Resin based obturation / /certified fixed orthodontic courses by Indian dental academy


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  • Resin based obturation / /certified fixed orthodontic courses by Indian dental academy

    1. 1. Resin Based Obturation INDIAN DENTAL ACADEMYLeader in Continuing Dental Education
    2. 2. INTRODUCTION Evolution of Specialty of endodontics over the years Endodontic Triad TRADITIONALLY DEBRIDEMENT SUCCESS IN R.C.T STERILIZATION OBTURATION
    4. 4. Final step in endodontic treatment – OBTURATIONMain objective – substitution of pulp tissue space with an inert filling materialPulp remnants, necrotic tissue, bacteria and its byproducts –Inaccessible areas of cleaned and shaped canal – poor defense ofHost – LesionOBTURATION – Must to prevent coronal leakage, bacterial Contamination, sealing of bacteria from p.a tissue fluids and sealing remaining irritnats in canals.
    5. 5. Study by Ingle and Beveridge (1985) :58% Endodontic failures – INCOMPLETE OBTURATIONPrincipal cause of failure of endodontic treatmentSince Ingle’s classic study – Great emphasis given on developing materials and obturation techniques for
    6. 6. Materials used for obturationCore + Sealer = ObturationAcc to Grossman:1. Plastics2. Solids3. Cements4. PastesRequirements of an ideal root canal filling material:1) Be easily introduced in canal2) Seal the canal laterally and apically3) Shouldn’t shrink after insertion4) Impervious to moisture5) Bacteriostatic6) Radiopaque
    7. 7. 7) Shouldn’t stain the tooth8) Shouldn’t irritate periradicular tissue9) Should be sterile or easily/quickly sterilized10) Easy removal if necessarySealers :• Zinc oxide-Eugenol based• Calcium hydroxide based• Resin• Glass ionomer basedIdeal requisites of a root canal sealer (Grossman):1) Should be tacky – for good adhesion2) Hermetic seal
    8. 8. 3) Radiopaque4) Fine particles - easy mixing with liquid5) Shouldn’t shrink6) Shouldn’t stain the tooth7) Bacteriostatic8) Set slowly9) Insoluble in tissue fluids10) Non irritating to periradicular tissues11) Soluble in common solvent – easy removal12) Should not provoke an immune response13) Neither mutagenic/carcinogenic
    9. 9. Most common solid core root canal filling material – Gutta PerchaGold standard for endodontic obturation !!! resently – Gutta percha filling – Weak point in R.C.TTorabinejad et al – G.P fillings challenged by bacteria 50% specimen allowed penetration to entire lengthDrawbacks of Gutta Percha: . Inability to achieve a fluid impervious seal . Inability to reinforce tooth structure
    10. 10. - Material that would effectively seal and reinforce the tooth
    11. 11.
    12. 12. Evolution of Adhesive endodontics Lack of adhesion of gutta percha and root dentin –Flared canalsCoronal microleakage with G.P fillings (Swanson and Madison, 1987) Coronal microleakage with temporary filling materials High incidence of vertical fractures Quest – a new material Resin sealers e.g. AH26, Epiphany etc with G.P RESILON – MONOBLOCK CONCEPT
    13. 13. Bonding to root dentin Entry of adhesive endodontics – PromisingContributing factors in root dentin bonding:a) Anatomy of rootsb) Tooth positionc) Presence of residual tissuesd) Curing techniquese) Experience and skill of operatorf) Tubular density, microbranching and tubular arrangement
    14. 14. Ferrari and Mjor (2000) – SEM insight of normal and etched root dentin NORMAL Coronal 3rd Middle 3rd Apical 3rd ETCHED
    15. 15. mportant considerations:) The dentin tubule- structure, size and number- affect bonding (Patrick etal)) Effects of etching more pronounced in coronal than in apical 3rd – Limitation of penetration of etchant (Ferrari)) Carrying of adhesives to the apical 3 rd – A limiting factor) Ferrari et al – Resin dentin interdiffusion zone not uniform at the apical 3rd
    16. 16. 5) Interaction of intracanal medicaments and irrigants with the adhesives: a) Calcium hydroxide – Neutralize the action of self etching primer, interfere with bonds in more coronal parts when present in excess b) NaOcl/ H2O2 – Decrease bond strengths (Erdemir)6) Difficulty in drying the canal - Self etch adhesives preferred
    17. 17. Geometric factors affecting bonding in root canals Polymerization of resins Decrease in volume of monomer Shrinkage Shrinkage stresses Debonding MICROLEAKAGE FAILURE
    18. 18. Stress relief α Cavity geometry and Resin film thicknessClass I cavity – Movement/flow of unbounded surface Stress reliefIn long narrow root canals – Small unbounded surface Insufficient stress relief Debonding of one/more surfaceConfiguration factor = Total bonded area Total unbonded areaC-factor α 1 (Franklin Tay et al) Sealer thickness
    19. 19. i.e. Greater sealer = Lesser C-factorFranklin’s study – C-factor of 46-23461 with increasing sealer thickness (500 - 1µ) Lesser the sealer thickness Lesser the Shrinkage Lesser Polymerization stresses Lesser chance of DEBONDINGVery high C-factor in root canals – Major obstacle inproducing gap free adhesive fillings
    20. 20. Shrinkage stresses - Higher in low filled, low viscosity resins Slow polymerizing resin Flow of resin Relief of shrinkage stresses due to prolonged gelation time (Autopolymerizes in 45 min)
    21. 21.
    22. 22.
    23. 23. DIAKET 1ST Resin sealer ( ESPE/Premier, Germany/USA) - 1951 Resin reinforced chelate formed between ZnOand polyvinyl resin dissolved in liquid DiketoneComposition:Powder – ZnO (90%), Bismuth Phosphate (3%)Liquid – Propylacetophenone (76%) Copolymers of vinyl acetate, vinyl chloride and vinyl isobutyl ether (23%) 2-2 dihydroxy, 5-5 dichlorophenylmethane (0.5%) Triethanolamine (0.2%) Very tacky, Contracts during setting but absorbs water Good sealing efficiency and biocompatible (Nencka, Regan et al)
    24. 24. HYDRON Rapid setting hydrophillic plastic material Goldman et al - is polymer of HEMA and is biocompatible Sets in a dry canal in 10 min Requires special syringe and needle Significantly high leakage
    25. 25. AH26 Schroder and Hermann Stich – Tried “Araldite” (Epoxy resin glue) Catalyst unsuitable for useTried Hexamethylene tetramine - disinfectant in urology SUCCESS – AH26 Story behind the name – A- Aethoxyline resin (Araldite) H- Hexamethylene tetramine 26- 26th Jackpot experiment
    26. 26.  Manufactured by DeTrey/Dentsply, Germany, supplied as powder liquid systemComposition:Powder – Silver powder (10%) Hexamethylene tetramine (25%) Bismuth oxide (60%) Titanium Oxide (5%)Liquid - 100% bisphenol-A epoxyAdvantages: Not sensitive to moisture No Cracking/debonding – larger setting time and fluidity High Radiopacity, less shrinkage and low solubility
    27. 27. isadvantages: Cytotoxixity – AH26 sets HMT decomposes in water/acid FORMALDEHYDE Film Thickness - 39µ - Thick – Limits the shrinkage stress relief (Wu et al, 1997) Michael Tagger (2003) - AH26 softened and increased the flow of of G.P. bisphenol – A epoxy – Partial solventGreyish Staining the tooth structureWeiner and schilder (1971) and DeGee et al (1994) – Initial expansion then shrinkage
    28. 28. AH Plus  Another milestone in endodontics by Dentsply DeTrey  Advantages of AH26 retained and the disadvantages eliminated Composition: Supplied as paste-paste system and double barrel syringe Epoxide paste Amine pasteBisphenol-A and F epoxy resin DibenzyldiamineCalcium tungstate AminoadamantaneZirconium oxide Tricycodecane- diamineSilica Silica, Zirconium oxide and Ca tungstateIron oxide pigments Silicone oil
    29. 29. Difference in composition of AH26 and AH Plus –Silicone oil as a vehicle as compared to formaldehydeSilicone oil – Hinders flowSetting reaction of AH Plus:Thermal polyaddition reaction – A step growth reactionMonomers, Amines & Diepoxides + Oligomers = Polymers Linear chain of repeating polymer unitsSetting time – 8 Hrs – long – Compensation for shrinkage stresses
    30. 30. Properties of AH26, AHPlus and DiaketRadiopacity: AH Plus = 13.6/mm Al thickness AH 26 = 9.3 Diaket = 4.6 Epiphany = 6.1Solubility: Acc to ISO standards 6876, wt loss >3% not permitted AH Plus = Approx 1% AH 26 = Approx 3% Diaket = Approx 2%Polymerization shrinkage: AH Plus = 1.76% of total volume AH 26 = 1.46 Diaket = 1.18 Epiphany = 2.31Linear expansion: AH Plus = 0.129±0.08 Epiphany = 4.827±0.183
    31. 31. Film Thickness: Acc to ISO standards – 50 mm Ideal AH Plus = 26mm AH 26 = 26-36mmFlow Behaviour: Acc to ISO standards- > 25mm AH Plus = 36mm (Thixotropic )Shear bond strength: Ayce (2005) compared AH Plus, Diaket and EndoRez. Diaket and EndoRez = 1.2 Mpa approx AH Plus = 6 MpaSealing Properties: O Zemner (1997) Compared AH 26 and AH Plus AH Plus - More leakage owing to its faster set that can lead to shrinkage stress Min-Kai Wu- Ketac endo better than AH26 due greater thickness of AH26
    32. 32. Lasers and sealing ability:Lasers – µ-scopically rough substrate without demineralization open dentinal tubules without smear layer Dentin surface sterilizationEr – YAG laser – Better bond strengths than acid etchingDISADVANTAGE – Heat productionCox et al – Nd:YAG laser produces – Melted dentin Crazing Debris formation Alteration in tubule structureAriyaratnam et al – Similar findings
    33. 33. Toxicological studies of AH Plus sealerTests done on both the individual pastes (uncured) andPolymerized in acc to ISO(10993)INDIVIDUAL PASTES:Mutagenicity: Non mutagenicSystemic toxicity: Non toxicCytotoxicity: non polymerized pastes – cytotoxic Bactericidal property Time limited – remains till 4 hrs Saleh et al – AH Plus kills E. Faecalis in tubulesAntimicrobial effects: Kaplan et al – AH Plus showed inhibtion of S.Mutans and A.IsraeliFormaldehyde release: Leonardo M R(1999), Cohen(1998): AH Plus (3.9 ppm) and AH26 (1347 ppm)
    34. 34. Polymerized material:Mutagenicity: Non mutagenicCytotoxicity: Less than individual components Leonardo M R – No inflammation and Hard tissue formation Koulaouzidou E A – AH Plus far less toxic than AH26Hepatotoxicity: If material released in periradicular area and absorbed into body – act on liver AH26 and AH Plus - HepatotoxicSensitization: AH Plus – doesn’t release sensitizing substancesAntibacterial action: Pizzo et al – Ah plus antibacterial action till 24 hrs
    35. 35. Heating of AH26 and AH Plus:Heat produced during warm vertical condensation – Alter theCytotoxic profilesTheodore – Heating of AH26 – Faster release of formaldehydeRemoval of AH26 and AH Plus from canals:Conventional techniques – Solvents and drillsSchafer et al – Epoxy resin sealers – high solubility in chlorofromHansen – AH26 soluble only in chloroform and not in xylene etc.Whitworth – AH Plus soluble in halothane
    36. 36. ENDORESIN Studies Reported – excellent sealing ability of C&B Metabond, a MMA/TBB resin Drawbacks as root filling material – Too short working time Low radiopacity Difficult removal Yohji Imai&Takashi – Replaced Fluoropolymer and added radiopacifier Endoresin (ISO Standards) Endoresin2 (Decreased availability of fluoropolymer)
    37. 37. Composition:Powder: PMMA (Polymethymethacrylate) – Polymer Barium Sulphate – RadiopacifierLiquid: MMA (Methylmethacrylate) – Monomer Tributylborane – CatalystProperties:Flow – 38 mmWorking time – 5.5 minSetting time – 35.5 minFilm Thickness – 5.6 µSolubility – 0.18%Radiopacity – 5.2 mm Al.
    38. 38.
    39. 39. RESILON Revolutionalized the adhesive endodonticsSequence of events: G.P + Sealer Poor sealing and lack of adhesion to dentin Epoxy Resin Sealers + G.P No Bonding/Monoblock Methacrylate resin sealers + G.P Methacrylate resin coated G.P RESILON
    40. 40. Resilon Obturating System (Resilon research ltd, LLC) Core + Primer + SealerCore Material:Thermoplastic, synthetic polymer based( Polyester) Core Composition: Polycaprolactone – 50% Methacrylate co-polymers – 10% Glass fillers – 40% - Bioactive glass Others – Bismuth oxychloride Resilon points – Available in ISO sizes in 0.02, 0.04, 0.06 tapers
    41. 41. roperties of Resilon: Thermoplasticity : Due to presence of polycaprolactone which has low glass transition temperature (-62ºC) Polymer – Cooled below glass transition temp – Brittle like glass Heated above - Soft and flexible like elastomer At room temp – Resilon is above glass transition temp – Rubbery At body temp - Below glass transition temp – Glassy Thermal properties – Marcus R Miner, 2006 Melting point – GP – 60.01ºC, Resilon – 60.57ºC Claimed by manufacturer – 70-80ºC Specific heat capacity – Heat that must be added to raise temp of 1 gm of material by 1ºC G.P – 0.94ºC, Resilon – 1.15ºC – More heat required to melt resilon
    42. 42. ) Enthalpy change – Amt of heat absorbed or released when reaction takes place G.P – 10.88 J/gm, Resilon – 25.2 J/gmNFERENCE – Resilon requires more heat to equally plasticize as G.P) Cytotoxicity – Jennifer key, 2006 Same biocompatibility as G.P) Resilon for root reinforcement: A myth or realityChad williams et al (2006) –Modulus of elasticity of dentin – 16000 MpaMaterial to reinforce dentin Should have the same elasticityModulus of elasticity – G.P – 74.22 Mpa, Resilon – 129.16
    43. 43. Cohesive strength of dentin – 36-100 MpaCohesive strength – G.P- 6.3 Mpa, Resilon – 7.8 MpaResilon has glass transition temperature below bodytemperature:Acts as an elastomer - undergo flow or elongate understressIdeal material to reinforce roots:1. Cohesive strength and modulus of elasticity = Dentin2. Polymer with glass transition tmperature above body temperatureComposite resins – Satisfy the criteria to some extent , Modulus of elasticity = 12000 Mpa
    44. 44. 5) Bondability of resilon with methacrylate sealers:Resilon – Introduced to bond with methacrylate selaers and produce a Monoblock with the toothFranklin Tay et al (2006):Weak chemical union between resilon and methacrylate sealerCause – Phase separation due to insufficient dimethacrylate inresilon and absence of free radicals within resilon for couplingAlternative – G.P coated with polybutadiene diisocyanate methacrylate resin
    45. 45. 6) Removal for retreatment:Heat or solvents like chloroform etcDaniel pinto ( 2006) – Resilon and epiphany - easy and faster to remove than G.P and AH26 with rotary K3 files and chloroformElie Ezzie (2006) – similar findings with rotary (Profiles) and chloroformReason – Resilon has low melting poin than G.P. When heated it exhibits flowability – Quicker removal
    46. 46. 7) Degradability: Polycaprolactone – Degradeable polymer Used as biodegradeable water or milk container, resorbable sutures Degrades slowly in water but the rate can be accelarated with enzymes e.g. esterases as it is a polyester Hydrolases e.g. lipases from bacteria, fungi and yeast – van also cleave the ester bonds Franklin and Pashley – Alkaline hydrolyses – Fissures seen on surface of resilon – susceptible to alkaline hydorlysis
    47. 47.  Enzymatic hydrolysis – surface erosion Alkaline hydrolysis – bulk degradation Another study by Franklin – Cholestrol esterase – thinning of material and exposing of larger bioactive glass fillersFrom above data :Microbial attack Bacterial enzymes Resilon degradeAt present – Susceptibility of resilon to degradation to plethora of microrganisms in root canal space – UNKNOWNFurther studies and long term clinical datarequired
    48. 48. Resilon sealer:A dual cured methacrylate resin based sealerComposition:BISGMA, Ethoxylated BISGMA, UDMA andHydrophillic, difunctional methacrylatesFillers (70%) – Ca hydroxide, barium sulfate, barium glass, bismuth oxychloride and silicaThinning resin – EBPADMA – To modify the viscosityResilon research limited (Madison, LLC) – Licensed the product toPentron (Epiphany), Sybron Endo (Realseal), Obtura Spartan( pellets for obtura system) and Light speed ( Simplifill)
    49. 49. roperties of resilon sealer: ) Radiopacity – Epiphany – 6.1/ m of al AH PLUS – 13.6 ) Solubility – Acc to ADA specification 57 – not more than 3% Epiphany – 3.41% AH Plus – 0.21%Reason – erosion of filler particles due to degradation ) Flow test – Acc to ADA – Not less than 20 mm Epiphany – 35.74 mm AH Plus – 38.57 mm ) Setting time – Acc to ADA – should be within 10 % of that stated by manufacturer Acc to manufacturer – Epiphany – 25 min, AH Plus –480 min Acc to studies – Epiphany – 24.75 min, AH Plus – 500 min
    50. 50. 5) Film thickness – Acc to ADA - not more than 50µ Epiphany – 20.1µ AH Plus – 10.66) Dimensional alterations – Acc to ADA – linear shrinkage of not more than 1% and expansion of 0.1% Expansion – Epiphany – 8.1%, AH Plus – 1.3%Reason – Water sorption due to:a) Hydrophillic difunctional methacrylates – Absorb waterb) Filler content – Ca hydroxide – Absorb water7) Sealing ability:Epiphany resistant to bacterial penetration – Shipper et al (2004), Teixeira et al(2004)Ryan Stratton et al - Epiphany and resilon leak less than G.P and AH PlusStephen G. Biggs – Comparable leakage to G.P and AH PlusTay et al - Similar results
    51. 51. 8) Effect of intracanal medicaments and irrigants:Porkaew et al, Wuerch et al - Ca hydroxide did not adversely affect the apical sealKim et al – Ca hydroxide increased the apical leakageReason – EDTA used forms complexes with CaRyan Stratton et al – Irrigants like 5.25% Sod Hypo, 0.12% CHX, or 2% CHX – did not alter sealing ability9) Biocompatibility:Cassio et al(2006) – Intraosseous implantation –AH Plus = Severe inflammation, EndoRez = Severe inflammation with chronic inflammation,Epiphany = None to slightJennifer key – Epiphany more cytotoxic than Grossman, Sealapex and Thermaseal
    52. 52.
    53. 53. Epiphany (Pentron) Simplifill Realseal (Light speed) (SybronEndo)Inno Endo (Hereus Kulzer) Resinate (Obtura Spartan)
    54. 54. Endo eze systemConsists of:• A Reciprocating handpiece• 7 Stainless steel files (3 shaping files used in hand piece and 4 hand files for apical 3 mm)3) Irrigants and Lubricants4) Delivery tips5) EndoRez Sealer and EndoRez points
    55. 55. EndoRez Sealer: (Ultradent) Methacrlylate based resin sealer consists of 30% UDMA Biocompatible Hydrophilic – Excellent penetration in dentinal tubules Supplied as a TwoSpense 2 syringe (Double barrel):
    56. 56.  Good radiopacity Equivalent to G.P and easy to remove Introduced directly in canal with a NavitipTM Can be used with conventional as well as hot G.P techniques Setting time – 15-20 min, final set -2 hrs.Disadvantages:Poor Sealing ability (Brian et al): After 7 days the sealer had not set, was seen bubbling out Oxygen in atmosphere could have prevented the setting SEM images- Sponge like appearance which allowed leakage
    57. 57. EndoRez PointsTechniques: Resilon Points Resin coated G.P: Can be used with any sealer Franklin et al – Radiographically acceptable results Drawback – Resin coating and sealer interface weak link – Shrinkage and Delamination Cause -Absence of oxygen inhibited layer, removed to prevent sticking of G.P during storagelternative – Adhesive resin application on resin coated G.P before insertion (Noriko Hiraishi, 2006)
    58. 58. Manipulation and dispensing of EndoRez Sealer
    59. 59. FIBERFILL SYSTEM Methacrylate Sealer + Primer + Mater coneSealer – UDMA, PEGMDA, HDDMA and BISGMA, Treated bariumborosilicate glasses, Barium sulfate, Ca phosphate, Initiators, Stabilizers, Pigments, Benzoyl peroxidePrimer:Primer A – Acetone + Surface active monomer (NTG-GMA magnesium)Primer B - Acetone + PMGDMA + HEMA + Initiator + Stabilizer + water
    60. 60. Single master cone – Glass fibers in resin matrix coronally – POST G.P apically – OBTURATIONSizes – 3 mm, 5 mm, 8 mm apical G.PTapers – 0.02, 0.04, 0.06Methacrylate sealer – sealer + post cementation
    61. 61. Advantages: Obturation and post placement – same visit 80 % root strengthening Immediate coronal seal Highly radiopaque sealerChristos et al – Highest bond strength of fiberfill as compared to Endion, Topseal and CRCS.Saleh et al – Bond strength of fiberfill less than AH PlusNikolas Economides – Good sealing ability
    62. 62. Introduction of resins into root canal has created arevolution in endodontics. But still known is a drop andunknown is an ocean.Further studies and long term clinical data is requiredbefore judging the credibility these adhesive root fillings.
    63. 63.