Endodontic Treatment - Case Study 

Endodontic therapy can be challenging for many providers, be it from the diagnosis to the instrumentation, disinfection, and obturation of the canal system. Advancements in technology and specialized armamentarium improve the efficiency and outcome of these critical steps, allowing for better success rates, especially complex cases. 

Creating a conservative, straight line access is key to reduce the strain and cyclic fatigue on the files. A glide path file improves the efficiency of the instrumentation process while preserving the natural anatomy of the canal. The new Traverse glide path file from Kerr replaces the need for extensive hand filing as well as consolidates several rotary instrumentation steps by integration into commonly used rotary file systems on the market. The non-end cutting tip follows the natural canal anatomy, and Kerr’s patented heat treatment technology significantly reduces the risk of file separa­tion, all the while providing significant debris removal towards the coronal aspect of the tooth. 

Image

Patient History 

In this particular case, the patient presented with her mandibular left first molar #19 having a diagnosis of symp­tomatic irreversible pulpitis and a symptomatic apical periodontitis. The tooth had a history of a large amalgam restoration with clinical cracking and recurrent decay and had recently been restored with an all ceramic crown. The tooth was periodontally stable and has a favorable prognosis. Endodontically treating this tooth would nor­mally have been somewhat of a challenge due to the presence of pulp stones occupying the chamber and stenotic canals; however, specially designed equipment helped to alleviate these difficulties and allowed me to achieve a great outcome for the patient in a timely fashion.

Following administration of local anesthesia and placement of a non-latex rubber dam to isolate the tooth, straight line access was created using a Zir-Cut™ (Kerr) bur to cut through the porcelain crown. Once the pulp chamber was penetrated, I used the NTI® Endo 269GK (Kerr) non-end cutting carbide to remove the pulp chamber roof and expose the canals. I then used a piezoelectric ultrasonic unit to scout the tiny canals, remove pulp stones and ledges over canal orifices and open the orifices to allow for better straight-line access and improved instrumentation. The ultra­sonic unit provided excellent visibility, precision cutting, and control.

Straight Line Access

Once I had clear access to the pulp chamber and canals, I began the process of decontamination and instrumentation. I irrigated with a pre-concentrated 3% sodium hypochlo­rite solution using a side vented needle canula in conjunc­tion with an EDTA impregnated lubricant called SlickGel™ ES (Kerr). Cleaning my files routinely after every pass through­out the entire process and using the 3% NaOCl and SlickGel™ together helped bring the debris coronally and disinfect the root canal system. Irrigation with 3% NaOCl was performed between each file used and while recapitulating to prevent blockage during the cleaning and shaping process. During the instrumentation and disinfection cycle, I used approximately 15-20cc of 3% NaOCl. 

I established my working lengths using the Apex ID™ (Kerr) digital apex locator. I have great confidence in this apex locator because it works in most any canal environment: wet, dry, bleeding, etc., and it continuously calibrates so I always get the most accurate reading. I also use an EndoRing® to keep my files organized, hold my SlickGel™ ES lubricant, and to measure my working length with ease.

Image

Once I established the working lengths with a 10 K-File, I continued with a hybridized file sequence starting with a Traverse™ (Kerr) glide path file. Prior to using the Traverse™ glide path file I used my M4 Safety™ Handpiece (Kerr) to instrument in a watch-winding, oscillating motion with multiple stainless steel files to achieve a glide path and main­tain patency. However, now I no longer have to use K-Files larger than a size 10, so I use the M4 Safety™ Handpiece regularly with a 10 K-File to negotiate intricate anatomy and constricted canals prior to moving on to the Traverse™ file. I can even connect my Apex ID™ to the 10 K-File while using the M4 Safety™ Handpiece to ensure instrumentation to the proper working length.

Creating a Glide Path 

The Traverse™ rotary glide path file has really made instrumentation and shaping of the root canal system a breeze. It comes in two tip sizes: .13/.06 and .18/.06, has a maximum flute diameter of 1mm, is non-end cutting, and it follows the natural canal anatomy and removes debris coronally. I do not have to worry about apical extrusion of debris, which leads to post-operative complications. I have had cases where I had to continuously re-instrument the tooth again and again to remove all the infected tissue. Instrumenting each canal with a Traverse™ file followed by a finish­ing file, has virtually eliminated this issue. By creating a glide path, I can more efficiently treat the tooth and worry less about file separation because I no longer have multiple sites where the file is binding. It also preserves significant tooth structure by not over instrumenting the canal system and therefore does not weaken the tooth further. 

For this case, I elected to start with a .13/.06 Traverse™ file size given the constrictions within the canals. Going from a size 10 K-File to a Traverse™ .13/.06 file is a less significant transition than going to a size 15 K-File; and the Traverse™ file also does most of my canal shaping, so it substantially reduces the overall number of rotary files I use. Once the canals were cleaned and shaped with the Traverse™ file, I used my finishing files in the order of .25/.06 and then .30/.06. Case permitting, I always try to finish with a size 30/.06 tip and taper, however some anatomical apices are wider or narrower than others, and I adjust accordingly. Studies show that instrumenting to a size 30 allows for better decontamination and delivery of irrigants to the apical 1/3. 

After I completed instrumentation of the canals, I verified the size of my apex with a size 30 K-File and performed a final rinse with the 3% NaOCl. I then flushed the canals with sterile saline, dried them, irrigated with an EDTA final rinse, and used ultrasonic agitation for 90 seconds to remove the smear layer within each canal. I dried the canals with sterile paper points that were sized to match my last finishing file. At that time, I went on to fit and select the appropriate size and taper of the heat plugger that would bind on the canal walls 3-5mm from the apex.

Image

Obturation 

After verifying the fit of the matching sized gutta percha into the canals, I coated them in Tubli-Seal™ Xpress (Kerr) canal sealer using the auto mix tip and re-inserted them into their respective canals. I then used the elements™ IC unit to sear off the excess gutta percha at the canal orifices and performed a single motion downpack with the heated plugger to approximately 3-5mm from the apex. Then, using the obturator cartridge tip, I applied additional Tubli-Seal™ Xpress into the canals and backfilled using a continuous wave obturation technique and compressed and condensed the gutta percha with Buchanan Hand pluggers. The elements™ IC system allows me to obturate complex cases with a three-dimensional volumetric fill and not have to rely on sealer alone to fill in the voids and lateral canals. It provides excellent visibility into the canals so that my view is not obstructed, and the tips are flexible so that they can follow the natural curvature of the canals and reach difficult to access areas. It is ergonomic, and easy to use, and the disposable cartridge system eliminates the need to use pellets that can be messy or carrier-based obtura­tors that come with their own set of problems. The elements™ IC has improved upon the many great attributes of its predecessors and consistently provides excellent results.

Image

Traverse and elements IC are trademarks of Kerr Corporation. All other trademarks are properties of their respective owners.

Disclosure: Dr. Miller has received an honorarium for his participation in this study.

The opinions and techniques discussed are based on the experience of Dr. Matthew Miller. Kerr is a medical device manufacturer
and does not dispense medical advice. Clinicians should use their own judgment in treating their patients.

MKT-20-0953_Rev1