Comprehensive Endodontics from

Diagnosis to Restoration
Trevor Blattner, DDS
Dr. Blattner has no relevant financial relationships to disclose.
Presentation sponsored by Delta Dental of Missouri

Friday, June 15, 2018

1:30pm – 4:30pm

The Missouri Dental Association is an ADA CERP Recognized Provider approved by the Missouri Dental Association.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors,
nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider
may be directed to the provider or to ADA CERP at www.ada.org/cerp.
Trevor C. Blattner DDS, MS
Blattner Endodontic Care
Cape Girardeau, MO USA
• University of Missouri-Kansas City

• University of Maryland
 only 20% by
Endodontists
• Is the Chief Complaint reproducible?

• What’s causing the Chief Complaint?

• Can the complaint be eliminated?

• Is endodontic treatment the way to alleviate the

complaint?
•Subjective
•Objective
•Assessment
•Plan
 Patient Questions

• History of Pain
• Severity of Pain • Duration of Pain
• Frequency of Pain • Location of Pain
• Stimulus of Pain • Spontaneity of Pain
Cold

•Use Endo Ice

Heat
• Must be current
• 2 PA’s/1BW

• Must show complete tooth

and surrounding tissues

• Consider a CBCT in select

cases
Pulpal diagnosis

Periradicular diagnosis
Pulpal diagnosis Periradicular diagnosis
• Normal pulp • Normal Apical Tissues
• Reversible pulpitis • Symptomatic Apical
• Irreversible pulpitis Periodontitis
• Necrotic pulp • Asymptomatic Apical
• Previously Treated Periodontitis
• Previously Initiated Therapy • Acute Apical Abscess
• Chronic Apical Abscess
Endodontic Therapy
•Emergency Treatment
•Elective Treatment
Extraction
Referral
 Rubber Dam Isolation

“Only dental dam isolation minimizes the risk of

contamination of the root canal system by indigenous
oral bacteria”
• Asepsis
• Better Vision
• Irrigation
• Lost instruments

• Clinical
• Protects patient by keeping irrigating solutions confined
to the operating field
• Some irrigants have systemic toxicity
• Most irrigants cause some local tissue damage
• NaOCl
• EDTA
• Chlorhexidine
• Protects patient from
swallowing or aspirating
Instruments
• 1, 2, 14
• 212
• Glickman Clamp
Fundamentals of Access

“A well-designed access
preparation is essential for a
good endodontic result”
1. Removal of the chamber roof and all coronal pulp
tissue
2. Location of all canals
3. Unimpeded straight-line access of the instruments in
the canals to the apical 1/3rd or the first curve
4. Conservation of tooth structure
• You have maximized
straight-line access to
the canal orifice

• Canal transportation
• Separated
instruments
• Missed canals
• Perforations
• Separation of
instruments
• Poorly cleaned and
shaped canals
 Endo
Access burs
Alpen Safe End Endo Carbides
• When you can hold your mirror over the access and can
see every orifice with out moving the mirror.
“A rotary file only likes to
bend one time”
• The ideal access cavity
creates a smooth, straight-
line path to the canal
system and ultimately to
the apex.
Anterior Teeth

41%
Maxillary 1st Bicuspid

• Sometimes 3 (6% of the time)

Mandibular 1st
Bicuspid

•25 – 35%

~5%
90 to 95%
Maxillary 1st Molar

•But usually 4
canals (MB2)
Mandibular 1st Molar

• 40% will meet apically

• 40% of time 2 canals are present

in distal root
“The distance from a predetermined
coronal reference point to the point
where the cleaning and shaping and
obturation should terminate”.
• Apical Constriction (AC)
• Apical Foramen (AF)
• Cementodentinal Junction (CDJ)
• Sometimes referred to as
minor apical diameter
• Considered the part of the
root canal with the smallest
diameter
• Reference point for the
apical termination for
cleaning and shaping and
obturation
• Sometimes referred to as
major apical diameter
• Opening at the apex of the
root of a tooth, through
which the nerve and blood
vessels that supply the
dental pulp pass
• Estimate the working
length from the PA
• Place a #15 at estimated
working length
• Take a PA
• Adjust to .5 to 1 mm short
of radiographic apex
• If more then 2 mm from
apex, readjust file and
make a new PA.
The radiographic apex is not
where the apical foramen is
located
• Working file is usually long
90% of the time
If working file is at
radiographic apex on PA
• Subtract 1 mm from working
length
• First investigated by Custer (1918)
• Suzuki (1942) studied the flow of direct current through
the teeth of dogs.
• Sunada (1962) took these principles and constructed a
simple device that used direct current to measure the
canal length.
CanalPro Apex Locator
• The CanalPro Apex Locator is dual impedance-
based, as opposed to conventional units which
operate on the direct current principle
• It uses the alternating current of two frequencies
to measure and compare two electrical
impedances that change as the file moves apically
• The benefit is that these devices are less affected
by fluid conductive media in the canal, resulting in
more accurate readings
• No “jumping” effect when measuring
• The movement of the file inside the canal from the beginning of the
measurements to the end is shown in the tooth image on the left part of the
display
• This provides uninterrupted feedback.
• The movement of the file inside the canal is shown in the tooth image on the left part of
the display and additionally in the enlarged root canal picture on the right
• Numerical value appears on the left side of the display under the tooth image
• CanalPro Apex Locator provides audio feedback - as the file advances deeper into the
canal, the series of beeps become progressively closer in duration
 Beginning of the Middle of the apical Apex
apical zone zone

• The apical zone is divided into 11 segments graduated from 1.0 to 0 (Apex) as
visual information of file progression
• When the apex is reached, solid tone is emitted
Apical constriction
• Equals area of the 3 green bars
• Recommended procedure
• Working length: length of the file is marked with
endodontic stopper and measured (preliminary):
no further tolerances have to be considered

Apical foramen
• “APEX” appears
• Recommended to take working length file to this
area to confirm patiency and PDL space
• Back working length file back up to bottom of green
bar or middle of yellow for a truer Apical
Constriction reading
• accuracy

• Speed and convenience

• Torsional Stress
• Cyclic (flexural)
Fatigue
Torsional fracture
• Occurs when the tip, or
any other part of the
rotating instrument,
binds to the root canal
walls while the rest of
the file keeps turning

• Due to much apical

pressure on rotating
instrument
Cyclic Fatigue (Flexural
Fatigue)
• Occurs when an
instrument that has
already been weakened by
metal fatigue is placed
under additional stress

• The instrument does not

bind to the root canal walls
but rotates freely until
fracture of the instrument
occurs at the point of
maximum flexure
• “S” shaped canal system
• Difficult canals to
negotiate, predisposes
to ledge/block
formation
• Double curves
overstress instruments
leading to greater file
separation
• Difficult Access
• Often requires microscope for increased magnification
• Difficulties in creating glide path
• Requires specialized
techniques
• Often times requires an
additional follow up
surgery depending on
resorption type
(especially with curves)
• 74-86%
• Key factors include existence of a long-standing
perforation, and a periapical lesion

• By far the Key factor in retreatment predictability is the

ability to respect the original RC morphology during
treatment (87% vs. 47%)
 Glide Path

Before any rotary instrument is

introduced into a canal, the canal
must be scouted with a hand file
and a glide path created.
• PathFile
• ProGlider
• HyFlex GPF
• ScoutRaCe
• V-Glide Path 2
• Channels
Ground NiTi (1993-Present)
• Profile™ System
• RaCe™ System
• ProTaper™ System
• K3™ System
• GT™ System
• Hero™ System
• HyFlex NT™ System
M‐Wire™ NiTi (2007 –
Present)
• GT Series X™ System
• Profile Vortex™ System
• ProTaper Next™ System
R‐Phase NiTi (2008 –
Present)
• Twisted File™ System
• K3 XF™ System
Controlled Memory NiTi
(2011-Present)
• HyFlex CM™ System
• TyphoonCM™ System
• EdgeEndo™ System
• 10 Series™ System
• ProTaper Gold (2013)
• Wave Gold (2015)
• Controlled Memory NiTi
EDM 2015
• Austenite Standard NiTi are in this Phase
• Martensite Shape Memory/Controlled Memory NiTi are in this Phase
 (or
under stress),

martensite
austenite
 austenitic
• Standard NiTi files
“remember “ their shape
and bounce back “like” a
swimming pool diving
board at room
temperature
 martensitic
• Controlled memory files
hold their shape and DO
NOT bounce back “like” a
swimming pool diving
board at room
temperature
• Standard NiTi Files are in the Austenite Phase at
Room Temperature. They are rigid and do not show
plastic deformation visually

• Controlled Memory Files are in the Martensite

Phase at room temperature and are highly flexible
and show plastic deformation visually after heat
treated (autoclaved)
 The advantages that “trained
shape” bring to NiTi is the ability
to distinguish between different
forms of Deformation.
Elasticity:

Deformation:
1. Elastic Deformation = Reversible
Elasticity:

http://ganywatch.de.tl

Deformation:
2. Plastic Deformation = Irreversible
 Foto: Polizei Stade

2. Plastic Deformation
• plastic deformation is irreversible
 elastic
plastic
  Unexpected Instrument Fractures 

• Files plastically deformed will break

• pseudo-elasticity of common or standard NiTi files masks the plastic deformation
 elastic plastic

true shape memory

properties
Controlled Memory Files
Shape Memory (Controlled Memory)
• “training” material to remember a shape

1.shape 1.shape 1.shape

Change of conditions Plastically
deform deformed



HyFlex CM files are mostly martensitic at room temperature
Controlled Memory Benefits
•Superior Canal Tracking
•Regenerative properties
•Outstanding fatigue resistance
Controlled Memory Benefits
•Superior Canal Tracking
•Regenerative properties
•Outstanding fatigue resistance
1. Superior Canal Tracking

take any given shape at room temperature

• Superior canal tracking
• Extreme Flexibility = easily follows very curved canals
• Controlled Memory = stays centered
• Reduced ledging & transportation
• No lateral force = no bounce back/spring effect

Common NiTi file Hyflex CM NiTi file

Controlled Memory Benefits
•Superior Canal Tracking
•Regenerative properties
•Outstanding fatigue resistance
 2. Regenerative properties
Before use

After use

• Excessive resistance straightens spirals:

– Avoids binding to the walls = reduced fracture risk

• The file can continue to be used, provided it has not started to wind in the opposite direction.

Journal of International Oral Health 2014; 6(6):1-4

Topographic analysis of HyFlex® CM NiTi files … Al-sudani D
HylFex Controlled Memory Files = Multi-Use

regains original shape

any sign of deformation

looks brand new

visual confirmation
Controlled Memory Benefits
•Superior Canal Tracking
•Regenerative properties
•Outstanding fatigue resistance
3. Outstanding Fatigue Resistance

> 300% higher fatigue resistance

 M&M: A total of 120
conventional and
controlled memory NiTi
rotary instruments were
tested at 35 and 45
curvatures.

Results: The present study

indicated that NiTi
instruments made from CM
Wire were nearly 300% to
800% more resistant to
fatigue failure than
instruments made from
conventional NiTi wire.

Shen et al. JOE — Volume 37, Number 7, July 2011

A New Era of Controlled Memory Files

...HyFlex™
EDM
HyFlex™ EDM Files (Controlled Memory)
Electric Discharge Machining

hardened surface structure

while keeping flexibility

2015 Mersen

2015 RGF-Funkenerosions-SGmbH
new surface hardness

improves
cutting performance
FIRST

.
• High surface hardness
• High cutting efficiency
 Results:
• No EDM files fractured and no
macroscopic signs of deformation
• All the instruments, after 10 uses,
preserved the crater-like irregular
surface without cutting-edge or
blunt disruption
• An increase up to approximately
700% in cyclic fatigue over similar
size and taper CM files

C. Pirani et al. 2015

 Conclusions:
• The new manufacturing process of
electrical discharge machining had
a substantial impact on fatigue
lifetime of HyFlex EDM files
• The spark-machined surface
remained unaffected after
multiple uses, confirming a high
wear resistance
• EDM files appeared suitable for
shaping severely curved canals

C. Pirani et al. 2015

• Up to 700% more breakage resistant then
HyFlex CM:
any
 Results:/conclusions:

Hyflex EDM was

significantly higher

WaveOne Primary and

WaveOne Gold

E. Pedulla et al. 2015

Access Glidepath OneFile Finishing Files

25/.12 10/.05 25/.08 40/.04 50/.03 60/.02

Recommendations:
• All EDM NiTi files:

Single pass until working

length is reach
• Glidepath file

• Very Light pecking motion

SEVERELY
HyFlex EDM Reduction in numbers of files:
• Without compromising root canal anatomy
Severely curved canals
-Consider adding HyFlex CM files

15/.04 20/.04
Instruments Shape
&
Irrigants Clean
ALL
• Debride the canal
• Dissolve pulp tissue
• Remove the smear layer
• Kill Microbes
Passive Irrigation

Active Irrigation
• Adding irrigating
solutions

• Minimally effective
• Actively

• Agitation

• Activation

• Key is keeping the

solutions in motion
Sodium Hypochlorite (NaOCl)
Sodium Hypochlorite (NaOCl)
luer lock

better
CanalPro™ NiTi Tips
• Gold Standard

• Extremely flexible

• Autoclavable
 • Dentin Shavings
• Cell Debris
• Pulp Remnants

• With pulp necrosis, the layer

becomes contaminated with
bacteria and their byproducts
Removal
(EDTA)
1 minute
Cross section of root dentin covered by Instrumented canal wall after
the smear layer created by removal of the smear layer by NaOCl
Instrumentation. Notice smear plugs in and EDTA.
dentin canals.
• CanalPro™ EDTA
• 17% EDTA Solution (pH 8.5)
• Removes smear layer and dentin mud
• Opens dentinal tubules for
• Disinfecting solutions to work more effectively
• Better adhesion of sealers and obturation material
Typically would consist of:

NaOCl

EDTA
Many dentists would use NaOCl again after EDTA

NaOCl

EDTA

NaOCl
Using Sodium Hypochlorite again after EDTA cause
excessive erosion of the canal wall dentin
If tooth is vital, current regiment recommends only the
following irrigants

NaOCl

EDTA
If tooth is necrotic, consider adding CHX as a final rinse

NaOCl

EDTA

CHX
• Broad-spectrum antimicrobial agent effective against gram-
negative and gram-positive bacteria
• Has little toxicity
• Has an antimicrobial action similar to that of 5.25% NaOCl
• More effective against E. Faecalis
Disadvantages
• CHX does not dissolve necrotic tissue
• Does not remove the smear layer

• Must be used as an adjunct with NaOCl

CanalPro™ CHX-ULTRA 2%
• 2% Chlorhexidine Gluconate with
powerful wetting agents and
proprietary surface modifiers
• Improves the depth of penetration and
kills planktonic bacteria 10X faster than
normal 2% Chlorhexidine
• Final Irrigation step for long-lasting
disinfection
• If NaOCl and CHX are used
immediately after one another, you
will see an orangish-brown
precipitate (para chloroaniline)
• Do not use these irrigants one after
the other
• EDTA neutralizes NaOCl, so typically
you should rinse with EDTA after
using NaOCl and before using CHX
NaOCl
• Antimicrobial/antibacterial - kills bacteria
• Dissolves organic material within the canal space - dissolves pulp (nerve)
tissue and collagen
EDTA
• Mildly antimicrobial/antibacterial
• Removes inorganic debris from the canal space - chelating agent that
removes smear layer
CHX
• Broad-spectrum antimicrobial/antibacterial
• Has sustainability - has a prolonged antimicrobial/antibacterial effect
lasting for approximately 60 days after use
• no tissue dissolution properties
• Cost-effect way to create a dedicated
area for syringe filling
• Syringe activated valve
• Low level light indicator
• Helps prevent counter, carpet and
scrub damage
• Several units may be connected to
create a convenient station for filling
multiple solutions
 Automated, simultaneous delivery of multiple wavelengths of sound energy

20k microns

3 microns

Frequency

Sonendo’s Multisonic technology creates a closed system that lets multiple

wavelengths of sound reach throughout the entire anatomy
Degassed Procedure Fluids

Accelerated Chemistry

Sealed Environment

Advanced Fluid Dynamics

Multisonic Energy
 NaOCl
1

2 Distilled
Water Rinse

3 EDTA

4 Distilled
Water Rinse
The GentleWave ® System with the
automated fluid management system prepares
and delivers the desired concentration Complete
Pre-Op Post-Op
Pre-Op Post-Op
Pre-Op Post-Op
Pre-Op Post-Op
Pre-Op Post-Op
Pre-Op Post-Op
Pre-Op Post-Op
 So now that everything is
cleaned and shaped, what’s
next?
Let’s Obturate
“The success of the treatment
is directly related to the
quality of the obturation”
 “Teeth that are poorly
obturated are often poorly
prepared.”
 Regardless of the
obturation technique used
today, Sealers are an
essential component of the
process.
Seal the space between dentinal wall
and the core

Fill voids and irregularities in the root

canal

Ideally flow into lateral and accessory

canals

Act as a lubricant

Adheres to smear layer free dentin

 Cold Warm Other
• Lateral Compaction • Warm Lateral • EndoRez
• Single Cone • Vertical Compaction • Paste
• Resilon • Warm Vertical • Apical Barrier
• Custom Cone • Thermo-Mechanical
• Injection • Injection: Obtura,
• (Gutta Flow) Calamus, Resilon
• Carrier: Thermafil,
GuttaCore
• Guttapercha cones
– Lateral Condensation

– Vertical Condensation

• Sealer
Match
Advantages • Disadvantages
• Speeds up the root canal • Perceived to be less effective
obturation process in sealing root canals than
• No need for accessory cones other techniques.
• Less operator fatigue by • Greater volume of cement
operator compared to lateral expected in absence of
condensation techniques condensation when used
with .02 taper due to canal
variation
 GuttaFlow® 2

A Sealer & Flowable Guttapercha in 1 Material

Ebert et al., 1999; Roggendorf et al., 2001, 2003; Bouillaguet et al., 2004
Cold Flowable Gutta-Percha
no shrinkage
one
material
expansion
How to Place GuttaFlow® 2
1. Use material as sealer & Place sealer
2. Coat matching gutta percha cone
3. Place cone in canal
4. Heat sear off cone
• 10 minute working time 25 minute set time
• Can check work on x-ray
• Can remove & replace if void is found or not
happy with fill result within 10 minutes
• Place master cone to working length (apical stop)