MATERIALS and instruments in endodonticspptx

materials and instruments used in endodontic procedures

1. DR.LAKSHMI J 1 ST YEAR MDS DEPT OF PUBLIC HEALTH DENTISTRY INSTRUMENTATION AND MEDICAMENTS 1

2. CONTENTS 2 Introduction History Standardization of instruments Classification Group I hand operated instruments Group II low speed instruments Group III engine driven instruments Group IV ultrasonic and sonic instruments Instrument deformation and breakage Instrument for filling root canals Irrigants Intracanal medicaments Temporary filling materials Pulp devitilizing agent Conclusion References

3. INTRODUCTION “ Worksman is known by his tool” As the enodontic therapy becomes a more routine part of general dental practice the clinician is bombarded with number of newer products designed to make treatment more precise and easier to perform Newer instruments overcome the deficiency seen in earlier instruments Thus a thorough knowledge in evolution of instruments is mandatory for operator 3

4. HISTORY 2200 years old Nabatean warrior skull-oldest root canal filling 1750-Fouchard recommended removal of pulp 1850- wooden pegs for debriding pulp Early 1900- introduction of files ,reamers,pathfinder,lentulospiral 1915- Kerr manufacturing company obtained patent for all instruments later known as k-type instruments 1957-Richman introduced first ultrasonic system 4

5. 1958 Ingle and Levine 1 st proposed standardization 1864- Introduction of giromatic handpiece 1988- First use of NiTi in endodontic instruments 1989- ANSI approved of ‘ADA specification number 28 for endodontic files and reamers’ 5

6. STANDARDIZATION OF INSTRUMENTS GIVEN BY INGLE AND LEVINE SIZE-Instruments are numbered from 10-100.each number should represent diameter of instrument in 100 th of millimeter at the tip There is increase in 5 units upto size 60 and in 10 units till they are size 100. LENGTH- Instruments are available in following length- 21,25,28,30&40 6

7. TIP ANGLE-75±15º TAPER-D1 to D2,D2 should be 0.32mm greater than D1 COLOR CODING-Instrument handles should be color coded for their easier recognition 7

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9. CLASSIFICATION Grossman’s Classification According To Function EXPLORING DEBRIDING OR EXTIRPATING CLEANING AND SHAPING OBTURATING To locate canal orifices and determine patency of root canal Eg - smooth broaches, enodontic explorer To extirpate the pulp and other foreign material from the root canal Eg - barbed broaches Used to shape the canal Eg - reamers and files To pack gutta percha points into the root canal space 9

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11. Classification Based On Method Of Use GROUP 1 Hand operated enodontic instruments Eg -broaches and rasp , k type reamers and files , hedstroem files GROUP 2 Low speed instruments with latch type attachment Eg -Gate glidden drills , peeso reamers GROUP 3 Engine driven instruments Eg -Rotary NiTi instruments , reciprocating instruments and self adjusting files GROUP 4 Ultrasonic and sonic instruments 11

12. BROACHES Broaches are of 2 types- Barbed broaches S hort handled instrument meant for single use . Will not cut the dentin M ade from round steel wire. T he smooth surface of wire is notched to form barbs 12

13. Uses- extirpation of pulp tissue removal of cotton or papper point in the canal removal of necrotic debris and foreign material from canal Smooth broaches Its free of barbs Previously it was used as pathfinder but currently flexible files are used for this 14

14. Rasp/Rat Tail Files Rasp has similar design to barbed broach except in taper and barb size Barb size is larger in broach than rasp It is used to extirpate pulp tissue from canal space 15

15. Clinical significance of broaches Broaches should not be inserted into root canal unless the canal has been enlarged to size no 25 Should not be forced apically into the canal If the selected broach used is too narrow ,it will not engage pulp tissue effectively If the broach is too wide ,it may bind to canal and cause fracture 16

16. BROACHS RASP ADA specification No-06 Barb extends to half of its core diameter,making it a weaker instrument Lesser taper (0.007-0.010) Barbs are very fine and longer about 40 in no) ADA specification No-63 Barbs extend to one third of the core , so it is not as weak as barbed broach More taper (0.015-0.020) Barbs are blunt, shorter and shallower(50-60 in no) 17

17. Reamer Ream the canals Penetration ,rotation (clockwise)and retraction It have triangular blank lesser number of flutes Cutting efficiency is the same as that of file 18

18. K files Its triangular , square or rhomboidal in cross section. stainless steel. 1.5-2.5 cutting blades per mm Triangular cross sectioned - superior cutting and increased flexibility than square blank. 19

19. filing and rasping action(no rotation in the canal) It is placed in root canal and pressure is exerted against the canal wall and instrument is withdrawn while maintaining the pressure 20

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21. K- flex file Rhombus in cross section 2 acute angle-increase sharping and cutting efficiency 2 obtuse angle- more space for debris removal Decrease in contact of instrument with canal walls –more space for irrigation Filing and rasping motion 22

22. Flexo file Its similar to k flex except its having triangular cross section More flexibility and resist fracture Tip of file-non cutting type More flexibility 23

23. Triple flex file Stainless steel Triangular cross section More flutes than reamer but less than k file Better flexibility and cutting efficiency 24

24. Flex R file/Roane file Non cutting tip-traverse along the canal rather than gouge into it Reduc the ledge formation Triangular cross section NiTi instrument Anticlockwise rotary motion 25

25. Hedstroem files H files Flutes –successively triangle set one on another Cuts only when instruments is withdrawn because its edge face the handle of the instrument Should not use in torquing motion –its edge can engage into the dentin of root canal and cause fracture 26

26. ADVANTAGE DISADVANTAGE Better cutting efficiency Push debris coronally Lack flexibility Tend to fracture Aggressive cutter Positive rake angle-cutting edge is turned in same direction in which force is applied Used in straight canal-strong and aggressive cutter 27

27. Modification of H files SAFETY HEDSTROEM FILE Have non cutting safty side along the length of the blade Reduces the chance of perforations Non cutting side-directed where cutting is not requred Prevent lodging of the file 28

28. S FILE S-file – because of its cross section Stiffer than H file Double helix design-2 spiral for cutting edge Hybrid design-good cutting efficiency in either filling or reaming action 29

29. A FILE Varient of H file Cutting edge- acute angle to long axis of the file Curved canal- flutes on inner aspects colapse,so no dentine removed outer edge flutes opens,filing the dentine inouter surface 30

30. UNIFILE Resembles H-files Less efficient Less pron to fracture Flutes- double helix pattern 31

31. C+ files and golden medium file C+ FILE GOLDEN MEDIUM FILE Greater stiffness Greater strength Twisted file design Available in size- 8,10,&15 length-18,21&25 Described by Weine Intermediate file-half size between conventional instruments Used in narrow canals-provide more gradual increase in size Available in size-12,17,22,27,32&37 32

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33. Group II low speed instruments with latch-type design GATES GLIDDEN DRILL Flame shaped cutting edge Side cutting instruments with safety tip and safety design Cuts laterally-gentle apically directed pressure Available in size 1 – 6 Brushing strokes-speed of 750-1500rpm both Crown down and step back fashion 34

34. Uses- For enlargement of root canal orifices Coronal flaring Remove lingual shoulder-anterior tooth Removal of guttapercha -retreatment and postspace preparation For preparing space while removal of separated instrument Clinical significance- High rpm,incorrect angle of insertion,forcefull drill-perforation and instrument separtion 35

35. FLEXOGATE Modified gate glidden drills made up of NiTi & have non cutting tip More flexible-used in apical preparation Can be rotated contiuously in a handpeice through 360 º-better debris removal Smooth and faster canal preparation Safty design 36

36. PEESO REAMERS Stainless steel Blade spread over wide surface and shape is cylindrical Used in postspace preparation when GP has to be removed Safe ended non cutting tip Tip diameter-0.7-1.7mm Used in brushing motion Disadvantage- Do not follow canal Curvature & may cause perforation (cutting laterally) Stiff & chance of iatrogenic error 37

37. GROUP III engine – driven instruments NITI ROTARY INSTRUMENT The greater innovation in endodontic instrumentation in recent times in probably the introduction of NiTi rotary instrument Super-elasticity and shape memory of NiTi alloy is because of phase transformation in their crystal structure Austenite Martensite Austenite On release of stress, the structure reverts back to austenite –shape memory Non cutting edge Size-15-60,all with taper of 0.02 38

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39. MANUAL PROTAPER Protaper NiTi file have patented, progressively tapered and advance flute design providing the flexibility and efficiency to achieve consistently successful cleaning and shaping result 40 SHAPING FILES

40. 41 Why manual protaper ??? For managing canals exhibits difficult anatomy like sharp apical curve For avoiding Iatrogenic mishap such as a ledge In Pathological defect resulting from internal resorption . FINISHING FILES

41. 42 How to use??   stainless steel Nos. 10 and 15 hand files, using a reciprocating back and forth motion.  Start the ProTaper sequence with S1 (purple). Irrigate, recapitulate withthe 10K File to break up debris, then re-irrigate

42. 43 sequentially carry first S1 then S2 to the full working length(Remember to irrigate, recapitulate and re-irrigate after each ProTaper instrument) F1 to length Then F2 and, when necessary, the F3

43. 44 Use a clockwise motion and gently rotate the handle until it is just snug. When thehandle is snug, the flutes of the file are lightly engaging dentin.b .   Cut dentin by rotating the handle clockwise while simultaneously withdrawing the file.c .   If over-engaged, disengage the file by rotating the handle counterclockwise 45-90degrees while concomitantly withdrawing the instrument to prevent any given file frominadvertently advancing deeper into the canal.d .   Repeat the handle motions until desired length is achieved.

44. PROTAPER GOLD 45 Developed with improve metallurgy Features - Convex triangular cross section and progressive taper Increased flexibility Greater resistance to cyclic fatigue,so lesser chance of separation. Noncutting tip design – safly follow the canal Small flat area on the tip-enhance its way through soft tissue and debris.

45. Clinical significance 46

46. Group IV sonic and ultrasonic in enodontics ULTRASONIC HANDPIECE It consist of piezoelectric or a magnetostrictive unit. Peizoelectric –more powerfull and generate lesser heat Hand piece holds a K file or a specially designed diamond file ,when activated produce movement of the shaft of the file between 0.001and 0.004inch at a frequency 25 -30kHz 47

47. 48 Oscillating movement provides cutting action of the file Ultrasonic wave of irrigation solution Increase the chemical effectiveness of the irrigation solution heat

48. 49 Physical process Cavitation Acoustic streaming Formation of small but intense eddy current or fulid movements around the oscillating instrument This increase cleaning ability through hydrodynamic stress Growth and colllapse of bubbles which increase the mechanical cleaning activity of the irrigant

49. 50 Before ultrasonic instrumentation the apical third of RC should be instrumented to at least No 30-40 No file They have very limited application on shaping of root canal, they do improve the cleaning ability of the irrigant Use sodium hypochlorite –may cause irritation of eyes and RS

50. SONIC HANDPIECE 51 Operates at 2-3kHz when used inside the root canal Similar to dental hand piece Used in similar way of ultrasonic Uses water as an irrigant and requires special instruments like- Rispi Sonic Shaper sonic Trio sonic ( helio sonic)

51. Clinical Significance 52 Both the sonic and ultrasonic instruments have been reported to cause transporation of the root canal if used carelessly

52. Instrument deformation and breakage occurs when torque limit is exceeded. As the instrument moves apically-torque increases(increase contact with the walls) Theoretically, instrument with high torque-very active but chances of deformation and separation is more 53 Torsional fracture

53. 54 Role of handpiece It’s a devise used to hold the instrument, transmitting power to them and position the intraorallly. Torque control allows the setting of the torque produced by the motor. Low torque control motor and high torque control motor Torque control is an important factor to reduce NiTi fracture

54. 55 Flexural fracture Instrument rotates in a curve-compressed at inner side of curve and stretch on outer surface With every 180degree of rotation instrument flexes and stretches again and again resulting in cyclic fatigue and fracture Larger size of file-more tensile and compressive force-early fatigue of instrument

55. Instruments used for filling root canal HAND SPREADER Stainless steel Used for placement of GP points around master cone during lateral compaction technique Not used routinely-excessive pressure may cause fracture of root 56

56. FINGER SPREADER Shorter in length Greater degree of tactile sense and rotation Color coded to match with GP points Stainless steel or NiTi Greater stress while compaction Difficult to penetrate into curved canal and cause wedging or root fracture 57

57. HAND PLUGGER Diameter larger than spreader and have blunt end Used to compact warm GP vertically and laterally Used to carry small GP into canal during sectional filling technique Calcium hydroxide or MTA like material may also be packed with this 58

58. FINGER PLUGGER Used in vertical plugging of GP Have more tactile sensitivity Should be cleaned before placing 59

59. LENTULOSPIRAL Used for applying sealer to the root canal walls before obturation Available in length of17,21&25mm Left handed screw threading-sealer flow down to the tip when rotated in low speed 60

60. Tips to avoid instrument separation 61 Always create a glide path and patency with small hand files Straight line access and good finger rest Crown down shaping technique Stiffer ,larger and stronger files to create coronal shape before using narrower more fragile files in apical region Light touch( never push hard on instrument) Avoid rapid jerking movements and do not hurry instrumentation Replace file sooner after narrow and curved canals Keep the instrument moving in a chamber flooded with sodium hypochlorite.

61. WHY ROOT CANAL FILLING ??? To prevent bacteria and bacterial elements from spreading from (or through) the canal system The fully instrumented root canal has to be provided with a tight lasting obturation . A root canal filling material should,therefore prevent infection/ reinfection of treated root canals.together with an acceptable level of biocompactibility this will provide the basic for promoting healing of the periodontal tissue and for maintaining healthy periapical conditions. 62

62. IRRIGANTS 63 IDEAL REQUIREMENTS Antimicrobial activity Mechanically flushes out the debris from the root canals Non toxic and biocompactable Dissolves necrotic and vital tissues Serves as a lubricant Low surface tension Remove the smear layer

63. Normal saline 64 Commonly used at 0.9%W/V Basically act as flushing action Can be used as final rise to remove chemical irritant after preparation Biocompatible and have same osmotic pressure as blood No adverse effect

64. 65 Drawbacks No disinfection and dissolving properties Cannot clear microbial flora Do not remove smear layer No antimicrobial activity

65. 66 Most widely used irrigating solution Reducing agent Clear,straw -colored solution containing 5% of available chlorine SODIUM HYPOCHLORITE

66. MECHANISM OF ACTION 67 NaOCl Hypochlorous acid Hypochlorite ion Antimicrobial activity Penetration into the bacteral cell wall Chemical combination with the protoplasm of the bacterial cell wall and disruption of DNA synthesis

67. 68 PROPERTIES Concentration – 0.5-5.2% of NaOCl can be used as irrigant most effective concentration recommended is 5.2%,however 2.5% is commonly used Tissue dissolution activity- it completely dissolve entire pulp tisse in 20minutes to 2 hours( th next most effective solution need 24 hours ) Its less effective in narrow root canals

68. 69 Drawbacks Cytotoxicity and causative effect on healthy periradicular tissue It doesn’t remove the inorganic component of the endodontic smear layer It has unpleasant taste Should be kept in cool place away from sunlight

69. 70 Clinical significance During instrumentation 1.3% of NaOCl can be used as working solution Is resilon /epiphany is used NaOCl is not recommended as final irrigant because of the formation of an oxygen inhibition layer which could affect the polymerization on resilon (distilled water , saline or chlorhexidine digluconate can be used)

70. 17% EDTA 71 Ethylene Diamine Tetra Acetic acid Chelating agent. It forms highly stable ,soluble metal chelates in combination with heavy metals or alkaline earth metals.

71. Mechanism of action 72 EDTA+ calcium ions of dentine Dentine becomes more friable and easier to instrument Calcium chelate solution This solution remove inorganic component of the endodontic smear layer

72. 73 Drawbacks Prolonged exposure may weaken dentine of root canal Over chelation can lead to perforation Extrusion affect the immunological regulatory mechanism

73. Chlorehexidine digluconate 74 Cationic bisbiguanide Can be used as intracanal medicament also It is less toxic compared to other commonly employed irrigants

74. Mechanism of action 75 Has broad spectrum antimicrobial activity against most of endodontic pathogens Has both bacteriostatic and bactericidal activity 2% chlorhexidine digluconate- electrostatically binds to negatively charged bacterial surface Antimicrobial activity of CHX against yeast and gram positive bacteria is because of the ability to permeate the microbial cell wall and cause coagulation of the cytoplasmic components

75. 76 Drawbacks Lacks tissue dissolving properties Does not remove the smear layer

76. Clinical significance 77 Not recommended in regenerative endodontic treatment It improves resin –dentine bond strength because of MMP inhibitory effect NaOCl and CHX cannot ne combined together –will cause a precipitation reaction

77. Factors affecting efficacy of irrigants 78 Volume Concentration Frequency of irrigation Temperature Length and time of intercanal contact Gauge of irrigating needle Depth of penetration Age of irrigating solution

78. INTRA CANAL MEDICAMENTS 79 WHY ???? To eliminate any remaining microbes in the pulp space To render root canal contents inert To neutralize tissue debris To dry persistently wet or the so called weeping canal To act as a barrier against leakage from an inter appointment dressing in symptomatic cases

79. Ideal requirements of ICM 80 Antimicrobial activity Non irritating Stable in solution Should be active in presence of blood serum and protein derivatives of tissue Low surface tension Should not cause stains Should not induce cell mediated immune response

80. 81 The 2 antimicrobial ICM recommended in contemporary endodontic practice- Calcium hydroxide Chlorhexidine digluconate

81. Calcium hydroxide 82 Introduced in dentistry 1920 Highly alkaline – PH12.5 The vehicle which is used and the manner in which it is dispensed have a significant role in its antimicrobial activity According to Fava and Saunders vehicles are of 2 types Aqueous-sterile water normal saline Viscouse - glycerine,polyethylene glycol,propylene glycol

82. MECHANISM OF ACTION Has antibacterial properties and ability to induce repair and hard tissue formation High alkaline PH Hydroxyl ions(oxidizing free radicle ) Damaging the cytoplasmic membrane Protein denaturation Damaging the DNA 83

83. Chlorhexidine digluconate 84 2% CHX gel Mixture of CHX and Ca(OH) Effective against both E.faecalis and Candida albicans Can be used as both ICM and irrigant

84. TEMPORARY FILLING MATERIAL 85 Ideal requirements Be impervious to fluids of the mouth and bacteria Hermetically seal the access cavity Not cause pressure on the dressing during insertion Harden within a few minutes after placement Withstand the force of mastication Be easy to manipulate and remove Harmonize with the color of tooth surface

85. Recommended materi al 86 Cavit ( ESPE,Seefeld Germany) IRM( Dentsply International ,Caulk Division ,USA) TERM( Dentsply International Caulk ,USA) Ideal thickness of temorary filling material should be 3-5mm

86. PULP DEVITALIZING AGENTS 87 The primary purpose of using devitalizing agents was to control pain during pulp extirpation  Some of the commonly used devitalizing agents are- Formaldehyde Cresol Para formaldehyde Gluteraldehyde

87. Conclusion 88 The evolution of endodontic instrumentation and medicaments is an ongoing process in which the benefit are continuously being refined which will dramatically improve the ability to shape root canals and give the best with least procedural complications.