Chapter 16

Cleaning and Shaping

William T. Johnson D.D.S., M.S.
W. Craig Noblett D.D.S., M.S.
1
LEARNING OBJECTIVES
After reading this chapter, the student should be able to:
1 State reasons and describe situations for enlarging the cervical portion of the canal
before performing straightline access.
2 Define ho! to determine the appropriate si"e of the master apical file.
3 Describe ob#ectives for both cleaning and shaping$ e%plain ho! to determine !hen
these have been achieved.
4 Diagram &perfect' shapes of flared (stepbac)* and standardi"ed preparations$ dra!
these both in longitudinal and crosssectional diagrams.
Diagram probable actual shapes of flared (stepbac)* and standardi"ed preparations
in curved canals.
6 Describe techni+ues for shaping canals that are irregular, such as round, oval,
hourglass, bo!lingpin, )idne,bean, or ribbonshaped.
! Describe techni+ues, stepb,step, for standardi"ed and flaring (stepbac) and-or
cro!ndo!n* preparations.
" Distinguish bet!een apical stop, apical seat, and open ape% and discuss ho! to
manage obturation in each.
# Describe the techni+ue of pulp e%tirpation.
1$ Characteri"e the difficulties of preparation in the presence of anatomic aberrations
that ma)e complete d.bridement difficult.
11 /ist properties of the &ideal' irrigant and identif, !hich irrigant meets most of these
criteria.
12 Describe the needles and techni+ues that provide the ma%imal irrigant effect.
0
13 Discuss the properties and role of chelating and decalcif,ing agents.
14 1%plain ho! to minimi"e preparation errors in small curved canals.
1 Describe techni+ues for negotiating severel, curved, &bloc)ed,' or constricted
canals.
16 Describe, in general, the principles of application of ultrasonic devices for cleaning
and shaping.
1! 1valuate, in general, alternative means of cleaning and shaping and list their
advantages and disadvantages.
1" Discuss nic)eltitanium hand and rotar, instruments and ho! the ph,sical properties
of this metal affect cleaning and shaping.
1# Discuss the properties and role of intracanal, interappointment medicaments.
2$% /ist the principal temporar, filling materials$ describe techni+ues for their placement
and removal.
21% Describe tempori"ation of e%tensivel, damaged teeth.
22% 2utline techni+ues and materials used for long3term tempori"ation.
4
O&TLINE
INTRO'&CTION
(rin)iple* +, Cleaning
(rin)iple* +, Shaping
C&RRENT CONTROVERSIES IN CLEANING AN' S-A(ING
Ter.inati+n +, Cleaning and Shaping
'egree +, Api)al Enlarge.ent
Eli.inati+n +, Eti+l+g/
Api)al (aten)/
(RETREAT0ENT EVALA&TION
(RINCI(LES O1 CLEANING AN' S-A(ING
IRRIGANTS AN' L&BRICANTS
S+di2. -/p+)hl+rite
Chl+rhe3idine
S0EAR LA4ER
'ECALCI14ING AGENTS
E'TA5Citri) A)id
0TA'
TEC-NI6&ES O1 (RE(ARATION
7at)h 7inding
Rea.ing
1iling
Cir)2.,erential ,iling
5
Standardi8ed preparati+n
Step9:a); Te)hni<2e
Canal Bed Enlarge.ent
Re=er*e 1laring Te)hni<2e
Anti9C2r=at2re 1iling
Balan)ed 1+r)e Te)hni<2e
Ni);el Titani2. R+tar/ (reparati+n
Api)al Clearing
Re)apit2lati+n
C+.:inati+n Te)hni<2e
General C+n*iderati+n* > A Re=ie?
CRITERIA 1OR EVAL&ATING CLEANING AN' S-A(ING
L&BRICANTS
INTRACANAL 0E'ICA0ENTS
(hen+l* and aldeh/de*
Cal)i2. h/dr+3ide
C+rti)+*ter+id*
Chl+rhe3idine
Te.p+rar/ re*t+rati+n*
O:@e)ti=e +, te.p+ri8ati+n
R+2tine a))e** )a=itie*
E3ten*i=e )+r+nal :rea;d+?n
6
INTRO'&CTION
Successful root canal treatment is based on7 establishing an accurate diagnosis and
developing an appropriate treatment plan$ appl,ing )no!ledge of tooth anatom, and
morpholog, (shape*$ and performing the debridement, disinfection, and obturation of the
entire root canal s,stem. 8nitiall, emphasis !as on obturation and sealing the radicular
space. 9o!ever no techni+ue or material provides a seal that is impervious to moisture
either from the apical or coronal areas. 1arl, prognosis studies indicated failures !ere
attributed to incomplete obturation.
1
This proved fallacious as obturation onl, reflects
the ade+uac, of the cleaning and shaping. Canals that are poorl, obturated are often
incompletel, cleaned and shaped. :de+uate cleaning and shaping and establishing a
coronal seal are the essential elements for successful treatment !ith obturation being less
important for short term success.
0
1limination (or significant reduction* of the inflamed
or necrotic pulp tissue and microorganisms are the most critical factors. The role of
obturation in long term success has not been established but ma, be significant in
preventing recontamination either from the coronal or apical areas. Sealing the canal
space follo!ing cleaning and shaping !ill entomb an, remaining organisms
4
and, !ith the
coronal seal, prevent recontamination of the canal and periradicular tissues.
(rin)iple* +, Cleaning
Nonsurgical root canal treatment is a predictable method of retaining a tooth that
other!ise !ould re+uire e%traction. Success of root canal treatment in a tooth !ith a vital
pulp is higher than that of a tooth that is necrotic !ith periradicular pathosis. The
difference is the persistent irritation of necrotic tissue remnants, and the inabilit, to
remove the microorganisms and their b,products. The most significant factors affecting
;
this process are tooth anatom, and morpholog,, and the instruments and irrigants
available for treatment. 8nstruments must contact and plane the canal walls to debride
the canal (<igure 1;1, 1;0, 1;4*. Morphologic factors such as lateral (<igures 1;0*
and accessor, canals, canal curvatures, canal !all irregularities, fins, culdesacs (<igures
1;1*, and ishmuses ma)e total debridement virtuall, impossible. Therefore the goal of
cleaning not total elimination of the irritants but it is to reduce the irritants.
Currentl, there are no reliable methods to assess cleaning. The presence of clean dentinal
shavings, the color of the irrigant, and canal enlargement three file si"es be,ond the first
instrument to bind have been used to assess the ade+uac,$ ho!ever, these do not correlate
!ell !ith debridement. 2btaining glassy smooth walls is a preferred indicator.
5
The
properl, prepared canals should feel smooth in all dimensions !hen the tip of a small file
is pushed against the canal !alls. This indicates that files have had contact and planed all
accessible canal !alls thereb, ma%imi"ing debridement (recogni"ing that total
debridement usuall, does not occur*.
(rin)iple* +, Shaping
The purpose of shaping is to 1* facilitate cleaning and 0* provide space for placing the
obturating materials. The main ob#ective of shaping is to maintain or develop a
continuousl, tapering funnel from the canal orifice to the ape%. This decreases
procedural errors !hen cleaning and enlarging apicall,. The degree of enlargement is
often dictated b, the method of obturation. <or lateral compaction of gutta percha the
canal should be enlarged sufficientl, to permit placement of the spreader to !ithin 10
millimeters of the corrected !or)ing length. There is a correlation bet!een the depth of
=
spreader penetration and the apical seal.
6
<or !arm vertical compaction techni+ues the
coronal enlargement must permit the placement of the pluggers to !ithin 4 to 6 mm of
the corrected !or)ing length.
;

:s dentin is removed from the canal !alls the root is !ea)ened.
=
The degree of shaping
is determined b, the preoperative root dimension, the obturation techni+ue, and the
restorative treatment plan. Narro! thin roots such as the mandibular incisors cannot be
enlarged to the same degree as more bul), roots such as the ma%illar, central incisors.
>ost placement is also a determining factor in the amount of coronal dentin removal.
A(ICAL CANAL (RE(ARATION
Ter.inati+n +, Cleaning and Shaping
While the concept of cleaning and shaping the root canal space is a simple concept, there
are areas !here consensus does not e%ist. The first is the e%tent of the apical preparation.
1arl, studies identified the dentinocemental #unction as the area !here the pulp ends and
the periodontal ligament begins. ?nfortunatel,, this is a histologic landmar) and the
position (!hich is irregular !ithin the canal* cannot be determined clinicall,.
Traditionall, the apical point of termination has been one millimeter from the
radiographic ape%. 8n a classic stud, it !as noted the apical portion of the canal consisted
of the ma#or diameter of the foramen and the minor diameter of the constriction (<igure
1;5*.
@
The apical constriction is defined as the narro!est portion of the canal and the
@
average distance from the foramen to the constriction !as found to be A.6 millimeters.
2ne stud, found the classic apical constriction to be present in onl, 5;B of the teeth and
!hen present varied in relation to the apical foramen.
C
Dariations from the classic
appearance consist of the tapering constriction, the multiple constriction and the parallel
constriction.
C
Eased on the variations in apical morpholog,, the term apical constriction
is misnomer. To complicate the issue the foramen is seldom at the ape%. :pical anatom,
has also been sho!n to be +uite variable (<igure 1;5*. : recent stud, found no t,pical
pattern for foraminal openings and that no foramen coincided !ith the ape% of the root.
1A

The foramen to ape% distance can range from .0A to 4.@ mm.
1A

8t has also been noted that the foramen to constriction distance increases !ith age
@
and
root resorption ma, destro, the classic anatomical constriction. Fesorption is common
!ith pulp necrosis and apical bone resorption and this can result in loss of the
constriction
11
therefore root resorption is an additional factor to consider in length
determination.
8n a recent prospective stud, evaluating prognosis, significant factors influencing success
and failure !ere perforation, preoperative periradicular disease, and ade+uate length of
the root canal filling.
10
The authors speculated that canals filled more than 0.A mm short
harbored necrotic tissue, bacteria and irritants that !hen retreated could be cleaned and
sealed.
10
: metaanal,sis evaluation of success-failure indicated a better success rate
!hen the obturation !as confined to the canal space.
14
: revie! of a number of
prognosis studies confirms that e%trusion of materials decreases success.
15
With pulp
C
necrosis, better success !as achieved !hen the procedures terminated at or !ithin 0 mm
of the radiographic ape%. 2bturation shorter than 0 mm from the ape% or past the ape%
resulted in a decreased success rate. 8n teeth !ith vital inflamed pulp tissue, termination
bet!een 04 mm !as acceptable.
While the guideline of 1.A0.A mm from the radiographic ape% remains rational, the point
of apical termination of the preparation and obturation remains empirical. The need to
compact the guttapercha and sealer against the apical dentin matri% (constriction of the
canal* is essential for success. The decision of !here the minor diameter of the canal lies
is based on )no!ledge of apical anatom,, tactile sensation, radiographic interpretation,
ape% locators, apical bleeding, and the patientGs response. To prevent e%trusion, the
cleaning and shaping procedures must be confined to the radicular space. Canals filled to
the radiographic ape% are actuall, overe%tended.
1A
'egree +, Api)al Enlarge.ent
While generali"ations can be made regarding tooth anatom, and morpholog,, each tooth
is uni+ue. /ength of canal preparation is often emphasi"ed !ith little consideration given
to important factors such as canal diameter and shape. Since morpholog, is variable,
there is no standardi"ed apical canal si"e. Traditionall, preparation techni+ues !ere
determined b, the desire to limit procedural errors and b, the method of obturation.
Small apical preparation limits canal transportation and apical &"ipping', but decreases
the efficac, of the cleaning procedure. 8t appears that, !ith traditional hand files, apical
transportation occurs in most curved canals enlarged be,ond a si"e H06 stainless steel
1A
file.
16
The criteria for cleaning and shaping should be based on the abilit, to ade+uatel,
remove the tissue, necrotic debris, and bacteria and not a specific obturation techni+ue.
8rrigants are unable to reach the apical portion of the root if the canal is not enlarged to a
si"e H46 or H5A file.
1;1@
The larger preparation si"es have been sho!n to provide
ade+uate irrigation and debris removal as !ell as significantl, decreasing the number of
microorganisms.
1C00
Thus there appears to be a relationship bet!een increasing the si"e
of the apical preparation and canal cleanliness
04
and bacterial reduction.
05, 06
8nstrumentation techni+ues that advocate minimal apical preparation ma, be ineffective
at achieving the goal of cleaning and disinfecting the root canal space.
0;, 04
Eacteria can penetrate the tubules of dentin. These intratubular organisms are protected
from endodontic instruments, the action of irrigants, and intracanal medicaments. Dentin
removal appears to be the primar, method for decreasing their numbers. 8n addition it
ma, not be possible to remove bacteria that are deep in the tubules regardless of the
techni+ue. There is a correlation bet!een the number of organisms present and the depth
of tubular penetration$
0=
in teeth !ith apical periodontitis, bacteria penetrate the tubules to
the peripher, of the root.
0@, 0C

Eli.inati+n +, Eti+l+g/
The development of nic)el titanium instruments has dramaticall, changed the techni+ues
of cleaning and shaping. The primar, advantage to using these fle%ible instruments is
related to shaping. Neither hand instruments nor rotar, files have been sho!n to
completel, debride the canal.
4A40
Mechanical enlargement of the canal space
11
dramaticall, decreases the presence of microorganisms present in the canal
44
but cannot
render the canal sterile.
1C
To improve the mechanical preparation techni+ues
antimicrobial irrigants have been recommended.
45
There is no consensus on the most
appropriate irrigant or concentration of solution, although sodium h,pochlorite is the
most !idel, used irrigant.
Common irrigants include sodium h,pochlorite and chlorhe%idine.
464C
?nfortunatel,
solutions designed to )ill bacteria are often to%ic for the host cells,
5A54
so e%trusion
be,ond the canal space therefore is to be avoided.
55, 56
: ma#or factor related to
effectiveness is the volume. 8ncreasing the volume produces cleaner preparations.
5;

Api)al (aten)/
:pical patenc, has been advocated during cleaning and shaping procedures to ensure
!or)ing length is not lost and that the apical portion of the root is not pac)ed !ith tissue,
dentin debris and bacteria (<igure 1;6*. Concerns regarding e%trusion of dentinal debris,
bacteria and irrigants have been raised.
5=
Seeding the periradicular tissues !ith
microorganisms ma, occur.
5@
Studies evaluating treatment failure have noted bacteria
outside the radicular space,
5C, 6A
and bacteria have been sho!n to e%ist as pla+ues or
biofilms on the root e%ternal root structure.
61

The apical patenc, concept also has been advocated to facilitate apical preparation.
1%tending the file be,ond the ape% increases the diameter of the canal at !or)ing length
consistent !ith the instrument taper. The value of maintaining patenc, to prevent
10
transportation is +uestionable
60
and it does not result in bacterial reduction !hen
compared to not maintaining patenc,.
64
Small files are not effective in debridement
(<igure 1;4*.
(RETREAT0ENT EVALA&TION
>rior to treatment, each case should be evaluated for degree of difficult,. Normal
anatom, as !ell as anatomic variations are determined as !ell as variations in canal
morpholog, (shape*.
: parallel preoperative radiograph or image is assessed. The longer a root, the more
difficult it is to treat. :picall,, a narro! curved root is susceptible to perforation$ in
multirooted teeth a narro! area mid root could lead to a lateral stripping perforation.
The degree and location of curvature is determined. Canals are seldom straight and
curvatures in a faciallingual direction !ill not be visible on the radiograph. Sharp
curvatures or dilacerations are more difficult to manage than a continuous gentle curve.
Foots !ith an Sshape or ba,onet configuration are difficult to treat. Calcifications !ill
also complicate treatment. Calcification generall, occurs in a coronal to apical direction
(See Chapter 16, <igure 1615*. : large tapering canal ma, become more c,lindrical
!ith irritation or age. This presents problems !hen the tapered instruments are used in
the coronal third.
Fesorption also !ill complicate treatment. With internal resorption it is difficult to pass
instruments through the coronal portion of the canal, through the defect and into the
14
apical portion. :lso files !ill not remove tissue, necrotic debris and bacteria from this
inaccessible area. 1%ternal resorptions ma, perforate the canal space and present
problems !ith hemostasis and isolation. Festorations ma, obstruct access and visibilit,
as !ell as change the orientation of the cro!n in relation to the root.
(RINCI(LES O1 CLEANING AN' S-A(ING
Cleaning and shaping are separate and distinct concepts but are performed concurrentl,.
The criteria of canal preparation include7 developing a continuousl, tapered funnel,
maintaining the original shape of the canal, maintaining the apical foramen in its original
position, )eeping the apical opening as small as possible, and developing glass, smooth
!alls
;
. The cleaning and shaping procedures are designed maintain an apical matri% for
compacting the obturating material regardless of the obturation techni+ue.
;

Ino!ledge of variet, of techni+ues and instruments for treatment of the m,riad
variations in canal anatom, is re+uired. There is no consensus on !hich techni+ue or
instrument is superior.
4A

Nic)eltitanium files have been incorporated into endodontics due to their fle%ibilit, and
resistance to and c,clic fatigue.
65
The resistance to c,clic fatigue permits the instruments
to be used in a rotar, handpiece, an advantage over stainless steel. The instruments are
manufactured in both hand and rotar, versions. Eoth have been demonstrated to produce
superior shaping !hen compared to stainless steel hand instruments.
66, 6;

15
The instruments are designed !ith increased taper !hen compared to .A0 mm
standardi"ed stainless steel files. Common tapers are .A5, .A;, .A@, .1A, and .10 and the tip
diameters ma, or ma, not conform to the traditional manufacturing specifications. The
file s,stems can var, the taper !hile maintaining the same tip diameter or the, can
emplo, varied tapers !ith 8S2 standardi"ed tip diameters. The, ma, incorporate cutting
or noncutting tips.
8n general the nic)el titanium rotar, instruments are not indicated in Sshaped canals,
canals that #oin !ithin a single root (T,pe 88 configuration*, in canals !ith severe
dilacerations, canals in !hich ledge formation is present, and ver, large canals !here
the, fail to contact the canal !alls. Straight line access to the canal is essential and the
instruments should be used passivel,.
8nstrument fracture can occur due to torsional forces or c,clic fatigue. Torsional forces
develop due to frictional resistance, therefore as the surface area increases along the
flutes the greater friction and more potential for fracture. Torsional forces ma, produce
an unraveling of the flutes prior to fracture and inspection of the instruments after each
use is critical. Torsional stress can be reduced b, limiting file contact, b, using a cro!n
do!n preparation techni+ue, and b, lubrication. C,clic fatigue occurs as the file rotates
in a curved canal.
6=
:t the point of curvature the molecules on the outer surface of the
file are under tension !hile the molecules on the inner surface of the instrument are
compressed. :s the instrument rotates the areas of tension and compression alternate and
eventual fracture occurs. There is no visible evidence that fracture is imminent.
16
Therefore it is advised that the use of nic)el titanium instruments be monitored
6@
and
limited to one to five cases. <or difficult cases or calcified canals it is recommended the
instruments be used onl, once.
&ltra*+ni)*
?ltrasonics are used for cleaning and shaping, removal of materials from the canal,
removal of posts and silver cones, thermoplastic obturation, and root end
preparation during surger,.
The main advantage to cleaning and shaping !ith ultrasonics is acoustic micro
streaming.
6C
This is described as a comple% stead,state streaming patterns in a vorte%
li)e motion or edd, flo!s formed close to the instrument. :gitation of the irrigant !ith
an ultrasonicall, activated file after completion of cleaning and shaping has the benefit of
increasing the effectiveness of the solution.
;A;4

8nitiall, it !as proposed that ultrasonics could clean the canal !ithout procedural errors
such as apical transportation and remove the smear la,er.
;5, ;6
9o!ever later studies
failed to confirm these results.
;;;@

IRRIGANTS AN' L&BRICANTS
The ideal properties for an endodontic irrigant are listed in B+392%
6#
Currentl, no
solution meets all the re+uirements outlined.
1;
8rrigation does not completel, debride the canal. Sodium h,pochlorite !ill not remove
tissue from areas that are not touched b, files (<igures 1;1 and 1;0*.
=A
8n fact no
techni+ues appear able to completel, clean the root canal space.
=1=4, 00
<re+uent irrigation
is necessar, to flush and remove the debris generated b, the mechanical action of the
instruments.
B+392 (r+pertie* +, an ideal irrigant
Organi) ti**2e *+l=ent
In+rgani) ti**2e *+l=ent
Anti.i)r+:ial a)ti+n
N+n9t+3i)
L+? S2r,a)e Ten*i+n
L2:ri)ant
Anti.i)r+:ial a)ti+n
S+di2. -/p+)hl+rite
The most common irrigant is sodium h,pochlorite (household bleach*. :dvantages to
sodium h,pochlorite include the mechanical flushing of debris from the canal, the abilit,
of the solution to dissolve vital
=5
and necrotic tissue,
=6
the antimicrobial action of the
solution,
40
and the lubricating action.
=;
8n addition it is ine%pensive and readil,
available.
1=
<ree chlorine in sodium h,pochlorite dissolves necrotic tissue b, brea)ing do!n proteins
into amino acids. There is no proven appropriate concentration of sodium h,pochlorite,
but concentrations ranging form A.6B to 6.06B have been recommended. : common
concentration is 0.6B$ !hich decreases the potential for to%icit, !hile still maintaining
some tissue dissolving and antimicrobial activit,.
==, =@
Since the action of the irrigant is
related to the amount of free chlorine, decreasing the concentration can be compensated
b, increasing the volume. Warming the solution can also increase effectiveness of the
solution.
=C, @A

Eecause of to%icit,, e%trusion is to be avoided.
56, @1, 51
The irrigating needle must be
placed loosely in the canal (<igure 1;;*. 8nsertion to binding and slight !ithdra!al
minimi"es the potential for possible e%trusion and a &sodium h,pochlorite accident'
(<igure 1;=*. Special care should be e%ercised !hen irrigating a canal !ith an open
ape%. To control the depth of insertion the needle is bent slightl, at the appropriate length
or a rubber stopper placed on the needle.
The irrigant does not move apicall, more than one millimeter be,ond the irrigation tip so
deep placement !ith small gauge needles enhances irrigation (<igure 1;;*.
@0

?nfortunatel, the small bore can easil, clog, so aspiration after each use is
recommended. During rinsing, the needle is moved up and do!n constantl, to produce
agitation and prevent binding or !edging of the needle.
Chl+rhe3idine
1@
Chlorhe%idine possesses a broad spectrum of antimicrobial activit,, provides a sustained
action
@1, @4
, and has little to%icit,.
@5@=
T!o percent chlorhe%adine has similar antimicrobial
action as 6.06B sodium h,pochlorite
@5
and is more effective against enterococcus
faecalis.
@1
Sodium h,pochlorite and chlorhe%adine are s,nergistic in their abilit, to
eliminate microorganisms.
@6
: disadvantage of chlorhe%adine is its inabilit, to dissolve
necrotic tissue and remove the smear la,er.
L&BRICANTS
/ubricants facilitate file manipulation during cleaning and shaping. The, are an aid in
initial canal negotiation especiall, in small constricted canals !ithout taper. The, reduce
torsional forces on the instruments and decrease the potential for fracture.
Jl,cerin is a mild alcohol that is ine%pensive, nonto%ic, aseptic, and some!hat soluble.
: small amount can be placed along the shaft of the file or deposited in the canal orifice.
Countercloc)!ise rotation of the file carries the material apicall,. The file can then be
!or)ed to place using a !atch !inding or &t!iddling' motion.
>aste lubricants can incorporate chelators. 2ne advantage to paste lubricants is that the,
can suspend dentinal debris and prevent apical compaction. 2ne proprietar, product
consists of gl,col, urea pero%ide and eth,lenediaminetetraacetic acid (1DT:* in a special
!ater soluble base. 8t has been demonstrated to e%hibit an antimicrobial action
@@
. :nother
t,pe is composed of 1CB 1DT: in a !ater soluble viscous solution.
1C
: disadvantage to these 1DT: compounds appears to be the deactivation of sodium
h,pochlorite b, reducing the available chlorine
@C
and potential to%icit,
CA
. The addition of
1DT: to the lubricants has not proven to be effective
C1
. 8n general files remove dentin
faster than the chelators can soften the canal !alls. :+ueous solutions such as sodium
h,pochlorite should be used instead of paste lubricants !hen using nic)eltitanium rotar,
techni+ues to reduce tor+ue
=;
.
S0EAR LA4ER
During the cleaning and shaping, organic pulpal materials and inorganic dentinal debris
accummulates on the radicular canal !all producing a an amorphous irregular smear
la,er (<igure 1;@*.
;C
With pulp necrosis, the smear la,er ma, be contaminated !ith
bacteria and their metabolic b,products. The smear la,er is superficial !ith a thic)ness
of 16 microns and debris can be pac)ed into the dentinal tubules var,ing distances.
C0

There does not appear to be a consensus on removing the smear la,er prior to obturation.
C4, C5, ;C
The advantages and disadvantages of the smear la,er removal remain
controversial$ ho!ever, evidence supports removing the smear la,er prior to obturation.
C6,
;C
The organic debris present in the smear la,er might constitute substrate for bacterial
gro!th and it has been suggested that the smear la,er prohibits sealer contact !ith the
canal !all and permits lea)age. 8n addition, viable microorganisms in the dentinal tubules
ma, use the smear la,er as a substrate for sustained gro!th.

When the smear la,er is not
removed, it ma, slo!l, disintegrate !ith lea)ing obturation materials, or it ma, be
removed b, acids and en",mes that are produced b, viable bacteria left in the tubules or
0A
enter via coronal lea)age.
C;
The presence of a smear la,er ma, also interfere !ith the
action and effectiveness of root canal irrigants and interappointment disinfectants.
4=

With smear la,er removal filling materials adapt better to the canal !all.
C=, C@
Femoval of
the smear la,er also enhances the adhesion of sealers to dentin and tubular penetration
CC,
C=, 1AA, C@
and permits the penetration of all sealers to var,ing depths.
1A1
Femoval of the
smear la,er reduces both coronal and apical lea)age.
1A0

1A4
E'TA
Femoval of the smear la,er is accomplished !ith acids or other chelating agents such as
eth,lenediamine tetracetic acid (1DT:*
1A5
follo!ing cleaning and shaping. 8rrigation
!ith 1=B 1DT: for one minute follo!ed b, a final rinse !ith sodium h,pochlorite
1A6
is a
recommended method. Chelators remove the inorganic components leaving the organic
tissue elements intact. Sodium h,pochlorite is then necessar, for removal of the
remaining organic components. Citric acid has also been sho!n to be an effective
method for removing the smear la,er
1A;, 1A=
as has tetrac,cline.
1A@, 1AC
Deminerali"ation results in removal of the smear la,er and plugs, and enlargement of the
tubules.
11A

111
The action is most effective in the coronal and middle thirds of the canal
and reduced apicall,.
1A5, 110
Feduced activit, ma, be a reflection of canal si"e
;0
or
anatomical variations such as irregular or sclerotic tubules.
114
The variable structure of
the apical region presents a challenge during endodontic obturation !ith adhesive
materials.
01
The recommended time for removal of the smear la,er !ith 1DT: is 1 minute.
115, 1A5, 116

The small particles of the smear la,er are primaril, inorganic !ith a high surface to mass
ratio !hich facilitates removal b, acids and chelators. 1DT: e%posure over 1A minutes
causes e%cessive removal of both peritubular and intratubular dentin.
11;

0TA'
:n alternative method for removing the smear la,er emplo,s the use of a mi%ture of a
tetrac,cline isomer, an acid, and a detergent (MT:D* as a final rise to remove the smear
la,er.
11=
The effectiveness of MT:D to completel, remove the smear la,er is enhanced
!hen lo! concentrations of Na2Cl are used as an intracanal irrigant before the use of
MT:D
11@
. : 1.4B concentration is recommended. MT:D ma, be superior to sodium
h,pochlorite in antimicrobial action.
11C, 10A
MT:D has been sho!n to be effective in
)illing E. faecalis, an organism commonl, found in failing cases, and ma, prove
beneficial during retreatment. 8t is biocompatible
101
, does not alter the ph,sical properties
of the dentin
101
and it enhances bond strength.
100

TEC-NI6&ES O1 (RE(ARATION
Fegardless of the techni+ue used in cleaning and shaping, procedural errors can occur.
These included loss of !or)ing length, apical transportation, apical perforation, lateral
stripping and instrument fracture.
/oss of !or)ing length has several causes. These include failure to have an ade+uate
reference point from !hich the corrected !or)ing length is determined, pac)ing tissue
and debris in the apical portion of the canal, ledge formation, and inaccurate
00
measurements. :pical transportation and "ipping occurs !hen the restoring force of the
file e%ceeds the threshold for cutting dentin in c,lindrical nontapering curved canal
(<igures 1;C and 1;1A*.
104
When this apical transportation continues !ith larger and
larger files, a &teardrop' shape develops and perforation can occur apicall, on the lateral
root surface (<igure1;C*. Transportation in curved canals begins !ith a si"e H06 file
16
.
1nlargement of curved canals at the corrected !or)ing length be,ond a si"e H06 file
should be done onl, !hen an ade+uate coronal flare is developed.
8nstrument fracture occurs !ith torsional and c,clic fatigue. /oc)ing the flutes of a file
in the canal !all !hile continuing to rotate the coronal portion of the instrument is an
e%ample torsional fatigue (<igure 1;11*. C,clic fatigue results !hen strain develops in
the metal.
Stripping perforations occur in the furcal region of curved roots, fre+uentl, the mesial
roots of ma%illar, and mandibular molars perforation (<igures 1;10 and 1;14*. The
canal in this area is not al!a,s centered in the root and prior to preparation the average
distance to the furcal !all (danger "one* is less than the distance to the bul), outer !all
(safet, "one*. :n additional factor is the concavit, of the root.
7at)h 7inding
Watch !inding is reciprocating bac) and forth (cloc)!ise-countercloc)!ise* rotation of
the instrument in an arch. 8t is used to negotiate canals and to !or) files to place. /ight
apical pressure is applied to move the file deeper into the canal.
04
Rea.ing
Feaming is defined as the cloc)!ise, cutting rotation of the file. Jenerall, the
instruments are placed into the canal until binding is encountered. The instrument is then
rotated cloc)!ise 1@A4;AK to plane the !alls and enlarge the canal space.
1iling
<iling is defined as placing the file into the canal and pressing it laterall, !hile
!ithdra!ing it along the path of insertion to scrape the !all. There is ver, little rotation
on the out!ard cutting stro)e. The scraping or rasping action removes the tissue and cuts
superficial dentin from the canal !all. : modification is the turnpull techni+ue. This
involves placing the file to the point of binding, rotating the instrument CAK and pulling
the instrument along the canal !all.
Cir)2.,erential ,iling
Circumferential filing is used for canals that are larger and or not round. The file is
placed into the canal and !ithdra!n in a directional manner se+uentiall, against the
mesial, distal, buccal, and lingual !alls.
Standardi8ed preparati+n
:fter 1C;1, instruments !ere manufactured !ith a standard formula. Clinicians utili"ed a
preparation techni+ue of se+uentiall, enlarging the canal space !ith smaller to larger
instruments at the corrected !or)ing length.
105
8n theor, this created a standardi"ed
preparation of uniform taper. ?nfortunatel, this does not occur. This techni+ue !as
ade+uate for preparing the apical portion of canals that !ere relativel, straight and
tapered$ ho!ever in c,lindrical and small curved canals procedural errors !ere identified
!ith the techni+ue.
106

05
Step9:a); Te)hni<2e
The stepbac) techni+ue
=A, 106
reduces procedural errors and improves debridement. :fter
coronal flaring and determining the master apical file (initial file that binds slightl, at the
corrected !or)ing length*, the succeeding larger files are shortened b, A.6 or 1.A m
increments from the previous file length (<igure 1;15 and 1;16*. This stepbac)
process creates a flared, tapering preparation !hile reducing procedural errors. The step
bac) preparation is superior to standardi"ed serial filing and reaming techni+ues in
debridement and maintaining the canal shape.
=A
The stepbac) filing techni+ue results in
more pulpal !alls being planed !hen compared to reaming or filing.
Step9'+?n Te)hni<2e
The step do!n techni+ue is advocated for cleaning and shaping procedures as it removes
coronal interferences and provides coronal taper. 2riginall, advocated for hand file
preparation
10;
it has been incorporated into techni+ues emplo,ing nic)eltitanium files.
With the pulp chamber filled !ith irrigant or lubricant the canal is e%plored !ith a small
instrument to assess patenc, and morpholog, (curvature*. The !or)ing length can be
established at this time. The coronal one third of the canal is then flared !ith Jates
Jlidden drills or rotar, files of greater taper (.A;, .A@, .1A,*. : large file (such si"e H=A* is
then placed in the canal using a !atch !inding motion until resistance is encountered.
10;
The process is repeated !ith se+uentiall, smaller files until the apical portion of the canal
is reached. The !or)ing length can be determined if this !as not accomplished initiall,.
The apical portion of the canal can no! be prepared b, enlarging the canal at the
corrected !or)ing length. :pical taper is accomplished using a stepbac) techni+ue.
06
(a**i=e Step9:a);
The passive stepbac) techni+ue is a modification of the incremental stepbac)
techni+ue.
;, 10=
:fter the apical diameter of the canal has been determined, the ne%t higher
instrument is inserted until it first ma)es contact (binding point*. 8t is then rotated one half
turn and removed (<igure 1;1;*. The process is repeated !ith larger and larger instruments
being placed to their binding point. This entire instrument se+uence is then repeated. With
each se+uence the instruments drop deeper into the canal creating a tapered preparation.
This techni+ue permits the canal morpholog, to dictate the preparation shape. The
techni+ue does not re+uire arbitrar, rigid incremental reductions and forcing files into canals
that cannot accommodate the files. :dvantages to the techni+ue include7 )no!ledge of
canal morpholog,, removal of debris and minor canal obstructions, and a gradual passive
enlargement of the canal in an apical to coronal direction.
B+393 The dia.eter +, r+tar/ ,laring in*tr2.ent*%
Si8e Gate*9Glidden (ee*+9Rea.er*
H1 .6 mm .= mm
H0 .= mm .C mm
H4 .C mm 1.1 mm
H5 1.1 mm 1.4 mm
H6 1.4 mm 1.6 mm
H; 1.6 mm 1.= mm
0;
Anti9C2r=at2re 1iling
:nticurvature filing is advocated during coronal flaring procedures to preserve the furcal
!all in treatment of molars (<igure 1;1=*. Canals are often not centered in mesial roots
of ma%illar, and mandibular molars, being located closer to the furcation. Stripping
perforations can occur in these teeth during overl, aggressive enlargement of the canal
space. Stripping perforations occur primaril, during use of the Jates Jlidden drills
(Eo%4* (<igure 1;1@*. To prevent this procedural error, the Jates Jlidden drills should
be confined to the canal space coronal to the root curvature and used in a stepbac)
manner (<igure 1;1@ and 1;1C*. The Jates Jlidden drills can also be used
directionall, in an anticurvature fashion to selectivel, remove dentin from the bul),
!all (safet, "one* to!ard the line angle, protecting the inner or furcal !all (danger "one*
coronal to the curve (<igure 1;1=*. While this can be accomplished !ith the use of hand
files, it appears that directional forces !ith Jates Jlidden drills is not beneficial.
10@

Balan)ed 1+r)e Te)hni<2e
The balanced force techni+ue recogni"es the fact that instruments are guided b, the canal
!alls !hen rotated.
10C
Since the files !ill cut in both a cloc)!ise and countercloc)!ise
rotation, the balanced force concept of instrumentation consists of placing the file to
length and then a cloc)!ise rotation (less than 1@A degrees* engages dentin. This is
follo!ed b, a countercloc)!ise rotation (at least 10A degrees* !ith apical pressure to cut
and enlarge the canal. The degree of apical pressure varies from light pressure !ith small
instruments to heav, pressure !ith large instruments. The cloc)!ise rotation pulls the
instrument into the canal in an apical direction. The countercloc)!ise cutting rotation
0=
forces the file in a coronal direction !hile cutting circumferentiall,. <ollo!ing the
cutting rotation the file is repositioned and the process is repeated until the corrected
!or)ing length is reached. :t this point a final cloc)!ise rotation is emplo,ed to
evacuate the debris.
Ni);el Titani2. R+tar/ (reparati+n
Nic)el titanium rotar, preparation utili"es a cro!ndo!n approach. The specific
techni+ue is based on the instrument s,stem selected. 2ne instrument se+uence uses
nic)el titanium files !ith a constant taper and variable 8S2 tip si"es (<igure 1;0A*. With
this techni+ue, a .A; taper is selected. 8nitiall, a si"e .A;-56 file is used until resistance,
follo!ed b, the .A;-56, .A;-5A, .A;-46, .A;-4A, .A;-06, and .A;-0A. 8n a second techni+ue,
nic)el titanium files !ith a constant tip diameter are used. The initial file is a .1A-0A
instrument, the second a .A@-0A, the third a .A;-0A, and the fourth a .A5-0A (<igure 1;01*.
<or larger canals a se+uence of files using 8S2 standardi"ed tip si"es of 4A or 5A might be
selected. ?sing the cro!n do!n approach creates coronal flare and reduces the contact
area of the file so torsional forces are reduced.
1inal Api)al Enlarge.ent and Api)al Clearing
:pical clearing enhances the preparation of the apical canal, improves debridement, and
produce a more definite apical stop in preparation for obturation.
14A
:pical clearing is
generall, performed !hen there is an apical stop and the master apical file is less that a
si"e H5A file. 8f the apical configuration is open or a seat, apical clearing might ma)e the
opening larger and potentiate the possibilit, of e%trusion of the obturation materials.
:pical clearing consists of t!o distinct steps7 final apical enlargement and dr, reaming.
0@
<inal apical enlargement is performed after the canal has been cleaned and shaped. 8t
involves enlargement of the apical preparation three to five si"es be,ond the master
apical file (<igure 1;00*. The degree of enlargement depends on the canal si"e and root
curvature. 8n a small curved canal enlargement ma, onl, be three si"es to decrease the
potential for transportation. 8n a straight canal it can be larger !ithout producing a
procedural error. Since the prepared canal e%hibits taper, the small files at the corrected
!or)ing length can be used to enlarge the canal !ithout transportation. <inal apical
enlargement is performed !ith the irrigant and emplo,s a reaming action at the corrected
!or)ing length. The last file used becomes the final apical file. Since the file is onl,
contacting the apical 10 mm the !alls of the canal, the techni+ue !ill result in a less
irregular apical preparation. The canal is then irrigated. The smear la,er is removed
!ith a decalcif,ing agent and the canal dried !ith paper points.
:fter dr,ing the canals, the dr, reaming is performed. Dr, reaming removes dentin chips
or debris pac)ed apicall, during dr,ing. The final apical file (or the master apical file in
cases !here apical enlargement !as not performed* is placed to the corrected !or)ing
length and rotated cloc)!ise in a reaming action.
Re)apit2lati+n
Fecapitulation is important regardless of the techni+ue selected (<igure1;04*. This is
accomplished b, ta)ing a small file to the corrected !or)ing length to loosen
accumulated debris and then flushing it !ith 10 ml of irrigant. Fecapitulation is
0C
performed bet!een each successive enlarging instrument regardless of the cleaning and
shaping techni+ue.
C+.:inati+n Te)hni<2e
This techni+ue combines coronal flaring, nic)el titanium rotar, preparation, and the
passive stepbac) techni+ue (BOA94B. <ollo!ing access, the canal is e%plored !ith a H1A
or H16 file. 8f the canal is patent to the estimated !or)ing length a !or)ing length
radiograph can be obtained and the corrected !or)ing length established (Chapter 16,
<igure 165A*. 8n order to insure an accurate length determination a si"e H0A file or larger
should be used (Chapter 16, <igures 165A, 1651*. 8f a H0A file !ill not go to the
estimated !or)ing length passive stepbac) instrumentation can be performed b,
inserting successivel, larger files to the point of binding and reaming. This removes
coronal interferences and creates greater coronal taper permitting larger files access to the
apical portion of the root.
:fter establishing the !or)ing length, Jates Jlidden drills are used for straight line
access (<igure 1;1@*. : H0 Jates is used first follo!ed b, the H4 and H5. 8n ver,
narro! canals a H1 Jates ma, be needed. 8t is important to remember the si"e of the
Jates Jlidden drills. 8f the canal orifice cannot accommodate a si"e H=A file, passive
step bac) should be performed to provide ade+uate initial coronal space. To prevent
stripping perforations, the Jates should not be placed apical to canal curvatures.
Jenerall, the H0H5 provides ade+uate coronal enlargement and preserves root structure.
The use of nic)el titanium rotar, instruments !ith greater tapers can also be used for this
step (.A;, .A@, and .1A tapers are common*. The Jates Jlidden drills can be used in either
4A
a cro!ndo!n or stepbac) se+uence. <ollo!ing use, the Jates Jlidden drill should be
removed from the handpiece to prevent in#ur, to the clinician, assistant or patient (<igure
1;05*.
0a*ter Api)al 1ile
1mphasis has traditionall, been placed on determining the canal length !ith little
consideration of the canal diameter in the apical portion of the root. Since ever, canal is
uni+ue in its morpholog, the apical canal diameter must be assessed. The si"e of the
apical portion of the canal is determined b, placing successivel, larger instruments to the
corrected !or)ing length until slight binding is encountered (<igure 1;06*. 2ften the
ne%t larger instrument !ill not go to the corrected !or)ing length. 8f it does go to length
a sub#ective estimation of the apical diameter must be made depending on the degree of
binding. This file !ill be the master apical file (initial file to bind*. 8t is defined as the
largest file to bind at the corrected !or)ing length follo!ing straight line access. This
provides an estimate of the canal diameter before cleaning and shaping and it is the point
!here the stepbac) preparation begins.
Ni);el9Titani2. R+tar/
2nce the master apical file is identified, the middle to apical portion of the canal is
prepared using nic)el titanium rotar, instruments (<igure 1;0A and <igure 1;01**.
Fotar, files are used !ith a cro!ndo!n approach to !ithin 4 mm of the corrected
!or)ing length. :de+uate coronal taper is established !hen the .A;-56 goes to !ithin
4.A mm of the corrected !or)ing length. ?sing the cro!n do!n approach creates coronal
taper and reduces the contact area of the file so torsional forces are reduced.
Re)apit2lati+n
41
Fecapitulation is accomplished after each instrument used in the canal b, ta)ing a small
file to the corrected !or)ing length and then flushing the canal !ith 10 ml of irrigant
(<igure 1;04*.
Step9Ba); Api)al (reparati+n
When the bod, of the canal has been shaped, the apical portion is prepared using
standardi"ed stainless steel or nic)el titanium hand files in a stepbac) process (<igure
1;16*. The first instrument selected for this portion of the shaping process is one si"e
larger that the master apical file (initial file to bind slightl,*. /arger files are successivel,
shortened b, standardi"ed increments of A.A6 mm or 1.A mm. Jenerall, se+uentiall,
stepping bac) to a file si"e of H;A or H=A !ill produce ade+uate flare and blend the apical
and middle thirds of the canal.
Api)al Clearing
With a flared preparation from the orifice to the corrected !or)ing length, the apical
portion of the canal is enlarged. With a tapered preparation the canal can be enlarged
!ith a reaming action as the canal !alls !ill )eep the instrument centered (<igure 1;06*.

B+394 The C+.:inati+n Te)hni<2e Step*
Canal neg+tiati+n
7+r;ing length deter.inati+n
Straight line a))e**
0a*ter api)al ,ile deter.inati+n
R+tar/ preparati+n +, the .iddle +ne third +, the r++t
Api)al *tep9:a); preparati+n
40
Api)al )learing
General C+n*iderati+n* > A Re=ie?
The follo!ing principles and concepts should be applied regardless of the instruments or
techni+ue selected.
1. 8nitial canal e%ploration is al!a,s performed !ith smaller files to gauge
canal si"e, shape, and configuration.
0. <iles are al!a,s manipulated in a canal filled !ith an irrigant or lubricant
present.
4. Copious irrigation is used bet!een each instrument in the canal.
5. Coronal preflaring (passive stepbac) techni+ue* !ith hand instruments
!ill facilitate placing larger !or)ing length files (either hand or rotar,*
and !ill reduce procedural errors such as loss of !or)ing length and canal
transportation.
6. :pical canal enlargement is gradual, using se+uentiall, larger files from
apical to coronal, regardless of flaring techni+ue.
;. Debris is loosened and dentin is removed from all !alls on the outstro)e
(circumferential filing* or !ith a rotating (reaming* action at or close to
!or)ing length.
=. 8nstrument binding or dentin removal on insertion should be avoided. <iles
are teased to length using a !atch !inding or &t!iddling' action. This is a
bac)andforth rotating motion of the files (appro%imatel, a +uarter turn*
bet!een the thumb and forefinger, continuall, !or)ing the file apicall,.
44
Careful file insertion (t!iddling* follo!ed b, planing on the outstro)e !ill
help to avoid apical pac)ing of debris and minimi"e e%trusion of debris
into the periradicular tissues.
@. Feaming is defined as the cloc)!ise rotation of the file. Jenerall, the
instruments are placed into the canal until binding is encountered. The
instrument is then rotated cloc)!ise 1@A4;AK to cut and plane the !alls.
When !ithdra!n the instrument tip is pushed alternatel, against all !alls.
The pushing motion is analogous to the action of a paintbrush. 2verall,
this is a turn and pull.
C. <iling is defined as placing the file into the canal and !ithdra!ing it along
the path of insertion to scrap the !all. There is ver, little rotation on the
out!ard cutting stro)e. The scraping or rasping action removes the tissue
and cuts superficial dentin from the canal !all.
1A. Turn pull filing involves placing the file into the canal until binding. The
instrument is then rotated to engage the dentin and !ithdra!n !ith lateral
pressure against the canal !alls.
11. Circumferential filing is used for canals that e%hibit cross sectional shapes
that are not round. The file is placed into the canal and !ithdra!n in a
directional manner against the mesial, distal, buccal, and lingual !alls.
10. Fegardless of the techni+ue, after each insertion the file is removed and
the flutes are cleaned of debris$ the file can then be reinserted into the
canal to plane the ne%t !all. Debris is removed from the file b, !iping it
!ith an alcoholsoa)ed gau"e or cotton roll
141
.
45
14. The canal is effectivel, cleaned only !here the files actuall, contact and
plane the !alls. 8naccessible regions are poorl, cleaned or d.brided.
15. Fecapitulation is done to loosen debris b, rotating the master apical file or
a smaller si"e at the corrected !or)ing length follo!ed b, irrigation to
mechanicall, remove the material. During recapitulation the canal !alls
are not planed and the canal should not be enlarged.
16. Small, long, curved, round canals are the most difficult and tedious to
enlarge. The, re+uire e%tra caution during preparation, being the most
prone to loss of length and transportation.
1;. 2ver enlargement of curved canals b, files attempting to straighten
themselves !ill to lead to procedural errors (<igure 1;11*.
1=. 2verpreparation of canal !alls to!ard the furcation ma, result in a
stripping perforation in the danger "one !here root dentin is thinner.
1@. 8t is neither desirable nor necessar, to tr, to remove created steps or other
slight irregularities created during canal preparation.
1C. 8nstruments, irrigants, debris, and obturating materials should be contained
!ithin the canal. These are all )no!n ph,sical or chemical irritants that
!ill induce periradicular inflammation and ma, dela, or compromise
healing.
0A. Creation of an apical stop ma, be impossible if the apical foramen is
alread, ver, large. :n apical taper (seat* is attempted, but !ith care.
2verusing large files aggravates the problem b, creating an even larger
apical opening.
46
0A. <orcing or loc)ing (binding* files into dentin produces un!anted torsional
force. This tends to unt!ist, !rapup, either !ill !ea)en, and brea) the
instrument.
CRITERIA 1OR EVAL&ATING CLEANING AN' S-A(ING
<ollo!ing the cleaning and shaping procedures the canal should e%hibit &glass, smooth'
!alls and there should be no evidence of unclean dentin filings, debris, or irrigant in the
canal. This is determined b, pressing the M:< against each !all in an out!ard stro)e.
Shaping is evaluated b, assessing the canal taper and identif,ing the apical configuration.
<or obturation !ith lateral compaction, the finger spreader should go loosel, to !ithin
1.A mm of the corrected !or)ing length. <or !arm vertical compaction the plugger
should reach to !ithin 6 mm of the corrected !or)ing length (<igure 1;0;*.
The apical configuration is identified as an apical stop, apical seat, or open. This is
accomplished b, placing the master apical file to the corrected !or)ing. 8f the master
apical file goes past the corrected !or)ing length the apical configuration is open. 8f
master apical file stops at the corrected !or)ing length a file one or t!o si"es smaller is
placed to the corrected !or)ing length. 8f this file stops the apical configuration is a stop.
When the smaller file goes past the corrected !or)ing length the apical configuration is a
seat.
INTRACANAL 0E'ICA0ENTS
4;
8ntracanal medicaments have a long histor, of use as interim appointment dressings.
The, are emplo,ed for three purposes7 1* to reduce interappointment pain, 0* to decrease
the bacterial count and prevent regro!th, and 4* to render the canal contents inert. Some
common agents are listed in Eo% 1;6 .
B+3 169 Gr+2ping* +, C+..+nl/ &*ed Intra)anal 0edi)a.ent*
>henolics
1ugenol
Camphorated monoparachlorophenol (CMC>*
>arachlorophenol (>C>*
Camphorated parachlorophenol (C>C*
Metacres,lacetate (Cresatin*
Cresol
Creosote (beech!ood*
Th,mol
:ldeh,des
<ormocresol
Jlutaraldeh,de
9alides
Sodium h,pochlorite
8odinepotassium iodide
Steroids
Calcium h,dro%ide
:ntibiotics
Combinations
<rom Walton F7 8ntracanal medicaments, Dent Clin North Am 0@7=@4, 1C@5.
(hen+l* and aldeh/de*
The ma#orit, of the medicaments e%hibit nonspecific action and can destro, host tissues
as !ell as microbes
140145
. 9istoricall, it has been thought that these agents are effective$
their use !as based on opinion and empiricism. The phenols and aldeh,des are to%ic and
the aldeh,des are fi%ative agents
146, 14;
. When placed in the radicular space the, have
access to the periradicular tissues and the s,stemic circulation
14=, 14@
Fesearch has
demonstrated that their clinical use is not #ustified
14C154
. Clinical studies assessing the
4=
abilit, of these agents to prevent or control interappointment pain indicate that the, are
not effective.
15515=
Cal)i2. h/dr+3ide
2ne intracanal agent that is effective in inhibiting microbial gro!th in canals is calcium
h,dro%ide
15@
. 8t has antimicrobial action due to the al)aline p9 and it ma, aid in
dissolving necrotic tissue remnants and bacteria and their b,products
15C161
.
8nterappointment calcium h,dro%ide in the canal demonstrates no pain reduction
effects
160
. Calcium h,dro%ide has been recommended for use in teeth !ith necrotic pulp
tissue and bacterial contamination. 8t probabl, has little benefit !ith vital pulps. Calcium
h,dro%ide can be placed as a dr, po!der, a po!der mi%ed !ith a li+uid such as local
anesthetic solution, saline, !ater, or gl,cerin to form a thic) paste, or as a proprietar,
paste supplied in a s,ringe (<igure 1;0=*. : lentulospiral is effective and efficient.
164166

Spinning the paste into the canal b, rotating a file countercloc)!ise and using an
in#ection techni+ue is not as effective. 8t is important to place the material deepl, and
densel, for ma%imum effectiveness. To accomplish this straight line access !ith Jates
Jlidden drills or nic)eltitanium rotar, files should be performed and the apical portion
of the canal prepared to a si"e H06 file or greater. Femoval follo!ing placement is
difficult.
16;
This is especiall, true in the apical portion of the root.
C+rti)+*ter+id*
Corticosteroids are antiinflammator, agents that have been advocated for decreasing
postoperative pain b, suppressing inflammation. The use of corticosteroids as
4@
intracanal medicaments ma, decrease lo!er levels postoperative pain in certain
situations$
16=
ho!ever, evidence also suggests that the, ma, be ineffective particularl,
!ith greater pain levels
15=
. Cases irreversible pulpitis and cases !here the patient is
e%periencing acute apical periodontitis are e%amples !here steroid use might be
beneficial
16@, 16C, 16=
.
Chl+rhe3idine
Chlorhe%idine has recentl, been advocated as an intracanal medicament.
1;A, 1;1
: 0B gel
is recommended. 8t can be used alone in gel form or mi%ed !ith calcium h,dro%ide.
When used !ith calcium h,dro%ide the antimicrobial activit, is greater than !hen
calcium h,dro%ide is mi%ed !ith saline
1;0
and periradicular healing is enhanced.
1;4
8ts
ma#or disadvantages are$ it does not affect the smear la,er and it is a fi%ative.
4C
TE0(ORAR4 RESTORATIONS CC+2rte*/ +, 'r% -ar+ld 0e**erB
Foot canal treatment ma, involve multiple visits. :lso, unless it is limited to a
routine access cavit,, the final restoration is usuall, not completed in the same
appointment as the root canal treatment. : temporar, restoration is then re+uired,
normall, for 1 to 5 !ee)s. 8n special situations !hen definitive restoration must be
deferred, the temporar, must last several months.
O:@e)ti=e* +, Te.p+ri8ati+n
The temporar, restoration must
1. Seal coronall,, preventing ingress of oral fluids and bacteria and egress of
intracanal medicaments.
0. 1nhance isolation during treatment procedures.
4. >rotect tooth structure until the final restoration is placed.
5. :llo! ease of placement and removal.
6. Satisf, esthetics, but al!a,s as a secondar, consideration to providing a
seal.
These ob#ectives depend on the intended duration of use. Thus, different materials
are re+uired depending on time, occlusal load and !ear, comple%it, of access, and loss of
tooth structure.
5A
Routine Access Cavities
Most access cavities involve onl, one surface and are surrounded b, dentin !alls
or b, porcelain or metal (if the restoration is retained*. The temporar, must last from
several da,s to several !ee)s. Numerous t,pes are available, including premi%ed cements
that set on contact !ith moisture (Cavit*, reinforced "inc o%ideeugenol cements (such as
8FM*, glass ionomer cements and speciall, formulated lightpol,meri"ed composite
materials (such as T1FM
L
, temporar, endodontic restorative material*
1;5
. 1ase of use and
good sealing abilit, ma)e Cavit an e%cellent routine material, but lo! strength and rapid
occlusal !ear limit its use to shortterm sealing of simple access cavities. 8FM and
T1FM provide improved !ear resistance, although their sealing abilit, is probabl,
marginall, less than that of Cavit
1;6, 1;;
. More durable restorative materials, especiall,
glass ionomer cements, tend to provide the best seal.

: double seal of J8C over Cavit
!ill provide a durable and effective barrier to microbial lea)age. 8t is not )no!n !hether
e%perimental lea)age differences based on bacterial lea)age or d,e penetration are
significant clinicall,, especiall, if thermoc,cling and occlusal loading are not part of the
testing procedure
1;=
. Clinicall,, 5mm of Cavit provided an effective seal against bacterial
penetration for 4 !ee)s
1;@
. Most critical are the thic)ness and placement of the material.
Te)hni<2e* +, (la)e.ent The +ualit, of the coronal seal depends on the
thic)ness of the material, ho! it is compacted into the cavit,, and the e%tent of contact
!ith sound tooth structure or restoration. : minimum depth of 4 to 5 mm is re+uired
around the peripher,, preferabl, 5 mm or more to allo! for !ear. 8n anterior teeth, the
51
access is obli+ue to the tooth surface$ care must be ta)en to ensure that the material is at
least 4 mm thic) in the cingulum area.
Cavit (or a similar material* is placed as follo!s7 Chamber and cavit, !alls
should be dr,. Cavit can be placed directl, over the canal orifices, or more commonl, a
thin la,er of cotton is placed over the canal orifices to prevent canal bloc)age
1;C
. (<igure
1;0@* Care must be ta)en not to incorporate cotton fibers into the restorative material,
!hich can promote rapid lea)age
1=A
.

Cavit is pac)ed into the access opening !ith a plastic
instrument in increments from the bottom up and pressed against the cavit, !alls and into
undercuts (<igure 1;0C*. 1%cess is removed, and the surface smoothed !ith moist
cotton. The patient should avoid che!ing on the tooth for at least an hour.
Subse+uent removal using a high speed bur re+uires care to avoid damage to the
access opening. :lternativel,, an ultrasonic tip can be used.
E3ten*i=e C+r+nal Brea;d+?n
Teeth !ithout marginal ridges or !ith undermined cusps re+uire a stronger filling
material (highstrength glass ionomer cement*, ta)ing care to ensure an ade+uate
thic)ness and good marginal adaptation pro%imall,. The temporar, filling material
should e%tend !ell into the pulp chamber deep to the pro%imal margin to ensure a
marginal seal. Feducing the height of undermined cusps !ell out of occlusion reduces the
ris) of fracture. <or severel, bro)endo!n teeth, a cusponla, amalgam or a !ellfitting
50
orthodontic band cemented onto the tooth (restored !ith glass ionomer cement* provides
a durable temporar, restoration and strengthens the tooth against fracture
1=1
. :t the ne%t
appointment, access is prepared through the restoration.
(ROVISIONAL (OST CRO7NS
The use of a provisional cro!n !ith an incorporated resin post ma, be re+uired,
particularl, !hen a cast post and core is being fabricated for a visible tooth !ith little
remaining coronal tooth structure. 9o!ever, the use of such a provisional cro!n retained
!ith a post (preformed aluminum post, safet, pin !ire, paper clip, or a sectioned large
endodontic file* has inherent problems. ?sing the canal space for a provisional post
precludes use of an intracanal medicament, and the coronal seal depends entirel, on the
cement. The coronal seal is generall, inade+uate !ith a loosel, fitting and mobile
provisional post and cro!n
1=0
. 9o!ever, in spite of these potential difficulties, such
provisional restorations ma, be re+uired !hile cast posts and cores are being fabricated.
Due to the potential problems, it is prudent to cement the definitive post as soon as
possible.
When such a provisional cro!npost combination is being used, the post should
fit the canal snugl, (not binding* and e%tend apicall, 5 to 6 mm short of !or)ing length
and coronall, to !ithin 0 to 4 mm of the incisal edge. : pol,carbonate shell is trimmed to
a good fit$ autopol,meri"ing material then is added to the inside of the shell to mold to
the root face and attach to the post. : provisional luting cement (Temp Eond or similar
54
cement* is placed on the coronal 4 to 5 mm of the post and root face, and the unit is
cemented into place. : provisional removable partial overdenture is a useful alternative$
access remains e%cellent, and there is little chance of disturbing the coronal seal bet!een
appointments.
L+ng>ter. Te.p+rar/ Re*t+rati+n*
<e! indications e%ist to #ustif, dela,ing the final restoration, and endodontic
procedures (other than trauma management* rarel, re+uire prolonged treatment. 8f a
temporar, restoration has to last more than a fe! !ee)s, then a durable material such as
amalgam, glass ionomer cement, or acidetch composite should be used. The pulp
chamber is filled !ith Cavit to provide a good coronal seal, and covered !ith a sufficient
thic)ness of the restorative material to ensure strength and !ear resistance. Subse+uent
access to the canal space is readil, achieved !ithout damage to remaining tooth structure
because the la,er of Cavit can be easil, removed.
55
1ig2re*
<igure 1;1 Crosssection through a root sho!ing the main canal (C* and a fin (arro!*
and associated culdesac after cleaning and shaping, using files and sodium
h,pochlorite. Note the tissue remnants that remain in the fin.
<igure 1;0 The main canal (C* has a lateral canal (arro!* e%tending to the root surface.
:fter cleaning and shaping !ith sodium h,pochlorite irrigation, tissue remains in the
lateral canal.
<igure 1;34 :. : si"e H16 file in the apical canal space. Note the si"e is inade+uate for
planning the !alls. E. : si"e H5A file more closel, appro%imates the canal morpholog,
(Courtes, of Dr. Fand, Madsen*.
<igure 1;5 :. The classic apical anatom, consisting of the ma#or diameter of the
foramen and the minor diameter of the constriction. E. :n irregular ovoid apical canal
shape and e%ternal resorption. C. : bo!ling pin apical morpholog, and an accessor,
canal. D. Multiple apical foramina.
<igure 1;6 : small file (H1A or H16* is placed be,ond the radiographic ape% to maintain
patenc, of the foramen. Note the tip e%tends be,ond the apical foramen (arro!*.
<igure 1;; <or effective irrigation the needle must be placed in the apical onethird of
the root and must not bind.
56
<igure 1;= : sodium h,pochlorite accident during treatment of the ma%illar, left central
incisor. 1%tensive edema occurred in the upper lip accompanied b, severe pain.
<igure 1;@ :. : canal !all !ith the smear la,er present. E. The smear la,er removed it
1=B 1DT:.
<igure 1;C >rocedural errors of canal transportation, "ipping and strip perforation occur
during standardi"ed preparation !hen files remove dentin from the outer canal !all
apical to the curve and from the inner !all coronal to the curve. This is related to the
restoring force (stiffness* of the files. Note in the apical portion the transportation ta)es
the shape of a tear drop as the larger files are used.
<igure 1;1A The canals have been transported and there is an apical perforation.
<igure 1;11 :. : si"e H46 file fractured in the mesiobuccal canal. E. S1M
e%amination reveals torsional fatigue at the point of fracture. Note the tightening of the
flutes near the fracture and the un!inding of the flutes along the shaft.
<igure 1;10 :. The furcal region of molars at the level of the curvature (danger "one*
is a common site for stripping perforation. E. Note the distal concavit, (arro!s* in the
furcation area of this mandibular molar.
5;
<igure 1;14 Straight line access can result in stripping perforations in the furcal areas of
molars. :. The use of large Jates Jlidden drills and overpreparation has resulted in the
stripping perforation. E. Note that the perforation is in the concavit, of the furcation.
<igure 1;15 The stepbac) preparation is designed to provide a tapering preparation.
The process begins !ith one file si"e larger than the master apical file !ith incremental
shortening of either .6 or 1.A mm.
<igure 1;16 :s an e%ample of stepbac) preparation in a moderatel, curved canal. :.
The si"e H06 master apical file at the corrected !or)ing length of 01.A mm. E. The step
bac) process begins !ith the H4A file at 0A.6 mm. C. H46 at 0A.A mm. D. H5A file at 1C.6
mm. 1. H56 file at 1C.A mm. <. H6A file at 1@.6 mm. J. H66 file at 1@.A mm. 9. H;A
file at 1=.6 mm. 8. H=A file at 1=.A mm
<igure 1;1; >assive stepbac). Smaller to larger files are inserted to their initial point
of binding and then rotated 1@A to 4;AK and !ithdra!n. This process creates slight taper
and coronal space. This permits larger instruments to reach the apical one third.
<igure 1;1= The anticurvature filing techni+ue. 8nstruments are directed a!a, from the
furcal &danger "one' to!ard the line angles (safet, "one* !here the bul) of dentin is
greater.
5=
<igure 1;1@ Straight line access in a ma%illar, left first molar !ith JatesJlidden drills
used in a slo! speed handpiece using a stepbac) techni+ue. :. The H1 Jates is used
until resistance. E. This is follo!ed b, the H0 !hich should not go past the first
curvature. C. The H4 Jates is used 45 mm into the canal. D. <ollo!ed b, the H5
instrument.
<igure 1;1C : ma%illar, first molar follo!ing straight line access !ith the Jates
Jlidden Drills.
<igure 1;0A The mesiobuccal canal is prepared using nic)eltitanium rotar, files using a
cro!ndo!n techni+ue. 8n this se+uence each instrument e%hibits the same .A; taper !ith
varied 8S2 standardi"ed tip diameters. 8nstrument !ere used to resistance. :. The
process begins !ith a .A;M56 file to resistance at 1;.A mm. E. This is follo!ed b, a .
A;M5A instrument at 1=.A mm C. The .A;M46 file is used to 1@.A mm. D. The .A;M4A at
1C.A mm. 1. The .A;M06 at 0A.A mm. <. The .A;M0A file is to the corrected !or)ing
length of 01.Amm.
<igure 1;01 Nic)eltitanium rotar, files !ith a standardi"ed 8S2 tip diameter and
variable tapered files can be used in canal preparation. 8n this se+uence, the instruments
have a standardi"ed tip diameter of .0A mm. :. 8nitiall, a 1A-.A file is used. E. This is
follo!ed b, A@-.0A. C. The third instrument is a .A;-.0A. D. The final instrument is a
A5-.0A file to the corrected !or)ing length of 01.A mm.
5@
<igure 1;00 <inal :pical 1nlargement :. The master apical file of si"e H06 at the
corrected !or)ing length of 01.A mm. E. 1nlargement !ith a H4A file to the corrected
!or)ing length of 01.A mm. C. <urther enlargement !ith a H46 file. D. <inal
enlargement to a si"e H5A file. The final instrument used becomes the <inal :pical <ile.
<igure 1;04 Fecapitulation is accomplished bet!een each instrument b, reaming !ith
the Master :pical <ile or a smaller instrument. This minimi"es pac)ing of debris and
loss of length.
<igure 1;05 <ollo!ing their use, the Jates Jlidden drills should be removed from the
handpiece to prevent in#ur,. This H4 drill !as accidentall, driven into the palm of the
dentist.
<igure 1;06 <ollo!ing straight line access in this ma%illar, molar, the Master :pical
<ile is determined b, successivel, placing small to larger files to the corrected !or)ing
length. :. : H16 stainless steel file is placed to 01.A mm !ithout resistance. E. : H0A
is the placed is placed to 01.A mm !ithout resistance. C. The H06 file reaches 01.A mm
!ith slight binding. D. : si"e H4A file is then placed and does not go the corrected
!or)ing length indicating the initial canal si"e in the apical portion of the canal is a
si"eH06
<igure 1;0; The coronal taper is assessed using the spreader or plugger depth of
penetration. :. With lateral compaction a finger spreader should fit loosel, 1.A mm from
5C
the Corrected Wor)ing /ength !ith space ad#acent to the spreader. E. <or !arm vertical
compaction, the plugger should go to !ithin 6.A mm of the Corrected Wor)ing /ength.
<igure 1;0= Calcium h,dro%ide placement. :. Calcium h,dro%ide mi%ed !ith gl,cerin
to form a thic) paste. E. >lacement !ith a lentulo spiral. C. 8n#ection of a proprietar,
paste. D. Compaction of calcium h,dro%ide po!der !ith a plugger.
1ig2re* 1692" and 1692# are pr+=ided :/ 'r% -ar+ld 0e**er
<igure 1;0@. Techni+ues for tempori"ation. 2n the left are the correct techni+ues$ either
minimal space is occupied b, cotton or no cotton pellet is used, particularl, if the
pro%imal is to be restored. 8t is !rong to pac) most of the chamber !ith cotton, !hich
leaves inade+uate space and strength for the material (45 mm are re+uired*, and cotton
fibers ma, promote bacterial lea)age. (Courtes, of Dr / Wilco%*
<igure 1;0C. Techni+ues for placing temporar, material. A, : single large &blob' placed
in the access opening !ill not seal the !alls. B, The incremental techni+ue, !hich adds
successive la,ers, pressing each against the chamber !alls, is correct. (Courtes, of Dr /
Wilco%*
6A
Re,eren)e*
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;A