Combining technology and endodontics

Dr. Mark Colonna blends technologies for more effective treatment 

Recent developments in endodontic technology give clinicians today a definite advantage when performing root canal therapies. In particular, I have found success with the Endo-Eze^® TiLOS™ endodontic system (Ultradent) combined with magnification and cone beam technology. The following case study shows how these products and technologies work together to achieve a quality result using minimally invasive techniques. 

A female patient, age 46, with a nonremarkable health history, came into the office with a toothache. The upper right second molar had been bothering her for a few months prior to her coming to the office to have it checked. We took a digital periapical radiograph, which didn’t appear to have any pathology (Figure 1).

The patient exhibited advanced wear due to bruxism and had been treated for TMD at another dental office earlier in her life. Some small fractures and wear facets were found on the teeth upon examination with the dental microscope, and the tooth had a composite restoration that appeared to be in acceptable condition. We decided to perform a cone beam computed tomography (CBCT) scan using our Galileos^® Comfort^PLUS CBCT scanner (Sirona Dental). With the triangulation of data — i.e., magnification during exam (visual), digital X-rays (DEXIS), and CBCT scan — we were able to decide that tooth No. 2 was in need of endodontic treatment. With the CBCT scan, we are able to see a number of issues that pointed to pathology (Figure 2). 

On the tangential and cross-sectional slices, we were able to see the enlargement of the periodontal ligament in the periapical region (dark areas). Noted also was some tissue inflammation in the right sinus floor, which can be an indication of periapical pathology with irritation into the sinus. On the axial view, we saw the presence of four canals about mid-root. Views from the coronal and sagittal also helped confirm the diagnosis (Figure 3).

In addition to the inflammation noted in the oblique view, we also noted sinus inflammation above tooth No. 2 and a clean sinus on the left side in the coronal view. These differing views in the CBCT scan — the ability to see the pathology in 3D — is, in this author’s opinion, a huge advantage over traditional means of diagnosis. 

We scheduled the patient for endodontic treatment on tooth No. 2. We anesthetized the patient’s tooth using lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate (Onset from Onpharma^®). We placed the rubber dam, and proceeded to make access into the root canal chamber under the dental operating microscope (Global) (Figures 4 and 5).

Because of the road map that the CBCT scan gives the operator, it was fairly easy to find all four orifices quite quickly. Also, a minimally invasive access preparation was easy to facilitate because we knew where the anatomy was prior to access. 

We then used a No. 6-10 file and an electronic apex locator (EAL) to measure the length of all four canals (Figure 6).

We filed each canal to a size No. 15 file using Endo-Eze TiLOS files (Ultradent). We then used a reciprocating Endo-Eze handpiece and shapers (Ultradent) with File-Eze^® (Ultradent) as a lubricant during the complete enlargement phase of treatment (Figure 7).

In between each file and shaper, we used the LightWalker^® Er:YAG laser (Fotona) utilizing PIPS™ (Photon Induced Photoacoustic Streaming) technology, laser-assisted irrigation with NaOCl (ChlorCid^® from Ultradent), and sterile water¹ (Figures 8, 9).

By irrigating in between each TiLOS file and shaper, we are assured that the dentinal debris and biofilm are removed with copious amounts of irrigants. This allows for better three-dimensional obturation with a flowable sealer or even calcium hydroxide intracanal medicaments when needed. 

Once we were finished with the TiLOS reciprocating shaper files (started after enlarging canals to size 15 with TiLOS hand files), we then used the apical files to enlarge to a No. 25 final file size in all canals (Figure 10).

We then finished irrigation with sterile water and PIPS™, followed by a final rinse with a syringe and the double sideport irrigator NaviTip^® (Ultradent). We then used a capillary suction tip to remove excess fluid in the canals and paper points to dry prior to calcium hydroxide placement (Figures 11 and 12).

In this particular case, we dressed the canals with UltraCal^® XS calcium hydroxide paste (Ultradent) as an interim dressing (Figure 13).

As seen in Figure 14, placing UltraCal XS into the MB2 canal actually causes it to flow up the MB1 canal due to the combined three-dimensional cleansing of PIPS™ and TiLOS files and shapers. The anastomoses are clear and devoid of tissue and debris (Figure 15).

We then temporized with Fuji II™ LC glass ionomer cement (GC America) bonded in with Peak^® Universal Bond (Ultradent) (Figure 17).

Two weeks later, the patient returned, and we placed the rubber dam again, but this time no anesthetic was used. We used PIPS™ and Skini syringes (Ultradent) with NaviTip FX tips (Ultradent) to irrigate and remove excess calcium hydroxide. We then checked each canal for any excess fluid weeping or drainage under high magnification with the microscope. With each canal dry and patent, we then used EndoREZ endodontic sealer (Ultradent) to obturate each canal. Placing resin-coated gutta percha cones specially formulated to bond with EndoREZ in each canal to working length ensures that the cones are completely bonded to the resin sealer (Figure 16).

After obturation, we then needed to seal the orifice completely. We placed Peak Universal Bond (Ultradent) into the orifice and then covered with PermaFlo^® Purple flowable sealer (Ultradent). We used Fuji II LC as a final orifice filling material and cured with VALO^® Cordless LED curing light (Ultradent) (Figures 17–20).

In conclusion, using the Ultradent system for mechanical debridement of the root canal system allows for minimal filing and shaping. We have found that including PIPS™ along with the TiLOS file and shaping system helps us achieve three-dimensional debridement with minimal, if any, transportation or changing of the canal morphology. This allows us to maintain more of the original tooth integrity and strength as well. By using all the chemistries that are designed to work together in a synergistic fashion during canal preparation and obturation, the outcome becomes very predictable. The method we used is time efficient and cost efficient. Predictable patient treatment outcomes make performing endodontics both enjoyable and profitable. 

REFERENCES

1. Jarmillo DE, Aprecio AM, Agnelov N, DiVito E, McClammy TV. Efficacy of photon induced photoacoustic streaming (PIPS) on root canals infected with Enterococcus faecalis: A pilot study. Endodontic Practice US. 2012;5(3):28-32.