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CHAPTER 27

PREPARATION OF CORONAL
AND RADICULAR SPACES
OVE A. P ETERS, RA VI S. KOKA
It has been well established over t he past 30 years
that endodontic disease, the prescnce of apical perio-
dontitis, has a microbial pathogenesis.
I
,2 Conse
quently. root canal treatment is performed to treat
endodontic disease by eradicating bacteria from the
root canal space. It is widely accepted that disinfec-
tion and subsequent obturation of the root canal
space requi re mechanical enlargement of the main
canals,3 and the vast majority of techniques and
instruments today arc based on this objective. There-
fore. this chapter will focus 011 t he princi ples of
preparat ion of coronal and radicular canal spaces; it
breaks this down into two distinct steps: fi rst, pre-
paration of the coronal access cavity and second,
radicular canal shaping.
Coronal Access Cavity Preparation
The objective of the coronal access preparation is to
provide a smooth free-flowing tapered channel from
the orifice to the apex that allows instruments, irri -
gants, and medicaments to attempt cleaning and
shaping of the entire length and circumference of
the canal, with as minimal a loss of structural integrity
to the tooth as possible. The access preparation gen-
erally refers to that part of the cavity from the occlusal
table to the canal orifice. However, its design is
dependent on the position and curvat ure of the entire
length of the canal, not just the position of the orifice,
and is therefore not a simple cavity.
In this first section on coronal access cavity prepara-
t ion, the section on principles is intended for all teeth in
general. The following sections will deal with the indi-
vi dual nuances in access preparation for each toot h.
877
General Principles
" DO NO HARM"
No practitioner performs treatment wit h the intent to
harm and yet substandard quality does occur. The
problem seems to stem partially from a lack of aware-
ness and knowledge. In addition, the dail y stresses
within the practice environment compound t his issue,
and the stage is set for inadvertently causing harm or
damage to the tooth and ultimately the patient. To
minimize the frequency of harm clinicians may cause,
learning and awareness should be lifelong objectives.
A " mindful practice" is the objective that continu-
ously moni tors and reevaluates results and techniques
over t ime with introspection.
CONFIRMATION OF ETIOLOGY OF PULPAL
PATHOSIS
Part of the objective of the access preparation is to
confirm the etiology of pulpal breakdown assessed
duri ng diagnosis. The only proven etiological factors
are bacterial contamination (via caries, coronal leak-
age under restorations, fractures) and trauma (e.g.,
resorption, thermal, mechanical, and physical). As
the pulp chamber is entered, the clinician must
visually inspect the state of its contents to check that
it matches with the preoperative diagnosis. It is dis-
concerting to expose the vital tissue when a preopera-
tive diagnosis of necrosis has been made. Also the
etiology of t he pulpal breakdown has to be discerned.
At times, it is easy to confirm the etiology, for exam-
ple, the presence of a carious lesion, but in the absence
of obvious clinical evidence, the practitioner must
make a conscious effort to search for the cause. Clini-
cally, presentation of microlcakage and cracks is
878 / Endodontics
extremely subtle and difficult to detect. Staining,
high-power magnification under a microscope, tran-
sillumination may all help discover these sources.
ASSESSMENT OF RESTORABILITY
Although it is tempting to develop an "endodontics
mode" mindset, once root canal treatment has been
diagnosed, another major objective is to check the
restorability of the tooth prior to root canal treat -
ment. Existing restorations, caries, and unsupported
enamel and dentin should be removed and the
remaining tooth structure examined under a micro-
scope. The operator should search for the presence of
cracks, height, and thickness of the remaining dent-
inal walls for ferrule effect, the relationship of the
remaining coronal tooth margins relative to the oss-
eOuS crest, root length, location of the furcation,
amount and quality of attached gingiva, and position
of the tooth in the arch. This can result in several
advantages:
4
Before root canal treatment is started, the palient
can be forewarned of risks, benefits, and alterna-
tives of any further procedures andlor costs to
restore the tooth completed, for example, crown
lengthening, gingivectomy, extrusion, or placement
of orthodontic bands.
A more educated opinion on long-term prognosis
can be provided by the clinician to enable the
patient to choose whether root canal treatment or
implant therapy is more beneficial.
Leakage of bacteria back into the root canal space
under a preexisting defecti ve restoration can be
prevented.
Cracks on the remaining tooth structure can be
more readily assessed. This may change the clini-
cian's decision to extract versus restore, to place
build up immediately, to perform cuspal reduction
or warn the patient more emphatically of the
chance of fracture postoperatively.
However, in certain situations it can be argued that a
portion of the restoration should be left in place
until the root canal treatment is almost complete.
This provides a circumferential matrix to enable a
seal by the rubber dam or help hold the clamp in
place (as long as no leakage can be seen under higher
magnificati on).
A more difficult situation arises when an existing
crown is present on the tooth that requires endodontic
treatment. Accessing through a crown has several dis-
tinct disadvantages: the amount of remaining tooth
structure, the quality of the build-up restoration, the
extent of any decay, and the quality of the crown seal
cannot be thoroughly assessed. In fact , Abbotl
4
found
that there was less than 60% chance to detect caries,
fractures, and marginal breakdovm, without complete
removal of restorations. All of these factors have a
profound effect on the long-term success of the root
canal treatment, and longevity of the tooth. However, it
is impractical to suggest removing all crowns prior to
root canal lreatment, and therefore a careful assessment
of the integrity of the crown must be attempted
through history-taking and clinical examination before
and during treatment.
STRAIGHT-LINE ACCESS
It is well documented that to prepare the apical third
of the canal circumferentially, a straight path for the
cutti ng instrument from the orifice to the apex is
imperative.
5

6
As the curvature of the canal increases,
a fil e that enters into the canal is deflected at its tip by
the force exerted by the dentin. However, according
to Newton's Law, the file tip exerts back an equal and
opposite reaction upon the dentin, that is, force on
the outer dentinal surface of the canal as the file
attempts to straighten back to its original dimension.
If the dentin exerts a greater force than the file, the file
bends, but this changes as the file size increases. Even-
tually, the file will cut the dentin rather than bend. At
this point, the outer dentinal wall of the curvature is
cut preferentially, known as gouging, which is the
start of ledging and transportation. This effect is
accentuated with cutting-tip ftIes compared with non-
cutting tips and with a vertical filing motion versus
rotational motion.
A concomitant problem develops as the file tip
exerts a force back on the dentin. A fulcrum point
develops, which is the most protuberant point of
contact on the furcal dentinal surface. Therefore, pre-
ferential cutting occurs on the furcal surface also, the
site of a most common procedural error, known as
stripping that can lead to perforation.
The term "straight-line access" (SLA) describes a
preparation that provides a straight or outwardly
Oared, unimpeded path from the occlusal surface to
the apex. This allows the file to reach the apex with
minimal deflection (Figure I). The main corollary is
Chapter 27 I Preparat ion of Coronal and Radicular Spaces 1879
that it has to be accomplished without compromising
the furcal surface of the canal that could ul timately
lead to stri p perforation. Access is continually
Figure 1 Stra ight li ne access in a mandibular third molar A The ori fice opening and path of insertion preoperatively is indicated by a black line. The mesial
wall had to be cut to obtain a straight-line access B, The handles of the files are standing upright without crossing over each other indicating adequate Straight-
line aa::ess C, However, often the distal canals are angled such that the file handles project Qui of the orifice mesially while still maintaining SlA
880 I Endodont ics
adjusted until the selected master apical fde (MAF)
reaches the working length (WL) without undue stress
upon it. A more aggressive SLA is required as the size
of the file used and/or the degree of canal curvature
increases. (n this context, "aggressive" suggests that
the orifice wall leading to the canal has to be moved
and Oared more obtusely toward the corresponding
line angle.
The diameter of the apical preparation also effects
the access preparation. To prepare a larger apical
diameter, correspondingly larger, stiffer files that have
a stronger tendency to straighten the canal have to be
taken to the apex. In order to avoid stripping on the
furcal surface or transporti ng the apex, one must
achieve SLA beforehand. Unfortunately, the literature
does not provide a consensus on the ideal apical
diameter. However, in vitro studies have measured
canal diameters.
7
,s Other studies
9
-
12
have measured
canal cleanliness after a small versus larger diameter
apical prcparation and have shown belter cleanliness
with the larger diametcrs. Onc study, howevcr, found
that improvement gained with larger diamctcrs was
not statistically significant and concluded that small
apical diameters were sufficient for adequate bacterial
reduction.
13
Radiographically, canal curvature in the mesiodistal
plane can be directly observcd; however, Cunningham
and Scnia 14 demonstrated that canals possess a three-
dimensional curvature. Thcrefore to obtain an SLA,
sometimes tooth structure must be removed more on
the buccal or the lingual surface than just on the mesial
or the distal surface.
SLA involves the selective removal of the outer
canal tooth structure to protect the furcal surface.
Various methods have been advocated for this. The
so-called "anticurvature" ftling (see below) involves
cutting only on the outward stroke away from the
furcal surface but is not effective beyond curvatures.
Gates Glidden (GG) burs allow the selective removal
of dentin when used with a laterally directed motion
and similarly stiffer nickel-titanium (NiTi) rotaries
have significant lateral cutting ability (Paque F and
Peters OA, unpublished data).
Peters et al.,15.16 using microcomputed tomogra-
phy, have shown that significant portions of canals
are not touched during instrumentation due to the
irregularities and curvature of the canals. This reiter-
ates the importance of achieving SLA.
Mannan et al.
5
tested whether SLA would allow
mechanical cleaning of all the walls of the root canal
in a single-rooted anterior tooth with a simple root
canal anatomy. They prepared three types of access
cavity designs: a "lingual cingulum" just coronal to
the cingulum, a "l ingual conventional" where the
cavity was extended to within 2 mm of the incisal
edge, and an access cavity involving the "incisal edge"
but not the labial surface. They found that none of the
cavity designs allowed complete planing of the root
canal walls although the incisal edge design allowed a
greater proportion of the root canal walls to be filed
than the other two. This study, however, determined
the MAF size as three sizes larger than the first file to
bind, which had already been shown by other
researchers to be an ineffective technique to properly
clean the apical canal third.
s
Another possible defi -
ciency was that they did not extend the access cavities
onto the labial surface, which is often necessary for
true SLA as shown earlier.
l7

l s
However, the study did
emphasize that SLA provides the best chance of deb-
ridement of the entire canal.
THREE-DI MENSIONAL POSITION
OF TEETH IN JAWS
The true three-dimensional position that teeth hold in
each jaw cannot be assessed accurately by clinical or
radiographic perspectives. Therefore, using the occlu-
sal table of the tooth as a guide to the location of the
chamber can be quite misleading. Figure 2 shows the
lingual and mesial inclination of the mandibular
molars, the mesial inclination of the m a x i l l a r ~ molars,
and the labial inclination of all the incisors. 9 Corre-
spondingly, when accessing, the bur must be angled to
mimic these inclinations in both mesiodistal and buc-
colingual planes. However, other factors that limit the
ideal angulation come into consideration. A compro-
mise is reached, for example, trying to avoid
encroaching on the incisal edge when accessing ante-
rior teeth, or trying to avoid breaking through a
marginal ridge. Improper angulation results in the
Chapter 27 I Preparati on of Coronal and Rad icular Spaces I 881
A
Figure 2 Schematic views of the three-dimensional positions of teeth in jaws in frontal and sagg ital vi ews with long axes of the teeth displayed. It is
prudent during access to mimic these angulati ons to avoid unnecessary goug ing. Root types are indi cated by symbols on arrows, A, Maxilla. Note the mesial
and buccal angulation of the molars and procl inat ion of the anteriors. 8, Mandible. Note the mesial and li ngual angul ation of the molars and procl inat ion of
the anteriors. Adapted 2007 with permission from Dempster et aI. , J Am Dent Assoc 67:779, 1963. Copyright American Denta l Association.
19
common occurrence of unnecessary gouging of the
dent inal walls that weakens the remaining tooth struc-
ture and in extreme cases leads to external perforation
(Figure 3).
Part of the reason that these angulations are hard to
transfer to the clinical setting is that the operator usuaUy
sits in the 10, 11, or 12 O'clock position with the patient
reclined. This can be disorienting. The tooth is not viewed
from the perspective shown in the figure, and is not in line
with any external horizontal or vertical plane landmarks.
The operator has to physically move to view the angle of
t he bur relative to the patient's vertical and horizontal
planes. This is similar to taking a radiograph by the
paralleling technique.
EXTERNAL ROOT SURFACE AS A GUIDE
External root anatomy is determined by the internal
pulp. The mesenchymal pulp tissue gives rise to
odontoblasts that in turn lay down the dentin. As
882 I Endodont ics
Figure 3 Examples of unnecessary gouging of axial or furcation dentin due to improper angulation of the bur during access preparation. A Preoperative
and postoperative radiographs showing gouging of furcal dentin in the entrance to the mesiobuccal canals due to underextension of the mesial wall
during initial instrumentat ion. 8, Proper angulation was mai ntained allowing minimal tooth structure loss. C, Vertical instead of di stal angulation while
searching for distal canals.
the long axis of the tooth cannot be seen in the
clinical setting, the next best guide is the external
root surface. Acosta and Trugeda
20
sequentially
reduced t he clinical crowns of 134 extracted maxi l-
lary molars and examined the pulp chamber at the
level of the pulpal floor. They found the pulp cham-
ber in the center of the tooth, closely matching its
outer contour and maintaining the same distance
from the mesial, distal, buccal, and lingual surfaces.
This finding was confirmed more recently using
mathematical models based on microtomography
data.
21
It was noted that the shape of the pulp
chamber was trapezoidal, and it was therefore
recommended shaping the access preparation in the
same way. 20
In another study,22 500 teeth were used of which
400 were sectioned at the cementoenamel junction
(eEJ), 50 buccolingually, and 50 mesiodistally. The
Figure 4 The pulp chamber is usually centered at the cementa enamel
juncti on (CEJ) level all owing the use of external root sur faces as a guide
for access. The di stance from the pul p chamber to the outer contour
indicated by arrows. Fl. floor of the pulp chamber. Reprinted with
permission from Krasner P and Rankow HJ.
12
patterns in orifice location, size, color, shape, and
several conclusions were noted (Figure 4):
Law of Centrality: The floor of the pulp chamber is
always located in the center of the tooth at the
level of the CEJ.
Law of Concentricity : The walls of the pulp chamber are
always concentric to the external surface of the tooth
at the level of the eEl, that is, the external root surface
anatomy reflects the internal pulp chamber anatomy.
Chapter 27 1 Preparat i on of Coronal and Radi cular Spaces 1883
Law of the CEI: The distance from the external surface of
the clinical crown to the wall of the pulp chamber is
the same throughout the circumference of the tooth
at the k'VCl of the CEI-the CEJ is the most
consi,,1ent repeatable landmark for locating the
position of the pulp chamber.
Law of Symmetry 1: Except for the maxillary molars,
the orifices of the canals are equidistant from a
line drawn in a mesial- distal direction, through
the pulp chamber floor.
Law of Symmetry 2: Except for the maxillary molars,
the orifices of the canals lie on a line perpendicular
to a line drawn in a mesial-distal direction across
the center of the floor of the pulp chamber.
Law of Color Change: The color of the pulp chamber
floor is always darker than the walls.
Law of Orifice Location I: The orifices of the root
canals are always located at the junction of the
walls and the floor.
Law of Orifice Localion 2: The orifices of the root
canals are located at the angles in the floor- wall
junction.
Law of Orifice Location 3: The orifices of the root canals
are located at the terminus of the root
developmental fusion lines.
As the external root surface is a reliable guide, it can
be quite frustrating to place the rubber dam, which
completely obscures it. Therefore, in difficult cases, it
is prudent to prepare the initial access shape and find
the pul p chamber or at least one orifice prior to
rubber dam placement. Alternatively, multiple teeth
can be isolated by clamping one tooth more posterior
so that the eEl and the relationship of adjacent teeth
are visible and palpable on the treated tooth. The
Silker-Glickman clamp (Silk Pages Publishing, Deer-
wood, MN) was designed for this purpose. Otherwise,
a single tooth clamp may be used and the dam flossed
between the mesial contacts.
I<NOWLEDGE OF PERCENTAGES FOR THE
NUMBER OF CANALS WITHIN A ROOT
It has been known that roots contain multiple complex
canal systems since at least 1925 as described by Hess
and Zurcher.
23
Since then, research has focused on
determining their classification and incidence. Data for
canal numbers and configurations extracted from
selected references are presented in Chapter 6, "Mor-
phology of teeth and their root canal systems". Some
factors that affect such data have been noted, for exam-
ple, methods and materials, type of magnification, in
vivo, ex vivo, but many factors have not been noted, fo r
example, case report art icles, ethnic groups, age groups,
884 / Endodontics
individual interpretation of classification systems by the
various researchers.
From the material presented in Chapter 6, "Mor-
phology of teeth and thei r root canal systems", it can
be extrapolated that studies report the incidence of
multiple canals fro m 0% to as high as 95% for
certain roots. Therefore the clinician must, to
increase chances of finding them, have a thorough
knowledge of the number, incidence, location, and
the variability of the canal systems of each tooth and
root, in order to design the access cavity. Selective
removal of otherwise solid tooth structure can be
justified only when the operator is confident of the
knowledge that further canal systems may exist more
apically and that the subsequent weakening of the
tooth is offset by the significant advantage to long-
term prognosis in finding another canal system.
MINDSET
Knowing that roots can have multiple complex canal
systems, how zealous should the clinician be in look-
ing for them? Obviously, the downside in removing
the tooth structure to look for canals without success
is the decrease in structural integrity and reduced
long-term prognosis. Also, clinicians are trai ned to
conserve as much tooth structure as possible. A tooth
should be entered under the assumption that every
root has multi ple canals. This assumption can be
proved wrong only after adequate searching, defined
by objective criteria, for example, troughing through
the lighter-colored dentin of the walls compared to
the darker dentin of the pulpal floor or drilling
approximately 5 to 7 mm below the furcal floo r.
Clinicians can then regularly self-assess, by compar-
ison to the actual figures presented in the various
studies and by discussion with peers. There is a bal-
ance between selectively extending the access cavity to
search for canals and unnecessary overextension-the
art is in determining this line.
MAG NI FICA TID N/ M IC ROSCOP E
Little controversy remains over the effecti veness of the
denial operating microscope. Several studies have
shown that it increases the dentist's ability to find canals,
allows precise repair of perforations, aids in removing
separated files, and improves surgical visibil ity (see
Chapter 26F, Visual Enhancement for more details).
Clinical Armamentarium
Access preparation requires fC\v standard hand instru-
ments, but a wide range of equipment for differing
situations. The basic requirements are a mirror, a DG16-
type endodontic explorer (e.g., HuFriedy, Chicago, IL),
high- and slow-speed handpieces, a range of burs, and
a microscope. A standard set of burs (Figure 5) should
include at least a #2 round diamond, a # 1 round carbide, a
transmetal bur (Dentsply Maillefer, Ballaigues, Sv.ritzer-
land), various cylindrical diamonds (e.g., 859--Q1O, 859-
012, 859-014, BrasselerUSA, Savannah, GA), and an
EndoZ bur (Dentsply Maillefer).
The following are accessory items for differing situa-
tions or routine use depending on the practitioner's
preference. Bendable and differently sized heads of
mirrors (eie2, San Diego, CA) allow improved man-
euverability and visibility but can be particularly help-
ful in cases of difficult access due to the distal location
of the tooth or the patient's inability to open widely
(see Figure 5). An endodontic explorer that is finer
than the regular DG16 is also available, the Micro
IWI7 endodontic explorer (CK Dental, Orange, CA).
Some clinicians fi nd the Micro-Openers and
Micro-Debriders (Dentsply Maillefer) helpful. The
former have 7 mm of K-type flutes in 0.04 and 0.06
tapers in ISO sizes #10 and #15, and the latter have
16 mm of Hedstrom-type cutting flutes in sizes #20
and #30. Both are mounted as a handheld instrument
at a double angle and can be useful for initial orifice
location and widening.
BURS
Safe-ended diamonds and tungsten carbide burs that
do not cut at their tip, for example, Endo Access,
Endo Z burs, LA Axxess burs (SybronEndo, Orange,
CA), can be beneficial in avoiding gouging. However,
these burs are wide and should be used for final
refinement after precise extension has already been
determi ned wi th thinner cylindrical diamonds. The
Mueller bur (BrassclerUSA) is a latch-grip surgical
length round carbide bur available in sizes 0.9, 1.0,
1.2, l A, 1.6, and l.8 mm diameters. Similarly, Munce
Discovery burs (CJM Engineering, Santa Barbara, CA)
are 34-mm-long, narrow shafted, nonflexible round
carbide burs available in sizes 1/4 (0.5 mm diameter),
1/2 (0.6 mm), I (0.8 mm), 2 (1.0 mm), 3 ( 1.2 mm),
and 4 (1.4 mm). The ext.ended length of both these
burs reduces the head of the handpiece blocking the
operator's view. Tr e Munce burs are not as flexible as
the Mueller burs Que to a slightl y greater shaft dia-
meter and are available in smaller sizes. Both these
burs are useful for deep troughing to find canals,
opening isthmuses, or reaching separated instruments
and seem to leave an easier-to-read dentin surface
than ultrasonics (see Figure 5).
Chapt er 27 I Preparation of Coronal and Radicular Spaces I 885
c

=
$ ___ 5
c
Figure 5 Examples of armamentarium for access and inspection of pulp chambers. A, Mirrors with variable head sizes and bendable shafts. 8, Bur block
used in the practice of one of the authors (R.K.). C, Additional typical burs used for access: 12 round diamond. tapered diamond. EndoZ bur. 0, Munce
Discovery burs. f, Various ultrasonic tips. Images courtesy of Dr. Gary Carr, Dr. Cliff Ruddle and C.J.M. Engineering. Solvang, CA. USA.
ROTARY INSTRU MENTS
For gaining SLA in the coronal portion of the canals,
rotary instruments that selectively cut laterally are
useful to minimize excess removal of the furcal den-
lin. GG drills (siy-cs 1 (I SO #50), 2 (#70), 3 (#90),
4 (# IIO), 5 (#130), and 6 (# ISO have been used for
many years and are effi cient and relatively inexpen-
sive. Some of the stiffer NiTi rotaries also have lateral
cutting abi.lity.
ACCESSORY INSTRU MENTS
The Stropko Irrigator (Vista Dental Products, Racine,
WI) is an adapter that connects to the air/water syr-
inge and accepts standard Luer-Iock needle tips for
886/ Endodontics
pinpoint Irngation or aeration. It regulates air or
water flow to between 2 and 7 psi and provides a very
precise delivery. It aids visibility at high-power mag-
nification under a microscope.
Ultrasonically powered instrwnents with well-
adapted tips from various manufacturers have now
become indispensable (see Figure 5). They allow for
deep troughing with minimal co1]ateral loolh structure
removal. Visibility is better than with burs, and the tips
can be diamond-coated to increase their efficiency.
However, all tips develop significant heat and can cause
necrosis of the surrounding bone if used without a
coolant. Some practitioners finish their access prepara-
tions with sandblasting or finishing burs; this practice
may have an impact on composite bonding?4
Clinical Guidelines
PREOPERATIVE CLINICAL GUIDELINES
Determination of the poillt of penetration: Usually entry
is in the center of the occlusal table but in certain teet h
(e.g .. maxillary molars) it is deceiving, as the center of
Ihe occlusal table does not reflect the center of the pulp
chamber. Anatomy and strategies for access is detailed
in sections on individual teeth below.
Assessment of occlusal and external root form: Once
the point of entry has been determined, the bur's angula-
tion in three dimensions has to be mentally envisaged.
This is determined by taking into account the angulation
of the teeth in the jaws (see Figure 2) and assessing the
external root surface at the level of the CEJ.
Radiographic measurement of the depth of the pulp
chamber roof from the occlusal table: The initial bur in
the high-speed handpiece is placed against a radio-
graph or a measurement determined from a calibrated
digital image.
Assessment of compiicating factors: Rotationsltip-
ping of tooth, calcifications (stones, deep restorations,
buccal/lingual restorations (mid-root calcification),
root length, width, curvat ure) affect the angle of entry
and the degree of extension of the access cavity in the
horizontal and vertical dimensions.
Radiographic assessment: Angled views should be
taken in an attempt to visualize the breadth of the roots
and the centeredness of the canal within it. One also has
to assess the angle at which the canal leaves the pulp
chamber- the root may not seem curved but if there is a
sharp angle between the chamber and the canal, SLA will
require a significant reduction of the orifice walls. To aid
in orientation, the access preparation can be started
without rubber dam until the pulp chamber is located.
Access Cavity Preparation
Access cavity design has undergone changes through-
out the years. Originally, it was thought that the
cavities should be round in anterior teeth, oval in
premolars, and triangular in molars. This gave way
to triangular cavity shapes in anterior teeth and quad-
rilateral shapes in molars.
25
It was considered acceptable to state "make access
cavities large." Also, "make them like an inlay pre-
paration," where circumferentially around the access
cavity, every point coronal from the pul pal floor is
wider. However, these protocols resulted in excessive,
unnecessary tooth structure removaL With the advent
of microscopes, visibility has greatly improved and far
more precision is now possible. Therefore, an access
cavity should be made in such a way that only that
tooth structure necessary for the objectives of cleaning
and shaping is removed, and absolutely no more. It
has been shovVJl by several researchers that a difference
of 0.5 to 1 mm of the remaining dentin tooth structure
can improve a tooth's fracture resistance with statisti-
cal significance. Sorensen and Engelman
26
showed that
I mm of ferrule significantly increased fracture resis-
tance, while Libman and Nicholls
27
demonstrated that
there was a significant improvement bet\veen 1 and
1.5 mm of dentin ferrule height. A 5-year prospective
clinical stud/
8
showed that the remaining dentin
thickness and height affected survivability but found
no difference in survivability among cast post and core,
prefabricated post and core, and composite-only cores.
Tan et al.
29
showed a significant difference between a
uniform, circumferential 2-mm ferrule and a nonuni-
form ferrule with only 0.5 mm proximal but 2 mm
buccal and lingual dentin height (see Chapter 40,
Restoration of Endodontically treated Teeth).
It must be remembered that just having remaining
outer tooth structure around the access preparation is
not sufficient; the long-term prognosis is more accu-
rately assessed after both access preparation and
crown preparation are completed. A developing con-
cern is that full porcelain crowns require more dentin
removal to allow adequate strength to the crowns and
are becoming more popular due to their improved
esthetics. Therefore, the practitioner should not base
the access cavity design on the ease of visibility, but
only on removing what is absolutely necessary and no
more. The common retort is that restricting the access
cavity will jeopardize the success of the root canal
treatment, as visibility will be impaired. However, it
will be shown that all the objectives necessary for
cleaning and shaping can be adequately met, without
restriction of visibility or instrument access, as
unnecessary tooth structure removal is avoided. If the
access cavity has to be extended to facilitate visibility,
it should be done with precision.
An access cavity should be considered specific and
individual for each tooth and for each patient, as is a
class II restorative cavity or crown preparation. The
access cavity will vary according to the degree of
curvature within the canal (Le., the angle at which
the canal leaves the pulp chamber may be very differ-
ent from the root curvature), the position of the canal
apex relative to its cusp tip, canal length, degree of
calcification, size, shape, and position of the tooth in
the jaw. It is suggested that only the initial entry point
on the occlusal table should be based on a standar-
dized protocol but once the pulp chamber has been
found, the cavity should be " tailor-made."
Chapter 27 1 Preparat ion of Coronal and Radicul ar Spaces 1887
The sequence of steps for access preparation will be
discussed here and can also be followed in Figure 6.
The first objective is to penetrate through the occlusal
surface. Penetrating enamel or precious metal is pre-
dictable using a high-speed handpiece with a tungsten
carbide bur. Porcelain and non precious metals, how-
ever, present more difficulties, in particular with chip-
ping when a steel round bur is used. Diamond burs
easily penetrate porcelain but arc generallft much less
effi cient with metaL Stokes and Tidmarsh 0 evaluated
the cutting efficiency of diamond and tungsten car-
bide burs through metal crowns. They tested coarse
grit round and dome-ended cylinder diamonds and
si x-bladed tungsten carbide cross-cut fissure or round
burs. They found that for precious alloys, tungsten
carbide burs were significantly quicker. For the
Figure 6 Sequential steps in endodontic access preparation on an extracted lower molar. Initial entry A. with bur is angled toward buccal and distal;
narrow entry is sufficient to find the pulp chamber 8, A Uile size 110 or 115 is then used to find the position of orifices to determine points of extension
C, Further extension based on the position of orifices 0, and 8 file is now placed into the coronal portion of the canal to determine the location of the
restrictive dentin. The restriction can be seen under the microscope at the orifice level, and further extension of the occlusal surface is not warranted at
this time. The buccal surface is ufldercut to remove the pulp chamber roof mi nimizing the removal of occlusal dentin/enamel E. Similar extension is done
for li ngual. mesial. and distal surfaces F. Large pulp stones are removed by sectioning. not widening the cavity G, Once the restrictive dentin at the
orifice is removed, a file starts to contact the entire wa ll. Now only that slice of dentin contacted by the file from the occl usal surface to the orifice level
is cut with a flared-out ang le with a narrow tapered diamond bur H. so that a slot-shaped preparati on starts to develop I, This is repeatedly extended
after checking each time for location of dentinal contact with a file J. Completed access preparation shows straight-line access (SLA) into the
mesiobuccal K. and mesiolingual canal L. alter root canal filling. The fin between the mesiobuccal and mesiolingual canals can be identified under the
microscope as bli nd-ended. In case of less than ideal visibility, the mesial wall would have to be straightened and flared for deeper access and visibility.
M, A clinical example of a file placed at working length (Wl) without undue strain from the outer wall and precisely in its slol A similar clinical example
shows gutta-percha cones prior to taking master cone radiograph N.
888/ Endodontics
precious alloys, though no difference initially, after
five cavity preparations, only the dome-ended cylin-
der diamond cuts significantly faster than other bur
types. They found the di amond burs to be smoother
with less "chatter" during cutting than the tungsten
carbide burs. They concluded that cutting efficiency
appears to relate not only to grit size but to bur shape as
well. Teplitsky and Sutherland
3l
showed that of the 56
porcelai n crowns, none fractured after access preparation
with diamond burs, whereas tungsten carbide burs dulled
rapidly and were ineffecti ve. Cohen and Wallace
32
showed that of the Dicor crowns cemented with zinc
phosphate, porcelain chipped and the seal was lost after
accessing. However, when a bondable cement was used
(polycarboxylate), none of the crowns lost retention.
When penetrating a porcelain-fuscd-to-metal crown,
the porcelain should be removed with a dome-ended
cylindrical or a #2 round diamond and the nonprecious
metal penetrated with a #1 round carbide bur or a tung-
sten carbide transmetal bur.
The second objective is to find the pulp chamber. A
narrow opening is maintained initially and the penetrat-
ing bur is taken to a premeasured depth gauged by
measuring the distance betwccn the cusp tip and the pulp
chamber roof from the preoperative radiograph. As the
access preparation has not yet been extended, the clin-
ician relies on having premeasured the depth and correct
judgment of the angle of penetration of the bur based on
the parameters described above. If the pulp chamber is
large and tlle angulation is correct , the bur can be felt to
"drop" through into the chamber. However, relying on
this feeling is dangerous for it is unpredictable. If the
chamber is calcified or deep, the "drop" is often not
discernable, and unnecessary gouging of the walls or
floor or even perforation can occur, if the clinician is
not exactly on target. Therefore, the bur should penetrate
only to the premeasured distance, and if the chamber is
not found, the access should be minimally extended into
a narrow slot in the anticipated direction of the canals
using the microscope with good illumination to look for
signs of the chamber. Often a pulp horn may already be
exposed or the cavity already overextended in certain
spots. Extending the cavity without visualization usually
results in unnecessaty tooth structure loss, and therefore
extreme care must be paid. When searching for the pulp
chamber, tapered instruments should never be forced
but be allowed to cut their own way with a light touch
by the operator. \-\Then forced, they will act as a wedge.
This may cause the enamel to "check" or "craze" and will
materially weaken the tooth.
The third objective is to "unroof' the dentin that
covers the pulp chamber. This is carefully done under
the microscope with a thin needle diamond cylinder
(e.g., #859-0 10, BrasselerUSA) so as to avoid unneces-
sary widening of the isthmus. The bur is angl ed to
undercut the occlusal surface thereby maintaining as
much tooth struct ure as possible. Ultrasonic tips can
also be used very precisely to accomplish this. Round
burs should be avoided during access preparation other
than perhaps for initial penetration as they cause indis-
criminate gouging of the walls. Safe-ended cutting burs
can be used but their width is rather large for use at
this time. In this step, the clinician depends mostly on
the " feel" of the bur deep inside the tooth, against the
roof and walls of the pulp chamber, to judge the
extensions that are necessary.
The entire roofofthe pulp chamber is removed. In this
operation high-speed equipment should be operated
with vision and is not generally employed in a blind area
where reliance on tactile sensation is necessary.
The faurtll objective is to obtain uniform contact of
the file wi th the access cavity wall. A file is placed in
one of the canals and is viewed under the microscope
to evaluate the specific points along its length where it
is being held up by the access cavity or the canal dentin.
Then, with a thin needle diamond, only that area of the
cavity wall is relieved. The me is reinserted and the
process repeated unti l the file contacts dentin evenly
along its length in the chamber without undue strain. If
the restraining dentin is determined to be within the
coronal portion of the canal, GG burs or other instru-
ments that can cut a "relief channel" laterally may be
used, rather than extend the entire wall.
The fifth objective is to obtain SLA. The clinician
must assess the degree of taper to be imparted to the
dentin access wall in the one line the file is uniforml y
contacting. A radiograph can be used to help assess.
This single "slice" of dentin is then flared out to an
obtuse angle relative to the pulp chamber floor, creal-
ing a slot-like extension. All other points of the walls
are kept flared in or undercut or at as acute an angle as
possible that allows complete visibility of the floor
when viewed under a microscope. The floor and
canals will not be visible in one view-the mirror
has to be moved.
The diameter of the bur that cuts the slot extension
should only be the maximum diameter of the largest
file that is necessary at the canal orifice. A taper is not
required for that part of the access preparation
behveen the orifice and the occlusal table as compac-
t ion forces for obturation will not apply. The "010"
suffix of cylinder and tapered diamond burs connotes
the maximum cutting shaft diameter is I mm and of
"012" is 1.2 mm, etc. It should be remembered that
with natural hand movement, the diameter of the cut
made by these burs would be still larger. Therefore,
usually a #859-010 is large enough. The operator
should also be aware of the maximum diameters of
the files chosen, for example, GG4 ( l.l mm) and
ProTaper ( 1.2 mm). A 35/ 0.06 Profile is 1.3 mm at
D16, which will necessitate a larger access cavity than
is usually required for cleaning and shaping. An ori-
fice diameter can generally be maintained betv,reen 0.9
and 1.1 mm for adequate cleaning and shaping while
minimizing the loss of root strength.
The canal access slot is continually moved to the
outer surface to prevent cutting on the furcal surface
during cleaning and shaping as the larger files that
require more and more space are introduced.
The mesiodistal width of the access preparation can
be kept as small as possible. It has been shown that
the average dimensions between walls at the pulp
chamber tloor are 2.2 mm mesiodistally and 5.1 mm
buccolingually.2o Examples of basic access cavity pre-
parations, before individual slot extensions for SLA, as
well as plates covering common clinical errors, may be
seen on the DVD accompanying this text.
Maxillary Central Incisors
ANATOMY AND MORPHOLOGY
The tip of the root and the incisal edge are on the
midline from a proximal view (Figure 7).33 It is very
rare for these roots to have true second canals
34

35
but
quite common to have lateral canals. The roots are
straight and have the least incidence of dilacerations.
36
Kasahara et al.
37
used 510 extracted maxillary central
incisors wit h no abnormalities and decalcified them in
nitric acid for 48 hours. They suggested that over 60%
showed accessory canals that were impossible to clean
mechanically. Most lateral branches were small, 80%
were size #10 reamer or less, and 3% were larger than
a #40 reamer. Eighty percent of all apical foramina
Chapter 27 J Preparat ion of Coronal and Radi cular Spaces / 889
were located withi n 0.5 mm of the apex and 95%
within 1 mm.
There are many case reports showing two canals
(and one showing four canals) but usually the
crowns and/or roots are unusually large, suggesting
fusio n, gemi nation, or presence of a dens-in-dente.
However, case reports of maxillary centrals with
two roots/canals and normal crowns have been
reported.
38
.
39
CLINICAL
Initial penetration should be approximately in the
middle of the lingual surface of the tooth, just above
the Cingulum almost perpendicular to the lingual sur-
face. After locating the canal, long tapered diamonds
can be used to extend the access into a roughly trian-
gular outline. However, this extension when carried
out under the microscope can be made precisely to
each tooth to only uncover the pulp chamber and
horns and to provide continuous smooth walls down
the chamber into the canal.
Even though it has been shown that a better SLA
can be achieved through an incisal access cavity, 18
the lingual approach is used in order to maintain
as much toot h structure on the labial surface as
possible for esthetic reasons. The reciprocal com-
promise is that a lingual triangle is formed, which
has to be removed to achieve SLA. In fact,
LaTurno and Zillich
18
showed that only 10% of
the 50 maxillary central canals examined projected
solely onto the lingual surface with an SLA. Eighty-
four percent of the configurations involved at least
the incisal edge and 6% were solely on the buccal
(Figure 8) .
After initial penetration into the chamber, the
access cavi ty has to be extended precisely in both the
labiolingual and mesiodistal dimensions. In the labio-
lingual plane, there are two particular areas generally
described as the lingual and labial triangles that have
890 I Endodont ics
Figure 7 Example of a maxillary central incisor showing labiat mesial, and incisal views A, The access preparation can be assessed from a more incisal
view and a lingual view B. The width of the preparat ion in the Ci ngulum is 1.1 mm Note also the extension of the mesial and distal incisal areas to open
up the pulp horns.
to be removed to obtain an SLA. However, the lab-
ial triangle can often be a quadrilateral as shown in
Figure 9.
With rega rd to mesiodistal extension, all access
cavities should uncover the pulp horns, but special
attention has to be paid to the maxillary incisors as
the pulp horns are not in the direct line of vision of
the access cavity. If even minute amounts of tissue
remain in the pulp horns, they will subsequemly dis-
color the remaining tooth structure over time. Com-
plete extensions can be accomplished by fecling the
extension of the pulp horns under each mesial and
distal angle with a cowhorn explorer (HuFriedy). Fine
extensions that require opening with a half-round
1 2 3
A
Figure 8 Impact of initial entry int o pulp chambers of incisor teet h, from
labial (1) to incisal (21 and the usual oral access (3). A. Schemati c
diagrams for maxillary and mandibular inci sors. 8, Original micrographs
with access from incisal (top) and oral (bott om). Reprint ed with permi s-
sion from Sonnt ag 0 et al.
6
carbide bur often occur. These extensions should be
blended into the main access chamber so that residual
debris, sealer, or gUlla-percha does not become
trapped and cause discoloration. Younger patients
have more pronounced pulp horns and require parti-
cular care to remove the remaining potential tissue.
Chapter 27 I Preparat i on of Coronal and Radicular Spaces 1891
Due to the lingual approach, the points of restriction
on the files are against the coronal portion of the lingual
wall and the most incisal porrion of the labial wall .
Khademi
40
suggests notching the midpoint on the labial
preemptively to accommodate the larger files more easily.
There is a debate as to how far the incisal extension
should be taken. As we know that most anterior teeth
have a better SLA from the buccal or the incisal surface,
the operator has to assess on a case-by-case basis and
sometimes the extension will be more aggressive than
others.
Maxillary Lateral Incisors
ANATOMY AND MORPHOLOGY
These teeth have a function very similar to centrals
and are therefore si milar except for a smaller scale in
all dimensions except root length. They have more
rounded incisal angles and the root typically curves to
the distal although some can be straight or curving to
the mesial. There is often a deep developmental
groove running along the cingulum on the lingual
surface.
33
Again it is very rare to find more than one
canal,34,35 but several case reports have shown more
canals with separate apices.
41
-44 The pulp horns may
not be quite as pronounced, but the concept of lingual
shelf removal and extendi ng the pulp horns till it can
be verified with a cowhorn explorer that the angles are
smooth still holds.
Regarding SLA, LaTurno and Zillich
18
as well as
Zillich and Jerome
l7
showed that of the 131 teet h
examined, only 0.8% of canals had a coronal projec-
tion that was entirely lingual and did not involve the
incisal or buccal surfaces \vith 16% entirely on the
buccal (see Figure 9). Therefore, the clinician should
be more fastidious about the removal of the lingual
triangle for these teeth. Compounding the difficulty
of achieving SLA from a lingual approach is that
these teeth tend to have a curvature to the distal.
It must also be noted that incisors can have many
anomalies that severely increase t he difficulty in treat-
ment of these cases, for example, radicular palatal
grooves, fusion with supernumerary teeth, gemina-
tion, dens invaginatus, dens evaginatus, incomplete
apical closure; it is beyond the scope of this chapter
to cover these treatment protocols.
892 / Endodontics
Figure 9 Potential design of access into a maxillary incisor wi th schematic drawi ngs based on an original radiograph A The preoperative relation of the
canal wit hin the root can be estimated B, note how the true straight-li ne access (SlA) is labial to the incisal edge C, The initial access entry site and
angulation 0, tan-colored highlights) show the rest rictive denti n impedi ng SlA. The completed lingual access preparati on with SlA E, can be compared
to a completed access preparation done from a labial approach F, Note how far more toot h struct ure may be conserved wit h a labial access but at the
cost of disrupting the labial esthetic surface.
Maxillary Canines
ANATOMY AND MORPHOLOGY
The labiolingual measurement of the crown is about
I mm greater than that of the maxillary central incisor
and the mesiodistal measurement is approximately
J mm less (Figure 10). The position of the cusp tip
Chapter 27 1 Preparat ion of Coronal and Radicular Spaces 1893
relative to the long axis of the root is in line with the
center of the root tip in the labial view but lies labial
in the proximal view. LaTurno and Zillich
18
showed
that none of the 48 maxillary canines examined pro-
jected solel y onto the lingual surface with an SLA.
About 98% of the configurations involved the incisal
edge (of which 43% involved incisal and li ngual) and
2.1 % were purely on the buccal. UsualJy one root
Figure 10 Example of a maxillary canine showing labial. mesial. and incisal views A.. The access preparation can be assessed from a more incisal view
and a lingual view B.
894 / Endodont ics
Table 1 Summary of Studies Detallmg Root and Root Canal Anatomy of Maxillary First Premolars
Number
Author Year ,I Method
Teeth
Carns'
6
1973 100 Vacuum-<l rawn polyester cast resin, decalcil ied
Vertucci 4 ) 1979 400 Decalcified, dye injected. cast in resin, microscope
Wal kets 1987 11111 Radiographic in vitro
Pecora
4S
1991 240 OeCillcll ied. India inkdyed. gelat in injection
Caliska,,4s 1995 100 DyEKl. decalcified. stereomicroscope x12
Kartal
50
1998 300 Decafclfied, ink dye. microscope xO,&-4
PinEKl a:14 1972 259 Radiographic in vitro
Kerekes
S1
1977 20 SectionEKl. microscope
Belfilli5l 1W5 514 Radiographic in vivo
Green
53
1973 50 Gf(l und sections. microscope
Serf" 2004 200 DecafcifiEKl, dyed
I
3435 b h
cana IS present,' ut cases wIt two canals have
also been reported
45
(see Fi gure 8).
CLINICAL
These teeth have a point of entry just about the
cingulum with the tip of the bur aiming for the center
point at the CEJ level. The occlusal outline form is
oval as the single pulp horn does not tend to fan out
to the mesial or distal; however it is broad labiolin-
gually. Again, this is checked with a cowhorn explorer
and is adjusted according to the individual tooth. The
extension to the buccal or lingual is done only as
necessary to clearly uncover the horns and to allow
unheeded insertion of any file.
It is usually the longest tooth and the largest root in
the mouth and is critical to the occlusion. The canal
often curves apically. As with the central and lateral
incisors, the lingual triangle must be removed. The
main difficulty with these teeth is that they can be
long-often over 30 mm. This will affect the access
cavity in that to provide an adequate apical prepara-
tion size, SLA becomes more important.
Maxillary First Premolars
ANATOMY AND MORPHOLOGY
From the occlusal aspect, the tooth resembles roughly
a hexagonal structure, and it is much broader bucco-
lingually than mesiodistally (Table 1, Figure 11 ). As in
all posterior maxillary teeth, the measurement from
the buccal cusp tip to the lingual cusp tip is less than
the buccolingual measurement of the root at its cer-
vicalleveL As more of the buccal cusp is seen than the
lingual, the access preparation is angled buccally
into the cervical areas but not extended to the same
degree on the occlusal table. There is a marked
0"'
Tw, Three
0"'
Tw, Three
Coronal C(lr(l nal Coronal Apical Apical Apical
Callal Callais Callais Furamen Foramina Foramina
9% 85' 6% 22%
71'
S%
8% 87% 5% 25% 59% 5%
13% 87% 0% 36% 64% 0%
17.1% 80.4% 2.5% Not specifi ed Not s p ~ i f i e d Not specifiEKl
4% 97% 0% 10% 90% 0%
8.66% 89,64% 1.66% 9.66% 88.54% 1.66%
26,2% 73.3% 0.5% SO.1% 49.4% 0.5%
10% 80%
10'
10%
80'
2%
6.2% 90.5% 3.3% Not examined Not examined Not examined
8% 92% 0% 34% 66% 0%
10,5,% 85% 4.5% 28.5% 68.5% 3%
Figure 11 Example of a maxill ary first premolar showing bucca l. mesial.
and occlusal views A. and a typica l access preparation B, Note how the
buccal part of the preparation has been extended mesiodistall y to
explore a potent ial second buccal canal
developmental depression on the mesial surface that
extends from just below the mesial contact point
between the roots and ends at the bifurcation. There
is also a well-defined developmental groove in the
enamel of the mesial marginal ridge that runs into
the central groove on the occlusal table. This can be
deceiving during access as off-angulation of the bur
can result in perforation. It must be assumed that at
least two canals are present, and the third canal is
shown to exist in high enough numbers that the
access preparat ion must be designed to search for it
(either mesiobuccal or dist.obuccal canals, abbreviat.ed
Mil or DB). When three canals are present, the pulp
chamber morphology resembles that of a maxillary
molar, and they have been termed "mini-molars."
The width of the access can be kept minimal between
the canal orifices.
Chapter 27 I Preparation of Corona l and Radicu lar Spaces 1895
CLINICAL
The point of entry is centrally in the fossa, aiming at
the center point at the eEJ. The outline is an elon-
gated slot and can extend almost to the cusp tips
depending on the angle. However, the operator must
search for a third canal-usually the mesiobuccal
canal. If three canals are found, the orientation is very
similar to that of the maxillary molar (Figure 12),
Maxillary Second Premolar
ANATOMY AND MORPHOLOGY
The occlusal table is very similar to that of the first
premolar (see Figure 11), presenting without a
Figure 12 Two examples of maxi llary fi rst premolars with three canals that were endodontically treated. A clinical view of the access cavity is provided in A.
8% I Endodontics
depression in the mesial root surface (Figure l3). It has
a more rounded crown form and has a single root
when compared with the first premolar. Internally,
the incidence of hvo canals is significantly less but
Figure 13 Example of a maxillary second premolar showing buccal,
mesial. and occl usal views. The access preparation is virtual ly identical
to the one of maxillary fi rst premolar (see Figure 11).
when present they are not spaced so far apart from
each other.
Maxillary First Molar
ANATOMY AND MORPHOLOGY
It is the largest tooth in the maxillary arch wi t h four
well-defined cusps and a supplemental cusp of Cara-
belli of the mesiolingual cusp (Tables 2-4, Figure 14).
From the occlusal view, it has a roughl y rhomboidal
outline. The distobuccal cusp becomes progressively
smaller on the second and third maxillary molars.
There are two major fossae (central fossa mesial to
the oblique ridge and the distal fossa distal to the
oblique ridge) and two minor fossae (the mesial and
distal triangular fossae that li e just distal to the
mesial marginal ridge and just mesial to the distal
marginal ridge, respectively). The oblique ridge
crosses the occlusal surface from the ridge of the
distobuccal cusp to the distal ri dge of the mesioli n-
gual cusp.
CLINICAL
For the purpose of access cavities, the molars can be
viewed as having a triangular arrangement of the
Table 2 Summary of Studies Detailing Root and Root Canal Anatomy of the Mesiobuccal Root of First MaXillary Molars
0"
Two Three 0", Two Three
Number Con;mal Coronal Coronal Apical Apical Apical
Author Year 01 Teetlr Method Canal Canals Canal s Foramen Forami na Foramina
Gilles
55
1990 11 SEM aoo decalcified. injected ink dye, 9.5% 90.5% 619% 38.1%
microscope
Suhllers 2002 58 Clinically in vivo & Microscope 28.9% 71.1% Not examined Not examined

1994 208 Clinically in vivo and ioupes. headlamps Z9.8% 71.2% 68.3% 31.7%
Pomeranz!XI 1974 71 In viII{) cl inical 72% 28% 0% 89% 11% 0%
Seidberg
59
1973 100 Sectionad 38% 62% 0% 75% 25% 0%
Thomas
lO
1993 116 Radiography ex viVQ--fadiopaque 26.4% 61.1% 12 5% 53.7% 33.8% 12.5%
infusion of canals
Kulild
61
1901 51 Ex vivo accessed, ground sectrons. 3.9%% 96.1% 0% 54.2% 45.8%
microscope
200) 83 Dye, decalcified. cleared, microscope 19.3% 79.5% I.Z% 34.9% 63.9% 1.2%
magnificatioo
Vertucci.1S 1984 100 DecalCified. dye injected, cast in resin, 45% 55% 0% 82% IS% 0%
microscope
Pineda:>O 1972 262 Radiographic ex vivo 39.3% 60.7% 0% 51 .5% 48.5% 0%
Caliskan" 1995 100 Dyed. decalcil ied. 34% 66% 0% 75% 25% 0%
stereomlcroscopa x12
Weine
ll3
1999 300 Radiographic ex vivo 42% 58% 0% 66.2% 33.8% 0%
Alavi1;4 2002 52 Dyed, decalcified 32.7% 65.4% 1.9% 53.8% 46.2% 0%
ImuraS!; 1998 42 Root canal treatment ex viII{), decalcified 19% 81%' 0% 28.6% 714% 0%
5," 2004 200 Decalcified, dyed 6.5% 92.5% 1% 61 % 39% 0%
Weioo
6e
1'"9 208 Sectioned 48.6% 51.4% 0% 86.1% 13.9% 0%
Stropko
61
1999 168 Clinically in vivo (microscope onlyl 13.1% 86.9% 0% 54.B% 45.2% 0%
Wasti!i13 2001 30 Decalcified, ink dye. xlO dissect ing microscope 33.3% 66.7% 0% 56.6% 43.4% 0%
N9 2001 00 Ink dye, decalcified 30% 67.B% 2.2% 57.8% 41.1% 1.1%
Chapter 27 I Preparation of Coronal and Radicular Spaces I 897
Table 3 Summary of Studies Detailing Root and Root Canal Anatomy of the Distobuccal Root of First Maxillary Molars
0"
Two Throo
0"'
Two Three
Number Canal Canal s Canal s Apical Apical Apical
Author Voar 01 TO(lth M(lthod Coronall y Coronally Coronali y Foramen Forami na Foramon
ThomasO() 1993 108 Radiography ex vivo, radiopaque infusion of canals 95.7% 2.4% 1, 9% 95.2% 1,9% 1.9%
AI_Shalabi62 100] 81 Dye, decalcif ied, cleared. microscope xlO 97.5% 2.5% O. 97.5% 2.5% O.
Vertucci,5 1984 100 Decalcif ied, dye injected. cast in resin. microscope 100. 0% 0% 100% 0% 0%
Pieooa" 1972 161 Radiographic ex vivo 96.4% 3.6% 0% 95.4% 3.6% O.
Caliskan
5
1995 100 Dyed. decalcified. stereOOlicroscope x12 98% 1% 0% 98% 1% 0%
Alavis.. 1002 52 Dyed. decalcified 98.1% 1.9% 0% 100. 0% 0%
Sert
Sol
2004 100 Dyed. decalcified 90.5% 9.5% 0% 97. 3% 0%
Wast i
68
1001 30 Decalcified, ink dye. xl 0 dissecting microscope 83.3% 16.7% O. 83.3% 16,7% 0%
Ng 2001 00 Ink dye, decalcified 94,5% 4.4% 1,1 % 97.8% 1,1% 1.1%
Table 4 Summary of Studies Detallmg Root and Root Canal Anatomy of the Palatal Root of Ftrst MaXillary Molars
0"'
Two Three
0"
Two Threo
Number Callal Canals Canals Apical Apical Api cal
Author Vear 01 Teeth Method Coronally COfOnally COfOnali y Foramen Foramina Foramen
Thomas6() 1993 216 Radiography ex vivo. radiopaque infusion of canals 97.7% 2.3% 0% 98.2% 1.8% O.
AIShalabi
62
2000 82 Dye, decalCified. cleared, microscope xlO magnification 98.8% 12% 0% 98.8% 12% 0%
Vertucci
35
1984 100 Decalcified, dye injected, cast in resin, microscope 100% 0% 0% 100% 0% 0%
Pineda
34
1972 262 Radiographic ex vivo 100% O. O. 100. O. 0%
Cal iskan
4
, 1995 100 Dyed, decalcified, stereomicroscope x1 2 'l3% 7% 0% 97% 3% O.
Alavi
64
2002 52 Dyed, decalcified 100% 0% 0% 100' 0% 0%
Sert
M
1004 200 Dyed, decalcif ied 94.5% 4% 1.5% 96% 2.5% 1.5%
Wast i
6S
1001 30 Decalcified, ink dye. xl0 dissecti ng microscope 66.7% 33.3% 0% 66.7% 33.3% O.
Ng
69
2001 90 Ink dye, decalcified 100% 0% 0% 100% 0% 0%
Figure 14 Example of a maxillary mol ar shown in buccal. mesial palatal and occlusal views. A.- Access into both mesiobuccal canals and distobuccal and
pal atal canals is gai ned B, Note that the preparation has not been extended much on the occlusal table for the distobuccal canal as the canal prOjects
distally natural ly. All canals accept a siZe 140 or 150 hand fi le to working length (WL): access preparations may have to be extended further sli ghtly to
accommodate larger step-back files.
8981 Endodonti cs
Fi gure 15 A, 8, Schematic di agrams of maxill ary molar access preparation based on the original radiograph C, Access penet rati on and angulation shows
an initial narrow opening on the occlusal surface. 0, E, Dent in (blue areas) is removed carefully so that a file can stand upright to show exactly where the
access preparation must be extended furt her Note how the di stobuccal wall does not need to be extended sign ificantly as it naturall y proj ects distally.
cusps (without the distolingual cusp). In fact the
access cavity is made without encroaching onto
the distolingual cusp and is usuall y kept mesial to
the oblique ridge.
Maxillary molars are widely recognized as being
one of the most difficult teeth to treat endodontically.
They can present with mild to severe curvatures and
usually have hvo or three canals in any root (but most
commonly in the mesiobuccal root). Locating the
second mesiobuccal canal (MB2) orifice routinely can
be difficult as it is often buried under a bridge of
dentin. The canal can have a severe curvature to
the mesial and the buccal in its coronal section and
is usually much smaller than the principal first mesio-
buccal canal (MSl) (Figure 15). A dentin bridge may
occur due to the secondary dentin fonnation from
aging and/or reparative dentin from carious attack or
restorative procedures. This secondary or reparative
dentin is usually whiter than the pulpal floor and can
be selectively removed under magnification. The access
shape should be quadrilateral to allow for troughing
2- 3 mm lingual to MEl to search for MS2 (Figure 16).
The clinician should keep an eye on the mesial external
root surface as a guide to avoid perforating furcally or
mesially. Endodontists have reported \roughing weU
over 4 mm below the pulpal floor before uncovering
the MB2 orifice. In the following, each root will be
described separately (Figure 17).
In principle, all maxillary molars can be accessed
following a similar strategy. Entry should be in the
mesial fossa and should be kept small initially. Under
A
B
Figure 16 Variati ons in access cavity shapes in maxill ary molars_
Figure 17 A. The isthmus between the two mesiobuccal canals is
troughed and no furt her fi n or isthmus is evident. B, Measurement of
troughing depth with a periodontal probe gives the practit ioner an
obj ective perspective. C, Incorrect angulation of ultrasonic tip during
Iroughing due 10 inadequate extensi on of the mesial wall resulti ng in the
removal of furca l denti n.
Chapt er 27 ! Preparat ion of Coronal and Radicular Spaces I 899
higher-power magnification, it can be extended selec-
tively. Initial penetration may be aimed at the large
palatal canal orifice. There is ample evidence to
demonstrate that the mesiobuccal root has a second
canal with such frequency that it must be accommo-
dated for in the initial access and always searched for.
In vivo, Stropk0
67
reported finding two canals in
73.2% of first molars before using the microscope
and 93% after; 90% of the MB2s were negotiable to
the apex. He classified it as a canal if he could instru-
ment 4 mm into it. Baldassari -Cruz et al.
70
located
MB2 canals in 51% of the cases wit h the naked eye
compared to 82% with the microscope.
Gilles and Reader
55
found that the mean distance of
MB2 orifice from MBI was 2.31 mm (range 0.7 to
3.75 mm). Kulild and Peters
61
found that the distance
between MBI and MB2 was on average 1.82 mm and
the orifice was to the lingual of MBI. However, the
MB2 orifice can sometimes be found close to or even
in the palatal canal orifice (Figure 18). While two
mesiobuccal orifices are most common, three can also
be present (Figure 19).
The mesiobuccal canals have two separate apical
foramina or, more commonly, join to exit at one fora-
men (Figure 20). In contrast, the distobuccal root is
conical and usually straight but may have a slight
curvat ure to the mesial. Although far more infrequent
than the mesiobuccal root, the distobuccal root can
also have a second canal that almost invariably joins
the main (DB) canal to a common apex. It can be
found linguaUy to the main canal and usually in a
visible fin connecting the DB canal to the palatal canal.
The incidence of two DB canals ranges from 2% to 9%.
The access preparation for the DB canals does not
have to be extended as far toward its line angle as the
mesial canals. The distal canal is distally inclined and
so the file projects out of the orifice to the mesial
nat urally. Therefore, the transverse ridge can usually
be preserved (see Figure 15).
The palatal root is broad mesiodistally and its canal
mirrors it. Therefore the access should be extended
mesiodistall y. The extent to which it has to be
extended palatally can be deceiving as the orifice cor-
onally projects palatally naturally and therefore the
fil e does not seem to contact the palatal wall toward
the orifice. However, the apical third often curves to
the buccal, and to reach the apex with large files, one
needs to extend the palatal wall slot palatally and tlare
the coronal mid thirds of the canal. Again, a file is
inserted and only that area of the dentin that contacts
tbe fil e is removed to achieve SLA. This can also be
accomplished using an ultrasonic tip.
900 I Endodontics
A
B
c
Figure 18 The MB2 canal can be located anywhere along the fin between
the MBl and palatal canals. A Second mesiobuccal ori fice was found in
the entrance larrowhead) to the palatal canal and shows how the custom-
ary was inadequat e. 8, Obturation and the distance between
MBI and MB2. C, Proximity of MB2 to the palatal orifice.
Figure 19 Cli nical examples of molars with three mesiobuccal
canal orifices
Chapter 27 I Preparation of Coronal and Radicul ar Spaces 1901
Figure 20 Radiographs ill ustrating possible variati ons in the anatomy of mesiobuccal root canal system of maxillary first molars. A, Two canals joi ning
in the coronal root canal th ird. B, Widely separated cana ls but joining to a common apex. C, Separate apical foramina.
Also the palatal canal can split into two, and therefore
the access preparation needs be extended mesiodistally
(Figure 21). In such oval -shaped canals,s simple instru-
mentation with round cross-section files will not suffice for
complete debridement of the canals (see Figure 14A).
Maxillary Second Molars
ANATOMY AND MORPHOLOGY
Max.ilIary second molars are very similar in form and
function to the maxillary first molars with some varia-
tions (Table 5). The mesiobuccal and mesiolingual cusps
are larger but the distobuccal and distolingual cusps are
smaller. The cusp of Carabelli is usually absent. The
buccolingual diameter of the crown is about equal to
the firs t, but the mesiodistal diameter is approximately
I mm less. There are two types of maxillary second
molars when viewed from the occlusal aspect:
( 1) Rhomboidal: four-cusp outline similar to the first
molars but more rounded. This is the more
common form.
(2) Triangular: three-cusp form more similar to the
thi rd molar form where the distolingual cusp is
poorly developed.
The roots are usually closer together than the first
molar's and can also have two or three fused roots.
The canal system can vary from one large canal, two
canals, or three or four canals. The palatal root can
902 I Endodontics
Figure 21 Radiographs illustrat ing variat ions in the palatal root canal anatomy. A Fi rst molar showing one wide canal. B, Two canals in another first
maxil lary molar. C, Apical bifurcat ions in the pal atal root.
Table 5 Summary of Studies Detalhng Root and Root Canal Anatomy of the Mesiobuccal Root of Second MaXillary Molars
0"
Two Tliree
0"
Two Three
Number Curonal Curonal CUl onal Api cal Apical Apical
Allthor Year of Teeth Method Canal Canals Canals Foramen Forami na Forami na
Vertucci
35
1964 100 71% 57% 2% 76' 13%
" Pomeranz
58
1974 19 Clinical in vivo 61% 38. 0% 76.
14'
0%
Caliskan
45
Sert
54
2004 100 Decalcified. dyed 41% 57% 2% 76% 215% 0% (0.5%
four foramina)
Pi neda" 1972 194 64.6% 35.4% A. 72,8% 27.2% 0%
Eskoz
7
, 1995 67 Radiographic in vitro 59.7% 40.3% A. 80.6% 19.4% A.
G i l l e s ~ 1990 J7 SEM and decalcif ied. injected ink dye. microscope 29.7% 70.2% 0% 62.1% 37.8% 0%
Kuli ld
s1
''''
32 6.3% 93.7% 54.2% 45.8%
Buhrlef6 1001 36 Clinically in vivo, microscope 63.9% 36.1%
Alavi
ll4
1001 65 Dyed, decalcified 41.5% 55.4% 3.1%% 53.8% 44.6% 1.5%
Imura
65
1998 30 Root canal treatment ex vivo, sectioned, decalcified 33.3% 66.7% A. 53.3% 46.7% A.
Ng
69
1001 77 Ink dye, decalcified 49.3% 48.1 % 2.6%
74' 16'
0%
Chapter 27 I Preparat ion of Coronal and Radicular Spaces 1903
also have two separate roots with separate canals
within each. The occlusal table is smaller.
CLINICAL
Access is more complicated due to the tooth being further
back in the arch and more difficult to reach. Shorter length
burs may sometimes be needed. Gill es and Reader
55
found
that the mean diameter of the MB2 orifice in the second
molars was 0.42 mm with a range ofO.I5 to 1.00 mm. The
mean distance from MSI orifice to MB2 orifice was
2.6 mm (range 0.9 to 3.9 mm). The distobuccal canal
can sometimes be hidden tmder a large shelf of dentin.
The orifice appears on the same line joining the mesio-
buccal and palatal canals. However, during cleaning and
shaping, the shelf must be carefully removed so that the
furcal surface is not encroached upon.
The palatal root usually has one canal, as described
in vitro (see Table 6-18) . Peikoff et a1.
72
found in vivo
that only 1.4% of maxillary second molars had two
palatal roots and two palatal canals.
Maxillary Third Molars
ANATOMY AND MORPHOLOGY
From an occlusal viewpoint, this tooth usuall y pre-
sents with a heart-shaped triangular outline similar
to the second molar. The distolingual cusp is typi -
cally small and often completely absent. Unlike the
mandibular third molars, these teeth tend to have
underdeveloped crowns. The roots are often fused
forming one large root.
CLINICAL
Alavi et al.
64
found that 50.9% of third maxillary
molars had three separate roots of which 45.5% had {\VO
Table 6 Summary of Studies Detallmg Root and Root Canal Anatomy of Mandibular InCisors
0"'
Two Three
0"
Two Three
Number Coronal Coronal Coronal Apical Apical Apic81
Author Year Tooth 01 Tuth Method Canal Canals Canals Foramen Foramina Foramina
1972 ,,," III Radiographic ex vivo 59.5% 40.5% 94.6% 5.4%
Pineda].< 1972 Central 179 Radiographic ex viVll 724% 26.6% 97.9% 2.1%
lateral 184 Radiographic ex vivo 76.2% 23.8% 98,7% 1.3%
Madeira
7
1973 Central 683 Dyed, rendered 88.7% 11 .3% 99.7% 0.3%
transparent
by cleari ng agents
Lateral 6SO Dyed, rendered BB.2% 11.9% 99.3% 0.8%
transparent
by clearing agents
8enjamin
71i
1974 Born 364 Radiographic ex vivo 58.6% 41 .4% 98,7 1.3%
Venucci3!i 1984 Central 100 Decalcified. dye injected, 70% 30% 97% 3%
cast in resin, microscope
Lateral 100 Decalcif ied, dye injected, 75% 15% 98% 2%
cast in resin, microscope
Caliskan.\!;
'''5
Central 100 Dyed, decalcified, 69% 29% 1% 96% 2% 2%
stereomicroscope x1 2
Lateral 100 Dyed, decalcified, 69% 31% 98% 2%
stereomicroscope xt2
Kartal
75
1992 Born 100 Dyed, decalcilied. 55% ,,% 1% 92% 7% 1%
cleared, microscope
Miyashita
n
1997 Both 1,085 Ink dye, decalcified. 87.6% 12.4% 98.3% 1.7%
naked eye
Sen5< 2004 Central 100 Decalcif ied. ink dye 33.5% 65% 2.5% 87% 11% 2%
Lateral 101 Decalcified, ink dye 36. 8% 62.7% 0.5% 90% 9.5% 0.5%
Belliui
78
1983 Central 154 Radiographic in vivo 83.1% 16.9% No<
N"
examined examined
lateral 163 Radiographic in vivo 79.6% 20.2% No<
N"
examined examined
1988
Central 100 Radiographic ex vivo 78% ,,% ,,% 1%
La teral 100 Radiographic ex vivo 68%
31'
99% 1%
Green
53
73 Bom SOO Ground sections, microswpe 79%
"'
96% ..
AI-Qudahl:lO 06 Bom 4SO Decalcified, cleared. naked eye 73.8% 26.2% 91.4% B.7%
904 I Endodontics
or more canals in the mesiobuccal root. About 45.7% had
fused roots, 2% had C-shaped canals, and 2% had four
separate roots. Therefore, modifications must be made in
accessing these teeth compared to first and second molars
to accommodate these anatomical variations.
Mandibular Central and Lateral
Incisors
ANATOMY AND MORPHOLOGY
The mandibular central incisor is usually the smal-
lest looth in the mouth, having a little more than
half t he mesiodistal diameter of the maxillary central
incisor; however, the labiolingual diameter is only
about I mm less (Table 6, Figure 22). Bilateral
symmetry is usually evident wit h central incisors. )3
There are slight di fferences benveen central and lat-
eral incisors, but the most important wit h regard to
access is that the crowns of lateral incisors are not as
symmetrical as cent ral incisors from the incisal view
as they curve distall y to accommodate the curvature
of the arch and correspondi ngly the cingulum is
displaced slightly to the distal. Lateral incisors are
also slightl y larger than the centrals; t his is the
reverse relationship found in the maxiUary incisors.
33
The incisal edge relative to the long axis of the root
in the proximal vicw is lingually placed- this is clini-
cally corroborated by LaTurno and Zillich's study.18
However, this should have litt.le bearing on the access
preparation, and the two teeth can be approached with
the same criteria. It is important to note that often the
most bulbous or the broadest lingual aspect of the
tooth is below the free gingival margin. Therefore,
using the free gingival margin to determine the extent
of lingual extension of the access cavity can leave it
underextended. One has to use a probe to palpate the
contour of the crown below the free gingival margin.
CLI NICAL
According to LaTurno and Zillich,18 incisors do not
have SLA projections entirely on the lingual; all invol-
ved the incisal edge andlor the facial surface (6%
projected completely onto the buccal) (see Figure 8).
Mauger et 011.
8
in a similar study fowld that an ideal
SLA was at the incisal edge in 72.4% and in 27.6% was
facial of the incisal edge. They also found that as the
wear of the incisal edge increased, the ideal access
moved from the fadal toward the incisal. Similarl y,
Sonntag ct al.
6
showed that a shift toward the incisal
edge resulted in more adequate preparation and in
fact less loss of hard tissue.
The entry point for access should be just above the
cingulum with the bur angled perpendicularly to the
surface of the entry point. As these teeth are narrow
mcsiodistally, the main concern is the width of the
preparation. No more than a #112 round bur or a long
thin cylindrical diamond is used to initiate the access,
followed by a cylindrical diamond bur to extend only
as a slot in a labioli ngual dimension. The main point
bei ng t.ha l unnecessary extension toward the mesio-
distal surface is avoided. Even the thi nnest bur will
provide an adequate width once collateral hand
movement is taken into account. The disadvantage is
of course that visibility is restricted and therefore the
use of microscopes becomes paramount.
Once the chamber or Ihe canal is found, the access
can be precisely widened for each individual tooth
according to its SLA projection. The other point is
that 40% of mandibular incisors have two canals-
buccal and lingual with only 2 to 3% having separate
apical foramina (Figure 23). The lingual is by far the
harder to locate because the angulation of these teeth
in the jaws is proclined (see Figure 2). It is natural for
the hand to angle the bur toward the buccal (thereby
running the risk of gouging Ihe labial wall ). The
lingual canal lies I to 3 mm away from the buccal,
directly under the cingulum. Even when two canals
are present, there is often a fin or a groove with pulp
tissue between them (see Figure 23).
In summary. fi nding ext ra canals requires convic-
tion that they arc there and extending the access to
look for t hem. Although the two canals seldom exit as
separate apices, bacterial by-products from the necro-
tic tissue in t he unfilled canal can communicate with
the periodontal ligament via lateral canals or through
a poor apical seal.
Mandibular Canines
ANATOMY AND MORPHOLOGY
These tceth are very similar to their maxill ary coun-
terparts and can be described in relation to them
Chapter 27 1 Preparation of Coronal and Radicular Spaces 1905
Figure 22 A Example of a mandibular incisor showi ng labi al, mesial, and incisal views. 8, The access preparation can be assessed from a more inci sa l
view and a lingual view. Note how the lingual extension 01 the access preparati on extends well into the cingulum.
906 1 Endodont ics
Figure 23 Radiographs illustrating variat ions of lower incisors with two canals. A.. Although usually both canals exit from a common apex, they can,
B, have two separate or a figure eight-shaped foramen.
(see Figure 18A). Mandibular canines are usually nar-
rower than maxillary canines (approximately 1 mm) and
shorter in root length by 1 to 2 mm (Figure 24) . The
mesial edge is almost straight and therefore the access
cavity can be prepared more to the mesial of the center
point of the lingual surface. Also the cusp t i ~ is incli ned
more to the lingual, similar to the incisors.
3
According
to LaTurno and Zillich/
8
none have SLA projections
entirely to the lingual; 90% involved the incisal edge or
incisal edge and buccal surface with 4% entirely on the
buccal. Canine crowns are asymmetrical with a larger
distal half. Therefore, the access preparation can be
started just slightly to t he mesial of the mid-point mesio-
distal ly, and checked that it corresponds to the center
point at the CEJ. Similar to t heir maxillary counterparts,
mandibular canines extend buccolingually, albeit to a
smaller extent.
Heling et al.
82
reported a mandibular canine wi th
two roots and three canals but did not state whether
two or three apical foramina were present. Orguneser
and Kartal
83
reported a case of a three-canal mandibu-
lar canine with two apical foramina.
Chapter 27 / Preparati on of Coronal and Radicular Spaces / 907
Figure 24 A.. Example of a mandibular canine showing labia l, mesial, and incisal views B, The access preparat ion can be assessed from a more incisal
view and a lingual view. Note that the access is extended lingually to look for a second, usuall y linguall y located canal.
CLINICAL
The shape of the preparation ranges from an oval to a
rounded slot depending on the size of the pulp chamber
inside. As cani nes have large roots, the MAF (Box I) is
also large (size #40 to #60). Therefore, after creating a
tapered preparation via step-back or rotary files, the
Box 1 DeSCriptors of Canal Shapmg Procedures
Wl
WW
IAF (1M)
MAF(MAR)
FF IFR)
Worki ng length
Working wi dth
Initial apical file/rotary
Master apical file/rotary
Final file/rotary
908 I Endodontics
U 1'1[-
Figure 25 Radiographs of a treatment sequence illustrating two canals in a mandibular C<lnine.
coronal orifice will be larger than for incisors mesiodis-
tally (Figure 25).
Mandibular First Premolars
ANATOMY AND MORPHOLOGY
The mandibular first premolars have characteristics
of a small canine because of a sharp buccal cusp
(only occluding cusp) and a small lingual cusp that
sometimes resemble a cingUlum (Table 7, Figure
26). There is a characteristic mesiolingual develop-
mental groove that makes the tooth asymmetrical.
From the occlusal view, the outline is diamond-
shaped and similar to the mandi bular canine. These
teeth have a variable root anatomy. The crown is
lingually inclined that makes searchi ng for a lingual
canal difficult. Therefore, the access has to be
extended further to the lingual to search for it. This
feels counterintuitive, as the lingual cusp is very
small .
Nall apati
88
reported a case where both fi rst and
second premolars had type V anatomy, that is, three
canals with separat.e apices, while Baisden et al.
8S
reported the possibility of C-shaped canal anatomy
in mandibular premolars.
Table 7 Summary of Studies Detailing Root and Root Canal Anatomy of Mandibular First Premolars
'"'
Two Three
,,,
Two Three
Number Coronal Coronal Coronal Apical Apical Apical
Author Year of Teeth Method Canal Canals Canals Foramen Foramina Foramina
VertucdS.g.o
78/84 400 Decalcified. dye injected. cast in resin. ,,% 29.5% 0.5% '4% 25.5% 0.5%
microscope
72 102 Radiographic ex vivo 69.3% 29.8% 0.9% 74.2% 24.9% 0.9%
Baisdenll5 91 106 Seri al sect ions. stereomicroscope x12
".
16% ' 6% 24%
gs
100 Dyed, decalcified, stereomicroscope x12 64% 30% 6% '5% 19% 6%
Zili ich
all
73 1.297 Radiographic ex vivo 75.1% 24.5% 0.4% 77. 2% 22.5% 0.4%
Yoshioka
87
04 ", Ink-dyed. demine ralized BO.6% 15.1% 4.3% (three
"01 "01 "01
to four canals) reported reported reported
04 200 Decalcif ied, ink-dyed 60.5% 38.5% 1% 89.5% 9.5% 1%
G
reen
!l3
73
'"
Ground sections and microscope 86% ,,% 0%
""
10% 0%
Chapter 27 I Preparation of Coronal and Radicular Spaces I 909
Figure 26 A, Example of a mandibular first premolar showing buccal. mesial. and occlusal views_ 8, The access preparation can be assessed from an
occlusal view.
CLINICAL
The entry point is in the middl e of the central groove,
and the bur is directed to the buccal. Again, the access
shape is an oval slot. As the crown is li ngually
inclined, the access cavity will result in the removal
of more of the buccal cusp than the lingual
(Figure 27) .
Mandibular Second Premolar
ANATOMY AND MORPHOLOGY
Unlike the maxillary premolars, the mandibular sec-
ond premolar is quite distinct from its neighboring
first premolar (Figure 28) . It resembles the first only
fro m the buccal aspect but is othenvise larger. The
tooth has two forms from the occlusal aspect, the
more common three-cusp type and the two-cusp
type. With the three-cusp type, the buccal cusp is
the largest followed by the mesioli ngual cusp and then
the distolingual. The occlusal outline is square. The
two-cusp form is morc rounded and has a smaller
occlusal table. Case reports detailing four
S
9-91 and five
92
coronal canals but only one showing four apical for-
amina have also been reportcd.
89
CLINICAL
Access is similar to first mandibular premolars, taking
overall dimensions into account.
Mandibular First Molars
ANATOMY AND MORPHOLOGY
The occlusal surface of mandibular first molars has one
major (or central) and two minor (mesial and distal)
910 I Endodonti cs
Figure 21 A. 8, Two exampl es of lower first premolars with two canals. C, Photographs of an ext ract ed tooth demonst rate a C-shaped root cross
section and suggest the impossibility of adequately cleaning and shaping the enti re canal system.
triangular fossae (Tables 8 and 9, Figure 29). These
teeth usually have two distinct buccal and two lingual
cusps and one distal cusp. The buccal cusp tips are
located more to the midline on the occlusal table com-
pared to the lingual cusp tips that are almost directly
over the outer surface at the "neck" of the tooth. There-
fore, access preparations often encroach on the buccal
cusp tip (mesiobuccal) but rarely onto the lingual.
Mandibular molars are known to have complex
anatomy and like their upper counterparts can be
deceptively difficult to treat, as the radiographic
canal anatomy can appear simple in two dimensions.
There are usually four canals but three and five
canals are well documented and one, two, and six
canals have been reported. It is important to note
that there is almost always a concavity on the furcal
side of both the mesial and distal roots; therefore
care must be taken during cleaning and shaping to
avoid strip perforation. The roots start to bifurcate
3 mm below the eEJ. This gives a sense of the depth
at which furcal perforation is possible. As the access
cavity determi nes cleaning and shaping, the access
cavity has to be designed to allow for protection of
the furcal surfaces during instrumentation.
Chapter 27 I Preparation of Coronal and Radicular Spaces I 9n
Figure 28 A, Example of a mandibular second premolar showing buccal, mesial, and occlusal 8, The access preparati on can be assessed from an
occlusal view.
Table 8 Summary of Studies Detalhng Root and Root Canal Anatomy of the MeSial Root of Mandibular First Molars
Number
0"
,I Coronal
Author Year Teeth Method Canal
Gulabivala
93
2002 118 Vac uum applied. dyed. 3.4%
decalCified. melnyl
salicylale
S,rt" 2004 200 Decalcified aod dyed 2%
1998 49 VacuumdraWfl Ouralay resin 6.2%
Skidmore')!; 1971 45 Vacuum-draWfl polyeSlcr 6.7%
caSI resin. decalcified
PinedaJol 1972 300 Radiographic ex vivo 12.8%
Vertucci
JS
1984 100 Decalcif ied. dye 12%
injected. cast in resin.
microscope
1995 100 Dyed. decalcified. -4%
stereomicroscope x12
Walker'll:l 198B 100 ex ViVO 3%
Wasti
ll8
2001 30 Decalcified. Inkdyed. xl0 0%
dissecting microscope
Pomeranz'll 1001 51 Clinical in villU No<
reported
Fabra 1985 145 Radiographic clinical 0%
in vivo
Da Costa!jg 1996 199 Decalcif ied, India ink-dyed 7.5%
gelatin injection
Both mesial and distal roots arc broad and usuall y
have two canals and often have an interconnecting fin
that can be extremely variable in its persistence at the
Tw, Three Four
0"'
Tw, Three Four
Coronal Coronal Coronal Apical Apical Apical Apical
Canals Canals Canal s Foramen Foramina Foramina Foramina
89.8% 5.9% 0.8% 35.6% 60.2% 3.4% 0.8%
94% 4% 51% 47.5% 1.5%
91.8% 2% 53.3% 36.1% 0%
93.3% 44.4% 55.6%
87.2% 0% 43% 57% 0%
87%
"
4fl% 59% 1%
-00% -3%
37'
56.6% 3.4%
00'
.. 24% 75% 1%
96.7% 3.3% 23% 73.7% 3.3%
No< 11.5% No< No< 1.6% No<
reported reported reported reported
97.2% 2.8% No< No< 0%
reported reported
92.7% 54.8% 45.4%
apex. Mannocci ct aJ.
1oo
found that of the 20 mesial roots
observed with microcomputed tomography, 17 had isth-
muses in onc or morc of the secti oned apical five
912 / Endodontics
Table 9 Summary of Studies Detailing Root and Root Canal Anatomy of the Distal Root of Mandibular First Molars
Number
0"
Two Three Four 0", Two Three Four
of CorOllal Corollal CorOllal CorOllal Apical Api cal Apical Apical
Author Yaar Taeth Method Canal Canal s Canal s Canal s Foramen Foramina Foramina Foramina
Gulabivala
93
2002 lIB Vacuum appl ied, dyed, 59.3% 34.7% 5,1 % O.B% 66.9% 28% 4.3% 0.8%
decalcified,
methyl salicylate
"'''''
2004 200 Decalcified and dyed 53.5% 45.5%
"
87% 12%
"
1998 49 Vacuurn--drawn 8.2%% 91 .8% 0% 83.7% 16.3%% 0%
Duralay resin
SkidmOfe
95
1971 45 Vacuum-<lrawn polyester 71.1% 28.9% 88.9% 11.1%
cast resin, decalcif ied
PinedaJ.i 1972 300 Decalcified, dye injected, 70% 27% 0% 85.7% 14,3% 0%
cast in resin,
microscope
1984 100 Decalcififfil. dye 70% 30% 0% 85% 15% 0%
injected, cast in resin,
microscope
Cal iskan
5
1995 100 Dyed, decalcified, 60% 52% 2% ,,% 17% 2%
stereomicroscope x12
1988 100 Radiograpic in vitro 55% 45% 0% 72% 28% 0%
WastiOl! 2001 30 Decalcified, ink dye, xlO 30% 70% 0% 56.7% 43.3% 0%
dissecting microscope
Fabra-Campos96 1985 145 Radiographic clinical in vivo 50.34% 49,6% 0% No< No< No<
reponffil reported reported
Da Costa!19
'"
199 Decalcified, India inkdyed 78.9% 21.1% 90.5% 9.5%
gelatin injection
Figure 29 hample of a mandibular molar showing buccal mesial occlusal views. For access preparat ions, please see Figures 6 and 30.
millimeters. Only four of the 17 roots had an isthmus
that was continuous from its coronal beginning to its
apical end, the other 13 had sections with and without
the isthmus. The third section from the apex had the
highest incidence of ist hmuses (50%). Two distal roots
can occur but are rare--however, reported to be more
prevalent in the South .. ::.ast Asian population.
CLI NICAL
The important point to note with the mandibular
molars is the d e ~ r e e to which they are lingually and
mesiall y inclined. 9 To prevent unnecessary gouging of
the axial wall s of the access preparation, the bur should
mimic this angulation of the tooth in the mandible.
Chapter 27 1 Preparati on of Coronal and Radicul ar Spaces 1913
The entry point is just mesial to the central pit. Initially,
the access preparation should not be extended further
distally as the distal canals project mesially 100vard the
occlusal table. Once the angle of the canals has been
determined with files, the decision can then be made to
extend the access distally if needed. However, the access
will be located largely in the mesial half of the tooth, as
SLA for the mesial canals will dictate. Sometimes it is
necessary to encroach on the mesiobuccal cusp tip to
achieve SLA (Figure 30).
The groove between the mesiobuccallmesiolingual
and distobuccalldistolingual canals must always be
troughed with a bur and/or ultrasonics and checked with
files to search for mesial canals (Figure 31 )-this can be
best accomplished with a microscope.
Figure 30 A. Access preparation in a mandibular molar wi th moderate/severe root curvature. B, Hand files can be placed to length in all three mesial
canals after adequate access and canal preparat ion. C, However. the access preparati on requires an extreme extension for the mesiobuccal and
mesi olingual canals due to the root curvature.
914 I Endodontics
Figure 31 Anatomical variations in lower first molars and the potential for a negative clinical outcome. A, Tooth di agnosed with a failing root canal
treatment that had had an apicoectomy completed 8 months earl ier. The postoperative buccal and distal views show three mesial canals with separate
portals of exit. probably causing the persi stent infection. B, Mandibular third molar with preoperative view as well as stra ight and di stal postoperative
views. Thi s tooth presented with three mesial canals; typically the middle mesial canal jOins ei ther the mesiobuccal or the mesiol ingual canal early and is
a more common form than the one in A. C, Tooth diagnosed with radix entomolaris The distolingual root often has a signif icant curvature in the
buccolingual plane and can therefore be deceptively difficult to treat.
The distal canal is ovoid or figure eight-shaped
buccolingually if only one canal is present, and a
microscope should be used to confirm this. There
can be a second distal canal that bifurcates in the
apical thi rd- to minimize chances of missing these;
the walls of the preparation should be di vergent,
and the clinician should be able to see the entire
surface of the buccal and distal wall s of the canal to
the apex with a mi croscope. It is advisable to " feel"
the wall of the canal with precurved files for areas
in the middl e and apical thi rds of the canal where the
instruments may stick.
It is easy to assume that the canals curve only to the
mesial or the distal, but because these roots are so
broad, they always have a curvature in the buccolingual
dimension that cannot be assessed radiographically.
Cunni ngham and Senia
l4
showed that of the 100
mesial roots of mandibular molars. all demonstrated
curvature in mesiobuccal and mesiol ingual canals in
both buccal and proximal vi ew radiographs. They
reported a reduction of canal curvature after coronal
flaring. It is important to remember that the flaring will
have to occur in both the mesial and buccal planes for
mesiobuccal canals as well as in mesial and lingual
planes for mesiolingual canals. Similar planes need to
be addressed respectively for the distobuccal and dis-
tolingual canals. Fabra-Camposlol found that 4 molars
out of 145 had five canals that were confirmed radio-
graphically-the extra canal was the middle mesial
canal in the mesial root.
The presence and impact of furcat ion canals has
been widely discussed. Vertucci and Wiliiams, lo2
using decalcification and staining. fou nd that of the
100 mandibular fi rst molars, 46% had furcation
canals and 13% had a single lateral canal from
the floor to the interradicular region. Of these,
57.1% extended from the center of the pulp floor,
28.5% arose from the mesial aspect of the floor, and
14.4% extended from the distal aspect. In 23%. latcral
canals were found origi nating in the coronal third
(distal root 80%, mesial 20%). Finally, in 10% of the
cases, both lateral and furcation canals were found.
Vertucci and Al1 lhonylOJ used scanni ng electron
microscope (SEM) and fou nd 32% of mandibul ar
first molars and 24% of mandibular second molars,
a total of 56% wi th accessory canals. Although rela-
tivel y uncommon, mandi bular first molars can also
have Cshaped canals.
IM

IOS
In a study on Burmese
subjects, about 10.1 % of observed teeth had an extra
di stal foot on the lingual aspect (radix e"tomolaris).l06
Gulabivala et al.
93
found an additional distolingual
root with onc canal and one apical fo ramen 12.7%
of the time (see Figure 31 C).
Chapter 27 I Preparat ion of Coronal and Radicular Spaces f 915
Mandibular Second Molars
ANATOMY AND MORPHOLOGY
Generally, mandibular second molars differ from the
first molars in their capacity for variation (Figure 32).
Usually the crowns and roots of second molars arc
smaller than the first molars by less than a millimeter
in aU dimensions. The occlusal table is more symme-
tri cal and rectangular wi th four equally apportioned
cusps; a fifth cusp is not present. The roots of the
second molars are inclined more distall y, in relation
to the occlusal table. than the first molars, but less than
the third molars. Therefore, the access cavity may have
to be extended more toward the mesial marginal ridge
than for first molars. The roots, and therefore canals,
are usuall y closer together and can be fused to a single
conical root with varyi ng internal anatomr or often
C-shaped canal systems. Cooke and Cox
lO
were the
fi rst to report C-shapcd configurat ions in mandi bular
molars. Weine et al.
I08
evaluated 811 endodonti -
cally treated second molars and reported 7.6% had
C-shaped c., nal systems.
CLINICAL
The entry point of the access cavity should be mesial
to the central pit si milar to the fi rst molars, but may
not require the same degree of mesial extension if the
roots are closer together. Otherwise, a si milar pre-
paration as for the fi rst molar can be made. Cleaning
C- shaped canals is unpredictable as there are many
different types with several subtypes. The access cav-
ity will follow the curva ture of the canals.
According to Melton,109 C-shaped canals can be
di vided into three categories:
Category I: The continuous C-shaped canal is any
C-canal outline without any separation.
Category JJ: The "semicolon" -shaped canal-referred
to canal configurati ons in whi ch dentin separates
one distinct canal from a buccal or a lingual c-
shaped canal in the same section.
Cntegory III: Simply with two or more discrete and
separate canals.
Mandibular Third Molars
ANATOMY AN D MORP HOLOGY
Third molars have significant variations and anoma-
lies. They are usuall y less developed, with oversized
crowns and undersized roots. Due to the lack of space
in the jaws, they are often impacted and may have
916 I Endodont ics
Figure 32 Variati ons in mandi bular second molar anatomy. As Common anatomy. B, Apical bifurcation. C, Oilacerated roots. 0, Four separate apical
foramina. f. F, C-shaped configurati on.
very curved roots. They may have four or five cusps.
Usuall y. when in good alignment and occlusion, the
crmVll is likely to have four cusps and is similar to the
second molar. Usually third molars have two roots-a
mesial and a distal root that can be bifurcated or
fused. When fully erupted and in functional occlu-
sion, third molars provide excellent protection for the
first and second molars by spreading the occlusal
load. I n such situations, keeping these teeth is bene-
ficial and therefore knowledge of their anatomy and
morphology is important.
CLI NICAL
Similar to mandibular first molars, anatomical varia-
tions will requi re modifications compared to acces-
sing first and second molars.
Procedural Mishaps
Successful endodontic treatment originates from a
well-designed and executed access preparation. The
opposite is also true; errors during Toot canal
treatment can often be traced back to a problem
originating from an inadequate access preparation.
Errors generally stem from two access cavity charac-
teristics: underextension and overextension.
UNDEREXTENSION
Not opening up the access cavity across the width of
the root sufficiently can result in the operator missing
canals. They can often be buried under calcified dentin.
However, if the canal is found but the cavity is not
extended away from the furcation sufficiently, the file
will preferentially cut the furcal dentin causi ng a strip
perforation. Another possibility, of not extending the
access far enough, is that the coronal canal curvature is
not removed. This will increase chances of inslrument
separation as the file tries to go around more than one
curve, or transportation at the apex as the coronal
canal curvature renders the file tip uncontrollable.
Underextension of the access preparation also limits
the final diameter of the apical preparation size. In
anterior teeth, if the pulp horns are nOl adequately
exposed and cleaned, the remaining pulpal tissue will
cause coronal discoloration.
OVEREXTENSION
Generally, overextension will cause unnecessary
removal of tooth structure that weakens the remain-
ing crown and ultimately decreases the long-term
prognosis of restoration, and therefore the tooth.
With the acceptance of implants thaI have good
long-term prognosis, remaining tooth structure will
be the critical determinant between these two treat-
ment choices.
Effect of Access Cavity Preparation on
Structural Integrity
There is little debate that endodontic treatment weak-
ens teeth resulting in an increased susceptibiliry to
fracture (Figure 33).110 But it has been widely stated
that this may be due to endodontic treatment result-
ing in increased brittleness of the dentin. 11 1- 114 How-
ever, it does not seem that root canal treatment
changes the quality of the dentin, except some moist-
ure loss,1I5 and it is thought that weakening of the
tooth is more a result of tooth structure loss.
Usin
tP
strain gauges in extracted premolars, Reeh
et al. I ! showed that endodontic procedures reduced
the relative cuspal st iffness by only 5%. This was in
contrast to an occlusal cavity preparation (20%), an
Chapter 27 I Preparation of Coronal and Radicular Spaces 1917
MOIDO cavity (46%), and an MOD cavity prepara-
tion (63%). Howe and McKendryl1 7 examined 40
freshly extracted noncarious, unrestored human
mandibular first and second molars, prepared endo-
dontic access preparations and/or MOD amalgam
cavities, and then subjected them to increasing
occlusal load until fracture. They found that an
endodonti c access cavity, or a conservative MOD
cavity, fractured at the same load (225.5 and
222.4 kg, respect ively). On the other hand, an access
cavity with both marginal ridges breached fractured
with significantly less load (121.7 kg). Intact teeth
fractured at signi fi cantly more force (341.4 kg) than
all other groups. They suggested that when access
cavities are kept conservative and proximal tooth
structure remains intact, simple restoration of access
cavities might suffi ce.
Sedgley and Messer
l18
studied whether loss of pulp
vitality resulted in changes in tooth structure as mea-
sured by biomcchanical properties (punch shear
strength, toughness, load to fracture, and microhard-
ness). Twentythree matched pairs of teeth were
obtained where one tooth in each pair had endodontic
treatment while the other was vital. Teeth were extracted
and for comparison, data were collected immediately
after extraction and after 3 months. The authors found
no significant differences in punch shear strength,
toughness, and load to fracture between groups. Vital
dentin was 3.5% harder than the endodontically treated
matched pair. They suggested that the dentin does not
change in character but rather it is the cumulative loss
of tooth structure from caries, restorative, and endo-
dontic procedures that increases the susceptibility to
fracture. Another possibility is that loss of pressorecep-
tion or an elevated pain threshold may allow larger
loads without triggering a protective response.
In a study similar to eXferiments by Reeh et al.,!!6
Panitvisai and Messer
1
! measured actual cuspal
deflection (rather than relative cuspal stiffness) and
used more extensive cavity preparations (no tooth
structure between access cavity and box preparation)
to simulate clinical situations more closely. They used
13 extracted human mandibular molars and used a
ramped load of 100 N to the mesial cusps. Increas-
ingly extensive MO or MOD cavities were prepared,
tested, and finally followed by an access preparation.
They found that cuspaJ deflection increased with
increasing cavity size, with the greatest deflection after
access preparation when cuspal deflections of more
than 10 pm were observed. They reiterated the impor-
tance of cuspal coverage to minimize marginal leakage
and cuspal fracture.
918 1 Endodont ics
A B
Figure 33 A Improper angulation of the bur resulted in furca l perforation. 8, Underextension of the mesial wall causing a strip perforation in the
mesiolingual canal.
Radicular Preparations
OBJECTIVES
Upon the completion of the coronal access cavity
and the identification of root canal orifices, pre-
paration of the root canal system is initiated. Root
canal preparation serves two main objectives:
mechanical and chemical elimination of intracanal
tissue and pathogens, aided by antimicrobial sub-
stances and by optimized foot canal fiJ1ings.1 20-J22
A well-executed root canal preparation is a prc-
requisite for success (Figure 34).
Using anaerobic culturing, a reduction of intracanal
bacteria after canal preparation has been demon-
strated to a level of 10 to 100 CFU/mL,9.123- 127 but
Chapter 27 / Preparation of Coronal and Radi cular Spaces / 919
it is highly unlikely that any root canal is rendered
sterile in a clinical setting. Both clinically successful
and failing cases illustrate the presence of bacteria and
. II 128- 130 H .. " "
Immune ce s. owever, 10 usmg stnngent cn-
teria for assessing healing of apical periodontitis, that
is, the reconstitution of a lamina dura around the
entire root perimeter
131
as well as the absence of
inflammatory cells, only 6% of endodontically treated
teeth were deemed successful.
128
The fate of bacteria
initially remaining in inaccessible canal areas, regard-
less o"f the clinical technique, 132 has been a matter of
speculation: do they die from starvation,133 are they
killed by sealer components
134
or can they survive and
cause posttreatment disease? i35 On the other hand, a
comparison of histological and clinical material
Figure 34 Examples of root cana l-treat ed fi rst maxill ary and mandibular molars in which cl eaning and shaping was done adheri ng to the principles laid
out in thi s chapter. Radiographs represent situation immediately after root cana l filli ng
920 / Endodontics
..
. , I
B
" ..
. , .lo!
;'"" ... ,
. ,
Figure 35 Healing is commonly detected by clinical and radiographic appearances and only occasionall y it is possible to assess the outcome of root.
canal treatment histologicall y. Both cases shown here had preoperative diagnoses of chronic periapical periodontitis and were extracted for
nonendodontic reasons. A. During the 13-ycar follow-up period of this case, the mesial root apex of this mandibular molar di d not present complete
healing of the original radiolucency, despite the absence of symptoms. The obvious reason was the presence of bacteria, as shown in the histological
images. B. In this mandibular molar, the periapical region of the distal root exhibited radiographic healing. contrary to the mesial root. \'/here a vertical
fracture was the ultimate reason for extraction, Radiographic features of healing were confirmed by the histological picture. showing fibrous uninflamed
tissue in the apical part of the root canal and calcified ti ssue. The latter did not completely obturate the lumen, as shown by serial sections. Images
courtesy of Dr. Domenico Ricucci.
presented in Figure 35 demonstrates that histological
success is present only if microbial contamination is
absent.
136
Furthermore, it was recently shown that well-filled
and presumably well -shaped canals may still be asso-
ciated with failing rool canal treatments, mainly due
to the fact that microorganisms remain in inaccessible
areas of the root canal system.
137
,138 Consequently,
rather than "sterilizing" root canal systems, intracanal
procedures are tailored to reduce microbial burden,
9
....
8
E
7
'"
6
0
5
-
'"
0 4
""
3
::>
...
2
()
1
-
10 20 30 40 50 60 70
A MAF IISO ' I
100
~ 80
0
-!!
60
,
'"
40
~
c
20
e
....
B MAF IISO'I
Figura 36 Proposed relationships between preparation size and elim-
ination of bacteria as well as prepared canal surface. A Based on
bacterial sampling with a detection threshold of about "10 colony fOfming
units (CFUI. this threshold. essentially a canal with negative culture, may
be reached OIl various pathways (colored lines in graph). B, Based on
microcomputed tomography and analysis of cross sections, complete
preparation of canal surface is unlikely. Again. values between 40 and
60% treated surface may be obtained with various canal shapes and
apical sizes.
so that it becomes compatible with success, by creat-
ing condit ions prohibiting regrowth and persistent
infection.
Apparently. a threshold may be reached with
different disinfection and preparation paradigms
(Figure 36) that depend on numbers, virulence, and
location of surviving microorganisms. The objective
of root canal preparation, therefore. is to provide an
environment in which periapical disease is prevented
or the body's immune system achieves healing peria-
pical disease.
A futuristic vision of ideal endodontic treatment is
to replace necrotic or irreversibly inflamed pulp tissue
Chapter 27 / Preparation of Coronal and Radicular Spaces / 921
with new healthy pulp tissue. Revascularization of
empty pulp spaces in juvenile teeth may occur. but
it is an ongoing topic of investiation and many open
questions are yet to be solved. I 9, 140
Because this ultimate goal is not yet obtainable.
clinicians still have to deal with contaminated and
inflamed pulp tissue. Rendering or keeping root
canals bacteria-free during endodontic treatment is
one of the most important goals to achieve successful
heaLing or to maintain periapical health.
14 1
To reiter-
ate, the prime condition under which medical profes-
sionals work, nihil rlOcere or "do not harm." should
prevail in root canal t reatments and canal preparation
in particular, since obvious iatric errors are likely to
decrease the prognosis of a case.
EVIDENCE AND STRATEGIES FOR
SHAPING THE ROOT CANAL SYSTEM
The fi rst object ive. elimination of tissue and patho-
gens. is achieved by skillfuJ instrumentation includ-
ing copious irrigation and. if deemed necessary.
interappointment medication. Mechanical instru-
mentation alone is effect ive in reducing bacterial
load,142,143 but should be complimented with irriga-
. f h 1" 144:145
tlon to urt er e lmlllat e mlcroorgamsms. '
Some authors have differentiated behveen the mere
flushing action of saline142.146,147 and the added anti -
microbial effect of the most w i d e l ~ used irrigant,
sodium hypochlorite (NaOCI).148.14 Both of those
actions are dependent on canal size and shape,10,150
but (he latter depends also on factors such as NaOCI
turnover, t he amount of available chlorine, and con-
t act time (for a more detailed review of endodontic
irrigants, see Chapter 28, Irrigants and lntracanal
Medicaments).
The accessibility of the contaminated root canal
areas is key to disinfecting efficacy. Thus. overall canal
anatomy and in particular canal dimensions
(reviewed in detail in Chapter 6, Morphology of teeth
and their root canal systems) play an integral role in
radicular shaping (Figure 37). Two basic numerical
concepts govern root canal shaping procedures (see
Box 1): WL and apical size, recently also described as
working width.
151
Clinical experience has shown periapical bony
lesions to heal predictably if the offending tooth is
extracted, thus removing all intracanal and adhering
microorganisms. This observation supports the
notion that extraradicular bacteria playa minor role
in supporting periapical disease, insofar as they colo-
nize the periapical lesion.
IS2
Therefore, procedures
922 / Endodontics
Figure 37 Relationship between cross sect ions of roots and root canals.
Following the princi ples of dentinogenesis, the pul p space has a very
si milar outline as the outer root contour. As Sequence of microcomputed
tomography sli ces (resolution 36 /lmf of a second maxill ary molar. 8,
Clinical or buccolingual view of the reconstructed outer contour and root
canal system. C, Mesiodistal view clearly illustrating the of a
fourth canal, in this case a second distobuccal canal that merges into
the lingual (palatan. 0, Schematic illustration for the required amount of
dentin removal in the coronal third for adequate access to middle and
apical root canal thirds. Modified wi th permission from Peters OA. Pract
Proced Aesthet Dent 2006;18:277.
confined to the root canal space
l5
3-ISS seem to be
able to address most of the cases of endodontic
treatment needs.
figUre 38 Examples of two cases in which incomplete shaping and
short fills di d not result in periapical pathosis. Pati ents indi cated root
canal treatments were performed As 10 years and 8, 27 years earlier.
concepts have been proposed regarding
WL, 15 partially depending on preoperative diagnoses.
Clinical experience suggests that vital cases will
be clinically successful despite apparent short fills
(Figure 38). This may be explained by the absence of
microorganisms in these cases, and a vital stump
may be beneficial for periapical health. 1 6,1 How-
ever, with existing periapical lesions and contami-
nated canal systems, WL definitions closer to the apex
must be adopted. Classic studies suggest that a WL
between 0 and 2 mm from the radiographic apex


"'#;/ 119/127 rTI\'
> mm '"
2
1i\
4' / 194 %) ,<ii,'
/ \. '
-------------------- '
15/22 p=0.3 42155
A 168%) (16%)

",<?;, 34i51 '-"\,
>2 mm "
1n\
4'/ 167%) rfu
I / "-
- ------------------
11/ 17 p=O.53
B
165%)
113/26)
150%)
Figure 39 Relationship between the length of the fill and the presence
and absence of periapi cal pathosis, A, Cases with a diagnosi s of
irreverSi ble pulpitis B, Cases with pu lpa l necrosis and periapical patho-
sis. Repri nted with permission from SjOgren U et al.
l 60
rcsuhs more often in success (healing of periapical
lesions) than shorter or longer fill s (Figure 39).
One school of thought recommends the use of a
patency file, a small, that is, size #lO, K-file that is
gently just pushed through an apical foramen without
actuall y enlarging it. The purported benefit is to
"dean" a foramen and to avoid apical blockage; how-
ever, a clinical benefit of this approach has not been
demonstrated so far. In fact , the patency technique is
controversial and is not uniforml y accepted or taught
in all US dental schools.
l s 8
On the other hand, a deleterious effect that could
have been brought about by mechanically
periapical tissues or by inoculating microorganisms
l
may be suspected but was not conclusively demon-
strated:
60
This may be due 10 the fact that a con-
taminated file that passes through canal spaces filled
with NaDe l is unlikely to carry any significant num-
bers of microorganisms past the foramen.
161
How-
ever, the extrusion of debris is more likely if the apical
foramen is patent.
162
,163 Certainl y, cleaning the fora-
men, in the sense that the foramen is enlarged and
Chapter 27 I Preparat ion of Coronal and Radicul ar Spaces 1923
debris is mechanically removed with a small rue, is
unlikely. 1M
It should be stressed that the use of a patency file is
distinct from "apical clearing," which is defined as a
technique to remove loose debris from the apical
extent, and involves sequentially rotating files two to
four sizes larger than the initial apical file at WL; the
largest apical file is then again rotated after a final
irrigation and drying. 165 This technique may be useful
after hand instrumentation
l 66
but no effect has been
shown after rotary instrumentation.
It is commonly held that the use of a patency file
during preparation would minimize the blocking of
canal space with dentin mud and thus improving
shapes. However, Goldberg and Massone
167
showed
canal transportation in more than half of their speci -
mens shaped with stainless steel or NiTi K-files used
as patency fi les. Confining shaping procedures to the
canal space was already recommended by Schilder; he
in fact stressed that the apical foramen should remain
in its position and not be enlarged.
3
The question then is where does the root canal end
(Figure 40) and how close to that point can clinicians
estimate their WL. Histological studies indicated the
presence of the transition of the pulp to the periapical
tissue as well as dentin and cement um in the area of
constriction (Figure 41): 68 However, a constriction
in the classic sense may be absent. [69 In fact, high-
resolut ion tomographic studies suggest more compli-
cated apical canal configurations than previously
shown (Figure 42). Therefore, radiographic interpre
tation alone may not give the clinician a good esti-
mate for WL determination.
17
o-
172
Indeed, shaping to
the radiographic apex, or even slightly short of it, will
I d
r.' . 171173
ea to Irequent oveTmst rumentatlon. .
DETERMINATION OF WORI<ING LENGTH
The term "WL" (Figure 43 and Box 1) is defin(><i in
the Glossary of Endodontic Terms as " the distance
from a coronal reference point to the point at which
canal and obturation should termi -
nate." ] 4 The anatomical apex is the tip or the end
of the root determined morphologically, whereas the
radiographic apex is the t ip or the end of the root
determined radiographically. 174 It is well established
that root morphology and radiographic distort ion
may cause the location of the radiographic apex to
vary from the anatomical apex. The apical foramen is
the main apical opening of the root canal. It is often
eccentrically located away from the anatomical or the
radiographic apex. I68.169.1 75.176 KUlller' sl68 investiga-
tion showed that this deviation occurred in 68 to 80%
924 / Endodont ics
Figure 4D Microcomputed tomography reconstructions demonstrati ng external and internal anatomy of a maxillary anterior. The insert is a magnified
view of an apical segment of 2 mm length showi ng no appreciable constriction (see arrowhead in larger image) and a cross-sectional diameter of me
root canal of approximately 300 pm.
of teeth under investigation. An accessory foramen is
an orifice on the surface of the root communicating
with a lateral or an accessory canal.
171
They may be
found as a single foramen or as multiple foramina.
The apical constriction (minor apical diameter) (see
Figures 40 and 43) is the apical portion of the root
canal with the narrowest diameter. This position may
vary but is often 0.5 to 1.0 mm short of the center of
the apical foramen.
168
,169 The constriction wldens
apically to the foramen (major diameter) and assumes
a funnel shape.
Probably owing to its importance as a clinical entity,
the apical third of the root canal and the foramen loca-
tion have been the topic of numerous investiga-
tions. 7. 168,169.I75-18J Dummer et al. 169 reported four basic
variations in the apical canal area that included about
50% of cases where a constriction was present. They also
reported 6% of their cases where the constriction was
probably blocked by cementum. 169 The cementodentinal
junction is the region where the dentin and the cemen-
tum are united; this is the point at which the cemental
surfuce terminates at or near the apex of a tooth.
174
Of '
course the cementodentinal junction is a histological
landmark that cannot be located clinically or radiogra-
phically. Langeland
1S4
reported that the cementodentinal
junction does not ahvays coincide with the apical con-
striction. The location of the cementinodentinal junction
also r a n ~ e s from 0.5 to 3.0 mm short of the anatomical
apex. 168. 69.175. 176 Therefore, it is generaUy accepted that
the apical constriction is most frequently located 0.5 to
1.0 mm short of the radiographic apex. It has been
pointed out by Ricucci
153
that significant anatomical
variation makes difficult the direct clinical usc of these
average values as end points of canal preparation.
Further problems exist in locating apical landmarks
and in interpreting their positions on radiographs.
Chapter 27 / Preparat ion of Coronal and Radicular Spaces / 925
Figure 41 Compari son of radiographi c and histological aspects of working length jWL). Teeth were extracted for nonendodontic reasons and processed
for routine histological examination. A. Radiograph indicates adequate fill just short of the apex; light micrograph demonstrates short fill with connective
tissue in the apical canal segment. B, Radi ograph indicates adequate fil l just short of the apex; light micrograph demonstrates overfill with some
inflammatory cells surrounding the gutta-percha point. Images courtesy of Dr. Domenico Ricucci .
METHODOLOGICAL CONSIDERATIONS
Before determining a definitive WL, the coronaJ access
to the pulp chamber must provide a straight-line path-
way into the canal orifice. Modifications in access pre-
paration may be required \0 permit the instrument to
penetrate, unimpeded, into the apical constriction.
Similarly, a crown-down preparation, including WL
determi nation after initial shaping, will alleviate this
problem. The loss of WL during cleaning and shaping
can be a frustrating procedural error. Once the apical
preparation is accomplished, it is useful to reassess the
WL since the WL may shorten as a curved canal is
straightened. 18>-187 WL may also be lost owing to ledge
formation or blockage of the canal.
As stated above, most dentists agree that the desired
end point is the apical constriction. Fail ure to accu-
rately determine and maintain WL may result in the
length bei ng too long and may lead to perforation
through the apical constriction. Enlargement of the
apical narrowing may lead to overfilling or overexten-
sion and subsequently to increased incidence of post-
operative pain. In addition, one might expect a
926 / Endodontics
Figura 42 Apical root anatomy of the same mesiobuccal root of a maxillary molar assessed using seaMing electron microscopy (SEM) and micro
computed tomography. A. SEM pictures of multiple apical foramina at x20 and xl00 magni fication. Bar indicates long diameter of 0.35 mm. 8, Outer
contour and canal segments ill ustrated with /'leT at a resolution of 9tlffi. Note that all cana ls merge and connect. Images courtesy of Dr. Ephraim Radzik.
root canal
dentin
.3mm
cementum
apical constriction
apical foramen
'P'"
Figure 43 Schemat ic di agram of the root apex and anatomical landmarks. The distance between the anatomical apex and the narrowest point of the
mai n root cana l varies substantiall y and changes with cementum deposit ion during aging
prolonged healing period and lower success
rate.
153
,155,188--190 Failure to determine and maintain
Wi accurately may also lead to shapi ng and cleaning
short of the apical constriction. Incomplete cleaning
and underfilling may cause persistent discomfort, may
support the continued existence of v!able bacteria,
and thus contribute to a continued periapical lesion
and ultimately a lowered rate of success.
In this era of improved illumination and magni fi -
cation, WL determination should be to the nearest
one-half millimeter, which is the maximum resolution
of the naked eye in working distance. The measure-
ment should be made from a secure reference point
on the crown in close proximity to the straight-line
path of the instrument, a point that can be identified
and monitored accurately. The length adjustment of
the stop attachments should be made against the edge
Chapter 27 1 Preparation of Corona l and Radicu lar Spaces 1927
of a sterile metric ruler or a gauge made specifically
for endodontics (Figure 44). The requirements of an
ideal clinical method for determining WL include
rapid location of the apical constriction in all pulpal
conditions and all canal contents; easy measurement,
even when the relationship benveen the apical con-
striction and the radiographic apex is unusual; rapid
periodic monitoring and confirmation; patient and
cli nician comfort; minimal radiation to the patient;
ease of use in special patients such as those with severe
gag reflex, reduced mouth opening, pregnancy; and
23mm
Figure 44 Sequence of steps in working length (Wll determination. A Initial measurement. Tooth is measured on an orthogonal and diagnostic
preoperative radiograph. In this case the tooth seems to be about 23 mm long. B, Tentative Wl. as a safety measure during coronal pre-enlargement and
crown-down, subtract 1 mm from tooth length and allow instruments to go to two-thirds of this length. C, After the coronal two-thirds of the canal have
been prepared. advance the hand file to tentative full Wl, using the electronic foramen locator. and expose the radiograph. D, Final radiograph after root
canal filling and removal of rubber dam.
928 1 Endodontics
cost effecliveness.
I 72
,191.192 To achieve the highest
degree of accuracy in WL determination, a combina-
tion of several methods should be used. This is most
important in canals for which WL determination is
difficult.
193
The most common methods are radio-
graphic methods, digi tal tactile sense, patients' response
to a file introduced into the canal, or a point to which a
paper point can be placed and removed dry.l94 How-
ever, current electrical foramen locators (see Chapter
26D, Electronic Apex Locators) greatly aid in determin-
ing the narrowest cross-sectional diameter and width
dh
c .. WL '"
an t erelore m approXimatmg .
CLINICAL DETERMINATION OF WORKING
LENGTH
Methods requiring formulas to determine WL have
been largely abandoned. Bramanle and Berbert
l
%
reported great variability in formulaic determination
of WL, with only a small percentage of successful
measurements. The following items are essential to
perform radiographic WL estimation:
1. Good, undislorted, preoperative radiographs
showing the total length and all roots of the
involved tooth.
2. Adequate coronal access to all canals.
3. An endodontic millimeter ruler.
4. Working knowledge of the average length of all of
t he teeth.
5. A definite, repeatable plane of reference to an
anatomical landmark on the tooth, a fact that
should be noted on the patient' s record.
To secure reproduci ble reference points, cusps
severely weakened by caries or restoration may be
reduced 10 a flattened surface, supported by dentin.
Failure to do so may result in cusps or weak enamel
walls being fractured between appointments
(Figure 45). Thus the original site of reference is lost.
If this fracture is not accounted fo r, then there is the
Figure 45 Example of a root canal -treated tooth that presented with a fracture prior to placement of the planned definitive restoration. In this case, the
pa lata l root was preserved and crown was restored after placement of a post and core. A, Clinical sequence from temporized access to status after
surgica l extraction of the two buccal roots. 8, Radiographs immediately after endodontic treatment, after surgery and at l -year follow-up. Images
courtesy of Dr. Crai g Noblett
probability of overinstrumentation and overfilling. To
establish the lengt h of the tooth, a K-file with an
instrument stop on the shaft is needed. The exploring
instrument size must be small enough to negotiate the
total length of the canal but large enough not to be
loose in the ca nal. A loose inst rument may move in or
out of the canal after the radiograph and may also
cause errors in determinlng tooth lengths. Moreover,
tips of fine instruments (size #08 and # 10) are often
difficult to see in a radiograph, 197 as are NiTi instru-
ments.
Clinically, it is advisable to estimate canal lengths
from a preoperative radiograph (sec Figure 44).
About 1.0 mm "safety allowance" for possible image
distort ion is deducted/ 98. 199 the endodontic ruler is
set to this tentative WL, and t he stop on the instru-
ment adjusted at this level (see Figure 44). The
instrument is placed in the canal until the stop is at
t he plane of reference unless pain is felt, in which
case the instrument is left at this level and the rubber
stop readjusted. An electric foramen locat or (see
Chapter 26D, Apex Locator) should be used to verify
and potentially further adjust the rubber stop. A
radiograph is exposed and t he difference bet ween
t he end of t he instrument and the end of the foot
is determined.
Current apex locators are sufficiently precise
2
O to
allow WL determination, thus reducing the frequency
of overinstrumentation when only radiographs are
used. 173.201 Even in cases of apical resorption and
wide-open apices after root-end resect.ion, these apex
locators are shown to be accurate. 202.203 Therefore, it
scems warranted to focus on the electronically deter-
mined WL and to use the radiograph merely to avoid
gross errors in case the apex locator does not appear to
work correctly. This strategy eliminates approximation
strategies such as shortening WL, as suggested by
Weine,204 to allow for apical resorpt ion. Independent
of the strategy, the final WL and the coronal point of
reference are recorded on the patient's chart. When
two canals located in the buccolingual plane appear to
be superimposed, much confusion and time may be
saved by several simple means. Occasionally, it is
advantageous to take individual radiographs of each
canal with its length-of-tooth instrument in place. A
preferable method is to expose the radiograph from a
mesial-horizontal angle. This causes the lingual canal
to always be the more mesial one in the image (MLM,
also known as Clark's rule). For any mesial- or distal-
angulated radiographs, the SLOB ("same lingual,
opposite buccal") rule. or the Ingle MBD Rule
("Shoot" from the Mesial and the Buccal root will be
Distal ), may be applied to locate instruments.
Chapter 27 J Preparation of Coronal and Radicular Spaces I 929
Radiographic WL determination, using conven-
tional films alone, is accurate less than 90% of the
time, I 76,205.206 and it is unclear if digital radiography
is currently an improvement over conventional films
regardi ng WL determination accuracy.207 In fact,
. c . 21fS II . 209210 I
IllICrlor as we as superior' resu ts were
reported for phosphor plate systems. Sensor-based
radiovisiography performed similar to films regarding
accuracy in some studies21 1- 213 but was recently
h b
. 214
S own to e supenor.
Electronic foramen locators sometimes do not
function accurately, for example, in cases where cur-
rent may flow into the marginal gi ngiva or into metal
restorations causing erroneous readings. Therefore,
additional mcthods such as tactile assessment and
detection of moist ure on the tip of a paper point were
recommended. 176 If the coronal portion of the canal is
not constricted, an experienced clinician may also
detect an increase in resistance as the file approachcs
the apical 2 to 3 mm. This detection is by tactile sense.
In the apical region, the canal frequently features a
constriction or a smaller diameter before exiting the
root. There is also a tendcncy for the canal to deviate
f h d
" h" "h' . 7168175 d
rom I c ra IOgrap IC apex m t IS regiOn, ' , an
both these geometric features may be perceived by a
clinician. However, Seidberg et al.
19
reportcd an
accuracy in "VL determination of just 64% using
digital tactile sense. If the canals were preflared, it
was possible for an expert to detect the apical con-
striction in about 75% of the cases.
2lS
If the canals
were not preflared, determination of the apical con-
striction by tactile sensation was possible in only
about one-third of the cases.
216
Pret1aring and subse-
quently determining WL also reduce the amount and
incidence of WL changes during the course of canal
shaping procedures.
l86
All clinicians should be aware that this method, by
itself, is often inexact. It is ineffective in root canals
with an immature apex and is highly inaccurate if the
canal is constricted throughout its entire length or if
the canal has excessive curvature. Therefore, tactile
det.ection should be considered as a supplementary to
high-quality, carefully aligned, parallel WL radio-
graphs and/or an apex locator. Consequently, a survey
found that few general practice dentists and no endo-
dontists trust the digital tactile sense met hod of deter-
mining WL by itself?17 Even the most experienced
spccialist would be prudent to usc two or morc meth-
ods to determine accurate WLs in every canal.
In a root canal with an immature (i.e., wide open)
apex, a relatively reliable means of determining WL is
by gently passing the blunt end of a paper point into
the canal aft er profound anesthesia has been achieved.
930 J Endodontics
The moisture or blood on the portion of the paper
point that passes beyond the apex may be an estima-
tion of WL or the junct ion between the root apex and
the bone. In cases in which the apical constriction has
been lost owing to resorption or perforation, and in
which there is no free bleeding or suppuration into
the canal, the moisture or blood on the paper point is
an estimate of the amount the preparation overex-
tended. This paper point measurement method is also
a supplementary one. As stated earlier, nonsurgical
endodontic procedures should best be confined to
the root canal. This is true fo r files also, or paper
points, in the process of WL determination. WL
determination should be painless. Advancing an
instrument into a canal toward inflamed tissue may
cause moderate to severe instantaneous pain. At the
onset of the pain, the instrument tip may still be
several millimeters short of the apical constrict ion.
When pain is inflicted in this manner, little useful
information can be gained and considerable damage
is done to the patient's trust. When the canal contents
are necrotic, however, the passage of an instrument
into the canal and past the apical constriction may
evoke only a mild awareness or possibly no reaction at
all.
On the other hand, Langeland et a1.
184
,2 18
reported that vi tal pulp tissue wi th nerves and ves-
sels may remain in the most apical part of the main
canal even in the presence of a large periapical
lesion. Finall y, passing a file through necrotic canal
contents may inoculate bact eria-contaminated den-
tin shavings into periapical tissues, thus supporting
or causing apical periodonti tis. 219.22o However, fzu
et al. 161 showed that small fi les used as patency files
are unlikely to carry bacteria past a reservoir of
NaOel.
CLI NICAL DETERMINATI ON
OF WORKING WIDTH
The second factor to be considered is apical width or
preparation size. It is a matter of debate as to which
apical enlargement and more specifically which shape
would lead to an optimal reduction of the intracanal
microbial load.
221
Baumgartner's grouplO, ISO has
recently attempted to address this question in vitro,
and they concluded t hat an apical preparation size #20
would be inferior to sizes #30 and #40 regarding canal
debridement but that a larger taper (e.g., O. lO) may
potentially compensate for smaller sizes. This notion is
supported by an in vitro study on the efficacy of
ultrasonically activated irrigation that demonstrated
better debridement with O.lO taper preparation.
212
Similarly, Mickel et al.,12 based on microbiological
assays, as well as Khademi et al., 213 using SEM, found
that apical preparation to size #30 is required to effec-
tively clean root canals. Moreover, recent elegant ana-
lyses, using a thermal imaging system, revealed
detailed relationships between MAF size, needle dia-
meter, and insertion depth.224 Taken together, these
results indicate that sufficient apical preparation size
and the use of a small-caliber irrigation needle are
desirable to promote irrigation and hence antimicro-
bial efficacy.
In situ, h9wever, even larger apical preparation
sizes were favored by results from Trope's
group,9,125, 127 in particular, when an interappoint-
ment dressing of calcium hydroxide was used. Inter-
estingly, larger apical sizes (#40, taper 0.04 compared
to #20, taper O. lO) facili tated the apglicat ion of cal-
cium hydroxide medication in vitro. 5
Most clinical outcome studies incorporate the fac-
tor "apical preparation size" with often insufficient
. I. d . h fl I. 226-228
stahstlCa power an Wit con Ichng resu ts. A
review of the technical aspects of root canal treat-
ments
229
found that apical periodontitis was more
frequent with inadequate root canal fillings; however,
they did not find evidence that canal instrumentation
methods, and in particular apical sizes, had any mea-
surable effect on outcomes. Conversely, one result of
the Toronto st ud!30 on endodontic outcomes
seemed to favor smaller preparations in conjunction
with tapered shapes and vertically compacted gutta-
percha over step-back preparation to larger apical
shapes (90% and 80% success, respectively). Again
in contrast, using Periapical Index (PAT) scores deter-
mined from radiographs, 0 rstavik et al.
231
did not
find any significant impact of preparation size on
outcomes.
It is not possible to determine canal diameters from .
radiographs;151 however, IlCT scans may be able to
give more detai led information regarding root canal
anatomy in vivo (Figure 46). The resolution of current
systems is in the range of 100 Ilm, corresponding to a
size #10 K-file, and hence not sufficient to determine
canal diameters with precision. Clinically, canal width
may be determined by passing a series of K -files to WL
to gauge, as suggested by Ruddle.
232
This process may
depend on the me type and the amount of preflar-
ing.
8
,233,234 Clearly, the first instrument that gives the
clinician a sense o f b i n d i n ~ docs not correspond to any
canal diameter. Wu et al. demonstrated that the dia-
meter of the "binding" instrument was small er
than the canals' diameter in 90% of the cases wi th
a difference of up to 0. 19 mm. Unexpectedly,
Chapter 27 I Preparat ion of Coronal and Radicular Spaces J q31
A
B
Figure 46 Potential of a clinically used high-resoluti on computed tomography to show root canal anatomy. Scans were done in vivo using an Accuitomo
cone beam machine (Morita. Tokyo. Japan). A. Reconstructed jaw segment with three teeth is shown after apicoectomy and retrograde fill of mesial root
of lower left first molar in cli nical. B, Distally angled projection. Two teeth were segmented free from bone and are shown independently. Note
incomplete fill of mesi al root and two merging canals in the distal root of the molar.
LightSpeed (LS) instruments (Discus Dental, Culver
City, CA) that possess a fine noncutting shaft did not
perform better than K-files with 0.02 taper. Therefore.
they concluded that it is uncertain that circumferential
removal of dentin occurs based on the criterion that
one should prepare three sizes larger than the fi rst
binding file;8 this and also the criterion "clean dentin
shavings" are not considered adequate to indicate
ffi
""1 235
su ICient aplCa preparation.
It seems that preflaring, prior to any attempt at
" 1 d" " "1
13
.1.234..
assessmg cana lameter, IS essentla ' smce It
allows the probing file to approach the arical area
with less interferences. Tan and Messer
2
3 indeed
found that K-files and LS instruments determined
apical sizes about one ISO size larger after preflaring.
In their study. LS instruments that were felt to bind at
the apex were almost two ISO sizes larger than K-files.
After preoperative canal size is estimated, working
width determination may be done. Jou et al.
1SI
sug-
gested definitions based on variations in cross-sectional
canal shape. Their goal was to aUow clinicians to obtain
a more complete shape regarding instrumented surface
area; this strategy is in line with current guide-
I
236237 H h" 1 be " bl
mes. owever, t IS goa may unattama e
with current instrumentation techniques.
12o
In conclu-
sion, there may be no practical way to objectively
determine a final fil e size that predictably allows com-
plete instrumentation of canal walls. Consequently, all
potential mechanisms to increase irrigation efficacy
should be explored.
932 I Endodontics
Table 10 Measured Apical Diameters and Suggested Preparation SIZes for Mandibular and Maxillary Teeth, Taken from
Representative References over the Last 50 Years
Maxillary teeth
Reference Kuttler
l68
G
reen
177 MorfisH'O
WU
llll
Briseno
lS3
Sabala
lol l
Tronstad
1
' 2 Gli ckman
l43
TVI" 268 Teeth 110 Teeth 2m Teeth 213 Teeth 180 Teeth 1.097 Teeth Sll9gestions Review Suggestioo Suggestion
In Vitro In Vitro In Vitro In Vitro In Vitro In Vitro
Ce ntrals 25--35 45 30 34 80-00 80 7()-OO 3,""",
Latelals 25--35 60 30 45 7()-lJ0 80 6()-lJ0 25-40
Canines 25--35 45 31 60-90 80 50-70 3()-5IJ
First premolars 25--35 20 5IJ 21 37 3()-40 60 35--90 25-40
One canal 70 30 60
Two !;anals 20 23
Second premolars 25--35 21 37 50-55 3>-00 25-40
One canal 70 30 80
Two canals 35 23 4><0
Molars 25- 35 30-55
Mesiobuccal 25 60 24 43 11-73 45
3'""'"
25-40
One canal 40 19 09-<0
Two canals 40 19
Distobuccal 25 40 23 22 08-73 45
3'""'"
25-40
Palatal 35 40 30 29 "'-'9 60 80-100 25-40
Mandibular teeth
Centrals 25--35 70 26
laterals 25-35 70
Canines 25-35 70
First premolars 25--35 35 27
One carlal
Two carlals
Seeond premolars 25-35 40 27
One canal
Two canals
Molars 25--35
Mesial root 25 60 26
Distal root 30 60 39
Table lO presents an overview of anatomical studies
detailing physiological foramen diamelers. There is an
apparent variation in these measurements, probably
due to variation in experimental conditions. Conse-
quently, there is also a great deal of vanatlon in
recommended apical sizes, as shown in the lefl seg-
ment of Table lO.
For example, apical sizes ranging from sizes #20 to
#100 for maxillary molar roots have been recom-
mended. Figure 47 A illustrates apicaJ dimensions
before and after shaping with two rotary instrumenta-
tion paradigms.
A third as yet incompletely understood aspect of
canal shape is taper. Some have expressed concerns
that the importance of root canal taper should be
seen only in conjunction with root canal fill ing tech-
. bl'l . 244 H
mques, most nota y vertlca compaction. ow-
ever, as stated before, there are some experimental
37 4()-5IJ 60 35--70 25-40
37 4O-O<J 60 35--70 25-40
47 50-55 80 50-70 3()-5IJ
35 30-40 35-70 3()-5IJ
20 80
19 4,""",
35 50-55 35--70 3()-5IJ
20 BO
13 4,""",
30-55
_5 1()-64 45 35-45 25-40
46 12-<4 60 4O-8IJ 25-40
evidences that taper may be connected to the ability
to clean the root canal system by improving irrigant
action.
IO
,150,222 Limited microbiological data are con- .
fiicting regarding the potential of smaller apical pre-
parations with larger taper to disinfect root canal
13 127 U . hr' d I
system. smg t e amount a mstrumente cana
area as a surrogate outcome for disinfecting capacity,
no significant differences were found overall, compar-
ing shapes with GT 20 0.10 taper to apical size #40
with smaller tapers.245 However, there were signifi-
cant differences when the apical canal segment was
evaluated for instrumented canal surface area (Paque F,
Wlpublished data).
Schilder
3
described five design objectives for cases to
be fi ll ed with gutta-percha, which are as foll ows:
The shape should be a continuously taperi ng funnel
from the apex to the access cavity.
Chapter 27 I Preparation of Coronal and Radicul ar Spaces 1 933
12 r----r- ,---, 12
10
III
10 f-_. -ir-+-l
E
8 8
.s
i
'"
6 6 c
E
8
.s
i
'"
6 c
12
10

IN

ProTaper F3
....... ;a",..._ .. ---....
ProTaper F2
ProFile 35 .06

"iij "iij
c c

4 4 t)

4 t)
w
2 2 2
o o
J
0.4 0.8 1.2 o 0.4 0.8 1.2 o 0.4 0.8 1.2
A Diameter [mm] Diameter [mm]
B
Diameter (mm)
Figure 47 Pre- and postoperati ve canal diameters after shaping with common instrument types. Measurements are from microcomputed tomography
reconst ructions. A. Original data from 12 mesiobuccal canals shaped to an api cal size 140 with FlexMaster Ileft panel. VOW) and ProTaper Iright panel.
Dent sply Maill efer). B, Di mension of selected rotary inst ruments for comparison.
Cross-sectional diameters should be narrower at
every point apically_
The root canal preparation should flow with the
shape of the original canal.
The apical foramen should remain in its original
position.
The apical opening should be kept as small as
practical.
There were also four important biological objec-
tives that are as follows:
Procedures should be confined to the roots them-
selves.
Necrotic debris should not be fo rced beyond the
foramina.
All tissues should be removed from the root canal
space.
Sufficient space for intracanal medicaments and
irrigation should be created.
These form t.he basis for today's quality
criteria
23
.237 and also for the development of opera-
tional techniques that will be described below in
detail. All of these techniques rely on t.he adaptation
of geometric forms, of either handheld or engine-
driven instruments to root canal anatomy, by way of
particular instrumentation sequences and usage para-
meters. However, an experimental , noninstrumenta-
tion system for root canal cleaning has been tested in
. d' 2462-1 7 . h h'
vitro an III VIVO; smce nelt er t IS system nor
potential alternatives are currently available for the
clinic, mechanical preparation will be utilized to clean
and shape root canals for the foreseeable future.
In conclusion, the current strategy in radicular
preparation calls for the enlargement of rool canals to
a size sufficient to allow disinfection and subsequcnt
root canal filling. no Available evidence to support a
particular shape in direct connection with any given
root canal filling technique is limited to Allison et a1.,248
who found a bener seal when spreaders used for lateral
compaction could penetrate close to WL. Conse-
quently, efforts continuc to determine the best possible
root canal shape for management of intracana] infec-
tion by mechanical action, irrigant delivery, and place-
ment of interappomtment medicaments.
MEANS FOR RADICULAR SHAPING
Historically, painful teeth were opened and sympto-
matic pulps were treated with caustic substances or
934 I Endodont ics
cauterized with heat.
249
Some of these procedures as
early as 1728 by Pierre Fauchard are said to have
included root canal fillings with lead or gold.
250
Root
canal systems have been shaped with mechanical
instruments for more than 200 years. 250--2S2 According
to Liller5! at the end of the eighteenth century
" ... only primitive hand instruments and excavators,
some iron cautery instruments and only very few thin
and flexible instruments for endodontic treatment
had been available ... ".
The development of the first endodontic hand
instruments by Edwin Maynard involved notching a
round wire (e.g., watch springs, piano wires) to create
fine needles for pulp tissue extirpation and potentially
shaping.253 In 1852, Arthur used small files to enlarge
and shape root canals.
254
Subsequently, textbooks in
the middle of the nineteenth century recommended
that root canals should be enlarged with broaches:
"But the best method of forming these canals is with
a three- or four-sided broach, tapering to a sharp
point, and its inclination corresponding as far as
possible with that of the fang. This instrument is
employed to enlarge the canal and give it a regular
shape".1222s2 In 1885, the GG drill and in 1904 the
K-file were introduced, both of which are stili in use
to date. Standardization of instruments had been pro-
posed by Trebitsch in 1929 and again by Ingle in
1958
122
but remains an issue today with NiTi rotary
instruments.
255
For a detailed description of various
instrument types and alloys, the reader is referred to
Chapters 26B, "Introduction of Nickel-titanium Alloy
to Endodontics" and Chapter 26C, "Instruments for
Cleaning and Shaping".
Instrument Movements While Shaping
WATCH-WINDING
The least aggressive instrument action is most desir-
able in the earli fhases of root canal instrumentation.
Many clinicians 3 .256.257 recommend a "watch-winding"
movement with rotations of a quarter turn using small
(size #08 or #10) K-files to reach WL or to explore the
canal prior to coronal flaring (see below). Importantly,
copious irrigation and constant cleansing of the instru-
ment with sterile gauze are necessaty to clear the flutes
and to prevent packing debris at or through the apical
foramen.
REAMING
Reamers are instruments designed to enlarge or taper
preexisting spaces. Traditionally, endodontic reamers
were thought to cut by being inserted into the canal,
twisted clockwise one-quarter to one-half turn to
engage their blades into the dentin, and then with-
drawn, that is, penetration, rotation, and retrac-
tion.
258
The cut is made during retraction. The pro-
cess is then repeated, penetrating deeper and deeper
into the canaL When WL is reached, the next size
instrument is used, and so on. Reaming is a method
that produces a round, tapered preparation, and this
is used only in perfectly straight canals. In such a
situation, reamers can be rotated one-half turn before
retracting. In a slightly curved canal, a reamer should
be rotated only one-quarter turn.
FILING
The tighter spiral of a file establishes a rake angle that
achieves its primary cutting action on withdrawal,
although it will cut in the push motion as welL The
cutting action of the file can be effected in either a
filing or a reaming motion. In a filing motion, the
instrument is placed into the canal at the desired
length, pressure is exerted against the canal wall, and
while this pressure is maintained, the rake of the flutes
rasps the wall as the instrument is withdrawn without
turning. The file need not contact all walls simulta-
neously. For example, the entire length and circum-
ference of large-diameter canals can be filed by insert-
ing the instrument to the desired working distance
and filing circumferentially around all of the walls.
When using a file in a reaming action, the motion is
obviously the same as for a reamer.
25S
Withdrawing
the file then cuts the engaged dentin. Filing is very
efficiently done with Hedstrom files while K-files arc
the most popular instruments?59 One the other hand,
the often advocated technique of circumferential fil-
ing
260
has been shown to leave significant canal areas
unprepared.
26
! Finally, hand versions of current NiTi
rotary instruments, such as ProSystem GT (Dentsply '
Tulsa Dental, Tulsa, OK) and ProTaper (Dentsply
Maillefer), may be used in filing and reaming action.
ROTARY MOVE MENTS
Until the advent of NiTi alloy, continuous rotary
movement was thought undesirable for shaping curved
canals due to the danger of instrument fractures.
Nevertheless, it has been recommended to use stainless
steel GG drills into the apical third of straight root
canals,3,262 which have the potential of undesirable
canal shapes (Figure 48) and instrument fracture.
Furthermore, strip perforations may occur with indis-
criminate use of GG or Peeso drills. 263.264 However, it
has been clearly established that continuous rotary
Figure 48 Clinical examples of root canal filled teeth that do not
follow principles for an opt imized shape. A Very narrow shape that
is not conducive to cleaning and irrigant access. B, Overenlargement
that may predispose to vertical root fracture (arrowhead). C, The
so-called "coke bottle" shape produced by overzealous action of Gates
Glidden drills.
Chapter 27 / Preparation of Coronal and Radicular Spaces 1935
movement with NiTi instruments with noncutting tips
creates shapes with little or no incidence of preparation
error5.
120
POTENTIAL SHAPES
Figure 49 illustrates basic requirements for a radicu-
lar shape, with adequate WL and working width as
well as a homogenous taper that attempts to recreate
the original main canal shape in an enlarged form.
Cases present clinicians wlth a variety of anatomical
and other challenges but the principles for root canal
shaping remain the same for straight and curved
canals (see Figure 49). However, specific cases, such
as wide apices found in incompletely formed roots or
after apical root resorption, call for modified
approaches due to thin dentin walls and difficulties
in controlling the apical extent of the filL Special
procedures such as apexogenesis and apexification
may be required to provide adequate obturation (see
Chapter 30, Obturation of the Radicular Space).
Variations in apical shape have received special
attention and varying recommendations. Names were
given for the desired confifuration (lower ranel in
Figure 49): "apical stop,"26 "apical bOX, 24 " apical
capture or control zone.,, 266,267 The intent of all the
described techniques is two- fold: ( I) allow irrigant
access to the apical root canal system and (2) prevent
filling material from being extruded into the periapi-
cal space. As stated earlier, no conclusive evidence
favors one apical shape over another rerarding clinical
outcomes; however, Kast ' akova et al. 26 demonstrated
that an apical stop, prepared to follow the recommen-
dation to prepare three sizes larger than the first file to
bind at WL, did not prevent sealer or gutta-percha
extrusion.
Finally, the argument has been made that a tapered
apical preparation would reduce the incidence of
overpreparation that may occur following a l e n ~ t h
determination error and an apical stop preparation. 69
This idea derived its attraction from the well-sup-
ported notion that preparation errors should be
avoided as they are associated with inferior out-
270-27S p ' dh ' dl
comes. reparatIOn errors an t elr eve op-
ment are discussed further below.
Several systems to prepare canal with hand or engine-
driven instruments have been described, beginning with
Ingle's standardized technique
276
(Table 11). There are
two principally different approaches: the "apex first"
and the "coronal first" techniques. The former approach
advocates that WL is reached and the apical area
is prepared first with increasingly larger instrument
936/ Endodont ics
A B c
Figure 49 Schemat ic di agrams of potential root canal shapes after preparati on. Dependi ng on the inst rument and l he seQuence used, the canal is
enlarged into a tapered shape IA. for example, rotary inst rumentation), a taper with incremental si ze increase 18, step- bacK preparati on), or a sli ght taper
with defined apical stop C. The bott om panel shows magnified apical shapes produced.
sizes, whereas the latter uses descending instrument sizes
to prepare coronal canal areas first and apical ones last.
The following section will describe the basic techniques
and some subaspects of them in more detail. As these
Table 11 Summary of Preparation Techmques Suggested
for Hand and Rotary Instruments
Reference Year Technique
Ingle
V6
1951 Standardized instrumentation
Clem17l , Welne
V6
1969-1974 Ste>l' back, serial preparation
Schilde(l
Abou_Aass
179
' 9SO Ant icUivature filing
MarshaII
180
.ZS
1
' 980 Crowndown pressureless
Goerig1\;l 1982 Ste>l'dOWil
F
ava
2l32263
1983/1992 Double flare. with modifications
Aoane
1ll4
1985 BalarlCed force
T orabl neiad
185
.
1ll6
'""
Passive step back
Siquei ra
Zll7
2002 Altelnate rotalY mot ion
techniques are generally independent of the instruments
with which they arc performed, the reader is referred to
Chapter 26C, "Instruments for Cleaning and Shaping"
for a detailed review of design and properties of
handheld and engine-driven endodontic instruments.
However, it needs to be kept in mind that the li terature
is replete with references to the superiority of one
instrument or one method of preparation over an
others.
2
$6-290 The following statement may put expec-
tations on any parti cular file type into perspective:
"Regardless of the instrument type, none was able to
reproduce ideal resul ts; however, clinically acceptable
results could be obtained with all of them.,,291
Preparation Techniques
STANDARDIZED
The standardized technique uses the same WL defini-
tion for all instruments introduced into a root canal
and therefore relies on the inherent shape of the
instruments to impart the final shape to the canal. It
can therefore also be called a "single-length techni-
que," an approach that has recently gained popularity
with the ProTaper (Dentsply Maillefer) and MTwo
(Sweden and Martina, Padova, Italy) NiTi rotary
instruments.
Negotiation of fine canals is initiated with fine files
that are then advanced to WL and worked until a next
larger instrument may be used. Conceptually, the final
shape is predicted by the last-used instrument (also
named MAP, see Box I). A single matching gutta-
percha point may then be used for root canal filling.
In reality, this concept suffers from two factors of
variation: fi rst, canals (in particular those with curva-
Hi res), shaped with the standardized technique, end
up wider than the instrument size would sug-
gest, 292.293 and second, production quality is insuffi-
cient, both for instruments and for gutta-percha
cones, leading to size variations. 294.295
STEP-BACK
Realizing the importance of a shape larger than that
produced with the standardized approach, Clem
277
and Weine
27s
introduced the step-back technique,
sometimes also called telescopic technique.
296
This
paradigm relies on stepwise reduction of WL for lar-
ger files, typically in 1- or O.s -mm steps, resulting in
flared shapes with 0.05 and 0.10 taper, respectively.
Incrementally reducing WL for larger and stiffer
instruments in turn lessened the forces associated with
aberrant preparations, in particular in curved canals
(Figure 50).
Clem
277
originally described the step-back technique
for curved canals in teeth of adolescents, as the creation
of a single step, at the transition from the straight to
the curved portion of the root. The resulting shape is
somewhat similar to the "coke bottle" configurations
that occur when inflexible engine-driven instruments
such as GG or Peeso drills are advanced past the mid-
dle root canal third (see Figure 48). Taking GG and
Peeso drills deep into canals carries the risk of fracture
as they are not very resistant to fatigue occurring in
curved canals.
297
Furthermore, overpregaration and
subsequent strip perforations may occur, 63.264.298 and
therefore these shapes are generally not desirable.
Subsequently, Schilder
3
suggested a "serial prepara-
tion" that included enlarging to a fUe size #30 or #35
and then serially reducing WL for the following
instruments. Initially, he did not advocate a metrically
defined step but rather a tactile feedback and cutting
of dentin when initial wall contact was made. Thus,
Chapter 27 / Preparat ion of Coronal and Radicular Spaces / 937
Figure 50 Principles of radicular dentin removal. In a curved cana l.
apical pressure leads to transportati on toward the outer curvature. At
the same time. the reacti onary force bui lds up in the strai ght ening
inst rument agai nst the dentin coronal of the curvature and leads to
transportati on toward the inner curvature (e.g .. furcationl,
larger instruments would be used with decreasing WL
and finally a smoothly tapered canal shape would
result. The developed shape, however, may be very
similar to what had been described as the outcome of
a step-back procedure and in fact later, Schilder-type
preparation was illustrated as involving regular pre-
determined steps.258 Coffae and Brilliant,299 for exam-
ple, described a serial procedure that entailed the use
of a #35 file to Wl , stepwise reduction of WL for
subsequent ftles up to size #60, and then the use of
GG drills Nos. 2 and 3 approximately 16 and 14,
respectively, into the canal (Figure 51 ). They describe
superior debridement with serial preparation com-
pared to standardized shapes.
299
Walton et al.
3OO
cor-
roborated these results by histological evaluations.
Clearly, coronal enlargement (flarin.&) appeared ben-
eficial for cleaning and obturation.
2
However, there
938/ Endodontics
I
,
\
..
..
I
0
A B C 0 E
figure 51 Sequence of instruments in the step-back procedure. After corona l preenlargement with Gates Glidden burs A, apical preparat ion to the
desired master apica l file (MAF) size commences with K-Fi les to determine working length (WlJ 8 and then fil es of ascending size to the desired apical
dimension (also called Phase I, C). Then, the Wl is decreased !"stepped-back"") by 1 or 0.5 mm to create a more tapered shape (Phase lIa.
ill. Recapitulation with a small K-file is done to smooth canal walls and to ensure that the canal lumen is not blocked (Phase lib, EJ. Frequent irrigation
promotes disinfection and of soft tissue
was concern about the potential fo r overinst rumen-
tat ion and potential perforation. Development con-
tinued to modify shaping procedures.
Mullanero
l
described the step-back technique as
particularly effective in fine canals. He divided the
step-back preparation into two phases. Phase I is the
apical preparation starting at the apical constriction.
Phase II is the preparation of the remainder of the
canal, gradually stepping back while increasing the
instrument size. The completion of the preparation
is the Refining Phase Tla and TTb to produce the
continuing taper from the apex to the cervical (see
Figure 51). To start Phase I instrumentation, the canal
should have been explored with a fine instrument and
the WL established. It is important that a lubricant is
used at this point since fi brous pulp stumps may be
compacted against the apical constriction and cause
apical blockage. 302 In very fine canals, the irrigant that
will reach this area may be insufficient to dissolve
tissue. Lubrication is believed to emulsify tissue,
allowing instrument tips to macerate and remove this
tissue. It is only later, in canal filing, that dentin chips
pack apically blocking the constriction. When the
MAF size has been used to full WL, Phase I is con-
sidered complete and the 1.0- to 2.0-mm space back
from the apical constriction should be dean of debris.
It must be emphasized here that irrigation between
each instrument use as well as recapitulation with the
previous smaller instrument carried to full depth is
crucial. Then the step-back process (Phase II) begins
wit h a file one size larger than the MAF. Its WL is set
1 mm short of the full WL, and it is carried down the
canal to the new shortened depth. The same process is
repeated with subsequent instruments again shortened
by 1.0 or 0.5 mm from the MAF. Thus, the preparation
steps back up the canal with either 1 or 0.5 mm and
one larger instrument at a ti me. It has been recom-
mended to end this step-back phase at size #60
3
or
when the instrument has reached the wider straight
portion of the root canal. In any case, frequent turn-
over of the irrigant and recapitulation with the MAF
arc necessary to promote canal disinfection and prevent
blockage. The most coronal canal portion may then be
carefully flared with GG drills or Hedstrom fi les. The
refi ning Phase Ilb is a return to the MAF, smoothing all
around the walls to perfect the taper from the apical
constriction to the cervical canal orifice, which would
then be a larger replica of the original cana!.303
Although the step-back technique was primarily
designed to avoid preparation errors in curved canals,
it applies to straight canal preparation as well . In fact,
all root canals have some curvature. 14,304,305 Apparently
straight canals are usually curved to some degree and
canals that appear to curve in one direction often curve
in other directions as well. 14 While it has been main-
tained that only curved instruments should be intro-
duced into curved canals,302 it seems in fact unlikely
that one can successfully match canals' curvature with
a preClrrved file. Moreover, rotary instruments are
straight and should be introduced only into canal areas
that a straight hand instrument, size # 15 or #20, has
explored ("glide path," see below).
A modification of the step-down approach using
hand instruments has been described by Torabine-
jad.
285
.186 He advocated insertion of progressively lar-
ger hand instruments as deep as they would passively
go in order to gain insight into the canal anatomy and
to provide some enlargement prior to reaching the WL.
Subsequent use of GG drills or Peeso reamers will
provide additional coronal enlargement and improve
tactile fccdback from the apical region as well as better
access for irrigants.306.307 The use of an ultrasonically
activated size # 15 K-fUe has been advocated to furt her
blend canal irregularities.
286
A second, probably even
more important, benefit is the ultrasonic or sonic acti-
vation of the irrigam placed in the root canal for I to
2 minutes, and is turned over every 30 seconds.
222
,286
ANTICURVATURE FILING
In this context, Abou Rass, Glick, and Frank
308
described a method called "anticurvature filing" to
prevent excessive removal of dentin from thinner root
sections in curved canals. The underlying observation
was that the furcation side (danger zone) of cross
sections of mesial roots of mandibular molars has less
dentin thickness than the mesial side (safety zone) .34,3Q9
The technique included the use of precurved hand files
that were purposefully manipulated to file the canal
away from the danger zone. It also incorporates cor-
onal flaring with rotary instruments after the use of
hand instruments, but it is stated that such instruments
should not be introduced more than 3 mm into root
canals.
30S
The final use of a manual instrument to
blend the apical and coronal segments was advocated .
Kessler et a1.
310
as well as Lim and Stock
260
demon-
strated that "anticurvature" filing in fact helped to
reduce the risk of perforation. Later, Safety Hedstrom
files (KerrISybron, Romulus, MI) followed a similar
concept, namely ming away from the danger zone.
These files had cutting edges that were flattened and
thus dlilled at one side and were therefore believed to
remove less material in one direction.
3ll
However,
subsequent research showed that Safety Hedstrom files
when used as engine-driven versions are in fact not safe
but tend to create preparation errors.
311
STEP-DOWN
A different approach was taken by Goerig et al.,262 who
advocated shaping the coronal aspect of a root canal first
before apical instrumentation commenced. The authors
Chapter 27 / Preparat ion of Coronal and Radicular Spaces / 939
list the following advantages: the technique permits
straighter access to the apical region, it eliminates cor-
onal interferences, it removes the bulk of tissue and
microorganisms before apical shaping, it allows deeper
penetration of irrigants, and the WL is less likely to
change. Subsequently, several of these claims were inves-
tigated; it was found that shaping was subjectively easier
but had no measurable effect on canal transportation.
3l3
Furthennore, there was a small but significant beneficial
effect on Wl retention.
lS
6.314 The removal of coronal
obstructions does allow a better detennination of apical
canal sizes;133,234 however, it is not clear ifbetter irrigant
penetration occurs and if that has clinically measurable
benefits.
Another primary purpose of this technique is to
minimize or eliminate the amount of necrotic debris
that could be extruded through the apical foramen
during instrumentation. This would help prevent post-
treatment discomfort, incomplete cleansing, and diffi-
culty in achieving a biocompatible seal at the apical
constriction.
l80
One of the major advantages of step-
down preparation is the freedom from the constraint
of the apical enlarging instruments. By first flaring the
coronal two-thirds of the canal, the final apical instru-
ments are unimpeded through most of their length.
This increased access allows greater control and less
chance of zi pping near the apical constriction.
3ls
In
addition, it "provides a coronal escage way that
reduces the piston in a cylinder effect,,2 responsible
for debris extrusion from the apex. This is one possible
reason for the finding that coronal preflaring reduced
the amount of apically extruded debris.
3l6
The procedure itself involves the preparation of two
coronal root canal thirds using Hedstrom files of size
# 15, #20, and #25 to 16 to 18 mm or where they bind.
Thereafter, GG drills Nos. 2 and 3, and then poten-
tially No.4, are used sequentially shorter, thus flaring
the coronal segment of the main root canal. Then,
apical instrumentation is initiated; it consists of nego-
tiating the remainder of the canal with a small K-file,
shaping an apical "seat," and combining the two
parts, step-down and apical shape, by stepwise
decreasing of WL of incrementally larger files. Fre-
quent recapitulation with a #25 K-file to WL is
advised to prevent blockage.
Numerous modifications of the original step-down
technique have been used clinically but most include the
use of a small initial penetrating instrument, mostly a
stainless stccl K-file exploring the apical constriction and
establishing the WL To ensure this penetration, one may
have to enlarge the coronal third of the canal with
progressively smaller GG drills or with other rotary instru-
ments. At this point, and in the presence of NaOCl,
940 I Endodont ics
step-down cleaning and shaping may begin with a variety
of instruments. For example, starting with a size #50 K-file
and working down the canal, the instruments are used
until the apical constriction (or WL) is reached. When
resistance is met for further penetration, the next smallest
size is used. Irrigation should follow the usc of each instru-
ment and recapitulation after every other instnunent. To
properly enJarge the apical third and to round out ovoid
shape and lateral canal orifices, a reverse order of instru-
ments may be used starting with a size #20 (for example)
and enJarging this region to a size #40 or #50 (for example).
The tapered shape can be improved by stepping back up
the canal with larger instruments, bearing in mind all the
time the importance of irrigation and recapitulation.
BALANCED FORCE
After many years of experimentation, Roane et a1.
284
intro-
duced the "Balanced Force" concept of canal preparation
in 1985. The concept came to fruiti on, they claimed, with
the development and introduction of a new K-type file
design, the Fl cx-R File
284
,31? (originally manufactured by
Moyco Union Broach, now Miltcx, York, PAl . The tech-
nique can be described as " positioning and preloading
$
- ~ @'
-
~
"
N
~ ~
~ 1
H
N
~
~ " ~
~
N ,
""
,..
M
...
,
an instrument t hrough a clockwise rotation and
then shaging the canal with a counterclockwise
rotation." 84 The authors evaluated the damaged
instruments produced by t he use of this technique
and discovered that a greater risk of instrument
damage was associated with clockwise movemenl.
318
For the best results with the " Balanced Force" techni -
que, preparation is completed in a step-down
approach. The coronal and mid-thirds of a canal arc
flared with GG drills, beginning with sma!! sizes, and
t hen shaping with hand instrument is carried out in
the apical areas. Similar to techniques described above,
increasing t he diameter of the coronal and mid-thirds
of a canal removes most of the contami nation and
provides access for a more passive movement of ha nd
instruments into the apical thi rd. Shaping becomes
less difficult: the radius of curvature is increased as
t he arc is decreased. In other words, the canal becomes
straighter and the apex is accessible with less flexing of
the shaping instruments (see Figure SO).
1
After mechanical shaping with GG dri ll s, Balanced
Force hand instrumentation begins with the typical
triad of movements: placing, cutting, and removing
instruments using only rotary motions (Figure 52).
~ ~
~
C ~ )
, "
<#
~
,....
1
H
/' ..
N
N
N N
""

~
,..
,..
..
...
...
,
V
Figure 52 Principl es of the Balanced Force technique. Instruments with a symmetrical triangular cross sect ion and pilot l ips (e.g., Flex-R files, Moyeo
Union Broach, Montgomeryville. PAl were originally suggested to be used in three steps in a rotational movement. A file may be advanced into the canal
with a one-quarter clockwise rotation. The second movement involves adequate apical pressure to keep the instrument at this level of the canal while
rotate counterclockwise for a half- to three-quarter tum. Currently. it is recommended to use the first two movements repeatedly, progressing more
apically. Then the third movement pulls the instrument g8ntly out 01 the canal with clockwi se rotation.
Insertion is done by a quarter-turn clockwise rotation
while slight or no apical pressure is applied. Cutting is
then accomplished by counterclockwise rotation
applying suffi cient apical pressure to the instrument.
The amount of apical pressure must be adj usted to
match the file size (i.e., very light for fine instru-
ments to fairly heavy for large instruments).184 Pres-
sure should maintai n the instrument at or near its
clockwise insertion depth. Then counterclockwise
rota lion and apical pressure act toget her to enlarge
and shape the canal to the diameter of the instru-
ment. Counterclockwise motion should be 120
0
or
greater. It must rotate the instr ument sufficiently to
move the nexl larger cutting edge into the location of
the blade that preceded it in order to shape the fu ll
circumference of a canal. A greater degree of rotation
Ls preferred and will more completely shape the canal
to provide a diameter equal 10 or greater than that
established by the counterclockwise instrument
twisting during its manufacture. It is important to
understand that clockwise rotation allows the instru-
ment to engage dentin, and this motion should not
exceed 90. If excess clockwise rotation is used, the
instrument tip can become locked into place and the
file may unwind.
284
If conti nued, when twisted
counterclockwise, the file may fail unexpectedly.
The process is repeated (clockwise insertion and
counterclockwise cutting) as the instrument is
advanced toward the apex in shallow steps. After
the working depth is obtained, the instrument is
freed by one or more counterclockwise rotations
made, while the depth is held constant. The file is
then removed from the canal by a slow clockwise
rotation that loads debris into the flutes and elevates
it away from the apical foramen.
284
A more or less
flared final shape may be obtained by stepping back
in 0.5 or I mm increments.
Generous irrigation follows each shaping instru-
ment, since residual debris will cause transportation
of the shape. Debris applies supplemental pressures
against the next shaping instrument and tends to cause
straightening of the curvature. By repeating the pre-
viously described steps, the clinician gradually enlarges
the apical third of the canal by advancing to larger and
larger instruments. Working depths arc changed
between instruments to produce an apical taper. The
working loads can and should be kept very light by
limiting the clockwise motion and thereby reducing the
amount of tooth structure removed by each counter-
clockwise shaping movement. This technique can and
should be used with minimal force.
The Balanced Force technique may be used with
any file with symmetrical cross section;.3 19 however,
Chapter 27 / Preparat i on of Coronal and Radicular Spaces /941
shaping and transportation control are considered
optimal when a Flex-R file is used.
320
The Flex-R
file design removes the transition angles inherent
to the tip of standard K-files (see Chapter 26C,
Instruments for Cleaning and Shaping). These
angles may cut a ledge into the canal walJ.
J2 1
-
J24
The specific tip design prevents Flex- R files from
transporting the canal into the external wall of a
curve.
325
Balanced Force instrumentation initiated from
the belief that the apical area should be shaped to
sizes larger than were generally practiced (see Table
10). The original Balanced Force concept then refers
to apical control zones by, for example, first using
sizes #15 and #20 files to the periodontal ligament
(i. e., through the apical foramen) and then redu-
cing the working depth by 0.5 mm for subsequent
sizes #25, #30, and #35. The apical shape is then
completed I mm short using sizes #40 and #45
under continuing irrigation with NaOCl . Single-
appointment preparation and obturation played an
important role in the for mation of these shapi ng
concepts.
The success of this shaping technique and enlarging
scheme has been closely evaluated in both clinical
practice and student clinics, and it can be said that
files used in "Balanced Force" motion generally lead
to comparatively little canal transportation. However,
subsequent research has indicated that the underlying
mechanisms are different from what was originally
, d .326327 S 'fi II h ' 'd h
envisage. ' peCl ca y, t ere IS eVI ence t at
the force required to hold the instrument close to
the position during counterclockwise rotation closely
matches the amount of force required to bend an
instrument into a curve similar to the main curve of
the canal that is prepared . .326 Nevertheless, in vitro
reports indicate that shapes created with the Balanced
Force technique are of excellent qllalitl
28
and are
comparable to those with NiTi rotary instru-
ments.
245
,.329,330 Furthermore, extrusion of material
was less than with other techniques, such as the
step-back filinp technique and the CaviEndo ultraso-
nic method.
33
More recently, $iqllcira et al, 287 tested
a modification of the Balanced Forces technique they
had earlier called alternated rotary movements, This
approach did not recommend wi thdrawal of the
instrument after each set of rotations but emphasized
incremental apically directed movement and withdra-
wal only when the file, for example, a size #25 NitiFlex
(Dentsply Maillefer) has reached the WL, Canals
shaped to an apical size #40 had in vitro bacterial
reduction similar to canals prepared with GT rotaries
to size #20 0.1 2 taper.
287
942 / Endodontics
CROWN-DOWN PRESSURELESS
The first description of a crown-down preparation, in
which larger files are first used in the coronal two-
thirds of the canals and then progressively smaller files
,
A B
a


u

I
I
. !
o E
are used more can be found in a Master's
Thesis by John Pappin.3 2 and the endodontic
manual of the Oregon Health & Science University. 81
They described the approach as follows (Figure 53):
C
F
Figure 53 Sequence of instrument s in the crown-down approach. Coronal preenlargemont was originally suggested to commence after determination of
a provisional working length IWLj wi th a size 135 hand file A, Then, Gates Glidden ours were used B, followed by hand files start ing with a large file
le,g .. size #60) and progressing apically with smaller sizes C, The definitive Wl was determined as soon as the progress was made beyond the
provisional WL 0, Apical enlargement E, and recapitulation F, created a homogenous shape that may be similar to the one created with the step-oack
approach. provided that both techniques wero performed with little or no procedural errors. Both step-back and crown-down techniques may be used in
conjunction with hand and rotary instruments but in vi tro evidence suggests that a crown-down approach is preferred for tapered rotary instruments.
335
After completion of coronal access, a provisional WL is
determined and a size #35 K-file is introduced into the
root canal wit h no apicaUy directed pressure. Then, a
GG No.2 is used, short of or to the length explored by
the size #35 file. The GG No.2 flares the coronal root
canal and is followed by GG Nos. 3 and 4 \vith pro-
gressively shorter Wls. The next step is the core of
what is now known as crown-down technique: a size
#60 hand file is used with no apical force, and reaming
is employed to enlarge the canal, foll owed by incremen-
tally smaller instruments progressing deeper into the
canal. A radiograph is taken when an instrument pene-
trates deeper than the provisional WL; after that, the
apically directed procedure continues until an instru-
ment reached the definitive WL.
The final step is to enlarge the apical arca to three
sizes larger than the first file that bound at WL. This is
accomplished by going through the sequence of des-
cending instrument sizes starti ng with a file one size
larger than the starti ng size in the preceding series.
Copious irrigation and recapitulation at the end of the
procedure is advocated. Marshall in 1984 and 1987
amended the manual to include "Balanced Force"
movements (Tinkle 1, personal communication).
Morgan and Montgomerym described a slightly
different method where both GG Nos. 2 and 3 were
introduced to a straight portion of the canal and the
"crown-down" process was started ,vith a size #30 K-file.
They showed superior ratings by experts judging canal
shapes, but similar occurrence of preparation errors,
compared to the step-back preparation.
333
However, a
subsequent study found no differences in canal transpor-
tation when comparing "crown-down," "step-back,"
sonic instrumentation, and a NiTi rotary system.
334
Nevertheless, a crovro-down approach is currently advo-
catcd for the majority of engine-driven rotary systems due
to reduced contact areas and forces on the instruments.
335
DOUBLE FLARE
F
282 d 'h' h
ava presente a preparatIOn tec mque t at con-
sisted of an exploratory action with a small file, a
crown-down portion wi th K-files of descending sizes,
and an apical enlargement to size #40 or similar. He
recommended stepping back in 1 mm increments
with ascending files sizes and freq uent recapitulations
with the MAF. Copious irrigation is considered man-
datory. It is further emphasized that significant wall
contact should be avoided in the phase
to reduce hydrostatic pressure and the possibility of
blockage. At this time, the double- fl are technique was
fel t to be indicated for straight canals treated in one
.. 282 L d' d d b
VISIt. ater stu les emonstrate etter prepara-
Chapter 27 / Preparation of Coronal and Radicular Spaces / 943
tions in teeth with curved root canals shaped with a
modified double-flare technique and Flex-R files com-
pared to shapes prepared with K-files and step-back
technique. A double-flare technique was also sug-
gested for ProFile rotary instruments.
336
Rotary Instrumentation
The introduction of NiTi allo/
37
for
hand files, 338 and later engine-driven instruments,33
has altered canal shaping procedures drastically over
the past two decades.
340
The endodontic literature is
replete with accounts of shaping outcomes in vitro
and descriptions of forces to which NiTi instruments
are subjected (for review see references 120 and 122).
NiTi rotary instruments and their design specifics are
described in detail in Chapter 26B, "Introduction of
Nickel-titanium Alloy to Endodontics" and Chapler
26C, " Instruments for Cleaning and Shaping". The
following section is dedicated to their clinical use.
A major benefit of NiTi rotaries is their potential to
avoid preparation errors.
341
This in turn may result in
be I
' , 1 228273 M h h
ncr c Illica outcomes. I orcover, t roug
changes in instrument geometries, the creation of opti-
mized canal shapes has been simplified. There is an
ongoing debate over which shape is the most useful. In
any event, shapes that are apically narrow and have a
smooth taper can be safely prepared to become more
parallel and apicall y larger. In achieving these designs,
most manufucturers of rotary files recommend a strict
crovvo-down sequence, with the exception of the LS
instrument.
342
Several strategies have been recommended
for this instrument, most of which represent a double-
flare technique. Recently, other instruments (ProTaper,
MTwo) have appeared on the market that are to be used
in a single-length technique, somewhat similar to the
standardized technique for hand instruments.
A main reason for recommending a crown-down
approach is to avoid overloading rotating instruments
with large frict ional wall contact; this is believed to
reduce the incidence of file fracture, in particular
torsional fracture (Box 2) .343,344 One possible
Box 2 Fracture Mechamsms for EndodontiC Instruments
and Possible Mechanisms
Torsionallallure
Fat igue failure
Corrosive failure
forcing Ihe instrument into a narrow [;lI nal
space aod rotating it
Overusing an instrument by prolonged rotation
in a curved [;lInal
Combination of torsional and fatigue fai lure
of an Instrument with signs of corrosion
944! Endodont ics
A B c
t
Figure 54 Rotary instruments may be subject to taper lock as soon as the canal taper approaches their dimension. Then, a large proportion of the
instrument surface engages the canal wall (indicated by red barsl, frictional resistance and hence torque increases. with a high risk of instrument
fracture. This risk may be minimized by sequentially A to C using instruments with smaller tip sizes or taper. thus reduci ng contact areas and torque 336
mechanism for this type of fracture is an event known
as " taper lock," illustrated in Fi gure 54.
345
,346 Taper
lock occurs when the shape of the tapered root canal
being prepared becomes similar to the instrument in
use. Instruments may then become locked into the
canal, and the tip may fracturc.
343
In a crown-down
pattern, the next smaller instrument should be
selected before taper lock can occur. Blum et al.
335
were convinced that ProFiles used this way experi-
enced much less torque than when a step-back pattern
was followed. This finding can be extended to most of
the other rotaries that have a similar longitudinal
design, for example, K3 (SybronEndo), EndoSequence
(Brasse!erUSA), HERO 642 (MicroMega, BesanOon,
France), and several others.
The distincti ve design of LightSpeed instruments
(Discus Dental) maximizes flexibility and allows lar-
ger apical preparations without unnecessary removal
of dentin. The LightSpeed (LSX) has a noncutting
shaft and a very short blade. After making SLA to
about the mid-root, the coronal third is flared with
the instrument of choice (not with the LSX). After
flaring, at least #15 K-file is used to obtain patency to
WL. A #20 LSX and sequentially larger sizes are used
to prepare the apical third. The Final Apical instru-
ment Size (FAS) is the blade size that encounters
4 mm or more of cutting resistance apically. A
4-mm step back with the next larger instrument (than
the FAS) completes the apical preparation. The mid-
root is then cleaned and tapered with the next 1'."0 or
three sequentially larger LSX sizes, blending mid-root
instrumentation wi th the previously prepared coronal
third. Recapitulation is usually necessary only once,
with the FAS, at the end of canal preparation. The
new LSX is to be used at 2500 rpm, and irrigation is
required thro'ughout the procedure.
Apical enlargement is sometimes done after crown- .
down has been accomplished. At this stage, different
strategies are possible, that is, switching tapers or tip
sizes, changing to different instruments. Torsional
stresses that files are subjected to depend on the
sequence empJoyed.
341
LillIe is known of the inci-
dence of fractures with single-length techniques, 348
particularly when the recommendations of the man-
ufact urers are followed. In addition, it is not certain
how important overall NiTi instrument fractures
are for clinical outcomes.
349
Nevertheless, strict mon-
itoring of instrument use should be instituted so
that NiTi files can be periodically disposed of prior
f
-I 350 351 If- 1 - 1 d
to 3i ure. ' n act, Slllg e use III severe y curve
or calcified canals may be preferable due to j"co-
blems of decontamination
352
-)55 and corrosion
3s
358
in addition to the greater amount of stress that the
instruments are subjected to in such sit uations.
Three different main handling paradigms have
been described fo r the use of rotary instruments.
Buchanan
J59
recommends feeding the rotating fi le
into a root canal with very slight apical force, until
the inst rument stalls, and then to immediately with-
draw the file. At this point the file has done its cutting
action and the flutes are loaded with debris that must
be removed. The file is then reinserted. A similar
movement has been recommended for RaCe files
(FKG, La Chaux-dc-Fonds, Switzerland), designed to
avoid threading into the canal.
[n contrast, the second recommendation for most
other instruments is to use them in an up-and-down
movement
342
,360 with a very light touch to avoid taper
lock and to dist ribute forces throughout the canal. This
movement is continued until a certain resistance is met
or WL is reached. Rotation in a curved canal leads to
accumulation of cyclic fatigue, another potential reason
, . f (B 2) 34:3,361-363 F .
lor lIlstrument racture see ox .' "atlgue
occurs through cyclic compression and elongation of
metal. The compounded amount of strain leads to
fracture after a typical lifespan of up to 1,500 rotations
in the most commonly used experimental configura-
tion.
364
,36s While the lifespan, calculated as rotations to
fracture, is independent of the rotational speed,366 the
instrument undergoing fatigue will fracture in a shorter
time period with higher rotations per minute.
Regarding hand movements, there is mixed evi-
dence regarding the protective effect of up-and-down
movements on the accumulation of cyclic fati-
gue,360,363 but it does not appear \0 be harmful for
the instrument brands tested.
The third instrument usage recommendation is spe-
cificallJ,: for ProTaper instruments and is termed "brush-
ing".3 Instead of feeding the file axially into the root
canal, it is moved distinctly laterally in order to avoid
threading in. Such lateral cutting occurs most effectively
with a positive rake angle and a stiffer instrument.
Regarding operational safety, it was recently established
for MTwo instruments that the "brushing" motion
extended fatigue life for larger size instruments.
368
This
finding may be extended to other instruments using
lateral cutting (Peters OA, Paque F, Boessler C, unpub-
lished data). However, GG drills, used in this manner in
the coronal third of the canal, 308,310 occasionally separate
through fatigue. In this case, the GG shaft may be readily
removed since fracture usually occurs on the transition
from shaft to shank.
A guideline emphasized for ProTaper
367
that may
be extended to other currently available instruments
Chapter 27 / Preparation of Coronal and Radicular Spaces {945
suggests determination of a "glide path. " Specifically,
prior to the use of any rotary instrument, root canals
should be explored with # \0, #15, or even #20 K-files
to avoid overloading NiTi instrument tips with unex-
pected canal curves or excessive wall contact.
369
Spe-
cial pathftnding files with specially designed geometry
are available for this task (e.g., ProFinder, Dentsply
MaiUefer). Regardless of the design, it is important to
use straight, not precurved, files to allow the subse-
quent rotary files to reach the same depth, without
encounter ing acute bends or very narrow canal areas.
Finally, it has been recommended by manufacturers
to use gel-based lubricants in conjunction with NiTi
rotary files, or to fill the access cavity with NaOCi prior
. .. 232359
T
h fib dlb
tomstrumentmsertlQn.' euseo ge- ase u n -
cants could potentially reduce frictional resistance and
hence torsional load.
370
However, experimental evi-
dence, using a dentin disk model, suggests otherv.ise.
371
In fact, the use of ethylcnediaminetetraacetic acid
(EDTA)-containing gels such as RC-Prep (Premier
Dental Products, Norristown, PAl or Glyde (Dentsply
Maillefer) may be detrimental, due to increased torque
37 1 372 d . I d h I
scores ' an, more Important y, ue to c emlCa
interaction with its EDTA moiety and NaOCI action.
373
Therefore, and despite reports of its corrosive
pOlential,J74,)75 frequently replenishing a reservoir of
NaOCl
376
is presently advocated, providing lubrica-
tion and disinfection during canal shaping. After
rotary instrumentation is complete, irrigation with
EDTA and/or NaOCI mar be done
377
, with and with-
out ultrasonic activation. 47,222,378
The following ten principles apply to the successful
use of currently available NiTi rotary files:
I. As with any type of instrument, poor access
preparation will lead \0 procedural errors. While
generally important in root canal preparation, it is
crucial for the use of NiTi rotaries.
2. Files should never be forced, as NiTi instru-
ments require a passive technique. If resistance is
encountered, stop immediately and before conti-
nuing, increase the coronal taper and verify the
"glide path" using small stainless steel hand files.
3. Canals representing difficult anatomy should be
detected, analyzed, and carefuUy instrumented
following specific rules (Figure 55, see below for
more details).
4. Files should not be overused. Once only is the
safest number but the actual stress level depends
upon the case. Hence files may be used for more
t han one canal, but may have to be replaced when
shaping a particularly difficult canal .
946 / Endodonti cs
Figure 55 Example of a sequence of instruments to safely enlarge and shape the coronal part of the root canal system. This enables a complete shape of the
apical third also. ShOVvTl are magnified buccal views into the access cavity of a maxillary molar and respective radiographs. After pat hfi nding wit h a lubricated
(arrowhead) K-file, straight-line access ISLA) is created with ultrasonically pc:r.vered and rotary instruments. This is often difficult but equally important in the
second mesiobuccal canallshown accessed here). Then working lengths IVVLs) in all four canals are determined; subsequently canals are enlarged and filled.
5. Inst rument breakage occurs more often during the
initial stages of the learning curve. The clinician
changing from stainless steel to NiTi should take
continuing education courses with experienced
clinicians and educators, followed by in vitro
practice on plastic blocks and extracted teeth.
6. NiTi rotaries should not be used to bypass ledges.
Confirmation of a glide path with a straight K-file is
required prior to the use of any NiTi rotary.
7. Cutting with the entire length of the file blade
should be avoided. This total or frictional fit of
the file in the canal will cause the instrument to
lock.
8. Sudden changes in the direction of an instrument
caused by the operator (i.e., stopping and slarting
while inside the canal) must be avoided. A smooth
gentle reaming or rotary motion is most efficient.
9. Inspection of instruments, particularly used
instruments, by staff and doctor is essent ial. It
should be remembered that NiTi has an excellent
memory. The file should be slraighl. If any bend is
present, the instrument is fatigued and should be
replaced.
10. WL should be well established and controlled, as
should the actual length of the file. I f a file breaks
without the clinician taking notice, a very sharp
tipped instrument, upon the next insertion, will
create procedural errors.
It is extremely important, for successful root canal
preparation with rotary instruments, to carefully review
the specific anatomy of each case (see earlier in this
chapter and Chapter 6, Morphology of teeth and their
root canal systems). Straight access into the root canal
middle third should be created, with extended access
cavities and early coronal flaring. When using rotary
instruments, canals that curve, recurve, dilacerate,
divide, or merge should be approached with extra
care.
232
Figure 56 illustrates other problematic canal
configurations. For example, very long llarrO\v canals
do not allow early coronal enlargement to the same
extent as regular canals. The consequence is an
increased frictional contact area and the potential for
torsional overloading. There is no ideal solution to this
problem except for extra careful flaring and potentially
using hand instruments.
Acute bends, that is, those with a small radius of
curvature, more coronally (see Figure 568), puts a
larger instrument cross section under cyclic fatigue
and may cause breakage.
362
Here coronal flaring to
the point of curvature and the use of rotary files with
less laper to the WL are indicated. Ovoid canals that
are wide buccolingually, such as distal canals of man-
dibular molars or some premolars, present a different
problem. Instrument fracture is not very likely, but
they can rarely be prepared 10 be round; hence deb-
ridement may be incomplete. It may be appropriate to
approach these cases as if hvo canals existed buccally
and lingually, and then merge the preparations by
Chapt er 27 I Preparati on of Coronal and Radicul ar Spaces I 947
o
o
A
B
o
o
c
00
F
E
o o
G
H
Figure 56 Schematic diagram of typical root canal anat omy with
increasing degrees of di fficulty for root cana l preparation. Shown are
basic canal shapes and cross sections at the middle root canal thi rd Isee
text for more details). A.. Short straight canal. 8, longer canal with
moderat e curvature. C, Very long canal. 0, Canal that is wide buccoli n-
gually and may have multiple apical ramifi cations. E. Canal that splits
apically in two mai n canals. F, Cana ls merg ing at the transition of mi ddle
and apical thirds. G, Acute curvature in coronal root canal third. H,
Ext reme curve in the apical 2 to 3 mm.
filing action with ultrasonic files or hand files. For
merging canals, it is suggested to prepare the straigh-
t.er canal to WL and the other canal to the merging
948 / Endodontics
point. This avoids forcing a rotary instrument
through a sharp S-curve. Many procedures have been
suggested for very acute curves and narrow canals (see
Figure 56C) , although none is certain to be uni versally
successful.
By extending the strategies detailed earlier in this
chapter, the following recommendations represent
current thinking
379
for such a procedure. In part,
A
B
c
D
E
F
G
H
these are different from earlier descriptions for
hand instruments. 2s6.2s7 Coronal enlargement and
creation of SLA are important to allow rotary
instrument to work wi thout undue stress. More-
over, this procedure reduces the danger of ledging
and blocking. Figure 57 illustrates how this may be
accomplished for a curved canal in a maxillary
molar.
A
B
c
D
E
F
G
H
Figure 57 Example of a clinical sequence of instruments to Silfely enlarge and shape the apical two-thirds of curved root canal systems (palatal canal in A)
using hand and rotary instruments. After pathfinding with small hand instruments 8, aoo coronal preenlargemenl C, working length [Wl) is determined For
a safe use of rotary instruments. a glide path is established with a series of hand instruments 0, which rotary instruments can then follow E, Sufficient
apical enlargement F, allows small irrigation needles to be passively inserted deep into the ma in canal G, and facil itates fitting 01 master cones H
Calcifications occur nearest to the irritant to which
the pulp is reacting. Since most irritants are in the
coronal region of the pulp, the farther apical one goes
into the canal, the more unlikel y it is to be calcified.
When files bind in these canals, it may be from small
constrictions in the coronal part of the canal.
Obviously, before the canals can be entered, their
orifices must be found. Knowledge of pulp anatomy is
of first importance. Perseverance is the second
requirement, followed by a calm determination not
to become desperate and decimate the internal tooth
when the expected orifice does not appear. The endo-
dontic explorer is the greatest aid in finding a minute
canal entrance (see Figures 18 and 55), feeli ng along
the walls and into the floor of the chamber in the area
where the orifices are expected to be.
A valuable aid in finding and enlarging canal ori-
fices, particularly with magnification, is the Micro-
Opener (Dentsply Maillefer) or the EndoHandle
(Logan Dental, Logan, UT), with K-type fl utes in
0.04 and 0.06 tapers.
Radiographs are indispensable in determining
where and in which direction canals enter into the
pulp chamber. The initial radiograph is one of the
most important aids available to the clinician; a bite-
wing radiograph is helpful in providing an undis-
torted and metrically accurate view of the pulp cham-
ber. The handpiece and the bur may be held up to the
radiograph to estimate the correct depth of penetra-
tion and di rection to the orifices. Color is another
important aid in finding a canal orifice. The floor of
the pulp chamber and the continuous anatomical line
that connects the orifices (the so-called molar tri an-
gle) are dark gray or someti mes brown in contrast to
the white or light yellow of the walls of the chamber
(see Figure 55). Various ultrasonically powered tips
B
c==
Chapter 27 I Preparat ion of Coronal and Radicul ar Spaces 1949
are very helpful in relocating and enlarging orifices
once their position has been determined (see Figure
55).
Current rotary instruments have noncutting tips
and, with correct handling, pose relatively little risk
of ledging the canal, certainly not in the coronal two-
thirds. Provided that copious irrigation is used, api-
call y directed transport of debris is less than with
hand instruments and filing actions.
162
, 380.381 Verify-
ing a glide path, as illustrated earlier, is particularly
important when shaping narrow canals. This may be
accomplished with a small (size #6, #8, or #10) K- or
C-file (Dentsply Maillefer), lubricated and used in a
watch-winding motion (see Figures 55 and 57).
An argument against using a straight instrument is
that it tends to engage the wall at the curve or the
pivot on a catch on the wall. Rotary instruments,
however, are also straight. Therefore, the presence of
a glide path has to be verified wi th a straight hand file.
When the presence of sharp curves, debris, or very
narrow canal areas is expected, precurving an explora-
tory file is indeed indicated (Figure 58). Most often,
the pathfinding file can be advanced to Wl with
adequate hand movements, in particular gentle
watch-winding. If this cannot be accomplished, cor-
onal interferences must be removed by increasing the
taper of the already explored coronal canal segment
(see Figure 55).
When tentative WL is reached with a pathfinder
file, the clinician may determine the direction of a
major curvature by noti ng the direction of the tip of
the file when it is withdrawn. This is a valuable clue,
since the clinician understands the direction in which
the canal curves and may guide the instrument
accordingly. Valuable time may be saved when
exploration is eliminated each time the instrument is
Figure 58 Flellible endodontic files may be used st raight As to initially scout and pathfind a root canal, since a subsequent rotary instrument can more
safely be used in a canal area that a straight hand fil e negoti ated ("glide path'l. If an intracanal obstruction is encountered, an adequately precurved
manual instrument should be used to conform more to overall canal anatomy B, A more acutely curved instrument can be utilized to bypass ledges or
blockages C, Inset shows bacterial growth on blood agar after a Kfile was bent using "clean" gloved fingert ips.
950 I Endodontics
placed in the canal. A pointed silicone stop will clearly
show the direction of the file curvature. The WL may
then be confirmed wit h a radiograph using a size #15
K-file. After determining the WL, a curved pathfind-
ing fil e should be used if additional canals are sus-
pected, for example, in mandibular incisors, mandib-
ular premolars, the distal root of mandibular molars,
or the mesiobuccal root of maxillary molars.
While ultrasonically powered inserts are routinely
used under magnification to explore and refine access
into canals, rarely do they need to be used into middle
and even apical third of canals. However, when severe
calcification is present, there is the option to locate a
canal cross section that needs further shaping with
hand or rotary files to WL (Figure 59).
B
Others have recommended the use of EDT A buf-
fered to a pH of 7.3 to "dissolve" a pathway for
I
382383 Wh h . I I
exp onng mstruments. ' en t e mmera sa ts
have been removed from the obstructing dentin by
chelation, only the softened matrix remains.
384
How-
ever, this action has been disputed by others, since
chelation does not readil y occur in narrow parts of the
canal, although softening can occur in the cervical and
middle portions.
38s
,386 EDTA must be concentrated
enough in an area to be effective.
Like in many other situations in root canal therapy,
it is the obligation of an astute clinician to execute a
cost-benefit evaluation, in order to determine if
further progress without clear evidence of a canal
cross section IS indicated. Magnification and
Figure 59 Occasionally. calcification may occur more apically than usual In this case. ultrasonic instruments were used to remove the obstruction
larrowhead in A); both mesial and distal canals were shaped and filled to the desired working length (Wl). A. View through the operating microscope
before using ultrasonic tips and preoperative radiographs. 8, Canal lumen exposed as seen in the operating microscope and postoperat ive radiograph.
Images courtesy of Dr. Peter Velvart
illumination are keys to this task and experience will
help to guide the clinician here more than textbooks.
In conclusion, it needs to be emphasized that the
suggested methods are by no means the only way to
approach difficult root canals. Again, it is in the
hands of an artful clinician to master all aspects of
such a case.
Devices for Powered Canal Preparation
Engine-driven instruments have been used in root
canal preparation for more than 100 years beginning
with GG drills in 1885. These drills were mostly used
in hand pieces connected to belt drives and were
pedal-powered, even though the first electric dental
handpiece had been patented in 1875. Subsequently,
many modifications, and specifically hand pieces with
various oscillating movements, were brought to the
market, none of which provided superior preparation
quality.122 Currentl y, the newest major energy sources
for root canal preparation are again elect ric motors
for continuous rotary motion and ultrasonic/sonic
L1nits for vibration.
MOTORS FOR ROTARY
INSTRUMENTATION
Engine-driven instruments can be used in three types
of cont ra-angle handpieces: a full rotary handpiece,
mostly latch grip, a reciprocating/quarter-turn hand-
piece, or a special handpiece that imparts a vertical
stroke but with an added reciprocating quarter turn
that "cuts in" when the instrument is stressed. These
all are powered by electric or air-driven motors.
While electric motors are more popular in Europe,
air-powered motors are in much use in the United
States. Il is not clear if there are relevant differences
between these two motor types regarding file break-
age.
387
In addition to these two motors, there are
battery-powered, slow-speed hand pieces that may be
Chapter 27 I Preparation of Coronal and Radicular Spaces / 951
combined \vith an apex locator, designed to simplify WL-
control as well as torque-control motors (Figure 60).
As stated above, traditional hand pieces with non-
continuous movement such as the Gi romatic (Micro-
Mega) and M4 Safety handpiece (KerrISybron) (see
reference 122 for review) have been shown to lead to
aberrant canal preparations. Some reports for these
systems were favorable388-390 while most others
demonstrated problems, most notably a high inci-
d f
. 391-397 C I
ence 0 preparatiOn errors. onsequent y,
these hand pieces have lost popularity in the last years
with the increased market share of NiTi rotaries.
An exception may be the Canal Finder system
developed by Levy (currently marketed by SET,
Olching, Germany) that uses a handpiece, either air-
powered or electrically driven, that delivers a vertical
stroke ranging from 0.3 to 1 mm. The more freely the
instrument moves in the canal, t he longer is the
stroke. The handpiece also has a quarter-turn recipro-
cating motion that starts along with the vertical stroke
when the canal instrument is under bind in a tight
canal. If it is too tight, the motion ceases and the
clinician switches to a smaUer file.
More recently another handpiece with oscillating
action was introduced (EndoEZE AET, Ultradent,
South Jordan, UT) to more adequately prepare canals
with oval cross sections. Unfortunately, this technique
in its original configuration did not perform well in
curved canals/
98
but with updates, in file type and
alloy as well as instrument sequence, it may serve as
an adjunct to address cases not suitable for rotary
preparation alone.
399
Recommended speeds for currently available NiTi
rotaries are in the range of ISO to 600 rpm, with the
exception of LS that works predominantly above
1,500 rpm. This range of speeds is typically reached
with reduction gear handpieces (1:8 or 1:10). Higher
speed is occasionally advocated for better efficacy
and safely,400 but the majorit y of authors maintain
that lower speeds arc beneficial, offering a better
952/ Endodontics
A
- MlOWfSl _
6 .....
,)
00 .'
B
Figure 60 Selecti on of cablebound A. and cord less S, motors intended for use with nickel- titanium (NiTil rotary instruments.
, d' <' l't: 387401402 d
compromise regar IIlg latlgue llesfan " an
occurrence of taper lock.
For continuous rotary movement, electric motors
offer several benefits over air-powered ones, such as
stable preset rotations per minute. However, the most
attention has been focused on the potential to pre-
select maximum torque in order to protect instru-
ment tips from fracturing,405 This is accomplished
by setting a maximum current (DC motors) except
for the so-catled stepper motor that is software-con-
trolled (EndoStepper, SET), There is some evidence
that the use a of a torque-limiting motor reduces the
overall load on NiTi files and hence increases their
fatigue lifespan.
4Q6
,407 Moreover, these motors are
seen as useful for beginners, to avoid forcing an
instrument.
404
Various settings are possible for some
torque-limited motors; for example, the motor can
stop, go into reverse or into oscillations.
On the other hand, electronics inside motors and
hence their torque limits are not very precise;408-41O
wear and friction inside the handpiece must also be
further taken into account. Moreover, these motors
depend on correct presets for the expected fracture
limit. The limits are determined according to the
'"
E 15
"
!
,
,
"




! ,
0

,
-,
,
,
, I VV
,
,
,
, ,

,

A
VV
10 12 14 16 18
Chapter 27 I Preparat ion of Coronal and Radicular Spaces / 953
B

o 10 w ro 100
T1 .... (.j
"
,
,'"
j
,
I'

L
"

C ' D '
Figure 61 Relat ionship of torque during canal preparation arxJ fracture load: The McSpadden Factor. A. Working torque (in blue). directed force (in
green), and insertion depth (in red) into an extracted tooth simultaneously rocarded during preparation with a Profile 0,04 60 rotary USing a testmg platform.
Note that total length of the instrument use was about 16 seconds. B, Determination of fracture load according to ISO 3631).1 at 2 rpm. determined at 03. C,
Mean working torques (means SO. n" 10 each) in straight and curved plastic bloclo:s or in extracted teem (indicated by various shades of dark blue)
static fracture load (br ight blue bar, n = a). Mooifi ed with permission from Peters OA and aarbarow F.363 0, Val ues of the McSpadden factors for ProFile
0.04 60 are above 1 in all tested conditions, indicating a very fractureresistant instrument (bar shades to panel C).
pertinent norms at D3, 3 mm from the tip of the
file.
4 11
Hence, a short and less resistant segment of
the file can still break even when the presets are
correct.
A minimum torque is required for a rotary
instrument to work against friction to prepare a canal
(Figure 61). This torque level depends on instrument
cross sections and hand movements employed. The
relationship between fracture load at D3 and working
torque has been referred to by LT. McSpadden as the
"safety quotient"; it is calculated by dividing fracture
load by working torque.
If worki ng torque is high and the fracture limit is a
small torque value, the instrument's safety quotient is
below I. This indicates that the instruments may
operate with imminent danger of fracturing. In con-
trast, if there is very little working torque and a high
torque is required to fracture the instrument, the
quotient is well above 1, and hence safety is consid-
ered high (see Figure 61). However, Blum et al.
412
have correctl y pointed out that the quotient should
refer to a specific instrument cross section rather than
03 alone to be more meaningful.
ULTRASONIC CANAL INSTRUMENTATION
The use of ultrasonic in endodontics is based on
sound as an energy source (at 20 to 25 kHz) that
activates an endodontic file. As a result, three-dimen-
sional file movement in the surrounding medium of
root canals may be enlarged.
4 13
The main debride-
ment action of ultrasonics was initially thought to be
by cavitation, a process by which bubbles formed
from the action of the file become unstable, collapse,
and cause an implosion. A combined shock, shear,
and vacuum action resulted.
4 13
Ultrasonic handpieces
typically use K-files as instruments for canal shaping.
Before a size #15 file can fully function, however, the
canal must be enlarged with hand instruments to at
least a size #20 to allow the file to oscillate without
constraint. Although Richman must be credited with
the first report (1957) of the use of ultrasonics in
d d
. 414 M - de h 4 15-420
en 0 ontlCs, j artm an unmng am were
the first to develop a device, test it, and see it mar-
keted in 1976. It was named the Cavitron Endodontic
System by Oentsply Caulk and was followed by many
other devices on the market. These instruments all
deliver an irrigant/coolant, usually NaOC1, into the
954 / Endodontics
canal space while canal preparation is carried out by
a vibrating K-fUe. The canal shapes and surfaces
achieved, by preparat ion with ultrasonic units,
h d f d
419-424 d .
ave range rom outstan mg to ISWf,0mt-
ing, 166.425-'428 in particular regarding canal shapes, ,129,430
and the use of ultrasonics to shape canals has fallen into
disregard over the I a ~ t decade.
Research into the potent ial mechanisms of ultraso-
nic action has continued and has revealed that it is
not cavitat ion, but a different physical phenomenon,
acoustic streaming, that is responsible for the debri-
d
431-433 Cl I . . d d
emenl. ear y, acoustic streammg epen son
the free displacement amplitude of the file, and if the
vi brating file is at least partiall y constrained and da m-
pened in its action, it will become ineffective.
134
SONIC CANAL INSTRUMENTATION
Sonic endodontic handpieces attach to the regular
airline at a pressure of 0.4 MPa. Air pressure may be
varied with an adjustable ring on the handpiece to
give an oscillatory range of 1.5 to 3 kHz. Tap water
irrigant/coolant is delivered into the preparation from
t he handpiece. Walmsley et a1.
434
,435 studied the oscil-
latory pattern of sonically powered files. They found
that out in the ai r, the sonic file oscillated in a large
elliptical motion at the tip. However, when loaded, as
in a canal, they found that the osci ll atory motion
changed to a longitudinal motion, up and down,
" . .. a particularly efficient form of vibration for the
preparation of root canals .... "435
Similar to ultrasonic instrumentation, there is cur-
rently little support for the use of sonic vibration to
prepare root canals, with the only exception of retro-
grade canal preparation during endodontic surgery
(see Chapter 32, Endodontic treatment outcome: the
potenti al for healing and retained function).
Today ultrasonically activated instruments are used
for final canal debridement rather than canal prepara-
tion.
436
Passive sonic and ultrasonic irrigation is dis-
tinct from active irrigation; in the former, irrigant
deposited in the canal is activated, whereas in the
latter, a stream of solution is continuously delivered
from the ult rasonic or sonic unit. Passive irrigation
(after smear layer removal) with a size # 15 file for 3
minutes in the presence of 5.25% NaOCi produced
cleaner canals when compared to hand instrumenta-
tion alone.
437
Improvement in irrigation efficacy was
also reported by authors using 5.25% NaOCl for 30 to
60 seconds,438 2% NaOel for 3 minutes,222 or 2%
chlorhexidine for 1 minule.
439
There has been concern that cutting instruments
would in fact negatively impact canal surface and
shape and therefore blunt noncutting inserts have
been advocated. Figure 62 shows canal segments after
passive ult rasonic irrigation, demonstrating no
damage with either cutting or noncutting instru-
ments.
378
,440 It has also been of interest to see if
NaOel may be extruded out of the apical foramen
from ultrasonic filing and cause harmful effects.
Alacam44 1 intentionally overinstrumented beyond
the apex in a monkey study and then evaluated the
tissue response when NaOel was used with conven-
tional filing versus ultrasonic filing/i rrigat ion. He did
not find any difference between the two methods and
noted a low to moderate inflammatory response peri-
apicall y.
Ultrasonically and sonically activated passive irriga-
tion exerts its effects via acoustic st reaming and
.. 442443 (r 63) h h
mcrease m temperature ' I' lgure rat er t an
cavitations as previously thought. Using both
mechanisms, 3 minutes of ultrasonic instrumentation
wi th a size #15 file and 5.25% NaOel improved canal
deanliness.
444
It is presently not clear which combina-
tion of file size and canal shape produces the best
results. In one study, small er fi les generated greater
acoustic streaming and hence much cleaner canals.
432
As it had been shown that constraint of the activated
insert in the apical canal third was an important
actor,431,445 a freely oscillating size #15 K-file was
used for 5 minutes with a free flow of 1% NaOCI.
The same authors found that root canals had to be
enlarged to the size of a size #40 file to permit enough
clearance for the free vibration of the size # 15 file at
full ampli lude.
446
Others have also recommended a
size # 15 file;378,427,447 however, van der Sluis et a1.
440
recently speculated that the shape of the insert in
Chapter 27 I Preparation of Coronal and Radicular Spaces / 955
Figure 62 Varying effect of ultrasonic activation of deposited irrigation solution on apical canal wa ll morphology. In this experiment. both 5.25% sodium
hypochlorite (NaDell and 17% ethylenedi aminetet raacet ic acid (EDTA) irrigation were activated with ei ther K-fil e type or prototype noncutting inserts
after enlargement of singl e-rooted teeth to an apica l size #45. A. Scanni ng electron micrographs of Ultrasonic inserts, black bars are 300 I.m 8, Canal
surface with smear layer without the use of EDTA (control I. C, Apical segments after irrigati on with NaDel and EDTA with ultrasonic act ivati on, .
demonstrating thi n conti nuous (left) or no smear layer wit h open denti nal tubules (right. whi te bars are 50 11m).
relation to the canal shape may playa role for its efficacy.
Indeed, temperature changes during activation of irri-
gants vary with the geometry and the material of the
insert, indicative of energy transfer (Paque F and Peters
OA, unpublished data) (see Figure 63). While the major-
ity of in vitro studies support improved debridement
with the use of passive ultrasonic irrigation, potential
clinical benefit is as yet unproven. In fact, ultrasonic
inserts may fracture, representing an iatrogenic problem
during canal shaping (Figure 64).
Evaluation of Canal Preparation
Techniques
A variety of techniques have been used over the years
to assess preparation quality (sec references 120, 122
for review), and most of these investigations were
done in vitro. Previously, two main parameters were
addressed, mostl y from a mechanistic viewpoint:
canal shapes and appearance of canal surfaces, the
latter also termed cleanliness.
956 ! Endodont ics
8
A
B Coo,", Activator Passive US
40 40
" E
i
35
-
35 35
_ coronal
"
'-..:...-
f
- middle
- apical
e
30
~
30 30
t ~

t t
25 25 25
0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 0 1020 30 40 50 60 70 80
C time [s] time ls I time (s]
Figure 63 Effect of ultrasonic activation on intracanal temperature in vitro. Thermocoupl es were attached to single-rooted teeth and the assembly was
placed in a water bath at 3rC Irri gation sol ution was either added and activated or conti nuously deposi ted concurrent with ultrasonic acti vation usi ng
various inserts. A Three thermocouples fitted into holes drilled in radicula r denti n close to the int racanal surface. B, Bar diagrams showing maximum
and mini mum temperat ures at the coronal, middle, and apical levels. Measurement duration 2.5 minutes. fJ=15. C, Origi nal records of temperat ure over
time with no ultrasonic act ivation 1control, left), usi ng an agi tator at sonic frequency Iprototype. middle) and a blunt nickel- titanium INiTiJ wire for
passive ultrasonic agi tation (right. EndoSoft. EMS. Nyon, Switzerland). Begi nni ng of irrigation indicated by arrows.
The ability of an instrument or a technique to allow
the prepared canal to stay centered in root cross sec-
tions is seen as beneficial (Figure 65). Conversely,
canal transportation, or any deviation from the origi-
nal canal path, is seen as negative and in particular the
end points of transportation, namely preparation
errors (Figure 66). The term "zip" was coined by
I
AI
' 278 h d bd h f" d"
'veme, w 0 escn e t e appearance 0 a zippe
apex when viewed directly in vitro. The formation of
preparation errors is believed to be due to the interac-
tion of canal curvature, file design, and file handling
(see Figure 50). The tendency of a file to straighten
Chapter 27 I Preparation of Corona l and Radicu lar Spaces I 957
Figure 64 Use of activated irrigati on in the cli nica l setti ng. A size 115 K-file was attached to an ultrasonic unit Imiddle power setti ng) and activated for
30 s. During cone fit. it was noted that a segment of the inst rument had fractured, The fragment was removed and the root cana l system fill ed with
lhermoplaSl icized gutta-percha,
itself cannot be completely overcome by precurving
and leads to uneven distribution of forces and hence
material remova1.
284
,448
Moreover , the cutting action of instruments in the
apical region, particularly when extended beyond the
canal space, may create an apical zi p with perfora-
tion.
449
The occurrence of such apical preparation
errors has previously been linked to hand and rotary
. . h h . 450--452 Z d lb '
IIlstruments WIt s arp tIpS. lp-an -e OW lor-
mation and other weU-described preparation outcomes
such as ledges, stri p perforations, or excessive thinning
of canal walJs
453
may have clinical consequences such as
incomplete debridement, problems with root canal filJ -
ing, or eventual vertical root fracture (Figure 67). Pre-
paration errors may decrease outcomes, most likely via
reduced antimicrobial efficacy, but their clinical con-
sequences are still a matter of debate.
27
o-
274
,454,155
Generally, apical canal areas tend to be overprepared
toward the outer curve or the convexity of the cana\'
while more coronal areas are transported toward the
concavity or the furcation in multirooted teeth (see
Figure SO) . This results in an uneven preparation
demonstrated in canal cross sections with large areas
left unprepared.
4
56-460 This finding was validated by
three-dimensional analyses (see 66) using micro-
computed 64 While the amount
958 1 Endodontics
-
Figure 65 Canal cross sections before and after preparati on can be assessed usi ng a specia ll y designed mold that all ows sectioni ng of root. removal,
and precise reposi ti on of the resulti ng root disks A. Photographs can be taken and the effect of canal preparation numerically determinM, for example,
in the corona l, middle, and apical root thirds before B, and after preparation C, In this case shown, rotary preparation lIeft canals) resulted in round and
centered shapes, while hand instrumentation produced canal transportation and thinning of root structure (arrowhead, C). Gradation of bar is 0.5 mm.
of prepared canal surface seems to be independent
of the instrument type, it was affected
by preoperative canal anatomy.2 ;),46:\,464 Sequential
mechanical enlargement, as shown in Figure 68, may
be indicated in order to increase prepared surface
areas, in particular to remove tenacious biofilms pre-
sent in ret reatment cases.
465
While the use of microcomputed tomography
represents the latest available technology, lhere are
numerous olher ways to evaluate canal shapes, for
Figure 66 Root canal preparati on errors develop more readil y with
increasing instrument size and hence stiffness, This panel of microcom
puted tomography data shows canal straightening and perforati on after
shaping to size #25 in an experiment where quarter-turn pull motion was
employed with stainless steel hand files, A, Unprepared root canal
system of a maxill ary molar. 8, Accessed and coronal scouting with a
size 115 file. C, Enlargement to size 115 (buccal canals) and #25lpalatal
canal) to working length (Wl). note fractured instrument in second
mesiobuccal canal (arrowhead). 0, Enlargement to size 130 (buccal
canals) and 135 (palatal canal), note perforation in main mesiobuccal
canal. f, Enlargement to size 150 and 155 in buccal and palatal canals,
respectively. F. Enlargement to size 150 and 170 in buccal and palatal
canals, respectively.
example, sugerimposing radiographs before and after
shapin
S
.
334
,66----468 Bramante et aL
469
and later
others 0---474 embedded teeth with their roots in a
Chapter 27 I Preparation of Coronal and Radi cular Spaces I 959
Figure 67 Relationsh ip between verti cal root fracture locat ion, cli niGa l,
and radiographi c appearance, A buccal swelling but not appreciable
probing was present in this case. Only after the removal of the crown
and the buildup material, a fracture line extending to the mesial was
apparent (arrowhead in A), A periodontal defect (probing depth 11 mm)
was detected that cor responded to radiographically visible bone dest ruc-
tion 8, Images courtesy of Dr. Tri Huynh.
muffl e system (see Figure 65) . They were then cut
and the cross sections evaluated before and after canal
preparation. Center points of the canals were deter-
mined and movements of the canals' centers caicu-
lated.
4
72,474--480 Numerous studies evaluated shaping
capabilities of specific instruments using canals of
varying geometry in plastic blocks and extracted teeth.
Various factors for canal transportation have been
960 I Endodont ics
100
'*
80
-

~
60
"
~
40
~
-c
:::>
20
0
A GT K Fi le LS PF PTp Flo<
100
r=t
r I-
r - ~
o
B
Flo< PF PTIFLx PTIPF
Fi gure 68 Dependence of instrumented canal surface on tile geometry and usage. A. Bar diagram showing overall and apical fractions ot instrumented
cana l surface. Data recalculated tram Peters OA. et al.'45 B, Bar diagram showing increase 01 instrumented surface with increased apical sizes IPaque F,
Peters OA. unpubli shed data). C, Microcomputed tomography reconstructions 01 canals shaped with cutting and noncuning inst ruments used
subsequently.
identified, such as canal anatomy, instrument type,
cross-sectional and tip design, instrument taper,
sequence, operator eXferience, rpm, and the use of
irrigants or lubricants. 20
The effect of canal anatomy on shaping outcome is
well documented for LS, ProFile 0.4 and 0.06, Quan-
tec LX and SC (Analyt ic Endodontics, Glendora, CA,
USA), and HERO 642, in rarticular by experiments
from Dummer's group4S2,4 1-488 using plastic blocks,
Taken together, these studies demonst rated an
impact of canal geometry on outcome: the more
severe the angle and radius of the curve, the more
severe the canal transportation. On the other hand,
there was no significant effect of canal shape on
preparation times.
Furthermore, file design was crucial to avoid pre-
paration errors: activelr cutting tips such as wit h
Quantec SC and LX
452
,4 8 produced more aberrations
than instruments with noncutting tips,450,451,488-492
The direction of apical canal transportation varied,
but occurred mainly oun'lard in relation to the canals'
curve; the total amount of canal transportation varied
significantly, again in relation to canal geometry, and
ranged In most cases benveen 0.0 I and
0.150 mm,452,481-488
Compared to stainless steel hand files, NiTi
instruments were superior in their shaping abil-
ity.493,494 Schafer et al. reported that HERO 642,495
FlexMaster (VDW, Munich, Germany),496 and K3
instruments
497
maintained the original canal path in
curved plastic blocks better compared to stainless steel
hand instruments. They found little incidence of canal
aberrations and material removal in excess of
0,15 mm in less than 50% of the levels analyzed for
HERO, FlexMaster, and K3,495-497 while hand instru-
mentation resulted in significantly greater material
removal (up to 0,69 mm),497
ProTaper instruments prepared curved canals in
plastic blocks in less time and with no definite canal
aberrations, but with a larger amount of material
removed, compared to GT RotaIJ;' Quantec, and Pro-
File 0.04 and 0,06 instruments, 98 In a study using
another brand of plastic blocks, Hata et al. found
overly long preparation times (>250s) for ProFile
0.04 and 0,06, GT Rotary, and in particular for
" Balanced Force" instrumentation.
330
Instrument shaft design did not significantly mod-
ify shapes of similar apical sizes in one series of
studies,461,462 while it is generally held that a thin
flexible shaft will allow larger apical shapes with less
aberrations.
9
.
472
In contrast, ProFile 0.04 instruments
alone removed more material compared to a combi-
nation of ProFile 0.04 and 0,06,330
Chapter 27 f Preparation of Coronal and Radicular Spaces f 961
Cutting blade design was modified lately from pas-
sive, so-called U-file designs to more actively cutting
triangular ones in instruments such as ProTaper, Flex-
Master, K3, HERO 642, and RaCe. However, while
there is onz limited evidence for each individual
file,462-464.49 ,496,499,500 the introduction of actively
cutt ing cross sections does not appear to negatively
affect centering abilities.
K-files used in most techniques, with the exception
of "Balance inferior to NiTi rotary
in vitro.
290
,292.50 I- 3 Clearly, reamin3.t rcroduced
rounder canal shapes in cross section,S - 06 which
may be desirable as long as a canal may be reasonably
prepared round,
Handpieces with noncontinuous rotation have also
been extensively tested, and some are better in cutting
efficiency, some in foll owing narrow curved canals,
some in producing smooth canals, and some in allow-
ing irrigation and smear layer removaI.
398
,423,507-S14
While all of the automated devices may be occasion-
ally useful, none has proved to be outstanding; cur-
rently NiTi rotary instrumentation is widely believed
to be a better choice for root canal preparation,
As stated earlier, rotary instrumentation is poten-
tially associated with an increased risk of instrument
breakage.
349
.515--518 Substantial work has been done
in vitro to elucidate the fracture mechanisms
involved (see Box 2); however, the clinical impact
of instrument fractures is less well documented and
does not lend itself to assessment in prospective
clinical studies.
Currently available evidence for outcome studies
regarding the impact of file breakage, as recently
reviewed by Parashos and Messer,349 relates mainly
to the pre-NiTi era, with few exceptions.
SI8
,SI9 For
example, Strindberg
l31
using very stringent criteria
in his comprehensive outcome study found a 19%
higher incidence of failure when a file fragment was
retai ned. He speculated that infection of the root
canal apically of the retained fragment would render
the prognosis poorer. On the other hand, a retrospec-
tive analysis by Crump and Natkin
454
of the outcomes
of root canal treatments done by dental students
revealed instrument fractures in 178 out of approxi-
mately 8,500 cases. Matched control cases of the same
cohort without instrument fracture had statistically
similar outcomes when cases were evaluated as "suc-
cess," "failure," or "uncertain," based on clinical and
radiographic criteria, In fact, the success rate was
slightly higher in the cases vrith retained fragments
(81.2% versus 73.6%, p>0,05) ,
In a retrospective assessment of 66 cases with bro-
ken instruments, Grossman
520
found over a recall
962 I Endodontics
period of up to 5 yea rs, that out of cases without pre-
existing apical periodontitis (47/66) about 90% stayed
healthy and only 2 showed signs of a lesion. Of the 19
cases with a diagnosis of apical periodontitis, how-
ever, healing occurred only in 9 cases. Similar results
were reported by Fox et al.
52 1
referring to 204 cases
with accidentally broken files, out of which only 12
were scored as failures.
In a recent study on 8,460 cases, Spili et al.
518
found
overall a 3.3% prevalence of instrument fract ures but a
prevalence of 5.1% after the introduction of NiTi
rotaries (4.4% NiTi versus 0.7% stainless steel). How-
ever, success rates were similar for teeth with and
without a retained instrument fragment (9 1.8% versus
94.5%). Moreover, if an instrument fractured in a
tooth with existing apical periodontitis, the healing
raLe would be lower (86.7% versus 92.9%), but this
difference was not significant. Similarly, Wolcott
et a1.
519
in an analysiS of 4,652 cases found an overall
fracture incidence of 2.4% using Pro Taper instru-
ments; however, they did not report on clinical out-
comes of these cases.
From the descri bed outcome studies, fractures that
developed early compared to late during cleaning and
shaping may be viewed differently, regarding the
potential to remove microbes from the root canal
space. lrrigant efficacy is affected by the amount of
canal enlargement;9.10,222 therefore, a fragment lodged
in the canal before sufficient enlargement has taken
place may render canal disinfection ineffective. In case
of corrosion
356
,358.522 of the retained fragment, chan-
ged ion concentrations in the microenvironment may
inhibit microorganism growth.
523
At least this par-
tially explains acceptable outcomes, even in the pre-
sence of retained instrument fragments.
349
Opinions vary over the risk and incidence of rotary
instrument fractures, but even without solid clinical
data it is generally thought that NiTi rotary fracture
incidence is higher when compared to stainless steel
hand instruments. The impact of these fractures on
healing probabilities
524
is not dear.
349
In fact, conse-
quences of a retained or removed instrument fragment
are part of a complex array of impact factors governing
the spectrum of clinical outcomes. Therefore, an
immediate attempt to remove a fractured root canal
instrument is mainly indicated if the coronal aspect of
the fragment is visible, aided by magnification, and if
there is microbial contamination apical to the frag-
ment. A fragment position apical to a major curve
significantl y decreases the potential of successful
removal.
52
S".s26
In summary, available evidence from recall studies
would suggest to take a conservative approach after a
fracture of a root canal instrument: (I ) when a pre-
operative diagnosis of irreversible pulpitis and hence a
noncontaminated root canal system had been made;
(2) if the instrument fractured very late in the proce-
dure, after a sufficient attempt for canal disinfection
had been done; and (3) if the instrument fractured
apical to a significant curve. For a detailed account of
techniques for instrument removal, the reader is
referred to Chapter 31, " Retreatment of non-healing
endodontic therapy and management of mishaps".
Nontraditional Techniques
Besides hand and rotary instruments, lasers have been
proposed for root canal preparation for some time
and is still contemplated by some authors today. 527
On the other hand, if no enlargement of the root
canal system was required for disinfection and root
canal filling, no preparation errors could be made;
this may be possible with the so-called noninstrumen-
tation technique.
528
Finally, ongoing research is aimed
at changi ng the paradigm of root canal preparation
for disinfection and filling altogether, with the poten-
tial of seeding stem cells or at least allowing local cell
I
I dd' 529
popu atlOn to reco olllze en 0 ontlC spaces.
LASER-ASSISTED CANAL PREPARATION
Early studies of the effects of lasers on hard dental
tissues were based simply on the empirical use of
available lasers and an examination of the tissue mod-
ified by various techniques. Lasers emitting in the
ultraviolet, visible (i.e., argon laser, wavelengths of
488 and 514 nm), and near infrared (i.e., neodymiu-
m:yttrium-aluminum-garnet laser, 1.064 ,urn) are
weakly absorbed by dental hard tissues, such as enamel
and dentin.
530
.531 Nd:YAG laser energy, on the other
hand, interacts well with dark tissues and is trans-
mitted by water. Excimer lasers (193, 248, and
308 nm) and erbium lasers (-3.0 ~ m ) are strongly
absorbed by dental hard tissues. 53 ,531 Studies have
been conducted evaluating the effects of laser irradia-
tion inside root canals. The authors have discussed
laser endodontic therapy, some as supplementary and
others as a purely laser-assisted method.
s32
Applications of lasers in endodontic therapy have
been aggressively investigated over the last two dec-
ades, and this is discussed in more detail in Chapter
26E, "Lasers". Briefly, there are three main areas in
endodontics for the use of lasers: (1 ) hard tissue, (2)
root canal surface, and (3) the periapex. Obviously,
laser light travels straight; therefore, specific light-
Chapter 27 , Preparation of Coronal and Radicular Spaces 1963
15
before shaping
0 --
~ 10
.!.
J
5
A B
o
o "'"'""
--
-
Root canal third
.
. ~
c ~
-
Figure 69 Shapi ng of single-rooted teet h in vitro using an Er:YAG laser. A Canal di ameters compared using standardiled radiographs. 8, B<l r di agram
showing mean r SO) canal diameters before and after shaping. C, Scanning electron micrographs of lased apical canal surface (left) and control after
rotary instrumentation (right). D. Er:YAG laser used in the study. Images courtesy of Or. Mark Roper.
emitting probes have been developed to di rect laser
energy not only into straight but also into curved root
canals. Enlargement and cleaning of straight canals
wi th an Er:YAG laser was found to be effective and
in fact faster than with step-back preparation with
K_files.
527
However, shaping curved root canals, inde-
pendent of the probes used, has not been satisfactory
(Figure 69).
Several aUlhors have reported better removal of
debris, for example, using an erbium:YAG
laser,533.534 although areas covered by residual debri s
could be found where the laser light did not get into
contact with the root canal surface.
535
An erbium:YAG
laser was more effective in debris removal (Figure 70),
producing a cleaner surface with a greater num-
ber of open tubules when compared with a Nd:YAG
laser and an unlased control without laser treat-
ment.
Nd:YAG laser-irradiated samples presented not
only with melted and recrystallized dentin and smear
layer removal but also with charring in light micro-
scopic images.
536
However, SEM evaluation showed
specific patterns for crbium:YAG and Nd:YAG irra-
diation as a result of different mechanisms of laser--
. . . b h I h 533---535537
tissue ll1teractlon r t ese two wave engt s. .
Dederich et al.
53
used a Nd:VAG laser to irradiate
the root canal walls and showed melted, recrystallized,
and glazed surfaces. The process of melting and recrys-
tallizing root canal surfaces was hoped to create a clean
and less penet rable canal.
536
Laser energy transferred
into canal surfaces, when sufficient to melt dentin,
may overheat the periodontal ligament also. BaiKal!
et al. ,539 for example, investigated the use of the pulsed
Nd:YAG laser to clean root canals. Their results
showed that the Nd:YAG laser may cause harm to
the bone and periodontal tissues by overheating,
which was also s u ~ e s t e d by others.
S36
,540,54! Accord-
ing to Hibst et aI., 4 the use of a highly absorbed laser
light tends to loca\jze heating to a thin layer at the
sample surface, thus mini mizing the absorption depth.
964 / Endodontics
" ..
10
,
Figure 70 Intracanal denti n surfaces (apical th ird) under scann ing electron microscope (SEMI (orig. mag. xl 5001 after laser treatment. A, Dentin treated
with erbium:YAG laser (1 00 mJ, 15 Hz). Not e effective debris removal. 8, Control. unlased denti n surface. C, Denti n surface treated wi th Nd:YAG laser
(80 mJ, 10 Hz). Note melted and recrystallized denti n surface. Reproduced with permi ssion from Cecchi ni SCM et al.
537
Consequently, the risk of subsurface thermal damage
may decrease since less energy is necessary to heat the
surface.
543
One of the limitations of the laser treatment was
demonstrated in a study by Harashima et al.
544
Where the (argon) laser optic fiber had not touched
or reached the canal walls, areas with clean root canal
surfaces were interspersed with areas covered by resi-
dual debris. Access into severely curved roots and the
cost of the equipment are other limitations. Finally,
operator and patient safety are of concern in the
application of lasers in endodontics; safety precau-
tions include safety glasses specific for each wave-
length, warning signs, and high-volume evacuation
close to the treated area.
NONINSTRUMENTATION TECHNIQUE
Based on the premise that optimal cleansing of the
root canal system is a prime prerequisite for long-
term success in endodontics, Lussi et al.
246
introduced
a minimally invasive approach for removing canal
contents and accomplishing disinfection that did not
involve the use of a file (the noninstrumentation
technique or NIT). This system consists of a pump,
a hose, a special valve, and a connector that needs to
be cemented into the access cavity (Figure 71). Clean-
ing action is then provided by oscillations of the
irrigation solution (1% to 3% NaOCl ) at a reduced
pressure. Cavitation likely loosens the debris and
NaOCI dissolves viable and necrotic tissue compo-
nents that are then removed by suction from the low
pressure. It needs to be stressed that this system is
different from other recently proposed active irriga-
tion systems,545-547 since the latter techniques still rely
on mechanical shaping prior to the use of irrigation
while a canal undergoing NIT is not enlarged.
The evolution of the technique over the
years
548
,549 has resulted in good cleaning ability in
vitro. However, clinical moisture control and filling
Chapter 27 I Preparati on of Coronal and Radicular Spaces 1 965
-
A
B
Figura 71 Applicati on of the noninstrumentalion technique for root canal cleaning and filling, A.. Principle and clinical placement of the tubing system.
The pump is connetled to a tubing system and via a three-way valve to a cannula. This cannula is seal ed into the access cavity with impression material
to provi de an air-ti ght system. B, After removal of the soft tissue with osci llating pressure waves of sodi um hypochlor ite (NaDell. highly viscous sealer is
delivered into the canal system at low pressure. Micrographs show adaptation of Ma ler at canal walls and also di ffusion of sea ler stai ned with red dye
into the dentinal tubules. Images courtesy of Prof. Adrian lussi.
root canal system, while possible,550,551 is not
straightforward. Moreover, preliminary in VIVO
results are mixed and the technique is currently not
commercially available.
247
Canal Surface Modification
It has been established that mechanical canal prepara-
tion
l42
alone cannot predictably remove microbial
canal contaminants and therefore irrigation with anti-
microbial solutions is recommended. The effect of
various irriganls and medicaments is described in
Chapter 28, " Irrigants and Intracanal Medicaments"
but some issues pertinent to canal preparation will be
detailed below.
In addition to the removal of soft tissue and micro-
organisms, the canal surface is modified by irrigation
solutions.
ss2
Canal surface after shaping with mechan-
ical instruments is characterized by an irregularly dis-
tributed layer of soft and hard tissue debris that is
smeared onto dentin surfaces ( Figure 72).553--555 This
1- to 5-pm-thin superfi cial structure consists of two
separate layers: a loose superficial layer and an
attached layer that also extends into dentinal tubules
to form occluding plugs.
42
! A smear layer consists of
several components: dentin " mud," remnants of
odontoblastic processes, pulp tissue, and microorgan-
isms.
SS4
Its appearance and structure differs depend-
ing on the contacting instrument's cutting action:
more actively cutting blades shear off dentin leaving
thinner smear layer, while V-blade designs tend to
burnish a thicker smear layer deeper into dentinal
tubuli.
556
,557
The question as whether to leave the smear layer in
situ on the canal walls or to remove it has been a
966 J Endodontics
Figure 72 Appearance of root canal walls in a scann ing electron micrograph. The smear layer was part ially removed; there is a thin smear layer present
in the alea thaI was touched by an instrument Oeft half). Hard tissue debris and predentin calcospherites (arrowhead) were present in the area that was
not inst rumented bul had soft tissue removed by sodi um hypoch lorite (right hal f).
matter of debate for more than 50 years. For example,
some authors reported that the presence of a smear
layer delays but does not eliminate disinfection;558 it
may also increase microleakage after canal obtura-
tion.
554
In contrast, other researchers suggested that
the presence of a smear layer, while acting as a barrier,
might block solutions from entering the
dentinal tubules. 55,559 Others reported that a smear
layer might act as a beneficial barrier preventing
microorganisms from entering dentinal tubules when
a root canal is contaminated between appointments.
Their microbiological analyses of split root halves
showed that the early removal of the smear layer
may lead to significantly higher bacteria counts.
560
Smear layer removal may be accomplished by var-
ious chemicals, as suggested over the last 50 years
(Table 12), ranging from EDTA
382
to bisphospho-
nates.
552
Earlier studies had suggested a synergistic
mechanism with EDTA removing the organic smear
layer and then subsequently allowing NaOel better
access to deeper calcified layers;145 recent work has
demonstrated that EDTA and NaOCI show chemical
interactions;3?3 similar interactions were demon-
strated behveen citric acid and NaOC1.
552
These inter-
actions greatly reduce NaOCI efficacy and suggest
attention to irrigation sequencing. In fact, the often
cited "bubbling" that occurs between EDTA and
NaOCl suggests that the active component of NaOCl,
chlorine, is released from the solution and hence does
not actively kill microorganisms.
Salvizol is another root canal chelating irrigant that
has a broad spectrum of bactericidal activity. This
-
gives the product a cleansing potenff while being
biologically compatible.
5
?O Kaufman
56
reported the
success of several cases using bis-dequalinium acetate
as a disinfectant and chemotherapeutic agent. He
cited its low toxicity, lubrication action, disinfecting
ability, and low surface tension, as well as its chelating
properties and low incidence of posttreatment pain.
Table 12 Available and Potential Solutions and Pastes for
Smear Layer Removal.
Reference Year Chemical
Baumgartner
5ll'
198' Citric acid 10%
W
ayman
5ll2
1979 Citric acid 20%
Tidmarsh563 1978 Citri c acid 40%
Nygaard-0stb(8' 1957 EDTA (15%. ethylenediamineacetate)
Fehr
383
1963 EDTAC (15% EDTA plus cetri midej
StewarfG 1969. RC Prep (Premier Dental. Philadetphia, PAl
(10% urea peroxide, 15% EDTAf
Koskinen5/l'; 1975 Tubulicid (38% benzalkonium chloride. EDTA,
50% citric acid)
Koskinen56ll 1980 Largal Ultra (Septodont. Paris, Francel. 15%
EDTA, cetr imide. NaOH)
Kaufman
5ll7
1981 Salvizol {Ravensoorg, Konstanz, Germanyl.
5% aminoquinaldinium diacetate,
propylene glycol
Berry56S 1987 40% polyacrylic acid
Torabinejad
5ll9
1003 MTAD (Densply Tulsa Dental) (4.25% citric
acid, 3% doxycycline, 0.5% Tween 80)
1005 HEBP (7% l hydroxyethyli dene-l ,
lbisphosphonate)
Other preparations are similar, for example, Glyde {Dents ply Mailleferl. File
Care (VOWI. Fi leEze (Ultradentl. except for the base that could be carbowax or
glycerine.
Salvizo\, as well as several EDTA formulations, con-
tains surface-active substances that are supposed to
increase wetting and hence chelating action. There are
conflicting reports regarding the benefits of such sur-
e I T 80571- 574
lace-actIve components sue 1 as ween .
MTAD, commercially available as BioPure (Dents-
ply Tulsa Dental), contains citric acid and doxycycline
as decalcifying substances and has been shown to
effectively remove the smear layer;569,575 moreover, it
was shown to be effective against Enterococcus faeca -
lis.
576
,577 However, others report that 1.3% NaOel!
MTAO is less effective than 5.25% NaOCII1S%
EDTA;S78 moreover, of its effect on
outcomes is limited at this point. 57
Recently, substances such as bisphosponates
580
and
sodium triphosphateS
52
have been investigated as
potential chelators. While no significant interaction
between these substances and NaOCi activity was
found, the potential of these experimental chela tors to
remove the smear layer, measured both as smear layer
scores and amount of dissolved calci um, is lower than
27g
A
.r.;.
B
27g
82
Chapter 27 1 Preparat i on of Coronal and Radicular Spaces 1967
that of EDTA and citric acid. S52 A gel-based formula-
tion of a bisphosphonate, however, may offer advan-
tages in the initial Jihase of root canal instrumentation
wi th hand files.
372
, 0 Finally, the organic component of
dentin undergoes modifications in contact with
NaOCI, 581, 582 while EDTA may lead to erosions.
575
,583
Taken together, these results suggest that chelators and
concentrated NaOCI do have beneficial effects but
should be used with a clear understanding of potential
harmful effects to the substrate.
584
IRRIGATION DYNAMICS
As stated earlier, the relationship between prepared
canaJ shapes and irrigation needle size is important
for apical irrigation (Figure 73). 10, 146,150,224 On the
other hand, canal itself produces dentin
chips of various sizes 85 that need to be removed.
These chips are part of what is described as unclean
canals when observed in a SEM and should be
removed by irri gation.
30g
30g 27g 30g
F2
Figure 73 Effect of different irrigat ion needle sizes and canal diameters on needle position. A. Light micrographs of irrigation needles of size 27 and
30 gauge I 0.4 and 0.31 mm). B, Mandibular cani ne shaped with ProTaper instrument S2 and then F2, correspondi ng to apical diameters of size #1 7 and
#25. Shown are the insertion depths of both needles wi thout bindi ng in the cana l.
968/ Endodontics
Irrigation is commonly applied by a syringe and a
needle, with needle sizes varying typically between 27
and 30 gauge (see Figure 73), 0.635 and 0.305 mm,
respectively. With such a system, irrigation solutions
will not travel more than 1 mm beyond the
tip of the needle.
307

5
6 While it is therefore desirable
to place the irrigation needle into the shaped root
canals, the needle must not be locked in to avoid
expressing the irrigation solution into periapical tis-
sues. Serious incidents have been reported following
NaOCi exwessed into maxillary sinus or close to

nerves.
With careful use, the benefits of deep intracanal
irrigation dearly seem to outweigh the risks.
591
In fact
the proximity of the irrigation needle to the apex
an important role in removing root canal debris.
s
2
Druttman and Stock
593
found that irrigation perfor-
mance varied with the size of the needle and the
volume of the irrigant, while Walton and Torabine-
jad
594
stated in their textbook that perhaps the most
important factor is the delivery system and not the
irrigating solution per se.
Canal size and shape are crucial to the penetration of
the irriganl. The apical 5 mm are not flushed until they
have been enlarged to size #30 and more often size #40
file.
146
,S9S-597 Small-diameter needles were found to be
more effective in reaching adequate depth but were more
prone to problems of possible breakage and difficulty in
expressing the irrigant from the narrow needles.
591
Recently, Hsieh et al.
224
compared a shaped root
canal to a "wind tunnel" and evaluated the behavior
of irrigation solutions deposited into various depths of
Aared canals from irrigation needles measuring from
23 to 27 gauge. They showed that an undisturbed
laminar flow of irrigants occurred with a combination
of sufficiently enlarged canals, deep needle insertion,
and small needle diameter, for example, a 27-gauge
needle placed 3 mm from the apex in a canal prepared
to size #30. Similar observations had been made earlier
in experiments using radiopaque irrigation solutions
(Machtou P, personal communication).
Several methods have been devised to increase irri-
gant turnover and overall efficacy. As mentioned
earlier, the use of ultrasonic or sonic ITngatlOn to
remove dentin filings, debris, and bacteria fro m root
canals has been well documented (Figure 62 and
Figure 74).12), 147,222,351,417,598,599
However, there are doubts that passive ultrasoni-
cally or sonically assisted irrigation can in fact remove
all contaminants.
6OO
,601 While the time frames and
sequence of irrigation solutions is still a matter of
debate, 149.602 the cleanest canals were produced by
irrigating with ultrasonics and NaOel after the canal
has been full y prepared. Ultrasonics was shown to be
superior to syringe irrigation al one when the canal
was prepared to 0.3 rum (size #30 instruruent).603
Several novel strategies have been r roposed to
increase irrigation efficacy. Gutarts et al. 46 evaluated
the use of a 25-gauge irrigation needle, connected to
an ultrasonic unit, through which 6% NaOCl was
del ive red for I minute at the conclusion of canal
shaping. They reported significantly cleaner canals
compared to a control group that did not receive
ultrasonic irrigation,
Irrigation with positive pressure has also been tried,
for example, with the system RinsEndo (Duerr,
Bieti gheim-Bissingen, Germany). However, reports
for this particular device are sparse;604 moreover,
there is a potential for apical extrusion of NaOel,
and the necessary precautions should be taken.
More recently, Fukumoto et al.
547
described an
experinlental system that consisted of a washing nee-
dle, placed just into the root canal, and a 27-gauge
aspiration needle, ground flat at the tip and placed
deep into the shaped root canal. lrrigants, 14% EDTA
and 6% NaOel, were aspirated at - 20 kPa; their
results showed superior smear layer removal com-
pared to a control group that received conventional
irrigation wi th a needle of the same diameter.
This srstem is similar to a patent submitted by
Schoeffel 45 with the exception that his system does
not include a constantly operating washing line
(Figure 75) . Irrigant is deposited into the access cav-
ity; then, two sequentiall y operated and specially
designed aspiration needles are placed into the shaped
root canal. Preliminary data suggest good cleaning
Chapter 27 1 Preparation of Coronal and Radicular Spaces 1969
Figure 14 Canal surfaces as seen in scanning electron micrographs. A. Typical appearance after cleaning and shaping with wall areas that has
instrument contact and some smear layer r e m o ~ a l as well as uninstrumented areas with calcospherites as part of the mineral ization front in predentin
(arrow). B, Uninstrumented canal that was washed with 5.25% sodium hypochlorite INaOCI). C, Canal wall segment presenting with all dentinal tubules
open. 0, Completely shaped canal wa ll area with a thi n remaining smear layer. Bars are 30 pm.
capacity;605 however, currently no published results
are available regarding clinical outcomes using these
new irrigation techniques.
Currently, ultrasonically activated passive irrigation
seems to be the standard until more experimental
techniques are scientifically evaluated and brought to
the market. However, as mentioned earlier, using an
ultrasonically activated insert deep in a root canal
carries some risk (see Figure 63). Furthermore, more
work is needed to clarify insert shapes and materials
as well as activation times and power settings.
PHOTODYNAMIC THERAPY
While lasers are probably not a good alternative for
mechanical root canal preparation, they have been
970 I Endodont ics
A
-.




Figure 75 The EndoVac system IDiscus Dental) for apica l negative pressure irrigation. Recent in vitro resul ts demonstrate better debridement compared
to conventional syringe irrigation.
605
A. Overview of the micro cannula demonstrati ng a closed rounded tip and an array of 12 openings in the apical end
(inset. bar is 250 !lffil. B, Light microscopic images of canals irrigated with convent ional syringe Ileft) and with the EndoVac system Irightl. Orig. mag. xl 00.
Images courtesy of Dr. John Schoeffel.
shown to be effective for canal disinfection and canal
surface modification, as reviewed in detail in Chapter
26E, "Lasers". In this context, the use oflasers for photo-
activated disinfection, also known as photodynamic
therapy, has been promoted.
6
06--608 This technique does
not provide canal enlargement but assists in the eradica-
tion of intracanal microorganisms. Photodynamic ther-
apy is well known as a treatment for cancer and other
diseases
609
and is based on the concept that a nontoxic
photosensitizing agent can be preferentially locali zed in
target tissues. The agent is then activated by light of
appropriate wavelength to generate reactive molecules
that in turn are toxic to cells of the target tissue.
609
Yisible
light can also kill bacteria in root canal systems after
treatment wi th an appropriate agent (Kishen A, personal
communication).
Such photoactivated disinfection has only recently
been e x ~ o r e d to treat bacterial infections III
humans. A wide range of oral bacteria could be
killed by red light after sensitization with toluidine blue
and methylene blue.
610
More than 400 photoactive
substances are known that can be combined wit h lasers
tailored to their specific wavelengths of absorption.
Potentially one of these substances will be able to
penetrate into the root canal system better than cur-
rently available irrigants. In fact, partial inactivation of
Streptococcus intermedius biofilms in root canals of
extracted teeth usi ng t.oluidine blue and light applied
at the orifice level has been recentl y reported.
611
Clinicall y, the photoactivated agent is used as an
irrigant after mechanical canal enlargement (Figure
76) and activation; root canal filling is accomplished
Chapter 27 f Preparation of Coronal and Radicul ar Spaces 1 971
Figure 76 Use of photoactivated disinfection in a case of post-endodontic disease. The existi ng root canal fill ing was removed (Arrowhead) and the
canals reshaped wi th ProFi le instruments (upper panel). Then, tolonium chloride (also known as toluidine blue 0) was placed in the root canal system and
irradiated with a diode laser (lower panel , also showing root canal filling after retreatment). Images courtesy of Prof. Paul Lambrechts.
conventionally. This technique is experimental and its
impact on clinical outcomes needs to be evaluated_
Conclusion
The past decade has brought significant changes to
root canal preparation, for example, the use of rotary
NiTi instruments and magnification. These techni-
ques have allowed more complicated root canal treat-
ment to be undertaken safely and successfully (Figure
77). The way educational content is delivered is also
changing: private educational institutions are taking
the lead in presenting information to clinicians.
Moreover, electronic media and web-based content
have gained more widespread acceptance. Using these
972 / Endodont ics
Figure 77 Routine cases of second maxillary and mandibular mol ars that had coronal and radicul ar preparation done adhering to the principles laid out
in this chapter. Radiographs represent sit uati on immediat ely after root canal filling.
avenues, evidence-based information will reach clin-
icians who at present have limited access to book,
journals, or hands-on teaching.
Aseptic techniques are a prerequisite for successful
endodontic therapy as they are in the goal of eradicat -
ing the causative microbial flora (Figure 78). Asked
for any particular di rection for development in the
next decade, disi nfection and systems to increase its
efficacy are the most likely candidates. Seemingly exo-
tic applications such as the use of ozone (e.g., Healo-
zone, KaVa, Biberach, Germany) or high-frequency
current (Endox, Lysis, Nova Milanese, ltaly)61 2 or
photoactivated disinfection may be utilized more;
however, it will be difficult to prove with statisti <..a!
methods that any individual device will have signifi -
cant and clinically relevant impact.
Regarding instrument and strategies. new materials
may appear, such as more durable and flexibl e alloys
or plastic materials, but the basic strategy wi ll likely
remain the same in the next decade: enlargement for
subsequent disinfection and filling. The long-term
goal is certainly to replace root canal therapy, as part
Figure 78 Asept ic techniques and disinfect ion of me root canal system
A. Swabbing of the operation site, for example, with sodium hypcchlorite
(arrow). while marginal imperfections of the rubrer dam seal are corrected
with a caulking material (e,g" Oraseal, Ultradent). B, ReselVoir of sodium
hypochlorite (NaOCI) is always present in me access cavity during hand
and rotary instrumentation to promote disinfection and lubrication.
Chapter 27 I Preparat ion of Coronal and Radicul ar Spaces 1973
of current repai r methods, with tissue-engi neering
strategies that provi de healing in the sense of a resti -
tutio ad integrum.
ACKNOWLEDGMENT
The authors would like to express their special
gratitude to Vickie Leow, Master Graphic Designer
at the UCSF School of Dentistry, as well as Anjan Lall
for their expert help with the schematic drawings used
in this chapter.
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