Problem Solving in Cleaning and Shaping the Root Canal

Successful root canal treatment is based on: establishing an accurate diagnosis and
developing an appropriate treatment plan; applying knowledge of tooth anatomy and
morphology (shape); and performing the debridement, disinfection, and obturation of the
entire root canal system.

*The root canal system must be:

Cleaned of its organic remnants
Shaped to receive a three dimensional filling of the entire root canal space

*The canal is:

Cleaned primarily by irrigation
Shaped primarily by instrumentation

Basic Objectives in Cleaning and Shaping

 Removal of infected soft and hard tissues.
 Give disinfecting irrigants access to the apical canal space.
 Create space for the delivery of medicaments and subsequent obturation.
 Retain the integrity of radicular structure.

Biological Objectives
 To completely debride the pulp space of:
-Pulp tissue
-Bacteria/Microorganisms
-Endotoxins (dentin mud)

Mechanical Objective:
 Continuously tapering preparation
 Maintain original anatomy
 Maintaining the position of the apical foramen
 Foramen as small as practically possible

A well-designed access cavity permits:

 Complete debridement of the pulp chamber
 Visualization of its floor
 Unimpeded placement of instruments into the root canals; straight line access
 Conservation of tooth tissue

Working Length determination

Working Length
Definition: The distance from a predetermined coronal reference point to the point the
cleaning and shaping, and obturation should terminate.
Methods of working length determination
A. Radiographs
 It is the most widely accepted method for establishing working length.
 An estimated working length is initially established by measuring from an accurate, non-
distorted, preoperative radiograph.
 A file, preferably size 15 is then placed to the estimated working length and a second
radiograph is exposed.
 If the tip of the file is within 1mm of the ideal location then the radiograph can be
accepted as an accurate representation of the tooth length, if adjustments are need to
be made, working length should be reconfirmed with a new radiograph.
B. Electronic apex locators
 It is considered an accurate tool for determining working length.
 It consists of a lip clip, a file clip, a connection cord and the device itself
C. Digital Tactile sense
 It is more accurate than other methods for an experience clinician
*Drawbacks
 Difficulty in locating the apical constriction in teeth with immature apex
 Difficulty in locating the apical constriction in teeth which have constricted canal
throughout the length
D. Paper points evaluation
 In a root canal with an immature (wide open) apex
 The paper point is gently pass into the canal after profound anesthesia has been
achieved
 The moisture or blood on the portion of the paper point may be an estimation of
working length
E. By apical periodontal sensitivity
 Any method of working length determination, based on the patient’s response to pain,
does not meet the ideal method of determining working length.
 This is done by inserting an endodontic instrument and using the patient’s pain reaction
to determine working length

Various motions of the hand instruments

Watch winding/ Twiddling
 Reciprocating clockwise/counterclockwise rotation of the instrument in an arc of 30-90
degrees
 Used to negotiate canals and to work the file to the working length
 Least aggressive
Reaming
 Defined as the clockwise cutting rotation of the file
 Instrument is placed into the canal until binding is encountered and then rotated 180-
360 degrees to plane walls and enlarge the canal
Filing
 Defined as placing the file into the canal and pressing it laterally while withdrawing it
along the path of insertion to scrape the wall
 Indicates push-pull motion
 There is very little rotation
 Scraping action
*Circumferential filling
 The file is placed in the canal and withdrawn in a directional manner
sequentially against the mesial, distal, buccal and lingual walls.
Turn-pull technique
 Modification of the filling technique
 Placing the file to the point of binding, rotating the instrument 90 degrees and pulling
the instrument along the canal wall

Techniques for preparation

Canal preparation techniques can be broadly divided into those that adopt an ‘apical to
coronal’ preparation procedure and those that adopt a ‘coronal to apical’ approach.

Step back technique

 Also called telescopic or serial root canal preparation
 During the whole procedure recapitulation with a smaller file and copious irrigation is
essential so as to ensure patency of the canal
Advantages
 Less likely to cause periapical trauma
 Facilitates removal of more debris
 The greater flare resulting from instrumentation facilitates packing of additional gutta-
percha cones by either the lateral or vertical condensation method.
 Development of an apical matrix or stop prevents overfilling of root canal.
 Greater condensation pressure can be exerted, which often fills lateral canals with
sealer

Phase I – apical preparation

 Canal is generally explored with a fine instrument
 Working length is then determined
 First instrument to be inserted should be fine (no. 8, 10 or 15 k-file), pre-curved and
coated with a lubricant
 Motion is generally ‘watch winding’ – 2 or 3 quarter turns clockwise – counterclockwise
and then retraction.
 Upon removal, the instrument is wiped clean, recurved, relubricated and reinserted
 Procedure is repeated until the instrument is loose in position
 Then the next size K-file is used
 By the time a size 25 K-file has been used to full length, phase I is complete
Phase II – stepping back
 In a fine canal, step back process begins with a no. 30 K-file with a working length set
1mm shorter
 The instrument is pre-curved, lubricated, carried down the canal to the new working
length
 Process is repeated till no. 30 file is loose within the canal
 Recapitulation to the full length with a no. 25 K-file follows to assure patency to the
constriction
 Thus, preparation steps back up the canal one millimeter and one large instrument at a
time
 When the mid-canal is reached, where the instruments no longer fir, circumferential
filing may begin
 A Gates-Glidden drill can be used starting with a smaller drill (no. 1 &2) and then
gradually increasing the size to 4, 5, & 6
 The proper continuing taper is developed to finish Phase II A
 Refining Phase II B is a return to size no. 25 instrument, smoothening all around the
walls to perfect the taper from the apical constriction to the canal orifice

Crown down Technique

 Early debridement of the coronal part of the canal
 Better and deeper penetration of the irrigants
 Elimination of the coronal and middle dentin resistance
 Shorten the preparation time
Advantages
 Decrease chance of canal blockage
 Greater volume of irrigants can reach canal irregularities
 Enhance tactile sensation because of removal of coronal interference
 Enhance removal of debris
 Holds greater volume of irrigant thus enhancing cleaning
Phase I – coronal preparation
 Coronal flaring using Gates-Glidden drills no. 3,2,1 with increase in depth of the
penetration respectively
Phase II – body of the canal preparation
 Accomplished by filling action starting with larger files and gradually decrease in the size
of instrument with gradual increase in length
Phase III – apical preparation
 It includes preparation of the apical third of the canal till reaching the master apical file.

Endodontic Microscope
 Endodontic therapy was performed using our tactile sensitivity, and the only way to “see” inside
the root canal system was to take a radiograph.
 In endodontics, every challenge existing in the portion of the root canal system, even if located
in the most apical part, can be easily seen and managed competently under the microscope.
  This microscope had a magnification changer that allowed for five discrete magnifications (3.5-
30x), had a stable mounting on either the wall or ceiling, had angled binoculars allowing for sit-
down dentistry, and was configured withadapters for an assistant’s scope and video/35 mm
cameras
 Light sources are either of halogen or xenon
 In chronological order, the preparation of the microscope involves the following maneuvers:
1. Operator positioning
2. Rough positioning of the patient
3. Positioning of the microscope and focusing
4. Adjustment of the interpupillary distance
5. Fine positioning of the patient
6. Parfocal adjustment
7. Fine focus adjustment
8. Assistant scope adjustment

The use of the operating microscope in endodontics

 Diagnosis
 Locating the canal orifices
 Retreatment
 Removing fractured instruments
 Repairing of perforations
 Surgical Endodontics
 Soft tissue management

Balanced force technique

 Series of rotational movements
Steps:
First step
 Passive clockwise rotation of about 90 degrees to engage dentin.
Second step
 The instrument is held in the canal with adequate axial force and rotated
counterclockwise to break loose the engaged dentin chips from the canal wall
 This produces a characteristic clicking sound
Third step
 The file is removed with a clockwise rotation to be cleaned

Irrigants
Irrigants are used to clean the canal during the enlarging and shaping process. Irrigants
possess multiple characteristics such as tissue-dissolving attributes and bacteriostatic or
bacterial capabilities. Additional properties include rinsing away debris created during cleaning
and shaping, lubricating instruments, demineralizing and removing the smear layer.
No one solution has yet possesses all the properties of an ideal irrigant. The use of
neutral solutions for irrigation process (water, saline, anesthetic solution) serves no useful
purpose in the root canal system.
SODIUM HYPOCHLORITE
 The best irrigant used during root canal procedures. It is a highly effective solution that
is both antimicrobial and has tissue dissolving properties. NaOCL possesses bleaching
and lubricating properties and has been shown to inactivate endotoxins.NaOCL is also
an effective disinfectant for it accomplish the removal of the gross debris in the canal
system and the effective dissolution of the remaining pieces of tissue and fragmented
dentin following root shaping.
 Manipulations that enhance the efficacy of NaOCL include warming the solution up to
37 degrees Celsius. Bacterial properties doubles for each 5°C rise in temperature. Thus,
1% solution at 45°C is the same to 5.25% solution at 20°C.it is also a compatible irrigant
for up to 6%.
 NaOCL must not be used as a final rinsing solution for the canal when resin-bonded root
canal fillings are planned for obturation because the bonding of the sealer to the dentin
may be altered.
EDTA
 The use of EDTA as a final rinse may cause a collapse of the dentin structure on the
surface of the dentin, thereby impeding root canal sealer infiltration and formation of
high quality hybrid layer bonding. EDTA is a compatible irrigant at a 17% solution.
 *Chelating agents may assist in penetrating calcified orifices and root canals, enhancing
the removal of the smear layer during cleaning and shaping and serving as excellent
lubricants for both hand and rotary instruments. Detergents are added to EDTA to
reduce the surface tension of chelate thereby facilitating the wetting of the root canal
wall and increasing the chelator’s ability to penetrate the dentin.

CHLORHEXIDINE
 Chlorhexidine (CHX) is a broad-spectrum antimicrobial agent effective against gram-
negative and gram-positive bacteria. Chlorhexidine has a superior antimicrobial
property but if the smear layer is not removed, the agent has no access to the dentinal
tubules and the bacteria that may be present within. Chlorhexidine as a mouth rinse and
periodontal irrigant hasbeen used in periodontal therapy, implantology, and
cariologyfor many years to control dental plaque.Its use as an endodontic irrigantis
based on its substantivity and long-lasting antimicrobial effect, which arises from
binding to hydroxyapatite.Chlorhexidine (2%) has been advocated as a final rinse irrigant
owing to its substantivity, which allows binding to dentin and sustained antimicrobial
activity, especially in endodontic retreatment.

Other irrigating solution

 Sterile water
 Physiologic saline
 Hydrogen peroxide
-All of these lack antibacterial property when used alone, and they do not dissolve tissue either.
 NaOCL Hydrogen EDTA NSS Anesthetic Chlorhexidine
peroxide solution
Very good irrigant,    X X 
disinfectant and
antimicrobial
property
Must not irritate X X X   
tissue (periapical)
Remains stable in  X X   
solution
Biocompatible  X    
Low surface tension X X X   
Cost efficiency X X    
Does not stain  X X   
Long acting X X X X X 

Problems associated in cleaning and shaping

A. Loss of working length
Cause
 Failure to irrigate frequently and copiously
 Failure to recapitulate
 Failure to radiographically verify the working length
 Malpositioned rubber stops
 Failure to record and regularly use stable reference point
 Skipping instrument sizes
 Fracturing an instrument without realizing it has occurred
Prevention
 Frequent recapitulation and irrigation
 Accurate working length measurement
 Each file must be used until it is loose before a larger size is used
 Avoid application of severe forces during instrumentation
Prognosis
 The failure depends on the amount of debris left in the uninstrumented and unfilled
portion of the canal

B. Ledge formation
 A ledge has been created when the working length can no longer be negotiated and the
original patency of the canal is lost
Cause
 Inadequate straight line access into the canal
  Inadequate irrigation and recapitulation causing packed debris in the apical portion of
the canal
 Skipping files
Prevention
 Straight line access
 Frequent recapitulation and irrigation
 Each file must be used until it is loose before a larger size is used
Management
 An initial attempt should be made to bypass the ledge with a no. 10 file to regain
working length
 The file tip (2-3mm) is sharply bent and worked in the canal in the direction of the canal
curvature
 If the original canal is located, the file is then worked with a reaming motion and
occasionally an up and down movement to maintain the space and remove debris
 If the original canal cannot be located by this method, cleaning and shaping of the
existing canal space is completed at the new working length
Prognosis
 The amount depends on where ledge formation occurred during instrumentation
 In general, short and cleaned apical ledges have good prognoses

C. Apical transportation (zipping) leading to apical perforation

Clinical appearance
 Sudden pain
 Hemorrhage in the canal
 Sudden stop of the apical stop
 Bleeding at the tip of paper point
 File appears out of the canal (radiographically)
Cause
 Incorrect working length estimation
 Lack of pre-curving of the file
 Over enlargement of the canal
 Failure of locating the canal
Prevention
 Proper working length must be established and maintained throughout the procedure
 Pre-curve the files
Management
 Reestablishment of the working length short of the original length, then enlarging the
canal, with a larger instrument
 Placement of MTA as an apical barrier can prevent extrusion of obturation material
 Perforation in the apical third, try to negotiate the original canal
*one is now dealing with two foramina: one natural, the other iatral.
Prognosis
  Success of treatment depends primarily on the size and shape of the defect. An open
apex or reverse funnel is difficult to seal and also allow extrusion of the filling materials

D. Lateral stripping
Clinical Appearance
 Bleeding at the lateral side of the paper point
 Sudden pain
 Hemorrhage in the canal
Cause
 Direct perforation as a result of pressure and force applied to a file
 Over-instrumentation using files or drills through a thin wall in the root
Prevention
 To avoid these perforations some factors should be considered:
 Degree of canal curvature and size
 Inflexibility of the larger files
Management
 Use suitable restorative material like MTA
Prognosis
 It depends on several factors:
 Remaining amount of undebrided and unobturated canal
 Perforation size
 Surgical accessibility
 Obturation is difficult because of lack of a stop; a gutta percha tends to be extruded
during condensation
 Perforations close to the apex have a better prognosis
 In general, small perforations are easier to seal than large ones

E. Instrument fracture
Recognition
 Removal of shortened file from the canal
 Loss of canal patency
 Radiograph is essential for confirmation
Cause
 Limited flexibility
 Over use
 Excessive force applied
Prevention
 Continual irrigation
 Each instrument is examined before use
 Small files must be replaces ofthen
 To minimize binding, each file size is worked in the canal until it is very loose before the
next file size is used
Management
  Attempt to remove the instrument using
 Small file to bypass the instrument then retrieve it
 Using ultrasonic tips
 Using especially designed pliers
 If removal is unsuccessful, then the canal is cleaned, shaped, and obturated to its new
working length
Prognosis
 It depends on how much unbrided and unobturated canal remains
 The prognosis is best when separation of a large instrument occurs in the later stages of
preparation
 The prognosis is poor when small instrument is separated short of the apex or beyond
the apical foramen early in preparation
 For medical-legal reasons, the patient must be informed of an instrument separation
 If the patient remains symptomatic or there is a subsequent failure, the tooth can be
treated surgically

F. Sodium hypochlorite extrusion

Signs and symptoms
 Sudden prolonged and sharp pain
 Rapid diffuse swelling
 Profuse hemorrhage both through root canal and interstitially leading to bruising and
echymosis
Prevention
 Always place rubber dam
 Careful use of sodium hypochlorite
 Use a side-vented needle
 Use low pressure in delivering sodium hypochlorite
Management
 Stop treatment immediately and explain the situation to the patient
 Removal as much sodium hypochlorite from the tooth via an empty syringe to aspirate
or use of paper points
 Administer steroids (100 mg hydrocortisone sodium succinate IM) immediately
 Ice packs applied initially to the area, followed by warm saline soaks the following day,
should be initiated to reduce the swelling
 Oral antibiotics should be taken immediately and continued for 3 days
 Appropriate analgesic prescribed
 The patient should be under review for the nexr few hours to monitor swelling
Prognosis
 Generally is favorable
 In some cases, the long term effects of irrigant injection into the tissues have included
paresthesia, scarring and muscle weakness