Proven Strategies to Improve Endodontic Success and Promote Natural Tooth Retention
A series of clinically relevant steps to enhance the clinical success of endodontic therapy is presented. Emphasis has been placed on use of the surgical operating microscope, straight line access, patency, copious irrigation, frequent recapitulation, passive rotary nickel titanium file use, bonded obturation and placement of an early coronal seal.

Key words: Root canal, treatment planning, patency, straight-line access, recapitulation, bonded obturation.
While materials and methods to clean shape and fill the root canal space might differ, the principles required do not. The goal of endodontic therapy is the three dimensional cleaning, shaping and obturation of the canal space from the orifice to the minor constriction (MC) of the apical foramen. Coincident and vitally important to the long-term success of endodontic treatment is the placement of a coronal seal and a final restoration to provide function and esthetics.1-4 To achieve this goal, all mechanical shaping procedures must follow the same principle driven criterion. These criterion include: • Keeping the MC at its original position and at its original size. • Keeping the canal in its original orientation and position within the root. • Making the final prepared shape to resemble a tapering funnel, with a taper that is continuous along all levels of the root. • Preparing the canal to a biologically relevant master apical file (MAF) size. This implies that the clinician will remove dentin circumferentially at the MC. • Preparing the canal to a biologically relevant master apical taper. • Both that the MAF and master apical taper (MAT) are a size that facilitates the optimal flow of irrigants. At the same time, this size should not predispose the roots to either canal transportation or vertical root fracture. In the most general sense, files shape the canals but they do not clean canals. While irrigation as we know it today does not render a canal bacteria free, especially of biofilms, the goal of irrigation, during and after the shaping of the root canal system, is to kill bacteria, flush debris, lubricate, clear the smear layer and dissolve pulp tissue in all the areas of the canal that shaping instruments do not reach to. In concept, this combination of shaping goals and irrigation acts to clear the pulp space in such a manner as to facilitate apical healing through diminishing the bacterial load present within the root canal system once the coronal seal is placed. Several key concepts guide the steps in endodontic therapy. Adherence to these principles can enhance the long-term prognosis and improve healing and success rates. These concepts are, to a large degree, independent of the materials used and include: Use of the surgical operating microscope (SOM) increases the visual acuity of all stages of the endodontic treatment process, for example the use of Global Surgical microscope (Global Surgical, St. Louis MO, USA). The benefits of the SOM cannot be overstated. Most SOMs have between 3-6 magnification steps that range from approximately 2x-19x magnification power, some even more. This allows the clinician to move between powers as the case might require. In essence, in occlusal access, less magnification is needed and lower powers are used. Once access is made, the actual location of the canal can be easily found at higher powers and direct the removal of dentin and allow easier negotiation of the canal space throughout the initial stages of treatment. In clinical terms, this means that; 2nd mesial-buccal canals can virtually always be located with the SOM and improve the chances of their negotiation, that separated (fractured) rotary nickel titanium (RNT) files can usually be removed, that vertical
16 Smile Dental Journal Volume 4, Issue 1 - 2009

Dr. Richard E. Mounce DDS . International lecturer in endodontics . Private practice Vancouver, WA, USA Lineker@comcast.net

The Surgical Operating Microscope

amongst a host of other important clinical information. deficiency can often be addressed. CA. Once an orifice is uncovered. once all coronal restorations are removed. CA. Straight-line access under the SOM provides the best possible platform to manage the shaping of the orifice as well as canal enlargement. The use of the SOM is not limited to endodontics. Removal of the cervical dentinal triangle (CDT) is also critical to provide straight-line access. many ledges. In this example. Many teeth that would have had apical surgery in the past can now be retreated with great precision as the previous technical 18 Smile Dental Journal Volume 4. patent and negotiable. hand K files can be trimmed to match the optimal point of use. The hand K file can be trimmed to a length that is slightly longer than the ledge or blockage. 3). Orange. because it can both be observed and addressed (Fig. coronal fractures. Iatrogenic events are far more likely to occur without straight-line access as shaping instruments deflect off of the canal walls they should not touch. It is possible and occurs frequently enough. in part. A lack of straight-line access leads to a loss of both hand and rotary nickel titanium tactile control. unset restoratives amongst other sources of coronal leakage are hidden under restorations. 1). USA) used to pre curve hand K files for negotiation. all canals should be enlarged to a minimum #15 hand K file size ideally to the MC. Patency is highly valued and ideally obtained and maintained throughout the process of enlargement. Some canals will be open and negotiable easily to the minor constriction (MC) and others will need to be opened with hand K files to the MC. USA) can be used for this function. including crowns. MO. tactile control at all levels of the process is improved. such as the TCM III motor (SybronEndo. Arnaldo Castellucci). if the clinician were to cut the hand K file to 19 mm. calcification. using a 25 mm hand K file will not be efficient as a negotiation instrument. Hand K files are reciprocated at 900 rpm at the 18:1 setting. St. and the hand K files reach the position of the MC. The M4 Safety Handpiece (SybronEndo. (Figure 3) EndoBender pliers (SybronEndo. These hand K files should be precurved to make them match the expected canal curvature. if the clinician is having a challenge getting past 18 mm in a 22 mm root. and furcal floor fractures can be observed easily. Orange. (Image courtesy of Dr. Besides. The vast majority of the iatrogenic events that bedevil clinical procedures can be avoided through the intelligent. Irrigation becomes less effective as both the access to and the visualization of the orifices is diminished.Endodontics (Figure 1) The surgical operating microscope (Global Surgical. Little intentional pressure will be possible in attempting to bypass a ledge or blockage. CA. (Image courtesy of Dr. and precurve it as well. Arnaldo Castellucci). Louis. Removal of all coronal restorations. In addition. The hand K file in this example will buckle easily and lack function. 2). Issue 1 . USA). Before the use of rotary nickel titanium instruments. are found to be non restorable. Often caries. which may appear restorable. is most ideal. acute curvatures can be bypassed and allow the creation of patency (Fig. but rather the instrument has application in a wide variety of clinical situations that include all phases of general dentistry. For example. Patency of the Canals (Figure 2 b) Straight-line access and proper orifice management. Straight-line access is essential. it is advisable to use small hand K files to assure the clinician that the canal is open. the cervical dentinal triangle removed and the orifice enlarged. Reciprocation provides the movement of The Straight-line Access (Figure 2 a) Lack of Straight-line access and improper orifice management. Compromises in access can and will lead to deficiencies in apical third cleaning and shaping. the use of a reciprocating handpiece is highly valuable in efficiently shaping a glide path to make way for the use of rotary nickel titanium instruments.2009 . Once patency is achieved. copious and proper use of hand K files. knowledge of which has obvious clinical benefit (Fig. The M4 is a reciprocating handpiece with an attachment that fits onto an electric motor with an E type coupling. that some teeth. Orange. USA).

for example. With practice. to touch the walls. the primary bacteria found in cases of endodontic failure. CA. While a number of warmed techniques have been suggested and proven in the literature. UT. what is more important than the given technique per sey. a liquid EDTA solution that is used to clear the smear layer. Orange. some canal enlargement systems recommend reciprocation for the entire preparation. After this rinse. The #8 hand K file when reciprocated next will create the size of a #10 hand K file. The use of EDTA gel for emulsification is advised in the elimination of vital and necrotic pulp tissue from the chamber during access procedures. is that CHX does not dissolve tissue. It is not advised to take a hand K file. Each canal is activated 2-3 times with both the bactericidal irrigant and the liquid EDTA solution. 30 degrees counter clockwise (CCW) and/or it may have some other vertical competent or degree of CW/CCW movement depending on the brand used. Coincident to this goal is the desire to have a minimum film thickness of sealer. loads the files with excessive torsion and increases exponentially the possibilities that the instrument may fracture or that it may transport the canal. As a single file technique. Irrigation Irrigation should be copious and continuous throughout the instrumentation phase of treatment. USA) allows the preparation of canals to larger tapers and does so. The difference is related to the tissue dissolving capability of SH. This early enlargement of canals with reciprocation is much faster and predictable than the manual use of hand K files. While these systems have their champions. irrigation and recapitulation ensues and the desired TF is inserted next (Fig. Orange. the solution is refreshed. a quality that is more essential in vital cases. CA. fewer TF files and insertions are needed to accomplish the same preparation as the clinician becomes more experienced with the instruments. While a modification of the expected MAF and MAT will be possible. the clinician should evaluate the root form to determine the ideal master apical taper (MAT) and have some concept of the optimal master apical file (MAF).06 TF is often appropriate.etc.10 taper Twisted File (TF) is often appropriate. USA). Orange. CA. Each RNT file insertion should be followed by irrigation and recapitulation. the canal is ready for rotary nickel titanium files use. Regardless of the RNT system used. Adequate size in this context implies a size that gives optimal irrigation and in which SystemB heat pluggers can achieve their desired length of insertion apically. irrigants are heated and ultrasonically activated. This limited taper size is a result of the limitations of ground file technology. CHX also possesses antimicrobial qualities after it has been removed from the canal. when the canal resists their advancement.. SH which carries with it potentially severe toxicity if extruded into the apical tissues. Its drawback. CHX is relatively non-toxic and in the endodontic literature relatively equal in efficacy to SH without the toxicity. Once the chamber is cleared. 5. Recapitulation refers to the placement of a hand K file into the canal after every RNT insertion to verify that the canal is still open and negotiable. In every case. South Jordan.2009 19 . Issue 1 . This activation takes place with an ultrasonic file blank (EMS. safe and efficient use of rotary nickel titanium (RNT) files are a prerequisite for enlarging canals. It is rotated in hands at between 500-900 rpm with the torque control off. Clinically. and orifices are ready to be entered. Recapitulation is usually done with either #6 or a #8 hand file. RNT instruments must be inserted gently and passively. The use of 2% Chlorhexidine (CHX) is however ideal for non-vital and retreatment cases. For large canals (the palatal canal of an upper molar). if the given TF will allow passive insertion to the true working length. 4). Before RNT file preparation. USA). (lower anterior teeth) a . Irrespective of the brand or canal third being shaped. In addition.a hand K file 30 degrees clockwise (CW). barely allowed a #6 hand K file to be inserted. CHX is effective against E. it can be taken apically to the MC. USA). For small. Its use is much less desirable if a perforation or open apex is present. TF can often be used in a single file technique and done so with as few as 2-3 insertions. place it in the M4 handpiece and attempt to drive it to the MC in a calcified canal as ledging will result. a . For vital cases. it is vital that the canal be prepared to an MAF and MAT of an adequate size. the file is left in the canal and the clinician’s hands are taken away. are usually prepared to a taper of . such as SmearClear (SybronEndo. the smear layer has been cleared and the canal is ready for a bonded obturation. A final irrigation rinse is used. will enlarge the canal to the size of a #8 hand K file. The file is moved with a vertical amplitude (up and down motion) of 1-3 mm and in 15-30 seconds the canal that may have. safely and efficiently. Dallas Texas..08 TF is often appropriate. The M4 is attached to the file and the foot pedal engaged to power the file. for example File Eze (Ultradent. RNT files that are inserted with continuing force. while being a relative one. After each activation. is that the canal is three dimensionally filled with obturating material from the orifice to the MC. A final rinse of distilled water is carried out. the clinician can change to their liquid bactericidal irrigant. TF eliminates the need for Gates Glidden drills and other orifice openers.25% sodium hypochlorite (SH) is the ideal irrigation solution. Faecalis. the file withdrawn. there is no value in pumping the RNT file into the root repeatedly. While a comprehensive discussion of Smile Dental Journal Volume 4. The Twisted File (SybronEndo. the possibilities for canal transportation above a #15 hand file in delicate apical anatomy are substantial. RNT that are manufactured by grinding. The blank and holder are used with a relatively low power on an ultrasonic unit with the file blank passively moving vertically for 15-30 seconds per canal without attempting Warm Obturation Obturation should ideally be performed warm in order to move a heat-softened mass of material into all of the ramifications of the cleared root canal space. one insertion is made to resistance. complex and calcified canals. The clinician should irrigate and recapitulate the canal after every use of the M4 as well after every use of rotary nickel titanium files. USA). a . placed into an Ultrasonic File Holder (SybronEndo. once the hand K file can reach the MC. For more intermediate canals (the mesial root of a lower molar).06. Once a #15 hand K file can spin freely at the MC.5-17 Rotary Nickel Titanium Files Aside from the strategies above.

(Figure 8-10) Clinical cases using the materials and concepts discussed. bonded obturation in the form of RealSeal has been shown. bonded obturation and placement of an early coronal seal. straight line access. Orange. copious irrigation. Orange. Gutta percha does not bond to sealer. bacteria will leak along the length of the canal in either the gap between the gutta percha and the sealer or the sealer and the canal wall (depending on whether the smear layer was cleared and a resin based sealer used). CA.Endodontics (Figure 4) The Twisted File (SybronEndo. Orange. 7-10). suffice it to write that a greater degree of resistance to coronal leakage can be obtained with bonded obturation than gutta percha. a self adhesive and self-etching composite for build up procedures and/or coronal seal. patency. Placement of the coronal seal should be accomplished without delay while the rubber dam is still on and before the patient is released from the treatment visit. USA). USA). CA. USA). Orange. bonded obturation in the form of RealSeal (SybronEndo. Emphasis has been placed on use of the surgical operating microscope. Orange. Conclusion A series of clinically relevant steps to enhance the clinical success of endodontic therapy has been presented with the goal of optimizing endodontic therapy as an alternative to extraction and the placement of implants. CA. RealSeal One Bonded Obturators (SybronEndo. SEM courtesy of Dr. Gutta percha requires a coronal seal to make it function. Doing so will reduce the possibilities of vertical root fracture due to the lack of a coronal build up in addition to concerns of microleakage (Figs. to be superior to gutta percha in resistance of coronal microleakage in both in vivo and in vitro models (Figs.2009 . USA). 5 and 6). After obturation. the placement of a coronal seal is absolutely correlated with clinical success in the endodontic literature. 20 Smile Dental Journal Volume 4. While the resistance to leakage is not absolute. CA. CA.26-29 (Figure 5) RealSeal Bonded Obturation. in that otherwise. Gutta percha does not bond to dentin. Such a seal could be achieved by using Maxcem (Kerr. Martin Trope. Coronal Seal (Figure 6) RealSeal One Bonded Obturators (SybronEndo. Orange. (Figure 7) Maxcem Elite (Kerr. in a number of different studies. passive rotary nickel titanium file use. CA. if allowed to challenge gutta percha. in a time dependent fashion. frequent recapitulation. Acknowledgements The author does not have a financial interest in any of the products discussed in this article.18-25 Due to the limitations of gutta percha. Issue 1 . RealSeal comes in a master cone based and obturator (carrier) based variety of the product. USA) is preferred. USA). obturation techniques is beyond the scope of this paper.

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