Practical tips for reliable endodontic treatment
Dr Friederike Listander, Germany
Introduction
Orifice opener, glide path file, shaping file and finishing file—for classic endodontic treatment, a compact system of nickel–titanium (NiTi) files is often sufficient to achieve reproducible results in the preparation of the respective root canal anatomy.
The following case report illustrates how the skilful use of a fixed sequence of prebent files enables even dental practices with only occasional endodontic cases to develop a treatment routine in which they can have a high level of confidence. In addition, in this article, practical tips for drying and obturating root canals are provided.
The principle of maximum tooth preservation constitutes a key component of our practice philosophy. Owing to our broad range of services, we utilise state-of-the-art technology in the various indication areas in our daily routines to offer our patients the best possible treatment in each case. In endodontics, this means, among other things, automated preparation using a state-of-the-art motor as a navigation aid, as well as the use of an easy-to-remember NiTi file sequence. This structures workflows and ensures that the sequence of work steps becomes intuitive and quick to perform after a brief learning period. A standardised treatment protocol minimises potential sources of error on the one hand and facilitates an effective procedure on the other hand, as reflected in the following endodontic case.
Case presentation: Irreversible pulpitis of tooth #27
In February 2024, a 46-year-old female patient presented to our practice with severe pain in her left upper jaw. After a positive vitality test and strong response to the percussion test, a diagnosis of irreversible pulpitis of tooth #27 was confirmed radiographically (Fig. 1). The patient agreed to a two-session root canal treatment, which was started at the first appointment.
After surface anaesthesia and numbing of the affected tooth, a dental dam was placed, which is standardly done ahead of tooth preparation. Additional sealing of the dental dam with liquid dental dam effectively prevented irrigation solution from running into the patient’s throat. This was of particular advantage because treatment was made even more difficult by limited opening of the mouth.
After creating the access cavity, the individual root canals were probed and expanded under the operating microscope using a diamond-coated ultrasonic tip. The respective working lengths were determined with the aid of an apex locator. A measurement radiograph was taken as a confirmation and showed that the lengths matched the electronic measurements (Fig. 2).
The affected canals were first prepared manually using a hand file to the required size 20. This was followed by the electrochemical irrigation protocol using an ultrasonic tip (Fig. 3). The classic sequence of sodium hypochlorite,
EDTA, sodium chloride and chlorhexidine in 0.2% concentration to disinfect the canals supported the effective removal of tissue residue and debris. Medical calcium hydroxide was placed into the cleaned canals for temporary sealing and ultimately fixed with PTFE tape before sealing the tooth provisionally with DuoTEMP (COLTENE). Before polishing the temporary filling, the occlusion was checked, and the patient was then discharged symptomfree until the subsequent treatment session.
Efficient instrumentation with an easy-to-remember NiTi sequence
The actual preparation and final obturation of the root canals were performed during the second appointment. The patient was pain-free when she presented to our practice again. The dental dam placed for this treatment was again sealed with liquid dental dam after local anaesthesia to provide better protection for the patient.
The user-friendly endodontic motor CanalPro X-Move (COLTENE) and the HyFlex EDM instruments in the OGSF sequence (COLTENE; Fig. 4) were chosen for straightforward preparation. The abbreviation “OGSF” stands for the first letters of the four NiTi files, which can be used to treat the majority of typical endodontic cases quickly and conveniently: the Opener (orifice opener) opens the tooth to be treated, the Glider (glide path file) helps to create a glide path which follows the natural contour of the canal, the Shaper (shaping file) efficiently removes bacteria and infected tissue and creates the prerequisites for the canal obturation, and the Finisher (finishing file) ensures that the apical area is sufficiently cleaned and that there is sufficient space for irrigating solutions to reach the apex.
The mesiobuccal cusp tip served as a reference point for determining the working length of the mesiobuccal canal: preparation was performed over 19 mm up to size 30/.04 with the finishing file. Likewise, the distobuccal canal was instrumented to the same working length (reference point: distobuccal cusp tip). In comparison, the palatal canal had a working length of 21 mm; and here, too, the natural canal contour could be replicated with the
Fig. 5: Preparation with the cordless CanalPro X-Move endodontic motor.
compact OGSF sequence up to size 30/.04 with the finishing file.
The motion patterns programmed in the motor make handling the files extremely easy and enable the working length to be reached in just a single pass. Clamped in the cordless handpiece, the files also give one a good feel for the anatomical contour of the canal (Fig. 5).
The well-organised set of four coordinated special files with matching gutta-percha points offered the great advantage that no individual files had to be preselected ahead of treatment. The prebent files moved safely in the centre of the canal, making handling extremely smooth. Furthermore, the files are highly resistant to breakage, and this ultimately benefits both the patient and the practitioner.
Sustainable drying with fewer paper points
The sequence of electrochemical irrigation followed the same protocol as in the first treatment session. After the last irrigation sequence, the canals could be dried well with a particularly narrow endodontic suction cannula, therefore requiring fewer paper points. In addition, the paper points can be tested easily on a firm surface after they have been in the canal to see whether there is any remaining liquid in the canal. A master point fitting with 30/.04 HyFlex EDM gutta-percha points was selected to match the file system (Figs. 6a-c). Here, the palatal canal length was shortened by 0.5 mm.
HyFlex EDM master points of the same length were used for thermoplastic filling of the three root canals, and the canals were filled three-dimensionally with liquid guttapercha. The AH Plus bioceramic sealer (Dentsply Sirona) provided the required sealing. Here, it is perfectly sufficient to coat only the lower part of the gutta-percha points with sealer. Furthermore, the canal entrances were covered with a flowable composite in Shade A1 in combination with a matching acid etching gel, primer and bonding agent. BRILLIANT EverGlow Flow high-performance composite (COLTENE) in the opaque version in Shade A3 was used for the final restoration. The final radiograph confirmed the reliable sealing of the three canals in tooth #27 (Fig. 7).
Conclusion
Using a standardised NiTi file sequence such as HyFlex EDM OGSF, the majority of classic root canal treatments can be prepared quickly and reliably. Owing to the structured sequence of Opener, Glider, Shaper and Finisher files, practice teams and patients benefit from efficient and safe root canal treatment. With a few simple steps, one can save both time and material in order to achieve all-round sustainable treatment.
“A standardised treatment protocol minimises potential sources of error on the one hand and facilitates an effective procedure on the other hand […].”
about
Dr Friederike Listander studied dentistry at Ulm University in Germany from 2004 to 2009. She then worked from 2009 to 2012 as a dentist and research assistant at Ulm University’s dental clinic. In 2013, she specialised in endodontics and established her own practice in 2014. Since then, she has attended numerous training courses to continue to expand her expertise in endodontics, aesthetic dentistry, periodontics, implant dentistry and microsurgery. Dr Listander is also active as a speaker in Germany and abroad.
contact
Dr Friederike Listander
Kirchgasse 5 89179 Beimerstetten Germany
f.listander@zahnartzpraxis-listander.de
Fig. 7: Post-op radiograph of tooth #27.