Endodontic Success Reliable Endodontic Outomes Please Efficiency Through Simplicity Restoration Irrigation Be cautious about integrating new technology into your David Landwehr D.D.S., M.S. Capital Endodontics practice Madison, Wisconsin

InstrumentationDiagnosis Obturation Case Selection

Bacteria, Bacteria, Bacteria… Goals of Treatment

S Kakehashi, HR Stanley, RJ Fitzgerald. The effects of surgical exposures of dental pulps in germ-free and Prevent / resolve apical conventional laboratory rats. Oral Surg Oral Med Oral periodontitis by: Pathol 1965; 20:340-49. Removal of all organic G Sundqvist. Bacteriological studies of necrotic dental substrate from the canal pulps [odontologic dissertation no.7]. 1976 University of Umea Umea, Sweden system

AJ Möller, L Fabricius, G Dahlén, et al. Influence on Prevention of re-infection periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scan J Dent Res 1981; 89:475-84. Oral Surg Oral Med Oral Path 1965;20:340-9 Schilder, Dent Clin Nor Am 1974 Cracked Tooth ?? Goals of Treatment J-Shaped Lesion J-Shaped Bone Loss -Safely deliver irrigant to Narrow Deep Pocket within 2-3 mm of the working length Sinus Tract Location

-Preserve the natural anatomy Pain on release of Bite Limited Restorative History of the tooth Mobility Tooth Location

Apical Healing no Obturation Dental History Medical History The success of Pulp Testing endodontic treatment depends on the Endodontic Diagnosis Percussion Tooth Sleuth elimination of the Periodontal Probing microorganism, host response and coronal Palpation seal Radiographs JOE 2006 Pulpal Reversible Pulpitis Reversible Pulpitis

• Normal Stimulation is uncomfortable to the patient but Stimulation is uncomfortable to the patient but reverses quickly after irritation reverses quickly after irritation • Reversible Pulpitis

• Irreversible Pulpitis Caries, exposed dentin, recent dental treatment, Caries, exposed dentin, recent dental treatment, • Symptomatic and defective restorations and defective restorations

• Asymptomatic Conservative removal of the irritant will resolve Conservative removal of the irritant will resolve • Necrotic the symptoms the symptoms

Irreversible Pulpitis Irreversible Pulpitis

Symptomatic Asymptomatic Intermittent or spontaneous pain Deep caries may not produce any Heightened and prolonged episodes symptoms If a marginal ridge crack is identified early enough in of pain even after the thermal teeth with a diagnosis of RP and a crown is placed, root stimulus has been removed Left untreated, the tooth may become canal treatment will be necessary in about 20% of these symptomatic or the pulp will become cases within a 6-month period sharp or dull necrotic localized or diffuse referred Pulp Necrosis Pulp Necrosis Pulp Necrosis

Pulpal blood supply is nonexistent and Will not respond to electric pulp tests or to cold Partial or complete the pulpal nerves are nonfunctional stimulation May not involve all of the canals in a If heat is applied for an extended period of time, Only clinical classification that directly multirooted tooth attempts to describe the histologic status the tooth may respond to this stimulus of the pulp (or lack thereof) Confusing symptoms

Pulp Necrosis Pulp Necrosis

Bacterial growth can be sustained within the canal Radiographic changes may occur, ranging from a thickening of the periodontal ligament space to the appearance of a Periapical bone lesions suggesting necrosis When bacterial toxins extend into the periapical radiolucent lesion developed in 8.5% periodontal ligament space, the tooth may become symptomatic to percussion or Routine endodontic intervention of teeth with exhibit spontaneous pain ongoing obliteration of the root canal does not seem justified Previously Initiated Previously Treated Treatment Periapical

Has obturating material in canals Pulpotomy or pulpectomy performed before • Normal presenting for root canal • Asymptomatic Apical Perio May or may not present with signs or symptoms • Symptomatic Apical Perio • Acute Apical Abscess Will require additional nonsurgical or surgical endodontic procedures to retain the tooth • Chronic Apical Abscess

Asymptomatic Apical Normal Apex Perio Symptomatic Apical Perio

Asymptomatic Apical radiolucency Painful response to biting pressure or Tooth responds normally to percussion and Presents with no clinical symptoms percussion palpation testing Does not respond to pulp vitality tests May or may not respond to pulp vitality tests Intact lamina dura and periodontal ligament space around all the root apices This tooth is generally not sensitive to biting May or may not have an apical radiolucency pressure but may “feel different” to the patient associated with one or all of the roots on percussion Acute Apical Abscess Acute Apical Abscess Chronic Apical Abscess

Painful to biting pressure, percussion, and palpation Usually asymptomatic Swelling Does not respond to any pulp vitality tests Does not respond to pulp vitality tests Fever Mobility Apical radiolucency Lymph node tenderness

Radiograph can exhibit anything from a widened Not sensitive to biting pressure but can “feel periodontal ligament space to an apical different” to the patient on percussion radiolucency

Chronic Apical Abscess Testing Goals Pulp Testing

Sinus tract •Repeatable •Thermal •Redundancy •Electric • Laser Doppler Flowmetry (LDF) •Chief Complaint • Pulse Oximetry • Test Cavity • Selective Anesthesia Thermal EPT Periapical Testing

• Cold Response by the pulp to the • CO₂ snow (-108∘F/-75∘C) electric current only denotes • Percussion that some viable nerve fibers • Palpation • Endo Ice (-14∘F/ -50∘C) are present in the pulp and are capable of responding • Bite Stick •Heat ?

Limitations of pulp Other Testing testing Pulp Testing • Periodontal Probing Limitations The vitality of the pulp is determined by the health • Transillumination of the vascular supply, not the status of the pulpal nerve fibers

Sensibility Testing is not vitality testing Limitations of pulp Correlation of Histology testing No Proprioception and Clinical Diagnosis

-Not a good correlation Patients can localize The classification of pulp between the objective clinical painful tooth 73.3% signs and symptoms and the conditions as normal pulps, pulpal histology reversible pulpitis, and 89% if periradicular irreversible pulpitis have high -No proprioception in pulp chances of guiding the correct therapy in the large majority of cases

JOE 2010 Oral Sx 1963 JOE 2014

Limitations of pulp Limitations of pulp Limitations of pulp testing testing testing Specificity is the ability of a If a mature, untraumatized Sensitivity is ability of a test to test to identify teeth without tooth does not respond to identify teeth that are diseased disease both electric pulp test and 93% were correctly identified cold test, then the pulp Cold test correctly identified should be considered 83% of the teeth that had a by both cold and EPT necrotic necrotic pulp 41% of the teeth with healthy Heat 86% pulps were identified Electric pulp tests 72% correctly by the heat test

Peters DD, Baumgartner JC, Lorton L: Adult pulpal diagnosis. 1. Evaluation of the positive and negative T Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G: Evaluation of the ability of thermal T Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G: Evaluation of the ability of responses to cold and electric pulp tests. J Endod 1994; 20:506 and electric tests to register pulp vitality. Endod Dent Traumatol 1999; 15:127. ext thermal and electric tests to register pulp vitality. Endod Dent Traumatol 1999; 15:127. ext Limitations of pulp Who is testing Radiology Reading the Cold test and EPT used limitations in conjunction resulted in Radiograph ? a more accurate method One piece of Subjective diagnostic Interexaminer agreement ~ for diagnostic testing information 50% Intraexaminer agreement ~ Ten percent of the teeth not responding to any of 75 - 80 % the tests contained vital Goldman M, Pearson A, Darzenta N. Reliability of pulps radiographic interpretations. Oral The Validity of Pulp Testing: A Clinical Study Rebeca Weisleder, Shizuko Yamauchi, Daniel J. Caplan, Martin Trope and Fabricio B. Teixeira J Am Dent Assoc 2009;140;1013-1017 Surg 1974; 38(2):340.

Who is Reading the Radiology limitations Radiology limitations Digital Bone loss will not be Certain teeth are more detected if the lesion is only Radiograph ? prone to exhibit in cancellous bone 100% agreement < 25% radiographic changes than 5 agree ~ 50% others, depending on their PA lesion when bone loss anatomic location Intraobserver reliability extends to the junction of 41 % - 85 % the cortical and cancellous Average 68 % bone

Tewary S, Luzzo J, Hartwell G. Endodontic radiography: who is Bender IB, Seltzer S: Roentgenographic and direct observation of Bender IB, Seltzer S: Roentgenographic and direct observation of reading the digital radiograph? J Endod. 2011 Jul;37(7):919-21. experimental lesions in bone. Part I. J Am Dent Assoc 1961; 62:152. experimental lesions in bone. Part II. J Am Dent Assoc 1961; 62:708. Radiology limitations Radiology limitations Cone-Beam Computed 7.1% mineral bone loss to Can have PA produce a radiolucency radiolucency or PDL Tomography changes and inflamed (CBCT) Lesions 1-7 mm didn’t tissue in root canal produce a lesion in cancellous bone

Yamasaki M1, Kumazawa M, Kohsaka T, Nakamura H, Kameyama Bender IB. Factors influencing the radiographic appearance of bony Y. Pulpal and periapical tissue reactions after experimental pulpal lesions. J Endod 1982 Apr;8(4):161-70. exposure in rats. J Endod 1994 Jan;20(1):13-7.

CBCT CBCT CBCT Sensitivity CBCT is accurate in detecting CBCT devices demonstrated poor accuracy in detecting simulated lesions 1.3 - 2.9 incidental apical periodontitis smaller than 0.8 mm in diameter findings per CBCT

Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. fair to good accuracy when simulated Accuracy of cone beam computed tomography and lesion diameter was between 0.8–1.4 mm panoramic and periapical radiography for detection of 24 - 93 % of scans had apical periodontitis. J Endod 2008 Mar;34(3):273-9. excellent accuracy when simulated incidental findings

De Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, lesions were larger than 1.4 mm in Wesselink PR. Accuracy of periapical radiography and diameter cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam gold standard. J Endod 2009 Jul;35(7):1009-12. incidental findings in cone-beam computed tomographic scans of computed tomography and periapical radiography in detecting small the head and neck region: a systematic review. J Am Dent Assoc periapical lesions. J Endod 2012 Jul;38(7):965-70. 2013 Feb;144(2):161-70. Radiology Limitations CBCT Limitations CBCT Limitations

“interpreting the lamina dura Clinicians’ experience level continuity, shape and density, PDL spaces of healthy teeth appears to be correlated and the periodontal ligament demonstrated significant with their ability to width and shape proved to be variation when examined correctly diagnose the best radiographic by CBCT periapical disease in CBCT features” volumes

Pope O, Sathorn C, Parashos P. A comparative Kaffe I, Gratt BM. Variations in the radiographic investigation of cone-beam computed tomography and Parker JM, Mol A, Rivera EM, Tawil PZ. Cone-beam Computed interpretation of the periapical dental region. J periapical radiography in the diagnosis of a healthy Tomography Uses in Clinical Endodontics: Observer Variability Endod 1988 Jul;14(7):330-5. periapex. J Endod 2014 Mar;40(3):360-5. in Detecting Periapical Lesions. J Endod 2017 Feb;43(2):184-187.

Radiographic Radiographic Interpretation Interpretation

• 90% ≠ 100% RECOGNIZE WHAT • Common things occur more often ISN’T NORMAL AND • Similar clinical presentations but very • Smaller lesions- unilocular different treatments and potential outcomes • Larger lesions- multilocular DO SOMETHING • Same lesion can have many different ABOUT IT presentations • Patient can have more than a single pathology MULTILOCULAR RADIOLUCENCIES Systematic Unilocular Differential Diagnosis of Periapical Odontogenic keratocyst*** Pathology Ameloblastoma*** Multilocular Central giant cell granuloma**

MULTILOCULAR MULTILOCULAR Keratocystic RADIOLUCENCIES RADIOLUCENCIES Odontogenic Tumor

• 3-11% of all cysts Keratocystic Odontogenic Tumor*** Odontogenic keratocyst*** • Infancy to old age (rare before 10) Ameloblastoma*** Ameloblastoma*** • Mn in 60-80% • Posterior body and ramus Central giant cell granuloma** Central giant cell granuloma** Keratocystic Odontogenic Tumor Ameloblastoma Ameloblastoma

• Locally invasive • Usually asymptomatic- pain drainage • Tumor of Odontogenic epithelium swelling with larger lesions • Usually benign • Incidence • Grow in AP direction • Wide age range (rare before 10) • Expansion is frequent • 25-40% will have impacted tooth • Equal prevalence 3rd-7th decade • Resorption of roots common • Recurrence • M=F • Slow growing • 80% Mn (usually posterior)

Periapical Cemento- Multifocal osseous Dysplasia Isolated Cemento-osseous dysplasia*** • Early lesions will be radiolucent but with time this will change Nevoid basal cell carcinoma syndrome** Multiple myeloma** • Anterior Mn Multifocal • More common multiple, solitary Cherubism* possible Hyperparathyroidism* Langerhans cell histiocytosis* Periapical Cemento- Nevoid Basal Cell osseous Dysplasia Carcinoma Syndrome Differential Diagnosis

1 in 60,000 live births Dentigerous cyst • Female (10:1) • Jaw Cysts Adenomatoid Odontogenic Tumor • 70% african american- • Basal Cell Carcinomas Ameloblastic Fibroma • Initial Dx between 30-50 years of age • Intracranial Calcification Ameloblastic Fibro-odontoma (almost never before 20) Ameloblastoma • Rib / Vertebral anomalies Odontogenic Keratocyst • Vital pulps • Palmar and Plantar pits • Asymptomatic • Variability

RADIOPACITIES: WELL-DEMARCATED BORDERS*** Radiolucent Well Defined Torus or exostosis Mixed Retained root tip Condensing osteitis Radiopaque Idiopathic osteosclerosis Poorly Defined Drug Related Osteonecrosis RADIOLUCENCIES: of the Jaw RADIOLUCENCIES: ILL DEFINED* ILL DEFINED Sofarenib Bisphosphonates Osteosarcoma Cabozantanib Periapical granuloma or cyst*** Chondrosarcoma Focal osteoporotic marrow defect*** Aflibercept Sunitinib Ewing's sarcoma Everolimus Other primary bone malignancies: Denosumab fibrosarcoma, lymphoma Axitinib Osteomyelitis** Bevacizumab Metastatic tumors Bisphosphonate-associated osteonecrosis** Methotrexate Multiple myeloma Primary intraosseous carcinomas Steroids odontogenic or salivary

UNILOCULAR RADIOLUCENCIES: UNILOCULAR RADIOLUCENCIES: OTHER Unilocular PERIAPICAL Developing tooth bud*** Well Defined Periapical granuloma*** Isolated Periapical cyst*** Lateral radicular cyst** Nasopalatine duct cyst** Radiolucencies Periapical cemento-osseous dysplasia (early)** Lateral periodontal cyst** Residual (periapical) cyst** Periapical scar* Odontogenic keratocyst** Dentin dysplasia type I * Central giant cell granuloma** Stafne bone defect** Diagnosis

• Cardiac • Lichen Planus

• TMD/TMJ • Pemphigoid • Herpes Zoster • Cementoblastoma Conclusions • Pleomorphic Adenoma • Sinusitis • Dysplasia R/O SCCA • Systemic Sclerosis • Lymphoma • Osteomyelitis

• Migraine/headache • DR ONJ • Atypical Odontalgia • Eagle Syndrome

• Trigeminal Neuralgia • Nasopalatine Duct cyst • Trigeminal Autonomic Cephalgia • Vit D resistant rickets

• Multiple Sclerosis (x2) • UNKNOWN - R/O malignancy • Keratocystic Od. Tumor • Necrotic Pulp/ Irrev. Pulpitis Oral Sx 1965 • PA cemento osseous dysplasia

Rubber Dam Magnification Access, Anatomy & Glide Path Management Finding Canals Dentin Infection Preoperative Radiograph(s) Bite wing angle Canal Numbers CBCT ? Bacterial infection of the cervical and CEJ/Perio Probe midroot areas was similar, Others…. characterized as a heavy infection with bacteria penetrating as deep as 200 um

Apical Location Apical Location Apical Size

Teeth Mean (um) Mx incisors 289.4 • At or within 3mm of root apex • At or within 3mm of root apex Mn incisors 262.5 Mx premolars 210 • AF coincides with the apical root • AF coincides with the apical root Mn premolars 268.25 Mx molars vertex in 17% to 46% of cases vertex in 17% to 46% of cases Palatal 298 VARIABLE Mesiobuccal 235.05 Distobuccal 232.2 Mn Molars Mesial 257.5 Distal 392 Morfis et al OOO 1994 Apical Anatomy Apical Size Apical Anatomy

Teeth Mean (um) Close relationship Mx incisors 289.4 between the anatomic Approximately 75% Mn incisors 262.5 complexity of the root Mx premolars 210 of teeth have canal Mn premolars 268.25 canal system and the aberrations in the Mx molars persistence of Palatal 298 apical 3 mm of the VARIABLEMesiobuccal 235.05 periradicular pathosis De Deus QD. J Endod 1975; Distobuccal 232.2 1:361-66. tooth

Mn Molars Wada M, Takase T, et al. Clinical study of refractory apical Seltzer S, Soltanoff W, Mesial 257.5 periodontitis treated by apicectomy Part 1. Root canal morphology Bender IB, Ziontz M. Oral of resected apex. Surg Oral Med Oral Pathol Distal 392 Int Endod J 1998; 31:53-56. 1966; 22:375-85. Morfis et al OOO 1994

Root Canal Success Lateral Canals Sterile Root Canal ? Salehrabi R, Rotstein I. J Endod 2004;30:846-50. 1.4 million, 8 year , 97% 74% in the apical third of the survival root Chen SC, Chueh LH, Hsiao CK, et al. J Endod 2007;33:226-9. 11% in the middle third 1.5 million, 5 year, 93% 15% in the cervical third survival

Lazarski MP, Walker WA 3rd, Flores CM, et al. J Endod 2001;27:791-6. Vertucci FJ. Root canal anatomy of the 44 Thousand, 3.5 years, 94% human permanent teeth. Oral Surg Oral Med Oral Pathol 1984; 58:589-99. survival Root Canal Success Implants vs. Root Canal Treatment Rotary Glide Restored endodontically Path treated teeth and single- tooth implant restorations have similar failure rates

implant group: longer average time to function higher incidence of postoperative complications requiring subsequent treatment intervention

ENDODONTICS JOE 2006 Colleagues for Excellence Spring 2015

PathFile groups demonstrated ProGlider had less significantly less transportation than The glide path with NiTi Rotary PathFiles leads to modification of PathFiles or K-files curvature and fewer less postoperative pain canal aberrations than and faster symptom hand files resolution Glide Path All Mechanized File anatomy Armamentarium

Instrumentation Begins 0.02 taper with a Hand File

ISO 10 D-16 D-8 D-0

0.42 0.26 0.10

Vortex Orifice Openers Orifice Opening Options Vortex Orifice Openers

Hand Files Gates Glidden Size% Cutting% Tapered% Parallel% Maximum% Handle%% Stopper% Taper%Lines! ProTaper Sx Vortex (Tip/Taper)! Length! Length! Flutes%% Fluted% Color% Color% 00%%Taper% Diameter! %(Tip%Size)! (Taper)! Length%!

20/.08& 12&mm& 9.0&mm& 3.0&mm& 0.92&mm& Yellow& Blue& 4&

25/.08& 12&mm& 9.3&mm& 2.7&mm& 0.99&mm& Red& Blue& 4&

25/.10& 12&mm& 9.4&mm& 2.6&mm& 1.19&mm& Red& Yellow& 5&

25/.12& 12&mm& 7.9&mm& 4.1&mm& 1.19&mm& Red& Black& 6&

30/.12& 12&mm& 8.0&mm& 4.0&mm& 1.26&mm& Blue& Black& 6& 12mm of cutting flutes 40/.10& 12&mm& 7.9&mm& 4.1&mm& 1.19&mm& Black& Yellow& 5& Parallel flutes in the last 3-4 mm 16 mm 19 mm lengths Glide Path Options WaveOne GoldGlider WaveOne GoldGlider

Hand files Vortex Blue WaveOne 15/0.04 GoldGlider • Prepackaged Pathfiles ProGlider • Reciprocation • Single use • 0.15 mm tip • Metallurgy • Progressive Taper • 21, 25, 31 mm lengths

WaveOne GoldGlider Off-set, Rectangular Cross Variable Helical Angles Section

Variable Taper 2-6%

D1 .17

D0 D8 D16 .15 .413 .850 Reciprocating Motion File Comparisons Glide Path Technique

.79

.27 .82 .19 .22 .23 .18 .85 .15 .20 .16 .21 .17.19 .15

How big is the apex? Glide Path Goal Apical Size Teeth Mean (um) 10 or 15 file loose at the working Mx incisors 289.4 length Mn incisors 262.5 Mx premolars 210 Mn premolars 268.25 Mx molars Palatal 298 Mesiobuccal 235.05 Distobuccal 232.2 Mn Molars Mesial 257.5 Distal 392 Apical Location Patency Glide Path Management

Maintenance of apical patency does not increase • Estimate working length the incidence, degree, or • Straight Line Access duration of post-operative pain • Orifice Opening

• Instrumentation

J Endod 2009;35:189–192

Technique Technique Technique Larger straight canals

Which canal do I treat • Access first ? • Irrigate canal • 10 file to estimated WL (or slightly past) • Open orifice/canal • Determine WL (EAL +/or Xray) DO NOT ALLOW • 10 file • If not at WL continue to work down FILE TIP TO BIND canal without binding file tip • Vortex Orifice opener OR HIT CANAL WALL Glide Path Management Glide Path Management Glide Path Management Modifications Modifications Modifications small, long curved canals small, long curved canals small, long curved canals

• Estimate working length

• Straight Line Access

• Orifice Opening

• Instrumentation

Technique Technique Technique small, long curved canals small, long curved canals small, long curved canals

• Access • After orifice is opened • Irrigate canal DO NOT ALLOW • 10 file coronal to any binding • Open orifice/canal SHORT FILE TIP TO of WL (coronal to any MD • roughly 17-18 mm curve) BIND OR HIT • Rotary / Glider 1mm short of 10 file • 10 file CANAL WALL binding • Vortex orifice opener Technique Technique If 10 File Not Advancing Smaller curved canals Smaller curved canals • Open to Final Shape, • 10 file apical to first curve, • 10 file apical to est WL (23mm) • (.5 mm short of depth Rotary glide path binds) coronal to 2nd curve • Determine WL (EAL +/or Xray) • Pre-Bend 10 File • 20-21 mm • If not at WL continue to work down • Smaller file ( I don't do this) • Rotary / Glider 1mm short canal without binding file tip of 10 file binding • Rotary / Glider @ working length • Push 10 File and Engage Tip ( I try to never do this)

Technique Review NiTi Phases

• 10 file into canal (past dentin triangle)

• Orifice open (Vortex orifice opener 20/08, Instrumentation Cooling 16mm)

Heating • 10 file tap to resistance (or est WL) Austenite • Rotary Glider @ 1 mm short of 10 file (or at WL)

• If not at estimated WL repeat sequence of 10 file Deformation and Rotary / Glider until estimated WL • Final instrumentation de-twinned martensite twinned martensite Cyclic Fatigue Nickel Titanium Fracture Mechanisms Differences in the methodology affected the fatigue behavior of rotary instruments and the outcome • Super Elastic • Torque of these studies • Cyclic Fatigue • Shape Memory An international standard for cyclic fatigue testing of NiTi rotary instruments is required to ensure comparable results

J Endod 2009

Temperature Effects Temperature Effects

Temperature was found to Immersion in water at significantly affect the cyclic simulated body temperature fatigue of nickel-titanium rotary was associated with a files marked decrease in the fatigue life of all rotary Future cyclic fatigue studies instruments tested should be conducted at body temperature

J Endod 2016;42:782–787 J Endod 2017;43:823–826 Fixed Taper Varying Taper File Classifications

• Active Cutting or Radial Lands

• Fixed or Variable Taper D16 D16 D16 D16 D16 D16 .11 .04 .03 • Rotary or Reciprocation .10 .055 .045 .02 Taper .04 Taper .06 Taper .045 .065 .09 .32 mm .64 mm .96 mm increase increase increase .02 .07 .09 D1 D1 D1 D1 D1 D1

File Categorization

•GOLD results from post-grind heat treatment Landed Non-Landed Non-Landed Reciprocating (Passive) (Active) (Active) More flexibility Fixed Taper Variable Taper • Higher resistance to cyclic fatigue • ProFile • Vortex • ProTaper • Series 29 • WaveOne • Vortex Blue ProTaper • • WaveOne • ProFIle ISO Gold Gold • ProFile GT • ProGlider • GT Series X WaveOne® Gold WOG instruments were Reciprocating System approximately twice as resistant to failure as the • Small WO instruments were at a 0.955 .06 Taper 60 angle of curvature, • Primary whereas the WOG instruments were 3 times • Medium more resistant at a 90 0.390

angle of curvature • Large 0.320 .07 Taper 0.250

J Endod 2017;43:623–627

0.845 .045 Taper 0.945 .05 Taper 0.895 .04 Taper

0.345 0.470 0.550

0.275 .07 Taper 0.410 .06 Taper 0.500 .05 Taper 0.205 0.350 0.450 Apical Size vs. Taper

2 Points of Contact SEM View When a taper of .10 can be produced at the apical extent of the canal, there is no difference in debris removal between the two preparations sizes

JOE, Vol. 30, No. 6,425-428, Jun 2004

WaveOne Gold Reciprocation Single Use Why Single Use?

Prions European Experience Efficiency Safety Cost WaveOne™ NiTi System WaveOne™ NiTi System WaveOne™ NiTi System

Microcracks ? No causal relationship Small Canals Large Canals between dentinal microcrack formation and canal preparation J Endod 2013 procedures with Reciproc, WaveOne, and BioRaCe systems was observed

J Endod 2014 -Dentinal cracks are All instruments created produced irrespective of dentinal cracks motion kinematics • Glide path The flexibility of nickel- -Incidence is less with titanium instruments • Flood canals instruments working in because of heat treatment • Brushing motion away from furcation reciprocating motion seems to have a • Apical pressure to engage dentin compared with those in significant influence on • Several passes will be required to achieve WL continuous rotation dentinal crack formation • Rinse and patency file between each WaveOne™ gold cycle J Endod 2014 J Endod 2017

“…all instrumentation techniques left 35% Biofilm Irrigation or more of the canal’s surface area unchanged” • Biofilms are the preferred means of microbial

survival and growth • Attached (Biofilm) vs. Suspended (Planktonic) Peters OA, et al. Effects of four Ni-Ti preparaon techniques on • 99.9% of microorganisms prefer attachment root canal geometry assessed by micro- computed tomography. Internaonal Endodonc Journal • Microbes exist in 2 distinct life forms or phenotypes: 2001; 34(3):221-30 biofilms for survival planktonic for transmission Goals of Irrigation NaOCl Dissolves organic tissue EDTA Debride canal Current irrigation Kills microbes fast Dissolve tissue CHX solutions and No effect on inorganic tissue Remove smear layer protocols Kill microbes Weakens in contact with other materials Toxic/caustic effect on PA tissue

SEMs of smear layer partially covering Harmful effect on dentin structure?? instrumented sections of canal walls (Dr. Franklin Tay)

Smear Layer NaOCl Removes Smear Layer Smear Layer EDTA No Bacteria Killing Does Not Dissolve Soft Tissue CHX May Erode Dentin with Longer Time Exposure

5.25% NaOCl + Distilled Water as final rinse 17% EDTA (Negative Control) Removed smear layer at Significant amount of smear layer at all three levels of teeth all levels of the tooth NaOCl Kills bacteria (not fast) Most Common Irrigation Improves long term dentin Methods EDTA bonding to resins CHX Does not dissolve tissue Bleach + EDTA: Using hypochlorite Does not dissrupt biofilm Bleach + EDTA + CHX: again after EDTA can Bleach Only: cause Bleach + EDTA + Bleach erosion of dentin

NaOCl + EDTA + NaOCl Final irrigation with Dentin Erosion? long-term NaOCl after EDTA should NaOCl be avoided to avoid weakening of the + No root EDTA QMix™ 2in1 Surfactants No single final irrigant Contents Reduce surface tension (increase wetting) does all of the Improve penetration CHX required tasks EDTA Detergent

2 Sizes: 60 mL and 480 mL

QMix™ 2in1 Qmix and Smear Layer Qmix and Bacteria Benefits Comparable Smear Layer Removal QMix and NaOCl were To 17% EDTA QMix was effective as 17% superior to CHX and EDTA in removing canal wall MTAD in killing E. faecalis and plaque bacteria in Disinfection smear layers after the use of planktonic and biofilm Kills 99.99% Bacteria 5.25% NaOCl as the initial culture

in 5 seconds rinse Ability to remove smear Easy Chair Side Handing layer by QMix was Int Endod J. 2012 April; 45(4):363-71 Premixed comparable to EDTA J Endod. 2011 Jan;37(1):80-4 QMix 2in1 Effect of EDTA vs. QMix™ 2in1 removes smear on Dentin Surface QMix™ Technique layer at all levels SEM EX-VIVO CLINICAL RESULTS • Final NaOCl rinse • Activate • Water rinse and dry with paper points • QMix™ • If gutta core fill then size verify • Activate 90 Seconds Final Rinse 90 Seconds Final Rinse 17% EDTA QMix™ 2in1 • Dry Franklin R. Tay, Medical College of Georgia • Obtr8

® Glyde File Prep paste EndoActivator Tip during rotary Selection mechanical On/Off Button instrumentation favors the Small Medium Large accumulation of 15/.02 25/.04 35/.04 debris in the apical third of the root canals High Medium Low Activation Activation Obturation Root canal cleanliness EndoActivator provided benefits from solutions better obturation of activation in comparison lateral and accessory with no activation during canals and resulted in the final irrigation less remaining debris regimen

Obturation Obturation Obturation Goal: Four factors influenced success: -Absence of a pretreatment periapical Seal canal in three dimensions Means nothing lesion from orifice to apex with -Root canal fillings with no voids without a clean maximum gutta percha and -Obturation to within 2.0 mm of the apex -Adequate coronal restoration canal minimal sealer

Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K: Outcome of primary root canal treatment: systematic review of the literature. 2. Influence of clinical factors. Int Endod J 2008; 41:6. Obturation Gutta Percha

1,4 trans-polyisoprene Beta Alpha Thermafil produced significantly higher % Compaction to overcome shrinkage during cooling cold lateral warm vertical of gutta percha filled area than lateral condensation and System B techniques Biocompatible carrier

1. Cone Fit should be tight and to Depth of Heat within .5 mm of WL Calamus 2. Prefit pluggers and heat source Carrier-based obturation was first 3. Sear @ orifice first described in 1978 and involved the 4. Downpack to within 5 mm of WL coating of endodontic files with 5. Pack along sidewalls to prevent thermoplasticized GP mounding of GP 6. Heat apical plug prior to deeper heat penetration increased the quality placing final fill of GP adaptation to the canal walls 7. Fill in stages depending on W. B. Johnson, “A new gutta-percha technique,” Journal of taper and size of canal Endodontics, vol. 4, no. 6, pp. 184–188, 1978. 8. Add sealer as needed thermoplasticized GP extended 2 to 3 mm apical to the depth of heat penetration Thermafil® Carrier based obturation Why GuttaCore®

• Gutta-percha • Low viscosity “alpha phase”for • Difficult to retreat or remove material • Promote improved shaping, irrigation and shape flow verification • Difficult to create post space • Vented • Easy to create post space and retreat • Minimal shaping possible • Take the most scientifically researched filling technique • Evidence supports its superior fill and make it better • Great for difficult anatomies • Solve the problem of gutta-percha melting when heated

® Clinical Technique - Clinical Technique – GuttaCore Size Verification Indications Shaping 1. Irrigate the canal • Long Narrow Canals Recommend a minimal shape of 25/.06 2. Remove the GuttaCore™ size • sizes 20-90 verifier from the obturator Curves • .06 will usually match package 3. Confirm working length and Ledges • .04 one size smaller than MAF • waveone primary 25 or 30 passive fit Anatomy 4. Rotate in the canal 180° 5. Dry the canal with a paper Blister Pack point (5 obturators + 1 Size Verifier) (25 obturators + 5 Size Verifiers) Clinical Technique – Clinical Technique – Clinical Technique – Obturator Placement Working length Sealer Application Place obturator into canal in one 1.Use a paper point to brush Calibration rings: a very light coating of smooth continuous motion 18, 19, 20, 22, 24 ThermaSeal® Plus Ribbon Do not use excessive force 27 and 29 sealer throughout the Pressure should follow obturator (on the obturator handles) canal direction into canal 2.Use an additional paper point to wick up any excess sealer *Place paper point in any unfilled canals until time for obturation

Locking Pliers GuttaCore™

Slow HANDLE REMOVAL Placement – BENDS OFF Remove the handle by bending to either side of the canal wall without affecting the seal Levitan et al. 2003 J Endod 2003;29:505-08 GuttaCore® How to use the oven GuttaCore™ Clinical Technique –Removing Material Obturator Obturator Elevator Arm 1. Use rotary file Holder POST SPACE AND of same size RETREATMENT - as last file SIMPLIFIED taken to working length Heating Power On Chamber Create post space and 2. Use solvent Select Size remove the obturation to soften Cleaning Mode material with gutta-percha around core (Indicator Light) unprecedented ease (if needed)

Cleaning Mode (Press Both Buttons)

GuttaCore® Coronal Seal Ferrule Effects Keys to Success Crown preparations with as little as 1 mm coronal extension of dentin above the margin double the fracture resistance of preparations Great Shape Size Verify The most important part of the restored tooth is the Minimal Sealer tooth Slow Placement No contemporary restorative material or combination of materials will perfectly substitute for lost tooth structure IEJ 1995 Crown Preparation The Ideal Post Single Visit Maximal protection of the root from fracture Diagnosis Restoration The ferrule (dentin axial wall height) must be at least 2 Maximal retention within the root to 3 mm Maximal retention of the core and crown The axial walls must be parallel Maximal protection of the crown margin seal from Pain Management The restoration must completely encircle the tooth coronal leakage The margin must be on solid tooth structure Pleasing aesthetics, when indicated The crown and crown preparation must not invade the High radiographic visibility Antibiotics Surgery attachment apparatus Biocompatibility Anesthesia?