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Problem Solving in Cleaning and Shaping The Root Canal
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.
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
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
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.
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
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