Endodontics has entered the high tech era

with advances in ultrasonic

biotechnology. Endosonic endodontics
combines ultrasonic energy with flow
through activated irrigation to effectively,
efficiently and easily
shape,debride,cleanse and disinfect the
root canal system
Ultrasonics Generates vibration above the
audible range powered by means of
electric currents passing through a lamellar
arrangement of metal plates
Alternating attractive and repulsive forces
between the plates affect the mechanical
vibratory movements, which are then
transferred to the instrument.
Transducer element in the endosonic
insert transforms the electrical energy of
the cavitron into the acoustic mechanical
energy necessary to cause the
vibratory/oscillatory waves that energize
the files and diamonds The resulting
sound wave carries the vibratory energy
along the entire length of the instruments
and causes a reciprocal movement in
these files/diamonds
It is this reciprocal excitation of the
endosonic files/diamonds which shapes
the root canal system, The operator no
longer acts as the moving force but only as
a guide while the ultrasonic energy waves
causes the instruments to move in the
proper filing motion The energy wave
enables the instruments to remove
contaminated dentin, debris and tissue.
The endosonic insert is unique in its
design in that it allows the traditional
endodontic irrigant NaOCl to be used, The
solution will follow a precurved file thus
allowing the deepest penetration into the
canal and leads to complete irrigation of
the root canal system. In actuality the root
canal system has been transformed into
an ultrasonic bath.
Preparation of the root canal is a chemo-
mechanical procedure whose purpose is to
remove necrotic debris, and contaminated
dentin from the root canal.
In addition the dentist must
eliminate/reduce the pathogenic bacterial
component via a process of disinfection
while also preparing the canal for three
dimensional obturation
ENDOSONIC MECHANICAL ENERGY: The
ultrasonic wave energy is a mechanical
vibratory action. The file motion used in
ultrasonic root canal preparation is essentially
a push-pull action enhancing dentin removal
more effectively than hand instruments in the
same time frame and with greater control,
Circumferential movement of the files is also
advocated to achieve the smooth tapering
canal shape that is considered optimal for
obturation.
ENDOSONIC CHEMICAL ENERGY: The
activation of the endodontic irrigant is vital
to the effectiveness of the endosonic
system The irrigation solution NaOCl will
penetrate the root canal system more
effectively due to the ultrasonic activation
of the solution which can only be achieved
when it undergoes ultrasonation. This can
not be achieved with sonic systems.
Ultrasonics vibration is unparalleled in its
ability to enhance cleaning with irrigants.
Ultrasonic activation of NaOCl has been
shown to be most effective in the apical
third of the canal owing to the greater
amplitudes of vibratory movement at the
files.
(a) Cavitation.

(b) Acoustic steaming.

Cavitation occurs when ultrasound generates a
bubble in the irrigant which grows to a critical point
and then undergoes the implosion effect ( Internal
collapse) with the concomitant release of a shock
wave and tremendous force with a vacuum effect.
The main debriding action of ultrasonics was
initially thought to be by cavitation. It allows for
deep penetration into all ramifications of the canal
and draws out all the debris.
Acoustic steaming creates small, intense,
circular fluid movement ( i.e., eddy flow )
around the instruments (Cohen 8th edition)
Acoustic streaming- the rapid movement of
particles of fluid in vortex-like motion about
a vibrating object.
Ultrasonically energized file creates currents of
streaming of irrigant within the root canal
The eddying occurs closer to the tip than in the
coronal end of the file, with an apically directed
flow at the tip. Acoustic streaming increases the
cleaning effect of the irrigant in the pulp space
through hydrodynamic shear stress, Increased
amplitude occurring at smaller file sizes enhances
the acoustic streaming. This has proven to be of
great value in the cleaning of the root canals
because conventional irrigation solutions do not
penetrate small spaces well.

Cavitation does not play a role in root
canal debridement. Acoustic streaming
appeared to exert a more important role in
root canal debridement. (JOE 1987).
DIFFERENT TYPES OF ENDOSONIC
UNITS:

Satelec P5, MTS-1 and NSK, MiniEndo,
Enac.
Root canal obstructions
Identification of missed and hidden and
calcified canals.
Removal of posts.
Removal of core materials.
Removal of obturating materials
Removal of broken instrument tips.
Simple curves to multiangled bends
Long and slender or short and sturdy.
End cutting or side cutting.
Made of Stainless steel or Titanium alloys
Stainless steel may be coated with
Zirconium nitride or diamond grit.
Designed to function dry or with water
ports to increase the cooling and washing
effect .
Access refinement tips.
Vibratory tips.
Bulk removal tips.
Troughing tips.

CT TIPS First ultrasonic tips for endodontic surgery; the CT
tips made of stainless steel Designed by Dr.Gary Carr

KiS TIPS Introduced in the year1999 by Dr.Syngcuk Kim
Dramatically increases cutting efficiency due to their diamond
coating. Diamond Coating provides a microrough surface of
the inner wall of the retro prepared cavity.

PROULTRA TIPS Exists in two types namely Proultra endo 1-
8 ,Proultra surgical endo tips 1-6 .These tips are designed by
Dr.Clifford J. Ruddle.

PROULTRA ENDO, Remove intracanal obstruction materials,
Disassemble dental restorations and cores, Trough and chase
for calcified or hidden canals, Dislodge posts and broken
instruments and Efficiently eliminate pulp stones.

CPR TIPS Diamond coating enhances cutting efficiency, Remove
intra-canal obstruction materials, Water port allows to cut wet or dry
and reduces heat generation, Identifies hidden and calcified canals,
Efficiently eliminate pulp stones and obstructions.

CPR 1-5 are diamond coated and active along the side of the tips
CPR 3D,4D,5D are 15, 20 and 25mm in length respectively .These
instruments are used in the coronal, middle and apical third of canals
and their selection depends on the depth at which they need to be
operated.

CPR TITANIUM SERIES Remove Intracanal obstruction materials,
Dislodge posts and broken instruments, The flexibility and strength
of Titanium allows these Instruments to follow the anatomy of the
Root Canal Allows for deep canal instrumentation
CPR tips 6(red),7(Blue),8(Green), are used in deeper part of a
straight canal which are 20,24 and 27mm long respectively, These
instruments should be used with light touch.

BUC TIPS Designed by L. Stephen Buchanan
BUC-1: The Tapered fine diamond grit - cutting and refining
line angles, smoothing access walls, cutting MB trough
BUC-2: The Planer Disk Tip, medium diamond grit - planning
pulp chamber floors and safely plane attached pulp stones out
without cutting the chamber floor.
BUC-2a: Smaller Disk-used for corners of molar and bicuspid
access preps. 1mm in diameter
BUC-3: The Sharp Tipped, fine diamond grit - very active tip
for cutting into calcified roots and around posts.
BK 3 TIPS BK-3 surgical tips have three bends for easy
access to any preparation including MB2 canals. BK-3s
provides increased visibility and can finish an entire prep with
one tip. Water is directed down the three bends and is able to
reach the surgical site. BK-3s are for use with any
application. These tips should be used at low power levels.


ACCESS REFINEMENT TIPS:

Access cavity preparation is the most
important phase of endodontic therapy
Recently, a combination of access refinement
ultrasonic tips and magnification has
revolutionized the basic concept of access
cavity preparation. There are many
advantages to using ultrasonic tips rather
than burs to refine the access cavity to locate
the underlying anatomy .
Advantages are: No hand piece head to obscure vision and, therefore, the
progressive cutting action can be observed directly and continuously under
the microscope. The size of ultrasonic tips is smaller than the smallest burs;
therefore, the dentine can be brushed off in smaller increments and with
greater control. The process allows for exposure of any missed or hidden
canals or recesses containing necrotic pulp tissue without gutting down the
tooth structure.

Another advantage of ultrasonic instruments over burs is the production of-
cavitation within the cooling water that flows over the tip of the ultrasonic
instrument. Cavitation may be described simply as bubble activity in a liquid,
which is capable of generating enough shock waves to cause disruption of
remnants of necrotic pulp tissue -and any calcific deposits. Therefore, it is no
wonder that access cavities prepared with ultrasonic instruments have a
thoroughly washed out and clean appearance.

A number of tips are available to refine the access cavity. The uncovering of
the floor of the pulp chamber can be accomplished with the help of the CPR
2D or BUC 1 tips. If the dark, colored floor of the pulp chamber is not visible,
it usually is obscured by pulp stones or tertiary dentine deposits The pulp
stones sometimes can be vibrated or teased out by the CPR 2D or BUC 1
tips at other times, they can be planed with the help of a BUC 2 tip a
process similar to planning the root surface.

BULK REMOVAL TIPS:
Bulk removal tips are extremely sharp and
sturdy tips that are operated at moderate or
maximum intensity of the ultrasonic unit. BUC
1 and CPR 2D are examples of tips that fall
into this category. These tips are designed
primarily to remove dentine and core material
quickly and expeditiously before subjecting
the root canal obstruction to vibratory or
troughing procedures
REMOVAL OF BROKEN INSTRUMENT TIPS:
An ultrasonic instrument is selected based on the depth of the
broken file and space availability, It is activated at the lowest
power setting and used dry so that the clinician has constant
vision between the energized tip and the broken instrument
The selected CPR instrument is moved lightly in a CCW
direction around the obstruction except when removing
reverse-screw files, This ultrasonic action sands away dentin
and trephines around the coronal few millimeters of the
obstruction The obstruction begins to loosen, unwind and spin
Gently wedging the energized tip between the tapered file and
the canal wall oftentimes causes the broken instrument to
abruptly jump out of the canal.


Currently endosonics have wider
applications in endodontics. The multiple
effects of endosonics are physical,
Chemical and biological actions. Thus is
developed the Endosonic Ultrasonic
Synergistic effect.
Passive ultrasonic irrigation (PUI):

is after the root canal has been shaped to MAF. Small file (10-20) is placed
(without touching the canal walls) and activated by ultrasonic unit.
Proponents of this technique claim that this leads to acoustic streaming
around the file leading to efficient action. Basically Passive irrigation is
initiated by slowly injecting an irrigant into a canal. In this method, irrigant is
passively dispensed into a canal through a variety of different gauged and
flexible cannulas and needles. Compared to this; Active irrigation is intended
to initiate fluid hydrodynamics to improve cleaning into all aspects of the root
canal system.

Hydrodynamic irrigation:

When irrigant is energized with different techniques they may call it
hydrodynamic. Example is Endoactivator which uses sonic vibrations,
RinsEndo (attached to air tubing of your handpiece) delivers irrigant and air
in pulsating fashion with simultaneous suction.

When trials are done to remove broken
instruments u should:
Do straight access to the BI by providing enough flaring using
gates glidden .
Have good visualization either by dental loops or microscope.
Expose the head of the broken instrument to free it from
dentin.
Assess the case before removal and take inconsideration if
there is severe curvatures.
Use the proper ultrasonic tips according to your decision.
Use ultrasonic tips on low power for short period of time to
prevent heat generation on the external root surface which
might affect the periodontium .

When trials are done to remove posts you
should:
Expose the head of the post.
Have a good diagnosis to know type of the post.
Try to trough around the post and prevent vibrating it,
vibration without freeing it might coz the head of the post to
fracture which makes removal more difficult so expose first
then vibrate.
Fiber post are difficult to remove they can be removed by
special removal kits or ultrasonics but with great care as they
are abraded and you might coz root perforation.
Always take an x-ray to know where you are inside the root
Dont work if you dont have good visualization.

When trials are done to locate calcified
canals you should:
Know well the anatomy of your access and the location the
canals should be found.
Always follow the map in your access it will always drive you
to exact location of the canals.
Preoperative x-ray are necessary to evaluate the case before
work, not always you need to find it. Sometime u need follow
up only.
irrigation and good magnification is a must sometimes naocl
champagne tells you where the canal is .
Check for Bleeding points .




THANK YOU