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‫بسم الله الرحمن الرحيم‬ Endodontics lecture #3 ..Dr. nesreen taha

…Hello colleagues Dr nesreen started the lecture by giving us some comments about the clinics ………… Enjoy

if you are in obturation step now its better that you obturate all the canals-1 at the same visit but if you don’t have time, then its ok to complete one or two and the rest at the next session, but keep in mind that there is risk of .contamination don’t rush things -esp. for students who are in crown prep's or bridges- coz-2 you will be stressed and errors will occur and …. You know the rest ..so try to relax..(by the way dr nesreen didn’t complete any RCT while she was a 5th year .(student due to some circumstances so its 3ady if you are not confident of ur ability in using gates gliden its ok, bcoz step-3 back up to file # 60 is good and enough. and be careful when using the lentulospirals when placing non setting Ca(OH)2 and its preferable either not to use them due to possibility of fracture inside the canal (unless after step ..(back), or to use the smallest size (its color is red if you have a cavity of 4 mm depth, you don’t need to place IRM, you can put-4 2 mm cavit and 2 IRM, or the whole 4 mm cavit if class I cavity, if class II its better to place IRM unless you want to bring the patient a week or two after, then you can place cavit  and this is bcoz cavit is easier in manipulation and ..(removal (less time consuming start immediately when you enter the clinic and place the rubber dam and-5 …don’t wait best clamp for molars is 12A or 13A, serrated clamp.. and even if placed it-6 ..on the gingiva its ok, it will heal in few days

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…we are going to talk about materials and instrumentation in endo we will talk about new sealers (other than Ca(OH)2 based or zinc oxide based) :in dentistry which are the resin based ones.. we have two types AH26 (yellow in color and comes as powder and liquid.. it has a disadvantage -1 that it leaches formaldehyde which is cytotoxic for the periapical tissues when leaks, but after it sets (setting time =24 hours) it will stop being irritant and a week later it will disappear histologicaly, it has more advantages than the Ca(OH)2 based or zinc oxide based related to the working time.. i.e long working time (ya3ni law 5alatnah 3al 9 am w eshta3'alna feeh at 4 pm (WT >8 hours) its OK, and another advantage is the flow its not messy when worked with unlike working with ZO based sealers, and you don’t need to place this cement on every cone that you use, its enough to put it on the master cone, its also hydrophilic, i.e if you don’t completely dry the canal (which is better dry) its ok coz it will fit, it has antibacterial properties and penetrate into the dentinal tubules coz of the good flow and this was proven .( by cross sections This is a picture of AH26

.AH plus.  newer than the AH26-2 Lower toxicity bcoz there is no release of formaldehyde, but less desirable flow properties (AH26 is better)..you should pay attention to them just in ..(case you are asked about in the spots or viva(s Ratio of mixing is 3:1, but you can modify it according to the consistency that .you want

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This is a picture of AH plus

This is the old one (Ca(OH)2).. sealapex

?What is the disadvantage of sealapex Its solubility.. if there is coronal leakage and oral fluids went in, it will .dissolve By the way, if you have more sealer in the root canal filling, this will turn into empty spaces under the effect of oral fluids if coronal leakage happened, the .less the sealer, means more gutta percha, so the better the results Dr repeated that in the clinic you don’t need to put IRM in the cavity till the next session, you can put cavit (esp. if class one cavity or in deep cavity under .IRM), if class 2 then IRM is better Sometimes when you are placing the non setting calcium hydroxide in the ?canals, some of it goes to the chamber, do we need to clean it .No its alright, leave it

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Ideally we don’t put cotton pellet, but we do that in clinics so that when we re open the cavity with the drill, we wont make a perforations in the walls or the floor, it has to be small and not extending and only covering the root orifices, and actually its better for every one in his clinic to use an ultrasonic scaler to .(remove the IRM (with which you don’t need to place a pellet We can use glass ionomer (instead of IRM) which are available in our clinic as capsules evacuated by a special gun that has a long nozzle that places GI in the cavity easily, but in our DTC there are only 2 and if some one takes it ..he\she will not return it back.. so we don’t use them.. as simple as that And they also come in shades just like composite, it sets fast (20 seconds .only) and then you can place varnish This is a picture for them

Even IRM comes in capsules just like in this picture (with gun and placed into .(cavity, good consistency

This is the casual type

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?What does IRM stands for and why Intermediate restorative material, bcoz its not permanent, but it can last 6 months and even up to one year if no occlusal forces on the tooth restored .with it .Intra canal medications : ledermix .. dr said read more from old lectures Its an active compound which is highly effective anti-inflammatory cortisone derivative (triamcinolone acetonide) combined with a broad-range antibiotic (dimethylchlortetracyline). Therapeutical results: Rapid relief of pain associated with acute pulpal and .periodontal inflammations It has less antibacterial quality than the non setting Ca(OH)2, and it can be used .to relieve teeth with symptoms and not indicated in necrotic teeth This is a picture of it

You can read from this to know more about ledermix http://www.health.gov.il/units//pharmacy/trufot/alonim/1118.pdf when we irrigate the canals we use NaOCl, and we can use also Chlorhexidine, they have the same antibacterial activity, but the CHX is not used in cases of

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vital teeth coz it doesn’t dissolve organic tissues (e.g blood), but its excellent in retreatment cases, and when we have a case of open apex and we are afraid .from irrigation with NaOCl we can use CHX instead Its available in concentrations (same as perio) which are 0.12 % and 0.02%, and It has the same effectivity of 5.25 % NaOCL, its available in two names : savacol .and periogard

.Lubricants : EDTA (ethylene diamine tetracetic acid) or glyde From Wikipedia : EDTA is  Poly amino carboxylic acid with the formula [CH2N(CH2CO2H)2]2. This colorless, water-soluble solid is widely used to dissolve scale. Its usefulness arises because of its role as a chelating agent, i.e. its ability to "sequester" metal ions such as Ca2+ and Fe3+. After being bound by EDTA, metal ions remain in solution but exhibit diminished reactivity. EDTA is produced as .several salts, notably disodium EDTA and calcium disodium EDTA Smear layer : Adherent debris produced when cutting the enamel or dentin in cavity preparation. It is about 1 micron thick, different quantities and qualities of smear layer can be produced by the various instrumentation techniques. Its function is presumed to be protective, as it lowers dentin permeability. However, it masks the underlying dentin and interferes with .attempts to bond dental material to the dentin Better adaptation and sealing ability and antibacterial effect of .medicament increase when the smear layer is removed Its consist of organic and inorganic debris, and we remove it by NaOCL (to .(remove the organic), and EDTA (to remove the inorganic debris Another lubricant is glyde or endo ease (there was a 3rd name that I couldn’t hear) , which can be used with filing during step back technique, it

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facilitates movement with no need to forces which we usually do and end up ..with errors ..(MTA (mineral tri oxide aggregates High PH, antibacterial, induces cementogenesis. And we used it in pulp . capping , furcation perforations, apexification or as a root end filling .(This is a case of apexification, (from the internet.. didn’t get the slides

…(Another one (apexification

Dr showed us an x ray for deep caries in the lower six and apical foramen is wide, we should check vitality by endo ice, EPT is not so good in posterior teeth coz of contamination by saliva and not easy to apply… please refer to slides to see it.. improve the access occlusaly, excavate all the caries, with the rubber dam in place, two exposures happened (in the picture in the slide), and you should watch the bleeding, coz to guarantee the success of the case, the pulp should bleed normally, stop bleeding with a small cotton pellet damped with NaOCl to disinfect the area. (don’t forget good .(isolation ..Techniques of Gutta Percha Placement

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The technique that we use to condense GP in the clinics is the lateral ..condensation We have another one which is the vertical condensation, they do not differ in the success rate, but in some cases where the canal is branching you can use .vertical condensation, but it needs experience ..(This is the thermafil, and its special oven..(thermafil plus oven

We place the upper thing (gutta percha carrier that looks like a file) and .."place it in the oven and it will be hot and we use sealer with it "of course Another type…. Injectable GP

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And these are pictures of two different devices of thermafil..(from the (net

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You place GP rods in it and it will come out with 200 C temperature, this is useful if you placed MTA in the apical part of the canal bcoz it will be easy to put thermafil and it wont be necessary to use accessory cones, you hold the gun, one injection and that's it...(the above left device is called .(OBTURA System B… the upper right device… it has electric cutter (its heated up to 200-300 degrees) …so you don’t need to get torch and heat the plugger and cut…. It has endo pluggers that suit anterior teeth, and others for posterior teeth. They can be used for coronal cutting (when preparing for .posts) and post space preparation ..So one simple cut .This is a tooth whose roots filled by vertical condensation

One of our colleagues asked about how to control it (vertical condensation) .and make sure that warm GP does not leak to periapical tissues Dr : the most important thing is that there must be a tug back.. if there is no tug back in the cone that we have then don’t use it and select a larger one. (tug back, finish 1 mm shorter than the WL, and it must be very ..(tight

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: (Another answer to another Q (sorry couldn’t hear it ..The pt wont feel it (despite the heat), coz he/she will be anesthetized : Another answer slight shrinkage will happen but no considerable leakage will happen.. although older types (alpha phase, beta phase) had a percentage of .shrinkage… so the newer brands are better These are carriers of thermafil

They look like files and they have sizes ( green = 35), coated by GP, you place one carrier in each canal, and if u have a wide lonely distal canal you can place two after you place them in their special oven. And you cut the coronal part by a high speed bur or by system B (previously mentioned) and when using thermafil its not important the technique that u prepared the ..canal with (whether step back or rotary).. but be aware of overfill .There is also a rubber stopper to determine the length

Dr showed us a picture of an extracted tooth, it was filled by thermafil, cone was heated, placed and then cut.. it also gives very good adaptation in ..cross sections ..These are x rays showing sealer extrusion

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We also use the injectable in cases of internal resorbtion which u cant ..obturate with lateral condensation

…In the previous x rays : MTA is placed then thermafil … p.s you don’t always get good results … its not magic if the pt has symptoms, you need to reflect a flap to detect any extrusions ..and remove them if too much

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Ni\Ti files have many systems… they are rotary, old ones were pro files, …GT files and quantec and pro taper

..this is GT rotary file

This is pro taper file

…and these are quantec rotary files

People now use either pro taper or pro file, or combination between pro ..taper and single cone technique p.s you can find pictures in pathways of the pulp for all the systems.. if you … are interested

nowadays step back is not used, we do crown down technique, 1st coronal flaring then down to the apical part of the root, it is good bcoz there will be less accidents and perforations bcoz we do coronal flaring first, debris 12

are easily brought outside the canal, but still fracture of instruments can happen, files in these systems are divided to orifice shapers (S1, S2) (flare the coronal part), and apical shapers (F1, F2….).. we start with the orifice shapers.. so no Gates gliden any more.. be aware of over enlarging the coronal part coz it will lead to weakening the root and may be sub crestal ..fractures.. but if you enlarge the apical part  this is better

…(color coding (not necessarily the same . e.g red  tip size = 25 taper increases by 0.04 or 0.06 up to 0.12 (unlike the k-files which ..(increase in taper by 0.02 mm if you prepared the canal with a file whose taper 0.06, then you place a GP cone of 0.06 mm taper coz if you use a smaller one, then you will end up ..with lots of accessory cones in the canals in the hand files we have the cutting part extending for 16mm, while in the rotary it varies : some have cutting part only on tip some have more, active .cutting tip, non active tip that doesn’t coz perforations .These are Ni\Ti rotary files with different cutting edges

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This is the device that we use with rotary files

The most important thing about rotary files is that if it does not enter on a specific length, then don’t force it coz it will probably break.. so what to do?? Get the next smaller size, and work with it, and then return back to .the larger and it will enter a bit more

Dr showed us a histological x-section of an obturated canal (cleaned by rotary)… (refer to slides please), its regular, debris are gone, almost circular. And its obviously better than the one that was cleaned and shaped .using k-files

Another slide shows a tooth that was weakened coronally bcoz of using the gates gliden too much coronally.. it can make a step or a shoulder that may .(obscure the access (refer to slides Another x rays : 90 degree curved canals were cleaned and shaped using .hand files by some dentists, and they were excellent ..Rotary files preserve tissues

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This is an orifice shaper

We don’t place the rotary files on the usual low speed hand piece due to v.high risk of fracture, there is a special one called reduction hand piece, .but still there is a risk of fracture

(There is also a wireless hand piece which can be charged (picture

Dr showed us a wire less hand piece that has its own apex locater, it will .…give you a light when you are at the apex or beyond it And also a hand piece with PFOS (profile orifice shaper) written on it, that ..has a programmed speed that you don’t need to adjust

: We have two types of failure of instruments (torsional failure (due to over use-1 flexural failure-2

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Dr also showed us a good root filling but actually 1/2 of it was a broken instrument so be careful especially when working for people whom you know ..( (they will yefda7ook btw people if u screw up  Our references are principles of endodontics for Walton and Torabinejad, .and pathways of the pulp

Thank you for reading this long boring lecture… you surely noticed that it has lots of pictures (I repeat that they are from the internet) and I don’t ..know if they coincide with the pictures that dr nesreen showed us Any way… if you have any chief complaint ;p plz tell me ..Any feed back is really welcomed …(Now esma7ooly aktob some ehda2(s ‫ اسيل بحب اهديكي ابيات الشعر اللي من تأليفي‬.... ‫طبعا اول اهداء الى أسيل المومني‬ ‫ فعلتها في وقت الستراحه‬....‫تعاتبني في فعله زميله‬ ‫وعلى وجهي علمات راحه‬....‫شددت بلطف طرف شعرها‬ * ‫ليمل الفضاء والفارابي فضاحه‬....‫واذا بصوت منها ينطلق‬ ‫في محاضرتها الورثو بصراحه‬....‫وحلفت لي بأني سأفضح‬ ‫عشائك بي يا أم الفصاحه‬....‫وقلت لها سأتغدى بك قبل‬ ( : ...‫*حذفت الياء واضيفت الهاء لجل الوزن الشعري‬ : ‫وسلم لكل من‬ you)‫ فاطمه اسعد‬,(‫فكريه )مهجه قلبي‬,(all you need is love) ‫منى‬, (appealing) ‫ دعاء‬,‫شفاء‬ ‫ ايسر‬,‫ دعاء عودات‬,‫نور جيوسي‬,(on my head ya partner) ‫ نسرين‬,(are dead meat :D ,‫ الء عمايرة‬,‫ اسراء شطاره‬,‫ اسراء بطاينه‬,‫ سحر‬,‫هبه‬, ‫ ايه‬,‫ امل‬, ‫ رانيا‬,(‫)الم الروحيه للتشاؤم‬ ,(previous prostho partner) ‫ هاله‬,‫ نور بني هاني‬,‫ فرح القرم‬,‫ مديحه‬, ‫ دينا‬,‫ميس حتامله‬ take care of) ‫اسراء غزلن‬, (why ortho?? :S) ‫ روان رحال‬,‫ اروى‬,‫ جمانه‬,‫ ديما‬,‫ هدى‬,‫نور‬ ,‫ دانه‬,‫ مرام كاتبه‬,‫ ربى الطورة‬,‫ غاده‬,‫ زين صمادي‬, (your exposed flash.. it’s a treasure .....‫ فاطمه‬, ‫ لمياء‬, ‫اسماء المومني‬

: Done by 16

..Razan Mohammad al shehab

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