Having been a pioneer in the use of the surgical operating microscope in orthograde and surgical endodontics, I have had the opportunity to study the process of cleaning and shaping root canal systems while using high magnification for the past eighteen years. Perhaps the most frustrating part of using the operating microscope has been observing the inability of currently available irrigation delivery systems to adequately “clean” the prepared root canal space. To put it another way, nickel titanium rotary files have finally provided the opportunity for endodontists to create shapes that they could only dream about in the past. However, due to the inability of irrigating solutions to access fins, isthmuses and lateral canals which are offshoots of these spaces, endodontists have had to rely on entombing bacterial and pulpal debris with filling materials such as gutta-percha and Resilon.® Even irrigating materials like the recently introduced MTAD, while containing appropriate detergents and chemical disinfectants have lacked an appropriate irrigation system to deliver the chemicals to the previously unreachable parts of the root canal system.
I have been using the EndoVac® irrigation evacuation system on all of my patients for the past five years. During this period of
time I have marveled at how clean the canal walls appear. Debris is no longer visualized where its presence was noticed on a regular basis. Careful inspection of the MicroCannula while using the operating microscope under high power magnification reveals trapped debris in the microholes that would clearly have been left behind in the apical third of the root canal system. This debris is a potential source of post treatment disease. The system is so effective that we have been able to actually seal canals that were never touched with an endodontic file. Clearly we are able to seal more portals of exit than previously possible. However, it is not so much the number of sealed canals but rather the depth and breadth of the filling materials within those canals that can be seen on radiographs.
One serendipitous find when using the MacroCannula is the ability to decompress an acute apical abscess. The MacroCannula is inserted until it binds in the apical third of the root. As the fluid is evacuated from the periradicular tissue, the contents of the apical lesion are removed and the lesion is decompressed, thus eliminating the need of multiple paper points.
There is no question in my mind that the introduction of the EndoVac irrigation evacuation system will allow endodontists to write the final chapter in the book of cleaning, shaping and sealing root canal systems.
Biography Dr. Rubinstein received his DDS in 1971 from the University of Michigan and his endodontic training from the Rackham School of Graduate Studies in Ann Arbor, Michigan in 1973. He is an Adjunct Clinical Professor at the University of Michigan School of Dentistry in the department of Cardiology, Restorative Sciences and Endodontics. He is a fellow of the American College of Dentists.
Dr. Rubinstein is an internationally renowned speaker and a pioneer in the use of the operating microscope in endodontics.
In addition to writing numerous scientific articles on the surgical operating microscope and endodontic microsurgical technique, he is a contributing author to Endodontics, 4th and 5th editions, edited by Ingle and Bakland, and a contributing author to The Dental Clinics of North America, entitled Microscopes in Endodontics. He is a principal author of Practical Lessons in Endodontic Surgery, published by Quintessence and a principal author of A Color Atlas of Microsurgery in Endodontics, published by WB Saunders.
Dr. Rubinstein has completed over 5,000 cases using the EndoVac® irrigation system.
Richard RubinsteinDDS, MS, FACDFarmington Hills, Michigan
Discus Dental, LLC8550 Higuera St.Culver City, CA 90232(800) 817-3636
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Immediate Post-op Premolar irrigated with EndoVac at full Working Length, demonstrates minute lateral canals within the last 3 mm.Case by Dr. Richard Rubinstein
Summary The objective of this project was to evaluate the safety of various intracanal irrigation systems by measuring the apical extrusion of irrigant. Twenty-two single canal, extracted mature teeth were instrumented and secured through the lid of a scintillation vial to collect apically extruded irrigant.
The Micro and Macro Cannulae produced no extrusion of irrigant. Those groups that actively delivered irrigant into the canal all extruded greater than 60% of the irrigant through the apical foramen.
Note: Although the EndoActivator produced very little extrusion, its function is to sonically mix pre-delivered solution in the root canal. Thus, its safety is dependent upon the system used to initially deliver the irrigant.
A precision syringe pump delivered controlled amounts of irrigant at a constant flow. The irrigation systems used were EndoVac Micro and Macro Cannulae, EndoActivator, Max-i-Probe Needle, Ultrasonic Needle Irrigation, and Rinsendo.
“This study concluded that the EndoVac did not extrude irrigant after deep intracanal delivery and suctioning the irrigant from the chamber to full working length”.
Comparative Safety of Various Intracanal Irrigation SystemsJ Endod 2009;35:545-9.
Key
Micro EndoVac MicroCannula
Macro EndoVac MacroCannula
EA EndoActivator
MAX Max-i-Probe
UN Ultrasonic Positive Pressure Needle
RE Rinsendo
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Comparison of the EndoVac System to Needle Irrigation of Root CanalsJ Endod 2007;33:611-5.
These cross-sections were taken 1 mm from Working Length.
SummaryThe aim of this in vitro study was to determine whether irrigation with apical negative pressure was more effective than traditional positive-pressure irrigation in eradicating Enterococcus faecalis from pre-shaped root canals. Fifty-four extracted mandibular molars were instrumented, sterilized, inoculated with E. faecalis for 30 days,
Summary Past studies have shown that current irrigation methods are effective at cleaning root canals coronally but less effective apically. To be effective, endodontic irrigants should ideally be delivered near working length. The purpose of this study was to compare the efficacy of the EndoVac irrigation system and needle irrigation to debride root canals in the apical third.
One tooth of each matched pair was instrumented and irrigated by using
Twenty-four teeth were used in each testing group. The positive pressure group produced 33% positive cultures. The apical negative pressure (EndoVac) group did not produce a single colony.
and then randomly assigned into positive pressure and apical negative pressure (EndoVac) irrigation groups. Mesial canals were sampled before and after final irrigation and samples incubated aerobically for 48 hours at 37°C. Scanning electron microscopic analysis confirmed dense bacterial colonies in the positive control, consistent with biofilm formation.
“A statistically significant difference was evident when comparing apical negative-pressure irrigation to positive-pressure irrigation (p=0.004)…The results of this In Vitro study showed that apical negative- pressure irrigation has the potential to achieve better microbial control than traditional irrigation delivery systems”.
Antimicrobial Efficacy of Two Irrigation Techniques in Tapered and Nontapered Canal Preparations: An In Vitro StudyJ Endod 2008;34:1374-7.
remaining debris was determined as a percentage of the area of the canal lumen. Remaining debris and total irrigant were analyzed by using the Wilcoxon signed rank test at the 5% confidence level.
“This study showed significantly better debridement 1mm from working length for the EndoVac system compared with needle irrigation.”
the EndoVac. The other tooth of the matched pair was instrumented and irrigated with a 30-gauge ProRinse irrigating needle. All teeth were irrigated with full-strength sodium hypochlorite (NaOCl) and 17% EDTA for a predetermined amount of time, and total volume of irrigant used was recorded. After instrumentation and irrigation, the teeth were fixed, decalcified, and sectioned at 1 mm and 3 mm from working length. Serial sections were made and digitally photographed. The amount of
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A. Demonstrates significant residual instrumentation debris.
B. Demonstrates totally clean root canal walls and lumen.
