INTRODUCTION Predictable success of endodontic treatment requires accurate diagnosis, proper cleaning and shaping and hermetically obturation of the root canal. The technical demands and level of precision required for successful performance of treatment have traditionally been achieved by careful manipulation of instruments within root canal space and by strict adherence to biologic and surgical principle essential for disinfection and healing. Techniques for biomechanical preparation of the root canal differ in accordance with clinical observation and research discoveries. HISTORICAL PERSPECTIVE Pierre Fauchard (1733), one of the founders of modern dentistry described instruments for trepanation of teeth, preparation of root canals and cauterization of pulp. Edward Maynard (1838) has been credited with the development of the first endodontic hand instruments. Notching a round wire (in the beginning watch springs, later piano wires) he created small needles for extirpation of pulp tissue. In 1852 Arthur used small files for root canal enlargement. Ingle and Levine (1958) listed standardization for instruments. Ingle (1961) described conventional technique/ standardized taper technique of root canal preparation. Biomechanical preparation The biomechanical preparation of root canal is the attainment of free access to the apical foramen, through the root canal, by mechanical means. The objectives of biomechanical preparation are 1. To cleanse the pulp chamber and root canal of the pulp tissue remnants, bacterias and their toxins, altered dentin, foreign debris, caries and saliva. 2. To remove obstruction 3. To enlarge and taper the canal to receive maximum amount of irrigating solution and medicament 4. To smoothen the canal wall in order to improve contact of medicament with the infected canal surface and 5. To prepare apical stop and canal walls so as to facilitate obturation of canal. In order to achieve these objectives, biomechanical preparation of root canal involves three separate procedures i.e. debridement or cleaning, shaping and apical preparation. Cleaning 1
Usually performed with files. Are used initially during cleaning and shaping or any time an obstruction blocks the foramen. Irrigating, precurving different kinds of curves, curving all the way to the tip of the instrument and multiple curves in multiple directions of the instrument are all part of follow. A) Follow-withdraw
Files are used. This motion is used once the foramen has been reached and the next step is to create the path from access cavity to foramen. The motion is follow, then withdraw or follow and pull or follow and remove. It is simply an in and out passive motion that makes no attempt to shape the canal. B) Cart
Refers to the extension of a reamer to or near the radiographic terminus. The reamer should gently and randomly touch the dentinal walls and cart away debris. C) Carve Reamers are used for shaping. The key is not to press the instrument apically but simply to touch the dentin with a precurved reamer and shape on withdrawal randomly. D) Smooth Is accomplished with files. In the past, most endo procedures were performed with a smoothing or circumferential filing motion. If the previous four motions are followed smoothing is rarely required. E) Patency Is achieved with files/ reamers. It means that the portal of exit has been cleared of any debris in the path. Also included are 2 other terms given by Ruddle-Gauging and Tuning. Gauging refers to the knowing the cross sectional diameter of the foramen that is confirmed by the size of the instrument that snugs in at working length.
Rules governing biomechanical instrumentation During biomechanical preparation following rules should be followed. 1. Direct access should be obtained along straight lines. 2. Smooth instruments should precede barbed broach and rough instrument. 3. Narrow instruments should precede wide ones in sequential manner. 4. Reamer should precede files and should be given only to turn at a time. 5. Files should be used with a pull stroke. 6. Instrument should be fitted with instrument stops. 7. Short handle instruments should be preferentially used in the posterior teeth and lower anteriors ; long handle instrument in maxillary anterior teeth 6
Techniques according to type of Instrument movements 1. Circumferential filing technique It was given by Lim and stock in 1987. It is a movement of file around the circumference of canal while moving it in small vertical movements of 1to 3 mm amplitude. It is a method of filing whereby K or H file is first placed on the buccal side of the canal, then reinserted and placed mesially, then lingually and then distally until all walls have received planing. It is used for enhancing flaring, in oval root canals. Advantages: It maintains spatial relationship of root canal in root. It achieves rapid cutting of dentin. 2. Balanced force technique. This technique was introduced by Roane & Sabala in 1985. It was originally associated with specially designed stainless-steel with non cutting tip or Ni-Ti K-type 8
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8. Anti curvature technique It was introduced by Abou - Rass et al in1980. It was advocated for smaller curved canals with concavities on root surface so as to prevent strip perforation. Such canals are mostly seen on mesiobuccal canal of maxillary molar, mesial root of mandibular molar and mandibular incisors. In this method, access preparation is modified to achieve unobstructed approach h to canal as much as possible and then pressure is applied on instrument so that shaping will occur away from inside of the root curvature in coronal and middle third of canal i.e in bulky /safety zones. This pressure is applied as file is pulled from the root canal. Advantages: Prevent mid curvature straightening which prevents strip perforation in furcation area. 9. Reverse Flaring Technique It was given by Weine. In it minimal filing is done at tip, followed out by enlarge of coronal portion by 0.004/0.006 taper files or ultrasonic files or Gate Glidden drills or Peeso reamers. Then apical preparation is completed and finally apical flaring is done. It is used for curved canals mostly Advantages; Remove dentin on orifice of canal, thus providing straight line access. Prevents apical extrusion of debris. Less amount of procedural errors as zips and perforations. II. Corono apical methods 1. Step down technique. It was given by Marshall and Papin (1980) and Goerig et al (1982). After establishing straight line access and patency of canal, straight K file (no 35) is placed in straight portion canal with light apical pressure to the point where it 14
Acid method The acids which were used in root canal treatment for enlarging the canal and gaining access to the apical foramen were a. 30% hydrochloric acid (HCl), b. 50% Sulphuric acid (H2SO4), c. Phenolsulphonic acid and d. 50% reverse aqua regia. Purpose: The purpose of using acid was to dissolve inorganic structure of dentin and to make it soft which will facilitate its easy removal. This will assist root canal instrument in reaching apical foramina when canal is narrow or blocked Technique: The acid in small amount is pumped into the canal with instrument as far as it can go. It is allowed to remain there for few minutes. Instrumentation is then carried out until it reaches apical foramina or has widened the canal sufficiently. This technique resulted in quick corrosion of root canal instruments. a. Hydrochloric acid It was employed as 30% solution. It is more active than sulphuric acid and does not have self limiting action. (Grossman 1943). The dentin gets completely dissolved in it with no residue as the resultant calcium chloride is readily soluble in excess acid. It also interacts with sodium dioxide without leaving any residue It is desirable to neutralize acid in the root canal with a weak solution of sodium bicarbonate. b. Sulphuric acid It was introduced by Callahan in 1894. It is employed in concentrations varying from 30% to 50%. It destroys pulp tissue by precipitating proteins and abstracting water. Its solvent action on dentin is self limiting as it forms an insoluble calcium sulphate. This calcium sulphate can block the root canal. In order to prevent this canal is frequently irrigated with water or with weak solution of sodium bicarbonate. The bicarbonate neutralizes acid and also forms soluble salt sodium bisulphate. As a byproduct of this reaction, an effervescent solution is formed which helps in dislodging the organic debris. Sulphuric acid also interact with sodium dioxide but it leaves a residue. c. Phenolsulphonic acid It was recommended by Buckley in 1917, because it was not so destructive as sulphuric acid and because of its thick consistency which allowed it to be carried into root canal with ease. It is less potent than hydrochloric acid and sulphuric acid. If sodium bicarbonate is used to neutralize this acid, insoluble sodium phenolsulphonate is formed which can block the root canal. d. Reverse Aquaregia It was found that nitric acid was slightly more effective than hydrochloric acid. But it was not routinely used because of its highly irritating fumes. So in 17
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