Devitalized extirpation, amputation and combined method

Devitalized extirpation,Devitalized extirpation,
amputation and combinedamputation and combined
method of pulpitismethod of pulpitis
treatment. Mummification:treatment. Mummification:
stages, complications.stages, complications.
Comparative characteristicsComparative characteristics
of different methods ofof different methods of
pulpitis treatment.pulpitis treatment.

Cleaning and Shaping ofCleaning and Shaping of
the Root Canal Systemthe Root Canal System

Objectives of Canal PreparationObjectives of Canal Preparation
Start with the end in mindStart with the end in mind

Objectives of root canal preparationObjectives of root canal preparation
The root canal system must be:The root canal system must be:
 CleanedCleaned of its organic remnantsof its organic remnants
 ShapedShaped to receive a threeto receive a three
dimensional filling of the entiredimensional filling of the entire
root canal spaceroot canal space

Objectives of root canal preparationObjectives of root canal preparation
The canal isThe canal is
 First cleansed by irrigationFirst cleansed by irrigation
 Then shaped by instrumentationThen shaped by instrumentation

Cleansing of the root canalCleansing of the root canal
ObjectivesObjectives
 Removal of organic debrisRemoval of organic debris
 Elimination of bacteriaElimination of bacteria

IrrigationIrrigation
An ideal irrigant:An ideal irrigant:
 Is nontoxicIs nontoxic
 Dissolves vital and necrotic tissueDissolves vital and necrotic tissue
 Is bactericidalIs bactericidal
 Lubricates the canalLubricates the canal
 Removes the smear layerRemoves the smear layer

Sodium hypochloriteSodium hypochlorite
 Dissolves vital and necroticDissolves vital and necrotic
tissuetissue
 Is bactericidalIs bactericidal
 Lubricates the canalLubricates the canal

ProlubeProlube
EDTA and carbamide peroxide in
a water soluble base

ProlubeProlube
 Facilitates placement of fileFacilitates placement of file
 Entraps debrisEntraps debris
 Helps in removal of the smearHelps in removal of the smear
layerlayer

EDTAEDTA
 Chelating agentChelating agent
 Effectively removes smear layerEffectively removes smear layer

Shaping of the root canalShaping of the root canal
 Canal shape – produced byCanal shape – produced by
instrumentationinstrumentation
 Objective is a smooth taperedObjective is a smooth tapered
preparationpreparation

Shaping of the root canalShaping of the root canal

InstrumentsInstruments
Instruments differ according to:Instruments differ according to:
 MetalMetal
 TaperTaper
 Tip designTip design
 Cross sectional geometryCross sectional geometry
 Length of cutting bladesLength of cutting blades
 SizingSizing

MetalsMetals
Nickel titaniumNickel titanium Stainless steelStainless steel
Excellent flexibilityExcellent flexibility Less flexibleLess flexible
Conforms to canalConforms to canal Straightens andStraightens and
curvaturecurvature transports canaltransports canal
Plastic deformationPlastic deformation PermanentPermanent
deformationdeformation

MetalsMetals
Stainless steel files demonstrate permanent deformation

MetalsMetals
Nickel titanium files demonstrate plastic deformation

TaperTaper
DefinitionDefinition
Increase in diameter per unit lengthIncrease in diameter per unit length

What is Taper?What is Taper?
0.32 mm diameter increase
D16 D1
0.96 mm diameter increase
D16 D1

Tip DesignTip Design
 Non-cutting tipNon-cutting tip
 Bullet nose (60 degree) tipBullet nose (60 degree) tip
 Smooth transition angle whereSmooth transition angle where
tip meets flat radial landstip meets flat radial lands

Tip DesignTip Design
 Designed to follow a pilot holeDesigned to follow a pilot hole
 Guides instrument through canalGuides instrument through canal
during preparationduring preparation

Cross-sectional geometryCross-sectional geometry
 Three radial landsThree radial lands
 Each contains bidirectional cuttingEach contains bidirectional cutting
edgesedges
 Keep instrument centered in theKeep instrument centered in the
canalcanal
 Cutting edges scrape dentinCutting edges scrape dentin

Cross sectional geometryCross sectional geometry

•• NotNot
SelfSelf--ThreadingThreading
•• Gentle PlaningGentle Planing
ActionAction

 Radial lands separated by three u-Radial lands separated by three u-
shaped flutesshaped flutes
 Provide space for accumulation ofProvide space for accumulation of
debrisdebris
 Moves debris out of canalMoves debris out of canal

Length of cutting bladeLength of cutting blade
 Traditionally 16 mmTraditionally 16 mm
 Orifice shapers – 10 mmOrifice shapers – 10 mm

Sizing of instrumentsSizing of instruments
ISO sizesISO sizes
 Number refers to tip diameter inNumber refers to tip diameter in
tenths of mmtenths of mm
 The tip diameter increases byThe tip diameter increases by
0.05 mm from sizes 10 to 60,0.05 mm from sizes 10 to 60,
then by 0.10 mmthen by 0.10 mm

 % increase in diameter from #10% increase in diameter from #10
to #15 file is 50%to #15 file is 50%
 Difference between #55 and #60Difference between #55 and #60
is only 9%is only 9%

Series 29Series 29
 Progressive 29% increase in tipProgressive 29% increase in tip
diameterdiameter
 Instruments are better spacedInstruments are better spaced
 More instruments in smaller sizesMore instruments in smaller sizes
and fewer large instrumentsand fewer large instruments

Crown Down TechniqueCrown Down Technique
 The coronal portion is preparedThe coronal portion is prepared
before the apical portionbefore the apical portion
 Follows medical principle ofFollows medical principle of
cleansing before probing a woundcleansing before probing a wound

 Eliminates constrictions in theEliminates constrictions in the
coronal regioncoronal region
 Reduces effect of canal curvatureReduces effect of canal curvature
 Improves tactile awareness duringImproves tactile awareness during
apical preparationapical preparation

 Allows more effective irrigationAllows more effective irrigation
 Removes majority of tissue andRemoves majority of tissue and
microbes before apical third ismicrobes before apical third is
approachedapproached
 Reduces change in working lengthReduces change in working length
during apical preparationduring apical preparation

 Coronal thirdCoronal third Orifice shapersOrifice shapers
 Middle thirdMiddle third 0.06 taper rotary Profiles0.06 taper rotary Profiles
 Apical thirdApical third 0.04 taper hand Profiles0.04 taper hand Profiles

Clinical ProcedureClinical Procedure
 Estimate working lengthEstimate working length
 Parallel radiographParallel radiograph
 Estimated working length is the distanceEstimated working length is the distance
from the reference point to thefrom the reference point to the
radiographic apexradiographic apex

Parallel RadiographParallel Radiograph

 Establish straight line access toEstablish straight line access to
apical thirdapical third

Explore the canalExplore the canal
 Ensure that canal corresponds toEnsure that canal corresponds to
radiographic apexradiographic apex
 Small file – #10 K-fileSmall file – #10 K-file
 May need to precurve these SS filesMay need to precurve these SS files

 Files used in a push/pull orFiles used in a push/pull or
quarter turn pull motionquarter turn pull motion
 Never rotate these filesNever rotate these files
through 360 degreesthrough 360 degrees

Estimate canal sizeEstimate canal size
 Radiographic appearanceRadiographic appearance
 Crown/root morphologyCrown/root morphology
 Standardized tablesStandardized tables

Estimation of canal sizeEstimation of canal size

Estimation of canal sizeEstimation of canal size
See Table
in manual

Actual Working LengthActual Working Length
determinationdetermination
Preparation should terminate atPreparation should terminate at
 Apical constrictionApical constriction
 1 mm short of radiographic apex1 mm short of radiographic apex

Clinical TechniqueClinical Technique
Actual Working LengthActual Working Length
determinationdetermination
 RadiographRadiograph
 Apex locatorApex locator

Actual Working Length Determination

Apex LocatorApex Locator

Crown down cleaning and shaping of canalsCrown down cleaning and shaping of canals

This technique applies only to teethThis technique applies only to teeth
ranging from 18 – 23 mm in lengthranging from 18 – 23 mm in length
 Coronal third measurement is WL minus 8Coronal third measurement is WL minus 8
mmmm
 Middle third measurement is WL minus 4Middle third measurement is WL minus 4
mmmm

Apical third measurement is WLApical third measurement is WL

Preparation of the coronal thirdPreparation of the coronal third
 Coronal third measurement is working lengthCoronal third measurement is working length
minus 8 mmminus 8 mm
 Prepared using Profile orifice shapersPrepared using Profile orifice shapers

 Profile orifice shapersProfile orifice shapers
 In sequence larger to smallerIn sequence larger to smaller

Preparation of coronal thirdPreparation of coronal third
 Measure WL minus 8 mm on theMeasure WL minus 8 mm on the
largest Orifice Shaperlargest Orifice Shaper
 Lubricate the canal with ProlubeLubricate the canal with Prolube

 Rotate OS at 300 rpmRotate OS at 300 rpm
Note: Orifice shaper should be rotating atNote: Orifice shaper should be rotating at
300 rpm before it is placed in the canal300 rpm before it is placed in the canal
 Advance the OS in 1 mm incrementsAdvance the OS in 1 mm increments
 When resistance occurs, retract OSWhen resistance occurs, retract OS
while still rotatingwhile still rotating
 Never force any instrument apicallyNever force any instrument apically

 This OS will not extend to WL minusThis OS will not extend to WL minus
8 mm8 mm
 Irrigate copiouslyIrrigate copiously

 Move to next smallest OSMove to next smallest OS
This will extend further than previous instrumentThis will extend further than previous instrument
 Repeat the steps described for largest OSRepeat the steps described for largest OS
 Move to next smallest OSMove to next smallest OS
 Continue this sequence until working lengthContinue this sequence until working length
minus 8 mm is reachedminus 8 mm is reached

 Return to largest OSReturn to largest OS
 This will now extend further intoThis will now extend further into
the canal than it did previouslythe canal than it did previously
 Repeat this sequence until thisRepeat this sequence until this
(the largest) OS reaches WL(the largest) OS reaches WL

 Never force any instrumentNever force any instrument
apicallyapically
 Irrigate after every instrumentIrrigate after every instrument
 Use copious amounts of ProlubeUse copious amounts of Prolube

Preparation of middle thirdPreparation of middle third
 Middle third measurement is WLMiddle third measurement is WL
 Prepared using 0.06 taper SeriesPrepared using 0.06 taper Series
29 rotary Profiles in sequence29 rotary Profiles in sequence
larger to smallerlarger to smaller

Prepared with 0.06 Series 29 NiTi rotary Profiles

 Measure working length minus 4 mmMeasure working length minus 4 mm
on the largest 0.06 taper series 29on the largest 0.06 taper series 29
rotary filerotary file
 Set green rubber stop at that lengthSet green rubber stop at that length

 Rotate at 300 rpmRotate at 300 rpm
File must be rotating at 300 rpm before itFile must be rotating at 300 rpm before it
is placed in canalis placed in canal
 Advance file in 1 mm incrementsAdvance file in 1 mm increments
 When resistance occurs, retract fileWhen resistance occurs, retract file
while still rotatingwhile still rotating
 Copious irrigation with NaOClCopious irrigation with NaOCl

Preparation of the apical thirdPreparation of the apical third
 Prepare to actual working lengthPrepare to actual working length
 Use 0.04 taper NiTi hand files inUse 0.04 taper NiTi hand files in
sequence smaller to largersequence smaller to larger

Preparation of apical thirdPreparation of apical third

 Measure working length on #15 fileMeasure working length on #15 file
 Set rubber stop at that lengthSet rubber stop at that length

 Advance size 15 file to workingAdvance size 15 file to working
lengthlength
 Rotate file through 360 degreesRotate file through 360 degrees
 Irrigate copiously with NaOClIrrigate copiously with NaOCl
after each fileafter each file

Preparation of the apical thirdPreparation of the apical third
 Advance size 20 file to workingAdvance size 20 file to working
lengthlength
 Continue through sequence,Continue through sequence,
seating each file to working lengthseating each file to working length

 The largest file that extends to workingThe largest file that extends to working
length is the Master Apical file (MAF)length is the Master Apical file (MAF)
 For large canals – minimum MAF #40 - 50For large canals – minimum MAF #40 - 50
 For small canals – minimum MAF #35 - 40For small canals – minimum MAF #35 - 40

Master Apical FileMaster Apical File
 Take a radiograph with MAF in place.Take a radiograph with MAF in place.
This confirms:This confirms:
• LengthLength
• PlacementPlacement

Mission accomplishedMission accomplished
Smooth tapered preparationSmooth tapered preparation

Devitalized extirpation, amputation and combined method

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