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DEFINITION root canal system.

Thus we can say that coronal access forms


Access cavity preparation is defined as endodontic coronal the foundation of pyramid of endodontic treatment (Fig. 14.1).
preparation which enables unobstructed access to the canal As we have seen success of endodontic therapy depends
orifices, a straight line access to apical foramen, complete control on proper evaluation and thereafter placement of this step. Any
over instrumentation and to accommodate obturation technique.
It is a well established fact that success of endodontic therapy
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improperly prepared access cavity can impair the instru-
mentation, disinfection and therefore obturation resulting in
depends on the main three factors: poor prognosis of the treatment.
a. Cleaning and shaping Before going for access cavity preparation, after evaluating
b. Disinfection other factors, a study of preoperative periapical radiograph is
c. Three-dimensional obturation of the root canal system. necessary with a paralleling technique.
Proper cleaning and shaping establishes the necessary con- Radiographs help in knowing
ditions for next two factors. However, there is one step which i. Morphology of the tooth (Fig. 14.2).
precedes these factors, the error in this preliminary step would ii. Anatomy of root canal system (Figs 14.3 and 14.4).
compromise the whole subsequent work. This preliminary step iii. Number of canals.
is the preparation of the access cavity, i.e. opening through the iv. Curvature of branching of the canal system.
coronal portion of tooth which allows localization, cleaning, v. Length of the canal.
shaping, disinfection and a three-dimensional obturation of the vi. Position and size of the pulp chamber and its distance from
1.  Access Cavity occlusal surface.
vii. Position of apical foramen.
Preparation
viii. Calcification, resorption present if any (Fig. 14.5).
•  Isolation
The main objective of the access cavity preparation is to
•  Access opening

Endodontic Triad
create a smooth, straight line access to the canal system and
•  Length determination the apex. The optimal access cavity results in the straight entry
2.  Biomechanical into the canal orifices with line angles forming a funnel which
Preparation drops smoothly into the canals (Fig. 14.6). Sometimes depending
•  Cleaning and shaping upon the location and number of canals, modification of the
outline form may be needed.
•  Irrigations An ideal access preparation should have following qualities:
•  Intracanal medicament 1. An unobstructed view into the canal.
3.  Obturation 2. A file should pass into the canal without touching any part
of the access cavity.
Fig. 14.1: Pyramid of endodontic treatment 3. No remaining caries should be present in access cavity.

Danica Anastasia

Access Openings General Principles


•  Recommended shape for access of a normal tooth
•  Assures correct shape and location, provides straight-line access
Removal of the chamber roof and all coronal pulp tissue to the apical portion
•  Remove tooth structure that would impede the cleaning and
Outline form shaping process
Locating all canals

Unimpeded straight-line access of the instruments in the •  Allows modification of the ideal outline form to facilitate
canals to the apical one third unstrained instrument placement and manipulation
Convenience
form
Conservation of the tooth structure

1
Root Canal System
plan the whole treatment so as to obtain the successful treatment
results.
The clinician should evaluate the tooth to be treated to
ensure that the particular tooth has favorable prognosis. Before
performing cleaning and shaping, the straight line access to canal
orifice should be obtained. All the overlying dentin should be 1/22/19
removed and there should be flared and smooth internal walls
to provide straight line access to root canals (Fig. 17.8). Since
shaping facilitates cleaning, in properly shaped canals,
instruments and irrigants can go deeper into the canals to
remove all the debris and contents of root canal. This creates
a smooth tapered opening to the apical terminus for obtaining
Fig. 17.6: Radiograph showing obturated first molar
three-dimension obturation of the root canal system.

•  Permits the development of an aseptic environment before


entering the pulp chamber and radicular space
•  Allows assessment of restorability before treatment
Caries •  Provides sound tooth structure so that an adequate restoration
removal can be placed

Fig. 17.7: Doubling the file size apically, increases


•  Preventing materials and objects from entering the chamber and the surface area of foramen four times
canal space
Toilet of the
cavity Removal
Fig. of overlying
17.8: Removal dentin
of overlying dentin to get smooth
causes smooth internal
internal
Mechanical objectives of root canal preparation (given by
Schilder)
walls walls
and and
provide
providestraight-line access
straight line access to root
to root canalscanals

• The root canal preparation should develop a continuously


tapering cone. After obturation, there should be complete sealing of the
• Making the preparation in multiple plane which introduces the pulp chamber and the access cavity so as to prevent microleakage
concept of “Flow”. into the canal system (Fig. 17.9). Tooth should be restored with
• Making the canal narrower apically and widest coronally.
permanent restoration to maintain its form, function and
• Avoid transportation of foramen.
• Keep the apical opening as small as possible.
aesthetics and patient should be recalled on regular basis to
evaluate the success of the treatment (Fig. 17.10). For past many
Objectives of Biomechanical Preparation years, there has been a gradual change in the ideal configuration
of the prepared root canal. Earlier a round tapered and almost
Biologic Objectives of Root Canal Preparation parallel shape was considered an ideal preparation but later when
Biologic objectives of biomechanical preparation are to remove Schilder gave the concept of finished canal with gradually
the pulp tissue, bacteria and their by-products from the root increasing the taper having the smallest diameter apically and
canal space. widest diameter at the coronal orifice.
233

Maxillary Anterior Maxillary Posterior

2
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Mandibular Anterior Mandibular Posterior

Patency File Working Length


•  Small K-File (#10 or #15)
•  Passively extended slightly beyond
apical foramen Coronal
Cleaning,
shaping, and Working
reference
•  Suggested for most rotary technique point
obturation
point
Length

•  Objectives:
1.  Remove accumulate debris
2.  Maintain working length

3
Disadvantages of radiographic methods of working length
determination 10 or 15 size instrument. If it is of average wid
1. Varies with different observers or 25 size instruments. If canal is wide, use 30
2. Superimposition of anatomical structures instrument.
3. Two-dimensional view of three-dimensional object • Insert the selected file in the canal up to the estim
4. Cannot interpret if apical foramen has buccal or lingual exit length and1/22/19
take a radiograph.
was first introduced by John Ingle. Weine modified this 5. Risk of radiation exposure • If file is too long or short by more than 1 mm f
6. Time consuming

Textbook of Endodontics
subtraction rule (Figs 15.8A to C) as follows: diameter, readjust the file and take second rad
7. Limited accuracy
a. If radiograph shows absence of any resorption, i.e. bone • If file reaches major diameter, subtract 0.5 mm
or root apex, shorten the length by 1 mm (Fig. 15.8A). Grossman Method/Mathematic Method of younger patients and 0.67 for older patients.
b. If periapical bone resorption is present, shorten it by Working Length Determination
1.5 mm (Fig. 15.8B). Advantages
Length Determination c. If both bone and root resorption is seen, shorten length
by 2 mm. This is done because if there is root resorption,
It is based on simple mathematical formulations to calculate
the working length. In this, an instrument is inserted into the • Minimal errors
canal, stopper is fixed to the reference point and radiograph • Has shown many successful cases
loss of apical constriction may occur in such cases (Fig.
Radiographic Evaluation Electronic Apex15.8C).
Locators Grossman Formula
is taken. The formula to calculate actual length of the tooth
Figs 15.8A to C: Modification in length by substraction
is as follows: in case of root resorption
• Rapid development of increases the chances o
obturating material.
In curved canals, canal length is reconfirmed because final
•  Grossman formula •  Patientsworking
with gag reflex
length may shorten up to 1 mm as canal is straightened Actual length of the tooth Apparent length of tooth in radiograph Disadvantages
•  Metode Ingle and can’t
outtolerate films
by instrumentation. If root contains two canals, the cone _______________________________
By above,
= _____________________________________________
Actual length ofasthe
we see those threelength
Apparent variables are known and
of instrument • Time consuming and complicated
•  Patientsshould be positioned at 20 to 30o horizontal deviation from
with medical
•  Metode Weine by applying the formula, 4thinvariable,
instrument radiographi.e. actual length of tooth • Requires excellent quality radiographs.
the standard facial projection. 204
•  Metode Kuttler problem that prohibit the can be calculated.
holding ofRadiographic
film/sensormethod of length determination Actual length of the instrument ×
1. Measure the estimated working length from preoperative Apparent length of tooth in radiograph
•  Patients with pacemaker
periapical radiograph.
Actual length of tooth = ________________________________________________
Apparent length of instrument in radiograph
(?) 2. Adjust stopper of instrument to this estimated working length
and place it in the canal up to the adjusted stopper.
3. Take the radiograph. Disadvantages
4. On the radiograph measure the difference between the tip of 1. Wrong readings can occur because of:
the instrument and root apex. Add or subtract this length to a. Variations in angles of radiograph
the estimated working length to get the new working length. b. Curved roots
5. Correct working length is finally calculated by subtracting 1 mm c. S-shaped, double curvature roots.
from this new length.

Modification in the length subtraction (Fig. 15.8) Kuttler’s Method


1. No resorption - subtract 1 mm According to Kuttler, canal preparation should terminate at

Working Length Determination


2. Periapical bone resorption - subtract 1.5 mm apical constriction, i.e. minor diameter. In young patients, average
3. Periapical bone + root apex resorption - subtract 2 mm distance between minor and major diameter is 0.524 mm where
Advantages of radiographic methods of working length as in older patients it 0.66 mm.
Cleaning and Shaping
determination
1. One can see the anatomy of the tooth Technique
2. One can find out curvature of the root canal • Locate minor and major diameter on preoperative
3. We can see the relationship between the adjacent teeth and Apical 15.3: Anatomy
radiograph
Fig. Minor apical diameter
Principles of Cleaning Principles of anatomic
Shaping structures. • Estimate length of roots from preoperative radiograph.
•  Presence of clean •  Purpose: facilitate cleaning
Fig. 15.2: Usually the reference point is highest point on incisal
Disadvantagesedge ofofradiographic methods of working length • Estimate canal width on radiograph. If canal is narrow, use
anterior teeth and cusp tip of posterior teeth
dentinal shavings and provide space for placing
determination 10 or 15 size instrument. If it is A
of average width, use 20
Apex
obturating 1.
materials
Varies with different observers or 25 size instruments. If canal is wide, use 30 or 35 size
•  Color of the irrigant •  Maintain/develop a
2. Superimposition of anatomical structures instrument.
B Apical constriction
•  Canal enlargement 3 files continuously3. taperingTherefore
funnel
Two-dimensional in case
viewof teeth
of with undermined cusps and
three-dimensional fillings,
object • Insert the selected file in the canalCup toRoot canal
the estimated canal
sizes beyond the first from canal 4.orifice totheythe
Cannot should
interpret
apex be reduced
if apical considerably
foramen before
hasaccess
buccalpreparation.
or lingual exit length and take a radiograph. D Cementum
5. Riskshape
•  Maintain original of radiation
Anatomic of apex
rootexposure
is “tip or end of root determined morpho- • If file is too long or short by moreE thanDentin
1 mm from minor
instrument 6. Time logically”.
consuming
canal diameter, readjust the file and take
F second
Apical radiograph.
foramen
7. Limited accuracy
•  Maintain apical foramenRadiographicin itsapex is “tip or end of root determined radio- • If file reaches major diameter, subtract 0.5 mm from it for
Do not correlate graphically”.
well with original position
Grossman Method/Mathematic Method of younger patients and 0.67 for older patients.
debridement •  Keep the Working
apical opening Length
Apical as Determination
foramen is main apical opening of the root canal which
Advantages
It is basedmayonbesimple
small as possible located away from anatomic formulations
mathematical or radiographic apex. to calculate
the working Apical constriction
length. In this, anapical
(minor instrument
diameter) isisapical portion into the • Minimal errors
inserted
of root is
canal, stopper canal havingto
fixed narrowest diameter. It ispoint
the reference usually 0.5
and-1 mm radiograph • Has shown many successful cases
is taken. Theshort of apical foramen
formula (Fig. 15.3). The
to calculate minor length
actual of the tooth • Rapid development of increases the chances of retaining
diameter widens
apically to foramen, i.e. major diameter (Fig. 15.4). obturating material.
is as follows:
Cementodentinal junction is the region where cementum Fig. 15.4: Anatomy of root apex
and dentin
Actual length of thearetooth
united, Apparent
the point atlength
which cemental
of toothsurface
in radiograph Disadvantages
_______________________________ _____________________________________________
= apex
terminates at or near the of tooth. It is not always necessary
Actual length of the Apparent length of instrument • Time consuming and complicated
that CDJ always coincide with apical constriction.
instrumentCDJ ranges from 0.5 - 3 mmin radiograph
Location of
short of anatomic apex (Fig. 15.5). • Requires excellent quality radiographs.
4
204

SIGNIFICANCE OF WORKING LENGTH


• Working length determines how far into canal, instruments
ally”. of root canal system

iographic apex is “tip or end of root determined radio-


hically”.
Fig. 17.3: Three-dimensional obturation
cal foramen is main apical opening of the root canal which
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of root canal system

be located away from anatomic or radiographic apex.


cal constriction (minor apical diameter) is apical portion
oot canal having narrowest diameter. It is usually 0.5 -1 mm
t of apical foramen (Fig. 15.3). The minor diameter widens
ally to foramen, i.e. major diameter (Fig. 15.4).
Cementodentinal junction is the region where cementum Fig. 15.4: Anatomy of root apex Fig. 17.2: Portals of communication of root canal
dentin are united, the point at which cemental surface system and periodontium

inates at or near the apex of tooth. It is not always necessary

Mechanical Objectives
CDJ always coincide with apical constriction. Location of The mechanics of cleaning and shaping may be viewed as
an extension of the principles of coronal cavity preparation
ranges from 0.5 - 3 mm short of anatomic apex (Fig. 15.5). to the full length of the root canal system. Schilder gave five Fig. 17.4: Prepared root canal shape should

(Schilder)
mechanical objectives for successful cleaning and shaping 30 be continuous tapered
years ago. The objectives taught the clinicians to think and
NIFICANCE OF WORKING LENGTH operate in three dimensions.
1.  given
The objectives RC by preparation
Schilder are: should
Working length determines how far into canal, instruments 1 . The root canal preparation should develop a
develop a continuously
continuously tapering cone (Fig. 17.4.) : This shape
an be placed and worked. tapering
mimics the natural cone
canal shape. Funnel shaped preparation
t affects degree of pain and discomfort which patient will of canal should merge with the access cavity so that
2.  Making preparation
instruments will slide into the canal. Thus in multiple
access cavity
xperience following appointment by virtue of over and planes
and root canal which
preparation introduces
should the
form a continuous
channel.
nder instrumentation. concept of “flow”
2. Making the preparation in multiple planes which
f placed within correct limits, it plays an important role 3.  the
introduces Making
concept ofthe canal
“flow”: narrower
This objective preserves
the natural curve of the canal.
n determining the success of treatment. apically and widest coronally
3. Making the canal narrower apically and widest
Before determining a definite working length, there should Fig. 15.5: CDJ needs not to terminate at apical constriction. 4.  ToAvoid
coronally: create a transportation
continuous tapers up toof thethird
apical
CDJ needs not
It can beto0.5-3
terminate at apical
mm short of the constriction.
apex which creates the resistance form to hold gutta-percha in
foramen
be straight line access for the canal orifice for unobstructed the canal (Fig. 17.5).
0.5 – 3 mm short of the apex 4. Avoid 5. transportation
Keep the of the foramen:
apical opening asbe
There should
penetration of instrument into apical constriction. gentle and minute enlargement of the foramen while Fig. 17.5: Diagrammatic representation of objectives
Once apical stop is calculated, monitor the working length cleaning and underfilling. Apical leakage may occur into maintaining small as(Fig.
its position possible
17.6). of canal preparation
232
periodically because working length may change as curved uncleaned and unfilled space short of apical constriction.
anal is straightened. It may support continued existence of viable bacteria and
Failure to accurately determine and maintain working length contributes to the periradicular lesion and thus poor success
may result in length being over than normal which will lead rate.
o postoperative pain, prolonged healing time and lower
uccess rate because of incomplete regeneration of Working Width
ementum, periodontal ligament and alveolar bone. Working width is defined as “initial and post instrumentation
When working length is made short of apical constriction horizontal dimensions of the root canal system at working length
t may cause persistent discomfort because of incomplete and other levels”.
201

Biological Objectives Preparation Techniques

Remove the pulp tissue, bacteria and Apical to Coronal Coronal to Apical
their by-products from the RC Step-down
Conventional
Crown-down pressureless
Step-back
Hybrid technique
Modified step-back
Modified double flare
Passive step-back Balanced force technique

5
1/22/19

Watch Winding
•  Back-forth oscillation, right 4. Carve: Carve is performed with reamers to do shaping of

Textbook of Endodontics
the canals. In this a precurved reamer as touched with
and left dentinal wall and canal is shaped on withdrawal.
•  Angle of rotation 30o – 60o 5. Smooth: It is performed with files. In this circumferential
motion is given to smoothen the canal walls.
•  Efficient with K-type 6. Patency: It is performed with files or reamers. Patency means
instrument that apical foramen has been cleared of any debris in its
path.
•  Less aggressive
BASIC PRINCIPLES OF CANAL INSTRUMENTATION
1. There should be a straight line access to the canal orifices
(Fig 17.19). Creation of a straight line access by removing
overhang dentine influences the forces exerted by a file
in apical third of the canal.
Fig. 17.17: Rotation of file in watch winding motion
2. Files are always worked with in a canal filled with irrigant.
Therefore, copious irrigation is done in between the
instrumentation, i.e. canal must always be prepared in
wet environment.
3. Preparation of canal should be completed while retaining
its original form and the shape (Fig. 17.20).
4. Exploration of the orifice is always done with smaller
file to gauge the canal size and the configuration.

Fig. 17.18: Watch winding and pull motion

Watch Winding and Pull Motion


In this, first instrument is moved apically by rotating it right
and left through an arc. When the instrument feels any resistance,
it is taken out of the canal by pull motion (Fig. 17.18). This
technique is primarily used with Hedstroem files. When used Fig. 17.19: Straight line access to root canal system
with H-files, watch winding motion cannot cut dentin because
H-files can cut only during pull motion.

Motions of Instruments for Cleaning and Shaping


For effective use of reamers and files, following six different
motions are given.
1. Follow: It is performed using files during initial cleaning
and shaping. In this file is precurved so as to follow canal
curvatures.
2. Follow withdraw: It is performed with files when apical
foramen is reached. In this simple in and out motion is given
to the instrument. It is done to create a path for foramen 6
and no attempt is made to shape the canal.
3. Cart: Cart means transporting. In this precurved reamer is
passed through the canal with gentle force and random touch