Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.
Minimally invasive endodontics
Dr. Jagadeesh. K
P.G 3rd year
Contents
• Definition
• Introduction
• Principles of access cavity preparation
• Minimally invasive access strategies
• A ...
Definition
• The world congress of MID defines minimally invasive
dentistry as those techniques, which respect health,
fun...
Primary goals of endodontics ???
Tooth retention
Prevention/management of
pulpal and periapical disease
PRESERVING STRUCTURAL INTEGRITY
Maintaining strength and stiffness that resists
structural deformation becomes the recogni...
Endodontically treated teeth are more brittle
and hence more vulnerable to fracture??
Only moisture loss of 9% after root ...
Unfortunately, structural loss alone cannot
answer every clinical question that relates to
dentin failure.
• The relevance of fatigue as a main mechanism for
tooth fracture and the resistance of dental tissues
to both the initiat...
Why endodontically treated teeth fail?
• When endodontically treated teeth fail under function,
that outcome is determined...
PRINCIPLES IN ACCESS PREPARATION
 Do no harm.
 Assessment of restorability.
 SLA???
External root surface as guide
• Pa...
MINIMALLY INVASIVE ACCESS STRATEGIES
• Important factors that will affect the ultimate
outcome of treatment
• Operator nee...
• Traditional endodontic access has been
endodontic centric, primarily focused on operator
needs, and has been decoupled f...
SETTING THE STAGE FOR CONTEMPORARY
MOLAR ENDODONTIC ACCESS
• Directed dentin and enamel conservation is the
best and only proven method to buttress the
endodontically treated molar....
A NEW MODEL FOR ENDODONTIC
ACCESS
1. Implant success rates
2.Operating microscopes and micro-
endodontics
3. Biomimetic de...
Conservative and crafted
preparations
Sofitt
3D
Ferrule
Peri
cervical
dentin
Improved structural integrity
Three-Dimensional Ferrule
• It has historically been described as axial wall
dentin covered by the axial wall of the crown...
3 components of three dimensional ferrule
Net taper
thickness
Vertical
component
Thickness of ferrule
• The absolute minimum thickness is 1 mm; however, 2
mm is obviously a safer number. Girth becomes mo...
Total Occlusal Convergence (TOC) or net taper
3 mm ferrule needed
4 mm ferrule needed
Deep chamfer marginal
zones common w...
• Light axiomarginal reduction coupled with
apically placed finish lines and a nonzero-
degree emergence profile of the re...
Pericervical dentin (PCD)
Defined as the dentin near the alveolar crest.
• Critical zone roughly 4 mm coronal to the crest...
LOOK, GROOM, AND FOLLOW: SHAPING
VERSUS MACHINING
Why are round burs so destructive?
Why is complete deroofing so dangerous?
• attempts at removing the soffit that are far
more damaging to the surrounding PC...
Banking/Soffit (360)(Stepped access)
Small border amount of the chamber roof
near the point where it curves 90° and
become...
Dotted line shows the typical cut made to remove the entire
pulp horn.
Area between the lines should be maintained and is ...
Bend and flex at the cervical area - most common area of
occurrence for fracture failures in endodontically treated
teeth
...
Preservation of the roof-wall interface (or soffit). the
small shapes, and preservation of key dentin.
Redesigned Access
• The new vision-based mental model is Look, Groom,
and Follow.
• The new instruments are all round-ende...
CK burs or EndoGuide burs
Blind Tunneling
The enamel is cut back at 45 with the Cala Lilly shape. This
modified preparation will now allow engagement of nearly the
...
The Three Strikes Rule
(1) Excessive axial reduction (consistent with PFM or all-
porcelain restorations)
(2) Gouged endod...
Undesirable access shapes
• The inverse funnel
• Blind tunneling
• Blind funneling
SHAPING THE ROOT CANAL SPACE
• Complex root canal anatomy should be considered one of
the most significant challenges in c...
• Jou et al. coined the term ‘working width’ to alert
clinicians to the critical need to understand the horizontal
dimensi...
#30,#40 better than #20 - LARGER
TAPER may compensate smaller sizes
Baumgartner et al; JOE 2004
• Root canal preparation instruments sometimes associated
with this strategy such as V-Taper (SS White, Lakewood,
NJ, USA)...
• Current Descriptions Of Horizontal Dimensions Of Root
Canal
• Round(circular): Max IWW=Min IWW
• Oval: Max IWW > Min IWW...
Traditional Technology
Stainless-Steel Hand Files
• Inexpensive, has a track record, usually safe, but…
• Time consuming
•...
Issues with Rotary NiTi Files
• Peer-reviewed research has shown, so far, the following
consequences:
• Unpredictable File...
• Efficiency of NaOCl is reduced when used with single-
file systems, due to shorter working time and non-
sequential work...
Cone beam CT presenting oval cross-
sections of canals
• Achieve minimally-invasive
• 3D root canal shaping, cleaning
• and simultaneous Irrigation.
Abrasive surface
Compression
Gradual expansion by the SAF
1. Vertical vibration – 0.4 mm
amplitude at 5,000 rpm
2. Slow low-torque rotation – at ~80
rpm
3. Clutch mechanism to avoi...
Hero Shaper ProTaper (complete fracture)
SAF
Dentinal micro-Crack Formation during Root
Canal Preparations by Different NiTi Rotary
Instruments and the Self-Adjusting ...
C-Shaped canals - Danger zone
Green - before preparation Red - after preparation
Solomonov et al, J Endod 2012; 38:209-214...
PIPS
conclusion
REFERENCES
• Clark D, Khademi J. Modern molar endodontic access
and directed dentin conservation. Dent Clin North Am
2010
...
• Helfer A R, Melnick S, Schilder H. Determination of the
moisture content of vital and pulp less teeth. Oral Surg Oral
Me...
• Minimally invasive endodontics: challenging prevailing
paradigms A. H. Gluskin, C. I. Peters and O. A. Peters
• Pathways...
Thank u
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Minimally invasive endodontics by Dr. JAGADEESH KODITYALA
Nächste SlideShare
Wird geladen in …5
×

Minimally invasive endodontics by Dr. JAGADEESH KODITYALA

MINIMAL INTERVENTION

  • Als Erste(r) kommentieren

Minimally invasive endodontics by Dr. JAGADEESH KODITYALA

  1. 1. Minimally invasive endodontics Dr. Jagadeesh. K P.G 3rd year
  2. 2. Contents • Definition • Introduction • Principles of access cavity preparation • Minimally invasive access strategies • A new model for endodontic access • Endodontic working width • PIPS
  3. 3. Definition • The world congress of MID defines minimally invasive dentistry as those techniques, which respect health, function and esthetics of oral tissue by preventing disease from occurring, or intercepting its progress with minimal tissue loss (Nový and Fuller 2008)
  4. 4. Primary goals of endodontics ??? Tooth retention Prevention/management of pulpal and periapical disease
  5. 5. PRESERVING STRUCTURAL INTEGRITY Maintaining strength and stiffness that resists structural deformation becomes the recognized goal of all restorative procedures, especially in endodontics.
  6. 6. Endodontically treated teeth are more brittle and hence more vulnerable to fracture?? Only moisture loss of 9% after root treatment. The predominant reason that endodontically treated teeth are more prone to fracture relates more than any other attribute to the structural loss of those root treated teeth requiring restoration. Helfer A R, Melnick S, Schilder H. Determination of the moisture content of vital and pulp less teeth. Oral Surg Oral Med Oral Pathol 1972; 34: 661–670
  7. 7. Unfortunately, structural loss alone cannot answer every clinical question that relates to dentin failure.
  8. 8. • The relevance of fatigue as a main mechanism for tooth fracture and the resistance of dental tissues to both the initiation and propagation of cracks is an important research area • The resistance to propagation of fatigue cracks in dentin decreases with increasing patient age and the incremental rate of crack extension is up to 100 times greater in seniors.
  9. 9. Why endodontically treated teeth fail? • When endodontically treated teeth fail under function, that outcome is determined primarily by 2 aetiologies. Those causes stated most simply are: 1) the degree of stress experienced by the tooth under load 2) the inherent biomechanical properties of the remaining structure responsible for resisting fracture.
  10. 10. PRINCIPLES IN ACCESS PREPARATION  Do no harm.  Assessment of restorability.  SLA??? External root surface as guide • Patterns in orifice location, size, colour, shape: 9 LAWS. (Krasner P, Rankow HJ. Anatomy of the pulp chamber floor; JOE 2004,30:5)
  11. 11. MINIMALLY INVASIVE ACCESS STRATEGIES • Important factors that will affect the ultimate outcome of treatment • Operator needs, • Restoration needs, • Tooth needs.
  12. 12. • Traditional endodontic access has been endodontic centric, primarily focused on operator needs, and has been decoupled from the restorative needs and tooth needs. • Balance needs to be restored to these 3 needs, which are almost always in conflict when performing complete cusp-tip to root-tip treatment.
  13. 13. SETTING THE STAGE FOR CONTEMPORARY MOLAR ENDODONTIC ACCESS
  14. 14. • Directed dentin and enamel conservation is the best and only proven method to buttress the endodontically treated molar. • No man-made material or technique can compensate for tooth structure lost in key areas of the PCD. • The primary purpose of the redesigned access is to avoid the fracturing potential of the endodontically treated molar
  15. 15. A NEW MODEL FOR ENDODONTIC ACCESS 1. Implant success rates 2.Operating microscopes and micro- endodontics 3. Biomimetic dentistry 4. Minimally invasive dentistry 5. Esthetic demands of patients.
  16. 16. Conservative and crafted preparations Sofitt 3D Ferrule Peri cervical dentin Improved structural integrity
  17. 17. Three-Dimensional Ferrule • It has historically been described as axial wall dentin covered by the axial wall of the crown (or bridge abutment restoration). The research varies on the actual minimal vertical amount required, but the range of absolute minimums is from 1.5 to 2.5 mm
  18. 18. 3 components of three dimensional ferrule Net taper thickness Vertical component
  19. 19. Thickness of ferrule • The absolute minimum thickness is 1 mm; however, 2 mm is obviously a safer number. Girth becomes more important closer to the finish lines of the preparation. • The thickness of the remaining dentin (the wall thickness) between the external surface of the tooth at the finish line and the endodontic access is more important apically. • axially deep finish lines on root structure can be extremely damaging to 3DF.
  20. 20. Total Occlusal Convergence (TOC) or net taper 3 mm ferrule needed 4 mm ferrule needed Deep chamfer marginal zones common with today’s porcelain crowns Needed how much ferrule???
  21. 21. • Light axiomarginal reduction coupled with apically placed finish lines and a nonzero- degree emergence profile of the restoration can provide high 3DF. The concept of 3DF incorporates an interplay between these factors that, in sum, indicate the true ferrule quality.
  22. 22. Pericervical dentin (PCD) Defined as the dentin near the alveolar crest. • Critical zone roughly 4 mm coronal to the crestal bone -4 mm apical to crestal bone. crucial -transferring load from the occlusal table to the root, • PCD is irreplaceable. No man-made material or technique can compensate for tooth structure lost in key areas of the PCD. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010
  23. 23. LOOK, GROOM, AND FOLLOW: SHAPING VERSUS MACHINING
  24. 24. Why are round burs so destructive?
  25. 25. Why is complete deroofing so dangerous? • attempts at removing the soffit that are far more damaging to the surrounding PCD. • The primary reason to maintain the soffit is to avoid the collateral damage that usually occurs, namely the gouging of the lateral walls. • This 360 soffit or roof-wall interface can also be compared with the metal ring that stabilizes a wooden barrel.
  26. 26. Banking/Soffit (360)(Stepped access) Small border amount of the chamber roof near the point where it curves 90° and becomes the wall LEFT BEHIND Tiny “lip” or “cornice” 0.5 mm- 3.0 mm (strength and anatomy). strength continuous ring of dentin (BRAZING EFFECT).
  27. 27. Dotted line shows the typical cut made to remove the entire pulp horn. Area between the lines should be maintained and is referred to as the soffit
  28. 28. Bend and flex at the cervical area - most common area of occurrence for fracture failures in endodontically treated teeth Robust coronal dentin -maintained good distance away from the tooth’s centroid,(cervical) - tooth is stiffened, resists bending, and should resist fracturing. Clark D, Khademi J, Herbranson E. Fracture resistant endodontic and restorative preparations. Dent Today 2013.
  29. 29. Preservation of the roof-wall interface (or soffit). the small shapes, and preservation of key dentin.
  30. 30. Redesigned Access • The new vision-based mental model is Look, Groom, and Follow. • The new instruments are all round-ended tapers • The rounded ends are to increase the radii of the gouges and nicks that can act as stress concentration points. • The flat sides help create smoother, flatter walls and minimize the gouges and dings that inevitably occur even with the most careful technique • Small, cone-shaped, low-speed bur (such as the EG2 [SS White ])
  31. 31. CK burs or EndoGuide burs
  32. 32. Blind Tunneling
  33. 33. The enamel is cut back at 45 with the Cala Lilly shape. This modified preparation will now allow engagement of nearly the entire occlusal surface.
  34. 34. The Three Strikes Rule (1) Excessive axial reduction (consistent with PFM or all- porcelain restorations) (2) Gouged endodontic access (3) Large and arbitrarily round endodontic shape.
  35. 35. Undesirable access shapes • The inverse funnel • Blind tunneling • Blind funneling
  36. 36. SHAPING THE ROOT CANAL SPACE • Complex root canal anatomy should be considered one of the most significant challenges in creating root canal shapes that will support good obturation outcomes and leave sufficient remaining strength in the root. • After biomechanical instrumentation, the completed root canal shapes need to withstand the internal compressive forces of obturation; provide sufficient resistance form to contain softened and compressible filling materials and retain enough strength for mastication.
  37. 37. • Jou et al. coined the term ‘working width’ to alert clinicians to the critical need to understand the horizontal dimension of apical size and its clinical implication in cleaning the apical terminus. • Larger apical sizes -some literature credibility- bacterial reduction • “maintaining smaller sizes when possible (>20 ≤ 40) desirable-preservation of radicular dentin methods of canal cleaning and disinfection not at cost of losing retained, sound tooth structure” • James L Gutmann on MIE JCD 2013 (Guest editorial)
  38. 38. #30,#40 better than #20 - LARGER TAPER may compensate smaller sizes Baumgartner et al; JOE 2004
  39. 39. • Root canal preparation instruments sometimes associated with this strategy such as V-Taper (SS White, Lakewood, NJ, USA) and Endo-EZE AET (Ultradent, South Jordan UT, USA) have not been shown to actually perform in a superior way to traditional rotary instrumentation in the laboratory
  40. 40. • Current Descriptions Of Horizontal Dimensions Of Root Canal • Round(circular): Max IWW=Min IWW • Oval: Max IWW > Min IWW (2 times more) • Long oval: 2 or more times larger (upto 4) • Flattened(ribbon): 4 or more Circumferential filing better for oval, long oval & ribbon shaped canals Jou Y.et al; DCNA 2004
  41. 41. Traditional Technology Stainless-Steel Hand Files • Inexpensive, has a track record, usually safe, but… • Time consuming • Inflexible - difficulty negotiating curved canals • Extrude debris periapically • Pack debris into recesses • Sequential irrigation
  42. 42. Issues with Rotary NiTi Files • Peer-reviewed research has shown, so far, the following consequences: • Unpredictable File separation – even with advanced metallurgy and reciprocation • Excessive removal of dentin – especially with high-taper systems • Periapical debris extrusion – especially with reciprocation • Packing of debris into recesses
  43. 43. • Efficiency of NaOCl is reduced when used with single- file systems, due to shorter working time and non- sequential work • Formation of dentinal Micro-cracks, especially with single-file systems
  44. 44. Cone beam CT presenting oval cross- sections of canals
  45. 45. • Achieve minimally-invasive • 3D root canal shaping, cleaning • and simultaneous Irrigation.
  46. 46. Abrasive surface
  47. 47. Compression
  48. 48. Gradual expansion by the SAF
  49. 49. 1. Vertical vibration – 0.4 mm amplitude at 5,000 rpm 2. Slow low-torque rotation – at ~80 rpm 3. Clutch mechanism to avoid rotation while engaged with canal walls 4. Continuous irrigation
  50. 50. Hero Shaper ProTaper (complete fracture) SAF
  51. 51. Dentinal micro-Crack Formation during Root Canal Preparations by Different NiTi Rotary Instruments and the Self-Adjusting File Yoldas et al, J Endod 2012; 38:232-235
  52. 52. C-Shaped canals - Danger zone Green - before preparation Red - after preparation Solomonov et al, J Endod 2012; 38:209-214 SAF ProTaper
  53. 53. PIPS
  54. 54. conclusion
  55. 55. REFERENCES • Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010 • Clark D, Khademi J, Herbranson E. Fracture resistant endodontic and restorative preparations. Dent Today 2013 • Clark D, Khademi J, Herbranson E. The new science of strong endo teeth. Dent Today 2013. • Yi-Tai Jou et al Endodontic Working Width: current concepts and techniques
  56. 56. • Helfer A R, Melnick S, Schilder H. Determination of the moisture content of vital and pulp less teeth. Oral Surg Oral Med Oral Pathol 1972; 34: 661–670 • Sedgley C M, Messer H H. Are endodontically treated teeth more brittle? J Endod 1992; 18: 332–335. • Krasner P, Rankow HJ. Anatomy of the pulp chamber floor; JOE 2004,30:5 • Reeh E S, Messer H H, Douglas W H. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod 1989; 15: 512–516.
  57. 57. • Minimally invasive endodontics: challenging prevailing paradigms A. H. Gluskin, C. I. Peters and O. A. Peters • Pathways of pulp 10th ed. stephen cohen
  58. 58. Thank u

×