4th year

Endodontic division
Revision on instrumentation and obturation steps
during root canal treatment

v Aim of the instrumentation step.

1) Eliminate necrotic tissues and infective microorganisms from the root

canal system.
2) Shape the canal in proper funnel shape to be properly obturated.

v It should be chemo-mechanical preparation.

- Chemo: using the suitable irrigants.
- Mechanical: using the endodontic files.

v Where to start and when to stop.

The preparation should start from a reference point and end at the apical
constriction.
v The reference point should be: Fixed, stable, rrepeatable and easily seen.
v The apical constriction is usually 0.5 to 1 mm coronal to the apical foramen.

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v Steps:

1) Working length determination: It is the distance from the reference point

to a point at which the preparation and obturation should terminate = apical
constriction.

a) Measure the entire length of the tooth on the pre-operative x-ray (till
radiographic apex).
b) Subtract 1 mm (safety).
c) Adjust this length on the smallest file (estimated working length).
d) Insert it till the rubber stop rests on the reference point.
e) Take then develop the x-ray.
f) If it was over/under extended, re-adjust the length and take another x-ray.

2) The step-back technique of root canal preparation:

- Start at the apex with fine instruments and progress coronally with bigger
instruments.

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- It is composed of 2 phases:

Phase I: apical preparation using k-files.

Phase II: preparing the remainder of the canal (by stepping back) using H-
files .

Refining phase II A and II B for continuing taper to the coronal.

3) 2.5% NaOCl (Sodium hypochlorite) should be used before inserting any

file inside the canals
4) Determination of Initial file: it is the first file that binds apically at the
full-length engaging canal dentin and can’t be pushed further (if you try
inserting the successive file it will not reach the full WL). Always
introduce the files with gentle watch-winding and never in a dry canal.
5) Use this motion till the file is loose in the canal then proceed at the same
length with the next bigger file. This is repeated for 3 files larger than the
intiail file.
6) The last file used to full WL is called the Master Apical File (MAF) and
this should not be completely loose. The minimum size of MAF is 25
regardless of the initial file size. These steps will allow the creation of
proper retention and resistance forms in the apical 2 to 3 mms
7) Apical patency should be maintained using a #10 or 15 file that is gently
nudged through the apical constriction to clean these last few mms, cleaned
not shaped
8) Step-back: reduce the length by 1mm increments and take the next larger
file using it in a circumferential filing motion. (using H-files)
9) Recapitulate with the MAF: this will ensure remove steps created during
stepping-back and will ensure breaking-up debris and make sure that WL
is not lost.

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 10) Repeat steps 8 and 9 until 3 or 4 files larger than the MAF, each time
reducing the length by 1mm and recapitulating.

v Principles of radicular cavity preparation

1) Outline form and toilet of the cavity: walls should feel glassy smooth and
good irrigation ensures thorough debridement

2) Retention form: the apical 2 to 3 mm of the canal should be prepared with

nearly parallel walls to ensure a perfect fit of the primary gutta percha point. (tug-
back) Coronally from the area of retention the walls are deliberately flared.

3) Resistance form: resistance to overfilling by creating a definite apical stop.

The lack of stop leads to: violation of the periapex by bacteria or debris, foreign
body which can contribute to persistent disease, and no stop against which to
condense gutta percha.

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 Initial File

Master File

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 Obturation of The Root Canal Space
v Objectives of obturation:
a) Total obliteration of the root canal
b) Development of a fluid-tight seal at the apical foramen.

v Common material used for obturation?

Gutta-percha and sealer to fill spaces between GP cones and between them
and the walls of the canal to prevent leakage.

v Methods of obturating the root canal space

There are several techniques.

There are 2 basic technique of obturation:

1. Lateral compaction of cold gutta-percha.
2. Vertical compaction of warmed gutta-percha

v The armamentarium needed for obturation

1) Finger spreaders size 15-40
2) Hand plugger
3) Flame
4) Glass slab and spatula
5) Root canal sealer
6) Gutta percha points 15-40, 45-80, accessory cones
7) Endodontics ruler
8) Irrigation and syringe
9) Paper points
10) X-ray films
11) Locking tweezer

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v Steps for obturation: (Lateral Condensation Technique)
1) Selection of the master gutta percha point.
The master cone is color-coded and standardized to match the files.
Initially, try in the cone that is the corresponding size of the master apical
file.
The master gutta percha point should have good retention and resistance
Test the cone by these 4 methods:

a) Visual Test: To test the point visually, The point is then carried into the
canal until the cotton pliers touch the external reference point of the tooth.

b) Tactile Test: the apical 2 to 3 mm of the canal have been prepared with
near parallel walls, some degree of force should be required to seat the
point, and, once it is in position, a pulling force should be required to
dislodge it. This is known as “tugback.”
c) Patient Response. Patients who are not anesthetized during the treatment
of a nonvital pulp or at the second appointment of a vital pulp may feel the
gutta-percha penetrate the foramen.
d) Radiograph Test. After the visual and tactile tests for the trial point have
been completed, its position must be checked by the final test, the
radiograph.

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 2) Spreader size determination

It is mandatory to fit the spreader to reach to within 1.0 to 2.0 mm of the true
working length and to match the taper of the preparation.

3) Mixing and placement of sealer

The cement should be creamy in consistency but quite heavy, and should
string out at least an inch when the spatula is lifted from the mix.

The sealer can be inserted inside the canal by using:

a) The master gutta percha point

b) Endodontic file and rotated counterclockwise.
c) Rotary or spiral filler using rotary handpiece.

4) Placement of the master cone.

- The premeasured master point is now coated with cement and slowly
moved to full working length.

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- The premeasured spreader is then introduced into the canal alongside the
primary point, and with a watch winding vertical motion is slowly moved
apically to full penetration, marked on the shaft with a rubber stop. There
is no need to apply a lateral force to the spreader.
- It is recommended that the initial spreader be left in place a full minute to
allow the primary gutta-percha time to reconform to this pressure.

5) Placement of the accessory cones.

- The spreader is then removed with the same watch-winding motion and is
immediately followed by the first accessory point inserted to the full depth
of the space left by the spreader. Selecting accessory cones that are the
same size or smaller in diameter or taper than the spreader requires a
knowledge of ISO Standards for conventional gutta-percha.
- Additional sealer should be added with each point as a lubricant to
facilitate full penetration.
- Obturation is considered complete when the spreader can no longer
penetrate the filling mass beyond the cervical line.

6) Finalizing the obturation.

- At this time the protruding points are severed at the orifice of the canal
with a hot instrument.
- Vertical compaction with a large plugger will then ensure the tightest
possible compression of the gutta-percha mass and provide a more
effective seal against coronal leakage.
- All of the sealer and gutta-percha should then be removed from the pulp
chamber and a final radiograph taken.

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References:
1) https://www.pocketdentistry.com
2) Ingle’s Endodontics, 7th ed.
3) Textbook of endodontics.
4) Preclinical manual of conservative dentistry and endodontics.

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