Showing posts with label Endodontics. Show all posts
Showing posts with label Endodontics. Show all posts

Saturday, October 3, 2015

The Ideal Teeth Access Cavity Preparations for RCT (Root Canal Treatment)



The correct access preparation for RCT is as follows:

Upper Teeth:
central Incisors : triangular
lateral Incisors: ovoid
canines: ovoid
first premolars: ovoid
second premolars: ovoid
first molars: triangle
second molars: triangle


Lower Teeth:
central Incisors: ovoid
lateral Incisors: ovoid
canines: ovoid
first premolars: ovoid
second premolars: ovoid
first molars: triangle or trapezoid
second molars: triangle or trapezoid


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Monday, October 21, 2013

Root Canal Preparation


- Objectives of Root canal preparation:
1- Remove remaining pulp tissue
2- Eliminate microorganism
3- Remove debris
4- Shape the root canal
5- So that root canal system can be cleaned and filled

- Requirements of Root canal preparation:
1- Prepared canal should include the original canal
2- Apical constriction should be maintained
3- Canal should end in an apical narrowing
4- Canal should be tapered from crown to apex
5- Preparation should be undertaken with copious irrigation
6- The final length of the preparation should not be reduce by treatment

- Root canal preparation techniques:
According to Direction:
1- Apical to coronal
2- Coronal to apical

According to Type:
1.Standardized technique
2. Step back technique
3. Balanced forces technique
4- Step down technique
5- Double flared technique
6- Crown down pressure less technique

- Standardized technique
Can be use for straight tiny canal
Unsuitable for curve canals

Common problems:
1- Ledging
2- Zipping
3- Elbow formation
4- Perforation
5- Loss of working length

- Overcomes procedural errors of Standardized technique:
- Suitable for Slight to moderate curve canals
- Not suitable for severely curve canals
- Can be improve by: "Specific filing technique - Non-cutting tip - Flexible files"

- Steps of successful Root Canal Preparation:
1- Obtain a good pulp chamber cleaning.
2- Make sufficient deroofing for the pulp chamber area "ensure that files enter orifices in a straight manner"
3- Use GG to widen the orifices.
4- Insert the initial file which is "size 15 for centrals and premolars" and "size 10 for molars" Note: "size 8 may be useful for severely narrow canals ex: MB of the lower first molars"
5- Start to measure the full working length using the initial file and X-ray or by using the Apex Locator. Note: file size 10, 8 and 6 may not appear in the X-ray so that they may lead to misleading or interpretation for the working length, Note: It's better to have a good X-ray image with the length measured by Apex Locator to avoid false Apex Locator's readings ..
6- Start to widen canals to 3 files larger than the initial file to the full working length measured before, to create the good apical stop ... "The third file will be called the patency file".
7- Start to use the larger next file with a length 1 mm shorter than the previous one ..
8- Use 5 more larger files, every one 0.5 mm shorter the previous one.
9- Use the patency file between  files to avoid blockage of canals ...

10- Start to put the master cone and complete obturation ....

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Sunday, December 30, 2012

Removal Of Separated Endodontic Files Inside Canal


- First of all: the file type controls the treatment plan.
- Then, We should know the area that the files has been separated in,



If Coronal Third then the file should be by-passed or removed by the manual H files that engage it from a side,
If middle third then the file should be removed or even by-passed and flared as manual filing,
If Apical third then the file should be removed ONLY, or even may be left in place ONLY if it is sealed with the apical foramen, otherwise should be removed.
It Beyond the apex or pushed after separation to pass beyond the apex then it must be removed through the canal or through the surgical apicectomy.

- Note: Manual K file should be removed by H files, Manual H files is easier to separate inside canals and is very difficult to be removed from the canals,
while the rotary file is not liable to fracture unless with inexperienced endodontists and removal of it is nearly impossible (especially it is one of the first files in the sequence ex: S1 and S2 of Protaper rotary files),
all the files mentioned above can be removed by ultrasonic scaller that hits the dentin debris next to the broken file causing vibration and elevation of the file toward the crown (but if it is very fitting inside the canal and broke due to excessive force applied into the canal then it will not be elevated by ultra-sonic scaler),
Finally, we can remove the separated file by using the Gates Glidden (GG), by applying GG size 2 or 3 next to the file, taking care not to perforate the root, causing a small hole to apply a small H file inside to remove or by-pass the separated file.

- In All Cases:
Recall the patient for check up every 1 week, 1 month, 3 months and 6 months,
Using the Sodium Hypocloride is very effective in by-passing and removal of the separated files,
Using the Glyde is very effective in by-passing the separated files,
Try to pre-curve the the tip end of the file before inserting inside the canal with gentle pressure and clock and  anti-clock wise directions to by-pass the file so that you can remove it or complete filing,
Try to start trying to deal with the separated file with manual files size 10 then 8 then 6, taking in consideration that liability of those files to separate increases as the size decreases.

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Sunday, December 9, 2012

Dental Abscess


Definition:
Abscess is a (semi) liquid collection of pus lined by granulation tissue (if acute) or granulation tissue and fibrosis (if chronic).

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Pathological features:
- Contain PMNs/macrophages, lymphocytes (live and dead), bacteria (dead and viable), and liquefied tissue substances.
- May lead to rupture (‘pointing’), discharge into another organ (fistula formation), or opening onto an epithelial surface (sinus) .
- Incomplete treatment due to resistant organisms (myocbacteria) or poor treatment may lead to a chronic abscess.
- Complete elimination of the organisms in a chronic abscess without drainage can lead to a ‘sterile’ abscess (‘anti-bioma’).

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Typical causes:
- Suppuration of tissue infection (e.g. renal abscess from pyelonephritis).
- Contained infected collections (e.g. subphrenic abscesses).
- Haematogenous spread during bacteraemias (e.g. cerebral abscesses).

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Diagnosis:
Deep abscesses are characterized by swinging fever, rigors, high WCC, and i CRP. Untreated they lead to catabolism, weight loss, and a falling serum albumin. Ultrasound, CT, MRI, or isotope studies may be necessary to confirm the diagnosis.

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Treatment:
- Drain the pus e.g. incision & drainage (perianal abscess), radiologically guided drain (renal abscess), closed surgical drainage (chest empyema), or surgical drainage and debridement (intra-abdominal abscess).
- IV antibiotics (course may be prolonged).

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Wednesday, November 28, 2012

Diagnostic Tests Of Dental Pain


There are several simple tests that may assist in diagnosis of dental pain.

- Pulp Sensitivity Test:
This test can be done by using cold or hot stimuli.
Cold Stimulus is done by using Dry ice, or an ordinary ice stick that is placed in the cervical region of the tooth to detect posibility of pulpal inflammation.
Hot Stimulus is done by heating an instrument and placing it to one of the tooth surfaces.
In both of them, if pain occured and faded away once removing the stimulus indicating healthy tooth, if pain occured and persisted for a few minutes indicating inflammed pulp that must be treated endodontically and if the pain didnt occure indicating a necrotic pulp.

- Percussion Test:
Using an instrument handle, the tooth is tapped in the longitudinal axis. A painful response suggests possible periapical inflammation. (ex: Apical Periodontitis)

- Probing:
Placing a fine, blunt probe (Periodontal Probe) gently into the gingival sulcus surrounding the tooth to check the health of the gingival tissues. Bleeding and/or sulcus depths greater than 3-4 mm indicate a periodontal disease and a pocket which then should be diagnosed to have periodontal treatment.

- Mobility Test:
Holding a tooth firmly on the buccal and lingual sides between a finger and a solid instrument enables mobility to be assessed.
All teeth have a small amount of mobility (<0.5 mm) (Normal Or Mild Movement),
The teeth with movement of (0.5-2 mm) should be splinted (Moderate Movement),
While the teeth with (Severe Movement) of (2-4 mm) should be treated surgically or to be extracted.

- Palpation:
Careful digital palpation around the area of concern may reveal tenderness and the type and extent of swelling. (Usefull in cases of Tumor or Abscess or Soft Tissue Abnormalities)

- Radiographic Examination:
Sometimes we need a radiographic X-ray to detect some underlying abnormalities and possible pain sources.
We use periapical radiographes to check 3 neighboring teeth together and it's usefull to detect the extent of caries, reccurent caries, periapical lesions, crown root ratio and fructures.
We use orthopantomograph (OPG) to check the upper and lower full teeth set and neighboring important structures for abnormalities and possible causes of pain and it's very usefull in cases of impacted teeth, relation between upper teeth and maxillary sinus and presence of oral lesions in bone.

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Saturday, November 10, 2012

How To Use ProTaper Endodontic Files


ProTaper geometries:


The Endodontic ProTaper files have a unique features, including:

- Changing percentage tapers over the length of its cutting blades.
- The progressively tapered design replicates the Schilderian Envelope of Motion technique and serves to significantly improve flexibility, cutting efficiency, and safety.
- They are convex, triangular cross-section, which enhances the cutting action while decreasing the rotational friction between the blade of the file and dentin.
- They have a changing helical angle and pitch over their cutting blades, which reduces the potential of an instrument from inadvertently screwing into the canal.
- The noncutting, modified guiding tip. This feature allows each instrument to safely follow the secured portion of a canal, while the small flat on its tip enhances its ability to find its way through soft tissue and debris.
- The ProTaper system is comprised of three Shaping and five Finishing files

Types Of Protaper Endodontic Files:


There are two types of files for the ProTaper Endodontic Files;
"The Shaping Files" and "The Finishing Files" ...

The Shaping Files:

- Shaping Files are Two: File No. 1 & File No. 2, Termed S1 & S2, Purple and White Respectively.
- The Auxiliary Shaping File, termed SX, has no identification ring on its gold-colored handle and, with a shorter overall length of 19 mm.
- The S1 and S2 files have D0 diameters of 0.17 mm and 0.20 mm, respectively, and their D14 maximal flute diameters approach 1.20 mm.
- SX File, provides excellent access when space is restrictive. The SX file has a D0 diameter of 0.19 mm and a D14 diameter approaching 1.20 mm.
- The Shaping files have increasingly larger percentage tapering, allowing each instrument to engage, cut, prepare and shape the canal, performing its own 'crown down' work.
- SX File has a much quicker rate of taper between D1 and D9 as compared to the other ProTaper "S files", it is primarily used after the S1 and S2 files to more fully shape canals in "coronally broken down" or "anatomically shorter" teeth.

The Finishing files:

- There are five "Finishing files" named F1, F2, F3, F4, and F5 have yellow, red, blue, double black, and double yellow colores corresponding to D0 diameters and apical tapers of 20/07, 25/08, 30/09, 40/06, and 50/05, respectively.
- From D4–D14 each instrument has a decreasing percentage taper which serves to improve flexibility, reduce the potential for dangerous taper-lock, and reduce the potential to needlessly overenlarge the coronal two-thirds.

ProTaper shaping technique:


- First, one should know that: The potential to consistently shape canals and clean root canal systems is significantly enhanced when the coronal two-thirds of the canal is first pre-enlarged, followed by preparing its apical one-third.

Scout the coronal two-thirds:

- "Hand files" sizes 10 and 15 are measured and precurved to match the anticipated full length and curvature of the root canal.
- The 10 and 15 hand files may be utilized within any portion of the canal until they are loose and a smooth reproducible glide path is confirmed.
- The loose depth of the 15 file is measured and this length transferred to the ProTaper S1 and S2 files.

Shape the coronal two-thirds:

- The secured portion of the canal can be optimally pre-enlarged by first utilizing S1, then S2. Prior to initiating shaping procedures,
- The pulp chamber is filled with a full strength solution of NaOCl.
- Without pressure, the ProTaper Shaping files are inserted into the canal and follow the glide path freely and easily.
- For more optimize safety and efficiency, the Shaping files are used, like a brush, creating lateral space, which will make the Shaping file’s larger, stronger, and of more active cutting blades.
- N.B: this brush-cutting action can be used to:
Eliminate cervically positioned triangles of dentin,
More effectively shape into fins, isthmuses, and canal irregularities, and
To relocate the coronal aspect of a canal away from furcal danger.
- N.B: If any ProTaper File ceases inside the secure Portion of the canal, then withdraw it and know that the debris blocked the intrablade spaces making the walls push the file away and decrease the cutting effeciency.
- N.B: Upon removing each Shaping file, visualize where the debris is located along its cutting blades to better appreciate the region within the canal that is being prepared.
- Following the use of each Shaping file, irrigate, recapitulate with a 10 file to break up debris, and move it into solution, then re-irrigate.

Scout the apical one-third:

- The apical one-third of the canal is fully negotiated and enlarged to at least a size 15 hand file, Working length confirmed, then the patency file is established.
- NOW, A decision must be made between whether to finish the apical one-third with rotary or hand instruments.
- If, a new size 15 hand file glide easily inside the canal without any interupption, this means that the canal if of normal shape and having no irrigularities and anatomical morphologies, then the Rotary ProTaper will be very good, easy and successfull.
- While If, a size 10 or 15 hand files must be precurved and necessitate a reciprocating handle motion, then the Manual ProTaper File is the best and most successful choice.

Shape the apical one-third:

- Vigorous irrigation with NaOCl is very important now, to remove the debris that may decrease the effect of the shaping files (discussed befor in "Shape the coronal two-thirds" section), to avoid blockage of canals and facilitate the shaping proccess.
- The ProTaper sequence is to carry the S1, then the S2, to the full working length.
- Float, follow, and brush (discussed befor in "Shape the coronal two-thirds" section) until the terminus of the canal (Apical Foramen) is reached.
- S1, then S2, will typically move to length in one or more passes depending on the length, diameter, and curvature of the canal.
- Following each ProTaper file, irrigate, recapitulate with a size 10 file, then re-irrigate.
- After using the Shaping files, particularly in more curved canals, working length should be reconfirmed, as a more direct path to the apical foramen has been established, leading to decrease working length.
- The preparation can be finished using one or more of the ProTaper Finishing files in a non-brushing manner.
- The F1 is selected and passively allowed to move deeper into the canal, in one or more passes, until the terminus is reached.
- Apical flutes are inspected, and if they are loaded with dentin, then visual evidence supports, the shape is cut.
- After using the F1 file, Irrigate with NaOCl, recapitulate, confirm patency, then re-irrigate to liberate debris from the canal.

ProTaper finishing criteria:


- Following the use of the Protaper File F1, the ProTaper Finishing Criteria is to gauge the size of the foramen with a Manuale file 20 to determine if this instrument is snug or loose at length, If the 20 hand file is snug at length, then the canal is fully shaped and, if irrigation protocols have been followed, ready to pack.
- if the 20 hand file is loose at length, then gauge the size of the foramen with a 25 tapered hand file. If the 25 file is snug at length, then the canal is fully shaped and ready to pack.
- If the 25 file is short of length, proceed to the Protaper File F2 and, when necessary, the Protaper File F3, the Protaper File F4, and the Protaper File F5, gauging after each ProTaper Finisher with the same D0 correspondingly sized hand file.
- If the 50 hand file is loose at length, then use alternative NiTi rotary or manual files to finish the apical extent of these larger, easier, and more straightforward canals.

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Friday, October 19, 2012

Pulp Capping (Direct and Indirect)


- Pulp Capping Procedure:

- Pulp capping:It is a term is derived from the name pulp cap which means trying to sterilize the damaged tooth area as well as one can, followed by stopping the bleeding and placing the right filling material on it.

- The precaution being that teeth that are already abscessed should never be pulp-capped – this is done to those teeth where the nerve is irritated but still alive and healthy enough to repair themselves given a chance to do so.

- Pulp capping gives it a chance by getting out the decayed portions and the bacteria then putting a clean dressing on it with the filling.

- After eliminating the wounded dental tissues of a carious tooth, the next step is usually filing the cavity with a suitable restoring material. When pulpal tissue is exposed it gets contaminated by bacteria and mostly these are the conditions that warrant the clinician to perform pulp capping. When performing this procedure, the degree of the pain and the pulpal size exposure are considered.

- Capping Materials:

- Calcium Hydroxide is the best possible capping material known till now.

- Advantages of Calcium Hydroxide:
1-It's alkaline PH (11) ... Giving more chances to healing of inflamed tissues.
2-Amazing bio-compatibility with pulpal tissues.
3-It's antibacterial Abilities (Bacterio-static).
4-It's ease of application.
5-Availability.
6-It's proven Abilities to dentine bridging for regeneration of healing dentinal tubules in the pathosed dentine pulp complex.

- Disadvantages of Calcium Hydroxide:
1- Associated with primary tooth resorption
2- May dissolve after one year with cavo-surface dissolution.
3- May degrade during acid etching
4- Degrades upon tooth flexure
5- Marginal failure with amalgam condensation
6- Does not adhere to dentin or resin restoration.

- NOTE:
Calcium hydroxide was originally introduced to the field of endodontics by Hermannin:: 1920 as a pulp-capping agent.

- Many studies have showed that direct pulp capping with MTA Is as successful ...

- Placing the restoration directly without capping on a pinpoint exposed pulp:
1- Severe sensitivity the patient will suffer.
2- Failure of restoration.
3- Irreversible pulpal tissue damage that will require endodontic treatment.

- The Pulp Capping is two Types: Direct and Indirect Pulp Capping:

- Direct Pulp Capping:

- The exposed pulp is directly covered. This works best when the exposure is not infected - for example a traumatic exposure caused by slipping with the drill.

- If the pulp becomes exposed while removing soft infected dentine, the chances are that the pulp will be infected also, and a direct pulp cap will fail (that is, an irreversible pulpitis will develop).
- Although Calcium Hydoxide has been proven successful for many years, MTA (Mineral Trioxide Aggregate) is fast becoming the material of choice for direct pulp caps. MTA is however very expensive.

- Indirect Pulp Capping:

- The pulp is not exposed - a layer of infected dentine is deliberately left, rather than expose the pulp.

- Indirect pulp caps, when done correctly, are more successful at maintaining long-term vitality than direct ones.

- It is not currently (2010) known whether it is necessary to "go in again" after a couple of months for further caries removal.

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