RADICULAR CAVITY

PREPARATION

Written by:

Dr.Vineet R.V, MDS

Assistant Professor

1
 CONTENTS

 Introduction
 Definition
 History
 Objectives
 Schilder’s mechanical objectives
 Principles of canal preparation
 Rules for canal preparation
 Motions of instruments
 Factors related to preparation length

 Standardized technique(John Ingle,1961)

 Step-back preparation(Clem,Weine,Martin,Mullaney 1969)
 Serial shaping technique(Herbert Schilder 1969)
 Modified step-back preparation
 Balanced force technique(Roane,Sabla 1985)
 Passive step-back technique(Torabinejad,1994)
2
 Step-down technique(Goerig,1982)
 Modified crown down technique(Clifford Ruddle,1994)
 Double flare technique(Fava,1983)
 Crown down pressureless technique(Morgan & Montgomery, 1984)
 Reverse flare technique(Weine,1989)
 Modified double flared technique(Saunders,1992)
 Progressive enlargement technique(Backman,1992)
 Canal master technique(Wildey & Senia,1989)
 Alternated rotary motion technique (Sequiera 2002)
 Apical preparation technique
 Apical stop
 Apical seat
 Open apex
 Apical patency technique(Buchanan,1989)
 Apical clearing technique(Parris etal.)
 Apical box preparation(Tronstad,1991)
 Ultrasonic & sonic canal preparation technique
 Laser assisted canal preparation technique
 Non-instrumentation technique(Lussi et al. 1993)
 Procedural errors
 Conclusion
 References

3
INTRODUCTION

Success in endodontic treatment depends on how well the pulp space is shaped and
cleaned. Research into root canal preparation has led to significant changes in
instrumentation techniques.Recent designs of endodontic instruments have variable
tapers giving improved shaping ability. The principle of root canal preparation are
to remove all organic debris and all microorganisms from the root canal systems
and to shape the walls of the root canal to facilitate further cleaning and subsequent
obturation of the entire root canal space. (M.Hulsmann Endod.2005;10:35-70)

The current concept of root canal preparation is not cleaning and shaping but
shaping and cleaning. The main root canals should be rapidly and efficiently
shaped with instruments to permit thorough and extended cleaning of the entire
pulpal system with the irrigant solution. (P.M Dummer. Endod.truam. 2010;16:95-
100).

Preparation of root canal system includes both enlargement and shaping of the
complex endodontic space together with its disinfection

Synonyms: Biomechanical preparation, Chemomechanical

preparation, Cleaning & shaping, Root canal debridement,
Root canal preparation, Root canal instrumentation.

4
DEFINITION

Cleaning refers to the removal of all contents of the root canal system before and
during shaping: organic substrates, microflora, bacterial byproducts, food, caries,
denticles, pulp stones, dense collagen, previous root canal filling material, and
dentinal filings resulting from root canal preparation.

Shaping During this process, instrumentation must give the system a form that will
ensure tissue removal and a shape that will enhance total filling of the root canal
system in three dimensions. Inadequate shaping causes inadequate obturation.

Shaping is the development of a “logical” cavity

preparation that is specific for the anatomy of each root.

(Raiden G et al. JOE 1998)

HISTORY

1746 - one of the first instruments made specifically for use within the root canal,
(Fauchard). Similar to barbed broach, designed to remove pulp; without shaping
the root canal.

1852 - Dr. Robert Arthur of Baltimore, described how to make a fine pulp space
file; provided guidelines for its mechanical properties.

1858 - Maynard advocated pulp removal and became quiet an expert in filling
premolar and molar canals with gold foil. He invented the Barbed Broachs.

1915 - Kerr manufacturing Company patented all K-type instruments.

5
1957- Richman was first to use ultrasonics in endodonitics.

1958 - Ingle and Levine first proposed standardization of endodontic instruments

and suggested guidelines for the same.

1962 - A working committee on standardization; the International Standards

Organization (ISO) was formed, including Americal manufacturer’s and the
American Association of Endodontists.

1976 - The first approved specification for endodontic instruments American

National Standards Institute (ANSI) specification No. 28, was published.

Early 1980’s - K-style endodontic instruments came into a series of modifications

with hybrid designs.

1984 - The canal finder system that worked on a vertical stroke hand piece was
developed in France.

1985 - This was followed by the introduction of the Flex –R-File designed by
Roane, and developed by the union Broach Co. for use with balance force
technique.

1988 - Walia et al first reported the use of Nickel - titanium alloy for endodontic
use.

1989 - Wildey and Senia designed an instrument based on K-type files with a short
cutting segment known as canal master instruments (Brassler) and a modified
version later as canal master U.

1992 - Herbert Schilder Instruments with constant 29.17% increase in size (profile
29 series)

6
1992 - Flexo-gates, a hand instrument designed for apical preparation was
introduced by Maillefer .

1993 - The –safety – H file a further modification of the H-file by Buchanan was
introduced by the Kerr Manufacturing Company.

1993 - The improved form of canal master instrument were marketed as Canal
Master light speed for use a slow speed handpiece.

Mid 1994 - Profile 29 series Greater Taper instruments were introduced.

1996 - Quantec Series 2000, rotary instruments (NTCo) made of Nickel Titanium
with increases taper were developed to allow preparation of suitable tapared
canals.

1997 - The tri-auto ZX, which is a Cordless Engine driven pulp space preparation
system, that electronically monitors the location of file tip and torque applied to the
file, was introduced by J. Morita U. (Jpn.)

OBJECTIVES

Root canal preparation has two objectives:

7
A major objective, of course, is the total obturation of this designed space. The
ultimate objective, however, should be to create an environment in which the
body’s immune system can produce healing of the apical periodontal attachment
apparatus.

Biological objectives: Mechanical

objectives:
To completely
debride the pulp Continuously tapering
preparation
space of
Maintain original anatomy
Pulp tissue
Maintaining the position of
Bacteria / the apical foramen
Microorganisms
SCHILDER'S MECHANICAL OBJECTIVES
Foramen as small as
Endotoxins practically possible
 Develop a continuously tapering conical form in the root canal
preparation.

8
 Make the canal narrower apically, with the narrowest cross-sectional
diameter at its terminus.

 Make the preparation in multiple planes.

 Never transport the foramen.

 Keep the apical foramen as small as is practical.

9
Develop a continuously tapering conical form in the root canal preparation.

The shape mimics the natural shape of canals before they undergo calcification
and formation of secondary dentin. The goal is to create a conical form from access
cavity to foramen. The preparation should be smooth and appropriate for the
length, shape, and size of the root that surrounds it. The funnel must merge into the
access cavity so that instruments will slide into the canal.

The access cavity and the root canal preparationare continuous.

The narrowest part of the continuously tapering cone is located
apically, and the widest is found coronally.The continuously
tapering cone causes the guttapercha and sealer to take
the path of least resistance;namely the apical and lateral foramina.

Make the canal narrower apically, with the narrowest cross-sectional diameter
at its terminus.

The diameter becomes narrower as the preparation extends

apically. The only exception is a tooth with internal resorption
or an unusual bulge in the natural shape of the root canal.
This objective creates control and compaction at every level of
the preparation and on harmonizing cavity form with the
thermomechanical properties of gutta-percha to achieve a
hermetic seal.

10
Make the preparation in multiple planes.

The root canals within curved roots are similarly curved.The third objective
preserves this natural curve or "flow".

Never transport the foramen.

Only few of the exit foramina are located at the apex of the root. They usually are
located to the side of the apex.In addition, many root tips have several foramina
with root tips that curve significantly at the apical third or occasionally in the
middle third.Delicate foramina can be lost during root canal preparation by
improper sequencing of instruments, insufficient irrigation, not enough tactile
finesse, or not enough delicacy.This objective facilitates the achievement of
objective of a “flow”. Often the angle of access and angle of incidence differ.
The angle of access refers to the orientation of the instrument as it slides down the
body of the root canal.The angle of incidence refers to the turn required to follow
the path of the root canal. Foramina may be transported externally or internally.

External transportation is caused by failing to precurve files, using large

instruments, or being too heavy handed. The original apical foramen is torn. When

11
an instrument is overused, the elastic memory of the instrument may create the
teardrop and tearing of theapical foramen. This "hourglass" shape makes it more
difficult to properly obturate the foramen. Many endodontic failures result from
external transportation.

The second form of external transportation is direct perforation.This destructive

error usually begins with a ledge or apical blockage. The deflected instrument
continues its misdirection until it perforates the root surface.This external
perforation also can become an external teardrop tear.

Internal transportation occurs when the foramen becomes clogged

with dentin mud or denticles . These particles may irritate the attachment apparatus
after root canal filling or the particles may prevent obturation of other apical
foramina that branch off the "main" canal. Finally, this internally transported
foramen may perforate the external root surface through a false path.

Keep the apical foramen as small as is practical.

The final foramen size will vary, depending on the canal. Some foramina are small
and some arc large; some are round, some arc oval, and some have unusual shapes.
The goal of objective 4 is to preserve foraminal size and shape at the apical
constricture. This can be achieved only by carefully maintaining patency to the
radiographic terminus by constantly reconfirming patency through the foramen
with a loose-fitting instrument.

The goal is to produce a three-dimensional, continuously tapering,

multiplaned cone from access cavity to radiographic terminus while preserving
foraminal position and size.

12
PRINCIPLES OF ROOT CANAL PREPARATION

The root canal “cavity” is prepared with the following principles in mind:

The entire endodontic cavitypreparation, from outline form beginning at the

enamel’s edge to resistance form at the apical foramen.In some preparations,
retention form may be developed in the last 2 to 3 mm of the apical canal.Usually,
however, the preparation is a continuous tapered preparation from crown to root
end.

13
The entire length of the cavity falls under the rubric outline form and toilet of the
cavity. At the coronal margin of the cavity, the outline form must be continually
evaluated by monitoring the tension of the endodontic instruments against the
margins of the cavity.Remember to retain control of the instruments;they must
stand free and clear of all interference.Access may have to be expanded
(Convenience Form) if instruments start to bind, especially as larger, less flexible
instruments are used. The entire preparation, crown to apex, may be considered
extension for prevention of future periradicular infection and inflammation.

Concept of total endodontic cavity preparation,coronal and radicular as a continuum, based on Black’s
principles.Beginning at apex: A, Radiographic apex. B, Resistance Form,development of “apical stop”
at the cementodentinal junction against which filling is to be compacted and to resist extrusion of canal
debris and filling material. C, Retention Form, to retain primary filling point. D, Convenience Form,
subject to revision as needed to accommodate larger, less flexible instruments. External modifications
change the Outline Form. E, Outline Form, basic preparation throughout its length dictated by canal
anatomy.

14
Outline Form, basic preparation throughout its length dictated by canal
anatomy.At the coronal margin of the cavity, the Outline Form must be continually
evaluated by monitoring the tension of the endodontic instruments against the
margins of the cavity.

Toilet of the Cavity

Meticulous cleaning of the walls of the cavity until they feel glassy-smooth,
accompanied by continuous irrigation,will ensure, as far as possible, thorough
débridement.One must realize, however, that total débridement is not possible in
some cases, that some “nooks and crannies” of the root canal system are virtually
impossible to reach with any device or system.One does the best one can,
recognizing that in spite of microscopic remaining debris, success is possible.
Success depends to a great extent on whether unreachable debris is laden with
viable bacteria that have a source of substrate (accessory canal or microleakage) to
survive—hence the importance of thorough douching through irrigation, toilet of
the cavity.

Retention Form

In some filling techniques, it is recommended that the initial primary gutta-percha

point fit tightly in the apical 2 to 3 mm of the canal. These nearly parallel walls
(Retention Form) ensure the firm seating of this principal point.Other techniques
strive to achieve a continuously tapering funnel from the apical foramen to the
cavosurface margin. Retention Form in these cases is gained with custom-fitted
cones and warm compaction techniques.

15
These final 2 to 3 mm of the cavity are the most crucial and call for meticulous
care in preparation. This is where the sealing against future leakage or percolation
into the canal takes place. This is also the region where accessory or lateral canals
are most apt to be present.

Resistance Form

Resistance to overfilling is the primary objective of resistance form.Beyond that,

however, maintaining the integrity of the natural constriction of the apical foramen
is a key to successful therapy.

Violating this integrity by overinstrumentation leads to complications:

(1) acute inflammation of the periradicular tissue from the injury inflicted by the
instruments or bacteria and/or canal debris forced into the tissue,

(2)chronic inflammation of this tissue caused by the presence of a foreign body—

the filling material forced there during obturation,

(3) the inability to compact the root canal filling because of the loss of the limiting
apical termination of the cavity—the important apical stop.

Establishing Apical Patency

Bearing in mind that canal preparations should terminate at the dentinocemental

junction, slightly short of the apex, one is left with a tiny remaining portion of the
canal that has not been properly cleaned and may contain bacteria and packed
debris.It is this section of the canal that is finally cleaned,not shaped, with fine
instruments—No. 10 or 15 files.This action is known as establishing apical
patency.

16
RULES FOR CANAL PREPARATION

1.Preparation must enlarge the canal while retaining the general

form of the preoperative shape,but it also must develop the most
desired shape to fill.One of the most common faults occuring
during canal preparation is an attempt by the operator to alter
the canals original shape.Overuse of reaming action,failure
to precurve instruments,excessive use of chelating agents and
disregarding the path of the initial exploring instruments produce
a preparation that does not include the original canal shape.

2.Once the working length of a tooth is determined,all instruments

must be kept within the confines of the canal.Overinstrumentation
or the continued passage of an intracanal instrument through the
apical foramen,is a frequent cause of intratreatment pain.Therefore
as soon as the canal working length is determined,that measurement
is recorded and adhered to during instrumentation.

3.Instruments must be used in sequential order without skipping

sizes.Once the canal length is determined,the largest-size file that
will reach the apical extent of the preparation will begin the removal
of tissue from dentinal walls.Once this initial instrument becomes
loose within the canal,indicating that it has enlarged the canal and
completed the major portion of its effectiveness,the next size

17
larger file must be used.This enlarging and then using the next larger instrument is
continued until the desired degree of preparation is obtained.At no time should file
sizes be skipped.

4.Instruments must be used extravagantly,particularly in the smaller sizes.

Everytime a file or reamer is removed from the canal,it should be wiped clean of
any debris with a cotton roll or other suitable material.At this time the flutes of the
instrument must be examined for any sign of stress,fatigue or alteration of shape.

5.Canals must be prepared in a wet environment.Heavy

irrigation during canal preparation must always be observed.
Enlarging a dry canal may lead to packing of the area near the
apical foramen with dentin chips that would prevent proper
sealing.The use of an irrigant floats intracanal debris and dentinal filings to the
chamber,where they may be removed by aspiration or absorbent points.In
addition,canal walls moistened by irrigants are much less likely to bind
instruments,thereby reducing fatigue of the flutes and potential breakage.

Motions of instrumentation

Several motions of manipulation are useful for generating or controlling the cutting
activity of an endodontic file. These may be referred to as envelopes of motion,
historically

(1) filing

(2) reaming

18
 (3)Turn & pull

(4) watch winding

(5) watch winding & pull

(6) balanced force instrumentation

(7)Anti-curvature filing

Filing

The term filing indicates a push-pull action with the instrument.The inward
passage of a K-type file under working loads is capable of damaging the canal wall
very quickly, even when the slightest curvature is encountered. During the inward
stroke, the cutting force is a combination of both resistance to bending and the
apically directed hand pressure. These two combine at the junctional angle of the
instrument tip and gouge the curving canal wall very quickly.

19
Filing is an effective technique with Hedstrom type instruments since they do not
engage during the insertion action and cut efficiently during the withdrawal
motion.A major limitation of filing with a conventional Hedstrom is that it can
easily cut through the middle of a curvature and cause strip perforation of the root.
Precurving the file and anticurvature directing of the stroke must be used in order
to avoid a mishap.

Reaming

The term ream indicates clockwise or right-hand rotation of an instrument.Rotating

any endodontic hand instrument to the right may be risky, though this risk is subtle
and goes unnoticed until an instrument fractures under the load. The cutting edges
of all endodontic files and reamers spiral about the shaft of the instrument. This
configuration causes them to slide into the canal as the edges rotate to the right.

As they slide into the canal more and more of the length of the instrument engages
the canal. This in turn increases the strain or working load against the instrument.
That strain continues to rise until the instrument ceases to move and the rotation
force bends it or the clinician ceases rotation. If the instrument over inserts and

20
bends, further rotation will break it. Forcefully pulling it from the canal may also
fracture it.

Turn-and-pull

The turn-and-pull cutting motion is a combination of a reaming and filing motion

The file is inserted with a quarter turn clockwise and inwardly directed hand
pressure (i.e., reaming). Positioned into the canal by this action the file is
subsequently withdrawn (i.e., filling). The rotation during placement sets the
cutting edges of the file into dentin and the non rotating withdrawal breaks loose
the dentin that has been engaged. Schilder recommends clockwise rotation of a half
revolution followed by withdrawal.

Watch-winding

Watch-winding is the back-and-forth oscillation of a file (30 to 60 degrees) right

and (30 to 60 degrees) left as the instrument is pushed forward into the canal.It is
less aggressive than quarter turn-and-pull motions, as the tip is not pushed as far
into the apical regions of the canal with each motion and the chances for apical
ledging are reduced.Each cut opens space and frees the instrument for deeper
insertion with the next clockwise motion.The watch-winding technique is effective
with all K-type files

21
Watch-winding and pull

When used with Hedstrom files, watch-winding cannot cut dentin with the
backstroke. It can only wiggle and wedge the nearly horizontal unidirectional
edges tightly into opposing canal walls.Thus positioned, the engaged dentin is
removal during a subsequent pull stroke.

Anticurvature filing

Anticurvature is a method of applying instrument pressure so that shaping will

occur away from the inside of the root curvature in the coronal and middle third of
a canal.

Abou-Rass, Frank, and Glick described the anticurvature filing concept for
curved canals, emphasizing that during shaping procedures files should be pulled
from canals as pressure is applied to the outside canal wall. Anticurvature pressure
application is effective until the canal contacts the file at three points within the
canal. Beyond there, the canal curvature, not the clinician, determines the cutting
pressure.

This directionally applied pressure, they suggest, prevents

 Dangerous midcurvature straightening in curved canals

 Laceration of a furcal area during preparation
22
BALANCED FORCE TECHNIQUE (Roane, Sabala, Powell ,1985)

The file is placed in the canal and turned 90°,advancing it into the canal and
engaging dentin. The cutting motion involves turning the file anticlockwise, using
a light apical pressure to prevent it from working its way back out.

Phase I- file insertion

Handle of the file is reciprocated in a back and forth motion until it snuggly fits

Clockwise rotation in 45-90° - cutting blade moves deeper into to the canal and
engages dentin

Phase II- file cutting

Two simultaneous (balanced) forces are applied – counter clock wise rotation with
simultaneous apical push. After first cutting the instrument is extended into the
canal as in phase I and another phase II cutting cycle is repeated

Phase III- flute loading

The cut dentin lies partially in the inter blade spaces of the file and partially in the
canal apical to the instrument.The debris is removed from the canal by rotating the
file handle clock wise by simultaneously pulling the instrument coronally

23
When performed properly the position of the file tip never advances apically
because the tendency of the file to be drawn in to the canal is balanced by the force
of the file being lifted out of the canal. The file is removed after 2-3 rotations

Advantages

 File cutting occurs essentially at the apical extent of the file

 Safe ended file tip stays centered in the root when activate in phase II file
cutting

FACTORS RELATED TO PREPARATION LENGTH

 Use of a patency file

 Apical width

Patency File

This is a small K File (#10 size or #15 size) that is passed through the
foramen.This is suggested for most rotary techniques.It helps to remove
accumulated debris and thus maintain the working length.An in vitro study
suggested that risk of innoculation was minimal when canals were filled with
NaOCl . (JOE.2004; 30:92-98)

Apical Width

The position of apical constriction and diameter is difficult to assess

clinically.Some have recommended gauging canal diameters by passing a series of
fine files until one fits snugly-likely to result in under estimation of the
diameter.Initial canal size determines the desired final apical diameter

24
Ongoing debate between smaller or larger apical preparations.

Narrow Apical preparations

Benefits

 Minimal risk of canal transportation, extrusion of irrigants, or extrusion of

filling material

 Can be combined with tapered preparation to counteract drawbacks

Drawbacks

 Little removal of infected dentin

 Apical rinsing effect is questionable

 Possibly compromised disinfection during inter- appointment medication

 Not ideal for Lateral condensation

Wide Apical preparations

Benefits

 Removal of infected dentin

 Access of irrigants and medications in apical third of root canal

Drawbacks

 Risk of preparation errors and of extrusion of irrigants and filling

material

 Not ideal for thermoplastic obturation

25
Despite the disagreement it appears that the root canal preparation

 should be confined to the canal space

 should be sufficiently wide
 should incorporate the original root canal cross sections

(Buchanan IEJ 2000; 36:740.)

TECHNIQUES OF PREPARING ROOT CANALS

Ro o t c a n a l p re pa ra ti o n
te c h n i qu e s

Api c o -c o ro n a l Co ro n o -a pi c a l Hy bri d
te c h n i qu e s te c h n i qu e s te c h n i qu e s

*S ta n d a rd ize d *S te p -d o w n

p re p a ra ti on *Mo d i fi e d s te p -

*S te p -ba c k dow n

*Mo d i fi e d s te p *Cro w n d o w n

ba ck p re s s u re le s s
te ch n i qu e
*P a s s i v e s te p
ba ck D o u ble fla re d
te ch n i qu e

26
STANDARDIZED TECHNIQUE:

- John Ingle (1961)

Standardized files are used sequentially to produce a canal preparation that has the
same size and shape as the last standardized instrument used. The canal could then
be obturated with a filling material that has also the same size and shape.

Each instrument is placed to the full working length. Canal enlarged until clean
white dentin shavings are seen on the apical few mm of the instrument. Filing
continued for a further 2 or 3 sizes. Easy to perform in straight canals of mature
teeth exhibiting natural taper. In curved root canals problems like ledging, zipping,
elbow formation, perforation and loss of working length owing to compaction of
dentin debris

STEP-BACK PREPARATION

Weine, Martin, Walton,and Mullaney were early advocates of step-back, also

called telescopic or serial root canal preparation. This technique is designed to
overcome instrument transportation in the apical-third canal, and has proved quite
successful.This method of preparation has been well described by Mullaney.

27
 Mullaney divided the step-back preparation into two phases.

› Phase I is the apical preparation starting at the apical constriction.

› Phase II is the preparation of the remainder of the canal, gradually

stepping back while increasing in size.

› The completion of the preparation is the Refining

 Phase IIA and

 Phase IIB

The motion of the instrument is “watch winding,”two or three quarter-turns

clockwise-counterclockwise and then retraction. On removal, the instrument is
wiped, cleaned, recurved, relubricated, and repositioned.“Watch winding” is then
repeated. The instrument must be to full depth when the cutting action is made.
This procedure is repeated until the instrument is loose in position. Irrigation
should be done after each instrument is removed from the canal.Then the next size
K file is used length established, precurved, lubricated, and positioned. Again, the

28
watch-winding action and retraction are repeated. Very short (1.0 mm) filing
strokes can also be used at the apex.

Phase I

1.The first active instrument to be inserted should be a fine (No. 08, 10, or 15)
0.02, tapered, stainless steel file, curved and coated with a lubricant, such as Gly-
Oxide, R.C. Prep, File-Eze, Glyde, K-Y Jelly, or liquid soap.

2.The apical area has been enlarged enough that sodium hypochlorite can reach
the debris to douche it clear.

By the time a size 25 K file has been used to full working length, Phase I is
complete.Using a number 25 file here as an example is not to imply that all canals
should be shaped at the apical restriction only to size 25.Most canals should be
enlarged beyond size 25 at the apical constriction in order to round out the
preparation at this point and remove as much of the extraneous tissue, debris, and
lateral canals as possible.
29
A danger point lies beyond No. 25, as stainless steel instruments become larger,
they become stiffer. Metal “memory” plus stress on the instrument starts its
straightening It will no longer stay curved and starts to dig, to zip the outside
(convex) wall of the canal.

All of these maneuvers (curved instruments, lubrication, cleaning debris from the
used instrument, copious irrigation, and recapitulation) will ensure patency of the
canal to the apical constriction.

Phase II

1.In a fine canal (and in this example), the step-back process begins with a No. 30
K-style file.

2.Its working length is set 1 mm short of the full working length.

3.It is precurved, lubricated, carried down the canal to the new shortened depth,
watch wound, and retracted.

4.The same process is repeated until the No. 30 is loose at this adjusted length

5.Recapitulation to full length with a No. 25 file follows to ensure patency to the
constriction.

6.This is followed by copious irrigation before the next curved instrument is

introduced.

7.It is precurved, lubricated, inserted, watch wound, and retracted followed by

recapitulation and irrigation.

30
Thus, the preparation steps back up the canal 1 mm and one larger instrument at
a time.When that portion of the canal is reached, usually the straight
midcanal,where the instruments no longer fit tightly, then perimeter filing may
begin, along with plenty of irrigation.It is at this point that Hedstroem files are
most effective.They are much more aggressive rasps than the Kfiles. The canal is
shaped into the continuous taper so conducive to optimum obturation.Care must
be taken to recapitulate between each instrument with the original No. 25 file
along with ample irrigation.

Phase IIA

In this step Gates-Glidden drills is used, starting with the smaller drills (Nos. 1 and
2) and gradually increasing in size to No. 4 5, or 6.Proper continuing taper is
developed to finish Phase IIA preparation.Gates-Glidden drills must be used with
great care because they tend to “screw” themselves into the canal, binding and then
breaking. To avoid this, it has been recommended that the larger sizes be run in
reverse. But, unfortunately, they do not cut as well when reversed.

31
Lubricating the drill heavily with RC-Prep or Glyde, which “will prevent binding
and the rapid advance problem.”Newer instruments with various tapers from 0.04
to0.08 mm/mm of taper are now available for this purpose as well and can be used
as power-driven or hand instruments.With any of the power-driven instruments,
using them in a passive pecking motion will decrease the chances of binding or
screwing into the canal.

Phase IIB

Refining Phase IIB is a return to a size No. 25 (or the last apical instrument used),
smoothing all around the walls with vertical push-pull strokes, to perfect the taper
from the apical constriction to the cervical canal orifice. At this point, Buchanan
recommended that sodium hypochlorite be left in place to the apex for 5 to 10
minutes.This is the only way in which the auxiliary canals can be cleaned.
Gutmann and Rakusin pointed out that the “final preparation should be an exact
replica of the original canal configuration—shape, taper, and flow, only
larger”.“Coke-bottle” preparations should be avoided at all cost.This completes the
chemomechanical step-back preparation of the continuing taper canal.

MODIFIED STEP-BACK TECHNIQUE

One variation of the step-back technique is more traditional. The preparation is

completed in the apical area, and then the step-back procedure begins 2 to 3 mm up
the canal.This gives a short, almost parallel retention form to receive the primary
gutta-percha point when lateral condensation is being used to fill the canal. The
gutta-percha trial point should go fully to the constriction, and a slight tug-back
should be felt when the point is removed (retention form).This shows that it fits
tightly into the last 2 to 3 mm of the prepared canal.
32
SERIAL SHAPING TECHNIQUE

As an alternative to the step-back preparation,Schilder advocated “canal bed

enlargement”. After apical preparation the next larger instrument is placed into the
canal to the point of initial contact and rotated for one half turn. The canal is then
irrigated and the process repeated with increasingly larger instruments.

This technique allows the body of the canal to be prepared without the procedural
errors inherent in the standardized preparation technique. In addition, the technique
permits the natural morphology of the canal to influence the preparation, in
contrast to the more ridged incremental step-back technique. After completion of
the tapering process, Schilder advocates the use of Gates Glidden drills in the canal
orifice to remove coronal obstructions.

33
PASSIVE STEP-BACK TECHNIQUE

- Torabinejad (1994)

This technique uses a combination of hand instruments (files) and rotary

instruments(Gates Glidden drills and Peeso reamers) to achieve adequate coronal
flare before apical root canal preparation. This technique provides an unforceful
and gradual enlargement of canals in an apical-coronal direction. It is applicable in
every canal type, is easy to master, and reduces procedural accidents. After
preparation of the access cavity,locate the canal orifices and flare the walls of
access cavity using tapered diamond burs.

Determine the correct working length and insert a no.15 K-file to the length
with very light pressure and give one-eighth to one –quarter turn with push-pull
stroke to maintain apical patency. After this additional files of no.20,25,30,35 and
40 are inserted into the canal passively.Copious irrigation of the canal system is
frequently done with sodium hypochlorite.

34
After this no.2 G.G drill is inserted into mildly flared canal to a point,where it
binds slightly.It is pulled back 1-1.5mm and then activated. With up and down
motion and slight pressure,the canal walls are flared.In a similar manner G.G drill
no.3 and 4 are used coronally. After this a no.20 file is inserted into the canal upto
working length. The canal is then prepared with sequential use of progressively
larger instruments placed successively short of working length.

STEP DOWN TECHNIQUE

In this method, the access cavity is filled with sodium hypochlorite, and the first
instrument is introduced into the canal. At this point, there is a divergence in
technique dictated by the instrument design and the protocol for proceeding
recommended by each instrument manufacturer.All of the directions, however,
start with exploration of the canal with a fine, stainless steel, .02 taper (No. 8, 10,
15, or 20 file, determined by the canal width), curved instrument. It is important
that the canal be patent to the apical constriction before cleaning and shaping begin

Sometimes the chosen file will not reach the apical constriction, and one assumes
that the file is binding at the apex. But, more often than not, the file is binding in
the coronal canal. In this case, one should start with a wider (0.04 or 0.06
taper)instrument or a Gates-Glidden drill to free up the canal so that a fine
instrument may reach the mid- and apical canal.
35
Steps involved

1.Prepare the coronal portion of the canal to the depth of 16-18 mm or to the
beginning of the curve using Hedstroem files 15,20,and 25 in a circumferential
filling motion,.

2.In narrow calcified canals sizes 08 &10 should be first used to enable placement
of the Hedstroem files and establish patency. They are also used intermittently
between the Hedstroem files to maintain canal patency.

3.Gates glidden drills 1,2 &3 are then used to refine the coronal preparation, the no
3 drill extending 1-2 mm into the canal orifice.

4.This gradually increasing taper is effective in final filling for as Buchanan

pointed out, the “apical movement of the cone into a tapered apical preparation…
only tightens the apical seal.”

5.But, as Buchanan further noted, “overzealous canal shaping to achieve this taper
has been at the expense of tooth structure in the coronal two-thirds of the
preparation leading to perforations” and, one might add, materially weakening the
tooth.
6.The next sequence of instruments are used in crown down fashion. The
instruments are used in a watch-winding motion until the apical constriction is
reached.
7.When resistance is met to further penetration, the next smallest size is used.
8.Irrigation should follow the use of each instrument and recapitulation after every
other instrument
9.Then the apical preparation done upto 25 size with enough lubrication, irrigation,
and recapitulation

36
Step-down root canal preparation technique

37
Advantages
1.minimize or eliminate the amount of necrotic debris that could be extruded
through the apical foramen during instrumentation.

2.Preparation of the coronal portion tends to shorten the effective length of the
canal, and determining the working length after such enlargement will reduce the
problem of its alteration during preparation.

3.It allows better control over apical instruments 

This would help prevent
› post-treatment discomfort
› incomplete cleansing
› difficulty in achieving a biocompatible seal at the apical constriction.
   
This technique has raisen in popularity, especially among those using nickel-
titanium instruments with varying tapers.Rotary instruments are commonly used
in a crown down technique.

MODIFIED CROWN DOWN TECHNIQUE

A modified technique was described by Dr.Clifford Ruddle.Working length

determined after pre enlargment with gates glidden drills (starting from size 1).If
the clinician chooses 0.02 tapered files to “finish” the apical one third, Ruddle uses
a concept he calls “Gauging and Tuning.”

38
 “Gauging” is knowing the cross-sectional diameter of the foramen that is
confirmed by the size of instrument that “snugs in” at working length.

“Tuning” is ensuring that each sequentially larger instrument uniformly backs out
of the canal ½ mm.

CROWN-DOWN “PRESSURELESS” TECHNIQUE

-Marshall and Pappin (1980)

The aim of this coronal-apical technique is to facilitate preparation of curved

canals without causing deviation.

The following sequence is recommended:

1.Determine radicular access length ( the depth to which a No 35 file penetrated
to its point of first resistance) if this is more than 16mm the coronal portion of the
canal should be prepared to this length.

2.If the file penetrated less than 16mm a radiograph should be used to determine
whether it is because of canal curvature or calcification. If it is due to beginning of
a curve the canal is prepared to the point of first resistance

39
3.The canal is widened with smaller files until the no.35 file penetrates to 16mm.
4. Establish a provisional working length at 3mm short of the radiographic apex.

5.Place a No.35 file into the canal until it encounters resistance. At this point turn
the file two full revolutions without apical pressure.

6.Repeat using the next file down until the provisional length is reached

7.Establish the definitive working length with a check radiograph..

8.Repeat the sequence of placing a file and rotating twice without apical pressure
until the working length is reached starting with a No.40 file.

9.Repeat the sequence using the next instrument up in size until the apical portion
of the canal has been prepared to the desired diameter.
This technique is effective in maintaining canal shape.

Double-flared technique(Fava,1983)
This technique was devised with the fundamental principle of the coronal-apical
approach in mind. The following steps should be followed

1.Irrigate the pulp chamber and introduce a small file into the canal using only
gentle push-pull movements to a working length estimated from radiographs. The
aim of this is to introduce irrigant into the canal.

2.Take a further radiograph to check the working length.

40
3.Re-irrigate and introduce a larger instrument into the canal to a depth of about
14mm ( or in any case coronal to the curve). This should be loose in the canal but
is used to file the canal walls
4.Re-irrigate and introduce the next size down 1mm deeper into the canal
maintaining instrumentation coronal to the curve and file the walls gently. The
instrument should not bind in the canal.
5.Repeat this with the next size down.Continue until the working length is reached
taking another radiograph if necessary to establish definitive working length. Once
the working length is reached the full length of the canal is prepared to the
appropriate size.The canal is now prepared using the step-back technique except
that much less filing in necessary to establish the final taper.

This technique was originally recommended for straight canals and in the straight
portions of curved canals.It is contraindicated in calcified canals, young permanent
teeth and in those with open apices.The principles of the approach ( to neutralize
canal contents and minimize their extrusion ) may be applied to most teeth.

41
Canal master technique

This technique uses a revolutionary brand of root canal instrument in a coronal-

apical approach.Its aim is to aid the maintenance of curves using a rotary
instrument designed so that only the apical 1-2 mm is engaged dentine
removal.The instruments are both hand held and mechanized.

The apical 0.75mm of the hand instruments is safe ended to facilitate

maintenance of canal curvature and its is claimed that this technique avoids the
need of recapitulation.Intermediate file sizes are available enabling easier
negotiation of curves and a progressive development of flare at 0.5mm intervals.
The instruments may have a tendency to fracture.

APICAL PREPARATION

The apical portion of the root canal system can retain microorganisms that could
potentially cause periradicular inflammation. Nair et al. found that even after long
term therapy, apical microflora can play a significant role in endodontic treatment
failures.It is hence necessary to remove this heavily infected dentin when
instrumenting the canal.

42
Apical stop: A barrier at the preparation end is an apical stop.

Apical seat: Lack of a complete barrier but the presence of a constriction

represents an apical seat.

Open apex: The apical preparation resembles an open cylinder (neither barrier nor
constriction). Open apex is undesirable and will probably not confine materials to
the canal space.

Apical stop Apical seat Open apex

43
The apical patency concept has been proposed as another means of managing the
apex. The technique is to perform apical "trephination,” i.e., to pass small files
through the apical foramen at times during canal preparation. This will prevent
hard or soft tissue blockage of the foramen,thereby improving debridement and
reducing irritants. (Buchanan, 1996)

EVALUATION CRITERIA

An instrument one or two sizes smaller than the master apical file is the instrument
used for evaluation. If this smaller instrument is placed to length, tapped around,
and hits a dead end in all areas, this is an apical stop. If the file meets some
resistance but can be passed through the constriction, this is an apical seat. If the
instrument passes unimpeded through the apical preparation, neither seat nor stop
is present;this represents an open apex.

APICAL ENLARGEMENT

Guidelines or standards for apical preparation were espoused by Weine . He

advocated enlarging the apical part of the root canal to three sizes larger than
where the first file bound. However Levin etal. have concluded from their studies
that it is questionable whether filing three sizes larger than the first file that binds
will adequately remove dentin circumferentially in the canal. Buchanan has
advocated minimal apical preparation (i.e #20 or #25) based on his clinical
opinions. He proposed that enlarging the canal size would cause apical
transportation or zips.

44
APICAL CLEARING

-Parris et al.

This technique involves the rotation of the final largest file at working length
following irrigation and subsequent drying of the canal systems. Apical clearing
effectively removed debris remaining on the walls in the apical third.

APICAL BOX PREPARATION

With this technique one attempts to give the apical 2-5 mm of the root canal a
cylindrical shape rather than the tapered shape of the step-back technique. The
apical part of the canal is instrumented with a K-file with filing motion until the
file moves freely in the canal.The file is then rotated with its tip at the exact
working length to begin making a shelf in the root canal wall. The next file is
introduced into the canal with twiddling motion until the tip is again at the exact
apical level of instrumentation.

The preparation of the apical part of the canal continues systematically with
filing and reaming actions until the canal is enlarged two or three instrument sizes.
The canal is then flared beginning with a H-file or engine driven file one size
smaller than the last instrument used apically. The patency of the apical part is
checked at regular intervals during the flaring of the coronal part of the canal.
When the flare is considered adequate, the preparation of the apical part of the
canal is completed with K-type hand or engine-driven instruments.

45
In this way a shelf is prepared in the root canal wall at the apical-most level of
instrumentation. The shelf constitutes an effective apical stop against which a
master gutta percha point of the same size as the final apical instrument can be
seated.

ULTRASONIC CANAL PREPARATIONS.

The concept of using ultrasound in endodontic therapy was suggested in 1957 by

Richman. In 1976, Howard Martin developed a device for preparation and
cleaning of root canals and named this technique as ‘endosonics’. Ultrasonic
devices are driven by magnetostriction or piezoelectricity, resulting in oscillation
(25–40 kHz).

Method of action

During the oscillation of file,there is continous flow of irrigants solution from the
handpiece along the file. This produces “cavitation or implosion” and acoustic
streaming

46
Cavitation is growth and subsequent violent collapse of the bubbles in the fluid
which results in formation of shock wave,increase temperature, pressure and the
formation of free radicals.

Acoustic streaming is a process by which a vibrating file generates a stream of

liquid to produce eddies and flows of oscillation .(Ahmed et al)

Acoustic streaming is produced around an object oscillating in a liquid with

production of shear forces which are capable of dislodging the lumps of material.
Thus,acoustic streaming may be useful in reducing the number of smear layer and
loosening the aggregates of bacteria.

47
TECHNIQUE

Before starting with ultrasonic instrumentation apical third of the canal should be
prepared to atleast size no.15 K-file. After activation,ultrasonic file is moved in the
circumferential manner with push-pull stroke along the canal walls. File is
activated for one minute. This procedure is repeated till the apex is prepared to
atleast size no.25

Advantages

 Less time consuming

 Produce cleaner canals

 Heat produced by ultrasonic vibration increase the chemical effectiveness of

the sodium hypochlorite

Disadvantages

 Increased frequency of canal transportation

 Increased chances of overinstrumentation

 Presence of longitudinal grooves in root dentin

SONIC CANAL PREPARATION TECHNIQUES.

In sonic instrumentation,there is longitudinal pattern of vibration when activated in

root canal.This longitudinal file motion produces superior cleaning of canal walls.

48
Sonic system uses three types of file system for root canal preparation:

 Heliosonic

 Rispisonic

 Canal shaper instruments

These blades have spiral blades protruding along their length and non-cutting tips.

TECHNIQUE:

Camp recommended that stainless steel hand files size 10 or 15 first be used to
establish a pathway down the canals until resistance is met, usually about two-
thirds of the canal length. Next step is the step-down approach with the sonic
instruments. About 30 seconds are spent in each canal using a quick up and down,
2 to 3 mm stroke and circumferentially filing under water irrigation supplied by the
handpiece.

The use of each instrument is followed by copious sodium hypochlorite

irrigation. The water from the handpiece is turned off and the irrigant is agitated in
the canal with the fine Sonic file.At this point, working length is established by a
radiograph or an electric apex locator

Following sodium hypochlorite irrigation, Camp returns to the Sonic No. 15

(or a 20 or 25 in larger canals) Shaper or Rispisonic file for 30 seconds in each
canal . After irrigation, No. 30, 35, and 40 hand files are again used followed by a
larger Sonic instrument, and then No. 50 to 60 hand files are used to step-back up
the canal to ensure a tapered preparation.Final use of the small Sonic file, with
copious sodium hypochlorite to the constriction, removes the remaining debris and
filings.

49
Recapitulation with a No. 20 hand file will check the correct length of tooth and
the apical stop at the constriction.After final irrigation, the canal is dried with paper
points and is ready for medication or filling

Efficacy and Safety of Ultrasonic/Sonic Preparations.

The Iowa faculty tested step-back versus step-down approach with ultrasonic and
sonic devices. They found that the ultrasonic instruments produced a better
preparation when the step-back approach was used. The step-down preparation
was preferred for sonic preparation

Another group of clinicians compared step-down,step-back hand instrumentation

versus ultrasonic and sonic preparations. Both hand methods, as well as sonic
enlargement, caused the extrusion of debris apically.

In ranking from least to worst extrusion,

 Sonic was 1
 step-down was 2
 ultrasonic was 3
 conventional,circumferential, step-back preparation was 4, worst.
A French group evaluated the degree of leakage following obturation of canals
prepared with the Sonic Air unit using Shaper Sonic files versus hand
preparation.The researchers found that the highest degree of leakage occurred
overall with the manual method; however, both methods leaked apically.They felt
that the smear layer present might have been responsible.

50
LASER-ASSISTED CANAL PREPARATION

After the development of the ruby laser by Maiman in1960, Stern and Sognnaes
(1964) were the first investigators to look at the effects of ruby laser irradiation on
hard dental tissues.In 1971, at the University of Southern California, Weichman
and Johnson were probably the first researchers to suggest the use of lasers in
endodontics. In 1972,Weichman et al. suggested the occurrence of chemical and
physical changes of irradiated dentin.

According to Stabholz of Israel, there are three main areas in endodontics for the
use of lasers:
(1) the periapex,
(2) the root canal system
(3) hard tissue, mainly the dentin.
The Nd:YAG, argon, excimer, holmium, and erbium laser beams can be delivered
through an optical fiber that allows for better accessibility to different areas and
structures in the oral cavity, including root canals.The technique requires widening
the root canal by conventional methods before the laser probe can be placed in the
canal.The fiber’s diameter, used inside the canal space, ranges from 200 to 400
µm, equivalent to a No. 20-40 file.
51
Dederich et al., in 1984, used an Nd:YAG laser to irradiate the root canal walls and
showed melted, recrystalized, and glazed surfaces. Bahcall et al., in1992,
investigated the use of the pulsed Nd:YAG laser to cleanse root canals. Their
results showed that the Nd:YAG laser may cause harm to the bone and periodontal
tissues. According to Levy and Goodis et al., the Nd:YAG, in combination with
hand filing, is able to produce a cleaner root canal with a general absence of smear
layer.

Studies evaluating changes at the apical constriction and histopathologic

analysis of the periapical tissues were presented by Koba and associates. They
maintained the fiber optic at a stationary point, 1 mm from the apical foramen,for 2
to 3 seconds. Infiltration of inflammatory cells was observed in all groups in 2
weeks, including the control group. Indeed, the degree of inflammation reported in
the laser-irradiated group at 2 weeks, 30 Hz(0.67 mJ/p) for 2 seconds, was
significantly less than in the control group at 4 and 8 weeks.

The erbium:YAG laser, at 80 mJ, 10 Hz, was more effective for debris
removal , producing a cleaner surface with a higher number of open tubules when
compared with the other laser treatment and the control—without laser
treatment.Although areas covered by residual debris could be found where the
laser light did not enter into contact with the root canal surface.The efficacy of
argon laser irradiation in removing debris from the root canal system was
evaluated by Moshonov et al. After cleaning and shaping, a 300 µm fiber optic was
introduced into the root canals of single rooted teeth to their working length.During
irradiation, the fiber was then retrieved, from the apex to the orifice.Scanning
electron microscopic analysis revealed that significantly more debris was removed
from the lased group than from the control .
52
Recently a new laser system using the “Er,Cr:YSGG laser”
has been introduced to help reduce the patient fear and provide
better comfort to the patient-
“Waterlase –Hydrokinetic hard and soft tissue laser”.
By using hydrokinetic process in which water is energized by the YSGG laser
photons to cause molecular excitation and localized microexpansion, hard tissues
are removed precisely with no thermal side effects. The intracanal irradiation of
laser has shown to reduce the microbial colony,inflammation and other
postoperative complications.

NON INSTRUMENTATION TECHNIQUE

Lussi and his associates at the University of Bern, Switzerland, introduced devices
to cleanse the root canal "without the need of endodontic instrumentation." The
first device, reported in 1993, consisted of a "pump" that inserted an irrigant into
the canal, creating "bubbles" and cavitation that loosened the debris. This pressure
action was followed by a negative pressure (suction) that removed the debris: "The
irrigant fluid was injected through the outer tube while the reflux occurred through
the inner tube.

More recently, they have improved the device and reported that
the "smaller new machine produced equivalent or better cleanliness results in the
root canal system using significantly less irrigant (NaOCl). This cleanses the canal
but, of course, does nothing to shape the canal.

53
PROCEDURAL ERRORS

Over Instrumentation

 Over zealous shaping of the canal to accommodate large pluggers and / or

spreaders used in either vertical or lateral compaction of Gp leads to a weakening
of the tooth or even fracture of an apical tip . Over flaring can cause stripping
perforations particularly in mandibular molars and maxillary pre-molars both with
hour-glass shaped roots. Overflaring also makes it difficult to fit parallel posts for
core retention.Ledges and apical transports are created in curved canals if the final
apical size of canal preparation is too large.

Prevention – Proper instrumentation techniques should be followed

Ledge formation :

Ledges in canals can result from a failure to make acess cavities that allow direct
access to the apical part of the canals, or from using straight or too-large
instruments in curved canals.
 

54
Detection – Ledge formation should be suspected when the root canal instrument
no longer can be inserted into the canal to full working length.When ledge
formation is suspected, a radiograph of tooth with the instrument is place will
provide additional information.

Correction – Use a small file No.10, 15 place a distinct curve at the tip and explore
the canal to the apex. point the curved tip towards the wall opposite the ledge. The
filling is done in the presence of a lubricant or irrigant.

Prevention – Accurate interpretation of diagnostic radiograph should be completed

before placing the instrument in the canal.Pre-curving the instruments and not
“forcing” them is a sure preventive measure.

Perforations

Lateral canal perforations are often associated with ledge

formation and stripping of curved roots and include
cervical and mid-root perforations. Apical perforations are
sometimes referred as “apical transportation” or “apical zipping”.

55
Perforations is mainly by 2 errors.
(1)  Starting a ledge and then drilling out through the side of the root at a point of
canal obstruction or root curvature.

(2) Using too large or too long an instrument and either perforating directly out
through the apical foramen or wearing” a hole at the lateral surface of the root by
over instrumentation.

Cervicel Canal Perforation

The cervical portion of the canal may be perforated during the process of locating
the canal orifice or the canal may be stripped usually on the inner curve of a curved
root such as the medial root of lower molars. “Stripping” may occur with files or
engine – driven instruments, Gates Glidden (or) Peeso drills.

Detection – Patient complains of pain during canal preparation and sudden

appearance of blood in the canal. Placement of a paperpoint in the canal is a
reliable diagnostic tool for confirming a suspected perforation.

Correction – An effort to seal the perforation.

 
Prognosis – must be considered to be reduced and surgical correction may be
necessary if a lesion develops or symptoms occur.

Prevention – is by reviewing tooth morphology prior to acess opening and

searching for canal orifices. Stripping can be prevented by showing caution in ‘2’
areas.

56
(1)  Careful use of rotary instruments inside the canal.
(2)  Following recommendations for canal preparation in curved roots.

Mid – root Perforation

 ‘2’ types of perforations occur in mid-root

1. lateral perforation
2.‘Strip’ perforation.

Detection – “Stripping” is a lateral perforation caused by over – instrumentation

through a thin wall in the root and is most likely to happen on the inside or concave
wall of a curved canal, such as distal wall of mesial roots in lower first molar.
Stripping is detected by sudden appearance of hemorrhage in a previously dry
canal or sudden complaint of pain by the patient.
Prevention of stripping is by “anti-curvature filing”.
Stressing the importance of maintaining mesial pressure of the enlarging
instruments to avoid the delicate “danger zone” of the distal wall .

Correction – Repair of strip perforation has been attempted both non-surgically

and surgically. Material such cavit, amalgam, G.I.C. may be used to repair the
defect. CaOH 2 may also be used to control bleeding before filling the canal.

Apical Perforations
Perforations in the apical segment of the root canal may be due to
 file not negotiating the curved canal.
 not establishing accurate working length and instrumenting beyond the
apical confines.

57
Perforation of a curved root is the result of “ledging”, “apical – transportation” or
“apical Zipping”.

          

 Maxillary lateral incisor, mesio buccal and palatal roots of maxillary– molars and
mesial root of mandibular molars due to their curvatures are the most common
sites for these perforations.

Detection – Patient suddenly complains of pain during treatment .canal becomes

flooded with hemorrhage. if tactile resistance of the confines of the canal space is
lost.

Correction – Efforts to repair may be to attempt to renegotiate the apical canal

segment or to consider the perforation site as the new apical opening.                 
Surgery may be necessary if a lesion is present. If the perforation is due to over
instrumentation correction is by re-establishing tooth length short of the original
length and then enlarging the canal with a larger instruments to that length.         
Creating an apical barrier is another technique that can be used to prevent over
extensions during root canal filling.Materials used as such barriers are dention
chips, Ca(OH)2 Powder, Protoplast and hydroxy appatite.

Prognosis – Apical Perforations have less adverse effects than perforations closer
to the chamber.

58
Separated instruments and foreign objects

Many objects have been reported to break or separate and subsequently become
lodged in root canals. Most commonly files and reamers are involved in these
procedural mishaps.

   Cause for this being:

(1)  Usually the instrument is being advanced in to the canal until it binds and
efforts to remove it leads to breakage leaving a segment of it in the canal.

(2) Stressed instruments

(3)Placing exaggerated bends an instruments to negotiate curved canals

(4)forcing a file down the canal before it has been sufficiently opened with the
previous smaller file.

Correction – As a general rule efforts to remove the instrument should be made as

initial approach. Ultrasonic fine instruments have proven most effective in
loosening and “flushing out” broken fragments. Failing to remove the instrument
one of the following steps may be followed.

59
(1) If the instrument fragment is totally within the root canal system an attempt to
bypass it with a small file or reamer can be made.

(2) If the fragment cannot be by-passed one can prepare and fill the canal to the
level to which instrumentation can be accomplished.

(3) If the fragment extends past the apex and efforts to remove it non-surgically are
unsuccessful then a corrective apical surgery is needed.

Prognosis – For a tooth with a separated instrument may not change very much, if
the instrument can be by-passed. If surgical correction is needed the prognosis may
be reduced.

Prevention – is by careful handling of instruments and sequential instrumentation.

Increasing file size only after the current working file fits loosely in to the canal
without binding.

Canal Blockage

“A blockage is an obstruction in a previously patent canal system that prevents

access to the apical construction or apical stop .”Blockage occurs when files
compact tissue debris dentinchips, restorative materials, fractured instruments,
cotton pellets, paper prints. fibrous blockage occurs when vital pulp tissue is
compacted and solidified against the apical constriction.  

Detection – Its readily apparent, the confirmed working length is no longer

attained.

Correction - is by recapitulation

60
REVIEW OF LITERATURE

1. Hulsmann.M. Mechanical preparation of root canals: shaping goals,

techniques and means. Endodontic Topics 2005; 10; 30–76.

Preparation of root canal systems includes both enlargement and shaping of the
complex endodontic space together with its disinfection. A variety of instruments
and techniques have been developed and described for this critical stage of root
canal treatment. Although many reports on root canal preparation can be found in
the literature, definitive scientific evidence on the quality and clinical
appropriateness of different instruments and techniques remains elusive. To a large
extent this is because of methodological problems, making comparisons among
different investigations difficult if not impossible.

2. Siqueira JF, Lima KC, Magalhaes FA, Lopes HP, de Uzeda M. Mechanical
reduction of the bacterial population in the root canal by three
instrumentation techniques. J Endodon1999;25:332-5.

The purpose of this study was to compare the intraanal bacterial reduction
provided by instrumentation using hand NiTi K-type files, GT files, and Profile
0.06 taper Series 29 rotary files. The most reduction occurred with hand
instrumentation to a #40 (99.57%).

61
3. Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two
rotary instrumentation techniques. J Endodon 1998;24:180-3.

Step-back produced significantly more debris than any other method. Balanced
forces was similar to rotary because the technique uses a rotary motion. Hand or
engine-driven instrumentation that uses rotation seems to reduce the amount of
debris extruded apically when compared with a push-pull (filing) technique.
Stepback technique produced significantly more debris than balanced- force,
ProFile or Light speed instrumentation.

4. Kosa DA, Marshall G, Baumgartner JC. An analysis of canal centering

using mechanical instrumentation techniques. J Endodon 1999;25:441-5.

Compared ProFile Series 29, Quantec 2000, M4 with Shaping Hedstroms, and
Endo-Gripper with Flex-R hand files. All mechanical instrumentation systems
resulted in some degree of canal transportation with NSD between the groups.
Quantec 2000 system, with cutting tips, produced greater transportation than
ProFile Series 29 at the apical level.

5. Esposito PT, Cunningham CJ. A comparison of canal preparation with

nickel-titanium and stainless steel instruments. J Endodon 1995;21:173-6.

This study compared the maintenance of the original canal path of curved root
canals during instrumentation with NiTi hand files, NiTi rotary files, and SS K-
Flex files. NiTi hand and engine driven files were more effective in maintaining
the original canal path of curved root canals when the apical preparation was
enlarged to size 35, 40, & 45.
62
6. Baugh.D and Wallace.J. The Role of Apical Instrumentation in Root Canal
Treatment: A Review of the Literature. J Endod 2005;31(5):333-340.

The ultimate goal of root canal instrumentation is to eradicate bacteria from

the root canal system. The ability to thoroughly clean and shape the anatomic
complexities of the canal system is the primary determinant for endodontic
success. However, better microbial removal and more effective irrigation occurs
when canals are instrumented to larger apical sizes. Longitudinal studies have
shown instrumentation to larger files sizes doesn’t contribute significantly to the
enhanced statistical success for endodontic therapy. The clinical philosophy that
apical preparation sizes should be kept as small as possible, rather than as large as
required, disregards existing scientific literature and appears to be based primarily
upon clinical opinion.

CONCLUSION

Endodontic therapy is the only dental procedure that relies so much on “feel”. The
tactile sense is extremely important in endodontic treatment. A lighter touch, more
delicate use of instruments, and greater restraint by the practitioner will produce
better results. Endodontic treatment is performed primarily through the sense of
touch. In periodontics, orthodontics, and restorative dentistry, compliance of the
patient, their healing capacity, laboratory quality, home care, and susceptibility to
disease play significant roles in success. In endodontics, the clinician is the major
clinical variable. Our ability and willingness to deal with root canal anatomy is the
formula for success .

63
REFERENCES

 Pathways of the Pulp 10th edn. - Stephen Cohen, Richard C. Burns

 Endodontics, 5th edn, Ingle
 Endodontic Therapy 4th edn-Franklin .S.Weine
 Atlas Of Endodontics - Rudolf Beer
 Harty's Endodontics in Clinical Practice - Harty & T R Pitt-Ford
 Colour atlas of endodontics- William.T.Johnson
 Endodontics:problem solving in clinical practice- Pitt-Ford & J.S Rhodes
 Advanced Endodontics , 2nd edn. – John .S.Rhodes
 Endodontics :Principles & Practice, 4th edn – Mahmoud Torabinejad
 Jacob.S.Current trends in cleaning & shaping. Fam Pract Dent 2006;6(4):1-9
 Hulsmann.M. Mechanical preparation of root canals: shaping goals,
techniques & means. Endod.topics 2005;10:30-76
 Baugh.D and Wallace.J. The Role of Apical Instrumentation in Root Canal
Treatment: A Review of the Literature. J Endod 2005;31(5):333-340.
 Esposito PT, Cunningham CJ. A comparison of canal preparation with
nickel-titanium and stainless steel instruments. J Endodon 1995;21:173-6.
 Siqueira JF, Lima KC, Magalhaes FA, Lopes HP, de Uzeda M. Mechanical
reduction of the bacterial population in the root canal by three
instrumentation techniques. J Endodon1999;25:332-5.
 Kosa DA, Marshall G, Baumgartner JC. An analysis of canal centering using
mechanical instrumentation techniques. J Endodon 1999;25:441-5.
 Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two
rotary instrumentation techniques. J Endodon 1998;24:180-3.

64