Endodontic Instrumentation

With the Virginia Technique

Frederick R. Liewehr, DDS, MS
 Root Canal
I nstrumentation
 Aim
After instrumentation the root canal
space should be free of bacteria.
This should be achieved without
excessively weakening the root or
affecting the ability to adequately
restore the tooth.
Early endodontic access
preparation

(No longer practiced at VCU)

 Goerig "Step-down" technique
• Flaring the coronal portion of canal
before instrumenting to apex
• Allows deeper penetration of the irrigant
• Eliminates coronal interferences with the
files

Christie WH, Peikoff MD. Conservative treatment of apical foramen. J Canad Dent Assn 1980;3:187
Goerig "Step-down" technique

• Reduces canal curvatures allowing

straighter access to the apex
• Removes the bulk of radicular
tissue without penetrating apex
• Ideal emergency treatment
 I nitial opening
• Traditional openings were too small, in the wrong
areas
• Canals were missed
• Tooth structure misdirected files

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

 Let the tooth dictate your access –
Simply enlarge access to match pulp chamber

Messing JJ, Stock CJR. A Colour Atalas of Endodontics

Access improved
Traditional anterior cingulum
access

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

Frequent result – perforation!

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

Missed lingual canal

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

Again - simply enlarge access to match pulp
chamber

Messing JJ, Stock CJR. A Colour Atalas of Endodontics

Access improved
 I nitial opening
Need straight-line access to the apical 1/3

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

File types and
techniques
Stainless Steel K-Files
• Square blank twisted to produce the
spiral shaped cutting edges
• Flexible in small sizes
• Stiffness increases rapidly in larger
sizes
• Can be pre-curved

• Excellent for pathfinding, bypassing

obstructions and dealing with
procedural accidents
•Can cause transportation and perfs
Stainless Steel Hedstrom
Files
• Round blank cut to produce very sharp
cutting edges
• Very aggressive, fast dentin removal
• Must NEVER be twisted into canal
• Insert and cut by pulling outward
• Somewhat less strong than K-files due to
cut edges
Nickel Titanium Files
• I ncreased flexibility
• Conforms to canal curvature
• Memory – straight!
• Cannot precurve
• Too flexible for pathfinding,
bypassing obstacles, etc.
Stainless Steel K-File

Kink
Nickel Titanium

No kink
 This can be good or bad,
depending on what you are
trying to accomplish
• If you are instrumenting a canal,
the file tends to stay centered –
good…
• If you are trying to bypass an
instrument or ledge, the file tends
to stay centered – bad!
Taper

No, this is not crown and bridge!

 What is Taper?
D16 D1
0.02
taper

0.32 mm diameter increase

D16 D1

0.06
taper

Taper is expressed in mm 0.96 mm diameter increase

diameter increase per mm length
 How much is enough?
• Schilder said we need to develop a
continuously tapering form for debridement
and resistance form
• Black’s principles, modified by Ingle and
Bakland, said our form must be dictated by
the internal anatomy of the canal
• Some canals do NOT have a continuously
tapering form
• So, the taper we select must
match the anatomy of the canal.
 1
Some canals have 2

a lot of taper… 3

Distance from Size Taper 5

apex 6
1mm 40
7
2mm 60 .20
3mm 100 .40 8
4mm 110 .10
5mm 100 -.10
6mm 110 .10
7mm 130 .20
8mm 150 .20

Average taper = 0.157 mm/mm

 Some canals have
very little
Distance from Size Taper
apex
1mm 30
2mm 30 0
3mm 30 0
4mm 30 0
5mm 30 0
6mm 35 .05
7mm 45 .10
8mm 55 .10
9mm 60 .05
10mm 50 -.10

Average taper = 0.027

mm/mm
 The problem with
excessive taper
Binds Not
here here

Files tend to bind and cut coronally, where

they are largest, and not apically where we
think they are binding, leaving the coronal
portion overinstrumented and weak, and the
apical portion underinstrumented and
infected.
 The problem with
excessive taper

All files with a long cutting edge exhibit

taper, and the modern trend is to more and
more taper. This, however, is not appropriate
for all canals. For those canals a non-tapered
(LightSpeed), or minimally tapered (0.02) file
must be used
 Misconception about Ni-Ti
• “Superflexibility” somehow negates
characteristics of other metals
– Increasing size -> increasing stiffness
– Increasing taper -> increasing stiffness
• Reality – There is no magic!
 Do those look
flexible to you?
How do we create taper if we don’t
use very tapered instruments?
Step - Back Technique

Taper
= 0.05

By increasing file size in “steps” of 1mm

as you “back out” coronally
 Proper taper
• The appropriate taper for a canal is that
which it had initially
• Occasionally we have to increase the
taper slightly to allow for our obturation
technique
• Any dentin we remove, however, will
weaken the tooth
• So, we must err toward conservatism
 Proper taper
• For most molars and some premolars,
rotary files having 0.04 and and 0.06
taper will produce approximately the
correct taper
• Excessive taper will cause strip
perforations
• Insufficient taper is not really a problem
• So, err toward less taper
 Proper file size
• Some rotary systems are available
with only small tip sizes (e.g. <40)
• This is due to an erroneous belief that:
– All canals are tapering
– All canals are small at the apex
• Research shows that these
assumptions are not true
• Therefore, the apical portion may
need to be prepared with hand
instruments or LightSpeed Taper?
 Proper file size

• In rotary systems that are available

with tip sizes >40, tapers larger than
0.02 can lead to excessive coronal sizes
and resulting strip perfs

Principles & Practice of Endodontics, Walton & Torabinejad, Saunders, 2002

 But I thought more taper
was better?
• 0.06 taper means the file size enlarges by
0.06 mm/mm
• If the tip size is 40, and
• The length is 16mm, then
• 16 x 0.06 = 0.96
• Add to tip size 40 = size 136
• A GT 0.12 would be 40 + 1.92 = size 231!
 Proper file size

Since file taper should match canal

taper
– The only reason to exceed the natural
taper is to facilitate GP cone placement
– In larger canal sizes, this is no problem
• Therefore, in teeth with large
canals, less tapered files are
indicated
Canal is BIG and almost straight!
 Proper file size

• This means that in many

maxillary anteriors and many
premolars rotary instruments
are not indicated or needed
• It is often faster to instrument
teeth with large canals with
Hedstrom files than with rotary
instruments!
Be sure you instrument to a large
enough size apically!
Why is the preparation
size important?

Bacteria!
 Apical size chart
Tooth Initial file size Final file size

MAXILLARY ARCH

Central 45 60

Lateral 40 (30 if curved) 55 (45 if curved)

Canine 45 60

Premolar B: 25, P: 30; 1 canal: 40 B: 40, P: 45; 1 canal: 55

Molar MB: 25, DB: 25, P: 40 MB: 40, DB: 40, P: 55

MANDIBULAR ARCH

Anterior B: 25, L: 25; 1 canal 40 B: 40, L: 40; 1 canal 55

Canine 40 55

Premolar B: 25, L: 30; 1 canal 45 B: 40, L: 45; 1 canal 60

Molar MB: 25, ML: 25, D: 40 MB: 40, ML: 40, D: 55

• Based on morphological studies

• Not a rule but a starting point
• Adjust for each individual tooth
Clinical Procedures
Clinical Procedures

1. Determine canal
configuration
 Clinical Procedures

1a. Estimate working length

Expose a
parallel X- Ray
 Clinical Procedures
Pre-op film employs the XCP instrument
to produce a parallel radiograph

Why parallel?
 Clinical Procedures
Parallel films have the least distortion
and allow measurements to be made
with reasonable accuracy
 Clinical Procedures
Paralleling requires a film holder
Bisecting angle reduces but does not eliminate distortion

a b

Purple – tooth plane

A - with instrument
Red – Film plane
B – without instrument
Light blue – bisecting angle
Do not fixate on the apex
only!

Evaluate root
curvature!
 Clinical Procedures

1b. Estimate canal curvature

http://www.gearjammin.com/twisty/
 Clinical Procedures

Do NOT use rotaries in highly curved canals!

 Clinical Procedures

1c. Determine canal form

http://www.holylandmarket.com/html/731.htm
 Determine canal form
Small Medium Large

Rotary - OK Rotary - OK Rotary - NO

 Clinical Procedures

2. Obtain straight line access

 What burs do we
need?
• #4 or #6 high-speed round
carbide

• D11-T equivalent diamond

or Endo-Z bur
 Access the chamber…

Then let the internal anatomy

dictate your outline form
 I nitial opening
• Remove caries and defective
restorations
• High speed round #4 or 6 for
penetration into pulp chamber
• Aim for largest canal

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

Watch for procedural errors!

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

 I nitial opening
• After penetration,
enlarge by cutting on
withdrawal
• Locate largest canal,
follow road map on
chamber floor
• Endo explorer to Cohen S, Burns RC. Pathways of the Pulp, 7th Ed.

locate canals
 X Anteriors
Incorrect Correct

Penetrate, then
cut on
withdrawal

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

 Posteriors

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

Penetrate, then
cut on
withdrawal
 Enlargement
• Access preparation is a Binding
dynamic process
• Conservation of tooth
structure is SECONDARY
to convenience form
• Access opening should Oops!
NEVER bind or guide
instruments
Ingle JI, Beveridge EE. Endodontics 2nd Ed.
Remove the cervical
bulge!
Pull up

Then
smooth

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

 Completed access

• Continuously
tapering, conical
form desired
• Use a 1 DT
diamond for
outline form

Ingle JI, Beveridge EE. Endodontics 2nd Ed.

 Clinical Procedures

3. Explore canal patency

 Clinical Procedures

Pass a small, precurved file to the apex

 Clinical Procedures

4. Estimate canal size

(use chart + x-ray)
 Apical Size Chart
Tooth Initial file size Final file size

MAXILLARY ARCH
Central 45 60
Lateral 40 (30 if curved) 55 (45 if curved)
Canine 45 60
Premolar B: 25, P: 30; 1 canal: 40 B: 40, P: 45; 1 canal: 55
Molar MB: 25, DB: 25, P: 40 MB: 40, DB: 40, P: 55

MANDIBULAR ARCH
Anterior B: 25, L: 25; 1 canal 40 B: 40, L: 40; 1 canal 55
Canine 40 55
Premolar B: 25, L: 30; 1 canal 45 B: 40, L: 45; 1 canal 60
Molar MB: 25, ML: 25, D: 40 MB: 40, ML: 40, D: 55
Notice the variation in canal
size

Rotaries are not designed for

large canals!
 Clinical Procedures

5. Establish initial working

length (IWL)
 I nitial working length
• Study pre-op radiographs to determine the
approximate length to the apex
• Subtract 4mm; this is the IWL

IWL
4mm
 Rotary technique
• NEVER force a rotary instrument
• Use only light pressure (similar to
writing)
• Use intermittent tapping motion
• Listen to handpiece, reduce pressure if
it slows down (this does NOT work in
non-battery powered handpieces)
• Always use a torque-reverse handpiece
 Rotary technique

• All instrumentation is PASSIVE

• Instruments are chosen because they
very nearly fit to length (1-2mm)
• As they rotate, they clean and smooth
• 3 sizes allows sufficient dentin removal
for mechanical disinfection and
smoothing without weakening the tooth
 Clinical Procedures

6. Prepare coronal 1/3 with

orifice shapers
 Clinical Procedures
Prepare coronal 1/3 with Orifice Shapers:
Initial working length minus 4mm (apex – 8 mm)
Begin with size that nearly reaches the IWL – 4 mm
passively, increase 3 sizes (less if too much binding
occurs)
Coronal Flaring: Orifice Shapers

STRAIGHT-LINE
ACCESS

IWL - 4

IWL
 Clinical Procedures

Irrigation & RC Prep are essential!

Why irrigate and recapitulate?

Mud here…
Causes perf here
And failure here!
 Recapitulation and Apical
clearing
• Canal is like a snow globe
• An absorbent point would
remove the liquid but not the
snow
• It would pack into the bottom of
the globe, or apex of the tooth
• Snow, or dentinal “mud”, must
be removed mechanically
 Clinical Procedures

Instrument with a “tapping” motion

Light pressure (like writing with a pen)
NO MORE THAN 1MM AT A TIME !!!!!!!
 Clinical Procedures

Prepare coronal 1/3 with Orifice Shapers:

Initial Working Length minus 4 mm
Irrigation & RC Prep
Instrument with a “pecking” motion
Light pressure (like writing with a pen)
NO MORE THAN 1MM AT A TIME !!!!!!!
Small to large orifice openers until
largest at approximately IWL - 4
 Important note!
• The Virginia technique is PASSIVE
• NEVER force an instrument
• If it doesn’t tap easily to the IWL-4,
accept the new, shorter length
• Continue to tap the instruments only as
far as they go without causing the
handpiece to autoreverse
Very large, non-tapered canals
• If you can insert all the orifice openers
to the IWL-4 or beyond, the canal is too
large for rotary instrumentation with a
long cutting edge instrument like a
ProFile
• Hand instrumentation or the LightSpeed
system should be used
• Consult your instructor before
proceeding
 Clinical Procedures
7. Prepare mid 1/3 with 0.06 tapers

0.06 taper files

 Clinical Procedures
Prepare coronal 2/3 with 0.06 tapers
Select size that passively almost
reaches IWL, instrument 3 sizes more
Endpoint is the Initial Working Length

IWL
 Clinical Procedures

8. Determine the exact length to foramen

How long should we
go?
 The Apical Foramen
Minor
Cementum foramen

Dentin

"Natural" constriction in the

apical area 0.25 to 0.5 from the
Mesial view of an anterior tooth radiographic apex = MINOR
FORAMEN
 The Apical Foramen

0.5 to 1 mm
Cementum

Dentin

Note: File is
long, but it looks
short on the
radiograph!

Mesial view of an anterior tooth Standard radiographic view

 Instrument Length

Aim:
As close to minor foramen as
possible. Realize that the
radiographic apex is not necessarily
the anatomic apex!
Instrument Length

Ideal
 Instrument Length

Final Working length

will be ~1mm from radiographic
apex
 Instrument Length

Can I "feel“ the apex?

- Only useful with crown-down technique
- Not reliable
- Use only in conjunction with
other techniques
How about apex locators?

Studies suggest ever-increasing accuracy

Still remain technique-sensitive
Do not work in all cases
Useful adjunct, but can be difficult to interpret
Need a combination of techniques for accuracy
Radiographic Determination
Still the “gold standard”!

“Endo Ray” instrument allows paralleling

radiograph with instruments in place
Radiographic Determination

Ideal placement
Radiographic Determination

Short Long
 Shift shot

• Always make 2 radiographs from

slightly different angles
• Aids in overcoming 2-D limitation
Radiographic Determination

Hedstrom and K files make canal

identification easy!
 Clinical Procedures

9. Prepare apical 1/3 with 0.04 ISO

tapers from small to large
Prepare the apical 1/ 3

Working
length
Instrumentation of the apical 1/3

Coat a 0.04 hand file the

same size as the file you
used to take your FWL
radiograph with RC Prep
Place it to the FWL using a
watch-winding motion
Rotate it clockwise until it is
loose in the canal
Instrumentation of the apical 1/3

Irrigate copiously
Coat the next larger file with
RC Prep
Work it to the FWL using a
watch-winding motion
Rotate it clockwise until it is
loose in the canal
Instrumentation of the apical 1/3
Continue to repeat these
steps for three file sizes.
Recapitulate – after
irrigating, replace the
original file size to the FWL
and watch wind to place if
necessary. Then irrigate.
This will remove any
accumulated dentinal “mud”
Instrumentation of the apical 1/3
Now, begin step back as
follows:
Place the next larger size in
the same fashion, but only
to the FWL – 1mm.
Work the file in the same
fashion as previously
Instrumentation of the apical 1/3

Repeat this twice, with the

next larger size, to FWL –2
and FWL –3
This will give you a “step
back” taper
Instrumentation of the apical 1/3

Finally, recapitulate, irrigate,

and smooth the steps by
using the last size you took
to the FWL in an up-and-
down filing motion
This file size is your master
apical file, which will dictate
the size of your master gutta
percha cone
 Important note…

• Instrumentation near the apex is dangerous

• Many endodontists complete the apical 1/3
entirely with hand instruments
• However, the use of carefully controlled
rotaries can result in a smoother transition
• Once you have sufficient experience, the
alternate technique for finishing should
provide a smoother preparation
Instrumentation of the apical 1/3:
alternative to step-back
• After instrumenting to the WL
for three file sizes past the file
used to determine your FWL,
instead of the stepback,
simply:
• Place the next larger size 0.04
taper Profile in the handpiece
and gently tap it to the WL
• Be careful not to pass the WL!
 Remember:
• NEVER attempt to instrument a canal
with a rotary instrument that you have
not already instrumented to the FWL
with at least a size 25 hand instrument
 Remember:
• Always use any instrument, hand or
rotary, with RC Prep for lubrication
• Be sure to irrigate copiously after each
file
 Remember:
• Apical clearing is NOT
recapitulation!
• It consists of:
– Drying the canal
– Rotating (by hand) without
pressure the last size file used
(master apical file)
Irrigate copiously,
dry, apically clear,
and you are…