SHORTCUTS IN

ENDODONTICS

DR. YASSIN

‫دعواتكم بالتوفيق والنجاح‬

FDI numbering system: left number (quadrant number) + right number (number of tooth from 1 to 8)

Left Right
Upper 2 1
Lower 3 4

Examples: 46 = lower right first molar, 12 = upper right lateral, 35 = lower left first premolar.

Types of nerve fibers

1. A-ALPHA (‫)األسرع‬ Myelinated Large Fast sharp well localized
2. A-BETA pain
3. A-DELTA
4. C-FIBERS (‫)األقل سرعة‬ Unmyelinated small Slow dull / throbbing
pain / poor localized

 Nb. when you use the EPT the A fibers get stimulated at first then as the intensity increases c- fibers
get stimulated as well.
 Nb. in electrical / thermal pulp testing → A- delta fibers conduct the pain [sharp and well localized]
but in case of inflammation C – fibers are activated [not very well localized pain].
 Nb. Dentinal pain → A-delta fibers / stimulated by cold as air water spray
 Nb. Pulp pain → C fibers / stimulated by heat

Functions of the pulp:

1- Formation of the dentine.
2- Maintain tooth fluid movement.
3- Sensation.
4- Proprioception.
5- Defense [by blood supply forming reparative and secondary dentine].

 Nb. Pulp has minimal collateral supply which reduces its capacity for repair.
 Nb. Pulp develops from the ectomesenchyme cells of the dental papilla → the dental papilla
changes into the pulp.
 Nb. Intracanal pressure (intra-pulpal pressure) is 10mm/Hg.

Innervation of pulp is both simple and complex

 Simple – only free nerve endings and so lacks proprioception.

 Complex – innervation of odontoblastic process which produces high level of sensitivity to
thermal and chemical change.

 Nb. Caries - Most common cause of pulpal disease is bacterial contamination from caries
percolation around restorations.
 Nb. chronic trauma = bruxism.
 Q: can radiation cause pulpal disease? Radiation affects the pulpal blood supply → pulpal necrosis,
radiation also affects the salivary glands leading to hyposalivation → caries and pulpal disease.
  Q: how can caries cause pulpal inflammation? PMN infiltrate the pulp causing liquefactive necrosis
that spreads throughout the pulp.
 Nb. Pulpal infections are polymicrobial but anaerobes dominate (enterococci, bacteroides,
actinomyces, Spirochetes, Fusobacteria, e.faecalis).
 Nb. Fusobacteria – associated with severe pain, swelling, flare ups.
 Nb. e.faecalis is mostly present in re infection cases (retreatment cases) – most resistant bacterial
species.
 Nb. Most common bacteria associated with endo failure = e.faecalis [can survive at low PH and
high temp and withstand starvation + forms biofilms inside canals]
 Nb. Viruses – only in non – inflamed pulps of HIV / herpes pts.

Complications of untreated Pulpitis:

• Upper teeth → sinusitis → meningitis / brain abscess / orbital cellulitis and cavernous sinus
thrombosis.
• Lower teeth → ludwig’s angina / parapharyngeal abscess / mediastinitis / pericarditis /emphysema.

# The main objective of endodontic treatment = prevention or elimination of apical periodontitis.

• Colonization = establishment of microorganisms in a host.

• Infection= when bacteria damage the host and produce signs and symptoms.
• Pathogenicity = the ability of a microorganism to cause a disease.
• virulence = the degree of pathogenicity under certain circumstances.

 Nb. when a PA granuloma forms → it prevents the spread of infection to the surrounding tissue [a
granuloma is the place where bacteria is killed].
 Nb. Pulp sensibility tests - reproduce the pt’s symptoms (you need at least 2 signs and symptoms to
confirm a disease).
 Nb. You always test the suspicious tooth LAST – do the test on an adjacent tooth + contralateral
tooth and a tooth from the opposing arch.
Endo-Diagnosis methods
1. Electrical pulp test [EPT]
• Sensory test not vitality test.
• Act on (A-DELTA myelinated) fibers.
• Gives no indication about vascular blood supply.
• Sensibility test (only indicate nerve response not blood supply).
• Make sure the field is dry and apply conductive paste [ toothpaste or prophy paste] – apply EPT on
the buccal surface of the tooth.
• If the tooth is crowned → apply EPT on the margin of the crown (bridging technique).
• EPT not very reliable in pediatric patient because late formation of A delta fibers.
• EPT reaches a high # and the pt doesn’t feel anything → -ve response.
• False Negative = ‫الجهاز مطلع النتيجة إن السن ميت بس بالحقيقة هوعايش‬
• False Positive = ‫الجهاز مطلع النتيجة إن السن عايش بس بالحقيقة هو ميت‬
List of conditions showing false negative response:
 Recently traumatized teeth
 Recently erupted teeth with immature apex - incomplete root formation
 Teeth with extensive restoration and pulp protecting base
 Patients under LA or sedatives
 Recent orthodontic treatment
 Pulp stones (calcific metamorphosis – sclerosed canal)
 High amounts of reparative dentin in the tooth
 Patient heavily pre-medicated with analgesics, alcohol, tranquilizers
 Patient with psychotic disorders
 Inadequate contact with the stimulus
 Regressive neural changes in elderly patients (high amount of sclerotic dentin)
 The test is subjective (Not objective)

List of conditions showing false positive response:

 Anxious patient
 Pulp liquification necrosis (Multi rooted teeth)
 Contact with metal restoration
 Contact with gingiva or periodontium
 Stimulation of nerve fibers in the periodontium or adjacent tooth
 Inadequately dried tooth
 Vital tissue still presents in a partially necrotic canal
 Vital tissue still presents in multi rooted teeth
 Moist gangrenous pulp, which requires maximum current to elicit the response
 Presence of partially necrotic pulp in one of root canals in multirooted teeth
 C- fibers might still be present in the pulp [more resistant to necrosis]
 Cell bodies of neurons are located in ganglia outside the pulp
 2. Heat testing [only used if the CC is pain on hot food / drink] – you can use:
A. Heated Gutta percha / hot compound stick.
B. Dry rubber prophylaxis cup.
C. Hot water under rubber dam isolation [ best for testing full coverage restorations].

 NB. Apply a lubricant [petroleum gel] onto the tooth surface to prevent hot material from sticking -
then place the heated GP or hot compound stick on the buccal surface.

3. Cold testing [most common in endo diagnosis / used when the CC is pain to cold] – you can use:

# Cold testing / stimulate Type A delta fibers in the pulpal tissue, which elicit a short, sharp pain.
Material Note Degree in Celsius
Ice sticks (pencil of ice) Rarely used because cold water 0° Celsius
will leak into the gingiva and
cause a false positive response
Ethyl chloride spray Not cold enough like endo ice, no -12.3° Celsius
longer used
*Endo ice (endo frost) Better to use if present in -26.6° Celsius
or choices, colder than normal ice
(1,1,1,2 tetrafluoroethene) or ethyl chloride
dichlorodifluoromethane -30°
Carbon dioxide snow (CO2 – dry Extremely cold and can cause -78.5° Celsius
ice stick – commercially known infraction lines in the enamel or
as Odontotest) pulpal damage ☹

 NB. Cold test done at middle third of the facial surface for 5 sec, tooth surface must be dried first.
 NB. in case you need to repeat the cold test – wait for 5 mins.
 NB. Electrical and thermal pulp tests are called sensibility tests because they only indicate nerve
response not blood supply.
 Nb. Pulp vitality tests: indicate if the pulp has blood flow or not – more accurate than sensibility
tests [pulp oximetry, laser doppler flowmetry].

Pulp oximetry laser doppler flowmetry

• Non invasive • Able to assess blood flow within the
• Measures oxygen saturation of blood dental pulp directly
• Sensor is modified to be placed over the
tooth
• detection of a pulse.

 Nb. oxygen saturation values from the teeth are lower than the readings from the patient’s finger.

4. Cavity test (commonly indicated in cases of large restoration as amalgam):

- Drilling the tooth without LA to ensure a negative response to cold / hot test [specially when you
can’t notice a direct reason for necrosis].
- Used only if all the other tests an inconclusive.
Other tests that should be done during endo diagnosis:

1. Percussion test:
• when the inflammation spreads from the pulp to the PDL → the ability to localize the pain
increases [because the PDL contains proprioceptive fibers – there are no proprioceptive fibers
in pulp].
• Tapping on incisal or occlusal surface by [digital pressure, end of a hand instrument, tooth sloth
or a cotton swab] → Tenderness to percussion indicates periapical involvement.
• Always do percussion test first with your finger then with the handle of an instrument.

To detect cracks or fractures:

 Fiber optic transillumination can be used to detect cracks [the piece closer to the light will appear
brighter].
 dye staining: dye is applied inside the access cavity and then re-examined after one week.
 Radiolucent lesion associated with a vital tooth is NOT FROM ENDODONTIC ORIGIN.
 Tooth slooth allows the application of forces on individual cusps → very useful to detect fractured
teeth.
 Ask the pt to bite down deeply and slowly then open very quickly- If the pain occurs on
releasing → cracked tooth.
 To check for cracked tooth:
- Anterior tooth → transillumination.
- Posterior tooth → bite test.

• other causes of + ve percussion test:

1. Traumatic occlusion / trauma injury.
2. High restoration.
3. Cracked tooth or vertical root fracture.
4. Maxillary sinusitis.
5. Periodontal abscess.

2. Palpation test: when inflammation spreads beyond cortical bone → swelling can be detected by
digital palpation.

3. Mobility: done in buccolingual direction using index finger + end of mirror or ends of two mirrors.
Grade 1 Crown moves up to 1 mm in horizontal direction.
Grade 2 Crown moves more than 1 mm in horizontal direction.
Grade 3 Crown moves horizontally and vertically in any direction [easily displaced or depressible in the
socket – apicocoronal direction].
 4. Periodontal probing: around the entire circumference of the tooth to detect any pockets and bone
loss that might not be showing on x-ray (walk probing).

• Causes of isolated deep pockets:

1. Periodontal disease.
2. PA pathology draining through the periodontium.
3. Developmental defect like Vertical grooves.
4. Vertical root fracture*** => extraction.
5. External root resorption***.

NB.
- Sinus tract tracing is done using GP size 25.
- pulp necrosis has “hanging drop appearance” radiographically beginning on the lateral
surface of the root then extending apically. This lesion does not change location when angles
radiographs are taken.
- “ hanging drop appearance ” radiographically / deep pocket around one root at specific
aspect may be indicate vertical root fracture.
 Pulp diagnosis
NORMAL SYMPTOMS: • No treatment needed
• Asymptomatic.

PULP TESTS:
• Moderate response to electric pulp test [EPT] – response subsides upon
removal of stimulus.
• Sharp response to cold test but disappears upon removal of stimulus.

RADIOGRAPHS:
• Intact lamina dura, no resorption, no calcification or pulp abnormality.
REVERSIBLE SYMPTOMS: • Remove caries
PULPITIS • Sharp pain that stops upon the removal of stimulus - Stimulus might be • Adjust occlusion
[hot, cold, sweet]. • Apply appropriate base under the
• Pain can only be localized with cold stimulus. restoration

History:
• recent dental tx, cervical erosion / abrasion.

PULP TESTS:
• EPT and Heat test = normal.
• Cold test = exaggerated response that diminishes with the removal of
stimulus.

Percussion
• no pain.

RADIOGRAPHS:
• Caries or a restoration without an underlying base.
• Normal PA and PDL width.
IRREVERSIBLE SYMPTOMS:
• Pulpotomy or pulpectomy
PULPITTIS • Spontaneous intense pain – pain does not subside upon removal of
stimulus.
• Pain at night.
• Pain localization with hot stimulus.
• Referred pain is seen.

History:
• deep caries, trauma, large restoration.

PULP TESTS:
• EPT = elevated.
• Heat test = acute pain.
• Cold test = exaggerated response that lingers for around 30 sec (even
after removal of the stimulus).

Percussion
• if PDL is involved → Tenderness to percussion.

RADIOGRAPHS:
• Caries, defective restoration, might have PDL widening.
NECROTIC Symptoms:
• RCT
PULP • Dry necrosis [no tissue element in the pulp space].
• Liquefactive necrosis [pulp tissue but without vascular element] – more
likely to cause symptoms and less likely to cause PA pathosis.

Pulp tests:
• EPT / cold test / heat test = no response.

Radiograph:
• Large caries, large restoration, PDL widening an PA radiolucency might
be present.
 Peri apical diagnosis
APICAL A. Acute (Symptomatic) Symptomatic:
- Remove the cause
PERIODONTITIS • Tenderness to percussion and pain on chewing
- Vital tooth → might need
• PDL within normal limits – can occur around vital and non-vital occlusal adjustment
teeth
Causes: Non vital tooth → RCT
1- Mechanical or chemical irritation from endo treatment Asymptomatic: → RCT
2- Hyper occlusion [ vital pulp]
3- Inflammatory mediators from inflamed pulp
4- Microbial toxins from necrotic pulp
In case of granuloma & radicular cyst, you
always do RCT first if it heals → it was a
B. chronic (Asymptomatic)
granuloma if not it is a cyst
• Only with non-vital teeth – no pain → surgical removal is indicated
• Radiograph: wide PDL or a radiolucency
• Asymptomatic apical periodontitis has 2 histological variants:

A. Peri apical granuloma: Chronically inflamed granulation

tissue at the apex of the tooth. The epithelium in radicular
cysts comes from epithelial cell rest of malassez

Symptoms:
- Asymptomatic [ discovered on routine radiographs]
- No TTP/ No mobility
- No response to EPT / thermal test

Radiograph:
- Widening of the PDL near the apex
- Well circumscribed or poorly defined lesion
- Some root resorption

Management:
- Restorable tooth → RCT [to eliminate
microorganisms in PA region]
- Non restorable tooth → extraction + curettage

B. Radicular cyst: Extension of the inflammation from the

pulp to the PDL

Symptoms:
- Asymptomatic [discovered on routine radiographs]
- Involved tooth might be non-vital or has a failed RCT

Radiograph:
- Well defined radiolucency surrounded by a narrow radio
opaque margin

Management:
1. RCT
2. Extraction
3. Marsupialization [for large cysts]
4. Apicectomy
5. Enucleation [for small cysts]

ACUTE APICAL Localized collection of pus in the alveolar bone at the apex of the 1. Drainage by:
ABSCESS tooth – caused by bacterial invasion into the periapical tissue A. RCT
following pulp necrosis B. Incision and drainage
C. If non restorable tooth or for financial
Symptoms: reasons / → extraction
• Rapid onset spontaneous pain 2.Relieve the tooth out of occlusion
3. NSAIDs to control pain
• pain to percussion and palpation
• fluctuant swelling
• systemic manifestations Nb. if there are systemic
complications → fever, lymphadenopathy,
cellulitis → give ABX
Diagnosis:
1- Clinical examination [TTP]
2- Pulp tests → Pulp is necrotic

Nb. phoenix abscess = acute exacerbation

of a chronic lesion
 Radiograph:
• Might show slightly thickened PDL chronic apical abscess:
- Asymptomatic
- necrotic pulp
Nb.
- formation of a sinus tract [tracing of sinus tracts is
done using size 25 gutta percha]
- sinus tract can drain to [facial skin, gingival sulcus,
oral mucosa]
- chronic periapical abscess = sinus tract opening
CONDENSING • A type of chronic apical periodontitis to a long-standing irritant
OSTEITITS [tooth can be vital or non- vital]
• Asymptomatic Radiograph shows increased PA radiopacity

NB.
• Most diagnostic symptom of symptomatic apical periodontitis = pain on chewing / tenderness to
percussion.
• Most diagnostic symptom of radicular cyst = well defined radiolucency at the apex.
• Most diagnostic symptom of acute apical abscess = swelling.
• Most diagnostic symptom of chronic abscess = sinus tract.
• Apical abscess → pulp is non vital.
• Acute apical abscess is distinguished from lateral periodontal abscess by pulp vitality test.
• Sharp sound → normal.
• Dull sound → might indicate PA pathology.

Acute apical abscess Periodontal abscess

• Pulsating, pounding continuous pain, easy • Dull pain, localized by probing
to localize • No pain at night
• Continuous pain at night • Tooth is not mobile
• Tooth is mobile • EPT/ COLD/ HEAT TEST = normal
• EPT/ COLD/ HEAT TEST = no response • Occasional swelling
• Swelling is present • Radiograph = foreign body / vertical bone
• Radiograph = caries or defective restoration loss
• TX= drainage + ABX [ if needed] + analgesics • TX = remove foreign body + SRP

Management of abscess:
1. Identify and remove the cause.
2. RCT or if large do incision and drainage [I & D].
3. In case of fever, malaise, trismus, progressive swelling → ABX.
Nb. In case of deep infections spreads into submandibular space like Ludwig’s angina → air way is
compromised the pt must be referred to a hospital to maintain airway and provide drainage.
NB. ABX only given for pt’s with systemic manifestations [fever, malaise, cellulitis, lymphadenitis].

Q: what decides what type of pulpal protection is needed? the remaining dentine thickness.

Cavity sealers: [cavity varnish / bonding agents]

• seal the DT to protect the pulp from chemical / bacterial irritation.
• Usually used under amalgam to avoid amalgam tatto.
• cavity varnish should not be used under composite / GIC [interferes with adhesion & polymerization].

Cavity Liners: few microns → physical, bacterial, chemical protection + some therapeutic effect like
Fluoride release and antibacterial properties [CaOH2 & GIC].

Cavity bases: few mm thick → thermal and mechanical protection + replace missing dentine or block
out undercuts. [Zinc phosphate, zinc polycarboxylate, GIC].

Pulp capping: procedures done when there is a near exposure or an actual pulp exposure - to maintain
pulp vitality and limit the need for further endodontic treatments.

Nb. pulp capping is contraindicated if the tooth will have extensive restoration, pathological exposure.
Nb. Mechanical exposure (accidental) occurs during the cleaning of the affected dentine. In cases of carious
(pathological) exposure, the bacteria have already reached the pulp.
Nb. Direct pulp capping: Unsuccessful with pediatric patient.

Requirements of pulp capping:

a. Asymptomatic tooth.
b. Hemorrhage can be easily controlled.
c. Pulp is not inflamed or has signs of reversible pulpitis.
d. No PA pathology [ no radiolucency or TTP].

 Nb. Ca(OH)2 is the gold standard for pulp capping but it has poor bonding to dentine , high
material resorption and mechanical instability.
 Nb. biodentine = similar action compared to calcium hydroxide but without the drawbacks.
 Nb. Biodentine can be used for: direct / indirect pulp capping – pulpotomy – tx of external and
internal root resorption – apexification.

Pulpotomy Pulpectomy
• Differs from direct pulp capping in that a • coronal and radicular pulp is removed
portion of remaining coronal pulp is
removed before application of medicament vs
[radicular pulp is not removed]
• Usually better than pulp capping for
primary teeth.
• Most often used following trauma.
 mm

Nb. If after removing the coronal part of the pulp chamber, radicular pulp still bleeds → you need to do
pulpectomy***.

Pulp capping / pulpotomy materials:

1. Calcium hydroxide
 Most commonly used agent [gold standard].
 High PH that causes a superficial layer of necrosis.
 Broad spectrum antimicrobial.

2. Ledermix cement
 Corticosteroid: Triamcinolone + Antibiotic: Demeclocycline + Calcium hydroxide + Zinc oxide‐eugenol
 the main content of ledermix = ZOE.
 Very strong anti-inflammatory agent [full effect is reached after 3 days].
 Has the potential to inhibit inflammatory root resorption specially after luxation injuries.

3. MTA
 Ferrous oxide causes the grey color of MTA / Bismuth oxide causes the discoloration of MTA when
it is applied.
 Hydrophilic [can work in moisture areas].
 Excellent sealing ability [bacteria tight seal] + produced a hard tissue bridge (dentin bridge) faster
and with less defects compared to CaOH2.
 White MTA better than grey MTA.

Radiographic techniques:
1- Angle bisecting technique.
2- Parallel technique: (Most accurate radiograph for endo - More accurate than bisecting technique)
• Causes 10% magnification [magnification can be minimized by rectangular collimation and long cones].
3- Modified parallel technique:
• To overcome the 10% magnification caused by the parallel technique → increase vertical angulation by 15 °
[to shorten the image slightly].

Positioning devices:
1- Film holders [Rinn XCP]
- most accurate.
- easy to use – no hands needed.
- positions the beam correctly and holds the film.
- no film distortion or bending.
- reproducible image over time.
2- Styrofoam biteblock
3- hemostat with a bite block

 Nb. pt’s finger causes the most bending of the film → least accurate.

Film sizes:
- Size 1 Narrow arches and anterior teeth.
- Size 2 Standard size for PA.
- Size 4 Occlusal views.

 Nb. PA lesions are always smaller on radiographs.

 Nb. infection will be present for at least 3-4 months before a PA radiolucency develops.

Tube shift techniques

Vertical shift Horizontal shift
 Decreasing the angle → elongate the image [no  Mesial and distal = separate objects that are
diagnostic or practical value] superimposed over each other
 Increasing the angle by 15° [modified parallel  If you are suspecting an extra canal / perforation/
technique] → more apical detail looking for the other root:
- U & L Central incisors → mesial shift
- U & L Lateral incisors and canines → distal
shift
- U & L premolars → mesial shift
- Lower molars → mesial shift
- Upper molars → Mesial shift for DB root,
Distal shift for MB root

CBCT can be used to:

1. Get more accurate canal measurements.
2. Know exact direction of root curvature [PA will only show mesial and distal curvatures, CBCT
shows buccal and lingual].
3. look for calcified, missed and accessory canals.
4. Evaluate fractures/ root resorption/ perforations [a PA will only show mesial and distal perforations].
5. Best choice in traumatic cases.

Endodontic instruments
Hand instruments:

Hand files (taper 2) NITI Rotary files (taper 4 & 6)

• color coded • color coded
• The number represents the diameter of the • In rotary the length of the active part is variable but
instrument in [1/100 of a mm] at the tip the maximum is 14 mm [located at D14]
• Tip angle = 75 ± 15° • Constant taper, multiple taper, reverse taper
• Available lengths = 21,25,31 mm*** • Constant tapering of rotary file (large increase in
• Working blade (active part) in any size is always 16 tapering every 1 mm)
mm extending from D1 to D16 [ 16 mm away from] • Multiple taper: the increase in diameter is not
• Hand instruments have a constant increase in taper constant (present only in rotary files)
Ex: 2% taper the diameter increases by 0.02 mm • benefits of multiple tapers:
every 1mm so file (size 25) with taper 2 % what will 1- Increase file elasticity
the diameter be at D3? 2- Increase cutting ability
D0 = 0.25 mm 3- No need for recapitulation during prep
D1 / 0.25 + 0.02 = 0.27 mm 4- Decrease torsion and number of files in the
D2 / 0.27 + 0.02 = 0.29 mm system
D3 / 0.29 + 0.02 = 0.31 mm
• Tapering of hand files (small increase in
tapering every 1mm)

Color codded of manual files

pin gra Purpl white yellow re blu gree blac white yellow re blu gree black
k y e d e n k d e n
6 8 10 15 20 25 30 35 40 45 50 55 60 70 80

‫ وبتكرر األلوان إبتداء من األبيض‬10 ‫ بتزود‬80‫أي فايل بعد ال‬

Instruments for pulp removal

Barbed Broaches (manual – filing motion) Rasps
has barbs – used to remove the pulp have smaller barbs compared to broaches
 Manual instruments for cleaning and shaping the canals
Reamers (negative rake angle)*** K file (negative rake angle)*** H file (positive rake angle)***
- R-Flex - K-file
- K-Reamer - k-Flex

• reamers are k- type instrument • They cut by Inserting into the • Insert – apply pressure against
used to ream the canal (reaming canal then twisting clockwise to canal wall – withdraw the file
motion = rotation motion) ¼ or ½ turn then withdraw (turn while maintaining pressure
• They cut by Inserting into the and pull) – (reaming motion (filing motion)
canal then twisting clockwise to then pull action) • Flutes look like successive
¼ or ½ turn (reaming motion) • Stainless steel wire twisted to triangles on top of each other
• Less number of flutes than K file form the file (Christmas tree – cone over
but have same cutting efficiency • Tighter flutes (more number of cone)
because more spaces between flutes) • cut only when the file is
the flutes → better debris • Resist fracture better than withdrawn because the edge
removal faces the handle of the
reamers & H-Files
• Cutting efficiency 2.5 more than instrument (filing motion)
• K- file, square in cross section
K-File • Aggressive cutter
• K-flex, rhomboid or diamond
• Sharpness is lost rapidly • Used in straight canal
in cross section
• Remain self-centered in the • lack flexibility
canal → less chance of canal • break easily when used in torque
transportation motion
• Mainly triangular in cross • circular in cross section
section
Nb. Used to remove loose broken
Nb. (Flex o reamer): triangular in instrument***
cross section, have non-active/non Nb. Hero file = similar to H file in
cutting / bat tip making (flex o cross section without radial lines,
reamer) well suited for the non-cutting passive tip.
preparation of evenly curved Nb. Hedstroem files show a greater
canals without risk of ledging. risk for fracture than reamers and K-
files if used in a wrong way.

Manual instrumentation Motions

Filing push and pull – beak motion
Reaming Push then clockwise rotation
Watch winding file rotated 2- 3 quarter turns clockwise then anticlockwise then retracted [most useful
for initial canal negotiation]

Balanced force with flex O and Flex R files – insert with quarter (1/4) turn clockwise + apical
pressure then half to three quarter turn counter-clockwise to cutting

Lentilospir latch type attachment used to carry the sealer during obturation or cement during post
al cementation or even paste intracanal medication into the canals
(rotary)

Gates Glidden (GG) Peeso Reamer

 - Flame shaped - Flame shaped
- latch type attachment to a slow speed hand piece - They have safe ended non-cutting tip
- set of 6 sizes (0.50 - 0.70 - 0.90 - 1.10 - 1.30 - 1.50) - latch type attachment to a slow speed hand piece
- color coded on shank (white – yellow – red – blue – - Set of 6 sizes (0.70 – 0.90 – 1.10 – 1.30 – 1.50 –
green - black) 1.70)
- Advantages: - color coded on shank (white – yellow – red – blue –
A. Easy to use green - black)
B. Inexpensive - Disadvantages
C. Easy to retrieve if it breaks • Very stiff (are not flexible)
• Aggressive
- Disadvantages: • Does not follow canal curvature
A. Can cause ledges / stripping • may cause canal perforation
perforation (mostly in the distal wall Used for: mainly preparing space for a post but may be
of the mesial root of lower molars – used to removing GP from the canal or during
this can be prevented by using the GG retreatment
in a brushing motion against all walls).
B. Cannot be used in curved canals Nb. different from gates gladden in number 1.70
C. Aggressive + remove a lot of tooth
structure

- Used for:
A. Coronal flaring of the canal (only up to
coronal third)***
B. Orifice opener
C. Removal of GP
D. Preparing space for a post
E. Removal of lingual shoulder

Nb. Gates size number 1 (0.50) have the same number

of hand file number 50 (yellow color hand file)
Nb. Gates size number 2 (0.70) have the same number
of hand file number 70 (green color hand file)
Nb. different from peso reamer in number 0.50

spreaders pluggers
• sizes from 15 - 45 • wider than spreaders in diameter
• used to pack GP • blunt end

Q. What length should the spreader go for

optimum cold lateral compaction? 1-2 mm short
of the working length

Rake angle = angle formed between the radius of the file and the cutting edge.
• Cutting edge is exactly on the radius → zero rake angle.
• Cutting edge Infront of the radius → +ve rake angle [cutting action].
• Cutting edge behind the radius → -ve rake angle [scraping action].

Nickel titanium instruments (NiTi): the material has different properties at different temperatures
1- Very good elasticity and resilience.
2- Shape memory.
 3- Corrosion resistance.
Nb. Visual examination is not a reliable method to evaluate NiTi files because they can break without
any signs of permanent deformation or unwinding – to reduce this risk Bend the file at least (80 °) to
see if the instrument breaks every time before you re- insert the file.
Nb. NiTi files cause less canal transportation and ledge formation.
Nb. All (NiTi) instruments are used in crown down technique.
Nb. Success of rotary depends on irrigation***.

Martensite (M-phase) R phase Austenite (A-phase)

M- Wire it means the in between A- Wire it means the Austenite
martensite ratio is more. ratio is more.
• At cold temp • Intermediate phase [all files • At hot temp
• Excellent fatigue resistance now are made at this phase] • Excellent shape memory
• Great cutting efficiency,
edge fidelity, torque
resistance

Patency files: create a space before the use of rotary shaping files – they were invented to eliminate the
use of hand files and reduce their errors.
• faster in creating space for rotary shaping files.
• cause less canal transportation.
• more suitable for curved canals.
• can compensate for the lack of experience resulting in more conservative shaping.

first generation • 3 sizes (10,15,20) – constant taper

patency files
[path file]
second • one file, multiple taper with semi active tip – the file is made from M- wire Niti Alloy
generation [has reduced cyclic fatigue and more flexibility → can be used in very curved canals]
patency files • if you are using proglider you need to check WL 2 times [before using and after using
[Proglider] the file]– because if the canal is very curved the file can change It’s curvature and
change WL

Pro-taper system • Full rotation

• Protaper system has 6 files (3 shaping – 3 finishing)
- 3 shaping files [Sx, S1, S2]
- 3 finishing files [F1, F2, F3]
• S1 is used before SX because the tip is thinner and the file is more flexible
• small canals you can stop at F1
• use each file for max of 10 seconds in brushing motion
 Wave one / • Reciprocating rotation
Reciproc / endo- • Wave one (single file system)
eze • The file moves in one cycle clockwise and counterclockwise and every 3 cycles
completes one full rotation
• Wave one has 3 files
- 20k Yellow = small
- 25k Red = primary size [ used in most cases]
- 40k Black = large
• use the selected file for max of 10 seconds in beck motion
• If the K file can’t reach full WL → use the wave one again in brushing motion
SINGLE USE • disposable files
SYSTEMS • if you sterilize them, they change dimensions and don’t fit into a hand piece
again
• single use systems reduce chance of fracture
SINGLE FILE • you can finish the canal prep using one file only
SYSTEM • One shape, One curve, XP endo shaper (full rotation)
• Endo-Eze, wave one, wave one gold, reciproc, reciproc blue (Reciprocating
rotation)
Lightspeed system • used with Simplifill type of obturation
Self-adjusting file • flexible and has a hollow core, it adapts itself according to the shape of the
[SAF] canal + provides continuous irrigation during instrumentation
Revo s system • Full rotation
• set of 3 instruments
• snake like movement & higher flexibility inside the canal (used in curved
canals)

XP shaper • Max wire technology

XP finisher • snake shape, simple, safe, self-adjusting, super elasticity and extreme
flexibility, shape memory combined with continuous rotation at high speed
(800 rpm)

Profile rotary • Rounded tip

system • U shaped flutes

 Nb. All rotary files made of (NiTi) can be used in crown down technique.
 Nb. Lubricate the files with EDTA + irrigate properly with NaOCl.

Rotary instruments motions

Delivered by the file Delivered by the operator
• Full rotation • Beck motion [up and down]
• Reciprocation • Brush motion

Thread tendency:

 Adv of thread tendency: allows the file to reach the apical part easily.
 Disadvantages of thread tendency: the file can break.
  If the helicals are placed parallel to each other [constant helical angle] → higher thread tendency.
 If the helicals are not parallel [variable helical angle] → lower thread tendency.
 Thread tendency is mostly experienced when you are doing beck motion and the file rotation is full
rotation.

Q. why is it better to use rotary files? Q. what are the disadvantages of rotary
files?
1. Faster preparation 1. Higher risk of fracture compared to k Files
2. Provides the desired uniform shape of the canal 2. Might create micro cracks in the dentine
[continuous tapered conical form] 3. Can’t be used in curved narrow canals
3. Lesser chance of perforations, apical 4. Don’t clean oval / wide canals very well. [ fixed
transportation and zipping by doing brushing motion]
4. Centered preparation
5. less complications because they have non
active tip + they are made from nickel titanium
alloy - more flexible and can be used in curved
canals

Nb. Rotary files can be used in all RCT cases except: narrow canals, C or S shaped canals, oval and wide
canals.
Nb. C or S shaped canals: use manual filing with ultrasonic + focus on irrigation.

Access cavity:
Upper Lower
1 Triangular Oval
2 Triangular or oval Oval
3 oval Oval
4 Oval - buccolingually Oval
5 Oval - buccolingually Oval
6 Triangular base at buccal cusps Triangular – Rectangular - rhomboid -
Trapezoidal
7 Triangular base at buccal cusps Triangular - Rectangular – rhomboid -
Trapezoidal

NB. Cemento dentinal junction: where the cementum meets the dentine usually 0.1 mm away from apical
foramen.
Nb. If you need to gain access through a PFM restoration – use a round diamond bur to drill through the
porcelain then switch to carbide to drill through the metal.

Extra canals are mostly found in:

• Upper molars mostly have MB2.
• Lower molars can have extra distal canal.
• Mandibular incisors and premolars can have 2 canals (extra
lingual).
Canal configuration:

Nb. Maxillary second premolar the only tooth shows 8 Endo configuration.
Nb. Ultrasonic tips can be used in cases of Calcified canals & Sclerosed canals.
Nb. Dyes can be used to located the canal Sclerosed canals.

Working length estimation

Working length [WL] = the distance from the incisal edge or the cusp tip to 0.5 – 1mm short of the radiographical
apex.

Reference point: site on the tooth from which measurements are made [usually the tip of the cusp or the
highest point of the incisal edge] – must be easily visualized during prep and stable [ does not change
between appointments].
Q: How can you determine the working length?

1. From pre operative radiograph.

2. Using electronic devices [apex locator].
3. Tactile sensation.
4. Bleeding on paper point [in case of open apex].
Nb. WL should be measured after gaining straight line access to the canals.
Nb. initial size / initial file: the largest file that can go to the full WL [should have slight resistance at the
apical 3rd].
Nb. BEST WL ESTIMATION PROTOCL = APEXLOCATOR THEN CONFIRMED BY
RADIOGRPAH.
Indications of using an Apexlocator:
1- Pregnant patients to reduce radiation.
 2- Children who can’t tolerate taking radiographs.
3- Disabled or heavily sedated pts.
4- Pt’s who can’t tolerate radiograph because of gag reflex.
5- Apex is obstructed by [tori, impacted tooth, shallow palatal vault, zygomatic arch, overlapping
roots, excessive bone density].

Biomechanical preparation

Outline form: the RC prep should be wider coronally than the middle and apical parts.
Retention form: provided by the master cone tug back apically.
Resistance form: provided by keeping the apical constriction as narrow as possible – to prevent overfilling.
Extension for prevention: to locate any additional canals and remove all pulp debris.

Instrumentation techniques
Instrumentation techniques
Apical – coronal Coronal – apical Hybrid
 standardized  Step down  Step back step
 Step back (telescopic  Double flared down combination
preparation)  Crown down (pressure less procedure
 Balanced force technique technique)
(Roane)

what are the problems that can occur during instrumentation?

 Loss of working length → due to canal blockage with debris if you don’t recapitulate in between
files.
 Ledge formation (Gouging) → not following the canal curvature or pre-curving the files.
 Zipping [widening the apex].
 Strip perforation [lateral perforation].
 Apical transportation or apical perforation → lead to create 2 apical foramina.
 Over instrumentation [ instrumenting beyond the apex and injury to the PA region].
 Over preparation [widening the canal prep too much].
 File breakage.

Nb.
- Sticky sensation = perforation.
- Non sticky sensation = ledge.
IRRIGATION SOLUTIONS
SODIUM  The second most effective irrigant solution against e.faecalis
HYPOCHLORITE  Oxidizing action
[NAOCL]  Remove organic, proteolytic irrigation (breaking down proteins
Inhibiting protein & lipids) High PH = 12
synthesis  Pale greenish yellow liquid with strong odor of chlorine
  No difference between 0.5% and 5 % NaOCl in terms of anti-
bacterial activity
 5.25% NaOCl has better tissue dissolving capacity
 warming NaOCl syringes in a water bath at 60-70°C → increases
it’s effectiveness
 Does not remove smear layer
 3 main reactions:
- Soaping of lipids
- Neutralization of amino acids
- Chloramination
 Preferred concentrations of NaOCl:
- For antibacterial effect → low
concentration [0.5 – 1 %]
- For necrotic tissue dissolution→ higher
concentrations [5%]
 Pre-treatment with Ca(OH)2 can enhance tissue dissolving capacity
of NaOCl
 Combination of 5 % NaOCl + EDTA → better anti-bacterial
properties + removal of Smear Layer
CHLOROHEXIDI  Least effective irrigant solution against e.faecalis
NE [CHX]  At low concentrations it is bacteriostatic, at higher concentrations is
2% bactericidal
Damage the outer  Excellent antimicrobial properties but no protein dissolving
layer of cell wall. properties
 Does not remove smear layer
 High substantivity [antimicrobial action remains for a long
time]
 Less effective compared to NaoCl
 Stains canals and teeth
 if you mix CHX with NaOCl → better antibacterial effect
 increases effectiveness of Ca(OH)2 when combined as a dressing
EDTA  Little or no bactericidal effect
17%  remove inorganic, chelating agents
 Used in conjunction with NaOCl effectively removes smear layer
 Used before dressing the canal and before obturation
MTAD  The most powerful effective irrigant solution against e.faecalis
(a mixture of  Tetracycline or doxycycline [ABX] + citric acid + Tween 80
tetracycline isomer,  Best bactericidal activity [more than NaOCl and EDTA]
acid, and  Removes smear layer more than EDTA + open DT and allow
detergent) antimicrobial agents to penetrate the entire root canal system
 Doxycycline has high binding affinity to dentine providing long
antibacterial effect [main difference compared to EDTA]
 Effectiveness of MTAD increases when low concentrations of
NaOCl are used as an irrigant followed by a final rinse of MTAD
 Best protocol is using 1.3% NaOCl as an irrigant followed by
final rinse with MTAD (do not use NaOCl again before
obturation → this can lead to dentine erosion)
Q: how can you check if the canals are clean or not yet? Place a gauze near the access cavity and
irrigate then check the gauze to see how clean the solution is and if there are any debris.
Q: what can you do to improve your irrigation protocol?
1. Use a fine needle [yellow].
2. Insert the needle deep into the canal until you feel resistance then withdraw 0.5- 1mm and irrigate.
3. Heat NaOCl in a water bath at 60°C [ to increase it’s antimicrobial and tissue dissolving effect].
4. Build the broken walls of a tooth to keep the irrigants inside.
5. Passive ultrasonic irrigation [PUI] the energy will warm the solution + cause vibrations → dislodge
the debris.

Intracanal medication
Q. why do we place intracanal medications? Mechanical instrumentation + irrigation alone removes
only 70% of bacteria in the canals. Intra canal medications are placed in between appointment to:
1. Destroy bacteria that remains inside DT, lateral canals, ramifications and fins. And prevent
their growth.
2. Prevent bacterial contamination in between appointments.
3. Help in managing weeping canals.
4. Control inflammatory resorptions.
INTRACANAL MEDICATIONS
PHENOLIC COMPOUNDS  Dressing of choice for infected teeth
Ex: CMCP  High level of toxicity
  Antimicrobial activity might not last very long
ESSENTIAL OIL  Palliative effect – because it inhibits prostaglandins
[EUGENOL] synthesis and nerve activity
 High doses are toxic and irritating to PA tissue
ALDEHYDES  Formaldehyde / glutaraldehyde / paraformaldehyde
 Potent disinfectants
 Cytotoxic & carcinogenic
 Formacresol = formaldehyde is the main ingredient –
most widely used medication for pulpotomy
 paraformaldehyde is a component of endomethasone
obturating material – it decomposes slowly to give out
formacresol
HALOGENS  Chlorine = active ingredient of NaOCl
 Iodide = potassium iodide
QUATERNARY  Ex: Biocides = chemicals that can inactivate a variety of
AMMONIUM COMPOUNDS microorganisms
ABX +  PBSC paste – no longer used because it caused allergic
CORTICOSTEROIDS reaction
 Ledermix [ABX + corticosteroid] best choice for
intracanal medication
CALCIUM HYDROXIDE  Antiseptic action - antibacterial effect
CA (OH)2  high PH = 12.5
 Ca(OH)2 can easily be buffered by dentine and lose it’s
antibacterial effect
 Effective against dead bacteria that might remain in the
canal
 Best choice when you expect long delay between
appointments because it is effective as long as it
remains in the canals. But it can cause calcifications
inside the canals – has to be changed every 3 weeks
 Inhibits root resorption and stimulates PA healing
 Dressing of Ca(OH)2 is required for at least a week for
all necrotic teeth
 Resorption area contains acidic medium (PH 4.5 - 5),
the Calcium hydroxide act ad neutralizing agent.
 E. faecalis = fairly resistant to Ca(OH)2 ☹

Weeping canals: a constant reddish or clear exudate associated with radiolucency. the tooth might be
asymptomatic or TTP, next appointment exudate stops and then re appears again in the appointment after.
Management: dry the canal with paper points then place Ca(OH)2 → next appointment the canal is dry and
ready to obturate.

 Nb. how are intracanal medications applied? Intracanal medication on a cotton pellet is placed
inside the pulp chamber and over it a sterile dry cotton pellet and sealed with temporary filling.

Temporization
Good endo but poor coronal restoration will have higher failure than poor endo with good restoration.

Temporization of an access cavity done inside tooth structure

Zinc oxide/ calcium sulphate  High coefficient of thermal expansion → expands and has
preparations [Cavit – coltosol] excellent sealing ability
 Used for non-vital tooth***.
 Low compressive strength [needs sufficient bulk]
 Easy to place and remove
 cavit G & cavit W = vary in their resin content and their
hardness
Zinc oxide eugenol 1. Plain ZOE is less effective than cavit
preparations 2. Reinforced ZOE with 2% polystyrene polymer to increase it’s
compressive strength (Kalzinol)
3. IRM = ZOE reinforced with polymethyl methacrylate
- better compressive strength +
abrasion resistance
- Eugenol prevent bacteria
colonization in case of leakage
- comes as capsules used with
amalgamator
NB. IRM can be used safely underneath composite restorations or GI
restorations.
Nb. If the final restoration is going to be resin don’t use ZOE,
eugenol will compromise resin polymerization [cavit and IRM can
be used]
GIC  Chemical adhesion to tooth structure → very good sealing
ability [used when you need to temporize for a long time]
 Fluoride release → anti-bacterial
 difficult to distinguish GIC from tooth structure during
removal
 fuji VII – has pink color [easy to identify]
Composite resin  No antibacterial properties
 High hardness , compressive and tensile strength + good
marginal seal

 Nb. Zn phosphate or Zn polycarboxylate should not be used [they provide poor seal].

Obturation
 Single visit endodontics can be done if the tooth is vital.

Obturation materials
Gutta Percha  Composition: 
[semi solid] - 20% gutta-percha (matrix)
- 66% zinc oxide (filler)
- 11% heavy metal sulfates (radiopacifier)
- 3% waxes and/or resins (plasticizer)
 expands when heated and shrinks when cooled
 Can show some tissue irritation because of the high content
of Zno
  The melting point of gutta-percha is about 60°C
 Types:
- Solid core [standardized or non-standardized]
- Thermo-mechanical compactable GP
- Thermo-plactized GP
- Medicated GP
 Obturation techniques:
- Cold lateral condensation
- Warm lateral condensation
- Warm vertical condensation
- Thermo plasticized GP
- Single point obturation

Q. how do you sterilize GP? immersed in 5.25%of NaOcl and then

rinsed in H2O2 or alcohol.

Q. how do you dissolves GP?

 chloroform, methyl chloroform, benzene, xylene, eucalyptol
oil, halothane

Q. how do you remove GP?

 using heated endo probe / plugger, the tip of a system B or
touch”n heat device
 with H file or S file
 micro debrider: small files with 90° bends to remove any GP
remaining on the walls on the canal.
 Gates Glidden or active tip rotary files
 The best method to remove GP is US tips under microscope
magnification
Advantages: Disadvantages:
1. Compactible 1. Lack of rigidity – bends
2. Dimensionally stable easily and cannot be used
3. Inert in small canals
4. Radiopaque 2. Easily displaced by
pressure
3. Lacks adhesive properties
(need sealer)
4. Shrinkage.
Silver points Advantages: Disadvantages:
[solid] 1. Rigid – can be used in narrow 1. Not good sealing
curved canals 2. Corrosive products
Nb. Stieglitz plier used 3. Not easy to remove (need
to place or remove silver Stieglitz pliers to remove
point. it)
Nb. More radiodense
and radiopaque than
GP.
Pastes [ZOE, calcium Advantages: Disadvantages:
hydroxide, resin] 1. Easy to use 1. Some pastes are toxic
2. Fills irregularities 2. Some pastes dissolves
3. Acts as lubricant over time - Poor seal

Obturation techniques
 COLD LATERAL Can’t be used in:
COMPACTION - curved narrow canals
- internal resorption
- canals with irregular shape
WARM VERTICAL COMPACTION Uses a heat carrier [to warm the GP] and pluggers
(SCHILDER’S TECHNIQUE)
ADV: excellent sealing of the canal apically and lateral / accessory canals

DISADV: larger pluggers can bind the canal and split the root + lip burning from the
heat carrier + difficult to master

Touch’ n heat [Sybron endo] is an electric heat carrier that was later invented and
reduced the chance of lip burning and the need for torches
CONTINUOUS WAVE (SCHILDER’S warm vertical condensation but not done by hand instruments it is done using system
TECHNIQUE LATER BECAME B (heated gutta percha technique)
CONTINUOUS WAVE)
ADV:
- excellent seal [including lateral canals]
- less technique sensitive
- no need for separate pluggers and heat carriers
- the tip can deliver the exact heat for a long time
- can be used with standardized/ non standardized / rotary GP
WARM LATERAL CONDENSATION A heated spreader is inserted lateral to the cones → un heated larger spreader is
inserted → insert accessory GP until obturation is completed

ADV:
- no need for special GP or instruments
- Heat is not introduced to apex + Precise GP length control + Potential for root
fracture is reduced

Endotech / one button heats the tip to warm the GP laterally then another button will
cause vibrations

Enac / the tip only delivers vibrations which are enough to heat the GP You can achieve
the same effect if you touch the side of the spreader with and US tip → vibrations and
heat
INJECTABLE GP Ex: obtura, ultrafill, calamus
(THERMOPLASTICIZED INJECTABLE
TECHNIQUE) Nb. Need Definite apical stop is needed

Indications:
- abnormal canals with many irregularities [ramifications, C / S shaped canals]
- internal resorption - back filling of canals after WVC or continuous wave

Gutta-flow: easier to remove for retreatment and post preparation

THERMO MECHANICAL TECHNIQUE File compactor like coated by gutta percha martial [the energy delivered will melt the
(MC-SPADDEN COMPACTION) GP and the threads of the compacter will direct it apically]

DISADV:
- can’t be used in curved canals
- compacter breaks easily
- canals are usually over filled when using this technique

CARRIER BASED TECHNIQUE Ex: Therma fill, soft core, dense fil
 flexible steel, titanium, or plastic carriers coated with GP. The kit has a file called size
verifier [SV] to verify which size of GP to use

ADV:
- easy single insertion
- excellent seal
- quick

DISADV:
- needs apical stop
- can’t be used if you need to place a post
- difficult in case of re treatment

Gutta core: no plastic core remains in the canal [easier in case of retreatment]
CHEMO PLACTIZIED TECHNIQUE Indication: very wide canal with open apex

Apical barrier
1. Dentine chips / MTA (best) [permanent solution].
2. CaOH2 [temporary solution].

Sealers

1- Fills the space between GP and the canal wall to provide 3D obturation.
2- Fills accessory canals and small irregularities.
3- Lubricant that aids in the seating of the GP.

Types of sealers:
1- Zinc oxide
2- Calcium hydroxide
3- Glass ionomer
4- Resin
Sealer placement: lentilospiral OR with a clean file OR coating the master cone.

AH26 AH PLUS
 Powder liquid system  Paste system
 Release small amount of formaldehyde  Maintain the natural color of teeth*
(antibacterial - toxic)  Shorter setting time (8 hours)*
 staining to teeth  Has half the solubility of AH26*
 longer setting time (24 – 36 hours)  Mix too thick
  Not sensitive to moisture  Epoxy resin based
 Low solubility
 Epoxy resin based *Nb. the most popular hydrophobic epoxy resin-
based sealer that has been used as the gold
standard material

Nb. In general there is no actual contraindication for RCT, however there is limitation in 2 cases :
A. Pt on immune suppressants [specially kidney transplant patients].
B. Pt going to have cardiac surgery [there is risk of infective endocarditis].
Q. what is the correct consistency of the sealer? After mixing and lifting the spatula the sealer should cut
off when the spatula is 1- 1.5 cm away from the mixing slab.
Nb. All sealer cements are highly toxic when freshly mixed then reduced on setting.
Nb. Sealer should be thicker in cases of open apex, and less viscous in case of narrow canals or so many
lateral canals [best is to go for thick sealer in the master cone and less viscous for the accessory cones].
NB. In a kidney trans plant pt if the tooth is vital → do RCT but if there is a PA lesion → extraction because
periapical lesion represents a source of infection.
Nb. If the pt still has pain after LA in the mesial root of a lower 1st molar → tooth might have extra
innervation from superficial cervical plexus or mylohyoid nerve [in this case you need to anesthetize lingual
nerve].
NB. caries removal is always done by a hand excavator not by hand piece (To avoid force the bacteria &
microorganisms into periapical area).
Nb. Dentine map: darker dentine that connects the orifices of the root canals.
Nb. Mechanical preparation in RCT should start and end with irrigation.
Nb. no need to widen the orifice if you are using rotary.

Accidents in obturation
• Underfiling = lead to voids formation within obturation.
• Short filing= lead to improper cleaning & shaping of apical third (residual bacteria still present).
• Poor condensation = lead to voids formation within obturation.
• Over extension = the GP is beyond the apex but apical portion is not well condensed (pain like knife
stab during eating).
• Over filling = the GP is beyond the apex but the apical portion is well condensed (you don’t need to do
anything – just follow up) the pt will only feel some pain due to PDL irritation for a few days.
 Endodontic emergencies
 Emergency: situation associated with pain or swelling that requires immediate attention.
 rule of true emergency = only one tooth is the offender.
 Emergencies usually affect sleep, working, concentration etc.…
 Emergencies are associated with pain that started over a short duration and is un responsive to
medication.

Emergency Clinical presentation management

Acute pulpitis  Pain  If you have limited time:
 Vital tooth - Anteriors and premolars: pulp extirpation + dressing
 Radiograph = normal - Molars: pulpotomy
 Caries / large restoration
 If you have enough time →
- Anteriors / premolars/ molars: pulp extirpation +
dressing
Acute pulpitis  Pain  If you have limited time →
with apical  Tenderness to percussion - Anteriors and premolars: pulp extirpation + dressing
periodontitis  tooth feels high - Molar: pulp extirpation of the largest canal [palatal in
 Vital tooth the upper molars and distal in the lower molars] + call
 Radiograph = normal or slight the next day to continue pulp extirpation of the other
widening of the PDL or a small canals
radiolucency
 If you have enough time →
- Anteriors / premolars/ molars: pulp extirpation +
dressing
Pulp necrosis  Non vital tooth  Pulp extirpation + dressing
Rarely an  No Tenderness to percussion  Non restorable tooth → extraction
emergency  PA radiolucency
Acute apical  Swelling  Drainage through the canal OR Incision and drainage if
abscess  Tenderness to percussion the swelling is large and fluctuant
 LA infiltration around the periphery of swelling then
incise at the areas of max fluctuance down to the level
of bone. vertical incision provides better post op
healing [ position the incision that will aid drainage by
gravity]
  Keep the wound clean and promote drainage by hot
salt water mouth rinses.
 Systemic complications → ABX

Nb. infection not had enough time to demineralize cortical

bone, it takes 30%-50% of bone must altered to be visible.
Diffuse  Access the tooth + instrument the canal + irrigate
swelling  if there is no drainage → instrument beyond the apex
to encourage drainage from PA tissues
 If drainage through the canal fails → I & D + drain
placement
 CNS changes / toxicity / compromised airway →
hospitalization

Antibiotic guidelines:

 select the ABX with anaerobic spectrum + larger dose for a short duration.
 ABX only given for pt’s with systemic manifestations (fever, malaise, cellulitis,
lymphadenitis).

Single visit endodontics

Advantages of single visit Disadvantages of single visit
1. Pt comfort [less visits and less LA] 1. Pt fatigue [mouth opening for a long time]
2. Saves time [only one visit] 2. Clinician fatigue
3. Minimizes incomplete treatment 3. Needs experienced doctor
4. Constant WL, you are still familiar with the 4. If a flare up happens it is difficult to establish
canal anatomy drainage
5. Minimizes fear and anxiety 5. Not possible in all cases [weeping canals,
6. No risk of bacterial leakage in between calcified canals, severely curved canals etc]
appointments 6. You can’t place intracanal medications [you
depend only on the action of NaOCl]

Indications Contraindications
1. Uncomplicated cases of VITAL teeth 1. Acute abscess
2. Physically impaired pts that can’t come multiple 2. when there is tenderness to percussion
visits 3. Non vital tooth
3. Medically compromised pts that require ABX 4. Calcified / curved canals
prophylaxis 5. Limited mouth opening [TMJ pts]
4. Fractured anterior where esthetics is a concern 6. Limited accessibility
5. Un complicated cases of non- vital teeth with 7. Retreatment cases
sinus tract [tract because they rarely flare up +
the sinus tract will drain preventing
accumulation of pressure and pus]
6. Pts requiring sedation
7. Apprehensive but cooperative pts

Advancements in root canal prep:

Access cavity:
1. Conical carbide burs: Self centering – safer and less invasive → will allow you to find calcified canals
better than round burs.
2. Ultra-sonic tips: [ can be used in every step of RCT: access, irrigation, obturation] Used for: access
refinement and finding calcified canals removal of attached pulp stones / removal of posts /
removal of broken instruments.
3. Terauchi file removal kit (TFRK): to remove broken instruments.

Root canal irrigation:

A. MANUAL:
1. Monojet and closed end needle designs: prevent irrigants from going beyond the apex.
2. Navitip: a small flexible cannula [only the last 5 mm is flexible] that is used to deliver irrigants and
sealer into the canal – easily inserted into the apical 3rd and curved canals Needle = closed end.
3. Navitip FX: smaller than Navitip the needle is double side port [irrigation goes from both sides].
4. Manual dynamic agitation: after instrumentation and confirming tug back – insert the master cone
with few drops of irrigants and move the cone up and down few times [ done as the last step
before obturation].
5. Endobrush: Can’t be used till working length + cause dislodgement of radiolucent bristle.

B. MACHINE ASSITED:
1. Rotary brushes.
2. Quantec – E: continuous irrigation during rotary instrumentation.
3. Sonic devices [frequency below 20 kHz].
4. Ultrasonic devices [frequency above 20 KhZ]:
- Active ultrasonic irrigation: ultrasonic irrigation + instrumentation at the same time [no longer
used because when the US tip came in contact with the walls → created more debris]
- Passive ultrasonic irrigation: the tip does not touch the walls.
5. Endovac system: applies -ve pressure inside the canal – you guarantee that the irrigants reached
the apical 3rd you irrigate the canal and then insert the cannula, the cannula will apply -ve pressure
at the apical part of the canal [the irrigation will move from the pulp chamber to the apical part
and then sucked out of the tooth] Less PA extrusion of irrigants and less Post operative pain
 better irrigation and debridement 1 mm away from the apex Can relieve pressure from a PA
abscess].
6. RinsEndo system: applies +ve and -ve pressure cycles inside the canal [higher risk of apical
extrusion].
7. Gentle wave system: provide high energy waves that will effectively clean the canals then provides
negative pressure to suck the irrigant out. Gentle wave system has a very high success rate and
does not cause post op pain because there is no mechanical instrumentation & no apical trauma
+ the -ve pressure will prevent apical extrusion of irrigants.
8. Lasers: Co2 & Er: YAG [effective in melting the smear layer + seal DT] – but still inferior to naocl
irrigation.

Endo-crown: uses the pulp chamber for retention – need 3mm pulpal chamber wall length for retention &
2 mm occlusal reduction.

Indication Contraindication
 Inadequate clinical crown height  pulpal chamber is less than 3mm deep
 Inadequate thickness of the tooth walls  if the cervical margin is less than 2 mm wide for
 Inadequate inter occlusal space most of its circumference
 Inadequate ferrule  Long clinical crown height
 Teeth with very narrow slender roots [you can’t
place posts]

Nayyar Core: a core created inside the pulp chamber and the canal entrance.

Post & core

 The only advantage of the post is to retain the crown***

 The post weakens the tooth and makes it more prone to fracture + makes retreatment more
difficult.
 Fiber posts have similar physical properties like dentine → they can reinforce the tooth and have
less chance of fracture***.
 post + core are used when you don’t have enough tooth structure to retain a restoration but you
still need ferrule of at least 1.5 – 2mm.
 Indication Contraindication
 when you can’t do and endocrown  Small narrow canals, curved roots
 when you have one or no walls remaining  Alternative: nayyar core + crown
anteriorly or Nayyar core + endo crown/
crown posteriorly
 If you don’t have 2 mm ferrule [you can
obtain a ferrule by ortho extrusion or
crown lengthening]

Nb. 4-5 mm of GP should remain apically (easier with vertical condensation than lateral condensation).
Nb. You cannot obturate completely and then remove the GP and prepare for the post in the same session
because the sealer has to be completely set before you remove the GP otherwise it will disturb the apical
seal (two weeks after obturation optimal time to post & core insertion).
Nb. Post length should be 1 / 2 (minimal) to 2/3 (optimum) of the root length / minimum post length =
same length as clinical crown.
Nb. the post should extend 4 mm apical to the crest of the bone.
Nb. if the canal has a curvature → insert the post up to the point where the curvature starts.

Nb. post diameter: post diameter should not exceed 1/3 the diameter of the root [1 mm of sound
dentine should be maintained circumferentially].
- too narrow → post will fracture.
- too wide → root will fracture.

post designs
Parallel More retentive but can cause root fracture apically [because the canal is tapered]
Taper Can create wedging effect [ focus occlusal forces towards the apical region] leading to root
fracture
Parallel / taper Parallel coronally and tapered apically

Nb. parallel is more retentive than tapered, threaded is more retentive than cemented – cemented posts
distribute the forces better.
Nb. cement retained posts → distribute masticatory forces evenly to the tooth [cement acting as a buffer
between post and the tooth].
Nb. prefabricated post = no need to remove undercuts.
Nb. custom made cast post and core needs anti-rotational notch.
Nb. Posts can be:
- passive → retained only by cementation.
- Active → retained by threads engaging into the dentin + cementation.
Nb. Posts cause wedging effect, the ferrule will separate between the crown and the post → prevent root
fracture.
Nb. Fiber posts have shorter longevity than metal posts (less stiffness & strength).
Nb. Advantages of fiber posts:
1. Easy removal if re-RCT is necessary.
2. Post absorbs/ dissipates stress (rather than transfer to tooth).
3. More biocompatible than metal- low elastic modulus (similar to dentin- more compatible, not
traumatic to tooth).
4. Aesthetic - ideal for use with composites and all ceramic crowns.
5. No interim restoration is needed.
Nb. Most common cause of failure of post and core [most to least] crown fracture → periodontal
problems → root canal failure.
NB. Cleaning of post (Fiber post with alcohol - Cast post remove shiny spots with a bur).

Crown lengthening vs orthodontic extrusion

Crown lengthening orthodontic extrusion

Advantages: Faster/ can be done in one session Advantages: conservative way
Disadvantages: Slower/ Takes 2 – 3 weeks
DISADV:
1. Asymmetry of the gingival margin & should be Contraindicated:
avoided in pts with gummy smiles 1. short roots
2. unfavorable increase in crown to root ratio 2. If the extrusion will result in furcation exposure
3. Can cause damage to bone of adjacent teeth → 3. Inadequate prosthetic space
makes implant placement harder (lost bone
cannot be regained)

Nb. If you are unsure of the prognosis and the patient

might need implant later avoid crown lengthening

Bleaching of vital and non-vital teeth

Stains:
1. Extrinsic (good prognosis) – chromogenic bacteria adsorbed into plaque.
A. Non-metallic stains: coffee and tea, smoking, CHX stains.
B. Metallic stains:
- occupational exposures: iron → black stain / copper → green stain.
- Dietary supplements: iron supplements should be taken for few weeks then stopped for few weeks before
they can be taken again.
 2. Intrinsic (fair prognosis) – occurs during tooth formation of after eruption ex: fluorosis, tetracycline staining,
dentino / amelo genesis imperfecta, enamel hypoplasia, trauma, obturation material remnant, pulpal
remnant, iodine containing intracanal medications (metapex).

3. Age related: due to thinning of enamel + dentine deposition + prolonged exposure to staining agents.

Q: why do traumatized teeth get discolored? Hemoglobin from bleeding breaks down to hemosiderin and causes
staining.

Bleaching agents (3%): more suitable for in-office bleaching / gives the best results

1- Hydrogen peroxide / Hydrogen peroxide can break in 2 ways:

a. Into water and nascent oxygen [weak radicals] – in the presence of moisture.
b. Perhydroxyl and hydrogen [strong radicals].

Q. why should the teeth be dry before application of H2o2? To get more stronger, better bleaching because
moisture will cause H2o2 to give water and nascent oxygen which are weak radical and don’t bleach well.

2- Carbamide peroxide (3%): more suitable for home bleaching

- gives urea which will later give co2 and ammonia [the high PH of ammonia is what causes the bleaching].
- adding carbapol will extend it’s action for 8 hours → can be used overnight.
- Disadvantage: Needs to contact the tooth surface for longer time – better tolerated for home bleaching.

Nb. Overbleaching will increase enamel porosity → anything the pt drinks or eats will cause staining (management:
apply fluoride to remineralize the tooth surface).

Q. what are the most common side effects of bleaching? Sensitivity then gingival irritation.

Q. a pt asks you what is the best home bleaching agent, what do you reply? Look for any product that has the ADA
seal of acceptance.

Nb. ADA seal of acceptance means the company did safety studies on the product + at least 2 clinical trials that
showed at least 2 shade difference.

Nb. Whitening strips containing H2o2 [H2o2 action is only 30 mins] - If teeth are mal aligned → avoid strips.

Nb. After bleaching wait for 1 week before you place any ortho brackets or composite restorations [residual
peroxide will interfere with the polymerization of composite].

Nb. In home bleaching wear the tray with the bleaching agent for 1 hour daily for 2 weeks [more than will get porous
teeth].

Nb. OTC products - Unless a peroxide is present, the whitening effect is only stain removal.

Nb. bleaching kits have capsules of vit E used when there is seepage of the bleaching gel under the barrier. Vit E is a
powerful anti-oxidant, it reverses the soft tissue damage in the gingiva.

Nb. Best is doing in office bleaching then in home bleaching for 2 weeks.

Nb. Superoxol, Sodium perborate, Thiourea used in Non – vital teeth bleaching.

Nb. Superoxol can lead to external cervical root resorption. Sodium perborate safe to use.

Nb. 5% potassium nitrate → reduces sensitivity***.

 Regenerative endodontics
Immature teeth with open apex problems:
- Difficult to clean.
- Very hard to get proper apical seal.
- Dentinal walls are very thin & weak → increased risk of cervical fracture.

Treatment options for immature tooth with open apex

Apexogenesis Apexification Revascularization
 Done if you still have some VITAL  Done if the tooth is necrotic (non-  Done if the tooth is non
pulp tissue vital). vital.
 material [calcium hydroxide,  material [calcium hydroxide,  The only technique that can
MTA, biodentine] MTA, biodentine] increase the thickness of the
 biodentin the material of choice  biodentin the material of choice canal walls + close the apex
 if you placed MTA, you can  if you placed MTA, you can + makes the tooth respond
obturate immediately obturate immediately normally to sensibility
 if you placed Calcium hydroxide  if you placed Calcium hydroxide testing.
you can’t obturate immediately you can’t obturate immediately  Indicated for immature teeth
 the apex closes but the canal  the apex closes but the canal with necrotic pulps
walls are still thin and weak walls are still thin and weak.  First appointment:
 Root will not elongate more and Determine WL → irrigate
will stay at that stage of growth with NaOCl 5.25%, or CHX
 Very poor prognosis because the Second appointment: [after
root is short + dentine walls are 3-4 weeks] Make sure the pt
very thin → tooth fractures is pain free, there is no
 cervically exudate and the canals are
dry Insert a STERILE sharp
file and go beyond the apex
to induce apical bleeding
until the blood reaches the
CEJ – wait for 15 mins Apply
MTA then GIC
 don’t irrigate with NaOCl in
the second session when you
want to induce bleeding.
 the apex has called the
apical papilla which is rich in
stem cells (SCAP cells) that
goes into the canal when u
induce bleeding – after a
while pulp like tissue forms
to increase canal wall
thickness and close the apex
+ the tooth will have normal
sensibility response

Nb. both apexogenesis and apexification close the apex but the walls remain thin and weak, the only
option to allow the walls to get thicker is root canal revascularization.
Nb. always wait for revascularization and don’t rush to RCT.

Dental trauma
Concussion  injury to supporting structure without any displacement or mobility 1 year
or abnormal loosening follow-up
 the only sign is the tooth is tenderness to percussion
 Tenderness to percussion might not occur immediately, it might be
delayed for a few days
 Concussion does not require any treatment – but if severe discomfort
you can reduce the tooth from occlusion a little bit (Relief the contact
with the opposing)
subluxation  injury to supporting structure with pain on biting and sensitivity to
percussion accompanied by mobility but without tooth displacement
 Abnormal loosening [mobility] + No displacement + Bleeding from
gingival crevice + tenderness to percussion
Lateral  displacement of the tooth in a direction other than axially (horizontal 5 years
laxation displacement) follow-up
 the periodontal ligament is torn and contusion or fracture of
supporting alveolar bone (total separation of pdl)
 Always combined with fracture of the alveolar socket wall labial /
palatal alveolar bone [checked by palpation]
 High metallic sound at percussion
 Sensibility test: negative
 Radiography: enlargement of apical periodontal space
 no mobility because it is contacting bone
 if you see the pt immediately after trauma and both surgery + ortho
are indicated → do surgery, if you see the pt after the bone and soft
 tissue healed → do ortho [to avoid further tissue trauma]
extrusive  partial displacement of a tooth axially in a coronal direction
laxation  Clinically: the crown is longer than the adjacent tooth
(partial  Initially in lateral luxation / extrusion we don’t do RCT unless there is
avulsion) necrotic pulp. most cases of extrusive luxation will end up with
necrosis → do RCT shortly after splinting

intrusive  apical displacement of tooth into alveolar bone lead to compressing

laxation the periodontal ligament, crushing and fracture of alveolar socket
(most (Comminution of the alveolar socket)
destructive  Clinically: the crown is shorter than the adjacent tooth
trauma)  High metallic sound at percussion
 Sensibility test: usually negative
 Radiography: no periodontal space
 no mobility because it is contacting bone (Tooth is firm – locked
inside bone)
 if you see the pt immediately after trauma and both surgery + ortho
are indicated → do surgery, if you see the pt after the bone and soft
tissue healed → do ortho [to avoid further tissue trauma]
 If intrusion equal or less than 3mm go for (RCT), if more than 7mm
(surgically repositioning + splint)
 minimal intrusion without bone fracture → observation for 4 – 6
weeks with subsequent necessary treatment

In pediatric patient:
- Re-eruption is expected within 3 months for incompletely formed
roots.
- Ortho-assisted re-eruption is indicated in fully formed roots or if the
tooth did not erupt in 3 months, but it might fail should ankylosis
occur.
- Surgical repositioning may produce a faster result.
avulsion  complete displacement of the tooth out of its socket
 Best management for avulsion is to reimplant the tooth immediately
after avulsion [you can rinse it for a few seconds under running water
and then reimplant – but washing should not exceed 10 seconds]
 Best to worst storage mediums (Tissue culture medium → Hanks
Balanced Salt Solution→ milk (do not use yogurt or sour milk) → saliva
(Contains a lot of bacteria → risk of infection) → saline → water)
 Teeth should never be placed in water [it will cause lysis of the PDL
cells]
 By preventing the root surface from drying you decrease the chance
of replacement resorption
 By doing RCT + giving systemic ABX you are removing the source of
infection and reducing the chance of inflammatory resorption
 all cases of avulsion require abx for mature and immature apex
 ABX are only indicated in cases of avulsion
 If avulsion tooth exceeds 60 min extra orally (no pdl cells), do rct if
tooth have closed apex, then remove the attached non-viable soft
tissue carefully then treat the root surface with 2 % sodium fluoride
(NaFL) solution for 20 min to decrease the chance of replacement
resorption
  In pediatric patient if avulsion occur never ever to reimplant the
deciduous tooth Just wait for the permanent tooth to erupt
 Immediate replantation [Tooth replanted onsite of injury by parents
or by an adult in the vicinity] → Debride the mouth and congratulate
the parents for a well-done job
 Early replantation [Tooth brought to your clinic with “assumed” vital
PDL kept in the correct solution] → Debride the tooth gently [remove
visible dirt using saline] → Debride the socket gently → Re-insert the
tooth gently → Splint
 Late replantation [dry tooth] → Gently remove necrotic PDL → Rinse
tooth with 2% NaFl solution to help minimize possible ankylosis →
Extirpate pulp tissue → Then fill root canal with Ledermix paste →
Gently debride the socket → Gently insert the tooth back → Splint
 If the apex is closed → Start treatment within 2 weeks, fill the canal
with Ledermix for 3 months, Followed by CaOH for another 3 months
then proceed with RCT
 If the apex is open [more than 2 mm] and the tooth is replanted
immediately or early → no need for RCT unless there is evidence of
infection. In case of infection → do Apexification [Fill the canal with
Ledermix for 3 months, followed by repeated CaOH canal medication
every 3 months, Untill apical calcification is evident by x-ray]

Solution How long the PDL cells will stay viable

Hanks balanced salt solution 24 hours
Milk 6 hours
Saliva 2 hours
Saline 1 hour
Nothing 30 mins
Ellis’s classification of permanent teeth fractures
 Class 0 = crown infarction.
 Class I = only enamel (smoothening the site).
 Class II = enamel + dentine (smoothening the site with calcium hydroxide on exposed dentin).
 Class III = enamel + dentine + pulp (indicated for pulpotomy or pulpectomy).
 Class IV = tooth become non vital tooth with or without loss of crown structure (indicated for root
canal treatment).
 Class V = traumatically avulsed tooth.
 Class VI = root fracture with or without loss of crown structure (horizontal better than vertical,
oblique better than transverse, apical better prognosis than coronal).
 Class VII = Displacement of the tooth without fracture of crown or root fracture (laxation).
 Class VIII = complete fracture of crown and its replacement.
 Class IX = fracture of deciduous tooth .

Anderson classification:
 Uncomplicated crown fracture → Ellis 1 and 2.
 Complicated crown fracture → Ellis 3 and 4 [involves pulp or root or both].

Splinting
a. Rigid = does not allow physiological movement [composite with ortho wire] – high chance of ankylosis
indicted when there is bone fracture [mostly avulsion and lateral luxation cases].
b. Non rigid = allows physiological movement [composite with nylon thread or wired orthodontic bands] –
minimizes chance of ankylosis.

Nb. Q: why can’t we apply Ellis classification to primary teeth ? when primary teeth are subjected to
trauma they will not fracture and they will be displaced into the bone [because the jaw bone is weaker
than teeth in children].
NB. All types of fracture need flexible splint except (alveolar process fracture – root fracture in cervical 1/3)
need rigid splint.
Nb. Most common trauma is uncomplicated crown fractures.
Nb. Predisposing factors [increased overjet + insufficient lip closure]
Nb. for all crown root fracture cases f/u clinically and radiographically after 6-8 week and after 1 year.
Nb. Internal splinting: indicated if you have multiple root fractures using fiber post which connects all
parts together.
Nb. After traumatic injury control bleeding / pain the first priority.
Nb. Temporary restorations [MIGHT BE A PRIORITY IF ESTHETICS IS AFFECTED].
Nb. In pediatric patient ask the patient how did it happen? (Medico legal aspect) incoherent stories of how
the trauma happened indicate a planned trauma or abuse → you need to report.
Nb. Mobility test in pediatric patient tested only in horizontal direction (test in vertical direction may
cause damage to the permanent tooth germ).
Nb. root fracture in pediatric patient → Extraction, If there is a small root fragment left leave it → will be
pushed out by the erupting perm.
Nb. alveolar bone fracture in pediatric patient → Clean the area → LA → reposition fragment using 2
fingers [one palatal and one buccal] until you hear a click → place splint for 4 weeks - don’t attempt to
move after you hear the click you might damage the perm tooth bud.
Nb. If a primary tooth is subjected to trauma and breaks it is because it is weakened by caries and not
because of the trauma.
Nb. most to least affected teeth in pediatric: upper centrals → lower centrals → upper laterals → lower
laterals.
Nb. Infraction = Incomplete crack in the enamel without loss of tooth structure → Etch → bond and seal
or make small cavity and fill with composite according to the size of the damage.
Nb. fracture line will not appear on the x-ray.
Nb. Apical root fracture have best prognosis because they are closest to blood supply and furthest away
from the oral cavity + bacteria.
Nb. Intrusion considered as the worst prognosis (the most destructive).
Nb. In cases of total intrusion → Needs periapical radiography to distinguish from avulsion.
Nb. Open apex has better prognosis than closed apex + maxillary teeth have better prognosis than
mandibular teeth [because of rich blood supply]***.
Nb. not all discolored teeth have necrotic pulps - trauma can cause bleeding and discoloration.
Nb. Dystrophic pulp calcification can be left untreated if it is asymptomatic.
Nb. if the parent tells you that they couldn’t find the tooth, take a radiograph it might be a case of total
intrusion – if not take chest x ray the child might have inhaled the tooth.
Nb. To minimize ankylosis after reimplantation [rinse with 2% NaF + splinting with non-rigid splints]
Nb. young permanent teeth with open apex:
- tooth is vital → you can so pulp capping OR pulpotomy OR apexogenesis.
- tooth is non vital → you can do apexification OR pulp revascularization.

 Tetanus immunization status:

 Necessary (Advisable) if unknown or less than 3 doses.
 If equal or greater 3 doses:
1. No booster dose is needed if:
- clean wound.
- no more than 10 years have elapsed since the last dose.
2. Booster dose is needed if
- contaminated wounds.
- more than 5 years have elapsed since the last dose.

Tissue response to trauma

Favorable response Unfavorable response
 Recovery  Infection
 Pulp fibrosis  Pulp necrosis
 Pulp canal obliteration  Internal resorption
 Fibrous healing (peri radicular tissue)  External root resorption
 Transient apical breakdown [TAB]  Bone resorption
 Cessation of root development
 Disturbance in root development
 Gingival recession

Nb. the only indication for rct after trauma is evidence of infection – puss, sinus tract etc…

EXTERNAL ROOT RESORPTION [TYPES]

Surface  Small superficial resorption in cementum and outer dentine
 Rarely seen on radiograph
 Considered as a repair process – can’t be detected on xray
 Occurs after avulsion
 No treatment needed because it is part of the normal healing response

Inflammatory  Severely damaged cementum + exposed DT [loss of tooth surface

externally]
 Bacteria is present inside the canal – resorption can progress rapidly and
treatment will be needed
 Occurs after luxation, intrusion, avulsion
 Most common resorption after failed RCT***
 The only type that can be controlled
 Prevented by the systemic ABX and pulp removal [removing the source of
infection]
Replacement  Severely damaged cementum → direct contact between bone and dentine
→ root becomes part of the bone remodeling process [root surface is
replaced by bone]
 no lamina dura + moth eaten appearance of the root
 Associated with reimplantation
 Progressive [associated with PDL removal] → extraction
 treat the root surface with 2 % sodium fluoride solution for 20 min to
decrease the chance of replacement resorption
invasive  Usually occurs many years after trauma – always cervically Highly vascular
[bleeds on probing]
invasive cervical  Ortho treatment and orthognathic surgery the most common cause
resorption  Pink coronal discoloration (pink tooth) is found in both internal resorption
and ICR internal resorption and ICR
 To differentiate between root caries and ICR you need to depend on the
clinical features of ICR [ bleeding on probing ang pink discoloration]. In case
 there is a gap between cementum and enamel → most susceptible to ICR
 Radiographical features:
- radio-opaque white line between the lesion and
the pulp
- moth-eaten appearance

Q. how can you differentiate between external and internal root resorption? Take 2 radiographs while
doing horizontal shifting and then check.

Ankylosis:
- can occur before replacement resorption.
- can occur after all other types of resorptions.
- can occur without resorption.
- can lead to replacement resorption.

High to low prognosis:

- concussion → extrusion / lateral luxation → intrusion and avulsion no pulp exposure.
- small exposure → large exposure.
- partial pulpotomy → pulp capping → cervical pulpotomy.

Nb. less than 24 h → Direct pulp capping, more than 24 h → pulpotomy, more than 72 hours →
pulpectomy.

Radiographs:

 After traumatic injury best option is CBCT.

 take 3 PA + 1 occlusal for affected arch + opposing arch to check for root
fracture you need to do vertical shifting [you take 3 radiograph one at
90° to the tooth and one 45° above and one 45 ° below] when the x-ray
 beam is perpendicular to the tooth → fracture line appears as tilted line. When the bean is 45°
above or below → fracture appears as a circle.
 Clinical photographs for legal purpose + monitor the treatment progress later.

Vertical root fracture (VRF):

 Location:
- Commonly associated with endodontically treated teeth with or without a post.
- The most susceptible sites and tooth groups are the maxillary and mandibular premolars, the mesial
roots of the mandibular molars, the MB roots of the maxillary molars, and the mandibular incisors.
 Pathogenesis VRF (Result from wedging forces within the canal).
 Etiologies (post placement - condensation during root canal filling - wedging of restorations - expansion of
metallic posts).
 Signs & symptoms: mild or spontaneous pain on mastication - some mobility - localized swelling –
localized/isolated pocket with deep probing depth – narrow/isolated periodontal probing defect in
association with a tooth – PDL widening – dehiscence or fenestration – retrograde filling material - sinus
tract - Radiographic findings described as a vertical bone loss takes “J-shaped” or “halo” pattern. Lesions may
resemble failed root canal treatment because they have an apical “hanging drop” appearance, VRF difficult
to confirm radiographically unless separation of segments occurs.
 Treatment: only predictable treatment is removal of the fractured root. In multi-rooted teeth, this could be
done by root resection (amputation) or hemi section.

Flap designs
Advantages Disadvantages
Semi-Lunar  Small incision  Limited/poor access
 Easy to reflect  Incision often over the lesion
 Doesn’t interfere with oral  Difficult moisture control (hemorrhage)
hygiene  Difficult to reposition
 Doesn’t affect the gingiva (no  Uncomfortable during healing
recession)  Leaves scars
 Tension and tear
 can be mistakenly located beyond the root
defect due to miscalculation
Envelope flap - gingival  Horizontal incision not crossing  No access to apex
crest (intrasulcular) bone defect.  Difficult flap elevation
 Greater access for lateral root  causes gingival recession
One horizontal incision repair  Limited access
 Useful in short roots and coronal  Great tension during retraction
third defects  Irreversible pocket formation if used in
 Easy reposition presence of dehiscence
 Require long horizontal incision over 4 – 5
 Maximal blood supply
teeth
 Easily modified
 Changes in the level of the marginal gingiva
 Difficult suturing
 Difficult to maintain oral hygiene during
healing period
Triangular “First choice” flap for • Causes gingival recession
endodontic surgery
 one horizontal & one  Good access • Limited access to long roots
vertical incision  Good vision
 Good moisture control • Tension during retraction
 Heals without scars
 Easy to reposition
 Easily modified
Trapezoidal Second choice” for endodontic  Causes gingival recession
surgery, indicated in extensive
One horizontal & two surgical procedures
vertical incision (the base of  Excellent access & vision
flap should be bigger than  Good moisture control
apex to allow good blood  Heals without scars
supply)  Easy to reposition
 No tension when flap is
retracted
 Allows surgery on more than
one tooth
Luebke-Oschenbein  Simple  An unaesthetic scar may form
 Good access  Muscular attachments & frenums may need
 No gingival recession, because modification of the horizontal incision
the marginal gingiva is not  Misjudging the size of lesion may result in
disturbed. (Use for anterior the incision crossing the osseous defect
teeth with crowns)
 Easily repositioned flap
 The patient is able to maintain
good oral hygiene during the
healing period

Nb.
 RC-prep (remove calcifications and lubricates the canal to permit more efficient instrumentation.) =
canal lubricant, EDTA 17% + urea peroxide + glycol-based Glyde (wax-based).
 CHX = effective against E.faecalis (MTAD more efficient then sodium hypochlorite).
 E.faecalis organisms = associated with failed endo treatment.
 Retreatment endo = initially > Drills (Gates glidden or peezo) , Solvents > chloroform (most
effective).
 Best tech for sterilization of GP = 5.25% sodium hypochlorite for 1 min then cleaning by alchol 70%.
 Perforation near cervical area has poorer prognosis (oral contamination).
 Perforations below the crestal bone in the coronal third of the root = poorest prognosis.
 Recommended tech for pulpectomy of max primary incisors= facial approach.
 Predominant pathogen in primary endo = gram negative / obligate anaerobic (Bacteroides).
 Failed endo treatment = E faecalis > Facultative bacteria.
 treatment of orofaical infection of endo origin = penicillin, amoxicillin, Augmentin.
 If don’t respond to penicillin alone ? = clindamycin OR metronidazole (flagyl) add to amoxicillin =
effective against orofacial infection of endo origin.
 Antibiotics decrease the effect of birth control pills.
 Normal tissue pH (7.4), in presence of inflammation decreases to (4.5 to 5.5).
 Gow Gates block = indicated when unsuccessful of IANB because of infection***
 11 or 15 = best scalpel for drainage of endo abscess.
 Referred pain = preauricular pain (behind the ears) usually from mandibular molars.
 GP and sealer based on = main component => ZOE.
 incision = soft tissue
 trephination = opening hard tissue
 Orthograde = the use of material through the coronal access point to apical direction.
 Retrograde = the use of the material from the apex of the tooth to coronal direction.
 strip perforation = due to excessive coronal flaring, Furcal perforation = through the pulpal floor.
 Danger zone = distal wall of mesial root (less dentine).
 Pulp Necrosis = (concussion least, intrusion most).
 External resorption = damage to cementoblastic cells, internal resorption = damage to
odontoblastic cells & the treatment of both is (RCT).
 calcific metamorphosis (canal obliteration) = extensive amounts of reparative dentine (mainly in
intrusion) cause yellow-orange color.
 tissue will not regenerate = dentin & cementum (both have limited capacity to regenerate).
 root-end resection indicated when the apical third perpendicular to the long axis of the tooth
(severe curved canal).
 Diffused swelling = Antibiotics and analgesics should be prescribed, and the patient should be
monitored closely.
 Naocl when mixed with CHX = cause orange-brown occludes the dentinal tubules known as para-
chloroaniline (PCA).
 EDTA mixed with CHX = cloudy blue
 irrigation for open apex =0.5- 1.5% Naocl or diluted Naocl***.
 best effective irrigation for killing E, faecalis = MTAD.
 least effective for E. faecalis = CHX.
 Coronal (cervical) fracture = poor prognosis, management (extract coronal segment => ortho
extrusion if root is longer enough => restoration.
 Mid-root fracture = coronal necrosis and apical vital, RCT for coronal segment only.
 best media in open apex immerse before reimplant = Doxycycline, minocycline for 5min.
 Patient came late at the end of day with sever lingering pain, management = with irreversible
pulpitis => pulp extirpation (pulpectomy) + NSAIDs.
 Resorbable sealer = ZOE.
 AH plus = not released formaldehyde, AH-26 = releases formaldehyde (carcinogenic).
 AH-26, AH plus = epoxy resin sealers.
 Formaldehyde = called formocresol + formaline, bactericidal.
 K files = reaming motion (clockwise rotation).
 H files = filing motion (push and pull motion).
 % of accessory canals in apical third = 74%.
 % of second canal in lower anterior = 44%
 MTA = for its property to reduce external root resorption.
 K-reamer more flexible file.
 Differentiate between pulp and periodontal abscess = Vitality test***.
 Metallic sound = lateral luxation + Intrusion.
 Ledermix (corticosteroid antibiotic paste - intracanal medication + reduce internal resorption + anti-
inflammatory action - pH 8.13).
 component of ledermix which use in endo to reduce pain = Triamcinolone acetonide 1% (steroid).
 In case of Latex allergy (allergy o gutta-percha) - obturation material or eugenol allergy = resilon
obturation (resin-based filling)***
 perforation sealing = immediately.
 Tapering of K file = 0.02mm.
 VRF = CBCT for diagnosis or exploratory surgery.
 poorest avulsed tooth = closed apex with reimplantation after 24hr.
 Solvent for GP = chloroform.
 Zipping perforation = over preparation of outer wall of apical curvature of canal.
 Naocl accident = severe pain, edema of neighboring soft tissues, edema over the injured half of face
and upper lip, profuse bleeding from root canal, profuse interstitial bleeding with hemorrhage of
skin and mucosa (ecchymosis) - management: control pain with LA and analgesics, cold compresses
after 1day warm compresses.
 Access opening shape = maxillary premolars (oval).
 Bismuth Oxide = Radio-opacifier in MTA.
 Only tooth show 8 Endo configuration = max 2nd premolar.
 Least reliable in general = EPT.
 Least reliable for PFM + Pedo = EPT
 Best for PFM = cold.
 Least reliable for pedo = electrical.
 Gutta percha =
- advantages: plasticity, ease of manipulation, minimal toxicity, radiopacity, and ease of removal with
heat or solvents.
- Disadvantages: lack of adhesion to dentin and, when heated, shrinkage upon cooling
 intrapulpal anesthesia = Deposit anesthetic under pressure - Resistance to injection should be felt
for the success (contraindicated in pediatric patient => very painful).
 ledge = an artificial irregularity created on canal wall that impedes the placement of an instrument
to the apex.
 perforation = artificial opening occurs in the pulpal wall creating communication between the pulp
& the exterior area.
 Irrigation causes protein coagulation = eugenol – formocresol.
 Thermomechnical compaction = McSpadden Compactor.
 Thermoplastic injection technique = Obtura Il (internal resorption).
 Thermoplasticized technique = open apex - external root resorption.
 warm vertical compaction + continuous wave compaction technique = System B.
 Carrier-Based Gutta-Percha = thermafil + pro taper + SuccessFil.
 Pulp vitality testing= pulp vascularity.
 Tug back - resistance of cone GP in apex.
 Endo ice temperature = -26.2°C.
 Remove silver points & broken instrument = Stieglitz pliers.
 Best determination of crown root fracture = tooth sloth. THERMAFIL
 cells migrates to periodontal pocket = oral epithelium + gingival connective tissue + alveolar bone +
PDL.
 Cavit 3m = not used with Vital tooth, used as temporary materials in RCT.
 Most effective solvent and fastest and low risk = chloroform.
 NiTi files are less incident to make ledge why? because have non-cutting tip.
 Equal amounts of Tri-antibiotic paste (metronidazole, minocycline, and ciprofloxacin) for 3 weeks
used in cases of (revascularization).
 Necrotic pulp contains = PMN leukocytes + histiocytes.
 What to after ledge formed = bypass with pre-curve file.
 The tip of irrigation needle should be 2mm shorter than full WL.
 Formocresol 12.5 Ph
Sodium hypochlorite 11 - 12 Ph
Calcium hydroxide 10 - 14 Ph
AH plus 7.17 to 7.81 Ph
Antibiotic-corticosteroid paste (Ledermix) 8.13 Ph
Eugenol 4.34 Ph
CHX is a strongly basic 5.5 Ph

 Mesial aspect of upper first premolar is concave which often lead to supracrestal perforations and
gouging.
 Gouging (ledge) or perforation = Failure to analyze this penetration angle carefully.
 Avulsed immature tooth better prognosis than closed apex = there is a greater chance of regaining
pulp vitality after replantation***.
 Sequel of avulsed tooth = Undesirable periodontal ligament reactions cause > replacement
resorption (ankylosis) or inflammatory resorption of the root (controllable – more favorable).
 A patency file = small K-file #10 or #15 passively extended slightly beyond the apical foramen. use
for most rotary to remove accumulated debris.
 Peeso drills = coronal flaring + post preparation.
 Sings of mishap = instrument fracture, perforation, Canal transportation, ledge.
 Canal transportation = removal of canal wall structure on the outside curve in the apical half of the
canal.
 ledge = dentinal shelf that is created by shaping instruments that straighten and dig into the convex
side of the canal wall.
 MTA = repair the perforation even the cavity is contaminated with blood, its biocompatible.
 Granuloma = asymptomatic + non vital + no response to percussion test.
 Abscess = can be symptomatic + extreme sensitive to percussion.
 Allodynia (pain due to a stimulus that does not usually provoke pain) and hyperalgesia (increased
pain from a stimulus that usually provokes pain).
 Gutta percha sterilization = 1 min with sodium hypochlorite.
 DG-16 explorer = locate canal orifice and determine canal angulation.
 Explorer = detect root smoothing.
 Full pulpectomy = indication => traumatic exposures after more than 72 hours (3 days) and carious
exposure of a young tooth with a partially developed apex.
 Calcified canals = First CBCT then sharp explorer, color change in dentine, use ultrasonic tips,
statin with 1% methylene blue dye, sodium hypochlorite (champagne bubble test) > leave sodium
hypochlorite in pulp chamber then bubbles will appears indicate position of orifices.
 Overfilled GP = better to remove GP with heat plunger before sealer sets otherwise > No treatment
(follow up unless there is sign and symptoms).
 Hero file = similar to H file in cross section without radial lines, non-cutting passive tip.
 Voxel sizes (in CBCT) = endo imaging require high spatial resolution => the smallest voxel size = the
higher resolution - The absolute maximum voxel size for endodontic imaging should be 0.2 mm.
 most sealer has problem in long term stability = Calcium hydroxide based.
 Trephination = in absence of swelling, for drainage abscess to relive pain.
 The reason of Flare up (acute exacerbation of periradicular pathosis) = 1. over instrumentation 2.
chemical irritants (calcium hydroxide, sealers, obturation) - management: prophylactic antibiotic.
 Furcation + Strip perforation = MTA.
 Cervical perforation = glass ionomer, disadvantage of MTA long setting so it’s not preferable for
cervical.
 Gutta percha components = 20% gutta percha - 66% ZOE –11% radiopacifiers – 3% plasticizers.
 Length of D16 = 0.32.
 Taper at D16 (D number x taper + file number) = Answer.
 Crack + fracture = block the light transmission.
 Fungi found in persistent endodontic infections = Candida albicans.
 MTA =
- Advantages: good seal + antimicrobial + set in presence of moist and blood.
- Disadvantage: cause pulp obliteration + long setting time.
- Main component: tricalcium silicate + tricalcium aluminate.
 Intraoral periapical radiograph = 2mm of bone below root should be visible.
 EPT = measure pulp neural responses.
 Reason for endodontically treated posterior teeth fracture = loss of coronal structure.
 Resistance to fracture reduced in MOD cavities.
 Location of second canal in mandibular canine = Lingual.
 root canal preparation should stop at = minor constriction.
 SLOB (same lingual / opposite buccal):
- Mesial shift (lingual canal => right to film – buccal canal => left to film).
- Distal shift (lingual canal => left to film – buccal canal => right to film).
 Etiology of internal resorption = loss of predntin.
 Gates-Glidden drill = limited to straight canals.
 diameter of Transmetal Carbide bur = 1.6mm.
 IKI (Iodine potassium iodide) = is root canal medicaments (disinfectant) - able to kill the resistant
bacteria to Ca(OH) - don’t use it with patient has iodine allergy.
 Pulp stone removed by = ultrasonic scaler.
 action of inflammation which causes pulp necrosis = vascular dilation + increase intrapulpal
pressure.
 Tug back of gutta percha = to prevent excessive obturation materials into PDL.
 Root canal treated tooth and exposed to oral environment When you should do re-endo = after 2 -
3 months.
 shape of access cavity for the mandibular first molar= triangular or rectangular or rhomboid or
trapezoid.
 Gingival diseases of specific bacterial origin =
- Neisseria gonorrhoeae.
- Treponema pallidum.
- Streptococcus species.
 Dental/pulp trauma = is intrinsic stains.
 positive-pressure irrigation methods = cause risk of expressing debris or solution out of the apex
(apical extrusion of irrigation i.e sodium hypochlorite accident).
 Lateral perforation prognosis =
- at or above height of crest of bone > favorable.
- Below the crest of bone > poor.
 Location of MB2 = mesial and palatal to MB1.
 Ledermix = inhibition of the ribosomal protein synthesis.
 Yellow crown discoloration after Endo = pulp obliteration (calcification).
 To calculate diameter of file at (D14,15,16 etc…) = (Taper of file X D number + file number).
 Endodontic files are available with 0.02 (manual) / 0.04 - 0.06 taper (rotary).
 Obturation should be 0.5 – 1 mm short of the radiographic apex.
 Tetracycline decreases the root resorption.
 Uncomplicated crown fracture the most common dental traumatic injury.
 Functions of Radial land in rotary endodontic system:
- Reduce the tendency of file to thread into canal.
- Limit the depth of the cut and supports the cutting edge.
 Dentinal tubules :
- Hot => inward movement
- Cold => outward movement
 looking for small bubbles in the saliva at the margin of the retainers = loss of retention or vertical
root fracture or excessive gap cement.
 Aging pulp shows an increase in fibrous element.
 Consequence of reimplantation of avulsed tooth ? = external replacement resorption.