`

:PRESENTED TO
'DR.NAEF & DR.BASEM ABU-QUBO
:PREPARED BY
‘MOHAMMAD SALAH QREA
FIFTH YEAR DENTISTRY
2008\2007
 Main menu
MODERN ENDODONTICS

HISTORY OF ULTRASONICS

ULTRASOUND

ULTRASOUND PRODUCTION

MAGNETOSTRICTION

PEIZOELECTRIC PRINCIPLE

APPLICATIONS OF US
 !Modern endodontics
• The use of microscopes and ultrasonics
(US) in endodontics increases the quality
of the treatment, and represent an
important adjunct in the treatment of
difficult cases.
 History of theUS
• The use of ultrasonics (US) was first
introduced to dentistry for cavity preparations.
• In 1955 US was introduced for calculus
removal.
• The concept of using US in endodontics was
first introduced by Richman in 1957.
 Ultrasound
• Ultrasound is sound energy with a
frequency above the range of human
hearing, which is 20 kHz. The range of
frequencies employed in the original
ultrasonic units was between 25 and 40
kHz.
 Ultrasound production
• There are two basic methods of producing
ultrasound:
• The first is Magnetostriction.
• The second is Piezoelectric.
 Magnetostriction
• Converts electromagnetic energy to
mechanical energy.
• A stack of magnetostrictive metal strips in
a handpiece is subjected to a standing
and alternating magnetic field, as a result
of which vibrations are produced.
 Piezoelectric principle

Electrical charge mechanical

Crystals oscillation
 Magnetostriction .Vs. Piezoelectric
Category Magnetosriction Piezoelectric

Cycles/ sec. 24 KHz 40 KHz

Heat generation Requires cooling No heat

system generation

Lines of action Figure of eight & Linear, back &

elliptical. forth.
 Applications of US in Endodontics

Access
Irrigation
Gutta
Percha
MTA
Intracanal Root canal preparation
obstruction
Surgical endodontics

Press on icon
 Access Refinement, Finding
Calcified Canals, and Removal
of Attached Pulp Stones
?When do we use US for access
• Orifices occluded by secondary dentin or
in calcified dentin.
• A lack of a straight-line access leading to
separation, perforation, and the inability to
negotiate files to the radiographic
terminus.
• In difficult-to-treat teeth such as molars.
• Calcified canals and pulp stones.
 Advantages of US
• They do not rotate enhancing control,
cutting, and safety.
• The most convenient tool for removing
secondary dentin, while searching for
hidden canals.
 US tips
• A troughing tip is a good choice for
removing calcified dentin over orifices.
• Bigger tips with a limited diamond coated
extension should be used during the initial
phase of removing calcification,
interferences, materials, and secondary
dentin, as they offer maximum cutting
efficiency and enhance control while
working in the pulp chamber
 US tips
• Thinner and longer tips that facilitate
working in deeper areas while maintaining
clear vision, should be used in subsequent
phase of finding canal orifices.
• The diamond-coated tips used in
orthograde endodontic treatment have
shown significantly greater cutting
efficiency than either stainless steel tips
or zirconium nitride- coated tips, but they
have a tendency to break.
 US tips

• Thinner diamond-coated tips seem to

make more aggressive cutting action, so
that care should be exercised while
searching for canal orifices.
BUC
(a) The BUC-1 is an example of
diamond-coated spreader tip
of medium length that can be
used for gross dentin removal,
moving access line angles,
cutting a groove in the mesial
access wall to drop into MB2
canals, and quickly and
carefully unroofing pulp
chambers.

(b) The BUC-3 is similar to the

BUC-1 with a sharper tip and a
water port for increased
washing and cooling of the
operative site. It is used for
chasing canals or for digging
around a post or carrier-based
obturator with the objective to
remove it.
(c) This diamond-coated pear tip is
used to find canals, remove coronal
obstructions or restorative
materials, or remove calcifications,
temporary and permanent cements,
and posts. It creates a smooth,
clean flat troughing groove that
facilitates canal location.
(d) This diamond-coated ball tip
provides fine cutting control when
preparing a troughing groove and is
less aggressive than the pear tip
shown in c, yet it has the same
clinical indications.
e) A classic spreader)
tip with a diamond coating, which
offers a side- as well as an end-
cutting action. This is needed to
flare the walls of a troughing
.groove in an axial direction
f) A fine spreader tip indicated for)
troughing and removal of broken
.instruments
g) An extra-fine spreader tip used)
for extremely fine and deep
troughing or removal of a
separated instrument in the
.middle or apical third of the canal
h) A spreader tip designed for)
multiple uses such as instrument
or silver point removal, troughing
, removal of calcifications,
provisionals, cements, buildup
.materials, etc
SINE
Figure 1. The orifice of the second mesio-buccal canal (MB2) in an upper first
molar was located (a) and enlarged (b). Dentine spur at the orifice was effectively
eliminated with the use of a diamond-coated ultrasonic tip, thus permitting
easy location of the orifice of the canal.
Removal of intracanal
obstructions
 Intracanal obstruction
• Separated Instruments.
• Root Canal Posts.
• Silver Points and Fractured Metallic Posts.
• Removing of the rotary instruments.
Management of broken instruments
• Surgical approach.
• Orthograde:
• (a) attempt to remove the instrument;
• (b) attempt to bypass the instrument;
• And (c) prepare and obturate to the fractured
segment.
• In many cases the removal of fragments is
hopeless, and cause several complication:
include excessive loss of root canal dentin,
ledging, perforation, and extrusion of the
fractured instrument fragment through the apex
• For example: “staging platform” using
Gates Glidden drills (size 3 or 4) , cause
weakening of the root wall and may cause
perforation.
• Recently, it has been shown that
preparation of staging platforms was best
accomplished with the use of modified
Light Speed files .
• The inability to see the instrument with
direct vision and the difficulty of creating a
staging platform, as well as the use of US
in curved roots, has contributed to a lack
of success in removing fractured
instruments.
Gates Glidden bur modified by cutting it at the maximum diameter
viewed from an apical (a) and lateral direction (b). This permits the preparation
.of a platform at the extruded portion of the fragment to be removed
NiTi rotary instrument separated in the distobuccal canal of
an upper first molar
The fragment was removed using ultrasonic tips, and the root
canals were successfully negotiated to the apex
cleaned, shaped, and filled tooth
 Root Canal Posts
• US reduce the amount of tooth structure
loss.
• The preservation of maximum root
structure requires the use of specific
ultrasonic tips.
• There are some challenges.
 Challenges
• fiber-reinforced composite posts
cemented with adhesive systems.
• Esthetic white posts.
 Removing of posts
• Removal is done in a dry field using a
continuous stream of air with direct vision
of the ultrasonic tip and the coronal portion
of the post.
• It is important that the entire composite
material that was used in the luting
procedure be removed.
i) Vibrator tip specifically)
.designed for post removal
• Adhesive material.
• “Gray streaks” evidence.
• Composite resin cements causes a change
in the effectiveness of US as an aid in post
removal.
• No water…better US!!! (resin cements).
• As the mod. Of elasticity increase the
effectiveness of the US increase." stainless
steel”.
 ?How to remove
• Removal of restorative materials and
luting cement around the post, followed by
application of the tip of an ultrasonic
instrument to the post.
• This method of post removal minimizes
loss of tooth structure and decreases the
risk of tooth damage.
• The tip should not be too thin, because
small-diameter ultrasonic instruments are
weak and more predisposed to breakage,
On the other hand, the tip should not be too
large, because it must be kept in intimate
contact with the post.
• Adequate water-spray cooling.
• In prefabricated posts it is easy to separate
the coronal portion.
• Clinically, after removing all
circumferential restorative materials, the
majority of posts can be safely and
successfully removed within approximately
10 minutes.
Preoperative image (a) The metal-ceramic The gold cast posts
(and radiograph (b crown was were separated to
sectioned (c) and facilitate their
,(removed (d .(removal (e ,f

Perforations were repaired

using gray MTA compacted with This clinical image The three posts were
an ultrasonic tip (i). Root canals revealed two removed (g) by vibrating
were filled with gutta-percha perforations in the with an ultrasonic tip to
.(and sealer (l .(mesial root canal (h disrupt the cement seal
Post-endodontic pre-prosthetic restoration was performed using a fiber-
reinforced post in the distal canal and a dual-cure resin composite buildup
.(material (n
Silver Points and Fractured Metallic Posts

• Exposing the coronal part of the obstacle

by cutting an estimated 2.0-mm around
the obstacle with a fine diamond bur.
• The tip of an ultrasonic unit is then applied
to the side of the post fragment at full
power with water irrigation, then can be
removed by fine forceps.
• Large-diameter posts are more time
consuming compared with narrow ones
 .Removing of the rotary in steps
• A radiograph.
• After straight-line access to all canals.
• radicular access to the obstruction
• If radicular access is limited, rotary nickel-
titanium or hand files are used to create
sufficient space to safely introduce Gates
Glidden drills into the canal orifice.
• These Gates Glidden drills are then used
in a brush-like manner to create additional
space and allow maximum visibility of the
obstruction.
• Good visualization.
• Staging platform.
• then the use of US is indicated to remove
dentin just around the fractured
instrument, to loose it within the canal.
Increased Action of Irrigating
Solutions
 Irrigation
• Mechanical + chemical.
• US can reach difficult anatomy, irrigant
vibration, and cleaning of the canal space.
• US creates both cavitation and acoustic
streaming.
• Antibacterial effects (shear stress).
• There is a synergistic effect between
sodium hypochlorite (NaOCl) and US.(
NaOCl loves heat)
Acoustic streaming around a file in free water (left) and a schematic
.(drawing (right
• Ultrasonic vibration can also be effective
when touching the shank of a hand file
inserted inside the canal. The hand file will
transmit vibrations to the irrigant inside the
canal, but a greater risk for touching
dentinal walls exists.
• The use of a smooth wire during ultrasonic
irrigation in vitro was as effective as a K-
file in debris removal, and with EDTA it
enhances the cleanliness of the canal.
17% EDTA+ ultrasonic Ultrasonic followed by 1% NaOCl for 1 min.
NaOCl 1% followed by 1% NaOCl

Representative SEM photomicrographs.(2mm from the apex) Specimens with (A)

smear score 0 and debris score 0, (B) smear score 1 and debris score 1, and (C)
smear score 2 and debris score 2
Ultrasonic Condensation of Gutta-
Percha
 US & obturation
• Ultrasonically activated spreaders have
been used to thermoplasticize gutta-
percha in a warm lateral condensation
technique.
• A more homogeneous mass, less voids,
3D obturation.
 Obturation protocols
• (a) Ultrasonic softening of the master cone
followed by cold lateral condensation .
• (b) One or two times of ultrasonic
activation after completion of cold lateral
condensation.
• (c) Ultrasonic activation after placement of
each second accessory cone.
• (d) Ultrasonic activation after placement of
each accessory cone.
 Recommended Obturation technique
• Initial placement of a gutta-percha cone to
the working length.
• Followed by lateral condensation of two or
three accessory cones using a finger
spreader.
• The ultrasonic spreader is then placed into
the center of the gutta-percha mass 1 mm
short of the working length and activated at
intermediate power.
• After activation, the ultrasonic spreader is
removed, and an additional accessory
cone is placed, followed by energizing with
the activated ultrasonic spreader.
• The spreader must be in a canal only 10
sec.
• Using a sealer with US gives the best
results.
Root canals were filled
with gutta-percha and
sealer
Placement of Mineral Trioxide
(Aggregate (MTA
 MTA & US

• Placement of MTA with ultrasonic vibration

and an endodontic condenser improved
the flow, settling, and compaction of MTA,
denser, with few voids.
 Technique
• The recommended placement method
consists of selecting a condenser tip, then
picking up and placing the MTA with the
ultrasonic tip, followed by activating the tip
and slowly moving the MTA material down
using a 1- to 2-mm vertical packing
motion. Direct ultrasonic energy will
vibrate and generate a wavelike motion,
which facilitates moving and adapting the
cement to the canal walls.
Perforations were repaired The coronal portions of the mesial
canals were further filled with MTA to
using gray MTA compacted enhance the seal of the perforations
with an ultrasonic tip
 Apical to the canal curvature
• Placing MTA with trimmed G.P. as plugger.
• A precurved 15 or 20 stainless steel file is
then inserted into the material.
• This is followed by indirect ultrasound.
• This technique can be used also in:
• Open and diverging apices, in perforations and
especially in perforations of the floor of the pulp
chamber, and in root-end cavities.
Surgical Endodontics: Root-End
Cavity Preparation and
Refinement and Placement of
Root-End Obturation Material
 Conventional root-end cavity
preparation
• Using rotary burs in a microhandpiece is
faced with several problems, such as a
cavity preparation not being parallel to the
canal, difficult access to the root end, and
risk of lingual perforation of the root.
• Furthermore, the inability to prepare to a
sufficient depth “retention”.
 Ultrasonic and sonic retro-tips
• Better access to the root end.
• Ultrasonic retro-tips come in a variety of
shapes and angles.
• Less smear layer, and more conservative.
• YAG lasers have been shown to produce
significantly lower micro-leakage than
ultrasonic preparations.
 Diamond tips for surgical
endodontics
• Satelec.
• Trinity.
• CVD. new
 Designs of the tips
• ↑angulation of retro-tips ↑the transverse
oscillation and ↓the longitudinal oscillation,
putting the greatest strain at the bend of the
instrument.
• Straighter design will restrict access and a
thicker instrument prevents instrumentation
of isthmuses.
• Preparation with smooth stainless steel tips
produced fewer intra-dentin cracks than
diamond-coated stainless steel tips and
sonic diamond-coated tips.
.Diamond-coated stainless steel ultrasonic surgical retro-tips
.Smooth stainless steel ultrasonic surgical retro-tips
The KiS®
microsurgical
ultrasonic
instruments by
Spartan are designed
for use in endodontic
.microsurgery
 Procedure
• It has also been suggested that root-end cavities
should be initiated with a diamond-coated retro-
tip, using its better cutting ability to provide the
main cavity.
• A smooth retro-tip to smooth and clean cavity
walls.
• A condenser tip.
• Ultrasonic tips can also be used to polish root
end material and apical surfaces.
• Ultrasonic tips for refinement may be beneficial in
the elimination of extraradicular bacteria
 The success

• Apical resorption after healing may eliminate

the surface defects and contribute to the
overall success of treatment, that may be
removed by finishing resected.

• It is recommended that the ultrasonic unit be

set at medium power and the cavities be
prepared to a depth of 2.5-3 mm.
Root Canal Preparation
 Canals preparation & US
• Several studies have shown that
ultrasonically or sonically prepared teeth
have significantly cleaner canals than teeth
prepared by hand instruments.
• There is a relative inefficiency of US in
debridment of the canals, so we can used it
not as initial instrument but with handle files
to give the best results.
 In conclusion
• As a result, access refinement, location of
calcified canals, and removal of separated
instruments or posts have generated more
predictable results. In addition, better
action of irrigation solutions and
condensation of gutta-percha have
benefited from the use of US.
• Finally, integration of new technologies
such as US, leading to improved
techniques and use of materials, has
changed the way endodontics is being
practiced today.
REFERENCES
• Gianluca Plotino, Ultrasonics in Endodontics: A Review of the
Literature, JOE — Volume 33, Number 2, February 2007, P (81-95).

• Ahmed Abdel Rahman Hashem, Ultrasonic Vibration: Temperature

Rise on External Root Surface during Broken Instrument Removal,
JOE—Volume 33, Number 9, September 2007, P (1070-1073).

• Keith Carver, In Vivo Antibacterial Efficacy of Ultrasound after Hand

and Rotary Instrumentation in Human Mandibular Molars, JOE—
Volume 33, Number 9, September 2007, P (1038-1043).

• John T. Dominici, Analysis of Heat Generation Using Ultrasonic

Vibration for Post Removal, Journal of Endodontics: 31 Issue: 4,
April, 2005, p (301-303).

• L. W. M. van der Sluis, Passive ultrasonic irrigation of the root canal:

a
review of the literature, International Endodontic Journal, 40, 415–426,
2007.
• Yoshitsugu Terauchi, Evaluation of the Efficiency of a New File
Removal System in Comparison With Two Conventional Systems,
JOE — Volume 33, Number 5, May 2007.

• Ricardo A. Bernardes, Evaluation of Apical Cavity Preparation With

a New Type of Ultrasonic Diamond Tip, JOE—Volume 33, Number
4, April 2007.

• Jeen-Nee Lui, Effect of EDTA with and without Surfactants or

Ultrasonics on Removal of Smear Layer, JOE—Volume 33, Number
4, April 2007.
And ……………… THANK YOU