Dr.

YASIR KHATTAK
ASSISTANT PROFESSOR
SBDC
Root canal treatment is divided into three main steps
1. Biomechanical preparation(Cleaning & Shaping)
2. Disinfection
3. Obturation
The basic objectives of cleaning and shaping
includes removing of infected hard and soft tissues,
give disinfecting irrigant access to the apical canal
area, create space for the transport of medicaments
and retain the integrity of radicular structures
 1- Endodontic Diagnosis
 2- Patient Education
 3- Local Anesthesia
 4- Rubber Dam Isolation (single isolation)
 5- Access Cavity
 6- Working length
 7- Instrumentation
 8- Obturation
 9- Final restoration
Injection of local anaesthesia into the soft tissue near
the root apex is known as infiltration. Ideally the
needle is inserted into the muco-buccal fold mesial to
the tooth to be anesthetized.
In case of mandible, infiltration alone cannot
achieve this goal becz of thick dense buccal plate, thus
for the inferior alveolar and long buccal nerve, block
technique should be used(Inferior Alveolar Block).
Gow-gate technique is another type of anaesthesia for
mandibular nerves. In this type of technique
anaesthesia is deposited in the lateral aspect of the
neck of the condyle instead of mandibular sulcus.
Intra-pulpal anaesthesia is another type , which is used
when block or infiltration is not affective. In this,
anaesthetic solution is directly injected into the
exposed pulp by introducing the needle into the root
canal until it binds and then forcefully inject the
solution
 Root length- Longer roots are generally more
difficult to treat.
 Root width- Narrow, curved roots are at risk for
apical and lateral stripping perforations. Small canals
are more difficult to prepare and may not exhibit any
natural taper.
 Canal curvature- Difficulty increases as curves
progress from gentle to sharp dilacerations.
 Resorptions- Resorptions present potential problems
for negotiation, cleaning, shaping, and obturation.
 Restorations- Restorations may change the
orientation of the tooth in the dental arch, block
canals, and restrict vision.

 Previous treatment- Teeth exhibiting previous root

canal treatment are more difficult to manage for a
variety of reasons.
Complete removal of the pulp(both coronal and
radicular) is known as pulpectomy. The teeth in which
pulpectomy has been completed are known as dead or
devital.
TECHNIQUE:
Rubber dam is placed after local anesthesia. Access
cavity is prepared and coronal pulp is removed either
with high speed hand piece or excavators. The pulp
chamber is irrigated with 5.25%Naocl and canals
orifices are located with the help of endodontic
explorer such as DG16 along the anatomic
grooves(called Dentinal Maps) .
All the incisors and premolars except the maxillary
second premolar , have single centrally located canals.
Upper second premolar has two canals(Buccal and
Palatal) whose orifices are connected by a dark groove
and the floor of this tooth will be convex shape
Maxillary First Molar has 3 canals(MB,DB and Palatal), having
triangular floor. All the three canals will be in the mesial
aspect of the tooth. The MB canal will be located under the
MB cusp and is instrumented from DP side.
The mesial root may have another canal known as
MB2 which is usually present palatal to the MB canal
orifice. DB canal is located under DB cusp, distally to
the MB canal orifice. The maxillary second molar has
the same anatomic structure but with smaller pulp
chamber.
In case of mandibular first molar there are 3 canals i,e
MB, ML, and Distal canals. The distal larger canal will
be in the centre of the tooth bucco-lingually.
However sometimes there may be two distal canals
(DB & DL). Both mesial canals will be located under
their respected cusps.
 In some cases the orifice of the canal may be blocked
becz of calcification. In such cases first Periapical
radiograph is taken and then either sharp endodontic
explorer is inserted or slow hand piece is used. EDTA
can also be use in this regard as it is a chelating agent
which will soften the dentine and help in
instrumentation of block canals.
Length of the root canal from the reference point to the
apical constriction is known as working length,
reference point in the anterior teeth are incisal edges
and in posterior teeth they are the cusp tips. The
purpose of working length is to prevent mishaps such
as perforation , ledges, blockage etc.
Accurate working length determination plays an
important role in successful endodontic treatment.
Generally Radiograph, tactile sensation or presence of
moisture on the paper points helps in this regard
however accurate determination is not possible with
radiographs becz they are 2 dimensional.
Therefore use of electronic devices such as Apex
locator not only determine the exact working
length but also decreases the number of WL
radiographs(Fouad et al 2000) however some
studies recommend the use of both radiograph
and electronic apex locators to get better results.
Electronic method for the canal length
determination was first investigated by Custer in
1918. The main parts of Apex locator are i,e
1. Lip Clip
2. File Clip
3. Instrument Itself
4. Cord
The apex locator have several disadvantages as well
such as they should not be use in patients having
pacemakers, they should not be use in case of
inflammatory exuadate, blood , metallic restoration
, caries , saliva etc, Care should be taken so that the
patient should not swallow the lip clip.
The main advantages of apex locator on the other hand are
1. Less time
2. Accuracy
3. Perforation can be recognized
4. Reduction of X- ray exposures
Radiograph method which is described by Ingle is the
most common and reliable method in the determination
of working length however accuracy is difficult becz the
apical constriction is difficult to achieveS in this
technique. In addition radiation hazards both to the
patients and dentists is also another factor. Becz
radiographs are 2 dimensional
 therefore sometimes 2 length determination
radiographs may be neccessary , one at normal
angulation and another at 20 degree shift at mesial
or distal to the tooth.
 The working length should be 0.5 mm to 1 mm shorter
than the measured canal length becz the actual length
of the tooth is 1.2mm less than radiographic image and
the apical foramen is approximately 0.3mm short of
the actual root tip.
 Apical part of the root has three main parts i,e
1. Apical constriction
2. Cemento – dentinal junction (CDJ)
3. Apical foramen
Apical constriction is the narrowest point in the
root canal which is located 0.5mm to 1.5mm inside
the apical foramen. Many clinician believe that this
is the reference point for the termination of shaping,
cleaning and Obturation.
There are various theories regarding the working
length determination which are given below
1. Bone & root resorption:
Weine in 1982 recommended that the apical
termination should be 1.5mm from the apex when only
bone resorption occurred , 1 mm from the apex when
root resorption occur and 2mm when both root and
bone resorption occur.
2. Apical constriction:
Langland (1995) suggested that most favourable
prognosis is obtained when procedures are terminated
at apical constriction. He also mention that second
good prognosis can be achieved if termination point is
2mm from the apical constriction and worst prognosis
is established when instrumentation is extended
beyond the apical constriction.
3. Beyond the apical constriction:
Schilder in 1967 concluded that good prognosis can
be achieved if termination point is beyond the apical
constriction and he defend his view by declaring his
aim was to debride and fill the apex and fill the lateral
canals along with apical ramifications.
4. Radiographic apex:
Since apical constriction and apical foramen is
difficult to locate clinically therefore some researcher
consider radiographic apex as a reliable reference point
(Sjogren 1990). According to them root canal
preparation should terminate at or 3 mm from the
radiographic apex depending upon the status of the
pulp. In case of vital pulp , favourable point
of termination should be 2 – 3 mm short of radiographic
apex while in case of non – vital or necrotic pulp , the
termination point should be at or 2 mm of
radiographic apex. For retreatment cases the
termination should be 1 to 2 mm short of radiographic
apex. Similarly Strindberg (1956) concluded that
highest success rate was achieved when working
length ends 1 mm short of radiographic apex.
4. Cemento – dentinal junction:
Some studies concluded that CDJ is at same level as
apical constriction and it is located 1 mm coronal to
root apex. According to these studies instrumentation
and Obturation should end at CDJ.
 The shape of the access cavity is the prerequisite that
must be optimized before any canal preparation can
take place. The access cavity must allow instruments
unimpeded access to the middle third of the root
canal system.
Canal preparation or cleaning and shaping of the root
canal can be done in the following 2 main ways,
1. Apical coronal Technique
2. Corono-Apical Technique
1. Stepback preparation
2. Balance d force technique
3. Standard preparation
1. Crown – down Technique
2. Double flared Technique
3. Step – down technique
In a crown – down approach, the clinician passively inserts
a large instrument into the canal up to a depth that allows
easy progress. The next smaller instrument is then used to
progress deeper into the canal; the third instrument
follows, and this process continues until the terminus is
reached. Both hand and rotary instruments may be used in
a crown – down manner.
There are some advantages and disadvantages for crown –
down technique;
Advantages include removal of infected dentin, access of
irrigant and medications to apical third of root canal while
disadvantages include risk of perforation errors and
extrusion of irrigant and filling material. Not ideal for
thermoplastic obturation.
 The realization that curved canals may require less
aggressive instrumentation resulted in the introduction
of the step-back preparation technique.
 The step-back technique emphasizes on keeping the
apical preparation small, in its original position, and
producing a gradual taper.

 The working length is established and then the first file

to bind is set as the master apical file (MAF). Or the
last file which reaches to full working length. After
getting straight line access and apical preparation , step
back has to be started.
Subsequent larger files are introduced 1-mm or
shorter increments .
After each step back, the canal is irrigated and
the MAF replaced to the established working
length to remove any loosened debris.
The step-back "telescoped" preparation
produces a canal with greater taper compared
with the standard technique and results in more
dentin removal and cleaner canal walls.
 In the step – back approach, working length decreases in a
stepwise manner with increasing instrument size. This
prevents less flexible instruments from creating ledges in
apical curves while producing a taper for ease of
Obturation.
The advantages includes
1. It is likely to cause periapical trauma
2. Greater condensation pressure may sometimes fills the
lateral canals with the sealer
3. Greater flare that results from instrumentation
facilitates packing of additional gutta – percha cones by
either lateral or vertical condensation
4. Development of an apical stop prevents overfilling of the
root canal
 The disadvantages include;
1. Compromised disinfection
2. little removal of infected dentin
The aim of the apical widening is to fully prepare the
apical canal areas for optimal irrigation efficacy and
overall antimicrobial activity. Recently apical
enlargement has been broken down into 2 phases i,e
apical enlargement and apical finishing
 The Gates Glidden drills are used after a size 25MAF
can be introduced to the corrected working length.
 Provides straighter access to the apical region;
eliminates interferences and canal irregularities in the
coronal two thirds of the root.

 Permits deeper placement of instruments that

otherwise might not go to length; removes the bulk of
tissue, debris, and microorganisms; and allows
deeper penetration of irrigating solutions.
After lubricating the chamber with an irrigant ,Gates
drills #2,#3,#4 are introduce with light force. The
deepest penetration of the canal occurs with the #2
Gates Glidden. The #3 Gates Glidden is used next at a
shorter length and directed to the perimeter of the
canal .
Finally, #4 Gates Glidden is used to the depth of the
head of the bur to finalize the straight line access.
This step helps establish the space for the hand files
to reach the apical third without interference.
The passive step-back technique develop by
Torabinejad uses a combination of hand and rotary
instruments to develop a flared preparation.
This technique provides gradual enlargement of the
root in an apical to coronal direction without the
application of force and reduces the risk of procedural
accidents caused by transportation.
The passive step-back technique involves establishing
a corrected working length using a #15 file.
The #15 file is inserted to the corrected working length
with light pressure and then rotated one eighth to one
quarter turn.
Additional K-type files between #20 and #40 are then
inserted passively as far as they will go and rotated one
eighth to one quarter turn with light pressure.

Gates Glidden drills (#2 to #4) are then used coronally,

and apical preparation is accomplished
Narrow, curved canals should not be enlarged beyond
a #25 or #30 file.
WATCH WINDING:
It is clockwise/anticlockwise rotation of the
instrument to negotiate the canals.
REAMING:
It is defined as clock wise cutting rotation of the file.
FILING:
Filing is defined as placing the file into the canal and
pressing it laterally while with drawing it along the
path of insertion to scrap and plane the canal wall.
Hand files should be use for the balance force
technique. Roane et al described this technique as a
series of rotational movements for Flex R files(NiTi -K
type instrument) but it can also be use for K-files.
The balanced force technique involves 3 or 4 steps.
The first step ( after passive insertion of an instrument
into the canal) is a passive clockwise rotation of about
90 degrees to engage the dentin. In the second step the
instrument is held in the canal with adequate axial
force and rotated anticlockwise to break the engaged
dentin chips from the canal. In the last step the file is
removed with a clockwise rotation .
 in short Instruments are introduced into the root canal
with a
clockwise motion of maximum 180 and apical
advancement, followed by a counter clock wise
rotation of maximum 120.
The final removal phase is then performed with clock
wise rotation and with drawl of the file from the root
canal.
.
 Roane advocated the use of a triangular cross-sectional
instrument because the decreased mass of the
instrument and its deeper cutting flutes Improve
flexibility and decrease the restoring force of the
instrument placed in a curved canal.
 Before instrumentation, #1 to #6 Gates Glidden drills
are used for straight line access. In balanced force
instrumentation, the files cut in both clockwise and
counterclockwise rotation.
 An advantage to the technique is the ability to
manipulate the files at any point in the canal without
ledging or blockage.
 Instruments rotated in a clockwise direction tend to
move apically as the instrument engages the dentinal
wall, pulling the instrument into the canal.
 Instruments rotated in counterclockwise direction
tend to move coronally or out of the canal.
 In the balanced force technique the file is placed to
working length and rotated clockwise 90 degrees with
light pressure to engage the dentin.
1. ENGINE – DRIVEN INSTRUMENTS:
There are two types of engine driven instruments
for the root canal preparation i.e
a) Giromatic handpiece
It activates stainless steel barbed broach or
reamer in the root canal at a speed of 1000
cycles/min. When compared with hand
instrumentation , the giromatic was found to be less
effective for preparing the root canals as this method
takes longer time and had a tendency to create
ledges .
 b) Racer contra – angle hand piece
It uses a standard file and oscillates the file in the
root canal. A major disadvantage of this instrument is
that debris may be forced ahead of the instrument into
the periapical tissue
2. POWER – DRIVEN INSTRUMENTS:
There are 2 types of power driven instruments which
are commonly used in endodontics i,e Gates Glidden
Drills and peeso reamers.
Gates have long shaft which ends at flame shape head
, with safe tip. The head cuts laterally and is used with
gentle apical pressure. They are generally used to
remove the lingual shoulder during access cavity
preparation of anterior teeth, to enlarge root canal
Orifices and to clean and shape the cervical third of the
root canal in a step – back preparation.
The Peeso reamer has long sharp flutes which cuts
laterally and is primarily used for the preparation of
post space when gutta-percha has been removed from
the obturated root canal, however its main draw back
is its tendency to cause perforation of the root.
Both gates and Peeso reamers are inflexible and
therefore they should be use at slow speed and with
extreme caution.
THANKS