ENDODONTICS (lec) FINALS REVIEWER

REPORTING Errors in Cavity Preparation

Law of Centrality
- The floor of the pulp chamber is always located in the center
of the tooth at the level of the CEJ.
- The law of centrality can be used as a guide for the
beginning of access
Law of Concentricity
- The walls of the pulp chamber are always concentric to the
external surface of the tooth at the level of the CEJ, that is,
the external root surface anatomy reflects the internal pulp
chamber anatomy.
Law of CEJ
- The distance from the external surface of the clinical crown
to the wall of the pulp chamber is the same throughout the
circumference of the tooth at the level of the CEJ, making
the CEJ is the most consistent repeatable landmark for
locating the position of the pulp chamber.
Major problems in endodontic access preparation:
 Failure to identify and excavate all caries and to remove
unsupported, weak tooth structure or faulty restorations
 Failure to establish proper access to the pulp chamber space
and root canal system
 Failure to identify the angle of the crown to the root and the
angle of the tooth in the dental arch
 Failure to recognize potential problems in access openings
through crowned teeth or teeth with excessively large
restorations
Other errors in access preparation:
 Perforation
- Perforation at the labio cervical is caused
by failure to complete convenience
extension toward the incisal, prior to the
entrance of the shaft of the bur

Law of Pulp Chamber - Apical perforation of an invitingly straight

1. First Law of Symmetry conical canal. Failure to establish the exact
- Except for the maxillary length of the tooth leads to trephination of
molars, canal orifices are the foramen
equidistant from a line
drawn in a mesiodistal
direction through the
center of the pulp - Perforation into furcation caused by using a
chamber floor. longer bur and failing to realize that the
narrow pulp chamber had been passed.
2. Second Law of Symmetry Measure the bur against the radiograph ad
- Except for the maxillary molars, canal orifices lie on a line the depth to the pulpal floor marked on the
perpendicular to a line drawn in a mesiodistal direction shaft with dycal.
across the center of the pulp chamber floor.
 Ledge
Law of Color Change - Ledge formation at the apical labial curve is
- The pulp chamber floor is always darker caused by failure to complete the
in color than the walls. convenience extension. The shaft of the
instrument rides on the cavity margin and
“shoulder”

 Incomplete preparation
Laws of Orifice Location - Incomplete preparation and possible
1. 1st Law of Orifice Location instrument breakage caused by total loss of
- The orifices of the root canals instrument control. Use only occlusal access,
are always located at the never buccal or proximal.
junction of the walls and the
floor.

- Bifurcation of canal is completely missed,

2. 2nd Law of Orifice caused by failure to adequately explore the
Location canal with curved instruments
- The orifices of the root
canal are always
located at the angles in
the floor wall junction.

 Broken instrument
3. 3rd Law of Orifice Location - Broken instruments twisted off in a “cross-
- The orifices of the root canals over” canal. This frequent occurrence may be
are always located at the avoided by extending the internal preparation
terminus of the roots’ to straighten the canals
developmental fusion lines.
- The developmental root fusion
lines are darker than the floor
color.
- Reparative dentin are calcifications are lighter than the pulp
chamber floor and often obscure it and the orifices.
ROOT CANAL CLEANING & SHAPING

Root Canal Cleaning & Shaping Disinfection

- Cleans, shapes and allows sealing of the root canal system - Help remove infected pulp tissue, inflammatory and
in 3-dimension potentially inflammatory by-products from the canal
- Removes canal infection - Flush out necrotic pulp from the root canal system
- Neutralizes bacteria or infection within the canal
Cleaning
- Removal of all contents of the root canal before and during Lubrication
shaping - Facilitate instrument insertion
- Soften dentin for easy removal
Shaping - Prevent pulp tissue cohesion when packed apically
- Creates a specific cavity form of the root canal mechanically - Maintain a moist canal walls
to allow 3-dimension obturation of the root canal system
2) Exploration/ Scouting
Smear Layer
- The surface of the canal wall where debris, are compacted Exploration of the Root Canal
into the tubules by the burnishing action of the instruments - Objectives:
during filing  Provide tactile information of the root canal morphology
- Composition: S.S. K-Type File #8 or 10
 Fractured bits of dentin  Separates the pulp from the canal walls
 Soft tissues from the canal  Provides space for the insertion of succeeding rough
 Bacteria instrument
- It can be removed by chemical solution using EDTA before  Clinically identify approximate location of apical
sealing the canal permanently constriction

Ethylenediaminotetraacetic Acid (EDTA) 3 Important Landmarks:

- Used in 17% concentration 1. Apical Foramen
- Effective chelating agent - Opening at the end of the root
- Does not possess antimicrobial properties - Not always located at the end of root
- Aids in the instrumentation of very narrow calcified canals - 0.5-1 mm from radiographic apex
- Can remove smear layer
2. Radiographic Apex
PROCEDURE: - End of the root
1) Coronal Access
- Flush the chamber with irrigating solution 5.25% NaOCl 3. Apical Constricture
- Start with File # 80 for Anterior, File # 55/ 50 for Posterior - Aim to reach for endo
- Irrigate every after file to remove dentin debris inside the - End of root canal
canal - Basis for working length
- File # 6, 8, 10 – patency file for small/ narrow canals - 0.2-0.5 mm from apical foramen
- File # 15 – IAF - 1mm from radiographic apex

Sodium Hypochlorite (NaOCl)  1mm uncleaned canal = 80,000 microorganisms

- Mostly used irrigating solution at 5.25%
- Good antimicrobial properties Apical Blockage
- Dissolves vital and necrotic pulp tissues - Usually occur during the initial stages of canal preparation.
- Does not remove smear layer (unlike EDTA) - It may be in a form of:
- If this went to the periapex, it will cause hypochlorite  Collagen Blockage
accident  Packed pulp apically due to incorrect pulp extirpation,
- If you use 3-way syringe during access prep, it will lead to use of liquid irrigant at the start of instrumentation of
embolism narrow canals

- How do you irrigate:  Dentin Mud/ Hard Tissue Blockage

1. Use side-bended syringe (so that iikot yung irrigating
solution)
2. Dilute 1-part sodium hypochlorite: 8 parts water, but
most effective is full strength 5.25% sodium
hypochlorite
 Packed dentin shavings due to incorrect filing
technique, inadequate debridement and irrigation after
each filling
 Separated Instrument

- Why do you irrigate?

 Dentin shavings may be packed on apical portion

- Necrosis:
 You need to do 24-hour canal debridement (irrigation)
because it takes 24 hours for all pathogenic
microorganisms to kill by irrigation
ROOT CANAL CLEANING & SHAPING (Continuation)

Extirpation of Pulp Initial Apical File (IAF)

- Done on vital/ irreversible pulpitis - Smallest file that can bind
- Increase 3 times bigger → Master Apical File (MAF)
Debridement - File # 15 – smallest IAF that you can have
- For necrotic pulp
8) Step Back Preparation
3) Radicular Access - Double flare
- Objectives:
Orifice Opening (Coronal 1/3) 1. To create a taper at apical 3rd after establishing the
- Objectives: MAF
1. To enhance canal orifice
2. Provide direct insertion of instrument to the apical 3rd of 9) Final Flaring
the root canal  “Circumferential filing motion”
a. Use of gate glidden drills  All throughout the walls
- Opening of the orifice of the canal  “Glassy feel”
- TWL – 8
10) Disinfection
Irrigation or Lubrication before & after change of the file size 1. Irrigate
- Ensure that the chamber and canal is full of irrigant (2.5 – 2. Paper point
5.25% sodium hypochlorite) 3. Canal dressing
- Use a chelating agent (liquid or paste) (CaOH powder + distilled water) – thick and creamy
consistency, put using lentulo filler
4) Patency Check 4. Temporization
- Constantly checks of the canal is patent and the apical Temporary Filling (Restoration) – must be intact
foramen is open 5. Evaluation for possible obturation
- File # 6, 8, 10 – Patency files Necrotic – 7days
- “Negotiate” means you need to reach for apical constricture Irreversible Pulpitis – 3-5 days

5) Crowndown (Coronal 2/3)

- A higher file size is used and progressively moves apically
up to the cervical 2/3 of the canal in a crowndown manner

- Filing Motion:
 “Passive Filing Motion or Watch Winding Motion”
 Back and forth oscillation of a file (30-60 degrees) right
and left as the instrument is pushed forward into the
canal

6) Working Length Registration

- Ways to Determine the Working Length:
 Ingle’s Method (Add-Minus)
 Grossman’s Method (Mathematical equation)
 Weine’s Method (Substract 1mm from TLI)
 Tactile Sense
 Paper point method
 Electronic devices (apex locator, root ZX, etc.)

- Patency file (ex. #15) is inserted into the canal marked at

Trial Working Length (TWL)
- Expose a radiograph and estimate the Working Length (WL)

7) Apical preparation
- Objective:
1. To prepare the apical 3rd 3 sizes bigger than the original
2. To establish an apical matrix

- Identify:
1. IAF (ex. File # 25)
2. MAF (ex. File # 40)
3. Prepare canal 3x bigger

- Filing Motion:
 Passive-Pull Filing Motion”
 Back and forth oscillation of a file (30-60°) right and left
as the instrument is pushed forward into the canal
 Once the file binds on the wall, pull out the file
 Must be loose inside
TLI – Tooth Length Image Example # 4
TWL – Tentative/ Trial Working Length File # 15 is 3 or more mm short from
IAF – Initial Apical File radiographic apex
MAF – Master Apical File
AFL – Actual File Length You cannot use anymore Ingle’s Method.
Use Mathematical (Grossman’s) Method
𝐀𝐅𝐋 𝐱 𝐓𝐋𝐈−𝟏
WL =
𝐒𝐅

SF = Shadow File

IAF Fille # 25 23 mm
Fille # 30 23 mm
Fille # 35 23 mm
TRIAL WORKING LENGTH (TWL) MAF Fille # 40 23 mm
= TLI – 2mm Step-Back Fille # 45 22 mm
= 25mm – 2mm = 23mm (TWL) Fille # 50 21 mm
Fille # 55 20 mm

Example # 1
File # 15 is 1mm short from radiographic apex

WL = AFL
= 23 mm

Example # 2
File # 15 is exactly at the radiographic apex

WL = AFL – 1mm
= 23 – 1 mm
= 22 mm

Example # 3
File # 15 is 2mm short from radiographic
apex

WL = AFL + 1mm
= 23 + 1mm
= 24 mm
5 PHASES OF CANAL CLEANING AND SHAPING OBTURATION

Example: Evaluation for Possible Obturation:

Pre-op Vital – 3-4 days
TLI = 25mm Necrotic – 7 days

TWL = 25mm – 2mm Characteristic of Ideal Root Canal Filling:

TWL = 23mm  3-dimension filling of the root canal system as close to the
DCJ as possible
1. CORONAL 1/3 (ORIFICE SHAPING)  Obturated canal reflects a continuous tapering funnel
- “Passive Filing” preparation without excessive removal of tooth structure at
- Open the orifice any level of the Root Canal System
- Aim: TWL-8
Glass Ionomer
TWL - 8 - Orifice plug
23mm – 8 = 15mm - Root canal is still protected if crown brakes

Start with File # 80 = 13mm Appropriate Time for Obturation:

70 = 14mm 1. Tooth is asymptomatic
60 = 15mm STOP HERE 2. Canal is dry
Until you reach 15mm 3. There is no sinus tract
4. There is no foul odor
2. CORONAL 2/3 (CROWNDOWN) 5. The temporary filling is intact
- “Passive Filing”
- Aim: TWL-4 Canal Dressing
- CaOH + Distilled water
TWL – 4
23mm – 4 = 19mm How to remove CaOH
 Spoon excavator
Since your Coronal 1/3 is up to #60 you may start with #50  MAF file
 Round bur
Start with File # 50 = 16mm
45 = 17mm Paper point must be clean when it comes out
40 = 18mm
35 = 19mm STOP HERE Gutta Percha
Until you reach 19mm - Properties:
1. It is compactible
3. APICAL PREPARATION 2. It can be softened and made plastic by ..
- Aim: Working Length 3. Inert
4. Dimensionally stable
IAF 5. Minimal toxicity
- Smallest file that binds into the canal up to working length 6. ..
- Original side 7. Will not discolor tooth structure
8. It is radiopaque
WL = 23 mm 9. It can be removed from the canal when necessary

Start with File # 15 = 23mm Is it tight/bind or loose inside? - Disadvantages:

IAF 20 = 23mm 1. Lack adhesion to dentin
30 = 23mm 2. Shrinks when transformed from alpha to beta form
MAF 35 = 23mm (plasticized ..
3. ..
4. STEP-BACK
- Double flare Root Canal Sealers
- “Passive Filing” - Purpose:
1. To enhance possible attainment
MAF 35 = 23mm
40 = 22mm - Function:
45 = 21mm 1. Binding agent
50 = 20mm 2. Filler for irregularities and .. discrepancies
3. Lubricant
5. FINAL FLARING 4. Seals lateral and accessory canal
- “Circumferential filing” 5. Assists microbial control

MAF = 23mm - Properties:

To remove ledge go back to MAF 1. Biologically compactible
2. Well tolerated
Spreader Reach 3. Radiopaque
- Inserted next to the master cone 1-2mm short of the actual
working length Master Cone
- Objective:
1. To seal the apical opening of the canal and to occlude
the “tug-back”area
RECONSTRUCTIVE ENDODONTICS

Restoration of Endodontically-Treated Tooth

Facts:
 Long term leakage due to poor coronal restorations is a
potential cause of failure for any root canal procedure
Poor coronal restoration = poor coronal seal
 Salivary leakage through incompletely removed caries/
poorly placed temporary materials can cause
interappointments flare ups
 Caries should be completely removed before initiating root
canal treatments
 Defective or loose restorations should be removed before
RCT to assist in leakage control and evaluation for final
restoration
 Preparation for post. space should be done under rubber
dam isolation
 Treatment is considered incomplete until the treated tooth is
restored fully to function
 Failure to restore the crown of the treated tooth is restored
fully to function
 Failure to restore the crown of the treated tooth as soon as
possible may result to fracture that could render the tooth
unrestorable

Factors to be Considered in Selection for Restoration:

Anterior Teeth:
 Intact marginal ridges, cingulum and incisal edges

Restoration: (Anterior Teeth)

 Lingual/ palatal bonded composite
 If discolored, chemical or walking bleach technique
 Veneer crowns
 PFM crowns
 Structurally compromised crown
 Post and core

Posterior Teeth:
 Sufficient tooth structure
 Sufficient destruction of tooth structure
A normal occlusion

Restoration: (Posterior Teeth)

 Full coverage crown
 Onlay
 Dentin bonded cores
 Dentin bonded cores with intraradicular post