Cleaning and shaping

Cleaning and shaping of the root canal consists of removing the pulp tissues and debris from the canal and shaping the canal to receive an obturating material. Using sequentially larger sizes of files and irrigating and disinfcting the canal to clear it of the debris ,one shapes the canal to clear it of all debris, to receive a well condensed filling that seals the root apically and laterally and prevents any leakage

Rules to be observed in cleaning and shaping the canal:

1.access should be obtained along a straight line 2.length of the tooth should be accurately determined 3.use of instruments in size sequence Instruments should be used in successively larger sizes to prevent breakage and ledge formation .

Returning to a smaller instrument from time to time before advancing to the larger size (ie. Recapitulation ) helps to prevent packing of dentin fillings and ensure patency of the canal till the foramen 4.Instruments should be used with a quarter to a half turn stroke and withdrawn with a pull stroke 5.Barbed broaches should be used only when the canal is wide enough to prevent their insertion and rotation without binding

6.Instruments should be fitted with instrument stops 7.The apical portion of the root canal ,3 to 4 mm ,should be enlarged atleast 3 to 4 sizes greater than the first instrument that binds and until the wall are regularly tapered Ideally the minimum size of the canal corresponds to a no.25 or no.30 instrument in the apical portion and a no.40 or larger instrument in the midline and coronal portion of the canal

Importance of widening the root canal 1.Removes microorganisms from the surface mechanically 2.Removes the pulp tissue that clings to the canal wall and has not been removed from the body of the pulp 3.Increase permeating capacity for irrigation 4.Wider the canal easier to fill gutta percha

8.The remainder of the canal should be enlarged using a step back technique 9.One must not force an instrument if it binds 10.Discard the strained files 11.All instrumentation has to be done using sterile instruments in a wet canal 12.Debris should not be forced through the apical foramen 13.Confine instruments to the root canal

Precautions in instrumentation
1.An instrument should not be forced if it binds Or it will lead to breakage 2.Controlled finger pressure should be used in manipulating the instrument in the canal 3.The instrument should be coaxed rather than forced and should be withdrawn from time to time to make sure the instrument is still intact and that the flutes of the baldes are not deformed 4.All instrumentation must be done in a wet canal as (A)dentin is cut more effectively when its wet (B)as the instrument is withdrawn,wet debris cling to it

(C)as we generally use irrigants like 5.2%sodium hypochloride solution,the canal is disinfected as it is enlarged STEP BACK METHOD In this method each consecutively larger instrument used for shaping the canal is placed short of the apex once a no.25 or 30 instrument has enlarged the apical third

ADVANTAGES
1.Less chance of periapical trauma 2.Greater flare facilitates greater packing of the gutta percha 3.Development of an apical matrix that prevents overfilling of the canal 4.Greater condensation pressure can be applied,filling lateral canals within the sealer

Straight root canal

1.After the working length has been determined ,the canal has been flooded with 5.2% sodium hypochlorite solution ,stops are positioned on all sterile instruments to the working length 2.The file is engaged with lateral pressure and with drawn and this procedure is repeated circumferentially and the apical foramen is cleaned 3.Now the larger files are sequentially inserted for circumferential filing till the full working length to prevent packing of dentin and ledging kept just short of the apical terminus

4.Recapitulation must be practiced intermittently 5.When we reach file no.30,the next file will not reach the working length and the preparation of the apical 1 /3 is complete and apical dentinal matrix is prepared 6.To now prepare the body of the canal-use the last largest file that did not reach the apical foramen and using unforced contact file circumferentially at the new length 7.Irrigate and recapitulate again to maintain patency of the apical segment

4.A Headstroem file(H file) 1-2 sizes larger than the previous file is used to finish the instrumentation of the coronal third of the root 5.It is necessay to constantly recapitulate and irrigate to prevent blockage of the canal 6.A finished canal should have smooth and continuously tapering walls 7.The the size of the largest file that fits the apical third without binding is used for selecting the cone size for obturation

CURVED ROOT CANALS

1.The file is precurved according to the radioghraphic estimation using a gauze sponge and the directional silicon stop should indicate the direction in which the file has been curved 2.Precurved files no.8,10 ,15 pose no problem in a curved canal due to their flexibility and they are used to circumferrentially clean the apical third 3.Less flexible files need to be modified or they will produce an elliptical preparation on the outer surface of the curvature with its elbowtowards the midle third and its zip towards the cemental surface causing either internal or external transportation of

4.In preparing the apical segment the outer curvature flutes of the files may be dulled using a diamond file to prevent transportation of the foramen 5.Circumferential instrumentation with intermittent recapitulation and irrigation is practiced as described before
100 50 0 1st Qtr 3rd Qtr East West North

Special modifications
Narrow curved root canals In narrow roots ,where after the initial no.10 file is used,the no.15 file binds 1-2 mm short of the apex,the no.10 file can be cut in its terminal portion by 1 mm to make a no.15 file (as all standard files taper0.02 mm in diameter for 1 mm in length).subsequent modification for the other files may also be carried out

Double curved root canals

After preparing the apical foramen with an no.10 file ,the middle curve is eliminated by filing it with a H-file on the inner curve and then recapitulate with a no.10 file again.Care must be taken not to overinstrument and perforate the canal DILACERATED ROOT CANALS Non forceful contact filing circumferrentially of the middle and cervical thirds open up the dialceration sufficiently for the apical portion to be accessed using a no.15 file with dulled flutes in the outer region apically and inner portion of the middle third .

Mechanical instrumentation
1.ENGINE DRIVEN INSTRUMENTS: The giromatic and the racer are 2 contra angle handpieces available which run at a slow speed of 1000 cycles /min 2.POWER DRIVEN INSTRUMENTS: The Gates Glidden drill and the Peeso reamers 3. ULTRASONIC AND SONIC INSTRUMENTS Consists of a piezoelectric ceramic unit that generates ultrasonic waves that activates a magnetostrictive handpiece with a frequency of 20,000 -25,000/sec

Problems of cleaning and shaping

Accidental perforation: 1.In anterior teeth ,the direction of the bur in gaining access to the pulp chamber must be parallel to the long axis of the tooth 2.ln molars the bur should be directed to the largest canal orifice ,yet limited to the level of the chamber roof, thereby preventing the most common furcation perforation 3.Iatrogenic perforations may occur on overinstrumentation of the curved root(apical perforation),overinstrumentatio n in the coronal part(lateral perforation)

4.On a perforation,first control the hemorrhage by irrigating the chamber with sterile anesthetic solution and then packing a moist sterile pellet (or soaked in a vasoconstrictor ) and holding under pressure for 2 to 3 mins 5 .Locate all canal orifices and then place files in all canals to prevent blockage of the canals during packing.The files are removed after the filling sets 6.For repair of the perforation ,a calcific barrier(CaOH)is prepared and gutta percha is sealed around that will not hinder the periodontal repair

7. Amalgam may also be used to give a permanent seal 8.If the perforation is in the peri radicular area ,a periradicular surgical procedure should be considered and if it is close to the foramen it should be treated normally and observed for repair

OBSTRUCTION BY CALCIFICATION IN THE CANAL : 1. If a root canal is obstructed with a pulp stone, an attempt should be made to bypass the stone using both rotatory and translatory motions 2. If a stone becomes wedged and cannot be bypassed then a engine driven instrument should be used to grind away the stone 3.lf the calcification in present apically and the tooth is asymptomatic then there is

no need to obtain an apical access,but if symptomatic an access must be obtained BROKEN INSTRUMENTS IN THE CANAL lf an instrument breaks in the canal try to remove it by bypassing it with a smaller instrument lf it is not possible to remove the instrument ,then perform cleaning shaping and obturate the canal with the instrument in it lf there is a periapical rarefaction originally present in a root canal with a broken instrument apically,then a periradicular surgery must be considered lf the fragment extends beyond the apex,it could be removed surgically and a retrograde filling of amalgam must be carried out

Obstruction by obturating materials

When retreatment of a tooth previously treated endodontically is necessary,removal of the obturating material has to be done
Gutta percha: lt can be removed by mechanical force(no.20 or 25 file/ a Gates Glidden drill) ,by heat(heated excavator blade) or by solvents such as xylol or chloroform,the final segments of gutta percha are removed by embedding a hot file in the apical segment,allowing it to cool

and withdrawing it once it has cooled SILVER CONE: A silver cone must first be treated with xylol or chloroform and then a clavitron is used to break the cementing medium and finally a pair of narrow beaked pliers can be used to pry the cone out of the canal PASTE: Liberal application of xylol and then subsequent mechanical instrumentation to remove the paste

Ledge formation
A ledge can be caused by using a large instrumnet out of sequence ,not working at the proper length,use of a straight instrument in a curved canal. Ledges are recognized when a instrument cant be inserted to its original working length lf a ledge has been formed,shift to a no.10 or no.25 file with a severe curvature and tease past the obstruction .once the ledge is bypassed ,DO NOT remove the file but continue circumferential instrumentation and try to obliterate the ledge if the ledge cannot be bypassed then fill till the level of obstruction and consider a retrograde amalgam surgery ,hemisection or extraction.

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