PART ll : Endodontics

Index

Instruments, Apex Locator…........................ 1

Summer Mahmoud
Rubber-dam………………………................ 8
Jenan Abu Oss
Endo Diagnosis………………….…................ 14
Lina Abdel-Ghani
Access Cavity….......................................................... 22
Dania Ja’afreh
Step-back technique……………………….…. 27
Nada Abu Khalaf
Chemical Disinfectants.................................. 31
Nada Abu Khalaf
Temporization…………………..…………... 37
Reem Alsheikh Ali
RCF……………………………………………………… 45
Alaa’ Al-Qadi
Endodontic Radiology………………………… 55
Sarah Abu Hait
Radiologic Anatomy, Radiologic Errors....... 60
Farah Abu Rumman
Onto endodontic testers:

We must be able to differentiate between certain

instruments like:

1. Electric pulp tester:

2. Apex locators:
We have 7 generations; the 7th is the best because it doesn’t give us
mistakes regardless of having electrolytes or irrigants in the canal, so it
is very accurate.

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 3. Tooth sloth to detect fractures
4. Transillumination instruments to detect cracks and craze lines.

The IPEX II is the apex locator we use in the clinic and it is generation 4 apex
locator (according to Dr. Eyad Alkhateeb).

Advantages of apex locators:

 Useful in detecting fractures and resorption

 Helpful in detecting perforations
 Useful in cases where the apical constriction is a distance from the root
apex
 Reduces the number of radiographs so minimizes time

We use it with radiographs because:

 Unpredictability of position of apical constriction

 Superimposition of anatomic structures (in the radiograph so the apex
locator helps in this case).
 Risk of ionizing radiation (when using radiograph)
 Radiograph is technique sensitive in both its exposure and interpretation
 Radiograph is two-dimensional image of three dimensional structure

The meter in the apex locator doesn’t move when:

 Calcified canal

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  Obstructed canal
 Dry canal
 Root form restricts navigation
 Apex surrounded by pustule

The meter overreacts as the file enters the canal when:

 Pulp chamber is wet

 Large foramen
 Perforation
 Small file
 Pulp in canal
 File touching a metal restoration
 Leaking restoration

Erroneous (wrong) readings are given when:

 Retreatment with silver posts

 Large lateral canal
 Perforation
 Incomplete apex

This image shows the false positives and negative responses of vitality pulp
testing.

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 Blood flow of the tooth is assessed by laser Doppler flowmetry, while the
innervation is tested by pulp testers like cold test or electric pulp test

Types of files and their uses in endodontics:

Spreaders and pluggers are significant instruments in obturation:

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You should know the
difference between
reamers and files.

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Here is some hand instruments used in Endodontics:

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Here are the main burs used in Endo:
1. The Endo Z bur is a tapered
and safe-ended carbide bur.
This bur is popular in that its
non- cutting end can be safely
placed directly on the pulpal
floor without a risk of
perforation. The Endo Z bur's lateral cutting edges are used to
flare, flatten, and refine the internal axial walls.
2. The Endo Access bur is a Stainless Steel bur with a special
diamond coating to reduce gouging. This bur’s tip matches round bur
sizes for initial penetration, while its
diamond shaft flares the pulp chamber and
the canal walls. Cutting surface length: 10
mm. Overall length: 21 mm.
3. Long shank tungsten carbide burs are used for deroofing.
4. Gates glidden drills are used
primarily for shaping the coronal
third of the root canal.

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 Rubber dam
It is the best of several isolation methods including cotton rolls, gauze, retraction cord,
and saliva ejectors
Reasons for using a rubber dam:
1. Infection control
2. Patient safety – against aspiration of files or burs,
against burns by caustic materials, against injury
of the tongue with the handpiece, and against
mercury toxicity from amalgam excess
3. Patient comfort – too many cotton rolls don’t
have to be used, and cheek retraction is not
needed
4. Moisture control
5. Increased visibility – it covers facial such that it
doesn’t obstruct your work
6. Increased access – you can do it better, when you can see it better
7. Increased efficiency – the patient doesn’t keep on talking and interrupting your
work, and you don’t have to keep on changing cotton rolls. It is quick to apply
8. Medico-legal reasons
9. Improved treatment outcomes
Rubber dam equipment Highlighted things are the ones we use in the clinic

Excavators and plastic

instrument are used to release
the clamps and relieve the
rubber sheet. The idea behind
using these instruments is that
you need an instrument with a
blunt edge, so as not to tear the
RD (that’s why we don’t use a
probe). DON’T use your fingers!

Rubber dam size: 5x5, 6x6, or rolls Color: green, purple, blue, etc.
Rubber dam material: latex or non-latex Thickness: extra heavy, heavy, medium,
light – medium is used regularly

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Rubber dam punch is used to make holes in the rubber dam. The hole size ranges
from 0.7 to 2.0 mm.
 There are two types: Ivory punch (holes are too large and it’s hard to position
the rubber dam) and Ainsworth punch (the one we use)

 Use the largest hole only for all teeth – one size fits all
 Holes made through rubber sheets must have
a CLEAN CUT, NO TAGS, and must be
uniform circles, because otherwise once you
place it on the tooth it’ll tear.
Clamp forceps are used to place the clamp on the tooth. There are three types of
forceps: University of Washington forceps, Brewer forceps, and Ivory forceps

Clamps are made of stainless steel and are used to

anchor the rubber dam. There are also disposable dental
clamps. There are winged and wingless clamps. They
differ in how they are placed on the tooth
 Wingless clamps are first placed on the tooth, and
then the rubber dam is placed
 Winged clamps are placed together with the rubber
dam on the tooth.
Clamps can have straight or inverted (go deeper subgingivally) prongs.

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There are many different types of clamps but keep it simple.
 Anterior teeth: use 9T (butterfly clamp) or 2T
 Premolars: use 2T or 0 clamps
 Molars: use 4, 12A, 13A, or 2A
 4 is used on any molar
 12A is used on molars in quadrants 2 & 4. The
buccal jaw is serrated and longer than the lingual jaw.
The lingual jaw is not serrated
 13A is used on molars in quadrants 1 & 3. The buccal jaw
is serrated and longer than the lingual jaw
 2A is used on molars that are narrow MD like wisdom
teeth

Rubber dam frames are used to hold the rubber dam in place while they are being
used to isolate the operative tooth/teeth. There are different types of frames:
1. Young’s frame (metal) – the one we use in clinics
2. Star “Visi” frame (plastic)

3. Nygaard-Ostby frame – allows us to place the rubber dam away from the
patient’s face
4. Insti dam – with a built-in frame
5. Opti dam – 3D rubber dam
6. Optra dam – frame less and clamp less rubber dam
There are extra items used like:
1. OraSeal – blocks leakage around the tooth
2. Wedjets – holds and anchors the rubber dam sheets.
Sometimes we don’t use clamps, and simply use wedjets

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 instead to hold the rubber dam in place.
3. Wedges
4. Rubber dam strips – cut pieces from the corners of the
rubber dam sheet itself, and use them to anchor the rubber
dam in place instead of clamps
5. Lubricant – like Vaseline as rubber sheets dry patient’s faces
6. Dental floss – place it on the clamp to get the clamp if it fell
in the patient’s mouth. Floss both sides in case the bow
breaks. It is also used to hold the rubber dam in place
7. Orashield – rubber dam napkins
Procedure: there are four methods
Method 1 – preferred method:
1. Punch a hole in the rubber dam
sheet
2. Place the clamp in the whole
3. Use the forceps to place the clamp
and the sheet together
4. Place the rubber dam frame
5. Relive the wings using a blunt
instrument
6. Seal any spaces with OraSeal
Method 2:
1. Punch a hole in the rubber dam sheet
2. Place the sheet directly on the tooth
3. Use the forceps to place the clamp on the
tooth
4. Place the frame
Method 3:
1. Punch a hole in the rubber dam sheet
2. Place the frame on the sheet without tightening it
3. Place the clamp in the sheet
4. Use the forceps to place all three components on
the tooth
5. Relive the clamp’s wings
6. Tighten the sheet around the frame

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Method 4 – usually used with wingless
clamps:
1. Floss the clamp
2. Use the forceps to place the clamp on
the tooth
3. Punch a hole in the rubber dam sheet
4. Place the rubber dam on the tooth under
the clamp
5. Remove the floss
Rubber dam techniques:
1. Single tooth isolation – isolates a single tooth using the rubber dam. The clamp
is placed on the isolated tooth
 Hole positions for anterior teeth: ¼ from the labial side
 Hole position for posterior teeth: 1/3 from the mesial side

2. Cuff technique – isolates multiple teeth. The holes are overlapping like the Audi
sign or the Olympics logo
 The clamp doesn’t overlap with the tooth when taking a radiograph unlike
single tooth isolation
 Hole positions for anterior teeth: ¼ from the labial side – the overlapping
holes are horizontal
 Hole positions for posterior teeth: 1/3 from the mesial side – the
overlapping holes are vertical
3. Multiple tooth isolation – multiple teeth are isolated, but the holes don’t overlap
Rubber dam removal: Use forceps to remove the clamp & Cut the rubber dam
interproximally if a temporary filling is placed (Class II)
When should a rubber dam be placed?
1. Tooth investigation 4. Instrumentation and chemical
2. Access cavity preparation irrigation
3. Temporization 5. Intracanal medicament

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 6. Root canal filling 9. Trauma management – during the
7. Definitive restoration placement emergency appointment and
8. Restorative dentistry including subsequent visits
posts
The only time we might not place a rubber dam on is when there are distal or
buccal caries on the 7 with no adjacent distal tooth. Remove the caries without
reaching the pulp, do your buildup, place the clamp and rubber dam on the tooth, and
then do your access cavity
Important reminders:
 Winged clamps are preferred to wingless ones
 The bow should be on the distal side of the tooth
 Prongs must engage undercuts on the tooth surface. The clamp shouldn’t rock
 There should be a four-point clamp-to-tooth relationship
 The metal rubber dam frame should be removed before taking a radiograph
 Always place cotton rolls in the buccal/labial sulcus before placing the rubber
dam as it helps in the retraction of the surrounding tissues and increases
visibility while placing the rubber dam
 Avoid placing the clamp in the mouth without a rubber dam
 If you’re testing a clamp, then you floss on both sides of the clamp. Remove
the floss once the rubber dam is placed
 Cuff technique can be used during the investigation step of endodontic
treatment; when removing caries, crowns, etc. Single tooth isolation can be
used during the third appointment after you have done your investigation and
tooth build up.
 When using the multiple isolation technique and the cuff technique, the clamp is
placed on the most posterior tooth to be isolated
 When placing a restoration, isolate a tooth anterior and a tooth posterior to tooth
you are working on.
 When there are missing teeth, leave enough space on the sheet between the two
holes like the multiple isolation technique
 You can place a rubber dam around orthodontic brackets and wires
 If the rubber dam is not well adapted to the tooth, then tuck it under the clamp or
use OraSeal
 If the rubber dam clamp is unstable on the tooth due to insufficient undercuts,
then make an artificial undercut from resin composite on the buccal and lingual
surfaces. Don’t etch as you have to remove the composite later on
 Be sure to isolate the correct tooth

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We gain inforamaion from the patient by :

1-History taking :
1) Chief complaint:
The most important complaint in endodontics is pain. So we have to gather further information about pain,
which is known as pain history following the acronym: SOCRATES
(Site,Onset,character,radiation, Associations,Exacerbation and relieving factors,Time and Severity)
2) Medical, dental and social and familial histories.

2) Clinical examination:
Extraoral(lymphnodes ,muscles ,TMJ) and Intraoral (Visual and digital examination, Palpation, presence of
sinus tract and Probing depth.)
Sinus tract: swelling on the vestibular gingiva, and if it is pressured it will secrete pus.to determine the
causative tooth you have to insert a gutta percha point in to the sinus and then take a periapical RX.

3) Special investigations: 5 Ps
Percussion, Palpation, Periodontal probing and mobility, Periapical radiograph, and Pulp tests.

1.Percussion: the dentist strikes the tooth with the mirror handle, to check for
pain, normally there is no pain, you strike the tooth from the incisal edges/
occlusal surface and labial / buccal surface, if the tooth was susceptible to
pain this means there's apical periodontitis.
EXTRA NOTE:vertical percussion tenderness indicates periapical disease
Horizontal percussion tanderness indicates crack or fracture.

2.Palpation: with the tip of your index finger you check the periapical tissues, by pressuring apically and
checking for pain or tenderness.

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3.Periodontal probing and mobility: using the periodontal probe you check the depth of the gingival
sulcus.mobility : You place the mirror handle from one side and your finger (or another mirror handle) from
the other and you try to move the tooth.

Miller's tooth mobility classification:

CLASS 1: < 1 MM (HORIZONTAL, fixable

CLASS 2: 1-2 MM (HORIZONTAL)

CLASS 3: > 1 MM (HORIZONTAL AND VERTICAL MOBILITY) the tooth is most often
hopeless.

4.Periapical radiograph (Radiographic examination)

5.Pulp tests :
1- Thermal Test:
CO2 is the most accurate .We us dichlorodiflouromethane in our
clinics.
For the heat test, you heat a gutta percha or impression
compound and you apply lubricant to the tooth.
. You can also apply rubber dam, and pour hot or cold water to
the tooth but it is not reliable.
results :
normal tooth :cold or hot sensation “not painful”
reversile pulpitis: pain that is relieved as soon as you removed
the stimulus.
Irreversible : pain persisted, and it was lingering and sharp even
when you remove the stimulus .
- patients with gingival recession their tooth will be exposed to the oral cavity, and the cementum layer is a
thin layer, so it vanishes with time, so the dentine now is exposed, and the dentine is composed of dentinal
tubules, this cause dentine hypersensitivity. differentiate between irreversible pulpitis and dentine
hypersensitivity
2- Electric Pulp Test
Tests for the electric response of the pulp.
The electric tester we have in our clinics is graded from (0 – 64)
Start applaying the test in normal tooth and record it as the noraml
reading ,then apply it in the diseased tooth, if the patient felt pain in a less

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reading then the teeth has pulpitis .if you reached 64 and there is no pain then it is either
necrotic or calcified .
Mechanism of thermal and electric testing:
Thermal test: fluid movement causes vibration of the odontoblastic layer then the A-
delta fibers present in this layer are stimulated.
electric test :Through direct stimulation of nerves, and it has nothing to do with fluid movement .
**EPT is good for calcified teeth

False positive result :partial pulp necrosis,high anxity ,ineffective restoration ,contact with metal restoration ,
False negative:calcific obilteration of the root canal ,recent trauma,immature apex ,drugs that increase pain
threshold ,poor contact of pulp tester to the tooth.

3-Laser Doppler Flowmetry

Tests the vascular supply while The EPT and thermal tests are not vitality tests but sensibility.
To test for vitality, we can use the laser Doppler flowmetry test ( Laser light is transmitted to the pulp by
means of a fibre optic probe. Scattered light from moving red blood cells will be frequency-shifted whilst that
from the static tissue (necrotic pulp without moving RBCs) remains unshifted.
a very accurate and reliable test which is useful in trauma cases.

4- Selective Anesthesia
selective anesthesia, Intra-ligamentary injection is administered to the most posterior tooth in the quadrant
and is subsequently administered in an anterior direction, one tooth at a time, until the pain is eliminated.

5- Test Cavity
last resort, while preperaing cavity in a necrotic tooth ,there won’t be pain . Not a reliable method because a
positive response may be obtained from a necrotic tooth due to the vibration effect on the periodontium.

6- Staining and FOTI (Fibro Optic Trans Illumination)

If you suspect a crack or fracture in the tooth you can use the
1-staining test: if there's a crack, it will be colored.
. 2- FOTI: Apply a fibro-optic light at the level of the CEJ of
the examined tooth; if the light doesn't pass due to the
reflection caused by the crack (you will have a bright area
nearest to the light source and a dark area beyond the crack)
this indicates a fracture.

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7- Bite test
If a patient complains of pain on
chewing and there is no evidence of
periapical inflammation, an
incomplete fracture (crack) of the
tooth may be suspected. Biting on a
wood stick in these cases can elicit
pain, the pain is released by
pressure.
- You can use burlew disc, wood stick or tooth sloth to apply this test.

8- Periapical Radiographs
they address the inflammation in the periapical tissue.

-The normal tooth radiograph: after the tooth there is a dark line
which is PDL space, then there's a white line which is the lamina
dura, and then comes the cancellous bone.

-In an inflamed tooth: you will see widened PDL space, if kept
untreated it will result in loss of lamina dura, and then you will
observe periapical radiolucency, which indicates a very late stage of inflammation, and one cortical plate might have
been resorbed.

•When you want to diagnose, you have to firstly refer to the terminology, "According to the AAE 2009
classification,"AAE: American association of endodontists.

It divided the diseases into: pulpal disease and periapical diseases.

pulpal diseases:
1)Clinically normal pulp:
- symptom-free and normally responsive to pulp testing (mild or transient
response to thermal cold testing, lasting no more than one to two seconds after
the stimulus is removed). The response is comparable to that of adjacent or
contralateral teeth.
2)Reversible Pulpitis:
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- Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away
within a couple of seconds following the removal of the stimulus.
- Causative factors may include caries or deep restoration.
-treatment:removal of the cause (caries ).
-NO radiographic changes in the periapical region of the suspect tooth and the pain
experienced is NOT spontaneous
NOTE: ( don’t confuse it with dentinal sensitivity which is not an inflammatory process but all
of the symptoms of this entity mimic those of a reversible pulpitis:
•Sharp pain of short duration in response to a stimulus (thermal, evaporative, tactile,
mechanical, osmotic, or chemical) due to exposed dentine.
- tretment of dentinal hypersensitivity: use fluoride tooth pastes, and use splints made of
acrylic that will cover the labial surface, it's called gingival mask or gingival veneer, and is used
for both aesthetics and to decrease sensitivity. In severe cases surgery is performed.)

3)Symptomatic irreversible pulpitis

- sharp severe pain upon thermal stimulus, lingering pain (often 30 seconds or longer after
stimulus removal), spontaneity (unprovoked pain) and referred pain and poorly localized.
Sometimes the pain may be accentuated by postural changes such as lying down or bending
over. Over-the-counter analgesics are typically ineffective. Pain disturbs sleep.
- Common causative factors may include deep caries, extensive restorations, or fractures
exposing the pulpal tissues.
no pain or discomfort to percussion.
•initial stage : no radiographic changes in the periapical region.However, at advanced stages,
widening of the periodontal ligament may become evident on the radiograph
Treatment: perform RCT or extraction.

4)Asymptomatic irreversible pulpitis:

no clinical symptoms and usually respond normally to thermal testing but may have had
trauma or deep caries that would likely result in exposure following removal.

5)Chronic irreversible pulpitis

Form of irreversible pulpitis . in a chronically inflamed pulp in young
patients if there was rich vascular supply, adequate exposure for

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drainage and tissue proliferation there will be Outgrowth of the pulp which occupies large
space of the crown.
-Clinically appears as red cauliflower-like overgrowth in a large occlusal exposure
-Usually asymptomatic but can occasionally be associated with clinical signs of irreversible
pulpitis (spontaneous lingering pain).
Treatment: restoration or extraction.

6)Pulp necrosis
-No symptoms, but sometimes the patient might feel pain when he eats something hot due to
expansion of gases that are byproducts of necrosis in the canal.
-The pulp is non-responsive to pulp testing and is usually asymptomatic.
-Pulp necrosis by itself does not cause apical periodontitis (pain to percussion or radiographic
evidence of osseous breakdown) unless the canal is infected.
-Some teeth may be non-responsive to pulp testing because of calcification, recent history of
trauma, or simply the tooth is just not responding. This is why all testing must be of a
comparative nature.(FN)
-Treatment: RCT or extraction

7)Preciously treated
It is a clinical diagnostic category indicating that the tooth has been endodontically treated,
and the canals are obturated with various filling materials other than intra canal medicaments.
The tooth typically does not respond to thermal or electric pulp testing.

Periapical Diagnosis
1)Normal tissues:
-not sensitive to percussion or palpation testing (asymptomatic).
-Radiographically, the lamina-dura surrounding the root is intact and the periodontal ligament
space is uniform, and normal trabeculation pattern.
Comparative testing for percussion and palpation should always begin with normal teeth as a
baseline for the patient.

2)Symptomatic acute periapical periodontitis

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-painful response to biting and/or percussion or palpation (tenderness to percussion and to
palpation).
-Tenderness to percussion may also be a result of impact trauma, traumatic occlusion,
orthodontic tooth movement, or maxillary sinusitis.
-This may or may not be accompanied by radiographic changes (i.e.Depending upon the stage
of the disease, there may be normal width of the periodontal ligament or there may be a
periapical radiolucency).
-Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp and
root canal treatment is needed.

3)Asymptomatic periapical periodontitis

-A tooth with asymptomatic apical periodontitis generally presents with no clinical symptoms
(asymptomatic)
-This tooth does not respond to pulp vitality tests, and the radiograph will exhibit an apical
radiolucency.
-This tooth is generally not sensitive to biting pressure but may “feel different” to the patient
on percussion.
-Root canal treatment is needed.
4)Acute apical abscess
-rapid onset of spontaneous pain. The affected tooth is usually
extremely tender to percussion and the associated soft tissues
are tender to palpation.
-The affected tooth will not respond to any pulp vitality tests
and will exhibit varying degrees of mobility due to extrusion
out of the bony socket.
-Radiographs can reveal anything from a widened periodontal ligament space to an apical
radiolucency depending on the stage.
-Swelling will be present intraorally. The facial tissues adjacent to the tooth will almost always
present with some degree of swelling as a result of pus formation
-the patient often experiences malaise, fever and lymphadenopathy.
- Swelling from the anterior palate usually is associated with an abscess originating from the
lateral incisor because its root usually curves palataly.
-Treatment: drainage through the tooth or incision and drainage.
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5)Chronic apical abscess
-The affected tooth is generally asymptomatic
-This tooth will not respond to pulp vitality tests
-Radiographically, the tooth will exhibit an apical radiolucency
-The tooth is generally not sensitive to biting pressure (not
tender to percussion) but can “feel different” to the patient on
percussion. This entity is distinguished from asymptomatic
apical periodontitis because it will exhibit intermittent drainage through an associated sinus
tract.
-Treatment: RCT or extraction

6)Condensing osteitis
-Is a diffuse radiopaque lesion representing a localized bony reaction (overproduction of bone
in the periapical area) to a low-grade, long-standing inflammatory
stimulus usually seen at apex of the tooth (good patient immunity
and a low degree of virulence of the offending bacteria).
-The associated tooth may be carious or contains a large
restoration.
-The pulp of the involved tooth may be chronically inflamed or
non-vital.
-Treatment: RCT or extraction
-The radio opacity may or may not respond to endodontic
treatment .

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 Access cavity of anteriors and premolars
MAXILLARY CENTRAL INCISOR:
 A newly erupted central incisor has three pulp horns
 The pulp chamber is wider mesiodistally than buccolingually.
 100% have a single canal.
 Its access cavity is triangular in shape. ‘apex cervically and base incisally’
 The Cingulum is the point of strength for all anterior teeth, because it contains the major bulkiness of
dentin, we shouldn’t touch it while doing access cavity.
 The best Bur used firstly with this tooth to penetrate the lingual surface is the round diamond bur on a high
speed hand piece, we direct it perpendicular on the middle of the middle third, just above the Cingulum,
and start penetrating until a drop occurs . If the drop isn’t felt, another method is used. I can measure the
width of the tooth labiolingually, and divide it into half. By allowing the bur to penetrate half of the width
of the tooth that I measured, I can unsure then reaching the pulp, because the pulp chamber is exactly at the
center of the crown.
 After feeling the drop, I should immediately change the angle of the bur and the hand piece to become
parallel with the long access of the tooth.
 I start doing de-roofing immediately, by a brushing motion using a low-speed hand piece with round bur,
in order to eliminate any thing that prevents a straight line access to the root canal system.
 The lingual shoulder, if not removed, prevents a straight line access for the root canal, making our
instruments work under stress.
 The lingual shoulder is due to a Dentin bulkiness (bulge).
 We remove the lingual shoulder using Gates Glidden drills.

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Maxillary lateral incisor:
 Maxillary lateral incisor has two pulp horns.
 The pulp horns are closer to each other more than the central incisor.
 The access cavity in this tooth is in the shape of a “rounded triangle”, closer to become oval in shape.
 This tooth is wider mesiodistally than buccolingually
 The lingual shoulder of dentin must be removed before instruments can be used to explore the canal

Maxillary canine:
 Almost 100% have a single canal.
 Pulp chamber is wider buccolingually than mesiodistally.
 It has a single or no pulp horn
 External access outline is oval above the cingulum.

MANDIBULAR CENTRAL AND LATERAL INCISORS

 Root of lateral incisor is longer than central incisor .
 Roots are thin MD so their roots are more flat while max. roots are more
cylindrical and rounded ( developed) .
 95% have a single canal, 5% two canals (Vertucci et al., 1984)
 Pulp chamber is wider buccolingually than mesiodistally.
 External access outline is oval.
 As with the maxillary incisors, a lingual shoulder must be eliminated to
allow direct-line access.

 Steps :

1- High speed bur is placed perpendicular to lingual (palatal) surface. ( we can do that without using
mirrors by direct vision )

2- Remove enamel and dentine until feel drop-in (if the pulp chamber is not calcified).

3-Then we start to widen the cavity BL. ( draw the outline )

4-DEROOFING in which some use slow speed round bur and others use Endo Z bur and Endo access bur

Mandibular canine :
 94% have a single canal, 6% two canals.
 Pulp chamber is wider buccolingually than mesiodistally.
 External access outline is oval.
 A lingual shoulder must be removed to gain access to the lingual
wall of the root canal or to the entrance of a second canal.
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MAXILLARY FIRST PREMOLAR:
 Has 2 cusps ( B is larger and higher than L ) so the pulp chamber has 2 horns ( B is larger and higher
than palatal horn).
 note: If I’m doing a class 1 cavity preparation and I see a drop of blood, I expect it to be from the
exposure of B pulp horn because it’s higher and larger )
 Pulp chamber is wider BL than MD.
 In presence of 2 orifices, the palatal orifice is larger, and In presence of 2 separate canals, the palatal
canal is larger. So if we wanna use post we put it in the palatal canal .
 Access cavity is oval, wide buccolingually, narrow mesiodistally, and centered mesiodistally between the
cusp tips.
 IMPORTANT NOTE : Because of the mesial concavity of the root ( which mean less dentine in this
area) , the clinician must take care not to over extend the preparation in that direction, as this could result
in perforation.
 Starting point(entry point) is in the central groove in the middle of an imaginary line connecting the
buccal and the palatal cusp tips.
 Steps:
1) High speed bur is placed perpendicular to occlusal surface. ( using endo access or round bur )
2) Remove enamel and dentine until feel drop-in
3) Widen the initial outline Buccolingually.
4) Deroofing using the Endo Z bur. ( the best bur for deroofing of post
Teeth because it has a non-cutting end)
5) Widen the cavity buccolingually.

Variation :
• When three canals are present, the external outline form becomes triangular, with the base on the buccal aspect.
The mesiobuccal and distobuccal corners of the triangle should be positioned directly over the corresponding canal
orifices.

MAXILLARY SECOND PREMOLAR

 The pulp chamber is wider buccolingually than mesiodistally.
 2 pulp horns; buccal larger.
 This tooth usually has one root One, two or three canals can occur in a single root.
 Usually has a wide oval single canal.
24
  ACCESS CAVITY:
 is oval in shape.
 Wide buccolingually and narrow mesiodistally.
 If two canals are present, access identical to upper first premolar and have the same starting point.
 Triangular if 3 orifices. Base towards buccal surface.

MANDIBULAR FIRST PREMOLAR

 The pulp chamber is wider buccolingually than mesiodistally.
 2 pulp horns; buccal larger.
 Access cavity is oval in shape.
 Wide buccolingually and narrow mesiodistally
 Crowns of mandibular premolars are tilted lingually relative to their roots; therefore,the starting location
is halfway up the lingual incline of the buccal cusp on a line connecting the cusp tips.

 Steps:
1. High speed bur is placed perpendicular to occlusal surface and drill for about 1.5mm( endo access or
round bur )
2. Bur inclination changed to parallel to long axis, enamel and dentine removed until feel drop-in (if the
pulp chamber is not calcified).
3. Deroofing with slow speed round bur OR Endo Z .
4. identification of all canal orifices.

MANDIBULAR SECOND PREMOLAR

 Similar to lower first premolar.
 The pulp chamber is wider buccolingually than mesiodistally.
 2 pulp horns; lingual larger.
 Crowns of mandibular premolars are tilted lingually relative to their roots; therefore The starting location
for this tooth is one third the way up the lingual incline of the buccal cusp on a line connecting the
buccal cusp tip and the lingual groove between the lingual cusps.
 The mandibular second premolar can have two lingual cusps, sometimes of equal size. When this occurs,
the access preparation is centered mesiodistally on a line connecting the buccal cusp and the lingual
groove between the lingual cusp tips.

25
 Vertucci’s classification :

# of canals MAXILLARY FIRST MAXILLARY MANDIBULAR MANDIBULAR

PREMOLAR SECOND FIRST SECOND
Tooth PREMOLAR PREMOLAR PREMOLAR
One canal 26% (centre of pulp 75% (centre of pulp 74% (centre of pulp 97.5% (centre of
chamber). chamber). chamber). pulp chamber).

Two canals 69% (buccal and palatal). 24% (buccal and 25.5% (buccal and 2.5% (buccal and
palatal). lingual). lingual).
Three canals 5% (2 buccal and one 1% (2 buccal and 0.5%. 0.0%.
palatal). one palatal).

26
Mechanical instrumentation

**Taper: a gradual decrease in canal diameter in a corono-apical direction.( 5%,

0.05mm)

Why do we need a tapered canal preparation?

1- To facilitate the flow of irrigants in the canal.

2- To reduce the stress on the instrument during instrumentation.

3- To facilitate obturation and the placement of inter-appointment medication.

Basic instrumentation motions

Balanced force technique: which we use

Allows controlled manipulation of hand files whilst maintaining a centered

preparation and reducing the incidence of procedural errors. The file is inserted in
the canal until resistance is met and rotated 90° clockwise to engage dentine in its
flutes. The file is then rotated 180° counterclockwise whilst maintaining apical
pressure. This action cuts dentine from the canal wall and is associated with a
characteristic click. A further clockwise rotation collects debris on the flutes
before being withdrawn from the canal.

Other options: Filing, reaming or watch winding motions .

**note : Anti-curvature filing: preparation away from the thinner portions of the root structure
where perforation or stripping of the canal walls can occur, A concept described by Abou Rass.

Hand instrumentation techniques:

▪ Standardized, Step-back , Crown‐down ( ‫بنعمل فيها عكس ال‬step back) and Hybrid
techniques.

Step back technique:

A- Initial negotiation:

▪ size 10 or 15 k-file is worked apically using a watch-winding motion to ensure

that the coronal portion of the canal is negotiable.

27
Mechanical instrumentation

▪ Not necessary to negotiate the canal to the apex at this stage.

▪ Pulp chamber flooded with NAOCl to avoid blockages.

▪ File should not be forced apically.

B- Coronal flaring phase:

▪ Start with GG size 2 to about 1⁄2 to 2⁄3 of the canal length.

▪ Use GG size 3 in the coronal 1⁄3 of the canal length.

▪ Use G.G. size 4 no more than 3mm below the orifice of the canal.

(G.G. size 5 and 6 are used only to enlarge the orifice of canals in certain cases; e.g. long teeth
or severely curved canals)

▪ When using Gates Glidden burs, do not force them into the canal to avoid
perforation of the canal wall and/or instrument separation .( GG have non-cutting tips
, made of SS)

C- Apical preparation phase:

1. Flood the cavity with irrigant.

2. WL measurement.

3. Apical gauging: Identification of initial binding (apical) file; the first file that
binds at the working length. It Gives information about the original size of the
canal.

4. Insert the IAF to WL with “watch‐winding” and then with pull strokes work
against the canal walls.

5. Irrigation with NaOCl between every 2 instruments.

6. Insert the next larger file to WL, with ”watch‐winding” and pull strokes, work
against the canal walls until it fits loosely to WL.

7. Recapitulation

28
Mechanical instrumentation

8. Repeat steps 6‐8 until the desired file size = Master Apical File (MAF)

**Circumferential Filing: A Filing technique where the file is worked against the root canal wall
during its cutting action (pull stroke). This is done against all walls equally.

**The master apical file:

**MAF is the largest file used to WL in a completely prepared canal.

**MAF size is recommended to be usually three sizes wider than IAF, minimum
ISO 30.

**Preparing canals to sizes smaller than ISO 30 does not create sufficient room
for the irrigating solutions and medicaments.

**However, this should be balanced with root canal anatomy and type of
tooth/root.

*e.g. severe curvatures= 25, upper central incisor = 45

minimum.

D- The step-back phase:

1. Place a file one size larger than MAF into the canal
1mm short of the WL.

2. Work against the walls until it is loose within the canal.

3. Recapitulation to full length with MAF file to remove of dentine chips.

4. Copious irrigation before introducing next size instrument.

5. Repeat Until reaching middle third.

E- Refining phase:

**Return to MAF, smoothing all around the walls with vertical push‐pull strokes.

**Placing the file into the canal and pressing it laterally while withdrawing it along
the path of insertion to scrape (plane) the wall.

29
Mechanical instrumentation

Recapitulation: The introduction of smaller files to full WL during root canal

preparation to keep the apical area clean and patent. Helps prevent packing of
dentinal debris and loosening these debris to be flushed out with irrigation. Helps
in maintaining the WL and avoiding blockage

Patency filing: Refers to the passive placement of a small hand file (size 10 or
smaller) 0.5-1mm through the apical constriction during root canal preparation.

The aim of patency filing is to prevent blockage of the apical portion of the root
canal by debris created during instrumentation.

A potential drawback of patency filing is that infected debris might be extruded

into the periapical tissues, resulting in post-operative flare-up.

Instrumentation-related errors:

30
 Chemical Irrigants
-Intra-canal irrigation is an essential part of root canal treatment as it serves
both mechanical and biologic functions.

:‫ليه كتير مهمة ؟‬

-First, instruments do not access the complex shape of the root canal
system.Secondly, within these inaccessible regions complex biofilms can
develop that are not easily disrupted. Thirdly, instrumentation creates a
smear that further prevents decontamination of the canal surface dentine
and prevents a good adaptation of the obturation material to the canal wall.

Properties of the ideal irrigant:

1. Effective antimicrobial agent (bactericidal and fungicidal).

2. Able to dissolve pulp and organic tissue.

3. Able to remove the smear layer. 4. Non-cytotoxic, non-mutagenic.

5. Active in the presence of blood, serum, dentine and proteins.

6. Has a low surface tension. 7. Non-staining to tooth structure.

8. Substantive (remain active for a sustained period).

9. Has no adverse effects on the physical properties of dentine

10. Does not affect the sealing ability of filling materials .

11. Non-corrosive to dental instruments.

12. Inexpensive, readily available and has a long shelf life.

How to irrigate?

• Use small gauge needles (G27 or 30) on Luer-lock syringes.

• Apply light gentle force during irrigation (use index finger instead of thumb)

31
• Strictly control your working length.
Work 2-3mm short of it.

• Confine your irrigation to within the

root canal space. (Needle should be bent
accordingly to control the depth of placement
and for ease of use.)

• Use closed-ended needles when

possible.

• Place the irrigating needle loosely in

the canal (Needle should always be moving
up and down. If it binds in the canal, stop irrigating).

• Use large volumes of irrigant.

• Allow irrigant sufficient time to exert its effect.

1-Sodium hypochlorite (NaOCl): (In water, NaOCl ionizes to produce Na+ and
HClO (hypochlorus acid). HClO disrupts oxidative phosphorylation and other
membrane-associated activities and can affect DNA)

-Concentration used (0.5%‐6%) - the gold standard for endodontic

treatment.

Advantages:

➢ Broad antimicrobial spectrum ➢ Organic tissue-dissolving ability

(both vital and necrotic tissue)

➢ Efficacy enhanced by heating ➢ Rare allergic potential

Disadvantages:

➢ Extremely cytotoxic. ➢ Repulsive taste (and smell).

➢ can bleach clothes. ➢ cannot remove smear layer (inorganic

component).

32
➢ has deteriorative effects on mechanical properties of dentine.

2-EDTA (Ethylene diamine tetra‐acetic acid)

• A chelating agent • Concentration used 17% (also available as gel)

• Soften dentine; some use it to help negotiate narrow/calcified canals

• Little antibacterial activity • Self limiting effect (no more than 50μm)

• Used after instrumentation is completed to remove the inorganic part of

the smear layer (usually followed by another rinse of NaOCl).

3- Chlorhexidine gluconate:

▪ Concentration used 0.1-2% (when the concentration is 0.2% as in mouthwashes

it’s only bacterio-static) .

▪ Broad antibacterial spectrum (G+ve, G-ve, yeast/ Effective against E.faecalis and
S. aureus), and antifungal.

▪ Cationic bisguanide; capable of electrostatically binding to the negatively

charged surfaces of bacteria damaging their cell walls and rendering them
permeable.)

▪ Substantivity (up to12 weeks) ▪ Low toxicity

Disadvantages:

▪ No tissue dissolving ability. ▪ cannot remove the smear layer

▪ Reported anaphylactic shocks and allergic reactions (rare).

▪ should not be mixed with NaOCl due to the formation of PCA.

4-normal saline:

33
• 9 g/L sodium chloride • Chemically inactive irrigant (passive irrigation)

• No antimicrobial activity • Does not dissolve organic/inorganic tissues

• It only provides lubrication and gross debris removal functions

5- Hydrogen peroxide:

• An oxidizing agent used in concentrations of 3-5%.

• Production of O2 eliminates anaerobes.

• Weak antibacterial activity. • Tissue dissolving capacity less than NaOCL.

• Limited shelf life • Effervescent effect when mixed with NaOCl.

6-MTAD – a mixture of an antibiotic, an acid and a detergent.

-Antibiotic: 3% doxycycline (antibacterial effect). -Acid: 4.25% citric

acid.

-Detergent: 0.5% Polysorbate 80 (decreases surface tension and viscosity).

-MTAD is able to remove the smear layer and is effective against E.

faecalis.

-Shows substantivity up to 4 weeks.

Local anaesthetic,saline and/or water? . ‫ما الزم نستخدمهم‬

# #Do not mix chlorhexidine and hypochlorite. When mixed they form a
precipitate, parachloroaniline which is thought to be carcinogenic, it may
stain the tooth.

Increasing the irrigant efficacy:

34
1- Heating: heat NaOCl to 45-60°, Increases it’s antimicrobial and organic
tissue-dissolving ability.

2- Agitation:

a- Ultrasonic activation:

Cavitation and acoustic streaming: (This increases the turbulence of flow,

improving distribution of irrigant, penetration into isthmuses and tissue dissolution.)

b- Sonic activation

C- Gutta percha master cone in a pumping action

Sodium hypochlorite accident:

▪ Due to inadvertent extrusion of NaOCL under pressure into periapical

tissues.

▪ Sudden prolonged sharp pain along with rapid diffuse swelling followed by
ecchymosis due to interstitial bleeding

▪ Can be life threatening and may cause permanent tissue damage

Risk factors for the accident:

-Incorrect working length. -Widening of the apical foramen / open apex.

-Lateral perforations. -Binding of the irrgating needle.

-Irrigation with force.

How to avoid this NaOCl accident?

• Avoid wedging of the needle, needle should be loose in the canal.

• Needle depth into the canal should be less than WL by 2-3 mm depending
on apical size and technique.

• Use low concentration of NaOCL.

• Gentle pressure ( do not force the needle).

35
• Extra caution when apical size is large ( ex: open apex ).

Symptoms and Signs of Hypochlorite Injury:

- Sudden pain irrespective of presence of LA - Profuse bleeding

from within the canal

-Extensive edema - Delayed: Echymoses

- Delayed: Secondary infection - Delayed: Parasthesia

Management of sodium hypochlorite accident:

➢ Early recognition. ➢ Immediate irrigation with large amounts of

saline.

➢ Pain control with long acting local anesthetics (preferably longer acting such
as bupivucaine)and analgesics.( Paracetamol 500 mg QDS with Ibuprofen 400−600
mg QDS alternating doses).

➢ Cold packs on the first day to reduce the swelling, and on the second
day: Warm compressions and frequent warm mouth rinses thereafter.

➢ Antibiotics ?? (risk of secondary infection).

➢ In severe cases; incision and drainage +/- hospitalization.

➢ monitoring of improvement.

 Dress the tooth with non-setting calcium hydroxide: do not leave on

open drainage

36
 Temporization during endodontic treatment

During endodontic treatment we have to consider 2 aspects of temporization:

1. Coronal; interim and temporary restoration.
2. Root canal; intra-canal medicament.

Why we use medicaments?

1. Anti-bacterial action; sources of bacteria:
I. Residual bacteria in canals, tubules, fins, etc Protected from:
a. Chemo-mechanical preparation.
b. Immune host response (no blood supply inside the canals, so no Immune
cell can reach the bacteria inside the tubules).
c. Systemic antibiotic (no blood supply so these antibiotics can’t reach
bacteria).
II. Contaminants between visits (if we so temporization then there will be no
space available for bacteria).

2. Prevent or reduce pain.

3. Reduce periapical inflammation.
4. Induce apical hard tissue barrier formation.
5. Help eliminate apical exudates (when you have pus originating from the
canal you can’t fill them).
6. Stimulate periapical tissue repair.
7. Prevent or inhibit inflammatory root resorption.

Endodontic medicaments choices:

A. Corticosteriod/ antibiotic - CS/Ab
- Ex: ledermix paste/ Odontopaste.

*note that there are other pastes like Septomixine Forte paste and pulpomixine
paste but we don’t use them because they are toxic and carcinogenic.

37
 B. Calcium hydroxide – Ca(OH)2
- Ex: Calasept Plus paste/ PulpDent.

C. 50:50 mixture: CS\Ab + Ca(OH)2, may have the function of both but no
evidence.

Which one to choose?

Depending on which function we need;
D. Anti-inflammatory (irreversible pulpitis or acute apical periodontitis) :
corticosteroids
E. Anti-bacterial (pulpless or infected root canal space) : calcium hydroxide
F. Hard tissue repair (ex: apical repair): calcium hydroxide, because it helps in
the formation of calcified barrier.

Ledermix paste
- Developed in 1960, available since 1962.
- Components:
1. Triamiconolone (1%); corticosteroid part.
2. Demeclocycline (3%); tetracycline antibiotic -> it causes teeth
staining in children.
3. Other contents.

- It diffuses to the dentinal tubules and apical tissues).

 The pattern of diffusion is initial rapid diffusion (in the 1st 24 hours)
then steady release up to 6 weeks.

- Ledermix used in endo therapy for:

1. Anti-inflammatory action; reduce pain and nerve sprouting.
2. Anti-bacterial action.
3. Inhibition of clastic cells; reduce resorption of tooth and bone.
4. Inhibition of PMN neutrophil collagenase; reduce tissue destruction.

38
  The use of Ledermix paste is because of its corticosteroid content (we
don’t use it for its antibacterial activity because calcium hydroxide is
better antibacterial agent, but we use it for its anti-inflammatory action
(to reduce nerve sprouting), and the corticosteroid content is sufficient
to reduce the inflammatory action around the tooth).

Odontopaste:
- Similar to Ledermix but the antibiotic here is clindamysin and it has little
Ca(OH)2.
- Alternative when:
1. Non responsive infection; since it has different antibiotic.
2. Discoloration; we use it in anterior teeth, but in posteriors we can use
either one.

Calcium Hydroxide:
- It’s a powder that has high pH that inhibits bacterial growth.
- Low solubility in water, when it contact moisture it dissociates into Ca+2 and
OH-.
- The powder needs vehicle to be mixed with.
 The vehicle enhance radiopacity, consistency, flow and antimicrobial
activity.
 The vehicle can be: (listed from most flowable to the least)
1. Aqueous, has rapid dissociation, less longevity
2. Viscous, slow dissociation, more longevity.
3. Oily, slow dissociation, more longevity.
So when long term action is needed we use oily vehicle not aqueous

- Commercial preparations of Ca(OH)2:

1. Saline base: eg. Calasept Plus
2. Methyl-cellulose base: eg. Pulpdent paste
3. Powder - to mix with various liquids
4. Impregnated on GP points: eg. Roeko

39
 - These preparations have many uses ( uses of Ca(OH)2 ):
For periapical healing, root canal disinfection, inflammatory root resorption, lateral
canals disinfection, hard tissue repair, root fraction, open apex (in this case we
need a calcified barrier). (So the most commonly used intra-canal medicament is
Calcium Hydroxide).
- Properties of Ca(OH)2 (for these properties it’s the most common used)
1. Anti-bacterial activity (major property).
2. Stimulates hard tissue formation
3. Helps dissolve necrotic tissue (when we use calcium hydroxide then
we irrigate the canal by NaOCL, the activity of NaOCL (sodium
hypochlorite) will be enhanced.
4. Inhibits inflammatory tooth resorption.
5. Detoxifies bacterial endotoxin (LPS) (these endotoxins cause
inflammation, bone resorption, stimulate macrophages to release
cytokines).
- It works on cytoplasmic membrane.
- Efficacy of calcium hydroxide depends on the diffusion of (OH-) because they
are free radicals that can attach to the cytoplasmic membrane and causes
bacterial destruction.
- Release (depends on the vehicle type) and Diffusion of Hydroxyl Ions
depends on:
1. Period of exposure.
2. Dentine permeability (permeability of dentine isn’t the same, inner
dentine has larger diameter and more tubules so it’s more permeable,
and that’s why we have higher ph toward inner dentine).
3. Vehicle Type
4. Smear layer (if we don’t remove the smear layer it will compromise
diffusion).
5. Cementum layer (eg. If I want periradicular action , cementum has to
be lost )
6. Dentine buffering capacity? (No researches approve this until now).
7. Level of placement
8. Method of placement
9. Retreatment procedure.

40
 - Limitations of Ca(OH)2:
1. Toxicity - initial and long-term (if it leaks out to the tissues it’s
somehow toxic and may be carcinogenic).
2. Increased replacement resorption ( if it is put early in the socket
when the tooth falls, inflammation occurs )
3. Increased ankylosis (no peridontal ligament, and the tooth will stuck
to the bone).
4. May promote inflammatory resorption
5. May affect dentine mechanical properties (long-term?) (in case of
short term action it will not affect dentine , in long term it may
affect, but these effects may happen as a result of the tooth structure
itself (thin dentine) and not because of Ca(OH)2 (so we don’t have
enough evidence that it does affect the mechanical properties of
dentine).
Q: How long should the medicaments be placed?
 For Ledermix: min 2 weeks, max 4-6 weeks.
 For Calcium Hydroxide 3-4 weeks is the best time to get the highest
pH, however, it may differ according to the type of vehicle.
Q: How do we apply these medicaments?
 Spiral filler (the most efficient).
- Preferred: most effective & easiest
method.
- ONLY if the canal has been enlarged
(after we finish canal preparation).
- We put small amount on the tip then set
on a slow hand piece then we go in and
out for 3-4 mm shorter than the WL,
repeat for 3-4 times.
 Hand file (counter clockwise).
- If canal has NOT been enlarged / prepared.
 NOT advised:
- Injection - No control; over-extension likely (we can push it to the
periapical tissues).
- Paper point - break down; periapical irritant (not strong enough).

41
Temporary coronal Restorations
 Major functions:
- Prevent bacterial ingress during treatment (between appointments).
- Prevent bacterial ingress after treatment (until definitive restoration is
placed).
- Provide a sound base for rubber dam placement.
- Protect against tooth fracture during treatment.
- Provide a stable reference point.
- Provide aesthetics where required.
 We have to consider 2 aspects regarding coronal restorations:
1. All missing parts of the tooth -> walls replaced by interim restoration, if the
walls are intact then we don’t place interim.
2. Access cavity -> replaced by temporary restoration.
 Materials we shall use as INTERIM:
Glass ionomer (e.g. Ketac Silver, Ketac Fil) (glass ionomer bonds to dentine;
that’s why we try to remove the smear layer using conditioner before placing
them -to achieve better bond-, and after placing them we use Vaseline or glaze
or bond to protect them from moisture), also its very useful if we could find
Stainless Steel orthodontic bands (very expensive & not widely used in Jordan).
- We use silver (Ketac silver) in posterior teeth, because it has more
strain (stronger), less sensitive to moisture, and it provides the
contrast we need (so when we want to place the permanent
restoration, it’s easier to distinguish silver glass ionomer from tooth
colored ionomer).

- we first remove the restoration, do access

cavity, then do interim restoration, so we
have to protect our access, for this we put
TF (temporary filling) (we use CAVIT),
then we have to replace the wall using
glass ionomer, (we can use regular matrix
band, but here we use Stainless Steel band
which is the ideal one to use), then we
place the filling, then (after the first
appointment), we have to go through the
ionomer (do an access cavity through the
ionomer).

42
 - For aesthetic restoration, we can’t use silver, so we use Ketac fil,
although it isn’t 100% perfect, but It’s better than silver (aesthetically).

- In case we have broken anterior teeth, how could we do

temporization?
- We make temporary crown post, firstly,
we put the medicament inside the canal,
(but we will not place the post directly in
the canal), then we put a very small piece
of cotton, after that we put the white TF
(CAVIT), then we put the temporary post
with the crown. (By doing this, we are
going to have the temporization we need,
and if this crown falls, we still have the
CAVIT layer, which prevents root canal
contamination).
- If we don’t want to make this post &
crown procedure, we can fill with glass
ionomer, then we place denture (over
denture) or place composite crown and
stick it with adjacent teeth. (In this case
we fill the cavity, put small piece of
cotton, place CAVIT (we could also put
glass ionomer above it), then we place the
denture above this space or we make
composite crown then place it).

 Materials we can use as temporary restoration (to restore the access cavity not
the walls):
1. CAVIT (calcium based material).
2. IRM (reinforced zinc oxide eugenol).
Which one to use? The ideal thing is to do “double seal” why?
We place intra-canal medicament (temporary dressing of root canal), above it we put
cotton piece (must be sterile, if not don’t put, and ensure that it is well condensed, and
cover the orifice with no small projections orientating from it), then we place the CAVIT
(it works by preventing moisture, but it has high solubility (disadvantage) so if it is
exposed to the oral environment it will dissolve, another disadvantage is low wear
resistance), for these disadvantages of CAVIT, we protect it by placing another layer
which is IRM (reinforced zinc oxide eugenol, that will prevent bacterial penetration
(eugenol has anti-bacterial action) and has high wear resistance (another advantage of
IRM is low solubility).

43
Note that the TF we use in clinics are calcium based (CAVIT), it doesn’t seal, it
doesn’t really protect the tooth from fracture, and it doesn’t prevent bacterial
penetration, it only works on moisture.
 Eight essential steps to reduce to reduce the endodontic microbial flora:
1. Identify and remove the cause.
2. Aseptic procedures.
3. Mechanical instrumentation.
4. Anti-bacterial irrigants.
5. Intracanal medicaments.
6. Interim and temporary restoration.
7. Root canal filling.
8. Coronal restoration.

44
 Root canal Filling
• How do we Prevent future infection ?

1. Root canal filling

2. Coronal restoration
3. Reinforcing the patient's Oral hygiene, diet, etc.

• RCF's are short term antibacterial only (the main antibacterial agents are
chemicals and irrigations that we use)
• The sealing of canals by RCF's is doubtful
• Main function of a RCF is to FILL the canal space - and thus make it less
favorable for bacterial colonization to occur (having a seal also prevents the
entering of nutrients to the canal)
• Clinically, we base our assessment (for RCF's) on the radiographic
appearance (we can only see how radiopaque the root filling material is and
where it has been placed - nothing else-). ALSO, Radiographs do not
indicate the degree of filling of the root canal SYSTEM

• you should differentiate:

- SEAL Block or prevent entry into and exit out of the canal space
- FILL Obliterate the canal space

• the quality of the coronal restoration is more important than the quality of
the RCF for apical periodontal healing.
• POOR instrumentation & disinfections with a GOOD RCF would probably be
susceptible to failure!

Q/ why do we spend so much time and effort doing high quality RCF’s? A/
because they
✔ Fill most of the space
✔ Create an unfavorable environment for bacteria to survive in
✔ Slow down the process of further infection and apical periodontitis
✔ An indication of the overall technical standard of the endo treatment

• RCF’s only slow down the onset of apical periodontitis

•

45
- The RCF is not likely to have much effect on the outcome of the current
treatment
- Only has a minor effect on how long the tooth may remain free of infection

• First we asked why do we fill root canals, now we ask, when do we fill the
root canal? It’s done when all of the following have occurred:
a. Canal preparation and cleaning completed (remember that
every time you bring the patient back you have to irrigate)
b. There are no symptoms associated with the tooth (resolved
before)
c. The canals can be dried
d. Mobility, percussion and palpation are normal
e. The draining sinus has healed - if present pre-opal
f. Swelling has resolved - if present pre-operatively
g. Evidence of healing - if large lesion was present pre-
operatively.

Techniques :
- Single Cone
- Lateral compaction / condensation Cold, Warm (the one we're using)
- Vertical compaction / condensation
- Solvent techniques Chloroform, eucalyptus
- Thermomechanical compaction (McSpadden)
- Thermoplastic Injection techniques Obtura, Ultrafil, etc.
- Carrier-based techniques Stainless steel, titanium, plastic
- Hybrid techniques(mix of the previous )
Lateral compaction + thermomechanical techniques
Lateral + vertical compaction
Core + injection
Core + vertical compaction

• Your technique must suit the canal preparation technique –must suit the
instruments/materials available –materials and techniques should suit each
other.

46
• there's no technique better than the other or a material better than
another. As long as we have good disinfection, it really doesn’t matter that
much if we used any material as long as:

1) It seals the canal apically and laterally (why laterally? Because we have
dentinal tubules everywhere around the canal and bacteria may leak into
each one of them)
2) Maintains good compaction on walls
3) Doesn’t shrink
4) Resists moisture
5) Bacteriostatic
6) Sterile or can be sterilized or disinfected
7) Radiopaque (so I can see it)
8) Shouldn’t stain the tooth structure
9) Shouldn’t irritate periapical tissue if it was overextended a little bit
10) Should be easily removed so we can remove it if the treatment failed
and we want to retreat again, otherwise we’ll be extracting each tooth that
fails in treatment.
*This ideal material doesn’t exist

• As a root canal filling, we have our basics which are:

1) Core material.
2) Cement (sealer), actually it doesn’t SEAL the root canal but it’s just
a
common name to use.
• - The core material we’ll be using is, 1) Gutta Percha.
• - There are other core materials like, 2) Resilon and 3) silver points,
but they
are not used anymore (old fashion).
• - However, many cements can be used
• - The word gutta-percha comes from the plant's name in Malay,
getah perca, it
is a rigid latex that comes from the sap of specific trees.
• It is affected by heat (softened), it can bend too.
• - The composition of the cone (point) is:
Gutta percha: 19 - 22 %
Zinc oxide: 60 - 75 %

47
 Waxes and resins: 1 - 5 %
Metal sulfates: 1 - 17 %

• - The highest content in these gutta percha points is “zinc oxide” NOT
gutta percha.

• We have 2 types of points:

1) Standardized points, which come in match with the files (ISO sizes
= file
sizes), same taper (2%)
2) Non- standardized points (accessory points), which match the size
of the
spreader, spreaders can be finger spreader or hand spreader.

• Either standardized or non- standardized can be impregnated and/or

coated by the following :
1. Calcium hydroxide (Roeko): they believe it has an antibacterial
agent as an intra- canal medicament (although research
shown that it’s not true)
2. Glass ionomer (Active GP)
3. Methyl acrylate-resin
4. Bioceramics (Bio GP)

• It is believed that those coating materials can actually help the core
material in binding to the tooth structure and the cement used so the
whole thing can act as a “mono-block!” (Still not proven 100%)

• GP points aren’t sterile. We need to sterilize them or at least

disinfect them as we are trying to decrease no. of microorganisms as
much as possible. Placing these GP points in “sodium hypochlorite” –
the irrigant we are using – for like 60 seconds .

• Sometimes, expert people can place GP points while the canal is

filled with sodium hypochlorite, but this is too risky because we
might push the irrigant into the periapical tissues (out of the apical
foramen), especially if we don’t have a good apical seat (if the apical

48
 constriction isn’t tight or narrow as it should be for any reason) and
we might end up with a hypochlorite accident!!

• Now, about cements, we have lots of types such as:

✔ Resin based ( commonly used as there might be some bonds
with dentine)
◆ Zinc oxide-eugenol based ◆ Calcium hydroxide based
◆ Glass ionomer based
◆ Calcium-silicate/MTA based (bioceramics that coats bio GP,
mentioned above) ✖ Medicated cements ( Are not used
anymore bcz they contain carcinogens )

• Resin based :
- “AH plus” - 2 pastes
- “AH 26” - paste +powder

49
• Glass ionomer based sealers :

• Suggested Simple Techniques, for filling the root canal (using GP

points (core material) and AH plus (cement) :
1) Lateral Condensation: ➥ Standard technique
➥ Suits flared preparation technique perfectly
2) Obtura is used mainly for unusual cases, it is a thermoplasticised
injectable GP (paste-like form of GP) which can be loaded in a gun-
like instrument and inserted into canals, can be used in:
1) Wide canals, for young patients mostly
2) Apexification, also for young patients as they would have large
apical foramen
3) Internal resorption
4) Surgery

• **Instruments required for filling the canal:

- Spreader (hand or finger)
We need spreaders in lateral condensation technique, they come in:
- Standardized: usually in numbers so they match the file size (ISO
size)
- Non-standardized (accessory): fine-fine, medium-fine, x-fine, fine,
medium.
- Sometimes we use mixture of accessory and standardized like, GP
point 20
with the yellow spreader (fine-fine) or GP point 25 with the red
spreader (medium-fine), etc.

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 - Pluggers (Hand or Finger) For vertical condensation
- After we’re done with filling, we need to cut the GP points by an
instrument, usually “glick” is used

• Lateral condensation and filling of the root canal: (GP and AH26)

We have to prepare the canal for the filling, and we achieve this by:
1) Dry the canals ( if it wasn’t dried well recurrent caries or sodium
hypochlorite accident may occur )
2) Check the fit of the MASTER Gutta Percha cone (MAC)
3) Check the fit of the selected Spreader

After that, you’ll have to pick your master GP point or master cone.
There is a criteria that is mentioned which says:
~If the canal is small, you’ll have to choose ONE size smaller GP point
than your master apical file. (If MAF is 30 you’d pick 25 as your
master cone)~

~If the canal is medium, you’ll have to choose the same GP point size
as your master apical file. (If MAF is 30 you’d pick 30 as your master
cone)~

~If your canal is large, you’ll have to do the “heat-softened

impression” technique, by heating the tip of your GP point to make it
fit into your canal~

- You should achieve two things in order to choose your GP point:

1) Your chosen GP point must approach the complete working
length
2) Your chosen GP point must show some resistance upon removal
(tug back
action)

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 Well, 2 scenarios might show up:

First: If it reaches the working length without this slight resistance

upon removal (tug back) or simply exceeds the working length, you’ll
have to increase the size of your chosen cone. And sometimes you’ll
have to cut the tip slightly

Second: If it doesn’t reach the working length in the first place, we’ll
have to recheck our master apical file again + irrigate well, because
some debris might be packed apically. And sometimes you’ll have to
re-do apical preparation and to re- establish working length again

➢ Regarding spreaders, it is better to use small spreaders at the

apical one third of the canal and larger spreaders as we go up
to the coronal two thirds in order to avoid voids formation in
the prepared canal. (Allow well-compaction process)

How to choose our spreader?

The required spreader should reach 1-2 mm shorter than the
working length while the master cone is seated (NO MORE, NO
LESS)
Again: This criteria is so important to avoid voids formation in
the apical one third.
This indicates sufficient canal preparation, TAPER!

• Cement placement:
• cement should be placed into the canal by:
1) A hand file, or by covering the master GP point with cement and
wiping the canal’s walls with it. We have to make sure that the
master cone –which is covered by cement - has seated in its place
at the full working length (the mark on the master GP point is at
the same level of the reference point)

2) With a spiral root filler, a more effective way in cement placement

52
 Again: common mistake, master GP reaches the full working length,
everything is fine, but when we’re placing cement, master GP has to
return to its seat (full working length) because sometimes, cement
presence makes it hard for the master cone to approach full working
length again. So make sure you are not doing that. ( that’s why dr sari
told us when we r choosing the master cone we should choose it
when the CanaL is wet )

• After cement placing and master cone seating, we insert the

spreader (which is shorter than working length by 1-2 mm) in the
canal beside the master cone to compact it against the wall, no extra
pressure is used, no vertical compaction is used, just by insertion of
the spreader, we get the lateral vector (force) that we require to
push the cone against the wall so we create a space for accessory
cones to fit in.

• When we want to take out the spreader, we take it out in a twisting

movement so we don’t disturb or displace GP points that are
inserted in the
canal, the movement should be smooth and gentle.
• - Then we place accessory cones beside the master cone and after
each
insertion we have to use the spreader in order to create enough
spaces for the additional accessory cones.

• Apically :Usually we use white or yellow spreaders at first, sometimes

red spreader if the canal is wide, blue, green and black spreaders are
used mainly to compact accessory cones at the coronal two thirds of
the canal. (Accessory cones’ size should increase while going up too
or else it will take us forever to fill the canal!!)

• -If you are happy with your work, you can cut the GP points using a
Glick or any broken probe or even an excavator by performing a
scooping action

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• V.V. important note: the cutting instrument MUST be red hot while
doing the scooping action!!never cut vertically , So it doesn’t mess
everything up.

• After that, we have to clean our access cavity with alcohol, then we
do vertical condensation using any plugger or any broken instrument
and we clean with alcohol again so we make sure it is disinfected and
clean as possible

• Before removing the rubber dam, we have to place our coronal seal,
then we remove the dam and take the final radiograph.

• For special cases, we can combine lateral condensation with filling

using obtura (softened gutta percha) because it can reach the
irregularities in the anatomy which we may find in the future such as:
internal resorption, unusual anatomy etc.

• Assessment of RCF Quality

Generally reflects the overall technical standards of endodontic

treatment!
1) Length
2) Density
3) Taper
4) Level of RCF coronally
5) Adequate coronal seal (permanent or temporary)
All these have to be checked to ensure a very good root canal
treatment!

54
Radiography in endodontics

Most commonly radiograph used in endodontics: periapical

We use it to diagnose, determine WL, assess root canal anatomy, treatment and healing.

Adjunct "diagnostic" radiographs in endodontics:

Intraoral radiographs: Bitewings, Occlusal.

Extra-oral radiographs: CT scan, Panoramic, Cone beam.

Principle: beam passes through the tooth and hits the film giving different shades of grey according to
absorbance.

Remember:

X-ray source: beam (usually the tube)

Receptor or receiver: the film

Film sizes

Size 0: 22 x 35 mm

Size 1: 24 x 40 mm (for narrow arches such as lower anterior areas).

Size 2: 31 x 41 mm (PA).

Size 4: 57 X 76 mm (occlusal views).

Film orientation

Anterior: vertical. Posterior: horizontal.

The dot on the conventional film positioned away from the apical "toward the crown".

Radiography Techniques

1- Parallel technique. 2-Bisecting angle technique. 3-Modified parallel technique.

Parallel technique: film is parallel to the long axis of the tooth and
the x-ray beam will be perpendicular to the long axis of the tooth.
The resulting image is very close to reality.

Bisecting angle technique: film will be as close as possible to the

tooth, and the beam will be perpendicular to an imaginary line
(imaginary bisector) that bisecting the central axis of the tooth
and the film. The buccal root will appear a bit shortened and the
palatal root is a bit elongated.

55
Parallel technique is more accurate than bisecting technique. BUT still have approximately 10%
magnification since x-rays source comes from a point “point source” and then there will be a divergence,
leading to slight magnification. We can overcome this by using a long cone or tube, so this will
encourage the x-ray beams to be more parallel.

Modified parallel technique: increase the vertical angle

of the central beam by 15 degrees, so if I am taking a
radiograph for upper teeth, I just increase my vertical
angle by 15. If it is a lower tooth, I should go down by 15,
so move my x-rays tube more toward the apex of the
root, NOT toward the crown.

Tilting the beam towards the crown will result in elongated image.

Positioning Devices

patient fingers, Styrofoam bite block, artery forceps, Snap-A-

Ray, Snapex kit (straight for parallel and belt for modified) and
Rinn XCP Kit.

Rinn XCP is what we use in clinics and it applies parallel

technique.

Yellow for posterior teeth (molars and premolars). Blue for

anterior teeth (incisors and canines).

Most accurate to least accurate (used with parallel

technique):

Rinn XCP → Styrofoam bite block → Haemostat with bite

block → Patient’s finger (it has the greatest amount of
film bending).

Using the Rinn holder

Upper anterior teeth: we try to get a cotton roll above the bite block, it prevents the film from bending.

Lower anterior teeth: we place a cotton roll below the bite block because we have the lingual frenum.

Upper posteriors: we place a cotton roll above the bite block because I don’t want the film to bend.

Lower posteriors: we don’t use cotton rolls, tell the patient to relax his tongue and slightly close his
mouth.

Be systemic when you read radiographs, start with crown, then the root, then the apical tissue, and then
look at the horizontal bone level.

56
Tube Shift Techniques

Vertical shift, I can increase the angle or

decrease it vertically.

Horizontal shift, I can go mesial or distal.

Vertical Shift: increase the angle (move toward the apex of the root) by 15 degrees to get the modified

parallel technique (diagnostic value).

Middle pic: the two canals that are overlapped, if I take a decreased vertical angle radiograph "move
toward the crown", it will elongate the image, the buccal root will look longer than the lingual (it seems
that buccal root moves apically and the lingual root moves coronally) which has no diagnostic value (the
right image). But if I take an increased vertical angle radiograph " move toward the apex", it will shorten
the image, the lingual root will look longer than the buccal (it seems that the lingual root moves apically
and the buccal root moves coronally) which is in some cases helpful to overcome the overlapped roots.

Occlusal view is helpful in the case of root fracture or lateral luxation

Horizontal Shift: shift the tube distally or mesially, used to

differentiate the buccal root from the lingual root, recall
SLOB technique.

In straight view, the two roots will appear as one root.

When the tube head is shifted mesially, the lingual root will
be sifted mesially (in the same direction as the shifted tube
head) on the film and the buccal root will be shifted distally
(in the opposite direction as the shifted tube head) on the
film.

When the tube head is shifted distally, the lingual root will
be sifted distally (in the same direction as the shifted tube
head) on the film and the buccal root will be shifted
mesially (in the opposite direction as the shifted tube head)
on the film.

57
When the tube head is shifted mesially, the lingual root will
be shifted mesially on the film and the buccal root will be
shifted distally on the film (the MB will be more mesially
than the DB root)

When the tube head is shifted distally, the lingual root will
be shifted distally on the film and the buccal root will be
shifted mesially on the film (the DB will be more distally
than the MB root)

working length determination, cone fit radiograph

Snapex (can be used with rubber dam), Rinn (green, space for files), Endo ray film holder, Artery holding
forceps, use plastic frame (Nygaard-Ostby frame) so you don’t have to move it when taking Rx

Specific Techniques for Each Tooth (How you should direct the tube beam for each tooth)

Remember: the direction of the beam must be opposite to the way the tube head is moved.

the tube head is shifted distally (direction b in the picture)

but the x-ray beam is passing mesially through the tooth.

Remember that the shift is the same as the tube heads

direction, and the X-ray beam will pass opposite to the way
the tube head.

This is the midline of the tooth; the x-ray beam should pass
away from the midline of the tooth.

58
Upper incisors & canines:

** avoid horizontal shift around the corner of the mouth, so I can’t take a mesial shift of a canine
because of the corner, the image will have too much overlap so I can have to take a distal shift.

Upper + Lower incisors & canines:

Vertical: 15° increase Modified parallel technique to have a better view for the apical part.

Horizontal: only if a problem is suspected e.g. perforation, extra canal

Central incisors - Mesial shift

Lateral incisors and canines - Distal shift

(Remember it is more common to have a second canal in the lower anterior than the upper)

Upper & lower premolars:

Avoid making a horizontal shift around the corner of the mouth (never do a distal shift in premolars)

Vertical: 15° increase Modified parallel technique

Horizontal: Mesial shift

Lower molars: two distal canals in the distal

root

Vertical: 15° increase Modified parallel

technique

Horizontal: Mesial shift – usually Can do distal

shift if necessary

Upper molar: extra canal in MB root, zygomatic

arch interferes

Vertical: 15° increase Modified parallel technique

Sometimes also, vary vertical angle for Palatal root.

Horizontal: Distal shift - usually (for MB root).

Sometimes also, need mesial shift (for DB root).

59
 Intraoral radiography
Criteria of radiographic Quality
Every radiograph should provide optimal diagnostic quality, in case of periapical radiographs,
full length of the roots and at least 2-3 mm of periapical bone must be visible, since this is the
region where I expect to find lesions.
In the case of bitewings, margins between crowns (proximal surfaces) should
be visible without overlapping and maintaining an open contact*, and the
bite block must be parallel to the occlusal plane.
*Open contact: describes the space between adjacent teeth that you observe
without overlapping of the margins, you ensure open contact when the
beam is on right angle to the long axis of the tooth of interest.
When a full mouth series is indicated, it's not necessary to retake a failed
image as long as the missing information is available on another image.
You can see how the margins overlap horizontally in the first image due to
misdirection of the X-ray tube in the horizontal plane, while in the second
image we can notice the open contacts between crowns.

Radiographic projections

60
 Intraoral anatomy on radiographs

Nasal septum Nasal concha Nasal fossa ANS Incisive foramen

61
 white arrows: Malar
A: malar process A: maxillary tuberosity
(zygomatic) process
B: sinus septum B: coronoid process
Red arrows: lower border of
a = Floor of the
nasal fossa. C: maxillary sinus zygomatic bone C: hamular process

b = Maxillary Orange arrow: floor of sinus D: pterygoid plates

(thin and sharp)
sinus. E: zygoma (dotted lines)
c = Lateral fossa F: maxillary sinus

62
Lingual foramen Genial tubercle Mental ridge Mental fossa

(White arrow)

Red arrows:
mandibular canal

Blue arrows: mental

foramen

Green arrows:
cortical bone at the
lower border of the
Mylohyoid ridge Mandibular canal Submandibular gland fossa mandible

(internal oblique)

A: external oblique ridge

B: mylohyoid ridge

C: mandibular canal

D: submandibular gland fossa

63
 Radiographic errors and artifacts
Causes of faulty radiographs :
1- technique and projection errors
2- exposure errors
3- processing errors

Blurred image:
Double image: when an
movement of the
exposed film is re-exposed
film, patient or X-ray
tube during exposure
Metal objects superimpose the
dental image (radiopaque artifact)

Dot artifact Apices cut off: error in film

Reversed film: lines or dotes appear as a
result of directing the x-ray through the positioning
lead foil side of the film back

Crown not shown: Dropped film corner: Black line: due to Distortion: bending of
error in film positioning the film edge is not excessive bending of the the film to eliminate
placed parallel to the film prior to placement patient’s discomfort
occlusal plane in the patient’s mouth

64
 Elongated image: due to insufficient Overlapping: due to incorrect
Shortened image: due to excessive horizontal angulation
vertical angulation (too flat)
vertical angulation (too steep) (improper alignment)

Blank image: the film didn’t Low density image

Cone-cut
receive radiation at all
High density image

Reticulation: when the film is Black spot or patch: White spot or patch :
subjected to sudden developer contamination contamination with fixer Scratched film due to
temperature changes between improper handling
the developer and water

Developer cut off Fixer cut off Smudge (finger print)

Cervical burnout: over penetration
of thinner cervical areas produces
radiolucency, this happen due to
the invagination of the proximal
surface of the root
65