SGS Syllabus
2013-09-25
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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
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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)
K-File
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.
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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.
3. The flutes are more vertically oriented.
K-File
Relieved reamer
Relieved reamer
K- File
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.
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
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
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
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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
groundbreaking research, which has shown, despite the
use of endodontic rotary file systems,
35% to 50% of the root canal system
remained untouched.
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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Glide Path Pleezer
Stainless Steel
SafeSiders
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 bi-
directional spiral.
•Place master point.
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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.
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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!
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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;33:340-
345.
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).
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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.
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.
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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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.
Conclusions:
Tested Leakage for Following
Techniques: All used AH-26
Single Cone
Lateral
Condensation
Vertical
Condensation
Thermafil
Ultrafil
All Statistically the
Same
}
Single cone technique had the least deviation in
results.
Basics:
How to fit the point
1. Canals shaped with .02 tapers produce
little resistance form.
2. Gutta percha points of .02 tapers have
little lateral driving force.
Problems:
Producing:
. Overextensions and underfills
. Voids both apically and along length
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.02 Taper .06 Taper
VS.
Limited Frictional Fit Increased Frictional Fit
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. Three dimensional obturation is achieved
with room temperature systems.
2. The bidirectional spiral is key to flooding
the canal with cement without driving
excess over the apex.
3. The fill is now mainly dependent upon
the cement rather than the carrier (gutta
percha).
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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
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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…COMPRESS IVE,TENSILE A ND 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. CARBON-
FIBER EASIER TO REMOVE. GREAT ADHESIVE POTENTIAL WITH CEMENT.
COURTESY OF DOUGLAS TERRY, DDS AND EDWARD SWIFT, JR, DMD. 2009
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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
FLEXIPOSTS
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CAST POST & CORES
CAST POST AND CORES
VARIOUS MATERIALS AND TECHNIQUES
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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
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ROOT CANALS ON UPPER SIX TEETH.
PATIENT HAD GREAT BONE SUPPORT
COMPLETION OF TREATMENT
COMPLETE DENTAL REHABILITATION
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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
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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
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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
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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
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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
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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
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PROVISIONALIZATION WITH FULL MOUTH LAB
TEMPS, AND FINAL RESTORATIONS
RADIOGRAPHS SHOWING ENDO AND POST/CORES
COMPLETED CROWN AND BRIDGEWORK
WITH ENDO, POST/CORES, IMPLANTS
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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
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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
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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
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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
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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
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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
