"

ENDODONTICS

Todays lecture is about cleaning and shaping. You
should already have the good knowledge about it in
practical.

WHY DO WE DO CLEANING AND SHAPING ?


Chemo-mechanical preparation is equivalent terms for cleaning and
shaping. It is a combination for chemical and mechanical preparation. We
are using an irrigant (chemical) and its a disinfectant, while you are
cleaning. As for mechanical its because you are using instrumentation.

The term cleaning is removal of infected debris from the root canal system.
While in shaping we are creating an ideal shape thats suitable to perform
the task of cleaning. So you have to create a good shape that allows
penetration of the irrigants and a shape that will adapt 3 dimensional
obturation of root canal system.
#





WHERE DO WE END OUR CLEANING AND SHAPING ?


Its determination point of the canals. You should know the
cementoenamel junction, the apical constriction, and finally you should
know whats the average distance. By now most of you should know that
0.5 to 0.75 the average distance of apical constriction from your
anatomical apex that should finish chemical irrigation and mechanical
instrumentation of root canal systems.

Just to stress the importance of apically determining the initial apical size,
you have to make sure that you are finding you initial size otherwise you
wouldn't achieve adequate deprivment. Lets say you have size 10 as initial
apical file thats not good enough! You have to make sure that if you use
15 to your corrected working length it doesnt go to that length. So that
confirms that your size 10 is your initial apical size (cause 15 didnt reach
to the end).
Basic terms you should know

You already proceeded with
identifying canal orifice,
estimating working length, getting
access to finding initial apical
file with straight-line access.
Then going to Master apical file
and this morning finding the master
gutta percha cone, you have done
very good this far and also you are
familiar with step back
preparation.

$
Then after you determined your initial apical file size, you should go to
your master apical file by enlarging three sizes.


You have to check your work, notice when
you took a radiograph of the tooth filled
with gutta percha, if your working length
was 21 , the gutta percha reached only to
20. Why did that happen? Because you
have packed some debris down, even if we
kept telling you to irrigate, it seems like
you are not irrigating enough.

You have to irrigate thoroughly and between every file you use you have to
keep irrigating. Thats how your canals stay unblocked; if you did this your
work would have finished this morning in 15 minutes. While it took you
two hours today! So keep checking youre canal patency by cleaning with
file 15.

With straight-line access, next week we will work on
posterior teeth. You are supposed to establish good
straight-line access otherwise you will fracture
instruments easily in posterior teeth because the canal is
really tiny in posterior teeth. So we have to see the
importance of using gates glidden in posterior teeth. We
will know now you will be using SMALLER size of gates
glidden in posterior teeth. Most of the time size 2 will be
used. Maybe going to size 3 too. While in canine and central incisor you
use 4 and 3 and sometimes 5 or 6 in large canals.

Removing dentinal shelves is done with straight line access using ((gates
glidden)). This makes file penetration much easier. Working in posterior
teeth is harder than anterior teeth.

Make sure you remove any nearly broken file, cause if it breaks in the canal
you have to remove it and do access cavity again to another tooth.

You cant use one file on 10 teeth. You use the same file for 3 to 5 canals
only.

Remember to know the
right definitions in
the exam, rem its an
essay.

%
The dr. showed a picture in slide 7 and said this is to show you notice
when you remove this shaded area using size 2 glidden. Now for gates
glidden use makes canal straight so putting the file inside it is easy and
straight without bending. This is a challenge in the mesiobuccal canal and
mesiolingual canal. While in the distal or palatal root canal its easier. A
palatal canal of an upper six is just like a simple incisor. It has straight-line
access by default.


HOW MUCH SHOULD WE ENLARGE THE CANAL ?


We should enlarge it enough to minimize the bacteria but we shouldn't
enlarge excessively to destroy the tooth and make it very weak. It has to be
big enough to disinfect the root canal but not big enough to destroy the
tooth or create perforation of the tooth.

There was a research on how much we should enlarge it and from there we
got the initial apical file and 3 sizes bigger master apical file. This is by
Grossman criterion. He is a very old endodontist, he has one of the first
books in endodontics. He did an experiment and found that if you enlarge
the size 3 times more than the initial file the tooth will still be strong and
good for cleaning and shaping.

Its not that we like number 3 but its because of this criteria. In the past
they were following other procedures, we might find some demonstrators
who are not familiar with why there was enlargement of three sizes.

The root has dentinal tubules. (The doctor showed a picture of an electron
microscope of a root surface after you were cleaning and shaping probably
in slide 9). These are just debris on the surface. If we stain it in histological
section, the dark one will be debris while after you do irrigation with
sodium hypochlorite and another irrigant that we will know now called
EDTA you will get opening of dentinal tubule, so you will remove this
debris. So dentinal tubules here are patent, which means we minimized the
bacteria.

So when we enlarge the canal we will remove loose dentinal tubules and
bacteria.
&
General rule:
For small root canals the MAF should be at least 30!

For large root canals like central incisor, palatal root of
upper molar, distal root of lower molar it has to be MAF
size 40 and above.

If we have extremely calcified tooth and extremely curved
we might accept MAF size 25. So never stop at size 20.

You have to memories these.

HOW TO JUDGE YOU DID A GOOD JOB ?

With master apical file if you followed Grossmans criteria and then when
you file its clean and glassy walls they will say you did a good job - BUT
thats not accurate. Sometimes you can continue forever and not clean it!
If you spreader penetrate the canal within 2 mm of your working length
then your cleaning and shaping and step back is correct.
Doing a good step back shows on the radiograph making a good tapered
canal. Which shows by the opacity of the gutta percha used in the lab.

Obturation reflects the preparation.

You have to make sure that you created a good apical stop, sometimes if
you block the canal 1 mm shorter than the apical length its still acceptable
and much better than if you opened your apex.

When doing step back you use size 60 but if the canal is narrow and gates
glidden is not penetrating from coronal part its advised to take it to size 70.
So its a minimum of 60 but you can take it up to 70.

What if the central incisor MAF is 60?? You will have to step back at least 4
steps. You will go 70,80, 90 and a 100.

So far when we are preparing straight canals in central or incisor, we are
subtracting 1 mm step in our step back. When you go to molar teeth and
you have narrow curved canal you are going to do 0.5 mm step. So that
you maintain the natural curve of the tooth.
'
If you read the book you will find terms called apical stop, apical seat,
opened apex.
We have 3 terms to describe the apical anatomy.

APICAL STOP: is the desirable outcome you should get in the clinic.
MAF will stop at the apex and even one size smaller than MAF will not go
through the apex.

APICAL SEAT: you couldnt create apical stop, this is still ok. MAF and a
file smaller than MAF will still go through the apex but its not opened.

You have to avoid an open apex unless it is there naturally.

Now you know the actions, filing is the up and down stroke, the cutting is
in up stroke outward. When you move from IAF to MAF use a little bit of
rotation, which is called reaming.

If we have a blocked canal we have to do reaming the canal has to be
flooded with irrigant, full of water and sodium hypochlorite.


This is just an illustration of how
you wear your file although its
an up and down movement but
you have to trace the entire
circumference of the canal.

If you have a curved canal, maybe
you heard someone telling you
about pre-curving the file. Next week we will have curved canal
in molars, you are supposed to pre-curve the file in order to negotiate the
curve rather stop short at the start of the curve. This is how we curve files
(refer to slide 17).

THE SEQUENCE OF PREPARATION

Please remember you always start with irrigation and always end with
irrigation. In between comes instrumentation and recapitulation with a
small size, size 10 or 15.
In the book page 276 there are
general consideration on filing
and cleaning and shaping I want
you to review.
(
Never recapitulate with your master apical file cause you will lose it, it
wont be your master apical file anymore.

IRRIGANT

We said we need to use irrigant, what are the functions of an irrigant?

! Fabrication, it will ease the movement of your instrument.
! Antibacterial action.
! Wetting the dentine.
! It should be biocompatible, not toxic not irritant.

Sodium hypochlorite is an irritant if you push it into the periapical area -
soft tissues. But we are supposed to use it inside the tooth , so it should be
ok. If you push the irrigant beyond apex the patient face will be flush, he
might get necrosis and he might get swelling.

Anyone know the mouth wash called chlorohexidine? Its a very good
irrigant as well in terms of antibacterial activity, however it doesnt
solubilize organic tissue of the pulp.

Slide 21 shows a picture of colgate solution of chlorohexidine. The second
type of irrigation is called EDTA, when you instrument the canal you
notice there is debris, this debris is composed of both organic and
inorganic component with bacteria they also form a smear layer. This layer
is formed after instrumentation in the root canal surface. Sodium
hypochlorite solubilizes the organic part of this layer only. EDTA is a
chelating agent, which will remove the minerals covering the dentinal
tubules, making them open. It also contains glycerin, which serves as a
lubricant.

There are two preparations, EDTA solution for irrigation, and sometimes
if you get narrow canals in lower central incisor and the file is not going
inside there is something called RC prep it comes in a form of gel. You
can put the file in the gel before you insert it in the canal. It also reduces
the torsional forces in the final. Slide 23 shows how it comes in a tube just
like the non-setting calcium hydroxide.

)
In the book you will read about how some authors suggest the removal of
smear layer, some say leave smear layer, because it will block the dentinal
tubules and dont let bacteria get out! But most research found if smear
layer was found the saliva will remove the smear layer and will cause
leakage-making bacteria come again beside the gutta percha filling and will
cause failure.

Slide 25 shows an endoprep.

THE TECHNIQUES OF PREPARATION

There is plenty of techniques; step back, step down, the one in the lab is a
step back technique you are familiar with it so I am not going to explain it.
Step down is opposite you start from size 60 and go to a shorter length, to
size 55 to 1 mm longer etc. Its complex, its not an easy thing to do.

Step back technique is the most recommended one for hand
instrumentation. While in rotatory instruments its crown down. The new
instruments already have the crown down shape, wide from above and
narrow from down, so when you use it, it creates the funnel shape.

There is a technique called anti-curvature filing and a danger zone. If you
have a curved canal its always advisable to not prepare circumfuntially, if
you have a curved tooth you have to prepare on the outside of the tooth
only, the inside of the curve is considered as a danger zone it will be easily
perforated.

When you have a wide canal, half of the canal will be prepared already
with gates glidden. Only the last 3 mm you have to do the INF and MAF
and thats it the preparation is done.

Balance force technique is very complicated we don't need to know about
it. You have handout about section that I dont want you to read in the
book because it will mix the information in your head. So in the exam if
you have a question about step back you will reference to what you have
learned in the lab.



*
ERRORS IN PREPARATION


Loss of working length
Apical transportation
Stripping Perforation
Instrument fracture

Picture in slide 34 shows apical perforation. When using a large file
excessively you split the walls of the root. This is the natural canal path, the
canal was sitting at this spot and because you used large files in inadequate
way you transported a canal, created a canal of your own (!) to the side.

Whats the harm??? This part is still unprepared. It still has bacteria and it
will still allow apical leakage so you will get a high chance of failure in the
treatment. In the book also it explains definitions of whats transportation
whats zipping!!??? Its extremely complicated terminology I dont ask such
questions but you might need to be aware of it because you might get
another demonstrator who asks about it.

I just want you to know whats apical transportation (when you create an
opening of your own)

Zip is when you have both transportation and perforation.
When we talked about dangerous zone and excessive use of gates glidden,
this is how gutta percha will look like (slide 36) gutta percha seems out of
the root because there is part of dentine here and there, but here I cant see
any part of the root, this way there is root. Root is perforated!











"+
So it results from excessive coronal flaring or inappropriate file technique.
All the time you were leaning toward the furcation (division of root) this
area is very weak. File away from this area.

Now for slide 37 what is the problem there?

Transportation and perforation too. This was the natural canal; he changes
the working length, prepared short, perforated the root, and filled a little
bit long.

What about this gutta percha? This is the root and the gutta percha is
going all the way down to the patients tissues. So he opened the apex its
very wide, he didnt select a master cone equal to his master apical file,
there is poor apical seal there.

You might get radiographs like this you will find the
error off. But this is not now it is in the final
exam.




Done By:
Nadine AL Homoud