Endodontics & Conservative
Root Canal Treatments (Using Laser Endo Microscope)
NEVER UNDERESTIMATE THE POWER OF ROOT CANAL TREATMENT..IT GIVES LIFE TO HOPELESS TOOTH

Normal File-Technique

This technique was used for many years and required each instrument, file or reamer, to be placed to the full working length. The canal was enlarged until clean white dentine shavings were seen on the apical few millimetres of the instrument. The filing was continued for a further two or three sizes, to complete the preparation. This method was satisfactory in straight canals, but was quite unsuitable for curved canals. As the instrument sizes increase, they become less flexible and led to iatrogenic errors in curved root canals. Common problems encountered were ledging, zipping, elbow formation, perforation and loss of working length owing to compaction of dentine debris

Protaper File-Technique

Modern endodontic treatment allows patients to keep their natural teeth and, because endodontics represents the basis of restorative treatment, we can extend the lifespan of a tooth that was long meant to be extracted.

Endodontics is no longer blind treatment, based only on the touch and the experience of the clinician. The emergence of new canal preparation instruments, of means to electronically determining canal length, of the use of ultrasound in endodontics and, last but not least, of the endodontic surgical microscope have all led to an increase in treatment possibilities and indications and in success rates.

According to the fast evolution of science and technique, treatment methods are improving by the day, the technique and the instruments are perfecting, trying to closely mimic the internal root morphology, which represents the only stable element in this system. For this reason, the most difficult stage of endodontic treatment remains the method of making the root canals permeable up to the apex.

Typically, the requirements of an ideal endodontic preparation are:

1. Locate, make way and enlarge the canal without preparation errors;

2. Establish and maintain the proper working distance during the entire preparation;

3. Choose the enlargement degree of the canal in order to allow for disinfestations and adequate filling.

The emergence of NiTi has revolutionized the method of preparing the canalicular system, bringing a series of advantages to the clinician. The used alloy allows an extreme flexibility, a quality that makes them relatively safe in canal instrumentation, especially the curved ones.

The ProTaper System:

Denstply Maillefer has recently introduced those ProTaper Ni-Ti Hand files, especially designed to instrument difficult root canals, with accentuated or calcified curves. The system was created in order to reduce the number of instruments for a large number of cases. The number of progressively conical needles has been reduced to 6: 3 file needles for configuring the canal shape through the crown-down procedure (the shaping needles) and 3 file needles for preparing the apical third and achieving a fine transition between the coronary and medium thirds, resulting in that “deep preparation” (the finishing needles). The needles have the following design characteristics:

-        triangular shape with convex sides on transversal section;

-        blunt head especially designed for guidance;

-        variable helicoidal angle;

-        multiple and progressive conicity.

The golden rules of this needle system are:

-        access is granted in the long axis of the canal;

-        the enlargement of the entry orifice with Gates-Glidden (XGates) drills;

-        using instruments only in well lubricated and irrigated canals and only after the canal has been made permeable with ISO small number instruments;

-        the frequent inspection of spires for possible signs of distortion;

-        the use of instruments in the recommended movement.

Preparation needles (shaping files)

The first used needle is Sx, which is easily recognized because of its orange handle and smaller length than that of the other needles (14mm). All the needles are conical, increasing from the top to the handle (3,5-19%). Because of this thing, these needles are used to prepare the coronary portion of the canals, leading to the elimination of the dentinary triangle and of the constriction from the initial part of the canal, thus making the easier penetration of instruments and irrigation solutions possible on the distance of the root canal. The Sneedle becomes a substitute of Gates-Glidden drills.

The purple handled S1 and white handled S2 needles show a smaller  progressive conicity than the Sx needle; the S1 needle was designed to act especially in the coronary third of the canal, unlike Sthat acts especially in the middle third. These instruments can reach working length after the initial instrumentation, thus preparing the apical region.

Finishing files

The finishing needles are F1 (yellow), F2 (red) and F(blue); they represent a single conicity in the apical portion, being meant to prepare in the apical third, while the rest of the active part length presents reverse conicity in order not to excessively enlarge the coronary third and make a smooth transition between the coronary third and the medium third.

The manual ProTaper are used by making ¾ of a twist clockwise and a ½ twist counter-clockwise, thus cutting off the dentine. The movements are repeated until reaching the desired work length.

Abundant irrigation with sodium hypochlorite has to be used along the entire prepared portion and the instruments regularly retreated in order to remove detrituses and check the spires.

The 010 and 015 ISO needles are introduced in the canal on the working length, in order to keep the area along the preparation permeable.

Once repaired, the canal is irrigated with 17% EDTA, in order to remove the smear-layer, then irrigated one last time with sodium hypochlorite.

The ProTaper system technique

The pulp camera is filled with EDTA or sodium hypochlorite in order to accomplish any negotiation procedure; the 2/3 of the canal are explored with no. 010-015 ISO manual steel file needles using a forward-backward motion; these instruments are used passively and progressively until they move freely in the canal. (fig.1).

 

Fig.1 The aspect of the access cavity that allows the penetration of negotiation needles in the canal axis

The ProTaper sequence is begun with the Sx needle in the recommended motion, in order to achieve the enlargement in the coronary third of the canal; the purple S1 is then used; the apical area of S1 passively follows the region of canal that has been secured by the manual needles; S1 is designed to cut the dentine in a crown-down manner; the canal is irrigated and recapitulated with a 010 ISO file needle to break the detrituses, then re-irrigated.

In the more difficult canals one, two or even three recapitulations with S1 may be necessary in order to pre-enlarge the 2/3 coronaries; once the pre-enlargement procedure is finished, a 010 ISO file needle is used in association with EDTA in order to negotiate the rest of the canal and establish permeability  the work length is determined.(fig.2)

Fig.2 The radiological verification of the working length

Once the smooth reproducible slope to the apex has been established, S1 then S2 are successively used on the working length; irrigation, recapitulation and re-irrigation after using each ProTaper needle must be remembered.(fig.3)

The F1 needle is used on the working length in one or more steps, in order to prepare the apical area; if F1 stops advancing into the canal the needle is retracted, the spires cleaned and the motion is continued until reaching the working length.(fig.4)

Fig.3  Preparing the coronary and medium thirds

 

Fig.4. Preparing the apical and measuring the apical diameter

The apical preparation is continued with the measuring of the apical diameter with corresponding steel Kerr file needles; the canal is thus ready for filling.(fig.5)

 

Fig.5. Canals filled with the monocon technique

The advantages of using this system and not the ISO steel instruments are easy to notice:

- increased flexibility;

- the use of a smaller number of instruments for canal preparation (usually three instruments are necessary to funnel-shape the preparation on the entire working length);

- less time for canal preparation;

- the cutting efficiency increases due to the triangular section shape, without a screw effect into the dentine (each instruments creates its own crown-down effect, the larger conicity creating space for the smaller one);

- complete tactile control;

- keeping the canal curvature, with a small risk of apical transportation;

- reaching a uniform conicity on the entire length of the canal;

- ability to use in high curvature canals, even if only a pre-permeabilization with steel hand needles;

- reduced needle stress;

- progressive conicity engages reduced dentine areas, thus reducing needle stress and fracture potential (clinically, this leads to a significant decrease in flexibility, cutting efficiency and number of recapitulations needed to reach the working length).

Conclusions:

The manually used ProTaper system represents an excellent teaching tool for students, a superior alternative to the preparation with manual steel instruments, an innovation in the case of difficult anatomy canals and an cheaper alternative than the rotating system.

Smart Endomotor Technique

Since the introduction of nickel-titanium in endodontics, several canal preparation techniques involving the use of rotary instruments have become popular. Such engine-driven rotary instruments rotate between 150 and 2000 r.p.m. and may be high or low torque orientated. This paper describes one such engine-driven system called the ProFile technique. The instruments are of a different specification to that used for conventional endodontic files and reamers. The intention is to give any interested clinician a better idea of the technique using radiographs taken from both the buccolingual (clinical) perspective and the mesiodistal projection. Basically, the technique involves preparing the coronal portion of the root canal using Gates-Glidden burs and the ProFile instruments. Only when any constricting coronal parts of the canals have been removed is the working length established using conventional files. Finally, the apical part of the canal is prepared using only the ProFile instruments. Three clinical cases are also briefly described, in order to illustrate the potential of the technique in cases treated generally by clinicians.

Tilosfile (Most Advanced Technique)

Ultradent Products demonstrated a new endodontic file system, TiLOS, at the 2009 Greater New York Dental Meeting.

Building on Ultradent Anatomic Endodontic Technology, TiLOS is a new hybrid system that incorporates stainless steel and nickel titanium hand files, as well as engine-driven stainless steel shaping files and nickel titanium apical files that are optimized for Ultradents 30° reciprocating handpiece.

Ultradent developed the Endo-Eze TiLOS File System with the idea of bringing together the metal best-suited for files in specific areas of the root canal while using a safe and effective mechanical movement.

The system utilizes a cleaning and shaping hybridization technique, using the technology and speed of the biomechanical systems while maximizing the intuitive, traditional nature of hand instrumentation.

It reduces the influence of anatomical variations, pathological conditions, and complications often experienced with other systems, such as ledging, zipping, canal transportation, unnecessary tooth structure removal, and file separation.

In addition to a range of hand files and engine-driven files, the TiLOS patient packs consist of three stainless-steel shaping files-purple, white, and yellow- with the respective tip diameters of the active portion (0.10, 0.13, 0.13 mm) and respective tapers (0.020, 0.030 and 0.040 mm/mm), two hand K-type stainless steel files, #15 and #20, and three NiTi transitional files with an active portion initial diameter of 0.25 mm and tapers of 0.08, 0.04, and 0.02.

Single Sitting RCT


What Exactly Is Single Sitting RCT?

Single sitting root canal treatment is a new advance in dentistry, which has made root canal treatment painless & less time consuming. The single visit root canals are very common with the patients and dentists these days. In many special cases, we perform the entire root canal treatment in a single sitting and that too with an antibiotic coverage for about 2-3 days depending on the type of decay and oral health of the patient.


Indications When We Suggest Single Sitting RCT

The main reason why we suggest single sitting RCT is that the patient is in much pain and the decay is moving towards the nerves of the mouth. Apart from these, some other prominent reasons include:

● An injury has occurred in the teeth and it is at exposure to the nerve.

● A severe sensitivity of the teeth is making it impossible for the patient to consume hot or cold liquid and even food items.

● Non Vital teeth with no acute symptoms.

● Near Pulpal Carious exposure requiring RCT Prophylactically

● When there is an acute infection with no pus accumulation in &around the tooth, root canal treatment can be completed in a single sitting

Post & Core

Post and core technique minimizes the chance for root fracture and has the following advantages.

● Compared to preformed posts, there is no additional tooth removal after endodontic treatment. This maintains the natural strength of the tooth.

● Eliminates the possibility of root perforation.

● Because it is made when the Ribbond is in a pliable state, it conforms to the natural contours and undercuts of the canal and provides additional mechanical retention.

● There are no stress concentrations at the tooth-post interface.

● The post and core is passive and highly retentive.

Furthermore, because Ribbond's translucent fibers take on the color characteristics of the composite it allows for the natural transmission of light through teeth and crowns. This provides an exceptionally esthetic result.

Technique

Other than the normal endodontic treatment, further shaping is not required to accommodate the size and shape of a preformed post. The following is a brief description of the procedure. The Ribbond instruction manual, included with a purchase, clearly describes this technique in full detail.

Prepare the canal for normal dentin bonding. Inject a dual cured moderately filled composite such as a luting composite into the canal. Use the special post and core instrument to carry the wetted Ribbond through the luting composite in the canal to the apical end of the canal.

Apply composite to the protruding Ribbond ends and roughly form them into the shape of the core and cure. Build up the core with composite, cure it and shape it.

Before

Condensing Ribbond into canal

Finished core build up

Finished with crown

Silver Color Filling

Dental amalgam is made from a combination of metals that include mercury, silver, tin, and copper. Sometimes described as “silver- colored” fillings, dental amalgam has been used by dentists for more than 100 years because it lasts a long time and is less expensive than other cavity-filling materials such as tooth-colored composites or gold fillings.

Because of their durability, these silver-colored fillings are often the best choice for large cavities or those that occur in the back teeth where a lot of force is needed to chew. Amalgam hardens quickly so it is useful in areas that are difficult to keep dry during placement, such as below the gum line. Because it takes less time to place than tooth-colored fillings, amalgam is also an effective material for children and special needs people who may have a difficult time staying still during treatment.

One disadvantage of amalgam is that these types of fillings are not natural looking, especially when the filling is near the front of the mouth, where it may show when you laugh or speak. Also, to prepare the tooth, the dentist may need to remove more tooth structure to place an amalgam filling than for other types of fillings

Tooth Color Filling

Composite resins, or tooth-colored fillings, provide good durability and resistance to fracture in small- to mid-size fillings that need to withstand moderate pressure from the constant stress of chewing. They can be used on either front or back teeth. They are a good choice for people who prefer that their fillings look more natural.

Composites cost more than amalgam and occasionally are not covered by some insurance plans. Also, no dental filling lasts forever. Some studies show that composite fillings can be less durable and need to be replaced more often than amalgam fillings.

It generally takes longer to place a composite filling than it does for a metal filling. That’s because composite fillings require the tooth be kept clean and dry while the cavity is being filled. Tooth-colored fillings are now used more often than amalgam or gold fillings, probably due to cosmetics. In a society focused on a white, bright smile, people tend to want fillings that blend with the natural color of their teeth.

Ultimately, the best dental filling is no dental filling. Prevention is the best medicine. You can dramatically decrease your risk of cavities and other dental diseases simply by:

● brushing your teeth twice a day with fluoride toothpaste

● flossing daily

● eating a balanced diet

● visiting the dentist regularly.

Inlay & Onlay

Dental inlays and onlays are restorations used to repair rear teeth with mild to moderate decay or cracked and fractured teeth that are not sufficiently damaged to need a crown.

Ideal candidates for inlay or onlay work typically have too much damage or decay in the tooth structure to be successfully treated using a filling, but have sufficient healthy tooth remaining to avoid the need for a crown. This allows the dentist to conserve more of the patients original tooth structure.

There are other benefits to inlays and onlays in comparison to metal fillings:

● Inlays and onlays are durable - they are made from tough, hard-wearing materials which last up to 30 years.

● They help to strengthen teeth by up to 75 percent, unlike traditional metal fillings which can actually reduce the strength of the teeth by up to 50 percent.

● Inlays and onlays prolong tooth life and prevent the need for more dental treatment in the future.

Dental inlays and onlays are used when old fillings need to be removed or replaced. A dental inlay is similar to a filling and fits inside the cusp tips (top edges) of the tooth. A dental onlay is more extensive and extends over the cusps of the treated tooth.

During treatment the dentist removes the old fillings under local anesthesia and takes an impression of the tooth, which is sent to the dental laboratory. The new inlay or onlay is made from this mold in porcelain, gold or composite resin material. The inlay or onlay is then cemented into place at the next appointment. The inlay or onlay blends successfully with the treated tooth and the rest of the teeth to achieve a natural, uniform appearance.

How are inlays and onlays done?

It takes two appointments for the inlays and onlays treatment to be completed and to be finally bonded to the damaged area of the tooth.

Inlays and onlays are performed using very similar procedures. At the first appointment, your dentist begins the procedure by numbing the area to be treated with local anesthetic. Any decay or damage is removed by drilling, which cleans and prepares the tooth for the dental inlay or onlay.

Using a small tray filled with dental putty that fits over the teeth, the dentist takes a mold (impression) of the damaged tooth. This impression is sent off to the dental laboratory, where a dental inlay or onlay is created that will fit your tooth exactly. Inlays and onlays are usually made from porcelain, which often most closely matches the normal color of the tooth, but they can also be made from composite resin or gold. While the inlay or onlay is being created at the lab, the dentist creates a temporary restoration (cover or filling) for your tooth to protect it until your next appointment.

At the second appointment, your dentist will remove the temporary restoration and then take time to ensure the inlay or onlay fits correctly. Only when the inlay or onlay fits perfectly will the dentist bond the inlay or onlay to the tooth with a strong resin adhesive. The inlay and onlay treatment is completed with a polish to ensure a smooth and aesthetically pleasing finish.

Each visit to the dentist for inlay or onlay treatment takes about an hour, with the first appointment taking slightly longer due to the preparation process. There will probably be a little discomfort after the inlay or onlay procedure, and the new tooth surface may feel a little odd, but you soon get used to the new tooth surface and how it feels and looks in your mouth. The tissue around the treated tooth may feel sore or sensitive, but this should subside in a couple of days. If you do feel some discomfort, you can take over-the-counter pain medication to alleviate the symptoms.

Capping

Metallic

The metal ceramic bridge (known as the porcelain fused to metal bridge) has been a stalwart in the dental world for many years. This dental bridge has been worn by countless numbers of people and is considered a strong and resilient type of bridge.

Other options are all ceramic bridges, such as zirconia bridges which are metal free and prized for their translucent appearance.

But it is important that you weigh up the pros and cons of both types of bridge before making your decision.

What is a metal ceramic bridge?

This bridge is comprised of a metal alloy framework and ceramic crowns which are designed as a replacement for missing or crooked teeth.

There are different types of metal ceramic bridges which include: Metal alloy based

Noble alloy based, e.g.

contains gold and copper

High noble alloy based

Metal alloy based bridges have a silvery grey appearance and are strong, durable and resistant to staining. They are less likely to fracture compared to the all ceramic bridge and have a long lifespan. Noble alloy based bridges contain a variety of metals such as gold and copper which makes them resistant to tarnishing as well as being a strong and tough type of bridge. Plus gold alloy is tolerated well by the body so no risk of an allergic reaction and does not damage your natural teeth.

High noble alloy based bridges contain higher percentages of gold or other metals which means a very strong type of bridge. This bridge is able to withstand any amount of pressure or force placed upon it and only requires a tiny amount of tooth reduction in the preparation stage.

Advantages of a metal ceramic bridge  

In brief: metallic have great strength and durability. They are known to last for many years and are generally biocompatible. There is only a small risk of an adverse reaction to the metals used in its manufacture.

Plus they are hard wearing and unlikely to crack, chip or break, even if you are heavy biter or tend to grind your teeth.

Disadvantages of a metal ceramic bridge

One disadvantage is that of being able to see a dark grey line around the edge of the gums which you may find less than attractive.

Plus some people suffer a reaction to the metals used in the production of the bridge. 

metallic also cause a heightened sensitivity to hot and cold liquids in some people.

As a result of this many people opt for the all ceramic bridge as these are metal free with no risk of rejection and have a realistic looking appearance. They closely match the colour of your natural teeth.

How is a metal ceramic bridge fitted?

This procedure involves two visits to your dentist: the first visit is the initial consultation followed by an examination of your affected teeth. The dentist will also prepare the affected teeth by cleaning and reshaping them so that they will be an exact fit for the bridge.

He/she will also take an impression of your teeth, using a mould containing putty which you bite into. The imprint of your teeth along with any x-rays will be sent away to a laboratory for manufacture of your bridge.

This usually takes two to three weeks. You will wear a temporary bridge during this period.

The second visit is where you will be fitted with your new bridge. The dentist will check that the colour of the crowns in the bridge closely resemble the colour of your own teeth before fitting it into your mouth.

He or she will check that it is a good fit and is not likely to cause you any discomfort. The crowns will be given a final polish before the bridge is fixed in place with dental cement.

PFM Crown

Porcelain fused to metal crowns (or PFM crowns) can be referred to as full-cast crowns which has porcelain fused on most or all parts of the tooth. Metal alloys with a high melting temperature are used to fuse porcelain to the surface and preventing the metal from melting. This ensures the porcelain to bond without changing its color.

When the tooth is prepared for such crowns, a large part of the tooth tissue gets removed making space for porcelain as well as the metal.

Porcelain crowns are the most preferred crowns as they easily match the color of the adjacent teeth better than the metallic crowns. However, they cause more damage to the opposite teeth than the resin and metal crowns. Some cases show that the porcelain portion of the crown can also break or chip off from the teeth.

In receding gums, such crowns are not suitable as the porcelain can start showing distinctively. They are best suited for the back and front teeth.

Advantages of porcelain fused to metal crowns

● The underlying metal fused with the porcelain provides stability and strength to the crown.

● It has great aesthetic appeal and is most commonly preferred as it gives the restored tooth a natural look.

● They have a very high rate of success in the long run.

Disadvantages

●The cosmetic appearance of these crowns is commendable but they are less appealing than other types.

●They make the gums more vulnerable to gingival inflammation as compared to porcelain fused to gold and porcelain crowns.

●Restoring tooth with these crowns requires a large part of the tooth structure to be removed.

●Porcelain from the crown can easily break or chip off.

●The teeth which bite against these crowns bet worn out in the long run.

●Increased cost becomes a major drawback when precious metals are fused.

PFM crowns are nothing but a hybrid between porcelain and metal crowns. Initially a metal shell is prepared which can fit perfectly over the concerned tooth. Then a porcelain veneer is fused on the metal shell which gives the crown a natural looking appearance.

The best part of these crowns is the stability and strength which is unmatched to any other restorations available today.

These are best for patients looking for natural look and durability.

Last few years have seen a lot of advancement in the field of porcelain fused to metal crowns. Patients with all porcelain crowns are getting theirs replaced with these ones. The latest type of Captek crowns have also done away with the black line that becomes visible around the patients gum line. These crowns have been the commonest option for dentists as well as for patients for over 35 years.

PFM is a preferred choice when bridges for the long run are required and night grinding is a problem. Since these crowns are a combination of porcelain and metal they are accepted worldwide and well known for the treatment they cater. They are trusted not only by the patients but also by the doctors all over the globe.

Full Creamic Crown

These are a type of cosmetic crown which are made purely from ceramic and no other material. This is in contrast to other types of crowns such as the porcelain fused to metal variety and gold crowns.

The defining feature of these crowns is that they are made from a translucent material which is attractive to look at and blends in well with the rest of your teeth.  

This means a top quality crown which will last for many years. The majority of full ceramic crowns are produced using computer technology, e.g. CAD/CAM technology which is based upon 3D design.

Another option is metal ceramic crowns

There are two types of ceramic crown:


Zirconia

E-Max

These are both discussed further in separate sections.

Advantages of full ceramic crowns

These crowns are ideally suited to people who have minimal space within their mouth for a crown or prefer something which has a natural appearance.

They are made from a thinner material which results in a lighter crown. Plus the material used is ‘bio-compatible’  which is kind to natural gum tissue and enables it to grow back alongside the crown.

There is no risk of an allergic reaction or sensitivity to hot or cold foods.

Disadvantages of full ceramic crowns

Whilst there are advantages of these crowns it is only fair to highlight the disadvantages as well.

There appears to be a trade off between aesthetics and strength: this type of crown is lifelike and pleasant to look at but there is a downside. It is less durable than other types of crowns which mean it is more prone to cracking or breaking.

Plus the refinement needed to produce these crowns makes them more difficult to fit. They require a high degree of expertise on the part of the dentist which increases their cost.

How are full ceramic crowns fitted?

The procedure is the same as for any fitting of a crown. The dentist will clean and reshape the tooth to be treated as a form of preparation. The tooth is tapered so that it will allow the crown to fit snugly over the top.

An impression is then taken of your teeth with dental putty. This mould is sent to a dental laboratory where it will be used to fabricate a new crown.

It takes around 2 to 3 weeks for this to happen so you will be fitted with a temporary crown in the meantime.

Once it is ready you will asked to return to the surgery where you will be fitted with your new crown. This involves the dentist roughing the surface of the affected tooth with etching acid which will enable the crown to adhere to the tooth.

This will be checked by your dentist. Once both of you are satisfied with the fitting then it will be fixed firmly in place with dental cement.

Take care of your new crown. There is research being undertaken into the longevity of full ceramic crowns so take care not to put too much pressure upon it. Be careful when eating hard/crunchy foods and avoid grinding your teeth.

Patient reported to my clinic having pain and fractured tooth After proper investigation it was ellis class lll fracture, periapical lesion and faulty root canal treatment.. 2 year back By Apicoectomy surgery and CGF proper bone formation achieved