SGS Syllabus

2013-09-25

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9/25/2013

Secrets for eliminating
Endodontic Stress

A World You Never Thought
Of

The Causes of Endodontic Stress
. Clogging Canals, losing length and canal distortion in the
creation of the glide path
. Breaking rotating NiTi instruments
. Excessive removal of coronal tooth structure
. Shaping canals insufficiently for predictably thorough
obturation
. Overly expensive instruments that are recommended for
single usage.

Clogging Canals
A direct result of the use of K-files

9/25/2013

Why K-files, specifically, are the
wrong instruments to use

K-File

Horizontal flutes used in a watch winding
motion:
. Impact debris apically on the downstroke
. Shave on the upstroke straightening curved
canals
. Excessive engagement with the canal walls
. Poor tactile sense potentially producing ledges

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Consequence of the poor design and
utilization of the K-file:

. blocked and distorted canals
. the desire to find something better

The Solution

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Relieved Reamer

Vertical flutes in watch winding motion:
. Shave dentin from the canal walls without distortions
. Engage far less along length
. Superior tactile perception reducing distortions

The Process of Critical Thinking

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If the previous video does not
drive home the point that the
blades must be at right angles
to remove dentin, consider the
act of shaving one’s face or
legs.

Cardinal Rule # 1:
The cutting blade must be more or
less at right angles to the plane of
motion.

Relieved reamer
(aka vertically oriented flutes on a relieved shank)
We use reamers rather than k-files.
Comparing k-reamers to k-files we
observe the following:
1. Fewer flutes on the 16 mm of working
length of a reamer than on a k-file
approximately 16 flutes versus 30.

K-File

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Relieved reamer
Consequences of fewer flutes:
1. There is less engagement along length.

2. Relieved reamers are more flexible than
files because they are less work hardened
and thinner in cross section.

K-File

3. The flutes are more vertically oriented.

Relieved reamer
Consequences of less engagement:
1. Less resistance along the shank as we
negotiate apically.
Consequences of greater flexibility:
1. Able to negotiate curved canals with
less chance of distortion.

K- File

Consequences of more vertically oriented
flutes:
1. Able to cut dentin along canal length
when the motion of the instrument is
either horizontal rotation or
reciprocation.

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Taken together, the consequences of greater flexibility, less
engagement and more efficient cutting along length produce a
superior tactile perception along length and at the tip
of the instrument.

The consequences of superior tactile perception:
1. Allows the safe incorporation of a cutting tip.
The consequences of a cutting tip:
1. The ability to pierce pulpal tissue rather than
impact it apically.
2. The ability to distinguish between a tight
canal and hitting a wall when used in a
watchwinding motion or a reciprocating
handpiece.

Breaking rotating NiTi instruments

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This is what we want to
eliminate completely

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The Solution

The incorporation of the reciprocating
handpiece allows a 30º arc of motion
oscillating at 3000-4000 cpm.
A 30º arc of motion represents 1/12 of
a circle or 5 minutes on the face of a
clock.
The motion is so limited it virtually eliminates the 2 major
factors that cause rotary NiTi files to break and unwind,
namely, torsional stress and cyclic fatigue.

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Safety,

Safety, Safety,

Safety

Testing Apparatus

A Comparison between Reciprocating and Rotary Nickel-Titanium Instruments on Cyclic Fatigue Resistance. Jeffrey
Wan, Brian J. Rasimick, Barry L. Musikant, Allan S. Deutsch. Submitted to: Journal of Endodontics 2009

9/25/2013

Reasonable conclusion:
30º symmetric reciprocation is far
safer than rotation in keeping
instruments intact.

Excessive removal of coronal tooth structure

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Mandibular Central Incisor

www.rootcanalanatomy.blogspot.com

Mandibular Central Incisor

www.rootcanalanatomy.blogspot.com

Mandibular Central Incisor

www.rootcanalanatomy.blogspot.com

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The Solution

The use of predominantly .02
tapered stainless steel relieved
reamers to shape the canal from
start to finish

Used with a short amplitude of motion
both manually and in the 30º
reciprocating handpiece, the .02
tapered stainless steel relieved reamers
can be used with significant lateral
pressure to cleanse oval canals without
concern for instrument separation

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Shaping canals insuffciently for
predictably thorough obturation

Quality of preparation of oval distal root canals in mandibular molars using nickel-titanium
instruments. Rödig T., Hülsmann M., Mühge M., Schäfers F. Int Endod J. 2002 Nov;35(11):919-28.

CONCLUSIONS: The flexibility of the NiTi instruments investigated in this
study did not allow controlled preparation of the buccal and lingual
extensions of oval root canals. The instruments frequently produced a
circular bulge in the canal while the buccal and lingual extensions
remained unprepared, leaving smear layer and debris.
Root canal cleanliness was not good with much remaining debris and
smear layer in the unprepared extensions.

Articles discussing micro-computed tomography sparked
immediate interest among dental researchers, especially in
the area of rotary file design.
Bench-top micro-computed tomography (CT) allowed

despite the
use of endodontic rotary file systems,
35% to 50% of the root canal system
remained untouched.
groundbreaking research, which has shown,

O. A. Peters, A. L. Laib, T. N. Gohring and F.
Barbakow. Changes in Root Canal Geometry after
Preparation Assessed by High-Resolution Computed
Tomography. J Endodon, January 2001; 27:1:1-6.

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The solution

It helps if the shaping
instruments touch all the walls
of the canals or at least shape
the canals to a minimum of 35

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Stainless Steel
SafeSiders
Glide Path

Pleezer

NiTi
SafeSider

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Abilash, R. Mensudar, Vivekandhan, Subbiya, VG Sukymanan. Cutting
Efficiency, Surface Change and hardness: EZ-fill SafeSider Instruments vs
K-files. Indiam J of Multidisciplinary Dentistry 20111:110-114.
Conclusion
Under the conditions of this study, EZ-fill safe-sided instruments proved:

.More efficient than the conventional K-files
.Aids in better removal of debris
.Causes less fatigue to the operator
.Shows less cold working and therefore less chance of instrument
separation
.Maintained a smooth reproducible glide path

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Obturation:
How to do it with the least
stress

Coat the canal thoroughly with
room temperature epoxy-resin
cement using the bidirectional
spiral.

EZ-Fill®
Bi-Directional Spiral
and Epoxy Root
Canal Cement

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EZ-Fill Bi-Directional Spiral

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EZ-Fill
Obturation
®

Lateral Flow of EZ-Fill
Epoxy Resin Cement in Block

The Sequence:
• Fit a medium gutta percha point.
• Place EZ-Fill epoxy root canal cement
with the EZ-Fill bi-directional spiral.
• Repeat application of EZ-Fill epoxy
root canal cement with the EZ-Fill bidirectional spiral.
• Place master point.

9/25/2013

Medium Gutta Percha Point
with the apical 10-12 mm
coated with Cement

Benefits of the EDS EZ-Fill®
Obturation System
• Retains accurate placement of the prefitted gutta percha
point.
• No lateral stress to create potential fracture.
• No shrinkage of thermoplastic filling materials.
• An epoxy interphase that seals better than the best placed
gutta percha point.
• The elimination of the apical extrusion of cement into vital
periodontal ligaments.

9/25/2013

EZ-Fill epoxy root canal cement, a derivative of
AH-26, first introduced to the US in 1957:
A. Does not shrink or expand chemically due to its epoxy
base.
B. Has excellent flow due to its adjustable viscosity.
C. Is not clinically irritating to the periapical tissues.
D. Does not degrade over time.
E. Adheres to tooth structure and gutta percha chemically
and mechanically.

Shrinkage is an inherent property
of all thermoplastic techniques be
they carrier based, the squirt
technique or heated spreaders.

Shrinkage produces gaps

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Single point systems are the best
suited to prevent voids
How is this possible?
We all remember the description of
single point fills: A single point sitting
in a sea of cement!

9/25/2013

To seal three dimensionally long term requires:
. Flowability of the cement
. Adequate quantity of cement placed
. No shrinkage of the cement and gutta percha
. Some expansion (preferably)
. Stability of the sealing materials
. Cement that bonds chemically and physically to the
dentin and the gutta percha

We recommend obturation systems
that have all these characteristics.

Wu,MK, Ozok AR, Wesselink PR. Sealer distribution in root canals
obturated by three techniques. Int Endodon Journal 2000;33:340345.
At both 3 mm and 6 mm from the apex the sealer coated canal
perimeter (PSCP) was significantly higher after single cone (no
condensation) than after vertical or lateral condensation. Please
note: The EZ-Fill obturation technique employs the use of a
single cone with the patented EZ-Fill bidirectional spiral and
epoxy root canal cement (an AH26 derivative).

9/25/2013

Evaluation of the Apical Seal of Root
Canal Fillings with Different Methods

Antonopoulos KG, Attin T and Helwig
E
J Endodon 1998;24(10):655.

Evaluation of the Apical Seal of Root Canal Fillings with Different Methods.
Antonopoulos KG, Attin T and Helwig E. J Endodon 1998;24(10):655.
The purpose of the study was to compare dye penetration methods
conducted passively, under negative pressure, or under high pressure
conditions. Ninety human maxillary incisors were instrumented and
obturated with either the lateral condensation or single cone technique.
Lateral condensation and single cone techniques yielded similar sealing
abilities.

Comparison of Apical Leakage in Root Canals Obturated with Various
Gutta-Percha Techniques Using a Dye Vacuum Tracing Method.

Dalat DM, Spangberg LSW.
J Endodon 1994;20:315-319.

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Conclusions:

Tested Leakage for Following
Techniques: All used AH-26
Single Cone
Lateral
Condensation
Vertical
Condensation
Thermafil

}

All Statistically the
Same

Ultrafil
Single cone technique had the least deviation in
results.
Comparison of Apical Leakage in Root Canals Obturated with Various
Gutta-Percha Techniques Using a Dye Vacuum Tracing Method. Dalat DM,
Spangberg LSW. J Endodon 1994;20:315-319.

Basics:
How to fit the point

Problems:
1. Canals shaped with .02 tapers produce
little resistance form.
2. Gutta percha points of .02 tapers have
little lateral driving force.
Producing:
. Overextensions and underfills
. Voids both apically and along length

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Limited Frictional Fit

Increased Frictional Fit
.06 Taper

.02 Taper

VS.

Medium Gutta Percha Points

Locking Pliers

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Correct Fit

At
Apex

Correct Measurement

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Long

Over Apex

Short

Short of
Apex

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1. Make sure the apex is patent by going 0.5 mm
beyond the constriction with the 25 relieved
reamer.
2. Check patency to the constriction to a 35.
3. If the tooth is longer than 22 mm take the
relieved reamer into the coronal third of the
root and work a few strokes against both the
mesial and distal walls.

Pink
25/06 to
the apex

Correct Fit

At
Apex

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Interrelationship between
shaping and obturation: They are
mutually reinforcing in producing
a superior seal.

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Summary for obturation:

1.
2.

Three dimensional obturation is achieved
with room temperature systems.
The bidirectional spiral is key to flooding
the canal with cement without driving
excess over the apex.
The fill is now mainly dependent upon
the cement rather than the carrier (gutta
percha).

9/25/2013

RESTORATION AND
REHABILITATION OF
ENDODONTICALLY TREATED
TEETH
Mark H. Docktor DDS

HISTORY OF POST AND CORES

 USE OF “TENONS” AS POSTS 250 YEARS AGO (1732)
 MID 1800’S, WOOD RATHER THAN METAL WAS POPULAR
 LATE 19TH CENTURY, “RICHMOND CROWN” AS SINGLE P/C
 1930’S, CUSTOM CAST POST/CORE
 CREATION OF VARIOUS PRE-FABRICATED POSTS
 INTRODUCTION OF THE “FLEXIPOST”

 INTRODUCTION OF FIBERPOSTS



COURTESY OF DOUGLAS TERRY, DDS AND EDWARD SWIFT, JR. DDS. DENTISTRY TODAY. 12.2009

MOST POPULAR POST/CORE OPTIONS
 CUSTOM CAST POST/CORE
 FLEXIPOST/FLEXIFLANGE
 FIBERPOST
 CERAMIC/ZIRCONIUM
 VARIOUS BRANDS OF METAL PRE-FAB POSTS
 VARIOUS COMPOSITE CORE BUILDUP MATERIALS
 VARIOUS CEMENTS AND ADHESIVE MATERIALS
 THE OPTION TO USE WHAT YOU FEEL IS MOST COMFORTABLE,
WITH MOST ADVANTAGEOUS LONG TERM RESULTS

9/25/2013

FACTORS TO CONSIDER IN POST SELECTION
 ANATOMY OF TOOTH…ROOT CURVATURE/M/D

& B/L DIAMETER,ROOT SIZE

 LENGTH OF ROOT
 WIDTH OF CANAL/CANAL CONFIGURATION AND POST PREPARATION
 REMAINING CORONAL TOOTH STRUCTURE
 POSITION OF TOOTH IN THE ARCH
 STRESSES AND TORSIONAL FORCES…COMPRESSIVE,TENSILE

AND SHEAR

 HYDROSTATIC PRESSURE/ISSUES WITH CEMENTATION
 DESIGN OF POST/POST MATERIAL…SIMILAR

TO DENTIN, BIOCOMPATIBLE, SHOCK ABSORBER

 MATERIAL COMPATABILITY/WITH TOOTH AND RESTORATIVE, MATERIALS
 RETENTION OF POST AND CORE…PROPER

FIT, CEMENTATION, OR BONDING

 RETRIEVABILITY/IF REMOVAL IS NECESSARY


COURTESY OF DR. REEM AL-DHALAAN. PROSTHODONTIC MANAGEMENT OF ENDODONTICALLY TREATED TEETH

FLEXIPOSTS
 PROVIDES MAXIMUM RETENTION WITH MINIMAL STRESS

 SPLIT SHANK CLOSES UPON INSERTION, ADAPTS TO ROOT, AND
ELIMINATES POTENTIAL FOR VERTICAL ROOT FRACTURE
 DISTRIBUTES FUNCTIONAL STRESSES EVENLY
 MAXIMIZES RETENTION WITHOUT CONTRIBUTING TO THE
PRODUCTION OF TENSILE STRESSES
 RELEASES INTERNAL HYDROSTATIC PRESSURE UPON
CEMENTATION WITH APPROPRIATE VENTING
 HORIZONTAL AND VERTICAL GROOVES IN HEAD SECURELY
ANCHOR CORE MATERIALS
 OFFERS RETENTION COMPARABLE TO NATURAL DENTIN
 REDUCES LAB COSTS, SAVES TIME, EXPEDITES TREATMENT

ADVANTAGES/DISADVANTAGES TO VARIOUS
TYPES OF POSTS AND CORES
 CAST POSTS:…LAB EXPENSE, TWO VISITS, BUT ADAPT WELL TO CANALS,
ESPECIALLY WITH NON-CIRCULAR CROSS SECTIONS, AND PROVIDE
SUPPORT WITH MINIMAL CORONAL REMAINS. GREAT WITH LARGE FUNNEL
SHAPED CANALS. THE MODULUS OF ELASTICITY MUCH HIGHER THAN
DENTIN, AND OCCLUSAL FORCES CAN CREATE GREAT STRESS ON TOOTH,
YIELDING POTENTIAL FOR FRACTURE.
 METAL PRE-FAB POSTS:…EASY TO USE. ONE-VISIT FACTOR. EXCESSIVE
STIFFNESS AND MODULUS OF ELASTICITY FACTORS RELATED TO ROOT
FRACTURES. PARALLEL-SIDED AND SERRATED ARE THE MOST RETENTIVE.
 NON-METALLIC, CERAMIC OR FIBER-REINFORCED:…THEY ARE
BIOCOMPATIBLE AND CORROSION-RESISTANT. ONE VISIT, AND LESS
POTENTIAL FOR ROOT FRACTURE, DUE TO MORE SIMILAR MODULUS OF
ELASTICITY. VERY DIFFICULT TO CUT OR REMOVE IF NECESSARY. CARBONFIBER EASIER TO REMOVE. GREAT ADHESIVE POTENTIAL WITH CEMENT.


COURTESY OF DOUGLAS TERRY, DDS AND EDWARD SWIFT, JR, DMD. 2009

9/25/2013

PRE-FAB POST DESIGNS
 PARALLEL, TAPERED, OR PARALLEL AND TAPERED
 SMOOTH-SIDED VS. SERRATED VS. THREADED
 ACTIVE OR PASSIVE PLACEMENT
 POST VS. VARIOUS NOTCHES OR CORE-SUPPORT DESIGN
 LONGER BETTER THAN SHORTER
 BUT NOT WITHIN 3-5 MM OF APEX…NOT TO DISTURB APICAL SEAL
 IDEALLY WITH GOOD ROOT SUPPORT/CROWN-ROOT RATIO
 MUST HAVE APPROPRIATE DIAMETER FOR TOOTH SUPPORT,
BUT IDEALLY NOT GREATER THAN 1/3 ROOT DIAMETER

FLEXIPOSTS

9/25/2013

CAST POST & CORES

CAST POST AND CORES

VARIOUS MATERIALS AND TECHNIQUES

9/25/2013

CAUSES OF FAILURE OF POSTS AND CORES


FAILURE OF RESTORATIONS ON POST-RETAINED PULPLESS TEETH HIGHER THAN ON VITAL
TEETH



ENDODONTIC FAILURE



RECURRENT DECAY



PERIODONTAL BREAKDOWN



POST DISLODGEMENT



CEMENT FAILURE



POST/CORE OR CROWN/CORE SEPARATION



POST FRACTURE



LOSS OF CROWN RETENTION



POST DISTORTION



TOOTH OR ROOT FRACTURE



CORROSION OF METALLIC POSTS



COURTESY OF DOUGLAS TERRY, DDS AND EDWARD SWIFT, JR, DMD

TOTAL LOSS OF VERTICAL DIMENSION
AND DENTAL REHABILITATION

CROWN PREPARATIONS
AND POST/CORE DESIGN AND IMPRESSION

9/25/2013

ROOT CANALS ON UPPER SIX TEETH.
PATIENT HAD GREAT BONE SUPPORT

COMPLETION OF TREATMENT

COMPLETE DENTAL REHABILITATION

9/25/2013

ENDODONTIC THERAPY, POST & CORES,
PROVISIONAL CROWN AND BRIDGEWORK

CAST POST/CORE #6, AND FLEXIPOSTS ON #8,
#12, AND #23 WITH COMPOSITE CORE BUILDUPS

UPPER AND LOWER ANTERIOR CROWN AND
BRIDGEWORK WITH SEMI-PRECISION PARTIALS

9/25/2013

TOOTH #8 WITH SEVERE STAINING AFTER ROOT
CANAL AND PAPER CLIP POST/CORE

OLD POST REMOVAL, DEBRIDEMENT, INTERNAL
BLEACHING, FLEXIPOST AND BONDING

BEFORE AND AFTER
CLEANUP OF HAPHAZARD DENTISTRY

9/25/2013

FLEXIPOSTS/CORES WITH GOLD COPINGS,
IMPLANTS, CROWN AND BRIDGEWORK. 1994

ONE-VISIT PROVISIONALIZATION OF CASE WITH
LAB-PROCESSED TEMPORARY CROWNS

PHOTOS, MODELS, PROVISIONALS, AND LINING
OF PROVISIONAL, EXTRACTION #7.8.9, TEMPS
ALSO WITH FLEXIPOST IN TOOTH #15 FOLLOWING HEMISECTION OF PALATAL ROOT

9/25/2013

17 YEARS LATER, PERIO BREAKDOWN OF UPPER
TEETH, IMPLANTS, NEW POST/CORES ON #3,4,5
AND NEW BRIDGEWORK

COMPLETION OF INVOLVED DENTAL REHAB.
PATIENT FIRST PHASE DONE AROUND 1990,
PHASE 2 AROUND 2007

INTERNAL RESORPTION OF ROOT #9.
EXTRACT #9 AND TEMPORARY CROWNS #7-10

9/25/2013

ENDO AND POST/CORE #7. ROOT RESORPTION,
EXTRACTION, IMPLANT #9, AND CROWNS

FINAL RESTORATIONS WITH XRAY

PROVISIONAL REHABILITATION OF DENTISTRY
THAT DID NOT HAVE LONG-RANGE PLANNING.
LASER RECONTOURING OF UPPER CENTRALS

9/25/2013

CAST POST/CORES #19 AND #20

BEFORE AND AFTER VIEWS OF AESTHETIC
IMPROVEMENTS WITH THIS INVOLVED REHAB

CROWN AND BRIDGE RECONSTRUCTION,
WITH IMPLANTS, POST/CORES, AND AESTHETICS

9/25/2013

PROVISIONALIZATION WITH FULL MOUTH LAB
TEMPS, AND FINAL RESTORATIONS

RADIOGRAPHS SHOWING ENDO AND POST/CORES

COMPLETED CROWN AND BRIDGEWORK
WITH ENDO, POST/CORES, IMPLANTS

9/25/2013

COMPLETED CROWN AND BRIDGE CASE

FOUR CAST POST/CORES WITH COPINGS AND
THREE LOCATOR IMPLANT ABUTMENTS FOR
VERY SECURE OVERDENTURE

RADIOGRAPHIC IMAGES OF IMPLANTS FOR
LOCATORS AND CAST POST/CORE.COPINGS

9/25/2013

COMPLETED IMPLANT, ENDO AND POST/CORE
SUPPORTED OVERDENTURE

PROVISIONAL CROWNS, IMPLANTS, AND ENDO
W. POST/CORES ON #4, 5, 6. FINAL BRIDGEWORK

RADIOGRAPHS OF ENDO AND POST/PORES AND
IMPLANTS SUPPORTING UPPER BRIDGEWORK

9/25/2013

SEVERELY NEGLECTED TEETH AND
RESTORATIONS,ENDO, POSTS AND
PLACEMENT OF PROVISIONALS

DUE TO PERIO BREAKDOWN, TEETH
HAD TO BE REMOVED, IMPLANTS INSTALLED

ONCE OSSEOINTEGRATION COMPLETE, THE
PROVISIONAL ONE-VISIT IMPLANT-SUPPORTED
UPPER WAS INSTALLED

9/25/2013

SIMPLE BONDING AND RECONTOURING
TO CREATE A BEAUTIFUL, HEALTHY SITUATION
WAS CREATED ON THIS UPPER IMPLANT CASE

ENDO COMPLETED, POST/CORES BUILT IN,
AND FINAL COMPLETION OF THIS CASE

IMPLANT-SUPPORTED UPPER HYBRID OVERDENTURE.
IMPLANTS W. LL BRIDGE. ENDO,P/C W. LR BRIDGE

9/25/2013

THIRTY YEAR OLD BRIDGEWORK WITH ENDO
FAILURES. ALL ENDO REDONE. FLEXIPOSTS AND
CORES BUILT IN, SALVAGED BRIDGEWORK IN ‘06

2013…DECAY AND BREAKDOWN #6. POST STILL
STRONG. REMOVED DECAY. REBUILT W.BONDING

ENDO ON #6,8,9 AND 11. FLEXIPOSTS AND A
ONE-VISIT PROVISIONAL BIOTEMP BRIDGE
TO RE-ESTABLISH MORE HARMONIOUS OCCLUSION

9/25/2013

SEVERE EROSION, ABRASION, AND OCCLUSAL
STRESS. BONDING DONE TO RESTORE TEETH.
PATIENT WAS 99 YEARS OLD

DRAMATIC RESULT. PATIENT LIVED ‘TIL 103.
NO REPAIRS EVER NEEDED

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