Careful reading of preoperative radiographs to

recognize such complexities

– Careful negotiation and instrumentation of such root
canals keeping in mind the complex anatomy.
Teeth with Minimal Coronal Tooth Structure
• Challenge: To conserve as much sound tooth structure
as possible to protect it from fracture.
– Crown to root relation may not be identified due to
inadequate coronal tooth structure.
• Possible errors: Coronal or root perforation may occur
as a result of loss of significant coronal anatomy.
• Safe approach to face the challenge:
– Careful study of preoperative radiographs to study
the root angulation
– Careful probing of the cervical crown anatomy with
an explorer
– Palpate the root eminences
– Start access before placing rubber dam in such
cases
– If the canal is not located till a greater depth, then
instead of attempting to search the orifices, take
radiographs at various angles before proceeding.
Crowded Teeth
• Challenge: To obtain straight-line access while
conservation of tooth structure and without compromising
esthetics is the challenge.
• Possible errors:
– Inadequate access leading to inadequate cleaning
and shaping, missed canals, etc.
– Failure to achieve straight-line access (SLA) causing
further procedural errors
• Safe approach to face the challenge:
– Such cases may require an alternative approach of
access preparation
– Sometimes buccal access preparation will have to
be made to achieve SLA.
Rotated Teeth
• Challenge: To visualize the anatomic crown-to-root
relationship before making access preparation in order
to correctly angulate the bur with respect to the long axis
of root is the challenge.
• Possible errors:
– Perforations during access preparation
– Missed canals
– Excessive gouging of coronal or radicular tooth
structure in search of orifice of canal in a wrong
direction.
• Safe approach to face the challenge:
– Determine the anatomic relationship of the crown
to root by taking angled diagnostic periapical
radiographs
– Visualize and determine if there are any likely
variations that have to be made during access cavity
preparation.
Access Through Full Veneer Crowns
• Challenge: If the full veneer crown has to be retained,
making access cavity preparation through it is a
challenge.
• Possible errors:
– If you are conservative during access cavity
preparation, preparation may be underextended
causing various procedural errors.
– Failure to recognize crown to root angulation may
result in perforation.
– Leakage or recurrent caries may be left unattended
to resulting in failures later.
• Safe approach to face the challenge:
– When you prepare access through the full veneer
crown, do it with caution.
– Check the root prominence.
– Identify the long axis of the tooth.
– Carefully evaluate preoperative radiographs to find if
the full veneer crown has been altered. For example,
rotated tooth may have the full veneer crown that is
in the correct position and not in rotated position.
– Also, evaluate from preoperative radiograph, the
mesial/distal or axial inclination of the involved
tooth and its parallelism to the adjacent teeth.
– Check for the orientation of adjacent teeth clinically.
– Dental op erating micros cop e (D OM) and
transillumination of CEJ can be a valuable aid.
– When some doubt exists that the underlying tooth
may be rotated, drill through the center of the full
veneer crown for a safe access.
Table 13.1 shows the summary of the challenging
access preparations.
WHAT ERRORS CAN OCCUR DURING ACCESS
CAVITY PREPARATION?
Errors may occur in access cavity preparation if:
• There is clinician’s lack of understanding of the internal
or external morphology of tooth or
Endodontic Access Cavity Preparation 229
Challenging access
preparations
Possible errors Safety measures
• Teeth with
calcifications in
pulp chamber
and root
canals
• Perforations
• Weakening of
tooth structure
• Preoperative recognition
of calcification from
radiographs
• Knowledge about
progress of calcification
• Adequate illumination
and magnification
• Evaluating color
differences
• Knowledge of anatomic
location of root canal
orifices
• Diagnostic aids to locate
orifices
• Smaller Endodontic files
• Chelating agent
• Patience and caution
• Teeth with
curved canals
• Ledge formation
• Apical
transportation
and zipping
• Root perforations
• Incomplete
cleaning and
shaping
• Recognition
• Optimal reduction of
orifice walls for SLA
• Precurving of files
• Use more flexible files
• Careful use of rotary files
• Teeth with
unusual complex
anatomy of roots
and canals
• Inadequate
cleaning and
shaping
• Ineffective
obturation
• Recognition
• Careful negotiation and
instrumentation keeping
in mind the complex
anatomy
• Teeth with
minimal coronal
tooth structure
• Perforations • Evaluation of root
angulation by palpation
and using radiographs
• Start access preparation
before placing rubber
dam
• Radiographs at different
angulations
• Crowded teeth • Inadequate access
• Failure to achieve
SLA causing
procedural errors
• Alternate approach of
access preparation
• Buccal access
preparation may be
required
• Rotated teeth • Perforations
• Missed canals
• Excessive gouging
of tooth structure
• Radiographs at different
angulations
• Variations/alterations
in the usual access
preparation
• Access through
full veneer
crowns
• Under extended
preparation
• Perforations
unrecognized
• Leakage or
recurrent caries
• Caution
• Careful evaluation of
preoperative radiograph
• DOM and
transillumination
• Stay in center of tooth
when in doubt
TABLE 13.1 Summary of the challenging access preparations
Fig. 13.63 A mind-map to remember errors
in access cavity preparation
• The clinician does not follow access guidelines.
Poor Access Cavity Design
• Inadequate extension: Inadequate mesial or distal
extension may leave the orifices uncovered.
Failure to remove the pulpal roof completely is called
vertical underextension.
• Inadequate opening: Inadequate access opening results
in inadequate instrumentation
and obturation and it can
also cause various procedural problems like:
– Coronal discoloration when pulp horns are not
debrided.
– Instrument breakage (separation)
– Ledging of canal
– Apical transportation.
• Overextension: Gross overextension of access cavity
preparation will weaken the coronal tooth structure and
230 Short Textbook of Endodontics
hence compromise the final restoration and longevity
of the treated tooth.
• Overzealous tooth removal: Gouging
Improper bur angulation and failure to recognize
the inclination of tooth can result in overzealous tooth
removal. This results in weakening and mutilation of
tooth structure predisposing it to fracture.
These have been discussed in detail in Chapter 20
Endodontic Mishaps: Management and Prevention.
Perforations
Results in communication between root canal system and
the periodontal tissues.
(Discussed in detail in Chapter 20 Endodontic Mishaps:
Management and Prevention).
Figure 13.63 shows a mind-map to remember the errors
in access cavity preparation.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby. 2006.pp.165-228.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication. 1991.pp.151-77, 79.
3. Ingle J, Bakland L, Baumgartner J, Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton. 2008.pp.877-918.
4. Ingle, Bakland, Endodontics, 5th edn. Plates 3 to 27, BC Decker-
Elsevier. 2002.

Cleaning and Shaping of

the Root Canal System
Including Working Length
Determination
This chapter describes the objectives and the various concepts and strategies for effective root canal
preparation and discusses in detail the root canal preparation techniques.
 You must know
• What is Cleaning and Shaping of Root Canals?
• What are the Objectives of Cleaning and Shaping of Root Canals?
• Which are the Important Numerical Concepts in Root Canal Preparation and how to
Determine Them?
• What are the Current Concepts and Terminology for Root Canal Preparation?
• Which are the Different Instrument Motions for Effective Shaping of Root Canals?
• What are the Requirements before Starting Canal Preparation?
• Which are the Different Canal Preparation Techniques?
• What are the Precautions to be taken during Instrumentation?
• What are the Procedural Errors that can Occur during Root Canal Preparation?

14
CHAPTER
WHAT IS CLEANING AND SHAPING
OF ROOT CANALS?
Definition of Biomechanical Preparation
“Obtaining straight-line access to the apical foramen and
enlarging and disinfecting the root canals by chemomechanical
means without causing injury to the periapical
tissues is called biomechanical preparation of root canals”.
Earlier the term biomechanical preparation was
commonly used. However, now the terms ‘radicular
preparation’ and cleaning and shaping of root canals,’
are commonly used. ‘Cleaning’ and ‘Shaping’ are two
interdependent steps of root canal treatment procedure
performed in order to obtain complete disinfection of
root canal system and to obtain a continuously tapering
funnel from coronal access to apex in order to facilitate
3-dimensional obturation of root canals.
‘Cleaning’ and ‘Shaping’ Concepts
Effective ‘Shaping’ is the mechanical instrumentation of the
root canal with hand and rotary instruments to remove vital
and necrotic pulp tissue and eradicate microbes from the
accessible parts of the root canal and to shape the canals
in such a way that directs and facilitates optimal irrigation,
debridement and placement of local medicaments followed
by 3-dimensional obturation of the root canal system.
Shaping is specific for each root.
Effective ‘Cleaning’ refers to the use of chemicals
to eradicate microorganisms, dissolve necrotic tissue
and remove necrotic dentin and debris created from
instrumentation by means of antimicrobial irrigating
solutions, detergents and decalcifying materials and then
placement of intracanal medicaments to render the root
canal system free of microbes.
232 Short Textbook of Endodontics
Without irrigation, mechanical instrumentation
becomes ineffective rapidly due to accumulation of
debris. Without enlarging and shaping, the irrigating
solutions cannot reach all parts of the root canal system.
Shaping removes restrictive dentin thereby improving
the effectiveness and the control of canal preparation and
allows irrigation solution to completely penetrate the root
canal system. Thus, shaping facilitates cleaning and cleaning
facilitates shaping.
Also only well-shaped canals can be filled in three
dimensions. Thus, shaping facilitates 3-D obturation.
Various instrumentation and shaping techniques will
be discussed in this chapter. Various chemical agents used
for effective cleaning will be discussed in the next chapter
(Chapter 15).
WHAT ARE THE OBJECTIVES OF CLEANING AND
SHAPING OF ROOT CANALS?
Biologic objectives are to:
• Remove pulp tissue remnants and infected dentin from
the root canal system.
• Remove bacteria and their endotoxins and all potential
irritants from the entire canal system.
• Confine all instrumentation procedures within the root
canal space.
• Avoid pushing contaminated debris beyond the apical
foramina.
• Create sufficient space within the canal for irrigation
and intracanal medicaments (Remember biologic
objectives-CCARR).
Mechanical objectives:
(Remember these mechanical objectives with the help of
following sentence: Kindly Prepare Design Mechanically
with Anatomy Maintained and Less Disturbed.)
• Develop a smooth continuously tapering funnel-shaped
preparation in all three-dimensions such that the crosssectional
diameter of the canal narrows towards the
foramen.
• Maintain the original root canal anatomy by fully
incorporating all walls of canals into prepared shape
such that the preparation flows with the shape of the
original canal.
• Maintain the original position of apical foramen.
• Keep the apical opening as small as practically possible.
• Leave as much radicular dentin as possible to prevent
weakening of root structure.
• Prepare a sound apical dentin matrix at the cementodentinal
junction (CDJ) for apical seal.
• Design the preparation such that the cross-sectional
diameter becomes narrower at every point apically.
• Avoid preparation errors such as zipping, perforations,
etc.
Clinical objectives:
• To remove restrictive dentin in order to
– Improve effectiveness and control of canal
preparation,
– Allow irrigation solution to completely penetrate the
root canal system (Shaping facilitates cleaning).
• To remove the accumulated debris created by mechanical
instrumentation by means of root canal irrigation for
effective shaping (Cleaning facilitates shaping).
• To develop a logical cavity preparation specific for the
anatomy.
• To allow for three-dimensional filling of well-shaped and
cleaned root canals (Cleaning and shaping facilitates
three-dimensional obturation of the root canal system).
Figure 14.1 shows the mind-map to remember all
objectives of cleaning and shaping.
Fig. 14.1 Mind-map of objectives of cleaning and shaping
Cleaning and Shaping of the Root Canal System Including Working Length Determination 233
WHICH ARE THE IMPORTANT NUMERICAL
CONCEPTS IN ROOT CANAL PREPARATION
AND HOW TO DETERMINE THEM?
Endodontic treatment involves preparation of the coronal
and radicular spaces (Earlier called Biomechanical
preparation, now termed as Cleaning and Shaping of the
root canal system).
Coronal access cavity preparation has been described
in detail in the previous chapter (Chapter 13 Endodontic
Access Cavity Preparation).
Radicular preparation or root canal preparation is
discussed in detail in this chapter.
The important concepts in root canal preparation are as
follows:
Working Length
Canal length is the distance from a coronal reference point
to the apical exit of the root canal.
Anatomic apex of the root is the tip or end of the root
which is morphologically determined.
Radiographic apex of the root is the tip or end of the root
which is determined on the radiograph.
The radiographic apex may be different from the
anatomic apex due to variations in the morphology of the
root and factors related to the radiographic technique.
Definition of Working Length
According to Glossary of Endodontic terms: “Working length
is defined as the distance from a coronal reference point to
the point at which the canal preparation and obturation
should terminate”.
Significance
Figure 14.2 gives the importance of working length
determination.
Apical Limit of Working Length
• Theoretically, the apical extent for termination of root
canal preparation and obturation is the cemento-dentinal
junction (CDJ), which is a histological entity and cannot
be accurately determined clinically.
• Clinically, the desired apical extent considered is the
apical constriction, which does not always coincide with
the CDJ. Apical constriction is located about 0.5–1 mm
short of the radiographic apex. Apical constriction is the
portion of the root canal with narrowest diameter, also
referred to as minor apical diameter.
Figures 14.3A and B show how the position of apical
foramen changes