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fall09ecfe

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Published by -Okta 'dyaN' Onta-

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06/21/2014

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Colleagues
 for 
 
 Excellence
Published for the Dental Professional Community by the
 American Association of Endodontists 
Fall 2009
Obturation of Root Canal Systems
Endodontics
Cover artwork: Rusty Jones, MediVisuals, Inc.
 
he purpose o the obturation phase o endodontic treatment is to prevent the reinection o root canals that have beenbiomechanically cleaned, shaped and disinected by instrumentation, irrigation and medication procedures. Successulobturation requires the use o materials and techniques capable o densely lling the entire root canal system and providinga fuid tight seal rom the apical segment o the canal to the cavo-surace margin in order to prevent reinection. This alsoimplies that an adequate coronal lling or restoration be placed to prevent oral bacterial microleakage. It has been shownthat endodontic treatment success is dependent both on the quality o the obturation and the nal restoration.
1
The qualityo the endodontic obturation is usually evaluated using radiographic images upon completion. Additionally, during the rootcanal preparation and obturation phases o treatment, clinical criteria can be identied that are essential or achieving anadequate root canal obturation.
2,3,4,5
It’s All About Cleaning, Shaping andDisinection o Root Canal Systems
Prior to the obturation phase, the clinician must establish the propershape and size o the root canal. Figure 1 is an example o a retreatmentcase; it demonstrates the importance o locating all canals then cleaning,shaping and sealing them to the proper working length. Proper canalpreparation provides an apical resistance orm or the adequate adapta-tion o lling materials and the prevention o excessive apical extrusiono these materials. Remember, what is removed rom the root canal dur-ing cleaning, shaping and disinection is more important than what isplaced during obturation. Biomechanical preparation and disinectionare achieved through mechanical instrumentation and copious irrigation to remove bacterial and tissue debris, and by shap-ing the root canal space to allow or a three-dimensional obturation and seal o the root canal system. The importance o maintaining the original shape o a root canal during and ater cleaning and shaping in order to promote periapical healingin endodontic cases has been demonstrated in several studies.
6,7,8
The clinician’s inability to maintain the original shape andto develop the proper taper o canals can result in procedural errors such as ledges and perorations.When preparing root canals or obturation theclinician must maintain the working length duringthe instrumentation phase o treatment. Figure 2shows original, working length and nal obtura-tion image with post and core in place. Maintainingworking length is essential or preparing and seal-ing the root canal to its proper apical extent. It isalso necessary to create an apical resistance ormto obtain adequate compaction o the lling mate-rials and also to prevent excessive overextension o materials into the periapical tissues. Today’s clinicians have a numbero methods, materials and technologically advanced instruments at their disposal to achieve these goals. Examples o theseare electronic apex locators, nickel-titanium rotary instruments, various irrigation systems, newly ormulated sealers, andmicroscopic magnication and illumination.Poor obturation quality as judged by radiographs has been associated with nonhealing in 65% o retreatment cases.
9
 Theradiographic appearance o a completed case should show the obturation material: (1) at the apical terminus without exces-sive material overextending into periapical tissues; (2) completely lling the root canal system in three dimensions; and (3)appearing as a dense radiopaque lling o the root canal system.
4
Obturation errors oten are a result o inadequate cleaningand shaping (ledges, perorations, inaccurate working lengths, and underprepared or overprepared canals). I inadequateobturation is not a result o an instrumentation error, the clinician should recognize this reversible procedural error on theobturation check lm. The obturation material should then be removed and the canal re-obturated prior to restoration. I the procedural error is gross overextension o material into the periapical tissues, removal by conventional means may notbe possible and periapical surgery may be necessary.Many good techniques are available to the clinician or the instrumentation phase o root canal treatment. Smooth, clean,and properly shaped and sized canals will allow or ecient removal o debris with instruments and irrigants, and insertion
Endodontics:
 
Colleagues
 for 
 
 Excellence
T
Fig. 2a.5 November 2007:Original Image2b.10 March 2009: WorkingLength Image2c.3 April 2009: Post and CoreImageFig. 1.Retreatment case demonstrating the importance of locating allcanals then cleaning, shaping and sealing them to the proper workinglength.
 
o sealers and placement o root lling material. I a clinician is having diculty with the obturation phase o endodon-tic therapy, their cleaning and shaping technique should be reevaluated prior to consideration o changing obturationtechniques.
Why Obturate Canals?
Microorganisms and their byproducts are the major cause o pulpal and periapical disease.
11
However, it is dicult toconsistently and totally disinect root canal systems.
10
Thereore, the goal o three-dimensional obturation is to providean impermeable fuid tight seal within the entire root canal system, to prevent oral and apical microleakage.
12
Preparation o Dentin Surace (Irrigation)
The purpose o endodontic irrigation is to remove debris created during instrumentation, and to dissolve and/or fushout inorganic and organic remnants o the pulp system, bacteria and bacterial byproducts that are not removed bymechanical instrumentation. With the introduction o obturation materials designed to bond with dentin, irrigationsolutions must be used with consideration o the condition o the dentin surace that is most suitable or bonding. Fig-ure 3 shows the dentin surace beore and ater preparation or bonding. Attempts to eliminate pulp space inectionwith instrumentation only, without the use o antimicrobial agents, have proven to be unsuccessul.
13
Modern root canaltreatment requires the use o both mechanical and chemical preparation and disinection o the canal system.During cleaning and shaping procedures, a supercial amorphous layer o tissue remnants, organic and inorganicmaterials, and bacteria and their byproducts accumulate on the canal walls. This “smear layer” may interere or preventadhesion o sealers to the canal wall and serve as a substrate or bacterial growth. Evidence tends to support removingthe smear layer prior to obturation.
32
This removal supports reduction o potential irritants and permits better adapta-tion o sealer to the canal walls. Removal o the smear layer is easily accomplished by irrigating the canal with 17%disodium EDTA or one minute, ollowed by a nal rinse o sodium hypochlorite. Chelators remove the inorganiccomponents and sodium hypochlorite is necessary or removal o the remaining organic components.Adequate irrigation o root canals requires an eective irrigantas well as an ecient delivery system. The characteristics o an ide-al irrigant and irrigation system are listed in Table I.
14
The irrigatingsystem should be one that does not allow the irrigant to extrudebeyond the apical oramen into the periapical tissues.
Endodontics:
 
Colleagues
 for 
 
 Excellence
Continued on p. 4
Fig. 3a.Dentin surface before andFig. 3b.after preparation for bonding.
Table II list actors that can infuence the ecacy o irrigatingroot canal systems.
15
Table I: Characteristics o anIdeal Irrigation System
Physical fushing o debrisBiocompatibleBactericidal agentSustained eect
Disinfect and detoxify dentin and tubules of all microbial substances
Tissue solventLubricantSmear layer removalNot aect physical properties odentin
Table II: Factors Inuencing Efcacy o Irrigation
Diameter o the irrigating needleDepth o the irrigating needle engaged in root canalSize o enlarged root canal (radius o tube)Viscosity o the irrigating solution (surace tension)Velocity o the irrigating solution at the tip o the needle(ultrasonics, sonics)Orientation o the bevel o the needleTemperature

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