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TWELFTH EDITION, 2011; CO-EDITORS: Thomas A. Levy DDS, MS, Yaara Berdan, DDS


Expected Outcomes
Course Information
Lecture Schedule
Laboratory Schedule
Articles for Literature Review
Section 1
Selection and Mounting of Teeth, Processing Radiographs
Section 2
Rubber Dam
Section 3
Endodontic Armamentarium
Section 4
Endodontic Access Preparation
Common Objectives for Access Preparations
Anatomy and Access of Maxillary Anterior Teeth
Errors in Access Preparation of Maxillary Anterior Teeth
Anatomy and Access of Mandibular Anterior Teeth
Errors in Access Preparation of Mandibular Anterior Teeth
Anatomy and Access of Maxillary Premolars
Errors in Access of Maxillary Premolars
Anatomy and Access Preparation in Mandibular Premolars
Errors in Access of Mandibular Premolars
Anatomy and Access of Maxillary Molars
Errors in Access of Maxillary Molars
Anatomy and Access of Mandibular Molars
Errors in Access of Mandibular Molars
Variations in Molar anatomy
Section 5
Shaping and Cleaning the Root Canal System
Working Length
Electronic Apex Locator
Shaping the Root Canal System
Hand Files
Balanced Force
Rotary files
USC Technique
Fine Tuning
Section 6
Intracanal Medication
Section 7
Section 8
Temporary Restorations
Section 9
Procedural Accidents
Section 10
Clinical Applications
AAE Assessment Form
Presession Form
SOAP Notes
Diagnostic Terminology
Required Radiographs
Laboratory Progress Sheet
Brown Form for Clinic
Section 11
Practical Procedures and Grading
Section 12
10 Steps to Endodontic Heaven
Section 13
Endodontic Clinic Requirements

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This manual serves as a step-by step teaching guide for the introductory laboratory course in root canal therapy
for sophomore dental students. The information included in this manual together with the lecture material
presented will serve as a foundation for endodontic treatment in the clinic. It is not intended to be a complete
representation of endodontics, but as a basic reference for techniques and concepts that are basic to endodontics.
The recommended textbook and current literature will provide important additional information. The field of
endodontics continues to evolve with new materials, products and techniques, as we continually strive to
provide our patients with the best endodontic care available. The concepts presented here are the foundation on
which to build your endodontic knowledge.
Endodontics: The branch of dentistry concerned with the morphology, physiology and pathology of the human
dental pulp and periradicular tissues. Its study and practice encompass the basic and clinical sciences including
the biology of the normal pulp and the etiology, diagnosis, prevention and treatment of diseases and injuries of
the pulp and associated periradicular conditions.

Expected Outcomes:
Recognize pulpal and periradicular disease and be able to make a correct pulpal and
periradicular diagnosis
Know tooth/pulp anatomy
Evaluate a case for treatment or referral
Expose and interpret radiographs used in endodontics
Know the composition of materials used in endodontics
Safely make an endodontic access preparation
Accurately determine working length for canal preparation
Correctly clean and shape root canals using hand files and rotary files
Correctly prepare and place root canal sealer
Completely obturate root canals by lateral condensation of gutta-percha
Accurately evaluate rendered treatment
Thoroughly complete endodontic records



In order to accomplish these goals students must



Course Information
The sophomore endodontics course has a lecture component and a lab component.
Lecture is on Thursday from 8am-9am in the Century Club Lecture Hall.
Laboratory portion is Friday from 8am-12pm or 1pm–5 pm in the SIM lab.
The first half hour of lab will be spent reviewing the assigned literature and taking the occasional quiz.
Attendance at the laboratory sessions is mandatory.
There will be one grade for the course. The lecture will comprise half of the grade and the lab will comprise half
of the grade.
The lecture grade is based on one midterm (40%), one final (50%), and 5 quizzes (10%)
The final has two parts- a written multiple choice portion and an OSCE portion (Objective Structured
Clinical Exam)
The lab grade is based on 2 midterms (25% each), and one final (50%).
Each step of the root canal treatment is to be checked off on your lab sheet prior to moving on to the next step

Cohen, S, Hargreaves: Pathways of the Pulp, Tenth Edition. 2010
Endodontic Manual 12th edition (available electronically via the intranet)
PowerPoint presentations of the lectures (available on the intranet)


Lecture Schedule




Introduction to Endodontics
Lab Orientation
Anterior Access

Dr. Levy

Hand Instrumentation

Dr. Schechter


Dr. Berdan
Principles of Root Canal
Working Length Determination


Rotary Instrumentation

Dr. Thomson


Obturation and Post



Bicuspid and molar access

Dr. Levy


Endodontic Infections

Dr. Berdan

10/21/11 Fri 8-1SIM
2-4 CC/G

Pulp Bio, Caries, and VPT

Dr. Levy


Intracanal Medication

Dr. Levy



Dr. Berdan
Dr. Berdan


Happy Thanksgiving
Safety Lecture

Dr. Levy




Pathways: Ch 9 Framework for RCT
p. 283-289
Pathways: Ch 7;1.Objectives and
Guidelines for Access Cavity Prep,
2. Mechanical Phases of Access
Cavity Preparation (thru ant access
prep), 3. Morphology and Access
Preparation of Ant Teeth
p. 150-162, 177-183, 200-203
Pathways: Ch 9; 1. Cleaning and
Shaping: Technical Issues p. 289294. 2. Canal Preparation
Techniques (through Balanced
Force) p. 319-324
Pathways: Ch 9;1. Cleaning and
Shaping: Clinical Issues, 2. Canal
Preparation Techniques (through
Balanced Force Technique)
p. 316-324
Pathways: Ch 7 Anatomy of the
Apical Root.
Pathways: Ch 8 Devices for
Measuring Root Canal Length
p. 145-150, 242-243
Pathways: Ch 8 Rotary Instruments
for Canal Preparation
Pathways: Ch 9 Nickel titanium
Rotary Instruments
Read only the Profile System
p. 294-297, 324-326
Pathways: Ch 10
Pathways: Ch 22; Clinical
Procedures – Post Placement
p. 794
Pathways: Ch 7 Posterior Access
Cavity Preparations
p. 162-165, 184-199, 204-219
Pathways Ch 15

Ch 1 from Principles and
Practice of Endodontics (Holland)
Pathways: Ch 14 Vital Pulp Therapy
p. 625-629
Pathways: Ch 9 Disinfectants and
Lubricants, Irrigation Modes and
Devices p. 311-316, 331-340
Pathways; Ch 8 Material for
Disinfecting the Pulp Space p.
Pathways: Ch 1
Pathways: Ch 17
AAE Guidelines

Manual p. 89-105

Laboratory Schedule



8-9 or 1-2 lit review
9-12 or 2-5 lab

Instrument Identification with
Plastic anterior tooth – coronal and
radicular access
Find one upper and one lower
anterior tooth
Access first anterior tooth
Hand Instrumentation

Kakehashi and Vertucci
Manual p. 3-35

8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
Midterm 9-12 lab. 1-2 written
8-9 or 1-2 lit review
9-12 or 2-5 lab

8-9 or 1-2 lit review
9-12 or 2-5 lab
8-9 or 1-2 lit review
9-12 or 2-5 lab
Exam 8-12 or 1-5
8-9 or 1-2 intro to clinic
9-12 or 2-5 lab

Rotary demonstration
Obturate first anterior tooth
Access second anterior tooth
Rotary Instrumentation
Complete anterior teeth
Find and mount one lower and one
upper (2 canal) bicuspid
Coronal and radicular access of
plastic bicuspid
Access lower bicuspid and
instrument with hand files
Complete lower bicuspid
Access upper bicuspid and
instrument with rotary files
Complete bicuspids

Manual p. 59-62, 65-71
Manual p. 63-69, 73-79

Manual p. 36-42



Practical I – RCT of an anterior tooth

No article

Video of mounting in typodont
Coronal and radicular access of
plastic molar tooth.
Find one maxillary and one
mandibular molar.
Access and instrument maxillary
molar with hand instruments

Manual p. 13

Complete maxillary molar
Access and instrument mandibular
molar with rotary instruments
Bicuspid practical (upper two canal
Happy Thanksgiving
Finish all lab work



Manual p. 42-53

No article

Articles for Literature Review
Kakehashi S et al. The effect of surgical exposures of dental pulps in germ-free and conventional laboratory
rats. Oral Surg, Oral Med, Oral Path. 20(3):340-349, 1965
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg 58:589-599, 1984
Jafarzadeh H. Ledge formation: Review of a great challenge in endodontics. J of Endodon:1155-1162, 2007
Carvalho et al. Orifice locating with a microscope. J of Endodon: 532-534, 2000
Allison DA et al. The influence of the method of canal preparation on the quality of apical and coronal
obturation. J of Endodon 298-304, 1979
Brannstrom M. The hydrodynamic theory of dentinal pain: Sensation in preparations, caries, and the dentinal
crack syndrome. J of Endodon:453-457, 1986
Ibarrola et al. Effect of preflaring on Root ZX apex locators. J of Endodon:625-626, 1999
Spencer HR et al. Review: the use of sodium hypochlorite in endodontics-potential complications and their
management. Br Dent J: 555-559, 2007
Henry M et al. Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth.
J of Endodon 27(2):117-124, 2001
Sigurdsson A. Pulpal diagnosis. Endod Topics: 12-25, 2003
Sjogren U et al. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. International
Endo J: 119-125, 1991
Torabinejad M et al. Principles and Practice of Endodontics 4th Edition. Ch 4: Pulp and Periapical Pathosis. 4967, 2009
Swift EJ. Vital pulp therapy for the mature tooth – Can it work? Endod Topics: 49-56, 2003
Barrieshi-Nusair KM. A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in
cariously exposed permanent teeth. J of Endodon: 731-735, 2006
Holland et al. Principles and Practice of Endodontics 4th Edition. Ch 1: The dental pulp and periradicular
tissues. 1-20, 2009
AAE Guidelines for the Treatment of Traumatic Injuries


Tooth Selection
You will need to select the following 14 teeth for your laboratory projects and practical exams for this course:
Laboratory Projects:
2 anteriors
1 maxillary premolar
1 mandibular premolar
1 maxillary molar
1 mandibular molar
Practical Exams:
1 anterior (preferably maxillary) for midterm
1 two canal upper bicuspid for midterm
1 molar for final
The following teeth will only be accessed and therefore the canal anatomy is not important (i.e. can have open
apices or severely curved canals: 1 anterior, 1 premolar
Selection Criteria:
Visually inspect the teeth to assure that the apices are closed and that the roots are fairly straight or with a
gentle curve. Once teeth have been visually preselected, radiographs need to be taken to allow further
evaluation. Two radiographic images must be taken to assure that the tooth has a favorable anatomy and
would be appropriate for teaching purposes. A favorable tooth must have a clear pulp chamber and root
canal space with closed apices. The two views are a buccal lingual view and a mesial distal view. Orient the
film under the tooth so that the dimple is always at the incisal edge and or the occlusal surface of the tooth.
This is to keep the dimple away from the apex of the root. If the dimple falls close to or overlaps the apex
of the root, it will distort the image and make it unreadable. The dimple should also always be pointing out.
The entire tooth must be exposed on the film (crown to apex). Both views should be taken on one x-ray.
This is accomplished by placing the radiographic foil on one half of the film while the other half is being
exposed. To maximize your time, more than one x-ray can be taken at one time in the x-ray units.


Fold a piece of foil as shown and cover half of the film. Place the tooth on the uncovered side and orient it
for a buccal lingual (frontal) view. (Wax may be used to keep the tooth in the desired position) Expose the x-ray.
Place the foil on the half of the x-ray that was just exposed and place the tooth on the uncovered side. Orient the
tooth for a mesial distal (proximal) view. Expose the film again. Process the film and observe both views.


Processing Radiographs
The liquids in the portable dark rooms are arranged as follows:
5-10 sec


30 sec

3 sec

1. Be sure the cover on the developing box is properly in place obstructing leakage of light.
2. Holding the film packet with the dimple in the upper right hand corner (away from you), peel back the
tab and partially unfold the black paper liner.
3. Attach the film clip at this upper right corner – this will prevent clamping the film near the image of the
apex of the root. (Remember, the film was oriented with the dimple toward the occlusal, or incisal of the
4. Gently agitate the film in the developer (first cup) for 5-10 seconds. Remove from the developer once a
distinct image appears on the film.
6. Remove film from the developer and rinse in the water in the cup for 3-5 seconds.
7. Gently agitate the film in the fixer (third cup) for at least 30 seconds. The image will appear to darken.
8. Remove film from the fixer and rinse in the water in the fourth cup.
9. After removing the film from the developing box, rinse it again under running tap water. Photographic
fixer will leave a brown stain if it drips onto clothing.
10. Evaluate the radiograph. If all the information you need is there and it is of good quality, continue
fixing the radiograph in a separate cup at your work area. The image is not permanently fixed until the
film has been fixed for 3-4 minutes. Over fixing the x-ray will erase the image. The fixer then needs to be
removed by running the x-ray under water and rubbing the surface gently with your fingertips. The
radiograph now needs to be set out to dry.
11. Proper radiograph criteria are:
No fixer stains
No scratches
Tooth centered mesial-distal
Radiographic apex at least 4mm from the edge of the film
Proper exposure/contrast
The main problem students have with radiographs in the preclinical course is under fixation and
inadequate rinsing of the fixer from the films.


Following approval by an instructor, the teeth can now me mounted either in an acrylic block, or in the typodont,
depending on the lab exercise. The anterior teeth will NOT be mounted and will be treated by holding in the hand.
This will allow an appreciation for the relationship between the termination of the root canal and the anatomical

Materials Needed for Mounting Teeth
Paper cups
Tongue blades
Acrylic monomer and polymer
Dental stone
Boxing wax
Laboratory knife
Bunsen burner
Wax spatula
For each tooth to be mounted in an acrylic block:

Cut a piece of boxing wax 2 cm wide and 8.3 cm long.


Make shallow score marks at 2 cm intervals along the length of the wax strip.

Fold the wax strip with the score marks toward the outside to form a box. The score marks will be
the fold lines. The 4 mm excess at one end of the original strip will extend out from the side of the box.


Fold over the flap of excess wax and weld the box together with a heated wax spatula.




Cut a 2.5 cm square of boxing wax and weld onto one open end of the box to seal that end.

Roll up a 4-5 mm ball of wax and place at the end of each root.
This ball of wax simulates a periapical lesion and helps visualize the
apical portion of the tooth during root canal treatment on the tooth.
The balls of wax CANNOT touch the floor of the wax form. Acrylic
must be present at the bottom of the block, no wax can be exposed.

Natural tooth in acrylic block

Place 20 cc of acrylic polymer in a plastic cup. Add just enough stone (approximately one gram or 1/4th
teaspoon) to very thinly cover the surface of the polymer.

Add monomer and mix until runny and pour acrylic into the box.

With the box held on the laboratory vibrator, seat the tooth into the acrylic to the level of the cervical line.
Keep any caries or restorations at least 2mm above the acrylic and do not let the apical wax touch the
bottom of the box. Align the buccal, lingual, mesial, and distal surfaces of the tooth parallel with the sides of the
box, move the tooth out of the box slightly, if necessary to keep the apical wax from touching the bottom of the
box. Remove the box from the vibrator and place it on a table remote from the vibrator.

Keep the buccal surface of tooth parallel to the
wall of acrylic block



Ensure that the acrylic is about 2mm below the CEJ of the tooth.


Hold the tooth in place until the acrylic is at a consistency that will prevent the tooth sinking into the mix.


Allow the acrylic to set and cool, then strip away the wax with a lab knife.
The acrylic will damage the trimmer disc.




Take 2 radiographic views
of the mounted tooth

Use rope wax to hold the
film in place. Place the
sextant at a 20 degree
angle for the angled view

Mount typodont on manikin

Place rod (or high vacuum suction tip) to hold the mandible in

The rubber dam is one of the most important pieces of equipment in the endodontic armamentarium. One
should never perform root canal therapy without isolating the tooth with a rubber dam. The rubber dam protects
both you and the patient. The rubber dam provides unobstructed access to the tooth. It prevents salivary
contamination and protects the patient from leakage of sodium
hypochlorite and slipped files.
To get accustomed to using the rubber dam, it needs to be placed on the acrylic
block as well as the typodont. The standard of care requires the use of a rubber
dam for endodontic treatment. Medico legally, there is no excuse for not using
the rubber dam. In rare instances, i.e., when the tooth is tipped or the adjacent
teeth need to be used as a guide for access, the rubber dam can be left off for
the INITIAL access, orifice identification with an endo explorer, and the
occlusal reduction. During all other aspects of root canal therapy, the rubber
dam must be used.
In clinic, most of the time only the tooth to be treated will be isolated. (Single
tooth isolation)
File in the large intestine as a result of
not using a rubber dam during treatment.
Obviously, this is not where a file
belongs!!! And this is completely

Rubber dam instruments,
Frame, punch, clamp

Punch rubber dam with
the plastic frame in place


Rubber dam clamps

Determine proper clamp size, place floss for safety and place securely on the tooth.

Place the rubber dam sheet over the clamp and position the frame. When working with the typodont, place the
clamp on the adjacent tooth. This will prevent dislodgement of the tooth.


#2 and #4 round, #557 straight fissure, 169L, Endo-Z, friction-grip burs
These burs are used to outline the access preparation and to penetrate into the pulp chamber. Non-end
cutting burs such as Endo-Z are used to smooth the axial walls and refine the access preparation. These burs are
used in the high speed handpiece.

#2, #4, #6 right angle latch-type round bur
These burs are used to expand the deep part of the access preparation when necessary. They may be used
for preparation into the pulp chamber after the initial access is made with high speed round or diamond
burs. These long shanked burs are not necessarily used because of depth to be penetrated but they allow for
better visibility and an increased ability to angle the bur correctly in relation to the long axis of the tooth.
These burs are used in the slow speed handpiece.


Endodontic Excavator EXC 1, 2, 3
Long-shanked spoon excavator designed to remove debris and other materials from the pulp chamber.

Endodontic Explorer EXDG16/17
A sharp endodontic explorer is used to locate canal orifices and for chipping through calcifications. Do not
heat this instrument.

Gates-Glidden Drills
Latch-type Gates-Glidden drills are used to open the coronal 1/2 to 2/3 of the canal. Gates-Glidden drills
are intended to cut upon withdrawal from the canal. The cutting flutes are on the back of the instrument
head rather than the tip. Size 2=0.70mm; Size 3=0.90mm; Size 4=1.1mm
We do not use size 1 Gates Glidden drills (0.5mm) since they tend to break at the bud, not at the shank.


Files The symbol for stainless steel is 

The symbol for nickel titanium is

stainless steel hand files

NiTi hand files

In the school’s endo block, file sizes 8-20 are stainless steel, file sizes 25-60 are nickel titanium, and file
sizes 70-100 are stainless steel.

Endodontic rotary files
Rotary files are made from nickel-titanium and are more flexible than stainless steel.
There are many different types of nickel titanium rotary systems. At the USCDS we will be using the
Profile System from Tulsa Dent
Each ring at the top of the handle
indicates a 0.02 taper. We are
using the 0.04 taper Profiles as
indicated by 2 rings.
The color band on the handle
indicates the tip size and
corresponds to the ISO color

Silicone Stoppers
Used to set working length on files, spreaders, and pluggers.


Endodontic ruler (metal)
Sterilizable finger rulers are used to set lengths on files, gutta percha points, spreaders, and paper points
during root canal treatment. The flat ruler is used to make measurements from conventional radiographs.
When using digital radiography, use the measurement tool to approximate distance to the pulp chamber
canal length, etc… Students should have their own long ruler.

The endo ring is a convenient way to hold
endodontic files and gates glidden during a
procedure. The blue ring is autoclavable and the
foam insert is disposable. HOWEVER, IN

Moldable material used to obturate prepared canals. Gutta-percha comes in various sizes and shapes.
There are standardized and conventional gutta percha cones. The standardized gutta percha cones
correspond to the master apical file. The standardized gutta percha cones come in sizes 15-90+ and have a
0.02 taper. (0.02 increase in width for each mm increase in height). The conventional gutta percha cones
are named for the size at the tip and the size of the body. In the cold lateral obturation technique (which is
currently being taught at the USCSD) they are used as accessory cones.
The tolerance for gutta percha points is less stringent than for files and is 0.05mm. For that reason size #40
gutta percha can be anywhere from #35 to #45. (#40 +/- 0.05). If a gutta percha point does not go length or
is too long, then try another gutta percha point prior to re-shaping the apical portion of the canal. The FF
and MF gutta percha points are used as accessory points in lateral condensation.
We will use standardized .02 taper cones in sizes 25-80 for the main cone and accessory cones FF and MF.
(FF- a fine tip and a fine body, MF – a medium tip and a fine body) for use with the D11T spreader and
size 20 and 25 standardized gutta percha cones for use with the #25 and #30 finger spreaders, respectively.

Standardized gutta percha cones color
scheme is the same as for files

Conventional (non-standardized) gutta
percha cones

Iris scissors
Either straight or curved are, on rare occasions, used for cutting the tips of gutta-percha cones when fitting
a master cone.

Irrigation Syringe and Needle
An irrigation syringe and needle is used to deliver irrigants into the chamber and coronal portion of canals.
By pulling back on the syringe it can also be used to dry the canal and minimize the number of paper points
used. If used haphazardly, the irrigation syringe can cause serious injury, a sodium hypochlorite accident.
This is a completely preventable mishap for which there is no excuse. Refer to the article on sodium
hypochlorite accident in the supplementary reading. DO NOT WEDGE NEEDLE INTO CANAL!


Note the bend in the needle. It serves two
purposes 1) ease of access, 2) length
control. A rubber stopper can also be
placed on the needle for length control.
*Note- the needle is NOT bent at the hub

Paper points
Paper points come in many sizes and are used to dry fluids from canals. Remember to aspirate the canal
with your irrigation syringe first prior to using the paper points.

Hand Spreader, D-11T
This instrument is used to laterally condense gutta percha during obturation of the prepared root
canal system. Place a rubber stopper on the spreader as a guide for insertion depth. Non-standardized gutta
percha cones (FF, FM, MF) are used with this spreader.


Nickel Titanium Finger Spreader
This instrument is made of nickel titanium which allows for deeper penetration of the spreader into
curved canals. It has an 0.02 taper and results in less dentin deformation than a non-standardized
spreader. It also allows for easier rotation and movement than a hand spreader. When obturating with
the size 25 spreader, use standardized size 20 gutta percha points. When using the size 30 spreader, use
the size 25 gutta percha points.

Glick #1
The paddle end of the Glick is used to carry and place temporary filling material while the plugger end is
used to compact the temporary filling material. Both ends may be heated and used to sear off and remove
excess gutta-percha and to soften gutta-percha as needed.

Gutta-percha is seared off at the canal orifice at the end of completion of lateral condensation. The plugger
is a flat-ended instrument used to condense the cervical portion of this warm gutta-percha. (The plugger
end of the Glick instrument can also be used for this purpose. It is also used for the entire compaction of the
heat-softened gutta-percha with the vertical compaction technique. DO NOT USE AS A HEAT


Film clip
It is mandatory that you use film clips. YOU MUST BUY AT LEAST 4. They are used to hold
radiographic films during processing, viewing, and air-drying. A hemostat or other pliers should not be
used to hold the film. If you lose your clips, buy more.

This temporary material is used to the fill access opening. It is a thick putty-like paste requiring no mixing
and sets upon contact with water (saliva). It has better sealing ability but less strength than IRM.

This material is used to fill an access opening. Powder and liquid must be mixed to make a thick putty-like
paste. IRM also comes in capsules for ease of mixing.



Section 4 – Endodontic Access Preparations
1. Explain the objectives of endodontic access
2. Cite the most common error in making endodontic access
3. Discuss procedures to avoid making errors in endodontic access
4. Discuss general principles in controlling the depth of access
5. Describe the two basic outline shapes of access and give the reason for their shapes

Common Objectives for Access Preparations
Root canal treatment involves the removal of unhealthy pulp tissue followed by the filling of the root
canals with an inert filling material. Every root canal treatment begins with the preparation of an access
cavity. The access cavity is the opening prepared in a tooth to gain entrance to the pulp canal system for the
purpose of shaping, cleaning, and obturating. The access reflects the anatomy of the pulp chamber and
should allow straight line access to each canal. The access preparation is the critical first step in root canal
therapy and the key to successful treatment. A poor access cavity results in difficulty locating and
negotiating canals. This results in inadequate shaping, cleaning, and obturation of the root canal system.
Lack of straight line access subjects files to more stress during cleaning and shaping, since they are
negotiating an unnecessary coronal curve. If there are further curves within the canal system the stress on
the instrument is further multiplied. This contributes to instrument separation and aberrations of the canal
Most of the procedural errors that occur during root canal therapy are directly or indirectly related
to the access opening made into the tooth.

File inserted into a canal prior to
adequate access, results in inability
to properly negotiate the canal

Removing the roof of the pulp chamber
and the dentin triangles will result in
straight line access. A round bur working
from the inside out (B)

or a safe ended high speed bur
will accomplish this (C).


Initial Steps in the Preparation of Access Cavities
1. Evaluate the morphology, angulation, and long axis of the tooth. Study the pre-operative radiographs. These steps help prepare a mental image of the approximate preparation depth and the bur’s
angulation in three dimensions
2. Measure the initial radiograph for the distance from the occlusal or incisal surface to the roof and to the
floor of the pulp chamber (usually 4-6 mm to the roof of the chamber and 8-10 mm to the floor). Record
the measurements. Stay within these dimensions when making the access preparation. A bitewing
radiograph gives a more accurate representation of the pulp chamber and the extent of caries than a PA.
This is one of the reasons a bitewing film is necessary prior to starting root canal therapy.
2. Remove ALL caries and defective restorations BEFORE entering the pulp chamber. Caries and
defective restorations must be removed for three reasons: (1) to mechanically eliminate as many bacteria as
possible from the interior of the tooth, (2) to eliminate the possibility of any bacteria-laden saliva leaking
into the prepared cavity from the area of decay, (3) the restorability of the tooth can also more adequately
be determined once all the caries are removed, and (4) fragments of the restoration or carious dentin does
not occlude the canals.
3. BUILDUP -A provisional buildup must be done to replace any missing pulp chamber walls prior
to beginning instrumentation. This will facilitate isolation of the pulp space from saliva and will help
confine irrigants to inside the tooth. Provisional buildups may be done with composite, glass ionomer,
IRM and other appropriate materials.
4. Make an outline of the access preparation about 2 mm into tooth structure with a #557, #2 or #4 F.G.
5. Pulp horns are almost directly under the corresponding cusp tips - a little toward the central pit of the
tooth. Review tooth anatomy prior to starting access.
6. Make initial penetration into the pulp chamber with the same bur used for the outline of the access
preparation (or a similar sized bur in the slow speed handpiece) toward the most prominent part of the
chamber. The ―normal‖ pulp chamber in all teeth (those without excessive calcification) is usually
encountered within 4-6 mm of the tooth surface. (The cutting surface of a 557 bur is 4mm.)
If the pulp is not entered within this depth, radiographs must be taken and the angle and
direction of approach must be re-assessed and corrected or perforation of the tooth may occur.
7. Reduce the occlusion on a posterior tooth prior to entering the pulp chamber unless it has an existing
serviceable crown. A cusp may prevent straight line access to a tooth and it also assures a flat reproducible
reference point for length determination. Light occlusion on a posterior tooth also minimizes post-operative
pain and decreases the chance of the tooth fracturing. The occlusal reduction should result in flat
reproducible reference points. It is not like an occlusal reduction for a crown prep.
8. Once initial penetration into the pulp chamber has been made, the remainder of the roof of the chamber
is removed by withdrawal strokes with the latch type slow speed round bur, cutting with the edges on the
top of the bur or by using the EndoZ bur which is a safe ended bur. (The key to remember here is that the
access is not completed by cutting in an apical direction, but rather by removing the roof by cutting in a

horizontal and coronal direction. The concept is intended to prevent ledging of the canal or perforation of
the root surface during the access preparation.)

Using a round bur to remove the roof of
the pulp chamber

After complete removal of the pulp chamber roof, the preparation is refined. Special burs with a
blunt tip, such as Endo Z burTM or Endo Access bur TM have been designed for this purpose and allow
preparation without removing dentin from the pulpal floor. (However, care needs to be taken to prevent too
much removal of dentin from the chamber walls.) Canal orifices are located with an endodontic explorer.
All tissue, debris, pulp stones, and other loose mineralizations are removed. The pulp chamber is
disinfected by rinsing with sodium hypochlorite solution.

Using an EndoZ bur to refine the access

10. Once the access is completed in a clinical case, it should be possible to view the orifice of every
canal with minimal movement of the mirror. This is known as straight-line access.

Although the above steps should have completed the access cavity, in certain cases it may need to be
refined during the subsequent procedures to assure straight line access. It is often necessary to refine the
access as the canals are instrumented to assure straight line access. However, do not remove structure from
the walls or floor of the pulp chamber unless specifically instructed to do so by an instructor. Unnecessary
dentin removal results in weakening of the tooth.
12. To maintain a sterile work environment and to prevent an air embolism, water and the air water
syringe should not be used once the pulp chamber has been entered. The tooth should be irrigated with
sodium hypochlorite and the surgical suction can be placed inside the chamber to dry the tooth. The

irrigation syringe can also be used to aspirate the irrigant from the canals thereby quickly and efficiently
drying the canal and using fewer paper points.

Access Cavity Preparations in Individual Teeth
All access preparations are not arbitrary, but are dictated by the internal anatomy of the given tooth.
Using anatomical details of a tooth as landmarks facilitates access cavity preparation.
There are only two basic outline shapes of access preparations that encompass all teeth - oval and
triangular. A round preparation is never correct. A small, round access opening is under-extended in at
least one dimension, and a large, round opening is overextended in at least one dimension. Maxillary
incisors and all molars have triangular preparations, the molars sometimes having modifications of the
triangular form (trapezoid). All canines, premolars, and mandibular incisors have oval outlines in a facial
lingual direction.

In order to accomplish these objectives, adequate enlargement of the access must be made.
The most common error in making endodontic access is making it too small. The most critical error
is making the endodontic access in the wrong place. Excessive removal of tooth structure by
overextension of the access will needlessly weaken the tooth and make it more susceptible to fracture.
However, saving tooth structure at the expense of a proper access could result in failure of the treatment
and complete loss of the tooth. .
The illustrations following each tooth type depicts the size, shape, and location of the pulp space within
each tooth. Each illustration gives the following information:

In addition, the percentage of the more common morphologic variations of the roots and canals are given. With

many of the tooth groups, the percentages do no total 100%. The remaining percentage represents the less
common variations not illustrated.

Anatomy and Access of Anterior Teeth
1. Discuss the internal anatomy of all anterior teeth
2. Describe the access outline and process for making access into all anterior teeth
3. Describe common errors in making access in anterior teeth
The maxillary central incisor has a roughly triangular shaped crown with its pulp chamber reflecting that
same shape. The triangular shape of the pulp chamber creates two pulp horns, mesial and distal. During
endodontic treatment, all tissue must be removed from the pulp horns. If tissue is left behind in the pulp
horn extensions, pigments from the breakdown of the tissue can cause discoloration of the tooth.
The average length of the maxillary central is 22.5mm. Maxillary centrals very rarely have multiple
canals. They often have accessory canals, though, which are not visible on a radiograph before
endodontic treatment. Accessory canals may be implied on the radiograph of a tooth with necrotic pulp
by the location of a radiolucency in the bone adjacent to an accessory canal – a radiolucency is usually
centered on its source. Accessory canals can often be visualized after obturation of the root by the
presence of radiopaque sealer in the accessory canals. Approximately 45% of maxillary centrals have the
foramen located away from the anatomic terminus (apex) of the root, usually to the buccal or lingual.

Access into the maxillary central is triangular in shape, reflecting the triangular form of the pulp chamber.
It is made by first cutting the triangular outline into tooth structure to a depth of 2mm. A #4 F.G. round bur
or a fissure bur such as the 557 are usually used for access. Hold the bur perpendicular to the lingual
surface of the tooth. Entrance is always gained through the lingual surface of all anterior teeth. (Unless the
tooth is rotated and the lingual surface is not accessible.) This is purely for aesthetic reasons. Initial
penetration into the pulp chamber is made with the bur just above the cingulum as shown in the picture. A
common error is to begin the cavity too far gingivally. Make an outline extending from the cingulum to 2/3


of the cusp height 2mm into tooth structure.
At this point change the angle of the bur so it is parallel to the long axis of the tooth (mesial/distal and
buccolingual inclinations) and place the tip of the bur in the most cervical part of the access outline (cingulum

Change of angle of bur for access

Make initial penetration into the pulp chamber. Do not penetrate more than 4 mm from the lingual surface –
there is a risk of perforating the buccal surface. Get help if you have not found the pulp chamber at this
point. After penetration is made, the chamber is unroofed with withdrawal strokes, cutting with the top of the
round bur. It is very important to include the pulp horns in the access cavity so that all tissue and discolored
dentin are removed to prevent discoloration of the tooth. Removal of the pulp horns is evaluated with an

Need to remove the lingual triangle
Need to remove the incisal triangle

Discoloration of crown caused by failure to
remove pulp tissue during access

A round #2bur can be used for
this purpose laterally and


Checking for the removal of the pulp horns with the endo explorer.
The lingual overhang of dentin partially obstructing the orifice of the canal (the lingual triangle) is removed with
an Endo Z bur or a Gates-Glidden drills creating straight-line access into the canal.

Maxillary Lateral Incisors
The maxillary lateral has a coronal shape similar to the central but with smaller dimensions. The average
length is 22 mm, almost the same as the central. The shape of the pulp chamber in the lateral is triangular
like the central. Due to the smaller dimensions of the lateral, though, the access is usually oval. If the lateral
incisor is larger, with a corresponding larger pulp chamber, the outline may be triangular.
Maxillary lateral incisors very often have a moderate to severe distal curvature in the apical 1/3 of
the root with the foramen most often corresponding to the anatomic apex. The curve may also have a
palatal aspect to it. Mishandling of the apical curvature during instrumentation can result in failure of the
endodontic treatment (the maxillary later incisor has one of the highest failure rates).

Access is accomplished similarly to the maxillary central incisor. The outline is usually oval (as opposed to
triangular in the central) due to the smaller pulp chamber.

Maxillary Canines
The coronal pulp is ovoid in cross-section and the access preparation reflects this shape. The access

cavity is prepared as described for the maxillary and lateral incisor. The point of entry is at the cingulum
with the tip of the bur aiming for the center point at the CEJ level. The occlusal outline form is ovoid as
the single pulp horn does not tend to fan out to the mesial and distal; however it is broad labiolingually.
As with the central and lateral, the lingual triangle must be removed. The incisal extension is about 2/3 of
the distance to the cusp tip.
The maxillary canine is the longest tooth in the dental arch with an average length of 26.5mm. The root
may have mild to moderate apical curvature and the foramen is usually close to the anatomic apex.
Accessory canals occur less frequently than in maxillary incisors. The root apex may have a disto-labial

Errors in Access Preparation of Maxillary Anterior Teeth

Buccal perforation due to failure to change angulation to an apical direction when

Gouging of buccal wall due to failure to recognize the lingual inclination of
maxillary anterior teeth.



Inadequate preparation due to failure to remove the buccal and lingual



Ledge formation caused by using a too large instrument through an inadequately shaped access and
inadequate coronal canal preparation


Discoloration of the crown by a failure to remove the coronal pulp remnants
(inadequate extension of triangular shape)

Mandibular Central and Lateral Incisors
The mandibular central incisor is usually the smallest tooth in the mouth. Apart from the fact that the
mandibular central incisor is somewhat smaller than the lateral incisor, the teeth are quite similar and
therefore the access cavity preparation is similar. The entry point for access is just above the cingulum with
the bur angled perpendicular to the surface of the entry point. As with the maxillary incisors, after a 2mm
penetration, the bur is re-angled to follow the long axis of the tooth. As these teeth are narrow
mesiodistally, the main concern is minimizing the width of the preparation.
Mandibular incisors have their greatest cross-sectional dimension in the facial-lingual direction and are
very narrow mesio-distally. The pulp space is, therefore, ribbon shaped reflecting the same dimensional
proportions as the exterior root surface. Average length of mandibular incisors is 20.7mm. Two canals or
a dumbbell shaped canal occur in 30% of mandibular central incisors and 45% of mandibular
lateral incisors. However, two separate foramina occur 5% of the time in central and 15% of the time in
laterals. The second canal (or second lobe of the dumbbell shaped canal) is usually located toward the
lingual after initial access is made. It is very often obscured from view by an overhang of dentin that must
be removed to make complete access. The oval shaped access preparation is made very carefully and is not
expanded at all mesio-distally beyond the width of the #557 or #4 round bur. A #2 round bur may be used
to make the access preparation to prevent overextension. Access extends from the cingulum, 2/3 the
distance to the incisal edge or, sometimes, even to the incisal edge. Severely rotated mandibular incisors or
those with lingually tipped crowns may require access on the labial surface. This access is easily restored
with bonded composite.
Instrumentation is done in mandibular incisors at the expense of the facial and lingual surfaces of the
canal, sparing the mesial and distal surfaces. After obturation, the clinical radiographic view may not
reveal much taper in the shape of the canal, but if a view were taken from the proximal, a significant taper
would be seen. A mandibular incisor should always be treated as if it has 2 canals.


a. Incomplete removal of the lingual shoulder
resulting in missed lingual canal.
b. Removal of lingual shoulder resulting in
finding the lingual canal.

Mandibular Canine
The mandibular canine has an average length of 25.6mm. It is a fairly straightforward tooth with
minimal complications, similar to the maxillary canine. The mandibular canine, though, may on occasion
have two canals or two roots evidenced on the radiograph by an apparent termination of the visible canal
somewhere at mid-root level. Where two canals are present, it is usually easier to gain access into one than
the other. Nonetheless, both must be located and treated. Frequently the foramen exits to the buccal or
mesial (35%-50%).
The access preparation is oval as in the maxillary canine.


IMPORTANT NEWS FLASH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SUMMARY: The most common error made in accessing anterior teeth is perforation of the facial
crown or root surface. If the canal is not easily encountered within the confines of the crown of the tooth,
an instructor must be consulted. Remember to estimate the location of the pulp chamber and if you do
not find it there take a radiograph and ask for help
In order to minimize perforations you must evaluate the radiographs and estimate where the pulp chamber
will be found and determine if you are comfortable with this search.
If so, then go to this predetermined location. If you do not find the pulp chamber at this point, take at least
2 radiographs (at different angles) to help guide you along with faculty consultation. Always have an
objective when you cut on a tooth. When in doubt, ASK FOR HELP!!

Errors in Access Preparation of Mandibular Anterior Teeth
1) gouging and perforating buccal as in maxillary anterior teeth
2) ledge formation due to no straight line access as in maxillary anterior teeth
3) discoloration of crown as in maxillary teeth
4) gouging due to failure to recognize angulation of tooth


5) failure to treat the second canal due to inadequate access


6) no straight line access and no instrument control due to access in wrong location. Access is never
through the proximal. In rotated teeth access may need to be placed in buccal or through incisal but that still
allows for straight line access.

Be able to discuss the internal anatomy of maxillary premolars including the relative incidence of two
Be able to discuss the importance of occlusal reduction.
Be able to describe the access outline and process of making access into premolars.
Be able to discuss the internal anatomy of mandibular premolars including the relative incidence of
two canals
Be able to discuss the apical anatomy of mandibular premolars.

Maxillary First Premolar
The maxillary first premolar has two canals frequently enough that it must always be assumed there are two
canals until proven otherwise. Studies have revealed two separate canals and foramina in 73% of first
premolars. There is even a chance the first premolar may have three canals – a very difficult treatment situation.
The root structure may be a single bi-canalled root, a common trunk with apical separation of two root apices, or
two separate roots for their full length. Average length of the first premolar is 20.6 mm. The premolar has
significant coronal mass but a relatively small cervical diameter so; care must be taken in making the access
preparation. Along with mandibular incisors, the maxillary first premolar is the most likely tooth to be
perforated during access.


The access preparation is oval in shape with the largest dimension in the buccal-lingual direction. Buccal
and lingual extensions are 2/3 the distance up the cusp tips. Mesial-distal extension need be no greater than
the width of the #4 round bur.

Maxillary Second Premolar
The average length of the maxillary second premolar at 21.5 mm is slightly greater than that of the first
premolar. The incidence of two canals is almost 50% and one canal is slightly over 50%. There is a 1%
occurrence of three foramina. Two orifices do not always correspond with two foramina - there may be two
orifices with the canals joining to exit through one foramen. In this instance, the lingual canal is usually
straighter and treated as the ―primary‖ canal, and the buccal canal is treated as the ―secondary‖ canal.
Lateral canals may occur but less often than incisors. The crown is wider mesio-distally and narrower
bucco-lingually than the first premolar. Apical accessory canals are common (60%). The apical foramen is
often on the lateral surface of the root (78%). Access is oval in shape like the first premolar and with
similar extensions.


1. Measure, on a bitewing radiograph, the distance from the occlusal surface to the roof of the chamber and
to the floor of the chamber. Subtract 1mm to allow for occlusal reduction. This gives you an estimate of
where you should first encounter the pulp chamber and at what level you should find the
orifices of the canals. If you do not find the pulp chamber where you expect it, take a
radiograph and get help.
2. Using a #557 F.G. bur, reduce the occlusion 1mm, and then make an outline of the
access preparation 2mm into tooth structure. The preparation is centered mesio-distally
and is no wider than the diameter of the bur. Buccal-lingual extension is 2/3 the way up
the buccal and lingual cusps.


In the center of the outline, make initial penetration into the pulp chamber - it should be encountered
within 4-6 mm from the occlusal surface. In order to avoid furcal perforation in a multi-rooted premolar,
do not exceed 8 mm in penetration. Take radiographs if pulp chamber is not found. Evaluate location of
access and pulp chamber and adjust appropriately.
4. Locate the opening into the chamber with the endodontic explorer.
5. With light horizontal and outward (occlusal) motions, unroof the rest
of the chamber extending buccally and lingually.
6. Smooth the walls with the Endo-Z bur and create the occlusal
reference point(s).
7. Locate the canal orifice(s) with the DG16 endodontic explorer
Access cavity of maxillary premolars

Errors in Maxillary Premolar Access
1. Underextended preparation exposing only pulp horns. The white color of the roof of
the pulp chamber is a clue to a shallow cavity. The floor of the pulp chamber is darker
than the walls and roof of the chamber. There are also developmental groves (dark lines)
that extend from one orifice to the other.
2. Overextended preparation from a fruitless search for a receded pulp. The enamel walls have
been completely undermined. Gouging relates to failure to refer to the radiograph, which
clearly indicates pulp recession.


3. Perforation at the mesiocervical indentation. Failure to observe the distal-axial inclination of
the tooth led to bypassing receded pulp and perforation. The maxillary first premolar is one of the
most commonly perforated teeth.

Mandibular First Premolar

For a tooth that almost always has a single root, the mandibular first premolar has a great variety
in canal anatomy. The anatomy can be as simple as a single orifice and single foramen or as
complex as a single cervical orifice dividing in the mid-root into three canals terminating in three orifices.
Single-canal first premolars may have an apical arborization that divides into multiple apical foramina. The
single canal form occurs 70% of the time and two canals combining to exit in one foramen 4% totaling 74% of
first premolars with a single foramen.
The most common deviation from the single canal form is a single orifice dividing mid-root into two canals
with two foramina. This condition must be anticipated since it accounts for 25% of mandibular first premolars.
The radiographic appearance of a canal ―disappearing‖ mid-root is indicative of a bifurcation of the canal.
Delicate probing into the canal with a small file can also reveal much of the internal anatomy and can confirm
the presence or absence of a canal bifurcation.
Average length of the first premolar is 21.6 mm. The foramen very often deviates from the apex (85%-90%).
1/3 of deviations are toward the distal.
Access in the mandibular first premolar, like all other premolars, is oval to encompass the oval shape of the pulp

and to aid the search for divisions in the canal, extension to the buccal and lingual is 2/3 the distance to the cusp

Mandibular Second Premolar
In contrast to all the potential complexities of the mandibular first premolar, the second premolar is
relatively simple. Up to 85% of the teeth have a single canal. It must be kept in mind; however, the
remaining percentage of teeth may have any of the anatomic forms seen in mandibular first premolars. The
average length of the second premolar is 22.3 mm. Access is oval in shape, with dimensions and
extensions similar to the first premolar. Frequently there are deviations of the foramen from the root apex,
most often to distal.
An important consideration with both mandibular premolars is their proximity to the mental nerve.
Inflammation from these teeth can affect the mental nerve resulting in some degree of paresthesia of the lip.
Occasionally, even permanent paresthesia may result if gross over-instrumentation or over-filling occurs.
Also, inter-appointment and post-treatment sensitivity associated with endodontic treatment in these teeth
can be greater than other teeth because of their proximity to the nerve.

Mandibular Premolar Access Preparation Technique
1. The outline form of the access cavity for all mandibular premolar teeth is oval. The crown of the
mandibular premolars often tilts in a lingual direction so that the occlusal surface has a lingual
inclination. The lingual cusp is more developed in the mandibular second premolar and so the lingual
inclination is less pronounced than in the first premolar. This must be taken into account during
access cavity preparation or a buccal root perforation may occur. With the bur held parallel to the
lingual axis begin the access outline on the occlusal surface in the middle of the central groove. The
point of entry for the first premolar is slightly buccal to the central occlusal groove.
The bur will be felt to ―drop‖ when the pulp chamber is reached. If the chamber is calcified, initial penetration is

continued until the contra-angle handpiece rests against the occlusal surface. This depth of 9 mm is the usual
position of the canal orifice that lies at the cervical level. In removing the bur, the occlusal opening is widened
buccolingually to twice the width of the bur to allow room for exploration.
2. Working from inside the pulp chamber to outside, a regular-length round bur is used to
extend the cavity buccolingually by removing the roof of the pulp chamber. The Endo ZX
bur is used to smooth out the access and achieve straight line access.
3. Extend the cavity outline bucco-lingually. Keep the mesio-distal dimension smaller
than the bucco-lingual dimension.


Errors in Mandibular Premolar Access
1. Perforation at the distogingival caused by failure to recognize that the premolar has tilted to
the distal.
2. Loss of instrument control due to improper access preparation. Access is always through the
occlusal in posterior teeth.
3. Buccal perforation due to failure to orient the bur along the
long axis of the tooth, and orienting it according to the occlusal
table which tilts lingually.

1.Be able to discuss the internal anatomy of maxillary molars.
2.Be able to discuss the importance of occlusal adjustment.
3.Be able to describe the various canal configurations in mesio-buccal, disto-buccal and lingual roots.
4.Be able to describe and demonstrate proper access preparation for maxillary molars.
5. Be able to keep thorough and accurate treatment records.


Maxi1lary First Molar
The maxillary first molar has the most complex root canal anatomy of all teeth in the mouth. The
three principle roots of the tooth have markedly different anatomic features. The mesio-buccal root is the
most complex of the three roots and if it stood alone as a single root it would be one of the most varied
roots in the mouth. The mesio-buccal root almost always has some apical curvature, sometimes as great as
90° or more. The most enigmatic feature of the mesio-buccal root is the occurrence of a second canal (and
sometimes a separate second root). The principle mesio-buccal canal is often referred to as the MB1. The
MB1 orifice is relatively easy to locate after access is made, it being located at one of the angles of the base
of the triangle formed by the three major orifices. The mesial lingual or MB2 orifice is significantly smaller
than the MB1 and is located lingual to it. The MB2 may be found to be on the line connecting the MB1 with
the lingual orifice or mesial to that line. An overhang of dentin frequently obscures the orifice necessitating
removal of the overhang before the orifice can be identified. The incidence of a MB2 canal has been
reported to be from 75-95% by various investigators. Whatever the true percentage of maxillary first
molars with two separate foramina in the mesio-buccal root, the percentage with two separate orifices, MB1
and MB2, is greater. So, the MB2 must always be assumed to be present, sought out, and treated
unless found not to exist.
The disto-buccal root of the maxillary first molar is a relief after dealing with the mesio-buccal root. It
usually has a single canal. The disto-buccal and mesio-buccal roots are about the same length with the
mesio-buccal sometimes being slightly longer.
The lingual root is also fairly straightforward. The primary anatomic variation of the lingual root is a
curve toward the buccal in the apical 1/3 of the root. This curve is very common but is not detectable
radiographically unless the curve is extreme. Then the apex may have a knob-like or bull’s-eye appearance
on the radiograph. Occasionally, the curve may project more to the distal than to the buccal, which will be
visible on the radiograph.
The second anatomic variation of the lingual root, although rare, is the presence of a second canal.
Variations of the maxillary first molar may go so far as to present four separate roots with evenly spaced
orifices forming the corners of a square or even five roots, each with a separate canal. The lingual root is
usually 1.5-2 mm longer than the buccal roots and average length for the tooth is 20.8 mm.
Access for the maxillary molar as for all molars is triangular. For maxillary molars, the base of the
triangle is toward the buccal and a nearly right angle is formed between the base and the line connecting to
the lingual orifice. The preparation is positioned mesial to the transverse ridge. Variations from the threesided form may be made when searching for the MB2 by adding a fourth short side, if necessary, forming a


Maxillary Second Molar
The most striking differences in morphology of the maxillary second molar compared to the first molar
are the closer grouping of the relatively straighter roots, and slightly shorter length (average 20 mm). All of
the anatomic variants of the first molar can occur in the second molar but generally to a lesser degree. The
location of orifices of mesio-buccal and disto-buccal canals can be quite different from the first molar with
the disto-buccal positioned more toward the lingual than the mesio-buccal orifice. The more the occlusal
surface of the tooth is shaped like a triangle, the more likely the disto-buccal orifice will be located toward
the lingual. When in this location, the orifice may be mistaken for a perforation through the floor of the
chamber into the furcation.
Access form is triangular like the first molar, but the triangle may be flatter if the disto-buccal orifice is

located toward the lingual.

Maxillary Third Molar
Root canal morphology of the maxillary third molar is highly unpredictable. It may be much like a
shorter version of the second molar, it may have two canals, or it even may have just one conical root with
a high volume canal. Radiographic review of the anatomy should be made before commencing endodontic
treatment. The average length is 17 mm.
Access is similar to the other two molars. If a single canal is present, the access may take on a more

oval shape.

Access of maxillary molars
Measure, on a bitewing radiograph, the distance on the radiograph from the occlusal surface to the
roof of the pulp chamber (average 4-6 mm) and to the floor of the chamber (average 8-10 mm). Subtract
1mm to allow for occlusal reduction. If you do not find the pulp chamber where you expect, take a
radiograph and get help. Do not continue to remove dentin unless you are orientated and know what
direction you need to go. Unneeded removal of tooth structure will weaken the tooth, increase the
possibility of fracture and may leave it unrestorable.
Using a #557 F.G. bur reduce the occlusion by 1mm and make an outline of the access preparation 2
mm into tooth structure. The outline is triangular for both mandibular and maxillary molars.
The base of the triangle is on the buccal side of the occlusal surface of the tooth roughly parallel to
the buccal surface. It extends 2/3 of the way up the mesio-buccal cusp tip and distally just past the buccal
b) The apex of the triangle is 1/2 the way up the lingual cusp. The triangle formed is not equilateral - it
is almost 90 degrees at the distal angle.
A short fourth side might be added to the mesial line of the triangle forming a trapezium in order to
locate the MB2 orifice.
Holding the handpiece at a slight angle so the bur parallels the mesial surface of the
crown, make initial penetration into the pulp chamber, staying within the above limits. If
you do not find the pulp chamber where you expect, take a radiograph and get help. Do not
continue to remove dentin unless you are orientated and know what direction you need to
go. Unnecessary removal of tooth structure will weaken the tooth, increase the possibility of
fracture and may leave it unrestorable.

Locate the opening into the chamber with the DG16 endodontic explorer.


With outward sweeping motions, unroof the rest of the chamber.




Smooth the walls of the preparation with the Endo-Z bur and create the occlusal reference point(s).




Locate the canal orifices with the DG16 endodontic explorer.

Errors in Maxillary Molar Access
1. Underextended preparation – pulp horns have merely been ―nicked‖ and the
entire roof of the pulp chamber remains. White color of the roof and depth of bur
penetration are indications of underextension. The color of the pulpal floor is
darker then the dentin of the pulp chamber walls and roof.


2. Overextended preparation undermining enamel walls. The crown is badly gouged owing to failure to
observe pulp recession radiographically and searching for pulp in incorrect area.


3. Perforation into the furcation by failing to compare length of bur to depth of pulp chamber
4. Ledge formation due to failure to achieve straight line access.


Failure to remove dentin triangle impeded straight line
access to apical portion of canal.


1. Be able to discuss the internal anatomy of mandibular molars.
2. Be able to discuss the importance of occlusal adjustment.
3. Be able to describe and demonstrate proper access preparation for mandibular molars.
4. Be able to describe the various canal configurations in mesial and distal canals.
5. Be able to discuss apical anatomy of mandibular molars.

Mandibular First Molar
The mandibular first molar is usually a two-rooted tooth with three canals. The average configuration is
two canals in the bi-lobed mesial root and one broad oval-shaped canal in the distal root. One third of first
molars, though, have two distal canals, sometimes with the second canal in a separate second root.
Occasionally there may be three canals in the mesial root or the mesial may be divided into two separate
It is not unusual for the canal in the distal root to have a sharp distal curve in the apical 2-3 mm. This is
evidenced on the radiograph by a ―fish hook‖ or bulb-like appearance of the end of the root. Much like the
mandibular first premolar, the canal in the distal root may begin as a single broad orifice then divide midroot into two separate canals. The broader the orifice in the buccal-lingual direction, the more likely this
happens. With a 33% incidence of two canals in the distal root, the second canal must always be searched
for during endodontic treatment. It is generally best to instrument the distal canal as if it was 2 separate
canals, DB & DL.
It is quite common that the two mesial canals join in the apical 1/3 of the root to form a single
foramen exiting the tooth. These mesial canals sharing a common root also often have anastomoses
throughout their length, which may be seen filled with sealer when a radiograph is exposed at an angle.
The mesial canal usually has more curvature than the distal. Average tooth length is 21 mm.
Access is triangular. However, the distal orifice must be completely exposed, and if it is broad buccallingually, the access is made more like a trapezoid.

Mandibular Second Molar
All the same characteristics and variants of the first molar can occur in the second molar but usually to a
lesser degree. The second molar anatomy may be so simple as to have a single high-volume canal. A
unique anatomic variant that most often occurs in the mandibular second molar is the ―C-shaped‖ canal.
This occurs by a fusion of the mesio-buccal root lobe with the distal root. The canal orifice is a continuous
C-shaped swath starting at the mesio-lingual, sweeping to the mesio-buccal, then curving distally to the
distal root. The most common canal anatomy found beyond the orifice is a separate mesio-lingual canal
and orifice, and a curtain-like connection between mesio-buccal and distal exiting the tooth as a single
foramen in the location of a normal distal foramen. Rarely, the curtain-like anatomy extends to the mesiolingual and the foramen reflects the same form a very difficult situation to treat endodontically.

Average tooth length is 19.8 mm. Access is triangular in shape. The mandibular second molar is the
most frequent tooth to suffer a mesial-distal fracture.

Mandibular Third Molar
The mandibular third molar is unpredictable in its morphology. It may appear much like a
straightforward second molar or it may have severely curved or malformed roots. When assessing a
mandibular third molar for endodontic treatment, the primary consideration is not the ease of treatment almost any tooth can be treated endodontically with enough effort - but the ability of the tooth to withstand
occlusal loads. The tooth is usually quite short (average tooth length 18.5 mm). Often the crown is tipped
mesially, because first and/or second molars are missing (the best reason to consider doing endodontic
treatment on a third molar).

Access is triangular in shape as in other molars.
1. Measure, on a bitewing radiograph, the distance on the radiograph from the
occlusal surface to the roof of the pulp chamber (average 4-6 mm) and to the floor of
the chamber (average 8-10 mm). Subtract 1mm to allow for change caused by occlusal
reduction. If you do not find the pulp chamber where you expect, take a radiograph and
get help. Do not continue to remove dentin unless you are orientated and know what
direction you need to go. Unneeded removal of tooth structure will weaken the tooth,
increase the possibility of fracture and may leave it unrestorable.

8-10 m m


Using a #557 F.G. bur, reduce the occlusion 1mm then make an outline of
the access preparation 2 mm into tooth structure. The outline is triangular for both
mandibular and maxillary molars.
Mandibular molars:

The base of the triangle is on the mesial side of the occlusal surface of the tooth paralleling the

mesial marginal ridge. It extends 2/3 of the way up the cusp tips.

The apex of the triangle is just distal to the central pit.

c) The apex angle may need to be expanded into a straight side forming a trapezium if the distal canal is
broad bucco-lingually or there are two distal canals.
Holding the handpiece at a slight angle so the bur parallels the mesial surface of the
crown; make initial penetration into the pulp chamber, staying within the above limits.


Locate the opening into the chamber with the DG16 endodontic explorer.


With outward sweeping motions, unroof the rest of the chamber.




Smooth the walls of the preparation with the Endo-Z bur and create
the occlusal reference point(s).



Locate the canal orifices with the DG16 endodontic explorer.

Errors in Mandibular Molar Access Cavities
1. Similar errors to maxillary molars
2. Perforation of the mesial-cervical by failure to orient the bur with the long axis of a
tipped molar.
3. Failure to find a second distal canal owing to lack of exploration for a fourth canal.

Distal view. Missed distal canal




Variations in molar anatomy


Section 5 - Shaping and Cleaning the Root Canal System
Upon completion of the coronal access cavity and the identification of root canal orifices, preparation of the
root canal system is initiated. The root canal preparation has two main objectives:
1) thorough debridement of the root canal system (using instruments and irrigants)
2) shaping of the root canal preparation to receive a root canal filling.
The instruments shape the canal and the irrigants clean the canal.
Didactic Outcomes: Be able to:
1. Define the following terms: working length, foramen, reference point, master apical file, patency file,
step-back, recapitulation, master cone, and tug-back.
2. Discuss the objectives of cleaning and shaping.
3. Distinguish between stainless steel and nickel-titanium K-files.
4. Discuss the intended use of the above instruments.
5. Explain the significance of the numbering system of endodontic files.
6. Give the general dimensions of endodontic files.
7. Describe watch wind motion.
8. Describe reaming motion.
9.Describe balanced forces instrumentation.
10.Describe opposite force instrumentation.
11.Discuss a proper, systematic sequence of instrumentation of a straight canal.
12.Discuss how instrumentation techniques can lead to canal preparation errors.
Practical Outcomes: Be able to:
1. Create an apical stop at the apical constriction or 0.5 to 1.0 mm from radiographic apex
2. Keep the foramen in its original location to prevent zipping or perforation.
3. Keep the minor foramen (apical constriction) as small as possible to prevent zipping, perforation, and to
aid obturation.
4. Maintain the original canal shape to perform thorough cleaning and to prevent transportation or
stripping through the side of the root.
5. Create a continuously tapering preparation from the orifice to the apical stop to aid in irrigation and
6. The shape of the preparation should tend to duplicate or follow the shape of the root.
7. Remove organic material from the tooth and disinfect the tooth

The term chemo-mechanical preparation accurately describes two important goals that must be achieved
to obtain an ideally prepared root canal space. The mechanical removal of all organic debris, microbes, and
microbial irritants from the root canal system , and the desired final shape of the canal space are
accomplished to a great extent through the use of endodontic files. However, there are areas in the root
canal system which are inaccessible to files. Complex canal ramifications, fins, apical deltas, and

communications between canal systems are not able to be cleaned by files. In fact, depending on the
original shape of the root canal only 40-60% of the surface is mechanically prepared. In order to remove
bacteria and pulpal remnants from these inaccessible areas the remaining sections and the walls of the main
root canals need to be chemically cleaned by a disinfecting solution that also dissolves necrotic and residual
vital tissue. Clinically, this goal is achieved by copious irrigation with sodium-hypochlorite solution
(NaOCl). A chemo-mechanically disinfected and shaped root canal space represents an important step
towards a successful treatment outcome.

Basic Objectives of Shaping and Cleaning
The primary objectives in cleaning and shaping the root canal system
are to:
• Remove infected soft and hard tissue

Give disinfecting irrigants access to the apical canal space

Create space for the delivery of medicaments and subsequent

Retain the integrity of radicular structures

Working Length
Working length determines the depth of the canal to which cleaning and shaping will be accomplished.
Working length is the distance from an occlusal reference point, such as an incisal edge, a marginal ridge,
or a cusp tip to the apical endpoint of the radicular preparation and obturation of the canal. Occlusal
reduction on a posterior tooth makes the reference point more reproducible and easier to use. It is extremely
important to have an accurate working length so that the whole length of the canal is treated but the
periapical tissue is not encroached upon. Instrumentation and filling materials should terminate at the apical
constriction (minor foramen), the narrowest point within the canal. This is where the pulp tissue and ends
and the periapical tissue begins. This point is often 0.5 to 1.0mm from the radiographic apex or 0.5mm
from the major foramen. The apical stop preparation allows for the condensation of gutta-percha and for the
keeping the files within the root canal. This will maintain the integrity of periapical tissue and will
minimize postoperative pain and discomfort.


PDL – we don’t want to
instrument the PDL

Anatomical Apex
(Major Foramen)
Apical Constriction
(minor foramen)



Determining working length
Radiographic techniques have been used for length determination for decades, and have worked quite well.
However, studies have shown that the electronic apex locator is more accurate than radiographs in
determining working length of the root canal.
The minor diameter or apical constriction is usually 0.5 to 1.0mm short of the major diameter or apical
foramen. The apical foramen is the main apical opening of the root canal. For that reason, when using
radiographs to determine working length, the WL is determined at 0.5 to 1.0mm from the radiographic
apex. However, that is also assuming that the apical foramen is located at the radiographic apex. The
working length is measured in millimeters from the apical constriction to a reproducible reference point on
the cavosurface of the tooth. It should also be noted that the canal has a funnel shape from the apical
constriction to the major foramen since it widens as it extends from the minor constriction to the apical
Another method of length determination is with the electronic apex locator. This is a device that measures
the canal length electronically. There are many different EALs on the market. At the USCSD we will be
using the Root ZX II which is one of the most reliable EALs available. Whichever device is used it is
imperative to read the manual to familiarize yourself with the function and use of that particular EAL. The
EAL has been shown to be accurate and reduces the number of radiographs taken. Working length films are
still necessary since the radiograph gives more information than just length of the canal, i.e.; canal
curvature, presence of another canal in an angled radiograph.


Using the Electronic Apex Locator
1) Always read the manual for whichever apex locator you decide to use. At the USCSD we use the J Morita
Root ZX II.
2) Check the function daily. Contact the metal part of the file holder with the contrary electrode. All the canal
length indicator bars should be lit and the word ―APEX‖ should flash and there should be a continuous beep

3) Never use the unit when the battery power indicator is flashing on and off. The unit will not function
properly when the battery power is low.
4) The numerals 1,2,3 do NOT represent length in millimeters

Signifies apical constriction and apical
extent of root canal shaping.

5) The apical line indicates that the tip of the file is in the apical constriction. (That is the dark line in the
diagram above.) The apical constriction is considered the narrowest part of the canal and represents a junction
between the pulp and surrounding periapical tissue. Microscope studies have determined it is 0.5 to 1 mm from
the apex.

6) Turn the unit on first and then place the contrary electrode in the corner of the patient’s mouth preferably on
the opposite side of the tooth being treated.
7) Always clip the file holder to the upper part of the file shaft, near the handle. Do not clip to cutting part. Also
when the canal is longer than 23mm it may be easier to use the 31mm file for measurement with the EAL. This
allows more room for the stopper and file holder on the file.


Do not clip onto this part of the
file (cutting part and transition to
cutting part

8) Insert the file into the canal until the meter reads 0.5. Then advance the file apically until the word ―APEX‖
begins to flash. This signifies that the file is at the major foramen. When the apex is reached, turn the file slowly
counter clockwise until the meter reads 0.5 again. Since some canals have multiple constrictions, it is essential
that the file be taken to the apex and then returned to the apical constriction (0.5 reading). Position the rubber
stopper on the tooth surface at a reference point to determine the root canal’s working length.
9) When you are done with the measurements remove the lip clip from the patient and place the apex locator in
a safe place. You may forget about the lip clip and when seating the patient up the apex locator may fall to the
floor. A dropped apex locator will not function properly and need to be replaced. These are your apex locators.

Common Problem Solving
1) unstable electronic signal – usually when the file touches a metallic restoration or there is cervical leak
through subgingival caries.
2) sharp drop in signal as it reaches the apical foramen – try using RC prep.
3) apex reading from the beginning – usually due to severe bleeding or exudates, or chamber full of irrigant in
multi-rooted teeth. It may also indicate a perforation. Take an x-ray!!
4) open apex – may not get a good reading.
5) the best readings are attained when the file is in contact with the canal. Therefore, in large canals use a larger


Shaping the Root Canal System
A variety of techniques have been developed for canal preparation. The traditional cleaning and shaping strategy
(the step-back technique) was to instrument the apical portion of the canal first, followed by middle and coronal
instrumentation. Upon finding the orifice, a file would be inserted into the canal and negotiated to the canal
terminus. Usually the file could not reach full length because of coronal binding. Coronal binding is caused by
dentin overhangs at the orifice level and a tight coronal canal that has not been flared. The accepted sequence
now in root canal preparation is to prepare the coronal and middle areas of the canal first, and only then
to treat the apical third. The process begins with a coronal flare and then shaping of the middle and then apical
portions of the canal.

Shape first
Shape second
Shape last

The advantages to this process are:
1) straightening of the coronal curvature which allows better access to the apical third. This results in ease
of getting to the canal terminus.

This file did not go to length initially due to coronal obstructions. Once the canal has been flared with gates
glidden burs, the file fits easily to length. Also note the file initially being bent away from the cusp near the
orifice. This indicates the lack of straight line access in the coronal portion of the canal.
2) improved tactile sensation. It is easier to sense the apical portion of the canal once the middle and
coronal obstructions have been removed. Canal curvatures can be better assessed since they are not
confused with obstructions in the coronal and middle portion of the canal.
3) better apical gauging (studies have shown that the assessment of apical size is more accurate after
preflaring the canal). After coronal preflaring the first file to bind at the apex was 2 times larger than

before the preflare. That is because the smaller file was binding coronally prior to removal of coronal
4) less instrument separation (studies have shown less instrument separation when the canal has been
5) increased efficiency of irrigation. The irrigant is better able to penetrate the full length of the canal. As
the debris is being flushed out from the coronal to the apical area there is also less extrusion of debris
periapically. This results in less tissue irritation and less chance of a flare up.

Instruments in root canal preparation
Traditionally canal shaping was achieved with 0.02 tapered stainless steel instruments manipulated by hand.
Stainless steel files in sizes above #20 become inflexible and have a tendency to straighten in the canal causing
deviation from the original canal shape.
Nickel titanium instruments come in hand files and rotary files. The advantages of nickel titanium is
1) increased flexibility – more flexible files tend to negotiate curved canals better and reduce the tendency of
straightening, zipping, ledging, or perforating a curved canal.
2) superelasticity – nickel titanium files can be strained many more times than stainless steel without
undergoing plastic deformation.

The size designation of files is derived from the diameter at the tip of the instrument. D0 is the diameter of the
instruments in hundredths of a millimeter.
Dimensions of standardized K-type files and gutta percha cones





0.02 Taper Conventional Hand File

Stopper – used to set the working length

D16 is the diameter at
the end of the cutting

D0 is the diameter at
the tip of the file.
This is a size 25 file
so D0 is 0.25 mm

The cutting edge of the file is 16 mm.
The diameter at the tip is known as D0.

File tip diameters increase by 0.05 mm
increments up to size 60 (0.60mm at
the tip) and then by 0.1 mm
increments up to size 140.
Taper - The amount the file diameter increases each millimeter along its working surface (i.e. a #25 file with a
0.02 taper would have a 0.27mm diameter 1mm from the tip)
Files are available in 3 shaft lengths; 21mm, 25mm, and 31mm. The shorter files afford improved operator
control and easier access in posterior teeth. The 25 and 31 mm files are used for longer roots. The 25 mm files
are the most commonly used in root canal preparation.
The hand files used at the USCSD are stainless steel up to size 20 and nickel titanium up to size 60.
Due to the loss of flexibility in large sizes even with nickel titanium files, size 70 and up are also made of
stainless steel. (Note: for easy identification, the nickel titanium files have a solid square at the top of the handle
while the stainless steel files have an open square with the file size at the top of the handle.)
Hand instrumentation techniques with stainless steel files include reaming, watch winding, circumferential filing,
anti-curvature filing, balanced force. Balanced force is described below and is the recommended instrumentation
technique. Because of their superelasticity, nickel titanium instruments cannot be pre-curved. Since a filing
motion in a curved canal requires a curved instrument, nickel titanium instruments can only be used in a
ROTARY motion.
Reaming – is a continuous clockwise rotation of the instrument
Filing – is simply in-and-out motion of the file with amplitude of 2-3 mm. When a strictly filing motion is done,

the file is not tightly bound in the canal. With circumferential filing tooth structure is removed uniformly from
the canal walls.
Watch-Winding - is a back-and-forth movement of the file while it is gently being advanced apically. The
amplitude of the motion in a straight canal is 30-60 degrees right and left from the center point, with a curved
canal the rotation may be only a few degrees in each direction. It is much like the file handle is being rolled back
and forth between the thumb and forefinger while a slight apical pressure is applied.
Anti-curvature filing - instruments the walls of the canal away from DANGER AREAS such as the furcation
or root concavities to minimize the chance of a stripping perforation.

Lower Molar

Upper Molar

Large Arrows Show Danger Areas
Balanced force is the hand instrumentation technique taught at USC. It was developed by Dr. Jim Roane in
the 1980’s. It is a technique that minimizes canal transportation, ledge formation and perforation of root
canals due to its ability to keep the file centered in the canal. Balanced force should be the primary
instrumentation technique used for all canals. The balanced force technique consists of a sequence of
clockwise and counterclockwise rotations of hand instruments combined with apical pressure. It is used
with a straight file. The technique is performed in three steps:
1) Engagement
2) Cutting of dentin
3) Removal of the instrument for cleaning.
Engagement – a straight file is placed passively into the canal and rotated clockwise approximately 90o to
engage the walls of the canal. It is important that this motion not exceed 90o. If excess clockwise rotation is
used the instrument tip can become locked in the canal and fracture.
Cutting of dentin – the file is turned counterclockwise with light apical pressure to break loose the engaged
dentin. This step creates a characteristic clicking sound. Continue with the counterclockwise rotation until
no resistance is felt. This is usually after a ¾ or 1 counterclockwise turn. These 2 steps can be repeated
several times as the file progresses more apically. This technique can and should be used with minimal

Removal - A final clockwise rotation of approximately 90 degrees allows the
flutes of the canal to be loaded with debris and the file and debris are removed from the canal.
Balance Force Technique




Always inspect your files and other instruments for cleanliness and defects, e.g. unwinding, before
you place them in a canal and after you withdraw them. All your instruments work better when
cleaned of debris. The file you do not inspect is the one that will break!


All rotary instrumentation begins with handfiles. The operator should have a radiographic knowledge of
canal morphology and an established working length. A size 20 stainless steel handfile should create a
glide path to working length before any rotary instruments are used in the apical 1/3. When instrumenting
with nickel-titanium rotary files use a light touch, do not force the instrument. Each nickel-titanium
instrumentation system has its own usage guidelines. For the Profile rotary instruments which are used at
the USC the force applied should be no more than that required to snap a mechanical lead pencil point.
Ignoring this basic rule will increase the risk of instrument fracture. Go down the canal in small
increments using the same pressure that advanced the file into the canal 1mm in 1 second. This has been
described as a light ―pecking‖ force. The smaller the diameter of the rotary file, the less pressure the file
can withstand before deforming or separating. The greater the curvature of the canal, the less pressure the
rotary file can withstand before separation. BE GENTLE. If the rotary file gets stuck and does not
advance go to a smaller size or hand files. Ledging and then perforation occurs when files are used
for an extended period at the same position in the canal.
Rotary commandments:
The Rotary electric motor is set at 275 - 300 RPM-torque control is set at midrange
Keep the canal wet-NaOCl and EDTA
Frequently clean and inspect the rotary files-use the files on 3 cases or less
Always work with straight line access


A glide path to WL must be created with a size 20 stainless steel hand file prior to use of rotary
Never force rotary files - avoid the BEEP!
Look to see the area on the rotary file that is picking up dentin, this tells you where the file is
working in the canal
No more than 1 second at any length
Respect the nickel-titanium rotary and it will be good to you
Files should always enter and exit the canal while rotating. NEVER stop a rotary instrument
inside the canal.

Rotary instruments fracture for these two reasons:
• Torsional Failure – forcing the file into a narrow canal space and rotating it. The tip of the file engages
the dentin and is stopped while the shank keeps rotating
• Flexural Failure (cyclic fatigue) – overusing an instrument by prolonged rotation in a curved canal.
Fatigue occurs through cyclic compression and elongation of the metal . Thicker less flexible
instruments fatigue more quickly than thinner more flexible instruments
Each rotary file is to be used a maximum of three times to avoid fracture. For this reason it is very important
that the files get marked with a bur to denote the number of times they have been used. As always this is a
general rule and clinical judgment needs to be should be used to determine whether they files should be
replaced sooner.



Procedure for Cleaning and Shaping the Root Canal
Root canal preparation is divided into these treatment phases:
Coronal Flaring
Working length determination
Apical preparation
Step back
The initial stages of the root canal preparation apply to both hand and rotary instrumentation. When the
procedures differ it will be noted.
1) obtain straight line coronal access (see previous chapter)
2) fill the chamber with sodium hypochlorite NEVER WORK IN A DRY CANAL. Not only does the sodium
hypochlorite facilitate shaping, its antimicrobial and tissue dissolution properties should constantly be utilized.
The only time a canal should be dry is for visualization, occasionally for determining WL with an EAL, when
CaOH is placed or the tooth is obturated. At all other times the canals should be irrigated with copious amounts
of NaOCl.
3) Creating a guide path for the gates glidden burs – Prior to using the gates glidden burs a guide path needs to be
created. (This is done to get a tactile feel for the coronal portion of the canal and also to allow the gates glidden
to enter smaller canals).
With the light watch winding (1/2 to 3/4 turns clockwise-counterclockwise) a # 15, 20, 25, 30, 35, and
40 K-type files are carried into the canal as far as they can be inserted PASSIVELY. Passively means to the
first resistance (binding or curve) but no further than half the estimated working length. (This will prevent overinsertion of the file in large canals.) After passage of these files, the canal is irrigated with sodium hypochlorite
5) Once a guide path has been created the #2, #3, and #4 gates glidden burs can be used to flare the coronal
third to coronal half of the canal. Place the #2 gates into the canal while it is rotating and with a light ―pecking
motion‖ DO NOT FORCE THE GATES! and light brush strokes away from the furcation (danger zone) let
the gates slowly advance down the canal. Use the #3 gates in the same manner. It will progress less apically
than the #2, but will create more of a flare since it is wider.

Avoid removing dentin from the area
close to the furcation (area A). This will
result in a strip perforation.

Size 1 Gates is 0.5 mm (size 50). We do not use this size since it has a high tendency of breaking at the bud.
When larger size gates glidden burs break it is high on the shank and easily removed. In small canals use the tip
of the #4 gates to only flare the orifice with the chamber. Only insert it into the canal to the depth of the #4

gates. In large canals, upper incisors, lower cuspids, one canal bicuspids, the #4 gates can be inserted deeper,
but never forced. The gates are always brushed away from the furcation (danger zone) and toward the wall of
the canal you are shaping (i.e. mesial buccal canal brush the gates towards the mesiobuccal, palatal canal, brush
the gates towards the palatal). It is important to be as conservative as possible with the use of any instruments in
the root canal system. Unnecessary removal of tooth structure during access or of dentin during instrumentation
will not improve the treatment for the tooth. On the contrary, injudicious removal of tooth structure weakens the
tooth making it more susceptible to fractures and treatment failure. The careful use of gates glidden drills in the
coronal 3 – 5 mm of the root should not result in any mishaps. Since most teeth are 19-25 long and most clinical
crowns are 10mm long, most roots are 9-15 mm in length. Roots therefore can be divided into thirds that are 3-5
mm long.
Size of gates-glidden drills used at USC
Size 2 is 0.7 mm (Size 70)
Size 3 is 0.9 mm (Size 90)
Size 4 is 1.1 mm (Size 110)

This x-ray demonstrates the overuse of gates
glidden drills.

6) Determining working length. Now that the coronal portion of the canal is preflared, the apical portion of the
canal is ready to be negotiated and working length determined. Use a size 15 stainless steel file with a

―pathfinder bend‖ to try and reach the apex.
The pathfinder bend is always used in small stainless steel files since the apical portion of canals is usually
Use the electronic apex locator (EAL) to guide you. If the #15 file is not able to get to working length try
getting to working length with a #10 file. Confirm this length with a working length radiograph. The smallest
file with which to take a radiograph is a size 15. Files smaller than a #15 are not distinguishable on an x-ray.
Remove the file from the tooth and measure the distance from the tip of the file to the stopper. This is the
working length. Working length is the location at which we will create the apical stop.
The WL radiograph not only gives information regarding canal length, but it also gives information about canal
shape in the MD dimension and an angled radiograph will also provide information about the possible presence
of another canal in the root.
Evaluating working length after the coronal flare will decrease the likelihood of the length of the canal
changing. Make sure you record the length of each canal and the reference point so that you can return to this
length at the next appointment without having to re-measure the length.
7) Determine and record the first file to bind at working length. The first file to bind is the smallest file that fits
tightly in the canal at working length. Optimal enlargement at the apical constriction (the apical stop
preparation) is usually 3 – 5 times larger than the first file to bind at working length. This is the Master Apical

File (MAF). For example, if the FIRST FILE TO BIND is #20, MAF will be at least #35 with an optimal size
of 45. If the FIRST FILE TO BIND is #40 (possible in young maxillary anterior teeth), the optimal MAF is at
least #70. Minimal MAF is #30 for very narrow or curved roots and # 40 for straight roots, most MAF’s fall
into the range of #30-#80. As the file size increases, the stiffness of the file also increases. The stiffer the file,
the more of a tendency it has to straighten out in the canal and less of a tendency it has to follow the natural
curve of the canal. Therefore, the MAF is also dictated by the curvature of the canal. Using a large file in a
small curved canal would cause ledging, apical transportation, or perforation.
) Preparing the apical stop. We want to create an apical stop at the apical constriction (minor

Hand instrumentation with nickel titanium hand files. Use the balanced force technique in a crown down or
step back fashion until the desired file size reaches working length. This is the master apical file. Take a
radiograph of the MAF at WL.
Rotary instrumentation with Profiles. ALL rotary instrumentation begins with hand files. It is imperative to
create a glide path prior to the use of rotary files in any canal. This is accomplished by assuring that a #20
stainless steel file can go to working length. After a glide path is created begin using the rotary instruments in a
crown down fashion. Start with a size 40 Profile. Insert it into the canal as it is rotating. (Never start or stop a
rotary file in the canal. This significantly increases the risk of instrument breakage). Use the Profiles with a
light pecking motion. The force applied should be no more than that required to snap a sharp lead pencil.
Ignoring this simple yet basic rule will unnecessarily increase the risk of instrument fracture. When an
instrument is no longer advancing apically, it should be replaced with a smaller instrument. Ledging and
perforation occur when an instrument is used for an extended period at the same length. For example, start with
the size 40 Profile. When it can no longer advance, use the size 35 Profile. This instrument will advance further
apically. When the size 35 Profile can no longer advance apically, use the size 30 Profile. Continue this
sequence until your selected MAF reaches working length. This sequence may have to be repeated several
times. But each time the instruments are used they are able to more closely approach working length.
Crown down instrumentation denotes an instrumentation technique in which the root canal is instrumented from
the coronal portion to the apical portion. The advantages to this sequence is
1. less potential for bacteria and other irritants to be forced into the periapical tissue
2. less force is placed on the files resulting in less torsional fatigue
With both hand or rotary instrumentation it is important to recapitulate to the WL after the use of each
instrument. During root canal shaping, dentinal shavings are generated and these can become packed at the
apical end of the root canal. The resulting dentinal blockage prevents subsequent instruments from reaching the
established working length (WL). Forceful filing in an attempt to regain WL can lead to ledging, canal
transportation, and perforations. Recapitulation is the sequential re-use of previously used smaller files to full
WL. This achieves apical patency and eliminates blockages. Apical patency means keeping the foramen area

free of debris and preventing apical blockages by passing small files only (usually no larger than a size 10 file)
1 mm past working length. This step does not alter the size, shape, or position of the apical foramen, but stirs up
and facilitates subsequent irrigation of debris. Remember to pre-curve these small files with a ―pathfinder‖

INSTRUMENT IN A WET, LUBRICATED CANAL. In clinic we instrument with water, in clinic
we instrument with 3.25% sodium hypochlorite(50% dilution) and 17% EDTA.
Once the MAF has reached WL the apical stop has been established. Take a radiograph to confirm this.
Step back phase (or flaring the canal). This applies to both hand and rotary files. The purpose of the step back is
to provide adequate taper for obturation. The taper of root canal preparation refers to the increase of diameter
per mm of length. When using traditional 0.02 hand instruments, a 1.0 mm step back results in a 0.05 canal
taper. For example if the MAF is size 35, a size 40 is used 1mm back from WL, a size 45 is 2mm back from
WL and a size 50 is 3 mm back from WL. Each file size is increasing by 0.05 mm. Therefore the shape of the
canal is increasing 0.05 mm at each 1.0mm increase in length. This a 0.05 taper. For most obturation techniques
0.05 is the minimum taper required.

Step back and creating apical flare. After the root canal has been enlarged throughout its entire length to the size
of the MAF, the subsequent files are each made 1 mm shorter than the previous file. Set a file one size larger
than the MAF to WL less 1.0 mm. Decrease the length of each successively larger file by 1.0 mm until a file at
least 4sizes larger than MAF is reached. In most roots this will allow the creation of a flare in the apical portion
of the canal and allow the blending of the apical and middle portions of the root canal preparation.
A good stop should be present after the step back or flaring stage. A hand file the same size as the MAF should
be used to gently test the apical stop. It should virtually ―drop and stop‖ at the WL in a properly flared canal
with a proper apical stop preparation.


―Fine Tuning‖ of Endodontic Preparations
The MAF should be at least size 30 on curved canals and size 40 on straight canals and at least 3-5 sizes
larger than the first file to bind at working length."
A logical question would be, "Is my preparation complete when I have satisfied this criteria?" The answer
is maybe yes, maybe no. The operator needs to check or, in other words, "fine tune" the preparation to see if it
is complete.
Start by placing EDT A in the canal and see if a larger file will go to working length with moderate effort
using the balanced force technique. Remember, do not use an up and down filing motion in the apical one
third of the canal. Increase the size of the file until you reach a size that strongly resists going to the working
Prepare the canal in a step back manner extending to 4-5mm from the apical stop in 1.0 mm increments.
Place fresh EDTA and establish apical patency with a # 10 file. Then place the largest file that previously
went to WL to WL and exerting no apical pressure turn it gently 360 degrees clockwise. Remove the file and
clean off all the debris. Repeat this process until no debris is observed on the flutes. This is called apical
Now place a stopper set at WL length on the next largest file and place it in the canal. It should stop 1.0
mm short of the WL. Using the balanced force technique, check to see if it will advance to WL with a moderate
amount of apical pressure. If it proceeds to WL, it did so because there was room for it. Increase the file size
until you find the size that goes 1.0mm short of the WL and will not go closer using balanced forces. Then redo
the step back. Repeat the apical clearing procedure described in paragraph 3 and you have created an apical
stop and are done with the canal preparation.
In essence, you have now prepared the canal as large as the canal ―wants to be‖ or "will let you." (Do not
misinterpret this as meaning a gouging out the canal as large as you can.) The benefits of a larger canal
preparation are many. A larger canal preparation means more physical canal cleaning and more chemical
cleaning by exposing it to larger amounts of NaOCl. Also, the greater the difference between the diameter of
the minor foramen and the diameter of the MAF the wider and more secure the apical stop will be. This will
insure that a properly fitted Master Gutta Percha Point will stay where placed and not slide out through the
minor foramen.
Schilder described five design objectives for cases to be filled with gutta percha:
1) the shape should be a continuously tapering funnel from the apex to the access cavity.
2) cross-sectional diameters should be narrower at every point apically
3) the root canal preparation should flow with the shape of the original canal.
4) the apical foramen should remain in its original position
5) the apical opening should be kept as small as practical
There are also 4 important biological objectives:
1) procedures should be confined to the roots themselves
2) necrotic debris should not be forced beyond the foramina
3) all tissues should be removed from the canal space
4) sufficient space for intracanal medicaments and irrigation should be created.
These objectives form the basis for today’s quality criteria

Endodontic irrigation is an extremely important aspect of endodontic therapy as shaping and cleaning of all
pulp spaces is impossible to achieve with only instrumentation. Most root canal systems are complicated
and nothing like the schematic that is used to explain the basics. Compare this commonly used schematic to
a more accurate root canal system. Files alone cannot clean out the anastomoses between the mesial canals
but irrigants can dissolve that tissue and flush it out. Irrigants should be used at all times during canal
instrumentation. The pulp chamber should always be full of irrigant except for when visualizing anatomy,
using the electronic apex locator, and when obturating the canals. Files are never used in a dry canal.
The ideal irrigant should 1) kill bacteria, 2) dissolve vital and necrotic tissue, 3) lubricate the canal, 4)
remove the smear layer, and 5) not irritate healthy tissue.

Simplified root canal system

More accurate depiction of root canal system

Sodium Hypochlorite 5.25%, is a mainstay of modern endodontics; it is an excellent disinfectant,
tissue solvent and lubricant. As a tissue solvent it works best full strength, 5.25% (and heated), its efficacy,
as a disinfectant seems to be as good diluted as full strength. Care must be taken with the use of sodium
hypochlorite regardless of the strength used; its unpleasant taste can disturb patients and forceful injection
into or through the tooth can be catastrophic (See Sodium Hypochlorite Accident). When using sodium
hypochlorite a well fitting (sealed) rubber dam should be in place and the solution should be gently placed

into the pulp chamber not injected into a canal.
Do not use sodium hypochlorite in the SIM LAB!

EDTA, 16-20%, is a useful irrigant and its chelating properties facilitate instrumentation especially in
narrow canals. It is not particularly useful as an aid in searching for canals. It removes the smear layer
produced on the walls of canals during instrumentation by acting on the inorganic component of the dentin.
It has little if any antibacterial activity. However it has been shown that removal of the smear layer
improves the antibacterial effect of NaOCl since it improves access of the solution into the dentinal tubules.

Chlorhexidine, is a long lasting antibiotic solution. It is sometimes used as a final rinse after EDTA. It
has no tissue dissolving capability. It is used as a 2% solution for irrigation and as an intracanal
Note: mixing NaOCl with Chlorhexidine causes a brown/orange precipitate. These solutions should not be
used together for irrigation.

The 5 main benefits of using irrigants:
o Removal of particulate debris and wetting of the canal walls
o Destruction of microorganisms
o Dissolution of organic debris
o Opening of dentinal tubules by removal of the smear layer
o Disinfection and cleaning of areas inaccessible to endodontic instruments


Intracanal medications are used to prevent bacterial propagation in the root canal in between
appointments. Different compounds are available as intracanal medications, however, the preferred
intracanal medication is calcium hydroxide (CaOH). At the USCSD, once endodontic treatment is started,
calcium hydroxide will be used as an interim antimicrobial intracanal medication (temporary
root canal filling) in all canals and Cavit or IRM placed as a temporary restoration. The efficacy of CaOH is well
documented and it has few negative properties.
Calcium hydroxide kills bacteria effectively and safely disinfects a root canal within one week.
Therefore, to maximize its effectiveness it is recommended that interappointment times reflect this finding and
that the obturation appointment will not take place less than a week after the CaOH was placed. The high pH
makes it a hostile environment for many endodontic pathogens. Its high pH also has the effect of helping NaOCl
digest any remaining pulpal remnants at the next appointment.
Ca(OH)2 comes as a white powder. It is mixed with sterile water or anesthetic solution to a creamy
consistency, picked up on the hand file turning in a counter clockwise rotation. For maximum effectiveness the
canal should be filled homogeneously. If the canal does not appear full, repeat the process. When the canal is
full, remove the excess Ca(OH)2 from the chamber, place a cotton pellet into the pulp chamber and then place
Cavit or IRM as a temporary access filling. This filling should be at least 3 mm in thickness. Any less
temporary filling material will result in leakage into the canal.
Dycal or Life are liners that set hard and are not to be used as an intracanal medication.

(check placement
with a
radiograph in
the preclinical

A cotton pellet should always be placed in the access cavity to make reaccess more predictable. Always
indicate that a cotton pellet was placed and how many were placed. Upon re-entry the original operator or a
new operator will know what to expect. In a large anterior canal, it is possible to inadvertently force a cotton
pellet down the canal if one is not expecting to remove it.
To remove the calcium hydroxide at the next visit, irrigation and recapitulation with the MAF and several stepback sizes should be adequate. If CaOH is not completely removed from canals, it could interfere with the
properties of the sealer and affect the seal desired by obturation. As with any other material untoward events
may occur if CaOH is not used carefully, i.e., make sure not to extrude it beyond the canal and into the
periapical tissue.

Section 7 - OBTURATION

Be able to list the characteristics of an ideal obturation material.
Be able to discuss the composition of endodontic gutta-percha.
Be able to give the general characteristics of gutta-percha.
Be able to explain the sizing of gutta-percha cones.
Be able to list the basic ingredients of the most commonly used sealers.
Be able to discuss the purpose of obturation.

The purposes of obturating the prepared canal space are
1) to eliminate all avenues of leakage from the oral cavity or periradicular tissues into the root canal system,
2) to seal within the system any irritants that cannot be fully removed during canal cleaning and shaping
The importance of three-dimensional obturation of the root canal system cannot be overstated. The ability to
achieve this goal is primarily dependent on the quality of the canal shape. Preparation is the first step in
obturation. The tooth and canal should be prepared in a manner to facilitate obturation. Generally we want
a smooth even taper decreasing in diameter from orifice to apical stop.
Prerequisites for canal obturation
1) the canal must be thoroughly shaped and cleaned to accommodate the filling material. To assure adequate

shaping the spreader (or pluggers for vertical condensation) should be fit into the canal(s) to the desired
2) the tooth should be asymptomatic
3) the root should be able to be dried. Any fluid present should be easily removed with paper points.
Continued leakage of fluid, serous, purulent, or bloody, indicates that the canal is not ready for obturation.

Properties of an Ideal Obturation Material

Easily manipulated and provides ample working time
Dimensionally stable with no shrinkage once inserted
Seals the canal laterally and apically, conforming to its complex internal anatomy
Nonirritating to the periapical tissues
Impervious to moisture and nonporous
Unaffected by tissue fluids – no corrosion or oxidation
Inhibits bacterial growth
Radiopaque and easily discernible on radiographs
Does not discolor tooth structure
Easily removed from the canal if necessary

Gutta Percha
Gutta percha is the material of choice as a solid core filling material for canal obturation. Although it does not
meet all the criteria for an ideal filling material, it satisfies most of them. Gutta-percha is the trans isomer of
polyisoprene and exists in tow crystalline forms (alpha and beta). In the unheated beta phase the material is a
solid mass that is compactable. When heated the material changes to the alpha phase and becomes pliable and
tacky and can be made to flow when pressure is applied. A disadvantage to the alpha phase is the material
shrinks on setting. Gutta-percha consists of approximately 20% gutta-percha, 65% zinc oxide, 10%
radiopacifiers, and 5% plasticizers.
Gutta percha cones are available in conventional and standardized sizes. The conventional nomenclature refers to
the dimensions of the tip and body. A fine-medium cone has a fine tip with a medium body. Standardized cones
are designed to match the taper of stainless steel and nickel titanium instruments. Tolerance in less stringent for
gutta percha then for files. (0.02mm for files, 0.05mm for gutta-percha). This means that in a box of size 40
gutta-percha the cones can be anywhere from a size 35 to a size 45. (40 +/- 0.05).
Gutta-percha can be placed using lateral compaction, warm vertical compaction, or a carrier system.
Lateral compaction is a common method for obturation. The technique can be used in most clinical situations and
provides length control during compaction.
The lateral condensation technique involves fitting a master gutta-percha cone and condensing with accessory
cones and sealer to fill the root canal. A spreader with a pointy tip is used to condense the gutta-percha, creating
space for placement of accessory gutta-percha cones. The gutta-percha is added sequentially until the canal is
completely filled.

Root Canal Sealers
Root canal sealers are necessary to seal the space between the dentinal wall and the core obturating material.

Sealers are used with all the different obturation techniques. Sealers fill voids and irregularities in the root canal,
lateral and accessory canals, and spaces between gutta-percha points used in lateral condensation. Sealers also
serve as lubricants during the obturation process. The properties of an ideal sealer are listed below. Currently no
sealer satisfies all the criteria.

Properties of an Ideal Sealer

Exhibits tackiness when mixed to provide good adhesion between it and the canal wall when
No staining of tooth structure
Establishes a hermetic seal
Radiopacity so that it can be seen on the radiograph
Very fine powder so it can be mixed easily with the liquid
No shrinkage
Bacteriostatic, or at least does not encourage bacterial growth
Exhibits a slow set
Insoluble in tissue fluids
Tissue tolerant; that is nonirritating to periradicular tissue
Soluble in a common solvent if it necessary to remove the root canal filling

Sealers should be biocompatible and well tolerated by the periapical tissues. All sealers exhibit toxicity
when freshly mixed; however, their toxicity is greatly reduced on setting. Sealers are resorbable when
exposed to tissues and tissue fluids. The most popular sealers are zinc oxide-eugenol formulations, calcium
hydroxide sealers, glass ionomers, and resins.

Zinc oxide-Eugenol-mixing vehicle is eugenol, zinc oxide is anti-microbial
- chemicals added to modify antimicrobial and mummifying effects
- setting of this sealer is a chemical process with embedding of zinc oxide particles in a
a matrix of zinc eugenolate
- immediate inflammatory response if overfill occurs
- little adherence to dentin volume loss over time

Calcium Hydroxide Sealers-proposed therapeutic effect from Calcium hydroxide
- base is usually Calcium hydroxide and Zinc Oxide
- sealer has poor cohesive strength
- questionable release of Ca+ or OH- ions Tronstad L 1988
- Calcium hydroxide may dissolve , leaving voids
- Questionable sustained rise in pH

- epoxy resin sealer, positive handling characteristics
- good flow, seals well to dentin walls, sufficient working time
- initial toxicity due to a small release of formaldehyde
- After 24 hours, toxicity is extremely low. Weinberg et al 1974.
- Volume stability is good, low solubility

- resin composite sealer
- composed of BisGMA, methacrylates, CaOH, barium, silica
- designed for use with resilon
- self etch primer required
- biocompatibility established

Obturation of a Single Canal
1. Place a stopper on a D11T spreader or the nickel titanium finger spreader, insert it into the canal and
ensure it reaches WL. This is a test for adequate flare. Another test is to try the spreader alongside the
Master Cone placed at working length. The spreader should go passively to within 1-3 mm. As a learning
tool it is good to do both tests. If the spreader does not go to the preset length, it is an indication that the
flare is not adequate and that the canal needs additional shaping. Forcing the spreader to length is a good
way of fracturing the root. Remember, never use excessive force in instrumentation or obturation.
2. Select a standardized master cone the same size as the MAF and 1-3 medium-fine or
fine-fine accessory cones, or if using the finger spreader use #20 gutta percha cones for the #25 spreader
(red) and #25 gutta percha cones for the #30 spreader (blue).
3. Irrigate the canal. The canal is irrigated to provide lubrication for the master cone during try-in. This
creates a condition similar to when sealer is placed into the canal for obturation. (Sealer also acts as a
4. Mark the master cone at working length (mark the cone with a cotton forceps so you have a reference
for the WL) and try it in the WET canal. Check for correct working length and a strong apical stop.
Remember the tolerance level for gutta percha cones is not as stringent as for files. Therefore if the gutta
percha cone chosen does not go to the desired working length, (it is either long or short) then try a different
cone of the same size, or cut it back slightly. However, if the new cone or trimmed cone goes beyond
working length or does not reach working length the shaping procedure needs to be reevaluated.
REMEMBER, the canal must be adequately shaped to accommodate the filling material.
A note regarding tug back. Tug back is the resistance in the apical region of the canal to removal of a
gutta percha cone. It is intended to signify correct cone fit. However, the master cone that we use is a
0.02 tapered cone and the canal has been prepared to a taper in the range of 0.5 to 1.0 mm depending
on the step back increment. So the only region in the canal that approximates the taper of the master
cone is the apical 0.5 to 1.0 mm (and that is only if hand files were used. If rotaries were used they
will create a 0.04 taper). Logically we therefore expect only a slight tugback. If there is no tugback,
the cone fit may still be adequate if there is a good stop and the gutta perch cone reaches the
predetermined working length.
5. Taking a cone fit radiograph to verify proper placement of the cone.
6. If the master cone is properly sized, remove it and dry the canal. Aspirate with the irrigation syringe to
remove most of the irrigant, then use coarse and then medium or fine paper points.
7. Prepare the sealer.

8. Coat the master cone with sealer and place into the canal coating the walls with the sealer as you
progress to working length. Sealer is necessary to seal the space between the dentinal walls of the canal and
the core obturating material (gutta percha). However the sealer is resorbable when exposed to tissue fluids
and initially irritating to the periapical tissue. For these reasons a minimal amount of sealer should be used.
9. Set the silicone stop at 1 mm short of working length on the spreader. Insert the spreader into the canal
alongside the gutta-percha and work it to length with a light apical pressure. Ideally the spreader will go to
within 1mm of the working length and should get to at least within 3mm of working length. Remember, if
the spreader does not reach the required length, adequate condensation does not occur. (Allison et al,
J of Endod, 15(10) p. 298)
10. After the spreader has reached length, leave it in place briefly so the gutta-percha will distort and leave
a track for an accessory cone. Always monitor the position of the spreader and see that the accessory
point goes to the same level as the spreader it is replacing.
14. Slowly withdraw the spreader from the canal while rotating it in back and forth to prevent it from
sticking to the gutta-percha and pulling out the master cone.
15. Immediately upon removal of the spreader insert an accessory cone to length in the pathway left by
the spreader. A thin coat of sealer is placed on the accessory cones. This lubricates the cone to facilitate
full penetration. The sealer also fills the voids and minor discrepancies of fit between the gutta percha
cones and the root canal walls. Be sure the accessory cone inserts to the same length as the spreader.
The accessory cones should be premeasured so that they can be immediately placed to the correct length
into the space created by the spreader. If there is a delay the space created by the spreader will close and the
accessory will be placed short.
16. Initial condensation radiograph. After enough accessory cones have been placed in the canal to fill the
apical third and the spreader only goes to within 4 mm of working length, take a radiograph. This
INITIAL CONDENSATION radiograph allows the evaluation of the gutta-percha fill in the apical portion
of the canal, and if not acceptable, the gutta-percha can be grasped by the extended ends of the cones and
removed from the poorly filled canal. The canal can then be properly re-filled.

17. Add additional accessory points until the spreader will not penetrate more than 2-3mm past the CEJ
18. Heat the plugger end of the Glick instrument and sear off the gutta percha at the level of the orifice.
Condense the gutta-percha apically with a cooled Glick plugger.
20. Place a cotton pellet and an appropriate temporary restoration.
21. The final radiograph is taken with the rubber dam OFF. This is done to check obturation and the quality
of the seal of the access cavity.
See Examples of lateral condensation on p.79




Be able to densely obturate all roots on a multi-rooted tooth.
Be able to present completed cases with thorough treatment records.

Follow the same procedures as obturation of a single canal. The following are the differences in the
1. The cone fit radiograph should be taken with all the cones in place. A straight on and an angled view
should be taken.
2. Adjust the master cones as needed.
3. Place the master cones on a paper with a label for each canal i.e. MB, DB, B, L, etc.
4. Obturate as many canals as possible keeping in mind that the accessory points will start to fill the access
cavity as you proceed. Start with the canals with the easier access. (Usually start with the distal canal(s) of
a mandibular molar and the palatal canal of the maxillary molar. Always obturate canals that merge at the
same time.
5. In a curved canal, insert the spreader between the gutta-percha and the convex side of the curve to avoid
gouging the tip of the spreader into the gutta percha, which may prevent the spreader from advancing to full
length (e.g. in the mesial root of a mandibular molar, which has a curve toward the distal, the spreader is

inserted along the mesial side of the gutta-percha so the tip of the spreader contacts dentin as it passes
around the curve.)
6. Place a temporary restoration. The final radiograph is taken with the rubber dam off.

Obturation of a single canal with lateral condensation:

Fit of spreader

Cone Fit

Spreader with
Accessory cones

For demonstration purposes only. A
radiograph is not taken in lab or clinic.

Laterally filled canal


Laterally compacted

A well-sealed temporary restoration has the ability to prevent coronal leakage and subsequent
recontamination of the root canal.

Sealing of the access preparation between appointments and after final obturation is absolutely
necessary to prevent microorganisms from contaminating the root canal system. A number of recent
studies have demonstrated contamination of an obturated root canal as a result of an open access cavity or an access
with a deficient restoration. This leakage into the root canal system, therefore, has the potential
to be an etiologic factor for failure of a completed root canal treatment.
Temporary cements must be capable of providing a temporary seal to prevent bacteria and fluid products from
the oral cavity from contaminating the pulp space. The cement must be able to withstand masticatory forces
and retain a seal. The thickness of the temporary filling material in the access cavity should be at least 3 – 5 mm
in order to provide an adequate seal. The temporary restoration is placed prior to removal of the rubber
Many different materials have been used or recommended as endodontic temporary restorations. Two of the
more common materials are Cavit and IRM.

CAVIT - a ready mixed cement of zinc oxide , calcium sulfate, glycol,polyvinyl acetate, polyvinyl
chloride, triethanolamine
- sets on contact with water (calcium sulfate)
- excellent marginal adaptation
- 4-5mm of thickness necessary or a cover of harder cement for an adequate seal
- absorb fluid into the entire body of restoration
- supplies a significantly better seal than Term over 3 weeks-Beach CW, 1996.
- provides a better seal than IRM Anderson RW et al 1988
- only used if tooth is to be restored within 2 weeks
TERM-filled composite resin, light activated
-easily removed
-better seal than IRM
used if tooth will be restored after 2 weeks

- reinforced zinc oxide powder/ eugenol
- designed to last a year as a temporary
-generally greater marginal leakage vs. cavit or term
-bacterial barrier due to eugenol but allows fluid leakage
- shows significant micro leakage and loss of marginal adaptation after
thermo cycling and mechanical loading. Mayer T. 1997
- no difference in leakage by varying liquid /powder ratio- Lee YC 1993

Note- when compared as passive temporary filling, IRM and Cavit provide a similar quality of seal. When these
cements are exposed to repetitive ―occlusal‖ cyclic loading, IRM has been found to provide a superior seal. IRM
should be considered for temporary cement when occlusal forces are present. Liberman R. 2001. The author

contends that all microleakage studies should be done using radioactive tracers and with mastication forces present.
One of the most important factors in determining success of root canal treatment is the quality of the final coronal
restoration. The temporary restorations leak and a permanent restoration should be placed within at least 4 weeks
of completion of the root canal treatment. The final restoration is considered a part of the root canal therapy.
Patients should not consider them two different procedures. They should follow each other in a timely fashion or the
risk of failure is significantly increased.





The student will be able to:

List dental and restorative characteristics that may result in perforation during access preparation.
Describe various ways to avoid perforation during access preparation.
Discuss the prognosis of a tooth with a perforation made during access preparation.
Explain how blockage can lead to ledge and perforation formation.
Discuss the prevention of blockage, ledging, and perforation.
Describe the treatment and prognosis of blockage, ledging, and perforation.
Explain the cause, prevention, and treatment of file breakage.
Tell how a sodium hypochlorite accident can be avoided.
Discuss the causes and treatment of underfill and overfill.
Describe how vertical root fracture can be avoided.

I. Perforation during access preparation
Accidents can occur in endodontic treatment as early as making access - the principle problem being lateral
perforation of the crown or root, or perforation into the furcation. This problem can best be avoided by
thoughtful case selection and referral. In reality, any case, even an ―easy‖ case, has potential for
perforation if access is not done carefully and cautiously.
Tipped or crowded tooth with abnormal orientation of its long axis.
Beware the tipped posterior tooth that has a restoration recreating a normal occlusal table but with the long
axis of the crown not parallel to the long axis of the roots.
This situation is most often encountered when a mandibular bridge has been placed on a mesially tipped
distal abutment tooth.
l ong axis of roots

Full-coverage restoration obliterating the outline of the pulp

Calcified pulp, partially or completely obstructing the
radiographic outline of the chamber.


l ong axis of
c rown

Prevention of perforation
Case Selection! - let someone else struggle with it.
Remember, the average distance from occlusal surface to roof of chamber is 4-6 mm and to floor of
chamber is 8-10 mm.
Study the radiographs and measure the distance to roof and floor of the chamber on the particular tooth you
are treating.
Measure bur length and stay within the dimensions measured above.
In clinic, never extend a bur past the alveolar crest in search of the chamber or canals. Get an
instructor for help.
Canals are located with an endo explorer not with a bur
High and slow speed burs are used only to carve out the internal anatomy of a tooth to allow the operator to
locate the canals with the explorer
Burs are not probes - they are not used to locate canals
Begin access with the rubber dam off.
This allows visibility of the whole exposed part of the tooth and orientation on the long axis of the roots as
the crown emerges from the alveolus - the long axis of the crown may not be parallel to the long axis of the
roots. The ultimate goal is to gain straight-line access to the canals within the roots. Visibility of the
cervical outline of the tooth helps keep orientation on the true long axis of the roots.
Or, clamp a more distal tooth, eliminating the rubber dam clamp as an obstacle to seeing all of the tooth
Recreate the normal shape and volume of the chamber within the crown.
Progress slowly
Periodically take bitewing radiographs (perpendicular to the buccal crown surface i.e. bite-wing) to observe
Lateral perforation coronal to the attachment level can be included within the preparation of the restoration.
Lateral perforation at or just apical to the attachment level, and furcal perforation do not have a good
Periodontal defect will usually form Better prognosis if treated promptly
If a perforation occurs, inform the patient and make proper, prompt referral for treatment (may necessitate
hemisection or extraction)

II. Accidents during cleaning and shaping
Even when all of the above precautions are taken, perforation may still occur during access preparation,
especially in the case of severe calcification. Unfortunately, if access is successfully completed, the
potential for intra-operative problems does not cease. Several types of accidents can occur during cleaning
and shaping. The difference here, though, is that all accidents that may occur during instrumentation are
By far the most common problem seen during instrumentation is blockage. This is often noticed at the time
of fitting the master cone when it will not extend to working length. Debris has accumulated at the apical
end of the preparation preventing complete seating of the master cone.

This can be avoided by frequent irrigation and use of a patency file.
Irrigate the canal, carefully work a small file (#10-20) to working length, then follow with subsequent files
to remove debris and regain the MAF at WL. Keep the canal flooded with irrigant.
Use RC Prep or other chelating agent as irrigant and proceed as described above.
Ledge formation
Ledge formation is a frequent sequel to canal blockage in a curved canal. The apical canal becomes
blocked with debris because of inadequate use of irrigation and patency file. Subsequent files, then, are
prevented from following the path of the canal and are diverted off-axis forming a ledge. If large files are
forced, this misadventure continues, and creation of a new canal and perforation of the root can occur.
Ledge formation is most likely to happen in narrow, curved, and long roots.
Ledge formation can also occur by overfiling with a given file. All files have elastic memory - if confined
in a curved space, they want to straighten out. If a file is used repeatedly at a certain length in a curved
canal, it will try to straighten out, and the tip of the file will begin to cut preferentially on the outside of the
curve, thus creating a ledge.
Excessive use of chelating agents (RC Prep, EDTA) can result in ledge formation or perforation in curved
canals. Chelating agents are not selective in the type of dentin they affect - all dentin is softened by
chelating agents.
If a ledge is created, it might be possible to bypass and eliminate the ledge by precurving stainless steel
files and re-entering the original canal path. If this is not possible, the canal is filled to the point of the
ledge, and the case observed for development of pathology. A tooth that had a vital pulp at the start of
treatment, and a tooth with a necrotic pulp that had already been well debrided before the ledge was formed
have the best prognosis if the ledge cannot be passed.
Blockage or aggressive use of files (especially in an exaggerated filing motion) in the apical 1/3 of a canal
with an apical curve can result in a ―tearing‖ perforation of the foramen often referred to as an apical strip
or apical zip. The outcome of this mishap is a foramen that has been changed from essentially round to a
long slot extending from the original position of the foramen coronally along the outer surface of the curve.
Forcing files to length
Over-use of a given file at a given length
Misuse of chelating agent
Repeated recapitulation through the series of files from small to large creating a tapered shape that is
―carried‖ to the apex rather than forcing files to their assumed final lengths helps prevent ledge formation.
Do not use a particular file for a long time at a specific length. Keep moving through the sequence of files
repeatedly. Each file should be used for only 20-30 seconds before proceeding to the next-size file.
Do not use chelating agents (RC Prep, REDTA) with a file larger than #25.
Perform apical preparation with just watch-winding and minimal filing motion.
There are other situations in which perforation can occur during instrumentation besides that described
above. In two cases, the perforation penetrates to the furcation.
Perforation can occur while using the Gates-Glidden drills during coronal flaring. Gates-Glidden drills are
not intended to be used as flexible instruments and pass around a curve. They are meant to be used only in
the straight, coronal portion of the canal. The diameter of the canal preparation should never be larger than

1/3 the diameter of the root. The largest Gates-Glidden drill we routinely use is a #4, which is 1-1.1 mm in
diameter. This must be kept in mind when performing the coronal flare. If a root is observed on a
radiograph to be unusually narrow, the depth of each Gates-Glidden drill must be adjusted accordingly.
The second situation when perforation may occur on the furcal side of the root is during preparation of the
middle 1/3 of a severely curved canal. Over-aggressive filing motion in a sharply curved canal will
preferentially remove material from the inside of the curve in the mid-root area similar to the preferential
removal on the outside of the curve in the apical 1/3 due to the tendency of a file to straighten out. This is
referred to as a strip perforation and is very difficult to adequately obturate due to its linear nature.
Poor determination of working length and lack of length control with overextended instrumentation will
result in an apical perforation. Irritation to periapical tissue and difficulty in controlling gutta percha during
obturation due to the lack of an apical stop create problems similar to those associated with a perforation in
any other part of the root. Whereas an apical zip occurs in a root with an apical curve, an apical perforation
can occur with a curved or a straight canal.
Study the dimensions, curvature, and emergence of roots from the crown on radiograph and foresee
possible problems due to curvature.
Remember, canals curve buccal-lingually as often as mesial-distally – this curvature is not visible
Establish proper working length, use repeatable, stable reference points and control the depth of penetration
of instruments.
If significant resistance is felt with any instrument, do not force it. Adjust depth of instruments
Furcal perforations of any cause have a poor prognosis but prompt referral for treatment before periodontal
breakdown occurs may improve the prognosis.
Strip perforations are hard to obturate because there is no resistance form for the gutta-percha.
If on the furcal side, mid-root, the prognosis may not be good because surgical access for repair is very
Apical zips may have a less than good prognosis following orthograde treatment but are more easily
accessed surgically than mid-root strips.
An apical perforation is treated by shortening working length, creating an apical stop with a newly
determined, larger MAF and obturating to the new length.
Even these cases may have some long-term chronic inflammation.
The sooner a perforation is treated, the better.
The prognosis for a perforation changes, according to location - best prognosis for a perforation in the
apical 1/3, and worst prognosis for a perforation in the coronal 1/3.
Gates-Glidden drills are never extended into a curve. They are to be used only in the coronal portion of the
canal prior to any curvatures.

File breakage
Though file breakage can happen due to manufacturing flaws, it usually is due to overuse or misuse of files.
Failures to notice signs of excessive wear (kinking, tightening or unwinding of flutes or other deformationsometimes these show up as a shiny spot in the flute area) and continued use of an overused file will likely
result in its breakage. Inspect each file for cleanliness and defects before you place it in a canal and
after you remove it. When in doubt, throw it out. Regular disposal of files will greatly reduce the
incidence of file breakage. At USC, we discard files #10-25 (stainless steel) after each case if these files

were involved in the instrumentation performed on that day. Files sized #30-50 (nickel-titanium) are
discarded after 5 cases. Those files numbered 55-80 are discarded when they show wear or seem to cut
The most common cause of file breakage is using it too aggressively. The confusing thing about file
breakage is having it occur when the file is being used relatively gently or even during recapitulation after
larger files have already been used. This happens all too often, and the breakage is wrongly attributed to a
manufacturing flaw. In reality, the file had already been overstressed, probably showing some signs of
deformation, and the reinsertion into the canal was done in a manner that was sufficient to separate a
segment of the file. The one fortunate aspect of breakage with this nonaggressive use is that the file
segment is not tightly bound in the canal and might be removed or, more likely, bypassed and full treatment
of the canal completed.
Lubricant (i.e., irrigation solution) makes the files cut more efficiently without gouging and binding, and
should always be used during instrumentation.
Always instrument a wet canal.
Never instrument a dry canal.
Apply apical pressure on a given file no greater than the pressure you can apply with your fingertip directly
to the point of the file without causing pain.
Do not force files to predetermined lengths.
Recapitulate multiple times, if necessary, to progress a file to its expected, eventual length.
If a file becomes bound in a canal, gently manipulate it in a watch-winding motion of small amplitude and
with light withdrawal pressure.
Inspect each file for cleanliness and defects before you place it in a canal and after you remove it. If
in doubt, throw it out.
Inform the patient. Having an instrument break during treatment is not malpractice but failure to inform the
patient is. Use the phrase ―separated instrument‖
Attempt to bypass the fragment using RC-Prep and small (#8, 10, 15) files, then complete instrumentation.
The file segment becomes embedded within the gutta percha when obturated.
If the fragment cannot be bypassed, complete instrumentation to the fragment, fill to this length, inform the
patient and follow for an extended time.
Or, explain the presence of the separated instrument and refer.

It is a matter of fact that material is extruded into periapical tissues during instrumentation.
This debris can include bacteria, infected dentin shavings, and irrigating fluids. All of
these materials are toxic to periapical tissues. It is imperative, then, to minimize the amount of extruded
debris. This is the reason for preparing the apical 1/3 of the canal less aggressively than the middle and
coronal 1/3s.
Sodium hypochlorite, which we use almost exclusively as our irrigating/disinfecting agent, is a very strong
protein denaturant. It is nonspecific in its action, that is, it attacks normal, vital tissue as well as it bacteria
or necrotic tissue. Sodium hypochlorite that is expressed
through the foramen under pressure will immediately cause tissue damage resulting in an

acute, ballooning swelling and excruciating pain. The swelling will probably increase over the next couple
days accompanied by extensive ecchymosis. The pain will steadily decrease after the initial episode
although swelling may be increasing. This misadventure is completely avoidable with proper care and
handling of sodium hypochlorite.
Never wedge the irrigating syringe needle into the canal. There must be space for fluid to back-flow out of
the canal. Keep the irrigating needle in motion, going in and out of the canal.
Never express the irrigant rapidly out of the syringe. It is not being ―injected‖ into the canal - it is being
deposited slowly into the pulp chamber. The files carry the sodium hypochlorite into the canal.

Oral steroid
Ice pack
Reassure the patient and have daily monitoring of symptoms.
Advise the patient of likely severe increase in swelling and severe ecchymosis.
Unlike other procedural mishaps that have higher potential to occur due to anatomic or
restorative conditions, a sodium hypochlorite accident is totally avoidable.
III. Accidents during obturation
Under-extended fill
One of the most frequent mishaps during endodontic therapy is to underextend the fill of a canal, i.e., fill it
short of working length. The sequence of events is as follows: proper length has been determined and
verified radiographically, instrumentation has been completed, the canal obturated, but when a radiograph
is made, the fill is clearly short of working length. There are two reasons for a short fill. First, and
unfortunately much too common, is a short fill due to accumulation of dentin filings in the apical portion of
the canal preventing full seating of the master cone. The canal has not been kept irrigated and debris has
not been removed from the apical part of the canal by recapitulation.
The second situation of a short fill occurs after proper fitting of the master cone at correct working length.
It is noted after obturation that length has been lost. In this case, cement has been placed into the canal, the
master cone seated to working length, and the spreader inserted alongside the master cone. The tip of the
spreader, though, either has become imbedded into the master cone, or dried sealer on the spreader (the
spreader was not properly cleaned after prior use) has adhered to the sealer and master cone pulling it back
when the spreader is removed from the canal. This pullback usually occurs when placing the first or
second accessory cone. After 2-3 accessory cones have been placed and laterally condensed, the master
cone is usually locked in place and will not pull back.
At the end of instrumentation, irrigate and recapitulate through the files, inserting each file to its length,
rotating clockwise 1/2 turn and removing debris. Inspect the spreader before use and clean sealer off of the
spreader after use. Insert the spreader along the side of the master cone toward the outside of the curve so
the tip of the spreader runs along the dentin wall. Insert the spreader using a watch-winding motion;
continuing the watch winding while the spreader is left in place for 30 seconds and during withdrawal.


Irrigate; starting with #10-15 file, pick through debris regaining working length; recapitulate through the
whole series of files in a debris-removal manner. Always take a radiograph before searing off excess gutta
percha to evaluate proper fill - if short (or long), grasp and remove gutta percha, and refill.
Over-extended filling (filling longer than working length) is attributable to one cause - lack of length
control. Part of the design of root canal preparation is to provide resistance form to prevent extrusion of
filling material into periapical tissues. Lack of an apical stop and proper taper to the preparation will allow
gutta percha to be pushed through the foramen into periapical tissues.
Establish correct length determination.
Check stopper position on files throughout instrumentation to be sure they have not moved.
Expect effective working length to shorten slightly on a curved canal as the canal is widened and the curve
―straightened out‖
If there is question about length at completion of cleaning and shaping, check with paper points for the
consistent drying length - the length at which paper points come back dry and at which, if the paper point
were inserted further, it would come out with the tip wetted with blood or tissue fluid (tan or straw
colored). This is accomplished by first drying the bulk of irrigant out of the canal with large paper points.
Then, the largest sized paper point that will fit to length is grasped with the cotton pliers at WL, placed into
the canal to the reference point, withdrawn, and the tip of the paper point examined.
If the canal has not yet been filled, determine a shorter working length, and establish an apical stop with a
new, larger master apical file.
Fit a master cone 1/2 mm short of the new working length (when condensed, it will slide apically to
working length)
If the canal has already been obturated, grasp the extensions of gutta percha and pull the mass out of the
canal and then follow the above steps.
Although it is not an everyday occurrence, a vertical root fracture can be created during obturation by the
wedging action of the spreader. This is more likely to occur with a hand spreader than with a finger
spreader because of the greater taper of the hand spreader and the ability to generate more force. This is the
most common cause of vertical root fracture.
Properly shape the canal with adequate taper. Do not make the master apical file larger than necessary.
Slowly advance the spreader apically. If significant resistance is felt, do not force the spreader.
Treatment of Root Fracture –



Evaluating a tooth prior to treatment is essential to assure success and help prevent the previously
mentioned mishaps. For that reason the AAE case difficulty form and the presession form must be filled out
and then reviewed with an endodontic resident or faculty member prior to initiating root canal therapy.



Tooth #:

Endodontic Case #:

Appt Date:

Student Name:

Student #:

Patient Name:


Chart #:

Medical History:


Has Tooth Had Emergency Treatment
If YES than provide History of SOAP notes. If NO write SOAP notes at first endo appt. Use SOAP note in AXIUM
Subjective (Include subjective history i.e., symptoms prior to emergency treatment, why did patient go to ED
Objective (include previous treatment)-

Assessment (Diagnosis)-


Restorability Check Needed



Rotaries Approved



List Procedural Steps



Faculty Signature


SOAP Notes: Purpose of the Problem Oriented Dental Record
Diagnosis is the most critical aspect of treatment. If the diagnosis is incorrect then the treatment is not going to
be effective, since the treatment is based on the diagnosis. The SOAP format allows for a systematic approach
to analyzing the patient’s chief complaint. It is therefore imperative that the treatment record have
SUBJECTIVE information, OBJECTIVE information, an ASSESSMENT, and a PLAN for treatment.
The patient’s record is used to document patient care and to improve communication among all those caring for
the patient. Notes should be written clearly, so that anyone involved with the patient’s care will know what was
done and why by reading the notes in the patient’s chart.

The CHIEF COMPLAINT is generally the first information obtained. The chief complaint is the symptoms(s) or
problem(s) expressed by the patient in his or her own words relating to the condition that prompted the patient
to seek treatment. The chief complaint should be recorded in non-technical language: for example, ―I have a
tooth that really bothers me when I drink cold water.‖ Subjective symptoms must be differentiated from
objective findings. Subjective data includes 1) the chief complaint
2) history of the problem (i.e., how long the chief complaint has been present)
3) the character of the pain (i.e., sharp, throbbing, lingering)
4) what initiates or relieves the symptoms
5) significant dental history (i.e., new restoration placed in #30 one month ago)
6) or any other information the patient may convey concerning the problem
A thorough subjective description by the patient most probably will enable the dentist to gain some insight
as to the nature of the problem as well as to its management. For example, for a patient with a chief complaint
of lingering pain to cold, the dentist will suspect an irreversible pulpitis. The subjective symptoms need to be
duplicated and confirmed by objective findings.
Objective findings are the result of observations as well as pulp tests conducted by the dentist. They will
usually, but not always, correspond with information obtained from the patient in the subjective history.
The objective examination includes:
a) Visual Exam – includes hard and soft tissues. For example: large carious lesions, fracture lines in teeth,
crown discoloration, sinus tracts, redness or swelling of tissues.
b) Radiographs – Usually includes two periapical films (one angled and one straight on), and a bitewing
c) Percussion/biting – may determine the presence of periapical pathosis. The incisal or occlusal surface
of the tooth is tapped perpendicular to the occlusal surface and parallel to the long axis with the end of a mirror
handle. Adjust your tests according to the patient’s symptoms. If a patient complains of severe pain to biting,
do not percuss heavily on the offending tooth. With severe pain, light finger pressure may be all that is needed
to reproduce the patient’s pain. The bite test allows the patient to place as much pressure as they feel
comfortable putting on the tooth. Have the patient bite on the saliva ejector or a bite stick for this test.
d) Palpation – finger pressure is applied to the buccal and lingual mucosal areas to root apices attempting
to locate spots tender or painful to the patient. Like percussion, palpation determines how far the

inflammatory process has extended periapically. The degree of periradicular inflammation can be better assessed
if the apical area is palpated. Extraoral palpation of lymph nodes and tissues is also assessed. Palpation is an
underappreciated diagnostic tool. Early swelling can also be detected this way. By interpreting these results, the
patient’s post-op course can be better predicted.
e) Electric Pulp Test (EPT) – The electric pulp test is used only to determine whether the pulp is vital or nonvital. An electric current is applied to several teeth to stimulate the fast conducting myelinated sensory fibers of
the dental pulp. The EPT cannot be performed on teeth with full-coverage restorations. Always test the adjacent
and contralateral ―normal‖ teeth first. This is so the patient knows what to expect from the test and a baseline is
established. The tooth is isolated with cotton rolls and dried after the procedure is explained to the patient. Place
a small amount of electrolyte (such as toothpaste) on the electrode tip to assure good contact. The tip of the
electrode is then placed on the facial enamel near the incisal edge (in anterior teeth) and the cusp tips (in
posterior teeth) being certain not to contact any restoration (be sure to distinguish composite restoration) or the
gingiva. To complete the circuit and to start the (EPT), the patient is to contact the metal handle with two or more
fingers. The patient is to remove his/her fingers from the handle when a tingling, itching, or other sensation is felt
in the tooth. A number from 0 to 80 will be displayed and locked in on the pulp tester for several seconds.
Stimuli can pass through metal-to-metal contacts. Metal-to-metal contacts as with an MO amalgam adjacent to a
DO amalgam should be separated with a Mylar strip. Different numbers DO NOT indicate different stages of
pulp degeneration. Therefore, this test is not a measure of the degree of health of a pulp. The EPT is used ONLY
f) Thermal Tests
Cold Test – At the USCSD we use EndoIce R for the cold test. EndoIce R is a refrigerant spray of
tetrafluoroethane which is a clear, colorless liquefied gas, with a spearmint odor. It has a low liquid temperature
of -26O C and is therefore an effective cold test for restored and nonrestored teeth. A loosely woven cotton pellet
is held in cotton pliers. A short burst of EndoIce is sprayed onto the cotton pellet and then the cotton pellet is
gently placed buccally on the incisal edge or near the pulp horn of the tooth. Always test the adjacent and
contralateral ―normal‖ teeth first. Then test the tooth in question for comparison. The procedure is explained to
the patient, ensuring they understand they are to respond to cold sensation, not just to pain (the pulp has only
pain fibers, however, the patient’s interpretation of these signals varies. Some patients will interpret all cold as
pain, while others will interpret normal cold sensation as non-painful. Since a response to cold (painful or not)
indicates vital tissue, we want to ensure that the patient signals when they feel a sensation to cold. The patient is
instructed to raise his or her hand when the onset of cold is felt. The cotton pellet is immediately removed from
the tooth. The patient is instructed to put his/her hand down when the cold sensation is gone. The number of
seconds is noted as to when the onset of cold was felt initially and when the cold sensation ended. The patient
should also indicate if there is exaggerated or lingering discomfort relative to the other teeth. An exaggerated
and/or lingering response to cold indicates pulpitis. No response to the cold (no pain, no sensation whatsoever)
indicates pulpal necrosis. *Note – a cotton pellet is more effective than a cotton swab since the cotton pellet can
cover more of the tooth surface and better simulate the feeling of cold water around the tooth. Also the swab
cannot hold as much of the spray and may therefore give a false negative response.
Older techniques such as refrigerated ice sticks are less effective. Dripping water may result in a false positive
response from the gingival and the ice stick is also less effective for the same reason as the cotton swab.
Heat Test – the heat test is only used when the patient’s only complaint is sensitivity to heat. It is much more
difficult to carry out then a cold test and the only information it gives that a cold test does not is which tooth is
sensitive to heat and we want to duplicate the patients symptoms with our objective tests. As with the cold test,
always test adjacent and contralateral ―normal‖ teeth first. Then test the tooth in question. There are two methods
for the heat test. 1) Gutta percha is heated over a flame until it becomes soft and is then placed on the buccal
surface or the incisal edge of the tooth. The tooth should be lightly coated with Vaseline to prevent the gutta
perch from sticking to it. The response to the heat is evaluated similarly to the response to cold. (It is only a

different stimulus that is being evaluated). 2) The teeth are isolated with rubber dam one at a time. Hot water (not
scalding, not tepid) in a large syringe is flowed over the tooth while being evacuated. The patient should raise
his/her hand when they feel pain (whereas cold usually has an immediate sharp response, there may be a delay
before heat is recognized. Heat is more often interpreted as pain by the patient but will not linger once it is
removed from normal teeth). When the patient signals, irrigation is immediately stopped. As with cold, if the
response was exaggerated and lingering, this indicates pulpitis.
For poorly localized pain the objective data should be gathered from the whole quadrant in which the offending
tooth is located and also from a contralateral tooth to the one in question. The opposing arch should also be
evaluated since there can be referred pain from the upper to lower arch or vice versa.
A. ASSESSMENT: This is where you analyze the results of the subjective and objective evaluations and come
up with a diagnosis. You need to note a pulpal and an apical diagnosis.
Pulpal diagnosis:
Periapical diagnosis:

This describes your plans for the diagnosis that was made. (i.e. if the assessment was tooth #19 necrotic pulp
with an acute periradicular periodontitis the plan may be #19 caries removal. #19 evaluate for restorability. If
restorable, #19 RCT.
It is important to note that the diagnosis reached is based on the subjective and objective data. The dentist cannot
microscopically examine the pulp and surrounding periradicular areas to arrive at an accurate histopathologic
diagnosis. Furthermore, the diseases of the pulp and periradicular area correlate poorly with the actual
histopathology that may be present. However, this does not mean that it is not possible to differentiate normal
pulps from diseased pulps. The reliability of the diagnostic process is improved when it is possible to reproduce
the chief complaint. In fact the inability to reproduce a symptom should be a ―red flag‖ indicating that any
treatment rendered may not effectively address the physiological basis of the chief complaint.


The following is the terminology pulpal and periapical terminology used at USC.
Normal pulp - A clinical diagnostic category in which the pulp is symptom-free and normally responsive to
pulp testing.
Reversible pulpitis - A clinical diagnosis based on subjective and objective findings indicating that the
inflammation should resolve and the pulp return to normal.
Symptomatic irreversible pulpitis - A clinical diagnosis based on subjective and objective findings indicating
that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous
pain, referred pain. (On national boards irreversible pulpitis is used.)
Asymptomatic irreversible pulpitis - A clinical diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but
inflammation produced by caries, caries excavation, trauma. (On national boards irreversible pulpitis is used.)
Pulp necrosis - A clinical diagnostic category indicating death of the dental pulp. The pulp is usually
nonresponsive to pulp testing.
Previously treated - A clinical diagnostic category indicating that the tooth has been endodontically treated and
the canals are obturated with various filling materials other than intracanal medicaments.
Previously initiated therapy - A clinical diagnostic category indicating that the tooth has been previously
treated by partial endodontic therapy (i.e., pulpotomy,pulpectomy).
Normal apical tissues - Teeth with normal periradicular tissues that are not sensitive to percussion or palpation
testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.
Symptomatic apical periodontitis - Inflammation, usually of the apical periodontium, producing clinical
symptoms including a painful response to biting and/or percussion or palpation. It might or might not be
associated with an apical radiolucent area. (On national boards acute apical periodontitis is used.)
Asymptomatic apical periodontitis - Inflammation and destruction of apical periodontium that is of pulpal
origin, appears as an apical radiolucent area, and does not produce clinical symptoms. (On national boards
chronic irreversible pulpitis is used.)
Acute apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset,
spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.
Chronic apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by gradual
onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.
Condensing osteitis - Diffuse radiopaque lesion representing a localized bony reaction to a low-grade
inflammatory stimulus, usually seen at apex of tooth.

JOE — Volume 35, Number 12, December 2009

In the following table the pulpal and periradicular diagnosis are listed along with clinical information.
Normal Pulp







Hot &/or


Hot &/or

(cold is
No pain

us Pain








or widened


Widened PDL
Widened PDL





Apical Abscess



Biting or


Pain usually
Slight to


Widened PDL





e History /

Radiodensity /

Bad Taste
tic or


Widened PDL











Removal of

Root canal



No Response



Root canal













e / No



e or Not











e / No


e or Not

e or Not





, or

Root canal




will relieve
the pain
Open for
drainage, I
bone and
mucosa and









Necrotic or

Necrotic or
Necrotic or
due to

Required Radiographs
All lab radiographs have two views
1. Suitability radiograph: unmounted tooth. Check suitability for lab exercise. Pulp chamber
should be readily seen. Canal should be relatively straight from orifice to foramen. Apices
should be closed. In clinic, this is your pre-operative radiograph.
2. Working length (WL) radiograph: WL file (use at least a #15 file) is usually between 0.5 and
1mm from the radiographic apex. If it is not at the correct length, adjust the working length and
take a new radiograph. (If the discrepancy is less than 0.5mm another radiograph is not
necessary to confirm the corrected length). In the typodont mounted teeth and in clinic, use the
apex locator prior to taking the working length x-ray.
3. Master Apical File radiograph (MAF): Shows largest file taken to WL. This radiograph is
taken after you have completed the preparation of the apical constriction and prior to the step
back preparation.
4. Master gutta percha cone radiograph: Evaluate fit and length. Should appear to fill up the
apical 2-3mm of canal. Should have space around cone and canal walls in the middle and
coronal section signifying adequate flare. At WL (with slight tugback) is preferable.
5. Initial condensation radiograph: Evaluate fit and length after sealer is placed and enough
accessory gutta percha cones are placed to fill the apical third of the canal. Length control and
density of fill are evaluated.
6. Final radiograph: Evaluate gutta percha condensation from CEJ to apical stop. Temporary
fill should be in place from where the gutta percha stops to the cavo-surface margin. THE


Required recorded data for all teeth in the clinic as well as
preclinical endodontic block.
1. Depth to top and floor of pulp chamber
2. Estimated working length
3. Working length
4. First file to bind at working length
5. Master apical file size
6. Last file used in step back
7. Master cone size

Radiographs are to be examined for:
Extent and depth of caries
Extent and depth of restoration
Alveolar bone loss
Number of roots and canals
Canal anatomy
Calcifications, pulp stones
Resorptions; internal and external)
Previous treatment
Apical and lateral radiolucencies, widened PDL


Long axis of tooth parallel to side of the film
All required radiographs present


The endodontic preclinical laboratory-grading sheet must be filled out and signed by an instructor. Each step
must be checked prior to progressing to the next step.
Anterior Tooth





RL =

RL =

RL =

RL =



Tooth selection


Length Evaluation

Rubber Dam




Coronal Flare
Straight Line Access

Working Length

MAF size

Step Back
Last file size

Cone Fit

Initial Condensation

Completed Root
Canal Filling


Student Name

Student Number

Patient Name

Axium #

Endo Assist D3999
1st appointment

Endo Case #

Group #

Endo Assist D3310 (for anterior credit)
2nd appointment

Rubber Dam

Coronal Flare

Working Length

Master Apical File

Spreader Fit
Circle One: hand/finger

Cone Fit


Final X-Ray
No rubber, with


3rd appointment

4th appointment


Reference Point

Working Length

First File
to Bind




Last File in Step

Master Cone

Section 11 - Practical Procedures
Please turn the following to your T.A. in a baggie.
Tooth embedded in plaster/resin with student number.
Preoperative radiographs with 2 views: facial-lingual and mesial-distal.
Grade sheet—Label with name and student number

Grading Scale:
3 – Above clinical standard – clinical excellence – competent
2 – At clinical standard – clinical acceptability – beginner
1 – Below clinical standard – unacceptable – novice
All ones will need to be redone before proceeding to the next exercise.


3 – Outstanding performance – demonstrated excellence – clinical excellence
- Paperwork completed and concise
- Extracted teeth mounted cleanly and placed esthetically
- Pre-operative radiographs are clean, well fixed and dried
- Access cavity well oriented and refined
- Cleaning and shaping: Maintenance of the canal(s) configuration(s),
determination of working length is correct, final size and shape ideal
- Obturation: Canal filled to apical stop, obturation complete, no voids and
good density
- Access cavity properly filled
- Treatment radiographs well presented, radiographic technique excellent
- Excellent work habits, neat work area
- Sterile technique observed
- Demonstrates an understanding of the procedures
2 – Acceptable performance – adequate, average, clinically acceptable
- Paperwork complete
- Extracted teeth mounted cleanly
- All radiographs clean, well fixed and dried
- Radiographic technique good with minimal repetitions
- Access cavities adequate and need minimal refinement
- Cleaning and shaping: Canals well cleaned and shaped, apical stop in the
correct position and patency maintained, minor changes necessary
- Obturation: Filled to the apical stop, no apical voids, generally good density
- Student exhibited adequate work habits
- Demonstrates adequate understanding of the procedures
1 – Poor – Will require repeating the exercise – clinically unacceptable
- Paperwork incomplete
- Extracted teeth mounted unacceptably
- Radiographs of fair to poor quality (nondiagnostic), technique poor
- Access cavities inadequate, require major modifications, perforated
- Cleaning and shaping: Insufficiently prepared, over prepared, inadequate
maintenance of the apical stop, unacceptable transportation of the canal
- Obturation: Apical third of the canal poorly filled, voids in the apical third, or
gross or multiple voids in the middle and/or coronal thirds, filling beyond the
apical stop or short of the apical stop
- Poor work habits demonstrated, messy work space
- Demonstrates a lack of understanding of the procedures



10 Steps To Endodontic Heaven

Or how I succeeded in endo without really trying.


Take appropriate high quality preoperative radiographs (BW and 2 PA’s)
Treatment Plan & Restorability Check.
Examine, pulp test, record.
SOAP notes. Each visit is unique and the SOAP notes need to reflect that.
Measure and record RL, RPC, FPC.
Rubber dam
Occlusal reduction
Straight line access
Create guide path for Gates-Glidden burs
Using Gates-Glidden burs to create coronal flare
Use electronic apex locator
Confirm WL with radiograph
Determine and record first file to bind at WL (MAF should be 3-5 times larger)
Rotary or hand instrumentation to get to MAF
Continual irrigation and occasional patency file
Correct as necessary
Step back in 1 mm increments extending 4- 5 mm from WL
Apical stop verification
Flare check
5. Obturation
Sealer/Master Cone
Initial Condensation
GP removal to CEJ/orifice
Complete Obturation
Remove Rubber Dam
Final Radiograph (with rubber dam off!!)


Endodontic Requirements
1. Assist an endodontics resident with a root canal treatment in the endodontics clinic
This is a requirement PRIOR to treating any patients in the endodontics section on the second floor
2. Successful treatment of six teeth requiring root canal therapy (at least one tooth must be a molar, the
remaining teeth can be bicuspids or anterior teeth)
The following are required for each tooth treated in the endodontics clinic:

PRESESSION FORM - Prior to starting any root canal treatment a presession must be completed
and SWIPED by an endo resident or endo faculty.
AAE CASE DIFFICULTY FORM- this form is part of the presession and must also be
completed with the presession.
BROWN FORMS – These forms are to be checked off at each step of the procedure.
POSTSESSION FORM – This form is filled out and reviewed with the clinical instructor as soon
as the treatment is completed. The root canal treatment will not be swiped complete until the postsession review is done.
The completed cases are turned in to Jackie in the endodontics office on the first floor. Each case that you turn
in will consist of
1. AAE Case Difficulty Form
2. Brown Form
3. Postsession Form
4. Copy of final radiograph

Successful passage of the 3 bench exams may count as one of the anterior/bicuspid teeth of the 6 tooth
Assisting an endodontics resident on a root canal treatment case from start to finish may count as one of the
anterior/bicuspid teeth of the 6 tooth requirement. THIS IS IN ADDITION TO THE INITIAL ASSIST IN
THE POSTGRADUATE ENDODONTICS CLINIC. To receive credit for the assist, a brown form needs to be
filled out by the resident you assisted and the triplicate form needs to be signed by Dr. Levy.