Endo Lab Manual by Kelly Hendricks

SESSION OBJECTIVE

ISESSION

(I)

[n , trument inventory and ')Cl up; Clean vs. Sterile areas, Lab manu a l and objectives. Identification of SSK Files and Rotary Files (sizes and tapers). Lab Lecture (File J.D. and File Propelties) , Basic Skills Exam I, Curved Canal Exercise (file curved canal to size #40 足 plastic block)

(2)

Access preparation : Maxillary Anterior, Maxillary & Mandibular Premolar, Maxillary & Mandibular Molar. (Accessleach) PasslFail each accessed tooth. (5 Total must pass) . Need 5 sterile extracted teeth with OK crowns. If any fail , will need additional sterile extracted or plastic teeth. Mount I radio-opaque plastic tooth #14 in sextant (Other plastic #14 will be done in hand)

(3)

Clear Plaslic MobrTooth # 14 (in hand) : Canal instrumentation; ETL,TL,WL; Initial apical gauging, Patency # 10-# 15 file, 'rown down Rota ry LO within 4 mm . ofWL. Prepare 1 large & 2 small canals for obturation at session 5. Do same to mounted plastic #14.

(4)

Complete preparation of Apical Control Zone (ACZ) in last 4 mm. of both large and small canals of both plastic molars for obturation at the next session . Finish last 4 111 m. K : Hand File: erial Step Back cchniqu . Master Apical File (MAF) and final apical gauging.

(5)

Obturation: Lateral condensation of 6 canals in 2 plastic molars. You will do I tooth in your hand and 1 tooth mounted . However, all procedures following this must be done with the tooth mounted in Endodent and the rubber dam in place (except for taking radiographs). Mount in ModuPro: I extracted Mandibular Premolar, I extracted Mandibular Molar; Start RCT on Mandibular Molar. Review rubb r dam placement and use of Oraseal.

(6)

Continue RCT on Mandibular Molar. (Graded procedure); Learn use of Apex L cator from Lab Lec足 ture (posted on Black Board) Apex Locator Demonstration

(7)

Continue RCT on Mandibular Molar.

(8)

Completc RCT on Mandibular Molar, tllm in [or grading by end of session (Graded Procedure 1); Begin RCT on Mandibular premolar. (Graded Procedure)

(9)

Complete ReT on Mandibular Premolar, tum in Max. Anterior in Endodent (Graded Procedure)

r r grading (Graded Procedure 2);

Mount Plastic

SPRING BREAK (10)

Plastic Maxil lary nterior, RCT start to fini sh. (Craded procedure 3): This is a preview for Mock Boards, Mount extracted Maxillary Molar in Endodent. Begin ,tality tcsting (EPT & thermal, small room).

(II)

Bcgin RCT Maxillary Molar (extracted) Graded procedure. Continue vitality & thermal testing (large room).

(12)

Cnmpll'lc vl ax Illary Mo lar. tum in for gmding (C r ad ed Procrdurc 4). Plastic Maxillary Premolar (Prep and obturate both roots with Thermafil速 ). Continue vitality & thermal testing (large room).

( 13)

Maxillary Premolar RCT (do post space in I canal and retreat other canal and obturate with WLC. Complete vitality & thel111ultc -ling (both rooms).

(14)

Preparing for tbe clinic will be done later in Bridge Course. Complete all unfinished requirements, Have approved & mount your extracted Mandibular Premolar for Final exam. Do Curved Canal Exercise (plastic block)

(15)

Final Exam : RCT mand ibular rrem lar ' tart to tinish (Craded Procedure 5) You will be graded on sterile vs. clean areas, neatness, records, etc.

Revised 09/'09

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Endodontics Manual II

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Revised 09/'09

COLLECTION OF EXTRACTED TEETH FOR YOUR LAB EXPERIENCE

One of the biggest advantages you can create for yourself when preparing for 06442 Lab is the timely CoUection and the careful Selection of extracted teeth. In fact, you CANNOT be successful in D6442 Lab without these teeth and it would be useless to admit you to D6442 Lab without them. We have set dates during your first semester at which times you must document that you have collected certain numbers of these teeth and that they have been Inspected and Approved by designated Teaching Assis足 tants (Endo Honors-4th year students). As further motivation, 10% of your semester grade in D6435 (sec足 ond year, first semester-Lecture class) will depend upon successful approval of these teeth at or before the designated deadline dates. Failure to collect and have approved the designated numbers by the desig足 nated dates in anyone instance may result in the loss of the entire 10% (i.e, if you successfully collect eight of the required nine teeth on time and are late collecting #9, you may lose the entire 10% toward your grade in 0435). Designated Due Dates: Annually Sept. (last Friday) any two teeth due

Oct. (last Friday) any two teeth due

Nov. (last Fri. before break) any two teeth due

Dec. (last Fri. before break) any three teeth due

Required are: 1 Maxillary Central Incisor (1 for Access) 1 Maxillary Premolar (1 for Access) 2 Maxillary Molars (1 for Access, 1 for ReT) 3 Mandibular Premolars (1 for Access, 2 for ReT) 2 Mandibular Molars (1 for Access, 1 for RCT) Guidelines for Access and ReT teeth are: Pulp canal with chamber visible

Minimum decay

Less than 20 degree canal curvature

Apical forament less than size 20

The first two attributes above are most important in selecting teeth for Access. The canal configuation is less important for teeth to be used for Access. The last two attributes above are critical for ReT success and the first two attributes are also desireable for the best grades. No teeth containing metal filling are acceptable.

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Endodontics Manual II

We notify you during your first year that personal collection of the extracted teeth is necessary to your success in theis second semester, second-year pre-clinical lab. We encourage you to rely on dental sources (especially oral surgeons) of your acquaintance to save these teeth for you as early as possible. It is impossible to have too many teeth saved.

Extracted Teeth Collection for Endo Lab You should collect as many teeth as possible; however, you will be required to have each of the following teeth pre-approved: 1 Maxillary Central Incisor 1 Maxillary Premolar 2 Maxillary Molars 3 Mandibular Premolars 2 Mandibular Molars Please try to avoid third molars.

The teeth should be collected and stored in an air-tight container in a mixture of bleach, glycerin and water, one-third of each or 0.2% Thynol or 10% bleach. The following criteria will be evaluated during the approval process:

I. Amount of decay present, especially on the occlusal of posterior teeth and the mesial, distal and Iin足 gual of anteriors. 2. Curved roots: you do not want more than 20-30 degree curves in roots and in canals. 3. You don not want apical foramen(s) to be larger than a size 20 file. If you can see the opening it may be too big. 4. Pulp chamber location, you do not want the pulp chamber to be located too low or far down the root. 5. Free of pulp stones and calcified canals. 6. You will need to take two X-rays - one straight on and one at 90 degrees - of each potential tooth in order to evaluate some of the above criteria on the X-ray. 7. You can take an X-ray of more than one tooth per film to get teeth approved but before the begin足 ning of the lab class, you will need two pre-op films, one straight and one at 90 degrees (i.e. facial and proximal views) . 8. These films must be of good quality, not too dark or light. The teeth selected for your RCT should be printed out with two pre-ops AND two post-ops (FACIAL AND PROXIMAL). Keep print-outs clean and free of scratches and sho 2 mm beyond apices. Other films are not to be printed. 9. You will need to be able to label your X-rays and/or teeth to know which films go with each

approved tooth.

There will be a TA available in the help lab to approve your selected teeth.

The following is a guide prepared by a previous student to help you select good teeth.

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Revised 09/'09

Endodontic Tooth Selection Criteria I. Looking at the tooth in your hand: • Are there any significant curvatures in the root? Large root curvature usually means equally curved canals, which are much more difficult to hand file ... also, if you have a really curved canal, you should not take rotary instruments down them (reason: increased risk to break the file.) Try to find a rather straight root (canal). • Is the apical foramen really visible? You will be using extracted teeth during this course. Occasionally, during extractions, root tips may break off or if the teeth were extracted at an early age (or are third molars) the apex may not even be fOlmed yet. Also, these teeth may have been handled by many people prior to you, and the apex may have traumatized by some means. So, unless you are performing a root canal on a young person, most people have fully formed roots with closed apical foramen, hence we ask you to have a closed apical foramen. 2. Looking at the film of the tooth: • Are there any significant curvatures in the canal? This was explained above. Also, check for sharp turns in the apical third. Sharp curves are very diffi cult to negotiate and should not be used in this course. Look at X-rays from both straight on and side views to discover alJ curves in all planes. Notable is the maxillary first molar which commonly has a severe facial curve of the palatal root which can be very difficult to shape . • Can you see the pulp chamber? During the caries process, teeth try to heal themselves by making tertiary dentin which tends to obliterate the pulp chamber and sometimes canals - we call this sclerosis. Being unable to see the pulp chamber makes locating the canals very difficult. Also, when you can see the pulp chamber on a film, you can hold a perio explorer up to the film and then estimate the depth you need to enter the tooth in order to be in the pulp chamber. For example if you noted on your film that the pulp cham ber is 7 mm from the occlusal surface and you are in the tooth 10 mm and still not in the pulp cham ber, you should be very concerned about the angulation you are entering the tooth (canal). After all, you want to avoid perforating the root. So, try to find a tooth with a visible pulp chamber. • Can you see the canals? This sounds obvious, but make sure you can see the canals - this means the entire canal (all the way from the pulp chamber to the apex) not just part of it. Try to find a tooth with visible canals.

Christy Hager

Revised 09/,09

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Endodontics Manual II

Grading Procedures for the Lab Note the fol1owing Pass/Fail procedures in the Lab: Instrument inventory, LD. and set-up (Basic Skills Competency Exam I) Access of five teeth (See "Lab Access Grade Sheet #1") These teeth should have decent crowns to access (roots are irrelevant here). You will need at least one each ofMax. Anterior, Max. PremolQl~ Max. Molar, Mand. Premolar, Mand. Molar. Note: Four more teeth with good roots are necessary for your graded projects. Vitality Testing Plastic Molar Tooth #14 Rubber Dam Placement (Oraseal) Apex Locator Curved Canal Exercise Maxillary 2 rooted premolar RCT and Basic Skills Competency Exam II (Diagnosis of a Case Presentation) You must successfu]]y complete these procedures and be signed off on them in order to complete the class. There are five Graded Procedures in the Laboratory course: Each are weighted equally in your semester grade.) Mandibular Molar ........ . ...20% Mandibular Premolar .... . ....20% Maxillary Anterior .. . ..... . ..20% Maxillary Molar ........ . ....20% FINAL (mandibular premolar) ..20% Total ......................100% The grade on each of the Graded Procedure teeth above is comprised of the grade assigned on the related "Clinical Endodontic Grade Sheet" to be recorded in your Manual. Unless you gain or lose points (as determined by Dr. Lee) in addition to the above, your Laboratory grade would be determined as above with the grade scale below. Semester Grade: 90--100% 80-90% 75-79.9% 75%

= = =

A B C F

Here's how the points are earned: Each of the five graded procedures will be scored on the "CHnicaJ Endodontic Grade Sheet" by one or more table instructors at random. Table instructors will rotate so that you will probably be scored by a different instructor each time and perhaps never by your own table instructor. You will start out with a score of 100. You wiJJ lose zero (0) points for each category performed in an Ideal (Perfect) fashion. You will lose three (3) points for each category when performed within the Acceptable range and you will lose six (6) points for each category when performed in a Poor manner. The total of the point reductions subtracted from 100 will be your score for that Graded Procedure. Note: Late procedures will lose five points per week or more.

Endodontics Manual II

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Revised 09/,09

TABLE OF CONTENTS

Session (1)

Page

Instruments, equipment and supplies ............ . ..... . ..... . 10-23

Identification of Endodontic Files (short presentation ......... 13, 14, 16

Basic Skills Exam I ....... . ..... ...... . .. .... .... . . . . ..... .. 10

Session 1 check off sheet ....... . ... . ...... .. .... .. .......... . 24

Session (2)

Session 2 outline ................................ . ........... 25

File Properties (SS vs. Ni-Ti) (short presentation in Lab)

Access Preparations ....... .. ........... ... ................ 26-31

Session 2 check-off sheet (Access Preparations) ..... . ............ 31

Session (3)

Session 3 outline ..... ... .... ... .......... . ........... . ......32

Patency, ETL, TL, WL ... . ..... . ..... . . . ........ ... .... . ..... 33

(Initial) Apical gauging ......... . ............ .. .............. 34

Instrument separation prevention ... .. ............. . .... . . . ..... 36

Crown-down Rotary Shaping (WL-4rnm) .... . ...... . ..... . ..... . 37

Begin Canal Instrumentation (Plastic Max. Molar) hold in hand ....... 32

Session (4)

Session 4 outline ......... . ..... . .............................32

Master Apical File (MAF) selection (Shaping Objective) ...... 37,40-41

Development of the Apical Control Zone (ACZ), ................. 35

Serial Step-Back Technique ........ .... .......... . ............ 34

(Final) Apical Gauging . ...... . ........... . ............. . .... 35

Complete shaping preparation of your plastic molar ..... . .......... 32

Session 3 and 4 check off sheet ... ... .... . ..... . ............... 42

Session (5)

Session 5 outline ............................... . ........... .43

Obturation: Lateral Condensation (Plastic Molar) ............... 44, 45

Complete Plastic Max. Molar and check-off .... . ................. 46

Mounting teeth in the Modupro-Endo .... .. ........... . . Appendix M

Mount in Endodont:

1 mand. PM, 1 mand. Molar, . .. .. ...... .. ................... 46

Taking Radiographs with the ModuPro-Endo .. . ...... .... Appendix M

Start Mandibular Molar project (Graded Procedure) ............. 46

Session 5 Check-off Sheet . . . ...................... . .......... 46

Session (6)

Session 6 outline ..... . ......... .. ............ ... ....... . .. . . .47

Rubber Dam Placement ................................ .. .... 47

Caulk Sealer mixture ................................. Appendix I

Use of Ultradent Oraseal

Apex locator use ........... .. ........... ... ......... .Appendix L

Continue RCT on Natural Mandibular Molar ..................... 48

Session (7)

Session 6 and 7 outline .. ..... . ................. . .... ..... .... 47

Continue RCT of Mandibular Molar .. .... ...................... 48

Continue/Complete Apex Locator Exercise ... . .......... Appendix L

Session (8)

Session 8 outline ... . ........................................ 49

Complete RCT on Mandibular Molar (Graded Procedure) ........... 49

Turn in completed Mandibular Molar in ModuPro-Endo w/ Manual 49-50

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Endodontics Manual II

*Mandibular Molar grade sheet ................. . .............. . 50

Begin RCT on Mandibular Premolar (Graded Procedure) ... ......... 49

Session 6,7 ,and 8 check off sheet. ........... . ............. ... .. 49

Session (9)

Session 9 outline ..... . . . .......... .. ..... . ..................51

Complete Mandibular Premolar project; tum in for grading ... . ...... 51

*Mandibular Premolar grade sheet. .............................. 52

Mount plastic maxillary anterior in ModuPro-Endo (Graded Procedure) 51

Begin Vitality Testing: Electronic pulp tester (EPT) ................ 57

(small lab) Endo Ice (cold test) .............................. 58

Heat testing (read only) ......................... . 58

Session 9 check off sheet ..................... . .............. . 51

Session (10)

Session 10 outline .......................... . ............... 53

Complete vitality testing (small lab) ...................... . . . ... 57

Maxillary Anterior (Plastic tooth) RCT stali to finish ............... 53

This is a preview for Mock Boards ... . ... . ............. . . . .... . 53

Mount extracted Max . Molar & p.m in Modupro-Endo

(Graded Procedure) ..... .. ... ... .. ..... .... .. ..... .. ....... 53

Session 10 check-off sheet .................................... 54

*Plastic maxillary anterior endodontic Grad Sheet. ..... . ..... .. ... .. 55

Session (11) Session 11 outline ....................... .. .... . ..... . ....... 56

Begin Maxillary Molar (Graded Procedure) ...................... 56

Continue Vitality Testing (large lab) ............................ 57

Session (12)

Session 12 outline ........................................... 56

Complete Max. Molar & tum in for Grading ....... . ............. 59

*Max. Molar Grade Sheet ... . ................................. 60

Stali Max. Premolar (2 roots) - not a graded procedure ............. 56

(Molar may be substituted if premolar not available) ............. 56

Continue Vitality Testing ...... . ......... . ............... . ....57

Session 11 and 12 check off sheet ................. . ... '......... 59

Session (13) Session 13 outline ......... .. ........................ .. ...... 61

Complete Max. Premolar .................................. ... 61

Retreat one canal ................................... Appendix 0

Complete vitality testing (both labs) .......... . ............ . .... 57

Session 13 check off sheet .... . ..... . ................... . ..... 61

Session (14)

Session 14 outline ........ .. ................................. 62

Basic Skills Exam II .........................................62

Pulpotomy vs. Extirpation ............ .. ............ . ......... 62

Preparing for the clinic: ................................... 62-68

Endo Diagnosis Form ..... . ...... . ..... .. ............ . ..... 64

Case Difficulty/classification sheet ....... .. ................ 65-66

Endo procedural accident policy .............................. 67

Incident report .................................. .. ........ 68

Session 14 check off sheets ................................... 69

Do curved canal exercise .............................. Appendix J

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Revised 09{'09

Session (15)

Final Examination (mandibular premolar start to finish) . . ..... .. .... 69

Grading of Final Lab Exam will include sterile vs. clean areas, Neatness and completeness of records .... ... . .. ... . .. . .. . .. . ... 69

*Final Mandibular Premolar Endodontic Grade Sheet .... . .. . ...... 70

Appendix A:

Radiography ..................... . ... . ............ .. ..... . . 71

Appendix B:

Warm Vertical Compaction . ..... . .... . . ..... . ...... . . . ... . . 72-76

Appendix C:

Thermafil Technique . . . .... . ..... . . ......... . ............... 77

Appendix D : Retreatment ........... . ................. . ............... . . 77

Appendix E:

The "8-Step Prep" . . . ............ . .... ... ........ .. . .... . 79-81

Appendix F:

Dealing with the Curved Canal ... ... ....... . ..... . . . ... . .... 82-86

Appendix G: Discontinuity of Taper and Shaping Objective .. ... .. ..... . ..... 86-87

Appendix H: The Value of the radiographic "Shift-Shot" ....................... 88

Appendix I:

Mixing Caulk Rubber Dam Sealer ..... . ........................ 89

Appendix J:

Curved Canal Exercise . .......... . ..... . .... .. .... . ....... 90-92

Appendix K: D6442 Lab Syllabus . .. . . . ... ... .... .. .... . .... . ......... 93-101

Appendix L:

Use of the Apex Locator . ... . ......... . ........ . .... . .... 102-103

Appendix M: Mounting Teeth in the ModuPro-Endo . ... ... .... .. ..... .. .. 104-108

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Endodontics Manual II

ENDO LAB SET UP Below is a photographic guide to help you learn your Endo set up. Reproducing this exact Endo set up will be required on your Endo Competency I before you can perform any Endodontic procedure in the clinic.

23) Locking cotton pliers

3) Paper cup for used endo files

13) Rubber Dam RubberDam Punch Rubber Dam Clamp with !loss Plastic Rubber Dam Frame Rubber Dam Clamp Forceps

4) Alcohol Lamp

14) High speed hand piece

5) EDTA (Sffiear Clear@)

Di9f'leHse 8)' iflstll:letsr (Not

needed .)

15) 3cc syringe for ethanol (alcohol) 3cc syringe for EDTA

6) EndoRez sealer cartridge

16) Dis!38saele s)'riHge fer eal:l1i( sealer ffiiJltl:lre (Not needed.)

31) Mirror with ruler

17) Paper points

32) Endo ring with files

18) Titan slow speed motor Torque converter Endo contra-angle hand piece

33) Endo File Organizer

I) Sodium Hypochlorite (NaOCl)/specimen bottle 2) 12 cc syringe with Max-I-Probe needle for NaOCl

7) EndoRez mixing tips 8) Bur Block with #2, #4, #557, # 16 safe tip diamond and Foot足 ball shape diamond 9) Rubber stoppers

24) Heat eaffier 00* 25) Heat eaffier 0* 26) Pll:Igger 8P* 27) Pll:Igger 9P* 28) Pll:Igger IOP* 29) Pll:Igger II P* (24-29 not needed.) 30) Glick

34) Iris Scissors 35) Sterile 2x2 gauze

10) Al:ltsHt gl:ltta f'lereka (VeRieal) (Not needed .)

19) Bite block (dispense)

36) Sterile cotton pellets

20) Endo spoon

37) Filemate速

II) Autofit paper points

21) Endo Explorer

12) ISO gutta-percha Accessory cones (Lateral)

22) Non-locking cotton pliers

Endodontics Manual II

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Revised 09/'09

III lire clillic, 1I sterile elii/o sel-up is available lhnll the t!ispensaty. Do not pllt llsed files back ill tlte

box. Used & deformed IUlIld.liles should he placed ill the slwrps cOlltailler.

The Endo box will be wrapped in a blue serilization papa The paper should be opened carefully, so as to

maintain a sterile field on the internal aspect ofthe wrap. The sterile wrap should then be placed sterile足 side-up under your sterile instruments and box to maintain a sterile field. Keep a sterile area and a

"clean area" separate. This will be tested on Board exam.

HAND INSTRUMENTS The instruments pictured in figure A may be sterilized, but do not heat them with your torch or any flame.

Figure A I. Mirror with ruler on handle 2. Endo spoon excavator 3. Locking cotton pliers

4. Non-locking cotton pliers (From your first year instrument box) 5. Iris scissors

Then Endo explorer is used to detect canals and evaluate the walls of the pulp chamber. The Endo explorer cannot be heated by a flame but may be sterilized. The Glick instrument shown below in figure B may be heated by a flame and may be sterilized. The Glick is used to place interim fillings, remove excess gutta-percha when heated and to release the rubber dam from winged clamps.

Figure B. I. Endo explorer

Revised 09/'09

2. Glick 5-7 plugger

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Endodontics Manual II

r-",-----IL~~_ -

.77'"

DO NOT HEAT

.: : ••• ••

~~ai~~ OK TO HEAT -_ _"""'

The Schilder heat carriers 0 & 00 and pluggers 8P, 9P, lOP & 11 P are shown in Figure C. They are used for heating and down packing gutta-percha respectively. Never heat the 8P, 9P, lOP or 11 P pluggers, they will become damaged and need replacement. The heat carriers are supposed to be heated but eventually they will also need replacement.

Figure C (Do not need them in the Lab this semester.) 1. Heat carrier 00 (Red) 2. Heat Carrier 0 (Blue) 3. Plugger 8P (Yellow) Do Not Heat 4. Plugger 9P (Yellow) Do Not Heat 5. Plugger lOP (Yellow) Do Not Heat

Endodontics Manual II

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Revised 09/'09

HAND FILES AND FILE ORGANIZER

-----===---1

ett.

â&#x20AC;˘

1st & 2nd rows:

3rd & 4th rows:

Size 8 SSK hand file (gray)

13) Size 70 SSK hand file (green)

Size 10 SSK hand file (purple)

14) Size 80 SSK hand file (black)

Size 15 SSK hand file (white)

15) Size 90 SSK hand file (white)

Size 20 SSK hand file (yellow)

16) Si ze 100 SSK hand file (yellow)

Size 25 SSK hand file (red)

17) Size 110 SSK hand file (red)

6) Size 30 SSK hand file (blue)

Rotary

Size 35 SSK hand file (green)

18) 201. 10 GT rotary file (yellow/5 rings)

Size 40 SSK hand file (black)

19) 201.08 GT rotary file (yel1ow/4 rings)

Size 45 SSK hand file (white)

20) 201.06 GT rotary file (yellow/3 rings)

10) Size 50 SSK hand file (yellow)

21) 201.04 GT rotary file (yellow/2 rings)

11) Size 55 SSK hand file (red)

22) 301.06 GT rotary file (blue/3 rings)

12) Size 60 SSK hand file (blue)

23) 301.04 GT rotary file (blue/2 rings) 24) 401.06 GT rotary file (black/3 rings) 25) 401.04 GT rotary file (bl ack/2 rings) 26) 351. 12 GT rotary accessory file (green) 27) Spreaders: fine fine (size 20/yellow) fine (size 301b1ue)

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Endodontics Manual II

Figure D The handles of the hand files are color coded for ease of identification.

You will be expected to know color code. A Mnemonic may be helpful: Starting at #15 or #45: Will You

Really Be Going Back? (White, Yellow,Red,Blue, Green, Blk)

MANUALLY OPERATED SHAPING INSTRUMENTS (SSK-HAND FILES)

ISO COLOR CODE AND FILE SIZE Color Gra:t PuW le White Yellow . Red Blue Green Black

Small #8 #10 #15 #20 #25 #30 #35 #40

Medium

#45 #50 #55 #60 #70 #80

Large

#90 #100 #110 #120 #130 #140

See Figure D above. @

C!~

@ Endo Ring Set Up I) 2)

II) Size 15 file (white) (side)

Accessory file 35/. 12 (side)

12) Size 35 file (green)

Size 10 file (purple)

13) Size 40 file ( black)

Size 15 file (white)

14) Size 45file (white)

Size 20 file (yellow)

15) 30/.06 GT rotary

20/.10 GT rotary

16) 30/.04 GT rotary 17) 40/.06 GT rotary

20/.08 GT rotary

20/.06 GT rotary

18) 40/.04 GT rotary

20/.04 GT rotary

19) FF spreader (yellow)

Size 25 file (red)

20) F spreader (blue)

10) Size 30 (blue)

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Revised 09/'09

FINGER SPREADERS • The size 20 spreader is a fine/fine size which spreader corresponds to a size 20 or fine/fine gutta percha point (yellow) . (Use # 15 or #20 gutta percha .) • The size 30 spreader corresponds to a size 30 or fine gutta-percha point (blue) . (Use #20 or #25 gutta percha.) • Finger spreaders are used to create a space for the accessory cones during lateral condensation.

SILICONE LOCATOR STOPS These stops are placed on instruments to maintain a pre-set measurement. They can be placed on rotary and hand files, burs, and Endo instruments. They have a colored line or point that can be oriented toward a pre-curved file so you are able to determine which direction the file is curved when it is inside a canal.

1. Silicone rubber stops

ENDO FILEMATE® -

Endodontic file measuring device

The Endo FileMate® increases speed and accuracy when measuring files.

Inserting files in the holes on the top of the FileMate® automatically sets stops to the selected length . The holes located just above or below the numbers shown are the holes that correspond to the numbers in mm. The sunken holes next to the numbers are .5 mm longer than the numbers shown. This is a very handy instrument especially when working with an assistant.

1. Endo FileMate® Revised 09/'09

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Endodontics Manual II

ROTARY INSTRUMENTS STANDARD ROTARY

GT FILES

• Color band indicates tip diameter. Yellow = 20, 50; Blue = 30; Green = 35, 70; Black = 40 • Taper is indicated by number of rings. (each ring

0.02 mm of taper per mm .)

• Length of cutting blade varies with taper. Each increases to 1.0 mm maximum flute diameter (MFD). • Do not run above 300 rpm. • Use with light pressure only. • Sizes that you have: 201.10, 201.08, 201.06, 201.04., 301.06, 301.04, 401.06, 401.04 • These files all have a Maximum Flute Diameter (MFD) of 1.0 mm.

ACCESSORY ROTARY

GT FILE

• You have the size 351.12 only. • Run at 1000 to 1300 RPM. As orifice opener, otherwise 300. • Use light pressure only. • These files all have a Maximum Flute Diameter (MFD) of 1.25mm (Use only as Oriface opener-go only 113 to 3/4 the depth of flutes into canal, depending on the size of the root.)

Series 20

1. Standard Rotary GT Files

Endodontics Manual II

Series 30

Series 40

Accessory

2. Accessory GT file 35/.12

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Revised 09/,09

HAND PIECE ATTACHMENT AND TORQUE CONVERTER The Endo contra-angle is run on your Titan slow speed motor. Your Titan slow speed motor is a 20,000 RPM hand piece, however the Endo contra-angle is 1: 18 gear reduction. This will allow the Endo hand piece to run at 1100 RPM. When the torque converter (A 1:4 gear reduction) is also placed on the motor with the contra-angle it will only allow the hand piece to run at 278 RPM. These are the ideal speeds for the rotary files. Regular GT rotary files should be run at about 300 RPM with the torque converter and the accessory GT rotary file at 1000 to 1300 RPM without the torque converter.

MATERIALS SEALER ITEMS: Small sterile glass mixing slab, cement spatula and sealer. Only a small amount of sealer is required for a single canal. The sealer is mixed in equal amounts and it has a long working time. The sealer is expensive so do not waste it. You can always mix more. When doing endo in the clinic, your small endo glass-mixing slab should always be sterilized before mixing sealer. The large mixing glass slab will fracture if sterilized. Glass slab is preferred over mixing pads in clinic for sealer and JRM as it is sterile and paper pads are not. Should always use sterile glass slab.

If the Auto-mix EndoREZ速 is llsed you will not need mixing slab.

1. Small glass slab Revised 09/'09

2. Cement spatula - 17-

Endodontics Manual II

Auto-mix EndoREZ®

Is a two part chemical set methacrylate based root canal sealer.

EndoREZ® has hydrophilic characteristics providing excellent

penetration into even moist tubules and improves sealing ability.

It is radiopaque in nature and does not compromise dentin bond

ing agents. EndoREZ® can be used with conventional Endodon

tic obturation techniques and/or warm gutta-percha.

Absorbent Cones Absorbent cones or paper points are primarily used to dry the canal. They may also be used to place sealer in the canal or to apply etchant when cementing a post. The sizes correspond to the size of the prepared canal. The Autofit paper points have the same taper as the GT rotary files and the other paper points cor respond to the SSK .02 taper hand file sizes.

Smear Clea:r@ 17% EDTA)

A concentrated solution used for removing the smear

layer produced when shaping the canals. It should be

used for 60 seconds during the final stages of instrumen

tation. EDTA should be rinsed from the canal with sodi

um hypochlorite and then dried with paper points before

obturation.

Sodium Hypochlorite

(NaOel) is household bleach. This solution is used as a

disinfectant and an irrigator when cleaning and shaping

the canal(s). 5.25%

Lubricant

Sodium

Hypochlorite

Endodontics Manual II

Such as Endo-Eze, Glide, etc., should be used with

every file placed in the canal during cleaning and shap

ing the canal(s).

- 18-

Revised 09/'09

Luer Lock Syringes and Needles

The 12cc syringe is used for dispensing sodium hypochlorite (NaOCl).

The 3cc syringe is used for dispensing EDTA (SmearClear速), and/or ethanol.

Max-I-Probe Needle

This needle tip is used to dispense different solutions into the canal for irrigation and lubrication. This 30-gauge needle tip dispenses the solution laterally so irrigating solutions are not flushed or forced out the apex. The Max-I-Probe Needle should be attached to both the 12cc and the 3cc syringes.

* Be certain to rinse out your needle each day by running tap water through the

Revised 09/"09

- 19-

syringe and tip.

Endodontics Manual II

ISO,

AUTOFIT, BACKFILL

THERMAFIL速 GUTTA-PERCHA

ISO Gutta-Percha (these are all .02 taper) Used for (cold) lateral compaction obturation. ISO gutta-percha cones come in color coded vials that correspond to your hand file color and sizes. The size 20 and 25 ISO cones are used as accessory cones for lateral condensation. The rest of the sizes are used as master cones to correspond with your apical gauge size. You should have 5 boxes of size 20 cones, and 1 box of the other sizes up to a size 80.

#20

#25

#30

#35

#40

#45

#50

AUTO FIT GUTTA-PERCHA (these are various taper) Used for warm vertical compaction (WVC) obtura足

tion .

The Autofit cones are designed to fit in a canal prepared with your GT rotary files. The sizes correspond

with the size and taper of the GT rotary file used to prepare the canal to the apex . Usually, NO accessory

cones are used in WVC.

The Backfill gutta-percha is used only during some warm vertical condensation techniques.

R EF

9 7 2 -0100

GT.06

Endodontics Manual II

GT.OB

Antoftt _..-足 GT.10

GT.12S

- 20-

Revised 09/'09

Thermafil速 Gutta-percha Thennafil~,

,0 6

gutta-percha comes on a carrier and needs to be heated in an oven before it can be used. The carriers come in various sizes that correspond to the rotary file sizes.

We will be teaching only cold lateral com足 paction of gutta percha for oburation in this course Wann vertical compaction and Thennafil are additional methods of obturation. These meth足 ods will be mentioned in Lecture but not necessarily done in Lab. It is possible that a course covering these alternate methods will be available later in your dental school experIence.

ENDO TECHNIC GAUGE ("GUTTA GAUGE")

This gauge is used for sizing the Autofit cones and ISO gutta percha cones. The gutta-percha is inserted in the appropriate size opening and then the excess is cut off producing the proper size (gauge) at the tip to fit the apical gauge of the canal.

BUFFALO ALCOHOL TORCH This is your heat source that should be used for heating your Schilder heat carriers.

Revised 09/'09

- 21-

Endodontics Manual II

BUR BLOCK WITH ENDO BURS

The bur block should consist of the following: • #2 and #4 round burs for coronal access . • #16 safe-tip and #557 carbide burs for refining access. • Football-shaped Diamond for occlusal reduction.

RUBBER DAM SET UP AND CLAMPS

You should have a plastic frame, RD punch, RD pliers and a box of winged clamps. The clamps used for Endo will consist of 0, 1, 2, W2, 3, 4, w8A, 8A, 9 and 14A.

Endodontics Manual II

- 22-

Revised 09/'09

ENDO RING SET-UP The standard Endo ring set-up used for canal shaping is shown below. You need to reproduce this set up with your Endo ring and files. The set-up includes: o o

Endo ring with

l1Q!!.

autoclaved sponge

SS K-Files 10-30 plus an extra 15 file as a patency file.

Rotary GT's, 201.04, .06, .08, .10

Rotary GT's, 301.04, 301.06

Rotary GT's, 401.04, 40/. 06

Accessory file 35/.12.

In the clinic, the sponges are autoclaved for sinftle use onlv. (Front row left to right) 1) Accessory file 351. 12 (side) 2) Size 10 file (purple) 3) Size 15 file (white) 4) Size 20 file (yellow) 5) 201. J 0 GT rotary 6) 201. 08 GT rotary 7) 201. 06 GT rotary 8) 201.04 GT rotary 9) Size 25 file (red) J 0) Size 30 file (blue) ll) Size 15 file (white) (side)

(Back row right to left) 12) Size 35 file (green) 13) Size 40 file (black) 14) Size 45 file (white) 15) 301. 06 GT rotary 16) 301.04 GT rotary J 7) 401. 06 GT rotary 18) 401. 04 GT rotary 19) FF spreader (yellow) 20) F spreader (blue)

MODuPRo-ENDO

Revised 09/,09

- 23-

Endodontics Manual II

Instrument Inventory & Lab Set Up ~ession

(1)

Objectives for Session (1)

Evaluator

1) Make sure endo box is set up correctly.

2) Recognize and learn all Instruments & equipment, & be evaluated by faculty on

Instruments. 3) Review Lab manual; know grading process & expectations of class. 4) Read Session (2) material on access preparations & be prepared for next session. You may leave after all objectives have been completed for this session .

Instructor/Student - Instructor/Student

Student Initials

Instructors Initials

--~~

Notes

' 0\ Student

XXX

Student

XXX

----

*All checkoff sheets and

gradesheets will remain in student's lab manual.

They will not be torn out or collected. This will be your BACK-UP if instructor grades are lost.

Endodontics Manual II

- 24-

Revised 09/'09

SESSION

OUTLINE

ACCESS PREPARATION 1. Access of anterior teeth Anterior access preps have two angulations to prep technique : perpendicular and long axis. Steps for anterior access preparation: • Gauge depth of pulp chamber, place stopper or mark on bur at this measurement. • Pencil outline, then lightly prep outline form at a perpendicular angulation to the lingual surface of the tooth. • Change the anguJation so the bur is in the long axis of the tooth centered in access. • Remove entire roof of pulp chamber and smooth access walls. Things to remember for all access preps : ./' Make sure the access outline is centered on the lingual of the tooth between the incisal edge and the cingulum (3mm rule) .

./' Make sure the pulp chamber is compJetely un-roofed; check with explorer.

./' Make sure the walls are smooth but not damaged.

./' Make sure you have straight-line access to the canal.

./' Make sure the tooth integrity is not compromised.

2. Access of posterior teeth Posterior teeth have only one angulation to the prep technique; long axis. Steps for posterior access preparation: • Gauge depth of the pulp chamber; set stopper or mark on bur at this measurement (7mm) . • Pencil outline, then prep outline form with bur in the long axis of the tooth. • Continue to prep apically until you reach the pulp chamber; never prep deeper than the stopper. If unable to find pulp chamber, check with instructor. • Un-roof the entire puJp chamber, smooth walls and make sure you have straight-line access to canal. Things to remember for access preps on multiple canal teeth:

./' Make sure you don't prep too deep and damage or perforate the floor of the pulp chamber.

Perforation = start over (new tooth)

Have all five access preps checked and signed off by table instructor in your lab book.

Revised 09/'09

- 25-

Endodontics Manual II

ACCESS

To prepare the access for all teeth you will need the following: • #4 round bur; Mandibular Incisors will need #2 round bur. • 557 bur • # 16 safe tip flame diamond • High speed handpiece • Endo explorer

In future lab sessions, when you have mounted the teeth in the ModuPro-Endo, you will also need your nlbber dam set up, clamp with floss and mouth mirror. You may access the tooth with or without the nlbber dam in place, however once the pulp chamber has been reached, th e rubber dam must be placed. In the clinic it should remain in place throughout the procedure for isolation even during X-rays. However for lab pUlposes you may remove the rubber dam to take X-rays.

Maxillary Anterior tooth access preparation Before preparing the tooth, you will need to gauge the depth of the pulp chamber, from the incisal edge to the roof of the pulp chamber on the X-ray, to determine the approximate depth of the access prep. This will help you to know how deep you should continue to prep when looking for the pulp chamber.

Gauging

The shape of the access will be triangular in shape, with rounded comers, located just above the cingulum area. As shown below, it may be helpful to outline the access shape with a pencil. Have this outline form evaluated by your table instructor before you continue. The maxillary lateral incisor access is narrower mesio-distally and more ovoid.

Endodontics Manual II

- 26-

Revised 09/'09

First, begin the prep by using a #4 round bur or a 557 bur to lightly prep the access outline form , about .5 mm deep , into the tooth. Next, change the angulation of the bur and hand piece so the bur will penetrate the tooth in the long axis of the tooth so the pulp chamber can be reached. If the angulation is not in the long access of the tooth you may damage the walls of the pulp chamber or even perforate the tooth. Once the pulp chamber is reached you will feel the bur drop into the pulp chamber.

I~ine Fonn

/ o 1 6 Endodontic Explorer

Last, you wi II need to clean up the access prep. Remove the entire roof of the pulp chamber, with a #4 round bur, and smooth the walls with a safe tip or flame shape diamond or a #557 bur; make sure the walls are extended properly for straight line access. All of the decay must be removed from the tooth; if removal of the decay compromises the access, it must be restored with composite or triad material. Your access prep should allow for a straight-line access of the canal, but do not over extend your access and compromise the integrity of the tooth.

/ , \

Use a round-tipped bur to avoid gouging

Revised 09/'09

Removing Facial and Lingual "Triangles"

-27-

Endodontics Manual II

Below are common access errors that may occur. Most preparation errors are due to inaccurate angulation of the bur to the long axis of the tooth and pulp chamber. Most perforations occur to the facial or the proximal; seldom to the palatal. If you reach 7 mm. depth on your bur and are not in the chamber, STOP and call

an instructor (in Lab or on the Clinic floor).

Mandibular Anterior tooth access preparation The Mandibular Incisor has an access that is more oval or circular in shape, unlike the triangular access preparation of the maxillar central incisor, depending on the number of canals present. Mandibular central incisors often have two canals. A #2 size round bur may be needed to safely prep the access of Mandibu足 lar Incisors, which are much smaller.

Access must move incisally to find second (lingual) canal orifice

I canal

2 canals

Posterior tooth access preparations All posterior teeth access preparations are prepared entirely in the long access of the tooth, only the shape of the access changes. Max Molars Make sure to gauge the depth of the pulp chamber so you will not prep too deep in the chamber and perforate the furcation area or damage the pulp chamber floor. Seven millimeters is the critical depth. If you are at 7 mm, without dropping into pulp, STOP and call an instructor. First, pencil in the access outline and have it evaluated by a table instructor. The outline of the access will be triangular in shape and have rounded comers. The location of the triangular prep should usually be in the mesial pit area of the max molar. Endodontics Manual II

- 28-

Revised 09/'09

Begin access by using a #4 round bur and prep lightly the outline fonn of the access about .5 mm into the tooth, keeping the bur in the long axis of the tooth. The ideal access prep will not extend across the oblique ridge, but it may be necessary to find all the canals. Evaluate the floor of the pulp chamber to find canals; if the floor is undamaged you should be able to see lines that lead to the canal openings. Fol足 low the lines in the floor to find all of the canals. Occasionally you will find only three canals, the mesio-buccal, the disto-buccal and the palatal canal. Often you will find a fourth canal just palatal to the mesio-buccal canal. The mesio-buccal canal is gener足 ally located directly below the Mesio-buccal cusp tip.

I I

/ F

Revised 09/'09

Removing B. & L. "Triangles"

- 29-

Walls must diverge slightly to the occlusal.

Endodontics Manual II

MANDIBULAR MOLARS

The Mandibular Molar access prep is very similar to the Max Molar but with a slightly different size and shape to the triangular outline form as shown below. The apex of the triangle may be expanded somewhat (bucco-lingually in case of two distal canals). Look for two canals at the distal. You will prep the access in the same manner as the Max Molar as described above previously.

MAXILLARY AND MANDIBULAR PREMOLARS Both Maxillary and Mandibular Premolar access preps are oval in nature. The Maxillary Premolar prep will be more of an elongated oval to access both buccal and lingual canals. However, the Mandibular Premolar generally has one canal and therefore will be a smaller rounder oval unless the tooth appears to have two roots or canals.

Endodontics Manual II

- 30-

Revised 09/'09

Access Preparation

Session (2) Objectives for Session (2) 1) Prep 5 total; one prep tooth must be acceptable A) Correct Shape B) Proper Location C) Adequate size D) Straight-Line Access E) Smooth Walls of Access

Max Anterior

Instructor check off (+ or -) Max Mand. Max Mand. Premolar Premolar Molar Molar

1st

2nd

1st

2nd

1st

2nd

1st

Total %

2nd

2) Have all preps evaluated and checked off by the table instructor. 3) One tooth must be at least 80% acceptable in each category, or you will need to prep more teeth. 4) You may leave when all of the above objectives are completed.

Revised 09/'09

- 31-

Endodontics Manual II

SESSIONS 3

OUTLINE: CANAL INSTRUMENTATION

(PLASTIC MOlAR)

Hold molar in your hand for this exercise. After this, all teeth will be mounted in ModuPro-Endo and rub

ber cam used. I) Understand the following: • Patency (#10 or #15 file out apex up to Imm long)

• Working length (WL) = point of paten cy minus 1.0mm

• Estimated total length (ETL)

• Double Apical gauging (initial & final)

• Trial length (TL)=ETL- 1 mm.

• The Apical Control Zone (ACZ)

2) Steps for Instrumentation of each canal: See complete notes Appendix E. • Establish trial working length for each canal and take WL film with.02 SS hand fi les in all canals (use # 15 or 20 files in order to see clearly on XR).

• Obtain patency with lubricated file (no larger than a #10 or #15) no longer than 1 mm. long. • Estimate ETL and TL either by meas uring tooth in hand before mounting or measure on radiograph; document

• Determine working length & record same.

• Irrigate with NaOCI and continue to maintain NaOCl in the canal.

• File to WL with hand files up to a size 20 file.

• Open Radicular access of canal; use size 35/.12 and/or 20/.10 rotary file and instrument to pre-set stopper 5 mm away from apex. Irrigate.

• Check initial apical gauge for each canal and document; irrigate. • Instrument with GT rotary files 20/.1 0, 20/.08 , 20/.06 corresponding to apical gauge to (WL minus 4mm) for each canal; irrigate.

• Instrument with size 201. 10 rotary files to mid-root. Irrigate. (We will not be using Apex Locators for this exercise.)

• Confirm patency with # 10 or # 15 file

3) Hand file instrumentation with Watch-winding and Serial Step Back (SSB) technique. 4) *Please complete readine this complete section. definitions and descriptions as well as the section in the appendix entitled "The 8-Step Prep." (Appendix E) Before you continue with your preparation. Things to remember: ./ Make sure all files are checked each pass for damage and debris removal before re-insert ing into the canal. ./ Make sure to copiously irrigate and that NAOCL has been in tooth for at least 30 - 45 min. before obturation. ./ Use light apical pressure with rotary files; do not force them into canal.

./ Make sure XRs are properly exposed & you can see the apex of all canals. ./ Make sure the file used for the WL film is the largest file that binds at the TL; this should be at least a size 15 file so it will be visible in the film all the way to the apex . ./ Use lubrication for all files every time. ./ Follow with irrigation & re-check patency.

./ Make sure WL is 1mm from radiographic apex. Endodontics Manual II

- 32-

Revised 12/'03

When you have completed the instrumentation of the Molar have it evaluated and checked off by your table instructor. The Molar prep. must be completed at session 4.

*Small canals consist ofmesial canals ofMandibular Molars and buccal canals ofMax Molars, lower

incisors, 2 or 3 canal maxillary premolars and 2 canal mandibular premolars.

*Large canals consist of distal canals of Mandibular Molars and palatal canals of Max Molars.

Your "Shaping Objective" for: small canals is probably 30-.04 or 30-.06

medium canals is probably 30-.06 large canals is probably 40-.04 or 40-.06 Patency

Maintaining patency throughout the root canal process is very important. Patency is checked and main足

tained by placing a size #10 or #15 file into the canal so that it slightly passes slightly through the apex.

This can be measured by using the WL + 1mm. This must be established at initial scouting and maintained

following each active instrumentation.

Estimated Total Len2th

Estimated total length CETL) is the length of the tooth measured on the tooth or x-ray with an endo ruler

from cusp tip to apex.

Trial Len2th

Trial length CTL) is the ETL minus 1 mm.

Workin2 Len2th

The measurement to which you want to instrument the canal is the Working Length.

The Working Length (WL) is determined by the position of a pre-measured file (set at trial length) in the

WL x-ray. WL must be established 1 mm. short of radiographic apex.

Scenario 1: If your TL is 20mm and you take a WL X-ray with a file in place at 20mm and the file is 1mm or less short of the apex on the XR, then your working length is also 20mm, because your TL was correct.

Scenario 2: If your TL is 20mm and the file pre-set at 20mm appears long or short more than 2mm from apex, you need to adjust the length of the pre-set file. The amount of adjustment will correII spond to how long or short it appears in ! the x-ray. You must take a new film to \ verify that the adjustment made was cor足 rect and then document your correct WL. You do not have to change the document足 ed TL but save both WL x-rays to explain the difference in TL from the WL.

Revised 09/'09

- 33-

Endodontics Manual II

Scenario 3: If your TL is 20mm and the file pre-set to 20mm is within 1mm short Ii

or long, you may change your WL and document the correct WL. The Film will 1:- explain why the TL and the WL are not the same. So, if it appeared long 1mm your "\

WL would be 19, but if it appeared short your WL would be 21. If you only adjust ed the WL by 1mm or less from the trial length you do not need to take a new film.

(Double) Apical Gau2in2

Apical gauging means determining the size (diameter) of the apical foramen by

PASSIVELY inserting hand files into the canal until one binds at the apical con

struiction (without going patent). You check for binding by placing a file to the WL

and lightly tapping on the end of the file. If the file does not move, then the size of

that file is the apical gauge size. If the file moves apical, it is smaller then the api

cal foramen. If it will not go to WL it is larger than the apical gauge. You should

do the (INITIAL) apical gauging soon after first establishing patency and the

(FINAL) apical gauging should follow your final shaping to confirm your Master

Apical File (MAF) which is the largest file you took to WL. Of course, the Initial and Final Apical

Gauges should remain the same size. Your enlargement all takes place at working legth (WL) which is I

mm short of the Apical Gauge Area. The (FINAL) Apical Gauge merely confirms maintenace of the api

cal constriction and the diameter at WL of the MAF as well as the "step-back." Start with the size file that

corresponds to the tip size of the largest rotary or hand file used in the canal to the working length (it

should not tap past the WL). Next, you should check for the proper apical taper in the control zone when

successively larger hand files "step back" from the working length proper apical taper is reached.

Master Apical File

Once you have done your crown down procedure to (WL minus 4mm) and have established and docu

mented the correct WL and initial apical gauge, you may enlarge the canal at WL with SS hand files.

Start with the #20 hand file (watch-winding) and confirm that it has been worked until it is loose in the

canal at WL. The file will not be loose in the canal until you have done ~ tum and pull motion or Bal

anced Force Technique(BFT ) Next, proceed to #25 hand file. The #25 must be worked in the canal until

it is loose at WL (inspect file, irrigate, check patency and lubricate between each file).Then proceed to the

#30 and #35 as the minimum. The MAF is traditionally a minimum of 3 file sizes larger than the initial

apical gauge but one should file larger if the canal requires it to show clean, white filings. In cases of

extreme curvature of the canal a smaller MAF may be required. Special methods are necessary and tum

out to be a compromise between the need to adequately enlarge and the need to accommodate the natural

curvature of the canal.(see "Dealing with Curved Canals" in Appendix F). Your teeth have been selected

to have no greater than 20 degrees of curvature so this should not be much of a problem until you hit the

clinic floor.

Serial Step Back Filin2

Now that you have created your MAF size at the WL, it is time to create a tapered form (the Apical Con

trol Zone) or ACZ coronal to the MAF at WL. Do this by a technique called "Serial Step Back" (SSB).

SSB requires that you select the next size larger hand file than your MAF file and work it to within ~ to

1 mm. short of WL. If you select ~ mm step back, you will be creating a larger .10 taper while a 1mm .

step back produces a narrower .05 taper. Generally, the larger the canal, the greater (wider) the required

taper. In either instance, you will need to continue increasing file size and stepping back the prescribed

amount until you have stepped back at least to WL-4 mm.(4-8 files depending upon the taper selected).

Do your Final Apical Gauging now. Endodontics Manual II

- 34-

Revised 09/'09

THE APICAL CONTROL ZONE

(FINAL) APICAL GAUGING足

CONFIRMING THE TAPER Use the next size file larger than your final apical gauge (MAF) size and it should bind at ~ mm. to 1 mm shorter than the last. Then use the next size larger file and make sure it is binding another 112mm to 1mm . shorter than the last. Continue until you have checked the taper back from the working length by 4mm (total 4-8 files) . This 4 mm area is known as the Apical Control Zone (ACZ). This area needs to have an adequate taper so the Master Cone will fit properly and not be pushed out the apex during obtura足 tion. As shown in the picture below, the apical gauge is a 25 and the size 30 binds ~ mm from the apex and the 35 binds 1.0mm and the 40 binds 1and ~ mm from the apex. This displays the proper apical taper and resistance fonn needed to reduce the chance of pushing gutta-percha out the apex. If you do not have this continual taper you need to re-file stepping back in Y2 to I mm increments. The illustration demonstrates a .10 taper. If SSB increment was 1.0 mm rather than Y2 mm, the taper would be a .05 taper. In either case, one must continue the SSB to at least WL minus 4rnm. (4 files are required in the .05 taper and 8 in the case of the .10 taper).

The actual diameter (size) of the required Master Apical File (MAF) is detennined as a compromise between: 1. The need to adequately enlarge the canal for cleaning and shaping purposes 2. The need to maintain the basic shape of the curve of the canal without transporta足 tion of the apex. (see Appendix F)

Revised 09/'09

- 35-

Endodontics Manual II

20 Suggestions to help PREVENT the Heartbreak of Separation of NiTi Rotary Files 1. Proper Outline Form

2. Straight-Line Access 3. Pre-Flaring 4. Crown Down Procedure 5. Variation of File Taper & Recapitulation by going back to crown-down procedure 6. Continual Use of Lubricant in Canal (Glyde, R.C. Prep., etc.) 7. Use rotary instrument in canal NO LONGER THAN 4 sec./use. (At 250 r.p.m., this is 16.5 revolu足 tions) Would you rotate any instrument this many times (even by hand) without checking it? 8. Beware of Taper-Lock and Strain Concentration. 9. Continual Inspection oflnstrument after each 4 sec. Use in Canal 10. Inspect instrument before and after each use . 11. Use a new Instrument at least for each tooth (perhaps for each canal) 12. Change instruments even more often with extremely curved canals. (maybe 2 per canal). 13. Proper selection of Shaping Objective for each Canal. 14. Do not try to take Rotary Engine-Driven File to apex. (Do last 4 mm . by hand) 15. Do not try to take Engine-Driven File around a curve of 20 degrees or more. (Do by Hand) 16. Use ONLY recommended r.p.m. for each instrument and situation. 17. Do NOT change r.p.m. in contact with tooth (i.e. reach operating r.p.m. before touching tooth and do not change r.p.m. until free from tooth) 18. Do not sterilize Ni-Ti Files in contact with any Stainless Steel instruments (as this can deteriorate Ni-Ti) . 19. Use NO PRESSURE. Do not force instrument. Use no more pressure than you would use to "pet a razor blade" with your finger. Let the weight of the HP direct the milling. When resistance is met, recapitulate with the sequence of variable taper files. Resist the urge to push that last little bit! 20. Do NOT depend on any torque-control device to prevent instrument separation.

Motor-driven rotary files can break in a heart beat. Separation of a file in a canal is a serious inci足 dent and the file segmentation can rarely be removed or by-passed. A separated file results in an automatic grade reduction of 21 points and requires an "Incident Report" in the Clinic. In real life, instrument separation can be very expensive.

Endodontics Manual II

- 36-

Revised 09/'09

INSTRUMENTATION Checking patency:

You should always irrigate with NaOCI and leave the NaOCI in the canal at all times.

Insert a lubricated size 10 or 15 hand file, with stopper set Imm longer than the ETL, into the canal until the stopper reaches your reference point or landmark (incisal edge) to establish patency. Make sure the stopper is perpendicular to the reference point. If the stopper will not go down to the reference, the canal is not patent. Do NOT force - call an instructor. If the canal is patent continue to next step. If the canal is not patent, find the table instructor to evaluate your tooth, as you may have excess debris or a ledge in the canal. If you forgot to lubricate (Glyde, Endo-EZE, etc.) you may have already blocked yourself out. Do NOT push on your file to FORCE it apically (you will create a worse ledge or a block age which will prevent you from reaching the apex). The instructor will determine if you have LOOSE resistance to apical advancement which indicates an abrupt curve and he/she will demonstrate a special technique to deal with the issue. Irrigation and lubrication of the file goes a long way toward preventing the packing of debris in the canal to constitute a blockage. Instrumentation of the canal(s) can be done with rotary or hand files. We will initially use the Crown Down Technique which employs rotary instrumentation. (When hand files are used exclusively, an apical stop is first created and the taper of the canal is prepared with the Serial Step Back technique). We will then finish the ACZ using SSB hand filing techniques. The Crown Down technique: is considered a preparation which prepares the canal(s) in the coronal region first, then the mid-root, and finally the apical region. Larger instruments are used in the beginning and you work your way down to smaller instruments as you work through the sequence. Rotary to 4mm away from the apex (WL-4mm) Radicular access: (Must have straight line access before using rotary files in canal) Open canals up with a 351. 12 and/or 20/.10 accessory rotary file into the first 113 of the canal; about 3-5mm. This will allow for better access to the mid-root to prevent instrument separation and better prepare the canal for obtura tion.

t tl ·" ..

Rotary GT instrumentation to mid-root: Before you instrument the canal you should irrigate with NAOCL. All files should be used with lubrication and placed in the canal for 2-4 second intervals only. Never leave rotary files rotating in a canal for longer than 4 sec to avoid strain concentration and breakage. Make sure to clean and inspect the files after each pass. Use a 20/. 10 GT rotary file (5 rings) to instrument the first 2/3 the root; unless the root is greatly curved* or has a "high cervical break"

~\(\\ .. •

• Every time you remove a file from the tooth you need to clean it and evaluate the file for damage before re-inserting it into the tooth . • You should also irrigate the canal with NaOCI following every active instru ment. To properly clean the canal, the NaOCI must be in the canal for a full 30 mm . or more. • If the 20/.10 begins to bind go to a size 20/.08 or step down to 20/.06 or even a 20/.04 if necessary. • See following if the roots are curved.

Revised 09/'09

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Endodontics Manual II

*GT Rotary files in curved canals: The root anatomy must be evaluated carefully before using rotary files. When a root is curved, straight line access is even more important. If you have a "high cervical break" (which is a severe curve in the cervical region of the canal) the rotary instrument will "stall" at the break. When this happens the student will usually push or force the rotating file in the canal, which may cause instrument separation. One must improve the straight-line access in this case. The alternative to using rotary instruments in a curved canal is the SSK Hand File Step Back Technique using only hand files for final instrumentation. However, when using hand files in curved canals it may be necessary to gently Precurve the files, so the files can progress down the curved canal without producing a ledge or zip in the canal. When you pre curve hand files the stopper should be placed with the stopper mark or point directed toward the curve, so when the file is in the canal, you know which direction the file is curved by the mark on the stopper. Pre curve the files slightly more than the canal curve, so you don't gouge (ledge) the outside.

High Cervical Break: The angle of access vs. the angle of the rest of the canal is extreme in the cervical region. The more severe the angle or the higher the break, the greater the problem for rotaries.

Establishing Working Length: Now you will need to establish your working length (WL) . The working length is the length at which you want to instrument the canal. It is very important to determine the proper working length. The WL is determined by evaluating the accuracy of the trial length file in place on an x-ray and can also be checked with an apex locator. Your trial length TL equals the ETL minus 1mm . Adjust the stopper on a size IS or larger hand file to this trial length. Place the pre-measured file into canal. When determining your work ing length in the mouth WL you can use an apex locator, if available, in addition to taking a WL film. A WL film should be taken with the #15 or larger file in place to your TL. See Appendix L for instructions on Apex locator use. • If you are not using an apex locator you will estimate your trial length (ETL minus Imm). Get a size IS file and place a stopper to your TL. Insert the file into the canal until the stopper is at the refer ence point. Take a WL film to verify if the file is .Smm to Imm from the apex. Ifit is within Imm from the apex then this is your correct WL. So your TL will equal your WL. If it is more than I mm from the apex but you are within 2mm of the apex you can re-adjust your file measurement and note Endodontics Manual II

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Revised 09/'09

the correct WL based on how far the file appears to be from the apex. If the file is more than 2mm from the apex, re-adjust the length of the file , by moving the stopper to what appears to be the cor足 rect length and note your adjusted TL. Take a new film to verify if you are now within 1mm from the apex. Note your correct WL. Keep both x-rays to explain why your WL is different than your TL and why the TL is not 1mm less than the ETL. Note only the corrected TL measurement but do not adiust the ETL.

Hand filing apical third of the canals: Next use hand files set at your WL and file up to a size 30 hand file (minimum) using the Balanced Force Technique or watch winding technique . Make sure you irrigate throughout this process.

Balanced Force Technique: The file is engaged 1f4 turn clock足 wise; apical pressure is maintained and then the file is rotated 180足 360 degrees counter-clockwise to shear off the engaged dentin. The procedure is repeated. USE ENOUGH PRESSURE TO PREVENT FILE FROM BACKING OUT OF THE CANAL!

Instrumentation using SSK Hand File Step Back Technique to create canal taper: To prepare the canal for Lateral or Vertical Obturation using hand files you will need to first create an apical stop, then prepare an adequate flare in the canal for proper use of the spreaders or pluggers. Creating a stop is done using hand files to the working length with the Balanced Force Shaping technique or watch winding technique. The previous initiated hand filing to a size 30 should be adequate to prepare a stop unless your apical gauge is larger than a size 30 file. If the apical gauge is larger than a size 30 file, continue to file to the WL with a size 35 and then a size 40 to create a stop. Remember to always place NAOCL or a lubricant in the canal during instrumentation with rotary or hand files . Sometimes with younger anterior teeth, it may be necessary to instrument to a larger apical gauge. Recapitulate with your # 10 or # 15 patency fi Ie after each active instrument. Once the stop has been created, you will begin to shape the flare (taper) with the step back technique. To do this you will take the next larger size hand file, than was used to create the stop, and set it 1mm short足 er than the WL. This file is inserted in the canal bringing the stopper to your reference point and filing upward and outward along the walls of the canal in a circular manner, creating an evenly flared canaL Set the next larger size file 2mm shorter than the working length and again file in the same manner. This process is repeated one or two more times, with each file getting one size larger and Imm shorter from the previous length, creating a continuous flare. This flare (.05 taper) will allow room for the spreader to fit within 1-2 mm of the WL during obturation. Use your Endo File Mate to set the SSB files.

Revised 09/'09

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Endodontics Manual II

Serial Step Back Technique Table (SSB) Length 17mm 18mm 19mm 20mm

You will complete the hand file step back technique for the mesial canal of the Mandibular Molar then proceed to using GT rotary files in the distal canal.

XX XX XX 30

File Size

Final instrumentation using GT Rotary files (only when canal is straight): Place a stopper on your 201.08 or 201.06 rotary file to your WL and try to instrument to the WL. (Make sure that the canal has NAOCL in it for lubrication andlor place lubrication on the file). Do not force the files down. Use light pressure in downward motion, pulling back if you feel any binding. Make sure to clean and examine the files between each pass in the canal. Remember files break because of cyclic fatigue not because they bend. Cyclic fatigue is caused by repeated rotation of a bent or curved file. The sharper the curve in the canal the greater the cyclic fatigue; which leads to a greater chance of instrument separation. Do not re-use files that have been used in a sharply curved canal. • If the 201.08 does not easily go to the working length (WL) then set the WL on the 201.06 file and repeat instrumentation. If needed use the 201.04 next to get to the WL. Once you have reached the WL with the smaller files, re-instrument with the larger files until the correct taper is created for each size canal. (See chart below to determine the appropriate file size for y our "shaping objective " for each canal). • If the 201.04 will not go to the working length, watch wind a size 10 hand file to WL. Use the Bal anced Force Technique (114 tum then back full tum) or the watch winding technique to instrument to the WL, then continue with a size 15 and 20 (may use up to a 30) hand file to WL then go back to your rotary instruments. Recapulate (go 1 mm. patent) with your patency file after each active instrument. • If you are able to take a rotary file to WL (if anatomy allows), i.e. straight canal, eventually you will use a GT 301.06 to the working length . *If anatomy does not allow rotary to W-L, finish the last 4 mm. with SS. hand files and SSB. If the 301.06 will not go to the working length try a 301.04 to the WL. Then go back with the 301.06 to the WL. When cleaning and shaping a medium canal , you may even need to use a 301.08 to properly instrument the canal. A large canal may need to be instrument ed to the WL with a 401.06 if the apical gauge is larger than a size 30. (See chart below). LOOK TO SEE IF WHITE DENTIN SHAVINGS ARE AT APICAL 2-3MM OF THE FILE.

Shaping Objective:

Large Canal = 30-40/.08 or .06 Medium Canal = 30-40/.06 or .04 Small Canal = 20-30/.06 or .04

Small Canals

Medium

20/10

30/10

_ ............... 20108

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Endodontics Manual II

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Revised 09/'09

Maxillary Teeth Small (Yellow): Buccal canals of molars Medium (Blue): 1st and 2nd premolars Large (Black) : Canines, centrals, laterals, & palatal canals of molars

Mandibular Teeth Small (Yellow) : Mesial canals of molars &

laterals

Medium (Blue): Centrals and I st premolars

Small â&#x20AC;˘ Medium â&#x20AC;˘ Large

Large (Black) : Canines, 2nd premolars and

distal canals of molars

*Small canals consist of mesial canals ofMandibular Molars and buccal canals ofMax Molars, lower incisors, 2 or 3 canal maxillary premolars and 2 canal mandibular premolars. *Large canals consist of distal canals of Mandibular Molars and palatal canals of Max Molars. **Select the proper "Shaping Objective" for the size root your are shaping using the guidelines above.

Revised 09/'09

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Endodontics Manual II

Canal Instrumentation: Plastic Molar Tooth (#14) Sessions (3) and (4) Student Initials Small Large Canal Canal

Objectives for Session (3J & (4)

1) Canal Instrumentation; Molar

Instructor Initials Small Large Canal Canal

A) Understand ETL, TL; know how and where to document B) Understand im portance of and know how to check initial apical gauge. (lAG) C) Radicular access and mid-root instrumentation. D) Determine and verify WL; WL film. E) Instrumentation with Hand files to WL completed. F) Final instrumentation with Hand Files (step Back Technique) completed for mesial canals. G) Final instrumentation with GT Rotary files for distal canal. H) Checked final apical gauge and documented. (FAG) I) Verified control zone for consistent taper.

~ou must pass all objectives or you will need to re-instrument another tooth. rv'Vhen Instrumentation completed and checked off by table instructor you may leave for the day. ~dditional Canal Instrumentation; Molar

Small Canal

Large Canal

Small Canal

Large Canal

A) ETL & TL. B) Radicular Access. C) Mid-root I nstrum entation. D) Determine and verify WL; WL film. E) GT Hand Files to WL. F) Final Instrumentation com pleted to WL with Hand or Rotary Files. G) Apical Gauge. H) Control Zone.

ETL=Estimated total length 213 of the tooth=(ETL l3)x2 TL=Trial Length WL=Working Length Grades: 90-100 80-89.9 75-79.9 < 75

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Session 5 Outline Obturation: Lateral Condensation Rubber Dam Placement and Mixing/Using Caulk Sealer 1) Lateral Condensation of a small and large canal of a molar: o Verify apical gauge and apical control zone taper for each canal. o lITigate canals with NaOCI. Leave damp. o Fit ISO master cones in damp canal to working length for each canal; check tug back. o Take master cone film . Have XR and fit evaluated by table instructor. o Place EDTA in canal for one minute; final ilTigation with NAOCL Soak GP. in NAOCL to disin足 fect. o Dry canals with paper points; check paper point tips for wetness. o Mix sealer. o Place master cone to WL with sealer on it; do one canal at a time. o Insert spreader next to master cone to pack to within 1 mm of WL and prepare space for accessory cone. o Place accessory cones; repeat process until canal is filled . o Remove excess gutta-percha with heated plugger end of a Glick instrument and clean chamber. o Repeat obturation steps for other canals as necessary o Take final films; straight on and at 90 degrees. Things to remember:

Yellow/Red spreader: use 15-20 GP.

Blue spreader: use 20-25 GP.

Black spreader: use 30-35 GP.

~ ~ ~ ~

Make sure all master cones fit to within .5 mm . of WL the apex.

Make sure master cone has tug back and fits apical 113 of the canal.

Use spreader to within 1-2 mm of WL with moderate apical force rotating it to remove it.

Clean spreader by wiping with alcohol sponge. Do not use excessive force on the spreader or you can fracture the tooth.

Make sure all of the gutta-percha is removed coronal to the CEl

Make sure final images are properly exposed and printed with the entire tooth present on the film.

Make sure there are no voids in the fill and canals were not missed.

When you have completed the obturation of the molar have it checked off by your Table Instructor. Make sure the gutta percha is removed from the pulp chamber below the CEl If the gutta percha is left above the CEl, there may be staining of the clinical crown. On multiple canal teeth, (i.e.) premolars and molars, where a floor is present in the pulp chamber, you should remove all of the gutta-percha from the floor leaving only the canal openings of gutta-percha showing, like small pink circles.

Revised 09/'09

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Endodontics Manual II

LATERAL CONDENSATION 1. Know working length (WL), check final apical gauge, and verify apical control zone taper. 2. Verify the correct length of the master cone by using the same size paper points. Irrigate and dry canal with Ultradent .014" suction device and/or 2-3 points until totally dry. Then evaluate tip of paper points checking for wetness. If the tip of the next few points comes out wet (blood), measure the area of redness. This is the amount you want to trim off the master cone. This, of course, is appropriate only in the clinic. Your teeth do not normally bleed. 3. The canal(s) must be clean and slightly wet with NaOCI irrigation to fit Master Cone (MC). Gutta Percha cones must be disinfected by placing in NaOCI bath for 3-5 minutes. 4. Place a presoaked ISO master cone (the same size as apical gauge) to working length. Check for tug back. Take a master cone x-ray. The master cone must be within .5mm from the WL. Have table instructor check. *If the film looks good continue to next step.

*If the master cone is long or short--re-check apical gauge & WL and adjust.

(You may have to re-instrument if the WL is ok but the cone is short or long. Just because you can get a particular size file to WL does not mean the softer gutta percha will go to WL. The file must be worked in the canal until it is loose for the GP to fitlf the GP is long vs. WL. the GP tip can simply be cut off to the proper length).

5. Get spreaders ready; size FF and F. Set stoppers on the spreaders 1mm short of WL and get acces足 sory cones ready. Obtain at least 2 size 20 and 2-3 size 30 accessory cones. Soak them in NaOel bath for at least 5 min prior to use. Use the top of the specimen bottle as bath. Place them in the slots of the measuring block, starting with size 20 first then size 30, 1-2mm from WL and continue with the next in each slot back from that. You can also measure them and put a crimp with cotton forceps at correct lengths so that each one can be inserted about 1mm back from the previous cone. Have a clean, dry, size fine or size 30 paper point ready for placing sealer or use a clean file one size smaller than MAF rotated counterclockwise. 6. Place EDTA in the canals for 1 minute then irrigate with NaOCI and dry with paper points. 7. Mix sealer 8. Place sealer in canal with paper point or file. 9. Take master cone and place sealer on the tip; about 4-5mm . (only use a thin film , not too much)

insert in canal to the measured WL.

Endodontics Manual II

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Revised 09/'09

10. Take clean alcohollu bricated spreader with stopper set at l-2mm from WL and insert in the canal with a slight downward pressure using the watch winding technique until the stopper reaches reference point. (It is especially important to place 1st accessory cone within 1-2mm of WL for a good fill) Twist and remove spreader carefully while holding master cone in place. You should be able to see what appears to be a hole in the sealer where the spreader created a space for the acces足 sory cone. Insert the accessory cone in this prepared hole making sure it goes all the way to length (you may place sealer on the accessory cone to lubricate). 11. Repeat this process knowing that the stopper, on the spreader, will continue to become about Imm shorter with each accessory cone that is inserted. Continue this process until you cannot insert the spreader anymore. In the clinic, ifyou are going to leave a space for a post, (for post and core build-up) you only have to use spreader until 5-7mm short of working length. Then use heated instrument to remove excess gutta足 percha leaving only the last 5-7mm filled at the apex. A

MASTER GUTTA- PERCHA POINT

FINE ACCESSORY POINT

12. Before cutting off the gutta-percha cones you may want to check the fill with an X-ray. (If voids OCcUl~ it is much easier to remove the gutta percha if you haven't cut it oJf) 13. Cut off gutta-percha cones and remove excess gutta-percha with heated Glick instrument and down pack slightly. 14. Clean pulp chamber so the gutta-percha is below the CEl and smooth. You can do this with a hot Glick instmment, a bur, and/or some alcohol on a cotton pellet. 15. Take 2 final films: straight on and at 90 degrees. Print these out (no larger than 114 page).

Revised 09/'09

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Endodontics Manual II

Obturation: Lateral Condensation (plastic molar) Rubber Dam Placement Use of Oraseal Session (5) Objectives for Session (5) Obturation: Lateral Condensation

Student Initials Small Large Canal canal

Instructor Initials Small Large Canal Canal

1) Rubber Dam Placement 2) Understand use of Oraseal. 3) Molar Obturation A) Master cone fit acceptable. B) Master cone film acceptable. C) Access clean below CEJ. D) Obturation filled to proper length. E) Obturation complete & free of voids. F) Final films acceptable. 4) Mount Mand. Molar and one mand. P.M. ~hen

obturation of both small and large canals completed and checked off by table instructor you may leave for the day.

Endodontics Manual II

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Revised 09/'09

SESSIONS

AND

OUTLINE

Rubber Dam Placement Rubber Dam Caulk Sealer/Oraseal Mounting Teeth in ModuPro-Endo Apex locator & Mandibular Molar Endo

RUBBER DAM PLACEMENT For endo, it is usually preferable to isolate only the tooth to receive ReT (if possible). It is very important to use and place a rubber dam properly when doing Endo. The rubber dam protects the patient from dropped instruments, irrigants and debris, as well as, prevents salivary contamination and spread of infection while improving visibility. The use of the rubber dam just may keep you out of court as it positively prevents aspiration of instruments when properly used. The rubber dam is established as the standard of care. Don't do endo without it! Access may be done w/o dam but then dam must be used. You will want to use the plastic frame when performing Endo so the frame will not mask any part of the x-ray. You should choose the appropriate clamp for the specific tooth being treated and always tie a piece of floss around the clamp. The #9 is for Anteriors, the #2 is for Premolars, the #8A is for Mandibular Molars and the # l4A is for Maxillary Molars. Then punch the appropriate size hole in the rubber dam (RD). Place the clamp loop or the clamp wings in the hole punched in the RD and using the forceps place the clamp on the tooth that you will be doing Endo on. Using the Glick instrument, release the RD under the clamp to seal it around the tooth. Try to tuck the ends of the RD under. To prevent moisture leakage, you must place the caulk sealer or Oraseal (available at dispensary) around the edges of the clamp and RD. Make sure that there is no moisture leakage before you continue. If your dam leaks, your tooth is con tam ina ted.

Isolation with Rubber Dam punching tips

Nu:k

NI\:-h and Tags Ic:ul to lcann!) III the dam <:bed rur ddlris and .Il""ment of pWl< h

To lubricate underside of punched dam hole. for ease in passing through contacts. use small amount ofKY-jeUy Vaseline is difficult to remove and has an offensive taste lor some patients

Revised 09/'09

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Endodontics Manual II

MOUNTING TEETH IN MODUPRO-ENDO AND RADIOGRAPHY 1) Mount Mandibular Molar and Premolar in ModuPro-Endo. (See Manufacturers Instructions for mounting) 2) Begin Endo on Mandibular Molar: (Have steps checked off by Instructor) • Pre-op films : ETL & TL documentation. • Access (See notes on access). • Check patency; irrigate (NaOCl) • Initial Apical Gauge • Radicular access; 351.12 GT rotary file ; irrigate. (See notes on Instrumentation) • Mid-root instrumentation with GT rotary files 201. 10 and down; irrigate. • Determine WL and verify with WL film. • Hand files to size 30 at WL with serial step back technique; irrigate. • Check (Final) Apical Gauge, check MAF and Apical Control Zone taper. (FAG should = lAG) • Trim and fit ISO master cone; take master cone film verify length and fit. • EDTA ; irrigate with NaOCI. • Dry and obturate canals. (See notes on Lateral Condensation) • Clean chamber; take final films. An unacceptable Performance would include: Canals filled more than I mm short of apex. Gutta-percha extending beyond the apex. (Puff of sealer is OK) Voids in the fill. Missed canals. Un-clean pulp chamber or gutta-percha above CEl in chamber. Decay left in tooth or unfilled decay removal that compromised the access. Error in or no documentation of ETL, TL, WL, apical gauge or taper. Perforation of tooth.

(N ew tooth must be done)

Instrument separation. (New tooth must be done) You have two lab sessions (6 and 7) to complete the Mandibular Molar Endo. When you finish the Mandibular Molar you will begin the Mandibular Premolar.

At the end of session 8 you will leave your ModuPro-Endo with the completed Mandibular molar as well as pre- and post-op X-ray printouts, completed check off sheet with the grading section filled out properly, on your bench for grading. They will be graded immediately following Session 8. After the lecture you must return to the lab to pick them up one hour later. See Appendices A, L, M.

Endodontics Manual II

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Revised 09/'09

Mounting Teeth in the Endodent Apex locator Mandibular Molar Endo ~ession (6) & (7) & (8) Objectives for Session (6) & (7) & (8) Student Initials

Instructor Initials

Notes

1) Mancibular Molar mounted 2) Mandibular Premolar mounted 3) Mandibular Molar Endo a) Access b) All canals found a) Access + initial Apical Gauge d) WL determination & Apex locator e) WL film f) Hand file to size 25-30 g) Final instrumentation h) (Rnal) Apical Gauge i ) Control zone taper j) Master cone fit (tug back) & film k) Obturation acceptable I) Access chamber clean & GP below CEJ m) Final films (total 6-8) rt'ou will have two lab periods to complete endo on Mandibular Molar. This is a graded procedure iIlf"'Id must be ready for grading at the end of session (8).

Session (8) Outline

Complete Endo on Mandibular Molar

Begin Endo on Mandibular Premolar

1) Complete Endo on Mandibular Molar. Turn tooth in today at the end ofthe session. 2) Begin Endo on Mandibular Premolar: • Pre-op Films: ETL & TL documentation. • Access. • Check Patency; irrigate. • Initial Apical Gauge • Radicular Access; 35/,12 GT rotary file; irrigate. • Mid-root instrumentation with #20/ GT rotary files; irrigate throughout. • Determine WL and verifY with WL film. • Hand files to size 30 at WL; irrigate. • Appropriate size hand files to WL; irrigate. • Check final Apical Gauge and create and gauge control zone taper. • Trim and fit IS 0 master cone; take MC film to verify length and fit. • EDTA; irrigate. • Obturate canals using Lateral Condensation. • Clean Chamber; take final films

Revised 09/'09

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Endodontics Manual II

Clinical Endodontic Grade Sheet iStudent Name:

Team #

Tooth #:

(canals

-> r--_ D_a_te_:_ _ _ _ __

jpatient Name:_ _ _ _ _ _ _ __ CII

:Chart Number: __________

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Initials Required:

i lDX & Sign-in:

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ration Notes:

Grading Faculty Must Sign ::;;,t,,:.;~---=--=,'--i Below:

Notc: It is the responsibility of faculty signing in student to check for the necessary requirements and to initial OX. Faculty checking access shall e access. "'acuity grading obturation must OK fonns & films, grade obturation & assign final score and sign. Student is responsible for gradc on Gradc Shcct by Faculty rked with. Student is responsible for bringing completed graded sheet to Endo. to have grade recorded in Endo mputer. Grading begins with the full 100 nts. Each item above is evaluated and points subtracted from 100 for the final percentage score. Green Form is Regular RCT, Pink Form is Competency. Yellow form is ror DX only or ion only as on e-chair. Working past linic Hours is automatic -10 points

Endodontics Manual II

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Revised 09/'09

SESSION (9) OUTUNE Complete Endo on Mandibular Premolar

Tum in Mandibular Premolar for Grading (Graded Procedure)

Mount Plastic Maxillary Anterior in ModuPro-Endo (Graded Procedure)

1) Complete Endo on your Mandibular Premolar. Leave your Endodent, x-rays and session check off sheet on your bench for grading at the end of the session 9 today. 2) Mount Maxi11ary Anterior in your Endodent.

Mandibular Premolar Endo Mount Maxillary Anter,i or Session (9) Objectives for Session (9) Student Initials

Inst. Initials

Notes

1) Complete Endo on Mandibular Premolar. A) Pre-op films. 8) Access initial Apical Gauge C) Mid-root Instrumentation D) WL determination; WL film. E) Hand Files to WL. F) (Rnal) Apical Gauge. G) Final inst. with rotary files to WL. H) Control Zone Taper. I) Master Cone fit and film. J) Obturation. K) Oean Chamber below CEJ. L) Final Films. ~) Mount Max Anterior. rYou have until the end of Session 9 to finish Endo on Mandibular Premolar. (Graded Procedure). When the above objectives are completed, you may leave for the day.

Revised 09/'09

- 51-

Endodontics Manual II

Clinical Endodontic Grade Sheet IStudent Name:

Team #

Tooth #:

(canals->

Date:

,-------------------

iPatient Name: _ _ _ _ _ _ __

iChart Number:_ _ _ _ _ _ __

Notes:

Grading Faculty Must Sign ..:..c..:"'' t ----=-=-'-f Be Iow:

-26p Notc: It is the responsibility offaculty signing in student to check for the necessary requirements and to initial DX. Faculty checking access shall grade access. Faculty grading obturation must OK forms & films, grade obturation & assign final score and sign. Student is responsible for gctting gradc on Gradc Shcct by Faculty worked with. Student is responsible for bringing completed graded sheet to Endo. Office to have grade recorded in Endo Computer. Grading begins with the full 100 points. Each item above is evaluated and points are subtracted from 100 for the final percentage score . Green Form is Regular ReT, Pink Form is Competency . Yellow form is ror OX only or Extirpation only as on e-chair. Working past ICiinic Hours is automatic -10 points

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j - 52-

Revised 09/'09

SESSION

(10)

OU"rUNE

Plastic Maxillary Anterior ReT start to finish (Graded Procedure) This is a preview for Mock Board Exams Mount Maxillary Molar & Premolar in Endodont

1) Maxillary Anterior Endo, start to finish: (Graded Procedure) plastic tooth • Pre-op films: ETL & WL documentation. • Access. • Check patency; irrigate. • Initial Apical Gauge • Radicular access; 35/.12 Accessory fi Ie, 20/.10 GT rotary file; irrigate. • Mid-root instrumentation with GT rotary files; irrigate. • Determine WL and verify with WL film. • Hand files to size 30 minimum at WL; irrigate. • Appropriate size profile to WL; irrigate. • Check final Apical Gauge and control zone taper. • Trim and fit ISO master cone; take master cone film to verify length and fit. • EDTA; irrigate. • Obturate canal using Lateral Condensation. • Clean chamber; take final films.

2) Mount Maxillary Molar and Maxillary Premolar (extracted).

You must complete the Maxillary Anterior today_ Leave your ModuPro-Endo with completed Max illary Anterior, X-rays and session check off sheet on your bench for grading.

Revised 09/'09

- 53-

Endodontics Manual II

Maxillary Anterior Endo Mount Maxillary Anterior $ession (10) Pbjectives for Session (10) 1) Max Anterior Endo; start to finish. A) Pre-op films . B) Access initial Apical Gauge C) Mid-root Instrumentation D) WL determination; WL film. E) Hand Files to WL. F) (Final) Apical Gauge. G) Final inst. with rotary files to WL . H) Control Zone Taper. I) Master Cone fit and film . J) Obturation . K) Clean Chamber below CEJ. L) Final Films . 12) Mount Maxillary Anterior.

Student Initials

Inst. Initials

Notes

Maxillary Anterior Endo must be completed from start to finish in this session. (Graded Procedure). When all of the above objectives are completed you may leave for the day. Leave your endodont to be graded.

Endodontics Manual II

- 54-

Revised 09/'09

Clinical Endodontic Grade Sheet !Student Name:

Team #

(canals ---.J

Tooth #:

Date:

,Patient Name:,_ _ _ _ _ _ _ __

ell

c.. ell

I'CI

(,) (,)

ell

uired:

..c

I'CI

Chart Number:_ _ _ _ _ _ __

Initials

..c

I'CI

c.. OX & Sign-in:

ell

0 0 11.

(,)

(,) I'CI

Access:

Shape, Size Caries Com ete Removed Straight line access Smooth walls & access

Notes:

Grading Faculty Must Sign

~::;....,jIa.lo.~~~-_-=2--=--6P ~ Below:

-26p Note: It is the responsibility of faculty signing in I student to check for the necessary requirements land to initial DX. Faculty checking access shall :i •grade access. Faculty grading obturation must :i (I).lI: (,) " OK forms & films, grade obturation & assign !:=. Cl 3: I: I'CI .c:: I:.c:: final score and sign. Student is responsible for -eE - 0, : ~ 0, getting grade on Gradc Shcct by Faculty ~I .! o I'CI (I) I'CI .~; worked with. Student is responsible for a:: U a:: ...J I-...J ;:...J I bringing completed graded sheet to Endo. I Office to have grade recorded in Endo Computer. Grading begins with the full 100 • points. Each item above is evaluated and points are subtracted from 100 for the final percentage I I score. Green Form is Regular RCT, Pink Form

is Competency. Yellow form is ror OX only or

i Extirpation only as on e-chair. Working past Clinic Hours is automatic -10 points

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I - 55-

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I Endodontics Manual II

SESSION

(11)

OUTLINE

Maxillary Molar Endo I) Begin Endo on Maxillary Molar: (The below steps are for each canal). • Pre-op films : ETL & TL documentation. • Access. • Check patency; ilTigate. • Initial Apical Gauge • Radicular access; 35 /.12, 201.10 GT rotary file ; irrigate. • Mid-root instrumentation with GT rotary files; irrigate. • Determine WL and verify with WL film . • Hand file to size 30 minimum WL; irrigate .. • Check final Apical Gauge and control zone taper. • Trim and tit ISO master cone; take master cone film to verify length and fit. • EDTA ; irrigate. • Obturate canals using lateral condensation. • Clean chamber; take final films.

You have two lab sessions to complete the Endo on the Maxillary Molar (today and Session 12).

SESSION

(12)

OUTLINE

Complete Maxillary Molar Endo, tum in for grading (Graded Procedure) Start Maxillary Premolar (2 roots) (The Maxillary Premolar can be replaced with another molar if a two rooted premolar cannot be found). Begin vitality testing (EPT and cold, small room) 1) Finish Maxillary Molar Endo . (Graded procedure) 2) Mount Maxillary Premolar in your Modupro-End? Start ReT. 3) Begin vitality testing (EPT).

At the end of the session today leave your ModuPro-Endo with the completed Maxillary Molar, X rays, and session check off sheet on your bench for grading.

Endodontics Manual II

- 56-

Revised 09/'09

ELECTRONIC PULP TESTER(EPT) 1. Explain to patient what you are doing and that they will feel a tingling sensation at different times during the procedure. Make sure they understand that when they feeJ this they should let go of the wand. 2. Use toothpaste or fluoride on tip for conduction. 3. The tooth must be dry and isolated with cotton roJJs. 4 . Place tip on the center of the tooth being tested. (For a crowned tooth you can only test it if there is root structure showing.) Or use a "mini-probe." 5. Have the patient place their ungloved hand on the wand to complete the circuit. 6. The numbers on the dispJay will start to count upwards. 7. The speed can be changed if the display is counting too slowJy or too fast. (Start slowJy.) 8. Have patient let go of wand when they feel the tingling. If they do not feel it, the numbers will

stop at 80.

9. Document results by tooth number. Range:

Normal

30-50

Suspicious <50-60 Necrotic

<60-80 (But you still must consider control teeth.)

Control teeth must be used and documented as well; test adjacent, opposing and contra-lateral teeth before you test the suspected tooth. (Always test control teeth first.)

EPT testine: can be inconclusive if the tooth has vital pulp tissue remaining anywhere in the tooth. (i.e. th e mesial canal can be necrotic but still have vital tissue in the distal canal.) However the response is usually more vague and delayed somewhat. Healthy adolescent permanent pulp may not respond at all until late teenage years. Temperature testing may be more accurate, if done properly, than EPT testing. Isolation is the key to get足 ting accurate thermal test results. Revised 09/'09

- 57-

Endodontics Manual II

Cold Testing: is done with endo ice sprayed on a large cotton pellet held with cotton pliers or an ice stick applied to an isolated tooth. Do not use Q-tip (use cotton pellet held in cotton pliers). You must apply the saturated cotton pellet to the buccal, occlusal and the lingual surfaces and then document the results.

Heat Testing: is done with hot water in an endo syringe or with a wanned compound stick in a hot water bath. Frictional heat with a burlew wheel may also be useful. When heat testing, start with control teeth first, and then check the suspected tooth. Once you elicit a response with a temperature stimulus, the patient may give false positives to avoid recurrence of the pain. Keep cold water handy. No response to thennal testing usually means the tooth is non-vital. However no response can also be a false negative because of excessive calcification, immature apex, recent trauma, or recent use of pain meds. A mild to moderate momentary response is with in nonnallimits (WNL). An exaggerated response that subsides quickly is characteristic of reversible pulpitis. A painful response that lingers is consistent with irreversible pulpitis.

Endodontics Manual II

- 58-

Revised 12/'06

Maxillary Molar Mount Maxillary Premolar Begin Vitality Testing with EPT Sessions (11) & (12) Pbjectives for Session (11) & (12)

1) Maxillary Molar Endo. A) Pre-op films; ETL & TL. B) Access. C) Locate all canals. D) Mid-root I nstrumentation; each canal. E) WL determination; WL film . F) Hand Files to WL; each canal. G) Apical Gauge; each canal. H) Finallnst with rotary files to WL; each canal. I) Control Zone; each canal. J) Master Cone fit; Master Cone film. K) Obturation; each canal. L) Clean Chamber below CEJ. M) Final Films. ~) Mount 2 rooted Maxillary Premolar. 3) Begin vitality testing with the EPT.

Student Initials

Instructor In itials

Notes

XX XX XX XX XX XX XX XX XX

You will have 2 sessions to complete Maxillary Molar. (Graded Procedure). When you are finished with the above objectives you may leave for the day.

Revised 09/'09

- 59-

Endodontics Manual II

Clinical Endodontic Grade Sheet jStudent Name:

Team #

Tooth #:

Date: -> r----------------------

(canals

iPatient Name: _________________ ~

I ~~~~~~~~~

~ OX & Sign-in :_ __

iChart Number: _ _ _ _ _ __

°g 41

Z ta

---r~~~~'-~~

Access:

Notes:

Grading Faculty Must Sign npvn': ,::-'+---~ Below:

Note: It is the responsibility of faculty signing in student to check for the necessary requ irements and to initial DX. Faculty checking access shall grade access. Faculty grading obturation must OK forms & films. grade obturation & assign final score and sign. Student is responsible for getting grade on Gradc Shect by Faculty worked with. Student is responsible for bringing completed graded sheet to Endo. Office to have grade recorded in Endo Computer. Grading begins with the full 100 points. Each item above is evaluated and points are subtracted from 100 for the final percentage scorc. Green Form is Regular ReT, Pink Form is Competcncy. Yellow form is for DX only or Extirpation only as on e-chair. Working past Clinic Hours is automatic -10 points

Endodontics Manual II

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I - 60-

Revised 09/'09

SESSION

(13)

OUTLINE

Instrument and Obturate Maxillary Premolar (Molar may be substituted) Continue vitality testing (large room) I) Begin Endo on Maxi lIary Premolar: (The Premolar must have two roots). • Pre-op films : ETL & TL documentation. • Access . • Check patency. • Radicu lar access; 201.10 rotary file; irrigate. • Mid-root instrumentation with GT rotary files ; irrigate. • Determine WL and verify with WL fi 1m. • Initial Apical Gauge. • Dot not use a hand file any larger than a size 20 • Use GT rotalY files to your WL up to a .06 taper (if possible) • Check Final Apical Gauge and control zone taper. (If your apical gauge is larger than a size 20 or the taper of the control zone is prepared larger than a .06 taper check with your Instructor. In order for the Autofit cones and the Thermafil® to work for Obturation, you can not exceed these limits). 2) Continue vitality testing (EPT) . You will complete the instrumentation and obturation of the Maxillary Premolar.

Have all steps checked off by your Table Instructor.

Be sure to get your vitality testing session checked off.

Maxillary Premolar Access & Iinstrumentation Continue Vitality Testing with EPT Session (13) Student Initials

Objectives for Session (13)

1) Maxillary Premolar: Access & Instrumentation Only A) Pre-op films: ETL & TL B) Access C) Locate both canals D) Mid-root instrumentation; each canal E) WL determination, each canal: WL film Initial Apical Gauge F) Hand Files at WL to size 20 File; each canal G) Apical gauge; each canal (Needs to be size 20) H) GT rotary 20/ .06 to WL; each canal Final Apical Gauge I) Control Zone; each canal (Need .06 taper) 2) Continue vitality testing (EPT). Obturate with lateral compaction iYou May leave after you complete the objectives listed above.

Revised 09/'09

- 61-

Instructor Initials

XX XX

XX XX XX XX

Endodontics Manual II

SESSION

(14)

OUTLINE

Preparing for the Clinic: Forms and Procedures will be outlined and explained. A Brief presentation of Emergency Triage will be reviewed Indications for Pulpotomy vs. Extirpation decisions. Complete vitality testing and be sure to be marked off. Complete all requirements of course. Have your mandibular premolar approved by your table instructor and mount it in your ModuPro足 Endo in preparation for your Final Lab exam. Do NOT begin access or preparation on the mounted premolar.

Session Objectives: 1) Complete Basic Skills Exam

n. (Diagnosis and TX planning of a clinical case)

2) Review guidelines for Emergency Diagnosis and Endo classification. 3) Learn difference between Pulpotomy and Extirpation and know when they should be performed. 4) Continue vitality testing with the EPT. 5) Perform vitality test on partner and learn to fill out the Emergency Diagnosis form. (This will be done in groups)

BASIC SKILLS EXAM I To complete your basic skills exam you will need to set up your area as if you were going to perform Endo in the clinic. No written test will be administered. Your set ups will be evaluated by table instruc足 tors .. You must pass the set up exam before you may perform any Endo on the clinic floor. You did this during Session I, so you don't need to repeat it. Your first endo procedure must be scheduled with an endo faculty in the endo clinic. The patient does not need to know but please tell your endo. faculty that this is your first clinic case and ask him to stay with you.

The following Items are necessary to start RCT in the Clinic: 1. Complete Medical History, vital signs 2. At least 2 x-rays of diagnostic quality 3. Diagnosis is complete and Documented on proper Form 4. Treatment Planning in the Team is completed 5. AAE Case Difficulty Form is completed (Approval by endo faculty above Levell Risk Cases) 6. Informed Consent perf01med and appropriate consent forms completed 7. Instructor sign-in 8. paid or Fee Waivered.

PULPOTOMY VS. EXTIRPATION (EMERGENCY TRIAGE) Pulpotomy: is the removal of the coronal portion of the pulp leaving vital pulp tissue. A pulpotomy should always be performed with a RD in place. Prep access to the pulp chamber removing the entire roof. The coronal portion of the pulp should be removed with a sterile sharp spoon or round bur. An abrasive round diamond bur may also be used. Once the coronal pulp tissue is removed you should irrigate with sterile saline or sterile water to remove all debris. Do not blow air on the exposed pulp tissue because it can cause desiccation and tissue damage. Hemorrhage is controlled by applying light pressure with cotton pellets slightly moistened with saline. NaOCI can also be used to control hemEndodontics Manual II

- 62-

Revised 09/'09

orrhage. If hemorrhage can not be controlled then you need to evaluate the pulp chamber for remnants of

pulp tissue above the amputation that may still be bleeding. If the chamber is clean then you may need to

remove more pulp tissue apical to the existing level and try again to control the bleeding. In a primary

tooth hemorrhage control may be performed with fonnocresoJ, check with your Pedo. instructors. Once the

hemorrhage is controlled calcium hydroxide or MTA is placed in the canal against the pulp stump and the

tooth is sealed with IRM and composite. A pulpotomy should be performed when you have an immature

permanent tooth with open apexes and a vital pulp or when vital pulp tissue is exposed in a prjmary tooth.

Sometimes a pulpotomy can be perfonned in a permanent tooth, as an emergency treatment, when you

have a carious exposure. This will always require full RCT at a later appointment. If a pulp extirpation can

be performed in this situation it is recommended, unless the tooth has an open apex. An open apex will

require apexogenesis (or apexification if pulp is necrotic).

Extirpation: is the removal of vital or necrotic pulp tissue to the apex.

A pulp extirpation is the emergency treatment of choice when you have a necrotic pulp, irreversible pul

pitis or a carious pulpal exposure of a pennanent tooth with closed apexes. An extirpation is always per

fonned with a RD in place. The tooth is accessed and instrumented to the WL as described previously.

When all of the pulp tissue has been removed and the canal has been irrigated and dried (calcium hydrox

ide) TempCanal® , may be placed in the canals. TempCanal® can also be used when you are unable to

control hemorrhage in the initial visit. If during the removal of decay any wall structure was removed,

flowable composite should be placed as a temporary to restore the wall structure. If IRM or Cavit® is

placed without adequate retention it will come out. The occlusal access can be sealed with IRM or Cavit®,

however if you are not re-appointing the patient within a few days for the completion of the RCT, flowable

composite should also be placed over the temporary to seal the occlusal access.

The Endodontic Diagnosis Form

In the clinic you will need to fill out an Endodontic Diagnosis form for every root canal procedure you do.

You wiH use the yeUow form for emergency chair diagnosis. When the yellow fonn is used during

emergency chair, only the procedures completed will be filled out. If an extirpation is completed in E.

chair, use the green form then only half of the back will be completed. In this case you will want to make a

notation on the sheet that an extirpation was completed so you will get credit for both the emergency diag

nosis and the extirpation. If the endo is then completed at a later date, you will want to complete the green

Clinical Endodontic grade sheet (similar to the grade sheets you used in this course) for the remaining pro

cedure steps so you will receive credit for the number of canals you completed. These completed sheets

will be stapled together for that patient and turned in together. When the RTC is completed by you and

your faculty member make sure they also fill out a grade sheet for this endo case. Each case wi II be graded

and recorded to give you your Clinical Endodontic grade. Pink form is used for competency exam only.

Endodontic Case Difficulty Assessment Form

The Endodontic case difficulty assessment fonn should be filled out for every endo case you diagnose.

Endo. faculty will initial the fonn.This will help you and the faculty member to detennine if the case can

be treated by you, in the undergraduate clinic, or by an Endo Honors student or by Grad Endo.

Endodontic Accident Policy

Please read this policy and become familiar with it so you have an understanding of the policy before you

begin treating patients in the clinic.

Procedural Incident Report Form

This form must be filled out for every endodontic incident. (Perforation/Instrument separation) When an

incident occurs in the clinic the above policy and procedure is followed.

Revised 09/'09

- 63-

Endodontics Manual II

Clinical Endodontics Diagnosis Form: Chart # _ _ _ __

StudentDoctor: ____________________________________________

Chief Complaint:

Symptoms:

o Tooth #

Objective Findings: Hot

Cold

EPT

Necrotic Percussion Palpation

Probing

Mobility

AssessmentlDiagnosis:

Is it PERIODONTALLY sound? Is it RESTORABLE? Is it FUNCTIONAL & STRATEGIC?

Yes Yes Yes

No No No

Planrrreatment Indications: Tooth #_ _ _ _ __

RCT TE Otber DIAGNOSIS: _ _ _ _ _ _ _ _ _ _ _ (Faculty)

Endodontics Manual II

- 64-

Revised 09/'09

Sf'CUlhcr side (or directions.

Endodontic Case Difficulty Assessment Form Patient Information Name __ _ Address ____

City/State/ Zip _ _ _

Phone __ _ _ __ _ _ __

OBJECTIVE CLINICAL FINDINGS

PATIENT CONSIDERATIONS

Medical History cardiovascular di s eas(~s

ADDITIONAL CONDITIONS

~D_i~a~g~n_o_s~is~_________ ___

Restorabilitv

inconclu sive or contradictory findings

caries

iso lation cha llenge

cerebral vascular considerat ions

f-- "-- ....!2.e~.1lor crown lengthen ing

bl eeding disorders renol dvsfunctio n

difnCuity in obti) ini~g fil ms of diag nostic valu e

medical prostht'ses abnormalities in host defen se

diabetes

f---E xistina Restoration porcelain crown

acu te systemic disease

calcificat ion

pregnancv

chamber

. need for pre-medications o ther svstem ic cond itions

I-

guldcastin~ imDa ir~c1

access to root canal

abutment

o rifice

long ax is of crown vs. long axis of root

canal

~lze

number of cana ls

crown an atomy vs. original ana tom y

Local Anesthetic Considerations

o f crown

post and core (Rate 2 or 3 only)

I vasoconstrictor con traindication

Root Morphology curvature

I anest heti c allergy history of difficulty in obtaining profound an esthes ia

Fractured Tooth

dilaceration

I crown

long

i roo t

recurvature

Personal Factors and General Considerations I limited ability to open mouth

Resorptions

length long

internal

short

external apical

_ga~er

I Apical Morphology Iopen

fear of dentistry motivation to orese rve dentition physical impairment-difficu lty holding film limit ation to be reclined si ze o f mO\lth

! 100th

~M~a~l.p~o~s~it~io~n~e~d~T~e~e~t~h~________ :J I I buccal version ~~~~~~----------~

rotated or tipped I too far dista ll y

Endo-Perio Lesion

-----.J

mobility

I attached gingiva minimal/inadequate

furcation in vol ved I--

periodontal prog nosis root section or hemisecti on considerd ti oll

Trauma

1av ulsio n

Disposition Treat in Office

PBM/PFM

Pulpal Space

menta l impairment

Radiographic Finding .:.. s _______--I

Yes

I luxation

Refer patient t o : _ _________ __ _ _ _ _ __

Previous Endodontic Treatment Ra te 2 or 3 oll,,,ly'--_ __ _ _

Date: _ _ _ __ _ _ _

TJIf' AII/f'nc.-ln I I Hori:Hion of EI/(10do" (J~/.\ " { ; \l li l l' lir l '~'> JOI A"" I·-S'•• ,~jo) I) ," Dnrlt ult " r,f r ndod(lnlir C ", ·.,

, /I ,.

(1t~\ if!IIp(I I(l ,lid

Ihe pr.-1 C'IJliGoer in rle{Cnn;f1fns ,' p/Jlopn,/{I' (I1H~ d l rpoHliol 1 111(' , Imrl ir ,l n 11H(I(' Ul iio/ I (If F' I,/Or/OIlfi(fJ 1)('Jl hf'r " .\f,, 'e.~s /; 01 illlpltc i fZI' \I / IOclf1f 5 c1 n)" f)()Slf/l J.J I t" "/!I ,H ~t'h. J ~l u·d 11 '1,11 ,II(" L.' \ !' <, fll ll 'I(' G lfldl'lllll'S TI /i' ~{' C llld d il l('\ J)I,l.' be f t'IJI (JriuCfY/IJl JI 11/<1 ., I/UI I)(; , III W ; I r/(' r/ (Jr ,l/1('rN/ i ll ,11!\ (1;1. ' (0 The t\ nJl""ril"ot ll A~soch'ljon End odontis lS, 21 1 [<lSI Chi(';)go

-_i

t\wnul"" , Suile 1100. Chiugo, 1[ 606 1 ) ·2691 ; 3 12 / 266725 5.

Revised 09/'09

- 65-

Endodontics Manual II

@ Guidelines for Assessing the Difficulty of Endodontic Cases After arriving at a diagnosis, practitioners should consider all conditions associclted with a specific procedure to be potential risk factors that could complicate treatment. Levels of risk are sets of conditions that may not be controllable by the dentist. Risk factors can • alter the course and outcome of treatment, • inOuence the ability to provide care at a consistently predictable level, and • impact the appropriate provision of care and C'juality assurance. The AAE designed the Endodontic Case Difficulty Assessment Form on the opposite page for students to use in the predoctoral clini c. The Assessment Form makes student case selection more efficient , more consistent, and easier to document. Referring dentists may also choose to use the Ass ess ment Form to help wit h referral decision making and record keeping, To use the Endodontic Case Difficulty Assessment Form to evaluate risk and determine the appropriate clinical disposition of a particular endodontic case: 1. Complete the Endodontic Case Difficulty Assessment Form by evaluating ri sk levels and assigning a rating of (I) for average risk, (2) for high risk, and (3) for extreme risk for each entity.

= Average Risk:

= Extreme Risk:

High Risk:

Preoperative condition indicates average or routine complexity (uncomplicated) and no treatment or patient impediment factors. Achieving a predictable treatment outcome should be attainable by a competent practitioner. Preoperative co ndition is complicated, presenting one or more treatment or patient impediment factors, Achieving a predictable treatment outcome will be challenging for a highly skilled practitioner. Preoperative condition is exceptionally complicated. presenting one or more difficult treatment or patient impediment factors. Achieving a predictable treatment outcome will be challenging for even the most highly skilled practitioner.

Review your evaluation of risks involved in this case to determine disposition. If anyone or more factor is rated high (2) or extreme (3) risk, then referral to an endodontist may be appropriate.

Record disposition on the lower portion of the form .

Thr III1}Cflt"tl l) ;\SSo('I{lIIOn ofEndodonliSI,{Gu ldeitnes fur i\ss~:'I!o irlg Ille Difficult y of End odolllic Cases c1rc designed 10 €lid IhtJ Pf'.1cIIIJunr/ In r!PlnminmR :-tppl'0lmEIle caSf! (iljpmillVlI. (he Allie/lean Associatioll ofEndadonrisfs n('l(lw(" (!XPI(,ss~y or I/llpllr}/~r LVDrmnts tmy posHil't rf!.w /ts a.\.wClCf/cd wilh Ih~ we or'/}t!~ (' CUJdelirres T"e5~ (;ulI:"1"Jinc.':o /lle/y IX' rf!prori(lcrd hul nI<,Y 1101 be Dm(>ndffi 01" a lfrrrri in ('lny \V.1y -0 The Arnl!ric~1ll Assuciation of Endodonllsls, 211 East Chicago Avt'nu(' , StillE' 1100, Chin;go, IL 60611 ·2 691; 3121266-7255

Endodontics Manual II

- 66-

Revised 09/'09

Endodontic Procedural Accident Policy A II Endodontic Procedural Accidents shall be rep0l1ed by the student to the appropriate faculty at the time of occurrence. Procedural Accidents include, but are not limited to: Separated instrument Perforation Root fracture These are serious incidents and we should strive to PREVENT as many occurrences as possible (see page 28 for suggestions). An Incident Report must be filled out by the student the day of the incident and the report shall be deliv足 ered to the Endodontic office or faculty member. This is not a punitive report - we are just trying to keep track of our procedural incidents. Further, some or all of the following will be required of the student by the Endodontic department follow足 ing said incident as a remediation opportunity:

1. A complete typed documentation of precisely how the incident occurred and specific steps that the student will take in the future to preclude a reoccurrence. 2. An oral interview with members of the Endodontic staff to ensure that the student is clear on proper processes and procedures. 3. Perfonn abstracts on 2 articles related to the procedural accident. 4. Perfonn abstracts on 2 articles related to the procedural accident. 5. Perfonn 4 RCF on extracted teeth in the lab. Complete with radiographs . 6. Review of clinical privileges (See Clinic Orientation Manual , Introduction Section, Page VI) .

Discovery of any attempt to conceal such procedural accident or failure to report the incident will

result in an automatic review of clinical privileges (See Clinic Orientation Manual, Introduction

Section, page VI, under "Due Process Regarding Clinical Privileges".)

And may result in suspension of privileges.

Revised 09/'09

- 67-

Endodontics Manual II

Procedural Incident Report Form (Print Clearly) Date of Incident Patient's Last Name File Number Student's Last Name

First Name

Team #

First Name

Tooth Number Through Restoration Rubber dam isolation

a. Yes a. Yes

b. No b. No

Type of incident: (fill in the blank and circle answer) A. Perforation (Size in mm.) mm 2. Zip I. Puncture Type 2.Cervical Location: I.Coronal b. Lingual a. Facial Instmment:

3. Strip 3.Mid-Root c. Mesial

f--足

5.Furcal

4. Apical

5. Furcal

J. Bur (Type & Size) a. Regular length b. Surgical length 2. Rotary instrument (Size) a. Gates-Glidden b. Peeso

c. NiTi File

3. Hand instrument (Size) b. NiTi File a. SS File

c. GT Hand File

B. Instmment Separation (Length of separated segment in mm) 2. Cervical Location: I. Coronal 6. Beyond root Instrument:

4 .Apical d. Distal

mm 3. Mid-Root

I. Bur (Type & Size) a. Regular length b. Surgical length 2. Rotary instrument (Size) b. Peeso a. Gates-Glidden

c. NiTi File

3. Hand instmment (Size) a. SS File b. NiTi File

c. GT Hand File

d. Broach

Corrective Measure (Date) Description of procedure:

'--足

Instructor Signature:

Endodontics Manual II

Student Signature:

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Revised 09/'09

Preparing for the clinic Endo Basic Skills Exam I Continue Vitality Testing Emergency Treatment: PUlpotomy VS Extirpation ~ession (14) ~bjectives for Session (14)

Student Instructor Initials Initials

1) Complete Basic Skills Exam I and II A) Pass Set Up B) Pass Written Test 2) Perform Vitality testing on partner ~) Learn how to fill out Emergency OX form ~) Review Guidelines for Emergency Ox and Endo Classification ~) Review Endodontic Procedural Accident Policy & Incident Report 6) Know difference between pUlpotomy & extirpation 7) Continue vitality testing with EPT. You will have one more session to complete the vitality testing.

Complete Vitality Testing Prepare for Fina'i Mount Mandibular Premol'ar

Session (14) Student Instructor Initials Initials

Objectives for Session (14) 1) Select and get approved Mandibular Premolar for final Mount Mandibular Premolar any single canal tooth 3) Practice for final on different tooth 4) Complete vitalrty testing with EPT. 5) Curved canal exercise When you are signed off and prepared for final you may leave for the day. ~)

Have all of the above objectives checked and signed off.

When this is complete you may leave for the day.

SESSION

(15)

OUTLINE

FINAL

Session Objectives: 1) Final exam : Mandibular Premolar ReT, start to finish. 2) Treat this as you would a Board Exam. 3) Give attention to sterile procedure .. 4) Keep sterile and clean areas separate and neat.

You may leave when you have completed your final. You will need to return to the lab at noon to pick up your ModuPro-Endo, X-rays and grade sheet.

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Endodontics Manual II

Clinical Endodontic Grade Sheet ,Student Name:

Team #

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Instrument separation Grading Non-diagnostic x-rays: entire tooth, including 1-2mm bey...o... n"'" d"'"'r------=-2-:-SP'-' Below: not resent on all no final XR w/o RD Clam -2Sp NaOCI accident or Unacceptable Treatment of Patient (100 points possible) Total Score Note: It is the responsibility of faculty signing in student to check for the necessary requirements and to initial [)X. Faculty checking access shall grade access. Faculty grading obturation must OK fonns & films , grade obturation & assign final score and sign. Student is responsible for getting grade on Gradc Shcct by Faculty worked with. Student is responsible for bringing completed graded sheet to Endo. Office to have grade recorded in Endo Computer. Grading begins with the full 100 points. Each item above is evaluated and points are subtracted from 100 for the [mal percentage score. Green Form is Regular RCT, Pink Form is Competency. Yellow form is for OX unly ur Extirpation only as on e-chair. Working past .Clinic Hours is automatic -10 points

EndodontiCS Manual II

Faculty Must Sign

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Revised 09/'09

ApPENDIX A: RADIOGRAPHS NOTE: Should digital radiography be available, you will NOT be required to print and retain your working radiographs (i.e. working length, master cone, etc.) You should print out and have availÂ able at grading only the following: your pre-op and final films. Size of the print-outs to no larger nor smaller than ~ page. Plan your work to avoid long lines at the digital terminals. Please work swiftly at the terminal and sheet as few films as you can to gain the information you need. Your courtesy at the terminal wiJI be appreciated by your fellow students.

* A TA will be available in the lab to assist with digital radioraphs (at least the first session or so). You should have one facio-lingual and one mesio-distol radiograph for pre-op films and the same for post-op films.

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ApPENDIX

VERTICAL COMPACTION OF WARM GUTTA PERCHA

VERTICAL CONDENSATION Make sure the canal(s) are cleaned and shaped properly before obturation. Canal(s) must be properly shaped in order to allow penetration of heat source and pluggers to within 4mm of WL. 1) Fill one canal of the Maxillary premolar with Vertical Condensation. • Verify apical gauge, WL and control zone taper. • Choose the appropriate size Autofit cone and trim if necessary using the Endotech gauge. • Insert the Autofit cone into the canal to the WL and check for tug back. • Take a WL film to verify length and fit. • Set lengths of the heat can-iers and pluggers as noted. • Mix sealer. • Obturate using Vertical Condensation. (See notes for Vertical condensation). • Clean chamber; take final films.

2) Continue Vitality Testing with the EPT.

Things to Remember: -/ Make sure the apical gauge is not larger than a size 20. -/ Make sure the taper is not larger than a size .06 taper. Determined by white dentin on apical of rotary. OK for small canals, but may be larger for large canals. -/ Make sure when you set the lengths of the heat carriers and the pluggers they do not bind in the canals at those lengths. -/ Make sure that you take a down pack film and check for voids in the apical 113 of the canal before continuing to the mid-root. -/ Make sure there are no voids in the fill before it's graded . 2) Fill the second canal of the Maxillary premolar with the Thermafil® Technique. • Verify apical gauge, WL, and control zone taper. • Measure your WL on the Thermafil® can-ier and move stopper to this length. Remove the excess gutta-percha near the stopper. • Mix sealer and place sealer in the canal with a paper point to the WL. • Place Thermafil® carrier in the oven, set the oven to the appropriate taper and press carrier down into the oven to start. • When the carrier is ready, remove it and quickly but carefully insert it to the WL in the canal. • Verify length and fill with a film. • Cut carrier of at the floor of the chamber with a #4 round bur. • Clean chamber; take final films.

3) Retreat Endo with Thermafil® carrier in canal:

To prepare to Obturate: 3) Place EDTA in the canal for 1 min then irrigate.

4) Place the gutta-percha to be used for obturation in a CAOH bath for 1-5 min.

5) Verify apical gauge.

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6) Know taper of canal(s); choose corresponding auto fit cone. (master cone) • Trim cone to correct length by using the Endotech gauge. The auto fit cones can be chosen by taper but you must trim them to fit your apical gauge. Always fit master cones in a slightly wet canal. • Verify the correct WL and determine the correct amount of gutta-percha to trim off of the master cone by using a paper point. Irrigate canal with NAOCL, dry with the correct size paper points. (2-3 paper points). Then check to see if the tip continues to maintain a consistent length of wet ness on each paper point. Measure the wet area and this is the amount you need to trim off the master cone. • You want the master cone to be .5mm WL. You should feel tug back when inserted to working length. The Autofit cone will almost completely fill the prepared canal as shown in the figure below. Take a film to verify you are to the correct length and your master cone fits the canal well and is not distorted. You must be able to see all canals to the apex in this X-ray.

NOTE: Newer instrument such as System B, ObturaCalamus, Elements, etc. Automate the below method and simplify it greatly.

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7) Place stoppers on each plugger; One at about 4-Smm back from WL, one at the mid-root length and the other about 1-3mm into the canal. These are used to condense the gutta-percha. (Do not heat your pluggers). Check to make sure the pluggers set at these measurements do not bind in the canal at the set lengths. If the pluggers bind at these measurements you may need to re-shape your canals and increase taper by one size. You need a little bit of room to condense. Check with your table instructor.

8) Place a stopper on your larger heat carrier so it will only go into the canal 1-3 mm. And the smaller heat carrier so it will go in about Smm from the WL. If neither heat carrier will fit to with in Smm of WL you need to re-shape your canals. The heat can only travel through about 4-Smm of gutta-percha to allow it to flow and seal the canal. 9) Dispense equal amounts of base and catalyst on glass mixing slab. (About a cm to 112 inch)

10) Light alcohol torch.

Begin obturation: 1. Mix sealer well using equal amounts of catalyst and base on a sterile glass slab. 2. Clip the Endo pliers on the master cone at the correct WL. Wipe the master cone into the sealer so the last 3-Smm of the master cone is covered with sealer. (Don't use too much) 3. Insert the master cone with sealer into the canal to your working length, using the Endo pliers as a stop. 4. Place the heat carrier into the flame and heat to a cherry red. Sear the orifice of the canal removing the excess gutta-percha. S. Then immediately use your plugger, pre-set to go 1-3mm into canal, and down pack the gutta-per足 chao This will necessitate a moderate amount of force.

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6. Re-heat your heat carrier and remove the first 1-3mm of gutta-percha from the canal. Then repeat step (4). As you remove more gutta-percha you will need to switch to the smaller heat carrier set 5mm short of the WL and the next size . 7. Continue to heat and pack the gutta-percha removing more and more until you have completed your down pack to with in 5mm from the apex. Try to make sure the walls are clean to the down pack fill. Take a film to verify your density and length from the apex. (If you do not get with in 5mm of

the apex the gutta-percha near the apex will not be heated enough to flow and seal. If you do not use enough pressure while packing you will get voids.)

Gutta

5mm

Heat Carrier

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Endodontics Manual II

8. When the down pack is complete. Take a backfill cone and insert it into the canal with sealer on it. Try to make sure it goes all the way down to the gutta-percha already in the canal to prevent voids. 9. Flame your heat carrier to a cherry red and sear the gutta-percha at the orifice and repeat step 4-6 to fill to mid root. 10. Place another backfill cone with sealer and re-peat the heat and pack steps until the fill is dense up to the pulp chamber floor or to just below the CEl. 11. Clean the pulp chamber and make sure the gutta-percha is smooth. Use either a bur or hot instru足 ment. 12. Take two final films, one straight on and one at 90 degrees if possible. You must be able to see all canals to the apex in both films.

These procedures are much simplified by the use of such instruments as "System B," "Obtura II or III," Calamus" or "Elements" equipment. Special related courses may be available at a later date.

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ApPENDIX C: THERMAFIL® First place EDTA in the canal for I min then irrigate and dry canal with paper points. I. Canals must be clean and DRY.

2. Know apical gauge, working length and taper. 3. If apical gauge is larger than 20 and only a 20/.06 or 20/.08 was used to WL the apical portion of the canal has not been properly cleaned out and instrumented. You will need to go back and use hand files or larger rotary instruments . You may then have to cut the Thermafil® to have a proper apical seal. This is difficult to do, check with instructor. You may also need to remove a little gutta-percha from the top of the carrier, by the handle, so there will not be a lot of excess. 4. The apical gauge and taper must equal the size of Thermafil® used. 5. Measure WL on Thermafil® carrier and place stopper at WL. (You can remove some of the extra gutta-percha off of the carrier up by the stopper if needed, so you will not over fill pulp chamber and so the stopper can be placed at the correct WL) 6. Mix sealer and use paper point to place sealer into canal to WL. 7. Place Thermafil® gutta-percha carrier on the oven holder, (set on correct taper), press holder down into oven and start. The light will continue to blink while the carrier is heating. You will hear a beep and the light will remain green when the carrier is ready for use. Press holder to retrieve carrier. 8. Remove the carrier from oven and quickly but carefully place into canal with slight apical pressure to WL, making sure the stopper meets the reference point. Do this all in one motion. 9. Let set for 1-2 min. (You may want to takefllm to checkflll before cutting the carrier off) 10. Take a small round bur and cut off carrier and remove excess gutta-percha so it is below the CEl and clean pulp chamber with alcohol on a cotton pellet. 11. Take final films straight on and at 90 degrees.

Appendix D: Retreatment Using a #2 round bur make a small trough around the Thermafil® carrier. When the carrier is exposed you may try to pull it out. If you are unable to pulI it out you can take a 20/. 04 rotary file at 1000 to 1300 RPM and delicately insert it along side of the carrier. The frictional heat will melt the gutta-percha and allow the instrument to advance in the groove pushing the carrier upwards. If you are still unable to pull the carrier out you may go to a 20/. 06 and try again . Chloroform may be necessary to soften the gutta percha. This is not an easy process and most Endodontists do not use Thermafil® because of the difficulty to re-treat.

Retreatment of Conventional Gutta Percha: Use a heat source and heat carriers to warm the gutta-percha (GP). Continue to insert the heat carriers far ther into the canals removing gutta-percha. Hand files or a 35112 at 1000-\300 RPM can be used as well. Often it is necessary to place chloroform in the canal with a small syringe to soften the gutta-percha enough to remove it. Once the majority of the GP is removed use rotary and/or hand files to re-instrument the canal.

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Endodontics Manual II

Vertical Condensation Thermafil Technique Re-Treatment Objectives Vertical CondensationlThermafillRetreat

Student Instructor Initials Initials

1) Vertical Condensation: 1 canal of Maxillary Premolar A) Trim Autofit cone to correct apical gauge: .06 B) Place Autofit cone and check tug back C) Take WL film; verify WL D) Obturate 'lJith Vertical Condensation: Clean Chamber E) Take Final films; evaluate fill is acceptable 2) Thermafil Technique: and canal of Maxillary Premolar A) Verify apical gauge and control zone B) Measure WL on Thermafil carrier & set stopper C) Mix and place sealer; Heat Thermafil carrier and insert to WL D) Take 1 film to verify fill E) Cut off carrier and clean chamber F) Take final films 3) Retreat Thermafil and Lateral A) Remove carrier B) Clean Canal

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ApPENDIX

E: CLEANING AND SHAPING FOR LAB

THE "S-STEP PREP"

Assuming that Access is perfected : Step 1: Locate all canal orifices Step 2: Scouting to Patency: Using a scout file (usually a #10 SSK hand file) lubricated with some足 thing like "Glyde", "RC Prep" or similar product, attempt to negotiate the canal to patency. Patency is easily determined in the mouth using the Apex Locator (AL). In the lab, you may have to rely on your Estimated Total Length (ETL) which you carefully measured before mounting your tooth. Your goal is to place the scouting file one mm. patent and ONLY one mm. patent. At this point, your scouting file becomes your patency file and is the ONLY instrument to pass through the apex of the tooth. a. Tip: If you fail to lubricate your scout file, on your very first and subsequent insertions into the canal, you will likely create a blockage consisting of dentin filings and pulp remnants which will prevent you from getting to the apex and establishing patency. Believe it or not, the dentin filings and pulpal remnants will quickly become harder than dentin and will "block yourself out" short in the canal and you may never get to the apex. Do not be fooled into thinking this is calcification at the apex which prevents your progress. We know that tertiary (reparative) dentin forms in response to injury (caries, trauma, etc.) at the site of the injury (i .e. the crown of the tooth). Teeth do not calcify closed at their apices . If they did, they would strangulate themselves routinely and most teeth would soon become necrotic from lack of blood supply. If you can't get to patency, you have either blocked your足 self out or failed to recognize and properly negotiate a canal bend or curve. b. Tip : If you meet LOOSE resistance to apical advancement of your scouting file in negotiating to patency: STOP! Do NOT Force the file, You have encountered an obstruction (most likely a bend or curve in the canal at that point). If you force the file, you will create a ledge on the outside wall of the curve and you may never get any further in the canal. Remove the file, and create a 45-degree bend in the last 1 mm. of the tip of your scouting file , lubricate and then carefully go back into the canal, turning the file 1/8 of a circle at a time and "bouncing" the file in an attempt to fall into the bend. You will feel the file drop and become tight rather than the previous loose feel. Note the direction of the curve on your rubber stopper so that you can reproduce the path and continue to scout the canal until you have a mental image of its path and reach patency. c. Tip: Once your # 10 file reaches patency, work the file up and down until it becomes quite loose in the canal without any hint of tightness before you go any further. Be advised that simply watch-winding a file to a particular spot in the canal does NOT appreciably enlarge, shape nor clean the canal. You must do considerable circumferential filing to effect any real change in the dentin. These files are designed to cut on a pull stroke. c. Once you become 1 mm. patent with your #10 patency file and it is loose in the canal , d. your initial scouting and negotiation of this canal is complete. We will next create a "glide path" for rotary instruments to come later in the process. Step 3: Determining the Working Length (WL) and WL XR : Irrigate the canal (NaOCI) and care足 fully watch-wind a lubricated # 15 SSK hand file to Trial Length (TL) . Remember: Estimated Total Length (ETL) minus 1 mm. = Trial Length (TL). Take a radiograph at this point with the

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file in place at TL to detennine WL It is CRITICAL to establish the proper Working Length (WL) within the root. (see TL vs WL section) . Step 4: Creating a Glide Path: Once the WL is confirmed, you may work the # 15 file until loose at the WL. Be certain to irrigate and recapitulate to patency with your patency file after each active file in the canal. Now irrigate, recapitulate to patency and work a lubricated #20 SSK hand file until loose at WL. Irrigate and again confinn patency. Step 5: a. Begin Crown-Down Rotary Procedure: Place a lubricated .351.12 NiTi Rotary accessory file in your endodontic contra-angle. You will remove your torque converter here to achieve 1000 rpm. The accessory files are the ONLY files used above 250 rpm. Take the rotating .35/.12 into the canal a distance of Y2 of the flutes or more depending upon the size of the canal and root (a mandibular incisor would take no more than Yz the flutes whereas a maxillary canine would take the total depth of the flutes creating a canal diameter of 1.25 mm at that point (maximum flute diameter of accessory GT files) . You have created the top of the funnel leading to the apex. Now, remove the accessory file and replace your torque converter. All sub足 sequent files will be used at 250 rpm which is the speed of rotation with the torque converter in place. All GT files other than the accessory files have a maximum flute diameter of 1.0 mm. Irrigate and confinn patency Step 5: b. Continue Crown-Down Rotary Procedure: Place a lubricated .20/.10 NiTi GT Rotary File in your contra-angle (with torque converter installed for 250 rpm). Set the rubber stop at WL-4mm. and lightly introduce the rotation file into the canal and allow it to mill the canal for no more than 4 seconds maximum. Remove the still rotating file from the canal and inspect it for damage and filings. The filings should be near the top of the flutes. Clean file and repeat the above. Do not be concerned if you are still several mm. from your stop at the WL. You are cre足 ating more of the desired funnel shape and will go deeper at a later time using smaller tapers. Irrigate and confinn patency Step 5: c. Now, irrigate, confinn patency and go back with a lubricated .20/.08 Rotary Ni-Ti GT file at 250-300 rpm. Lightly for 4 sec. Irrigate, inspect clean and repeat. If you are at 4mm. short of WL, stop here (your Crown-Down is complete). If not at the 4mm. mark, drop down to the .20/. 06 or.20/.04 and proceed very carefully to the 4 mm. mark. Irrigate and confinn patency. We have now completed the Crown Down Procedure which has the following benefits: We do not want to push infected pulp through apical tennination, inoculating periapical tissues with pulpal and microbial irritants (Crown-Down will minimize this contamination). We want to excavate and irrigate our way to apex (This allows us to get NaOCI to the apical regions to do a more effective job of disinfection. Once the restrictions of the coronal part of the canal are removed, we have less stress on the files which now have less work to do. Tactile awareness is more acute and safer. Less separated instruments, less ledges, transporta足 tions, and perforations. Step 6: Initial Apical Gauging: This is a good time to do initial apical gauging to get an idea of the current size (diameter) of the canal at WL. (We know it is bigger than a size # 10 since we placed our #10/.02 SSK hand patency file 1 mm. long making it a .12). We will now PASSIVE足 LY enter the canal with increasing sizes of SSK hand files to see which is the first file that BINDS at the WL. It is critical to place the file PASSIVELY without any rotation at all for fear of enlarging the apical gauge while attempting to measure it. In this instance, the hand files are being used as a sort of "ring gauge" to measure/gauge the diameter of the canal at WL as if it Endodontics Manual II

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Revised 09/'09

were a ring. The first file that binds at WL is the Initial Apical Gauge (lAG) for this canal. Mark down the Initial Apical Gauge as this is the measurement which serves as your guide to how much we must enlarge the canal diameter at WL in order to clean and shape it thoroughly. Step 7: Master Apical File (MAF): We are now ready to prepare the critical apical 4 mm. of the canal. Use pre-curved SSK hand files to carefully increase the initial apical gauge at the WL to the Master Apical File (MAF). The MAF is selected as the diameter at which the canal is pre dictably clean and can accept a shape which can be filled to predictably with gutta percha. It is traditionally 3 file sizes larger than the lAG (as a minimum). This may need to be modified to a larger size if the canal is not clean (see your filings) or smaller if the canal has abrupt curva tures which would transport the apex if a SSK hand file of the desired size is used. Altemate methods have been devised for dealing with abrupt curvatures. (See section on prevention of zips, strips and transportation). Once your MAF is loose within the canal, you are ready for Serial Step-Back (SSB) . Step 8: Serial Step-Back (SSB) and the Apical Control Zone (ACZ): Once you are pleased with your MAF at WL, you may go I file size larger with a SSK hand file Yz to 1 mm. short of WL. This may be followed by 2 file sizes larger than MAF 1 to 2 mm. short of WL and then 3 files sizes larger than MAF 1 and jj to 3 mm. short ofWL. The Y2 mm. Step-Back will create a .10 taper while the 1.0 mm Step Back will yield a .05 taper. It may be well to start with the I mm. step-back and then try your Master Cone (MC). If your MC does not go to WL, try working the MAF file a bit more and consider increasing the taper by going to I12mm step-back or increasing the number of files used in SSB (You can serially step-back all the way to a # I 00 SSK hand-file and achieve the same result as taking the same tip diameter Rotary Ni-Ti GT file to WL as the maximum flute diameter of the regular GT files is 1.0 mm (# 100). Optionally, you may wish to take the appropriate GT Rotary file to WL IF the anatomy allows (e.g. mini mal curve or complications). Beware, however that GT Rotary files do break and they come only in sizes 20, 30 and 40 at the tip and these must coincide with your MAF size in order to avoid discrepancy of taper. The net result of either technique is that you have now created a regularly tapered shape at the WL of the canal (the Apical Control Zone or ACZ) which will provide a Resistance Form against which you can pack gutta percha with minimal fear of push ing it out the apex . At this point, it is appropriate to do your Final Apical Gauging. The objec tive here is to confirm the diameter of final apical gauge remains the same as the initial gauge and that the MAF diameter is 1 mm short of the lAB (FAG). WITHTI'J the canal at the WL and to confirm that a proper SSB taper has been created at the ACZ. Next: Fitting the Master Cone (MC) and MC XR: Once the MAF and the SSB is created, an appro priately sized .02 standard (ISO) Gutta Perch a cone should go to place at WL. To aid this, it is wise to irrigate the canal with NaOCL and leave it wet while fitting the Me. It is then appro priate to take a MC XR to again confinn the WL as well as the fit of the Me. If all is well, you are ready to place your MC to soak and disinfect in NaOCI while you irrigate the canal with 17% EDTA ("Smear-Clear"). The EDTA should stay in the canals 1 minute only to remove the smear layer and then the canal is flushed out the final time with NaOCI and dried in prepara tion for obturation.

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ApPENDIX

DEALING WITH THE CURVED CANAL

DEALING WITH PROBLEMS OF THE CURVED CANAL:

BLOCKAGE, LEDGES,

TRANSPORTATION, ZIPS, ELBOWS AND STRIPS If all canals were straight, endodontics would be much simpler and require minimal instruction. Howev足 er, the truth of the matter is that all canals are curved to some extent. The greater the curvature, the more difficult the problem and the more complicated the cleaning and shaping of the curved canal. Complexity and degree of curvature is what generally makes molar endodontics night and day different from "simple" anterior RCT. Start all canals with a gentle bend in the file. Blockage: You can block yourself out quickly and easily even in a straight canal in two ways: I.Failure to religiously use lubrication (such as Glyde, RC Prep, etc .) in the canal during initial nego足 tiation with your scouting file. This is especially true with a vital pulp. Believe it or not, if you poke into the pulp without lubrication, the collagen will form a solid mass in the canal which can become harder than the dentin. Failure to lubricate at the outset and following can prevent you from ever reaching patency. 2. Failure to religiously irrigate (NaOCI) and 3. Failure to recapitulate to patency with your #10 or #15 patency file following each active instru足 ment will generally guarantee a blockage as the dentin chips and filings can quickly create a plug which is harder than the dentin of the canal. If you have ever drilled a hole in concrete, you know that you must stop periodically and blow or wash out the filings or else your drill ceases to advance. The principle is the same. Sometimes, blockages can be cleared or bypassed successfully, but blockages seriously and unnecessarily escalate the difficulty and time requirements of the job. It is much easier and more desirable to prevent the blockage by adherence to these basic principles. Curved Canals: With curved canals, one becomes concerned with not only blockage, but also ledging and transportation of the canal which leads to apical zipping and elbow creation as well as possible api足 cal perforation or even strip perforation. Curvature of canals vary greatly and can be qu ite severe (F ig. 1). Note the 75 degree curve on the mesial canal. This would be a challenge to treat successfully for any endodontist. The 25 degree curve seen on the distal canal is considerably easier to treat but demonstrates the same principles but to a lesser severity. Your lab teeth should have been selected to have no greater than 20 degree curves. Of course, you will encounter non-selected canals in the Clinic. You must understand how to deal with these curves which are found in all teeth .

Figure 1

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When using SS Files (common ISO hand files) in curved canals, one must be highly conscious of the characteristics of SS. SS(unlike NiTi) is rather inelastic and tends to retain the form in which it is manufactured (i.e. straight). The straight SS file tends to track the convex wall of any curve and can easily dig into this wall and create a gouge or ledge here. (Fig. 2).

Figure 2 Straight file in curved canal.

Figure 3a

Figure 3b

A straight file wI! tend to gauge the convex wall of a curved canal.

One should attempt to ~ tl:l.e....fil.e to track the concave wall of the curved canal.

Figure 4 Creation of apical zip and elbow 足 impossible to create a seal apical to the elbow by orthograde endo.

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The stiffness and tendency to gouge or ledge increases dramatically as the diameter of the SS file increases. Failure to recognize and deal specifically with these characteristics of SS files will invari ably lead to the creation of a ledge within the body of the canal (fig.3a) or a transportation of the canal in the apical region creating both a zip and an elbow. (fig. 3a and 4) As you can see, we now have an impossible situation in which the elbow prevents obturating material from filling the apical zip properly (you can't tightly fill a funnel from the small end) . This situation must be avoided if the tooth is to be retained for if there is no proper apical seal, the ReT will fail ! Below (Fig. 5) note that the curved canals in this molar are fairly successfully negotiated at the WL radi ograph using small (# 15-#20) files . However, when the canals were enlarged to a size #35 SS hand file, the canal curvatures were destroyed. This tooth will have to have apical resection and retroseal to obtain a seal but due to the short root of this tooth, it will probably be extracted.

Figure 5

Canal transportation (apical zip) in the Clinic.

Four additional failures contribute greatly to the creation of ledges, blockage, zips and elbows:

1. The failure to establish a correct WL within the canal will generally guarantee a zip. 2. Failure to obtain and maintain patency with a # 10 or # 15 file following each active instrument will virtually guarantee a blockage and potentially a zip or apical perforation when instrumentation is forced. 3. Failure to irrigate and lubricate the canal following each active instrument will create an accu mulation of "dentin mud" within the canal which will pack down and become harder than the dentin. At this point, it becomes easier for the file to stray from the canal than to penetrate the dentin mud blockage which you have created. This is an apical perforation waiting to happen as soon as you force the instrument. 4. Failure to pre-curve the SS hand files to match or exceed the curvature of the canal. Here's where we can take advantage of the characteristic of SS files to easily take and retain a bend. This is dif ferent than NiTi which can take and hold a bend only with special techniques and considerable diffi culty. Placing a straight SS file into a curved canal will inescapably track along the convex wall of the curve and usually insure at least a ledge or blockage.

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However, if we pre-curve the SS fi Ie properly and orient it carefully within the canal, we can cause the file to track the center or even the concave wall of the curve where it is not possible to ledge. If such a pre-curved file actually does track the concave wall of the curve and if it should straighten slightly in the canal, it would simply pull itself to the center of the canal rather than gouge the out side or convex wall.(Fig. 3b) Do not deceive yourself by the old excuse that your canal is calcified at the apex and you can't get patent.. We know that tertiary dentin occurs not only in response to injury but also at the site of the injury. It's pretty hard to have caries or trauma at the apical extent of the canal. This leaves us with the conclusion that canals simply do not calcify closed at the apical foramen : if they did, the blood supply would be eventually lost in all teeth and all pulps

would ultimately become ischemic and ultimately necrotic. This does not

happen. If you can't get patent, you either created a blockage or encoun

tered a curve which you are not negotiating. Excep60ns to this are extreme

ly rare.

Figure 7 Acute bend at tip of file to bypass ledge (maybe)

Once you create a blockage, ledge, zip, elbow or apical perf., you have dra

matically increased the difficulty and time requirements of the job at a minimum or you have insured fail

ure of the RCT and loss of the tooth.

Occasionally, an acute bend can be imparted to the last flutes of the file and the ledge can be bypassed by

special techniques requiring much 6me and effort.

Hopefully, this will motivate the serious student to become interested in techniques to minimize or pre

vent the above disasters. The rules are simple:

I. Establish a proper WL (112 to I mm. short of the anatomical apex) i.e. within the root. 2. Obtain patency with a # I 0 or # 15 patency file at the outset and maintain it by insuring that your patency file gets Ii to 1 mm. beyond the apex following each active instrument. 3. Do not neglect to copiously irrigate with NaOCI following each active instrument to wash out debris and dentin mud. This helps to clean as your files shape. Also do not neglect to lubricate the files with Glide, RC Prep or similar lubricant following irrigation. 4. Pre-curve all your files to follow the inner (concave) curve of each curve and orient the file correctly as regards each curve you encounter. An option might be to use NiTi hand files which are super elastic and tend to follow the canal curvatures without pre-curving in most cases. The down side of this approach is that NiTi hand files cut like a dull knife through concrete. Additionally, NiTi hand files are expensive and useless for the path-finding neces sary to initial establishment of patency. If a really difficult curve is encountered, NiTi files may be pre curved with difficulty and special techniques and may be useful here. NiTi are also generally useless for getting around a ledge or blockage. Engine driven NiTi rotary files are much more efficient in crown down shaping techniques but are easily broken in a heartbeat without warning especially in the restricted areas of the apical region so they may not be safely used in the apical regions of many teeth. They generally serve well in the crown down pro cedure in the body of the canal. The 8-Step Prep. as taught in Lab will provide you with one relatively predictable, successful and safe technique for the cleaning and shaping of most curved canals IF all the above considerations are observed.

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The future will undoubtedly bring new and different products, materials and techniques but you will understand the concepts desired and the problems inherent so that you can evaluate how you want to pro足 ceed in your evolving practice.

ApPENDIX

G: UNDERSTANDING DISCONTINUITY OF TAPER AND

SHAPING OBJECTIVE "DISCONTINUITY OF TAPER" AND "SHAPING OBJECTIVE"

Discontinuity of Taper refers to a situation in which the degree of taper of the Apical Control Zone (ACZ) differs from the taper created in the body of the canal which is coronal to the ACZ. The taper of the ACZ can be the same, greater, or less than the taper of the body of the canal coronal to the ACZ. A CZ Tilper is SAllIE is T~p .. of BadV ~ c~nill ca"1nill to ACZ

ACZ Tllper is GREATER thlln Tllper of Bad, of Cll III corpnlll to ACZ

t1 I,

\ \

+ " ,02 Body of

./ ' - .06 Body of Canal Taper

Canal Taper

a ~.06ACZ

-.o6ACl Taper

Taper

ACZ Taper is LESS tl'lan Taper of Body of canal coronal to ACZ

..- ,06 Body 01 Canal Taper

Taper

If the tapers are the same and the Master Cone (MC) is selected to match the common taper, one will not have space available for placement of the finger pluggers to laterally compact the gutta percha in the Lat足 eral Compaction (LC) technique of obturation. However, minor discontinuity of taper appears to be of little consequence when the lateral compaction of gutta percha technique is used to obturate as long as the MC is selected to be less than the taper of the ACZ so it can fit at the ACZ and not bind on the body of the canal. When the standard gutta percha .02 taper cones are used, it is unlikely that the taper of the MC will be greater than any shape produced in the canal (either at the ACZ of the body of the canal). It is, of course, critical to be able to compact to within 1 mm. of the WL and add accessory cones at the level of compaction. Moreover, if an adequate ACZ is created, slight differences in taper coronal to the ACZ seem to be adequately handled by the technique. Additionally, the angular "steps" created by the Serial Step Back (SSB) technique are not crucial to suc足 cess in a laterally compacted gutta percha fill. It appears that these two issues can largely be ignored as long as one performs the lateral compaction technique correctly.

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However, discontinuity of taper and the "steps" mentioned above both appear to be contributors to an undesirable result when a warm gutta percha vertical compaction obturation technique is employed. The various warm gutta percha techniques employ a fitted master cone which must have an intensely intimate fit in the apical portion of the canal as Warm Gutta Percha (WGP) is essentially a single canal technique in the apical 4-5 mm. Any discontinuity of taper which challenges or prevents this essential intimacy of fit will reflect is a poor apical seal. If the tapers of the ACZ and the body of the canal are the same, this is ideal for the Warm Vertical Compaction (WVC) technique of obturation and the Master Cone is easily selected to match the common taper. If the ACZ taper is less than the taper of the body, the gutta percha master cone (if selected for the body taper) will not go to place at WL until the ACZ taper is increased to match the MC selected or else the MC is selected to meet the lesser taper of the ACZ. If the ACZ taper is greater than the taper of the body, the gutta percha MC (if selected to match the body taper) will not go to place at the WL If the MC is selected to match the ACZ taper, it will also not go to place at WL. (see figures 1,2,and 3) The same may be true of the "steps". Therefore in the WVC technique, it is essential to minimize or eliminate these challenges to success. Essentially, the best way to eliminate both of these problems is to take the proper tapered rotary file to WL in each canal which is planned to be obturated by WVCGP. This use of the rotary file to WL carries with it two new concerns: 1. The rotary file can break without warning thereby creating a difficult or impossible situation and 2. The opportunity for selection of an inappropriate shaping objective is always a factor which can contribute to rotary file separation. It seems therefore that an understanding of how to select an appropriate shaping objective is yet another factor critical to the avoidance of a separated file. Roots obvious vary in size, diameter, anatomy and cur足 vature. Broadly speaking, we have large, medium and small size roots and each have a basic preferred shaping objective. When using GT rotary files, small roots would be mandibular anteriors, buccal roots of maxillary molars, mesial roots of mandibular molars and two rooted premolars and perhaps a .301.04 or .301.06 size would be considered appropriate (no larger). Large roots would be palatal roots of maxillary molars, possibly distal roots of mandibular molars (especially if singe canal distal roots), maxillary cen足 tral incisors and canine teeth both maxillary and mandibular and perhaps a .301.06 to a .401.06 or larger may be appropriate (no smaller). Medium sized roots are those remaining and perhaps a .301.06 to a .301.08 may be appropriate. If the root is curved more than 20 degrees or the proximal invagination is greater than usual, a smaller shaping objective should be selected and if the curvature is greater than 45 degrees, the case should be done entirely by hand at the smallest shaping objective that will clean the canal at WL and allow Obturation. Of course, teeth vary in size from person to person and this cannot be considered a hard and fast rule. Look at the anatomy and decide what is appropriate.

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ApPENDIX

The Value of the Radiographic "Shift-Shot": Varying the horizontal angle of the XR tube head from the straight-on perspective to an angular projection is not only valuable in disclosing possible overlapped or unseen canals, but the technique also proves to be critical in determining which mesial canal of the mandibular molar you are working on or whether you are working on the facial or the palatal canal of a maxillary premolar.

The SLOB Rule works out if you shift the XR to come from the mesial (lower molar), the M-L canal will appear to have moved to the mesial.

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ApPENDIX I: CAULK RUBBER DAM SEALER

It is imperative that the rubber dam be placed so that no leakage occur thereby preventing salivary con足 tamination to the operating field. Often, it is necessary in the Clinic to add some type of Caulk Sealer to accomplish an effective seal. Caulk Sealer may be mixed in the office by adding zinc oxide powder to Fixodent dental adhesive to cre足 ate a thick paste. This is worked into a large syringe and stored for use. Instead of mixing your own Caulk Sealer, you may opt to use Ultradent Oraseal at a far greater cost. Oraseal is available at the dispensary. Proper use in shown below

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ApPENDIX

CURVED CANAL EXERCISE

Most of us fail to recognize the night and day difference between a simple straight canal and the canal which curves 30 degrees or more. A straight canal is easy and (if it is truly straight) any file can be rotat足 ed freely without damage to the root. Endo would not be a specialty if all canals were straight. Problem is - they're NOT. The introduction of a curved canal tremendously increases the difficulty of cleaning & shaping and the likelihood of disastrous results such as ledging, transportation of the apex, zipping and possibly stripping. If you end up obturating a curved canal which appears to be "off center" in the radiograph, chances are you transported the canal. We know this because (as you recall from dental embryology) the pulp forms first and the root structure then forms in a regular manner around the pulp so that the canal is almost always centered in the root. If you wish to master curved canals, it will be to your advantage to study and practic~ some of the proven techniques as presented here and in your text. , If you do not learn to master curved canals, you have effectively limited yourself to only the simplest of endodontic therapy cases. Problem is - you can't see what you are doing in the tooth until after the fact and then - it's too late.

In this regard, it may be helpful to practice preparing a clear curved plastic block which will allow you to visualize what is happening with your technique. These blocks are available for your use in the endodon足 tic office as "ENDO-VU" Model 001 - Curved Additional blocks are available from Tulsa Dental or Richard W. Pecina & Associates, Inc. 2348 North Lewis Waukegan, Illinois 60087 While these blocks do not reproduce th "ti el" and hardn ' or working chara teri tic of the natural tooth , they do a go d job in visually demonstrating how ledge" elbows. transportations and zips develop dUring your cleaning and haping operation. It would be good to try a block or two to develop your tech足 nique to prevent transportation of the apex. To began, lubricate a #10 SS hand file (KY jelly or Endo-Eze is OK). Note how easily the file follows the extreme curve of the canal (possibly even if you neglect to pre-curve the file). However, it is a good idea Endodontics Manual II

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to place at least a gentle curve in every file introduced to a canal. Go patent I mm with the #10. This makes the apical foramen about a size .12mm . Work the # 10 within the canal at the WL to enlarge and smooth it in preparation for the # 15 SS hand file The # 15 SS hand file should now be lubricated and curved to match the canal curve discovered with the # 10 file and placed in the canal I mm SHORT of the terminus of the canal. This is your working length (WL). Only the patency file (# I 0 should pass the WL to patency) . . Remember to go to patency with your #10 ("Patency file") and irrigate and re-Iubricate following each and every active instrument. If you neglect this step, you will almost certainly create a ledge and you will block yourself out. From this point on in the process of enlargement of the canal, your chance of transportation becomes progressively greater as the STIFFNESS of the SS file increases geometrically with each increase in diameter making it much more difficult to negotiate the curve as shown below. You now have 3 choices to AVOID the transportation which generally starts with the #20 SS File. We are assuming that you are using the most flexible SS File available having a "safe tip" such as the Flex-R or Flex-O types. 1. Match or exceed the curvature at the apex with your #20 SS File and perhaps use a diamond nail file to file off the cutting edges on the convex size of your file. You will need to do this same procedure with increasing care as file size increases to your selected MAF. 2. If you desire, you may use nickel-titanium hand files to complete the procedure from a size #20 up to your selected MAF. The super flexibility of the nickel-titanium and its lack of memory may prove to be quite beneficial in preventing transportation. a. Ni-Ti hand files are available in standard ISO sizes (.02 taper). You will find that these cut tooth structure very slowly. b. Ni-Ti Files are also available in a GT Taper hand file (.06 taper in various tip diameters) Tulsa dental stocks these which have a "backwards" twist which allows you to use "Balanced Force" by locking in via a counter-clockwise bite and spinning clockwise with apical pressure. These files may also be bent follow a particularly curved canal by "over-bending" the file to allow it to" take a set". 3. Also available are handpiece driven GT Taper rotary files which remove much of the effort of Ni-Ti hand files when enlarging the canal. The biggest problem here is that they BREAK in a heartbeat - probably at or near the greatest canal curvature which generally makes them ilTetrievable.

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Endodontics Manual II

None of these are terrific choices. So invent something better! Remember, curves make ReT difficult! This exercise should encourage you to appreciate the fact.

One must appreciate the impossibility of creating an adequate seal in the area of the zip.

In other words, with a transportation of the apex (zip) it is possible to properly obturate ONLY to the elbow area with all areas beyond the elbow being extremely vulnerable to leakage and microbial attack.

Tip: Keep MAF as small as possible while adequately cleaning and shaping the canal. A #30 MAF is about as big as one should go. In some cases, a #25 MAF with Yz mm . SSB (Serial Step-Back) may be as large as you want to go in cases with extreme canal curvature. This exercise suggests the difficulty of trying to do a 40 degree or greater curve on a young adult lateral incisor for example where the Apical Gauge may be #40 or greater. Successful shaping here would be much more difficult than a cursory evaluation would suggest due to the extreme problem with trying to get larger instruments of any type to bend to negotiate the curve. This situation (considerable curvature combined with large apical diameter) may require special techniques and materials and may be a candi足 date for referral to your local endodontist.

The purpose of this exercise is to help you visualize and appreciate the problems which can and do occur in shaping curved canals. Additionally, we hope you will be able to develop a careful tech足 nique which works for you to safely avoid transportation of the canal in the majority of cases. We also hope you would become skilled in recognizing and referring those cases which have limited expectation of excellence in your hands at your current particular level of development.

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ApPENDIX

K: D6442L SYLLABUS

I. IDENTIFYING INFORMATION COURSE NUMBER: D6442L COURSE TITLE: ENDODONTICS LABORATORY CREDIT HOURS:

COURSE DIRECTOR: CHARLES LEE, DDS , MS

OFFICE PHONE : 8 I 6.235 .2092

lig@ umkc .edu

ROOM 23 I C (Endodontic Offices)

Office Hours: By Appointment COURSE FACULTY: Dr. Charles Lee - DIRECTOR

Dr. Ron Riley - Coordinator

Dr. Joy Wiley - Coordinator

Dr. Shara Dunlap

Endodontic Residents

Other Instructors: TBA

Endo Honors Students: TAs FORMAT: Laboratory LOCATION: Rooms 28 I and 286

TIME: I :00-3:50 p.m. Tuesdays YEAR IN CURRICULUM: Spring Semester, Second Year

Students who encounter difficulty in their courses because of the English proficiency of their instructors should speak directly to their instructors. If additional assistance is needed, they may contact the UMKC Help Line at 816-235-2222 for assistance.

II. COURSE DESCRIPTION: The preparation and filling of root canals of plastic and extracted teeth in the laboratory setting. III. MAJOR COURSE GOALS/OBJECTIVES: Endodontics is the branch of dentistry that is concerned with morphology, physiology and pathology of the human dental pulp and its extensions into the peri radicular tissues. Its study and practice encompasses related basic and clinical sciences includ足 ing biology of the normal pulp; the etiology, diagnosis , prevention and treatment of diseases and injuries of the pulp and resultant pathological periradicular conditions. The scope of Endodontics includes: the differential diagnosis and control of oral pain of pulpal and/or periradicular origin; pulp capping, pulpotomy, apexogenesis, apexification and non-surgical treatment of root canals and peri足 radicular pathosis of endodontic origin, the obturation of the canal systems of these teeth; selective surgical removal of pathological tissues resulting from the pulpal pathosis; replantation ; intentional replantation; hemisection; root amputation; repair of root perforations and bleaching of discolored non-vital teeth. Overall Goals: The purpose of the course is to guide students to an understanding and experience level of competence in simulated endodontic procedures that will prepare them for assignment of Revised 09/'09

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Endodontics Manual II

patients with endodontic problems in the UMKC School of Dentistry Undergraduate Clinic. The Laboratory Exercises will utilize various methods of shaping, cleaning and obturation of root canal systems to advance students toward competence in a wide variety of uncomplicated endodontic cases with safety, efficiency and predictable success. Case difficulty assessment, principles of asepsis, avoidance of procedural accidents and self-assessment of treatments that are likely to result in clini cally successful treatment will be stressed. Significance of the Course: This is the final pre-clinical technique experience prior to entering the Clinic. The objective is to achieve a basic level of RCT competency for student using one technique in non-complicated cases. IV. DENTAL COMPETENCIES ADDRESSED IN THE COURSE: The following are the UMKC SOD Competencies addressed in D6442Lab. and Lecture. The competencies listed below are the minimum levels of performance that are expected of the den tist graduate of the University of Missouri-Kansas City School of Dentistry. Due to special interests, experiences and opportunities many students will exceed these minimums in various areas. However, every dental student must meet these minimum competencies to graduate.

I. Apply legal and ethical principles to the practice of dentistry. 2. Provide empathetic care for all patients, including members of diverse and vulnerable populations. 3. Monitor professional knowledge and practice outcomes to develop and implement a plan of profes sional improvement. This includes: a. Monitor therapeutic outcomes and re-evaluate and modify initial diagnoses or therapy. b. Use of scientific evidence to guide treatment decisions c. Development of a plan for improvement d. Knowledge of one's levels of competence and the necessity to refer when one is not competent. 4. Perform a complete dental examination to arrive at a diagnosis of the patient's oral condition. This includes: a. Assess patient goals, values, and concerns to establish rapport and guide patient care. b. Identify the patient's chief complaint. c. Obtain and assess the significance of medical, dental, psychosocial, and behavioral histories. d. Perform head and neck and intraoral examinations. e. Select, obtain, and interpret clinical, radiographic, and other diagnostic information and proce dures. f. Obtain medical and dental consultations when appropriate. g. Develop and maintain accurate and complete patient records. h. Recognize signs of abuse or neglect and report and refer as necessary. i. Recognize predisposing and etiologic factors that require intervention to prevent disease. j. Use clinical and epidemiological data to diagnose and establish a prognosis for dental abnormalities and pathology. k. Recognize the normal range of clinical findings and significant deviations that require monitor ing, treatment or management. \. Implement and monitor infection control and environmental safety programs according to cur rent standards.

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5. Develop, present and implement an integrated treatment plan to address a patient's dental needs. This includes: a. Develop treatment alternatives based on clinical and supporting data. b. Integrate multiple disciplines into an individual, comprehensive, sequenced treatment plan using diagnostic and prognostic information. c. Discuss etiologies, treatment alternatives, and prognoses with patients and educate them so they can participate in the management of their own care. d . Develop and implement a sequenced treatment plan that incorporates patients' goals, values, and concerns. e. Obtain informed consent from patient, parent, or guardian. 6. Manage medical emergencies and complications that may occur during dental treatment. This includes a. Recognize and manage acute pain and hemorrhage, trauma, and infection of the orofacial com plex. b. Anticipate, prevent and manage complications arising from the use of therapeutic and pharma cological gents employed in patient care. 7. Manage patients with pain and anxiety by the use of non-pharmacological and pharmacological agents 8. Select and administer or prescribe pharmacological agents in the treatment of dental patients. 9. Treat patients with endodontic conditions. This includes : a. Perform uncomplicated endodontic procedures. b. Recognize and refer complex cases of pulpal and periradicular diseases . 10. Treat patients requiring restoration of single defective teeth II. Treat patients with partial or complete edentulism. This includes: 12. Treat patients with soft tissue lesions and oral manifestations of systemic diseases. a. Recognition and referral of patients with advanced oral manifestations of systemic diseases or advanced or sinister intraoral soft tissue lesions .

UMKC SOD Required Knowledge

In addition to the curriculum competencies, there are a number of areas in which the graduate is

expected to have knowledge but not necessarily expected to perform competently. These may be test

ed via written examination or other types of examinations.

Recognize when a patient requires hospitalization for their dental care and refer them to an appropri

ate source of care.

v. COURSE

REQUIREMENTS AND METHODS OF EVALUATION

A. Number of Examinations: The first lab period will require all students to display all of their col lected extracted teeth and have them checked off by the table instructor. There will be one final (clinical) examination at the last lab session which consists of preparation and obturation of a mandibular premolar during this period. This final exam will account for 20% of your lab grade. Additionally, there wi II be four (4) other graded procedures during the semester .. . each of which accounts for 20% of your semester grade. B. Types of Questions: There are no written exams planned for D6442 Lab. C. Number, type and length of papers : There are no papers planned for D6442L D. Number and type of projects to be completed: In addition to the Lab Final and the 4 Graded Pro cedures listed in VA. above, the student will be expected to complete and have checked off the fol-

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Endodontics Manual II

lowing exercises: COMPETENCY I: Instrument Set-up (as shown in your Lab Guide)

The student must demonstrate to a table Instructor that helshe understands all the instrumentation required for endodontic treatment and the proper set-up for RCT in the Lab and the Clinic. Under足 standing of Sterile versus Clean areas is essential, as is the practice of avoiding cross contamina足 tion. The student may not proceed until helshe has mastered this competency. Access Preparation (five must pass) Plastic Molar Tooth #14 (two teeth as described in Lab Guide) Use of the Electric Pulp Tester Plastic Maxillary Premolar Exercise Additionally, you are expected to become familiar with: the operation and use of the Electronic Apex Locator, proper application and sealing of the rubber dam for RCT and the Curved Canal Exercise. NOTE:

STERILIZATION OF EXTRACTED TEETH REQUIRED regarding teeth collection for D6442 Lab.

UMKC-SOD PROTOCOL FOR STERILIZATION OF EXTRACTED TEETH

Sterilization of Extracted teeth regarding tooth collection for D6442 Laboratory and also applicable to any extracted tooth to be used in Endodontics Manikin and Trial Boards or any endodontic pursuit in which the tooth may otherwise present a hazard. Essentially ALL extracted teeth to be used at UMKC足 SOD. Our first and second year students are instructed to begin the process of collecting extracted teeth for Endodontic Laboratory. Obviously, all extracted teeth are considered to be contaminated objects. Students are instructed to collect as many teeth as possible from dental offices. Teeth containing amalgam are unacceptable and are rejected. Students will bring the teeth collected from outside the school to the Endo Department. These teeth, regardless of whether they were sterilized outside UMKC, will be sterilized again by the Oral Surgery Department. The students are given a container that holds a solution of 113 water, 113 glycerin and 1/3 6% bleach in which to keep their teeth. Oral Surgery's Sterilization Process of Student Teeth 1. Teeth are checked into OS from Endo Department

2. Student teeth are strained of bleach solution using universal precautions. 3. Teeth are examined for any signs of amalgam. The teeth having any signs of amalgam are rejected and disposed of per protocol. 4. Sterile water is poured into teeth containers, covering teeth. 5. The teeth are then sterilized in the autoclave's liquid cycle. The cycle has 40 minutes @ temp of 249 degrees Fahrenheit and 15 lbs psi. Process takes 70 minutes. 6. The teeth are lightly covered to cool. When cooled, the lids are placed on containers. 7. The teeth are then checked back into the Endo Department. Oral Surgery's Sterilization of teeth collected in the OS Department 1. Extracted teeth are stored in a labeled container for teaching teeth in a solution of 1: lOb leach/water.

2. At least once per week the teeth are drained out of the solution to prepare for sterilization. Repeat Endodontics Manual II

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Revised 09('09

steps 3-6 from above. 3. Sterilized teeth are taken to Endo Department to be processed in and properly labeled. Waste of Extracted Teeth in Oral Surgery Not Used for Teaching

1. Teeth containing no signs of amalgam are considered biohazard waste and disposed of in a red trash container or in a red sharps container. 2. Amalgam teeth are set aside in a container labeled biohazard waste/amalgam teeth. This container is to be given to HAZMAT personnel for them to dispose of properly. UMKC-SOD Guidelines follow CDC and ADA recommendations as follow: Extracted teeth may be considered sterilized when autoclaved at 121°C. and 15 Ibs psi for 40 minutes. No other method is acceptable for sterilization. Should you fail any of your projects or exercises, additional sterile extracted teeth or plastic teeth will be required to be supplied by the student. Plastic teeth available at book store. Students will each be required to layout ALL of their teeth for final approval by your table instructor at the first Lab session (second semester). Additionally, retain ALL of your teeth as they will be required to be displayed at the last Lab session . You will also require two plastic teeth #14, one plastic tooth # 5 and one Plastic tooth #8 for the course. These are included in your course supplies. E. Grading Criteria: All Graded Procedures are graded by one or more table instructors (not your own) using the Clinical Endodontic Grade Sheet as follows: Grading Criteria: Accurate length control by development of a well designed and executed Apical Control Zone (ACZ) is CRlTICAL to consistent endodontic success. Working length MUST be exact. Therefore, although variations may occur and be addressed in actual clinical cases, we have estab lished that the desired parameters for excellent obturation in pre-clinical laboratory will be 0.5 to 1.0 rnm. short of the radiographic apex or terminus of the root. If cases are not within this desired range, it will not be possible to obtain the grade of "A" for the case. Prep and fill to the Minor apical Diameter, i.e. 0.5 to 1.0 mm short of Radiographic Apex (RA) The ONLY WAY you will get an "A" is to have your obturation terminate 0.5 to 1.0 mm short of the radiographic apex. Anything else will be a lower grade. Your professional development and course grade will also be evaluated and will depend upon proper attention to "standard precautions". Students are required to wear appropriate personal protection at all times in the Laboratory and to adhere closely to standards of infection control and biohazard con trol and disposal so that all may learn in a safe environment. Additionally, the student is expected to keep his/ her working area neat, clean, disinfected and orderly as in the set-up illustration.

The following Clinical Endodontic Grade Sheet will be used for grading of completed projects both in

pre-clinical laboratory and in The Clinic. Pay close attention to the categories of evaluation.

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Endodontics Manual II

.---- ~

Student Name:

Clinical Endodontic Grade Sheet

Team #

Tooth #:

Date:

(canals-->

Patient Name:

Initials Reguired: III

:c III

:2 -

Inadequate Anesthesia R·ubber Dam Leakage

III OU

z~ Access:

-Op -Op

DX & Sign-in :_ _ J! Q.

...0

III U U

iii ~.

J! Q.

Chart Number:

III

-10p -10p

CanalT~nsportation

"Blow Out" any canal Workino..past Clinic Hrs

Accea Shape, Size & Location Caries Completely Removed Straight line access .. . Smooth walls & access Shaping and Obtuntlon Cnl. shape/proper taper /transportation GP below CE.J /clean pulp chamber Voids mm from the apex (short) Length of fill (short) mm from the apex (long) Length of fill (long)

-Op -Op -Op -Op

-3p -3p

-6p

-Op -3p -6p -10p -Op -3p ~p -10p -6p -10p -Op -3p 0.5-1 1-1.5 1.5-2. >2.0 -0 -10p -15p -26p <0.5 0.5 >0.5 -10p -15p -26p

Forma & X~Y. (caH not gnlded until completed) 1) X-Rays Diagnostic, No cone cuts

-10p -10p -10p -10p

-3p

-Op

~th temporized proper1y

-Op -Op

-10p -10p

4) Endo OX & Assessment forms completed

-Op

-3p

-10p

AutomatIc Reduction: Incident Report

.•.

~on"I""""below

Perforation (Strip-perf. or Zip) Instrument separation Non-diagnostic x-rays: entire tooth. induding 1-2mm beyond apex, not present on all x-rays(no final XR w/o RDj:lamp NaOCI accident or Unacceptable Treatment of Patient (100 points possible) Total Score Note: It is the responsibility of faculty signing in student to check tor the necessary requirements and to initial OX. Faculty checking access shall grade access. FaLwty grading obturation must OK forms & films, grade obturation & assign final score and sign. :J' III of t:. Student is responsible for getting grade on Grade U (II I: E .s: Shut by Faculty worked with. Student is _ii I!!-c _ CI responsible for bringing completed graded sheet to o I: . ! I : (II I: o (II III (II 't:1II Endo. Office to have grade recorded in Endo 0::0 0::....1 1-....1 Computer. Grading begins with the full 100 points. Each ilt!m above is evaluated and points arc subtracted from 100 for the final perecntagc score. Green Form is Regular RCT, Pink Form is Competency. Yellow form is for OX only or Extirpation only as on e-chair. Working past Clinic Hours is automatic -10 points

Endodontics Manual II

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Working L.

Master Cone

Obturation

-- Notes:

Done in Endo. Done in Team

-10p

SJ) -3p -6p -3p -6p

2) Two final films w/o clamp (1 angled)

-26p -26p .-: -2Sp

Grading Faculty Must Sign Below:

-2Sp

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Revised 09/'09

Mesial Canals l.Omm from RA Distal Canal O.Smm from RA

COPyri9ht

2006, !"Isevier, Inc.

Additionally, the "A" range requires exacting attention to the principles of ideal access and thor足 ough and correct cleaning and shaping as well as flawless obturation density and avoidance of voids. Even if your work qualifies for the "A" range in regards to length control, you may not receive a grade of "A" if any other components of quality such as those mentioned above and oth足 ers fall short of perfection. The percentage grades from the 4 Graded Procedures and the Final Clinical Examination will be averaged (by adding together the 5 scores and dividing by 5) to arrive at the final percentage score. Grades will be assigned as follow: A= B= C= F=

90-100% 80-89.99% 75-79.99% <75%

Excellent

Above Average

Average

Unacceptable (must be remediated or repeated)

Note: Regardless of average score, every exercise and project must be completed with a mini足 mum score of 75% in order to pass this course. Other considerations may modify final semes足 ter grade from the mathematical percentage above. Completion of all exercises and projects is necessary. All sessions will require completion of the session check off sheet and a credit/pass notation by table instructor. Students are expected to be able to demonstrate their knowledge of the principles and skills involved in simulated endodontic procedures. The final examination (practical) will consist of mounting a single canal Mandibular Premolar in the ModuPro-Endo device and treating it as a single visit case (i.e. shaping, cleaning and obturation in one three-hour period) . If a student must leave the lab during the exam, for any reason, they must leave the tooth/ModuPro-Endo with their instructor until they return. VI. ASSIGNED LEARNING RESOURCES A. Textbook: Cohen and Hargreaves, Pathways of the Pulp, 9th Edition, 2006 (required) B. Lee and Parkinson, A Laboratory Guide, 2009 Edition (required) C. Buchanan Videos: Shaping and Cleaning I & II and Obturation (available in library) (www.buchananendo.com) (suggested)

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Endodontics Manual II

D. Dumsha and Gutmann, Clinician s Endodontic Handbook, 2 nd Edition, 2005 Lexicomp. (suggested) VII. ATTENDANCE POLICIES: The student is expected to attend all laboratory sessions; focusing attention on the endodontic exercises and techniques presented. VIII. OTHER POLICIES: A. Rules for Taking Examinations 1. Physical Arrangements: Students will remain at your assigned Bench in the Laboratory. 2. Location of Non-necessary Materials: Anything not necessary to the job at hand will be put away. 3. Examination Conditions: Questions will be answered in association with creation of your Graded Procedures at the convenience of instructors. No questions will be answered during the Final Clinical Examination. 4. Others: Each student will be responsible for doing his/her own work on all projects. Stu dents must be present for the scheduled final exam. B. Make-up Examinations: Graded procedures and Clinical Final will be treated as late projects with a penalty of 5 points per week late (must be coordinated with Course Director). C. Cheating: Cheating and or unethical behavior will not be tolerated. All incidents will be dealt with severely and referred to the Academic Standards Committee or the Student Honor Council and the student will not be allowed to return to the lab until there is a resolution by those enti ties.

D. Tardiness: The student is expected to be on time with instruments properly set up and ready to begin work at I :00 p.m.; additionally, the student will be expected to cease work and render their own laboratory space clean and disinfected prior to 3:50 p.m. Students must arrive at Lec ture no later than 4:00 sharp. A Lecture quiz will regularly be given precisely from 4:00 to 4:05 . Should you arrive late, you will simply have LESS than the intended five minutes to complete the quiz. Abuse of this policy or of any of the equipment will result in a reduction of five points for that exercise. Repeated or serious abuse will result in failure of the course and referral to the Honors Council. E. Remediation Policy: Remediation will be at the discretion of the Course Director.

1. Instructor Responsibilities: Instructors are expected to be present on time having reviewed the material and ready to teach. The Course Director will be charged with clearly explaining what is expected of the student at each session. All instructors are available to answer ques tions and to clarify expectations. 2. Student Responsibilities: The student should prepare for exercises by reading and viewing reference material and Laboratory Guide pertaining to the exercises in advance of the ses sion. Student evaluations will consider preparedness. Repeated lack of preparedness, working past time or failing to clean up area may result in failure of the course.

F. Other: Each graded project must appear for grading solidly mounted in the appropriate Modu Pro segment which must be engraved on the lingual aspect of the segment with the student's Bench number and the Year (e.g. #42 - 2008).

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Revised 09/'09

Do NOT throwaway any teeth or projects, X-Rays, etc. related to this course. Students must SAVE all 2raded projects to be displayed and turned in at the time of the final lab practical exam. Failure to present all graded projects will result in repeating the project on those missing. All must have bench # and yr. engraved in segment. If any of the "Graded Projects" is not present and displayed at this time, 10 points will be lost and the absent project must be repeated and turned in within 2 weeks. If the original or repeated project fails to be turned in within the 2 week period, ALL points for that project will be lost. All late projects lose 5 points per week late. Any student who wishes to repeat a project in hopes of attaining a better grade may do so with the same penalty of 5 points per week late with a dead1 ine of 2 weeks following the original due date. If a student receives a poor grade on the final practical examination, the student may elect to repeat the final if redone within 2 weeks following the final exam with only a 5 point late penal ty in this case. All make-ups following the lab final must be scheduled as if a regular patient in the Clinic and must be signed in to start and must remain under direct supervision of endodontic faculty until completed. If any subject or point is unclear to any student, it is their responsibility to ask for clarification. *NOTE: If a student satisfactorily completes an exercise prior to its due date they may proceed to the next exercise.

IX. Cou rse Schedule: A complete listing of lab sessions will be found on page 1 in the front of the Lab Guide. X. Detailed Contents: The Lab Guide Outlines each specific procedure and session as well as objectives and intended learning outcomes for each class session.

STATEMENT ON DISCRlMINATION, INTIMIDATION, AND SEXUAL HARASSMENT

The faculty, administration, staff, and students of the University of Missouri-Kansas City are dedicated to the pursuit of knowledge and the acquisition of skills that will enable us to lead rich and full lives. We can pursue these ends only in a culture of mutual respect and civility. It is thus incumbent upon all of us to create a culture of respect everywhere on campus and at all times through our actions and speech. As a community of learners, we are committed to creating and maintaining an environment on campus that is free of all forms of harassment, intimidation, and discrimination. Any form of discrimination or coercion based on race, ethnicity, gender, class, religion, sexual orientation, age, rank, or any other char acteristic will not be tolerated.

•

Should you, a friend, or a colleague ever experience any action or speech that feels coercive or discrimi natory, you should rep0l1 this immediately to the department chair, the office of the Dean, and/or the Affirmative Action Office. The Affirmative Action Office, which is ultimately responsible for investigat ing all complaints of discrimination or sexual harassment, is located at 218A Administrative Center, 5115 Oak Street; the office may be contacted at 816-235-1323. All formal complaints will be investigated and appropriate action taken. THE END

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Endodontics Manual II

ApPENDIX L: APEX LOCATOR • Dry canal(s) slightly with paper points. • Place the metal grounding clip of the apex locator on the ModuPro-Endo metal contact areas . • Take a size 8 or 10 hand fi Ie, which should be pre-set at the pre-measured TL + Imm, and place a small amount of lubricant on it. • Insert the file into the access and place small clip on the end of the file above the stopper. • Watch wind the file down the canal to bring the stopper to your landmark while viewing the measure ments on the apex locator, evaluating your TL calculation. • The display will tell you how far you are from the apex. (i.e. 2mm, 1mm, .5mm) If the file is 1mm from the apex your trial length is correct and this becomes your Working length (WL). The apex locator gives a more accurate reading when the file exits the canal. • If it is not correct you must adjust the stopper to the correct length to bring the apex locator reading within I mm from the apex . After you move the stopper do not forget to re-measure the file to obtain your correct WL and document it. • Once you have a reading, verify the reading by duplicating the same procedure with a size 15 file. If you get the same reading it should be accurate.

• *Another method

is to purposely allow the file to become slightly patent (solid tone) and then move the file slowly back until the intermittent tone begins. This interface should be determined accurately and will coincide with the anatomical apical foramen and the dial should then be at the APEX mark. WL is then 1 mm. shorter.

• In either case, remove the apex locator clip and take a WL film with a #15 or larger file in place to the corrected WL. Make sure the X-ray also verifies that the file appears to be Imm from the apex.

Endodontics Manual II

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Revised 09/'09

Right on

Short

Long

Revised 09/,09

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Endodontics Manual II

Appendix M: Mounting Teeth in the Endodont The Acadental Modupro Endodont is a device that roughly simulates the oral environment for your pre-clinical endodontic experiences. Your first exercise (Plastic molar # 14) may be done in your hand (un-mounted). Following that, ALL exercises and projects must be donewith your teeth mounted in the Endodont using the rubber dam at all times (except when taking radiographs.

Th~

Enclodont consists of <In mticulatol plus 2 C<11112r trays (maxillary anel manclibular) Each c<tHier tray acc~pts 3 removable modules (one anterior anel 2 posteriormodnl~s). The segments are secmeclm the carners trays magll~tically This makes remov<ll anclreplacement simple and quick for lacliograpl1s.

Each endo module (sextant) has an expanded socket in which natural teeth can be mounted with Acadental's proprietary mounting materials (Apex PUttyTM and Fixing GeITM) adjacent to the existing artificial teeth, which are intended to be used as a guide .

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Revised 09/'09

Here ;ue the i.lldi\"icl11:11 Jllod111es or sext:1nts . U.Il the left we see - N ~-6 (premolar motu) - N -:: -1 ~ (centralc11spici) - N 13-15 (mobr (\n the right are il111strated - N 13-20 (mohr) - N ~1-2i (lHClsorC118pid) - N ~3-31 (JlwhUIHellloLu) Yom extI:1ctec1 teeth

be placed lJl the :1pplOpnate modnle 1H the :1pplOpriate location and posItIon (lllsofn :1S po;';slble) PbstIc central iJlc1~or tooth \nll be used as yom m:1xillmy cenu:11 lJlcisor and shollid be pbce ill 10C:1tlOn for tooth ~3 \Ylll

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To mount the teeth, you will need the following :

Fixing Gel Syringe with mixing tip

Additional Mixing Tips available

('olldllctl\"e A.pex P11tty is designed to be pbced around the (tpex of the tooth to rephc:1te the PDL. TIle plltty LS q11ite r(ldiohlcent to IHO\"ide excellent apIcal YlS1wlizatioll (tnd a contrast ,,"ith the Fixing Gel The condllctiYe capability of the p11tty allows silllnbtlOn of the 11se of the Apex LOC(ltOL

Revised 09/'09

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Endodontics Manual II

Placing Teeth in the ModuPRO Endo

Step 1 To he lp lock the tOOti足 , in the Fixin g Gel, cut a hOrIZ ontal notch in the coron al third of the tooth root on the faci al an d lingu al surface. Do not ente r the ro ot canal space . .I'Ifter notchlll g, be ~uru tha tooth is cl ea n ~n d dry before mounting in the endo module.

Step 3

Step 2 Use only Ape x Putty wh en mounting extracted te eth w ith the MoeJuF'RO En do

Place the A pe x Pu tty In th e bottom of the socket See illust ration for dete rmilling the am ount of Apex Putty necess ary .

M(l/iuPt<O

Placing Teeth in the ModuPRO Endo

,.. W Step 4

Step 5

Pla ce th e toOtil in til e Apex Pu y an d align with th e ocd usal plan e of the adjacent artifi Cial to oth . Ensure the Ape x Putty is in compli ance with the illu stration

Fill the en tire soc l(et around the [Oath with FIXIIlQ Gel to cover th e entire tooth s ro ot surface to tile CEJ refe rencing th e Illustrati on to the rigrlt. (The FiXing Gel ls som ewhat visco us so the flow can be

contro ll ed .)

Allow the FiXi ng Gel to set appro x 30 rn nu tes (full st rength in 24 hours) A n e>-' !ra MiXi ng TIp IS Included with eac h syri nge be cause the Fix ing Gel sets-up inSid e trle ti p if ti me el ap se s betwee n mounting Kee p tile Fi xin g Gel synnge stored at ro orn te rn perature i\l ote: Mounted teeth should be stored in an w tight ba g or container Wltll m oist cloth or gauz e to help H prevent tooth f ra cture during treatment.

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Revised 09{,09

Helpful Tips • Follow the instructions • Completely dry the t ooth before mounting. • Use only the materials specified: (Apex PuttyTM and Fixing GeI™). • Do not use additional materials beyond th ose required when mounti n g each tooth as the tooth may become dis lodged from the tooth sock et. • After mounting a tooth. store the endo mod ule in moist gauze to prevent the tooth from drying out and/or fracturi ng. • Strict ly adhere t o the guidelines found in the Candidate Gui de w hen used for a board exam • Mount back-up teeth when using for a board exam in the event a rejection occurs. Wn,/uPR()

Note: When mounting multiple teeth, be aware that additional natural teeth may ma ke it difficult to obtain clear radiograp hs in the proximal view . Plea se plan accordingly.

Radiograph Results As you can see. the Apex Putty allows for excellent apical visualization. The Apex Putty can be easily applied around the root without voids. Fi xing Gel

Ape x Putty

ModIlJ'J~O

Revised 09/'09

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Endodontics Manual II

Distribution Channels UMKC Dental Bookstore

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ModuPRO

Endodontics Manual II

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Revised 09/'09