JOURNAL OF DENTAL SCIENCES

Volume 2 Issue 2

WONDERFUL WORLD OF ENDODONTIC WORKING WIDTH THE FORGOTTEN DIMENSION A REVIEW

Dr. Shashin J. Shah M.D.S., F.R.S.H. Dr. Jayshree S. Shah M.S. Abstract: Working width- if you are familiar with this term It was first used by Dr.Jou from the University of Pennsylvania. He emphasized on this as a valuable reminder that canals are three dimensional. This means that all instrumentation techniques have to contend with both a working length and a working width. Incidentally, this area of the canal (coronal to the apical constriction) was called, and with good reason, The Forgotten Dimension by Carl Hawrish, an endodontist from Canada. Techniques for cleaning and shaping root canals differ in accordance with clinical observations, research discoveries and traditionally accepted values. Our goal should be to avoid both under and over preparation of the canal. Achieving this doesnt seem to be a mystery anymore. Anatomical research tells us that canals come in many different diameters, from narrow to wide and from straight to extremely curved. Key words: WW [Working Width], WL [Working Length], IWW [Initial Working Width], FWW [Final Working Width], Instrumentation, Major Diameter, Minor Daimeter. Introduction : Root canal morphology is a critically important part of conventional and surgical endodontics. Many in vitro studies1,2,3,4,5 have recorded the scales and average sizes of root canals, but there have been few clinical attempts to determine the working width [WW] . The initial and post instrumentation horizontal dimensions of the root canal system at WL and other levels The horizontal dimension of the root canal system is not only more complicated than the vertical dimension (root canal length or working length) but also more difficult to investigate because the horizontal dimension( root canal width or working width)varies greatly at each vertical level of the canal. It goes without saying that as professionals we should strive for the highest possible success rate of root canal therapy. Successful cases should be fully functional and painfree. Similarly, how much time should elapse, until you can consider a root canal treatment successful? Three years6 is a common figure. Inadequate and even very poorly done root canal treatment often last at least that long or even longer- thanks to an efficient host immune system. It is known that most true endodontic failures are caused by:[1] Inadequate pulpal space cleaning, [2] Inadequate disinfection,both are simultaneously interrelated.In dental schools we are taught that cleaning and sealing the root canals especially in the apical third, is the most critical part of the procedure. This basic concept has not changed. Anatomical criteria also plays an important role as root canals are curved in one or more directions. Shape also varies from oval, round, cylindrical, rhomboidal, double Reader Department of Conservative Dentistry and Endodontics Faculty of Dental Science, Dharamsinh Desai University. Nadiad - 387 001. Gujarat, India Lecturer Dept of Physiology, Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387001. Gujarat, India pear shaped etc. Review of literature : A clinicians primary concern is to thoroughly cleanse the root canal system during root canal therapy, mechanically and chemically removing microorganisms and their substrates from the canal. Without proper chemo mechanical instrumentation, the remaining irritants may reduce the success rate and cause failure of the treatment. In addition, canal surface irregularities require proper instrumentation for adequate root canal filling. Many textbooks and much literature focus on canal instrumentation in terms of filing, reaming, or other instrument motions and usage and always stress the importance of enlarging the canal size. Without solid scientific evidence, however, it is still not clear how large is large enough. There is widespread agreement among endodontists that cleaning & shaping of the root canal is the most important phase in endodontic therapy7,8 .The aim of endodontic treatment is chemomechanical cleaning of the root canal and its obturation hermatically with an inert material. Ingle et al9 have suggested that apical percolation is the main cause of endodontic failure. The main reasons for this failures are incomplete canal obturation or the presence of an untreated canal, for successful endodontic therapy the dentist should be aware of the variations in the root canal morphology. Many investigators have worked on the tooth morphology, topography, curvature, ramifications of the main root canal, diameters, localization and no. of foramina, and apical deltas by using different methods10,11 .Since there are differences in

Address for Correspondence: Dr. Shashin J. Shah M.D.S., F.R.S.H. Faculty of Dental Science, Dharmsinh Desai University. College Road, Nadiad - 387001. Gujarat, India Phone : +91 079 27471883, 27551624, +91 268 2527077 Mobile : +91 98252 50405 Email : smartyrushabh@gmail.com 20

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selection of material, methods used, and classification of canal configurations different opinions have arisen about root canal morphology12,13. Many studies have also demonstrated that widely accepted endodontic cleaning and shaping techniques are inadequate. Haga1 found that mechanical preparation of root canal to two sizes larger than original was still not adequate. Gutierrez and Garcia14 showed that often, canals are improperly cleaned. They attributed this inadequate instrumentation to the fact that root canal diameter is larger than the instrument caliber used in each particular case. This finding suggests that each canal should be calibrated independently before instrumentation so that proper preparation can be achieved. Waltons15 histologic study showed that canals that were instrumented to three sizes larger still were not thoroughly cleaned. Recent in- vitro investigations16 concluded that stainless steel and nickel-titanium [NiTi] rotary instruments were not able to clean the root canals satisfactorily. In the absence of a study that defines what the original width and optimally prepared horizontal dimensions of canals are, clinicians are making treatment decisions without any support of scientific evidence. It is difficult to section all levels of the teeth and make the section plane exactly perpendicular to the canal curvature. Therefore, most morphometric studies cannot show the true picture of the horizontal dimensions of the root canal system. Until recently, most investigations have involved counting the number of canals and foramina and categorizing how the canals join or split. Current studies pay more attention to the shape of the canal systems and its clinical implications than to the actual preoperative size of the canal 17,18,19. Routine clinical radiographs may mislead clinicians to make a different plan to clean the root canal system. Unfortunately, this area of critical importance hasnt been investigated thoroughly. Some clinicians may still have the impression that all root canals are round in shape because of radiographs.If we see radiograph in Illus.1 & 2 the actual difference of dimensions of root canal area (Diameter) mesio distally and facio lingually is noticeable. Recent studies18 reported a high prevalence of oval root canals in human teeth. Crosssections of 90% of the mesiobuccal canals of maxillary first molars were found to be oval or flat. This article provides definitions and perspectives on the current concepts and techniques to handle WW (the horizontal dimension of the root canal system) and its clinical implications.

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Illustration 2. The faciolingual direction of the routine radiograph gives an impression of roundshaped canal in a mandibular first premolar. The mesiodistally directed radiograph indicates a flattened root canal in the same tooth. (TAKEN FROM JOU Y T- DENT CLIN NORTH AM ) Determination of the minimal and maximal final working width at working length: To what extent the canal is supposed to be prepared has been a myth in the endodontic field. Grossman20 described the rules governing biomechanical instrumentation in his textbook Endodontic Practice. Two guidelines were considered sufficient for instrumentation: [1] Enlarge a root canal at least three sizes beyond the size of the first instrument that binds; [2] Enlarge the canal until clean, white dentinal shavings appear in the flutes of the instrument blade. Root canals should be enlarged, regardless of initial width, to remove irregularities of dentin and to make the walls of the canal smooth and tapered. Root canals should be widened for four reasons: [1] To remove microorganisms on the canal surface mechanically. [2] To remove pulp tissue ,because even when a vital pulp is extirpated, tags of pulp tissue and odontoblasts cling to the canal wall and are not removed with the body of the pulp; they later undergo necrosis and provide an environment for bacterial growth. [3] To increase the capacity of the root canal, to permit irrigating solutions to reach the apical third of the root canal for effective debridement. [4] To shape the root canal to receive gutta-percha, because the wider the canal, the easier it is to fill it. Definition of working width Working width21 is defined as: The initial and post instrumentation horizontal dimensions of the root canal system at WL and other levels. Minimum initial working width (Min IWW) corresponds to the initial apical file size that binds at the WL. The maximum final working width (Max FWW) corresponds to master apical file size that is generally three ISO sizes larger than the Min IWW. 21
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Illustration 1 The mesiodistally directed radiograph indicates a flattened distal root canal in a mandibular first molar. In the same tooth, the faciolingual direction of the routine radiograph gives an impression of a round-shaped distal canal. (TAKEN FROM JOU Y T- DENT CLIN NORTH AM22)

JOURNAL OF DENTAL SCIENCES

Working Width

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MinlWW

MaxFWW

The factors affecting the determination of Min IWW are: Canal shape Canal length Canal taper Canal curvature Canal contents Canal wall irregularity Type of instruments used to determine the initial WL In a round canal, it is easy to determine the working width, but in canals that are oval, long oval, flattened ribbon like or irregular, discrepancy arises leading to incomplete cleaning and produces a key hole or adumb bell preparation of the root canal.

Illustration 3. Cross-section of a Mandibular first premolar, indicating a long-oval and irregular rootcanal. In the same tooth, the faciolingual direction of the routine radiograph may be mistakenly recognized as a round-shaped canal because a mesiodistally directed radiograph is rarely available clinically. (TAKEN FROM JOU Y T- DENT CLIN NORTH AM ) Current descriptions of the horizontal dimensions (crosssections) of the root canal. 1. Round (circular) : MaxIWW equals MinIWW 2. Oval : MaxIWW is greater than MinIWW (upto two times more) 3. Long Oval : MaxIWW is two or more times greater than MinIWW (upto four times more) 4. Flattened (flat, ribbon) : MaxIWW is four or more times greater than MinIWW. 5. Irregular : cannot be defined by 1-4. (TAKEN FROM JOU Y T- DENT CLIN NORTH AM22) Significance of working width21 To obtain an apical stop which is as round as possible so as to get an impermeable seal So that the dentinal tubules at the apical 1 mm is devoid
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of any micro organism. Apical preparation width with large working width removes more bacteria than small apical preparation. It also permits irrigation solutions to be placed closer to WL with easier exchange of irrigants. The initial and post instrumentation horizontal dimensions of the root canal system at working length and other levels are different at different levels in a relatively round canal, the lesser and the greater initial horizontal dimensions are approximately the same. In an oval, long oval or flat canal (as shown in Box), the maximal initial horizontal dimension (MaxIWW) may be several times larger than the minimal initial dimension (MinIWW) at different levels of the canal. For example, in a maxillary cuspid22, MinIWW at working length (MinIWW0) may be the same as MaXIWW at working length (MaxIWW0). But 12 mm short of working length, its MaxIWW12 is probably three to four times larger than MinIWW12. This is because at that level, the cross section of a cuspid very often is a long oval or flat canal shape. Determination of initial working width at working length (initial apical file determination estimation of initial canal diameter) In the course of cleaning and shaping the root canal system, the clinician must determine three critical parameters. These are the length of the canal, the taper of preparation, and the horizontal dimension of the preparation at its most apical extent, also referred to as the initial apical file size. Factors affecting the determination of minimal initial working width at working length Several factors may affect the accuracy of determining the MinIWW0. The canal shape, length, taper, curvature, content, and wall irregularities and the instrument used may all influence the result because each can affect the clinicians tactile sense. The combination of those factors makes correct determination of IWW very difficult, if not impossible. Understanding these factors can minimize the underestimation of the IWW. Canal shape The variation of canal shape as stated earlier, the round canal can be measured more easily because the MinIWW and MaxIWW are the same. Other factors, however, make determination of IWW difficult, even in straight canals. The proper instrument and tactile sensation may determine the MinIWW of the oval, long oval, and flat canals. The determination of MaxIWW, however, cannot easily be realized with current methods. One of the most common method to evaluate canal shape is sectioning of the root. Cross sections at different level in a root allows direct viewing of canal shape & position relative to the borders of the root surface23,24 Canal length When using an instrument to gauge working length, the longer the canal, the greater the frictional resistance. In a very long canal (>25 mm), the frictional resistance may increase to affect the clinicians tactile sense for determining the IWW correctly. In addition, if the coronal flare is too conservative or limited to the coronal third of the canal, then the shaft of the 22

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instrument may engage the canal wall and cause a false/premature conclusion as to WW. Canal taper Any tapering discrepancy between the gauging instrument and canal may lead to an early instrument engagement of the canal wall, causing a false sensation of apical binding. Early coronal flare can increase the taper of the canal and reduce the tapering discrepancy between the gauging instrument and canal wall. The last 3 to 5 mm of the canal can have parallel walls, making correct determination of IWW difficult. Canal curvature Curved canals can cause deflection of the gauging instrument and increase the frictional resistance. The curvature of the root canal can be categorized into twodimensional, three-dimensional, small radius, large radius, and double curvature (S-shaped, bayonet-shaped) and with different degrees of severity. Each of these curvatures has a different effect on a clinicians tactile sense. The combination of these curvatures makes correct determination of IWW extremely difficult, if not impossible. In curved mandibular premolars, the study by Wu et al25 indicated that the first K file and the first Light speed instrument that bound at the working length failed to accurately reflect the diameter of the apical canal. Careful canal Preparation is an important part of Successful root canal therapy. The ability to enlarge a canal without deviation from the original canal curvature is a primary objective in endodontic instrumentation9,26,27. It has been stated that The final Preparation should be an exact replica of the original canal Configuration in shape, taper and flow, only larger28. After studying the effects of several instrumentation techniques, Weince et al26 noted that every file,whether precurved or straight , tended to straighten within the canal. They reported that the largest amount of apical canal preparation occurred at the outer portion of the curvature, away from the furcation. An attempt to solve this problems has led to the development of various instrumentation technique like step back, crown down, balanced force, anti curvature filling etc in addition several instruments like k flex, flex arc, flex-o, protaper, race files, light speed, hero shaper-hands and rotary files have been designed. This instruments aim at alleviating procedural difficulties at coronal, middle, apical regions of root canal. The Schneider method is the primary technique used to measure canal angulation28 . Canal content The content of the root canal may be fibrous in nature. Calcified material (calcific metamorphosis) may also be part of the canal content. During determination of IWW, the mixed canal contents can create different degrees of frictional resistance against the gauging instrument. It can eventually affect the clinicians tactile sense. This factor makes correct determination of IWW somewhat more difficult. Canal wall irregularities Attached pulp stones, denticles, and reparative dentin canal create convexities on the canal wall surface. Resorption can produce concavities on the canal wall surface. These phenomena can serve as an impacting factor that induces a

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false estimation of the true canal dimension at working length and other levels.

(TAKEN FROM JOU Y T- DENT CLIN NORTH AM ) Instrument for determining initial working width The rigidity, flexibility, and tapering of the instrument used for determining IWW can affect accuracy. As mentioned previously, any tapering discrepancy between the gauging instrument and canal may lead to an early instrument engagement of the canal wall, altering the tactile sensation. In addition, the rigid instrument in a curved canal also can lead to a false tactility. During IWW determination, the combination of those affecting factors can have a great impact on the accuracy. Understanding these factors can minimize the underestimation of the IWW and maximize its accuracy. Eliminating or minimizing the influence of affecting factors: Being aware of the existence of the affecting factors in IWW determination is the primary step in maximizing the accuracy of the technique. Without knowing these factors, clinicians can repeatedly make the same mistakes in underestimating IWW, which will lead to incomplete cleaning and shaping of the root canal system as shown in Illustration 4-6. (TAKEN FROM JOU Y T- DENT CLIN NORTH AM22)

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Illustration 5. A cross-section of prepared and filled canals indicates an incomplete instrumentation and may result in a failed root canal treatment. The dumbbell effects are typical pictures that demonstrate the unprepared parts of the root canal. This misadventure can come from underestimation of the IWW and the lack of understanding of endodontic WWconcepts 23

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Illustration 6 A cross-section of incompletely prepared and filled canals demonstrates the complicated situation of endodontic WW. Understanding the concepts and the techniques of endodontic WW can minimize misadventures of incomplete instrumentation & a failed root canal treatment. Before the IWW determination, it is suggested to widen the orifices, to do early coronal flaring and additional canal flaring (crown down, double flaring ) to ensure effective irrigation, and minimize any interferences with tactile sensation. Carefully selecting the adequate instrument of maximal flexibility and minimal taper such as Light Speed may avoid interference and help to achieve better results. Ideally, root canal preparation should follow the exact outline of the horizontal dimensions of the root canal at every level of the canal. In this ideal condition, especially for long oval and flattened root canals, they can be cleaned and shaped properly with minimal mishaps of weakening, stripping, or perforating the canal walls as shown in Illustration 4D. Circumferential preparation or instrumentation may have to be considered for these cases to minimize incomplete cleaning of the root canal system. Most of the NiTi rotary instruments provide a continuous reaming action that makes the canal relatively circular in shape. Indiscriminate use of NiTi rotary instruments alone for root canal cleaning and shaping may result in incomplete cleaning of the root canal system and lead to failure of the endodontic therapy. Recent studies 3 0 , 1 6 , 3 1 , 3 2 , 3 3 have indicated that no current instrumentation technique was able to completely clean dentin walls of the oval, long oval and flattened root canals. The manual crown down instrumentation technique, however, was more efficient and effective in cleaning root canals than rotary instrumentation. Canal anatomy Computer tomography has made visualizing canal systems a much simpler task. Weve learned that nearly every canal is curved. What may appear as a straight canal in a twodimensional X-ray almost always has some degree of curvature in an unseen plane. Illusration 7: Anatomical variations in canals of posterior teeth33

Illustration 86 Dental CT , called dentascan is dedicated post processing and image evaluation software for the teeth and the jaw which creates panoramic and paraxial views of maxilla and mandible. Dentascan can play in assessment of variation of root canal morphology and thus helpful in prediction the prognosis of a complex case. CT or dentascan are primarily utilized for pre-evaluation of implant sites, buccolingual extend of cysts, tumors, periapical lesions34,35,36.Furthermore, the cross-sectional shape of most canals is not round but oval (mimicking the oval shape of most roots). Lastly, few canals have a constant taper; instead, they exhibit nearly parallel walls in multiple segments throughout the length of the canal. Most canals are curved in one or more directions. The more severe a curve, the more difficult the treatment. Most canals are oval in cross-section6. Oval canals have two diameters, a minor (smaller) and a major (larger) diameter.The quality of cleaning is dependent on instrumenting to the larger diameter; its Working Width Working Width (WW) is best understood by studying cross-sections of apical canals. If the greater diameter of the original canal is measured, the correct WW is an instrument size slightly larger than that dimension. The apical constriction is the narrowest point of the canal with an average diameter of just under 0.50mm.Howeverand this is importantjust coronal to the apical constriction canal diameters increase significantly; ranging from 0.55 to 1.00 mm and higher2,3,4. Maxillary Apical Sizes(Working Widths)
Compendium Light Speed 1991 1997 OOO 200 J Endodon 1997

Central & Lateral Canine Premolar Molar MB DB P JOE 10/99

80 80 45-80 45 45 60 MB:40-65

60-70 60 50-60 45 40 50 DB:40-55

50-60 60 40-65 35-50 35 40 P-55-80

60-90 50-70 35-90 35-60 40-60 80-100

TAKEN FROM ENDO TRIBUNE-MARCH 2008 E STEVE SENIA (6)

MandibularApicalSizes(Working Widths)
Compendium Light Speed 1991 1997 OOO 200 J Endodon 1997

Incisors Canine Premolar Molar MB ML D

60 80 45-80 45 40 50

60 55 55 45 35 50

55 45 40 35-50 40-60 50-80

45-70 50-70 50-70 35-60

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Discussion: Proper access cavity preparation and obturation form the keystone for successful root canal therapy.nearly 60% of the failures are apparently caused by incomplete obliteration of the radicular space.Root canal variation predispose to inadequate root canal preparation and should be recongnized before or during treatment34. Studies have suggested that root canals have not been thoroughly cleaned even after being enlarged three sizes greater than their original diameters. The enlarging of root canals is one of the most challenging & decisive steps during endodontic therapy37. Weine et al26 described the problems concerning the preparation of curved root canals. Undesirable shaping effects such as zips and elbows can readily occur when appropriate shaping precautions are not taken. Several authors38-45 have reported on the effects produced by different enlarging techniques & /or instruments .Ideally the root canal path should be followed during root canal preparations without substantial deviation from its originally position26,46,7 The concepts and techniques of WW may play an important role in this finding. Any investigation of the effectiveness of cleaning the root canal system without carefully estimating the MinIWW and MaxIWW in the oval, long oval, and flattened root canals may result in misleading data, especially if the horizontal canal morphology was not carefully assessed. In an oval, long oval or flat canal, circumferential instrumentation seems to be the only reasonable way to properly clean and shape the canal. Especially in the infected canals, the infected dentin has to be removed to ensure a successful treatment. Ideally, during root canal preparation, the instruments and techniques used should always confirm to and retain the original shape of the canal to maximize the cleaning effectiveness and minimize unnecessary weakening of tooth structure to achieve the optimal result. It is very challenging to aggressively clean and shape the infected canal without weakening the tooth structure. Clinically, the heavily infected cervical part of the canal has often been enlarged with Gates-Glidden burs or canal wideners to a round shape instead of following the original oval, long oval or flat shape. Although the strength of the tooth structure is evidently reduced47, the FWW in the cervical area has been determined by the clinicians preference instead of scientific evidence.1,2,3,4,13,14,19 Literature reveals a periodic renewal of interest in the root canal morphology of teeth in order to learn more about them or to search for different ways in which to improve endodontic techniques and, ultimately success48,49 . CONCLUSION Most of the research21 for the root canal instrumentation has not addressed the importance of the horizontal dimensions or WW of the root canal system. In preparing, the long oval or flat canals, the WW concept plays a more critical role that alerts the operator to the possibilities of incomplete root canal preparation. There has been minimal development of concepts, techniques, and technology to measure IWW and to determine FWW accurately or properly. Understanding the current concepts and techniques of WW can help to solidify the concepts & improve techniques of cleaning and shaping of the root canal system. Carefully maintaining the aseptic

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chain, using adequate irrigating solutions to enhance efficacy and cautiously applying current concepts and techniques of WW may provide a better quality of endodontic therapy for the patient. In vitro studies found that manual circumferential filing had statistically significant better effectiveness than rotary instrumentation for cleaning flattened root canals15. The concepts of the WW indicate that different approaches and techniques are needed to improve root canal preparation and promote better quality of root canal treatment. Since we cannot see deep into curved canals, we rely on an instruments tactile feedback to give us clues about canal anatomy.Canal statistics are handy, but because canals differ widely we are working blindly without feedback. Lets stop thinking canals are basically the same size and shape , because they are not. The solution is to stop guessing and begin using instruments that provide accurate feedback . We should customize every one of our canal preparations. As Spanberg50 so aptly stated, treating canals similarly is like forcing everyone to wear the same size shoe- one size doesnt fit all! Respect the canal morphology diameter variability as the fingerprint of a person, which is never similar. Reference: 1) Haga CS. Microscopic measurements of root canal preparations following instrumentation. J Br Endod Soc 1968;2:41. 2) Kerekes K, Tronstad L. Morphometric observations on the root canals of human molar. J Endodon 1977;3(3):114-8. 3) Kerekes K, Tronstad L. Morphometric observations on the root canals of human pre molar. J Endodon 1977;3(2):74-9. 4) Kerekes K, Tronstad L. Morphometric observations on the root canals of human anterior teeth. J Endodon 1977;3(1):24-9. 5) Kuttler Y. Microscopic investigation of root apexes . J AM Dent Assoc 1955;50:544-52. 6) E.Steve Senia Instrumentation . Endo Tribune 2008 (March); Page 8,10,11. 7) Schilder H. Cleaning and shaping the root canal. Dent Clin North Am 1974 ;18:269-96. 8) weine f. endodontic therapy. in weine f,ed. endodontic therapy 3rd ed. st louis :cv mosby, 1982:256-340. 9) Ingle ji, Beveridge ee, glick DH, weichman, about-rass m. modern endodontic therapy .in: ingle ji, taintor fj.eds.endodontics .3rd Philadelphia, lea& febiger, 1900:36-7 9) Ingle. Endodontics .3rd edition. Philadelphia,PA; Lea and Febiger, 1985 37-8. 10) P i n e d a f , k u t t l e r y. m e r i o d i s t a l & b u u o l i n g a d l roentgenographic investigation of 7,275 root canals oral surg 1972,33,:101-10 11) Baisden MK , Kulid JC, Weller RN. Root canal configuration of the Mandibular first premolar. JEndodon 1992;18:505-8 12) Green D.Double canals in single roots. Oral surgery 25

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1973,35,689-96. 13) Vertucci fj. Root canal anatomy of the human permanent teeth oral surg 1984,58:589-99 14) Gutierrez JH, Garcia J. Microscopic and macroscopic investigation on results of mechanical preparation of root canals. Oralsurg 1968;25:108-16. 15) Walton RE. Histological evaluation of different methods of enlarging pulp canal space. J Endodon 1976;2:30411 16) Barbizam JVB , Fariniuk LF, Marchesan MA, Pecora JD, Sousa-Neto MD. Effectiveness of manual and rotary instrumentation techniques for cleaning flattened root canals. J Endodon 2002;28(5);365-6. 17) Gani O, Visvician C. Apical canal diameters in the first molar at various ages. J Endodon 1999;25(10):689-91. 18) Mauger MJ, SchindlerWG, Walker WA. An evaluation of root canal morphology at different levels of root resection in mandibular incisors. J Endodon 1998;24(10):607-9. 19) Wu MK, Barkis D, Roris A. Wesselink PR. Prevalence and extent of long oval canals in the apical third. Oral surg 2000;89(6):739-43. 20) Grossman L. Endodntic practice.11 t h edition. Philadelphia: Oliet and Delrio ;1988 page 203 21) Jayshree Hegde, Endodontics, Prep Manual for Undergraduates ; pages 111 and 112. 22) Jou YT , Karabucak B, Levin J et al. Endodontic working width :current concepts and techniques. Dent Clin North Am 2004 ;48:323-35. 23) pedicord d,eideeb m,messer h,hand vs. endodontic instrumentation effect on canal shape & instrument time. J endodontic 1986,12:375-81 24) lesserbeg d ,Montgomery s. the effects of canal master ,flex-r&k-=fles instrumentation on roof canal morphology j endodon 1991,17:59-65 25) Wu MK , Barkis D, Roris A, Wesselink PR. Does the first file to bind correspond to the diameter of the canal in the apical region ? Int Endodon J 2002;35(3):264-6. 26) Weine Fs, keliy RF,Li ops. The effect of preparation procedures on original canal shape and on apical foramen shape. Jendodon 1975, 1,255-62 27) Cohen s, Burns R. pathways of the pulp. Hthed.st.Louis ,Mo,cvmosby, 1987,162 28) schneider s .a comparison of canal preparation in straight & curved root canals .oral surg1971,32:271-7 29) Tan BT , Messer HH . The quality of apical canal preparation using hand and rotary instruments with specific criteria for enlargement based on initial file size. 30) Liu DT, Jou YT. A technique estimating apical constricture with K- files and NT Lightspeed rotary instruments .J Endodon 1999;25(4):294 31) Weiger R, Lost C. Efficiency of hand and rotary instruments in shaping oval root canals. J Endodon 2002;28(8):580-3. 32) Wu MK ,Wesselink PR . A primary observation on the preparation and obturation of oval canals. Int Endodon J 2001;34:137-41

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33) Textbook of Endodontics, edited by Dr. Anil Kohli Ch25:pg 380 1st edition-2010. 34) Jayprakash patil.shushma jagu,prashant p jagu.Dental C Ta s di a g nosti c a i d i n a ca se of mul ti p l e extracanals.endodontology p:84:89 vol.23.issue 1.june 2011 35) schworz ms,rotherman sl,Rhodes ml chafetz n.compulated tomography.Preoperative assessment of the mandible for endoosseous implant surgery Int j oral maxillo implants1987 2:137_141. 36) james j abrehamas:dental CT imagind,a look at the jaw radiology,2001.219_334_345 37) Ingle JI Endodontic instruments & instrumentation. Dent clin North America 1957,1:805-22. 38) Wildey WL,senia ES. A new root canal instrument and and instrumentation technique :a preliminary report .Oral Surg 1989;67:198-207. 39) Briseno BM,Sonnabend E.The influence of different root canal instruments on root canal preparation, an in vitro study, Int Endod J 1991,24,15-23 40) Briseno MB ,Kremers l, Hamm G, Nitsch C. Comparison by means of a computer-controlled device of the enlarging characteristics of two different instruments. J Endodon 1993,19:281-7 41) Giles JA , del Rio CE . A comparison of the Canal Master endodontic instrument and K-type files for enlargement of curved canals . J Endodon1990;16:561-5. 42) Leseberg DA , Montgomery S . The effects of Canal Master , Flex-R and K Flexinstrumentation on root canal configuration.J Endodon 1991;17:59-65. 43) Powell SE , Wong PD , Simon JHS. A comparison of the effect of modified and nonmodified instrument tips on apical canal configuration. Part 2 , J Endodon 1988;14:224-8. 44) Roane JB, Sabala CL , Duncanson MG. The balanced force concept for instrumentation of curved canals .J Endodon 1985;11:203-11 45) Sepic AO ,Pantera EA Jr,Neaverth EJ , Anderson RW. A comparison of Flex-R files and K-type files for enlargement of severely curved molar root canals . J Endodon 1989;15:240-5 46) Mullaney TP . Instrumentation of finely curved canals . Dent Clin North Am 1979 ;23:575-92. 47) Carter JM , Sorenson SE, Johnson RL, Teitelbaum RL, Levine MS.Punch shear testing of extracted vital and endodontically treated teeth. J Biomech 1983;16:841-8. 48) Skidmore AE,Bjorndal AM . Root canal morphology of the human Mandibular first molar. Oral Surg 1971;32:778-84. 49) Kassahara E, Yasuda E, Yamamoto A, Anzai M. Root canal system of the maxillary central incisor.J Endodon 1990 ;16:158-61. 50) Spangberg L .The wornderful world of rotary canal preparation.Oral Surg Oral Med Oral Patho Oral Radio Endodon 1977;92:479.

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