled human tooth: a long-term post-treatment follow-up. term post-treatment follow-up. Int Endo JInt Endo J 1993: 1993: 2626: 225–: 225–233.233.

Repeat surgeryRepeat surgeryA repeat of surgery is associated with a worse outcome than surgery performed the first A repeat of surgery is associated with a worse outcome than surgery performed the first

timetime

Should periapical resurgery be considered for failed cases before extraction and Should periapical resurgery be considered for failed cases before extraction and replacement with a prosthesis or implant? replacement with a prosthesis or implant?

Gagliani et al. compared periapical surgery and resurgery with a 5-year follow-up period. Gagliani et al. compared periapical surgery and resurgery with a 5-year follow-up period. Using magnification and microsurgical root-end preparations, the positive outcome for Using magnification and microsurgical root-end preparations, the positive outcome for primary surgery was 86% and 59% for resurgeryprimary surgery was 86% and 59% for resurgery

Rud et al.: 76 initially – 81% for resurgeryRud et al.: 76 initially – 81% for resurgery

Direct comparison between these investigations is difficult, in part because the apical Direct comparison between these investigations is difficult, in part because the apical preparation techniques and root-end filling materials differ. The dentine-bonded composite preparation techniques and root-end filling materials differ. The dentine-bonded composite technique has not been widely reported by other authors, but it shows promise technique has not been widely reported by other authors, but it shows promise

While periapical resurgery requires further study, it appears to be a realistic alternative to While periapical resurgery requires further study, it appears to be a realistic alternative to tooth extraction (82) and is preferable to the loss of the toothtooth extraction (82) and is preferable to the loss of the tooth

A repeat of surgery is associated with a worse outcome than surgery performed the first A repeat of surgery is associated with a worse outcome than surgery performed the first timetime

Should periapical resurgery be considered for failed cases before extraction and Should periapical resurgery be considered for failed cases before extraction and replacement with a prosthesis or implant? replacement with a prosthesis or implant?

Gagliani et al. compared periapical surgery and resurgery with a 5-year follow-up period. Gagliani et al. compared periapical surgery and resurgery with a 5-year follow-up period. Using magnification and microsurgical root-end preparations, the positive outcome for Using magnification and microsurgical root-end preparations, the positive outcome for primary surgery was 86% and 59% for resurgeryprimary surgery was 86% and 59% for resurgery

Rud et al.: 76 initially – 81% for resurgeryRud et al.: 76 initially – 81% for resurgery

Direct comparison between these investigations is difficult, in part because the apical Direct comparison between these investigations is difficult, in part because the apical preparation techniques and root-end filling materials differ. The dentine-bonded composite preparation techniques and root-end filling materials differ. The dentine-bonded composite technique has not been widely reported by other authors, but it shows promise technique has not been widely reported by other authors, but it shows promise

While periapical resurgery requires further study, it appears to be a realistic alternative to While periapical resurgery requires further study, it appears to be a realistic alternative to tooth extraction (82) and is preferable to the loss of the toothtooth extraction (82) and is preferable to the loss of the tooth

Gagliani MM, Gorni FGM, Strohmenger L. Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison. Int Endo J 2005: 38: 320–327.Rud J, Rud V, Munksgaard EC. Long-term evaluation of retrograde root filling with dentine-bonded resin composite. J Endod 1996: 22: 90–93.Rud J, Rud V, Munksgaard EC. Periapical healing of mandibular molars after root-end sealing with dentine-bonded composite. Int Endo J 2001: 334: 285–292.

The compromised tooth : The compromised tooth : Conservative treatment or Extraction?Conservative treatment or Extraction?

1 - Potentials of endodontics1 - Potentials of endodontics2 - Quantity of residual tooth substance2 - Quantity of residual tooth substance3 - Integrity of residual tooth substance3 - Integrity of residual tooth substance4- Condition of the periodontal tissues4- Condition of the periodontal tissues

1 - Potentials of endodontics1 - Potentials of endodontics2 - Quantity of residual tooth substance2 - Quantity of residual tooth substance3 - Integrity of residual tooth substance3 - Integrity of residual tooth substance4- Condition of the periodontal tissues4- Condition of the periodontal tissues

Ricucci D, Grosso AEndodontic TopicsVolume 13 Page 108 - March 2006

Sorenson JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthe Dent 1990:63:529-536.

Quality of residual tooth structureQuality of residual tooth structure

Quantity of residual tooth structureQuantity of residual tooth structureQuantity of residual tooth structureQuantity of residual tooth structure

Short conical post, decementation, absence of ferrule effect

Quantity of residual tooth substanceQuantity of residual tooth substance

Reconstruction of a severely broken down tooth with a full crown Reconstruction of a severely broken down tooth with a full crown is usually necessary to ensure long-term maintenance. Then, a is usually necessary to ensure long-term maintenance. Then, a post and core often has to be placed. There should also be coronal post and core often has to be placed. There should also be coronal dentine remaining to obtain the so-called ferrule effect. dentine remaining to obtain the so-called ferrule effect.

The ferrule must be uniform around the cervical circumference of The ferrule must be uniform around the cervical circumference of the tooth. It has been demonstrated in vitro that teeth restored the tooth. It has been demonstrated in vitro that teeth restored with a fused post and core and a crown with a uniform ferrule of with a fused post and core and a crown with a uniform ferrule of 2 mm are more resistant to fracture than teeth restored with a 2 mm are more resistant to fracture than teeth restored with a non-uniform height of ferrule, varying from 0.5 to 2 mm. Both non-uniform height of ferrule, varying from 0.5 to 2 mm. Both groups of teeth in that study, with uniform and non-uniform groups of teeth in that study, with uniform and non-uniform ferrules, were more resistant to fracture compared with teeth ferrules, were more resistant to fracture compared with teeth without a ferrule.without a ferrule.

In the absence of In the absence of a ferrule it is not a ferrule it is not unusual for a unusual for a post and core to post and core to debonddebond

Bergman B., Lundquist P., Sjogren U.,Sunsquit Bergman B., Lundquist P., Sjogren U.,Sunsquit G.,Restorative and endodontic results after treatment with G.,Restorative and endodontic results after treatment with cast post and core.J.Pros.Dent.1989;61:10-5cast post and core.J.Pros.Dent.1989;61:10-5 Lewis R.Smith BGN., A clinical survey of failed post and Lewis R.Smith BGN., A clinical survey of failed post and core crown.Br Dent. J.1988;165:9507core crown.Br Dent. J.1988;165:9507 Sorenson J.A., Martinoff J.G., Endodontically treated teeth Sorenson J.A., Martinoff J.G., Endodontically treated teeth as abutments.J. Pros.Dent.1985; 53: 631-6 as abutments.J. Pros.Dent.1985; 53: 631-6 Mertink AGB, Meeuuissen R., Kaysen AF,Mulden J., Mertink AGB, Meeuuissen R., Kaysen AF,Mulden J., Survival rate and failure characteristics of the all metal post Survival rate and failure characteristics of the all metal post and core restorations. J. Oral.Rehab.1993; 20: 455-61and core restorations. J. Oral.Rehab.1993; 20: 455-61 Torbjorner A., Karlsson S., Odman P., Survival rate and Torbjorner A., Karlsson S., Odman P., Survival rate and failure characteristics for two post design.J Pros.Dent. failure characteristics for two post design.J Pros.Dent. 1995; 73-5: 439-4441995; 73-5: 439-444

Biologic widthBiologic width

Calcium Sulphate Calcium Sulphate Hemihydrate 98%Hemihydrate 98%

Quality of residual tooth Quality of residual tooth substancesubstance

Not only the quantity but also the quality of the residual supragingival Not only the quantity but also the quality of the residual supragingival tooth substance be evaluated. Sometimes is needed to remove tooth substance be evaluated. Sometimes is needed to remove completely all carious tissues and all restorative materials present to completely all carious tissues and all restorative materials present to allow proper assessment. This is particularly relevant when a root allow proper assessment. This is particularly relevant when a root fracture is suspected or is seen at a coronal level.fracture is suspected or is seen at a coronal level.

ProRoot™ MTAProRoot™ MTA(Portland Cement – 75%)(Portland Cement – 75%)

ProRoot™ MTAProRoot™ MTA(Portland Cement – 75%)(Portland Cement – 75%)

Tricalcium Silicate, Dicalcium Silicate, Tricalcium AluminateTricalcium Silicate, Dicalcium Silicate, Tricalcium Aluminate

Tetracalcium Aluminoferrite, Bismuth Oxide – 20%Tetracalcium Aluminoferrite, Bismuth Oxide – 20%

Calcium Sulfate Dihydrate (gypsum) – 5%Calcium Sulfate Dihydrate (gypsum) – 5%

Tricalcium Silicate, Dicalcium Silicate, Tricalcium AluminateTricalcium Silicate, Dicalcium Silicate, Tricalcium Aluminate

Tetracalcium Aluminoferrite, Bismuth Oxide – 20%Tetracalcium Aluminoferrite, Bismuth Oxide – 20%

Calcium Sulfate Dihydrate (gypsum) – 5%Calcium Sulfate Dihydrate (gypsum) – 5%

ph when mixed (12.5) similar to ph when mixed (12.5) similar to Ca(OH)Ca(OH)22

hydrophilic, sets in the presence of hydrophilic, sets in the presence of moisturemoisture

high compressive strength - 21 days high compressive strength - 21 days 70 Mpa 70 Mpa

ProRoot™ MTAProRoot™ MTAProRoot™ MTAProRoot™ MTA

Furcation perforationFurcation perforation

Extra-radicular perforation repairExtra-radicular perforation repair

ApexificationApexification

Surgical root repairSurgical root repair

Internal resorption repairInternal resorption repair

Pulp capPulp cap

PulpotomyPulpotomy






Pulp capPulp cap

PulpotomyPulpotomy

Thoroughly disinfect the areaThoroughly disinfect the area

Avoid washing out the materialAvoid washing out the material

Check placement radiographicallyCheck placement radiographically

Protect from Acid EtchProtect from Acid Etch

Can cause a slight discolorationCan cause a slight discolorationof tooth structure above the of tooth structure above the gingival linegingival line

5 minute working time5 minute working time

4 to 6 hour set time4 to 6 hour set time

Cover mixture with moist gauzeCover mixture with moist gauzepad to extend working timepad to extend working time

Thoroughly disinfect the areaThoroughly disinfect the area

Avoid washing out the materialAvoid washing out the material

Check placement radiographicallyCheck placement radiographically

Protect from Acid EtchProtect from Acid Etch

Can cause a slight discolorationCan cause a slight discolorationof tooth structure above the of tooth structure above the gingival linegingival line

5 minute working time5 minute working time

4 to 6 hour set time4 to 6 hour set time

Cover mixture with moist gauzeCover mixture with moist gauzepad to extend working timepad to extend working time

ProRoot™ MTAProRoot™ MTAProRoot™ MTAProRoot™ MTA






Pulp capPulp cap

PulpotomyPulpotomy






Pulp capPulp cap

PulpotomyPulpotomy

Extra-radicular

Perforation Repair

Extra-radicular

Perforation Repair

Danger Zone

Iatrogenic Iatrogenic PerforationPerforationMTA repairMTA repair

4 – 6 hour setting 4 – 6 hour setting timetime

Iatrogenic Iatrogenic PerforationPerforationMTA repairMTA repair

4 – 6 hour setting 4 – 6 hour setting timetime

2.5 years2.5 years2.5 years2.5 years

2.5 years2.5 years

3 years3 years

Perhaps endodontists have colluded in the creation of such advocacy by defining endodontic

success too narrowly and conversely “implantologists” have defined the outcome criteria for

implants too loosely. If endodontic success was limited to healthy, vital teeth with

uncomplicated root canal anatomy in patients who had no systemic disease processes, one

could expect 99.9% success. This is as illogical as claiming 100% implant success when 5

out of 6 implants are finally restorable in a patient, providing a fully functional dentition. In

endodontics that would represent a 16.5% failure rate..........

all endodontically teeth present with reconstructive needs

long term prognosis can be impaired by post placement (length, width, form and material choice), position in the arch, location in complex prosthesis, quantity of residual tooth structure

marginal periodontitis must be addressed to obviate loss of support

loss more often due to reconstructive failure

interdisciplinary collaboration NOT exclusion establishes standard of care

decision making process

Newburg RE, Pameijer CH, Retentive properties of post and core systems. J Prosthet Den 1976:36;636

Goodacre CJ, Bernal G et al. Clinical Complications in fixed prosthodontics. J Prosthet Dent 2003:90:31-41.

Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. Prosthet Dent 2002:87:256-263.

RetreatmentRetreatment Endo Restorative ContinuumEndo Restorative Continuum

Endo Restorative ContinuumEndo Restorative Continuum

New New challenge of challenge of implantologyimplantology

Long lasting Long lasting osseointegration osseointegration

> 10 yrs.> 10 yrs.

Increased amount of Increased amount of single crown single crown

restorations in the restorations in the posterior regionposterior region

Fatigue of implant Fatigue of implant materials and materials and componentscomponents

F

RF = diameter: 3.75 – 4.00 mmRF = diameter: 3.75 – 4.00 mmWBI = diameter: 5.00 WBI = diameter: 5.00

mm mm

43 patients

64 implants

43 patients

64 implants

5 year

cumulative survival rate:

96.8 %

5 year

cumulative survial rate:

80.9 %

A retrospective study on the outcome of wide-bodied implants retrospective study on the outcome of wide-bodied implants

Shin SW, Bryant SR, Zarb GA: Int J Prosthodont, Vol. 17(1), 52-58, 2004Shin SW, Bryant SR, Zarb GA: Int J Prosthodont, Vol. 17(1), 52-58, 2004

Conclusion:

Wide-bodied Branemark implants placed in the posterior jaw can suffer a

significantly elevated risk of implant failure compared to regular-diameter implants.

An implant-abutment-joint design An implant-abutment-joint design

with high strength to non-axial loads:with high strength to non-axial loads:

Precise cone connectionPrecise cone connection

Solution

F

Bone will react to loads placed on it..increased load -

strength...decreased load - weakness

• orient along long axis

• narrow occlusal table

• absent cantilever

• Wolf’s law - growing bone

• based on load or absence

• diameter, rigidity

• orient along long axis

• narrow occlusal table

• absent cantilever

• Wolf’s law - growing bone

• based on load or absence

• diameter, rigidity

Case selection Treatment PlanningCase selection Treatment Planning

Formulating a treatment

planEvalute the endodontic

potentialNumbers GameDo you measure success based on resolution of the necrotic condition or an apical lesion or do you measure tooth survival..

Salehrabi and Rotstein - survey of 1.5 million teeth, 97% fully functional 8 years after initial non-surgical treatment

The risk for deteriorated apical status seems higher for teeth with root fillings of substandard quality

Prostho-orthoProstho-ortho

c a r e

C o m p r e h e n s i v e

... apical periodontitis was .. apical periodontitis was confirmed as the main prognostic confirmed as the main prognostic factor in initial endodontic factor in initial endodontic treatment.treatment.

Hoskinson et al 2002; Friedman et al 2003; Chugal et al 2003Hoskinson et al 2002; Friedman et al 2003; Chugal et al 2003

Prognosis of Endodontic TreatmentPrognosis of Endodontic Treatment

Apical Periodontitis: Apical Periodontitis: TreatmentTreatment

Ca(OH)2: in-vivoCa(OH)2: in-vivo

24 teeth with apical periodontitis

cleaning and shaping with 1% NaOCl

inactivation

sampling

Effectiveness of CHX, Effectiveness of CHX, in-vivoin-vivo

Zamany, Safavi, Spangberg. OOOE 2003

Saline (12)✦ 4ml, 30 sec.✦ agitated w/file WL✦ inactivation✦ sample

2% CHX (12)✦ 4ml, 30 sec.✦ agitation w/file, WL✦ inactivation✦ sample

2% CHX

8% infected

Despite the small sample size, the results Despite the small sample size, the results demonstrate that an additional rinse with demonstrate that an additional rinse with

2% CHX resulted in enhanced disinfection2% CHX resulted in enhanced disinfection

Effectiveness of CHX, Effectiveness of CHX, in-vivoin-vivo

Zamany, Safavi, Spangberg. OOOE 2003Zamany, Safavi, Spangberg. OOOE 2003

Saline

58% infected

Canal free of infectionCanal free of infection

Treatment of the Vital Treatment of the Vital (non-infected) Canal(non-infected) CanalAsepsisAsepsis

Mechanical instrumentation

& irrigation

Mechanical instrumentation

& irrigation

Root fillingRoot filling

Apical PeriodontitisApical Periodontitis

PrevalencePrevalence

Increases with ageIncreases with age

Age 50: 50%Age 50: 50%

Age 62: 62%Age 62: 62%

US Census data: 420 million root filled US Census data: 420 million root filled

At 90% success: 42 million failing At 90% success: 42 million failing

At 80% success: 84 million failing At 80% success: 84 million failing

At 60% success: 168 million failingAt 60% success: 168 million failing

Eriksen 1991, 1998; Figdor 2002Eriksen 1991, 1998; Figdor 2002

Spread of infectionSpread of infection

Nair, 2000

The “Red” Zone….the last 1 The “Red” Zone….the last 1 mm of the root canal space mm of the root canal space has created more arguments, has created more arguments, debates and research...debates and research...

The “Red” Zone….the last 1 The “Red” Zone….the last 1 mm of the root canal space mm of the root canal space has created more arguments, has created more arguments, debates and research...debates and research...

Root Canal Therapy Looks Good Root Canal Therapy Looks Good

LengthLength

Shape Shape

Why did it fail?Why did it fail?

Primary Apical PeriodontitisPrimary Apical Periodontitis

Prognosis of non-surgical RCTPrognosis of non-surgical RCT

Sonnets from the Sonnets from the SwedishSwedishSonnets from the Sonnets from the SwedishSwedish

deep, multiple restorations, crowns, inlays or onlaysdeep, multiple restorations, crowns, inlays or onlays deep bases, canal constriction, chamber constriction, pulp stonesdeep bases, canal constriction, chamber constriction, pulp stones focal sclerosis, widened pulp spacesfocal sclerosis, widened pulp spaces thickened PDL, loss of lamina durathickened PDL, loss of lamina dura pins, periodontal diseasepins, periodontal disease

deep, multiple restorations, crowns, inlays or onlaysdeep, multiple restorations, crowns, inlays or onlays deep bases, canal constriction, chamber constriction, pulp stonesdeep bases, canal constriction, chamber constriction, pulp stones focal sclerosis, widened pulp spacesfocal sclerosis, widened pulp spaces thickened PDL, loss of lamina durathickened PDL, loss of lamina dura pins, periodontal diseasepins, periodontal disease

Warning signs of Warning signs of pulpal insultpulpal insultWarning signs of Warning signs of pulpal insultpulpal insult

Spectral Spectral ArchaeologArchaeolog

yy

Chromatic Chromatic TopographTopograph

yy

Remove restorationsRemove restorationsExpose and trace fracturesExpose and trace fractures

Eliminate decayEliminate decay

Oral microorganismsOral microorganisms

Pulpal and Periapical Pulpal and Periapical DiseaseDisease

Pulpal and Periapical Pulpal and Periapical DiseaseDisease

Extreme complexity Extreme complexity of the root canal systemof the root canal system

Three dimensional - x, y, z

Three dimensional - x, y, z

> flare of mesial wall of molars by > flare of mesial wall of molars by extension into marginal ridge with extension into marginal ridge with > > oo of apical curvature of apical curvature

bevel cavo surface angle to improve bevel cavo surface angle to improve opticsoptics

> flare of mesial wall of molars by > flare of mesial wall of molars by extension into marginal ridge with extension into marginal ridge with > > oo of apical curvature of apical curvature

bevel cavo surface angle to improve bevel cavo surface angle to improve opticsoptics

Precurve files used Precurve files used in pre-enlargement phasein pre-enlargement phase

3x3x5x5x

8x8x13x13xMBMB

MPMP

DBDB

PP

21x21x

Begin with the end in mindBegin with the end in mind

Locate root canal orifices – stains, caries detection Locate root canal orifices – stains, caries detection agentsagents

Locate root canal orifices – stains, caries detection Locate root canal orifices – stains, caries detection agentsagents

Follow the mapFollow the map

Maxillary Anterior TeethMaxillary Anterior Teeth

Lingual TriangleLingual Triangle

Initial PenetrationInitial Penetration

Incisal TriangleIncisal Triangle

Mandibular Anterior TeethMandibular Anterior Teeth

Maxillary Premolar TeethMaxillary Premolar Teeth

Mandibular Premolar TeethMandibular Premolar Teeth

Maxillary Molar TeethMaxillary Molar TeethMaxillary Molar TeethMaxillary Molar Teeth

Serial Cross SectionSerial Cross SectionSerial Cross SectionSerial Cross Section

MicroCTMicroCTMicroCTMicroCT Courtesy of Dr. Cliff RuddleCourtesy of Dr. Cliff Ruddle

The spatial orientation of orifices isThe spatial orientation of orifices isThe spatial orientation of orifices isThe spatial orientation of orifices is

aassyymmmmeettrriiccaall

UltrasonicUltrasonicss

Trough the lineTrough the line

Relocate the canal orificesRelocate the canal orificesRelocate the canal orificesRelocate the canal orifices

UsesUses✦ disassemble restorations

✦ UNcover hidden or calcified canals!

✦ remove canal obstructions

✦ post/core removal

✦ agitate/energize irrigants

✦ separated instrument removal

UsesUses✦ disassemble restorations

✦ UNcover hidden or calcified canals!

✦ remove canal obstructions

✦ post/core removal

✦ agitate/energize irrigants

✦ separated instrument removal

UltrasonicsUltrasonicsUltrasonicsUltrasonics


Relocation of the canal orificesRelocation of the canal orifices


Composite finishing burs

Composite finishing burs

Brasseler H274-016Brasseler H274-016

Mandibular Molar TeethMandibular Molar TeethMandibular Molar TeethMandibular Molar Teeth

Deep ShapeDeep Shape Apical GaugingApical Gauging

Apical SizingApical Sizing

Deep ShapeDeep Shape Apical GaugingApical Gauging

Apical SizingApical Sizing

Cusp TipsCusp Tips

Mesial Lingual Mesial Lingual Canal Relatively Canal Relatively

StraightStraight

Mesial Lingual Mesial Lingual Canal Relatively Canal Relatively

StraightStraight

Mesial Buccal Mesial Buccal Canal CurvedCanal CurvedMesial Buccal Mesial Buccal Canal CurvedCanal Curved

Why is Straight Line Access SO Important?

Why is Straight Line Access SO Important?

What we seeWhat we see What we don’t seeWhat we don’t see

Ledge

Extend buccal slotExtend buccal slot

access the apical terminus not the orifice

align cusp tip + pulp horn + orifice of the root canal space + the apical constrictionalign cusp tip + pulp horn + orifice of the root canal space + the apical constriction

Trough the Line!Trough the Line!Trough the Line!Trough the Line!

Locate all orifices to root canal systemLocate all orifices to root canal system

Mandibular Middle Mesial CanalsMandibular Middle Mesial CanalsMandibular Middle Mesial CanalsMandibular Middle Mesial Canals

0 to 15%0 to 15%

Jung IY, et al. Apical Anatomy in Mesial and Mesial and Mesiobuccal Roots of Permanent First Molars. J EndoMay 2005 (31)5; 364-368

Mannocci et al. The isthmuses of he mesial root of mandibular molars: a micro-computed tomographic study.Int Endo J. 2005 Aug,38(8):558-63

0 to15%0 to15%

@100%@100%

MB2 and MB3MB2 and MB3 Middle MesialMiddle Mesial

Locate all orifices of the root canal system

F5F5

S1S1 S2S2 SxSx

F1F1F2F2

F3F3 F4F4

Wu MK, Dummer PMH, Wesselink PR. Consequences and strategies to deal with residual post-treatment root canal infection. IEJ; 39(5): May 2006 343.

Wu MK, Dummer PMH, Wesselink PR. Consequences and strategies to deal with residual post-treatment root canal infection. IEJ; 39(5): May 2006 343.

Debridement - awareness of Debridement - awareness of native anatomy - eccentricities - native anatomy - eccentricities - instrumentation must address instrumentation must address out of round areasout of round areas

Debridement - awareness of Debridement - awareness of native anatomy - eccentricities - native anatomy - eccentricities - instrumentation must address instrumentation must address out of round areasout of round areas

Definitive Risk Assessment Algorithm

Finishing File 1, 2, 3, 4, 5Finishing File 1, 2, 3, 4, 5

Shaping File 2Shaping File 2

Shaping File 1Shaping File 1

Bergmans et al. Progressive versus constant tapered shaft design using NiTi rotary instruments. IEJ 36(4) April 2003. 288 The progressive tapered shaft design of the Protaper instrument was less influenced by the mid-root curvature than the constant tapered design of the K3 instrument thereby providing a good centred apical preparationed

Coronal 1/3

Middle 1/3

Apical 1/3

Obtain and maintain accurate working length to the apical apertureObtain and maintain accurate working length to the apical aperture

Obtain and maintain accurate working length to the apical apertureObtain and maintain accurate working length to the apical aperture

apical foramenapical foramen

radiographic apexradiographic apex

cemento-dentinal junctioncemento-dentinal junction

shortshort

flushflush

RT RT

Working LengthWorking Length

Electronic Foramenal Locator

Apex LocatorsApex LocatorsApex LocatorsApex Locators• attempt initial WL, prior to pre-attempt initial WL, prior to pre-

enlargement enlargement

• confirm WL after coronal debridementconfirm WL after coronal debridement

• take radiograph - RCDSO?take radiograph - RCDSO?

• reconfirm working length during procedurereconfirm working length during procedure

• re-confirm WL......re-confirm WL......

at time of sealer placementat time of sealer placement

• attempt initial WL, prior to pre-attempt initial WL, prior to pre-enlargement enlargement

• confirm WL after coronal debridementconfirm WL after coronal debridement

• take radiograph - RCDSO?take radiograph - RCDSO?

• reconfirm working length during procedurereconfirm working length during procedure

• re-confirm WL......re-confirm WL......

at time of sealer placementat time of sealer placement

EAL = 0.0EAL = 0.0

Anatomic apexAnatomic apexAnatomic apexAnatomic apex

PDL, cementum & bonePDL, cementum & bonePDL, cementum & bonePDL, cementum & bone

Bleeding pointBleeding pointBleeding pointBleeding point

EAL = 0.0EAL = 0.0

Anatomic apexAnatomic apexAnatomic apexAnatomic apex

PDL, cementum & bonePDL, cementum & bonePDL, cementum & bonePDL, cementum & bone

Bleeding pointBleeding pointBleeding pointBleeding point



re-establish correct working lengthre-establish correct working length

2nd appointment

Paper PointsPaper Points

RTRTRTRT

CDJCDJCDJCDJ

MADMADMADMAD

Apical Control Apical Control ZoneZone

Apical Control Apical Control ZoneZone

The ‘Apical Control Zone’ is a matrix-like The ‘Apical Control Zone’ is a matrix-like region created in the apical third of the root region created in the apical third of the root canal space. The zone demonstrates an canal space. The zone demonstrates an exaggerated taper from the clinician defined exaggerated taper from the clinician defined apical constriction whether this is spatially a apical constriction whether this is spatially a linear or point determination. This enhanced linear or point determination. This enhanced taper in the apical control zone provides taper in the apical control zone provides resistance form against the condensation resistance form against the condensation pressures of obturation and acts to prevent pressures of obturation and acts to prevent the extrusion of the filling material during the extrusion of the filling material during obturation.obturation.

The ‘Apical Control Zone’ is a matrix-like The ‘Apical Control Zone’ is a matrix-like region created in the apical third of the root region created in the apical third of the root canal space. The zone demonstrates an canal space. The zone demonstrates an exaggerated taper from the clinician defined exaggerated taper from the clinician defined apical constriction whether this is spatially a apical constriction whether this is spatially a linear or point determination. This enhanced linear or point determination. This enhanced taper in the apical control zone provides taper in the apical control zone provides resistance form against the condensation resistance form against the condensation pressures of obturation and acts to prevent pressures of obturation and acts to prevent the extrusion of the filling material during the extrusion of the filling material during obturation.obturation.

Apical enlargement - morphometric accuracyApical enlargement - morphometric accuracy

weiger et al. a clinical method to determine the apical preparation size. Part I. OS OM OP OR Endo 2006; 102:686-91

bartha et al. extended apical enlargement with hand files versus rotary niti files. Part II. OS OM OP OR Endo 2006; 102:692-7

Debridement of native anatomyDebridement of native anatomy

Resid

ual n

ecro

tic deb

ris

Control of Endodontic InfectionControl of Endodontic InfectionControl of Endodontic InfectionControl of Endodontic Infection

Card et al. JOE 2002Card et al. JOE 2002Sjøgren U et al. IEJ 1997 Sjøgren U et al. IEJ 1997 Ørstavik D et al. IEJ 1991Ørstavik D et al. IEJ 1991Bystrøm et al. EDT 1987Bystrøm et al. EDT 1987Kerekes et al. JOE 1979Kerekes et al. JOE 1979

Card et al. JOE 2002Card et al. JOE 2002Sjøgren U et al. IEJ 1997 Sjøgren U et al. IEJ 1997 Ørstavik D et al. IEJ 1991Ørstavik D et al. IEJ 1991Bystrøm et al. EDT 1987Bystrøm et al. EDT 1987Kerekes et al. JOE 1979Kerekes et al. JOE 1979

DebridementDebridement

Apical Apical ApertureAperture Preparation Preparation

Vo

lum

e o

f V

olu

me

of

Mic

rob

ial C

on

ten

tsM

icro

bia

l Co

nte

nts#25

#30

#35

#40

Mickel AK et al. The role of apical size determination and Mickel AK et al. The role of apical size determination and enlargement in the reduction of intracanal bacteria. JOE in pressenlargement in the reduction of intracanal bacteria. JOE in press

artifactartifact

isthmusisthmus

bacterialmass

bacterialmass

Howship’s lacunae

Howship’s lacunaeIrrigationIrrigationIrrigationIrrigation

Canal Infection and OutcomeCanal Infection and OutcomeSuccess by culturing resultsSuccess by culturing results

(+) culture(+) culture (-) culture(-) culture

Engstrom et al (1964)Engstrom et al (1964) 76%76% 89%89%

Zeldow & Ingle (1963)Zeldow & Ingle (1963) 83%83% 93%93%

Oliet & Sorin (1969)Oliet & Sorin (1969) 80%80% 91%91%

Sjögren et al. (1997)Sjögren et al. (1997) 68%68% 94%94%

Bystrom et al (1987)Bystrom et al (1987) 95%95%

How do we accomplish this?How do we accomplish this?

Sodium Sodium HypochloriteHypochlorite

Sodium Sodium HypochloriteHypochlorite

NaOClNaOClNaOClNaOCl

Current irrigant of choiceCurrent irrigant of choiceeffective antimicrobial agent (Kuruvilla & Kamath effective antimicrobial agent (Kuruvilla & Kamath 1998, Leonardo et al. 1999)1998, Leonardo et al. 1999)excellent organic tissue solvent (O’Hara et al. 1993)excellent organic tissue solvent (O’Hara et al. 1993)lubricateslubricateseffective fairly quicklyeffective fairly quicklyaccelerate reactivity with heataccelerate reactivity with heat

Sodium HypochloriteSodium HypochloriteConcentrations: 0.5% --------- 5.25%Concentrations: 0.5% --------- 5.25%Concentrations: 0.5% --------- 5.25%Concentrations: 0.5% --------- 5.25%

The lower and higher concentrations are equally efficient The lower and higher concentrations are equally efficient in reducing the number of bacteria in infected RCin reducing the number of bacteria in infected RC

Spangberg et al 1973Spangberg et al 1973

Cveck et al 1976Cveck et al 1976

Bystrom and Sundqvist 1985Bystrom and Sundqvist 1985

Siqueira et al 2000Siqueira et al 2000

But the tissue dissolving effect is directly related to the But the tissue dissolving effect is directly related to the concentrationconcentration


Hand et al 1978Hand et al 1978

The lower and higher concentrations are equally efficient The lower and higher concentrations are equally efficient in reducing the number of bacteria in infected RCin reducing the number of bacteria in infected RC


Cveck et al 1976Cveck et al 1976

Bystrom and Sundqvist 1985Bystrom and Sundqvist 1985


But the tissue dissolving effect is directly related to the But the tissue dissolving effect is directly related to the concentrationconcentration


Hand et al 1978Hand et al 1978

VolumeVolumeVolumeVolume

is considered more critical for disinfection than its is considered more critical for disinfection than its concentrationconcentration

Baker et al 1988Baker et al 1988

Lima et al 2001Lima et al 2001

frequent exchange and use of large amount of irrigant frequent exchange and use of large amount of irrigant compensated for lower concentration compensated for lower concentration


is considered more critical for disinfection than its is considered more critical for disinfection than its concentrationconcentration

Baker et al 1988Baker et al 1988

Lima et al 2001Lima et al 2001

frequent exchange and use of large amount of irrigant frequent exchange and use of large amount of irrigant compensated for lower concentration compensated for lower concentration


✦ a broad-spectrum antimicrobial agent - concentration dependenta broad-spectrum antimicrobial agent - concentration dependent

✦ (Delany et al. 1982; O’Hara et al. 1993, Vahdaty et al. 1993; White et al (Delany et al. 1982; O’Hara et al. 1993, Vahdaty et al. 1993; White et al 1997; Siquira et al 1988) 1997; Siquira et al 1988)

✦ effective against resistant strains effective against resistant strains

✦ (White et al. 1997; Basrani et al. 2003)(White et al. 1997; Basrani et al. 2003)

✦ creates residual antimicrobial activity of the dentin surface after prolonged creates residual antimicrobial activity of the dentin surface after prolonged exposure of the root canal exposure of the root canal

✦ (Heling et al. 1992; White et al. 1997; Komorowski et al. 2000; Lenet et (Heling et al. 1992; White et al. 1997; Komorowski et al. 2000; Lenet et al. 2000; Basrani et al. 2002)al. 2000; Basrani et al. 2002)

✦ has a low grade of toxicity has a low grade of toxicity

✦ (Jeansonne et al., Fergusson et al. 2003)(Jeansonne et al., Fergusson et al. 2003)

✦ NEITHER NaOCl nor CHX is effective in removal of a smear layer NEITHER NaOCl nor CHX is effective in removal of a smear layer

✦ a broad-spectrum antimicrobial agent - concentration dependenta broad-spectrum antimicrobial agent - concentration dependent

✦ (Delany et al. 1982; O’Hara et al. 1993, Vahdaty et al. 1993; White et al (Delany et al. 1982; O’Hara et al. 1993, Vahdaty et al. 1993; White et al 1997; Siquira et al 1988) 1997; Siquira et al 1988)

✦ effective against resistant strains effective against resistant strains

✦ (White et al. 1997; Basrani et al. 2003)(White et al. 1997; Basrani et al. 2003)

✦ creates residual antimicrobial activity of the dentin surface after prolonged creates residual antimicrobial activity of the dentin surface after prolonged exposure of the root canal exposure of the root canal

✦ (Heling et al. 1992; White et al. 1997; Komorowski et al. 2000; Lenet et (Heling et al. 1992; White et al. 1997; Komorowski et al. 2000; Lenet et al. 2000; Basrani et al. 2002)al. 2000; Basrani et al. 2002)

✦ has a low grade of toxicity has a low grade of toxicity

✦ (Jeansonne et al., Fergusson et al. 2003)(Jeansonne et al., Fergusson et al. 2003)

✦ NEITHER NaOCl nor CHX is effective in removal of a smear layer NEITHER NaOCl nor CHX is effective in removal of a smear layer

ChlorhexidineChlorhexidine

Two visit protocol

The placement of an antimicrobial disinfectant to assist in dissolution of tissue and neutralization of toxins as well as microflora that are left behind in spite of our best efforts - incomplete debridement = deficient root filling (inadequate asepsis, missed, ledged, transported canals, coronal leakage, fractures, marginal periodontitis, extra-radicular infection, biofilm (Engstrom /64 - Sjogren /96 - Kaufman /2005)

The placement of an antimicrobial disinfectant to assist in dissolution of tissue and neutralization of toxins as well as microflora that are left behind in spite of our best efforts - incomplete debridement = deficient root filling (inadequate asepsis, missed, ledged, transported canals, coronal leakage, fractures, marginal periodontitis, extra-radicular infection, biofilm (Engstrom /64 - Sjogren /96 - Kaufman /2005)

Periapical lesionPeriapical lesion

BiofilmBiofilmBiofilmBiofilm

Swanson et al. 1987 - Dye Swanson et al. 1987 - Dye

leakage to apexleakage to apex

Torabinejad et al. 1990 - Torabinejad et al. 1990 -

Bacteria to apexBacteria to apex

Khayat et al. 1993 - Bacteria to Khayat et al. 1993 - Bacteria to

apexapex

Trope et al. 1994 – Endotoxins Trope et al. 1994 – Endotoxins

to apexto apex

Swanson et al. 1987 - Dye Swanson et al. 1987 - Dye

leakage to apexleakage to apex

Torabinejad et al. 1990 - Torabinejad et al. 1990 -

Bacteria to apexBacteria to apex

Khayat et al. 1993 - Bacteria to Khayat et al. 1993 - Bacteria to

apexapex

Trope et al. 1994 – Endotoxins Trope et al. 1994 – Endotoxins

to apexto apex

Coronal LeakageCoronal LeakageCoronal LeakageCoronal Leakage

A root filled and restored tooth offers rich opportunities for periodontal bacteria to contaminate the coronal part of the root canal and the pulp chamber area as no known restoration provides a permanent hydraulic seal - Lars S. W. Spangberg

A root filled and restored tooth offers rich opportunities for periodontal bacteria to contaminate the coronal part of the root canal and the pulp chamber area as no known restoration provides a permanent hydraulic seal - Lars S. W. Spangberg

Effect of Ca(OH)2 on Microorganismsin Necrotic PulpS, RETREATMENT and APICAL PERIODONTITIS

Effect of Ca(OH)2 on Microorganismsin Necrotic PulpS, RETREATMENT and APICAL PERIODONTITIS

1- 4 weeks1- 4 weeks

200μ200μ

Ca(OH)2 effects, in-vitro:Ca(OH)2 effects, in-vitro:

antibacterialantibacterial

denatures and hydrolyzes proteins, toxins, LPS, TNFdenatures and hydrolyzes proteins, toxins, LPS, TNF

denatures necrotic tissuedenatures necrotic tissue

enhances the effect of NaOClenhances the effect of NaOCl

Hasselgren et al, 1988; Metzler et al, 1989; Estrela et al, 1995,8; Hasselgren et al, 1988; Metzler et al, 1989; Estrela et al, 1995,8; Safavi et al, 1993,4; Turkun et al, 1997; Barthel et al, 1997; Barbosa et Safavi et al, 1993,4; Turkun et al, 1997; Barthel et al, 1997; Barbosa et al, 1997; Wadachi et al, 1998; Olsen et al, 1999; Siqueira et al, 1999; al, 1997; Wadachi et al, 1998; Olsen et al, 1999; Siqueira et al, 1999; Behnen et al, 2001Behnen et al, 2001



The filling ability of calcium hydroxide The filling ability of calcium hydroxide may be more effective than its chemical may be more effective than its chemical effect by acting as a physical effect by acting as a physical barrier...can kill remaining microflora by barrier...can kill remaining microflora by withholding substrate...withholding substrate...Siqueira JF, Lopes HP. Mechanisms of Siqueira JF, Lopes HP. Mechanisms of antimicrobial activity of calcium antimicrobial activity of calcium hydroxide: a critical review. IEJ 32, 361-hydroxide: a critical review. IEJ 32, 361-369, 1999.369, 1999.

Continuous and deep irrigationContinuous and deep irrigation



Apical FinishingApical Finishing

#10#10#10#10

#25#25#25#25

#40#40#40#40

EndoVac - EndoVac - macrocannulmacrocannul

aa

EndoVac - EndoVac - macrocannulmacrocannul

aa

0.70 mm0.70 mm

0.32 mm0.32 mm

EndoVac - EndoVac - microcannulmicrocannul

aa

EndoVac - EndoVac - microcannulmicrocannul

aa

300 microns

Lateral canalLateral canalLateral canalLateral canal

In Vivo Debridement Efficacy of Ultrasonic Irrigation Following Hand-Rotary In Vivo Debridement Efficacy of Ultrasonic Irrigation Following Hand-Rotary Instrumentation in Human Mandibular Molars. Gutarts R, Nusstein J, Reader A, Beck Instrumentation in Human Mandibular Molars. Gutarts R, Nusstein J, Reader A, Beck M. JOE. JEndo 31(3); Mar 2005 166-170.M. JOE. JEndo 31(3); Mar 2005 166-170.

Irrigating needle, when connected to an ultrasonic Irrigating needle, when connected to an ultrasonic unit can be activated at the highest power setting unit can be activated at the highest power setting without breakage. NaOCl can be delivered apically without breakage. NaOCl can be delivered apically through the needle and produce significantly cleaner through the needle and produce significantly cleaner canals and isthmus using non-parametric analysis canals and isthmus using non-parametric analysis than current techniques.than current techniques.

Irrigating needle, when connected to an ultrasonic Irrigating needle, when connected to an ultrasonic unit can be activated at the highest power setting unit can be activated at the highest power setting without breakage. NaOCl can be delivered apically without breakage. NaOCl can be delivered apically through the needle and produce significantly cleaner through the needle and produce significantly cleaner canals and isthmus using non-parametric analysis canals and isthmus using non-parametric analysis than current techniques.than current techniques.

Irrigation ProtocolIrrigation Protocol

• NaOCl 5.25% closed bottle no NaOCl 5.25% closed bottle no lightlight

• EDTA Prolube at start with EDTA Prolube at start with tissuetissue• Citric Acid 10%, CHX 2% soakCitric Acid 10%, CHX 2% soak

• BioPure MTAD - 5 minute soakBioPure MTAD - 5 minute soak• ultrasonic or sonic activationultrasonic or sonic activation

• 10-30 sec.10-30 sec.• ENDODONTIC ACTIVATORENDODONTIC ACTIVATOR

• Flush - dryFlush - dry

Irrigation ProtocolIrrigation Protocol

• NaOCl 5.25% closed bottle no NaOCl 5.25% closed bottle no lightlight

• EDTA Prolube at start with EDTA Prolube at start with tissuetissue• Citric Acid 10%, CHX 2% soakCitric Acid 10%, CHX 2% soak

• BioPure MTAD - 5 minute soakBioPure MTAD - 5 minute soak• ultrasonic or sonic activationultrasonic or sonic activation

• 10-30 sec.10-30 sec.• ENDODONTIC ACTIVATORENDODONTIC ACTIVATOR

• Flush - dryFlush - dry

Don’t piss ‘em Don’t piss ‘em offoff

……..kill the ..kill the buggers!buggers!

Don’t piss ‘em Don’t piss ‘em offoff

……..kill the ..kill the buggers!buggers!

Microstructurally replicate the canal systemMicrostructurally replicate the canal system

Distal RootDistal Root1 mm from Apex1 mm from Apex


Necrotic tissueNecrotic tissueNecrotic tissueNecrotic tissue

Canal not debrided and shaped Canal not debrided and shaped to the correct diameter to the correct diameter

Canal not debrided and shaped Canal not debrided and shaped to the correct diameter to the correct diameter

IsthmusIsthmus



Canals not debrided and shaped Canals not debrided and shaped to the correct diameter to the correct diameter

Canals not debrided and shaped Canals not debrided and shaped to the correct diameter to the correct diameter

Necrotic tissue and Necrotic tissue and debrisdebris

Necrotic tissue and Necrotic tissue and debrisdebris

IsthmusIsthmus

Standardized Technique Standardized Technique Ingle 1961 Ingle 1961Serial Instrumentation Schilder 1974Serial Instrumentation Schilder 1974Step-Back Step-Back Mullaney 1979 Mullaney 1979Crown-DownCrown-Down Marshall 1980 Marshall 1980Step-DownStep-Down Goerig 1982 Goerig 1982Balanced ForceBalanced Force Roane 1985 Roane 1985

Standardized Technique Standardized Technique Ingle 1961 Ingle 1961Serial Instrumentation Schilder 1974Serial Instrumentation Schilder 1974Step-Back Step-Back Mullaney 1979 Mullaney 1979Crown-DownCrown-Down Marshall 1980 Marshall 1980Step-DownStep-Down Goerig 1982 Goerig 1982Balanced ForceBalanced Force Roane 1985 Roane 1985

Evolution of Evolution of Root Canal Space PreparationRoot Canal Space Preparation

Evolution of Evolution of Root Canal Space PreparationRoot Canal Space Preparation

➡ monitor files – team effort

➡ inspect files – if a file is stresse it will unwind – stainless steel ➡ 720 degrees – NiTi – at 300 rpm??

➡ discard after single use

➡ too much pressure on the handpiece

➡ inconsistent RPM

➡ not doing a “crown down” preparation

➡ monitor files – team effort

➡ inspect files – if a file is stresse it will unwind – stainless steel ➡ 720 degrees – NiTi – at 300 rpm??

➡ discard after single use

➡ too much pressure on the handpiece

➡ inconsistent RPM

➡ not doing a “crown down” preparation

Instrument Fatigue/Usage ProblemsInstrument Fatigue/Usage Problems

Coronal ScoutingCoronal Scouting

SS hand files #’s .08, .10, .15, .20SS hand files #’s .08, .10, .15, .20provides data onprovides data on

canal diametercanal diametercanal curvature orientationcanal curvature orientationdegree of curvaturedegree of curvaturecalcificationscalcificationsstraight line accessstraight line access

re-orientation re-orientation


SS hand files #’s .08, .10, .15, .20SS hand files #’s .08, .10, .15, .20provides data onprovides data on

canal diametercanal diametercanal curvature orientationcanal curvature orientationdegree of curvaturedegree of curvaturecalcificationscalcificationsstraight line accessstraight line access

re-orientation re-orientation

Instrumentation StrategiesInstrumentation StrategiesInstrumentation StrategiesInstrumentation Strategies


insert file, “watch-wind” motioninsert file, “watch-wind” motion

no attempt to reach WLno attempt to reach WL

to first resistanceto first resistance

““bounce off”bounce off”

coronal pull, 1 - 2mmcoronal pull, 1 - 2mm

repeat w/same file @ 5xrepeat w/same file @ 5x

repeat to file size #15 or 20repeat to file size #15 or 20


insert file, “watch-wind” motioninsert file, “watch-wind” motion

no attempt to reach WLno attempt to reach WL

to first resistanceto first resistance

““bounce off”bounce off”

coronal pull, 1 - 2mmcoronal pull, 1 - 2mm

repeat w/same file @ 5xrepeat w/same file @ 5x

repeat to file size #15 or 20repeat to file size #15 or 20

Instrumentation StrategiesInstrumentation StrategiesInstrumentation StrategiesInstrumentation Strategies

Never use a rotary NiTi instrument, where a SS

hand file has not gone first

Wet FieldWet Field• never, ever cut drynever, ever cut dry

• lubricants & irrigantslubricants & irrigants

• reduces torque on rotary filesreduces torque on rotary files

• keeps debris in suspensionkeeps debris in suspension

• antimicrobialantimicrobial

Never use a rotary NiTi instrument, where a SS

hand file has not gone first

Wet FieldWet Field• never, ever cut drynever, ever cut dry

• lubricants & irrigantslubricants & irrigants

• reduces torque on rotary filesreduces torque on rotary files

• keeps debris in suspensionkeeps debris in suspension

• antimicrobialantimicrobial

Minimizing FractureMinimizing FractureMinimizing FractureMinimizing Fracture

DTCDTC

The Mack Truck of MotorsThe Mack Truck of MotorsThe Mack Truck of MotorsThe Mack Truck of Motors

Lil’ BroLil’ BroLil’ BroLil’ Bro

Mother-In-Law RulesMother-In-Law Rules

Don’t stay too long !Don’t stay too long ! Don’t push too hard !!Don’t push too hard !! When you’re done …. When you’re done ….

get the get the hell out !!!hell out !!!

Mother-In-Law RulesMother-In-Law Rules

Don’t stay too long !Don’t stay too long ! Don’t push too hard !!Don’t push too hard !! When you’re done …. When you’re done ….

get the get the hell out !!!hell out !!!

F5F5

S1S1 S2S2 SxSx

F1F1 F2F2 F3F3 F4F4

Taper Taper% debris

% debris

Apical Debris RemovalApical Debris Removal Albrecht, Baumgartner, Marshall; JOE 2004 Albrecht, Baumgartner, Marshall; JOE 2004

Evaluation of Apical Debris Removal Using Various Sizes and Tapers of Profile GT Files. Albrecht LJ, Baumgartner JC, Marshall JG. JEndo 30(6); June 2004, 425-429.

7.0 mm 80

6.0 mm 70

5.0 mm 60

4.0 mm 50

3.0 mm 50

2.0 mm 40

1.0 mm 30

0.0 mm 20

7.0 mm 80

6.0 mm 70

5.0 mm 60

4.0 mm 50

3.0 mm 50

2.0 mm 40

1.0 mm 30

0.0 mm 20

7.0 mm 82

6.0 mm 76

5.0 mm 70

4.0 mm 64

3.0 mm 58

2.0 mm 52

1.0 mm 46

0.0 mm 40

7.0 mm 82

6.0 mm 76

5.0 mm 70

4.0 mm 64

3.0 mm 58

2.0 mm 52

1.0 mm 46

0.0 mm 40

When a taper of .10 can be produced at When a taper of .10 can be produced at the apical extent of the canal, there is the apical extent of the canal, there is no difference in debris removal between no difference in debris removal between the two preparation sizes.the two preparation sizes.

Apical FinishingApical Finishing

#10#10#10#10

#25#25#25#25

#40#40#40#40

0.0 mm 20 0.25 mm 25 0.5 mm 30 0.75 mm 35 1.0 mm 40

2.0 mm 42

3.0 mm 44

4.0 mm 46

0.0 mm 20 0.25 mm 25 0.5 mm 30 0.75 mm 35 1.0 mm 40

2.0 mm 42

3.0 mm 44

4.0 mm 46

Serota KS et al. Predictable endodontic success. The apical control zone. Dentistry Today. 2003 May;22(5):90-7

Text

0.0 mm 20 0.25 mm 25 0.5 mm 30 0.75 mm 35 1.0 mm 40

2.0 mm 42

3.0 mm 44

4.0 mm 46

0.0 mm 20 0.25 mm 25 0.5 mm 30 0.75 mm 35 1.0 mm 40

2.0 mm 42

3.0 mm 44

4.0 mm 46

Serota KS et al. Predictable endodontic success. The apical control zone. Dentistry Today. 2003 May;22(5):90-7

1mm.08 taper

1mm.08 taper

4141

3333

4949

5757

F2F2

1mm.07 taper

1mm.07 taper

3434

2727

4141

4848

F1F1F3F3

3939

4848

5757

6666

Open the PathwayOpen the PathwayOpen the PathwayOpen the Pathway

Shaping File 2 : 9 tapersShaping File 2 : 9 tapersShaping File 2 : 9 tapersShaping File 2 : 9 tapers

20 /.0420 /.0420 /.0420 /.04

Shaping File 1 : 12 tapersShaping File 1 : 12 tapers Shaping File 1 : 12 tapersShaping File 1 : 12 tapers

17 /.0217 /.0217 /.0217 /.02

FlexibilitFlexibilityy


Multiple tapers : Shaping Multiple tapers : Shaping

Files Files

Multiple tapers : Shaping Multiple tapers : Shaping

Files Files

Variably Variably Increasing Increasing

TaperTaperS1, S2S1, S2

Variably Variably Increasing Increasing

TaperTaperS1, S2S1, S2

Define apical configurationDefine apical configuration

F4 - .06F4 - .06F5 - .05F5 - .05

Multiple Tapers : Multiple Tapers :

FinishersFinishers

Multiple Tapers : Multiple Tapers :

FinishersFinishers


FlexibilitFlexibilityy Variably Variably

Decreasing Decreasing Taper Taper

F1, F2, F3F1, F2, F3

Variably Variably Decreasing Decreasing

Taper Taper F1, F2, F3F1, F2, F3

Finishing File 1 : 2 Reversed Tapers Finishing File 1 : 2 Reversed Tapers Finishing File 1 : 2 Reversed Tapers Finishing File 1 : 2 Reversed Tapers

20 /.0720 /.0720 /.0720 /.07.055.055.055.055

25 /.0825 /.0825 /.0825 /.08.055.055.055.055 .06.06.06.06


30 /.0930 /.0930 /.0930 /.09.07.07.07.07.05.05.05.05


GGGG

Finishing File 1, 2, Finishing File 1, 2, 3, 4, 53, 4, 5

Shaping Shaping File 2File 2

Shaping Shaping File 1File 1

20

Pressure Required

Pressure Required

Pressure Required

Pressure Required

Create a smooth Create a smooth reproducible glide path reproducible glide path with the #10 and #15 with the #10 and #15 hand fileshand files

Create a smooth Create a smooth reproducible glide path reproducible glide path with the #10 and #15 with the #10 and #15 hand fileshand files

AccessAccess

NaOClNaOClNaOClNaOClViscous Viscous chelatorchelatorViscous Viscous chelatorchelator

Light resistanceLight resistance

EAL = 0.0EAL = 0.0

Anatomic apex

Anatomic apex

PDL, cementum & bonePDL, cementum & bone

Bleeding point

Bleeding point

**

Electric Foramenal Locatorslectric Foramenal LocatorsElectric Foramenal Locatorslectric Foramenal Locators



In 1962 Sunada determined that the In 1962 Sunada determined that the resistance between oral mucosa resistance between oral mucosa and periodontal ligament is a and periodontal ligament is a constant value 6.5 ohms (40/μAmp)constant value 6.5 ohms (40/μAmp)

In 1962 Sunada determined that the In 1962 Sunada determined that the resistance between oral mucosa resistance between oral mucosa and periodontal ligament is a and periodontal ligament is a constant value 6.5 ohms (40/μAmp)constant value 6.5 ohms (40/μAmp)

Electric Foramenal LocatorsElectric Foramenal LocatorsElectric Foramenal LocatorsElectric Foramenal Locators

must turn unit on before attaching probe to unit… must turn unit on before attaching probe to unit…

““might think in previous tooth”might think in previous tooth”

canals can be wet, but chamber must be dry… canals can be wet, but chamber must be dry…

no shared fluid between canalsno shared fluid between canals

instrument must be free in access opening… instrument must be free in access opening…

no contact with metalno contact with metal

must turn unit on before attaching probe to unit… must turn unit on before attaching probe to unit…

““might think in previous tooth”might think in previous tooth”

canals can be wet, but chamber must be dry… canals can be wet, but chamber must be dry…

no shared fluid between canalsno shared fluid between canals

instrument must be free in access opening… instrument must be free in access opening…

no contact with metalno contact with metal

gives the clinician an early sense of the three gives the clinician an early sense of the three dimensional curves not seen on the filmdimensional curves not seen on the film

gets the NaOCl down the RCS early – active gets the NaOCl down the RCS early – active irrigationirrigation

false paths due to blockages are prevented when false paths due to blockages are prevented when patency is confirmed frequentlypatency is confirmed frequently

chance of ledging is minimizedchance of ledging is minimized

NaOCl is refreshed, and therefore more effective, NaOCl is refreshed, and therefore more effective, by the action of the file going to the point of patencyby the action of the file going to the point of patency

allows the clinician to negotiate past denticles, allows the clinician to negotiate past denticles, either suspended in the tissue or attached to the either suspended in the tissue or attached to the canal walls, without pushing them ahead of the canal walls, without pushing them ahead of the instrumentinstrument

gives the clinician an early sense of the three gives the clinician an early sense of the three dimensional curves not seen on the filmdimensional curves not seen on the film

gets the NaOCl down the RCS early – active gets the NaOCl down the RCS early – active irrigationirrigation

false paths due to blockages are prevented when false paths due to blockages are prevented when patency is confirmed frequentlypatency is confirmed frequently

chance of ledging is minimizedchance of ledging is minimized

NaOCl is refreshed, and therefore more effective, NaOCl is refreshed, and therefore more effective, by the action of the file going to the point of patencyby the action of the file going to the point of patency

allows the clinician to negotiate past denticles, allows the clinician to negotiate past denticles, either suspended in the tissue or attached to the either suspended in the tissue or attached to the canal walls, without pushing them ahead of the canal walls, without pushing them ahead of the instrumentinstrument

PatencyPatencyPatencyPatency



Wu M-K et al. Diameters of the first binding file and the apical canal at working length. 25% of the binding files did not touch any wall and in the other 75% it touched only one wall.

MicrostructuralMicrostructuralReplicationReplication

MicrostructuralMicrostructuralReplicationReplication Obturation??Obturation??

ToothToothToothTooth

CarrierCarrierCarrierCarrier

Gutta-PerchaGutta-PerchaGutta-PerchaGutta-Percha

ProTaper ProTaper ®® Obturator Obturator

surrounded by gutta-perchasurrounded by gutta-perchaProTaper ProTaper

®® Obturator Obturator

surrounded by gutta-perchasurrounded by gutta-percha

Advantages• excellent apical sealexcellent apical seal

• excellent three-dimensional excellent three-dimensional fillfill

• well studied techniquewell studied technique

• easy to mastereasy to master

• easily retreatedeasily retreated

• rapid placementrapid placement

• cannot fracture root during cannot fracture root during placementplacement

Solid Core ObturationSolid Core ObturationSolid Core ObturationSolid Core Obturation

ALGORITHMALGORITHM

Microstructural Replicaion

Microstructural Replicaion

A significant difference in gutta-percha flow A significant difference in gutta-percha flow into the lateral grooves was seen at into the lateral grooves was seen at 3 mm 3 mm from WL.from WL. Bowman et al, 2002 Bowman et al, 2002

Best results were obtained with a plugger Best results were obtained with a plugger depth depth 3.5 to 4.5 mm3.5 to 4.5 mm from the working from the working length. Guess et al, 2003length. Guess et al, 2003

Down PackDown Pack

Heat source off 3 Heat source off 3 mm from mm from

reference pointreference point

Sustained pressureSustained pressureSustained pressureSustained pressure

Separation burstSeparation burst

Sealed Apical Control ZoneSealed Apical Control ZoneSealed Apical Control ZoneSealed Apical Control Zone



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Education

December 1st