ENDODONTIC – Pre-Clinical Book REVISION

What are the hand instruments for Endodontic Treatment?

Mirror, Scissor, DG16 Endo Probe, D-11 T Spreader, 5-7 Endo Plugger, Tweezer

What is the point of using handfile despite of it not clearing out canals properly?

To establish “guide path” or “guide” for rotary file later

Tell me about the shape and location of the pulp chamber

- Location: @ center of crown, @ CEJ level

- Shape: smaller external shape of tooth

What is “Access”?

The pathway through which:

- Pulp chamber is entered

- Pulp tissue, irritant and dentinal debris are removed

- Canals are shaped

KEY: aim at the LARGEST canal of the tooth

How do you do Anterior Tooth Access Prep?

High Speed Tapered diamond bur  Perpendicular to Lingual Surface @ depth of 2mm  Turn bur as close to
long axis of tooth  Refine outline of access

What is the concept of straight-line access?

Instrument should enter the canal freely with minimal curving, bending or obstruction by the coronal structure

Why remove restoration on tooth before accessing the pulp chamber? To ensure:

- No caries, leakage or crack present

- Assess restorability

- Conservative assess prep

Why is cuspal reduction required for Posterior teeth requiring endodontic treatment?

To prevent cuspal flexure. Benefits are:

- Prevent Cuspal Fracture

- Create flat reference point for measurements

- Assess thickness of cusps for restorative planning

What are the options to temporise the tooth? Why is it important?

(1) GIC + Orthoband

(2) GIC temporary restoration (Dome Technique)

- To provide reservoir for irrigants

- To prevent leakage, reinfection

- Easy re-access and removal for definitive restoration

What are key features of Premolar Access?

- Can have upto 3 canals (2 Buccal, 1 Lingual)

- Canals symmetrical to Mid-Line

- Den Invaginatus (rare) OR Den Evaginatus (common – sticking out)  referral recommended)

What are the root configuration % of Pre-Molars?

Maxillary 1st Maxillary 2nd Mandibular 1st Mandibular 2nd

1 Canal 25% 50% 75% 95%
2 Canals 75% 50% 25% 5%
3 Canals < 3% <1% < 1% < 1%
What are key features of Maxillary 1st Molars?

- Access should be ‘Mesial to Transverse Ridge – ridge crossing the occlusal surface
from Buccal to Lingual’

- Shape determined by Canal Location – Palatal Canal should be biggest

 Typically: MB1, MB2 (70% of the time), and DB canals should be present

 Locate Palatal Canal first  Extend Access Cavity to MB direction

What are key freatures of Maxillary 2nd Molars?

- Access is similar to Maxillary 1st Molar

 But canals are closer together

 Rarely: only 2 canals

What are key features of Mandibular 1st Molar?

- Access: “Mesial to Center of the tooth”

- Hard to predict the number of canals

 Must follow the (1) midline/developmental groove on pulpal floor and (2)
Symmetry in relation to crown outline

 Distal Canal often biggest (BUT there might be 2 canals)

 Variation:

 2 Canals ONLY

 C-Shape canal

 Radix Entomolaris  additional root in permanent mandible molar (LINGUAL)

 Radix Paramolaris  additional root in permanent mandible molar (BUCCAL)

KEY: MB canal is the MOST difficult canal to access  DUE TO its location and angulation

- Be careful not to cause perforation

Which burs are used for access?

TF-12 (tapered diamond bur)

Size 90 Pulp bur (slow speed bur w/ long shank)

- To remove undercut, roof of the pulp chamber, smoothen out everything

How do you identify canal orifices?

- By using DG-16 Endodontic Explorer (two ended probe)

 Pointing down long-axis of the tooth

What size hand file do you use to take X- ray? What do you look for on X-ray?

Size 15

- Working Length confirmation

- 0-0.5mm away from radiographic apex

What is SLOB Rule?

Technique to read multiple files in the canal – tilt the x-ray beam slightly mesial or distal

SLOB stands for “Same side Lingual, Opposite side Buccal”

- ONLY useful for “working radiograph”; DON’T USE for Pre-Op and Post-Op radiographs

What does “notch” on rotary file represent?

- Represents “tapering” (ex. 2 notches + 3 = 5 % tapering)

What are the orders of rotary NiTi to instrument the canals?

Red: 25/07 (4 nothches)  KEY: ONLY goes 5-6mm away from working length

Blue: 30/05

Green: 35/04

Black: 40/04

White: 45/04

Blue: 60/04
All hand files have what % tapering?

2%

What are the different types of hand files?

Reamer: cut and enlarge canal with rotational motion

Barbed Broaches and Rasps: have sharp projecting barbs that cut or snag tissues

K-file: clean canal by planning dentine

H-file: more efficient at cutting the dentine

What are the standard lengths of hand files?

21, 25, 31 mm w/ silicon stopper that’s 1.5 mm

What is the standardized technique for hand instrumentation?

Watch-winding movement w/ “quarter-turned-and-pull” motion and gentle apical force to reach working length

What do numbers for rotary file represent?

“Tip Size” / “Tapering”

What is the material used for modern rotatory file? Why is it good?

Nickel Titantium Alloy  very elastic; allows larger tip size and tapering & retain canal curvature better than stainless
steel

How are tapering identified in MTWO and FLEXMASTER?

MTWO – # of empty rings

FLEXMASTER - # of black lines

Which settings need to be adjusted for ENDODONTIC MOTORS

RPM (Rotations Per Minute) – how fast instrument rotates during function [250-350 RPM avg]

Torque – force that motor exerts to TURN the instrument inside the canal
How does intra-canal fracture occur?

- Resistance force > Torque

 Rotatory file either stop or auto-reverse to prevent torsional fracture

Why do Coronal Flaring?

- Straight-Line Access: reduce friction for instrumentation

- Better visibility of canals

What is Glide Path?

- Path of least resistance for rotary instruments established by hand instruments (often to radiographic
working length)

What is the minimum apical size required for mechanical removal of canals?

Size 35/04

How do you identify “Master Apical File”?

- If the file cuts the last 3mm of dentine from apex, it’s MAF

 If it doesn’t cut, next size up!

 Ideally, use larger apical size to ensure that apical part of canal is fully cleaned BUT ask yourself if it
will weaken the structure

What does “Tapering” of instrument determine? Why do we need tapering?

Tapering  flaring out of the canal

- Easy to obturate

- Easy for irrigation needle to reach close to apex

KEY: TARGET TAPER = 4%

- Every 1 mm away from apex, the diameter of file increases by 0.04 mm

How are working length determined? 2 Methods:

- Radiographs  identify radiographic apex

- Electronic Apex Locator (EAL)

 A device detects the presence of periodontal ligament (PDL); accuracy higher than radiograph

 Detect presence of PDL because @ CDJ, periodontal attachment terminates

Why do we always instrument the canal to radiographic apex?

- Because Tip of the file DOES NOT cut; giving us 0.5 mm lee way

How does Torsional Fracture occur?

- Excessive apical pressure

 Tip of the instrument bind tightly inside canal but coronal portion continues to turn

 Fracture once force exceeds metal strength (unwinding, winding until it breaks)

What can you do to minimize the risk of Torsional Fracture?

- Gentle apical pressure and torque control motor

- Irrigant to reduce friction

- Instrument constantly moving in and out

- Examine signs of “unwinding” before using it

What is Flexural Fracture?

- Fracture due to repetitive flexing at one point (rotating around sharp curve)

 Break suddenly w/o distortion

How do you minimize the risk of Flexural Fracture?

- Create straight-line access

- Instrument constantly moving in and out

- Discard file after specific number of uses (or after severe curvature)
What is Crown-Down technique? What are the advantages?

- Early coronal prepreation is done (including flaring) before apical preparation, followed by incremental
removal of dentine from coronal to apical

Advantages include:

- Removal of coronal debris and Improve canal irrigation

- Better access

- Reduce instrument breakage

What is the point of obturation?

- To fill the root canal (that’s fully instrumented to remove bacteria) so nutrients can’t reach the apex and
biofilm can’t form

 Acts as physical barrier to entomb bacteria

What is the filling material used for obturation?

Gutta Percha (GP) – made of 75% Zinc Oxide and 25% rubber (trans-form)

- Elastic, Biocompatible, and Retrievable

- GP cone must correspond to MAF (Master Apical File)

Sealer Cement – made of Epoxy Resin

- To fill gaps between GP and root dentine

- (usually) 1:1 ratio – thin mix  less sealer extrusion

What are the different techniques for GP obturation?

(1) Cold/Warm Lateral Compaction

(2) Warm Vertical Compaction

(3) Core carrier System

What are the aims of obturation?

- Pack filling material apically and laterally

- Ensure root filling is close to apex but not beyond

- Within root canals NOT chamber

What happens if sealer goes beyond radiographic apex?

- Seal is biocompatible  inflammatory tissues remove them over time

 Outcome not affected

What is Cold Lateral Compaction?

- Compact GP sideways by inserting smaller GP cones to fill up the gap using “spreader”

 Hand spreaders vs. Finger Spreaders

What do you do with Endo Plugger?

- Heat it up using blow torch to cut off at orifice / level of CEJ

 Insert it into the canal by 0.5mm

What is Mid-Obturation radiograph?

- X-ray you take before sealing the chamber to check length and density of obturation

What are some Warm Vertical Compaction methods?

- System B

- Obtura Unit

- BeeFill

- Elements