DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

MAMATA DENTAL COLLEGE, KHAMMAM.

Seminar on

Success and failures in endodontics

By

Dr.Amulya

II Yr PG student
Contents

Introduction.

Definition.

Evaluation of success of endodontic treatment

Causes of endodontic failures

Factors affecting the success or failure of endodontic therapy.

Measures to be employed to improve success.

Treatment modalities.

Conclusion
Introduction

Current, relevant knowledge on the outcome of endodontic therapy is key to clinical decision
making, particularly when endodontic treatment is weighed against tooth extraction and
replacement

As the specific goal set out by the individual patient may either be healing/prevention of disease
(apical periodontitis) or just functional retention of the tooth,

Definition of Success: According to European Soc.Endodontology (1994 IEJ) Clinical symptoms

originating from an endodontically-induced apical periodontitis should neither persist nor
develop after RCT and the contours of the PDL space around the root should radiographically be
normal

for endodontic therapy, the definition of “success” has been ambiguous, with requirements
ranging from stringent (radiographic and clinical normalcy) to lenient (only clinical

The usual goal of endodontic therapy is to prevent or heal disease, apical periodontitis.
Accordingly, endodontic treatment outcomes should be defined in reference to healing and
disease as follows:

Healed: Both the clinical and radiographic presentations are normal

Outcome classified as “healed.” Pre-operative radiograph of a mandibular lateral

incisor with apical periodontitis and associated apical external resorption.
 Follow-up radiograph at one year; the radiolucency has completely resolved and
the tooth is asymptomatic, indicating it has healed.

(Figures 1 and 2).

Healing: Because healing is a dynamic process, reduced radiolucency combined with normal
clinical presentation can be interpreted as healing in progress (Figure 3).

Outcome classification as “healed” vs. “healing.” Immediate post-operative

radiograph of maxillary first and second premolars with apical periodontitis

Follow-up radiograph at one year; both teeth are asymptomatic. While the second

premolar is classified as healed the reduction of the radiolucency in the first premolar is
indicative of healing in progress . Regrettably, both the restorations are inadequate.

Disease: Radiolucency has emerged or persisted without change, even when the clinical
presentation is normal (Figure 4), or clinical signs or symptoms are present, even if the
radiographic presentation is normal
 Outcome classified as “disease.” Preoperative radiograph of a maxillary lateral
incisor with apical periodontitis.

Immediate post-operative radiograph.

Followup radiograph at one year; the tooth is asymptomatic but the radiolucency
has not been reduced, indicating persistence of the disease.

Endodontic success rates range from 7% to 95%. A possible reason for this wide discrepancy
may be related to the myriad of variables studied. This in turn, makes interpretation of the
results of the studies very difficult. Factors that may affect the results of a study and create
variances between studies include differences in:

criteria for success and failure;

radiographic interpretation;

recall periods; sample size;

endodontic techniques;

operator qualification;
complexity of the cases.

Historical Highlites aid in the success of endodontic therapy:

Hudson 1862 - Credited with performing some of the first NSRCT (obturated with gold) in US

Price 1901 - Discussed use of radiography in performing NSRCT and evaluating success-failure

Callahan 1914 - Introduced a technique of filling root canals with a rosin-gutta-percha material
as well as theorize on proper filling needs of a root canal.

Scientific basis for modern endodontics established by Davis (1922)

Hatton 1922 - advocated confinement of instrumentation to the inside of canal. And also
determined histologically, that repair was possible at the root apex

1943 the AAE was formed in Chicago

1963 the ADA recognized endodontics as a special area of dentistry.

Karl Koller introduced cocaine in 1884

Alfred Einhorn introduced Novocaine in 1905

Wilhelm Roentgen discovered x-rays and 1896 the first dental apparatus was built by Rollins

Hall patented (1847) gutta-percha as canal filling material (was named "Hall's Stopping").

Elmer Jasper in 1930 - the use of silver points.

The rubber dam was first used in 1862 and 20 years later the first set of retainers were born

Bowman and Allen in 1873 developed the rubber dam forceps

Coolidge 1919 Introduced NaOCl to endodontics

Nygard-Ostby 1957 Introduced EDTA to Endodontics

Hermann 1920 - introduced Ca(OH)2 as intracanal medicament for necrotic teeth

CAUSES OF ENDODONTIC FAILURES

LOCAL FACTORS SYSTEMIC FACTORS

- Infection - Nutritional deficiencies

- Incomplete debridement - Diabetes mellitus

- Excessive hemorrhage - Renal failure

- Over instrumentation - Blood dyscrasias

- Chemical irritants - Hormonal imbalance

- Iatrogenic errors - Autoimmune disorders

- Anatomic factors - Opportunistic infections

- Root fractures

- Traumatic occlusion

- Periodontal considerations

Etiology of endodontic failures :

Operator errors – 18.42%

Ledge Formation -12.6%

Separated instrument -1.9%

Access cavity perforations -3.85%

Case selection errors-18.56%

Root resorption -5%

Poor pdl support-9.7%

Extra radicular infections- 2%

Intraradicular infections -62.32%

Incomplete preparation -53.54%

Missed canals -9.83%

(JOE –vol 2 1no 7 july 1995)

EVALUATION OF ENDODONTIC THERAPY:( CDR James Y. M. Chau)

Endodontic success rates range from 7% to 95%. A possible reason for this wide
discrepancy may be related to the myriad of variables studied. This in turn, makes
interpretation of the results of the studies very difficult. Factors that may affect the
results of a study and create variances between studies include differences in: criteria for
success and failure; radiographic interpretation; recall periods; sample size; endodontic
techniques; operator qualification; and complexity of the cases. In this handout, we will
review the different methods and criteria used to evaluate endodontic success and failure,
and the various factors that may influence the outcome of endodontic therapy.

Methods of evaluation

Histologic

Clinical

Radiographic

Only clinical and radiographic evaluations are available to the clinician.Tissue for
histologic examination is generally taken only for research purposes. Clinical evaluations
should include all of the following: presence or absence of percussion or palpation
sensitivity, mobility, sinus tract, periodontal disease, infection or swelling, other
subjective symptoms, tooth function and vitality tests. More than one properly exposed
and processed radiographs should be obtained for the radiographic evaluation. Many
factors may influence the interpretation of radiographs. These include changes in
angulation; quality of the radiograph (type of film and processing used); lack of
radiographic changes; proximity of anatomical landmarks, and differences in
radiographic interpretations between observers. Agreement between independent
observers on the presence or absence of a periradicular area has been found to be less
than 50%. This disagreement even occurs with the same observer at subsequent
examinations (Goldman ).

To improve the reliability of radiographic interpretation, studies should evaluate a large

number of cases, use a few, calibrated observers, and take into account chance
agreement.

II. Criteria for success

A. Histologic

1. Absence of inflammation.

2. Normal tissue architecture.

3. No resorption is evident and previous areas of resorption demonstrate cemental

deposition

B. Clinical : Bender (1966)

1. Absence of pain and swelling.

2. Resolution of a sinus tract.

3. No loss of function.

4. No evidence of tissue destruction.

Gutmann (1992)

1. No tenderness to percussion or palpation.

2. Normal mobility.

3. No sinus tracts or integrated periodontal disease.

4. Normal tooth function.

 5. No signs of infection or swelling.

6. No evidence of subjective discomfort.

C. Radiographic

1. Normal to slightly thickened PDL space.

2. Elimination of a previous radiolucency.

3. Normal lamina dura in relation to adjacent teeth.

4. No evidence of root resorption.

5. Dense, three-dimensional obturation of the root canal space that extends to the
cementodentinal junction

Murphy (1991

Resolution of a lesion can occur as early as three months, or an average of 3.2 mm 2 per
month. 70% of lesions need more than twelve months to resolve.

Strindberg’s criteria : To judge the treatment failure.

Persistence of Clinical signs and/or symptoms (pain, swelling, draining sinus tract, …)

Development of draining sinus tract

Increased, unchanged, or an appearance of new periradicular reinfection. (Journal of Dentistry,

Tehran University of Medical Sciences, Tehran, Iran (2004; Vol. 1, No. 2)

WHEN should we assess the outcome?

6 months - initial indication of healing

1 - 3 years - more accurate assessment

4 years - generally considered the time required to accurately assess the outcome of the
endodontic treatment
 Periapical index given by Orstavik – based on these radiological observations one can assess
the treatment outcome after one year

The development of an apical radiolucency/post –endodontic periodontitis (low (6%) and the
majority (76%)) develop with in 1 year.

Complete healing of periapical lesion may occur within one year (51%) but typically most cases
(85%) will heal within 2 years

Signs of definite but incomplete healing is apparent with in 1 year (it may be as early as 4
months) in the majority cases (89%) that undergo complete healing

III. Criteria for failure

A. Histologic

1. Presence of moderate to severe inflammatory infiltrate.

2. Lack of osseous repair with concomitant resorption of surrounding bone.

3. Presence of zones of necrotic or foreign tissue remnants.

4. Presence of granulation tissue and possible epithelial proliferation

B. Clinical

1. Persistent subjective symptoms.

2. Persistent or recurrent sinus tract or swelling.

3. Discomfort to percussion or palpation.

4. Evidence of irreparable tooth fracture.

5. Excessive mobility or progressive periodontal breakdown.

6. Inability to function on the tooth

C. Radiographic

1. Increase in the size of the lesion.

2. No change in size of lesion.

3. Increased PDL space.

4. Lack of lamina dura.

5. Root resorption.

6. Visible, patent canal space that is unfilled or represent significant void in the
obturation of the canal.

7. Excessive overextension of the filling material with obvious voids in the apical third of
the canal.
IV. Factors affecting prognosis of success or failure

A. Crump (1979) suggests a mnemonic POOR PAST to help identify causes of failure
and to summarize items to consider during treatment planning and diagnosis.
Perforation Perio

Obturation Another tooth

Overextension Split tooth

Root canal missed Trauma

B. Anatomic factors

1. Curved canals.

2. Calcifications.
3. Accessory canals and apical bifurcations.

4. Fins, isthmuses, deltas.

5. Palatal grooves.

C. Pathologic factors

1. Periradicular lesion.

2. Periodontal involvement.

3. Traumatic occlusion.

D. Bacteriologic factors

E. Treatment factors

1. Operator-dental students, general dentists vs endodontists.

2. Different techniques.

3. Apical extent of canal preparation and obturation.

4. Coronal seal after completion of root canal treatment.

F. Procedural accidents

1. Ledges or perforations.

2. Separated instruments.

3. Vertical root fracture.

4. Extruded materials.

G. Host factors

1. Age

2. Sex
 3. Health

H. Single vs multiple appointments

V. Recall

A. Reasons for recall

1. Assess healing

a. Reconfirm initial diagnosis.

b. Rule out other causes such as a neoplasm.

2. Continue treatment plan.

B. Time period

1. 6 months, 12 months, 24 months.

2. Reit (1987) - One year and four years best.

VI. What do you tell the patient?

Success rates vary due to the different factors that may be involved. Under ideal
circumstances, success rates can be in the high 90's, while retreatment success rates will
be considerably lower.

A. Non surgical phase: 95% success rate for asymptomatic vital cases

<80% in teeth with a preexisting lesion

B. Retreatment
Nonsurgical retreatment offers some distinct advantages over surgery. First, it is
sometimes very easy to remove the root canal filling and improve the previous
instrumentation and obturation. Second, retreatment has a greater long-term success
rate than surgery. Third, retreatment may identify the etiology for failure and
overcome the obstacles encountered during the initial treatment. Finally, the
 retreatment will prepare the tooth for surgery and contribute to the ultimate success
of the case.
C. Surgical phase
Surgery should be performed and tissues submitted for biopsy in cases where there
is a doubt as to the origin of the pathosis. When endodontic retreatment cannot
provide access to the root canal system or the apical foramen, surgical endodontics
must be considered. Surgery may be preferable in cases where the removal of a
large post poses serious risk of root fracture. Severe ledges, transportation of the
foramen, and irretrievably extruded material would have a better prognosis if treated
by surgery.Allen (1989) reported Nonsurgical retreatment had a success rate of
72.7% Surgical treatment with apicoectomy alone had a 57.4% success rate.
Surgical treatment with retrograde filling had a 60.0% success rate.
D. When to retreat
1. Can retreatment be done?

2. Will retreatment result in a predictable outcome?

3. Can correction of failure be accomplished?

The different methods and criteria used to evaluate endodontic success and failure, and the
various factors that may influence the outcome of endodontic therapy

Methods of evaluation

Histologic

-Clinical

-Radiographic

Only clinical and radiographic evaluations are available to the clinician. Tissue for histologic
examination is generally taken only for research purposes.
Clinical evaluations should include all of the following: presence or absence of percussion or
palpation sensitivity, mobility, sinus tract, periodontal disease, infection or swelling, other
subjective symptoms, tooth function and vitality tests.

than one properly exposed and processed radiographs should be obtained for the radiographic
evaluation. Many factors may influence the interpretation of radiographs.These include changes
in angulation; quality of the radiograph (type of film and processing used); lack of radiographic
changes; proximity of anatomical landmarks, and differences in radiographic interpretations
between observers. Agreement between independent observers on the presence or absence of a
periradicular area has been found to be less than 50%. This disagreement even occurs with the
same observer at subsequent examinations (Goldman ).

The endodontic literature is replete with success and failure studies. Those of Strindberg Bender
and associates, Storms, and Heling and Tomshe are representative examples of some of the more
recent ones. All of the authors examined the success and failure percentages from various
aspects. Strindberg studied the overfilling-underfilling asp&, whereas Bender and Seltzer studied
the positive or negative culture aspect. Others compared silver cones and gutta-percha fillings.
Each group was meticulous in its approach and carefully reported its findings. However, most of
the results were based on the interpretation of radiographs, and upon this rather questionable
foundation the whole structure of each study was based. Anyone who has rendered endodontic
therapy knows that on many occasions the radiograph is misleading. Is there an area of
radiolucency? Where is the apex of the root? How large is the area? These and many other
problems trouble all of us each day; Bender and Seltzer have shown in their study of
radiographic diagnosis that, unless an area of bone destruction encroaches on the cortical plate, it
is usually not evident on a radiograph.
Measures to be employed to improve success
Endodontic Access Preparation: An Opening For Success - By Clifford J. Ruddle,
Endodontic performance is enhanced when clinicians thoughtfully view different horizontally-
angulated, pre-operative radiographic images, visualize minimally invasive, yet complete,
treatment, then use this mental picture to guide each procedural step.1 There is an old
expression…“Start with the end in mind”. Before initiating the access preparation, think,
visualize, and plan to more effectively execute a predictably successful result.
PRE-TREATMENT

Prior to endodontic treatment, an inter-disciplinary evaluation of pulpally involved teeth should

be performed to ensure that optimal health is both possible and attainable. At times, it is
advantageous to band and build up a tooth to facilitate subsequent endodontic procedures.
Seriously broken-down teeth should be evaluated for periodontal crown lengthening

figure 1a: The microscope (Carl Zeiss;

Thornwood, New York) provides magnification, and coaxial lighting,procedures.

2 Crown lengthening facilitates endodontic isolation and enables the restorative dentist to create
the ferrule effect and achieve a healthy biological width.3 When indicated, crown lengthening
serves to improve all phases of inter-disciplinary treatment.4 Endodontically, pre-treatment
procedures elevate the potential for success by improving the predictability of each ensuing step.
Another endodontic pretreatment consideration is whether to access through or remove an
existing prosthetic restoration. Clinicians typically access the pulp chamber through a restoration
if it is judged to be well fitting, functionally designed, and esthetically pleasing. If the restoration
fails to meet this criterion, then it is typically sacrificed.
figure 1b: A photo demonstrates isolation and straightline access to the orifices.

ISOLATION

Excellent vision in conjunction with complete isolation promotes predictably safe and successful
endodontic treatment (Figure 1). Isolation accomplishes soft tissue retraction, protects the oral
pharynx and prevents salivary leakage. Fortunately, the vast majority of all teeth can be easily
and quickly isolated for endodontic treatment in a one step procedure. To accomplish this, an
appropriately sized hole is punched at a pre-determined position through a rubber dam. The
rubber dam may be stretched onto a nonmetallic, polymer frame and then a pre-selected clamp is
mounted onto the rubber dam. A non-metallic frame allows working films to be taken without
concern for inadvertent metal superimposition over the region to be viewed. The rubber dam
forceps guide the jaws of the clamp over the crown and are released so they securely engage the
tooth and do not impinge on soft tissue. An explorer may be used to lift the rubber dam off the
facial and lingual wings of the clamp. Dental floss may be used to work the rubber dam  between
the contact points and carry it gingivally so as to establish a dry working field. On occasion, even
when the dam has been well placed, there may be a nuisance contamination leak. As such,
caulking materials, such as OraSeal (Ultradent; South Jordan, Utah), are available to secure a
fluid-tight treatment environment. Infrequently but on occasion, it may be useful to initiate an
endodontic access cavity without a rubber dam to improve orientation. This may be considered
when encountering heavily restored teeth, significant calcification within the pulp chamber, or
when the clinical crown is not aligned with the underlying root.

ACCESS OBJECTIVES
The access preparation is an essential element for successful endodontics.  Preparing the
endodontic access cavity is a critical step in a series of procedures that potentially leads to the
three-dimensional obturation of the root canal system. Access cavities should be cut so the pulpal
roof, including all overlying dentin, is removed. The size of the access cavity is primarily
influenced by the anatomical position of the orifice(s). The axial walls are extended laterally
such that the orifice(s) is just within this outline form. When required, access preparations are
further expanded to eliminate any other restrictive interference that could compromise any aspect
of ensuing treatment.   Endodontic access cavities should parallel the principle of restorative
dentistry.

ACCESS TECHNIQUES

Having knowledge regarding the external and internal anatomy of human teeth is fundamental
and serves to prepare the clinician to more successfully treat endodontically involved teeth.11
From experience, it is best to initially prepare the size of

figure 3: Smoothly prepared and divergent axial walls, and that the preflared orifices are just
within this outline formthe access window about 80% of what the final outline form will
ultimately expand and become. Initially preparing a close to optimal opening improves vision as
the preparation moves deeper into the tooth. Once the pulpal roof has been removed, then the
position of the orifice(s) may be identified on the pulpal floor. With anatomical orientation, the
position of the axial walls may be adjusted, and the access preparation fully expanded and
finished accordingly.12

Depending on the material comprising the clinical crown, the appropriate bur is selected to
initiate treatment . Subsequent restorative materials, at times, require a different bur to improve
efficiency while reducing unwanted vibration (Figure 4b). Like a painter painting a canvas, the
clinician moves the handpiece utilizing a light brushing motion. The bur is swept mesial to distal
and facial to lingual, as the access preparation is extended toward the pulp chamber. A light
brushing motion with a new sharp bur reduces friction and related heat, and affords more control
when progressively carrying the access preparation pulpally. From a patient’s perspective, brush
cutting versus drilling dentin promotes peaceful endodontics, especially when accessing pulpitic
teeth. The access cavity is continued until the pulpal roof is penetrated. Upon entry, an
appropriately sized surgical length carbide round bur is placed inside the chamber and is
repetitively dragged occlusally until the entire pulpal roof has been removed (Figure 4c).

After completely de-roofing the pulp chamber and identifying the orifice(s), a surgical length

tapered diamond (Brasseler; figure 4a: A round

bur diamond in conjunction with a water coolant is utilized to initiate access through a
porcelain fused to metal crown figure 4b: This
transmetal bur has a saw-tooth blade configuration which may be used to efficiently cut a

window through metal restoratives figure 4c: A

surgical length carbide round bur provides a line-of-site for safely and progressively extending
the access preparation figure 4d: Continuous
vision and may be utilized to smooth the axial walls and finish the access preparationSavannah,
Georgia) may be used to flare, flatten, and finish the axial walls (Figure 4d).

The axial walls are tapered so they diverge from the pulpal floor towards the occlusal surface.
Smooth, flat, and tapered axial walls improve the refraction of light and, hence, vision. Tapered
diamonds serve to create straightline access to each orifice. When radicular space is available, an
explorer may be placed into an orifice to determine the entry angle of any given canal relative to
the long axis of the tooth. When radicular space is more restrictive, a small-sized hand file can
generally be inserted into the coronal-most aspect of a canal to judge the entry angle of the canal
relative to the long axis of the tooth. Placing a small-sized hand file will disclose the existence of
any irregularities or interferences that could pose a nuisance during subsequent cleaning and
shaping procedures.

In the author’s opinion, Gates Glidden (GG) burs, sizes 1-4 (Dentsply Maillefer; Tulsa,
Oklahoma), are the rotary cutting burs of choice to preflare the orifice(s), intentionally relocate
the coronal aspect of a canal away from external root concavities, and remove internal triangles
of dentin. This procedure establishes a reproducible opening to any canal, facilitating subsequent
instrumentation. Research has shown that a single X-Gates, comprised of GG sizes 1-4,
(Dentsply Maillefer; Ballaigues, Switzerland) or a few GGs can be safely used with a “brushing
action” and at a “low speed” of about 750 rpm to selectively cut dentin and produce a final
preparation that is centered within the circumferential dimensions of the root (Figure 5). The
size of figure 5a: Mandibular molar demonstrates
the distal root has been removed and that the mesial root has a furcal side concavity

figure 5b: Orifices have been intentionally

relocated away from furcal danger. figure 5c: This
μCT image shows before (green) and after (red) shaping proceduresthe GG initially selected is
dependent on the size of the orifice. As a guideline, select the largest GG that can passively fit
into any given orifice, and then proceed from the big to smaller sizes. Excluding teeth that
exhibit calcification within the pulp chamber, most orifices can typically accommodate a GG-4.
The selected and non-rotating GG is placed just within the orifice and, upon activation, the head
of the handpiece is moved in a circular motion above the GG/orifice pivot point. The belly of the
GG serves to flare and blend the orifice into the adjacent axial wall. A preflared orifice produces
a smooth, flowing funnel to easily facilitate the subsequent placement of small-sized hand files.
In smaller diameter canals, typically associated with the buccal roots of maxillary molars or the
mesial roots of mandibular molars, limit the use of the GG-4 so that its flame-shaped active
portion is no more than one bud depth below the orifice. In non-calcified teeth, GGs are
strategically used starting with the bigger and sequentially proceeding through the smaller sizes.
As such, if the orifice was initially preflared with a GG-4, then proceed to a GG-3. Since the
GG-3 is smaller than the GG-4, its loose fit will enable the clinician to use its belly to selectively
brush and cut dentin on the outstroke. The goal of this specific procedure is to improve radicular
access by intentionally relocating the coronal most aspect of the canal away from external root
concavities and toward the greatest bulk of dentin. Fortuitously, utilizing GGs with a brushing
action allows the clinician to more fully address root canal cross-sections that are irregularly-
shaped anatomically. Following the use of the GG-3, sequentially proceed to the smaller sized
GG-2, then to the GG-1. It is perfectly normal to break the shafts of these smaller sized GGs
when they are correctly and deliberately used like a brush. Breaking the shaft of a GG is
clinically a non-issue, as the active portion is completely loose in the canal during use.
Preflaring and intentionally relocating the coronal most aspect of the canal is a strategic decision
that will influence all subsequent steps of treatment. As a single example, the coronal aspects of
mesial canals of mandibular molars are rarely anatomically centered within a root (Figure 6).
Using NiTi rotary files to uniformly expand the coronal portion of a canal

figure 6: Orifices are generally positioned

anatomically closer toward the furcal side of the rootoutward from its original anatomical
position results in preparations that tend to move toward furcal danger. Preparations which are
not centered within any given root are predisposed to root thinning, radicular fractures, and strip
perforations.5,13

Preflaring the coronal one-third of a canal is especially important in the clinical situation where
the handle of the initially placed file is not aligned with the long axis of a tooth. Clinicians can
observe the handle position of the smaller sized instruments to see if they are upright and
paralleling the long axis of the tooth or skewed off-axis. When the handle of the file is upright, or
“ON” the long axis of the tooth then the clinician is able to confirm both coronal and radicular
straightline access. However, when the handle of the initial instrument is “OFF” the long axis of
the tooth, then recognize the triangle of dentin must be removed to upright the file handle and
position it ON axis (Figure figure 7a: The
handle of a small-sized hand file is frequently “OFF” axis in furcated teeth due to an internal

triangle of dentin. figure 7b: The shaft of a GG is

arced so the bud will cut and intentionally move the coronal most aspect of a canal away from
furcal danger7).7

Scouter files confirm the presence or absence of straightline coronal and radicular access.
Complete straightline endodontic access simplifies all subsequent instrumentation procedures
while virtually eliminating many cleaning and shaping frustrations. 5 Following the use of GGs,
the access cavity is almost routinely adjusted and subtly refined with a surgical length tapered
diamond to fulfill the mechanical objectives for straightline access and to promote all ensuing
treatment steps. The access preparation should be thought of as a progressive procedure that
frequently requires adjustment during canal preparation procedures.
ACCESS REFINEMENT PROCEDURES

The challenge of every dentist initiating endodontic treatment is to safely prepare the access
cavity and to definitively identify the orifice(s). Today, this procedure can be more predictably
performed due to better vision, advancements in ultrasonic instrument designs, and improved
clinical techniquees. Importantly, ultrasonically driven procedures remove the bulky head of a
traditional handpiece, providing an unsurpassed line-of-sight into the operating field.
Specifically, the new SINE ultrasonic instruments (Advanced Endodontics; Santa Barbara, CA),
provide an important breakthrough for access refinement procedures

figure 8a: The SINE ultrasonic instruments

 figure 8b: There are nearly 3 times more
diamond particles per unit area as compared to other competitive lines(Figure 8a). This 6-
instrument set is available in 18 mm lengths, offers unique tip configurations, and has a contra-
angled design for better access. Additionally, the SINE ultrasonic instruments have water ports,
as well as a unique and corrosion-resistant double composite diamond coating. Remarkably, this
instrument line has nearly 3x more diamond particles per unit area than other popular tips on the
market today (Figure 8b). A denser coating equates to a safer and more efficient cutting action.
The SINE ultrasonic instruments are strategically designed to remove stones, trough for hidden
orifices, chase calcified canals, refine and finish axial walls and line angles, eliminate triangles
of dentin, flare orifices, cut-off the coronal aspect of a carrier-based obturator, and clean the pulp
chamber post-treatment in preparation for restorative dentistry

The specific SINE instrument chosen is based on the tip configuration required to effectively
perform any given procedure. The SINE tips should be used with a light brush-cutting motion at
the lowest power setting that will efficiently accomplish the clinical task. The SINE ultrasonic
instruments have been designed and tuned to work optimally on the new piezoelectricultrasonic
generators that more safely regulate tip movement. The P5 (Dentsply Tulsa Dental Specialties;
Tulsa, Oklahoma), P5 Newtron (Acteon Group; Merignac, France), or NSK (Brasseler;
Savannah, Georgia) represent state-of-the-art A SINE instrument used to track and explore
grooves, trough for hard-to-find orifices, and uncover hidden canals

De-roofing dentin, flaring and relocating an orifice away from furcal danger, smoothly blending
the orifice into the line angle A SINE instrument eliminating a pulp stone and cleaning the pulp
chamber post treatmentgenerators that provide the technology to optimize ultrasonic
instrumentation procedures. To avoid thermal injury, when performing certain ultrasonic
procedures requiring higher energy levels conducted over longer intervals of time, a water mist
should be used to provide a coolant.

Conclusion:

Endodontic treatment must be evaluated over a sufficient period of time to determine

success or failure. When evaluating for success or failure, the clinician must have
firm clinical and radiographic criteria that he or she will use consistently. Failure can be
avoided by careful diagnosis, proper case selection, and precise treatment.
However, if a case should fail, all the factors that can influence the treatment outcome
must be considered. Proper retreatment planning must then be formulated with the goal
of maximizing the success of the retreatment. Both nonsurgical retreatment and surgery
should be included as possible treatment options.

References:

• Path ways pulp- cohen

• Text book of endodontology- ingle 5th and 6th edition

• Problem solving in endodontics – Gutmann

• IEJ (1998)

• JOE -1991-vol 17 no 7

• JOE 1995 vol 21 no 10

• DCNA 2004

• J Endod 2006;32:687–91

• JOE — Volume 36, Number 5, May 2010

• (Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2004;

Vol. 1, No. 2)