CLINICAL

ENDODONTIC TREATMENT:
THE PREREQUISITE FOR THE PLACEMENT
OF FIBER POSTS
SIMONE GRANDINI, ANIELLO MOLLO

T
he study and practice of Endodontics includes basic should not be under-estimated nor carried out superficially, as
clinical science comprising the biology of healthy pulp, an error at this stage could compromise the rest of the
and the etiology, diagnosis, prevention and treatment of treatment.
diseases and injuries of the pulp and associated periradicular If the tooth cannot be isolated, neither the endodontic nor
conditions.1 the restorative treatment can be performed. Apart from a
Until the middle of the 19th century, endodontics did not situation where the tooth is in such a poor state that extraction
play a significant role in dental therapeutics, as there was no is the only possible solution, there are cases where the isolation
prevention, no scientifically tested materials, no standardized of a tooth may be difficult. In endodontics, the pre-treatment
and reliable clinical protocols. During this era, endodontic phase may be defined as a set of techniques which prepare the
treatment was performed on a trial and error basis, with little tooth for endodontic treatment and which allows and/or
chance of predicting clinical outcomes. However, during the simplifies an optimal isolation of the operative field.3
last 50 years, a whole generation of dentists has become Root canal treatment, therefore, does not begin with the
committed to this field of dentistry, with the ultimate placing of the rubber dam, but rather with all the periodontal
realization of endodontics as a clinical speciality. and restorative procedures necessary to simplify its placement.
The innovations in restorative dentistry over the past decade In any endodontic treatment, it is of fundamental importance
have contributed significantly to improving the quality of the to have a sterile operative field. Once the dam is in position,
restorations of root-treated teeth, giving them a better long the clamp and the tooth must be disinfected with cotton wool
term prognosis. Microbiologic studies have demonstrated that soaked with a fast- evaporating antiseptic.4
controlling pulpal infection is of utmost importance for There are several disinfectants and techniques which can be
successful endodontic treatment, and directed the therapy to used to remove contaminated bacteria from treated surfaces,
a rational approach no longer founded on an empirical but on with simple and standardized protocols being suggested by
a scientific basis. some authors. Dental plaque should be removed with rubber
The introduction of new materials and instruments for the points and prophylactic pastes prior to the placement of the
preparation, cleaning, shaping and obturation of the root rubber dam after which the operative field should be cleaned
canals has contributed to the dissemination of endodontic initially with 30% hydrogen peroxide and subsequently with
practice among general dentists. While this has allowed an iodine-based disinfectant.5,6
clinicians to restore teeth that previously would have been The pre-treatment procedures which are used to prepare a
extracted, it has clearly demonstrated the limits of tooth for endodontic treatment may be divided into two types
contemporary endodontics. Like every discipline, endodontics according to their duration: provisional pre-treatment types
has guidelines and clinical protocols, which every dentist and semi-definitive pre-treatment types. The former are self-
should carefully follow to achieve success and reduce the explanatory and have a limited time duration, whereas the
number of failures. latter may be used even after the conclusion of endodontic
therapy. From a clinical point of view, however, pre-treatment
Pre-Endodontic Restoration procedures are separated into periodontal procedures and
The success of endodontic therapy depends on the correct restorative procedures. Not included in these descriptions are
cleaning, shaping and filling of the root canals,2 but before
starting these procedures, the tooth must be isolated with the
use of rubber dam and the cavity access prepared. These first
two steps of the therapy are of particular importance and

Simone Grandini, DDS, MSc, PhD, Chair of Endodontics and

Restorative Dentistry, University of Siena. Italy

Aniello Mollo, DDS, Dept of Endodontics and Restorative Dentistry, Figure 1: Examples of different methods of isolation of the operative
University of Siena, Italy field.

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2a 2b

2c 2d 2e

Figure 2: Example of pretreatment; 2a: diagnostic x-ray; 2b: clinical situation; 2c: after initial opening of the pulp chamber, and use of the rubber dam,
the buccal side still needs further isolation; 2d: isolation completed with the help of fluid silicon (OpalDam, Manufact, Country); 2e: 1 yr post-op control.

clinical cases in which the prevailing periodontal conditions Once the clamp has been stabilized, any gap between the
must be first addressed before endodontic therapy can rubber dam and the crown of the tooth should be eliminated
commence. However, should clinicians find themselves even if one or more of the tooth walls are missing or if there
working under emergency conditions and are thus unable to has been pre-endodontic restoration. Common dental
request that the patient undergoes periodontal treatment, materials such as zinc oxide-eugenol cement, resins, or
they should still eliminate any plaque or calculus near the polyvinylsiloxane impression materials may be used for this
access cavity. purpose.9,10 There are also “fluid dams” available that are
Teeth requiring endodontic treatment seldom have the designed to prevent the infiltration of saliva, blood or irrigation
anatomy which is suitable for treatment “lege artis”. fluid into the operative field.
Reductions in the height of clinical crowns due to anatomical Walton and Torabinejad suggest that the best preparation
or pathological reasons may render the application of the for cavity access is to section the tooth at the cervical level, as
rubber dam difficult. However, if the operative field is this gives full visibility and allows for the most direct access as
inadequately isolated this could jeopardize the optimal seal the pulp chamber is completely exposed.6 Although the
that is required to prevent re-infection of the root canal space authors indicated that any restorative pre-treatment would
in the time between appointments. compromise subsequent endodontic procedures, there are
It has been suggested that the stabilization of the clamp in clinical cases where restorative pre-treatment is mandatory
order to position the rubber dam is the crucial moment for (Figure 2).
deciding whether or not to carry out endodontic The aim of restorative techniques of endodontic pre-
pretreatment.7 There are cases which appear difficult but treatment is to restore the previously mutilated dental anatomy
which may be solved with methods which do not change the to a state that makes endodontic therapy easier and gives
dental structure. The use of a rubber dam clamp which has not better post-endodontic coronal seals. Different restorative
been designed for that specific purpose may be a viable materials may be used, including reinforced zinc oxide-eugenol
alternative, such as using a clamp made for incisors for cements, glass-ionomer cements, and both auto- and light-
premolars or even molars (Figure 1). On other occasions, it may cured resin composites. It should be pointed out that pre-
be sufficient to modify the conformation of the clamp to adapt endodontic restorations with resin composites may be re-used
it to a tooth with poor crown structure. For example, the as the foundation for subsequent post-endodontic
clinician may tilt the top of the points that anchor the clamp to restorations. Mechanical devices such as copper bands and
the tooth.6 Alternatively, the clamp may be stabilized by using orthodontic bands are used less frequently than in the past due
a composite with adhesive properties.8 to the difficulties encountered in trying to ensure a hygienic

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environment as well as the periodontal problems these

accessories may cause. Other studies suggest that the cusp tips
of posterior teeth should be completely removed in more
complex cases as this eliminates crown interference, avoids
tooth fracture during treatment, and provides constant and
precise reference points during obturation of the root canals.12
In general, an optimal pre-treatment method is based on the
ease and economy of time and work with which a procedure Figure 4: Access cavity in molars with unusual shape and size
is completed. However, when pre-treatment is indicated, it
should not be seen as a laborious task by the clinicians, but pulp chamber may be achieved by using a rosette bur of various
rather an effort on their part to ensure success, reduce failures, diameters or an ultrasonic tip. This enlargement procedure is
and avoid discomfort for the patient. performed only if required, and with limited tissue removal.
In contrast to restorative dentistry where the cavity outline
Access Cavity form depends on the size of the carious lesion, the access
The access cavity is the first step in root canal preparation and cavity form in root canal therapy is dictated by the shape of the
a fundamental stage in its treatment. This consists of forming pulp chamber and the number of canal orifices (Figure 3).12,13
an access path in the crown of the tooth, which is of a well The factors which regulate this are the size and shape of the
defined form, size and position. Not only does this allow the pulp and the number, direction and curvature of the root
dentist to locate the root canals, but also permits proper canals. The outline form is often modified during the
cleaning, shaping and obturation. preparation of the coronal third of the root canal to enable
The importance of access cavity preparation is often under- straight line access into the root canals (Figure 4). Initial access
estimated. In reality, the prognosis of root canal treatment is is achieved along the occlusal or lingual surface of the tooth.
directly linked to the accuracy and care taken when initially The roof of the pulp chamber is removed and all organic
accessing the root canal system. Should the access cavity be matter eliminated. This facilitates cleaning of all the coronal
improperly prepared in position, depth, or width, the root pulp (including pulpal horns) and avoids potential problems
canal treatment becomes unpredictable. such as crown discoloration or re-infection of the filled root
The instruments used for preparing the access cavity include: canal space. If the access preparation is correctly performed,
- Diamond burs (e.g. Intensive 206, 314S, 117M) for the the pulpal floor and the canal orifices should be clearly visible
penetration phase; without perforating the furcation area.
- Zekrya-Endo Maillefer bur, for the finishing phase; It is important that the access cavity facilitates the use of the
- Contra-angle handpiece round burs (28mm) N° 010, 014, instruments in the root canals and provides unrestricted access
016; to the apical third of the root canals. This ensures enough
- Contra-angle handpiece round bur Maillefer LN 205-006; space for the endodontic instruments to work freely in the
- Explorative root canal investigation probe (Hu-Friedy DG16) canals without interference from the coronal portion of the
cavity. The access cavity must therefore be extended in the
Preparation of the access cavity may be schematically divided opposite direction to the root thus eliminating any interference
into 3 stages: penetration, enlargement and finishing. that may block direct access by the instruments.
Penetration is carried out using a diamond bur of various Failure to eliminate crown interference may result in
shapes depending on the anatomy and type of the tooth. Once incomplete cleaning of the canal system, and an increased risk
the pulp chamber has been opened, the chamber walls are of creating ledges, perforations, stripping and transportation
extended and finished. If the pulp chamber has calcified or if of the apical foramen. However, excessive enlargement of an
the roof is close to the pulpal floor, then enlargement of the access cavity to the extent of destroying a cusp should be
avoided from a restorative perspective. With the advent of
contemporary ultrasonic devices and long shank burs with
smaller heads, it is possible to remove dentin selectively while
preserving sound dentin structure for post-endodontic
rehabilitation.
The access cavity should also provide stable support to the
provisional restoration and preferably, should have four walls.
This is especially important when there has been a loss of a
a b large amount of tooth structure due to caries or if the root
Figure 3: access cavities in lower (3a) and upper molars (3b). canal treatment has to be completed over several

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and mechanical root canal preparation and although traditional

Table I. The most important elements of
stainless steel instruments have been in use for almost a century,
endodontic treatment
the most suitable technique has not yet been established.
Removal of vital and necrotic tissue from the main root canal(s)
Creation of sufficient space for irrigation and medication Manual Root Canal Preparation
Preservation of the integrity and location of the apical canal anatomy For many years, the step-back technique15 was the one most
Avoidance of iatrogenic damage to the canal system and root structure commonly employed, using 0.02 tapered stainless steel manual
Facilitation of canal filling
instruments, to obtain root canal preparation with a
Avoidance of further irritation and/or infection of the periradicular
progressively funneled shape. The technique utilizes a “apico-
tissues coronal” approach; i.e. the first instrument has to reach the
Preservation of sound root dentine to allow long-term function of the apex and subsequent canal preparation commences from the
tooth
apical third. For this reason smaller instruments are used initially
and then replaced by larger instruments to obtain a conical
appointments. It is important to have considerable knowledge shape. Finally, Gates-Glidden drills are used to shape and
of the anatomy of the tooth before attempting to prepare the enlarge the coronal third to complete the desired canal shape.
access cavity, particularly when a tooth is tilted due to the Frequently, root canals requiring endodontic treatment have
extraction of an adjacent tooth. Careful clinical examination of lost their natural conical shape through caries, preceding
the tooth inclination and good pre-operative x-rays at different therapies, traumas and are either calcified or partially occluded
angulations will help to avoid unnecessary errors. with filling materials. The first instrument used in the root
canal is thus often blocked before reaching the apex. Forcing
Root Canal Preparation these instruments can easily create ledges, stripping or
The major goals of root canal preparation are the prevention separation of the instrument. Although Schilder15 was the first
of periradicular disease and promotion of healing in cases to recognize the importance of removing coronal interferences
where disease already exists. Root canal preparation is in order to more effectively shape the apical third of root
undoubtedly the most delicate and complex part of the whole canals, the technique of “crown-down” preparation is often
treatment, as illustrated by the statement that “what comes attributed to the studies reported by other authors.17-20 These
out of the canal is much more important than what goes into authors confirmed the concepts introduced by Schilder
it”.14 In 1974, Schilder outlined the most important elements regarding the funnel-shape preparation, but performed the
of endodontic treatment (Table I), and established that proper shaping procedure in the opposite direction, from the crown to
cleaning and shaping of the root canal is the basis for the apex. Laurichesse et al. in 1971 17 and Riitano in 1976 18
successful treatment,15,16. Cleaning and shaping are usually proposed the preparation of the apical third of a root canal
performed simultaneously using instruments and irrigants. only after the preparation of the middle and coronal third. In
Schilder 14-16 also described the following five design objectives: this way, the instruments are free to reach the apical third and
I. A continuously tapering funnel from the apex to the are not forced towards the root canal walls, hence avoiding
access cavity; iatrogenic damage. Moreover, the preparation of the apical
II. The cross-sectional diameter should be narrower at every third as a final step is more logical, as preparation of the most
point apically; delicate and hazardous area of the root canal occurs in the
III. The root canal preparation should follow the shape of the final stages where there is better access after the flaring of the
original canal; coronal and middle thirds of the root canals.
IV. The apical foramen should remain in its original position; In 1980, Abou-Rass at al.19 introduced the anti-curvature
V. The apical opening should be kept as small as practical. filling method, which requires the removal of an adequate
and the following four biological objectives: quantity of dentin on the external area of the curvature in the
I. Confinement of instrumentation to the roots themselves; coronal third, avoiding the danger zones close to furcations. In
II. No forcing of necrotic debris beyond the foramen;. the same year, Morgan and Montgomery20 described a new
III. Removal of all tissue from the root canal space; technique with a crown to the apex approach called the
IV. Creation of sufficient space for intra-canal medicaments. “crown-down pressureless technique”. This requires an early
To satisfy the aforementioned objectives, irrespective of the coronal enlargement using Gates-Glidden drills and
preparation technique adopted, the dentist must have a subsequently using files with an inverted sequence, from the
comprehensive knowledge of the root canal anatomy, the largest to the smallest, in a rotary movement. In 1982, Goering
instruments must be used strictly according to their features, and et al. 21 proposed another technique known as the “step-
standardized filling procedures should be followed. Over the last down” technique. This is similar to the aforementioned
decade, numerous studies have been published on both manual technique (early coronal enlargement or preflaring) using

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Hedstrom files and Gates-Glidden drills, but using the the transition of the alloy from an austenitic phase (more
instruments from the smallest to the largest. stable) to a martensitic phase (more dynamic). The two main
The “balanced force technique” was introduced by Roane et features of the alloy are shape memory and super-elasticity.30
al. in 1985.22 The technique was originally associated with the The elasticity of Ni-Ti instruments in bending and torsion is two
use of specially designed stainless-steel or nickel-titanium (NiTi) to three times higher than that of stainless steel instruments.
K-type instruments (Flex-R-Files) with modified tips in a step- The modulus of elasticity is significantly lower for Ni-Ti alloys
down manner. The instruments are introduced into the root than for stainless steel. As a result, lower forces are exerted on
canal with a clockwise motion of a maximum of 180 degrees intraradicular dentin when compared to stainless steel
and apical advancement (placement phase), followed by a instruments.31 In order to take advantage of these features, Ni-
counterclockwise rotation of a maximum of 120 degrees with Ti instruments should be kept active, through constant and
adequate apical pressure (cutting phase). The final removal continuous rotation within the root canal. Kazemi et al.
phase is then performed with a clockwise rotation and demonstrated that Ni-Ti instruments require less force to bend
withdrawal of the file from the root canal. Apical preparation and can sustain a greater strain than those made of stainless
should be larger than that recommended for other manual steel before surpassing the elasticity limit and fracturing.32
techniques, e.g., to size #80 in straight canals and size #45 in Because of the metallurgical properties of Ni-Ti, it was
curved canals. The major advantages of the “balanced force possible to engineer instruments with tapers greater than 2%,
technique” are: 1) good apical control of the file tip as the which is the norm for stainless steel instruments, as well as
instrument does not cut over the complete length; 2) optimal reduce the lateral forces during instrumentation. Greater taper
centering of the instrument because of the non-cutting safety instruments are well-suited to the “crown-down” technique.
tip; and 3) eliminating the need to pre-curve the instrument. During treatment, the part of the instruments with the greater
In 1993, Scianamblo et al. 23 described another root canal taper makes contact with the coronal third of the root canal
preparation procedure that is based on the aforementioned and enlarges it, eliminating any interference at this level. This
techniques, and stressed the concept of early coronal subsequently allows access to the apical third of the root canal
enlargement. Following pre-enlargement, the apical third is by instruments with reduced tapers. In this way a reduced
negotiated last, establishing patency, and confirming working lateral force is applied on the curved canal walls during
length. The apical zone is then finished so that a smooth instrumentation, decreasing the number of canal damages
uniform taper from the orifice level to the radiographic when compared with the results obtained using traditional
terminus is obtained. The disadvantage of this procedure is the stainless steel instruments.31 Recent studies have shown that
large amount of time required, the large number of Ni-Ti instruments: a) reduce the number of zips, ledges and
instruments used, and the risk, with Gates-Glidden drills, to apical transportations; b) remain more centered in the apical
provoke stripping at the middle and coronal level. lumen; c) remove less dentin, d) produce rounder preparations;
Many studies have shown that pre-enlargment (preflaring) of and e) are faster in shaping the root canal walls.33-36
root canals has several advantages.22,24 Firstly, preflaring removes Many Ni-Ti instruments are commercially available and their
the bulk of the necrotic and infected tissues from an infected manufacturers claim greater safety and easier instrumentation
root canal prior to apical instrumentation. The technique also than with stainless steel instruments. Although Ni-Ti
increases the tactile sensibility and control of the instrument tip instruments vary considerably in their design,31 the blades may
in the most difficult working area of the root canal. Enlargement be classified in two main categories: active cutting angles or
of the apical third may then be carried out without forcing the radial planes (rake angle). The former allows a cutting action
instruments, thus avoiding iatrogenic damages such as and a faster progression of the instruments than the latter,
displacement or blockage of the apical foramina. Finally, which works with a smoothing action rather than with a real
preflaring allows a greater penetration of the irrigants, and less cutting action. The instruments also vary considerably
extrusion of debris into the periapical regions 25-28 according to their transversal section. By reducing the area of
contact with the root canal walls, the cutting action is more
Canal Preparation with Rotary Ni-Ti Instruments efficient and torsional stress is reduced.31 The core of the
With the advent of the Ni-Ti alloy,29 endodontists have the instrument influences its flexibility and its mechanical
option of using a more pliable material that can follow the properties. When the core is reduced in dimension, the
canal curvature more easily. Ni-Ti is composed of instrument has a greater flexibility which respects the root
approximately 55% nickel and 45% titanium, and has a canal anatomy.31 A deep groove allows more debris
variable formula. It has the ability to alter its type of atomic transportation, increasing its cleaning effectiveness. Cutting
bonding, generating unique changes in the metallurgical efficiency and flexibility may also be regulated by balancing the
properties and crystallographic arrangement of the alloy. These flute angle. The greater the flute angle, the greater the
changes depend on temperature and stress, which can induce flexibility. Regarding the instrument tip, most of the recently

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marketed Ni-Ti instruments have a non-cutting or safe-cutting Table II.

tip design, thus reducing the possibility of altering the root
canal anatomy (Figure 5). SYSTEM Speed (rpm)
Profile (Dentsply-Maillefer) 150-350
Practical Advice when using Ni-Ti Instruments GT Rotary (Dentsply-Maillefer) 150-350
Although the flexibility of Ni-Ti instruments is greater than that Protaper (Dentsply-Maillefer) 250-350
of stainless steel instruments, fracture (separation) is still a risk
HERO 642 (Micromega) 300-600
and often occurs insidiously.37 In the majority of clinical
HERO Shaper (Micromega) 300-350
situations, instrument separation occurs in the apical third of
Flexmaster (VDW) 280-300
the root canal, rendering the fractured portion very difficult to
K3 (SybronEndo) 300
remove. There are two main reasons for the separation of
these instruments: torsion fractures and cyclic fatigue MTwo (Sweden & Martina) < 350

fractures.38 The former occurs when the tip of the instruments Lightspeed (LSX) 750-2000
is blocked in the root canal yet the shaft continues to rotate,
exceeding the elasticity of the alloy. This kind of fracture is of this cyclic stress is not usually visible to the naked eye.
often due to an excessive force applied to the instruments by However, evidence of microcrack formation may be observed
the dentist.39 However, cyclic fatigue is the most common when used instruments are examined with scanning electron
reason for the separation of Ni-Ti instruments.40 As an microscopy. These microcracks represent surface flaws that are
instrument rotates inside a canal, it undergoes alternate shifts generated during the manufacture of the instruments or slip-
from compression to tension during each rotation cycle, thus planes that are generated after clinical use of the instruments.
creating fatigue stress along the instrument surface. The result Crack initiation stress along these regions may be further
increased by dentin chip embedding and wedging. Once these
cracks are initiated, they propagate progressively during each
rotation cycle, creating heavy stress concentrations that rapidly
spread inward and eventually result in damage along the center
of the instrument shafts. To minimize instrument separation via
cyclic fatigue, several important issues must be borne in mind
regarding the use of rotary Ni-Ti instruments. This includes
limiting the re-use of these instruments, using low-speed, low-
torque motors, having pre-operative knowledge of the root
canal curvature, inserting the instruments along the correct
entry axis (i.e. straight line access), and limiting the length of
time in which an instrument is allowed to rotate within the
canal. Some practical suggestions are included below to reduce
the risk of instrument separation.

Using the correct speed

To optimize the superelasticity of the Ni-Ti alloy, rotation of an
instrument should be continuous and kept at a constant
speed. The rotation velocity varies according to the system
used. As each manufacturer recommends a range of speed
within which the instrument should be used (Table II), it is
advisable to follow these instructions closely. The higher the
speed, the better the cutting efficiency - however, this is
achieved at the expense of increasing the torsional stress on
the instruments. If the speed is incorrect, together with an
inappropriate torque, rotation can be discontinuous. This
Figure 5a: (Rake angles) Calculation of rake angles using a SEM of the decreases the efficacy of the instrument in removing debris
cross-section of a ProTaper instrument. The rake angle is the angle
which subsequently remains between the blades and can
between the cutting edge of the instrument and a plane perpendicular
to the working surface to which the instrument is applied. cause instrument separation.
Figure 5b: (Flute angles) Calculation of flute angles using a SEM of a
ProTaper instrument. The flute angle is the angle between the flute
Rotation and apical progression of the instrument must be
orientation and the long axis of the instrument. continuous. Forcing the instrument toward the apex should be

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avoided in situations such as calcified and narrow canals where

the cutting blades are heavily stressed, and progression to the
apex is difficult. The problem causing this should be
investigated. A push-pull motion should then be used instead,
pulling the instrument up and then reinserting it. Ideally, the
instrument should not touch the canal walls for more than 3
mm and should not rest in the same position for more than a
few seconds. The clinician should avoid bringing the
instrument to the same length more than once while trying to Figure 7: Upper molar before and after root canal treatment, insertion of a
progress to the apex. When obstacles are present in the canal fiber post and porcelain fused to metal restoration.

(ledges, zips, separated instruments, false paths, sharp curves),

it is advisable to reach the working length initially with
traditional stainless steel hand instruments prior to the use of
rotary Ni-Ti instruments.

Irrigation and lubrication

Ni-Ti instruments generally have a blade design which allows
them to carry debris more easily to the surface. However,
according to some scanning electron microscopy studies, these
Figure 8: Root canal treatment and restorative procedure on a second
files produce a thicker smear layer, particularly in the apical upper molar.
third of the root canal walls.41 It is therefore advisable to use a
hypochlorite do not diminish the number of rotations prior to
lubricant in the initial preparation stages, not only to reduce
the separation of these instruments via cyclic fatigue.44 It is very
the accumulation of the debris, but also to reduce friction and
difficult to quantify the amount of stress each instrument
torsional stress. Furthermore, even if using Ni-Ti files allows the
undergoes during its use. However, some authors agree that
clinician to reduce the amount of time spent on the
an instrument should not be used for more than ten canals in
preparation, the irrigant should be left to act inside the root
standard situations. This number is reduced to one in complex
canal for the required amount of time.
cases where calcified canals or sharp curves are present. It is
therefore very important to take note of how often the
Avoiding excessive pressure
instrument has been used and the type of root canal in which
The instrument should be inserted into the canal with a “push-
it was used.
pull” movement, and a light and gentle touch. Theoretically
In order to keep instrument separation to a minimum, the
progression to the apex should be achieved one millimeter at
root canal anatomy should be accurately evaluated before the
a time, applying a constant pressure and without forcing the
commencement of root canal treatment. It is always advisable
instruments.
to start the preparation of the root canal (negotiation and pre-
enlargement) using hand instruments, and only employ Ni-Ti
Using and not abusing the instrument
instruments for the final shaping of the root canal walls.
Although many clinical and research studies have been carried
Furthermore, before storing the instruments after sterilization,
out, they have not been able to give a definitive answer on the
the number of times the instrument was used should be
number of times an instrument may be re-used before its
recorded on the box so that this information is immediately
deterioration warrants its disposal (Figure 6). Some authors
available.
suggest it should be discarded after each use,42 while others
maintain that deterioration is caused not only by the number
Operator skills
of times it has been used, but is rather an accumulation of
Finally the skills and experience of the dentist are crucial
several factors such as the instrument design and the anatomy
factors in the correct use of rotary Ni-Ti instruments.45-47 Like
of the root canals.43 Sterilization has also been suggested as
any other instrument or technique, mastering the art of Ni-Ti
one of the possible causes of instrument separation. However,
rotary instrumentation requires time and practice. On the
a study demonstrated that dry heat and contact with sodium
acquisition of a new type of rotary Ni-Ti instrument, it is
imperative that clinicians test it on extracted teeth prior to
using it clinically (Figures 7,8).

Endodontic Irrigants
Figure 6: Deteriorated instrument. If used again, separation is likely to
occur. Cleaning and shaping of the root canal is the combined result

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of mechanical cleansing of the root canal walls, and the

Table III. Irrigants commonly used in endodontics
dissolution of debris, removal of endodontic smear layers and
sterilization of the instrumented canals.14,15 Complete removal Saline
of debris cannot be achieved by mechanical instrumentation
Sodium hypochlorite
alone. Irrigation is used as a “physical” flush that removes
Chlorhexidine digluconate
debris, and also serves as a bactericidal agent, tissue solvent,
Iodophors
and lubricant.48-56 Many authors are of the opinion that the
Hydrogen peroxide
mechanical action of flushing an endodontic irrigation solution
from the root canal results in a significant reduction of the Citric acid

bacterial flora inside the canal.49-51 Several studies have shown Phenolic compounds
that the inclusion of a chemical agent as a supplement to the Quaternary ammonium compounds
mechanical action makes the irrigant more effective in Alcohols
eliminating bacteria.48-56 The antibacterial effectiveness of
irrigants is evaluated using a sterile saline solution as the reducing the risk of instrument separation.
control. In an in vivo study on 40 teeth, Kuruvilla and Kamath • Low surface tension, to reach the apical delta and all of the
demonstrated that 0.9% saline solution reduced the CFU/ml areas which are not accessible to instrumentation.
(CFU - colony forming unit) by 25%, while chemical irrigants • No detrimental effect on subsequent filling of the root canal
are more than 60% effective.54 In an in vitro study on 30 case by endodontic filling materials and root canal sealers
mandibular premolars with pulpal pathology, Siqueira and co- • Possess substantivity by binding to root dentin to maintain its
workers found that using a saline solution as an irrigant bactericidal action
reduced the bacterial cells by 38.3% whereas 2.5% sodium • Be relatively innocuous for the patient and for the clinician.
hypochlorite was effective in reducing the bacterial flora by • Be easily acquired and have a low cost.
60%.55 Of the commonly used endodontic irrigants (Table III),
The efficacy of an endodontic irrigant also depends on its sodium hypochlorite has been the most thoroughly
capacity to reach un-instrumented areas. For this reason, investigated. Its most desirable characteristic is undoubtedly its
tensioactive substances have been included in the irrigant in wide spectrum anti-bacterial activity and anti-viral effect.
order to improve its penetration along the root canal walls. Direct contact with it eliminates bacteria, spores, fungi,
However, to facilitate the penetration of the irrigant, the root protozoa and viruses (including HIV, HSV-1, HSV-2, HBV and
canal walls must be properly instrumented. With the use of the HAV).48,55,59 It also has a solvent action on organic tissues, is
“crown-down” technique, early coronal flaring facilitates the easily acquired, has a low cost, and has a slight bleaching
penetration of the irrigant. Moreover, Ram demonstrated that effect on dentin. Unfortunately, it can have a potential
an irrigant can only reach the apex if the canal has been cytotoxic effect on the vital tissues, except for keratinized
enlarged to a dimension greater than ISO size 40.57 Ideally, an epithelia.59 It does not completely dissolve the smear layer, has
endodontic irrigant should have a potent bactericidal effect an unpleasant smell and taste, and can cause allergic
but exhibit minimal cytotoxicity on the periapical tissues. reactions.50,59 Household bleach, which is commercially
However, Spånberg et al. demonstrated, with in vivo and in available o the general public, contains 5.25% sodium
vitro studies, that no irrigant is able to combine all of these hypochlorite. The solution may be used clinically at this
characteristics.58 All antimicrobial agents have potential concentration or diluted with distilled water to a concentration
toxicity that could eliminate the potential advantages derived as low as 0.5%. However, it is still controversial whether the
from using these agents at higher concentrations. solution should be used in its diluted form, and whether it
should be used in combination with other irrigants.53,54
An ideal irrigant should have the following characteristics: Spånberg et al. found that 5.25% sodium hypochlorite is
• Bactericidal, to reduce the quantity of bacteria in an infected stronger than necessary and is toxic for the patient, and
canal system; suggested using it at 1% concentration. Conversely, other
• Solvent action, by means of proteolytic digestion and authors have demonstrated that diluting NaOCl diminishes the
dissolution of the necrotic tissues. antimicrobial properties and increases the time required to
• Ease of removal of dentinal debris, by maintaining them in destroy Enterococcus faecalis. 48,51,60-62 Others suggested the use
suspension. of 2.5-3% sodium hypochlorite as an endodontic irrigant.62,63
• Biocompatibility, in particular the irrigant should not be toxic or Mechanisms to increase the effectiveness of sodium
irritating to the periapical tissues should it flow out of the apex. hypochlorite include; increasing the temperature, applying
• Lubricating action, to facilitate the use of endodontic frequently, increasing contact time, using ultrasonic energy,
instruments, particularly in narrow canals, and consequently combining with chelating agents and other irrigants, adding

16 INTERNATIONAL DENTISTRY SA VOL. 9, NO. 1

tensioactive solutions and reducing pH (buffered solutions).
As sodium hypochlorite removes only the organic phase of
the smear layer, alternating the use of sodium hypochlorite
with irrigants that have the capacity to remove the inorganic
phase of the smear layer, is a well-accepted irrigation strategy
in clinical endodontics. To date, ethylenediamine tetraactetic
acid (EDTA) is commonly used in association with sodium
hypochlorite to remove endodontic smear layers that are
created during shaping of the root canals.64-66 Morphologic
studies have been extensively performed to evaluate the
efficacy of smear layer removal after endodontic
instrumentation and irrigation of the root canal.67,68 Recently, a
new chelating agent containing doxycycline hyclate, citric acid
and a tensioactive agent (BioPure MTAD, Dentsply Tulsa
Dental, Tulsa OK, USA) has been introduced for the
disinfection of root canals and removal of endodontic smear
layers.69 This irrigant is recommended to be used with 1.3%
sodium hypochlorite.

Root Canal Filling

Over the years, many materials and techniques have been
developed to fill prepared canals. Irrespective of the material
chosen for the root canal filling, proceeding to the obturation
step can only occur once the cleaning and shaping of the canal
have been completed. Theoretically, a cleaned and shaped
canal is not required to be filled for apical periodontitis to
heal.70 The objective of a root canal filling, irrespective of the
technique or material employed, is to generate a fluid tight
seal that allows the root canal to be retained in the same
aseptic conditions as it was in the cleaning and shaping stage.
Current literature supports the importance of a secondary
coronal seal to prevent subsequent leakage through filled root
canals.71 Different materials have been proposed for the
obturation of the root canal system. Despite a recent challenge
as a 150-year old material that represents the end of an era,
gutta-percha remains to be the most time-tested and reliable
root canal filling on the market, as it possesses most of the
characteristics of an ideal material.72-77
Gutta-percha is a trans-1,4-polyisoprene based polymer
derived from the juice extracts of Palaquium gutta trees. It is
easily sterilized, relatively inert and well tolerated by the soft
tissues, although overextension of this material in the periapex
should be avoided. Due to its thermoplastic nature, it adapts
well to the root canal walls with the use of root canal sealers
and once these materials harden, they are relatively stable
dimensionally. Although gutta-percha is insoluble in organic
fluids, it is easily removed when dissolved in a solvent such as
chloroform, eucalyptol, or essence of turpentine.
Dental gutta-percha is commercially available in standardized
and non-standardized points, pellets or as a component in core-
carrier systems. Only 20% of the endodontic composition is
gutta-percha with 60 - 75% being zinc oxide fillers. The
 CLINICAL

A frequent clinical question is: when should one complete

the obturation of the root canal? Should it be done at the end
of the cleaning and shaping stage, or postponed to a future
appointment? This is sometimes a complex decision and
depends on the following factors. Firstly, operative difficulties,
such as difficult anatomy, time constraints, complex cases.
Secondly, the presence of exudates, after the drying stage of
the root canal, obliges the dentist to postpone the obturation
stage. Finally, if the tooth is still sensitive, it is advisable to
Figure 9: examples of cold lateral compaction.
postpone the completion of the treatment.
remaining constituents are wax or resin to render the material The methods for the obturation of the root canal vary
more pliable and/or compactable, and metal salts such as according to the direction of the compaction (lateral or
barium sulphate to render it radiopaque. There is evidence of vertical) and/or the temperature of the gutta-percha (cold or
slight antibacterial activity from gutta-percha, although it is too warm). However clinicians tend to divide the procedures into
weak to be considered as an effective antimicrobial agent. two main fields: lateral compaction of cold gutta-percha and
Chemically, pure gutta-percha exists in two different vertical compaction of warm gutta-percha. All the other
crystalline forms (alpha and beta) that can be converted into methods are variations of the aforementioned procedures.
each other. Gutta-percha in the alpha phase has a fusion
temperature of about 70°C and horizontally aligned molecular Cold Lateral compaction
chains. The property gives it good flowing qualities when Lateral compaction of cold gutta-percha points (standardized
heated, but a certain rigidity at environmental temperatures. gutta-percha cones) with root canal sealers is the technique
Gutta-percha in the beta phase has a fusion temperature of that has been most commonly used by dentists. This technique
approximately 60°C and randomly aligned molecular chains includes placement of a sealer (that serves as a lining in the
which gives it less flowing qualities but more elasticity than the canal walls), followed by a primary point (previously measured).
a-gutta-percha making it more suitable for cold compaction This is then compacted laterally with the use of a spreader, in
techniques. Recent studies have shown that new generations order to make room for an additional point. The spreader is
of dental gutta-percha, often identified as a-gutta-percha, are then used again to compact laterally and other points are used
in reality all b-gutta-percha; these different properties depend to fill the root canal space. The final mass of points is detached
on a breakage of the polycarbon chains, leading to a decrease at the orifice of the canal with a hot instrument, and then a
in the molecular weight. vertical compaction is used with a large plugger to give final
From a practical point of view, as all new gutta-percha compaction of the whole gutta-percha. If well executed, the
compounds (except for points and Obtura) are high flow and result will be a solid canal obturation which will reflect the
adhesive gutta-percha, it is not necessary to assert a lot of shape of the prepared root canal. However several studies have
pressure to adapt these to the root canal walls. However, the shown that this cold method has certain shortcomings,
effect of heating on the volumetric change of gutta-percha is particularly in providing a fluid-proof seal of the apex.
most important to dentistry. These materials expand slightly Schilder described this technique as inefficient in that the
upon heating (which is desirable for an endodontic filling gutta-percha cones do not melt to form a homogenous mass,
material), giving the clinician an increased volume of material but are simply “stuck in a sea of cement”.15 Backing this
that may be compacted into a root canal cavity. Unfortunately observation are several studies which show that the contents
they also shrink on cooling, losing some of their adhesive of gutta-percha in fillings, carried out with the lateral
properties. It is therefore recommended to use small doses of technique, are inferior to those achieved with other methods.
an endodontic cement. Sakhale et al. have shown, however, that the cones adequately
fill the canal and cover the space with only a small quantity of
inter-filling cement (Figure 9).78

Warm Vertical compaction

At the end of the 60’s, Schilder introduced the concept of
obturating the space “three-dimensionally” with gutta-percha,
warmed in the canal and compacted vertically with pluggers.79
In his opinion, this is the perfect technique for sealing all the
“portals of exit” that would be filled with a maximum amount
of gutta-percha and a minimum amount of sealer. This
Figure 10: examples of warm vertical compaction.

18 INTERNATIONAL DENTISTRY SA VOL. 9, NO. 1

technique is based on a fundamental property of gutta-percha
- thermoplasticity.
The first step is the fitting of the master gutta-percha cone.
A conventional cone-shaped (non standardized) point is
chosen to reach slightly short of the radiographic terminus.
Radiography is used to evaluate the fitting. The clinical
interpretation of good cone-fitting is known as “tug-back”. A
small amount of cement is used. Then, using pre-fitted
pluggers, and a heat carrier (heat transfer instrument), the
gutta-percha is compacted, moving apically with the so-called
“wave of compaction” until the pluggers reach a 5 mm
distance from the radiographic terminus. Finally the back-
packing step completes the root canal filling.
Over the years, many other techniques have been proposed,
that are basically variations of warm gutta-percha compaction.
Examples are the Thermafil core carrier system, Endotec,
continuous “wave of condensation” by Buchanan (System B
and Obtura; Spartan, Fenton, MO, USA), thermo-mechanical
compaction by McSpadden. Among these, the most
commonly used is probably the System B technique first
introduced by Buchanan.80 It is derived from the Schilder
technique and is in effect a true evolution of the warm vertical
compaction technique of gutta-percha. The most notable
feature in the System B device is that the pluggers and heat-
carriers are combined in a single instrument (one single wave
of condensation until 5 mm vs multiple wave of condensation).
Back-packing can then be done with System B cutting cones,
or with Obtura (Figure 10).
Looking to the future, a number of quicker, less aggressive
and more reliable methods of cleaning, shaping and
obturating root canals can be anticipated. A more significant
development is the use of stem cells to repair pulp tissue,
currently under investigation by certain groups of researchers
While extensive further laboratory and clinical research is still
needed, encouraging results have already been obtained.81

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