Osce aid.

Content …
1 Instruments and apex locator ..by heba radwan

2 Endo diagnosis .. by afnan ali

3 Rubber dam .. by hasan alsadi

4 Access cavity .. by balqees alsheik theeb

5 Step back .. by balqees alsheik theeb

6 RCF.. by hasan alsadi

7 Pulp protection .. by taimaa huussien

8 Temporization .. by taimaa huussien

9 Endo radiology .. by nada adel

 Endodontic Instruments
Instruments for access cavity preparation:
o Basic instrument pack
o Front surface mirror
o Endodontic locking tweezer
o DG16 endodontic explorer
used for locating and opening of canal orifices
o Briault probe
o Long shank excavator
o Surgical hemostat
o Millimeter ruler)‫(الزم الصفر يكون واضح فيها‬
o Amalgam plugger
o Flat plastic
BURS:
1. Endo Z bur
-used for deroofing, The Endo Z bur's lateral
cutting edges are used to flare, flatten, and
refine the internal axial walls.
-it has non cutting tip, can be safely placed directly on the
pulpal floor without a risk of perforation.
-tapered and safe-ended carbide bur
2. Endo Access bur
- a Stainless Steel bur with a special diamond coating to
reduce gouging.
- This bur’s tip matches round bur sizes for
initial penetration, while its diamond shaft
flares the pulp chamber and the canal walls
3. Long shank tungsten carbide burs are used for
deroofing.
4. Gates glidden drills:
- low speed burs
- a set of 6 sizes. (The No. of bands refer to the
size).
- Gates glidden diameter: 0.5-1.5 mm (we increase
0.2 mm for each size).
- We use sizes from 1-4 because 5-6 will be aggressive.
 Gates Gidden uses:
a. Preparation of the coronal two-thirds of molar
canals, in coronal flaring technique.
#NOTE: coronal flaring is better because you
remove all the infection, hence the infection is
concentrated in the coronal part of the tooth.
b. Removing gutta percha from a canal
c. Retrieval of broken instrument

Cross-section:
o Square: K-file
o Triangular: flexofile
o Rhomboid: K-flex
o Circular: Hedstrom file
o S-shaped: Unifile

Clinical use:
o Files can be both
filed and reamed.

o Reamers can only be

reamed
K-reamers: not highly twisted K-files: highly twisted

.
• K-Files:
1. the length of their cutting segment = 16 mm.(standard)
2. the taper = .02 (which means that the instrument diameter increases by
0.02 mm with each 1 mm back from instrument tip).
example: if I want to measure the diameter on the top of cutting
segment:
16 * 0.02 = 0.32 mm
 3. they have different sizes with different colors.
#NOTE: from size 0.15 to 0.60 we increase 0.05 mm for each size,
after that we start to increase 0.10 mm.
4. they have different lengths (19,21,25,28,31 mm); because we have
different root canal’s length, the length of canine canal = 25-31mm.

Q: size 30 K file means the tip of the file has a diameter of 0.3mm, so if
we moved 2mm away from the tip, what would the diameter be? to
solve this question, you have to remember that All K files have a standard
taper of 2% which means the file increases in diameter 0.02mm for every
1mm of length, so the answer is 0.34 mm

Why You Read Before Going Bed

White, yellow, red, blue, green, black
Spreaders and pluggers are significant instruments in obturation:
.
 Electronic root canal length measuring devices (Electronic apex
locators (EALs)):

o Based on this fundamental principle, these

resistance based devices should be able to
detect the periodontal tissue at the ‘apical
foramen’.
o Clearly, they do not assess the position of
the root apex and the name ‘electronic
apex locator’ is not appropriate;
‘electronic apical foramen locator’ or
‘electronic root canal length measurement
device’ (ERCLMD)as a generic name
would be more appropriate.
How does it work?
Two cords are connected to the EAL device: on the opposite ends, one
has a metal clip that will contact the patient’s lip and the other one has a
hook that will be attached to an endodontic instrument as it advances in
the root canal. The EAL alerts the operator with an audible and/or visual
signal when it finds the tip of this instrument is at the adequate length.

•Only when the very tip of the file protrudes through the foramen
the EAL indicate that the proper length has been reached

Advantages using EAL reflex:

o Accurate, easy and fast of using
o Reduction of x-ray exposure especially for multi canaled tooth like in
molars if you got a false reading, you’ll repeat it several times for
each canal.
o Used in pregnant women or in patients with gagging as you’re
avoiding repetitive images.
o Useful in detecting fractures and resorption
o Helpful in detecting perforations
o Useful in cases where the apical constriction is a distance from the
root apex
Classification of electronic apex locators (EALs):
We have 7 generations; the 7th is the best because it doesn’t give us
mistakes regardless of having electrolytes or irrigants in the canal, so it is
very accurate.

You’ve trouble with Your apex locator? No accurate readings? Always

check the following:
• If the unit is witched off
• If the leads are not all connected and the lip hook is not in
place
• If batteries are not fully charged
• If the canal is too dry, as it should be wet

Root canal → should be wet

Chamber → is usually dry
The IPEX II is the apex locator we use in the clinic and it is generation
4 apex locator (according to Dr. Eyad Alkhateeb).

➢ We use it with radiographs because:

• Unpredictability of position of apical constriction
• Superimposition of anatomic structures (in the radiograph so the
apex locator helps in this case).
• Risk of ionizing radiation (when using radiograph)
• Radiograph is technique sensitive in both its exposure and
interpretation

➢ Radiograph is two-dimensional image of three dimensional

structure The meter in the apex locator doesn’t move when:
• Calcified canal
• Obstructed canal
• Dry canal
• Root form restricts navigation
• Apex surrounded by pustule
➢ The meter overreacts as the file enters the canal when:
• Pulp chamber is wet
• Large foramen
• Perforation
• Small file
• Pulp in canal
• File touching a metal restoration
• Leaking restoration

➢ Erroneous (wrong) readings are given when:

• Retreatment with silver posts
• Large lateral canal
• Perforation
• Incomplete apex

.
This image shows the false positives and negative responses of vitality
pulp testing:

Other endodontic testers:

Blood flow of the tooth is assessed by laser Doppler flowmetry, while the
innervation is tested by pulp testers like cold test or electric pulp
test.

1. Electric pulp tester:

The electric pulp tester is an instrument used to
stimulate a response by electric excitation of the neural
tissue within the pulp. The electric pulp tester; doesn’t
tell you the status of the pulp tissue
(Cannot tell us if it's reversible or
irreversible pulpitis)
it only tells if the tooth is vital or non-vital (Either black or white no grey
in between).
• What to expect?
We tell the patient that they will feel a
slight tingling sensation.
• Media used:
We need to place a conducting media like
toothpaste on the tooth.
• How does it work?
Has similar working mechanism as the apex locater; a lip clip is
applied over patient’s lip or the patient is asked to hold the metal part
of the tester and another electrode is applied on middle third of the
facial surface of the tooth. The test is performed on the control tooth
first and then on the test tooth. The patient is instructed to report a
response from the test tooth that mimics the response from the control
tooth.
2. Laser doppler flowmetry:
This measures the blood flow inside the tooth, and it’s mainly used in the
research field.
3. Pulse oximetry:
The same device that measure the oxygen saturation. Also mainly used in
research.
Both measure the true vitality and not the sensibility, unlike the
thermal and electric pulp test which measure the sensibility, which is a
nerve supply.
Rarely used.
4. Transillumination and staining
It’s basically using high intensity light with stains to detect any
fractures or craze lines or anything that might be separating the tooth.
5. Tooth sloth to detect fractures
 Endodontics Diagnosis
QUIK REV:

Data analysis:
Differential
Clinical Special Definitive
Listen Ask diagnoses/prov
examintaion investigation isional diagnosis
diagnosis
 **It is best to test the adjacent teeth and contralateral teeth (control teeth) first so
that the patient is familiar with the experience of a normal response to cold.
• Normal pulp: The pulp is symptom free and normally responsive to pulp testing (mild
or transient response to thermal cold testing, lasting no more than one to two seconds after
the stimulus is removed).
• Reversible pulpitis: Indicates that the inflammation should resolve and the pulp return
to normal following conservative removal of the irritant (RCT is not required).
- There are NO radiographic changes in the periapical region of the suspect tooth and
the pain experienced is NOT spontaneous.
- Causative factors may include caries or deep restorations.
- Discomfort is experienced when a stimulus such as cold or sweet is applied and goes
away within a couple of seconds following the removal of the stimulus.
- Treatment: removal of the cause (caries).
 ➔Dentine hypersensitivity: It is not an inflammatory process but all of the
symptoms of this entity mimic those of a reversible pulpitis.
- Results from exposed dentin, without evidence of pulp pathosis.
- Sharp pain of short duration in response to a stimulus (thermal, evaporative, tactile,
mechanical, osmotic, or chemical).
- The hydrodynamic theory: The fluid movement within dentinal tubules stimulates the
odontoblasts and associated fast-conducting A-delta (A!) nerve fibers in the pulp,
which in turn produce sharp, quickly reversible dental pain.
- Treatment: use fluoride tooth pastes, and use splints made of acrylic that will cover
the labial surface, it's called gingival mask or gingival veneer (is used for both
aesthetics and to decrease sensitivity) , In severe cases surgery is performed.
• Symptomatic irreversible pulpitis: Indicates that the vital inflamed pulp is incapable
of healing.
- Characteristics may include sharp severe pain upon thermal stimulus, lingering pain
(often 30s or longer after stimulus removal), spontaneity (unprovoked pain) and
referred pain. Sometimes the pain may be accentuated by postural changes such as
lying down or bending over. Over-the-counter analgesics are typically ineffective. Pain
disturbs sleep.
- Causative factors may include deep caries, extensive restorations, or fractures exposing
the pulpal tissues.
- No pain or discomfort to percussion.
- Initial stage: no radiographic changes in the periapical region. However, at advanced
stages, widening of the periodontal ligament may become evident on the radiograph.
- Treatment: perform RCT or extraction.

• Asymptomatic irreversible pulpitis: Indicates that the vital inflamed pulp is incapable
of healing and the RCT is indicated.
- No clinical symptoms and usually respond normally to thermal testing but may have
had trauma or deep caries that would likely result in exposure following removal.
• Pulp necrosis: Indicates death of the dental pulp. The pulp is nonresponsive to pulp
testing and is usually asymptomatic (but sometimes the patient might feel pain when he
eats something hot due to expansion of gases that are byproducts of necrosis in the canal).
 - Pulp necrosis by itself does not cause apical periodontitis (pain to percussion or
radiographic evidence of osseous breakdown) unless the canal is infected.
- Some teeth may be non-responsive to pulp testing because of calcification, recent
history of trauma, or simply the tooth is just not responding. This is why all testing
must be of a comparative nature.
- Treatment: RCT or extraction.
• Chronic hyperplastic pulpitis (Pulp polyp): A form of irreversible pulpitis,
results from the growth of chronically inflamed young pulp into the occlusal surface.
- Clinically appears as red cauliflower-like overgrowth in a large occlusal exposure.
- Rich vascular supply, adequate exposure for drainage and tissue proliferation.
- Usually asymptomatic but can occasionally be associated with clinical signs of
irreversible pulpitis (spontaneous lingering pain).
- Treatment: Extraction under LA when it’s badly distracted or sometimes we
can preform RCT with crown set after you cut hyperplastic tissue to get access to the
canals.

• Previously treated: Indicates that the tooth has been endodontically treated and the
canals are obturated with various filling materials other than intracanal medicaments.
- The tooth typically does not respond to thermal or electric pulp testing.

• Previously initiated therapy: Indicates that the tooth has been previously treated by
partial endodontic therapy (e.g., pulpotomy, pulpectomy).
- Depending on the level of therapy, the tooth may or may not respond to pulp testing
modalities.
• Normal apical tissues: Teeth with normal periradicular tissues that are not sensitive to
percussion or palpation testing (asymptomatic).
- Radiographically: The lamina dura surrounding the root is intact, and the periodontal
ligament space is uniform.
• Symptomatic apical periodontitis: R e p r e s e n t s i nflammation of the apical
periodontium, producing clinical symptoms including a painful response to biting
and/or percussion or palpation. (tenderness to percussion and palpation)
- Tenderness to percussion may also be a result of impact trauma, traumatic occlusion,
orthodontic tooth movement, or maxillary sinusitis. (So you need to be careful and
exclude all other factors that might cause severe pain to percussion before.)
- Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp
and RCT is needed.
- It might or might not be associated with an apical radiolucent area. (radiographic
changes depending upon the stage of the disease there may be normal width of the
periodontal ligament or there may be a periapical radiolucency).
• Asymptomatic apical periodontitis: Inflammation and destruction of the apical
periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not
produce clinical symptoms (asymptomatic).
- The tooth does not respond to pulp vitality tests and it is generally not sensitive to
biting pressure but may “feel different” to the patient on percussion.
- RCT is needed.
• Acute apical abscess: An inflammatory reaction to pulpal infection and necrosis
characterized by rapid onset of spontaneous pain (it can just formed overnight).
- Swelling will be present intraorally. The facial tissues adjacent to the tooth will
almost always present with some degree of swelling as a result of pus formation.
- The affected tooth is usually extremely tender to percussion and the associated soft
tissues are tender to palpation.
- The affected tooth will not respond to any pulp vitality tests and will exhibit varying
degrees of mobility due to extrusion out of the bony socket.
- The patient often experiences malaise, fever and lymphadenopathy, So when we have
systemic manifestations we prescribe antibiotics. (Amoxicillin 500 mg ,3X/d)
- Radiographs can reveal anything from a widened periodontal ligament space to an
apical radiolucency.
 Swelling from the anterior palate usually is associated with an abscess
originating from the lateral incisor because its root usually curves palataly.

- Treatment: drainage through the tooth or incision and drainage.

- The immediate task is to relieve pressure by establishing drainage, and in the
majority of cases this can be achieved by first opening up the pulp chamber.
- The tooth should never be left open (between appointments) for drainage.
The microbial flora of the canal will be changed, making treatment more difficult and
lowering the long-term prognosis.

• Chronic apical abscess: An inflammatory reaction to pulpal infection and necrosis

characterized by gradual onset, little or no discomfort, and the intermittent discharge of
pus through an associated sinus tract.
- The affected tooth is generally asymptomatic.
- This tooth will not respond to pulp vitality tests.
- Radiographically, the tooth will exhibit an apical radiolucency.
- The tooth is generally not sensitive to biting pressure (not tender to percussion) but
can “feel different” to the patient on percussion. This entity is distinguished from
asymptomatic apical periodontitis because it will exhibit intermittent drainage
through an associated sinus tract.
- Treatment: RCT or extraction.
To identify the source of a draining sinus tract when present, a gutta- percha (size 25)
cone is carefully placed through the stoma or opening (sinus tract) until it stops and a
radiograph is taken. As you can see in the radiograph above the GP will end around
the root apex that cause the problem.

• Condensing osteitis: Diffuse radiopaque lesion representing a localized bony reaction

(overproduction of bone in the periapical area) to a low-grade, long-standing
inflammatory stimulus (that body can deal with), usually seen at apex of tooth.
- The associated tooth may be carious or contains a large restoration.
- The pulp of the involved tooth may be chronically inflamed or non-vital.
- Treatment: RCT or extraction.
- The radiopacity may or may not respond to endodontic treatment.
Diagnosis of pulpal pathosis

Diagnosis of periapical disease

Dental pain: History

Dental pain: examination and investigations

 Rubber dam isolation
• Why we should use it?
Infection control , Patient Safety , Patient Comfort, Moisture control,
Increased visibility & access (when you see you know but when you
don’t see you guess ) , “Dento-Legal” reasons , Improved treatment
outcome( We do aseptic procedures because we want our treatment
outcome to be more predictable (more survival rates).
• Rubber dam equipment
1- Rubber dam sheet. 2- Rubber dam clamps. 3- Rubber dam forceps. 4-
Rubber dam frame. 5-Rubber dam punch. 6- Rubber dam template. 7-
Scissors. 8- Lubricant. (I can replace it with Vaseline) 9- Dental floss.
10- Rubber dam napkin. 11- Excavators & Plastic instruments.
Rubber dam sheet: 1-Size: 5x5 (we commonly use this size, or
4x4 size), 6x6 or rolls. 2-Material: Latex or non-latex. (You have
to check for latex sensitivity) 3-Color: Green, purple, blue. 4-
Thickness: Extra heavy, heavy, medium (commonly used), and
light (can tear easily), Available as sterilized (every sheet packed
separately) and non-sterilized (many sheets packed together)
sterilized used in surgery & medium non sterilized used in
operative dentistry .
Rubber dam punch: It has to completely penetrate the rubber
dam; the hole should be exactly circular.
*Forceps; to carry the clamps
*Napkin; put around the mouth before applying the rubber dam, to
absorb the saliva coming out of the patient’s mouth
*Lubricant; to lubricate the lips to prevent dryness especially in
long procedures mouth edges may crack.
*Rubber dam template; to guide you in determining the holes
sizes and location
*Rubber dam frame: to hold the sheet in place, so that the
concavity is inwards at the side of the chin and convexity is
outwards and at the nose it should be open.
Metallic frame is the one that we have in the clinics. It is U-
shaped, there are many types:

The doctor prefers this type of

frames. Because it’s also plastic so
This is a plastic version, but
you don’t have to remove it when
the doctor doesn’t prefer it
taking an X-ray, so saliva won’t drip
because it’s hard on the
from the patient’s mouth while on
patient’s lips.
the way to the Xray room.
Clamp forceps: -Forceps is used to apply the clamp on the tooth
such as ivory, Brewer, Uni of Washington forceps.
Rubber dam clamps: every clamp is composed of a bow that
connects two jaws and every jaw has two prongs
(4 prongs) and a hole.

Clamps can be made from different materials, but they are usually
made from stainless-steel.
We have wings and wing-less clamps, Straight prongs at the same
plane and inverted prongs slightly sub-gingivally.
 To make sure you have right application on the tooth; you need to
have 4 points of contact, and it has to be in the undercut. - You
always have to be at the level beyond the cervical bulge (At the
level of CEJ) - It is difficult to place clamps on prepared teeth for
crown because the undercut is missing.
Winged clamps are more preferable. (because winged clamps help
in holding the rubber dam sheet).
There are different types of clamps other than stainless steel:
1- Disposable clamps 2- Soft clamps (The doctor prefers to use
these clamps when she applies rubber dam on a tooth that has a
newly prepared crown or porcelain tooth).
- We are going to mention the suitable clamps for each tooth:

You should be able to distinguish between 12A & 13A (The long part of the clamp should
follow the buccal surface of the tooth) *12A is used for upper left and lower right teeth
(remember: ‘12’ is an even number, and it is used for teeth in quadrants number ‘2’ and ‘4’)
/ (‘13’, the numbers ‘1’ and ‘’3’).
Extra items:
1-OraSeal: a very good material that blocks out any leakage around
the tooth margin and seal holes in rubber dam. “You can use
Teflon instead of OralSeal” 2-Wedjets: rubbers to hold and anchor
rubber dam sheets. “You can use 2 wedjets instead of clamps” 3-
Wedges: use within adjacent. 4-Rubber dam strips: by cutting
 rubber dam sheet and insert it between the teeth to give anchorage
5- -Dental floss: It is really important to floss your clamp from
both ends because in case the clamp drops into the oral cavity, you
can pull it with the floss and this will prevent swallowing it.
Wingless clamps -it can’t really hold RD so you have to place it
first on the tooth and RD is then placed from underneath the
clamp, t’s not safe; it may get exhausted and fail (break) from the
bow area inside the patient‘s mouth and he may swallow it or
inhale it as well. To save the situation, the clamp should be
FLOSSED so you can pull it out if it breaks. AVOID placing
clamp in mouth without RD or floss.

Rubber Dam Techniques for Endodontics:

Single tooth isolation: Use it after you have done Cuff Technique: -It is multiple teeth isolation by overlapping
the investigation “your coronal temporary restoration” and holes with no RD in between teeth so it will make it easier to place
then you can place RD on the tooth, BUT if the tooth has matrix band. -I can use it at investigation or initial stages of
missing walls you can’t place the clamp on the same tooth. endodontics treatment where you have to remove the existing
Also imagine when you make access cavity on this tooth, the restoration, carries, or cracks. and it’s done by isolating the one
handpiece will keep hitting the bow and that’s WHY dentists
tooth distal to the tooth which I’m working on because I can’t
don’t use RD because they think that its restricted space for
working.
really remove the things we mentioned while covering the other
teeth, so it provides more space for working so the handpiece can
move freely without hitting the bow so you will have more room to
work comfortably and don’t feel restricted. -You can easily see
position of the tooth and its relation with adjacent teeth in the arch
so it makes doing access cavity easier and that’s another reason of
WHY dentists don’t prefer to use RD they think that they will can’t
control the orientation of the handpiece and bur and also they think
that they can’t determine the exact position of tooth in the arch. -It
allows you to probe (check) gum, and to check proximal surfaces
after removing the old restoration to check if the tooth has cracks
reaching the root which would mean the tooth needs extraction and
RCT is pointless. Note: After I finish the initial stage using cuff
technique, I now have the temporary restoration and I have all the
walls which mean I can use single tooth isolation in the next
appointment like we mentioned before. -It helps to locate the root
canal clearly at radiograph by having the clamp away from
overlapping on the tooth I work on so (its appear radiopaque).
 Multiple tooth isolation: Multiple holes separating not overlapping so you
may find it hard placing the matrix band in this technique, because there is RD
between teeth. -Use it when there is missing teeth.
Use template to mark the teeth wanted for isolation helps to make holes
accordingly.
HINTS

*Orthodontic brackets / arch wires -You can use RD on patients with braces on.
*RD not well adapted to the tooth -Usually RD placed underneath the clamp. -
Especially in the lower molars, where saliva might enter lingually, you can simply
open the clamp and let the RD slide into the tooth and then clamp over it.
*RD clamp unstable on the tooth - Due to the lack of a sufficient under cusp in the
tooth you can bond resin composite on buccal and lingual surfaces.
Be sure to isolate the correct tooth -Especially while working on the lower anterior
teeth, they all Look the same so they can be very tricky. Record keeping -Very
important to record which clamps you have placed so you can save the time and
don’t have to redo your testing.
*Rubber Dam Removal -Depend on what type of RD isolation we use: 1-Cuff
technique: just remove the clamp and it will completely come out. 2-Multiple
isolation: you must cut interproximal RD strips by forceps otherwise your
temporary filling can be dislodged.
When RD should be placed?
Stages of Endodontic Treatment:  Examination and diagnosis (only in
heat test) , Tooth investigation, Access cavity preparation, Temporization
by cuff technique ,Instrumentation and chemical irrigation , Intracanal
medicament , Root canal filling , Definitive restoration (composite
restoration= multiple isolation technique)
Rubber Dam for Everything -All restorative dentistry including posts.
Trauma Management (Emergency + Subsequent): at gingival bleeding use
cuff technique.
Q
- relative contraindication of RD
1.Partially erupted teeth, third molars and rotated teeth, in the past we couldn’t put retainers for
them but now there are very thin clamps especially for these cases.
2.Asthmatic patients and patients with gag reflex, now there are smaller rubber sheets that can
provide isolation without closing all the oral cavity. With gag reflex you may use anesthetic
spray on the palate so the sensation decreases, and the patient will not feel he wants to vomit
when applying the rubber dam.
3.Badly destructed teeth, you can put auto matrix and build a wall then you can apply the
clamp.

- According to Rubber dam punch

Hole size range from 0.7 to 2.0 mm.
There are two types: Ivory punch and Ainsworth punch (the one we use)

❖ Important reminders:
✓ The bow should be on the distal side of the tooth
✓ Prongs must engage undercuts on the tooth surface. The clamp
shouldn’t rock
✓ There should be a four-point clamp-to-tooth relationship
✓ The metal rubber dam frame should be removed before taking a
radiograph
✓ Always place cotton rolls in the buccal/labial sulcus before placing the
rubber dam as it helps in the retraction of the surrounding tissues and
increases visibility while placing the rubber dam
✓ Avoid placing the clamp in the mouth without a rubber dam
✓ If you’re testing a clamp, then you floss on both sides of the clamp.
Remove the floss once the rubber dam is placed
✓ When using the multiple isolation technique and the cuff technique, the
clamp is placed on the most posterior tooth to be isolated
✓ When placing a restoration, isolate a tooth anterior and a tooth
posterior to tooth you are working on.
✓ Excavators and plastic instrument are used to release the clamps and
relieve the rubber sheet. The idea behind using these instruments is that
you need an instrument with a blunt edge, so as not to tear the RD
(that’s why we don’t use a probe). DON’T use your fingers!
 Steps of access cavity preparation

Pulp Pulp horns Canal Access outline Steps of access cavity

chamber
Maxillary Wider MD 3 %100 -rounded triangular 1-start with high speed round bur
central than BL Single (base into incisal and perpendicular to palatal surface exactly
incisors canal apex into cingulum) above cingulum →rounded cavity
- width of base 2-enter till half BL or drop in
determined by M and D 3-straight fissure bur or endo z with
horns changing direction to go parallel to
tooth access to remove roof of pulp
chamber
4-draw outline of access cavity
5- A lingual shoulder (lingual shelf of
dentin that extends from the cingulum
to a point
approximately 2 mm apical to the
orifice) usually is present and prevent
direct access so files deflects labially so
ledge or perforation might happen so it
must be removed by GG to gain access
to the lingual wall of the root canal and
allow the file to gain equal access to all
walls of the canal.
Max Wider MD 2 or none Normally Rounded triangle or Same as Max CI
Lateral than single but oval if pulp horns not
incisors BL(similar variation prominent
to Max CI reported
but
smaller)
Max Wider BL Single or Almost oval Using high speed round bur above the
canines than MD none 100% cingulum till drop in then expand the
single outline and remove lingual shoulder by
-its root GG
inclined
distally so
it helps in
knowing R
or L
Mand Wider BL -95% Oval( small pulp horns) -we remove lingual shoulder bcz 2nd
Central than MD single, 5% canal may be under it
and two canals *how to determine if one or 2 canals?
Lateral -If 2 roots 1-radiographs with angle
Incisors (B and L) 2-CBCT 3-Failure after proper RCT
Mand Wider BL -94% oval Same as max canine + we remove
canine than MD single Lingual shoulder to see if there's 2nd
-6% 2 canal
canals
-longest
root in
arch
Max 1st Wider BL 2 (buccal: One, two 2rootcanals➔oval(wide Starting point: central groove in the
PM than MD larger+higher or three BL, narrow MD, middle of an imaginary line connecting
and palatal) roots and centered MD between B+L cusp tips by High speed Endo-
exposure of canals cusp tips. access bur perp to occlusal surface until
the 3rootcanals ➔rounded drop-in Deroofing using the Endo Z bur.
buccal pulp triangle (base:buccal + (once we penetrate the roof of
horn before apex toward palatal the pulp chamber, we change the bur
palatal one to endo Z bur) in BL dimension
except when then Identification of all canal orifices
there is caries then Removal of cervical dentine bulges
in the buccal
cusp and the
pulp starts to
deposit a 3ry
dentin
Max 2nd same 2, buccal One root Acess cavity is oval in shape
PM larger with 1,2 or -if 2 canals, similar to 1st PM
3 canals -if one, smaller in size
Usually -if 3 orifices, triangular with base
wide toward buccal
single oval
canal
Mand 1st same 1st PM : 2, Access cavity oval in shape
PM buccal larger - Crowns tilted lingually relative to their
Roots so starting must be adjusted to
compensate for this tilt, can’t be as max
PMs to avoid lingual perforation
- starting is halfway up the lingual
incline of the buccal cusp on a line
connecting the cusp tips
start with high speed round bur for
about 1.5 mm then incline until drop in
then deerofing by low speed round etc..
Mand 2, lingual Same but less inclination so less
2nd PM larger adjustment (lingual half is more
developed than 1st PM)
- The starting for is one third the
way up the lingual incline of the buccal
cusp on a line connecting the buccal
cusp tip and the lingual groove between
the lingual cusps.

*can have 2 lingual cusps:

If equal size➔ access is centered MD
on a line connecting the buccal cusp
and the lingual groove between the
lingual cusp tips.
If MD cusp> DL cusp➔ lingual
extension of the oval outline form is
just distal to the tip of the ML cusp
notes about max 1st premolar

1-The floor of the pulp chamber is located just apical to the cervical line or at it so if reached
the cervical line during drilling and still I didn’t find the root canals, I would expect that I am
drilling deep and I should look for the canals in another place

2-Because of the mesial concavity of the root, the clinician must take care not to overextend
the preparation in that direction, as this could result in perforation.

3- if 2 orifices or 2 separate canals, the palatal larger, So if we wanna use post we put it in
the palatal canal

4- if 2 roots, same length but diff WL bcz B cusp higher as reference point

Notes about max 2nd PM:

1- Root(s) are close to or inside the maxillary sinus (As we move post teeth’s roots become
closer to a vital structures) so we should be extra careful during instrumentation and
irrigation because we don’t want for the debris , bacteria or the irrigation materials to
overcome the minor apical diameter of the root canal and get inside these structures (it may
cause an inflammation if it’s get inside the maxillary sinus)

* While at the mandibular arch as we move post, we become more concern about the
inferior alveolar nerve

2-demonstrate all Vertucci’s eight canal configuration

 Vertucci’s classification :

Max 1st PM Max 2nd PM Mand 1st PM Mand 2nd PM

One canal (center of 26% 75% 74% 97.5%
pulp chamber)
Two canals 69% 24% 25.5% 2.5%
(buccal and lingual)
Three canals 5% (2 buccal and 1 1% (2 buccal and one 0.5% zero
palatal) palatal)
 Basic instrumentation motions:

Filling motion -A linear motion (push and pull) effective during pulling. It aims to scrape the canal wall
(rasping -The most effective cutting motion especially with H-files.
motion) -Can pack debris apically which can block the canal or be pushed out of the apex.
Reaming motion -A clockwise, cutting rotation of the file. -Instrument is inserted until binding is encountered Then It is
rotated clockwise 180-360º and pulled out.
-we use the hand files as reamers (up and down straight strokes) but if we do this with a file:more
aggressive bcz curved canal, so acting more on the outer wall of the curvature and debris that is created by
filing getting packed inside the canal and getting pushed it toward the periodontal tissues causing abscess
or it may block the canal.
Watch winding -A reciprocating back and forth (clockwise/counterclockwise)
motion -Light apical pressure is applied to move the file deeper into the canal.
Balanced force -rotating the file certain degrees to engage dentine then half turn anti-clockwise with firm apical pressure
technique to cut dentine then rotate quarter turn clockwise to remove dentine
-advantages: remaining central in the canal, being conservative to tooth structure.
Anti-curvature -to avoid strip-perforation (which is perforation of the inside canal wall –the wall that is with the curvature
filiing as it’s thinner than the outside wall-)
-filling more on the outside wall and less on the inside wall.

Hand instrumentation techniques:

1-Standardized -entering with whatever file suites the canal then increasing the file size gradually, till
technique you reach the desired canal size
2-Crown down technique -can be with hand file but mainly with rotary instruments
3-Hybrid technique -any combination of any techniques because there is no technique sufficient to all cases
4-Step back technique -increasing file sizes in an apical to coronal direction
- after determining the working length of the canal to create room for my irrigant to
reach the apex because if it doesn’t reach the apex we won’t eliminate the infection
and to create a shape of the canal that is easy to operate

* Recapitulation: The introduction of smaller files to full WL during root canal preparation to
keep the apical area clean and patent and Helps prevent packing of dentinal debris and
loosening these debris to be flushed out with irrigation. Helps in maintaining the WL and
avoiding blockage
* Patency filing: passive placement of a small hand file (size 10 or smaller) 0.5-1mm through the
apical constriction during root canal preparation. aims to prevent blockage of the apical portion
of the root canal by debris created during instrumentation.
A potential drawback of patency filing is that infected debris might be extruded into the
periapical tissues, resulting in post-operative flare-up.
 Step back technique:
1-initial negotiation: -To reach the apical constriction by trying out files -e.g if we start with 15 then 20 then
starting from the smallest and going bigger until I 25, and at 25 we felt some
reach what is known as the initial binding file which resistance at the apex thus 25 is the
the first file that binds to the apical part initial binding file
-size 10 or 15 k-file is worked apically using a watch-
winding motion to ensure that the coronal portion of
the canal is negotiable (Not necessary to negotiate the
canal to the apex at this stage)
-Pulp chamber flooded with NAOCl to avoid blockages.
2-coronal flaring -By Gates Glidden burs without forcing into the canal -Start with GG size 2 to about 1⁄2 to
to avoid perforation (GG have non-cutting tips made 2⁄3 of the canal length.
of SS) -Use GG size 3 in the coronal 1⁄3 of
1-to create funnel shaped reservoir for irrigant the canal length.
2-to reduce stress on instruments -Use G.G. size 4 no more than 3mm
3-To remove the bulk of the infection coronally below the orifice of the canal.
instead of pushing it to apex -G.G. size 5 and 6 are used only to
enlarge the orifice of canals in
certain cases; e.g. long teeth or
severely curved canals)
3-Apical preparation -irrigant→ WL→ Apical gauging (identify initial apical -order to clean the apical part we go
phase binding file)→ insert it to WL with watch winding then three sizes larger to have THE
pull strokes → irrigate → next larger file to WL with MASTER APICAL FILE(the largest to
same motion → recapitulation → reach MAF reach full working length) so we use
size 40 file if Initial= 25
4-Step back phase 1-increase the file size for every 1 mm of WL → 2. -If MAF=40 go with size 45 file for a
Work against the walls until it is loose → 3. certain length that equals (the
Recapitulation → 4. Copious irrigation → 5. Repeat working length minus 1mm)
Until reaching middle third. -Size 50 will be 2 mm shorter than
WL
5-refining phase between each step we go with the master apical file
and round the edges with vertical push pull strokes to
achieve a taper canal
 RCF
How do we Prevent future infection?
1. Root canal filling
2. Coronal restoration
3. Reinforcing the patient's Oral hygiene, diet, etc. oral hygiene of the
patient must be up to high standards to prevent recurrent caries and
reinfection.
How do RCF’s help in this prevention process?
• RCF's are short term antibacterial only (the main antibacterial agents
are chemicals and irrigations that we use)
• The sealing of canals by RCF's is doubtful. (If they were able to do
that, we wouldn’t have put coronal restoration materials)
• Main function of a RCF is to FILL the canal space - and thus make
it less favourable for bacterial colonization to occur (having a seal also
prevents the entering of nutrients to the canal)
you should differentiate between SEAL & FILL:
- SEAL: Block or prevent entry into and exit out of the canal space
- FILL: Obliterate the canal space
• the quality of the coronal restoration is more important than the
quality of the RCF for apical periodontal healing.
 • POOR instrumentation & disinfections with a GOOD RCF would
probably be susceptible to failure!
Q/ why do we spend so much time and effort doing high quality
RCF’s?
A/ because they:
✔ Fill most of the space
✔ Create an unfavourable environment for bacteria to survive in
✔ Slow down the process of further infection and apical periodontitis
✔ An indication of the overall technical standard of the endo treatment

• RCF’s only slow down the onset of apical periodontitis.

• The RCF is not likely to have much effect on the outcome of the
current treatment.
• Only has a minor effect on how long the tooth may remain free of
infection.

Favourable conditions for bacterial colonization of root canals:

1) Space *co-colonizing organisms.
2) Low oxygen tension
3) Nutrients: pulp tissue remnants, necrotic debris, saliva, food,
inflammatory exudate …etc.

The main function of the RCF is to fill the space thus making the
environment less favourable for the colonization of bacteria to occur (by
filling “not sealing” the canal space we compromise the first condition that
bacteria needs to grow).
Also, if we obtained a good seal (coronal) and a good filling for the canals,
we would prevent oxygen and nutrients from reaching the bacteria thus
compromising these favourable conditions for its growth.

Aims of root canal fillings:

1. Apical “seal” (in the bottom part of the root canal) to keep tissue fluids
out of the canal, this “seal” aims to stop bacteria or endotoxins from
reaching the periapical region (prevent apical periodontitis).
2. Coronal “seal” to keep the bacteria out of the canal (stop reinfection),
The bacteria penetrate the canal from the coronal part of the tooth
 (coronal penetration of the bacteria), coronal “seal” keeps nutrients
out of the canal so bacteria cannot survive (like saliva, food
remnants…), and prevents flare up & swelling from happening between
appointments.

We need both coronal & apical “seal”, it was written “seal” in the slides
and the doctor used this word, but remember that this is not actual seal, it’s
only filling.
How do we asses RCF’s?
Clinically, we base our assessment (for RCF's) on the radiographic
appearance (we can only see how radiopaque the root filling material is
and where it has been placed - nothing else-).
• radiographs don’t tell us anything about the process of cleaning the
canals, I can’t tell if there is bacterial infection or not using a
radiographic image
• ALSO, Radiographs do not indicate the degree of filling of the root
canal SYSTEM.
• radiographs don’t really indicate the degree of filling of the root
canal system and don’t indicate the complex the root canal system
that we have.

First we asked why do we fill root canals, now we ask, when do we fill
the root canal? It’s done when all of the following have occurred:
a. Canal preparation and cleaning completed (remember that every
time you bring the patient back you have to irrigate)
b. There are no symptoms associated with the tooth (resolved before)
c. The canals can be dried
d. Mobility, percussion and palpation are normal
e. The draining sinus has healed - if present pre-operatively
f. Swelling has resolved - if present pre-operatively
g. Evidence of healing - if large lesion was present pre-operatively.

Techniques:
- Single Cone
- Lateral compaction / condensation Cold, Warm (the one we're using)
- Vertical compaction / condensation
- Solvent techniques Chloroform, eucalyptus
- Thermomechanical compaction (McSpadden)
- Thermoplastic Injection techniques Obtura, Ultrafil, etc. - Carrier-based
techniques Stainless steel, titanium, plastic
- Hybrid techniques (mix of the previous )
Lateral compaction + thermomechanical techniques
Lateral + vertical compaction
Core + injection
Core + vertical compaction

• Your technique must suit the canal preparation technique –must suit the
instruments/materials available –materials and techniques should suit each
other.

• there's no technique better than the other or a material better than

another. As long as we have good disinfection,
it really doesn’t matter that much if we used any material as long as:
1. It seals the canal apically and laterally (why laterally? Because we
have dentinal tubules everywhere around the canal and bacteria may
leak into each one of them)
2. Maintains good compaction on walls
3. Doesn’t shrink
4. Resists moisture
5. Bacteriostatic
6. Sterile or can be sterilized or disinfected
7. Radiopaque (so I can see it)
8. Shouldn’t stain the tooth structure
9. Shouldn’t irritate periapical tissue if it was overextended a little bit
10.Should be easily removed so we can remove it if the treatment
failed and we want to retreat again, otherwise we’ll be extracting
each tooth that fails in treatment.
*This ideal material doesn’t exist

• As a root canal filling, we have our basics which are:

1) Core material.
2) Cement (sealer), actually it doesn’t SEAL the root canal but it’s just a
common name to use.
 • The core material we’ll be using is:
1) Gutta Percha.
There are other core materials like:
2) Resilon and 3) silver points, but they are not used anymore
(old fashion).
However, many cements can be used
• The word gutta-percha comes from the plant's name in Malay, getah
perca, it is a rigid latex that comes from the sap of specific trees.
• It is affected by heat (softened), it can bend too.

The composition of the cone (point) is:

Gutta percha: 19 - 22 %
Zinc oxide: 60 - 75 %
Waxes and resins: 1 - 5 %
Metal sulfates: 1 - 17 %

- The highest content in these gutta percha points is “zinc oxide” NOT
gutta percha.

We have 2 types of points:

1) Standardized points, which come in match with the files (ISO sizes =
file sizes), same taper (2%)
2) Non- standardized points (accessory points), which match the size of
the spreader, spreaders can be finger spreader or hand spreader.

Ex: notice the f-f (fine-fine) accessory point

in the picture, it matches with the FF finger
spreader or the D11T hand spreader, f
accessory point & D11 …

Either standardized or non- standardized can be used-Alone (without

coating) or can be impregnated and/or coated by the following:
 1. Calcium hydroxide (Roeko): they believe it has an antibacterial
agent as an intra- canal medicament (although research shown that
it’s not true)
2. Glass ionomer (Active GP): increases the bonding between the GP
& canal walls and sealer (not really effective as well)
3. Methyl acrylate-resin: such as resilon
4. Bioceramics (Bio GP): (improved bonding & adhesion)

• It is believed that those coating materials can actually help the core
material in binding to the tooth structure and the cement used so the
whole thing can act as a “mono-block!” (Still not proven 100%)
• GP points aren’t sterile. We need to sterilize them or at least
disinfect them as we are trying to decrease no. of microorganisms as
much as possible. Placing these GP points in “sodium hypochlorite”
– the irrigant we are using – for like 60 seconds.
• Sometimes, expert people can place GP points while the canal is
filled with sodium hypochlorite, but this is too risky because we
might push the irrigant into the periapical tissues (out of the apical
foramen), especially if we don’t have a good apical seat (if the apical
constriction isn’t tight or narrow as it should be for any reason) and
we might end up with a hypochlorite accident!!
• Now, about cements, we have lots of types such as:
✔ Resin based (commonly used as there might be some bonds with
dentine)
◆ Zinc oxide-eugenol based
◆ Calcium hydroxide based
◆ Glass ionomer based
◆ Calcium-silicate/MTA based (bioceramics that coats bio GP,
mentioned above)
✖ Medicated cements (Are not used anymore bcz they contain
carcinogens)

Resin based:
1) “AH plus” - 2 pastes
2) “AH 26” - paste +powder
Suggested Simple Techniques, for filling the root canal (using GP points
(core material) and AH plus (cement):
1) Lateral Condensation:
➥ Standard technique
➥ Suits flared preparation technique perfectly
2) Obtura is used mainly for unusual cases, it is a thermoplasticised
injectable GP (paste-like form of GP) which can be loaded in a
gun-like instrument and inserted into canals, can be used in:
1) Wide canals, for young patients mostly
2) Apexification, also for young patients as they would have
large apical foramen
3) Internal resorption
4) Surgery

.
.
Instruments required for filling the canal:

1) Spreader (hand or finger) We need spreaders in lateral condensation

technique, They are smooth (not like files, no flutes are present in the
spreaders) they come in:
- Standardized: usually in numbers so they match the file size (ISO
size)
remember that they match the size of the accessory
points).
- Non-standardized (accessory): fine-fine, medium-
fine, x-fine, fine, medium.
- Sometimes we use mixture of accessory and
standardized like, GP point 20 with the yellow
spreader (fine-fine) or GP point 25 with the red spreader (medium-
fine), etc.
DH11T (hand spreader) or FF (finger spreader) = Fine-Fine GP. D11
(hand spreader) or F = Fine GP

2) Pluggers (Hand or Finger) For vertical condensation

- After we’re done with filling, we need to cut the GP

points by an instrument, usually “glick” is used ‘-Glick
no. 2 (endo-spoon): for cutting of GP’

3) Heat in Bunsen burner, or touch & heat glick

Lateral condensation and filling of the root canal: (GP and AH26)
We have to prepare the canal for the filling, and we achieve this by:
1) Dry the canals ( if it wasn’t dried well recurrent caries or
sodium hypochlorite accident may occur )
2) Check the fit of the MASTER Gutta Percha cone (MAC)
3) Check the fit of the selected Spreader .

There is a criteria that is mentioned which says:

• If the canal is small, you’ll have to choose ONE size smaller GP
point than your master apical file. (If MAF is 30 you’d pick 25 as
your master cone)
 • If the canal is medium, you’ll have to choose the same GP point
size as your master apical file. (If MAF is 30 you’d pick 30 as your
master cone)
• If your canal is large, you’ll have to do the “heat-softened
impression” technique, by heating the tip of your GP point to make
it fit into your canal
✓ Sometimes we may choose size 30GP cone for example but when we
insert it into the canal we don’t feel the tug-back sensation, first thing
to do in this case is to take another cone from the same size (because
minor differences between the cones of the same size may be present
sometimes ‫ مصنعية أخطاء زي‬,(then if it didn’t work for you, go one size
smaller than the MAP (most often the guide is the MAF).
✓ However, it is not a must that the master cone size to be equal to the
size of the MAF or less, for example if you inserted a cone and it was
loose (no tug back sensation), then you have to go one size larger!

You should achieve two things in order to choose your GP point:

1) Your chosen GP point must approach the complete working
length
2) Your chosen GP point must show some resistance upon removal
(tug back action) (sometimes if you used a tapered cone, you will feel
resistance in the coronal third, however, if you used a standard cone, its
taper will be the same as the taper of the canal, and you will feel the tug
back in the apical third as required), It has apical stop, meaning that if
you pushed it slightly further than the working length it doesn’t go
beyond the apex.

To sum things up:

2 scenarios might show up:
First: If it reaches the working length without this slight
resistance upon removal (tug back) or simply exceeds the
working length, you’ll have to increase the size of your chosen
cone. And sometimes you’ll have to cut the tip slightly.
Second: If it doesn’t reach the working length in the first place,
we’ll have to recheck our master apical file again + irrigate well,
because some debris might be packed apically. And sometimes
 you’ll have to re-do apical preparation and to re- establish working
length again.

RCF clinical steps:

✓ Here, we dried the canals, and inserted the
master cone, it’s better to insert it till you feel
the tug back then measure the length of its
portion that was inserted, this length should be
the same as the working length, and if it wasn’t,
well that means you did something wrong & you
should reassess things on the radiograph
GP ‫ عال‬working length‫هاي الطريقة أحسن من إنو نحدد ال‬
‫ من االساس انا‬WL ‫ النو ممكن يكون ال‬canal ‫بعدين ندخلها بال‬
‫ وتذكرو دايما الزم‬،‫ وهي معلقة بالهوا‬canal ‫محددو غلط وتكون مثال بس واصلة لنص ال‬
!! tug back ‫يكون ف‬

✓ When you determine the WL on the Master cone, mark this length by
cutting it or just bending it with the tweezer because it doesn’t have a
rubber stopper like the ISO files, then you have to check it
radiographically (cone fit radiograph).

✓ When you assess the master cone in the radiograph, it must be reaching
the working length, not shorter nor longer so that the filling will be at
the same length of the length that you ended your work at.
If it was going beyond the working length in the radiograph, or if
there wasn’t any apical stop, you need to go one size larger or you can
just cut its tip (as it has 2% taper, when you cut it you will change the
tip size to a known value).
Ex: if you cut 1mm from the tip of size 25 GP, its tip diameter will be
0.27 mm.

✓ On the other hand, if it was shorter than the working length, it is

most commonly that you have debris in the apical third that are
blocking the canal (when you can’t reach the working length again),
and here we notice the importance of recapitulation, canal preparation,
irrigation... (when you insert the GP, there must be a clear & clean path
for it without anything interfering (if it was soft >> debris (most
commonly)).
 Also, the problem may be due to a ledge (formed during preparation
or transportation). Furthermore, you may need to redo the apical
preparation or re-establish the working length.

✓ After doing the cone fit radiograph, now we have to check the fit of the
spreader, mostly we will be dictated by what is available (Ex: if I have
MF accessory points, I must use MF (Red) spreader).
Remember that the size of accessory points MUST be the same as
the spreader, because for example, if you chose a spreader larger than
the accessory points,
you will be creating a space bigger than what the accessory points
can fill, and that will affect the density of your filling.
You can select the appropriate spreader by choosing the one that
reach 1-2mm shorter than the working length while the master
cone is in the canal (NO MORE, NO
LESS),
Again: This criteria is so important to avoid
voids formation in the apical one third.
This indicates sufficient canal preparation,
TAPER!

✓ DON’T choose accessory points & spreaders with a great taper because
they will fill the coronal part while the apical part will have remaining
spaces (as the size of the accessory point increases, its taper increases,
so try to choose small points & spreaders to fill the apical part and
larger ones to fill the coronal part).

✓ Cement placement: Cement should be placed into

the canal by:
1) A hand file, or by covering the master GP point with
cement and wiping the canal’s walls with it. We have
to make sure that the master cone –which is covered by
cement - has seated in its place at the full working
length (the mark on the master GP point is at the same
level of the reference point)
2) With a spiral root filler, a more effective way in
cement placement
 Again: common mistake, master GP reaches the full working length,
everything is fine, but when we’re placing cement, master GP has to
return to its seat (full working length) because sometimes, cement
presence makes it hard for the master cone to approach full working
length again. So, make sure you are not doing that. (that’s why dr sari
told us when we’re choosing the master cone we should choose it while
the Canal is wet)

✓ Insert the master cone in a vibrating manner to dissipate the sealer and to
make it reach fully seated to the full WL.
✓ After cement placing and master cone seating, we insert the spreader
(which is shorter than working length by 1-2 mm) in the canal beside
the master cone to compact it against the wall, no extra pressure is used,
no vertical compaction is used, just by insertion of the spreader, we get
the lateral vector (force) that we require to push the cone against the
wall so we create a space for accessory cones to fit in.
✓ When we want to take out the spreader, we take it out in a twisting
movement so we don’t disturb or displace GP points that are
inserted in the canal, the movement should be smooth and gentle.
✓ Then we place accessory cones beside the master cone and after each
insertion we have to use the spreader in order to create enough spaces
for the additional accessory cones.

✓ Now we insert the accessory point in the space that we’ve created by
the spreader (in the same exact hole we’ve made).
Then again, we insert the spreader one more time to add more
accessory points, notice that each time we insert the spreader in the
canal it will reach to a shorter length because we are filling the apical
part of the canal (remember that when we fill the apical part, we use
small accessory points with small spreader).
✓ Apically: Usually we use white or yellow spreaders at first,
sometimes red spreader if the canal is wide, blue, green and black
spreaders are used mainly to compact accessory cones at the
coronal two thirds of the canal. (Accessory cones’ size should
increase while going up too or else it will take us forever to fill the
canal!!)
✓ If you are happy with your work, you can cut the GP points using a
Glick or any broken probe or even an excavator by performing a
scooping action

✓ V.V. important note: the cutting instrument MUST be RED HOT

while doing the scooping action!!never cut vertically, So it doesn’t
mess everything up.

✓ the level of the final cut must be at the level of the CEJ (just below it
in the anterior teeth)
✓ After that, we have to clean our access cavity and pulp chamber
with alcohol (by using a microbrush or cotton), then we do vertical
condensation using any plugger or any broken instrument and we clean
with alcohol again so we make sure it is disinfected and clean as
possible

✓ Before removing the rubber dam, we have to place our coronal seal,
then we remove the dam and take the final radiograph.

✓ For special cases, we can combine lateral condensation with filling

using obtura (softened gutta percha) because it can reach the
irregularities in the anatomy which we may find in the future such as:
internal resorption, unusual anatomy etc.

Assessment of RCF Quality Generally reflects the overall technical

standards of endodontic treatment!
1) Length
2) Density
3) Taper
4) Level of RCF coronally
5) Adequate coronal seal (permanent or temporary)
All these have to be checked to ensure a very good root canal treatment!

*If the sealer reached the Inferior alveolar nerve, paresthesia may happen…
 Pulp protection

Materials used for pulp protection :

Ø Bases
Ø Liners
Ø sealers

Here there is between the

restoration and the dentine
and sometimes the pulp
protecting materials ( resin
modified glass ionomer liner
and calcium hydroxide )

Aims for using such materials :

§ Either protection

v Chemical protection residual reactants that diffusing out of

the restoration, oral fluids that may penetrate leaky
restoration
v Electrical protection
v Thermal protection
v Mechanical protection
 § Or produce Pulpal response

v relieve inflammation
v facilitate dentinal bridging when there is pulp exposure

• The most important factor that should be considered when

protecting the pulp from insults is the remaining dentine
thickness (RDT).to conserve dentine is much better than liners
and bases ..

• The use of liners and bases depends on the depth of our

cavity, if it was shallow and there is 2 mm residual dentine
then no need for liners, but if it was very deep then we have to
use liners and bases to protect the pulp.
• The greatest impact on the pulp occurs when the RDT is not
more than 0.25 to 0.30 mm

• The hot stimuli are less common and do not affect badly as
much as the cold or evaporation or sweet stimuli do.

Dentine near the surface Dentine near the pulp

Causes of pulpal pain and sensitivity:

v Increased intra-pulpal pressure on nerve endings,

secondary to an inflammatory response
v Thermal sensitivity in cases of absence of inflammation.
especially when remaining dentine is thin

Materials that we use …

1.Cavity sealers

1. Varnish

A protective coating to the walls of the prepared cavity

A barrier to leakage
varnish contains 10% resin and 90% volatile non-aqueous
solvent (ether, alcohol and acetone) and most solvent loss
occurs in 8-10 seconds and does not require forced air
assistance.(dry in 8-10 sec.)
dentine is hydrophilic and varnish hydrophobic so a single
layer is not enough to cover dentin surface.
Varnish not used under composite
Varnish has commonly been used under amalgam
restorations and before cementation of indirect restorations
with zinc phosphate cement.
 significantly reducing micro-leakage for 4 to 6 months. not
used as much now
varnishes (also Gluma Desensitizer or G5 desensitizer)are
not adhesively bonded to the tooth structure.

2. Adhesive sealers

Include adhesive bonding systems, resin luting cements,

and glass-ionomer luting cements
These sealers adhere to the tooth structure , for example GI
adheres chemically but adhesive bonding systems and resin
luting cements adhere by micro-mechanical retention

2. Liners

Cement or resin coating of minimal thickness (usually less

than 0.5 mm) usually applied only to dentin cavity walls that
are near the pulp to achieve:
1. a physical barrier
2. to provide a therapeutic effect, such as an antibacterial or
pulpal anodyne effect.
3. contribute initial electrical insulation.
4. Generate some thermal protection.
Indications for using liners…

1. In pulpally extended metallic restorations

(moderate to deep) use a liner these are not
well bonded to tooth structure and that are
not insulating such as amalgam and cast
gold, or with other indirect restorations.
2. As a stress breaker under insulating restorations
(composite restorations) in pulpally extended cavity
preparations or in cavity extended to root surfaces. (we
do not use lining materials under composite to seal
dentinal tubules because it will interfere with the bonding
agent function ,but these liners will help in stress
breaking in polymerization shrinkage that happens in
composite restorations )

Types of liners…

A. Eugenol

- highly acidic
- produces palliative or obtundent action on the pulp when
used in low concentrations
- alleviate discomfort resulting from mild to moderate
pulpal inflammation
- High concentrations might be irritating
- Not used under composite because it inhibits
polymerization of layers of bonding agent or composite
that are in contact with it.
- In liners small amount of eugenol is released over a
period of several days.
B. Calcium Hydroxide (commonly used )

2 paste sys ..

- Used in the deepest portions of the preparation or when

pulp exposure is suspected to do direct pulp capping .
- it is supplied by 2 paste system , mixed together in 1:1
proportion
- encourages dentinal bridging.
- Reparative dentin formation is assisted, rather than
stimulated due to the antibacterial action of calcium
hydroxide (high pH (9–14)), which reduces or eliminates
the inflammatory effects of bacteria and their by-
products on the pulp. so that’s why it is good to use them
in clean non symptomatic cavity.
- may release growth factors from dentin that can assist in
pulpal healing.
- They may degrade severely over a long period of time so
that they no longer provide the mechanical support for
the overlying restoration so they are applied on the
deepest part only not the walls
- Unfavourable physical properties restrict calcium
hydroxide use to application over the smallest area that
would suffice to aid in the formation of reparative dentin
when a known or suspected pulp exposure exists.
to improve the physical properties 1 paste sys have been
developed where they enforced the calcium hydroxide with a
resin part like HEMA or like RMGIC and this material is light
cured (visible light cured)

1 paste sys ..

- Used as a liner or root canal sealing paste

- Visible light cured calcium hydroxide preparations have
demonstrated clinical success and maybe less susceptible
to hydrolysis
- Don’t provide perfect reparative dentine formation
because it does not give the needed PH(not very high)
- these materials have better physical properties but they
do not have better medical properties because of low
calcium hydroxide amount

Note : nowadays we have better materials like MTA and BIO-

DENTINE that have better properties than calcium hydroxide
, CaOH is mechanically weak so it will break easily under
strong restoration.
c. Glass Ionomer

The conventional glass ionomer and Resin modified glass

ionomer are the more commonly used as liners and bases than
compomers and MRGI(metal reinforced glass ionomer)

- these liners emphasis on the chemical protection by

sealing, adhesion and mechanical protection rather than
medical effect
- Sealing is the most important property.
- Ceramic and or polymeric materials provide excellent
thermal insulation.

3. Bases

Materials to replace missing dentin and are thicker than liners,

Cement bases typically 1-2mm

They are used to:

- for bulk build-up

- for blocking out undercuts in preparations for indirect
restorations. (this is the primary use for bases )
- Provide thermal or chemical protection for the pulp.
- Supplement mechanical support for the restoration by
distributing the stresses from the restoration across the
underlying dentin surface.
- if RDT is less than 0.5 mm we use base to replace this
loss of dentine
Materials we use ..

1- Zinc phosphate cement and resin reinforced zinc oxide

eugenol
2- poly carboxylate cements
3- glass ionomer cements.(the best material so far )

RMGI is the best as a base material because it has the best

compressive strength, bonds chemically to the tooth structure ,
user friendly as its light cured reaction supported by an acid-
base reaction.

Clinical considerations

• The need for specific types of liners and bases depends on:
1. the remaining dentin thickness.
2. Consideration of the adhesive material.
3. Type of restorative material being used.

The ultimate goal is to have a minimum of 2 mm of tooth

structure or a combination of tooth structure base and liner
between the restorative material and the pulp.
NOTE: if there’s no RMGIC available in your
clinic you can use conventional GIC or
flowable composite (this type is the same as
normal composite but the filler part is less so
they are not thick as the normal composite).

Survival of liners and bases under restorations:

- Varnishes are relatively thin and brittle and may only

provide chemical protection for a couple of days to
weeks.
- Liners and bases may be sufficiently intact to limit the
extent of tooth re-preparation to only the outline
necessary for removal of the old restorative material.
- if you will redo a restoration it is better to remove the old
restoration with all liner and base layers underneath it.
- Calcium hydroxide may continue to dissolve and may
loose10-30% of their volume over 10 or more years.
- Cavity sealers should be used routinely under amalgam
restorations.
- Resin-modified glass ionomers are used with deep caries
prior to bonding because bonding to deep dentin with
available dentin-bonding agents is not predictable due to
the lack of inter-tubular dentin.
- Liners are hydrophilic materials, whereas varnishes are
hydrophobic materials àthere is only physical contact
between varnish and dentine so within few days varnish
will dissolve and as we said it is used with amalgam that
will produce corrosion products and fill the space that
was produced by the varnish.
- Red pulp or pink dentine à there is exposure
Temporisation During Endodontic Treatment

Temporisation during endodontics includes:

- temporary coronal restoration (coronal seal)
- temporary root canal filling (by placing the intracana
medicament)

Temporisation of root canal with root canal medicaments :

§ they have anti-bacterial action that reduces the

number of residual bacteria in canals and inaccessible
area and this action acts in periapical region and in
periodontal tissue and it prevents contamination
between visits
§ prevent or reduce pain specially when using a
medicaments that contains steroids
§ reduce periapical inflammation
§ induce apical hard tissue barrier formation (this is
important in case of having an open apex or any
perforation along the canal)
§ help eliminate apical exudate
§ prevent or inhibit inflammatory resorption
Materials used as canal medicaments ..

1- corticosteroid / antibiotic based medicaments (CS/Ab)

e.g: Ledermix paste, Odontopaste
2- calcium hydroxide medicaments ( Ca(OH)2 ) e.g:
Calasept Plus paste, PulpDent
3- 50:50 mixture { CS/Ab + Ca(OH)2 }

we will talk about each type in more details ..

v Corticosteroid / Antibiotic medicaments
1- Ledermix paste
Most common
2- Odontopaste
3- Septomixine Forte paste
4- Pulpomixine paste Not used anymore because they are carcinogenic

Ledermix paste:
It contains triamcinolone + demeclocycline (tetracycline)

A good thing about Ledermix is having a very rapid release in

the first day → which is important in case that the patient
cannot sleep because of his tooth pain so using Ledermix will
reduce post-operative pain immediately at the same day. Its
therapeutic effect last for 6 weeks so you shouldn't leave it in
the canals more than 6 weeks).
used for anti-inflammatory action in case of:
1- acute irreversible pulpitis
2- acute apical periodontitis
3- trauma
4- reduces and prevents pain, reduces nerve sprouting
5- even it contains AB but its not reliable alone for anti-
bacterial action
6- reduces resorption of tooth and bone (by inhibiting the
clast cells) by the AB part tetracycline
7- reduces tissue destruction

the main disadvantage of ledermix is: if the access cavity

isn't cleaned well from ledermix then the tooth exposed
to light (especially ant teeth), discoloration of tooth will
happen.

Odontopaste
It contains triamcinolone + clindamycin+ Ca(OH)2 1-5 %

Provides an alternative for some cases:

e.g. If an infection is not responding (resistant infection)
e.g. If discoloration is a concern (it is good for using in
anterior teeth)
Calcium hydroxide (most popular )
calcium hydroxide is powder originally but we mix it with
another substance (vehicle) in order to improve its flow and to
facilitate its dissociation. It has high pH (12.5-12.8) so its
antibacterial
vehicle type (aqueous, viscous and oily) determines the rate of
dissolution and longevity
aqueousà very quick result and a rapid dissociation
viscousà have the effect for longer time like in
some cases like apexification for example when I need to
put Ca(OH)2 in the canals for 3 months

Commercial preparation of Ca(OH)2 :

1) Saline base (aqueous vehicle)
Calasept Plus
2) Methyl-cellulose base ( a little bit more viscous)
Pulpdent paste
3) Powder - to mix with various liquids such as:
(saline ,local anesthesia)
4) Impregnated on GP points (not effective)
Roeko
 • used for
1- anti-bacterial action that is needed in pulpless or
necrotic teeth and or root-filled + infected root
canals
2- stimulate hard tissue repair in case of having an
open apex where we should do apexification
3- root fracture (I need to put a calcific barrier)
4- inflammatory root resorption (apical and lateral)
5- helps dissolve necrotic tissue (improve the tissue
solubility of NaOCl

efficacy of calcium hydroxide depends on release and

diffusion of hydroxyl ions through dentine , Release and
diffusion of hydroxyl ions through dentine depends
clinically on:
• Period of exposure (if you put calcium hydroxide for one
day, the dentine will not have any OH- ion or any change in
pH →so calcium hydroxide should be put in the canal for
enough period of time)
• Vehicle type (viscous / aqueous)
• Smear layer existence , so clean properly
• Retreatment procedure , clean gutta percha very well for the
calcium hydroxide to reach the periapical areas
• Level of placement ,make sure that you have put it apically
in the canal not just coronally
• Cementum layer ,remove enough cementum to reach the
apex
Limitations and potential problems with calcium
hydroxide:
1. toxicity if pushed to the apex (initial and long-term) ,the
patient will have inflammatory reaction and pain
2. increased replacement resorption (resorbed root will be
replaced by bone) (especially when using it in case of
trauma) .. trauma àuse ledermix
3. increased ankylosis especially in case of trauma
4. may promote inflammatory resorption
5. may affect dentine mechanical properties (long term) but
not on short terms

For how long should medicaments be used?

• Absolute MINIMUM time: 2 weeks
→Since inflammation takes 10-14 days to resolve
• Most BENEFICAL and MAXIMUM times:
-Ledermix paste 4 →6 weeks (because after 6 weeks, it will
not be therapeutic anymore)
-Calcium hydroxide
3 - 4 weeks →6 months (depends on the type of vehicle used)
Application of medicaments:
1-Either by spiral filler , most effective & easiest method -
ONLY if the canal has been enlarged

-it is used in the slow speed handpiece then put inside the
canal(it should not bind to the walls)
- we should insert it (3-4)mm shorter than the working length
in 'in and out' motion many times
-you should repeat this procedure (2-3) times then the
medicament will be float

2-Or hand file , it resembles putting the sealer in the canal

using endo files ,used if canal has NOT been enlarged or
prepared
Don’t !! put it with injection or paper point because they may
push the material peri-apically causing harm to the patient
Temporisation of the crown
functions of temporary coronal restoration:
• prevent bacterial ingress during and after treatment
• provide a sound base for rubber dam placement
• protect against tooth fracture during treatment
• provide a stable reference point
• provide aesthetics where required
The two considerations of temporary coronal restoration:
1. restoration of the tooth (interim restoration)
-interim restoration replaces all the walls that are missed after
removing a previous restoration or caries.
-done by using glass ionomer (ketac silver / ketac fil (tooth-
colored) ) with or without using stainless steel orthodontic
bands.
ketac silver for posteriors / ketac fil for anteriors
-use dentine conditioner (in order to remove the smear layer
and to have a better retention) (it is different than acid
etching)
- use resin cover (ketac glaze or bond) after placing the glass
ionomer while setting (we use it to cover the restoration- not
the dentine- for moisture control)
after I place the interim restoration, in the next appointment I
will drill through this interim (so now I have interim replacing
the walls + access cavity) then I prepare the canals and take
the working length. After that, I should temporise the access
cavity à I think this process for badly destructed teeth ,, so I
think the 1st visit is for build up and giving the tooth a strength

Note : we don't use glass ionomer inside the canals because

it will be very hard to re-access the tooth

ketac silver is preferred wherever possible because:

• color contrast helps removal
• stronger material
• less sensitive to moisture loss ,mportant in cases of
having deep margins during setting ,, later when isolated
with rubber dam
how to temporize a crowned tooth for re-doing the crown
and the post ..
put firstly dressing in the canal then cotton wool (CW)
then cavit (is a calcium sulphate based material )deep in post
hole
(using the internal of canals for retention of the temporary
crown) then temporary post/crown with IRM or temporary
cement , this is the order of things to be layed à temp.
crown→ temp. post→ cavit→ CW→ dressing : ‫اﻟﺘﺮﺗﯿﺐ ﻣﻦ ﺑﺮا‬
‫ﻟﺠﻮا‬

-I cannot place the temporary

post directly into the canal,
instead I have to protect the
canal by putting a small cotton
wool and cavit (temporary
filling) inside the canal then I
can do cementation of
temporary post and crown
-Why I should place cotton and cavit? Because if the crown
fall , the root canal would be protected
But if you put the CW/cavit in pulp chamber
then place a GIC over exposed dentine (over the cavit) AND a
temporary overlay denture (removable denture )
dressing→ CW→ cavit → GI →denture

or place a temporary composite bridge bonded to root and to

the adjacent teeth after the CW/cavit
2. restoration of the access cavity (temporary restoration)
we use both cavit and IRM (intermediate restoration material and is a
reinforced zinc oxide eugenol)→ double seal
 Endodontic radiography
Radiography is used in endodontics for:
1-Diagnosis
2-Pre-operative assessment of root canal anatomy
3-Determine working length
4-Technical assessment of treatment
5-Review healing and tissue responses
*Periapical radiograph is the most commonly employed
radiograph used in the practice of endodontics .
Adjunct “diagnostic” radiographs in endodontics
Intraoral radiographs: Bitewings, Occlusal.
Extra-oral radiographs: CT scan, Panoramic, Cone beam.
Principles of radiology
X-ray source (the central ray)
Object (the tooth)
Film / image receptor (conventional films , phosphor plates ,
attached record films )
Film sizes
Size 0: 22 x 35 mm
Size 1: 24 x 40 mm (for narrow arches such as lower anterior
areas).
Size 2: 31 x 41 mm (PA).
Size 4: 57 X 76 mm (occlusal views).
Film orientation
Anterior: vertical. Posterior: horizontal.
The dot on the conventional film positioned away from the
apical "toward the crown".
Radiography Techniques
1- Parallel technique. 2-Bisecting angle technique. 3-Modified
parallel technique.
Parallel technique: film is parallel to the long axis of the tooth
and the x-ray beam will be perpendicular to the long axis of
the tooth.
The resulting image is very close to reality.

Bisecting angle technique: film will be as close as possible to

the tooth, and the beam will be perpendicular to an imaginary
line (imaginary bisector) that bisecting the central axis of the
tooth and the film. The buccal root will appear a bit shortened
and the palatal root is a bit elongated.

*Parallel technique is more accurate than bisecting technique.

BUT still have approximately 10% magnification since x-rays
source comes from a point “point source” and then there will
be a divergence, leading to slight magnification. We can
overcome this by using a long cone or tube, so this will
encourage the x-ray beams to be more parallel.
Modified parallel technique: increase the vertical angle of the
central beam by 15 degrees, so if I am taking a radiograph for
upper teeth, I just increase my vertical angle by 15. If it is a
lower tooth, I should go down by 15, so move my x-rays tube
more toward the apex of the root, NOT toward the crown.
Tilting the beam towards the crown will result in
elongated image.

Positioning Devices
patient fingers, Styrofoam bite block, artery forceps, Snap-A-
Ray, Snapex kit (straight for parallel and belt for modified)
and Rinn XCP Kit.
Rinn XCP is what we use in clinics and it
applies parallel technique.
Yellow for posterior teeth (molars and
premolars). Blue for anterior teeth (incisors
and canines).
Most accurate to least accurate (used with parallel technique):
Rinn XCP → Styrofoam bite block → Haemostat with bite
block → Patient’s finger (it has the greatest amount of film
bending).

Using the Rinn holder

Upper anterior teeth: we try to get a cotton roll above the bite
block, it prevents the film from bending.
Lower anterior teeth: we place a cotton roll below the bite
block because we have the lingual frenum.
Upper posteriors: we place a cotton roll above the bite block
because I don’t want the film to bend.
Lower posteriors: we don’t use cotton rolls, tell the patient to
relax his tongue and slightly close his mouth.
Be systemic when you read radiographs, start with crown,
then the root, then the apical tissue, and then look at the
horizontal bone level.
Viewing conditions
Correctly mounted→ Raised side of the dot towards you
Block out peripheral light
Even light source
Magnify the image(which is achieved by troller viewer
which also block out the light)
Tube Shift Techniques
Vertical shift, I can increase the angle or decrease it vertically.
Horizontal shift, I can go mesial or distal.
Vertical Shift: increase the angle (move toward the apex of
the root) by 15 degrees to get the modified parallel technique
(diagnostic value).
Middle pic: the two canals that are overlapped, if I take a
decreased vertical angle radiograph "move toward the crown",
it will elongate the image, the buccal root will look longer
than the lingual (it seems that buccal root moves apically and
the lingual root moves coronally) which has no diagnostic
value (the right image). But if I take an increased vertical
angle radiograph " move toward the apex", it will shorten the
image, the lingual root will look longer than the buccal (it
seems that the lingual root moves apically and the buccal root
moves coronally) which is in some cases helpful to overcome
the overlapped roots.
Occlusal view is helpful in the case of root fracture or lateral
luxation
Horizontal Shift: shift the tube distally or mesially, used to
differentiate the buccal root from
the lingual root, recall
SLOB technique.
In straight view, the two roots will
appear as one root.
When the tube head is shifted
mesially, the lingual root will
be sifted mesially (in the same direction as the shifted tube
head) on the film and the buccal root will be shifted distally
(in the opposite direction as the shifted tube head) on the
film.
When the tube head is shifted distally, the lingual root will
be sifted distally (in the same direction as the shifted tube
head) on the film and the
buccal root will be shifted
mesially (in the opposite
direction as the shifted tube
head) on the film.
When the tube head is shifted
mesially, the lingual root will
be shifted mesially on the
film and the buccal root will
be shifted distally on the film
(the MB will be more mesially than the DB root)
When the tube head is shifted distally, the lingual root will
be shifted distally on the film and the buccal root will be
shifted mesially on the film (the DB will be more distally
than the MB root)

working length determination, cone fit radiograph

Snapex (can be used with rubber dam), Rinn (green, space for
files), Endo ray film holder, Artery holding forceps, use
plastic frame (Nygaard-Ostby frame) so you don’t have to
move it when taking Rx
Specific Techniques for Each Tooth (How you should direct
the tube beam for each tooth)

Remember: the direction of the beam must be opposite to the

way the tube head is moved.
the tube head is shifted distally (direction b in the picture) but
the x-ray beam is passing mesially through the tooth.
 Remember that the shift is the same
as the tube heads direction, and the
X-ray beam will pass opposite to
the way the tube head.

This is the midline of the tooth; the

x-ray beam should pass away from
the midline of the tooth.
Upper incisors & canines:
** avoid horizontal shift around the corner of the mouth, so I
can’t take a mesial shift of a canine
because of the corner, the image will have too much overlap
so I can have to take a distal shift.
Upper + Lower incisors & canines:
Vertical: 15° increase Modified parallel technique to have a
better view for the apical part.
Horizontal: only if a problem is suspected e.g. perforation,
extra canal
Central incisors - Mesial shift
Lateral incisors and canines - Distal shift
(Remember it is more common to have a second canal in the
lower anterior than the upper)
Upper & lower premolars:
Avoid making a horizontal shift around the corner of the
mouth (never do a distal shift in premolars)
Vertical: 15° increase Modified parallel technique
Horizontal: Mesial shift
Lower molars: two distal
canals in the distal root
Vertical: 15° increase
Modified parallel technique
Horizontal: Mesial shift –
usually Can do distal shift
if necessary
Upper molar: extra canal in MB
root, zygomatic arch interferes
Vertical: 15° increase Modified
parallel technique
Sometimes also, vary vertical angle for Palatal root.
Horizontal: Distal shift - usually (for MB root).
Sometimes also, need mesial shift (for DB root).